British medical bulletin
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Significant progress has been made since the first successful human heart-lung transplantation (HLT) for pulmonary vascular disease performed in 1981. The refinement of surgical techniques, use of cyclosporin as the main immunosuppressant, technique of distant organ procurement to expand the donor organ pool, and improved diagnosis and management of pulmonary infection and rejection have all contributed to this accomplishment. ⋯ Because of the success, consideration was given to transplantation for parenchymal pulmonary diseases, initially pulmonary fibrosis and emphysema, and then suppurative lung disease such as in cystic fibrosis (CF). However, the application of HLT to patients with CF lagged behind because of concern related to the risk of sepsis, the systemic nature of the disease, malnourishment, and fear of recurrence of the epithelial CF defect in the transplanted lungs.
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Measures to increase individual participation in adequate amounts of physical exercise have a key place among the strategies to improve health and prevent disease. The scientific justification is based on a variety of evidence drawn from numerous epidemiological, clinical and physiological studies and is accepted as sound. The prevalence of physical disability is high. ⋯ Weight-bearing exercise has been shown to prevent osteoporosis at any age. The links between many of the functional adaptations which occur with exercise and improvements in health have been demonstrated. The exercise programmes which are effective have been defined.
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Pain can either be 'nociceptor-mediated', produced as a consequence of the activation of high threshold nociceptors, or 'A-fibre mediated', resulting from the activation of low threshold A beta afferent fibres. Under normal circumstances nociceptor mediated pain only occurs in response to high intensity noxious stimuli. Following peripheral tissue injury the inflammatory reaction generates a complex set of chemical signals that alter the transduction properties of nociceptors such that they can be activated by low intensity stimuli, the phenomenon of peripheral sensitization. ⋯ This is the phenomenon of central sensitization. Because afferent inputs can provoke prolonged alterations within the central nervous system, optimal treatment of acute pain states should be directed both at abolishing peripheral sensitization and to preventing the establishment of central sensitization. The latter involves the strategy of pre-emptive analgesia.
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Successful treatment of sympathetic pain is directed at the restoration of normal function. This can be achieved in the majority of cases with a combination of appropriate sympathetic or somatic nerve block, usually coupled with aggressive physiotherapy. ⋯ Other non-invasive techniques such as stimulation-produced analgesia and pharmacology, particularly the use of adrenergic blocking agents, hold some promise of future benefit. Here too, more effort should be made to carry out properly designed studies, as there is scepticism about the place of permanent or potentially destructive therapy in any painful condition.
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British medical bulletin · Jul 1991
ReviewOpioid-responsive and opioid-non-responsive pain in cancer.
Cancer pain in general responds in a predictable way to analgesic drugs and drug therapy is the mainstay of treatment, successfully controlling pain in 70-90% of patients. The two major problem areas are pain associated with nerve damage, and 'incident' (movement-related) bone pain. Nerve damage pain tends not to respond well to morphine or other opioids. ⋯ The patient may then experience excessive side-effects at rest, but still have pain on movement. Other examples of pain which may be resistant to treatment with opioid analgesics are bladder and rectal tenesmus, pancreatic pain, and pain associated with decubitus ulcers or other superficial ulcers subjected to pressure or shearing forces. Management of non-opioid-responsive pain may include a variety of treatments involving adjuvant analgesic drugs and non-drug measures.