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The purpose of the Canadian Anesthesia Research Priority Setting Partnership (CAR PSP) was to identify a top ten list of shared priorities for research in anesthesia and perioperative care in Canada.We used the methods of the James Lind Alliance to involve patients, caregivers, healthcare professionals, and researchers in determining the research priorities in Canada. In a first survey, participants submitted questions that they want research to answer about anesthesia and perioperative care. We summarized those responses into a longlist of questions. We reviewed the literature to see if any of those questions were already answered. In a second survey, participants chose up to ten questions from the longlist that they thought were most important to be answered with research. From that list, the highest ranking questions were discussed and assigned a final rank at an in-person workshop.A total of 254 participants submitted 574 research suggestions that were then summarized into 49 questions. Those questions were checked against the literature to be sure they were not already adequately addressed, and in a second survey of those 49 questions, participants chose up to 10 that they thought were most important. A total of 233 participants submitted their priorities, which were then used to choose 24 questions for discussion at the final workshop. At the final workshop, 22 participants agreed on a top ten list of priorities.The CAR PSP top ten priorities reflect a wide variety of priorities captured by a broad spectrum of Canadians who receive and provide anesthesia care. The priorities are a tool to initiate and guide patient-oriented research in anesthesia and perioperative care.RéSUMé: OBJECTIF: L’objectif du Partenariat canadien pour l’établissement des priorités de la recherche en anesthésie (CAR-PSP) était d’établir une liste des dix principales priorités pour la recherche sur les soins anesthésiques et périopératoires au Canada. MéTHODES: Nous avons utilisé la méthodologie de la James Lind Alliance pour impliquer des patients, des aidants, des professionnels de la santé et des chercheurs afin de déterminer quelles étaient les priorités en matière de recherche au Canada. Dans une première enquête, les participants ont envoyé des questions sur les soins anesthésiques et périopératoires auxquelles ils voulaient que la recherche réponde. Nous avons résumé ces envois par une liste exhaustive de questions. Nous avons passé en revue les publications pour voir s’il existait déjà des réponses à ces questions. Dans une deuxième étude, les participants ont choisi dans la liste jusqu’à dix questions qui leur semblaient les plus importantes et pour lesquelles la recherche devrait fournir des réponses. À partir de cette liste, les questions les mieux classées ont été discutées et un classement définitif leur a été attribué au cours d’un atelier où tous les participants étaient présents en personne. RéSULTATS: Au total, 254 participants ont envoyé 574 suggestions de recherche qui ont été résumées en 49 questions. La littérature a été examinée pour s’assurer que ces questions n’avaient pas déjà reçu des réponses adéquates, et dans une seconde étude, les participants ont choisi jusqu’à 10 questions qu’ils jugeaient les plus importantes parmi ces 49 questions. Au total, 233 participants ont communiqué leurs priorités qui ont alors servi à choisir 24 questions ouvertes pour la discussion dans un atelier final. Dans cet atelier, 22 participants se sont mis d’accord sur une liste des dix principales priorités. CONCLUSION: Les dix principales priorités du CAR-PSP sont le reflet d’un grand éventail de priorités venant de Canadiens de tous horizons qui reçoivent ou fournissent des soins d’anesthésie. Ces priorités sont un outil permettant d’entamer et de guider une recherche axée sur le patient dans le domaine des soins anesthésiques et périopératoires.

Ketamine is considered a dissociative anesthetic medication, and it is commonly administered by a parenteral route. It works mainly by blocking the N-methyl-D-aspartate receptor. It inhibits the voltage-gated Na and K channels and serotonin and dopamine reuptake; also, it affects specific receptors, such as α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, kainate, and aminobutyric acid A receptors. Ketamine appears to have particular mechanisms that are potentially involved during analgesic induction, including enhancing of descending inhibition and antiinflammatory effects. More recently, it has been shown that ketamine has potential in clinical practice for the management of chronic pain, cognitive function, depression, acute brain injury, and disorders of the immune system.

Introduction:Chronic radicular pain is often treated by epidural steroid infiltration (ESI). In 2014, Food and Drug Administration (FDA) issued a letter warning that ESI may result in rare but serious adverse events, including “loss of vision, stroke, paralysis, and death”. In this retrospective study, we compare retrolaminar paravertebral infiltration (PVI) of a non-steroid-mixture with ESI.Method: We identified 31 patients registered in the Quebec Pain Registry suffering from chronic lumbar or cervical radicular pain referred to the Centre Hospitalier de l’Université de Montréal (CHUM) pain clinic between 2009 to 2014. These patients received ultrasound-guided retrolaminar PVI with a mixture of morphine 1 mg, ketamine 10 mg, neostigmine 0.5 mg, naloxone 2 ng, and bupivacaine 10 mg. The control group, matched for gender, age, and DN4 sub-scale score at baseline, consisted of 31 patients with the same pathology; they were treated by fluoroscopic-guided ESI. Principal pathologies in both groups were disc disorders and/or foraminal stenosis. All patients received only one infiltration during the six months following the initial visit. The numerical rating scale (NRS-11) was assessed at the first visit and six months later. The BPI, PCS and SF-12 were compared in both groups. Overall satisfaction in pain relief after six months was assessed with a scale of 1 (very unsatisfied) to 6 (very satisfied).Results: Average NRS-11 scores for the seven days preceding the first visit and after six months were compared in both groups. The same comparison was made for overal1 treatment satisfaction. There is no significant difference in the NRS-11 and in the satisfaction scores between the two groups.Discussion/conclusion: Neither of the two methods was shown to be superior to the other in pain relief and overall treatment satisfaction after six months. Considering the possible complications and side effects of ESI, PVI with a non-steroid mixture might be considered as an alternative method. Possibly, multiple PVIs could further decrease pain. Well-designed studies are needed to evaluate this hypothesis.

Chronic pain in patients with Alzheimer's disease or dementia is a complex issue in the medical field; these patients suffer from the common causes of chronic pain, especially in geriatric medicine. To ensure the correct type and level of given treatment, medical care should be taken to avoid the contribution of chronic pain and cognitive impairment in the elderly population. Acetylcholinesterase inhibitors (AChE-Is) have been proven as an efficient therapeutic resource for significant improvement in dementia of Alzheimer's disease and chronic pain due to the fact that cholinergic deficit is considered as an early finding in cognitive impairment and persisting pain. Some AChE-Is are investigated here in terms of treatment of dementia and chronic pain management. Neostigmine has been used as an adjunct analgesic in the postoperative period and in combination with other analgesic medications in an intrathecal approach. Rivastigmine has, over the past ten years, become the approved agent for the management of dementia of mild to moderate Alzheimer's disease and has gained approval for treating different types of non-Alzheimer's dementia. In this review, we will focus on the two types of AChE-Is (rivastigmine and neostigmine) in the development of their clinical use and their respective mechanisms of actions on improving cognitive function and managing chronic pain.

Erythropoietin (EPO) is the main regulator of red blood cell production. Since the 1990s, EPO has been used for the treatment of anemia associated with end-stage renal failure and chemotherapy. The erythropoietin receptors were found on other organs such as the brain, spinal cord, heart and skin. In addition, it has been shown that many tissues produce and locally release EPO in response to hypoxic, biochemical and physical stress. In cellular, animal and clinical studies, EPO protects tissues from ischemia and reperfusion injury, has antiapoptotic effects and improves regeneration after injury. In this article, we mainly review the nonhematopoietic effects and new possible clinical indications for EPO.

Context: Hypoventilation and apnea after epidural morphine is a serious concern after surgery and an issue in chronic pain. A low dose of naloxone added to morphine can prevent this complication. Objective: To determine that the low dose of naloxone added to epidural morphine analgesic could change the effect of this opioid in chronic low back pain. In addition, we evaluate its effect on respiratory function and patient satisfaction. Patients: Twenty-seven adults suffering from chronic low back pain (LBP) who were candidates for epidural injection treatment. Intervention: This was a randomized double-blind, uniform crossover, controlled clinical trial. The patients were treated with mixture of morphine-bupivacaine and mixture of morphine-bupivacaine-naloxone. Main outcome measure: The primary goals were to evaluate pain intensity and respiratory function after epidural injection of morphine or morphine combined with naloxone. Secondary end-points were the incidence and the side effects (pruritus, nausea, vomiting, and urinary retention) of neuraxial injection of morphine or morphine combined with naloxone for 14 days after each epidural injection. Results: There was no significant difference between morphine and morphine combined with naloxone on mean peripheral capillary oxygen saturation (SpO2m), the lowest peripheral capillary oxygen saturation (SpO2), and the respiratory disturbance index (RDI). Morphine combined with naloxone seemed to decrease pain more than morphine alone, but the result was not significant (p=0.2116). In the group that received morphine and naloxone, pain decreased sooner by half from baseline pain (at day 2 versus at day 6) than the other group. Vomiting, pruritus, and urinary retention were seen with no significant difference in both groups. Conclusion: We conclude that epidural administration of naloxone can preserve the analgesic effect of morphine in treatment of chronic LBP. Naloxone does not have any effects on respiratory function. It reduces itching, nausea, and pruritus after epidural injection of morphine. We cannot be certain whether this is the ideal dose or whether any changes in the doses might produce fewer side effects without interfering with analgesia.

Ketamine is considered a dissociative anesthetic medication, and it is a commonly administered by a parenteral route. It works mainly by blocking the N-methyl-D-aspartate (NMDA) receptor. It inhibits the voltage-gated Na_ and K_ channels and serotonin and dopamine re-uptake; also, it affects specific receptors, such as α-amino-3-hydroxy- 5-methyl-4-isoxazolepropionic acid (AMPA), kainite and amino butyric acid A receptors. Ketamine appears to have particular mechanisms that are potentially involved during analgesic induction, including enhancing of descending inhibition and anti-inflammatory effects. More recently, it has been shown that ketamine has potential in clinical practice for the management of chronic pain, cognitive function, depression, acute brain injury and disorders of the immune system.

The alpha-2 adrenergic receptor (α-2 AR) agonists have a long history of use in treating different clinical conditions, such as hypertension, psychiatric entities (e.g., attention-deficit hyperactivity disorder), chronic pain, panic disorders, and, lately, for treating opioid withdrawal syndrome. In recent years, α-2 AR medications have been administered as adjuncts for managing inflammatory conditions, depression, chronic pain, sleep and cognitive disorders. This review will provide some clinical applications in neuroscience for this class of drugs. Understanding the pharmacological mechanisms is essential to obtaining neurochemical data that demonstrate that α-2 AR agonists have potential clinical significance in neuroscience.

Introduction: New research shows shown that erythropoietin has neuro-protective effects. In preclinical trial and human clinical trials, it was demonstrated that erythropoietin is effective treatment for spinal cord injury. Early administration of medications after injury increases the hope of attenuating secondary damage and maximizing an improved outcome. Case presentation: A 42-year-old female patient presented with gait instability and progressive weakness in her right leg over a 6-year period. She was diagnosed as myelomalacia and was candidate for cervical discectomy. After surgery, she suffered from right hemiplegia due to spinal cord injury that did not respond well to routine treatment. Darbepoetin alpha (Aranesp) 100 mcg, subcutaneous daily for three days, was added to the patient’s treatment seven days after trauma and resulted in rapid improvement. The patient recovered progressively and was discharged from the hospital ten days after erythropoietin therapy. Conclusions: This case report supports the beneficial role of erythropoietin in function, maintenance, and recovery of neurons. Erythropoietin is a double-edge sword, as long-term erythropoietin therapy has some complications, like thromboembolism and stroke. Recent studies suggested that erythropoietin should be given as single high dose to exert a rapid neuro-protective effect with minimal hematopoietic side effects. We believe that the effects and other adverse consequences of erythropoietin and its non-erythropoietic derivatives should be evaluated in clinical trials.