Current management of breakthrough cancer pain according to physicians from pain units in Spain.

PURPOSE: Current evidence suggests the need to improve the management of breakthrough cancer pain (BTcP). For this reason, we aimed to assess the opinion of a panel of experts composed exclusively of physicians from pain units, who play a major role in BTcP diagnosis and treatment, regarding the key aspects of BTcP management. METHODS: An ad hoc questionnaire was developed to collect real-world data on the management of BTcP. The questionnaire had 5 parts: (a) organizational aspects of pain units (n = 12), (b) definition and diagnosis (n = 3), (c) screening (n = 3), (d) treatment (n = 8), and (e) follow-up (n = 7). RESULTS: A total of 89 pain-unit physicians from 13 different Spanish regions were polled. Most of them agreed on the traditional definition of BTcP (78.9%) and the key features of BTcP (92.1%). However, only 30.3% of participants used the Davies' algorithm for BTcP diagnosis. Respondents preferred to prescribe rapid-onset opioids [mean 77.0% (SD 26.7%)], and most recommended transmucosal fentanyl formulations as the first option for BTcP. There was also considerable agreement (77.5%) on the need for early follow-up (48-72 h) after treatment initiation. Finally, 65.2% of participants believed that more than 10% of their patients underused rapid-onset opioids. CONCLUSIONS: There was broad agreement among pain experts on many important areas of BTcP management, except for the diagnostic method. Pain-unit physicians suggest that rapid-onset opioids may be underused by BTcP patients in Spain, an important issue that need to be evaluated in future studies.

Quantitative Thermal Testing Profiles as a Predictor of Treatment Response to Topical Capsaicin in Patients with Localized Neuropathic Pain.

There are no reliable predictors of response to treatment with capsaicin. Given that capsaicin application causes heat sensation, differences in quantitative thermal testing (QTT) profiles may predict treatment response. The aim of this study was to determine whether different QTT profiles could predict treatment outcomes in patients with localized peripheral neuropathic pain (PeLNP). We obtained from medical records QTT results and treatment outcomes of 55 patients treated between 2010 and 2013. Warm sensation threshold (WST) and heat pain threshold (HPT) values were assessed at baseline at the treatment site and in the asymptomatic, contralateral area. Responders were defined as those who achieved a > 30% decrease in pain lasting > 30 days. Two distinct groups were identified based on differences in QTT profiles. Most patients (27/31; 87.1%) with a homogenous profile were nonresponders. By contrast, more than half of the patients (13/24, 54.2%) with a nonhomogenous profile were responders (p = 0.0028). A nonhomogenous QTT profile appears to be predictive of response to capsaicin. We hypothesize patients with a partial loss of cutaneous nerve fibers or receptors are more likely to respond. By contrast, when severe nerve damage or normal cutaneous sensations are present, the pain is likely due to central sensitization and thus not responsive to capsaicin. Prospective studies with larger patient samples are needed to confirm this hypothesis.

Revealing the nature of excitons in liquid exfoliated monolayer tungsten disulphide.

Transition metal dichalcogenides (TMD) hold promise for applications in novel optoelectronic devices. There is therefore a need for materials that can be obtained in large quantities and with well understood optical properties. In this report, we present thorough photoluminescence (PL) investigations of monolayer tungsten disulphide obtained via liquid phase exfoliation. As shown by microscopy studies, the exfoliated nanosheets have dimensions of tens of nanometers and thickness of 2.5 monolayers on average. The monolayer content is about 20%. Our studies show that at low temperature the PL is dominated by excitons localized on nanosheet edges. As a consequence, the PL is strongly sensitive to the environment and exhibits an enhanced splitting in magnetic field. As the temperature is increased, the excitons are thermally excited out of the defect states and the dominant transition is that of the negatively charged exciton. Furthermore, upon excitation with a circularly polarized light, the PL retains a degree of polarization reaching 50% and inherited from the valley polarized photoexcited excitons. The studies of PL dynamics reveal that the PL lifetime is on the order of 10 ps, which is probably limited by non-radiative processes. Our results underline the potential of liquid exfoliated TMD monolayers in large scale optoelectronic devices.

Eficacia y tolerancia de la pregabalina en el tratamiento del dolor neuropático. Estudio multicéntrico / No disponible

Introducción: Se pretendió evaluar la eficacia y tolerabilidad de la pregabalina, para el tratamiento del dolor neuropático en las Unidades de Dolor hospitalarias. Material y método: Estudio prospectivo, multicéntrico, abierto, que se llevó a cabo en 10 unidades del dolor de hospitales de Cataluña. Se prescribió pregabalina, a criterio del facultativo, de manera consecutiva. Criterios de inclusión: consentimiento, dolor neuropático, mayor de edad y paciente externo. Criterios de exclusión: alteraciones cognitivas, embarazo. Se estipularon 5 visitas: basal, 15 días, 1 mes, 2 y 3 meses de tratamiento. La titulación de las dosis de pregabalina estaba preespecificada. Se registró edad, sexo, tipo de dolor neuropático, EVA (basal, 15 días, 1 mes, 2 meses, 3 meses), escala MOS de sueño (basal y tercer mes), tratamiento farmacológico concomitante y episodios de efectos adversos. Se crearon 3 grupos de estudio: pregabalina + antiinflamatorios no esteroideos (AINE) + antidepresivos tricíclicos (AINE + ATC), pregabalina + AINE + ansiolíticos (AINE + ANS), pregabalina + AINE + opioides (AINE + OPI). Se efectuó prueba paramétrica t de Student y test no paramétrico de Wilcoxon para datos apareados de variables cuantitativas. Resultados: Se reclutaron 578 pacientes de los que 472 (81,66%) completaron el estudio. El 98,8% recibieron politerapia. El alivio del dolor registró una media de -3,6 (± 1,9) (p < 0,0001) puntos. Por tipo de dolor: mixto -3,7 (±1,7) (p < 0,0001); puro -3,4 (± 2,2) (p < 0,0001). Por medicación coadyuvante: grupo AINE + ATC -3,1 (± 1,9) (p = 0,0002); AINE + ANS -3,4 (± 2,0) (p < 0,0001); AINE + OPI -3,7 (± 1,9) (p < 0,0001). Mejora del sueño: media de -1,9 (± 6,4) (p < 0,0001) puntos. Por tipología: mixto -3,1 (± 7,0) (p < 0,0001); puro -1,1 (± 4,2) (p < 0,0001). Por medicación coadyuvante: grupo AINE + OPI -2,1 (± 6,0) (p < 0,0001); AINE + ATC y AINE + ANS ambos -1,0 no estadísticamente significativo, (p = 0,1250 y p = 0,4063 respectivamente). 90 pacientes (15,6%) discontinuaron el estudio debido a efectos adversos. Conclusiones: La pregabalina produjo una reducción rápida y significativa del dolor neuropático, una relevante mejoría del sueño, demostrando un perfil bajo de interacción y buena tolerancia (AU)

Aim and objective: This study was intended to avaluate the efficacy and tolerability of pregabalin in patients with neuropathic pain and concomitant medication. Material and methods: Investigator-initiated, prospective multicenter study, open-label, uncontrolled conducted in 10 pain units from Catalonia hospitals. Pregabalin was consecutively prescribed at the physicians’ discretion to avoid selective bias. Inclusion criteria were: outpatient, age >18 years, admission diagnosis as “neuropathic pain” and informed consent. Exclusion criteria were pregnancy or cognitive disorders. Protocol scheduled five study visits: at baseline, 15 days, 1 month, 2 months, and 3 months of treatment. Titration of pregabalin doses was pre-specified. We recorded: age, sex, type of neuropathic pain (pure or mixed), VAS (baseline, 15 days, 1 month, 2 and 3 months), MOS sleep scale (baseline and third month), concomitant drug treatment and adverse effects episodes. Patients were divided into three groups: pregabalin + NSAID + tricyclic antidepressants (NSAID+TCA), pregabalin + NSAID + anxiolytics (NSAID+ANX), pregabalin + NSAID + opioids (NSAID+OPI). A parametric Student’s t test and non-parametric Wilcoxon test for paired data of quantitative variables were performed. Results: 578 patients were recruited and 472 (81.66%) completed the study. 98.8% of patients were treated with politherapy. Pain relief: mean reduction by -3.6 (± 1.9) (p < 0.0001) points. By type of pain: mixed pain -3.7 (± 1.7) (p < 0.0001); pure neuropathic pain -3.4 (± 2.2) (p < 0.0001). By adjuvant medication, the NSAID + TCA group -3.1 (± 1.9) (p = 0.0002); NSAID + ANX -3.4 (± 2.0) (p < 0.0001); NSAID + OPI -3.7 (± 1.9) (p < 0.0001). Sleep improvement: mean reduction by -1.9 (± 6.4) (p < 0.0001) points. By type of pain: mixed pain -3.1 (± 7.0) (p < 0.0001); pure neuropathic pain -1.1 (± 4.2) (p < 0.0001). By adjuvant medication, NSAID+OPI -2.1 (± 6.0) (p < 0.0001); NSAID + TCA and NSAID + ANX groups both - 1.0 not statistically significant (p = 0.1250 and p = 0.4063 respectively). 90 patients (15.6%) discontinued the study due to adverse effects. Conclusions: Treatment with pregabalin induces a fast and significant relief of neuropathic pain, improves sleep and shows a low drug interaction profile (AU)

[Ultrasound-guided puncture: applications in a chronic pain clinic]. / La punción guiada con ultrasonidos aplicada a una unidad de dolor crónico.

Ultrasonography provides an excellent tool for the real-time visualization of peripheral nerve structures in regional anesthesia. Techniques are enhanced further when the progress of the needle and diffusion of the anesthetic can be observed. In a chronic pain clinic, ultrasound-guided puncture offers the advantages of accurate images of structures where pain arises: muscles, fascias, tendons, periostea, and joint structures. Visualization also helps the anesthetist to keep the needle away from structures (eg, the esophagus, pleura, vessels or peritoneum) that might lie near the target site. Unlike fluoroscopy, which produces radiation that is potentially dangerous for both patient and health care staff, ultrasound imaging is not harmful. Disadvantages are poor quality images of structures at a certain depth, acoustic shadows from bone structures that block the view of underlying tissues, and poor transport of ultrasound waves by air. Our aim is to describe a series of techniques for ultrasound-guided puncture and the results obtained on applying them weekly for 12 months in a chronic pain clinic.

La punción guiada con ultrasonidos aplicada a una unidad de dolor crónico / Ultrasound-guided puncture: applications in a chronic pain clinic

La ecografía en anestesia regional es una excelente herramienta para la visualización en tiempo real de las estructuras nerviosas periféricas. Además, el hecho de observar en tiempo real el avance de la aguja y la difusión del anestésico realza todavía más la excelencia de la técnica. La aplicación de la punción ecoguiada en una unidad de dolor crónico tiene un gran número de ventajas debido a que proporciona una correcta visualización de las estructuras generadoras de dolor como son músculos, fascias, tendones, periostio y estructuras articulares. Asimismo, la punción ecoguiada nos permite alejar la punta de la aguja de determinadas estructuras próximas al lugar o en el trayecto de punción como pueden ser el esófago, pleura, vasos y peritoneo. Por otra parte, los ultrasonidos no son nocivos a diferencia de la fluoroscopia que producen radiaciones potencialmente peligrosas tanto para el paciente como para el personal sanitario. Como desventajas destacan la menor calidad de imagen obtenida de las estructuras situadas a una determinada profundidad y el hecho de que las barreras óseas producen una sombra acústica que no permite la visualización de los tejidos situados por debajo, y el aire conduce deficientemente los ultrasonidos. Nuestro objetivo es ofrecer la descripción de una serie de técnicas de punción ecoguiada y los resultados obtenidos de su aplicación clínica en la actividad semanal realizada por el autor principal durante un periodo de 12 meses(AU)

Ultrasonography provides an excellent tool for the realtime visualization of peripheral nerve structures in regional anesthesia. Techniques are enhanced further when the progress of the needle and diffusion of the anesthetic can be observed. In a chronic pain clinic, ultrasound-guided puncture offers the advantages of accurate images of structures where pain arises: muscles, fascias, tendons, periostea, and joint structures. Visualization also helps the anesthetist to keep the needle away from structures (eg, the esophagus, pleura, vessels or peritoneum) that might lie near the target site. Unlike fluoroscopy, which produces radiation that is potentially dangerous for both patient and health care staff, ultrasound imaging is not harmful. Disadvantages are poor quality images of structures at a certain depth, acoustic shadows from bone structures that block the view of underlying tissues, and poor transport of ultrasound waves by air. Our aim is to describe a series of techniques for ultrasound-guided puncture and the results obtained on applying them weekly for 12 months in a chronic pain clinic(AU)

Aclaraciones a los comentarios sobre "Evaluación y manejo de la vía aérea difícil prevista y no prevista: adopción de guías de práctica" / No disponible

No disponible

Tratamiento psiquiátricos y creatividad / Psychiatric treatment and creativity

Planteamiento y objetivos: Las posibles relaciones entre creatividad y enfermedad mental no han sido explicadas satisfactoriamente. Por el contrario, en su investigación han surgido nuevas controversias. En el presente trabajo se analiza la influencia de la enfermedad mental y sus tratamientos en la creatividad artística. Para ello se ha realizado una revisión bibliográfica que incluye aportaciones literarias y estudios realizados al respecto. Conclusiones: Por el momento no se ha aclarado la influencia de los tratamientos psiquiátricos en la creatividad artística; no existen suficientes estudios y estos ofrecen resultados dispersos además de utilizar muestras reducidas. Ninguna investigación ha demostrado que los psicofármacos deterioren las capacidades creativas. Se proponen los nuevos antidepresivos, antipsicóticos y eutimizantes por su perfil de efectos adverso

Background, objetives and methodology: The study of the connections between creativity and mental illness has offered more questions than answers. A bibliographical research was performed in order to check the influences of psychiatric treatments in artistic creativity. Conclusions: The influences of psychiatric treatments on artistic creativity have not been explained successfully.There are not enough studies yet and their results are not quite reliable. The research shows psychiatric treatments have not been demonstrated to cause a decrease in creativity. New psychiatric drugs are proposed to be a better option because of their better side effects

Tratamiento farmacológico del trastorno por déficit de atención con hiperactividad / Drug treatment of attention deficit hyperactivity disorder

El trastorno por déficit de atención con hiperactividad (TDAH) es la patología psiquiátrica infantil que con más frecuencia se atiende en la práctica clínica, tanto por sus síntomas nucleares, como por la afectación de todos los ámbitos de la vida del niño. Aunque el tratamiento es multimodal, los fármacos constituyen un tratamiento fundamental. Dentro de ellos, los psicoestimulantes son los más utilizados por su eficacia y buena tolerabilidad. En una segunda línea se sitúan los antidepresivos y los agonista alfa-adrenégicos, utilizados cuando no han resultado efectivos los psiocoestimulantes o se dan ciertas circunstancias clínicas. La atomoxetina es un novedoso fármaco que se ha desarrollado específicamente para esta patología y que ofrece un buen perfil de eficacia con pocos efectos adversos. Otros fármacos están siendo estudiados para su uso en este trastorno y pueden abrir nuevas vías en el tratamiento farmacológico del TDAH

Attention deficit-hiperactivity disorder (ADHD) has become almost the major pathology in the field of child and adolescent clinical Psychiatry because of its prevalence and biographical impact. Although a multidimensional treatment is required, pharmacologic therapy represents the basic resource. The primary alternative are psychostimulants, shown as effective and well tolerated. Antidepressants and alpha adrenergic agonists are prescribed as a second option of treatment, suitable when stimulants do not work or in special clinical circumstances. Recent publications about atomoxetine, as a new medicament specifically developed for ADH, have assessed its safety and effectiveness. Investigation of pharmacological treatment of ADH keeps on, lately focused in different neurochemical mechanisms

[The incidence of intraoperative conciousness in emergency surgery and its possible relation to the post-traumatic stress syndrome. Presentation of three cases]. / Incidencia de conciencia intraoperatoria en cirugía urgente y su posible relación con el síndrome de estrés postraumático. A propósito de tres casos.

Intraoperative awakening and recall of specific events is a rare complication (0.2 to 1.3%) of surgery. The possibility of developing serious psychiatric complications, such as posttraumatic stress disorder (PTSD) makes the prevention and detection of intraoperative awareness a subject of special interest. We describe our experience with three patients in whom awareness was detected during emergency surgery under general anesthesia. We conducted two structured interviews with the patients three months after surgery in order to detect the possible development of psychiatric complications. One patient suffered insomnia and reexperience of the event during the first two weeks after surgery. Improvement was spontaneous. None of the patients suffered PTSD. Efforts to decrease the incidence of episodes of intraoperative awakening with specific recall must be based on clinical observation and exhaustive monitoring of the patient, including anesthetic gases, given that no ideal method of monitoring depth of anesthesia exists. Cases should be detected in the first few days after surgery by means of a specific test. Likewise, possible causes for the episode should be explained to the patient, who should be followed for six months so that early diagnosis of PTSD or other psychiatric complications can be made.

[Percutaneous femoro-porto-jugular venovenous shunt in orthotopic liver transplantation]. / Derivación venovenosa percutánea fémoro-porto-yugular en el trasplante ortotópico de hígado.

Veno-venous bypass (VVB) by the percutaneous introduction of cannulas in the right internal jugular vein during liver transplantation may reduce the complications derived from the classical method of axillary vein dissection. The results and complications observed over a two and a half year period in 126 consecutive patients submitted to liver transplantation in whom preparation for femoral-portal-jugular veno-venous bypass was carried out are reported. Twelve complications (9.5%) were observed in the 126 patients. All the complications were due to jugular cannulation and were divided as follows: in 7 patients (5.5%) some of the guide introductions were unsuccessful following multiple punctures; in 2 patients (1.6%) the right carotid artery was punctured; 2 hemothorax (1.6%) were observed and one pneumothorax (0.8%). Forty patients required veno-venous bypass. The blood flows obtained during VVB were suffice in all the cases with a mean +/- standard deviation of 2.21 +/- 0.44 l/min-1. The technique of femoral-portal-jugular veno-venous bypass is a good alternative to the classical method of the axillary approach. It has advantages such as in the speed of installation of VVB and the utility of the large jugular vein during the remainder of the surgery for rapid fluid transfusions. Although the number of complications is low, they may be important thereby hindering intra management and post operative of the patients.

Elevated exhaled nitric oxide in patients with hepatopulmonary syndrome.

The hypoxaemia of hepatopulmonary syndrome, seen in severe chronic liver dysfunction, occurs as a result of precapillary pulmonary arterial dilatation and arteriovenous communications. These abnormalities contribute to the mismatch between ventilation and perfusion, and the right to left blood flow shunting. Nitric oxide (NO) is a powerful vasodilator concerned with the regulation of pulmonary vascular tone in man. Using a chemiluminescence analyser, we have measured endogenously produced NO in the exhaled air of three patients with the hepatopulmonary syndrome, six normoxaemic cirrhotic patients and six healthy volunteers. The subjects breathed NO-free air throughout the measurements. The molar rate of production of exhaled NO was raised almost threefold in the patients with hepatopulmonary syndrome compared with normal volunteers and with normoxaemic cirrhotic patients. Hypoxia per se, achieved in the normal volunteers by breathing a hypoxic gas mixture, reduced rather than increased the exhaled NO. One hepatopulmonary syndrome patient received an orthotopic liver transplant and achieved normoxaemia after 3 months. The exhaled NO also returned to normal. Increased pulmonary production of NO could contribute to the development of the hepatopulmonary syndrome.

[Hepato-pulmonary syndrome: meta-analysis]. / Síndrome hepatopulmonar: metaanálisis.

INTRODUCTION AND OBJECTIVES: The clinical introduction of multiple elimination of inert gases (MEIG) has meant a qualitative advance in our understanding of the physiopathology of a wide range of pulmonary diseases. This meta-analysis aims to bring together data on patients with cirrhosis of the liver from 3 similar studies in which MEIG was used. PATIENTS AND METHODS: The results from 30 patients in 3 studies, divided into 2 groups based on baseline partial arterial O2 pressure (hypoxemic: PaO2 < 80 mmHg, n = 17; normal: PaO2 > or = 80 mmHg, n = 13) were subjected to statistical analysis. RESULTS: The hypoxemic group experienced an increase in the percentage of cardiac output perfusing regions of shunting (10.1 +/- 10 vs. 1.08 +/- 1.6%; p < 0.01) and low ventilation/perfusion relationships (16.3 +/- 10.3 vs. 3.5 +/- 5.8%; p < 0.01). We also observed greater dispersion in the distribution of perfusion (1.09 +/- 0.43 vs. 0.67 +/- 0.34; p < 0.01) and ventilation (0.62 +/- 0.14 vs. 0.49 +/- 0.13; p < 0.05), with the ventilation mean located in regions with higher ventilation/perfusion relationships (1.3 +/- 0.5 vs. 0.85 +/- 0.15; p < 0.01). The difference between observed and calculated PaO2 was significant in the hypoxemic group (7.3 +/- 5.5 vs. 1.2 +/- 1.3 mmHg; p < 0.01). CONCLUSIONS: Hypoxemia in patients with cirrhosis of the liver is mainly due to changes in ventilation/perfusion relationships and shunting. In the most hypoxemic patients, however, we cannot rule out a role for the causes of hypoxemia, such as diffusion changes.