1,721,013 research outputs found
Comments on: Methylene blue? therapeutic alternative in the management of septic shock refractory to norepinephrine
Full text linkIt is a comment on an interesting case report focusing on the use of methylene blue in septic shock refractory to noreprinephrine.
In septic shock, the response to pathogen-associated molecular patterns (PAMPS) and damage-associated molecu- lar patterns (DAMPS) generates a combination of vasodilation and increased capillary permeability. Capillary leak, coupled with greater vessel capacitance mediated by vasoplegia, may result in absolute or more commonly relative hypovolemia. The L-arginine nitric oxide (NO) pathway plays a pivotal role in regulating cardiovascular hemodynamics and vascular permeability. Methylene blue inhibits inducible NO synthase (NOS) and guanylate cyclase, thereby reversing NO induced vasodilation. In septic shock, it was firstly used at the beginning of the 1990s. This drug has resulted beneficial and safe in randomized clinical trials and case reports. Recently, its clinical use has been deeply reviewed, and we are strongly convinced that it would deserve further attention and prospective, randomized, clinical trials
The Routes of Administration for Acute Postoperative Pain Medication
Full text linkEffective treatment of postoperative acute pain, together with early mobilization and nutrition, is one of the perioperative strategies advocated to improve surgical outcome and reduce the costs of hospitalization. Moreover, adequate pain control reduces perioperative morbidity related to surgical stress and can also prevent the incidence of chronic postoperative pain syndromes, whose treatment is still a challenge. The choice of the most appropriate analgesics depends not only on the drug class, but also on the most suitable route of administration, the best dosage for that route, and unique limitations and contraindications for every patient. In the present review, a comprehensive analysis was performed on the different routes of administration of acute postoperative pain medications and their indications and limitations, focusing on recent evidence and international recommendations
Monitoraggio del dolore intraoperatorio: nuove frontiere
No full textSono stati proposti diversi metodi per quantificazione il rapporto tra nocicezione ed analgesia farmacologica in corso di anestesia, quali la conduttanza cutanea, la pupillometria, la fotopletismografia e la variabilità della frequenza cardiaca (HRV).
Quest’ultimo parametro è stato quello che ha destato maggiore interesse negli ultimi anni per il suo possibile utilizzo clinico ed è da poco disponibile in Italia una tecnologia che sfrutta un indice, chiamato ANI (Analgesia/Nociception Index), che si basa proprio sulla HRV per il monitoraggio della analgesia in pazienti anestetizzati. Nello specifico, la tecnologia ANI (Mdoloris Medical Systems- MDMS) si basa sulla registrazione dell’ECG e sulle fluttuazioni respiratorie della frequenza cardiaca che riflettono il tono parasimpatico del paziente. Grazie ad un algoritmo matematico, il monitor elabora quindi un valore numerico, compreso tra 0 (massima nocicezione) e 100 (massima analgesia). Se il valore dell’ANI è compreso in un intervallo numerico che va da 50 a 70, il paziente si trova in una situazione di adeguata analgesia, con un tono parasimpatico che predomina su quello simpatico. Se il valore medio dell’ANI scende sotto i 50 il paziente si trova in una condizione di scarsa analgesia, se il valore medio supera il 70, è plausibile che la dose di oppioidi sia superiore alla richiesta indotta dalla nocicezione.
Ci sono, in letteratura, diversi studi di validazione dell’ANI sia durante l’anestesia che nell’immediato periodo post-operatorio.
Dalla nostra esperienza clinica possiamo dire che l’ANI è un indice utile nel monitoraggio della analgesia intraoperatoria ma va sempre associato al monitoraggio della profondità dell’anestesia, in modo da poter discriminare variazioni emodinamiche secondarie a superficializzazione della stessa
Acute Kidney Injury in Coronavirus Disease 2019 Infected Patients: A Meta-Analytic Study
Full text linkIntroduction: In clinical reports on coronavirus disease 2019 (COVID-19), the incidence of acute kidney injury (AKI) is extremely variable, although AKI is described as an independent risk factor for mortality. A meta-analysis was performed to clarify the incidence and the impact of COVID-19-related AKI on mortality. Methods: All trials reporting the incidence of AKI in COVID-19 patients were searched using MEDLINE, the Cochrane Library, and EMBASE databases (last update April 26, 2020). Results: Ten trials with a sample of 5,166 patients were included. AKI occurred in 947 out of 5,166 (18.3%) patients. AKI incidence was higher in severe cases: 62/305 severe patients developed AKI (20%) versus 27/1,268 nonsevere patients (2%) (p = 0.00001). AKI occurred in 475 out of 915 (52%) deceased patients versus 183 out of 2,678 (7%) survivors (p = 0.00001). Continuous renal replacement therapy was significantly more frequent in severe cases and in dead patients. Conclusion: A significant increase in mortality rate was observed in COVID patients who developed AKI, and AKI incidence was also higher in severe cases. Any supportive strategies to protect kidney could represent valuable intervention to reduce mortality in severe COVID-19 patients
Therapeutic exercise and radiofrequency in the rehabilitation project for hip osteoarthritis pain: a case series.
Full text linkBACKGROUND:
Severe hip osteoarthritis is responsible for disabling pain and functional impairment of the joint. Although total hip arthroplasty (THA) is a successful treatment, some patients have multiple comorbidities that represent contraindications for THA. Conventional drug therapies are often ineffective or responsible for numerous side effects. For these patients, it is difficult to draw up an acceptable rehabilitation path, as the main limitation is intense pain. New rehabilitation strategies need to be developed that relieve pain and improve articular function. The combination of traditional treatments such as education and therapeutic exercise with innovative, minimally-invasive therapies such as continuous radiofrequency (CRF) appears to reduce hip pain by determining the neurolysis of the joint.
AIM:
The aim of our study was to describe the reduction in pain and improvements in joint function when CRF is combined with the therapeutic exercise in rehabilitation of patients with severe hip osteoarthritis.
DESIGN:
Case series study.
SETTING:
Rehabilitation service outpatients.
POPULATION:
Twenty-five patients with severe hip osteoarthritis causing disabling pain and with contraindications to THA, and for whom conventional drug therapies were ineffective or responsible for numerous side effects.
METHODS:
The study design included: initial clinical-functional assessment using the Harris Hip Score (HHS), the Numeric Rating Scale (NRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); a pre-lesion anaesthetic block; hip neuroablation with CRF; a three-week kinesitherapy protocol (3 sessions per week); two further assessments using the same scales one month (T1) and six months (T2) after CRF.
RESULTS:
Improvements at T1 and T2 follow-ups, after CRF (p=0.000) were recorded for articular pain and function. However, results at T2 were worse than those at T1 (p=0.000).
CONCLUSIONS:
CRF combined with therapeutic exercise in rehabilitation of severe hip osteoarthritis is an attractive option for significant pain relief as it allows patients to carry out kinesitherapy more easily.
CLINICAL REHABILITATION IMPACT:
CRF could represent a valid alternative in the rehabilitation of patients with severe hip osteoarthritis especially when other therapeutic approaches are unworkable
Intrathecal (IT) Morphine and Ziconotide combined with Levobupivacaine: a winning triangle?
No full textThis prospective trial investigates the effects of intrathecal Ziconotide combined with Morphine and Levobupivacaine in malignant pain.
Methods
Adult patients with malignant pain refractory to high doses of oral opioids were enrolled. Mean VASPI scores and mean doses of 3 drugs were recorded at 48 hours and every week until 2 months of treatment. Adverse events were also recorded.
Results
56 patients were recruited (age 63 + 12, F/M 18/38). 16 patients had lung, 14 had gastro-intestinal, and 9 had urologic cancer. At T0 the mean VASPI score was 88±6, and the mean doses of Morphine, Ziconotide and Levobupicaine were 0.8±0.3 mg/day, 1.6±0.8 mcg/day and 2.9±0.9 mg/day, respectively. At 48 hours the mean VASPI score was significantly reduced to 48.5±17 (p<0.05). This significant re- duction persisted over 2 months of follow-up. At 1 month, mean doses of Morphine, Ziconotide and Levobupicaine were 1.4±0.9 mg/day, 2.5±1.3 mcg/day and 3.9±2.1 mg/day, respectively. At 2 month, mean doses of Morphine, Ziconotide and Levobupicaine were 2.0±1.2 mg/day, 2.8±1.1 mcg/day and 3.8±2.0 mg/day, respectively. The mean VASPI score at that time was 43.7±21. Adverse events were con- fusion (9%), dizziness (10%), nausea (10%), vomiting (5%), urinary retention (16%), hallucination (3%). There was one infection related to the infusion system, and it occurred in a HIV patient.
Conclusions
The present trial suggests that the combination of IT Morphine and Ziconotide plus Levobupicaine could be a rationale choice to achieve a rapid control of refractory malignant pain: the decrease of VASPI score is significant as soon as 2 days and persists during the 2 months of study. The addition of Levobupivacaine seems to potentiate the effects of the other 2 drugs, allowing a reduction in cumulative doses of both Morphine and Ziconotide over time, compared to those reported in similar populations (1,2). The low doses of the 3 drugs could also explain the reduced incidence of adverse events in these difficult to treat patients, compared with recent reports (2,3). However, uri- nary retention can be emphasized by the addiction of Levobupivacaine in patients with pelvic cancer. Other trials are needed to confirm the safe, rapid and effective synergistic action of IT combination of Morphine, Ziconotide and Levobupivacaine
Complete relief of a severe feet and hand necrotising Raynaud’s phenomenon with double cervical and dorsal spinal cord stimulation
No full textRationale of the study
Several evidences suggest that spinal cord stimulation (SCS) can effectively treat vascular disorders. Raynaud’s phenomenon is a vaso- spastic condition affecting primarily the distal resistance vessels. Usually it is triggered by cold temperatures, or by emotions such as anxiety and stress. High levels of sympathetic activity seem to be related to Raynaud’s phenomenon as well as low levels of calcitonin gene-related peptide expression in the local sensory fibers.
Methods
We present a case of a severe necrotising Raynaud’s phenomenon involving one hand and feet refractory to conservative treatment successfully treated with cervical and dorsal SCS electrodes.
Results
A 37-year-old woman presented in November 2016 complaining of pain involving both feet and the V finger of the right hand; the diagno- sis was necrotising Raynaud’s phenomenon. The character of pain was tearing; touching objects or dresses led to an immediate increa- se in pain intensity, so that she even could not wear shoes, walk or take objects. The pain ratings were mean 8/10, maximum 10/10, and minimum 6/10 on the nominal analogue scale. Her pain did not respond to any kind of therapeutic manoeuvre or behavioural factors. She had been immediately treated with vasodilators iv, with scarce clinical response and increasing pain and necrosis. Indication of amputa- tion was therefore made. Before amputation, a trial of SCS was performed. A double octopolar SCS lead was implanted, one in cervical region (C3-C4), and one in the dorsal region (D8-D9), in a medial position in order to obtain an analgesic and vasodilator effect on both hand and feet. The patient referred in subsequent days a net improvement of symptoms, with a reduction of mean pain ratings until 2/10. Also perfusion in hand and feet significantly improved, so that necrosis completely reversed and amputation was no longer necessary. The system was therefore totally implanted.
Conclusions
It has been proposed that SCS increases cutaneous blood flow by antidromic activation of afferent fibers in the dorsal roots. Moreover it has a direct inhibitory effect on peripheral vasoconstriction that is maintained by efferent sympathetic activity including nicotinic transmis- sion in the ganglia and the postganglionic alpha-1-adrenergic receptors. Furthermore, it is believed that pain relief is mediated by sup- pression of nociceptive transmission via descending inhibitory pathways. This is the first case report, to our knowledge, in which a dou- ble cervical and thoracic lead was implanted. This approach was chosen in order to achieve a better pain control in the extremities and to program each side separately from the other. The present case once more highlights that epidural neurostimulation is a promising the- rapeutic option for severe Raynaud’s phenomenon
An Italian Expert Consensus on the Use of Opioids for the Management of Chronic Non-Oncological Pain in Clinical Practice: Focus on Buprenorphine.
Full text linkConsalvo Mattia,1,2 Livio Luongo,3,4 Massimo Innamorato,5 Luca Melis,6 Michele Sofia,7 Lucia Zappi,8 Filomena Puntillo9,10 1Department of Medical and Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, Rome, Italy; 2Anesthesia, Intensive Care and Pain Unit, ICOT-Polo Pontino, Latina, Italy; 3Department of Experimental Medicine, Division of Pharmacology, University of Campania “L. Vanvitelli”, Naples, Italy; 4NEUROMED, Pozzilli, Italy; 5Pain Therapy Unit, AUSL Romagna, S.M.Croci Hospital Ravenna, Ravenna, Italy; 6Poliste, Cagliari, Italy; 7Department of Palliative Care and Pain Therapy, ASST Rodhense, Garbagnate Milanese, Itlay; 8UOC Antalgic Therapy, Emergency and Acceptance Department, San Martino Polyclinic Hospital, Genoa, Italy; 9Department of Interdisciplinary Medicine, “Aldo Moro” University of Bari, Bari, 70124, Italy; 10Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital of Bari, Bari, 70124, ItalyCorrespondence: Consalvo MattiaDepartment of Medical and Surgical Science, University Sapienza, Corso della Repubblica, 79, Latina, 04100, ItalyTel +39 0773 6511Email [email protected]: The aim of the present work was to evaluate the knowledge and prescriptive habits of clinicians involved in the management of chronic non cancer pain (CNCP), with a special focus on the use of opioids.Methods: A Delphi method was used. A Board of specialists elaborated and discussed a series of statements, based on available literature and personal clinical expertise, about particularly controversial topics on pain pathophysiology and treatment. A Panel of experts in the field of pain management, selected by the Board, was invited to vote the proposed statements, indicating the level of agreement on a 5-point Likert scale (1: strongly disagree; 2: disagree; 3: partially agree; 4: agree; 5: strongly agree). The threshold for consensus was set at minimum 66.6% of the number of respondents with a level of agreement ≥ 4 (Agree or Strongly agree).Results: The Board included 5 pain therapists, 1 pharmacologist and 1 methodology expert and drew up a total of 36 statements (for a total of 40 requested answers)”. A total of 100 clinicians were included in the Expert Panel. Respondents were 89 (89%). Consensus was achieved for 32 out of 40 answers. Most of the lack of consensus was recorded for statements regarding opioids use, and resulted from a low level of agreement (3 on the Likert scale), suggesting a neutral position deriving from a lack of knowledge rather than a strong contrary opinion.Conclusion: Most of the proposed items reached consensus, suggesting a generally homogeneous approach to CNCP management. However, the lack of consensus recorded for several items regarding opioid use confirms the need to fill important gaps in the knowledge of available agents. A clear explanation of the peculiar pharmacological properties of drugs associated with potential clinical advantages (such as buprenorphine) will help optimize pain treatment in both primary care and hospital settings and improving pain control in CNCP patients.Keywords: pain, chronic, non-oncological, strong opioids, buprenorphine, Delphi surve
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
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