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Fortunately discount viagra professional 100 mg with mastercard erectile dysfunction cure video, these difficult problems may be treated safely and As the cornerstone of a building provides its stability order viagra professional discount erectile dysfunction raleigh nc, the quad- effectively. Todosorequiresathoroughknowledgeoftheanat- rangular cartilage and the osseous foundation upon which it omy and structural mechanics of the nose, careful analysis and rests provide structural support to the nasal framework. The localization of the deformity, excellent exposure and isolation of septum separates the two sides of the nose and stabilizes the the septal L-strut, and meticulous technique. If one tries to avoid the nerve, one may be unable to perpendicular plate of the ethmoid and the vomer. Theactiveearsur- plate and result in cerebrospinal fluid leakage and/or olfactory geon, who uses a systematic anatomic approach to find, isolate, nerve injury. At its cephalic border, the osseous septum and protect the nerve, is more likely to perform a safe and effec- attaches to the frontal bone and its posterior free edge forms tive operation. There is an active thought process involved, in the midline partition of the nasal choanae. Similarly, Anteriorly and caudally, the septum is cartilaginous, formally in nasal surgery, the surgeon must thoughtfully approach the sep- termed the “quadrangular cartilage. Dorsally, the paired, shieldlike upper lateral Ebers Papyrus describes initial attempts by Egyptians in cartilages are fused in the midline to the dorsal edge of the 114 Management of Naso-septal L-strut Deformities cartilaginous septum. The septum and the upper lateral carti- internal airway must be assessed to diagnose and localize the lages are fused early in embryonic development and form a sin- deformities needing correction. Caudally, the lower lateral carti- geon may formulate a surgical plan and select the appropriate lages have an intimate relationship with the caudal edge of the techniques. The intercrural ligament, also termed “the ligamentous In the normal nose, the orientation, size, and shape of the sling,” binds the medial aspect of the lateral crura, the intermedi- upper lateral cartilages and lower lateral cartilages form the ate crura, and the medial crura to each other. In certain cases of variant anatomy, however, the cartilagi- Incorporating the perichondrium into the flap will ensure nous septum does become externally conspicuous. In these sit- greater vascular supply to the flaps and will result in a biome- uations, the dorso-caudal L-strut is in a position or shape that chanically stronger flap less likely to result in septal perforation. The most common examples are This is supported by cadaver studies in which stress tests on the noses in which lateral deviation of the septum results in an out- constituent layers of human septal lining demonstrated that the wardly crooked or twisted nose. Other examples are the col- perichondrial layer imparted most of the mechanical strength. In general, the upper lat- The cartilaginous nasal septum serves two structural roles in eral cartilages and middle vault parallel the dorsal deviations of supporting the nose: a cantilever and a supporting beam. Like a the cartilaginous septum, the cartilaginous domes and nasal tip cantilever, the upper cartilaginous vault projects as a beam, follow deflections of the anterior septal angle, the medial crura supported cephalically through the thick fibrous attachment of and columella parallel the caudal septal margin, and the colum- the upper lateral cartilages and dorsocephalic septum to the ellar base (medial crural footplates) mirrors the posterior septal nasal bones and osseous septum. In the collapsed nose, the upper lateral and/or lower lat- support depends on the length and thickness of the nasal eral cartilages are pulled downward into an under-projected bones. Thus the adage “where the the osseous vault and the upper cartilaginous vault with the septum goes, so goes the nose” is applicable for the crooked or dorsal edge of the septum forms the basis of dorsal support for collapsed nose. Disruption of these connections greatly weakens the lateral cartilages form the external contour of the nose. However, by virtue of the intimate relationship of the septum The quadrangular cartilage also supports the dorsum and tip to the upper and lower lateral cartilages, the septal deformities of the nose from beneath much as a support wall holds up a roof. Because the quadrangular cartilage is inherently made to determine their etiology. The most common causes are rigid and sits firmly in an osseous foundation from the nasal spine trauma and previous surgery. In some cases, these types of along the maxillary crest and up the osseous septum to the nasal deformities may be congenital. In the case of saddle nose or col- bones, it provides significant stabilization to the nose. Active nasal buttressing caudal element forms the basis of the L-shaped granulomatous or rheumatic disease, continued cocaine abuse, strut—the most structurally important aspect of the quadran- and other progressive destructive processes of the nasal septum gular cartilage. Compromise to the caudal component may lead to nasal tip ptosis, particularly in the presence of weak 15. Traumatic or iatrogenic injury is most often the Analyses of these types of deformities must be meticulous and cause. On the frontal view, the symmetry and width of ginous septum in cadavers has been shown to result in a signifi- the nose should be assessed. The external nasal contour and the ness at the middle vault, and width again at the tip. Most importantly, tip support should be determined by palpation and noting the degree of resistance and recoil. Lack of support noted by ease of downward compression of the middle nasal vault may indicate complete loss of underlying septal support, which will dictate the method of reconstruction. Severe loss of nasal tip support may indicate total loss of caudal septal support. The three-quar- ters view aids in confirming the assessment made with the aforementioned views. Deviation of the caudal septum may cause canting of the tip, lobule, or columella. Severe caudal septal deformities can result in foreshortening of the nose and loss of the normal columellar/lobular angle. The entire caudal septum should be palpated to localize the deformity (anterior septal angle, midcaudal septum, or posterior septal angle). Dorsal or caudal deviation of the septum may correspond to distorted areas of the middle vault, tip, and nasal base. The internal angle between the septum and upper lateral cartilage is normally 15 degrees. In such cases, inspection may reveal dynamic collapse of the upper lateral car- tilages with inspiration. The non-L-strut sep- tum must be assessed to determine impact on the nasal airway, need for excision or rearrangement, and availability of cartilagi- Fig. Management of is clear that there is insufficient cartilage in the septum to pro- posttraumatic nasal deformities: the crooked nose and the saddle vide adequate grafting material, the surgeon may need to har- nose. In some techniques used to correct common nasal deformities related to cases, the direction of deviation varies at different levels of the the L-strut. On the lateral view, the projection of the radix, bony dorsum, cartilaginous dorsum, and nasal tip must be evaluated. However, considerable normal variation of the dorsal line exists depending on ethnic- In some crooked nose deformities, the attachment of the dorsal ity and familial traits of the individual. If a saddle nose deform- septum and upper lateral cartilages to the bony septum and ity is present, the areas of maximum deficiency should be local- nasal bones will allow the middle vault and tip to move into ized along the dorsal line. An attempt should be made to quan- favorable position with bony vault repositioning. In some of these position should be assessed by determining the projection as cases, medial and lateral osteotomies will reposition the oss- compared with the length of the nose. The nasolabial angle is a eous vault and allow the tilted septum to return to the midline, helpful metric to assess nasal tip rotation, though is not reliable bringing the middle vault and nasal tip with it. If the lower two Analysis of these types of deformities must be meticulous and thirds of the nose do not straighten with bony vault correction, methodical.

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Over the past 2 days buy 50mg viagra professional amex erectile dysfunction and premature ejaculation underlying causes and available treatments, he has also developed a productive cough with greenish sp utum purchase viagra professional on line amex erectile dysfunction shakes menu, which occasionally is b lood streaked. He rep orts no dyspnea,but sometimes he experiences chest pain with deep inspiration. He does not have headache, abdominal pain, urinary symptoms, vomiting, or diarrhea. He smokes cigarettes and marijuana regularly, drinks several beers daily, but denies intravenous drug use. He h a s n o o ra l le s io n s, a n d fu n d u s c o p ic e xa m in a t io n re ve a ls n o a b n o rm a lit ie s. His ju g u la r ve in s sh o w p ro m in e n t V wa ve s, a n d h is h e a r t rh yt h m is t a ch yca rd ic but regular with a harsh holosystolic murmur at the left lower sternal border that becomes louder with inspiration. On both of his forearms, he has linear streaks of induration, hyper- pigmentation, and some small nodules overlying the superficial veins, but no erythema, warmth, or tenderness. Ch e st rad iograp h shows multip le p erip heral, ill-d efined nod ules, some with cavitation. H e has linear st reaks of indurat ion on both forearms, and chest radiograph shows multiple ill-defined nodules. Most likely diagnosis: Infective endocarditis involving the tricuspid valve, with probable septic pulmonary emboli. Next step: Obtain serial blood cultures and institute empiric broad-spectrum ant ibiot ics. Understand the differences in clinical presentation between acute and subacut e, and left -sided versus right -sided endocardit is. Learn the most common organisms that cause endocarditis, including“culture- negative” endocarditis. Know the diagnostic and therapeutic approach to infective endocarditis, including the indicat ions for valve replacement. H e h as fever, a n ew h ear t m u r m u r ve r y typical of tricuspid regurgitation, and a chest radiograph suggestive of multiple septic pulmonary emboli. Serial blood cultures, ideally obt ained before antibiotics are st arted, are essent ial to est ablish the diagnosis of infect ive endocardit is. The rapidity with which antibiotics are started depends on the clinical presentation of the patient: a septic, critically ill patient needs antibiotics immediately; a patient wit h a subacute present at ion can wait many hours while cultures are obt ained. H ighly virulent species, such as Staphylococcusaureus, produ ce acut e in fect ion, an d less vir u lent or gan isms, su ch as the vir id an s gr ou p of st r ep t o co cci, t en d t o p r o d u ce a m or e su b acu t e illn ess, wh ich m ay evolve over weeks. For acute endocarditis, pat ient s often present wit h high fever, acut e valvular regurgit at ion, and embolic phenomena (eg, to the extremities or to the brain, causing stroke). Subacute endocarditis is m o r e often associated with constitutional symptoms such as anorexia, weight loss, night sweat s, and findings att ribut able t o immune complex deposit ion and vasculit is; these include petechiae, splenomegaly, glomerulonephritis, Osler nodes, Ja n e w a y lesions, and Roth spots. These classic peripheral lesions, although frequently discussed, are actually seen in only 20% to 25% of cases. Splinter hemorrhages under the nails may also be seen, but this finding is very nonspecific. Right-sided endocarditis usually involves the tricuspid valve, causing pulmo- nary emboli, rather than involving the systemic circulation. Accordingly, patients develop pleuritic chest pain, purulent sputum, or hemoptysis, and radiographs may show mult iple peripheral nodular lesions, oft en wit h cavit at ion. The murmur of tricuspid regurgitation may not be present, especially early in the illness. In all cases of endocarditis, the critical finding is bacteremia, which usually is sustained. T h e in it iat in g event is a t ran sient bact eremia, wh ich may be a r esu lt of mucosal injury, as in dental extraction, or a complication of the use of intravascular cat h et er s. P r eviou sly damaged, abnormal, or prost het ic valves form veget at ions, wh ich are composed of plat elet s and fibrin, and are relat ively avascular sites where bacteria may grow protected from im mu n e at t ack. Serial blood cultures are the most important step in the diagnosis of endocarditis. Acutely ill patients should have three blood cultures obtained over a 2- to 3-hour period prior to initiating antibiotics. In subacute disease, three blood cultures over a 2 4 -hour period maximize t he diagnost ic yield. O f course, if pat ient s are crit ically ill or hemodynamically unst able, no delay in init iat ing t h erapy is appropriate, and cu lt ures are obt ain ed on present at ion, even wh ile broad-spect r um ant ibiot ics are administered. Usually it is not difficult to isolat e t he infect ing organism, because the hallmark of infective endocarditis is sustained bacteremia; thus, all blood cul- tures often are positive for the microorganism. Table 12– 1 lists typical organisms, fr equ en cy of in fect ion, an d associat ed con d it ion s. The clinical features, blood cultures, and echocardiography are used to diagnose cases of infective endocarditis using the highly sensitive and specific Duke criteria. Endocarditis is considered to definitely be present if the patient satisfies two major criteria; one major and three minor criteria; or five minor criteria (Table 12– 2). O t h er car diac complicat ion s are int racar diac abscesses an d con du ct ion dist ur ban ces caused by septal involvement by infection. Systemic arterial embolization may lead to splenic or renal infarct ion or abscesses. Veget at ions may embolize t o t he coronary circulat ion, cau sin g a myocardial in far ct ion, or t o the br ain, cau sing a cerebr al infarct ion. A stroke syndrome in a febrile patient should always suggest the pos- sibilit y of endocarditis. In fect ion of the vasa vasor um may weaken the wall of major arteries and produce mycotic aneurysms, which can occur anywhere but are most common in the cerebral circulation, sinuses of Valsalva, or abdominal aort a. T hese aneurysms may leak or rupture, producing sudden fat al int racranial or ot her hemorrhage. Ant ibiot ic t reat ment is usually begun in the hospit al but because of the pro- longed nat ure of t h erapy is oft en complet ed on an out pat ient basis wh en the patient is clinically stable. If the or gan ism is susceptible, such as most St r eptococcus species, penicillin G is the agent of choice. For Staphylococcus aureus, nafcillin is t he drug of choice, oft en used in combinat ion with gentamicin init ially for synergy, t o help resolve bact eremia. T herapy for int ra- ven o u s d r u g u ser s sh o u ld b e d ir ect ed again st S aureus. Vancomycin is used when methicillin-resistant S aur eus or coagulase-negative staphylococci are present. Deciding appropri- ate therapy for culture-negative endocarditis may be challenging and depends on the clinical situation.

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The nasal bones are poorly devel- lage generic 100 mg viagra professional with mastercard erectile dysfunction doctors in massachusetts, conchal cartilage effective 50mg viagra professional erectile dysfunction medication causes, costal cartilage, and fascia. The septal cartilage is to harvest and shape the septal cartilage, it can be used to mod- thin and small. Altogether, when compared with Caucasian erately elevate the nasal dorsum, to camouflage a partial con- noses, the typical Asian nose appears to be relatively small and cavity on the dorsum, and for nasal tip surgery. In an aesthetic analysis of the patients have relatively small noses, it is practically difficult to nasal profile, the nasolabial angles of Asians are typically more harvest enough amount of septal cartilage, leaving at least 1-cm acute than those of Caucasians, but the nasofrontal angles do 1 width of the L-strut, suitable for a full-length dorsal graft. Unlike septal cartilage, conchal cartilage has an intrinsic curva- ture that hampers its routine use in a dorsal augmentation in its original shape. In addition, the conchal cartilage Dorsal augmentation is the most commonly addressed issue in is frequently too small to yield a cartilage piece suitable for one- Asian rhinoplasty and also the most common reason for revi- piece dorsal augmentation. When performing augmentation rhinoplasty on tion of the septal cartilages and to overcome the limitation in Asians, it is preferable or mandatory to first perform tip surgery size, the author (Y. The thickness of the patient’s Also, when using conchal cartilage, it may be necessary to over- skin must be taken into consideration. If excessive dorsal aug- lap pieces of cartilage in opposite directions of their curvature mentation is performed on a patient whose skin is too thin, to neutralize their intrinsic curvature. Although costal cartilage there is a risk of implant visibility through the skin or an extru- is difficult to harvest and is associated with more serious sion of the implant. Conversely, too thick skin can decrease the donor-site morbidity such as pneumothorax, as well as the effect of nasal augmentation. Therefore, with patients who have problem of warping, it is the most useful autologous cartilage thin skin, it is preferable to use soft implants such as Gore-Tex for substantial augmentation or for patients who have experi- (W. In patients Although strongly advocated by some surgeons for routine use with thick skin, a relatively solid material such as silicone, rein- in Asian rhinoplasty,5 during the primary rhinoplasty, it is very forced Gore-Tex, or costal cartilage can be used without signifi- difficult to persuade Asian women to use costal cartilage cant problems. One other critically important limitation of autologous tissue is that except for only a few highly experienced surgeons, most rhino- 70. Materials used in rhinoplasty can be divided largely Warping, graft visibility, and unnatural-looking noses are com- between biologic tissues (autologous and homologous tissue) mon complications of augmentation using costal cartilage. Alloplastic implants generally need to more difficult cases, and use of these implants is associated be biocompatible, nontoxic, chemically safe, and nonimmuno- with unpredictable scarring, warping, and at times visible graft genic. At present, Autologous fascia, including temporalis fascia, can be used in the most commonly used alloplastic implants that meet these rhinoplasty as radix graft or dorsal onlay grafts. Furthermore, it shown conflicting results regarding the degree of resorption is not always possible to harvest sufficient fascia of reasonable and warping. The high complica- tion rate associated with homologous cartilage may limit its Homologous Tissue or Tissue Allograft 10 utility for dorsal augmentation. For example, homologous costal used for smoothening grafts for dorsal irregularity after correc- cartilage harvested from cadaveric donors and processed in var- tion of a deviated nose, as additional graft material when an ious ways has been shown to be useful in rhinoplasty. Due to its stable chemical structure, silicone has several advantages, including its low degree of tissue reaction and ease of handling. More- over, the availability of ready-made products makes application convenient, and the relative hardness of silicone makes it suit- able for fashioning the desired nasal shape for Asians with a thick skin. Some surgeons favor an L-shaped or a variation of I-shaped silicone (covering the nasal tip) capable of coverage from the radix all the way down to the nasal tip. However, because the nasal tip is an area that is always exposed to exterior stimulation, use of L-shaped silicone carries a higher risk of extrusion regardless of the thickness of nasal subcutaneous tissue in Asians. Thus, placement of an I-shaped implant at the nasal dorsum area and tip plasty using an autologous material (septal cartilage, conchal cartilage) at the nasal tip area is the more preferred surgical method. In addition to using prefabricated silicone implants, the author has used silicone sheeting for nasal dorsal augmentation, which is more versatile and carries no increased risk of complica- tions. Revision rhinoplasty after silicone implants may be needed for implant deviation, floating, displacement, extrusion, impending extrusion, and infection. Gore-Tex implants are porous, inducing the surrounding tissue to grow inward through the pore, and have the advan- tages of increased stability and lower risk of capsule formation. The soft texture of Gore-Tex reduces patient dis- and extrusion, an unpredictable degree of resorption could be a comfort and the occurrence of unnatural visible implant problem. Reports of delayed inflammation are increas- The typical endonasal approach for Caucasian noses involves ing, thus one must be cautious when using Gore-Tex in the cephalic resection through a delivery or nondelivery approach presence of inflammation within the nasal cavity (sinusitis, ves- and placement of transdomal and interdomal sutures and col- tibulitis, and active acne). This approach can also be used for the placement tions that may create microcommunication with the nasal cav- of shield or onlay graft. It has been reported that infection gery requiring only a cephalic resection is very rare in Asian rate in primary surgery is 1. Among the multitude of cartilage strong enough to push up thick skin after the skin is tip surgery techniques, the following have an important role covered up again. Therefore, even when a leading edge higher and should be emphasized for the Asian tip. The new tip graft complex should be able to project the tip to an antero-caudal direction. This method is usually effective in lengthening various nasal deformities, including overprojection or under- the infratip lobular segment and thereby enhancing the tip pro- projection, suboptimal rotation, disproportionate lobule ratios, jection. If the length of the graft is long, in addition to the and broad or asymmetric tips. Asian nasal tips require more increase in the tip projection, one can expect an increase in the structures to project into the thicker skin to gain the desired overall length of the columellar. Should the length of the graft refinement because Asians have thick skin in comparison with be short and placed on the infratip lobule portion, there is a that of Caucasians. However, while performing this procedure on were designed to borrow a large amount of cartilage from the patients, there is a risk of overrotation of the tip due to a blunt- caudal margin, so that the lateral view of the medialized carti- ing of the columellar lobular angle or for the infratip lobule to lage had a triangular projection shape in an antero-caudal Fig. This technique makes it easier to place strengthen the support and then an onlay graft positioned. Although the underprojection of the tip among Asians fre- quently results from an inadequately developed lower lateral 70. If Onlay tip grafting is a procedure that places one or several an adequate quantity of septal cartilage can be obtained after layers of graft horizontally at the dome of the tip. It can be per- preserving its L-strut, this cartilage can be used as a septal formed on a patient with proper tip support to increase the tip extension graft to project the anterior septal angle of the septal projection or to camouflage a tip irregularity. One of the advantages of this technique tip projection may be improved to some extent when viewed is that besides the projection/rotation of the tip, it can be useful from the lateral side, the infratip lobule area can become exces- in correcting short nose deformity, which can be commonly sively long when viewed from the basal side, causing an found among Asians. Therefore, it is desirable that the colum- a retracted columella, a caudal extension of the graft can be ellar strut be first applied to project the middle crus further and particularly effective in improving the columellar retraction, as Fig. Incisions were made on both domes, borrowing a large amount of cartilage from the caudal margin. A shield-shaped tip graft was placed just in front of the newly created cartilage-strut complex. The leading edge of the graft was adjusted according to the desired height of the new tip. Irradiated homologous carti- septal extension graft surgery, it is preferable to position the lage grafts. Reconstruction with irradiated homograft costal carti- reduced risk of causing nostril asymmetry, as well as the stron- lage. Plast Reconstr Surg 2003; 111: 2405–2411, discussion 2412–2413 ger nature of the grafting.

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The probe extends electrodes that emit high-frequency electrical current discount 50mg viagra professional otc erectile dysfunction caused by medications, producing heat to destroy cancer cells; hence the technique is best suited for localized tumors discount viagra professional 100 mg mastercard erectile dysfunction emotional. With radiation therapy, as with chemotherapy, damage to normal tissue is dose limiting. Therefore the challenge is to deliver a dose of radiation that is large enough to kill cancer cells, but not so large that it causes intolerable damage to healthy tissue. Fortunately, in the regimens employed for palliation, these acute effects are generally mild. The most common late reaction is fibrosis, which occurs mainly in tissues that have a limited ability to regenerate (e. Late reactions are of limited concern, however, because most patients die of their cancer before late reactions can develop. Pain Management in Special Populations Older Adults In older-adult patients, two issues are of special concern: (1) undertreatment of pain and (2) increased risk for adverse effects. Paradoxically, a third issue— heightened drug sensitivity—contributes to both problems. Heightened Drug Sensitivity Older adults are more sensitive to drugs than are younger adults, owing largely to a decline in organ function. As a result, drugs tend to accumulate in the body, causing responses to be more intense and prolonged. In addition to the usual reasons (fears about tolerance, addiction, adverse effects, and regulatory actions), older adults are denied adequate medication for two more reasons: difficulties with assessment and erroneous ideas about “old age. Because of these obstacles, special effort must be made to help ensure that assessment is accurate. However, because accuracy cannot be guaranteed, frequent reassessment is recommended. Specifically, providers may believe (incorrectly) that dosage should be low because (1) older adults are relatively insensitive to pain; (2) if pain occurs, older adults can tolerate it well; and (3) older adults are highly sensitive to opioid side effects. The first two concepts have no basis in fact, and therefore must not be allowed to influence treatment. Although there is some truth to the third concept, concern about side effects is no excuse for inadequate dosing. Increased Risk for Side Effects and Adverse Interactions For several reasons, older-adult patients may experience more side effects than younger adults. As noted, drug elimination in older adults is impaired, posing a risk that drug levels may rise dangerously high. However, with careful dosing, drug levels can be kept within a range that is both safe and effective. Gastric erosion can be reduced by concurrent therapy with misoprostol or a proton pump inhibitor (e. The risk for serious injury from drug interactions can be reduced by careful drug selection and by monitoring for potential reactions. Young Children Management of cancer pain in children is much like management in adults. In addition, children frequently experience more pain from chemotherapy and other interventions than from the cancer itself. Selecting an appropriate assessment method is especially important for children with developmental delays, learning disabilities, and emotional disturbances. Assessment can be greatly facilitated by open communication about pain between the child, family, and health care team. Assessment methods include self-reporting, behavioral observation, and measurement of physiologic parameters (e. As stressed earlier, self-reporting is preferred and should be employed whenever appropriate. Because many factors other than pain can alter physiologic parameters, measuring these is the least reliable way to assess pain. Verbal Children For children who can verbalize and are older than 4 years, self-reporting is the most reliable way to assess pain. These include (1) fear that revealing their pain will lead to additional injections and other painful procedures, (2) lack of awareness that we can help their pain go away, (3) a desire to protect their parents from the knowledge that their cancer is getting worse, and (4) a desire to please. Because the self-report may conceal pain, it can be helpful to supplement the self-report with behavioral observation (see later). Preverbal and Nonverbal Children Because preverbal and nonverbal children cannot self-report pain, a less reliable method must be used for assessment. Behavioral cues suggesting pain include vocalization (crying, whining, groaning), facial expression (grimacing, frowning, reduced affect), muscle tension, inability to be consoled, protection of body areas, and reduced activity. The biggest drawback to behavioral observation is the risk for a false- negative conclusion. That is, a child may be in pain although his or her behavior may lead the observer to conclude otherwise. Similarly, although sitting quietly might indicate comfort, it could also mean that moving and talking are painful. When behavioral observation leaves doubt about whether the child is in pain, a trial with an analgesic can help confirm the assessment. Treatment Therapy of cancer pain in children is essentially the same as in adults. As in adults, drugs are the cornerstone of treatment; nondrug therapies are used only as supplements. More invasive routes should be reserved for patients who cannot take drugs by mouth. Children generally object to rectal administration and may refuse treatment by this route. Neonates and infants are highly sensitive to drugs and hence must be treated with special caution. Because of heightened drug sensitivity, neonates and infants are at increased risk for respiratory depression from opioids. Accordingly, when opioids are given to nonventilated infants, the initial dosage should be very low (about one third the dosage employed for older children). Furthermore, use of opioids should be accompanied by intensive monitoring of respiration. Opioid Abusers When treating cancer pain in opioid abusers, we have two primary obligations: we must try to (1) relieve the pain and (2) avoid giving opioids simply because the patient wants to get high. Because of the challenge, treatment should be directed by a clinician trained in substance abuse as well as pain management. Remember, abusers feel pain like everyone else and therefore need opioids like everyone else.