Jack M. Berger

Tapentadol extended release in the management of peripheral diabetic neuropathic pain

Tapentadol, a μ-opioid agonist and norepinephrine reuptake inhibitor, has been found to be an effective medication for a wide variety of chronic pain conditions, including back pain, cancer-related pain, and arthritic pain. It has also been found to have fewer gastrointestinal side effects than more traditional opioid-based therapies. More recently, tapentadol extended release has been demonstrated to be effective in the management of painful diabetic neuropathy, an often debilitating condition affecting approximately one-third of all patients with diabetes. This review highlights the most up-to-date basic and clinical studies by focusing on the mechanisms of action of tapentadol and its clinical efficacy, especially with regard to painful diabetic neuropathy.

Ketamine-fentanyl-midazolam infusion for the control of symptoms in terminal life care

In this report, we describe nine terminally ill patients with metastatic cancer who were treated with an intravenous infusion consisting of ketamine (2 mg/ml)/fentanyl (5αg/ml)/midazolam (0.1 mg/ml) (K/F/M) to control pain after traditional analgesic therapies were unsuccessful. In addition to pain, all patients exhibited some symptoms of cognitive compromise and agitation. After initiation of the K/F/M infusion, all patients exhibited some degree of qualitative improvement in these symptoms as well as in overall pain control. We feel that these observations warrant reporting of the efficacy of this infusion for the treatment of uncontrolled pain and agitation in terminally ill patients when the traditional methods of pain control are inadequate.

You need not make the journey alone: overcoming impediments to providing palliative care in a public urban teaching hospital.

The majority of dying patients continue to receive care in acute, tertiary settings. This has generated the development of hospital-based palliative care (HBPC). The Symptom Management and Palliative Care Program (SMPCP) at LAC+USC Medical Center provides HBPC. The SMPCP operates as an interdisciplinary consultative service, assessing inpatients, and documenting recommendations for primary physicians. Over a 28-month period the SMPCP provided clinical recommendations, education, and research for patients, family members, and hospital staff. Demographic, clinical, psychosocial, financial, and outcome information was collected on 265 patients. The SMPCP documented the attainment of defined quality end-points, including pain control within 24 hours, a Do Not Resuscitate (DNR) discussion with patient and family within 72 hours, and control of nausea and vomiting within 24 hours. Team members also documented impediments to implementing recommendations and the success of interventions to overcome impediments. Results indicated that the SMPCP achieved a high rate of quality end-point attainment when impediments were not present. The most significant impediments resulted from behaviors by primary physicians. The SMPCP’s ability to overcome barrier behaviors improved the rate of end-point attainment, confirming the importance of palliative care at the end of life.

The Clinical Applications of Extended-Release Abuse-Deterrent Opioids

Opioids are the mainstay for treatment of acute pain and cancer pain, and also have a role in the treatment of chronic non-malignant pain. There has been, however, a growing public health problem stemming from the misuse of opioid analgesics leading to serious consequences. To deter abuse, new formulations of extended-release opioid analgesics and tamper-resistant opioids have recently been developed. The concept of abuse-deterrent extended-release opioids is relatively new and, although abuse may not be completely prevented, the utilization of such abuse-deterrent extended-release opioids could reduce this risk. Extended-release abuse-deterrent opioids have been found to have important clinical applications in cancer, acute pain, and chronic non-malignant pain for analgesia control with decreased incidence of tampering and abuse. In this review, different extended-release formulations of opioids available for clinical applications are presented with descriptions of the formulations, their physical properties, and the clinical studies performed to provide physicians with a better understanding of their uses.

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Essentials of Palliative Care

Essentials of palliative care / , Essentials of palliative care / , کتابخانه دیجیتال جندی شاپور اهواز

Ethics in Palliative and End-of-Life Care

In treating patients with terminal disease, physicians are faced with multiple situations that require balancing a respect for life with the dying process and the inevitable death of the patient. Difficult decisions must be made, but with proper utilization of the principles of ethical conduct and the “Rule of Double Effect” moral and ethical dilemmas can be avoided. In this chapter, the principles of ethical conduct will be discussed in association with moral obligations, legal limitations, and protections provided to the physician dealing with end-of-life care.

Nonopioid Analgesics in Pain Management

Since patients rarely present with pure nociceptive pain (i.e., pain caused by activity in the neural pathways in response to damaging or potentially damaging stimuli) or neuropathic pain (i.e., pain initiated by a primary lesion or dysfunction in the nervous system), but rather suffer a mixed pain syndrome (i.e., pain caused by a combination of both the primary injury and secondary effects), a rational polypharmacy approach that targets key peripheral and central pain mechanisms and modulating pathways may yield the best outcomes (Management of Chronic Pain Syndromes 2005).

Review of herpes zoster

E R P E S IS A Greek term meaning someng that creeps. In the Hippocratic era, medical practitioners used the term to denote a rash. Zos t e r is another Greek term used to denote a belt or a girdle. Acute herpes zoster and chronic postherpetic neuralgia (PHN) are two ends of a spectrum of diseases that comprises a subset of patients commonly encountered in pain clinics. Although this disease has been epidemiologically and clinically well discussed for more that 30 years, it remains one of the most elusive diseases to treat for pain clinicians, most notably in the chronic state referred to as PHN. In order to adequately treat and potentially prevent PHN, it is imperative to fully understand the nature of the course of acute herpes zoster. Therefore, the first part of this article discusses the pathogenesis, clinical manifestation, and treatment of acute herpes zoster.

The utility of abnormal initial arterial blood gas values in determining clinical futility of trauma cases with severe hemorrhage

Background: Patients who experience trauma with severe hemorrhage requiring immediate surgery and massive blood transfusion often present with markedly abnormal laboratory values. These cases require valuable resources; however, little is known regarding prognostic factors that correlate with mortality. The purpose of this study was to determine whether abnormal initial arterial blood gas (ABG) pH, a marker for severe blood loss, could serve as a prognostic indicator for these patients. Methods: An IRB approved retrospective study was performed at LAC + USC Medical Center Level I Trauma Center. Data was collected from trauma patients with severe hemorrhage admitted between June 2015 and April 2016 who were immediately admitted to the OR following entry into the ER. Baseline variables of age, sex and mechanism of trauma were collected. The pH readings from the initial three ABG data were obtained, and mortality was determined for each patient. Results: We identified 247 patients, 84.2% of which were male. Ages ranged from 1 to 91 years (average = 38.4). Overall mortality was 13.8%. The average initial pH value for non‐survivors (7.10 ± 0.13) was significantly lower than for survivors (7.34 ± 0.07) [p < 0.001]. Among patients whose initial three ABG pH values averaged ≤7.15, the survival rate was 8.7%. Ten patients had any single recorded pH value ≤ 6.91. The mortality rate among these patients was 90%. Conclusions: Consideration should be given to initial pH values when resuscitating “red blanket” patients. However, the pH values alone cannot reliably be used to determine clinical futility in individual patients in the early period after injury.