Silviu Brill

Patients' Perception of Postoperative Pain Management : Validation of the International Pain Outcomes (IPO) Questionnaire

UNLABELLEDnPAIN OUT is a European Commission-funded project aiming at improving postoperative pain management. It combines a registry that can be useful for quality improvement and research using treatment and patient-reported outcome measures. The core of the project is a patient questionnaire-the International Pain Outcomes questionnaire-that comprises key patient-level outcomes of postoperative pain management, including pain intensity, physical and emotional functional interference, side effects, and perceptions of care. Its psychometric quality after translation and adaptation to European patients is the subject of this validation study. The questionnaire was administered to 9,727 patients in 10 languages in 8 European countries and Israel. Construct validity was assessed using factor analysis. Discriminant validity assessment used Mann-Whitney U tests to detect mean group differences between 2 surgical disciplines. Internal consistency reliability was calculated as Cronbachs alpha. Factor analysis resulted in a 3-factor structure explaining 53.6% of variance. Cronbachs alpha at overall scale level was high (.86), and for the 3 subscales was low, moderate, or high (range, .53-.89). Significant mean group differences between general and orthopedic surgery patients confirmed discriminant validity. The psychometric quality of the International Pain Outcomes questionnaire can be regarded as satisfactory.nnnPERSPECTIVEnThe International Pain Outcomes questionnaire provides an instrument for postoperative pain assessment and improvement of quality of care, which demonstrated good psychometric quality when translated into a variety of languages in a large European and Israeli patient population. This measure provides the basis for the first comprehensive postoperative pain registry in Europe and other countries.

Correlates of satisfaction with pain treatment in the acute postoperative period: results from the international PAIN OUT registry.

Summary In an international cohort of surgical patients, satisfaction was strongly influenced by pain relief received, no desire to have received more pain treatment, and more allowed participation in pain treatment decisions. ABSTRACT Patient ratings of satisfaction with their postoperative pain treatment tend to be high even in those with substantial pain. Determinants are poorly understood and have not previously been studied in large‐scale, international datasets. PAIN OUT, a European Union‐funded acute pain registry and research project, collects patient‐reported outcome data on postoperative day 1 using the self‐reported International Pain Outcome Questionnaire (IPO), and patient, clinical, and treatment characteristics. We investigated correlates of satisfaction and consistency of effects across centres and countries using multilevel regression modelling. Our sample comprised 16,868 patients (median age 55 years; 55% female) from 42 centres in 11 European countries plus Israel, USA, and Malaysia, who underwent a wide range of surgical procedures, for example, joint, limb, and digestive tract surgeries. Median satisfaction was 9 (interquartile range 7–10) on a 0–10 scale. Three IPO items showed strong associations and explained 35% of the variability present in the satisfaction variable: more pain relief received, higher allowed participation in pain treatment decisions, and no desire to have received more pain treatment. Patient factors and additional IPO items reflecting pain experience (eg, worst pain intensity), pain‐related impairment, and information on pain treatment added little explanatory value, partially due to covariate correlations. Effects were highly consistent across centres and countries. We conclude that satisfaction with postoperative pain treatment is associated with the patients actual pain experience, but more strongly with impressions of improvement and appropriateness of care. To the degree they desire, patients should be provided with information and involved in pain treatment decisions.

Prevalence of fibromyalgia syndrome in patients referred to a tertiary pain clinic.

Background Fibromyalgia syndrome (FMS), the prototypical central pain augmentation syndrome, is characterized by widespread pain and tenderness. Although patients referred to tertiary care pain clinics are recognized as suffering from chronic pain, they are generally considered to have pain attributable to discrete peripheral, nociceptive, or neuropathic etiology. The purpose of the current study was to assess the prevalence of FMS among consecutive patients referred to a tertiary pain clinic and to evaluate the contribution of central pain to the clinical impact upon such patients. Methods Eighty-five consecutive patients (38 were male, and 47 were female) attending a pain clinic were assessed for the presence of FMS. The presence of FMS was determined according to the 1990 American College of Rheumatology (ACR) classification criteria. Quality of life and physical functioning were assessed, utilizing a structured questionnaire. Results The ACR criteria for the classification of FMS were fulfilled by 41.2% of patients. Patients fulfilling FMS criteria ranked significantly lower on all domains of the SF-36, including general health, physical functioning, role limitation due to physical and emotional problems, vitality, social functioning, bodily pain, and mental health. Composite physical and mental health scores were significantly lower among patients fulfilling ACR FMS criteria. Patients fulfilling the ACR criteria for FMS felt significantly more tenderness, based on the mean number of tender points and the mean tenderness threshold, when compared with patients not fulfilling the ACR FMS criteria. Conclusions A significant proportion of patients referred to a tertiary pain clinic were found to fulfill the ACR criteria for classification of FMS and thus exhibit an important element of central pain. Central pain augmentation should be actively searched for and therapeutically addressed in the evaluation and management of all patients with chronic pain.

PAIN OUT: an international acute pain registry supporting clinicians in decision making and in quality improvement activities

RATIONALE, AIMS AND OBJECTIVESnManagement of post-operative pain is unsatisfactory worldwide. An estimated 240 million patients undergo surgery each year. Forty to 60% of these patients report clinically significant pain. Discrepancy exists between availability of evidence-based medicine (EBM)-derived knowledge about management of perioperative pain and increased implementation of related practices versus lack of improvement in patient-reported outcomes (PROs). We aimed to assist health care providers to optimize perioperative pain management by developing and validating a medical registry that measures variability in care, identifies best pain management practices and assists clinicians in decision making.nnnMETHODSnPAIN OUT was established from 2009 to 2012 with funding from the European Commission. It now continues as a self-sustaining, not-for-profit project, targeting health care professionals caring for patients undergoing surgery.nnnRESULTSnThe growing registry includes data from 40u2009898 patients, 60 hospitals and 17 countries. Collaborators upload data (demographics, clinical, PROs) from patients undergoing surgery in their hospital/ward into an Internet-based portal. Two modules make use of the data: (1) online, immediate feedback and benchmarking compares PROs across sites while offline analysis permits in-depth analysis; and (2) the case-based clinical decision support system offers practice-based treatment recommendations for individual patients; it is available now as a prototype. The Electronicu2005Knowledgeu2005Library provides succinct summaries on perioperative pain management, supporting knowledge transfer and application of EBM.nnnCONCLUSIONnPAIN OUT, a large, growing international registry, allows use of real-life data related to management of perioperative pain. Ultimately, comparative analysis through audit, feedback and benchmarking will improve quality of care.

Tactile allodynia in patients with lumbar radicular pain (sciatica).

Summary Most radicular pain patients tested experienced tactile and/or cooling allodynia on the painful leg, often extending into the foot. Mapping of allodynia can inform the underlying low back pain mechanism, prognosis, and treatment options. ABSTRACT We report a novel symptom in many patients with low back pain (LBP) that sheds new light on the underlying pain mechanism. By means of quantitative sensory testing, we compared patients with radicular LBP (sciatica), axial LBP (LBP without radiation into the leg), and healthy controls, searching for cutaneous allodynia in response to weak tactile and cooling stimuli on the leg and low back. Most patients with radicular pain (˜60%) reported static and dynamic tactile allodynia, as well as cooling allodynia, on the leg, often extending into the foot. Some also reported allodynia on the low back. In axial LBP, allodynia was almost exclusively on the back. The degree of dynamic tactile allodynia correlated with the degree of background pain. The presence of allodynia suggests that the peripheral nerve generators of background leg and back pain have also induced central sensitization. The distal (foot) location of the allodynia in patients who have it indicates that the nociceptive drive that maintains the central sensitization arises paraspinally (ectopically) in injured ventral ramus afferents; this is not an instance of somatic referred pain. The presence of central sensitization also provides the first cogent account of shooting pain in sciatica as a wave of activity sweeping vectorially across the width of the sensitized dorsal horn. Finally, the results endorse leg allodynia as a pain biomarker in animal research on LBP, which is commonly used but has not been previously validated. In addition to informing the underlying mechanism of LBP, bedside mapping of allodynia might have practical implications for prognosis and treatment. Social media question: How can you tell whether pain radiating into the leg in a patient with sciatica is neuropathic, ie, due to nerve injury?

Is adenosine a modulator of peripheral vasoconstrictor responses

BackgroundLocal vasoconstrictor reflexes, the vascular myogenic response (VMR) and the veno-arterial reflex (VAR) are necessary for the maintenance of regional blood flow and systemic arterial blood pressure during orthostatic stress. Their molecular mechanism is unknown. We postulated that adenosine is involved in the activation of these local reflexes.MethodsThis hypothesis was tested in 10 healthy male volunteers (age 29xa0±xa03xa0years, BMI 24xa0±xa01xa0kg/m2). We used veno-occlusive plethysmography method for the assessment of forearm arterial blood flow at baseline and upon causing local venous congestion by inflating a second cuff to 40xa0mmHg for 4xa0min (VAR) and during placement of the forearm 40xa0cm below cardiac level for 4xa0min (VMR). These measurements were repeated after local infusion of either saline or aminophylline, non-selective adenosine blockers, using the Bier block method.ResultsRest baseline forearm blood flow was comparable in both arms. Saline did not affect the baseline forearm blood flow. However, aminophylline causes a significant increase in baseline forearm blood flow of 34xa0±xa06xa0% (pxa0=xa00.002). VAR demonstrated a decrease in forearm blood flow of 49xa0±xa04.5xa0% and after saline infusion it remained unchanged, 49xa0±xa05xa0% (pxa0=xa00.92). However, aminophylline causes significant decrease in the VAR by 35xa0±xa03xa0% (pxa0=xa00.02). But, both, saline and aminophylline did not affect the VMR.ConclusionArterial vasoconstriction triggered by venous congestion, which is the veno-arterial reflexis seems to be modulated by adenosine, at least partially. This “sensory” reflex requires further pharmacologic physiologic investigation.

Tracking the effects of policy changes in prescribing analgesics in one emergency department: a 10-year analysis.

According to the WHO, the yearly national consumption of opioids is one indicator of a countrys investment on relieving moderate-to-severe pain. We implemented guidelines for treatment of pain in our emergency department (ED) and tracked the major analgesics used in this ED to monitor trends in pain management over a decade. The study was carried out in a Level I trauma center ED. Data were obtained from the pharmacys computerized records before (1998–2002) and after (2003–2007) implementing the guidelines. The hospitals admission system provided accurate patient census data. Parenteral morphine and oral oxycodone use increased significantly (Pu2009=u20090.016 and Pu2009=u20090.008, respectively). Meperidine use did not change. In conclusion, our ED patients are now generally receiving more analgesics than 10 years ago. Electronically stored data on analgesics are accurate and easily accessible for tracking the nature and quantity of prescriptions, but not for correlating their association with patient outcome.

Chronic pain in pachyonychia congenita: evidence for neuropathic origin

Pachyonychia congenita (PC) is a rare autosomal dominant skin disease, with chronic pain being the most prominent complaint. Histological studies showing alterations in sensory innervation, along with reports on alterations in mechanical sensitivity, suggest that PC may be a form of neuropathy.

Increased sympathetic outflow induces adaptation to acute experimental pain

There are interrelationships between the autonomic nervous system and pain. This study aims to explore the effect of different autonomic manipulations on pain perception and modulation.

An internet based survey to assess clinicians' knowledge and attitudes towards opioid induced hypogonadism.

Long‐term opioid therapy for chronic pain management requires regularly assessing and documenting benefits and side effects. Opioid‐induced sex hormone disturbances are a complication that needs to be assessed routinely and perhaps not only when suspected. There is abundant literature about its prevalence, clinical consequences, and treatment, yet routine hormone screening and appropriate treatment are seldom performed in pain clinics. Ignorance, skepticism, and/or indifference are possible reasons explaining why opioid‐induced hypogonadism (OIH) remains underdiagnosed among chronic pain patients.