The Utilization of Low Dose Naltrexone for Chronic Pain

Naltrexone is a mu-opioid receptor antagonist with a long half-life compared with naloxone. Both of these drugs, along with others, were developed with the intention of reversing the effects of opioid abuse or toxicity. Evidence has also shown that naltrexone has a benefit in preventing relapse by reducing opioid cravings and reducing symptoms of opioid withdrawal. The benefits of this drug were not only shown with opioid abuse. In 1984 this drug was also approved for alcohol abuse. Naltrexone has been proven to decrease alcohol relapse by decreasing the craving. Apart from these approved indications for the use of naltrexone, with time, it has been seen that this drug has a benefit in treating chronic pain. A number of studies have shown the benefits of this drug with inflammatory bowel disease, fibromyalgia, multiple sclerosis, diabetic neuropathy, and complex regional pain syndrome, among others. More studies are needed to approve this medication for specific chronic pain conditions.

A comprehensive review of intraarticular knee injection therapy, geniculate injections, and peripheral nerve stimulation for knee pain in clinical practice

The knee is the most common joint in adults associated with morbidity. Many pathologies are associated with knee damage, such as gout or rheumathoid arthritis, but the primary condition is osteoarthritis (OA). Not only can osteoarthritis cause significant pain, but it also can result in signficant disability as well. Treatment for this condition varies, starting off with oral analgesics and physical therapy to surgical total knee replacmenet. In the gamut of this various treatments, a conservative approach has included intra articular steroid injections. With time, researchers and clinicians determined that other components injected to the knee may additionally provide relief of this condition. In this investigation, we describe different types of knee injections such as platelet-rich plasma (PRP), hyaluronic acid, stem cells, and prolotherapy. Additionally, we describe the role of geniculate knee injections, radiofrequency, and periopheral nerve stimulation. These treatments should be considered for patients with knee pain refractory to conservative therapies.

Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice

Stem cells are types of cells that have unique ability to self-renew and to differentiate into more than one cell lineage. They are considered building blocks of tissues and organs. Over recent decades, they have been studied and utilized for repair and regenerative medicine. One way to classify these cells is based on their differentiation capacity. Totipotent stem cells can give rise to any cell of an embryo but also to extra-embryonic tissue as well. Pluripotent stem cells are limited to any of the three embryonic germ layers; however, they cannot differentiate into extra-embryonic tissue. Multipotent stem cells can only differentiate into one germ line tissue. Oligopotent and unipotent stem cells are seen in adult organ tissues that have committed to a cell lineage. Another way to differentiate these cells is based on their origins. Stem cells can be extracted from different sources, including bone marrow, amniotic cells, adipose tissue, umbilical cord, and placental tissue. Stem cells began their role in modern regenerative medicine in the 1950's with the first bone marrow transplantation occurring in 1956. Stem cell therapies are at present indicated for a range of clinical conditions beyond traditional origins to treat genetic blood diseases and have seen substantial success. In this regard, emerging use for stem cells is their potential to treat pain states and neurodegenerative diseases such as Parkinson's and Alzheimer's disease. Stem cells offer hope in neurodegeneration to replace neurons damaged during certain disease states. This review compares stem cells arising from these different sources of origin and include clinical roles for stem cells in modern medical practice.

Buprenorphine and its formulations: a comprehensive review

Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.

Aduhelm, a novel anti-amyloid monoclonal antibody, for the treatment of Alzheimer's Disease: A comprehensive review

Alzheimer's disease (AD) is the most common form of dementia affecting millions of individuals, including family members who often take on the role of caregivers. This debilitating disease reportedly consumes 8% of the total United States healthcare expenditure, with medical and nursing outlays accounting for an estimated $290 billion. Cholinesterase inhibitors and N-methyl-D-aspartate receptor antagonists have historically been the most widely used pharmacologic therapies for patients with AD; however, these drugs are not curative. The present investigation describes the epidemiology, pathophysiology, risk factors, presentation, and current treatment of AD followed by the role of the novel monoclonal antibody, Adulhelm, in the treatment of AD. Currently, Adulhelm is the only Food and Drug Administration (FDA) approved drug that acts to slow the progression of this disease. Adulhelm is an anti-amyloid drug that functions by selectively binding amyloid aggregates in both the oligomeric and fibrillar states. Studies show Adulhelm may help to restore neurological function in patients with AD by reducing beta-amyloid plaques and reestablishing neuronal calcium permeability. At present, there is concern the magnitude of this drug's benefit may only be statistically significant, although not clinically significant. Despite skepticism, Adulhelm has proven to significantly decrease amyloid in all cortical brain regions examined. With such high stakes and potential, further research into Adulhelm's clinical efficacy is warranted in the treatment of AD.

A minimally invasive lumbar decompression procedure after an interspinous spacer device implantation: an uncommon order of treatment with a successful outcome

A patient with lumbar spinal stenosis (LSS) was referred to our clinic due to refractory low back pain, radicular pain, and neurogenic claudication despite conservative treatment with medical management. Imaging of the lumbar spine revealed spinal canal and foraminal stenosis. Multiple epidural steroid injections (ESI) were performed which did not resolve her condition. We offered her an Implantation of an Interspinous Spacer Device (ISD) since her primary symptoms were predominantly characteristic of radicular pain. Her radicular symptoms improved but experienced worsening of her lower back pain and neurogenic claudication. For these reasons, we then offered her a Minimally Invasive Lumbar Decompression (MILD) procedure. Though both procedures share the same incisional approach, the first one deploys an implant in the interspinous process, as opposed to the MILD procedure which does not. We therefore describe the intricacies of performing a MILD procedure after an ISD implant and share the patient's outcome.

Inferior vena cava filter removal - Hope for the best and prepare for the worst: An anesthesiology perspective

A patient presented to our institution for an elective removal of an inferior vena cava (IVC) filter under local anesthesia. Once removed, it was noticed that the filter had a missing secondary leg. The patient had a chest CT done which showed a hyper-attenuating structure in the region of the tricuspid valve highly suspicious for the fractured strut of the filter. Upon these findings, the patient was taken once again to the surgical suite for an endovascular retrieval of the strut. For fear of a possible cardiac injury and a potential need for a sternotomy, the patient received general anesthesia and was placed with appropriate IV access and full cardiac monitors. The strut was removed successfully without any complications. Despite the relative benign nature of this endovascular procedure, one should always be prepared for an appropriate resuscitation in case of an occurrence of a surgical complication.

Quadricuspid aortic valve associated with aortic insufficiency contributors

A 51-year-old male presented with a wound in his right hand that was suspicious for possible septic emboli of cardiac origin. With transesophageal echocardiography, the patient was found to have a rare quadricuspid aortic valve. This quadricuspid valve can present with variable symptoms and physical exam findings. Due to embryological defects, this pathology is associated with several other anatomical defects that are important to recognize prior to surgical intervention. Transesophaegeal echocardiography remains the gold standard in detection of quadricuspid aortic valve and identification of other possible cardiac lesions.

[Bioethical problems in the definition of the beginning of life in Judaism]

In accordance with the Jewish view human life begins with the first breath. The consequences following are wide reaching for the bioethical arguing within prenatal medicine and abortion in particular. The Jewish understanding of the beginning of life is based on theological grounds (like the special emphasis on this life or the principle of "actuality before potentiality"). whose consequences are philosophically contestable.

[Criteria for determining death in the Jewish religion]

In accordance with Jewish thinking, life ends with the last breath. Analogous to the beginning of life, two leading principles are important for the bioethical assessment of the end of life: the sanctity of life and the fundamental importance of this world. Thus the criteria for the definition of death are the following, which have consequences for the questions of euthanasia, organ-transplantation, autopsies and the status of the dead.