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Vice Chair, University of Alaska at Fairbanks
Malignant melanoma (7%) Lung cancer (6%) Other (8%) Pain sites of these metastases: Lumbar spine (34%) Thoracic spine (33% Pelvis (27%) Hip (27%) Sacrum (17%) Humerus (19%) Femur (14%) Breast cancer cell metastasis to bone promotes osteoclastic activity arrhythmia kardiak buy 75 mg triamterene overnight delivery. It exhibits a mixed picture of both lytic and sclerotic areas blood pressure 3 readings purchase triamterene without prescription, with fractures usually occurring through the lytic areas arrhythmia course purchase triamterene overnight. These different mechanisms correspond to typical radiological features showing mixed lytic and sclerotic metastases pulse pressure variation formula purchase genuine triamterene on-line, osteolytic metastases, or sclerotic metastases (see Table 3). However, a study at a multidisciplinary bone metastasis clinic found that 57% of patients reported severe (7?0) pain, and 22% had experienced intolerable pain. The pathophysiological mechanism of pain in patients with bone metastases without fracture is poorly understood. The presence of pain is not correlated with the type of tumor, location, number and size of metastases, or gender or age of patients. While about 80% of patients with breast cancer will develop osteolytic or osteoblastic metastases, about Table 3 Characteristics of skeletal assessment in the most common tumors associated with bone metastases Myeloma Hypercalcemia Bone scans Alkaline phosphatase Histology X-ray 30% Osteoclastic Osteolytic Breast 30% + + Mixed Mixed Prostate Rare ++ ++ Osteoblastic Sclerotic Osseous Metastasis with Incident Pain two-thirds of all demonstrated sites of bone metastases are painless. Many nerves are found in the periosteum, and others enter bones via the blood vessels. Microfractures occur in bony trabeculae at the site of metastases, resulting in bone distortion. The stretching of periosteum by tumor expansion, mechanical stress on the weakened bone, nerve entrapment by the tumor, or direct destruction of the bone with a consequent collapse are possible associated mechanisms. The weakening of bone trabeculate and the release of cytokines, which mediate osteoclastic bone destruction, may activate pain receptors. The release of algesic chemicals within the marrow probably accounts for the observation that pain produced by tumors is often disproportionate to their size or degree of bone involvement. Nerve root infiltration and the compression of nerves by the collapse of osteolytic vertebrae are other sources of pain. These characteristics are fully described by the patient, so the condition should be investigated as probable osseous metastasis with bone pain. The gnawing pain described by the patient is characteristic sign suggesting neuropathic elements. It is radicular in distribution (L2/3) and unilateral, suggesting an origin from the lumbosacral spine. Pain is usually bilateral when originating in the thoracic spine and is exacerbated in certain positions that the patient usually tries to avoid. Straight leg raising, coughing, and local pressure can exaggerate the pain, while pain may be relieved by sitting up or lying absolutely still. Weakness, sphincter impairment, and sensory loss are uncommon at presentation, but they develop when the disease progresses in the compressive phase, and should be prevented. As half of the calcium is albumin-bound, the total calcium value should be adjusted for the albumin level to correctly evaluate the calcemic status. Symptoms occur with calcium values exceeding 3 mmol/L, and their severity is correlated with higher values. In elderly and very ill patients, very slight increases of ionized calcium plasma levels may be symptomatic. Increases in urinary calcium levels are caused by the release of calcium into the circulation secondary to an increased bone resorption. Both urinary hydroxyproline/creatinine and calcium/creatinine ratio have been used to monitor the effects of bisphosphonate treatment. Gastrointestinal symptoms are often mistaken for opioid effects or are potentiated by opioid-related symptoms, and neurological symptoms are often attributed to cerebral metastases. Hypercalcemia complicates the Clinical presentation Case study A female patient, aged 63 years, came to the pain clinic with vague aching pain in the lower back, which she has had for 3 months, accompanied by gnawing pain in the middle of her right thigh, particularly on standing up or walking. Pain scoring by the patient defined the pain at rest as 4, and pain on walking as 6, on a 10-cm line. The back pain has been steadily increasing during this time, and now she lies in bed all the time to prevent her pain from increasing further.
Headache still calls for a thorough neurological examination heart attack american order triamterene 75 mg overnight delivery, however blood pressure during exercise buy generic triamterene on line, as missing those uncommon neurological headaches (raised intracranial pressure blood pressure medication beta blocker order triamterene 75mg on-line, meningitis arrhythmia facts generic triamterene 75mg overnight delivery, tumors, etc. Find out the type of headache, its character, anatomical site, severity, frequency, and duration; the nature of onset, timing and periodicity; precipitating factors (straining, coughing, posture, sex, etc. Other symptoms can largely be evaluated along the same lines with variations as necessary, since not all aspects apply to all symptoms. A history of common neurological symptoms such as loss or impairment of consciousness, visual disturbances, speech and language disturbances, sensory disturbances, and motor disturbances (including sphincters) should be obtained along the same lines where possible. Further details regarding individual symptoms can be added as appropriate during direct questioning to establish potential etiological factors, including exposure to drugs (alcohol included), environmental toxins, past injuries, and systemic illnesses. In conclusion, at least basic neurological examinations are indicated in every patient to detect somatic etiologies of pain, mainly lesions of the cerebrum, spinal cord, and peripheral nerves, including myopathies. It would be harmful to our patients to overlook pain etiologies that could be treated causatively! Therefore, 79 Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Thus, objective findings such as muscle atrophy have greater value, since they may not be voluntary influenced! Every examiner will experience at times "inadequate" or "unexpected" results from the examination. The patient should never be confronted with the suspicion of aggravation or simulation, so as to avoid an irreversible loss of mutual trust, but the suspicion should be integrated into the whole picture of the patient evaluation. Starting with the symptoms presented by the patient, it is advisable to continue trying to identify a syndrome, which includes all symptoms. A topical diagnosis may then be made (which is the "level" of neurological dysfunction), which should lead to the final etiological diagnosis. Paraclinical testings, such as electrophysiology and imaging techniques, help by confirming or ruling out a certain etiological diagnosis. However, the availability of such technical examinations is not a prerequisite to make a diagnosis in many cases. Therefore, in environments without the possibility for further testing, careful and thorough history taking and physical examination will be able to collect relevant and most often sufficient findings to make a diagnosis, helping the clinician to understand and possibly treat neurological diseases causing pain. Everything necessary for an orientating neurological examination should be easily available. Remember that in a very busy clinic, one may not be able to do a thorough examination for all patients. But with experience, one develops a quick and efficient personal examination protocol. In the usual clinical manner, establish a rapport with the patient and explain the nature and purpose of the examination to reassure him or her. The patient should be comfortable on the examination couch and adequately but decently exposed. The physician normally begins the examination of any patient with an examination of the appearance of the subject in general, his/her skin and mucous membranes, followed by palpation for lumps, lymph nodes, pulses, and any superficial points of tenderness. An evaluation of vital functions should normally be done at this time, including blood pressure, pulse, respiration, and temperature. To be able to draw conclusions from the neurological examination, it is advisable to follow a certain stepwise approach to avoid imperfection. A checklist of activities is often useful for the non-neurologist who is not yet experienced. For many, it is easy to follow the examination in a rostral caudal direction, but one may find other methods equally effective. Establish that the patient is fully conscious, able to understand and follow instructions, and fully oriented in time, space, and person. If any impairment is noted, a full description should be recorded as precisely as possible. Cognitive skills can quickly assessed using simple observations during history taking and can then be supplemented by direct examination of specific skills. Assessment of language pattern and fluency can easily pick up those patients with motor dysphasia, while ability to follow instruction in the course of general examination may raise the suspicion of receptive dysphasia. With this tool, orientation, memory and recall, abstraction, comprehension, reading, drawing, and writing ability can be assessed.
All electric stimulation requires two electrodes; the negative terminal is termed the cathode hypertension pamphlet order triamterene once a day, and the positive terminal is the anode blood pressure low range discount 75 mg triamterene free shipping. By convention exforge blood pressure medication buy triamterene 75 mg lowest price, the stimulating electrodes are called bipolar if they are encased or attached together and are called monopolar if they are not artaria string quartet cheap triamterene 75mg line. Electric stimulation for nerve conduction studies generally requires application of the cathode in the vicinity of the neural tissue to produce depolarization. The method is used in patients who are unable to produce a steady voluntary muscle contraction. The stimulation can be delivered to intramuscular axons, nerve trunks, or muscle fibers. Stimulus: Any external agent, state, or change that is capable of influencing the activity of a cell, tissue, or organism. It may be described in absolute terms or with respect to the evoked potential of the nerve or muscle. In absolute terms, it is defined by a duration (ms), a waveform (square, exponential, linear, etc. With respect to the evoked potential, the stimulus may be graded as subthreshold, threshold, submaximal, maximal, or supramaximal. The maximal stimulus is the stimulus intensity after which a further increase in intensity causes no increase in the amplitude of the evoked potential. By convention, an electric stimulus of approximately 20% greater voltage/current than required for the maximal stimulus is used for supramaximal stimulation. Strength?uration Curve: Graphic presentation of the relationship between the intensity (Y axis) and various durations (X axis) of the threshold electric stimulus of a nerve or muscle. The rheobase is the intensity of an electric current of infinite duration necessary to produce a minimal action potential. The chronaxie is the time required for an electric current twice the rheobase to elicit the first visible action potential. Measurement of the strength?uration curve is not a common practice in modern electrodiagnostic medicine. The earliest component is monosynaptic and is also called the myotatic reflex, or tendon reflex. Subnormal Period: A time interval that immediately follows the supernormal period of nerve which is characterized by reduced excitability compared to the resting state. Supernormal Period: A time interval that immediately follows the refractory period which corresponds to a very brief period of partial depolarization. It is characterized by increased nerve excitability and is followed by the subnormal period. Supraclavicular Plexus: That portion of the brachial plexus which is located superior to the clavicle. Supraclavicular Stimulation: Percutaneous nerve stimulation at the base of the neck which activates the upper, middle, and/or lower trunks of the brachial plexus. Surface Electrode: Conducting device for stimulating or recording placed on the skin surface. Sympathetic Skin Response: Electrical potential resulting from electrodermal activity in sweat glands in response to both direct and reflex peripheral or sympathetic trunk stimulation of autonomic activity. Synkinesis: Involuntary movement made by muscles distant from those activated voluntarily. T Wave: A compound muscle action potential evoked from a muscle by rapid stretch of its tendon, as part of the muscle stretch reflex. Tardy Ulnar Palsy: A type of mononeuropathy involving the ulnar nerve at the elbow. The nerve becomes compressed or entrapped due to deformity of the elbow from a previous injury. Template Matching: An automated method used in quantitative electromyography for selecting motor unit action potentials for measurement by extracting only potentials which resemble an initially identified potential. Temporal Dispersion: Relative desynchronization of components of a compound muscle action potential due to different rates of conduction of each synchronously evoked component from the stimulation point to the recording electrode. It may be due to normal variability in individual axon conduction velocities, especially when assessed over a long nerve segment, or to disorders that affect myelination of nerve fibers. Tetanic Contraction: the contraction produced in a muscle through repetitive maximal direct or indirect stimulation at a sufficiently high frequency to produce a smooth summation of successive maximum twitches.
Rescue or breakthrough medication should be prescribed for patients with advanced disease blood pressure treatment guidelines order 75mg triamterene mastercard, where exacerbations of pain or other symptoms are possible heart attack arm pain purchase triamterene overnight delivery, and rapid treatment of these exacerbations is required arrhythmia icd 10 code generic triamterene 75mg without prescription. Rescue medications can include different drugs heart attack i was made for loving you purchase triamterene master card, but for most patients they should include at least an opioid with fast onset for treatment of pain, dyspnea, and anxiety as well as a benzodiazepine such as lorazepam for the treatment of dyspnea, anxiety, and agitation (Table 2). Respiratory secretions may lead to labored breathing in dying patients, and may cause distress in patients as well as in caregivers. Anticholinergic drugs such as hyoscine butylbromide may alleviate this "death rattle" quickly. Oral application may be much easier if no professional help is available, but in some patients oral intake is not possible. Opioids as well as many other drugs used in palliative care can be injected subcutaneously, with little risk of complications and with a faster onset of action than with oral application. Intravenous application offers the option for rapid titration with small bolus administrations if trained staff are available. Exacerbation of pain and other symptoms as well as severe psychological distress with anxiety or even panic may lead to emergency situations that require immediate action. In these emergencies, the onset of symptom relief should not be delayed unduly by prolonged assessment or differential diagnosis. However, the usual medical emergency procedures may also be detrimental, for example when pain exacerbation leads to a hospital admission with transport time as well as radiographic and laboratory investigations, but without analgesic intervention or comforting care. Emergencies that have to be treated rapidly and adequately are exacerbations of preexisting symptoms, new symptoms with sudden and intense onset, or rare complications such as massive hemorrhage. Individual treatment plans in palliative care should try to foresee such emergencies and provide adequate interventions. Prescription (or even better, provision) of rescue medication for emergencies is especially important when health care professionals are not available out of office What should be done in the case of massive hemorrhage? Cancer growth in the skin or mucous membranes may lead to excessive bleeding if major blood vessels are ruptured. This can manifest with sudden onset or with Table 2 the essence of symptom control: emergency intervention Medication Rescue Medication (Given as Required) Morphine 10 mg Hydromorphone Hyoscine butylbromide 40 mg Lorazepam 1 mg Palliative Sedation Midazolam 3? mg/h s. For more severe bleeding, benzodiazepines or morphine via subcutaneous bolus administration may be indicated, but often they will not take effect fast enough. With massive hemorrhage the patient will quickly become unconscious and die with little distress, and treatment should be restricted to comfort measures. Psychosocial issues are often neglected by medical staff, even though they are paramount for many patients. For most patients in resource-poor countries the loss of support is an immediate implication of a life-threatening disease, often endangering the survival of the patient as well as of the family. Social support that provides the means to sustain basic requirements is as mandatory as the medical treatment of symptoms. Most patients with life-threatening disease also have spiritual needs, depending on their religious background and cultural setting. Spiritual support from caregivers as well as from specialized staff, for example religious leaders, may be helpful. Rarely, patients with extreme distress from pain, dyspnea, agitation, or other symptoms that are resistant to palliative treatment, or do not respond fast enough to adequate interventions, should be offered palliative sedation. This means that benzodiazepines are used to lower the level of consciousness until distress is relieved. In some patients deep sedation is required, rendering the patient unconsciousness. However, for other patients mild sedation may be enough, so that patients can be roused and can interact with families and staff to some degree. Intravenous or subcutaneous midazolam is used most often, as it can be titrated to effect easily. It should be realized that palliative sedation is the last resort if symptomatic treatment fails.
The myelinated axon of the motor neuron divides into numerous branches (collaterals) hypertension fact sheet purchase triamterene in india, each of which loses its myelin sheath near the muscle fiber and joins the muscle fiber midway along its length prehypertension nhs triamterene 75 mg on line. As the axonal branch nears the muscle fiber blood pressure medication vertigo purchase online triamterene, it expands into a presynaptic terminal bouton that lies within a depression in the muscle cell membrane arrhythmia strips buy triamterene 75mg visa. The muscle cell membrane (postsynaptic membrane) beneath the nerve terminal has a highly specialized structure, with numerous junctional folds. These specialized presynaptic neural and postsynaptic muscle cell membrane structures constitute the neuromuscular junction, that is, the synapse between nerve and muscle (Fig. The presynaptic nerve terminal has specialized anatomical and metabolic features for the formation, storage, release, and reuptake of acetylcholine. Acetylcholine is required for chemical synaptic transmission and is stored in synaptic vesicles that release their contents into the synaptic cleft under appropriate conditions (Fig. The postsynaptic membrane contains acetylcholine receptor protein molecules concentrated on the crest of the junctional folds (Fig. When acetylcholine binds to the postsynaptic acetylcholine receptor protein Figure 24. Repetitive Stimulation Studies 371 molecules, it causes a change in configuration of the receptor, opening a pore or channel in the membrane, resulting in sodium influx and depolarization of the muscle cell membrane. Randomly, presynaptic vesicles containing acetylcholine join the presynaptic membrane and release their quantal contents into the neuromuscular junction. The acetylcholine joins with the acetylcholine receptor and produces a small depolarization of the muscle membrane in the area around the neuromuscular junction. When an action potential reaches the nerve terminal, voltage-gated channels in the nerve terminal open, allowing influx of calcium. This triggers the release of a large number of vesicles (quanta) of acetylcholine in a short time. The calcium causes a change in configuration of the muscle fiber filaments and leads to excitation?ontraction coupling. Thus, through excitation?ontraction coupling, the action potential results in contraction of the muscle fiber. The amount of acetylcholine released at the neuromuscular junction varies under different conditions. The mechanisms involved in the release of acetylcholine by an action potential are such that if another action potential occurs within 200 ms after the first one, the amount of acetylcholine released is greater with the second action potential (Fig. Thus, if a nerve is stimulated repetitively, the amount of acetylcholine released with each stimulus varies depending on the rate of stimulation. At fast rates of repetition, that is, more than 10 per second (short interval between successive stimuli), the amount of acetylcholine released increases or is potentiated. After a series of rapid stimuli (called tetanic stimulation), the potentiation of acetylcholine release may persist for 30?0 seconds. With slow rates of repetitive stimulation, that is, less than 5 per second (long interval between stimuli), the amount of acetylcholine released is less with each of the first four stimuli. This decrease is more pronounced for 2? minutes after a period of exercise or after repetitive, or tetanic, stimulation. Key Points ?The neuromuscular junction is composed of a synapse where an axonal branch of a motor neuron joins with a muscle fiber. The muscle fiber action potential spreads in an all-or-none fashion and leads to contraction of the muscle fiber. The amount of acetylcholine released with each action potential depends on the frequency of nerve stimulation. Technique is very important because, on the one hand, poor technique can result in "abnormal" findings in patients with normal neuromuscular transmission, leading to an erroneous diagnosis of a disorder of neuromuscular transmission. The basic techniques required are those used for routine motor nerve conduction studies (see Chapter 23). These basic techniques must be mastered before repetitive stimulation is attempted.
