Palliative Care Emergency: A Rare Etiology of Acute Pain

Patients with serious or life-threatening illnesses are typically referred to palliative care to discuss goals of care, advance care planning, and to seek control of their cancer-related pain. Physicians who care for patients near the end of life quite often attribute worsening pain to advancing disease. We present a case of a patient with metastatic gallbladder adenocarcinoma who presented to a palliative care clinic with complaints of worsening chest and back pain, uncontrolled with her established opioid pain regimen. Findings on physical examination prompted the search for other etiologies of this patient’s worsening pain. An initial review of her recent investigations revealed a suspicious positron emission tomography (PET) scan obtained prior to her clinic appointment, which showed a large right-sided pneumothorax with tension physiology. The patient was urgently sent to the emergency room for emergent placement of a chest tube. This case attempts to bring awareness to the potential bias physicians may have regarding the pain experienced by patients with advanced disease and who are near the end of life. The performance of a thorough physical examination can be neglected in a developed, resource-rich country where imaging is easily accessible. Although the adoption of a stepwise ladder in pain management for patients at the end of life is frequently implemented, forgoing a thorough history and physical examination can have detrimental effects. Consideration of other etiologies of acute pain remains imperative when treating patients at the end of life.

Malignant Müllerian Adenocarcinoma Manifesting With Cardiac Tamponade and Pleural Effusion

A 54-year-old woman with a past medical history of untreated stage IV Müllerian adenocarcinoma presented for dyspnea. She was found to have a large right-sided pleural effusion through basic radiology and clinically improved after a CT-guided therapeutic thoracocentesis. However, the patient rapidly deteriorated shortly afterward. A broader workup that included echocardiography revealed a large pericardial effusion with tamponade physiology. The patient underwent an emergent pericardiocentesis, which briefly improved hemodynamics, but her clinical status kept declining until she eventually expired. Subsequent cytology of the pleural and pericardial fluid revealed malignant cells of Müllerian origin.

Biological therapies in otology

Hearing loss is present in millions of people worldwide. Current treatment for patients with severe to profound hearing loss consists of cochlear implantation. Providing the cochlear nerve is intact, patients generally benefit greatly from this intervention, frequently achieving significant improvements in speech comprehension. There are, however, some cases where current technology does not provide patients with adequate benefit. Ongoing research in cell transplantation and gene therapy promises to lead to new developments that will improve the function of cochlear implants. Translation of these experimental approaches is presently at an early stage. This review focuses on the application of biological therapies in severe hearing loss and discusses some of the barriers to translating basic scientific research into clinical reality. We emphasize the application of these novel therapies to cochlear implantation.

[Biological therapies in otology. German version]

Millions of people worldwide suffer from hearing loss. Current treatment for patients with severe to profound hearing loss consists of cochlear implants. Providing the cochlear nerve is intact, patients generally benefit enormously from this intervention, frequently achieving significant improvements in speech comprehension. There are, however, some cases where current technology does not provide patients with adequate benefit. New therapeutic concepts based on cell transplantation and gene therapy are developing rapidly, at least in the research sector. Compared to the wealth of basic research available in this area, translation of these new experimental approaches into clinical application is presently at a very early stage. The current review focuses on translatable treatment concepts and discusses the barriers that need to be overcome in order to translate basic scientific research into clinical reality. Furthermore, the first examples of clinical application of biological therapies in severe hearing loss are presented, particularly in connection with cochlear implants.