A painful encounter with the weever (Echiichtis vipera)

The National Poisons Information Centre of the National Institute of Public Health and the Environment in the Netherlands in the past 2 years received dozens of requests for information about intoxication due to stings of the weever, Echiichtis vipera. The venomous apparatus of the weever consists of gill cover spines and 5 to 8 dorsal fin spines. The fish buries itself in the sandy or muddy bottom of the sea to wait for prey. The mixture of toxins that enters the skin upon contact with the spines causes a heavy local reaction, characterized mostly by pain, which untreated persists for 24 hours. An erythematous oedema may develop locally, spread over the entire extremity and persist for days. Systemic reactions are rare. Since the toxin mixture is heat labile, treatment is essentially simple: clean the wound and immerse the affected limb as soon as possible in warm water (45 degrees C) for 30 to 90 minutes. This makes the pain disappear.     

A novel muscle sodium channel mutation causes painful congenital myotonia

Mutations in the skeletal muscle voltage-gated sodium channel alpha-subunit gene (SCN4A) have been associated with a spectrum of inherited nondystrophic myotonias and periodic paralyses. Most disease-associated SCN4A alleles occur in portions of the gene that encode the third and fourth repeat domains with the conspicuous absence of mutations in domain 1. Here we describe a family segregating an unusual autosomal dominant congenital myotonia associated with debilitating pain especially severe in the intercostal muscles. A novel SCN4A mutation causing the replacement of Val445 in the sixth transmembrane segment of domain 1 with methionine was discovered in all affected individuals and is the likely genetic basis for the syndrome. Myotonia was resistant to treatment; however, the most severely affected family member responded dramatically to the sodium channel blocking agent flecainide.     

Is the reexperience of painful emotion therapeutic?

Recently, a great deal of attention has been focused on the health promoting benefits that can accrue from revisiting painful emotion. The rationales for revisiting painful emotions include those that assume reexperiencing emotion per se can be health-promoting. Another view stipulates that revisiting painful emotion will only yield benefit if there is some recasting/restructuring of the emotional memory. Research pertinent to the various rationales is discussed. Then research on the impact of emotional expression and outcomes studies of therapies designed to enhance emotional experience are reviewed. Good supporting evidence is found for the effectiveness of behavioral exposure therapies where the duration of emotional exposure is carefully controlled, as well as for the salutary impact of talking or writing about trauma by normally functioning individuals. On the other hand, studies evaluating the impact of experiencing and expressing painful emotion in an unstructured fashion with clinical samples suggest that the process can be harmful. Incorporating findings from the behavioral exposure literature and from the Pennebaker writing-about-trauma studies, the case for evoking emotional memories for the purpose of developing new responses is advanced. The dangers of encouraging emotional experience in absence of acquisition of a new response to the emotion-evoking material are discussed.     

Desmoid tumor of the thoracic wall. A case manifesting as painful stiffness of the shoulder

BACKGROUND: Desmoid tumors are uncommon fibromatous tumors arising from musculoaponeurotic tissue characterized by spindle cell fibroblast and myofibroblast proliferation. The cause is unknown (trauma, hormonal factors, genetic anomaly...). Locally invasive, they tend to recur increasing morbidity or even mortality. CASE REPORT: Stiff shoulder resulting from blockage of the scapulothoracic articulation was the inaugural sign. Three-phase bone scintigraphy demonstrated early uptake in the soft tissue in contact with the scapula. Magnetic resonance imaging and biopsy confirmed the diagnosis of desmoid tumor. Complete resection was performed. No adjuvant radiotherapy nor hormone treatment were given since no antiestrogen receptor antibodies were identified on the surgical specimen. DISCUSSION: The clinical manifestation (stiff shoulder) and the scapular localization observed in this case are unusual for desmoid tumors. Initially tendinopathy of the shoulder, acromio-clavicular arthropathy and capsular retraction of the shoulder joint had been entertained. Early diagnosis and wide surgical resection are indicated in desmoid tumors.     

The painful bipartite patella

Two skeletally immature patients with bipartite patella, a lesion normally classified as a developmental variation, proved to have a symptomatic lesion with a traumatic etiology. In both patients, appropriate treatment resulted in complete subsidence of symptoms; one patient was treated with cast immobilization, while the other eventually required surgical resection. In addition, normal and bipartite patellar specimens from skeletally immature cadavers were histologically and morphologically assessed. These clinical and anatomic studies suggest that in some cases a bipartite patella may be a traumatically induced, chondroosseous disruption of the superolateral pole of the incompletely ossified patella, analogous to Sinding-Larsen-Johansson disease at the inferior patellar pole or Osgood-Schlatter disease in the tibial tuberosity. The possibility of bipartite patella being such a chronic stress fracture in a symptomatic patient should be considered in order to render appropriate treatment.     

Mexiletine. A review of its therapeutic use in painful diabetic neuropathy

Mexiletine is an orally active local anaesthetic agent which is structurally related to lidocaine (lignocaine) and has been used for alleviating neuropathic pain of various origins. Mexiletine has been evaluated in several randomised, placebo-controlled trials in patients with painful diabetic neuropathy. The drug decreased mean visual analogue scale (VAS) pain ratings in all studies that used this measure, although in only 2 studies was this effect significantly greater than the often substantial responses seen with placebo. The clinical significance of these decreases is not clear. Statistically significant (vs placebo) reductions in VAS pain ratings were observed in 16 patients receiving mexiletine 10 mg/kg/day for 10 weeks in 1 study and in nocturnal (but not diurnal) pain in 31 patients receiving mexiletine 675 mg/day for 3 weeks in another. Retrospective analysis of another study revealed that mexiletine recipients (225 to 675 mg/day) who described their pain as stabbing, burning or formication on the pain-rating-index-total instrument of the McGill Pain Questionnaire, experienced statistically significant reductions in VAS pain scores after 5 weeks, compared with placebo recipients. Mexiletine generally did not have a significant influence on the quality of sleep in patients with diabetic neuropathy. In Japanese patients, statistically significant reductions in subjective pain ratings were achieved with mexiletine 300 mg/day in 1 study and with 450 mg/day in a further study. In controlled trials, the frequency of adverse events in patients receiving mexiletine for painful diabetic neuropathy ranged from 13.5 to 50%. Gastrointestinal complaints, of which nausea was the most frequent, were the most common adverse events in mexiletine recipients. Central nervous system complaints were uncommon, but included: sleep disturbance, headache, shakiness, dizziness and tiredness. Serious cardiac arrhythmias have not been reported in patients receiving mexiletine for painful diabetic neuropathy; however, transient tachycardia and palpitations have been reported. There are significant differences in the metabolism of mexiletine between people who have cytochrome P450 2D6 [CYP2D6; extensive metabolisers (EMs)] and those who lack this isoenzyme [poor metabolisers (PMs)]. EMs, but not PMs, are susceptible to drug interactions between mexiletine and drugs that inhibit CYP2D6 (e.g. quinidine). Moreover, mexiletine inhibits CYP2D6-mediated metabolism of metoprolol and cytochrome P450 1A2-mediated metabolism of theophylline. Phenytoin and rifampicin (rifampin) induce the metabolism of mexiletine. Clearance of mexiletine is impaired in patients with hepatic, but not renal, dysfunction. Hence, dosage adjustments may be necessary in patients with liver disease. CONCLUSIONS: Tricyclic antidepressants (TCAs) are the agents of choice for painful diabetic neuropathy; however, they are ineffective in approximately 50% of patients and are generally not well tolerated. Mexiletine is an alternative agent for the treatment of painful diabetic neuropathy in patients who have not had a satisfactory response to, or cannot tolerate, TCAs and/or other drugs.     

The painful reality of street children

CT, MRI and contrast angiography of 20 patients with 21 developmental venous anomalies (DVAs), so-called venous angiomas, were compared with magnetic resonance angiography employing a two-dimensional time-of-flight technique (2D-MRA). MRA was diagnostic in 17 DVAs, when both the primary 2D slices and the maximum-intensity-projection images were read. Contrast angiography still provides the best visualization of both DVA components: dilated medullary veins and transcerebral draining vein; however, it is an invasive procedure and delivers no information about brain parenchyma. We regard MRI as necessary in cases with a suspected DVA because of the high rate of association with cavernomas: 33% in this study. Acute neurological symptoms were caused by haemorrhage from an associated cavernoma and not from the DVA in 4 such cases. Thus MRA combined with MRI obviates angiography in most cases and offers a noninvasive diagnostic strategy adequate for DVAs.     

Anterior-inferior capsular length insufficiency in the painful shoulder

BACKGROUND: Haemophilus influenzae type b (Hib) conjugate vaccines have demonstrated an impressive impact in diminishing Hib disease in industrialized countries. However, their high cost prompts nonindustrialized countries to corroborate their effectiveness under local conditions before considering their programmatic implementation. Such a postlicensure evaluation of vaccine effectiveness was undertaken in Chile. METHODS: After its licensure in Chile polyribosylribitol phosphate-tetanus toxoid protein conjugate vaccine (PRP-T), combined with diphtheria-tetanus-pertussis vaccine, was introduced into the Expanded Program on Immunization schedules in 36 health centers throughout metropolitan Santiago for 12 months, whereas 35 similar health centers administered only diphtheria-tetanus toxoid-pertussis vaccine. Bacteriologic surveillance data for invasive Hib cases collected over the ensuing 30 months were analyzed. RESULTS: In an intent-to-vaccinate (effectiveness) analysis, PRP-T provided 90.2% protection (95% confidence interval, 74.5 to 100%) against invasive Hib disease (40 vs. 4 cases, P < 0.001). Vaccine effectiveness was 91.3% against meningitis (22 vs. 2 cases) and 80% against pneumonia and empyema (10 vs. 2 cases, P = 0.039). Vaccine efficacy among infants who received all three doses of PRP-T was 91.7% (95% confidence interval, 64.8 to 100%). CONCLUSIONS: Programmatic use of Hib conjugate vaccine administered in combination with diphtheria-tetanus-pertussis vaccine constitutes a highly effective and practical intervention in Chile, a newly industrializing country.     

Ultrasonography in the management of painful hips in children

It has been suggested that nitric oxide could be implicated in the pathogenesis of Alzheimer's disease (AD). Recently Kuiper et al. reported decreased CSF nitrate levels (oxidation product that provides an indirect estimation of nitric oxide) in AD patients, assessed with a colorimetric method. However other group, using a microplate version of the Griess reaction, did not confirm these findings. We studied the CSF and plasma levels of nitrate with kinetic cadmium-reduction method in 32 AD patients and 36 matched controls. The CSF and plasma nitrate levels did not differ significantly between the two study groups. CSF and plasma nitrate levels did not correlate with age at onset and duration in the patient group. These data suggest that CSF and plasma levels of nitrate are apparently unrelated with the risk for AD.     

Talonavicular arthrodesis for the painful adult acquired flatfoot

Twenty-seven consecutive patients with posterior tibial tendon insufficiency were treated with talonavicular arthrodesis as the primary stabilizing procedure. Twenty-six patients were followed a minimum of 12 and an average of 27 months. Twenty-four patients had either no pain or pain only after heavy usage. Eleven patients were completely satisfied with postoperative foot function, 13 were satisfied, with minor reservations, and 2 were satisfied, with major reservations. Results were rated as excellent in 10 patients, good in 14 patients, and fair in 2 patients. Successful arthrodesis was achieved in all patients, although one patient required two additional bone grafts. Progressive arthrosis in adjacent joints was noted in five patients, four of whom had arthrosis preoperatively. No deterioration of foot position was seen in any patient with follow-up as long as 5 years. An isolated talonavicular arthrodesis seems to offer patients with this disorder both reliable pain improvement and lasting stability.     

Cubital tunnel syndrome and the painful upper extremity

Cubital tunnel syndrome is the second-most-common compressive neuropathy. With the increasing prevalence of entrapment neuropathies, the presentation of ulnar nerve compression with a painful upper extremity appears to be more common. Although our knowledge and understanding of this disease are increasing, the principles of management remain constant. We are obliged to reach a timely and appropriate diagnosis to minimize the extent of neurologic injury and institute an appropriate treatment regimen to preserve and restore normal neural function. Although there are many ways to reach these goals, the avoidance of complications is paramount to achieve a reliable and pain-free outcome. Preventing injury to the medial antebrachial cutaneous nerve, complete release of all sites of compression, and avoidance of creating new compressive sites are the keys to this end.     

Acute painful and red eyes

Pain or redness of the eye are frequent symptoms of out patient ophthalmological visit. Diagnosis is based both on the patient symptoms and a careful eyeball examination. After an eye trauma, it is necessary to check the absence of corneal or subpalpebral foreign body, and the absence of an eyeball laceration or an intraocular foreign body. Without traumatism, pain or redness of the eye suggest an anterior segment pathology with various diagnosis: keratitis is mostly due to bacterial infection, a significant intraocular pressure elevation is frequently due to angle closure glaucoma or inflammation of the anterior uvea in case of iridocyclitis. When pain and redness of the eye are associated with visual impairment, it is mostly due to a severe ocular pathology. In that case an ophthalmological referral is mandatory.     

Bone-scintigraphy in painful bipartite patella

We report the scintigraphic-appearances of painful bipartite patella in 25-year-old man a 2 1/2 years history of unexplained patellar pain. Painful bipartite patella is a rare cause of chronic post-traumatic patellar pain. Bone scintigraphy, by demonstrating increased uptake by the painful accessory bipartite fragment, appears to be an imaging method of choice in the diagnosis of this condition.