54 research outputs found
âMedically unexplainedâ symptoms and symptom disorders in primary care: prognosis-based recognition and classification
Background: Many patients consult their GP because they experience bodily symptoms. In a substantial proportion of
cases, the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. This may be because
symptoms are recent and evolving or because symptoms are persistent but, either by their character or the negative
results of clinical investigation cannot be attributed to disease: so-called âmedically unexplained symptomsâ (MUS).
MUS are inconsistently recognised, diagnosed and managed in primary care. The specialist classification systems
for MUS pose several problems in a primary care setting. The systems generally require great certainty about
presence or absence of physical disease, they tend to be mind-body dualistic, and they view symptoms from a
narrow specialty determined perspective. We need a new classification of MUS in primary care; a classification
that better supports clinical decision-making, creates clearer communication and provides scientific underpinning
of research to ensure effective interventions.
Discussion: We propose a classification of symptoms that places greater emphasis on prognostic factors.
Prognosis-based classification aims to categorise the patientâs risk of ongoing symptoms, complications, increased
healthcare use or disability because of the symptoms. Current evidence suggests several factors which may be
used: symptom characteristics such as: number, multi-system pattern, frequency, severity. Other factors are:
concurrent mental disorders, psychological features and demographic data. We discuss how these characteristics may
be used to classify symptoms into three groups: self-limiting symptoms, recurrent and persistent symptoms, and
symptom disorders. The middle group is especially relevant in primary care; as these patients generally have reduced
quality of life but often go unrecognised and are at risk of iatrogenic harm. The presented characteristics do not
contain immediately obvious cut-points, and the assessment of prognosis depends on a combination of several factors.
Conclusion: Three criteria (multiple symptoms, multiple systems, multiple times) may support the classification into
good, intermediate and poor prognosis when dealing with symptoms in primary care. The proposed new classification
specifically targets the patient population in primary care and may provide a rational framework for decision-making in
clinical practice and for epidemiologic and clinical research of symptoms
Prostanoid receptor EP1 and Cox-2 in injured human nerves and a rat model of nerve injury: a time-course study
BACKGROUND: Recent studies show that inflammatory processes may contribute to neuropathic pain. Cyclooxygenase-2 (Cox-2) is an inducible enzyme responsible for production of prostanoids, which may sensitise sensory neurones via the EP1 receptor. We have recently reported that while macrophages infiltrate injured nerves within days of injury, they express increased Cox-2-immunoreactivity (Cox-2-IR) from 2 to 3 weeks after injury. We have now investigated the time course of EP1 and Cox-2 changes in injured human nerves and dorsal root ganglia (DRG), and the chronic constriction nerve injury (CCI) model in the rat. METHODS: Tissue sections were immunostained with specific antibodies to EP1, Cox-2, CD68 (human macrophage marker) or OX42 (rat microglial marker), and neurofilaments (NF), prior to image analysis, from the following: human brachial plexus nerves (21 to 196 days post-injury), painful neuromas (9 days to 12 years post-injury), avulsion injured DRG, control nerves and DRG, and rat CCI model tissues. EP1 and NF-immunoreactive nerve fibres were quantified by image analysis. RESULTS: EP1:NF ratio was significantly increased in human brachial plexus nerve fibres, both proximal and distal to injury, in comparison with uninjured nerves. Sensory neurones in injured human DRG showed a significant acute increase of EP1-IR intensity. While there was a rapid increase in EP1-fibres and CD-68 positive macrophages, Cox-2 increase was apparent later, but was persistent in human painful neuromas for years. A similar time-course of changes was found in the rat CCI model with the above markers, both in the injured nerves and ipsilateral dorsal spinal cord. CONCLUSION: Different stages of infiltration and activation of macrophages may be observed in the peripheral and central nervous system following peripheral nerve injury. EP1 receptor level increase in sensory neurones, and macrophage infiltration, appears to precede increased Cox-2 expression by macrophages. However, other methods for detecting Cox-2 levels and activity are required. EP1 antagonists may show therapeutic effects in acute and chronic neuropathic pain, in addition to inflammatory pain
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