Friday, 22 June 2018

Humanity and Science in Pain Managements


Pain is known to be the first medical consultation pattern and a global health concern. Therapeutic medicine was for a long time interested in treatment of disease more than relieving patients. Although medically correct, this approach remains insufficiently human. Unfortunately, such conducts still practiced actually. For example, in emergency, when a patient with acute appendicitis arrives, he’s accusing an abdominal pain. So, pending diagnosis using all necessary examinations, the patient still suffering, because the medical team is concentrated on diagnosis establishment more than relieving pain. Such approaches were based for a long time on the convenience that if pain is relieved, the diagnosis became more difficult. It’s actually known that this idea is absolutely false. This is the proof that, despite of all efforts, pain management still insufficient. Whatever the type of pain or its origin, suffer pain is causing significant health and social problems with evidence that patients are receiving inadequate care. Several reflections are raised.

Progress in understanding mechanisms involved in the onset of pain improved the management. In fact, distinguishing acute pain and chronic pain is fundamental basis. Defining pain is the first step to manage it. If acute pain (like acute inflammation, postoperative pain, or trauma) therapies are overall excellent, they still not satisfying in chronic pain such as neuropathic pain, complex regional pain syndrome or fibromyalgia. The first reason is that acute pain mechanisms are clearer than chronicles. The second reason, also related to the first, is pharmacotherapies availability. The necessity of improve basic understanding of the mechanisms underlying pain is likely to suggest new avenues for the development of novel pharmacotherapies. Epigenetic abnormality in the spinal cord during neuropathic pain is confirmed since few years. Epigenetic modifications in the spinal cord are caused by long-term increases in chemokine expression. Nerve injury activates primary afferent nociceptors, which transmit information to the dorsal horn of the spinal cord. Activation of secondary neurons in spinal pathways by long-term chemokine expression is capable of inducing epigenetic modifications. The final result is central sensitization leading to a neuropathic pain-like state. The complexity of pain mechanisms explains the multitude of analgesics and numerous used protocols.

Thursday, 21 June 2018

The High Cost of Perfection: Medical Student Suicides


Debt + Deadlines +Depression: A formula for suicide, during medical school?
When you’re a student, especially a medical student, the need for achievement is high and the sources of stress are many: regular exams, National Boards, mounting debt, the need for perfectionism, the fear of failure, isolation, guilt, fatigue, and uncertainty are just a few. For one thing medical school encompasses regular, seemingly endless exams. Some exams are computer or paper-based, riddled with multiple choice questions requiring students to choose the single best answer from a sea of possible selections while others are performance-based, requiring students to demonstrate the clinical skills they’ve learned on real, live simulated patients.

And if that’s not enough, the fear that even bigger exams are ahead is instilled during medical school. Early in Year I, students are made acutely aware of that they’ll soon be facing the National Board Exams; and not just one, but three, innocently referred to as steps 1, 2, and 3. Students are not only under pressure associated with exam-taking, but they must also study for these exams and earn passing scores. These often occur under low fuel, sleep-deprived, and sometimes even panic-stricken conditions. While passing produces relief, near-misses or failed exams incite their own form of stress.

Uncertainty abounds. This begins in the early weeks of medical school, when transitioning from the competitive arena faced as a pre-med student to the pass or fail expanse of medical school. Another source of uncertainty is associated with the inexactitudes of medical knowledge a problem magnified if there is any ambiguity in the learning objectives or course content. All of these have offshoots that impact medical school performance, leaving students who are high achievers with the feeling that it’s never enough, a feeling which paves the way for a fear of failure. High achievers strive for perfection, especially in medical school. Perfectionism has been linked to a fear of failure. When the fear of failure is combined with the need to maintain a strong outward demeanor, ever-increasing debt, the isolation that comes with always having to study and the guilt of spending time away from family and friends, the vulnerability to suicide/suicidal ideation heightens.

Wednesday, 20 June 2018

Poetry and Mental Health


Poetry like otherforms of literature or art can enrich our lives. It can be used to find new meaning in our daily lives. The Australian poet Les Murray described poetry as “a zoo in which you keep your demons and angels” and Mich Imlan, the poetry editor of the Times Literary Supplement, said it is “ a way of talking about things that frighten you. Poetry is not an antidepressant or antipsychotic or anxiolytic medication or cognitive behavioural therapy, but it can play a role in the therapeutic journey of a patient.

My interest in poetry is only recent. I learnt through poetry one can re-imagine the things we usually experience on daily basis. I found poetry to be an excellent medium to express our feelings and can feel cathartic. With poetry, one starts to see and interpret things differently. Through poetry, our use of five senses heightens when we read words that have an emotive content. Eventually, I started writing poems which I have continued to do since.

I found writing poetry a solacing, stimulating and creative exercise. It gave me a medium to express my views and emotions in a way that is nonjudgmental. I have been able to express my views, beliefs and emotions that would not have been possible through ordinary conversations. It has helped me to make sense of my thoughts, feelings, emotions, values and gave a new meaning to my life. Through poetry, one can express both personal and universal truths. Writing poems has slowly given me a sense of accomplishment as well, as I have been able to share my poetry with others. I was eventually able to publish the first collection of my poems. “Gushing Fountain: A Collection of Poems”. Most importantly I was able to write about things that would have been otherwise impossible. Australian poet Peter Porter suggests. Writing a poem is crucially about making something”. Word poetry is derived from the Greek verb Poiesis, which means to make. That very approach gives a sense of accomplishment after writing a poem.

Tuesday, 19 June 2018

Importance of Oral Care Before, During and After Chemotherapy


Within the mostcurrent concepts of health, it is of fundamental importance to consider the patient in a holistic manner. A multidisciplinary team should form the oncology group, especially in the hospital setting. The role of a dentist on this team is to diagnose, prevent and minimize the immediate effects of chemotherapy and/or radiotherapy as well as identify the effects of treatment to improve the quality of life of patients.

The objective of the protocol is to establish a standard for the care of patients with cancer. Emphasize the importance of oral health, in support for outcomes associated with oral care health, the knowledge of oral health for effectiveness in continuing the therapeutic treatment of cancer and awareness of effects acute and late in the mouth from cancer therapy: prevention of local and systemic infections, control pain, maintain oral functions, reduce side effects and improve the quality of life of patients.

Hematopoietic Stem Cell Transplantation (HSCT) is a procedure that requires conditioning to high doses of chemotherapy and/or radiotherapy. Dental treatment prior of HSCT is important. The oral mucosa and teeth should be examined using panoramic radiography to document oral status prior to HSCT. Moreover, such patients need to develop a specific oral hygiene regimen, the instructions for which should be clear and concise. Motivation and understanding with regard to oral care can have a considerable impact during HSCT. Bacterial plaque should also be evaluated, as this is a key factor to the development of gingival and periodontal disease and can contribute to acute infection as well as systemic disorders.

The dental evaluation should be initiated with a panoramic radiograph to gain a broad view of dental treatment and remove any sources of active or potential infection in the oral cavity. Acute and chronic oral infections, such as dental caries and periodontal disease, as well as teeth with questionable prognoses justify an aggressive approach, as any odontogenic infection in an immune suppressed patient can progress to a systemic infection with a possible risk of death. The goal of dental care is to establish a standardized oral evaluation.

Monday, 18 June 2018

Palliative Care - An Ideal Environment for Interprofessional Education and Practice


Palliative care involves an interprofessional collaborative approach in working with patients and their families and caregivers by providing patient-centered and individualized pain relief compassion, caring, and overall minimization of symptom severity. Because palliative care patients most often also have one or more chronic illnesses, the need for the interprofessional practice model is even more important. This type of collaborative care is often referred to as “comfort” care or “end-of-life” care, with the focus being on improving quality of life for both the patient, family, and both family and non-family caregivers. This paper discusses palliative care and the importance of it in the interprofessional education of students in the educational pipeline and of professionals for ongoing effective practice in addition to the interprofessional education of students placed under their supervision during practicums and clinical supervision. There has been a paucity of research specifically in the area focused on the interprofessional proponent in the palliative care setting. A thorough literature review was conducted to analyze the unique components of palliative care that make it an ideal setting for the interprofessional team-building model. Given the increased emphasis on interprofessional education over the past five years with the establishment of the Core Competencies for Interprofessional (IPE) Collaborative Practice, the incorporation of interprofessional education standards into over 60 professional health education organizations, and the need to increase the clinical training and active participation for students in interprofessional settings, palliative care should be utilized more in educational settings as a primary interprofessional education environment for learning about the interprofessional core competences through active involvement of students, practitioners, patients, family members, and caregivers. Although the literature is limited in relationship to Interprofessional education and practice in palliative care, it is clear that palliative care emphasizes a focus on both the patient and family and provides an ideal interprofessional environment including but not limited to physical, social, emotional, and spiritual care. Interprofessional care is integral in palliative care. Additionally, the high risk of burnout among professionals in palliative care further suggests the need for interprofessionalism and integration of IPE core competences in both preservice and continuing education. IPE can build resilience among professionals, family members, and caregivers. While the interprofessional proponent is critical to the outcomes of palliative care, the resilience of team members must be taken into consideration. These findings need to be further developed so that interprofessional care in palliative care settings is used more extensively to prepare students and practicing professionals in interprofessional patient-centered care. The clinical component of interprofessional education is most often lacking in student education. Palliative care environments can help in developing interprofessional leaders for the entire health care delivery system. In addition, there is a need to collect ongoing outcomes data related to the Interprofessional outcomes resulting from effective collaborative care delivery in the palliative care setting. A meta review of the literature was implemented to review the peer-reviewed literature and other professional publications of the past 20 years (1996-2016) to examine the role of palliative care in interprofessional education and practice for professionals and for students in the academic pipeline.

Friday, 15 June 2018

Low-Dose Pamidronate Therapy for Pediatric Osteoporosis: Influence of Diagnosis on Changes in Fracture Rate and Bone Mineral Density


Controversy surrounds the optimal agent, dose and duration of bisphosphonate therapy for pediatric osteoporosis. We conducted a prospective, observational study of low-dose (4 mg/kg/year) intravenous pamidronate in 31 children with Osteogenesis Imperfecta (OI) or non-OI osteoporosis treated for a median of 39 months (range 6.5-164). Subjects in both diagnostic groups showed significant gains in spine areal Bone Mineral Density (aBMD) during the first year of therapy (29% median gain in children with OI and 15% in children with non-OI osteoporosis). Fracture frequency also declined significantly in both patient groups during the first year of treatment, including for two patients who had <10% improvement in spine aBMD over this time frame. The correlation between % change in aBMD and % change in fracture rate for our study population was weak, as demonstrated by a Spearman’s rank correlation coefficient (rho) of 0.13 (p-value 0.32, 95% confidence interval -0.32 to 1.00). Minor side effects of bisphosphonate therapy were self-limited, and no osteopetrosis, jaw osteonecrosis, or atypical femur fractures occurred during treatment for up to 13.6 years. These data suggest that low dose pamidronate is safe and effective for long-term use in pediatric osteoporosis, and that change in aBMD is an imperfect predictor of reduction in fracture risk.

Bone fragility and osteoporosis (OP) are common complications of several genetic and acquired disorders of childhood. Pediatric patients with Osteogenesis Imperfecta (OI), inflammatory bowel disease, rheumatologic disorders, cerebral palsy, muscular dystrophy, cystic fibrosis, or a history of transplantation may develop low bone mass and fragility fractures. Treatment of pediatric osteoporosis begins with optimizing nutrition, vitamin D stores, endocrine function, and weight-bearing physical activity. When these measures are insufficient to prevent bone loss and fracture, use of pharmacologic therapies is considered.

Pharmacologic options for treating OP in adults include bisphosphonates to reduce bone resorption and anabolic agents to stimulate bone formation. The safety and efficacy of these medications in older patients have been established in large randomized controlled trials (RCTs), but data are limited in pediatrics. The best studied anabolic agent, synthetic parathyroid hormone, should not be used in children due to a black box warning about the risk of osteosarcoma. The anti-resorptive bisphosphonates have been used to treat primary and secondary osteoporosis in children, but the optimal agent, dose and duration of therapy remain controversial due to a lack of RCTs comparing different drugs and dosing regimens.

Thursday, 14 June 2018

Petrous Bone Eosinophilic Granuloma


Eosinophilic granuloma is a lytic lesion, driving from histiocyte proliferation of the bone. The lesions mostly occur in long bones, rib or skull, but the involvement of temporal bones is rare. We report the case of a 4-year-old girl with isolated eosinophilic granuloma of petrous apex, presenting with fever and right abducens paralysis. Eosinophilic granuloma is a lytic lesion, driving from histiocyte proliferation of the bone and is a form of Langerhans Cell Histiocytosis (LCH) that is classified into three spectrums of diseases: Letterer Siwe disease, Hand schuller Christian syndrome and Eosinophilic granuloma. These three patterns of disease have specific clinical manifestation.

Eosinophilic granuloma might be confused with chronic otitis media, external otitis and chronic mastoiditis. It usually occurs before the age of ten years and has been reported in skull, spine, ribs, femur and pelvis.Treatment includes curettage, radiation, radiosurgery and injection of steroid in lesions.In this report we present a 4 year old girl with petrous apex Eosinophilic granuloma. A 4-year-old girl was referred to the infectious ward of Children Medical Center, the referral pediatric center in Tehran, Iran from ENT ward with diagnosis of mastoiditis. She had a history of fever and headache for one month and right eye internal deviation for fifteen days before admission to ENT department. Her CT scan which was done in ENT ward revealed a destructive lesion on the tip of petrous bone due to petrositis (Figures 1 & 2). Brain MRI revealed the increase of signal in air cells of mastoid and right petrous apex in T2 that suggested right mastoiditis and AOM (Figures 3 & 4).

On admission in our department she had fever without headache and vomiting. A complete examination showed that her ears were normal but she had abducens paralysis in right side and other exam was normal. The results of initial laboratory tests were as follows: WBC=8040/mm3, neutrophils=47/8%, lymphocytes=42/2%, hemoglobin=10/6g/dl, Platelet=456000/mm3.

Humanity and Science in Pain Managements

                                   Pain is known to be the first ...