The association between inflammatory biomarkers and low back disorder: a systematic review and meta-analysis

INTRODUCTION

Low back disorder (LBD) is a major cause of disability worldwide. Inflammation results in proliferation of cytokines or consequent degradation products (collectively known as inflammatory biomarkers) that activate pain pathways which can result in non-specific LBD. This systematic review and meta-analysis aim to evaluate the relationship between inflammatory biomarkers and clinical outcomes in patients with LBD.

METHODS

The PRISMA guideline was followed for the systematic reivew. Three online databases were searched. Four RCTs and sixteen observational studies with 1142 LBD patients were analysed. The primary outcomes were back and leg pain scores, back-specific disability scores and expression of inflammatory biomarkers. Standardized mean difference (SMD) and their 95% confidence intervals (CI) were evaluated. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to summarize the strength of evidence.

RESULTS

Four RCTs and sixteen observational studies were included in the analysis of 1142 patients with LBD. There was a statistically significant reduction in back pain score and IL-1 beta and increase in the expression of CTX-1 and IL-10 levels post treatment. There was a significant relationship between increase in the expression of MCP- and reduction in the expression of hsCRP with increase in back pain. Significant relationship was also observed between increase in the expression of MCP-1 and reduction in the expression of IL-6 with increase in leg pain. Increase in the expression of IL-8 and reduction in the expression of hsCRP was also associated with increased disability score.

CONCLUSION

Inflammatory biomarkers play a significant role in the pathogenesis of LBD. CTX-1, IL-10 and IL-1 beta may be responsible for the decrease in back pain scores post treatment. There is a relationship between MCP-1, IL-6, IL-8 and hsCRP with clinical and functional assessments for LBD. Further studies will improve understanding of the pathogenesis of LBD and aid in targeted management strategies.

Blood Interleukin-18 (IL-18) and IL-18 Binding Protein (IL-18BP) Levels Following Midline Laparotomy: A Prospective Randomized Study of Patients With Benign Disease and Patients With Cancer

BACKGROUND/AIM

The acute phase immune response (APR) in midline laparotomy (MLa) patients following surgery has been rarely studied, with no studies assessing the association of blood IL-18 (interleukin-18) and IL-18BP (IL-18 binding protein) values with the numeric rating scale (NRS) pain score following MLa.

PATIENTS AND METHODS

Blood levels of seven cytokines (CYT) (IL-18, IL-18BP, IL-1ra, IL-6, IL-8, IL-10, IL-1β) and high-sensitivity C-reactive protein (hs-CRP) were measured at three time points; before operation (PRE), immediately after operation (POP1), and 24 h after operation (POP2) in 56 patients with MLa. The satisfaction of the patients at 24 h following MLa (SFS24; 0=fully unsatisfied; 10=fully satisfied) was recorded on a 11-point numeric rating scale.

RESULTS

In all patients, the IL-18 and IL-18BP blood levels decreased at POP1 and the drop between the preoperative and POP1 levels in the IL-18 and IL-18BP was highly significant (p<0.001). However, the median IL-18 and IL-18BP blood levels increased significantly at POP2 (p<0.001) with the linear mixed-effect model (LME) showing a statistically significant time effect (p<0.001). The hs-CRP blood levels increased significantly at POP2 with the LME model showing a statistically significant time effect. The preoperative and POP2 IL-18 values were clearly higher in patients with cancer versus benign disease (177/182 vs. 135/126, p=0.039/p=0.013, respectively). Interestingly, in all patients of the study, the median IL-18 versus IL-18BP blood levels correlated at POP1 (r=0.315, p=0.036).

CONCLUSION

A noteworthy discovery of this study is the correlation of IL-18BP with SFS24 (r=0.361, p=0.05), proposing that APR and quality of life are associated in MLa patients.

Effect of Music Therapy on Pain During Thyroid Fine Needle Aspiration Biopsy; A Randomized Controlled Clinical Trial

INTRODUCTION

High-resolution ultrasonography devices have led to the increased detection of thyroid nodules and the need for fine-needle aspiration biopsy (FNAB). However, FNAB is an invasive procedure that can cause discomfort and pain. Music therapy has been used for centuries to alleviate pain, and our clinical trial was conducted to investigate its impact on pain scores during thyroid FNAB.

MATERIALS AND METHODS

We conducted a randomized, controlled clinical trial, including adult patients undergoing thyroid FNAB. We evaluated the nonpharmacological intervention of listening to music before and during thyroid FNAB. We used a slow, nonlyrical, flowing melody with a tempo of 60 to 80 beats per minute as a therapeutic intervention for managing anxiety and pain. It had low tones, minimal percussion, and a volume of around 60 dB. The Beck Anxiety Inventory and Visual Pain Scale were used.

RESULTS

The study included 529 patients assigned to either the music group (n = 258, 48.7%) or the control group (n = 271, 51.2%). The patients were categorized into subgroups based on either a single nodule (73.63%) or multiple nodules (24.18%). When all patients or single nodule and multiple data are examined separately, the intervention group showed statistically significantly lower pain scores than the control group.

CONCLUSION

Our study is among the first on this topic and the largest in the available literature to demonstrate that listening to music during FNAB significantly reduces pain and anxiety. Music therapy is an effective, safe, and noninvasive intervention that can improve patient care and reduce distress and pain.

Reporting outcome measures in veterinary physiotherapy with particular reference to the treatment of canine and equine joint cases in the UK

BACKGROUND

Outcome measures are extensively used within human physiotherapy, but a widely accepted issue in veterinary physiotherapy is that outcome measures lack sufficient evaluation and standardisation in terms of how they are implemented. This cross-sectional study aimed to provide clarity on (1) the current selection of outcome measures in canine and equine physiotherapy and (2) investigate external influences on outcome measure selection, including comparative literature availability, professional memberships and background.

METHODS

A structured scoping literature review consolidated current understanding and limitations. This informed a survey of qualified veterinary physiotherapists (n = 40). The statistical analysis comprised descriptive statistics.

RESULTS

Key observations included (1) a lack of difference in outcome measure application between veterinary physiotherapists with and without a human physiotherapy background, (2) enhanced outcome measure utilisation by registry body members and (3) an overall skew towards subjective, rather than objective, outcome measure use.

LIMITATIONS

The study was limited by the absence of a defined veterinary physiotherapist population and subsequent convenience sample size.

CONCLUSION

The apparent skew towards subjective outcome measures highlights objective outcome measure underutilisation and the need for a more extensive evidence base. In conclusion, there is a need to develop comprehensive professional development resources promoting the use of repeatable outcome measures such as goniometers and the Liverpool osteoarthritis scoring.

Comparison of preoperative retrobulbar bupivacaine and postoperative subcutaneous liposome-encapsulated bupivacaine on postoperative analgesia in dogs undergoing enucleation

OBJECTIVE

To compare the effectiveness of preoperative bupivacaine inferotemporal retrobulbar blocks to postoperative liposome-encapsulated bupivacaine (Nocita) line blocks for analgesia following enucleation.

ANIMALS

39 client-owned dogs (40 eyes) presenting to the Ophthalmology Service for enucleation.

METHODS

Dogs were randomly assigned to receive either a preoperative inferotemporal retrobulbar block with 0.5% bupivacaine or a peri-incisional line block with liposome-encapsulated bupivacaine (Nocita) at closure. Patients underwent unilateral enucleation and were hospitalized for 24 hours after surgery. Pain scores were performed by a masked observer with the Glasgow Composite Measure Pain Scale and the University of Wisconsin Ocular Pain Scale at 0.25, 0.5, 1, 2, 4, 6, 8, and 24 hours following surgery. Intraoperative use of blood pressure and anesthetic support mediations as well as need for rescue pain control were recorded and compared between groups.

RESULTS

There was no significant difference in rescue rates between treatment groups. When comparing the use of medical intraoperative heart rate, blood pressure, or anesthetic plane support, there were no significant differences in use between groups.

CLINICAL RELEVANCE

Use of preoperative bupivacaine retrobulbar blocks and postoperative Nocita line blocks were equally effective at postoperative pain control with similarly low complication rates.

Clinical observation on 90 cases of primary dysmenorrhea treated by buccal acupuncture therapy: a randomized controlled study

OBJECTIVE

To explore the short-term and long-term efficacy of buccal acupuncture therapy in the treatment of patients with primary dysmenorrhea (PD).

METHODS

A total of 90 patients with PD who were admitted to the Second Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine from January 2020 to December 2021 were included in this study and randomly divided into three groups, including the observation group, the control group, and the placebo group, with 30 patients in each group. Patients in the observation group were treated according to the syndrome types of Traditional Chinese Medicine, those in the control group were treated with Saridon, and those in the placebo group received a placebo. The visual analog scale (VAS) scores of these patients were evaluated at different time points (before treatment, 5 min after needle retention, 30 min after needle retention, 1 h after treatment, 2 h after treatment, 1 d after treatment, and 2 d after treatment). The Cox Menstrual Symptom Scale (CMSS) scores were assessed before the treatment and after three courses of treatment. Besides, these two scales were also evaluated during follow-up. Moreover, the pain score and adverse reactions of these patients were assessed during treatment.

RESULTS

After treatment, the VAS and CMSS scores in the observation group decreased significantly (P < 0.05) 5 and 30 min after needle retention and after treatment.

CONCLUSION

Buccal acupuncture therapy is verified to have short-term efficacy in the treatment of PD. In addition, this therapy has an immediate analgesic effect and long-term efficacy in reducing the severity and frequency of PD.

General anesthesia with local infiltration reduces urine retention rate and prolongs analgesic effect than spinal anesthesia for hemorrhoidectomy

Introduction

Postoperative pain and complications pose significant challenges following a hemorrhoidectomy. Attaining effective anesthesia with minimal complications is crucial. The ideal anesthesia method for ambulatory hemorrhoidectomy remains uncertain. This study aimed to investigate whether the combination of general anesthesia plus local infiltration (GAL) is associated with lower complications and reduced pain compared to spinal anesthesia (SA) in the context of hemorrhoidectomy.

Methods

This retrospective single-center cohort study, conducted in a tertiary medical center in East Asia, evaluated excisional hemorrhoidectomies performed between January 1, 2017, and March 31, 2023, utilizing GAL or SA. Data on the six most common complications-pain, constipation, acute urine retention (AUR), bleeding, nausea, and headache-were extracted from medical records. A total of 550 hemorrhoidectomies were included: 220 in the GAL group and 330 in the SA group. Patient characteristics were comparable between the two groups.

Results

The AUR rate was significantly lower in the GAL group compared to the SA group (15.5% vs. 32.1%, P < 0.001). Although the proportion of pain scores ≥4 did not differ significantly between the GAL and SA groups (36.2% vs. 39.8%, P = 0.429), the pain score curve indicated a stable trend. Overall, the GAL group exhibited a lower rate of adverse effects (56.9% vs. 67.4%, P = 0.023). There were no significant differences in the rates of other complications and emergency department readmission between the GAL and SA groups.

Discussion

GAL emerges as a favorable choice for anesthesia in hemorrhoidectomy, demonstrating a lower incidence of urine retention and a prolonged analgesic effect in multiple hemorrhoidectomies. These findings support the conclusion that GAL represents an optimal anesthetic method for enhancing the postoperative experience in patients undergoing hemorrhoidectomy.

Neural Correlates of Pain-Autonomic Coupling in Patients With Complex Regional Pain Syndrome Treated by Repetitive Transcranial Magnetic Stimulation of the Motor Cortex

OBJECTIVES

Complex regional pain syndrome (CRPS) is a chronic pain condition involving autonomic dysregulation. In this study, we report the results of an ancillary study to a larger clinical trial investigating the treatment of CRPS by neuromodulation. This ancillary study, based on functional magnetic resonance imaging (fMRI), evaluated the neural correlates of pain in patients with CRPS in relation to the sympathetic nervous system and for its potential relief after repetitive transcranial magnetic stimulation of the motor cortex.

MATERIALS AND METHODS

Eleven patients with CRPS at one limb (six women, five men, aged 52.0 ± 9.6 years) were assessed before and one month after the end of a five-month repetitive transcranial magnetic stimulation (rTMS) therapy targeting the motor cortex contralateral to the painful limb, by means of electrochemical skin conductance (ESC) measurement, daily pain intensity scores on a visual numerical scale (VNS), and fMRI with motor tasks (alternation of finger movements and rest). The fMRI scans were analyzed voxelwise using ESC and VNS pain score as regressors to derive their neural correlates. The criterion of response to rTMS therapy was defined as ≥30% reduction in VNS pain score one month after treatment compared with baseline.

RESULTS

At baseline, ESC values were reduced in the affected limb vs the nonaffected limb. There was a covariance of VNS with brain activation in a small region of the primary somatosensory cortex (S1) contralateral to the painful side on fMRI investigation. After rTMS therapy on motor cortex related to the painful limb, the VNS pain scores significantly decreased by 22% on average. The criterion of response was met in six of 11 patients (55%). In these responders, at one month after treatment, ESC value increased and returned to normal in the CRPS-affected limb, and overall, the increase in ESC correlated with the decrease in VNS after motor cortex rTMS therapy. At one month after treatment, there also was a covariance of both variables (ESC and VNS) with fMRI activation of the S1 region previously mentioned. The fMRI activation of other brain regions (middle frontal gyrus and temporo-parietal junction) showed correlation with ESC values before and after treatment. Finally, we found a positive correlation at one month after treatment (not at baseline) between VNS pain score and fMRI activation in the temporo-parietal junction contralateral to painful side.

CONCLUSIONS

This study first shows a functional pain-autonomic coupling in patients with CRPS, which could involve a specific S1 region. However, the modulation of sympathetic sudomotor activities expressed by ESC changes was rather correlated with functional changes in other brain regions. Finally, the pain relief observed at one month after rTMS treatment was associated with a reduced activation of the temporo-parietal junction on the side in which rTMS was performed. These findings open perspectives to define new targets or biomarkers for using rTMS to treat CRPS-associated pain.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT02817880.

A Retrospective Study: Multimodal Analgesia Quality Measure Implementation and Patient Outcome Assessment

Current research has demonstrated that nonopioid multimodal analgesia decreases perioperative opioid consumption, postoperative nausea and vomiting (PONV), and pain scores. However, no research has been conducted to examine the patient outcomes of Merit-based Incentive Payment System (MIPS) 477. This study evaluates those outcomes following implementation of MIPS 477. The medical records of 400 adult patients who underwent elective and urgent laparoscopic gynecological procedures at a facility in the Mid-Atlantic region were reviewed. Data collection included patient characteristics, analgesics administered, pain scores at postanesthesia care unit (PACU) arrival and discharge, and antiemetic administration in PACU. This study's primary outcomes were postoperative pain scores, total intraoperative and postoperative opioid consumption, and PONV. Twenty-nine patients (7.8%) met the criteria as a control group, and 341 patients (92.2%) met the criteria as a treatment group. Pain scores were higher upon PACU arrival among the control group (P = .001). The total intraoperative morphine milligram equivalents (MMEs) administered was less among the treatment group (P = .04). The treatment group had reduced total intraoperative MMEs and pain scores at PACU arrival. However, there was no statistical significance in PACU discharge pain score, total PACU MMEs, and PONV in both groups.

Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique

Objectives

To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain.

Methods

In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively.

Results

Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032).

Conclusion

Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.

Effect of skeletonisation and pedicled bilateral internal mammary artery grafting in coronary artery bypass surgery on post-operative wound infection: A meta-analysis

The results showed that different internal thoracic artery (ITA) was associated with the rate of postoperative wound infection and the severity of pain following coronary artery bypass grafting (CABG). In order to ascertain if there was any genuine difference in the rate of postoperative infection and severity of the pain, we conducted a meta-analysis to evaluate if there was any actual difference in the wound complication that had been identified with the ITA method. Through EMBASE, Cochrane Library and Pubmed, and so forth, we systematically reviewed the results by August 2023, which compared the impact of skeletonised versus pedicled internal mammary artery (IMA) on wound complications following CABG. The trial data have been pooled and analysed in order to determine if a randomisation or fixed-effect model should be applied. The meta-analysis of data was performed with Revman 5.3 software. The results of this meta-study included 252 related articles from four main databases, and nine articles were chosen to be extracted and analysed. A total of 3320 patients were treated with coronary artery transplantation. Based on current data analysis, we have shown that the rate of postoperative wound infections is reduced by the use of the skeletonised internal mammary artery (SIMA) (OR, 1.84; 95% CI, 1.13, 3.01; p = 0.01). But the results showed that there were no statistically significant differences in the post-operation pain score of the patients (MD, 0.09; 95% CI, -0.58, 0.76; p = 0.79). Furthermore, the duration of the operation was not significantly different between the SIMA and pedicled internal mammary artery (PIMA) (MD, 3.30; 95% CI, -3.13, 9.73; p = 0.31). Overall, the SIMA decreased the rate of postoperative wound infection in CABG patients than the PIMA.

Remifentanil for External Cephalic Version: A Systematic Review and Meta-Analysis

The purpose of this study was to examine the efficacy of remifentanil on external cephalic version (ECV) in breech presentation. An extensive search was conducted using PubMed, Cochrane Library, and other grey literature. Only randomized controlled trials using remifentanil for ECV were included. Risk ratio (RR) and mean difference (MD) were used to estimate outcomes and quality of evidence was assessed using the Risk of Bias and GRADE system. Five studies consisting of 602 patients were analyzed. Remifentanil resulted in a moderate increase in ECV success rate (RR, 1.19; 95% CI, 1.00 to 1.43; P = .05), a large reduction of pain score (MD, -2.02; 95% CI, -2.32 to -1.72; P < .00001) with fewer transient fetal bradycardia (RR, 0.40; 95% CI, 0.19 to 0.85; P = .02). However, remifentanil did not affect cesarean section rates, (RR, 0.97; 95% CI, 0.49 to 1.93; P = .93) instrumental delivery (RR, 0.94; 95% CI, 0.41 to 2.15; P = 0.89), and spontaneous delivery rate (RR, 1.02; 95% CI, 0.78 to 1.35; P = 0.87). Mothers treated with remifentanil have a higher patient satisfaction score. The use of remifentanil may be a good strategy for ECV. However, extrapolation of this finding to clinical settings must consider the study limitations.

Forecast of pain degree of lumbar disc herniation based on back propagation neural network

To further explore the pathogenic mechanism of lumbar disc herniation (LDH) pain, this study screens important imaging features that are significantly correlated with the pain score of LDH. The features with significant correlation imaging were included into a back propagation (BP) neural network model for training, including Pfirrmann classification, Michigan State University (MSU) regional localization (MSU protrusion size classification and MSU protrusion location classification), sagittal diameter index, sagittal diameter/transverse diameter index, transverse diameter index, and AN angle (angle between nerve root and protrusion). The BP neural network training model results showed that the specificity was 95 ± 2%, sensitivity was 91 ± 2%, and accuracy was 91 ± 2% of the model. The results show that the degree of intraspinal occupation of the intervertebral disc herniation and the degree of intervertebral disc degeneration are related to LDH pain. The innovation of this study is that the BP neural network model constructed in this study shows good performance in the accuracy experiment and receiver operating characteristic experiment, which completes the prediction task of lumbar Magnetic Resonance Imaging features for the pain degree of LDH for the first time, and provides a basis for subsequent clinical diagnosis.

The Efficacy of Oral Etoricoxib in Pain Control During Colposcopy-Directed Cervical Biopsy: A Randomized Control Trial

OBJECTIVE

To investigate the effectiveness and safety of oral etoricoxib administration before colposcopic procedure for pain relief during and after colposcopy.

METHODS

A prospective double-blind, randomized controlled trial was conducted at the colposcopy unit of Thammasat University Hospital, Thailand from August 2022 to January 2023. The participants were women undergoing colposcopy. They were allocated into two groups: etoricoxib group and control group. Thirty minutes prior to colposcopy, the participants received etoricoxib or placebo tablet. A numerical rating scale was used to evaluate pain upon speculum insertion, 3% acetic acid application, directed cervical biopsy (CDB), endocervical curettage (ECC), and 10 minutes and 24 hours after colposcopy.

RESULT

One hundred and ten women were recruited and were divided equally into study and control groups. The mean age of participants was 42.6 years old. One-fourth of cases (29/110) had cervical intraepithelial neoplasia grade 2 or more histology. Subjects in etoricoxib group had less median pain scores during CDB, ECC, and 10-minute and 24-hour post procedure than the control group with statistical significance. Both groups had comparable side effects.

CONCLUSION

Administration of oral etoricoxib 30 minutes before colposcopy could reduce pain during and up to 24-hour post colposcopy with minimal side effects.

Antepartum depressive symptoms are associated with significant postpartum opioid use

BACKGROUND

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant.

OBJECTIVE

This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization.

STUDY DESIGN

This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome.

RESULTS

The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms.

CONCLUSION

Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

Post-anesthetic CPS and EQUUS-FAP scores in surgical and non-surgical equine patients: an observational study

Background

Equine pain scoring may be affected by the residual effect of anesthetic drugs.

Objectives

To compare pain scores in the hours immediately following anesthetic recovery to baseline pre-anesthetic scores in equine patients undergoing surgical and non-surgical procedures.

Study design

Clinical observational study.

Methods

Fifty adult horses undergoing anesthesia for surgical or non-surgical procedures were enrolled. Horses underwent pain scoring using the Composite Pain Score (CPS) and Equine Utrecht University Scale for Facial Assessment of Pain (EQUUS-FAP) prior to anesthesia (T0) and following anesthetic recovery to standing, every hour for 5 h (T1-T5). Data were analyzed using a generalized linear mixed effects model. A post-hoc Dunnett's test for multiple comparisons was performed for variables where an effect was detected.

Results

Mean (95% confidence interval) CPS scores for T0-T5 were 1.6 (1.2-2.0), 6.8 (6.0-7.6), 5.1 (4.3-5.9), 4.3 (3.4-5.2), 3.7 (2.8-4.6), and 2.8 (2.0-3.6) and EQUUS-FAP scores were 0.6 (0.3-0.9), 3.0 (2.5-3.5), 1.9 (1.6-2.2), 1.1 (0.8-1.4), 0.6 (0.4-0.8), and 0.7 (0.4-1.0), respectively. For the CPS, scores greater than 5, and for the EQUUS-FAP scores greater than 3, are consistent with minor pain. There was no effect of type of procedure (surgical vs non-surgical) on CPS or EQUUS-FAP scores. There was an effect of time with CPS scores significantly greater than baseline at T1-T5 and EQUUS-FAP scores significantly greater than baseline at T1 and T2.

Main limitations

Discomfort caused by hoisting was not quantified and it was difficult to ascertain if this affected the results.

Conclusions

Post-anesthetic pain scores may be influenced by the residual effect of anesthetic agents for as long as 5 h and 2 h for the CPS and EQUUS-FAP, respectively.

Lutetium-177 Prostate-Specific Membrane Antigen-617 Treatment in Metastatic Castration-Resistant Prostate Adenocarcinoma: Results of Single-Center Experience

OBJECTIVE

Lutetium-177 prostate-specific membrane antigen-617 is a novel alternative therapeutic option in metastatic castration-resistant prostate cancer, especially useful for patients who do not respond to standard therapy methods. The aim of this study was to define the efficacy and safety profile of lutetium-177 prostate- specific membrane antigen-617 treatment in a group of patients with metastatic castration-resistant prostate cancer.

MATERIALS AND METHODS

Study group included 34 men with metastatic castration-resistant prostate cancer (median, 69.6 ± 7.7 years) who were treated with lutetium-177 prostate-specific membrane antigen-617 therapy (22/34; 4 courses, 12/34; 2 courses). Patients were evaluated by physical examination, Eastern coop- erative oncology group performance status, gallium-68 prostate-specific membrane antigen positron emis- sion tomography/computed tomography, brief pain inventory-short form questionnaire, biochemical tests, and complete blood counts. Treatment response and adverse effects were examined by brief pain inventory scores, SUVmax values, biochemical tests, and complete blood counts. Independent variables were analyzed statistically (significance; P < .05).

RESULTS

The Eastern cooperative oncology group performance was grade 0 in 5/34 (14.7%), grade 1 in 25/34 (73.5%), and grade 2 in 4/34 (11.8%) patients. Distribution of patient numbers according to brief pain inven- tory scores (score: <1, scores: 1-4, and scores: 5-10) was 2, 10 and 22 at the beginning, 6, 16 and 12 after the second course, and 10, 10 and 2 after the fourth course of treatment, respectively. Serum prostate-specific antigen decreased in 15 of 22 patients (68%) (P < .05). Before and after the treatment, we found a substan- tial decrease in SUVmax values (22.3 vs. 11.8, P < .001) and brief pain inventory scores (score ≥ 5; 22/34 pts vs. 0/22 pts). The counts of white blood cells (P < .05), hemoglobin (P < .05), and thrombocytes (P = .001) were all significantly lower at the conclusion of the therapy. The most important adverse events were severe leukopenia (1/34 pts; 2.29 × 103/μL) and thrombocytopenia (3/34 pts; 32 000, 36 000, 32 000 106/L). Q1 Conclusion: We found that lutetium-177 prostate-specific membrane antigen-617 therapy is a promising treatment method for metastatic castration-resistant prostate cancer patients who are unresponsive to conventional therapy, according to our biochemical, positron emission tomography/computed tomography, and pain score outcomes.

Poor Association between Facial Expression and Mild Lameness in Thoroughbred Trot-Up Examinations

Musculoskeletal injuries in racehorses are difficult to detect prior to catastrophic breakdown. Lameness is commonly attributed to orthopaedic pain in horses, therefore, subtle lameness may be a pre-clinical sign of injury and, if identified early, could allow for preventative intervention. Our objective was to determine if facial expressions could be used to detect mild lameness as an indicator of orthopaedic pain in 'fit to race' horses. The Horse Grimace Scale (HGS) and the facial expressions in ridden horses (FEReq), were used to score images (n = 380) of mildly lame (n = 21) and non-lame (n = 17) Thoroughbred horses by two independent observers. Using an Equinosis Lameness Locator®, the lameness status of each horse was determined according to published thresholds [forelimb lameness (>|14.5 mm|) and hindlimb lameness (>|7.5 mm|)]. Inter and intraobserver reliability were assessed using two-way random-effects models. Univariable associations between lameness and facial expression parameters were identified using logistic and linear regression. Interobserver reliability was moderate (κ 0.45; 95% CI 0.36, 0.55). Horses with moderate mouth strain (HGS) and tense and extended upper lip (FEReq) were less likely to be lame (p = 0.042 and p = 0.027, respectively). Exposed sclera was associated with lameness (p = 0.045). Higher orbital tightening (HGS) scores were associated with a lower degree of maximum head amplitude (HDmax) lameness (p = 0.044). Tension and moderate tension above the eye, for the HGS and FEReq scores, were associated with increasing amplitude of HDmax (p = 0.048 and p = 0.034, respectively). Inconsistent associations between lameness status and HGS and FEReq scores may limit the potential use of the facial expression for the prediction of mild orthopaedic pain during pre-race lameness examinations. More objective parameters associated with mild orthopaedic pain should be explored.

Clinical Significance of a Pain Scoring System for Deep Endometriosis by Pelvic Examination: Pain Score

Endometriosis-associated pain is an essential factor in deciding surgical indications of endometriosis. However, there is no quantitative method to diagnose the intensity of local pain in endometriosis (especially deep endometriosis). This study aims to examine the clinical significance of the pain score, a preoperative diagnostic scoring system for endometriotic pain that can be performed only with pelvic examination, devised for the above purpose. The data from 131 patients from a previous study were included and evaluated using the pain score. This score measures the pain intensity in each of the seven areas of the uterus and its surroundings via a pelvic examination using a numeric rating scale (NRS) which contains 10 points. The maximum value was then defined as the max pain score. This study investigated the relationship between the pain score and clinical symptoms of endometriosis or endometriotic lesions related to deep endometriosis. The preoperative max pain score was 5.93 ± 2.6, which significantly decreased to 3.08 ± 2.0 postoperatively (p = 7.70 × 10^-20). Regarding preoperative pain scores for each area, those of the uterine cervix, pouch of Douglas, and left and right uterosacral ligament areas were high (4.52, 4.04, 3.75, and 3.63, respectively). All scores decreased significantly after surgery (2.02, 1.88, 1.75, and 1.75, respectively). The correlations between the max pain score and dysmenorrhea, dyspareunia, perimenstrual dyschezia (pain with defecation), and chronic pelvic pain were 0.329, 0.453, 0.253, and 0.239, respectively, and were strongest with dyspareunia. Regarding the pain score of each area, the combination of the pain score of the pouch of Douglas area and the VAS score of dyspareunia showed the strongest correlation (0.379). The max pain score in the group with deep endometriosis (endometrial nodules) was 7.07 ± 2.4, which was significantly higher than the 4.97 ± 2.3 score obtained in the group without (p = 1.71 × 10^-6). The pain score can indicate the intensity of endometriotic pain, especially dyspareunia. A local high value of this score could suggest the presence of deep endometriosis, depicted as endometriotic nodules at that site. Therefore, this method could help develop surgical strategies for deep endometriosis.

Clinical Equivalence of Monoglyde® and Monocryl® Absorbable Poliglecaprone-25 Sutures: A Single-Blind, Randomized Study

OBJECTIVES

Poliglecaprone-25 is a synthetic monofilament suture commonly used for post-cesarean subcuticular skin closure. The present study was designed to assess the effect of subcuticular skin closure using Monoglyde® vs. Monocryl® poliglecaprone-25 absorbable sutures on the risk of wound composite outcomes in the first 30 days post-partum [surgical site infection (SSI), wound dehiscence, hematoma or seroma].

STUDY DESIGN

This is a prospective, single-blind, randomized (1:1), multicentric, two-arm study performed between September 2020 and December 2021 at two different centers across India. Women (18-40 years) with a singleton pregnancy requiring cesarean delivery were randomized to Monoglyde® (n=62) or Monocryl® (n=62) suture groups. The primary endpoint is the incidence of wound composite outcomes in the first 30 days post-partum (SSI, wound dehiscence, seroma, or hematoma). In addition, the secondary outcomes, incidence of wound composite outcome at all visits (till four months), suture extrusion and loosening, suture removal and evaluation of microbial deposits on sutures (in case not absorbed or infection), operative time, intraoperative suture handling, postoperative pain, return to normal day-to-day activities, modified Hollander cosmesis score, subject satisfaction score, and adverse events were noted.

RESULTS

Non-significant difference between the groups regarding demographic characteristics and primary endpoint; the incidence of wound composite outcome was observed. Moreover, no significant difference in suture extrusion and loosening, suture removal and evaluation of microbial deposits on sutures, operative time, intraoperative suture handling, pain, return to normal day-to-day activities, modified Hollander cosmesis, and subject satisfaction score were registered between the groups.

CONCLUSIONS

This study establishes the clinical equivalence of Monoglyde® and Monocryl® poliglecaprone-25 sutures, and both sutures can be used for subcuticular skin closure following cesarean delivery with minimal risk for wound complications.

Impact of Active Physiotherapy Rehabilitation on Pain and Global and Functional Improvement 1-2 Months after Lumbar Disk Surgery: A Systematic Review and Meta-Analysis

Introduction: Lumbar disc surgery is a common procedure for patients with lower back pain associated with lumbar disc herniation. This study aims to evaluate the impact of active physiotherapeutic rehabilitation on global/functional improvement and subjective pain score reduction among patients 1–2 months following lumbar disc surgery. The outcomes of this study are to assess the impact of active physiotherapeutic rehabilitation on functional improvement and subjective improvement in pain behavior post active rehabilitation. The outcomes are measured as pain assessed using the visual analog scale, global measurement of improvement, back pain functional status, and return to work. Methods: Databases, including MEDLINE/PubMed (10 June 1996, 2022), Web of Science (10 June 1997, 2022), Scopus (15 March, 10 June 2004, 2022), CINAHL Plus (10 June 1961, 2022), and Cochrane (10 June 1993, 2022) were reviewed without any language restrictions. All studies were systematically screened; however, only randomized controlled trials were eligible against the inclusion/exclusion criteria. All statistical tests were conducted in Review Manager (RevMan) 5.4. The quality of studies was appraised using the grading of recommendations assessment, development, and evaluation (GRADE) approach and the risk-of-bias 2 (RoB 2) tool. Results: Fifteen articles were identified, enrolling a total of 2188 patients, where the majority of active rehabilitation interventions continued for 3 months. All these interventions began 1–2 months postoperatively, and quantitative findings were presented as mean scores. The subjective pain scores were significantly lower in the interventional group, with a mean difference (MD) of −7.01 (p = 0.004). The pain disability score was considerably lower in the interventional group, with an MD of −3.94 (p = 0.002). Global improvement was higher in the interventional group (OR = 1.94, p = 0.0001). Conclusions: This study presents significant improvement in all parameters concerning pain and functionality. Postoperative rehabilitation requires optimization concerning timing, duration, intensity, and associated components to benefit patients post lumbar disc surgery.

Reduction of pre-procedural anxiety for repeat sessions in extracorporeal shockwave lithotripsy (ESWL) reduces pain intensity: A prospective observational study

Pain control is a major determinant for successful stone clearance in extracorporeal shockwave lithotripsy (ESWL) for urolithiasis. Pain perception during ESWL may be influenced by patient factors like gender, age, body habitus and anxiety level, and stone related factors like size, laterality and location of stone. We investigated in general, the confounding patient and stone factors influencing pain perception during ESWL with importance given to procedural anxiety in first and the subsequent session of ESWL. This was a prospective observational study of all new consecutive patients who underwent ESWL for a period of 1 year at a tertiary Urological Centre. Demographic and stone anthropometry were analyzed. Pre-procedural anxiety was assessed prior to procedure using hospital anxiety and depression score (HADS) and pain was scored using numerical rating scale-11 at baseline, 30-minutes (i.e., during) and 24 hours after ESWL. Univariate and multivariate analysis for confounding factors included HADs were performed for pain perception. A P value < .05 was considered to be statistically significant. For the study duration, 119 patients were recruited and 72 of them returned for a second session. Procedural anxiety was the only independent factor affecting pain score in ESWL for the first session in multivariate analysis. A statistically significant reduction of mean procedural anxiety score from 6.7 ± 4.5 to 3.2 ± 2.7 (P < .05) for the second ESWL session was observed (n = 72). This was in conjunction with statistical reduction of mean pain score 30 minutes after ESWL from 5.2 ± 2.1 to 4.2 ± 2.1 (P < .05). Patients with HADS ≥ 8 had statistically significant higher mean pain score at all 3 intervals in the first ESWL session. This study has shown that pre-procedural anxiety mainly anticipatory, reduces and shows reduction in pain intensity among patients undergoing repeat ESWL. Hence, anxiety reducing methods should be explored in patients undergoing ESWL to avoid unnecessary analgesic use.

Spinal anaesthesia with clonidine: pain relief and earlier mobilisation after open nephrectomy - a randomised clinical trial

Objectives

Early mobilisation and effective pain management after open nephrectomy for renal cell carcinoma often include epidural analgesia (EDA), requiring an infusion pump and a urinary catheter, thus impeding mobilisation. Spinal anaesthesia (SpA) may be an alternative. This randomised clinical trial evaluated whether SpA improves analgesia and facilitates mobilisation over EDA and which factors influence mobilisation and length of stay (LOS).

Methods

Between 2012 and 2015, 135 patients were randomised and stratified by surgical method to either SpA with clonidine or EDA. Mobility index score (MobIs), pain scale, patient satisfaction questionnaire, and LOS were the main outcome measures.

Results

SpA patients exhibited an increase in MobIs significantly earlier than EDA patients. Among SpA patients >50% reached MobIs ≥13 by postoperative day 3, while 29% of EDA patients never reached MobIs ≥13 before discharge. SpA patients had higher maximum pain scores on postoperative days 1 and 2, but both groups had similar patient satisfaction. One day before discharge, 36/64 SpA versus 22/67 EDA patients (56% and 33%, respectively) were opioid-free. SpA patients were discharged significantly earlier than EDA patients.

Conclusions

SpA facilitates postoperative pain management and is associated with faster mobilisation and shorter LOS.

The trial was registered at ClinicalTrials.org (ID-NCT02030717).

Surgeon-Placed Erector Spinae Plane Catheters for Multilevel Lumbar Spine Fusion: Technique and Outcomes Compared With Single-Shot Blocks

BACKGROUND

Postoperative pain management of multilevel lumbar fusion remains challenging. There are few reports of opioid-sparing regional analgesia for spine surgery. We present a novel method for surgeon-placed erector spinae plane (ESP) catheters for multilevel lumbar spine fusion and compare pain- and opioid-related outcomes in a matched cohort who received anesthesiologist-placed ESP blocks.

METHODS

A retrospective matched pilot study of 18 patients: 6 received intraoperative, bilateral ESP catheters. Tunneled catheters were placed under the intact ESP at the proximal end of the incision. Continuous infusions of ropivacaine (0.2%) were started in the postanesthesia care unit (PACU) after emergence from anesthesia and maintained for 48 hours. Catheter patients were matched 1:2 with 12 patients who received preincision single-shot ESP blocks administered by an anesthesiologist, according to age, gender, American Society of Anesthesiologists class, body mass index, and number of spinal levels fused. All patients were provided opioid intravenous patient-controlled analgesia (IV-PCA). Numeric rating scale pain scores (NRS, 0-10), length of stay (LOS), opioid consumption (oral morphine equivalents, mg), opioid side effects, and complications (motor weakness, local anesthetic toxicity, infection, technical issues, and failure), were compared in the PACU and on the nursing floor.

RESULTS

Only 1/6 patients with ESP catheter used opioid IV-PCA, compared with 11/12 who received ESP blocks. There were no differences in total opioid consumption (catheters: 135 ± 141 mg; blocks: 183 ± 112 mg; P = 0.448) or median (interquartile range) LOS (catheters: 73 [50,107] hours; blocks: 90 [72,116] hours, P = 0.708). NRS pain was significantly higher in the PACU after ESP catheters (5.9 ± 1.7) vs ESP blocks (3.3 ± 2.4; P = 0.036), but no differences were found at later timepoints (5.0 ± 1.6 vs 4.3 ± 1.1, respectively; P = 0.383). No catheter-related complications were found.

CONCLUSION

Surgeon-placed ESP catheters represent a simple technique to provide regional analgesia, particularly in centers lacking regional anesthesiology services. Risks, benefits, and efficacy compared to other techniques require prospective study.

LEVEL OF EVIDENCE: 3

Caudal Morphine in Pediatric Patients: A Comparison of Two Different Doses in Children Undergoing Infraumbilical Surgery - A Prospective, Randomized, Double-Blind Study

Background

One of the most feared symptoms of any disease is PAIN. It is a complex phenomenal experience, especially in children. Various methods and medications have been administered through different routes. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children. Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children. The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Various articles use various doses of morphine as an adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 μg.kg-1 and 30 μg.kg-1 of caudal epidural morphine for infraumblical surgeries with regard to its efficacy and safety and side effect profiles.

Materials and Methods

The study is a prospective, randomized, double-blinded study. Sixty patients were divided into two groups. Group A: 20 μg.kg-1 of morphine was added to 0.2% ropivacaine 1 mL.kg-1 and the solution was made. Group B: 30 μg.kg-1 of morphine was added to 1 mL.kg-1 of 0.2% ropivacaine. Heart rate, systolic blood pressure, diastolic blood pressure, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h were recorded.

Results

The mean duration of analgesia is similar in both groups (P = 0.011). The mean duration was 20.517 ± 1.9143 h in Group A and 22.233 ± 1.6853 h in Group B. Children with the requirement of one dose of rescue analgesia in Group A was 83.3% which was higher than Group B being 66.7%. Children with no analgesic requirement were 16.7% in Group A and 33.3% in Group B. The incidence of side effects was more in Group B (8 [26.7%] children with nausea and vomiting; 1 [3.3%] children with urinary retention) than in Group A (2 [6.6%] children with nausea and vomiting.

Conclusion

From the above observations, it can be concluded that morphine of less dosage (20 μg.kg-1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 μg.kg-1) as the duration of analgesia is similar with decreased incidence of side effects.

3D printing in orthopaedic surgery: a scoping review of randomized controlled trials

Aims

The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing.

Methods

A literature search was performed in PubMed, Embase, and Web of Science databases. The keywords used for the search criteria were ((3d print*) OR (rapid prototyp*) OR (additive manufactur*)) AND (orthopaedic). The inclusion criteria were: 1) use of 3D printing in orthopaedics, 2) randomized controlled trials, and 3) studies with participants/patients. Risk of bias was assessed with Cochrane Collaboration Tool and PEDro Score. Pooled analysis was performed.

Results

Overall, 21 studies were included in our study with a pooled total of 932 participants. Pooled analysis showed that operating time (p < 0.001), blood loss (p < 0.001), fluoroscopy times (p < 0.001), bone union time (p < 0.001), pain (p = 0.040), accuracy (p < 0.001), and functional scores (p < 0.001) were significantly improved with 3D printing compared to the control group. There were no significant differences in complications.

Conclusion

3D printing is a rapidly developing field in orthopaedics. Our findings show that 3D printing is advantageous in terms of operating time, blood loss, fluoroscopy times, bone union time, pain, accuracy, and function. The use of 3D printing did not increase the risk of complications.

Cite this article: Bone Joint Res 2021;10(12):807–819.

Long-term patient-reported outcomes for open surgery of the triangular fibrocartilage complex

Aims

Studies on long-term patient-reported outcomes after open surgery for triangular fibrocartilage complex (TFCC) are scarce. Surgeons and patients would benefit from self-reported outcome data on pain, function, complications, and satisfaction after this surgery to enhance shared decision-making. The aim of this study is to determine the long-term outcome of adults who had open surgery for the TFCC.

Methods

A prospective cohort study that included patients with open surgery for the TFCC between December 2011 and September 2015. In September 2020, we sent these patients an additional follow-up questionnaire, including the Patient-Rated Wrist Evaluation (PRWE), to score satisfaction, complications, pain, and function.

Results

A total of 113 patients were included in the analysis. At ≥ 60 months after an open TFCC reinsertion, we found a mean PRWE total score of 19 (SD 21), a mean PRWE pain score of 11 (SD 11), and a PRWE function score of 9 (SD 10). The percentage of patients obtaining minimum clinically important difference rose from 77% at 12 months to 83% at more than 60 months (p < 0.001). Patients reported fewer complications than surgeons, and overall complication rate was low.

Conclusion

Outcomes of patient-reported pain, function scores, and satisfaction are improved five years after open surgery for the TFCC.

Cite this article: Bone Jt Open 2021;2(11):981–987.

Pre-delivery angiogenic factors and their association with peripartum perceived stress and pain in pre-eclampsia with severe features and normotensive pregnancies

OBJECTIVE

To determine if any of maternal pre-delivery soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PIGF), or sFlt-1/PIGF ratio correlate with either perceived stress scale (PSS) or verbal numeric rating scale (VNRS) pain scores.

METHODS

Among 50 pregnant women with severe pre-eclampsia and 90 normotensive pregnant women observed from 48 h or less before delivery until day 3 postpartum, correlations between the following were performed: (1) serum concentrations of each angiogenic factor (sFlt-1, PIGF, and sFlt-1/PIGF ratio) sampled within 48 h before childbirth and a four-item PSS (pre-delivery and one-off 48-72 h postpartum score); (2) the same angiogenic factors above and VNRS ranging from 0 to 10; and (3) PSS and VNRS (both pre-delivery and postpartum).

RESULTS

In the normotensive group, there was a positive correlation between sFlt-1 and postpartum PSS (ρ +0.214 and P = 0.043), and between sFlt-1/PIGF ratio and postpartum PSS (ρ +0.213 and P = 0.044). In the normotensive and severe pre-eclampsia groups there were non-significant negative correlations between PIGF and postpartum PSS (P > 0.096) and non-significant positive correlations between pre-delivery PSS and pre-delivery VNRS (P > 0.053). Other correlations were uninformative.

CONCLUSION

Maternal pre-delivery sFlt-1/PIGF ratio in normotensive pregnancy is a promising biomarker for identifying risk of increased postpartum PSS to enable early counselling.

Effect of tranexamic acid in arthroscopic anterior cruciate ligament repair: A systematic review and meta-analysis of randomised clinical trials

PURPOSE

Perioperative blood loss remains a major challenge to surgeons in anterior cruciate ligament reconstruction (ACLR) surgery, despite of the introduction of minimally invasive approach. Tranexamic acid (TXA) is believed to reduce blood loss, which may minimise the complication of postoperative haemarthrosis with insufficient evidence on its effectiveness in ACLR. The primary aim of this study was to examine the effect of TXA on postoperative blood loss and other secondary outcomes in patients undergoing arthroscopic ACLR surgery.

METHOD

PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched from its inception until November 2020. All randomised clinical trials (RCTs) comparing TXA (intravenous or intra-articular) versus placebo in the arthroscopic ACLR surgery were included. Case series, case report and editorials were excluded.

RESULTS

Five RCTs comprising of a total of 580 patients (291 in TXA group, 289 in control group) were included for qualitative and quantitative meta-analysis. In comparison to placebo, TXA group was significantly associated with lower postoperative blood loss (mean difference (MD): -81.93 ml; 95% CI -141.80 to -22.05) and lower incidence of needing knee aspiration (odd ratio (OR): 0.19; 95% CI 0.08 to 0.44). Patients who randomised to TXA were also reported to have better range of movement (MD: 2.86; 95% CI 0.54 to 5.18), lower VAS Pain Score (MD: -1.39; 95% CI -2.54 to -0.25) and higher Lysholm Score (MD: 7.38; 95% CI 2.75 to 12.01).

CONCLUSION

In this meta-analysis, TXA reduced postoperative blood loss with lesser incidence of needing knee aspiration along with better range of knee movement and Lysholm score in patients undergoing arthroscopic ACLR surgery.

Comparing the efficacy and safety of Dexmedetomidine/Ketamine with Propofol/Fentanyl for sedation in colonoscopy patients: A double-blinded randomized clinical trial

BACKGROUND

In this double-blinded randomized clinical trial, we aimed to compare the safety and efficacy of a combination of dexmedetomidine and ketamine [DK] with propofol and fentanyl [PF] for sedation in colonoscopy patients.

METHODS

In this study, 64 patients who underwent colonoscopy were randomized into two groups: 1) A, which received PF, and 2) B, which received DK for sedation. Among 64 patients, 31 patients were included in PF, and 33 patients were included in the DK group. Both groups were similar in terms of demographics. Patients' sedation score (based on Ramsay sedation scale) and vital signs were recorded at 2, 5, 10, and 15 minutes. Complications including apnea, hypotension, hypoxia, nausea, and vomiting, along with gastroenterologist satisfaction and patients' pain score (based on Wong-Baker faces pain assessment scale), were recorded by a checklist. Data were analyzed by SPSS v.18 software, using chi-square, independent t-tests, and repeated measures analysis with p<0.05 as the criterion for significant differences.

RESULTS

The mean score of sedation was 4.82±0.49 in the DK group and 5.22±0.45 in the PF group [p value=0.001]. Serious complications, including hypotension [p value=0.005] and apnea [p value=0.10] were significantly higher in the PF group. Satisfaction of gastroenterologist [p value= 0.400] and patients' pain score [p value = 0.900] were similar among groups.

CONCLUSION

Combination of DK provides sufficient sedation with fewer complications in comparison with PF in colonoscopy patients.

Comparison of the efficacy of lotrafilcon B and comfilcon A silicone hydrogel bandage contact lenses after transepithelial photorefractive keratectomy

Background

At completion of transepithelial photorefractive keratectomy (t-PRK) surgery, the eye is usually fitted with a bandage contact lens to reduce discomfort and promote epithelial healing. This study aimed to compare the outcomes of eyes fitted with lotrafilcon B versus comfilcon A, silicone hydrogel bandage contact lenses after t-PRK for the correction of low to moderate myopia, with or without astigmatism.

Methods

In this comparative, prospective study, patients with myopia < -6 D with or without astigmatism (< 1.75 D), who underwent t-PRK between January and June 2018, were randomly allocated to the lotrafilcon B and comfilcon A groups. Preoperative characteristics, including age, sex, eye treated, uncorrected visual acuity (UCVA), best-corrected visual acuity, mesopic pupil size, central corneal thickness, and refractive error were recorded. Postoperatively, pain score, UCVA, and corneal epithelial defect size on days 1, 4, and 7 were compared between the two groups.

Results

Twenty-nine eyes were included in each group. Demographic characteristics and preoperative measurements were similar between the two groups. UCVA was significantly improved on day 7 as compared to day 1 in the comfilcon A group (P = 0.03), but remained the same in the lotrafilcon B group (P = 0.70) as on day 1 postoperatively. There was no significant difference in UCVA between the two groups at any follow-up visits (all P > 0.05). The pain score on the first postoperative day was significantly higher in the lotrafilcon B-fitted eyes than in the comfilcon A group (P < 0.001), but was significantly reduced in both groups compared to day 1 (both P < 0.001). The epithelial defect in the comfilcon A group was significantly greater than in the lotrafilcon B group (P < 0.001) at day 1 postoperatively, with significant improvement in both groups (both P < 0.001).

Conclusions

Healing responses were better with lotrafilcon B than with comfilcon A bandage contact lenses. The patients had a greater mean pain score with lotrafilcon B than with comfilcon A lenses on the first postoperative day, yet the final outcome was comparable between the two groups. We did not encounter any postoperative complications related to contact lens wear.

Acute Pain Management for Patients with Substance Use Disorder Receiving Buprenorphine or Methadone Compared to Patients without Opioid-Dependence Disorder

This single-center retrospective study assessed pain management between patients being treated for SUD and compared them to those without SUD who underwent orthopedic surgery. Patients with SUD could be admitted for any reason, while the control arm consisted of patients undergoing total knee arthroplasty or hip arthroplasty surgery. Primary endpoints were average pains scores and morphine milligram equivalents (MME) over the first 48h. Secondary endpoints include adjuvant pain medications and the average MME prescribed upon discharge. A total of the 60 patients were enrolled, 30 patients had history of SUD and 30 patients in the control arm. Average MME between the SUD and control was not significantly different (139.9 mg vs. 96.6 mg, p = 0.889). Average pain scores between the groups were significantly different (7.46 vs. 5.94, p = 0.002). Patients with SUD were not given a statistically different amount of MME for acute pain and experienced higher pain scores than patients without SUD. However, this study had a small population size, and further case-control studies are needed to confirm this result.

Pre-Hospital Pain Management in Children with Injuries: A Retrospective Cohort Study

Background: The all-too-frequent failure to rate pain intensity, resulting in the lack of or inadequacy of pain management, has long ceased to be an exclusive problem of the young patient, becoming a major public health concern. This study aimed to evaluate the methods used for reducing post-traumatic pain in children and the frequency of use of such methods. Additionally, the methods of pain assessment and the frequency of their application in this age group were analysed. Methods: A retrospective analysis of 2452 medical records of emergency medical teams dispatched to injured children aged 0–18 years in the area around Warsaw (Poland). Results: Of all injured children, 1% (20 out of 2432) had their pain intensity rated, and the only tool used for this assessment was the numeric rating scale (NRS). Children with burns most frequently received a single analgesic drug or cooling (56.2%), whereas the least frequently used method was multimodal treatment combining pharmacotherapy and cooling (13.5%). Toddlers constituted the largest percentage of patients who were provided with cooling (12%). Immobilisation was most commonly used in adolescents (29%) and school-age children (n = 186; 24%). Conclusions: Low frequency of pain assessment emphasises the need to provide better training in the use of various pain rating scales and protocols. What is more, non-pharmacological methods (cooling and immobilisation) used for reducing pain in injured children still remain underutilized.

A comparative study of epidural labor analgesia and natural delivery without analgesia

OBJECTIVE

To investigate the effects of epidural labor analgesia and natural delivery without analgesia on labor duration, pain, uterine continuous contraction time, abnormal labor process and complications.

METHODS

A total of 220 primiparas in our hospital were selected and divided into two groups according to whether they accepted epidural labor analgesia, including 146 cases in the study group and 74 cases in the blank group. Primiparas in the study group received epidural block analgesia, and those in the blank group received routine labor without analgesia. Duration of the first, second and third stages of labor was observed and recorded. The NRS pain score and uterine continuous contraction time were detected before and after the analgesia. The abnormal situation and complications of primiparas in the two groups were recorded.

RESULTS

Compared with those in the blank group, the duration of the first stage of labor and the amount of postpartum hemorrhage in the study group were decreased (all P<0.001). The primiparas' NRS score in the study group was lower than that in the blank group at 10 min, 15 min, 30 min, 60 min and 120 min after analgesia (all P<0.001). The duration of uterine contractions in the study group was lower than that in the blank group at 15 min, 30 min and 60 min after analgesia (all P<0.01). Compared with those in the blank group, primiparas in the study group had a higher probability of active phase arrest in the process of labor (P<0.05). Compared with the blank group, the probability of urinary retention in the study group increased (P<0.05).

CONCLUSION

The effect of epidural labor analgesia is better, which is conducive to shorten the time of the first stage of labor, good analgesic effect, shorter duration of the uterine contraction and higher safety.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook.

RESULTS

Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I²= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I² = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I² = 33%) did not differ between the groups. The quality of evidence was low or very low.

CONCLUSIONS

ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis

BACKGROUND

Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief.

METHODS

A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications.

RESULTS

Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups.

CONCLUSION

Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade.

LEVEL OF EVIDENCE

Level 1, randomized controlled trial.

A Comparison of Pain Scores in Dysmenorrheic Patients With or Without Dyspeptic Symptoms

Introductıon: Dysmenorrhea attacks may be accompanied by extragenital symptoms such as nausea, vomiting, diarrhea, headache and leg pain and by emotional symptoms such as tension and irritability. Therefore, we think that dysmenorrheic symptoms may be more severe in patients with dyspeptic symptoms. The purpose of this study was to determine whether pain scores would differ between dysmenorrheic patients with or without dyspeptic symptoms.

METHODS

Patients presenting to the emergency department with dysmenorrhea attacks and volunteering to participate were included in this case-control study. Subjects with dyspeptic symptoms were enrolled as the case group and those without dyspeptic symptoms were enrolled as the control group. Participants were administered the Faces Pain Scale and a questionnaire involving demographic characteristics.

RESULTS

Pain scores on arrival were higher in the case group than in the control group (4.20 ± 0.71, 3.70 ± 0.74, n=30, p=0.011). A significant difference was observed between pain scores on arrival and at discharge in both the control and case groups. A decrease in pain scores was determined in all the subjects in the case group, while no change was observed in three volunteers in the control group.

CONCLUSIONS

We conclude that pain is significantly more severe in dysmenorrheic patients with dyspeptic symptoms.

Effects of acupoint catgut embedding on the postmenopausal osteoporosis patients and related mechanism

OBJECTIVE

To study the effect and mechanism of acupoint catgut embedding on patients of postmenopausal osteoporosis (PMOP).

METHODS

In this prospective study, 90 patients with PMOP who received treatment in our hospital were randomly divided into the drug treatment group (n=45) and drug treatment + catgut embedding group (n=45) according to SPSS random table method. The drug treatment group was given conventional western medicine treatment, and the drug treatment + catgut embedding group was given point embedding therapy. Bone mineral density (BMD), calcium (Ca²⁺), osteoprotegerin (OPG), estrogen (E₂), receptor activator of nuclear factor-kB ligand (RANKL), liver and kidney function and blood lipids were detected before treatment in the two groups, and visual analogue score (VAS) and PMOP symptom score were evaluated. The above-mentioned indexes were detected again 3 months and 6 months after treatment.

RESULTS

At 3 and 6 months after treatment, the BMD and the levels of Ca²⁺ and E₂ in the two groups were increased, while the levels of OPG and RANKL were decreased, and the improvement in the drug treatment + catgut embedding group was significantly better than that in the drug treatment group (P<0.05). The symptom scores of VAS and PMOP in the drug treatment + catgut embedding group were significantly lower than those in the drug treatment group (all P<0.001). There was no significant difference in the levels of alanine aminotransferase (ALT), total bilirubin (TBil), albumin (ALB), blood urea nitrogen (BUN), serum creatinine (SCr) and serum uric acid (SUA) between the two groups, but the levels of total cholesterol (TC) and triglyceride (TG) in the drug treatment + catgut embedding group were significantly lower than those in the drug treatment group (all P<0.001).

CONCLUSION

Acupoint catgut embedding has a good effect on PMOP, and it can increase BMO and improve the clinical symptoms of patients, which is worthy of clinical promotion.

Transrectal ultrasound guided prostate biopsy in university of Benin teaching hospital: effect of prostate volume on pain amongst Nigerian patients

Prostate volume has been reported to have an effect on the severity of pain during prostate biopsy. This study assessed the effect of prostate volume on pain during TRUS guided prostate biopsy when apical peri-prostatic block is compared with intra-rectal xylocaine gel. This was a prospective randomized study which involved 90 patients. Group (A) had 2% intra-rectal plain xylocaine gel instillation, while Group (B) had peri-prostatic block with 1% plain xylocaine infiltration. Both groups were further stratified into prostate volume of < 50 mls and ≥50 mls. An 11 point visual analogue scale was used to assess pain during probe insertion, biopsy and 1 hour after biopsy. The mean pain score analyzed for each group. The mean pain score for Group (A) patients with prostate volume < 50 mls was 3.22.2, 7.31.7 and 2.11.4 during probe insertion, biopsy, and one hour after biopsy respectively. For Group (A) patients with prostate volume ≥50 mls, the mean pain score recorded was 2.81.8, 5.71.6, and 2.31.8 during probe insertion, biopsy and one hour after biopsy respectively (P{during biopsy} = 0.003). For Group B patients, the mean pain score during probe insertion, biopsy and one hour after biopsy for patients with prostate volume < 50 mls was 3.11.8, 2.81.7, 1.00.6 respectively. While for patients with prostate volumes ≥50 mls, the mean pain scores were 2.91.8, 3.21.8 and 1.30.9 respectively. This study revealed that prostate volume did not affect the severity of pain during prostate biopsy when apical peri-prostatic block was used as the anesthetic agent. Significantly reduced pain during trans-rectal ultrasound guided biopsy of the prostate for all prostate volumes. Intra-rectal xylocaine though inferior to peri-prostatic block was more effective for patients with prostate volume ≥50 mls.

Ultrasound guided central line insertion in neonates: Pain score results from a prospective study

BACKGROUND

Central lines can be placed through different techniques, either peripherally or centrally. Although they have the same aim, decision to use one of these modalities depends on the patient outcomes. The aim is to compare pain scores between ultrasound-guided central line insertion and peripherally inserted catheter in neonates in a prospective randomized single center study.

METHODS

A randomized controlled trial was conducted in neonates requiring central venous access for any of the following reasons: total parenteral nutrition (TPN), antibiotics treatment for at least 7 days and having poor or difficult venous access. The study compared pain difference, in neonates, that were randomized between peripherally and ultra-sound guided centrally placed central lines using the validated pain score N - PASS.

RESULTS

61 neonates were enrolled in the study. US-guided CICC was associated with less pain as reported by the statistically significant lower pain score difference (p-value <0.001) than the standard PICC. Additionally, the US-guided CICC had a higher rate of successful first attempt (p = 0.012), lower overall number of attempts (p < 0.001), and shorter procedure duration (p < 0.001) as compared to standard PICC.

CONCLUSION

US-guided CICC is a less painful technique than PICC line insertion associated with higher rate of successful first attempt, lower overall number of attempts and shorter procedure duration.

An investigation of the effects of dexmedetomidine and fentanyl as an adjuvant to ropivacaine on pain scores and hemodynamic changes following laparoscopic cholecystectomy

Postoperative pain control is recognized as a challenging surgical issue receiving high priority in the healthcare system, and opioids are routinely prescribed for anesthesia and pain relief. This study aimed to investigate the effects of ropivacaine administered intraperitoneally alone or combined with dexmedetomidine or fentanyl on postoperative pain control following laparoscopic cholecystectomy. This randomized double-blind clinical trial recruited three equal-size block-randomized groups of patients (n = 138) scheduled for elective laparoscopic cholecystectomy at Valiasr Hospital, Arak, Iran, in 2019–2020 who received ropivacaine (40 mL/0.5%), ropivacaine (40 mL/0.5%) + dexmedetomidine (1 μg/kg), and ropivacaine (40 mL/0.5%) + fentanyl (1 μg/kg). No significant differences were observed among the three groups according to the vital signs (mean arterial pressure/heart-rate/oxygen saturation) in the study period and during surgery (P > 0.05). Lower pain was revealed in the ropivacaine + dexmedetomidine group (P = 0.001), with the lowest opioid dose in postoperative 24 hours (P = 0.001). Moreover, no clinically significant differences were observed in complications among the three groups (P = 0.483), and no patient developed ileus. Intraperitoneal ropivacaine administered with dexmedetomidine could relieve pain and reduce opioid use in postoperative 24 hours, without any complication and ileus. Therefore, intraperitoneal ropivacaine administered with dexmedetomidine is recommended for postoperative pain control in patients undergoing laparoscopic cholecystectomy. This study was approved by the Ethical Committee of Arak University of Medical Sciences (approval No. IR.ARAKMU.REC.1397.267) on December 30, 2018 and was registered in the Iranian Registry of Clinical Trials (No. IRCT 20141209020258N117) on July 13, 2019.

Aqueous Chlorhexidine Compared with Povidone-Iodine as Ocular Antisepsis before Intravitreal Injection: A Randomized Clinical Trial

PURPOSE

Topical povidone-iodine (PI) is widely used as an ocular surface antiseptic for intravitreal injections (IVIs). Although PI is generally well tolerated, it can be associated with significant ocular irritation. Aqueous chlorhexidine (AqCHX) has been described as a possibly better tolerated antimicrobial for ophthalmic procedures. We compared patient pain scores, ocular surface characteristics, and antimicrobial efficacy between PI 5% and AqCHX 0.1% during IVIs.

DESIGN

Prospective single-center, randomized clinical trial.

PARTICIPANTS

Patients receiving same-day bilateral intravitreal anti-vascular endothelial growth factor (VEGF) injections.

METHODS

Each patient had 1 eye randomized to PI or AqCHX, and the second eye received the other agent. Both eyes received topical proparacaine 0.5%.

MAIN OUTCOME MEASURES

After IVIs, participants rated their pain (Wong-Baker, scale 0-10) for each eye 1 minute after PI or AqCHX instillation and 1 day after the procedure. Each eye was assessed using a standardized quantitative grading system of corneal epitheliopathy (ocular staining score). Microbial swab cultures of the conjunctiva both before instillation of topical antisepsis and 10 minutes after IVIs were given.

RESULTS

A total of 100 eyes of 50 patients were included. The mean patient age was 68 years (range, 39-92), and 30 of 50 (60%) were male. Compared with AqCHX, eyes receiving PI had a greater mean pain score immediately after injection (1.44 vs. 0.44, P < 0.001) but not on postprocedure day 1 (1.04 vs. 0.48, P = 0.06). Eyes that received PI had a higher ocular staining score indicating worse corneal epitheliopathy (4.22 vs. 3.10, P < 0.001). There was no difference in rates of positive microbial cultures between groups. There was no difference in rates of adverse events between groups (P = 0.99), and no cases of endophthalmitis occurred.

CONCLUSIONS

Povidone-iodine demonstrated greater ocular surface discomfort and corneal epitheliopathy compared with AqCHX during same-day bilateral IVIs. The 2 agents otherwise demonstrated no difference in positive microbial cultures or adverse events. Aqueous chlorhexidine may be a better tolerated alternative to PI for antimicrobial prophylaxis during IVIs for some patients.

Histone Deacetylase Inhibitors Prevented the Development of Morphine Tolerance by Decreasing IL6 Production and Upregulating μ-Opioid Receptors

BACKGROUND

Morphine tolerance on long-term usage leads to chronic pain conditions. Preclinical studies demonstrated that the upregulation of HDACs is associated with a decrease in the sensitivity of μ-opioid receptors, which results in morphine tolerance.

OBJECTIVE

The present study was designed to assess the influence of the selected known HDAC inhibitors (NMJ2 and NMJ3) on the pain tolerance induced by chronic administration of morphine in Balb/c mice.

METHODS

In the present study, morphine was administered in incremental doses 1, 2, 3.6, 6.5, 11.2, 21, and 21 mg/kg daily for seven days to develop morphine tolerance. The nociceptive thresholds, analgesia, and tolerance were assessed 30 min after morphine administration alternatively from 1st day to 7th day using the hot plate and mechanical allodynia methods.

RESULTS

The morphine control group showed a reduction in the Paw Withdrawal Threshold (PWT) and the percentage Maximum Possible Effects (MPEs). In contrast, the combination of SAHA and test drugs with morphine increased the PWT and MPEs as compared to the morphine alone group. Administration of morphine alone also showed an increase in the production of the pro-inflammatory mediator, IL-6, and down-regulation of the μ-opioid receptor in the brain tissues. Treatment with HDAC inhibitors, SAHA, and test drugs showed a reversal in these changes.

CONCLUSION

Results indicated that HDAC inhibitors were involved in the prevention of morphine tolerance in normal mice by inhibiting pro-inflammatory marker production and by increasing the sensitivity of neurons towards morphine in producing an analgesic effect in morphine tolerated mice.

Postoperative Pain Scores After Open Inguinal Hernia Repair: Comparison of Three Postoperative Analgesic Regimens

INTRODUCTION

Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis.

AIM

The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair.

METHODS

A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation.

RESULTS

The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001).

CONCLUSION

The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.

Robotic surgery enables safe and comfortable single-incision cholecystectomy: A comparison of robotic and laparoscopic approaches for single-incision surgery

Background:

Although single-incision robotic cholecystectomy (SIRC) overcomes various limitations of single-incision laparoscopic cholecystectomy (SILC), it is associated with high cost. In this study, we intended to investigate if SIRC is recommendable and advantageous to patients despite its high cost.

Materials and Methods:

We prospectively collected and analysed data of patients who had undergone either SILC (n = 25) or SIRC (n = 50) for benign gallbladder diseases, with identical inclusion criteria, between November 2017 and February 2019.

Results:

SILC and SIRC showed similar operative outcomes in terms of intra- and post-operative complications and verbal numerical rating scale (VNRS) for pain. However, the SIRC group exhibited significantly longer operation time than the SILC group (83.2 ± 32.6 vs. 66.4 ± 32.8, P = 0.002). The SIRC group also showed longer hospital stay (2.4 ± 0.7 vs. 2.2 ± 0.6, P = 0.053). Although the SILC and SIRC groups showed no significant difference in VNRS, the SIRC group required a higher amount (126.0 ± 88.8 mg vs. 87.5 ± 79.7 mg, P = 0.063) and frequency (3.0 ± 2.1 vs. 2.0 ± 1.8, P = 0.033) of intravenous opioid analgesic administration. During surgery, the critical view of safety (CVS), the prerequisite for safe cholecystectomy, was identified in only 24% (n = 6) of patients undergoing SILC and in 100% (n = 50) of patients undergoing SIRC (P < 0.05).

Conclusion:

We conclude that although SILC and SIRC have similar operative outcomes, SIRC is advantageous over SILC because of its potential to markedly enhance the safety of patients by proficiently acquiring CVS.

Treatment effect of oil-based contrast is related to experienced pain at HSG: a post-hoc analysis of the randomised H2Oil study

STUDY QUESTION

Does pain or volume of used contrast medium impact the effectiveness of oil-based contrast during hysterosalpingography (HSG)?

SUMMARY ANSWER

In women who report moderate to severe pain during HSG, the use of oil-based contrast resulted in more ongoing pregnancies compared to the use of water-based contrast, whereas in women who reported mild or no pain, no difference in ongoing pregnancies was found.

WHAT IS KNOWN ALREADY

We recently showed that in infertile women undergoing HSG, the use of oil-based contrast results in more ongoing pregnancies within 6 months as compared to the use of water-based contrast. However, the underlying mechanism of this fertility-enhancing effect remains unclear.

STUDY DESIGN, SIZE, DURATION

We performed a post-hoc analysis of the H2Oil study, a multicentre randomised controlled trial (RCT) evaluating the therapeutic effect of oil- and water-based contrast at HSG. Here, we evaluated the impact of pain experienced at HSG and volume of used contrast media during HSG on ongoing pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In a subset of 400 participating women, pain during HSG by means of the Visual Analogue Scale (VAS) (range: 0.0–10.0 cm) was reported, while in 512 women, we registered the volume of used contrast (in millilitres). We used logistic regression analyses to assess whether pain and volume of used contrast media modified the effect of oil-based contrast on ongoing pregnancy rates. Data were analysed according to intention-to-treat principle.

MAIN RESULTS AND THE ROLE OF CHANCE

In 400 women in whom pain scores were reported, the overall median pain score was 5.0 (Interquartile range (IQR) 3.0–6.8) (oil group (n = 199) 4.8 (IQR 3.0–6.4); water group (n = 201) 5.0 (IQR 3.0–6.7); P-value 0.28). There was a significant interaction between pain (VAS ≤5 versus VAS ≥6) and the primary outcome ongoing pregnancy (P-value 0.047). In women experiencing pain (VAS ≥6), HSG with oil-based contrast resulted in better 6-month ongoing pregnancy rates compared to HSG with water-based contrast (49.4% versus 29.6%; RR 1.7; 95% CI, 1.1–2.5), while in women with a pain score ≤5, 6-month ongoing pregnancy rates were not significantly different between the use of oil- (28.8%) versus water-based contrast (29.2%) (RR 0.99; 95% CI, 0.66–1.5). In the 512 women in whom we recorded contrast, median volume was 9.0 ml (IQR 5.7–15.0) in the oil group versus 8.0 ml (IQR 5.9–13.0) in the water group, respectively (P-value 0.72). Volume of used contrast was not found to modify the effect of oil-based contrast on ongoing pregnancy (P-value for interaction 0.23).

LIMITATIONS, REASONS FOR CAUTION

This was a post-hoc analysis that should be considered as hypothesis generating. The RCT was restricted to infertile ovulatory women, younger than 39 years of age and with a low risk for tubal pathology. Therefore, our results should not be generalised to infertile women who do not share these features.

WIDER IMPLICATIONS OF THE FINDINGS

The underlying mechanism of the fertility-enhancing effect induced by HSG with the use of oil-based contrast remains unclear. However, these findings suggest a possible mechanistic pathway, that is increasing intrauterine pressure occurring prior to dislodging pregnancy hindering debris or mucus plugs from the proximal part of otherwise normal fallopian tubes. This information might help in the search of the underlying fertility-enhancing mechanism found by using oil-based contrast during HSG.

STUDY FUNDING/COMPETING INTEREST(S)

The original H2Oil RCT was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports consultancy for Guerbet. H.V. reports consultancy fees from Ferring. C.B.L. reports speakers’ fees from Ferring and research grants from Ferring, Merck and Guerbet. V.M. reports receiving travel and speakers fees as well as research grants from Guerbet. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research grants from Merck KGaA and Guerbet. The other authors do not report conflict of interests.

TRIAL REGISTRATION NUMBER

The H2Oil study was registered at the Netherlands Trial Registry (NTR 3270).

TRIAL REGISTRATION DATE

1 February 2012.

DATE OF FIRST PATIENT’S ENROLMENT

3 February 2012.

Analgesic effect of extracorporeal shock-wave therapy for frozen shoulder: A randomized controlled trial protocol

BACKGROUND

Till date only a few studies have reported the efficacy and clinical improvements obtained by extracorporeal shock-wave therapy (ESWT) on frozen shoulder. Limited by small number of studies and insufficient outcomes, it is important and necessary to conduct a new randomized controlled trial. The purpose of the present study is to determine whether ESWT could be more effective than oral steroid in treatment of frozen shoulder.

METHODS

This randomized, single-blind, superiority clinical trial was approved by the institutional review board in The Third People's Hospital of Linyi. The inclusion criteria were patients aged >18 years with shoulder pain and restriction in range of motion. A symptom duration >3 months was required, with no radiographic findings on anteroposterior shoulder plain radiographs except for osteoporosis. Group 1 patients were given 30 mg of oral prednisolone daily for 2 weeks as a single morning dose and then 15 mg daily for another 2 weeks. Group 2 patients received 3 sessions of ESWT on the first, 14th, and 28th days. The primary outcome measure was shoulder pain score. The secondary outcomes included Disabilities of the Arm, Shoulder, and Hand score, range of motion, satisfaction rate, and complications.

RESULTS

It was hypothesized that there would be a significant difference between ESWT and control groups in improving shoulder pain and functions in frozen shoulder.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5736).

Comparison of preoperative versus postoperative transversus abdominis plane and rectus sheath block in patients undergoing minimally invasive colorectal surgery

AIM

Ultrasound-guided transversus abdominis plane and rectus sheath block (TAPRSB) decreases pain scores and narcotic use postoperatively after colorectal surgery (CRS). It is unclear if the effectiveness of TAPRSB varies according to whether it is performed preoperatively or postoperatively. Our aim was to investigate this.

METHOD

We compared patients who underwent preoperative TAPRSB or postoperative TAPRSB during minimally invasive CRS. Primary end-points were pain scores and oral morphine milligram equivalent (MME) use postoperatively. Secondary end-points included perioperative factors affecting pain scores and postoperative MME. Summary statistics and univariate analysis by nonparametric tests were utilized. The mixed-effect model was applied to model the repeatedly measured pain score.

RESULTS

From April 2015 until May 2018 168 patients received TAPRSB before (115) or after (53) minimally invasive CRS. The cohort included 79 (47.0%) women, and had an average age of 59.11 (±12.32) years and mean body mass index of 28.32 (±5.82) kg/m² . Indication for surgery was cancer in 66 (39.3%), polyp in 43 (25.6%) and diverticulitis in 43 (25.6%). Right colectomy was performed in 61 (36.3%), low anterior resection in 46 (27.4%) and sigmoid colectomy in 40 (23.8%) patients. The demographics of the groups were similar. Postoperative TAPRSB was only associated with lower pain scores at 12 h postoperatively. As secondary outcomes, average pain scores and MME were lower in patients who were older, had right colectomy or intracorporeal anastomosis.

CONCLUSIONS

Postoperative TAPRSB resulted in lower pain scores than preoperative TAPRSB 12 h after minimally invasive CRS, but otherwise no differences were seen in pain scores or MME use.

Postoperative Pain Management in Emergency Surgeries: A One-year Survey on Perception and Satisfaction among Surgical Patients

Background:

Postoperative pain varies from an individual to individual. It also varies with types and extent of surgery. In general, postoperative pain is inadequately managed in most centers worldwide, especially in developing countries. Therefore, this study presents the perception and satisfaction of postoperative pain management in emergency surgeries.

Methods:

A 1-year prospective study of the 891 patients who underwent emergency general surgeries at Ahmadu Bello University Teaching Hospital, from January to December 2018 is hereby presented. Pain scores and patient's satisfaction toward postoperative pain management were considered at 8 and 24 h postoperatively through a predesigned questionnaire. Numeric Pain Rating Scale was used to determine pain intensity and the level of satisfaction following postoperative pain management. Student's t-test was used to compare the pain scores and patient's level of satisfaction of the postoperative pain management.

Results:

A total of 891 patients were recruited for this study, with a mean age of 36.4 ± 8.9 years with a male-to-female ratio of 1.3:1. Postoperative pain management satisfaction score for patients (98%) who had pain 8-h postoperative period was 4.8 ± 1.6. Similarly, 96.4% of the patients who had pain 24 h postoperatively scored 2.8 ± 1.7. Majority of the patients 481 (54%) were of the American Society of Anesthesiologist physical Class II. Most of the patients underwent general surgery using the technique of general anesthesia.

Conclusion:

This study indicated that the perception and level of patient's satisfaction regarding postoperative pain management are inadequate. The health professionals and policy makers should be aware that postoperative pain management is suboptimal, as patients still have severe postoperative pain. Therefore, the need for improved postoperative pain management.