The Role of Cannabis, Cannabidiol and Other Cannabinoids in Chronic Pain. The Perspective of Physicians.

Currently, there is a renewed interest in treatments with medical cannabis and cannabinoids. Based on an increasing number of publications over the last decades that permitted new insights into mechanisms, efficacy and safety of cannabinoids, the use of cannabinergic medications is authorised in an increasing number of European and non-European countries. The alleviation of chronic, painful conditions is, since thousands of years, one of the primary reasons for the use of cannabis. Depending on the country, a wide range of medicinal cannabis preparations are available:ranging from defined cultivars of medical cannabis, mainly varying in their THC:CBD ratio, that are inhaled or taken as whole plant extracts,to highly purified single cannabinoids, such as delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD),or mixtures of two enriched extracts, standardised to a 1:1 ratio of THC:CBD (nabiximols). Although conflicting opinions continue to exist, the majority of reviews in the past concluded that medical cannabis and cannabinoids play a significant role in the management of pain. Surprisingly, systematic studies to date do not support an "entourage effect" of the other plant constituents of cannabis (mainly terpenoids) in treatment of chronic pain. An emerging cannabinoid is CBD which is the only cannabinergic medication available at present that does not cause the typical "cannabis high"; it is not a "controlled substance". However, despite years of research, there is either no study or no well-conducted, head-to-head, comparison available between different cannabis cultivars, between pure cannabinoids, and between pure cannabinoids and extracts. It remains unanswered which is the optimal treatment approach.

Feasibility of the ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in very small weight infants: A case series.

BACKGROUND: The aim of this retrospective analysis was to evaluate the clinical feasibility of the supraclavicular ultrasound-guided cannulation of the brachiocephalic vein in infants weighing less than 1500 g. METHODS: The ultrasound probe was placed in the supraclavicular region so as to obtain the optimum sonographic long-axis view of the brachiocephalic vein. By using an in-plane approach the brachiocephalic vein was cannulated by using a 24-gauge intravenous cannula under real-time ultrasound guidance into the vein followed by the insertion of a 2-French single lumen catheter using the Seldinger technique. RESULTS: Forty-six brachiocephalic vein cannulations in infants weighing between 0.55 and 1.5 kg (Median: 1.2; 95%-CI: 0.9-1.2) were included. Ultimate success rate was 89.1% (41 out of 46). One cannulation attempt was required in 30 (65.2%) patients, 2 in 6 (13%) and 3 in 5 (10.8%), respectively. Smaller weight babies did not require significantly more cannulation attempts. The probability of successful cannulation on the first attempt increased significantly from 40% (2010) to more than 80% (2019) over the time course of this series. Median catheter dwell time was 15 days (95%-CI: 9-20) with one catheter being removed prematurely after 8 days due to obstruction. CONCLUSION: Supracalvicular in-plane real-time ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and feasible option to provide large-bore central venous access for very small and sick babies.

Advance directives in Austrian intensive care units: An analysis of prevalence and barriers.

PURPOSE: To investigate the prevalence of advance directives, healthcare proxies, and legal representatives in Austrian intensive care units (ICUs), and to explore barriers faced by adults engaged in the contemplation and documentation phase of the advance care planning process. METHODS: Two studies were conducted: (1) A 4-week multicenter study covering seven Austrian ICUs. A retrospective chart review of 475 patients who presented to the ICUs between 1 January 2019 and 31 January 2019 was conducted. (2) An interview and focus group study with 12 semi-structured expert interviews and three focus groups with 21 adults was performed to gain insights into potential barriers faced by Austrian adults planning medical decisions in advance. RESULTS: Of the 475 ICU patients, 3 (0.6%) had an advance directive, 4 (0.8%) had a healthcare proxy, and 7 (1.5%) had a legal guardian. Despite the low prevalence rates, patients and relatives reacted positively to the question of whether they had an advance directive. Patients older than 55 years and patients with children reacted significantly more positively than younger patients and patients without children. The interviews and focus groups revealed important barriers that prevent adults in Austria from considering planning in advance for potentially critical health states. CONCLUSION: The studies show low prevalence rates of healthcare documents in Austrian ICUs. However, when patients were asked about an advance directive, reactions indicated positive attitudes. The gap between positive attitudes and actual document completion can be explained by multiple barriers that exist for adults in Austria when it comes to planning for potential future incapacity.

A Pilot Study of Pharyngeal Electrical Stimulation for Orally Intubated ICU Patients with Dysphagia.

OBJECTIVE: Dysphagia is a common disorder in neurological and non-neurological intensive care unit (ICU) patients and can lead to aspiration pneumonia, prolonged ventilation, and delayed extubation. Dysphagia is an independent predictor of increased mortality. In dysphagic stroke patients with tracheotomy, the use of pharyngeal electric stimulation (PES), an emerging technique to treat dysphagia, has been shown to improve airway protection and shorten time to decannulation. The objective of this study was to determine whether patients who receive PES have a lower prevalence of pneumonia and frequency of reintubation. DESIGN: Secondary analysis of a non-blinded interventional subject sample from a large clinical study with a historical age, pathology, and severity-matched control group. SETTING: ICU of a tertiary care medical center. PATIENTS: In this pilot non-blinded study, a group of 15 intubated patients in a general and a neurologic ICU received PES while orally intubated during ICU stay. A control group (n = 25) matched for age, type, and region of pathology, and severity of illness expressed by Simplified Acute Physiology Score and Therapeutic Intervention Scoring System was used to compare for pneumonia and need for reintubation. MAIN RESULTS: Patients treated with PES had significantly lower prevalence of pneumonia (4 vs 21, p = 0.00046) and frequency of reintubation (0 vs 6, p = 0.046) when compared to controls. CONCLUSION: Although limited by its small size and non-blinded design, this is the first study demonstrating the benefits of PES in ICU patients still orally intubated, thus offering a potential new method to reduce morbidity, mortality, and economic burden in a mixed ICU population. In order to further investigate and strengthen our findings, a statistically powered, randomized controlled study is recommended.

Prevalence of palliative care patients in emergency departments.

BACKGROUND: Emergency departments (ED) serve as a contact point for critically ill patients. According to experience, a fraction of patients visiting ED present with palliative symptoms and require palliative care; however, the prevalence of these patients has not been determined in Austria so far. METHODS: In the ED of a tertiary care medical centre in Carinthia all adult patients presenting between 8 January 2018 and 17 January 2018 were classified on arrival with the Manchester triage system (MTS) and were afterwards assessed with a validated 2­tier screening tool for palliative care. Patient records were screened in April 2018 to find out whether they received palliative care. RESULTS: In total 1277 patients visited the ED during the investigation period. Of these patients 1096 were screened and 145 of these patients (13.2%) showed palliative symptoms and needed a goal-oriented therapy. Of these 145 patients 10.9% were assessed by MTS as emergency, 2.7% as very urgent, 34.7% as urgent, 51% as normal, and 0.7% as not urgent. Only 8 (5.5%) of the patients with palliative medical symptoms actually received palliative care consultation. CONCLUSIONS: More than 1 in 10 patients attending an ED suffered from palliative symptoms. Hence it is to be expected that healthcare providers in an ED in Austria will frequently encounter patients with palliative symptoms in emergency admissions. Therefore, it is necessary to develop suitable structures to provide these patients with the best possible care.

Effects of intermittent hypoxia-hyperoxia on mobility and perceived health in geriatric patients performing a multimodal training intervention: a randomized controlled trial.

BACKGROUND: Additional benefits of passive exposures to intermittent hypoxia and hyperoxia on cognitive performance and functional exercise capacity have been demonstrated in geriatric patients who performed a multimodal training program. The main goal of the present study was to evaluate effects of adding intermittent hypoxic-hyperoxic training (IHHT) to a multimodal training intervention (MTI) on mobility and perceived health in old individuals at a Geriatric Day Hospital. METHODS: Thirty-four patients between 64 and 92 years participated in the double blind, randomized and controlled clinical trial. The elderly patients attended in a 5-7 weeks lasting MTI (strength, endurance, balance, reaction, flexibility, coordination, and cognitive exercises) and performed IHHT (breathing 10-14% oxygen for 4-7 min followed by 2-4 min 30-40% oxygen) in the Hypoxic Group (HG) or placebo treatment with ambient air in the Normoxic Group (NG) in parallel. Before and after all treatments, mobility was assessed by the Tinetti Mobility Test (TMT), the Timed-Up-and-Go Test (TUG) and Barthel-Index, while perceived health was assessed by one part of the EQ-5D Test, the EQ visual analogue scale (EQ VAS). RESULTS: After the MTI plus IHHT or normoxia sessions, results of the TMT, TUG, Barthel Index and EQ-VAS revealed no significant difference between HG and NG (+ 14.9% vs + 15.4%, p = 0.25; - 21% vs - 26.3%, p = 0.51; + 4.2% vs + 3.6%, p = 0.56; + 37.9% vs + 33.9%, p = 0.24;). CONCLUSIONS: IHHT added to MTI did not elicit additional improvements in perceived health and mobility compared to MTI alone.

A Retrospective Analysis of the Clinical Effectiveness of Supraclavicular, Ultrasound-guided Brachiocephalic Vein Cannulations in Preterm Infants.

BACKGROUND: The aim of this retrospective analysis was to evaluate the clinical effectiveness of the supraclavicular ultrasound-guided cannulation of the brachiocephalic vein in preterm infants. METHODS: The ultrasound probe was placed in the supraclavicular region so as to obtain the optimum sonographic long-axis view of the brachiocephalic vein. By using a strict in-plane approach the brachiocephalic vein was cannulated by advancing a 22- or 24-gauge iv cannula from lateral to medial under the long axis of the ultrasound probe under real-time ultrasound guidance into the vein. RESULTS: One hundred and forty-two cannulations in infants weighing between 0.59 and 2.5 kg (median: 2.1; CI: 2.0 to 2.2) were included. Ultimate success rate was 94% (134 of 142). One cannulation attempt was required in 100 (70%) patients, two attempts in 21 (15%), and three attempts in 13 (9%). The smaller the weight of the infant the more attempts were needed. More attempts also were needed for the right brachiocephalic vein, which was primarily targeted in 75 (53%) neonates. One (1%) inadvertent arterial puncture was noted. CONCLUSIONS: This supraclavicular, in-plane, real-time, ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and effective method to insert central venous catheters in preterm infants.

Intermittent hypoxic-hyperoxic training on cognitive performance in geriatric patients.

INTRODUCTION: Intermittent hypoxic-hyperoxic training (IHHT) may complement a multimodal training intervention (MTI) for improving cognitive function and exercise tolerance in geriatric patients. METHODS: Thirty-four patients (64-92 years) participated in this randomized controlled trial. Before and after the 5- to 7-week intervention period (MTI + IHHT vs. MTI + ambient air), cognitive function was assessed by the Dementia-Detection Test (DemTect) and the Sunderland Clock-Drawing Test (CDT), and functional exercise capacity by the total distance of the 6-Minute Walk Test (6MWT). RESULTS: DemTect and CDT indicated significantly larger improvements after MTI + IHHT (+16.7% vs. -0.39%, P < .001) and (+10.7% vs. -8%, P = .031) which was also true for the 6MWT (+24.1% vs. +10.8%, P = .021). DISCUSSION: IHHT turned out to be easily applicable to and well tolerated by geriatric patients up to 92 years. IHHT contributed significantly to improvements in cognitive function and functional exercise capacity in geriatric patients performing MTI.

Clinical factors influencing death rattle breathing in palliative care cancer patients : Non-interventional study.

BACKGROUND AND AIM: In the last days of life the clinical symptom of death rattle breathing is manifested in many awake or semiconscious patients in palliative care. Scientific studies on relevant influencing factors on the characteristics of the clinical symptom of death rattle breathing in patients in palliative care are rare. MATERIAL AND METHODS: The design of the study is based on a non-interventional prospective study with questionnaire evaluation and was implemented at the palliative care unit at the Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care at the Clinical Center Klagenfurt, Austria. The questionnaire was developed by the authors of this study. RESULTS: The study had a predefined duration of 10 months (from February to November 2012) and during this period a total of 273 patients were admitted to the palliative care unit of the Clinical Center in Klagenfurt. Of these 105 (38.5 %) died and could therefore be included in the evaluation but 3 patients in palliative care (2.9 %) did not fulfil the inclusion criteria of a malignant disease. In total 102 patients, 43 females (42.2 %) and 59 males (57.9 %) were evaluated. The average age was 69 years with a range of 41-92 years. The largest proportion of the random sample (62.8 %) was in the patient age group from 61 to 80 years old and death rattle breathing could be observed in 26 patients (25.3 %) of the total sample. In a specific subgroup analysis regarding the intensity of the symptom, many of the affected patients suffered noisy breathing or severe death rattle breathing. In these cases it was primarily women in the group of patients with death rattle breathing. Gender was found to be a statistically relevant influencing factor (p = 0.034) on the intensity of the symptom. CONCLUSION: The great majority of the variables studied showed no influence on the development of the symptom of death rattle breathing; however, more intensive forms were manifested in female patients. The small study population could be a limitation of the present study although the prospective design allows valid conclusions to be drawn. In the future studies should be implemented in order to improve treatment of patients suffering from death rattle breathing.

Ultrasound-guided supraclavicular cannulation of the right brachiocephalic vein in small infants: a consecutive, prospective case series.

BACKGROUND: The supraclavicular ultrasound (US)-guided cannulation of the brachiocephalic vein (BCV) is one option of central venous line placement in infants. AIM: The aim of this prospective study was to evaluate whether there was an association between the optimum ultrasonographic view as obtained of the entire longitudinal extension of the right BCV and the ease of supraclavicular cannulation when using a strict in-plane technique via a linear US probe in small infants. METHODS: The US probe was placed in the right supraclavicular region. If the optimum obtainable sonographic view presented the entire longitudinal extension of the right BCV demonstrating clearly its path caudally alongside the pleura, it was graded as I. If, however, only a circular view, i.e., the initial part of the right BCV was obtainable via US, it was graded as II. The right BCV was cannulated by advancing a 22-gauge i.v. cannula from lateral to medial strictly under the long axis of the US probe under direct US vision into the vein. RESULTS: Seventy-nine infants weighing between 0.8 and 4.5 kg (Median: 3.4 ± 0.09) were included. In 50 (63.3%) patients, the sonographic view was graded as I and in 29 (36.7%) as II. The proportion of patients successfully cannulated on the first attempt was significantly smaller in patients graded as II, i.e., circular, sonographic view of the right BCV than in patients graded as I, i.e., sonographic view of the entire longitudinal extension of the right BCV (41% vs 90%; chi-square analysis: P < 0.01). CONCLUSION: The sonographic view obtainable of the entire longitudinal extension of the right BCV resulted in significantly fewer required cannulation attempts.

Treatment of localized neuropathic pain of different etiologies with the 5% lidocaine medicated plaster - a case series.

OBJECTIVE: To assess the efficacy and safety of the topical 5% lidocaine medicated plaster in the treatment of localized neuropathic pain. STUDY DESIGN: This was a case series at an Austrian pain clinic, using retrospective analysis. PATIENTS AND METHODS: Data of 27 patients treated for localized neuropathic pain with the 5% lidocaine medicated plaster were retrospectively analyzed. Assessment included changes in overall pain intensity, in intensity of different pain qualities, and of hyperalgesia and allodynia, and changes in sleep quality. RESULTS: Patients (17 female, ten male; mean age 53.4±11.4 years) presented mainly with dorsalgia (16 patients) or postoperative/posttraumatic pain (seven patients); one patient suffered from both. The mean overall pain intensity prior to treatment with lidocaine medicated plaster was 8.4±1.2 on the 11-point Likert scale. In the majority of cases, the lidocaine plaster was applied concomitantly with preexisting pain medication (81.5% of the patients). During the 6-month observation period, overall mean pain intensity was reduced by almost 5 points (4.98) to 3.5±2.6. Substantial reductions were also observed for neuralgiform pain (5 points from 7.9±2.6 at baseline) and burning pain (3 points from 5.2±4.1). Sleep quality improved from 4.6±2.6 at baseline to 5.5±1.8. Stratification by pain diagnosis showed marked improvements in overall pain intensity for patients with dorsalgia or postoperative/posttraumatic pain. The lidocaine plaster was well tolerated. CONCLUSION: Overall, topical treatment with the 5% lidocaine medicated plaster was associated with effective pain relief and was well tolerated.