Management of Metastatic CA (Cancer) Pancreas Pain in Post Chemotherapy, Radiotherapy Patient With Combination of Neural Interventions (Oral Neuromodulators, Peripheral Nerve Blocks) and Muscular Intervention USGDN (Ultrasonography Guided Dry Needling): A Case Report

Aims: To describe combined neural and muscular interventions in post covid exacerbations of cancer pain with disabilities.To present a new perspective of neuromyopathy to explain Intractable CA pancreas pain. Introduction: Additional challenges in cancer pain management are due to cancer treatment complications (chemotherapy, radiotherapy). CA Pancreas pains routinely addressed with oral neuromodulators, opioids neurolytic coeliac plexus block (NCPB) or splanchnic nerve radiofrequency ablation (SRF). 75 years male, CA pancreas with spine, pelvic bone metastasis, post chemotherapy radiotherapy. 6 months bedridden with post covid exacerbations in pain (vas 10/10) received prior painkillers. Started oral pregabalin 75mg od, ultracet bd, myospaz bd. Result(s): With 15 days medications vas 6/10, patient could sit on wheelchair. Given sciatico-femoral block, pain reduced vas 2/10 but recurred in 7 day vas 5/10. Started USGDN of tight back and lower limb muscles with 32G solid needles.post3 sessions vas 2/10, able to walk with support after 4 weeks. Discussion(s): Viscerosomatic convergence at the dorsal horn neurons produces visceral pain referred to back and abdominal muscles led to muscle spasm with generation of myofascial trigger points(MTrPs)and pain. USGDN addresses MTrPs. Needle insertion produces local twitch reflex (LTR) followed by muscle relaxation with pain relief. Neural interventions addresses only visceral nociceptive afferents from celiac plexus which forms 10% of total spinal cord afferent input which sensitizes peripheral and central motor nociceptive pathway processing neuromyopathy. Conclusion(s): Viscerosomatic convergence with muscles involvement (neuromyopathy) proved to be effectively managed by using combined approaches, neuromoduation and USGDN in Ca pancreas pain with disabilities.Copyright © 2023

A rare case of central post-stroke pain in a patient with migraine and lacunar infarcts in the medulla oblongata

Studies about headaches associated with acute ischemic stroke in patients suffering from migraine were limited, and therefore we present a clinical case of central post-stroke pain (CPSP) in a 47-year-old woman with migraine and lacunar infarcts in the medulla oblongata and also possible mechanisms of CPSP in patients with migraine. Magnetic resonance imaging of the brain revealed lacunar infarction in the medulla oblongata on the right (vertebral artery basin) and a single focus of gliosis in the parietal lobe on the right. Magnetic resonance angiography of cerebral vessels showed the fetal type of structure of both posterior cerebral arteries. This clinical case is a complex clinical situation of a combination of secondary headaches (post-stroke) in a patient with a primary headache (migraine), which was successfully treated by the combined administration of first-line drugs for the treatment of neuropathic pain in a patient with lacunar infarcts in the medulla oblongata. The treatment of CPSP is a difficult task due to the insufficiently unexplored mechanisms of development, the most effective approaches are those aimed at reducing the increased excitability of neurons.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.

Top 20 Research Studies of 2021 for Primary Care Physicians

This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. Among patients in this age group with type 2 diabetes treated with medication, an A1C level of less than 7% is associated with increased risk of hospitalization for hypoglycemia, especially when using a sulfonylurea or insulin. For patients with chronic low back pain, exercise, nonsteroidal anti-inflammatory drugs, duloxetine, and opioids were shown to be more effective than control in achieving a 30% reduction in pain, but self-discontinuation of duloxetine and opioids was common. There is no clinically important difference between muscle relaxants and placebo in the treatment of nonspecific low back pain. In patients with chronic pain, low- to moderate-quality evidence supports exercise, yoga, massage, and mindfulness-based stress reduction. For acute musculoskeletal pain, acetaminophen, 1,000 mg, plus ibuprofen, 400 mg, without an opioid is a good option. Regarding screening for colorectal cancer, trial evidence supports performing fecal immunochemical testing every other year. For chronic constipation, evidence supports polyethylene glycol, senna, fiber supplements, magnesium-based products, and fruit-based products. The following abdominal symptoms carry a greater than 3% risk of cancer or inflammatory bowel disease: dysphagia or change in bowel habits in men;rectal bleeding in women;and abdominal pain, change in bowel habits, or dyspepsia in men and women older than 60 years. For secondary prevention in those with established arteriosclerotic cardiovascular disease, 81 mg of aspirin daily appears to be effective. The Framingham Risk Score and the Pooled Cohort Equations both overestimate the risk of cardiovascular events. Over 12 years, no association between egg consumption and cardiovascular events was demonstrated. Gabapentin, pregabalin, duloxetine, and venlafaxine provide clinically meaningful improvements in chronic neuropathic pain. In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic.Copyright © 2022 American Academy of Family Physicians.

The Impact of COVID-19 on Intoxication Pattern by Drugs of Abuse in Egypt

Background: Drug abuse is considered a global and growing problem worldwide. Emergency medical care is required for acute intoxication, which adds to the threat of COVID-19. This study aims to evaluate the effect of the COVID-19 pandemic on the pattern of acute toxicity in drug abuse patients admitted to National Environmental and Clinical Toxicology and Research Center (NECTR), Cairo University. Method(s): This comparative study included 978 cases admitted to NECTR during 12 months before the COVID-19 pandemic (2018-2019) and 12 months during the pandemic (2020-2021). Result(s): The number of cases during the pandemic was lower than before;adults and men predominate in both periods. During the pandemic, cannabis, heroin, opium, and alcohol showed a mild increase, while the new synthetic drugs, tramadol, and pregabalin, showed a mild decrease. A significant increase in discharges and a decrease in intensive care unit (ICU) admissions were observed during the pandemic. Besides, more oxygen (O2) therapy was required, and more cases died on mechanical ventilation. The worst outcome was associated with old age, male gender, heroin and opium toxicity, and the highest score of poisoning severity. Conclusion(s): The COVID-19 pandemic had a definite reforming effect on the pattern of intoxication by drugs of abuse in NECTR, Egypt.Copyright © 2023 Authors. All rights reserved.

Unboxing herpes zoster ophthalmicus and the recombinant shingles vaccine

Reactivation of the varicella zoster virus as herpes zoster (shingles) typically affects the peripheral nerves, resulting in a painful rash, most often on the torso. However, it can also manifest ophthalmologically, affecting the ophthalmic division of the trigeminal nerve. This manifestation is associated with a particularly high level of morbidity and may result in blindness. A new recombinant shingles herpes zoster vaccine protects patients against this virus and post-infection sequelae, improving medical and psychosocial outcomes. © 2021 Medicine Today Pty Ltd. All rights reserved.

Managing Delirium in a patient with Extracorporeal Membrane Oxygenation (ECMO) machine for bridge to lung transplant: A Case report

Background: Due to COVID pandemic, there have been increased needs for ECMO circuits to support patients with respiratory failure1. Unfortunately, due to pharmacokinetics alteration of commonly used sedative and psychotropic medications by the ECMO circuits2,new sedation approaches to manage delirium and agitation is required. We present a case of COVID pneumonia patient on ECMO support, whose delirium symptoms were managed with a novel psychopharmacotherapy protocol. Case: Mr. M is a 57-year-old male patient with past medical history of obesity, hypertension, admitted to Stanford Hospital due to COVID pneumonia, complicated by respiratory failure, required to be on Veno-Venous ECMO support with bridge to transplant. He had significant hyperactive delirium with Richmond Agitation-Sedation Scale (RASS) score of +3 and ICDSC score of 7 for most of the days, despite heavy conventional pharmacological sedation. We observe the same problems with most patients placed on the ECMO system, leading to an investigation and development of a new protocol. Discussion: Patient on ECMO support requires adequate sedation to prevent clinical deterioration that can result from hyperactive delirium (ie., chugging, blood clots or decannulation)2. Nevertheless, ECMO circuit’s significant alterations of drug pharmacokinetics, such as increased volume of distribution and sequestration of lipophilic and protein bound medications, with no clear guidelines on managing sedation/delirium in patients with ECMO support at this time2, we conducted an extensive literature search and developed a novel protocol. This new sedation approach includes alpha-2 agonists, opioids, barbiturates and calcium channel modulators with the lowest lipophilicity and protein binding potential of each medication in its class4,5,thus overcoming the challenges introduced by ECMO circuits. The new protocol allowed the patient to participate in lung transplant work-up, physical therapy, and eventually facilitated receiving bilateral lung transplantation. Conclusion/Implications: ECMO is a life saving device that can help patient with cardiac-respiratory failure, and its use has been increasing in clinical practice. However, there needs to be an improvement in successful sedation/delirium management to minimize adverse events, and optimize the success of this lifesaving technologies. References: 1. Cho HJ, et al. ECMO use in COVID-19: lessons from past respiratory virus outbreaks-a narrative review. Crit Care. 2020 Jun 6;24(1):301 2. deBacker J, et al. Sedation Practice in Extracorporeal Membrane Oxygenation-Treated Patients with Acute Respiratory Distress Syndrome: A Retrospective Study. ASAIO J. 2018 Jul/Aug;64(4):544-551 3. Lemaitre F, et al. Propofol, midazolam, vancomycin and cyclosporine therapeutic drug monitoring in extracorporeal membrane oxygenation circuits primed with whole human blood. Crit Care. 2015;19(1):40 4. Hansch C, et al. Hydrophobicity and central nervous system agents: on the principle of minimal hydrophobicity in drug design. J Pharm Sci. 1987 Sep;76(9):663-87 5. Bockbrader HN, et al. A comparison of the pharmacokinetics and pharmacodynamics of pregabalin and gabapentin. Clin Pharmacokinet. 2010 Oct;49(10):661-9

Case Series: Post-COVID Small Fiber Neuropathy

Objective: To report a case series documenting biopsy-proven small fiber neuropathy (SFN) after COVID-19. Background: Patients recovering from COVID-19 who present with sensory as well as autonomic symptoms, including positional orthostatic tachycardia syndrome (POTS), frequently have negative electrodiagnostic testing. Skin biopsy may be required to reveal SFN. Design/Methods: This is a retrospective case series of patients seen in the Yale Neurology COVID-19 Clinic with positive SARS-CoV-2 PCR or antibody or a clinically consistent illness. After laboratory testing and a negative nerve conduction study, all patients underwent skin biopsy to test for intraepidermal SFN. Case 1: A 40F with pre-diabetes (HbA1c 6.2%) developed burning, numbness, and tingling in the hands and legs and POTS 6 weeks after acute COVID-19. Skin biopsy demonstrated non-length dependent SFN. Complete remission of neuropathy symptoms occurred within days of intravenous immunoglobulin (IVIG) therapy, which has been continued longitudinally. Case 2: A 65F with non-insulin dependent diabetes (HbA1c 8.0%) developed excruciating burning pain in her feet and orthostasis within weeks of acute COVID-19. Skin biopsy demonstrated non-length dependent SFN. She experienced partial relief of symptoms after IVIG and gabapentin. Case 3: A 43F with pre-diabetes (HbA1c 6.0%) developed orthostasis, numbness, paresthesias, and a “sunburned” feeling in her face, back, hands, and feet 2 weeks after acute COVID-19. Skin biopsy demonstrated length-dependent SFN. Symptoms improved over several months of pregabalin treatment, but have not resolved. The patient deferred immunotherapy. Case 4: A 40M developed POTS, numbness, and paresthesias in his face and left leg up to the knee within weeks of a clinical COVID-19 illness. Skin biopsy demonstrated non-length dependent SFN. IVIG therapy has resulted in significant improvement in symptoms. Conclusions: Sensory symptoms and POTS occur post-COVID, and SFN should be considered in the differential. Given the time of onset and response to immunotherapy, post-COVID SFN may have an underlying autoimmune etiology.

42nd International Congress of the European Association of Poisons Centres and Clinical Toxicologists

The proceedings contain 209 papers. The topics discussed include: an illicit drug early warning system utilizing comprehensive toxicological analysis of emergency department presentations in Victoria, Australia;4-fluoroamphetamine (4-FA) intoxication results in exaggerated blood pressure effects compared to 3,4-methylenedioxymethamphetamine (MDMA) and amphetamine: a retrospective analysis;single nucleotide polymorphisms of mu opioid receptor gene OPRM1 in emergency department patients with acute opioid overdose;ketamine in acute recreational poisonings in the Balearic Islands;the neuro-respiratory effects of pregabalin and the potential deleterious effects of its combination with diazepam or morphine ? a rat investigation;cobaltism from metal-on-metal (MoM) hip implants: how to manage and treat with acetylcysteine;analytically-confirmed polydrug use is more common in drug misuse patients attending emergency departments in Scotland compared with those in England and Wales;and it is not always COVID-19: a case of respiratory failure from lung damage associated with electronic cigarettes (EVALI).

OPIOID-FREE SURGERY: IMPLEMENTATION OF SUCCESSFUL NON- OPIATE COLECTOMY AT COMMUNITY TEACHING CENTER

Purpose/Background: With ERAS protocols advocating for multi-modal non-opiate options, amongst a surging opiate crisis, we reviewed published data to create our own protocol for non-narcotic colorectal surgery. Hypothesis/Aim: Non narcotic options in the perioperative period of colectomy is a viable, safe management plan Methods/Interventions: Our institution implemented an updated ERAS protocol beginning 1/1/2020. Our study was conducted from 7/1/19- 6/30/20. There were two groups, the prior ERAS protocol (p-ERAS) and the current non opiate (c-ERAS) group. Data was collected from 1/1/2019- 6/1/2020, acknowledging the decreased colectomies performed during the Coronavirus pandemic. Any patient during that time who was scheduled for surgery with a preoperative ERAS designation was included. Pain control was reviewed by comparing nursing reported pain scales. Other compared end points between the two groups included: length of stay (LOS), return of bowel function, and outpatient pain control based on the discharge medication orders and the number of patients who requested additional medications. Results/Outcome(s): 134 patients were studied with 25 patients (18.7%) c-ERAS compliant, compared to 109 patients (81.3%) who received opiates. Mean pain scores were reported by nursing as no pain (0), mild (1-3), moderate (4-6), or severe (7-10). A distribution of the duration of time (calculated in hours spent during the different pain levels) was determined for each of the four levels. The c-ERAS group was found to have a significantly longer duration with no pain, 34 vs 23 hours, (p = 0.062). The p-ERAS group was found to have elevated duration of moderate pain, 23.2 hours, in contrast to spending 17.7 and 14.1 hours with mild and severe pain, respectively. Overall, there was a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain. There was no statistically significant difference in the average length of stay. Limitations: Small population, only some of the recommended non - narcotic therapy options were available, analyzed pain scales were subjective findings reported to the staff and retrospectively reviewed. Conclusions/Discussion: In 2015, our community-based teaching institution implemented a colorectal ERAS protocol, which was later recognized to be dated. In 2019, a resident driven revision of the ERAS protocol was performed. This resulted in the implementation of a non-opiate colectomy regimen. Aside from immediate pre-operative opiate use by Anesthesia, no other peri-operative opiate medications were routinely ordered. Our regimen included preoperative celecoxib, tylenol, and pregabalin, intraoperative lidocaine infusion, and a postoperative rotation of toradol and IV tylenol, then transition to oral tylenol, and no narcotics prescribed on discharge. With this protocol, we have found a significant time difference favoring the c-ERAS population in time with no pain, moderate pain, and severe pain.

Availability of Illegal Drugs During the COVID-19 Pandemic in Western Germany.

Background: In response to the COVID-19-pandemic, a lockdown was established in the middle of March 2020 by the German Federal Government resulting in drastic reduction of private and professional traveling in and out of Germany with a reduction of social contacts in public areas. Research Questions: We seek evidence on whether the lockdown has led to a reduced availability of illegal drugs and whether subjects with substance-related problems tried to cope with possible drug availability issues by increasingly obtaining drugs via the internet, replacing their preferred illegal drug with novel psychoactive substances, including new synthetic opioids (NSO), and/or by seeking drug treatment. Methods: A questionnaire was anonymously filled in by subjects with substance-related disorders, typically attending low-threshold settings, drug consumption facilities, and inpatient detoxification wards from a range of locations in the Western part of Germany. Participants had to both identify their main drug of abuse and to answer questions regarding its availability, price, quality, and routes of acquisition. Results: Data were obtained from 362 participants. The most frequent main substances of abuse were cannabis (n = 109), heroin (n = 103), and cocaine (n = 75). A minority of participants reported decreased availability (8.4%), increased price (14.4%), or decreased quality (28.3%) of their main drug. About 81% reported no change in their drug consumption due to the COVID-19 pandemic and the lockdown. A shift to the use of novel psychoactive substances including NSO were reported only by single subjects. Only 1-2% of the participants obtained their main drug via the web. Discussion: Present findings may suggest that recent pandemic-related imposed restrictions may have not been able to substantially influence either acquisition or consumption of drugs within the context of polydrug users (including opiates) attending a range of addiction services in Germany.

Addictovigilance contribution during COVID-19 epidemic and lockdown in France.

Addictovigilance is a safety monitoring targeted at substances with potential for abuse and dependence. This vigilance was involved during the period of COVID-19 epidemic due to the significant changes in access to drugs and psychological disruption caused by the pandemic and lockdown. This article aims to present the different steps implemented by the French Addictovigilance network in collaboration with the French Health authorities from March to May 2020, including monitoring of potential harmful events, and scientific communication. The first events were identified through the continuity of the networking between the French addictovigilance centres and their partners: community pharmacies, general practitioners, specialized structures and emergency wards. As soon as the lockdown began, first cases of overdoses (lethal or not) were reported with opioids, mainly with methadone, and other opioids (heroin, oxycodone, tramadol or antitussive codeine). Lockdown-related noteworthy events consisted in clinical cases or other relevant information for which lockdown clearly played an important role: among the many substances identified at least once, pregabalin, benzodiazepines, cannabis, cocaine and nitrous oxide were the most significant in terms of prevalence, seriousness or particularly specific to the lockdown context. Despite significant decrease in the activity and travel limited to vital needs, community pharmacies continued to identify falsified prescriptions in this period, highlighting an increase in suspicious requests for pregabalin, codeine and tramadol. In parallel, the French addictovigilance network continued its communications efforts in the period, issuing a newsletter on tramadol, a press release on methadone and naloxone, and participating in the COVID-19 frequently asked questions (FAQs) of the French Society of Pharmacology and Therapeutic website (https://sfpt-fr.org/covid19). COVID-19 epidemic has been an important challenge for addictovigilance, and has proved that this monitoring is highly essential for alerting health professionals and health authorities to points of vigilance in the field of psychoactive substances.