Postgraduate medicine
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A significant proportion of the workforce in industrialized countries (16%) are employed as shift workers. These workers may be susceptible to shift work disorder (SWD), a circadian rhythm sleep disorder, particularly those who work at night or on early-morning shifts. Shift work disorder remains an underdiagnosed and undertreated problem among this population. ⋯ In addition, medications that contain melatonin or caffeine may have clinical benefits in some patients with SWD. However, modafinil and armodafinil are approved by the US Food and Drug Administration to improve wakefulness in patients with excessive sleepiness associated with SWD, and recent data suggest a clinical benefit. The use of these therapies can significantly improve sleep, performance, and quality of life for patients with SWD.
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Postgraduate medicine · Sep 2011
ReviewReview of current guidelines on the care of postherpetic neuralgia.
An unfortunate minority of patients with acute herpes zoster (AHZ) experience pain beyond the typical 4-week duration, and roughly 10% develop the distressing complication of postherpetic neuralgia (PHN), often defined as pain persisting for > 4 months after the onset of the rash. Elderly patients are at increased risk of PHN. The pathophysiology of PHN is complex, likely involving both peripheral and central processes. ⋯ Therapies that have demonstrated effectiveness for other types of neuropathic pain are discussed, such as serotonin-norepinephrine reuptake inhibitors, the anticonvulsants carbamazepine and valproic acid, and botulinum toxin. Invasive procedures such as sympathetic blockade, intrathecal steroids, and implantable spinal cord stimulators have been studied for relief of PHN, mainly in patients refractory to noninvasive pharmacologic interventions. The main guidelines considered here are those issued by the American Academy of Neurology for the treatment of postherpetic neuralgia (2004) and general guidelines for the treatment of neuropathic pain issued by the Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain (2007) and the European Federation of Neurological Societies (2010).
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Postgraduate medicine · Sep 2011
Multicenter Study Clinical TrialOpioid titration and conversion in patients receiving morphine sulfate and naltrexone hydrochloride extended release capsules.
To determine the number of steps and identify characteristics associated with attaining a stable dose of morphine sulfate and sequestered naltrexone extended release capsules (MS-sNT). ⋯ The study provides information about anticipated rates of achieving stable opioid dose in patients who received MS-sNT for up to 1 year to manage chronic, moderate-to-severe pain. Both opioid-naïve and opioid-experienced patients achieved a stable dose of MS-sNT, generally in ≤ 2 steps. Opioid experience and previous opioid use may influence ability to achieve a stable dose and number of steps required. More studies are needed on the anticipated experience of opioid titration/conversion to help physicians and patients set expectations for initiation of and conversion between opioid therapies.
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Many patients with chronic noncancer pain present with comorbid depression, which can greatly complicate the treatment of pain. Chronic pain and depression each increase the risk of licit and illicit substance abuse, including the abuse of opioids, and of suicide. Patients attempting suicide may overdose on opioids, which are commonly perceived as potentially harmful, or acetaminophen, an agent that is believed to be safe but is actually the leading cause of liver failure in the United States. ⋯ These agents limit systemic drug exposure, reducing the risk of systemic adverse events without risk of accidental or deliberate overdose. However, use of topical agents is generally limited to localized pain syndromes and therefore does not substantially eliminate the need for systemic analgesics in those patients with diffuse persistent pain, central sensitization, and opioid-responsive pain. This review will discuss the challenges associated with treating chronic pain in depressed patients and will provide recommendations for optimizing treatment.
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Postgraduate medicine · Sep 2011
Review Case ReportsIs shift work making your patient sick? Emerging theories and therapies for treating shift work disorder.
"Shift work" is a term that applies to a wide array of nontraditional work schedules. Shift work disorder (SWD) is a circadian rhythm sleep disorder experienced by a subset of shift workers that is characterized by excessive sleepiness during work and/or insomnia during scheduled sleep times. It is estimated to affect up to 2 million Americans, and is associated with increased morbidity and mortality from metabolic risk factors, cardiovascular and gastrointestinal diseases, depression, accidents, and some kinds of cancers. ⋯ However, evidence is limited with these approaches in patients diagnosed with SWD. Other treatment options may include pharmacologic interventions such as modafinil and armodafinil, which have shown efficacy in this population. Combined therapy can reduce insomnia and excessive sleepiness, and improve attention and alertness during work shifts and the subsequent commute home.