Treating the New Chronic Pain Patient

By my friend, Amy Givler, MD–strategies for treating the new patient with chronic pain and taking opioids.

Around her hospital, Dr. Amy Givler is known as “The Wall” when it comes to opioid prescribing. She simply doesn’t believe they benefit the vast majority of patients who receive them, especially for chronic pain. In this post in Christian Medical and Dental Associations, she discusses why she is convinced opioids actually lower the pain threshold, as well as strategies she’s developed to help her patients.

A well-written article and a reasonable approach.

Life expectancy has dropped because of antibiotic resistance, says ONS

Antibiotic resistance has caused a fall in life expectancy for the first time, the Office for National Statistics has said.

Life expectancy in future years has been revised down after the statistics authority said that “less optimistic views” about the future had to be taken into account.

Opinions on “improvements in medical science” had declined, it said, and fears of the “re-emergence of existing diseases and increases in anti-microbial resistance” meant people would not live as long as was previously expected.

My “You gotta be kidding me!” moment

Last month, I was in my doctor’s office, and at the end of the visit, I asked him if I should get the “shingles shot”, or varicella zoster vaccine. Since I was a year past my due date, of course he said “yes”. So I got the shot, and left feeling smug and righteous about being immune to another disease. I have seen senior citizens with post-herpetic neuralgia, the common complication of shingles in older folks, and I *really* don’t want that.

Then, last week, this comes out in the news:

…(A)n advisory panel to the Centers for Disease Control and Prevention on Wednesday recommended the use of a new vaccine to prevent shingles over an older one that was considered less effective.

The decision was made just days after the Food and Drug Administration announced approval of the new vaccine, called Shingrix and manufactured by GlaxoSmithKline, for adults ages 50 and older. The panel’s recommendation gives preference to the new vaccine over Merck’s Zostavax, which has been the only shingles vaccine on the market for over a decade and was recommended for people ages 60 and older.

The Advisory Committee on Immunization Practices also recommended that adults who have received the older vaccine get the new one…Insurance companies must also agree to cover the cost of the vaccine, which GSK estimates to be $280 for two doses.

Given in one dose, Zostavax had shown a 51 percent reduction in shingles and a 67 percent reduction in nerve pain. Shingrix is given in two doses, and the company said clinical trials showed it to be about 98 percent effective for one year and about 85 percent over three years.

So, as soon as my insurance company will pay for it, I will be trekking back to my PCP’s office again, and rolling up my sleeve.

Wednesday’s derm consult

A 2 year old male patient presents with a red, swollen thumb with a dystrophic nail for 9 months, with no improvement. Antibiotics have not helped. He is not a thumb-sucker. All other nails are normal.

Parakeratosis pustulosa is a nail disorder that occurs almost exclusively in children. In most cases the disease is limited to one nail, usually the thumb or the index finger, and presents with distal onycholysis, fingertip desquamation, and mild subungual hyperkeratosis. Parakeratosis pustulosa begins with an acute eczematous inflammation of the periungual skin, causing hyperkeratosis and thickening of the free edges of the nail. Scaling is more marked than pustulation. The course is often protracted and recurrences are the rule. Spontaneous regression may occur after puberty.

Today in history

October 12, 1928–An iron lung respirator is used for the first time at Children’s Hospital, Boston. This negative pressure ventilator has been replaced by positive pressure ventilation, and the disease most associated with it, polio, has been mostly eradicated by vaccines.

I remember seeing some old iron lung respirators in a basement in the LSU hospital when I was a medical student.

A smart bandage that could lead to faster healing?

Researchers from the University of Nebraska-Lincoln, Harvard Medical School and MIT have designed a smart bandage that could eventually heal chronic wounds or battlefield injuries with every fiber of its being.

The bandage consists of electrically conductive fibers coated in a gel that can be individually loaded with infection-fighting antibiotics, tissue-regenerating growth factors, painkillers or other medications.

A microcontroller no larger than a postage stamp, which could be triggered by a smartphone or other wireless device, sends small amounts of voltage through a chosen fiber. That voltage heats the fiber and its hydrogel, releasing whatever cargo it contains.

A single bandage could accommodate multiple medications tailored to a specific type of wound, the researchers said, while offering the ability to precisely control the dose and delivery schedule of those medications. That combination of customization and control could substantially improve or accelerate the healing process, said Ali Tamayol, assistant professor of mechanical and materials engineering at Nebraska.

Measles kills first patient in 12 years

The USA has suffered its first measles death in 12 years, according to Washington state health officials.

The woman’s measles was undetected and confirmed only through an autopsy, according to the Washington State Department of Health. The woman’s name was not released, but officials said she lived in Clallam County. . . .

Pneumonia is one of several serious common complications of measles and the most common cause of death from the virus, said William Schaffner, a professor at Vanderbilt University School of Medicine in Nashville. Measles kills one or two children out of every 1,000 infected, according to the CDC.

It’s not surprising that the woman had no obvious measles symptoms; people with compromised immune systems often don’t develop a rash when infected with the virus, said Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia.

The woman’s death was a preventable, but predictable, consequence of falling vaccination rates, said Peter Hotez, president of the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development in Houston.

Measles has surged back in recent years as groups of like-minded parents have opted against fully vaccinating their children. Last year, 644 people contracted the virus.

am_140609_measles_virus_800x600

Cialis and other ED meds linked with reduced heart attack risk and improved heart attack survival

Men with type 2 diabetes taking treatments for erectile dysfunction could be reducing their risk of a heart attack and improving their chances of surviving a heart attack, according to a study funded by the British Heart Foundation (BHF) and the National Institute of Health Research (NIHR).

The findings, published in the BMJ journal Heart, provide strong evidence that erectile dysfunction treatments that block an enzyme called PDE5 act to reduce risk of death in type 2 diabetes, according to the researchers. Viagra is one example of an erectile dysfunction treatment that works by blocking the PDE5 enzyme.

Compared with non-users, the 1,359 men who were prescribed PDE5 inhibiting drugs experienced lower percentage of deaths during follow-up (19.1 per cent vs. 23.8 per cent) and lower risk of death (31 per cent) by any cause. Risk of death was still reduced after adjusting for age and other factors that affect heart disease risk. They also found that there were significantly fewer heart attacks in people taking erectile dysfunction treatment over the study period. And in a subgroup of patients who had a history of heart attack or had one during the study period, the drugs were associated with significantly lower risk of death.

This is good news, but note that it is a retrospective rather than a prospective study. More investigation is forthcoming, I am sure.

ecg-1