Bladder Pain Sensitivity Is a Potential Risk Factor for Irritable Bowel Syndrome.

BACKGROUND: Although dysmenorrhea is a highly prevalent risk factor for irritable bowel syndrome (IBS), the factors underlying this risk are not fully understood. Prior studies support a hypothesis that repeated distressing menstrual pain promotes cross-organ pelvic sensitization with heightened visceral sensitivity. AIMS: To further explore cross-organ pelvic sensitization we examined the association of dysmenorrhea, provoked bladder pain, and other putative factors with self-reported IBS-domain pain frequency and new onset after 1-year follow up. METHODS: We measured visceral pain sensitivity with a noninvasive provoked bladder pain test in a cohort of reproductive-aged women, enriched for those reporting moderate-to-severe menstrual pain intensity but without any prior IBS diagnosis (n = 190). We analyzed the relationship between menstrual pain, provoked bladder pain, pain catastrophizing, anxiety, and depression with primary outcomes: (1) frequency of self-reported IBS-domain pain and (2) new onset of IBS-domain pain after 1-year follow up. RESULTS: All hypothesized factors correlated with the frequency of IBS-domain pain (p's ≤ 0.038). In a cross-sectional model, only menstrual pain (standardized adjusted odds ratio 2.07), provoked bladder pain (1.49), and anxiety (1.90) were independently associated with IBS-domain pain ≥ 2 days/month (C statistic = 0.79). One year later, provoked bladder pain (3.12) was the only significant predictor of new onset IBS-domain pain (C statistic = 0.87). CONCLUSION: Increased visceral sensitivity among women with dysmenorrhea could lead to IBS. Because provoked bladder pain predicted subsequent IBS, prospective studies should be performed to see if the early treatment of visceral hypersensitivity mitigates IBS.

Development and validation of a real-time method characterizing spontaneous pain in women with dysmenorrhea.

AIM: Prior research has primarily focused on static pain assessment, largely ignoring the dynamic nature of pain over time. We used a novel assessment tool for characterizing pain duration, frequency, and amplitude in women with dysmenorrhea and evaluated how these metrics were affected by naproxen treatment. METHODS: Dysmenorrheic women (n = 25) rated their menstrual pain by squeezing a pressure bulb proportional to the magnitude of their pain. To evaluate whether bulb squeezing was affected by naproxen, we compared parameters before and after naproxen. We also analyzed the correlation between pain relief on a numerical rating scale to changes in bulb squeezing parameters. Random bulb-squeezing activity in pain-free participants (n = 14) was used as a control for nonspecific effects or bias. RESULTS: In dysmenorrheic women, naproxen reduced the duration of the squeezing during a painful bout, the number of painful bouts and bout intensity. Before naproxen, the correlation between these bulb squeeze parameters and self-reported pain on numeric rating scale was not significant (R2 = 0.12, p = 0.304); however, there was a significant correlation between changes in bulb squeeze activity and self-reported pain relief after naproxen (R2 = 0.55, p < 0.001). CONCLUSION: Our study demonstrates a convenient technique for continuous pain assessment, capturing three different dimensions: duration, frequency, and magnitude. Naproxen may act by reducing the duration and frequency of episodic pain in addition to reducing the severity. After further validation, these methods could be used for other pain conditions for deeper phenotyping and assessing novel treatments.

An analysis of fear inhibition and fear extinction in a sample of veterans with obstructive sleep apnea (OSA): Implications for co-morbidity with post-traumatic stress disorder (PTSD).

Obstructive sleep apnea (OSA) is a respiratory condition characterized by interrupted sleep due to repeated, temporary collapse of the soft tissue of the upper airway that can lead to a cascade of physiological and psychological adverse health outcomes. The most common therapeutic interventions for OSA patients include the application of continuous positive airway pressure (CPAP) which acts to keep the airway open and, as such, provides less interrupted and more restorative sleep. Improved sleep has been linked to more efficacious treatments for psychiatric conditions most notably those that include cognitive-behavioral elements, new learning, and memory consolidation. In the current study, we investigated the acquisition, inhibition, and extinction of conditioned fear in OSA patients, before and after CPAP therapy, using an established fear-potentiated startle paradigm. Patients with OSA displayed an intact ability to acquire, inhibit, and extinguish fear prior to CPAP treatment and this ability was significantly enhanced following CPAP usage. In addition, those patients with more severe OSA, as measured by apnea-hypopnea index (AHI), were more likely to show improved fear inhibition and extinction. Lastly, we observed impairments in discrimination between reinforced and nonreinforced conditioned stimuli, in the inhibition of fear, and in fear extinction in a subset of patients with OSA and co-morbid posttraumatic stress disorder (PTSD). These data suggest that evolving treatment algorithms for PTSD should address disrupted sleep problems prior to initiation of inhibition/extinction-based exposure therapies.

Wikipedia: A Medical Student Educational Project to Edit Wikipedia in Preparation for Practicing Evidence-Based Pain Medicine.

OBJECTIVE: Wikipedia is commonly used to acquire information about various medical conditions such as chronic pain. Ideally, better online pain management content could reduce the burden of opioid use disorders. Our goal was to improve the quality of the content available on Wikipedia to make it more accurate and applicable to medical students and the general public while training medical students to practice evidence-based medicine and critically assess their sources of information. METHODS: An elective class in Neuroscience, Pain, and Opioids composed of 10 medical students met biweekly to discuss landmark and practice-changing research articles in the fields of acute pain, chronic pain, and opioid management. The professor chose Wikipedia articles relevant to this course. Three independent viewers analyzed the quality of citations, anecdotal medical content, and content value for both patients and medical professionals. As part of their coursework, students then edited the Wikipedia articles. RESULTS: Although some of the Wikipedia pain topic content (6.7% ± 2.0) was anecdotal, financially biased, or inconsistent with Western Medical Practice content, overall articles included primarily high-quality citations (85.6% ± 3.1). On a 0-5 Likert scale, students felt content would be moderately helpful for both medical students/professionals (3.4 ± 0.2) and laypersons (3.5 ± 0.2). Editing and adding citations was feasible, but novel material was often reverted. CONCLUSION: A significant amount of pain medicine content was relevant and amenable to student editing. Therefore, future use of this tactic could provide a unique opportunity to integrate evidence-based medicine into the medical curriculum and have a direct impact on the widely available medical information. Future refinement in the editorial process may also further improve online information.

Increased Incidence of Villitis in Placentas Exposed to Chemotherapy During Pregnancy: Is There a Correlation?

We have identified 9 pregnant patients who were diagnosed with malignancy and initiated chemotherapy during their second trimester (cervical cancer [n = 3], leukemia [n = 3], breast cancer [n = 2], and Hodgkin's lymphoma [n = 1]). Five of the patients' placentas were small for gestational age (SGA). Pathologic examination revealed inflammatory changes in 4 of the placentas: 2 from the SGA placentas and 2 from non-SGA placentas. Examination revealed 3 placentas with villitis of unknown etiology (VUE) and 1 with intervillositis; all were negative for bacterial and viral cultures and by immunohistochemical (IHC) stains. In the VUE cases, IHC stains showed positivity of CD25+/FOXP3+ with focal positivity and CD3 and CD4 IHC were focally to strongly positive. Literature suggests that the use of chemotherapy during pregnancy can be detrimental to both the mother and the fetus; however, there has been limited focus on the effects of chemotherapy on the placenta. We suggest that the inflammatory process noted in the placentas is due to chemotherapy-induced toxic effects.

Four new cases of pediatric thoracic aortic aneurysm (TAA) with review of the molecular genetic basis, utilizing the newly published consensus nomenclature.

The majority of thoracic aortic aneurysms (TAA) in the pediatric population are due to post repair etiology (iatrogenic). Although rare, underlying inheritable disease and congenital cardiac anomalies represent the most common non-iatrogenic cause of TAA among patients in this age group (1-21 years of age). Herein, we present a case series of 9aortic aneurysms with varying underlying etiology. We discuss the molecular genetic basis of these syndromes in conjunction with the radiological findings and histological description utilizing the newly published consensus criteria article.

Primary Pediatric Breast Lesions: Comparing the Prevalence of Malignancies in the Middle East with North America; Review of 1031 Cases.

Benign breast masses are uncommon but are becoming more recognized among the pediatric population. Malignant breast lesions are very rare. The aim of our study was to review and compare the demographics, clinical presentation, treatment, and outcomes of breast lesions, including primary malignancies, and to discuss theories that may explain why there is an increased rate of breast cancers diagnosed at a younger age in the Egyptian population. A total of 1031 cases were reviewed. Comparisons were made between the Egyptian (n = 846) and US (n = 185) cohorts. There were 30 (3.5%) malignant tumors in the Egyptian group with 17 (2%) deaths versus 3 (1.6%) malignant tumors in the US group with 2 (1%) deaths (p = 0.247). The relative risk of breast cancer in the Egyptian group was 2.16 (95% confidence interval (CI): 0.67-7.01) compared with the US group. The trend for increased risk of breast cancer in Egypt may be due to delayed diagnosis because of decreased awareness.

Pediatric Meckel's Diverticulum: Report of 208 Cases and Review of the Literature.

We report a review of 208 cases of Meckel's diverticulum among pediatric patients from one single institution. One of the aims of this report is to highlight the different diagnostic modalities of Meckel's diverticulum since a majority of cases is undiagnosed prior to surgery. Our review shows 58 cases containing gastric and/or pancreatic heterotopic tissue, including two unique cases. The first case reported is a desmoid tumor arising at the tip of diverticulum, a case that, to our knowledge, has not been previously reported. The second case involves a female patient appearing with an acute abdomen thought to be appendicitis, instead surgery revealed a diverticulum arising from the ileum. The cause of acute abdomen was due to gonococcal infection. In conclusion, we hope that this large series of Meckel's cases will enrich our readers on the differential diagnosis and preoperative diagnostic techniques of Meckels' diverticulum.