Podcasts about analgesics

Join me for a summary of the management of impacted canines, the latest evidence regarding different techniques for alignment. This podcast is based on an excellent lecture by Julia Naoumova delivered at last year's British Orthodontic Conference. Part 1 will focus on recent findings of a modified open exposure technique Vs closed exposure, in terms of duration but also other key outcomes, health, pain, use of analgesics,  time absent from school and costs. The next episode, part 2, will look at the prognosis of resorbed incisors related to impacted canines long term. Previous research  no difference between closed Vs open exposure for alignment, aesthetics, treatment time, surgical success, treatment times. Limited to 2D views Parkin 2017, Sampaziotis 2018, Cassina 2018. Questionnaire of current decision making of open Vs closed: n=48 orthodontists = current clinical decision making by orthodontists based on preference Naoumova 2018Multicentre RCT Margitha Björksved 2018, 2021 Modified open exposure with Glass ionomer OPen Exposure, first described by Nordenval 1999 6/12 of spontaneous eruption Traction with orthodontic appliancesResults Total time: no difference 26 months (95% CI −3.2 to 2.9, P = 0.93) Canine eruption time: Open exposure quicker by 3 months 8.5 months Vs 11.5 months (95% CI 1.1 to 4.9, P = 0.002). With no traction in open exposure group  No difference in periodontal status, root resorption, surgery time, complications,  Pain:  greater in closed group Greater pain with bilateral open exposure Closed exposure more painful applying traction  Analgesics use (preliminary data): Day 1 nearly all patients use Day 5 drops to less than 50% of patients use Day 10 most have stopped taking analgesics Costs: – no difference  €3,400  healthcare costs €6,300 including patient costs Missed days of school (preliminary data) Day 1 -  76% open Vs 65% closed exposure  Day 2 -  3% open Vs 6% closed exposureOpen exposure with GOPEX Not appropriate for: Close to adjacent tooth, to avoid material on adjacent teeth Very high canine position  Older patient – start traction straight away, probability of ankylosis increases Cernochova 2024 1% at age 15 4% at age 20 14% at age 25 97% at age 45Conclusion: Both open and closed techniques are viable, however with open exposure of GOPEX technique the canine erupts spontaneously and quicker Less pain with open exposure unless bilateral Most patient will miss 1-2 days from school  Pain relief common for the first 5 days, but maybe used until day 10PapersOpen vs closed surgical exposure of palatally displaced canines: a comparison of clinical and patient-reported outcomes—a multicentre, randomized controlled trial Margitha BjörksvedOpen and closed surgical exposure of palatally displaced canines: a cost-minimization analysis of a multicentre, randomized controlled trial Margitha Björksved

In this episode, we review the high-yield topic ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Analgesics⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠⁠⁠⁠⁠⁠⁠⁠from the Drugs section at ⁠⁠⁠⁠⁠⁠Medbullets.com⁠⁠⁠⁠⁠⁠ Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets Linkedin: https://www.linkedin.com/company/medbullets

Proper pain management after surgery is essential to promote healing and improve patient satisfaction. In this BackTable OBGYN Brief, Dr. Steven McCarus and Dr. Paula Bilica with host Dr. Amy Park discuss how to advocate for non-opioid analgesia following OBGYN surgery.  The discussion focuses on the importance of reducing opioid use in women's health through various strategies such as utilizing Exparel and ERAS protocols. They share compelling arguments and data for covering costs, enhancing patient satisfaction, and hospital administration's role. The guests emphasize the need for a team approach and the presence of a dedicated champion to advocate for better pain management practices in women's health.

09-11-2024 Jim Lepis Learn more about the interview and get additional links here: https://usabusinessradio.com/otc-topical-analgesics-rapid-growth-in-the-u-s-market/ Subscribe to the best of our content here: https://priceofbusiness.substack.com/ Subscribe to our YouTube channel here: https://www.youtube.com/channel/UCywgbHv7dpiBG2Qswr_ceEQ

In this episode of Join the Docs, Professor Jonathan Sackier and Dr. Nigel Guest dive into the surprisingly hilarious and sometimes cringe-worthy history and evolution of anaesthesia, affectionately dubbed "the surgeon's best buddy." The Docs take us on a wild ride from the days when biting a bullet was considered a viable pain relief method to the sophisticated modern techniques involving sedatives, analgesics, and muscle relaxants that we rely on today. With their signature blend of wit and wisdom, The Docs ensure that even the squeamish will be laughing along, making this episode a real gas.Who knew that the journey to painless surgery could be so entertaining? The episode shines a spotlight on key historical figures like Sir James Simpson, the brave soul who decided that inhaling chloroform might be a breath of fresh air—and lived to tell the tale! His pioneering work paved the way for the development of specialised anaesthetists, those unsung heroes who ensure that we can snooze through surgeries without a care in the world. It's a real knockout!Have you ever imagined what it would be like to be a fly on the wall during the early days of anaesthesia experimentation? Through a series of laugh-out-loud stories, The Docs recount the often bizarre and occasionally disastrous attempts at pain relief before the advent of modern anaesthesia. From ancient herbal concoctions that were more likely to put you under permanently than temporarily, to the trial-and-error approach of early anaesthetists, the episode is a rollercoaster of historical hijinks. By the end, you'll have a newfound appreciation for the crucial role anaesthesia plays in making surgeries not just bearable, but downright dreamy. So, why is anaesthesia considered the unsung hero of the medical world? Jonathan and Nigel make it clear that without anaesthesia, the world of surgery would be a much scarier place. They emphasise how this miraculous medical advancement has transformed surgeries from nightmarish ordeals into routine procedures, all while keeping us in stitches—both literally and figuratively. Tune in for a dose of history, a dash of humour, and a whole lot of appreciation for the magic of anaesthesia. It's an episode that will leave you breathless with laughter and gratitude!—--DISCLAIMER: The views and opinions expressed on Join the Docs are those of Dr. Nigel Guest, Jonathan Sackier and other people on our show. Be aware that Join the Docs is not intended to be medical advice, it is for information and entertainment purposes only - please, always take any health concerns to your doctor or other healthcare provider. We respect the privacy of patients and never identify individuals unless they have consented. We may change details, dates, place names and so on to protect privacy. Listening to Join the Docs, interacting on our social media, emailing or writing to us does not establish a doctor patient relationship.To Contact Us: For a deeper dive on this episode's issue, merchandise and exclusive content, head to www.jointhedocs.comFollow us on youtube.com/JoinTheDocs Follow us on instgram.com/JoinTheDocsFollow us on tiktok.com/JoinTheDocsFollow us on: facebok.com/JoinTheDocsFollow us on: x.com/JoinTheDocs

Host: Peter Buch, MD, FACG, AGAF, FACP Guest: Naga Chalasani, MD It's recommended that if patients with cirrhosis are using acetaminophen long-term, it should be a limited dosage. But should we be avoiding nonsteroidals in patients with decompensation cirrhosis? To walk through the impacts of analgesics in patients with cirrhosis, join Dr. Peter Buch as he speaks with Dr. Naga Chalasani, David W. Crabb Professor of Gastroenterology and Hepatology at Indiana University School of Medicine.

John Incledon, President and CEO of Hisamitsu America, the makers of Salonpas, has seen enormous growth in the acceptance of over-the-counter topical pain management options since introducing the Salonpas analgesic patch in the US market 37 years ago. This growth is partly due to television ads featuring doctors touting the benefits of Salonpas for mild to moderate nerve-related and muscle-related pain and the sampling program that aims to get doctors and patients to try out the products.   John explains, "Topical medications have only been around since the 1960s, with the introduction of the first OTC monograph by the FDA. Salonpas itself was formally introduced to the United States in 1987, so we've been around some 37 years or so as a brand in this country. And so, it's been a challenge. I'll give you a couple of fun facts: 85% of US households have a pill form of an OTC pain reliever in their house, and 30% have a topical analgesic of any sort, a cream, a roll-on, or a patch. So, there's a great disparity there. Pills remain a modality, topicals are up and coming, and I think the horizon for them is excellent." "Topicals work locally, at least OTC topical analgesics. You can wear patches and things intended to be systemic, but in this category and the products we're talking about, they're not. They're intended basically just to work below the surface of the skin. There are pain receptors that certain actives will trigger to help minimize the pain. However, they're not intended to get into the bloodstream, so by working locally and acting locally, they're generally safer than systemic analgesics."   "We have basically two mechanisms of action in our products. One is anesthetic-based and uses lidocaine, and lidocaine is going to be most appropriate to the extent that you can diagnose this if your source of pain is from aggravated nerves. So if your lower back pain is tending to move outward, say, from the spine, you want to use an anesthetic to treat that, and so, a lidocaine-based product would be best." "If it's purely muscle-related, then you're better off with our alternative formulas, which include menthol, methyl salicylate, and camphor. Methyl salicylate is an aspirin derivative, so it's categorized as a non-steroidal anti-inflammatory but topically applied, as opposed to systemically." #Salonpas #Hisamitsu #GoodMedicine #ItsGoodMedicine #PainManagement #OTC #OvertheCounterDrugs #TopicalAnalgesics us.hisamitsu Listen to the podcast here

John Incledon, President and CEO of Hisamitsu America, the makers of Salonpas, has seen enormous growth in the acceptance of over-the-counter topical pain management options since introducing the Salonpas analgesic patch in the US market 37 years ago. This growth is partly due to television ads featuring doctors touting the benefits of Salonpas for mild to moderate nerve-related and muscle-related pain and the sampling program that aims to get doctors and patients to try out the products.   John explains, "Topical medications have only been around since the 1960s, with the introduction of the first OTC monograph by the FDA. Salonpas itself was formally introduced to the United States in 1987, so we've been around some 37 years or so as a brand in this country. And so, it's been a challenge. I'll give you a couple of fun facts: 85% of US households have a pill form of an OTC pain reliever in their house, and 30% have a topical analgesic of any sort, a cream, a roll-on, or a patch. So, there's a great disparity there. Pills remain a modality, topicals are up and coming, and I think the horizon for them is excellent." "Topicals work locally, at least OTC topical analgesics. You can wear patches and things intended to be systemic, but in this category and the products we're talking about, they're not. They're intended basically just to work below the surface of the skin. There are pain receptors that certain actives will trigger to help minimize the pain. However, they're not intended to get into the bloodstream, so by working locally and acting locally, they're generally safer than systemic analgesics."   "We have basically two mechanisms of action in our products. One is anesthetic-based and uses lidocaine, and lidocaine is going to be most appropriate to the extent that you can diagnose this if your source of pain is from aggravated nerves. So if your lower back pain is tending to move outward, say, from the spine, you want to use an anesthetic to treat that, and so, a lidocaine-based product would be best." "If it's purely muscle-related, then you're better off with our alternative formulas, which include menthol, methyl salicylate, and camphor. Methyl salicylate is an aspirin derivative, so it's categorized as a non-steroidal anti-inflammatory but topically applied, as opposed to systemically." #Salonpas #Hisamitsu #GoodMedicine #ItsGoodMedicine #PainManagement #OTC #OvertheCounterDrugs #TopicalAnalgesics us.hisamitsu Download the transcript here

In this episode, Professor Temmermand discusses key non-opioid analgesics that are key players in delivering multimodal, opioid anesthesia. In this two part series, we lay the foundation to discuss opioid free anesthesia in next week's episode. [SPECIAL DOWNLOAD]: Non-Opioid Analgesics Cheat Sheet[FREE DOWNLOAD] FOR THE SRNA: GRAB YOUR FREE SEE/NCE STUDY PLAN HERE [FREE DOWNLOAD] FOR THE RN: GRAB YOUR FREE ICU DRUG CHART HEREFollow us on Instagram at: @Atomic_AnesthesiaCheck out our other free resources at AtomicAnesthesia.com

The conversation discusses patient positioning during procedural sedation and the use of Versed (Midazolam) as a sedative. The speakers explore the importance of patient positioning and the need to have a plan for airway management in different positions. They also provide insights into the mechanism of action and dosing of Versed, highlighting the importance of individual patient factors and context in determining the appropriate dose. The conversation emphasizes the need for a staged approach when using sedatives and the importance of communication with the patient to assess their response. In this conversation, Dennis discusses the use of different medications for sedation and anesthesia, focusing on the challenges and considerations involved. He explains that there is no specific dose for achieving amnesia with medications like Midazolam, Propofol, and Ketamine. The dose depends on various factors, including the patient's physiological state and the presence of alcohol in their system. Dennis emphasizes the importance of closely monitoring vital signs and respiratory rate during sedation to ensure the patient remains comfortable and ventilating properly. He also discusses the use of analgesics and local anesthesia to manage pain during procedures. The conversation concludes with a discussion on the reversal agent for sedatives and the importance of considering the set and setting when administering medications like Ketamine. Takeaways Consider patient positioning during procedural sedation and have a plan for airway management in different positions. Understand the mechanism of action and dosing of Versed (Midazolam) as a sedative. Take into account individual patient factors and context when determining the appropriate dose of Versed. Use a staged approach when administering sedatives and communicate with the patient to assess their response. There is no specific dose for achieving amnesia with sedative medications like Midazolam, Propofol, and Ketamine. The dose of sedative medications depends on various factors, including the patient's physiological state and the presence of alcohol in their system. Monitoring vital signs and respiratory rate is crucial during sedation to ensure the patient remains comfortable and ventilating properly. Analgesics and local anesthesia can be used to manage pain during procedures. The reversal agent for sedatives, such as Versed, is Ramazicon, but it should be used cautiously and only after ruling out other causes for the patient not waking up. Consider the set and setting when administering sedative medications, especially in high-stress environments like combat situations.

Unsere aktuelle Folge der Serie English for PTA beschäftigt sich mit Analgetika. Hören Sie den Dialog zwischen der PTA und einer Kundin, die sich zur Schmerztherapie einer älteren Angehörigen beraten lässt. Frischen Sie Ihre Englischkenntnisse für die Beratung im HV auf. Eingelesen haben den Dialog Native Speakerin Jane Funke und ihre Tochter. Listen and repeat! (04:14 Min) https://www.das-pta-magazin.de/news/podcast-pta-funk-einfach-englisch-lernen-analgesics-3500470.html

In this Healthed lecture, pain expert, Joyce McSwan will unpack the evidence for NSAIDs, lotions and potions, heat packs, as well as "electroceuticals", and explain how and when to use them with a focus on those options that have some evidence.See omnystudio.com/listener for privacy information.

Welcome to the Happy Nurse Educator podcast by nursing.com. Since 2018, nursing.com has been at the forefront of nursing education, guiding over 400,000 nursing students to academic success while helping the average student raise their lowest grade by 11.6% with an impressive 99.25% NCLEX pass rate. Download free Lesson Plans at HappyNurseEducator.com Must Know NCLEX Meds Lesson Plan Objective By the end of the lesson, the nursing student will be able to identify and understand key medications commonly encountered on the NCLEX, focusing on Analgesics, Anticonvulsants, Anti-inflammatory/Steroids, Anticoagulants, Anti-Parkinsonian drugs, Beta Blockers, Potassium supplements, Respiratory drugs, Cardiac Glycosides, Antihypertensives, Psychotropic drugs, Maternity drugs, Antifungals, Anticholinergics, Oncology medications, Anti-Gout medications, and Ophthalmic medications (miotics and mydriatics). Through this lesson, nursing students will acquire knowledge about medication classes, indications, contraindications, and essential nursing considerations. The emphasis will be on recognizing potential side effects, monitoring for complications, and understanding the rationale behind medication administration. This foundational knowledge will empower students to approach NCLEX questions with confidence and ensure safe medication practices in clinical  settings. Download free Lesson Plans at HappyNurseEducator.com  

Non narcotic analgesics are a commonly prescribed and widely used drugs for mild to moderate pain. It is important for the dental hygienist to be aware of the therapeutic effects, side effects, contraindications, dental implications and precautions surrounding this category of drugs. Additional resources:  Study Sheets: https://thehappyflosserrdh.etsy.com/  Other Podcasts: blog.feedspot.com/dental_hygiene_podcasts/   Take a look at a recent product I have tried and recommend. bit.ly/thehappyflosser promo code: HAPPYFLOSSER   Send Messages to: https://anchor.fm/billie43/message. --- Send in a voice message: https://podcasters.spotify.com/pod/show/billie43/message

Live Nursing Review with Regina MSN, RN! Every Monday & Wednesday we are live. LIKE, FOLLOW, & SUB @ReMarNurse for more.     Quick Facts for NCLEX Next Gen Study Guide here - https://bit.ly/QF-NGN Study with Professor Regina MSN, RN every Monday as you prepare for NCLEX Next Gen.   ► Create Free V2 Account - http://www.ReMarNurse.com ► Get Quick Facts Next Gen - https://bit.ly/QF-NGN ► Subscribe Now - http://bit.ly/ReMar-Subscription ► GET THE PODCAST: https://remarnurse.podbean.com/ ► WATCH LESSONS: http://bit.ly/ReMarNCLEXLectures/ ► FOLLOW ReMar on Instagram: https://www.instagram.com/ReMarNurse/ ► LIKE ReMar on Facebook: https://www.facebook.com/ReMarReview/   ReMar Review features weekly NCLEX review questions and lectures from Regina M. Callion MSN, RN. ReMar is the #1 content-based NCLEX review and has helped thousands of repeat testers pass NCLEX with a 99.2% student success rate! ReMar focuses on 100% core nursing content and as a result, has the best review to help nursing students to pass boards - fast!

In this episode, my guest is Dr. Sean Mackey, M.D., Ph.D., Chief of the Division of Pain Medicine and Professor of Anesthesiology, Perioperative and Pain Medicine and Neurology at Stanford University School of Medicine. His clinical and research efforts focus on using advanced neurosciences, patient outcomes, biomarkers and informatics to treat pain. We discuss what pain is at the level of the body and mind, pain thresholds, and the various causes of pain. We also discuss effective protocols for controlling and reducing pain, including the use of heat and cold, acupuncture, chiropractic, physical therapy, nutrition, and supplementation. We also discuss how pain is influenced by our emotions, stress and memories, and practical tools to control one's psychological perception of pain. And we discuss pain medications, including the controversial use of opioids and the opioid crisis. This episode will help people understand, manage, and control their pain as well as the pain of others. For show notes, including referenced articles and additional resources, please visit hubermanlab.com. Thank you to our sponsors AG1: https://drinkag1.com/huberman AeroPress: https://aeropress.com/huberman Levels: https://levels.link/huberman BetterHelp: https://betterhelp.com/huberman InsideTracker: https://insidetracker.com/huberman Momentous: https://livemomentous.com/huberman Timestamps (00:00:00) Dr. Sean Mackey (00:02:11) Sponsors: AeroPress, Levels & BetterHelp (00:06:13) Pain, Unique Experiences, Chronic Pain (00:13:05) Pain & the Brain (00:16:15) Treating Pain, Medications: NSAIDs & Analgesics (00:22:46) Inflammation, Pain & Recovery; Ibuprofen, Naprosyn & Aspirin (00:28:51) Sponsor: AG1 (00:30:19) Caffeine, NSAIDs, Tylenol (00:32:34) Pain & Touch, Gate Control Theory (00:38:56) Pain Threshold, Gender (00:44:53) Pain in Children, Pain Modulation (Pain Inhibits Pain) (00:53:20) Tool: Heat, Cold & Pain; Changing Pain Threshold (00:59:53) Sponsor: InsideTracker (01:00:54) Tools: Psychology, Mindfulness-Based Stress Reduction, Catastrophizing (01:08:29) Tool: Hurt vs. Harmed?, Chronic Pain (01:12:38) Emotional Pain, Anger, Medication (01:20:43) Tool: Nutrition & Pain; Food Sensitization & Elimination Diets (01:28:45) Visceral Pain; Back, Chest & Abdominal Pain (01:34:02) Referenced Pain, Neuropathic Pain; Stress, Memory & Psychological Pain (01:40:23) Romantic Love & Pain, Addiction (01:48:57) Endogenous & Exogenous Opioids, Morphine (01:53:17) Opioid Crisis, Prescribing Physicians (02:02:21) Opioids & Fentanyl; Morphine, Oxycontin, Methadone (02:07:44) Kratom, Cannabis, CBD & Pain; Drug Schedules (02:18:12) Pain Management Therapies, Acupuncture (02:22:19) Finding Reliable Physicians, Acupuncturist (02:26:36) Chiropractic & Pain Treatment; Chronic Pain & Activity (02:31:35) Physical Therapy & Chronic Pain; Tool: Pacing (02:36:35) Supplements: Acetyl-L-Carnitine, Alpha Lipoic Acid, Vitamin C, Creatine (02:42:25) Pain Management, Cognitive Behavioral Therapy (CBT), Biofeedback (02:48:32) National Pain Strategy, National Pain Care Act (02:54:05) Zero-Cost Support, Spotify & Apple Reviews, YouTube Feedback, Sponsors, Momentous, Social Media, Neural Network Newsletter Disclaimer

Dave and Matt discuss some updates to the banned substances list including pain killers, russian drugs and an amendment to the rules around Cannabis. Show Notes:  WADA List of Major Changes to the Banned Substance List: https://www.wada-ama.org/sites/default/files/2022-09/2023list_explanatory_list_en_final_26_september_2022.pdf WADA Full List: https://www.wada-ama.org/sites/default/files/2022-01/2022list_final_en_0.pdf  USADA Information on changes to the 2023 prohibited List: https://www.usada.org/athlete-advisory/key-changes-2023-prohibited-list/ PAINKILLER & ENDURANCE SPORTParacetamol impacts on Endurance Performance:https://www.mdpi.com/2075-4663/9/9/126 Painkillers and Sport Performance: https://www.researchgate.net/publication/318722082_Analgesics_and_Sport_Performance_Beyond_the_Pain_Modulating_Effects Endure by Alex Hutchinson (mention and reference to multiple studies on painkillers and endurance):https://www.amazon.com/Endure-Curiously-Elastic-Limits-Performance/dp/153850202X  

On this episode of the podcast, I was incredibly excited to be joined by Adam Meakins to discuss his back injury and how he recovered from it.   The aim of the podcast was to provide people who might be in a similar situation with acute, severe low back and possibly leg pain an example of how a Physio was able to self manage and get back to full health and fitness without anything fancy.   It's my hope that this episode is a resource for clinicians and people in pain alike. When you are severe pain it is normal to have fear and concern but I hope this episode can provide some hope of the amazing ability of the body to heal.   If you want to check out Adam's original back injury video you can do so here: https://twitter.com/AdamMeakins/status/1557775099721293825   All of the videos are great to watch and you can find them on Adam's Instagram if you scroll back to August 2021: https://www.instagram.com/adammeakins/?utm_medium=copy_link   More details about what we chatted about follow. --------------------------------------------------------------- We dived into a great discussion about what happaned as well as the reocvery process he went through. Some of the recovery principles that came up include: Stay active but also allowed to rest  Do movements that feel good - do you need to push into pain to restore eg extension  Analgesics and sleeping medication  Hot baths / water bottles  Patience    Criticism he copped Should see a physio, get scans etc  Manual therapy  Specific exercises (McKenzie)  Self blame - technique    Evidence about specific treatments / exercises What does the evidence say about whether any specific treatments are superior to others?  Do people need to get manual therapy for acute back pain?  Does this mean they shouldn't get manual therapy just to anticipate a common strawman argument?  Is this negative or does it provide people more choice?   If people want to see a physio Advice for members of the public who might want some guidance from a healthcare practitioner, what should they look for and what should they be wary of? Why did he get injured? Upon reflection with the aid of hindsight, what factors do you think might have contributed to your injury? Can we take any lessons from this? Technique? Evidence Programming - RPE, Training history with COVID External factors that could have placed a stress on your system? Shit happens?   Fear avoidance - deadlifts How hard was it to get back into deadlifts? Do you still have any residual fears or concerns in the back of your mind?  I really hope you enjoyed this episode. If you did I would be incredibly grateful if you could please leave a review on your favorite viewing platform.    Geoff Ford from Be Strong Physio 

As a prelude to our next episode, where we discuss the issue of pain and opioid dependency, we are replaying a classic from the Aural Apothecary Archive. This is particularly timely as this is also the month that guidance on ‘Optimising personalised care for adults prescribing medicines associated with dependence or withdrawal symptoms' has been issued in England. We will pick up on this guidance next time. In the meantime enjoy this prelude…This was a fascinating episode where we talked to Tracy Brown – an award winning pharmacist working in Glasgow. As well as running primary care pain clinics Tracy runs the Pain Teach and Treat Programme. We talked about the difficulties of supporting people with chronic pain along with the concept of Analgesic Stewardship. As ever we threw a bit of behaviour change into the mix.Our micro-discussion focused on General Practice responses to opioid prescribing feedback – a paper which examines how detailed feedback to prescribers can improve patient care https://bjgp.org/content/71/711/e788.As with all our guests we asked Tracy to pick her ‘Desert Island Drug', a career defining anthem and a book that has influenced her work. The choices do not disappoint.We reference a number of pain resources – these include; - Live Well with Pain – https://livewellwithpain.co.uk- Flipping Pain – https://flippinpain.co.uk To get in touch follow us on Twitter @auralapothecary or email us at auralapothecarypod@gmail.com You can listen to the Aural Apothecary playlist here; https://open.spotify.com/playlist/3OsWj4w8sxsvuwR9zMXgn5?si=tiHXrQI7QsGtSQwPyz1KBg You can view the Aural Apothecary Library here; The Aural Apothecary - Bookcase:Tracy's BioTracy moved from community pharmacy to primary care 17 years ago. She ran a benzodiazepine step down clinic for several years before, in 2006, Tracy started a pain clinic in one of the GP practices in Glasgow {Govanhill Health Centre.}In 2020 Tracy applied for Scottish Government funding under the Modernising Patient Pathways Programme to expand her pain clinic to cover the three additional GP practices in Govanhill Health Centre.She now runs the Pain Teach and Treat programme, attends the Pain Network meetings and is a become a member of the Scottish Pain Pharmacists Network In 2021 Tracy won the PRESCQIPP award for Addressing Overprescribing and was voted the Silver award winner for her work on deprescribing.

One of the biggest questions you might ask yourself before you have your baby, is this: "How will I handle the pain of labor?". You have choices. That is the first thing I want you to focus on. After that I want you to be educated on what causes the pain and how you can lean into it, prior to utilizing your pain management plan. Labor pain is not a pain that you should fear, it is a pain that is necessary to bring you the baby. During birth, there are pretty much 3 common options for pain control: Analgesics, Anesthetics, Nitrous Oxide, and Unmedicated options. Today we talked about the first three options which all fall into the medicated pain management options. Analgesics include IV narcotics such as Nubain, Stadol, Morphine, Fentanyl (which works the best in my opinion), and sometimes Demerol. Analgesics do not take the pain away, rather they lessen the pain, and still allow you to move somewhat freely. They cross the placenta and affect the baby, for this reason, they can not be given later in active labor. Nitrous Oxide is another option for pain relief. It does not eliminate the pain. is administered through a face mask during the contractions. Once you remove the mask, the effects are almost gone immediately. Many women love this option as it allows movement throughout labor. I have found that some women love it and some women hate it. An epidural is the most favored option for pain management during labor. It is considered an anesthetic and if it works properly will eliminate the pain. I teach my students to not solely rely on it being the savior of the day, as there are many times an epidural might not work out. Always have a backup plan. I hope this episode helped you understand pain relief options during labor. I would be so grateful if you hit subscribe and write a review!! Resources: https://offers.labornursemama.com/insider-tips (Take my free birth workshop now!) https://labornursemama.com/door (Ready to be empowered & Prepared for Birth, Take a Birth Class!) https://labornursemama.com/pregnancy-weekly-update (Grab a Free Pregnancy/Postpartum Checklist Bundle ) Connect w/ Trish: https://www.instagram.com/labor.nurse.mama/ (Come hang with Trish on Instagram) For more pregnancy & birth education, subscribe to The Birth Experience on Spotify, Apple Podcasts, or wherever you listen to podcasts. https://labornursemama.com/about-us/privacy-policy/ (Privacy Policy!)

Professor Conception completes the lecture on pain & analgesic medications.

Learn more about several common medicines in your patients' medicine chests. Credit available for this activity expires: 3/10/2023 Earn Credit / Learning Objectives & Disclosures: https://www.medscape.org/viewarticle/969743?src=mkm_podcast_addon_969743

In this episode, we review the high-yield topic of Analgesics from the Drugs section. Follow Medbullets on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets

Join our expert faculty to learn more about the use of over-the-counter analgesics for the treatment of osteoarthritis pain. Credit available for this activity expires: 2/22/2023 Earn Credit / Learning Objectives & Disclosures: https://www.medscape.org/viewarticle/968732?src=mkm_podcast_addon_968732

Can you appropriately counsel patients on the safe and effective use of OTC analgesics and antipyretics? Credit available for this activity expires: 1/28/2023 Earn Credit / Learning Objectives & Disclosures: https://www.medscape.org/viewarticle/967314?src=mkm_podcast_addon_967314

From Samantha Catanzano, PharmD, BCPP, this episode delves into nonopioid options for pain management. Listen as Dr Catanzano provides information on the available nonopioid medications, including valuable details on their indications, mechanisms of action, contraindications, and adverse event profiles. The episode ends with an overview of factors to consider when choosing the best nonopioid pharmacologic agent for a patient.  Presenter:Samantha Catanzano, PharmD, BCPPClinical Assistant ProfessorDivision of Pharmacy PracticeThe University of Texas at Austin College of PharmacyBoard-Certified Psychiatric PharmacistIntegrated Behavioral Health DepartmentAustin, TexasThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please seehttps://bit.ly/3mgrfb9 for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC, and in partnership with the American Academy of Physical Medicine and Rehabilitation, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi

From Samantha Catanzano, PharmD, BCPP, this episode delves into opioid options for pain management. Listen as Dr Catanzano provides information on the indications and mechanisms of action of opioid medications, including tips for converting dosages among medications, recognizing adverse events, and discussion of short-acting vs long-acting formulations. The episode ends with an overview of factors to consider when choosing the best opioid pharmacologic agent for a patient.  Presenter:Samantha Catanzano, PharmD, BCPPClinical Assistant ProfessorDivision of Pharmacy PracticeThe University of Texas at Austin College of PharmacyBoard-Certified Psychiatric PharmacistIntegrated Behavioral Health DepartmentAustin, TexasThis activity is supported by an independent educational grant from the Opioid Analgesic REMS Program Companies. Please seehttps://bit.ly/3mgrfb9 for a listing of REMS Program Companies. This activity is intended to be fully compliant with the Opioid Analgesic REMS education requirements issued by the FDA.Provided by Clinical Care Options, LLC, and in partnership with the American Academy of Physical Medicine and Rehabilitation, Practicing Clinicians Exchange, and ProCE.Link to full program:https://bit.ly/3mcDHsi

Sponsor: Click here for Dandy Labs or go to https://www.meetdandy.com/melissa/ Instagram: @dental_digest_podcast  Dr. Matthew Chesler is a native of Wayzata, Minnesota, near the Twin Cities. After high school, he left the “frozen tundra” behind for sunnier days in Southern California, where he earned a Bachelor's degree in Psychology at UCSD and then moved on to USC School of Dentistry for his DDS degree in 2004. During his studies he received a faculty award for excellence in Endodontics.  While at USC, Dr. Chesler received a full scholarship from the US Navy. He first reported for active duty to Camp Pendleton where he completed a one year residency in Advanced Education in General Dentistry. Shortly afterwards, he became one of the youngest residents to ever be selected for the Endodontics residency program at the Naval Postgraduate Dental School in Bethesda, MD. He completed the program in 2008 and concurrently earned a postdoctoral Master of Science degree from The George Washington University, Washington, DC.  After graduation, he reported to Pearl Harbor, Hawai'i as the Endodontics department head. Lieutenant Commander Chesler was transferred back to the San Diego area in early 2011 where he served as the head of the Endodontics department at Marine Corps Air Station, Miramar. In 2015 he separated from the Navy after eleven years of active duty, but is currently a naval reservist. Dr. Chesler has remained academically active. In Hawai'i he was chairman of the annual Tri-Service Dental Symposium, providing lectures to all Oahu-based dental officers.  He is successfully mentoring promising junior officers to follow his training path. Annually, he attends the American Association of Endodontists continuing education program and stays abreast of the latest research by keeping up with multiple endodontic publications. He holds professional memberships with the American Dental Association, American Association of Endodontists, California Dental Association, and the San Diego County Dental Society. Dr. Chesler (“Matt”) and his wife, Trang Chesler, also a dentist, have two sons.  Matt's hobbies include 3-putting the greens of various San Diego golf courses, hiking, and posing as potential shark bait when he's scuba diving.  His main interest is in all things automotive, where he is doing his best to get his two young sons as car crazy as he is.

In this episode, we are joined by Robert Karpinos, MD, Assistant Vice President, Medical Director of Perioperative Services and Chairman Department of Anesthesiology at St. Barnabas Hospital, The Bronx, NY, to discuss how pain management has evolved in recent years, what to know about The Joint Commission's new emphasis on narcotic avoidance, how providers can create pain management programs that limit narcotic exposure but still adequately manage patients' pain and more.This episode is sponsored by Somnia Anesthesia. 

To help prepare you for your PM&R Board Exams, we're bringing you a podcast series dedicated to current practices and core knowledge. Main Learning Objectives: • Review high yield pearls about opioids and acetaminophen • Discuss MOA of NSAIDs • Discuss MOA of capsaicin • Review common adverse effects of steroids • Learn about the different types of pain • Explore treatment options for fibromyalgia Credits: This episode was written and hosted by: Benjamin Gill, DO, MBA & Rafid Rahman, MD This episode was reviewed for accuracy by: Nick Madaffer, DO; Ebby Varghese, MD This podcast series is directed by: Margaret Beckwith, MD & Benjamin Gill, DO, MBA Please send feedback to aapdigitaloutreach@gmail.com so we can best suit your learning needs!

In this episode, board certified oral maxillofacial surgeon Dr. Jay Platt will discuss analgesics, how to prescribe antibiotics, antibiotic resistance, new guidelines related to antibiotics, MRONJ, oral pathology and more.  Jay Platt, DDS is originally from Fort Wayne, graduating from high school in 1979. From there he spent three years at Indiana University in Bloomington and entered Indiana University School of Dentistry in 1983. After graduating from IUSD in 1986 he did a one-year general practice residency at the Indiana University Medical Center. From 1987-1990 he did an Oral & Maxillofacial Surgeon Residency at the IU Medical Center, gaining his certificate in 1990. In 1992, Dr. Platt became Board Certified by the American Board of Oral and Maxillofacial Surgeons and has maintained it since.  He was awarded fellowship in the American College of Dentists and he is a member of the American Association of Oral and Maxillofacial Surgeons, American Dental Association, Indiana Society of Oral and Maxillofacial Surgeons, the Northwest Indiana Dental Society, he is a diplomate of the National Dental Board of Anesthesiology, and a member of the International College of Oral Implantologists. He is a past member of the Board of the Northwest Indiana Dental Society and past President of the Indiana Society of Oral and Maxillofacial Surgeons. He is on faculty at Spear Education and speaks regularly at the AAOMS annual meeting in addition to the AAOMS Dental Implant Conference.  Dr. Platt practices all phases of oral and maxillofacial surgery concentrating on all types of extractions, placement of dental implants, exposure of impacted teeth, pathology and corrective jaw surgery. He has great interest and experience in intraoral bone grafts and placement of dental implants. As the founder of the Northwest Indiana Dental Implant Study Club he has been a leader in the area of dental implants for many years. He maintains two Spear Study clubs as well. The use of Nitrous Oxide and IV anesthetics in the office to allow for maximum patient comfort is a big part of his practice. Dr. Platt currently resides in Munster with his wife Bobbie.

Up in Smoke: Will Cannabis Replace Analgesics in Dental Pain Management? Episode #332 with Dr. Tom Viola, R.Ph., C.C.P. You might know that one person who really loves their mints. But it turns out, those could be edible cannabis, not Altoids or Tic Tacs! And because so many different forms are available today, it's almost impossible to know who could be using cannabis. So, why is this important to dentistry? To answer that question, Kirk Behrendt brings back Dr. Tom Viola to explain some of the direct and indirect impacts, as well as some of the ethical dilemmas of cannabis. To learn what dental school didn't teach you about cannabis, listen to Episode 332 of The Best Practices Show! Main Takeaways: Cannabis is still an unknown, and its use has an impact on dentistry. There are many myths and misconceptions about cannabis. Cannabis actually raises your blood pressure and heart rate. In high enough doses, cannabis can increase anxiety. Cannabis can cause immunosuppression and increased risk of infection. Patients who use cannabis are more resistant to the effects of anesthetics. Because cannabis isn't standardized, we don't know how much a patient may be taking. Cannabis can span any age group. It's not just younger people taking it.   Always ask patients about their cannabis use. Quotes: “Cannabis is an unknown. I didn't learn about it in school, you didn't learn about it in school, because at the time, cannabis was still a Schedule I substance under the federal law, which meant it was illegal, like heroin, like LSD. So, we didn't learn much about it, and we really didn't anticipate that cannabis was going to get such widespread political and social acceptance — and medical acceptance — as it has now. Honestly, it's still a quagmire. It's still illegal, Schedule I, at the federal level, but approved in, if you want to call it that, or legalized or decriminalized in 35 states throughout the country. So, it leaves everybody in a quandary because, again, your patients have never had such widespread access to a drug that we, in our education, never really learned much about.” (07:50—08:37) “The first thing you need to know as a dental professional is that what your patient is smoking, consuming as a gummy, vaping, is probably not one of the three original strains but some hybrid of those three strains that specializes in a specific THC or CBD content that the patient is demanding or the patient expects.” (14:57—15:17) “The next thing to realize is that many people believe that cannabis, marijuana, mellows you out. And therefore, by logical extension of “mellows you out,” that means it must lower your blood pressure, lower your heart rate, make you calm and less anxious. Actually, that's not true. Actually, cannabis raises blood pressure and raises heart rate, and in high enough doses can actually cause paradoxical effects of dysphoria, anxiety, agitation.” (15:21—15:54) “From our perspective as dental professionals, it's like, ‘Yeah, you're right. If you can use cannabis, why do we need to prescribe an opioid? I'm good with that too.' But if you look at the legislation in all these states where opioid education is mandatory, what's one of the primary things that's central to all of those education programs? Did you educate the patient? Did you ask an at-risk patient one question: do you have, or have you had, an issue with substances in your past? And guess what? Cannabis is a substance. Your patient may not agree with it. Heck, you may not agree with it. But at the end of the day, it is. So, all of a sudden, it's easy for the patient to say, ‘Hey, don't worry about it, doc. I had a gummy an hour ago. I'm good.' But is that substance abuse?” (18:39—19:28) “The big question is about how to take a good medical history. The fourth question [to ask patients] is, ‘Do you use cannabis? And if you do, when was the last time you used it?' Because that's going to affect the vital signs, increased blood...

We're talking about analgesic medications and how they can have both a positive and a negative impact on how your muscles function. Analgesic medications are simply medicines that are used to alleviate pain. You may have seen them marketed as painkillers or pain relievers. Technically the term analgesic refers to any medication that provides pain relief without putting you to sleep or causing you to lose consciousness. There are many different types of medications that have pain, relieving properties. Some people tend to lump these all together, but they're different groups or types of medications.   Some common names you might have heard of are non-steroidal anti-inflammatory medications, such as NSAIDs. These include things like Aleve and Advil. Another group is narcotic opioids, like oxycodone and morphine, and then another common group or non-opioid analgesics typically falls into that category are things like acetaminophen or Tylenol. In many cases, the effect of treatment of chronic pain may include one or more of the analgesic medications I previously mentioned.   However, the use of analgesic medications can be potentially challenging for physical therapists because they're faced with a paradox. On the one hand, an analgesic medication may alleviate pain, which you may think makes it easier for people to move and function. Yet, on the other hand, these medications may negatively impact the physiology of your muscles, nervous system and other parts of your body. Here to talk to us about analgesic medication is Dr. Bahar Shahidi.   Bahar is a physical therapist and a researcher investigating how analgesics impact muscle physiology, pain as well as physical function. She is an assistant professor in the Department of Orthopedic Surgery at the University of California at San Diego. Her academic background includes a Bachelor's in Chemistry, a Doctorate Degree in Physical Therapy and a PhD in Neurophysiology. Her research focuses on muscle physiology changes in the presence of chronic spinal pain.   In this episode, we discuss how analgesic medications impact clinical outcomes in people with chronic low back pain, exercise responsiveness, how to time the use of analgesic medication relative to physical therapy treatment, and balance medication use and exercise for optimizing patient outcomes. Let's begin and meet Dr. Bahar Shahidi and learn about how analgesics impact muscle physiology.   Love the show? Subscribe, rate, review, and share! Here's How » Join the Healing Pain Podcast Community today: integrativepainsciencinstitute.com Healing Pain Podcast Facebook Healing Pain Podcast Twitter Healing Pain Podcast YouTube Healing Pain Podcast LinkedIn Healing Pain Podcast Instagram    

Contributor: Aaron Lessen, MD Educational Pearls: Recent RCT compared pain relief in patients receiving five medications for acute musculoskeletal pain Acetaminophen 1000mg/ibuprofen 400 mg  Acetaminophen 1000mg/ibuprofen 800 mg Acetaminophen 300 mg/codeine 30 mg Acetaminophen 300mg/hydrocodone 5mg Acetaminophen 325mg/oxycodone 5mg No significant difference in pain relief at 1 and 2 hours between all of 5 groups References Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department. Ann Emerg Med. 2021;77(3):345-356. doi:10.1016/j.annemergmed.2020.10.004   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

The USA continues to wrestle with the legacy of an epidemic of opioid abuse, believed to have cost the lives of over half a million people through overdose.Until the pandemic struck, it looked as though the tide had turned, thanks to remedial actions on the part of drugmakers - prompted no doubt by a raft of lawsuits - as well as changes to prescribing practices.Now, opioid abuse is on the rise again, leading a broad swathe of society, from patients and drugmakers to lawmakers and regulators, to consider the best course of action.For several years, the US Food and Drug Administration has committed to a number of measures designed to encourage the development of non-addictive analgesic alternatives.These changes have created a positive regulatory framework for stem cell specialist Mesoblast (ASX: MSB), a Melbourne-based biotech developing an off-the-shelf cell therapy targeting chronic low back pain (CLBP) - an indication which absorbs half of US opioid prescriptions at present.In Episode 2 of The Pharma Letter Podcast, we discuss this option, as well as the broader therapeutic landscape, with the company's chief executive, Silviu Itescu.

  Vidcast:  https://youtu.be/vcfiQPA_eSs   Seventy-two percent of patients with chronic pain associated with fibromyalgia were able to use CBD to reduce their use of pain medications including narcotics.  This the conclusion from a University of Michigan study that reviewed records of 878 fibromyalgia patients who tried CBD as a part of their therapeutic regimen.   CBD took the place of NSAIDS in 59%, opioids in 53%, gabapentanoids in 35% and benzodiazepines in 23%.  In most cases, this substitution permitted complete discontinuation of these drugs and improved sleep patterns and memory.   This is one of the first studies that shows the chronic pain of fibromyalgia may be controlled with the plant-based CBD in place of sometimes more dangerous medications.    https://www.jpain.org/article/S1526-5900(21)00220-0/fulltext   #fibromyalgia #cbd #analgesics #opioids  

Dr. Ebell and Dr. Wilkes discuss the POEM titled ' Single-dose opioid analgesics offer no benefit over non-narcotic analgesia for musculoskeletal pain '

O efeito das analgésicos e anti-inflamatórios no contexto do exercício físico. @fabiodominski Fonte: Barlas, P., Craig, J. A., Robinson, J., Walsh, D. M., Baxter, G. D., & Allen, J. M. (2000). Managing delayed-onset muscle soreness: lack of effect of selected oral systemic analgesics. Archives of physical medicine and rehabilitation, 81(7), 966-972. Feucht, C. L., & Patel, D. R. (2010). Analgesics and anti-inflammatory medications in sports: use and abuse. Pediatric Clinics, 57(3), 751-774. Lundberg, T. R., & Howatson, G. (2018). Analgesic and anti‐inflammatory drugs in sports: Implications for exercise performance and training adaptations. Scandinavian journal of medicine & science in sports, 28(11), 2252-2262. Oester C, Weber A, Vaso M. Retrospective study of the use of medication and supplements during the 2018 FIFA World Cup Russia. BMJ Open Sport Exerc Med. 2019 Aug 12;5(1):e000609. --- Support this podcast: https://anchor.fm/fabio-dominski/support

Receptor functions of opioid agonists, mixed agonist-antagonists, and opioid antagonists; Drug interactions and pharmacokinetics and metabolism of opioid medications The clinical uses and possible side effects and toxicity of different classes of opiate-active medications Drugs discussed include full agonists, codeine, tramadol, propoxyphene, buprenorphine, nalbuphine, butorphanol, nelmefene, naloxone, naltrexone

The Better Birth podcast is hosted by hypnobirthing and antenatal teacher Erin Fung. You can find out more about Erin at www.better-birth.co.uk. In this episode, I speak to Tess and Leonie, private midwives from Your Neighbourhood Midwives, about the options for comfort measures and drugs for birth. This is an essential listen for anyone who is pregnant, and covers a wide range of options, from holistic and natural methods you can use at home, to the risks and benefits of drugs such as pethidine and epidurals. If you'd like to find out more about Tess and Leonie you can find them at www.yourneighbourhoodmidwives.co.uk

Narcotic Analgesics are drugs that relieve pain without causing unconsciousness or deadening the senses.

In this podcast Sarah Smith summarises the article 'Epidural administration of opioid analgesics improves quality of recovery in horses anaesthetised for treatment of hindlimb synovial sepsis’ by Louro et al.

Cns-- classification opioid analgesics --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

Alex talks about how inflammatory responses in pain work, as well as scientifically tested natural remedies for them, including capsaicin, white willow bark, and Frankincense.As always, if you enjoyed the show, follow us and subscribe to the show: you can find us on iTunes or on any app that carries podcasts as well as on YouTube. Please remember to subscribe and give us a nice review. That way you’ll always be among the first to get the latest GSMC Health & Wellness Podcasts.We would like to thank our Sponsor: GSMC Podcast NetworkAdvertise with US: http://www.gsmcpodcast.com/advertise-with-us.html Website: http://www.gsmcpodcast.com/health-and-wellness-podcast.html ITunes Feed : https://itunes.apple.com/us/podcast/gsmc-health-wellness-podcast/id1120883564 GSMC YouTube Channel: https://www.youtube.com/watch?v=mnvoV83f1_ATwitter: https://twitter.com/GSMC_Health Facebook: https://www.facebook.com/GSMCHealthandWellness/ Instagram: https://www.instagram.com/gsmc_health/ Disclaimer: The views expressed on the GSMC Health & Wellness Podcast are for entertainment purposes only. Reproduction, copying or redistribution of The GSMC Health & Wellness Podcast without the express written consent of Golden State Media Concepts LLC. prohibited.

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2020.09.10.290908v1?rss=1 Authors: Wilson, K. A., Mostyn, S. N., Frangos, Z. J., Shimmon, S., Rawling, T., Vandenberg, R. J., O'Mara, M. L. Abstract: The human glycine transporter GlyT2 (SLC6A5) has emerged as a promising drug target for the development of new analgesics to manage chronic pain. N-acyl amino acids inhibit GlyT2 through binding to an allosteric binding site to produce analgesia in vivo with minimal overt side effects. In this paper we use a combination of medicinal chemistry, electrophysiology, and computational modelling to explore the molecular basis of GlyT2 inhibition at the allosteric site. We show how N-acyl amino acid head group stereochemistry, tail length and double bond position promote enhanced inhibition by deep penetration into the binding pocket. This work provides new insights into the interaction of lipids with transport proteins and will aid in future rational design of novel GlyT2 inhibitors. Copy rights belong to original authors. Visit the link for more info

Episode 09: Analgesics | In this episode we will discuss analgesic medications including opioids and NSAIDs. | Show notes: https://tinyurl.com/y5khbjqe |---Inspirational Corporate by MaxKoMusic | https://maxkomusic.com/Music promoted by https://www.free-stock-music.comCreative Commons Attribution-ShareAlike 3.0 Unportedhttps://creativecommons.org/licenses/by-sa/3.0/deed.en_USSound effects from https://www.free-stock-music.com

Pharmacology Opioids vs. Nonopioid Pain meds  Free quiz & full course at https://Simplenursing.com/nursing-school    Pharmacology Master Class - Try it for Free: https://Simplenursing.com/nursing-school  100 videos not on YouTube    FREE Access to new app + 1,000 videos not on youtube!  https://Simplenursing.com/nursing-school   NCLEX FREE TRIAL:  https://simplenursing.com/NCLEX   STAY IN TOUCH

Pharmacology Opioids vs. Nonopioid Pain meds  Free quiz & full course at https://Simplenursing.com/nursing-school    Pharmacology Master Class - Try it for Free: https://Simplenursing.com/nursing-school  100 videos not on YouTube    FREE Access to new app + 1,000 videos not on youtube!  https://Simplenursing.com/nursing-school   NCLEX FREE TRIAL:  https://simplenursing.com/NCLEX   STAY IN TOUCH

Join our expert faculty as they review the safety of over-the-counter analgesics in the primary care setting. Earn Credit / Learning Objectives & Disclosures: https://www.medscape.org/viewarticle/931873?src=mkm_podcast_addon_931873

I've been discussing topicals with a few people this week. I personally don't use them a lot, but I know they have benefits and efficacy for therapy and many people rely on them for help at home. Let's revisit this discussion in a classic rebroadcast. Find John on social media: Instagram - @drjohncampione Check out www.knackbags.com whenever you buy a bag just use our affiliate code ROCKCAST. It won’t cost you anything extra and shipping on all bags is free. Trust me when I tell you, you are going to love your Knack bag. Don’t forget 15% off your next order of tape, topicals, mobility tools and apparel at shop.rocktape.com. 15% off of the best tape and gear around! Use Promo code: ROCKCAST

Pain in cancer patients—whether because of the condition or treatment—can be managed. This episode looks into pain and its management.

Opioid analgesics, also known as painkillers, are an important type of medicines used in the management of pain. Despite their established benefit in acute pain, their usefulness in chronic pain has been questioned. While they bring relief to those with moderate to severe pain they also carry inherent risks that, when used in vulnerable populations or when combined with sedative-hypnotics, increase the possibility of serious complications such as opioid induced pain, addiction and death.

When treating acute and chronic pain conditions, there is a need for “balanced” analgesia or multimodal analgesia. These are cases in which opioids as monotherapy are rarely appropriate. The therapeutic role of adjuvant analgesics is to increase the therapeutic index of opioids by producing an opioid-sparing effect. The use of nonopioid analgesics, adjuvant agents, and, in some cases antidepressants, may provide additional pain relief by opioid-sparing effects. Many of these agents have additional benefits in treating other related comorbid conditions present in those who suffer from chronic pain. Newer regulatory guidelines, like the CDC Guideline for Prescribing Opioids for Chronic Pain, recommend that first-line treatment for acute and chronic pain should be nonopioid analgesics as an initial trial, emphasizing the need to optimize multimodal analgesia including nonpharmacologic interventions to improve outcomes. It is vital to have an appreciation and knowledge of alternative pain treatments in an era where mass opioid use has been the norm. During the so-called opioid epidemic, practitioners should provide patients with effective tools to help manage pain while minimizing the negative effects of opioid exposure. Adjuvant agents are not primarily identified as analgesic in nature but have been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when used with opioids. Adjuvants add a unique action in opioid-resistant pain and can play a role in reducing opioid side effects. Knowledge of this class of medications is critical for the prescriber to be able to document their thought process in treatment plan development in the event of regulatory review. The goal of this course is to provide you with the tools to successfully evaluate the appropriate role of these agents in your practice. (Recorded at PAINWeek 2018)

We're talking about an important topic. It's the effect of bullying on chronic pain in children and adolescents. When I did an interview with Dr. Christine Chambers, a psychologist who treats children and adolescents with chronic pain, I said that I was going to be dedicating more episodes to this important topic because if we can prevent pain in children, it won't carry over to having pain in adults. We won't have the mass of chronic pain that we have now. When I saw this topic on a med search I did, I said this is someone I have to invite on the podcast to discuss what her research has shown. Our guest is Dr. Pernilla Garmy. She is a registered nurse specializing in children's health. She has several years of experience working as a school nurse in Sweden. She's an Associate Professor at Kristianstad University in Sweden. Her research is focused on sleep, mental health and lifestyle in school-aged children and adolescents, as well as the link between pain, bullying and mental health problems, which we'll talk about more. She's published more than twenty scientific articles and published an article called Bullying, pain and analgesic use in school-age children, which was published in the journal, Acta Paediatrica. Pernilla is Chair of the Sleep and Health Section of the Swedish Society of Nursing and the editor of the Swedish journal, Sleep and Health. I know you're going to enjoy this episode. We talk a lot about pain in children through the context of bullying and analgesic use. This is great information. If you're a physical therapist, a mental health professional, a school nurse and even parents of children with pain will be interested in this topic so make sure to share it out with your friends and family. Let's welcome Pernilla to the show. Sign up for the latest episode at www.integrativepainscienceinstitute.com/podcasts/. Love the show? Subscribe, rate, review, and share! Here’s How » Join the Healing Pain Podcast Community today: integrativepainsciencinstitute.com Healing Pain Podcast Facebook Healing Pain Podcast Twitter Healing Pain Podcast YouTube Healing Pain Podcast LinkedIn Healing Pain Podcast Instagram

Medicine and science builds and grows on the foundations of those who came before. Although pain management discoveries have been at a relative snail’s pace, there have been recent advances in existing medications and analgesic devices, as well as exciting new molecules and formulations on the horizon. With progressive changes in technology come advances in medicine. Inasmuch, this lecture will discuss newer formulations of older molecules (NSAIDs, local anesthetics, opioids, gabapentinoids), touch on developments in the abuse deterrent opioid space, and introduce some exciting animal based, preclinical, and early phase molecules in development. Come hear a discussion of the future of analgesics including topics such as NMDA, TRK-A, NOS, beta-arrestin, ORL-1, kappa, GABA, liposomes, and more! (Recorded at PAINWeek 2018)

In this podcast we discuss the key concepts in assessing drug efficacy trials, and provide you with a bottom line recommendation for the use of gabapentinoids, NSAIDs and acetaminophen for low back pain and radicular symptoms, topical NSAIDs and cyclobenzaprine for sprains and strains, caffeine as an adjunct analgesic, why we should never prescribe tramadol, dexamethasone for pharyngitis, calcium channel blockers for hemorrhoids and anal fissures, buscopan for abdominal pain and renal colic and why morphine might be a better analgesic choice than hydromorphone... The post Ep 126 EM Drugs That Work and Drugs That Don’t – Part 1: Analgesics appeared first on Emergency Medicine Cases.

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!   Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)

Common heavy hitters when combating the most common symptoms: nausea, vomiting, and pain.

Join the EMGuideWire Team as we discuss Pain Management issues and options in our Emergency Departments. EM physicians Sergey Motov and Chris Griggs discuss concepts that may help alleviate not only the patients' pain, but also the challenges physicians face in today's environment.

Hello Listener! Thank you for listening.  If you would like to support the podcast, and keep the lights on, you can support us whenever you use Amazon through the link below: It will not cost you anything extra, and I can not see who purchased what. Or you can become a Fluffle Supporter by donating through Patreon.com at the link below: Patreon/Hare of the Rabbit What's this Patreon? Patreon is an established online platform that allows fans to provide regular financial support to creators. Patreon was created by a musician who needed a easy way for fans to support his band. What do you need? Please support Hare of the Rabbit Podcast financially by becoming a Patron. Patrons agree to a regular contribution, starting at $1 per episode. Patreon.com takes a token amount as a small processing fee, but most of your money will go directly towards supporting the Hare of the Rabbit Podcast. You can change or stop your payments at any time. You can also support by donating through PayPal.com at the link below: Hare of the Rabbit PayPal Thank you for your support, Jeff Hittinger. Meissner Lop The Virginia museum of Natural History offers innovative, award-winning exhibits highlighting the unique features of Virginia’s natural history.  All exhibits and presentations are correlated to Virginia education standards. https://www.vmnh.net/events/details/id/330/dragon-festival The Meissner Lop rabbit is a recognized rare breed by the BRC. It is similar but more slender than the French Lop. The Meissner Lop is one of the oldest German rabbit breeds, but it is so rare today that is considered endangered. This breed got it start in 1900, when Leopold Reck, from Meissner (hence the name), decided to breed a large rabbit with a silvery fur, which was quite popular at the time. Although the true origin of the Meissner Lop rabbit is unknown, it is believed that it is the results of crossing French Lop with Mini Silver Rabbit. Even though it’s not commonly found today, there are many breeders interested in preserving this stunning rabbit breed. Meissner Lop is mostly bred in Europe, and it is recognized by The British Rabbit Council (BRA). A rare and beautiful breed, Meissner Lop rabbits are an excellent choice for a pet, as they have great, lively personality and sweet nature. Overall Description Meissner Lop rabbit is unique among the lop breeds because of their silver-dusted hair. Considered to be medium to large sized, Meissner Lop rabbits weigh from 7.5 to 10 lbs. Apart from their unique shimmery coat, these rabbits share most of their physical traits with other lop rabbits. Their body type is compact, and their bodies are stocky, slightly stretched, with arched, well rounded back. Meissner Lop rabbits have a rounded head with the distinct long ears that fall to the sides of their head. The legs and short and sturdy. The silvering of the coat (not seen until 5 - 6 weeks old) should be evenly distributed. Larger than the Klein Widder but smaller than the German Lop, the Meissner Lop Rabbit is one of the most beautiful and yet most uncommon breeds of lop-eared rabbit in the world. Known for bold coloration and prominent silver ticking, it's surprising to learn that these rabbits aren't more popular. While less massive than German and French Lops, the Meissner is known for his size and beautiful coat. Commonly weighing anywhere from 7 lbs. 12 oz. to 12 lbs. this makes the breed a size larger than the Klein Widder – the rabbit that eventually came to be known as the Mini Lop in the United States, and a bit less compact than his American cousin. In fact, the body shape of the Meissner is considerably lower in the shoulders and rising to a slow, graceful arch over the hips, rather than the basketball tightness of the Mini Lop. They still posses good bone and an overall feeling of muscled power. The head of the Meissner is not as broad nor as massive as that Of the larger French Lops, though it possesses a beautiful round shape and an nicely arched profile when viewed from the side. Does (females) have a slightly ‘weaker’ head that possesses a more feminine appearance and are also permitted to have a small dewlap. The ears hang straight down, falling just behind the eyes, with a length of 15-16 inches, when measured tip-to-tip. Additional Information: This rabbit is less massive than the German Lop. The ears are carried full. Alternative names: Meissner Hangoor (The Netherlands) Meissner Widder (Germany) The History of the Meissner Widder The true origins of the Meissner Widder are a mystery, though it’s believed that they developed in Germany during the 1920’s, when rabbit breeders began crossing silver rabbits into the lop breeds, hoping to increase the size of the beautiful silver rabbits, thereby making their valuable coats even more highly prized. At the time, it was less popular to raise one group of rabbits for fur and another for meat – ideally, if you could cross the two, you had the ideal rabbit to raise in your pens. Coat Meissner Lop rabbits have a beautiful, soft fur. Their coats are very dense, with plenty of guard hair, and of medium length- their hair is around 3 centimeters long. But the most distinctive quality of Meissner Lop’s coat is the silver ticking, which gives it a shimmery, shiny effect. None of the other Lop breeds display this silver dusting, which makes this breed unique. Their fur is easy to groom and doesn’t require any special attention, except during the molting season, when these rabbits should be brushed more often, to help them with shedding and prevent hair from ending up in their digestive tract. The coat is dense, soft and has a lustrous sheen; it lies smoothly against the body. There are distinctive "bumps" where the ears and head meet; the ends of the ears are rounded. Colors The Meissner Lop rabbit comes in all self colors, but only four of them are recognized- black, blue, yellow and Havana. Black and Blue Meissner Lops are the most common, while other colors are rarely found, due to their diminished numbers. Regardless of the color of the coat, their fur is always silvered evenly throughout the body (less so on the ears and legs), giving the hair a mesmerizing sheen. Their body is to possess an even dusting of silver hairs throughout, though the face and toes may be slightly less silvered. Meissner Lop rabbit is unique among the lop breeds because of their silver-dusted hair. BRC 1. Type – Not as stocky and compact as the French Lop. The body is longer with the back nicely arched and well rounded at the rear. The legs are strong and straight. A small well formed dewlap is permissible in older does. 2. Weight - Ideal weight 4.5kg (10lb) to a maximum weight 5.5kg (12lb). Minimum weight 3.5kg (7.3/4lb) 3. Head and Ears – The head has a beautiful arched profile. The forehead is broad but not as massive as that of the French Lop. The head of the doe is somewhat weaker than that of the buck. The ears rise from the crown and are carried with the inside aspect close to and facing the cheeks. They should hang down straight, behind the eyes, without being carried forward or backwards. Ear length 38-42cm (15-16 in) 4. Fur – The fur is of medium length approximately 3cm (1.1/4in) and quitedense. Evenly interspersed with guard hairs. 5. Color – All self colors and yellow. 6. Silvering and Evenness – Top color to be evenly silvered over the whole body. It is permissible for the nose, muzzle and toes to be less strongly silvered. 7. CONDITION - as standard for all breeds. FAULTS - Minor deviation in type. Poor ear carriage. Deviation from ideal ear length. DISQUALIFICATIONS - Severe deviation in type. Adult ear length less than 36cm and over 42cm. Horizontal or partly erect ears. Too short in body. Completely dark head without any silvering. Plus standard faults and disqualifications. Note, that a lack of any silvering on the Meissner may look strikingly beautiful, it is considered a disqualification from the show table. The Meissner should also have all dark toenails. Care Requirements Meissner Lop rabbits are well known as lively and friendly. When it comes to living conditions, Meissner Lop rabbits are no different than other breeds. They can be kept indoors or outdoors, provided that all their needs are met, but, if you want to keep this breed as a family pet, it’s best to keep them in your home. That way, the rabbit can socialize better with his family and will be much friendlier to people. In both cases, your bunny will need a proper enclosure to spend their time in. Due to their size, Meissner Lop rabbits will require a relatively large enclosure, in which they can lounge around, stretch their legs and sit. The floor of the hutch or the enclosure should be lined with rabbit-friendly bedding, which is to be cleaned daily and replaced entirely every week. Meissner Lop rabbits are well known as lively and friendly, and they need to be let out of their enclosures each day for some quality playtime. However, when you allow your bunny outside, whether in your yard or indoors, you need to make sure to create a safe environment for them. Inside your home, you’ll need to rabbit-proof everything, hiding or removing any items that could hurt them or that they could damage, like electric cables or dangerous foods. In the outdoor areas, their playing space needs to be fenced and protected from potential predators. Their diet is the same as that of any other rabbit. They require a lot of hay, with the addition of pellets, fruits, and veggies and a constant source of fresh water. Meissner Lop rabbits are known as good feeders, so they are not usually picky and have a healthy appetite. Health Meissner Lop rabbits don’t have any hereditary diseases or breed-specific health issues, but they do need proper care to lead long and healthy lives. The most common problems that affect all rabbit breeds are overgrown teeth, GI stasis, and viruses such as myxomatosis (prevented by vaccination). Rabbit’s teeth continuously grow throughout their life, so it’s essential to provide them with a way to grind them down. This means you’ll need to feed them a lot of roughage, like hay, which helps their teeth stay in good shape. But, rabbits don’t only nibble on hay and carrots. They are big on grooming themselves, which often leads to hairballs getting stuck in their digestive tract. Since rabbits can’t vomit the hair out (like cats), the hair blocks their intestines, which, if left untreated, can have fatal consequences. To prevent this, groom your bunny regularly and watch out for any warning signs- constipation, lethargy, loss of appetite or poop connected by strands of hair. Unless you plan on breeding your rabbits, you should consider spaying or neutering. It’s a simple, routine procedure that will make them more calm and docile, prevent potential problems with reproductive organs, and eliminate the possibility of urine marking. Temperament/Behavior Not unlike all Lop breeds, Meissner Lop rabbits are friendly, affectionate and sweet-tempered. However, Silver Rabbits are a part of their ancestry, which means these bunnies are more active and lively than other lop rabbits. They will need to be let out of their enclosures each day, because they like to roam about and spend all that energy. Meissner Lop rabbits love playing, so bunny toys and some quality playtime with their owner is all they need to be happy. They enjoy attention and being petted and make great pets for singles or seniors. Playful, sweet, and friendly, these rabbits make lovely family pets. As they have a good character and are relatively calm, they can be an excellent choice for families with older children, as well. However, it is important to educate your kids how to safely handle a rabbit, to prevent injuries or accidents. If you plan on keeping a rabbit as a pet in your apartment or house, litter training them will make things much easier for both you and them. Even though rabbits are not as easy to potty train like, say, cats, with a little patience and effort they can be taught to “do their business” in a designated area. The Meissner Lop Rabbit as a Pet Part of the reason that the Meissner Lop is considered a rare or endangered breed is most likely due to his inability to compete with larger meat rabbits, yet the large size makes him less popular as a pet as well. With dwarf and mini breeds being all the rage, the average 10-pound Meissner lop will require more space to keep and usually eats a considerable amount more than his smaller cousins. Perhaps the most challenging thing about keeping a Meissner Widder as a pet is simply finding one. Found only in Europe, the American Rabbit Breeders Association (ARBA) does not recognize the Meissner Lop breed and, even in their home country, you may find yourself paying a bit more for the rabbit, as well as doing quite a bit of legwork before you find someone who raises quality Meissner Widder. When you do, however, it’s certainly worth all the wait. Perhaps raising interest in the breed can help to revitalize them and keep this beautiful breed of bunny from being lost. http://www.petguide.com/breeds/rabbit/meissner-lop/ http://vetbook.org/wiki/rabbit/index.php?title=Meissner_Lop http://devonminilops.weebly.com/meissner-lops.html http://wildpro.twycrosszoo.org/S/0MLagomorph/Leporidae/Oryctolagus/Oryctolagus_cuniculus/Img_O_cuniculus_dom/BRC21-30p04_Meissner_Lop.htm https://treepony.com/rabbit-breed-profiles-the-meissner-lop/ Matted Hair and Hairballs in the Stomach in Rabbits Trichobezoars in Rabbits A trichobezoar is a technical reference for a mat of hair that has been ingested, and that is often combined with thick or undigested food. It is located in the stomach and/or intestines. It is not abnormal to find hair in a rabbit's stomach, since they self-groom, and this normally would not cause symptoms or be a cause for concern or a sign of disease. However, inspissated stomach contents (thick, dry, and less fluid and motile), which may include hair, is an abnormal finding and a cause for further inspection. The finding of inspissated contents or a mass of hair may suggest that your rabbit is receiving too little fiber in its diet, or that there is a problem with its gastrointestinal tract. Unlike cats, which also can suffer from excessive trichobezoars, rabbits are not physically capable of vomiting the contents of their stomachs. For this reason, everything that goes into a rabbit's mouth must be able to pass through the digestive tract, otherwise, the presence of excess hair can lead to severe complications, such as intestinal blockage. If the issue is not resolved quickly, the condition can be fatal. Symptoms and Types The signs, symptoms, and type of trichobezoars suffered by the rabbit can depend largely on the causes for the disease and the severity of the problem. Some common signs and symptoms of matted hair in the stomach may include: Inappropriate eating habits, including consumption of too many pellets, cereals, and grains during the day History of illness or stress Weight loss Chronic disease Scant and small fecal pellets Diarrhea Abdominal distension Slow movement in the stomach, distension or hardening of the stomach Firm indigestible material found in the stomach Few abdominal sounds coming from the stomach Delayed emptying of the stomach Abdominal pain on palpation or touching of the stomach Decreased activity, and too much time spent in caged quarters Teeth grinding, hunched posture and other signs of pain Weakness or collapse Symptoms of shock Causes There are several causes for trichobezoars, or hairballs, in the stomachs of rabbits. These include improper nutrition, and dehydration of the stomach contents. Sometimes metabolic diseases, pain, or stress can contribute to the formation and accumulation of hairballs or matted hair in the stomach. Usually, the finding is that too little gastrointestinal motility is to blame for the collection of hair and other materials in the stomach. One of the culprits may be feeding the rabbit too little hay or coarse fiber, necessary for pushing contents through the digestive tract. Anorexia - an inability to eat -- or simply a prolonged poor appetite can also contribute to the problem. Diagnosis There will always be conditions to rule out prior to diagnosing trichobezoars, or related conditions. Diagnostic imaging, such as what can be viewed on X-ray, will allow your veterinarian to investigate the functions of the colon and gastrointestinal tract, and to view the stasis (obstruction), or inability of the digestive tract to pass fecal matter through to the anus. Your doctor will need to determine if there is in fact an obstruction in the gastrointestinal tract, or in the motility, and whether a life-threatening emergency may exist. If an obstruction is found, emergency treatment will be necessary, as this can quickly cause a life threatening situation. In acute (sudden) cases, shock may occur, so it is important to take sensible action quickly. Distension of the stomach is usually clear, and a quick inspection by your veterinarian will find food and hair in the gastric contents. Ultrasound is an excellent diagnostic tool for visualization of the stomach's contents, and to confirm the diagnosis. Treatment Severe bloating of the abdomen can be life-threatening, so prompt treatment will be vital to the life of your rabbit. If you find your rabbit with an abnormally distended belly, you will need to take it to the veterinary clinic to be evaluated as soon as possible. Treatment will consist of immediate administration of fluid therapy to re-hydrate the gastric contents in the hope of making the contents more motile. Stomach massage can also sometimes help relieve impacted contents from the stomach cavity. Decompression may also be helpful. Activity is often recommended for more mobile animals to help promote action within the gastrointestinal system, and a proper diet is essential for restoring proper growth of intestinal flora, and prevention of the overgrowth of bacterial pathogens that could disrupt the healthy growth of bacteria in the gut. A large selection of natural greens, including collard greens, romaine lettuce, parsley, and spinach are a few of the many greens that are recommended as part of a healthy daily diet for rabbits. Living and Management If your rabbit is capable of moving, you should continue to encourage it to do so, avoid pellets and other unhealthy snacks unless otherwise advised by your veterinarian. Rest and relaxation is recommended, with frequent breaks for stretching and motion. Analgesics (pain relievers) can be helpful for relieving intestinal pain, and antibiotic therapy may be helpful for patients with the diarrhea that is associated with bacterial infections. Be sure to continue the full prescribed treatment until the medication is completely used, and then follow-up with your veterinarian for further advice. Some drugs, such as NSAIDs, are not indicated for rabbits that are suffering from renal (kidney) failure, and in fact could be placed at further health risk of administered the wrong drugs. You will need to make sure that your veterinarian is aware of your rabbit's health history, especially if your rabbit needs to be treated on an emergency basis and the animal caregiver is not familiar with your rabbit's background health. There are safer drug alternatives that can be just as effective. Rabbits that are treated promptly and effectively for trichobezoars have a good prognosis for a complete recovery. https://www.petmd.com/rabbit/conditions/digestive/c_rb_trichobezoars The Girl Who Transformed Herself into a Hare Germany In Trent there formerly lived a girl who had inherited a witch's thong from her grandmother. Whenever she tied the thong around herself she would turn into a hare. In this form she often heckled a forester who lived in the vicinity. Whenever he would shoot at her, his bullets just glanced off her pelt. When he came to realize that there was something uncanny going on here, he loaded his flintlock with a coffin nail that he had somehow acquired. The next time he saw the hare, he shot it as it was running away. In an instant the hare disappeared, and the girl stood before him in its place. With tears she asked him for help, for she had a serious wound on her foot. In order to gain his sympathy, she confessed her evil power to the forester, promising never again to make use of it. For a time she kept her promise, but no sooner had her foot healed than she fell back into her old vices. Now her fiancé worked as a herdsman at a nearby estate, and she frequently made use of her thong in order to visit him often and undisturbed. Her fiancé knew nothing of her powers, and one day when she appeared before him as a hare -- for she had not yet had time to assume her human form -- he struck her with a water carrier. As a result she started to bleed profusely, and with tears she confessed to her fiancé what her situation was. He broke off his relationship with her. She remained lame for the rest of her life. It is said that the witch's thong was later buried in the grandmother's grave. Germany On two days a hunter from Freiburg saw a hare in Schlossberg Forest and shot at it.] Both times it stood still, looked mockingly at the man, only running away when the latter hurried toward it. The hunter presumed that he was dealing with witchcraft, so he loaded his gun with consecrated powder, then used this to shoot at the hare when he saw it a third time. Instead of a hare, a female personage was there, standing on her head and bleeding from a gunshot wound in her breast. When the hunter touched her, she fell to the ground dead. https://www.pitt.edu/~dash/type3055.html#haas Word of the week: Obligation © Copyrighted

Nonopioid analgesics are oftentimes considered first-line therapy for most chronic pain syndromes. A strong understanding of these agents' mechanism of action, pharmacokinetics, and toxicity profiles is paramount for today's pain practitioner. This course will provide an in-depth look at each of the agents within these drug classes, their potential role in pain management, and available data supporting their use. Additionally, clinically relevant monitoring pearls will be discussed.

On this episode of the #AskMikeReinold show we are joined by Phil Page at the annual ICCUS Society meeting to discuss the latest research on kinesiology tape, self myofascial release, and topical analgesics. To view more episodes, subscribe, and ask … Read more > The post Research Updates on K-Tape, Self Myofascial Release, and Topical Analgesics appeared first on Mike Reinold.

N.B.: This month's show notes are a departure from the usual summary.  Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features.  In children often the predominant feature may not be initially apparent.  Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach.  What is the age and developmental stage of the child?  How is the child reacting to his condition?  What are the circumstances?  What is the family or caregiver dynamic? We rely much on how patients and families interact with us to gauge pain.  Assessing and managing children’s pain can be challenging, because they may not exhibit typically recognized signs and symptoms (Srouji 2010).  Further, children participate in and absorb their family’s culture and specific personality from a very young age (Finley 2009).  Knowing the context of the episode may help.  For example, a very anxious caregiver can easily transmit his or her anxiety to the child, which may either inhibit or amplify presentation of symptoms (Bearden 2012). The guiding principles in pediatric pain assessment and management are: know the child; know the family; and know the physiology.  Children have long suffered from an under-treatment of their pain, due both to our incomplete acknowledgement of their pain and our fear of treatment (Howard 2003).  As the pendulum on pain management swings one way or the other, do not let your pediatric patient get knocked by the wayside.  Take a thoughtful approach: know the signs and symptoms, and aggressively treat and reassess. ASSESSMENT Each stage of development offers a unique framework to the child’s signs and symptoms of pain.  In pre-verbal children, use your observational skills in addition to the parent’s report of behavior.  Verbal children can self-report; younger children require pictorial descriptions, while older children and adolescents may use standard adult scales.  In all ages, ask open-ended questions and allow the child to report and speak for himself whenever possible. Neonates Neonates are a unique group in pain assessment.  The neonate (birth to one month of age) has not yet acquired social expression of pain, and his nascent nervous system is only now learning to process it.  Do not expect typical pain behaviors in neonates.  Facial grimacing is a weak indicator of pain in neonates (Liebelt 2000).  When this behavior is present, look for a furrowed brow, eyes squeezed shut, and a vertically open mouth.  Tachycardia, tachypnea, and a change in behavior can be indicators not only to the presence of pain, but possibly to its etiology as well. Neonatal observational scales have been validated in the intensive care and post-operative settings; ED-specific quantitative scales are lacking.  CRIES is a 10-point scale, using a physiologic basis similar to APGAR: Crying; Requires increased oxygen administration (distress and breath-holding); Increased vital signs; Expression; and Sleeplessness (Krechel 1995).  CRIES (Table 1) was validated for post-operative patients; to adapt its use for the ED, the most conservative approach is to substitute “preoperative baseline” with normal range for age.  Although the numerical values of CRIES have not been validated to date in the ED, the clinician may find the domains included in CRIES to be a useful cognitive construct in assessing neonatal pain. Neonatal pain pathways are particularly plastic; prompt assessment of and increased alertness to neonatal pain may help to mitigate long-lived pain sensitivity and hyperalgesia (Taddio 2002).  In other words, treat the neonate’s pain seriously, as you may save him long-term pain sequelae in the future. Infants and Toddlers This group will begin to exhibit more reproducible, reliable signs and symptoms of pain. For infants of less than one year of age, the Neonatal Infant Pain Scale (NIPS) uses observational and physiologic parameters to detect pain (Table 2).  A score of 0-2 indicates no pain present.  A score of 3-4 indicates mild to moderate pain; non-pharmacologic techniques may be tried first.  A score of 5 or greater indicates severe pain; some pharmacologic intervention is indicated (Lawrence 1993). For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability (Table 3). Contextual and caregiver features predominate in this group.  Frequent reassessments are helpful, as the initial trepidation and fright in triage may not accurately reflect the child’s overall pain status. Preschool and School-age children Increasing language development offers the hope of more information to the clinician, but be careful not to ask leading questions.  Do not jump directly to “does this hurt?”.  Preschoolers will say ‘yes’ to anything, in an attempt to please you.  School-age children may passively affirm your “statement”, if only to validate their human need for care or attention.  Start with some ice-breaking banter, lay down the foundations for rapport, and then ask open-ended questions.  Be careful not to allow the caregiver to “instruct” the child to tell you where it hurts, how much, how often, etc.  Rather, engage the parents by asking them what behavior they have noticed.  Eliciting history from both the child and the parent will go a long way in constructing a richer picture of the etiology and severity of the pain, and will help to build rapport and trust. The Baker-Wong FACES Pain Rating scale (Figure 1) was developed with feedback from children and has been validated for use in those 3 years of age and older (Keck 1996, Tomlinson 2010). Adolescents Adolescents vary in their development, maturity, and coping mechanisms.  You may see a mixture of childhood and adult behaviors in the same patient; e.g. he may be initially stoic or evades questioning, then later exhibits pseudo-inconsolability.  Do what you can to see the visit from the adolescent’s perspective, and actively transmit your concern and intention to help – many will respond to a warm, open, non-judgemental, and helpful attitude.  The overly “tough” adolescent is likely secretly fearful, and the “dramatic” adolescent may simply be very anxious.  Take a moment to gauge the background behind the presentation. You may use the typical adult scale of 0 (no pain) to 10 (worst pain), or the Faces Pain Scale–Revised (FPS-R).  The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain (Tsze 2013). PAIN PHYSIOLOGY Pain includes two major components: generation and perception.  Generation of pain involves the actual propagation of painful stimuli, either through nociceptive pain or neuropathic pain.  Nociceptive pain arises from free nerve endings responding to tissue damage or inflammation. Nociceptive pain follows a specific sequence: transduction (an action potential triggered by chemical mediators in the tissue, such as prostaglandins, histamine, bradykinin, and substance P); transmission (the movement of the action potential signal along the nerve fibers to the spinal cord); perception (the impulse travels up the spinothalamic tract to the thalamus and midbrain, where input is splayed out to the limbic system, somatosensory cortex, and parietal and frontal lobes); and modulation (the midbrain enlists endorphins, enkephalins, dynorphin, and serotonin to mitigate pain) (Pasero 2011).  As clinicians we can target specific “stations” along the pain route to target the signal more effectively. Simple actions such as ice, elevation, local anesthetics, or splinting help in pain transduction.  Various standard oral, intranasal, or IV analgesics may help with pain’s transmission. Non-pharmacologic techniques such as distraction, re-framing, and others can help with pain perception.  The sum of these efforts encourage pain modulation. A phenomenon separate from nociceptive pain is neuropathic pain, the abnormal processing of pain stimuli.  It is a dysregulated, chaotic process that is difficult to manage in any setting.  Separating nociceptive from neuropathic symptoms may help to select specific pain treatments and to clarify treatment goals and expectations. Neonates Neonates are exquisitely sensitive to many analgesics.  Hepatic enzymes are immature and exhibit decreased clearance and prolonged circulating levels of the drug administered.  Once the pain is controlled, less frequent administration of medications, with frequent reassessments, are indicated. The neonate’s vital organs (brain, heart, viscera) make up a larger proportion of his body mass than do muscle and fat.  That is to say, the volume of distribution is unique in a neonate.  Water-soluble drugs (e.g. morphine) reach these highly perfused vital organs quickly; relatively small overdosing will have rapid and exaggerated central nervous system and cardiac effects.  The neonate’s small fat stores and muscle mass limit the volume of distribution of lipophilic medications (e.g. fentanyl, meperidine), also making them more available to the central nervous system, and therefore more potent.  Other factors that predispose neonates to accidental analgesic overdose are their decreased concentrations of albumin and other plasma proteins, causing a higher proportion of unbound drug.  Renal clearance is also decreased in the first few months of life. Clinical note: in the ED, neonates often require analgesia for procedures more than for injury.  Non-pharmacologic techniques predominate (see below).  Make liberal use of local anesthetics such as eutectic mixture of local anesthetics (EMLA; for intact skin, e.g. IV access, lumbar puncture) and lidocaine-epinephrine-tetracaine gel (LET; for superficial open skin and soft tissue application).  Oral sucrose (30%) solutions (administered either with a small-volume syringe or pacifier frequently dipped in solution) are effective for minor procedures (Harrison 2010, Stevens 2013) via the release of dopamine and through distraction by mechanical means.  Neonates with severe pain may be managed with parenteral analgesics, on a monitor, and with caution. Infants and Toddlers With increasing body mass comprised of fat stores in conjunction with an increase in metabolism, this group will require a different approach than the neonate.  For many medications, these children will have a greater weight-normalized clearance than adults (Berde 2002).  They will often require more frequent dosing.  Infants and toddlers have a larger functioning liver mass per kilogram of body weight, with implications for medications cleared by cytochrome p-450. Clinical note: some drugs, such as benzodiazepines, will have both a per-kilogram dosing as well as an age-specific modification.  When giving analgesics or anxiolytics to young children, always consult a reference for proper dosing and frequency. School-age children and Adolescents This group retains some hyper-metabolic features of younger children, but the dose-effect relationship is more linear and transparent.  Physiologic clearance is improved, and from a physical standpoint, these are typically lower-risk children.  From a psychological standpoint, this group may need more non-pharmacologic consideration and support to modulate pain optimally. NON-PHARMACOLOGIC TREATMENT The first line of treatment in all pain management is non-pharmacopeia (Horeczko 2016).  Not only is this the safest of all techniques, but often the most effective.  Some are simple comfort measures such as splinting (fracture or sprain), applying cold (acute soft tissue injury) or heat (non-traumatic, non-specific pain), or other targeted non-pharmacology. Many a pain control regimen is sabotaged without consideration of non-pharmacologic techniques, which may augment, or at times replace, analgesics.  Think of non-pharmacopoeia as your “base coat” or “primer” before applying additional coats of analgesic treatment.  With the right base coat foundation, you have a better chance of painting a patient’s symptoms a more tolerable and long-lasting new color. A tailored approach based on age will allow the practitioner to employ a child’s developmental strengths and avoid the frustration that results in asking the child to do what he is not capable of doing.  A brief review of Piaget’s stages of development will help to meet the child at his developmental stage for best effect (Piaget 1928, Sheppard 1977) during acute painful presentations and minor procedures. Sensorimotor stage (from birth to age 2): Children use the five senses and movement to explore the world.  They are egocentric: they cannot see the world from another’s viewpoint.   At 6 to 9 months, object permanence is established: understanding that objects (or people) exist even without seeing them. Preoperational stage (from ages 2 to 7):  Children learn to use language.  Magical thinking predominates. They do not understand rational or logical thinking. Concrete operational stage (from age 7 to early adolescence): Children can use logic, but in a very straightforward, concrete manner (they do well with simple examples).  By this stage, they move from egocentrism to understanding another point of view.  N.B. Some children (and adults) never completely clear this stage. Formal operational stage (early adolescence to adult): children are capable of abstract thinking, rationalizing, and logical thinking. It is important to assess the child’s general level of development when preparing and guiding him through the minor procedure or distracting him until his pain is controlled.  It is not uncommon for acutely ill or injured to regress temporarily in their behavior (not their development) as a coping mechanism. Neonate and Infant (0-12 months) Involve the parent, and have the parent visible to the child at all times if possible.  Make advances slowly, in a non-threatening manner; limit the number of staff in the room.  Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly.  Swaddle the infant and encourage the parent to comfort him during and after the procedure.  Engage their developing sensorimotor skills to distract them. Toddler to Preschooler (1-5 years) Use the same techniques as for the infant, and add descriptions of what he will see, hear, and feel; you can use a doll or toy to demonstrate the procedure.  Use simple, direct language, and give calm, firm directions, one at a time.  Explain what you are doing just before doing it (do not allow too much time for fear or anxiety to take root).  Offer choices when appropriate; ignore temper tantrums.  Distraction techniques include storytelling, bright and flashy toys, blowing bubbles, pinwheels, or having another staff member play peek-a-boo across the room.  The ubiquitous smart phone with videos or games can be mesmerizing at this age. School age (6-12 years) Explain procedures using simple language and (briefly) the reason (understanding of bodily functions is vague in this age group).  Allow the child to ask questions, and involve him when possible or appropriate.  Distraction techniques may include electronic games, videos, guided imagery, and participation in the minor procedure as appropriate. Adolescent (13 and up) Use the same techniques for the school age child, but can add detail.  Encourage questioning.  Impose as few restrictions as possible – be flexible.  Expect more regression to childish coping mechanisms in this age group.  Distraction techniques include electronic games, video, guided imagery, muscle relaxation-meditation, and music (especially the adolescent’s own music, if available). APPLIED PHARMACOLOGY No amount of knowledge of the above physiology, pharmacology, or developmental theory will help your little patient in pain without a well constructed and enacted plan.  Aggressively search out and treat your pediatric patient’s presence and source of pain.  Frequent reassessments are important to ensure that breakthrough pain treatment is achieved, when re-administration is indicated, or when a change of plan is necessary.  This is the time to involve the parents or caregivers to let them know what the next steps are, and what to expect. Start with the least invasive modality and progress as needed.  After non-pharmacologic treatments such as splinting, ice, elevation, distraction, and guided imagery, have an escalation of care in mind (Figure 2). From a pharmacologic perspective, various options are available.  Your pain management plan will differ depending on whether a painful procedure is performed in the ED (Table 4).  Once pain is addressed, create a plan to keep it managed.  Consider the trajectory of illness and the expected time frame of the painful episode.  Include practicalities such as how well the pain may be controlled as an outpatient.  Poorly controlled pediatric pain is more often managed as an inpatient than the same condition in an adult.  Speak frankly with the parents about what drug is indicated for what type of pain and that treatment goals typically do not include absence of all pain, but function in face of the pain, in anticipation for clinical improvement. A special note on codeine: Tylenol with codeine (“T3”) has never been a very effective pain medication, as up to 10% of patients lack enzymatic activity to metabolize it into morphine, its active form (Crews 2014).  New evidence is emerging on the erratic and unpredictable individual metabolism of codeine.  Some children are ultra-rapid-metabolizers of codeine to morphine, causing a rapid “bolus” of the available drug, with respiratory depression and death in some cases (Ciszkowski 2009, Racoosin 2013).  Author’s advice: take codeine off your formulary. COMMON SCENARIOS Head and neck pain Most common non-traumatic head and neck complaints can be managed non-pharmacologically (e.g. headache: improved hydration, sleep, stress, nutrition) or with PO medications, such as NSAIDs.  The anti-inflammatory nature of ibuprofen (10 mg/kg PO q 4-6 h prn, up to adult dose) for example, will treat the cause as well as the symptoms of ear pain, sore throat, and muscular pain.  Ibuprofen may be more effective than acetaminophen (paracetamol) for odontogenic pain (Bailey 2013).  For most applications, acetaminophen may be as effective; however, the combination of both NSAIDs is not likely to be more effective than either agent individually (Merry 2013). True migraine headache may be treated with all of the above, and rescue therapy may include prochlorperamide (0.15 mg/kg IV, up to 10 mg ) (Brousseau 2004), often given with diphenhydramine (1 mg/kg PO or IV, up to 50 mg) and IV fluids.  Ketoralac (0.5 mg/kg IV, up to 10 mg) may be substituted for ibuprofen (Paniyot 2016).  Other specific therapies may be considered, although evidence for them varies. Chest pain After ruling out important pulmonary (e.g. the under-recognized spontaneous pneumothorax) and cardiac (e.g. pericarditis, myocarditis) etiologies, many chest complaints are amenable to NSAIDs.  There is often a large component of anxiety in the child and/or parents in chest pain; no amount of medication will assuage them without addressing their concerns as well. Abdominal pain Abdominal pain in children is challenging, as it is common, often benign, but may be disastrous if the etiology is missed.  For mild pain, consider acetaminophen as indicated (15 mg/kg/dose q 4-6 h prn, up to 650 mg).  The oral route is preferred, but intravenous acetaminophen is an option for patients unable to tolerate PO, or for those in whom the per rectum (PR) route is contraindicated (e.g. neutropenia) (Babl 2011, Dokko 2014).  For children with moderate to severe abdominal pain in whom a nil per os (NPO) status is ideal, consider rehydration/volume repletion, and small, frequent aliquots of a narcotic agent.  Surgical pain is not “erased” by opioids (Thomas 2003, Poonai 2014); treating pain improves specificity to certain surgical emergencies with retained diagnostic accuracy (Manterola 2007).  If there is inter-departmental concern about prolonged effects, sedation, limitation in the physical exam, or there is a need to “see if the pain will come back”, you may opt to use fentanyl initially for its shorter half-life.  More frequent re-assessments may help the surgical team in its deliberations.  Transition quickly to a longer-acting opioid as soon as possible. Long-bone injuries Fracture pain should be addressed immediately with splinting and analgesia.  Oral, intranasal, and intravenous routes are all acceptable, depending on the severity of the injury and symptoms. Intranasal (IN) medications offer the advantage of a fast onset for moderate-to-severe pain (Graudins 2015), either as monotherapy or as a bridge to parenteral treatment (Table 4).  The ideal volume of IN medication is 0.25 mL/naris, with a maximum of 1 mL/naris.  Common concentrations of fentanyl limit its mg/kg use to the school-aged child; intranasal ketamine may be used for pain (i.e. sub-dissociative dose) up to adult weight. Long-bone injuries are a good opportunity to employ a speedy modality that requires little technical skill in administration: nebulized fentanyl.  Clinically significant improvement in pain scales are achieved with 3 mcg/kg/dose of fentanyl administered via standard nebulizer in children 3 years of age or older (Miner 2007, Furyk 2009).  Nebulized fentanyl is a rapid, non-invasive alternative to the IN route for older children, adolescents, or adults, in whom the volume of IN medication would exceed the recommended per naris volume (Deaton 2015). Consider an aggressive, multi-modal approach to control symptom up front.  For example, for a simple forearm fracture, you may opt to give an oral opioid, perform a hematoma block, and offer inhaled nitrous oxide for reduction, rather than a formal intravenous procedural sedation (Luhmann 2006). Ultrasound-guided peripheral nerve blocks are a good pain control adjunct, after initial treatment, and in communication with referring consultants (Ganesh 2009, Suresh 2014). Skin and Soft tissue Skin and soft tissue injuries or abscesses often require solid non-pharmacopoeia in addition to local anesthetics.  For IV cannulation, consider EMLA if the patient is stable and a minor delay is acceptable. Topical ethyl chloride vapo-coolant offers transient pain relief due to rapid cooling and may be used just prior to an IV start (Farion 2008).  Try this: engage your young child’s imagination to distract him and say, “have you ever held a snow ball? You are in luck – it’s just like that – here, do you feel it?”. Vibratory adjuncts such as the “BUZZY” bee can be placed near the IV cannulation site to provide mechanical and cognitive distraction (Moadad 2016). Needleless lidocaine injectors may facilitate IV placement without obscuring the target vein (Spanos 2008, Lunoe 2015).  The medication is propelled into the dermis by a CO2 cartridge that makes a loud popping sound; try this to alleviate anxiety, just before using it: “your skin looks thirsty – it needs a drink – there you are!”. As with any minor procedure, when you tell the child what you are doing, be sure to do it right away.  Do not delay or build suspense. Lidocaine-epinephrine-tetracaine gel (LET) is used for open or mucosal wounds.  Apply as soon as possible in the visit.  The goal of LET is to pretreat the wound to allow for a painless administration of injectable anesthetic.  A common practice to apply LET two or three times at 15-minute intervals for deeper anesthesia, in an attempt to avoid injection altogether.  Researchers are currently working to offer an evidence base to this anecdotal practice. Pediatric burns should be assessed carefully and treated aggressively.  Submersion of the affected extremity in room-temperature water (if possible) or applying room-temperature saline-soaked gauze will both thwart ongoing thermal damage, soothe the wound, and provide foundational first-aid.  Minor burns can be treated topically and with oral medications.  Major burns require IN, IM, or IV analgesics with morphine.  Treatment may escalate to ketamine (Gandhi 2010), in analgesic or dissociative dosing, depending on the context.  Post-traumatic disorders are common in burns; effective pain management is ever-more important in these cases. SPECIFIC SCENARIOS The child with chronic medical problems Children with acute exacerbations of their chronic pain or episodic painful crises require special attention.  Some examples of children with recurring pain are those suffering from sickle cell disease, juvenile idiopathic arthritis, complex regional pain syndrome, and cancer.  Find out whether these symptoms and circumstances are typical for them, and what regimen has helped in the past.  Previous unpleasant experiences may prime these children with amplified anxiety and perception of pain (Cornelissen 2014).  Target the disease process and do your best to show the patient and his family you understand his condition and needs. An equally challenging scenario is the child with chronic pain.  Treat the entire patient with a multimodal approach.  Limit opioids as possible.  As an opioid-sparing strategy or as rescue therapy, consider sub-dissociative ketamine, especially for conditions such as sickle cell crisis, complex regional pain syndrome, autoimmune disorders, or chronic pain due to sub-acute trauma (Sheehy 2015). Intranasal ketamine may be used for sub-dissociative pain control at 0.5 – 1 mg/kg (Andolfatto 2013, Yeaman 2013).  Intravenous infusions of ketamine at 0.1 – 0.3 mg/kg/h may be initiated in the ED and continued 4 – 8 h/d, up to a maximum of 16 h total in 3 consecutive days (Sheehy 2015).  In vaso-occlusive episodes, dexmedetomidine has been shown to be an effective adjunct for severe pain poorly responsive to opioids and/or ketamine (Sheehy 2015b). The child with cognitive impairment Children with cognitive impairment such as those with various genetic or metabolic syndromes, or primary neurologic conditions such as some with cerebral palsy are a challenge to assess and treat properly.  These children not only cannot explain their symptoms, but they also have atypical expressions of pain.  Pain responses in severely intellectually disabled children include a full-blown smile (which may or may not accompany inappropriate laughter), stiffening, and non-cooperation (Hadden 2002).  Other observed behaviors include the freezing phenomenon, in which the child acutely feels the pain, and he abruptly pauses without moving his face for several seconds.  Look also for episodes of unexplained pallor, diaphoresis, breath-holding, and shrill vocalizations. The FLACC has been revised (r-FLACC) for children with cognitive impairment and appears to be reliable for acute care (Malviya 2006). The most distressing and perplexing presentation is the parent who brings his or her child with cognitive impairment for “fussiness”, “irritability”, or “I think he’s in pain”.  Often, this is after significant investigations have been performed, sometimes repeatedly.  Poorly controlled spasticity is an often under-appreciated cause of unexplained pain; treat not with opioids, but with GABA-receptor agonists, such as baclofen or benzodiazepines. Take special precautions in the administration of opioids or benzodiazepines in children with metabolic disorders (e.g. mitochondrial disease) or various syndromes (e.g. Trisomy 21).  They may have a disproportionate reaction to the medication.  Start with a low dose in these children and reassess frequently, titrating in small aliquots as needed. After careful, meticulous investigation in the ED to rule out occult infection, trauma, electrolyte imbalance, or surgical causes, the child with cognitive impairment who continues to be symptomatic despite ED treatment may be admitted for observation.  However, in some cases, the addition of gabapentin to the typical regimen has been shown to manage unexplained irritability in these children (Hauer 2007) by treating visceral hyperalgesia. Multi-trauma The child with multi-trauma is in need of meticulous critical care.  Frequent assessments of pain analgesic response (typically via the intravenous route) are necessary to gauge the child’s trajectory.  Unexplained tachycardia may be the early signs of shock.  Without controlling the child’s pain, it is difficult to distinguish the extreme tachycardia from pain or from blood loss.  If intubated, control the pain first with a fentanyl drip, then use a sedative in addition as needed to keep him comfortable. The child under palliative care Children undergoing palliative care require a multidisciplinary approach.  This includes engaging the patient’s car team as well as “treating” members of the patient’s family.  Examples include the natural course of devastating chromosomal, neurologic, and other congenital conditions; terminal cancer; and trauma, among others (Michelson 2007).  Family dynamics and family members’ needs are often overlooked; the family as a whole must be considered.  Focus on the productive and beneficial treatments that can be offered.  Treat pain promptly, but speak with the parents about end-of-life goals as early as possible, as any analgesic or sedative may have an untoward effect.  You do not want to be caught in the position of potentially precipitously providing cardiopulmonary resuscitation in a child undergoing palliative care, because of a lack of understanding of how increasingly large doses of pain medications can affect breathing and circulation (AAP 2000). Children with ongoing opioid requirements may present not so much with an exacerbation of their chronic pain, but a complication of its treatment.  Identify, assess and aggressively treat constipation, nausea and vomiting, pruritus, and urinary retention (Friedrichsdorf 2007); treating side-effects of pain management may be just as important for quality of life as treating the pain itself. PEARLS AND PITFALLS IN PEDIATRIC PAIN Allow the child to speak for himself whenever possible.  After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you.  Tell me more.” Engage parents and communicate the plan to them.  Elicit their expectations, and give them of preview of what to expect in the ED. Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible.  Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction. Premature infants present a challenge in pain control.  Their pain is under-recognized, as they often display atypical responses to painful stimuli.  Treatment is equally difficult, as they are particularly sensitive to analgesia-sedation.  This is important, as this group is even more likely to undergo painful procedures due to their higher-risk status. Give detailed advice on how to manage pain at home.  Set expectations.  Let them know you understand and will help them through your good advice that will carry them through this difficult time.  Patients and families often just need a plan.  Map it out clearly. SUMMARY In pediatric acute pain, know the child; know the family; and know the physiology. Use your observational skills enhanced with collateral information to assess and reassess for pain in children. Treat pediatric pain well and often. Failure to address the child’s pain has long-lasting consequences. Non-pharmacologic treatments for all, pharmacologic treatments for many. 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Validation of Self-Report Pain Scales in Children. Pediatrics. 2013 Oct; 132(4): e971–e979. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013 Apr;25(2):161-7   This post and podcast are dedicated to Sergey M. Motov, MD, FAAEM, for his integrity, hard-won expertise, humility, and innovation.  Thank you for making us better doctors, Sergey, and for getting us ever closer to a pain-free ED. Pediatric Pain Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Generic Name ketorolac Trade Name Toradol Indication pain Action pain relief due to prostaglandin inhibition by blocking of the enzyme cyclooxygenase (COX) Therapeutic Class nonsteroidal anti-inflammatory agents, nonopioid analgesics Pharmacologic Class pyrroziline carboxylic acid Nursing Considerations may cause GI bleeding,… The post Ketorolac: Toradol (nonsteroidal anti-inflammatory agents, nonopioid analgesics) appeared first on NURSING.com.

Generic Name ibuprofen Trade Name Advil / Motrin Indication Mild to moderate pain, inflammatory states Action Decreases pain and inflammation by inhibiting prostaglandins Therapeutic Class antipyretics, antirheumatics, nonopioid analgesics, nonsteroidal anti-inflammatory agents Pharmacologic Class nonopioid analgesics Nursing Considerations may cause… The post Ibuprofen: Advil / Motrin (antipyretics, antirheumatics, nonopioid analgesics, nonsteroidal anti-inflammatory agents) appeared first on NURSING.com.

Learn about medication options for providing sedation and analgesia before endotracheal intubation. Initial publication: September 1, 2012. Last reviewed: March 7, 2019.

http://www.aliem.com/category/clinical/60-second-soapbox/ Authors submit a 60 second rant, that we remix and deliver as a podcast. Any topic is on the table - clinical, academic, economic, or anything else that may interest an EM-centric audience.

Dr. Rosenblum discusses atypical opiate analgesics, such as tramadol and tapentadol   References Benzon Package insert   DISCLAIMER: Doctor Rosenblum IS HERE SOLELY TO EDUCATE, AND YOU ARE SOLELY RESPONSIBLE FOR ALL YOUR DECISIONS AND ACTIONS IN RESPONSE TO ANY INFORMATION CONTAINED HEREIN. This podcasts is not intended as a substitute for the medical advice of physician to a particular patient or specific ailment.  You should regularly consult a physician in matters relating to yours or another's health.  You understand that this podcast is not intended as a substitute for consultation with a licensed medical professional.    Copyright © 2015 QBazaar.com, LLC  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording or otherwise, without the prior written permission of the author.

The consumer view that a hangover is a chemical process that can be solved with chemicals helps explain the correlation between sales of alcoholic drinks and aspirin/ibuprofen in the four Latin American countries included in this study. When weight management products are added to the equation, these industry verticals form a chain that reaches far into the festive consumer culture in these markets.

In this session of the RFUMS Top 200 Drugs Podcast, we discuss opioid analgesics: morphine sulfate, codeine/APAP, oxycodone, oxycodone/APAP, hydrocodone/APAP, hydrocodone/ibuprofen, fentanyl, and bisacodyl.

The Danish government recently introduced restrictions on pack sizes for over-the-counter analgesics. Packs that used to contain as many as 300 pills are now restricted to no more than 20. The restrictions are a means to curb the suicide rate in Denmark, as overdosing on analgesics is a sadly common method amongst young women. Analgesic manufactures welcomed the restrictions, and negative press for over-the-counter medication is expected to subside. Unit volume prices are rising as a result of the smaller packs, and the total market size of analgesics in Demark are expected to increase by 18 percent in value terms in 2014.

Interview with Nora D. Volkow, MD, author of Curtailing Diversion and Abuse of Opioid Analgesics Without Jeopardizing Pain Treatment

Evaluierung von Metamizol und Carprofen als postoperative Analgetika nach Hüftgelenksersatz bei Hunden. Das Ziel dieser Studie war es, die analgetische Wirkung der von den jeweiligen Arzneimittelfirmen für den Hund empfohlenen Dosierungen von Metamizol im Vergleich zu Carprofen nach Hüftgelenkersatz zu bewerten. Es ist bekannt, dass Metamizol ein potentes Analgetikum beim Menschen ist. Bis heute gibt es keine Studien zur postoperativen Wirksamkeit von Metamizol beim Hund. Subjektive (Melbourne Schmerzskala (mMPS) und visuelle Analogskala (VAS)) und objektive (Ganganalyse, in welcher die vertikale Spitzenkraft (PVF) und der vertikale Impuls gemessen wurden) Bewertungsverfahren wurden in dieser Studie für die Evaluierung der Schmerzen herangezogen. 39 klinisch gesunde Hunde mit einem Körpergewicht zwischen 5,5 und 60,5 kg (keine Rassespezifität) wurden in diese Studie eingeschlossen. Die Hunde wurden nach Randomisierung in zwei Gruppen verteilt: Tiere der Gruppe M (n = 19) erhielten 50 mg•kg-1 IV Metamizol TID. Tiere der Gruppe C (n = 20) erhielten 4 mg•kg-1 Carprofen IV SID. Die Patienten wurden 3, 6, 9, 12, 20, 24, 28, 32, 36, 44, 48 and 56 Stunden nach Operationsende subjektiv beurteilt. Wurden bei der Evaluierung mittels mMPS bzw. VAS Punktwerte von 12 bzw. 50 Punkten überschritten, so wurde dies als Anzeichen von Schmerzen betrachtet, welche mit einer intravenösen Gabe von Buprenorphin, 10 μg•kg-1, behandelt wurden (rescue analgesia). Eine Ganganalyse wurde einmal präoperativ (preOP) und dann am ersten (OP1) und zweiten (OP2) postoperativen Tag durchgeführt. Drei Patienten in der Gruppe C benötigten in den ersten 3 bis 6 postoperativen Stunden rescue analgesia. Keines der Tiere in Gruppe M benötigte die Gabe zusätzlicher Schmerzmittel. Sowohl bei der mMPS als auch bei der VAS zeigten Tiere der Gruppe M im Vergleich zu Gruppe C über den gesamten Zeitraum niedrigere Schmerz-Werte. Je nach verwendeter Schmerzskala waren diese Unterschiede nach 6 h (mMPS) bzw. nach 24 h (VAS) als signifikant zu betrachten (p < 0.05). Die postoperativen Ganganalysen zeigten bei Hunden der Gruppe M eine bessere Belastung der operierten Gliedmaße (p < 0.05). Diese Ergebnisse zeigen, dass die alleinige Verwendung von Metamizol als Analgetikum eine potente und zufriedenstellende Analgesie nach orthopädischen Eingriffen bei Hunden gewährleistet. Des Weiteren wurde gezeigt, dass die alleinige Verwendung von Carprofen in der vom Hersteller empfohlenen Dosierung nach Hüftgelenksersatz bei Hunden nicht immer eine zufriedenstellende Analgesie hervorruft.

Background: Pain in general and headache in particular are characterized by a change in activity in brain areas involved in pain processing. The therapeutic challenge is to identify drugs with molecular targets that restore the healthy state, resulting in meaningful pain relief or even freedom from pain. Different aspects of pain perception, i.e. sensory and affective components, also explain why there is not just one single target structure for therapeutic approaches to pain. A network of brain areas ("pain matrix") are involved in pain perception and pain control. This diversification of the pain system explains why a wide range of molecularly different substances can be used in the treatment of different pain states and why in recent years more and more studies have described a superior efficacy of a precise multi-target combination therapy compared to therapy with monotherapeutics. Discussion: In this article, we discuss the available literature on the effects of several fixed-dose combinations in the treatment of headaches and discuss the evidence in support of the role of combination therapy in the pharmacotherapy of pain, particularly of headaches. The scientific rationale behind multi-target combinations is the therapeutic benefit that could not be achieved by the individual constituents and that the single substances of the combinations act together additively or even multiplicatively and cooperate to achieve a completeness of the desired therapeutic effect. As an example the fixesd-dose combination of acetylsalicylic acid (ASA), paracetamol (acetaminophen) and caffeine is reviewed in detail. The major advantage of using such a fixed combination is that the active ingredients act on different but distinct molecular targets and thus are able to act on more signalling cascades involved in pain than most single analgesics without adding more side effects to the therapy. Summary: Multitarget therapeutics like combined analgesics broaden the array of therapeutic options, enable the completeness of the therapeutic effect, and allow doctors (and, in self-medication with OTC medications, the patients themselves) to customize treatment to the patient's specific needs. There is substantial clinical evidence that such a multi-component therapy is more effective than mono-component therapies.