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Introduction Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. Methods Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. Results In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). Conclusion In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.

Contains fulltext : 235055.pdf (Publisher’s version ) (Open Access) INTRODUCTION/AIMS: Oxaliplatin often causes acute or chronic peripheral neuropathy in patients with an intestinal or pancreatic tumor, but in-depth insights in its influence on quality of life (QoL) are lacking. We explored the influence of acute oxaliplatin-induced peripheral neuropathy (OIPN) on daily QoL in these patients. METHODS: We performed semistructured interviews with a purposive sample of patients receiving oxaliplatin and possibly experiencing acute OIPN. Interviews were audio-recorded, transcribed verbatim, and coded by two researchers. Data were analyzed by using the constant comparative method for content analysis with ATLAS.ti software. RESULTS: After nine patients, saturation took place. In total, 11 patients were interviewed. Four themes were extracted from the data: (1) adverse effects, (2) physical (un)well-being, (3) emotional aspects, and (4) treatment aspects. All participants were suffering from acute OIPN to a certain extent, leading to restrictions in daily activities such as household chores, but also to a decrease in mobility and independency. Other adverse effects such as general malaise and gastrointestinal side effects also influenced the participants' well-being, as did the diagnosis and prognosis of their disease. CONCLUSION: Acute OIPN, together with other side effects of chemotherapeutic treatment and the difficulties that come with the diagnosis of cancer and its prognosis, largely influences patients' daily QoL. Managing expectations (by patient education) seems important.

Contains fulltext : 225328.pdf (Publisher’s version ) (Closed access) Persistent postsurgical pain (PPSP) is a common complication of surgery that significantly affects quality of life. A better understanding of which patients are likely to develop PPSP would help to identify when perioperative and postoperative pain management may require specific attention. Quantitative sensory testing (QST) of a patient's preoperative pain perception is associated with acute postoperative pain, and acute postoperative pain is a risk factor for PPSP. The direct association between preoperative QST and PPSP has not been reviewed to date. In this systematic review, we assessed the relationship of preoperative QST to PPSP. We searched databases with components related to (1) preoperative QST; (2) association testing; and (3) PPSP. Two authors reviewed all titles and abstracts for inclusion. Inclusion criteria were as follows: (1) QST performed before surgery; (2) PPSP assessed ≥3 months postoperatively; and (3) the association between QST measures and PPSP is investigated. The search retrieved 905 articles; 24 studies with 2732 subjects met inclusion criteria. Most studies (22/24) had moderate to high risk of bias in multiple quality domains. Fourteen (58%) studies reported a significant association between preoperative QST and PPSP. Preoperative temporal summation of pain (4 studies), conditioned pain modulation (3 studies), and pressure pain threshold (3 studies) showed the most frequent association with PPSP. The strength of the association between preoperative QST and PPSP varied from weak to strong. Preoperative QST is variably associated with PPSP. Measurements related to central processing of pain may be most consistently associated with PPSP.

Objectives The aim was to explore pain characteristics in individuals with knee OA (KOA), to compare pain sensitivity across individuals with KOA, individuals with chronic back pain (CBP) and pain-free individuals (NP) and to examine the relationship between clinical characteristics and pain sensitivity and between pain characteristics and pain sensitivity in KOA. Methods We carried out a cross-sectional, community-based online survey. Two data sets were combined, consisting of Dutch individuals ≥40 years of age, who were experiencing chronic knee pain (KOA, n = 445), chronic back pain (CBP, n = 504) or no pain (NP, n = 256). Demographic and clinical characteristics, global health, physical activity/exercise and pain characteristics, including intensity, spreading, duration, quality (short-form McGill pain questionnaire) and sensitivity (pain sensitivity questionnaire), were assessed. Differences between (sub)groups were examined using analyses of variance or χ2 tests. Regression analyses were performed to examine determinants of pain sensitivity in the KOA group. Results The quality of pain was most commonly described as aching, tender and tiring–exhausting. Overall, the KOA group had higher levels of pain sensitivity compared with the NP group, but lower levels than the CBP group. Univariately, pain intensity, its variability and spreading, global health, exercise and having co-morbidities were weakly related to pain sensitivity (standardized β: 0.12–0.27). Symptom duration was not related to pain sensitivity. Older age, higher levels of continuous pain, lower levels of global health, and exercise contributed uniquely, albeit modestly, to pain sensitivity (P Conclusion Continuous pain, such as aching and tenderness, in combination with decreased physical activity might be indicative for a subgroup of individuals at risk for pain sensitivity and, ultimately, poor treatment outcomes.

Contains fulltext : 286735.pdf (Publisher’s version ) (Open Access) BACKGROUND: Though the incidence, characteristics, and pathogenesis of chemotherapy induced peripheral neuropathy (CIPN) by taxane based chemotherapy were extensively studied, diagnostic guidelines extent only recently. AIM: To observationally investigate whether specific tests can be used to predict and monitor CIPN severity. METHODS: Fourteen female breast cancer patients receiving paclitaxel or docetaxel were evaluated using the McGill Pain Questionnaire (MPQ), National Cancer Institute Common Toxicity Criteria (NCI-CTC) grading, clinical total neuropathy score (TNSc), quantitative sensory testing (QST) of pressure pain threshold (PPT), and numeric rating scale (NRS) scores and stocking and glove distribution testing (SGDT), at the start (T0), midst (T1), and end (T2) of their treatment and after 3 months (T3). RESULTS: At T3, patients scored NCI-CTC neuropathy grade 1 (14.3%), 2 (64.3%), and 3 (14.3%) respectively. Fifty percentage scored at least grade 1 at T0, with complaints not caused by CIPN. Pain, if present, was denominated "tingling" and "cold" in the MPQ. Median TNSc score increased from T0 (2.43) to T1 (4.71) to T2 (5.50) to T3 (5.57), as did pinprick and cold sensation disturbances in SGDT. PPT and associated NRS remained unchanged. TNSc and SGDT at T1 could not predict the NCI-CTC grade at T3. CONCLUSION: NCI-CTC, TNSc, and stocking and glove distribution testing can be used in the early diagnosis and monitoring of CIPN, with false-positive findings at baseline. Final NCI-CTC grades could not be predicted.

Background During the first peak of the COVID-19 pandemic in the Netherlands, relatives of patients with COVID-19 admitted to Intensive Care Units (ICUs) were severely restricted in visiting their relatives and in communicating with treating physicians. Family communication is a core element of critical care, however, this pandemic forced medical ICU staff to arrange alternative family support for instance by Family Support Teams (FSTs), consisting of non-ICU affiliated staff who telephonically contacted relatives. This study aims to examine relatives’ experiences with FSTs on two ICUs of a Dutch university medical centre, and to evaluate its working strategies. . Methods In a semi-structured interview study, relatives of patients with COVID-19 admitted to ICU’s, who had been supported by the FSTs, were sampled purposively. Twenty-one interviews were conducted telephonically by three researchers. All interviews were topic list guided and audio-recorded. Data was analysed thematically. Results All participants indicated they went through a rough time. Almost all evaluated the FSTs positively. Four major themes were identified. First, three important pillars of the FSTs were providing relatives with transparency about the patients’ situation, providing attention to relatives’ well-being, and providing predictability and certainty by calling on a daily basis in a period characterised by insecurity. Second, relatives appeared to fulfil their information needs by calls of the FSTs, but also by calling the attending ICU nurse. Information provided by the FSTs was associated with details and reliability, information provided by nurses was associated with the patient’s daily care. Third, being a primary family contact was generally experienced as both valuable and as an emotional burden. Last, participants missed proper aftercare. Family support often stopped directly after the patient died or had left the ICU. Relatives expressed a need for extended support after that moment since they had strong emotions after discharge or death of the patient. Conclusions Family support in times of the extreme COVID-19 situation is important, as relatives are restricted in communication and have a strong need for information and support. Relatives feel encouraged by structure, frequency, support and understanding by FSTs. However, remote family support should be tailored to the needs of relatives. A fixed contact person on de ICU and video calling might be good extra options for family support, also in future post COVID-19 care, but cannot replace physical visits.

Contains fulltext : 203051.pdf (Publisher’s version ) (Open Access) OBJECTIVES: Oxaliplatin-induced neurotoxicity can be a dose-limiting side effect to effective chemotherapy. Acute hyperexcitability causes cold-evoked sensory and motor symptoms, which resemble neuromyotonia. An accessible and non-invasive technique for early detection could help select patients for potential treatments. We assessed the use of a simple surface electromyography (sEMG) in patients directly after oxaliplatin infusion. METHODS: In patients with colorectal cancer, acute neurotoxicity was evaluated by means of a physical examination, a questionnaire, and sEMG directly after the second and fourth cycle of oxaliplatin. Questionnaires were also assessed 1 day after infusion. RESULTS: 14 patients were measured after the second cycle and 8 patients were also measured after the fourth cycle of oxaliplatin. All patients reported to a variable degree oxaliplatin induced neurotoxicity symptoms: sensitivity to touching cold or swallowing cold items were reported as most severe. Clinical signs of hyperexcitability were observed in 55% of the measurements. Spontaneous activity compatible with neuromyotonia was observed in 82% of the sEMG recordings. CONCLUSIONS: Patient reported symptoms, physical examination and simple sEMG are complementary measurements to detect acute oxaliplatin induced neurotoxicity. After further validation, sEMG recording can be used as a simple objective screenings tool to detect nerve hyperexcitability directly after oxaliplatin administration.

Background Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered. Methods We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease. Results In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics. Conclusions Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient.

Contains fulltext : 238058.pdf (Publisher’s version ) (Closed access) Patients with a limited life expectancy have an increased risk of thromboembolic and bleeding complications. Anticoagulants are often continued until death, independent of their original indication. We aimed to identify the opinions of physicians about the use of anticoagulants at the end of life. A mixed-method research design was used. A secondary analysis was performed on data from a vignette study and an interview study. Participants included general practitioners and clinical specialists. Physicians varied in their opinions: some would continue and others would stop anticoagulants at the end of life because of the risk of thromboembolic or bleeding complications. The improvement or preservation of patients' quality of life was a reason for both stopping and continuing anticoagulants. Other factors considered in the decision-making were the types of anticoagulant, the indication for which the anticoagulant was prescribed, underlying diseases, and the condition and life expectancy of the patient. Factors that made decision-making difficult were the lack of evidence on either strategy, uncertainty about patients' life expectancy, and the fear of harming patients. Which decision was eventually made seems largely dependent on the choice of the patient. In conclusion, there is a substantial variation in physicians' opinions regarding the use of anticoagulants in patients with a limited life expectancy. Physicians agree that the primary goal of medical care at end of life is the improvement or preservation of patients' quality of life. An important barrier to decision-making is the lack of evidence about the risks and benefits of stopping anticoagulants.

Contains fulltext : 231669.pdf (Publisher’s version ) (Open Access) INTRODUCTION: When neither pharmacological therapies nor alternative interventions provide sufficient pain relief, spinal cord stimulation (SCS) can be used to treat Failed Back Surgery Syndrome (FBSS). Although it seems reasonable that quality of life (QoL)- and psychosocial-related factors contribute to the outcome of SCS since pain is a multidimensional experience, few qualitative studies have explored the expectations of SCS and experiences on SCS to treat FBSS from the patient perspective. OBJECTIVES: The aim of this study was to qualitatively and quantitatively map the FBSS patients' experiences with SCS and the effects of SCS on low back pain caused by FBSS. MATERIALS AND METHODS: A qualitative study with in-depth semi-structured interviews, assisted by the Brief Pain Inventory (BPI)-questionnaire. RESULTS: Seven themes regarding patients' experiences, subdivided into 15 categories, were identified, including an understudied theme within this field of research, Spiritual Well-Being. "Acceptance" and "coping" emerged as pre-eminent motifs throughout these themes. Moreover, the realization of patients' expectations were variable throughout the presented themes. According to the BPI Questionnaire, four out of 13 patients (31%) had significant pain relief (≥50%). Seven out of 13 (54%) reported a ≥50% increase regarding enjoyment of life. CONCLUSION: Multiple QoL- and psychosocial-related themes are related to SCS-outcomes. In order to improve SCS-outcomes for both short- and long-term, these themes should be implemented as a multidimensional approach, both prior to implantation as during follow-up.

Background Oxaliplatin is a chemotherapeutic agent used to treat malignancies of the gastrointestinal tract. Neuropathy is a frequent dose-limiting side-effect of oxaliplatin therapy, without preventive or curative strategies. Concomitant administration of intravenous lidocaine could be a promising treatment. However, the effect of intravenous lidocaine on oxaliplatin pharmacokinetics was never studied before. We evaluated the effect of lidocaine on the area under the curve and Cmax of oxaliplatin as a part of a larger study addressing the prevention and treatment of oxaliplatin induced peripheral neuropathy with lidocaine. Methods In this prospective cross-over trial, patients received an oxaliplatin cycle with and without lidocaine (bolus 1.5 mg kg−1 followed by 1.5 mg kg−1 h−1 in 3 h). Levels of oxaliplatin, measured as ultrafiltrable platinum were determined at 10 min after cessation of oxaliplatin infusion and hourly thereafter. Outcomes are the difference in area under the curve of oxaliplatin (primary) and the difference in the Cmax of oxaliplatin (secondary). Results No difference in the %Δ area under the curve of oxaliplatin (–2.40 ± 7.66, 90% CI +10.50 to –15.31) was found. However, %Δ Cmax of oxaliplatin (–28.72 ± 6.01, 90% CI –18.59 to –38.85) was lower to a statistically significant extent in the chemotherapy cycle with lidocaine. No (serious) adverse events were reported. Conclusions Lidocaine does not affect the area under the curve of oxaliplatin, which is the most important parameter in drug interaction studies and for oxaliplatin treatment effect. The lower Cmax in the chemotherapeutic cycle with lidocaine is significant and remarkable, but with an unknown exact mechanism or clinical significance, making further research desirable.

Contains fulltext : 221711.pdf (Publisher’s version ) (Closed access) Our research group recently published a positive association between early postoperative pain and 30-day postoperative complications in a broad surgical population. To investigate whether heterogeneity of the population and surgical procedures influenced these results, we explored this association in a homogenous surgical population. A secondary analysis of the LEOPARD-2 (clinicaltrials.gov NCT02146417) and RELAX-1 study (NCT02838134) in laparoscopic donor nephrectomy patients (n = 160) was performed. Pain scores on the postanesthesia care unit and postoperative day (POD) 1 and 2 were compared between patients with infectious, noninfectious, and no complications 30 days after surgery. Patients who developed infectious complications had significantly higher pain scores on POD1 and 2 (6.7 ± 2.1 and 6.4 ± 2.8) than patients without complications (4.9 ± 2.2 and 4.1 ± 1.9), respectively (P = 0.006 and P = 0.000). Unacceptable pain (numeric rating scale [NRS] ≥ 6) on POD1 was reported by 72% of patients who developed infectious complications, compared to 38% with noninfectious complications and 30% without complications (P = 0.018). This difference was still present on POD2 at 67% with infectious complications, 21% with noninfectious, and 40% without complications (P = 0.000). Multiple regression analysis identified unacceptable pain (numeric rating scale ≥6) on POD2 as a significant predictor for 30-day infectious complications (odds ratio 6.09, P = 0.001). Results confirm the association between early postoperative pain and 30-day infectious complications in a separate, homogenous surgical population. Further clinical trials should focus on finetuning of postoperative analgesia to elucidate the effects on the endocrine and immune response, preserve immune homeostasis, and prevent postoperative infectious complications.

Objectives: ENT surgeons and anesthesiologists work closely together in managing challenging airway cases. Sharing knowledge, experiences, and expectations interdisciplinary is essential in order to facilitate decision-making and adequate management in emergency front-of-neck airway cases.Methods: A survey was performed, to analyze level of experience, technique of preference, training, knowledge of material and protocols, and self-efficacy scores of Dutch ENT surgeons and residents in performing an urgent or emergency front-of-neck airway.Results: Within one year (January 2014-2015), 25.7% of the 257 respondents had performed an urgent or emergency front-of-neck airway. Of all reported emergency front-of-neck airways (N = 30), 80% were managed by tracheotomy. In future emergency front-of-neck airway cases, 74% stated cricothyrotomy would be their technique of preference. The majority would choose an uncuffed large-bore cannula technique. Post-academic hands-on training was attended by 42% of respondents. Self-efficacy scores were highest for surgical tracheotomy, and higher when trained or experienced. In case of an emergency scenario, 8.6% would not perform a front-of-neck airway themselves. The main reasons for reluctance to start in general were lack of experience and lack of training. Reported items for improvement were mainly the development of a protocol and training.Conclusion: The chance of encountering an airway emergency scenario requiring front-of-neck airway is realistic. There is inconsistency between advised technique, technique of preference and technique actually performed by ENT surgeons. This study shows that there is both a need and desire for improvement in training and organization of care. Interdisciplinary guidelines and education is needed and could eventually safe lives.Level of evidence: 5.

Hans Timmerman,1 Oliver HG Wilder-Smith,1,2 Monique AH Steegers,3 Kris CP Vissers,3 André P Wolff4 1Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; 2Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark; 3Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; 4Department of Anesthesiology, Pain Center, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands Background: The assessment of a neuropathic pain component (NePC) to establish the neurological criteria required to comply with the clinical description is based on history taking, clinical examination, and quantitative sensory testing (QST) and includes bedside examination (BSE). The objective of this study was to assess the potential association between the clinically diagnosed presence or absence of an NePC, BSE, and the Nijmegen–Aalborg screening QST (NASQ) paradigm in patients with chronic (≥3 months) low back and leg pain or with neck shoulder arm pain or in patients with chronic pain due to suspected peripheral nerve damage.Methods: A total of 291 patients participated in the study. Pain (absence or presence of neuropathic pain) was assessed independently by two physicians and compared with BSE (measurements of touch [finger, brush], heat, cold, pricking [safety pin, von Frey hair], and vibration). The NASQ paradigm (pressure algometry, electrical pain thresholds, and conditioned pain modulation) was assessed in 58 patients to generate new insights.Results: BSE revealed a low association of differences between patients with either absent or present NePC: heat, cold, and pricking sensations with a von Frey hair were statistically significantly less common in patients with present NePC. NASQ did not reveal any differences between patients with and without an NePC.Conclusion: Currently, a standardized BSE appears to be more useful than the NASQ paradigm when distinguishing between patients with and without an NePC. Keywords: quantitative sensory testing, NASQ, Nijmegen–Aalborg screening QST, clinical assessment, diagnostic accuracy

Background: Chronic abdominal pain is occasionally due to entrapped intercostal nerve endings (ACNES, abdominal cutaneous nerve entrapment syndrome). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a neurectomy may be considered. Pulsed radiofrequency (PRF) is a relatively new treatment option for various chronic pain syndromes. Evidence regarding a beneficial effect of this minimally invasive technique in ACNES is lacking. The aim was to assess the effectiveness of PRF treatment in ACNES patients. Methods: A series of ACNES patients undergoing PRF treatment between January 2014 and December 2015 in two hospitals were retrospectively evaluated. Pain was recorded prior to treatment and after 6 weeks using a numerical rating scale (NRS, 0 (no pain) to 10 (worst possible pain)). Successful treatment was defined as > 50% NRS pain reduction. Patient satisfaction was scored by patient global impression of change (PGIC, 1 = very much worse, to 7 = very much improved). Results: Twenty-six patients were studied (17 women, median age 47 years, range 18 - 67 years). After 6 weeks, mean NRS score had dropped from 6.7 ± 1.2 to 3.8 ± 2.3 (P < 0.001). A mean 4.9 ± 1.4 PGIC score was reported by then. Short term treatment success (6 - 8 weeks) was 50% (n = 13, 95% CI: 29 - 71), while 8% was pain-free on the longer term (median 15 months). Median effect duration was 4 months (range 2 - 26). Conclusions: PRF is temporarily effective in half of patients with ACNES. PRF is safe and may be favored in neuropathic pain syndromes as nerve tissue destruction is possibly limited. A randomized controlled trial determining the potential additional role of PRF in the treatment strategy for ACNES is underway. J Clin Med Res. 2018;10(6):508-515 doi: https://doi.org/10.14740/jocmr3354w

Background Spinal cord stimulation (SCS) is an effective therapy to reduce pain in patients that suffer from failed back surgery syndrome (FBSS). In order to inform patients optimally prior to this therapy, knowing their expectations is crucial. Methods Thirteen patients suffering from FBSS and scheduled for SCS were interviewed, using a semi-structured protocol. Patients were interviewed either at home or at their treating hospital. Data from these interviews were analyzed using directed content analysis. In addition to the qualitative interviews, an adjusted Brief Pain Inventory (BPI-) questionnaire was used to quantify expectations. Results The expectations of patients with regard to SCS could be subdivided into 13 categories, which could be grouped into six general themes: 1) physical well-being, 2) social well-being, 3) material well-being, 4) emotional well-being, 5) development and activity and 6) constraints of the procedure of SCS. These findings confirm patients’ expectations about the improvement of their quality of life by SCS for FBSS. This indicates that assessing pain relief is not enough to adequately evaluate the effects of SCS. The small diversity within the studied population and the lack of patient-to-patient education are two possible limitations of this study. Conclusions To improve education for patients prior to SCS surgery and to evaluate the effects of SCS, a multidimensional approach needs to be implemented. Possible disadvantages of SCS need to be discussed prior to the treatment. This article is protected by copyright. All rights reserved.

Background Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES. Methods Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. Discussion Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. Trial registration Nederlands Trial Register (Dutch Trial Register), NTR5131 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131). Registered on 15 April 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2110-5) contains supplementary material, which is available to authorized users.

Sandra AS van den Heuvel,1 Selina EI van der Wal,1 Ewald M Bronkhorst,2 Michiel C Warlé,3 May Ronday,4 Judith Plat,4 Nens van Alfen,5 Leo AB Joosten,6 Jos GC Lerou,1 Kris CP Vissers,1 Monique AH Steegers7 1Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; 2Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands; 3Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands; 4Department of Anesthesiology, Alexander Monro Breast Cancer Hospital, Bilthoven, the Netherlands; 5Donders Institute for Brain Cognition and Behavior, Department of Neurology, Radboud University Medical Centre, Nijmegen, the Netherlands; 6Department of Internal Medicine and Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, the Netherlands; 7Department of Anesthesiology, Pain and Palliative Medicine, Amsterdam University Medical Centre, Amsterdam, the NetherlandsCorrespondence: Sandra AS van den HeuvelDepartment of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Internal mail 630, P.O. Box 9101, Nijmegen 6525 GA, the NetherlandsTel +31 243615244Email Sandra.vandenHeuvel@radboudumc.nlPurpose: An imbalance in perioperative cytokine response may cause acute pain and postoperative complications. Anesthetic drugs modulate this cytokine response, but their role in non-major breast cancer surgery is unclear. In an exploratory study, we investigated whether intravenous lidocaine and dexamethasone could modulate the cytokine response into an anti-inflammatory direction. We also evaluated interrelationships between cytokine levels, pain scores and postoperative complications. Our goal is to develop multimodal analgesia regimens optimizing outcome after breast cancer surgery.Patients and Methods: Forty-eight patients undergoing a lumpectomy were randomly assigned to placebo or lidocaine (1.5 mg⋅kg− 1 followed by 2 mg⋅kg− 1⋅hour− 1) supplemented by dexamethasone zero, 4 or 8 mg, yielding six groups of eight patients. Interleukin (IL)-1β, IL-1Ra, IL-6, IL-10 levels and pain scores were measured at baseline and four hours postoperatively. We assessed postoperative complications occurring within 30 days. We noted persistent pain and infections as potential immune-related complications (PIRC). We used multiple regression to disentangle the effects of the individual study drugs (given by their partial regression coefficients (b)). Odds ratios (OR) estimated the link between pain scores and complications.Results: Dexamethasone 8 mg increased IL-10 (b=12.70 (95% CI=8.06– 17.34), P< 0.001). Dexamethasone 4 mg and 8 mg decreased the ratio IL-6/IL-10 (b=− 2.60 (− 3.93 to − 1.26), P< 0.001 and b=− 3.59 (− 5.04 to − 2.13), P< 0.001, respectively). We could not show modulatory effects of lidocaine on cytokines. High pain scores were linked to the occurrence of PIRC’s (OR=2.028 (1.134– 3.628), P=0.017). Cytokine levels were not related either to acute pain or PIRC.Conclusion: Dexamethasone modulated the perioperative cytokine response into an anti-inflammatory direction. An overall lidocaine effect was not found. Patients with higher pain scores suffered from more 30-day PIRCs. Cytokine levels were not associated with pain or more postoperative complications, even not with PIRC. Larger studies in breast cancer surgery are needed to confirm these explorative results.Keywords: acute pain, anesthetic agents, immune response, lumpectomy, perioperative outcomes

An increased sensitivity to painful stimuli has been proposed to be related to the development of chronic pain. Therefore, assessment of individual pain sensitivity is useful in clinical practice. However, experimental pain testing may be uncomfortable for patients and requires specific equipment. The Pain Sensitivity Questionnaire (PSQ) has been developed to facilitate assessment of pain sensitivity. In this study, we aimed to translate and cross-culturally adapt the PSQ from its published German and English versions into the Dutch language and to assess validity of the PSQ in healthy volunteers. After translation and cross-cultural adaptation of the PSQ following international guidelines, we validated the PSQ in 394 healthy volunteers by comparing the PSQ-values with two different experimental pain tests: electrical pain tolerance (EPT) and pressure pain threshold (PPT). In addition, ratings of pain intensity during these tests were obtained on the numerical rating scale (NRS, 0–10). We found that the reliability of the PSQ based on internal consistency was good (Cronbach’s alpha 0.90). PSQ-scores, adjusted for age and sex, were statistically significant and weakly inversely correlated to EPT (PSQ-moderate: rho = −0.24, p=0.007; PSQ-total: rho = −0.22, p=0.016). No statistically significant correlation between PSQ-scores and PPT was found. Concerning the pain scores, PSQ-scores were weakly to moderately correlated to EPT-NRS (PSQ-minor: rho = 0.21, p=0.021; PSQ-moderate: rho = 0.22, p=0.016; PSQ-total: rho = 0.23, p=0.009) as well as PPT-NRS (PSQ-minor: rho = 0.32, p<0.001; PSQ-moderate: rho = 0.36, p<0.001; PSQ-total: rho = 0.37, p<0.001). Therefore, we concluded that the Dutch version of the PSQ is culturally appropriate for assessing self-reported pain sensitivity in healthy volunteers.

CASE DESCRIPTION: A frail 85-year-old woman with chronic neuropathic pain after hip surgery, not responding to treatment with acetaminophen and morphine patches. Should she be prescribed a gabapentinoid? DISCUSSION: Gabapentinoids and antidepressants are considered first-line therapies. They achieve clinically relevant (i.e. >/= 50%) pain reduction in approximately one-third of patients with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is limited. Adverse events occur frequently and are mostly mild in nature; serious adverse effects are rare. Prescription of gabapentinoids in specific patient groups (e.g. elderly patients and patients with a history of depression or substance abuse) deserves careful consideration, because the risk/benefit ratio in those groups may be altered. In order to reduce the risk of withdrawal symptoms, slow tapering is recommended. CONCLUSION: Chronic neuropathic pain often has a negative impact on the quality of life and is difficult to treat. In general, treatment with a gabapentinoid is a possible first-line treatment option. However, they may be relatively contraindicated in vulnerable patients.

Background. Treatment of intractable pain due to chemotherapy induced peripheral neuropathy (CIPN) is a challenge. Intravenous (iv) lidocaine has shown to be a treatment option for neuropathic pain of different etiologies. Methods. Lidocaine (1.5 mg/kg in 10 minutes followed by 1.5 mg/kg/h over 5 hours) was administered in nine patients with CIPN, and analgesic effect was evaluated during infusion and after discharge. The immediate effect of lidocaine on pressure pain thresholds (PPT) and the extent of the stocking and glove distribution of sensory abnormalities (cold and pinprick) were assessed. Results. Lidocaine had a significant direct analgesic effect in 8 out of 9 patients (P=0.01) with a pain intensity difference of >30%. Pain reduction persisted in 5 patients for an average of 23 days. Lidocaine did not influence mean PPT, but there was a tendency that the extent of sensory abnormalities decreased after lidocaine. Conclusion. Iv lidocaine has direct analgesic effect in CIPN with a moderate long-term effect and seems to influence the area of cold and pinprick perception. Additional research is needed, using a control group and larger sample sizes to confirm these results.

OBJECTIVE: The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications.BACKGROUND: Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population.METHODS: Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting.RESULTS: In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery.CONCLUSIONS: Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.

Item does not contain fulltext BACKGROUND: Chronic abdominal pain can be due to entrapped intercostal nerves (anterior cutaneous nerve entrapment syndrome [ACNES]). If abdominal wall infiltration using an anesthetic agent is unsuccessful, a neurectomy may be considered. Pulsed radiofrequency (PRF) applies an electric field around the tip of the cannula near the affected nerve to induce pain relief. Only limited retrospective evidence suggests that PRF is effective in ACNES. METHODS: A multicenter, randomized, nonblinded, controlled proof-of-concept trial was performed in 66 patients. All patients were scheduled for a neurectomy procedure. Thirty-three patients were randomized to first receive a 6-minute cycle of PRF treatment, while the other 33 were allocated to an immediate neurectomy procedure. Pain was recorded using a numeric rating scale (NRS, 0 [no pain] to 10 [worst pain possible]). Successful treatment was defined as >50% pain reduction. Patients in the PRF group were allowed to cross over to a neurectomy after 8 weeks. RESULTS: The neurectomy group showed greater pain reduction at 8-week follow-up (mean change from baseline -2.8 (95% confidence interval [CI] -3.9 to -1.7) vs. -1.5 (95% CI -2.3 to -0.6); P = 0.045) than the PRF group. Treatment success was reached in 12 of 32 (38%, 95% CI 23 to 55) of the PRF group and 17 of 28 (61%, 95% CI 42 to 72) of the neurectomy group (P = 0.073). Thirteen patients were withdrawn from their scheduled surgery. Adverse events were comparable between treatments. CONCLUSIONS: PRF appears to be an effective and minimally invasive treatment option and may therefore be considered in patients who failed conservative treatment options before proceeding to a neurectomy procedure. Anterior neurectomy may possibly lead to a greater pain relief compared with PRF in patients with ACNES, but potential complications associated with surgery should be discussed.

Chronic postsurgical pain (CPSP) following laparoscopic donor nephrectomy (LDN) is a disregarded topic. In this cross‐sectional study, all consecutive patients who underwent an LDN at the Radboud University Medical Center (Radboudumc; 2003‐2016) were approached for participation. Five hundred twelve living kidney donors were included and asked to complete two questionnaires, including the McGill Pain Questionnaire and the RAND Short Form‐36 Health Status Inventory (RAND SF‐36) regarding their health‐related quality of life (HRQoL). The mean prevalence of CPSP following LDN was 5.7%, with a mean follow‐up time of 6 years. Possible predictors of CPSP following LDN are severe early postoperative pain, previous abdominal surgery, and preexisting backache. The RAND SF‐36 revealed an impaired HRQoL in patients with CPSP when compared to patients without CPSP. In conclusion, this study revealed that the prevalence of CPSP following LDN is substantial. Given the possible association between the presence of CPSP and impaired HRQoL scores, living kidney donors should be well informed in the preoperative phase about the risk of CPSP., A cross‐sectional study of 512 patients who underwent laparoscopic donor nephrectomy shows a prevalence of chronic postsurgical pain of 5.7%, associated with an impaired quality of life.

Fleur Meijer,1 Petra Cornelissen,2 Corina Sie,3 Michel Wagemans,4 Anja Mars,5 Tiny Hobma,1,6 Marieke Niesters,1 Albert Dahan,1 J Seppe Koopman,6 Monique AH Steegers2 1Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands; 2Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands; 3Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, the Netherlands; 4Department of Anesthesiology and Pain Medicine, Reinier de Graaf Hospital, Delft, the Netherlands; 5Department of Anesthesiology and Acute Pain Service, Alrijne Hospital, Leiderdorp, the Netherlands; 6Department of Anesthesiology, Maasstad Hospital, Rotterdam, the Netherlands Background: The sublingual sufentanil tablet system (SSTS) is a novel hand-held patient-controlled analgesia device developed for treatment of moderate-to-severe postoperative pain. Here we present the first results of its clinical use. Methods: Adult patients undergoing major surgery in five hospitals in the Netherlands received the SSTS for postoperative pain relief as part of multimodal pain management that further included paracetamol and a nonsteroidal anti-inflammatory drug (NSAID). The following variables were collected: postoperative pain scores using the 11-point numerical rating score (NRS) at rest, number of tablets used, occurrence of nausea, and patient satisfaction scores. Results: We included 280 patients in the study; the majority underwent laparoscopic abdominal (49%) or orthopedic (knee replacement) surgery (34%). The median NRS was 3.5 (interquartile range 2.3–4.0) on the day of surgery, 3.3 (2.3–4.0) on the first postoperative day, and 2.8 (2.0–4.0) on the second postoperative day; pain scores did not differ between surgery types. Mean number of tablets used was 19 (range 0–86). Nausea occurred in 34% of patients, more often in women (45% vs 19%). Overall satisfaction was high in 73% of patients. Satisfaction was correlated with pain relief (p

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Background Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system and is a major therapeutic challenge. Several screening tools have been developed to help physicians detect patients with neuropathic pain. These have typically been validated in populations pre-stratified for neuropathic pain, leading to a so called “Catch-22 situation:” “a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule”. The validity of screening tools needs to be proven in patients with pain who were not pre-stratified on basis of the target outcome: neuropathic pain or non-neuropathic pain. This study aims to assess the validity of the Dutch PainDETECT (PainDETECT-Dlv) in a large population of patients with chronic pain. Methods A cross-sectional multicentre design was used to assess PainDETECT-Dlv validity. Included where patients with low back pain radiating into the leg(s), patients with neck-shoulder-arm pain and patients with pain due to a suspected peripheral nerve damage. Patients’ pain was classified as having a neuropathic pain component (yes/no) by two experienced physicians (“gold standard”). Physician opinion based on the Grading System was a secondary comparison. Results In total, 291 patients were included. Primary analysis was done on patients where both physicians agreed upon the pain classification (n = 228). Compared to the physician’s classification, PainDETECT-Dlv had a sensitivity of 80% and specificity of 55%, versus the Grading System it achieved 74 and 46%. Conclusion Despite its internal consistency and test-retest reliability the PainDETECT-Dlv is not an effective screening tool for a neuropathic pain component in a population of patients with chronic pain because of its moderate sensitivity and low specificity. Moreover, the indiscriminate use of the PainDETECT-Dlv as a surrogate for clinical assessment should be avoided in daily clinical practice as well as in (clinical-) research. Catch-22 situations in the validation of screening tools can be prevented by not pre-stratifying the patients on basis of the target outcome before inclusion in a validation study for screening instruments. Trial registration The protocol was registered prospectively in the Dutch National Trial Register: NTR 3030. Electronic supplementary material The online version of this article (10.1186/s12883-018-1094-4) contains supplementary material, which is available to authorized users.

Introduction The neuroinflammatory response plays a key role in several pain syndromes. Intravenous (iv) lidocaine is beneficial in acute and chronic pain. This review delineates the current literature concerning in vitro mechanisms and in vivo efficacy of iv lidocaine on the neuroinflammatory response in acute and chronic pain. Databases and data treatment We searched PUBMED and the Cochrane Library for in vitro and in vivo studies from July 1975 to August 2014. In vitro articles providing an explanation for the mechanisms of action of lidocaine on the neuroinflammatory response in pain were included. Animal or clinical studies were included concerning iv lidocaine for acute or chronic pain or during inflammation. Results Eighty-eight articles regarding iv lidocaine were included: 36 in vitro studies evaluating the effect on ion channels and receptors; 31 animal studies concerning acute and chronic pain and inflammatory models; 21 clinical studies concerning acute and chronic pain. Low-dose lidocaine inhibits in vitro voltage-gated sodium channels, the glycinergic system, some potassium channels and Gαq-coupled protein receptors. Higher lidocaine concentrations block potassium and calcium channels, and NMDA receptors. Animal studies demonstrate lidocaine to have analgesic effects in acute and neuropathic pain syndromes and anti-inflammatory effects early in the inflammatory response. Clinical studies demonstrate lidocaine to have advantage in abdominal surgery and in some neuropathic pain syndromes. Conclusions Intravenous lidocaine has analgesic, anti-inflammatory and antihyperalgesic properties mediated by an inhibitory effect on ion channels and receptors. It attenuates the neuroinflammatory response in perioperative pain and chronic neuropathic pain.

Chronic intractable shoulder pain (CISP) is defined as shoulder pain which is present for longer than 6 months and does not respond to standard treatments like medication, physical therapy, rehabilitation, selective nerve blocks and local infiltrations, or orthopedic procedures. The etiology of CISP may be very diverse, varying from many orthopedic conditions to non-orthopedic conditions. The fact that the suprascapular nerve is one of the most important nerves supplying the shoulder region makes this nerve an interesting target in treating patients suffering shoulder pain. Invasive treatment options are peripheral nerve blocks, temporary electrical stimulation, and neurostimulation. To our best knowledge, thus far there are only a few reports describing the technique of permanent neurostimulation of the suprascapular nerve. In this article we present a patient suffering shoulder pain after she underwent surgery for cervical stenosis. After a step by step treatment protocol was done, we finally offered her trial stimulation of the suprascapular nerve. A single quad lead was implanted via a posterior approach under fluoroscopic and ultrasound guidance. Two weeks after successful stimulation, we implanted a permanent neuromodulation system. Permanent neurostimulation of the suprascapular nerve and its end branches may be a new interesting target in treating patients suffering shoulder pain due to various etiologies. In our patient the followup period is 9 months with an excellent result in pain relief, we observed no complications thus far, especially no dislocation or breakage of the lead. In this report, literature on this subject is reviewed, and our technique is well documented with additional anatomical illustrations. Key words: Suprascapular nerve, shoulder pain, peripheral nerve stimulation, neuromodulation, neurostimulation, chronic pain

Background: Measuring pain is important for the adequate pain management of postoperative patients. The actual compliance with pain assessment in postoperative patients after implementation of a national safety program is unknown.Objectives: The aim of this study is to examine the compliance with pain assessment in postoperative patients after implementation of a national safety program, according to the national quality indicators for pain assessment in postoperative patients. Furthermore, organisational factors associated with this compliance were determined.Study design: In this study, two data sources were used: 1) data from an evaluation study of the Dutch Hospital Patient Safety Program; and 2) data from a questionnaire survey.Methods: The compliance with two different pain process indicators was determined: 1) 3 pain measurements a day, all three full days after surgery; and 2) >= 1 pain measurement a day, all three full days after surgery. Multilevel logistic regression analysis was used to investigate the association between organisational factors in hospitals and compliance with pain process indicators.Results: Data of 3895 patient records from 16 hospitals was included in this study. In 12% of the postoperative patients, pain was measured 3 times a day, all three full days after surgery. In 53% of the postoperative patients, pain was measured >= 1 time a day, all three full days after surgery. Compliance was highest in general hospitals compared to tertiary teaching and academic hospitals, and was statistically significantly higher at the surgery and surgical oncology department compared to the other departments.Conclusions: Low compliance was shown with pain assessment in postoperative patients, according to the process indicator pain after surgery in Dutch hospitals. This suggests that the implementation of measuring pain in hospitals is still insufficient. (C) 2016 Elsevier Ltd. All rights reserved.

Background: Mechanical ventilation (hit one) during surgery (hit two) is often needed and both induce an inflammatory response. Dysregulation of the inflammatory response can cause chronic postoperative pain. Methods: Healthy C57BL6 mice (n = 56) were mechanically ventilated (MV) and allocated to receive sham (MV-sham) or mechanically ventilation with chronic constriction injury (MV-CCI) surgery in the left hind paw. Plasma interleukin (IL)-1β, IL-6, IL-10, keratinocyte derived chemokine (KC) and tumor necrosis factor (TNF)-α were determined on day 0 and 16. Sensory testing was performed on day 0, 3, 7 and 16 by cold plate test (number of lifts (NOL) and cumulative reaction time (CRT)) and von Frey test. The effect of lidocaine on cytokines and sensory testing was analyzed. Results: MV-Sham showed an increase in IL-1β and TNF-α, and MV- CCI-lido increased levels of KC compared with MV on day 0. No difference in cytokine levels was observed on day 16. NOL of the left paw versus the right was increased in MV-CCI on day 7, and in MV-CCI-lido on day 7 and 16. The NOL of the left paw was decreased in MV-sham and MV-CCI-lido compared with MV-CCI on day 16. The CRT of the left paw was increased for MV-CCI on day 3 and 7, and for MV-CCI-lido on day 7. On day 16, MV-sham and MV-CCI-lido showed a decreased CRT of the left paw compared with MV-CCI. Conclusion: Nerve injury and not systemic inflammatory response seems mandatory for development of neuropathic pain in this “two-hit” model. Lidocaine attenuates cold allodynia in mice.

Chronic pain following surgery, persistent postsurgical pain, is an important highly prevalent condition contributing to significant symptom burden and lower quality of life. Persistent postsurgical pain is relatively refractory to treatment hence generating a high need for preventive strategies and treatments. Therefore, the identification of patients at risk of developing persistent pain is an area of active ongoing research. Recently it was demonstrated that peri-operative disruptions in central pain processing may be able to predict persistent postsurgical pain at long term follow-up in breast cancer patients. The aim of the current report is to present a short protocol to obtain pain thresholds to different stimuli at multiple sites and a measure of endogenous analgesia in breast cancer patients. We have used this method successfully in a clinical context and detail some representative results from a clinical study.

BACKGROUND: Acute postoperative pain is still inadequately managed, despite the presence of acute pain services (APSs). This study aimed to investigate the existence, structure, and responsibilities of Dutch APSs and to review the implementation of the Dutch Hospital Patient Safety Program (DHPSP).METHODS: Information was gathered by a digital questionnaire, sent to all 96 Dutch hospitals performing surgical procedures.RESULTS: Completed questionnaires were received from 80 hospitals (83%), of which 90% have an APS. Important duties of the APS are regular patient rounds, checking complex pain techniques (100%), supporting quality improvement of pain management (87%), pain education (100%), and pain research (21%).IMPLEMENTATION OF THE DHPSP: Regular in-hospital pain training is not provided in 46% of the hospitals. Thirteen percent of the hospitals offer no patient information about pain management.CONCLUSIONS: Almost all hospitals have an APS. They differ in both the way they are locally organized, along with the activities they employ. Future research needs to compare the effect of patient and nonpatient-related activities of APSs on outcomes related to pain management.

BACKGROUND: Mechanical ventilation (MV) induces an inflammatory response that may result in (acute) lung injury. Lidocaine, an amide local anesthetic, has anti-inflammatory properties in vitro and in vivo, possibly due to an attenuation of pro-inflammatory cytokines, intracellular adhesion molecule-1 (ICAM-1), and reduction of neutrophils influx. We hypothesized an attenuation of MV-induced inflammatory response with intravenously administered lidocaine. METHODS: Lidocaine (Lido) (2, 4, and 8 mg/kg/h) was intravenously administered during 4 h of MV with a tidal volume of 8 ml/kg, positive end expiratory pressure 1,5 cmH2O and FiO2 0.4. We used one ventilated control (CON) group receiving vehicle. After MV, mice were euthanized, and lungs and blood were immediately harvested, and cytokine levels and ICAM-1 levels were measured in plasma and lung homogenates. Pulmonary neutrophils influx was determined in LEDER-stained slices of lungs. Anesthetic need was determined by painful hind paw stimulation. RESULTS: Lidocaine-treated animals (Lido 2, 4 and 8 mg/kg/h) showed higher interleukin (IL)-10 plasma levels compared to control animals. Lidocaine treatment with 8 mg/kg/h (Lido 8) resulted in higher IL-10 in lung homogenates. No differences were observed in pro-inflammatory cytokines, ICAM-1, and pulmonary influx between the different ventilated groups. CONCLUSIONS: Intravenously administered lidocaine increases levels of plasma IL-10 with infusion from 2, 4, and 8 mg/kg/h and pulmonary levels of IL-10 with 8 mg/kg/h in a murine mechanical ventilation model. Intravenously administered lidocaine appears to reduce anesthetic need in mice.

Item does not contain fulltext OBJECTIVE: Chronic noncancer pain influences patient's quality of life and their ability to cope. Pain relieving medication and other specific treatments commonly integrated in biopsychosocial rehabilitation demonstrate modest benefits in pain relief and improved functioning of individuals. Spiritual care, covering the fourth dimension provides insight, inspires hope and purpose, and is thought to mediate mental and physical health for patients. This study explores the need for its inclusion in interdisciplinary pain rehabilitation and describes the requirements and test environment for evaluation. METHODS: Outcomes of spiritual care and interdisciplinary pain rehabilitation in follow-up studies of randomized controlled trials contained in systematic reviews were summarized. Pubmed, Cochrane, and PsycINFO were searched, citation tracking was applied, articles of follow-up studies therein were located. Literature was searched for insights pertaining to requirements for an assessment of including this fourth dimension. RESULTS: No systematic reviews for spiritual care were identified. Five systematic reviews of biopsychosocial rehabilitation containing 14 studies describing long-term outcomes were retrieved. The importance of coping in maintaining long-term outcomes was empirically illustrated. The required test environment is provided by a structured multidimensional care pathway separating spirituality from well-being and mental health, with measures of treatment outcome installed enabling a comparison with benchmarks. CONCLUSIONS: Active coping seems beneficial for maintaining positive long-term outcomes of interdisciplinary pain rehabilitation Spiritual care may be conducive to active coping. Further research is warranted to explore the additive value of this spiritual care in the context of a multidimensional care pathway.

Contains fulltext : 133898.pdf (Publisher’s version ) (Closed access) INTRODUCTION: Over the past 15 years, the number of ambulatory surgical procedures worldwide has increased continuously. Studies show that 30% to 40% of the patients experience moderate-to-severe pain in the first 48 hours. The objective of this observational study is to compare the percentage of moderate-to-severe pain, side effects, and the use of escape medication of two different analgesic regimes after ambulatory surgery. METHODS: In this observational study, at the day care center of the Radboud University Nijmegen Medical Centre, patients were followed during the period from April 2010 till October 2011. At the day care center, a multimodal analgesic regime with paracetamol (1000), diclofenac (75), and tramadol (50) and an analgesic regime with a combination tablet tramadol/paracetamol (37.5/325) and diclofenac (75) were prescribed in different periods for ambulatory surgery. Prior to surgery and during the first 3 days after surgery, patients were asked to complete five questionnaires. In these questionnaires, they were asked about pain (NRS) at rest and when moving, experienced side effects, and the analgesic medication taken. RESULTS: A total of 375 patients participated in the study, of which 99 in the tramadol group and 138 in the combination tablet tramadol/paracetamol group. The percentage of patients with moderate-to-severe postoperative pain was 25% to 40%. In both the groups, an equal percentage of patients experienced moderate-to-severe postoperative pain. Both analgesic regimes have a comparable analgesic effectiveness with each with its own specific advantages and disadvantages. On the first day after surgery, patients with the tramadol/paracetamol regime experienced more side effects (drowsiness and nausea) were less therapy compliant, but needed a smaller amount of escape medication than the patients from the tramadol group.

Background: In more and more countries, a specific pain education curriculum is provided to instruct pain physicians. However, there is little literature on pain education and in particularly how to evaluate their knowledge. One of the modules interesting to assess is the use of clinical practice guidelines (CPGs) by pain physicians. Objectives: The aim was to investigate if a case vignette is useful to evaluate pain physicians’ knowledge about recommendations contained in CPGs. Setting: An E-mail survey was conducted with the support of the Société Française d’Etude et de Traitement de la Douleur to all pain specialists (primary and secondary care) in France. Methods: The survey consisted of a case vignette about a patient with pain suffering from an intractable pancreatic cancer with multiple choice questions about diagnosis and treatment of pain. Percentages of participants who treated the patient as suggested in the CPGs were calculated. Results: A total of 214 of those invited to participate (921) answered the questionnaire (24%). More than 85% of the respondents declared to know and use CPGs. Half of the participants diagnosed and treated neuropathic pain components in the case vignette according to the recommendations in the CPGs. Limitations: This exercise needed to be explained: pain physicians should be trained to this kind of questionnaire. It explains the low response rate and the progressive diminution of responders during the questionnaire. Conclusions: Case vignette is an interesting instrument for pain education because it is cheap, easy to use, and can be repeated. However, training before using this instrument is needed for pain physicians, in particular during their pain education. Key words: Education, case vignette, cancer pain, neuropathic pain, evidence basedmedicine, treatment, guideline, pain physician

Item does not contain fulltext BACKGROUND: Many patients with cancer suffer from pain, which is often not optimally treated. In 2008, the evidence-based, multidisciplinary Dutch guideline on the diagnosis and treatment of pain in this patient group was published. We assessed knowledge about and adherence to the guideline by pain specialists. METHODS: A cross-sectional case vignette survey describing a palliative patient with intractable pancreatic cancer and pain was sent to all 350 Dutch anesthesiologists registered as pain specialists at the Netherlands Association of Anesthesiology. Descriptive statistics were conducted. RESULTS: Ninety-three pain specialists completed the questionnaire (27%). The majority appeared to follow the guideline recommendations on pharmacological (99%) and invasive treatment (95%) in the diverse stages of the disease. However, the recommendation to use a one-dimensional pain scale to evaluate the effect of pain treatment and the recommendation to perform a multidimensional pain assessment if the patient in pain is in a deteriorating stage were only followed by a minority of the respondents (23% and 15%, respectively). CONCLUSIONS: Regarding most recommendations, Dutch pain specialists know and intend to follow the national multidisciplinary cancer pain guideline. Yet, only a minority of them perform structural pain assessment of the patient with cancer pain. However, as the response rate was low (27%), the results should be interpreted with caution and cannot be generalized to the entire population of pain specialists in the Netherlands. We recommend that, in the guideline update and implementation programs, more attention be given to thorough assessment of the patient with pain and cancer.

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Item does not contain fulltext BACKGROUND: Motor cortex stimulation (MCS) was introduced in the early 1990s by Tsubokawa and his group for patients diagnosed with drug-resistant, central neuropathic pain. Inconsistencies concerning the details of this therapy and its outcomes and poor methodology of most clinical essays divide the neuromodulation society worldwide into "believers" and "nonbelievers." A European expert meeting was organized in Brussels, Belgium by the Benelux Neuromodulation Society in order to develop uniform MCS protocols in the preoperative, intraoperative, and postoperative courses. METHODS: An expert meeting was organized, and a questionnaire was sent out to all the invited participants before this expert meeting. An extensive literature research was conducted in order to enrich the results. RESULTS: Topics that were addressed during the expert meeting were 1) inclusion and exclusion criteria, 2) targeting and methods of stimulation, 3) effects of MCS, and 4) results from the questionnaire. CONCLUSIONS: Substantial commonalities but also important methodologic divergencies emerged from the discussion of MCS experts from 7 European Centers. From this meeting and questionnaire, all participants concluded that there is a need for more homogenous standardized protocols for MCS regarding patient selection, implantation procedure, stimulation parameters, and follow-up-course.