Role of Alternative Therapies for Chronic Pain Syndromes.

There is increasing interest in the use of complimentary and alternative medicine (CAM) for the treatment of chronic pain. This review examines alternative and complimentary therapies, which can be incorporated as part of a biopsychosocial approach in the treatment of chronic pain syndromes. In the present investigation, literature from articles indexed on PubMed was evaluated including topics of alternative therapies, complimentary therapies, pain psychology, biofeedback therapy, physical exercise therapies, acupuncture, natural and herbal supplements, whole-body cryotherapy, and smartphone technologies in the treatment of chronic pain syndromes. This review highlights the key role of psychology in the treatment of chronic pain. Cognitive behavior therapy appears to be the most impactful while biofeedback therapy has also been shown to be effective for chronic pain. Exercise therapy has been shown to be effective in short-, intermediate-, and long-term pain states. When compared to that in sham controls, acupuncture has shown some benefit for neck pain immediately after the procedure and in the short term and improvement has also been demonstrated in the treatment of headaches. The role of smartphones and whole-body cryotherapy are new modalities and further studies are needed. Recent literature suggests that several alternate therapies could play a role in the treatment of chronic pain, supporting the biopsychosocial model in the treatment of pain states.

PERIOPERATIVE PAIN CONTROL IN GASTROINTESTINAL SURGERY.

Perioperative pain control in the setting of gastrointestinal surgery presents unique challenges for the clinician, including the incidence of ileus and its potential exacerbation by analgesics, large incisions, patient characteristics and a wide variety of other factors. At the same time, optimizing postoperative pain control is of key significance in this patient population and has implications for both medical and surgical outcomes, length of hospital stay and associated costs and risks of developing chronic postsurgical pain. Data from recent clinical trials and other studies have highlighted the impact of specific surgical and anesthetic techniques on post-operative pain for several types of abdominal surgeries, including pancreatoduodenectomy, hepatectomy, gastric bypass, cholecystectomy, colectomy, and appendectomy. The management of pain may be optimized through the multidisciplinary and concerted efforts between clinicians involved in the perioperative care of patients undergoing gastrointestinal surgery.

Newer developments in the immunotherapy of malignant melanoma.

Individuals with malignant melanoma present a variety of immune abnormalities including but not limited to cellular immune dysfunction, antigen presentation deficits, and cytokine production defects. Therefore, enhancing the immune system potential represents an appealing avenue for melanoma therapy. The authors review the immune therapies currently in clinical use as well as the most promising immunotherapy candidates. Ipilimumab, a monoclonal antibody against the CTLA-4, was approved for the therapy of advanced melanoma in 2011. In addition, sizeable anti-melanoma activity has recently been shown with the use of other agents including anti-PD-1/anti-PD-1 ligand antibodies. Consequently, these experimental immunotherapy agents may soon become important items in the anti-melanoma armamentarium.

Malignant melanoma in pigmented skin: does the current interventional model fit a different clinical, histologic, and molecular entity?

BACKGROUND: Although the incidence of malignant melanoma in African Americans is considerably lower than in Caucasians, African Americans have a less-favorable prognosis related to later presentation and more deeply invasive lesions at diagnosis. OBJECTIVE: To review the current literature addressing the specific clinical, histopathologic, and molecular features of melanoma in darkly pigmented individuals. METHODS: We reviewed the most up-to-date literature pertaining to melanoma in this patient population, including data from clinical studies, epidemiologic analyses, and molecular and genetic studies. RESULTS: Several studies have suggested differences between lightly and darkly pigmented populations with regard to clinicopathologic character and the underlying genetic processes affecting its pathogenesis. CONCLUSION: Further investigation is warranted to better elucidate the clinical and underlying biological differences in melanoma between Caucasians and African Americans. Such research may help to ameliorate the disparities in melanoma outcomes through improved screening, public health measures aimed at prevention, and potentially novel targeted therapeutic approaches.

Safety Considerations in the Use of Ketorolac for Postoperative Pain.

BACKGROUND: Ketorolac use has significantly expanded for postoperative pain management since it first became available in the United States, primarily due to well established effects on patient pain scores and its ability to reduce perioperative opioid requirements. As an inhibitor of cyclooxygenase, ketorolac use has raised clinical concern including particular controversy regarding its potential effects on bone healing, postoperative kidney function and perioperative bleeding. OBJECTIVE: To review the supporting data from clinical studies addressing the safety of ketorolac use for postoperative pain. METHOD: This review highlights the most up-to-date research from clinical trials as well as from retrospective studies and meta-analyses regarding the effects of perioperative use of ketorolac on bone healing, kidney function and blood loss. RESULTS: Based on the most up-to-date literature, ketorolac in normal doses has been demonstrated to be safe with respect to bone healing. In patients with normal kidney function, numerous studies have established the safety of Ketorolac; however other studies have raised safety concerns in patients with comorbid kidney, heart and liver disease. While there is evidence that ketorolac may cause prolonged bleeding time and may be associated with increased postoperative blood loss after tonsillectomy, large scale prospective randomized controlled trials and subsequent meta-analyses have failed to establish an association of ketorolac use and perioperative blood loss. CONCLUSION: Perioperative administration of ketorolac has been demonstrated to be safe and effective in healthy patients and is particularly beneficial as an opioid-sparing agent in vulnerable patient groups. However, in certain surgical and medical contexts, proper patient selection based on the multidisciplinary collaboration between perioperative clinician specialists will optimize patient safety and pain management outcomes.

Perioperative Safety of Warfarin Therapy and Reversal.

BACKGROUND: Warfarin is the most widely prescribed oral anticoagulant frequently encountered in the patients presenting for both elective and emergent surgery. Maintaining therapeutic levels of warfarin therapy may increase the risk of blood loss and procedural complications, including complications from neuraxial and regional anesthetic techniques. However, in some vulnerable patient groups, discontinuing therapy may result in negative thromboembolic consequences. OBJECTIVE: To review the published guidelines and supporting data from clinical studies addressing the safe and coordinated management of patients on warfarin therapy who present for perioperative care. METHOD: This review highlights the most up-to-date research from clinical trials as well as from retrospective studies in addition to multidisciplinary consensus guidelines regarding the safety of warfarin therapy and reversal in the perioperative period. RESULTS: Based on the most up-to-date literature, certain patient groups may be more vulnerable to cessation of warfarin therapy before surgery and there exists a risk stratification algorithm. In many other cases, particularly emergent surgery, it may be necessary to reverse warfarin therapy preoperatively. There are anesthetic, surgical and safety implications in these clinical decision points. CONCLUSION: With the aging of the United States population, the prevalence of preoperative patients therapeutic on warfarin will continue to increase, necessitating the multidisciplinary and coordinated care of perioperative clinicians to ensure patient safety and optimize clinical outcomes.

Efficacy and Safety of Nonopioid Analgesics in Perioperative Pain Control.

Opioids have been the mainstay for management of acute postoperative pain for several decades. Extensive use, however, has been associated with multiple side effects. Multimodal approaches that incorporate nonopioid medications and techniques have been observed to achieve optimum pain control whilst decreasing side effects. Such strategies are particularly important to consider for opioid-dependent and tolerant patients with various comorbidities undergoing different types of surgery. This review assesses recent data on nonopioid analgesics for postoperative pain control, highlighting evidence of their safety profiles in contemporary pain management.

Role of regional anesthesia in foot and ankle surgery.

UNLABELLED: Regional anesthesia has increasingly expanded its role in the perioperative care of patients undergoing foot and ankle surgery. In addition to avoiding side effects associated with both general anesthesia and neuraxial anesthetic techniques, especially those related to cardiovascular and pulmonary systems, regional nerve blocks have been shown to improve postoperative pain and reduce hospital stay and associated expenses. The techniques utilized to achieve analgesia of the foot and ankle are diverse, multifaceted, and often incorporate ultrasound guidance. Given the aging of patient populations, and especially the growing incidence of cardiovascular-, pulmonary-, and obesity-related morbidity, the use of regional blocks is likely to expand in these surgical procedures. This review highlights some of the most current developments in the expanding role of regional anesthesia in foot and ankle surgery. LEVELS OF EVIDENCE: Therapeutic, Level II.

Tapentadol extended release in the management of peripheral diabetic neuropathic pain.

Tapentadol, a µ-opioid agonist and norepinephrine reuptake inhibitor, has been found to be an effective medication for a wide variety of chronic pain conditions, including back pain, cancer-related pain, and arthritic pain. It has also been found to have fewer gastrointestinal side effects than more traditional opioid-based therapies. More recently, tapentadol extended release has been demonstrated to be effective in the management of painful diabetic neuropathy, an often debilitating condition affecting approximately one-third of all patients with diabetes. This review highlights the most up-to-date basic and clinical studies by focusing on the mechanisms of action of tapentadol and its clinical efficacy, especially with regard to painful diabetic neuropathy.