1/9. amputation: two views.It has been over one year now since his surgery, and Allen has returned to school and work, ambulating on his prosthesis most of the time. As his phantom limb pain decreased and his proficiency in walking increased, his acceptance of his amputation has been demonstrated in his comments and references to himself and his relations with others. As he states, the more comfortable he is about his amputation, the easier it is for others to accept and relate to him. This, I think, is the key to approaching that final stage of acceptance mentioned earlier. The more we can help our patients accept their amputation initially by supporting them through this crisis period, the easier it will be for them to relate to others and grow emotionally from these relationships.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
2/9. amputation and the prevention of phantom pain.Although it has been proposed that preoperative analgesia with epidural administration of analgesics may prevent long-term phantom pain, published results to date have been contradictory and controversial. In this case report, we describe a 41-year-old man with local recurrence of squamous cell carcinoma of the anus who underwent a hemipelvectomy. Preoperatively he had a significant neuropathic pain syndrome requiring oxycodone 60 mg every 4 hours. An epidural infusion of morphine and bupivacaine was started 24 hours preoperatively and discontinued on the third postoperative day. Over the next 10 days the oxycodone was gradually decreased and eventually discontinued prior to discharge. A review of the literature reveals conflicting reports on the benefit of preoperative epidural pain management in the prevention of postoperative pain syndromes. Conflicting research and conclusions of commentators leaves unanswered questions for clinicians. Nevertheless, we do know that we need to provide the best pain relief for patients both before and after amputation. This may require a combination of the oral, subcutaneous or intravenous, and epidural routes.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
3/9. A case of intoxication after a bite by Latrodectus tredecimguttatus.A case of intoxication in Southern bulgaria after a bite from the venomous spider Latrodectus tredecimguttatus is reported. The development of both local (acute pain, itching erythema, paraesthesiae in the area of the bite) and general (weakness, headache, dizziness, fever, vomiting, myalgia, muscle cramps) symptoms, which passed relatively easily, is described. The clinical picture and treatment are briefly commented on.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
4/9. Terminal illness and suicide.Case vignette: Henry, age 19, has been under medical care struggling for 5 months with a non-Hodgkin's lymphoma that has been resistant to treatment. Proven chemotherapy protocols have failed to sustain a remission, and it is evident that his condition is terminal, although not immediately so. When not in temporary remissions he is in extreme pain. The quantity of analgesic medication needed to control the pain also leaves him feeling, in his own words, "too snowed out to do anything." During his last hospital admission, a week ago, he had talked obliquely about ending his life when signs of another painful relapse become evident. Today he appeared in the outpatient clinic, although he had no appointment scheduled. He sought out several of the people who had cared for him over the past few months to thank them and to "say good-bye." He gave some prized personal possessions to one or two of the staff with whom he felt especially close. As this was happening, some of the staff members realized that Henry had a sufficient stock of narcotics at home to end his life. Our commentators are Sanford Leikin, MD, and Richard A. McCormick, SJ.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
5/9. The reach of neurology.Neurologists experienced in the interpretation of disease in terms of disordered action of the nervous system should be well suited to extend their field of interest to the more complex disorders of human behavior, including hysteria, delirium, ill-defined pain syndromes, unexplained fatigue, disorders of thought, atypical depression, and delusions. To illustrate the potential of neurology in approaching the more complex disorders of behavior, several examples from clinical neurology are presented in which phenomena calling for inquiry and analysis in neurological terms are described. The categories are temporal lobe epilepsy, delirium, drug toxicity, disease processes of the cerebrum, obscure pain, dyslexia, and hysteria. Inquiry into complex disorders of behavior is inseparable from the broad subject of normal mental activity, the neural organization subserving all human thought, emotion, and action. Because of this close association, the comment on hysteria includes an introduction to the important question of whether we humans possess a free will to choose our course of behavior.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
6/9. Sickle cell vaso-occlusive pain crisis in adults: alternative strategies for management in the emergency department.The gene for sickle cell disease is carried by 8% of the African-American population in the united states. The primary care physician is often called upon to recognize and treat one of the major sequelae of sickle cell disease--vaso-occlusive pain crisis. An injectable nonsteroidal anti-inflammatory drug has recently become available and may offer some improvement in outcome of vaso-occlusive pain crises. We present five case reports reviewing various current therapeutic options, including newer pharmacologic agents, and comment on alternatives to impatient management of pain crises. The use of the emergency department short-term observation unit as an alternative to hospitalization is discussed.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
7/9. thinking the unthinkable:the clinician as perpetrator of elder abuse in patients in pain.Some advocates for improved pain management have devised and had initial success utilizing a controversial new weapon-the elder abuse claim. In california, two recent cases have been brought under the state's elder abuse statutes against physicians and health care institutions. The first lead to a much publicized jury verdict against a physician, and the second was recently settled as to all defendants, with related disciplinary actions against a treating physician and a skilled nursing facility by their respective regulatory agencies. This commentary reviews the phenomenon of litigating cases of undertreated pain, analyzes the most recent cases, and considers the implications of invoking elder abuse statutes in such cases.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |
8/9. Levetiracetam as an adjunctive analgesic in neoplastic plexopathies: case series and commentary.Certain types of pain associated with cancer may be difficult to treat with standard therapies, often resulting in intractable pain and suffering for the patient. The use of an opioid as analgesic monotherapy can lead to poorly controlled pain as well as multiple side effects. Non-opioid adjunctive analgesics, such as antidepressants and antiepileptic drugs (AEDs) often improve both pain control, and side effect prevalence. Levetiracetam is an AED with unique mechanisms of action that may have analgesic properties in various pain syndromes. Seven patients with neoplasms involving neural structures (four invading the brachial plexus, and three the lumbosacral plexus) had severe pain of 8 to 9 out of 10 on a visual analog scale (VAS), despite the use of parenteral opioids and various adjunctive therapies. These patients were treated with oral levetiracetam titrated over days to two weeks, depending on the location of pain, drug response, and tolerance to tapering of opioid analgesics. Opioid and adjunctive analgesic use and VAS scores were recorded periodically. The maximum levetiracetam dose ranged from 500 mg to 1500 mg BID. All patients experienced pain control improvement after the addition of levetiracetam, with VAS scores decreasing from 8-9 out of 10 to 0-3 out of 10 within two to 14 days of therapy initiation. overall opioid use decreased by at least an estimated 70%, without drug related adverse events. In this small series of patients, levetiracetam effectively and safely improved pain relief in patients with neoplastic plexopathies previously resistant to standard analgesic approaches.- - - - - - - - - - ranking = 4keywords = comment (Clic here for more details about this article) |
9/9. Abrupt onset of severe pain at term. A case report.This case report involves an adolescent primigravida at term who was admitted with urinary complaints to the labor and delivery unit of a medical center. Within an hour, she suddenly began screaming and complaining of severe pain running from her anterior pelvis through her vagina and up her spine. Three days of very challenging co-management of the patient, with several recurrences of acute pain, followed. Differential diagnoses that could explain this patient's symptoms are reviewed and discussed. Difficult management issues, including the stress of clinical management in the face of unidentified disease processes, are addressed. Lacking a certain diagnosis even retrospectively, the authors request comments from readers.- - - - - - - - - - ranking = 1keywords = comment (Clic here for more details about this article) |