[INTENSIVE PALLIATIVE CARE FOR INTRACTABLE PAIN].

INTRODUCTION: Opioid drugs are the most powerful painkillers known. Thus, they are the pivotal treatment for the severe pain often associated with oncological disease. Most of their side effects are known and common. Opioid-induced hyperalgesia (OIH) is one of their unknown and uncommon side effects. This phenomenon is characterized by a paradoxical reaction to opioid administration. In this condition, an increase in the dose and frequency of opioid administration aggravates the pain instead of reducing it. Misdiagnosis of this phenomenon can result in excessive opioids usage which does not relieve the pain, and opioid dependency effect. Presented below is a case report of a young man suffering from Ewing's sarcoma who was referred to the Emergency Department due to a pain crisis. During the last year, he was treated with accelerated doses of many opioids, up to ten times the maximal accepted dose of methadone. To alleviate his severe and intractable pain he was admitted to the Intensive Care Unit where he was sedated and ventilated. During his hospitalization he was diagnosed with OIH and underwent an opioid withdrawal procedure called ultra rapid opioid detoxification (UROD). After five days of hospitalization, he was discharged and sent home opioid-free. This paper will discuss therapeutic dilemmas that arise when dealing with pain balance in the unique and challenging circumstances described.

[END-OF-LIFE PROGNOSTICATION IN ACUTE HOSPITAL PALLIATIVE PATIENTS: IS THE PALLIATIVE PERFORMANCE SCALE USEFUL?]

AIMS: This study examined PPS (Palliative Performance Scale) use as a tool estimating life expectancy in patients with various life-threatening diseases who required palliative consultation during hospitalization in an acute regional hospital in northern Israel. BACKGROUND: Prognostication is the ability to evaluate outcome and expected course of a medical condition based on knowledge and experience. Special emphasis is given to the prediction of life expectancy in end-of-life situations, as prognosis directs the treatment approach, the policy regarding tests and procedures, and discharge planning. Research mentions two main methods for assessing life expectancy: one is CPS - Clinician's Prediction of Survival and the other is AES - Actuarial Estimation of Survival based on test results, statistics and clinical tools. Since physical status correlates well with survival, it is included in most prognostication tools. METHODS: A retrospective study for the period January 2015-September 2018 examined the records of patients assessed by the Palliative Consult Team (PCT), using PPS. Variables were initial PPS score, age, gender, ethnic origin, diagnosis and survival time. Patients were monitored six months from initial assessment. RESULTS: A total of 588 patients' records assessed by PCT using PPS, were included in the study. Findings showed PPS to be a significant predictor of survival for all research groups, with no ethnic differences. In the current study population, differences were found between varied diagnoses in life expectancy and functional status. It also became clear that life expectancy of most subjects with a functional status of PPS-40 and below did not exceed six months. DISCUSSION: This research strengthens the link between functional status and life expectancy and is the first in Israel to support the use of the PPS tool as part of the prognostication process in patients with a variety of incurable diseases. The presentation of findings in survival ranges according to the value of PPS is unique to this study and its ability to assist medical staff both in making clinical decisions and in choosing the appropriate terminology for the sensitive and complex procedure of delivering a prognosis to a patient and loved ones.

Late myocardial sequelae of electrical injury.

Electrocution poses serious complications seen mostly at the time of the event. Physicians and patients are usually not aware of the progressive nature and its potentially delayed effect as demonstrated in our case. We believe that a risk stratification model should be designed to guide physicians for proper management.

Antinuclear antibodies measured by enzyme immunoassay in patients with systemic lupus erythematosus: relation to disease activity.

To evaluate the correlation between measurements of antinuclear antibodies serum levels by enzyme immunoassay (ANA-EIA), and the degree of systemic lupus erythematosus disease activity. To retest the performance of the test compared to measurement of antinuclear antibodies by immunofluorescence (ANA-IIF). Eighty-five sera from 71 patients with SLE were tested. Demographic, clinical, laboratory, and SLEDAI status were collected. The sera were tested for ANA-EIA and by ANA-IIF at 1:40 and 1:160 dilutions. Serum levels of ANA-EIA were compared to the overall SLEDAI score and to each of its components. A SLEDAI score of > or =6 was considered clinically significant. The sera of fifty-one healthy volunteers served as controls. Serum levels of ANA-EIA were significantly higher in patients with a SLEDAI score of > or =6 compared to the group of patients with a SLEDAI score of <6 (P = 0.004). High serum levels of ANA-EIA correlated significantly with elevated anti DS-DNA antibodies (P < 0.001), low C(3) or C(4) levels (P < 0.001), pyuria (P < 0.011), arthritis (P = 0.019), and new rash (P = 0.019). Levels of ANA-EIA were significantly higher in patients tested positive by IIF compared to those who tested negative. Higher serum levels of ANA-EIA correlated with clinically significant disease activity in patients with SLE. Higher serum levels of ANA-EIA also correlated with some single items of the SLEDAI. The results also reiterated the validity of ANA-EIA testing in patients with SLE. Further longitudinal studies are needed in order to test the hypothesis that serum ANA-EIA levels might reflect fluctuations in disease activity.

Cerebral syncope in a patient with spinal cord injury.

An 80-year-old patient suffering from traumatic paraplegia due to spinal cord compression was admitted due to recurrent orthostatic syncope. Tilt table testing revealed that the patient lost consciousness without hypotension. Doppler flow measurements of the middle cerebral arteries showed a significant decrease in diastolic velocity during syncope without systemic hypotension. Treatment with beta-blockers was highly effective. The patient suffered from cerebral blood flow disregulation probably due to abnormal baroreceptor responses triggered during orthostatic stress. This is the first reported case of a patient with spinal cord injury suffering from such an unusual cause of syncope.