European journal of pain : EJP
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Randomized Controlled Trial
Ketamine infusion for 96 hr after thoracotomy: Effects on acute and persistent pain.
Why is this significant?
This is the first randomised controlled trial looking at the impact of perioperative ketamine on persistent post-surgical (PPS) pain 1 year after thoracic surgery. Thoracotomy is associated with both severe and a high incidence (up to 50% at 6 months) chronic pain.
Ketamine has important analgesic properties through NMDA blockade, and has been long thought (hoped) that via this it may modify chronic post-surgical pain. Nonetheless, many studies have been unable to show a benefit for ketamine in reducing PPS pain.
What did they show?
Chumbley et al. ran ketamine infusions at 0.1 mg/kg/hour for 96 hours in patients undergoing thoracotomy, starting with a 0.1 mg/kg bolus 10 minutes before surgery. Patients also received either an epidural or paravertebral infusion for post-operative analgesia.
Although there were small differences in acute pain (notably the ketamine group used less PCA morphine) there was no difference in persistent post-surgical pain at 12 months.
Bottom-line
The evidence continues to mount against perioperative ketamine, suggesting it does not reduce persistent post-surgical pain, not-withstanding its acute analgesia benefits. Await results of the ROCKet trial (Reduction Of Chronic Post-surgical Pain with Ketamine) to provide greater clarity...
An afterthought
Notably, the researchers did demonstrate a dramatically lower incidence of PPS pain than for similar studies (27%, 18%, 13% at 3, 6, 12 months) across both the ketamine and placebo group. This suggests that either the study participants were not representative of the typical thoracotomy patient (unlikely), or other care associated with the study had a beneficial effect on reducing PPS – perhaps even via a Hawthorne-like effect.
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Within the Fear Avoidance Model of pain, quantitative neurophysiological factors provide additional conceptual benefit when integrated along with traditional psychologically aspects of the FAM.
pearl -
Fibromyalgia represents a condition still controversial in its entity, pathophysiology, diagnosis and management (Figure ). In a world where everybody is connected, and everybody is sharing their own image, fibromyalgia (FM) represents the emblematic pathology of misconnection and lack of specific biomarker. ⋯ The concept of misconnection defines FM in a different and holistic view and proposes different views of assessment, management and representation: FM pathophysiology: the desynchronization of brain and body FM recognition: the broken link between patients and physicians FM assessment: merging the body and mind for an optimal diagnosis and management FM treatment: re-establishing the good connections at different levels We hope to reconnect FM patients with all healthcare providers, help FM patients reconnect with their painful body and integrate FM into regular medical practice. SIGNIFICANCE: The concept of misconnection defines FM in a different and holistic view, and propose different views of assessment, management and representation.
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Estimation of a patient's pain may have a considerable impact on the level of care that patient receives. Many studies have shown that contextual factors may influence an observer's pain estimation. Here, we investigate the effect of an observer's impression of a person in pain and justification of his/her pain on the observer's pain estimation, tendency to help and perceived empathy. ⋯ Observers' estimation of pain, perceived empathy and tendency to help biases by their understanding of the characteristics of the person in pain. In clinical settings, these biases may influence the quality of care and well-being of patients. Understanding the underlying mechanisms of these biases can help us improve the quality of care and control the effect of prejudices on pain assessment.
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Observational Study
Spinal cord stimulation for chronic refractory pain: long-term effectiveness and safety data from a multicentre registry.
Spinal cord stimulation (SCS) is an established therapy for refractory neuropathic pain. To ascertain the balance between treatment benefits and risks, the French National Authority for Health requested a post-market registry for real-world evaluation of the long-term effectiveness and safety of the therapy. ⋯ This observational, prospective study in a real-life setting followed a large cohort of patients suffering from chronic pain and implanted with SCS devices in France. The study assessed the long-term effectiveness and safety of SCS therapy in a representative sample of implanting sites in France.