Buttonhole cannulation is superior in securing hemostasis as compared to conventional cannulation, but not in reducing pain and ease of cannulation. More educational workshops should be conducted to improve the skill

Hemodialysis patients are a group of critically ill patient with multiple co-morbidities as the risk factors of developing vascular access complications and death. Creation of fistula before initiation of hemodialysis will reduce the IJC related complications. Vascular access complications will contribute to the increased mortality and socioeconomic burden.

In this study, the frequency of infection and thrombosis were not significantly increased in the buttonhole group but it might be due to small sample size, high dropout rate and short duration of the study. The practice of buttonhole cannulation should be encouraged provided cost is not a factor.

INTRODUCTIONWhile opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed.

MATERIALS AND METHODSA multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions.

RESULTSAvailable data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour.

CONCLUSIONDue to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as secondor third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required.

Analgesics, Opioid ; therapeutic use ; Chronic Pain ; drug therapy ; etiology ; Evidence-Based Medicine ; Humans