BACKGROUND AND PURPOSE:Comprehensive diagnostic criteria encompassing the varied clinical and radiographic manifestations of spontaneous intracranial hypotension are not available. Therefore, we propose a new set of diagnostic criteria.

Background Pain comorbid with depression is frequently encountered in clinical settings and often leads to significant impaired functioning. Given the complexity of comorbidities, it is important to address both pain and depressive symptoms when evaluating treatment options. Aim To review studies addressing pain comorbid with depression, and to report the impact of current treatments. Method A systematic search of the literature databases was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 28 articles to be included in this review. Results Overall, studies suggested that pain and depression are highly intertwined and may co-exacerbate physical and psychological symptoms. These symptoms could lead to poor physical functional outcomes and longer duration of symptoms. An important biochemical basis for pain and depression focuses on serotonergic and norepinephrine systems, which is evident in the pain-ameliorating properties of serotonergic and norepinephrine antidepressants. Alternative pharmacotherapies such as ketamine and cannabinoids appear to be safe and effective options for improving depressive symptoms and ameliorating pain. In addition, cognitive-behavioral therapy may be a promising tool in the management of chronic pain and depression. Conclusion The majority of the literature indicates that patients with pain and depression experience reduced physical, mental, and social functioning as opposed to patients with only depression or only pain. In addition, ketamine, psychotropic, and cognitive-behavioral therapies present promising options for treating both pain and depression.

This retrospective analysis suggests an association between increased doses of opioids during the initial 96 h postoperative period with a higher recurrence rate of NSCLC within 5 yr.

Previously we tested the validity ofthe one-dimensional diffusion equation for 02 in the excised frog sartorius muscle and used it to measure the diffusion coefficient (D) for 02 in this muscle and the time course of its rate of 02 consumption (Qoe) after a tetanus (Mahler, 1978, 1979 . A transverse section of the frog sartorius is in fact well fit by a hemi-ellipse with width divided by maximum thickness averaging 5 .1 ± 0.2. Using the previous techniques with the two-dimensional diffusion equation and this hemi-elliptical boundary yields a value for D that is 30% smaller than reported previously ; the revised values at 0, 10, and 22 .8°C are 6.2, 7 .9, and 10 .8 X 10 -6 cm2/s, respectively . After a tetanus at 20'C, Qos rose quickly to a peak and then declined exponentially, with a time constant (r) -15% faster than that reported previously ; r averaged 2.1 min in Rana temporaria and 2 .6 min in Rana pipiens. A technique was devised to measure the solubility (a) of 02 in intact, respiring muscles, and yielded "(muscle)/ a(H 2 0) = 1 .26 ± 0.04 . With these modifications, the values for 0 2 consumption obtained with the diffusion method were in agreement with those measured by the direct method of Kushmerick and Paul (1976,J . Physiol. [Loud .] ., 254 :693-709) . Using results from both methods, at 20°C the ratio of phosphorylcreatine split during a tetanus to 0 2 consumption during recovery ranged from 5 .2 to 6.2 Amol/jmol, and postcontractile ATP hydrolysis was estimated to be 13 .6 ± 4 .1 (n = 3) nmol/umol total creatine .

The outcome of spontaneous intracranial hypotension has been unpredictable. The results of initial MRI were correlated to outcome of treatment in 33 patients with spontaneous intracranial hypotension. A good outcome was obtained in 25 (97%) of 26 patients with an abnormal MRI vs only 1 (14%) of 7 patients with a normal MRI (p 0.00004). These findings show that normal initial MRI is predictive of poor outcome in spontaneous intracranial hypotension. Spontaneous intracranial hypotension is increasingly recognized as an important cause of new daily persistent headaches, although an initial misdiagno-sis remains common. 1 The cause of spontaneous in-tracranial hypotension is a spontaneous spinal CSF leak often associated with an underlying generalized connective tissue disorder. 2 Most cases of spontaneous intracranial hypotension are believed to be self-limiting, and initial treatment is centered around a course of bedrest and hydration. Nevertheless, persistent symptoms are present in the majority of patients who come to medical attention; for those, a variety of treatment options are available, including epidural blood patching, 3 percutaneous fibrin sealant placement, 4 and surgical repair of the underlying CSF leak. 5 The reported results of these various treatments have generally been good, but the outcome of spontaneous intracranial hypotension is unpredictable and some patients have persistent and often incapacitating symptoms in spite of maximal medical and surgical treatments. The vast majority of patients with spontaneous intracranial hypoten-sion undergo cranial MRI scanning early in their clinical course prior to any therapeutic intervention. It has been our experience that patients with recalci-trant symptoms generally have had normal MRI findings. We therefore investigated a large group of patients with spontaneous intracranial hypotension to determine whether abnormalities on initial MRI can predict outcome. Methods. The patient population consisted of a group of 33 consecutive patients with spontaneous spinal CSF leaks and intracra-nial hypotension who were referred to us for evaluation and treatment. The mean age of the 23 women and 10 men was 41 years (range 13 to 72 years). The presenting symptom was a positional headache in 31 patients, a nonpositional headache in one patient, and nonpositional neck pain in one patient. Cranial MRI was available for all patients, which was reviewed for features of intracranial hypotension. The presence of a spinal CSF leak was confirmed by CT myelography in all patients. Radionu-clide cisternography was performed in only a few patients because CT myelography has almost completely replaced this nuclear medicine study in our practice. None of the patients had a cranial CSF leak. Treatment consisted of 1) conservative measures such as bedrest, oral hydration, oral caffeine, and use of an abdominal binder; 2) high-volume epidural blood patching (up to 80 mL) injected at the thoracolumbar junction; 3) percutaneous placement of a fibrin sealant; or 4) surgical repair ...