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Kistemaker KRJ, Sijani F, Brinkman DJ, de Graeff A, Burchell GL, Steegers MAH, van Zuylen L. Corrigendum to "Pharmacological prevention and treatment of opioid-induced constipation in cancer patients: A systematic review and meta-analysis" [Cancer Treat. Rev. 125 (2024) 102704]. Cancer Treat Rev 2024; 127:102738. [PMID: 38678643 DOI: 10.1016/j.ctrv.2024.102738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
- K R J Kistemaker
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands; Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - F Sijani
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands
| | - D J Brinkman
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands; Amsterdam UMC Location Vrije Universiteit Amsterdam, Internal Medicine, Section Pharmacotherapy, De Boelelaan 1117, Amsterdam, The Netherlands
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, de Bilt, The Netherlands
| | - G L Burchell
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M A H Steegers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - L van Zuylen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
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van Haren FGAM, Steegers MAH, Vissers KCP, van den Heuvel SAS. A qualitative evaluation of the oncologists', neurologists', and pain specialists' views on the management and care of chemotherapy-induced peripheral neuropathy in The Netherlands. Support Care Cancer 2024; 32:301. [PMID: 38647694 PMCID: PMC11035431 DOI: 10.1007/s00520-024-08493-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE In treating cancer, different chemotherapy regimens cause chemotherapy-induced peripheral neuropathy (CIPN). Despite recent international guidelines, a gold standard for diagnosis, treatment, and care is lacking. To identify the current clinical practice and the physicians' point of view and ideas for improvement, we evaluated CIPN care by interviewing different specialists involved. METHODS We performed semi-structured, audio-recorded, transcribed, and coded interviews with a purposive sample of oncologists, pain specialists, and neurologists involved in CIPN patients' care. Data is analyzed by a constant comparative method for content analysis, using ATLAS.ti software. Codes, categories, and themes are extracted, generating common denominators and conclusions. RESULTS With oncologists, pain specialists, and neurologists, nine, nine, and eight interviews were taken respectively (including three, two, and two interviews after thematic saturation occurred). While useful preventive measures and predictors are lacking, patient education (e.g., on symptoms and timely reporting) is deemed pivotal, as is low-threshold screening (e.g., anamnesis and questionnaires). Diagnosis focusses on a temporal relationship to chemotherapy, with adjuvant testing (e.g., EMG) used in severe or atypical cases. Symptomatic antineuropathic and topical medication are often prescribed, but personalized and multidimensional care based on individual symptoms and preferences is highly valued. The limited efficacy of existing treatments, and the lack of standardized protocols, interdisciplinary coordination, and awareness among healthcare providers pose significant challenges. CONCLUSION Besides the obvious need for better therapeutic options, and multidisciplinary exploration of patients' perspectives, a structured and collaborative approach towards diagnosis, treatment, referral, and follow-up, nurtured by improving knowledge and use of existing CIPN guidelines, could enhance care.
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Affiliation(s)
- F G A M van Haren
- Department of Anesthesiology Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands.
| | - M A H Steegers
- Department of Anesthesiology Pain- and Palliative Medicine, AmsterdamUMC, Amsterdam, The Netherlands
| | - K C P Vissers
- Department of Anesthesiology Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - S A S van den Heuvel
- Department of Anesthesiology Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
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Kistemaker KRJ, Sijani F, Brinkman DJ, de Graeff A, Burchell GL, Steegers MAH, van Zuylen L. Pharmacological prevention and treatment of opioid-induced constipation in cancer patients: A systematic review and meta-analysis. Cancer Treat Rev 2024; 125:102704. [PMID: 38452708 DOI: 10.1016/j.ctrv.2024.102704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Cancer-related pain often requires opioid treatment with opioid-induced constipation (OIC) as its most frequent gastrointestinal side-effect. Both for prevention and treatment of OIC osmotic (e.g. polyethylene glycol) and stimulant (e.g. bisacodyl) laxatives are widely used. Newer drugs such as the peripherally acting µ-opioid receptor antagonists (PAMORAs) and naloxone in a fixed combination with oxycodone have become available for the management of OIC. This systematic review and meta-analysis aims to give an overview of the scientific evidence on pharmacological strategies for the prevention and treatment of OIC in cancer patients. METHODS A systematic search in PubMed, Embase, Web of Science and the Cochrane Library was completed from inception up to 22 October 2022. Randomized and non-randomized studies were systematically selected. Bowel function and adverse drug events were assessed. RESULTS Twenty trials (prevention: five RCTs and three cohort studies; treatment: ten RCTs and two comparative cohort studies) were included in the review. Regarding the prevention of OIC, three RCTs compared laxatives with other laxatives, finding no clear differences in effectivity of the laxatives used. One cohort study showed a significant benefit of magnesium oxide compared with no laxative. One RCT found a significant benefit for the PAMORA naldemedine compared with magnesium oxide. Preventive use of oxycodone/naloxone did not show a significant difference in two out of three other studies compared to oxycodone or fentanyl. A meta-analysis was not possible. Regarding the treatment of OIC, two RCTs compared laxatives, of which one RCT found that polyethylene glycol was significantly more effective than sennosides. Seven studies compared an opioid antagonist (naloxone, methylnaltrexone or naldemedine) with placebo and three studies compared different dosages of opioid antagonists. These studies with opioid antagonists were used for the meta-analysis. Oxycodone/naloxone showed a significant improvement in Bowel Function Index compared to oxycodone with laxatives (MD -13.68; 95 % CI -18.38 to -8.98; I2 = 58 %). Adverse drug event rates were similar amongst both groups, except for nausea in favour of oxycodone/naloxone (RR 0.51; 95 % CI 0.31-0.83; I2 = 0 %). Naldemedine (NAL) and methylnaltrexone (MNTX) demonstrated significantly higher response rates compared to placebo (NAL: RR 2.07, 95 % CI 1.64-2.61, I2 = 0 %; MNTX: RR 3.83, 95 % CI 2.81-5.22, I2 = 0 %). With regard to adverse events, abdominal pain was more present in treatment with methylnaltrexone and diarrhea was significantly more present in treatment with naldemedine. Different dosages of methylnaltrexone were not significantly different with regard to both efficacy and adverse drug event rates. CONCLUSIONS Magnesium oxide and naldemedine are most likely effective for prevention of OIC in cancer patients. Naloxone in a fixed combination with oxycodone, naldemedine and methylnaltrexone effectively treat OIC in cancer patients with acceptable adverse events. However, their effect has not been compared to standard (osmotic and stimulant) laxatives. More studies comparing standard laxatives with each other and with opioid antagonists are necessary before recommendations for clinical practice can be made.
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Affiliation(s)
- K R J Kistemaker
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands.
| | - F Sijani
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - D J Brinkman
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC location Vrije Universiteit Amsterdam, Internal Medicine, Section Pharmacotherapy, De Boelelaan 1117, Amsterdam, the Netherlands
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, de Bilt, the Netherlands
| | - G L Burchell
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M A H Steegers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
| | - L van Zuylen
- Amsterdam UMC location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, the Netherlands
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Renckens SC, Onwuteaka-Philipsen BD, Jorna Z, Klop HT, du Perron C, van Zuylen L, Steegers MAH, Ten Tusscher BL, van Mol MMC, de Ruijter W, Pasman HR. Experiences with and needs for aftercare following the death of a loved one in the ICU: a mixed-methods study among bereaved relatives. BMC Palliat Care 2024; 23:65. [PMID: 38433194 PMCID: PMC10910713 DOI: 10.1186/s12904-024-01396-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/23/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Bereaved relatives of intensive care unit (ICU) patients are at increased risk of psychological complaints. Aftercare might help them cope with processing the ICU admission and their loved one's death. There is little (qualitative) evidence on how bereaved relatives experience aftercare. Also, the COVID-19 pandemic likely impacted aftercare provision. We aim to examine how many relatives in Dutch ICUs received aftercare before and during the pandemic and to qualitatively describe their experiences and needs regarding aftercare. METHODS A mixed-methods study among relatives of patients who died in an ICU before or during the COVID-19 pandemic. Bereaved relatives in six ICUs completed a questionnaire (n = 90), including two items on aftercare. These were analyzed using descriptive statistics and Chi-squared tests. Subsequently, both relatives that received and relatives that did not receive aftercare were interviewed about their experiences and needs regarding aftercare. The interviews were thematically analyzed. RESULTS After the passing of a loved one, 44% of the relatives were asked by a healthcare professional from the hospital how they were doing, and 26% had had a follow-up conversation. Both happened more often during the first wave of the pandemic than during the second wave or before the pandemic. The most common reason for not having had a follow-up conversation was not knowing about this option (44%), followed by not feeling a need (26%). Regarding the latter, interviewed relatives explained that this would not revive their loved one or that they had already discussed everything they wanted. Relatives who wanted a follow-up conversation, wanted this because this would help them realize the severity of their loved one's illness, to exchange personal experiences, and/or to thank the ICU team. Those with a follow-up conversation said that they had reviewed the medical course of the admission and/or discussed their (mental) well-being. CONCLUSIONS ICU healthcare professionals may play a vital role in addressing aftercare needs by asking relatives how they are doing in the weeks following the death of their loved one and offering them a follow-up conversation with an ICU physician. We recommend to include aftercare for bereaved relatives in ICU guidelines.
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Affiliation(s)
- Sophie C Renckens
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands.
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands.
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Zina Jorna
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Viaa University of Applied Sciences, Zwolle, The Netherlands
| | - Chantal du Perron
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, location VU Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Birkitt L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Margo M C van Mol
- Department of Intensive Care Medicine Adults, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
| | - Wouter de Ruijter
- Department of Intensive Care Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - H Roeline Pasman
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
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Renckens SC, Pasman HR, Jorna Z, Klop HT, Perron CD, van Zuylen L, Steegers MAH, Ten Tusscher BL, van Mol MMC, Vloet LCM, Onwuteaka-Philipsen BD. Varying (preferred) levels of involvement in treatment decision-making in the intensive care unit before and during the COVID-19 pandemic: a mixed-methods study among relatives. BMC Med Inform Decis Mak 2024; 24:46. [PMID: 38347583 PMCID: PMC10863197 DOI: 10.1186/s12911-024-02429-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND In the intensive care unit (ICU) relatives play a crucial role as surrogate decision-makers, since most patients cannot communicate due to their illness and treatment. Their level of involvement in decision-making can affect their psychological well-being. During the COVID-19 pandemic, relatives' involvement probably changed. We aim to investigate relatives' involvement in decision-making in the ICU before and during the pandemic and their experiences and preferences in this regard. METHODS A mixed-methods study among relatives of ICU patients admitted to an ICU before or during the COVID-19 pandemic. Relatives in six ICUs completed a questionnaire (n = 329), including two items on decision-making. These were analysed using descriptive statistics and logistic regression analyses. Subsequently, relatives (n = 24) were interviewed about their experiences and preferences regarding decision-making. Thematic analysis was used for analysing the qualitative data. RESULTS Nearly 55% of the relatives indicated they were at least occasionally asked to be involved in important treatment decisions and of these relatives 97.1% reported to have had enough time to discuss questions and concerns when important decisions were to be made. During the first COVID-19 wave relatives were significantly less likely to be involved in decision-making compared to relatives from pre-COVID-19. The interviews showed that involvement varied from being informed about an already made decision to deliberation about the best treatment option. Preferences for involvement also varied, with some relatives preferring no involvement due to a perceived lack of expertise and others preferring an active role as the patient's advocate. Discussing a patient's quality of life was appreciated by relatives, and according to relatives healthcare professionals also found this valuable. In some cases the preferred and actual involvement was in discordance, preferring either a larger or a smaller role. CONCLUSIONS As treatment alignment with a patient's values and preferences and accordance between preferred and actual involvement in decision-making is very important, we suggest that the treatment decision-making process should start with discussions about a patient's quality of life, followed by tailoring the process to relatives' preferences as much as possible. Healthcare professionals should be aware of relatives' heterogeneous and possibly changing preferences regarding the decision-making process.
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Affiliation(s)
- Sophie C Renckens
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands.
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Zina Jorna
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Viaa University of Applied Sciences, Zwolle, The Netherlands
| | - Chantal du Perron
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, location VU Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Birkitt L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
| | - Margo M C van Mol
- Erasmus MC, Department of Intensive Care Medicine Adults, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
| | - Lilian C M Vloet
- Foundation Family and patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC, location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
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Have TT, Geffen STV, Zwaans WAR, Maatman RC, Boelens OBA, Steegers MAH, Scheltinga MRM, Roumen RMH. Pulsed radiofrequency or surgery for anterior cutaneous nerve entrapment syndrome: Long-term results of a randomized controlled trial. Pain Pract 2024; 24:288-295. [PMID: 37823480 DOI: 10.1111/papr.13305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/26/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Patients with anterior cutaneous nerve entrapment syndrome (ACNES) often require a step-up treatment strategy including abdominal wall injections, pulsed radiofrequency (PRF) or a neurectomy. Long-term success rates of PRF and surgery are largely unknown. The aim of the current study was to report on the long-term efficacy of PRF and neurectomy in ACNES patients who earlier participated in the randomized controlled PULSE trial. METHODS Patients who completed the PULSE trial were contacted about pain status and additional treatments in the following years. Treatment success was based on numerical rating scale (NRS) following IMMPACT recommendations and Patient Global Impression of Change (PGIC) scores. RESULTS A total of 44 of the original 60 patients were eligible for analysis (73.3%). Median follow-up was 71.5 months. One patient (4.3%) was still free of pain after a single PRF session, and five additional patients (21.7%) were free of pain by repetitive PRF treatments. By contrast, 13 patients (61.9%) in the neurectomy group were still free of pain without additional treatments. All pain recurrences and therefore primary re-interventions occurred in the first 2 years after the initial treatment. CONCLUSION Approximately one in five ACNES patients undergoing PRF treatment reports long-term success obviating the need of surgical intervention. Surgery for ACNES is long-term effective in approximately two of three operated patients. Recurrent ACNES beyond 2 years after either intervention is rare.
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Affiliation(s)
- Tom Ten Have
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx Center of expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Sem T van Geffen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx Center of expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Willem A R Zwaans
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx Center of expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Robbert C Maatman
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx Center of expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | | | - Monique A H Steegers
- Department of Anaesthesiology & Pain and Palliative Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marc R M Scheltinga
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx Center of expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands
- SolviMáx Center of expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven, The Netherlands
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Baggen JHM, Koevoets AC, Koutris M, Steegers MAH, Lobbezoo F. Chronic temporomandibular disorder pain patients with a history of neuropathic pain treatment: a narrative research on their diagnosis and treatment history. BMC Oral Health 2024; 24:22. [PMID: 38178030 PMCID: PMC10768420 DOI: 10.1186/s12903-023-03796-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024] Open
Abstract
The aims of this qualitative research were (1) to gain more insight in the diagnostic and treatment history of patients with chronic temporomandibular disorder (TMD) pain; (2) to get a deeper understanding of possible factors that are involved in the possible delay in setting a TMD-pain diagnosis and receiving appropriate treatment; and (3) to get a deeper understanding of the perspectives and experiences of chronic TMD-pain patients on the possible improvement of various aspects of their diagnostic and treatment journey.MethodsIn this narrative research, semi-structured interviews took place with patients who experienced chronic orofacial pain (OFP) for at least three years before getting diagnosed with, and treated for, TMD pain by an OFP specialist in an interprofessional setting.ResultsIn total, ten patients were interviewed in-depth. Patients experienced their chronic OFP in different ways, but all reported a significant impact of their pain on their quality of life. All patients visited numerous health care professionals before their TMD diagnosis was set. Among others, they underwent anti-neuropathic pain medication therapies and invasive surgeries, which did not significantly reduce their chronic OFP. The interprofessional TMD-pain treatment reduced the suffering of the chronic OFP substantially, also 6 months after the start of therapy, and improved the quality of life for all patients. In most of them, the OFP intensity was also decreased.ConclusionChronic TMD-pain patients with a history of neuropathic pain treatment may experience a long journey until receiving the appropriate diagnosis and treatment. This stresses the need to improve the implementation of chronic TMD-pain guidelines.
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Affiliation(s)
- Jeanne H M Baggen
- Department of Orofacial Pain & Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan, 3004, 1081 LA, Amsterdam, The Netherlands.
| | - Anna C Koevoets
- Department of Orofacial Pain & Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan, 3004, 1081 LA, Amsterdam, The Netherlands
| | - Michail Koutris
- Department of Orofacial Pain & Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan, 3004, 1081 LA, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Amsterdam UMC, Vrije Universiteit Amsterdam, Anesthesiology, Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain & Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan, 3004, 1081 LA, Amsterdam, The Netherlands
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8
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Admiraal M, van Zuylen ML, Hermanns H, Willems HC, Geurtsen GJ, Steegers MAH, Kallewaard JW, Hollmann MW, Hermanides J. The Effect of Preoperative Disability, Cognitive Impairment, Frailty and Opioid Use on Acute Postoperative Pain in Older Patients Undergoing Surgery A Prospective Cohort Study. J Pain 2023; 24:1886-1895. [PMID: 37270141 DOI: 10.1016/j.jpain.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/01/2023] [Accepted: 05/23/2023] [Indexed: 06/05/2023]
Abstract
Globally, life expectancy is increasing, leading to more surgeries being performed in older patients. Postoperative pain is associated with complications after surgery. The aim of this study is to explore potential age-related risk factors for acute postoperative pain in older patients undergoing surgery. This was a prospective, single-center study. Patients ≥65 years, with and without disability, as defined by the WHO Disability Assessment Schedule 2.0, undergoing elective surgery, were compared. Primary outcome was the postoperative pain (ie, numeric rating scale (NRS) score) on the first postoperative day. Secondary outcomes were postoperative pain and pain trajectories in patients with and without mild cognitive impairment (MCI), frailty, preoperative opioid use, and new-onset disability after surgery. Between February 2019 and July 2020, 155 patients were enrolled. On the first day after surgery, postoperative pain did not differ between patients with and without disability. NRS scores differed between patients with-, and without MCI on the first (P = .01), and second postoperative day (P < .01). Patients who used opioids before surgery reported higher median NRS score on the first (P < .001) and second (P < .01) postoperative day. Out of a total of 1816 NRS scores, 2 pain clusters were identified. Acute postoperative pain did not differ between patients with or without preoperative disability and frailty in older patients undergoing surgery. Reduced postoperative pain in older patients with MCI warrants further investigation. The PIANO study (Comparison of Postoperative NeurocognitiveFunction in Older Adult Patients with and without Diabetes Mellitus) was registered with www.clinicaltrialregister.nl (search term: Which can predict memory problems after surgery better; blood sugar levels or memory before surgery?). PERSPECTIVE: This study explored risk factors for acute postoperative pain in older patients. No differences in postoperative pain were observed in patients with or without preexistent disability or frailty, however, patients with mild cognitive impairment experienced reduced pain. We suggest to simplify pain assessment in this group and take functional recovery into account.
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Affiliation(s)
- Manouk Admiraal
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands
| | - Mark L van Zuylen
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands
| | - Henning Hermanns
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands.
| | - Hanna C Willems
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section Geriatrics, Amsterdam, The Netherlands
| | - Gert J Geurtsen
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Department of Medical Psychology, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Neurodegeneration, Department of Medical Psychology, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Amsterdam UMC, Vrije Universiteit, Department of Anesthesiology, Amsterdam, The Netherlands
| | - Jan Willem Kallewaard
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands; Rijnstate Arnhem, Department of Anesthesiology, Arnhem, The Netherlands
| | - Markus W Hollmann
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, The Netherlands
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9
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Renckens SC, Pasman HR, Klop HT, du Perron C, van Zuylen L, Steegers MAH, Ten Tusscher BL, Abbink FCH, de Ruijter W, Vloet LCM, Koster SCE, Onwuteaka-Philipsen BD. Support for relatives in the intensive care unit: lessons from a cross-sectional multicentre cohort study during the COVID-19 pandemic. BMC Health Serv Res 2023; 23:763. [PMID: 37464434 DOI: 10.1186/s12913-023-09756-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Support for relatives is highly important in the intensive care unit (ICU). During the first COVID-19 wave support for relatives had to be changed considerably. The alternative support could have decreased the quality and sense of support. We aimed to evaluate how support for relatives in Dutch ICUs was organised during the first COVID-19 wave and how this was experienced by these relatives in comparison to relatives from pre-COVID-19 and the second wave. Additionally, we aimed to investigate which elements of support are associated with positive experiences. METHODS We performed a cross-sectional multicentre cohort study in six Dutch ICUs in the Netherlands. Written questionnaires were distributed among relatives of ICU patients from pre-COVID-19, the first wave and the second wave. The questionnaire included questions on demographics, the organisation of support, and the experiences and satisfaction of relatives with the support. RESULTS A total of 329 relatives completed the questionnaire (52% partner, 72% woman and 63% ICU stay of 11 days or longer). Support for relatives of ICU patients during the first COVID-19 wave differed significantly from pre-COVID-19 and the second wave. Differences were found in all categories of elements of support: who, when, how and what. Overall, relatives from the three time periods were very positive about the support. The only difference in satisfaction between the three time periods, was the higher proportion of relatives indicating that healthcare professionals had enough time for them during the first wave. Elements of support which were associated with many positive experiences and satisfaction were: fixed timeslot, receiving information (e.g. leaflets) on ≥ 2 topics, discussing > 5 topics with healthcare professionals, and being offered emotional support. CONCLUSIONS Although, support for relatives in the ICU changed considerably during the COVID-19 pandemic, relatives were still positive about this support. The altered support gave insight into avenues for improvement for future comparable situations as well as for normal daily ICU practice: e.g. daily contact at a fixed timeslot, offering video calling between patients and relatives, and offering emotional support. ICUs should consider which elements need improvement in their practice.
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Affiliation(s)
- Sophie C Renckens
- Department of Public and Occupational Health, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands.
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Department of Public and Occupational Health, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Viaa University of Applied Sciences, Zwolle, The Netherlands
| | - Chantal du Perron
- Department of Public and Occupational Health, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
| | - Lia van Zuylen
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Birkitt L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Floor C H Abbink
- Department of Paediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter de Ruijter
- Department of Intensive Care Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Lilian C M Vloet
- Foundation Family and Patient Centered Intensive Care (FCIC), Alkmaar, The Netherlands
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Stephanie C E Koster
- Department of Anaesthesiology and Department of Intensive Care Medicine, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
- Expertise Center for Palliative Care Amsterdam UMC, Amsterdam, The Netherlands
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10
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Kistemaker KRJ, de Graeff A, Crul M, de Klerk G, van de Ven PM, van der Meulen MP, van Zuylen L, Steegers MAH. Magnesium hydroxide versus macrogol/electrolytes in the prevention of opioid-induced constipation in incurable cancer patients: study protocol for an open-label, randomized controlled trial (the OMAMA study). BMC Palliat Care 2023; 22:22. [PMID: 36915062 PMCID: PMC10012532 DOI: 10.1186/s12904-023-01143-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Opioid-induced constipation (OIC) is a common symptom in cancer patients treated with opioids with a prevalence of up to 59%. International guidelines recommend standard laxatives such as macrogol/electrolytes and magnesium hydroxide to prevent OIC, although evidence from randomized controlled trials is largely lacking. The aim of our study is to compare magnesium hydroxide with macrogol /electrolytes in the prevention of OIC in patients with incurable cancer and to compare side-effects, tolerability and cost-effectiveness. METHODS Our study is an open-label, randomized, multicenter study to examine if magnesium hydroxide is non-inferior to macrogol/electrolytes in the prevention of OIC. In total, 330 patients with incurable cancer, starting with opioids for pain management, will be randomized to treatment with either macrogol/electrolytes or magnesium hydroxide. The primary outcome measure is the proportion of patients with a score of < 30 on the Bowel Function Index (BFI), measured on day 14. The Rome IV criteria for constipation, side effects of and satisfaction with laxatives, pain scores, quality of life (using the EQ-5D-5L), daily use of laxatives and escape medication, and cost-effectiveness will also be assessed. DISCUSSION In this study we aim to examine if magnesium hydroxide is non-inferior to macrogol/electrolytes in the prevention of OIC. The outcome of our study will contribute to prevention of OIC and scientific evidence of guidelines on (opioid-induced) constipation. TRIAL REGISTRATION This trial is registered at clinicaltrials.gov: NCT05216328 and in the Dutch trial register: NTR80508. EudraCT number 2022-000408-36.
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Affiliation(s)
- K R J Kistemaker
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands. .,Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands. .,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - A de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, Academic Hospice Demeter, De Bilt, The Netherlands
| | - M Crul
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Clinical Pharmacology and Pharmacy, De Boelelaan 1117, Amsterdam, The Netherlands
| | - G de Klerk
- Spaarne Gasthuis Location Hoofddorp, Medical Oncology, Spaarnepoort 1, Hoofddorp, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M P van der Meulen
- Department of Epidemiology and Health Economics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L van Zuylen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Medical Oncology, De Boelelaan 1117, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
| | - M A H Steegers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Treatment and Quality of Life, Amsterdam, The Netherlands
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11
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Witkam RL, Kragt EAM, Arnts IJJ, Bronkhorst EM, van Dongen R, Kurt E, Steegers MAH, van Haren FGAM, Maandag NJG, Gort C, Henssen DJHA, Wegener JT, Vissers KCP. Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial? J Pain 2023:S1526-5900(23)00070-6. [PMID: 36878384 DOI: 10.1016/j.jpain.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practised to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialled and non-trialled implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multi-centre cohort analysis was performed in two comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least three months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within one session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients(N=570), respectively. A statistically but not clinically significant difference in pain intensity (p=0.003; effect=0.506 (0.172-0.839)) was found in favour of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialled SCS patients were more likely to cease opioid usage (p=0.003; OR=0.509 (0.326-0.792)), patients in the No-Trial group endured fewer infections (p=0.006; proportion difference=0.43 (0.007-0.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.
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Affiliation(s)
- Richard L Witkam
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Elisabeth A M Kragt
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge J J Arnts
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert van Dongen
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erkan Kurt
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Department of Anaesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frank G A M van Haren
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natasja J G Maandag
- Department of Anaesthesiology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Cees Gort
- Department of Anaesthesiology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Dylan J H A Henssen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jessica T Wegener
- Department of Anaesthesiology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Kris C P Vissers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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12
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Timmerman H, van Boekel RLM, van de Linde LS, Bronkhorst EM, Vissers KCP, van der Wal SEI, Steegers MAH. The effect of preferred music versus disliked music on pain thresholds in healthy volunteers. An observational study. PLoS One 2023; 18:e0280036. [PMID: 36649221 PMCID: PMC9844868 DOI: 10.1371/journal.pone.0280036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 12/20/2022] [Indexed: 01/18/2023] Open
Abstract
Pain is a prevalent and debilitating healthcare problem. Since pharmacological treatments have numerous side-effects, additional treatment could be beneficial. Music has been shown to affect the pain perception and the pain threshold. The objective of this observational study was to evaluate the effect of preferred music as opposed to disliked music on pain (tolerance) thresholds and perceived pain intensity in healthy volunteers. Pain thresholds were measured via quantitative sensory testing. The volunteers were randomly assigned to either handheld pressure algometry to assess the pressure pain threshold to or electrical measurements to assess the electrical pain tolerance threshold while listening to preferred and disliked music. The pain thresholds were administered on the dorsal side of the forearm. The perceived pain intensity was assessed via a numerical rating scale, ranging from 0 (no pain) to 10 (worst pain imaginable). In total 415 volunteers were included in this study. The pressure pain threshold was assessed in 277 volunteers and in the electrical pain tolerance threshold test 138 volunteers were entered. In both groups, preferred music yielded higher pain thresholds than disliked music (P<0.001) and lower perceived pain intensity during the stimulus (P = 0.003). Moreover, the highest pain thresholds of both pressure pain and electrical pain tolerance thresholds were obtained when the preferred music was preceded by disliked music. Listening to preferred music when receiving noxious stimuli leads to higher pain thresholds and lower perceived pain scores in comparison with disliked music. Preferred music could be beneficial for patients with pain or undergoing painful procedures.
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Affiliation(s)
- Hans Timmerman
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail: ,
| | - Regina L. M. van Boekel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ludo S. van de Linde
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ewald M. Bronkhorst
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kris C. P. Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Selina E. I. van der Wal
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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13
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Thijssen M, Timmerman L, Koning NJ, Rinia M, van Dijk JFM, Cheuk-Alam J, Olthof K, Rekker S, Steegers MAH, van Boekel RLM. Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry. PLoS One 2022; 17:e0279606. [PMID: 36548295 PMCID: PMC9778981 DOI: 10.1371/journal.pone.0279606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.
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Affiliation(s)
- Marloes Thijssen
- Department of Anesthesiology and Pain medicine, Antonius Hospital, Nieuwegein, The Netherlands
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Leon Timmerman
- Department of Anesthesiology and Pain medicine, Antonius Hospital, Nieuwegein, The Netherlands
| | - Nick J. Koning
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Myra Rinia
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jacqueline F. M. van Dijk
- Department of Anesthesiology and Pain medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juanita Cheuk-Alam
- Department of Anesthesiology and Pain Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kees Olthof
- Department of Anesthesiology and Pain Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Sjaak Rekker
- Department of Anesthesiology and Pain Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology and Pain Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Regina L. M. van Boekel
- Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
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14
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van Helden EV, van Uitert A, Albers KI, Steegers MAH, Timmers HJLM, d'Ancona FCH, van der Wal SEI, Scheffer GJ, Keijzer C, Warlé MC, Langenhuijsen JF. Chronic postsurgical pain after minimally invasive adrenalectomy: prevalence and impact on quality of life. BMC Anesthesiol 2022; 22:153. [PMID: 35590236 PMCID: PMC9118616 DOI: 10.1186/s12871-022-01696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/14/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Minimally invasive adrenalectomy is the standard of care for small adrenal tumours. Both the transperitoneal lateral approach and posterior retroperitoneal approach are widely used and have been proven to be safe and effective. However, the prevalence of chronic postsurgical pain has not been specifically investigated in previous studies. The primary goal of this study was to identify the prevalence of chronic postsurgical pain after minimally invasive adrenalectomy. METHODS A cross-sectional study was performed among all consecutive patients who had undergone minimally invasive adrenalectomy in a single university medical centre. The primary outcome was the prevalence of chronic postsurgical pain. Secondary outcomes were the prevalence of localized hypoesthesia, risk factors for the development of chronic postsurgical pain, and the Health-Related Quality of Life. Three questionnaires were used to measure the prevalence and severity of chronic postsurgical pain, hypoesthesia, and Health-Related Quality of Life. Logistic regression analysis was performed to determine risk factors for development of chronic postsurgical pain. RESULTS Six hundred two patients underwent minimally invasive adrenalectomy between January 2007 and September 2019, of whom 328 signed informed consent. The prevalence of chronic postsurgical pain was 14.9%. In the group of patients with chronic postsurgical pain, 33% reported hypoesthesia as well. Young age was a significant predictor for developing chronic postsurgical pain. The prevalence of localized hypoesthesia was 15.2%. In patients with chronic postsurgical pain, Health-Related Quality of Life was significantly lower, compared to patients without pain. CONCLUSIONS The prevalence of chronic postsurgical pain following minimally invasive adrenalectomy is considerable. Furthermore, the presence of chronic postsurgical pain was correlated with a significant and clinically relevant lower Health-Related Quality of Life. These findings should be included in the preoperative counselling of the patient. In the absence of evidence for effective treatment in established chronic pain, prevention should be the key strategy and topic of future research.
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Affiliation(s)
- Esmee V van Helden
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - Allon van Uitert
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Kim I Albers
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam University Medical Center, De Boelelaan 1118, 1081, HV, Amsterdam, The Netherlands
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Frank C H d'Ancona
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Selina E I van der Wal
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Gert Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Johan F Langenhuijsen
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
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15
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Vriezekolk JE, Peters YAS, Steegers MAH, Davidson ENB, van den Ende CHM. Pain descriptors and determinants of pain sensitivity in knee osteoarthritis: a community-based cross-sectional study. Rheumatol Adv Pract 2022; 6:rkac016. [PMID: 35350719 PMCID: PMC8947773 DOI: 10.1093/rap/rkac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/22/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
To explore pain characteristics in individuals with knee osteoarthritis (KOA), to compare pain sensitivity across individuals with KOA, chronic back pain (CBP) and pain-free individuals (NP), and to examine the relationship between clinical and pain characteristics with pain sensitivity in KOA.
Methods
Cross-sectional, community-based online survey. Two datasets were combined comprising Dutch individuals of ≥ 40 years of age, experiencing chronic knee pain (KOA, N = 445), chronic back pain (CBP, N = 504), or no pain (NP, N = 256). Demographic and clinical characteristics, global health, physical activity/exercise, and pain characteristics including intensity, spreading, duration, quality (SF-MPQ), and sensitivity (PSQ) were assessed. Differences between (sub)groups were examined using analyses of variance or Chi-square tests. Regression analyses were performed to examine determinants of pain sensitivity in the KOA group.
Results
Quality of pain was most commonly described as aching, tender, and tiring-exhausting. Overall, the KOA group had higher levels of pain sensitivity compared to NP group, but lower levels than the CBP group. Univariately, pain intensity, its variability and spreading, global health, exercise, and having comorbidities were weakly related to pain sensitivity (standardized betas: 0.12-0.27). Symptom duration was not related to pain sensitivity. Older age, higher levels of continuous pain, lower levels of global health, and exercise uniquely contributed, albeit modest, to pain sensitivity (P<0.05).
Conclusion
Continuous pain such as aching and tenderness in combination with decreased physical activity may be indicative for a subgroup of individuals at risk for pain sensitivity and, ultimately, poor treatment outcomes.
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Affiliation(s)
- Johanna E Vriezekolk
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Yvonne A S Peters
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Monique A H Steegers
- Radboud Institute for Health Sciences,Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Anesthesiology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Cornelia H M van den Ende
- Department of Rheumatology Research, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, the Netherlands
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16
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Kopsky DJ, Szadek KM, Schober P, Vrancken AFJE, Steegers MAH. Study Design Characteristics and Endpoints for Enriched Enrollment Randomized Withdrawal Trials for Chronic Pain Patients: A Systematic Review. J Pain Res 2022; 15:479-496. [PMID: 35210848 PMCID: PMC8860756 DOI: 10.2147/jpr.s334840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- David J Kopsky
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
- Institute for Neuropathic Pain, Amsterdam, 1056 SN, the Netherlands
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Correspondence: David J Kopsky Institute for Neuropathic Pain, Vespuccistraat 64-III, Amsterdam, 1056 SN, the NetherlandsTel +31-6-28671847 Email
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
| | - Patrick Schober
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, 1081 HV, the Netherlands
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17
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Huisman BAA, Geijteman ECT, Arevalo JJ, Dees MK, van Zuylen L, Szadek KM, van der Heide A, Steegers MAH. Use of antithrombotics at the end of life: an in-depth chart review study. BMC Palliat Care 2021; 20:110. [PMID: 34271885 PMCID: PMC8285840 DOI: 10.1186/s12904-021-00786-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered. Methods We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease. Results In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics. Conclusions Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00786-3.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Hospice Kuria, Amsterdam, The Netherlands.
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jimmy J Arevalo
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Marianne K Dees
- Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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18
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Huisman BAA, Geijteman ECT, Kolf N, Dees MK, van Zuylen L, Szadek KM, Steegers MAH, van der Heide A. Physicians' Opinions on Anticoagulant Therapy in Patients with a Limited Life Expectancy. Semin Thromb Hemost 2021; 47:735-744. [PMID: 33971680 DOI: 10.1055/s-0041-1725115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with a limited life expectancy have an increased risk of thromboembolic and bleeding complications. Anticoagulants are often continued until death, independent of their original indication. We aimed to identify the opinions of physicians about the use of anticoagulants at the end of life. A mixed-method research design was used. A secondary analysis was performed on data from a vignette study and an interview study. Participants included general practitioners and clinical specialists. Physicians varied in their opinions: some would continue and others would stop anticoagulants at the end of life because of the risk of thromboembolic or bleeding complications. The improvement or preservation of patients' quality of life was a reason for both stopping and continuing anticoagulants. Other factors considered in the decision-making were the types of anticoagulant, the indication for which the anticoagulant was prescribed, underlying diseases, and the condition and life expectancy of the patient. Factors that made decision-making difficult were the lack of evidence on either strategy, uncertainty about patients' life expectancy, and the fear of harming patients. Which decision was eventually made seems largely dependent on the choice of the patient. In conclusion, there is a substantial variation in physicians' opinions regarding the use of anticoagulants in patients with a limited life expectancy. Physicians agree that the primary goal of medical care at end of life is the improvement or preservation of patients' quality of life. An important barrier to decision-making is the lack of evidence about the risks and benefits of stopping anticoagulants.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Hospice Kuria, Amsterdam, The Netherlands
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nathalie Kolf
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marianne K Dees
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Karolina M Szadek
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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19
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van Haren FGAM, Steegers MAH, Thijssen M, van der Wal SEI, Vissers KCP, Engels Y. Qualitative Evaluation of the Influence of Acute Oxaliplatin-Induced Peripheral Neuropathy on Quality of Life and Activities of Daily Life. Pain Pract 2021; 21:513-522. [PMID: 33301649 PMCID: PMC8247978 DOI: 10.1111/papr.12981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/17/2020] [Accepted: 08/05/2020] [Indexed: 12/30/2022]
Abstract
Introduction/Aims Oxaliplatin often causes acute or chronic peripheral neuropathy in patients with an intestinal or pancreatic tumor, but in‐depth insights in its influence on quality of life (QoL) are lacking. We explored the influence of acute oxaliplatin‐induced peripheral neuropathy (OIPN) on daily QoL in these patients. Methods We performed semistructured interviews with a purposive sample of patients receiving oxaliplatin and possibly experiencing acute OIPN. Interviews were audio‐recorded, transcribed verbatim, and coded by two researchers. Data were analyzed by using the constant comparative method for content analysis with ATLAS.ti software. Results After nine patients, saturation took place. In total, 11 patients were interviewed. Four themes were extracted from the data: (1) adverse effects, (2) physical (un)well‐being, (3) emotional aspects, and (4) treatment aspects. All participants were suffering from acute OIPN to a certain extent, leading to restrictions in daily activities such as household chores, but also to a decrease in mobility and independency. Other adverse effects such as general malaise and gastrointestinal side effects also influenced the participants’ well‐being, as did the diagnosis and prognosis of their disease. Conclusion Acute OIPN, together with other side effects of chemotherapeutic treatment and the difficulties that come with the diagnosis of cancer and its prognosis, largely influences patients’ daily QoL. Managing expectations (by patient education) seems important.
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Affiliation(s)
- Frank G A M van Haren
- Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Marloes Thijssen
- Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Selina E I van der Wal
- Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain- and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
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20
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Ndebea AS, van den Heuvel SAS, Temu R, Kaino MM, van Boekel RLM, Steegers MAH. Prevalence and Risk Factors for Acute Postoperative Pain After Elective Orthopedic and General Surgery at a Tertiary Referral Hospital in Tanzania. J Pain Res 2020; 13:3005-3011. [PMID: 33244259 PMCID: PMC7684026 DOI: 10.2147/jpr.s258954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/03/2020] [Indexed: 02/01/2023] Open
Abstract
Background In Africa, postoperative pain management is still a major problem with a prevalence of postoperative pain in up to 95.2% of the patients. There are little data on the prevalence and potential risk factors for postoperative pain in Tanzania. Therefore, we aimed to investigate these at Kilimanjaro Christian Medical Centre in Northern Tanzania. Our goal is to optimize pain management. Methods A prospective cohort study was carried out from December 2016 to April 2017. Patients ≥18 years admitted for elective general or orthopedic surgery were included in the study. Demographic data were collected during a pre-operative visit, and pain was assessed with a numerical rating scale (NRS 0–10) at 4, 24, 36 and 48 hours postoperatively. A NRS >3 was considered as moderate to severe postoperative pain. Potential risk factors for postoperative pain were identified using univariate and multivariable binary logistic regression analyses. Results A total of 281 patients were included in the study. The prevalence of postoperative pain was 61%, 73%, 67% and 58% at 4, 24, 36 and 48 hours after surgery, respectively. Pethidine was the most frequently prescribed analgesic for postoperative pain management (85.1%) in the first 24 hours postoperatively; only 1% received paracetamol or diclofenac, and 13% received tramadol. In the multivariable model, general anesthesia and intra-operative analgesia (OR = 3.70, 95% CI 1.70–8.04) were significant risk factors for postoperative pain. Conclusion Pain is still inadequately managed at Kilimanjaro Christian Medical Centre leading to a high prevalence (73% on the first day after surgery) of reported postoperative pain in this study. It reflects the need for adequate postoperative analgesia, especially in low- and middle-income countries. Further research identifying risk factors in larger cohorts can be performed if adequate analgesia is given.
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Affiliation(s)
- Ansbert S Ndebea
- Department of Anesthesiology, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Sandra A S van den Heuvel
- Department of Anesthesiology and Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rogers Temu
- Department of Orthopedic and Trauma, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Mwemezi M Kaino
- Department of Anesthesiology, Kilimanjaro Christian Medical Centre, Kilimanjaro, Tanzania
| | - Regina L M van Boekel
- Department of Anesthesiology and Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Amsterdam University Medical Center Location VU, Amsterdam, the Netherlands
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21
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Witkam RL, Kurt E, van Dongen R, Arnts I, Steegers MAH, Vissers KCP, Henssen DJHA, Engels Y. Experiences From the Patient Perspective on Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Qualitatively Driven Mixed Method Analysis. Neuromodulation 2020; 24:112-125. [PMID: 32969151 PMCID: PMC7891647 DOI: 10.1111/ner.13277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION When neither pharmacological therapies nor alternative interventions provide sufficient pain relief, spinal cord stimulation (SCS) can be used to treat Failed Back Surgery Syndrome (FBSS). Although it seems reasonable that quality of life (QoL)- and psychosocial-related factors contribute to the outcome of SCS since pain is a multidimensional experience, few qualitative studies have explored the expectations of SCS and experiences on SCS to treat FBSS from the patient perspective. OBJECTIVES The aim of this study was to qualitatively and quantitatively map the FBSS patients' experiences with SCS and the effects of SCS on low back pain caused by FBSS. MATERIALS AND METHODS A qualitative study with in-depth semi-structured interviews, assisted by the Brief Pain Inventory (BPI)-questionnaire. RESULTS Seven themes regarding patients' experiences, subdivided into 15 categories, were identified, including an understudied theme within this field of research, Spiritual Well-Being. "Acceptance" and "coping" emerged as pre-eminent motifs throughout these themes. Moreover, the realization of patients' expectations were variable throughout the presented themes. According to the BPI Questionnaire, four out of 13 patients (31%) had significant pain relief (≥50%). Seven out of 13 (54%) reported a ≥50% increase regarding enjoyment of life. CONCLUSION Multiple QoL- and psychosocial-related themes are related to SCS-outcomes. In order to improve SCS-outcomes for both short- and long-term, these themes should be implemented as a multidimensional approach, both prior to implantation as during follow-up.
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Affiliation(s)
- Richard L Witkam
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Unit of Functional Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erkan Kurt
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Unit of Functional Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert van Dongen
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge Arnts
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Anaesthesiology, Pain and Palliative Medicine, Amsterdam University Medical Center VUmc, Amsterdam, The Netherlands
| | - Kris C P Vissers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dylan J H A Henssen
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Unit of Functional Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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22
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van Poelgeest EP, El Houssein L, Kallewaard J, Hollmann MW, Steegers MAH, Wartenberg HCH. [Whether or not to use gabapentinoids in adults with chronic neuropathic pain]. Ned Tijdschr Geneeskd 2020; 164:D4797. [PMID: 32940971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE DESCRIPTION A frail 85-year-old woman with chronic neuropathic pain after hip surgery, not responding to treatment with acetaminophen and morphine patches. Should she be prescribed a gabapentinoid? DISCUSSION Gabapentinoids and antidepressants are considered first-line therapies. They achieve clinically relevant (i.e. ≥ 50%) pain reduction in approximately one-third of patients with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is limited. Adverse events occur frequently and are mostly mild in nature; serious adverse effects are rare. Prescription of gabapentinoids in specific patient groups (e.g. elderly patients and patients with a history of depression or substance abuse) deserves careful consideration, because the risk/benefit ratio in those groups may be altered. In order to reduce the risk of withdrawal symptoms, slow tapering is recommended. CONCLUSION Chronic neuropathic pain often has a negative impact on the quality of life and is difficult to treat. In general, treatment with a gabapentinoid is a possible first-line treatment option. However, they may be relatively contraindicated in vulnerable patients.
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23
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Van Boekel RLM, Timmerman H, Bronkhorst EM, Ruscheweyh R, Vissers KCP, Steegers MAH. Translation, Cross-Cultural Adaptation, and Validation of the Pain Sensitivity Questionnaire in Dutch Healthy Volunteers. Pain Res Manag 2020; 2020:1050935. [PMID: 32774564 PMCID: PMC7397447 DOI: 10.1155/2020/1050935] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/03/2020] [Indexed: 12/13/2022]
Abstract
An increased sensitivity to painful stimuli has been proposed to be related to the development of chronic pain. Therefore, assessment of individual pain sensitivity is useful in clinical practice. However, experimental pain testing may be uncomfortable for patients and requires specific equipment. The Pain Sensitivity Questionnaire (PSQ) has been developed to facilitate assessment of pain sensitivity. In this study, we aimed to translate and cross-culturally adapt the PSQ from its published German and English versions into the Dutch language and to assess validity of the PSQ in healthy volunteers. After translation and cross-cultural adaptation of the PSQ following international guidelines, we validated the PSQ in 394 healthy volunteers by comparing the PSQ-values with two different experimental pain tests: electrical pain tolerance (EPT) and pressure pain threshold (PPT). In addition, ratings of pain intensity during these tests were obtained on the numerical rating scale (NRS, 0-10). We found that the reliability of the PSQ based on internal consistency was good (Cronbach's alpha 0.90). PSQ-scores, adjusted for age and sex, were statistically significant and weakly inversely correlated to EPT (PSQ-moderate: rho = -0.24, p=0.007; PSQ-total: rho = -0.22, p=0.016). No statistically significant correlation between PSQ-scores and PPT was found. Concerning the pain scores, PSQ-scores were weakly to moderately correlated to EPT-NRS (PSQ-minor: rho = 0.21, p=0.021; PSQ-moderate: rho = 0.22, p=0.016; PSQ-total: rho = 0.23, p=0.009) as well as PPT-NRS (PSQ-minor: rho = 0.32, p < 0.001; PSQ-moderate: rho = 0.36, p < 0.001; PSQ-total: rho = 0.37, p < 0.001). Therefore, we concluded that the Dutch version of the PSQ is culturally appropriate for assessing self-reported pain sensitivity in healthy volunteers.
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Affiliation(s)
- Regina L. M. Van Boekel
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hans Timmerman
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Pain Center, University Medical Center Groningen, Groningen, Netherlands
| | - Ewald M. Bronkhorst
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ruth Ruscheweyh
- Department of Neurology, Ludwig Maximilians University of Munich, Munich, Germany
| | - Kris C. P. Vissers
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU, Amsterdam, Netherlands
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24
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van den Heuvel SAS, van der Wal SEI, Bronkhorst EM, Warlé MC, Ronday M, Plat J, van Alfen N, Joosten LAB, Lerou JGC, Vissers KCP, Steegers MAH. Acute Cytokine Response During Breast Cancer Surgery: Potential Role of Dexamethasone and Lidocaine and Relationship with Postoperative Pain and Complications - Analysis of Three Pooled Pilot Randomized Controlled Trials. J Pain Res 2020; 13:1243-1254. [PMID: 32547185 PMCID: PMC7266394 DOI: 10.2147/jpr.s252377] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose An imbalance in perioperative cytokine response may cause acute pain and postoperative complications. Anesthetic drugs modulate this cytokine response, but their role in non-major breast cancer surgery is unclear. In an exploratory study, we investigated whether intravenous lidocaine and dexamethasone could modulate the cytokine response into an anti-inflammatory direction. We also evaluated interrelationships between cytokine levels, pain scores and postoperative complications. Our goal is to develop multimodal analgesia regimens optimizing outcome after breast cancer surgery. Patients and Methods Forty-eight patients undergoing a lumpectomy were randomly assigned to placebo or lidocaine (1.5 mg⋅kg−1 followed by 2 mg⋅kg−1⋅hour−1) supplemented by dexamethasone zero, 4 or 8 mg, yielding six groups of eight patients. Interleukin (IL)-1β, IL-1Ra, IL-6, IL-10 levels and pain scores were measured at baseline and four hours postoperatively. We assessed postoperative complications occurring within 30 days. We noted persistent pain and infections as potential immune-related complications (PIRC). We used multiple regression to disentangle the effects of the individual study drugs (given by their partial regression coefficients (b)). Odds ratios (OR) estimated the link between pain scores and complications. Results Dexamethasone 8 mg increased IL-10 (b=12.70 (95% CI=8.06–17.34), P<0.001). Dexamethasone 4 mg and 8 mg decreased the ratio IL-6/IL-10 (b=−2.60 (−3.93 to −1.26), P<0.001 and b=−3.59 (−5.04 to −2.13), P<0.001, respectively). We could not show modulatory effects of lidocaine on cytokines. High pain scores were linked to the occurrence of PIRC’s (OR=2.028 (1.134–3.628), P=0.017). Cytokine levels were not related either to acute pain or PIRC. Conclusion Dexamethasone modulated the perioperative cytokine response into an anti-inflammatory direction. An overall lidocaine effect was not found. Patients with higher pain scores suffered from more 30-day PIRCs. Cytokine levels were not associated with pain or more postoperative complications, even not with PIRC. Larger studies in breast cancer surgery are needed to confirm these explorative results.
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Affiliation(s)
- Sandra A S van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Selina E I van der Wal
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Michiel C Warlé
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - May Ronday
- Department of Anesthesiology, Alexander Monro Breast Cancer Hospital, Bilthoven, the Netherlands
| | - Judith Plat
- Department of Anesthesiology, Alexander Monro Breast Cancer Hospital, Bilthoven, the Netherlands
| | - Nens van Alfen
- Donders Institute for Brain Cognition and Behavior, Department of Neurology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jos G C Lerou
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Pain and Palliative Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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25
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Bruintjes MHD, van Helden EV, de Vries M, Wirken L, Evers AWM, van Middendorp H, Kloke H, d'Ancona FCH, Langenhuijsen JF, Steegers MAH, Warlé MC. Chronic pain following laparoscopic living-donor nephrectomy: Prevalence and impact on quality of life. Am J Transplant 2019; 19:2825-2832. [PMID: 30868731 PMCID: PMC6790588 DOI: 10.1111/ajt.15350] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/21/2019] [Accepted: 03/03/2019] [Indexed: 01/25/2023]
Abstract
Chronic postsurgical pain (CPSP) following laparoscopic donor nephrectomy (LDN) is a disregarded topic. In this cross-sectional study, all consecutive patients who underwent an LDN at the Radboud University Medical Center (Radboudumc; 2003-2016) were approached for participation. Five hundred twelve living kidney donors were included and asked to complete two questionnaires, including the McGill Pain Questionnaire and the RAND Short Form-36 Health Status Inventory (RAND SF-36) regarding their health-related quality of life (HRQoL). The mean prevalence of CPSP following LDN was 5.7%, with a mean follow-up time of 6 years. Possible predictors of CPSP following LDN are severe early postoperative pain, previous abdominal surgery, and preexisting backache. The RAND SF-36 revealed an impaired HRQoL in patients with CPSP when compared to patients without CPSP. In conclusion, this study revealed that the prevalence of CPSP following LDN is substantial. Given the possible association between the presence of CPSP and impaired HRQoL scores, living kidney donors should be well informed in the preoperative phase about the risk of CPSP.
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Affiliation(s)
| | - Esmee V. van Helden
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands
| | - Marjan de Vries
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands
| | - Lieke Wirken
- Institute of Psychology, Health, Medical and Neuropsychology UnitLeiden UniversityLeidenThe Netherlands,Department of Medical PsychologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Andrea W. M. Evers
- Institute of Psychology, Health, Medical and Neuropsychology UnitLeiden UniversityLeidenThe Netherlands,Department of Medical PsychologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Henriët van Middendorp
- Institute of Psychology, Health, Medical and Neuropsychology UnitLeiden UniversityLeidenThe Netherlands,Department of Medical PsychologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Heinrich Kloke
- Department of NephrologyRadboud University Medical CenterNijmegenThe Netherlands
| | | | | | | | - Michiel C. Warlé
- Department of SurgeryRadboud University Medical CenterNijmegenThe Netherlands
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Heuvel SASVD, Doorduin J, Steegers MAH, Bronkhorst EM, Radema SA, Vissers KCP, Wal SEIVD, Alfen NV. Simple surface EMG recording as a noninvasive screening method for the detection of acute oxaliplatin-induced neurotoxicity: a feasibility pilot study. Neurosci Lett 2019; 699:184-188. [PMID: 30753911 DOI: 10.1016/j.neulet.2019.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Oxaliplatin-induced neurotoxicity can be a dose-limiting side effect to effective chemotherapy. Acute hyperexcitability causes cold-evoked sensory and motor symptoms, which resemble neuromyotonia. An accessible and non-invasive technique for early detection could help select patients for potential treatments. We assessed the use of a simple surface electromyography (sEMG) in patients directly after oxaliplatin infusion. METHODS In patients with colorectal cancer, acute neurotoxicity was evaluated by means of a physical examination, a questionnaire, and sEMG directly after the second and fourth cycle of oxaliplatin. Questionnaires were also assessed 1 day after infusion. RESULTS 14 patients were measured after the second cycle and 8 patients were also measured after the fourth cycle of oxaliplatin. All patients reported to a variable degree oxaliplatin induced neurotoxicity symptoms: sensitivity to touching cold or swallowing cold items were reported as most severe. Clinical signs of hyperexcitability were observed in 55% of the measurements. Spontaneous activity compatible with neuromyotonia was observed in 82% of the sEMG recordings. CONCLUSIONS Patient reported symptoms, physical examination and simple sEMG are complementary measurements to detect acute oxaliplatin induced neurotoxicity. After further validation, sEMG recording can be used as a simple objective screenings tool to detect nerve hyperexcitability directly after oxaliplatin administration.
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Affiliation(s)
- Sandra A S van den Heuvel
- Expertise center for Pain and Palliative Medicine, Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonne Doorduin
- Donders Institute for Brain Cognition and Behavior, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Expertise center for Pain and Palliative Medicine, Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sandra A Radema
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kris C P Vissers
- Expertise center for Pain and Palliative Medicine, Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Selina E I van der Wal
- Expertise center for Pain and Palliative Medicine, Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nens van Alfen
- Donders Institute for Brain Cognition and Behavior, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
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Timmerman H, Wolff AP, Bronkhorst EM, Wilder-Smith OHG, Schenkels MJ, van Dasselaar NT, Huygen FJPM, Steegers MAH, Vissers KCP. Avoiding Catch-22: validating the PainDETECT in a in a population of patients with chronic pain. BMC Neurol 2018; 18:91. [PMID: 29958535 PMCID: PMC6026336 DOI: 10.1186/s12883-018-1094-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/22/2018] [Indexed: 12/19/2022] Open
Abstract
Background Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system and is a major therapeutic challenge. Several screening tools have been developed to help physicians detect patients with neuropathic pain. These have typically been validated in populations pre-stratified for neuropathic pain, leading to a so called “Catch-22 situation:” “a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule”. The validity of screening tools needs to be proven in patients with pain who were not pre-stratified on basis of the target outcome: neuropathic pain or non-neuropathic pain. This study aims to assess the validity of the Dutch PainDETECT (PainDETECT-Dlv) in a large population of patients with chronic pain. Methods A cross-sectional multicentre design was used to assess PainDETECT-Dlv validity. Included where patients with low back pain radiating into the leg(s), patients with neck-shoulder-arm pain and patients with pain due to a suspected peripheral nerve damage. Patients’ pain was classified as having a neuropathic pain component (yes/no) by two experienced physicians (“gold standard”). Physician opinion based on the Grading System was a secondary comparison. Results In total, 291 patients were included. Primary analysis was done on patients where both physicians agreed upon the pain classification (n = 228). Compared to the physician’s classification, PainDETECT-Dlv had a sensitivity of 80% and specificity of 55%, versus the Grading System it achieved 74 and 46%. Conclusion Despite its internal consistency and test-retest reliability the PainDETECT-Dlv is not an effective screening tool for a neuropathic pain component in a population of patients with chronic pain because of its moderate sensitivity and low specificity. Moreover, the indiscriminate use of the PainDETECT-Dlv as a surrogate for clinical assessment should be avoided in daily clinical practice as well as in (clinical-) research. Catch-22 situations in the validation of screening tools can be prevented by not pre-stratifying the patients on basis of the target outcome before inclusion in a validation study for screening instruments. Trial registration The protocol was registered prospectively in the Dutch National Trial Register: NTR 3030. Electronic supplementary material The online version of this article (10.1186/s12883-018-1094-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hans Timmerman
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Huispost 549, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - André P Wolff
- Department of Anesthesiology, Pain Center, University of Groningen, University medical center Groningen, Groningen, the Netherlands
| | - Ewald M Bronkhorst
- Department for Health Evidence, Radboud university medical center, Nijmegen, the Netherlands
| | - Oliver H G Wilder-Smith
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Huispost 549, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.,Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
| | - Marcel J Schenkels
- Bernhoven Ziekenhuis, Department of Anesthesiology, Uden, the Netherlands
| | - Nick T van Dasselaar
- Reinier de Graaf Gasthuis, Department of Anesthesiology, Pain Medicine and Palliative Care, Delft, the Netherlands
| | - Frank J P M Huygen
- ErasmusMC, Department of Anesthesiology, University Center of Pain Medicine, Rotterdam, the Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Huispost 549, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Huispost 549, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
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Maatman RC, Steegers MAH, Boelens OBA, Lim TC, van den Berg HJ, van den Heuvel SAS, Scheltinga MRM, Roumen RMH. Pulsed radiofrequency or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES) (the PULSE trial): study protocol of a randomized controlled trial. Trials 2017; 18:362. [PMID: 28768538 PMCID: PMC5541413 DOI: 10.1186/s13063-017-2110-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
Background Some patients with chronic abdominal pain suffer from an anterior cutaneous nerve entrapment syndrome (ACNES). This somewhat illusive syndrome is thought to be caused by the entrapment of end branches of the intercostal nerves residing in the abdominal wall. If ACNES is suspected, a local injection of an anesthetic agent may offer relief. If pain is recurrent following multiple-injection therapy, an anterior neurectomy entailing removal of the entrapped nerve endings may be considered. After 1 year, a 70% success rate has been reported. Research on minimally invasive alternative treatments is scarce. Pulsed radiofrequency (PRF) treatment is a relatively new treatment for chronic pain syndromes. An electromagnetic field is applied around the nerve in the hope of leading to pain relief. This randomized controlled trial compares the effect of PRF treatment and neurectomy in patients with ACNES. Methods Adult ACNES patients having short-lived success following injections are randomized to PRF or neurectomy. At the 8-week follow-up visit, unsuccessful PRF patients are allowed to cross over to a neurectomy. Primary outcome is pain relief after either therapy. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and unanticipated adverse events. The study is terminated 6 months after receiving the final procedure. Discussion Since academic literature on minimally invasive techniques is lacking, well-designed trials are needed to optimize results of treatment for ACNES. This is the first large, randomized controlled, proof-of-concept trial comparing two therapy techniques in ACNES patients. The first patient was included in October 2015. The expected trial deadline is December 2017. If effective, PRF may be incorporated into the ACNES treatment algorithm, thus minimizing the number of patients requiring surgery. Trial registration Nederlands Trial Register (Dutch Trial Register), NTR5131 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5131). Registered on 15 April 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2110-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robbert C Maatman
- Department of General Surgery, Máxima Medical Centre, PO Box 7777 5500 MB, Veldhoven/Eindhoven, The Netherlands. .,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands.
| | - Monique A H Steegers
- Department of Anaesthesiology and Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Toine C Lim
- Department of Anaesthesiology and Pain and Palliative Care, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Hans J van den Berg
- Department of Anaesthesiology and Pain and Palliative Care, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Sandra A S van den Heuvel
- Department of Anaesthesiology and Pain and Palliative Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marc R M Scheltinga
- Department of General Surgery, Máxima Medical Centre, PO Box 7777 5500 MB, Veldhoven/Eindhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
| | - Rudi M H Roumen
- Department of General Surgery, Máxima Medical Centre, PO Box 7777 5500 MB, Veldhoven/Eindhoven, The Netherlands.,SolviMáx, Center of Expertise for ACNES, Center of Excellence for Abdominal Wall and Groin Pain, Máxima Medical Centre, Eindhoven, The Netherlands
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van Boekel RLM, Vissers KCP, van der Sande R, Bronkhorst E, Lerou JGC, Steegers MAH. Moving beyond pain scores: Multidimensional pain assessment is essential for adequate pain management after surgery. PLoS One 2017; 12:e0177345. [PMID: 28489926 PMCID: PMC5425226 DOI: 10.1371/journal.pone.0177345] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/26/2017] [Indexed: 12/01/2022] Open
Abstract
Background Clinical experience teaches us that patients are willing to accept postoperative pain, despite high pain intensity scores. Nevertheless, relationships between pain scores and other methods of pain assessment, e.g. acceptability of pain or its interference with physical functioning, are not fully established. Our aims were to examine these relationships. Methods A cross-sectional study was conducted on patients who underwent major surgery between January 2008 and August 2013. Using logistic regression, we quantified the relationships between movement-evoked pain scores on the numerical rating scale (NRS-MEP) and three dichotomous dependent variables: patient’s opinion on acceptability of pain (PO: acceptable or unacceptable pain); nurses’ observation of patient’s performance of necessary activities to expedite recovery (NO: good or bad performance); a compound measure judging the presence of the clinically desirable situation of acceptable pain associated with good patients’ performance (PONO: present or not). Using Receiver Operating Characteristics (ROC) analysis, NRS cut-off points were determined such that they best discriminate between patients having one versus the other outcome for PO, NO and PONO. Results 15,394 assessments were obtained in 9,082 patients in the first three postoperative days. Nine percent of the patients had unacceptable pain while having an NRS-MEP of 0–4. An estimated 47% (95%CI = 45%-49%) of patients with an NRS-MEP of 7 described their pain as acceptable on day one. Moreover, 33% (31%-35%) performed all required physical activities, and 22% (21%-24%) combined acceptable pain with appropriate movement. NRS cut-off points for PO, NO and PONO were five, four and four, respectively, but had insufficient discriminatory power. Conclusions Our results suggest pain management should be guided by the many dimensions of the patient’s pain experience, not solely by NRS cut-off points. Future research should evaluate the impact of such multidimensional pain assessment on patients’ functional outcome.
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Affiliation(s)
- Regina L. M. van Boekel
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
| | - Kris C. P. Vissers
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob van der Sande
- Faculty of Health, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Ewald Bronkhorst
- Department of Medical Statistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos G. C. Lerou
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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van der Wal SEI, van den Heuvel SAS, Radema SA, van Berkum BFM, Vaneker M, Steegers MAH, Scheffer GJ, Vissers KCP. The in vitro mechanisms and in vivo efficacy of intravenous lidocaine on the neuroinflammatory response in acute and chronic pain. Eur J Pain 2015; 20:655-74. [PMID: 26684648 DOI: 10.1002/ejp.794] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The neuroinflammatory response plays a key role in several pain syndromes. Intravenous (iv) lidocaine is beneficial in acute and chronic pain. This review delineates the current literature concerning in vitro mechanisms and in vivo efficacy of iv lidocaine on the neuroinflammatory response in acute and chronic pain. DATABASES AND DATA TREATMENT We searched PUBMED and the Cochrane Library for in vitro and in vivo studies from July 1975 to August 2014. In vitro articles providing an explanation for the mechanisms of action of lidocaine on the neuroinflammatory response in pain were included. Animal or clinical studies were included concerning iv lidocaine for acute or chronic pain or during inflammation. RESULTS Eighty-eight articles regarding iv lidocaine were included: 36 in vitro studies evaluating the effect on ion channels and receptors; 31 animal studies concerning acute and chronic pain and inflammatory models; 21 clinical studies concerning acute and chronic pain. Low-dose lidocaine inhibits in vitro voltage-gated sodium channels, the glycinergic system, some potassium channels and Gαq-coupled protein receptors. Higher lidocaine concentrations block potassium and calcium channels, and NMDA receptors. Animal studies demonstrate lidocaine to have analgesic effects in acute and neuropathic pain syndromes and anti-inflammatory effects early in the inflammatory response. Clinical studies demonstrate lidocaine to have advantage in abdominal surgery and in some neuropathic pain syndromes. CONCLUSIONS Intravenous lidocaine has analgesic, anti-inflammatory and antihyperalgesic properties mediated by an inhibitory effect on ion channels and receptors. It attenuates the neuroinflammatory response in perioperative pain and chronic neuropathic pain.
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Affiliation(s)
- S E I van der Wal
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
| | - S A S van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
| | - S A Radema
- Department of Medical Oncology, RUMC, Nijmegen, The Netherlands
| | - B F M van Berkum
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
| | - M Vaneker
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
| | - M A H Steegers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
| | - G J Scheffer
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
| | - K C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center (RUMC), Nijmegen, The Netherlands
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van Dongen RTM, Samwel H, Arnts IJJ, Steegers MAH, Joosten EA, van Kleef M. [Neuromodulation in severe neuropathic pain]. Ned Tijdschr Geneeskd 2015; 160:A9704. [PMID: 27007929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Pain relief in patients with chronic neuropathic pain can be difficult to accomplish. If pharmacological treatment combined with a form of physical therapy and psychological support does not lead to improvement, nerve blocks and rehabilitation can be considered. Appropriately screened patients with persistent incapacitating pain may respond to neuromodulation. A specific form of this technique - spinal cord stimulation - delivers electric pulses via an implanted electrode connected to a battery in the epidural space around the spinal cord. We describe three patients, two of whom had persistent leg pain after disc surgery. The third patient suffered from diabetic neuropathy. Despite thorough pre-procedural screening by an anaesthetist-pain specialist, psychologist, physical therapist and specialised nurse, spinal cord stimulation failed in one patient. Psycho-social factors, inadequate coping skills and depression may lead to inadequate improvement and failure of this therapy.
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de Goeij M, Steegers MAH, Veldhoven CMM, Vissers KC. [Measuring pain is useful and every doctor can do it: 7 tips]. Ned Tijdschr Geneeskd 2015; 159:A8276. [PMID: 25740186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Pain is one of the main factors influencing quality of life; its incidence is higher than is generally assumed. Pain is not spontaneously reported in all cases; it should be asked about more often. Not measuring pain is one of the main reasons for inadequate pain treatment. Pain should be assessed and recorded more routinely in both primary and secondary healthcare. This can be done in simple and quick ways. Self-reporting using a visual-analogue scale or numeric rating scale is the preferred method. This can be done even by patients with a mild cognitive disorder. Several simple and reliable observational scales exist for patients who cannot report well, e.g. elderly patients with a cognitive disorder or young children. For chronic pain, the low-threshold use of a multi-dimensional scale will increase the likelihood of successful treatment.
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Affiliation(s)
- Moniek de Goeij
- Radboudumc, afd. Anesthesiologie, Pijn en Palliatieve geneeskunde, Nijmegen
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van Boekel RLM, Steegers MAH, Verbeek-van Noord I, van der Sande R, Vissers KCP. Acute Pain Services and Postsurgical Pain Management in the Netherlands: A Survey. Pain Pract 2014; 15:447-54. [DOI: 10.1111/papr.12192] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 01/10/2014] [Indexed: 12/20/2022]
Affiliation(s)
- Regina L. M. van Boekel
- Department of Anesthesiology Pain & Palliative Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology Pain & Palliative Medicine; Radboud University Medical Center; Nijmegen the Netherlands
| | - Inge Verbeek-van Noord
- Department of Public and Occupational Health; EMGO Institute for Health and Care Research; VU University Medical Centre; Amsterdam the Netherlands
| | | | - Kris C. P. Vissers
- Department of Anesthesiology Pain & Palliative Medicine; Radboud University Medical Center; Nijmegen the Netherlands
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van Boekel RLM, Steegers MAH, de Blok C, Schilp J. [Pain registration: for the benefit of the inspectorate or the patient?]. Ned Tijdschr Geneeskd 2014; 158:A7723. [PMID: 25096042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Increasing attention is currently being directed to the measurement and treatment of pain. A recent study concluded that the implementation of a patient safety programme was successful because 99% of the hospitals indicated that they measure postoperative pain. However, another recent study, evaluating this safety programme, concluded that hospitals could improve the implementation of pain measurements, as only 56% of the postoperative patients were subject to standardized pain measurements during the first 3 days following surgery. The reason for this notable difference may be the tendency to implement pain registration mainly for external justification purposes. The attitude towards pain needs to change; too often it is still considered as an uninteresting side effect of treatment. Insight in the internal utility and effects of pain registration might help to further improve the quality of postoperative pain management. Acute Pain Service teams should have a facilitating role.
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van der Worp F, Stapel JT, Lako S, Hendriks J, Vissers KCP, Steegers MAH. The Comparison of Two Analgesic Regimes after Ambulatory Surgery: An Observational Study. Pain Pract 2013; 14:260-70. [DOI: 10.1111/papr.12068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 02/14/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Froukje van der Worp
- Department Anesthesiology Pain and Palliative Medicine; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Jeroen T. Stapel
- Department Anesthesiology Pain and Palliative Medicine; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Sandra Lako
- Department Anesthesiology Pain and Palliative Medicine; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Jan Hendriks
- Department of Epidemiology; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Kris C. P. Vissers
- Department Anesthesiology Pain and Palliative Medicine; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Monique A. H. Steegers
- Department Anesthesiology Pain and Palliative Medicine; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
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Steegers MAH, Wilder-Smith OHG. [Late chronic pain after surgery is prevented with good perioperative analgesics]. Ned Tijdschr Geneeskd 2009; 153:562-566. [PMID: 19368111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Monique A H Steegers
- Universitair Medisch Centrum St Radboud, afd. Anesthesiologie, Pijn en Palliatieve Zorg, onderzoeksgroep Pijn en Nociceptie, Nijmegen
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Steegers MAH, van de Luijtgaarden A, Noyez L, Scheffer GJ, Wilder-Smith OHG. The Role of Angina Pectoris in Chronic Pain After Coronary Artery Bypass Graft Surgery. The Journal of Pain 2007; 8:667-73. [PMID: 17569594 DOI: 10.1016/j.jpain.2007.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 04/12/2007] [Accepted: 04/23/2007] [Indexed: 12/01/2022]
Abstract
UNLABELLED Visceral nociception readily sensitizes the central nervous system, causing referred somatic pain and hyperalgesia via somato-visceral convergence. Hyperalgesia in the perioperative period may increase vulnerability to subsequent development of chronic pain. The study aim is to investigate the role of angina pectoris, an ischemic visceral pain, in long-term pain after coronary artery bypass surgery (CABG). We sent questionnaires to 369 patients who underwent CABG surgery in 2003. Questions were asked about angina pectoris and other pain in the period before surgery, the first week postoperatively (= acute pain), and the period after 3 months after surgery (= chronic pain). We obtained results from 256 patients (response rate = 69%). The point prevalence of chronic pain after CABG was 27% after a mean follow-up of 16 months (SD +/- 3 months). Patients with chronic pain after CABG had more angina pectoris than those without chronic pain: Before surgery (P = .07), early on postoperatively (P = .004), and more than 3 months after surgery (P = .000004). We found cumulative prevalences of chronic pain after CABG at 3 months of 39%, and of 32% after 6 months. Other predictive factors for chronic pain after CABG were acute postoperative pain (P = .00002) and younger age (P = .002). Angina pectoris is associated with chronic pain after CABG surgery. Other predictive factors include acute postoperative pain and younger age. PERSPECTIVE The influence of postoperative angina pectoris for chronic pain after CABG surgery has not been described in the literature to date. Visceral nociception may play an important role in the development of chronic pain after surgery and should be taken into account in future studies.
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Affiliation(s)
- Monique A H Steegers
- Pain and Nociception Research Group, Department of Anesthesiology, Pain, and Palliative Care, Nijmegen, The Netherlands
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Abstract
BACKGROUND Chronic pain is common after thoracotomy. The primary goal of this study was to investigate the incidence of chronic post-thoracotomy pain. The secondary goal was to identify possible risk factors associated with the development of chronic post-operative pain. METHODS We contacted 255 patients who had undergone a classic postero-lateral thoracotomy at our institution in the period between January 2001 and December 2003. All patients received a letter requesting participation; a questionnaire was included with the letter. One week later patients were contacted by telephone to obtain the answers to the questionnaire. RESULTS We ultimately obtained results from 149 patients (58% of all thoracotomies, 84% of survivors). The overall incidence of chronic post-operative pain was 52% (32% mild, 16% moderate and 3% severe chronic post-operative pain). Patients with chronic post-operative pain reported acute post-operative pain more frequently than those without (85% vs. 62%, P = 0.01), had more severe acute post-operative pain (P = 0.0001), underwent more extensive surgical procedures (P = 0.01), had more constant acute pain (vs. fluctuating pain or pain in attacks) (P = 0.0004) and reported less absence of pain during the first post-operative week (P = 0.0001). There was no significant decrease in chronic pain with time after thoracotomy. CONCLUSION Our study confirms that chronic post-thoracotomy pain is a common problem. The results from our study suggest that chronic post-thoracotomy pain may be associated with more intensive and extensive nociceptive input due to thoracic surgery.
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Affiliation(s)
- W A Pluijms
- Pain and Nociception Research Group, Pain Centre, Department of Anaesthesiology, University Medical Center St Radboud, 6500 HB Nijmegen, The Netherlands
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