Chronic pain: 2. The case for opioids.
Explore the source record for details and available documents.
Analgesics, Opioid↗
Biomedical subjects
D Brookoff
Publications and source records attributed to D Brookoff.
Chronic pain: 1. A new disease?
Chronic pain continues to be perceived as a characterologic disorder rather than a serious, potentially fatal, medical disease. The general lack of understanding of how persistent pain becomes magnified and ingrained prevents many patients from receiving the level of care that they need to regain control of their lives and resume normal activities.
Chronic Disease↗
Marijuana and injury: is there a connection?
Explore the source record for details and available documents.
Accidents, Traffic↗
Characteristics of participants in domestic violence. Assessment at the scene of domestic assault.
OBJECTIVE: To evaluate the characteristics of victims and perpetrators of domestic assault. DESIGN AND SETTING: Consecutive-sample survey study conducted at the scenes of police calls for domestic assault in Memphis, Tenn, in 1995. PARTICIPANTS: A total of 136 participants (72 victims and 64 assailants) involved in 62 incidents of domestic violence and 75 adult family members at the scene. MAIN OUTCOME MEASURES: Participants' responses to a confidential survey and review of police records. RESULTS: Of 62 episodes of domestic assault, 42 (68%) involved weapons and 11 (15%) resulted in serious injury. Fifty-five (89%) of 62 assault victims reported previous assaults by their current assailants, 19 (35%) of them on a daily basis. Although nearly all assault victims had called the police for help on previous occasions, only 12 (22%) reported having ever sought medical care, counseling, or shelter because of domestic assault. Sixty (92%) of the 64 assailants reportedly used alcohol or other drugs on the day of the assault. Of the assailants, 28 (44%) had a history of arrest for charges related to violence, and 46 (72%) had an arrest for substance abuse. Eleven (15%) of the victims were children. Children directly witnessed 53 (85%) of the assaults. CONCLUSIONS: Most victims of domestic violence who had called the police rarely used medical or mental health facilities for problems related to family violence despite frequent assaults. Victims and assailants were willing to discuss their histories of family violence and undergo assessments at the scenes of police calls.
Adolescent↗
Coacaethylene levels in patients who test positive for cocaine.
STUDY OBJECTIVE: To determine the presence of cocaethylene, an active metabolite of the combination of cocaine and ethanol, among trauma patients who test positive for cocaine. METHODS: We assembled a case series of 416 consecutive urban trauma center patients with major trauma. Urine was tested for the presence of the cocaine metabolite benzoylecgonine. Plasma was quantitatively assayed for cocaine, ethanol, and cocaethylene. RESULTS: Of the study subjects, 158 (38%) were positive for benzoylecgonine. Of the 114 of these subjects who had adequate plasma specimens, 68 (60%) tested positive for cocaethylene (mean, 41 +/- 27 ng/mL; range, 3 to 213 ng/mL), all tested positive for cocaine (mean, 92.9 +/- 52 ng/mL), and 56% were positive for ethanol (mean, 175 +/- 85 mg/mL). We found poor correlation between admission levels of cocaethylene and cocaine (R=.02), even when subjects were stratified by ethanol level. The correlation between cocaethylene and ethanol levels was weak (R=.24). Of the 68 patients who tested positive for cocaethylene, 29% tested negative for ethanol. Plasma was also assayed from 94 subjects who tested negative for benzoylecgonine; 9% had detectable levels of cocaine, and 2% had detectable levels of cocaethylene. CONCLUSION: Cocaethylene was present in more than half of the subjects who tested positive for cocaine.
Adolescent↗
Testing reckless drivers for cocaine and marijuana.
BACKGROUND: Driving under the influence of intoxicating drugs other than alcohol may be an important cause of traffic injuries. We used a rapid urine test to identify reckless drivers who were under the influence of cocaine or marijuana. METHODS: We conducted a consecutive-sample study in Memphis, Tennessee, in the summer of 1993. Subjects arrested for reckless driving who were not apparently impaired by alcohol (did not have an odor of alcohol, tested negative on breath analysis, or both) were tested for cocaine and marijuana at the scene of arrest. The results of the drug tests were compared with clinical evaluations of intoxication made at the scene by a police officer. RESULTS: A total of 175 subjects were stopped for reckless driving, and 150 (86 percent) submitted urine samples for drug testing at the scene of arrest. Eighty-eight of the 150 (59 percent) tested positive: 20 (13 percent) for cocaine, 50 (33 percent) for marijuana, and 18 (12 percent) for both drugs. Ninety-four of the 150 tested drivers were clinically considered to be intoxicated, and 80 of them (85 percent) tested positive for cocaine or marijuana. The intoxicated drivers had a broad range of affects and appearances. Nearly half the drivers intoxicated with cocaine performed normally on standard sobriety tests. CONCLUSIONS: Over half of the reckless drivers who were not intoxicated with alcohol were found to be intoxicated with other drugs. Toxicologic testing at the scene is a practical means of identifying drivers under the influence of drugs and is a useful adjunct to standard behavioral sobriety testing.
Adult↗
Emergency department-based home care.
STUDY OBJECTIVE: To assess the feasibility of coordinating home care services from an inner-city emergency department. INTERVENTION: In a preintervention survey, the home care needs of 650 consecutive patients being discharged from the ED were evaluated. A nurse-coordinator who arranged and managed rapidly deployed home care services then was assigned to the ED for eight months. Patients were referred, and home care services were provided regardless of insurance status. SETTING: Teaching hospital serving a large indigent population. PARTICIPANTS: Adult patients about to be discharged home from the ED. MAIN RESULTS: Forty-five of 650 (7%) surveyed patients were not receiving home care services for which they were eligible. In the subsequent eight-month period, 670 patients were referred for home care on discharge from the ED (2% of all discharges). Seventy-six percent of these patients were women, and the average age was 73.5 years. Four hundred fifty patients (67%) received visits from home care providers managed by the ED coordinator. For 99 of these patients (22%), the availability of rapidly deployed home care services obviated the need for emergency admission to the hospital. Net billings to third-party payers exceeded the costs of the program. CONCLUSION: A significant proportion of elderly patients being discharged from the ED need home health services. Access to rapidly deployed home care services can obviate the need for hospital admission for a select group of debilitated patients. The provision of home care services from the ED is economically feasible.
Adult↗
Do blacks get bystander cardiopulmonary resuscitation as often as whites?
STUDY OBJECTIVE: To determine whether there is an association between the race of a victim of out-of-hospital cardiac arrest and the provision of bystander-initiated CPR. DESIGN: Record review of 1,068 consecutive cases of nontraumatic out-of-hospital cardiac arrest. SETTING: Memphis, Tennessee, a city of more than 600,000 with roughly equal numbers of white and black residents. PARTICIPANTS: Every adult who was seen by municipal emergency medical services personnel for nontraumatic cardiac arrest between March 1, 1989, and June 5, 1992. INTERVENTION: None. RESULTS: Although black and white cardiac arrest victims were similar in many respects, black victims received bystander CPR substantially less frequently than whites (9.8% versus 21.4%; odds ratio, 0.46; 95% confidence interval, 0.34 to 0.61). This difference was slightly more pronounced when the victim collapsed in a public place. In addition to race of the victim, location of the arrest outside the home and having the arrest witnessed were independent determinants of whether a victim was given bystander CPR. Multiple logistic regression analysis showed that the effect of race was independent of the other variables studied. CONCLUSION: Black victims of out-of-hospital cardiac arrest receive bystander CPR less frequently than white victims. Targeted training programs may be needed to improve the rates of bystander CPR among certain groups.
Black or African American↗
Compliance with doxycycline therapy for outpatient treatment of pelvic inflammatory disease.
Women discharged from a municipal emergency department with the diagnosis of pelvic inflammatory disease were surveyed by telephone about their compliance with a standard 10-day regimen of doxycycline. Of the 386 women who completed the survey, 31% reported complete compliance; 28% reported that they did not fill their prescriptions for doxycycline. The most common reasons given for not filling prescriptions were cost, resolution of symptoms, and inconvenience. Forty-one percent reported that they stopped their medication early (average 4.1 +/- 1.4 days). Lack of symptoms, persistence of symptoms, and side effects were the major reasons given for the discontinuation of medications.
Adolescent↗
Abuse potential of various opioid medications.
The abuse potentials of various narcotic medications were assessed by surveying 130 hospital patients who admitted to having abused prescription narcotics within the preceding six months. 85% of the subjects surveyed reported having tried controlled-release narcotic preparations for abuse purposes and 60% reported that they were of little or no use. To obtain another index of abuse potential, the author asked the subjects to estimate the street prices of various medications. The street prices of controlled-release formulations were lower than those of other narcotic medications and those of some uncontrolled nonnarcotic medications. These results suggest that controlled-release narcotic formulations may have a lower potential for abuse than do other narcotic medications. In situations where there is concern about potential abuse or diversion of prescribed narcotics, controlled-release preparations may be an appropriate alternative to high-peaking, rapid-onset opioid formulations.
Adolescent↗
A randomized trial of bromocriptine for cocaine users presenting to the emergency department.
OBJECTIVE: To determine the practicality of treating heavy cocaine users with bromocriptine in an outpatient setting to reduce cocaine use and increase entry into drug treatment. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: VA Medical Center emergency department. PARTICIPANTS: Twenty-nine men presenting for minor medical complaints who used cocaine at least four times per week for the previous month. INTERVENTION: Subjects received either bromocriptine, 1.25 mg, or placebo three times per day for two weeks. MEASUREMENTS AND MAIN RESULTS: On three follow-up visits, subjects were tested for cocaine metabolites and surveyed about their drug use and symptoms. Eight of 14 subjects randomized to the bromocriptine group appeared for follow-up evaluation and seven enrolled in drug treatment. Three of these patients tested negative for cocaine at all three visits. Ten of 15 control patients appeared for follow-up visits and five enrolled in drug treatment. None of the control patients tested negative for cocaine for all three visits. There was no major side effect. CONCLUSION: Bromocriptine can be administered safely to heavy cocaine users in an emergency department setting. The question of whether bromocriptine will reduce the use of cocaine or promote entry into drug treatment deserves further research.
Adult↗
Multiple cerebral aneurysms in patients with sickle cell disease.
Patients with sickle cell disease appear to have a high incidence of cerebral aneurysm. These aneurysms are not associated with the usual risk factors of hypertension, renal disease, or connective tissue disease. We present two recent cases of patients with sickle cell disease and multiple cerebral aneurysms, review the literature on the association between sickle cell disease and cerebral aneurysms, and discuss a mechanism by which sickle cell disease may lead to the formation of cerebral aneurysms.
Adult↗
The underreporting of cocaine-related trauma: drug abuse warning network reports vs hospital toxicology tests.
OBJECTIVE: The purpose of this study was to assess whether cocaine-related trauma is underreported to the US Federal Drug Abuse Warning Network (DAWN). METHODS: We compared DAWN reports filed by an urban emergency department with the department's toxicology results for patients treated for major trauma. DAWN regulations in effect during the study period required the reporting of all patients treated for injury who used drugs or who tested positive for drugs of abuse. RESULTS: Of 520 patients treated for major trauma, 217 (42%) were tested for a variety of drugs. Of these, 82 (38%) tested positive for cocaine. Of the 102 patients injured in motor vehicle accidents, 20 (20%) tested positive for cocaine. Of the 59 patients injured in motor vehicle accidents who were under age 40, 18 (30%) tested positive for cocaine. Of 100 victims of violent assault, 57 tested positive for cocaine. During the time period studied, DAWN recorded 48 hospital visits associated with cocaine, none involving trauma or injury. CONCLUSIONS: Cocaine-related trauma was unreported to DAWN despite the hospital's compliance with the system's guidelines. The pattern of DAWN reports from other institutions suggests that underreporting of cocaine-related injury is widespread.
Accidents↗
Treating sickle cell pain like cancer pain.
OBJECTIVE: To assess the effect of a structured analgesic regimen on hospital use by patients with sickle cell disease. INTERVENTION: Intravenous and oral controlled-release morphine was used instead of intramuscular meperidine and short-acting oral opioids for the treatment of sickle cell pain. DESIGN: Time series in which emergency and admission records for four 6-month periods before and two 6-month periods after the institution of the new analgesic protocol were reviewed. SETTING: Inner-city university hospital providing care for adults with sickle cell disease. PATIENTS: All patients (an average of 50) who used the emergency department of the inpatient medical service for treatment of sickle cell crisis during the study periods. MEASUREMENTS AND MAIN RESULTS: The number of admissions for sickle cell pain decreased by 44%, total inpatient days by 57%, length of hospital stay by 23%, and the number of emergency department visits by 67% after initiation of the morphine protocol. Hospital use remained at these lower levels one year later. Similar declines were seen for a subset of 15 patients who had a history of frequent admissions for sickle cell pain and who used this hospital exclusively and accounted for more than half of the admissions for sickle cell disease. CONCLUSIONS: A pain-control program modeled on regimens used to treat chronic cancer pain reduced hospital use by adult patients with sickle cell pain.
Acute Disease↗
Changes in hematopoietic stem cells in bone marrow of mice with Plasmodium berghei malaria.
An impaired erythropoietic response to anemia has been noted in human patients with malaria and in rodents experimentally infected with Plasmodium berghei. We have attempted to characterize the erythropoietic response in mice with a fatal P berghei infection, with particular emphasis on changes in marrow hematopoietic stem cells. Mice infected with P berghei had dramatic decreases in bone marrow cellularity, erythroblasts, BFU-E, and CFU-E as early as 24 hours postinfection and before there was any change in hematocrit. With development of anemia, marrows became erythropoietic with some expansion of the CFU-E compartment, but the BFU-E pool remained depleted and reticulocyte response was inadequate. There was no significant change in CFU-S from marrows of malaria-infected mice one day after infection. The lethality of malaria infection may take three weeks to be revealed, but it may be determined within hours of the infection by the irreparable changes in marrow erythroid stem cells.
Animals↗
Ultrastructure of the bone marrow in three murine strains with non-malignant lymphoproliferative syndromes NZBxW, BXSB, and MRL/lpr.
Three mouse strains, NZBxW, BXSB, and MRL/lpr have well documented congenital lymphoproliferative syndromes and lupus-like disease. We studied the ultrastructures of the marrows of these mice searching for a model for intramedullary lymphopoiesis. In MRL/lpr, the strain with the most severe disease, the marrow was largely populated by large lymphocytes associated with dark branching stromal cells. These stromal cells are apparently of a recently recognized cell type which has been associated with extremely accelerated eosinophilopoiesis and erythropoiesis. They did not appear in the lymph nodes and spleens of the MRL/lpr mice or in the marrows of the other strains. BXSB marrows showed some non-proliferant lymphocytic infiltrates and heightened erythropoiesis while NZBxW marrows resembled controls. We suggest that the dark stromal cells in the MRL/lpr marrows were important in supporting the production or differentiation of lymphoid precursor cells.
Animals↗
Erythropoiesis in ha/ha and sph/sph mice, mutants which produce spectrin-deficient erythrocytes.
In order to characterize chronically accelerated erythropoiesis, we studied the ultrastructure of bone marrow and spleen of ha/ha and sph/sph mice, two mutants with profound hemolytic anemia secondary to deficiency of the erythrocyte membrane protein spectrin. The marrows and spleens of both varieties were extremely erythropoietic and were without histological abnormalities directly related to spectrin deficiency. Erythropoiesis was consistently associated with distinctive, dark branched cells which constituted large proportions of the stroma of the mutant spleens and marrow. These dark cells were not present in untreated and acutely bled controls. Plasma clot assays for erythroid progenitors revealed that CFU-E concentrations in the mutant marrows were significantly increased over those in untreated controls while BFU-E concentrations were approximately half. In addition, mutant CFU-E often gave rise to abnormal appearing colonies. Spectrin, though crucial to erythrocyte function is probably not important to the process of erythroid differentiation and maturation. The status of erythroid precursors in the marrows of the spectrin deficient mice is similar to that of mice subjected to an acute bleed. The divergent changes in CFU-E and BFU-E may indicate that these two cells play different roles in accelerated erythropoiesis. The dark cells that we describe are similar to stromal cells observed in models of the early stages of erythropoiesis.
Anemia, Hemolytic↗
Adipocyte development and the loss of erythropoietic capacity in the bone marrow of mice after sustained hypertransfusion.
In this electron microscopic study, erythropoiesis in mice was completely suppressed by repeated hypertransfusion for up to 6 wk. We describe a sequence of ultrastructural changes in the marrow's stromal cells that accompany the resulting shift from erythropoietic to granulopoietic tissue. These include the destruction of medullary macrophages, the accelerated development of marrow adipocytes and reticular cells, and a reduction in the amount of vascular space in the marrow. The absence of macrophages was highlighted by the complete lack of erythrophagocytosis in the marrows of hypertransfused mice that were injected with the hemolysing agent, phenylhydrazine. The changes in the marrow stroma probably underlie the shift in the marrow's hematopoietic microenvironment. Repeated phlebotomy of mice that had been hypertransfused for 2 wk evoked the appearance of unique stromal cells in the marrow, similar to cells that have been associated with accelerated erythropoiesis. The newly anemic mice were otherwise unable to mount an erythropoietic response to repeated bleeding, showing that the decline in the erythropoietic microenvironment brought on by sustained hypertransfusion was a lasting one.
Adipose Tissue↗