Knee replacement can be extremely painful. Previously, opioids or narcotics were administered for pain relief. But excessive addition of opioids is not exactly effective for controlling pain. 

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.

Multimodal denotes administering two or more than two types of medications that work with different mechanisms. The following are the techniques used:

Pre-operative Femoral Nerve Block: Prior to the surgery, a catheter is placed beside the femoral nerve for blocking it. This nerve is located in the upper thigh. Medication is delivered through the catheter for the nerve to be numbed for 24 hours. Thus, pain signals to the brain are blocked. This method reduces the use of narcotics and the consequent side effects.

Patient Controlled Analgesia (PCA): This method is also known as  Pain Pump . An intravenous pump is used to administer pain relief medications, such as oxymorphone or morphine, after the surgery. The control button of the machine could be pressed, by the patient for 6 to 10 times per hour. The machine is used for two post-operative days.

Oral Medications: The oral medications include Non-Steroidal Anti-Inflammatory drugs or NSAID; such as Celebrex which is similar to aspirin, structurally. Alternatively, acetaminophen, such as Tylenol or its equivalent composition, can also be used.

Acetaminophen: It acts on the Central Prostaglandin Synthesis and relieves the patient of pain through multiple mechanisms.

Epidural Analgesia: It produces lower pain scores and involves less time for achieving physical therapy goals. However, this is subject to side effects such as dizziness, urinary retention and itchiness.

Gabapentinoids: These medications include membrane stabilizers such as Gabapentin and Pregabalin.

The objective of multimodal treatments is to provide quick relief to the patient and immediately so. Earlier the rehabilitation, more successful will be the knee replacement surgery.

Multimodal Pain Relief After Total Knee Replacement

Heart attack, also known as myocardial infarction, is a severe condition where death of the heart muscle occurs because of the loss of blood supply. The blood loss usually happens because of the blockage of a coronary artery. Due to electrical instability, ventricular fibrillation is caused. Heart attacks may result in permanent brain damage or even death.

Symptoms of heart attack
There are many early symptoms and signs of heart attack, which should be recognized. Symptoms of heart attack vary from person to person. Here is a list of the primary heart attack symptoms:

Chest pain and discomfort:
Chest pain is the basic symptom of a heart attack and occurs in different forms. The chest pain has a pressure, fullness and squeezing sensation and starts from the center of the chest. The pain may go away and re-occur and may spread down to other limbs of the body.
Headache, toothache:
The chest pain occurring due to a heart attack spreads all over the body and the jaw. Even the back and head are affected. Sometimes pain in these regions is present while chest pain is absent.
Shortness of breath:
A gasping sensation or feeling shortness of breath is another common sign of a heart attack. Such breathing difficulty is called dyspnea. The shortness of breath occurs before or during the chest pain.
Nausea and vomiting:
The feeling of nausea or sickness in the stomach is another possible symptom. It is accompanied by belching or burping and sometimes, the heart attack is associated with a feeling of indigestion. Nausea is more common in women. Vomiting also occurs alongside nausea.
General epigastric discomfort:
In several cases, patients describe the pain of a heart attack as stomach pain. The pain is heavy and uncomfortable and persists for several minutes.
Sweating:
Perspiration or sweating occurs during a heart attack and the patient experiences cold sweat in avid amounts.

Emergency treatment for heart attack-
A person who has a heart attack should be rushed to a hospital.
Several tests are carried out to detect the cause of the attack. A 12 lead ekg is carried out to supervise electrical activity within the heart and detect the damaged areas.
Blood tests are undertaken to check enzymes and in certain cases, cardiac catheterization is required where pictures of the blood vessels are examined.
Emergency medicines are given to the patient to stop the formation of blood clots and include aspirin, heparin and other drugs. Other medicines are given for thrombolytic therapy, which dissolve already formed blood clots. They work to reduce the heart damage. Nitrates are also used.

A heart attack is a severe condition and must be attended to immediately. Emergency treatment procedures are essential to save the life of an affected person.

Heart Attack - Signs, Symptoms and Emergency Treatment

Psoriasis is a chronic dermatosis characterised by an unpredictable course of remissionn & relapse. It is an non-infectious skin disaease chracterised by scaly, silvery patches mainly on the scalp and extensior surface of the body. Its exact cause is unkown. In ayurveda, it is closely resembles with ekakushta. The features of ekakushta explains in ayurveda classics resembles with the symptoms of psoriasis. Psoriasis is the challenge for modern science. There is no definite treatment for psoriasis in modern science till today. The drug available in the market use to treat psoriasis are not very effective and have local and systemic effects.

In ayurveda, vata pitta and kapha dosha is the main contributory factor for the disease. Due to vitiation of three dosha, the disease manifest and main line of treatment for psoriasis is panchkarma and internal medicine. It is considering the best approach for skin disorder in ayurveda. A case report of 42-year old male, presented with well demarcated red scaly, silvery patches mainly on both legs, hands, scalp, chest and back with itching, and also nail and joint involvement has been presented in this article.

Etiology of Psoriasis: 

Unknown but many factors have been associated-

Genetic: may be autosomal dominant

Triggers: physical trauma ,infection and drugs.

Biochemical change: like increase level of arachidonic acid and Cgmp.

Immunological factors: helper T cells PLAY A KEY ROLE.

Epidemiology: 

Roughly, 1% of population is affected. Can occur at any age and affected both sex. Most patients as worse in winters.around 7 million people are affected in developed country.

Histopathogenesis:

Increased epidermal cell proliferation.

Retention of nuclei in stratum corneum.

Proliferation of fibroblast.

Dilated and tortous capillary loops.

Shortened epidermal turnover time from normal of 60 to 10 days.

Clinical features: Usually chronic indolent lesions which persist for month. Lesions are mildly papule or plaque.erthematous plaque lesions with characteristic slivery, large, loose scales. The patients of psoriasis may also suffer from depression and low self-esteem.

In a patients with psoriasis always check for nail and joint involvement.

Nail: 10 to 15% of the patients have nail involvement. Pitting, nail plate thickening, subungual debris, discolouration of nail plate and oil spot seen in the nails.

Joints: 10% patients have joint involvement.

Sites: Scalp, pressor points & extensor. Sometimes generalised.

Chronic recurrent psoriasis is difficult to treat. Modern science treat with PUVA and corticosteroids but these drugs having local and systemic side effects like liver and kidney failure etc. So, it is the time to find out the effective and safe treatment for Psoriasis. Medicines which are used in ayurveda are safe and practised since many years. A huge numbers of drugs are prescribed in ayurveda for the treatment of kushta.

Case details: A 42-year old male patient, hindu brahman by religion, presented on 10 april 2016 with well demarcated raised red scaly, silvery patches on chest, back and both legs and hands. He complained of itching all over the body and on scraping, white powder like substances fall down and leaves a bleedy surface. On history, patients had complaints since 20 years and diagnosis of psoriasis by allopathic physician. Since 20 years he has been taking allopathy and homoepathy patients from various practioners of U.P and delhi. He is brahman and lives in well known temple of delhi and visit homes of peoples for religious ceremony. He is afraid that if the disease is spreading continously, then he is unable to work as priest because people neglect him due to disease. The disease is spreading all over his body and also involves nail and joint. Destruction of nail plates of hand and legs was also developed. For this, patients took allopathic treatment for such a long time but do not get relief.

The patients visit our clinic for the first time. He told use that his problem not solves since 20 years and spreading continuously. So, he is unable to trust us. So, we first give him counselling because reassurance and emotional support are invaluable. Physical and mental rest enhance the effects of the treatment. It is also important to tell him that the disease is not contagious and is benign.

SYMPTOMS OF THE PATIENTS :

Itching all over body

Silvery patches, especially, on legs ,chest ,back but now spreading in his hand and scalp.

Destruction on nail plates

Swelling and pain in left middle fingers and flexor deformity in proximal interphalangeal joint

Swelling in right middle metatarso phangeal joint and pain

Some blood test of the patients were done like CBC, LFT, KFT, SR, URIC ACID to assess outcome.

His general health was good and both physical and all blood test were within the normal limts.we advise patients for panchkarma and oral medication but patients refuse for panchkarma so we start his oral or internal medication. 

Investigation Done :

CBC(Complete Blood Count)

LFT(Liver Function Test)

KFT(Kidney function Test)

Sr. Uric Acid

Investigation was done to rule out any other pathology. Investigation were within normal limit.

Internal Medication :

Medication are given into two phase. In First Phase, we are given panchsakara churna - one spoon two times daily for anulomana and pachan, Panchnimba churna- one spoon two times daily with luke water, panchtikta ghrita gugulu - two tab two times daily, and one oil for local application containing jyotishmati,bakuchi, and chakramad for five days. We told patient to apply the oil firstly only on legs for 5 days. Patient taking the same for 5 days and come on 5th day, we see the fabulous result, the rashes which are developed within 4 to 5 months just disappear and other rashes are also subsiding.

After 5 days, in second phase, we continue the same treatment and also added haridra khand - one spoon two times daily, gugulu tiktam kashaya - three spoon two times daily (one hour before food for 15 days). The patient came back on 20th day, with great result, the rashes were almost 60 % subsiding and pain and swelling in finger and ankle also reduce to great extent. Now, patient is not taking any pain killer for pain. Patient also get improvement in nails of legs.

We prescribe the same medicine for one month that time and ask him to do some physiotherapy additional for finger deformity. After that patient came with 70 to 75 % relief in symptoms and patients also tell that during the treatment, he will not develop any additional rashes.

During the treatment, we also told the patients to follow some dietary changes and live according to the rules of Ayurveda.

Result: Psoriasis is a disease with unkown etiology and triggered by many factors. In modern science, treatment of psoriasis is a challenge. They do not have any safe and proper medicine for psoriasis. But, ayurveda treatment gives satisfactory results as well as the quality life to the patients. Ayurveda removes toxin out of the body and corrects the formation of aama. Ayurveda gives the prevention as well as the treatment. So, by following the dietary and lifestyle change we prevent the reoccurrence of the disease.

Ayurveda For Psoriasis 

Gastric (stomach) cancer occurs when malignant cells form in the lining of the stomach. By far, it is known to be the second most common cause of cancer-related deaths not only in Asia but also worldwide. Though it can affect both male and female populace, it is seen more commonly in men and in people aged 50 years or older.

Type: Gastric cancers can present as one of the following types - 

Adenocarcinoma: Begins in the glandular cells lining the inside of the stomach. This forms a majority of the stomach cancers.
Lymphoma: Begins in immune system cells present in the walls of the stomach. Occurrence of lymphoma, in the stomach, is rare.
Carcinoid Tumor: Begins in hormone producing cells of the stomach.  Occurrence of carcinoid cancer, in the stomach, is rare.
Gastrointestinal Stromal Tumor (GIST): begins in nervous system cells of the stomach. Occurrence of GIST, in the stomach, is rare.
Gender: It affects both male and female populace.

Etiology: The factors that are associated with increased risk of gastric cancer include the following mostly  

 Helicobacter Pylori  bacterial infection in the stomach is a common cause of gastric cancer of both the intestinal (expanding) & diffuse (infiltrative) type. Furthermore, studies indicate that high salt intake is synergistic with H. Pylori infection in the manner that it is likely to increase the risk of gastric cancer that is induced by H. Pylori bacteria.
Smoking, consuming alcohol, red meat, salty/ smoked/ processed foods, low intake of fruits and vegetables, diets rich in nitroso compounds, eating foods contaminated with aflatoxin fungus etc all.
Atrophic gastritis characterized by chronic stomach inflammation is known to increase the risk multi-fold. Chronic gastric inflammation can lead to atrophy of the gastric mucosa, metaplasia, dysplasia and finally carcinoma.
History of pernicious anaemia, gastric ulcers, adenomatous gastric polyp etc all.
Family history of gastric cancer. Several familial syndromes that have been associated with a pre-disposition to gastric cancer include familial adenomatous polyposis, Lynch syndrome, Peutz-Jeghers syndrome and e-cadherin mutation (diffuse type)
Blood group A, Obesity etc all are known to be associated with diffuse or cardia gastric cancer.
Low socioeconomic status - persistent lifestyle issues/ irregularities including high stress coupled with an improper diet/ dietary pattern.
Epidemiological evidence is indicative of a risk or pre-disposition to gastric/ stomach cancer for people suffering from diabetes mellitus (DM).
Very high dose ionizing radiation exposure is an uncommon risk for gastric cancer.
Features: There are often no early stage symptoms. Early stage symptoms, if any, are non-specific and are likely to be ignored, thus delaying the diagnosis most often. Hence, gastric/ stomach cancer is often detected at an advanced stage where the disease is either locally advanced or metastatic. The various presentations (of signs & symptoms), by stage (early or advanced), of gastric cancer are as enumerated below:

Early Stage   can present with one or more of the following non-specific symptoms/ signs -

Dyspepsia (Indigestion),
Stomach/ Epigastric discomfort,
Bloated feeling after eating,
Mild Nausea/ Vomiting,
Blood in Vomit (Haematemesis),
Heartburn,
Weight loss (Cachexia)
Anaemia,
Occult blood in stool/ Melaena,
Advanced Stage   presents with one or more of the following symptoms/ signs -
GI Bleeding with black tarry stools (Melaena),
Persistent Nausea/ Vomiting,
Blood in Vomit (Haematemesis),
Early Satiety,
Anaemia,
Loss of Appetite (Anorexia),
Weight loss (Cachexia),
Persistent pain in the abdomen,
Fluid build-up in the peritoneal cavity (Ascites),
Edema of the lower extremities,
Liver Enlargement (Hepatomegaly)/ Jaundice,
Difficulty swallowing food (Dysphagia)
Screening: Is generally recommended for asymptomatic populations in high incidence areas or as surveillance for high risk individuals. The goal of screening, as usual, is to be able to detect & diagnose gastric cancer at an early stage which is potentially curable. It is mostly endoscopic/ radiologic.
Diagnosis: Following are the diagnostics employed in gastic cancer - 

Physical Examination: May be remarkable for palpable abdominal mass, weight loss (cachexia), abdominal distension, ascites, hepatomegaly, lower extremities edema and lymphadenopathy for gastric cancers in the advanced stage. For early gastric cancers, however, physical examination is largely uninformative.
Blood: Hb- may be low, ESR   raised, tumor markers CEA & CA-19-9 could be raised sometimes in adenocarcinoma but are not frequently elevated. Abnormal blood test results may be indicative of malignancy, but a follow-up gastroscopy/ biopsy is always the gold standard for accurate diagnosis.
Stool: Occult blood may be +ve
Barium Meal X-Ray: Could show a filling defect at the site of the carcinoma/ cancer growth.
Gastroscopy/ Biopsy: Clinches the diagnosis.
Endoscopic Ultrasound: Maximizes tumor staging as it helps determine the depth of invasion of the tumor.
CT Scan: Of chest, abdomen & pelvis helps detect metastatic disease, if any, and also helps stage the disease (TNM) appropriately.
Bone Scan: Helps detect osseous metastasis (bone mets), if any.
Treatment: Conventional treatment includes surgery, chemotherapy and radiotherapy as contextually appropriate. Surgery (i.e. gastrectomy either sub-total or total), with an adjuvant chemotherapy and/ or radiotherapy as contextually relevant, is the only treatment that is known to cure the disease in light of the prognostic indicators as briefly enumerated in the section below. Chemptherapy and/ or radiation alone cannot be curative. Mostly, it can improve symptoms, and may prolong survival. Simultaneously, an adjunctive or integrative naturopathic treatment with suitable complementary & alternative medicines (CAM) too can help improve clinical outcomes and facilitate recovery as feasible contextually.
Prognosis: For gastric cancer is variable. Preventive measures, earlier diagnosis and right early treatment is key for an effective therapeutic management & better prognosis. Like most other cancers, the chances of cure for an early stage gastric cancer are more. The cure/ recovery chances are influenced by the grade, stage of cancer, recurrence and the patient s general health & vitality etc all. Distal tumors are known to be cured more often than the proximal ones. Again, intestinal-type gastric cancers are known to have a better treatment outlook in comparison to the diffuse-type gastric cancers.

Prevention: Rightly said, prevention is always a better choice. Although genetic risks are difficult to modify, still an adherence to a relative Mediterranean diet, maintaining an ideal body weight and an active lifestyle with due emphasis on regular exercising, de-stressing and relaxation is highly recommended for reducing the risks of many cancers including gastric cancer. A healthy eating plate comprises essentially a low fat diet, fibre rich foods including whole grain cereals, green leafy vegetables cooked using healthy vegetable oils, fresh fruits of all colours as seasonally available and healthy proteins/ fats including fresh fish, poultry, beans, nuts etc all. The consumption of alcohol, if any, has to be strictly in moderation, and is best avoided in a high risk scenario. Smoking is to be avoided too. Again, red meat, butter, refined grains, sweets, sugary drinks including carbonated beverages and other high calorie foods etc all, if any, are to be taken sparingly. Not only it is important to eat healthy, but also it is equally important to eat properly. Insufficient chewing, eating until full, eating meals within a short time etc all are best avoided so as to ease off digestive burden on the stomach/ other organs in the GI tract. Last but not the least, consumption of clean and filtered water, natural probiotics like freshly prepared yogurt/ butter milk, maintenance of cleanliness & hygiene including oral hygiene etc. all can help guard against H. Pylori infections. Breastfeeding is known to be protective against H. Pylori infections too.

Gastric Cancer - In a Nutshell!

Is someone close to you into drugs? Are you concerned about him or her having a drug problem? There are several patterns of drug abuse, which help you to determine the extent of drug abuse a person is undergoing. It is important for you to recognize your dear ones  drug use patterns and analyse whether you need to take further steps. The different drug abuse patterns are classified as follows:

Hard drug use
Hard drugs like cocaine, heroin, and methamphetamine are considered to be the most dangerous in terms of their harmful effects on health and behavior.
They are associated with risks of addiction. Most people start with such drugs recreationally, but addiction can set in very quickly.
People engaging in hard drugs are subjected to high risk behavior. They usually become isolated and live in their own world, away from society.
Frequent drug use
The frequency of drug abuse is not good enough for determining, if a person is addicted.
People engaging themselves in binge drinking during weekends can have serious issues in spite of not drinking every day.
Frequent drug use indicates a person s drug tolerance and dependence. A person who drinks or uses drugs regularly is quite likely to continue this pattern.
Early drug use
People who start taking drugs from early adolescence are at an enhanced risk of developing drug problems in their adulthood.
The earlier a child gets into drugs, the sooner they become addicts.
During adolescence, a person s body and brain still undergo development and any kind of drug-related consequences may be quite severe.
Drug use from an early age is quite a common phenomenon.
Solitary drug use
Teenagers who use marijuana, cigarettes and alcohol while they are alone are at a higher risk of developing drug problems later in life.
They are quite likely to have poor physical health by the age of 23, compared to social drug users.
Solitary drug use is also quite a common aspect that prevails.
Escapist drug use
The reasons for using alcohol and drugs vary from person to person.
People who use drugs for coping with stress, medicating anxiety or depression, and building self-esteem are prone to becoming addicts.
Teens using substances for coping with boredom and grief are highly subjected to drug problems.
A lot of people drink on some occasions, and try some substance just for the sake of experimenting. However, when the substance starts affecting your career, relationships and activities, a pattern of drug use is recognized. These patterns increase the risk of addiction, no matter how many months, years or weeks a person is engaged in them.

Drug Abuse - Understanding The Pattern!

Also known as contact dermatitis or contact eczema, allergic eczema is a condition wherein one experience symptoms of skin rash on coming in contact with an allergen. Other symptoms include a burning sensation in the eyes, coughing and a runny nose.

Causes-

This condition is caused when you come in contact with an allergen. Some common triggers that cause your immune system to react in this manner are:

Perfumes in cosmetics

Hair dyes

Metals such as nickel found in jewelry

Latex based products

Chemicals present in soaps and other cleansing agents

Certain antibiotic creams and lotions

Adhesives

Symptoms-

With allergic eczema, the most common symptoms include itching and pain around the affected area, and tender skin. Inflammation and dry skin are some other common symptoms that one may experience. Pus-filled red bumps are common occurrences along with this disorder. The skin may start to thicken and turn scaly. The symptoms may show up when one is exposed to sunlight.

Treatments-

The treatment for this disorder begins after a thorough diagnosis of the symptoms. Based on how severe the symptoms are, the treatment is prescribed accordingly. The first step is usually to wash the affected area with warm water to wash away the allergens. In case of mild symptoms, you may not need any treatment. It is also advised to use apply moisturizing cream to maintain hydration of the skin. To reduce inflammation and itching, use of corticosteroid creams is recommended.

In case of severe symptoms, strong corticosteroid pills may be prescribed.

If the treatments are carried out properly, the symptoms tend to clear up within 15-20 days. However, it is important to remember that the condition may erupt again if you come in contact with the allergen once more. Thus identification of the allergen is very important for long-term treatment and preventive measures. By seeing an allergist contact dermatitis can be ruled out by doing an Allergy Patch Testing.

Allergic Eczema: Causes, Symptoms and Treatments

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