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Special Articles
An Evidence-Based Algorithm for the Treatment of Neuropathic Pain

Nanna B. Finnerup, MD; Marit Otto, MD; Troels S. Jensen, MD, PhD; Søren H. Sindrup, MD, PhD
Medscape General Medicine.  2007;9(2):36.  ©2007 Medscape
Posted 05/15/2007

Abstract
Objective: The purpose of this article is to discuss an evidence-based algorithm that can be implemented by the primary care physician in his/her daily clinical practice for the treatment of patients with neuropathic pain conditions. Method: A treatment algorithm for neuropathic pain was formulated on the basis of a review of 105 high-quality, randomized, placebo-controlled clinical trials. The number needed to treat (NNT) and number needed to harm (NNH) were used to compare the safety and effectiveness of current treatments for neuropathic pain syndromes. Most of the clinical trials reviewed in the analysis assessed tricyclic antidepressants (TCAs) and antiepileptic drugs (AEDs). Results: TCAs had the lowest NNT followed by opioids and AEDs, such as gabapentin and pregabalin. The nature of the retrospective calculation of the NNT and NNH involves obvious limitations because of the pooling of studies with different experimental designs and outcomes. Conclusion: Patients presenting with neuropathic pain are becoming a more frequent occurrence for the primary care physician as the population ages. Evidence-based treatment options allow for the most efficient and effective pharmacotherapy regimen to be implemented.


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Good kids fever info:
http://www.bmj.com/cgi/content/full/334/7604/1163

Clinical features of specific serious diseases in conjunction with fever
Meningococcal disease

Non-blanching rash, particularly with one or more of:

* An ill looking child
* Lesions larger than 2 mm in diameter (purpura)
* A capillary refill time of ≥3 seconds
* Neck stiffness


Meningitis

* Neck stiffness
* Bulging fontanelle
* Decreased level of consciousness
* Convulsive status epilepticus

Herpes simplex encephalitis

* Focal neurological signs
* Focal seizures
* Decreased level of consciousness

Pneumonia

* Cyanosis
* Tachypnoea: respiratory rate >60 breaths/min if age 0-5 months; >50 breaths/min if age 6-12 months; >40/min if age >12 months
* Nasal flaring
* Chest indrawing
* Crackles on auscultation
* Oxygen saturation ≤95%

Urinary tract infection

* Vomiting
* Poor feeding
* Lethargy
* Irritability
* Abdominal pain or tenderness
* Urinary frequency or dysuria
* Offensive urine or haematuria

Septic arthritis or osteomyelitis

* Swelling of a limb or joint
* Not using an extremity
* Non-weight bearing

Kawasaki disease

Fever for more than five days and at least four of:

* Bilateral conjunctival injection
* Change in mucous membranes
* Change in the extremities
* Polymorphous rash
* Cervical lymphadenopathy



Measure and record temperature, heart rate, respiratory rate, and capillary refill time in all children with feverish illness.*

Management in primary and specialist care is determined by the assessment of risk of serious illness (figs 2Go and 3Go). Children who progress to the later stages of the guideline are likely to have fever without apparent source, a relatively common problem that is recognised as being particularly challenging to manage.3

Other key recommendations

* Parental perception of fever should be taken seriously
* Measuring body temperature:

1. Do not routinely use the oral and rectal routes in children aged 0-5 years*
2. In infants under the age of 4 weeks, use an electronic thermometer in the axilla
3. In children aged 4 weeks to 5 years, use an electronic thermometer in the axilla, a chemical dot thermometer in the axilla, or an infrared tympanic thermometer

* Do not routinely use antipyretic agents with the sole aim of reducing fever in children who are otherwise well*
* Do not routinely administer paracetamol and ibuprofen either in combination or alternately; but consider using the alternative drug if the child does not respond to the first agent
* Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose
* Do not prescribe oral antibiotics to children with fever without apparent source.




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Keep the carbs down to lower BP?


"The slightly higher blood pressure of subjects following the high-carbohydrate diet may be due to accentuation of hyperinsulinemia," Dr. Shah's team suggests. "Hyperinsulinemia is suggested to enhance sympathetic nervous system activity, which increases heart rate, cardiac output, vascular resistance, and sodium retention and thus blood pressure."

Am J Clin Nutr 2007;85:1251-1256.



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Why there are 2 chinese articles this week, I do not know!

FDA Warns on Chinese-Manufactured Toothpaste
The FDA is warning consumers to throw out any Chinese toothpaste after it found a component of antifreeze in several products.
Because diethylene glycol (DEG) is not always listed in the ingredients on the package, the FDA says people should examine their toothpaste and discard any imported from China. So far there have been no reports of injuries from DEG-contaminated toothpaste, but there have been deaths in several countries from DEG-contaminated products like cough syrup. The FDA is concerned about chronic exposure to DEG, particularly to vulnerable populations like children and people with kidney or liver disease.
The following brands are affected by the advisory: Cooldent Fluoride, Cooldent Spearmint, Cooldent ICE, Dr. Cool, Everfresh, Superdent, Clean Rite, Oralmax Extreme, Oral Bright Fresh Spearmint Flavor, Bright Max Peppermint Flavor, ShiR Fresh Mint Fluoride Paste, DentaPro, DentaKleen, and DentaKleen Junior.
FDA advisory (Free)



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SHANGHAI: The former head of China's top food and drug safety agency was sentenced to death Tuesday after pleading guilty to corruption and accepting bribes, the state-controlled news media reported.

Zheng Xiaoyu, who served as commissioner of the Food and Drug Administration from its founding in 1998 until mid-2005, was detained in February as part of a government investigation into corruption at the agency.

The unusually harsh sentence for the 62-year-old former commissioner came at a time of heightened concern about the quality and safety of China's food and drug system, following a series of scandals here involving tainted food and counterfeit drugs.

China is under mounting pressure to overhaul its food export controls after two local companies were accused this year of shipping contaminated pet food ingredients to the United States, leading to one of the largest pet food recalls in U.S. history

http://www.iht.com/articles/2007/05/29/news/beijing.php<</span>http://www.iht.com/articles/2007/05/29/news/beijing.php>

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Thank goodness Donald let me know about this little article in www.chiroweb.com .

DID YOU KNOW:

A "...recent analysis supports ... that patients enrolled in the chiropractic network experienced fewer hospital visits, spent less time in the hospital for care, underwent fewer surgeries and used far fewer pharmaceuticals than other HMO patients who received traditional medical care, resulting in low utilization costs and high patient satisfaction scores. Moreover, chiropractors succeeded in diagnosing and treating patients at a level nearly equal to medical doctors.

check out this analysis of the study:
http://www.chiroweb.com/archives/22/18/16.html

If you are not quite sure if you want to click the above article, look at this snippet:

When asked what he hoped members of the chiropractic and medical professions would take from the study, Dr. Sarnat, a medical doctor, commented:
“The study really shows the enormous power and benefit of two things: 1) the utilization of chiropractic in a primary care setting; and 2) the magnitude of outcomes, both clinical and cost, that can be achieved when all members of the health sciences work together as a team for the betterment of the patient, putting aside all professional rivalries. Hopefully, these results are so dramatic that they will ‘wake up’ the health care system (or lack thereof) to the immediate need for true integration among all qualified health care providers.”
HOW about this for a media snippet of interest? Amazing?
My view is that both medical and chiropractic fraternities working together would be a powerful alliance of monumental propulsion to the promotion of health.

Chiropractic care week is coming up in the third week of May.
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Here is a landmark study for the blog that all chiro's should be aware of.
Using nutrition to help subluxations get better quicker may have a place?
--Donald

Journal of the American College of Nutrition, Vol. 23, No. 5, 545S-548S (2004)
Published by the American College of Nutrition
Magnesium VitB6 Intake Reduces Central Nervous System Hyperexcitability in Children
Marianne Mousain-Bosc, MD, Michele Roche, PhD, Jean Rapin, MD, PhD and Jean-Pierre Bali, MD, PhD

Department of Pediatry (M.M.-B.), CHU Nimes, FRANCE
Department of Biochemistry (M.R.), CHU Nimes, FRANCE
Laboratoire de Biochimie, Groupe Hospitalier Carémeau (J.P.B.), Nimes Cedex, FRANCE
Department of Pharmacology, Faculty of Medicine, University of Bourgogne, Dijon (J.R.), FRANCE

Address reprint requests to: Dr. Jean-Pierre Bali, Laboratoire de Biochimie, Groupe Hospitalier Carémeau, Place du Professeur Robert Debré, 30029 Nimes Cedex, FRANCE. E-mail: bali2003@yahoo.fr

Objective: Ionic magnesium (Mg2+) depletion has long been known to cause hyperexcitability with convulsive seizures in rodents, effects that have been reversed by treatment with magnesium (Mg). Metabolic disorders and genetic alterations are suspected in this pathology, in which Mg2+ transport and intracellular distribution may be reduced without change in serum Mg2+ concentrations. We evaluated the effects of Mg2+/vitamin B6 regimen on the behavior of 52 hyperexcitable children (under 15 years of age) and their families.

Methods: To assess intracellular Mg2+, we measured intra-erthrocyte Mg2+ levels (ERC-Mg). Our reference values for normal subjects were 2.46 to 2.72 mmol/L. In 30 of the 52 hyperactive children, there were low ERC-Mg values: 2.041 ± 0.279 mmol/L). Combined Mg2+/vitamin B6 intake (100 mg/day) for 3 to 24 weeks restored normal ERC-Mg values (2.329 ± 0.386 mmol/L).

Results: In all patients, symptoms of hyperexcitability (physical aggressivity, instability, scholar attention, hypertony, spasm, myoclony) were reduced after 1 to 6 months treatment. Other family members shared similar symptoms, had low ERC-Mg values, and also responded clinically to increased Mg2+/vitamin B6 intakes. Two typical families are described.

Conclusion: This open study indicates that hyperexcitable children have low ERC-Mg with normal serum Mg2+ values, and that Mg2+/vitamin B6 supplementation can restore normal ERC-Mg levels and improve their abnormal behavior.
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Interaction of psychosocial risk factors explain increased neck problems among female office workers

Venerina Johnstona, , , Nerina L. Jimmiesonb, Tina Souvlisa and Gwendolen Julla aPhysiotherapy Division, School of Health and Rehabilitation Sciences, The University of Queensland, Level 3, Therapies Building 84A, St Lucia, Qld. 4072, Australia bSchool of Psychology, The University of Queensland, Qld., Australia Received 5 June 2006;  revised 14 October 2006;  accepted 17 October 2006.  Available online 6 December 2006.
Abstract
This study investigated the relationship between psychosocial risk factors and (1) neck symptoms and (2) neck pain and disability as measured by the neck disability index (NDI). Female office workers employed in local private and public organizations were invited to participate, with 333 completing a questionnaire. Data were collected on various risk factors including age, negative affectivity, history of previous neck trauma, physical work environment, and task demands. Sixty-one percent of the sample reported neck symptoms lasting greater than 8 days in the last 12 months. The mean NDI of the sample was 15.5 out of 100, indicating mild neck pain and disability. In a hierarchical multivariate logistic regression, low supervisor support was the only psychosocial risk factor identified with the presence of neck symptoms. Similarly, low supervisor support was the only factor associated with the score on the NDI. These associations remained after adjustment for potential confounders of age, negative affectivity, and physical risk factors. The interaction of job demands, decision authority, and supervisor support was significantly associated with the NDI in the final model and this association increased when those with previous trauma were excluded. Interestingly, and somewhat contrary to initial expectations, as job demands increased, high decision authority had an increasing effect on the NDI when supervisor support was low.

Resolution of Cervical Complications
Secondary to Motor Vehicle Accidents
by the Application of Stereotactic Cervical
Alignment (SCALE) Methods:
Statistical Review of 54 Patients

Jack Carleton
Richard Hammond
Joseph O. Obebe
Scott Rosa
Roy Sweat
Matthew Sweat
Marty Moss

ABSTRACT.

Introduction.
Cervical complications secondary to motor vehicle accidents (MVA) continues to be an area where patients experience long-term complications despite having received therapy. Many of these problems relate to the delicate structures associated with the cervical
Spine and the precise alignment needed. We report on the findings of a Specific cohort of patients from our larger multi center study that presented specifically with MVA related complications and how these patients were successfully treated with what is defined as Stereotactic Cervical Alignment (SCALE) methods.


Method.
A total of 221 patients were seen in private chiropractic practice. Inclusion criteria included existing head, neck, and shoulder pain caused by MVA. Patients who failed to complete treatment or study questionnaires were excluded. The equipment and techniques were consistent with standard SCALE methods. Patients received an average of 2.76 of treatment sessions over 11.1 weeks.

Results.
Upon entry, patients had significant debilitating pain and complications from neck injuries secondary to MVA. After application of SCALE methods, 84% of the patients experienced complete or near complete resolution of their pain and other neck related complications. All
patients reported significant improvements in their conditions with 53% of the patients experiencing complete recovery. Range of motion (ROM) and other measurements of cervical spine function also improved. These findings showed durability for the duration of the measured post-treatment period.

Conclusions. From these findings, it would appear that SCALE methods are a useful adjunct for treating specific types of neck injuries that are secondary to MVA. Further testing of this technique is currently underway to further determine its use in treating MVA and other spinal injuries.

Jack Carleton, MD, is affiliated with Crystal Run Healthcare, Middletown, NY.

RichardHammond, MD,is affiliated with Magic Valley Regional Medical Center, Twin Falls, ID.
Joseph O.Obebe, MD,FAC,is affiliated with Legacy Medical Center, Atlanta, GA and the Oconee Medical Center, Millegeville, GA.

ScottRosa, DC, BA, BCAO; RoySweat, DC, BA, BCAO andMatthewSweat, DC, BA, BCAO are all on the Board of Directors of the R.W. Sweat Foundation, Atlanta, GA.

MartyMoss, PA, BS, is affiliated with MM Medical Consulting, West Monroe, LA.

Address correspondence to: JackCarleton, MD, P.O. Box 437, Rock Hill , NY 12775

(E-mail: atlas55@hvc.rr.com).

Journal of Whiplash & Related Disorders, Vol. 5(1) 2006 doi:10.1300/J180v05n01_03 15

Available online at http://www.haworthpress.com/web/JWRD
©2006 by The Haworth Press, Inc. All rights reserved.


Head and Neck
This one will stare them in the face
I recall a patient asking me if a suboccipital nerve block would help her mother's neck pain. I'd just finished adjusting her atlas, and in front of her was big poster demonstrating the nerve...oh, well 
 

Chronic Daily Headache Linked to Prior Head or Neck Injury

Thomas S. May
Medscape Medical News 2007. © 2007 Medscape
May 9, 2007 — Head and neck injury (HANI) is a significant risk factor for the occurrence of chronic daily headaches (CDH), with a dose-response relationship between the 2 conditions, results of a large, population-based study indicate.
The research was conducted by James R. Couch, MD, PhD, a professor of neurology at the University of Oklahoma Medical School, in Oklahoma City, and colleagues and was presented here at the American Academy of Neurology 59th Annual Meeting.
These results suggest that head injury is a significant risk factor for chronic daily headache, and the risk is cumulative, Dr. Couch concluded. "So the effect of a head injury doesn't really go away," he said. "It's not like in the movies, where the private investigator gets a lick on the head, then runs off and catches the bad guy. In real life, there is continued risk after a serious head injury."
Frequent Headaches
"Studies have shown that 50% to 80% of patients with head injury have headaches immediately after the head injury, and 2 years later, 20% to 30% of these people still have headaches," Dr. Couch told meeting attendees. "However, the reverse situation — head injury as a risk factor for chronic daily headache — has not been studied in a controlled population," he said.
To evaluate HANI as a risk factor for CDH, the researchers analyzed data from the Frequent Headache Epidemiology Study, which surveyed 53,000 subjects in the Baltimore and Atlanta areas by telephone interview.
Subjects who reported having frequent headaches were asked whether they ever had an injury to the head or neck and, if so, whether the injury was followed by fainting or loss of consciousness. "The fainting or loss-of-consciousness question was meant to try to differentiate between those who had a more severe [injury] and [those who had a] less severe injury," Dr. Couch explained.
Subjects experiencing more than 180 headaches per year were classified as having CDH, whereas individuals with 2 to 102 headaches per year were classified as episodic headache controls. "This is the first study to look at head and neck injury as a risk factor for chronic daily headache using a control population," Dr. Couch noted.
Injuries were classified as potentially precipitating injuries if they occurred within 2 years of CDH onset (cases) or in an equivalent randomly generated 2-year period in controls.
The investigators found that after adjustment for age, sex, and headache type, CDH cases were more likely to have experienced HANI than episodic headache controls, and the odds of CDH in association with a potentially precipitating injury were also elevated.
Risk for Chronic Daily Headaches (CDH) Associated with Any Head and Neck Injury (HANI) or Potentially Precipitating Injuries (PPI) vs Episodic Headache Controls