Predictors of postoperative pain and analgesic requirements following abdominal hysterectomy: an observational study

Purpose

A prospective observational study is conducted to identify independent predictors of pain and morphine consumption following abdominal hysterectomy.

Methods

Preoperative State Trait Anxiety Inventory (STAI), Numerical Rating Scales (NRS) for anxiety and pain expectations, thermal pain thresholds and pain scores at forearm and incision site, and pain scores generated from the insertion of an intravenous catheter were measured in female patients undergoing abdominal hysterectomy. Pearson correlations between the predictors and the two outcome measures postoperative pain scores and morphine consumption were studied and multiple regression analysis was conducted to identify independent predictors (primary outcome). Secondary outcomes included cut-off values of predictive tools for morphine consumption.

Results

Data from 60 patients were analyzed. STAI state anxiety, NRS pain expectations, and NRS anxiety scores were identified as independent predictors of postoperative morphine consumption. We identified a cut-off value of 4.5 (sensitivity 90 %, specificity of 60 %) for the NRS anxiety and a cut-off of 42.5 (sensitivity 70 %, specificity 70 %) for the state anxiety STAI score for increased postoperative morphine consumption.

Conclusions

Preoperative STAI state anxiety scores and NRS pain expectations are independent predictors for increased morphine consumption following hysterectomy. The STAI state anxiety tool and NRS 0-10 anxiety tool can be used interchangeably. The NRS 0-10 anxiety is a much simpler tool than STAI state anxiety and is associated with a higher sensitivity for high morphine consumption. Thermal pain thresholds and IV pain scores were not predictive of postoperative morphine consumption.

     

A Preoperative Scoring System for Adnexal Mass in Children and Adolescents to Preserve Their Future Fertility

Study Objective

To develop a predictive score for ovarian malignancy to avoid unnecessary adnexectomy in cases of adnexal mass in pediatric and adolescent girls.

NADPH-diaphorase expression in neurons and glia of the normal adult rat retina

In the rat retina, nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) staining has been described previously in a population of amacrine cells, most of which were located in the inner nuclear layer. In the present study, a number of parameters such as the nature of the fixative, the time of fixation and photointensification were optimised to obtain the strongest possible reaction for this enzyme. As a result, a very different staining pattern emerged: with short paraformaldehyde fixation, numerous neurons (identified as a combination of ganglion cells and amacrines) were labelled in the ganglion cell layer, NADPH-d-positive amacrine cells (described previously) were seen in the inner nuclear layer and Müller cells were labelled strongly, particularly in the inner retina. Glutaraldehyde fixation of the same duration resulted in the preferential staining of Müller cells while neurons appeared less reactive. Therefore, fixation conditions are a determining factor in the cellular localisation of NADPH-d in the rat retina. By taking fixation into account, future studies should gain more rigorous insights into the possible functions of this enzyme in the vertebrate retina.     

Assessing pain in persons with dementia: relationships among the non-communicative patient's pain assessment instrument, self-report, and behavioral observations.

Pain is a common problem for many older adults, with up to 50% of community-dwelling and 70% to 80% of nursing home residents experiencing pain regularly. Effective pain management requires thorough assessment, appropriate intervention, and systematic reassessment. Pain assessment, however, is complicated by dementia, which impairs memory, reasoning, recognition, and communication, and affects elders’ ability to verbally report pain. As such, observational measures are needed to assess pain in this vulnerable population. The Non-communicative Patient’s Pain Assessment Instrument (NOPPAIN) was developed for this purpose, but more validation of this measure is needed. Thus, the purpose of this study was to (1) evaluate reliability of the NOPPAIN tool when used by nurses and to (2) compare NOPPAIN ratings with self-report and other well-established behavioral rating procedures. Forty participants (20 cognitively intact and 20 impaired) were randomly selected for this study from a larger sample. In the parent study, participants were asked to perform everyday activities (i.e., sit, stand, walk in place, transfer in and out of bed) while being videotaped. The tapes, all previously scored using microanalytic observational coding, were rated again by naïve raters using the NOPPAIN measure. Results indicated (1) high inter- and intrarater reliability of the NOPPAIN and (2) significant correlations of the NOPPAIN with self-reported pain and detailed behavioral coding. Findings support the reliability and validity of the NOPPAIN measurement tool and suggest this easy-to-use tool may be adequate for measuring pain indicators in older adults.     

The aryl hydrocarbon receptor ligand ITE inhibits TGFβ1-induced human myofibroblast differentiation

Fibrosis can occur in any human tissue when the normal wound healing response is amplified. Such amplification results in fibroblast proliferation, myofibroblast differentiation, and excessive extracellular matrix deposition. Occurrence of these sequelae in organs such as the eye or lung can result in severe consequences to health. Unfortunately, medical treatment of fibrosis is limited by a lack of safe and effective therapies. These therapies may be developed by identifying agents that inhibit critical steps in fibrotic progression; one such step is myofibroblast differentiation triggered by transforming growth factor-β1 (TGFβ1). In this study, we demonstrate that TGFβ1-induced myofibroblast differentiation is blocked in human fibroblasts by a candidate endogenous aryl hydrocarbon receptor (AhR) ligand 2-(1'H-indole-3'-carbonyl)-thiazole-4-carboxylic acid methyl ester (ITE). Our data show that ITE disrupts TGFβ1 signaling by inhibiting the nuclear translocation of Smad2/3/4. Although ITE functions as an AhR agonist, and biologically persistent AhR agonists, such as 2,3,7,8-tetrachlorodibenzo-p-dioxin, cause severe toxic effects, ITE exhibits no toxicity. Interestingly, ITE effectively inhibits TGFβ1-driven myofibroblast differentiation in AhR(-/-) fibroblasts: Its ability to inhibit TGFβ1 signaling is AhR independent. As supported by the results of this study, the small molecule ITE inhibits myofibroblast differentiation and may be useful clinically as an antiscarring agent.     

A neurochemical signature of visual recovery after extrastriate cortical damage in the adult cat

In adult cats, damage to the extrastriate visual cortex on the banks of the lateral suprasylvian (LS) sulcus causes severe deficits in motion perception that can recover as a result of intensive direction discrimination training. The fact that recovery is restricted to trained visual field locations suggests that the neural circuitry of early visual cortical areas, with their tighter retinotopy, may play an important role in attaining perceptual improvements after damage to higher level visual cortex. The present study tests this hypothesis by comparing the manner in which excitatory and inhibitory components of the supragranular circuitry in an early visual cortical area (area 18) are affected by LS lesions and postlesion training. First, the proportion of LS-projecting pyramidal cells as well as calbindin- and parvalbumin-positive interneurons expressing each of the four AMPA receptor subunits was estimated in layers II and III of area 18 in intact animals. The degree to which LS lesions and visual retraining altered these expression patterns was then assessed. Both LS-projecting pyramidal cells and inhibitory interneurons exhibited long-term, differential reductions in the expression of glutamate receptor (GluR)1, -2, -2/3, and -4 following LS lesions. Intensive visual training post lesion restored normal AMPAR subunit expression in all three cell-types examined. Furthermore, for LS-projecting and calbindin-positive neurons, this restoration occurred only in portions of the ipsi-lesional area 18 representing trained visual field locations. This supports our hypothesis that stimulation of early visual cortical areas-in this case, area 18-by training is an important factor in restoring visual perception after permanent damage to LS cortex.     

European 2--a clonal complex of Mycobacterium bovis dominant in the Iberian Peninsula

Mycobacterium bovis isolates from the Iberian Peninsula are dominated by strains with spoligotype patterns deleted for spacer 21. Whole-genome sequencing of three Spanish strains with spacer 21 missing in their spoligotype pattern revealed a series of SNPs and subsequent screening of a selection of these SNPs identified one in gene guaA that is specific to these strains. This group of strains from the Iberian Peninsula missing spoligotype spacer 21 represents a new clonal complex of M. bovis, defined by the SNP profile with a distinct spoligotype signature. We have named this clonal complex European 2 (Eu2) and found that it was present at low frequency in both France and Italy and absent from the British Isles.