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Insufficient analgesia affects around 50% of emergency department patients. The use of a protocol helps to reduce the risk of oligoanalgesia in this context. Our objective was to describe the feasibility and efficacy of a multimodal analgesia protocol (combining paracetamol, oxycodone, and inhaled methoxyflurane) initiated by triage nurse. We performed a prospective, observational study in an emergency department (Grenoble Alpes University Hospital, France) between December 2017 and April 2018. Adult non-severe trauma patients with a numerical pain rating scale (NRS) score ≥ 4 were included. The primary efficacy criterion was the proportion of patients with an NRS score ≤ 3 at 15 min. Pain intensity was measured for 60 min and during radiography. Data on adverse events and satisfaction were recorded. A total of 200 adult patients were included (median [interquartile range (IQR)] age: 32 [23-49] years; 126 men (63%)). Sixty-six patients (33%) reported an NRS score ≤ 3 at 15 min. The time required to achieve a decrease of at least 2 points in the NRS score was 10 (5-20) min. The median [IQR] pain intensity was 4 [2-5] before radiography and 4 [2-6] during radiography. Adverse events were frequent (n = 128, 64%). No serious adverse events were reported. The patients and caregivers reported good levels of satisfaction. The administration of a nurse-driven multimodal analgesia protocol (combining paracetamol, oxycodone, and methoxyflurane) was feasible on admission to the emergency department. It rapidly produced long-lasting analgesia in adult trauma patients.Trial registration: NCT03380247.

Background Chronic pain affects approximately 30% of the general population, severely degrades quality of life (especially in older adults) and professional life (inability or reduction in the ability to work and loss of employment), and leads to billions in additional health care costs. Moreover, available painkillers are old, with limited efficacy and can cause significant adverse effects. Thus, there is a need for innovation in the management of chronic pain. Better characterization of patients could help to identify the predictors of successful treatments, and thus, guide physicians in the initial choice of treatment and in the follow-up of their patients. Nevertheless, current assessments of patients with chronic pain provide only fragmentary data on painful daily experiences. Real-life monitoring of subjective and objective markers of chronic pain using mobile health (mHealth) programs can address this issue. Objective We hypothesized that regular patient self-monitoring using an mHealth app would lead physicians to obtain deeper understanding and new insight into patients with chronic pain and that, for patients, regular self-monitoring using an mHealth app would play a positive therapeutic role and improve adherence to treatment. We aimed to evaluate the feasibility and acceptability of a new mHealth app called eDOL. Methods We conducted an observational study to assess the feasibility and acceptability of the eDOL tool. Patients completed several questionnaires using the tool over a period of 2 weeks and repeated assessments weekly over a period of 3 months. Physicians saw their patients at a follow-up visit that took place at least 3 months after the inclusion visit. A composite criterion of the acceptability and feasibility of the eDOL tool was calculated after the completion of study using satisfaction surveys from both patients and physicians. Results Data from 105 patients (of 133 who were included) were analyzed. The rate of adherence was 61.9% (65/105) after 3 months. The median acceptability score was 7 (out of 10) for both patients and physicians. There was a high rate of completion of the baseline questionnaires and assessments (mean 89.3%), and a low rate of completion of the follow-up questionnaires and assessments (63.8% (67/105) and 61.9% (65/105) respectively). We were also able to characterize subgroups of patients and determine a profile of those who adhered to eDOL. We obtained 4 clusters that differ from each other in their biopsychosocial characteristics. Cluster 4 corresponds to patients with more disabling chronic pain (daily impact and comorbidities) and vice versa for cluster 1. Conclusions This work demonstrates that eDOL is highly feasible and acceptable for both patients with chronic pain and their physicians. It also shows that such a tool can integrate many parameters to ensure the detailed characterization of patients for future research works and pain management. Trial Registration ClinicalTrial.gov NCT03931694; http://clinicaltrials.gov/ct2/show/NCT03931694

Resume Introduction Le syndrome fibromyalgique est un trouble frequent, percu comme un modele de douleur chronique. Dans une conception biopsychosociale, nous voulons preciser en quoi l’approche cognitive, comportementale et emotionnelle peut aider a comprendre et traiter la fibromyalgie. Methode Cette revue de litterature utilise la base de donnees MedLine sur la periode janvier 2000–janvier 2017. Certains mots cles explores sont : fibromyalgie, depression, anxiete, stress, strategie d’adaptation, evitement et peur du mouvement. Resultats Colere, tristesse et anxiete contribuent a aggraver les perceptions douloureuses. La douleur, conceptualisee comme un stresseur chronique, permet d’appliquer le modele transactionnel du stress de Lazarus et Folkman, et etablir ainsi un lien entre douleur et souffrance emotionnelle. Le catastrophisme, phenomene emotionnel et cognitif, est une strategie adaptative dysfonctionnelle frequemment retrouvee dans la fibromyalgie. L’evitement et, a l’inverse, le maintien excessif du mouvement sont egalement des facteurs comportementaux deleteres dans la fibromyalgie. Ces differents facteurs justifient des programmes therapeutiques graduels, individualises, associant notamment des approches psychocorporelles et les psychotherapies. Ces dernieres ameliorent la gestion du stress et le sentiment d’efficacite personnelle par une implication active des patients. Des techniques (therapies comportementales et cognitives, therapie de pleine conscience, therapie d’acceptation et d’engagement) permettent de cibler les strategies adaptatives dysfonctionnelles (catastrophisme, kinesiophobie, hyperactivite) pour en diminuer l’impact negatif et developper des strategies plus fonctionnelles comme la distraction, la relaxation et l’acceptation. Discussion Les resultats confirment l’importance des mecanismes psychologiques dans l’entretien des symptomes de la fibromyalgie. A l’avenir, les facteurs psycho-comportementaux pourraient permettre de definir des sous-groupes de patients et d’etablir des prises en charges plus specifiques a chaque profil ainsi defini.

Current therapeutic modalities for fibromyalgia (FM) do not provide satisfactory results and new approaches have to be explored.To assess efficacy and safety of adding a phytotherapy treatment (Fib-19-01) to the current therapeutic regimen in patients with FM.Double-blind controlled trial: women with active FM (Fibromyalgia Index Questionnaire FIQ40) were randomised to receive Fib-19-01 or a food supplement (FS) undistinguishable from Fib-19-01 or no supplementary treatment (NoST). All continued the conventional therapy throughout the 6 month follow-up. Primary endpoint: change in FIQ between Day 0 and month 6 (M6). Secondary Criteria: variation over time FIQ ( repeated measurements), change in Pichot fatigue scale, Pittsburgh Sleep Quality Index (PSQI), SF-12 and Hospital Anxiety and Depression (HAD) scales.100 patients (Intent-To-Treat population) were analyzed. FIQ decreased significantly only in the Fib-19-01 group (P.001) at both week 12 and 24. Improvement was higher for Fib-19-01 (-13.4 ± 18.9) than in the 2 other groups (-5.5 ± 15.6 and -5.6 ± 11.3) despite there was no statistical between-group difference at week 24 in FIQ score (P = .08 and P = .09 respectively). Analysis of variance in repeated measurements of FIQ showed a significant difference between Fib-19-01 and FS throughout the follow-up period (P = .03). Fib-19-01 was superior to both FS and NoST for Pichot scale decrease over time: -4.6 (range -6.9; -2.28), -0.29 (-2.7; 2.1) and -0.72 (-3.1; 1.66) (P = .013 and 0.023 respectively), mental and social SF12 [+8.1 (range 3.5; 12.6), -0.27(range -5.3; 4.8 ) and -0.02 (range -5.0; 4.9 ) P = .02 and 0.018)],HAD depression [-2.0 (range -3.3; -0.7), +0.5 (range -0.9; 1.9 ) and +0.71 (range -0.7; 2.1) P = .013 and 0.007]. No significant difference was found between FS and NoST groups for any outcome. All treatments were well and similarly tolerated.In patients with FM taking conventional therapy, Fib-19-01 has a therapeutic effect on fatigue, emotion and social life, and depression associated with the disease.

To assess the feasibility of greater occipital nerve (GON) intermediate site infiltration with MRI guidance. Eleven consecutive patients suffering from chronic refractory cranio-facial pain who underwent 16 GON infiltrations were included in this prospective study. All of the procedures were performed on an outpatient basis in the research facility of our institution, with a 1.5 T scanner. The fatty space between inferior obliquus and semispinalis muscles at C1-C2 level was defined as the target. Technical success was defined as the ability to accurately inject the products at the target, assessed by post-procedure axial and sagittal proton density-weighted sequences. Clinical success was defined as a 50% pain decrease at 1 month. Technical success was 100%. GON was depicted in 6/11 cases on planning MRI sequences. Mean duration of procedure was 22.5 min (range 16–41). Clinical success was obtained in 7/11 included patients (63.6%) with a mean self-reported improvement of 78%. Interventional MR-guidance for GON infiltration is a feasible technique offering similar results to an already established effective procedure. It may appear as a useful tool in specific populations, such as young patients and repeat infiltrations, and should be considered in these settings. • MR guidance for GON infiltration is a feasible technique. • Preliminary results are in agreement with other guidance modalities. • MR guidance may be seen as a useful tool in specific populations. • Specific populations include young patients and repeat infiltrations. • Target patients may also include patients with potentionally previously reported complications (torticollis).

Resume La fibromyalgie reste une pathologie dont la physiopathologie est mal connue et le traitement particulierement difficile. L’utilisation croissante de la ketamine dans cette indication hors AMM souleve des incertitudes. Afin d’evaluer les pratiques locales, une etude observationnelle retrospective a ete menee au CHU de Grenoble aupres de patients fibromyalgiques traites, de facon chronique (plus de 3 mois) par ketamine en ambulatoire. Cinquante-neuf patients ont ete inclus dont la moitie etaient traites depuis plus de quatre a cinq ans avec des doses moyennes hebdomadaires superieures ou egales a 100 mg/semaine pour 55 % d’entre eux. L’efficacite globale ressentie etait satisfaisante pour plus de 80 % des patients. Il a ete necessaire pour 80 % des patients d’augmenter les doses de ketamine (dont 53 % au cours des 6 premiers mois de traitement). Enfin, 50 % des patients ont ressenti des effets indesirables majoritairement neuropsychodysleptiques. Quatre cas de syndrome de sevrage sont survenus a l’arret, meme progressif, du traitement. Cet etat des lieux a souleve differents points critiques : valider des schemas posologiques integrant le poids des patients, tracer les autres traitements antalgiques associes, utiliser des outils d’evaluation d’efficacite standardises, organiser la surveillance et la gestion des effets indesirables, des phenomenes de tolerance pharmacodynamique et de pharmacodependance. Les professionnels de sante impliques souhaitent structurer et coordonner leurs actions et travaillent a etablir un consensus de pratiques pour rediger un protocole de soins destine a la prise en charge du patient fibromyalgique traite par ketamine a domicile.

The original version of this article, published on 12 July 2017, unfortunately contained mistakes. The following corrections have therefore been made in the original.

Resume Nous rapportons notre experience de l’utilisation de la stimulation magnetique transcrânienne repetitive (SMTr) dans le traitement des douleurs faciales rebelles chroniques et refractaires. Notre objectif est d’evaluer l’efficacite de la SMTr dans cette indication et de determiner les modalites du suivi et du traitement a long terme. Treize patients souffrant de douleurs faciales refractaires ont ete inclus (sept nevralgies trigeminales, quatre algies vasculaires de la face, deux douleurs post-zosteriennes) avec une douleur de fond moyenne de 5,9 sur 10 et de crise de 9,2 sur 10. La cure de SMTr a permis une diminution de la douleur de fond evaluee a j90 a 2,5 sur 10 (disparition des douleurs chez quatre patients). Parmi les patients, 53,1 % ne presentaient plus de crises et 23,1 % des crises moins intenses. Pour 38,5 % des patients, l’espacement des seances entraine un soulagement moindre des douleurs. Chez les patients repondeurs, cette technique parait un outil interessant permettant d’obtenir un effet antalgique cumulatif par la repetition prolongee des seances.

Resume Nous rapportons le cas d’un patient atteint d’un cancer du rein metastatique au niveau du bassin ayant necessite une analgesie perimedullaire au long cours a domicile, compliquee par une infection du dispositif. La place des techniques interventionnelles dans l’arsenal therapeutique des douleurs du cancer et leur impact sur la survie sont discutes a partir du cas clinique.

Depuis 2007, notre equipe developpe la rTMS dans les protocoles de recherche clinique et le traitement des douleurs chroniques refractaires. Indications : algies faciales (AF), douleurs post-AVC, membre fantome, avulsion du plexus brachial, glossodynie, nevralgie pudendale. Notre protocole therapeutique actuel utilise les parametres de stimulation suivants : intensite a 80 % du seuil moteur, frequence 10 Hz, trains 5 s, inter-trains 25 s, soit 2000 stimulations/20 min. Cible de stimulation : aire corticale motrice de la zone algique. Les seances sont guidees par un systeme de neuronavigation, sauf dans les nevralgies pudendales (utilisation d’une sonde MagVenture B70 (Mag2Health, France), adaptee pour stimuler le cortex moteur bilateral correspondant aux territoires pelvi-perineaux). Nombre et rythme des seances : une « phase d’induction » : 1 seance/jour pendant 5 jours, 2 semaines consecutives (S1–S2), puis 2 seances (S3). Une « phase de maintien » chez les repondeurs (amelioration ≥ 30 %) : 1 seance (S4), puis 1 seance/15 jours pendant 5 mois. Si remission incomplete : seances mensuelles pendant 6 mois. Si reponse faible ou recidive en cours du protocole : arret des seances de maintien. Avantages : maintien de l’effet antalgique a long terme. Inconvenients : seances frequentes et temps medical incompressible. L’analyse de la litterature confirme l’efficacite de la rTMS dans les douleurs neuropathiques chroniques [3] . En general, les etudes sont de courte duree. Quelques etudes ont observe une meilleure reponse a la rTMS dans les AF, par rapport a d’autres sites douloureux [2] . Etude de notre centre [1] : 55 patients souffrant d’AF chroniques, effet antalgique ≥ 30 % obtenu chez 73 % des patients a j15 et 40 % a j180. L’effet antalgique est moindre apres l’espacement mensuel des seances. Une diminution de la duree des seances de 20 a 10 min (nombre identique de stimulations) est moins efficace.