The use of cannabis has substantially reduced the use of
conventional pain medications, chiefly opioids.
Cannabis may improve the efficacy of other pain medicines as
well.
It prevents the cancer cells growth and enhances the action
of chemotherapy
Studies have shown that cannabis can make the daily
functioning and quality of life better, particularly for those
with chronic pain.
Medical cannabis is well tolerated and has few adverse
effects.
ü
Cannabis is an effective intervention for chronic
pain in adults. ü
Its active ingredients are ·
delta-9-tetrahydrocannabinol (THC) ·
cannabidiol (CBD) ü
A huge number of evidence demonstrate the efficacy
of cannabis’ use. ü
Cannabis reliefs pain via its antihyperalgesic and
antinociceptive effects. ü
A growing body of clinical research have
shown a clinically noteworthy lessening in pain with the use of cannabis. ü
It has been useful in cancer-related
pain, fibromyalgia, migraines, and other pain conditions. From 1975 to December 2023, there have been plenty
of researches demonstrating that cannabis can help patients get relief from
their pain.
Alleviation of chronic pain is by far the most prevalent
reason provided by patients for using cannabis for medical purposes.
A recent review published
by the Pain and Therapy journal found cannabinoids to be a likely favourable
adjunctive or replacement for opioids for diverse forms of acute and chronic
pain. According to it, cannabinoids have yielded positive results in various
trials over opioids, particularly for neuropathic pain. It has been
demonstrated to alleviate chronic pain in the elderly population and to result
in the discontinuation of opioids medications. The review also found
cannabinoids have a lower side-effect profile than opioids and may be used in
tandem with opioids to produce more powerful analgesia.
A survey by
researchers from the United States reported that patients found cannabis use to
be a helpful adjunct and alternative to opioids in managing their chronic pain.
They also claimed to get the extra benefit of enhancing their ability to work
and quality of life.
The Tilray Observational Study from
Canada gives an individual-level insight on cannabinoids substitution for
opioids and other prescribed medicines, along with the resulting improvement in
quality of life over a 6-month period. According to this study, the use of
cannabis for chronic pain can result in a reduction in opioid use and its
subsequent harmful effects. This has the potential to improve patient quality
of life and general public health.
Cannabis consists of various
biologically active molecules that can influence pain physiology. Comprehensive
reviews of the
literature support the potential safety and pain-relieving efficacy of
cannabinoids for chronic pain. The beneficial effects appear to peak after
three months of frequent cannabis use. Another study has
claimed to decrease the illicit use of opioids for chronic pain as well as
fentanyl exposure rates.
Microdosing CBD is a method of
consuming very small doses of cannabidiol on a daily basis. In a randomised
control trial, a
significant decline in pain intensity was observed with a dose of 0.5mg to 1mg
of cannabis in 27 patients with chronic neuropathic pain. The trial concluded
that people can benefit from cannabis-based treatments for their chronic pain.
A retrospective
evaluation found a low dose of cannaboids helpful in reducing chronic
pain, post-traumatic stress disorder-related insomnia, self-harm and nightmares
in inmates with serious mental illness. It can be useful in reducing emotional
exhaustion, anxiety, and burnout.
For a new cannabis user,
microdosing can be an excellent starting point. The goal of microdosing
marijuana is to achieve the desired impact throughout the day with a few
repeated doses instead of one huge dose.
Microdosing of marijuana can be
carried out via various forms like tinctures, gummies, pastilles, etc.
A huge number of diverse pain killers or analgesics are available that can help alleviate pain in different ways. They can be used with other types of analgesics to reduce pain.
Nonopioid Analgesic Agents
·
Nonsteroidal
anti-inflammatory drugs (NSAIDs)
·
Acetaminophen (paracetamol)
·
Antiepileptic medications
·
Antidepressant medications
·
Local anesthetics (lidocain)
Opioid Agents
·
Morphine
·
Hydrocodone
·
Oxycodone
Codeine
Combination
Analgesics
·
Paracetamol and codeine
·
Paracetamol and tramadol
· Paracetamol and dihydrocodeine
·
Creams --
ibuprofen, diclofenac, capsaicin cream, etc
·
Sprays
·
Gels
· Patches
·
Spinal Cord Stimulators
·
Acupuncture
·
Steroid Injections
·
Disc Procedures
·
Manipulation
·
Trigger Point Injections
·
Massage
·
Intrathecal Pump Therapy
·
Radio Frequency Ablation
·
Mobilisation
· Nerve Blocks
To anyone living in unrelenting pain: it is possible to
overcome chronic pain.
1 In 5 People Suffer From Pain Globally
Pain destroys the soul. No one should endure the unbearable pain.
What is Pain?
Pain is a multifaceted unpleasant bodily sensation that
involves both a physiological and psychological reaction to a noxious stimulus.
It will feel like an ache, sting,
burn, prick, or tingle.
Acute Pain
It has a sudden onset, a definite cause and short
duration.
Chronic Pain
It is a pain that lasts or reappears for longer than
3 months duration. Chronic pain includes
·
Nociceptive pain (skin, joints, muscle, bones
ligaments)
·
Neuropathic (nerves)
·
Nociplastic pain
·
Mixed pain
·
Inflammatory pain
Nociceptive
Pain—Pain caused by the activation of nociceptors as a result of
actual or potential injury to non-neural tissue.
Neuropathic
Pain—Pain induced by a disease or lesion of the somatosensory
nervous system.
Nociplastic
Pain—Pain caused by changed nociception in the absence of any
clear evidence of tissue damage or disease of the somatosensory system.
Pain can affect the emotional, social and physical aspect of
life.
Study link: https://pubmed.ncbi.nlm.nih.gov/32053298/
Question: Do plasma exchange and reduced-dose
regimens of oral glucocorticoids effective treatment options for patients with
severe antineutrophil cytoplasmic antibody (ANCA) associated vasculitis?
Trial design and population: In this, an
open-label trial, n= 352 were
randomized to plasma exchange and reduced-dose regimen of glucocorticoids or no
plasma exchange and reduced-dose regimen of glucocorticoids.
Primary outcome: The use of plasma exchange was
not effective in reducing the incidence of death or end stage kidney disease
among patients with severe ANCA-associated vasculitis (HR0.86, 95% CI, 0.65 to
1.13; P=0.27).
Secondary outcome: A reduced-dose regimen of glucocorticoids was noninferior to a
standard-dose regimen concerning death or end stage kidney disease (ARR 2.3%,
90% CI 3.4-8.0).
Exclusion criteria: Key exclusion criteria included patients below age 15
years, a diagnosis of vasculitis other than granulomatosis with polyangiitis
(Wegener’s) or microscopic polyangiitis, plasma exchange in 3 months prior to
randomization, a positive serum test for anti-glomerular basement membrane or a
renal biopsy showing linear glomerular immunoglobulin deposition, treatment
with >1 IV dose of cyclophosphamide and/or >14 days of oral
cyclophosphamide and/or >14 days of prednisone/prednisolone (>30 mg/day)
and/or treatment with >1 dose of rituximab within the last 28 days, receipt of
dialysis for greater than 21 days immediately prior to randomization or prior
renal transplant, a comorbidity or condition that, in the opinion of the
investigator, precludes the use of cyclophosphamide/rituximab, glucocorticoids,
or plasma exchange or absolutely mandates the use of plasma exchange.
This assignment requires you to use the available
(scholarly) information about the research on adolescence and risk taking to
think about how you would develop and implement a prevention program in one
“risk” area.
Begin
with the following sources provided by your instructor:
•
Dr.
Linda Mayes discusses the science on adolescent brain development and factors and risks that impact decisionCmaking (Yale School of Medicine 12 minute
podcastCTeen Brains Wired to Take Risks)
•
Steinberg,
L. (2007). Risk taking in adolescence: New perspectives from brain and
behavioral science. Current Directions in Psychological Science, 16, 55C59.
1. This project will
require you to first process, synthesize, and then summarize the information
from the assigned sources. (1 page minimum, 2 page maximum)
2. After you have
finished reading and summarizing the main points from the two sources, conduct
further research related to prevention programs for one area of riskCtaking. (For example, research
on the prevention of reckless
driving, substance abuse, the
effectiveness of pregnancy prevention through abstinence only interventions;
HIV prevention; prevention of teen violence.) For this portion, you must
locate at least 2 additional scholarly sources that are recent (e.g. it is 2012K please do not include source information
older than 5K7 years old unless you
have discussed it with your instructor). Here is one link that describes
“scholarly” sources:
Abstract
Aortic stenosis is one of the most common cardiac valve disease and can
lead to death and different other morbidities. Doppler Echocardiography is the
important diagnostic tool for the evaluation of different cardiac conditions
including aortic stenosis. It is a safe and key non-invasive imaging technique
for hemodynamic assessment as well as of aortic valves and stenosis. By the
help of continuous-wave, pulse-wave and colour Doppler diagnosis can be made
and also optimization and monitoring of therapy can be carried out accurately.
The paper focuses on the use of a non-invasive imaging approach in assessment
of cardiac valves of an old aged patient with different co-morbidities and
aortic stenosis in particular.
Keywords: Doppler echocardiography, continuous-wave Doppler, pulse-wave
Doppler, Aortic stenosis, Heart.
Cardiac valve diseases are quite frequently presented, however their
clinical course and management is still challenging and therefore demands
accurate information regarding severity of valve damage, heart function and
patient symptoms. Aortic stenosis is mainly due to age-related degenerative
disease and is characterised by shortness of breath with activity and chest
pain (Carita et al, 2016). In view of the number of co-morbidities including
cardiac issues, the morphology of the different cardiac valves and the velocity
of blood flow within them is necessary to determine. In order to do so great
deals of diagnostic techniques have emerged and they are offering valuable
benefits. Early intervention of the valve disease can prevent valve
replacement/ implantation surgeries and poor prognosis (Everett et al, 2018). Doppler echocardiography is one of the latest non-invasive
techniques that have acquired a central place in the cardiovascular ultrasound
assessment. It illustrates hemodynamic status corresponding to the tomographic
anatomy (Płonska-Gosciniak et al, 2019). This paper aims to review the role of Doppler
echocardiography (including both pulse-wave and continuous wave Doppler) in the
non-invasive detection of cardiac abnormalities.
Case
A 80-year-old woman with osteoarthritis and type II diabetes and
hypertension presented with self-resolving chest tightness while making the
bed. She had a background of bilateral knee replacements and closure of
cerebral AV malformation. She had an atonic bladder which required
self-catheterisation. She had previously had an echocardiogram demonstrating
mild aortic stenosis. She stopped smoking about 15 years ago.
Before the patient’s episode about 6 weeks ago, she reported strange
sensations in the chest with something apparently moving. This could possibly
be a sort of palpitation or apprehension. Whilst she did describe a degree of
exertional tiredness there had been no convincing recurrence of the chest
discomfort. She had no claudication as well.
She was on Amlodipine 10mgs, Atorvastatin 20mgs, Citalopram 10mgs,
Empagliflozin 10mgs, Ferrous Fumarate 305mgs, Gliclazide 80mgs, Lansoprazole
30mgs, Loratadine 10mgs, Perindopril 4mgs, Sitagliptin, Naproxen, and
Paracetamol. Whilst she was not allergic to any definite medications she was allergic
to Ibuprofen, Codeine and also fish.
Her ECG showed sinus rhythm with normal axis, normal PR, QRS and QTC
interval. There were no pathological Q waves. There was a non-specific ST flattening
in V6, AVL and lead I. No evidence of ischemia was found on ECG.
Her BP was 141/81 and pulse 71bpm regular. She had an ejection systolic
murmur over the aortic region with an audible second heart sound and no
clinical aortic regurgitation. The JVP was not raised, there was no oedema and
the chest was clear.
The ejection systolic murmur and symptoms of this patient are consistent
with the existence of aortic stenosis (Thomas and Makaryus, 2019). Aortic stenosis is a condition characterised by
reduction in the size of aortic valve orifice owing to the malfunction of the
aortic valve leaflets. They fail to open completely during systole with
resultant increase in after load and hypertrophy of left ventricle (Carita et
al, 2016). The characteristic triad of symptoms of this condition are dyspnea,
angina and syncope.
Aortic stenosis is commonly seen in older people age above 60 years due
to senile degeneration or aortic valve calcification (Fattouch, Castrovinci and
Carità, 2016). Although, exact cause not known, it is
believed that turbulence and high pressures over many years lead to the
endothelial damage, lipid penetration, and an inflammatory condition that
causes infiltration of T lymphocytes and macrophages. This further initiates
the thickening and fibrosis of leaflet and ultimately calcification (Dweck,
Boon and Newby, 2012).
Once symptoms of aortic stenosis develop, the prognosis becomes poor
while at present, there is no medical treatment to prevent the disease. The
mainstay of treatment is surgical valve replacement (Fattouch, Castrovinci and
Carità, 2016). Hence, it is of prime significance to delineate and recognize
the crucial basic mechanisms and heart’s anatomy.
In this particular case in order to gain a better understanding of the
function, hemodynamic and structure of the heart and considering the patient’s
condition, the help of Doppler echocardiography was taken. It offers precise
estimation of severity of valve disease and any cardiac dysfunction (Gaspar,
Azevedo, and Roncon-Albuquerque, 2018). It provides an accurate assessment of
hemodyanamic function of the heart as well as quantification of both diastolic
and systolic via tissue doppler and blood pool. By the help of it valve areas,
shunt volume, pressure gradients, regurgitant volume and intracardiac pressures
are easily evaluated (Anavekar and Oh, 2009).
In this case using continuous-wave, pulse-wave and colour Doppler echocardiography
a number of images were obtained as shown below.
Figure 1: Continuous wave doppler ultrasound
showing anterograde and retrograde blood flow.
Figure 1 is an image obtained via continuous wave doppler ultrasound and
it shows anterograde and retrograde blood flow. In case of a suspected aortic
stenosis, a high velocity flow of blood should be observed across the aortic
valve. The figure above demonstrates the line of cursor of the continuous wave
Doppler going by the aortic valve in the chamber view. The inferior segment illustrates
the tongue like Doppler signal as a result of systolic blood flow in the aorta ahead
of the aortic valve. The scale underneath
shows the time axis while the velocity is represented by the vertical scale. The
jet of velocity here is a little high, almost 3 m/s, pointing to moderate
aortic stenosis.
Figure 2: Pulsed wave Doppler at the LVOT
This is an image obtained through pulsed wave Doppler ultrasound at the
left ventricular outflow tract (LVOT) (figure 2). The velocities are plotted in
the y axis and time is plotted on the x axis. All velocities are plotted as one
yellow point comprising a decent flow profile. The image shows more intensity of
the density of yellow points which means signal coming back to the probe is
stronger at the velocity/frequency (Anavekar and Oh, 2009).
The green line demonstrates the baseline and point below this line are
velocities moving away from the transducer. On the other hand, velocities
moving towards the transducer are situated above the green line and represent
a pulsatile flow. The velocities are slightly elevated i.e. above 1m/s so
Bernoulli equation cannot be considered here and for this reason the aortic
valve area (AVA) can be underestimated.
Figure 3: Parasternal long axis of the AV demonstrating calcification
and cusp excursion
In this figure 3 aortic valves appear to be thick calcified and stenosed
since they give the appearance of being
brighter on the scan. The thick valves can
obstruct blood flow significantly. Calcific aortic valves are also linked to
increased stiffness of the leaflet, leading to high pressure gradients across
the valves (Saikrishnan
et al, 2014). In this particular figure reduced aortic valve excursion can also
be observed resulting in diminished aortic cusp separation. Evidence has shown
that an aortic cuspal separation points towards the severity of aortic stenosis
(Jayaprakash, Dilu and George,
2017). Maximum aortic cuspal separation thus is a useful screening tool for
assessing the severity of stenosis especially when there is disagreement among the other parameters
of echocardiography.
Additionally, Doppler colour flow mapping also plays a vital role in the
precise non-invasive assessment of a number of heart associated haemodynamic
disorders (Mitchell et al, 2019). It is especially helpful in detecting regurgitant
lesions in cardiac valves. In colour Doppler the direction and mean velocity of
blood flow are colour coded in the scan plane and are placed over on to the
cross sectional image to create a spatially adjusted map of flow (Temporelli et al, 2010). This is shown
below in figure 4. 
Figure 4: Parasternal long axis view- colour Doppler demonstrating
turbulent flow at valve level
Colour Doppler is used to measure the direction and velocity of blood
flow overlay a colour pattern (Anderson, 2017). Conventionally, red colour is the blood flowing towards
the transducer while blue colour shows flow moving away from the transducer.
The high velocities are illustrated in lighter colours or by altering colour to yellow. In order
to appreciate the turbulent flow, a threshold velocity is taken as a reference,
above which any change in colour indicates the turbulence (Mitchell et al,
2019). Generally a “mosaic pattern” is regarded as a turbulent flow in colour
Doppler ultrasound. Same is the case in figure 4 which shows a mosaic pattern
i.e. turbulence at the valve level.
Once disease is established, management depends on its progression.
Nevertheless, it is definite that the huge numbers of unfavourable cardiac
events take place in patients with symptoms; hence, the common approach is an observant
waiting with series of ultrasounds, echocardiograms as well as visits to
doctors to evaluate the development of severity (Czarny and Resar, 2014). For
this particular case the guidelines suggest that the patients should have a
transthoracic Doppler echocardiogram for at least every 1–2 years (Czarny and
Resar, 2014). Since this patients have valve calcification and less than 4 m/s
peak aortic jet velocity, she should be re-examined every six month. Also,
aortic stenosis accompanies with Hypertension may cause further problems, such
as it can mainly affect gradients and flow (Mascherbauer et al., 2008). Thus, it needs to be managed medically
although medical therapy is inefficient in aortic stenosis. When aortic stenosis becomes severe, only
definitive management for this patient would be transcatheter or surgical aortic
valve replacement.
Discussion
The clinical usefulness of Doppler echocardiography for the evaluation
of aortic stenosis was discussed in a patient with multiple co-morbidities.
A precise assessment of the severity of aortic stenosis is essential for
risk stratification and patient treatment as well as to assign symptoms
rightfully to the valvular disease
(Baumgartner et al, 2009). Doppler echocardiography not only helps to
examine the severity of this disease but also takes part in the therapeutic
management of aortic stenosis (Feigenbaum, Armstrong and Ryan, 2010). It gives
insight into the morphology of the aortic valve. Nevertheless, there are other
modalities as well in addition to Doppler, for instant, cardiac
catheterisation, magnetic resonance
imaging (MRI), and computerized
tomography (CT) scan. Cardiac catheterization is conventionally used for
definitive examination of valvular heart disease as well as a therapeutic
procedure but it’s an invasive procedure (Manda & Baradhi, 2019). For this
reason there are chances of certain complications like retroperitoneal bleeding, hematoma, formation
of arteriovenous fistula, allergic reactions, stroke, etc. Moreover,
cardiac catheterization requires an interventional cardiologist, radiologic
technologists and nurses to perform it whereas for doppler echocardiography sonologist
is enough (Otto, 2018). Yet, cardiac catheterisation can remove discrepancy in
echo diagnosis (Saikrishnan et al, 2014). Besides, studies have also found
echocardiography equally reliable to magnetic resonance imaging (MRI) in
assessing aortic stenosis (Wong, 2016). Nonetheless, MRI offers greater
sensitivity and specificity in the detection of severe aortic stenosis and also
provides three-dimensional anatomy (Mathew et al, 2018).
Doppler
echocardiography allows seeing the calcification and thickening of valve and valve mobility as does the
cardiac catheterization. It can help differentiate the congenital anomalies
with the acquired one (Otto, 2018). The major principle of Doppler echocardiography is that it
uses ultrasound to trace flow of blood in the vascular and cardiac system (Kisslo, and Adams, NA). The
alterations in the frequency of the signals coming back from tiny moving
targets such as red blood cells are caught by the ultrasound beam. These moving
targets cause the ultrasound beam to move back to the transducer. When these
targets move towards the transducer, the higher frequency is detected and when
they move away from the transducer the lower frequency is detected (Oh, Seward and Tajik. 2007).
In the present paper, for the particular case, cardiac catheterization
can cause a number of complications since patient had multiple co-morbidities
and had also been operated for AV malformation. Thus, best practice here would
be the use of non-invasive Doppler ultrasound. Thus, three different Dopplers
were used to find out the pathology and highlighted their importance especially
in detecting aortic stenosis and its severity.
Continuous wave Doppler echocardiography has been an established
technique in quantitating and observing the blood flow disturbances and high
velocity that describes several regurgitant and stenotic valvular problems (Savage and Aronson, 2004). It
continuously transmits the Doppler signals toward the red blood cells (RBCs)
which are moving and also continuously receives these signals coming back from
these RBCs. Its chief advantage is in its capability to show high velocity
signals. It can reliably measures any velocity shift and predicts the pressure
gradient even in aorta with calcification (Otto, 2018). Continuous wave Doppler
can determine the severity of aortic stenosis via modified Bernoulli
equation P = 4V2 and it measures the
mean and the pressure drop all through the valve (Anderson, 2017). In this
patient it was not found to be beyond 70 mmHg, thus ruled out severe
stenosis. However, continuous wave has
no ability to restrict blood flow velocity measurements (Moorthy, 2002).
On the other hand, the pulsed wave Doppler sends a solo ultrasound
crystal in pulses or short bursts and entertains sound beams. The pulse wave
Doppler via range gating can choose Doppler information from any spot within
the cardiovascular system consuming a sample volume (Anderson, 2007). It means it can make localized
measurements of flow velocity. However, it has a shortcoming in its capacity to
quantitate the high velocities. The Doppler equation used to measure these
velocities is shown in the figure 5 below.
Figure 5: Doppler formula
The best ultrasound system must demonstrate an ability to carry out
continuous wave assessment as well as repetition frequency examination at high
pulse in patients with several cardiac issues (Baumgartner et al, 2009). In order to obtain an optimize image an
apt transducer, adequate depth and spatial resolution are very essential
elements. The dynamic range setting helps to adjust the hues of gray on the
image (Mitchell et al, 2019). Non-guided CW (PEDOF) probe is very much required
to precisely examine native aortic valve stenosis (Feigenbaum, Armstrong and
Ryan, 2010).
In this particular case Doppler ultrasound had helped to locate and
assess the primary lesion. Continuous wave doppler ultrasound showed high jet
velocities (> 1.5m/s) demonstrating the presence of moderate aortic stenosis
while pulse-wave showed slow velocity i.e. <1.5m/s. Colour Doppler
illustrated the presence of turbulent flow across the valve.
Overall, all these findings were suggestive of ‘moderate’ aortic
stenosis. In order to get more precise information nuclear imaging, CT scan and
MRI are recommended (Czarny and Resar, 2014).
Conclusion
Using Doppler echocardiographic that provides objective information on
the cardiac valves, clinicians can not only diagnose the disease but also they
can recommend treatment options and requirement for valve replacement.
