Pain physician
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Although only a small percentage of patients with COVID-19 deteriorate to a critical condition, because of the associated high mortality rate and the sheer number of cases, it imposes a tremendous burden on the society and unprecedented strains the health care resources. Albeit lung is the primary organ involved resulting in acute respiratory distress syndrome (ARDS), many patients additionally present with secondary multiorgan failure. Unfortunately, there is no definitive or curative treatment for this condition, and the management has been predominantly confined to supportive care, which necessitates an urgent need for novel therapies. Mesenchymal stem cell (MSC) therapy has a vast array of preclinical data and early, preliminary clinical data that suggests its potential to regenerate and restore the function of damaged tissues and organs. To date, there has been no review of all the clinical trials that have assessed the safety and efficacy of MSC therapy in organ failure commonly seen in seriously complicated COVID-19 patients. ⋯ MSC therapy seems to be promising to treat multiorgan failure from COVID-19. More studies are urgently needed to assess both safety and efficacy.
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Randomized Controlled Trial
Relationship Between Epidural Steroid Dose and Suppression of Hypothalamus-Pituitary-Adrenal Axis.
The suppression of hypothalamic-pituitary-adrenal (HPA) axis is a common complication associated with epidural steroid injections (ESIs). However, the effect of different doses is unknown. ⋯ Although the difference in pain relief according to the ESI dose is not significant, the HPA suppression is prolonged with a higher dose than a lower dose, and the recovery is slower. Therefore, the time interval between consecutive ESIs should be adjusted depending on the steroid dose to ameliorate the adverse effects of steroids.
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The coronavirus emergency obliged Italy's government to stop production and trade activities to limit the =risk of contagion. Italy will restart activities in a few days and some security measures will have to be taken to limit the risks of spreading the virus as much as possible. ⋯ A narrative review with paucity of literature.
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A primary concern in the use of EBP in these patients is the possibility of seeding the virus in the CNS. Another important concern is related to the known hypercoagulable state in COVID-19 positive patients and associated organ dysfunction that may alter the metabolism of anticoagulants. The safety of the providers performing the EBP, the position of the patient and choices for image guidance (blind, fluoroscopic) are also key considerations to review. It is also important to explore the current state of knowledge about using allogenic instead of autologous blood as well as emerging techniques to eliminate the coronavirus from the blood. ⋯ Going forward, an effective treatment for COVID-19 or a safe vaccine and a deeper understanding of the pathophysiology of the virus will certainly change the risk calculus involved in performing an EBP in a COVID-19 patient.
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Throughout the COVID-19 pandemic, clinicians have had to think quickly, adapt to changing recommendations sometimes on a daily basis, and have often had to rely on trial-and-error-based treatment protocols under various conditions. As we move on past the apex of the COVID-19 curve, new treatment protocols for the safe reintegration of elective interventional pain procedures into chronic pain practice are needed. ⋯ Herein we describe one such model in the hopes that through similar knowledge sharing, we can draw on others experiences to reach a collective conclusion on the safest, most effective, and efficient way(s) to move forward.