Pain management
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This article surveys the use of pain charts or pain drawings in eliciting information about the location of pain symptoms from children and adolescents. While pain charts are widely used and have been incorporated in multidimensional pediatric pain questionnaires and diaries, they present a number of issues requiring further study. ⋯ Where the investigator's interest is restricted to a few areas of the body, checklists of body parts may have greater utility than pain charts. A new pain chart adapted for use in studies of pediatric recurrent and chronic pain is presented.
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Despite state-of-the-art palliative care, some patients will require proportionate palliative sedation as a last-resort option to relieve intolerable suffering at the end of life. In this practice, progressively increasing amounts of sedation are provided until the target suffering is sufficiently relieved. Uncertainty and debate arise when this practice approaches palliative sedation to unconsciousness (PSU), especially when unconsciousness is specifically intended or when the target symptoms are more existential than physical. ⋯ Although relatively rare, PSU and more aggressive end-of-the-spectrum proportionate palliative sedation represent responses to some of the most challenging cases faced by palliative care clinicians. These complex cases clearly require open communication and collaboration among caregivers, patients and family. Knowing how to identify these circumstances, and how to approach these interventions of last resort are critical skills for practitioners who take care of patients at the end of life.
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The intradiscal electrothermal therapy (IDET) procedure is a minimally invasive technique designed to treat discogenic chronic low back pain. The debate surrounding IDET ranges from the concept of the procedure, the technique and patient selection, to its effectiveness. ⋯ The effectiveness evidence is limited at the present time, but based on the results of six recently published positive single-arm studies, it appears that patients experienced a perceptible clinical benefit from the IDET procedure. Thus, IDET is recommended in patients with moderate functional impairment, relatively well-maintained disc heights and discogenic pain caused by annular tears or protrusions less than 3-4 mm after the failure of less invasive procedures.
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Epidemiology is an essential clinical tool in designing and evaluating management and prevention strategies, and is particularly relevant to neuropathic pain. Despite its relevance to neuropathic pain however, there is a paucity of accurate information on its prevalence, distribution and determinants, for several reasons. In many ways, it is appropriate to study neuropathic pain merely as a symptom or a pain mechanism rather than a specific disease. ⋯ Older estimates of the prevalence of neuropathic pain (based on specific diagnoses) tend to be lower (1-2%) than newer estimates that are based on questionnaires examining classic symptoms (6-8%). Further methodological research is needed to clarify these. Associated poor general health is a feature of all neuropathic pain, similar to other severe chronic diseases.
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Inflammation is a well-established contributor to numerous medical conditions, and has discrete roles in disease processes ranging from coronary artery disease and end-stage renal disease to both acute and chronic pain conditions. In some disease processes, inflammatory biomarkers are used clinically to track disease progression and efficacy of treatment, as is seen with complex regional pain syndromes and coronary artery disease. The recognition of such inflammatory biomarkers, and the use of immunomodulating agents for the treatment of chronic pain conditions has become an area of interest, due in part to the successful use of immunomodulating therapy not only for disease progression, but also for symptomatic relief in patients with chronic inflammatory conditions. This article will review this topic and the evidence related to immunomodulation for chronic pain conditions.