Severe altered mentation due to cervicothoracic intrathecal pump after correction of cervical stenosis: a case report.

BACKGROUND: Cerebral spinal fluid (CSF) dynamics are complex and changes in spinal anatomy may influence the rostrocaudal movement of intrathecal medications. We present the first reported case demonstrating that acute cervical spinal stenosis may impede the distribution of adjacent intrathecal medications, and that correction of such stenosis and the resulting changes in CSF flow may necessitate significant adjustments in the intrathecal infusates. CASE PRESENTATION: We present a case of a 60-year-old male patient with a cervicothoracic intrathecal pump (ITP) infusing morphine, bupivacaine, and baclofen for chronic neck pain. The alert and oriented patient had a recent fall resulting in an acute severe cervical stenosis and cord compression which required urgent surgical decompression. Postoperatively, after the cervical decompression, the patient had significant altered mental status requiring a naloxone infusion. Multiple attempts to reduce the naloxone infusion were initially not successful due to worsened somnolence. The previously tolerated ITP medications were continuously reduced over the next 14 days, allowing concomitant decrease and eventual cessation of the naloxone infusion while maintaining patient mental status. The only opioids the patient received during this period were from the ITP. CONCLUSIONS: This case presents clinical evidence that severe spinal stenosis may impede the rostral CSF distribution of intrathecal medications. Intrathecal medications previously tolerated by patients prior to decompression may need to be significantly reduced in the postoperative period.

History and Epidemiology of Cancer Pain.

Pain is indelibly associated with the cancer experience. A systematic review and meta-analysis indicate that the prevalence of cancer pain is 55% during anticancer treatment, 66.4% in advanced, metastatic, or terminal disease, and 39.3% after curative treatment.

Responding to the Opioid Epidemic: Educational Competencies for Pain and Substance Use Disorder from the Medical Schools of the University of California.

OBJECTIVE: The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). METHODS: The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. RESULTS: The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other prescription drug misuse. The final competencies covered three domains: pain, SUD, and public health issues related to the opioid crisis. CONCLUSIONS: The authors present a novel set of educational competencies as a response to the opioid crisis. These competencies emphasize the subject areas that are fundamental to the opioid crisis: pain management, the safe use of opioids, and understanding and treating SUD.

Advancing Simulation-Based Education in Pain Medicine.

Background: The Accreditation Council for Graduate Medical Education (ACGME) has recently implemented milestones and competencies as a framework for training fellows in Pain Medicine, but individual programs are left to create educational platforms and assessment tools that meet ACGME standards. Objectives: In this article, we discuss the concept of milestone-based competencies and the inherent challenges for implementation in pain medicine. We consider simulation-based education (SBE) as a potential tool for the field to meet ACGME goals through advancing novel learning opportunities, engaging in clinically relevant scenarios, and mastering technical and nontechnical skills. Results: The sparse literature on SBE in pain medicine is highlighted, and we describe our pilot experience, which exemplifies a nascent effort that encountered early difficulties in implementing and refining an SBE program. Conclusions: The many complexities in offering a sophisticated simulated pain curriculum that is valid, reliable, feasible, and acceptable to learners and teachers may only be overcome with coordinated and collaborative efforts among pain medicine training programs and governing institutions.

Risk Management for Opioid Prescribing in the Treatment of Patients With Pain From Cancer or Terminal Illness: Inadvertent Oversight or Taboo?

As the United States experiences an epidemic of prescription drug abuse, and guidelines on safe practices in prescribing opioids in chronic pain have subsequently emerged from professional organizations and governmental agencies, limited guidance exists for prescribers of opioids to treat pain in patients with cancer or terminal illness. Patients with active cancer or terminal illness often have pain and are frequently prescribed opioids and other controlled substances. Current studies suggest that patients with cancer have similar rates of risk for misuse, abuse, and addiction as the general public. Moreover, palliative care and hospice programs appear poorly prepared for assessing or managing patients with aberrant behaviors or evidence of drug abuse. Further research and professional consensus are needed to help address the challenges associated with misuse, abuse, and addiction in patients with cancer and terminal illness.

Total economic cost and burden of dengue in Nicaragua: 1996-2010.

The burden of dengue in Nicaragua has been steadily rising during the last three decades; however, there have been few efforts to quantify the burden (measured in disability-adjusted life years [DALYs]) and cost to society. Using primary data from the Nicaraguan Ministry of Health (MINSA), the total cost and burden of dengue were calculated from 1996 to 2010. Total costs included both direct costs from medical expenditures and prevention activities and indirect costs from lost productivity. The annual disease burden ranged from 99 to 805 DALYs per million, with a majority associated with classic dengue fever. The total cost was estimated to be US$13.5 million/year (range: US$5.1-27.6 million). This analysis can help improve allocation of dengue control resources in Nicaragua and the region. As one of the most comprehensive analyses of its type to date in Nicaragua and Latin America, this study can serve as a model to determine the burden and cost of dengue.

Opioids, pain management and the law.

PURPOSE OF REVIEW: Approximately 100 million people suffer from chronic pain in the USA. Opioid medications are commonly prescribed to treat pain, but are becoming the most widely misused controlled substance nationally. Physicians who treat patients with chronic pain must be cognizant of the federal and state policies that govern the distribution of opioid medications as well as the current standards of medical practice for opioid prescribing. RECENT FINDINGS: The laws and policies regarding the standard medical practice for opioid prescribing are constantly subject to revision. The National Drug Control Policy announced its plan to fight prescription drug abuse in 2011 and unveiled the Risk Evaluation and Management Strategy initiative. Currently there is a Risk Evaluation and Management Strategy for Transmucosal Immediate-Release Fentanyl. Other resources, such as state-run prescription drug monitoring programs, are also available to many physicians. The level of participation in these programs by physicians and pharmacists varies by state, and funding for continuation of these programs is an ongoing issue. SUMMARY: The problems of undertreated pain and the epidemic of prescription drug abuse have coincided, creating a need for medical and social policy that protects society and access to appropriate care for those in pain. Federal and state laws are in evolution, and clinicians must remain aware of these changes as well as the issues behind them that will impact safe and appropriate care of patients in pain.

Combining Google Earth and GIS mapping technologies in a dengue surveillance system for developing countries.

BACKGROUND: Dengue fever is a mosquito-borne illness that places significant burden on tropical developing countries with unplanned urbanization. A surveillance system using Google Earth and GIS mapping technologies was developed in Nicaragua as a management tool. METHODS AND RESULTS: Satellite imagery of the town of Bluefields, Nicaragua captured from Google Earth was used to create a base-map in ArcGIS 9. Indices of larval infestation, locations of tire dumps, cemeteries, large areas of standing water, etc. that may act as larval development sites, and locations of the homes of dengue cases collected during routine epidemiologic surveying were overlaid onto this map. Visual imagery of the location of dengue cases, larval infestation, and locations of potential larval development sites were used by dengue control specialists to prioritize specific neighborhoods for targeted control interventions. CONCLUSION: This dengue surveillance program allows public health workers in resource-limited settings to accurately identify areas with high indices of mosquito infestation and interpret the spatial relationship of these areas with potential larval development sites such as garbage piles and large pools of standing water. As a result, it is possible to prioritize control strategies and to target interventions to highest risk areas in order to eliminate the likely origin of the mosquito vector. This program is well-suited for resource-limited settings since it utilizes readily available technologies that do not rely on Internet access for daily use and can easily be implemented in many developing countries for very little cost.