Vulvodynia. Theory and management

Vulvodynia, defined as vulval pain, soreness or burning as opposed to itching or pruritus, is a common and important problem. Although not a sexually transmitted disease, it often presents to physicians working in that field. The main groups of vulvodynia are those where the symptoms are the consequence of an active dermatosis or infection, and those where it is not attributable to such conditions. In the latter group, the patients fall into two main categories: those of dysesthetic vulvidynia, with constant unprovoked pain, and vulval vestibulitis, with pain provoked by attempted vaginal entry. The recent realization that dysesthetic vulvodynia and vulval vestibulitis may be regarded as pain syndromes is proving a fruitful concept as regards both theory and management of these troublesome conditions.     

Sleep and rheumatic disease

Patients with rheumatic diseases often exhibit sleep disturbance. Identification of primary sleep disorders; medical, neurologic, and psychologic illnesses; circadian factors; and the use and effect of medications, drugs, and alcohol will provide a strong basis for pursuing both pharmacologic and nonpharmacologic intervention. Recent clinical research confirms the frequent comorbidity of sleep disturbance, pain, fatigue, stress, and mood disturbance in patients with rheumatic disease. It is essential for effective management to recognize these "symptom syndromes" that are often responsive to treatment (suggesting a common biologic action and effect of the drugs used) despite a continuing presence of underlying chronic disease. The pathophysiologic relationships of these comorbid symptoms are mostly unknown, so this is an area for further study.     

The concept of rehabilitation of cancer patients

The scope of supportive care and cancer rehabilitation is very wide and heterogeneous. In this review we focus on nutritional aspects, sexual and gonadal function, psychological rehabilitation, treatment of cancer pain, and rehabilitation of patients with bone metastases. The anorexia-cachexia syndrome is a particularly frequent manifestation of cancer that profoundly affects body image and significantly impairs quality of life of cancer patients. However, enteral feeding through nasogastric tubes, gastrostomies, or jejunostomies is an efficient method for providing long-term enteral nutrition at home and for contributing to complete rehabilitation after cancer therapy. Recent effort has focused on nutritional pharmacology and on the optimalization of the use of appetite-stimulating drugs, such as progestational agents. The psychological components of cancer, anticancer therapy, and quality of life have now been widely recognized and studied. Effective pharmacological and psychotherapeutic interventions help patients and their family to better adjust to the chronic stress of cancer, but more specific determinants of psychological morbidity should be developed. In particular, the safe and efficient use of the most recent classes of antidepressants and anxiolytics should be urgently studied. More than 90% of cancer patients present one or more pain syndromes during their illness. The adequate use of drugs is the cornerstone of treatment. The development on new molecules and new routes of administration opens interesting perspectives for cancer pain control. Bone metastases are the source of considerable morbidity. Intravenous bisphosphonates have been successfully used for the treatment of the symptoms of metastatic bone disease, especially bone pain. Moreover, monthly pamidronate infusions in addition to chemotherapy reduce the mean skeletal morbidity rate by more than one third and contribute to the rehabilitation of cancer patients with bone metastases from breast cancer or with multiple myeloma.     

Pseudoneurologic syndromes: recognition and diagnosis

Physicians may encounter patients with a collection of psychologic disorders that present with neurologic symptoms or signs, yet have no identifiable structural or functional etiology within the nervous system. These disorders comprise the so-called pseudoneurologic syndromes, which can mimic almost any organic disease. A careful history and physical examination often can identify the psychologic origin of the symptoms. Presenting syndromes can include pseudoparalysis, pseudosensory syndromes, pseudoseizures, pseudocoma, psychogenic movement disorders and pseudoneuro-ophthalmologic syndromes. These presentations may be distinguished from organic disease by observing signs and symptoms or eliciting test responses that are nonphysiologic and incompatible with organic disease. Once a pseudoneurologic syndrome is identified, patients require compassionate and understanding care to resolve underlying emotional problems.     

Lower extremity manifestations of neuromuscular diseases

Neuromuscular disorders must be considered when a patient presents with a pes cavus deformity; lower extremity weakness; difficulty in walking; or cramps, stiffness, fatigue, pain, or paresthesia in the extremities. In those instances in which a neurologic disease is considered, distinctions between central and peripheral nervous system origin, focal versus generalized pathology, and static versus progressive course are critical in the diagnosis and treatment of the disorder. The complexities of the nervous system often result in missed or delayed diagnosis of these syndromes. Patients affected with neurologic diseases often require diagnostic and therapeutic interventions from various specialists. This article presents a systematic approach to the patient with a neurologic disorder, with special emphasis on neuromuscular manifestations in the lower extremities. Key observations to aid in the recognition of neuromuscular dysfunction are presented, along with an approach to diagnostic evaluation and management for these patients.     

A short (3-day) course of azithromycin tablets versus a 10-day course of amoxycillin-clavulanic acid (co-amoxiclav) in the treatment of adults with lower respiratory tract infections and effects on long-term outcome

The majority of patients with cancer experience significant pain during their illness. Most cancer pain can be readily managed with oral analgesic therapy. However, cancer pain is often under-treated because of poor communication between physicians and patients and inadequate training of physicians in pain management. A systematic pain-oriented history, pain intensity assessment physical exam, and diagnostic evaluation are needed to delineate the cause of pain. A therapeutic plan can then be tailored to the patient's needs, preferences, and severity of pain. This paper reviews the evaluation and treatment of cancer pain, with guidelines for initiating and monitoring non-opioid and opioid analgesic therapy.     

Human cancer syndromes: clues to the origin and nature of cancer

More than 20 different hereditary cancer syndromes have now been defined and attributed to specific germline mutations in various inherited cancer genes. Collectively, the syndromes affect about 1 percent of cancer patients. An individual who carries a mutant allele of an inherited cancer gene has a variable risk of cancer that is influenced by the particular mutation, other cellular genes, and dietary, lifestyle, and environmental factors. Though hereditary cancer syndromes are rare, their study has provided powerful insights into more common forms of cancer. Somatic mutations in sporadic cancers frequently alter the inherited cancer genes, and the functions of cell signaling pathways have been illuminated by study of the affected genes. Further investigation of inherited mutations that affect susceptibility to cancer will aid efforts to effectively prevent, detect, and treat the disease.     

Paraneoplastic syndromes affecting the nervous system

Paraneoplastic syndromes can affect virtually any portion of the nervous system. Most paraneoplastic syndromes are believed to be caused by an autoimmune reaction to an "onconeural" antigen shared by the cancer and the nervous system. The immune reaction may retard growth of the cancer, but it also damages the nervous system. Specific autoantibodies found in some individual paraneoplastic syndromes are usually associated with specific tumors. Neurological disorders, clinically and pathologically identical to paraneoplastic syndromes, may occur in some patients without cancer, but paraneoplastic antibodies are not found in these patients. The diagnosis of a paraneoplastic syndrome is based on its increased incidence in patients with cancer, the occasional response of the neurological syndrome to treatment of the underlying cancer, or the presence of specific autoantibodies. Some paraneoplastic syndromes respond to treatment of the underlying cancer or to immunosuppression but, for most syndromes, no effective treatment exists.     

Prospective evaluation of pain in exocrine pancreatic cancer

BACKGROUND: Although pain is the most feared part of the terminal life of many patients with cancer, the intensity and the quality of the pain is all too often only scantly described. METHOD: The quality and quantity of pain were prospectively registered by five variables, including a visual analogue scale (VAS), in 46 consecutive patients with exocrine pancreatic cancer. RESULTS: Twenty-seven percent of the patients were completely pain free and 24 (53%) patients reported little or no pain at the time of diagnosis. Only 5 (11%) patients had severe pain. Patients with tumors in the head of the pancreas had less pain than patients with cancer in the body or tail of the pancreas, which could not be explained by stage or size of the tumor. With time there were less and less patients with little or no pain (VAS 0-2), but after 8 and 10 weeks about one third of the patients were still without any pain (VAS < or = 0). With time there was also a tendency to treat patients more frequently with morphine in spite of a low pain score. Preoperative pain simply measured with VAS is an addition to prognostic information. CONCLUSION: Pain in pancreatic cancer is not as common as usually stated at the time of diagnosis, but is related to the site of the tumor. Eventually more patients are treated with opioid drugs. Evaluation of the pain pattern is an addition to prognostic information.     

Small cell lung cancer: pathophysiologic mechanisms and nursing implications

PURPOSE/OBJECTIVES: To review current incidence and treatment perspectives for small cell lung cancer (SCLC). DATA SOURCES: Published articles, book chapters, American Cancer Society materials. DATA SYNTHESIS: SCLC constitutes 20%-30% of lung cancer cases and accounts for 40,000 deaths annually. Characterized by rapid cell division, SCLC is very sensitive to radiation and chemotherapy; however, long-term survival rates are very low. A number of paraneoplastic syndromes are associated with this disease, thereby increasing the medical and nursing management challenges. CONCLUSIONS: Because SCLC usually is diagnosed late in the disease process and survival rates are poor, quality of life and palliation of metastatic symptoms (e.g., pain, breathing difficulties) are important focuses of care. Smoking deterrence and cessation programs, as well as early detection of lesions, are key to reducing incidence and mortality. IMPLICATIONS FOR NURSING PRACTICE: Nursing care focuses on promoting comfort and preventing and managing disease and treatment complications. Nursing diagnoses include ineffective airway clearance, impaired gas exchange, pain, altered nutrition, activity intolerance, and ineffective coping. A patient care standard is presented.     

Is early differentiation between psychogenic and somatogenic lumbago-ischialgia syndrome patients possible by anamnesis? Results of a screening study

Low back pain (LBP) is one of the most frequent causes for early retirement, hospital treatment and loss of days of work (Raspe u. Kohlmann 1993). Further differentiation and earlier diagnosis of psychogenic LBP could significantly reduce health costs. We interviewed 101 patients with LBP in the departments of Neurology and Neurosurgery (Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke) with the "structured biographical interview for patients with pain" (Egle 1992). This questionnaire has been used successfully differentiating between patients with organic and psychogenic chronic pain syndromes. It is a semi-standardised instrument based on observations, mainly made by Engel (1959), showing that many patients suffering from chronic benign pain syndromes had experienced psychic traumatisation during childhood. We compared a group of patients with clear neurological deficits and organic pain origin (n = 47) with a group of patients with psychogenic LBP (n = 25). Parameters were among others their biographical family constellations, their past medical history (also looking for symptoms of dissociation [conversion]), their present life and their coping with pain. In comparison with other studies examining similar aspects in patients who had pain in other parts of the body (Egle et al. 1991), our groups showed less discriminating results concerning biographical aspects. We found that also 40% of patients with organic pain origin hat traumatic constellations in their childhood. The following factors differentiated best between the both groups and characterised the psychogenic group: Intensity of pain was judged to be significantly higher with the "visual analog scale": age of the patient less than 40 years; distraction does not alter the pain; preceding experiences with physicians had often been negative; pain leads to impairment of familiar contacts; conflicts with parents during childhood could not adequately discussed with them at that time. These seven aspects can very well be part of a clinical history taking in a general medical setting, so that patients with LBP can be differentiated more effectively.     

Replacement neobladders in men and women: our experience

About 350,000 persons in the United States have multiple sclerosis, and primary care physicians are often called on to provide symptomatic therapy for these patients. We review our current pharmacologic approach to the management of multiple sclerosis exacerbations and the symptoms of spasticity, fatigue, bladder and bowel involvement, neurobehavioral complaints, pain syndromes, dystonic spasms, and tremor and ataxia.     

Back pain in patients with ductal pancreatic cancer. Its impact on resectability and prognosis after resection

BACKGROUND: Back pain is a frequent and often ominous clinical sign in patients with ductal pancreatic cancer. METHODS: From 1971 to 1993 a pancreatic carcinoma could be resected in 192 patients, whereas 261 patients underwent either probatory laparotomy alone or palliative bypass procedures. In a retrospective study including uni- and multi-variate survival analysis we have determined the impact of preoperative back pain on both resectability and long-term prognosis after resection. RESULTS: Among the presenting symptoms of patients with ductal pancreatic cancer back pain was a predictive sign of irresectability. In the presence of preoperative back pain the long-term prognosis after resection of the tumour was also significantly impaired. In a multivariate analysis it could be demonstrated that the prognostic impact of back pain was as strong as the influence of residual tumour, tumour grading, and tumour size. CONCLUSIONS: Back pain often indicates irresectability of ductal pancreatic carcinoma and also impairs the long-term prognosis even after curative resection.     

Changes in crystallinity by sterilization and processing of ultrahigh molecular polyethylene used in endoprosthetics]

Research in animals shows that the levels of neuropathic pain expression is genetically associated with a characteristic response profile to sensory stimuli. The aim of the present investigation was to examine if pressure algometry can identify a specific pain sensitivity profile in patients with complex regional pain syndrome, Type I (reflex sympathetic dystrophy), and to distinguish complex regional pain syndromes from other chronic pain dysfunction syndromes. Pressure pain threshold and pain tolerance measured at the sternum in 17 patients with complex regional pain syndrome, Type I (reflex sympathetic dystrophy), were compared with values obtained in 13 patients suffering from other chronic pain dysfunction syndromes and in a control group of 24 pain-free volunteers. The pressure algometer consisted of a force displacement transducer with a 0.25 cm2 tip connected to a recorder. The rate of force application was 1 kg/0.25 cm2/s. The difference between threshold and tolerance was defined as the pain sensitivity range. Young patients with complex regional pain syndrome (<40 yr) demonstrated a significantly higher mean pain sensitivity range compared with young subjects who had chronic pain or who were pain-free. Mean threshold and tolerance values were significantly lower in patients with complex regional pain syndrome (2.7+/-1.0 kg (mean +/- standard deviation) and 5.4+/-2.0 kg, respectively) and in patients suffering from other chronic pain syndromes (2.6+/-1.1 and 4.6+/-1.7 kg) than in healthy subjects (5.4+/-2.3 and 8.4+/-2.6 kg). Women in the chronic pain group exhibited a significantly lower pressure pain threshold than all other subgroups. Regardless of group, women exhibited lower pressure pain tolerance than men. In conclusion, the study contained herein shows a specific pain sensitivity profile to experimental stimuli behavior in young patients with complex regional pain syndrome expressed by a large pressure pain sensitivity range, at a location away from the painful area. However, one single pressure pain measurement over the sternum is insufficient for differentiation of patients with complex regional pain syndrome from those with chronic pain because of intersubject variation.     

Evaluating back pain in older patients

Low back pain in the elderly has a much wider range of possible causes than in younger patients. In addition to nonspecific mechanical causes, malignancy presenting as back pain occurs more often in older patients. Other systemic and visceral causes of back pain such as polymyalgia rheumatica, aortic aneurysm, Paget disease, Parkinson disease, and osteoporosis with compression fracture occur almost exclusively in persons over age 50. Keys to diagnosis and management of low back pain in older patients are presented.     

Establishing a research agenda for investigating alternative medical interventions for chronic pain

This article describes the University of Maryland School of Medicine's Center for Complementary Medicine Research approach to developing an agenda for investigating alternative medical treatments for chronic pain syndromes. This agenda includes conducting extensive literature searches and analyses to form a knowledge base for making clinical decisions on which chronic pain syndromes are in greatest need of better therapies, as well as which alternative medical therapies offer the greatest therapeutic promise for these specific chronic pain syndromes. To date, the Center has identified back pain, arthritis, and fibromyalgia as the chronic pain syndromes that contribute the greatest clinical and economic burden to overall chronic pain statistics. Not coincidentally, patients with these diagnoses are the greatest users of alternative therapies. The Center has identified acupuncture, homeopathy, manual/manipulative therapies, and mind-body therapies as the alternative medical therapies offering the greatest clinical potential for these three general chronic pain diagnoses. Preliminary data from the Center's ongoing clinical trials programs are presented.     

C-reactive protein as a marker for acute coronary syndromes

BACKGROUND: For several years, acute coronary syndromes have been perceived as causing the most hospital admissions, and even hospital mortality. The syndrome of unstable angina frequently progresses to acute myocardial infarction but its pathogenesis is poorly understood, and prognosis determination is still problematic. We tested the hypothesis that measurement of the C-reactive protein in patients admitted for chest pain could be a marker for acute coronary syndromes. METHODS AND RESULTS: We studied 110 patients admitted with suspected ischaemic heart disease, but without elevated serum creatine-kinase levels at the time of hospital admission. Patients were subsequently divided into two groups based on their final diagnosis: group 1 comprised patients with unstable angina; group 2 patients with acute myocardial infarction. We measured the C-reactive protein at the time of hospital admission. The concentration of C-reactive protein was elevated in 59% of the patients with a final diagnosis of acute myocardial infarction, and in 5% of the patients with a final diagnosis of unstable angina, (P < 0.001). CONCLUSION: This study indicates that C-reactive protein levels measured at the time of admission in patients with suspected ischaemic heart disease could be a marker for acute coronary syndromes, and helpful in identifying patients at high risk for acute myocardial infarction. Measurement of C-reactive protein may have practical clinical significance in the management of patients hospitalized for suspected acute coronary syndromes.     

Facial pain as a symptom of nonmetastatic lung cancer

Patients with nonmetastatic lung cancer may rarely experience facial pain as a presenting symptom, during the course of the disease or upon recurrence of the disease. This study reviews a 10-year experience at Mayo Clinic. The aim of this study was to (1) further characterize the clinical features of facial pain as a symptom of nonmetastatic lung cancer, and (2) assist clinicians in recognizing this association. Ten cases were identified. All patients complained of severe, aching, facial pain typically aural-temporal in location, ipsilateral to the lung cancer. Six of the 10 cases involved the left side. Recent weight loss was present in 7 of 10 patients, with an elevated sedimentation rate in 6. Digital clubbing was documented in three. Neurologic examinations and neuroimaging were normal in all patients. Lumbar puncture, when performed, was normal. Facial pain preceded the diagnosis of lung cancer by 1 to 24 months. In three patients, facial pain was the initial symptom of tumor recurrence. Four of the 10 tumors were adenocarcinoma; radiation with or without chemotherapy appears to be the treatment of choice for the facial pain. The presumed mechanism is local invasion of the vagus nerve. In suspected cases, a chest x-ray and chest CT are indicated.     

Pharmacologic pain. Management for cancer patients at home

Pain management is one of the most important responsibilities of the home care nurse serving cancer patients. Patients and caregivers often fear uncontrolled pain, and need frequent reassurance that effective pain control can be achieved. This article discusses the etiology and types of cancer pain, pain assessment, pharmacologic pain management interventions, and evaluation of pain management for home care patients.     

Tight glycaemic control prevents diabetic complications

About 70% of all patients with sickle cell disease suffer from pain crises. Pain crises are recurrent episodes of pain that range in severity from mild to severe, usually occur very abruptly and are often localized around joints. Pain crises are caused by vaso-occlusions in the vascular bed of the bone marrow, leading to necrosis, edema and increased pressure. For effective analgesia morphine or morphine analogues are often required. When treating a pain crisis the patient's complaints need to be taken seriously and analgesic therapy should be started promptly with analgesics in proportion to the severity of the patient's pain. With mild pain oral non-opioid analgesics are sufficient, in moderate pain they are given in combination with oral codeine. Severe pain requires IV morphine, also combined with a non-opioid analgesic. Intravenous morphine makes a thorough monitoring of ventilation and level of consciousness mandatory. Sickle cell patients do not become drug dependent if given morphine for adequate analgesia. While bone marrow transplantation has become an accepted treatment modality for sickle cell patients with severe pain crises, treatment with hydroxyurea to increase HbF levels and reduce incidence and severity of pain crises, however, is still experimental.