Context Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients. Objective To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer. Design, Setting, and Patients Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death. Intervention Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment. Main Outcome Measures Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer. Results Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, PՅ.01 for both groups; QOL, PϽ.001 for both groups), with a larger decrease in pain for the NCPB group (P = .005). From repeated measures analysis, pain was also lower for NCPB over time (P = .01). However, opioid consumption (P = .93), frequency of opioid adverse effects (all PϾ.10), and QOL (P=.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of Ն5/10) vs opioid-only patients (14% vs 40%, P=.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P=.26, proportional hazards regression). Conclusion Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.

Survivors who were active were not afraid to exercise. However, concern about lymphedema and knowledge about safe and effective exercise programs influenced choices regarding physical activity and exercise.

Produced water from oil and gas development requires management to avoid negative public health effects, particularly those associated with dissolved solids and bromide in drinking water. Rapidly expanding drilling in the Marcellus Shale in Pennsylvania has significantly increased the volume of produced water that must be managed. Produced water management may include treatment followed by surface water discharge, such as at publically owned wastewater treatment plants (POTWs) or centralized brine treatment plants (CWTs). The use of POTWs and CWTs that discharge partially treated produced water has the potential to increase salt loads to surface waters significantly. These loads may cause unacceptably high concentrations of dissolved solids or bromide in source waters, particularly when rivers are at low-flow conditions. The present study evaluates produced water management in Pennsylvania from 2006 through 2011 to determine whether surface water discharges were sufficient to cause salt or bromide loads that would negatively affect drinking water sources. The increase in produced water that occurred in 2008 in Pennsylvania was accompanied by an increase in use of CWTs and POTWs that were exempt from discharge limits on dissolved solids. Estimates of salt loads associated with produced water and with discharges from CWTs and POTWs in 2008 and 2009 indicate that more than 50% of the total dissolved solids in the produced water generated in those years were released to surface water systems. Especially during the low-flow conditions of 2008 and 2009, these loads would be expected to affect drinking water. Environmental Practice 14: 288-300 (2012)

Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.

The intrinsic excitability of spinal motoneurons is mediated in part by the presence of persistent inward currents (PICs), which amplify synaptic input and promote self-sustained firing. Studies using animal models have shown that PICs are greater in extensor motoneurons over flexor motoneurons, but this difference has not yet been demonstrated in humans. The primary objective of this study was to determine whether a similar difference exists in humans by recording from motor units in biceps and triceps brachii during isometric contractions. We compared firing rate profiles of pairs of motor units, in which the firing rate of the lower-threshold "control" unit was used as an indicator of common drive to the higher-threshold "test" unit. The estimated contribution of the PIC was calculated as the difference in firing rate of the control unit at recruitment versus derecruitment of the test unit, a value known as the delta-F (ΔF). We found that ΔF values were significantly higher in triceps brachii (5.4 ± 0.9 imp/s) compared with biceps brachii (3.0 ± 1.4 imp/s; P < 0.001). This difference was still present even after controlling for saturation in firing rate of the control unit, rate modulation of the control unit, and differences in recruitment time between test and control units, which are known to contribute to ΔF variability. We conclude that human elbow flexor and extensor motor units exhibit differences in intrinsic excitability, contributing to different neural motor control strategies between muscle groups.