Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids.

Physicians involved in cancer pain management treat thousands of patients with opioids, whose effective analgesia improves overall functioning. Side effects generally are tolerable, and treatment can be maintained with stable doses for long periods. Problems with addiction are infrequent. Many physicians, however, assume that opioids should be used only for chronic malignant pain. Research and clinical experience have demonstrated that opioids can safely and effectively relieve most chronic moderate to severe nonmalignant pain. Fears of addiction, disciplinary action, and adverse effects result in ineffective pain management. With current information on the use of opioids in chronic nonmalignant pain, primary care physicians can overcome these obstacles. Guidelines must clearly define the role of the primary care physician in the proper management of pain and the integration of opioid therapy. Used appropriately, opioids may represent the only source of relief for many patients.

Demyelinating and neoplastic diseases in pregnancy.

Multiple sclerosis (MS) has no significant effect on fertility, conception, fetal viability, and delivery. Exacerbations of MS decrease during pregnancy and increase significantly during the 3 months postpartum. Pregnancy does not increase the risk of brain tumors, but physiologic changes induced by pregnancy affect the diagnosis and biologic behavior of glial tumors, meningiomas and vascular tumors, and pituitary adenomas. MR imaging and computed tomography scanning are the most useful modalities for diagnosis.

Provocation of nonepileptic seizures by suggestion in a general seizure population.

Nonepileptic seizures (NES) are common and are often diagnosed at epilepsy centers by video-EEG recording of both spontaneous and suggestion-induced episodes, but no study has evaluated provocative testing in a general seizure population. We studied consecutive patients with a tentative diagnosis of epilepsy using saline provocation during video-EEG recording, suggesting that this could produce a typical seizure. Of 52 patients, 40% had no response, 23% had responses unlike their seizures, and 37% had typical episodes (positive test). Patients whose usual episodes resembled complex partial seizures (CPS) were more likely to have NES than were patients with a history of generalized tonic-clonic seizures (GTC). Of patients with positive provocations, the primary physician predicted NES in 68% of cases. This preliminary study suggests that NES are frequent in a general neurology setting, and that saline provocation is a sensitive method of identifying NES.

Schwannoma of the fourth ventricle presenting with hemifacial spasm. A report of two cases.

Two cases of cystic brainstem schwannomas protruding into the fourth ventricle are described. Both patients presented with hemifacial spasm. While there is only one previous case report of an intraventricular brainstem schwannoma, there has been no prior description in the literature of hemifacial spasm associated with such a tumor. The clinical, radiographic, surgical, and histopathological features of these tumors are elaborated. The relationship of hemifacial spasm to the various putative theories of origin proposed for intraparenchymal schwannomas is discussed.

Dermatoglyphic patterns in Alzheimer's disease.

Selected dermatoglyphic variables were analyzed in 50 patients with presumed Alzheimer's disease (AD), 50 patients with dementia referable to other causes, and 100 control patients without known dementia matched for age, sex, and race. AD patients have a significantly increased frequency of ulnar loops on the fingertips, Simian creases on the palms, palmar hypothenar patterns; and large distal loops in the hallucal region. A trend involving an increased frequency of radial loops on the fourth and fifth digits, Sydney lines on the palms, and small distal loops on the soles was also observed. The presence of eight or more ulnar loops or bilateral hypothenar patterns separates AD patients from controls with 84% sensitivity and 63% specificity, supporting the discriminant value of dermatoglyphics in the categorization of patients and in the potential identification of asymptomatic persons at increased risk for AD by dermatoglyphic criteria. The dermatoglyphic patterns observed in the AD patients correspond remarkably with patterns repeatedly observed in Down's syndrome and parents of Down's syndrome children, suggesting that a common genetic factor modulates epidermal ridge formation during fetal development, meiotic non-disjunction during gametogenesis, and accelerated neuronal senescence.

Fingerprint patterns in Alzheimer's disease.

Fingerprint dermatoglyphic patterns in 50 patients with presumed senile dementia of the Alzheimer type (SDAT) were compared with a control group of 50 patients with other neurologic diseases and with population norms. Patients with SDAT showed a significantly increased frequency of ulnar loops on their fingertips and a concomitantly decreased frequency of whorls and arches. A pattern of eight or more ulnar loops was found significantly more often in patients with SDAT (72%) than in the control group (26%). Fourteen patients with SDAT had ulnar loops on all ten fingers; this occurred in four patients in the control group. Radial loops on the fourth and fifth digits were more prevalent in patients with SDAT. The fingerprint patterns observed in patients with SDAT are congruent with patterns repeatedly found in Down's syndrome, and support the known associations between these two diseases at a further level.