Measurement of prevalence of 'major depressive syndrome' among Indian patients attending pain clinic with chronic pain using PHQ-9 scale.

BACKGROUND: Presence of major depressive syndrome (MDS) in chronic pain patients (CPPs) requires more attention from the clinicians because of its clinical nature, association of suicidal thoughts and their actual completion, and treatment difficulties. The prevalence of MDS among Indian CPPs is not well studied. AIM: To determine the prevalence of MDS among Indian CPPs visiting pain clinic. MATERIALS AND METHODS: In this prospective study, 476 patients who attended a pain clinic in a metropolitan city of India for chronic pain (pain more than six months) were included. They were assessed by 'PHQ-9 depression scale' for presence of MDS. Intensity of pain was assessed by 'Visual analogue scale' (VAS). Patient details (viz. age, sex), duration and site of pain, and scores of PHQ-9 depression scale and VAS, were noted and statistically analyzed. RESULTS: 146 out of 476 CPPs (30.67%) were found to suffer from MDS. Women were more prone (F: M =3:2) to develop MDS while suffering from chronic pain. Among 146 CPPs who were suffering from MDS, 108 (73.97%) patients also had suicidal thought. The prevalence of suicidal thought among all CPPs was found to be 22.69%. The depression severity was found to be strongly associated with intensity of pain (P = 0.005 < 0.05) but not associated with the duration of pain (P = 0.159 > 0.05) and age of the patient (P = 0.24 > 0.05). CONCLUSION: We found a high prevalence of MDS among CPPs from India and majority of them also harbored suicidal thought. Therefore, for successful outcome in chronic pain management routine psychological assessment in CPPs should be done to exclude the presence of MDS and suicidal thought.

Efficacy of combined treatment with medial branch radiofrequency neurotomy and steroid block in lumbar facet joint arthropathy.

PURPOSE: To evaluate the long-term efficacy of combined radiofrequency (RF) neurotomy and steroid nerve block in patients with lumbar facet joint arthropathy. MATERIALS AND METHODS: Combined RF neurotomy and steroid nerve block was performed in 34 patients with chronic paravertebral low back pain. The diagnosis was confirmed by comparative double diagnostic block of the medial branch with bupivacaine and lidocaine. Under fluoroscopy, RF thermal ablation of the medial branch was performed (at RF needle tip temperature 85°C for 90 seconds), three times for each target nerve. At the end of the procedure, 20 mg of methylprednisolone acetate (sustained-release preparation) was infiltrated on each ablated nerve. Outcome variable was the degree of improvement in pain using visual analog scale (VAS) and numerical rating scale (NRS). Improvement in the quality of life was assessed using the Roland-Morris (RM) questionnaire. The procedure was repeated in cases of unbearable pain (>5 VAS score). RESULTS: Patients had a mean VAS score of 8.6 before the procedure. Thereafter, VAS score was 0.91 immediately after the procedure and 3.0, 2.8, 3.7, and 3.6 at 1 month, 2 months, 6 months, and 1 year. NRS showed pain relief after the procedure of 85%, 65%, 78%, 62%, and 59.5% at the same time points. RM score was 18 before the procedure, 7.6 at 6 months after the procedure, and 8.5 at 1 year after the procedure. No major complication was noted except local pain in all patients and numbness of the back in six patients after the procedure. CONCLUSIONS: Combined RF neurotomy and steroid nerve block produced substantial improvement in terms of long-term pain relief and quality of life.

The efficacy of transforaminal epidural steroid injections in lumbosacral radiculopathy.

BACKGROUND: Transformational epidural steroid (TFES) is commonly used to treat lumbosacral radicular pain. However, very few studies have systematically evaluated the quality of analgesia following such procedures with respect to time. OBJECTIVE: To evaluate long-term efficacy of TFES in patients with lumbosacral radiculopathy. MATERIALS AND METHODS: A prospective study including 30 patients having lumbosacral radiculopathy secondary to prolapsed disc. Outcome variables were the amount of improvement just after the procedure and thereafter at 24 hrs, 1 month, 6 month and 1 year post-procedure, respectively, using visual analog scale (VAS) and numeric rating scale (NRS). Patients also filled Roland-Morris questionnaire pre-procedure, 6 month and 1 year follow-up. All patients received Ibuprofen for 3 days following the procedure, to alleviate post- procedural pain. An option of rescue surgery was reserved in case of unbearable pain (>7 VAS), appearance of sudden motor deficit or if patient opts for surgery. Same injection was repeated if at any point of time pain had >5 in VAS. RESULTS: As per NRS, almost all patients had complete pain relief (mean 98%) immediate postprocedure. At 24 hrs, the score was 79%, at 1 month 60%, at 6 months 58.5% and at 1 year 59%. Preprocedure VAS was 9.2 and thereafter 0.6, 1.8, 3.9, 3.8 and 4.2 at similar time points. Roland-Morris score was 18/24, 10/24, 9/24, at pre-procedure, at 6 months and at 1 year, respectively. No complication was noted in any patient except post procedural local pain. CONCLUSION: Quality of pain relief produced by TFES was significant. Long-term quality of pain relief was better in patients with pain duration less than 6 months. Even though, the study was designed to inject the drug once, many of the patients required second injection. A further study with multiple injections at prefixed time interval might probably result in a better overall outcome.

Cryoneurolysis of Innervation to Sacroiliac Joints: Technical Description and Initial Results-A Case Series.

The sacroiliac joint (SIJ) is a common source of pain in patients with low back pain. Untreated pain from the SIJ can lead to prolonged discomfort and financial burden. Interventional treatments for SIJ-related pain include intraarticular steroid injection and radiofrequency ablation but both procedures provide pain relief for a limited duration. Cryoneurolysis is another neuroablative technique that is effective in various chronic pain conditions. However, there is no clear description of SIJ cryoneurolysis in the published literature. In this report, we present 5 patients with SIJ-related pain and we describe the ultrasound-guided SIJ cryoneurolysis technique and its analgesic efficacy.

Comparative Efficacy of Methylprednisolone Acetate and Dexamethasone Disodium Phosphate in Lumbosacral Transforaminal Epidural Steroid Injections.

OBJECTIVE: Transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. But in view of accidental intravascular injections and consequent neurological injuries, the safety profile of particulate steroids has been questioned. Dexamethasone (DEXA), being non-particulate, is presumed to be a safe replacement for earlier particulate agents. However, the efficacy of DEXA is still doubtful as compared to particulate steroids. The present study aims to determine the comparative efficacy of DEXA and methylprednisolone (MP) in terms of pain relief and improvement of disability. METHODS: Seventy-six patients were sorted into two groups (MP and DEXA) to receive lumbar TFESI. A protocol of one-time single- or two-level TFESI with equipotent doses of MP or DEXA was followed. Numeric Rating Scale (NRS) and Roland-Morris Disability Questionnaire (RMDQ) scores were collected pre-treatment and at different times for a duration of 6 months at follow-up appointments. RESULTS: Overall, the extent of pain relief (determined from NRS) and quality of life (determined from RMDQ) were significantly better (p<0.01) in patients belonging to MP group following TFESI. NRS was 2.8±1.2, 3.3±1, 5.1±1.6 and 3.9±1.4, 4.5±1.3, 6.2±1.1 respectively in MP and DEXA group at 1 month, 3 months and 6months of follow-up, whereas RMDQ was 7.9±2.8, 7.4±2.3, 8.5±2.4 and 10±2.2, 11.4±2.6, 12.4±2.7 respectively in MP and DEXA group at similar time points. CONCLUSION: The immediate and short term pain relief following TFESI in lumbar radicular pain remained satisfactory and is comparable between MP and DEXA groups, but the long term benefit is significantly more with the use of MP, as evidenced by the NRS and RMDQ scores.

Validated Stability-Indicating RP-HPLC Method for the Estimation of Degradation Behaviour of Organic Peroxide and Third-Generation Synthetic Retinoids in Topical Pharmaceutical Dosage Formulation.

The objective of the current study was to establish a validated stability-indicating, high-performance liquid chromatographic method to determine the purity of benzoyl peroxide (BPO) and adapalene (ADP) in the presence of its impurities, forced degradation products, and placebo in pharmaceutical dosage forms. The desired chromatographic separation was achieved on the Kinetex(™) C18 (250 × 4.6 mm, 5 µm) column using gradient elution at 272 nm detection wavelength. The optimized mobile phase consisted of solvent A (mixture of 0.1% v/v glacial acetic acid in water and acetonitrile in the ratio of 80:20 v/v, respectively) and solvent B (mixture of acetonitrile: tetrahydrofuran: methanol in the ratio of 50:30:20 v/v/v, respectively). The stability-indicating capability of the developed method was established by analysing forced degradation samples in which the spectral purity of BPO and ADP along with separation of all degradation products from the analyte peaks was achieved. The developed method was validated as per ICH guidelines with respect to specificity, linearity, limit of detection, limit of quantification, accuracy, precision, and robustness.

Radiofrequency ablation of stellate ganglion in a patient with complex regional pain syndrome.

Complex regional pain syndrome (CRPS) is characterized by a combination of sensory, motor, vasomotor, pseudomotor dysfunctions and trophic signs. We describe the use of radiofrequency (RF) ablation of Stellate ganglion (SG) under fluoroscopy, for long-term suppression of sympathetic nervous system, in a patient having CRPS-not otherwise specified. Although the effects of thermal RF neurolysis may be partial or temporary, they may promote better conditions toward rehabilitation. The beneficial effect obtained by the RF neurolysis of SG in this particular patient strongly advocates the use of this mode of therapy in patients with CRPS.

Quality by Design-Based Development of a Stability-Indicating RP-HPLC Method for the Simultaneous Determination of Methylparaben, Propylparaben, Diethylamino Hydroxybenzoyl Hexyl Benzoate, and Octinoxate in Topical Pharmaceutical Formulation.

A stability-indicating RP-HPLC method has been developed and validated for the simultaneous determination of methylparaben (MP), propylparaben (PP), diethylamino hydroxybenzoyl hexyl benzoate (DAHHB), and octinoxate (OCT) in topical pharmaceutical formulation. The desired chromatographic separation was achieved on the Kinetex(TM) C18 (250 × 4.6 mm, 5 µm) column using gradient elution at 257 nm detection wavelength. The optimized mobile phase consisted of a buffer : acetonitrile : tetrahydrofuran (60 : 30 : 10, v/v/v) as solvent A and acetonitrile : tetrahydrofuran (70 : 30, v/v) as solvent B. The method showed linearity over the range of 0.19-148.4 µg/mL, 0.23-15.3 µg/mL, 1.97-600.5 µg/mL, and 1.85-451.5 µg/mL for MP, PP, DAHHB, and OCT, respectively. Recovery for all the components was found to be in the range of 98-102%. The stability-indicating capability of the developed method was established by analysing the forced degradation samples in which the spectral purity of MP, PP, DAHHB, and OCT, along with the separation of the degradation products from the analyte peaks, was achieved. The proposed method was successfully applied for the quantitative determination of MP, PP, DAHHB, and OCT in the lotion sample. The design expert with ANOVA software with the linear model was applied and a 2(4) full factorial design was employed to estimate the model coefficients and also to check the robustness of the method. Results of the two-level full factorial design, 2(4) with 20 runs including four centrepoint analysis based on the variance analysis (ANOVA), demonstrated that all four factors, as well as the interactions of resolution between DAHHB and OCT are statistically significant.

Development and Validation of a Stability-Indicating RP-HPLC Method for the Simultaneous Determination of Phenoxyethanol, Methylparaben, Propylparaben, Mometasone Furoate, and Tazarotene in Topical Pharmaceutical Dosage Formulation.

A stability-indicating RP-HPLC method has been developed and validated for the simultaneous determination of phenoxyethanol (PE), methylparaben (MP), propylparaben (PP), mometasone furoate (MF), and tazarotene (TA) in topical pharmaceutical dosage formulation. The desired chromatographic separation was achieved on the Waters X-Bridge™ C18 (50×4.6mm, 3.5µ) column using gradient elution at 256 nm detection wavelength. The optimized mobile phase consisted of 0.1%v/v orthophosphoric acid in water as solvent-A and acetonitrile as solvent-B. The method showed linearity over the range of 5.88-61.76 µg/mL, 0.18-62.36 µg/mL, 0.17-6.26 µg/mL, 0.47-31.22 µg/mL, and 0.44-30.45 µg/mL for PE, MP, PP, MF, and TA, respectively. The recovery for all of the components was in the range of 98-102%. The stability-indicating capability of the developed method was established by analysing the forced degradation samples, in which the spectral purity of PE, MP, PP, MF, and TA along with the separation of degradation products from the analyte peaks was achieved. The proposed method was successfully applied for the quantitative determination of PE, MP, PP, MF, and TA in a cream sample.

Evaluation of downstaging in the detection of cervical neoplasia in Kolkata, India.

Unaided visual inspection or "downstaging" has been suggested as a potential alternative method for cervical cancer screening in developing countries. Our study was designed to evaluate the accuracy of downstaging to detect cervical neoplasia in a low-resource setting. A total of 6,399 women aged 30-64 years were screened with downstaging by trained nonmedical health workers. Two thresholds were used to define positive downstaging: "low threshold" when any visible abnormality on the cervix was considered positive and "high threshold" when selected abnormalities such as bleeding on touch, bleeding erosion, hypertrophied oedematous cervix, congested stippled cervix and growth or ulcer constituted the positive test. All women underwent a colposcopy examination. Biopsies were directed when colposcopy revealed abnormal lesions. True disease status was defined as histologically proven moderate dysplasia and worse lesions. Since all the participants received a diagnostic (reference) investigation (biopsy and/or colposcopy), sensitivity, specificity and predictive values were estimated directly. Low- and high-threshold downstaging were positive in 1,585 (24.8%) and 460 (7.2%) women, respectively. The sensitivities of low- and high-threshold downstaging to detect high-grade precursors and invasive cancers were 48.9% and 31.9%, respectively. The specificities were 75.8% and 93.3%, respectively. These results indicate that downstaging is not suitable as an independent primary screening modality for cervical neoplasia.