David A. Nardone

The Chronic Pain Syndrome: Misconceptions and Management

The management of chronic pain is a universal and vexing problem for physicians. Literature indicates that health care providers have a poor understanding of basic concepts relating to pain, which leads to frustration for the physician and inadequate relief for the patient. This paper addresses misconceptions about organic versus functional pain, discusses placebos and administration of narcotic analgesics, and outlines therapeutic alternatives. Emphasis is on distinguishing chronic pain of benign origin from that secondary to malignancy as an individual treatment plan is formulated.

Mechanisms in hypokalemia: clinical correlation.

Hypokalemia is seen most often with the use of diuretics and in patients with emesis. Other common clinical settings in which it may be significant include corticosteroid therapy, antibiotic usage, diarrhea, diabetic ketoacidosis, or psychiatric illness. Occasionally the cause may be obscure. In such situations the determination of urine potassium and arterial pH may prove helpful. Subclassification of hypokalemia into such categories as acidosis, alkalosis, extra-renal, or renal loss is then possible. The cases discussed demonstrate the utilization of these methods to define the etiology and to understand the pathophysiology in hypokalemia.

Review: vaginal signs and symptoms perform poorly in diagnosing vaginal candidiasis.

(1). I concur that the laboratory evaluation of vaginitis, in general, is superior to individual historical and physical findings. However, 3 additional points deserve emphasis. First, evaluating combinations of clinical findings for calculating likelihood ratios (LRs) would be helpful, as combinations have been evaluated in at least 1 other clinical entity (2). Second, evaluating LRs for previous use of antibiotics may prove useful, since they can predispose to vaginal candidiasis. Third, I would like to emphasize the value of the lack of odor in bacterial vaginosis (BV) and lack of yellow discharge in vaginal trichomoniasis (VT), as the negative LRs are 0.07 and 0.12, respectively. A physician could make the decision to treat a woman empirically for vaginal candidiasis with over-the-counter intravaginal miconazole without performing an expensive laboratory examination, provided there was no history of odorous discharge (BV) or yellow discharge (VT). For example, based on the prevalence of BV (46%) and VT (12%) (3), the posttest probabilities for the absence of odor and yellow discharge are 6.0% (BV) and 2% (VT). Neither probability is likely to be above one’s treatment threshold. Only if miconazole therapy has failed and the patient has persistent or recurrent external genital symptoms would laboratory examinations be performed.