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Amyotrophic Lateral Sclerosis (ALS) is a progressive and incurable neurodegenerative disease resulting in the loss of motor neurons, eventually leading to death. ALS results in complex physical, emotional, and spiritual care needs. Specialty Palliative Care (SPC) is a medical specialty for patients with serious illness that provides an extra layer of support through complicated symptom management, goals of care conversations, and support to patients and families during hard times. Using MEDLINE, APA Psychinfo, and Dynamed databases, we reviewed the literature of SPC in ALS to inform and support an expert opinion perspective on this topic. This manuscript focuses on several key areas of SPC for ALS including insurance and care models, advance care planning, symptom management, quality of life, caregiver support, and end-of-life care. Recommendations to improve specialty palliative care for patients with ALS are reviewed in the discussion section.

Introduction: Chronic opioid use is unfortunately perceived among these postoperative patients, specifically within orthopedic surgery. Patients having orthopedic surgeries are at risk for becoming addicted to opioids, and one benefit of peripheral nerves blocks could be to provide an alternative mode of pain control. This study takes a retrospective look at the use of peripheral nerve blocks for pain control following surgery for isolated traumatic ankle injuries. We hypothesize that when peripheral nerve blocks are administered preoperatively to patients with closed ankle fractures, they will have overall better control of postoperative pain compared to patients who did not receive a peripheral nerve block. Objectives: The objective of this investigation was to evaluate the effect of preoperative peripheral nerve blockade on pain outcomes after ankle fracture surgery. Methods: After approval from our institutional review board, a Current Procedural Terminology code search was performed of all patients within our institution over a 3-year data collection period (August 2016-June 2019). This resulted in 177 subjects who underwent isolated closed ankle fracture open reduction internal fixation (ORIF), of which 71 subjects met inclusion criteria. Results: Results of the primary outcome measures found no difference in the mean postoperative care unit (PACU) pain scores between the groups (2.39 6 2.91 vs 3.52 6 3.09; P 5 0.1724) nor the frequency of those who reported only mild pain (63.0% vs 47.10%; P 5 0.2704). Subjects who received a peripheral nerve block spent more time in the PACU before discharge (2.06 6 1.05 vs 0.94 6 1.21 hours; P 5 0.0004). Subjects receiving a peripheral nerve block were more likely to be given no analgesics in the PACU (38.9% vs 11.8%; P 5 0.042) and less likely to receive a narcotic analgesic in the PACU (53.7% vs 82.4%; P 5 0.047). Conclusion:Although the results of this investigation demonstrate no significant difference in the mean PACU pain scores, they do demonstrate a significant difference in the amount of pain medication given in the PACU setting. This information will be used for future investigations of this discrepancy between pain perception and need for immediate postoperative pain medications as it relates to multimodal pain control in the setting of ankle fracture surgery.

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Blunt chest trauma and the treatment of associated pain can lead to impaired respiratory drive and abnormal pulmonary mechanics, in turn resulting in significant respiratory system complications. These can include pneumonia, hypoxia, atelectasis, and a prolonged need for invasive mechanical ventilation. Epidural analgesia can decrease the need for systemic pain control and may improve cooperation with pulmonary rehabilitation exercises. However, this treatment modality also carries a small risk of severe neurological complications such as spinal cord trauma, spinal cord ischemia, and epidural hematoma or abscess. This case report describes one such rare neurological complication: acute quadriparesis after thoracic epidural placement.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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