Pain management.

This article provides information regarding treatments for the management of moderate to severe pain in patients who are at the end of life. Discussion focuses on the use of strong opioids and adjuvant analgesics. Special attention also is given to the most frequently used forms of interventional pain management.

The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program.

Background: The Accreditation Council for Graduate Medical Education work-hour limitations (WHLs) were implemented in July 2003. Effects on resident well-being, patient care, and education are not well understood. We investigated these effects of WHLs.

Indications for hormone therapy: the post-Women's Health Initiative era.

Information from the Women's Health Initiative (WHI) trial has given physicians valuable tools for counseling women aged 50 to 79 years about the short-term risks of hormone therapy (HT). Unanswered questions remain, particularly on the risks and benefits of discontinuing HT among long-term users. The decision to discontinue HT should be carefully considered, because stopping and re-starting after several months may "reset the clock" for risks associated with changes in hepatic protein synthesis.

Transient rotational compression of the vertebral artery caused by herniated cervical disc. Case report.

Of the many causes of vertebrobasilar insufficiency (VBI), extrinsic compression of the vertebral artery (VA) is relatively uncommon. A syndrome of VBI caused by extrinsic compression of the VA secondary to head rotation has been termed positional vertebrobasilar ischemia. The authors present a case of transient VBI caused by herniation of a cervical disc.

Indirect reduction and plating of distal femoral nonunions.

Objective: To observe and report the clinical results of indirect reduction and plating in the treatment of distal femoral nonunions.

Design: Prospective consecutive study.

Setting: Regional trauma center.

The "reverse Segond" fracture: association with a tear of the posterior cruciate ligament and medial meniscus.

Objective: We describe three patients who presented with radiographic findings of a fragment on the medial side of the tibial plateau of the knee that represented an avulsion of the deep portion of the medial collateral ligament. These findings were all associated with disruption of the posterior cruciate ligament and a peripheral medial meniscal tear-the so-called reverse Segond fracture.

Conclusion: Avulsion fracture at the tibial insertion of the deep component of the medial collateral ligament is a rare finding.

Advance directive preferences among subpopulations of Asian nursing home residents in the Pacific Northwest.

Objective: To study advance directives (code status) among subgroups of Asian nursing home residents.

Design: Cross-sectional design.

Participants And Setting: A total of 423 residents of Asian descent (aged >55) from two ethnic nursing homes in Seattle, Washington.

Determining risk of traumatic aortic injury: how to optimize imaging strategy.

Objective: Our objective was to develop and validate a clinical prediction rule that determines patient probability of traumatic aortic injury to guide selection of optimal screening imaging strategy.

Materials And Methods: A 2-year, single-institution retrospective case-control study was conducted of 31 cases of traumatic aortic injury and 171 random major trauma control subjects. The presence of potential injury predictors was determined from chart review.

Protease inhibitor-associated angiolipomatosis.

Treatment with protease inhibitors in some persons infected with HIV-1 is associated with a syndrome of lipodystrophy manifesting as peripheral lipoatrophy, relative central adiposity, insulin resistance, and serum lipid abnormalities. We report 3 cases of HIV-1 infected patients who experienced symptomatic angiolipomas shortly after starting antiretroviral therapy including the protease inhibitor indinavir. The mechanism behind this observation may be similar to that of previously reported protease inhibitor-associated fat redistribution, but instead involving the adipose tissue of discrete uncommon benign tumors.

Focal extratemporal epilepsy: clinical features, EEG patterns, and surgical approach.

The objective of this review is a summary of the clinical and electrographic findings in those forms of epilepsy to which the term 'extratemporal' (ExT) can be applied. They form a group that differs in many ways from the better known temporal lobe epilepsies. Seizure foci are difficult to localize by clinical semiology alone but modern imaging now often allows a precise definition of the epileptogenic area.

Relationship between intracranial pressure and the development of vasospasm after aneurysmal subarachnoid hemorrhage.

The relationship between intracranial pressure (ICP) and the development of vasospasm after subarachnoid hemorrhage caused by the rupture of an intracranial aneurysm was investigated. Eleven patients were divided into high (6 cases) and low (5 cases) ICP groups based on ICP data obtained during the perioperative period by continuous ICP monitoring. Transcranial Doppler ultrasonography was performed every 24 hours for 7 days and the severity, distribution, and duration of vasospasm were assessed.

Mild hypothermia during reperfusion reduces injury following ischemia of the rabbit ear.

Ischemia and reperfusion causes tissue injury that can be partially prevented by mild hypothermia. In this study we postulated that hypothermic protection could occur if imposed only during reperfusion. Rabbit ears were partially amputated, the central artery occluded for 6 h followed by reperfusion at an ambient temperature of either 20 or 24 degrees C resulting in ischemic ear temperatures of 22.

Endothelium-dependent regulation of cerebrovascular tone by extracellular and intracellular ATP.

ATP receptors and ATP-sensitive potassium channels (KATP) are expressed in vascular smooth muscle (VSM) and endothelial cells (EC). In isolated penetrating vessels, ATP caused a dilatation when applied intraluminally but not extraluminally. The actions of ATP were blocked by the nitric oxide (NO) synthesis inhibitor N omega-nitro-L-arginine (0.

Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair.

To evaluate the efficacy of arthroscopic repair of the triangular fibrocartilage complex (TFCC) tears treated within 4 months after injury, functional outcome after repair was determined following arthroscopic repair in 24 patients. The patients' average age was 31 years (range, 22-38 years); the average follow-up period was 34 months (range, 26-48 months). All patients had wrist pain limiting their participation in work prior to surgery.

Is immediate decompression of high voltage electrical injuries to the upper extremity always necessary?

Objective: To determine if immediate decompression is required for all high voltage injuries to the upper extremity.

Design: Retrospective review.

Materials And Methods: Charts reviewed of 62 patients who had upper extremity contact with >1,000 volts of electricity over a 10-year period.

Triple arthrodesis using internal fixation in treatment of adult foot disorders.

Forty adult patients with 44 fused feet were evaluated at an average of 4.9 years after triple arthrodesis. The average age of the patients at operation was 41 years.

Evaluation and significance of the pupillary light reflex in trauma patients.

The pupillary light reflex is an important component of the neurologic examination of the trauma victim. Although the normal reflex can be predictably altered by specific head injuries, a variety of other factors common to trauma patients such as alcohol, illicit drugs, narcotics, paralyzing agents, hypothermia, and orbital or ophthalmic injury can confound the evaluation of the pupillary light reflex. This report reviews the anatomy and neurophysiology of the pupillary light reflex and discusses the impact these confounding variables may have on this key component of the initial trauma evaluation.

Cortical bone microperfusion: response to ischemia and changes in major arterial blood flow.

In order to investigate the effects of short-term ischemia on cortical bone microperfusion, an isolated porcine tibia diaphyseal preparation based on intact nutrient vessels was developed. Laser Doppler flowmetry (LDF) was utilized to assess continuously the cortical microcirculation and the response to short-term ischemia. The femoral artery was isolated and clamped to develop the condition of bone ischemia.