Anileridine-induced delirium.

Delirium is a common complication in hospitalized patients and is often associated with significant morbidity. It is important to recognize this syndrome early so that potential causes can be identified and properly managed. Although the etiology of delirium in critically or terminally ill patients is often multifactorial, opioid analgesics are often implicated as a potential underlying cause. Certain opioids, such as meperidine, have been identified as having a greater potential for causing delirium than others. There have been no published reports of anileridine-induced delirium and an illustrative case is presented.

Endoscopic palliation of oesophageal carcinoma with Atkinson prosthesis.

To assess the degree of palliation, the associated morbidity and mortality and to compare our results with other published series, we reviewed our use of the Atkinson prosthesis in 100 consecutive patients for the palliation of unresectable oesophageal carcinoma. The group had a mean age of 71.2 +/- 2.3 years. All prostheses were placed by the pulsion method. Intubation was successful in 91%. Improvement in swallowing was seen in 82.1%. Major early procedure-related morbidity was high at 23% with 11 perforations (11%). Procedure-related mortality was 12%. Those aged 70 years or more had a 34.5% risk of morbidity and 15.5% risk of dying from the procedure. Late procedure-related complications requiring further endoscopic procedures occurred in 27%. Our 7 day mortality was 14.7% (14 patients) and 31 patients (32.6%) had died within 30 days, usually from the disease itself. Those surviving the procedure (> 7 days) had a mean survival of 105 (range 9-735) days. We obtained acceptable palliation but with a significant morbidity and mortality. Endoscopic intubation remains a useful palliative treatment for patients with unresectable carcinoma of the oesophagus and cardia.

Complications of biliary stents in obstructive pancreatic malignancies. A case report and review.

Biliary stents have become a common palliative measure in the treatment of unresectable obstructive pancreatic cancer. Survival after endoscopic stenting rivals that of surgical bypass. Complications involving stents are not uncommon and can be categorized as related to placement, obstruction, migration, or fracture. A case report and review of stent-related morbidity is presented. Overall complication rates range from 15 to 34%, often requiring stent replacement and occasionally requiring surgical intervention.

Case report: intestinal perforation--an unusual complication of endoscopic biliary stenting.

The endoscopic placement of stents to decompress biliary obstruction is accepted practice in the management of malignant biliary strictures. In our patient, a 73-year-old man with a presumed malignant common hepatic duct stricture, palliation of his obstructive jaundice has been achieved. However, his clinical course was complicated by a colonic perforation--a previously unreported complication of distal stent migration.

A study of acute side-effects related to palliative radiotherapy treatment of lung cancer.

Two recent studies carried out by the Medical Research Council Lung Cancer Working Party have suggested that large fraction radiotherapy to the chest in either 10-Gy single fraction or 17-Gy two-fraction doses, 1 week apart, is safe and effective for patients who require palliation for bronchogenic cancer. The Beatson Oncology Centre, Glasgow, participated in the original MRC trial and anecdotal reports of acute chest pains, fevers, sweats and rigors in some patients during the first 24-hour period after radiotherapy treatment were noted. These acute side-effects were not monitored during the Medical Research Council trials. It was felt that this area warranted further evaluation in order to identify the incidence of such acute side-effects and to what extent they caused a reduction in the patients' remaining quality of life. A pilot study of 10 patients confirmed the manifestation of the side-effects reported anecdotally in the MRC trial. It was on this basis that the study was extended, with a further 51 patients being invited to participate over a 4-month period. The findings indicate a significant incidence of adverse side-effects in patients receiving large fraction radiotherapy to the chest in either 10-Gy single fraction or 17-Gy two-fraction doses, but that these are transient and do not cause unacceptable disruption to the patients over an extended period.

Quality of life and survival with continuous hepatic-artery floxuridine infusion for colorectal liver metastases.

Very few patients with liver metastases from colorectal cancer can be cured. We have investigated whether a treatment to slow the growth of liver metastases, hepatic-artery infusion of floxuridine, improves palliation in this setting. In a randomised study of 100 patients, we compared quality of life and survival in patients who received hepatic-artery infusion of floxuridine and in those who received conventional symptom palliation. 95% of control patient survival time was spent with normal quality-of-life scores, which suggests that the aim of treatment should be to prolong normal-quality survival rather than merely to sustain quality of life. There was a significant prolongation (p = 0.03) in overall survival in floxuridine-treated patients compared with controls (median 405 vs 226 days). There were similar significant prolongations in normal-quality (ie, normal symptom scores) survival for physical symptoms (p = 0.04), anxiety (p = 0.04), and depression (p = 0.04). This survival benefit was associated with significant reductions in metastasis size on computed tomography (p = 0.001) and in serum carcinoembryonic antigen concentration (p = 0.006) in floxuridine-treated patients. There was no evidence of treatment-related hepatotoxicity as assessed by serum aspartate aminotransferase and bilirubin measurements. This is the first demonstration that survival can be prolonged with normal quality of life in patients with colorectal liver metastases. We conclude that hepatic-artery floxuridine infusion can be recommended for suitable patients.

Organic brain syndromes and opioid administration for cancer pain.

To clarify the range of potential etiologies that may contribute to organic brain syndrome in patients receiving systemic opioids for cancer pain, we describe 15 patients who presented this complication. In 11 cases, concomitant conditions were found that could contribute to the onset of organic brain syndrome. These data illustrate that multiple causes often play a role in the development of mental status changes in advanced cancer. Opioids are seldom the only causal factor implicated.

Endoscopic laser therapy for esophageal cancer.

Neodymium:YAG laser therapy has been shown to be a safe and effective palliative treatment for esophageal cancer. Exophytic tumors in a straight segment of the mid- and distal esophagus are most amenable to therapy. Perforation or fistula, the most serious complications, occur in less than 5% of patients.

Cervicalgias em emergencias / Cervical pain in emergency ward

Revisao da fisiopatologia e clinica de cervicalgia, com objetivo de orientar o medico "emergencista" no tratamento da mesma. A cervicalgia, bem como as outras sindromes dolorosas de coluna, e um dos problemas de saude publica que leva as emergencias e postos de saude uma das maiores demandas de pacientes. Estes pacientes sao tratados de forma paleativa, com isso, ha um retorno excessivo a estas unidades, causando transtornos as emergencias e falta de tratamento adequado ao paciente. O objetivo e alertar ao emergencista sobre este aspecto e sugerir a terapeutica mais adequada, conforme experiencia clinica

Liability issues in the management of pain.

Liability issues associated with pain management are important to health-care providers, patients, pharmaceutical companies, manufacturers of pain-management devices, health-care payors, and society at large. This article discusses five specific legal liability concerns: (a) health-care providers' liability to patients and/or exposure to professional discipline for inappropriate pain management, (b) health-care providers' liability to third parties for injury caused by patients treated for pain, (c) the legal distinction between pain management and euthanasia or physician-assisted suicide, (d) health-care payors' liability to patients for cost-containment decisions that impact on pain management, and (e) manufacturers' and health-care providers' liability for the risks and side effects of prescription drugs and pain-management devices.

Paraneoplastic pemphigus appearing as bullous pemphigoid-like eruption after palliative radiation therapy.

Paraneoplastic pemphigus is a recently described disease in which patients have polymorphous skin lesions suggestive of both erythema multiforme major and pemphigus vulgaris in association with internal neoplasms, especially non-Hodgkin's lymphoma. These patients have characteristic autoantibodies that bind specific epidermal proteins. A Nikolsky-negative bullous pemphigoid-like eruption developed within the radiation therapy field in a 72-year-old man receiving palliative treatment for recurrent large cell lymphoma. The eruption rapidly progressed to a Nikolsky-positive bullous process more typical of pemphigus vulgaris with extensive involvement of respiratory epithelia. Despite aggressive treatment with high-dose corticosteroids and antibiotics, the patient rapidly succumbed. Results of immunofluorescence studies and autopsy findings confirmed the diagnosis of paraneoplastic pemphigus.