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PURPOSE Six key elements of opioid medication management redesign in primary care have been previously identified. Here, we examine the effect of implementing these Six Building Blocks on opioid-prescribing practices. METHODS Six rural-serving organizations with 20 clinic locations received support for 15 months during the period October 2015 to May 2017 to implement the Six Building Blocks. Patients undergoing long-term opioid therapy (LtOT) at these study sites were compared with patients undergoing LtOT enrolled in a regional health plan who did not receive care at the study sites but who resided in the same primary care service areas (control group). Outcomes were monthly trend in the proportion of patients undergoing LtOT prescribed a >100 morphine equivalent dose (MED) of opioids daily and the total number of patients receiving an opioid prescription. An interrupted time series using difference- indifference analysis was used for tests of significance. RESULTS The proportion of patients prescribed a >100 MED of opioids daily decreased 2.2% (11.8% to 9.6%) among patients at the intervention clinics and 1.3% (14.0% to 12.7%) among patients in the control group. The rate of decrease was significantly greater among study patients than among patients in the control group (P = .018). The rate of decrease in the number of patients on LtOT at intervention clinics increased during the intervention period compared with the preintervention period (P CONCLUSIONS Efforts to redesign opioid medication management in primary care resulted in a significant decrease in opioid prescribing. Future research is needed to determine if these results are generalizable to other settings and to assess implications for patient-reported outcomes., INTRODUCTION Use of opioid medication long term for chronic pain has contributed to an epidemic of opioid overdose and addiction. (1) Although rates of opioid prescribing have moderated in recent [...]

Purpose To determine the analgesic efficacy and analgesic duration of lidocaine 20 mg and 40 mg on eliminating the vascular pain associated with hypertonic saline infusion. Method Patients who complained pain during infusion of hypertonic saline were randomized into three groups. They received normal saline (Group C), or lidocaine 20 mg (Group L20), or lidocaine 40 mg (Group L40). An electronic stopwatch was used to record the time to onset (T1) and the time to termination (T2) of the analgesic effect, and the analgesic duration (AD) was calculated as T2 - T1. Results The incidence of pain elimination was significantly higher in both of the lidocaine groups (83.3 and 56.1% in Groups L40 and L20, respectively) than in the saline group (16.3%). Furthermore, lidocaine 40 mg was significantly more effective than 20 mg in eliminating the pain. The analgesic duration was significantly longer in Group L40 than in Group L20 (211.4 ± 50.2 vs. 130.3 ± 39.5 s, P < 0.001) and Group C (211.4 ± 50.2 vs. 45.1 ± 14.5 s, P < 0.001), and the analgesic duration in Group L20 was significantly longer than in Group C (P < 0.001). The incidence of transient tinnitus/dizziness was significantly higher in Group L40 than in Group L20 (19.0 vs. 2.4%, P < 0.05). Conclusion A single bolus of Lidocaine was effective in eliminating the pain induced by hypertonic saline infusion, but just for a short period of time. Lidocaine (without venous occlusion) only provides a short analgesic duration for local vein., Author(s): Zhiping Song [sup.1] , Zhen Liu [sup.1] , Yang Zhang [sup.1] Author Affiliations: (Aff1) 0000 0004 1758 4073, grid.412604.5, Department of Anesthesia, First Affiliated Hospital of Nanchang University, , [...]

In the case of open urological surgeries, analgesic coverage at mid thoracic dermatomal levels is required. As shown in cadaveric studies, the site of QL block injection is an important determinant of the extent of dye spread and presumably local anesthetic dermatomal coverage. In this case series, we evaluated dermatomal blockade and analgesic efficacy of a subcostal approach to anterior QL block following open urological surgeries. Twenty-two adult patients undergoing renal transplant surgery (60%) and open nephrectomy (40%) received unilateral ultrasound-guided subcostal anterior QL block with catheter insertion. Sensory level, pain score (numeric rating scale, NRS), local anesthetic consumption, and opioid consumption (morphine equivalent dose, MED) were assessed daily for 3 days. The block achieved sensory blockade between T6-7 and L1-2. The most frequently affected dermatomes were T8 -T12 and the number of blocked segments was 3 (mean 2.8). The median (interquartile range Q1, Q3) of NRS pain score was 3.7 (2.8-5.5), 3.3 (2.4-4.7), 2.9 (1.9-3.6), and 2.3 (1.0-4.2) on POD0, POD1, POD2, and POD3, respectively. Our preliminary data showed that the subcostal approach to anterior QL block provides appropriate thoracic dermatome level needed for analgesia following open urological surgical procedures between T6-7 and L1-2., Author(s): Hesham Elsharkawy [sup.1] [sup.2] , Sanchit Ahuja [sup.3] , Sean DeGrande [sup.4] , Kamal Maheshwari [sup.1] , Vincent Chan [sup.5] Author Affiliations: (Aff1) 0000 0001 0675 4725, grid.239578.2, Department [...]

Doctors have long known that patients' expectations have a significant impact on the effectiveness of treatments prescribed for them. But much less is known about the effect of providers' expectations [...]

Glucocorticoids are utilized for their anti-inflammatory properties in the skeletal muscle and arthritis. However, the major drawback of use of glucocorticoids is that it leads to senescence and toxicity. Therefore, based on the idea that decreasing particle size allows for increased surface area and bioavailability of the drug, in the present study, we hypothesized that nanodelivery of dexamethasone will offer increased efficacy and decreased toxicity. The dexamethasone-loaded poly(lactic-coglycolic acid) (PLGA) nanoparticles were prepared using nanoprecipitation method. The morphological characteristics of the nanoparticles were studied under scanning electron microscope. The particle size of nanoparticles was 217.5 [+ or -] 19.99 nm with polydispersity index of 0.14 [+ or -] 0.07. The nanoparticles encapsulation efficiency was 34.57% [+ or -] 1.99% with in vitro drug release profile exhibiting a sustained release pattern over 10 days. We identified improved skeletal muscle myoblast performance with improved closure of the wound along with increased cell viability at 10 nmol/L nano-dexamethasone-PLGA. However, dexamethasone solution (1 [micro]mol/L) was injurious to cells because the migration efficiency was decreased. In addition, the use of dexamethasone nanoparticles decreased lipopolysaccharide-induced lactate dehydrogenase release compared with dexamethasone solution. Taken together, the present study clearly demonstrates that delivery of PLGA-dexamethasone nanoparticles to the skeletal muscle cells is beneficial for treating inflammation and skeletal muscle function. Key words: dexamethasone, PLGA, nanoparticles, skeletal muscle. Les glucocorticoides sont utilises pour leurs proprietes anti-inflammatoires dans le muscle squelettique et l'arthrite. Cependant, le principal probleme de l'utilisation des glucocorticoides tient au fait qu'elle mene a de la senescence et de la toxicite. Par consequent, a partir de l'idee qu'en diminuant la taille des particules on augmente la surface de contact et la biodisponibilite du medicament, dans la presente etude, nous avons formule une hypothese selon laquelle l'administration de nanoparticules de dexamethasone permet d'en augmenter l'efficacite et d'en diminuer la toxicite. Nous avons prepare des nanoparticules d'acide poly(lactique co-glycolique) [ou PLGA pour << poly(lactic-co-glycolic acid)>>] chargee de dexamethasone a l'aide de la methode de nanoprecipitation. Nous avons etudie les caracteristiques morphologiques des nanoparticules a l'aide de la microscopie electronique par balayage. Les nanoparticules avaient une taille de 217,5 [+ or -] 19,99 nm avec un indice de polydispersion de 0,14 [+ or -] 0,07. L'efficacite de l'encapsulation des nanoparticules etait de 34,57 [+ or -] 1,99 % avec un profil in vitro de liberation du medicament presentant un schema de liberation soutenue sur 10 jours. Avec le complexe PLGA-nano-dexamethasone a 10 nmol/L, nous avons observe une amelioration de la performance des myoblastes du muscle squelettique avec une amelioration de la fermeture de plaie ainsi qu'une augmentation de la vitalite des cellules. Toutefois, une solution de dexamethasone (1 [micro]mol/L) provoquait des lesions cellulaires en raison d'une diminution de l'efficacite de la migration. De plus, l'utilisation de nanoparticules de dexamethasone entrainait une diminution de la liberation de lipopolysaccharides produite par la deshydrogenase lactique plus marquee qu'avec la solution de dexamethasone. Dans l'ensemble, la presente etude montre que l'administration de nanoparticules de PLGA-dexamethasone aux cellules de muscle squelettique est avantageuse pour traiter l'inflammation et le fonctionnement du muscle squelettique. [Traduit par la Redaction] Mots-cles: dexamethasone, PLGA, nanoparticules, muscle squelettique., Introduction Dexamethasone and other glucocorticoids are used for the treatment of inflammation and pain related to skeletal muscle injury, wound healing, and arthritis (Bijlsma 2012; Klein 2015; Vyvey 2010). However, [...]

Upper quadrant pain secondary to active myofascial trigger points (MTrPs) is a common cause of referral for physical therapy intervention. Dry needling (DN) is the use of needles inserted directly into the muscle at an MTrP. The literature contains conflicting reports to whether DN of MTrPs or trigger points (TrPs) in the upper quadrant is efficacious in reducing pain. The purpose was to determine if DN treatment to the trapezius muscle in patients with proximal upper quadrant pain reduced pain intensity in comparison to controls and other interventions using outcome measures known as Cohen's d. Eleven randomized clinical trials were assessed in this systematic review. The mean PEDro score of the studies was 6.5 with a range of 4 - 8. Using Cohen's d to measure the efficacy of DN treatment, DN had a large effect and more superior for pain control in five studies compared to the controls/interventions (ES range of 0.81 to 17.46; CI of 0.08 - 1.50 and 15.19 - 19.50 respectively); moderate effect in one study which was not significant (ES of 0.52; CI: -0.15 - 1.8) and trivial/small effect, also not significant, in two studies (ES of 0.07 to 0.23; CI: -0.86 - 1.00 and -0.18 - 0.63). In three studies, DN appeared to be less effective but insignificant, when compared to the control or other interventions (ES range of -0.32 to -0.14; CI of 0.18 -0.63 and -0.89 -0.60 respectively). Besides having a large effect size in favor of DN in study 2, DN appeared less effective (but not significant) versus STT post-intervention and OMT at both post-intervention and follow up (ES range of 0.61 to -0.23; CI of -1.41 - 0.23 and -1.03 - 0.58.). However, p-value and Cohen's d as measures of outcomes do not totally not see results or outcomes at the same lenses. Cohen's d may probably be better in looking for clinical significance and the magnitude of such significance. Chronic pain, such as pain in the upper quadrant/trapezius that may not respond to traditional physical therapy, may be relieved with DN treatment. When considering treatment options for pain reduction, it is suggested that DN be taken into consideration. More research is necessary to document the effectiveness and to elucidate the mechanism of DN. Keywords: Dry needling, pain, myofascial trigger points, acupuncture, mechanism., INTRODUCTON The management of Pain continues to be a mayor focus in physical therapy clinics and varying therapeutic interventions are employed. There are conflicting reports in the literature that DN [...]

The present study was conducted to evaluate the local antinociceptive actions of fluoxetine, a selective serotonin reuptake inhibitor, and the possible involvement of the l-arginine/NO/cGMP/[K.sub.ATP] channel pathway in this effect using the formalin test in rats. To elucidate the underlying mechanisms, animals were pre-treated with L-NAME, aminoguanidine, methylene blue, glibenclamide, l-arginine, sodium nitroprusside, or diazoxide. Local ipsilateral, but not contralateral, administration of fluoxetine (10-300 [micro]g/paw) dose-dependently suppressed flinching number during both early and late phases of the test, and this was comparable with morphine also given peripherally. Pre-treatment with L-NAME, aminoguanidine, methylene blue, or glibenclamide dose-dependently prevented fluoxetine (100 [micro]g/paw)-induced antinociception in the late phase. In contrast, administration of l-arginine, sodium nitroprusside, and diazoxide significantly enhanced the antinociception caused by fluoxetine in the late phase of the test. However, these treatments had no significant effect on the antinociceptive response of fluoxetine in the early phase of the formalin test. Our data demonstrate that local peripheral antinociception of fluoxetine during the late phase of the formalin test could be due to activation of l-arginine/NO/cGMP/[K.sub.ATP] channel pathway. The peripheral action of fluoxetine raises the possibility that topical application of this drug (e.g., as a cream, ointment, or jelly) may be a useful method for relieving the inflammatory pain states. Key words: fluoxetine, local antinociception, l-arginine/NO/cGMP/[K.sub.ATP], formalin test, rat. La presente etude a ete menee en vue d'evaluer l'action antinociceptive locale de la fluoxetine, un inhibiteur selectif de la recapture de la serotonine, et le role eventuel de la voie de signalisation l-arginine/NO/GMPc/canal [K.sub.ATP] dans cet effet, a l'aide de l'epreuve a la formaline chez le rat. Afin d'elucider les modes d'action sous-jacents, nous avons administre au prealable du L-NAME, de l'aminoguanidine, du bleu de methylene, du glibenclamide, de la l-arginine, du nitroprussiate de sodium ou du diazoxide. L'administration de fluoxetine (10-300 [micro]g/patte) ipsilaterale--mais pas controlaterale -- a entrame une diminution proportionnelle a la dose du nombre de tressaillements au cours des phases precoce et tardive de l'epreuve, ce qui etait comparable a l'administration peripherique de morphine. Au cours de la phase tardive, l'administration prealable de l- NAME, d'aminoguanidine, de bleu de methylene ou de glibenclamide entramait une inhibition proportionnelle a la dose de l'antinociception provoquee par la fluoxetine (100 [micro]g/patte). Inversement, l'administration de l-arginine, de nitroprussiate de sodium et de diazoxide entramait une augmentation de l'antinociception causee par la fluoxetine au cours de la phase tardive de l'epreuve. Cependant, ces traitements n'avaient aucun effet notable sur la reaction antinociceptive entramee par la fluoxetine au cours de la phase precoce de l'epreuve a la formaline. Nos donnees montrent que l'action antinociceptive peripherique de la fluoxetine au cours de la phase tardive de l'epreuve a la formaline pourrait etre le fait de l'activation de la voie de signalisation l-arginine/NO/GMPc/canal [K.sub.ATP]. L'action peripherique de la fluoxetine souleve la possibilite que l'application topique de ce medicament (p. ex. sous forme de creme, d'onguent ou de gelee) soit une methode utile pour soulager les etats de douleur inflammatoire. [Traduit par la Redaction] Mots-cles: fluoxetine, antinociception locale, l-arginine/NO/GMPc/[K.sub.ATP], epreuve a la formaline, rat., Introduction Pain can cause a reduction in normal activities and can negatively affect quality of life. Depression and a feeling of sadness are commonly associated with chronic pain (McCleane 2008). [...]

Purpose We aimed to evaluate the effect of the intraoperative dexmedetomidine (DEX) on the incidence and severity of catheter-related bladder discomfort (CRBD) after non-urologic surgery. The secondary aim was to find the correlation between the levels of CRBD and postoperative pain sensation. Methods Adult male patients undergoing lumbar microdiscectomy were enrolled. Patients were randomized into two groups. After propofol administration, group D (n = 35) received DEX at a loading dose of 1 [mu]g/kg over 10 min, followed by a continuous infusion of 0.3-0.5 [mu]g/kg/h until the end of surgery. In group C (n = 35), an identical volume of 0.9% saline was infused in the same manner. Induction and maintenance of anesthesia were standardized. The incidence and severity of CRBD, postoperative pain, and adverse effects were assessed at 1, 3, and 6 h after surgery. Results The incidence of CRBD was significantly lower in group D than in group C at 1 h (34.3 vs. 62.9%, P = 0.017), 3 h (25.7 vs. 60%, P = 0.004), and 6 h (17.1 vs. 54.3%. P = 0.001) postoperatively. The severity of CRBD at 1, 3, and 6 h postoperatively was less in group D than in group C. Postoperative pain score was significantly lower in group D than in group C at 3 and 6 h postoperatively. Adverse events were comparable between two groups. There was a significant correlation between the severity of CRBD and postoperative pain score. Conclusions Intraoperative administration of DEX is a safe and effective practice for the prevention of CRBD after lumbar microdiscectomy and can reduce postoperative pain., Author(s): Youngsuk Kwon [sup.1] , Ji Su Jang [sup.1] , Sung Mi Hwang [sup.1] , Jae Jun Lee [sup.1] , Hyonjin Tark [sup.1] Author Affiliations: (Aff1) 0000 0004 0470 5964, [...]

Byline: Sourav. Chakrabarty, Samar. Biswas, Tamoghna. Maiti, Abhijit. Das, Ananya. Mandal, Prasun. Banerjee Objectives: The main objective is to compare efficacy and safety of pregabalin and amitriptyline monotherapy with their [...]

Byline: Amit. Gupta, Sweety. Gupta, Udit. Chauhan, Utkarsh. Kumar, Nidhi. Sharma, Rachit. Ahuja, Deepak. Rajput, Manoj. Gupta Aim: Palliation of symptoms of patients with advanced carcinoma gallbladder (GB). Materials and [...]

Byline: Deepak. Agrawal, Kanwaljeet. Garg Background and Aims: Dorsal root entry zone (DREZ) lesioning is a widely-used procedure for neuropathic pain which is refractory to other modes of treatment. However, [...]

Byline: Gunasekara. Fernando, Lagath. Wanigabadu, Buddhika. Vidanagama, Terancy. Samaranayaka, Jeewandara. Jeewandara Aims: Pain, a distressing symptom frequently suffered by cancer patients, is inherently associated with anxiety and depression yet often [...]