“It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.”

Julius Caesar

In most instances, painful sensations arise from tissue injury in the body. Sensitive nerve endings pick up pain signals and carry these messages along nerves to the spinal cord and then onto the brain. All along these complex pathways, there are biological “gates” that can be either opened or closed. When these gates are closed, pain is reduced or eliminated. When open, pain messages continue through the circuit. It is when these gates are jammed open that chronic pain cycles begin.

As you recall, acute pain is short lived and serves as a warning signal. When you fix whatever is wrong, the pain usually goes away. In the case of chronic pain, pain does not necessarily signal that the body is undergoing more damage. Most chronic pain is caused by a malfunction of the nervous system, either in nerves or the brain. The malfunction or opening of the pain gates causes and endless barrage of pain signals to cycle. Chronic pain then becomes a disease itself, taking on a life of its own.

How can we close the gates of pain?
The gates are affected by several factors, most importantly by the pattern of nerve impulses which reach the spinal cord from the rest of the body, and nerve impulses coming from the brain. Sometimes the nerve impulses traveling through the spinal gates can be affected by other forms of physical stimulation. Giving your nervous system a competing source of input can fool the nervous system and alter your perception of pain.

There are many ways to accomplish this. You may have noticed that rubbing or massaging a painful area may have relieved your pain in the past. Applying electrical stimulation (e.g. TENS), applying heat or cold, acupuncture, or nerve blocks may also provide a competing source of input. It is also important to realize that certain mental activities or thoughts taking place in the brain can help to close the spinal gates.

Another way we can work to close the gates of pain is to affect the release of several chemicals that help pain signals travel to the brain. Neurotransmitters are biochemical messengers that carry pain signals from one nerve cell to the next. The three main neurotransmitters that send pain signals to the brain are substance P, NMDA (n-methyl-d-aspartate), and glutamate. Excess amounts of these chemicals, especially substance P, make it easier for pain signals to reach the brain.

Therefore, another way of stopping pain involves manipulating pain provoking neurotransmitters. This can be accomplished by prescription or over the counter medications, acupuncture, injections, hypnosis, or biofeedback.

The role of the Endorphins
The endorphins are another class of chemicals which are produced in the brain and serve an important role in the pain experience. These chemical are naturally occurring pain relieving substances, similar to morphine or other opiates, produced in the body. Endorphins work on special receptor sites in the brain. They act as keys which unlock receptors thus generating nerve impulses to shut down pain. Morphine and other opiates have similar chemical structures which turn off pain.

Several situations or conditions raise endorphin levels in the brain thus reducing pain. They include thinking with a positive attitude, happiness, and regular exercise.

The Role of Stress
It is natural to connect a physical stress to the body, such a broken arm, to the perception of pain. The role of psychological stress may not seem as obvious. The brain structures involved in stress can affect the production of key hormones in the body, suppress the body’s immune system, and activate the autonomic nervous. These are the same biological changes that may occur from physical stresses on the body-the body may not differentiate between physical and psychological stress. The net effects of these changes on the body are to lower our internal resistance to pain, thus further encouraging the chronic pain cycle.

Many sources of stress feed into the chronic pain cycle. First off, as you would expect, pain itself is stressful. Pain sensations are perceived as undesirable and are at very least annoying. Pain creates tension, both physical and emotional. Physical tension may show itself as muscle tension or affect the cardiovascular, gastrointestinal, or immune systems. Emotional tension may reveal itself as anger, frustration, worry, depression, or frustration. Both physical and emotional tension, initially set in motion by pain, worsen pain. Thus the vicious cycle of pain is begins-pain leads to tension and tension leads to more pain.

A second source of stress comes from all the negative consequences that occur as a result of a chronic pain condition. Chronic pain may create difficulties with family relationships, social or recreation activities, self-esteem, and employment.

Yet another source of stress arises from the hardships that can be encountered from the stresses of everyday living. Everything from difficulties putting on your shoes in the morning to difficulties standing long enough to go grocery shopping are added on top of pain-related stressors. In the end, an individual not only suffers from chronic pain, but from chronic stress.

The consequences of chronic stress
Whatever the type of stress, either physical or psychological, the outcome on pain is to worsen it. Chronic stress also may result in other physical ailments such as tension headaches, muscle spasms, gastrointestinal problems, and elevated blood pressure. It can also lead to fatigue, depression, and a sense of hopelessness.

Chronic pain can’t always be prevented. But staying in good physical and mental health may be the best way to prevent it or help you cope with it.

• Treat your health problems early.

• Get enough sleep every night. Learn to alternate activity with rest throughout each day.

• Exercise.

• Eat a balanced diet.

• Try to reduce stress in your life.

‘This is potentially a very important discovery which may go a long way to explain the marked differences in pain sensitivity and chronicity between women and men.”

says James McRoberts, a pain researcher at the University of California-Los Angeles

“When a loved one dies, you might be faced with grief over your loss again and again — sometimes even years later. Feelings of grief might return on the anniversary of your loved one’s death, birthday or other special days throughout the year. This is called anniversary reaction, its not a set back. You’re reflecting memories and that this loved one was important to you. To continue on the path toward healing, know what to expect — and how to cope with reminders of your loss.”

MAYO CLINIC

Losing someone or something you love or care deeply about is very painful. You may experience all kinds of difficult emotions and it may feel like the pain and sadness you’re experiencing will never let up. These are normal reactions to a significant loss. But while there is no right or wrong way to grieve, there are healthy ways to cope with the pain that, in time, can renew you and permit you to move on.

For me personally I lost an old friend this year and last year; and anyone out their who has had a loss recently I can relate with providing my deepest condolences to you but know you can move on.  Like I told so many last year when my friend Karen died  that she is in the next world including a friend Ken this year.  Both are in a better world and both are so much happier out of misery but it is us on earth in misery but it will heal in time like a wound.  The other thing to know is that both have never left us.  They are both with old and new loved ones that they saw all the time and some rarely.  They will never leave us helping us get through this rough time just like my father was there in 1999 when he died of cancer but never left me.  I know my friends are so much happier, no longer ill and Karen is with her sister who she missed terribly with others she hasn’t seen for a long time.  I know she is happier and no longer ill keeping a close eye on all loved ones she had in her life.  As long as she is better off I know that is for the better which overrides my misery.  Being a RN over 25 years seeing so many types of patients including being a oncology nurse loss of a loved one might be easier for me in dealing with than some but trust me I still have feelings like everyone else in this world.  Karen what kills me the most is we reconnected this the year she died and planned to hangout more but God has his reasons for her to leave this world and we couldn’t do more time with each other in this world.   I am very thankful I got to see her again last year and was there for her in getting through her few days left. 

Grief is a natural response to loss. It’s the emotional suffering you feel when something or someone you love is taken away. The more significant the loss, the more intense the grief will be. You may associate grief with the death of a loved one—which is often the cause of the most intense type of grief—but any loss can cause grief, including: Divorce, loss of health, loss of a job, loss of financial stability, retirement, loss of a friendship, loss of a cherished dream (ex. spouses in their own business, planning to get married that never happens, loss of a mortgage on a new home, a loss of a baby, etc…).

The more significant the loss, the more intense the grief. However, even subtle losses can lead to grief. For example, you might experience grief after moving away from home, graduating from college, changing jobs, selling your family home, or retiring from a career you loved.

Grieving is a personal and highly individual experience. How you grieve depends on many factors, including your personality and coping style, your life experience, your faith, and the nature of the loss. The grieving process takes time. Healing happens gradually; it can’t be forced or hurried—and there is no “normal” timetable for grieving.  Some people start to feel better in weeks or months. For others, the grieving process is measured in years. Whatever your grief experience, it’s important to be patient with yourself and allow the process to naturally unfold.

Dr Elisabeth Kübler-Ross pioneered methods in the support and counselling of personal trauma, grief and grieving, associated with death and dying. She also dramatically improved the understanding and practices in relation to bereavement and hospice care. This is quite aside from the validity of her theoretical work itself, on which point see the note, right.

Her ideas, notably the five stages of grief model, the model was first introduced by American Psychiatrist Elisabeth Kübler-Ross in her 1969 book, On Death and Dying, and was inspired by her work with terminally ill patients but simply a significant loss can experience these steps as well.  They are: 1.) Denial 2.) Anger 3.) Bargaining 4.) Depression 5.) Acceptance .  You go through all these steps in a loss and repeat them and not in order for all.   Contrary to popular belief, you do not have to go through each stage in order to heal.   In fact, some people resolve their grief without going through any of these stages. And if you do go through these stages of grief, you probably won’t experience them in a neat, sequential order, so don’t worry about what you “should” be feeling or which stage you’re supposed to be in.Kübler-Ross herself never intended for these stages to be a rigid framework that applies to everyone who mourns. In her last book before her death in 2004, she said of the five stages of grief: “They were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss, as there is no typical loss. Our grieving is as individual as our lives.”

While loss affects people in different ways, many experience the following symptoms when they’re grieving. Just remember that almost anything that you experience in the early stages of grief is normal—including feeling like you’re going crazy, feeling like you’re in a bad dream, or questioning your religious beliefs.

Symptoms of Grief:  Shock and disbelief – Right after a loss, it can be hard to accept what happened.  Sadness – Profound sadness is probably the most universally experienced.  Guilt – You may regret or feel guilty about things you did or didn’t say or do. Anger – Even if the loss was nobody’s fault, you may feel angry and resentful. If you lost a loved one, you may be angry with yourself, God, the doctors, or even the person who died for abandoning you.  You may feel injustice has been done to you.  Fear – A significant loss can trigger a host of worries and fears. You may feel anxious, helpless, or insecure. You may even have panic attacks.  You may feel fears of how do  I live without this person.  Physical Symptoms – We often think of grief as a strictly emotional process, but grief often involves physical problems, including fatigue, nausea, lowered immunity, weight loss or weight gain, aches and pains, and insomnia.

Coping with grief and loss is one get support.                                                        

The single most important factor in healing from loss is having the support of other people. do not grieve alone. Connecting to others will help you heal.

Finding support after a loss

• Turn to friends and family members

• Draw comfort from your faith

• Join a support group – To find a bereavement support group in your area.

• Talk to a therapist or grief counselor – If your grief feels like too much to bear, call a mental health professional with experience in grief counseling.Face your feelings, express your feelings in a  tangible and creative way (I am writing about it in my blog for example).  Take care of your health (especially not on alcohol or drugs to numb the pain for it will be only temporary and unhealthy).  Don’t have people inform you how to feel and when you will be better.  Don’t tell yourself how you should feel.  This is YOUR grief no one elses and when its time to move on or that you have gotten over the grief you will know.  It is ok to be angry, ask why God did you do this to me, not understand why this took place,  laugh at moments of good time memories

• When you’re grieving, it’s more important than ever to take care of yourself. If you don’t care for yourself you can’t take care of others.  The stress of a major loss can quickly deplete your energy and emotional reserves.

• Don’t let anyone tell you how to feel, and don’t tell yourself how to feel either. Your grief is your own, and no one else can tell you when it’s time to “move on” or “get over it.” Let yourself feel whatever you feel without embarrassment or judge- ment.   It’s okay to be angry, to yell at the heavens, to cry or not to cry. It’s also okay to laugh, to find moments of joy, and to let go when you’re ready.  As time passes, these emotions should become less intense as you accept the loss and start to move forward.The sadness of losing someone you love never goes away completely, but it shouldn’t remain center stage. If the pain of the loss is so constant and severe that it keeps you from resuming your life, you may be suffering from a condition known as complicated grief .  Unable to get rid of the intense grieving loss feelings and move on with your life.  Still in intense mourning and unable to accept the death or loss you have had after a long period of time.  A loss can effect you weeks to months to a year and if you move on at that point it is therapeutically dealing with it.  Your feeling can still be present till you die but in less intensity since the occurrence of the loss.Contact a grief counselor or professional therapist if you:

• Distinguishing between grief and clinical depression isn’t always easy as they share many symptoms, but there are ways to tell the difference. Remember, grief can be a roller coaster. It involves a wide variety of emotions and a mix of good and bad days. Even when you’re in the middle of the grieving process, you will have moments of pleasure or happiness. With depression, on the other hand, the feelings of emptiness and despair are constant.
• Complicated grief

• Feel like life isn’t worth living

• Wish you had died with your loved one

• Blame yourself for the loss or for failing to prevent it

• Feel numb and disconnected from others for more than a few weeks

• Are having difficulty trusting others since your loss

• Are unable to perform your normal daily activities!

• This article was done in memory of John Spear, Ken Crumley and Karen Guttridge-Foster-Saher – an old dear girlfriend who I will never forget and have never lost.

1. Block SD. Grief and bereavement. http://www.uptodate.com /index. Accessed Aug. 31, 2012.
2. Dealing with the effects of trauma — A self-help guide. Substance Abuse and Mental Health Services. http://store.samhsa.gov/shin/content//SMA-3717/SMA-3717.pdf. Accessed Aug. 31, 2012.
3. Holtslander L, et al. An inner struggle for hope: Insights from the diaries of bereaved family caregivers. International Journal of Palliative Nursing. 2008;14:478.
4. Vale-Taylor P. “We will remember them”: A mixed-method study to explore which post-funeral remembrance activities are most significant and important to bereaved people living with loss, and why those particular activities are chosen. Palliative Medicine. 2009;23:537.
5. Benkel I, et al. Managing grief and relationship roles influence which forms of social support the bereaved needs. American Journal of Hospice and Palliative Medicine. 2009;26:241.
6. Reminders of trauma: Anniversaries. United States Department of Veterans Affairs. http://www.ptsd.va.gov/public/pages/anniversary-reactions.asp. Accessed Aug. 31, 2012.

Article is all from the Mayo clinic Nov 2012

“Sepsis is the systemic response to infection and is defined as the presence of SIRS (systemic inflammatory response syndrome) in addition to a documented or presumed infection.”

Lewis J Kaplan, MD-author SIRS  Medscape.com

Part 3 talks to you about the multi-hit theory of SIRS with Inflammatory Cascade of SIRS and lastly the coagulation process in SIRS.   It also tells you an extensive amount of infectious and non-infectious causes of SIRS. Lastly the key antidote to SIRS.

Multi-hit theory

A multi hit theory behind the progression of SIRS to organ dysfunction and possibly multiple organ dysfunction syndrome (MODS). In this theory, the event that initiates the SIRS cascade primes the pump. With each additional event, an altered or exaggerated response occurs, leading to progressive illness. The key to preventing the multiple hits is adequate identification of the ETIOLOGY or CAUSE of SIRS and appropriate resuscitation and therapy.

Inflammatory cascade

Trauma, inflammation, or infection leads to the activation of the inflammatory cascade. Initially, a pro-inflammatory activation occurs, but almost immediately thereafter a reactive suppressing anti-inflammatory response occurs. This SIRS usually manifests itself as increased systemic expression of both pro-inflammatory and anti-inflammatory species. When SIRS is mediated by an infectious insult, the inflammatory cascade is often initiated by endotoxin or exotoxin. Tissue macrophages, monocytes, mast cells, platelets, and endothelial cells are able to produce a multitude of cytokines. The cytokines tissue necrosis factor–alpha (TNF-α) and interleukin-1 (IL-1) are released first and initiate several cascades.

The release of certain factors without getting into medical specific terms they ending line induces the production of other pro-inflammatory cytokines, worsening the condition.

Some of these factors are the primary pro-inflammatory mediators. In research it suggests that glucocorticoids may function by inhibit-ing certain factors that have been shown to be released in large quantities within 1 hour of an insult and have both local and systemic effects. In studies they have shown that certain cytokines given individually produce no significant hemodynamic response but that they cause severe lung injury and hypotension. Others responsible for fever and the release of stress hormones (norepinephrine, vasopressin, activation of the renin-angiotensin-aldosterone system).

Other cytokines, stimulate the release of acute-phase reactants such as C-reactive protein (CRP) and pro-calcitonin.

The pro-inflammatory interleukins either function directly on tissue or work via secondary mediators to activate the coagulation cascade and the complement cascade and the release of nitric oxide, platelet-activating factor, prostaglandins, and leukotrienes.

High mobility group box 1 (HMGB1) is a protein present in the cytoplasm and nuclei in a majority of cell types. In response to infection or injury, as is seen with SIRS, HMGB1 is secreted by innate immune cells and/or released passively by damaged cells. Thus, elevated serum and tissue levels of HMGB1 would result from many of the causes of SIRS.

HMGB1 acts as a potent pro-inflammatory cytokine and is involved in delayed endotoxin lethality and sepsis.

Numerous pro-inflammatory polypeptides are found within the complement cascade. It is thought they are felt to contribute directly to the release of additional cytokines and to cause vasodilatation and increasing vascular permeability. Prostaglandins and leukotrienes incite endothelial damage, leading to multi-organ failure.

Polymorphonuclear cells (PMNs) from critically ill patients with SIRS have been shown to be more resistant to activation than PMNs from healthy donors, but, when stimulated, demonstrate an exaggerated micro-bicidal response (agents that kill microbes). This may represent an auto-protective mechanism in which the PMNs in the already inflamed host may avoid excessive inflammation, thus reducing the risk of further host cell injury and death.^[4]

Coagulation

The correlation between inflammation and coagulation is critical to understanding the potential progression of SIRS. IL-1 and TNF-α directly affect endothelial surfaces, leading to the expression of tissue factor. Tissue factor initiates the production of thrombin, thereby promoting coagulation, and is a proinflammatory mediator itself. Fibrinolysis is impaired by IL-1 and TNF-α via production of plasminogen activator inhibitor-1. Pro-inflammatory cytokines also disrupt the naturally occurring anti-inflammatory mediators anti-thrombin and activated protein-C (APC).

If unchecked, this coagulation cascade leads to complications of micro-vascular thrombosis, including organ dysfunction. The complement system also plays a role in the coagulation cascade. Infection-related pro-coagulant activity is generally more severe than that produced by trauma.

What the causes of SIRS can be:

The etiology of systemic inflammatory response syndrome (SIRS) is broad and includes infectious and noninfectious conditions, surgical procedures, trauma, medications, and therapies.

The following is partial list of the infectious causes of SIRS:

• Bacterial sepsis
• Burn wound infections
• Candidiasis
• Cellulitis
• Cholecystitis
• Community-acquired pneumonia ^[5]
• Diabetic foot infection
• Erysipelas
• Infective endocarditis
• Influenza
• Intra-abdominal infections (eg, diverticulitis, appendicitis)
• Gas gangrene
• Meningitis
• Nosocomial pneumonia
• Pseudomembranous colitis
• Pyelonephritis
• Septic arthritis
• Toxic shock syndrome
• Urinary tract infections (male and female)
• The following is a partial list of the noninfectious causes of SIRS:

• Acute mesenteric ischemia
• Adrenal insufficiency
• Autoimmune disorders
• Burns
• Chemical aspiration
• Cirrhosis
• Cutaneous vasculitis
• Dehydration
• Drug reaction
• Electrical injuries
• Erythema multiforme
• Hemorrhagic shock
• Hematologic malignancy
• Intestinal perforation
• Medication side effect (eg, from theophylline)
• Myocardial infarction
• Pancreatitis ^[6]
• Seizure
• Substance abuse – Stimulants such as cocaine and amphetamines
• Surgical procedures
• Toxic epidermal necrolysis
• Transfusion reactions
• Upper gastrointestinal bleeding
• VasculitisThe treatment is don’t get it since it is hard to get rid of especially for people over 65 and in hospitals.  There is no one Rx for it.  If you’re unfortunate enough to be diagnosed with SIRS the sooner you get diagnosed with it including being in stage one as opposed to three the higher the odds the turn out will be for you.  Again the key is prevention; don’t get it. There is no one antidote to this SIRS.
• QUOTE FOR THIS ARTICLE:
• PREVENTION IS THE KEY ANTIDOTE!   So stay healthy and out of  hospitals!

“SIRS can be incited by ischemia, inflammation, trauma, infection or a combination of several “insults”. SIRS is not always associated with infection. While not universally accepted, some have proposed the terms “severe SIRS” and “SIRS shock” to describe serious clinical syndromes that are not infectious in nature and thus cannot be labeled according to the various sepsis definitions”

Steven D. Burdette M.D. (Infectious Disease Medicine M.D.– Wright State Physicians in Dayton, Ohio – http://www.healthgrades.com/physician/dr-steven-burdette-yhfgy)

“The idea behind defining SIRS was to define a clinical response to a nonspecific insult of either infectious or noninfectious origin. In 1992, the American College of Chest Physicians (ACCP) and the Society of Critical Care Medicine (SCCM) introduced definitions for systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock, and multiple organ dysfunction syndrome MODS).”

^{Lewis J Kaplan, MD FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine.}

“Current theories about the onset and progression of sepsis and SIRS focus on dysregulation of the inflammatory response, including the possibility that a massive and uncontrolled release of proinflammatory mediators initiates a chain of events that lead to widespread tissue injury.”

Dr. Remi Neviere, MD/Professor/Author of Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis  http://www.uptodate.com/contents/sepsis-and-the-systemic-inflammatory-response-syndrome-definitions-epidemiology-and-prognosis & http://circ.ahajournals.org/content/111/20/2596

MD Department of Physiology, Univ. Droit et Sante – Lille II