Enhanced recovery pathways and patient-reported outcome measures in gynaecological oncology.
2021; 76 Suppl 4: 131?38
Comprehensive peri-operative care for women with gynaecological malignancy is essential to ensure optimal clinical outcomes and maximise patient experience through the continuum of care. Implementation of peri-operative enhanced recovery pathways in gynaecological oncology have been repeatedly shown to improve postoperative recovery, decrease complications and reduce healthcare costs. With increasing emphasis being placed on patient-centred care in the current healthcare environment, incorporation of patient-reported outcome data collection and analysis within the enhanced recovery pathway as part of quality measurement is not only useful, but necessary. Inclusion of patient-reported outcome enhanced recovery pathway evaluation enables clinicians to capture authentic patient-reported parameters such as subtle symptoms, changes in function and multiple dimensions of well-being, directly from the source. These data guide the treatment course by encouraging shared decision-making between the patient and clinicians and provide the necessary foundation for ongoing peri-operative quality improvement efforts. Elements of the gynaecological oncology enhanced recovery pathway are divided into five phases of care: pre-admission; pre-operative; intra-operative; postoperative; and post-discharge. The development process starts with detailing each step of the patient's journey in all five phases, then identifying stakeholder groups responsible for care at each of these phases and assembling a multidisciplinary team including: gynaecologists; anaesthetists; nurses; nutritionists; physical therapists; and others, to provide input into the institutional pathway. To practically integrate patient-reported outcomes into an enhanced recovery pathway, a validated measurement tool should be incorporated into the peri-operative workflow. The ideal tool should be concise to facilitate longitudinal assessments by the clinical staff.
View details for DOI 10.1111/anae.15422
View details for PubMedID 33682089
Awake CT-guided percutaneous stylomastoid foramen puncture and radiofrequency ablation of facial nerve for treatment of hemifacial spasm.
Journal of neurosurgery
Hemifacial spasm (HFS) is a debilitating neuromuscular disorder with limited treatment options. The current study describes a novel minimally invasive procedure that provided effective and sustained relief for patients with HFS. The authors provide a detailed description of the awake CT-guided percutaneous radiofrequency ablation (RFA) of the facial nerve for treatment of HFS, and they examine its clinical efficacy. This is the first time in the literature that this procedure has been applied and systematically analyzed for HFS.Patients with a history of HFS were recruited between August 2018 and April 2020. Those with a history of cerebellopontine lesions, coagulopathy, ongoing pregnancy, cardiac pacemaker or defibrillator implants, or who declined the procedure were excluded from the study. Fifty-three patients who met the study criteria were included and underwent awake CT-guided RFA. Under minimal sedation, a radiofrequency (RF) needle was used to reach the stylomastoid foramen on the affected side under CT guidance, and the facial nerve was localized using a low-frequency stimulation current. Patients were instructed to engage facial muscles as a proxy for motor monitoring during RFA. Ablation stopped when the patients' hemifacial contracture resolved. Patients were kept for inpatient monitoring for 24 hours postoperatively and were followed up monthly to monitor resolution of HFS and complications for up to 19 months.The average duration of the procedure was 32-34 minutes. Postoperatively, 91% of the patients (48/53) had complete resolution of HFS, whereas the remaining individuals had partial resolution. A total of 48 patients reported mild to moderate facial paralysis immediately post-RFA, but most resolved within 1 month. No other significant complication was observed during the study period. By the end of the study period, 5 patients had recurrence of mild HFS symptoms, whereas only 2 patients reported dissatisfaction with the treatment results.The authors report for the first time that awake CT-guided RFA of the facial nerve at the stylomastoid foramen is a minimally invasive procedure and can be an effective treatment option for HFS.
View details for DOI 10.3171/2020.10.JNS203209
View details for PubMedID 33862595
A Narrative Review on Perioperative Pain Management Strategies in Enhanced Recovery Pathways-The Past, Present and Future.
Journal of clinical medicine
2021; 10 (12)
Effective pain management is a key component in the continuum of perioperative care to ensure optimal outcomes for surgical patients. The overutilization of opioids in the past few decades for postoperative pain control has been a major contributor to the current opioid epidemic. Multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) pathways have been repeatedly shown to significantly improve postoperative outcomes such as pain, function and satisfaction. The current review aims to examine the history of perioperative MMA strategies in ERAS and provide an update with recent evidence. Furthermore, this review details recent advancements in personalized pain medicine. We speculate that the next important step for improving perioperative pain management could be through incorporating these personalized metrics, such as clinical pharmacogenomic testing and patient-reported outcome measurements, into ERAS program.
View details for DOI 10.3390/jcm10122568
View details for PubMedID 34200695
- Perioperative Care and Airway Management for a Patient With Sagliker Syndrome CUREUS 2020; 12 (9)
Follow-Up Phone Interviews and Attendance Motivation From A Free Head and Neck Cancer Screening.
Ear, nose, & throat journal
Head and Neck Cancer Awareness and Screening Programs (HNCASP) are popular community outreach events hosted by academic and community otolaryngology departments. However, long-term follow-up of participants is lacking.Participants of a HNCASP held at an academic cancer center prospectively filled out demographic and risk factor surveys followed by HNC screening examination. A phone interview was conducted for participants between 2012 and 2016 with suspicious findings to assess outcomes.Participants were largely Caucasian, female, and had health insurance, reflecting the setting at an academic medical center. Despite this, there were 156 (16.8%) positive screenings; 47 of these completed follow up interviews. Twelve (1.1% of all participants) cancer cases were confirmed.A significant proportion of HNCASP participants benefited from this screening opportunity. Education regarding HNC is the primary benefit and motivational factor for attendance of HNCASPs, although a significant subset of patients was identified that needed follow-up, and several cancers were detected.
View details for DOI 10.1177/0145561320940866
View details for PubMedID 32703031
Role of fragile X mental retardation protein in chronic pain
2020; 16 (1744806920928619)
View details for DOI 10.1177/1744806920928619
- Descending Control Mechanisms and Chronic Pain CURRENT RHEUMATOLOGY REPORTS 2019; 21 (5)
Plasticity in the Link between Pain-Transmitting and Pain-Modulating Systems in Acute and Persistent Inflammation
JOURNAL OF NEUROSCIENCE
2019; 39 (11): 2065?79
There is strong evidence that spinoparabrachial neurons in the superficial dorsal horn contribute to persistent pain states, and that the lateral parabrachial complex (PB) conveys relevant nociceptive information to higher structures. The role of PB itself in hyperalgesia and how it recruits descending facilitation has nevertheless received significantly less attention. The current study is a first step toward delineating the functional dynamics of PB and its link to descending control in acute and persistent inflammatory pain. In lightly anesthetized rats, we recorded behavioral withdrawal evoked by mechanical stimulation of the hindpaw and, simultaneously, the activity of identified pain-modulating neurons, "ON-cells" and "OFF-cells," in the rostral ventromedial medulla (RVM). This was done before and after the inactivation of PB, contralateral or ipsilateral to an inflamed paw [1 h, 1 d, or 5-6 d after intraplantar injection of Complete Freund's Adjuvant (CFA)]. The inactivation of contralateral, but not ipsilateral, PB interfered with nociceptive input to RVM under basal conditions, as well as in acute inflammation. By contrast, blocking ipsilateral, but not contralateral, PB in established inflammation interfered with behavioral hyperalgesia and ON-cell and OFF-cell responses. The lesioning of contralateral PB before CFA injection prevented this recruitment of ipsilateral PB in persistent inflammation. These experiments show that contralateral PB is required to initiate hyperalgesia, which is then maintained by ipsilateral PB, most likely in both cases via the engagement of pain-modulating neurons of the RVM.SIGNIFICANCE STATEMENT The lateral parabrachial complex (PB) relays nociceptive information to brain circuits that are important for the transmission and modulation of pain, but its specific role in persistent pain and engagement of descending control mechanisms has received relatively little attention. We show here that PB contralateral and ipsilateral to an inflammatory insult demonstrate different functions as inflammation persists, likely by engaging pain-facilitating neurons of the rostral ventromedial medulla. While the contralateral PB, the target of the major spinoparabrachial pathway, relays acute nociceptive information, the ipsilateral PB is recruited or unmasked in persistent inflammation to maintain hyperalgesia. These data point to plasticity in the PB itself or its direct and indirect connections with pain-modulating systems as central to the development and maintenance of persistent pain.
View details for PubMedID 30651329
Descending Control Mechanisms and Chronic Pain.
Current rheumatology reports
2019; 21 (5): 13
PURPOSE OF REVIEW: The goal of the review was to highlight recent advances in our understanding of descending pain-modulating systems and how these contribute to persistent pain states, with an emphasis on the current state of knowledge around "bottom-up" (sensory) and "top-down" (higher structures mediating cognitive and emotional processing) influences on pain-modulating circuits.RECENT FINDINGS: The connectivity, physiology, and function of these systems have been characterized extensively over the last 30years. The field is now beginning to ask how and when these systems are engaged to modulate pain. A recent focus is on the parabrachial complex, now recognized as the major relay of nociceptive information to pain-modulating circuits, and plasticity in this circuit and its connections to the RVM is marked in persistent inflammatory pain. Top-down influences from higher structures, including hypothalamus, amygdala, and medial prefrontal areas, are also considered. The challenge will be to tease out mechanisms through which a particular behavioral context engages distinct circuits to enhance or suppress pain, and to understand how these mechanisms contribute to chronic pain.
View details for PubMedID 30830471
Efficacy of Dextromethorphan/Quinidine for Patients With Psychosis-Related Aggression: A Retrospective Case Series.
The primary care companion for CNS disorders
2018; 20 (3)
Treatment-resistant aggressive behavior is a complex psychoneurological phenomenon with high health care and societal costs commonly observed in mental illnesses involving psychosis. Here, we report a preliminary evaluation of treatment with dextromethorphan/quinidine in 4 adult patients with significant history of psychosis-related aggression and impulsive behaviors.The files of 4 inpatients with DSM-5-defined psychotic disorder and treatment-resistant aggression treated at the Oregon State Hospital (Salem, Oregon) between June and November of 2017 were retrospectively analyzed. The patients (age: mean ± SD = 59.8 ± 7.6) received open-label treatment with dextromethorphan/quinidine (final dose 20 mg/10 mg twice daily) for at least 12 weeks. Outcome was measured on the basis of patient self-report, treatment team evaluation, and physical examination by psychiatrists and primary care physicians.Three of the 4 patients were considered responders to dextromethorphan/quinidine based on clinical impressions of reduction in aggression and impulsive behavior. The nonresponder, who had a history of multiple traumatic brain injuries, showed mild improvement in agitation but continued to display impulsive self-harm behavior despite treatment. Dextromethorphan/quinidine was generally well-tolerated. No metabolic, gastrointestinal, or cardiovascular side effects were observed.These preliminary findings support dextromethorphan/quinidine as a potential alternative to conventional regimens for treating aggression and impulsive behavior in patients with psychotic disorder. These results should be interpreted cautiously, as extended, double-blinded, placebo-controlled studies with a larger sample size are needed to validate findings from this retrospective case series.
View details for PubMedID 29985567
Unmasking the Pain in Latent Sensitization.
2018; 381: 159?60
View details for PubMedID 29776485
Effectiveness of Dextromethorphan/Quinidine in Frontotemporal Dementia.
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
2018; 26 (4): 506
View details for PubMedID 29132987
Optogenetic Evidence for a Direct Circuit Linking Nociceptive Transmission through the Parabrachial Complex with Pain-Modulating Neurons of the Rostral Ventromedial Medulla (RVM).
2017; 4 (3)
The parabrachial complex (PB) is a functionally and anatomically complex structure involved in a range of homeostatic and sensory functions, including nociceptive transmission. There is also evidence that PB can engage descending pain-modulating systems, the best characterized of which is the rostral ventromedial medulla (RVM). Two distinct classes of RVM neurons, "ON-cells" and "OFF-cells," exert net pronociceptive and anti-nociceptive effects, respectively. PB was recently shown to be a relay of nociceptive information to RVM ON- and OFF-cells. The present experiments used optogenetic methods in a lightly anesthetized rat and an adult RVM slice to determine whether there are direct, functionally relevant inputs to RVM pain-modulating neurons from PB. Whole-cell patch-clamp recordings demonstrated that PB conveys direct glutamatergic and GABAergic inputs to RVM neurons. Consistent with this, in vivo recording showed that nociceptive-evoked responses of ON- and OFF-cells were suppressed by optogenetic inactivation of archaerhodopsin (ArchT)-expressing PB terminals in RVM, demonstrating that a net inhibitory input to OFF-cells and net excitatory input to ON-cells are engaged by acute noxious stimulation. Further, the majority of ON- and OFF-cells responded to optogenetic activation of channelrhodopsin (ChR2)-expressing terminals in the RVM, confirming a direct PB influence on RVM pain-modulating neurons. These data show that a direct connection from the PB to the RVM conveys nociceptive information to the pain-modulating neurons of RVM under basal conditions. They also reveal additional inputs from PB with the capacity to activate both classes of RVM pain-modulating neurons and the potential to be recruited under different physiological and pathophysiological conditions.
View details for PubMedID 28660248
View details for PubMedCentralID PMC5483601
Parabrachial complex links pain transmission to descending pain modulation.
2016; 157 (12): 2697?2708
The rostral ventromedial medulla (RVM) has a well-documented role in pain modulation and exerts antinociceptive and pronociceptive influences mediated by 2 distinct classes of neurons, OFF-cells and ON-cells. OFF-cells are defined by a sudden pause in firing in response to nociceptive inputs, whereas ON-cells are characterized by a "burst" of activity. Although these reflex-related changes in ON- and OFF-cell firing are critical to their pain-modulating function, the pathways mediating these responses have not been identified. The present experiments were designed to test the hypothesis that nociceptive input to the RVM is relayed through the parabrachial complex (PB). In electrophysiological studies, ON- and OFF-cells were recorded in the RVM of lightly anesthetized male rats before and after an infusion of lidocaine or muscimol into PB. The ON-cell burst and OFF-cell pause evoked by noxious heat or mechanical probing were substantially attenuated by inactivation of the lateral, but not medial, parabrachial area. Retrograde tracing studies showed that neurons projecting to the RVM were scattered throughout PB. Few of these neurons expressed calcitonin gene-related peptide, suggesting that the RVM projection from PB is distinct from that to the amygdala. These data show that a substantial component of "bottom-up" nociceptive drive to RVM pain-modulating neurons is relayed through the PB. While the PB is well known as an important relay for ascending nociceptive information, its functional connection with the RVM allows the spinoparabrachial pathway to access descending control systems as part of a recurrent circuit.
View details for PubMedID 27657698
Contribution of adenylyl cyclase modulation of pre- and postsynaptic GABA neurotransmission to morphine antinociception and tolerance.
Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology
2014; 39 (9): 2142?52
Opioid inhibition of presynaptic GABA release in the ventrolateral periaqueductal gray (vlPAG) activates the descending antinociception pathway. Tolerance to repeated opioid administration is associated with upregulation of adenylyl cyclase activity. The objective of these studies was to test the hypothesis that adenylyl cyclase contributes to opioid tolerance by modulating GABA neurotransmission. Repeated microinjections of morphine or the adenylyl cyclase activator NKH477 into the vlPAG decreased morphine antinociception as would be expected with the development of tolerance. Conversely, microinjection of the adenylyl cyclase inhibitor SQ22536 reversed both the development and expression of morphine tolerance. These behavioral results indicate that morphine tolerance is dependent on adenylyl cyclase activation. Electrophysiological experiments revealed that acute activation of adenylyl cyclase with forskolin increased the frequency of presynaptic GABA release. However, recordings from rats treated with repeated morphine administration did not exhibit increased basal miniature inhibitory postsynaptic current (mIPSC) frequency but showed a decrease in mean amplitude of mIPSCs indicating that repeated morphine administration modulates postsynaptic GABAA receptors without affecting the probability of presynaptic GABA release. SQ22536 reversed this change in mIPSC amplitude and inhibited mIPSC frequency selectively in morphine tolerant rats. Repeated morphine or NKH477 administration also decreased antinociception induced by microinjection of the GABAA receptor antagonist bicuculline, further demonstrating changes in GABA neurotransmission with morphine tolerance. These results show that the upregulation of adenylyl cyclase caused by repeated vlPAG morphine administration produces antinociceptive tolerance by modulating both pre- and postsynaptic GABA neurotransmission.
View details for PubMedID 24622471
Empathy is moderated by genetic background in mice.
2009; 4 (2): e4387
Empathy, as originally defined, refers to an emotional experience that is shared among individuals. When discomfort or alarm is detected in another, a variety of behavioral responses can follow, including greater levels of nurturing, consolation or increased vigilance towards a threat. Moreover, changes in systemic physiology often accompany the recognition of distressed states in others. Employing a mouse model of cue-conditioned fear, we asked whether exposure to conspecific distress influences how a mouse subsequently responds to environmental cues that predict this distress. We found that mice are responsive to environmental cues that predict social distress, that their heart rate changes when distress vocalizations are emitted from conspecifics, and that genetic background substantially influences the magnitude of these responses. Specifically, during a series of pre-exposure sessions, repeated experiences of object mice that were exposed to a tone-shock (CS-UCS) contingency resulted in heart rate deceleration in subjects from the gregarious C57BL/6J (B6) strain, but not in subjects from the less social BALB/cJ (BALB) strain. Following the pre-exposure sessions, subjects were individually presented with the CS-only for 5 consecutive trials followed by 5 consecutive pairings of the CS with the UCS. Pre-exposure to object distress increased the freezing responses of B6 mice, but not BALB mice, on both the CS-only and the CS-UCS trials. These physiological and behavioral responses of B6 mice to social distress parallel features of human empathy. Our paradigm thus has construct and face validity with contemporary views of empathy, and provides unequivocal evidence for a genetic contribution to the expression of empathic behavior.
View details for DOI 10.1371/journal.pone.0004387
View details for PubMedID 19209221
View details for PubMedCentralID PMC2633046
Affiliative behavior, ultrasonic communication and social reward are influenced by genetic variation in adolescent mice.
2007; 2 (4): e351
Social approach is crucial for establishing relationships among individuals. In rodents, social approach has been studied primarily within the context of behavioral phenomena related to sexual reproduction, such as mating, territory defense and parental care. However, many forms of social interaction occur before the onset of reproductive maturity, which suggests that some processes underlying social approach among juvenile animals are probably distinct from those in adults. We conducted a longitudinal study of social investigation (SI) in mice from two inbred strains to assess the extent to which genetic factors influence the motivation for young mice to approach one another. Early-adolescent C57BL/6J (B6) mice, tested 4-6 days after weaning, investigated former cage mates to a greater degree than BALB/cJ (BALB) mice, irrespective of the sex composition within an interacting pair. This strain difference was not due to variation in maternal care, the phenotypic characteristics of stimulus mice or sensitivity to the length of isolation prior to testing, nor was it attributable to a general difference in appetitive motivation. Ultrasonic vocalization (USV) production was positively correlated with the SI responses of mice from both strains. Interestingly, several USV characteristics segregated with the genetic background of young mice, including a higher average frequency and shorter duration for the USVs emitted by B6 mice. An assessment of conditioned place preference responses indicated that there was a strain-dependent difference in the rewarding nature of social contact. As adolescent mice aged, SI responses gradually became less sensitive to genetic background and more responsive to the particular sex of individuals within an interacting pair. We have thus identified a specific, genetic influence on the motivation of early-adolescent mice to approach one another. Consistent with classical theories of motivation, which propose a functional relationship between behavioral approach and reward, our findings indicate that reward is a proximal mechanism through which genetic factors affect social motivation during early adolescence.
View details for DOI 10.1371/journal.pone.0000351
View details for PubMedID 17406675
View details for PubMedCentralID PMC1831495