The nature of the transition from acute to chronic pain still eludes explanation, but chronic pain resulting from surgery provides a natural experiment that invites clinical epidemiological ...investigation and basic scientific inquiry into the mechanisms of this transition. The primary purpose of this article is to review current knowledge and hypotheses on the transition from acute to persistent postsurgical pain, summarizing literature on clinical epidemiological studies of persistent postsurgical pain development, as well as basic neurophysiological studies targeting mechanisms in the periphery, spinal cord, and brain. The second purpose of this article is to integrate theory, information, and causal reasoning in these areas. Conceptual mapping reveals 5 classes of hypotheses pertaining to pain. These propose that chronic pain results from: 1) persistent noxious signaling in the periphery; 2) enduring maladaptive neuroplastic changes at the spinal dorsal horn and/or higher central nervous system structures reflecting a multiplicity of factors, including peripherally released neurotrophic factors and interactions between neurons and microglia; 3) compromised inhibitory modulation of noxious signaling in medullary-spinal pathways; 4) descending facilitatory modulation; and 5) maladaptive brain remodeling in function, structure, and connectivity. The third purpose of this article is to identify barriers to progress and review opportunities for advancing the field. This review reveals a need for a concerted, strategic effort toward integrating clinical epidemiology, basic science research, and current theory about pain mechanisms to hasten progress toward understanding, managing, and preventing persistent postsurgical pain.
The development of chronic pain after surgery is a major clinical problem that provides an opportunity to study the transition from acute to chronic pain at epidemiologic and basic science levels. Strategic, coordinated, multidisciplinary research efforts targeting mechanisms of pain chronification can to help minimize or eliminate persistent postsurgical pain.
This paper advances a psychophysiological systems view of pain in which physical injury, or wounding, generates a complex stress response that extends beyond the nervous system and contributes to the ...experience of pain. Through a common chemical language comprising neurotransmitters, peptides, endocannabinoids, cytokines, and hormones, an ensemble of interdependent nervous, endocrine, and immune processes operates in concert to cope with the injury. These processes act as a single agent and comprise a supersystem. Acute pain in its multiple dimensions, and the related symptoms that commonly occur with it, are products of the supersystem. Chronic pain can develop as a result of unusual stress. Social stressors can compound the stress resulting from a wound or act alone to dysregulate the supersystem. When the supersystem suffers dysregulation, health, function, and sense of well-being suffer. Some chronic pain conditions are the product of supersystem dysregulation. Individuals vary and are vulnerable to dysregulation and dysfunction in particular organ systems due to the unique interactions of genetic, epigenetic and environmental factors, as well as the past experiences that characterize each person.
Acute tissue injury activates an ensemble of interdependent nervous, endocrine, and immune processes that operate in concert and comprise a supersystem. Some chronic pain conditions result from supersystem dysregulation. Individuals vary and are vulnerable to dysregulation due to the unique interactions of genetic, epigenetic, and environmental factors and past experiences that characterize each person. This perspective can potentially assist clinicians in assessing and managing chronic pain patients.
Accelerated contamination of habitats with debris has caused increased effort to determine ecological impacts. Strikingly, most work on organisms focuses on sublethal responses to plastic debris. ...This is controversial because (i) researchers have ignored medical insights about the mechanisms that link effects of debris across lower levels of biological organization to disease and mortality, and (ii) debris is considered non-hazardous by policy-makers, possibly because individuals can be injured or removed from populations and assemblages without ecological impacts. We reviewed the mechanisms that link effects of debris across lower levels of biological organization to assemblages and populations. Using plastic, we show microplastics reduce the ‘health’, feeding, growth and survival of ecosystem engineers. Larger debris alters assemblages because fishing-gear and tyres kill animals and damage habitat-forming plants, and because floating bottles facilitate recruitment and survival of novel taxa. Where ecological linkages are not known, we show how to establish hypothetical links by synthesizing studies to assess the likelihood of impacts. We also consider how population models examine ecological linkages and guide management of ecological impacts. We show that by focusing on linkages to ecological impacts rather than the presence of debris and its sublethal impacts, we could reduce threats posed by debris.
Floating and stranded marine debris is widespread. Increasing sea levels and altered rainfall, solar radiation, wind speed, waves, and oceanic currents associated with climatic change are likely to ...transfer more debris from coastal cities into marine and coastal habitats. Marine debris causes economic and ecological impacts, but understanding the scope of these requires quantitative information on spatial patterns and trends in the amounts and types of debris at a global scale. There are very few large-scale programs to measure debris, but many peer-reviewed and published scientific studies of marine debris describe local patterns. Unfortunately, methods of defining debris, sampling, and interpreting patterns in space or time vary considerably among studies, yet if data could be synthesized across studies, a global picture of the problem may be avaliable. We analyzed 104 published scientific papers on marine debris in order to determine how to evaluate this. Although many studies were well designed to answer specific questions, definitions of what constitutes marine debris, the methods used to measure, and the scale of the scope of the studies means that no general picture can emerge from this wealth of data. These problems are detailed to guide future studies and guidelines provided to enable the collection of more comparable data to better manage this growing problem.
A new fully coupled meteorology‐chemistry‐aerosol model is used to simulate the urban‐ to regional‐scale variations in trace gases, particulates, and aerosol direct radiative forcing in the vicinity ...of Houston over a 5 day summer period. Model performance is evaluated using a wide range of meteorological, chemistry, and particulate measurements obtained during the 2000 Texas Air Quality Study. The predicted trace gas and particulate distributions were qualitatively similar to the surface and aircraft measurements with considerable spatial variations resulting from urban, power plant, and industrial sources of primary pollutants. Sulfate, organic carbon, and other inorganics were the largest constituents of the predicted particulates. The predicted shortwave radiation was 30 to 40 W m−2 closer to the observations when the aerosol optical properties were incorporated into the shortwave radiation scheme; however, the predicted hourly aerosol radiative forcing was still underestimated by 10 to 50 W m−2. The predicted aerosol radiative forcing was larger over Houston and the industrial ship channel than over the rural areas, consistent with surface measurements. The differences between the observed and simulated aerosol radiative forcing resulted from transport errors, relative humidity errors in the upper convective boundary layer that affect aerosol water content, secondary organic aerosols that were not yet included in the model, and uncertainties in the primary particulate emission rates. The current model was run in a predictive mode and demonstrates the challenges of accurately simulating all of the meteorological, chemical, and aerosol parameters over urban to regional scales that can affect aerosol radiative forcing.
For 2 weeks following surgery, 55 patients with preexisting chronic pain (CP) reported daily postoperative pain with movement and at rest. Of these, 30 CP patients used opioid pharmacotherapy for CP ...management and 25 did not. We modeled pain resolution in each patient using a linear fit so that each patient yielded 2 scores for each pain rating: 1) an intercept, or initial level of pain, immediately after surgery; and 2) a slope, or rate of pain resolution. The patients not using opioid pharmacotherapy had a mean pain with movement intercept of 5.4 and a slope of -.20, while the patients using opioid pharmacotherapy had a significantly higher mean intercept of 7.68 (P = .001) and a slope of -.21, sustaining higher pain levels over days. The opioid pharmacotherapy patients had the same rate of pain resolution as the other CP patients, and both groups resolved their pain more slowly than normal surgery patients. Preexisting CP may predispose a patient undergoing surgery to a slower rate of postoperative pain resolution. Chronic pain patients who use opioids share this predisposition but in addition, they are at risk for markedly higher postoperative pain across the entire pain resolution trajectory.
This is an observational rather than a randomized controlled study, and as such is less definitive. Nonetheless, these findings are consistent with those of animal studies showing that prolonged exposure to opioids can produce opioid-induced hyperalgesia. Patients with opioid pharmacotherapy for chronic pain who undergo surgery merit special attention for acute pain management.
Abstract Objective This article looks at lessons learned from the 1995 Kikwit Ebola outbreak and suggests how modern hospitals should apply these lessons to the next lethal viral epidemic that ...occurs. Method The 1995 Kikwit Ebola outbreak in the Democratic Republic of the Congo (formally Zaire) is one of the most well studied epidemics to have occurred to date. Many of the lessons learned from identifying, containing and treating that epidemic are applicable to future viral outbreaks, natural disasters and bioterrorist attacks. This is due to Ebola's highly contagious nature and high mortality rate. Results When an outbreak occurs, it often produces fear in the community and causes the basic practice of medicine to be altered. Changes seen at Kikwit included limited physical examinations, hesitance to give intravenous medications and closure of supporting hospital facilities. The Kikwit Ebola outbreak also provided beneficial psychological insight into how patients, staff and the general community respond to a biological crisis and how this will affect physicians working in an epidemic. Conclusions General lessons from the outbreak include the importance of having simple, well-defined triage procedures; staff who are flexible and able to adapt to situations with unknowns; and the need to protect staff physically and emotionally to ensure a sustained effort to provide care.
This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating ...guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence.
Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.
This study extends recent coach stress research by evaluating how coaches perceive their stress experiences to affect athletes, and the broader coach-athlete relationship. A total of 12 coaches ...working across a range of team sports at the elite level took part in semi-structured interviews to investigate the 3 study aims: how they perceive athletes to detect signals of coach stress; how they perceive their stress experiences to affect athletes; and, how effective they perceive themselves to be when experiencing stress. Following content analysis, data suggested that coaches perceived athletes able to detect when they were experiencing stress typically via communication, behavioural, and stylistic cues. Although coaches perceived their stress to have some positive effects on athletes, the overwhelming effects were negative and affected "performance and development", "psychological and emotional", and "behavioural and interaction" factors. Coaches also perceived themselves to be less effective when stressed, and this was reflected in their perceptions of competence, self-awareness, and coaching quality. An impactful finding is that coaches are aware of how a range of stress responses are expressed by themselves, and to how they affect athletes, and their coaching quality. Altogether, findings support the emerging view that coach stress affects their own, and athlete performance.
Pain is a perceived threat or damage to one's biological integrity. Suffering is the perception of serious threat or damage to the self, and it emerges when a discrepancy develops between what one ...expected of one's self and what one does or is. Some patients who experience sustained unrelieved pain suffer because pain changes who they are. At a physiological level, chronic pain promotes an extended and destructive stress response characterised by neuroendocrine dysregulation, fatigue, dysphoria, myalgia, and impaired mental and physical performance. This constellation of discomforts and functional limitations can foster negative thinking and create a vicious cycle of stress and disability. The idea that one's pain is uncontrollable in itself leads to stress. Patients suffer when this cycle renders them incapable of sustaining productive work, a normal family life, and supportive social interactions. Although patients suffer for many reasons, the physician can contribute substantially to the prevention or relief of suffering by controlling pain. Suffering is a nebulous concept for most physicians, and its relation to pain is unclear. This review offers a medically useful concept of suffering that distinguishes it from pain, accounts for the contributory relation of pain to suffering by describing pain as a stressor, and explores the implications of these ideas for the care of patients.
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