Articles: human.
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To provide current information regarding the efficacy and tolerability of the anticonvulsant gabapentin in the management of neuropathic pain. ⋯ In human pain models using patients with neuropathic pain, gabapentin has been found effective against both spontaneous and evoked pain, and these effects are independent of the pain source. Gabapentin, in doses ranging up to 3.6 g/day, has demonstrated efficacy in a variety of neuropathic pain states, including those refractory to agents such as the tricyclic antidepressants (TCA) and other anticonvulsants. A major question today is whether gabapentin should be considered as first-line therapy (i.e., even before a trial of a TCA or carbamazepine) or as second-line therapy for individuals unresponsive to or intolerant of TCAs and/or carbamazepine.
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It is the responsibility of clinician investigators to advance clinical knowledge and specifically its application to patient care. Randomized controlled trials remain near the top of the hierarchy of evidence based medicine. The acquisition of evidence based medicine by means of randomized controlled trials presents general difficulties and additional pitfalls specific to interventional treatments. ⋯ To generate clinically useful research results requires an understanding of the mechanics of performing studies and the reporting of methodologies to ensure appropriate interpretation. Placebo arms and sham interventions present serious ethical issues, which must be analyzed on a case by case basis. The conscientious researcher must always abide by the principles of ethical research and the tenets of human subject protection.
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Individual electric and geometric characteristics of neural substructures can have surprising effects on artificially controlled neural signaling. A rule of thumb approved for the stimulation of long peripheral axons may not hold when the central nervous system is involved. This is demonstrated here with a comparison of results from the electrically stimulated cochlea, retina, and spinal cord. ⋯ Bipolar cells in the retina are expected to respond with neurotransmitter release before a spike is generated in the ganglion cell, even when they are far away from the electrode. Epidural stimulation of the lumbar spinal cord predominantly stimulates large sensory axons in the dorsal roots which induce muscle reflex responses. Analysis with the generalized activating function, computer simulations of the nonlinear neural membrane behavior together with experimental and clinical data analysis enlighten our understanding of artificial firing patterns influenced by neural prostheses.
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Behavioral emergencies are a common and serious problem for consumers, their families and communities, and the healthcare providers on whom they rely for help. In recent years, serious concerns about the management of behavioral and psychiatric emergencies-in particular, the misapplication and overuse of physical and chemical restraints and seclusion-have become a focus of attention for mental health professionals and policy makers as well as for the lay public, the media, and patient advocacy organizations. Policy leaders and clinicians are searching for ways to balance the rights of consumers with considerations of safety and good care in an area in which it is difficult to conduct research. ⋯ The consumer panel preferred benzodiazepines and ranked haloperidol as a least preferred option. Among their key recommendations for improving psychiatric emergency care, the consumer panel stressed the development of alternatives to traditional emergency room services, the increased use of advance directives, more comfortable physical environments for waiting and treatment, increased use of peer support services, improved training of emergency staff to foster a more humanistic and person-centered approach, increased collaboration between practitioners and patients, and improved discharge planning and post-discharge follow-up. The implications of these findings for improving psychiatric emergency care are considered.