Hazem Adel Ashmawi

Percutaneous sciatic nerve block with tramadol induces analgesia and motor blockade in two animal pain models

Local anesthetic efficacy of tramadol has been reported following intradermal application. Our aim was to investigate the effect of perineural tramadol as the sole analgesic in two pain models. Male Wistar rats (280-380u2005g; N = 5/group) were used in these experiments. A neurostimulation-guided sciatic nerve block was performed and 2% lidocaine or tramadol (1.25 and 5u2005mg) was perineurally injected in two different animal pain models. In the flinching behavior test, the number of flinches was evaluated and in the plantar incision model, mechanical and heat thresholds were measured. Motor effects of lidocaine and tramadol were quantified and a motor block score elaborated. Tramadol, 1.25u2005mg, completely blocked the first and reduced the second phase of the flinching behavior test. In the plantar incision model, tramadol (1.25u2005mg) increased both paw withdrawal latency in response to radiant heat (8.3 ± 1.1, 12.7 ± 1.8, 8.4 ± 0.8, and 11.1 ± 3.3u2005s) and mechanical threshold in response to von Frey filaments (459 ± 82.8, 447.5 ± 91.7, 320.1 ± 120, 126.43 ± 92.8u2005mN) at 5, 15, 30, and 60u2005min, respectively. Sham block or contralateral sciatic nerve block did not differ from perineural saline injection throughout the study in either model. The effect of tramadol was not antagonized by intraperitoneal naloxone. High dose tramadol (5u2005mg) blocked motor function as well as 2% lidocaine. In conclusion, tramadol blocks nociception and motor function in vivo similar to local anesthetics.

Chronic pain after cesarean section. Influence of anesthetic/surgical technique and postoperative analgesia

BACKGROUND AND OBJECTIVESnBrazil ranks second among countries with the highest rates of cesarean section in the world. Little is known about the future consequences of this procedure on maternal health. This study investigated the influence of anesthetic/surgical technique and postoperative analgesia on the onset of chronic pain after three months of cesarean section.nnnMETHODnThis is a prospective randomized study of 443 patients undergoing cesarean section (elective and emergency), with different doses of hyperbaric bupivacaine 0.5% and opioids in spinal anesthesia. Patients were alocated into five groups as follow: G1 received hyperbaric bupivacaine (8 mg), sufentanil (2.5 μg), and morphine (100 μg); G2 received hyperbaric bupivacaine (10 mg), sufentanil (2.5 μg), and morphine (100 μg); G3 received hyperbaric bupivacaine (12.5 mg) and morphine (100 μg); G4 received hyperbaric bupivacaine (15 mg) and morphine (100 μg); G5 received hyperbaric bupivacaine (12.5 mg) and morphine (100 μg), without perioperative anti-inflammatory. Pain at rest and in movement were evaluated in the immediate postoperative period. Phone contact was made after three months of surgery for identification of patients with chronic pain.nnnRESULTSnThe incidence of chronic pain in the groups was G1=20%; G2=13%; G3=7.1%; G4=2.2%, and G5=20.3%. Patients who reported higher pain scores in the postoperative period had a higher incidence of chronic pain (p<0.05).nnnCONCLUSIONnThe incidence of chronic pain decreases with higher doses of local anesthetics and use of anti-inflammatory drugs. The higher pain scores in the postoperative period were associated with chronic pain development after three months of cesarean section.

Methadone patient-controlled analgesia for postoperative pain: a randomized, controlled, double-blind study.

PurposePostoperative pain is an important health-care issue. Patient-controlled analgesia (PCA) is considered the gold standard for systemic postoperative pain treatment. Methadone PCA is used for patients with chronic pain and those in the palliative care setting. However, its efficacy as a first-line drug for acute postoperative pain is unknown. This study evaluated the use of postoperative methadone PCA after total hip arthroplasty (THA) compared with morphine PCA.MethodsThis was a randomized, double-blind, controlled, parallel-group study. Patients were randomized into two groups: group methadone—methadone PCA, and group morphine—morphine PCA, for postoperative analgesia. Drugs were delivered through PCA pumps throughout the first 24xa0h after surgery (T1:6, T2:12, T3:18, T4:24xa0h).ResultsOpioid consumption in 24xa0h was significantly lower for group methadone than for group morphine. Group methadone patients experienced significantly less pain than group morphine at rest. Pain after movement was significantly lower in group methadone at T1 and T3 and marginally lower at T2 and T4. Adverse events more frequently reported were sleepiness, nausea, and vomiting, but no statistical difference between groups was found.ConclusionThis study demonstrated that methadone PCA prompted less opioid consumption and lower pain scores at rest and at motion in comparison with morphine PCA as postoperative analgesia after THA.

Resilience and hope during advanced disease: a pilot study with metastatic colorectal cancer patients

BackgroundThe balance between hope-hopelessness plays an important role in the way terminally ill patients report quality of life, and personal resilience may be related to hope at the end of life. The objective of this study was to explore associations between personal resilience, hope, and other possible predictors of hope in advanced cancer patients.MethodsA cross-sectional pilot study was carried out with metastatic colorectal cancer patients in a tertiary hospital. The patients answered the Connor-Davidson Resilience Scale, Herth Hope Index, Barthel Index, an instrument addressing family and social support, visual-numeric scales for pain and suffering, a two-item screening for depression, socio-demographic and socio-economic information about the family.ResultsForty-four patients were interviewed (mean age 56xa0years; range 29-86). A strong correlation was noted between resilience and hope (0.63; pu2009<u20090.05). No correlation was found between hope and independence for activities of daily living, support from family and community, and pain and suffering levels. Of the 44 patients, 20 presented with depressive symptoms. These depressive patients had lower resilience (pu2009=u20090.005) and hope (pu2009=u20090.003), and higher scores of suffering (pu2009<u20090.001). The association between resilience and hope kept stable after adjusting for age, gender, and presence of depression (pu2009<u20090.001).ConclusionGiven that resilience is a dynamic, changeable path that can improve hope, resilience-fostering interventions should be most valued in palliative care settings and should be commenced as soon as possible with cancer patients. Patients with advanced stages of non-malignant conditions would also probably benefit from such interventions.

Antagonistas serotoninérgico e noradrenérgico por via subaracnoidea aumentam a resposta álgica em ratos

JUSTIFICATIVA Y OBJETIVOS: Existen evidencias de que el paso de informaciones nociceptivas por el cuerno posterior de la medula espinal (CPME), y que continua hacia niveles rostrales del sistema nervioso central, sufre profundas influencias excitatorias e inhibitorias. La presente investigacion quiso comparar los efectos de la metisergida, de la fentolamina y de la fentolamina asociada a la metisergida, administrados por via subaracnoidea, sobre las fases I, intermedia y II del test de la formalina modificado en ratones. METODO: Fueron utilizados en el experimento, 28 ratones Wistar machos, distribuidos aleatoriamente en cuatro grupos (n = 7), para recibir una solucion salina (GC), fentolamina (GF), metisergida (GM) o fentolamina asociada a la metisergida ((GFM). El dolor fue inducido por la administracion de formalina en la region dorsal de la pata posterior derecha. El test fue dividido en tres fases: fase I, intermedia y fase II. El analisis estadistico de los resultados fue hecho utilizando el programa SPSS (Statistical Package for Social Sciences), [Paquete Estadistico para las Ciencias Sociales], adoptando el nivel de significancia de un 5%. RESULTADOS: En la fase intermedia, el numero de elevaciones de la pata fue significativamente mayor en los grupos GF, GM y GFM cuando se comparo con el grupo GC. CONCLUSIONES: Los resultados nos sugieren la existencia de un efecto noradrenergico y serotoninergico en el sistema inhibitorio descendiente del dolor agudo, con la posibilidad del uso de agonistas serotoninergicos y α1-adrenergicos para el control del dolor agudo.

Magnesium sulfate improves postoperative analgesia in laparoscopic gynecologic surgeries: a double-blind randomized controlled trial

STUDY OBJECTIVEnThe aim of this study is to compare the analgesic effect of intravenous infusion of magnesium sulfate to ketorolac during laparoscopic surgeries.nnnDESIGNnDouble-blind randomized controlled trial.nnnSETTINGnUniversity-affiliated teaching hospital.nnnPATIENTSnSixty women submitted to laparoscopic gynecologic oncology surgeries.nnnINTERVENTIONSnIntravenous ketorolac 30 mg in bolus followed by saline infusion (group K), intravenous magnesium sulfate 20 mg/kg in bolus followed by magnesium 2 mg kg(-1) h(-1) (group M) or intravenous saline solution 20 mL in bolus followed by saline infusion during the entire procedure (group S).nnnMEASUREMENTSnPostoperative pain, nausea, vomiting, sedation, opioid consumption, time to first dose of analgesic.nnnMAIN RESULTSnMagnesium sulfate reduced opioid consumption compared with placebo in the postoperative, but not in the intraoperative, period. Nausea, not vomiting, was reduced in ketorolac but not in the magnesium group. Pain intensity was higher in placebo than in the other 2 groups during all periods of observation. In the first 60 minutes, pain intensity was lower in the magnesium than in the ketorolac or the placebo group.nnnCONCLUSIONnIntraoperative magnesium sulfate improves postoperative pain control, acting as an opioid-sparing adjuvant, and is similar to ketorolac 30 mg administered in the beginning of surgery.

Factor structure and psychometric properties of the Connor-Davidson resilience scale among Brazilian adult patients

CONTEXT AND OBJECTIVEnPersonal resilience is associated with several mental health outcomes. The Connor-Davidson resilience scale (CD-RISC) is a widely used self-report measurement of resilience. This study aimed to investigate the reliability and validity of a Brazilian Portuguese version of the CD-RISC.nnnDESIGN AND SETTINGnCross-sectional validation study carried out in the outpatient clinics of a public university hospital.nnnMETHODSnThe cross-cultural adaptation followed established guidelines and involved interviews with 65 adults in psychiatric and non-psychiatric outpatient clinics at a teaching hospital. Validation was assessed through concurrent application of the Lipp Brazilian Stress Symptom Inventory (ISSL), Self-Report Questionnaire (SRQ), Sheehan Disability Scales (SDS) and Chronic Pain Grade (CPG) to 575 patients at the same setting. Temporal stability was verified through a second application to 123 participants.nnnRESULTSnFactor analysis identified four factors, named tenacity, adaptability-tolerance, reliance on support from outside and intuition. The alpha coefficient of 0.93 and intraclass correlation coefficient of 0.84 indicated good internal consistency and temporal stability. Significant correlations between this version of the CD-RISC and the ISSL, SRQ, SDS and CPG were noted. The patients at the outpatient clinic for borderline personality had resilience scores that were significantly lower than those of the patients at the general anxiety or post-traumatic stress outpatient clinics.nnnCONCLUSIONnThis Brazilian Portuguese version of the Connor-Davidson resilience scale exhibited adequate reliability and validity among a sample of Brazilian adult patients.

Dor crônica pós-cesariana. Influência da técnica anestésico-cirúrgica e da analgesia pós-operatória

JUSTIFICATIVA Y OBJETIVOS: Brasil ocupa el segundo lugar entre los paises con mayores tasas de cesarea en el mundo. Poco se sabe respecto de las consecuencias futuras de ese procedimiento sobre la salud materna. Este estudio investigo la influencia de la tecnica anestesico-quirurgica y de la analgesia postoperatoria en el aparecimiento del dolor cronico despues de tres meses de hecha la cesarea. METODO: Este estudio prospectivo randomizado se hizo en 443 pacientes sometidas a cesarea (electiva y urgente), con diferentes dosis de bupivacaina al 0,5% hiperbarica y opioides en la raquianestesia. Los grupos fueron los siguientes: G1- 8 mg bupivacaina hiperbarica + 2,5 mg sufentanilo + 100 mg morfina; G2- 10 mg bupivacaina hiperbarica + 2,5 mg sulfentanilo + 100 mg morfina; G3- 12,5 mg bupivacaina hiperbarica + 100 mg morfina; G4- 15 mg bupivacaina hiperbarica + 100 mg morfina; G5- 12,5 mg bupivacaina hiperbarica + 100 mg morfina (sin anti-inflamatorio perioperatorio). Los dolores en estado de reposo y en movimiento fueron evaluados en el postoperatorio inmediato. Se realizo el contacto por telefono despues de tres meses del procedimiento quirurgico para la identificacion de las pacientes con dolor cronico. RESULTADOS: La incidencia de dolor cronico en los grupos fue la siguiente: G1 = 20%; G2 = 13%; G3 = 7,1%; G4 = 2,2% y G5 = 20,3%. Las pacientes que indicaron sentir puntajes de dolor mas elevados en el periodo postoperatorio, tuvieron una mayor incidencia de dolor cronico (p < 0,05). CONCLUSIONES: La incidencia de dolor cronico se reduce con el uso de dosis mas altas de anestesicos locales y con el uso de anti-inflamatorios no hormonales. Los puntajes mas elevados de dolor en el periodo postoperatorio estuvieron asociados con el aparecimiento de dolor cronico despues de tres meses de efectuada la cesarea.

Subarachnoid serotonergic and noradrenergic antagonists increase the pain response in rats

BACKGROUND AND OBJECTIVESnThere is evidence that the passage of nociceptive information through the posterior horn of the spinal cord (PHSC) on its way to rostral levels of the central nervous system undergoes profound excitatory and inhibitory influences. The objective of the present study was to compare the effects of the subarachnoid administration of methysergide, phentolamine, and phentolamine associated with methysergide on phases I, intermediate, and II of the modified formalin test in rats.nnnMETHODSnTwenty-eight male Wistar rats distributed randomly in four groups (n=7) to received subarachnoid saline solution (GC), phentolamine (GF), methysergide (GM), or phentolamine associated with methysergide (GFM). Pain was induced by the administration of formalin in the dorsal region of the right hind paw. The test was divided in three phases: phase I, intermediate, and phase II. Statistical analysis of the results was performed using the software SPSS (Statistical Package for Social Sciences), adopting a level of significance of 5%.nnnRESULTSnIn the intermediate phase the number of paw elevations was significantly higher in GF, GM, and GFM groups when compared to the GC group.nnnCONCLUSIONSnThe results suggest the existence of a noradrenergic and serotonergic effect in the inhibitory descending system of acute pain, with the possibility of using serotonergic and α1-adrenergic antagonists to control acute pain.

Local analgesic effect of tramadol is mediated by opioid receptors in late postoperative pain after plantar incision in rats

Tramadol is a drug used to treat moderate to severe pain. It is known to present a peripheral effect, but the local mechanisms underlying its actions remain unclear. The role of peripheral opioid receptors in postoperative pain is not well understood. In the present study, we examined the peripheral opioid receptors to determine the local effect of tramadol in a plantar incision pain model. Rats were subjected to plantar incision and divided into four groups on postoperative day (POD) 1: SF_SF, 0.9% NaCl injected into the right hindpaw; SF_TraI, 0.9% NaCl and tramadol injected into the right hindpaw; SF_TraC, 0.9% NaCl and tramadol injected into the contralateral hindpaw; and Nal_Tra, naloxone and tramadol injected into the ipsilateral hindpaw. To determine the animals’ nociceptive threshold, mechanical hyperalgesia was measured before incision, on POD1 before treatment and at 15, 30, 45, and 60 minutes after the incision. The same procedure was repeated on the POD2. The expression levels of μ-opioid receptor (MOR) and δ-opioid receptor (DOR) were obtained through immunoblotting assays in the lumbar dorsal root ganglia (L3–L6) in naïve rats and 1, 2, 3, and 7 days after the incision. Our results showed that the plantar incision was able to cause an increase in mechanical hyperalgesia and that tramadol reversed this hyperalgesia on POD1 and POD2. Tramadol injections in the contralateral paw did not affect the animals’ nociceptive threshold. Naloxone was able to antagonize the tramadol effect partially on POD1 and completely on POD2. The DOR expression increased on POD2, POD3, and POD7, whereas the MOR expression did not change. Together, our results show that tramadol promoted a local analgesic effect in the postoperative pain model that was antagonized by naloxone in POD2, alongside the increase of DOR expression.