The Journal of family practice
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Successful treatment of pain syndromes is one of the most common and most difficult problems facing family physicians. Frequently analgesics provide inadequate treatment, and clinicians are forced to consider alternatives. This article reviews the neurophysiologic similarities between depression and the chronic pain syndromes and describes several well-designed double-blinded studies that give evidence for the efficacy of antidepressants in chronic pain syndromes. ⋯ For chronic pain, antidepressants should be started at a low dosage and increased in a stepwise manner until an improvement in the pain occurs or intolerable side effects intervene. Side effects are a bothersome aspect of antidepressant therapy but are more tolerable at the doses generally needed for pain relief than at antidepressive doses. At least three weeks of antidepressant therapy is generally needed to gain significant relief of symptoms.
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The case presented here is typical of the localized fibrous mesotheliomas reviewed in the literature. It had a disastrous impact on an otherwise unremarkable pregnancy. There is no discussion in the literature of humeral factors related to localized fibrous mesotheliomas, but the fever, chills, and rheumatoid complaints in some patients may suggest such factors. ⋯ Anticoagulation led to hemorrhage from the thin-walled vascular areas of the tumor. This acute bleeding produced the hypovolemic shock on the third postpartum day, with a cascade of events leading to adult respiratory distress syndrome and the patient's ultimate death. This case underscores the importance of broad differential diagnosis as a continuing challenge in the practice of medicine.