Perception of Pain Expression Among Surgical Patients and Families from Three Ethnic Groups of a Nation: A Multicenter Qualitative Study

Background

Despite its universal nature; perception, coping, responses, treatment options, and overall experiences of pain are influenced by biopsychosocial factors to various extents. Pain perception, expression, and control are progressively learned behaviors among members of a society and are culture-specific. Effects of ethnicity-related culture (ethnoculture) on pain experience in a broader context have increasingly been reported. However, evidence from ethnoculturally diverse groups of a nation, particularly based on surgical patients, is limited. Therefore, as a qualitative research effort of a broader project aimed at assessing ethnocultural determinants of surgical pain management, this study explored the perception of ethnoculturally diverse patients and families about expressing surgical disease-related pain.

Methods

This study follows subjectivist-interpretivist philosophical assumptions as an underpinning research paradigm. We purposively selected 11 patients for in-depth interviews and 12 patients' family members for focus group discussions in three hospitals of ethnic-based regions of Ethiopia. In the phenomenological frame, thematic analysis was employed.

Finding

Ethnocultural background influences how individuals express and respond to pain according to emergent themes of finding- Pain and overlooked cultural influence, Pain expressiveness in cultural context, Stereotypes of pain expressiveness, and Bravehood through stoic response. Pain feelings are commonly hidden where the domestic culture values stoic response to pain compared to ethnoculture where pain expressiveness is encouraged.

Conclusion

Individuals can express and respond to pain differently due to ethnocultural diversity within a nation. Researchers and clinicians should consider cultural context while applying the prevailing one-size-fits-all pain assessment tools among surgical patients of a nation with ethnocultural diversity.

Effects of parental holding on pain response in young children during cystometry: A randomized controlled trial

INTRODUCTION

Cystometry is essential for evaluating bladder function. However, children may react negatively to the physical pain of urethral catheterization or anxiety and fear of an unfamiliar environment. These pain responses during the cystometry procedure may interfere with the cystometry procedure and make it difficult to interpret the cystometry result. In this regard, the International Children's Continence Society has advised performing cystometry while holding infants as an effective nonpharmacological pain management method, but there is insufficient evidence to support this.

PURPOSE

This study aimed to analyze the effect of parental holding on reducing pain in children during cystometry.

METHODS

This was an experimental study in a randomized controlled pre-post test design. A total of 64 participants aged 6-18 months were recruited. During cystometry, the participants in the experimental group were placed on the parent's laps and held in the parents' arms. The participants in the control group were laid down on the examination table. During the procedure, both groups of parents were allowed to touch their children in all ways except holding them and to use the pacifier if they wished. The behavioral (face, leg, activity, cry, consolability scale) and physiological (oxygen saturation and heart rate) pain responses were measured at three-time points (immediately, 3, and 10 min after urethral catheter insertion).

RESULTS

Comparing the two groups, in the experimental group, the behavioral pain response at 3 min after urethral catheter insertion (t = -2.165, p = 0.034) and 10 min after (t = -3.155, p = 0.002) was decreased compared with that immediately after urethral catheter insertion. In addition, oxygen saturation increased more (t = 2.021, p = 0.048), and the heart rate decreased more (t = -2.033, p = 0.047) at 10 min than at 3 min after urethral catheter insertion in the experimental group.

CONCLUSIONS

This study revealed that parental holding could reduce pain responses during cystometry in children. Further research is required to confirm the applicability and usefulness of parental holding during cystometry.

The effect of oscillometric blood pressure measurement on pain response in preterm infants

AIM

Preterm neonates are exposed to many painful procedures in neonatal intensive care units. This study aims to evaluate the effect of oscillometric blood pressure (BP) measurement on pain response in preterm infants.

METHODS

This prospective study was performed over 4 months in a level III neonatal intensive care unit. Premature neonates whose gestational age was <34 weeks and postmenstrual age <36 weeks were included if they had no systemic diseases. BP measurement was performed on the right arm. The Premature Infant Pain Profile-Revised (PIPP-R) scores were evaluated three times before, during, and 10 min after BP measurement.

RESULTS

During the 5-month period, 100 preterm neonates (53 male infants) were included in the study. Median birth weight and gestational age of the infants were 1148 (IQR: 1015-1300) g and 28 (IQR: 27-30) weeks, respectively. PIPP-R scores were found to be ≥7 in 34% of neonates. PIPP-R scores increased during BP measurement and decreased after.

CONCLUSION

Our results demonstrated that oscillometric BP measurement which is generally accepted as a non-invasive tool for monitoring can produce mild pain in premature neonates of postmenstrual age <36 weeks.

Pain Outcomes in Patients with Metastatic Castration-Resistant Prostate Cancer Treated with 223Ra: PARABO, a Prospective, Noninterventional Study

223Ra, a targeted α-therapy, is approved for the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) who have bone metastases. In the phase 3 ALSYMPCA study, 223Ra prolonged survival and improved quality of life versus placebo. Our real-world study, PARABO, investigated pain and bone pain-related quality of life in patients with mCRPC and symptomatic bone metastases receiving 223Ra in clinical practice. Methods: PARABO was a prospective, observational, noninterventional single-arm study conducted in nuclear medicine centers across Germany (NCT02398526). The primary endpoint was a clinically meaningful pain response (≥2-point improvement from baseline for the worst-pain item score in the Brief Pain Inventory-Short Form). Results: The analysis included 354 patients, who received a median of 6 223Ra injections (range, 1-6). Sixty-seven percent (236/354) received 5-6 injections, and 33% (118/354) received 1-4 injections. Of 216 patients with a baseline worst-pain score of more than 1, 59% (128) had a clinically meaningful pain response during treatment. Corresponding rates were 67% (range, 98/146) with 5-6 223Ra injections versus 43% (range, 30/70) with 1-4 injections, 60% (range, 60/100) in patients with no more than 20 lesions versus 59% (range, 65/111) in those with more than 20 lesions, and 65% (range, 69/106) in patients without prior or concomitant opioid use versus 54% (range, 59/110) in those with prior or concomitant opioid use. Mean subscale scores (pain severity and pain interference) on the Brief Pain Inventory-Short Form improved during treatment. Conclusion: 223Ra reduced pain in patients with mCRPC and symptomatic bone metastases, particularly in patients who received 5-6 injections. The extent of metastatic disease did not impact pain response.

Investigating the use of local nerve blocks and general anaesthesia in reducing pain during and after disbudding procedure in goat kids

The aim of this study was to compare the pain responses (as measured by noise and movement) during administration of local anaesthetic and during and after disbudding in goat kids. Eighty, seven- to ten-day-old, Saanen goat kids from one farm were enrolled and randomly assigned to one of four different methods of pain relief. Twenty kids had local anaesthetic (LA) applied at two sites per horn bud (LA group), 20 kids had LA applied to the two locations using a jet injector (JI group) and 20 kids were given a general anaesthetic (GA) using a combination of 0.02 mg/kg medetomidine and 2 mg/kg ketamine followed by a horn bud block applied as per the LA group (GA group). The remaining 20 kids had no treatment other than meloxicam (control group). Although responses between goat kids and at different time periods were variable, in comparison to the control group, GA eliminated the responses associated with injection of lignocaine and the responses during the period of disbudding, and provided a reduction in head scratches and shakes across multiple time periods.

Risk-adapted stereotactic body radiotherapy for patients with cervical spinal metastases

Owing to the complex anatomical structure and biomechanics, the current standard palliative treatments for cervical spinal metastases are associated with a high risk of recurrence and complications. Stereotactic body radiotherapy (SBRT) can provide radical dose to tumors while protecting normal organs to the maximum extent. However, the efficacy and safety of SBRT for cervical spinal metastases is not well characterized. Data from 71 patients with cervical spine metastases who were treated with SBRT using CyberKnife between 2006 and 2021 were obtained from our prospectively maintained database. Primary endpoint was pain response at 12 weeks following SBRT completion; secondary endpoints included local control (LC), overall survival (OS), and adverse events. Standard-risk patients were planned to receive 30 Gy (range 21-36) with median fractions of 3 (range 1-3) and high-risk patients 35 Gy (range 24-50) with median fractions of 5 (range 4-5) according to the spinal cord and esophagus dose constraints. The median follow-up time was 17.07 months (range 3.1-118.9). After 12 weeks of SBRT completion, 54 (98.2%) of 55 patients with baseline pain achieved pain response and 46 (83.6%) achieved complete pain response. LC rates were 93.1% and 90% at 1 year and 2 year, respectively. The 1-year and 2-year OS rates were 66.2% and 37.4%, respectively. Eight patients experienced grades 1-4 adverse events (six vertebral compression fracture [VCF], five of them had VCF before SBRT; and two hemiparesis). No grade 5 adverse events were observed. Therefore, risk-adapted SBRT for cervical spine metastases achieved high pain control and LC rates with acceptable adverse events.

Comparison of Three Anaesthetic Options to Reduce Acute Pain Response in Kid Goats

Three options for anesthetizing the skin around the horn bud of dairy goat kids were explored. Forty-five <10-day-old Saanen goat kids from were randomly split into five treatment groups (topical anesthetic cream (TA), vapocoolant spray (VS), local anesthetic applied by jet injector (JI), control - no treatment but painful stimulus applied (C), sham - no treatment and touching sites with a finger. The painful stimulus was multiple needle pricks on the skin around the horn bud. The outcome variables measured were heart rate movement, and vocalization during treatment application and administration of a painful stimulus around the horn bud. Heart rates were greater during application of a VS compared to TA.Neither the TA nor the VS appeared to have any effect on the response to the painful stimulus. Kids in the JI group had a 96% reduced odds of expressing a marked pain response in comparison to TA group and an 83% reduction in the odds of a high movement grade during a painful procedure in comparison to the combined results of the other three treatment groups.

Palliative Efficacy of High-Dose Stereotactic Body Radiotherapy Versus Conventional Radiotherapy for Painful Non-Spine Bone Metastases: A Propensity Score-Matched Analysis

(1) Background: The superiority of stereotactic body radiotherapy (SBRT) over conventional external beam radiotherapy (cEBRT) in terms of pain palliation for bone metastases remains controversial. (2) Methods: This propensity score-matched study compared the overall pain response (OR) 3 months after radiotherapy among patients with painful (≥2 points on a 0-to-10 scale) non-spine bone metastases. Patients with lesions that were treated with SBRT or cEBRT and whose pain scores were evaluated 3 months after radiotherapy were included in this study. Pain response was evaluated according to the International Consensus Criteria. (3) Results: A total of 234 lesions (SBRT, n = 129; cEBRT, n = 105) were identified in our institutional database. To reduce the confounding effects, 162 patients were selected using a propensity score-matched analysis (n = 81 for each treatment). The OR rate at 3 months after SBRT was significantly higher than that after cEBRT (76.5% vs. 56.8%; p = 0.012). A noteworthy finding of our study is that the same trend was observed even after 6 months (75.9% vs. 50.0%; p = 0.011). The 1-year local failure rates after SBRT and cEBRT were 10.2% and 33.3% (p < 0.001), respectively. (4) Conclusions: Our findings suggest that SBRT is superior to cEBRT for pain palliation in patients with non-spine bone metastases.

Effect of Olfactory Stimulation with Breast Milk on Pain Responses to Heel Stick in Premature Infants: A Randomized Controlled Trial

Purpose: This study aimed to evaluate the effect of breast milk olfactory stimulation on pain response in premature infants during heel stick tests. Methods: A quasi-experimental randomized controlled trial was conducted in the neonatal intensive care unit of a tertiary-level hospital in Seoul, Korea. A breast milk group was provided olfactory stimulation with breast milk 30 seconds before the start of heel stick sampling, and a control group underwent heel stick sampling without olfactory stimulation. To evaluate infants' pain response, the heel stick procedure was video recorded, and pain response was assessed separately by two blinded research assistants using the Premature Infant Pain Scale (PIPS) through behavioral response, heart rate on physiological monitoring, and blood oxygen saturation on pulse oximetry through the video recording. Results: Forty-eight premature infants (gestational age, within 28-37 weeks, n = 24; control) were included in this study. The pain scores of the breast milk group were significantly lower than those of the control group (z = -2.04, p = 0.021). Conclusion: Breast milk odor may reduce pain in premature infants during heel stick tests.

Pupil response to painful stimuli during inhalation anaesthesia without opioids in children

BACKGROUND

Pupil dilation reflex measured by a pupillometer is known to be a useful parameter for assessing the response to perioperative noxious stimuli. In children, pupillometer can reflect changes after painful stimuli during anaesthesia or guide anaesthesia to reduce opioid consumption. However, to date, there are no data regarding pupil response during inhalation anaesthesia with analgesia by intravenous acetaminophen in children.

METHODS

We planned a prospective, single-armed study of children aged between 3 and 12 years who underwent surgery under general anaesthesia. Anaesthesia was maintained by 1 minimum alveolar concentration (MAC) of sevoflurane, and 15 mg/kg of acetaminophen was administered. Patients' left eye was examined using a pupillometer after induction, before and after skin incision and train-of-four stimulus. Pupil diameter and other pupillometric parameters were recorded. Increase in heart rate by 15% was regarded as insufficient analgesia to skin incision and indicative powers of pupillometric parameters for insufficient analgesia were examined by receiver-operating characteristics.

RESULTS

A total of 33 patients were included. Enlarged pupil, large increase in pupil diameter and low neurological pupil index (NPi) after skin incision were good indicators of insufficient analgesia for skin incision. Children with insufficient analgesia showed abnormal NPi value. However, increase in pupil diameter and decrease in NPi were observed even in patients without increase in the heart rate after the skin incision.

CONCLUSIONS

We suggest dilation of the pupil and decrease in NPi can indicate response to noxious stimuli in children. Regardless of sufficiency of analgesia, pupil dilation and decrease in NPi were observed after skin incision in children under general anaesthesia with 1 MAC of sevoflurane and intravenous acetaminophen.

Palliative radiotherapy for multiple liver metastases: a retrospective analysis of 73 cases

BACKGROUND

Whole-liver radiotherapy for diffuse liver metastases can improve symptoms and abnormal liver-related blood data. However, whole-liver radiotherapy is uncommonly used in clinical practice in Japan. Therefore, we aimed to clarify palliative radiotherapy outcomes in Japanese patients with liver metastases.

METHODS

We retrospectively reviewed databases in our institution to identify patients treated with radiotherapy (8 Gy in a single fraction) for multiple liver metastases between December 2014 and April 2021. The endpoints included pain response, liver-related blood data and adverse effects. We investigated aspartate transaminase, alanine transaminase, lactate dehydrogenase, alkaline phosphatase, γ-glutamyl transpeptidase and albumin. The mean values at whole-liver radiotherapy and after 2-4 weeks were compared using the Wilcoxon rank-sum test.

RESULTS

A total of 73 cases in 71 patients were included. The median clinical target volume was 2118 ml (range, 133-7867 ml). Fifty-seven patients (78%) had finished aggressive treatment at the time of radiotherapy. The median follow-up period was 6 weeks. The pain response rate was 64% (18/28). The mean values of five parameters significantly improved 2-4 weeks after radiotherapy compared to those at baseline: aspartate transaminase (118 vs. 83 U/l P < 0.01); alanine transaminase (84 vs. 61 U/l P < 0.01); lactate dehydrogenase (1351 vs. 1007 U/l P = 0.027); alkaline phosphatase (1624 vs. 1216 U/l P < 0.01) and γ-glutamyl transpeptidase (663 vs. 450 U/l P = 0.037). No patients experienced radiation-induced liver disease.

CONCLUSIONS

Palliative radiotherapy is efficient and safe in Japanese patients with liver metastases. These findings will help encourage whole-liver radiotherapy use in Japan.

Genetic Factors Associated With Pain Severity, Daily Opioid Dose Requirement, and Pain Response Among Advanced Cancer Patients Receiving Supportive Care

BACKGROUND

Current understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy (PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care.

METHODS

In this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Association of genetic factors with pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis.

RESULTS

About 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P = 0.038; rs62052210, P = 0.038. Opioid daily dose was positively associated NFKBIA rs2233419, P = 0.008; rs2233417, P = 0.007; rs3138054, P = 0.008; rs1050851, P = 0.015; ORPM1 rs9479759, P = 0.046; rs2003185, P = 0.047; rs636433, P = 0.044; COMT (rs9306234, P = 0.014; rs165728, P = 0.014; rs2020917, P = 0.036; rs165728, P = 0.034); ARRB2 (rs1045280, P = 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339, P = 0.024; rs34427887, P = 0.048; and COMT rs4646316, P = 0.03; rs35478083, P = 0.028, respectively. SKATO analysis showed association between pain severity and CXCL8 (P = 0.0056), and STAT6 (P = 0.0297) genes respectively, and pain response with IL-6 (P = 0.00499).

CONCLUSIONS

This study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.

Maximal cardiopulmonary exercise test in patients with chronic low back pain: feasibility, tolerance and relation with central sensitization. An observational study

PURPOSE

To analyze the feasibility of and pain-related tolerance to a maximal cardiopulmonary exercise test (CPET), and the relationship between the aerobic capacity and central sensitization (CS) in patients with chronic low back pain (CLBP).

METHODS

An observational study, combining a cross-sectional and a prospective 24-hour follow-up was performed. Participants underwent a maximal CPET on a cycle ergometer and were assessed with three measures of CS (CS Inventory, quantitative sensory testing and heart rate variability). Before the CPET, immediately afterwards and 24 h after, the Pain Response Questionnaire (PRQ) was filled out. The CPET was considered feasible when >80% performed maximally, and tolerable when <20% reported relevant pain increase, body reactions and additional pain medication use in the PRQ. Multiple regression analyses were applied to assess the relationship between the aerobic capacity (VO2max) and CS measures, corrected for confounders.

RESULTS

74 patients with CLBP participated of which 30 were male, mean age was 40.4 years (SD: 12.4) and median VO2max was 23.9 ml/kg/min (IQR: 18.2-29.4). CPET was completed by 92%. No serious adverse events occurred. A relevant pain increase was reported in the upper legs by 40% immediately after CPET and by 28% 24 h afterwards, 27% reported body reactions after 24 h, and 22% increased pain medication use 24 h after CPET. Very weak and not significant relations (r_partial=-0.21 to 0.05; p > 0.10) were observed between aerobic capacity and CS measures.

CONCLUSIONS

A maximal CPET is feasible in patients with CLBP. Most, but not all, tolerated it well. CS was not related to aerobic capacity.Implications for rehabilitationMaximal CPET is feasible in patients with CLBP and well tolerated by most patients.Maximal CPET can be safely applied to assess the aerobic capacity of patients with CLBP.Aerobic capacity is unrelated to central sensitization.Outcomes of a maximal CPET and the pain response to straining activity can be used to provide valid information for the decision-making of exercise therapy.

Clinical pain management by a multidisciplinary palliative care team: Experience from a tertiary cancer center in China

To investigate the effect of multidisciplinary interventions on pain management in cancer inpatients.Four hundred thirty eight patients with cancer pain, who performed the multidisciplinary intervention were recruited. Before and after intervention, the Brief Pain Inventory (BPI) and the MD Anderson Symptom Inventory (MDASI) score as the primary endpoints and QOL scores as the secondary endpoint were all evaluated. To investigate the factors that led to different responses to multidisciplinary interventions, patients were classified as non-responders or responders.Finally, 92 patients (63 male and 29 female) scheduled for cancer pain management by inter-professional team were studied. After individualized multidisciplinary therapy, both pain and symptom severity was improved, as demonstrated by lowered BPI worst and average pain scores, as well as symptom severity score measured by MDASI (P = .017, P = .003, and P = .011, respectively). The proportion of patients with mild pain increased regarding the BPI worst and average pain at baseline and after treatment (P < .05). The QOL analyses showed multidisciplinary interventions could significantly improve the function and symptom scores (P < .001). More patients in responder group received chemotherapy (58, 70.7%, P = .003), while fewer received mini-invasive therapy (6, 7.32%, P = .011).Multidisciplinary interventions had certain beneficial effect on cancer pain management, especially in patients with moderate or severe pain.

Impact of a Topical Anaesthesia Wound Management Formulation on Pain, Inflammation and Reduction of Secondary Infections after Tail Docking in Lambs

Simple Summary

Tail docking is routinely conducted in sheep husbandry around the world, often without anaesthesia or analgesia despite recognition that it is a painful process. Several methods are used, although the Council of Europe states that surgical methods with anaesthesia should be used to dock the tail, with these recommendations copied into national legislation by most European countries. However, no studies have been documented comparing the use of general anaesthesia and stitching. This study compared different surgical approaches with and without general anaesthesia, and with and without surgical stitching, plus examined the efficacy of applying a commercially available wound gel spray containing topical anaesthetics and an antiseptic, immediately on tail amputation. Results demonstrated that lambs display more pain when the surgery included stitching and these wounds became more readily infected, potentially requiring antibiotic therapy. As the generation of potential antimicrobial resistance and drug residues issues in food-producing animals from over-use of antibiotics is an emerging one health consideration, the availability of a topical anaesthetic formulation that provides pain relief and contains an antiseptic that reduces secondary infections and hasten wound healing, is of potential importance for improving husbandry procedures such as tail docking.

Abstract

We examined several procedures for surgical tail docking; with and without general anaesthesia (GA), including the use of a topical wound gel formulation to provide pain relief (PR) and improve healing after surgery, containing local anaesthetics lignocaine and bupivacaine, with cetrimide and adrenalin. Forty-four lambs were recruited into four equal cohorts: Groups A and C, the tail was excised with a scalpel without anaesthesia or stitches; Groups B and D, the tail was surgically excised and stitched under GA; Groups C and D wounds were immediately sprayed with PR. Behavioural observations identified that Groups A and C displayed significantly less pain-related behaviours than Groups B and D shortly after the procedure, especially if treated with PR. Similarly, the mean of days when animals showed no signs of wound infection was longer in the groups not undergoing stitching. Finally, treatment with PR appeared to reduce the cortisol response and avoided the elevation of serum amyloid A in lambs where the tail was excised without general anaesthesia. In conclusion, surgical tail-docking without GA but where wounds are immediately sprayed with PR, appears as an affordable and more welfare-appropriate method for conducting tail docking in lambs.

Body Image in Athletes and Nonathletes With Low Back Pain: Avoidance-Endurance-Related Subgroups and Sports Status Play a Role

CONTEXT

Low back pain (LBP) is a serious health problem, both in the general population as well as in athletes. Research has shown that psychosocial aspects, such as dysfunctional pain responses, play a significant role in the chronification of LBP. Recent research supports the relevance of the multidisciplinary concept of body image in the interpretation of LBP.

OBJECTIVE

To examine the differences in 2 psychosocial aspects, body image and pain responses, between athletes and nonathletes with LBP.

DESIGN

Cross-sectional design.

SETTING

The questionnaires were distributed in the course of LBP treatment.

PARTICIPANTS

Data from 163 athletes (mean age = 28.69 [9.6] y) and 75 nonathletes (mean age = 39.34 [12.63] y) were collected.

INTERVENTIONS

Data were collected by questionnaires assessing body image, pain behavior, training activity, and LBP.

MAIN OUTCOME MEASURES

To examine group differences between athletes and nonathletes regarding body image and pain behavior, the authors performed 2-way analyses of variance with Bonferroni post hoc tests.

RESULTS

The results showed (1) a significant main effect regarding pain responses and body image, showing that participants with eustress endurance or adaptive pain behavior revealed a more positive body image in both groups compared with participants with distress endurance or fear-avoidance behavior, and (2) a significant main effect for the factor group in the body image dimension of physical efficacy, indicating a more positive body image for athletes.

CONCLUSION

These results suggest that considering multiple risk factors for LBP, such as body image and dysfunctional pain behavior, as well as subgrouping, might be valuable for research and for broadening therapy options.

Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis

OBJECTIVE: Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution. METHODS: The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented. RESULTS: A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors' final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors' institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors' institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment. CONCLUSIONS: The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.

The pathophysiology, incidence, impact, and treatment of opioid-induced nausea and vomiting

PURPOSE

Opioid medications are integral in managing acute moderate-to-severe pain. Opioid analgesics bind to μ (mu), κ (kappa), or δ (delta) opioid receptors in the brain, spinal cord, and digestive tract. However, opioids cause adverse effects that may interfere with their therapeutic use. Some adverse effects wane over time, but patients using opioids for acute pain struggle with opioid-induced nausea and vomiting (OINV) the entire time they take the opioid. This article discusses the underlying mechanisms, clinical implications, and treatment strategies of OINV.

DATA SOURCES

Systematic search and review of Medline, PubMed, and Google Scholar for articles relating to OINV. In addition, package inserts provided pharmacologic data and dose recommendations as needed.

CONCLUSIONS

Research suggests approximately 40% of patients may experience nausea and 15%-25% of patients may experience vomiting after opioid administration. Nausea often precedes vomiting, although they can occur separately. Many patients receiving opioids rate the nausea and vomiting as worse than their pain. Nausea and vomiting can lead to complications including electrolyte imbalances, malnutrition, and volume depletion, and can also negatively affect quality of life and postoperative recovery.

IMPLICATIONS FOR PRACTICE

There are several medications that can be used to treat OINV including serotonin receptor antagonists, dopamine receptor antagonists, and neurokinin-1 receptor antagonists. Healthcare providers should be proactive about discussing OINV with patients, as this may improve patient outcomes and pain relief.

What Happened to Paul? Manifestation of Abnormal Pain Response for Individuals With Autism Spectrum Disorder

During the progression of a pilot nutrition intervention designed to teach cooking skills to young adults with autism spectrum disorder (ASD), one participant-Paul-fell in the parking lot. Prior to the accident, Paul had been making significant gains in the program and had communicated in a number of ways his enthusiasm. After his accident, which resulted in broken and dislocated bones in his ankle, his demeanor was dramatically altered, program gains were lost, and staff noted the appearance of many new challenging behaviors. This article analyzes Paul's behavior in reference to the pain response in autism. For some time, it was believed that many individuals with ASD did not experience pain based on anecdotal reports of how individuals responded to injury with seeming indifference. This view has given way of late to a more nuanced understanding of how atypical sensory processing and stimulus over-selectivity spill over into pain pathways and pain amplification mechanisms. The consequence is not a reduction in pain sensation, but a different expression of pain, determined by that individual's particular communicative, cognitive, or physiological challenges. From this perspective, many of the disruptive and harmful behaviors that emerged after Paul's accident can be seen as a delayed response to the incident. This article concludes by arguing that professionals across all domains of health care need to begin to see behavior as communicative for those with ASD. This is particularly true of changes in behavior, which can be significant indicators of health care problems rather than something to be dismissed as another manifestation of the condition.

Efficacy of single fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review and meta-analysis

BACKGROUND

Single fraction radiotherapy (SFRT) and multiple fraction radiotherapy (MFRT) are effective for painful uncomplicated bone metastases and have been shown to be of similar efficacy. The optimal conventional external beam SFRT dose for maximum pain relief remains uncertain. The aim of this systematic review was to comprehensively review and synthesize overall pain response rates by dose.

METHODS

A literature search was conducted in Ovid MEDLINE(R) (1946 to June 2016 week 3), Embase Classic & Embase (1947 to 2016 week 26) and Cochrane Central Register of Controlled Trials (May 2016) using keywords such as bone metastases, radiotherapy and single fraction (SF).

RESULTS

The 635 results from the search were screened, and ultimately 27 were included for quantitative synthesis. The review indicated that 10 and 6 Gy may produce superior overall response (OR) and complete response (CR) rates compared to 8 Gy, and 6 Gy may result in better partial response (PR) than 8 Gy. However, only a few studies documented doses other than 8 Gy. In trials that directly compared 8 Gy to 4 Gy or 6 Gy, 8 Gy was deemed statistically superior.

CONCLUSIONS

8 Gy SFRT was the most commonly administered dose for palliation of bone metastases supporting its efficacy and safety. Future studies should explore the efficacy of 10 Gy while minimizing its side effects.

An ethnographic exploration of postoperative pain experiences among Ghanaian surgical patients

BACKGROUND

The experience of pain associated with surgery has been a challenge for health care professionals for many years, and culture is said to influence pain.

PURPOSE

This study focused on patients' experiences of postoperative pain (POP) and factors that affect POP.

DESIGN

The study employed qualitative ethnographic principles.

METHOD

Data were collected through individual face-to-face interviews. Data were saturated after analyzing data from 13 patients from two hospitals in Ghana.

FINDINGS

Themes that emerged were the subjective nature of pain, which described pain dimensions and communication; psycho-sociocultural factors, such as personal inclinations and sociocultural background; and health system factors, such as personnel attitudes and health financing.

IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE

Health professionals need to understand the sociocultural effects of pain in order to give effective care.

CONCLUSION

The study highlighted the need for patient education and the importance that health care professionals understand context-specific factors that influence POP management.

Oral sucrose for pain control in nonneonate infants during minor painful procedures

PURPOSE

To provide information regarding the effective use of oral sucrose as an analgesic for immunization and venipuncture procedures in the older infant.

DATA SOURCES

Evidence-based literature including original clinical trials, reviews, and clinical practice guidelines.

CONCLUSIONS

Most infants are exposed to multiple minor painful procedures during the first year of life. Oral sucrose solution in a 24% concentration at a dose of 2 mL approximately 2 min prior to the painful procedure has been shown effective in reducing pain during immunizations and venipuncture in the outpatient setting in infants aged 1-12 months old.

IMPLICATIONS FOR PRACTICE

Oral sucrose solution should be used as a pain reduction intervention in infants up to 12 months of age undergoing minor painful procedures. Its proven effectiveness as an analgesic, low rate of minor adverse events, ease of administration, and excellent availability make sucrose a good choice for this purpose. Additional research is needed regarding dose response in different infant age groups, optimal concentration of sucrose solution, need for multiple sucrose dosing, adjustment for multiple painful procedures, and addition of optimal nonpharmacologic interventions as a combination approach.

Race and unequal burden of perioperative pain and opioid related adverse effects in children

BACKGROUND

Interindividual variability in pain perception and analgesic response is a major problem in perioperative practice. Adult studies suggest pain management is influenced by patient's race. The objective of this study is to evaluate the influence of race on perioperative pain treatment in children.

METHODS

Prospective observational study evaluating effect of race on analgesia and opioid related adverse effects after tonsillectomy in African American and Caucasian children. A sample of 194 healthy children between 6 and 15 years of age were included. Race was self-identified by parents. All participants received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine. Analgesia outcomes included maximum postoperative pain scores, postoperative opioid requirement, and analgesic interventions. Safety outcomes included incidences of opioid related adverse effects.

RESULTS

African American children experienced significantly more postoperative pain than Caucasian children as measured by postoperative opioid requirement (P = .0011), maximum postoperative pain scores (P < .0001), and analgesic interventions (P < .0001) in the recovery room. Although Caucasian children received relatively less opioids perioperatively, they had significantly higher opioid related adverse effects (P = .039). African American children with obstructive sleep apnea were more likely to have prolonged post anesthesia recovery unit stay due to inadequate pain control.

CONCLUSIONS

After similar uses of intraoperative morphine for tonsillectomy, there was an unequal burden of increased pain in African American children and increased opioid adverse effects in Caucasian children in the recovery room. Though Caucasian children received relatively less opioids perioperatively, they had higher incidences of opioid related adverse effects than African American children.

Pain response of healthy workers following a functional capacity evaluation and implications for clinical interpretation

BACKGROUND AND AIM

Functional Capacity Evaluations (FCEs) are used to quantify physical aspects of work capacity. Safety is a critical issue for clinical use of an FCE. Patients with Chronic Low Back Pain (CLBP) are known to report a temporary increase in pain following an FCE, but it is not known whether this increase is a normal pain response to FCE. It is currently unknown how healthy subjects respond to an FCE and whether this should be interpreted as a normal reaction after physical exercise. This study was performed to quantify the intensity, duration, location and nature of the pain response following an FCE in healthy subjects and to compare this pain response with the pain response of patients with CLBP from a previous study.

METHODS

A total of 197 healthy working subjects between 20 and 60 years of age volunteered to participate in this study. All subjects performed a 12-item FCE. Pain response was measured by a self-constructed Pain Response Questionnaire (PRQ). Descriptive statistics were used to describe the pain response following an FCE. Mann-Whitney and t-tests were performed to compare the data from this study with data of patients with CLBP from a previous study.

RESULTS

About 82% of all subjects reported a pain response following the FCE. The intensity of the pain response after 24 h post FCE was a median of 3.0 on a numeric rating scale (0-10). About 78% of all pain was reducible to muscle soreness. Pain was most often reported in the upper legs (51%), the lower back (38%) the shoulders (37%) and upper arms (36%). Symptoms decreased to pre-FCE levels in a mean of 3 days. The pain response of 2 subjects (1%) lasted for 3 weeks. The intensity and duration of the pain response of healthy subjects was not significantly different from the response of patients with CLBP.

CONCLUSION

Pain response of 99% of all subjects who reported a pain response was interpreted as normal. It was concluded that a pain response following an FCE can be expected in healthy subjects and that this pain response is a normal musculoskeletal reaction. The pain response of patients with CLBP resembles the pain response of healthy subjects.

Pharmacological differences between the human and rat vanilloid receptor 1 (VR1)

Vanilloid receptors (VR1) were cloned from human and rat dorsal root ganglion libraries and expressed in Xenopus oocytes or Chinese Hamster Ovary (CHO) cells. Both rat and human VR1 formed ligand gated channels that were activated by capsaicin with similar EC(50) values. Capsaicin had a lower potency on both channels, when measured electrophysiologically in oocytes compared to CHO cells (oocytes: rat=1.90+/-0.20 microM; human=1.90+/-0.30 microM: CHO cells: rat=0.20+/-0.06 microM; human=0.19+/-0.08 microM). In CHO cell lines co-expressing either rat or human VR1 and the calcium sensitive, luminescent protein, aequorin, the EC(50) values for capsaicin-induced responses were similar in both cell lines (rat=0.35+/-0.06 microM, human=0.53+/-0.03 microM). The threshold for activation by acidic solutions was lower for human VR1 channels than that for rat VR1 (EC(50) pH 5.49+/-0.04 and pH 5.78+/-0.09, respectively). The threshold for heat activation was identical (42 degrees C) for rat and human VR1. PPAHV was an agonist at rat VR1 (EC(50) between 3 and 10 microM) but was virtually inactive at the human VR1 (EC(50)>10 microM). Capsazepine and ruthenium red were both more potent at blocking the capsaicin response of human VR1 than rat VR1. Capsazepine blocked the human but not the rat VR1 response to low pH. Capsazepine was also more effective at inhibiting the noxious heat response of human than of rat VR1.