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admin | Category: Erective Dysfunction 2016 | 12.12.2014
The chest radiograph zones are useful when describing the location of pathology on a frontal chest radiograph.The chest radiograph is a 2D representation of a 3D structure. Renew Your Subscription and List Your Practice for Free!Chronic pain sufferers are using our pain specialist directory to find pain specialists in your area.
Opioid intrathecal therapy offers the advantage of delivering medication directly to the dorsal horn of the spinal corda€”increasing potency and reducing the systemic exposurea€”thus reducing side effects.By Jason E. Intrathecal therapy for the management of malignant and nonmalignant pain has undergone a paradigm shift in recent years. The intrathecal drug delivery system (IDDS) functions as a platform, much as transdermal and intraveneous formulations, to deliver medication as a pharmacologic therapy. The advantages to opioid intrathecal therapy are numerous, including the ability to deliver medications where they commonly work (ie, the dorsal horn of the spinal cord), increasing potency, and reducing the systemic exposure and dose required to achieve the desired pharmacologic effect, thus reducing side effects.1 Table 1 compares systemic and intrathecal drug delivery systems. The purpose of this review is to reintroduce the technology, dissect the indications and the risks, comment on the efficacy of the therapy, and provide a few case examples. The mechanics behind intrathecal therapy are very simple: surgically, a catheter is placed in the intrathecal space and tunneled to an implanted reservoir, where the medication is housed. Recent work into cerebral spinal fluid (CSF) flow dynamics of the intrathecal space has offered an insight into pharmacokinetic modeling. Employing the current IDDS platforms availablea€”as the rate and volume available for delivery is largely fixeda€”concentration is typically manipulated. The Synchromed II by Medtronic (Figure 2), is a pump that has a geared mechanism that is programmable with a variety of infusion strategies. Recommendations on drug choice, concentration limits, and starting doses were outlined by the Polyanalgesic Consensus Conference (PACC) latest reiteration in 2012.14 A panel of experts on behalf of the International Neuromodulation Society (INS) convened on intrathecal therapy to promote safety and efficacy. To date, only two medications are approved by the FDA to treat chronic pain via intrathecal therapy: morphine (Infumorph) and ziconotide (Prialt).
Degrell I, Nagy E: Concentration gradients for HVA, 5-HIAA, ascorbic acid, and uric acid in cerebrospinal fluid. Do you recommend using technology (smartphone apps, Fitbits, etc) to help your patients become more active? Vertical Health Media, LLC does not, by publication of the advertisements contained herein, express endorsement or verify the accuracy and effectiveness of the products and claims contained therein.

Practical Pain Management is sent without charge 10 times per year to pain management clinicians in the US. Gone are the days of positioning the therapy as a salvage treatment for high-dose opioid patients.
The reservoir has a mechanism to dose the intrathecal space, based on the volume infused (Figure 1). This has led to some challenges with intrathecal therapy for nonmalignant pain, and will be addressed later in the review. It has the ability to have variable programmable dosing strategies, along with a patient therapy manager, which functions as a patient controlled bolus delivery mechanism much like an inpatient patient controlled analgesia (PCA) system. The medication tiers were designed based on nociceptive or neuropathic pain (see Tables 2-4). Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival.
Effect of Anatomic Fine Structure on the Flow of Cerebrospinal Fluid in the Spinal Subarachnoid Space.
Cerebrospinal fluid and spinal cord distribution of baclofen and bupivacaine during slow intrathecal infusion in pigs. Cerebrospinal fluid and spinal cord distribution of hyperbaric bupivacaine and baclofen during slow intrathecal infusion in pigs. Mortality associated with implantation and management of intrathecal opioid drug infusion systems to treat noncancer pain. Accuracy and efficacy of intrathecal administration of morphine sulfate for treatment of intractable pain using the prometra programmable pump. Localization of Ca 2+ channel subtypes on rat spinal motor neurons, interneurons, and nerve terminals. Chemical stability of admixtures combining ziconotide with morphine or hydromorphone during simulated intrathecal administration.
Chemical stability of admixtures combining ziconotide with baclofen during simulated intrathecal administration. Chemical stability of ziconotidea€“clonidine hydrochloride admixtures with and without morphine sulfate during simulated intrathecal administration.

Chemical stability of an admixture combining ziconotide and bupivacaine during simulated intrathecal administration.
Chemical stability of admixtures combining ziconotide with fentanyl or sufentanil during simulated intrathecal administration. Combination of intrathecal opioids with bupivacaine attenuates opioid dose escalation in chronic noncancer pain patients.
Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. Correlation between withdrawal symptoms and medication pump residual volume in patients with implantable SynchroMed pumps. Vertical Health Media, LLC disclaims any liability for damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing.
With careful selection and vigilance, advanced techniques like intrathecal therapy can be implemented in a manner that greatly improves functionality and pain care.
Prior to implantation, a successful trial needs to be performed with at least 50% pain reduction without side effects.
Much of the morbidity and mortality associated with intrathecal therapy centers on iatrogenic causes, specifically around the refill and reprogramming of the device.11 The life of the battery within the reservoir typically lasts 7 to 10 years, and although the mechanics behind the deployment of volume from the reservoir differ based on the manufacturer, the refill procedure is largely the same. It is magnetic resonance imaging (MRI) compatible, with the advisory to read the pump before and after the scan, without the need to remove medication from the internal tubing or reservoir. If the pump were to malfunction during an MRI, the therapy would have a motor stall without restarting, with the abrupt withdrawal of the therapy, potentially creating loss of analgesia and withdrawl symptoms. Studies have demonstrated improved volume delivery accuracy as compared to the Medtronic Synchromed II.12 The pump is MRI compatible after complete removal of the medication from the reservoir. There currently is no PCA dosing strategy available with the Prometra pump, although it appears to be on the horizon.

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