Unpleasant Subjective Emotional Experiencing of Pain

The field of pain medicine that once began as a supportive and compassionate care, adding value to the management of acute and chronic ailments, has now transformed into a vital and essential specialty with structured training programs and service units with professionals dedicating their careers to it. The expansion of understanding of the direct relationship of pain relief to the quality of life, uncovering of neuronal pathways, and technological advances in imaging as well as in interventional techniques have all contributed to this phenomenal growth. However, there is a growing concern whether the training programs and the specialized practitioners are gradually limiting their skilled inputs primarily within the sensory realm of the pain experience with sophisticated interventional techniques and relegating its subjective and emotional dimensions to perfunctory realms within the schema of service provision. While the specialty is still young, if we can understand the inherent aspect of these dimensions within the pain experience and acknowledge the gaps in service provision, it may be possible to champion development of truly comprehensive pain relief programs that responds effectively and ethically to a patient''s felt needs. This article attempts to position the subjectivity of pain experience in context and surface the need to design complete systems of pain relief services inclusive of this dimension. It presents authors’ review of literature on perspectives of ‘unpleasant subjective emotional experiencing of the pain” to elucidate possible clinical implications based on the evidences presented on neuro-biology and neuro-psychology of the pain experience; the aim being to inspire systems of care where this dimension is sufficiently evaluated and managed.     

New perspectives in the management of cranio-mandibular ankylosis

Cranio-mandibular ankylosis is characterized by the formation of a bony mass, which replaces the normal articulation. Although the bony mass represents the pathology responsible for the ankylosis, it is not a neoplastic process capable of continued growth. For this reason excision of this mass is not necessary for the release of ankylosis. An osteotomy performed inferior to the base of the ankylotic mass converts this into a situation akin to that of a subcondylar fracture. The technical details of this conceptually new approach to the management of TMJ ankylosis is described and the advantage of this technique over the conventional ones, particularly in cases of recurrent ankylosis, is discussed.     

Fentanyl-Induced Neurotoxicity in Children

Fentanyl-induced neurotoxicity is an uncommon adverse effect of fentanyl and is seldom seen in pediatric palliative care practice. It presents as myriad of nonspecific symptoms such as severe pain, allodynia, insomnia, agitation, hallucinations, behavioral changes, and headache. In children, it is often missed and misdiagnosed. This is a case report of an 11-year-old girl; a case of locally advanced neuroblastoma, progressed on disease-modifying treatment, and referred to pediatric palliative care for best supportive care. She developed features of fentanyl-induced neurotoxicity during upward titration of transdermal fentanyl that was promptly identified and managed in a pediatric palliative care setting.     

Vital root retention: a clinical procedure

Retention of vital roots retards the resorption of residual alveolar ridges under complete dentures. It also eliminates the patient's responsibility of maintaining the periodontal health of overdenture abutments. The procedure involves (1) preparing the teeth to be retained from a periodontal standpoint to reduce the possibility of contamination of the surgical site, (2) removing hopeless teeth, (3) sectioning and contouring the teeth so that the retained roots are contiguous with the crestal bone, (4) preparing and suturing labial and lingual flaps to cover the prepared roots and maintain proper vestibular depth, and (5) placing an immediate denture relined with tissue-conditioning material.     

Differential induction of gamma interferon in Legionella pneumophila-infected macrophages from BALB/c and A/J mice

Gamma interferon (IFN-gamma), a pleiotropic cytokine, is now known to be produced by macrophages as well as by NK cells, gammadelta cells, and activated T cells. The autocrine biological functions of IFN-gamma on the macrophage include the upregulation of major histocompatibility complex MHC class II and the activation to an antiviral state. In this study, the production of IFN-gamma by macrophages was demonstrated to correspond to antibacterial activity. Legionella pneumophila replicates intracellularly in thioglycolate (TG)-elicited macrophages (TG-macrophages) from A/J mice, while TG-macrophages from BALB/c mice restrict bacterial growth after an initial period of growth. BALB/c TG-macrophages were shown to express IFN-gamma mRNA at 24 and 28 h, which corresponded to the initiation of anti-L. pneumophila activity. Moreover, IFN-gammaneutralization by antibody treatment of the cultures resulted in increased L. pneumophila growth in the macrophages. In contrast, no IFN-gamma mRNA was expressed in TG-macrophages from A/J mice, where L. pneumophila grew unrestricted. As would be expected, IFN-gamma treatment decreased bacterial growth. An IFN-gamma-mediated antibacterial activity was, however, inducible in A/J macrophages by the addition of interleukin-12 following L. pneumophila infection. Thus, autocrine IFN-gamma is involved in anti-L. pneumophila activity associated with different growth patterns and appears to be important during intracellular infection.     

Medical Management of Pediatric Malignant Bowel Obstruction in a Patient with Burkitt's Lymphoma and Ataxia Telangiectasia Using Continuous Ambulatory Drug Delivery System

Malignant bowel obstruction (MBO) is commonly seen in patients with advanced abdominal cancers. The incidence of pediatric MBO in a patient with Burkitt's lymphoma and ataxia telangiectasia is rare, with no published case reports till now. Conservative management of inoperable MBO results in relief of symptoms and improves quality of life. An 11-year-old boy with Burkitt's lymphoma and ataxia telangiectasia was referred to pediatric palliative care with MBO. The objective of this report is to demonstrate conservative management of pediatric MBO using continuous ambulatory drug delivery system. The patient was initiated on continuous ambulatory drug delivery (CADD) system for symptom relief. MBO was reversed with conservative management and the child was discharged on self-collapsible portable elastomeric continuous infusion pump under the supervision of a local family physician. The child remained comfortable at home for 4 weeks until his death. His parents were satisfied with the child's symptom control, quality of life, and were able to care for the child at home. In a resource-limited setting, managing patients at home using elastomeric continuous infusion pumps instead of expensive automated CADD is a practical pharmacoeconomic approach.