RESUMEN
BACKGROUND: Previous reports have indicated that ketamine anesthesia may produce significant improvement if not complete recovery of patients with complex regional pain syndrome (CRPS). AIMS: Here we report on a patient who had CRPS affecting mainly the right side of her body who underwent functional magnetic resonance imaging (fMRI) scans prior to and in the months following apparent successful treatment with anesthetic doses of ketamine. MATERIALS AND METHODS: The patient underwent two imaging sessions: one during her pain state (CRPS+) and 1 month after her ketamine treatment in her pain-free state (CRPS-). Both spontaneous and evoked (brush, cold, and heat) pain scores decreased from 79/10 on a visual analog scale prior to the treatment to 01 immediately following and for months after the treatment. For each imaging session, the identical mechanical (brush) and thermal (cold and heat) stimuli were applied to the same location (the skin of the dorsum of the right hand). RESULTS: Comparison of CRPS+ vs CRPS- for the three stimuli showed significant changes throughout the cerebral cortex (frontal, parietal, temporal, cingulate, and hippocampus), in subcortical regions such as caudate nucleus, and in the cerebellum. In addition, resting state network analysis showed a reversal of brain network state, and the recovered state paralleled specific default networks in healthy volunteers. DISCUSSION: The observed changes in brain response to evoked stimuli provide a readout for the subjective response. CONCLUSION: Future studies of brain function in these patients may provide novel insight into brain plasticity in response to this treatment for chronic pain.
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Mapeo Encefálico/métodos , Encéfalo/fisiopatología , Síndromes de Dolor Regional Complejo/tratamiento farmacológico , Síndromes de Dolor Regional Complejo/fisiopatología , Ketamina/administración & dosificación , Adulto , Encéfalo/efectos de los fármacos , Síndromes de Dolor Regional Complejo/diagnóstico , Potenciales Evocados Somatosensoriales/efectos de los fármacos , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Resultado del TratamientoRESUMEN
A validated LC-MS/MS method was developed for the determination of d -Serine in human plasma. The method was fully validated for use with human plasma samples and was linear from 0.19 nmol/ml to 25 nmol/ml. The coefficient of variation was ≤5% for the high QC standards and ≤8% for the low QC standards in plasma. d -Serine and l -serine were resolved by pre-column derivatization using (R)-1-Boc-2-piperidine carbonyl chloride as the derivatizating agent. The method was used to determine the concentration of d-serine in plasma samples obtained in patients receiving a continuous 5-day intravenous infusion of (R,S)-ketamine. The changes in d-Ser levels varied in the six patients, with circulating d-Ser levels increasing as much as 35% in a patient, while decreasing 20% in a patient. While only preliminary data, the results suggests the potential importance in determining the d-Ser levels in plasma and their potential role in physiological response.
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Cromatografía Liquida/métodos , Plasma/química , Serina/química , Espectrometría de Masas en Tándem/métodos , HumanosRESUMEN
Complex regional pain syndrome (CRPS) is a chronic pain disorder. Although its pathophysiology is not completely understood, neurogenic inflammation is thought to play a significant role. Microglia and astrocytes are activated following tissue injury or inflammation and have been reported to be both necessary and sufficient for enhanced nociception. Blood-borne monocytes/macrophages can infiltrate the central nervous system (CNS) and differentiate into microglia resulting in hypersensitivity and chronic pain. The primary aim of this study was to evaluate the proportion of the proinflammatory CD14(+) CD16(+) monocytes as well as plasma cytokine levels in blood from CRPS patients compared to age- and gender-matched healthy control individuals. Forty-six subjects (25 CRPS, 21 controls) were recruited for this study. The percentage of monocytes, T, B or natural killer (NK) cells did not differ between CRPS and controls. However, the percentage of the CD14(+) CD16(+) monocyte/macrophage subgroup was elevated significantly (P<0·01) in CRPS compared to controls. Individuals with high percentage of CD14(+) CD16(+) demonstrated significantly lower (P<0·05) plasma levels on the anti-inflammatory cytokine interleukin (IL)-10. Our data cannot determine whether CD14(+) CD16(+) monocytes became elevated prior to or after developing CRPS. In either case, the elevation of blood proinflammatoty monocytes prior to the initiating event may predispose individuals for developing the syndrome whereas the elevation of blood proinflammatory monocytes following the development of CRPS may be relevant for its maintenance. Further evaluation of the role the immune system plays in the pathogenesis of CRPS may aid in elucidating disease mechanisms as well as the development of novel therapies for its treatment.
Asunto(s)
Síndromes de Dolor Regional Complejo/inmunología , Receptores de Lipopolisacáridos/sangre , Monocitos/inmunología , Receptores de IgG/sangre , Adulto , Síndromes de Dolor Regional Complejo/sangre , Síndromes de Dolor Regional Complejo/fisiopatología , Femenino , Proteínas Ligadas a GPI/sangre , Humanos , Inflamación/sangre , Inflamación/inmunología , Interleucina-10/sangre , Interleucina-1beta/sangre , Interleucina-6/sangre , Interleucina-8/sangre , Masculino , Persona de Mediana Edad , Monocitos/metabolismo , Dimensión del Dolor/métodos , Factor de Necrosis Tumoral alfa/sangreRESUMEN
The aim was to assess the relative frequency of migraine and the headache characteristics of complex regional pain syndrome (CRPS) sufferers. CRPS and migraine are chronic, often disabling pain syndromes. Recent studies suggest that headache is associated with the development of CRPS. Consecutive adults fulfilling International Association for the Study of Pain criteria for CRPS at a pain clinic were included. Demographics, medical history, and pain characteristics were obtained. Headache diagnoses were made using International Classification of Headache Disorders, 2nd edn criteria. Migraine and pain characteristics were compared in those with migraine with those without. anova with Tukey post hoc tests was used to determine the significance of continuous variables and Fisher's exact or χ(2) tests for categorical variables. The expected prevalence of migraine and chronic daily headache (CDH) was calculated based on age- and gender-stratified general population estimates. Standardized morbidity ratios (SMR) were calculated by dividing the observed prevalence of migraine by the expected prevalence from the general population. The sample consisted of 124 CRPS participants. The mean age was 45.5 ± 12.0 years. Age- and gender-adjusted SMRs showed that those with CRPS were 3.6 times more likely to have migraine and nearly twice as likely to have CDH as the general population. Aura was reported in 59.7% (74/124) of participants. Of those CRPS sufferers with migraine, 61.2% (41/67) reported the onset of severe headaches before the onset of CRPS symptoms Mean age of onset of CRPS was earlier in those with migraine (34.9 ± 11.1 years) and CDH (32.5 ± 13.4 years) compared with those with no headaches (46.8 ± 14.9 years) and those with tension-type headache (TTH) (39.9 ± 9.9 years), P < 0.05. More extremities were affected by CRPS in participants with migraine (median of four extremities) compared with the combined group of those CRPS sufferers with no headaches or TTH (median 2.0 extremities), P < 0.05. The presence of static, dynamic and deep joint mechano-allodynia together was reported by more CRPS participants with migraine (72.2%) than those with no headaches or TTH (46.2%), P ≤ 0.05. Migraine may be a risk factor for CRPS and the presence of migraine may be associated with a more severe form of CRPS. Specifically: (i) migraine occurs in a greater percentage of CRPS sufferers than expected in the general population; (ii) the onset of CRPS is reported earlier in those with migraine than in those without; and (iii) CRPS symptoms are present in more extremities in those CRPS sufferers with migraine compared with those without. In addition, as we also found that the presence of aura is reported in a higher percentage of those CRPS sufferers with migraine than reported in migraineurs in the general population, further evaluation of the cardiovascular risk profile of CRPS sufferers is warranted.
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Síndromes de Dolor Regional Complejo/epidemiología , Trastornos Migrañosos/epidemiología , Adulto , Edad de Inicio , Síndromes de Dolor Regional Complejo/etiología , Síndromes de Dolor Regional Complejo/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastornos Migrañosos/complicaciones , Trastornos Migrañosos/fisiopatología , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
Four patients with chronic inflammatory demyelinating polyneuropathy (CIDP) who were refractory to conventional treatment were treated with high-dose cyclophosphamide (200 mg/kg over 4 days). All improved in functional status and muscle strength. Nerve conduction studies improved in three of four. Other immunomodulatory medications have been discontinued. High-dose cyclophosphamide can be given safely to patients with CIDP and patients with disease persistence after standard therapy may have a response that lasts for over 3 years and results in long-term disease remission.
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Ciclofosfamida/administración & dosificación , Inmunosupresores/administración & dosificación , Polirradiculoneuropatía Crónica Inflamatoria Desmielinizante/tratamiento farmacológico , Trasplante de Células Madre , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polirradiculoneuropatía Crónica Inflamatoria Desmielinizante/inmunología , Polirradiculoneuropatía Crónica Inflamatoria Desmielinizante/fisiopatología , Células Madre/inmunología , Resultado del TratamientoRESUMEN
OBJECTIVE: Assessment of the diagnostic criteria of reflex sympathetic dystrophy (RSD) and evaluation of the impact of the introduction of the diagnostic criteria of complex regional pain syndrome (CRPS) on the international application of diagnostic criteria of RSD. METHODS: Randomized controlled trials and clinical investigations, published between January 1980 and June 2000, were evaluated with regard to the applied diagnostic criteria of RSD. RESULTS: One hundred seven studies were identified. Thirty-four of these studies were excluded because of inadequate reporting of diagnostic criteria. The 73 included studies were not homogeneous with regard to the diagnostic criteria because they applied many different aspects of sensory and autonomic features. Only 12% of the studies considered the presence of motor features, mostly vaguely described, as mandatory for the diagnosis RSD. Although 10 of the 23 studies published since the introduction of CRPS have applied this term, only 3 used the exact criteria without additions or other modifications. CONCLUSION: Diagnostic criteria sets of RSD focus on many different aspects of sensory and autonomic features that generally are described vaguely. This has not changed since the introduction of the CPRS criteria. These findings question whether the current criteria adequately define RSD.
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Ensayos Clínicos como Asunto/métodos , Distrofia Simpática Refleja/diagnóstico , Ensayos Clínicos como Asunto/estadística & datos numéricos , Humanos , Examen Neurológico/métodos , Examen Neurológico/estadística & datos numéricosRESUMEN
BACKGROUND: Nociceptive pain is a major problem in clinical neurology. Peripheral nerve injury may change the physiology of the dorsal horn so that pain becomes progressively centralized. OBJECTIVE: To review mechanisms underlying the plasticity of dorsal root ganglia and dorsal horn neurons that lead to central pain from a peripheral nerve injury. RESULTS: Evidence is reviewed that points to molecular changes in nociceptive terminals, ectopic firing of afferent pain fibers at the level of the dorsal root ganglia, and physiologic changes of the N-methyl-D-aspartate receptor that cause chronic nociceptive pain. CONCLUSIONS: Central sensitization is the physiologic manifestation of many severe peripherally induced pain states. It is maintained by nociceptive input and a physiologic change in the N-methyl-D-aspartate receptor. It consists of: (1) hypersensitivity at the site of injury; (2) mechanoallodynia; (3) thermal hyperalgesia; (4) hyperpathia; (5) extraterritoriality in the case of complex regional pain syndrome/reflex sympathetic dystrophy; and (6) associated neurogenic inflammation, autonomic dysregulation, and motor phenomena.
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Enfermedades del Sistema Nervioso Central/epidemiología , Enfermedades del Sistema Nervioso Central/etiología , Enfermedades del Sistema Nervioso Central/terapia , Manejo del Dolor , Dolor/epidemiología , Dolor/etiología , Humanos , Hiperalgesia/fisiopatología , Hipersensibilidad/fisiopatología , Actividad Motora/fisiología , Neuralgia/epidemiología , Dolor/fisiopatología , Receptores de N-Metil-D-Aspartato/fisiología , SíndromeRESUMEN
BACKGROUND: The left ventricular assist device (LVAD) is a bridging mechanism for patients with severe heart failure to remain viable until heart transplantation. The rate of cerebral embolism has been reported as high as 47% in some studies but the rate of other neurologic complications in patients with LVADs is not known. METHODS: Retrospective chart review of all patients who had LVADs implanted at our hospital from September 1993 until September 1997. Complications from the time of implantation until heart transplantation or death and functional outcome were assessed. RESULTS: Twenty-three patients had LVADs placed in the four-year period. Of 23 patients, 9 had neurologic complications after placement of the LVAD. These included four strokes, three seizures, and two cases of delirium. The 3 patients with seizures all died from multiorgan failure. All of the patients with strokes received a transplant. One patient with delirium died from multiorgan failure and another received a transplant. The most devastating medical complication was renal failure, which occurred in 7 patients and was associated with 100% mortality. All surviving patients with neurologic complications went on to transplant and good functional outcome. CONCLUSIONS: Neurologic complications are common in patients with LVADs, occurring in 9 out of 23 patients in our series. Seizures are a poor prognostic indicator and were associated with 100% mortality. Strokes did not have a negative impact on outcome. Patients with delirium had a mixed outcome, which reflects the multifactorial nature of delirium. Further study needs to be done to limit the neurologic complications associated with LVADs and further improve outcomes.
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Delirio/diagnóstico , Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Examen Neurológico , Complicaciones Posoperatorias/diagnóstico , Convulsiones/diagnóstico , Accidente Cerebrovascular/diagnóstico , Adolescente , Adulto , Anciano , Causas de Muerte , Delirio/mortalidad , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/mortalidad , Complicaciones Posoperatorias/mortalidad , Factores de Riesgo , Convulsiones/mortalidad , Accidente Cerebrovascular/mortalidad , Tasa de SupervivenciaRESUMEN
An acute stroke from an aortic arch tumor is reported. These tumors are rare and have to be differentiated from atheromas. Aortic atheromas commonly present with embolic phenomena and occasionally as masses. Aortic tumors are more likely to produce obstructive phenomena, presenting as a coarctation or dissection. Magnetic resonance imaging with gadolinium can facilitate the diagnosis. A literature review of aortic masses and their diagnosis and treatment are presented.
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Enfermedades de la Aorta/complicaciones , Accidente Cerebrovascular/etiología , Neoplasias Vasculares/complicaciones , Aorta Torácica , Enfermedades de la Aorta/diagnóstico , Femenino , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Neoplasias Vasculares/diagnósticoAsunto(s)
Baclofeno/uso terapéutico , Terapia por Estimulación Eléctrica , Agonistas del GABA/uso terapéutico , Distrofia Simpática Refleja/terapia , Distonía/tratamiento farmacológico , Distonía/etiología , Humanos , Distrofia Simpática Refleja/complicaciones , Distrofia Simpática Refleja/etiología , Distrofia Simpática Refleja/fisiopatologíaRESUMEN
OBJECTIVE: Patients with complex regional pain syndrome type I (CRPSD1) may have thermal allodynia after application of a non-noxious thermal stimulus to the affected limb. We measured the warm, cold, heat-evoked pain threshold and the cold-evoked pain threshold in the affected area of 16 control patients and patients with complex regional pain syndrome type 1/RSD to test the hypothesis that allodynia results from an abnormality in sensory physiology. SETTING: A contact thermode was used to apply a constant 1 degrees C/second increasing (warm and heat-evoked pain) or decreasing (cold and cold-evoked pain) thermal stimulus until the patient pressed the response button to show that a temperature change was felt by the patient. Student t test was used to compare thresholds in patients and control patients. RESULTS: The cold-evoked pain threshold in patients with CRPSD1/RSD (p <0.001) was significantly decreased when compared with the thresholds in control patients (i.e., a smaller decrease in temperature was necessary to elicit cold-pain in patients with CRPSD1/RSD than in control patients). The heat-evoked pain threshold in patients with CRPS1/RSD was (p <0.05) decreased significantly when compared with thresholds in control patients. The warm- and cold-detection thresholds in patients with CRPS1/RSD were similar to the thresholds in control patients. CONCLUSIONS: This study suggests that thermal allodynia in patients with CRPS1/RSD results from decreased cold-evoked and heat-evoked pain thresholds. The thermal pain thresholds are reset (decreased) so that non-noxious thermal stimuli are perceived to be pain (allodynia).
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Hiperalgesia/fisiopatología , Neuronas Aferentes/fisiología , Umbral del Dolor/fisiología , Distrofia Simpática Refleja/fisiopatología , Adulto , Frío , Femenino , Calor , Humanos , Hiperalgesia/etiología , Masculino , Persona de Mediana Edad , Estimulación Física , Distrofia Simpática Refleja/etiologíaRESUMEN
Pain is clearly one of the most daunting problems of modern medicine. Posttraumatic neuropathic pain syndromes are a major component of the clinical problem. Structural lesions affecting roots, nerves, the plexi, and central structures can be imaged noninvasively. The molecular biology of the intraneural cascades that cause sensitization of the central pain-projecting neurons of the dorsal horn and subsequent allodynia, hyperalgesia, and hyperpathia is a subject of intense inquiry. The role of the clinician in identifying and eliminating the source of the pain is crucial before the effects of excitotoxicity and central sensitization permanently alter the physiology of the central pain-projecting neurons and make treatment ineffectual.
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Dolor/etiología , Dolor/fisiopatología , Enfermedades del Sistema Nervioso Periférico/complicaciones , Enfermedades del Sistema Nervioso Periférico/fisiopatología , Heridas y Lesiones/complicaciones , Plexo Braquial/lesiones , Humanos , Síndromes de Compresión Nerviosa/complicaciones , Síndromes de Compresión Nerviosa/fisiopatología , Enfermedades del Sistema Nervioso Periférico/etiología , Distrofia Simpática Refleja/etiología , Distrofia Simpática Refleja/fisiopatología , Heridas y Lesiones/fisiopatologíaRESUMEN
OBJECTIVE: There is controversy regarding the importance of psychological/psychiatric factors in the development of the Complex Regional Pain Syndrome (CRPS). Our objective was to determine whether CRPS type I patients were psychiatrically different from other chronic pain patients, with particular attention to personality pathology. DESIGN: A standardized clinical assessment of all major psychiatric categories, including personality disorders, was performed on 25 CRPS type I patients and a control group of 25 patients with chronic low back pain from disc-related radiculopathy. MEASURES: Both sections of the Structured Clinical Interview for the Diagnostic and Statistical Manual (3rd ed., rev.) and the visual analog scale. RESULTS: Both groups were similar in terms of pain intensity and duration. Statistical analysis showed both groups to have a significant amount of major psychiatric comorbidity, in particular major depressive disorder, and a high incidence of personality disorders. Therefore, intense chronic pain was associated with significant psychiatric comorbidity in both groups and in similar proportions. CONCLUSION: The high incidence of personality pathology in both groups may represent an exaggeration of maladaptive personality traits and coping styles as a result of a chronic, intense, state of pain.
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Determinación de la Personalidad , Distrofia Simpática Refleja/psicología , Adulto , Trastorno Depresivo Mayor/etiología , Femenino , Humanos , Desplazamiento del Disco Intervertebral/complicaciones , Entrevista Psicológica , Dolor de la Región Lumbar/etiología , Dolor de la Región Lumbar/fisiopatología , Dolor de la Región Lumbar/psicología , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Enfermedades del Sistema Nervioso Periférico/complicaciones , Trastornos de la Personalidad/etiología , Distrofia Simpática Refleja/fisiopatología , Raíces Nerviosas Espinales/fisiopatologíaRESUMEN
We performed a retrospective study of 29 patients with CRPS1 (RSD) who were initially examined between 1983 and 1993, and had either transthoracic (lower third of stellate ganglia to T3) or lumbar (L2-L4) sympathectomy. The patients were followed from 24 to 108 months after surgery. Patients with unsuccessful surgical outcomes had significantly longer duration of symptoms before surgery (median, 36 months) than those with successful outcomes (median, 16 months) by Wilcoxon rank sum test (chi2=8.69, df=1, P<0.01). All seven patients (100%) who had sympathectomy within 12 months of injury, nine of 13 patients (69.2%) who had sympathectomy within 24 months of injury, and only four of nine patients (44.4%) who had sympathectomy after 24 months of injury obtained permanent (greater than 24 months) symptom relief. Patient age, sex, occupation, site of injury, type of injury, presence of trophic changes, and duration of follow-up were not significantly related (P>0.05) to surgical outcome.
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Distrofia Simpática Refleja/etiología , Distrofia Simpática Refleja/cirugía , Simpatectomía , Heridas y Lesiones/complicaciones , Adulto , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The central nervous system has high-affinity uptake systems for the clearance of amino acid transmitters. These systems are found in both neurons and astrocytes. Previous studies have shown that the uptake of amino acid transmitters by astrocytes in culture can be modulated by adrenergic agents. The objectives of this study were to develop a methodology that evaluates the brain's reuptake capacity for glutamate in awake, behaving animals and to determine whether glutamate reuptake is under alpha-adrenergic regulation in the intact central nervous system. Male Sprague-Dawley rats weighing 250-450 g were used in this study. The extraction fraction of L-[3H]glutamate with [14C]mannitol as a reference was measured. The cortical extraction fraction of L-[3H]glutamate corrected for [14C]mannitol (EL-glu) reaches steady state rapidly and is both stable and repeatable. EL-glu is a measure of L-glutamate reuptake and not metabolism. EL-glu is decreased in a dose-dependent manner by the addition of the glutamate reuptake blocker D,L-threo-beta-hydroxyaspartic acid or unlabeled L- glutamate. In addition, EL-glu is increased in a dose-dependent manner by the alpha1-adrenergic agonist phenylephrine, and this increase is blocked by the alpha-adrenergic antagonist phentolamine.
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Conducta Animal/fisiología , Lóbulo Frontal/metabolismo , Ácido Glutámico/farmacocinética , Lóbulo Parietal/metabolismo , Ácido 3,4-Dihidroxifenilacético/metabolismo , Animales , Antibacterianos/farmacología , Ácido Aspártico/análogos & derivados , Ácido Aspártico/farmacología , Radioisótopos de Carbono , Estado de Conciencia , Ácido Glutámico/metabolismo , Glutamina/metabolismo , Ácido Homovanílico/metabolismo , Ácido Hidroxiindolacético/metabolismo , Masculino , Manitol/farmacocinética , Microdiálisis , Norepinefrina/metabolismo , Fentolamina/farmacología , Fenilefrina/farmacología , Ratas , Ratas Sprague-Dawley , Simpaticolíticos/farmacología , Simpatomiméticos/farmacología , Transmisión Sináptica/efectos de los fármacos , Tritio , Ácido gamma-Aminobutírico/metabolismoRESUMEN
PURPOSE: To analyze the magnetic resonance (MR) imaging findings in idiopathic acute transverse myelitis (IATM) in relation to pathologic findings and MR findings in Guillain-Barré syndrome and ischemia. MATERIALS AND METHODS: The cases of 19 patients with IATM seen over a 4-year period were retrospectively reviewed. Clinical parameters and laboratory test findings were recorded for each patient independently of the MR findings. RESULTS: Ten (53%) patients experienced upper respiratory infection or vaccination within 4 weeks of symptom onset. The majority (82%) of cases occurred between December and May each year. In seven of 12 patients who underwent electromyography and nerve conduction examinations, evidence of peripheral nerve injury was seen. On T2-weighted axial images, 13 of 18 lesions were depicted with holocord abnormal signal intensity, seven (39%) had gray matter involvement similar to that seen in spinal cord ischemia, and three (16%) had isolated white matter involvement. Enhancement patterns varied. In three (17%) of the 18 lesions, enhancement in the cauda equina was similar to that seen in Guillain-Barré syndrome. CONCLUSION: IATM may be caused by a small vessel vasculopathy. MR findings in IATM also occasionally are similar to those described in Guillain-Barré syndrome and suggest a possible relationship.
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Mielitis Transversa/diagnóstico , Adolescente , Adulto , Anciano , Femenino , Humanos , Aumento de la Imagen , Masculino , Persona de Mediana Edad , Mielitis Transversa/patología , Examen Neurológico , Estudios Retrospectivos , Médula Espinal/patologíaRESUMEN
PURPOSE: We determined the effect of reflex sympathetic dystrophy on lower urinary tract function. MATERIALS AND METHODS: A total of 20 consecutive patients (16 women and 4 men) with neurologically verified reflex sympathetic dystrophy was referred for voiding symptoms, including urgency, frequency, incontinence and urinary retention. No patient had had voiding symptoms before the initial trauma that induced reflex sympathetic dystrophy. Evaluation included medical history, physical examination, video urodynamic testing and cystoscopy. RESULTS: Mean patient age was 43.4 +/- 10.2 years (range 28 to 58) and mean duration of urological symptoms was 4.9 +/- 3.6 years (range 1 to 14). Urodynamic study demonstrated a mean cystometric bladder capacity of 417 +/- 182 ml. (range 120 to 700). The urodynamic diagnoses included detrusor hyperreflexia in 8 patients, detrusor areflexia in 8, sensory urgency in 3 and detrusor hyperreflexia with detrusor-external sphincter dyssynergia in 1. In 4 women genuine stress urinary incontinence was also documented urodynamically. CONCLUSIONS: Reflex sympathetic dystrophy may have a profound effect on detrusor and sphincter function.
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Distrofia Simpática Refleja/complicaciones , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Brain tissue of a patient with multiple myeloma suffering from neurological disorders similar to those seen in progressive multifocal leukoencephalopathy (PML) patients was evaluated for the presence of the papovavirus, JCV. Results from polymerase chain reaction (PCR) revealed the presence of JCV with structural organization at the control region which is distinct from well-characterized isolates, ie Mad-1 and Mad-4. The control region of the new isolate, named JCVPhila-1' contains a 22 nucleotide insertion which separates the TATA box from the NF-1 regulatory motif. Only 18 nucleotides of the insert are duplicated in the second copy of the enhancer/promoter of the new isolate, which is 84 nucleotides in size. Results from a transcription assay indicate a modest elevated level of JCVPhila-1 early promoter activity compared to that of JCVMad-4 in glial cell lines. The basal and T-antigen-induced transcriptional activities of the JCVPhila-1 late promoter was lower with respect to Mad-4 late gene activity in glial cells. Of particular interest was the observation that in the cells producing the early protein, T-antigen, JCVPhila-1 DNA replicated more efficiently then the Mad-4 DNA. These results suggest that the alterations seen in the JCVPhila-1 control region may differentially influence early and late gene expression and facilitate amplification of the viral genome in cells derived from the CNS.