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Background: This randomised controlled trial evaluated the effect of radiofrequency ablation (RFA) of genicular nerve on muscle strength in osteoarthritis knee patients with chronic pain., Methodology: Fifty-four patients with chronic knee osteoarthritis, experiencing significant pain (VNRS > 50) and moderate to severe disease (KL grade ≥ 2) were enrolled. Group 1 received RFA of genicular nerves of the affected knee while Group 2 received a sham procedure. The primary outcome was change in knee muscle strength evaluated using isokinetic peak torque(IPT) using IsoforceTM isokinetic dynamometer at 3 months. Secondary outcomes included changes in pain scores, function, perceived effect of the treatment and compliance to physiotherapy., Results: At 3 months, significant difference was observed between IPT of flexor muscle at 60 and 180 degrees between the treatment and the Sham control (p-value = 0.01). No significant difference was observed in the extensor muscle strength. Within-group analysis revealed a significant increase in the IPT values for both extension and flexion at 60 and 180 degrees/sec evident across various time intervals. Group1 consistently reported lower VNRS scores at all time points. WOMAC scores of both groups were significantly different at all timepoints, with higher scores indicating reduced functionality in Group2. The GPE and compliance to physiotherapy were higher in Group1 patients at all times of follow up albeit decreasing trend in later periods., Conclusion: Application of RFA to genicular nerves in chronic OA knee patients resulted in better pain relief, improved functionality and increased muscle strength at extension and flexion at 3 months follow-up., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

BACKGROUND: The Lancet Low Back Pain (LBP) Series highlighted the lack of LBP data from low- and middle-income countries (LMICs). The study aimed to describe (1) what LBP care is currently delivered in LMICs and (2) how that care is delivered. DESIGN: An online mixed-methods study. METHODS: A Consortium for LBP in LMICs (n = 65) was developed with an expert panel of leading LBP researchers (>2 publications on LBP) and multidisciplinary clinicians and patient partners with 5 years of clinical/lived LBP experience in LMICs. Quantitative data were analyzed using descriptive statistics. Two researchers independently analyzed qualitative data using inductive and deductive coding and developed a thematic framework. RESULTS: Forty-seven (85%) of 55 invited panel members representing 32 LMICs completed the survey (38% women, 62% men). The panel included clinicians (34%), researchers (28%), educators (6%), and people with lived experience (4%). Pharmacotherapies and electrophysiological agents were the most used LBP treatments. The thematic framework comprised 8 themes: (1) self-management is ubiquitous, (2) medicines are the cornerstone, (3) traditional therapies have a place, (4) society plays an important role, (5) imaging use is very common, (6) reliance on passive approaches, (7) social determinants influence LBP care pathway, and (8) health systems are ill-prepared to address LBP burden. CONCLUSION: LBP care in LMICs did not consistently align with the best available evidence. Findings will help research prioritization in LMICs and guide global LBP clinical guidelines. J Orthop Sports Phys Ther 2024;54(8):560-572. Epub 11 April 2024. doi:10.2519/jospt.2024.12406 .

Competing Interests: There are no conflicts of interest.

Background and Aim: Sevoflurane, a preferred anaesthetic for children, exhibits a dose-dependent reduction in intraocular pressure (IOP). However, consensus is lacking regarding optimal end-tidal sevoflurane concentration for safe IOP measurement. This study aimed to identify the concentration at which IOP measurement could be attempted without inducing movements in paediatric patients after inhalational induction., Methods: Two paediatric groups (1-12 months and 12-36 months) with glaucoma undergoing examination under anaesthesia were recruited. After induction with 8% sevoflurane and 100% oxygen, the first child had an end-tidal sevoflurane concentration maintained at 2% for 4 min, followed by IOP measurement. Success was defined as 'no movement', and subsequent concentrations (adjusted in 0.2% steps) were determined using the Dixon and Massey method based on the previous patient's responses., Results: The study included 75 children. The effective concentration of sevoflurane causing 'no movement' during IOP measurement in 50% of the study population for successful IOP measurement was 1.98% (95% confidence interval [CI] 1.63, 2.17, P = 0.017) for 1-12 months group and 0.55% (95% CI 0.39, 0.66, P = 0.002) for 12-36 months group. Probit regression analysis yielded effective concentration of sevoflurane causing 'no movement' during IOP measurement in 95% of the study population values of 2.47% (95% CI 2.24, 4.58, P = 0.017) for 1-12 months group and 0.94% (95% CI 0.78, 1.57, P = 0.002) for 12-36 months group., Conclusion: In paediatric patients, a higher end-tidal sevoflurane concentration of 2% is needed for IOP measurement in 1-12 months age group compared to 0.5% required in 12-36 months age group, achieving success in 50% of the study population., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Anaesthesia.)

Essential care workers like police personnel, social workers, and office and administrative staff of health institutions are also at increased risk of coronavirus disease 2019 (COVID-19) exposure along with healthcare workers. The present study aims to estimate the distress, anxiety, depression, and sleep impact of COVID-19 pandemic on essential workers through an online survey. This cross-sectional study (included 369 participants) was conducted in Chandigarh through an online survey using three psychological scales: Peritraumatic Distress Inventory (PDI), Insomnia Severity Index, and Depression Anxiety Stress Scale. Three-hundred-sixty-nine frontline warriors from hospital and community settings were included in the study. The respondents include police personnel (274; 73.66%), office staff (24; 6.45%), social workers (53; 14.24%), and media staff (21; 5.65%). Maximum distress was reported by media/transport officials on duty (85.7%). The majority of them scored high (>14), and slightly less than one-fourth (23.8%) scored significantly abnormal (>23) on PDI. About 42.9% reported moderate insomnia, 52.4% exhibited severe anxiety, and 33.3% of media/transport participants reported severe depression. Psychological morbidity is high in media/transport and social workers working in the community during the COVID-19 pandemic., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Journal of Community Medicine.)

Background: Chronic low back pain is associated with both psychological and functional limitation. Yoga therapy has been shown to improve both the aspects. The present study was planned to evaluate integrated approach of yoga therapy with usaul care., Aims: This controlled randomized trial was done to evaluate the clinical and molecular changes resulting from integrated approach of yoga therapy (IAYT) as an adjunct regimen and compared it with usual care for the management of chronic low back pain patients., Material and Methods: We enrolled 29 adult patients with non-specific chronic low back pain (CLBP). Patients were randomly divided into two groups. The control group received the usual care of treatment as per institutional protocol. The yoga group received IAYT as an adjunct to usual care. Primary outcomes were pain intensity assessed by verbal numerical rating scale (VNRS) and functional ability assessed by Modified Oswestry Disability Index (MODI). Secondary outcomes were pain catastrophizing, quality of life, fear of movement related to CLBP, type of pain, levels of β-endorphin and TNF-α, and salivary CGRP. All parameters were measured at baseline, 1 and 3 months., Results: A Significant decrease in VNRS score at 1 and 3 months was observed in both the groups with the yoga group showing a more significant reduction in pain over time than the control group (p = 0.036). MODI improved significantly only in the yoga group at 1 and 3 months. Intergroup comparison revealed significantly better MODI over time in the yoga group (p < 0.001). DN4, PDQ, PCS, HADS (anxiety), and Euro QOL had a statistically significant improvement at 1 and 3 months in the yoga group compared with the control group. The HADS (depression) had a statistically significant reduction scores in the yoga group at 3 months compared with the control group (p = 0.012). There was a significant reduction in TNF-α values in the yoga group compared with baseline (p = 0.004)., Conclusion: IAYT therapy helped in addressing the psychological components of pain and improved quality of life patients with chronic low back pain compared with usual care., (© 2023 World Institute of Pain.)

Background: Telehealth has emerged as an alternative model for treatment delivery and has become an important component of health service delivery. However, there is inconsistency in the use of terminologies and a lack of research priorities in telehealth in musculoskeletal pain. The purpose of this international, multidisciplinary expert panel assembled in a modified three-round e-Delphi survey is to achieve a consensus on research priorities and for the standard terminology for musculoskeletal pain telehealth practice., Methods: In this international modified e-Delphi survey, we invited an expert panel consisting of researchers, clinicians, consumer representatives, industry partners, healthcare managers, and policymakers to participate in a three-round e-Delphi. Expert panels were identified through the Expertscape website, PubMed database, social media, and a snowball approach. In Round 1, potential research priorities and terminologies were presented to panel members. Panel members rated the agreement of each research priority on a 5-point Likert scale and an 11-point numerical scale, and each terminology on a 5-point Likert scale for the "telehealth in musculoskeletal pain " field over rounds. At least 80% of the panel members were required to agree to be deemed a consensus. We analyzed the data descriptively and assessed the stability of the results using the Wilcoxon matched-pairs signed rank test., Results: We performed an international e-Delphi survey from February to August 2022. Of 694 invited people, 160 panel members participated in the first round, 133 in the second round (83% retention), and 134 in the third round (84% retention). Most of the panel members were researchers 76 (47%), clinicians 57 (36%), and consumer representatives 9 (6%) of both genders especially from Brazil 31 (19%), India 22 (14%), and Australia 19 (12%) in the first round. The panel identified fourteen telehealth research priorities spanned topics including the development of strategies using information and communication technology, telehealth implementation services, the effectiveness and cost-effectiveness of telehealth interventions, equity of telehealth interventions, qualitative research and eHealth literacy in musculoskeletal pain conditions from an initial list of 20 research priorities. The consensus was reached for "digital health" and "telehealth" as standard terminologies from an initial list of 37 terminologies., Conclusion: An international, multidisciplinary expert consensus recommends that future research should consider the 14 research priorities for telehealth musculoskeletal pain reached. Additionally, the terms digital health and telehealth as the most appropriate terminologies to be used in musculoskeletal telehealth research., Register: Open Science Framework ( https://osf.io/tqmz2/ )., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: The present study is an attempt to validate the Hindi version of the EuroQoL (EQ-5D-3L) questionnaire for patients with chronic low back pain (CLBP)., Design: Prospective clinical study., Setting: The study was conducted on an outpatient basis with the subjects being followed via online platform on day 3., Subject: Native Indian patients above 18 years of age having CLBP who could speak and read Hindi were enrolled in the study., Methods: This study is a cross-sectional study on 132 patients presenting with CLBP. Hi-SF-36 was used as a reference scale. Pain was evaluated using the numeric rating scale. Psychometric properties including internal consistency, test-retest reliability on day 3 and convergent validity were evaluated. Confirmation factor analysis was carried out in order to establish the relationship between the five dimensions of Hi-EQ-5D-3L and the eight domains of Hi-SF-36., Results: The Cronbach alpha of 0.984 for index value and 0.944 for visual analog scale confirmed internal consistency of the Hi-EQ-5D. Intraclass correlation coefficient was found to be excellent for EQ index value (0.969, 95% CI: 0.954-0.979) and very good for visual analog scale (0.894, 95% CI: 0.844-0.928). Spearman rho correlation coefficients for the index value correlated strongly with all domains except role emotion ( r =0.181 on day 0 and r =0.239 on day 3). A good relationship between Hi-SF-36 and Hi-EQ-5D-3L was confirmed through factor analysis., Conclusion: The Hindi version of the EQ-5D-3L demonstrated comprehensibility, reliability and proved to be a valid instrument for the evaluation of health-related quality of life in CLBP patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Chronic low back pain (CLBP) is a common and significant cause of disability globally. In their lifetime, 70% to 80% of adults will have low back discomfort at some point. Even though CLBP is a very disabling disorder, information about its prevalence and associated factors is sparse in the literature., Objectives: We aimed to determine the prevalence of CLBP and its risk factors among an adult population, as well as related health concerns and health-seeking behaviors., Study Design: Cross-sectional study., Setting: A tertiary care setting in Chandigarh, India from November 2017 through February 2020., Methods: Adults of either gender who provided informed consent were included in the study. Sociodemographic and CLBP awareness data were collected using a standard questionnaire. Prevalence was expressed as proportion of sample, with 95% CI. For categorical and quantitative data, the chi squared and independent t test were utilized. Logistic regression was applied to identify significant risk variables and outcomes. A P value of <= 0.05 was considered significant., Results: A total of 2,847 patients were enrolled, with a mean (SD) age of 38 (14) years; 61% of them were men. These patients had a CLBP lifetime prevalence of 16% (95% CI, 15-17; 457/2,847). In addition, 62% (285/457) of these patients visited their doctor/physician more than 10 times and 23% (103/457) sought the advice of 2 physicians to treat their CLBP. Increasing age (odds ratio[OR], 1.040, 95% CI, 1.032-1.049; P < 0.001), being underweight (OR, 3.315; 95% CI, 1.494-7.359; P < 0.003) and increasing pain frequency (OR, 1.616; 95% CI, 1.139-2.293; P < 0.007) were identified as potential CLBP risks., Limitations: The study was carried out in a single tertiary hospital in northern India; hence its results cannot be extrapolated. Also, we were unable to categorize CLBP based on how severe the symptoms were, such as complaint-only or debilitating., Conclusion: An effective, supervised program addressing the younger productive population to maintain a healthy weight, give up smoking, and encourage an active lifestyle should be implemented., Key Words: Chronic low back pain, prevalence, health concerns, risk factors, public health.

Background Studying loneliness among children is important because it causes much social pain and is considered to be a risk factor for many mental and physical problems. Methods We did an online survey between July and September 2020 among students and their parents from a cluster of government and private schools chosen from north, south, east and west of Chandigarh. The survey consisted of child and parent versions of the Loneliness and Social Dissatisfaction Questionnaire, Parent-Child Relationship (PCR) Questionnaire and Conflict Behaviour Questionnaire SF. Parental distress was assessed using the Depression, Anxiety and Stress Scale-21. Results The majority of children and parent participants reported high loneliness and dissatisfaction among children. A significant positive association was found between children and parent reported loneliness and dissatisfaction, and between child reported PCR and parent perception of PCR. A child's appraisal of her loneliness had a significant negative association with depression among parents. Parent's perception of child loneliness and dissatisfaction was negatively associated with PCR and parental anxiety. High loner boys reported poor quality of relationship and more conflicts with their parents than girls. Children who share cordial relations with their parents had fewer conflicts and also scored low on loneliness. Conclusion These results suggest that the issue of loneliness and dissatisfaction among children has attained epidemic proportions in the Covid-19 era, and active interventions are needed to safeguard the mental health of children. Our study emphasizes the need to plan guidance strategies with a joint effort of schools and families to strengthen within family relations of children.

Study Design: A cross-cultural adaptation, validation, and psychometric analysis., Objective: The main aim was to assess the validity and reliability of the Hindi version of the Roland Morris Disability Questionnaire (Hi-RMDQ) for chronic low back pain., Summary of Background Data: Roland Morris Disability Questionnaire is a standardized, self-administered tool for disability assessment in patients with chronic low back pain. However, its Hindi version has not been validated., Materials and Methods: Cognitive debriefing was carried out with 10 patients to ensure the comprehensibility of the Hi-RMDQ. Following this, 120 patients were asked to complete the finalized questionnaire along with the modified Oswestry Disability Index Questionnaire, Quebec Back Pain Disability Score, and the Verbal Numeric Rating Scale. The patients were then asked to again fill out the finalized questionnaire after 72 hours. The internal consistency and retest reliability of the Hindi translated version of the questionnaire was tested. Its correlation with the other scores was also analyzed., Results: The translated questionnaire showed excellent internal consistency (Cronbach α=0.989) and excellent retest reliability (intraclass correlation coefficient=0.978). There was a positive and statistically significant association between the Hi-RMDQ, modified Oswestry Disability Index Questionnaire ( r =0.807; P <0.01), Quebec Back Pain Disability Score ( r =0.839; P <0.01), and Verbal Numeric Rating Scale ( r =0.713; P <0.01)., Conclusion: The Hi-RMDQ version is an easy-to-use, acceptable, reliable, and valid tool to measure disability in the Indian population with nonspecific back pain with or without leg pain., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Background and Aims: This cross-sectional study aimed to analyze the psychosocial, behavioral, and sleep impact of coronavirus disease-19 (COVID-19) pandemic on healthcare workers (HCWs) at a tertiary-care hospital in Northern India., Materials and Methods: An online questionnaire including three psychological scales - peritraumatic distress inventory (PDI), insomnia Severity Index (ISI), and Depression anxiety stress scale was circulated among the HCWs at a tertiary-care hospital in Northern India., Results: Three hundred and ninety-six HCWs (Mean age standard deviation: 34.8 [8.1%] years; 181 females) responded. Place of posting was active COVID area (27.2%), reserve active COVID team (23.2%), trained reserve pool (29.5%), and non-COVID areas (19.9%). More than half of all the respondents (51%) had abnormal PDI score (>14) with a propensity to develop posttraumatic stress disorder. Furthermore, there was a significantly higher prevalence of abnormal PDI scores in those involved in active COVID care units (74%) versus non-COVID care unit (24%, P = 0.001). More than 60% of all the respondents had abnormal ISI score suggesting significant insomnia. Stress was seen in 71% of all the respondents while 82% were anxious and 77% participants had depressive symptoms. Hence, the psychological morbidity among the HCWs was high., Conclusion: Our study found a much higher prevalence of peritraumatic distress, insomnia, anxiety, stress, and depression among the HCWs, more so in those working in COVID areas. Factors indigenous to Indian population in terms of psychological health must be studied and addressed to reduce this psychological morbidity since the battle with COVID is long., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Industrial Psychiatry Journal.)

Background: To compare ultrasound-guided pulsed radiofrequency (PRF) of the genicular nerve with the genicular nerve block using local anesthetic and steroid for management of osteoarthritis (OA) knee pain., Methods: Thirty patients with OA knee were randomly allocated to receive either ultrasound-guided PRF of the genicular nerve (PRF group) or nerve block with bupivacaine and methylprednisolone acetate (local anesthetic steroid [LAS] group). Verbal numeric rating scale (VNRS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were measured at pre-procedure and 1-, 4-, and 12-weeks post-procedure., Results: VNRS scores decreased significantly ( P < 0.001) in both the groups at 12 weeks and other follow up times compared to baseline. Seventy-three percent of patients in the PRF group and 66% in the LAS group achieved effective pain relief (≥ 50% pain reduction) at 12 weeks ( P > 0.999). There was also a statistically significant ( P < 0.001) improvement in WOMAC scores in both groups at all follow up times. However, there was no intergroup difference in VNRS ( P = 0.893) and WOMAC scores ( P = 0.983). No complications were reported., Conclusions: Both ultrasound-guided PRF of the genicular nerve and blocks of genicular nerve with local anesthetic and a steroid provided comparable pain relief without any complications. However, PRF of the genicular nerve is a procedure that takes much more time and equipment than the genicular nerve block.

Objectives: We sought to translate the parallel forms (parent and child versions) of English versions of the Loneliness and Dissatisfaction Questionnaire (LSDQ-C), Parent Child Relationship (PCRQ-C), and Conflict Behavior Questionnaire (CBQ-C) into Hindi and evaluate their psychometric properties., Methods: Hindi translation and cross-language adaptation of LSDQ-C, PCRQ-C, and CBQ-C were done following WHO guidelines. Children aged 10-18 years old studying in either government or private schools of Chandigarh were enrolled through snowball convenient random sampling technique. Psychometric properties were assessed using intraclass correlation (ICC), Chronbach's alpha, test-retest reliability, paired t -test, and split-half reliability., Results: Item wise test-retest reliability of the Hindi version of all scales was assessed, and for most items, the ICC value was > 0.80, indicting good to excellent reliability. ICC value was in the acceptable range for a few items for the child version of the scales (0.70). Split half reliability was > 0.80. Our findings suggest good to excellent agreement between the English and Hindi version of all the scales., Conclusions: The internal consistency, split-half reliability, and test-retest reliability are good to excellent. Thus, the Hindi version of parallel forms (parent and child versions) LSDQ, PCR, and CBQ as translated in this study is a valid instrument., (The OMJ is Published Bimonthly and Copyrighted 2022 by the OMSB.)

Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Objectives: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty., Setting: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless., Participants: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone., Results: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment., Conclusion: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Low back pain (LBP) is a major health concern and is closely associated with psychosocial morbidity and diminished Health-related quality of life (HRQoL). This is minimally investigated in community-based samples of developing nations like India. This study is aimed to specifically investigate the exposure-outcome associations between LBP and burden of disability (Modified Oswestry questionnaire (MODQ)), psychological morbidities (Depression, Anxiety and Stress Scale (DASS-21)), and HRQoL (Short Form -12 version 2 (SF12V2). A Cross-sectional study using a community-based sample of LBP positive population was conducted. The range of treatment options sought was also collected. Chi-square tests and independent t-test were used to analyze the data. Of 1531 recruited participants, 871(57%) were identified as LBP positive of whom 60% were females. Mean (SD) of age and pain intensity of LBP patients was 33 (11) years and numeric rating scale4.2 (2.6) respectively. Two-third reported minimal/moderate disability. Mean (SD) scores of depression 11.87 (4.05), anxiety (8.32), stress 13.7 (5.98), physical and mental summary scores of SF-12v2 were 47.9 (7.4) and 42.2 (10.4). A multitude of remedial options was sought for the ailment. LBP causes significant disability and psychological morbidity among affected population. This may adversely affect their HRQoL and subsequently productivity. Acupuncture was a preferred treatment sought by Indian LBP patients.

Background: Chronic low back pain (CLBP) incurs huge costs owing to increased healthcare expenditure, disability, insurance, and work absenteeism. Opioid analgesics are commonly used for the management of CLBP., Objective: To compare and rank the opioids used in the management of CLBP, in terms of efficacy and safety., Study Design: Systematic review and network meta-analyses (NMA)., Method: The search was conducted in Embase, PubMed, Cochrane databases for randomized controlled trials (RCTs) that had evaluated the efficacy and safety of opioids in CLBP. Two authors independently performed data extraction and quality assessment. The proportion of patients reporting either 30% or 50% reduction in pain from baseline to follow-up on the numeric rating scale, was measured as efficacy outcome. Pairwise meta-analyses and Bayesian NMA, within the random-effects model, were used to synthesize data. Effect estimates from Bayesian NMA were presented as odds ratio (OR) with 95% credible intervals (CrI). Heterogeneity and convergence were assessed by using I 2 and deviation information criteria., Results: Twenty-three RCTs with a total of 8,420 patients, evaluating 13 different opioids were included in this NMA. For 30% pain reduction, oxymorphone (OR: 5.36; 95% CrI: 1.02-30.3), tramadol with acetaminophen (OR: 2.37; 95% CrI: 1.08-5.17), and buprenorphine (OR: 2.29; 95% CrI: 1.05-5.07) shown statistically significant more effective than placebo. For 50% pain reduction, the statistically significant difference is observed with buprenorphine (OR: 2.38 95% CrI: 1.08-5.24), oxymorphone (OR: 5.10; 95% CrI: 1.31-20.41), and tramadol with acetaminophen (OR: 2.11; 95% CrI: 1.07-4.21). Hydrocodone (OR: 0.33; 95% CrI: 0.14-0.77) was found statistically safer compared to the other opioids., Limitations: Only 5 trials had more than a 12-week study duration. We need clinical trials with longer follow-up as CLBP management requires a longer duration, and long-term prescribing of opioids associated with severe adverse event profile, development of tolerance, and dependence., Conclusions: Oxymorphone has an advantage over other opioids to reduce pain by 30% and 50% in patients with CLBP.

Precis: This study evaluated 2 doses of intranasal dexmedetomidine (IND) (3.0 and 3.5 µg/kg) as a procedural sedative for postoperative examination of children with glaucoma. A dose of 3.5 µg/kg was more efficacious and obviated the need for repeated general anesthesia., Purpose: This study was carried out to determine the safety and effective dose of IND as a procedural sedative for postoperative follow-up examinations after glaucoma surgery in children in place of repeated examination under anesthesia., Materials and Methods: In this prospective randomized double-blinded interventional study, consecutive children aged 6 months to 6 years were randomized to receive 3.0 and 3.5 µg/kg IND using a mucosal atomizer device in the preoperative area of the operating room, under continuous monitoring of vital signs. Intranasal midazolam 0.25 mg/kg was used as a rescue agent in case of inadequate sedation, and general anesthesia was administered in case of persistent failure. All infants underwent a complete anterior and posterior segment evaluation including intraocular pressure and corneal diameter measurements., Results: A total of 30 and 31 children aged 23.9±15.0 and 19.2±10.1 months, respectively, received 3.0 and 3.5 µg/kg IND. Adequate sedation was possible in 18 of 30 (60%) children receiving 3.0 µg/kg and 24 of 31 (77.4%) receiving 3.5 µg/kg IND alone (P=0.17). In combination with midazolam, successful sedations were 86.6% versus 100%, respectively (P=0.052). One patient in the 3.5 µg/kg group had ventricular arrhythmia, reversed with dextrose-saline infusion and injection glycopyrrolate., Conclusions: IND appears to be a safe and effective procedural sedative for postoperative follow-up examinations of pediatric glaucoma patients at doses of 3 and 3.5 µg/kg. The dose of 3.5 µg/kg was successful in more children.

Background and Aims: Literature documents EC 50 (End-tidal) of sevoflurane for CLMA (Classic Laryngeal Mask airway) insertion between 1.5 and 2% and most of these studies suggest maintaining the required end-tidal sevoflurane concentration for 10-25 minutes before LMA insertion. Waiting for this long interval for blood brain sevoflurane equilibration may not be feasible in children especially during failed ventilation. We aimed to estimate EC 50 of sevoflurane for CLMA insertion at equilibration time points of 2.5 min and 5.0 min., Material and Methods: In this randomized trial, children aged 2&#95;8 years of either sex having American Society of Anesthesiologists status I undergoing elective cataract surgery were included. After inhalational induction of general anesthesia with 8% sevoflurane and 100% oxygen, intravenous cannulation was secured. The sevoflurane vaporizer was finely adjusted to maintain an end-tidal sevoflurane concentration at 2% for 2.5 min for first child in group 2.5 and 5 min in group 5.0. This was followed by LMA insertion which was considered to be unsuccessful if there was "movement" and successful if "no movement" occurred. End-tidal concentration was increased/decreased (step-size 0.2%) using Dixon and Massey up and down method in the next patient depending upon the previous patient's response., Results: EC 50 of sevoflurane for insertion of classic LMA in children aged 2-8 yrs in 100% oxygen was 1.1% (0.9-1.2) at 2.5 min and 1.6% (1.5-1.7) at 5.0 min. Derived EC 95 (95% CI) at 2.5 min was 1.8% (1.5-9.2) and at 5.0 min was 1.8% (1.4-8.8) respectively., Conclusion: We suggest maintaining end-tidal sevoflurane of 1.6% for 2.5 min and 1.8% for 5 min for successful CLMA insertion., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.)

Competing Interests: The authors have no conflicts of interest to declare.

Background: Low back pain (LBP) ranks first for disability and sixth for overall burden on world health, with an annual approximate cost of $135 billion. There are limited data on the prevalence and risk factors for LBP in developing countries, such as India., Objectives: To assess the prevalence, pain intensity, and quality of life (QOL) associated with LBP in northern India., Study Design: Cross-sectional study., Settings: Northern states of India., Methods: Adult population of different strata of the community were interviewed. Lifetime, point, 1-year, and age standardized lifetime prevalence with 95% confidence intervals (CI) and QOL, and pain intensity using the Numeric Rating Scale (NRS-11) were determined. Binary logistic regression test was conducted to determine the predictors of LBP prevalence; odds ratio (OR) with 95% CI are presented. Significance level was set at P <= 0.05., Results: A total of 1,531 patients were interviewed of whom 48% were men and mean (standard deviation [SD]) age was 32 (10) years. Lifetime, point, 1-year, and age standardized lifetime prevalence (95% CI) were 57% (54%-59%), 32% (30%-34%), 48% (46%-51%), and 59% (56%-62%), respectively. Average (SD) NRS-11 was 4.2 (2.6). Significant impact of LBP on sleep (24%), depression/psychological problems (24%), and social life (28%) were observed. Women (OR, 2.23; 95% CI, 1.80-2.77; P < 0.05), walking/lifting activity (OR, 1.362; 95% CI, 1.097-1.692; P < 0.05), and increasing age (OR, 1.03; 95% CI, 1.02-1.04; P < 0.05) were most significant positive predictors of LBP., Limitations: The progression of LBP could not be assessed in the enrolled patients., Conclusions: LBP is highly prevalent in India, adversely affecting QOL in respondents. This calls for action by health officials to plan prevention, education, and management programs in the society., Key Words: Low back pain, pain intensity, prevalence, incidence, quality of life.

Background: Transforaminal (TF) lumbar injection is a commonly used minimally invasive intervention for management of chronic low back pain. TF injection can be performed using various approaches to inject the drug to the anterior epidural space (AES)., Objectives: To identify the volumes of contrast medium needed to reach the AES and other landmarks in the Kambin triangle (KB) and subpedicular (SP) approach of TF injection in patients with lumbosacral radicular pain., Study Design: Randomized controlled trial., Setting: Pain clinic and operating room of a tertiary care hospital., Methods: Seventy-five eligible patients were randomized to receive TF epidural injection either by SP (SP group; n = 38) or the KB (KB group; n = 37) approach under fluoroscopic guidance. After confirming the appropriate needle position, contrast medium was injected at 0.5 mL increments up to 2 mL under intermittent fluoroscopy. Contrast medium volumes needed to reach specific landmarks, that is, AES, medial to superior pedicle, medial to inferior pedicle, medial aspect of both the superior, and neural spread, were recorded. Following this, 4 mL of the drug (0.5% lidocaine 1 mL + methylprednisolone 80 mg + 1 mL normal saline solution) was injected. Patients were evaluated for Visual Analog Scale (VAS) and modified Oswestry Disability Questionnaire (MODQ) scores after epidural injections at 2 weeks, 1 month, and 2 months., Results: Average volume of contrast medium needed to reach AES was 1.10 ± 0.46 mL in the KB approach and 1.10 ± 0.38 mL in the SP approach. Contrast medium volume needed to reach other landmarks showed comparable results in both groups. AES was seen in 27.02% (10/37) patients in the KB group and 23.6% (9/38) patients in the SP group with 0.5 mL of contrast medium. This increased to 56.76% (21/37) and 77.7% (28/38) with 1 mL of contrast medium (P = 0.03, chi-square test). No anterior spread was seen even after 2 mL of contrast medium in 4 patients in the KB group and 2 patients in the SP group. Neural spread was seen in 100% of patients in the KB group after 0.5 mL of contrast medium, but in 34 (89.4%) patients in the SP group (P = 0.03, chi-square test). We did not note any contralateral spread. Short-term effectiveness in pain relief in terms of VAS for back pain and functional improvement in terms of MODQ score over time showed similar results in both groups. Intravascular needle puncture and needle paresthesia was comparable in both groups., Limitations: Small follow-up duration is one the limitations of this study. Future studies will be needed to assess any long-term differences in outcome between approach methods. Also, use of intermittent fluoroscopy might have limited detection of intravascular injections of the contrast medium in comparison to the continuous fluoroscopy., Conclusions: To conclude, our study revealed that average volume of contrast medium needed to reach AES and other landmarks were comparable with both approaches of TF injection., Key Words: Transforaminal injection, subpedicular approach, Kambin triangle approach, contrast medium spread, anterior epidural spread.

Treatment of chronic pain is an essential service. Due to lockdown, travel restrictions, social and physical distancing requirements or fear that health care facilities may be infected; patients may avoid visiting health care facilities in person. It is also imperative to decrease the risk of exposure of the health care workers (HCWs) to severe acute respiratory syndrome corona virus 2 (SARS CoV2) and to ease the overtly burdened health care system. But any disruption in pain practice will have alarming consequences for individuals, society, and whole of health care system and providers. In the current scenario of COVID-19 pandemic, telemedicine is emerging as a key technology for efficient communication and sustainable solution to provide essential health care services and should be considered for chronic pain patients (CPPs). Recently, Board of Governors in supersession of Medical Council of India along with National Institution for Transforming India (NITI Aayog) released "Telemedicine Practice Guidelines" enabling registered medical practitioners to provide healthcare using telemedicine. This article describes the challenges in CPPs during COVID-19 pandemic and the use of telemedicine as the rescue management vehicle for CPPs in current scenario., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Anaesthesia.)

Background: Low back pain (LBP) is ranked highest in terms of disability-adjusted life-years lived. Patient education and self-management have shown to play a crucial role in the overall pain management. However, the literature on the same with respect to Indian context is still lacking. The study was aimed to develop, validate and assess the acceptability and effectiveness of self-instructional educational module among Indian chronic LBP (CLBP) patients., Methods: A prospective single-arm open-label study was conducted in a pain clinic of a tertiary care public hospital in North India with 'Backcare booklet-self-instructional module (SIM)' as an intervention in patients with CLBP. SIM was developed with the intent to provide up-to-date evidence-based information in an easy understanding way to patients with CLBP. 132 patients were administered SIM with a single session of verbal explanation. Pain intensity (numeric rating scale [NRS]), disability, fear-avoidance belief Questionnaire (FABQ), quality of life (EQ5D) and knowledge level were assessed at baseline and after 3 months of intervention. Student's paired t -test and Chi-square test were used. Data were analysed using SPSS version 15.0., Results: 120 patients successfully completed the 3 months' follow-up. Significant reductions were observed in pain intensity (76[12] vs 55 [15, P < 0.01); disability (51[14] vs 43 [10], P < 0.01); FABQ (46[12] vs 41 [10], P < 0.01); EQ5D (0.35 [0.27] vs 0.18 [0.26], P < 0.01)., Conclusion: Backcare booklet as an intervention, along with usual pharmacological care is a cost-effective educational medium to promote self-management of CLBP in the clinical outpatient settings., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Anaesthesia.)

Background: Intra-articular injections of platelet-rich plasma to treat symptoms of knee osteoarthritis have been successfully used in young patients. However in most of these studies the control and test knees were present in different patients thus incorporating a large amount of bias in the results. Therefore, the present study was designed in which patients with bilateral osteoarthritis knee were included and platelet-rich plasma was administered in one knee and normal saline in another knee of same patient., Methods: 20 patients aged 30-65 years with bilateral osteoarthritis knees (ASA class I and II) of either gender were included in the study. Patients were randomized to receive platelet-rich plasma and normal saline in one of the two knees. The primary outcome was VAS and WOMAC score at 6months after procedure. The secondary outcome included changes in joint stiffness, physical function, any adverse effects noted during the course of study., Results: The baseline VAS score in platelet-rich plasma knee was 8.4 ± 0.88 which improved significantly to 4.85 ± 2.48 (p < 0.001) at 6months as compared to normal saline knee (p = 0.017). The WOMAC pain score also improved from baseline (14.5 ± 1.3) to over 6month 7.00 ± 4.24 (p < 0.001) in platelet-rich plasma knee while in the normal saline knee, no significant change occurred from baseline to six months (10.2 ± 1.2 to 10.05 ± 1.23). There was also significant decrease in stiffness and improvement of physical activity in the platelet-rich plasma knee as compared to normal saline knee., Conclusion: The present study showed significant decrease in pain and stiffness and improvement of physical functions of knee joint with intra-articular platelet-rich plasma injection as compared to normal saline., (Copyright © 2019 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Objective: We evaluated the accuracy and feasibility of transcutaneous laryngeal ultrasonography as an alternative to videolaryngoscopy for assessing vocal cord mobility to rule out recurrent laryngeal nerve injury following thyroidectomy., Methods: Forty-five adult patients scheduled to undergo elective thyroidectomy under general anesthesia were included. Preoperatively, indirect laryngoscopy and transcutaneous laryngeal ultrasonography was done for assessing vocal cord mobility. Intraoperatively, following induction, patients were intubated using videolaryngoscope. On completion of the surgical procedure, one anesthetist performed videolaryngoscopy so as to record vocal cord mobility while the patients were being extubated in deep plane of anesthesia. Simultaneously another anesthesiologist performed transcutaneous laryngeal ultrasonography.Vocal cord mobility, changes in hemodynamics and total time duration for the two procedures was recorded. Indirect laryngoscopic assessment and flexible fiberoptic laryngoscopy was done on postoperative day 1 and 7 respectively., Results: Postoperative videolaryngoscopy picked up bilaterally mobile vocal cords in 88.8% cases. Transcutaneous laryngeal ultrasonography could correctly identify 39(86.6%) of these patients, with 1(2.5%) patient being misdiagnosed as having bilaterally immobile vocal cords. Further, videolaryngoscopy identified 5 patients of vocal cord palsy, of which transcutaneous laryngeal ultrasonography correctly identified 3 (60%) patients. Hence, in comparison to videolaryngoscopy, the sensitivity, specificity, positive predictive value, and negative predictive value of transcutaneous laryngeal ultrasonography for assessment of vocal cords was 75%, 95.1%, 60%, and 97.5% respectively., Conclusion: In patients undergoing thyroidectomy, transcutaneous laryngeal ultrasonography can serve as a non-invasive, bedside screening tool for assessing vocal cord palsy postoperatively., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Intravenous cannulation at lighter planes of anaesthesia can lead to adverse respiratory and haemodynamic events. So far, there is no consensus on optimum end tidal sevoflurane concentration required for intravenous cannulation in children. We aimed to evaluate the optimum end tidal concentration at which an intravenous cannulation can be successfully attempted without movements in paediatric patients after inhalational induction of general anaesthesia., Material and Methods: In this clinical trial, paediatric subjects of either sex aged 1-3 years, weighing 7-15 kg having American Society of Anaesthesiologists physical status I/II of undergoing elective cataract surgery were included. After inhalational induction of general anaesthesia with 8% sevoflurane and 100% oxygen, end tidal sevoflurane concentration was maintained at 2% for 4 minutes for the first child. This was followed by intravenous cannulation attempted by an experienced anesthesiologist. The intravenous cannulation was considered to be unsuccessful if there was "movement" and successful if there was "no movement" in response to the stimuli of cannulation. End-tidal concentration was increased/decreased (step-size 0.2% for sevoflurane) using Dixon and Massey up and down method in the next patient depending upon previous patient's response., Results: The sevoflurane EC50 for successful intravenous cannulation is 1.32% ± 1.0%. Pearson correlation (r) between weight of the child and response to intravenous cannulation was found to be 0.40 with P value of 0.008., Conclusion: Intravenous cannulation can be accomplished without movements at end tidal sevoflurane of 1.3% in children aged 1-3 years in 50% of children., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Postamputation limb pain or phantom limb pain (PLP) develops due to the complex interplay of peripheral and central sensitization. The pain mechanisms are different during the initial phase following amputation as compared with the chronic PLP. The literature describes extensively about the management of established PLP, which may not be applicable as a preventive strategy for PLP. The novelty of the current narrative review is that it focuses on the preventive strategies of PLP. The institution of preoperative epidural catheter prior to amputation and its continuation in the immediate postoperative period reduced perioperative opioid consumption (Level II). Optimized preoperative epidural or intravenous patient-controlled analgesia starting 48 hours and continuing for 48 hours postoperatively decreased PLP at 6 months (Level II). Preventive role of epidural LA with ketamine (Level II) reduced persistent pain at 1 year and LA with calcitonin decreased PLP at 12 months (Level II). Peripheral nerve catheters have opioid sparing effect in the immediate postoperative period in postamputation patients (Level I), but evidence is low for the prevention of PLP (Level III). Gabapentin did not reduce the incidence or intensity of postamputation pain (Level II). The review in related context mentions evidence regarding therapeutic role of gabapentanoids, peripheral nerve catheters, and psychological therapy in established PLP. In future, randomized controlled trials with long-term follow-up of patients receiving epidural analgesia, perioperative peripheral nerve catheters, oral gabapentanoids, IV ketamine, or mechanism-based modality for prevention of PLP as primary outcome are required., Competing Interests: There are no conflicts of interest.

Background: Emerging evidence suggests an association between vitamin D deficiency and low back pain (LBP)., Objective: To pool evidence on the prevalence of hypovitaminosis D in patients with LBP., Study Design: Meta-analysis., Methods: A comprehensive literature search was done in PubMed, Cochrane Database, and Google scholar for observational studies including cohort, cross sectional (CS), and case control (CC) evaluating the prevalence of hypovitaminosis D in LBP patients. The primary outcome assessed was a prevalence of hypovitaminosis D in patients with LBP, presented as weighted pooled prevalence ratio (WPPR) with 95% confidence interval (CI) using the random effects model. Heterogeneity and inconsistency of the measurements were identified through Cochran's Q statistic and I² statistic. We also performed sensitivity analysis, publication bias (using funnel plot and Begg's test), and subgroup analysis., Results: Fourteen studies (6 were CC, 6 CS, and 2 cohort) involving 2602 patients were included in the final analysis. The WPPR (95% CI) of hypovitaminosis D in patients with LBP was found to be 0.72 (0.60-0.83). Marked heterogeneity was observed, median quality score of all studies was 7.5 interquartile range (IQR) (6.2 - 8.7) on a scale of 0 to 11. Sensitivity analysis showed robustness of the results. The WPPR of hypovitaminosis D was lower in CS at 0.60 (0.35-0.85) as compared to CC studies at 0.81 (0.72-0.90) (P < 0.01). The WPPR was lower in men at 0.74 (0.63-0.86) as compared to women at 0.84 (0.78-0.89) (P < 0.01). No publication bias was observed., Limitations: Heterogeneity in the cut off level of vitamin D to classify the included patients as vitamin D deficient., Conclusions: The high prevalence of hypovitaminosis D was observed in patients with LBP. This provides a chance to screen the deficiency and correct it by supplementation, which can be therapeutic adjunct in the management of LBP patients., Key Words: Low back pain, hypovitaminosis D, meta-analysis, pooled prevalence, systematic review.

Purpose: Intraperitoneal local anesthetic nebulization is a new and novel technique for providing pain relief following laparoscopic cholecystectomy. We compared the analgesic efficacy of intraperitoneal ropivacaine-fentanyl nebulization with ropivacaine nebulization alone for providing pain relief following laparoscopic cholecystectomy Materials and Methods: This prospective, randomized, double-blind, placebo-controlled trial included 75 American Society of Anesthesiologists I/II patients, 18-60 years old, scheduled to undergo laparoscopic cholecystectomy under general anesthesia. Patients were randomly allocated to one of the three groups of 25 patients each to receive intraperitoneal nebulization using normal saline (group I), 30 mg of 0.75% ropivacaine (group II), or 30 mg of 0.75% ropivacaine with 100 μg fentanyl (group III). Visual analogue scale (VAS) scores for pain during rest and movement, shoulder pain, nausea or vomiting, and sedation were recorded for 48 hours postoperatively. Time to providing first rescue analgesia and 48-hour tramadol consumption were also noted., Results: Significantly greater number of patients in the placebo group had overall VAS >30 both at rest and during movement. Greater number of these patients also complained of postoperative shoulder pain and had significantly more tramadol consumption in the postoperative period. Furthermore, patients in the ropivacaine-fentanyl group demanded first dose of rescue analgesic significantly later than the other two groups., Conclusions: Nebulization results in better and uniform dispersion of analgesic drug intraperitoneally. Following laparoscopic cholecystectomy surgeries, ropivacaine nebulization of intraperitoneal cavity, with or without fentanyl, provides highly effective postoperative analgesia, with decreased incidence of shoulder pain. Furthermore, addition of fentanyl to ropivacaine prolongs the duration of analgesia.

Background: In this study, we compared effectiveness of two doses of dexmedetomidine (0.15 μg/kg and 0.3 μg/kg) in preventing desflurane-induced emergence agitation (EA) in pediatric patients undergoing elective cataract surgery., Methods: It is a prospective double-blinded randomized study conducted on 65 American Society of Anesthesiologists 1 children (2-10 years) who underwent elective cataract surgery at our institute. They were randomized into two equal groups, who received either dexmedetomidine 0.15 μg/kg (Group D 0.15 ) or dexmedetomidine 0.30 μg/kg (Group D 0.3 ) intravenously after induction of anesthesia. An observer blinded to groups recorded heart rate (HR), arterial blood pressure, oxygen saturation, end-tidal carbon dioxide, and respiratory rate (RR) at regular intervals and evaluated preoperative anxiety, state of agitation, and postoperative pain using validated scores., Results: Both groups (Group D 0.15 , n = 27 vs. Group D 0.3 , n = 26) were demographically identical. In intraoperative period, the difference in HRs was significantly lower in Group D 0 . 3 from 5 min till 15 min of the surgery ( P < 0.05), but thereafter, from 20 min till end of surgery, the rates were comparable in both the groups, whereas RR and blood pressure fluctuations were comparable throughout. Postoperative pain scores and postoperative agitation score were significantly lower in Group D 0.3 than D 0.15 at all time intervals ( P < 0.05)., Conclusions: In our study, 0.3 μg/kg intravenous dexmedetomidine was found to be superior to 0.15 μg/kg group in effectively reducing EA and postoperative pain, without producing adverse effects such as hypotension or bradycardia., Competing Interests: There are no conflicts of interest.

Background: Epidural injections (EIs) are the most commonly performed minimally invasive intervention in managing chronic low back pain (CLBP). There is inconsistency in data to accurately predict the degree of hypothalamic-piuitary-adrenal (HPA) axis suppression in patients receiving exogenous steroid therapy, especially in the form of epidural steroid injections (ESIs)., Objective: We aim to quantify the degree and duration of HPA axis suppression after a single ESI of 80 mg methyl prednisolone acetate in patients with CLBP., Study Design: A single open-label prospective study., Setting: An operating room of a tertiary care hospital., Methods: Patients with CLBP and unilateral radicular pain were included in this study. An ESI of 80 mg of methylprednisolone acetate was administered in each patient. Blood samples for cortisol and adrenocorticotropic hormone (ACTH) were collected before the ESI and on days 7, 14, and 28 after the ESI. The patients' pain levels were graded on the numeric rating scale (NRS) at baseline and on days 7, 14, 28, and 60 after the ESI in the pain clinic., Results: A total of 30 patients were enrolled in this study. The median with interquartile range (IQR) serum cortisol level at baseline and on days 7, 14, and 28 after intervention were found to be 329.55 (208.49 - 399.48) nmol/L, 72.99 (52.95 - 119.82) nmol/L, 194.45 (73.88 - 292.52) nmol/L, and 302.56 (257.68 - 357.43) nmol/L, respectively. A significant discrease in the serum cortisol levels was observed on days 7 (P < 0.001) and 14 (P < 0.001). Twenty-six (87%), 13 (43%), and 2 (7%) patients had serum cortisol levels below normal (<170 nmol/L) on days 7, 14, and 28, respectively. HPA axis suppression was observed in all of the patients for a median (IQR) period of 14 days (range: 11-17 days)., Limitations: This study was an unblinded observational study. The effect of a single ESI was studied and the sample collection of day 21 serum cortisol and ACTH were passed over., Conclusions: HPA axis function was suppressed after the ESI until day 14 and returned to the normal range by postoperative week 4., Key Words: Epidural injections, steroids, HPA, suppression, cortisol, ACTH.

Objective: The contribution of neuropathic pain (NeP) in chronic pain conditions is increasingly emphasized with the development of multiple questionnaire-based measurement scales. The painDETECT questionnaire (PDQ) is a frequently used self-reported outcome measure to assess NeP in patients with chronic pain conditions in research and regular clinical practice. The aim of the study was to translate and cross-culturally adapt the PDQ into Hindi (Hi-PDQ) for use in India and to investigate its psychometric properties., Methods: PainDETECT questionnaire translation into the Hindi language was carried out according to standard guidelines. Patients suffering from chronic pain attending a pain clinic were recruited. Patients completed the Hi-PDQ at baseline and were retested was conducted after 3 days Exploratory factor analysis (EFA) was carried out to assess the factor structure of the Hi-PDQ. Measurement properties, including floor and ceiling effects, discriminative validity, and psychometric properties, were also assessed., Results: A total of 160 patients with chronic pain were recruited, including 80 in each NeP and non-NeP group. The retest was completed in 82 patients. Mean Hi-PDQ scores were significantly higher in the NeP group compared with the non-NeP group (20.7 [SD 5.9] vs. 9.9 [SD 5.9]; P < 0.01). EFA revealed a 2-factor structure explaining 56.9% variance. The Hi-PDQ was found to have adequate internal consistency (Cronbach's alpha = 0.83), test-retest reliability (intraclass correlation coefficient = 0.94), and excellent discriminant validity (area under the curve = 0.88), with an optimal cutoff value of > 18 (sensitivity and specificity of 82.5% and 91.2%, respectively)., Conclusion: The PDQ was successfully translated into the Hindi language. The Hi-PDQ showed good discriminative validity and psychometric properties. The Hi-PDQ is a reliable instrument to assess NeP in chronic pain conditions., (© 2017 World Institute of Pain.)

Background: Pain with neuropathic characteristics is generally more severe and associated with a lower quality of life compared to nociceptive pain (NcP). Short form of the Douleur Neuropathique en 4 Questions (S-DN4) is one of the most used and reliable screening questionnaires and is reported to have good diagnostic properties. This study was aimed to cross-culturally validate the Hindi version of the S-DN4 in patients with various chronic pain conditions., Methods: The S-DN4 is already translated into the Hindi language by Mapi Research Trust. This study assessed the psychometric properties of the Hindi version of the S-DN4 including internal consistency and test-retest reliability after 3 days' post-baseline assessment. Diagnostic performance was also assessed., Results: One hundred sixty patients with chronic pain, 80 each in the neuropathic pain (NeP) present and NeP absent groups, were recruited. Patients with NeP present reported significantly higher S-DN4 scores in comparison to patients in the NeP absent group (mean (SD), 4.7 (1.7) vs. 1.8 (1.6), P < 0.01). The S-DN4 was found to have an AUC of 0.88 with adequate internal consistency (Cronbach's α = 0.80) and a test-retest reliability (ICC = 0.92) with an optimal cut-off value of 3 (Youden's index = 0.66, sensitivity and specificity of 88.7% and 77.5%). The diagnostic concordance rate between clinician diagnosis and the S-DN4 questionnaire was 83.1% (kappa = 0.66)., Conclusions: Overall, the Hindi version of the S-DN4 has good internal consistency and test-retest reliability along with good diagnostic accuracy.

Background: Low back pain (LBP) is a complex syndrome which includes a nociceptive (NcP) component, a neuropathic (NeP) component, or a mixture of components (mixed pain). The NeP component (NePC) in LBP is defined as the presence of NeP with or without an NcP., Objective: This meta-analysis aimed at assessing the pooled prevalence of NePC in patients with LBP and at identifying the factors causing significant heterogeneity in reported prevalence., Study Design: Meta-analysis., Methods: A systematic literature search was carried out, with inclusion of all epidemiological studies describing the NeP prevalence levels in LBP patients while using standard diagnostic methods. The "pooled prevalence rate (PPR)" of NePC, either on its own or in combination with NcP, was calculated. A pre-specified subgroup analysis was carried out, considering LBP duration, presence of leg pain, diagnostic method(s), and questionnaire(s) used., Results: The meta-analysis included 20 studies relating to a total of 14,269 LBP patients, of whom 7,969 patients (55.8%) were identified as presenting with NePC. The pooled PR (95% CI) of NePC in patients with LBP was 0.47 (0.40 - 0.54), while the pooled PR of NcP was 0.56 (0.48 - 0.63). Higher NePC pooled PR values were identified in LBP with leg pain as compared to uncomplicated LBP (respectively: 0.60; 0.47 - 0.73 vs 0.27; 0.23 - 0.31; Pinteraction < 0.01)., Limitations: The quality of the included studies was assessed using ad-hoc criteria. Due to the limited number of available studies, one may need to be cautious in reaching conclusions about the impact of disease duration on NePC prevalence values. We pooled studies which used a range of different diagnostic methods, with putatively different sensitivity/specificity diagnosing levels., Conclusions: Overall, high NePC prevalence levels were here identified in LBP patients. As the pain is a subjective phenomenon and there is no gold standard for the diagnosis of NePC, there is the possibility that the pooled effect estimate may alter depending upon the diagnostic method used., Key Words: Neuropathic pain, nociceptive pain, low back pain, symptom-based questionnaire, chronicity.

Background: Vitamin-D deficiency may possibly be related to chronic low back pain (CLBP)., Objective: The study is aimed to assess the impact of vitamin-D supplementation on pain intensity, functional disability, and vitamin-D levels in patients with CLBP., Study Design: Single arm open-label study., Setting: Outpatient pain clinic of a tertiary care hospital., Methods: Sixty-eight eligible patients (CLBP for = 3 months, pain score = 50 on visual analogue scale (VAS) and plasma 25-Hydroxyvitamin D3 levels < 30 ng/mL) were enrolled. Patients were supplemented with 60,000 IU of oral vitamin-D3 given every week for 8 weeks. Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3, and 6 months post-supplementation. Plasma 25(OH) D3 levels were measured at baseline and 8 weeks., Results: Baseline mean (SD) vitamin-D levels were 12.8 (5.73) ng/mL and increased to 36.07 (12.51) post supplementation (P < 0.01). Forty-five (66%) patients attained normal levels (> 29 ng/mL) post supplementation. Significant reduction in VAS was observed at 2, 3, and 6 months [61 (19), 45 (19), 36 (18)] as compared to 81 (19) at baseline (P = 0.001 at all-time intervals). A significant improvement in the functional ability was also observed at 2, 3, and 6 months [36 (12), 31 (13), and 26 (10)] as compared to baseline 45 (16) (P = 0.001 at all-time intervals)., Conclusion: Vitamin-D supplementation in deficient CLBP patients may lead to improvement in pain intensity and functional ability apart from normalization of the levels. Future controlled clinical trials are required to confirm the hypothesis.Key words: Vitamin D, deficiency, screening, low back pain, chronic, supplementation.

Background: Recently symptoms-based screening questionnaires have gained attention for screening for a neuropathic pain component (NePC) in various chronic pain conditions. The present study assessed the usefulness of four commonly used NePC screening questionnaires including the Self-completed douleur neuropathique 4 (S-DN4), the ID Pain, the painDETECT questionnaire (PDQ), and the Self-completed Leeds Assessment of neuropathic Symptoms and Signs (S-LANSS) questionnaire in patients with chronic low back pain (CLBP) to assess the presence of NePC., Methods: This is a single-center cross-sectional study where patients with CLBP, with or without leg pain, were included. Participants were initially screened for NePC presence by a physician according to the regular practice, and later assessed using screening questionnaires. The diagnostic accuracy of these questionnaires was compared assuming the physician-made diagnosis as the gold standard., Results: A total of 215 patients with CLBP of which 164 (76.3%, 95% CI, 70.2-81.5) had a NePC were included. S-DN4, ID Pain, and PDQ have an area under the curve (AUC) > 0.8 indicating excellent discrimination. However, S-LANSS has an AUC of 0.69 (0.62-0.75), indicating low discrimination. S-DN4 has a significantly higher AUC as compared to ID Pain (d(AUC) = 0.063, P < 0.01) and S-LANSS (d(AUC) = 0.197, P < 0.01). But the AUC of S-DN4 does not significantly differ from that of PDQ (d(AUC) = 0.013, P = 0.62)., Conclusions: S-DN4, ID Pain, and PDQ, but not S-LANSS, have good discriminant validity to screen for NePCs in patients with CLBP. Despite using all the tests, 20-30% of patients with an NePC were missed. Thus, these questionnaires can only be used as an initial clue in screening for NePCs, but do not replace clinical judgment.

Background: Children undergoing computerized tomography (CT) frequently require sedation to allay their anxiety, and prevent motion artifacts and stress of intravenous (IV) cannulation., Aims: The aim of this trial was to compare the effectiveness of oral midazolam and intranasal dexmedetomidine as sole premedicants in children for carrying out both IV cannulation as well as CT scanning, without the need for additional IV sedatives., Methods: Fifty-nine children, aged 1-6 years, scheduled to undergo CT imaging under sedation were randomized to receive either 0.5 mg·kg -1 oral midazolam (group M) or 2.5 mcg·kg -1 intranasal dexmedetomidine (group D). After 20-30 min, intravenous cannulation was performed and response to its placement was graded using the Groningen Distress Rating Scale (GDRS). After cannulation, children were transferred on the CT table, and assessed using the Ramsay sedation score (RSS). CT imaging was performed without any further sedative if the RSS was ≥4. If there was movement or decrease in sedation depth (RSS ≤ 3), ketamine 1 mg·kg -1 IV was given as an initial dose, followed by subsequent doses of 0.5 mg·kg -1 IV if required., Results: A Significantly higher proportion of children in group D (67%) achieved RSS ≥ 4 as compared to group M (24%) (P-0.002). The risk ratio (95% CI) was 2.76 (1.38-5.52). Significantly lower GDRS scores were noted in group D (1(1-2)) as compared to group M (2(1-2)) at the time of venipuncture (P = 0.04)., Conclusion: In the doses and time intervals used in our study, intranasal dexmedetomidine (2.5 μg·kg -1 ) was found to be superior to oral midazolam (0.5 mg·kg -1 ) for producing satisfactory sedation for CT imaging., (© 2016 John Wiley & Sons Ltd.)

Background: A previous study by our group demonstrated an increase in oropharyngeal leak pressures and a deterioration of ventilation in maximum neck flexion with the I-Gel ™ . To ascertain the optimal degree of neck flexion which increases OPLP without compromising ventilation we conducted a prospective self-controlled trial with the I-Gel ™ in different degrees of neck flexion in anesthetized paralyzed children., Methodology: The I-gel ™ was inserted in 60 children undergoing inhalation induction with muscle paralysis for routine general anesthesia. Recordings of peak inspiratory pressures (PIP) at flexion of 15°, 30°, and 45° were taken as the primary outcome. Expired tidal volume, ventilation scoring, fiberoptic gradings, and OPLP in different degrees of flexion were recorded as secondary outcomes., Results: There was a significant increase in mean PIP in cm H 2 O at flexion 30° [13.3 (95% CI 12.8-13.8) cm H 2 O, P < 0.001] and 45° flexion (16.5 [15.9-17.1] cm H 2 O, P < 0.001) compared to neutral. A decrease in the expired tidal volume was seen at flexion of 30° (7.6 [7.3-7.8] cm H 2 O, P = 0.00) and 45° (7.6 [7.3-7.8] cm H 2 O, P = 0.00). There was deterioration of ventilation score, mean [range] at 30° flexion 2[0-3], and 45° flexion 1[0-3] compared to the neutral 3[2-3]. There was a significant increase in OPLP with an increase in degree of flexion., Conclusion: We conclude that 15° neck flexion can safely be applied without compromising ventilation with the I-Gel ™ in anesthetized paralyzed children. However, Flexion of 30° or more warrants caution or the use of alternative devices like an endotracheal tube due to increase in PIP and worsening of ventilation score., (© 2016 John Wiley & Sons Ltd.)