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Question Set A
Student’s Name
Institutional Affiliation
Number and Name of Course
Instructor’s Name
Due Date
Question Set A
Introduction
Most patients with multiple myeloma (MM) suffer from chronic pain at each stage of the natural disease course. Multiple myeloma (MM) is the second most common hematological malignancy after non-Hodgkin lymphoma, accounting for 2.1 percent of all new cancer cases and the 9th prominent source of cancer death in the United States (Kazandjian, 2016). Pain affects patients with MM at various phases of their sickness, with the pervasiveness of 69 percent and a significant detrimental influence on their quality of life (Ramsenthale et al., 2016). This essay emphasizes the pathophysiology of multiple myeloma, the pharmacodynamics actions, and different medications to treat patients with multiple myeloma and acute medical and nursing management that should be provided to patients after the decompression of the spinal fracture surgery is completed.
Multiple Myeloma
One of the most prevalent consequences of MM is osteolytic bone lesions, with 80% of patients reporting bone pain. MM is identified in two-third of patients after a bone rupture, resulting in acute hurt and increased illness and death (Panaroni, Yee, & Raje, 2017). Chemotherapy-Induced Peripheral Neuropathy (CIPN) is a side effect of the medications used to treat MM, and it has a substantial impact on patients’ quality of life. Bortezomib, a proteasome inhibitor, has been linked to CIPN in more than 80% of people who have taken it. Chemotherapy-induced immunosuppression increases the risk of infections, such as recrudescence of the Herpes Zoster Virus (HZV), which causes post-herpetic neuralgia and herpetic neuralgia in a small number of patients. In MM patients, this is the most common type of chronic localized neuropathic pain.
Advances in MM treatment options and supportive care have significantly increased in patients who persist in the illness. They, however, develop a particular “cancer fighter” disorder, which includes long-lasting pain, exhaustion, sleeplessness, despair, emotional and physical damage, intellectual dysfunction, cancer-related neuropathies, and a lower worth of life overall (Shapiro, 2018).
Myeloma Bone Disease. Bone metastases are usually connected with particular cancer kinds, containing MM, kidney, prostate, breast, and lung cancer. Skeletal consequences, also known as skeletal-related events (SREs), are expected after bone lesions and include neurotic rupture, the necessity for spinal cord compression, bone surgery or irradiation, and hypercalcemia. These consequences can reduce overall survival and austere chronic pain, loss of flexibility and communal role, and a substantial decrease in quality of life (Coleman et al., 2014).
Back localization is a presenting characteristic in nearly three-quarters of individuals with MM, and osteolytic bone lesions occur in 70 percent–80 percent of them. Myeloma bone disease (MBD) is linked to several clinical outcomes, containing bone pain (60–70%), ruptures (40–50%), hypercalcemia (20%), and spinal cord compression (1–2%) (Hameed et al., 2014). Decubitus ulcers, osteoporosis, pulmonary problems, and deep vein thrombosis are all risk factors related to MBD pain and impaired mobility.
Pathophysiology of Bone Pain
Finely myelinated tropomyosin receptor kinase A (TrkA) + sensory nerve fibers innervate the mature skeleton (A-delta). It does not get innervation from more giant A-beta fibers or TrkA unmyelinated C fibers simultaneously. Because bones are abysmal structures that do not need the skin’s sensitivity to light brushing and pressure, they do not get A-beta fiber innervation. Bone sensory fibers are most likely quiet nociceptors that only respond to injury or trauma (Mantyh, 2014). The sensory innervation of the periosteum is linked to acute and intense pain after a bone fracture. The density of A-delta and C-fibers is 900 times larger than that of cortical bone.
Sensory nerve fibers do not innervate normal articular cartilage, but the subchondral bone and the synovial membranes innervate and get a vascular supply. Sympathetic nerve fibers from the adrenergic and cholinergic systems also reach the bones. Sympathetic nerve sprouting has been demonstrated to occur in conjunction with the ectopic sprouting of primary afferent sensory fibers following bone fracture; thus, regulating sensitive nerve development may considerably reduce pain comportment in investigational models (Castañeda-Corral et al., 2017).
Bone damage, like other musculoskeletal diseases, causes marginal and central sensitization, which heightens pain sensitivity. Neuroplasticity in the dorsal horn of the spinal cord, for example, generates heightened pain sensations after non-painful incentives (allodynia) or increased pain sensitivity after even slight painful stimuli (hyperalgesia). The functional and structural changes in these central nervous systems have been linked to pain. (Morlion et al., 2018).
These findings point to using a fundamental painkiller to treat severe persistent bone pain and the use of adjuvants, for example, gabapentin and antidepressants, to treat MBD’s neuropathic component. Dysregulation of physical bone alteration, well-defined as the interplay of bone marrow, immune cells, osteoclasts, osteocytes, and osteoblasts, is a hallmark of MBD. MM cells modify the milieu of the bone marrow and cause apoptosis in osteocytes. Furthermore, development aspects generated by the resorptive process, such as osteopontin, promote MM cell proliferation while inhibiting cytotoxic T and NK cell action alongside MM cells.
Sclerostin, SFRP-2, and DKK are all inhibitors of osteoblastogenesis produced by osteocytes and MM cells. To regulate osteoclast differentiation, the Receptor Activator of Nuclear Factor-Kappa B (RANK) and its ligand (RANKL) pathway is essential. Beta-catenin pathways and the wingless-type (Wnt), on the other hand, are the primary regulators of osteoblast activity (Terpos, Ntanasis-Stathopoulos, & Dimopoulos, 2019). Improved osteoclast function and impaired osteoblast action result in decreased bone compactness and osteolysis due to this bone metabolic imbalance.
Medicines to Treat Myeloma Bone Disease (MBD)
MBD controlling is continuously analgesic, but it is necessary for improving patients’ quality of life. Antiresorptive medicines, which ambition to prevent new SREs, corticosteroids, radiation, analgesics, and surgical procedures, are used to lessen bone pain severity.
Antiresorptive Therapy. Antiresorptive medications should be used for two years in myeloma patients with bone damage, according to ESMO practice recommendations, and then the therapy should be restarted in relapsed individuals. Bisphosphonates and the lately accepted denosumab are two antiresorptive therapies.
Biphosphonates. In the treatment of MM, Bisphosphonates (BPs) are the basis of antiresorptive therapy. They work by preventing bone resorption by inducing apoptosis in osteoclasts, which quickly absorb BPs attached to the wide-open mineralized bone (Coluzzi et al., 2015). Because bone wounds frequently fail to heal even with an effective anti-myeloma cure and are worsened by coexisting osteoporosis, BPs are recommended in any patient with BMD.
For the treatment of MBD, Intravenous Zoledronic Acid (ZA), Oral Clodronate (CLO), Intravenous Pamidronate (PAM) and have been licensed. Overall, there is insufficient data to endorse one bone-modifying medication over alternative or determine the appropriate therapy period.
Acute Medical and Nursing Management to Provide After Spinal Fracture Surgery
The following is acute medical and nursing management that should be provided once the spinal fracture surgery decompression is complete. Spinal Cord Injury (SCI) is a catastrophic injury that considerably compromises a patient’s quality of life, social independence, and functional status. Because of advances in knowledge of damage causes, illness pathophysiology, and the importance of surgical procedures, the control of people with SCI has changed dramatically over the last time.
Specific controlling approaches for the treatment of SCI, such as the usage of corticosteroids like Methylprednisolone Sodium Succinate (MPSS), the work of Magnetic Resonance Imaging (MRI), the ideal scheduling of surgical intervention, the type and scheduling of anticoagulation prophylaxis, and the type and timing of rehabilitation, are still controversial. Because of this lack of agreement, standardization of care has been hampered among treatment institutions and among the numerous specialties that deal with SCI patients.
Surgical Decompression Timing Preclinical. The research proposes that continuous compression of the spinal cord following the significant hurt is a changeable form of secondary damage that, if treated quickly, can result in minor neural tissue injury and better outcomes (Park et al., 2017). Macrophage activation, Microglial stimulation, and apoptosis are all methods of cellular damage that occur after an injury, commonly known as the subacute phase.
Methylprednisolone Sodium Succinate (MPSS). MPSS is a corticosteroid with anti-inflammatory properties that has been used to treat a variety of disorders. MPSS can facilitate neuronal excitability, prevent the loss of spinal cord neurofilament proteins, impulse conduction, advance blood flow, improve Na+K+-ATPase activity, and preserve the cord structure by lessening lipid peroxidation and preventing ischemia, according to early preclinical studies (Fehlings et al., 2017).
Anticoagulation Prophylaxis: Types and When to Use Them Due to neurologic impairment, immobility, intimal damage, and hypercoagulability, patients with SCI have a higher risk of Deep Venous Thrombosis (DVT) (Mackiewicz-Milewska et al., 2016). Additionally, these individuals have substantial tissue impairment, are frequently treated surgically, and are in danger of hemorrhage or bleeding around neural structures. DVTs can go to the lungs and embolize, obstructing the pulmonary arteries and causing life-threatening physiologic alterations such as right-sided heart failure, cardiovascular compromise, and decreased gas exchange.
The Importance of Baseline Magnetic Resonance Imaging in Clinical Decision-Making and Prognosis. Imaging the spine is a crucial element of the first care of acute SCI; typical trauma protocols use computed tomography or plain X-rays to detect most fractures and ligamentous injuries (Ropper, Neal, & Theodore, 2015). On the other hand, these imaging methods cannot view the spinal cord or neighboring soft tissue to the same extent as MRI. In the case of acute SCI, MRI has the potential to detect continuing spinal cord compression, portray soft tissue structures that cause contraction, such as preexisting canal stenosis, disc herniation, intramedullary hematoma, and epidural hematoma, sense ligamentous instability at the level of injury or other spinal groups, and identify vertices.
The Type of Rehabilitation and when it should be done. Once a patient is stable, rehabilitation begins, intending to minimize additional problems and optimize function through compensatory approaches. The general goals of rehabilitation are to advance a patient’s freedom in daily activities such as cleaning, eating, wearing, training, and wheelchair use; second, to assist a patient in accepting a new way of life in terms of sensual and leisure activities, as well as accommodation decisions; and third, to help a patient’s restoration into society.
Conclusion
MM patients experience chronic, moderate-to-severe pain. The severity of pain is only one factor that influences the sort of analgesia required. Effective pain management requires identifying the pathophysiological mechanisms behind chronic pain and pain classification as primarily neuropathic, primarily nociceptive, or diverse pain syndromes. Nursing management is crucial because it encourages nurses to work together as a team, resulting in better patient care. Teamwork and effective communication are essential for providing high-quality patient care.
References
Castañeda-Corral, G., Jimenez-Andrade, J. M., Bloom, A. P., Taylor, R. N., Mantyh, W. G., Kaczmarska, M. J., … & Mantyh, P. W. (2017). The majority of myelinated and unmyelinated sensory nerve fibers that innervate bone express the tropomyosin receptor kinase A. Neuroscience, 178, 196-207.
Coleman, R., Body, J. J., Aapro, M., Hadji, P., Herrstedt, J., & ESMO Guidelines Working Group. (2014). Bone health in cancer patients: ESMO Clinical Practice Guidelines. Annals of oncology, 25, iii124-iii137.
Coluzzi, F., Pergolizzi, J., Raffa, R. B., & Mattia, C. (2015). The unsolved case of “bone-impairing analgesics”: the endocrine effects of opioids on bone metabolism. Therapeutics and Clinical Risk Management, 11, 515.
Fehlings, M. G., Tetreault, L. A., Wilson, J. R., Kwon, B. K., Burns, A. S., Martin, A. R., … & Harrop, J. S. (2017). A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope.
Hameed, A., Brady, J. J., Dowling, P., Clynes, M., & O’Gorman, P. (2014). Bone disease in multiple myeloma: pathophysiology and management. Cancer growth and metastasis, 7, CGM-S16817.
Kazandjian, D. (2016, December). Multiple myeloma epidemiology and survival: A unique malignancy. In Seminars in oncology (Vol. 43, No. 6, pp. 676-681). WB Saunders.
Mackiewicz-Milewska, M., Jung, S., Kroszczyński, A. C., Mackiewicz-Nartowicz, H., Serafin, Z., Cisowska-Adamiak, M., & Rość, D. (2016). Deep venous thrombosis in patients with chronic spinal cord injury. The journal of spinal cord medicine, 39(4), 400-404.
Mantyh, P. W. (2014). The neurobiology of skeletal pain. European journal of Neuroscience, 39(3), 508-519.
Morlion, B., Coluzzi, F., Aldington, D., Kocot-Kepska, M., Pergolizzi, J., Mangas, A. C., & Kalso, E. (2018). Pain chronification: what should a non-pain medicine specialist know? Current medical research and opinion, 34(7), 1169-1178.
Panaroni, C., Yee, A. J., & Raje, N. S. (2017). Myeloma and bone disease. Current osteoporosis reports, 15(5), 483-498.
Park, J. H., Kim, J. H., Roh, S. W., Rhim, S. C., & Jeon, S. R. (2017). Prognostic factor analysis after surgical decompression and stabilization for cervical spinal-cord injury. British journal of neurosurgery, 31(2), 194-198.
Ropper, A. E., Neal, M. T., & Theodore, N. (2015). Acute management of traumatic cervical spinal cord injury. Practical neurology, 15(4), 266-272.
Shapiro, C. L. (2018). Cancer survivorship. New England Journal of Medicine, 379(25), 2438-2450.
Terpos, E., Ntanasis-Stathopoulos, I., & Dimopoulos, M. A. (2019). Myeloma bone disease: from biology findings to treatment approaches. Blood, the Journal of the American Society of Hematology, 133(14), 1534-1539.
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