Non-pharmacological interventions for chronic pain in people with spinal cord injury.

BACKGROUND: Chronic pain is frequent in persons living with spinal cord injury (SCI). Conventionally, the pain is treated pharmacologically, yet long-term pain medication is often refractory and associated with side effects. Non-pharmacological interventions are frequently advocated, although the benefit and harm profiles of these treatments are not well established, in part because of methodological weaknesses of available studies. OBJECTIVES: To critically appraise and synthesise available research evidence on the effects of non-pharmacological interventions for the treatment of chronic neuropathic and nociceptive pain in people living with SCI. SEARCH METHODS: The search was run on the 1st March 2011. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), four other databases and clinical trials registers. In addition, we manually searched the proceedings of three major scientific conferences on SCI. We updated this search in November 2014 but these results have not yet been incorporated. SELECTION CRITERIA: Randomised controlled trials of any intervention not involving intake of medication or other active substances to treat chronic pain in people with SCI. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias in the included studies. The primary outcome was any measure of pain intensity or pain relief. Secondary outcomes included adverse events, anxiety, depression and quality of life. When possible, meta-analyses were performed to calculate standardised mean differences for each type of intervention. MAIN RESULTS: We identified 16 trials involving a total of 616 participants. Eight different types of interventions were studied. Eight trials investigated the effects of electrical brain stimulation (transcranial direct current stimulation (tDCS) and cranial electrotherapy stimulation (CES); five trials) or repetitive transcranial magnetic stimulation (rTMS; three trials). Interventions in the remaining studies included exercise programmes (three trials); acupuncture (two trials); self-hypnosis (one trial); transcutaneous electrical nerve stimulation (TENS) (one trial); and a cognitive behavioural programme (one trial). None of the included trials were considered to have low overall risk of bias. Twelve studies had high overall risk of bias, and in four studies risk of bias was unclear. The overall quality of the included studies was weak. Their validity was impaired by methodological weaknesses such as inappropriate choice of control groups. An additional search in November 2014 identified more recent studies that will be included in an update of this review.For tDCS the pooled mean difference between intervention and control groups in pain scores on an 11-point visual analogue scale (VAS) (0-10) was a reduction of -1.90 units (95% confidence interval (CI) -3.48 to -0.33; P value 0.02) in the short term and of -1.87 (95% CI -3.30 to -0.45; P value 0.01) in the mid term. Exercise programmes led to mean reductions in chronic shoulder pain of -1.9 score points for the Short Form (SF)-36 item for pain experience (95% CI -3.4 to -0.4; P value 0.01) and -2.8 pain VAS units (95% CI -3.77 to -1.83; P value < 0.00001); this represented the largest observed treatment effects in the included studies. Trials using rTMS, CES, acupuncture, self-hypnosis, TENS or a cognitive behavioural programme provided no evidence that these interventions reduce chronic pain. Ten trials examined study endpoints other than pain, including anxiety, depression and quality of life, but available data were too scarce for firm conclusions to be drawn. In four trials no side effects were reported with study interventions. Five trials reported transient mild side effects. Overall, a paucity of evidence was found on any serious or long-lasting side effects of the interventions. AUTHORS' CONCLUSIONS: Evidence is insufficient to suggest that non-pharmacological treatments are effective in reducing chronic pain in people living with SCI. The benefits and harms of commonly used non-pharmacological pain treatments should be investigated in randomised controlled trials with adequate sample size and study methodology.

Recommandations pour la prise en charge de la forme systémique l'arthrite juvénile idiopathique (maladie de Still) [Guidelines for diagnosis and treatment in systemic-onset juvenile idiopathic arthritis.]

A guideline group of pediatric rheumatologist experts elaborated guidelines related to the management of idiopathic juvenile arthritis in association with the Haute Autorité de Santé (HAS). A systematic search of the literature published between 1998 and August 2008 and indexed in Pubmed was undertaken. Here, we present the guidelines for diagnosis and treatment in systemic-onset juvenile idiopathic arthritis.

Anatomic and functional outcome after 23-gauge vitrectomy, peeling, and intravitreal triamcinolone for idiopathic macular epiretinal membrane.

PURPOSE: To report both the functional and anatomic outcome and safety profile of 23-gauge pars plana vitrectomy combined with membrane peeling and intravitreal injection of triamcinolone acetonide in eyes with idiopathic macular epiretinal membranes. METHODS: Retrospective study of 39 consecutive patients who underwent 23-gauge transconjunctival sutureless vitrectomy, membrane peeling, and intravitreal triamcinolone acetonide injection for an idiopathic macular epiretinal membrane between February 2007 and February 2008. Minimum follow-up was 6 months. RESULTS: Thirty-nine eyes of 39 patients were included in the study. The mean follow-up was 7 +/- 2.2 months (range, 6-15 months). Twenty-two eyes (56%) were pseudophakic and 17 (44%) were phakic at the time of surgery. Five of the phakic eyes (29.4%) had worsening of cataracts during the follow-up period. Mean preoperative intraocular pressure was 14 +/- 3.5 mmHg. At the final follow-up, mean intraocular pressure was 14.5 +/- 2.7 mmHg, which did not differ significantly from the intraocular pressure at baseline (P = 0.14, two-tailed t-test). Five (13%) patients needed topical antiglaucoma treatment. Mean preoperative best-corrected visual acuity (BCVA) was 0.28 decimal equivalent (20/71 Snellen equivalent; logarithm of the minimum angle of resolution 0.54 +/- 0.2, range: 1.0-0.2) and improved significantly (P < 0.0001, two-tailed t-test) to a mean of 0.6 decimal equivalent (20/33 Snellen equivalent; logarithm of the minimum angle of resolution 0.22 +/- 0.16, range: 0.6-0) at the final follow-up. The BCVA improved by a mean of 3.2 +/- 2.1 lines (range: 0-8). Twenty-nine patients (74%) demonstrated a gain of > or =3 lines. Mean central macular thickness was 456 +/- 77 microm (mean +/- SD) at baseline, which was significantly reduced at the final follow-up to 327 +/- 79 microm (mean +/- SD; P < 0.0001, two-tailed t-test). Average central macular thickness reduction was 131 +/- 77 microm (mean +/- SD; range: 36-380 microm). A subgroup analysis of 15 selected cases, which had central macular thickness and BCVA measurements after the first postoperative week, demonstrated that 84% of the total final reduction in central macular thickness and 84% of the total final improvement in BCVA occurred already during the first postoperative week. CONCLUSION: Twenty-three-gauge sutureless transconjunctival vitrectomy is a safe and effective technique for the treatment of idiopathic macular epiretinal membranes. The concomitant administration of intravitreal triamcinolone acetonide after pars plana vitrectomy may speed up and improve the anatomic and functional outcome.

Predictive ability of an early diagnostic guess in patients presenting with chest pain; a longitudinal descriptive study.

ABSTRACT: BACKGROUND: The intuitive early diagnostic guess could play an important role in reaching a final diagnosis. However, no study to date has attempted to quantify the importance of general practitioners' (GPs) ability to correctly appraise the origin of chest pain within the first minutes of an encounter. METHODS: The validation study was nested in a multicentre cohort study with a one year follow-up and included 626 successive patients who presented with chest pain and were attended by 58 GPs in Western Switzerland. The early diagnostic guess was assessed prior to a patient's history being taken by a GP and was then compared to a diagnosis of chest pain observed over the next year. RESULTS: Using summary measures clustered at the GP's level, the early diagnostic guess was confirmed by further investigation in 51.0% (CI 95%; 49.4% to 52.5%) of patients presenting with chest pain. The early diagnostic guess was more accurate in patients with a life threatening illness (65.4%; CI 95% 64.5% to 66.3%) and in patients who did not feel anxious (62.9%; CI 95% 62.5% to 63.3%). The predictive abilities of an early diagnostic guess were consistent among GPs. CONCLUSIONS: The GPs early diagnostic guess was correct in one out of two patients presenting with chest pain. The probability of a correct guess was higher in patients with a life-threatening illness and in patients not feeling anxious about their pain.

Effectiveness of Pregabalin as Monotherapy or Combination Therapy for Neuropathic Pain in Patients Unresponsive to Previous Treatments in a Spanish Primary Care Setting

BACKGROUND AND OBJECTIVE Patients from a previous study of neuropathic pain (NP) in the Spanish primary care setting still had symptoms despite treatment. Subsequently, patients were treated as prescribed by their physician and followed up for 3 months. Since pregabalin has been shown to be effective in NP, including refractory cases, the objective of this study was to assess the effectiveness of pregabalin therapy in patients with NP refractory to previous treatments. METHODS This was a post hoc analysis of pregabalin-naïve NP patients treated with pregabalin in a 3-month follow-up observational multicenter study to assess symptoms and satisfaction with treatment. Patients were evaluated with the Douleur Neuropathique en 4 questions (DN4), the Brief Pain Inventory (BPI) and the Treatment Satisfaction for Medication Questionnaire (SATMED-Q) overall satisfaction domain. RESULTS 1,670 patients (mean age 58 years, 59 % women), previously untreated or treated with ≥1 drug other than pregabalin, were treated with pregabalin (37 % on monotherapy). At 3 months, pain intensity and its interference with activities decreased by half (p < 0.0001), while the number of days with no or mild pain increased by a mean of 4.5 days (p < 0.0001). Treatment satisfaction increased twofold (p < 0.0001). Patients with a shorter history of pain and those with neuralgia and peripheral nerve compression syndrome (PCS) as etiologies had the highest proportion on monotherapy and showed the greatest improvements in pain-related parameters in their respective group categories. CONCLUSION Treatment with pregabalin (as monotherapy or combination therapy) provides benefits in pain and treatment satisfaction in patients with NP, including refractory cases. Shorter disease progression and neuralgia and PCS etiologies are favorable factors for pregabalin treatment response.

Is the effect of inguinal field block with 0.5 % bupivacaine on postoperative pain after hernia repair enhanced by addition of ketorolac or S(+) ketamine ?

Résumé Malgré l'apparition de nouvelles techniques chirurgicales dites « sans tension », l'antalgie post-opératoire après cure de hernie inguinale reste un défi pour les anesthésiologistes. Récemment on a suggéré que l'addition de ketamine ou d'un anti-inflammatoire non-stéroïdien (AINS) à un anesthésique local pourrait améliorer et prolonger l'analgésie postopératoire. Le but de cette étude, à laquelle ont participé 36 patients ASA I-II, était d'évaluer si la coadministration de S(+) ketamine ou de ketorolac renforcerait les effets analgésiques de la bupivacaïne après cure ambulatoire de hernie inguinale sous anesthésie générale. L'analgésie a consisté en une infiltration de la plaie associé à un bloc inguinal avec soit 30 ml de bupivacaïne 0,5 % (n=12), soit 27 ml de bupivacaïne 0,5 % + 3 ml de S(+) ketamine (75 mg) (n=12), soit 28 ml de bupivacaïne 0,5 % + 2 ml de ketorolac (60 mg) (n=12). La prise orale d'antalgique en phase postopératoire était standardisée. L'intensité des douleurs a été évaluée au moyen d'une échelle visuelle analogique (EVA), d'un score verbal d'estimation et par algométrie de pression respectivement 2, 4, 6, 24 et 48 heures après l'intervention. Les trois groupes de patients ont présenté le score de douleur évalué par EVA le plus élevé à 24 heures, score significativement différent de ceux mesurés à 6 et 48 heures (P <0.05). A part une sensation de douleurs significativement moindre (score verbal d'estimation) dans le groupe ketorolac à 24 et 48 heures et seulement à 48 heures dans le groupe ketamine, il n'y avait aucune autre différence entre les groupes pour la durée de l'étude (48 heures) en ce qui concerne les scores de douleur, les seuils de douleur à la pression ou la prise postopératoire d'antalgiques « de secours ». En conclusion, l'addition de S(+) ketamine ou de ketorolac, n'améliore que marginalement l'effet analgésique de la bupivacaïne. Ceci peut-être mis en relation avec la technique de cure de hernie « sans tension » induisant un bas niveau de douleur postopératoire. Abstract Objective: The aim of the study was to assess whether coadministration of S(±) ketamine or ketorolac would enhance or prolong local analgesic effect of bupivacaine after inguinal hernia repair. Design: Prospective double-blind randomized study evaluating pain intensity after surgery under general anesthesia. Setting: Outpatient facilities of the University Hospital of Lausanne. Patient: Thirty-six ASA I-II outpatients scheduled for elective day-case inguinal herniorraphy. Intervention: Analgesia strategy consisted of a wound infiltration and an inguinal field block either with 30 mL bupivacairie (0.5%) or with the same volume of a mixture of 27 mL bupivacaine (0.5%) + 3 mL S(+) ketamine (75 mg) or a 28 mL bupivacaine (0.5%) + 2 ML ketorolac (60 mg). Postoperative analgesic regimen was standardized. Outcome Measures: Pain intensity was assessed with a Visual Analog Seale, a verbal rating score, and by pressure algometry 2, 4, 6, 24, and 48 hours after surgery. Results: The 3 groups of patients experienced the highest Visual Analog Scale pain score at 24 hours, which was different from those at 6 and 48 hours (P < 0.05). Apart from a significantly lower pain sensation (verbal rating score) in the ketorolac group at 24 and 48 hours and only at 48 hours with ketamine, there were no other differences in pain scores, pain pressure thresholds, or rescue analgesic consumption between groups throughout the 48-hour study period. Conclusion: The addition of S (+)-ketamine or ketorolac only minimally improves the analgesic effect of bupivacaine. This may be related to the tension-free hernia repair technique associated with low postoperative pain.

Applications of the hexanic fraction of Agave sisalana Perrine ex Engelm (Asparagaceae): control of inflammation and pain screening

The present study evaluated the anti-inflammatory and analgesic properties of Agave sisalana Perrine in classic models of inflammation and pain. The hexanic fraction of A. sisalana (HFAS) was obtained by acid hydrolysis followed by hexanic reflux. Anti-inflammatory properties were examined in three acute mouse models (xylene ear oedema, hind paw oedema and pleurisy) and a chronic mouse model (granuloma cotton pellet). The antinociceptive potential was evaluated in chemical (acetic-acid) and thermal (tail-flick and hot-plate test) models of pain. When given orally, HFAS (5, 10, 25 and 50 mg/kg) reduced ear oedema (p < 0.0001; 52%, 71%, 62% and 42%, respectively). HFAS also reduced hind paw oedema at doses of 10 mg/kg and 25 mg/kg (p < 0.05; 42% and 58%, respectively) and pleurisy at doses of 10 mg/kg and 25 mg/kg (41% and 50%, respectively). In a chronic model, HFAS reduced inflammation by 46% and 58% at doses of 10 mg/kg and 25 mg/kg, respectively. Moreover, this fraction showed analgesic properties against the abdominal writhing in an acetic acid model (at doses of 5-25 mg/kg) with inhibitory rates of 24%, 54% and 48%. The HFAS also showed an increased latency time in the hot-plate (23% and 28%) and tail-flick tests (61% and 66%) for the 25 mg/kg and 50 mg/kg doses, respectively. These results suggest that HFAS has anti-inflammatory and analgesic properties.

Breakthrough cancer pain - still a challenge.

Breakthrough cancer pain is defined as transient pain exacerbation in patients with stable and controlled basal pain. Although variable, the prevalence of breakthrough cancer pain is high (33%-95%). According to the American Pain Foundation, breakthrough pain is observed in 50%-90% of all hospitalized cancer patients, in 89% of all patients admitted to homes for the elderly and terminal-patient care centers, and in 35% of all ambulatory care cancer patients. The management of breakthrough cancer pain should involve an interdisciplinary and multimodal approach. The introduction of new fentanyl formulations has represented a great advance and has notably improved treatment. Among these, the pectin-based intranasal formulation adjusts very well to the profile of breakthrough pain attacks, is effective, has a good toxicity profile, and allows for convenient dosing - affording rapid and effective analgesia with the added advantage of being easily administered by caregivers when patients are unable to collaborate.

Wandering, verbally and physically abusive behaviour and their relation with pain in nursing homes residents

Backgrounds:¦Behavioural and psychological symptoms of dementia (BPSD) include, among others, hallucinations, delusions, depression, euphoria, agitation, aggression, sexual desinhibition, sleep disturbances, and apathy (1). To our knowledge, surprisingly few studies looked into the possible association between pain and BPSD in nursing home residents. Given this dearth of studies, we wondered whether or not there is an association, in nursing home residents, between pain and BPSD, in particular wandering as well as verbally and physically abusive behaviour, and whether or not this possible association changes with the degree of cognitive impairment.¦Method:¦All nursing home residents in the three Swiss cantons Aargau, Basel-City, and Solothurn (corresponding to 13.5%¦of the total Swiss population) receive a Resident Assessment Instrument Minimum Data Set (RAI-MDS)¦assessment within the first two weeks upon entry. This yielded a total sample of 16'430 nursing home residents considering that the residents' assessment took place between 1997 and 2007 and that we only took into account the admission RAI-MDS assessment. Only residents for whom data on pain was recorded were included in the study (n = 16'183).¦Results:¦Wandering correlated significantly with pain although the effect size was small (Spearman correlation coefficient = 0.052; p = 0.000), a result very similar to that found for VAB (Spearman correlation coefficient = 0.034; p = 0.000) and PAB (Spearman correlation coefficient = 0.043; p = 0.000). Likewise, using linear regression analyses, pain was very significantly associated with any of the three BPSD considered, but it predicted astonishingly little of the¦variance observed (wandering: B = 0.036; p = 0.000; R2 = 0.002; VAB: B = 0.021; p = 0.000; R2 = 0.001 PAB: B = 0.012; p = 0.000; R2 = 0.001). The interaction of pain and cognition had a significant effect on the three BPSD, suggesting that cognition was a moderator of the relationship between pain and all three behaviours.¦Conclusion:¦Wandering behaviours, VAB and PAB seem to be predicted by many factors. Although pain predicts only a small part of variance of these behaviours, it still remains important to recognise and treat pain in order to reduce these behaviours at least a little both in intensity and frequency. Given the dearth of studies and their somewhat contradictory results, further studies ought to investigate the role, the type and localisation of pain might play on the expression of different BPSD or how residents suffering from dementia perceive pain.

2003-2013 : bilan de dix anx de recherche sur la parentalité lors de la naissance d'un enfant avec une fente oro-faciale

La naissance d'un enfant avec une fente oro-faciale est souvent vécue comme un événement à portée traumatique pour les parents, pouvant avoir un impact sur les représentations de l'enfant et la mise en place de la relation. Cet article propose un bilan des dix années de recherche lausannoise sur le développement de la parentalité et des liens précoces, auprès des familles d'enfants naissant avec une fente, depuis l'annonce du diagnostic jusqu'à l'âge préscolaire. Des aspects tels que les représentations parentales. les interactions précoces, ainsi que la qualité de l'attachement sont investigués.

Free flaps in surgical dermatology. Comparison between fasciocutaneous and myocutaneous free flaps in facial reconstructions.

BACKGROUND Dermatologic surgeons routinely harvest pedicled flaps at distance with an axial or random pattern to repair facial defects. These types of skin flaps are time-consuming and have high economic, social and personal costs. These drawbacks could be avoided with the introduction of a single-step transfer of free flaps to the recipient site, with microvascular anastomosis. OBJECTIVE To demonstrate that better results are obtained with myocutaneous or fasciocutaneous free flaps and which one is more suitable in surgical dermatology. MATERIAL AND METHODS We selected two patients of opposite sexes and similar ages who had undergone Mohs surgery to remove recurrent malignant tumors that were located in the upper cheek bordering the zygomatic zone. The woman was treated with a fasciocutaneous radial free flap and the man with a rectus abdominis free flap. RESULTS Both patients had excellent immediate postoperative outcomes. Complications observed in the male patient were related to a previous pulmonary alteration. The fasciocutaneous radial free flap reconstruction was easier to perform than the rectus abdominis free flap; nevertheless, the radial free flap is very thin and, although the palmaris longus tendon is used, it does not yield enough volume, requiring later use of implants. In contrast, the rectus abdominis free flap transfers a wide flap with enough fat tissue to expand in the future. As for the cosmetic results regarding the donor site, the rectus abdominis free flap produces better-looking scars, since secondary defects of the palmar surface cannot be directly closed and usually require grafting - a situation that some patients do not accept. CONCLUSIONS In surgical dermatology, each case, once the tumor has been extirpated, requires its own reconstructive technique. The radial free flap is suitable for thin patients who are willing to cover their arm with a shirt. The rectus abdominis free flap is best suited for obese patients with deep and voluminous defects, although it is necessary to dislocate the navel from its original position.

Paralysie faciale: diagnostic et prise en charge [Diagnosis and management of facial paralysis]

Facial palsy is an unusual pathology that requires standard investigations and management. A clinical overview of the current attitudes is suggested to the general practitioners in order to help them in initiating the adequate investigations and treatment before referring the patient to a specialist.