End-stage reflex sympathetic dystrophy

Reflex sympathetic dystrophy is an automatic dysfunction that occasionally complicates healing after trauma or surgery. The syndrome is characterized by pain, swelling, stiffness, and discoloration often out of proportion to the original injury. Early diagnosis and appropriate treatment are the most important factors in the successful outcome of this disabling condition. A case of longstanding, previously untreated reflex sympathetic dystrophy secondary to a minor injury is presented.     

Anaphylactic reaction to penicillin O

Although normally the sympathetic nerves aid vascular dilatation during effort, in certain diseases of the vascular system they have a reverse effect. Abolition of sympathetic vasoconstrictive impulses by sympathectomy is the most effective treatment in some chronic peripheral vascular conditions. The authors have used electrocoagulation for a number of years and found it quick, effective and more likely to prevent regeneration of the affected nerves. Improvement was obtained by sympathectomy in arteriosclerotic vascular insufficiency, thromboangiitis obliterans, Raynaud's disease, reflex sympathetic dystrophy following thrombophlebitis or trauma, scleroderma, spinal sympathetic dystrophy and acquired megacolon. A case of causalgia was aggravated by the operation. Abstention from the use of tobacco appears to be sufficient for control of symptoms in many cases. Since vasospasm is manifested in many conditions long before a thrombotic catastrophe occurs, not only relief of symptoms but prevention of irreversible changes may be achieved by early operation.     

Anaphylactic Reaction to Penicillin O

Although normally the sympathetic nerves aid vascular dilatation during effort, in certain diseases of the vascular system they have a reverse effect. Abolition of sympathetic vasoconstrictive impulses by sympathectomy is the most effective treatment in some chronic peripheral vascular conditions. The authors have used electrocoagulation for a number of years and found it quick, effective and more likely to prevent regeneration of the affected nerves.Improvement was obtained by sympathectomy in arteriosclerotic vascular insufficiency, thromboangiitis obliterans, Raynaud''s disease, reflex sympathetic dystrophy following thrombophlebitis or trauma, scleroderma, spinal sympathetic dystrophy and acquired megacolon. A case of causalgia was aggravated by the operation.Abstention from the use of tobacco appears to be sufficient for control of symptoms in many cases.Since vasospasm is manifested in many conditions long before a thrombotic catastrophe occurs, not only relief of symptoms but prevention of irreversible changes may be achieved by early operation.     

Psychological stress and fibromyalgia: a review of the evidence suggesting a neuroendocrine link

The present review attempts to reconcile the dichotomy that exists in the literature in relation to fibromyalgia, in that it is considered either a somatic response to psychological stress or a distinct organically based syndrome. Specifically, the hypothesis explored is that the link between chronic stress and the subsequent development of fibromyalgia can be explained by one or more abnormalities in neuroendocrine function. There are several such abnormalities recognised that both occur as a result of chronic stress and are observed in fibromyalgia. Whether such abnormalities have an aetiologic role remains uncertain but should be testable by well-designed prospective studies.     

Causalgic form of postphlebitic syndrome. A variety of reflex sympathetic dystrophy caused by acute deep thrombophlebitis.

The causalgic form of the postphlebitic syndrome or reflex sympathetic dystrophy resulting from acute deep thrombophlebitis is a relatively uncommon and, unfortunately, frequently unrecognized form of the postphlebitic syndrome. The usual signs of venous insufficiency are minimal, but severe burning pain is characteristic, usually increased by dependency. The diagnosis is confirmed by phlebography and the response to a lumbar sympathetic block. A lumbar sympathectomy produces permanent pain relief.     

The use of temperature biofeedback in the treatment of chronic pain due to causalgia.

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5 degrees C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.     

Heterogeneity of psychophysiological stress responses in fibromyalgia syndrome patients

Dysregulated psychophysiological responses have been observed in patients with fibromyalgia syndrome (FMS), although the results are inconsistent. Surface electromyographic (EMG), systolic and diastolic blood pressure, heart rate (HR), and skin conductance levels (SCLs) were continuously recorded at baseline, and during a series of stress and relaxation tasks in 90 FMS patients and 30 age and sex matched healthy controls (HCs). The patient sample demonstrated lower baseline EMG levels compared to the HCs on all tasks. In contrast, the patients displayed elevated HR and SCL (sympathetic vasomotor and sudomotor indices, respectively) during both stress tasks. A cluster analysis identified four psychophysiological response patterns: 63.3% of HCs showed increased muscle tension and stable cardiovascular responses; 34.8% of FMS patients showed a pattern of increased sympathetic vasomotor reactivity with stable sudomotor and reduced muscular response; 12.2% of FMS patients showed a pattern of increased sympathetic sudomotor reactivity connected with increased sympathetic vasomotor response and reduced muscular response; and, in contrast, 46.7% of FMS patients showed a pattern of parasympathetic vasomotor reactivity and reduced sudomotor as well as muscular response. The identification of low baseline muscle tension in FMS is discrepant with other chronic pain syndromes and suggests that unique psychophysiological features may be associated with FMS. The different psychophysiological response patterns within the patient sample support the heterogeneity of FMS.     

Heterogeneity of psychophysiological stress responses in fibromyalgia syndrome patients

Dysregulated psychophysiological responses have been observed in patients with fibromyalgia syndrome (FMS), although the results are inconsistent. Surface electromyographic (EMG), systolic and diastolic blood pressure, heart rate (HR), and skin conductance levels (SCLs) were continuously recorded at baseline, and during a series of stress and relaxation tasks in 90 FMS patients and 30 age and sex matched healthy controls (HCs). The patient sample demonstrated lower baseline EMG levels compared to the HCs on all tasks. In contrast, the patients displayed elevated HR and SCL (sympathetic vasomotor and sudomotor indices, respectively) during both stress tasks. A cluster analysis identified four psychophysiological response patterns: 63.3% of HCs showed increased muscle tension and stable cardiovascular responses; 34.8% of FMS patients showed a pattern of increased sympathetic vasomotor reactivity with stable sudomotor and reduced muscular response; 12.2% of FMS patients showed a pattern of increased sympathetic sudomotor reactivity connected with increased sympathetic vasomotor response and reduced muscular response; and, in contrast, 46.7% of FMS patients showed a pattern of parasympathetic vasomotor reactivity and reduced sudomotor as well as muscular response. The identification of low baseline muscle tension in FMS is discrepant with other chronic pain syndromes and suggests that unique psychophysiological features may be associated with FMS. The different psychophysiological response patterns within the patient sample support the heterogeneity of FMS.     

Catechol-O-methyltransferase gene haplotypes in Mexican and Spanish patients with fibromyalgia

Autonomic dysfunction is frequent in patients with fibromyalgia (FM). Heart rate variability analyses have demonstrated signs of ongoing sympathetic hyperactivity. Catecholamines are sympathetic neurotransmitters. Catechol-O-methyltransferase (COMT), an enzyme, is the major catecholamine-clearing pathway. There are several single-nucleotide polymorphisms (SNPs) in the COMT gene associated with the different catecholamine-clearing abilities of the COMT enzyme. These SNPs are in linkage disequilibrium and segregate as 'haplotypes'. Healthy females with a particular COMT gene haplotype (ACCG) producing a defective enzyme are more sensitive to painful stimuli. The objective of our study was to define whether women with FM, from two different countries (Mexico and Spain), have the COMT gene haplotypes that have been previously associated with greater sensitivity to pain. All the individuals in the study were female. Fifty-seven Mexican patients and 78 Spanish patients were compared with their respective healthy control groups. All participants filled out the Fibromyalgia Impact Questionnaire (FIQ). Six COMT SNPs (rs2097903, rs6269, rs4633, rs4818, rs4680, and rs165599) were genotyped from peripheral blood DNA. In Spanish patients, there was a significant association between three SNPs (rs6269, rs4818, and rs4680) and the presence of FM when compared with healthy controls. Moreover, in Spanish patients with the 'high pain sensitivity' haplotype (ACCG), the disease, as assessed by the FIQ, was more severe. By contrast, Mexican patients displayed only a weak association between rs6269 and rs165599, and some FIQ subscales. In our group of Spanish patients, there was an association between FM and the COMT haplotype previously associated with high pain sensitivity. This association was not observed in Mexican patients. Studies with a larger sample size are needed in order to verify or amend these preliminary results.     

Treatment of lower extremity reflex sympathetic dystrophy with continuous intrathecal morphine infusion

Continuous intrathecal morphine infusion has been used in 3 patients with refractory lower extremity reflex sympathetic dystrophy syndromes. Two patients have experienced prolonged significant benefit.     

The use of temperature biofeedback in the treatment of chronic pain due to causalgia

A patient with chronic pain due to a reflex sympathetic dystrophy in his hand and arm was successfully treated with temperature biofeedback after several months of conservative standard medical care brought little relief. Over the 18 treatment sessions the patient learned to emit a reliable handwarming response of 1 to 1.5°C. Coincident with his learning, the pain in his hand and arm decreased markedly and remained absent at 1-year follow-up.The author wishes to acknowledge the assistance of Dr. Kit S. Mays and the staff of the Pain Clinic of the University of Tennessee Center for the Health Sciences.     

Rupture of Descemet's membrane secondary to presumed forceps trauma

Ruptures in Descemet's membrane can occur secondary to forceps injury at birth, prolonged labor, blunt trauma, keratoconus, and congenital glaucoma as well as other less frequent causes. The rupture initially causes acute comeal hydrops which resolves within weeks to leave permanent linear thickening of Descemet's membrane. It is important to differentiate Descemet's rupture from other entities like syphilitic interstitial keratitis, posterior polymorphous dystrophy and congenital hereditary endothelial dystrophy which may have a similar clinical presentation. Although treatment is rarely required, proper diagnosis is important to prevent unnecessary referrals and provide appropriate counseling. This case report examines a 66-year-old female with Descemet's rupture secondary to presumed forceps trauma at birth. Discussion of clinical presentation, differential diagnosis and clinical management are presented.     

Satellite cell depletion in degenerative skeletal muscle

Adult skeletal muscle has the striking ability to repair and regenerate itself after injury. This would not be possible without satellite cells, a subpopulation of cells existing at the margin of the myofiber. Under most conditions, satellite cells are quiescent, but they are activated in response to trauma, enabling them to guide skeletal muscle regeneration. In degenerative skeletal muscle states, including motor nerve denervation, advanced age, atrophy secondary to deconditioning or immobilization, and Duchenne muscular dystrophy, satellite cell numbers and proliferative potential significantly decrease, contributing to a diminution of skeletal muscle's regenerative capacity and contractility. This review will highlight the fate of satellite cells in several degenerative conditions involving skeletal muscle, and will attempt to gauge the relative contributions of apoptosis, senescence, impaired proliferative potential, and host factors to satellite cell dysfunction.     

Role of intracellular calcium ions in the physiopathology of fibromyalgia syndrome.

Calcium ions have a key role in the physiology of muscular contraction: changes in calcium ion concentration may be involved in the pathogenesis of fibromyalgia. Although, since the plasmatic level of calcium in fibromyalgia patients is always in the normal range, it seemed interesting to evaluate the intracellular calcium concentration. The study was carried out on two groups of subjects: 70 affected by fibromyalgia and 40 healthy controls. The results obtained show that in fibromyalgia patients the intracellular calcium concentration is significantly reduced in comparison to that of healthy controls: the reduced intracellular calcium concentration seems to be a peculiar characteristic of fibromyalgia patients and may be potentially responsible for muscular hypertonus. The effective role of this anomaly in the physiopathology of fibromyalgia and the potential role of drugs active on the calcium homeostasis are still to be confirmed.     

Effect of hyperbaric oxygenation on several functional and morphologic properties of the heart and catecholamine metabolism in the presence of compensatory myocardial hypertrophy]

Rabbits subjected to hyperbaric oxygenation (HBO) for one month following ascending aorta stenosis developed less distinct hypertrophy and signs of myocardial dystrophy with a more distinct enhancement of the left ventricular contractility than animals with aortic stenosis kept under normal pressure. In rabbits with heart hypertrophy developing under HBO the increasing adaptive capacity of the myocardium was accompanied by an elevation in functional reserve of the sympathetic regulation apparatus. Apparently HBO aided the development of the optimum cardiac adaptation to a high afterload.     

Biology and therapy of fibromyalgia. New therapies in fibromyalgia

Fibromyalgia is a chronic, musculoskeletal pain condition that predominately affects women. Although fibromyalgia is common and associated with substantial morbidity and disability, there are no US Food and Drug Administration-approved treatments. However, progress has been made in identifying pharmacological and non-pharmacological treatments for fibromyalgia. Recent pharmacological treatment studies have focused on selective serotonin and norepinephrine reuptake inhibitors, which enhance serotonin and norepinephrine neurotransmission in the descending pain pathways and lack many of the adverse side effects associated with tricyclic medications. Promising results have also been reported for medications that bind to the α₂δ subunit of voltage-gated calcium channels, resulting in decreased calcium influx at nerve terminals and subsequent reduction in the release of several neurotransmitters thought to play a role in pain processing. There is also evidence to support exercise, cognitive behavioral therapy, education, and social support in the management of fibromyalgia. It is likely that many patients would benefit from combinations of pharmacological and non-pharmacological treatments, but more study is needed.     

One hundred years ago: A medical minister in Russia

ObjectivesTo evaluate cardiovascular fitness exercise in people with fibromyalgia.DesignRandomised controlled trial.SettingHospital rheumatology outpatients. Group based classes took place at a “healthy living centre.”Participants132 patients with fibromyalgia.InterventionsPrescribed graded aerobic exercise (active treatment) and relaxation and flexibility (control treatment).ResultsCompared with relaxation exercise led to significantly more participants rating themselves as much or very much better at three months: 24/69 (35%) v 12/67 (18%), P=0.03. Benefits were maintained or improved at one year follow up when fewer participants in the exercise group fulfilled the criteria for fibromyalgia (31/69 v 44/67, P=0.01). People in the exercise group also had greater reductions in tender point counts (4.2 v 2.0, P=0.02) and in scores on the fibromyalgia impact questionnaire (4.0 v 0.6, P=0.07).ConclusionsPrescribed graded aerobic exercise is a simple, cheap, effective, and potentially widely available treatment for fibromyalgia.

What is already known on this topic

Fibromyalgia is common debilitating medically unexplained condition affecting around 1% of the populationCurrent treatments are unsatisfactory and most people remain the same after several years of treatmentExercise as a treatment given by healthcare professionals in highly specialised centres is of some short term benefit

What this study adds

For people with fibromyalgia prescribed graded aerobic exercise is an effective treatment that leads to improvements in self reported health statusPrescribed exercise can be undertaken effectively in the community by personal trainers previously inexperienced in management of people with ill health     

Studies on the regulation of beta-nerve growth factor gene expression in the rat iris: the level of mRNA-encoding nerve growth factor is increased in irises placed in explant cultures in vitro, but not in irises deprived of sensory or sympathetic innervation in vivo

Beta-nerve growth factor (NGF) is a protein necessary for the survival and maintenance of sympathetic and sensory neurons that appears to be produced by the target tissues of these neurons in vivo. Both denervation and the culture of explants of one model target, the rat iris, leads to an increase in the NGF content, suggesting that innervating neurons may regulate a step in synthesis or turnover of NGF. To determine whether there is a change in synthesis controlled at the mRNA level, the rat iris has been assayed for its content of NGF mRNA after surgical and chemical denervation and after explant into culture. Using a sensitive blot hybridization assay, a large, rapid increase in the content of NGF mRNA was observed upon explant of the rat iris. The increase was readily detectable within 1 h, reached a maximum increase of 10- to 20-fold by 6 to 12 h, and was still evident after 3 d in culture. The distribution of NGF mRNA in different areas of the iris does not change during this time. This rapid increase in NGF mRNA is also seen in the fully innervated iris in vivo after trauma to the anterior chamber. In contrast, denervation to varying degrees in situ had no effect on NGF mRNA levels. Neither removal of sympathetic innervation by surgical or chemical methods nor combined surgical removal of sympathetic and sensory innervation detectably altered NGF mRNA content. Thus, denervation of the rat iris in situ does not cause the observed accumulation of NGF by increasing the level of NGF mRNA, and the increase in NGF content must be due to other factors.     

Molecular basis of myotonic dystrophy: expansion of a trinucleotide (CTG) repeat at the 3' end of a transcript encoding a protein kinase family member.

Using positional cloning strategies, we have identified a CTG triplet repeat that undergoes expansion in myotonic dystrophy patients. This sequence is highly variable in the normal population. PCR analysis of the interval containing this repeat indicates that unaffected individuals have been 5 and 27 copies. Myotonic dystrophy patients who are minimally affected have at least 50 repeats, while more severely affected patients have expansion of the repeat containing segment up to several kilobase pairs. The CTG repeat is transcribed and is located in the 3' untranslated region of an mRNA that is expressed in tissues affected by myotonic dystrophy. This mRNA encodes a polypeptide that is a member of the protein kinase family.