[The chemical neuromodulation of pain: a review]. / La neuromodulazione chimica del dolore: una rassegna.

The chronic pain is a true emergency. In fact, the study "Pain in Europe 2005" showed that 26% of the Italian population is suffering by it. Chronic pain can be benign, when caused by a tissular damage, or malignant when cancer-related. The study of the pain has made a lot of progress in the last years. An example is the chemical neuromodulation, that interferes with the transmission of the pain afferences toward the brain, through the administration of chemical substances in the spinal or cranial compartment in well selected patients. This allows the use of doses lower than those required for other ways of administration, with less collateral effects and a more rapid response.

[Our experience in the chemical spinal neuromodulation in chronic pain from spinal collapse due to osteoporosis.]. / La nostra esperienza sulla neuromodulazione chimica spinale nel dolore cronico da collasso vertebrale di origine osteoporotica.

AIMS: Osteoporosis is a metabolic disease of the bone characterized by reduced bone mass and microstructural deterioration of bone tissue with a consequent increase in bone fragility and risk of vertebral collapse. Treatment of osteoporosis with the new molecule is effective in improving the density and quality of bone but does not provide an analgesic effect for patients with vertebral collapse. The treatment of chronic pain from vertebral collapse is difficult and may require the use of opioids, but for some patients the intake of these drugs is burdened with systemic side effects. The aim of our study is to use the way in reducing intrathecal opioid dosage and at the same time have good pain control without significant side-effects. We report our experience in the use of continuous infusion pump for intrathecal morphine in patients with chronic pain from osteoporotic vertebral collapse that can not tolerate therapy with systemic opioids because of severe side effects. MATERIALS AND METHODS: 24 patients (19 women and 5 men with average age of 73.3 years) with a diagnosis of chronic pain from vertebral collapse refractory to treatment for systemic analgesic were treated with the use of pumps for intrathecal infusion of morphine. All patients were fit the criteria for inclusion. For the measurement of pain the visual analogue scale (VAS) in three stages: T0, T1, T2 was administered to all patients. For the evaluation of the quality of life the Questionnaire of quality of life of the European Foundation for Osteoporosis (QUALEFFO) was administered in three times. RESULTS: In the one year follow-up there was a significant reduction in pain measured by VAS, from 8.5 to 1.9 in T0 to T2 in all patients. Similarly there was a reduction in the average score of QUALEFFO of all variables, from T0 equal to 114.7 to T2 equal to 79.1. With the intrathecal infusion of morphine no patient required an additional systemic treatment. CONCLUSIONS: This study demonstrates that intrathecal-morphine therapy offers patients relief from pain and a good quality of life. Continuous intrathecal infusion of morphine is a valuable therapy and is particularly suitable for those patients who show side effects with the administration of systemic opioids.

Spinal cord stimulation in the management of pain from brachial plexus avulsion.

This is a retrospective study of four patients suffering from brachial plexus root avulsion of traumatic origin. Spinal cord stimulation was used to treat pain in all patients. A seven-contact electrode was percutaneously introduced in the epidural cervical space and under fluoroscopic control, advanced to the level were stimulation provoked a tingling sensation in the painful region. A stimulation trial was performed for 2 weeks and during this period the patients showed significant pain relief, so the system was permanently implanted. A significant difference of more than three points in the pain between the first and the last follow-up (0-9 months) on the Visual Analog Scale was obtained with a steady and progressive decrease of the pain scores.

Acute cardiovascular effects of insulin-like growth factor I in patients with chronic heart failure.

Insulin-like growth factor I (IGF-I) enhances myofibrillar development in cardiomyocytes of rats in culture and in vivo. In addition, IGF-I has vasodilatory effects and improves cardiac function in healthy volunteers. This study was conducted to evaluate the acute hemodynamic effects of IGF-I in patients with chronic heart failure Eight patients with chronic heart failure were randomized to receive recombinant human IGF-I (60 micrograms/kg) or placebo, i.v., over 4 h in a cross-over, double blind study on 2 consecutive days. Electrocardiogram as well as systemic hemodynamics were continuously monitored over 7 h by flow-guided thermodilution and radial artery catheters. IGF-I was well tolerated by all patients, and no pathological changes on electrocardiogram were recorded. Compared with placebo, IGF-I increased the cardiac index by 27 +/- 3.7% (+/- SE; P < 0.0005) and the stroke volume index by 21 +/- 5.6% (P < 0.05), and decreased systemic vascular resistance by 28 +/- 4.4% (P < 0.0002), right atrial pressure by 33 +/- 9.0% (P < 0.003), and pulmonary artery wedge pressure by 25 +/- 6.1% (P < 0.03). Mean systemic and pulmonary artery pressure as well as heart rate and pulmonary vascular resistance were not significantly influenced by IGF-I treatment. Insulin and C peptide levels were decreased by IGF-I, whereas glucose and electrolyte levels remained unchanged. Urinary levels of norepinephrine decreased significantly (P < 0.05) during IGF-I infusion. Thus, acute administration of IGF-I in patients with chronic heart failure is safe and improves cardiac performance by afterload reduction and possibly by positive inotropic effects. Further investigations to establish whether the observed acute effects of IGF-I are maintained during chronic therapy appear to be warranted.