The Central African Republic (CAR) is if anything worse than a failed state: it has become virtually a phantom state, lacking any meaningful institutional capacity at least since the fall of Emperor Bokassa in 1979.
Phantom-limb pain is a common sequela of amputation, occurring in up to 80% of people who undergo the procedure. It must be differentiated from non-painful phantom phenomena, residual-limb pain, and non-painful residual-limb phenomena. Central changes seem to be a major determinant of phantom-limb pain; however, peripheral and psychological factors may contribute to it. A comprehensive model of phantom-limb pain is presented that assigns major roles to pain occurring before the amputation and to central as well as peripheral changes related to it. So far, few mechanism-based treatments for phantom-limb pain have been proposed. Most published reports are based on anecdotal evidence. Interventions targeting central changes seem promising. The prevention of phantom-limb pain by peripheral analgesia has not yielded consistent results. Additional measures that reverse or prevent the formation of central memory processes might be more effective.
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Phantom limb pain is the perception of pain or discomfort in a limb that is no longer there. PLP most commonly presents as a sequela of amputation. The underlying pathophysiology remains poorly understood. The condition should be differentiated from other related clinical conditions such as residual limb pain, which was formerly called "stump pain" and is pain that originates from the actual site of the amputated limb that tends to resolve with wound healing. This activity describes the evaluation and management of phantom limb pain and highlights the role of the interprofessional team in the management of this pain.
Objectives:Describe the epidemiology of phantom limb pain.Review the presentation of a patient with phantom limb pain.Outline the treatment options for phantom limb pain.Explain the importance of improving coordination amongst interprofessional team members to optimize outcomes for patients suffering from phantom limb pain.Access free multiple choice questions on this topic.
In the United States (U.S.), 30,000 to 40,000 amputations are performed each year. Amputations can occur for many reasons including severe trauma, tumors, vascular disease, and infection. Pain after amputation of a limb is a common symptom and is separated into two types of pain including residual limb pain (RLP) and phantom limb pain (PLP). PLP is clinically defined as the perception of pain or discomfort in a limb that no longer exists. Although PLP most commonly presents as pathological sequelae in amputee patients, the underlying pathophysiology remains poorly understood. Furthermore, PLP can present along a wide clinical spectrum and varying severity of symptoms. The condition should be differentiated from other related but separate clinical conditions, including RLP. This latter condition, formerly known as "stump pain", is pain that originates from the actual site of the amputated limb. It is most common in the early post-amputation period and tends to resolve with wound healing. Unlike PLP, RLP is often a manifestation of an underlying source, such as nerve entrapment, neuroma formation, surgical trauma, ischemia, skin breakdown, or infection.[1][2] Of note, more than half of people with PLP also have RLP. It is important to know the difference between the two because the causes and treatments for each differ, but also be aware that both of these elements can coexist at the same time.[3]
PLP and RLP represent an important challenge in medicine, in terms of epidemiology and therapeutic difficulties. Ninety-five percent of patients, indeed, report experiencing some amputation-related pain, with 79.9% reporting phantom pain and 67.7% reporting RLP. Again, these clinical manifestations can significantly worsen the health-related quality of life (HR-QOL) and in some cases are very difficult to manage.
The exact etiology of PLP is unclear. Multiple theories have been debated, and the only agreement is that multiple mechanisms are likely responsible. The predominant theory for years involved the irritation of the severed nerve endings causing phantom pain. This was enforced by evidence that almost all amputation patients will develop neuromas in the residual limb. Over the last few decades, advances in imaging and laboratory techniques have shown evidence of central nervous system (CNS) involvement. Imaging studies such as MRI and PET scans show activity in the areas of the brain associated with the amputated limb when the patient feels phantom pain. The pain is now thought to involve many peripheral and central nervous system factors.[4][5]
Despite, the phantom limb sensation was described by French military surgeon Ambroise Pare (1510-1590) in the sixteenth century, even today we do not have a clear explanation of this complex phenomenon and, therefore, the pathophysiology is explained by a wide range of mechanisms. These mechanisms. which are the basis of theories, they are not necessarily mutually exclusive
In the spinal cord, a process called central sensitization occurs. Central sensitization is a process where neural activity increases, the neuronal receptive field expands, and the nerves become hypersensitive. This is due to an increase in the N-methyl-D-aspartate, or NMDA, activity in the dorsal horn of the spinal cord making them more susceptible to activation by substance P, tachykinins, and neurokinins followed by an upregulation of the receptors in that area. This restructuring of the neural components of the spinal cord can cause the descending inhibitory fibers to lose their target sites. The combination of increased activity to nociceptive signals as well as a decrease in the inhibitory activity from the supraspinal centers is thought to be one of the major contributors to phantom limb pain. [7]
Over the past few years, there has been significant research into cortical reorganization and is a commonly cited factor in phantom limb pain. During this process, the areas of the cortex that represent the amputated area are taken over by the neighboring regions in both the primary somatosensory and the motor cortex. Cortical reorganization partially explains why nociceptive stimulation of the nerves in the residual limb and surrounding area can cause pain and sensation in the missing limb. There is also a correlation between the extent of cortical reorganization and the amount of pain that the patient feels. [8]
Chronic pain has been shown to be multi-factorial with a strong psychological component. Phantom limb pain can often develop into chronic pain syndrome and for treatment to have a higher chance of success the patient's pain behaviors and pain processing should be addressed. Depression, anxiety, and increased stress are all triggers for phantom limb pain. [9]
Phantom spawning is similar to other monsters spawning: the spawn location must have a light level of 7 or less, and spawns are limited by the monster population cap. Phantoms are also subject to a density cap of 5. Phantom spawn attempts are made on surface blocks throughout the same spawn radius as other monsters. However, when a phantom spawn attempt succeeds the phantom appears somewhere in a 211521 cube centered 28 blocks above the player instead of at the block where the spawn attempt occurred.
Phantoms can move through water at their normal speed. In Bedrock Edition, a phantom underwater attempts to fly to the surface, and dies from drowning after 20 seconds if trapped underwater. Phantoms do not drown in Java Edition.
Like other undead mobs, phantoms are harmed by the Instant Health effect, healed by the Instant Damage effect, immune to the Poison and Regeneration effects, ignored by the wither, and affected by the Smite enchantment.
But phantoms are also useful scientific devices. In the biomedical research community, medical imaging phantoms are objects used as stand-ins for human tissues to ensure that systems and methods for imaging the human body are operating correctly.
NIST staff test the relevant properties of candidate materials and use the best-performing ones to design and fabricate prototype phantoms. NIST either produces the phantoms, or transfers these models to companies, which manufacture and sell their own versions. Commercial phantoms are then purchased by medical facilities and manufacturers to compare scanner performance with respect to standards and other machines at different clinics.
Among its contributions to the field, NIST has developed phantoms for magnetic resonance imaging (MRI), positron emission tomography (PET), computed tomography (CT or CAT), computer-assisted orthopedic surgery, optical medical imaging, digital computations and metal detectors.
NIST also develops phantoms for novel MRI imaging techniques and works with academic and other collaborators on research studies and clinical trials, such as for detecting traumatic brain injury in veterans.
NIST demonstrated the first calibration system for PET scanners directly tied to national measurement standards. PET phantoms are unusual because the scanners detect radioactive materials injected in the patient. The phantoms are hollow cylinders that contain a small amount of radioactive germanium. This is part of a NIST effort to improve medical imaging, speed up clinical trials of drugs and support the development of more individualized medical treatment.
NIST developed phantoms to improve CT scans, which use computer processing to combine multiple X-ray images into three-dimensional (3D) slices of the body that may reveal cancers or disease. NIST phantoms include a standard reference material for lung tissue and disposable diapers, which contain known quantities of water, as stand-ins for tumors.
Orthopedic surgeons need simple, lightweight phantoms to establish the traceability of length measurements performed with computer-assisted orthopedic surgery (CAOS) systems. NIST collaborated with medical professionals to develop novel CAOS phantoms such as a surrogate hip joint and pelvis. be457b7860
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