The acute pain crisis in sickle cell disease: What can be done to improve outcomes?

The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.

An exploratory study of acute analgesia in tibial shaft fractures: a comparison between Maori and Non-Maori.

BACKGROUND: Published research suggests Indigenous peoples are less likely to receive analgesia in acute pain settings however there is limited data on the indigenous New Zealand Maori population. The aim of this exploratory pilot study was to compare management between Maori and non-Maori for acute fracture pain in a regional trauma centre. METHODS: A retrospective review was undertaken for 120 patients with isolated tibial shaft fractures presenting at a tertiary level trauma center between 2015 and 2020. Outcome measures reflected the patient journey including type of analgesia charted pre-hospital, in the ED and on the ward. RESULTS: Out of 104 matched patients, 48 (46%) were Maori and 65% were male. Fewer Maori received pre-hospital analgesia compared with non-Maori (odds ratio 0.29, p = 0.006). Pain scores were similar on arrival to ED (6.1 ± 3.5 versus 5.4 ± 2.7, p = 0.2). Once at hospital, there were similar rates of prescribed analgesia (paracetamol, NSAIDs, synthetics, or opioids) both in ED and the ward. Time to analgesia were also similar for both groups (72 ± 71 min versus 65 ± 63 min, P > 0.9). DISCUSSION: We found differences in pre-hospital administration of analgesia between Maori and non-Maori patients with tibial shaft fractures. However once in hospital although there was a trend towards lower prescribing for Maori, there were no significant differences. Exploring the reasons underpinning this difference and the development of robust analgesic guidelines for tibial shaft fractures may help in reducing this inequity in care, particularly in the pre-hospital setting.

Risk Factors of Acute Pain in Elderly Patients After Laparoscopic Radical Resection of Colorectal Cancer.

OBJECTIVE: To investigate the risk factors of acute pain after laparoscopic radical resection of colorectal cancer (CRC) in elderly patients. METHODS: Totally, 143 elderly patients (≥ 60 y old) who received laparoscopic radical resection of CRC in the People's Hospital of Xinjiang Uygur Autonomous Region from March 2021 to August 2022 were retrospectively analyzed. The patients were divided into 2 groups according to visual analog scale (VAS) scores 24 h after surgery: mild pain group (VAS score ≤ 3, n=108) and moderate to severe pain group (VAS score >3, n=35). The data of the patients, including sex, age, height, body mass, intraoperative blood loss, intraoperative urine volume, intraoperative opioid dosage, operation duration, preoperative Hospital Anxiety and Depression Scale (HADS) scores, preoperative Mini-Mental State Examination scores, VAS scores, postoperative nausea and vomiting scores were recorded. Multivariate logistic regression analysis was used to screen the risk factors of postoperative acute pain in elderly patients undergoing laparoscopic radical resection of CRC. RESULTS: The preoperative HADS score of the moderate to severe pain group was significantly increased compared with that of the mild pain group (10.8±2.4 vs. 6.2±1.9), as well as the operation duration (226.4±18.3 vs. 186.1±12.7), the intraoperative dosage of remifentanil (3.7±0.2 vs. 3.2±0.4), the preoperative VAS score [4(2, 7) vs. 2 (0, 4)] and postoperative VAS score [5 (4, 6) vs. 3 (2, 3)] ( P <0.05). Multivariate logistic regression analysis showed that high preoperative HADS score, long operation duration, and high preoperative VAS score ( P <0.05) were independent risk factors for acute pain after laparoscopic radical resection of CRC in elderly patients. CONCLUSION: Preoperative anxiety and depression, preoperative pain, and long operation duration are risk factors for acute pain in elderly patients after laparoscopic radical resection of CRC.

Comparison of Acute Pain Syndrome after Surgical Interventions in the Nasal Cavity and Rhinoplasty.

Comparison of acute pain syndrome after septoplasty, rhinoplasty, and rhinoseptoplasty was carried out. It is shown that the intensity of acute pain is higher in patients after rhinoseptoplasty in the first 3-6 h after surgery.

Comparative analysis of periodontal pain and quality of life in patients with fixed multibracket appliances and aligners (Invisalign®): longitudinal clinical study.

BACKGROUNDS: The aim of this longitudinal clinical study is to analyse and compare according to location, degree and type, the pain presented by patients during their first year of treatment, as well as the quality of oral life after the placement of two types of orthodontic appliances: conventional brackets and removable Invisalign ® aligners. METHODS: The sample consisted of 140 patients grouped into 2 study groups of 70 patients each. The first group (brackets group- BG), with fixed multibracket appliances, using the MBT technique and a 0.022" slot. The second group (invisaling group- IG), in treatment with removable aligners (IG), using the Invisalign ® system. They were providen with a questionnare where they had to record the degree (mild, moderate or intense), the type and location of the pain monthly during the first year of treatment. The second form was the Spanish version of the OHIP-14, oral quality of life questionnaire, which was provided the twelfth month after the start of treatment. RESULTS: In both groups, we found that the most frequent location of pain occurred during the first phase: mandibular for the IG group and maxillary in the BG group. Throughout the whole analysis, the intensity was mild-moderate with lower values in the conventional brackets' group. The BG group reported acute pain while the IG group reported sensitive pain during the first month; later both reported sensitive pain. CONCLUSIONS: There are differences in terms of periodontal pain in its degree, location, and type according to the different orthodontic techniques used. TRIAL REGISTRATION: The study was approved by the bioethics committee of the University of Salamanca (USAL_20/516).

Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN).

BACKGROUND: Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury. METHODS: A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes. DISCUSSION: The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia. TRIAL REGISTRATION: ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.

Study protocol for a randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: 2 (TOPIC 2).

BACKGROUND: Thoracotomy is considered one of the most painful surgical procedures and can cause debilitating chronic post-surgical pain lasting months or years postoperatively. Aggressive management of acute pain resulting from thoracotomy may reduce the likelihood of developing chronic pain. This trial compares the two most commonly used modes of acute analgesia provision at the time of thoracotomy (thoracic epidural blockade (TEB) and paravertebral blockade (PVB)) in terms of their clinical and cost-effectiveness in preventing chronic post-thoracotomy pain. METHODS: TOPIC 2 is a multi-centre, open-label, parallel group, superiority, randomised controlled trial, with an internal pilot investigating the use of TEB and PVB in 1026 adult (≥ 18 years old) patients undergoing thoracotomy in up to 20 thoracic centres throughout the UK. Patients (N = 1026) will be randomised in a 1:1 ratio to receive either TEB or PVB. During the first year, the trial will include an integrated QuinteT (Qualitative Research Integrated into Trials) Recruitment Intervention (QRI) with the aim of optimising recruitment and informed consent. The primary outcome is the incidence of chronic post-surgical pain at 6 months post-randomisation defined as 'worst chest pain over the last week' equating to a visual analogue score greater than or equal to 40 mm indicating at least a moderate level of pain. Secondary outcomes include acute pain, complications of regional analgesia and surgery, health-related quality of life, mortality and a health economic analysis. DISCUSSION: Both TEB and PVB have been demonstrated to be effective in the prevention of acute pain following thoracotomy and nationally practice is divided. Identification of which mode of analgesia is both clinically and cost-effective in preventing chronic post-thoracotomy pain could ameliorate the debilitating effects of chronic pain, improving health-related quality of life, facilitating return to work and caring responsibilities and resulting in a cost saving to the NHS. TRIAL REGISTRATION: NCT03677856 [ClinicalTrials.gov] registered September 19, 2018. https://clinicaltrials.gov/ct2/show/NCT03677856 . First patient recruited 8 January 2019.

Trajectory of pain threshold and its association with acute pain after thoracic surgery: a prospective observational study.

BACKGROUND: Postoperative analgesic management is an ongoing challenge. The pain threshold (PT) is an objective index that reflects the body's sensitivity to pain and can be used for quantitative pain assessment. We hypothesized that the PT is correlated with postoperative pain and can thus be used to guide postoperative pain management. METHODS: This study involved 93 patients who underwent thoracoscopic surgery from December 2019 to February 2020. The PT was measured with transcutaneous electrical stimulation before surgery (T0) and at 1 h (T1), 6 h (T6), and 24 h (T24) after surgery. The visual analogue scale (VAS) score was used to evaluate the severity of postoperative pain at the same time. The PT variation (PTV) after surgery was calculated as the ratio of the postoperative PT to preoperative PT. RESULTS: The postoperative PT was higher than the preoperative PT and showed a downward trend within 24 h after surgery; the PTV also showed a downward trend within 24 h after surgery. PT-T1 was negatively correlated with VAS-T1 at rest and during motion (rest: VAS-T1r = - 0.274, P = 0.008; motion: VAS-T1r = - 0.298, P = 0.004). PTV-T1 was negatively correlated with VAS-T1 during motion (r = - 0.213, P = 0.04). Lower VAS-T1 scores (< 4) at rest and during motion were associated with higher PT-T1 (rest: t = 2.452, P = 0.016; motion: t = 2.138, P = 0.035). The intraoperative sufentanil dose was associated with a postoperative increase in PTV-T1. Increased rescue analgesic administration was associated with PTV elevation. However, the incidence of dizziness in patients with moderate PTV-T24 was lower than that in patients with high or low PTV-T24 (χ2 = 8.297, P = 0.015). CONCLUSIONS: The postoperative PT was higher than the preoperative PT and showed a downward trend within 24 h after surgery; PTV also showed a downward trend within 24 h after surgery. The PT and PTV were negatively correlated with the pain intensity at rest and during motion and were associated with perioperative analgesic consumption and the incidence of adverse events.

The challenge of clinical end points in sickle cell disease.

As most patients with sickle cell disease (SCD) do not have access to curative therapies, the availability of drug therapies that can modify disease severity remains highly desirable. Despite an increased understanding of the pathophysiology of SCD, only 4 drugs are approved by the US Food and Drugs Administration. Most drug trials in SCD have involved the use of acute pain episodes as the primary clinical end point. These studies have typically been to prevent or shorten the duration of such episodes. To date, no drug has received regulatory approval for shortening the duration of acute vaso-occlusive complications, likely highlighting the complex pathophysiology of acute pain episodes. Trials to prevent acute pain episodes have largely evaluated those episodes requiring health care use as a surrogate end point. However, with differences in culture and health care practices among countries, health care use may not reliably predict clinically important effects on acute pain episodes. This article discusses issues related to the use of health care use as the primary end point for prevention trials of acute pain episodes and highlights the importance of evaluating patient-reported outcomes as well as other SCD-related complications as outcome measures.

[Acute vulvar pain after covid-19]. / Acute vulvaire pijn na covid-19.

This case describes a 36-year-old woman who presents with acute painful ulcers of the vulva four days after a covid-19 infection. Extensive additional examination ruled out sexually transmitted diseases and auto-immune diseases, leaving acute vulvar ulcers, triggered by a covid-19 infection, as likely diagnosis. The ulcers healed spontaneously without scarring.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors.

PURPOSE OF REVIEW: Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases). RECENT FINDINGS: Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated. SUMMARY: This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Evaluation of Acute Pelvic Pain in Women.

Acute pelvic pain is defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months. Signs and symptoms are often nonspecific. The differential diagnosis is broad, based on the patient's age and pregnancy status and gynecologic vs. nongynecologic etiology. Nongynecologic etiologies include gastrointestinal, urinary, and musculoskeletal conditions. Urgent gynecologic conditions include ectopic pregnancy, ruptured ovarian cyst, adnexal torsion, and pelvic inflammatory disease. Approximately 40% of ectopic pregnancies are misdiagnosed at the presenting visit. Urgent nongynecologic conditions include appendicitis and pyelonephritis. Less urgent etiologies include sexually transmitted infections, pelvic floor myofascial pain, dysmenorrhea, and muscle strain. Approximately 15% of untreated chlamydia infections lead to pelvic inflammatory disease. History and physical examination findings guide laboratory testing. Questions should focus on the type, onset, location, and radiation of pain; timing and duration of symptoms; aggravating and relieving factors; and associated symptoms. Performing a urine pregnancy test or beta human chorionic gonadotropin test is an important first step for sexually active, premenopausal patients. Imaging options should be considered, with transvaginal ultrasonography first, followed by computed tomography. Magnetic resonance imaging can be useful if ultrasonography and computed tomography are nondiagnostic.

Acute Pain in Perspective.

KEY TAKEAWAYS: Acute pain is a common and nearly universal experience that usually has a sudden onset and is limited in duration. It is a normal physiologic response to a noxious stimulus that can become pathologic if untreated or not treated effectively. Acute pain has a limited duration (<1 month) and often is caused by injury, trauma, or medical treatments such as surgery. Primary care practitioners (PCPs) who encounter patients with acute pain can help preserve function and quality of life and prevent progression to chronic pain by implementing appropriate management strategies. PCPs in rural settings may bear greater responsibility for acute pain management because of the lack of accessible specialists. All current guidelines support using a multimodal approach to pain management and reserving use of opioids for patients with severe pain that cannot be managed with other agents. There are several new agents and formulations recently approved or in development for the treatment of acute pain. The recently approved co-crystal formulation of celecoxib and tramadol hydrochloride provides an additional option for acute pain management and utilizes a single-medication multimodal approach.