Pravardhan Birthi

Hypogonadism associated with long-term opioid therapy: A systematic review.

BACKGROUND Sexual dysfunction and Opioid-Induced Sexual Hormone Deficiency (OPISHD) have been associated with patients on long-term opioid pain therapy. There have been few comprehensive reviews to establish a relation between hypogonadism with chronic opioid pain management. The OPISHD is often not treated and literature guiding this topic is scarce. OBJECTIVE To investigate hypogonadism associated with long-term opioid therapy based on qualitative data analysis of the available literature. STUDY DESIGN Systematic review. INTERVENTIONS The review included relevant literature identified through searches of PubMed, Cochrane, Clinical Trials, US National Guideline Clearinghouse, and EMBASE, for the years 1960 to September 2013. The quality assessment and clinical relevance criteria used were the Cochrane Musculoskeletal Review Group Criteria for randomized control trials and the Newcastle-Ottawa Scale Criteria for observational studies. The level of evidence was classified as good, fair, and poor, based on the quality of evidence. MAIN OUTCOME MEASURES The primary outcome measures were clinical symptoms and laboratory markers of hypogonadism. Secondary outcome measure was management of OPISHD. RESULTS Thirty-one studies were identified, of which 14 studies met inclusion criteria. There were no randomized control trials and eight of 14 studies were of moderate quality. The remaining studies were of poor quality. Four studies report most patients on long-term oral opioid therapy have associated hypogonadism and three studies of patients receiving intrathecal opioid therapy suggest that hypogonadism is common. CONCLUSIONS There is lack of high-quality studies to associate chronic opioid pain management with hypogonadism. At present, there is fair evidence to associate hypogonadism with chronic opioid pain management, and only limited evidence for treatment of OPISHD.

Subcutaneous Botulinum Toxin A for the Treatment of Refractory Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain condition of unclear etiology that can be very difficult to treat. Typically, CRPS affects the extremities, although it can affect any area of the body [1]. In 2010, the Budapest criteria for the clinical diagnosis of CRPS were established as an update to the more nonspecific criteria originally given in 1994 [2]. Currently, to meet the diagnosis of CRPS, a patient must present with the following conditions: 1. Continuing pain that is disproportionate to any inciting event. 2. At least one symptom reported in 3 of the 4 following categories: a. Sensory: reports of allodynia and/or hyperesthesia type symptoms. b. Vasomotor: temperature asymmetry and/or skin color changes. c. Sudomotor/edema: edema and/or sweating changes/asymmetry. d. Motor/trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin). 3. At least one sign at the time of evaluation in 2 or more of the following categories: a. Sensory: hyperalgesia to pinprick and/or allodynia to light touch (or deep somatic pressure or joint movement). b. Vasomotor: temperature asymmetry and/or skin color changes (or asymmetry). c. Sudomotor and/or edema: edema and/or sweating changes (or asymmetry). d. Motor and/or trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin).

A Rare Case of Tardive Dyskinesia and Akathisia Induced by Citalopram

epression is one of the most commonly encountered problems in clinical practice. It also s a very common condition in patients with traumatic brain injury (TBI). Citalopram is one f the most commonly used antidepressants agents, and as is true for all selective serotonin euptake inhibitors (SSRIs), it exerts its antidepressant effect by blocking the reuptake of erotonin, thereby increasing extrasynaptic serotonin levels [1]. Tardive dyskinesia is a movement disorder characterized by involuntary movements of he tongue, lips, face, trunk, and extremities that has been shown to occur in patients treated ong term with dopaminergic antagonist medications. The medications most commonly ssociated with this disorder are older antipsychotic agents such as haloperidol, fluphenaine, and trifluoperazine. Other nonantipsychotic medications associated with this synrome include cinnarizine, flunarizine, and metoclopramide. Tardive dyskinesia is most ommon in patients with schizophrenia, schizoaffective disorder, or bipolar disorder who ave undergone long-term treatment with antipsychotic medication. However, patients ith fetal alcohol syndrome, other developmental deficits, and various brain disorders are ulnerable to the development of tardive dyskinesia, even after receiving a single dose of the ausative agent [2]. Extrapyramidal symptoms (EPS), such as akathisia, are commonly reported side effects f SSRIs. Tardive dyskinesias also have been reported in the literature in conjunction with the se of some SSRIs such as paroxetine, fluoxetine, and sertraline but not with citalopram. These ide effects are thought to be a consequence of serotonergically mediated inhibition of the opaminergic system. Here, we report a case of tardive dyskinesia and akathisia that occurred fter the use of citalopram to treat depression in a patient with history of head injury.

The Use of Intrathecal Baclofen Therapy for Myoclonus in a Patient With Lance Adams Syndrome

Myoclonus is a movement disorder characterized by the sudden onset of jerking, “shock-like” involuntary movements that may be triggered by voluntary movement or sensorystimulation. Lance Adams syndrome (LAS) is a type of myoclonus associated with hypoxicinjury to the brain. It was initially described by Lance and Adams in 1963 in a series of 4patients in whom action myoclonus developed as sequelae of hypoxic encephalopathy [1].Since that initial description, more than 100 cases have been reported in medical literature;however, LAS remains a rare condition.When myoclonus is secondary to hypoxic events, it can occur as 2 variants [2]: (1) acuteposthypoxic myoclonus (PHM), which usually occurs within 24 hours of the insult and ischaracterized by generalized myoclonus and poor prognosis; and (2) chronic PHM or LAS,which begins after a delay of generally a few days to a month and manifests predominatelyas action myoclonus. The presence of LAS adds significantly to the functional decline andreduction in quality of life in patients with anoxic brain injury because it causes additionaldifficulties with motor control, dexterity, and pain.Therapeutic options for persons with PHM are scarce and usually unsuccessful. Multiplepharmacologic treatments have been suggested, including clonazepam, levetiracetam, andlevodopa [2]. Baclofen also has been used in both experimental models [3] and in humans[4,5] with promising results.Theuseofintrathecalbaclofen(ITB)therapyinpatientswithposthypoxicmyoclonushasnotbeendescribedintheliteraturetoourknowledge.WepresentacaseofPHMthatimprovedwiththe use of ITB therapy.

Interventional treatment of refractory cancer pain.

Recent advances in medical science have prolonged the life expectancy for many cancer patients. However, many studies demonstrate that cancer pain is a symptom for two thirds of patients in the advanced stages of the disease and nearly universal in the last 48 hours of life. Whereas most cancer patients can be effectively treated with conventional analgesics, 10% to 15% of patients require additional, and sometimes invasive, therapy. The most commonly used procedures for the treatment of this refractory cancer pain is the topic of review in this paper. Neurolytic blocks, such as celiac plexus and ganglion of impar block, are still used in the management of pain related to abdominal and pelvic cancers. Nondestructive interventional techniques include the use of epidural and intrathecal spinal analgesics. The efficacy, recommended medications, and adverse effect profile of these therapies are reviewed.

Neuroleptic Malignant Syndrome Associated With the Use of Carbidopa/Levodopa for Dystonia in Persons With Cerebral Palsy

Cerebral palsy (CP) is a disorder of movement and posture resulting from a nonprogressive injury to the immature brain that is marked by changes in muscle tone at rest and with activity [1]. The diagnosis is usually made during childhood. Affected children have delayed motor development that usually is substantiated by magnetic resonance imaging findings [1]. Hypotonia may be present in the early stages of CP, but upper motor neuron findings ultimately predominate, with increased tone and hyperreflexia and impaired motor control, balance, and coordination. These changes often lead to secondary contractures and deformities. Various movement disorders are found in patients with CP, including spasticity, dystonia, choreoathetosis, and ataxia. Dystonia is usually treated medically with agents that stimulate dopaminergic activity. The combination drug consisting of levodopa and carbidopa uses levodopa as a precursor to dopamine that is able to cross the blood-brain barrier for conversion to dopamine in the central nervous system [2]. Trihexyphenidyl and benztropine are anticholinergic medications used to treat dystonia by antagonizing remaining cholinergic receptors. All these medications are used to re-establish a balance between injured dopamine and acetylcholine pathways, which are hypothesized to coexist in the substantia nigra of the basal ganglia [3]. Neuroleptic malignant syndrome (NMS), a disorder thought to be caused by dopamine receptor blockade, causes fever, rigidity, and altered mental status [4,5]. Normally this disorder is caused by antipsychotic medications or abrupt withdrawal of dopamine agonists [6].

Botulinum toxin a injection to facial and cervical paraspinal muscles in a patient with stiff person syndrome: a case report.

Stiff person syndrome (SPS) is a rare neurologic disorder of unknown etiology characterized by increased resting muscle tone, progressive rigidity, and stiffness of the axial musculature. We present a case of a 48‐year‐old male patient with SPS who experienced facial and neck muscle spasms that were uncontrolled with oral medications and the use of an intrathecal baclofen pump. Botulinum toxin A injections into the bilateral masseter and neck paraspinal muscles provided pain relief and spasm control, illustrating the use of botulinum toxin A injections in the small muscles of face and neck in patients with SPS.

Arnold-Chiari 1 malformation type 1 with syringohydromyelia presenting as acute tetraparesis: A case report

Abstract Context A 19-year-old woman who presented to a community hospital after awakening with tetraparesis, generalized paresthesia, and severe neck pain, and was transferred to an acute care hospital. Findings Magnetic resonance imaging of the head and spine was performed and revealed a cystic lesion extending from the C1 level to the C6 level as well as an Arnold-Chiari type 1 malformation. Emergent surgical posterior fossa decompression with duraplasty and C1 laminectomy was undertaken. Most symptoms improved immediately postoperatively. On post-operative day 15, the patient was transferred to our acute rehabilitation hospital for an additional 16 days. With continued aggressive therapy, she demonstrated complete resolution of tetraparesis as well as significant improvement in muscle strength and function in addition to resolution of paresthesia and neck pain. Functional independence measure scores were 69/126 on admission to 110/126 on discharge from the rehabilitation hospital. Her tetraparesis eventually resolved; manual muscle testing scores on follow-up 2 months later were 5/5 in all four extremities. Clinical relevance This is the first reported case of Chiari I malformation with syringohydromyelia presenting as acute tetraparesis, generalized paresthesia, and neck pain. Surgical decompression leading to resolution of symptoms made other etiologies extremely unlikely and there was no history of trauma. The different theories on the pathogenesis of syringomyelia are discussed.

Opioid Use in Chronic Pain Patients with Chronic Kidney Disease: A Systematic Review

Objectives To investigate the prevalence of chronic pain and opioid management among patients with chronic kidney disease (CKD). Design Systematic review. Methods A systematic search was performed, including citations from 1960 to May 2015. The review highlights methodological quality assessment of the selected studies; prevalence of pain; type, dose, and reason for opioid use; effectiveness of pain control and associated adverse effects of opioids in CKD patients. Results Twelve of 131 articles met inclusion criteria. There were no randomized controlled trials (RCT) evaluable, and 12 were observational studies. Out of 12 studies, four were of high quality, six were of moderate quality, and the remaining two were low-quality studies. The studies were from different countries with sample size ranging from 10 to 12,782. Several studies showed a high prevalence of chronic uncontrolled pain. The effectiveness of different categories of opioids, dose, duration, and commonly prescribed opioids varied across studies. Conclusions Based on a systematic review of the current literature, there is fair evidence for the high prevalence of chronic pain among patients with CKD, which is not being effectively managed, probably due to underprescription of analgesics or opioids in the CKD population. Clinicians are in need of additional and well-designed randomized control trials that focus on the indications for opioid therapy, appropriate opioid doses and dosing intervals, outcomes with adequacy of symptom control, and reporting on the incidence of adverse side effects.

Chronic Opioid Pain Management for Chronic Kidney Disease

ABSTRACT Questions from patients about pain conditions, pain treatment, and responses from authors are presented to help educate patients and make them effective self-advocates. The topics addressed in this issue are renal or kidney failure and chronic pain management with opioids, morphine, and oxycodone effect in the body over a period of time. This includes process of absorption, distribution, localization in tissues, biotransformation and excretion in chronic kidney disease, expected side effects and recommendations.