Pain forum. A total approach to pain management. Conceptual overview.

Recognition of the relevant pathophysiologic processes, and the psychological, emotional and spiritual components of suffering in both normal and psychologically dysfunctional cancer patients, will enable the clinician to rapidly choose the initial course of action, select the most appropriate therapies, and liaise effectively with other health care professionals. This series of papers examines each component of the pain process separately, giving an overview of currently available therapies, and recommends a holistic approach to pain management, with treatment stratagems weighted according to which components predominate in each patient.

Pain forum. Part 3. Other types of pain.

A holistic pain assessment and management plan for patients with advanced cancer is presented, together with treatment guidelines for each component of the process. The integration of these components into the clinical assessment of patients with cancer pain requires practice and continued clinical review by the attending clinicians. When mastered, the holistic approach should ensure optimum pain management in individual patients, and hopefully avoid some of the pitfalls of therapeutic endeavour. It is suggested that clinicians try to ascribe an approximate 'percentage input' to each component, and weight respective treatment strategies accordingly. An individual algorithm of pain management can then be developed for each patient. If the task is performed to the best of one's ability, we clinicians can rest assured that although not all suffering will be completely relieved, we will have managed the pain relief process in a scientific, rational and humane manner.

Pain forum. Part 1. Nociceptive cancer pain.

The components of a holistic pain assessment process in advanced cancer are presented. Central to the assessment and management process is recognition of different types of cancer pain, which have their own individual management emphasis. An overview of nociceptive cancer pain management is presented outlining current drugs available and the 'analgesic ladder' approach.

Pain forum. Part 2. Neuropathic pain.

Neuropathic pain is often a reason for an unfavourable response to morphine or other opioids in treating cancer pain. This type of pain is difficult to manage and may co-exist with nociceptive cancer pain. There is still a potential for opioid responsiveness, although the doses needed will be higher, and adjuvant drug therapies are best employed concurrently with opioid drugs. Adjuvant drugs used are the antidepressants, anticonvulsants, including benzodiazepines, corticosteroids and neurolepts. Less commonly, agents such as baclofen and clonidine, and sympatholytic drugs such as prazosin can be employed for sympathetically maintained neuropathic pain (discussed in Part 3). The type of agent selected will depend on the natural history of the disease process, as well as a description of the pain--the lancinating pains tending to respond better to anticonvulsants. Non invasive neurostimulatory approaches such as transcutaneous electrical nerve stimulation (TENS) may be useful in management, and a few patients may require an invasive procedure such as dorsal column stimulation.

Standards of antimicrobial prescribing for prophylaxis in selected surgical operations: A study conducted in a teaching hospital.

A study of the prescribing habits of the surgeons of Fremantle Hospital for antimicrobial prophylaxis was conducted in the period from July to October, 1979. In selected operations, an assessment of use was made according to generally accepted principles of prophylaxis. In 109 "clean" surgical operations and in 38 cholecystectomies, antimicrobial agents were rarely used for prophylaxis. It was concluded that there was no overusage of prophylactic antimicrobial agents in surgery. In 58 operations on the appendix and large bowel, it was found that administration of the antimicrobial agents was started either too late or the choice of agent was illogical in 15 cases. In 12 total hip replacements, the prescribing was satisfactory, but, in 21 Richards' pin-and-plate operations and in 35 minor orthopaedic implants, prophylaxis was continued for longer than 48 hours in 33 of 41 courses of therapy. The mean duration of a course was 6.5 days for pin-and plate and 6.7 days for minor implants. In only seven of 30 hysterectomies were patients covered for Bacteroides fragilis infection at the time of operation, the mean duration of a course was 5.5 days. It is suggested that a reduction in costs and increase in quality of care are most likely to be achieved by surgical teams adopting a protocol in operations where prophylaxis is of proven value.

Permanent retinal damage following massive dapsone overdose.

A massive dose of 7.5 g of 4,4'-diamino, diphenyl sulphone (dapsone) taken as a suicide attempt in a patient on long-term therapy for tuberculoid leprosy resulted in permanent bilateral retinal necrosis, previously unreported side effect of this drug. The patient developed a severe haemolytic anaemia, methaemoglobinaemia, and acute renal failure requiring peritoneal dialysis. It is proposed that the retinal damage was due to a combination of severe hypoxaemia and the physical effects of red cell fragmentation producing vascular occlusion in the macular and perimacular region, with consequent ischaemic necrosis.