Dorsal root ganglion pulsed radiofrequency for the management of intractable vertebral metastatic pain: a case series.

OBJECTIVE: Metastatic bone pain is characteristic of cancer pain and is a form of refractory cancer pain, as the pain includes not only nociceptive but also neuropathic pain. Although some drugs are effective in the management of painful bone metastases, pain while moving is one of the most refractory forms of pain. Although pulsed radiofrequency (RF) dramatically reduces neuropathic pain, chronic pain, and vertebral metastatic pain, the number of cases reported in these studies was very small (five or less). DESIGN: Case report. SETTING: Single pain center. PATIENTS: Fifteen patients suffering from intractable vertebral metastatic pain. INTERVENTIONS: Dorsal root ganglion (DRG) pulsed RF. OUTCOME MEASURES: A numerical rating scale (NRS) of pain at rest and while moving. RESULTS: Almost all patients experienced sound pain relief after the pulsed RF treatment. There were no severe side effects reported. CONCLUSION: DRG pulsed RF procedure provided sound pain relief for patients with intractable vertebral metastatic pain. Metastatic bone pain is characteristic of cancer pain and is a form of refractory cancer pain, as the pain includes not only nociceptive but also neuropathic pain. Although some drugs are effective in the management of painful bone metastases, pain while moving is one of the most refractory forms of pain. DRG pulsed RF procedure provided sound pain relief for patients with intractable vertebral metastatic pain.

Automatic and intentional brain responses during evaluation of face approachability: correlations with trait anxiety.

BACKGROUND: The judgment of the approachability of others based on their facial appearance often precedes social interaction. Whether we ultimately approach or avoid others may depend on such judgments. METHOD: We used functional magnetic resonance imaging to determine the neural basis for such approachability judgments and the relationship between these judgments and trait anxiety. Participants viewed ambiguous (i.e. neutral) or relatively unambiguous (i.e. angry, happy) faces, assessing either the approachability or the sex of the person depicted. RESULTS: Neutral faces elicited more inconsistent responses within participants only during approachability judgment, suggesting ambiguous property as signals. The contrast pertaining to the interaction between task and face valence demonstrated activation in several areas, such that the left amygdala and medial, middle and inferior frontal gyri were responsive to angry faces when subjects were asked to recognize the sex (implicit task) and to neutral faces when required to discern the approachability (explicit task). Moreover, the blood oxygenation level-dependent change within the left amygdala in response to neutral faces during the judgment of approachability was positively correlated with participant trait anxiety. CONCLUSIONS: These findings extend a proposed model of social cognition by highlighting the functional engagement of the amygdala in approachability judgments, which underlie an individual's sensitivity to ambiguous sources of probable threat.

Neurolytic celiac plexus block reduces occurrence and duration of terminal delirium in patients with pancreatic cancer.

PURPOSE: WHO's three step ladder sometimes cannot provide adequate pain relief for pancreatic cancer. Some patients develop terminal delirium (TD). The aim of this study was to test if the addition of a celiac plexus block (CPB) to pharmacotherapy could reduce the incidence of TD. METHODS: Pancreatic cancer patients under the care of our palliative-care team were investigated with regard to the duration and occurrence of TD, pain scores [numerical rating score (NRS)] and daily opioid dose. Between August 2007 to September 2008, 17 patients received only pharmacotherapy (control group). Then, we modified our guideline for analgesia, performing CPB 7 days after the first intervention of our team. Between October 2008 to September 2009, 19 patients received CPB. RESULTS: The opioid doses in CPB group were significantly lower both at 10 days after the first intervention (3 days after CPB) (27 ± 11 vs. 66 ± 82 mg; p = 0.029) and 2 days before death (37 ± 25 vs. 124 ± 117 mg; p = 0.009). NRS in the CPB group were significantly lower both at 10 days after the first intervention (0 [0-2] vs. 3 [2-5], p < 0.0001) and 2 days before death (1 [0-2] vs. 3 [1-4.5], p = 0.018). The occurrence and duration of TD in CPB group were both reduced (42 vs. 94 %, p = 0.019; and 1.8 ± 2.9 vs. 10.4 ± 7.5 days, p = 0.0003). CONCLUSION: The duration and occurrence of TD and the pain severity were significantly less in pancreatic cancer patients who underwent neurolytic CPB.

Pulsed radiofrequency treatment within brachial plexus for the management of intractable neoplastic plexopathic pain.

We report on the use of pulsed radiofrequency (RF) within the plexus for the management of intractable pain in three patients with metastatic or invasive plexopathy. The patients were a 38-year-old woman with a history of breast cancer 6 years earlier whose computed tomography (CT) scans revealed a mass lesion at the infraclavicular part of the right brachial plexus, a 68-year-old man diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the right humerus invading the axillary region of the right brachial plexus, and a 67-year-old woman diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the left humerus invading the axillary region of the left brachial plexus. Ultrasound-guided pulsed RF was performed within the interscalene brachial plexus. During the follow-up period, their intractable pain was moderately controlled.

Sex differences in neural activation to ambiguous facial expression in happy and sad context.

Functional magnetic resonance imaging (fMRI) was used to investigate brain activation associated with a facial expression identification task (stimuli were full emotional, half emotional, or ambiguous in both happy and sad context) in 10 men and 10 women, fMRI assessment revealed significant interaction of sex x context in the right putamen for the ambiguous faces. Women showed a greater BOLD response to ambiguous facial expression in the sad context than in the happy context, while men showed a greater response in the happy context. Further, women showed a greater BOLD response than did men to ambiguous facial expression in the sad context, while men showed a greater response than women in the happy context. These results suggest that sad and happy context differentially modulate right putamen activation related to processing of ambiguous facial expression in men and women.

Psychosocial functioning in patients with Treatment-Resistant Depression after group cognitive behavioral therapy.

BACKGROUND: Although patients with Treatment Resistant Depression (TRD) often have impaired social functioning, few studies have investigated the effectiveness of psychosocial treatment for these patients. We examined whether adding group cognitive behavioral therapy (group-CBT) to medication would improve both the depressive symptoms and the social functioning of patient with mild TRD, and whether any improvements would be maintained over one year. METHODS: Forty-three patients with TRD were treated with 12 weekly sessions of group-CBT. Patients were assessed with the Global Assessment of Functioning scale (GAF), the 36-item Short-Form Health Survey (SF-36), the Hamilton Rating Scale for Depression (HRSD), the Dysfunctional Attitudes Scale (DAS), and the Automatic Thought Questionnaire-Revised (ATQ-R) at baseline, at the termination of treatment, and at the 12-month follow-up. RESULTS: Thirty-eight patients completed treatment; five dropped out. For the patients who completed treatment, post-treatment scores on the GAF and SF-36 were significantly higher than baseline scores. Scores on the HRSD, DAS, and ATQ-R were significantly lower after the treatment. Thus patients improved on all measurements of psychosocial functioning and mood symptoms. Twenty patients participated in the 12-month follow-up. Their improvements for psychosocial functioning, depressive symptoms, and dysfunctional cognitions were sustained at 12 months following the completion of group-CBT. CONCLUSIONS: These findings suggest a positive effect that the addition of cognitive behavioural group therapy to medication on depressive symptoms and social functioning of mildly depressed patients, showing treatment resistance.

Low-dose gabapentin as useful adjuvant to opioids for neuropathic cancer pain when combined with low-dose imipramine.

PURPOSE: Painful neuropathic conditions of cancer pain often show little response to nonopioid and opioid analgesics but may be eased by antidepressants and anticonvulsants. Although gabapentin is effective in the treatment of neuropathic pain in patients with cancer, some patients experience intolerable side effects sufficient to warrant discontinuation. The aim of this study was to see whether low-dose gabapentin is effective in treating cancer-related neuropathic pain when combined with low-dose imipramine. METHODS: Fifty-two cancer patients diagnosed as having neuropathic pain were allocated into four groups: G400-I group took gabapentin 200 mg and imipramine 10 mg every 12 h orally; G400 group took gabapentin 200 mg every 12 h orally; G800 group took gabapentin 400 mg every 12 h orally; I group took imipramine 10 mg every 12 h orally. RESULTS: Low-dose gabapentin-imipramine significantly decreased the total pain score and daily paroxysmal pain episodes. Several patients developed mild adverse symptoms in the four groups, and three patients discontinued treatment due to severe adverse events in the G800 group. CONCLUSION: Low-dose gabapentin-antidepressant combination with opioids was effective in managing neuropathic cancer pain without severe adverse effects.

Anterior cingulate cortex modulates preparatory activation during certain anticipation of negative picture.

We studied the neural activation associated with anticipations of emotional pictures using functional magnetic resonance imaging (fMRI) by directly comparing certain with uncertain anticipation conditions. While being scanned with fMRI, healthy participants (n=18) were cued to anticipate and then perceive emotional stimuli having predictable (i.e., certain) emotional valences (i.e., positive and negative), given a preceding cue, as well as cued stimuli of uncertain valence (positive or negative). During anticipation of pictures with certain negative valence, activities of supracallosal anterior cingulate cortex, ventrolateral prefrontal cortex, insula, and amygdala were enhanced relative activity levels that for the uncertain emotional anticipation condition. This result suggests that these brain regions are involved in anticipation of negative images, and that their activity levels may be enhanced by the certainty of anticipation. Furthermore, the supracallosal anterior cingulate cortex showed functional connectivity with the insula, prefrontal cortex, and occipital cortex during the certain negative anticipation. These findings are consistent with an interpretation that top-down modulation, arising from anterior brain regions, is engaged in certain negative anticipation within the occipital cortex. It is thought that the limbic system involving the amygdala, ACC, and insula, engaged emotional processes, and that the input system involving the visual cortex entered an idling state.

Colitis associated with Clostridium difficile in specific-pathogen-free C3H-scid mice.

Soft feces and a decreased delivery rate were observed in a specific-pathogen-free (SPF) C3H-scid mouse breeding colony. Grossly, the ceca were shrunken and edematous in the affected mice. Histopathologically, severe edema in the cecal submucosa as well as infiltration of inflammatory cells in the lamina propria and submucosa of the ceca and colon were observed. No pathogenic microorganisms were detected by the routine microbiological tests. By anaerobic bacterial-examination, Clostridium (C.) difficile with toxin A was isolated from the cecal contents of the affected mice. The mice were diagnosed with C. difficile-associated colitis. This case appears to be the first report of natural infection with C. difficile in SPF mice with clinical signs.

Anticipation of affective image modulates visual evoked magnetic fields (VEF).

We investigated the interaction between anticipation of positive and negative affective images and visual evoked magnetic fields (VEF). Participants (n = 13) were presented emotionally positive or negative images under different anticipatory conditions, and their subsequent brain responses were recorded by magnetoencephalography (MEG). In the Affective Cue conditions, the cue stimulus indicated the emotional valence of the image, which followed 2 s later. In the Null Cue conditions, the cue stimulus did not include any information about the valence of the image. In the No Cue conditions, the affective image was suddenly presented, without a cue stimulus. The VEF amplitude for the negative image in the Affective Cue condition was smaller than that of the positive image in the Affective Cue condition and that of the negative image in the Null Cue condition. This result suggests that anticipation of the valence of affective images modulates the processes of the visual cortex.

Quetiapine treatment for behavioral and psychological symptoms in patients with senile dementia of Alzheimer type.

The purpose of this study was to assess the effect of quetiapine in the treatment of behavioral and psychological symptoms of dementia (BPSD) in patients with senile dementia of Alzheimer type (SDAT). Sixteen SDAT patients with BPSD were recruited and quetiapine (25- 200 mg/day) was prescribed for 8 weeks. BPSD were evaluated with the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) and Cohen-Mansfield Agitation Inventory (CMAI) at week 0 (baseline) and week 8 (endpoint). The severity of the extrapyramidal symptoms was also assessed by the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) at baseline and endpoint. Significant improvements were seen in the CMAI total score and in the BEHAVE-AD subscales of delusions, activity disturbances, aggressiveness, diurnal rhythm disturbances and in the BEHAVE-AD overall severity. There was no significant difference between the baseline and endpoint in the DIEPSS score. These data indicate that quetiapine is effective in controlling BPSD with favorable adverse-event profiles.