Articles: chronic.
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Patients with cystic fibrosis (CF) have an abnormal propensity for recurrent and chronic infections of the lower respiratory tract (LRT), and the most common cause of a shortened lifespan is chronic infection with Pseudomonas aeruginosa. A few other gram-negative organisms, primarily Burkholderia cepacia complex have, however, emerged as serious pathogens capable of establishing chronic LRT infection. Details of these and other CF pathogens can be found in the article by Dr. ⋯ Other more rare pathogens such as Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria (NTM) appear less capable of causing patient-to-patient transmission. Both the physical proximity and the duration of exposure of noninfected patients to patients chronically infected with P. aeruginosa and B. cepacia complex are important determinants of the risk of cross-infection. Cohorting of patients according to presence or absence of specific pathogens coupled with conventional hygienic precautions can, however, lead to a decrease in incidence and prevalence of chronic infections with these two species, wherefore patient cohorting is now an integral component of infection control in patients with CF.
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Migraine is a common, chronic neurologic disorder that affects approximately 12% of the adult population in Western countries. Once migraine is diagnosed, illness severity must be assessed. Clinicians and patients should then work together to develop a treatment plan based on patient needs and preferences. ⋯ A variety of behavioral interventions are helpful. The clinician has an armamentarium of ever-expanding variety of medications. With experience, clinicians can match individual patient needs with the specific characteristics of a drug to optimize therapeutic benefit.
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Chronic axial neck pain and cervicogenic headache are common problems, and there have been significant advances in the understanding of the etiology and treatment of each. The severity and duration of pain drives the process. For patients who have had slight to moderate pain that has been present for less than 6 months and have no significant motor loss, strength training of anterior, posterior, and interscapular muscle groups coupled with body mechanics training is prescribed. ⋯ For patients with one or two level disc degeneration that has not responded, a psychologic evaluation and discography is recommended. If there are no significant psychologic abnormalities, and one or two (rarely three) painful discs, surgical consultation is recommended. Adjunctive low-dose opioid analgesics, nonsteroidal anti-inflammatory drugs, and perhaps tricyclic antidepressants are used to supplement the program at mid- and late stages.
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Facet (zygapophysial) joint pain can be diagnosed by anesthetization of the medial branch divisions of the dorsal rami. In accordance with the criteria established by the International Association for the Study of Pain, lumbar facet (zygapophysial) joints have been implicated as the source of chronic pain in 15% to 45% of the patients with chronic low back pain. The reasons for the wide variations have not been systematically evaluated. ⋯ A false-positive rate of 17% in patients with low back pain only and 21% in patients with involvement of multiple regions of the spine was demonstrated with single blocks. This study demonstrated a lower incidence of facet joint pain in patients with spinal pain of a single region in the low back compared to the patients with multiple region involvement of the spine (21% vs 41%), in an interventional pain management setting. These results may not be extrapolated to the general population or chronic low back pain population at large.
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The lifetime prevalence of spinal pain has been reported as 65% to 80% in the neck and low back. In the US each year, 500,000 - 1,000,000 spine surgeries and 2 to 5 million interventional procedures are estimated to be performed. The burden created by chronic pain is enormous on the patient and society. ⋯ The optimal course of care requires an integrated delivery system involving a variety of specialists. Due to the complexities of diagnosis and management, patients are best managed utilizing a multidisciplinary approach under an umbrella of services offered by a spinal diagnostic and interdisciplinary pain center. This review identifies various pain syndromes and conditions and provides a model for the establishment of an interdisciplinary pain center as well as the resources, guidelines, and infrastructure required for operating a successful pain center in any setting; free-standing, hospital-based, or academic.