1/10. Low-dose ketamine in the management of opioid nonresponsive terminal cancer pain.Two patients with far-advanced cancer, near death, who were experiencing excruciating and intractable pain that was poorly responsive to rapidly escalating doses of morphine and hydromorphone were treated with low-dose intravenous ketamine (0.1-0.2 mg/kg). This intervention eliminated the need for any further opioid use, providing profound analgesia and a sense of calm during the last hours and days of these patients' lives. These case reports add to the small but growing body of clinical literature suggesting that ketamine may have a significant place in the care of patients with pain that is poorly responsive to opioids, or who experience dose-limiting adverse effects, near the end of life. This is an important matter to disseminate in order to reassure the public that we do have the tools necessary to keep the promise that no one need die with uncontrolled pain. This therapeutic approach may also serve to reassure concerned physicians that their efforts to assure pain relief may not be misconstrued as hastening death.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/10. The debate on elder abuse for undertreated pain.Presented is a review of the pain management provided to an elderly male patient dying of mesothelioma in an acute care hospital and, subsequently, in a nursing home. Discussed are the medico-legal aspects of the case, including the patient's survivors' efforts to hold the treating physicians, hospital, and nursing home accountable for inadequate pain management through complaints submitted to the state medical board, the state department of health services, and the Center for medicaid/medicare Services, and in state court.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/10. Treatment challenges and complications with ziconotide monotherapy in established pump patients.BACKGROUND: The U.S. food and Drug Administration (FDA) recently approved Ziconotide intrathecal infusion for the management of severe chronic pain in patients for whom intrathecal therapy is warranted, and who are intolerant of, or refractory to, other methods of treatment, including intrathecal morphine. Ziconotide is approved as a monotherapy, but there are challenges associated with the decision to wean intrathecal opioids for Ziconotide alone. Maintaining adequate analgesia and managing opioid withdrawal symptoms may be difficult. Additionally, a variety of adverse physiological, cognitive and psychiatric events may be associated with this new drug. patients with pretreatment psychiatric disorders may be at increased risk for treatment complications. OBJECTIVE: To present a report of a case series describing treatment challenges and complications associated with the decision to convert established pump patients from intrathecal opioid therapy to Ziconotide monotherapy. DESCRIPTION OF CASES: Three established pump patients, refractory to intrathecal opioid therapy, were converted to Ziconotide monotherapy. All of these patients experienced significant emotional distress or psychological symptoms that threatened the success of the treatment. Achieving adequate analgesia, reducing Ziconotide to mitigate adverse physiological effects, managing opioid withdrawal symptoms, and supportive psychological consultation were combined to achieve successful outcomes in two of our three patients. CONCLUSION: This report describes challenges associated with the decision to convert established pump patients from intrathecal opioid therapy to Ziconotide monotherapy. Inadequate analgesia, adverse medication effects, and opioid withdrawal symptoms can precipitate a stressful situation that may be perceived as dangerous or threatening by patients who are predisposed to anxiety. Screening patients for psychiatric disorders, anxiety-proneness and/or vulnerability to stress should be considered to reduce the risk of treatment complications. A multimodal approach is strongly advocated, including rapid responses of treating physicians and nurses along with strong psychological support.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/10. Intraventricular morphine for intractable craniofacial pain.This case management report on a patient with advanced craniofacial neoplasm discusses the successful treatment of chronic pain by the cortical intraventricular narcotic administration. A previously treated patient with surgery and radiotherapy for carcinoma of the palate developed severe intractable pain despite high dose oral morphine therapy. Investigations revealed that neoplasm had reoccurred with extensive infiltration. Intraventricular morphine therapy was discussed and accepted by the patient and family. A ventricular shunt with an Ommaya reservoir was inserted under local anaesthesia. Preservative-free morphine sulphate in increasing doses of 0.25 to 1 mg was administered, once daily, which kept the patient in a pain-free state. The treatment was initiated in the hospital and continued at home till the demise of the patient on the 9th week. The home care was provided by the nurses of home nursing Foundation and singapore Cancer Society under physician supervision. There were no complications which had been reported in the literature, observed in the management of this patient.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/10. Goal-Directed Health Care and the chronic pain patient: a new vision of the healing encounter.We introduce a new way to engage the patient with chronic pain, Goal-Directed Health Care (G-DHC). Identifying the patient's major life goals during the medical interview is the key element of this approach along with connecting these life goals to specific health-related goals. The implementation of G-DHC is a shift in process from the usual focus on disease-related goals such as relief of pain, titrating narcotic refills, and working on condition management to broader, long-term, personal goals. It emphasizes the importance of identifying the global life goals of patients and the reasons they wish to be well for and what they would do with improved health once they had it. Utilizing these life goals as a point of reference, discussion, and motivation makes clearer what specified health goals mean, whether or not the patient is ready to work on them, and most significantly, what the underlying motivation is to participate in their own care. We anticipate such a model of patient-centered care will shift the dynamic of the medical encounter with the patient with chronic pain to one that is ultimately more productive and satisfying for both patient and physician. Illustrations of cases, questions to ask patients, and a detail of the process may allow the reader to adopt this method into their practice.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/10. hypnosis as an adjunct in management of pain.hypnosis in the management of intractable pain is a valuable but frequently overlooked tool for the practicing physician. Two cases are presented which illustrate some of the benefits and limitations of hypnosis in pain management. hypnosis is most effective when the patient is motivated, and pain is a strong motivating force. Secondary gain from the pain and underlying psychiatric illness must be considered when seemingly routine pain problems do not respond to hypnosis. hypnosis may be equally effective for pain of organic or psychogenic origin. Ancillary benefits from hypnosis may include a diminution of secondary anxiety and depression. The technic is impractical for some patients because of the time requirements, but proper patient selection can obviate much of this objection. Self-hypnosis and/or the supervised use of a relative as a substitute for the physician enhances effectiveness. Training in hypnosis for adjunctive use in the management of pain is available to primary care physicians.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
7/10. Treatment of chronic pain in the general psychiatric hospital.patients with chronic pain present many diagnostic and therapeutic challenges to primary physicians and psychiatric consultants. The authors present a series of twelve patients with chronic pain who were hospitalized on the psychiatric ward of a general hospital. Ten of the twelve patients presented decreased their medication use and were markedly improved at the end of their brief stay. Treatment goals, attitudes and interventions are discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/10. Clinical efficacy of methadone in patients refractory to other mu-opioid receptor agonist analgesics for management of terminal cancer pain. Case presentations and discussion of incomplete cross-tolerance among opioid agonist analgesics.BACKGROUND. Development of tolerance to opioid analgesics occurs often in patients with cancer-related pain. Cross-tolerance among opioid analgesics provides the physician with a major management problem. Incomplete cross-tolerance among opioid analgesics has been demonstrated to occur in animals and humans. The current study provides clinical evidence of the incomplete cross-tolerance of methadone with a number of mu-opioid agonist analgesics in patients with advanced cancer-related pain. RESULTS. patients presented in the current study had cancer-related pain refractory to other mu--opioid receptor agonist analgesics as evidenced by inadequate analgesia despite escalation of opioid dose. All patients were adequately managed by conversion of their opioid dose to methadone. Additionally, the dose of methadone required to establish and maintain analgesia in these patients was modest compared with previous opioid dose requirements. CONCLUSIONS. methadone is a potent opioid analgesic that demonstrates incomplete cross-tolerance with other mu-opioid receptor agonist analgesics. Conversion of the opioid-tolerant patient with cancer-related pain to methadone may represent an important therapeutic option in the management of patients with this difficult problem.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/10. gas gangrene from subcutaneous insulin administration.A case of gas gangrene that caused intractable shoulder pain refractory to narcotics in an immunocompromised host is presented. gas gangrene has been associated with severe trauma involving penetrating wounds, compound fractures, extensive soft-tissue injury, intramuscular injection of epinephrine, and interruption of arterial blood supply. This case describes an elderly insulin-dependent diabetic woman who developed gas gangrene in her arm and leg at the site of her subcutaneous insulin injections. The responsible organism was clostridium septicum. emergency medicine physicians must consider gas gangrene Clostridium infection in immunocompromised individuals without evidence of trauma who present with localized and intractable pain.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/10. Chronic groin pain in an athlete: an unusual presentation.Persistent disabling groin pain in an active sportsman is a frustrating diagnostic and management problem for both the athlete and physician. After clinical examination and investigation there remains a group of patients who have unexplained groin pain, and may undergo lengthy periods of conservative management with numerous radiological investigations. Here we highlight such a case.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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