Pain management
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The management of pain in pediatric palliative care (PPC) is essential. Whilst the field of pain management has developed over the years, much of what is done in PPC is based on anecdotal evidence or adult studies. ⋯ Key issues discussed include the definition, assessment, pharmacological and integrative management of pain, availability of medications, education and research. Whilst advances have been made, including publication of the guidelines, significant gaps exist in terms of the evidence base, education and access to essential medications and both interdisciplinary and international collaboration are required to meet these gaps.
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Quantitative sensory testing (QST), a set of noninvasive methods used to assess sensory and pain perception, has been used for three decades. The precision of the instruments and the uninvasiveness encouraged many QST-based trials. The developments made have benefited multiple disciplines. ⋯ The sensory pathway cannot be assessed in isolation from the affective and cognitive characteristics of patients or testers. Many variables potentially affect the reliability and reproducibility of QST, which after all, is designed for the testing of individuals by other individuals. Several decades of QST research have yielded exciting contributions, but the future of QST cannot be fully known.
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Chronic postsurgical pain (CPSP) may develop after any surgical procedure, and is a common feature after abdominal and pelvic surgery with a prevalence varying between 10 and 40%. The pathological mechanisms leading to chronic CPSP are probably inflammation, tissue and nerve damage and alterations in central pain processing. The mechanisms in chronic postsurgical abdominal and pelvic pain are poorly studied and research has largely focused on reporting of prevalence and describing risk factors, including patient characteristics, psychological factors, surgical procedure and pre- and acute postoperative pain. In this review, the most important risk factors are discussed, and aiming for preventive, personalized health care, possible methods for prediction of susceptibility and potential strategies for diminishing chronic postsurgical abdominal and pelvic pain are provided.
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Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. ⋯ Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities.
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Total knee arthroplasty is one of the most commonly performed operations in the USA. As with any elective joint surgery, the primary goal includes functional restoration that is not limited by pain. ⋯ Concern has been raised over the potential risks of femoral nerve block, and there has been growing support for the adductor canal block. It is the author's opinion that when not contraindicated, intraoperative neuraxial anesthesia combined with a continuous adductor canal block and a multimodal medication regimen for postoperative pain control is the best analgesic protocol for knee arthroplasty.