BACKGROUND: Addiction to tramadol, a widely used analgesic, is becoming increasingly common. Tramadol can also induce seizures even after a single clinical dose. We tested whether the epileptogenicity of tramadol was associated with any changes in cortical excitability and inhibitory transmission using transcranial magnetic stimulation (TMS). METHODS: The study included 16 tramadol dependent patients and 15 age and sex matched healthy volunteers. Clinical evaluation was conducted using an addiction severity index. TMS assessment of excitability was conducted on the motor cortex since the response to each TMS pulse at that site is easily measured in terms of the amplitude of the twitches it evokes in contralateral muscles. Measures included resting and active motor threshold (RMT and AMT respectively), motor evoked potential (MEP) amplitude, cortical silent period (CSP) duration, transcallosal inhibition (TCI), and short interval intracortical inhibition and facilitation (SICI and ICF respectively). Urinary level of tramadol was measured immediately before assessing cortical excitability in each patient. RESULTS: RMT and AMT were significantly lower, the duration of the CSP was shorter and SICI was reduced in patients compared with the control group. These findings are suggestive of increased neural excitability and reduced GABAergic inhibition following exposure to tramadol. Also there were negative correlations between the severity of tramadol dependence and a number of cortical excitability parameters (AMT, RMT, and CSP with P=0.002, 0.005, and 0.04 respectively). CONCLUSIONS: The results provide evidence for hyperexcitability of the motor cortex coupled with inhibitory deficits in tramadol dependent patients.

BACKGROUND: Addiction to tramadol, a widely used analgesic, is becoming increasingly common. Tramadol can also induce seizures even after a single clinical dose. We tested whether the epileptogenicity of tramadol was associated with any changes in cortical excitability and inhibitory transmission using transcranial magnetic stimulation (TMS). METHODS: The study included 16 tramadol dependent patients and 15 age and sex matched healthy volunteers. Clinical evaluation was conducted using an addiction severity index. TMS assessment of excitability was conducted on the motor cortex since the response to each TMS pulse at that site is easily measured in terms of the amplitude of the twitches it evokes in contralateral muscles. Measures included resting and active motor threshold (RMT and AMT respectively), motor evoked potential (MEP) amplitude, cortical silent period (CSP) duration, transcallosal inhibition (TCI), and short interval intracortical inhibition and facilitation (SICI and ICF respectively). Urinary level of tramadol was measured immediately before assessing cortical excitability in each patient. RESULTS: RMT and AMT were significantly lower, the duration of the CSP was shorter and SICI was reduced in patients compared with the control group. These findings are suggestive of increased neural excitability and reduced GABAergic inhibition following exposure to tramadol. Also there were negative correlations between the severity of tramadol dependence and a number of cortical excitability parameters (AMT, RMT, and CSP with P=0.002, 0.005, and 0.04 respectively). CONCLUSIONS: The results provide evidence for hyperexcitability of the motor cortex coupled with inhibitory deficits in tramadol dependent patients.

BACKGROUND: Recent studies have shown that novel neuro-modulating techniques can have pain-relieving effects in the treatment of chronic pain. The aim of this work is to evaluate the effects of transcranial direct current stimulation (tDCS) in relieving fibromyalgia pain and its relation with beta-endorphin changes. MATERIAL AND METHODS: Forty eligible patients with primary fibromyalgia were randomized to receive real anodal tDCS or sham tDCS of the left motor cortex (M1) daily for 10 days. Each patient was evaluated using widespread pain index (WPI), symptom severity of fibromyalgia (SS), visual analogue scale (VAS), and determination of pain threshold as a primary outcome. Hamilton depression and anxiety scales (HAM-D and HAM-A) and estimation of serum beta-endorphin level pre and post-sessions were used as secondary outcome. All rating scales were conducted at the baseline, after the 5th, 10th session, 15 days and 1 month after the end of the sessions. RESULTS: Eighteen patients from each group completed the follow-up schedule with no significant difference between them regarding the duration of illness or the baseline scales. A significant TIME × GROUP interaction for each rating scale (WPI, SS, VAS, pain threshold, HAM-A, HAM-D) indicated that the effect of treatment differed in the two groups with higher improvement in the experimental scores of the patients in the real tDCS group (P = 0.001 for WPI, SS, VAS, pain threshold, and 0.002, 0.03 for HAM-A, HAM-D respectively). Negative correlations between changes in serum beta-endorphin level and the changes in different rating scales were found (P = 0.003, 0.003, 0.05, 0.002, 0002 for WPI, SS, VAS, HAM-A, and HAM-D respectively). CONCLUSION: Ten sessions of real tDCS over M1 can induce pain relief and mood improvement in patients with fibromyalgia, which were found to be related to changes in serum endorphin levels.

BACKGROUND: Recent studies have shown that novel neuro-modulating techniques can have pain-relieving effects in the treatment of chronic pain. The aim of this work is to evaluate the effects of transcranial direct current stimulation (tDCS) in relieving fibromyalgia pain and its relation with beta-endorphin changes. MATERIAL AND METHODS: Forty eligible patients with primary fibromyalgia were randomized to receive real anodal tDCS or sham tDCS of the left motor cortex (M1) daily for 10 days. Each patient was evaluated using widespread pain index (WPI), symptom severity of fibromyalgia (SS), visual analogue scale (VAS), and determination of pain threshold as a primary outcome. Hamilton depression and anxiety scales (HAM-D and HAM-A) and estimation of serum beta-endorphin level pre and post-sessions were used as secondary outcome. All rating scales were conducted at the baseline, after the 5th, 10th session, 15 days and 1 month after the end of the sessions. RESULTS: Eighteen patients from each group completed the follow-up schedule with no significant difference between them regarding the duration of illness or the baseline scales. A significant TIME × GROUP interaction for each rating scale (WPI, SS, VAS, pain threshold, HAM-A, HAM-D) indicated that the effect of treatment differed in the two groups with higher improvement in the experimental scores of the patients in the real tDCS group (P = 0.001 for WPI, SS, VAS, pain threshold, and 0.002, 0.03 for HAM-A, HAM-D respectively). Negative correlations between changes in serum beta-endorphin level and the changes in different rating scales were found (P = 0.003, 0.003, 0.05, 0.002, 0002 for WPI, SS, VAS, HAM-A, and HAM-D respectively). CONCLUSION: Ten sessions of real tDCS over M1 can induce pain relief and mood improvement in patients with fibromyalgia, which were found to be related to changes in serum endorphin levels.

BACKGROUND: Recent studies have shown that novel neuro-modulating techniques can have pain-relieving effects in the treatment of chronic pain. The aim of this work is to evaluate the effects of transcranial direct current stimulation (tDCS) in relieving fibromyalgia pain and its relation with beta-endorphin changes. MATERIAL AND METHODS: Forty eligible patients with primary fibromyalgia were randomized to receive real anodal tDCS or sham tDCS of the left motor cortex (M1) daily for 10 days. Each patient was evaluated using widespread pain index (WPI), symptom severity of fibromyalgia (SS), visual analogue scale (VAS), and determination of pain threshold as a primary outcome. Hamilton depression and anxiety scales (HAM-D and HAM-A) and estimation of serum beta-endorphin level pre and post-sessions were used as secondary outcome. All rating scales were conducted at the baseline, after the 5th, 10th session, 15 days and 1 month after the end of the sessions. RESULTS: Eighteen patients from each group completed the follow-up schedule with no significant difference between them regarding the duration of illness or the baseline scales. A significant TIME × GROUP interaction for each rating scale (WPI, SS, VAS, pain threshold, HAM-A, HAM-D) indicated that the effect of treatment differed in the two groups with higher improvement in the experimental scores of the patients in the real tDCS group (P = 0.001 for WPI, SS, VAS, pain threshold, and 0.002, 0.03 for HAM-A, HAM-D respectively). Negative correlations between changes in serum beta-endorphin level and the changes in different rating scales were found (P = 0.003, 0.003, 0.05, 0.002, 0002 for WPI, SS, VAS, HAM-A, and HAM-D respectively). CONCLUSION: Ten sessions of real tDCS over M1 can induce pain relief and mood improvement in patients with fibromyalgia, which were found to be related to changes in serum endorphin levels.

BACKGROUND: Recent studies have shown that novel neuro-modulating techniques can have pain-relieving effects in the treatment of chronic pain. The aim of this work is to evaluate the effects of transcranial direct current stimulation (tDCS) in relieving fibromyalgia pain and its relation with beta-endorphin changes. MATERIAL AND METHODS: Forty eligible patients with primary fibromyalgia were randomized to receive real anodal tDCS or sham tDCS of the left motor cortex (M1) daily for 10 days. Each patient was evaluated using widespread pain index (WPI), symptom severity of fibromyalgia (SS), visual analogue scale (VAS), and determination of pain threshold as a primary outcome. Hamilton depression and anxiety scales (HAM-D and HAM-A) and estimation of serum beta-endorphin level pre and post-sessions were used as secondary outcome. All rating scales were conducted at the baseline, after the 5th, 10th session, 15 days and 1 month after the end of the sessions. RESULTS: Eighteen patients from each group completed the follow-up schedule with no significant difference between them regarding the duration of illness or the baseline scales. A significant TIME × GROUP interaction for each rating scale (WPI, SS, VAS, pain threshold, HAM-A, HAM-D) indicated that the effect of treatment differed in the two groups with higher improvement in the experimental scores of the patients in the real tDCS group (P = 0.001 for WPI, SS, VAS, pain threshold, and 0.002, 0.03 for HAM-A, HAM-D respectively). Negative correlations between changes in serum beta-endorphin level and the changes in different rating scales were found (P = 0.003, 0.003, 0.05, 0.002, 0002 for WPI, SS, VAS, HAM-A, and HAM-D respectively). CONCLUSION: Ten sessions of real tDCS over M1 can induce pain relief and mood improvement in patients with fibromyalgia, which were found to be related to changes in serum endorphin levels.

BACKGROUND: Recent studies have shown that novel neuro-modulating techniques can have pain-relieving effects in the treatment of chronic pain. The aim of this work is to evaluate the effects of transcranial direct current stimulation (tDCS) in relieving fibromyalgia pain and its relation with beta-endorphin changes. MATERIAL AND METHODS: Forty eligible patients with primary fibromyalgia were randomized to receive real anodal tDCS or sham tDCS of the left motor cortex (M1) daily for 10 days. Each patient was evaluated using widespread pain index (WPI), symptom severity of fibromyalgia (SS), visual analogue scale (VAS), and determination of pain threshold as a primary outcome. Hamilton depression and anxiety scales (HAM-D and HAM-A) and estimation of serum beta-endorphin level pre and post-sessions were used as secondary outcome. All rating scales were conducted at the baseline, after the 5th, 10th session, 15 days and 1 month after the end of the sessions. RESULTS: Eighteen patients from each group completed the follow-up schedule with no significant difference between them regarding the duration of illness or the baseline scales. A significant TIME × GROUP interaction for each rating scale (WPI, SS, VAS, pain threshold, HAM-A, HAM-D) indicated that the effect of treatment differed in the two groups with higher improvement in the experimental scores of the patients in the real tDCS group (P = 0.001 for WPI, SS, VAS, pain threshold, and 0.002, 0.03 for HAM-A, HAM-D respectively). Negative correlations between changes in serum beta-endorphin level and the changes in different rating scales were found (P = 0.003, 0.003, 0.05, 0.002, 0002 for WPI, SS, VAS, HAM-A, and HAM-D respectively). CONCLUSION: Ten sessions of real tDCS over M1 can induce pain relief and mood improvement in patients with fibromyalgia, which were found to be related to changes in serum endorphin levels.

Background: Steal syndrome complicates access in an increasing number of chronic renal failure (CRF) patients. Surgical procedures as (banding or stula ligation) to manage this issue have proved to be entirely unsatisfactory because of loss of the recently created access through ligation or attempted salvage by increasing resistance within the stula. Objective: To determine the results of DRIL technique in treating steal syndrome in CRF patients. Methods: A retrospective study (2015 to 2017) was conducted on 49 patients complaining of steal syndrome (out of 1200 CRF patients) with ages ranged from 35 to 71 years (mean=57 years) after obtaining written informed consent. Twenty nine patients were females (59.1%) and 20 (40.9%) were males. These subjects have undergone DRIL procedure in Vascular Surgery Departments, Qena and Assiut University Hospitals. Pre-procedural angiography was performed in most cases. Patient characters, risk factors, types of stulae and indications for surgery were listed. The clinical outcomes of the procedure, Arteriovenous Access (AVA) and bypass graft patency were determined as well. Results: The AVA, which led to steal syndrome, was proximally located in the arm (brachiocephalic in 14, brachiobasilic in 14, and prosthetic brachio-axillary in the remaining 21 patients). Steal symptoms comprised hand ache, neurologic de ciency and gangrenous ulcerations. The procedure was technically effective in all subjects. Prompt and total pain release was accomplished in 43 (87.7%) of the 49 patients. One patient (2%) with gangrene later underwent transmetacarpal amputation. No patient required hand amputation. During follow-up (range 0.5 ± 17 months) hemodialysis was carried out continuously using the AVA in 40 subjects. AVA thrombosis had happened in 8 (16.3%) subjects only post DRIL. Signi cant difference was found between diabetes and occurrence of steal syndrome (p value0.05) and between type of stula (prosthetic AVF) and steal syndrome as well (p value0.05). Six subjects died from other causes not related to the performed procedure. Conclusion: In certain subjects DRIL technique is a secure and ef cient method to manage steal syndrome. AVA durability is not in uenced by this procedure. Pre-operative angiography pre and post AVA manual compression is essential for adequate patients’ selection in which bene t will be gained mostly by the performed procedure.

Background: Steal syndrome complicates access in an increasing number of chronic renal failure (CRF) patients. Surgical procedures as (banding or stula ligation) to manage this issue have proved to be entirely unsatisfactory because of loss of the recently created access through ligation or attempted salvage by increasing resistance within the stula. Objective: To determine the results of DRIL technique in treating steal syndrome in CRF patients. Methods: A retrospective study (2015 to 2017) was conducted on 49 patients complaining of steal syndrome (out of 1200 CRF patients) with ages ranged from 35 to 71 years (mean=57 years) after obtaining written informed consent. Twenty nine patients were females (59.1%) and 20 (40.9%) were males. These subjects have undergone DRIL procedure in Vascular Surgery Departments, Qena and Assiut University Hospitals. Pre-procedural angiography was performed in most cases. Patient characters, risk factors, types of stulae and indications for surgery were listed. The clinical outcomes of the procedure, Arteriovenous Access (AVA) and bypass graft patency were determined as well. Results: The AVA, which led to steal syndrome, was proximally located in the arm (brachiocephalic in 14, brachiobasilic in 14, and prosthetic brachio-axillary in the remaining 21 patients). Steal symptoms comprised hand ache, neurologic de ciency and gangrenous ulcerations. The procedure was technically effective in all subjects. Prompt and total pain release was accomplished in 43 (87.7%) of the 49 patients. One patient (2%) with gangrene later underwent transmetacarpal amputation. No patient required hand amputation. During follow-up (range 0.5 ± 17 months) hemodialysis was carried out continuously using the AVA in 40 subjects. AVA thrombosis had happened in 8 (16.3%) subjects only post DRIL. Signi cant difference was found between diabetes and occurrence of steal syndrome (p value0.05) and between type of stula (prosthetic AVF) and steal syndrome as well (p value0.05). Six subjects died from other causes not related to the performed procedure. Conclusion: In certain subjects DRIL technique is a secure and ef cient method to manage steal syndrome. AVA durability is not in uenced by this procedure. Pre-operative angiography pre and post AVA manual compression is essential for adequate patients’ selection in which bene t will be gained mostly by the performed procedure.

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