1) Acupuncture may reduce pain through the release of endogenous opioid peptides like enkephalins and endorphins in response to stimulation. Evidence includes naloxone reducing or blocking acupuncture analgesia and increased levels of opioids in cerebrospinal fluid after acupuncture.
2) Low frequency electroacupuncture may specifically increase beta-endorphin levels while high frequency increases met-enkephalin levels.
3) Additional neurotransmitters like serotonin may also contribute to acupuncture's analgesic effects through complex spinal pathways.
Still’s Disease and Recurrent Complex Regional Pain Syndrome Type-I: The Firs...Samantha Adcock
Clinical Study
Still’s Disease and Recurrent Complex Regional Pain Syndrome
Type-I: The First Description
C´esar Faillace and Joz´elio Freire de Carvalho
Still’s Disease and Recurrent Complex Regional Pain Syndrome Type-I: The Firs...Samantha Adcock
Clinical Study
Still’s Disease and Recurrent Complex Regional Pain Syndrome
Type-I: The First Description
C´esar Faillace and Joz´elio Freire de Carvalho
CHRONIC PAIN AND DEPRESSION: Cause or Effect or Linked?Sudhir Kumar
Chronic pain and depression are both common conditions, and in many patients, they co-exist. This presentation looks at the link between chronic pain and depression. Various drugs that can be used to treat chronic pain/depression have been discussed, with a special emphasis on tricyclic antidepressants.
CHRONIC PAIN AND DEPRESSION: Cause or Effect or Linked?Sudhir Kumar
Chronic pain and depression are both common conditions, and in many patients, they co-exist. This presentation looks at the link between chronic pain and depression. Various drugs that can be used to treat chronic pain/depression have been discussed, with a special emphasis on tricyclic antidepressants.
Final presentation for the class of Toxicology of Natural Sourced Medicine (EMK Lui)
March 31 st.
If you are going to use this presentation, please, give credit to our work ¬¬U.
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...Dr. Rafael Higashi
Aula apresentada por Dr. Rafael Higashi, médico neurologista sobre quando retirar droga antiepilética. A guideline for discontinuing antiepileptic drugs in seizure-free patients – Summary Statement
Current Update in the Management of Post-operative Neuraxial Opioid-induced P...asclepiuspdfs
Introduction: Itching is an extremely bothersome side effect that frequently appears after the epidural and intrathecal administration of opioids. This common side effect can be severe enough to be considered by the patient to be as bad or worse than the pain itself. Both prevention and treatments remain a challenge in the clinical management of these patients. Many drugs have been used to either treat or prevent the condition with variable results. Materials and Methods: This article’s purpose is to review the clinical literature and summarize the current evidence of efficacy and efficiency of pharmacological treatments available to manage opioid-induced pruritus mediated by spinal opioids in the post-operative setting. An analysis of how the mechanism of action of the most common drugs affects in their clinic usefulness is presented. This comprehensive review is limited to published papers in English, found on PubMed, Medline, and Scopus until December 2017. The papers used in this review were systematized reviews, randomized controlled trials, and opinion articles by subject experts. Results: The most useful drugs are mu opioid antagonists, such as naloxone, and mixed opioids kappa agonists/mu antagonists, such as nalbuphine and butorphanol, the latter being capable of maintaining analgesia in addition to reduce itching. Some efficacy has also been observed, to a lesser extent, from 5-hydroxytryptamine 3 serotonin receptor antagonists, such as prophylactically administered ondansetron, and D2 dopaminergic receptor antagonists, such as droperidol. Moreover, propofol at subanesthetic doses, midazolam, and prophylaxis with mirtazapine and oral gabapentin have been used with efficacy. Finally, a clinical practical guide is suggested for general management of pruritus induced by spinal opioids in the perioperative setting.
IJERA (International journal of Engineering Research and Applications) is International online, ... peer reviewed journal. For more detail or submit your article, please visit www.ijera.com
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
1. 746 BRITISH MEDICAL JOURNAL VOLUME 283 19 SEPTEMBER 1981
The clinical evidence shows, therefore, that metronidazole
is effective in non-specific vaginitis, but these results pose a How does acupuncture
difficult question: Does the drug achieve clinical success by
virtue of its antianaerobic activity, by its (much less good)
work?
activity against G vaginalis, or by both mechanisms ? Further Acupuncture is a potentially cheap and safe form of treatment
possible evidence for the part played by anaerobes, particularly for relieving some types of pain, yet many doctors in the West
Bacteroides spp (but not B fragilis) and peptococci in non-
specific vaginitis, has been produced by Spiegel et al,'1 who remain sceptical of its value. They find the ancient Chinese
suggest that non-specific vaginitis may be caused by anaerobes concepts of traditional acupuncture and its claim to be a treat-
in conjunction with G vaginalis. Such a hypothesis would be ment for all ills unacceptable, but these concepts may be
compatible with many other so-called anaerobic infections, largely irrelevant to the practice of effective analgesic acu-
notably those in the gastrointestinal tract, where mixed puncture. Sceptics suggest that acupuncture may be nothing
infections including aerobes are so common and pure more than a powerful placebo. If, however, acupuncture exerts
anaerobic infection so rare. Not only is treatment of these some specific analgesic effect like other physical treatments,
mixed infections with metronidazole alone frequently very this is not amenable to proof by formal clinical trial. Acu-
effective'2 13 but prophylaxis with metronidazole alone also puncture may be performed in several ways, including manual
successfully prevents postoperative wound infection after rotation of the needles and low-frequency or high-frequency
elective colorectal surgery.'4 The therapeutic success of electrical stimulation through them. No truly double-blind
metronidazole is more difficult to evaluate in non-specific comparison can be made with alternative treatments since the
vaginitis than in the mixed infections of the gastrointestinal needles must be inserted in the conscious patient. Despite the
tract, since it is active in vitro against both the aerobic and the scepticism, however, evidence is accumulating about its
anaerobic components of the infection in the vagina but only mechanisms of action.
against the anaerobes in the gut. If it were possible to use a The possibility that acupuncture analgesia is mediated by a
drug highly active against anaerobes but inactive against G humoral factor was first suggested by a report that transfer of
vaginalis their relative contributions to pathogenesis might cerebrospinal fluid from rabbits having acupuncture produces
become clear. analgesia in recipient rabbits.' The time course of analgesia is
In practical terms, however, these studies suggest that non- similar whether induced by acupuncture or by stimulation of
specific vaginitis is yet another infection which comes into the the brainstem periaqueductal grey matter, both forms of
anaerobic category currently so fashionable; and they offer stimulation producing effects with a delayed beginning and
some cause for real optimism to those concerned with treat- end.2 Analgesia induced by stimulating neurones of the
ment of this recalcitrant condition. Nevertheless, this optimism periaqueductal grey matter appears to be mediated by endo-
should be tempered with caution: before metronidazole genous opiate-like peptides,3 so perhaps analgesia after
becomes widely used in an uncritical fashion some more acupuncture is produced by the release of similar endogenous
carefully controlled studies are needed. substances.
The endogenous peptides with opiate-like analgesic effects
Leopold S. Heretofore undescribed organism isolated from the genito-
are broadly classed as enkephalins and endorphins. Research
urinary system. United States Armed Forces Medical J7oturnal 1953;4: into the role of these opioids in acupuncture analgesia falls into
263-6. into two main categories: firstly, the use of drugs modifying
2 Gardner HL, Dukes CD. Haemophilus vaginalis vaginitis. A newly defined opiate action and, secondly, the measurement of opioid
specific infection previously classified "nonspecific" vaginitis. Ami Y
Obstet Gynecol 1955;69:962-76. peptide concentrations in blood and cerebrospinal fluid. The
3 Zinnemann K, Turner GC. The taxonomic position of "Haemophilus specific opiate-receptor-blocking drug naloxone reduces or
vaginalis" (Corynebacterium vaginale). 7ournal of Pathology and abolishes low-frequency (2-6 Hz) electroacupuncture analgesia
Bacteriology 1963 ;85 :213-9.
4 Greenwood JR, Pickett MJ. Transfer of Haemophilus vaginalis Gardner in various animals subjected to pain.4 Naloxone has no effect,
and Dukes to a new genus, Gardnerella: G. vaginalis (Gardner and however, on the analgesia induced by high-frequency (200 Hz)
Dukes) comb nov. International Journal of Systematic Bacteriology electroacupuncture in mice.4 The degree of analgesia in these
1980 ;30:170-8.
Smith RF, Dunkelberg WE. Inhibition of Corynebacterium vaginale by studies was assessed by behavioural measurements,4 5 by the
metronidazole. Sex Transm Dis 1977;4:20-1. depression of the firing rate of pain-transmitting (nociceptive)
6 Ralph ED, Austin TW, Pattison FL, Schieven BC. Inhibition of Haemo- spinal neurones,6 or by changes in pain-induced cortical
philus vaginalis (Corynebacterium vaginale) by metronidazole, tetra-
cycline and ampicillin. Sex Transm Dis 1979;6:199-202. evoked potentials.7 In human subjects with chronic or experi-
Ralph ED, Amatnieks YE. Relative susceptibilities of Gardnerella vaginalis mental pain all but one group of workers report that naloxone
(Haemophilus vaginalis), Neisseria gonorrhoeae, and Bactcroides fragilis reduces the analgesia produced by manual acupuncture or
to metronidazole and its two major metabolites. Sex Tratisns I)is 1980;7:
157-60. low-frequency electroacupuncture via needles or surface
8 Pheifer TA, Forsyth PS, Durfee MA, Pollock HM, Holmes KK. Non- electrodes.2 8-10
specific vaginitis. Role of Haemophilus vaginalis and treatment with Certain D-amino-acids inhibit the peptidases that otherwise
metronidazole. N EnglJ7 Med 1978;298:1429-34.
Balsdon MJ, Taylor GE, Pead L, Maskell R. Corynebacterium vaginale rapidly degrade the endorphins, thus limiting the duration of
and vaginitis: a controlled trial of treatment. Lanicet 1980;i:501-3,4. their effects. These D-amino-acids enhance the effect of low-
0 Malouf M, Fortier M, Moran G, Dube J-L. Treatment of Haemophilus frequency electroacupuncture in mice, the resulting analgesia
vaginalis vaginitis. Obstet Gynecol 1981 ;57:711-4. being reversible by naloxone.11 Mice of the inbred strain
I Spiegel CA, Amsel R, Eschenbach D, Schoenknecht F, Holmes KK.
Anaerobic bacteria in nonspecific vaginitis. N Engl 7 Med 1980;303: CXBK have a low density of opiate receptors in the brain and
601-7. achieve little analgesia after morphine or acupuncture.12 In
12 Eykyn SJ, Phillips I. Metronidazole in surgical infections. J Antimlicrob contrast, the related group of C57BL mice, which have a
Chemother 1978;4, suppl C:75-81.
3 Willis AT, Ferguson IR, Jones PH, et al. Metronidazole in prevention and normal density of brain opiate receptors, respond to acu-
treatment of bacteroides infections in elective colonic surgery. Br MedJ3 puncture and morphine with normal analgesia. This evidence
1977;i :607-10. further supports a role for endogenous opioid peptides in
14 Eykyn SJ, Jackson BT, Lockhart-Mummery HE, Phillips I. Prophylactic
peroperative intravenous metronidazole in elective colorectal surgery. acupuncture analgesia.
Lancet 1979;ii:761-4. Some recent evidence points to the release of opioid pep-
2. BRITISH MEDICAL JOURNAL VOLUME 283 19 SEPTEMBER 1981 747
tides in cerebrospinal fluid during acupuncture analgesia. control pathways. An important 5-hydroxytryptamine-contain-
Several workers have shown an increase in opiate-like activity ing pathway that inhibits pain arises in the nucleus raphe
in the cerebrospinal fluid of animals and man during acu- magnus in the medulla and projects to the spinal dorsal horns.
puncture,13- 15 but this was measured by a radioreceptor assay Stimulation of this serotoninergic system activates inhibitory
that lacked specificity and did not identify structurally discrete enkephalinergic interneurones situated in the spinal dorsal
peptides. Clement-Jones et al16-18 measured cerebrospinal horns, which in turn inhibit the activity of nociceptive
concentrations of beta-endorphin and met-enkephalin by neurones in the dorsal horns.30 Possibly high-frequency
radioimmunoassay in two groups of patients before and electroacupuncture has an effect in activating this serotonin-
after 30 minutes of electroacupuncture. They used a highly ergic-enkephalinergic system.
specific met-enkephalin assay that had insignificant cross- Can we now assert that acupuncture is more than a placebo ?
reaction with other peptides.'6 A group of patients with recur- This question seems no longer relevant, since the relief of pain
rent pain received low-frequency electroacupuncture. Concen- associated with placebos is probably also mediated by release
trations of met-enkephalin in the cerebrospinal fluid were of endogenous opioids and can be blocked by naloxone.31
unchanged but those of beta-endorphin rose after electro- Perhaps the evidence that different forms of acupuncture
acupuncture.'7 In a second study, in heroin addicts who were elicit specific neurohumoral effects to produce analgesia in
being withdrawn from their drugs, high-frequency electro- animals and man gives acupuncture some physiological
acupuncture was given to suppress the symptoms and signs of respectability. In any event, if acupuncture provides effective
withdrawal. Clinically the treatment was highly effective and it and safe pain relief then its mechanism of action is of secondary
was associated with a rise in met-enkephalin concentrations, importance. The most fruitful result of research into the
which had been low before treatment; beta-endorphin neurochemical basis of acupuncture may be the discovery of a
concentrations, which were raised initially, did not change after means of increasing cerebral release of specific opiate-like
electroacupuncture.18 The difference between the effects on peptides and other neurotransmitters. This may be useful for
beta-endorphin and met-enkephalin may be due to the investigating and treating pain and perhaps also some neuro-
different conditions being treated, but more probably relate logical, psychiatric, and neuroendocrine diseases.
simply to the frequencies of the stimuli. Thus low-frequency
electroacupuncture releases beta-endorphin, whose effects Research Group of Acupuncture Anaesthesia, Peking. The role of some
can be blocked, at least in part, by naloxone; whereas high- neurotransmitters of brain in finger-acupuncture analgesia. Sci Sin 1974;
17:112-30.
frequency electroacupuncture may release met-enkephalin, 2 Mayer DJ, Price DD, Rafii A. Antagonism of acupuncture analgesia in man
whose effects are not blocked by conventional doses of nal- by the narcotic antagonist naloxone. Brain Res 1977;121 :368-72.
oxone. 3
Hosobuchi Y, Rossier J, Bloom FE, Guillemin R. Stimulation of human
pariaqueductal gray for pain relief increases immunoreactive P-endor-
Information about changes in opioids in blood during acu- phin in ventricular fluid. Science 1979;203:279-81.
puncture is more confused. The results of two studies suggest Cheng RS, Pomeranz B. Electroacupuncture analgesia could be mediated
by at least two pain-relieving mechanisms: endorphin and non-
that circulating immunoreactive beta-endorphin rises during endorphin systems. Life Sci 1979;25:1957-62.
electroacupuncture,l' 20) but stress was not excluded as a cause Fu T-C, Halenda SP, Dewey WL. The effect of hypophysectomy on
of the changes. Beta-endorphin is released from the pituitary in acupuncture analgesia in the mouse. Brain Res 1980;202:33-9.
6 Pomeranz B, Cheng R. Suppression of noxious responses in single neurons
parallel with adrenocorticotrophic hormone and the lipo- of cat spinal cord by electroacupuncture and its reversal by the opiate
trophins during stress and indeed all other known stimuli. antagonist naloxone. Exp Neurol 1979;64:327-41.
1 Jieshi C, Zhijin Y, Shupei 0. The effect of naloxone on the inhibitory
Other workers have reported a fall in plasma adrenocortico- action of electroacupuncture upon cortical potentials evoked by tooth
trophic hormone as well as beta-endorphin and cortisol pulp stimulation in rabbits. In: National symposium of acupuncture and
concentrations during electroacupuncture,'8 21 an effect com- moxibustion and acupuncture anaesthesia. Beijing, China: World Books,
1979:482.
patible with the central release of enkephalins.22 23 In any event, Chapman CR, Benedetti C. Analgesia following transcutaneous electrical
beta-endorphin released into the blood is unlikely to mediate stimulation and its partial reversal by a narcotic antagonist. Life Sci 1977;
the central analgesia induced by acupuncture, since this 21:1645-8.
Sjolund BH, Eriksson MB. The influence of naloxone on analgesia pro-
peptide penetrates poorly into the central nervous system. duced by peripheral conditioning stimulation. Brain Res 1979;173:
Pomeranz et al found that hypophysectomy blunted the 295-301.
analgesic response to low-frequency electroacupuncture,24 but Chapman CR, Colpitts YM, Benedetti C, Kitaeff R, Gehrig JD. Evoked
potential assessment of acupunctural analgesia: attempted reversal with
this has not been confirmed.) In man the pituitary is probably naloxone. Pa in 1980;9:183-97.
not an important source of cerebral beta-endorphin, since the Cheng RS, Pomeranz B. A combined treatment with D-amino acids and
electroacupuncture produces a greater analgesia than either treatment
concentrations in the cerebrospinal fluid are normal in patients alone; naloxone reverses these effects. Pain 1980;8:231-6.
with panhypopituitarism, who have undetectable plasma 12 Peets JM, Pomeranz B. CXBK mice deficient in opiate receptors show poor
concentrations of beta-endorphin.25 clectroacupuncture analgesia. Nature 1978 ;273 :675-6.
Gang Z, Shixiang W, Fangsheng W, et al. Increased levels of endorphins
5-Hydroxytryptamine (serotonin) probably plays an in the cisternal cerebrospinal fluid of rabbits in acupuncture analgesia.
important part in mediating the analgesic effect of acu- In: National symposium of acupuncture and moxibustion and acupuncture
anaesthesia. Beijing, China: World Books, 1979:447.
puncture.26- 28 The tryptophan hydroxylase inhibitor para- Sjolund B, Terenius L, Eriksson M. Increased cerebrospinal fluid levels of
chlorphenylalanine decreases concentrations in the brain of endorphins after electroacupuncture. Acta Physiol Scand 1977;100:
5-hydroxytryptamine but works in the opposite way to 382-4.
15
Xiaoping P, Xianhong L, Suying Y, et al. The relationship between the
naloxone, reducing the analgesic effect of high-frequency human CSF levels of endorphins and acupuncture analgesia. In:
electroacupuncture in mice but having no effect on low- National symposium of acupuncture and moxibustion and acupuncture
frequency electroacupuncture analgesia.4 Other neurotrans- anaesthesia. Beijing, China: World Books, 1979:479-80.
16 Clement-Jones V, Lowry PJ, Rees LH, Besser GM. Development of a
mitter systems may mediate some effects of acupuncture but so specific extracted radioimmunoassay for methionine enkephalin in
far their role is uncertain.28 29 human plasma and cerebrospinal fluid. 7 Endocrinol 1980;86:231-43.
17 Clement-Jones V, Tomlin S, Rees LH, McLoughlin L, Besser GM, Wen
The effects of low-frequency electroacupuncture and HL. Increased P-endorphin but not met-enkephalin levels in human
manual acupuncture may be mediated, at least in part, by cerebrospinal fluid after acupuncture for recurrent pain. Lancet 1980;ii:
stimulation of beta-endorphin-containing neurones of the pern- 946-8, 9.
18 Clement-Jones V, Lowry PJ, McLoughlin L, Besser GM, Rees LH, Wen
aqueductal grey matter, thereby activating endogenous pain- HL. Acupuncture in heroin addicts: changes in met-enkephalin and
3. 748 BRITISH MEDICAL JOURNAL VOLUME 283 19 SEPTEMBER 1981
3-endorphin in blood and cerebrospinal fluid. Latncet 1979;ii:380-2, 3. medullary rod. In all cases a biopsy specimen should be taken
19 Malizia E, Andreucci G, Paoluci D, Crescenzi F, Fabbri A, Fraioli F.
Electroacupuncture and peripheral 3-endorphin and ACTH levels. at the time of operation to confirm the nature of the lesion and
Lancet 1979;ii:535-6. help in planning radiotherapy or chemotherapy after operation.
2(1 Abbate D, Santamaria A, Brambilla A, Panerai AE, Di Giulio AM. Fractures of the femoral neck are best treated by replacement
,3-Endorphin and electroacupuncture. Lancet 1980;ii:1309.
21 Wen HL, Ng YH, Ho WKK, et al. Acupuncture in narcotic withdrawal: a arthroplasty.4 When a large part of the upper femur is
preliminary report on biochemical changes in the blood and urine of destroyed special femoral prostheses designed for extensive
heroin addicts. Bull Narc 1978;30,2:31-9. replacement of bone may be required. Problems may arise with
22 Stubbs WA, Delitala G, Jones A, et al. Hormonal and metabolic responses
to an enkephalin analogue in normal man. Lancet 1978;ii:1225-7. large lesions that destroy much bone, and here metal plates may
23 Gaillard RC, Grossman A, Smith R, Rees LH, Besser GM. The effects of be combined with high-density polyethylene plates6 or nylon
a met-enkephalin analogue on ACTH, Q.-LPH, 9-endorphin and met-
enkephalin in patients with adrenocortical disease. Clin Endocrinol 1981; plates and straps.
14 :471-8. During the last 10 years methyl methacrylate cement has
24 Pomeranz B, Cheng R, Law P. Acupuncture reduces electrophysiological been used to supplement internal fixation, the material being
and behavioural responses to noxious stimuli: pituitary is implicated.
Exp Neurol 1977;54:172-8. used to replace the tumour and restore the mechanical continuity
25 Jeffcoate WJ, McLoughlin L, Hope J, et al. 3-Endorphin in human cere- of the bone. By moulding methyl methacrylate round a metal
brospinal fluid. Lancet 1978 ;ii :119-21. device the shape of the bone can be restored.8 Yablon and
26 Chi-Sheng H, Pao-Ho C, Chen-Chy L, Lian-Hua L, Tsung-Hsien Y,
Min-Feng J. The role of central 5-hydroxytryptamine in acupuncture Paul" reported the use of methyl methacrylate in 73 patients
analgesia. Sci Sin 1979;22:91-104. with 81 pathological fractures. They concluded that although
27 Ching-Cheng Y, Ta-Hsien L, Shih-Hsiang W, Kang T. A study on the
release of 3H-5-hydroxytryptamine from brain during acupuncture and methyl methacrylate probably had an adverse effect on fracture
morphine analgesia. Sci Sin 1977 ;20:113-24. healing fixation was adequate, there being no failure of
28 McLennan H, Gilfillan K, Heap Y. Some pharmacological observations fixation in their series. Twelve of their patients had survived
on the analgesia induced by acupuncture in rabbits. Pain 1977;3:229-38.
29 Jisheng H, Minfeng Re, Jian T, Shaoguang F, Jinmin X, Xinmin G. The over five years, and only four failed to regain function in the
role of central catecholamine in acupuncture analgesia. Chin MedJ7 1979; limb that had been operated on. Harrington et all" achieved
92:793-800. similar success in a smaller series of patients. More recently
30 Basbaum AI, Fields HL. Endogenous pain control mechanisms: review
and hypothesis. Ann Neurol 1978;iv:451-62. Harrington" has used methyl methacrylate for replacement
31 Levine JD, Gordon NC, Fields HL. The mechanism of placebo analgesia. and stabilisation of vertebral bodies in pathological fracture-
Lancet 1978;ii:654-7.
dislocations of the spine. In a series of 14 patients followed up
for 13-45 months there was only one failure of fixation. Of
12 patients with major neural lesions before operation, nine
had complete neurological recovery after surgery. Two others
were improved and one was unchanged. None deteriorated
Pathological fractures due neurologically.
Pathological fractures occur in under ",, of patients with
to bone metastases advanced carcinoma.'2 When a fracture does occur, however, it
inflicts a dismal burden on a patient, often at the end of life. As
The observation that cancerous tumours may spread to bone the number of elderly people in the population increases the
and destroy it was first made by clinicians in the late eighteenth incidence of these fractures is likely to rise. Improved surgical,
and early nineteenth centuries.' With increased understanding radiological, and chemotherapeutic techniques have given
of the "carious" condition of the bone they became aware of patients with advanced cancer a longer life span. The resources
the need to treat this secondary problem in an active way for dealing with disabling secondary disease will need to be
despite the patient's poor overall prognosis. correspondingly increased if these patients are to live the end of
The surgeon today has several techniques for dealing with their lives in dignity and without pain.
bone metastases, as well as modern anaesthesia and chemo-
therapy to help him in his task. Indeed, the problem is often Onuigbo W'IB. Recogiition and treatment of pathologic fracturcs in the
nincteenth century. SurXgery 1975 ;77 :553-6.
technically simple; but it raises profound ethical problems Galasko CSB. The pathological basis for skecletal scintigraphy.7 Bone Joint
about the welfare of a patient who has only a short time to live. Snv- (Br) 1975 ;57B :353-9.
Fidler MW, Stollard G. The management of secondary n-eoplastic deposits
Surgery, however, may produce the considerable benefits of in long bones by prophylactic internal fixation. Arcli2vuni Chirurgiclurn
pain relief and increased mobility, and should not be withheld Neerlatdiculcm 1977 ;29:177-85.
from any patient if even brief improvement is likely. Galasko CSB. Pathological fracture secondary to mctastatic canccr. J R
Coil Surg Edlinb 1974;19:351-62.
Skeletal scintigraphy2 is now established for early diagnosis Heistcrberg L, Johansen TS. Treatment of pathological fractures. Acta
of skeletal metastases. This poses the problem of whether ()rthop Scatid 1979;50:787-90.
prophylactic internal fixation should be carried out, as not all Gallannaugh SC. High density polyethylene plate for fracture fixation in
the elderly. Br A/ed]7 1975;iv:560.
metastases in bone are likely to cause a fracture. But prophy- Partridge A. Nylon plates and straps for internlal fixation of osteoporotic
lactic fixation prevents stress and pain, and is technically much bone. LatIcet 1977;i:808.
easier than fixation of a comminuted displaced fracture in soft Ray AK, Romine JS, Pankovich AM. Stabilisation of pathologic fractures
with acrylic cement. Clin Orthop 1974;101:182-5.
bone. In long bones increasing pain and destruction of more 9 Yablon IG, Paul GR. The augmentive use of methyl methacrylate in the
than half the cortex as seen on an x-ray film are indications for management of pathologic fractures. Stnrg Gyneticol Obstet 1967;143:
177-83.
prophylactic internal fixation3 4; local irradiation of the lesion Harrington KD, Johnston JO, Turner RH, Green DL. Thc use of methyl-
is a further indication, since this increases the risk of fracture.4 methacrylate as an adjunct in the internal fixation of malignant neo-
In patients with advanced disease any risk of local or general plastic fractures. _7 Botne ot7ob l Siv-' (Anm) 1972 ;54A: 1665-76.
Harrington KD. The use of methylmethacrylate for vertebral-body
spread of the tumour is outweighed by the benefits of the replacement and anterior stabilisation of pathological fracture-disloca-
procedure.3-5 tions of the spilne due to metastatic malignant disease. 7 Bone o'int Snlrg
Most pathological fractures of the long bones will be treated (Am) 1981 ;63A:36-46.
12 Galasko CSB. Skeletal metastases and mammary cancer. Anin R Coll Snirg
by internal fixation with a plate or nail plate or with an intra- Egii1 1972;50:3-28.