Form Of Analgesia Research Articles

Systematic Review of the Effectiveness of Remifentanil in Term Breech Pregnancies Undergoing External Cephalic Version

(Int J Obstet Anesth. 2023:54:103649) Approximately 3% to 4% of pregnancies involve a fetus in the breech position. External cephalic version (ECV) is supported and recommended to reduce the cesarean delivery rate. Neuraxial analgesia for ECV can improve the success rate; however, there are associated risks with the use of neuraxial analgesia in these cases. Remifentanil has recently been proposed as an alternative to neuraxial analgesia for ECV. This study aimed to assess and analyze the use of remifentanil in cases where ECV is necessary, as well as compare it to outcomes in ECV with other forms of analgesia.

Public and industry knowledge and perceptions of US swine industry castration practices.

In the United States (US), surgical castration of male piglets is typically performed without any form of analgesia. This may raise concerns with the public; however, there is no information regarding current public knowledge on swine industry practices in the US. In this study we gained insight into public knowledge and perception on castration with and without analgesia in comparison to knowledge of industry stakeholders on these same topics. Through an online survey, 119 respondents were asked four questions about castration in the US swine industry. Industry respondents were contacted via social media and networking. The general public sample was accessed through Mechanical Turk. Survey responses were categorised by experience (industry vs public). Industry respondents were more aware of practices compared to the general public. Most public respondents were unaware of castration practices and the lack of analgesia use. Respondents from rural communities were more aware of castration practices than (sub)urban communities and more aware of analgesia use than those from urban communities. Those with more education had greater awareness of castration practices (occurrence not frequency). Based on the results from this first US sample, knowledge on industry practices was especially lacking for public respondents, but also for a minority of industry respondents, indicating opportunities for education and further research on the topic.

A Cut Above the Rest: The Historic Perspectives of Circumcision and Anesthesia

Introduction: Circumcision is the oldest known recorded surgical procedure dating to at least 4000 BCE and held religious, cultural, and military significance. Preputial resection connoted contrasting meanings among different cultures; in some, circumcision was and remains an important transtion into infancy and then adulthood. In Bronze Age and early Egyptian cultures, however, circumcision was performed on vanquished enemies and improved upon the morbidity and mortality of phallic resectoin as a war trophy. The circumcision of Jesus was a significant subject for many Medieval and Renaissance artists who often portrated the event as an allegroical commentary on contemporary socio-political events. While there has been much literature, anthropological analysis, and art on circumcision, little is known about the anesthesia provided to those undergoing the procedure, especially those for whom the act was not a punitive militaristic procedure. We aimed to identify descriptions of the anesthesia provided to patients or victims undergoing circumcision and how the anesthesia may have evolved into the modern techniques used in the modern era. Sources and Methods: We performed a literature review via PubMed journal articles, texts, and historical discussions detailing the evolution of circumcision and accompanying anesthesia throughout history. Results: Earliest records of circumcision described religious rather than scientific rationale, marking a boy’s ascension to manhood. Documentation of the earliest practices of anesthesiology are relevant to urology through these traditions. Circumcision is first noted in Egyptian temple hieroglyphics dated to 4000 BCE, depicting young men restrained with a priest performing the cut wielding a knife. As early as 2500 BCE, circumcision in ancient Egypt was the first known surgical procedure utilizing anesthesia. A mixture rendered from calcium carbonate and acetic acid formed carbon dioxide on the prepuce resulting in the first rendition of cryo-analgesia. Egypt was not the only culture performing circumcision during this time period. Assyrian records dating back to 400 BCE describe a similar methodology, but also transcribed another primitive method of anesthesia. Assyrians utilized digital compression of the carotid arteries to produce anesthetic effects of both altered consciousness and decreased procedural pain. Carotid compression was commonplace enough that it influenced the language for which the carotid blood vessels are described in both Greek and Russian with translation as “The Artery of Sleep.” The Jewish tradition of brit milah utilizes a few drops of wine in the mouth of the infant, both as a form of analgesia and symbolic of the sealed covenant. It is hypothesized that the sugar interacts with the opiate receptors in the brain which is enhanced by the suckling action, providing comfort. Conclusions: Since their earliest documented history, anesthetic techniques have contributed to and been intertwined with the practices of circumcision.

HF01-09 A CUT ABOVE THE REST: HISTORIC PERSPECTIVES OF CIRCUMCISION AND ANESTHESIA

You have accessJournal of UrologyHistory of Urology Forum I (HF01)1 Sep 2021HF01-09 A CUT ABOVE THE REST: HISTORIC PERSPECTIVES OF CIRCUMCISION AND ANESTHESIA Ellen Lutnick, Kyle Waisanen, and Kevin Pranikoff Ellen LutnickEllen Lutnick More articles by this author , Kyle WaisanenKyle Waisanen More articles by this author , and Kevin PranikoffKevin Pranikoff More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001992.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To explore the origins of circumcision and the use of anesthesia along the journey. METHODS: Literature review via PubMed journal articles, texts, and historical discussion detailing the evolution of circumcision and accompanying anesthesia throughout history. RESULTS: Earliest records of circumcision described religious rather than scientific rationale, marking a boy’s ascension to manhood. Documentation of the earliest practices of anesthesiology are relevant to urology through these traditions. Circumcision is first noted in Egyptian temple hieroglyphics dated to 4000 BCE, depicting young men restrained with a priest performing the cut wielding a knife. As early as 2500 BCE, circumcision in ancient Egypt was the first known surgical procedure utilizing anesthesia. A mixture rendered from calcium carbonate and acetic acid formed carbon dioxide on the prepuce resulting in the first rendition of cryo-analgesia. Egypt was not the only African culture performing circumcision during this time period. Assyrian records dating back to 400 BCE describe a similar methodology, but also transcribed another primitive method of anesthesia. Assyrians utilized digital compression of the carotid arteries to produce anesthetic effects of both altered consciousness and decreased procedural pain. Carotid compression as anesthesia was commonplace enough that it influenced the language for which the carotid blood vessels are described in both Greek and Russian with translation as “The Artery of Sleep”. As the practice was adopted by the Israelites, infant circumcision was acknowledged on the eighth day of life representative of the covenant between God and Abram. It is considered that this shift may have been related to a pubescent male’s ability to refuse the religious covenant on the basis of the painful procedure, while an infant is unable to object. The Jewish tradition of brit milah utilizes a few drops of wine in the mouth of the infant, both as a form of analgesia and symbolic of the sealed covenant. It is hypothesized that the sugar interacts with the opiate receptors in the brain which is enhanced by the suckling action, providing comfort. Today, approximately 1 of 3 males worldwide are circumcised, with 55% of physicians performing infant circumcision choosing not to utilize any form of anesthesia, citing lack of necessity and anesthetic risk. CONCLUSIONS: Since their earliest documented history, anesthetic techniques have contributed to and been intertwined with the practices of circumcision. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e230-e230 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ellen Lutnick More articles by this author Kyle Waisanen More articles by this author Kevin Pranikoff More articles by this author Expand All Advertisement Loading ...

Acute recurrent and chronic pancreatitis in children.

Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step-up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non-opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner.

Obstetric anal sphincter injuries (OASIS) in multiparous women with the use of epidural anaesthesia: A retrospective cohort study.

The use of epidural as a form of analgesia is increasingly common in labour, but this has shown to have been associated with increased rates of instrumental delivery, and prolonged second stage, resulting in increased rates of OASIS (Obstetric Anal Sphincter Injury). This study aimed to investigate the impact of epidural anaesthesia in multiparous women undergoing vaginal deliveries on OASIS and secondary maternal outcomes. A retrospective cohort study of multiparous women with singleton pregnancies delivering at term ≥37weeks and the use of epidural analgesia in labour at a tertiary hospital in Melbourne, Victoria, Australia, the Royal Women's Hospital was undertaken between the period 2012-2018. Maternal outcomes were collated and dichotomised according to the presence of epidural use. Multiparous women with no prior history of a vaginal birth and non-cephalic presentation during labour were excluded. There were 14124 multiparous women who met the inclusion criteria; spontaneous labour is associated with an increased risk of OASIS at adjusted odds ratio (aOR) 1.46, P=0.012. The overall rate of epidural use was 17%. Women with epidural use had significantly lower chances of sustaining OASIS in normal vaginal births and instrumental vaginal births. (1% vs 1.8%, aOR 0.49, P=0.004). Epidural is associated with increased rates of prolonged second stage (8.5% vs 3.8%, P<0.05), instrumental delivery (26.1% vs 4%, P<0.05), and episiotomy use (23.8% vs 10.2%, P<0.05). The use of epidural analgesia in multiparous women is associated with a reduction in anal sphincter injuries.

P1468ASSESSING THE BURDEN OF CHRONIC PAIN IN PATIENTS UNDERGOING HAEMODIALYSIS: A CROSS-SECTIONAL OBSERVATIONAL STUDY

Abstract Background and Aims Chronic pain is a global health problem estimated to affect between 20- 50% of the population and is associated with increased hospitalisations placing a significant burden on healthcare resources. The burden of chronic pain is thought to be especially high in patients undergoing renal replacement due to underlying co-morbidities such as diabetes, peripheral vascular disease and renal bone disease. There is, however, a lack of data out with the United States quantifying the burden in patients undergoing chronic dialysis. The aim of this study was to establish the burden of chronic pain through examination of prescribing records in patients undergoing chronic dialysis. Method We performed a cross sectional observational study in 2 Scottish health boards (together serving 1.9 of Scotland’s 5 million population). Data were collated on age, dialysis vintage, primary renal diagnosis and analgesia prescribing specifically examining whether patients were prescribed paracetamol, non-steroidal anti-inflammatory agents, opioids or gabapentinoids. Descriptive statistics were performed. Results 721 patients receiving haemodialysis were included in the analysis (141 from the Tayside area and 580 from Greater Glasgow and Clyde). Mean age was 64 years old (SD 14.4) with a median time since commencing renal replacement therapy of 3 years (IQR 1.4-6.4). The primary renal diagnosis was diabetes for 28% of the patients, multisystem diseases for 21.6%, interstitial nephropathies for 21.5%, primary glomerulonephritis for 15.8%, and unknown or related to another disease for 10%. Of these 527 (73%) were prescribed a form of analgesia. 404 patients (56%) were prescribed paracetamol, 14 (1.9%) were prescribed a non-steroidal anti-inflammatory, 96 (35.4%) an opioid, 71 (9.8%) a combination of paracetamol with opioid, 170 (23.6%) a gabapentinoid and 100 (14%) were prescribed both a gabapentinoid and opioid. There was no difference in age between those receiving analgesia and those who were not (63.5 vs 65.2, p=0.13). However patients receiving opioids were significantly younger than those who were not prescribed any opioid (62.2 SD 13.9 vs 65 SD 14.5, p-value = 0.001; Wilcoxon rank sum test). There was no difference in percentage of patients receiving analgesia by primary renal diagnosis: Figure 1 (Chi-square test, p=0.1). Conclusion Prescribing rates of analgesia are high in patients undergoing chronic dialysis suggesting a high burden of chronic pain. Number of patients receiving analgesia (in red) or not (in blue), depending on their primary renal diagnosis. 1=primary glomerulonephritis, 2=interstitial nephropathies, 3=multisystem diseases, 4=diabetic nephropathy, 5=not known or other

Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis.

Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectivelythan metamizole (mean difference 32mm on a 100mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.

Pain and stress: functional evidence that supra-spinal mechanisms involved in pain-induced analgesia mediate stress-induced analgesia.

Analgesia induced by stressful and painful stimuli is an adaptive response during life-threatening situations. There is no evidence linking the mechanisms underlying them, while the former depends on the activation of stress-related brain pathways, the second depends on opioidergic mechanisms in the nucleus accumbens and on nicotinic cholinergic mechanisms in the rostral ventromedial medulla. In this study, we hypothesized that stress-induced analgesia is also dependent on opioidergic mechanisms in the nucleus accumbens and on nicotinic cholinergic mechanisms in the rostral ventromedial medulla. We used immobilization, a classical procedure to induce acute stress, and evaluated its ability to decrease the nociceptive responses induced either by carrageenan or by formalin in rats. Immobilization stress significantly decreased either carrageenan-induced hyperalgesia or formalin-induced tonic nociception in a time-dependent manner. This stress-induced analgesia is similar to pain-induced analgesia, as revealed by contrasting the antinociceptive effect induced by immobilization and by a forepaw injection of capsaicin. The administration of a µ-opioid receptor antagonist (CTOP, 0.5 µg) into the nucleus accumbens, as well as that of a nicotinic cholinergic receptor antagonist (mecamylamine, 0.6 µg) into the rostral ventromedial medulla, blocked immobilization stress-induced analgesia in both pain models. These results demonstrate that supraspinal mechanisms which are known to mediate pain-induced analgesia also mediate stress-induced analgesia. Therefore both forms of analgesia have overlapping mechanisms, probably recruited in response to the perception of danger.

The Influence of a Positive Empathetic Interaction on Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia.

Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) are 2 forms of endogenous analgesia. Many forms of analgesia can be influenced by the nature of the patient-clinician interaction. The aim of this study was to evaluate the influence of an empathetic and supportive interaction on CPM and MIA in people with lateral epicondylalgia (LE). In a double-blind, randomized, controlled trial, 68 participants with LE were assigned to 2 groups: the empathetic and neutral interaction groups. The interactions were carried out by a trained, professional role-play actor, playing the part of a research assistant. The research assistant actor spent 15 minutes before CPM and MIA assessment interacting with the participants in an empathetic or neutral manner. Immediately after the interaction, a blinded assessor measured pressure pain threshold at the symptomatic elbow and ipsilateral wrist during CPM and MIA testing. Linear mixed models were used to evaluate differences in CPM and MIA responses between the interaction groups. There was a significant difference in Consultation and Relational Empathy scores between the groups (P<0.001), indicating that the intervention group experienced a more empathic interaction. Both groups showed a significant increase in pressure pain threshold measures, indicative of a CPM and MIA analgesic response (P<0.001), however, the analgesic responses were greater in the group that had experienced a supportive, empathetic interaction (post CPM, wrist: P<0.001; elbow: P=0.001) (post MIA wrist: P<0.001; elbow: P=0.001). A single session of empathetic interaction positively influenced both CPM and MIA responses in people with LE.

Regional pain management for oesophagectomy: Cohort study suggests a viable alternative to a thoracic epidural to enhance recovery after surgery

Ivor Lewis oesophagectomy (ILO) is associated with significant acute postsurgical pain and persistent chronic pain. The purpose of this study was to compare the Concord technique, which involves a combination of a surgeon-inserted paravertebral catheter, a single injection of intrathecal morphine and surgeon-inserted bilateral preperitoneal catheters, with the other available analgesic techniques. The study was designed as a retrospective cohort study and performed at the Concord Repatriation General Hospital, a tertiary teaching hospital affiliated with Sydney University. The participants comprised 60 consecutive patients in whom ILO was undertaken from January 1, 2011 to December 31, 2017, who were retrospectively analysed according to analgesic technique. The maximum, minimum and average pain numerical rating scale (NRS) scores were prospectively recorded daily for 3 days, opioid use for 3 days, and hospital length of stay, intensive care unit (ICU) length of stay, 30-day mortality and postoperative complications were also recorded. The Concord regional anaesthetic technique group had an average NRS pain scores which appeared favourable for day 0 (0.90 vs. 1.42), but no statistical differences were found between either group on day 1 (1.34 vs. 1.54), day 2 (0.94 vs. 1.13) or day 3 (0.94 vs. 1.00). The 30-day mortality, length of stay in hospital and ICU, and postoperative complications were comparable. The Concord regional technique for ILO analgesia appears to provide a simple alternative to other forms of analgesia, with similar analgesic efficacy and with no differences in postoperative complications. This may provide a pathway to enhanced recovery and is suitable to be evaluated in a Randomised control trial (RCT) of techniques.

Analgesia for procedural pain: Current practice among Nigerian paediatricians

Background: Minor procedures such as venepuncture and lumbar puncture among others are routinely performed in the neonatal intensive care units (NICUs) and paediatric wards. These procedures are accompanied by varying degrees of pain which, if not addressed, can lead to undesirable physiological, cardiovascular, respiratory, hormonal, metabolic and behavioural responses. This study evaluated the current strategies for reducing procedural pain in children in Nigeria. Methods: This was a questionnaire-based, cross-sectional random survey of the current practice of analgesic techniques for procedural pain among 240 respondents out of 700 consultant paediatricians and residents who attended the annual Paediatric Association of Nigeria Conference in 2018. Results: The male-to-female ratio was 1:1.3, the mean age of the respondents was 38.28 ± 7.36 years and the median year of practice was 10 years. Of the surveyed respondents, consultants and trainees constituted 40.8% and 59.2%, respectively, whereas 46.2% and 51.3% of them assessed pain and routinely administered analgesia to treat procedural pain, respectively. Breastfeeding and topical analgesic agent were prescribed by 18.3% and 12.9% of the respondents, respectively. Pain of venous access and lumbar puncture were treated by 38.8% and 19.6% of the respondents, respectively. Only 13.3% of the respondents have institutional guidelines for pain assessment and treatment in their practice locations. Conclusion: The survey showed that, even though a sizeable proportion of paediatricians do assess pain and provide some form of analgesia for procedural pain, there is a lack of institutional pain treatment guidelines in most hospitals attending to the medical needs of children in Nigeria.

Analgesia and pain

Acupuncture is shown as a treatment to reduce some types of pain, a compendium of some reviews on analgesia and pain is presented, but mainly the acupuncture technique. The types of pain and the different forms of analgesia are described, as a fundamental element, assessing acupuncture as one of the oldest and most reliable methods to face pain. In addition, a brief review is made of other types of analgesia such as hypnosis, general anesthesia, local, digit puncture, or shiatsu, the twelve common channels (meridians). Knowing always that the success of acupuncture depends in the first place on the correct choice of the points on which to act; secondly, it depends on the medium used, which should be the most appropriate in each case (type of needle to be used); In addition, the way in which they should be applied is analyzed. The work sends a reflection related to healthy life, proposing that the traditional methods used to alleviate the different pains and achieve the integral harmony of the human body.

Analgesia linked to Nav1.7 loss of function requires µ- and δ-opioid receptors

Background: Functional deletion of the Scn9a (sodium voltage-gated channel alpha subunit 9) gene encoding sodium channel Nav1.7 makes humans and mice pain-free. Opioid signalling contributes to this analgesic state. We have used pharmacological and genetic approaches to identify the opioid receptors involved in this form of analgesia. We also examined the regulation of proenkephalin expression by the transcription factor Nfat5 that binds upstream of the Penk gene. Methods: We used specific µ-, δ- and κ-opioid receptor antagonists alone or in combination to examine which opioid receptors were necessary for Nav1.7 loss-associated analgesia in mouse behavioural assays of thermal pain. We also used µ- and δ-opioid receptor null mutant mice alone and in combination in behavioural assays to examine the role of these receptors in Nav1.7 knockouts pain free phenotype. Finally, we examined the levels of Penk mRNA in Nfat5-null mutant mice, as this transcription factor binds to consensus sequences upstream of the Penk gene. Results: The pharmacological block or deletion of both µ- and δ-opioid receptors was required to abolish Nav1.7-null opioid-related analgesia. κ-opioid receptor antagonists were without effect. Enkephalins encoded by the Penk gene are upregulated in Nav1.7 nulls. Deleting Nfat5, a transcription factor with binding motifs upstream of Penk, induces the same level of enkephalin mRNA expression as found in Nav1 .7 nulls, but without consequent analgesia. These data confirm that a combination of events linked to Scn9a gene loss is required for analgesia. Higher levels of endogenous enkephalins, potentiated opioid receptors, diminished electrical excitability and loss of neurotransmitter release together contribute to the analgesic phenotype found in Nav1.7-null mouse and human mutants. Conclusions: These observations help explain the failure of Nav1.7 channel blockers alone to produce analgesia and suggest new routes for analgesic drug development.

Analgesia linked to Nav1.7 loss of function requires µ- and δ-opioid receptors.

Background: Functional deletion of the Scn9a (sodium voltage-gated channel alpha subunit 9) gene encoding sodium channel Nav1.7 makes humans and mice pain-free. Opioid signalling contributes to this analgesic state. We have used pharmacological and genetic approaches to identify the opioid receptors involved in this form of analgesia. We also examined the regulation of proenkephalin expression by the transcription factor Nfat5 that binds upstream of the Penk gene. Methods: We used specific µ-, δ- and κ-opioid receptor antagonists alone or in combination to examine which opioid receptors were necessary for Nav1.7 loss-associated analgesia in mouse behavioural assays of thermal pain. We also used µ- and δ-opioid receptor null mutant mice alone and in combination in behavioural assays to examine the role of these receptors in Nav1.7 knockouts pain free phenotype. Finally, we examined the levels of Penk mRNA in Nfat5-null mutant mice, as this transcription factor binds to consensus sequences upstream of the Penk gene. Results: The pharmacological block or deletion of both µ- and δ-opioid receptors was required to abolish Nav1.7-null opioid-related analgesia. κ-opioid receptor antagonists were without effect. Enkephalins encoded by the Penk gene are upregulated in Nav1.7 nulls. Deleting Nfat5, a transcription factor with binding motifs upstream of Penk, induces the same level of enkephalin mRNA expression as found in Nav1 .7 nulls, but without consequent analgesia. These data confirm that a combination of events linked to Scn9a gene loss is required for analgesia. Higher levels of endogenous enkephalins, potentiated opioid receptors, diminished electrical excitability and loss of neurotransmitter release together contribute to the analgesic phenotype found in Nav1.7-null mouse and human mutants. Conclusions: These observations help explain the failure of Nav1.7 channel blockers alone to produce analgesia and suggest new routes for analgesic drug development.

A Review of the Burden of Trauma Pain in Emergency Settings in Europe.

Trauma pain represents a large proportion of admissions to emergency departments across Europe. There is currently an unmet need in the treatment of trauma pain extending throughout the patient journey in emergency settings. This review aims to explore these unmet needs and describe barriers to the delivery of effective analgesia for trauma pain in emergency settings. A comprehensive, qualitative review of the literature was conducted using a structured search strategy (Medline, Embase and Evidence Based Medicine Reviews) along with additional Internet-based sources to identify relevant human studies published in the prior 11 years (January 2006–December 2017). From a total of 4325 publications identified, 31 were selected for inclusion based on defined criteria. Numerous barriers to the effective treatment of trauma pain in emergency settings were identified, which may be broadly defined as arising from a lack of effective pain management pan-European and national guidelines, delayed or absent pain assessment, an aversion to opioid analgesia and a delay in the administration of analgesia. Several commonly used analgesics also present limitations in the treatment of trauma pain due to the routes of administration, adverse side effect profiles, pharmacokinetic properties and suitability for use in pre-hospital settings. These combined barriers lead to the inadequate and ineffective treatment of trauma pain for patients. An unmet need therefore exists for novel forms of analgesia, wider spread use of available analgesic agents which overcome some limitations associated with several treatment options, and the development of protocols for pain management which include patient assessment of pain.Funding: Mundipharma International Ltd.Electronic supplementary materialThe online version of this article (10.1007/s40122-018-0101-1) contains supplementary material, which is available to authorized users.

Noninfectious Fever in the Near-Term Pregnant Rat Induces Fetal Brain Inflammation: A Model for the Consequences of Epidural-Associated Maternal Fever.

Women laboring with epidural analgesia experience fever much more frequently than do women who chose other forms of analgesia, and maternal intrapartum fever is associated with numerous adverse consequences, including brain injury in the fetus. We developed a model of noninfectious inflammatory fever in the near-term pregnant rat to simulate the pathophysiology of epidural-associated fever and hypothesized that it would produce fetal brain inflammation. Twenty-four pregnant Sprague-Dawley rats were studied at 20 days gestation (term: 22 days). Dams were treated by injection of rat recombinant interleukin (IL)-6 or vehicle at 90-minute intervals, and temperature was monitored every 30 minutes. Eight hours after the first treatment, dams were delivered of fetuses and then killed. Maternal IL-6 was measured at delivery. Fetal brains (n = 24) were processed and stained for ED-1/CD68, a marker for activated microglia, and cell counts in the lateral septal and hippocampal brain regions were measured. Fetal brains were also stained for cyclooxygenase-2 (COX-2), a downstream marker of neuroinflammation. Eight fetal brains were further analyzed for quantitative forebrain COX-2 by Western blotting compared to a β-actin standard. Maternal temperature and IL-6 levels were compared between treatments, as were cell counts, COX-2 staining, and COX-2 levels by Mann-Whitney U test, repeated-measures analysis of variance, or Fisher exact test, as appropriate. Injection of rat IL-6 at 90-minute intervals produced an elevation of maternal temperature compared to vehicle (P < .0001). IL-6 levels were elevated to clinically relevant levels at delivery in IL-6 compared to vehicle-treated animals (mean ± standard deviation: 923 ± 97 vs 143 ± 94 pg/mL, P = .0006). ED-1-stained cells were present in significantly higher numbers in fetal brains from IL-6 compared to saline-treated dams (median [interquartile range]: caudal hippocampus, 99 [94-104] and 64 [57-68], respectively, P = .002; lateral septum, 102 [96-111] and 68 [65-69], respectively, P = .002), as well as COX-2 immunostaining (lateral septum, 22 [20-26] and 17 [15-18], respectively, P = .005; dorsal hippocampus, 27 [22-32] and 16 [14-19], respectively, P = .013) and quantitative COX-2 Western blotting activity (mean ± standard error of the mean: vehicle, 0% of β-actin intensity versus IL-6, 41.5% ± 24%, P < .001). Noninfectious inflammatory fever is inducible in the near-term pregnant rat by injection of IL-6 at levels comparable to those observed during human epidural labor analgesia. Maternal IL-6 injection causes neuroinflammation in the fetus.

Effects of Acupuncture in Anesthesia for Craniotomy: A Meta-Analysis.

Acupuncture treatment has been used in China for >2500 years, and at present it is used worldwide as a form of analgesia in patients with acute and chronic pain. Furthermore, acupuncture is regularly used not only as a single anesthetic technique but also as a supplement or in addition to general anesthesia (GA). The aim of this systematic review and meta-analysis was to assess the level of evidence for the clinical use of acupuncture in addition to GA in patients undergoing craniotomy. This is a systematic review of randomized controlled trials with meta-analyses. The literature search (PubMed, Cochrane Library, and Web of Science) yielded 56 citations, published between 1972 and March 01, 2015. No systematic review or meta-analyses on this topic matched our search criteria. Each article of any language was assessed and rated for the methodological quality of the studies, using the recommendation of the Oxford Centre for Evidence Based Medicine. Ten prospective randomized controlled clinical trials with a total of 700 patients were included. Included in the meta-analysis were studies that involved any craniotomy under GA compared with a combination of GA and acupuncture. Exclusion criteria were no acupuncture during surgery, no GA during surgery, only postoperative data available, animal studies, and low grade of evidence. The use of acupuncture significantly reduced the amount of volatile anesthetics during surgery (P<0.001) and led to faster extubation time (P=0.001) and postoperative patient recovery (P=0.003). In addition, significantly reduced blood levels of the brain tissue injury marker S100β 48 hours after operation (P=0.001) and occurrence of postoperative nausea and vomiting (P=0.017) were observed. No patient studied suffered from awareness. The analysis suggests that the complementary use of acupuncture for craniotomy has additional analgesic effects, reduces the needed amount of volatile anesthetic, reduces the onset of postoperative nausea and vomiting, and might have protective effects on brain tissue. Our findings may stimulate future randomized controlled trials to provide definitive recommendations.

Assisted reproduction technology: Comparison of anesthetic techniques for oocyte retrieval in a tertiary health facility in Ilorin, Nigeria

Background: Transvaginal ultrasound-guided oocyte retrieval (TUGOR) technique is minimally invasive and requires shorter time compared to previous techniques. Yet, it is a potentially stressful and painful procedure and thus requires some form of analgesia with or without sedation. The effects of various anesthetic techniques used for TUGOR on reproductive outcomes remain controversial. Aims and Objectives: This study aimed at comparing the efficacy of paracervical block (PCB) and conscious sedation for pain relief and pregnancy outcomes during TUGOR. Materials and Methods: This is a cross-sectional comparative study of 137 eligible clients that underwent assisted reproduction program in our facility. All clients were treated with antagonist protocol for controlled ovarian hyperstimulation. The choice of analgesia for TUGOR was influenced by clients' and/or clinicians' preference. PCB and conscious sedation were administered for TUGOR in 66 and 71 clients, respectively. Pain was assessed using a 10-cm Visual Analog Scale (VAS), while clients' overall satisfaction was rated using Likert scoring system. Results: There was no statistically significant difference in the clinical pregnancy, miscarriage, and live birth rates between the two groups. The mean VAS 10-point scores at 1, 6, and 24 h postretrieval and on the day of embryo transfer were significantly higher for paracervical group. The mean Likert score for conscious sedation group was significantly higher than that of paracervical group. Conclusion: Conscious sedation is superior to PCB as anesthetic/analgesic agent for pain relief and clients' satisfaction for TUGOR. However, a multimodal approach to anesthesia/analgesia for TUGOR is suggested to further improve overall clients' satisfaction.

Management of Bladder Pain Syndrome: Green-top Guideline No. 70.

Management of Bladder Pain Syndrome: Green-top Guideline No. 70.