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Introduction: Numerous studies show that the prevalence of pain in pre-hospital emergency setting ranges from 20% to 53%. Additionally, the scientific literature reveals a prevalence of moderate-to-severe pain in 20-64% of patients. According to the latest guidelines, it is essential to ensure proper and effective pain management for all patients experiencing pain. Inadequate pain management can result in complications such as delayed recovery and increased patient distress. In pre-hospital setting, emergency nurses are capable of assessing and treating pain using medications such as fentanyl, ketamine, morphine, NSAIDs and paracetamol. Objective: To evaluate the assessment and treatment of pain by emergency nurses in the pre-hospital setting and assess the potential need for additional training in accordance with the Tuscany region for nurse-staffed ambulances’ analgesia procedure guidelines. Methods: Retrospective study of 4,738 pre-hospital interventions from September 2022 to September 2023. Data were retrieved from EmMaWeb system and included pain assessment using the Numeric Rating Scale (NRS) and administration of analgesics. Results: Pain was assessed at least once in 98.3% of the cases. Moderate to severe pain (NRS ≥ 4) was recorded in 14.2% of the patients. Analgesic drugs were administered in 63.6% of patients with NRS ≥ 4, yet the Tuscany region for nurse-staffed ambulances’ analgesia procedure guidelines was not followed in 36.4% of these cases. 79% of the findings with NRS ≥ 7 (severe pain) received analgesic drug treatment. Paracetamol was the most commonly used analgesic, followed by fentanyl, morphine, and ketamine. Conclusions: Pain assessment practices are well-established in pre-hospital care, but there is still room for improvement in pain management. Pain management does not comply with the Guidelines set by the World Health Organisation and the European Society of Emergency Medicine, a substantial proportion of patients experiencing moderate to severe pain did not receive adequate analgesia. This highlights the need for additional education and training for pre-hospital nurses in pain management and the effective use of analgesic medications to ensure greater adherence to the treatment protocols for nurse-staffed ambulance shared within the Tuscany Region.

Liza Grosman-Rimon,1 Linda Jorgoni,1 Jane Casey,2 Susan Tory,1 Dinesh Kumbhare,3 Jhanvi Solanki,1 Barbara E Collins,1 Pete Wegier1,4 1Humber River Health, Research Institute, Toronto, Canada; 2Tampa General Hospital, Tampa, FL, USA; 3Department of Medicine, Division of Physical Medicine and Rehabilitation, University Health Network, Toronto, Canada; 4University of Toronto, Institute of Health Policy, Management and Evaluation University of Toronto, Toronto, CanadaCorrespondence: Liza Grosman-Rimon, Humber River Health, 235 Wilson Ave, North York, Toronto, ON, M3M 0B2, Canada, Tel +1416-242-82109, Email l.grosman@hrh.caIntroduction: In the last decade, clinical alert systems were developed for clinical use, including patient deterioration and other urgent clinical situations. However, investigations focusing on digital pain alert systems to assess and manage pain on time in in-hospital patients are scarce. The objective of the study was to assess the implementation of digital pain alerts in the various departments of a community hospital.Methods: Administrative data from the year 2020 to 2023 were collected. Only data from cases when pain alert was activated were included. Data included pain alert activation frequency, pain alert response duration (time from pain alert activation to alert stop when medication was administered), the department from which the pain alert was activated.Results: There was a steady significant decrease in the mean pain alert response duration over time from 2020 to 2023. The department with the shortest pain alert response duration was the Department of Surgery, and Cardiology (252.76 ± 4.712). The longest time delay was in the ICU (463.27± 2.73 min) and at the Mental Health Department (440.59± 5.46 min) (p < 0.01). The pain alert response duration gradually decreased from 2020 to 2023, with decreases from the first year in all of the units/departments, except for the ICU. NPS scores at the start of the alert to 30 minutes after alert stop decreased significantly.Conclusion: Management of pain improved over time across the hospital, and in most of the departments, suggesting that with experience, digital pain alert systems have the potential to improve pain management by providing timely pain intervention.Keywords: digital pain alert, community hospital, pain management, command centre

Abstract Introduction Intraoperative analgesia and sedation are closely related to postoperative delirium. Depth of sedation based on bispectral index (BIS) guidance has been shown to reduce the occurrence of postoperative delirium (POD). However, the correlation between intraoperative analgesia levels and POD is unclear. The aim of this study was to investigate the effect of intraoperative analgesic management guided by the nociceptive stimulus index (NOX) on postoperative delirium. Methods In this prospective single-center randomized controlled study, elderly patients aged 65 and above, who are scheduled to undergo unilateral total knee arthroplasty (TKA), were allocated into two groups: the routine monitoring group (group R), which solely monitored patient sedation levels using BIS; and the NOX monitoring group (group N), which monitored patient analgesic levels using NOX based on BIS-monitored sedation levels. The primary outcome was the incidence of postoperative delirium within 3 days after surgery, using the confusion assessment method (CAM). Results From May 2022 to December 2022, a total of 240 patients were randomized; 12 were excluded because of failure to meet experimental conditions or were lost to follow-up. Patients in group N had a lower incidence rate (%) of POD on the first day compared to those in group R (8 (7%) vs 18 (16%), P = 0.041). The dosage of remifentanil administered in group N was significantly higher than that in group R (927.07 ± 268.09 vs 882.32 ± 187.91 mg, P = 0.002). Conclusions Appropriate intraoperative analgesia guided by NOX is associated with POD. When sedation levels were consistent, the incidence of POD was significantly reduced in older patients with NOX-guided analgesic management during unilateral TKA surgery.

Abstract Background Uterine fibroid embolization can be associated with significant pain due to fibroid ischemia and interventions of the procedure itself. Fentanyl and midazolam are commonly provided for sedation and pain relief, but are not tolerated by all patients. This report outlines a novel pain management strategy for uterine fibroid embolization in a patient who could not receive either opioids or benzodiazepines. Methods A 51 year old woman presenting with menorrhagia due to uterine fibroids was referred to interventional radiology for embolization. She was allergic to most opiates and had previously become agitated with IV midazolam, resulting in termination of a previous attempt at embolization. Thus, a combination of three analgesic modalities was used: intraarterial ropivacaine in the uterine arteries, superior hypogastric nerve block with ropivacaine, and intravenous acetaminophen. The patient underwent successful embolization and reported only intermittent pain of 1–2 out of 10 intensity. Discussion This combined analgesic cocktail represents a novel alternative to traditional sedation for uterine fibroid embolization and may serve as a viable option for patients with similar contraindications.

Abstract Background Multidisciplinary programs are the first recommendation for non-specific chronic low-back pain, but implementing this type of program is complicated to get up and running. The primary aim of this study was to assess the feasibility and appropriateness of the PAINDOC multidisciplinary program for subjects with chronic low-back pain. The secondary objectives were to evaluate the decrease in pain intensity, pain-related disability and pain catastrophizing, as well as the improvement in quality of life with this program. Furthermore, another of the secondary objectives was to calculate the sample size for a future randomized clinical trial. Methods This study was conducted in a hospital pain unit using two successive recruitment waves. First, the feasibility outcomes (recruitment, completion, and drop-out rates) of a 5-month non-random prospective cohort (n = 227) were recorded. Then, the clinical outcomes (pain intensity, quality of life, disability, and pain catastrophizing) were recorded from a prospective, controlled, two-armed and single-blind feasibility study (ClinicalTrials.gov, NCT05974072). It included 41 participants that were randomly allocated to either the pharmacological treatment (n = 21) arm or PAINDOC program (n = 20) arm. Results The recruitment rate was 66%, with the completion rate standing at 80.7% and the drop-out rate at 19.3%. Significant differences and a medium size effect were observed between groups in terms of pain intensity (p = .017, r = .408) at the 4-month follow-up. The intragroup analysis of the PAINDOC group revealed significant lessening in pain intensity (p =

Abstract This study aimed to investigate the effect of cervical length on procedure time and VAS pain scores during office hysteroscopy. A cross-sectional study was conducted on 50 patients who underwent office hysteroscopy for various indications such as abnormal uterine bleeding and infertility. Exclusion criteria included active vaginal infection, previous cervical surgery, and chronic pelvic pain. Cervical length was measured via transvaginal ultrasound prior to the procedure. Procedure time and VAS pain scores were recorded and analyzed. Patients with a retroverted uterus had higher post-procedure VAS scores (7.6 ± 0.8) compared to those with an anteverted uterus (4.9 ± 1.9, p

Abstract Introduction Chronic pain negatively impacts on quality of life and is often underreported and undertreated. Therefore, it is essential for medical schools to provide education in pain management for students. This study evaluated the current state of pain education in the Portuguese medical schools, focusing on integrating pain-related topics into the curriculum. Methods A cross-sectional study was employed, involving all the eight public medicals schools in Portugal. The study, approved by the Ethics Committee of the Faculty of Medicine of the University of Porto, utilized a previous validated questionnaire sent via electronic mail. The data collection spanned from January 2023 to October 2023, and responses were analysed using the SPSS software for descriptive statistics. Results All eight public medical schools responded to the questionnaire, providing insights into their pain education practices. Over the six years of medical education, 50% of the schools offered dedicated course content on chronic pain within the curriculum. This instruction is primarily provided in the second year, with variations in the hours for both theoretical and practical teaching. Additionally, 62.5% integrate pain-related topics into other discipline-based courses, predominantly in the fourth year. Post-graduate pain education activities were reported in only three of the eight schools (37.5%). Conclusions These findings represent the first analysis of pain education in public Portuguese Medical Schools. The findings indicate that enhancements in pain education through the introduction of mandatory pain topics, curriculum integration, and investment in post-graduation courses are needed. These improvements aim to provide medical students the essential knowledge and skills to proficiently manage the intricate challenges of chronic pain, thereby enhancing patients’ quality of life and reducing social burdens.

Background: Inadequate management of acute post-haemorrhoidectomy pain is a major concern. Optimal pain management is necessary to reduce acute postoperative pain and improve care quality. Therefore, we investigated the efficacy of postoperative pudendal nerve block (PNB) in reducing acute post-haemorrhoidectomy pain in Asian individuals. Methods: This retrospective cohort study analysed 108 adult patients with grade 3 haemorrhoids. Patients with anorectal cancer were excluded from this study. Among the 108 patients, 79 and 29 received spinal anaesthesia (SA) with PNB (SAPNB) and SA alone, respectively. Propensity score matching and inverse probability of treatment weighting were performed to adjust for the effects of confounders. Results: Patients receiving SAPNB had significantly lower postoperative pain scores 6, 12, and 18 h after haemorrhoidectomy but significantly higher postoperative pain scores 24 and 48 h after haemorrhoidectomy than did patients receiving SA alone. PNB, older age, female sex, reduced operation time, and absence of cardiovascular disease reduced the risk of moderate to severe postoperative pain. Only the addition of PNB was consistently associated with a reduced risk of moderate to severe pain 6, 12, and 18 h after haemorrhoidectomy. Patients receiving SAPNB had significantly lower risks of perianal swelling and urinary retention but a significantly higher risk of nausea than did those receiving SA alone. The two groups exhibited similarity in their rates of postoperative readmission because of poor pain management and their lengths of stay upon readmission. Conclusion: The addition of PNB to SA may effectively reduce acute post-haemorrhoidectomy pain.

Abstract Background The ongoing opioid epidemic in the United States has reinforced the need to provide multimodal and non-opioid pain management interventions. The PAMI-ED ALT program employed a multifaceted approach in the Emergency Department (ED) developing electronic health record (EHR) pain management order panels and discharge panels, as well as educating patients, clinicians, and ED staff on opioid alternatives, including non-pharmacologic interventions. The primary objective of this analysis was to compare changes in opioid and non-opioid analgesic administrations and prescribing in ED patients with select pain conditions (renal colic, headache, low back, and non-low back musculoskeletal pain) before and after implementation of PAMI ED-ALT. Secondary outcomes included characterizing changes in 30-day ED all-cause recidivism and hospital all-cause admissions within these pain populations. Methods Demographics, opioid and opioid alternative utilization, hospital admission, 30-day ED returns and change in pain intensity score were collected from January 2019-March 2020 (pre-program implementation) and January 2021-March 2023 (post-program implementation) for both the ED aggregate and program target pain populations. Results Pain management order panel utilization increased throughout the post-implementation period. When comparing pre to post program data, there was a reduction in opioid administrations and prescriptions for most of the target pain conditions, as well as within the ED aggregate population. Opioid alternative administrations and prescriptions increased for all pain conditions except renal colic. Hospital admissions decreased significantly amongst those with low back pain and headache/migraine and 30-day ED returns significantly declined in those with musculoskeletal pain. Conclusion Our findings demonstrate an opioid-alternatives program implemented within a safety-net hospital system serving a predominantly socially disadvantaged patient population can lead to changes in ED pain management and potentially reduce 30-day ED recidivism and hospitalizations.

Abstract Background Trigeminal neuralgia (TN) is a prevalent and debilitating craniofacial pain disorder characterized by severe, unilateral, shock-like pain. Standard treatments include anti-epileptic drugs and surgical interventions, but many patients experience limited relief or adverse effects. Non-invasive therapies, such as transcutaneous electrical nerve stimulation (TENS), have emerged as alternative options. This systematic review and meta-analysis aimed to evaluate the efficacy of TENS in managing primary trigeminal neuralgia. Methods A comprehensive search of PubMed, Cochrane Library, and Google Scholar was conducted, yielding 89 papers. Following selection criteria, five clinical trials involving 101 patients with primary TN and TENS treatment were included. Data on pain severity, TENS parameters, and outcomes were extracted. Statistical analysis was performed using RevMan software, with outcomes assessed using Visual Analogue Scale (VAS) scores before and after TENS treatment. Results Pre-treatment VAS scores averaged 8.75 ± 0.18, indicating severe pain. Post-treatment, the mean VAS score significantly decreased to 1.17 ± 0.55, demonstrating substantial pain relief. The meta-analysis revealed a mean difference of 7.49 (95% CI: 7.05 to 7.93) in VAS scores, with a p-value

Abstract Background Postoperative pain remains a significant problem in patients undergoing donor nephrectomy despite reduced tissue trauma following laparoscopic living donor nephrectomy (LLDN). Inadequately treated pain leads to physiological and psychological consequences, including chronic neuropathic pain. Materials and methods This randomized controlled double-blinded trial was conducted in sixty-nine (n = 69) participants who underwent LLDN under general anesthesia. Participants were randomized into Group B (n = 34) and Group C (n = 35). Group B received ultrasound-guided bilateral erector spinae plane block (ESPB) with bupivacaine 0.125% 20 ml on the surgical side and 10 ml on the contralateral side before extubation, while Group C received wound infiltration with bupivacaine 0.125% 15 ml. The primary objective of the study was to compare cumulative 24-hour morphine consumption postoperatively. The secondary objectives were time to first rescue analgesia, visual numeric rating scale (VNRS) pain scores at rest and during movement, incidence of postoperative nausea and vomiting (PONV), and complications associated with ESPB. Results Participants in Group B required significantly less median (IQR) 24-hour morphine compared to Group C [6 (6–9) mg vs. 15 (12–15) mg; median difference 9; 95% CI in median difference 6–12; p

Kyphoplasty is a minimally invasive surgical procedure of the spine used to treat osteoporotic vertebral fractures that commonly affect the elderly, postmenopausal women, and patients with osteoporotic bone disease. Prolonged immobility in these patients often results in multiple comorbidities. Anesthetic modalities that have been used in kyphoplasty include general anesthesia, monitored anesthesia care, lumbar spinal anesthesia, and interfacial plane blocks, each with its advantages and disadvantages. This study examines thoracic segmental spinal anesthesia (TSSA) as an innovative anesthetic modality in treating kyphoplasty. This study investigates the case of four patients undergoing L1 kyphoplasty to evaluate its safety and efficacy. TSSA was performed at the T11–T12 interspace, and 1.5 mL of 0.5% heavy bupivacaine with 60 μg of buprenorphine was injected. The patients were positioned in a prone position after achieving the desired block level. Blood pressure, pulse, oxygen saturation, and respiratory rate were monitored throughout the procedure. Postoperative pain was assessed using the visual analog scale. Any adverse events were documented. Assessment of the results demonstrated significant perioperative benefits, including stable hemodynamics, enhanced analgesia, and early motor recovery. None of the patients complained of pain or discomfort during the procedure, and there were no instances of hypotension, bradycardia, or respiratory depression. Thus, TSSA was found to be a safe and viable anesthetic option for kyphoplasty. Our preliminary findings indicate that TSSA combined with minimal sedation can improve patient outcomes and enhance perioperative pain management. More research is needed to validate its broader application in spinal surgery.

Introduction: One of the most common reasons for visiting dental clinics is dental pain. Seeking timely and professional dental care is a crucial step to maintain good oral health. Aims: The aim of the present study was to explore the prevalence of acute dental pain, the different management methods, and the use and practicality of teledentistry and online dental consultations among the population of Taif, Saudi Arabia. Materials and Methods: A total of 556 adults were enrolled in the study by answering an online survey that was distributed through different social media websites. Data were collected on the type of dental pain, pain-related characteristics using the Modified Dental Pain Screening Questionnaire, self-and formal care methods for pain relief, and the utilization of teledentistry services. Data analysis was performed using descriptive statistics, the Chi-square test, and the logistic regression model. Results and Discussion: Of the 556 participants, approximately 68% reported having dental pain, and almost 39% reported that the pain originated from a tooth. In addition, 73.2% reported that the pain was exacerbated after eating/drinking something cold. Regarding self-care methods, prescribed drugs were found to be mostly taken by those aged 41–50 years (adjusted odds ratio [AOR] = 3.38, P = 0.01), whereas nonprescribed drugs and home remedies were mostly taken by those aged 51 years or older (AOR = 2.25, P = 0.02; AOR = 2.65, P = 0.007; respectively). For formal-care methods, those who obtained professional help to control their pain were more likely to be dentists/dental students (AOR = 6.17, P = 0.02). Furthermore, a borderline effect was observed regarding teledentistry usage, with most users who were connected to a dentist being 31–40 years old (P = 0.09) and less likely to be men (P = 0.08). Conclusion: The prevalence of acute dental pain and self-medication practices was notably high among the study population. Therefore, it is imperative to educate the general public on appropriate management strategies for this type of pain. In addition, the utilization of teledentistry services was minimal within this population.

Abstract Purpose To investigate the association between intravenous methylprednisolone administration and the risk of surgical site infection (SSI) following posterior lumbar fusion (PLF) surgery. Methods This retrospective, single-center study analyzed data from 800 adult patients who underwent elective PLF surgery at our institution. Patients were classified according to postoperative intravenous methylprednisolone administration. Univariate and multivariable logistic regression, and subgroup analysis were used to assess the association between methylprednisolone administration and SSI risk, as well as its impact on postoperative pain management. Results Our analysis showed no significant association between intravenous methylprednisolone administration and the development of a SSI after PLF. Subgroup analyses suggested that methylprednisolone was potentially protective in patients with a body mass index (BMI)

Background: Little is known regarding the effectiveness of pain protocols and guideline use in Emergency Departments (ED) in Sub-Saharan Africa. Therefore, to shed light on this research gap, this study had the following objectives: 1) to evaluate if the implementation of the Essential Pain Management (EPM) course combined with mentorship to use the World Health Organization (WHO) pain ladder-based protocol improves the quality of pain management among trauma patients at the ED of two teaching hospitals in Rwanda; and 2) to determine barriers to implementing the WHO pain ladder-based protocol among trauma patients in the same settings. Methods: This was a pre- and post-intervention study. The intervention was 1-day essential pain management training for ED clinical staff followed by 1 week mentorship on the use of the WHO pain ladder-based protocol. Results: We enrolled 261 patients (47.5% pre versus 52.5% post intervention), most of them were aged between 21 and 40 (60% pre versus 33% post intervention), and male (76% pre versus 73% post intervention). The quality of pain management at the ED improved as shown by the decrease of the number of patients with undocumented pain scores from 58% to 24% after the intervention (p-value > 0.001) and the increase of the number of patients with mild pain from 37% to 62% (p-value > 0.001). In addition, patients who were satisfied with the quality of pain management increased significantly from 42% before the intervention to 80% (p-value > 0.001). Barriers to the implementation of the WHO pain ladder-based protocol were identified related to staff (i.e. inadequate experience), to the hospital (i.e. poor documentation), and to patients (i.e. reluctance to report pain). Conclusion: The implementation of the EPM course along with mentorship to use the WHO pain ladder-based protocol significantly improved the quality of pain management for trauma patients in EDs of both referral hospitals. Despite this, some barriers remain unfixed such as inadequate staff experience, poor documentation, and patient's reluctance to report pain. Appropriate interventions should be implemented to address the identified barriers and ensure adequate pain management for patients admitted at EDs in public hospitals in Rwanda.

Background : This study aims to measure patients’ POP to understand the status of patients after surgery and to identify factors, which can influence POPM. Methods : This cross-sectional survey involved a convenience sample of 105 patients with abdominal surgery. The response rate was 70%. The American Pain Society Patient Outcome Questionnaire (APS-POQ-R) was used for data collection. Data analysis was done using Statistical Package for Social Sciences (SPSS), version 26 software. The pain was measured by using the Numerical Rating Scale (NRS) at 2, 12, and 24 hours post-operatively. Results : Libyan patients, who had undergone abdominal surgeries showed higher barriers to effective POPM than patients in other countries, as very few Libyan patients (8.6%), received strong opioids for POPM, and 19.0% of them had weak opioids for their POPM. This finding could mean that Libyan patients received inadequate POPM compared to patients in other countries, as few patients had opioids for POPM. Multiple regression results revealed only significant differences with the type of medications for Post-Operative Pain Management (POPM) (B = -0.0330, P < 0.05). Conclusions: Our results showed that Libyan patients received inadequate POPM compared to patients in other countries, as view Libyan patients received opioids for POPM. The Author subscribes to the necessity for further implementation of POPM and teaching about POPM of HCPs and patients concerning acute POP in Libya.

In the previous article, the author demonstrated the close relationship between bloodletting practices in medieval Europe and acupuncture in Traditional Chinese Medicine. This study aimed to explore how acupuncture-based treatment was applied in medieval Europe. The author hypothesizes that the physical stimulation of acupuncture points associated with bloodletting was one of the main methods of pain management at that time. The study examined the indications for phlebotomy as depicted in the original illustration from Practica Medicinalis written by the 15th-century Archbishop of Prague, Sigismundus Albicus, supplemented by two other European medieval medical manuscripts. A total of 76 distinct symptoms (corresponding to 25 bloodletting acupuncture points) from the Practica Medicinalis illustration were assembled into four groups: 1) Pain and inflammation symptoms; 2) Symptoms commonly associated with pain and inflammation; 3) General symptoms affecting various organs and functions; and 4) Conditions unrelated to pain or inflammation. Among the 76 symptoms and 25 acupuncture points, only nine symptoms and a single bloodletting point were not associated with the treatment of pain or inflammation. This suggests that acupuncture-based therapy was an effective method for managing pain and inflammation in the Middle Ages and that such treatment could still be valuable from a modern clinical perspective.

Objective: Transperineal prostate (TP) biopsy is the key diagnostic tool for evaluating prostate cancer and is feasible under local anaesthetic (LA) alone. However, concerns about its tolerability encourage use of a multimodal analgesia approach. Pre-emptive over-the-counter analgesia with LA may provide a simple and low-risk option. The objective of this study was to investigate the effects of over-the-counter analgesia on TP biopsies conducted under LA. Methods: This interventional single-centre study investigated 160 participants who undertook a TP biopsy under LA, with and without pre-emptive analgesia (1 g of paracetamol and 400 mg of ibuprofen). Pain tolerability was measured using a visual analogue scale (VAS) at three procedural points (probe insertion, LA infiltration, and biopsy); an overall average VAS score was subsequently calculated. The abstracted secondary variables include patient details (age, prostate size, and PSA level), biopsy details (number of cores and volume of LA used), and preferability for LA use in future TP biopsies. An inferential statistical analysis was performed using Wilcoxon’s Rank Sum non-parametric test, Pearson’s test of correlation, and Pearson’s Chi-squared test. Results: The groups were comparable in age, prostate size, and PSA level. Median VAS scores were consistently lower in the intervention cohort, but without statistical significance. A higher volume of LA was associated with lower overall VAS (p = 0.03). LA was strongly preferred over GA for hypothetical future TP biopsies in both cohorts. Conclusions: Pre-emptive analgesia does not significantly improve tolerability of TP biopsy under LA. Our study substantiates evidence that TP biopsy is generally well tolerated under LA and preferred over GA.

Objective: This review aims to provide a synopsis of regional analgesic modalities in the intensive care unit (ICU) context and to evaluate existing literature regarding the benefits and limitations of performing these procedures in critically ill patients. Specifically, we review regional techniques in the setting of traumatic rib fractures and extremity fractures, thoracic surgery, major abdominal surgery, and cardiac surgery. We additionally discuss the limitations of clinical practice in performing regional anesthesia in the ICU setting. Overall, the current literature demonstrates promising benefits of regional analgesia in critically ill patients. However, more extensive high-powered studies are needed to determine optimal analgesic strategies in this tenuous population.

Abstract Background Standardized and systematic quality assessments of chronic pain management, particularly among older adult populations, are lacking in resource-limited community settings. A specific set of indicators to evaluate the quality of chronic pain management in this population has yet to be developed. Therefore, the present study constructed a set of indicators to assess the quality of chronic pain management in Chinese community-dwelling older adults, providing a standardized reference and guidance for community health centers to manage chronic pain in this population. Methods The indicator set was developed in three steps. Step 1 involved preparation by forming a research team and establishing the guiding theory. Step 2 included developing an expert inquiry questionnaire based on a literature review and semi-structured interviews. Step 3 completed the construction of the indicator set through the Delphi method and hierarchical analysis to quantify the relative importance of each indicator and ensure the development of a scientifically validated and practically applicable evaluation model. Results The final set of indicators for evaluating the quality of chronic pain management among community-dwelling older adults in China comprised three primary indicators: structural quality indicator, process quality indicator, and outcome quality indicator. Structural quality indicators included 3 secondary and 11 tertiary indicators; process quality indicators included 4 secondary and 21 tertiary indicators; and outcome quality indicators included 2 secondary and 4 tertiary indicators. Across two rounds of questionnaires, the response rate was 100%, with expert authority coefficients of 0.924 and 0.938, coefficients of variation ranging from 0 to 0.32 and 0 to 0.20, and Kendall’s concordance coefficients of 0.302 and 0.220, respectively. Hierarchical analysis showed that the consistency ratios of all indicators were

Yuqin Wang,1 Xiuxiu Song,1 Siqi Wang,2 Ting Bai,3 Rui Li,3 Haonan Liu,4 Yuping Liu,3 Zhengxiang Han4 1Department of General Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, People’s Republic of China; 2Xuzhou Medical University, Xuzhou, Jiangsu Province, People’s Republic of China; 3Nursing Department, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, People’s Republic of China; 4Department of Oncology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, People’s Republic of ChinaCorrespondence: Zhengxiang Han; Yuping Liu, The Affiliated Hospital of Xuzhou Medical University, No. 99 huaihai West Road, Quanshan District, Xuzhou City, Jiangsu Province, People’s Republic of China, Email cnhzxyq@163.com; 1647221333@qq.comPurpose: To develop and summarize pain management strategies after hepatectomy for liver cancer based on the best evidence summary, and to improve the strategy of the Delphi study.Methods: According to the “ 6S” evidence pyramid model, the database was systematically searched, with a search deadline of December 2023. Two researchers independently conducted literature screening and quality evaluation. Relevant evidence on pain management was extracted and integrated. Relevant evidence for pain management formed a preliminary strategy through a one-day, face-to-face meeting. Subsequently, a Delphi process was performed to improve the strategy. The scientific soundness of the Delphi method was expressed by the effective response rate, authority coefficient (Cr), and coordination coefficient. The coordination of expert opinions was assessed using the coefficient of variation (CV) and Kendall’s coefficient (W). Cr should be above 0.700 and the coefficient of variation (CV) should be below 0.25. Data analysis was performed using SPSS V.25.0.Results: A total of 14 studies were included, and we summarized 13 first-level items and 48 second-level items by two rounds of Delphi. The effective response rate of the two rounds of Delphi was 100.00%, and the authority coefficient of the experts was 0.832. The coefficients of variation were 0.00– 0.41 and 0.05– 0.17, respectively. The Kendall’s W values for the two rounds were 0.114– 0.222 (p< 0.05).Conclusion: Pain management strategy after hepatectomy is scientific and applicable. We plan to translate this into a plan and confirm its feasibility in the future.Keywords: pain management, hepatectomy, evidence-based nursing, Delphi method, liver cancer

Background: Cancer, a prevalent non-communicable disease globally and in Indonesia, poses significant health challenges. Pain, a frequent and dreaded symptom in cancer patients, can severely impact their functional abilities, quality of life, and elevate stress levels within families. Non-pharmacological approaches to pain management, like hypnotherapy, offer safe, affordable, and readily applicable solutions.Objectives: This research seeks to evaluate the impact of varying approaches to managing mild pain, specifically comparing the use of hypnotherapy speakers versus their absence, in post-operative cancer patients at RSPAD Gatot Soebroto during the period from December 2023 to January 2024.Methods: This quantitative study employs a Quasi-Experimental design with a Two Group Pretest-Posttest format. The research took place in the Obstetrics Ward on the second floor of PIS RSPAD Gatot Soebroto from December 16, 2023, to January 17, 2024. A total of 44 participants were included, divided into a control group and an intervention group. Data collection was carried out using observation sheets and universal pain assessment tools. Descriptive statistics were analyzed using univariate analysis, and normality tests were performed before conducting bivariate analysis to assess data distribution.Results: The research revealed a notable decrease in pain scores following the use of hypnotherapy speakers. Initially, the average pain score was 2.59 (SD=0.59) prior to the therapy, which dropped to 0.73 (SD=0.83) post-therapy. Both the administration of Paracetamol alone and in combination with hypnotherapy speakers significantly alleviated pain in patients with ovarian and cervical cancer (pConclusions: These results suggest that combining Paracetamol with hypnotherapy speakers is more effective at alleviating pain in patients with ovarian and cervical cancer than using Paracetamol alone. This study serves as a valuable reference for future research on the utilization of hypnotherapy speakers and offers practical guidance for midwives to adopt hypnotherapy speakers to expedite pain relief in cancer patients.

Purpose Continuous wound infiltration (CWI) has been introduced as a component of multimodal analgesia to counteract the adverse effects of the most frequently used opioids. Advantages of reduced-port laparoscopic surgery (RPLS) include cosmetic benefits and decreased postoperative pain. We aimed to investigate the effect of CWI in patients using intravenous (IV) patient-controlled analgesia (PCA) for pain management after RPLS for colorectal cancer. Methods This retrospective study included 25 patients who received both CWI (0.5% ropivacaine infused over 72 hours) and IV PCA (fentanyl citrate) and 52 patients who received IV PCA alone. The primary endpoint was pain scores on postoperative days (PODs) 0, 1, and 2. Univariate and multivariate analyses were conducted to determine the factors affecting the pain score on POD 0. Results On POD 0, the mean numeric rating scale score was significantly lower in the CWI group than in the control group (3.2±0.8 vs. 3.7±0.9, P=0.042). However, the scores were comparable between the groups during the rest of the period. Within 24 hours of surgery, the CWI group consumed fewer opioids (0.7±0.9 vs. 1.3±1.1, P=0.018) and more nonsteroidal anti-inflammatory drugs (2.0±1.4 vs. 1.3±1.4, P=0.046) than the control group. Time to removal of IV PCA was significantly longer in the CWI group than in the control group (4.4±1.6 days vs. 3.4±1.0 days, P=0.016). Conclusion CWI with ropivacaine and IV PCA was more effective than IV PCA alone in controlling postoperative pain within 24 hours of surgery, and opioid use could be reduced further.

Background: This cross-sectional study investigates the knowledge, attitudes, and practices regarding knee pain and its treatment modalities among patients in India. Aims: The aim of this study was to identify the prevalent beliefs, barriers to quality treatment, and factors influencing knee pain management. Settings and Design: This was a cross-sectional, multicentric survey. Materials and Methods: The study was conducted using a prestructured, prevalidated online questionnaire comprising 30 items in each section. Before data collection, the research received ethical approval from the Institutional Ethical Committee of Adesh Medical College and Hospital, Shahabad, Haryana. Data collection was done over a period of 3 months from various outpatient department-based settings using a nonprobability type, convenience sampling. A total of 731 participants were obtained in the study time frame who returned the completed questionnaire. Statistical Analysis: Tests of significance such as the Chi-square tests were used to find any associations between the categorical and ordinal variables. Some association between certain variables was also calculated using the Chi-square tests on the SPSS version 27 wherever required. Results: The study encompassed 731 participants, predominantly aged 30–70 years. Knee pain was reported by 80.8% of participants, with the most common diagnosis being knee osteoarthritis. Most participants consulted a doctor within a month, but a significant portion delayed seeking medical attention. Pain severity varied, with mild pain being the most reported. The majority relied on medical practitioners for information but also turned to nonprofessional sources. Conservative therapy with medication was the most common treatment. A significant knowledge gap existed regarding advanced interventional procedures, with only a small fraction aware of options such as platelet-rich plasma injections and other minimally invasive interventions. Overall, there was a high level of satisfaction with conservative management, but awareness and utilization of advanced treatment options were low. Conclusion: The study reveals substantial knee pain prevalence among adults, primarily attributed to osteoarthritis, with a significant impact on daily activities and quality of life. Despite a high reliance on medical practitioners for information, there are abundant misconceptions regarding the condition and significant delays in seeking treatment. Conservative management remains the preferred approach, but there is limited awareness of advanced interventional treatments. Enhancing patient education on knee pain causes, treatment options, and the benefits of minimally invasive procedures is crucial for improving management and outcomes. Addressing these gaps can lead to better pain management strategies and reduced disease burden, especially in resource-constrained settings like India.

Introduction: Myofascial pain syndrome (MPS) is a common cause of pain. The trapezius and rhomboid muscles in the dorsal region are a frequent location because of their anatomical location and mechanical loading. An interfacial block technique has been described that intervenes this syndrome in this specific location. Materials and Methods: A trapezius–rhomboid plane block (TRB) was performed in six patients diagnosed with dorsal MPS. The procedure was performed with ultrasonographic guidance, using 10 mL of 0.25% bupivacaine and 40 mg of methylprednisolone. An additional 2 mL of contrast was applied for fluoroscopic confirmation of the interfacial distribution. Results: A pain improvement of up to 80% was achieved in a follow-up performed up to week 10. No complications occurred, and we were able to illustrate the interfacial distribution in this plane, in addition to being able to theorize its mechanism of action in the blockade of the ventral cutaneous sensory branches, the terminal branches of the accessory nerve, and the dorsal nerve of the scapula. Conclusions: Our study develops an anatomical analysis of a recently described procedure and demonstrates a wide interfacial distribution with favorable clinical outcomes without complications, making it an interesting therapeutic tool in the management of dorsal MPS.

Introduction: Effective pain management is crucial in the emergency department (ED), particularly for trauma patients. Ultrasound-guided regional analgesia (UGRA) has emerged as a promising technique for acute pain relief. The objective of this study is to describe the various UGRA performed and assess their effectiveness among trauma patients in our Level 1 Trauma Center ED over the past 2.5 years. Methods: Data from 485 trauma patients who underwent UGRA over 2.5 years were analyzed retrospectively. The primary outcome was the median Defense and Veterans Pain Rating Scale (DVPRS) reduction at 30 min and 1 h after nerve block administration. Patient characteristics, types of nerve blocks administered, procedural details, and outcomes were also noted. Statistical analysis was performed to determine the median reduction in pain scores and evaluate the success of UGRA. Results: UGRA demonstrated a significant reduction in pain scores, with a median DVPRS decrease from 9 (interquartile range [IQR]: 9–10) preprocedure to 4 (IQR: 2–5) at 30 min and 1 (IQR: 0–2) at 1 h postprocedure. Sixteen types of nerve blocks were administered in our ED, with the serratus anterior block (n = 91) and fascia iliaca compartment block (n = 58) being the most common. Pain relief was the most common indication for block administration. A higher volume was injected for plane blocks compared to nerve-specific blocks. No complications or failed blocks were reported. Conclusion: This study describes 16 different UGRA that can be performed by emergency physicians (EPs) in ED for trauma patients. UGRA is effective in providing substantial pain relief for trauma patients in the ED. UGRA performed by EPs offers a safe and feasible approach for managing acute pain in the ED.

Ying Yang,1,&ast; Wenjun Lin,1,&ast; Yifen Zhuo,2,&ast; Yuxin Luo,1 Xiaoyan Wu,1 Junyu Li,1 Yusheng Yao1 1Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, People’s Republic of China; 2Department of Anesthesiology, Xiamen Haicang Hospital, Xiamen, Fujian, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Junyu Li; Yusheng Yao, Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, 134 Dongjie Street, Fuzhou, Fujian, 350001, People’s Republic of China, Email lijunyu0907@163.com; fjslyys@126.comPurpose: Intrathecal morphine is increasingly used for pain management in laparoscopic colorectal surgery. While ropivacaine shows advantages of reduced cardiotoxicity and faster motor recovery compared to bupivacaine, the impact of intrathecal morphine-ropivacaine combination on postoperative recovery quality remains unclear. This study aimed to evaluate this combination’s effect on recovery outcomes after laparoscopic colorectal surgery.Patients and Methods: In this randomized, double-blind, placebo-controlled trial, 78 patients undergoing laparoscopic colorectal surgery received either preservative-free intrathecal morphine 250 μg with ropivacaine 15 mg (Intrathecal group) or a sham subcutaneous saline injection (Control group). The primary outcome was the Quality of Recovery-15 (QoR-15) score 24 hours after surgery. Secondary outcomes included pain scores, opioid consumption, and adverse effects.Results: The intrathecal group showed significantly higher QoR-15 scores 24 hours postoperatively compared to the control group (median [IQR]: 121 [109− 128] vs 111 [102− 116], p < 0.001), with improvements in pain management (p < 0.001), physical comfort (p = 0.001), and physical independence (p = 0.002). The intrathecal group had lower pain scores at rest (area under the curve 0– 48 h: 66 [59– 90] vs 107 [89– 126], p < 0.001) and during coughing (152 [137– 172] vs 191 [166– 213], p < 0.001), particularly from 0.5 to 24 hours. They also required less postoperative morphine (0– 48 h: 10 [6– 20] vs 26 [22– 36] mg, p < 0.001). While hypotension (43.6% vs 17.9%, p = 0.014) and pruritus (35.9% vs 2.6%, p < 0.001) were more frequent in the intrathecal group, but no respiratory depression occurred in either group.Conclusion: Intrathecal morphine-ropivacaine administration improves 24-hour postoperative recovery quality and provides superior pain relief after laparoscopic colorectal surgery, despite increased but manageable side effects. Further research should focus on dose optimization and comparative studies of different intrathecal local anesthetic combinations.Trial Registration: The Chinese Clinical Trial Registry, ChiCTR2100052337. Keywords: intrathecal morphine, ropivacaine, pain management, quality of recovery, laparoscopic colorectal surgery

Timmy Li, Daniel Koloden, Jonathan Berkowitz, Dee Luo, Howard Luan, Charles Gilley, Gregory Kurgansky, Devin M Howell, Paul Barbara Department of Emergency Medicine, Northwell, New Hyde Park, NY, USACorrespondence: Timmy Li, Department of Emergency Medicine, Northwell, 2000 Marcus Ave, Suite 300, New Hyde Park, NY, 11042-1069, USA, Tel +1 516 240-3933, Email TLi2@northwell.eduPurpose: We describe emergency medical services (EMS) protocols for pain management in the United States to elucidate systemic variability in protocols. We describe types of pain medications included in protocols, routes of administration, indications for use, standing orders for dosing, and use in pediatric patients.Methods: We performed a review of all publicly accessible EMS protocols from the website http://www.emsprotocols.org, supplemented with internet searches. Data were abstracted into a data collection form from June 2021 to January 2022. We developed categories of responses to summarize the data, using frequencies and proportions to describe outcome measures.Results: We reviewed 104 EMS protocols, spanning 43 states. The most common pain management medications include fentanyl (94.2%), morphine (70.2%), ketamine (61.5%), ketorolac (40.4%), oral acetaminophen (36.5%), oral ibuprofen (22.1%), and nitrous oxide (19.2%). The most common route of administration across all protocols and medications is intravenous. Severe pain, without a specified level, is the most common indication for fentanyl (65.3%), morphine (61.6%), ketorolac (50.0%), and nitrous oxide (40.0%). Musculoskeletal injuries and burns are the most common indications for morphine, 15.1% and 19.2% of protocols, respectively. The majority of protocols dictate the weight-based dosing of fentanyl (74.5%), morphine (64.4%), ketamine (87.3%), oral acetaminophen (56.8%), and oral ibuprofen (59.1%). However, 97.6% and 100.0% of protocols dictate a fixed dose of ketorolac and nitrous oxide, respectively. Fentanyl, morphine, oral acetaminophen, and oral ibuprofen can be administered to pediatric patients based on standing orders among > 90.0% of protocols. However, only 46.2% and 75.0% of protocols allow the use of ketorolac and nitrous oxide in pediatric patients, respectively.Conclusion: We found variability in EMS pain management protocols including the types of allowed medications, routes of administration, dosing, and indications for use. Further studies may assess whether standardized protocols across EMS systems could improve patient safety and quality of care.Keywords: pain management, pediatrics, emergency medical services, protocols, variability

Peripheral artery disease (PAD) is quite prevalent, and its incidence will increase with aging of population. Pain is a key diagnostic feature of symptomatic PAD and has been linked to disease progression and poor quality of life. Symptom improvement is of utmost importance in PAD; therefore, optimal and comprehensive pain therapy is mandatory. However, the management of acute pain in PAD remains challenging due to the lack of high-quality evidence, the complex pathophysiological mechanisms of pain, and the high comorbidity of patients. On the other hand, inadequate pain control leads to several pathophysiological deviations, such as the aggravated neuroendocrine stress response, which may be detrimental in patients with PAD. Experts suggest that the management of acute pain in patients with vascular diseases should be oriented toward the underlying pathophysiological mechanisms of each modality and should follow a multifactorial approach. Although the exact pain pathways in PAD are still poorly understood and more probably multifactorial, they may be key to an effective, individualized, patient-centered, multimodal pain strategy. The aim of this review was to provide a holistic, beyond-opioids, individualized multimodal pain approach for patients with PAD.

Abstract Introduction Sickle cell disease (SCD) is characterized by acute episodes called vaso‐occlusive crises (VOC). VOC is marked by severe pain due to blocked blood vessels by sickled cells. Ketamine has been reported to be effective and safe in managing VOC in SCD patients. Objectives/methods This review aims to determine ketamine's safety and efficacy through analysis of clinical trials and observational studies. Methods Adhering to PRISMA guidelines, this systematic review and meta‐analysis systematically searched seven databases on May 20, 2024 for randomized control trials (RCT), cohorts, and case–control studies. Results Five studies with 689 participants met the inclusion criteria. A meta‐analysis of two studies (518 observations) for the Numerical Rating Scale (NRS) pain score showed no significant difference, with a standardized mean difference (MD) of 0.23 (95% CI: −0.13 to 0.59, p = 0.21, I2 = 0%). For morphine milligram equivalent (MME), a meta‐analysis of two studies (344 observations) resulted in an MD of −0.03 (95% CI: −0.09 to 0.04, p = 0.45, I2 = 97%). However, the side effects analysis from four studies (608 observations) showed a significantly higher relative risk (RR) of 5.74 (95% CI: 2.80–11.79, p

Abstract The use of a rapid, easy‐to‐use intervention could improve needle‐related procedural pain management practices in the context of the Emergency Department (ED). As such, the Buzzy device seems to be a promising alternative to topical anesthetics. The aim of this study was to determine if a cold vibrating device was non‐inferior to a topical anesthetic cream for pain management in children undergoing needle‐related procedures in the ED. In this randomized controlled non‐inferiority trial, we enrolled children between 4 and 17 years presenting to the ED and requiring a needle‐related procedure. Participants were randomly assigned to either the cold vibrating device or topical anesthetic (4% liposomal lidocaine; standard of care). The primary outcome was the mean difference (MD) in adjusted procedural pain intensity on the 0–10 Color Analogue Scale (CAS), using a non‐inferiority margin of 0.70. A total of 352 participants were randomized (cold vibration device n = 176, topical anesthetic cream n = 176). Adjusted procedural pain scores' MD between groups was 0.56 (95% CI:−0.08–1.20) on the CAS, showing that the cold vibrating device was not considered non‐inferior to topical anesthetic. The cold vibrating device was not considered non‐inferior to the topical anesthetic cream for pain management in children during a needle‐related procedure in the ED. As topical anesthetic creams require an application time of 30 min, cost approximately CAD $40.00 per tube, are underused in the ED setting, the cold vibrating device remains a promising alternative as it is a rapid, easy‐to‐use, and reusable device.

Abstract Wound catheter infusion (WCI) with local anesthetics (LA) is a regional anesthesia technique, which has shown to produce effective postoperative analgesia in adults, without any adverse effects on wound healing. To investigate the efficacy and safety of WCI with LA for the treatment of postoperative pain in children, we conducted a systematic review of literature published until 2020. The literature search included articles concerning subcutaneous WCI with LA, in the surgical wound, as treatment of postoperative pain, in children

Abstract Background Pain management for knee osteoarthritis (KOA) patients is challenging. Pain arises from both physiological and psychological interactions, with anxiety and depression potentially contributing as risk factors that hinder effective pain management in KOA patients. Methods Before treatment(T1), A total of 206 elderly inpatients with KOA were enrolled based on initial screening criteria. After treatment (T2), patients were selected based on inclusion and exclusion criteria, and completed follow-up through phone or online questionnaires. The interval between T1 and T2 was three months. Outcome measures included the Visual Analogue Scale (VAS) for pain intensity, Beck Anxiety Inventory (BAI) for anxiety, and Geriatric Depression Scale (GDS) for depression. Descriptive and bivariate analyses were used to evaluate the pain, anxiety and depression of the participants. A cross-lagged model was used to examine the temporal and causal associations among pain, anxiety, and depression. Results 91% of elderly patients with KOA experienced at least mild depression. Furthermore, 31% of patients reported mild or higher levels of anxiety. At the same time, pain, depression, and anxiety were significantly correlated and mutually predictive(all p

Abstract Background Effective pain management in elderly patients is crucial for quality of life, yet cultural and institutional factors can significantly impact care delivery, particularly in Arab healthcare settings. Aim To explore the barriers and facilitators to effective pain management in elderly Arab patients from the perspective of nurses. Methods A qualitative descriptive study was conducted with 12 registered nurses from various departments at Tanta University Hospitals, Egypt. Data were collected through semi-structured interviews, observations, and document analysis. Content analysis was used to identify themes and subthemes. Results Five main themes emerged: (1) Cultural Barriers to Pain Expression, including stoicism and religious beliefs; (2) Institutional Barriers to Pain Management, such as resource limitations and time constraints; (3) Facilitators to Effective Pain Management, including family support and nurse adaptability; (4) Interdisciplinary Collaboration, emphasizing teamwork and education; and (5) Emotional and Professional Rewards for nurses. Cultural factors often led to underreporting of pain, while institutional constraints hindered thorough assessments. Nurse adaptability and family support, when present, facilitated better pain management. Conclusion The study reveals complex interplay between cultural, institutional, and professional factors influencing pain management in elderly Arab patients. Findings suggest the need for culturally sensitive pain assessment tools, enhanced nurse education in pain management, and policies promoting family-centered care and interdisciplinary collaboration. Implications Results can inform the development of culturally appropriate pain management strategies and policies in Arab healthcare settings, potentially improving care quality for elderly patients.

Abstract Nail-patella syndrome (NPS) is a rare genetic disease characterized by dysplastic nails, patella abnormalities, skeletal malformation, and chronic pain. Although chronic pain in NPS is mainly due to bone and musculoskeletal symptoms, it can also result from neurological dysfunction. Conventional analgesics are often insufficient to relieve NPS-associated chronic pain. Cannabinoids, which act on the serotonergic and/or noradrenergic pain systems, may therefore represent valuable non-psychoactive alternatives for managing pain in these patients. The effectiveness and safety of synthetic cannabidiol (CBD) for the management of NPS-associated pain was assessed using real-world data from a pilot cohort of patients with NPS who received a 3-month treatment with oral CBD. The treatment (median dose of 900 mg/day) was associated with a significant reduction in pain intensity (mean score of 7.04 ± 0.24 at initiation versus 4.04 ± 0.38 at 3 months, N = 28, p

Abstract Background Racial and ethnic disparities in the treatment of perioperative pain have not been well-studied, despite being observed in a variety of other medical settings. The goal of this investigation was to evaluate the relationship between race and ethnicity and intra- and postoperative opioid administration for patients undergoing open liver resection surgery. Methods In this single-center retrospective cohort study, adult patients undergoing open liver resection from January 2012 to May 2019 were identified. Demographic, intraoperative, and postoperative data were extracted from the institutional perioperative data warehouse. The primary outcome was weight-based intraoperative morphine milligram equivalents (MME/kg). Secondary outcome variables included use of neuraxial analgesia and length of stay (LOS). Multivariable regression models were used, which controlled for pertinent factors such as age and duration of surgery. Results There were 1294 adult open liver resections included in this study: 532 (41%) patients self-reported as White, 401 (31%) as Asian, 159 (12%) as Black, 97 (7%) as Hispanic, and 105 (8%) as Other. The risk adjusted mean intraoperative MME/kg was not different among racial groups (White: 3.25 [95% CL 3.02–3.49] mg/kg vs. Asian: 3.38 [95% CL 3.10–3.69] mg/kg, p = 0.87; Black: 2.95 [95% CL 2.70–3.23] mg/kg, p = 0.19; Hispanic: 3.36 [95% CL 3.00–3.77] mg/kg, p = 0.97). In the multivariable models for secondary outcomes, length of stay was significantly higher for Black (estimate: 1.17, CL: 1.00 to 1.35, p = 0.047) and Hispanic (1.30, CL: 1.05 to 1.65, p = 0.018) patients relative to White patients. No racial/ethnic groups were significantly associated with higher or lower odds of receiving regional anesthesia. Conclusions For patients undergoing liver resection surgery, no racial and ethnic disparities were observed for weight-based intraoperative MME.

Abstract Background The rate of caesarean section in Iran has significantly increased. The main reason cited by Iranian mothers for it is labor pain and fear of it. However, the experience of pain during childbirth has different meanings for mothers in various conditions. Therefore, this study aims to examine the components from the mothers’ perspective that helped them manage pain in labor. The findings of this article may help prevent unnecessary medical interventions. Methods The current article is one component of a mixed-method study conducted in Iran. Its primary objective was to develop protocols for maternity unit design to enhance maternal satisfaction, promote husbands’ involvement, and improve pain management. The current study focuses on examining contextual components that are effective in managing pain among 25 mothers selected through stratified purposive sampling. Data collection from mothers who gave birth in four large hospitals in Iran was carried out through unstructured in-depth interviews. The data were analyzed using interpretative phenomenological analysis. Findings The data show that two major environmental factors affect mothers’ perception of pain and their ability to control it: (1) Internal and (2) External environments. The main components of the internal factor are identified as “Personal beliefs”, “Self-confidence and lack of fear”, and the external environment includes three subfactors: “Spatial environment”, “Social environment”, and “Interactive environment”. The overall meaning attributed to pain caused by these factors determines how mothers can cope with it. Conclusion In this study, self-confidence and a positive mindset were significant factors in managing pain during labor among this group of mothers. Furthermore, each mother’s perception of pain was shaped by a combination of physical, social, and interactive influences. The research identified the importance of support during labor according to mothers’ individual, subjective needs, while improving the physical environment, with a view to reducing interventions and promoting positive experiences for mothers and husbands. Consequently, enhancing internal resources and the birthing environment during labor which involve identifying the optimal blend of physical, mental, and emotional strategies tailored to the specific needs of mothers, can be considered to a potential reduction in the perceived intensity of pain in future.

Introduction: Trigeminal Neuralgia (TN) is one of the most painful diseases. Typically, medication therapy starts at an initial titrated dose of 100 mg every other day of Carbamazepine (CBZ) 200-1200 mg/day. There is less evidence to support second-line treatments such as clonazepam, valproic acid, baclofen, gabapentin, lamotrigine, and baclofen. Transcutaneous Electrical Nerve Stimulation (TENS) is a widespread technique used for managing neuropathic pain. TENS therapy, which involves the transmission of an electric current across the intact skin surface to activate deeper nerves in an attempt to relieve pain, is a recent and promising alternative for the treatment of both acute and chronic pain. Need of the Study: Few research has been done on TENS therapy for pain management in TN. These studies have poor study designs, no control groups, and unclear information regarding the type of concurrent pharmacological therapy. TENS in combination with CBZ may reduce the dose of CBZ therapy, therefore, there is a need to conduct the study on “Comparative efficacy of CBZ therapy with and without TENS therapy for the management of TN”. Aim: To evaluate and compare the efficacy of CBZ therapy with and without TENS therapy for the management of TN. Materials and Methods: A Randomised Controlled Trial (RCT) will be conducted in the Outpatient Department (OPD) of Oral Medicine and Radiology at Sharad Pawar Dental College and Hospital, Wardha, Maharashatra, India between July 2024 and May 2026. Once diagnosed and enrolled, 38 individuals between the ages of 20 years and 80 years will receive a primary diagnosis of TN will be included and they will receive further treatment, based on International Headache Soceity (IHS) diagnostic criteria (IHS, 2018). Then these patients will randomly be allocated to one of the following groups, 19 subjects in each group, respectively: Group 1 (CBZ therapy): The baseline parameters of patients will be evaluated who will be treated with CBZ Initially at 100 mg TDS per day (300 mg), the patient will receive an additional titrated dose 100 mg of CBZ every 48 hours until they reach the maximum tolerated dose or total relief and Group 2 (CBZ with TENS therapy): CBZ initially, at 100 mg TDS per day (300 mg), the patient will receive an additional titrated dose 100 mg of CBZ every 48 hours until they reach the maximum tolerated dose or total relief. The pulse duration of TENS therapy will be 125 μS. The TENS will be applied during the first twenty minutes at a low frequency (2 to 10 Hz) and the last twenty minutes at a high frequency (50 to 100 Hz), with no break in between, for a total of 40 minutes per session. The outcome of Group 2 will be more efficacious in reduction of Visual Analogue Scale (VAS) score as compare to Group 1. The statistical analysis will be performed using Chi-square test at 5% level of significance (p

Abstract Cancer is a major public health issue, with an estimated 20 million new cases and 9.7 million cancer-related deaths worldwide in 2022. Approximately 44.5% of patients experience cancer pain, significantly impacting their quality of life and causing physical and psychological burdens. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive neuromodulation technique, shows potential in managing cancer pain. This review summarizes current research on rTMS for cancer pain, focusing on pain directly caused by tumors, pain from cancer treatments, postoperative pain, and cancer-related symptoms. Additionally, rTMS shows promise in improving cancer-related fatigue, anxiety, depression, and cognitive dysfunction, which can indirectly reduce cancer pain. The analgesic mechanisms of rTMS include inhibiting nociceptive signal transmission in the spinal cord, modulating hemodynamic changes in brain regions, and promoting endogenous opioid release. High-frequency stimulation of the primary motor cortex (M1) has shown significant analgesic effects, improving patients' emotional and cognitive functions and overall quality of life. rTMS has a favorable safety profile, with most studies reporting no severe adverse events. In conclusion, rTMS holds substantial potential for cancer pain management, offering a non-invasive and multifaceted therapeutic approach. Continued research and clinical application are expected to establish rTMS as an essential component of comprehensive cancer pain treatment strategies, significantly enhancing the overall well-being of patients with cancer.

This paper summarized the pain management during radiotherapy in a patient with liver cancer. Nurses had conducted comprehensive assessments on pain and health needs of the patient, and carried out pain control strategy through drug intervention, psychology support, diet guidance, lifestyle guidance and exercise, aiming to relieving the pain and improve patient’s quality of life. (本文总结1例肝癌患者放治疗期间的疼痛管理经验。护理人员积极评估患者疼痛程度和性质, 了解患者需求, 针对性给予药物镇痛、心理支持、饮食干预、健康宣教、运动指导等护理措施, 有效减轻患者疼痛, 提高生活质量。)

Background: Pain is a significant health problem, and it is estimated that 1 in 5 adults suffers from pain, and even more alarmingly, 1 in 10 adults is diagnosed annually with chronic pain. Pharmacological treatments remain a core element of pain management for acute and chronic conditions, and more so for chronic painful conditions. In India, the major pharmacological options include paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) or combination therapies. Aims and Objectives: The cross-sectional study aimed to understand the practices for prescribing analgesics in either mono-or combination -therapy in management of chronic painful conditions. Materials and Methods: The KAP, was designed for dentists and orthopaedicians. A carefully crafted questionnaire was developed comprising 5 multiple-choice questions with subsets in orthopaedics and 7 multiple-choice questions in dentistry. Results: The survey included general dentists and specialists (n = 200) and orthpaedicians (n = 300). Most of the dentists (97.92%) agreed that their choice of analgesics prescribed depended on the severity of dental pain. While choosing NSAIDs as monotherapy, Diclofenac was the choice of drug for 72.4% of the participants. Dentists favoured combination therapies, with more than 50% preferring, either Diclofenac with Paracetamol and Serratiopeptidase. For management of acute low back pain and osteoarthritis most of the orthopaedicians preferred using Etoricoxib. A combination therapy was preferred with muscle relaxant. Conclusion: The (KAP) survey provided further insight into the selection of NSAIDs as analgesics in dentistry and orthopedic practices in India. There was a notable inclination toward COX-2 inhibitors.

Introduction: Flap surgery is used to treat deep periodontal pockets and recent innovations like Low-level LASER Therapy (LLLT), or Photobiomodulation (PBM), help reduce postsurgical pain. LLLT works by emitting red or infrared light at wavelengths between 660 and 940 nm, which penetrates tissues and interacts with cytochrome c oxidase to modulate immune responses, reduce inflammation and ease pain, promoting faster healing. Aim: To evaluate and compare postoperative pain in periodontal flap surgery with and without PBM using a diode laser. Materials and Methods: A split-mouth randomised controlled study was carried out in the Department of Periodontology at KM Shah Dental College and Hospital, Vadodara, Gujarat, India. The study took place from August 2023 to January 2024. Based on the inclusion and exclusion criteria, 14 participants (28 sites) with bilateral pocket probing depths of 5-7 mm diagnosed with generalised periodontitis stage II grade A were treated with open flap debridement. After open flap debridement, the test group (Group A) received PBM using a diode LASER (940 nm in a continuous mode with 0.5 W for 112 seconds) applied with a whitening handpiece at a 3 mm distance to the flap surfaces, whereas the contralateral arch, or control group (Group B), received no LASER treatment. The parameters assessed for postoperative pain following flap surgery included the Visual Analogue Scale (VAS) to track the patients’ pain levels and the amount of analgesics they took throughout the first week following surgery. For inter group comparison of the amount of analgesics taken and assessing the VAS score, the Mann-Whitney U test was used. Data analysis was done using IBM Statistical Package for Social Sciences (SPSS) Statistics 20.0 (IBM Corporation, Armonk, NY, USA), with the level of significance set at p=0.05. Results: The mean age of the participants was 41.14±2.95 years. Patients in the test group had statistically significant differences in their VAS scores from the day of surgery (day 0) to day 7 compared to the control group. The number of analgesics taken on day 1 postsurgery did not show statistically significant results, as the number of analgesics taken was similar in both the control group as well as LASER group (p-value 0.063). However, patients receiving LASER treatment used fewer analgesics on days 2, 3, 4, 5 and 6 than the control group, with a p-value of less than 0.05, indicating statistically significant findings in this regard. Conclusion: Based on the present study’s findings, it can be concluded that the 940 nm diode LASER has the potential to greatly minimise postoperative discomfort and reduce the quantity of analgesics that patients require following flap surgery.

Xiao Wang,1,&ast; Ying Cao,2,&ast; Jing Hu,3 Lian-Cheng Jia,4 Bo Li,3 Baoli Liu,5 Wei-Hai Yao,2 Xiao-Lu Pei,6 Wei Peng,2 Shuang Wang,2 Cun-Zhi Liu,1,7 Jian-Feng Tu,1,7 Zhi-Cheng Qu2 1School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People’s Republic of China; 2Emergency Department, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China; 3Evidence Based Medicine Center, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China; 4Urinary Surgery, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China; 5Nephrology Department, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China; 6Nursing Department, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, People’s Republic of China; 7International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Zhi-Cheng Qu, Emergency Department, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, 23 Meishuguanhou Street, Dongcheng District, Beijing, 100010, People’s Republic of China, Email qzhch0824@163.com Jian-Feng Tu, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, People’s Republic of China, Email tujianfeng1@126.comIntroduction: Analgesia is often delayed for suspected acute renal colic due to urinary calculi (ARCUC) even in emergency department. Acupuncture has a rapid onset and is effective for analgesia, however, evidence about early-acupuncture for suspected ARCUC is limited. This trial aims to evaluate the efficacy of early-intervention acupuncture compared with sham acupuncture on pain relief among emergency department suspected ARCUC patients.Methods and Analysis: A total of 84 eligible patients who are suspected diagnosed with ARCUC will be randomly allocated to the acupuncture group or the sham acupuncture group. Each patient will receive 1 session of acupuncture or sham acupuncture before diagnostic imaging. The primary outcome will be the response rate at 10 min after needle manipulation, defined as the proportion of patients whose Numeric Rating Scale (NRS) score decrease by at least 50% from baseline. Secondary outcomes will include pain intensity assessed by NRS, further analgesia requirement, revisit rate, surgical intervention rate, satisfaction evaluation, and adverse events. The final diagnosis rate determined by radiography will be recorded and reported. All patients who receive randomization will be included in the intention-to-treat analysis.Conclusion: This study’s findings are anticipated to evaluate the analgesic effect of early-intervention acupuncture for acute renal colic in emergency department, which could be useful for moving the timing of analgesia forward and aligning pain management for acute renal colic more with the guidelines.Trial Registration Number: ChiCTR2100049069 (https://www.chictr.org.cn/showproj.html?proj=125338).Keywords: acupuncture, complementary medicine, pain management, emergency medicine, renal colic

Abstract Background There are avoidable differences (i.e., inequities) in the prevalence and distribution of chronic pain across diverse populations, as well as in access to and outcomes of pain management services. Digital pain self-reporting tools have the potential to reduce or exacerbate these inequities. This study aimed to better understand how to optimise the health equity impact of digital pain self-reporting tools on people who are experiencing (or are at risk of) digital pain inequities. Methods This was a qualitative study, guided by the Health Equity Impact Assessment tool—digital health supplement (HEIA-DH). We conducted three scoping focus groups with multiple stakeholders to identify the potential impacts of digital pain self-reporting tools and strategies to manage these impacts. Each group focused on one priority group experiencing digital pain inequities, including older adults, ethnic minorities, and people living in socio-economically deprived areas. A fourth consensus focus group was organised to discuss and select impact management strategies. Focus groups were audio-recorded, transcribed verbatim, and analysed using a framework approach. We derived codes, grouped them under four pre-defined categories from the HEIA-DH, and illustrated them with participants’ quotes. Results A total of fifteen people living with musculoskeletal pain conditions and thirteen professionals took part. Participants described how digital pain self-reports can have a positive health equity impact by better capturing pain fluctuations and enriching patient-provider communication, which in turn can enhance clinical decisions and self-management practices. Conversely, participants identified that incorrect interpretation of pain reports, lack of knowledge of pain terminologies, and digital (e.g., no access to technology) and social (e.g., gender stereotyping) exclusions may negatively impact on people’s health equity. The participants identified 32 strategies, of which 20 were selected as being likely to mitigate these negative health equity impacts. Example strategies included, e.g., option to customise self-reporting tools in line with users’ personal preferences, or resources to better explain how self-reported pain data will be used to build trust. Conclusion Linked to people’s personal and social characteristics, there are equity-based considerations for developing accessible digital pain self-reporting tools, as well as resources and skills to enable the adoption and use of these tools among priority groups. Future research should focus on implementing these equity-based considerations or strategies identified by our study and monitoring their impact on the health equity of people living with chronic pain.

Abstract Background Unnecessary childbirth interventions are still common in most hospitals in Jordan. Despite the recommendations from the WHO that unnecessary interventions during childbirth should be avoided, these interventions are still used. Non-pharmacological pain management interventions are considered a convenient alternative to unnecessary childbirth interventions because they can prevent unsafe side effects for mothers during childbirth. The study aims to determine the feasibility of non-pharmacological pain management interventions during childbirth and then to evaluate their influence on mothers’ experience. Methods Between May and June 2022, we implemented a quality improvement project with a bundle of non-pharmacologic comfort measures during childbirth. We started our project by (1) approaching all low-risk pregnant mothers who visited the hospital’s antenatal clinic with a gestational age greater than 36 weeks. (2) Following the agreement, the researcher indicated that she would accompany the mother during the birthing process. (3) The researcher discussed different non-pharmacological pain management techniques and asked the mothers to choose how and when to utilize them. Non-pharmacological pain management techniques include breathing exercises, back massages, enabling mothers to move around, and providing modest amounts of water and soft food. (4) A few days after birth, the mother was interviewed one-to-one utilizing semi-structured audio-recorded interviews. The researcher interviewed eighteen postpartum mothers at a place of their choosing. Results Three main themes emerged from the interview analysis. The following themes were selected from the participants’ own words: “Positive, respectful, and satisfying childbirth experience”; “Maintain mother’s sense of control and cope with childbirth pain”; and “Birth outcome”. These themes are connected and impacted by one another. Discussion Different research studies from diverse cultures recommend limiting the unnecessary use of interventions during childbirth and not interfering with childbirth unless medically necessary. Our participants expressed satisfaction with the use of culturally appropriate birth interventions during childbirth. These interventions were generally simple and safe, resulting in a satisfying birthing experience. Conclusion The study findings contribute to achieving Sustainable Development Goal #3, “Good health and well-being” by reducing maternal and neonatal mortality, providing evidence of the effectiveness of non-pharmacological pain management, and avoiding unnecessary childbirth interventions.

Abstract Background Open liver surgery remains a primary surgical approach for complex liver resections and liver transplantation. However, the postoperative pain management is still a major challenge. Ultrasound-guided external oblique intercostal (EOI) plane block is a novel approach of regional anaesthesia and has a great potential to relieve postoperative pain after upper abdominal surgeries. This study aims to investigate the efficacy and safety of ultrasound-guided EOI plane block in managing postoperative pain after open liver surgery. Methods Seventy-four participants scheduled for open liver surgery will be randomly assigned to either the intervention group, receiving an ultrasound-guided EOI plane block with a single dose of 30 ml 0.375% ropivacaine, or the control group, which will not receive this block. All participants will be provided with opioid-based patient-controlled intravenous analgesia (PCIA) postoperatively. The primary outcome is resting pain score at 3 h postoperatively, assessed using numerical rating scale. Secondary outcomes include pain score at 6, 24, 48, and 72 h postoperatively, perioperative opioid consumption, remedial analgesics within 72 h postoperatively, PCIA usage within postoperative 72 h, postoperative recovery, length of hospital stay, postoperative side effects, block-related complications, and ropivacaine plasma concentration of participants receiving the block. Discussion This study is a randomised controlled trial to evaluate the efficacy and safety of ultrasound-guided EOI plane block for postoperative analgesia after open liver surgery. As regional anaesthesia plays an important role in the multimodal pain management, EOI plane block may prove to be an effective regional technique for enhancing postoperative pain relief and contributing to enhanced recovery after open liver surgery. Trial registration Chinese Clinical Trial Registry ChiCTR2200065745. Registered on November 14, 2022.

Rachel Weissbrod,1 Charlene Blake2 1Medasense Biometrics Ltd, Ramat Gan, Israel; 2Department of Anesthesia at the University of San Francisco, San Francisco, CA, USACorrespondence: Rachel Weissbrod, Medasense Biometrics, 4 hachilazon St, Ramat Gan, Israel, Email Rachel@medasense.comAbstract: The NOL-Nociception Level Index® is a multiparameter index, based on artificial intelligence for the monitoring of nociception (physiological pain response) during anesthesia that has recently been authorized by the FDA. The monitor utilizes continuous streams of information from a finger probe comprising four sensors, including photoplethysmography, to provide a personalized nociception score on a scale of 0– 100. Recent studies have suggested racial bias in pulse oximeter measurements due to the effect of melanin levels on photoplethysmography measurements. Therefore, there is a need to clinically validate new monitoring technologies in patients of all skin tones. The performance of the NOL scale in 8 patients that self-identified as Black or multiracial was compared to a database of 447 consented patients, assessing the response to surgical events at different levels of intensity. The descriptive, pilot data suggest that NOL performance in Black and multiracial patients is not different from the performance shown for the large database. Larger studies utilizing recognized skin tone scales to ensure accurate assessment of skin pigmentation are planned for the future.Keywords: nociception monitoring, pain management, inequity in healthcare, patient monitoring

Research question: What coping strategies have people with long-term pain brought with them after an eight-week low threshold pain management course, consisting of ACT and supervised physical activity, to manage their pain? Design: The study utilized a qualitative approach with semi-structured interviews. Method: Individual interviews were conducted with five women aged 47-59 who had participated in a pain management course in a Norwegian municipality in spring 2021. The data were analysed using phenomenology. Findings: The participants learned coping strategies that could be used during exacerbations of pain. The pain course did not change the participants' pain levels. The key coping strategies the participants took away were related to valuing work, relaxation, and physical activity. Although the participants felt they learned useful strategies from the coping course, the findings of this study show that it was challenging to implement the strategies in daily life after the course. Conclusion: The findings of this study indicate that working to identify one's values, exploring various forms of physical activity, and relaxation techniques can be effective coping strategies for managing pain. However, the findings also suggest that implementing these strategies in everyday life outside the course's framework may be challenging.

Objectives Pain is a common side effect of cancer that negatively impacts biopsychosocial well-being and quality of life. There has been increasing interest in using digital game interventions for managing pain in cancer patients. The present study aimed to consolidate and summarize knowledge regarding the role of games in reducing pain among cancer patients and enhancing their overall quality of life. Methods We reviewed studies published between 2000 and April 8, 2023, from databases such as PubMed, Scopus, and Web of Science. The focus was on determining the impact of health games on pain management in cancer patients. Results An initial search identified 2,544 studies, which were narrowed down to 10 relevant articles after removing duplicates and assessing quality. These studies examined the use of mobile and computer games across various types of cancer, including both pediatric and adult cases. The findings indicate that digital games, particularly those utilizing virtual reality technologies, can diminish pain and anxiety while enhancing treatment outcomes. Overall, the application of these technologies has the potential to improve cancer treatment. Conclusions Digital game interventions empower cancer patients by fostering effective communication and patient-centered approaches, which enhance perceptions, outcomes, and overall well-being. These games provide real-time feedback and facilitate interaction with healthcare professionals, which promotes self-management and boosts patient motivation and adherence to treatment protocols. As personalized educational platforms, they increase engagement through educational resources and symptom tracking, while also encouraging physical activity. Furthermore, they act as distraction tools during painful procedures, presenting new research opportunities in pain management and enhancing overall quality of life.