Pain Management

Biography

Abstract

Eye pain is common and initially managed by primary care physicians. Questions to consider when examining patients: 1) Are there any alarming eye findings that need an urgent ophthalmology referral? 2) Is this particular eye condition part of a larger systemic disorder or one of a primary eye disease? 3) Is there a need for additional testing such as HIV or HPV screening? 4) Should a biopsy be performed? Meticulous patient history and risk factor analysis combined with a clinical examination will help formulate a differential diagnosis and inform further management. By doing so, it obviates the need for unwanted testing, early specialist referral, and improves patient outcome. Familiarization with the typical presentation and appearance of a pterygium will portend an opportunity for the comprehensive practitioner to treat with conservative therapy, thus saving the patient time and discomfort. In the rare refractory case or atypical appearance, consultation with ophthalmology is needed. A 35-year-old Hispanic male patient with a history of pterygium presented with complaints of worsening left eye pain for months. Prior to these symptoms, the patient had been treated for pterygium for years without eye pain. Over the past two weeks, the patient had also noticed more redness and soreness that occured all day. He noticed darkening in the medial vision of his left eye, persistence of left eye pain and visual changes. An excisional biopsy of the lesion was performed. The final biopsy reports revealed an ocular surface squamous cell carcinoma in situ causing pterygium.

Biography

Dr. Mayank Ohri graduated medical school from American University of Antigua. Currently a full time Internal Medicine Physician at Kendall Regional Medical Center in Miami Florida. Participated in multiple research projects including quality im­provement, oral and poster presentations at National Internal Medicine Conferences. He is anticipated to complete his MBA majoring in Healthcare Administration in 2019.

Abstract

Introduction: Transient cortical blindness after contrast induced media is an extremely rare occurrence. It has been estimated that approximately 1% of the patients suffer cortical blindness after undergoing a cerebral or vertebral angiography. Based on our literature review only 18 documented cases have been reported of transient cortical blindness secondary to coronary angiography using modern, non-ionic, low-osmolality based contrast agents. We present a case of an elderly man with symptomatic bradycardia who underwent dual-chamber permanent pacemaker implantation that had transient contrast induced cortical blindness.

Case Report: Patient is a 77-year-old male truck driver with a past medical history of hyperlipidemia that presents to our hospital after a syncopal episode that resulted in left rib pain. He reported loss of consciousness after drinking several beers and felt as if the room was spinning around him. He denied any postictal confusion, loss of urinary or bowel incontinence. CT scan of the chest was done which showed 4th and 5th rib fractures. On EKG his heart rate was 47 beats per minute with a new onset of right bundle branch block with no ST segment changes. His 2D echocardiogram and troponins were within normal limits. He underwent a tilt table study, which showed classic mixed cardio inhibitory and vasodepressor response, with heart rate in 20’s, consistent with neurocardiogenic syncope. Based on these findings, a dual chamber cardiac pacemaker was implanted successfully, without any complications. Agents that were used during the procedure included lidocaine for local anesthesia and low osmolality, non ionic iodine based contrast. Approximately 1 hour after the procedure the patient started to experience blurred vision, which soon progressed to bilateral blindness. On examination, his fundoscopic examination was normal and no neurological deficit was present except for blindness. Since, he was not a candidate for an MRI; he underwent head/neck CTA that was within normal limits. Next day at 1:30 am the patient started to notice improvement in his vision and by 9:00 am his vision was restored back to normal. Based on this clinical picture it was concluded that his transient bilateral loss of vision was contrast induced. Patient was safely discharged from the hospital soon after.

Conclusion: Contrast induced cortical blindness is an extremely rare finding. This is an excellent case to inform healthcare professionals of a potential serious side effect from a commonly used agent. There is no specific measure that needs to be taken for protection against this unusual and alarming complication. Careful neurological assessment and consultation accompanied by MRI or CT scanning can confirm the diagnosis. When these agents cause cortical blindness then it is anticipated and it takes 24-72 hours for resolution back to normal vision.

Biography

Laurent Ecochard has completed his PhD in Physiology by Uni­versity of Lyon, France. He has served as a study coordinator in oncology and hematology units of Paris Public Hospital and has acted as a Clinical Research Associate in different thera­peutic areas across the pharmaceutical industry in France. He has then endorsed responsibilities as Project Manager and ultimately as Clinical Study Leader in General Medicines at Novartis. He has published several papers in reputed journals and is currently working as a Clinical Development Director on the Olodanrigan Program of Development in Peripheral Neuro­pathic Pain at Novartis Pharma AG, Switzerland.

Abstract

Pain is a symptom related to a heterogeneous group of disorders. Pain can be further subdivided into whether the origin of the pain is nociceptive, neuropathic, or mixed nociceptive/neuropathic origin. Peripheral neuropathic pain is a pain initiated or caused by a primary lesion or dysfunction in the nervous system. For the indication of the treatment of neuropathic pain, FDA recommends to conduct one in each of atleast three separate neuropathic conditions while EMA only recommends two separate conditions (one trial each). In this context, several investigational drugs have failed to show benefit in reducing the pain intensity in the past two decades and have led the sponsors of the same compounds to terminate their programs of development prematurely. Several design considerations are now widely recommended to improve assay sensitivity and increase the chance of success of the chronic pain therapies under investigation. Besides these study design factors, patient, study site and outcome measurement factors have to be carefully taken into consideration. Once the multi-centre pain trials are actively recruiting, the operational teams frequently deal with difficulties to identify the right candidates for enrolment and as many screened patients do not qualify due to uncontrolled co-morbid conditions and/or prescribed pain medications that are not allowed per protocol. Given the prevalence and incidence of neuropathic pain, there is a clear need for better treatment as the related conditions have such a severe impact on the patient’s ability to function on a daily basis thus affecting overall quality of life, but also represent a substantial burden for family and caregivers. In this regard, innovative adaptive (enriched) study designs may have a major impact on increasing the probability of positive study results with these potential better treatments that are randomly compared to placebo as randomized placebo controlled multi center pain trials are recommended in neuropathic pain.

Biography

Abstract

Patients with failed back surgery syndrome, treated with spinal cord stimulation (SCS) rarely report absence of pain after the procedure. Most of them have been struggling with chronic pain in the back and/or legs for many years, consequently confronting functional limitations in various areas, which may not resolve automatically after SCS procedure. Main goals of interdisciplinary pain rehabilitation program for patients with failed back surgery syndrome after SCS are directed in behavioral change to support adaptation of patients’ functioning in different areas (physical functioning, balance training, body mechanics, endurance, mood, quality of sleep, fatigue and participation in meaningful activities) without pain exacerbations. The lecture I will present the consecutive case series study of 10 patients followed one year after SCS combined with interdisciplinary rehabilitation on the basis of outcome measures, routinely applied in our clinical practice, aimed to capture physical symptoms, functioning and possible goal fulfilment: six min walk test with pain assessment after walking, berg balance scale, COPM, video analysis of body mechanics, brief pain inventory - pain interference, maximal pain in the last week by numerical analogue scale, pain detect and beck depression inventory. Our previous study right after completion of interdisciplinary rehabilitation program already demonstrated same measurable changes which might point to the fulfilment of goals set individually directed generally into the behavioral change to adapt better in different areas of functioning despite remaining pain and sequel of past long-term chronic pain syndrome. The cognitive behavioral training seems to be the key processes supporting the behavioral change.

Biography

Midori Ura started working as a Medical Technologist in Tokyo after graduating from University. She completed her Master’s Degree in Public Health in the United Kingdom, following which she participated in organizations for international cooperation, such as JICA (Japan International Cooperation Agency) and UNFPA (United Nations Population Fund), and did a research project on the developing countries for the purpose of global health. In order to be a qualified technologist, she started work­ing as a Medical Technologist at the Shinshu University Hospi­tal, Japan again and has obtained the Registered Medical So­nographer certification in the field of vascular and OBGYN in­cluding fetus screening. In the meantime, she also completed her PhD in Health Science at Shinshu University in Japan. She has been a Lecturer of Clinical Physiology and Public Health at Junshin Gakuen Univeristy.

Abstract

Purpose: Sleeping in the lateral position during pregnancy can potentially reduce the severity of sleep disordered breathing (SDB). However, this hypothesis has not been formally investigated in pregnant women. Unlike previous studies that have relied largely on self-reported measures of sleeping position, we investigated the relationship between SDB and sleeping position during late pregnancy using objective measurements.

Methods: Thirty pregnant women at the 37th gestational week and 30 non-pregnant women (n-Pr) participated in the present study. The pregnant women were divided into two groups: those with body mass index (BMI) ≥30 kg/m2 (with obesity, p-Ob), and those with BMI <30 kg/ m2 (without obesity, p-nOb). Data were collected using a portable screening device to detect SDB indicated by the respiratory disturbance index (RDI) as well as sleeping position.

Results: The occurrence of the lateral sleeping position was higher in pregnant women than in n-Pr (P < .05). The total RDI significantly differed among the three groups [P < .01; p-Ob, 10.7 (3.1); p-nOb, 7.0 (3.0); n-Pr, 4.3 (2.9)]. The p-Ob group showed significantly lower RDI in the lateral position than in the supine position (P = .04). Moreover, there was a significant difference in RDI between p-Ob and p-nOb for the supine position (P = .001), but there was no between group difference for the lateral position.

Conclusions: Sleeping in the lateral position is likely to mitigate existing SDB in pregnant women with obesity in late pregnancy and may be an effective precaution against undiagnosed SDB and associated complications.

Biography

Jayawickreme K P is an MBBS Graduate from the Faculty of Medicine at University of Peradeniya who passed out with second upper class honors and a distinction in Paediatrics. She is currently a Registrar in Internal Medicine at The Sri Jayawardenepura General Hospital, Sri Lanka and is a Postgraduate trainee of the Postgraduate Institute of Medicine, of the University of Colombo. She worked as a Temporary Lecturer at the Department of Medicine at the Peradeniya University. She has published seven researches and five case reports in internationally recognized reputed journals and has presented oral and poster presentations in local and international medical conferences.

Abstract

Background & Aim: Pain is not pathology per se, but a symptom indicating underlying disease. Blind treatment of pain will result in masking the only presentation of a possible sinister underlying pathology. The objective of this study is to analyze the knowledge, attitudes and practices on pain management among doctors to prevent underuse, misuse and abuse of analgesics and to optimize pain management.

Methodology: This is a descriptive study, where a standardized self-administered questionnaire; knowledge and attitudes survey regarding pain (KASRP) was filled by doctors at the Sri Jayewardenepura General Hospital and analyzed.

Results: Among 102 participants the mean KASRP score was 56.25%, with majority of 59.8% subjects having moderate scores (50-70%) and only 7.8% having high scores (>70%). The mean number of years of experience among those who had low scores was 3.52 years and that of high scores was 6.25 years, but there was no statistically significant correlation between years of experience and KASRP score according to the spearman non parametric test (p=0.073). The mean score of postgraduate trainees was 61.9%. Post graduate trainees have a statistically significant higher score than intern medical officers (p=0.001) and Intern medical officers have a statistically significant higher score than medical officers (p=0.04) according to Post HOC test.

Conclusion: The awareness on pain management among the study population is average and needs to be improved. The knowledge, attitudes and practices are higher among those who have a continuous medical education and training and who are aware of current pain management guidelines. Introducing pain management workshops will be beneficial in improving the outcome.

Biography

Nevena Ilic has completed her Sub Specialization in Endocri­nology at Belgrade University Medical School in 2009 and Mas­ter’s Degree in Thyroid Diseases in Italy 2014. She completed Internal Medicine Specialization at Military Medical Academy Hospital, Belgrade in 2002. Since, 2014 she works as Prime En­docrinologist at Euromedik General Hospital, Belgrade where, she organized endocrinology service and several symposiums in Belgrade and Rome where she was a speaker. She spoke at several international congresses. She has published 23 papers in reputed journals. She is a member of European and Italian Endocrinology Society.

Abstract

Epidemiological studies in last ten years have shown that 30-50% of obese men have lower testosterone levels for age. Pathophysiological mechanisms of so called dysmetabolic hypogonadism are complex and they involve cytokine (TNF , IL 1, IL 6) and adpokine (leptin) secretion, insulin resistance, abnormal turnover of many hormones due to an endocrine axis changes (GNRH-LH-testosterone, GH-IGF-1, TSH-T4,T3, ACTH-cortisol) and obstructive sleep apnea with disturbed REM sleep phase. Low testosterone level causes body composition changes with higher total body fat percentage and loss of muscle mass. High body fat worsens insulin resistance which increases weight gain and obesity, creating a vicious cycle. Consequences of low testosterone level in obese men are higher risk of type 2 diabetes, metabolic syndrome and cardiovascular diseases, cancer, infertility, erectile dysfunction, bone loss, bone marrow changes depression, alzheimer’s disease and higher overall mortality. The dilemma is weather to treat these patients with hormone replace therapy or not. Recent studies have shown positive results in metabolic response such as better lipid status and increased insulin sensitivity, weight loss and body composition changes with a decrease of fat mass and increase of muscle mass in patients treated with testosterone replacement therapy. Further studies are required to prove if this kind of treatment decreases mortality risk.

Biography

Dhruba Jyoti Borgohain is Assistant Professor, Anesthesiology, Assam Medical College, Dibrugarh, Assam, India. He did his MBBS from the same institute in 1994 and the MD in Anesthe­siology in 2001. He did a fellowship in pain medicine from Delhi Pain Management Centre, New Delhi in 2008 and since then running a pain clinic in the institute. He is a prolific speaker in the national and regional conferences and seminars. His main interest is pain medicine and obstetric anesthesia.

Abstract

Chronic pelvic pain is a very common pain especially in women due to a multitude of factors. In a country like India, because of the prevalence of age old traditions and gender bias, the sufferers come to the care givers at a late stage. The management then becomes quite difficult and tasking. In our study, we evaluated 65 cases, where the patients were suffering from cancers of the cervix and lower gut with intractable pain. After going through the history, physical examination and the required investigations, we performed superior hypogastric plexus block with absolute alcohol, after a successful block with steroids and local anesthetics. The study was done to relieve the pain and to improve the quality of life in those patients in whom surgery was not feasible or who were unable to afford surgery for various reasons. The study was followed up for duration of six months thereafter.

Biography

Patti Kastanias is a Nurse Practitioner at the University of To­ronto Collaborative Bariatric Surgery program at the Toronto Western Hospital, University Health Network since 2011 and is a Lecturer at the Lawrence Bloomberg Faculty of Nursing, University of Toronto. Prior to this she was a nurse practitioner for over 10 years in the Toronto Western Hospital Acute Pain Service. She has published several original articles on pain management practice and presented nationally and interna­tionally on the topics of pain management, bariatric and nurse practitioner practice.

Abstract

Surgical patients consider information about pain management to be highly important. At the same time, evidence indicates that individuals of racial/ethnic minorities are more likely to experience inadequate pain management. This study investigated the needs of Limited English Proficiency (LEP) general day surgery patients, who spoke primarily Italian, Cantonese, or Portuguese at home for information about postoperative pain. LEP subjects who had undergone a day surgery procedure completed a telephone information needs survey in their native language (Italian, Portuguese, or Cantonese) within 72 hours after discharge from a large urban Canadian hospital center. Composite mean scores were calculated for each item. Chi-squared analyses were used to probe for intergroup differences. Sixty-three subjects in total completed the survey: 41% Italian, 38% Portuguese, 21% Cantonese. Mean age of the sample was 70 years old, 89% were born outside of Canada and 52% were male. All survey items were rated as moderate (5-6/10) to high ( >7/10) importance. Surgical subtype, health status and age had no effect on the importance of any item. There were no significant differences between the three language groups on any of the items. Overall, the top ranked information items were: the plan for which drugs to take and when; what I can do if I still have pain or side effects and side effects I was most likely to get. When compared with English fluent subjects, LEP subjects overall placed more importance on information regarding help with paying for pain medication (p = 0.001) and the side effects they were most likely to get (p< 0.05). Due to a paucity of literature in this area, further research is warranted.

Biography

Katerina Ristoska has completed her Graduation in Medical Faculty, Skopje, Republic of Macedonia, where she also attend­ed her specialization in internal medicine. Currently, she is the Author and Coauthor of 57 publications at the international congresses at home and abroad, as same in the several other journals. She was Contributor on two multi-centric studies of pharmaceutical company “Krka-Farma” DOOEL Skopje. She is a Fellow of New Westminster College, Vancouver, British Co­lumbia, Canada; Member of The Macedonian Association of internal medicine, ESC, EAPCI, HFA, EACVI, EAPC and ACCA; Member of ESC Council on Cardiovascular Nursing and Al­lied Professions, ESC Council on Hypertension, ESC Council on Valvular Heart Disease, the Member of Working Group on Grown-up Congenital Heart Disease, the Member of Working Group on Aorta & Peripheral vascular disease; Member of ERA–EDTA Diabesity Group, ERA– EDTA EUREKA -M Working Group of European renal and Cardiovascular medicine, ERA - EDTA CKD- MBD Working Group and an Accredited Examiner of a doctor’s professional exam for obtaining a work license and Editor-In-Chief in the International Journal of Medicine and Healthcare and Section Editor in the Interdisciplinary Studies, for Healthcare in International Journal Anglisticum.

Abstract

Background: Cardio renal syndrome (CRS) is used to describe clinical conditions in which cardial and renal dysfunction co-exist. First were classified in 2008 and divided into five subtypes. Its pathogenesis is not fully understood. Additionally available therapeutic strategies are challenged to manage this syndrome.  Case presentation: We report the case of 60-year-old diabetic man, hypertronic, with adipositas permagna, previous myocardial infarction (1998), LVH and diastolic dysfunction, with implanted St. Jude’s prosthesis and the aneurysm of ascending aorta. In 2013, he was diagnosed with bilateral renal cysts, with a worsening of renal function, which was characterized as chronic renal failure stage three (GFR 39mL/ min according to MDRD formula), with albuminuria of 90mg/L and an increased quotient albumin/creatinine of 164mg/dL. Same year, after Enterococcus faecalis bacteremia, without the development of endocarditis, he develop atrial thrombus, which is resumed by conservative treatment. Due to the development of Stanford B aortic dissection and aneurysmal endoleak, with the tendency of aneurysm growth, was performed the stenting with prosthesis of the thoraco-abdominal transition of the aorta and of truncus coeliacus. He is suffering from restrictive, moderate peripheral obstructive ventilatory insufficiency, with the development of respiratory acidosis, dependent on oxygen therapy and CPAP mask (SAP syndrome). Infectiously affected by gastroenteritis and right-side pneumonia he developed an acute decompensation of chronic renal failure, with a worsening of heart failure, develops pulmonary edema, with an increase in degradation products, and commences hemodialysis three times a week. In December 2016, during dialysis he developed VF with a state of unconsciousness, which was treated with CPR with electro shock therapy. After that he developed bradycardia, AF and AV block third degree, therefore AICD was implanted. In December 2017 he was diagnosed that stentprothese in the thoracolumbar junction with supply of the celiac trunk via a stent with a retrograde restoration of the truncus was compromited and developed new atrial thrombus.

Conclusion: Since renal function is the single most important factor in the outcomes of patents with heart failure, the importance of early recognition, after adjusting the differences in baseline data, etiology and severity of disease, as much of early therapeutic strategy have impact of long life outcomes.