Answering the call to address chronic pain in military service members and veterans: Progress in improving pain care and restoring health.

Chronic noncancer pain (CNCP) in military and veteran populations mirrors the experience of chronic pain in America; however, these two populations have unique characteristics and comorbid conditions such as traumatic brain injuries, postconcussive syndrome, posttraumatic stress disorder, and behavioral health disorders that complicate the diagnosis and treatment of chronic pain. Military members and veterans may also be stigmatized about their conditions and experience problems with integration back into healthy lifestyles and society as a whole following deployments and after military service. The military and veteran health care systems have made chronic pain a priority and have made substantial strides in addressing this condition through advances in practice, education, research, and health policy. Despite this progress, significant challenges remain in responding to the wide-spread problem of chronic pain. The purpose of this article is to: (a) examine the state of CNCP in military and veteran populations; (b) discuss progress made in pain practice, education, research, and health policy; and (c) examine research, evidence-based practice guidelines, and expert consensus reports that are foundational to advancing pain care and improving health for military service members and veterans with CNCP. In addition, recommendations are proposed to address this widespread health problem through the expanded use of advanced practice registered nurses, the implementation of models of care, and use of national resources to educate health care providers, support practice, and promote effective pain care.

Chapter 7 Investigations on the Relationship Between the Autonomic Nervous System and the Triggering of Malignant Hyperthermia: A State-of-the-Science Review.

Early research in malignant hyperthermia (MH) focused on the autonomic nervous system (ANS) as a primary trigger of the syndrome. This hypothesis was based on the initial signs and symptoms of MH such as tachycardia, cardiac arrhythmias, hypertension, and signs of increased metabolism in patients who developed MH. Supporting these early links between MH and the ANS were case reports from anesthesia providers who reported that patients who subsequently developed MH after a nontriggering previous anesthetic had appeared unusually stressed prior to the surgical procedure in which they triggered. There is no disagreement in the scientific community that a primary disorder in MH lies in the inability to control myoplasmic calcium levels in skeletal muscles. However, considering the variability in genetic and clinical presentation, the timing of intraoperative triggering, and the unexplained phenomenon of nonanesthetic triggering, the identification of cofactors in MH triggering remains paramount. A careful review of existing research supports the hypothesis that the autonomic nervous system plays a significant role as a cofactor in the triggering and progression of an MH episode. If a differentiation can be made and a link can be demonstrated between abnormalities in receptor sensitivity for or release, reuptake, or metabolism of catecholamines in malignant hyperthermia susceptible individuals, we may be able to use these as additional markers/predictors of disease.

Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study.

The purpose of this investigation was to evaluate the effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures. Forty-four adults scheduled for head and neck procedures were randomly assigned into 2 groups for this single-blind investigation. Anxiety and baseline pain levels were documented preoperatively. Both groups received 28 minutes of privacy, during which subjects in the experimental group listened to a guided imagery compact disk (CD), but control group patients received no intervention. Data were collected on pain and narcotic consumption at 1- and 2-hour postoperative intervals. In addition, discharge times from the postoperative anesthesia care unit (PACU) and the ambulatory procedure unit and patient satisfaction scores were collected. The change in anxiety levels decreased significantly in the guided imagery group (P = .002). At 2 hours, the guided imagery group reported significantly less pain (P = .041). In addition, length of stay in PACU in the guided imagery group was an average of 9 minutes less than in the control group (P = .055). The use of guided imagery in the ambulatory surgery setting can significantly reduce preoperative anxiety, which can result in less postoperative pain and earlier PACU discharge times.

Effect of Norepinephrine on Intracellular Ca2+ Levels in Malignant Hyperthermia-Susceptible B Cells: Pilot Study in the Search for a New Diagnostic Test for Malignant Hyperthermia.

Malignant hyperthermia (MH) crises may induce morbidity or death in MH-susceptible (MHS) individuals. The only sensitive method of determining susceptibility is the caffeine-halothane contracture test, requiring muscle biopsy. Early research on MH demonstrated an abnormal response to catecholamines in MHS individuals. The purpose of this study was to determine whether MHS B lymphocytes would demonstrate an increased sensitivity to norepinephrine as indicated by an adrenergic augmentation of intracellular calcium ion (Ca2+) accumulation, to possibly develop a less invasive laboratory assay for determining MH susceptibility. The fluorescent Ca2+ indicator dye fura-2 acetoxymethyl was used to identify Ca2+ flux within Epstein-Barr virus- immortalized MH-negative (MHN) and MHS B cells exposed to the RyR1 agonist 4-chloro-m-cresol (4-CmC) before and after administration of 1 µM of norepinephrine. In the presence of 4-CmC and norepinephrine, the area under the curve dose responses were significantly elevated in MHS B cells compared with MHN B cells (F[1,10] = 27.37; P < .01). Epstein-Barr virus-immortalized B cells from MHS humans displayed an increased sensitivity to norepinephrine compared with those from MHN individuals. These data suggest that an abnormal response to exogenous norepinephrine could potentially be used to develop a diagnostic laboratory assay to determine MH susceptibility.