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back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change. Les lombalgies sont la principale cause d'annees de vie vecues avec une incapacite dans le monde. En 2018, un groupe de travail international a invite l'Organisation mondiale de la Sante a attirer l'attention sur la charge que representent les lombalgies et sur la necessite d'eviter le recours excessif aux solutions medicales. En effet, selon les dernieres recommandations cliniques internationales, de nombreux cas de lombalgie ne necessitent pas ou peu de traitement formel. Lorsqu'un traitement est requis, il est recommande de limiter la prise d'analgesiques, les injections de steroides et la chirurgie rachidienne, et d'encourager plutot les therapeutiques physiques et psychologiques. Tres souvent, les systemes de sante ne sont pas concus pour appliquer cette approche. Dans cet article, nous abordons les raisons pour lesquelles un changement des systemes s'impose si l'on veut prendre en charge les lombalgies suivant les recommandations. Nous detaillons les principales difficultes de la prise en charge des lombalgies dans le cadre des systemes de sante. Il s'agit notamment des interets financiers des laboratoires pharmaceutiques, entre autres; des systemes de paiement obsoletes qui privilegient la prise en charge medicale a l'autogestion par les patients; et de croyances et traditions medicales profondement ancrees parmi les medecins et la population. Nous donnons des exemples internationaux de solutions, de politiques et de pratiques prometteuses pour les systemes de sante confrontes de plus en plus souvent a une prise en charge inefficace des lombalgies. Nous suggerons des politiques qui, sans incidence sur les couts, en transferant les ressources allouees aux soins inutiles vers des soins conformes aux recommandations, pourraient avoir un impact considerable. De petits ajustements des politiques de sante ne suffiront cependant pas. Les systemes des milieux professionnels, les cadres juridiques, les croyances personnelles, les politiques et le contexte societal global dans lequel s'inscrit la sante devront egalement changer. El dolor lumbar es la causa principal de vivir con discapacidad durante anos en todo el mundo. En 2018, un grupo de trabajo internacional pidio a la Organizacion Mundial de la Salud que prestara mas atencion a la carga del dolor lumbar y a la necesidad de evitar soluciones excesivamente medicas. De hecho, las principales directrices clinicas internacionales reconocen ahora que muchas personas con dolor lumbar requieren poco o ningun tratamiento formal. Cuando se requiere tratamiento, el enfoque recomendado es desalentar el uso de analgesicos, inyecciones de esteroides y cirugia de la columna vertebral y, en su lugar, promover las terapias fisicas y psicologicas. Muchos sistemas de salud no estan disenados para apoyar este enfoque. En este documento, se expone por que el cuidado del dolor lumbar de acuerdo con las directrices requiere cambios en todo el sistema. Se detallan los retos clave de la atencion del dolor lumbar en los sistemas de salud. Estos incluyen los intereses financieros de las companias farmaceuticas y de otro tipo, los sistemas de pago obsoletos que favorecen la atencion medica por encima del autocuidado de los pacientes, asi como las tradiciones y las creencias medicas profundamente arraigadas sobre la atencion del dolor de espalda entre los medicos y el publico general. Se presentan ejemplos internacionales de soluciones prometedoras y de politicas y practicas para los sistemas de salud que se enfrentan a una carga cada vez mayor de la atencion ineficaz para el dolor lumbar. Se sugieren politicas que, al desplazar los recursos de la atencion innecesaria a la atencion acorde con las directrices para el dolor lumbar, podrian ser neutras en cuanto a costes y tener un impacto generalizado. Sin embargo, los pequenos ajustes en la politica sanitaria no funcionaran de forma aislada. Los sistemas del lugar de trabajo, los marcos juridicos, las creencias personales, la politica y el contexto social general en el que vivimos la salud tambien tendran que cambiar., Introduction Low back pain is the single biggest cause of years lived with disability worldwide, and a major challenge to international health systems. (1) In 2018, the Lancet Low Back [...]

Pain signals are transmitted by multisynaptic glutamatergic pathways. Their first synapse between primary nociceptors and excitatory spinal interneurons gates the sensory load. In this pathway, glutamate release is orchestrated by [Ca.sup.2+]-sensor proteins, with N-terminal EF-hand [Ca.sup.2+]-binding protein 2 (NECAB2) being particular abundant. However, neither the importance of [NECAB2.sup.+] neuronal contingents in dorsal root ganglia (DRGs) and spinal cord nor the function determination by NECAB2 has been defined. A combination of histochemical analyses and single- cell RNA-sequencing showed NECAB2 in small- and medium-sized C- and A[delta] D-hair low-threshold mechanoreceptors in DRGs, as well as in protein kinase C [gamma] excitatory spinal interneurons. NECAB2 was downregulated by peripheral nerve injury, leading to the hypothesis that NECAB2 loss of function could limit pain sensation. Indeed, [Necab2.sup.-/-] mice reached a pain-free state significantly faster after peripheral inflammation than did WT littermates. Genetic access to transiently activated neurons revealed that a mediodorsal cohort of [NECAB2.sup.+] neurons mediates inflammatory pain in the mouse spinal dorsal horn. Here, besides dampening excitatory transmission in spinal interneurons, NECAB2 limited pronociceptive brain-derived neurotrophic factor (BDNF) release from sensory afferents. Hoxb8-dependent reinstatement of NECAB2 expression in [Necab2.sup.-/-] mice then demonstrated that spinal and DRG NECAB2 alone could control inflammation-induced sensory hypersensitivity. Overall, we identify NECAB2 as a critical component of pronociceptive pain signaling, whose inactivation offers substantial pain relief., Introduction Acute pain (nociception) is a physiologically relevant sensation aimed at alerting an individual to, and thus limiting, tissue damage upon contact with harmful stimuli. In turn, chronic pain is [...]

Agonists of the vanilloid receptor transient vanilloid potential 1 (TRPV1) are emerging as highly efficacious nonopioid analgesics in preclinical studies. These drugs selectively lesion [TRPV1.sup.+] primary sensory afferents, which are responsible for the transmission of many noxious stimulus modalities. Resiniferatoxin (RTX) is a very potent and selective TRPV1 agonist and is a promising candidate for treating many types of pain. Recent work establishing intrathecal application of RTX for the treatment of pain resulting from advanced cancer has demonstrated profound analgesia in client-owned dogs with osteosarcoma. The present study uses transcriptomics and histochemistry to examine the molecular mechanism of RTX action in rats, in clinical canine subjects, and in 1 human subject with advanced cancer treated for pain using intrathecal RTX. In all 3 species, we observe a strong analgesic action, yet this was accompanied by limited transcriptional alterations at the level of the dorsal root ganglion. Functional and neuroanatomical studies demonstrated that intrathecal RTX largely spares susceptible neuronal perikarya, which remain active peripherally but unable to transmit signals to the spinal cord. The results demonstrate that central chemo-axotomy of the [TRPV1.sup.+] afferents underlies RTX analgesia and refine the neurobiology underlying effective clinical use of TRPV1 agonists for pain control., Introduction Severe chronic pain remains a medically intractable problem with life-altering consequences. While most chronic pain is currently treated with any number of drugs, including opioids, NSAIDs, and calcium channel [...]

Purpose Current analgesic strategies for propofol injection pain may cause adverse reactions during electroconvulsive therapy (ECT), such as shortening seizure duration. This study investigated whether dexmedetomidine could attenuate propofol injection pain in ECT. Methods Participants were randomly allocated to receive 0.2 [mu]g/kg dexmedetomidine (Dex-0.2 group), 0.5 [mu]g/kg dexmedetomidine (Dex-0.5 group) or saline (control group) prior to ECT. The composite pain scale and objective Surgical Pleth Index (SPI) were used to measure the intensity of injection pain, and the percentage of patients with pain score > 2 was the primary outcome. Results Of 137 patients recruited, 46 were assigned to each of the Dex-0.2 or Dex-0.5 groups, while 45 were in the control group. The percentage of pain score > 2 was reduced from 68.9% (31/45) in the control group to 34.8% (16/46) in the Dex-0.2 group (P < 0.001) and 15.2% (7/46) in the Dex-0.5 group (P < 0.001). The pain score and SPI at 5 s after propofol injection were greater in the control group than in the Dex-0.2 [pain scores 3 (2-4) vs. 1 (1-3), P < 0.001, SPI 76.6 ± 10.0 vs. 58.0 ± 11.0, P < 0.001] and Dex-0.5 groups [pain scores 3 (2-4) vs. 1 (0-1), P < 0.001, SPI 76.6 ± 10.0 vs. 51.2 ± 12.3, P < 0.001]. There were no significant differences in seizure duration between the three groups. No patients developed bradycardia and hypotension. Conclusions Pretreatment with dexmedetomidine was able to reduce the propofol injection pain in ECT without interfering with the seizure duration and causing adverse effects such as bradycardia and hypotension. In addition, close monitoring of hemodynamic variables and preparation of a treatment plan and drugs for bradycardia are essential., Author(s): Xiang Li [sup.1] , Chao-jin Chen [sup.1] , Fang Tan [sup.1] , Jing-ru Pan [sup.1] , Ji-bin Xing [sup.1] , Qian-qian Zhu [sup.1] , Zi-qing Hei [sup.1] , Shao-li [...]

Byline: Sumitra. Bakshi, Ajay. Gawri, Amit. Panigrahi Background: Emergency laparotomies present a challenge in pain management given sick patients, odd timings and poor outcomes. Current recommendations favour multimodal opioid-sparing analgesia [...]

Purpose 'Hockey stick incision' used in renal transplant is large enough to cause severe postoperative morbidity especially in pediatric recipients. Although epidural analgesia is known to be effective in pain control, the resulting sympathectomy might affect hemodynamics interfering with the transplant process. In our study, we evaluated the feasibility and safety of inserting an epidural catheter to the thoracic level via the caudal route, and the effect of using epidural local anesthetics at low concentrations on hemodynamics. Methods After approval from the ethical committee at Kasr Al Ainy University Hospital and consent from parents/legal guardians, sixty patients aged 3-12 years who were scheduled for renal transplant were randomly divided into two equal groups. Group I (epidural group) received continuous caudal epidural bupivacaine 0.125 % with fentanyl together with intravenous (IV) fentanyl and paracetamol. Group II (control group) received only IV fentanyl and paracetamol. Intraoperative data included heart rate (HR), mean arterial blood pressure (MAP) and central venous pressure (CVP). Postoperative variables included HR, MAP, CVP, pain score and complications. Results Threading failure via the caudal route occurred in 6.67 % of cases. Intraoperative differences in hemodynamics and CVP were not clinically significant between groups. Postoperative HR, MAP, and CVP were generally higher in the control group. Pain control was more satisfactory and postoperative complications were less in the epidural group. Conclusion Caudal epidural anesthesia in pediatric renal transplant is a valuable addition to general anesthesia as it provides stable perioperative hemodynamics, excellent postoperative analgesia and is associated with fewer complications than narcotic-dependent analgesia. Clinical trial registration number: NCT02037802, Author(s): Sherif M. Soaida[sup.1] [sup.4] , Mohammed S. ElSheemy[sup.2] , Ahmed M. Shouman[sup.2] , Ahmed I. Shoukry[sup.2] , Hany A. Morsi[sup.2] , Doaa M. Salah[sup.3] , Fatina I. Fadel[sup.3] , [...]