Drugs used for pain management in gastrointestinal surgery and their implications

Pain is the predominant symptom troubling patients.Pain management is one of the most important aspects in the management of surgical patients leading to early recovery from surgical procedures or in patients with chronic diseases or malignancy.Various groups of drugs are used for dealing with this;however,they have their own implications in the form of adverse effects and dependence.In this article,we review the concerns of different pain-relieving medicines used postoperatively in gastrointestinal surgery and for malignant and chronic diseases.

Comparing role of ATP between acute pain in neuromyelitis optica spectrum disorder and peripheral neuropathic pain

In this article, we present our previous research, which highlighted adenosine triphosphate(ATP) as the cause of neuropathic pain during the acute phase of neuromyelitis optica spectrum disorder(NMOSD). In NMOSD pathology, damageassociated molecular patterns(DAMPs), including ATP, are released from damaged astrocytes, triggering the activation of innate immune cells. ATP is a central mediator of acute pain in NMOSD.

Lighting the shades of hidden pain:a role for spinal cord neurons and microglia in vestibulodynia

Vulvodynia,a chronic pain disorder affecting the vulvar region,represents a significant challenge in both diagnosis and treatment within the field of women’s health.This condition is characterized by chronic pain that significantly affects the quality of life of afflicted women.The present perspective paper examines the role of spinal sensitization and microglial activation in vulvodynia.

Inhibitory gamma-aminobutyric acidergic neurons in the anterior cingulate cortex participate in the comorbidity of pain and emotion

Pain is often comorbid with emotional disorders such as anxiety and depression.Hyperexcitability of the anterior cingulate cortex has been implicated in pain and pain-related negative emotions that arise from impairments in inhibitory gamma-aminobutyric acid neurotransmission.This review primarily aims to outline the main circuitry(including the input and output connectivity)of the anterior cingulate cortex and classification and functions of different gamma-aminobutyric acidergic neurons;it also describes the neurotransmitters/neuromodulators affecting these neurons,their intercommunication with other neurons,and their importance in mental comorbidities associated with chronic pain disorders.Improving understanding on their role in pain-related mental comorbidities may facilitate the development of more effective treatments for these conditions.However,the mechanisms that regulate gamma-aminobutyric acidergic systems remain elusive.It is also unclear as to whether the mechanisms are presynaptic or postsynaptic.Further exploration of the complexities of this system may reveal new pathways for research and drug development.

Protein arginine methyltransferase-6 regulates heterogeneous nuclear ribonucleoprotein-F expression and is a potential target for the treatment of neuropathic pain

Protein arginine methyltransferase-6 participates in a range of biological functions,particularly RNA processing,transcription,chromatin remodeling,and endosomal trafficking.However,it remains unclear whether protein arginine methyl transferase-6 modifies neuropathic pain and,if so,what the mechanisms of this effect.In this study,protein arginine methyltransferase-6 expression levels and its effect on neuropathic pain were investigated in the spared nerve injury model,chronic constriction injury model and bone cancer pain model,using immunohistochemistry,western blotting,immunoprecipitation,and label-free proteomic analysis.The results showed that protein arginine methyltransferase-6 mostly co-localized withβ-tubulinⅢin the dorsal root ganglion,and that its expression decreased following spared nerve injury,chronic constriction injury and bone cancer pain.In addition,PRMT6 knockout(Prmt6~(-/-))mice exhibited pain hypersensitivity.Furthermore,the development of spared nerve injury-induced hypersensitivity to mechanical pain was attenuated by blocking the decrease in protein arginine methyltransferase-6 expression.Moreover,when protein arginine methyltransferase-6 expression was downregulated in the dorsal root ganglion in mice without spared nerve injury,increased levels of phosphorylated extracellular signal-regulated kinases were observed in the ipsilateral dorsal horn,and the response to mechanical stimuli was enhanced.Mechanistically,protein arginine methyltransferase-6 appeared to contribute to spared nerve injury-induced neuropathic pain by regulating the expression of heterogeneous nuclear ribonucleoprotein-F.Additionally,protein arginine methyltransfe rase-6-mediated modulation of hete rogeneous nuclear ribonucleoprotein-F expression required amino atids 319 to 388,but not classical H3R2 methylation.These findings indicated that protein arginine methyltransferase-6 is a potential therapeutic target fo r the treatment of peripheral neuro pathic pain.

Effect of esketamine on reducing postpartum pain and depression

In this editorial,we comment on a recent article by Chen et al,that addressed the effect of intraoperative injection of esketamine on postoperative analgesia and postoperative rehabilitation after cesarean section.Poor management of postcesarean pain is associated with decreased maternal care for the baby,longer hospitalization,and higher risk of developing postpartum depression.Esketamine is a more potent S-enantiomer of ketamine which has shown promising analgesic and antidepressant properties for managing post-cesarean pain and depression in clinical studies.However,due to its potential adverse effects on the neurological and hemodynamic status of patients,it is recommended that its usage in low doses should be limited to cesarean candidates experiencing unbearable pain.Before any recommendation for routine perioperative use of esketamine,more standardized clinical trials are needed to strengthen our existing knowledge of its effectiveness in reducing postpartum pain and depression.

Application of virtual reality technology improves the functionality of brain networks in individuals experiencing pain

Medical procedures are inherently invasive and carry the risk of inducing pain to the mind and body.Recently,efforts have been made to alleviate the discomfort associated with invasive medical procedures through the use of virtual reality(VR)technology.VR has been demonstrated to be an effective treatment for pain associated with medical procedures,as well as for chronic pain conditions for which no effective treatment has been established.The precise mechanism by which the diversion from reality facilitated by VR contributes to the diminution of pain and anxiety has yet to be elucidated.However,the provision of positive images through VR-based visual stimulation may enhance the functionality of brain networks.The salience network is diminished,while the default mode network is enhanced.Additionally,the medial prefrontal cortex may establish a stronger connection with the default mode network,which could result in a reduction of pain and anxiety.Further research into the potential of VR technology to alleviate pain could lead to a reduction in the number of individuals who overdose on painkillers and contribute to positive change in the medical field.

The sexually dimorphic expression of glutamate transporters and their implication in pain after spinal cord injury

In addition to the loss of motor function,~60% of patients develop pain after spinal cord injury.The cellular-molecular mechanisms are not well understood,but the data suggests that plasticity within the rostral,epicenter,and caudal penumbra of the injury site initiates a cellularmolecular interplay that acts as a rewiring mechanism leading to central neuropathic pain.Sprouting can lead to the formation of new connections triggering abnormal sensory transmission.The excitatory glutamate transporters are responsible for the reuptake of extracellular glutamate which makes them a critical target to prevent neuronal hyperexcitability and excitotoxicity.Our previous studies showed a sexually dimorphic therapeutic window for spinal cord injury after treatment with the selective estrogen receptor modulator tamoxifen.In this study,we investigated the anti-allodynic effects of tamoxifen in male and female rats with spinal cord injury.We hypothesized that tamoxifen exerts anti-allodynic effects by increasing the expression of glutamate transporters,leading to reduced hyperexcitability of the secondary neuron or by decreasing aberrant sprouting.Male and female rats received a moderate contusion to the thoracic spinal cord followed by subcutaneous slow-release treatment of tamoxifen or matrix pellets as a control(placebo).We used von Frey monofilaments and the“up-down method”to evaluate mechanical allodynia.Tamoxifen treatment decreased allodynia only in female rats with spinal cord injury revealing a sexdependent effect.The expression profile of glutamatergic transporters(excitatory amino acid transporter 1/glutamate aspartate transporter and excitatory amino acid transporter 2/glutamate transporter-1)revealed a sexual dimorphism in the rostral,epicenter,and caudal areas of the spinal cord with a pattern of expression primarily on astrocytes.Female rodents showed a significantly higher level of excitatory amino acid transporter-1 expression while male rodents showed increased excitatory amino acid transporter-2 expression compared with female rodents.Analyses of peptidergic(calcitonin gene-related peptide-α)and non-peptidergic(isolectin B4)fibers outgrowth in the dorsal horn after spinal cord injury showed an increased calcitonin gene-related peptide-α/isolectin B4 ratio in comparison with sham,suggesting increased receptive fields in the dorsal horn.Although the behavioral assay shows decreased allodynia in tamoxifen-treated female rats,this was not associated with overexpression of glutamate transporters or alterations in the dorsal horn laminae fibers at 28 days post-injury.Our findings provide new evidence of the sexually dimorphic expression of glutamate transporters in the spinal cord.The dimorphic expression revealed in this study provides a therapeutic opportunity for treating chronic pain,an area with a critical need for treatment.

Enhancing postoperative pain control by surgically-initiated rectus sheath block in abdominal aortic aneurysm open repair: A case report

BACKGROUND Abdominal aortic aneurysm(AAA)repair often involves significant postoperative pain,traditionally managed with systemic opioids,which can cause undesirable side effects.This case report explores the novel use of a surgically-initiated rectus sheath block with a catheter-over-needle assembly for pain management in AAA repair.CASE SUMMARY A 67-year-old female with hypertension and previous aortic dissection underwent elective open repair of an infrarenal AAA,which had grown from 3.4 cm to 4.3 cm over 14 months.A rectus sheath block was initiated surgically for postoperative pain control.The patient reported low pain scores and did not require systemic intravenous opioids,enabling early ambulation and discharge on postoperative day seven without complications.By preventing complications of systemic opi-oids,the method indicating a promising direction for postoperative pain management in major vascular surgeries.CONCLUSION Surgically-initiated rectus sheath block as a valuable tool for managing postoperative pain in AAA repair.

Research progress of pain catastrophizing in patients with lumbar disc herniation

Pain catastrophization is one of the negative emotional factors and an important psychological factor associated with patients with lumbar disc herniation(LDH).Currently,the concept of pain catastrophization of LDH is relatively mature abroad;however,there are only few research studies on this in China.To understand the status quo of pain catastrophization(PC)in patients with LDH and its influencing factors,the intervention measures of PC and their efficacy were further analyzed.In the present paper,the research status of PC at home and abroad is briefly expounded,and the influencing factors and clinical intervention measures for PC are analyzed.This paper reviews the concept of PC,the assessment tools,influencing factors,and the relevant intervention measures.In order to evaluate the pain degree of patients,understand the incidence of pain in patients,and improve the cure rate and quality of life of patients,the basic situation of patients with pain disaster is summarized to provide reference for medical personnel.

重型创伤性脑损伤去骨瓣减压应用改良Paine点穿刺监测脑室内颅内压的优势

目的探讨重型创伤性脑损伤(TBI)开颅去骨瓣减压术(DC)中应用改良Paine点穿刺行脑室内颅内压(ICP)监测探头置入的优势。方法回顾性分析2020年4月-2022年4月嘉兴市第二医院收治的48例重型TBI患者的临床资料。所有患者均行DC联合脑室内ICP监护术,按照ICP监测术式的不同,分为观察组(23例)与对照组(25例),其中观察组行DC切口内改良Paine点穿刺脑室内ICP监测探头置入术,对照组行传统DC对侧切口颅骨钻孔经Kocher点脑室内ICP监测探头置入术。比较两组术前一般资料、手术用时、术后甘露醇使用剂量及持续时间、ICP监测持续时间、术后再出血率、颅内感染率、术后3个月时格拉斯哥预后评分(GOS)。结果两组一般资料、甘露醇使用剂量、甘露醇持续时间和ICP监测持续时间比较差异均无统计学意义(P>0.05);观察组手术用时、术后再出血率、颅内感染率明显少于或低于对照组(P<0.05);两组术后3个月GOS评分比较差异无统计学意义(P>0.05)。结论相较传统的DC对侧切口颅骨钻孔经Kocher点行脑室内ICP监测探头置入术,重型脑外伤DC术中通过切口内改良Paine点穿刺行脑室内ICP监测探头置入术可缩短手术用时,降低术后再出血率、颅内感染率。

Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery

BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.

Genetic Evidence for Causal Association Between Hypertension and Chronic Pain:A Bidirectional Two-Sample Mendelian Randomization Study

Objective The extent to which the association between hypertension and chronic pain in observational studies is either causally linked or influenced by other shared risk factors has not been substantially addressed.In the present study,Mendelian randomization(MR)was employed to examine the potential causal relationship between hypertension and risk of chronic pain.Methods The study data were derived from the pooled dataset of the genome-wide association study(GWAS),enabling the evaluation of the causal effects of hypertension on various types of chronic pain including chronic headache as well as chest,abdominal,joint,back,limb,and multisite chronic pain.We performed a bidirectional two-sample MR analysis using random effect inverse variance weighting(IVW),MR-Egger,weighted median,and weighted mode,quantified by odds ratio(OR).Results Genetically predicted essential hypertension was associated with an increased risk of chronic headache(OR=1.007,95%CI:1.003-1.011,P=0.002)and limb pain(OR=1.219,95%CI:1.033-1.439,P=0.019).No potential causal associations were identified between chronic pain and essential hypertension in the reverse direction MR(P>0.05).In addition,there was no potential causal association between secondary hypertension and chronic pain(P>0.05).Conclusion This study provided genetic evidence that a unidirectional causal relationship exists between essential hypertension and the increased risks of chronic headache and limb pain,and no causal relationship was found between secondary hypertension and chronic pain.These findings offer theoretical underpinnings for future research on managing hypertension and chronic pain.

Differences between the healthcare systems of Quebec and France for the treatment of pain due to spinal disorders

In Quebec,Canada,the public healthcare system offers free medical services.However,patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage.In contrast,private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses.Once a patient with pain caused by a spinal disorder meets a pain medicine specialist,spinal intervention is quickly performed when indicated,and patients are provided lifestyle advice.Transforaminal epidural steroid injections are frequently administered to patients with radicular pain,and steroid injections are administered on a facet joint to control low back or neck pain.Additionally,medial branch blocks are performed prior to thermocoagulation.France’s universal healthcare system ensures accessibility at controlled costs.It emphasizes physical activity and provides free physical therapy services.However,certain interventions,such as transforaminal and interlaminar epidural injections,are not routinely used in France owing to limited therapeutic efficacy and safety concerns.This underutilization may be a potential cause of chronic pain for many patients.By examining the differences,strengths,and weaknesses of these two systems,valuable insights can be gained for the enhancement of global spinal pain management strategies,ultimately leading to improved patient outcomes and satisfaction.

Percutaneous cervical cordotomy for managing refractory pain in a patient with a Pancoast tumor:A case report

BACKGROUND According to the World Health Organization analgesic ladder,cancer-related pain generally begins with pharmacotherapy in a stepwise approach.Nevertheless,some patients continue to experience poorly controlled pain despite medications,particularly when considering adverse effects and self-care quality.Percutaneous cervical cordotomy is an alternative interventional procedure for unremitting unilateral intractable cancer-related pain.CASE SUMMARY The patient was diagnosed with lung cancer with destruction of the brachial plexus and ribs.For 2 mo,the patient experienced progressive severe weakness and pain in the right upper extremity.Notably,the pain intensity reached an extreme level,particularly when lying supine,even under heavy sedation.This heightened pain response posed a significant challenge;as a result,the patient was unable to undergo further evaluation through magnetic resonance imaging.Ultimately,he underwent percutaneous cervical cordotomy for symptom relief,resulting in complete resolution of right arm pain.After a 3-mo follow-up,the pain did not recur,and only a flurbiprofen local patch was required for mild scapular tightness.CONCLUSION Cordotomy,under careful patient selection,appears to enhance the quality of life of patients with unilateral cancerrelated pain.

Protocol for lower back pain management: Insights from the French healthcare system

In this editorial we comment on the article published in a recent issue of the World Journal of Clinical Cases.This article described a novel ultrasound-guided lateral recess block approach in treating a patient with lateral recess stenosis.The impact of spinal pain-related disability extends significantly,causing substantial human suffering and medical costs.Each county has its preferred treatment strategies for spinal pain.Here,we explore the lower back pain(LBP)treatment algorithm recommended in France.The treatment algorithm for LBP recommended by the French National Authority for Health emphasizes early patient activity and minimal medication use.It encourages the continuation of daily activities,limits excessive medication and spinal injections,and incorporates psychological assessments and non-pharmacological therapies for chronic cases.However,the algorithm may not aggressively address acute pain in the early stages,potentially delaying relief and increasing the risk of chronicity.Additionally,the recommended infiltrations primarily involve caudal epidural steroid injections,with limited consideration for other injection procedures,such as transforaminal or interlaminar epidural steroid injections.The fixed follow-up timeline may not accommodate patients who do not respond to initial treatment or experience intense pain,potentially delaying the exploration of alternative therapies.Despite these limitations,understanding the strengths and weaknesses of the French approach could inform adaptations in LBP treatment strategies globally,potentially enhancing patient outcomes and satisfaction across diverse healthcare systems.

Optimizing pain management in elderly patients post-knee surgery:A novel collaborative strategy

Total knee replacement,a common surgery among the elderly primarily necessitated by osteoarthritis,replaces the damaged knee joint with an artificial one.Given the aging population and the increasing prevalence of such surgeries,the article highlights the critical need for effective postoperative care strategies.This editorial provides an overview of rehabilitation care for pain in elderly knee replacement patients,emphasizing the importance of a multimodal approach to postoperative recovery.Furthermore,the article advocates for a patient-centered,comprehensive rehabilitation regimen that enhances recovery and quality of life in elderly patients undergoing knee replacement surgery.

Clinical Effect Observation of Constructing PERMA Model in Psychological Intervention for Patients with Chronic Cancer Pain

Background:The constructing PERMA model in psychological intervention was applied to patients with chronic cancer pain to provide data reference for reducing pain,fear of cancer recurrence,and improving the level of psychological capital.Aim:To explore the clinical effects of constructing PERMA model in psychological intervention for patients with chronic cancer pain.Methods:A total of 98 patients with chronic cancer pain admitted to our hospital from March 2021 to March 2023 were randomly divided into two groups,49 cases in each group.The control group received routine intervention,while the research group constructed PERMA model based on the routine intervention for psychological intervention.The pain severity,fear of cancer recurrence,psychological capital and quality of life before and after intervention were compared between the two groups.Results:After two months of intervention,the pain in the research group was milder than that in the control group(p<0.05).The scores and total scores of all dimensions of fear of cancer recurrence in the research group were lower than those in the control group(p<0.05).The scores and total scores of each dimension of psychological capital in the research group were higher than those in the control group(p<0.05).The scores of all dimensions of quality of life in the research group were higher than those in the control group(p<0.05).Conclusion:The PERMA model constructed in psychological interventions for patients with chronic cancer pain can assist analgesic medications to reduce pain and alleviate the fear of cancer recurrence,increase the level of psychological capital,and thus improve quality of life.

Reconstructive surgery for phantom and residual limb pain in post-conflict settings

Traumatic amputations remain one of the most frequent and disturbing wounds of armed conflict.In this scenario,most amputees develop residual and phantom limb pain,impacting their quality of life.There are several elective surgical procedures available for both conditions,such as neuroma excision followed by nerve reconstruction,nerve relocation,e.g.,surgically implanting a transected nerve into a muscle,nerve transfers in cases of associated paralysis,and most recently,regenerative peripheral nerve interface surgery.Whenever possible in the post-conflict phase,a coordinated effort between traveling humanitarian surgeons specializing in reconstructive microsurgery and local healthcare providers is essential for successfully treating phantom and chronic residual limb pain in post-conflict amputees.While providing a detailed logistical framework for global humanitarian missions is beyond the scope of this article,we provide a brief perspective on a topic of utmost importance for reconstructive surgeons worldwide:the high-quality care and treatment of refugees and those whose lives have been impacted by conflict,disaster,or displacement.

Pain management in acute musculoskeletal injury: Effect of opioid vs nonopioid medications

BACKGROUND The use of opioids for pain is linked to an increased risk of developing opioid use disorder,and has resulted in the emergence of the opioid crisis over the last few years.AIM The systematic review question is“How does the use of opioid medications in pain management,compared with non-opioid medications,affect pain intensity over the short,intermediate,and long-term in adults with acute traumatic pain?”.METHODS The protocol was prospectively registered on the International Prospective Re-gister of Systematic Reviews:CRD42021279639.Medline and Google Scholar were electronically searched for controlled peer-reviewed studies published in full,with the PICO framework:P:Adult patients with traumatic injuries,I:Opioid medications,C:Non-opioid medi-cations,O:A minimum clinically important difference(MCID)in pain.RESULTS After full-text screening,we included 14 studies in the qualitative synthesis.Of these 14 studies,12 were rando-mized clinical trials(RCTs)and 2 were pseudo-RCTs with a total of 2347 patients enrolled.There was heteroge-neity in both medication utilized and outcome in these studies;only two studies were homogeneous regarding the type of study conducted,the opioid used,its comparator,and the outcome explored.The MCID was evaluated in 8 studies,while in 6 studies,any measured pain reduction was considered as an outcome.In 11 cases,the setting of care was the Emergency Department;in 2 cases,care occurred out-of-hospital;and in one case,the setting was not well-specified.The included studies were found to have a low-moderate risk of bias.CONCLUSION Non-opioids can be considered an alternative to opioids for short-term pain management of acute musculoskeletal injury.Intravenous ketamine may cause more adverse events than other routes of administration.