Disease-specific HRQoL outcome measures should be considered when evaluating treatments for venous leg ulcers.

Chronic, nonmalignant pain is a substantial public health problem in the United States. Research over the past 2 decades has defined chronic pain by using a "biopsychosocial model" that considers a patient's biology and psychological makeup in the context of his or her social and cultural milieu. Whereas this model addresses the pathology of chronic pain, it also places many demands on the physician, who is expected to assess and manage chronic pain safely and successfully. There is a growing body of evidence suggesting that opioids can be effective in the management of chronic pain, but there has also been a rise in opioid-related overdoses and deaths.Clinicians should be aware of assessment tools that may be used to evaluate the risk of opioid abuse. A basic understanding of chronic pain pathophysiology and a uniform approach to patient care can satisfy the needs of both patients and physicians. pain is of short duration and quickly forgotten. Unfortunately, for some the pain does not pass but becomes a continuous burden, an unrelenting suffering, and the "perfect misery" described in Paradise Lost.1 With these patients, however, the physician faces one of the greatest challenges: the relief of chronic pain.In a 2011 report, authors at the Institute of Medicine 2 underscored that "effective pain management is a moral imperative, a professional responsibility, and a duty of people in the healing profession." Nonetheless, few physicians are formally trained in effectively managing pain, and achieving this goal remains problematic.In the current review we examine chronic pain, discuss theories regarding its cause, evaluate nonpharmacologic and pharmacologic therapy, address the unique aspects of prescribing opioids, and provide a list of take-home points regarding the problem of chronic pain (Figure 1). Chronic pain is defined as pain that persists for longer than 3 to 6 months, or the "normal healing" time of an injury. 2 A physician may be frustrated by the lack of objective findings in a patient with chronic pain, because the extent of an injury does not always correlate with the severity of the patient's discomfort.The "biopsychosocial model" is currently accepted as the optimal conceptual approach, 5 one that envisions chronic pain in terms of the biological parameters in conjunction with the psychological, social, and cultural contexts of the patient. processing. Melzack 6 developed the "neuromatrix theory," which suggests that pain is "produced by the output of a widely distributed neural network that is genetically determined and modified by sensory experience." Accordingly, chronic pain is affected by neural output and not only by sensory input from tissue injury.

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Although small cell carcinoma of the lung has a high incidence of skeletal metastasis and is frequently associated with paraneoplastic syndromes, it is only rarely associated with hypercalcemia. Similarly, the more unusual small cell carcinoma of the pancreas has not been associated with hypercalcemia. The authors describe the first such patient with small cell carcinoma of the pancreas and hypercalcemia. Comprehensive metabolic measurements (fasting calcium excretion, renal phosphorus threshold, 1,25 dihydroxyvitamin D, 25 hydroxyvitamin D levels, nephrogenous cyclic AMP and immunoreactive PTH levels) suggest that although bone metastases were present, the hypercalcemia may have been caused in part by humoral mechanisms.

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