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Query: UMLS:C0030193 (pain)
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Loxoscelism is the clinical condition produced by the venom of spiders belonging to the genus Loxosceles. Human cases of loxoscelism have been observed in diverse countries of different continents in temperate and tropical regions. In Chile loxoscelism is caused by Loxosceles laeta, spider with domestic habits. Loxoscelism can be observed into two well definited clinical variants: cutaneous loxoscelism (CL) and systemic or viscerocutaneous loxoscelism (VCL) which occur in around 83.3 and 16.7% cases respectively. Within the universe of CL patients a clinical modality in which necrotic lesion is not present or is insignificant, but presenting a remarkable edema, particularly when the bite is on the face, which has received the name of CL with an edematous predominance (CLEP). In this paper the individual description and the assambled analysis of 10 cases, four males and six females, age ranging from 6 to 68 years, of CLEP are presented. Nine cases occurred in warm periods spring through fall and one in winter. In six cases the accident causing spider was seen and two of these were identified as L. laeta adult females. In all cases the patients went or were transported to emergency medical services 4-24 h after the bite. The predominant initial symptom was a burning stinging sensation at the site of the bite, followed by intensive pain which expanded the neighbour areas concomitantly with the emerging and progressive edema. In four of the nine patients in who the bite was on the face, the edema involved all of it, closed both eyelids and expanded to the neck and upper part of the thorax. In three cases the enormous edema was the only significant clinical manifestation, whereas in the remaining seven conjunctly with the edema, a small violaceous plaque or a blister of serous content gave place to a little livedoid plaque (diameter 0.3-0.8 cm) which evolved to desquamation without leaving any scarring. The edema was characterized by its brilliant rose color, painful and hard which is not accompanied by regional adenopathy. Treatment of the 10 patients depended on the moment in they were seen by us. It consisted on parenteral administration, according to age and weight, of 5-10 mg of chloroprofenpyridamine maleate every 8 hours for be continued every 12-24 hours until the patient was discharged. Parenteral route was preferred in order that it was going to be adequately absorbed. With the beginning of the antihistaminic treatment a clear diminution of pain and edema was obtained, being possible its total disappearance within 4-10 days. CLEP occurs in about 4% of loxoscelism cases, has a benign prognosis and an early response to adequate medical treatment. Without discarding the sensibility factor of the affected individual, there exist the impression that the edema may abort the necrotic process when it dilutes the enzymatic process produced by L.laeta venom. In Chile, the differential diagnosis must be planted with the following clinical entities: bites of hematophagous insects on the face, bee stings, Chagas' disease with facial port of entry and angioneurotic edema.
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PMID:[Cutaneous loxoscelism with edematous predominance]. 1041 84

Pain relief and nutritional support represent two main efforts of palliative medicine. A considerable proportion of surgical patients might not be treated with adequate analgetic medication. Those patients are often treated too late, too short or with an insufficient amount of drug. Particularly if the treatment goal is palliation problems of drug abuse are of less importance. However, randomized trials aiming at best pain relief have rarely been carried out in oncological patients. Psychological factors (suffering, affective aspects) have to be borne in mind when deciding upon pain treatment. The surgeon often knows best the local problem inducing pain whether it is due to intestinal obstruction, infiltration of bone and joints, arising from the viscera, or resulting from nerve compression. This information is of utmost value to select the most appropriate treatment. Parenteral, local, or regional measures to relief pain can be combined with chemical neurolysis. Receptor-specific drugs may be the analgetics of the future. Regarding nutritional support the patient's acceptance must be respected. Other guidelines concern life expectancy, nutritional status, or intestinal function and influence the decision whether or not nutritional support should be offered. Enteral feeding should always be the treatment of first choice due to economical and logistic reasons but also due to the fact that translocation of bacteria and endotoxin can be minimised with this technique.
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PMID:[Supportive measures in palliation: pain therapy and nutrition]. 1063 97

Bowel obstruction may be an inoperable complication in patients with end-stage cancer. Scopolamine butylbromide (SB) and octreotide (OCT) have been successfully used with the aim of reducing gastrointestinal (GI) secretions to avoid placement of a nasogastric tube (NGT); however, there have been no comparative studies concerning the efficacy of these drugs. Furthermore, there is little information about the role played by parenteral hydration in symptom control of these patients. In a prospective trial that involved all 17 inoperable bowel-obstructed patients presenting to our services with a decompressive NGT, patients were randomized to OCT 0.3 mg/day or SB 60 mg/day for 3 days through a continuous subcutaneous infusion. Clinical data, survival time, and the time interval from the first diagnosis of cancer to the onset of inoperable bowel obstruction were noted. The intensity of pain, nausea, dry mouth, thirst, dyspnea, feeling of abdominal distension, and drowsiness were assessed by means of a verbal scale before starting treatment with the drugs under study (T0) and then daily for 3 days (T1, T2, T3). Moreover, daily information was collected regarding the quantity of GI secretions through the NGT, the oral intake of fluids, the quantity of parenteral hydration, and the analgesic therapy used. The NGT could be removed in all 10 home care and in 3 hospitalized patients without changing the dosage of the drugs. OCT significantly reduced the amount of GI secretions at T2 (P = 0.016) and T3 (P = 0.020). Compared to the home care patients, the hospitalized patients received significantly more parenteral hydration (P = 0.0005) and drank more fluids (P = 0.025). There was no difference in the daily thirst and dry mouth intensity in relation to the amount of parenteral hydration or the treatment provided (OCT or SB). Independent of antisecretory treatment, the patients receiving less parenteral hydration presented significantly more nausea (T0 P = 0.002; T1 P = 0.001; T2 P = 0.003; T3 P = 0.001) and drowsiness at T3 (P < 0.5). Pain relief was obtained in all 17 patients and only two patients required an increase in morphine dose at T1. All patients with inoperable malignant bowel obstruction should undergo treatment with antisecretory drugs so as to evaluate the possibility of removing the NGT. When a more rapid reduction in GI secretions is desired, OCT should be considered as the first choice drug. Parenteral hydration over 500 ml/day may reduce nausea and drowsiness.
J Pain Symptom Manage 2000 Jan
PMID:Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial. 1068 23

The most frequent consequence of chronic alcohol intake is a toxic polyneuropathy. It results from inadequate nutrition, mainly deficiency of thiamine and other B vitamins. Additionally there is a direct neurotoxic effect of ethanol. Signs and symptoms are 1. distal sensory disturbances with pain, paresthesia, and numbness in a glove and stockings-pattern, 2. weakness and atrophy of distal muscles, pronounced in the lower limbs, 3. loss of tendon jerks, 4. affection of autonomic fibers. Therapy consists in absolute alcohol abstinence, high-caloric nutrition, parenteral thiamine and other vitamins. Against paresthesia and pain, carbamazepine, salicylates, amitryptiline are effective. Parenteral tioctacid may be tried. The prognosis of alcoholic polyneuropathy is favorable, with alcohol abstinence, within several months up to a few years. In chronic alcoholic patients peripheral nerves frequently are injured by compression during alcohol intoxication. Peroneal nerve lesions result from compression in the region of the neck of the fibula during a prolonged lying position, the radial nerve is injured during sitting with the upper arm placed on the backrest of a bench. Usually pressure palsies resolve spontaneously. Rhabdomyolysis is a rare but life-threatening complication of alcoholic delirium. Symptoms are severe muscle pain, swelling of extremities, pigmenturia. The major complications of rhabdomyolysis are renal and respiratory failure, and cardiac arrhythmias due to electrolyte imbalance. Intensive care is needed with control of hyperkalemia, hydration, alkalinization of urine, hemodialysis if indicated.
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PMID:[Alcohol and the peripheral nervous system]. 1080 76

The past 20 years have seen a great surge of interest in understanding and treating pain. The introduction of sustained-release opioid delivery systems has tremendously advanced our ability to provide improved pain control. Parenteral opioid delivery systems, although available in many developed nations, remain expensive and cumbersome. New advances in parenteral sustained-release systems are currently in development. These advances include liposomal opioid preparations for intrathecal use, transcutaneous patient-controlled delivery, and implantable diffusion reservoirs. Even more exciting are new developments in tissue engineering that may allow the transplantation of human or animal cells, capable of producing natural analgesic substances, into the vicinity of the spinal cord.
Curr Rev Pain 1999
PMID:Developing Techniques and Strategies for the Management of Cancer Pain. 1099 72

Giving an analgesic to patients with right lower quadrant (RLQ) pain causes greater alteration of abdominal signs predictive of appendicitis than placebo. A randomized double-blinded controlled trial of 68 patients who received either tramadol or placebo. Absence or presence of seven abdominal signs (tenderness on light and deep palpation, tenderness in the RLQ and elsewhere, rebound, cough, and percussion tenderness) and pain (100 mm Visual Analog Scale [VAS]) at 0 and 30 minutes were recorded. The predictive value of each physical finding (PF) was measured using an 11-point PF score weighted by likelihood ratios. There was significant reduction in mean VAS of 14.2 mm (95% CI 5.6 to 22.8) in analgesic group versus 6.5 mm (95% CI 1.6 to 11.4) in placebo group. The analgesic group had less normalization of signs as measured by the PF score in all patients [32 of 154 (20.8%) versus 40 of 121 (33.1 %) (P = .031)] and in those with proven appendicitis [4 of 33 (12.1%) versus 10/22 (45.5%) (P = .014)]. Parenteral use of tramadol in emergency department patients with RLQ pain resulted in significant levels of pain reduction without concurrent normalisation of abdominal examination findings indicative of acute appendicitis.
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PMID:Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain. 1110 23

We sought in this prospective study to use a multimodal approach to reduce stress and improve recovery in patients undergoing major surgery. During an initial study period, 30 patients were randomly allocated to receive general anesthesia (GA; Group 1) or a combination of GA and intraoperative thoracic epidural analgesia (TEA; Group 2) when undergoing radical cystectomy. Parenteral nutrition was provided for 5 days after surgery. During the second period, 15 patients were treated with a multimodal approach (Group 3) consisting of intraoperative GA and TEA, postoperative patient-controlled TEA, early oral nutrition, and enforced mobilization. Data for plasma and urine catecholamines, plasma cortisol, the nitrogen balance, the postoperative inflammatory nutrition index, pain relief, fatigue, sleep, overnight recovery, recovery of bowel function, and mobilization were recorded up to the fifth postoperative day. Plasma concentrations of catecholamines and cortisol were comparable in all patients, but those in Group 3 had lower levels of urinary catecholamine excretion. Protein intake was more effective with parenteral nutrition. Nitrogen balances were less negative, and the postoperative inflammatory nutrition index score increased significantly in the traditional groups but not in Group 3. Multimodally treated patients reported less fatigue and better overnight recovery. Along with improved pain relief, recovery of bowel function, and ambulation, there were no differences in the postoperative complication rates among the three groups. The multimodal approach reduced stress and improved metabolism and recovery after radical cystectomy.
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PMID:Multimodal perioperative management--combining thoracic epidural analgesia, forced mobilization, and oral nutrition--reduces hormonal and metabolic stress and improves convalescence after major urologic surgery. 1172 57

The aim of this study was to investigate for which conditions antibiotics are being used in community dental practice, and which clinical features represent the most common reason for an antibacterial approach to the treatment of dental conditions. The study was carried out from November 1998 to June 1999. Dentists were selected according to the different areas of southern Italy, from a list provided by the Italian Society of Dentists. Out of 87 selected dentists, 33 agreed to participate and filled in 1615 questionnaires for each therapeutic intervention ending with antibiotic treatment. Analysis of data indicated that alveolar-gingival abscesses were the most commonly treated infection, accounting for 23.6% of total treatments, followed by acute periodontitis (20.6%) and disodontiasis of the 3rd molar (18.5%). Parenteral antibiotics were chosen in 7.8% of cases. Penicillins were the most commonly used group, 40.1% of total treatments, followed by macrolides (30.2%) and cephalosporins (13.4%). Moreover, penicillins were widely used for post-surgery therapy (52.1%) and disodontiasis of the 3rd molar (50.8%), while macrolides were the most commonly used group for gingivitis (44.1%) and parodontal diseases (55.0%). The choice of parenteral antibiotics was related to severe general symptoms (odds ratios [OR], 4.4; 95% CI: 2.2-9.0), pain (OR, 2.7; 95% CI: 1.2-6.1) and lymphonodal involvement (OR, 6.4; 95% CI: 2.7-15.1). In conclusion, our study demonstrates that antibiotic treatment is often based on the eradication of as many microorganisms as possible, and on the clinical assessment of the patients, rather than on any knowledge of the pathogens involved.
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PMID:Antibiotic prescribing for dental conditions: a community-based study in southern Italy. 1189 2

Although the hazards of using Demerol for pain management is well documented, physicians at a 350-bed tertiary-care center in the upper midwest continued to follow the antiquated practice of ordering intramuscular Demerol and Vistaril to manage pain for patients with acute pancreatitis. Their reasoning was based on early evidence that Demerol, unlike morphine, does not cause biliary-tract spasms resulting in epigastric or right upper quadrant pain. In an effort to change practice patterns, a multidisciplinary team was formed to study the efficacy of using Transdermal Therapeutic System (TTS) fentanyl to manage pain in this patient population. Thirty-two subjects were enrolled in a double-blind, placebo-controlled study to evaluate the efficacy of using TTS fentanyl with intramuscular Demerol for breakthrough pain in comparison to using a placebo system and intramuscular Demerol. There was no statistically significant difference in self-reported pain intensity between the control and experimental groups on the first day of hospitalization. This finding would be expected because serum fentanyl concentrations rise gradually during the first 12 to 14 hours after application of the TTS fentanyl and plateau at 24 hours. There was a statistically significant difference between groups at 36 hours (exact p <.0154) and 45 hours (exact p <.0132) after application of the TTS fentanyl. This is probably because of greater serum fentanyl concentrations observed during the 36- to 48-hour period after application of TTS fentanyl. Although not statistically significant, trends in the data revealed that the experimental group had lower self-reported pain intensity scores than the control group throughout the course of hospitalization. Even though the experimental group had significantly more previous hospitalizations for acute pancreatitis and a higher pain intensity score on admission, this group had a significantly shorter length of stay in the hospital c2 (1, N = 31) = 4.3706 p <.05. There was no statistically significant difference between the two groups for self-reported satisfaction with pain management.
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PMID:Transdermal fentanyl for the management of acute pancreatitis pain. 1199 27

Parenteral opioids are commonly used for labor pain relief and have been the subject of research for many years. The objectives of this review were to determine the safety and effectiveness of parenteral opioids in this context. Of 85 trials systematically reviewed, 48 comprising more than 9800 were included, but the number of trials contributing data to individual outcome measures is very limited. Epidural provides better pain relief. However, if women opt for systemic analgesia, no strong preference for any of the opioids can be recommended. Pethidine is the most commonly used opioid worldwide, and although there are considerable doubts about its analgesic effectiveness and concerns about its potential maternal, fetal, and neonatal side effects, it has the virtue of familiarity and low cost. There is as yet no convincing research evidence to show that alternative opioids are better. In view of the large number of women who receive opioids in labor and the paucity of research evidence about the relative effectiveness and side effects of different opioids and opioids compared with other methods (apart from epidural), well-designed and suitably sized trials of pethidine versus the main alternatives that address substantive outcomes for mothers and babies are strongly recommended.
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PMID:Parenteral opioids for labor pain relief: a systematic review. 1201 76


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