Gary A. Mellick

Reflex sympathetic dystrophy treated with gabapentin

The use of the recently released anticonvulsant, gabapentin (Neurontin), in the treatment of severe and refractory reflex sympathetic dystrophy (RSD) pain in six patients ranging in age from 42 to 68 years is reported. Satisfactory pain relief obtained in all six patients suggests that this medication is an effective treatment for RSD pain. In addition to pain control, early evidence of disease reversal in these patients is suggested. Patient 6 is the first documented case of successful treatment and cure of the RSD pain syndrome using gabapentin alone. Specifically, reduced hyperpathia, allodynia, hyperalgesia, and early reversal of skin and soft tissue manifestations were noted. Gabapentin was chosen because it has properties similar to other anticonvulsant drugs and because previous studies have shown that it is well tolerated and appears to have a benign efficacy-to-toxicity ratio. It was considered an acceptable and compassionate therapeutic choice because previous medical and surgical approaches had been ineffective for these patients, who represent the first case series documenting the use of gabapentin for pain management. Presently, the mechanism of pain relief in these patients is unknown. In this article, the pathophysiology of RSD is discussed, and a mechanism by which gabapentin provides pain relief is proposed. In view of encouraging results in these and other RSD patients, further scientific investigation is needed to delineate the role of gabapentin in the treatment of reflex sympathetic dystrophy.

Hemifacial spasm: Successful treatment with felbamate

Medical treatment of hemifacial spasm has generally been ineffectual. This report describes a 36-year-old man with a 7-year history of right hemifacial spasm who responded to felbamate (Felbatol) at doses of 1800-2800 mg per day. During treatment, he was able to achieve complete control of all spontaneous facial muscle spasms at rest. Activated hemifacial spasms, initiated by chewing, speaking, smiling, or grimacing were reduced in frequency and intensity of contraction by 40%-50%. Spontaneous worsening of the hemifacial spasms occurred at a dose of 3600 mg/day. Control of the hemifacial spasm was regained at a lower dose. This is the first reported use of felbamate for the control of hemifacial spasm. Microvascular decompression of the facial nerve has been the only known effective treatment for this condition. Successful felbamate therapy would provide an alternative to those patients for whom surgery is not a treatment option.

Cluster headache management with methylphenidate (Ritalin).

The authors report rapid cluster headache relief in a 43‐year‐old man with a 5‐year history of refractory cluster headache. The patient described complete headache relief within 10 minutes of taking 10 mg of methylphenidate (Ritalin) when used to abort the onset of his headaches. Subsequently, a scheduled Ritalin dose taken each morning was sufficient to prevent his nightly headaches. In addition, 1 week of prophylactic methylphenidate therapy halted the series of cluster headaches. This is the first reported case of relief of cluster headaches with methylphenidate.

Presentations of acute phenytoin overdose

A 15-year-old boy ingested 19.6 g (15 g verifiable) phenytoin sodium approximately four hours before emergency department presentation. The patient survived the suicide attempt with only supportive care, despite the ingestion of 392 mg/kg and a peak serum level of 100.8 micrograms/mL. A wide spectrum of physical findings consistent with acute massive ingestion of phenytoin was noted. This case report and a review of cases reported in the English literature of acute single anticonvulsant ingestion further delineate the clinical presentation of acute phenytoin overdose.

Lower Cervical Intramuscular Injections for Headache Relief

A previously unrecognized cervical reflex that is produced when intramuscular anesthetic blockade is placed near the seventh cervical spinal level is postulated in this letter. A series of patients seen in a private pain practice over the past 5 years have experienced rapid headache relief with myofascial trigger point injection at the C7-T1 level. Following injection, a characteristic paresthesia rises to the ipsilateral occiput and is followed by rapid and consistent headache relief. Injections at the lowest cervical levels most reliably generate this unique symptomatic response. The procedure is simple. The anesthetic blockade is placed at approximately the seventh cervical spinal level, with myofascial “trigger point” injection 1 to 4 cm lateral to the seventh cervical and upper first thoracic spinous processes; (in some patients, a better therapeutic response is obtained with injection at a slightly lower level) following preparation of a sterile field, 0.5 to 1 cc of 0.25% or 0.5% bupivacaine hydrochloride is introduced with a 25-gauge, 1.5-inch needle, 0.5 to 1 inch into the spinal paravertebral muscles. For long-term anti-inflammatory relief, a small amount of methylprednisolone acetate may be injected simultaneously. The consequent rising paresthesia which patients frequently experience involves a sensation variously described as “tingling,” “cold,” “numb,” “releasing,” “heavy,” or “warm;” ipsilateral headache relief typically follows. On occasion, a descending paresthesia occurs, and in that event the needle should be redirected upwards; alternatively, the needle can be withdrawn and reinserted at a slightly higher cervical level. Application of pressure to the ipsilateral occiput following injection often reveals diminished allodynia and mechanical hyperalgesia occurring in conjunction with headache relief. This innovative injection has been useful in treating migraine, muscle tension, cervicogenic, and posttraumatic headaches. There is minimal risk to the patient. The only real disadvantages associated with this procedure are the patient apprehension, minor discomfort at the injection site and, infrequently, brief presyncope following the injection. The autonomic nervous system (ANS) contributes to many of the primary headache syndromes. The ANS trigeminovascular system may interact as anatomical substrates for generation of headache. Bogduk has postulated specifically that sympathetic innervation of the cervical spine (via the vertebral and sinuvertebral nerves) and the trigeminovascular system may function together to cause neck pain and headache. 1 The sinu-vertebral nerves accompany the vertebral artery as a repeating series of intersegmental sympathetic anastomoses from C2 to C7. Blume has reported that radiofrequency neurotomy of the sinu-vertebral nerves in the C3 and/or C4 roots provides effective relief from headache. 2

Treatment of benign essential blepharospasm and hemifacial spasm with lacosamide

L is one of the major organs that could be affected by chronic exposure to stress because stress may result in hepatic inflammation in particular due to accumulation of reactive oxygen species (ROS). The present study was done to investigate the potential antioxidant effect of paroxetine, as a selective serotonin re-uptake inhibitor (SSRI), to protect against chronic restraint stress-induced oxidative damage in the liver. Thirty Wister albino rats were divided into 3 equal groups. Group 1 was control, non-stressed non-treated group. Group 2 was exposed to chronic restraint model by placing them in wire mesh cages exactly fit to their size for 6 hours daily for 21 days. Group 3 were also exposed to chronic restraint model for 21 days while they were administered by paroxetine 1 mg/kg/day ip during the restraint period. At the end of the study, liver transaminases (ALT and AST) & GPx, catalase enzymes and TBARS were determined by spectrophotometric methods. Glutathione repletion ability by hepatic cells with and without paroxetine treatment was also determined in all tested groups. The results showed a significant (p<0.05) increase in serum levels of ALT & AST and liver levels of GPx and catalase enzymes while levels of TBARS were significantly (p<0.05) reduced in paroxetine-treated group compared with non-stressed non-treated control rats. Glutathione repletion ability was also significantly (p<0.05) increased in treated group to a level comparable to the control nonstressed non-treated values. Paroxetine could possess a protective effect to liver tissue of chronic restrained rats.W report single-unit responses recorded from the human subthalamic nucleus (STN) in patients undergoing deep brain stimulation while engaged in a financial decision-making task. The task is modeled as a simplified version of the classic card game “war”. The subject is dealt a card and asked to make a high or low wager (

Gabapentin in the management of reflex sympathetic dystrophy

5 or

Management of restless legs syndrome with gabapentin (Neurontin)

20). Immediately following their choice they are shown their opponent’s card-the player with the highest card wins. We recorded 20 individual neurons from 5 patients. We found that during the go-cue period, neuronal activity in the STN predicted whether the subject would ultimately bet high or low on trials where the probability of a positive or negative outcome were equal (6-card trials, two-tailed t-test, p=0.03). To explore this further, we used intermittent electrical stimulation to assess changes in financial decision-making. Using modified stimulator, we applied one of three stimulation conditions during 6-card trials: no stimulation, 1 sec of stimulation at the fixation, or 1 sec of stimulation at the go-cue epoch. We found that intermittent stimulation at the go-cue epoch-the same period STN neurons encode the upcoming decision-biases subject to make a low wager (binomial proportion, 95% c.i.). Fixation and no stimulation categories had no effect on decision-making. In this study, we demonstrated that neuronal activity in the dorsal STN predicts financial decisions. We then showed that we could apply intermittent electrical stimulation through the implanted electrode to bias the decision signal and ultimately alter the subject’s behavior.Background: Cerebral ischemia is a chief cause of death worldwide. After cerebral ischemia/reperfusion, the reactive oxygen species production is dramatically increased and overwhelms endogenous antioxidant systems, leading to oxidative stress. The brain is particularly vulnerable to oxidative stress injury due to its high consumption of oxygen, abundant polyunsaturated fatty acids and low levels of endogenous antioxidants. Many antioxidants are described to block reactive oxygen speciesmediated reactions and rescue neurons from ischemia/reperfusion-induced injury in experimental transient middle cerebral artery occlusion models.Increased levels of proinflammatory cytokines have been recorded after the onset of transient or permanent brain ischemia and are usually associated with exacerbation of ischemic injury. Embolic stroke model is more relevant to the pathophysiological situation in such patients, because the majority of ischemic injuries in humans are induced by old thrombi that originate from the heart and carotid arteries. Therefore, the aim of the present study was to investigate changes of inflammatory cytokines after embolic stroke. Rats were subjected to embolic stroke, induced by a natural old clot which was injected in Middle Cerebral Artery (MCA), or sham stroke, which the same volume of saline was injected into the MCA. At 48 h after stroke induction, the levels of 5 cytokines (IL-1α and β, IL-6, IFN-γ and TNF-α) were determined in 500 µg of total protein using the Bio-Plex Rat Cytokine Array (BioRad), according to the manufacturers instructions in ischemic and non-ischemic cortices. While stroke animals showed infarctions and neurological deficits, we did not observe any cerebral infarction and neurological deficits in sham-operated animals. The levels of IL-1α (p=0.000) and -β (p =0.004), IL-6 (p =0.008), TNF-α (p =0.000) and IFN-γ (p =0.044) were significantly increased compared to sham treated animals. The findings of the present study suggest that part of ischemic injury in the embolic stroke may be mediated through the increased levels of inflammatory cytokines.I this work, the connection into individual reactions at abstract artwork vision and personal background is related. Moreover, worth of the embodied simulation is also estimated. This research involved 100 subjects of the same age (equally divided into males and females, mean age 18) and a sample of 14 unsorted subjects with mean age 28.3. The sample of 100 subjects has been selected according to their scholastic skills (Mechanical experts, art students, building surveyor students, vocational institute students). The analysis has shown the subjects’ interpretation of simple abstract artwork (as Lucio Fontana’s works) produces a variety of responses that can’t be connected to the embodied simulation only. On the basis of the obtained data, the hypothesis is the existence of a complex functional model that can be defined as Neuronal Comparative Mnestic System (CMS). During the artwork’s observation, in the subject there is an empathic reaction and we can’t also neglect cultural and environmental factors that influence individual characteristics in the empathic event. The brain, during art fruition, recalls the subject’s cultural background, and his social and familiar context and environmental influences. This emotional experience combines to the common unconscious brain activity searching a sense or an emotional value in the images. There’s a brain activation of a very complex series of connections, a functional valence and not reducible to a motor or premotor valence. It was hypothesized that these connections involve a lot of sub-system of perception. So, a more complex functional model than known models is supposed, and called as neuronal Comparative Mnestic System (CMS). In CMS the involvement of typically motor cortical areas is the result of the “recovery” of knowledge and skills already present in the self, in response to what has been observed by the subject. According to the author, only in respect of this theory, a direct association between visual perception and motor competence is justified. CMS model has a functional valence, resolving the problem of a more feed-forward phenomenon, that characterizes the complete corporal system, in particular, referred to action comprehension and other feelings comprehension phenomena we can see during the comparison with similar and dissimilar subjects.Since the average of life expectancy continues to ascend, the number of elderly p eople increases remarkably. Simultaneously diseases including PD and related disorders rise. particularly in PD patients, should not be viewed as a routine public health concern that need orthopedic intervention only, but it is a challenge with consequences that override the orthopedic problem aim of this manuscript is to shed light and to try to identify the underlying causes of and circumstances surrounding the fall and hip fractures in Parkinsons disease (PD) patients, in order to find prevention strategies and choose appropriate therapy. analyzed, discussed and overviewed the latest literature concerning PD and the orthopedic complications. chronic neurodegenerative disorder characterized by rigidity, bradykinesia and loss of postural reflexes, leading to immobility and gait disturbance. The usual age of onset is between the sixth and eighth decades. Globally, the percentage of elderly aged 65 years and over was calculated to be 8 percent (521 million) in 2011 and it is expected to be 11 percent (939 million) of the total global population 2030. Hip fractures are life-threatening and frustrated usually seen among elderly people that requires expenses. Plethora of factors contributes to falls and to increased risk of hip fractures in patients with PD. These factors include potential physiological aging changes and medical causes. identify the underlying causes of and circumstances surrounding t fall and hip fractures in PD patients specifically, in order to find prevention strategies and choose appropriate therapy multidisciplinary approach interventions that include physiatrist, podiatrist, and family or caregivers in optimal outcomes for patients with PD.