Background: The long-term outcomes of patients with chronic pain treated in a multidisciplinary pain management center remain variable. Objective: This study aims to evaluate the changes in outcomes of patient’s self...Background: The long-term outcomes of patients with chronic pain treated in a multidisciplinary pain management center remain variable. Objective: This study aims to evaluate the changes in outcomes of patient’s self-reported pain, psychosocial status, health related quality of life and gender differences following treatment in amultidisciplinary pain management centre. Design: A prospective longitudinal cross-sectional study uses questionnaires. Treatment Setting: A pragmatic and individualized patient centered approach in a tertiary level multidisciplinary pain management center. Subjects: Patients with chronic pain referred to the centre from 2004-2010. Outcome Measures: Pain Numerical Rating Scale (NRS), Pain Temporal Description (1 - 6), Pain Self- Efficacy Questionnaire (PSEQ), Depression Anxiety Stress Scales (DASS-21) and Short Form-36 (SF- 36). Follow-up questionnaires were sent at 6 and 12 months after initial assessment. Results: Mean duration of baseline chronic pain was 8.1 years and 61% of chronic pains were involving the musculoskeletal system. At 6 and 12 month follow-ups, 273 and 180 participants had been surveyed respectively. At 6-month follow-up, there were significant improvements on pain intensity (Cohen’s d = 0.8), pain self-efficacy (Cohen’s d = 0.47), depression and stress scores (Cohen’s d = 0.16) and six out of eight domains of SF-36 (Cohen’s d = 0.2 - 0.4). At 12-month follow-up, improvements were maintained on pain intensity, self-efficacy and three out of eight domains of SF-36. There were distinctive pre- and post-treatment gender differences in these outcomes and overall females showed better short- and long-term outcomes than males. Conclusion: Multidisciplinary pain management using an individualized patient centered approach remains an effective treatment for chronic pain in both the short- (6 month) and long-term (12 month). The distinctive pre- and post-treatment gender differences particularly in the psychological outcomes, suggest that it may be beneficial to further delineate and better manage vulnerable patient subgroups.展开更多
Background: Complex Regional Pain Syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a neuropathic pain condition that usually develops after an injury to an extremity. CRPS can be a d...Background: Complex Regional Pain Syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a neuropathic pain condition that usually develops after an injury to an extremity. CRPS can be a debilitating condition with high levels of pain and reduced function. Aim: This case report aims to discuss the multimodal approach in the management of a patient who presented with ongoing poorly controlled pain secondary to CRPS from an injury that happened years prior. Case Presentation: A 45-year-old female was involved in a motor vehicle accident where her right leg was injured. She underwent several surgeries and developed CRPS that significantly reduced her mobility and quality of life. She presented to the pain clinic years after her initial injury and a multimodal regimen was started for her resulting in significantly improved function. Conclusion: CRPS can be a severely debilitating condition. While early diagnosis and management are important, ongoing management in the outpatient chronic pain setting is important in maintaining a good level of function.展开更多
Background: Necrotizing soft tissue infections (NSTIs) are potentially life threatening medical emergencies associated with devastating and rapidly spreading destruction of soft tissues. Atypical presentations and del...Background: Necrotizing soft tissue infections (NSTIs) are potentially life threatening medical emergencies associated with devastating and rapidly spreading destruction of soft tissues. Atypical presentations and delayed early diagnosis can be significant challenges in managing NSTIs. The infectious process can start at any part of the body with rapid progression leading to limb amputation and high mortality rate. We present a case of a patient with NSTI, the sequelae and management of the chronic pain that developed. Aim: This case report looks to shed light on the importance of a plan for management of subacute and chronic pain in treating patients who present with Necrotizing soft tissue infection. Case presentation: A 53-year-old female who presented with septicemia and was subsequently admitted and treated for NSTI in 2014 resulting in amputation of her distal foot, toe digits, and now with ongoing chronic wound of the lower extremities along with chronic pain. Conclusion: Chronic pain as part of the sequelae of Necrotizing soft tissue infections needs to be anticipated by the health care management team in order to optimize patient care post operatively.展开更多
Introduction With growing concerns about the opioid crisis,the adoption of multimodal analgesia has significantly increased in clinical settings over the last 20 years.Multimodal analgesia refers to the use of various...Introduction With growing concerns about the opioid crisis,the adoption of multimodal analgesia has significantly increased in clinical settings over the last 20 years.Multimodal analgesia refers to the use of various analgesic agents that act via distinct mechanisms at multiple sites along the nociceptive pathway,thereby enhancing pain management and minimizing opioid use.Opioid-sparing or opioid-free approaches can be effective for perioperative analgesia;however,their necessity and appropriateness depend on the circumstances of the individual patient.Common perioperative analgesics include opioids and non-opioid systemic analgesics,such as dexmedetomidine(DEX),ketamine,acetaminophen,non-steroidal antiinflammatory drugs,gabapentinoids,and regional or local anesthetics administered intravenously or through infiltration.展开更多
With the acceleration of China's aging society,elderly patients have become a high-risk group for malignant tumors and exhibit high prevalence of pain.For a long time,the diagnosis,treatment,and management of canc...With the acceleration of China's aging society,elderly patients have become a high-risk group for malignant tumors and exhibit high prevalence of pain.For a long time,the diagnosis,treatment,and management of cancer pain in elderly Chinese patients have been inadequate.This study used"Older adults,geriatric patients,cancer pain,pain assessment,pain management,elderly cancer,geriatric oncology,medication management,palliative care,interdisciplinary pain management,Analgesics,quality of life"as key words.We systematically searched PubMed,Web of Science,CNKI,and Wanfang databases from their inception to September 2024.The search primarily included phase I to III clinical trials,randomized controlled trials,meta-analyses,systematic reviews,and case reports.Elderly patients typically present with complex pain mechanisms,including both cancer-related and non-cancer pain,cognitive dysfunction,comorbidities,and polypharmacy,posing significant challenges for clinical diagnosis and treatment.Notable clinical differences exist between elderly and younger patients in the epidemiology,assessment,diagnosis,and treatment of cancer pain.Currently,the awareness of comprehensive management for elderly cancer pain patients is limited,and specific,implementable clinical guidelines are lacking.Therefore,developing a comprehensive,localized management model for elderly cancer pain patients in China—incorporating factors such as age-related impacts,organ function status,and comorbidities—has become an urgent necessity.展开更多
AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.METHODS: The review process applied systematic evidence-based assessment methodol...AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including Pub Med from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources includingprevious systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques- Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level Ⅰ to level Ⅴ.RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level Ⅰ, based on a range of level Ⅰ to Ⅴ derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level Ⅱ to Ⅲ, with level Ⅱ evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement(greater than 6 mo), and level Ⅲ evidence for lumbosacral zygapophysial joint injections for short-term improvement only.CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.展开更多
Objective Pectus excavatum is a congenital deformity characterized by a caved-in chest wall.Repair requires surgery.The less invasive Nuss procedure is very successful,but postoperative pain management is challenging ...Objective Pectus excavatum is a congenital deformity characterized by a caved-in chest wall.Repair requires surgery.The less invasive Nuss procedure is very successful,but postoperative pain management is challenging and evolving.New pain management techniques to reduce opioid reliance include the erector spinae plane(ESP)block.We retrospectively examined opioid consumption after Nuss procedure comparing three pain management techniques:ESP block,thoracic epidural(TE),and patient-controlled analgesia(PCA).Methods This retrospective cohort study compared pain management outcomes of three patient groups.Seventy-eight subjects aged 10–18 years underwent Nuss procedure at our institution between January 2014 and January 2020.The primary outcome measure was opioid consumption measured in morphine milligram equivalents.Secondary measures included pain ratings and length of stay(LOS).Pain was quantified using the Numeric Pain Rating Scale.Analysis of variance was performed on all outcome measures.Results Average cumulative opioid use was significantly lower in the ESP block(67 mg)than the TE(117 mg)(p=0.0002)or the PCA group(172 mg)(p=0.0002).The ESP block and PCA groups both had a significantly shorter average LOS(3.3 and 3.7 days,respectively)than the TE group(4.7 days).ESP block performed best for reducing opioid consumption and LOS.Reduced opioid consumption is key for limiting side effects.This study supports use of ESP block as a superior choice when choosing among the three postoperative pain management options that were evaluated.Conclusion ESP resulted in reduced opioid consumption postoperatively and shorter LOS than TE or PCA for patients undergoing the Nuss procedure for surgical repair of pectus excavatum.展开更多
Neuropathic pain is chronic pain generated by disorders of the peripheral and central nervous system, including skull base tumours. A skull base tumour can be any type of tumour that forms in the skull base, and this ...Neuropathic pain is chronic pain generated by disorders of the peripheral and central nervous system, including skull base tumours. A skull base tumour can be any type of tumour that forms in the skull base, and this includes vestibular schwannomas which arise from the sheath of the inner ear vestibulocochlear nerve(eighth cranial nerve). Growth of the tumour, surgical resection, and/or stereotactic radiotherapy may result incompression and/or irritation of the fifth cranial nerve(trigeminal nerve) resulting in facial pain and/or numbness. Non-trigeminal afferent input may contribute to the wide constellation of symptoms seen in orofacial pain patients. The purpose of this report was to develop a decision tool to guide the recognition and treatment of neuropathic pain in this specialized population. Recommendations for treatment are based on evidence presented in Canadian and international neuropathic treatment guidelines. Algorithms are included for assessment and treatment of adult patients with agents that are recognized to have analgesic efficacy within the broad context of neuropathic pain.展开更多
Neuropathic pain,a debilitating condition caused by dysfunction of the somatosensory nervous system,remains difficult to treat due to limited understanding of its molecular mechanisms.Bioinformatics analysis identifie...Neuropathic pain,a debilitating condition caused by dysfunction of the somatosensory nervous system,remains difficult to treat due to limited understanding of its molecular mechanisms.Bioinformatics analysis identified cerebellin 2(CBLN2)as highly enriched in human and murine proprioceptive and nociceptive neurons.We found that CBLN2 expression is persistently upregulated in dorsal root ganglia(DRG)following spinal nerve ligation(SNL)in mice.In addition,transcription factor SOX11 binds to 12 cis-regulatory elements within the Cbln2 promoter to enhance its transcription.SNL also induced SOX11 upregulation,with SOX11 and CBLN2 co-localized in nociceptive neurons.The siRNA-mediated knockdown of Sox11 or Cbln2 attenuated SNL-induced mechanical allodynia and thermal hyperalgesia.High-throughput sequencing of DRG following intrathecal injection of CBLN2 revealed widespread gene expression changes,including upregulation of numerous NF-κB downstream targets.Consistently,CBLN2 activated NF-κB signaling,and inhibition with pyrrolidine dithiocarbamate reduced CBLN2-induced pain hypersensitivity,proinflammatory cytokines and chemokines production,and neuronal hyperexcitability.Together,these findings identified the SOX11/CBLN2/NF-κB axis as a critical mediator of neuropathic pain and a promising target for therapeutic intervention.展开更多
Objective To evaluate the clinical efficacy of different acupuncture-related therapies in treating postoperative pain in patients with osteoporotic vertebral compression fractures(OVCFs)after percutaneous kyphoplasty(...Objective To evaluate the clinical efficacy of different acupuncture-related therapies in treating postoperative pain in patients with osteoporotic vertebral compression fractures(OVCFs)after percutaneous kyphoplasty(PKP)or percutaneous vertebroplasty(PVP)using a network meta-analysis.Methods A systematic search was conducted in PubMed,Cochrane Library,Embase,Web of Science,China National Knowledge Infrastructure,Wanfang Database,Chinese Scientific Journal Database,and Chinese Biomedical Literature Database(SinoMed)from their inception to January 15,2025.Outcome measures included the Visual Analog Scale(VAS)score,Oswestry Disability Index(ODI)score,and overall efficacy rate.Literature screening,data extraction,and risk-of-bias assessment were independently performed by two researchers.Data analysis was conducted using Stata 17.0 software.Results A total of 35 randomized controlled trials involving 2860 patients were included.The data analysis revealed that,in terms of improving VAS and ODI scores,the top three effective therapies were Fu's subcutaneous needling,wrist-ankle acupuncture,and acupotomy.For the overall efficacy rates in pain treatment,the top three therapies were wrist-ankle acupuncture,warm acupuncture and moxibustion,and Fu's subcutaneous needling.Based on the combined results across the three outcome measures,Fu's subcutaneous needling was found to be the most effective in relieving pain and improving lumbar function.Conclusion Fu's subcutaneous needling,wrist-ankle acupuncture,warm acupuncture and moxibustion,and acupotomy were all effective in treating postoperative pain post-PKP/PVP and improving lumbar function.However,further high-quality,large-sample studies are required to confirm these findings.展开更多
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusi...From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity(need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both proand anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shownimprovements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.展开更多
Artificial nutrition(AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over whic...Artificial nutrition(AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition(PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel "myths" about PN-related complications and show how prevention and monitoring are able to reach the goal of "near zero" PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider:(1) an appropriate blood glucose control;(2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones;(3) the adoption of insertion and care bundles for central venous access devices; and(4) the implementation of a policy of targeting "near zero" catheter-related bloodstream infections. Adopting all these strategies, the goal of "near zero" PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.展开更多
Tobacco smoking is considered to be one of the main risk factors in the development of chronic pain.Long-term chronic exposure to nicotine and other forms of tobacco have been shown to be associated with an increased ...Tobacco smoking is considered to be one of the main risk factors in the development of chronic pain.Long-term chronic exposure to nicotine and other forms of tobacco have been shown to be associated with an increased incidence of pain.Studies have shown that acupuncture can help smokers to reduce their desire to smoke,reduce their withdrawal symptoms,and avoid a relapse after treatment.However,little has been reported about the effects of acupuncture on pain sensitivity caused by long-term smoking.Models of hyperalgesia were established in rats exposed to nicotine for 6 weeks.After 6 weeks of continuous nicotine exposure,electroacupuncture at bilateral acupoints Zusanli(ST36)and Taichong(LR3)was performed 20 minutes per day for 6 days at a continuous wave with a frequency of 2 Hz and a stimulus intensity of 1 m A.The results revealed that electroacupuncture treatment increased the mechanical response threshold of hind paw of nicotine-dependent rats with hyperalgesia and up-regulated the protein expression of pain-related factorsμ-opioid receptor,β-endorphin and glutamic acid decarboxylase 65 in the spinal cord and midbrain periaqueductal gray and the protein expression of glutamic acid decarboxylase 67 in the spinal cord.These findings suggest that electroacupuncture treatment has positive analgesic effects on pain sensitivity caused by long-term chronic nicotine exposure.One possible mechanism for the improved analgesia is that electroacupuncture increases the expression of painrelated factors in the spinal cord and midbrain periaqueductal gray.This study was approved by Institutional Animal Care and Use Committee(IACUC)of the University of Miami(#18-167)on December 12,2018.展开更多
Post-amputation pain causes great sufering to amputees,but still no efective drugs are available due to its elusive mechanisms.Our previous clinical studies found that surgical removal or radiofrequency treatment of t...Post-amputation pain causes great sufering to amputees,but still no efective drugs are available due to its elusive mechanisms.Our previous clinical studies found that surgical removal or radiofrequency treatment of the neuroma at the axotomized nerve stump efectively relieves the phantom pain aficting patients after amputation.This indicated an essential role of the residual nerve stump in the formation of chronic post-amputation pain(CPAP).However,the molecular mechanism by which the residual nerve stump or neuroma is involved and regulates CPAP is still a mystery.In this study,we found that nociceptors expressed the mechanosensitive ion channel TMEM63A and macrophages infltrated into the dorsal root ganglion(DRG)neurons worked synergistically to promote CPAP.Histology and qRT-PCR showed that TMEM63A was mainly expressed in mechanical pain-producing non-peptidergic nociceptors in the DRG,and the expression of TMEM63A increased signifcantly both in the neuroma from amputated patients and the DRG in a mouse model of tibial nerve transfer(TNT).Behavioral tests showed that the mechanical,heat,and cold sensitivity were not afected in the Tmem63a-/-mice in the naïve state,suggesting the basal pain was not afected.In the infammatory and post-amputation state,the mechanical allodynia but not the heat hyperalgesia or cold allodynia was signifcantly decreased in Tmem63a-/-mice.Further study showed that there was severe neuronal injury and macrophage infltration in the DRG,tibial nerve,residual stump,and the neuromalike structure of the TNT mouse model,Consistent with this,expression of the pro-infammatory cytokines TNFα,IL-6,and IL-1βall increased dramatically in the DRG.Interestingly,the deletion of Tmem63a signifcantly reduced the macrophage infltration in the DRG but not in the tibial nerve stump.Furthermore,the ablation of macrophages signifcantly reduced both the expression of Tmem63a and the mechanical allodynia in the TNT mouse model,indicating an interaction between nociceptors and macrophages,and that these two factors gang up together to regulate the formation of CPAP.This provides a new insight into the mechanisms underlying CPAP and potential drug targets its treatment.展开更多
Introduction: Complex regional pain syndrome (CRPS) is a disorder characterized by pain as well as a myriad of sensory, autonomic, and motor disturbances. We are reporting a case of child diagnosed with CRPS and succe...Introduction: Complex regional pain syndrome (CRPS) is a disorder characterized by pain as well as a myriad of sensory, autonomic, and motor disturbances. We are reporting a case of child diagnosed with CRPS and successfully treated with supraclavicular brachial plexus catheter infusion of local anesthetic. Case Report: An eight-year-old male underwent a left thoracotomy, repair of esophageal vascular ring, and translocation of the left subclavian to the left carotid artery. Post-operative course was relevant for severe intractable left shoulder and left arm pain associated with allodynia and hyperalgesia. A supraclavicular catheter was inserted, and an infusion of ropivacaine 0.2% was started. The child was sent for physical therapy as he gradually regained all functions of his left arm and resumed his regular activities. Conclusion: Continuous supraclavicular brachial plexus catheter infusion of local anesthetic is a valuable method of reducing pain in severe cases of upper extremity pediatric CRPS and may be safer and more effective than other invasive measures such as sympathetic blocks and epidural catheterization. Further research surrounding the diagnosis and treatment of pediatric CRPS is needed to allow early diagnosis and treatment and to improve outcome.展开更多
AIM To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.METHODS Specific intervention strategies(i.e.,comfort po...AIM To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.METHODS Specific intervention strategies(i.e.,comfort positioning,nonnutritive sucking and sucrose analgesia,distraction) were identified,selected and introduced in three waves,using a Plan-Do-Study-Act framework.System-wide change was measured from baseline to post-intervention by:(1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and(2) caregiver satisfaction ratings following the visit.Additionally,self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts.RESULTS Significant improvements were noted post-intervention.Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received.Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50,P ≤ 0.05],as well as greater agreement that the pain prevention strategies used helped their children's pain [t(180) = 2.17,P ≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26,P ≤ 0.001] as compared to baseline.Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention.Specifically,staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47 vs 3.10; t(70) =-2.11,P ≤ 0.05],less agreement that pain from vaccinations is "just part of the process" [3.94 vs 3.23; t(70) = 2.61,P ≤ 0.05],and less agreement that parents expect their children to experience pain during vaccinations [4.81 vs 4.38; t(69) = 2.24,P ≤ 0.05].Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas,including safety,cost,time,and effectiveness,as well as less concern about the pain their children experience with vaccination [4.08 vs 3.26; t(557) = 6.38,P ≤ 0.001],less need for additional pain prevention strategies [3.33 vs 2.81; t(476) = 4.51,P ≤ 0.001],and greater agreement that their doctors' office currently offers pain prevention for vaccinations [3.40 vs 3.75; t(433) =-2.39,P ≤ 0.05].CONCLUSION Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.展开更多
The cytochrome P450 proteins(CYP450s)have been implicated in catalyzing numerous important biological reactions and contribute to a variety of diseases.CYP26A1,a member of the CYP450 family,carries out the oxidative m...The cytochrome P450 proteins(CYP450s)have been implicated in catalyzing numerous important biological reactions and contribute to a variety of diseases.CYP26A1,a member of the CYP450 family,carries out the oxidative metabolism of retinoic acid(RA),the active metabolite of vitamin A.Here we report that CYP26A1 was dramatically upregulated in the spinal cord after spinal nerve ligation(SNL).CYP26A1 was mainly expressed in spinal neurons and astrocytes.HPLC analysis displayed that the content of all-trans-RA(at-RA),the substrate of CYP26A1,was reduced in the spinal cord on day 7 after SNL.Inhibition of CYP26A1 by siRNA or inhibition of CYP26A1-mediated at-RA catabolism by talarozole relieved the SNL-induced mechanical allodynia during the maintenance phase of neuropathic pain.Talarozole also reduced SNL-induced glial activation and proinflammatory cytokine production but increased anti-inflammatory cytokine(IL-10)production.The RA receptors RARα,RXRβ,and RXRγwere expressed in spinal neurons and glial cells.The promoter of Il-10 has several binding sites for RA receptors,and at-RA directly increased Il-10 mRNA expression in vitro.Finally,intrathecal IL-10 attenuated SNL-induced neuropathic pain and reduced the activation of astrocytes and microglia.Collectively,the inhibition of CYP26A1-mediated at-RA catabolism alleviates SNL-induced neuropathic pain by promoting the expression of IL-10 and suppressing glial activation.CYP26A1 may be a potential therapeutic target for the treatment of neuropathic pain.展开更多
BACKGROUND Intracranial hypotension(IH)is a disorder involving cerebrospinal fluid(CSF)hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed,especially in these pati...BACKGROUND Intracranial hypotension(IH)is a disorder involving cerebrospinal fluid(CSF)hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed,especially in these patients without the prototypical manifestation of an orthostatic headache.At present,the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas(SDHs)is still unclear.CASE SUMMARY A 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo.Computed tomography revealed bilateral SDHs and a midline shift.However,neurotrophic drugs were not effective,and 3 d after admission,he developed a non-orthostatic headache and neck stiffness.Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature,and IH was suspected.Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine,confirming the diagnosis of having IH.The patient fully recovered following multiple targeted epidural blood patch(EBP)procedures.CONCLUSION IH is a rare disease,and to the best of our knowledge,IH with diplopia as its initial and primary symptom has never been reported.In this study,we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.展开更多
Lumbar synovial cysts are benign fluid collections thought to form in a background of facet joint degeneration, allowing for fluid to leak from the joint capsule and form cysts in the synovium. Although often asymptom...Lumbar synovial cysts are benign fluid collections thought to form in a background of facet joint degeneration, allowing for fluid to leak from the joint capsule and form cysts in the synovium. Although often asymptomatic, patients with symptomatic synovial cysts will present with low back pain and possibly an associated radiculopathy. Clinicians can consider conservative management, epidural steroid injection, surgical intervention, or facet joint block with aspiration and rupture. This case describes a 59-year-old male facilities manager with intermittent low back pain for one year with worsening right-sided radicular symptoms secondary to a lumbar facet joint synovial cyst in the context of severe facet arthropathy and microinstability. The patient’s low back pain and radicular symptoms were refractory to conservative treatment. Imaging demonstrated a lumbar synovial cyst and subsequent management included transforaminal epidural steroid injection and facet joint block with cyst aspiration and rupture. The patient’s radicular pain resolved but axial lumbar pain returned after 3 weeks of relief. Follow-up imaging demonstrated decreased cyst size with fluid accumulation and joint space widening. Although the cyst was successfully decompressed with resolution of radicular pain, the underlying facet arthropathy remains contributing to persistent axial low back pain and potential for continued degenerative changes including cyst recurrence.展开更多
Approximately 20%of cirrhotic patients with ascites develop umbilical herniation.These patients usually suffer from multisystemic complications of cirrhosis,have a significantly higher risk of infection,and require ac...Approximately 20%of cirrhotic patients with ascites develop umbilical herniation.These patients usually suffer from multisystemic complications of cirrhosis,have a significantly higher risk of infection,and require accurate surveillance–especially in the context of the coronavirus disease 2019 pandemic.The rupture of an umbilical hernia,is an uncommon,life-threatening complication of largevolume ascites and end-stage liver disease resulting in spontaneous paracentesis,also known as Flood syndrome.Flood syndrome remains a challenging condition for clinicians,as recommendations for its management are lacking,and the available evidence for the best treatment approach remains controversial.In this paper,four key questions are addressed regarding the management and prevention of Flood syndrome:(1)Which is the best treatment approach–conservative treatment or urgent surgery?(2)How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients?(3)How can we prevent umbilical hernia ruptures?And(4)How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?展开更多
文摘Background: The long-term outcomes of patients with chronic pain treated in a multidisciplinary pain management center remain variable. Objective: This study aims to evaluate the changes in outcomes of patient’s self-reported pain, psychosocial status, health related quality of life and gender differences following treatment in amultidisciplinary pain management centre. Design: A prospective longitudinal cross-sectional study uses questionnaires. Treatment Setting: A pragmatic and individualized patient centered approach in a tertiary level multidisciplinary pain management center. Subjects: Patients with chronic pain referred to the centre from 2004-2010. Outcome Measures: Pain Numerical Rating Scale (NRS), Pain Temporal Description (1 - 6), Pain Self- Efficacy Questionnaire (PSEQ), Depression Anxiety Stress Scales (DASS-21) and Short Form-36 (SF- 36). Follow-up questionnaires were sent at 6 and 12 months after initial assessment. Results: Mean duration of baseline chronic pain was 8.1 years and 61% of chronic pains were involving the musculoskeletal system. At 6 and 12 month follow-ups, 273 and 180 participants had been surveyed respectively. At 6-month follow-up, there were significant improvements on pain intensity (Cohen’s d = 0.8), pain self-efficacy (Cohen’s d = 0.47), depression and stress scores (Cohen’s d = 0.16) and six out of eight domains of SF-36 (Cohen’s d = 0.2 - 0.4). At 12-month follow-up, improvements were maintained on pain intensity, self-efficacy and three out of eight domains of SF-36. There were distinctive pre- and post-treatment gender differences in these outcomes and overall females showed better short- and long-term outcomes than males. Conclusion: Multidisciplinary pain management using an individualized patient centered approach remains an effective treatment for chronic pain in both the short- (6 month) and long-term (12 month). The distinctive pre- and post-treatment gender differences particularly in the psychological outcomes, suggest that it may be beneficial to further delineate and better manage vulnerable patient subgroups.
文摘Background: Complex Regional Pain Syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a neuropathic pain condition that usually develops after an injury to an extremity. CRPS can be a debilitating condition with high levels of pain and reduced function. Aim: This case report aims to discuss the multimodal approach in the management of a patient who presented with ongoing poorly controlled pain secondary to CRPS from an injury that happened years prior. Case Presentation: A 45-year-old female was involved in a motor vehicle accident where her right leg was injured. She underwent several surgeries and developed CRPS that significantly reduced her mobility and quality of life. She presented to the pain clinic years after her initial injury and a multimodal regimen was started for her resulting in significantly improved function. Conclusion: CRPS can be a severely debilitating condition. While early diagnosis and management are important, ongoing management in the outpatient chronic pain setting is important in maintaining a good level of function.
文摘Background: Necrotizing soft tissue infections (NSTIs) are potentially life threatening medical emergencies associated with devastating and rapidly spreading destruction of soft tissues. Atypical presentations and delayed early diagnosis can be significant challenges in managing NSTIs. The infectious process can start at any part of the body with rapid progression leading to limb amputation and high mortality rate. We present a case of a patient with NSTI, the sequelae and management of the chronic pain that developed. Aim: This case report looks to shed light on the importance of a plan for management of subacute and chronic pain in treating patients who present with Necrotizing soft tissue infection. Case presentation: A 53-year-old female who presented with septicemia and was subsequently admitted and treated for NSTI in 2014 resulting in amputation of her distal foot, toe digits, and now with ongoing chronic wound of the lower extremities along with chronic pain. Conclusion: Chronic pain as part of the sequelae of Necrotizing soft tissue infections needs to be anticipated by the health care management team in order to optimize patient care post operatively.
文摘Introduction With growing concerns about the opioid crisis,the adoption of multimodal analgesia has significantly increased in clinical settings over the last 20 years.Multimodal analgesia refers to the use of various analgesic agents that act via distinct mechanisms at multiple sites along the nociceptive pathway,thereby enhancing pain management and minimizing opioid use.Opioid-sparing or opioid-free approaches can be effective for perioperative analgesia;however,their necessity and appropriateness depend on the circumstances of the individual patient.Common perioperative analgesics include opioids and non-opioid systemic analgesics,such as dexmedetomidine(DEX),ketamine,acetaminophen,non-steroidal antiinflammatory drugs,gabapentinoids,and regional or local anesthetics administered intravenously or through infiltration.
文摘With the acceleration of China's aging society,elderly patients have become a high-risk group for malignant tumors and exhibit high prevalence of pain.For a long time,the diagnosis,treatment,and management of cancer pain in elderly Chinese patients have been inadequate.This study used"Older adults,geriatric patients,cancer pain,pain assessment,pain management,elderly cancer,geriatric oncology,medication management,palliative care,interdisciplinary pain management,Analgesics,quality of life"as key words.We systematically searched PubMed,Web of Science,CNKI,and Wanfang databases from their inception to September 2024.The search primarily included phase I to III clinical trials,randomized controlled trials,meta-analyses,systematic reviews,and case reports.Elderly patients typically present with complex pain mechanisms,including both cancer-related and non-cancer pain,cognitive dysfunction,comorbidities,and polypharmacy,posing significant challenges for clinical diagnosis and treatment.Notable clinical differences exist between elderly and younger patients in the epidemiology,assessment,diagnosis,and treatment of cancer pain.Currently,the awareness of comprehensive management for elderly cancer pain patients is limited,and specific,implementable clinical guidelines are lacking.Therefore,developing a comprehensive,localized management model for elderly cancer pain patients in China—incorporating factors such as age-related impacts,organ function status,and comorbidities—has become an urgent necessity.
文摘AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including Pub Med from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources includingprevious systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques- Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level Ⅰ to level Ⅴ.RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level Ⅰ, based on a range of level Ⅰ to Ⅴ derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level Ⅱ to Ⅲ, with level Ⅱ evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement(greater than 6 mo), and level Ⅲ evidence for lumbosacral zygapophysial joint injections for short-term improvement only.CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.
文摘Objective Pectus excavatum is a congenital deformity characterized by a caved-in chest wall.Repair requires surgery.The less invasive Nuss procedure is very successful,but postoperative pain management is challenging and evolving.New pain management techniques to reduce opioid reliance include the erector spinae plane(ESP)block.We retrospectively examined opioid consumption after Nuss procedure comparing three pain management techniques:ESP block,thoracic epidural(TE),and patient-controlled analgesia(PCA).Methods This retrospective cohort study compared pain management outcomes of three patient groups.Seventy-eight subjects aged 10–18 years underwent Nuss procedure at our institution between January 2014 and January 2020.The primary outcome measure was opioid consumption measured in morphine milligram equivalents.Secondary measures included pain ratings and length of stay(LOS).Pain was quantified using the Numeric Pain Rating Scale.Analysis of variance was performed on all outcome measures.Results Average cumulative opioid use was significantly lower in the ESP block(67 mg)than the TE(117 mg)(p=0.0002)or the PCA group(172 mg)(p=0.0002).The ESP block and PCA groups both had a significantly shorter average LOS(3.3 and 3.7 days,respectively)than the TE group(4.7 days).ESP block performed best for reducing opioid consumption and LOS.Reduced opioid consumption is key for limiting side effects.This study supports use of ESP block as a superior choice when choosing among the three postoperative pain management options that were evaluated.Conclusion ESP resulted in reduced opioid consumption postoperatively and shorter LOS than TE or PCA for patients undergoing the Nuss procedure for surgical repair of pectus excavatum.
文摘Neuropathic pain is chronic pain generated by disorders of the peripheral and central nervous system, including skull base tumours. A skull base tumour can be any type of tumour that forms in the skull base, and this includes vestibular schwannomas which arise from the sheath of the inner ear vestibulocochlear nerve(eighth cranial nerve). Growth of the tumour, surgical resection, and/or stereotactic radiotherapy may result incompression and/or irritation of the fifth cranial nerve(trigeminal nerve) resulting in facial pain and/or numbness. Non-trigeminal afferent input may contribute to the wide constellation of symptoms seen in orofacial pain patients. The purpose of this report was to develop a decision tool to guide the recognition and treatment of neuropathic pain in this specialized population. Recommendations for treatment are based on evidence presented in Canadian and international neuropathic treatment guidelines. Algorithms are included for assessment and treatment of adult patients with agents that are recognized to have analgesic efficacy within the broad context of neuropathic pain.
基金supported by STI2030-Major Projects(2022ZD0204700)the National Natural Science Foundation of China(32030048,32200817,and 82271256).
文摘Neuropathic pain,a debilitating condition caused by dysfunction of the somatosensory nervous system,remains difficult to treat due to limited understanding of its molecular mechanisms.Bioinformatics analysis identified cerebellin 2(CBLN2)as highly enriched in human and murine proprioceptive and nociceptive neurons.We found that CBLN2 expression is persistently upregulated in dorsal root ganglia(DRG)following spinal nerve ligation(SNL)in mice.In addition,transcription factor SOX11 binds to 12 cis-regulatory elements within the Cbln2 promoter to enhance its transcription.SNL also induced SOX11 upregulation,with SOX11 and CBLN2 co-localized in nociceptive neurons.The siRNA-mediated knockdown of Sox11 or Cbln2 attenuated SNL-induced mechanical allodynia and thermal hyperalgesia.High-throughput sequencing of DRG following intrathecal injection of CBLN2 revealed widespread gene expression changes,including upregulation of numerous NF-κB downstream targets.Consistently,CBLN2 activated NF-κB signaling,and inhibition with pyrrolidine dithiocarbamate reduced CBLN2-induced pain hypersensitivity,proinflammatory cytokines and chemokines production,and neuronal hyperexcitability.Together,these findings identified the SOX11/CBLN2/NF-κB axis as a critical mediator of neuropathic pain and a promising target for therapeutic intervention.
基金supported by the National Natural Science Foundation of China(82305273)the Central High-Level Clinical Research Fund for Traditional Chinese Medicine Hospitals(DZMG-QNGG0010).
文摘Objective To evaluate the clinical efficacy of different acupuncture-related therapies in treating postoperative pain in patients with osteoporotic vertebral compression fractures(OVCFs)after percutaneous kyphoplasty(PKP)or percutaneous vertebroplasty(PVP)using a network meta-analysis.Methods A systematic search was conducted in PubMed,Cochrane Library,Embase,Web of Science,China National Knowledge Infrastructure,Wanfang Database,Chinese Scientific Journal Database,and Chinese Biomedical Literature Database(SinoMed)from their inception to January 15,2025.Outcome measures included the Visual Analog Scale(VAS)score,Oswestry Disability Index(ODI)score,and overall efficacy rate.Literature screening,data extraction,and risk-of-bias assessment were independently performed by two researchers.Data analysis was conducted using Stata 17.0 software.Results A total of 35 randomized controlled trials involving 2860 patients were included.The data analysis revealed that,in terms of improving VAS and ODI scores,the top three effective therapies were Fu's subcutaneous needling,wrist-ankle acupuncture,and acupotomy.For the overall efficacy rates in pain treatment,the top three therapies were wrist-ankle acupuncture,warm acupuncture and moxibustion,and Fu's subcutaneous needling.Based on the combined results across the three outcome measures,Fu's subcutaneous needling was found to be the most effective in relieving pain and improving lumbar function.Conclusion Fu's subcutaneous needling,wrist-ankle acupuncture,warm acupuncture and moxibustion,and acupotomy were all effective in treating postoperative pain post-PKP/PVP and improving lumbar function.However,further high-quality,large-sample studies are required to confirm these findings.
基金Supported by Department of AnesthesiaPain Management academic program support
文摘From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity(need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both proand anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shownimprovements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
文摘Artificial nutrition(AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition(PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel "myths" about PN-related complications and show how prevention and monitoring are able to reach the goal of "near zero" PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider:(1) an appropriate blood glucose control;(2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones;(3) the adoption of insertion and care bundles for central venous access devices; and(4) the implementation of a policy of targeting "near zero" catheter-related bloodstream infections. Adopting all these strategies, the goal of "near zero" PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.
基金supported by a grant from Department of Anesthesiology,Perioperative Medicine and Pain Management,University of Miami Miller School of Medicine,USA。
文摘Tobacco smoking is considered to be one of the main risk factors in the development of chronic pain.Long-term chronic exposure to nicotine and other forms of tobacco have been shown to be associated with an increased incidence of pain.Studies have shown that acupuncture can help smokers to reduce their desire to smoke,reduce their withdrawal symptoms,and avoid a relapse after treatment.However,little has been reported about the effects of acupuncture on pain sensitivity caused by long-term smoking.Models of hyperalgesia were established in rats exposed to nicotine for 6 weeks.After 6 weeks of continuous nicotine exposure,electroacupuncture at bilateral acupoints Zusanli(ST36)and Taichong(LR3)was performed 20 minutes per day for 6 days at a continuous wave with a frequency of 2 Hz and a stimulus intensity of 1 m A.The results revealed that electroacupuncture treatment increased the mechanical response threshold of hind paw of nicotine-dependent rats with hyperalgesia and up-regulated the protein expression of pain-related factorsμ-opioid receptor,β-endorphin and glutamic acid decarboxylase 65 in the spinal cord and midbrain periaqueductal gray and the protein expression of glutamic acid decarboxylase 67 in the spinal cord.These findings suggest that electroacupuncture treatment has positive analgesic effects on pain sensitivity caused by long-term chronic nicotine exposure.One possible mechanism for the improved analgesia is that electroacupuncture increases the expression of painrelated factors in the spinal cord and midbrain periaqueductal gray.This study was approved by Institutional Animal Care and Use Committee(IACUC)of the University of Miami(#18-167)on December 12,2018.
基金supported by grants from the Ministry of Science and Technology of China(2021ZD0203201)the National Natural Science Foundation of China(81971034,81672237)+3 种基金The Innovative Research Team of High-level Local Universities in Shanghai,Shanghai Pujiang Program(19PJ1401700)the Natural Science Foundation of Shanghai Municipality(22ZR1413800)The Program for Professor of Special Appointment(Eastern Scholar)at Shanghai Institutions of Higher Learning,Shanghai Municipal Science and Technology Major Project(2018SHZDZX01)ZJ Lab,and Shanghai Center for Brain Science and Brain-Inspired Technology,Innovation Team and Talents Cultivation Program of the National Administration of Traditional Chinese Medicine(ZYYCXTD-C-202008).
文摘Post-amputation pain causes great sufering to amputees,but still no efective drugs are available due to its elusive mechanisms.Our previous clinical studies found that surgical removal or radiofrequency treatment of the neuroma at the axotomized nerve stump efectively relieves the phantom pain aficting patients after amputation.This indicated an essential role of the residual nerve stump in the formation of chronic post-amputation pain(CPAP).However,the molecular mechanism by which the residual nerve stump or neuroma is involved and regulates CPAP is still a mystery.In this study,we found that nociceptors expressed the mechanosensitive ion channel TMEM63A and macrophages infltrated into the dorsal root ganglion(DRG)neurons worked synergistically to promote CPAP.Histology and qRT-PCR showed that TMEM63A was mainly expressed in mechanical pain-producing non-peptidergic nociceptors in the DRG,and the expression of TMEM63A increased signifcantly both in the neuroma from amputated patients and the DRG in a mouse model of tibial nerve transfer(TNT).Behavioral tests showed that the mechanical,heat,and cold sensitivity were not afected in the Tmem63a-/-mice in the naïve state,suggesting the basal pain was not afected.In the infammatory and post-amputation state,the mechanical allodynia but not the heat hyperalgesia or cold allodynia was signifcantly decreased in Tmem63a-/-mice.Further study showed that there was severe neuronal injury and macrophage infltration in the DRG,tibial nerve,residual stump,and the neuromalike structure of the TNT mouse model,Consistent with this,expression of the pro-infammatory cytokines TNFα,IL-6,and IL-1βall increased dramatically in the DRG.Interestingly,the deletion of Tmem63a signifcantly reduced the macrophage infltration in the DRG but not in the tibial nerve stump.Furthermore,the ablation of macrophages signifcantly reduced both the expression of Tmem63a and the mechanical allodynia in the TNT mouse model,indicating an interaction between nociceptors and macrophages,and that these two factors gang up together to regulate the formation of CPAP.This provides a new insight into the mechanisms underlying CPAP and potential drug targets its treatment.
文摘Introduction: Complex regional pain syndrome (CRPS) is a disorder characterized by pain as well as a myriad of sensory, autonomic, and motor disturbances. We are reporting a case of child diagnosed with CRPS and successfully treated with supraclavicular brachial plexus catheter infusion of local anesthetic. Case Report: An eight-year-old male underwent a left thoracotomy, repair of esophageal vascular ring, and translocation of the left subclavian to the left carotid artery. Post-operative course was relevant for severe intractable left shoulder and left arm pain associated with allodynia and hyperalgesia. A supraclavicular catheter was inserted, and an infusion of ropivacaine 0.2% was started. The child was sent for physical therapy as he gradually regained all functions of his left arm and resumed his regular activities. Conclusion: Continuous supraclavicular brachial plexus catheter infusion of local anesthetic is a valuable method of reducing pain in severe cases of upper extremity pediatric CRPS and may be safer and more effective than other invasive measures such as sympathetic blocks and epidural catheterization. Further research surrounding the diagnosis and treatment of pediatric CRPS is needed to allow early diagnosis and treatment and to improve outcome.
基金Supported by the Pfizer Medical Education Group in part
文摘AIM To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.METHODS Specific intervention strategies(i.e.,comfort positioning,nonnutritive sucking and sucrose analgesia,distraction) were identified,selected and introduced in three waves,using a Plan-Do-Study-Act framework.System-wide change was measured from baseline to post-intervention by:(1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and(2) caregiver satisfaction ratings following the visit.Additionally,self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts.RESULTS Significant improvements were noted post-intervention.Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received.Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50,P ≤ 0.05],as well as greater agreement that the pain prevention strategies used helped their children's pain [t(180) = 2.17,P ≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26,P ≤ 0.001] as compared to baseline.Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention.Specifically,staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47 vs 3.10; t(70) =-2.11,P ≤ 0.05],less agreement that pain from vaccinations is "just part of the process" [3.94 vs 3.23; t(70) = 2.61,P ≤ 0.05],and less agreement that parents expect their children to experience pain during vaccinations [4.81 vs 4.38; t(69) = 2.24,P ≤ 0.05].Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas,including safety,cost,time,and effectiveness,as well as less concern about the pain their children experience with vaccination [4.08 vs 3.26; t(557) = 6.38,P ≤ 0.001],less need for additional pain prevention strategies [3.33 vs 2.81; t(476) = 4.51,P ≤ 0.001],and greater agreement that their doctors' office currently offers pain prevention for vaccinations [3.40 vs 3.75; t(433) =-2.39,P ≤ 0.05].CONCLUSION Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.
基金supported by STI2030-Major Projects(2022ZD0204700)the National Natural Science Foundation of China(32030048,31700899,and 32200817)+1 种基金the Graduate Student Scientific Research Innovation Projects of Jiangsu Province(KYCX18-2397)the Startup Foundation for Doctors of the Affiliated Hospital of Nantong University(Tdb1906).
文摘The cytochrome P450 proteins(CYP450s)have been implicated in catalyzing numerous important biological reactions and contribute to a variety of diseases.CYP26A1,a member of the CYP450 family,carries out the oxidative metabolism of retinoic acid(RA),the active metabolite of vitamin A.Here we report that CYP26A1 was dramatically upregulated in the spinal cord after spinal nerve ligation(SNL).CYP26A1 was mainly expressed in spinal neurons and astrocytes.HPLC analysis displayed that the content of all-trans-RA(at-RA),the substrate of CYP26A1,was reduced in the spinal cord on day 7 after SNL.Inhibition of CYP26A1 by siRNA or inhibition of CYP26A1-mediated at-RA catabolism by talarozole relieved the SNL-induced mechanical allodynia during the maintenance phase of neuropathic pain.Talarozole also reduced SNL-induced glial activation and proinflammatory cytokine production but increased anti-inflammatory cytokine(IL-10)production.The RA receptors RARα,RXRβ,and RXRγwere expressed in spinal neurons and glial cells.The promoter of Il-10 has several binding sites for RA receptors,and at-RA directly increased Il-10 mRNA expression in vitro.Finally,intrathecal IL-10 attenuated SNL-induced neuropathic pain and reduced the activation of astrocytes and microglia.Collectively,the inhibition of CYP26A1-mediated at-RA catabolism alleviates SNL-induced neuropathic pain by promoting the expression of IL-10 and suppressing glial activation.CYP26A1 may be a potential therapeutic target for the treatment of neuropathic pain.
文摘BACKGROUND Intracranial hypotension(IH)is a disorder involving cerebrospinal fluid(CSF)hypovolemia due to spontaneous or traumatic spinal CSF leakage and is easily being misdiagnosed or missed,especially in these patients without the prototypical manifestation of an orthostatic headache.At present,the management of IH with both cranial nerve VI palsy and bilateral subdural hematomas(SDHs)is still unclear.CASE SUMMARY A 67-year-old male Chinese patient complained of diplopia on the left side for one and a half mo.Computed tomography revealed bilateral SDHs and a midline shift.However,neurotrophic drugs were not effective,and 3 d after admission,he developed a non-orthostatic headache and neck stiffness.Enhanced magnetic resonance imaging revealed dural enhancement as an additional feature,and IH was suspected.Magnetic resonance myelography was then adopted and showed CSF leakage at multiple sites in the spine,confirming the diagnosis of having IH.The patient fully recovered following multiple targeted epidural blood patch(EBP)procedures.CONCLUSION IH is a rare disease,and to the best of our knowledge,IH with diplopia as its initial and primary symptom has never been reported.In this study,we also elucidated that it could be safe and effective to treat IH patients with associated cranial nerve VI palsy and bilateral SDHs using repeated EBP therapy.
文摘Lumbar synovial cysts are benign fluid collections thought to form in a background of facet joint degeneration, allowing for fluid to leak from the joint capsule and form cysts in the synovium. Although often asymptomatic, patients with symptomatic synovial cysts will present with low back pain and possibly an associated radiculopathy. Clinicians can consider conservative management, epidural steroid injection, surgical intervention, or facet joint block with aspiration and rupture. This case describes a 59-year-old male facilities manager with intermittent low back pain for one year with worsening right-sided radicular symptoms secondary to a lumbar facet joint synovial cyst in the context of severe facet arthropathy and microinstability. The patient’s low back pain and radicular symptoms were refractory to conservative treatment. Imaging demonstrated a lumbar synovial cyst and subsequent management included transforaminal epidural steroid injection and facet joint block with cyst aspiration and rupture. The patient’s radicular pain resolved but axial lumbar pain returned after 3 weeks of relief. Follow-up imaging demonstrated decreased cyst size with fluid accumulation and joint space widening. Although the cyst was successfully decompressed with resolution of radicular pain, the underlying facet arthropathy remains contributing to persistent axial low back pain and potential for continued degenerative changes including cyst recurrence.
文摘Approximately 20%of cirrhotic patients with ascites develop umbilical herniation.These patients usually suffer from multisystemic complications of cirrhosis,have a significantly higher risk of infection,and require accurate surveillance–especially in the context of the coronavirus disease 2019 pandemic.The rupture of an umbilical hernia,is an uncommon,life-threatening complication of largevolume ascites and end-stage liver disease resulting in spontaneous paracentesis,also known as Flood syndrome.Flood syndrome remains a challenging condition for clinicians,as recommendations for its management are lacking,and the available evidence for the best treatment approach remains controversial.In this paper,four key questions are addressed regarding the management and prevention of Flood syndrome:(1)Which is the best treatment approach–conservative treatment or urgent surgery?(2)How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients?(3)How can we prevent umbilical hernia ruptures?And(4)How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?
