Articles: pain-management.
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Surveys indicate that clinicians are frequently ill equipped to treat cancer pain. Pain is often poorly assessed, and many caregivers lack sufficient knowledge to optimize treatment. Effective management requires an understanding of pain pathophysiology, the ability to identify and evaluate pain syndromes, and familiarity with proven therapeutic strategies. ⋯ Sedation is an option at the end of life for the treatment of pain that is refractory to other interventions. These approaches can provide adequate relief to the vast majority of patients, most of whom will respond to systemic pharmacotherapy alone. Patients with refractory pain should have access to specialists in pain management or palliative medicine.
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Despite its use for a long time, the way thalamic ventrobasal (VB) stimulation acts to produce pain relief is still unknown. One of the most accepted hypotheses, sponsored by Tsubokawa among others, proposes that VB stimulation excites raphespinal and reticulospinal neurons of the rostroventral medulla which in turn send respectively inhibitory serotonergic and noradrenergic axons through both dorsolateral funiculi (DLF) to the dorsal horn (DHA) nociceptive neurons; this pathway would be the same as is involved in periventricular-periaqueductal gray (PVG-PAG) stimulation induced inhibition of DH nociceptive neurons. This hypothesis implicates the necessity of DLF intactness; in fact, it was showed that section of bilateral DLF inhibits the response of DH nociceptive neurons to VB stimulation. ⋯ In order to check these possibilities, the patients with central cord-based pain admitted to the Division of Neurosurgery, Toronto Hospital between June 1978 and July 1991 to undergo deep brain stimulation (DBS) were reviewed. Sixteen patients were operated on. Based on clinical criteria, four out of these sixteen patients were thought to present complete cord transection (all four were men, with an average age of 48 years and pain secondary to cord injury).(ABSTRACT TRUNCATED AT 250 WORDS)
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Clinical Trial
Epidural spinal cord stimulation in the treatment of severe peripheral arterial occlusive disease.
Epidural spinal cord stimulation (ESCS) has been suggested to improve microcirculatory blood flow and reduce amputation rates in patients with severe peripheral arterial occlusive disease (PAOD). Pain relief, limb salvage, and skin circulation were studied in 177 patients with ischemic pain caused by nonreconstructible PAOD who were receiving ESCS. Medical or surgical therapy had failed and vascular reconstruction was impossible in all cases. ⋯ Clinical improvement was associated with increased TcPO2, with limb salvage improving from 24.2 to 48.1 mm Hg in stage III (p < 0.02) and from 16.4 to 37.2 mm Hg in stage IV (p < 0.03) disease. A TcPO2 increase of more than 50% within the first 3 months after implantation was predictive of success. TcPO2 changes are correlated with the presence of adequate paresthesias in the painful area during the trial period.(ABSTRACT TRUNCATED AT 250 WORDS)
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State of the art techniques for perioperative pain management in orthopaedic surgery have evolved from cumulative advances in basic sciences, technology, psychology, and changes in physician and nursing practices. Each advance in the understanding of pain physiology and pharmacology and the pain experience has suggested more effective strategies for intervention. ⋯ Coincident with an increase in demand for these services has been the evolution of interdisciplinary pain management teams commonly known as the Acute Pain Treatment Service. In the context of the national debate on health care reform, research priorities in the field include documentation of impacts on patient outcomes, and influences on the cost of health care.