Option of interventional pain therapy in multimodal treatment of chronic cancer and non-cancer pain
Established role when pharmacotherapy or surgery not suitable
Indications well accepted
Evidence for efficacy moderate to strong
Option of interventional pain therapy in multimodal treatment of chronic cancer and non-cancer pain
Established role when pharmacotherapy or surgery not suitable
Indications well accepted
Evidence for efficacy moderate to strong
The International Association for the Study of Pain (IASP)1 defines trigeminal neuralgia (TN) as a sudden, usually unilateral, severe brief stabbing recurrent pain in one or more branches of the fifth cranial nerve
synonyms
Idiopathic trigeminal neuralgia / Tic Doulourex.
Trifacial Neuralgia.
Fothergell’s disease.
In 1677 John Locke, a American physician and philosopher, accurately identified the major clinical features of TN
In 1756 the French physician Nicolaus Andre coined the term “Tic douloureux” to the condition.
The English physician John Fothergill in 1773 published detailed description of TN, since then, it has been referred to as ‘Fothergill’s disease’.
Peripheral injections
Long acting LA
Alcohol
Glycerol
Peripheral neurectomy/ nerve avulsion
Cryotherapy
Gasserian ganglion procedures
Percutaneous stereotactic radiofrequency thermal lesioning of the trigeminal ganglion and/or root (rfl)
percutaneous glycerol gangliolysis of the trigeminal ganglion
percutaneous balloon microcompression of the trigeminal ganglion
Intracranial procedures
MVD
Partial sensory rhizotomy
Gamma knife radiation to the trigeminal root entry zone GKR
pain management after craniotomy and spine surgery. as a neuroanesthesiologist it our duty to manage post operative pain. pain in these patient are under treated.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation
The International Association for the Study of Pain (IASP)1 defines trigeminal neuralgia (TN) as a sudden, usually unilateral, severe brief stabbing recurrent pain in one or more branches of the fifth cranial nerve
synonyms
Idiopathic trigeminal neuralgia / Tic Doulourex.
Trifacial Neuralgia.
Fothergell’s disease.
In 1677 John Locke, a American physician and philosopher, accurately identified the major clinical features of TN
In 1756 the French physician Nicolaus Andre coined the term “Tic douloureux” to the condition.
The English physician John Fothergill in 1773 published detailed description of TN, since then, it has been referred to as ‘Fothergill’s disease’.
Peripheral injections
Long acting LA
Alcohol
Glycerol
Peripheral neurectomy/ nerve avulsion
Cryotherapy
Gasserian ganglion procedures
Percutaneous stereotactic radiofrequency thermal lesioning of the trigeminal ganglion and/or root (rfl)
percutaneous glycerol gangliolysis of the trigeminal ganglion
percutaneous balloon microcompression of the trigeminal ganglion
Intracranial procedures
MVD
Partial sensory rhizotomy
Gamma knife radiation to the trigeminal root entry zone GKR
pain management after craniotomy and spine surgery. as a neuroanesthesiologist it our duty to manage post operative pain. pain in these patient are under treated.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
Neuropathic pain poses a challenge to effective rehabilitation. Best practice, considerations & the use of Action Potential Simulation therapy to effectively treat neuropathic pain, sharing our results from a 2 year research project in people with MS.
Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Intervention Pain Management on Treating Postherpetic Neuralgia- dr. Rivan Danuaji Sp.N (K) ,M.Kes.pdf
1. Intervention Pain
Management on Treating
Postherpetic Neuralgia
Rivan Danuaji
Head of Neurology Department
Dr Moewardi Hospital/Medical Faculty of Universitas Sebelas Maret Surakarta
September 4th, 2021
2. Introduction
• Post herpetic neuralgia (PHN) is one of the most resistant chronic pain problems, commonly
affecting elderly patients.
• It presents as a pain that persists after the resolution of the rash caused by herpes zoster (HZ).
• Postherpetic neuralgia is defined as the occurrence of chronic, persistent, debilitating pain
with dermatomal distribution in patients who have recovered from shingles (Shiang Lin, et.al,
2019)
• Characteristic of PHN:
• aching, itchy, lancinating, or sharp
• allodynia, hyperalgesia,
• areas of anesthesia, and deficits in thermal, tactile, pinprick, or vibration sensations
• within or extending beyond the margins of the affected dermatomes
3. Introduction
• At 3months after the onset of shingles:
• Patients aged < 60 years have a 1.8% risk of postherpetic neuralgia,
• Patients aged > 60 years have risks of 3.3% (after 12 months).
• Despite the low probability, however, severe postherpetic neuralgia is considered
intolerable by the affected patients
• Postherpetic neuralgia is initially treated with medication à first line and second line
treatment option
• However, patients who experience persistent pain despite conservative treatment may
benefit greatly from interventional therapies
6. Pain
Intervention
for PNH
• IT injection of methylprednisolone
• Epidural injection of methylprednisolone
• Spinal Cord Stimulation
• rTMS
Central:
• Subcutaneous botulinum toxin A injection
• Local triamcinolone injection
• TENS
• Stellate ganglion block
• Paravertebral block
• DRG destruction
• Pulsed radiofrequency (DRG)
• Pulsed radiofrequency (intercostal nerves)
Peripheral
7. Intrathecal Injection of
Methylprednisolone
• Histopathologic studies of patients with PHN have
revealed subacute or chronic inflammatory processes
involving the infiltration and accumulation of
lymphocytes around the spinal cord
• PHN patients have relatively higher interleukin-8 (IL-
8) concentrations in the CSF
• A possible anti-inflammatory role for
methylprednisolone IT is the ability reduce the IL-8
concentration
9. Epidural Injection
of MP
• Interlaminar to transforaminal
epidural steroid injection (ESI)
approach
• In transforaminal approach, drug
is deposited close to the site of
inflammation of the targeted
DRG and spinal nerve, thereby
possibly providing the greatest
potential for benefit with limited
systemic impact
• Use MP 60mg and lidocaine
injected to epidural space or
near DRG
11. Spinal Cord Stimulation
• The mechanism of spinal cord
stimulation remains uncertain, The
“gate control theory of pain”
suggests that neural signal
transmission is regulated by the
dorsal horn of the spinal cord,
where A-beta fibers inhibit the
transmission of pain signals carried
by C-fibers
• Spinal cord stimulation may also
affect the levels of γ-aminobutyric
acid (GABA) and adenosine in the
dorsal horn and consequently
reduce neuropathic pain
12. Spinal Cord
Stimulation
• 3 studies reported
significant reductions in
postherpetic neuralgia
following spinal cord
stimulation
• By contrast, patients with
marked sensory loss and
those experiencing
constant pain without
allodynia would not
benefit from spinal cord
stimulation, as
deafferentation and
degeneration of the dorsal
column might be the
dominant mechanism
13. rTMS: 5Hz and 10 Hz
• Clinical practice has demonstrated that TMS applies not only to cranial stimulation, but
also to the simulation of peripheral nerves and muscles
• rTMS at 5 Hz and 10 Hz is effective in improving pain, sleep quality, and anxiety of patients
with PHN (Shalaby N et.al, 2016)
• Qian Pei et.al (2019) à RCT rTMS plus peripheral nerve block and standar medication.
• 60 patients with dx PHN à devide into 3 groups: ST + Sham rTMS, ST + 5Hz rTMS,
ST+10 Hz rTMS
• rTMS protocol: Intencity:80% MT, total number of stimulation 1500, location: M1 on
healthy side, duration: 17,5 minutes, 15 days (3 weeks)
• Follow up 1 months, 3 months
(Qian Pei et.al; Pain Physician 2019; 22:E303-E313 • ISSN 2150-1149)
14. Result
VAS reduction at different time points in the 3 groups Changes in QOL scores in the 3 groups
(T0: start treatment; T12: 12 weeks after rTMS)
(Qian Pei et.al; Pain Physician 2019; 22:E303-E313 • ISSN 2150-1149)
16. Subcutaneous Botulinum Toxin
A Injection
• Botulinum toxin is a neurotoxic protein purified
from the bacterium Clostridium botulinum
• Botulinum toxin reduces peripheral nociceptive
input by inhibiting the release of glutamate, a
peripheral neurotransmitter involved in
neurogenic inflammation.
• Botulinum toxin was injected subcutaneously
within a 1- to 2-cm radius over the painful region,
and the maximum doses did not exceed 200 and
100 IU
17. Subcutaneous Botulinum Toxin A Injection
• The observed benefits in both
studies included improved VAS
scores and sleep durations and
reduced numbers of patients
using opioids
• These effects emerged at 7 days
after injection and persisted for
3 months
• NNT of 1.2 for a 50% reduction
in the VAS score
• Smaller than conservative
medical treatments
18. Local Triamcinolone Injection
• Peripheral sensitization, which involves neural
damage and inflammation with subsequent
edema consequent to varicella zoster virus
reactivation, is among the mechanisms underlying
the development of postherpetic neuralgia
• the injured tissue releases inflammatory
mediators that reduce the nociception threshold,
and thus activate peripheral nociceptors
• Corticosteroids may ameliorate postherpetic
neuralgia by modulating this inflammatory
process
19. Local Triamcinolone Injection
• Patients received 3 injections at 2-week intervals and reported pain relief
at weeks 6 and 12
• There were some refractory events occur
20. Transcutaneous Electrical Nerve Stimulation (TENS)
• TENS is a noninvasive and safe
application of electrical stimulation to
the skin for pain control
• Produces segmental inhibition in the
dorsal horn, as well as descending
inhibition, and stimulates the release
of endogenous opioids to relieve pain
at both low and high frequencies
• Combine with medication, high-
frequency TENS for 30 minutes per
day during total periods of 4 to 8
weeks
• NNTs were 3.3 in the transcutaneous
electrical nerve stimulation plus
cobalamin group and 4.3 in the
transcutaneous electrical nerve
stimulation plus cobalamin and
lidocaine
21. Stellate Ganglion Block
• Sympathetic nervous system is
believed to be an important
mediator of pain
• After nerve injury or tissue
inflammation, collateral sprouting
in the peripheral and dorsal root
ganglia and the upregulation of
functional adrenoceptors may lead
to the formation of anatomic and
chemical couplings between
sympathetic postganglionic and
afferent neurons
• Sympathetic terminals also
contribute to the sensitization of
nociceptive afferents
• Mechanisms by which the
sympathetic nervous system
affects postherpetic neuralgia
remain uncertain
23. Paravertebral
Block
• Common alternative to epidural
injection, might provide short-term
relief of intractable postherpetic
neuralgia
• paravertebral block was also used to
prevent postherpetic neuralgia in
patients with acute herpes zoster-
related pain
• a lower VAS score and reduced doses
of pregabalin and acetaminophen
were observed during the first 4 weeks
after a single paravertebral block
injection, although the effects did not
persist beyond that point
24. Dorsal Root Ganglion Destruction
• PHN, the pain sensation may be caused by
an ectopic discharge in the nociceptors
and low-threshold afferents at the dorsal
root ganglion
• Use Adriamycin, is an anthracycline
topoisomerase II inhibitor, associated with
cytotoxic effects such as apoptosis,
autophagy, and necrosis à it could be
used to destroy the dorsal root ganglion,
and thus relieve pain by disrupting the
related signaling pathway
• In Indonesia à Use RF Ablation
25. Pulsed Radiofrequency (PRF)
• A minimally invasive, targetselective
technique that can be used to reduce
chronic postherpetic neuralgia-related
pain
• The underlying mechanism is attributed
to the effects of a rapidly changing
electrical field on neuronal membranes,
which results in electrolyte conduction
and subsequent depolarization
• Mitochondrial degeneration and a loss
of nuclear membrane integrity in the
continuous RF, but not in the PRF.
pulse frequency of 2 Hz and a pulse width of 20 ms
26. Pulsed Radiofrequency (PRF)
• All study
outcomes
favored pulsed
radiofrequency
• Observed
effects began
on Day 2 or 3
after treatment
and persisted
for 2-6 months
27. In Our Pain Clinic (RSUD Dr Moewardi)
• A 56 yrs old with severe PHN, VAS 8-9, burning, lancinating in the are right costa 4-5-6.
there were also allodynia around the burning lesion.
• It was already given gabapentine, mecobalamin and amitriptilline from previous hospital
for more than 4 months, and the pain better after take the medicine (VAS 5-6), but some
time “explosive pain” (VAS 9).
• We Injected Triamcinolon + Lidocain in Paravertebral Block USG Guide, and suddenly VAS
1-2.
• 1 week after à pain is already controlled (VAS 1-2) and gabapentine stoped, plan to
follow up for 2 weeks.
• We lost of follow up
28. Conclusion
• PHN remains a potentially debilitating and undertreated
form of neuropathic pain
• Conservative treatment still the first line of therapy
• With the advent of IPM options, one can provide
effective and long-lasting pain relief to patients not
responding to medical management
• the current evidence is insufficient for determining the
single best interventional treatment
• Considering invasiveness, price, and safety, the
subcutaneous injection of botulinum toxin A or
triamcinolone, transcutaneous electrical nerve
stimulation, and stellate ganglion block are
recommended first, followed by paravertebral block and
pulsed radiofrequency
• If severe pain persists, spinal cord stimulation could be
considered