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PubMed1992

Viscerosomatic convergence onto feline spinal neurons from esophagus, heart and somatic fields: effects of inflammation.

One objective of this study was to examine a mechanism for the inability of patients to distinguish esophageal pain from cardiac pain. Patients with esophageal disease and angina pectoris often perceive pain as originating from the same somatic fields. Another objective was to compare the effect of esophageal distension between animals with a non-inflamed or with an inflamed esophagus. For this study in anesthetized cats, we recorded extracellular action potentials from T2-T7 spinal neurons that responded to intraluminal distension of an untreated or a turpentine-inflamed distal esophagus. Threshold distension volumes were compared between these 2 groups of animals. Neurons also were examined for effects of intracardiac bradykinin injection and somatic stimuli. Results showed that spinal neurons responded to a smaller threshold distension volume when cells in animals with an inflamed distal esophagus were compared to cells in animals with a non-inflamed distal esophagus. Spinal neurons that received input from the distal esophagus also received convergent input from the heart and somatic fields. Our data supported the hypotheses that (1) referred pain from the distal esophagus resulted from activation of the same spinal neurons by visceral and somatic input, (2) pain originating from the distal esophagus and heart might be difficult to distinguish because of viscerosomatic and viscerovisceral convergence onto the same spinal neurons, and (3) an inflamed distal esophagus might be more sensitive to distension than a non-inflamed esophagus.

Afferent Pathways↗

PubMedDate not supplied

Imaging findings in patients with-right lower quadrant pain: alternative diagnoses to appendicitis.

Patients with right lower quadrant (RLQ) pain referred for imaging studies with a clinical diagnosis of appendicitis may have other pathologic conditions mimicking appendicitis. Appropriate diagnostic imaging may establish other specific diagnoses and thereby play a significant role in determining proper medical or surgical treatment. In this pictorial essay, we present a spectrum of imaging findings in patients whose clinical features were suggestive of appendicitis, but the diagnoses of a broad spectrum of other diseases were established with the imaging studies. The differential diagnoses of diseases mimicking appendicitis are reviewed.

Abdominal Pain↗

PubMed2003

Pain and biomechanical responses to distention of the duodenum in patients with systemic sclerosis.

BACKGROUND & AIMS: Abnormalities of the small intestine have been indicated in systemic sclerosis. The aim was to use a new method to study the active-passive mechanical and sensory properties of the duodenum in these patients. METHODS: A volume-controlled ramp-distention protocol was used in the duodenum in 9 patients and 8 healthy controls. The nonpainful/painful sensations, pressure, cross-sectional area, wall tension, and strain were evaluated. Using butylscopolamine for muscle relaxation, the active (contractile muscular component) and passive (other mechanical tissue components) were computed. RESULTS: The contraction amplitude was smaller and the cross-sectional area higher in the patients (P < 0.05). Both the active and passive tension as function of strain was translated to the left in the patients, indicating a stiffer wall. The maximum active tension and the corresponding strain were 62% and 69% lower in the patients (P < 0.05). An association was found between the duration of the disease and the strain (P < 0.05). The perception score was higher as function of pressure, tension, and strain (P = 0.01, P = 0.03, and P < 0.01, respectively) in the patients than in the controls, with strain as the most sensitive variable to describe the sensory response. In 5 patients who complained of regular clinical symptoms, the referred pain area to distention was enlarged. CONCLUSIONS: Systemic sclerosis resulted in increased stiffness and impaired muscle function of the duodenum. The pain evoked by a controlled strain of the gut was increased and can explain many of the symptoms reported in the clinic.

Adult↗

PubMed2006

Differential responses of rostral subnucleus caudalis and upper cervical dorsal horn neurons to mechanical and chemical stimulation of the parotid gland in rats.

Blockage of the salivary duct can produce pain and inflammation from the build up of saliva in the parotid gland. The processing of parotid inflammation-induced pain, however, is poorly understood. The purpose of this study was to clarify the functional involvement of the trigeminal subnucleus interpolaris/caudalis transition region (Vi/Vc) and upper cervical spinal cord (C1/C2) in processing nociceptive input relevant to parotitis. The effect of capsaicin-induced parotitis was examined on a total of 37 nociceptive neurons isolated from the Vi/Vc (n = 23) and C1/C2 (n = 14) regions. Eight of 23 Vi/Vc neurons responded to mechanical distention of the parotid gland, whereas no C1/C2 neurons responded to the parotid distention. Receptive field characteristics in all neurons were examined following capsaicin injections into the parotid gland. Mechanical and cold responses increased significantly in C1/C2 but not Vi/Vc neurons following capsaicin. Receptive field sizes also increased in C1/C2 but not Vi/Vc neurons. At the Vi/Vc transition region, pinch-evoked activity increased in neurons receiving convergent inputs from the parotid gland and facial skin when compared to non-convergent neurons. The present data indicate that the hyperalgesia and referred pain associated with parotitis may result from sensitization of C1/C2, but not Vi/Vc nociceptive neurons.

Action Potentials↗

PubMed2006

Needle electromyographic activity of myofascial trigger points and control sites in equine cleidobrachialis muscle--an observational study.

BACKGROUND: Myofascial trigger points are commonly described in humans, and many studies have shown abnormal spontaneous electrical activity, spike activity and local twitch responses at these sites. Myofascial trigger points have only rarely been described in horses, and studies of their electrophysiological characteristics have not previously been published. The objective of this study was to explore the electromyographic (EMG) and other characteristics of myofascial trigger points in equine muscle, and to compare them with normal muscle tissue. METHODS: Four horses with chronic pain signs and impaired performance were examined. They had previously been examined at the second author's practice, and showed signs compatible with the diagnosis of myofascial trigger points in their cleidobrachialis (brachiocephalic) muscle, ie localised tender spots in a taut band of skeletal muscle which produced a local twitch response on snapping palpation. They had therefore been selected for treatment with acupuncture. Needle EMG activity and twitch responses were recorded at 25 positions at the trigger point and at a nearby control point during the course of each horse's acupuncture treatment. RESULTS: All subjects demonstrated objective signs of spontaneous electrical activity, spike activity and local twitch responses at the myofascial trigger point sites within taut bands. The frequency of these signs was significantly greater at myofascial trigger points than at control sites (P<0.05). CONCLUSION: Equine myofascial trigger points can be identified, and have similar objective signs and electrophysiological properties to those documented in human and rabbit skeletal muscle tissue. The important differences from findings in human studies are that referred pain patterns and the reproduction of pain profile cannot be determined in animals.

Acupuncture Therapy↗

PubMed2005

Sensory-motor responses to mechanical stimulation of the esophagus after sensitization with acid.

AIM: Sensitization most likely plays an important role in chronic pain disorders, and such sensitization can be mimicked by experimental acid perfusion of the esophagus. The current study systematically investigated the sensory and motor responses of the esophagus to controlled mechanical stimuli before and after sensitization. METHODS: Thirty healthy subjects were included. Distension of the distal esophagus with a balloon was performed before and after perfusion with 0.1 mol/L hydrochloric acid for 30 min. An impedance planimetry system was used to measure cross-sectional area, volume, pressure, and tension during the distensions. A new model allowed evaluation of the phasic contractions by the tension during contractions as a function of the initial muscle length before the contraction (comparable to the Frank-Starling law for the heart). Length-tension diagrams were used to evaluate the muscle tone before and after relaxation of the smooth muscle with butylscopolamine. RESULTS: The sensitization resulted in allodynia and hyperalgesia to the distension volumes, and the degree of sensitization was related to the infused volume of acid. Furthermore, a nearly 50% increase in the evoked referred pain was seen after sensitization. The mechanical analysis demonstrated hyper-reactivity of the esophagus following acid perfusion, with an increased number and force of the phasic contractions, but the muscle tone did not change. CONCLUSION: Acid perfusion of the esophagus sensitizes the sensory pathways and facilitates secondary contractions. The new model can be used to study abnormal sensory-motor mechanisms in visceral organs.

Adult↗

PubMed2002

The therapeutic impact of abdominal ultrasound in patients with acute abdominal symptoms.

AIM: The technical performance of abdominal ultrasound in the investigation of acute abdominal pain has been thoroughly investigated but its therapeutic effects are less well understood. We aimed to determine the therapeutic effect of abdominal ultrasound in the investigation of acute abdominal pain. MATERIAL AND METHODS: A pre- and post-intervention observational study design was used to determine the diagnostic and therapeutic effects of abdominal ultrasound for acute abdominal pain. Referring clinicians completed a pre-ultrasound questionnaire that detailed their leading diagnosis, confidence in this and intended management in 100 consecutive adult patients. Following ultrasound a second questionnaire was completed. This again detailed the leading diagnosis, confidence in this and their intended management. Clinicians quantified the management contribution of ultrasound both for the individual case in question and in their clinical experience generally. RESULTS: The leading diagnosis was either confirmed or rejected in 72 patients and a new diagnosis provided where no prior differential diagnosis existed in 10. Diagnostic confidence increased significantly following ultrasound (mean score 6.5 pre-ultrasound vs 7.6 post-ultrasound, P < 0.001). Intended management changed following ultrasound in 22 patients; 15 intended laparotomies were halted and a further seven patients underwent surgery where this was not originally intended. Ultrasound was rated either 'very' or 'moderately' helpful in 87% of patients, with 99% of clinicians finding it either 'very' or 'moderately' helpful generally. CONCLUSION: Abdominal ultrasound has considerable diagnostic and therapeutic effect in the setting of acute abdominal pain.

Abdomen, Acute↗

PubMed1981

[Peritoneal pseudocysts as a complication of cerebrospinal fluid shunt. Report of 3 cases and contribution for diagnosis].

Three cases of peritoneal pseudocysts are reported with guidelines for the diagnosis of this type of complication. The authors point out the value of the following signs: 1--increase of ventricular pressure with worsening of the clinical picture; 2--localized pain in the abdomen; 3--difficulty to depress the capsule; 4--occurrence of subcutaneous collection of CSF around the pathway of the catheter. In some occasions it is possible to palpate the mass of the pseudocyst. The presence of subcutaneous collection of CSF around the pathway of the catheter is an important warning sign of peritoneal pseudocyst and must be differentiated from that originated by the disconnection between the capsule and the catheter. In this condition however, the accumulation of liquid begins in the cervical region. Also in this case the capsule depresses easily. The most precise diagnosis is achieved by X-Ray. The authors describe a method that consists in introducing a needle through the capsule and injecting 8cc of Dimer-X contrast. The catheter and the cavity of pseudo-cyst appear contrasted in the X-Ray film, establishing the definitive diagnosis. The authors discuss the physiopathology of CSF accumulation; once the pseudocyst is formed, the intracranial pressure increases, and the fontanelle bulges, this leads to repeated pumping by the relatives and subsequent rising of pressure within the pseudo-cyst. At this point the patient refers pain at the location of the pseudo-cyst and the CSF tends to lead around catheter. In babies the abdominal pain leads to crying, thus increasing once more the intra-cystic pressure which favors the leakage of CSF from the pseudo-cyst around the catheter.

Cerebrospinal Fluid Shunts↗

PubMed1982

A study of occlusal relationships and the incidence of myofacial pain.

A survey of 123 subjects (dental students) was performed to evaluate quantitative data that may be of value in the incidence and treatment of myofacial pain. Social statistics, subjective and objective symptoms, and the influence of occlusal interferences on these symptoms were quantitated and recorded. The data indicated that, 123 subjects, 26% had maximum intercuspation of the teeth at terminal hinge closure, 42% had maximum intercuspation of the teeth with the condyles located symmetrically anterior to terminal hinge, and 32.5% had maximum intercuspation of the teeth with assymmetric variations of the condyles anterior to terminal hinge. Averages were obtained for the maximum intercuspal open, the condylar inclination, and the distance anterior from the terminal hinge of both condyles in symmetrical and asymmetrical variations. The location of the transverse (terminal hinge) axis from the external auditory meatus was measured on the ala-tragus line. These latter averages indicate that a significant occlusal discrepancy can result from prevailing techniques of locating an arbitrary hinge axis 10 to 13 mm anterior from the external auditory meatus. The results showed that most subjects demonstrated, both subjectively and clinically, symptoms of neuromuscular dysfunction without occlusal interferences. Therefore, it may be concluded that treatment modalities considered within the first 6 weeks should be conservative and reversible to eliminate or decrease myofascial trigger zones and their areas of referred pain. Alteration of the existing occlusion and maxillomandibular relations may be adjusted with caution, if necessary.

Adult↗

PubMed1999

Curvature of the lower lumbar facet joints: variations at different levels and relationship with orientation.

The curvature of the lower lumbar facet joints in the transverse plane was measured using an innovative computed tomographic approach, and its relationship with the orientation of the joints was evaluated. Two hundred three vertebral levels were examined in 116 patients with low back pain. Reference circles were used to quantify joint curvature. The mean curvature (+/- SD) at the levels L3-L4, L4-L5, and L5-S1 conformed to circles of 27.3 mm +/- 11.5; 35.1 mm +/- 14.6; and 51.0 mm +/- 34.5 in diameter respectively. The ratio between the curvature of the facets and their orientation was 62.6% +/- 19.0; 57.8% +/- 21.6; and 64.9% +/- 48.9. From L3-L4 down to L5-S1 the curvature of the facet joints decreases. The differences between L3-L4 and L4-L5 is smaller than between L4-L5 and L5-S1. The curvatures of the joints conform to circles that are in mean approximately 40% in diameter smaller than those to which their orientations conform.

Anthropometry↗

PubMed1999

Carotid artery disease as a marker for the presence of severe coronary artery disease in patients evaluated for chest pain.

BACKGROUND AND PURPOSE: We sought in this study to elucidate whether carotid artery disease detected by ultrasonography can be a clinically useful marker for the presence of severe coronary artery disease (CAD) in patients evaluated for chest pain. METHODS: Duplex ultrasonography and quantitative coronary angiography were used to assess carotid and coronary artery atherosclerosis in 225 consecutive patients (mean age, 58+/-9 years) with chest pain referred for cardiac catheterization. RESULTS: CAD was present in 197 patients (88%). Fifty-seven patients (25%) had 1-vessel disease, 52 (23%) had 2-vessel disease, 53 (24%) had 3-vessel disease, and 35 (16%) had left main stem CAD (LMS-CAD). The incidence of severe CAD (3-vessel disease or LMS-CAD) was 24% and 63% in the normal and impaired ejection fraction (EF) subgroups, respectively (P<0.005). Carotid disease (lumen diameter stenosis of >/=50%) was present in 5.3%, 13.5%, 24.5%, and 40% of patients with 1-, 2-, and 3-vessel disease and LMS-CAD, respectively. Moreover, the incidence of carotid disease in patients with severe CAD was 31% in the entire study population and 46% and 5% in the subgroups with impaired and normal EF, respectively (P<0.005). In the entire study population, the presence of severe CAD was determined by age, male sex, and carotid disease; in the impaired EF group by age and carotid disease; and in the normal EF group only by age. Carotid disease has a high negative (92%) and a high positive (91%) predictive value for the presence of severe CAD in the subgroup with normal and impaired EF, respectively. CONCLUSIONS: In patients evaluated for chest pain, carotid disease is significantly correlated with severe CAD. Furthermore, in patients with impaired left ventricular systolic performance the presence of carotid disease reflects the presence of severe CAD, while in patients with normal EF the absence of carotid disease reflects the absence of severe CAD.

Adult↗

PubMedDate not supplied

Framework invasion by laryngeal carcinomas.

The accuracy of standard clinical and radiologic methods in detecting invasion of the laryngeal framework or the presence of a transglottic tumor was examined by comparing clinical and pathologic findings in a series of 50 randomly selected laryngectomies for squamous carcinoma. Forty-two of the patients had received radiation therapy as primary treatment. The presence of pain referred to the ear immediately before laryngectomy indicated invasion of the laryngeal framework or spread into the extralaryngeal soft tissues in 11 of 12 patients. Transglottic tumors were correctly identified in 10 of 14 patients from laryngeal tomograms, but seven additional tumors were incorrectly designated as transglottic. Both transglottic tumors and infraglottic extension were seriously underdiagnosed by direct laryngoscopy. Framework invasion was seen to be a feature of transglottic tumors 2 cm or more in diameter. The morphology of this process is described. Limited follow-up has already shown a pattern of early recurrence, frequently as cervical node metastases, that is significantly more common in patients with framework invasion.

Adult↗

PubMed2003

Prediction of prolonged work disability in occupational low-back pain based on nurse case management data.

This study evaluated whether risk prediction data captured by nurse case managers (NCMs) could predict prolonged disability from occupational low back pain. Cases of uncomplicated occupational low back pain referred to NCMs, with dates of injury between January 1, 1997 and June 30, 1998, were selected (n = 986). Predictive information was obtained from the NCM screening checklist of potential risk factors and other administrative claims data. Data were collected on 23 variables thought to predict work status at 6 months postinjury. In a multivariate logistic regression model, being out of work was significantly associated with older age, language barriers, earlier referral to NCM, and neutral or negative attorney attitude toward return to work. The overall predictive power of the model was low (area under curve = 0.6). Although NCM risk factor data collection is feasible and practical in insurance settings, future studies should explore additional variables and refined data collection methods in order to achieve a more accurate prediction.

Adult↗

PubMed1991

Is the benign joint hypermobility syndrome benign?

Over a period of two years, joint hypermobility was identified in 95 female and 19 male patients who attended rheumatology and rehabilitation units in Ismailia city. Pauciarticular pains referring to large and medium-sized joints was their most frequent complaint. Clinical diagnosis of carpal and/or tarsal tunnel syndromes was made in 45.6% of patients, and various forms of soft tissue rheumatism were evident in 73% of them. On radiologic evaluation of the involved joints, 60.5% of the examined patients showed significant degenerative lesions. The most prominent finding in the study, however, was the aggregation of varieties of articular and extra-articular abnormalities in the same patient. Extra-articular features included high frequencies of occurrence of varicose veins, piles and uterine prolapse among other abnormalities. Thus, results of the study lend support to the view that joint hypermobility predisposes to several articular and nonarticular lesions raise serious questions about the reputable benignity of the syndrome.

Adolescent↗

PubMed1991

Noncardiac chest pain in patients with heart disease.

This is a retrospective study of cardiac patients with noncardiac chest pain referred for evaluation of esophageal motility. Sixty-eight patients with heart disease were compared with 210 patients without heart disease according to findings from symptom questionnaires and a psychologic test (Brief Symptom Inventory). More than 70% of each group qualified for an anxiety or depressive diagnosis on the symptom questionnaire. These diagnoses were supported by significant elevations of scores on the anxiety and depression scales of the Brief Symptom Inventory. Male gender and a diagnosis of panic disorder occurred significantly more often in the patients with heart disease. "Stress" was cited as the cause of illness in about half the sample, but this led to less than satisfactory rates of psychiatric evaluation or pharmacotherapy. This is of particular concern for the cardiac patients because of the known adverse effect of anxiety and depression in those with heart disease.

Adolescent↗

PubMed1994

Psychological symptom profiles in patients with chest pain.

Five-hundred and thirty-two patients with ischaemic-like chest pain referred for symptom-limited exercise thallium myocardial perfusion studies, were assessed on a range of psychosocial measures. Three groups of patients were identified on the basis of their perfusion studies: (1) normal thallium perfusion; (2) current myocardial ischaemia; and (3) past myocardial infarction (but no current ischaemia). There were no significant psychological differences between these groups on a wide range of measures which included depression, state and trait anxiety, Type A behaviour, personality, suppression of affect, locus of control, alexythymia, and hypochondriasis. Significant differences were identified, however, on measures of anger and coping style. Subjects with no current ischaemia (normal thallium perfusion and those with past myocardial infarction) had higher scores on 'immature coping' and 'anger in', than subjects with current myocardial ischaemia. These findings are discussed in the light of other published research.

Adult↗

PubMed1986

Radionuclide bone imaging in patients with low back pain presenting to the orthopaedic surgeon.

This study looks retrospectively at 113 patients with low back pain referred by orthopaedic surgeons for bone scanning. 79 scans (70%) were reported normal and 34 scans (30%) abnormal. 61 out of the 79 patients with normal scans were diagnosed and managed as "chronic back strain". Negative bone scans were also encountered in 3 patients with degenerative disease, 3 with prolapsed intervertebral disc and one with spondylolysis. In those patients with positive scans, a varied range of diagnoses was encountered, the main ones being bone metastases, previous trauma, osteomyelitis and degenerative disease. The scan was shown to be helpful in deciding on the presence or absence of pathology, and in identifying the sites of involvement, but not the nature of the disease. A higher likelihood of positivity is seen in the more elderly patients as well as those below 20 years of age. In interpreting the scan, the clinical context is important e.g. a history of trauma, previous surgery or of malignant disease. The bone scan may be normal in disc prolapse and in degenerative disease of the spine.

Adolescent↗

PubMed2003

Caecal-diverticulitis: a rare differential diagnosis for right-sided lower abdominal pain.

OBJECTIVE: There are several differential diagnoses for acute abdominal discomfort with pain referred to the right lower quadrant region. The objective of this report is to outline our experience with diverticulitis of the caecum, which is a rare condition that is particularly difficult to diagnose correctly pre-operatively. METHODS: A retrospective analysis of acute diverticulitis of the caecum was performed over the period from January 1992 to December 2000 within the Surgical Department of the RWTH Aachen, Germany. The progress of each patient was assessed by interviewing the patient and by telephone contact with the patient's general practitioner. RESULTS: Seven patients with isolated infective diverticulitis of the caecum were encountered in the course of this study. In five of these cases, the pre-operative diagnosis was either unclear or incorrect. Four patients underwent surgery for suspected appendicitis. In one patient, the diverticulitis was diagnosed during laparoscopic surgery undertaken for presumed adnexal disease. Intestinal continuity was restored in all cases. The postoperative course was uneventful. CONCLUSIONS: Right-sided caecal diverticulitis is rare in comparison to diverticulitis of the sigmoid or descending colon. Nevertheless, it should be actively considered in the differential diagnosis of patients with acute tenderness in the right lower abdominal region.

Abdominal Pain↗