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Postherpetic Neuralgia: A Patient’s and a Physician’s Perspective

    • Today, most experts in interventional pain management recommend an evidence-based stepladder approach for the management of all patients with PHN that includes an advancing combination of therapeutic strategies as needed on a graduated basis to control pain and anxiety and prevent complications, including suicide.
    • The most important immunologic risk factor for herpes zoster and PHN is the decline in cell-mediated immunity to VZV that occurs over time as people age, with an onset around 50 years of age. Although possible, second episodes of zoster are uncommon due to the boosting or anamnestic effect of the first episode of zoster.
    • The nonpharmacologic treatment options for PHN include combinations of acupuncture, cryotherapy, heat therapy, and transcutaneous and/or percutaneous electrical nerve stimulation. The multimodal nonpharmacologic treatment options for PHN are stratified and compared by their evidence levels.

Compartment Syndrome

    • Compartment syndrome of the extremity is a clinical diagnosis in an awake and alert patient.
    • Measurement of intracompartmental pressures should be performed in the obtunded patient or if clinical assessment is inconclusive.
    • Once the diagnosis is made, emergent fasciotomy is the treatment of choice as time to fasciotomy is the most important factor determining outcome.
    • Any patient with risk factors for developing abdominal hypertension should have intra-abdominal pressure assessed, preferably via intermittent or continuous transbladder pressure.
    • Patients diagnosed with abdominal compartment syndrome require emergent decompressive laparotomy and the creation of a temporary abdominal closure.

Compartment Syndrome

    • Compartment syndrome of the extremity is a clinical diagnosis in an awake and alert patient.
    • Measurement of intracompartmental pressures should be performed in the obtunded patient or if clinical assessment is inconclusive.
    • Once the diagnosis is made, emergent fasciotomy is the treatment of choice as time to fasciotomy is the most important factor determining outcome.
    • Any patient with risk factors for developing abdominal hypertension should have intra-abdominal pressure assessed, preferably via intermittent or continuous transbladder pressure.
    • Patients diagnosed with abdominal compartment syndrome require emergent decompressive laparotomy and the creation of a temporary abdominal closure.

Sleep Disorders

    • The MSLT is essential in documenting pathologic sleepiness (e.g., sleep-onset latency of less than 8 minutes) and in diagnosing narcolepsy. The presence of two sleep-onset REMs on four or five nap studies and sleep-onset latency of less than 8 minutes strongly suggests a diagnosis of narcolepsy in the context of an appropriate history.
    • RLS is a lifelong sensorimotor neurologic disorder with a severe impact on sleep and quality of life that may begin at any age. RLS is most severe in middle-aged or elderly persons, in whom it has a chronic, progressive course. The overall prevalence of RLS for the adult population has been estimated to be about 7.2%, particularly in those of European descent, but the prevalence of the most severe cases (severe symptoms occurring at least two nights a week) is approximately 2.7%
    • For transient insomnia or insomnia of short duration, treatment with sedative-hypnotics (e.g., zolpidem, zolpidem extended release, zolpidem tartrate sublingual tablets, zaleplon, eszopiclone, or low-dose doxepin) or short- or intermediate-acting benzodiazepines (e.g., temazepam), as well as ramelteon, a melatonin receptor (MT1 and MT3) agonist, for a few nights to a few weeks is appropriate.

Sleep Disorders

    • The MSLT is essential in documenting pathologic sleepiness (e.g., sleep-onset latency of less than 8 minutes) and in diagnosing narcolepsy. The presence of two sleep-onset REMs on four or five nap studies and sleep-onset latency of less than 8 minutes strongly suggests a diagnosis of narcolepsy in the context of an appropriate history.
    • RLS is a lifelong sensorimotor neurologic disorder with a severe impact on sleep and quality of life that may begin at any age. RLS is most severe in middle-aged or elderly persons, in whom it has a chronic, progressive course. The overall prevalence of RLS for the adult population has been estimated to be about 7.2%, particularly in those of European descent, but the prevalence of the most severe cases (severe symptoms occurring at least two nights a week) is approximately 2.7%
    • For transient insomnia or insomnia of short duration, treatment with sedative-hypnotics (e.g., zolpidem, zolpidem extended release, zolpidem tartrate sublingual tablets, zaleplon, eszopiclone, or low-dose doxepin) or short- or intermediate-acting benzodiazepines (e.g., temazepam), as well as ramelteon, a melatonin receptor (MT1 and MT3) agonist, for a few nights to a few weeks is appropriate.

Sleep Disorders

    • The MSLT is essential in documenting pathologic sleepiness (e.g., sleep-onset latency of less than 8 minutes) and in diagnosing narcolepsy. The presence of two sleep-onset REMs on four or five nap studies and sleep-onset latency of less than 8 minutes strongly suggests a diagnosis of narcolepsy in the context of an appropriate history.
    • RLS is a lifelong sensorimotor neurologic disorder with a severe impact on sleep and quality of life that may begin at any age. RLS is most severe in middle-aged or elderly persons, in whom it has a chronic, progressive course. The overall prevalence of RLS for the adult population has been estimated to be about 7.2%, particularly in those of European descent, but the prevalence of the most severe cases (severe symptoms occurring at least two nights a week) is approximately 2.7%
    • For transient insomnia or insomnia of short duration, treatment with sedative-hypnotics (e.g., zolpidem, zolpidem extended release, zolpidem tartrate sublingual tablets, zaleplon, eszopiclone, or low-dose doxepin) or short- or intermediate-acting benzodiazepines (e.g., temazepam), as well as ramelteon, a melatonin receptor (MT1 and MT3) agonist, for a few nights to a few weeks is appropriate.

Bleeding and Transfusion

    • When massive bleeding exists and direct control of the site of bleeding is under way, the decision to transfuse should be based primarily on hemodynamic status rather than on the hemoglobin or hematocrit level. These laboratory values do not reflect acute hemorrhage because there is a time lag before these levels equilibrate from fluid shift between the extravascular and vascular compartments and from administration of IV fluids.
    • The concept of liberal, early use of plasma and platelets developed in large part from the recent US-led military campaigns in Iraq and Afghanistan. Initially in those conflicts, the lack of a reliable supply of blood products near the scene of injury—and platelets especially—led to the use of fresh whole blood transfusion. Although fresh whole blood would be impractical in the civilian setting because of logistical issues and the risk of transmitting transfusion-related infections, the perception of improved outcomes associated with its use prompted military surgeons to advocate 1:1:1 transfusion.
    • Beyond recognition and correction of the underlying problem causing DIC and the associated coagulopathy, the diagnosis of DIC represents something of an academic exercise because there is no specific treatment for the condition. Scoring systems that assess the severity of DIC are most useful for distinguishing DIC from other causes of coagulopathy (e.g., hypothermia, dilution, and drug effects).

Bleeding and Transfusion

    • When massive bleeding exists and direct control of the site of bleeding is under way, the decision to transfuse should be based primarily on hemodynamic status rather than on the hemoglobin or hematocrit level. These laboratory values do not reflect acute hemorrhage because there is a time lag before these levels equilibrate from fluid shift between the extravascular and vascular compartments and from administration of IV fluids.
    • The concept of liberal, early use of plasma and platelets developed in large part from the recent US-led military campaigns in Iraq and Afghanistan. Initially in those conflicts, the lack of a reliable supply of blood products near the scene of injury—and platelets especially—led to the use of fresh whole blood transfusion. Although fresh whole blood would be impractical in the civilian setting because of logistical issues and the risk of transmitting transfusion-related infections, the perception of improved outcomes associated with its use prompted military surgeons to advocate 1:1:1 transfusion.
    • Beyond recognition and correction of the underlying problem causing DIC and the associated coagulopathy, the diagnosis of DIC represents something of an academic exercise because there is no specific treatment for the condition. Scoring systems that assess the severity of DIC are most useful for distinguishing DIC from other causes of coagulopathy (e.g., hypothermia, dilution, and drug effects).
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