CBD Use Research Articles

Prevalence, symptom management, and reporting of cannabis use among invasive cancer patients.

e24114 Background: Interest in the use of cannabis-based products, including marijuana (products containing ≥0.3% tetrahydrocannabinol [THC]) and cannabidiol (CBD; containing < 0.3% THC) for cancer symptom management, is increasing. Preliminary studies suggest that marijuana and CBD products are effective in alleviating common cancer- or treatment-related symptoms. Few studies have reported on the magnitude of cannabis use among cancer patients, but data remain limited to states with legalized non-medical (i.e., recreational) use. Further, none have assessed the prevalence of CBD use in cancer patients. The reasons for cannabis-based product use and patient attitudes towards discussing use with their physicians are not well understood. Methods: We report preliminary results from an ongoing anonymous cross-sectional study of cannabis use among patients attending 8 clinics at the Ohio State University Comprehensive Cancer Center. Eligible patients were diagnosed with invasive cancer and treated in the past 12 months. Between July 2021 and January 2022, 771 patients were contacted and 639 (82.9%) agreed to participate. Participants answered a validated, extensive cannabis-focused questionnaire and were remunerated with a gift card. We report here frequencies and prevalence proportions of cannabis-based product use, and cannabis-related behaviors and attitudes on reporting use with cancer providers. Missing values were included in the denominator of prevalence calculations, thereby making estimates conservative. Results: Participants were equally distributed by sex, White (86.4%), and resided within Ohio (90.3%). Among 433 patients who reported age, the median was 47 years (IQR 38-53). The prevalence of current cannabis-based product use was 15.2% (97/639), with overall prevalence of 6.9% for exclusive marijuana use, 1.7% exclusive CBD use, and 5.2% poly-use. Among current users, patients primarily reported inhaling or ingesting cannabis products; fewer reported topical or other applications. The top 5 reported reasons for cannabis use were to treat stress, improve sleep, reduce pain, improve appetite, and to treat depression. Among current users, 66% reported that their cancer care team was aware of their cannabis use, 17.5% reported none of their healthcare providers were aware, and 15.4% reported a medical professional unaffiliated with their cancer care was aware. A large proportion (86.6%) felt comfortable discussing cannabis with their treating physician. Conclusions: Our results indicate current cannabis-based product use for symptom relief among a sizeable minority of adults with cancer in a state where only medicinal marijuana is legalized. Further research is needed to characterize provider perspectives and communication about reported cannabis use among their patients.

Cannabinoid use is enhanced by stress and changes conditioned stress responses.

Individuals diagnosed with post-traumatic stress disorder (PTSD) are often comorbid for substance use disorders. Cannabis is widely used by PSTD patients, and the literature is mixed on whether cannabis use ameliorates or exacerbates patient responses to stress-associated conditioned stimuli (stress-CS). We determined if cannabis use affects responsivity to stress-CS in rats receiving 2 h stress in the presence of an odor stress-CS. Three weeks after acute stress, rats self-administered cannabinoids (delta9-tetrahydrocannabinol + cannabidiol; THC + CBD) for 15 days, and the stressed males consumed more THC + CBD than sham males. We then used the stress-CS or a novel odor (stress-NS) to reinstate THC + CBD seeking. Surprisingly, the stress-NS reinstated THC + CBD seeking, an effect blocked by N-acetylcysteine. Moreover, the stress-CS inhibited THC + CBD-CS induced reinstatement. To determine if the unexpected effects of stress-NS and -CS resulted from THC + CBD altering conditioned stress, the effect of THC + CBD use on stress-NS/CS-induced coping behaviors and spine morphology was quantified. In THC + CBD-treated rats, stress-NS increased active coping (burying). Conversely, stress-CS reduced active coping and increased passive coping (immobility) and other behavioral parameters associated with stress responses, including self-grooming and defecation. Transient spine head expansion in nucleus accumbens core is necessary for cue-induced drug seeking, and THC + CBD self-administration prevented the increase in head diameter by stress-CS in control rats. These data show THC + CBD self-administration altered the salience of environmental cues, causing neutral cues to promote active behavior (drug seeking and burying) and stress-CS to switch from active to passive behavior (inhibiting drug seeking and immobilization). We hypothesize that cannabis may exacerbate conditioned stress responses.

Use of Prednisolone, CBD and Behavior Modification as a Treatment for Atopic Dermatitis in a Canine: A Case Report

In this patient, the stereotypical behavior was treated with CBD. Factors that contribute to stereotypic behavior are frustration and conflict. It is likely that the behavior began due to lack of care and unsatisfied motor drive. To date, potential efficacy has been reported in human dermatology; however, there have been no reports of CBD being used to treat CAD in dogs. These results highlight the importance of careful medical evaluations and treatment of a primary illness even when behavioral issues are prominent, as well as the potential use of CBD to treat stereotypical behaviors.

Patterns and correlates of cannabidiol product and marijuana co-use in a sample of U.S. young adults

ObjectiveCannabis-derived products containing cannabidiol with no or minimal levels of delta 9-tetrahydrocannabinol (CBD products) are widely available in the United States and use of these products is common among young adults and those who use marijuana. The purpose of this study was to examine patterns and correlates of CBD product use and co-use with marijuana in a sample of young adults. MethodThe study used cross-sectional survey data collected in 2019–2020 from a cohort of young adults (n = 2534; mean age 23) based primarily in California. The survey assessed lifetime, past-year, and past-month frequency and type of CBD products used, frequency and amount of marijuana consumption and indicators of marijuana use-related problems. Linear, Poisson, and logistic regression models compared individuals reporting past month CBD-only use, marijuana-only use, concurrent CBD + marijuana use (co-use), and use of neither product. Among those reporting co-use, we examined associations between CBD use frequency and marijuana use frequency and heaviness of use (occasions per day) and indicators of problem marijuana use (e.g., Cannabis Use Disorder Identification Test Short-Form, solitary use, marijuana consequences). ResultsApproximately 13% of respondents endorsed past-month CBD use; of these, over three-quarters (79%) indicated past-month co-use of marijuana. Among individuals reporting co-use, more frequent CBD use was associated with more frequent and heavier marijuana use but was not associated with marijuana use-related problems. ConclusionsCBD use was common and associated with higher levels of marijuana consumption in this sample. Routinely assessing CBD use may provide a more comprehensive understanding of individuals’ cannabis product consumption.

Comparison of CBD and Cannabis Use Motives.

Cannabidiol, also known as CBD, has increasingly gained popularity as a cure-all product and is now found in products across a variety of industries. Despite the surge in popularity, little remains known about individual motives and patterns of CBD use. The goal of this study was to gain a better understanding of the similarities and differences between motives for CBD and cannabis use as well as comparing motives for younger and older users. Participants (N= 171) in U.S. states and territories with legalized cannabis for recreational use were recruited via Amazon MTurk and were asked to complete an anonymous survey assessing their CBD and cannabis use, effects, and motives for use. The greatest differences between self-reported CBD and cannabis use were for side effect profiles. While the recreational use motive was more commonly endorsed for cannabis, use for beauty purposes was more common for CBD. No age group differences emerged for motives to use CBD or cannabis. Future research examining age-related differences in a larger, more age-diverse samples is recommended.

Cannabis for Chronic Osteoarthritis Pain: A Case of an Older Person

OBJECTIVE: To review the safety and efficacy of cannabis use for chronic pain in older people.<br/> SETTING: The case took place in a geriatric primarycare clinic in Colorado.<br/> PRACTICE DESCRIPTION: The clinic serves adults 75 years of age and older where clinical pharmacists are used for medication consults and follow-up.<br/> PRACTICE INNOVATION: Older people are using cannabis to treat a variety of conditions, with use increasing as more states legalize cannabis medically and recreationally. The primary reason for use is pain. Pharmacists in Colorado can assist with education regarding cannabis use and evaluate if cannabis may be safe for older people.<br/> MAIN OUTCOME MEASUREMENT: This case evaluates the use of a combination CBD:THC cannabis product in a 78-year-old female patient who was previously using opioids for degenerative disc disease and osteoarthritis.<br/> RESULTS: The patient found improvement in her pain when using the combination cannabis product without any adverse effects.<br/> CONCLUSION: Further safety and efficacy evidence is needed for using combination cannabis products for pain management in older people.

The Perceived Effectiveness of Cannabidiol on Adult Women With Inflammatory Bowel Disease

ObjectivesTo analyze the perceived effectiveness of cannabidiol in women over 18 years old with Inflammatory Bowel Disease. MethodsThis was a cross-sectional survey. The population included women diagnosed with either Crohn’s Disease or Ulcerative Colitis, who were not currently pregnant or nursing. The main outcome measures were descriptive characteristics, Harvey Bradshaw Index (disease severity), Partial Mayo Score (disease severity), Short Inflammatory Bowel Disease Questionnaire (quality of life), Prime Screen Short Food Frequency Questionnaire, Bristol Stool Scale, CBD use, administration and dosage, reasons for not using CBD, and the effect of legalization on medical use of CBD. Pearson and Spearman’s correlations and Chi Square analyses were performed using SPSS Version 24.0. ResultsSeventy one patients, twenty five of which are current CBD users and forty six of which are past/never users, completed the study. Correlations showed no association between CBD use and disease severity, quality of life (QOL), food intake, or fecal consistency. However, disease severity and quality of life were inversely correlated (past/never users: p = 0.000, r = –0.544; current users: p = 0.042, r = –0.427) and CBD users reported decreases in IBD-related pain and nausea (76% and 64% respectively), and improvement in appetite (60%). ConclusionsThere is no significant relationship between disease severity, QOL, and food intake with CBD use. Results showed that, overall, disease severity and QOL are inversely associated. Although no significant clinical associations were found, this study indicates the need for future research of CBD use on IBD-related symptoms as medical utilization grows in popularity. Funding SourcesSimmons University.

Laparoscopic common bile duct exploration with primary closure is beneficial for patients with previous upper abdominal surgery.

Previous upper abdominal surgery (PUAS) is considered a contraindication to laparoscopic surgery. Whether LCBDE-PC is feasible and beneficial for patients with PUAS remains unclear. This study aimed to evaluate the feasibility and benefits of LCBDE-PC for patients with PUAS. From June 2011 to September 2019, 1167 patients who underwent laparoscopic procedures for choledocholithiasis were reviewed retrospectively. Perioperative outcomes were compared between patients with and without PUAS in un-matched and matched cohorts. LCBDE-PC was performed successfully in 88.3% of patients with PUAS, and 92.5% of patients without PUAS (P > 0.05). Multivariate analysis showed that PUAS was not a risk factor that affected successful performance of LCBDE-PC. Although a higher rate of conversion to open surgery and longer operative time were observed in patients with PUAS, no significant differences were found between patients with and without PUAS in multivariate and propensity score analysis (P > 0.05). A predictive nomogram for LCBDE-PC failure was developed based on potential predictors from the least absolute shrinkage and selection operator (LASSO) regression model. Successful performance of LCBDE-PC was associated with operative time. A linear regression model for operative time showed impacted stone in the CBD and intraoperative laser use was the most important factor in determining the operative time. LCBDE-PC is feasible and beneficial for patients with PUAS. However, patients with PUAS with a high possibility of LCBDE-PC failure from the nomogram and a longer operative time from the linear regression model should be cautious when undergoing LCBDE-PC.

Cannabidiol: Background and Literature Review of Potential Treatments

Cannabidiol, commonly abbreviated CBD, is one of the hundreds of compounds present in the flowering cannabis plant, along with its more well-known structural isomer, Δ9-tetrahydrocannabinol or THC. CBD can be extracted from the plant and utilized in many forms, from topical oils to smokable flowers. Recently, availability, interest in and use of CBD across the nation have grown exponentially, with internet searches for CBD increasing 160% between 2017 and 2018 and 14% of Americans citing current CBD use. Users of this compound endorse numerous perceived benefits, including anxiolysis, analgesia and much more. Most users claim to employ CBD to treat specific medical conditions spanning from autoimmune, to psychiatric, to musculoskeletal. Evidence supports some of these reported effects in recent studies, as CBD has demonstrated anticonvulsant, antipsychotic and antinociceptive properties, among others. However, the implications of these findings are still in their infancy. As of June 2018, one FDA-approved pure CBD product for seizure treatment, Epidiolex®, is available for prescription use and many more are in various stages of testing. However, numerous safety and legal concerns remain regarding off-label and over-the-counter CBD usage. Physicians and other health care professionals are likely to encounter CBD use by their patients. As usage continues to grow, so does the duty of care providers to understand its role and serve as a source of evidence-based information for their community on this relevant health topic.

Cannabidiol Interactions with Medications, Illicit Substances, and Alcohol: a Comprehensive Review.

Cannabidiol, a non-intoxicating phytocannabinoid, has potential therapeutic effects over a broad range of disorders. Recently, there has been increased interest in CBD, as several studies showed promising anticonvulsant efficacy with few side effects. In 2018, a CBD-based oral solution, Epidiolex®, was approved by the FDA to treat two severe forms of pediatric epilepsy, Dravet syndrome, and Lennox-Gastaut syndrome. Although only these two syndromes are recognized indications for CBD, it has been consumed in an unregulated fashion for a variety of indications including chronic pain, muscle stiffness, inflammation, anxiety, smoking cessation, and even cancer. While CBD legislation in the USA is confusing due to the differences in state and federal laws, CBD has proliferated in the US market in several forms such as CBD oil or capsules, hemp oil/extract, and also as an ingredient in several dietary supplements, syrups, teas, and creams. With the ever-increasing use of CBD and its widespread availability to the general public, it is important to examine and report on possible drug-drug interactions between CBD and other therapeutic agents as well as addictive substances such as alcohol and tobacco. A detailed literature search for CBD's possible interactions was conducted using online databases. As expected, CBD has been reported to interact with anti-epileptic drugs, antidepressants, opioid analgesics, and THC, but surprisingly, it interacts with several other common medications, e.g. acetaminophen, and substances including alcohol. This review provides a comprehensive list of interacting drugs. The possible mechanisms for these drug-drug interactions are presented in table format. Given the growing popularity of CBD as a medication and the dearth of available information on CBD drug-drug interactions, it is critical to be aware of current drug-drug interactions and it will be important to investigate the impact of CBD upon concomitant medication use in future randomized, controlled trials.

Condom use self-efficacy centered on sexual experience, cannabis, and CBD use among college students

Objectives The goal of this study was to understand how condom use self-efficacy varies based on sexual experience, cannabis and CBD use. Methods A cross-sectional survey was implemented through Qualtrics. A total of 455 undergraduate students were surveyed at a large U.S. northeastern university. Results Findings suggested that sexual experience itself and sexual experience with cannabis and CBD are associated with a person’s condom use self-efficacy. Precisely, non-sexually active and cannabis or CBD nonusers perceived themselves as less efficacious in their future use of condoms compared with sexually active adolescents. Conclusions Implications for health interventions are discussed, such as the importance of giving attention to non-sexually active adolescents and strengthening their condom use self- efficacy. It is critical to promote healthy sexual behaviors among future sexually active college students and reinforce healthy sexual behaviors among sexually active adolescents

NURS-11. MARIJUANA, HEMP, AND THE CHILD WITH CANCER: PATIENT, PARENT, AND CLINICIAN EDUCATION

Many pediatric oncology patients report medical marijuana (MMJ) and hemp-based CBD use. Eleven states and Washington, DC have legalized marijuana for recreational use for adults greater than 21. Medical marijuana is legalized in 33 states. Additionally, due to the bipartisan Farm Bill passed in December of 2018, hemp is federally legal. Marijuana has medical legalization in 23 countries worldwide. Clinical trials in adults have examined MMJ for cancer-related symptoms. New research is emerging on MMJ in anticancer therapy, MMJ receptors on tumor cells, and the potential role for MMJ as an immunomodulator. Few pediatric oncology studies have evaluated MMJ. We describe the initial findings of a prospective observational study of MMJ on the quality of life (QOL) in pediatric brain tumor patients. Specific aims included (1) MMJ’s association with symptoms (nausea, anxiety, pain, fatigue, and cognitive problems) and (2) MMJ’s impact on family dynamics. The legality of hemp plus the increasing use of MMJ raises concerns with pharmacological interactions with CBD and the medications routinely administered to children with cancer. Nurses are the frontline for discussions with patients about MMJ and must be aware of the emerging field of MMJ in pediatric cancer. Additionally, nurses can influence patient care protocols and processes for alternative therapy administration enabling an open dialogue between providers, parents, and patients regarding treatments, symptoms, adverse effects, and drug interactions. Education about how to have conversations about important facets to cover and consider is crucial to patient safety and increased quality of life.

Comparison of cannabidiol to citalopram in targeting fear memory in female mice

BackgroundCannabidiol (CBD) and selective serotonin reuptake inhibitors (SSRIs) are currently used to treat post-traumatic stress disorder (PTSD). However, these drugs are commonly studied after dosing just prior to extinction training, and there are gaps in our understanding of how they affect fear memory formation, their comparative effects on various types of memory, and of sexual dimorphisms in effects. Also, more studies involving female subjects are needed to balance the gender-inequality in the literature. Therefore, the purpose of this study was to directly compare the effects of CBD to citalopram in affecting the formation of auditory cued, contextual, and generalized fear memory, and to evaluate how extinction of these different memories was altered by pre-acquisition treatment in female mice. We also evaluated the impact of the estrous cycle on each of these.MethodsAuditory-cued trace fear conditioning was conducted shortly after dosing female C57BL/6 mice, with either CBD or citalopram (10 mg/kg each), by pairing auditory tones with mild foot shocks. Auditory-cued, contextual, and generalized fear memory was assessed by measuring freezing responses, with an automated fear conditioning system, 24 h after conditioning. Each memory type was then evaluated every 24 h, over a 4-day period in total, to create an extinction profile. Freezing outcomes were statistically compared by ANOVA with Tukey HSD post hoc analysis, N = 12 mice per experimental group. Evaluation of sexual dimorphism was by comparison to historical data from male mice.ResultsAuditory cue-associated fear memory was not affected with CBD or citalopram; however, contextual memory was reduced with CBD by 11%, p < 0.05, but not citalopram, and generalized fear memory was reduced with CBD and citalopram, 20% and 22%, respectively, p < 0.05. Extinction learning was enhanced with CBD and citalopram, but, there was considerable memory-type variability between drug effects, with freezing levels reduced at the end of training by 9 to 17% for CBD, and 10 to 12% with citalopram. The estrous cycle did not affect any outcomes.ConclusionsBoth drugs are potent modifiers of fear memory formation; however, there is considerable divergence in their targeting of different memory types which, overall, could support the use of CBD as an alternative to SSRIs for treating PTSD in females, but not males. A limitation of the study was that it compared data from experiments done at different times to evaluate sexual dimorphism. Overall, this suggests that more research is necessary to guide any therapeutic approach involving CBD.

Cannabidiol prescription in clinical practice: an audit on the first 400 patients in New Zealand.

BackgroundCannabidiol (CBD) is the non-euphoriant component of cannabis. In 2017, the New Zealand Misuse of Drugs Regulations (1977) were amended, allowing doctors to prescribe CBD. Therapeutic benefit and tolerability of CBD remains unclear.AimTo review the changes in self-reported quality of life measurements, drug tolerability, and dose-dependent relationships in patients prescribed CBD oil for various conditions at a single institution.Design & settingAn audit including all patients (n = 400) presenting to Cannabis Care, New Zealand, between 7 December 2017 and 7 December 2018 seeking CBD prescriptionsMethodIndications for CBD use were recorded at baseline. Outcomes included EuroQol quality of life measures at baseline and after 3 weeks of use, patient-reported satisfaction, incidence of side effects, and patient-titrated dosage levels of CBD.ResultsFour hundred patients were assessed for CBD and 397 received a prescription. Follow-up was completed on 253 patients (63.3%). Patients reported a mean increase of 13.6 points (P<0.001) on the EQ-VAS scale describing overall quality of health. Patients with non-cancer pain and mental-health symptoms achieved improvements to patient-reported pain and depression and anxiety symptoms (P<0.05). There were no major adverse effects. Positive side effects included improved sleep and appetite. No associations were found between CBD dose and patient-reported benefit.ConclusionThere may be analgesic and anxiolytic benefits of CBD in patients with non-cancer chronic pain and mental health conditions such as anxiety. CBD is well tolerated, making it safe to trial for non-cancer chronic pain, mental health, neurological, and cancer symptoms.

Evidence on CBD Use for Pediatric Epilepsy Emerges Slowly

Evidence on CBD Use for Pediatric Epilepsy Emerges Slowly

A Case Report and Literature Review of Clobazam Toxicity Related to CBD and Clobazam Drug-Drug Interaction

Background: The interest in the anti-seizure efficacy of cannabinoids has significantly increased over the past decade. Trials have shown a remarkable reduction in the frequency of convulsive seizures in Dravet and Lennox-Gastaut syndromes patient population. Studies have shown that CBD reacts with clobazam leading to a significant increase in the levels of N- desmethylclobazam, the active metabolite of clobazam. We present a case of a patient with Dravet Syndrome who presented to the ED with altered mental status secondary to clobazam toxicity related to CBD and clobazam drug-drug interaction. Methods and Findings: We present a case of a patient with Dravet Syndrome who presented to the ED with altered mental status. Patient was hospitalized and CBD was held off. Clobazam level and N-desmethylclobazam levels were obtained and came back elevated at 512 and 15020 respectively. Studies have reported clobazam toxicity secondary to CBD and clobazam drug- drug interaction since both drugs are metabolized by cytochrome P450 enzymes and glucuronyl transferases. Conclusion: Studies have shown the drug interactions of CBD with co-anti-epileptics, including a remarkable increase in the N-desmethylclobazam levels, the active metabolite of clobazam,which confirms the significant importance of monitoring blood levels for clobazam and norclobazam in patients using both CBD and clobazam, in addition for the need to reduce the Clobazam doses for this group of patients. Additional well-controlled studies are essential to establish the recommended doses and the management of the doses of other concomitant anti- epileptics medications with CBD use.

Cannabis use in active athletes: Behaviors related to subjective effects.

Cannabis use has not been well characterized in athletes. Studies primarily examine problematic use or its categorization by anti-doping bodies as a banned substance. Patterns of use, reasons for use, and responses to cannabis consumption have not been studied in a community-based sample of adult athletes. The Athlete PEACE Survey examined cannabis use patterns and subjective effects to cannabis in a community-based cohort of adult athletes. We used mainly social media and email blasts to recruit and SurveyGizmo to collect data. 1,161 (91.1%) of the 1,274 athletes taking the survey completed it. Current cannabis use was evaluated by asking “In the past two weeks, have you used marijuana (including THC and/or CBD)?” and cannabis type used was assessed by asking “What do you primarily use THC, CBD, or both?”. Cannabis benefits and adverse effects (i.e. subjective effects) and patterns of use were reported. 302 athletes (26%) currently use cannabis of whom 301 had complete data for cluster analysis. Cluster analysis was used to determine cannabis user phenotypes and exploratory factor analysis (EFA) was used to create subjective effects factors. Associations between cannabis user phenotype clusters and the subjective effects factors were explored using multivariate analysis. Cluster analysis identified three statistically distinct cannabis user phenotypes: (1) older athletes who primarily use medical CBD, (2) mixed age athletes who use cannabis mainly recreationally with both THC and CBD use, and (3) mixed age athletes who used cannabis the longest with primary THC and CBD use. EFA showed three subjective effects factors: (1) Well-being, (2) Calm, and (3) Adverse. Mean positive subjective were higher than mean adverse subjective effects (p<0.001). The cluster using THC and CBD showed the highest mean scores for all three subjective effects factors (p<0.001). Athletes who use a combination of THC and CBD exhibited the most benefit to well-being and calm with minimal adverse effects. Our methodology can be used to develop real-world evidence to inform future use of medical cannabis products.

Cannabidiol modulates phosphorylated rpS6 signalling in a zebrafish model of Tuberous Sclerosis Complex

Tuberous sclerosis complex (TSC) is a rare disease caused by mutations in the TSC1 or TSC2 genes and is characterized by widespread tumour growth, intractable epilepsy, cognitive deficits and autistic behaviour. CBD has been reported to decrease seizures and inhibit tumour cell progression, therefore we sought to determine the influence of CBD on TSC pathology in zebrafish carrying a nonsense mutation in the tsc2 gene.CBD treatment from 6 to 7 days post-fertilization (dpf) induced significant anxiolytic actions without causing sedation. Furthermore, CBD treatment from 3 dpf had no impact on tsc2−/− larvae motility nor their survival. CBD treatment did, however, reduce the number of phosphorylated rpS6 positive cells, and their cross-sectional cell size. This suggests a CBD mediated suppression of mechanistic target of rapamycin (mTOR) activity in the tsc2−/− larval brain.Taken together, these data suggest that CBD selectively modulates levels of phosphorylated rpS6 in the brain and additionally provides an anxiolytic effect. This is pertinent given the alterations in mTOR signalling in experimental models of TSC. Additional work is necessary to identify upstream signal modulation and to further justify the use of CBD as a possible therapeutic strategy to manage TSC.

Day-case laparoscopic cholecystectomy: analysis of the factors allowing early discharge.

Despite a number of studies have already demonstrated that majority of patients can be safely discharged early after laparoscopic cholecystectomy, this approach did not gain widespread diffusion yet. The present study was set up to assess safety and feasibility of 24 h or same-day discharge after laparoscopic cholecystectomy and to identify the prognostic factors. Perioperative variables of 229 patients undergoing cholecystectomy have been analyzed. Primary endpoints were: postoperative length of stay, rate of patients discharged within 24h, and rate of those discharged on the same day. Secondary endpoints were rate of 30-day readmission and rate of 30-day postoperative complications. Two-hundred twenty-three cases have been started by laparoscopy. Conversion rate was 3.1%. Overall mean postoperative stay was 1.8±3.5days (median 1day). Seventy-eight percent of patients have been discharged within 24h, and 22.3% have been discharged on the same day. Postoperative morbidity was 2.2%. Readmission rate was 3.9%. At univariate analysis, factors related to early discharge were age (more or less than 65), diagnosis (simple symptomatic gallstones vs complicated gallstones), ASA score, timing of operation (elective vs emergency), history of CBD stones, laparoscopic operation, and use of drain. No single factor was significantly related to readmission rate, but the use of drains in laparoscopic cases. At multivariate analysis, only elective operation, simple symptomatic gallstones, no history of CBD stones, laparoscopic approach, and no abdominal drain resulted independently associated with discharge within 24h from the operation. The predictive models are all fit and significant. Early postoperative discharge within 24h should be considered in all patients with simple symptomatic gallstones who had laparoscopic cholecystectomy. Same-day discharge should be considered if no drain was left at the end of the operation.

Clinical benchmarks regarding multimodal peripheral nerve blocks for postoperative analgesia: observations regarding combined perineural midazolam-clonidine-buprenorphine-dexamethasone.

In a separate commentary [1], we reported on potential clinical research priorities with respect to multimodal perineural anesthesia and analgesia (MMPNA). This was based on our group's review of institutional quality assurance/improvement (QA/QI) data routinely using this technique for over 1,300 patients from late 2011 to the present at the Veterans Affairs Pittsburgh Healthcare System. This previous commentary addressed the four-drug combination of bupivacaine, clonidine, buprenorphine, and dexamethasone (BPV-CBD) used for postoperative perineural analgesia (e.g., combined with intraoperative spinal anesthesia), or for the dual role of intraoperative perineural anesthesia and postoperative analgesia. The average block duration (block insertion time until peak rebound pain score on a 0 to 10 scale) in this previous commentary was 33 to 37 hours, depending on the context. We believe that this clinical observation warrants high-priority research for the specialty, especially in the context of the effects of buprenorphine dose response and the parameters of block duration and rebound pain. In this current commentary, we will direct separate attention toward the four-drug combination of midazolam (MDZ) with CBD used for specific contexts of motor-sparing perineural analgesia. Both BPV-CBD and MDZ-CBD four-drug nerve block combinations were shown to be safe in vivo, as reported in a separate manuscript [2] in this issue of Pain Medicine . Based on the previously reported in vitro safety of MDZ-CBD [3], we used MDZ-CBD blocks in selected cases where the risk of motor block (and subsequent falls) was deemed as high as the potential short- and long-term risks of escalating systemic opioid analgesia (and/or intraoperative conversion to general endotracheal anesthesia [GETA]). All patients were fully informed before the use of MDZ-CBD as an “off-label” good-faith effort to 1) avoid motor block (i.e., routinely resulting from perineural bupivacaine use with or without perineural CBD use); 2) avoid GETA; and …