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In this episode, we discuss a complex ethical dilemma concerning a pregnant woman diagnosed with advanced ovarian cancer who refuses recommended termination and chemotherapy due to prior fertility struggles. Several experts in medicine, ethics, law, spiritual care, and social work provide differing perspectives on the case. The medical oncology perspective discusses the individualized management of cancer during pregnancy, while the ethics perspective grapples with patient autonomy versus the potential harm to both mother and fetus. The legal and social work perspectives emphasize the patient's right to self-determination. Ultimately, the article advocates for a multidisciplinary approach that respects the patient's wishes while providing comprehensive support and information. It highlights the need for healthcare providers to navigate these difficult situations with compassion and discernment.

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This case report explores the use of botulinum toxin type A (BTX-A) injections for treating post-thoracotomy pain syndrome (PTPS), a chronic neuropathic condition affecting many patients after thoracotomy. The study highlights that traditional treatments often fail to provide adequate relief, prompting investigation into alternative therapies. BTX-A's mechanism, which involves reducing inflammation and peripheral neurotransmitters, suggests a potential benefit for localized pain syndromes like PTPS. Prior studies indicate the effectiveness of BTX-A in managing other neuropathic pain conditions such as trigeminal neuralgia and diabetic neuropathy. The case report details a successful instance where subcutaneous BTX-A injections significantly alleviated PTPS symptoms, allowing the patient to discontinue opioid medications. While the treatment appears promising and carries minimal risk, the authors suggest that further clinical trials should be conducted.

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I. Introduction

This briefing document synthesizes key findings from several sources exploring the potential of cannabinoids in managing neuropathic pain. The sources include pre-clinical investigations, clinical trial reviews, and decision analysis models, offering a multifaceted view of the topic. We will examine the potential of Cannabidiolic Acid Methyl Ester (CBDA-ME), the effectiveness of cannabis-based medicines, and compare these to traditional pain management techniques.

II. Pre-Clinical Investigation: CBDA-ME

• Focus: The research primarily centers around CBDA-ME, a modified version of cannabidiolic acid (CBDA), which has been enhanced for stability. The study investigates its analgesic effects in rats with peripherally induced neuropathic pain, considering sex as a biological variable.
• Key Findings:
• Improved Stability: CBDA is unstable which limits its potential as a therapeutic target. The addition of the methyl ester group enhances its stability in in vivo studies.
• Dose-Dependent Analgesic Effects (Males): CBDA-ME exhibited a clear dose-dependent increase in mechanical pain threshold in male rats, with a significant reduction in sensitivity to touch. The most effective dose was 1 μg/kg. For example, at week 5, the 1 μg/kg group showed a mechanical threshold of 12.27g compared to a 4.70g for the vehicle group. By week 8, the same groups had thresholds of 12.56g vs 3.53g respectively.
• Inconsistent Results (Females): Female rats showed less consistent responses to CBDA-ME, with some increase in mechanical threshold at weeks 3-5 at 1 μg/kg, but less pronounced and less sustained than in males. At week 5 females had a threshold of 8.81g in the high dose group compared to 4.33g in the vehicle group. At week 8 the numbers were 6.20g vs 5.26g.
• Impact on Thermal Thresholds: The study found less clear or consistent effects of CBDA-ME on thermal thresholds.
• Reduced Neuronal Excitability: CBDA-ME reduced the excitability of specific sensory neuron types (AβHTM, CUT, CHTM, CLTM) by decreasing the current threshold required to evoke an action potential, suggesting a mechanism for its analgesic effect.
• Quote: "This study examines early treatment efficacy of CBDA-ME in a rat model of peripherally induced NEP and evaluates sex as a biological variable."
• Implications: These findings suggest CBDA-ME as a potential analgesic, particularly for mechanical pain, with significant sex differences that need further investigation.

III. Clinical Trial Review: Cannabis-Based Medicines (CBMs)

• Source Focus: A Cochrane review examining the effectiveness of CBMs for chronic neuropathic pain in adults.
• Key Findings:
• Herbal Cannabis: The review found that herbal cannabis was not significantly different from placebo in reducing pain or causing dropouts due to side effects, rated as very low-quality evidence.
• Short-Term Studies: CBMs were not superior to placebo in short-term studies for pain reduction or patient-reported global improvement.
• Intermediate-Term Studies: Some studies showed slight superiority of CBMs over placebo in intermediate-term studies, but these were marginal and sometimes lacked statistical significance, such as a positive Risk Difference in studies reporting improvement in pain (RD=0.03 95% CI 0.00 to 0.06, p=0.05), and similar results reported for a composite measure of improved function

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Hiccups, while often seen as a minor inconvenience, can become a significant health issue when they are persistent or intractable. This episode explores the science behind hiccups, their potential medical causes, and treatment options, particularly the use of gabapentin as an off-label solution.

• Discussion of the three types of hiccups: acute, persistent, and intractable
• Explanation of the hiccup reflex arc and its neurological basis
• Overview of the myriad causes of intractable hiccups, including central nervous system and psychological factors
• Introduction and definition of gabapentin, including its off-label use for hiccups
• Presentation of case studies demonstrating the efficacy of gabapentin
• Examination of potential side effects of gabapentin relative to other treatments
• Alternatives to gabapentin, including other medications and non-pharmacological home remedies
• Ethical considerations regarding off-label prescriptions and open communication with doctors

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This case report details a patient with chronic lymphocytic leukemia whose initially misdiagnosed joint pain was ultimately attributed to the rare syndrome of remitting seronegative symmetrical synovitis with pitting edema (RS3PE). The report discusses RS3PE's characteristics, often overlooked due to its rarity and lack of definitive diagnostic criteria, emphasizing the importance of recognizing it in palliative care settings. The paper explores RS3PE's association with malignancy, its clinical presentation mimicking other rheumatological disorders, and its effective treatment with corticosteroids. Furthermore, the study investigates the potential role of vascular endothelial growth factor (VEGF) in RS3PE's pathophysiology. Early diagnosis is crucial for effective pain management and avoiding reliance on ineffective opioid treatments.

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This retrospective study from a 21-hospital system analyzed the effect of palliative medicine consultations on 30-day hospital readmission rates for patients with six diagnoses (heart failure, sepsis, pneumonia, COPD, AMI, and stroke). The research found statistically significant reductions in readmissions for heart failure, sepsis, and pneumonia patients who received consultations. While reductions were observed in other groups (stroke, AMI, COPD), these were not statistically significant. The study suggests that palliative care consultations may improve patient outcomes and reduce healthcare costs, warranting further investigation and potential policy changes. The findings add to existing literature supporting the value of palliative care in mitigating readmissions.

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This article presents an ethics case study concerning a 52-year-old male declared brain dead, whose family refuses to remove life support. Multiple perspectives—medical, nursing, chaplain, social work, legal, and ethical—are offered, exploring the conflict between the family's emotional denial of death and the medical team's obligation to uphold accepted medical standards. The case highlights the complexities of defining death in the modern era, the importance of cultural sensitivity in end-of-life care, and the challenges of navigating legal and ethical considerations when families disagree with medical assessments. The discussion examines various ethical frameworks, including Kantian ethics and utilitarianism, to guide decision-making. Ultimately, the article emphasizes the need for compassion and patience in dealing with grieving families while upholding medical and legal standards.

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This case report details a rare instance of post-radiation lichen planus in a 64-year-old male, following radiation therapy for squamous cell carcinoma. The report examines the patient's medical history, clinical presentation, and treatment response to topical triamcinolone. The authors review existing literature on lichen planus, emphasizing its T-cell mediated inflammatory nature and its rare association with radiation therapy. The study highlights the need for further research to understand the pathophysiology and improve treatment of this complication. The case underscores the importance of considering radiation-induced lichen planus in patients with relevant exposure and symptoms.

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