Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel.

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Epidural adhesiolysis: an evidence-based review.

First described over 25 years ago, epidural lysis of adhesions (LOA) involves the mechanical dissolution of epidural scar tissue, which may directly alleviate pain and facilitate the spread of analgesic substances to area(s) of pain generation. Although it most commonly performed for lumbar failed back surgery syndrome, there is a growing body of evidence that suggests it may be effective for spinal stenosis and radicular pain stemming from a herniated disc. There is weak positive evidence that LOA is more effective than conventional caudal epidural steroid injections for failed back surgery syndrome and spinal stenosis, and that LOA is more effective than sham adhesiolysis and conservative management for lumbosacral radiculopathy. For cervical disc herniation and spinal stenosis, there is only anecdotal evidence suggesting effectiveness and safety. Factors that may contribute to the enhanced efficacy compared to traditional epidural steroid administration include the high volume administered, the use of hypertonic saline, and to a lesser extent the use of hyaluronidase and a navigable catheter to mechanically disrupt scar tissue and guide medication administration. Although LOA is widely considered a safe intervention, the complication rates are higher than for conventional epidural steroid injection.

Interaction of single-strand binding protein and RecA protein at the single-stranded DNA site.

Escherichia coli single-strand binding protein (SSB), which participates in DNA replication, also plays a role in DNA repair and induction of SOS functions. We show that the formation of RecA-dATP-single-stranded DNA complexes is influenced by the presence of SSB. In equilibrium reactions with limiting bacteriophage fd DNA, the mutant SSB113 protein competes more effectively than SSB with RecA protein for sites on the DNA. This result can account for the inability of strain ssb113 to amplify RecA protein synthesis and induce lambda prophage. SSB fails to displace RecA protein completely, even at very high concentrations. Both proteins inhibit the dATPase activity of RecA protein in spite of a large proportion of RecA protein still complexed to single-stranded DNA. Analysis of the multiple RecA protein activities and how they respond to the presence of SSB suggests that they fall into two distinct classes. Those that are enhanced by SSB (proteolysis and strand assimilation) and those inhibited by SSB (NTPase, reannealing of complementary single-stranded DNA). We propose a two-state model of conformational change of RecA protein, affected by the number of available free bases in single-stranded DNA relative to the number of RecA monomers, that would explain the choice of mutually exclusive catalytic activities.

Early catheter removal vs. conventional practice in patients undergoing transurethral resection of prostate.

A retrospective analysis of 127 of 146 consecutive patients undergoing transurethral resection of the prostate from February 1985 to January 1988 (3-year period) was performed. The catheter was removed on postoperative day 1 in 66 patients (group I) and on postoperative day 2 in 61 patients (group II). There were no significant differences between the two groups in terms of population age, weight of resected glands, operative time, and management. Both groups I and II had 8 complications following catheter removal. Postoperative hospital stay was reduced by an average of 1.37 days in group I. Total hospital cost was reduced by approximately $466.00. We conclude that catheter removal on postoperative day 1 is safe with no added morbidity while having the advantage of reduced hospital costs.

Spontaneous expulsion of intravesical bullet.

The first reported case of spontaneous expulsion per urethra of an intravesical bullet which initially entered through the left flank is presented. Recognition of the truc location of the millile might have been facilitated had lateral and/or oblique films have been obtained under emergency conditions as advocated by the authors.

Phenylmethylsulfonyl fluoride (PMSF) inhibits 17 beta-estradiol binding to estrogen receptor from human prostate.

Estrogen receptor binding studies were performed on cytosol obtained from human benign prostatic hyperplasia (BPH) tissue. Binding assays were done in the absence or presence of various concentrations of phenylmethylsulfonyl fluoride (PMSF). Saturation analysis and Scatchard plots showed that the binding of 17 beta -estradiol to the estrogen receptor (ER) was inhibited by PMSF. The nature of the inhibition appears to be uncompetitive, as determined from double-reciprocal plots. Glycerol density gradient centrifugation analysis also confirmed the results obtained with Scatchard plots. The inhibition observed in the presence of dithiothreitol (DTT) was greater than the inhibition observed in the absence of DTT. The maximum number of binding sites (Bmax) observed in our present study was 59.1 +/- 34.1 fmol/mg protein with an equilibrium dissociation constant (KD) of 2.2 +/- 2.2 nM. Our study indicates that PMSF significantly affects 17 beta -estradiol binding to ER and consequently alters the estimation of ER in Human BPH.

High tech-soft touch: breastfeeding issues.

Hospital practices and staff interactions need to be reviewed carefully in each institution and community to examine the direct or indirect effects on human lactation and breastfeeding. With the increased incidence of breastfeeding and the continued promotion by the Surgeon General and the American Academy of Pediatrics, it is imperative that health care professionals examine the attitudes that affect their behavior as they interact with their patients about lactation. The high-tech routines must be altered to facilitate the normal aspects of the breastfeeding process. A mother must be close to learn how to interact with and touch her new infant. The greatest challenge is not in changing the written policies nor the curtains or surroundings but in changing the attitudes and beliefs of the staff, so that human lactation and breastfeeding are treated as normal physiologic, psychological, and nurturing activities of mothers and infants.

Elicitation of the oculocardiac reflex during endoscopic forehead lift surgery.

Elicitation of the oculocardiac reflex is a well-documented phenomenon encountered during ophthalmologic surgical procedures. Familiarity with and prompt recognition of this entity has significantly reduced the morbidity associated with it; however, potentially lethal arrhythmias and cardiac arrest still occur. We report elicitation of the reflex during manipulation of the supraorbital nerve during endoscopic forehead lift surgery. To our knowledge this is the first case of elicitation of the oculocardiac reflex reported during endoscopic forehead lift surgery.

Effects of priming with pancuronium or rocuronium on intubation with rocuronium in children.

Rocuronium is a non-depolarizing neuromuscular blocking agent which has a rapid onset and intermediate duration of action. The goal of this study was to compare the neuromuscular blocking actions of rocuronium with and without a priming dose of pancuronium or rocuronium in children. Thirty patients were randomly allocated into 3 groups. Ten patients received a single dose of 0.6 mg/kg rocuronium (Group I). The others received either 0.015 mg/kg pancuronium (Group II) or 0.06 mg/kg rocuronium (Group III) 3 minutes before an intubating dose of 0.54 mg/kg rocuronium was given. Neuromuscular blockade was measured via accelerographic response to single stimulations (1 Hz) of the ulnar nerve until maximal twitch depression was reached followed by train-of-four (TOF) stimuli (2 Hz) at 15 second intervals for the remainder of recovery. Groups were compared with regard to onset time, duration and recovery indices. The onset time and duration of block did not differ significantly between groups. However, the time to recovery in group II (24.5 +/- 9.9 min) was significantly prolonged compared to that in group I (12.7 +/- 3.1 min) or group III (12.7 +/- 3.9 min). We concluded that the use of rocuronium with a preceding dose of either pancuronium or rocuronium provided no advantage for intubation in children.

Prostate cancer Tx. Therapeutic options based on tumor grade, life expectancy, and patient preferences.

Cancer of the prostate is the most common malignancy in American men. Its incidence is associated with age, race, family history, and life style factors, such as high-fat diets. Some men develop prostate cancer before age 55, but 80% of tumors occur in men older than age 65. For organ-confined prostate cancers, treatment options include observation, radical prostatectomy, external beam or interstitial radiation, and cryoablation. The appropriate therapeutic decision is based on analysis of multiple factors by the physician and the individual patient. Advanced prostate cancer remains incurable, but hormonal manipulation and newer chemotherapeutic regimens offer palliation in later stages of the disease.

The role of social work in a veterinary hospital setting.

Social workers can assist veterinarians and their clients in dealing with such difficult situations as euthanasia decisions, grief reactions, and professional stress. They are already at work at The Animal Medical Center, where they counsel clients individually and in groups, consult with veterinarians on client relations and how to cope with their own stress, and develop educational programs for employees and others.

Mucoid impaction following nasal intubation in a child with an upper respiratory infection.

We describe a case of mucoid impaction following nasotracheal intubation in a child with an upper respiratory infection that was successfully treated with a fiberoptic bronchoscope too large to pass through the endotracheal tube lumen. To the best of our knowledge, it is the first report in the anesthesia literature in which the placement of a nasal tracheal tube is implicated as the cause of the mucous obstruction. The physiologic changes that occur with anesthesia and that place patients at increased risk for this phenomenon, as well as the differential diagnosis, treatment, and prevention of this entity, are discussed.

Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study.

BACKGROUND: Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy. METHODS: The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread. RESULTS: The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients. CONCLUSIONS: Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

Suffering and euthanasia.

Suffering is a powerful but elusive concept in veterinary medicine. Because the companion animal cannot talk, assessment of suffering requires the best judgment of veterinarian, family, and other interested participants. Determining whether euthanasia is appropriate rests on a similar consensus but is based on the entire medical and social situation. Clinicians need skill, sensitivity, and a well-developed sense of timing to uncover what clients really feel and want. Offering the family options, such as to be present during the euthanasia, makes the veterinarian's task easier and helps clients cope.