(Great Britain—The Practitioner, September 2000, p. 764.) Patients with Peyronie's disease develop thick plaques on the dorsal shaft of the penis, resulting in painful erection. These plaques can also lead to fibrous scarring and curvature of the penis. The condition occurs in about 1 percent of men, most of whom are middle aged. Although the cause is unknown, previous trauma has been implicated. Histologically, Peyronie's disease causes inflammation that results in collagen deposition and the formation of fibrous plaques. The condition progresses slowly, stabilizing after about one year in some patients and resolving spontaneously in others. Use of tamoxifen may relieve pain on erection and surgery may be indicated to correct curvature of the penis, but no definitive therapy has been identified to prevent progression or hasten resolution of this condition.
Use of Opiates in Patients with Cancer
(Hong Kong—The Hong Kong Practitioner, August 2000, p. 382.) Although opiates are the mainstay of analgesia in patients with cancer, they are frequently not given in adequate doses or are used inappropriately. Patients with cancer may experience different types of pain. Opiates are highly effective against visceral pain, partially effective in somatic and neuropathic pain, and not effective for pain caused by muscle spasm or psychosocial distress. Pharmacokinetics are important in the selection and prescription of opiates. Short-acting agents such as buprenorphine can be absorbed through the buccal mucosa and used to provide additional analgesia during procedures such as wound dressing. When long-acting agents such as dextropropoxyphene (half-life of 15 hours) are used, care must be taken to avoid an accumulation of metabolites. The most widely-used opioids are codeine and morphine. They should be provided in adequate doses to control pain and scheduled on a regular basis, not given “as needed.” About seven doses are needed to reach the steady-state of effect, depending on whether the formulation is immediate or slow release. Initial nausea often resolves during the first few days, but the patient may need to use antiemetics. Severe vomiting may be caused by preservatives in the solution. Pharmacists can provide special formulations, but these require refrigeration. The dosage should be increased until pain is prevented without intolerable side effects. Double doses at bedtime may help the patient to sleep. Constipation is inevitable with opiate therapy, so concurrent use of a laxative is essential. Tolerance and physical dependence are not major problems when opiates are used appropriately in cancer therapy.
Traveling Abroad Safely
(Canada—Canadian Family Physician, August 2000, p. 1634.) Physicians should advise prospective travelers to avoid risk-taking behavior while visiting other countries. About 25 percent of all deaths of U.S. citizens who travel to other countries are caused by accidents. The leading causes of accidental deaths in tourists are motor vehicle crashes, drowning and homicide. The rate of traffic accidents in many developing countries is very high. Exacerbating factors include alcohol use and vehicles that are overloaded and poorly maintained. Unsafe sexual practices while overseas are common among young male tourists and military personnel. In surveys of two military groups, 50 percent of each group reported visiting prostitutes and, of these, only 25 to 50 percent reported consistent use of condoms. The risk of infection with a sexually transmitted disease is particularly high in parts of Asia and in some African and Caribbean countries. Rates of human immunodeficiency virus infection among prostitutes include 81 percent in Kenya, 69 percent in Haiti and 44 percent in Thailand. Infection with gonorrhea, chlamydia and hepatitis is also common. These infections may be complicated by antibiotic resistance. In parts of Africa and southeast Asia, 50 percent ofNeisseria gonorrhoeae is resistant to penicillin.
(Canada—Canadian Family Physician, August 2000, p. 1575.) Glomangiomas arise from the glomus, a specialized arteriolovenular shunt in the skin that acts as a temperature-regulating mechanism. Small glomus tumors usually occur in peripheral areas of the body, especially the nail beds of the fingers. The tumors are red to violaceous tender dermal nodules that can erode the distal phalanx. Because of specialized innervation of the glomus cells, the tumors may cause severe paroxysmal pain following cold or minor trauma. Multiple glomangiomas represent an autosomal dominant condition that becomes apparent in early adult life. The nodules may be grouped or widely scattered over the body. Multiple glomangiomas are less likely than the solitary form to be tender. Symptomatic glomangiomas are treated by excision.