Shiv Pratap Singh Rana

A Comparative Efficacy of Amitriptyline, Gabapentin, and Pregabalin in Neuropathic Cancer Pain: A Prospective Randomized Double-Blind Placebo-Controlled Study

Neuropathic pain is difficult to diagnose and difficult to treat with certainty. So the aim of the study was to evaluate comparative clinical efficacy of pregabaline with amitriptyline and gabapentin in neuropathic cancer pain. A total of 120 patients with cancer having severe neuropathic cancer pain were enrolled in the study after taking approval from Institutional Ethics Committee and divided in to 4 groups: group AT—amitriptyline, group GB—gabapentin, group PG—pregabalin, and group PL—placebo. Oral morphine was used for rescue analgesic for continued pain. Pain score (Visual Analogue scale) and secondary outcome measures such as intensity of lancinating, dysesthesia, and burning on numerical rating scale, Global satisfaction score (GSS), Eastern Co-operative Oncology Group scoring (ECOG), and adverse effects were assessed. At the end of study there was significant decrease in pain score in group PG as compared to the other groups; group AT (P = .003), group GB (P = .042), and group PL (P = .024). Percentage of patients with lancinating pain and dysesthesia were significantly less in group PG as compared to groups GB and PL. All the patients in group PL needed rescue morphine. After 4 visits, maximum improvement in ECOG scoring and GSS scoring was observed in group PG patients. Our results suggested that all antineuropathic drugs are effective in relieving cancer-related neuropathic pain. There was statistically and clinically significant morphine sparing effect of pregabaline in relieving neuropathic cancer pain and neuropathic symptoms as compared to other antineuropathic drugs.

Early ultrasound-guided neurolysis for pain management in gastrointestinal and pelvic malignancies: an observational study in a tertiary care center of urban India.

Abstract:  Patients with advanced gastrointestinal and pelvic malignancies commonly present with pain of varying severity. In a majority of these patients, pain can be effectively managed using an integrated systemic pharmacological approach with oral morphine being the cornerstone of treatment. However, with escalating doses, intolerable side effects of oral morphine may lead to patient dissatisfaction. When oral pharmacotherapy fails to adequately address the issue of pain or leads to insufferable side effects, neurolytic blocks of the sympathetic axis are usually used for pain alleviation. As these blocks may reduce oral analgesic requirement, a reevaluation of their timing is merited. This article presents our hospital‐based in‐patient palliative care unit experience with early ultrasonography‐guided neurolysis of celiac plexus, superior hypogastric plexus and ganglion impar. Of the 44 patients we studied, 20 underwent celiac plexus neurolysis, 18 superior hypogastric plexus neurolysis, and 6 ganglion impar neurolysis. Their pain was being managed with oral morphine before neurolysis, but only 11.4% patients required oral morphine for satisfactory pain control, 2 months after neurolysis. The mean Visual Analog Scale score before block placement was 5.64 ± 0.69 and fell to 2.25 ± 1.33 at 2 months post neurolysis (P < 0.001). We suggest that bedside ultrasonography‐guided sympathetic axis neurolysis may be employed early in patients with incurable abdominal or pelvic cancer. Its use as a first‐line intervention for achieving pain control with minimal complications warrants further consideration and investigation. ▪

Breakthrough cancer pain: Review of prevalence, characteristics and management

Breakthrough pain has been associated with a reduced likelihood of adequate pain control. Despite the large and variable incidence of this phenomenon due to varied definitions of this type of pain, only a few studies have been conducted to assess and effectively treat breakthrough pain though the importance of managing breakthrough pain has been acknowledged by all. A large number of drugs from various classes and novel methods of administration like nasal and transmucosal buccal route, as in the case of fentanyl, have been used in these studies to manage this type of pain. A drug is needed with a quick onset of action and optimal duration that matches the characteristics of breakthrough pain. Some steps have been taken in earlier studies which used nasal formulation of fentanyl as it was found to achieve adequate and quick pain relief. However, further studies are required to confirm this so that in the future we can have as effective protocols for managing breakthrough pain as we have today for managing persistent pain as given by the World Health Organization.

Successful treatment of an intractable postherpetic neuralgia (PHN) using peripheral nerve field stimulation (PNFS).

Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome that arises as a sequel of herpes zoaster eruption. The treatment of postherpetic neuralgia is medically challenging and often frustrating in some situation as the exact mechanism of neuralgia is poorly understood and multiple and complex pathophysiology is postulated requiring poly pharmacy, which itself leads to many side effects. Here, we present a successful management of supra-orbital PHN using peripheral nerve field stimulation (PNFS), which was refractory to the commonly used pharmacological treatment. After successful trial stimulation, permanent stimulator was placed successfully, patient medication were tapered off within 2 weeks. At present, patient is in 8-week poststimulation with excellent pain relief, without any side effect.

Efficacy of the Anterior Ultrasound‐Guided Superior Hypogastric Plexus Neurolysis in Pelvic Cancer Pain in Advanced Gynecological Cancer Patients

BACKGROUND AND AIMS Pelvic cancer pain is a chronic pain related to the involvement of viscera, neural, and pelvic muscular. The study was carried out to evaluate the efficacy of anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in gynecological cancer patients. MATERIAL & METHODS The study was conducted after approval of our Institutional Ethics Committee. A total of 50 patients diagnosed with the advanced stage of a gynecological malignancy with severe pelvic pain were enrolled and randomly divided in two groups; in Group I, patients were given oral morphine, while in Group II, patients underwent anterior ultrasonography (USG)-guided superior hypogastric neurolysis. Oral morphine was given as rescue analgesia in both the groups. The parameters recorded were pain, functional capacity, global satisfaction score, and adverse effects. RESULTS There was a significant decrease in visual analog scale (VAS) score in the both groups, but the decline in VAS scores from baseline in Group II was significantly (P < 0.05) greater. The daily morphine consumption in Group II decreased throughout the study, and more patients in Group II improved in their functional capacity, although it was statistically insignificant. It was observed that global satisfaction scores were better in Group II during the initial first (P = 0.001) week and 1 month (P = 0.04) compared with Group I. CONCLUSION The anterior USG-guided superior hypogastric plexus neurolysis is a useful technique in relieving pelvic pain in gynecological malignancies. However, it requires expertise to perform the block. It also avoids the radiation exposure involved with computed tomography-guided and fluoroscopy-guided superior hypogastric block.

Psychosocial Concerns in Patients With Advanced Cancer: An Observational Study at Regional Cancer Centre, India

Introduction: The diagnosis and treatment of cancer is associated with substantial physical, psychological, and social morbidity. The objective of this study was to identify the prevalence of psychosocial concerns in the patients with advanced cancer admitted to our institute. Materials and Methods: A total of 100 patients admitted to the inpatient palliative care unit of our institute were enrolled in this study. A descriptive questionnaire that dealt with the patient’s psychological acceptance of the disease and emotional distress that accompanies the diagnosis was prepared. Patient’s social and spiritual needs were addressed, and the future concerns that the patient is preoccupied with were discussed on a one-on-one basis with the patient himself or herself. Results: It was found that a majority of patients, though aware of their diagnosis, were not aware of the disease prognosis. There was a generalized anxiety regarding the treatment of the disease and fear of suffering. Most patients preferred to keep the revelation of the diagnosis to those close to them and not reveal it publicly. Financial drain out of resources was a major concern. Future concerns about their own fitness, the settlement of their children, and the family’s well-being were seen commonly in almost all the patients. Conclusions: Attention to psychosocial and spiritual health needs of patients with cancer is an integral part of an effective palliation, though they are less commonly expressed but are strongly felt by patients with cancer. It is therefore recommended that all clinicians and health care providers should address psychosocial health needs as a part of their routine practice.

Prevalence of phantom breast pain and sensation among postmastectomy patients suffering from breast cancer: a prospective study.

With the advent of newer treatment modalities, survival rate among breast cancer patients has improved substantially over the last few years. Hence, the concern has also shifted to the impact of treatment, side effects, and the morbidities arising from disease management. Among them is the development of phantom breast pain (PBP) and sensation (PBS) after mastectomy.

Radio Frequency Ablation in Drug Resistant Chemotherapy-induced Peripheral Neuropathy: A Case Report and Review of Literature

Chemotherapy-induced peripheral neuropathy (CIPN) is a frequently encountered complication. It can result from a host of agents. Various modalities of treatment have been advocated, of which a novel method is radio frequency ablation. A 63-year-old male, a case of carcinoma prostrate with bone metastases, presented with tingling and numbness in right upper limb. He was given morphine, gabapentin and later switched to pregabalin, but medications provided only minor relief. Initially he was given stellate ganglion block, then radiofrequency ablation of dorsal root ganglion was done, but it failed to provide complete relief. Pulsed radiofrequency ablation (PRF) was then done for 90 seconds; two cycles each in both ulnar and median nerve. After the procedure the patient showed improvement in symptoms within four to five hours and 80% relief in symptoms. We conclude that PRF can be used for the treatment of drug resistant CIPN.

Bedside ultrasound-guided celiac plexus neurolysis in upper abdominal cancer patients: a randomized, prospective study for comparison of percutaneous bilateral paramedian vs. unilateral paramedian needle-insertion technique.

Percutaneous anterior abdominal ultrasound guidance for performing celiac plexus neurolysis is a relatively new but more economical, less time‐consuming, more comfortable bedside technique for interventional pain management. Paucity of studies evaluating the efficacy of single‐site vs. double‐site injections at celiac trunk for ultrasound‐guided celiac plexus neurolysis (USCPN) prompted us to conduct a prospective, randomized, single‐blind clinical trial to compare USCPN using bilateral paramedian (double needle) technique with unilateral paramedian (single needle) technique.

Quality of life of ostomates with the selected factors in a selected hospital of delhi with a view to develop guidelines for the health professionals.

Background: A correlational survey to assess the quality of life (QoL) of ostomates with selected factors in a selected hospital of Delhi and to develop guidelines for the health professionals to improve QoL of ostomates was undertaken during the year 2005-2007. The objectives of the study were as follows: (1) To assess QoL of ostomates (2) To identify the factors associated with QoL of ostomates (3) To seek relationship between selected factors and QoL of ostomates (4) To develop guidelines for the health professionals to improve QoL of ostomates. Materials and Methods: The corelational survey was conducted on 50 ostomates from Surgical Oncology OPD of B.R.A. Institute Rotary Cancer Hospital, AIIMS, Delhi. Purposive sampling technique was employed to select the sample subjects. Structured interview schedule was prepared. Guidelines were prepared for health professionals to improve the quality of life of ostomates. Result: Majority of the ostomates possessed best quality of life. There was a significant association between QoL score of ostomates with age, sex, duration of surgery, education, income, and occupation. There was no significant association between QoL scores of ostomates and marital status and type of ostomy. Conclusion: This study conclude that nurses have a great role to play in the physical, psychological, economical, social, familial, and sexual aspects in the care of ostomates and to offer psychological support and empathy, to reinforce coping skills to promote an optimal QoL.also she has a great role to influence and educate all the aspects of care to the patients and their relatives. Their is a need to develop staff development program for nursing personnel in the clinical area in healthcare system.