Psychological and endocrine factors and pain after mastectomy

Systematic Review of Methods for Individual Prediction of Postoperative Pain

Background: Acute postoperative pain is a common problem in clinical practice and merits attention considering its potential long-term adverse effects. This systematic review covers current knowledge on methods for individual prediction of postoperative pain. Methods: A systematic literature search was conducted using the PubMed, EMBASE, and CINAHL databases for original studies with adult patients published in English between 2016 and 2022. Inclusion required assessment of risk factors preoperatively and assessment of postoperative pain. No reviews, meta-analyses, or study protocols were included, nor studies with outcomes other than pain or where risk factor analysis was not performed preoperatively. A two peer-reviewed system was utilized using the screening and data collection tool Covidence, with a focus on new tools for preoperative pain prediction. The results were only analyzed qualitatively. Results: The search yielded 1950 abstracts to be screened. In total, 208 articles were subjected to full-text review, and 107 articles were included in the data synthesis of this review. The evaluated scientific methods were grouped and analyzed separately. Psychometric questionnaires and methods for quantitative sensory testing are still being studied. New methods proposed include the evaluation of pain induced by tourniquet inflation, venous cannulation, or pin-prick stimulation, the analgesia/nociception index, electroencephalographic recording, and other new equipment developed for this purpose. Conclusion: Various screening methods have been proposed to identify patients prone to postoperative pain. The focus has shifted from procedure-specific to individualized strategies to improve early management of pain. However, many traditional predictive methods still have a questionable role in clinical practice. Trial Registration: ClinicalTrials.gov identifier: CRD42022298479.

Antepartum depressive symptoms are associated with significant postpartum opioid use

BACKGROUND

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant.

OBJECTIVE

This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization.

STUDY DESIGN

This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome.

RESULTS

The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms.

CONCLUSION

Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

Prevalence and determinants of anxiety and depression in long-term breast cancer survivors

BACKGROUND

There is a significant number of long-term breast cancer survivors in Germany. However, research on the psychological challenges of cancer survivors is limited. This analysis describes prevalence, development and determinants of depression and anxiety 5 to 6 years after diagnosis and identifies predictors for an increase of anxiety and depression over time.

METHODS

Data from 164 women was collected by survey and tumour documentation during post-operative hospital stay, 40 weeks and 5 to 6 years after diagnosis. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale. Sankey-diagrams were created for visual presentation of prevalence over time. Logistic and linear regression models were calculated to identify determinants of anxiety and depression.

RESULTS

Respondents had higher levels of depression and anxiety 5 to 6 years than 40 weeks after the diagnosis. Lower vocational status and having children were associated with depression, surgery type was correlated with anxiety, and age, as well as comorbidities, were predictors for both anxiety and depression 5 to 6 years after diagnosis. An increase of depression over time was more likely when having children and comorbidities. An increase in anxiety was less likely after cancer recurrence.

CONCLUSIONS

Findings highlight that anxiety and depression are relevant burdens for breast cancer survivors in Germany. Several sociodemographic and clinical predictors are identified. There is need for psychosocial support after acute treatment and in the long-term. Research on psychological burdens of long-term breast cancer survivors in the identified vulnerable groups is needed.

Biopsychosocial risk factors for pain and pain-related disability 1 year after surgery for breast cancer

PURPOSE

Knowledge regarding risk factors for pain in the long term after surgery for breast cancer may be of great value in preventing this prevalent and debilitating side effect. Despite the biopsychosocial nature of pain, the predictive value of both pre- and postoperative biopsychosocial functioning for long-term pain intensity and pain-related disability has not yet been studied.

METHODS

One hundred sixty-six women planned for unilateral breast cancer surgery were included in this prospective cohort study. Pre- and postoperative outcomes related to pain, psychosocial, and somatosensory functioning (questionnaires and quantitative sensory testing) were evaluated as risk factors for pain intensity (visual analog scale) and pain-related disability (pain disability index) 1 year after surgery for breast cancer. Both bivariable and stepwise linear regression analyses were performed.

RESULTS

The most consistent biopsychosocial risk factors were symptoms related to altered central somatosensory functioning (central sensitization inventory), psychological symptoms, and social support (psychological symptoms and support subscale of McGill Quality of Life Questionnaire). Results also showed that a pre- and postoperative disturbed functioning of the somatosensory nervous system in the surgical area could provide additional information regarding pain intensity or pain-related disability in the long term after surgery for breast cancer.

CONCLUSION

This study revealed several biopsychosocial characteristics that might be used to identify women more vulnerable to have pain and pain-related disability in the long term after surgery for breast cancer, allowing for more effective pain management and prevention.

Post-Mastectomy Pain: An Updated Overview on Risk Factors, Predictors, and Markers

After breast surgery, women frequently develop chronic post-mastectomy pain (PMP). PMP refers to the occurrence of pain in and around the area of the mastectomy lasting beyond three months after surgery. The nature of factors leading to PMP is not well known. When PMP is refractory to analgesic treatment, it negatively impacts the lives of patients, increasing emotional stress and disability. For this reason, optimizing the quality of life of patients treated for this pathology has gained more importance. On the basis of the findings and opinions above, we present an overview of risk factors and predictors to be used as potential biomarkers in the personalized management of individual PMP. For this overview, we discuss scientific articles published in peer-reviewed journals written in the English language describing risk factors, predictors, and potential biomarkers associated with chronic pain after breast surgery. Our overview confirms that the identification of women at risk for PMP is fundamental to setting up the best treatment to prevent this outcome. Clinical practice can be planned through the interpretation of genotyping data, choosing drugs, and tailoring doses for each patient with the aim to provide safer and more effective individual analgesic treatment.

What the blogosphere has to say about adult tonsillectomy

OBJECTIVES

Tonsillectomy has generated extensive comment on the internet, but this content has not been examined in a scientific manner. This study aimed to determine what the blogosphere has to say about adult tonsillectomy and to report whether this information can be used to improve post-surgical care.

METHODS

The internet was searched to find personal blogs relating to tonsillectomy. A retrospective review of data collected on these blogs was carried out and the blogs were conceptually analysed by the authors.

RESULTS

Fifty blogs were included. Seventy per cent of patients had read blogs prior to their procedure. The average pain score where available was 7.2. Complications occurred in 10 per cent of patients. Only 1 patient (2 per cent) regretted having a tonsillectomy.

CONCLUSION

It is important for otolaryngologists to stay in tune with the blogosphere as this unregulated and easily accessible source of information is both friend and foe but will ultimately help in pre-operative counselling and post-operative management.

Psychological Factors Are Associated with Pain at All Time Frames After Breast Cancer Surgery: A Systematic Review with Meta-Analyses

OBJECTIVE

This systematic review aimed to 1) assess associations between psychological factors and pain after breast cancer (BC) treatment and 2) determine which preoperative psychological factors predicted pain in the acute, subacute, and chronic time frames after BC surgery.

DESIGN

A systematic review with meta-analysis.

SUBJECTS

Women with early-stage BC.

METHODS

The Medline, EMBASE, CINAHL, and Web of Science databases were searched between 1990 and January 2019. Studies that evaluated psychological factors and pain after surgery for early-stage BC were included. Associations between psychological factors and pain, from early after surgery to >12 months after surgery, were extracted. Effect size correlations (r equivalents) were calculated and pooled by using random-effects meta-analysis models.

RESULTS

Of 4,137 studies, 47 were included (n = 15,987 participants; 26 studies ≤12 months after surgery and 22 studies >12 months after surgery). The majority of the studies had low to moderate risk of bias. Higher preoperative anxiety and depression were weak but significant predictors of pain at all time points up to 12 months (r equivalent: 0.15-0.22). Higher preoperative pain catastrophizing and distress were also weak but significant predictors of pain during the acute (0-7 days) and chronic (3-12 months) periods (r equivalent: 0.10-0.20). For the period >12 months after surgery, weak but significant cross-sectional associations with pain were identified for anxiety, depression, pain catastrophizing, and distress (r equivalents: 0.15, 0.17, 0.25, 0.14, respectively).

CONCLUSION

Significant pooled effect size correlations between psychological factors and pain were identified across all time frames. Though weak, these associations should encourage assessment of key psychological factors during preoperative screening and pain assessments at all postoperative time frames.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background:

Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete.

Objectives:

This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research.

Methods:

A PubMed search with the relevant keywords was done for articles published in the last 10 years.

Results:

The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy.

Conclusions:

PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

Perception of pain and influences on opioid use in implant-based breast reconstruction patients

Although there has been a recent focus on decreasing opioid prescribing through alternative pain medication protocols, the patient's perception of pain related to breast reconstructive surgeries has not been well described. We sought to evaluate patient perception of pain control as it influences opioid use. We hypothesize that modifiable factors may influence patterns in pain perception and postoperative opioid use. Patients undergoing consultation for mastectomy with immediate, implant-based breast reconstruction were enrolled in a prospective, cohort survey study. A survey was administered at preoperative and postoperative appointments to collect data on pain expectations and pain control. Of 100 patients enrolled, 85% completed the postoperative survey. Over half of patients (52%) reported feeling anxious about pain control after surgery. Patients with preoperative opioid use were more likely to expect complete relief of pain postoperatively (P = .038). Patients with psychiatric comorbidity were more likely to report feeling anxious about postoperative pain (P = .012; 70% vs 42%; OR 3.0 CI 1.2-7.4). Patients who reported feeling anxious about pain control preoperatively were more likely to report trying opioids (P = .047; 67% vs 44%; OR 2.5 CI 1.0-6.1) and benzodiazepines (P = .020; 80% vs 56%; OR 3.0 CI 1.2-8.0) postoperatively. Anxiety related to pain control is common and results in an increased likelihood of trying opioid and benzodiazepine medications postoperatively. This presents an opportunity to educate patients preoperatively by addressing anxiety related to pain control to decrease controlled substance use.

AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery

Acute pain after breast surgery decreases the quality of life of cancer survivors. Previous studies using a variety of definitions and methods report prevalence rates between 10% and 80%, which suggests the need for a comprehensive framework that can be used to guide assessment of acute pain and pain-related outcomes after breast surgery. A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the 5 dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks [ACTTION], American Academy of Pain Medicine [AAPM], American Pain Society [APS] Pain Taxonomy) to acute pain after breast surgery. Application of the AAAPT taxonomy yielded the following: 1) Core Criteria: Location, timing, severity, and impact of breast surgery pain were defined; 2) Common Features: Character and expected trajectories were established in relevant surgical subgroups, and common pain assessment tools for acute breast surgery pain identified; 3) Modulating Factors: Biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: Domains of impact were outlined and defined; 5) Neurobiologic Mechanisms: Putative mechanisms were specified ranging from nerve injury, inflammation, peripheral and central sensitization, to affective and social processing of pain. PERSPECTIVE: The AAAPT provides a framework to define and guide improved assessment of acute pain after breast surgery, which will enhance generalizability of results across studies and facilitate meta-analyses and studies of interindividual variation, and underlying mechanism. It will allow researchers and clinicians to better compare between treatments, across institutions, and with other types of acute pain.

Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis

OBJECTIVES

Inadequate postoperative pain control is common and is associated with poor clinical outcomes. This study aimed to identify preoperative predictors of poor postoperative pain control in adults undergoing inpatient surgery.

DESIGN

Systematic review and meta-analysis DATA SOURCES: MEDLINE, Embase, CINAHL and PsycINFO were searched through October 2017.

ELIGIBILITY CRITERIA

Studies in any language were included if they evaluated postoperative pain using a validated instrument in adults (≥18 years) and reported a measure of association between poor postoperative pain control (defined by study authors) and at least one preoperative predictor during the hospital stay.

DATA EXTRACTION AND SYNTHESIS

Two reviewers screened articles, extracted data and assessed study quality. Measures of association for each preoperative predictor were pooled using random effects models.

RESULTS

Thirty-three studies representing 53 362 patients were included in this review. Significant preoperative predictors of poor postoperative pain control included younger age (OR 1.18 [95% CI 1.05 to 1.32], number of studies, n=14), female sex (OR 1.29 [95% CI 1.17 to 1.43], n=20), smoking (OR 1.33 [95% CI 1.09 to 1.61], n=9), history of depressive symptoms (OR 1.71 [95% CI 1.32 to 2.22], n=8), history of anxiety symptoms (OR 1.22 [95% CI 1.09 to 1.36], n=10), sleep difficulties (OR 2.32 [95% CI 1.46 to 3.69], n=2), higher body mass index (OR 1.02 [95% CI 1.01 to 1.03], n=2), presence of preoperative pain (OR 1.21 [95% CI 1.10 to 1.32], n=13) and use of preoperative analgesia (OR 1.54 [95% CI 1.18 to 2.03], n=6). Pain catastrophising, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopaedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control. Study quality was generally high, although appropriate blinding of predictor during outcome ascertainment was often limited.

CONCLUSIONS

Nine predictors of poor postoperative pain control were identified. These should be recognised as potentially important factors when developing discipline-specific clinical care pathways to improve pain outcomes and to guide future surgical pain research.

PROSPERO REGISTRATION NUMBER

CRD42017080682.

The Effect of Comedy Films on Postoperative Pain and Anxiety in Surgical Oncology Patients

Objectives: To determine the effect of watching Turkish comedy films on postoperative pain and anxiety in oncology surgical patients. Design: This study was conducted using a pre- and post-test randomized controlled trial model. Materials and Methods: The study was conducted in a general surgery clinic of a hospital in eastern Turkey between January 2016 and January 2017. The sample of the study consisted of 88 patients (44 test, 44 control) selected by using the randomized sampling method. In the experimental group, funny videos from Turkish old comedy movies were watched for 10 min before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. In the analysis of the data, descriptive statistics, χ2 and t test were used. Results: The state-trait anxiety pre- and post-test mean score of the experimental group was found to be 39.59 ± 3.66 and 37.54 ± 3.52 before and after watching the video, respectively, indicating a statistically significant difference between these two values (p ≤ 0.05). No statistically significant difference was found between the pre- and post-test state-trait anxiety scores of the patients in the control group. The decrease from the pre- to post-test mean pain score was determined as 0.65 ± 1.05 in the experimental group and 0.11 ± 0.96 in the control group. A statistically significant difference was found between the groups’ post-test mean pain scores (p ≤ 0.05). Conclusion: The study results suggest that watching Turkish comedy movie videos has a positive effect on postoperative pain and anxiety in surgical oncology patients.

Preoperative Psychosocial and Psychophysical Phenotypes as Predictors of Acute Pain Outcomes After Breast Surgery

The severity and impact of acute pain after breast surgery varies markedly among individuals, underlining the importance of comprehensively identifying specific risk factors, including psychosocial and psychophysical traits. In this prospective observational study, women (n = 234) undergoing breast-conserving surgery, mastectomy, or mastectomy with reconstruction completed a brief bedside quantitative sensory testing battery, along with measures of psychosocial characteristics. Postoperative pain severity, impact, and opioid use at 2 weeks were assessed using Brief Pain Inventory and procedure-specific breast cancer pain questionnaires. Moderate-severe average pain (>3/10) was reported by 29% of patients at 2 weeks. Regression analysis of pain outcomes revealed that pain severity was independently predicted by axillary dissection, pre-surgical pain, temporal summation of pain (TSP), (-)positive affect, and behavioral coping style. Pain impact was predicted by age, education, axillary dissection, reconstruction, but also by negative affect and depression scores. Lastly, opioid use was predicted by age, education, axillary dissection, reconstruction, TSP, and reinterpreting coping style. Our findings suggest that, individuals with certain phenotypic characteristics, including high TSP and negative affect, may be at greater risk of significant pain and continued opioid use at 2 weeks after surgery, independent of known surgical risk factors. PERSPECTIVE: We measured differences in the psychosocial and psychophysical processing of pain amongst patients before breast surgery using simple validated questionnaires and brief quantitative sensory testing. Independent of younger age and procedural extent (axillary surgery and reconstruction), affect and greater temporal summation of pain predicted acute postoperative pain and opioid use.

Age and pain as predictors of discomfort in patients undergoing transfemoral percutaneous coronary interventions

BACKGROUND

Transfemoral percutaneous coronary intervention (PCI) requires strict bed rest, causing pain and discomfort in patients. However, no studies have investigated this issue.

OBJECTIVES

To investigate the predictors of discomfort in transfemoral PCI patients.

METHODS

A cross-sectional sample of 110 patients from two coronary care units completed questionnaires on demographic and clinical characteristics, visual analogue pain scale, and discomfort.

RESULTS

Eight factors predicted overall discomfort: physiologic pain, physiological discomfort, psychological discomfort, analgesic use after sheath removal, hemostasis method, and bed rest duration. Psychological discomfort was associated with age, chronic obstructive pulmonary disease, analgesic use after sheath removal, successful hemostasis, and hematoma >5 cm. A hierarchical regression model explained 70.5% of the variance in overall discomfort.

CONCLUSIONS

Age and physiologic pain are major predictors of overall discomfort, especially in patients aged <60 years having high pain sensitivity. Critical care providers should note patients' physiological and psychological issues throughout the PCI process.