Effect of Transcranial Direct Current Stimulation of Motor Cortex versus Insula Cortex on Chronic Post-Mastectomy Pain: Randomized Sham-Controlled Trial

Background: Transcranial direct current stimulation (tDCS) across cortical brain areas appears to improve various forms of pain, yet evidence of tDCS efficiency and ideal stimulation target is lacking. This study aimed to compare the add-on analgesic efficacy of concentric electrode transcranial direct current stimulation (CE-tDCS) stimulation over the primary motor cortex versus the insular cortex on the management of chronic postmastectomy pain. Method: Prospective randomized double-blind sham-controlled study enrolled eighty patients with chronic postmastectomy pain that were randomly assigned to four groups: active motor (AM), sham motor (SM), active insula (AI) and sham insula (SI) group, each received 5 sessions for 20-minute duration with 2 mA tDCS over the targeted area of the contralateral side of pain. Our primary outcome was VAS score, the secondary outcomes were VDS score, LANSS score and depression symptoms by HAM-D scores, assessment was done at 4 time points (prestimulation, after 5th session, 15th day and one month after the last session). Results: Both active tDCS groups (motor and insula) showed reduction of VAS (P Conclusion: Active tDCS stimulation either targeting the primary motor cortex or the insula cortex has add-on analgesic effect for controlling neuropathic chronic post mastectomy pain and the maximum effect was at 15 days after the last session.

Effect of Local Wound Infiltration with Ketamine versus Dexmedetomidine Added to Bupivacaine on Inflammatory Cytokines, a Randomized Clinical Trial

Background: Ketamine or dexmedetomidine as an adjuvant to bupivacaine in local wound infiltration attenuated postoperative stress response, especially with ketamine in patients undergoing total abdominal hysterectomy. Objectives: Compare effect of local wound infiltration with ketamine or dexmedetomidine added to bupivacaine to bupivacaine alone on inflammatory cytokine response after total abdominal hysterectomy. Methods: Sixty female patients with endometrial carcinoma underwent total abdominal hysterectomy and scheduled to receive local wound infiltration before wound closure either with one of three;40 ml of 0.25% bupivacaine alone (C Group) or with the addition of 2 mg/kg ketamine (K Group) or 2 μg/kg dexmedetomidine (D Group). After extubation, they were followed up for postoperative interleukin 6 (IL6), IL1β, IL10, and TNF-α levels were assessed at baseline, pre-infiltration, 6, and 24 h by blood samples obtained from each patient, hemodynamic variables, analgesic profile and side effects. Results: Inflammatory cytokines response was attenuated in K and D groups, evidenced by decreased mean pro-inflammatory cytokines IL6, TNF-α, and increased anti-inflammatory IL10 at 6 and 24 h postoperatively compared to pre-infiltration levels (p ≤ 0.01) with preservation of IL1β at its preoperative level (p > 0.05). Attenuation was more in K and D groups than in the C group and was highest in the K group with decreased 1st request, total morphine consumption without serious side effect. Conclusion: Local wound infiltration with ketamine or dexmedetomidine added to bupivacaine has a good postoperative analgesic profile and attenuated cytokines inflammatory response more than bupivacaine alone after total abdominal hysterectomy, with highest attenuation in ketamine group.

Effect of Ketamine Instillation on Acute and Chronic Post Mastectomy Pain, a Dose Finding Clinical Study

Background: Uncontrolled acute postoperative pain is considered a risk factor for the development of chronic pain afterward. Objectives: To explore the most effective dose of ketamine instillation (1 of 3 doses: 1, 2, or 3 mg/kg) for acute and chronic post mastectomy pain (PMP). Methods: Ninety female patients with cancer breast, aged (18 - 60 yrs), weighted (50 - 90 kg), scheduled for modified radical mastectomy, randomly allocated into 3 groups to receive ketamine instillation after surgical homeostasis before wound closure (1 of 3 doses;1, 2, or 3 mg/kg as A, B or C groups respectively) patients were followed up for 48 h for acute pain (total morphine consumption, the first request of analgesia and visual analog scale at rest and movement (VASR/M), chronic pain by Leeds assessment of neuropathic signs and symptoms (LANSS) for six-months, hemodynamics, and side effects. Results: Median total dose of morphine consumption was 8 mg (5 - 10) versus 6 mg (6 - 7) in A and B groups respectively in the first 48 h postoperatively. Lowest VASR/M was recorded in C then B and lastly A group (P = 0.037). No patients in the C group requested analgesia versus thirty (100%) and nine (30%) patients in the A and B groups respectively with the first request of analgesia was 12 h (5 - 36) in the A group versus 30 h (12 - 36) in the B group respectively (P Conclusion: Ketamine instillation effectively controlled acute post mastectomy pain (PMP) in a dose-dependent manner and reduced the incidence and severity of chronic pain in patients who undergoing a modified radical mastectomy.

Safety and Efficacy of Intrathecal Morphine in Children Undergoing Surgery for Abdominal Neuroblastoma. Dose Finding, Randomized, Clinical Study

Background: Pediatric patients have remained undertreated for postoperative pain because of the difficulty of pain assessment and apprehension. Intrathecal opioids—including morphine—have become a popular method for providing post-operative analgesia in children. Objectives: To compare different doses of morphine via intrathecal route (2 μg/kg, 5 μg/kg, and 10 μg/kg) for post-operative analgesia in pediatric patients following for abdominal neuroblastoma surgery. Methods: This randomized, double-blinded, study was approved by local ethics committee of South Egypt Cancer Institute, Assiut University, Assiut—Egypt, and registered at https://www.clinicaltrials.gov/ at no.: “NCT03158584”. Forty-five patients scheduled for surgical excision of abdominal neuroblastoma were divided into 3 groups (15 patients each);group (I): received intrathecal morphine 2 μg/kg added to normal saline (3 mL volume). Group (II): received intrathecal morphine 5 μg/kg. Group (III): received intrathecal morphine 10 μg/kg. Intra-, and post-operative hemodynamics, FLACC score, time to first request of rescue analgesia, total analgesic consumption, and side effects were recorded for 24 hours. Results: there was a significant reduction in FLACC score in groups II and III starting immediately till 24 hours postoperatively compared to group I (P 0.05). No significant difference was observed between groups in side effects. Conclusions: 5 μg/kg of IT morphine achieved a reasonable balance between postoperative analgesia, and the incidence of side effects in pediatric patients following major abdominal cancer surgeries.