Cases reported "Pain"

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1/15. Preliminary evaluation of a fixed dose of zwitterionic piperazine (TVZ-7) in clinical cancer.

    One of the zwitterion buffers that has shown significant therapeutic value in the treatment of pain due to cancer, immunologically mediated diseases, and the pain associated with these conditions is in the class of N-substituted amino-sulfonic acids known as "Good buffers." Zwitterion molecules have neither a negative nor a positive charge; thus, they are neutral. 4-(2 Hydroxyethyl)-1-piperazine ethane sulfonic acid has been used for several decades in artificial biological systems (tissue culture) as a buffer. We have been exploring the therapeutic value of these zwitterionic buffers. Pilot animal studies have demonstrated that zwitterionic piperazine increases bone marrow hypercellularity and induces extramedullary hematopoiesis. We report the initial human use to explore dose toxic and physiologic effects of a fixed dose of the zwitterionic piperazine molecule. There appears to be potential therapeutic value in the treatment of pain due to cancer, and there are preliminary indications that tumor activity and tumor size are reduced. Immunologically mediated diseases may also be affected. Toxicity is low and there appear to be minimal side effects.
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2/15. Human "autotomy".

    We describe two cases of self-injurious behaviour. One was a man with central post-stroke pain with maximal pain in the tip of the nose, who excavated his ala nasae--in which he subsequently continued to experience phantom pain. The second case a man who, following ophthalmic herpes zoster and possibly mild postherpetic neuralgia. He subsequently scratched his anaesthetic forehead down to the bone, while denying he experienced any pain. We would describe the first case as one of true autotomy; but the second as destruction of an anaesthetic part of the body. The implications for human and animal physiopathology are discussed.
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3/15. Walterinnesia aegyptia envenomation in a 22-year-old female: a case report.

    A 22-year-old woman was bitten on the third finger of her left hand by a Walterinnesia aegyptia (desert black cobra). Local signs included a marked swelling of the entire hand with pain along the left upper limb. Systemic reactions were irritability, fever, tachycardia, ventricular premature beats, nausea and high blood leukocytes count. About 15 h post-envenomation the patient had no symptoms except for a mild swelling of the hand. Despite the severe toxic venom composition of the W. aegyptia, the clinical course of our patient was relatively benign. This could be explained by the snake's behavior and the mechanism by which the venom penetrates the body. A survey of the literature revealed only a few clinical cases reported. Most of the information concerning W. aegyptia was collected from laboratory and animal studies.
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4/15. Antineuropathic effects of the antibiotic derivative spicamycin KRN5500.

    Excellence in neuropathic pain management continues to challenge the ability of health care providers. Current medications are helpful but often create significant side effects or simply fail to provide adequate analgesia. We report here on a serendipitous finding of the successful attenuation of neuropathic pain in a patient with long-standing monoclonal gammopathy, Raynaud's disease, and neuropathic pain who received the trial chemotherapeutic agent KRN5500. This finding led to animal studies that have provided support for the possible use of KRN5500 in the treatment of neuropathic pain in humans as well as some insight into the possible mechanism(s) of action of this drug.
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5/15. Central neuropathic itch from spinal-cord cavernous hemangioma: a human case, a possible animal model, and hypotheses about pathogenesis.

    Cavernous hemangiomas (cavernomas) of the spinal cord are rare congenital malformations that comprise less than 5% of all intramedullary lesions. Despite this rarity, we describe the third case of central neuropathic itch associated with intramedullary cavernoma. Since fewer than 10 cases of central spinal itch from all causes have been published, this concurrence suggests the possibility of a specific association. A middle-aged man developed chronic disabling neuropathic itch and pain affecting his left shoulder and arm after frank hemorrhage of a midcervical cavernoma. We hypothesize that the relatively rostro-dorsal location of his lesion increased its likelihood of causing itch as well as pain. The microscopic pathology of cavernomas, specifically their gliotic rim containing hemosiderin-laden phagocytes, fosters ectopic firing of nearby neurons and makes cranial cavernomas highly epileptogenic. We hypothesize that these pathological features predispose cavernomas to cause central itch if they are located near, but spare, the central itch projection neurons in lamina I of the dorsal horn. Quisqualate injections into the deeper layers (neck) of the dorsal horns of rats produce pathologically similar lesions. Such rats develop unilateral dermatomal hyperalgesia and self-injurious scratching and biting (autotomy). Although this pathological grooming is currently interpreted as a response to chronic pain, we propose that it more likely models scratching provoked by central neuropathic itch, as seen in our patient and others. Study of quisqualate-injected rats may provide leads towards new treatments for neuropathic itch.
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6/15. Neuropathological findings after continuous intrathecal administration of S( )-ketamine for the management of neuropathic cancer pain.

    Questions have been raised about the potential neurotoxicity of the neuraxial use of ketamine although ketamine and its active enantiomer S( )-ketamine have been used intrathecally and epidurally (caudally) for the management of perioperative pain and in a variety of chronic pain syndromes. Clinical experience following neuraxial administration of S( )-ketamine has been documented without reference to local central nervous system toxicity following this approach. In addition, there are no preclinical safety data regarding stability, compatibility, and neurotoxicity on intrathecal use of single S( )-ketamine or combinations of S( )-ketamine, morphine, bupivacaine, and clonidine. In the present case, the continuous intrathecal administration of S( )-ketamine, in combination with morphine, bupivacaine, and clonidine resulted in adequate pain relief in a patient suffering from intractable neuropathic cancer pain. However, postmortem observation of the spinal cord and nerve roots revealed severe histological abnormalities including central chromatolysis, nerve cell shrinkage, neuronophagia, microglial upregulation, and gliosis. Based on our results, neuraxial administration of S ( )-ketamine cannot be recommended for clinical practise before a systematic study of toxicology of neuraxial S( )-ketamine in animals or humans has been performed.
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7/15. Suffering and euthanasia.

    Suffering is a powerful but elusive concept in veterinary medicine. Because the companion animal cannot talk, assessment of suffering requires the best judgment of veterinarian, family, and other interested participants. Determining whether euthanasia is appropriate rests on a similar consensus but is based on the entire medical and social situation. Clinicians need skill, sensitivity, and a well-developed sense of timing to uncover what clients really feel and want. Offering the family options, such as to be present during the euthanasia, makes the veterinarian's task easier and helps clients cope.
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8/15. Psychological regression and marital status: determinants in psychiatric management of burn victims.

    Major burn trauma is ordinarily associated with psychological regression, which regularly assumes either an immature, dependent (childlike), or primitive (animal-like) form. Also, the severely burned patient is exquisitely responsive, both constructively and destructively, to behavioral nuances in his or her "significant other," typically, the spouse. Two variables, type of regression and marital status, provide an empirically derived rationale for the psychiatric treatment of behavioral problems affecting patient management, including especially (1) pain-related behavior, (2) intrusive reexperiencing of the trauma, (3) depletion/despair phenomena, and (4) problems related to scarring. Results are more favorable when regression is of the dependent type rather than primitive type. Treatment is enhanced when the partner in a committed relationship is included in the treatment program.
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9/15. sodium cholate dissolution of retained biliary stones: mortality rate following intrahepatic infusion.

    The reported complication rate from T-tube infusion of sodium cholate for dissolution of retained biliary stones is low. Among 84 patients reported in the English-language literature, and 10 additional cases of our own, there have been no deaths, an incidence of liver enzyme elevation in 7%, fever in 5%, cholangitis in 2%, and pancreatitis in 2%. Recently, we have infused 100mM sodium cholate at 30 cc/hr into patients through transhepatic biliary stents in an effort to rid the intrahepatic biliary tree of retained stones and biliary sludge. Appropriate precautions were taken to prevent increased biliary pressures by the insetion of a 30 cm manometer into the perfusion system. During four transhepatic infusions in three patients, all experienced nausea and vomiting, and two of the three patients developed diarrhea and abdominal pain. liver enzymes became elevated during all four infusions, and two of the three patients became septic and died shortly after their infusions. Experimental work in animals suggests that intrahepatic sodium cholate infusion results in injury to the ductal epithelium and predisposes patients to bactermia and sepsis. Even though T-tube infusion of sodium cholate into the common bile duct is well tolerated, direct infusion into the intrahepatic biliary tree through a transhepatic tube is not and carries a high risk of sepsis and death.
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10/15. Painful neuroma: changes produced in peripheral nerve after fascicle ligation.

    Sixteen months after resection of a painful neuroma and fascicle ligation of the proximal nerve segments, the fascicle ligated neural tissue was examined by light and electron microscopy. No significant neuroma formation was found in the fascicle-ligated regions. The distal portion consisted mainly of connective tissue fibroblasts with an absence of neural elements. Maintaining the perineurium intact by fascicle ligation seems to alter significantly axonal regeneration in humans, as is indicated by minimal neuroma formation. Similar findings after fascicle ligation in animals have also been reported. This lack of neuroma formation after resection of a painful neuroma and fascicle ligation may play a significant role in relieving pain in patients with painful neuromas.
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