LAM KID

[Pain management in rheumatology]

NAGY Katalin

OCTOBER 20, 2011

LAM KID - 2011;1(02)

[Pain is the most common symptom in rheumatology, which can be of mechanical or inflammatory origin, acute and chronic, nociceptive, neuropathic and psychogenic. Pain can be relieved by analgesics, nonsteroidal anti-inflammatory drugs, opioids, adjuvants and special drugs depending on the etiology, for example a gout attack can be stopped by colchicine. For pain relief, we use therapeutic guidelines of the World Health Organization (WHO), which recommends the use of analgesics, NSAIDs and adjuvants as the first step, weaker opioids as the second, and strong opioids as the third step. In rheumatology, the first step's drugs are generally used. If possible, NSAIDs should be administered briefly, potentially combined with analgesics and muscle relaxants. If pain management is insufficient, tramadol should be given. Pain relief in rheumatology also include the use of local and intraarticular injections, physiotherapy, TENS and balneotherapy. Complex therapies that combine the above mentioned methods is often more effective than the use of medications only.]

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[Inhibition of receptor activator of nuclear kappa-B ligand: pathophysiology and preclinical data]

LAKATOS Péter, NÁDASI Edit

[Bone remodeling is a lifelong process, in which the balanced functions of osteoclasts and osteoblasts have a key role. In certain conditions, for example during the dramatical hormonal changes in the postmenopausal period, the upset of this balance leads to a pathologically increased bone loss. Such conditions lead to an increased bone loss, which results in an increased risk of fractures. Bone resorption is primarily regulated by a member of the tumor necrosis factor family, receptor activator of nuclear factor κB ligand, which plays a central role in the development, function and survival of osteoclasts. Catabolic effects of this ligand is inhibited by another member of the tumor necrosis factor family, osteoprotegerin, which binds to the ligand and prevents its interaction with its receptor, the receptor activator of nuclear factor κB. Osteoclast activity is at least partly dependent on the relative balance of the ligand and osteoprotegerin. It has been shown in a number of animal models that inhibition of the ligand markedly decreases bone resorption and increases cortical and cancellous bone volume, density and strength, without having any significant effect on other organs. On the basis of these findings, inhibition of receptor activator of nuclear κB ligand is a promising therapy of conditions characterised by increased bone loss. In phase 3 clinical trials, denosumab therapy significantly increased bone mineral density at various regions of the skeleton and significantly decreased the levels of bone turnover markers compared with placebo and alendronate therapy, and significantly decreased the incidence of new vertebral, total hip and nonvertebral fractures compared with placebo. On the basis of these findings, denosumab therapy offers a novel, revolutionary solution for the treatment of postmenopausal osteoporosis.]

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[Pain relief in the neurologist’s view]

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[Pain, on the basis of its anatomical origin, can be nociceptive (somatic, visceral) or neuropathic, that is, occuring as a direct consequence of a lesion or disease affecting the somatosensory system. The past few years’ epidemiological studies showed that chronic neuropathic pain affects 7-8% of the general population. Diagnosis of neuropathic pain can be established without instrumental examinations, with the help of validated tests that can be used by any physician. Neuropathic pain greatly deteriorates the patients’ quality of life, and the effect of traditional analgesics is insufficient for its treatment. Thus, it is important to know those treatment procedures and drugs that have been proved to be efficient for relieving neuropathic pain.]

LAM KID

[Connections of bone turnover and energy homeostasis in women]

BUDAY BARBARA, PACH Péter, LITERÁTI-NAGY Botond, VECSEI Zsuzsa, KORÁNYI LÁSZLÓ

[BACKGROUND - A new discovery of the past decade has been the previously unknown relationship between the bone metabolic unit and energy homeostasis. On the basis of data from previous animal and clinical studies, osteocalcin has been considered the major mediator of this relationship. Cathepsin K is a cysteine protease type osteolytic enzyme, which has a role in bone resorption, and which is a pharmaceutical target in the treatment of osteoporosis and bone metastasis. According to data from animal studies, its deficiency or selective inhibition decreases the differentiation of preadipocytes, body weight and serum levels of insulin and glucose in obese mice. The aim of our study was to elucidate the role of cathepsin K in the human bone - metabolic axis in women (n=66). PATIENTS AND METHODS - 21 healthy and 45 glucose intolerant women were examined. OGTT, IVGTT and hyperinsulinaemic euglycaemic clamp were performed to assess carbohydrate homeostasis, insulin secretion, whole-body and muscle glucose utilization (M-1 and M-3). Circulating levels of bone markers and adipokines were measured, and DEXA was used to measure BMD, fat and muscle mass. RESULTS - Cathepsin K levels showed a significant (p<0.05), negative correlation with BMI, body fat percent and OGTT glucose and insulin area under the curve (AUC), and a positive correlation with M values. No correlation was found between cathepsin K levels and IVGTT measurements. CONCLUSION - Cathepsin K - in women - is not only a participant of the bone metabolism - energy homeostasis axis. Its role in human glucose homeostasis differs from what could be expected on the basis of animal experiments, because increasing cathepsin K levels indicate, paradoxically, improving metabolic state in women. Our data suggest that insulin regulation of cathepsin K is mediated by the incretin system.]

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[Current treatment and rehabilitation of the hip fractures - The role of orthopedic surgeons in the investigation and treatment of osteoporosis]

FLÓRIS István, KRICSFALUSY Mihály, UDVARDY Csaba, SOMOGYI Péter

[The treatment of proximal femoral fractures is one of the most common surgical indications in traumatology, on the other hand, it requires a significant proportion of health expenditures. The structure of our society is going to shift toward the older generation in the next decades, which increases the importance of the above factors. New implants and surgical techniques appear in order to make the treatment more effective, thus allowing the patient’s early rehabilitation. In this article, we summarise the diagnosis and treatment of hip fractures, the most serious consequence of osteoporosis, and describe the results of rehabilitation. We describe the role and possibilities of orthopedic surgeons in the investigation and treatment of patients with osteoporotic hip fractures as well as possibilities of tertiary prevention and suggest possibilities of cooperation among the co-professions dealing with osteoporosis in the treatment of this patient group.]

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[PAIN RELIEF IN THE CLINICAL PRACTICE - THE USE OF MAJOR ANALGETICS]

HORVÁTH J. Attila

[The use of opioids to relieve strong, unbearable pain is a method that has been known for thousands of years and is still effective today. In contrast to the earlier view, opioids today are not only given to cancer patients. The application area of morphine derivatives is generally the relief of exceptionally strong pain regardless of the diagnosis, but opiates are undoubtedly most commonly used to treat cancer-related or strong acute pain. Strong pain reducers are used much more in developed countries for the treatment of non-cancer related severe pain refractory to other approaches. Today the use of opiates and their derivatives (fentanyl, oxycodon) for non-cancer related pain relief is recognized by the national health insurance in that it allows general practitioners to prescribe them, upon the recommendation of a neurosurgeon, orthopaedic surgeon, traumatologist or rheumatologist, with a significant 90% subsidy for six months to ensure easy access for patients in severe, refractory pain due to degenerative musculoskelatal diseases (ICD: M47, M48, M16.9, M17.9, M54.4, M51.0, M51.1). The indications of opioid use, however, are not limited to strong nociceptive pain since they are also effective in certain types of peripheral neuropathic pain. In brief, a basic principle of the use of major analgetics is that their indication is primarily based on the intensity of pain and not on the nature of the disease, even though the latter has a major influence on the clinician's strategy of pain relief.]

LAM Extra for General Practicioners

[PAIN MANAGEMENT IN RHEUMATOLOGY]

NAGY Katalin

[Pain is the most common symptom in rheumatology, which can be of mechanical or inflammatory origin, acute and chronic, nociceptive, neuropathic and psychogenic. Pain can be relieved by analgesics, nonsteroidal anti-inflammatory drugs, opioids, adjuvants and special drugs depending on the etiology, for example a gout attack can be stopped by colchicine. For pain relief, we use therapeutic guidelines of the World Health Organization (WHO), which recommends the use of analgesics, NSAIDs and adjuvants as the first step, weaker opioids as the second, and strong opioids as the third step. In rheumatology, the first step's drugs are generally used. If possible, NSAIDs should be administered briefly, potentially combined with analgesics and muscle relaxants. If pain management is insufficient, tramadol should be given. Pain relief in rheumatology also include the use of local and intraarticular injections, physiotherapy, TENS and balneotherapy. Complex therapies that combine the above mentioned methods is often more effective than the use of medications only.]

Journal of Nursing Theory and Practice

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TAMÁS Judit, FULLÉR Noémi

[Aim of the research: The objective of investigation was to survey the efficiency of the rehabilitation of the patients operated with complete knee endoprosthesis (TKR) nursed in the Rehabilitation Centre and whether the bath course with the applied complex physiotherapy and the spring water of induce any change in the life quality of the patients and whether the efficiency of the physiotherapy can be measured. Research and sampling methods: prospective, quantitative, describing research, with non-random, convenience sampling method. 50 TEP-operated patients have filled in the self-filling questionnaires and participated in the examination of the walking time. The examination was performed between 03/01/2013-12/01/2013 in the Musculoskeletal Rehabilitation Centre of the Gunaras. The patients have filled in the WOMAC, SF-36, BDI, questionnaire compiled by us. Additionally we have measured the walking speed on flat ground and during climbing stairs. The patients have taken a bath in 36C spa for 3 weeks, 7-times a week for 20 minutes and 5-times a week they have received electrotherapy, physiotherapy and hydrotherapy. Results: The majority of the participants of the investigation belonged to the age group of 71-75. The patients avail themselves of the treatments regularly, once or twice a year, which are evaluated by women as more efficient than by men (p <0,001). After the treatments the extent of depression has significantly reduced (p <0,001). There was a significant improvement in the walking speed (p < 0,001), in the SF-36 (TF, PCS) dimensions and we have detected a significant relation between physical and mental health (p <0,001). The movement range of the patients has significantly improved (WOMAC, p=0,001). Between the result of the SF-36 and WOMAC questionnaires we have found also a significant relation (p=0,001), with the improvement of the physical function the life quality has also improved. Conclusions: The results have shown, that the application of the spring water and physiotherapy have proven as efficient treatment in the life quality improvement of the patients operated with complete knee prosthesis. ]

Clinical Neuroscience

[PLASTICITY OF NOCICEPTION: RECENT ADVANCES IN FUNCTION-ORIENTED STRUCTURAL PAIN RESEARCH]

KNYIHÁR Erzsébet, CSILLIK Bertalan

[Traditional concept holds that the pain unit consists of three neurons. The first of these, the primary nociceptive neuron, starts with the nociceptors and terminates in the dorsal spinal cord. The second one, called spinothalamic neuron, crosses over in front of the central canal and connects the dorsal horn with the thalamus. The third one, called thalamo- cortical neuron, terminates in the “pain centres” of the cerebral cortex. While this simplistic scheme is useful for didactic purposes, the actual situation is more complex. First, in the periphery it is only nociception that occurs, while pain is restricted to the levels of thalamus and the cortex. Second, pain results from interactions of excitation and inhibition, from divergence and convergence and from attention and distraction, in a diffuse and plastic system, characteristic for all levels of organization. This study describes the major cytochemical markers of primary nociceptive neurons followed by the presentation of recent data on the functional anatomy of nociception and pain, with special focus on the intrinsic antinociceptive system and the role of nitrogen oxide, opiate receptors, nociceptin and nocistatin. In addition to the classic intrinsic antinociceptive centres such as the periaqueductal gray matter and the raphe nuclei, roles of several recently discovered members of the antinociceptive system are discussed, such as the pretectal nucleus, the reticular formation, the nucleus accumbens, the nucleus tractus solitarii, the amygdala and the reticular thalamic nucleus, this latter being a coincidence detector and a centre for attention and distraction. The localisation of cortical centres involved in the generation of pain are presented based on the results of studies using imaging techniques, and the structural basis of corticospinal modulation is also outlined. Seven levels of nociception and pain are highlighted where pharmacological intervention may be successful, 1. the peripheral nociceptor, 2. the spinal ganglion, 3. the multisynaptic system of the dorsal horn, 4. the modulatory system of the brain stem, 5. the antinociceptive system, 6. the multisynaptic system of the thalamus, and 7. the cortical evaluating and localisation system that is also responsible for descending (inhibiting) control. The many levels of nociception and pain opens new ways both for pharmacological research and the general practitioner aiming to alleviate pain.]

Journal of Nursing Theory and Practice

[The annual health insurance activity of the physiotherapy procedures related to definition in outpatient care]

MOLICS Bálint, ÁGOSTON István, ENDREI Dóra, ÉLIÁS Zsuzsanna, KRÁNICZ János, SCHMIDT Béla, BONCZ Imre

[Aim of the study: The aim of the study is mapping the extent, prevalence, specialty distribution of physiotherapy procedures in out-patient care and the health insurance expense on provisions. Methodology and sample: The data concerning the number of cases were requested from the Healthcare Strategic Research Institute, Healthcare Detailed Data Base according to the data of National Health Insurance Fund (OEP). Paragraph J17 in Book of Rules on the application of the code list of out-patient activities provided the OENO activity list with the scores, number of cases in 2008, and we obtained the financing expense/year from the 1.46 FT/point score. Results: The total number of cases of 151 physiotherapy activities /year were 24.748.877. The 20 most prevalent procedures accounted for 72.56% (17.958.097) of the total number of cases. The procedures performed by physiotherapists, masseurs, conducters and physiotherapy assisstants accounted for 7.339.446.299 Fts financed by OEP in 2008. Among the BNO main groups, most interventions occured in musculoskeletal and connective tissue diseases. Conclusions: According to results OEP financed 7,339 billion FTs on physiotherapy treatment in out-patient care, mostly in procedures of musculoskeletal disorders in 2008.]