Introduction . Skin giant neoplastic ulcers are a very serious diagnostic and therapeutic problem. The objective of this work was to present the experiences and strategies of our center concerning the treatment of this type of neoplastic ulcers. Material and methods . In this paper we present and analyze 15 cases of patients treated for giant ulcers. This represented 0.4% of all patients treated surgically for skin cancer in our center (n = 3983). Ulcers in this group of patients were located within the head (n = 6), chest (n = 4), abdomen (n = 2), male genitals (n = 1) and lower limbs (n = 2). Results . Our observations indicate that the treatment of giant skin neoplastic ulcers (although they are relatively rare) is a major clinical challenge and requires individualized multidirectional diagnostic and therapeutic methods.
Treatment of radicular pain depends on etiology and symptoms. If non-invasive causal treatment of radiculopathy is possible, it should be used. For example discitis should be treated with antibiotics. 1 There are three categories of radicular symptoms and signs. 2 Mild radiculopathy is considered a sensory loss and pain without motor deficits, moderate radiculopathy is the sensory loss or pain with mild motor deficits, and severe radiculopathy is considered sensory loss and pain with marked motor deficits. The primary treatment for lumbar radiculopathy will include conservative management such as nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, manual therapy and exercises. Most cases of lumbosacral radiculopathy are self-limited. Counselling is essential for patients with radicular symptoms since most cases are mild and will resolve within six weeks after the onset of symptoms. It is vital to encourage patient to weight loss reduction considering that in most cases elevated body mass index is observed. Spontaneous improvement following a disc herniation or lumbar spinal stenosis is very high. 4 However minimal invasive treatment if there are no contraindications, should be considered at any level of symptoms. On the one hand, minimally invasive procedures modulate inflammation within the compressed root. [6][7][8] On the other hand, they prevent peripheral and central sensitization. The minimally invasive methods of treating radicular pain include steroid epidural blockade, pulsed RF of dorsal root ganglion (DRG), transforaminal epidural ozone (O 3 ) injection. In properly qualified patients intradiscal injection of gelified ethanol (Discogel) is effective. For radiculopathy in patients after multiple surgeries and peri-root scar confirmed in MRI epidural adhesiolysis should be considered. 3 if there is no improvement and muscle strength deficits persist after non-invasive and minimal invasive treatment, neurosurgical intervention should be considered .Treatment depends on patient condition and needs. Although most radicular symptoms resolve spontaneously, effective treatment should not be delayed. 4
prevention of hypotension consisted of ephedrine and atropine. 8 This rate of hypotension is acceptable and would probably be less with the preventive use of phenylephrine or noradrenaline recommended in patients with a spinal anaesthesia. 28 While respecting these precautions, this practice has demonstrated to be safe. 25 In a recent survey among all the Obstetric Anaesthetists' Association in the UK, the respondents considered to use a spinal anaesthesia after a conversion failure (no objective sensory block or below a T10 level or unilateral block), and to decrease the dose of spinal anaesthesia. 20 An algorithm published by Vaida et al. 29 also considered the level of emergency of the CD to indicate a spinal block: the authors only recommended a spinal anaesthesia for category-2 CD, when parturients presented an epidural analgesia failure.Finally, false identification of intradural space due to the presence of local anaesthetic in the epidural space is one of the cause of failed rescue spinal block. 3 For this reason, new spinal anaesthesia should be performed by an experienced anaesthesiologist, to decrease the risk of failure in emergency situations. Conclusions Even though a new spinal anaesthesia should not be the first-line anaesthetic technique for intrapartum caesarean delivery in a patient with well-functioning labour epidural analgesia, it is a safe and efficient rescue technique to avoid general anaesthesia in case of failing labour epidural analgesia for emergent caesarean delivery.Its indications must always be discussed with the obstetricians because onset time to establish a surgical block is longer than for general anaesthesia. Although decision to delivery time is acceptable in many cases with spinal anaesthesia, the situation does not always allow to wait before foetal extraction.So, YES, For Emergency caesarean delivery, a Labour Epidural Analgesia catheter should be removed, and a Spinal Anaesthetsia used instead, but only for failed epidural conversion and not in all the situations.
Chronic pain has become dominant problem in recent years affecting not only patient quality of life but having economic impact and heavy burden on the health systems. The first line in pain management would be patient education, physical rehabilitation and pharmacotherapy. Unfortunately aforementioned treatment often appears incomplete and specialised, targeted pain interventions are warranted. With significant progress in pain medicine, the number of available and effective interventional procedures and techniques have increased. In this manuscript authors have carried out an up to date review of modern interventional techniques with emphasize of anatomy, level of advancement and complexity. Authors classified procedures according to anatomical location: head and neck, spine, upper and lower limb, trunk as well as pathophysiology: interventions in neuropathic pain, cancer pain including neuromodulation techniques. Whenever possible authors relied on evidence based medicine (EBM) but with emphasize of its limitation, especially in assessment of pain relief which remains patient subjective experience. In summary, reimbursement of up to date pain procedures, in the outpatient and hospital setting has been shown. It hopefully guide pain specialists to choose the right intervention and facilitate renumeration within NFZ fee schedule.
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