Diagnostic epidural opioid technique

Diagnostic epidural blocks were performed on 27 chronic pain patients sequentially using saline, fentanyl, and lidocaine solution. The patients were divided into one of four groups based on their response to the epidural solutions: placebo response group--pain relief with placebo solutions; fentanyl response group--pain relief with epidural fentanyl; lidocaine response group (LRG)--pain relief with lidocaine but not fentanyl; and no response group--no pain relief with any of the solutions used. The four groups were compared on the basis of age, sex, site of pain, duration of pain, narcotic use, pain assessment index, and workmen's compensation claims. The comparisons resulted in the conclusion that LRG patients had a much longer average duration of pain than the other groups. On the basis of the information gathered, it was theorized that, despite their response to epidural lidocaine, LRG patients may actually be a group of operant pain patients. Their failure to receive analgesia from epidural fentanyl may be a learned response such that they associate any sensory input from the affected area as painful. If follow-up studies support these findings, then the diagnostic opioid technique may be a more sensitive tool in diagnosing chronic pain.     

Normative model for cold pressor test

The cold pressor test elicits an emotional/motivational pain experience from the immersion of a limb in cold water. It has been widely used to evaluate (experimental and chronic) pain. However, normative models for quantification and comparison for pain tolerance have not previously been established. This study developed a normative mathematical model for pain tolerance using the cold pressor test with over 600 subjects. Norms for age, sex, and ethnic group were calculated. In addition, chronic pain patients were compared with pain-free patients to determine normative differences in response. The results indicate that at any given age Anglo-Saxon males have the longest tolerance time followed by non-Anglo-Saxon males, Anglo-Saxon females, and finally non-Anglo-Saxon females. There is a consistent decrease in tolerance time as the male age increases and minimal change in tolerance time as the female age increases. Chronic pain patients exhibited the same type of pain response pattern as healthy volunteers when corrected for age, sex, and ethnocultural subgroup.     

Nocardia asteroides osteomyelitis

Nocardia asteroides osteomyelitis has previously been described only in acutely ill patients. It may occur as an isolated event or part of the disease spectrum of disseminated nocardiosis. An 84 year old immune competent man with N. asteroides right tibial osteomyelitis had an unusual presentation, presumed mechanism of disease and outcome. His course affords an opportunity to review the literature on N. asteroides osteomyelitis and to discuss the unique features of his case.     

Neoadjuvant treatment of advanced stage esophageal adenocarcinoma increases survival.

Sophisticated surgical approaches have a definite but limited role in esophageal cancer. The majority have systemic disease at presentation, minimal residual disease following resection or co-morbid conditions that preclude extensive surgery. This paper examines whether neoadjuvant therapy is effective in advanced-stage disease. A randomized trial, closing September 1995, was followed up to determine results at 5 years. All patients were followed up for more than 5 years. Median survival, based on intention-to-treat, was 17 months for multimodal therapy vs. 12 months for surgery alone (P=0.002). Survival based on treatment received was 27 months vs. 14 months (P=0.0006). Multimodal therapy enhances survival for patients with minimal residual disease. This is consistent with the literature. Under-powered trials cannot prove a real difference to be significant. Future trials should target patients with minimal residual disease.     

Interleukin-1 modulates T6 expression on a putative intra-epithelial Langerhans cell precursor population

T6 is an antigen which is a highly specific marker for Langerhans cells. Previous studies have demonstrated that Interleukin-1 (IL-1) and an IL-1 inhibitor (ILS) modulate T6 expression (T6E) in explant culture. The present study examined the effects of IL-1 and ILS on T6E in dispersed gingival epithelial cell (EC) cultures. EC were obtained by trypsinization of gingival fragments obtained during periodontal surgery. T6E by EC was demonstrated using OKT6 monoclonal antibody in an immuno-peroxidase technique. In both unseparated and T6-depleted EC, IL-1 (0.5 U/mL) stimulated T6E, and this effect was abrogated by ILS (1:30). ILS alone depressed T6E in unseparated EC cultures. All effects were consistent between four- and 24-hour culture periods, and no treatment affected EC viability, thus excluding cell proliferation or necrosis as a vector for the action of IL-1 and ILS. These results indicate that a population of epithelial cells exists which is induced to express T6 under the influence of IL-1. IL-1 and ILS act in combination to regulate T6E on these precursor cells and on DR(-) Langerhans cells in gingival epithelium.     

Continuing care in a medical center: the Cleveland Clinic Foundation Palliative Care Service

Approximately 500,000 people die of cancer in the United States each year. Most attention has focused on curative approaches to cancer management. Despite the fact that 80% of persons with advanced cancer suffer from chronic pain and an equal number have a major problem with anorexia and weight loss, little systematic evaluation of these problems has been conducted, although they have a high medical, psychological, and socioeconomic impact. The need for a palliative care service (PCS) at the Cleveland Clinic Foundation was originally identified by physicians within the Department of Hematology and Medical Oncology. During 1987, a pilot study was conducted to evaluate the service, define its potential patient base, and assess its impact on patient care. It is astonishing that so little attention has been paid to this area by the major institutions and organizations involved in care of patients with advanced cancer, despite the hundreds of thousands dying of the disease each year. A dedicated palliative care service would therefore seem appropriate in any major medical institution dealing with significant numbers of cancer patients. It also seems appropriate that the provision of a PCS should be part of the requirements for a comprehensive cancer center, if a center is to claim to provide the entire spectrum of services, from diagnosis until death.     

Parenchymal and vascular magnetic resonance imaging of the brain after extracorporeal membrane oxygenation

Three-dimensional (volume) magnetic resonance angiography is a new and noninvasive method for imaging the intracranial vasculature. The combination of magnetic resonance angiography and conventional magnetic resonance imaging was used to evaluate brain parenchyma and vessels in 30 survivors of extracorporeal membrane oxygenation. Magnetic resonance imaging findings were abnormal in 33% of the patients, with no increased frequency of right hemispheric lesions. Magnetic resonance angiography demonstrated good intracranial flow in all infants and demonstrable right internal carotid arterial flow in 35% of those patients with permanent carotid ligation. An abnormal magnetic resonance imaging study was found more often in infants with abnormal predischarge neurologic examination results. These techniques have several advantages over other neuroimaging modalities, including better definition of deep structures, myelin formation, and intracranial vasculature, the absence of bone artifact, and the elimination of catheter or contrast use.