Desmoid Tumors: A Review of the Literature and Pharmacologic Management

Desmoid tumors represent a nonmalignant proliferation of fibroblast-related cells. These rare tumors are difficult to treat and often persist as indolent, lifelong conditions. There are a number of treatments available for both anatomic and symptom regression. Some of these treatments, unfortunately, may not provide long-lasting results and may result in further complications. Pain is a distressing symptom that may be due to the tumor itself or the result of utilized treatments. Pharmacologic therapies represent a noninvasive alternative to surgical resection. Pain symptoms require therapeutic regimens that must be modified as the tumor evolves in expression. The individualized pain treatment program utilized may often reflect principles used in both nonmalignant and malignant pain management models. This review seeks to increase awareness of desmoid tumors through a review of the literature and discussion of its pharmacotherapeutic management

Pain Pathways and Pain Physiology

Pain is a multidimensional sensory experience that is mediated by complex peripheral and central neuroanatomical pathways and mechanisms. Typically, noxious stimuli activate specific peripheral nerve terminals onto Aδ‎ and C nerve fibers that convey pain and generate signals that are relayed and processed in the spinal cord and then conveyed via the spinothalamic tracts to the contralateral thalamus and from there to the brain. Acute pain is selflimited and resolves with the healing process, but conditions of extensive injury or inflammation sensitize the pain pathways and generate aberrant, augmented responses. Peripheral and central sensitization of neurons (as a result of spatially and temporally excessive inflammation or intense afferent signal traffic) may result in hyperexcitability and chronicity of pain, with spontaneous pain and abnormal evoked responses to stimuli (allodynia, hyperalgesia). Finally, neuropathic pain follows injury or disease to nerves as a result of hyperexcitability augmented by various sensitizing mechanisms

Opioid-induced Hallucinations: A Review of the Literature, Pathophysiology, Diagnosis, and Treatment

Despite their association with multiple adverse effects, opioid prescription continues to increase. Opioid-induced hallucination is an uncommon yet significant adverse effect of opioid treatment. The practitioner may encounter patient reluctance to volunteer the occurrence of this phenomenon because of fears of being judged mentally unsound. The majority of the literature concerning opioid-induced hallucinations arises from treatment during end-of-life care and cancer pain. Because the rate of opioid prescriptions continues to increase in the population, the rate of opioid-associated hallucinations may also conceivably increase. With a forecasted increase in the patient-to-physician ratio, opioid therapy is predicted to be provided by practitioners of varying backgrounds and medical specialties. Hence, knowledge of the pharmacology and potential adverse effects of these agents is required. This review seeks to increase awareness of this potential complication through a discussion of the literature, potential mechanisms of action, diagnosis, and treatment strategies

Two for One: A Case Report of Intravenous Lipid Emulsion to Treat Local Anesthetic Systemic Toxicity in Term Pregnancy

Combined spinal–epidural (CSE) analgesia is a frequently used method of labor analgesia. Although it is considered safe and effective, CSE can be complicated by local anesthetic systemic toxicity (LAST), a potentially life-threatening condition. We present a case of LAST that developed in a primigravida 50 minutes after uneventful placement of a CSE. Her symptoms resolved within 10 minutes of administering intralipid emulsion. She subsequently underwent cesarean delivery under spinal anesthesia for failure to progress without sequelae in the mother or infant. LAST in pregnancy can occur at traditionally subthreshold dosing; anesthesiologists must be vigilant to ensure prompt and effective treatment

Noninvasive Electrical Stimulation for the Treatment of Chronic Ocular Pain and Photophobia

Introduction “Dry eye” or “keratoconjunctivitis sicca” is a multifactorial disease estimated to have a worldwide prevalence of 5–33%. Conventional therapies targeting the ocular surface with artificial tears, anti‐inflammatories, punctal closure, eyelid hygiene, and antibiotics do not provide relief in all patients, especially those with neuropathic‐like ocular complaints (wind hyperalgesia and photophobia). We anticipated that ocular transcutaneous electrical nerve stimulation (TENS) would alleviate symptoms of ocular pain, photophobia, and dryness in these latter individuals. Methods All individuals who received electrical stimulation between May 10, 2016 and April 6, 2017 for the treatment of chronic ocular pain at the oculofacial pain clinic of the Miami Veterans Administration Hospital were included in this retrospective review. All patients had symptoms of dryness along with other neuropathic‐like symptoms (e.g., photophobia) and minimal signs of tear dysfunction. Ocular pain intensity, symptoms of dryness, and light sensitivity were compared pre‐treatment and five min post‐treatment via a two‐tailed paired Student's t‐test. Results The use of TENS significantly reduced the mean pain intensity in both the right and left eyes five min after treatment compared to prior to treatment (p < 0.05, paired t‐test). The use of TENS significantly decreased light sensitivity in both eyes (p < 0.05). The findings for symptoms of dryness, however, were equivocal with a significant decrease in the left eye but not the right (p < 0.05, paired t‐test). Discussion Our data indicate that TENS may similarly provide analgesia in patients with dry eye symptoms as it does for many other chronic pain conditions. Furthermore, the noted effect on symptoms of photophobia and dryness suggest that all may be linked by similar trigeminal–thalamic–cortical pathways. Prospective studies with electrical stimulation of dry eye are needed to further elucidate its benefit and mechanism of action

Modified open-access scheduling for new patient evaluations at an academic chronic pain clinic increased patient access to care, but did not materially reduce their mean cancellation rate: A retrospective, observational study

Study objectiveTo determine if open-access scheduling would reduce the cancellation rate for new patient evaluations in a chronic pain clinic by at least 50%.DesignRetrospective, observational study using electronic health records.SettingChronic pain clinic of an academic anesthesia department.PatientsAll patients scheduled for evaluation or follow-up appointments in the chronic pain clinic between April 1, 2014, and December 31, 2015.InterventionsOpen-access scheduling was instituted in April 2015 with appointments offered on a date of the patient's choosing ≥1 business day after calling, with no limit on the daily number of new patients.MeasurementsMean cancellation rates for new patients were compared between the 12-month baseline period prior to and for 7months after the change, following an intervening 2-month washout period. The method of batch means (by month) and the 2-sided Student t-test were used; P&lt;0.01 required for significance.Main resultsThe new patient mean cancellation rate decreased from a baseline of 35.7% by 4.2% (95% confidence interval [CI] 1.4% to 6.9%; P=0.005); however, this failed to reach the 50% reduction target of 17.8%. Appointment lag time decreased by 4.7days (95% CI 2.3 to 7.0days, P&lt;0.001) from 14.1days to 9.4days in the new patient group. More new patients were seen within 1week compared to baseline (50.6% versus 19.1%; P&lt;0.0001). The mean number of new patient visits per month increased from 158.5 to 225.0 (P=0.0004). The cancellation rate and appointment lag times did not decrease for established patient visits, as expected because open-access scheduling was not implemented for this group.ConclusionsAccess to care for new chronic pain patients improved with modified open-access scheduling. However, their mean cancellation rate only decreased from 35.7% to 31.5%, making this a marginally effective strategy to reduce cancellations

Modified open-access scheduling for new patient evaluations at an academic chronic pain clinic increased patient access to care, but did not materially reduce their mean cancellation rate: A retrospective, observational study

To determine if open-access scheduling would reduce the cancellation rate for new patient evaluations in a chronic pain clinic by at least 50%. Retrospective, observational study using electronic health records. Chronic pain clinic of an academic anesthesia department. All patients scheduled for evaluation or follow-up appointments in the chronic pain clinic between April 1, 2014, and December 31, 2015. Open-access scheduling was instituted in April 2015 with appointments offered on a date of the patient's choosing ≥1 business day after calling, with no limit on the daily number of new patients. Mean cancellation rates for new patients were compared between the 12-month baseline period prior to and for 7months after the change, following an intervening 2-month washout period. The method of batch means (by month) and the 2-sided Student t-test were used; P<0.01 required for significance. The new patient mean cancellation rate decreased from a baseline of 35.7% by 4.2% (95% confidence interval [CI] 1.4% to 6.9%; P=0.005); however, this failed to reach the 50% reduction target of 17.8%. Appointment lag time decreased by 4.7days (95% CI 2.3 to 7.0days, P<0.001) from 14.1days to 9.4days in the new patient group. More new patients were seen within 1week compared to baseline (50.6% versus 19.1%; P<0.0001). The mean number of new patient visits per month increased from 158.5 to 225.0 (P=0.0004). The cancellation rate and appointment lag times did not decrease for established patient visits, as expected because open-access scheduling was not implemented for this group. Access to care for new chronic pain patients improved with modified open-access scheduling. However, their mean cancellation rate only decreased from 35.7% to 31.5%, making this a marginally effective strategy to reduce cancellations. •Modified open-access scheduling was implemented for new patients at an academic chronic pain clinic.•Appointments were offered on the date of the patient's choosing ≥1 business day after calling.•The mean cancellation rate decreased from 35.7% to 31.5%, not meeting the target of a 50% reduction.•Modified open-access scheduling was effective in increasing the number of patients seen