Pain management policy formulation at a tertiary care teaching institute in India: A prospective observational study.

Background: Access to pain management has been recognized as a fundamental human right. Inadequate pain relief hampers the quality of life and has a physiological and psychosocial impact on the patient and caregivers. Inadequate pain relief remains the leading cause of suffering in hospitalized patients worldwide. Objective: The objective of this article is to provide adequate pain relief to hospitalized patients through proper assessment, treatment, and monitoring of pain by the trained health-care workers through a sustainable and effective institutional pain management policy. Methods: The formulation of pain management policy at a tertiary care teaching institute was conducted in three phases - Phase 1: need assessment by an open-label, uncontrolled, prospective observational study over 1 month period, Phase 2: teaching, training, and awareness of health-care workers, and Phase 3: constitution of the committee at the institute level with the formation of pain resource teams. Results: An open-label, prospective observational study conducted over 1 month revealed that among 814 hospitalized patients, 108 out of 235 (46%) patients in medical and 385 out of 579 (66.5%) patients in the surgical cohort had NRS score of ≥3, implying an inadequate pain relief even at 24 h following medical or surgical intervention, respectively. Conclusion: The provision of effective and adequate pain relief to hospitalized patients requires trained health-care workers and a uniform and structured pain management policy at the institutional level. Recognition and addressal of the barriers and challenges while framing an institutional pain policy is of utmost importance.

Comparison of General and Spinal Anaesthesia on Systemic Inflammatory Response in Patients Undergoing Total Knee Arthroplasty: A Propensity Score Matching Analysis.

Background and Objectives: Some of the postoperative complications following orthopaedic surgeries are associated with a systemic inflammatory response (SIR), which varies depending on the anaesthetic technique. We aimed to compare the effects of general and spinal anaesthesia on the SIR after total knee arthroplasty (TKA), based on C-reactive protein (CRP) levels, the platelet-lymphocyte ratio (PLR), and the neutrophil-lymphocyte ratio (NLR). Materials and Methods: Patients who underwent TKA between January 2014 and December 2018 were included. Electronic medical records of the patients were retrospectively reviewed and analysed. To reduce the impact of potential confounding factors, we performed propensity score matching according to the anaesthetic technique. Results: A total of 1311 TKA cases were analysed. After propensity score matching, the maximal CRP value and changes in CRP levels in the general anaesthesia group were higher than those in the spinal anaesthesia group. However, the maximal NLR and PLR and the changes in NLR and PLR were not different between the two groups. There were no differences in postoperative clinical outcomes. Conclusion: Spinal anaesthesia tended to induce a lower inflammatory response than general anaesthesia when considering CRP levels in patients undergoing TKA. However, the effects of anaesthetic techniques on the overall outcomes were not significant.

State of the science: cannabis and cannabinoids in palliative medicine-the potential.

Cannabinoids are chemicals derived naturally from the cannabis plant or are synthetically manufactured. They interact directly with cannabinoid receptors or share chemical similarity with endocannabinoids (or both). Within palliative medicine, cannabinoid receptors (CB1 and CB2) may modulate some cancer symptoms: appetite, chemotherapy-induced nausea and vomiting, and mood, pain and sleep disorders. Opioid and cannabinoid receptors have overlapping neuroanatomical receptor distribution, particularly at the dorsal horn, dorsal striatum and locus coeruleus. They have a favourable safety profile compared with opioids, and cannabis-based medicines help chronic pain. While cannabidiol (CBD) has anti-inflammatory properties, tetrahydrocannabinol (THC) is the psychoactive substance for issues such as mood and sleep. Nabiximols (Sativex), a CBD:THC combination, is Food and Drug Administration approved for some multiple sclerosis symptoms and epilepsy. There has been a swift societal evolution in attitudes about use of cannabis and cannabinoid medicines for chronic pain. In the USA, 33 states have now legalised prescription-based medical cannabis for several medical conditions; Canada has had legislation since 2001 authorising medical use. The European Union (EU) recently declared all EU citizens must have access to medical cannabis over the next 4 years. The integration into medicine and routine clinical use of cannabis is fraught with information gaps, regulatory issues and scarcity of research. Each patient should have a comprehensive assessment and risk-benefit discussion before any cannabis-based intervention to avoid possible complications such as hallucinations, psychosis and potential cardiac harm.

[Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports]. / Bloqueio do gânglio esfenopalatino autoaplicado para cefaleia pós­punção dural: relato de quatro casos.

BACKGROUND AND OBJECTIVES: The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. CASE REPORT: This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. CONCLUSION: The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

Self-applied sphenopalatine ganglion block for postdural puncture headache: four case reports / Bloqueio do gânglio esfenopalatino autoaplicado para cefaleia pós-punção dural: relato de quatro casos

Abstract Background and objectives The Sphenopalatine Ganglion Block (SGB) is an effective, low-risk treatment option for Postdural Puncture Headache (PDPH) refractory to conservative management. Case report This report presents four complex cases of patients with headache related to low cerebrospinal fluid pressure. Three of them were successfully treated with the application of local anesthetic topical drops through the nasal cavity. Conclusion The novel approach described in this report has minimal risks of discomfort or injury to the nasal mucosa. It is quick to apply and can be administered by the patient himself.

Resumo Justificativa e objetivos: O Bloqueio do Gânglio Esfenopalatino (BGEP) é opção de tratamento efetivo associado a baixo risco para Cefaleia Pós-Punção Dural (CPPD) refratária às medidas conservadoras. Relato de caso: Este relato apresenta quatro pacientes com alta complexidade que apresentaram cefaleia relacionada à baixa pressão do líquido cefaloraquidiano. Três pacientes foram tratados com sucesso pela instilação de gotas de anestésico local tópico na cavidade nasal. Conclusões: A nova abordagem descrita neste relato apresenta riscos mínimos de desconforto ou lesão à mucosa nasal. A aplicação é rápida e pode ser administrada pelo próprio paciente.

Transforaminal Sacral Nerve Neurostimulation for the Treatment of Intractable Chronic Pelvic Pain: Case Report.

This article aims to report the successful treatment of 2 patients with intractable chronic pelvic pain treated with transforaminal sacral nerve neurostimulation. At 18-month follow-up, both patients reported significant pain relief and improved performance. The implantation of a percutaneous transforaminal sacral nerve neurostimulator is usually reserved for the treatment of bladder incontinence. In both reported cases, it proved to be useful for pain management. This technique should be evaluated in clinical trials.

Central Venous Catheter as Peritoneal Indwelling Catheter for the Management of Recurrent Malignant Ascites: A Case Series.

BACKGROUND: Malignant ascites is an accumulation of fluid in the peritoneal cavity due to the manifestation of terminal metastatic malignancies. Accumulation of ascitic fluid could cause abdominal distention, early satiety, and shortness of breath. The onset and progression of these symptoms are not only distressing but also cause deterioration of the quality of life. Malignant ascites is associated with poor prognosis with anticipated life expectancy ranging from 1 to 4 months. Therapeutic paracentesis is the mainstay of palliation for malignant ascites. It only provides a temporary relief of symptoms, ascites re-accumulates, and paracentesis has to be repeated. OBJECTIVES: The aim of this case series was to evaluate our experiences when treating malignant ascites with placement of central venous catheter in the peritoneal cavity, with special emphasis on patient satisfaction, comfort of caregiver, technical success, and adverse events. METHODS: Five patients with advanced disease and recurrent malignant ascites who required multiple paracentesis were selected for placement of 7-FG triple-port Central venous catheter in the peritoneal cavity. Maximum fluids that can be tapped were removed in ward. Patients and their relatives were assessed for satisfaction with the procedure. RESULTS: Out of 5 patients, 3 were female and 2 male (age between 46 and 62 years). Two patients had carcinoma gallbladder and one each of carcinoma ovary, breast, and prostate. All patients were followed up till 1 month from catheter placement. Patients and their relatives were well satisfied in terms of frequent hospital visit for paracentesis. CONCLUSION: In summary, we suggest that central venous catheter may be used as indwelling peritoneal catheter for the symptom management of recurrent malignant ascites. It provides a relatively safe and cost-effective alternative to serial large-volume paracentesis that requires multiple hospital admissions.