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International audience; Chronic postsurgical neuropathic pain (CPSNP) is frequent. While prevalence varies considerably according to type of operation and means of evaluation, it can reach 37% following breast surgery. Identification of risk factors related to the procedure and to the patient and taking into account the development of new, minimally invasive surgical techniques is increasingly nerve-sparing and reduces the likelihood of injury. CPSNP diagnosis in daily practice is facilitated by simple and quickly usable tools such as the NP4 4-question test. Management is based on pharmacological (analgesics, antiepileptics, antidepressants, local anesthetics) and non-pharmacological (kinesitherapy, neurostimulation, psychotherapy) approaches. In light of the present review of the literature, the authors, who constitute an expert group specialized in pain management, anesthesia and surgery, express their support for topical treatments (lidocaine, capsaicin) in treatment of localized postsurgical neuropathic pain in adults.

Background: the control of pain is the cornerstone of patient’s management with multiple ribs fractures. Ribs fractures are indeed associated with significant morbi-mortality. Epidural analgesia or Paravertebral Block (PVB) are proven to be efficient in pain management but these techniques may be provider major adverse event. Erector Spinae Plan (ESP) block may be a credible alternative. The main goal of our study was to compared the efficacy of continuous erector spinae plan block with Paravertebral Block and IV opioid analgesia alone in cumulative morphine consumption. Methods: a prospective, randomized comparative clinical study was conducted. A total of 76 patients were enrolled, who were randomized to either ESP block, PVB group and control group. The primary endpoint was the cumulative morphine consumption 24 h after randomization. Secondary endpoints were analysis of visual analogue scale scores during cough, sniff test values and outcomes. Results: the cumulative morphine consumption 24 hours after ICU admission (primary outcome measure) was not significantly lower in the ESP Block group and in the PVB group compared to the control group, (respectively 17.0 mg [13.0 – 35.0] vs 18.0 mg [12.0 – 35.0] vs 30.5 mg [15.0 – 59.0], p=0,07). The use of ESP Block was also significantly non inferior to PVB according to the primary outcome, p=0,004. Conclusion: the use of the ESP block seems to reduce the consumption of morphine. A lack of statistical power prevents us from achieving the significance of the results. ESP may be a strong alternative to PVB.; Le contrôle de la douleur est la pierre angulaire de la prise en chargedes patients atteints de multiples fractures de côtes. Ces dernières sont en effetassociées à une morbi-mortalité importante. L'analgésie péridurale ou le blocparavertébral (PVB) se sont avérés efficaces dans la gestion de la douleur, mais cestechniques peuvent causer des événements indésirables majeurs. Le bloc des musclesérecteurs du rachis (ESP) peut être une sérieuse alternative. L'objectif principal denotre étude était de comparer l'efficacité de l’analgésie continue des muscles érecteursdu rachis par rapport à l’analgésie continue en espace paravertébral et à l'analgésieopioïde IV seule sur la réduction de la consommation cumulée en morphine.Méthodes : une étude clinique comparative, prospective et randomisée a été réalisée.Un total de 76 patients ont été inclus. Ils ont été randomisés en trois groupes : legroupe du bloc ESP, le groupe PVB et le groupe témoin. Le critère de jugementprincipal était la consommation cumulée en morphine 24h après la randomisation. Lescritères de jugements secondaires étaient l'analyse du score de l'échelle visuelleanalogique pendant la toux et les valeurs du Sniff test.Résultats : la consommation cumulée de morphine au cours des 24 premières heuresaprès l’admission en unité de soins intensif n’est pas significativement diminuée dansle groupe ESP et dans le groupe PVB par rapport au groupe contrôle, (respectivement17.0 mg [13.0 – 35.0] vs 18.0 mg [12.0 – 35.0] vs 30.5 mg [15.0 – 59.0], p=0,07).Selon le critère de jugement principal, l’utilisation du bloc érecteur du rachis estsignificativement non inférieure à l’utilisation du bloc paravertébral, p=0,004.Conclusion : le bloc des muscles érecteurs du rachis semble réduire l'utilisation de lamorphine chez les patients présentant de multiples fractures de côtes. Un manque depuissance dû au fait que cet article ne présente que des résultats intermédiaires nousempêche de démontrer la significativité des résultats. Le bloc des muscles érecteurs durachis pourrait être une solide alternative au bloc paravertébral.

International audience; Background Sickle cell disease (SCD) induces chronic haemolytic anaemia and intermittent vaso-occlusion that results in tissue ischaemia causing acute, severe pain episodes that can lead to frequent hospitalizations. These consequences can have repercussions on family, social, school and/or professional life. Here, we present some of the results of the PHEDRE study (Pharmacodépendance Et DREpanocytose—drug dependence and sickle-cell disease), which is the largest study of patients with SCD in France. This paper intends to describe characteristics of the French SCD population. We also aimed to assess the impact of the disease on the lives of patients using objective and subjective variables. Methods The PHEDRE study was a national multicentric observational study. Adults, adolescents and children with a confirmed SCD diagnosis were included in the study by their referring doctor. Then, they were interviewed by phone about their socioeconomic status, about the impact of the disease on their lives and about their analgesic and psychoactive drug use. Results The study population consisted of 872 patients (28% were minors). Seventy-two percent of adults were active, and all minors were in school. Many patients presented criteria of severe SCD. Seventy-five percent were homozygous SS, 15% were double heterozygotes SC and 8% were heterozygotes Sβthal, 87% received specific treatment, 58% were hospitalized at least once for vaso-occlusive crisis in the past 12 months, and the number of analgesic drugs taken averaged 3.8. Seventy-five percent of patients reported academic or professional consequences related to their SCD, and 52% reported social consequences. Conclusions The impact of SCD on patients’ lives can be significant, nevertheless their social integration seems to be maintained. We highlighted respect of recommendations regarding analgesic treatments and only a few patients used tobacco, alcohol or cannabis. Trial registration Clinical Trials, NCT02580565 ; https://clinicaltrials.gov/ Registered 16 October 2015.

Pain management has been a national priority since 1998 when the first « Plan Douleur » was released. For several years, homecare has faced a regular progression as an alternative to conventional hospitalisation, resulting from public health policies and patients demand. However, there are currently no data available on pain management efficiency among homecare patients. We conducted a prospective study to measure pain management efficiency among homecare patients in two homecare departements of Assistance Publique – Hôpitaux de Paris. One hundred and two homecare stays were analysed between September and December 2015, among them 76 had a follow up of 15 days. On admission, pain is observed in 31% of the stays. In 20% of the stays, analgesic prescription is not appropriate for homecare. When pain is absent on admission, mean time to pain occurrence is 2.4 days after admission. Prescription changing regarding pain management occurs 4.3 days after pain onset. We conclude that pain management is insufficient among homecare patients. Better coordination with hospital doctors to reduce the proportion of inadequate homecare prescription and a general practitioner visit within 48 hours following homecare initiation could further improve pain management among homecare patients.; La prise en charge de la douleur est une priorité depuis le premier Plan Douleur en 1998. Actuellement, l’hospitalisation à domicile (HAD) connait une forte progression résultant de choix de santé publique et d’une demande croissante des patients. Pourtant, aucune donnée n’existe sur l’efficacité de la prise en charge de la douleur dans cette population. Dans ce contexte, nous avons mené une étude prospective dont l’objectif était de mesurer le contrôle de la douleur chez les patients adultes admis en HAD, dans deux unités de soins de l’HAD de l’Assistance publique- Hôpitaux de Paris. Cent deux séjours ont été analysés entre septembre et décembre 2015, parmi eux, 76 ont été suivis pendant les quinze premiers jours du séjour. La douleur est présente à l’admission dans 31% des séjours, et pour 20% des séjours, la prescription d’antalgiques n’est pas applicable aux soins au domicile. Lorsque la douleur est absente à l’admission elle survient en moyenne 2,4 jours après l’admission, et le délai moyen d’intervention du prescripteur est de 4,3 jours après la survenue de la douleur. En conclusion, le contrôle de la douleur est encore insuffisant dans la population que nous avons étudiée. Une meilleure coordination entre le médecin généraliste et le médecin hospitalier afin de réduire la proportion de prescriptions non applicables au domicile ainsi qu’une visite systématique du médecin traitant au domicile dans les 48 heures suivant l’admission pourraient améliorer le contrôle de la douleur.

International audience; PURPOSE:This paper presents a literature review of post-traumatic stress disorder (PTSD) and its link to chronic pain.DESIGN AND METHODS:Twenty-four papers are reviewed (included research and reviews), with the goal of improving and updating our understanding on this issue and its theoretical and clinical repercussions.FINDINGS:The tight interdependence of symptoms that can be observed in both PTSD and chronic pain syndromes lends support to the idea that these disorders both constitute a reactive disorder.PRACTICE IMPLICATIONS:Various forms of therapy and treatment focus on PTSD, but chronic pain symptoms must also be assessed.

ObjectiveThe eumusc.net project is an initiative founded by the European Community and the European League Against Rheumatism. One aim of the project was to facilitate equal standards for musculoskeletal health across Europe. The aim of this work-package was to develop patient-centred and consensus based standards of care (SOC) for osteoarthritis (OA), which should be available in a professional and a patient version.MethodsA systematic review concerning guidelines dealing with OA was conducted. Furthermore, experts in musculoskeletal diseases were contacted to ensure that ‘grey’ literature was not excluded. Documents that fulfilled predefined inclusion/exclusion criteria were included and all interventions for OA were extracted and categorised. Based on this list of interventions, a three round Delphi exercise with an international and multidisciplinary expert panel, including patient research partners, was performed to achieve expert consensus.ResultsSix documents were included and used for further analysis. Out of them, 46 interventions have been extracted and 10 consensus based SOC were formulated. In addition, a patient version, written in a lay-understandable wording and in the format of checklist questions was developed. An example is SOC 5: “People with OA should achieve optimal pain control using pharmacological and non-pharmacological means.” The matching patient-centred checklist question reads: “Do I know how to control pain associated with OA?”ConclusionsThe SOC for OA will be available in the 23 languages of the European Union to enhance unified information to patients and professionals and to further harmonise the treatment/care of OA within Europe.

International audience; OBJECTIVE:To assess the effectiveness of hypnosis to reduce pain and facilitate external cephalic version (ECV).DESIGN:Cohort study.SETTING:Geneva University Hospitals, Switzerland.PARTICIPANTS:63 women attempting ECV under hypnosis from 2010 to 2011 were compared with 122 women who received standard care from 2005 through 2008.INTERVENTION:Immediately after the ECV attempt, both groups completed the same questionnaire evaluating the participants' pain (visual analogue and verbal rating scales) and experience with the procedure. Physicians also completed a questionnaire that elicited their views on the effect of hypnosis on the intervention. A chi-squared test was used to compare differences in proportions, and the Mann-Whitney U test was used for differences in continuous variables. A thematic content analysis of the obstetricians' responses to the open question regarding their experience of hypnotist accompaniment was also performed.OUTCOME MEASURES:Pain evaluated by women (visual analogue and verbal rating scales) and success rate of ECV.RESULTS:Pain intensity reported by women did not significantly differ between the hypnosis group and the standard care group (visual analogue scale score, 6.0 versus 6.3, respectively; p=.25; difference for verbal rating scale, p=0.31. In 72% of cases, physicians reported that hypnosis facilitated the procedure. The success rates in both groups were not significantly different (30% with hypnosis compared with 38% without; p=.31). Most women in both groups found the ECV attempt painful and a source of anxiety but would undergo it again if necessary.CONCLUSION:Hypnosis accompaniment during ECV does not reduce pain intensity associated with the procedure or improve the probability of a successful version.

International audience; Inflammatory and degenerative diseases of the joint are major causes of chronic pain. Long-lasting pain symptoms are thought to result from a central sensitization of nociceptive circuits. These processes include activation of microglia and spinal disinhibition. Using a monoarthritic rat model of pain, we tried to potentiate neural inhibition by using etifoxine (EFX), a nonbenzodiazepine anxiolytic that acts as an allosteric-positive modulator of gamma-aminobutyric acid type A (GABAA) receptor function. Interestingly, EFX also can bind to the mitochondrial translocator protein (TSPO) complex and stimulate the synthesis of 3α-reduced neurosteroids, the most potent positive allosteric modulator of GABAA receptor function. Here we show that a curative and a preventive treatment with 50mg/kg of EFX efficiently reduced neuropathic pain symptoms. In the spinal cord, EFX analgesia was accompanied by a reduction in microglial activation and in the levels of proinflammatory mediators. Using electrophysiological tools, we found that EFX treatment not only amplified spinal GABAergic inhibition, but also prevented prostaglandin E2-induced glycinergic disinhibition and restored a "normal" spinal pain processing. Because EFX is already distributed in several countries under the trade name of Stresam for its anxiolytic actions in humans, new clinical trials are now required to further extend its therapeutic indications as pain killer.

International audience; Background: Pathological pain states are often associated with neuronal hyperexcitability in the spinal cord. Reducing this excitability could theoretically be achieved by amplifying the existing spinal inhibitory control mediated by GABAA receptors (GABAARs). In this study, we used the non-benzodiazepine anxiolytic etifoxine (EFX) to characterize its interest as pain killer and spinal mechanisms of action. EFX potentiates GABAAR function but can also increase its function by stimulating the local synthesis of 3α-reduced neurosteroids (3αNS), the most potent endogenous modulators of this receptor.Methods: The efficacy of EFX analgesia and the contribution of 3αNS were evaluated in a rat model of mononeuropathy. Spinal contribution of EFX was characterized through changes in pain symptoms after intrathecal injections, spinal content of EFX and 3αNS, and expression of FosB-related genes, a marker of long-term plasticity.Results: We found that a 2-week treatment with EFX (>5 mg/kg, i.p.) fully suppressed neuropathic pain symptoms. This effect was fully mediated by 3αNS and probably by allopregnanolone, which was found at a high concentration in the spinal cord. In good agreement, the level of EFX analgesia after intrathecal injections confirmed that the spinal cord is a privileged target as well as the limited expression of FosB/ΔFosB gene products that are highly expressed in persistent pain states.Conclusions: This preclinical study shows that stimulating the production of endogenous analgesics such as 3αNS represents an interesting strategy to reduce neuropathic pain symptoms. Since EFX is already prescribed as an anxiolytic in several countries, a translation to the human clinic needs to be rapidly evaluated.

International audience; BACKGROUND: Pain intensity is usually self-rated by patients with a numeric rating scale (NRS) but this scale cannot be used for noncommunicating patients. In anesthetized patients, experimental noxious stimulus increases pupillary diameter (PD) and pupillary light reflex amplitude (PLRA), the difference between PD before and after light stimulation. Labor pain is an intense acute nonexperimental stimulus, effectively relieved by epidural analgesia. In this prospective observational study, we therefore describe the effects of labor pain and pain relief with epidural analgesia on PD and PLRA, determine their association with pain intensity and determine the ability of a single measurement of PD or PLRA to assess pain. METHODS: In the first stage, pain (11-point NRS), PD, and PLRA were measured in 4 conditions in 26 laboring women: before and after epidural analgesia and in the presence and absence of a uterine contraction. Pupillometry values among the 4 conditions were compared, and the strength of the association between absolute values of pain and PD or PLRA and between pain and changes in PD or PLRA brought about by uterine contraction was assessed with r(2). In the second stage, 1 measurement was performed in 104 laboring women. The strength of the association between pain and PD or PLRA was assessed with r(2). The ability of PD or PLRA to discriminate pain (NRS > 4) was also assessed. RESULTS: In the first stage, a statistically significant increase in pain, PD, and PLRA was observed during a contraction, and this change was abolished after epidural analgesia. The r(2) for the association between pain and changes in PD (r(2) = 0.25 [95% confidence interval, 0.07-0.46] or PLRA (r(2) = 0.34 [0.14-0.56]) brought about by a uterine contraction was higher than the r(2) for the association between pain and absolute values of PD (r(2) = 0.14 [0.04-0.28]) or PLRA (r(2) = 0.22 [0.10-0.37]) suggesting a stronger association for changes than for absolute values. In the second stage, r(2) was 0.23 [0.10-0.38] for PD and 0.26 [0.11-0.40] for PLRA and the area under the receiver operating characteristics curve was 0.82 [0.73-0.91] and 0.80 [0.71-0.89], respectively. CONCLUSIONS: Changes in PD and PLRA brought about by a uterine contraction may be used as a tool to assess analgesia in noncommunicating patients.

International audience; BACKGROUND: Pain intensity is usually self-rated by patients with a numeric rating scale (NRS) but this scale cannot be used for noncommunicating patients. In anesthetized patients, experimental noxious stimulus increases pupillary diameter (PD) and pupillary light reflex amplitude (PLRA), the difference between PD before and after light stimulation. Labor pain is an intense acute nonexperimental stimulus, effectively relieved by epidural analgesia. In this prospective observational study, we therefore describe the effects of labor pain and pain relief with epidural analgesia on PD and PLRA, determine their association with pain intensity and determine the ability of a single measurement of PD or PLRA to assess pain. METHODS: In the first stage, pain (11-point NRS), PD, and PLRA were measured in 4 conditions in 26 laboring women: before and after epidural analgesia and in the presence and absence of a uterine contraction. Pupillometry values among the 4 conditions were compared, and the strength of the association between absolute values of pain and PD or PLRA and between pain and changes in PD or PLRA brought about by uterine contraction was assessed with r(2). In the second stage, 1 measurement was performed in 104 laboring women. The strength of the association between pain and PD or PLRA was assessed with r(2). The ability of PD or PLRA to discriminate pain (NRS > 4) was also assessed. RESULTS: In the first stage, a statistically significant increase in pain, PD, and PLRA was observed during a contraction, and this change was abolished after epidural analgesia. The r(2) for the association between pain and changes in PD (r(2) = 0.25 [95% confidence interval, 0.07-0.46] or PLRA (r(2) = 0.34 [0.14-0.56]) brought about by a uterine contraction was higher than the r(2) for the association between pain and absolute values of PD (r(2) = 0.14 [0.04-0.28]) or PLRA (r(2) = 0.22 [0.10-0.37]) suggesting a stronger association for changes than for absolute values. In the second stage, r(2) was 0.23 [0.10-0.38] for PD and 0.26 [0.11-0.40] for PLRA and the area under the receiver operating characteristics curve was 0.82 [0.73-0.91] and 0.80 [0.71-0.89], respectively. CONCLUSIONS: Changes in PD and PLRA brought about by a uterine contraction may be used as a tool to assess analgesia in noncommunicating patients.

The fibromyalgia syndrome (FMS) affects 2%–10% of the population. Its diagnosis is only based on a history of widespread pain involving limbs and trunk and mild or greater tenderness to digital palpation of tender points.1 While the role of several neurotransmitters including serotonin, dopamine and SP has been suggested, the influence of endogenous adenosine has never been investigated. Adenosine exerts strong antinociceptive effects mostly via the activation of A1 adenosine receptors2 following its release by endothelial cells and myocytes3 into the extracellular space where it is degraded by the enzyme adenosine deaminase (ADA). Large amounts of ADA are found at the surface of mononuclear cells …

International audience; Primary Sjögren syndrome (pSS) is a progressive autoimmune disease characterized by sicca and systemic manifestations. In this Review, we summarize the available data on topical and systemic medications, according to clinical signs and disease activity, and we describe the ongoing studies using biologic drugs in the treatment of pSS. Expanding knowledge about the epidemiology, classification criteria, systemic activity scoring (ESSDAI) and patient-reported outcomes (ESSPRI) is driving active research. Treatment decisions are based on the evaluation of symptoms and extraglandular manifestations. Symptomatic treatment is usually appropriate, whereas systemic treatment is reserved for systemic manifestations. Sicca is managed by education, environment modification, elimination of contingent offending drugs, artificial tears, secretagogues and treatments for complications. Mild systemic signs such as fatigue are treated by exercise. Pain can require short-term moderate-dose glucocorticoid therapy and, in some cases, disease-modifying drugs. Severe and acute systemic manifestations indicate treatment with glucocorticoids and/or immunosuppressant drugs. The role for biologic agents is promising, but no double-blind randomized controlled trials (RCTs) proving the efficacy of these drugs are available. Targets for new treatments directed against the immunopathological mechanisms of pSS include epithelial cells, T cells, B-cell overactivity, the interferon signature, proinflammatory cytokines, ectopic germinal centre formation, chemokines involved in lymphoid cell homing, and epigenetic modifications.