Acute and chronic pain has a major impact on the individual, the family, the National Health Service and society. Acute pain is common following surgical procedures and often only partially controlled. Chronic pain currently affects around 7–8 million people in the UK, and in the USA, estimates suggest that more than 75 million people live with chronic pain.1 It is likely that the number of people with chronic pain will continue to grow as a result of increasing longevity, rising prevalence of co-morbidities such as diabetes mellitus and obesity, and improving survival rates for cancer and trauma patients. Rather than solely being a normal adaptive response following tissue injury, we now understand pain as an evolving plastic phenomenon that can be influenced by a variety of physiological, pharmacological, psychological and environmental factors.
Until recently, acute and cancer pain management predominantly consisted of opioids and compassionate care.
26% of people living with HIV in the UK remain undiagnosed and over 50% of adults with HIV are significantly immunocompromised at the time of diagnosis. Current guidelines recommend routine testing in all patients presenting with a range of conditions in low prevalence areas (<2/1000).
Methods
The authors conducted an online survey of the knowledge, attitudes and practice of non-HIV specialist physicians with regard to HIV testing in two areas of the UK with a lower prevalence of HIV. Key outcomes included recognition of recommended clinical indications for HIV testing and perceived barriers to performing HIV tests more routinely. All responses were collected in July 2009.
Results
Recommended indications for HIV testing were identified by 0–43.7% of 119 respondents. 47.9% cited a low prevalence of HIV as a barrier to routine testing. 88% of 60 consultant physicians were unaware of current guidelines on testing for HIV.
Conclusion
The authors found a low awareness of current guidance on testing for HIV and a high level of perceived barriers to testing. Reducing the high number of late diagnoses is a clinical and public health priority. To achieve this, the authors recommend improved policy dispersal coupled with education that targets perceived barriers to testing.
Chronic pain is pain that persists past the normal time of healing, and is seen as a common problem with a significant socioeconomic impact. Pharmacological management for chronic non-cancer pain also involves the prescription of opioids, with the aim of an improved quality of life for the patient. New guidelines have been published to aid prescribing clinicians improve opioid safety and patient care, and include recommendations on when to refer patients to a pain specialist. In recent years there has been a rapid increase in opioid prescription in the UK and USA, prompting further concern regarding opioid abuse and side effects. Opioid use may also result in physical dependence and tolerance. Earlier recognition and diagnosis of unwanted effects of long term opioid use is needed, such as opioid induced suppression of the hypothalamic–pituitary–gonadal axis, and opioid induced immunosuppression. Patients may themselves discontinue opioids, however, due to minor side effects. Recent advances in opioid prescription include the increasing use of transdermal preparations and extended release, oral, once daily preparations. New formulations of existing drugs have been developed, as well as a new chemical entity. Abuse deterrent formulations and delivery systems may prevent the artificial acceleration of drug delivery and reduce the potential for opioid addiction. Overdose concerns and the potential for fatal overdose may necessitate mandatory training for all clinicians who prescribe opioids. Despite the widespread use of opioids in the management of chronic non-cancer pain, significant research gaps remain. An improvement in the evidence base for its prescription is required.
Chronic pain can lead to significant disability with social and economic implications in the community. Traditional non-steroidal anti-inflammatory drugs (NSAIDs) have been part of the management of chronic pain. The risk of adverse events with traditional NSAIDs has led to the development of alternative therapeutic options. Differential blockade of the enzymes involved in pain and inflammation can offer therapeutic options without the gastrointestinal side effects. However, this may be at the expense of other major cardiovascular side effects. Pain pathways that involve peripheral transmission may be altered by local application of analgesia to the skin overlying the painful area. Recent guidelines for osteoarthritis treatment from the National Institute for Health and Clinical Excellence highlight the importance of topical NSAIDs in the armamentarium of pain management. NSAID combination drugs with gastric protection have provided alternatives to traditional NSAIDs, but the long term sequelae are unknown.
With the availability of improved brain imaging techniques, the high prevalence and clinical importance of cerebral small vessel disease have been increasingly recognised in recent years. As age is one of the most important risk factors for this condition, its prevalence is set to rise further as populations age. This may lead to an increase in the clinical consequences of white matter disease, namely cognitive decline, decreased mobility and increased stroke risk. Given the impact this will have on individuals and on healthcare systems, knowledge of the risk factors for small vessel disease, its prevention and its treatment is becoming more important. Although a lot of data are now available on the epidemiology, risk factors, clinical consequences and prognosis of leukoaraiosis, some of this information is conflicting. In this review, we summarise the current literature on cerebral small vessel disease, with an emphasis on its clinical aspects.
Long lists of causes of peripheral neuropathy make peripheral nerve disease a dry and uninspiring subject. A simple scheme based on the answers to just six questions should enable the clinician to recognise characteristic patterns, investigate relevant subgroups appropriately, and identify treatable disorders quickly: which systems are involved? What is the distribution of weakness? What is the nature of the sensory involvement? Is there any evidence of upper motor neuron involvement? What is the temporal evolution? Is there any evidence for a hereditary neuropathy? Standard screening investigations suffice for the common length dependent axonal neuropathies while complex presentations need more detailed investigations targeted to their clinical phenotype.
Chronic kidney disease (CKD) is defined as evidence of kidney damage or a glomerular filtration rate (GFR) ≤60 ml/min/1.73 m2 (table 1). The most common causes of CKD are hypertension and diabetes mellitus. The many causes of CKD are associated with different varying prognoses. Patients with adult polycystic kidney disease have a 50% lifetime risk of needing dialysis compared with 25% for type 1 diabetes and <5% for type 2 diabetes. Dialysis is usually considered when GFR falls below 10 ml/min/1.73 m2 but the exact timing will often be dictated by clinical circumstances. This may be refractory oedema, hyperkalaemia and acidosis, uraemia or unacceptable symptoms. Dialysis only partially replaces the excretory function of the kidneys and so the morbidity and mortality associated with CKD are not completely resolved with dialysis. In fact, mortality in the dialysis patient is very high. The life expectancy of a 25-year-old dialysis patient is 12 years, compared...
One of the most important objectives in cardiology is to gain knowledge about the function of the left ventricle (LV). The patient's prognosis is closely related to LV function in nearly all cardiac diseases affecting myocardial function. The ventricular mechanics are complicated. LV mechanics consist of longitudinal and circumferential shortening and lengthening, radial thickening and thinning and twist. This means that every attempt to assess LV function by cardiac imaging will be a simplification of true LV deformation.1 The most recent imaging techniques from echocardiography have improved diagnostics considerably and will give the cardiologist valuable information on the diagnosis and prognosis of the patient.
This article describes the assessment of ventricular mechanics by echocardiographic techniques which are widely available to all cardiologists. The different deformation patterns and how the assessment of these can be used in the clinical setting are discussed.
A 77-year-old man was admitted to our hospital with a 2-day history of dyspnoea that had started suddenly. Chest x-ray showed a left hydropneumothorax under tension with mediastinal shift (figure 1); blood analyses revealed a high inflammatory reaction. Chest drainage improved symptoms initially with re-expansion of the collapsed lung and a yellowish purulent effusion discharged from the chest drain with little or no air leakage under continuous suction. Biochemical test results of the fluid included: lactate dehydrogenase (LDH) 1522 IU/l, glucose 2 mg/dl and protein 5.7 g/dl.
Figure 1
Chest x-ray showing a left hydropneumothorax under tension with mediastinal shift.
After admission, the patient continued to eat with no epigastric pain despite his severe condition. Although 1.5 l of purulent effusion was drained over 24 h, the chest x-ray unexpectedly showed a completely opaque left lung field. Suspecting re-expansion pulmonary oedema, chest CT examination was performed...
Since 2008, coroners' courts in the UK have allowed ‘narrative verdicts’. They now accept that it is sometimes impossible to assign any single cause to a death, such as natural or accidental death. Instead of forcing juries to strive for the illusion of certainty, or to try and squeeze all the evidence into pre-ordained categories, the law now allows them to describe what has happened, to set out what is known and unknown, and to express their views in narrative form. This is such a sensible option, and so clearly fits with all the complexities and ambiguities of real life that it seems surprising that it took so long for anyone to come up with the idea.
It also makes one wonder why a parallel concept of ‘narrative diagnosis’ hasn't become established in medicine. Complexity and uncertainty are surely as common in medical practice as in the law, if...
