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Purpose This study aims to examine if mindfulness is associated with pain catastrophizing, depression, disability, and health-related quality of life (HRQOL) in cancer survivors with chronic neuropathic pain (CNP). Method We conducted a cross-sectional survey with cancer survivors experiencing CNP. Participants ( n  = 76) were men (24 %) and women (76 %) with an average age of 56.5 years (SD = 9.4). Participants were at least 1 year post-treatment, with no evidence of cancer, and with symptoms of neuropathic pain for more than three months. Participants completed the Five Facets Mindfulness Questionnaire (FFMQ), along with measures of pain intensity, pain catastrophizing, pain interference, depression, and HRQOL. Results Mindfulness was negatively correlated with pain intensity, pain catastrophizing, pain interference, and depression, and it was positively correlated with mental health-related HRQOL. Regression analyses demonstrated that mindfulness was a negative predictor of pain intensity and depression and a positive predictor of mental HRQOL after controlling for pain catastrophizing, age, and gender. The two mindfulness facets that were most consistently associated with better outcomes were non-judging and acting with awareness. Mindfulness significantly moderated the relationships between pain intensity and pain catastrophizing and between pain intensity and pain interference. Conclusion It appears that mindfulness mitigates the impact of pain experiences in cancer survivors experiencing CNP post-treatment. Implications for cancer survivors This study suggests that mindfulness is associated with better adjustment to CNP. This provides the foundation to explore whether mindfulness-based interventions improve quality of life among cancer survivors living with CNP.

Background The objective of this study was to compare the effect of thoracic paravertebral block (TPVB) and local anesthetic (LA) on persistent postoperative pain (PPP) 1 year following breast cancer surgery. Secondary objectives were to compare the effect on arm morbidity and quality of life. Methods Women scheduled for elective breast cancer surgery were randomly assigned to either TPVB or LA followed by general anesthesia. An NRS value of >3 at rest or with movement 1 year following surgery defined PPP. Blinded interim analysis suggested rates of PPP much lower than anticipated, making detection of the specified 20 % absolute reduction in the primary outcome impossible. Recruitment was stopped, and all enrolled patients were followed to 1 year. Results A total of 145 participants were recruited; 65 were randomized to TPVB and 64 to LA. Groups were similar with respect to demographic and treatment characteristics. Only 9 patients (8 %; 95 % CI 4–14 %) met criteria for PPP 1 year following surgery; 5 were in the TPVB and 4 in the LA group. Brief Pain Inventory severity and interference scores were low in both groups. Arm morbidity and quality of life were similar in both groups. The 9 patients with PPP reported shoulder-arm morbidity and reduced quality of life. Conclusions This study reports a low incidence of chronic pain 1 year following major breast cancer surgery. Although PPP was uncommon at 1 year, it had a large impact on the affected patients’ arm morbidity and quality of life.

Background. Chronic pain (CP) accounts for 10–16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives. To describe patients with CP attending the ED and identify factors contributing to their visit. Methods. We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results. Fifty-eight patients (66% women; mean age 46.5, SD = 16.9) completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions. Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED.

Painful diabetic peripheral neuropathy (PDPN) is a chronic pain condition with modest response to pharmacotherapy. Participation in mindfulness-based stress reduction (MBSR) leads to improvements in pain-related outcomes but the mechanisms of change are unknown. The present study examined the mediators and moderators of change in 62 patients with PDPN who participated in a randomized controlled trial comparing MBSR to waitlist. Changes in mindfulness and pain catastrophizing were tested simultaneously as mediators. Increased mindfulness mediated the association between participation in MBSR and improved pain severity, pain interference, and the physical component of health-related quality of life (HRQoL) 3 months later. The mediation effect of pain catastrophizing was not significant. Linear moderated trends were also found. Post-hoc moderated mediation analyses suggested that MBSR patients with longer histories of diabetes might increase their mindfulness levels more, which in turn leads to improved pain severity and physical HRQoL. These results allow for a deeper understanding of pathways by which MBSR benefits patients with PDPN.

OBJECTIVES: To determine whether the prevalence of opioid use among patients requiring elective same‐day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid‐tolerant patients and to examine clinical outcomes. METHODS: A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted. RESULTS: Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long‐acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long‐acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti‐inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti‐inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid‐tolerant and opioid‐naïve patients. CONCLUSION: Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking.

AbstractObjectivesTo evaluate the effect of a collaborative interdisciplinary pain assessment program on pain and health‐related quality of life among individuals with chronic pain who frequently visit the emergency department (ED). MethodsIndividuals with chronic pain who frequented the ED (ie, ≥8 visits within the previous 12 months) were randomly assigned to a collaborative chronic pain management program or treatment as usual. Primary outcomes were change in physical function and visits to the ED from baseline to 12 months using validated measures. Secondary measures included physical and emotional functioning, insomnia, health‐related quality of life, risk of aberrant opioid use, and health care use. Mixed model analyses of variances were used to evaluate intervention effectiveness among the whole sample (ie, using intention to treat principles) and individuals who completed more than 50% of follow‐up assessments. ResultsOne hundred participants were assessed for eligibility and 46 patients were enrolled with 24 being randomized to intervention and 22 to treatment as usual (TAU). Eleven of the 24 patients randomized to the intervention were lost to follow‐up and 3 withdrew participation. Two of the 22 patients randomized to TAU were lost to follow‐up, and 7 withdrew. Although patients assigned to the intervention improved more rapidly on measures of pain and health related quality of life, both groups had similar improvements overall between baseline to 12 months. Average pain intensity reduction (numeric rating scale [SE]) was 4.63 (0.40) in the intervention and 4.82 (0.53) in the treatment as usual at the 12‐month follow‐up. A significant group × time interaction was present for risk of aberrant opioid use, with individuals in the intervention group reporting greater improvement in risk of aberrant opioid use by 12‐month follow‐up. ConclusionParticipation in an interdisciplinary program may accelerate improvements in pain‐ and health‐related quality of life and reduce risk of aberrant opioid use to manage pain and related distress. Further research is needed to better understand and address barriers to engagement in chronic pain care.

The mismatch negativity (MMN), an auditory event-related potential, has been identified as a good indicator of recovery of consciousness during coma. We explored the predictive value of the MMN and other auditory-evoked potentials including brainstem and middle-latency potentials for predicting awakening in comatose patients after cardiac arrest or cardiogenic shock. Auditory brainstem, middle-latency (Pa wave), and event-related potentials (N100 and MMN waves) were recorded in 17 comatose patients and 9 surgical patients matched by age and coronary artery disease. Comatose patients were followed up daily to determine recovery of consciousness and classified as awakened and nonawakened. Among the auditory-evoked potentials, the presence or absence of MMN best discriminated between patients who awakened or those who did not. Mismatch negativity was present during coma in all patients who awakened (7/7) and in 2 of those (2/10) who did not awaken. In patients who awakened and in whom MMN was detected, 3 of those awakened between 2 and 3 days and 4 between 9 and 21 days after evoked potential examination. All awakened patients had intact N100 waves and identifiable brainstem and middle-latency waves. In nonawakened patients, N100 and Pa waves were detected in 5 cases (50%) and brainstem waves in 9 (90%). The MMN is a good predictor of awakening in comatose patients after cardiac arrest and cardiogenic shock and can be measured days before awakening encouraging ongoing life support.

Preoperative renal dysfunction is a risk factor for adverse events in cardiac surgery. This study compared creatinine clearance (ClCr), estimated from the Cockroft and Gault formula, and plasma creatinine level as predictors of outcome after cardiac surgery. Prospective, observational. University hospital. A total of 6,364 cardiac surgical patients. The measured outcomes were postoperative renal failure requiring dialysis, and mortality and major morbidity. For each outcome, two multivariable risk models were developed, using either estimated ClCr as a measure of renal function, or plasma creatinine level. Risk-adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated for each outcome. Discrimination was compared using receiver operating characteristic (ROC) curves. For each 10 mL/min/1.73 m(2) decrement of estimated ClCr, the ORs for renal failure requiring dialysis, mortality, and major morbidity in the whole population were 1.52 (95% CI, 1.35 to 1.67), 1.27 (95% CI, 1.19 to 1.35), and 1.18 (95% CI, 1.14 to 1.21), respectively; for each 0.2 mg/dL increment of plasma creatinine, ORs were 1.20 (95% CI, 1.15 to 1.26), 1.08 (95% CI, 1.04 to 1.13), and 1.12 (95% CI, 1.09 to 1.15), respectively. The areas under the ROC curves for prediction of renal failure requiring dialysis were 0.83 with both risk models. For prediction of mortality and major morbidity, areas under the ROC curves were 0.83 and 0.72, respectively, with the models using estimated ClCr, and 0.74 and 0.65, respectively, with the models using plasma creatinine level (p < 0.001 vs estimated ClCr for both outcomes). In patients with normal plasma creatinine levels (n = 4,603), estimated ClCr remained a significant predictor of each outcome with similar ORs, but plasma creatinine level was not a predictor of any outcome. The risk-adjusted association between preoperative renal dysfunction and adverse events after cardiac surgery is stronger with estimated ClCr than with plasma creatinine level, particularly in patients with normal plasma creatinine levels. The routine preoperative estimation of ClCr may improve the identification of higher-risk cardiac surgical patients.

The Cappadocian Fathers composed letters for a wide variety of audiences. A large number of their epistles accentuated a heritage they shared with addressees who were proficient in the complex education of Greek παιδεία. This study addresses the bishops' letters through a sociological lens by characterizing the epistles as a form of cultural capital: evidence of an individual's comprehension of the Hellenic values guiding social interaction among elites. By exchanging letters with leaders of similar training in the eastern Roman Empire, the Cappadocians and their correspondents were participating in a trans-historical camaraderie with noble Greeks from the past. Like the heroes of Homeric epics, they were engaging in a form of gift giving that accentuated the virtues of φιλία (friendship) and τιμή (honor). The epistles were manifestations of an accumulated cultural knowledge that informed the policies of rhetoricians and select bishops and officials within the eastern provincial administration. The Cappadocians' conveyance of letters imbued with Greek references and allusions facilitated their acts of civic patronage by transcending potential religious differences with the language of a nostalgic pre-Christian past. Lessons from this venerated antiquity resonated within the fellowship of the learned and reinforced a social and political administration rooted in Hellenic tradition.