Protracted Pain Research Articles

Radiotherapy for painful shoulder syndrome: aretrospective evaluation.

We evaluated the efficacy of low-dose radiotherapy for painful shoulder syndrome from an orthopedic perspective. Patients with painful shoulder syndrome were recruited for this retrospective clinical quality assessment from January 2011 to December 2017. Patients were treated with alinear accelerator or an orthovoltage device at individual doses of 0.5-1.0 Gy and total doses of 3.0-6.0 Gy. To assess response, we used the von Pannewitz score with five levels: "worsened," "unaffected," "improved," "significantly improved," and "symptom free." "Good treatment success" was defined as "significantly improved" and "symptom free." Within-group and between-group differences were statistically evaluated. Of 236 recruited patients (150 women, 86men; mean age66.3 [range 31-96] years), 180 patients underwent radiotherapy with alinear accelerator and 56with an orthovoltage device. Fractionation was 12 × 0.5 Gy in 120 patients, 6 × 0.5 Gy in 74, and 6 × 1 Gy in 42patients. Treatments were completed in one series for 223 and in two series at least 6weeks apart for 13patients. Of the 236 patients, 163 patients (69.1%) agreed to be re-interviewed at amedian of 10.5 (range 4-60) months after radiotherapy completion. Directly after radiotherapy, 30.9% (73patients) had "good treatment success," which had increased to 55.2% (90patients) at follow-up. Protracted pain improvement with low-dose radiotherapy is possible in painful shoulder syndrome. Patients with refractory pain because of subacromial syndrome or shoulder osteoarthritis should also be evaluated for radiotherapy.

Flourishing at the end of life

Flourishing is an increasingly common construct employed in the study of human wellbeing. But its appropriateness as a framework of wellbeing at certain stages of life is contested. In this paper, we consider to what extent it is possible for someone to flourish at the end of life. People with terminal illness often experience significant and protracted pain and suffering especially when they opt for treatments that prolong life. Certain aspects of human goods, however, that are plausibly constitutive of flourishing—such as meaning and purpose, deep personal relationships, and character and virtue—can be uniquely realised when life is ending. We argue that there is a qualified sense in which one can flourish at the end of life but that one must make important modifications to the criteria implicit in conventional conceptions of flourishing. We close with a discussion of the empirical assessment of wellbeing at the end of life and explore the possibility of introducing a flourishing measure in palliative care practice.

P15 Acupuncture treatment of Costochondritis, a case series

Introduction/BackgroundI had been practising acupuncture for 30 years and noticed while working in the rheumatology clinic that costochondritis had a particular response to acupuncture. As this condition is extremely debilitating and often misdiagnosed, a case series of 8 cases is presented, the majority of whom were seen in primary care.Description/MethodCostochondritis is characterised by anterior chest pain associated with painful tender costochondral (CC) joints felt on palpation. These mainly affect the 2nd to 5th costochondral junctions, either unilateral or bilateral. Other areas of the anterior and lateral chest wall can also be affected. The pain is often severe and nocturnal, of sudden onset and can be associated with shock, nausea and dyspnoea, causing patients to call for an ambulance. Tietze's syndrome is a rare variant of this, usually affecting younger patients.Patients with persistent chest wall pain were offered acupuncture. Details of age, duration of symptoms, number of treatments and VAS pain scores were recorded day and night, (Table 1) pre and post treatment Patients with thoracic pain were excluded.0.25*25mm and 0.25*30mm needles were used with silicon tips and a guide tube, to help prevent painful insertion. An infra-red lamp (Bio-lamp) was used + electro-acupuncture (EA) if insufficient improvement after two close treatments, sessions were continued weekly.Acupuncture points used were local tender/trigger points + distal Chinese points P6 and LI4. Other points used were CV 17, GB 34, SI6, GB39 or Sp 6 and St36. An average of 4.7 sessions were needed.Audit of Acupuncture Treatment Table 1P15 Table 1PATIENTAGEDURATION OFNUMBER OFVAS INITIAL (0-10)VAS FINALYEARSPROBLEMTREATMENTSDAYNIGHTDAYNIGHT1375 MTHS410100022618 MTHS8 (1 EA)5.57.5023653 WEEKS5 (+EA)79114584 DAYS4972256210 WEEKS7 (+EA)68026346 WEEKS447227289 MTHS314008255 YEARS38700Recurrence of pain3651 WEEK4 (+EA)88126345 WEEKS228227282 WEEKS11311Six patients took daily analgesia which was rapidly reduced to nil. All completed their treatment until their pain stabilised. There were no adverse events.Average improvement in the day was 89% and night 85%. Recurrences of pain improved by 11% in the day and 72% at night. The attacks of severe chest pain and dyspnoea stopped, abating anxiety.Discussion/ResultsCostochondritis is a highly debilitating condition and I had noticed that acupuncture could be a dramatic treatment for this[i]. It can affect up to a third of patients attending emergency departments with atypical chest pain[ii] and 1-3% of patients in primary care[iii].It seems to be a missed diagnosis by Accident and Emergency (A&E) doctors and GPs, perhaps because the chest wall was not carefully palpated. One patient had ankylosing spondylitis (AS) and another had systemic lupus erythematosus but attributed her pain to prolonged laughter. Five patients attended cardiology clinics including one who had a coronary angiogram. Another had tests for upper abdominal pain which also were normal.All the patients were female although quoted F:M ratio is 7:3Differential diagnoses include: acute coronary syndromes, lung problems, trauma, upper gastroenterology pathology or neoplasiaPathogenesis is unclear but the onset can be acute and follow:Respiratory tract infection Extreme sneezing, coughing or laughterChest wall trauma Micro trauma from costovertebral dysfunctionFibromyalgia Inflammation from inflammatory joint disease.[i] Alexander R; White A. Acupuncture in a Rheumatology Clinic. Acupuncture in Medicine; Dec 2000 vol.18 (no.2): 100-103[ii] Disla E; Rhim HR; Reddy A; Karten I; Taranta A. A prospective analysis in an emergency department setting. Arch Intern Med. 1994; 154(21):2466-2469[iii] Ayloo A; Cvengros T; Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care (Review) Dec 2013 40(4): 863-87Key learning points/ConclusionNormal management of costochondritis includes analgesia, physiotherapy, steroid injections and occasionally surgery[i]. 30% can have protracted pain. There are isolated reports of acupuncture for this condition, integrated with conventional medicine[ii] [iii]. Acupuncture also has been used for myofascial trigger points including costochondritis[iv].Acupuncture is now an accepted modality of pain management and in 2021 was recommended in NICE guidelines for the treatment of Chronic Primary Pain alongside exercise programmes and CBT ahead of analgesic medication[v]. It has also been recommended in the management of low back pain in patients aged 60 years and over as a non-drug treatment[vi].This paper highlights the fact that acupuncture appears to be a safe effective treatment for costochondritis, with further research and more access needed for this therapeutic modality.Increased awareness of this condition would make complex invasive investigations less necessary.[i] Gologorsky R; Hornik B; Velotta J. Surgical Management of Medically Refractory Tietze's Syndrome. Annals of Thoracic Surgery; Dec 2017; vol. 104 (no. 6)[ii] Jonkman FAM.; Jonkman-Buidin M.L; Stolwijk P.W.J. Surprise after successful treatment of a patient with noncardiac chest pain using acupuncture. Medical Acupuncture; Feb 2015; vol.27(no 1):83-90[iii] Lin, Katerina; Tung, Cynthia. Integrating Acupuncture for the Management of Costochondritis in Adolescents. Medical Acupuncture; Oct 2017; vol.29(no 5): 327-330[iv] Baldry P. Cardiac and non-cardiac chest wall pain. Acupuncture in Medicine;1997; vol.15(no.2): 42-45[v] NICE guideline; Chronic Pain (primary and secondary) in over 16s (NG 193 April 2021)[vi] Traeger A; Underwood M;Ivers R; Buchbinder R. Low back pain in people aged 60 years and over. BMJ 2022 vol. 376: e066928

Postoperative pain course after paediatric tonsillectomy: A prospective observational study comparing one behavioural and one numerical pain assessment tool

IntroductionPaediatric tonsillectomy is often performed as outpatient surgery, although postoperative pain may be severe and protracted. This prospective observational study evaluated two paediatric pain assessment tools for use in telephone interviews with parents. MethodsASA I-II children, ≥1 and < 13 years, undergoing outpatient tonsillectomy were recruited. Anaesthesia (propofol-remifentanil) and intraoperative analgesia were standardized. Sedating premedication was not given.Before discharge, a “smiley face” numerical pain assessment tool was introduced to parents. In telephone interviews on postoperative days 1, 3, 7 and 14, parents scored their childrens pain numerically (0–10) and on the behavioural Postoperative Pain Measure for Parents (PPMP, 0-15). Number of analgesic doses (paracetamol/ibuprofen) per 24 h was noted. Values are median (quartiles). Results22 consecutive children were included, age 4 (3–6) years. Parents had administered analgesics to 100%, 95%, 80%, and 5% of children at the four interview times. Numerical pain scores were 3.5 (1–7) at hospital discharge, and 5.5 (3–7), 3 (2–6), 3.5 (0–6), and 0 (0-0) on postoperative days 1, 3, 7, and 14, respectively. In 12/22 children, pain declined to a value of 1 (0–2) on day 7. In 6/22 children pain initially declined, but surged to 5.5 (4–7) on day 7. Significant, protracted pain (9 (6–10) on day 7) was reported in 3/22 children. Behavioural (PPMP) scores were positively correlated to numerical pain scores (day 3: R2 = 0.48, day 7: R2 = 0.31, day 14: R2 = 0.85). With increasing age, children systematically had lower behavioural pain scores for the same numerical pain score (0.61 per years age; p < 0.023). ConclusionIn structured telephone interviews, parents effectively pain scored their children after outpatient tonsillectomy. Numerical and behavioural pain scores correlated well, however age-dependent. Pain courses varied considerably, and a majority of children had significant pain. Pain after paediatric tonsillectomy should be assessed and treatment individualised.

Granulomatous Mastitis: Comparison of Novel Treatment of Steroid Injection and Current Management

BackgroundGranulomatous mastitis (GM) is a rare entity of benign origin. Multiple treatment strategies, including surgical procedures, can have sequelae of recurrence, nonhealing wounds, and protracted pain. Even after GM is diagnosed, the best management strategy remains controversial. We sought to evaluate intralesional steroid injection as a potential treatment for GM. Materials and methodsElectronic medical records from 2003 to 2017 of patients diagnosed with benign breast lesions were retrospectively reviewed. Patients with pathologically confirmed GM were identified. All treatment methods were documented, which included observation, oral steroids, methotrexate, steroid injection, and surgical excision. Primary outcome was time to resolution. Effectiveness was based on relief of symptoms along with duration of symptoms from initial time of diagnosis to full relief. Analysis of variance was used to compare outcomes between groups. ResultsOf the 49 patients with confirmed GM diagnoses, 57% had observation only, 24% had steroid injection, and 19% had surgical resection. The average time to resolution differed significantly among the three groups (11.5 mo from the start of observation, 2.0 mo from the time of steroid injection, and 0.5 mo from the time of surgical excision, P < 0.001). ConclusionsIntralesional steroid injection is an effective treatment of GM. Selective management is appropriate for patients with GM, and surgical resection is not required for most patients.

Francisella tularensis as the cause of protracted fever

BackgroundTularemia, a re-emerging, potential life threatening infectious disease, can present itself with nonspecific clinical symptoms including fever, chills and malaise. Taking a detailed history of exposure and a highly raised index of clinical suspicion are necessary to take the appropriate diagnostic and therapeutic steps in this setting. Here, a case report of typhoid tularaemia is presented.Case presentationA 53-year old male forester and farmer with protracted fever, abdominal pain, diarrhoea and loss of weight, who experienced productive cough and a pulmonary infiltrate later in the course of disease, was admitted for further investigation. Tularaemia was suspected only owing to history and confirmed by serologic testing more than three weeks after the beginning of the symptoms. The initial antibiotic therapy with ceftriaxone/doxycycline was switched to ciprofloxacin, resulting in the resolution of fever and symptoms.ConclusionTularaemia has to be considered as a differential diagnosis in febrile patients, even more in cases with protracted fever. Since tularaemia is expanding geographically, involving more animal hosts and causing larger outbreaks, clinicians have to be aware of this potentially fatal disease.

432 Post Procedural Pain Assessment in Patients Undergoing Balloon Cryotherapy Compared to Radiofrequency Ablation (RFA) for Barrett’s Esophagus: A Prospective Multi-Center Study

INTRODUCTION: The two most commonly used modalities for ablation of dysplastic Barrett’s Esophagus (BE) are radiofrequency ablation (RFA) and cryotherapy, wherein cryoballoon (CB) ablation has emerged as a highly effective new modality. A common side effect of ablation is pain, making it an important factor when discussing treatment options. It is speculated that CB causes less pain than RFA, as CB preserves the extracellular matrix while maintaining depth of ablation, but no head-to-head comparison trials exist to date. METHODS: We designed a multi-center, prospective cohort study with aims to compare pre- and post-procedural pain outcomes for CB versus RFA in ablation-naïve BE patients. IRB approval was obtained, and the study was registered on clinicaltrials.gov. Patient demographics; pre- and post-procedural pain scores and at 48 hrs, 1-week and 4 weeks using PQAS on a scale of 0-10; ablation procedure details; pain medication use; and any adverse events were collected in REDCap. Statistical analysis was performed with SAS 9.2 using the t test, chi-square test and the Fisher’s exact test. RESULTS: We enrolled 97 ablation-naïve dysplastic BE patients, of which 2 withdrew, leaving 95 for analysis (53 CB, 42 RFA). Baseline demographics and level of dysplasia were similar in both groups, with overall 79% males, and mean age 64.8 yrs. The number of patients using oral analgesics was similar between both groups, P = 0.459. Although there were more patients with pre-procedure pain in the CB group (8% vs 5%), the incidence of post procedure pain after RFA was significantly higher (79% vs 70%) compared to CB, and this difference persisted at 2 days (74% vs 60%), 1-week (59% vs 28%), and 4 weeks (14% vs 8%) post procedure, P = 0.0073 (Figure 1). The pattern of mean pain level was slightly different, with higher mean pain score pre- and post-procedure in the CB group (0.5 vs 0.2 and 3.6 vs 2.8) compared to RFA, but then reversed to be higher in the RFA group at 2 days (2.8 vs 2.2), 1-week (2.1 vs 0.9), and 4 weeks (0.6 vs 0.4), P = 0.0025 (Figure 2). CONCLUSION: Cryoballoon ablation is associated with significantly less post procedural pain when compared to RFA which appears to have a more protracted pain course and may have an impact on lifestyle resumption and follow up. Most patients have resolution of pain by 4 weeks irrespective of treatment modality. This first head-to-head study about post ablation pain between CB and RFA may help guide treatment discussions regarding post ablation expectations and recovery.

The Role of Hydrocolonic Sonography in Diagnostics of the Intussusceptions due to Neoplastic Process in Children

Introduction. A nonsurgical reduction is the treatment of choice for intestinal intussusception. A neoplasm-associated intussusception always requires surgery. In case of a tumour it is very important to have the diagnosis determined prior to surgical treatment. The hydrocolonic sonography technique makes it possible to assess the tissue structure and to visualize the lumen of the intestine.Materials and methods. The study presents a retrospective comparative analysis of clinical manifestations and diagnosis methods in all the patients with intussusception (n = 380) treated at the Arkhangelsk Children’sClinicalHospital in 1981–2018. This included all the neoplasm-associated intussusception cases (tumours and polyps). The data was compared to clinical manifestations of intussusception associated with other causes (idiopathic, mesenteric node hyperplasia, diverticulum).Results. Neoplasm-associated intussusception is a rare occurrence (2.3%). If the cause of the intussusception is a tumour the typical recorded manifestations include the combination of the signs of gastrointestinal diseases and loss of weight (8–12%), and a chronic course of development (over one to three months). Polyp-associated small intestinal and ileocolic intussusception, a casuistically rare situation, first manifested as an acute intestinal obstruction with protracted abdominal pain syndrome in anamnesis, or recurrent intussusceptions. Traditional and hydrocolonic sonography made it possible to make the diagnosis of intussusception and to identify a tumour. Non-tumour-associated intussusception presented with an acute course of the disease in every case. It manifested with the typical triad of symptoms (abdominal colic pain, rectal haemorrhage, palpable intussusceptum mass) in every third case. The manifestation of the disease as the dyad of symptoms (vomiting and abdominal colic pain) was significantly more frequent (p = 0.001).Conclusions. Clinical presentation of neoplasm-associated intussusception has certain unique qualities. The ultrasound of abdominal cavity and hydrocolonic sonography make it possible to find the intussusception and to identify the tumour or polyp in the structure of the intussusceptum in 100 % of cases at primary examination. The data obtained is used for the optimisation of the surgical treatment strategy.

Prediction of outliers in pain, analgesia requirement, and recovery of function after childbirth: a prospective observational cohort study

BackgroundPrediction models to identify parturients who experience protracted pain, prolonged opioid use, and delayed self-assessed functional recovery are currently inadequate. MethodsFor this study, 213 nulliparous women who planned vaginal delivery were enrolled and assessed daily until they completed three outcomes: (1) pain resolution; (2) opioid cessation; and (3) self-assessed functional recovery to predelivery level. The primary composite endpoint, ‘pain and opioid-free functional recovery’ was the time required to reach all three endpoints. The subjects were divided into two categories (the worst (longest time) 20% and remaining 80%) for reaching the primary composite endpoint, and each individual component. Prediction models for prolonged recovery were constructed using multivariate logistic regression with demographic, obstetric, psychological, and health-related quality of life characteristics as candidate predictors. ResultsLabour induction (vs spontaneous labour onset) predicted the worst 20% for the primary composite endpoint in the final multivariate model. Labour induction and higher postpartum day 1 numerical rating score for pain were predictors for being in the worst 20% for both functional recovery and pain burden. Labour type, delivery type, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety score, RAND 36 Item Health Survey 1.0 (SF-36) physical health composite score, and postpartum breastfeeding success were predictive of delayed opioid cessation. ConclusionsLabour induction and elevated numerical rating score for pain are predictive of poor recovery after childbirth. Further research is necessary to determine whether modification would benefit mothers at risk for poor recovery.

Initially intact neural responses to pain in autism are diminished during sustained pain.

Pain assessments typically depend on self-report of the pain experience. Yet, in individuals with autism spectrum disorders, this can be an unreliable due to communication difficulties. Importantly, observations of behavioral hypo- and hyperresponsivity to pain suggest altered pain sensitivity in autism spectrum disorder. Neuroimaging may provide insight into mechanisms underlying pain behaviors. The neural pain signature reliably responds to painful stimulation and is modulated by other outside regions, affecting the pain experience. In this first functional magnetic resonance imaging study of pain in autism spectrum disorder, we investigated neural responses to pain in 15 adults with autism spectrum disorder relative to a typical comparison group (n = 16). We explored temporal and spatial properties of the neural pain signature and its modulators during sustained heat pain. The two groups had indistinguishable pain ratings and neural pain signature responses during acute pain; yet, we observed strikingly reduced neural pain signature response in autism spectrum disorder during sustained pain and after stimulus offset. The posterior cingulate cortex, a neural pain signature modulating region, mirrored this late signal reduction in autism spectrum disorder. Intact early responses, followed by diminished late responses to sustained pain, may reflect altered pain coping or evaluation in autism spectrum disorder. Evidence of a dichotomous neural response to initial versus protracted pain may clarify the coexistence of both hypo- and hyperresponsiveness to pain in autism spectrum disorder.

Life with an unwelcome guest - caring in a context of protracted bodily pain.

Protracted bodily pain is a phenomenon that often affects a human being's whole life. Care of human beings with protracted pain is challenging because pain is not always measureable, and the experiences of pain are subjective, unique and shapeshifting. Therefore, the aim is to highlight what protracted bodily pain signifies for the human being, and human beings' experiences of what is caring in a context of protracted bodily pain. Four informants with protracted bodily pain took part in a focus group interview. The interview was analysed by using a qualitative content analysis with a hermeneutic approach. The findings show that protracted pain renders human beings speechless, limits and robs them of their lives. The pain is described as a domineering, unpleasant and unwelcome guest. The pain can change the human being's personality and creates feelings of guilt. Uncertainty about the origin of the pain as well as a nonchalant treatment or not being believed intensifies the pain. Human being experience mastering the pain, encounters with caregivers who can ease the burden, community with others and finding that little something extra in everyday life is experienced as caring. From a caring science perspective, the relation between protracted pain and suffering is obvious. Suffering emerges as illness suffering, as life suffering and as suffering caused by care. Professional as well as natural caring is important in a context of protracted bodily pain. The human being longs to encounter caregivers who are courageous enough to lay themselves on the line. Community with people who are prepared to share the burden eases the heavy burden that pain brings to life, it brings hope and relief.

Acute Compartment Syndrome Following Fulkerson Surgical Technique in Patellofemoral Instability

Patellofemoral instability affects mostly young and active people. Patients present with Episodes of mechanical instability of the patella and anterior knee pain. Surgery can address both bony and soft-tissue components; however, no gold standard exists in the literature for surgical treatment. Fulkerson osteotomy technique for surgical repair was employed in this case, which resulted in immediate acute compartment syndrome for this patient. Acute compartment syndrome is an emergent condition requiring immediate surgical attention. This article assesses a case of acute compartment syndrome following Fulkerson osteotomy for anteromedial tibial tubercle transfer surgery in Patellofemoral syndrome involving a 19-year-old female. Resultant compartment syndrome following a Fulkerson technique surgery is rare in literature. This is a case of protracted pain, paresthesia, and paralysis through multiple surgical interventions and rehabilitation designed to preserve her lower limb due to the resultant acute compartment syndrome. This patient’s history is significantly unique in the literature and is reported here for study regarding occurrence and in preventing future potential surgical complications in similar patients.

Evidence for Sustained Mechanical Pain Sensitization in Women With Chronic Temporomandibular Disorder Versus Healthy Female Participants

Generalized dysfunction of the nociceptive system has been hypothesized to be an important pathophysiologic process underlying temporomandibular disorder (TMD) pain. Studies have not identified sensitization to painful stimuli administered prospectively across consecutive days among participants with TMD with chronic pain. We attempted to isolate an empirically derived laboratory-based marker of sustained mechanical pain sensitization. We examined whether this index accounted for variance in prospective assessments of clinical TMD pain. Participants were women with a clinical diagnosis of chronic TMD (n = 30) and healthy female controls (n = 30). Pain thresholds were assessed using digital algometry 4 times at 12-hour intervals over 48 consecutive hours and clinical TMD pain via follow-up telephone assessments. Sustained mechanical pain sensitization, defined by statistically significant linear decrements in pressure pain thresholds across the consecutive testing sessions, discriminated chronic TMD and control participants. An index of sustained sensitization at the masseter accounted for unique variance in clinical TMD pain over the subsequent 3-month assessment period, even controlling for mean pain threshold and baseline pain severity. These preliminary findings highlight discriminant and predictive validity characteristics of a novel marker of protracted pain sensitization among women with chronic TMD pain. PerspectiveA laboratory-based and empirically defined marker of sustained mechanical pain sensitization over the course of days with acceptable discriminant and predictive validity was identified. This marker may represent a clinically useful marker of chronic TMD pain in women.

出血による急激な下肢痛悪化を認めた腰椎synovial cystの1例

出血による急激な下肢痛悪化を認めた腰椎synovial cystの1例

Transformation of Acute Cancer Pain to Chronic Cancer Pain Syndromes

For many cancer survivors, disease-related long-term morbidities and the application of advanced cancer treatments have resulted in the development of a chronic pain state. This brief review explores the relationship between what is known about the treatment of active cancer pain syndromes-both continuous pain and breakthrough pain-and persisting pain syndromes in cancer survivors. We also posit that because there is evidence to suggest that poorly treated acute pain can lead to protracted pain conditions, acute pain should be recognized and treated promptly, both for short- and long-term gain. In the short term, better acute pain treatment can improve functionality and psychological well-being, whereas in the long term, mounting evidence suggests that it could prevent of future chronic pain.

A break in the glomerular basement membrane in Churg–Strauss syndrome

Breaks in the glomerular basement membrane (GBM) have been focused on as a significant contributor to the leakage of fibrin and/or fibrinoid material into the Bowman’s space, thereby accelerating crescent formation in various types of glomerular disease [1]. We would like to show our serendipitous finding of a break in the GBM discovered during routine diagnostic transmission electron microscopy in a 52-year-old male patient presenting with Churg–Strauss syndrome (CSS). He was admitted to our hospital due to a protracted fever, fatigue, and muscle pain of the extremities that had lasted 2 months. More than two decades prior to admission, he was found to have bronchial asthma, for which he had received sporadic medical care including the administration of montelukast, a leukotriene receptor antagonist (LTRA). Laboratory analysis revealed a white blood cell count of 8700/ll with 8.9% eosinophils, serum creatinine of 1.01 mg/dl, and serum immunoglobulin (Ig) E of 6531 mg/dl. An increase in the titer of anti-myeloperoxidase anti-neutrophil cytoplasmic antibody (MPOANCA) of 12.1 U/ml (the positive cut-off value is 9.0 U/ml), but not in anti-proteinase 3 ANCA or anti-GBM antibodies, was also found. His urine demonstrated microscopic hematuria with red blood cell casts, and contained 0.2 g of protein in a 24 h specimen. The renal biopsy consisted of renal parenchyma with thirty-three glomeruli, five of which were globally sclerotic. The presence of cellular crescents with focal segmental necrotizing lesions was confirmed in seven of the remaining glomeruli (Fig. 1a). A granulomatous lesion associated with eosinophil infiltration was confirmed around the interlobular artery (Fig. 1b). Of note, transmission electron microscopy demonstrated a break in the GBM associated with fibrin and platelet extravasation in Bowman’s space; however, no evidence of immune complex deposition was confirmed (Fig. 1c). Consequently, he was diagnosed to have CSS, and intravenous methylprednisolone at a dose of 500 mg/day was given for three consecutive days, followed by oral administration of prednisolone at 30 mg/day. His clinical course was uneventful, and the prednisolone dose was gradually tapered. A potential association between LTRA and CSS has been proposed in several reports, while there is no information available regarding the casual impact of LTRA on the development of MPO-ANCA among patients with CSS [2]. Therefore, the pathogenesis of CSS with MPO-ANCA in the current case should be evaluated carefully. Nevertheless, it is reasonable to consider that MPO-ANCA might act by modifying in a subset of patients with CSS, and contribute directly to the development of glomerular injuries. Indeed, it has been reported that the association of ANCA positivity with a clinical phenotype including inflammation, necrosis of small vessels, and crescentic K. Iwazu T. Akimoto (&) E. Kusano Division of Nephrology, Department of Internal Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: tetsu-a@jichi.ac.jp

Parasympathetic Nervous Activity Mirrors Recovery Status in Weightlifting Performance After Training

Heart rate variability (HRV) and parasympathetic power are closely related to the well-being and health status in humans. The main goal of the study was to determine whether these measures can reflect recovery status after weight training. After a 10-day detraining period, 7 weightlifters were challenged with a 2-hour weight training which elicited approximately fourfold increases in circulating muscle creatine kinase level and protracted pain feeling (p < 0.05). Weightlifting performance was then evaluated 3, 24, 48, and 72 hours after training to determine the degree of recovery from fatigue. Heart rate variability, circulating dehydroepiandrostendione sulfate (DHEA-S), and muscle damage markers were measured before each performance test. An electrocardiogram was recorded for 5 minutes continuously at rest in seated positions. After training, weightlifting performance of the subjects decreased below baseline in paralleled with suppressed parasympathetic power (high-frequency [HF] HRV), whereas sympathetic power (normalized low-frequency HRV) was slightly elevated at 3 hours of recovery (p < 0.05). Both weightlifting performances and parasympathetic power returned to baseline values in 24 hours and further increased above baseline during 48-72 hours of recovery in a similar fashion (p < 0.05). Circulating DHEA-S level dropped at 24 hours (p < 0.05) and returned to normal values by 48 hours. Muscle pain increased at 3 hours after training and remained higher than baseline values for the 72-hour recovery period (p < 0.05). Our data suggest that parasympathetic power, indicated by HF HRV, is able to reflect the recovery status of weightlifters after training.

251: What is the Need for Integration of Palliative Care in the Emergency Department?

Implementation of palliative care services has become widespread across the country. Palliative care consultation (PCC) provides 1) expertise in symptom management; 2) initiation of discussions regarding goals of care; and 3) hospice care assessment for patients at the end of life. These patients often use the emergency department (ED) for care, yet PCCs are not routinely identified and/or offered by ED staff. The Institute of Medicine 2006 report found that limited access to palliative care services in the ED could result in protracted pain and suffering and delays in diagnosis and treatment. We hypothesize that integration of PCC in the ED may improve quality of care and reduce ED crowding.

Paediatric Pain Management: Using Complementary and Alternative Medicine.

Children undergo acute painful procedures and many also experience chronic pain.Due to their developing systems, infants and children may be at greater risk than adults for protracted pain sensitivity.There is a need to manage acute and chronic paediatric pain to reduce children's suffering and to prevent future pain problems.Consistent with a biopsychosocial perspective, complementary and alternative medicine (CAM) should be considered in management of acute and chronic paediatric pain.Although research is limited for paediatric pain, CAM interventions receiving the most empirical attention include hypnotherapy, acupuncture and music therapy. Evidence also exists for the therapeutic benefits of yoga, massage, humor therapy and the use of certain biological based therapies.

Dysfonctions du système nerveux sympathique dans la fibromyalgie

Abnormal activity of the sympathetic nervous system is involved in the pathogenesis of protracted pain syndromes. The term sympathetically maintained pain is applied to those neuropathic pain cases that respond to sympatholytic maneuvers. The sympathetically maintained pain concept has strong and ample foundations in the animal model. After nerve injury, sympathetic sprouting at the dorsal root ganglia becomes apparent and form basket-like structures around large-diameter axotomized sensory neurons; sympathetic stimulation can activate such neurons repetitively. This article discusses the relationship between sympathetic dysfunction and chronic pain syndromes, the animal models of sympathetically maintained pain and novel clinical instruments that assess autonomic function. This article also reviews the evidence proposing that fibromyalgia is a sympathetically maintained, neuropathic pain syndrome and finally it discusses therapies that improve resting autonomic tone as well as FM symptoms.