Morphine-induced hallucinations - resolution with switching to oxycodone: a case report and review of the literature

Palliation of pain with morphine in cancer patients can be complicated by adverse effects. Tolerance to these effects such as nausea and drowsiness usually occurs within a few days allowing continuation of morphine therapy. However, some patients may develop intolerable adverse effects even after several months on morphine when the dose is increased. A case of morphine-induced hallucinations in a cancer patient who had been on a subcutaneous infusion of diamorphine for several months is discussed. A switch to oxycodone resolved his hallucinations and gave him a new lease of life. The theories behind and evidence for opioid-switching is discussed along with strategies for dealing with intolerable opioid-induced adverse effects

Whole-exome and HLA sequencing in Febrile infection-related epilepsy syndrome

Febrile infection‐related epilepsy syndrome (FIRES) is a devastating epilepsy characterized by new‐onset refractory status epilepticus with a prior febrile infection. We performed exome sequencing in 50 individuals with FIRES, including 27 patient–parent trios and 23 single probands, none of whom had pathogenic variants in established genes for epilepsies or neurodevelopmental disorders. We also performed HLA sequencing in 29 individuals with FIRES and 529 controls, which failed to identify prominent HLA alleles. The genetic architecture of FIRES is substantially different from other developmental and epileptic encephalopathies, and the underlying etiology remains elusive, requiring novel approaches to identify the underlying causative factors

High Precision Femtosecond Laser Ablation ICP‐MS Measurement of Benthic Foraminiferal Mn‐Incorporation for Paleoenvironmental Reconstruction: A Case Study From the Plio‐Pleistocene Caribbean Sea

Closure of the Central American Seaway (CAS) and hydrology of the Caribbean Sea triggered Northern Hemisphere Glaciation and played an important role in the Pliocene to modern-day climate re-establishing the deep and surface ocean currents. New data on Mn/Ca obtained with femtosecond laser ablation inductively coupled plasma mass spectrometry on well-preserved tests of the epibenthic foraminifer Cibicidoides wuellerstorfi and infaunal C. mundulus contribute to the interpretation of paleoenvironmental conditions of the Caribbean Sea between 5.2 and 2.2 Ma (million years) across the closure of the CAS. Hydrothermal activity at the Lesser Antilles may be a primary source of Mn in the well-oxygenated Plio-Pleistocene Caribbean Sea. Incorporation of Mn in the benthic foraminifer shell carbonate is assumed to be affected by surface ocean nutrient cycling, and may hence be an indicator of paleoproductivity. Key Points - Femtosecond-laser ablation inductively coupled plasma mass spectrometry provides a new approach on distinguishing Mn of the ontogenetic shell calcite from Mn of the authigenic coatings - Ontogenetic Mn within the foraminifer shell calcite may result from the regional nutrient cycle - Mn in the deep eastern Caribbean Sea may mainly derive from hydrothermal sources along the Antilles Island Ar

Trace Metals and Their Isotopes in the Tropical Atlantic Ocean - Cruise No. M81/1, February 04 – March 08, 2010, Las Palmas (Canary Islands, Spain) – Port of Spain (Trinidad & Tobago)

Summary Meteor Cruise M81/1 was dedicated to the investigation of the distribution of dissolved and particulate trace metals and their isotopic compositions (TEIs) in the full water column of the tropical Atlantic Ocean and their driving factors including main external inputs and internal cycling and ocean circulation. The research program is embedded in the international GEOTRACES program (e.g. Henderson et al., 2007), which this cruise was an official part of and thus corresponds to GEOTRACES cruise GA11. This cruise was completely dedicated to the trace metal clean and contamination-free sampling of waters and particulates for subsequent analyses of the TEIs in the home laboratories of the national and international participants. Besides a standard rosette for the less contaminant prone metals, trace metal clean sampling was realized by using a dedicated and coated trace metal clean rosette equipped with Teflon-coated GO-FLO bottles operated via a polyester coated cable from a mobile winch that was thankfully made available by the U.S. partners of the GEOTRACES program for this cruise. The particulate samples were also collected under trace metal clean conditions using established in-situ pump systems. The cruise track led the cruise southward from the Canary Islands to 11°S and then continued northwestward along the northern margin of South America until it reached Port of Spain, Trinidad & Tobago. The track crossed areas of major external inputs including exchange with the volcanic Canary Islands, the Saharan dust plume, as well as the plume of the Amazon outflow. In terms of internal cycling the equatorial high biological productivity band, as well as increased productivity associated with the Amazon Plume were covered. All major water masses contributing the Atlantic Meridional Overturning Circulation, as well as the distinct narrow equatorial surface and subsurface east-west current bands were sampled. A total of 17 deep stations were sampled for the different dissolved TEIs, which were in most cases accompanied by particulate sampling. In addition, surface waters were continuously sampled under trace metal clean conditions using a towed fish

A modified score to identify and discriminate neuropathic pain: a study on the German version of the neuropathic pain symptom inventory (NPSI)

<p>Abstract</p> <p>Background</p> <p>Neuropathic pain must be correctly diagnosed for optimal treatment. The questionnaire named Neuropathic Pain Symptom Inventory (NPSI) was developed in its original French version to evaluate the different symptoms of neuropathic pain. We hypothesized that the NPSI might also be used to differentiate neuropathic from non-neuropathic pain.</p> <p>Methods</p> <p>We translated the NPSI into German using a standard forward-backward translation and administered it in a case-control design to patients with neuropathic (n = 68) and non-neuropathic pain (headache and osteoarthritis, n = 169) to validate it and to analyze its discriminant properties, its sensitivity to change, and to detect neuropathic pain subgroups with distinct profiles.</p> <p>Results</p> <p>Using a sum score (the NPSI-G score), we found sensitivity to change (r between 0.37 and 0.5 for pain items of the graded chronic pain scale) and could distinguish between neuropathic and other pain on a group basis, but not for individual patients. Post hoc development of a discriminant score with optimized diagnostic properties to distinguish neuropathic pain from non-neuropathic pain resulted in an instrument with high sensitivity (91%) and acceptable specificity (70%). We detected six different pain profiles in the patient group with neuropathic pain; three profiles were found to be distinct.</p> <p>Conclusions</p> <p>The NPSI-G potentially combines the properties of a diagnostic tool and an instrument to identify subtypes of neuropathic pain.</p

Complex regional pain syndrome 1 – the Swiss cohort study

BACKGROUND: Little is known about the course of Complex Regional Pain Syndrome 1 and potential factors influencing the course of this disorder over time. The goal of this study is a) to set up a database with patients suffering from suspected CRPS 1 in an initial stadium, b) to perform investigations on epidemiology, diagnosis, prognosis, and socioeconomics within the database and c) to develop a prognostic risk assessment tool for patients with CRPS 1 taking into account symptomatology and specific therapies. METHODS/DESIGN: Prospective cohort study. Patients suffering from a painful swelling of the hand or foot which appeared within 8 weeks after a trauma or a surgery and which cannot be explained by conditions that would otherwise account for the degree of pain and dysfunction will be included. In accordance with the recommendations of International Classification of Functioning, Disability and Health (ICF model), standardised and validated questionnaires will be used. Patients will be monitored over a period of 2 years at 6 scheduled visits (0 and 6 weeks, 3, 6, 12, and 24 months). Each visit involves a physical examination, registration of therapeutic interventions, and completion of the various study questionnaires. Outcomes involve changes in health status, quality of life and costs/utility. DISCUSSION: This paper describes the rationale and design of patients with CRPS 1. Ideally, potential risk factors may be identified at an early stage in order to initiate an early and adequate treatment in patients with increased risk for delayed recovery

Derangement of body representation in complex regional pain syndrome: report of a case treated with mirror and prisms

Perhaps the most intriguing disorders of body representation are those that are not due to primary disease of brain tissue. Strange and sometimes painful phantom limb sensations can result from loss of afference to the brain; and Complex Regional Pain Syndrome (CRPS)—the subject of the current report—can follow limb trauma without pathology of either the central or peripheral nervous system. This enigmatic and vexing condition follows relatively minor trauma, and can result in enduring misery and a useless limb. It manifests as severe pain, autonomic dysfunction, motor disability and ‘neglect-like’ symptoms with distorted body representation. For this special issue on body representation we describe the case of a patient suffering from CRPS, including symptoms suggesting a distorted representation of the affected limb. We report contrasting effects of mirror box therapy, as well as a new treatment—prism adaptation therapy—that provided sustained pain relief and reduced disability. The benefits were contingent upon adapting with the affected limb. Other novel observations suggest that: (1) pain may be a consequence, not the cause, of a disturbance of body representation that gives rise to the syndrome; (2) immobilisation, not pain, may precipitate this reorganisation of somatomotor circuits in susceptible individuals; and (3) limitation of voluntary movement is neither due to pain nor to weakness but, rather, to derangement of body representation which renders certain postures from the repertoire of hand movements inaccessible

The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology

Small fibre neuropathy (SFN), a condition dominated by neuropathic pain, is frequently encountered in clinical practise either as prevalent manifestation of more diffuse neuropathy or distinct nosologic entity. Aetiology of SFN includes pre-diabetes status and immune-mediated diseases, though it remains frequently unknown. Due to their physiologic characteristics, small nerve fibres cannot be investigated by routine electrophysiological tests, making the diagnosis particularly difficult. Quantitative sensory testing (QST) to assess the psychophysical thresholds for cold and warm sensations and skin biopsy with quantification of somatic intraepidermal nerve fibres (IENF) have been used to determine the damage to small nerve fibres. Nevertheless, the diagnostic criteria for SFN have not been defined yet and a ‘gold standard’ for clinical practise and research is not available. We screened 486 patients referred to our institutions and collected 124 patients with sensory neuropathy. Among them, we identified 67 patients with pure SFN using a new diagnostic ‘gold standard’, based on the presence of at least two abnormal results at clinical, QST and skin biopsy examination. The diagnosis of SFN was achieved by abnormal clinical and skin biopsy findings in 43.3% of patients, abnormal skin biopsy and QST findings in 37.3% of patients, abnormal clinical and QST findings in 11.9% of patients, whereas 7.5% patients had abnormal results at all the examinations. Skin biopsy showed a diagnostic efficiency of 88.4%, clinical examination of 54.6% and QST of 46.9%. Receiver operating characteristic curve analysis confirmed the significantly higher performance of skin biopsy comparing with QST. However, we found a significant inverse correlation between IENF density and both cold and warm thresholds at the leg. Clinical examination revealed pinprick and thermal hypoesthesia in about 50% patients, and signs of peripheral vascular autonomic dysfunction in about 70% of patients. Spontaneous pain dominated the clinical picture in most SFN patients. Neuropathic pain intensity was more severe in patients with SFN than in patients with large or mixed fibre neuropathy, but there was no significant correlation with IENF density. The aetiology of SFN was initially unknown in 41.8% of patients and at 2-year follow-up a potential cause could be determined in 25% of them. Over the same period, 13% of SFN patients showed the involvement of large nerve fibres, whereas in 45.6% of them the clinical picture did not change. Spontaneous remission of neuropathic pain occurred in 10.9% of SFN patients, while it worsened in 30.4% of them

A Novel Tool for the Assessment of Pain: Validation in Low Back Pain

Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain

Same task rules, different responses:Goal neglect, stimulus-response mapping and response modalities

To complete complex tasks, individuals must actively maintain task rules to direct behavior correctly. Failure to use task rules appropriately, termed goal neglect, has been shown across both vocal and manual response modalities. However, previous goal maintenance studies have differed not only in the response modality that they require, but also in the complexity of the stimulus–response mappings that participants must use during the task. The present study examines the effects of both response modality and stimulus–response mapping complexity, separately, on the rate of goal neglect in a modification of a classic goal maintenance task. Seventy-two younger adults were administered a shape-monitoring task, with three between-subjects response conditions: a vocal response with a simple stimulus–response mapping, a vocal response with a complex stimulus–response mapping, and a manual response with a complex stimulus–response mapping. Contrasting the rate at which task rules were neglected between response conditions showed that participants using complex stimulus–response mappings committed more frequent goal neglect than those using simple mappings, but that participants using vocal or manual responses did not differ in their rate of goal neglect once both responses required complex mappings. This suggests that the need to represent novel and complex stimulus–response mappings, of any modality, at the same time as novel task rules within working memory leads to some task rules being insufficiently maintained