Search

After a year of exchange in Montreal, a South Korean academic physiatrist and his Canadian colleague have reflected on the strengths and weaknesses of their respective healthcare systems. They have focused more specifically on physiatrist-delivered pain medicine treatments. This article is written based on personal perspectives. It aims to present the differences between the systems in South Korea and Quebec, highlighting the issues arising from each system and providing perspectives on potential solutions.

Introduction: The fields of anesthesiology and pain medicine are experiencing significant changes driven by market forces and professional preferences. While demand for anesthesiologists is rising, pain medicine is facing a decline in fellowship applications., Methods: This study analyzed data from the Electronic Residency Application Service (ERAS) and the National Resident Matching Program (NRMP) from 2019 to 2023, focusing on trends in fellowship applications to pain medicine programs. Additionally, preliminary data from the 2024 match cycle were examined., Results: There has been a notable decrease in anesthesiology residents applying to pain medicine fellowships, with applications dropping from 351 in 2019 to 193 in 2023. The overall decline in anesthesia-based applicants to pain medicine fellowships was 45%, signaling the highest detriment among anesthesiology applicants compared to other specialties. Gender disparities have been prevalent, with the absolute number of female applicants decreasing every year since 2019. Additionally, the 2023 match saw a significant number of unfilled programs, with 35 out of 115 programs failing to fill all positions. Preliminary data from the 2024 match cycle suggest this downward trend is continuing., Conclusion: The decline in pain medicine fellowship applications, particularly among anesthesiology residents, signals potential future workforce shortages and challenges in patient care. Recruitment strategies should include early exposure to pain medicine during residency, enhanced mentorship programs, and robust recruitment efforts (including virtual options). Addressing these issues is essential to ensure enough trained specialists to meet the growing need for pain specialists nationally., (© 2024 The Author(s). Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain.)

The opioid crisis has continued despite efforts to intervene on its identified causes. In this article, we analyse responsibility claims in pain and addiction medical journals concerning the opioid crisis. Selected journals represent the opioid crisis as a medical problem. Using the method of discourse analysis, we examine 32 sampled articles from 3 medical journals published over the past decade to understand how the cause of the opioid crisis is represented. Drawing upon the sociological concept of responsibilization, we observe and explain two patterns in the responsibility claims. Pain medicine specialty journals tended to responsibilize physicians for their part in the crisis, whereas the addiction journal directed responsibility toward users. Despite some differences in proposed solutions, statements in both journals tend to responsibilize individual behaviours as the cause of the crisis. Accordingly, each article suggested solutions that target these behaviours. We argue that by focusing on individual behaviours, other factors and social conditions related to the crisis are omitted, including pharmaceutical companies, regulators, and health system infrastructure. We advocate for the need to redefine the assumptions related to the cause of the opioid crisis in order to consider alternative solutions., Competing Interests: Declarations. Ethical approval: N/A Informed consent: N/A Conflict of interest: The authors declare no competing interests. Endnotes: 1 The examined texts relied on diverse methods to responsibilize the patients and/or physicians for the opioid crisis. For instance, 11 articles relied on empirical data, 7 on qualitative, 3 on quantitative, and 1 on mixed methods, to support their claims. Four articles focused on intervention or quality improvement projects; two on patients’ self-report questionnaires as part of a quality assurance improvement project; one on electronic health records; one on pharmacy, hospital, medical enrolment, and demographic data for all study years; four on literature review; two on data set; one on autobiography; one on grey as well as peer-reviewed literature; one on patients’ self-report data; one on media coverage; and three on prescription data. In our sample, there were no articles that employed a historical or critical analysis to examine other regulatory and structural factors which are predominantly linked with the crisis. 2 See Hanemaayer (2019) for an analysis of how guidelines can also deresponsibilize physicians’ judgment., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background/Objectives : Ketamine offers effective pain relief with fewer side effects than traditional analgesics, making it a promising alternative for acute pain treatment. However, further research is needed to fully assess its role in perioperative care. This umbrella review aimed to compile the highest-quality evidence available regarding the application of ketamine in managing acute pain. Methods : A thorough search of the literature was carried out in PubMed, Scopus, and the Cochrane Library, including systematic reviews that focused on the application of ketamine in managing acute pain. The data extraction included the research type, analgesics used, number of studies and patients per review, pain types, scoring methods, ketamine doses, administration routes, and reporting guidelines. Results : Of the 807 records identified, 20 studies met the inclusion criteria. In accordance with the AMSTAR-2 evaluation, most of the systematic reviews were rated as critically low quality. Intravenous ketamine administered during the perioperative period was found to reduce the pain intensity of acute pain within 15-30 and 60 min following treatment, and decrease postoperative opioid consumption by 14-50% at both 24 and 48 h after surgery. Conclusions : Evidence shows that intravenous ketamine reduces the pain intensity, postoperative opioid use, and the risk of vomiting and nausea while improving analgesia, making it a valuable adjunct in perioperative pain management.

Introduction: Temporomandibular disorders (TMDs) are common musculoskeletal pain conditions that can significantly impact daily activities such as eating, talking, breathing, intimacy, and expressing emotion. TMDs are often complex and multifactorial, and many patients experience overlapping pain conditions, sleep difficulties, and mental health challenges. The National Academies of Sciences, Engineering and Medicine (NASEM) has called for improved TMD education and training for health professionals, as current training opportunities are limited., Methods: To prepare health professionals to care for patients who have a TMD, we designed a 5-hour, interactive, module-based curriculum aligned with the 2020 NASEM recommendations. The four-part module set addresses TMD physiology and pathophysiology, assessment, diagnosis, and management. Instructional methods are founded on the Cognitive Theory of Multimedia Learning and include engaging videos, clinical evaluation and education tools, and interactive digital simulation scenarios., Results: Thirty learners from diverse health professional backgrounds (medicine, dentistry, physician assistant, nursing, physical therapy) participated. Multiple-choice question assessments and pre/post retrospective survey scores demonstrated enhanced knowledge ( M = 2.9 vs. M = 4.2, p < .001) and perceived competence ( M = 1.9 vs. M = 3.4, p < .001), respectively. Encouragingly, all participants indicated applicability to their clinical practice., Discussion: Our modules offer educators and clinicians a valuable resource to improve TMD knowledge and facilitate best practices. Supplementary resources included in the curriculum are conducive to clinical implementation, fostering improved clinician assessment and patient education., (US Government work in the public domain.)

Introduction: Sedating and anesthetic drugs are widely used in clinical practice; however, relevant teaching remains underrepresented in undergraduate medical education. We developed a 2-hour flipped classroom activity integrating foundational science topics, evidence-based medicine, and clinical reasoning on anesthetic pharmacology for preclinical medical students., Methods: Presession, second-year medical students reviewed a study guide and completed a readiness assessment. The flipped classroom session was facilitated in a large-group format with learners in small groups. At session end, students completed a consolidation quiz. Two case-relevant questions were included on the midterm and one on the final exam. Student satisfaction was assessed through an anonymous postsession survey., Results: One hundred ten students participated in the session. Mean performance on the readiness assessment was 96%. Mean performance on the postsession quiz was also 96%. Mean performance on the three midterm and final exam questions was higher than the national mean (94% vs.72%, p < .005). Seventy-six students (69%) completed the survey, with mean satisfaction of 4.6 ( SD = 0.7) on a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree )., Conclusion: We developed a flipped classroom session teaching pharmacology of sedating and anesthetic drugs for preclinical medical students. Students performed well on pre- and postsession assessments and above the national mean on National Board of Medical Examiners questions, suggesting adequate knowledge acquisition. This session was found to be a highly satisfactory and effective teaching tool requiring students to integrate foundational and clinical science knowledge., (© 2024 Nunez et al.)

Introduction: Regional anesthesia aids in management of acute pain in the emergency department, but many emergency physicians remain inadequately trained. Further complicating medical education, our academic center continues to use remote learning as the primary setting for residency didactics. This project aims to create a remote conference session on ultrasound-guided serratus anterior plane blocks (USG-SAPB)., Methods: We used the ADDIE (analyze, design, develop, implement, evaluate) model for curricular design, with emergency medicine residents as our intended learners. For the analyze element, we examined clinical need and resident program evaluation feedback. For design, we utilized best practices for remote learning, principles of mental rehearsal, and multimodal instructional theory. For develop, we completed recruitment of faculty leads, materials, and beta testing of each component. We implemented our 50-minute session on the videoconferencing platform Zoom. For evaluate, we created a program evaluation survey based on Kirkpatrick's evaluation model., Results: Seventeen learners completed the evaluation. For Kirkpatrick level 1, 94% reported being very or extremely satisfied. For Kirkpatrick level 2, 91% ranked their presession confidence level in performing USG-SAPB as not at all or slightly confident, compared to the postsession, where 88% ranked themselves as moderately, very, or extremely confident. For Kirkpatrick level 3, 94% reported that they would incorporate at least a moderate amount of content into clinical practice., Discussion: This remote learning session on USG-SAPB demonstrated high levels of learner satisfaction, improvement in learner confidence, and potential to impact learners' clinical practice. Future studies can elucidate patient outcomes related to educational sessions., (© 2024 Weingart and Coneybeare.)

Objectives: While epidural anesthesia is an established technique for labor and perioperative pain, its use in the hospice setting remains limited, resulting in a reliance on oral opioids. We describe patients with intractable pain who pursued hospice enrollment with tunneled epidural analgesia for pain management. Methods: All patients who received a tunneled epidural prior to hospice enrollment between January 1, 2017, and September 20, 2023, were included. The medication infused, adverse effects, as well as changes in oral morphine equivalents (OME), pain scores, blood pressure, and heart rate were extracted from the medical record. Results: Seven patients underwent tunneled epidural placement for pain management. The average change in OME was -122.73 mg. Conclusions: Overall, tunneled epidural analgesia may be an underutilized method of pain management for patients at end-of-life with intractable pain. Further high-quality research on the subject is necessary to establish effectiveness, safety, and barriers to implementation.

Intercostal neuralgia is characterized by neuropathic pain along the distribution of the intercostal nerve, which can cause debilitating pain and interfere with daily activities. The literature is extremely limited in assessing the use of neuromodulation to treat trauma-induced intercostal neuralgia. This case reports a 40-year-old patient who presented with decades of refractory, long-standing thoracic pain. The pain ranged from a four out of 10 to a nine out of 10 on the numeric rating scale (NRS). The patient failed pharmacologic therapy, physical therapy, chiropractic care, injection therapy, transcutaneous electrical nerve stimulation (TENS), and spinal cord stimulation (SCS). The patient underwent a 60-day peripheral nerve stimulation (PNS) trial, which temporarily relieved the pain until it was explanted. The patient subsequently underwent placement of a permanent PNS implant, which provided between 80-100% daily pain relief at a six-month follow-up. At the two-year follow-up, the patient continued to experience sustained pain relief, had weaned from opioid medications, and returned to all desired daily activities. This case suggests that minimally invasive PNS can effectively manage pain for patients with intercostal neuralgia who fail conservative measures. Further, to our knowledge, this two-year follow-up is the longest-reported outcome in the literature for using PNS for intercostal neuralgia after traumatic injury., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gallacher et al.)

Introduction: Many youth with pain lack access to pediatric pain expertise. There is a critical shortage of pediatric pain physicians, due partly to a paucity of training programs in Pediatric Pain Medicine. Pain fellowships are Anesthesiology-based and there is no pathway to fellowship training or Pain Medicine board certification for pediatricians. This workforce assessment sought to examine the current state of Pediatric Pain Medicine in the United States and future interest in pursuing Pain Medicine among pediatricians., Methods: A multidisciplinary working group of Pain Medicine clinicians designed three surveys to examine pediatric comprehensive pain programs in the US, practice patterns of pediatricians and their motivations and opinions regarding Pain Medicine board certification, and current residents' exposure to and interest in Pediatric Pain Medicine., Results: Wait times for initial evaluations are two months or longer for two-thirds of responding centers, and barriers to increase staff size and resources were reported, including an inadequate number of trained or available physicians. Pediatricians expressed interest in earning board certification in Pain Medicine, given the opportunity. Additionally, there is interest among pediatric residents in pursuing Pediatric Pain Medicine, and qualitative data highlight information residents perceived needing in order to pursue a career in the field., Discussion: Results demonstrate the need for increased training opportunities in pediatric pain medicine. A formal pathway to Pain Medicine for Pediatricians should be developed to increase the potential workforce and to address the lack of trained pediatric pain specialists, thereby improving access to care for youth with pain., Competing Interests: RBW is a consultant for Human, LLC, and the Autism Healthcare Collaborative. WTZ is a consultant for Lundbeck, Editas, and OmmioHealth. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer NS, declares that they are an emeritus faculty from the same affiliation as the author AK., (© 2024 Theriault, Burns, Goldschneider, Koka, Logan, Weisman, Wilder, Windsor and Zempsky.)

WALANT (Wide Awake Local Anesthesia No Tourniquet) has been widely implemented in hand surgery. We conducted a systematic review from 1979 to 2022, led by a team of anesthesiologist. Only randomized studies comparing WALANT to other types of regional anesthesia were included. The outcomes studied were pain, duration of the procedure, intraoperative bleeding, complications, and patient satisfaction. Twelve articles were included in the analysis. We found a reduction of 2.77 on the VAS (95% CI -3.79; -1.75, I² 93%) for intraoperative pain in the WALANT group. There was no significant difference (MD 0.79, 95% CI 95% -0.11; 1.69, I² 73%) for duration of surgery. Patient satisfaction was consistently high in the WALANT group. Intraoperative bleeding was minimal and not clinically relevant. Compared to other types of regional anesthesia in hand surgery, the WALANT technique decreases pain for the patients without increasing the length of surgery., (Copyright © 2024 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Purpose of Review: A bibliometric analysis was performed to analyze and compare the top 100 articles from the most well-known five pain journals: Pain, Pain Physician, Pain Medicine, Regional Anesthesia & Pain Medicine, and Journal of Pain. A query of the Scopus database was performed to filter the top 200 most cited articles from each journal. CY score was calculated for the top 200 articles from each journal by dividing the total number of citations by the number of years the article has been published., Recent Findings: All articles had a collective analysis of the top CY scores, the top 100 of which were further analyzed. The pain subtype, type of publication, country of origin, and senior author were extrapolated from these top 100 articles. Frequency tables were organized, revealing Pain Journal as the highest publishing journal out of the top 100 articles. Chronic pain was the most studied subtype of pain and narrative reviews were the most common type of evidence. Studies were also organized in five-year epochs to analyze the frequency of publications in these intervals. Results show that 2010-2014 had the highest frequency of articles published overall. Journal Impact Factor (JIF) is also an objective indicator of the average number of citations per published article from each journal. The journal with the highest JIF was Pain with an impact factor of 7.926. (6)., (© 2024. The Author(s).)

Digital medicine has increasing influence on the German healthcare system. In times of social distancing during the ongoing coronavirus disease 2019 (COVID-19) pandemic, digital tools enable health professionals to maintain medical care. Furthermore, digital elements have potential to provide effective guideline-oriented treatment to a broad range of patients independently from location and time. This survey was used to assess the attitudes of members of the German Pain Society (health professionals) and of associated self-help groups (patients) towards digital medicine. It was sent out as an online survey to health professionals in September 2020 and to patients in February 2021. The survey referred especially to present usage, attitude and potential concerns regarding particular digital elements. Furthermore, technical affinity was assessed. In total, 250 health professionals and 154 patients participated in the survey. The results show that-although digital elements are already known-a substantial proportion of health professionals still lack broad transfer to regular treatment. The potential of digital tools seems to be recognized by both groups; interestingly, patients consider digital medicine as more useful than health professionals. Nevertheless, concerns about for example data security or digital competence remain in both groups. Taken together, our results indicate that disruptive changes, as the implementation of digital medicine in the healthcare system, have to be guided by intense education and channeled by political policies in order to successfully integrate digital elements into medicine on a long-term basis. This would be in favor for all involved parties and is demanded especially by patients., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The integration of telemedicine in pain management represents a significant advancement in healthcare delivery, offering opportunities to enhance patient access to specialized care, improve satisfaction, and streamline chronic pain management. Despite its growing adoption, there remains a lack of comprehensive data on its utilization in pain therapy, necessitating a deeper understanding of physicians' perspectives, experiences, and challenges., Methods: A survey was conducted in Italy between January 2024 and May 2024. Specialist center members of the SIAARTI were sent an online questionnaire testing the state of the art of telemedicine for pain medicine., Results: One-hundred thirty-one centers across Italy reveal varied adoption rates, with 40% routinely using telemedicine. Regional disparities exist, with Northern Italy showing higher adoption rates. Barriers include the absence of protocols, resource constraints, and bureaucratic obstacles. Despite challenges, telemedicine has shown positive impacts on service delivery, with increased service volume reported. Technological capabilities, including image sharing and teleconsultation with specialists, indicate promising interdisciplinary potential., Conclusions: The integration of advanced telemedicine software utilizing artificial intelligence holds promise for enhancing telemonitoring and alert systems, potentially leading to more proactive and personalized pain management strategies., (© 2024. The Author(s).)

Background: ChatGPT has been tested in health care, including the US Medical Licensing Examination and specialty exams, showing near-passing results. Its performance in the field of anesthesiology has been assessed using English board examination questions; however, its effectiveness in Korea remains unexplored., Objective: This study investigated the problem-solving performance of ChatGPT in the fields of anesthesiology and pain medicine in the Korean language context, highlighted advancements in artificial intelligence (AI), and explored its potential applications in medical education., Methods: We investigated the performance (number of correct answers/number of questions) of GPT-4, GPT-3.5, and CLOVA X in the fields of anesthesiology and pain medicine, using in-training examinations that have been administered to Korean anesthesiology residents over the past 5 years, with an annual composition of 100 questions. Questions containing images, diagrams, or photographs were excluded from the analysis. Furthermore, to assess the performance differences of the GPT across different languages, we conducted a comparative analysis of the GPT-4's problem-solving proficiency using both the original Korean texts and their English translations., Results: A total of 398 questions were analyzed. GPT-4 (67.8%) demonstrated a significantly better overall performance than GPT-3.5 (37.2%) and CLOVA-X (36.7%). However, GPT-3.5 and CLOVA X did not show significant differences in their overall performance. Additionally, the GPT-4 showed superior performance on questions translated into English, indicating a language processing discrepancy (English: 75.4% vs Korean: 67.8%; difference 7.5%; 95% CI 3.1%-11.9%; P=.001)., Conclusions: This study underscores the potential of AI tools, such as ChatGPT, in medical education and practice but emphasizes the need for cautious application and further refinement, especially in non-English medical contexts. The findings suggest that although AI advancements are promising, they require careful evaluation and development to ensure acceptable performance across diverse linguistic and professional settings., (©Soo-Hyuk Yoon, Seok Kyeong Oh, Byung Gun Lim, Ho-Jin Lee. Originally published in JMIR Medical Education (https://mededu.jmir.org), 16.09.2024.)

Purpose: Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial., Methods: The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved., Results: Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies., Conclusion: In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics., Competing Interests: RSD received investigator-initiated research grant funding from Nevro Corp and Saol Therapeutics paid to his institution. MES is a research consultant for Apurano, outside the submitted work. AKC is a consultant for Medtronic, Companion Spine, PainTeq, and Vertos; a speaker for Relievant; and receives research support from Medtronic, Nevro Corp, Stryker, Boston Scientific, Spine Biopharma, Biorestorative, Vivex, Vertos, DiscGenics, ReGelTec, Saol Therapeutics, PainTeq, Saluda, and Relievant. SGP is a consultant for Bioness, SPR Therapeutics, Nalu Medical, Medtronic; receives royalties from Oxford University Press and Wolters Kluwer; and receives research grant funding from Medtronic, Nevro Corp, Abbott, and Biotronik. CC is a shareholder and patent holder and chief medical officer of Regenexx LLC. SAS is on the board of directors for The Biologic Association (non-profit). YE is a research consultant for Autonomous Healthcare Inc, is on the advisory board for Saluda Medical Americas Inc and SPR Therapeutics. DS is a consultant to Abbott, Painteq, Saluda, Mainstay, Surgentec, Nevro, and holds stock options with Painteq, Neuralace, Mainstay, Vertos, and SPR Therapeutics. SD serves on the advisory board for CornerLoc. TRD is a consultant for Abbott, Vertos, SpineThera, Saluda Medical, Cornerloc, SPR Therapeutics, PainTeq, Spinal Simplicity, Aurora and Biotronik; he is an advisory board member for Abbott, Vertos, SPR Therapeutics, and Biotronik; he has a DRG Lead patent that is pending with Abbott; he has funded research with Abbott, Vertos, Saluda, Mainstay, SPR Therapeutic, Boston Scientific, and PainTeq. The authors report no other conflicts of interest in this work., (© 2024 D’Souza et al.)

Introduction: There are currently no published studies using patient reviews of pain physicians to quantitatively assess patient preferences for pain physician attributes. The aim of the present study was to use natural language processing to quantitatively analyze patient reviews of pain physicians by determining the effect of physician demographics and word frequency on positive review outcomes., Methods: Using a peer-reviewed algorithm, online Healthgrades reviews of pain physicians practicing in the USA were scored according to their positive sentiment from -1 to 1. These sentiment scores and star ratings were used to compare physicians by age, gender and region of practice. Frequency analysis of words and bigrams was performed for all reviews., Results: There were 15 101 reviews collected among 1275 pain physicians which showed male physicians received higher star ratings and review sentiment scores than female physicians. Pain physicians younger than 55 years received higher star ratings and sentiment scores than those of 55 years and older. Frequency analysis revealed that words most commonly used in the more positive patient reviews included 'care', 'professional', 'patient', 'help' and 'kind'; the words most commonly used in less positive reviews included 'pain', 'back', 'office', 'time' and 'years'., Conclusions: Male and/or younger pain physicians receive more positive reviews. Patients highly rate pain physicians who are perceived as personable. Patients lowly rate physicians who are perceived as providing ineffective treatment of their pain as well as when they experience barriers to their access to care., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education., Methods: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy., Results: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies., Conclusion: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization., (© 2024 World Institute of Pain.)

Context: Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists., Objectives: To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness., Methods: A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs., Results: The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians., Conclusion: This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Subacute combined degeneration (SCD) is a reversible cause of posterior and lateral spinal cord degeneration. Prolonged vitamin B12 deficiency is a common cause of SCD as it leads to inhibition of proper myelin synthesis and reduces myelin integrity. When left untreated, SCD causes progressive debility that can lead to irreversible damage. We describe the case of a 49-year-old male patient who presented with one year of worsening weakness, back pain, paresthesias, and gait abnormalities. Laboratory values revealed vitamin B12 deficiency, elevated homocysteine and methylmalonic acid, and megaloblastic anemia. Following a diagnosis of SCD, the patient began treatment with intramuscular vitamin B12, and his pain and ambulation improved considerably in the following weeks. Prompt identification of vitamin B12 deficiency can lead to considerable improvements in function and quality of life., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Demko et al.)

Background: Since 1992, when the Accreditation Council of Graduate Medical Education (ACGME) acknowledged pain medicine as a subspecialty, the field has experienced significant growth in its number of programs, diversity of sponsoring specialties, treatment algorithms, and popularity among applicants. These shifts prompted changes to the educational model, overseen by program directors (PDs) and the ACGME. The pool of pain fellowship applicants also changed during that period., Objectives: This study aims to investigate trainees' reasons for applying to pain medicine fellowship programs as well as the applicants' specific expectations, interests, and motivations, thereby contributing to the remodeling and universal improvement of programs across the country., Study Design: Online survey via SurveyMonkey. The online questionnaire targeted pain fellowship applicants in 2023 and current fellows in the US., Methods: Our study was designed by board members of the Association of Pain Program Directors (APPD). The board disseminated a survey to those who applied to ACGME Pain Medicine fellowships in 2023 as well as to existing fellows. The survey was emailed to residency and fellowship PDs for dissemination to their trainees. The participants answered a 12-question survey on their reasons for pursuing pain medicine fellowships, expectations of and beyond those fellowships, and educational adjustments., Results: There were 283 survey participants (80% applicants in residency training and 20% fellows). Participants ranked basic interventional procedures and a strong desire to learn advanced procedures as the most significant factors in pursuing a pain fellowship. Most trainees (70%) did not wish to pursue a 2-year fellowship, and 50% desired to go into private practice., Limitations: The relatively small number of respondents is a limitation that could introduce sampling error. Since most of the respondents were from the fields of physical medicine and rehabilitation (PM&R) and anesthesia, the use of convenience sampling reduced our ability to generalize the results to the wider community. Furthermore, approximately 80% of the trainees were residents, who might have had less experience in or knowledge of the survey's particulars than did the fellows., Conclusion: This survey demonstrated that procedural volume and diversity were important factors in trainees' decisions to apply to the field of pain medicine; however, extending the duration of a pain fellowship was not an option survey participants favored. Therefore, PDs and educational stakeholders in pain fellowship training need to develop creative strategies to maintain competitive applicants' interest while they adapt to our evolving field.

Background: Particulate steroids are thought to exert their effects for long durations at injection sites. However, these types of steroids carry higher risks when used in epidural steroid injections. Catastrophic spinal cord complications, including sudden-onset paraplegia, have been reported due to intravascular particulate steroid preparations that cause embolisms and occlusion of blood vessels, resulting in spinal cord infarctions. Clinicians, therefore, recommend nonparticulate steroids to mitigate these adverse events. To our knowledge, this is the first retrospective study that addresses the effectiveness and safety of methylprednisolone, dexamethasone, and betamethasone when used in transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar radiculopathy., Objectives: The primary goal of this study was to compare the proportion of patients who received injections of particulate steroids and required zero repeat injections within 12 months of their initial injection to the proportion of patients who received injections of nonparticulate steroids and also required zero repeat injections, as well as to compare the number of patients in the particulate cohort who required one or more repeat injections within 12 months of their initial injection to the number of patients in the nonparticulate cohort who required the same. The secondary goal was to evaluate the proportion of patients ultimately requiring surgery., Study Design: This is a single-center, IRB-approved, retrospective study evaluating the safety and effectiveness of nonparticulate as compared to particulate steroid medications when used in TFESIs as minimally invasive treatments for chronic lumbar radiculopathy., Setting: This study captured data (n = 1717) over a 4-year time frame (01/15/2018 to 01/15/2022)., Methods: The following data were collected from each patient's chart: age, gender, BMI, race, date of initial injection, number of repeat injections at the same lumbosacral level and on the same side within 12 months of the initial injection, and lumbar surgery date (if applicable). Inclusion criteria included: 1) having chronic low back pain of radicular etiology; 2) being at least 18 years old; 3) having experienced the failure of conservative therapy after 12 weeks (including physical therapy and/or medications); 4) having positive physical exam findings supporting nerve impingement (straight leg raise, slump test); and 5) showing lumbar MRI evidence of nerve impingement from disc herniation. Exclusion criteria included: 1) having received prior lumbar surgery at any level (L1-S1); 2) having been given prior TFESIs fewer than 6 months prior to initial injection; 3) having contracted a systemic infection at the proposed injection site; 4) undergoing active cancer treatment; and 5) having gotten any other spine injections., Results: A significantly greater proportion of patients in the nonparticulate steroid cohort received 0 repeat injections (87.5% vs 71.4%, P < 0.001). The particulate steroid cohort demonstrated a significantly greater proportion of patients who received repeat injections within 12 months after the initial injections (12.5% vs 29.6%, P < 0.001). There were no significant differences among patients requiring surgery between the 2 cohorts. Other outcome measures included the identification of risk factors significantly associated with repeat injections. There was a statistically significant weak positive correlation between age and repeat injections (Pearson corr = 0.102; P < 0.001) and a weak negative correlation between ethnicity/race and repeat injections (point-biserial corr = -0.093; P < 0.001).  No adverse events were reported., Limitations: Not all clinicians included in this study used each of the 3 steroid types, and all clinicians used either particulate or nonparticulate steroids exclusively., Conclusions: Our study demonstrates that the clinical outcomes associated with TFESIs of nonparticulate steroids are superior to those associated with TFESIs of particulate steroids when either variety of medication is used to treat lumbar radiculopathy. This is the first study to include a clinically useful predictive model using information on laterality, age, and steroid type.

Background and Objective: Chronic pain is a pervasive and often-complex condition that can severely detract from an individual's quality of life. When conservative measures of treatment fail, radiofrequency ablation (RFA) has emerged as a potential alternative. This narrative review subsequently explores recent advancements in the use of RFA on peripheral nerves as a means of attenuating chronic pain and providing relief to patients., Methods: A comprehensive literature search was conducted on the PubMed database using the keywords "Radiofrequency", "Ablation", "Pain", "Chronic", "Peripheral", and "Nerve". The search focused on articles published between 2018 to 2023 that discussed an application of RFA in a peripheral nerve. In total, 30 articles were selected for inclusion in this review., Key Content and Findings: Results indicate the successful use of RFA in an array of chronic pain conditions and anatomical sites. Applications include the treatment of trigeminal neuralgia (TN), occipital neuralgia, cluster headaches, knee pain derived from osteoarthritis (OA), hip pain, abdominal pain associated with pancreatic cancer, and several other chronic pain conditions., Conclusions: These findings suggest RFA is a viable option for reducing patient's pain scores and improving quality of life. Future research should build off extensive case reports/series with double-blind, randomized controlled studies to further investigate anecdotal successes.

Background: The gender bias in academic anesthesiology is well known. Women are not only a minority in the field but also underrepresented in leadership positions. Reported reasons for this underrepresentation include barriers to career advancement, lack of mentorship, and differences in compensation, among others. Interventional pain, a competitive procedural subspecialty of anesthesiology, sees the trickle-down effects of this disparity. According to a report from the ACGME that sorted medical subspecialties by number of female trainees, pain medicine ranked in the bottom quartile across all disciplines from 2008-2016., Objectives: To better understand the landscape for women physicians in the field of pain medicine, we undertook this investigation to review the knowledge about the topic and what questions remain unanswered., Study Design: This study is a review of the current literature and aims to summarize and describe the landscape of pain medicine for women physicians., Setting: All literature review and manuscript preparation took place at the Yale University School of Medicine., Methods: We performed a comprehensive search using the PubMed, Scopus, and Cochrane databases for the combined terms "gender disparity," "pain medicine," and "anesthesiology," limiting our search to the year 2000 onward for the most recent literature on the topic. Our initial search retrieved 38 articles. All relevant articles pertaining to this perspective piece were collated. The available literature is discussed below., Results: Women are underrepresented in interventional pain. The grim scarcity of female pain physicians is unlikely to improve soon, since while the number of Accreditation Council for Graduate Medical Education pain fellowship programs continues to grow, women trainees comprise only between 22-25% of all pain medicine fellows. Additionally, although studies have compared the numbers of male interventional pain faculty to their female counterparts in academic hospitals and shown the ratio to range from 71.84-82% to 18-28.52%, respectively, no studies have truly explored the landscape for women physicians in private practice. Patients prefer and have better experiences with physicians who are racially and ethnically like themselves. In fact, the preference for and the lack of female clinicians have been associated with delayed pursuit of care and adverse health outcomes. The consequences of the burnout and attrition caused by the gender disparity, especially in a field like pain medicine, cannot be understate., Limitations: The review might not have been comprehensive, and relevant studies might not have been included., Conclusion: While the gender disparity in academia is well documented for both anesthesiology and pain medicine, the reasons for this disparity have not been fully explored. Moreover, it is also unknown whether the minority of female physicians who select pain medicine as a subspecialty gravitate toward an academic or a private-practice path. To address the existing gender disparity, it is necessary to explore the landscape of interventional pain medicine in both academic and private practices and understand pain physicians' beliefs and sentiments regarding their subspecialty.

Background: Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians use them and if OTAs themselves modify clinician prescribing practices., Objective: To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing., Design: We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not., Participants: 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling., Approach: Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team., Key Results: Our analysis identified three main themes: (1) OTAs did not influence clinicians' decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation., Conclusion: This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians' decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs' purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education.

American Board of Anesthesiology (ABA) diplomates who pursue clinical fellowship training in pain medicine may be better suited to lead scholarly projects and serve as first authors of publications in peer-reviewed journals given their additional training and clinical expertise. The primary aim of this study was to determine whether ABA certification in pain medicine is associated with a greater number of peer-reviewed publications. The secondary aim included assessments of whether pain medicine fellowship training is associated with a higher publication rate (publications per year) or publication in a larger number of peer-reviewed journals. A literature search was conducted in December 2023 using the Scopus database for publications related to anesthesiology and pain medicine in the United States between 2013 and 2023. First authors identified through the search were then individually searched within the ABA physician directory. The following data were collected: author name and identification number, year of publication, publication type (article or review), year of primary anesthesiology certification, and year of fellowship, if applicable. This study identified 9,612 publications and 6,924 unique first authors. Pain medicine fellowship training was associated with a statistically significant increase (p-value < 0.001) in the number of publications (0.546; 95% confidence interval {CI}, 0.386-0.707), publications per year (0.140; 95% CI, 0.121-0.159), and publication in a larger number of peer-reviewed journals (0.256; 95% CI, 0.182-0.330) in regression models adjusted for the number of years from certification. This query of the Scopus database and ABA physician directory indicates that pain medicine fellowship training is associated with statistically significant increases in research productivity, as defined by the number of publications, publications per year, or the number of publications in peer-reviewed journals. However, these increases in research output would not lead to a marked increase in scholarship productivity to justify pursuing a fellowship for this purpose., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jones et al.)

Background: The S1 guideline on long/post-COVID of the AWMF [German Association of the Medical Scientific Societies] registration number 020-027) was updated in August 2022., Methods: Under the coordination of the German Society of Pneumology, the guideline was updated by 21 scientific associations, two professional associations and clinical centers each and one institute and statutory accident insurance each. Each scientific association was responsible for its own chapter. The German Pain Society prepared the chapter "Pain". The coordinators of each chapter performed a selective literature search and also received approval for the chapter within their scientific association. During an internal period of comments, all representatives of the participating institutions could comment on all chapters. The AWMF task force commented on the draft of the guideline, which was then finally approved by the boards of all participating institutions., Results: Coronavirus disease 2019 (COVID-19) increases the risk of persistent headache and musculoskeletal pain. Long/Post-COVID pain is frequently associated with fatigue and cognitive problems. A specialist assessment might be considered if symptoms with limitations of daily activities persist 3 months after the infection. The diagnostic workup of long/post-COVID-associated pain should be performed according to the standards of pain medicine. Management should follow the pain guidelines of the AWMF., Conclusions: The updated S1 guideline on long/post-COVID is a clinical manual which offers orientation for diagnostics and treatment despite limited data., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Zoledronate, a bisphosphonate, is a potent first-line treatment for osteoporosis. It is also a preferred treatment for hypercalcemia especially when unresponsive to intravenous fluids. Bisphosphonates can cause acute phase reactions that mimic opioid withdrawal symptoms, which can confound provider decision-making. Our case highlights cognitive bias involving a patient with opioid use disorder who received zoledronate for hypercalcemia secondary to immobilization and significant bone infection., Case Presentation: A 41-year-old male is admitted with a past medical history of active intravenous opioid use complicated by group A streptococcal bacteremia with L5-S1 discitis and osteomyelitis, L2-L3 osteomyelitis, and left ankle abscess/septic arthritis status post left ankle washout. His pain was well-controlled by acute pain service with ketamine infusion (discontinued earlier), opioids, acetaminophen, buprenorphine-naloxone, cyclobenzaprine, gabapentin, and naproxen. Intravenous opioids were discontinued, slightly decreasing the opioid regimen. A day later, the patient reported tachycardia, diaphoresis, myalgias, and chills, which the primary team reconsulted acute pain service for opioid withdrawal. However, the patient received a zoledronate infusion for hypercalcemia, on the same day intravenous opioids were discontinued. He had no other medications known to cause withdrawal-like symptoms per chart review. Therefore, it was suspected that an acute phase reaction occurred, commonly seen within a few days of bisphosphonate use., Conclusion: Zoledronate, well known for causing acute phase reactions, was likely the cause of withdrawal-like symptoms. Acute phase reactions with bisphosphonates mostly occur in the first infusion, and the incidence decreases with subsequent infusions. Symptoms typically occur 24-72 h post-infusion, and last at most for 72 h. Cognitive bias led the primary team to be concerned with opioid withdrawal rather than investigating other causes for the patient's presentation. Therefore, providers should thoroughly investigate potential etiologies and rule them out accordingly to provide the best care. Health care providers should also be aware of the implicit biases that potentially impact the quality of care they provide to patients., (© 2024. The Author(s).)

Purpose of Review: This review explores the current applications of artificial intelligence (AI) in the field of pain medicine with a focus on machine learning., Recent Findings: Utilizing a literature search conducted through the PubMed database, several current trends were identified, including the use of AI as a tool for diagnostics, predicting pain progression, predicting treatment response, and performance of therapy and pain management. Results of these studies show promise for the improvement of patient outcomes. Current gaps in the research and subsequent directions for future study involve AI in optimizing and improving nerve stimulation and more thoroughly predicting patients' responses to treatment., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Pain Medicine, a field that was once considered primarily a specialty of opioid medication management, evolved into a multimodal care model with the goal of limiting reliance on pain medications. Now, we see another revolution-the advancement from percutaneous procedures to minimally invasive surgical procedures. Despite these changes, Pain Medicine fellowships have consistently been recognized as a competitive subspecialty with more applicants than the number of available positions - until now. The most recent pain fellowship match suggests an abrupt change to the popularity of the specialty (with over 61 unmatched positions and over 35 unfilled programs) for applicants expected to matriculate in the year 2024 [1]. Unfilled positions have risen from 5% to 15% in the past three years. Similarly, unfilled programs have risen from 10% to 30% in the past three years. Several reasons for this sudden change in popularity have been proposed, including a lucrative general anesthesiology market, increasing difficulties with insurance coverage and reimbursement for procedures, and a dearth of advanced pain procedures performed at academic medicine programs. The field is at a critical juncture, necessitating ongoing discussions and collaboration among stakeholders to ensure that trainees are attracted to this dynamic field and are ultimately equipped to meet the evolving needs of patients., Competing Interests: Dr. Christiansen served on the Executive Committee for the Pacific Spine and Pain Society. Oregon Health & Science University (OHSU) has reviewed and managed this relationship. Dr. Christiansen serves on the Executive Committee for the American Society of Pain & Neuroscience (ASPN). Dr. Christiansen has received institutional research grant funding from AVANOS, Sorrento, and the Pacific Spine and Pain Society. Dr. Pritzlaff serves on the Board of Directors for the Association of Pain Program Directors. He is a paid consultant for SPR Therapeutics, Bioness, and Nalu Medical and receives royalties from Wolters Kluwer and Oxford University Press. He receives educational grants from Medtronic, Nevro, Abbott, and Biotronik. Dr. Escobar serves as an executive medical advisor and paid consultant for Medtronic, Nevro, Painteq and Vertos Medical. Dr. Kohan serves on the Board of Directors for the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine. She is the immediate past president of the Association of Pain Program Directors and the president-elect for the Society of Academic Associations of Anesthesiology and Perioperative Medicine. She receives (ed) institutional research funding from AVANOS and FUS Mobile., (© 2024 The Authors.)

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection., (© 2023. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Introduction: The global trend of legalizing medical cannabis (MC) is on the rise. In Germany, physicians have prescribed MC at the expense of health insurers since 2017. However, the teaching on MC has been scant in medical training. This study investigates medical students' attitudes and perceived competence regarding MC and evaluates how varying materials (videos/articles) impact their opinions., Methods: Fourth-year medical students were invited to participate in the cross-sectional study. During an online session, students viewed a video featuring a patient with somatoform pain discussing her medical history, plus one of four randomly assigned MC-related materials (each an article and a video depicting a positive or negative perspective on MC). Students' opinions were measured at the beginning [T0] and the end of the course [T1] using a standardized questionnaire with a five-point Likert scale. We assessed the influence of the material on the students' opinions using paired-sample t-tests. One-way analysis of variance and Tukey post-hoc tests were conducted to compare the four groups. Pearson correlations assessed correlations., Results: 150 students participated in the course, the response rate being 75.3% [T0] and 72.7% [T1]. At T0, students felt a little competent regarding MC therapy (M = 1.80 ± 0.82). At T1, students in groups 1 (positive video) and 3 (positive article) rated themselves as more capable in managing MC therapy [Formula: see text], and students in groups 3 (positive article) and 4 (negative article) felt more skilled in treating patients with chronic pain [Formula: see text]. Compared to the other groups, group 2 students (negative video) felt significantly less competent. They perceived cannabis as addictive, hazardous and unsuitable for medical prescription., Discussion: This study showed that medical students lack knowledge and perceived competence in MC therapy. Material influences their opinions in different ways, and they seek more training on MC. This underlines that integrating MC education into medical curricula is crucial to address this knowledge gap., (© 2024. The Author(s).)

Artificial intelligence was introduced 60 years ago and has evolved immensely since that time. While artificial intelligence is found in nearly all aspects of our life, the use of artificial intelligence in the healthcare industry has only recently become apparent and more widely discussed. It is expected that artificial intelligence will allow improved disease recognition, treatment optimization, cost and time savings, product development, decision making, and marketing. For pain medicine specifically, these same benefits will be translatable and we can expect better disease recognition and treatment selection. As adoption occurs with this impressive technology, it will be imperative for the pain medicine community to be informed on proper definitions and expected use cases for artificial intelligence. Our objective was to provide pain medicine physicians an overview of artificial intelligence, including important definitions to aid understanding, and to offer potential clinical applications pertinent to the specialty., Competing Interests: RSD has funded research with Nevro and Saol Therapeutics. All other authors report no conflicts of interest in this work., (© 2024 Hagedorn et al.)

Background: Spinal cord stimulator (SCS) surgeries, whether performed using the open or percutaneous approach, are becoming increasingly common for a range of neuropathic pain conditions, including post-laminectomy syndrome and complex regional pain syndrome. However, there is limited knowledge regarding the factors linked to same-day discharge patterns following SCS., Objective: The purpose of this study was to identify factors associated with same-day discharge after SCS placement. The primary outcome was same-day discharge., Study Design: Retrospective, cohort study using a nationwide database., Methods: Inclusion criteria included patients who underwent percutaneous or open SCS from January 1, 2014 through December 31, 2021. Exclusion criteria included patients with missing data (n = 178) and those with SCS implants for unlisted indications (n = 1,817). A multivariable analysis was conducted on the outcome data and co-variates associated with same-day discharge after SCS., Results: After applying inclusion and exclusion criteria, a total of 18,058 patients remained in the final data set, including 7,339 patients who underwent percutaneous SCS and 10,719 patients who underwent open SCS procedures. After analysis, factors associated with increased rates of same-day discharge after SCS included men (odds ratio [OR] 1.16; 95% CI, 1.09 -1.24;  P < 0.001), patients on Medicaid (OR 1.64; 95% CI, 0.1.34 - 2.01; P < 0.001), and hospitals in the US Midwest (OR 1.66; 95% CI, 1.45 - 1.90; P < 0.001) and hospitals in the US West (OR 1.32; 95% CI, 1.20 - 1.46; P < 0.001). Factors associated with decreased rates of same-day discharge after SCS included the open approach (OR 0.21; 95% CI, 0.19 - 0.23; P < 0.001), Hispanic ethnicity (OR 0.61; 95% CI, 0.54 - 0.69; P < 0.001) and increased age (OR 0.99; 95% CI, 0.98 - 0.99; P < 0.001)., Limitations: Since our study is retrospective, the data are subject to various biases, including variable confounding, human error in data entry, and generalizability of the results., Conclusion: These results can be used to help determine hospital bed needs post-SCS surgery. Future research should focus on identifying the specific reasons certain demographic and geographic factors might influence same-day discharge rates. Our study provides important insights into the factors associated with same-day discharge rates post open and percutaneous SCS implant and highlights the need for patient-centered, evidence-based approaches to health care delivery.

In the initial wave of the opioid crisis, uninformed prescribing practices and lax oversight were the drivers of opioid addiction and death. Although opioid prescriptions have decreased by 44.4 percent between 2011-2020, 1 the number of deaths linked to prescription opioids has decreased only marginally. 2 The marked fall in opioid prescribing without a concomitant reduction in opioid-related deaths suggests that an at-risk population continued to receive prescription opioids, whether directly or indirectly, from a medical professional. Currently, illicitly manufactured fentanyl (IMF) is the culprit for the majority of the approximately 81,000 annual opioid-related deaths. 3 This finding has been misleadingly used to suggest that prescription opioids for chronic pain are no longer (and never were) a relevant concern, 4 while the reality is that their lethal consequences are simply dwarfed by the marked rise in IMF deaths. 5 .

Purpose: Primary dysmenorrhea (PD) is 1 of the most prevalent gynecologic conditions. The main aim of this umbrella review was to assess the effects of therapeutic exercise (TE) on PD., Methods: A systematic search was carried out in PubMed, Embase, SPORTDiscus, CINAHL, and PEDro (December 10, 2022). The outcome measures assessed were menstrual pain intensity, menstrual pain duration, and quality of life. Methodological quality was analyzed using the AMSTAR and ROBIS scales, and the strength of evidence was established according to the advisory committee grading criteria guidelines., Results: Nine systematic reviews were included. The results showed that TE, regardless of the exercise model and intensity, has a clinical effect in improving menstrual pain intensity in women with PD with moderate quality of evidence. In addition, the results showed that TE has a clinical effect in improving the duration of menstrual pain in women with PD with a limited quality of evidence. However, the results are controversial on the improvement of quality of life in women with PD with a limited quality of evidence., Conclusions: TE seems an effective option to implement in women with PD to improve the intensity and duration of menstrual pain. We cannot draw robust results for quality of life due to the low number of primary studies. More research in this field can help us establish more robust conclusions, as well as to assess whether there is one exercise model or intensity of training that is more effective than others.PROSPERO number: This review was previously registered in PROSPERO (CRD42022371428)., (© The Author(s) 2023. 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.)

Introduction: Interlaminar epidural steroid injections (ILESIs) are mainstay in the management of low back, neck and radicular pain and are a commonly performed pain management procedure in the United States. Our survey aims to provide an update in practice patterns of ILESIs among interventional pain physicians., Methods: We distributed a 91-item survey nationwide to private and academic interventional pain physicians who perform epidural steroid injections (ESIs). The survey was distributed via REDCap with a series of questions inquiring about current practices in epidural steroid injections from March 2021 to March 2022. Cross sectional data from survey responses specific to ILESI-related practices were captured and synthesized., Results: Of 103 complete survey responses, 96 physicians perform ILESIs (cervical, 87.5 %; thoracic, 82.3 %; lumbar 99 %). Nearly all surveyed physicians utilize fluoroscopy (98.1 %) over other modalities like MRI and ultrasound. For CIESIs, dexamethasone was the preferred steroid (52.4 %) over methylprednisolone (23.7 %); the converse was true for LIESIs in which methylprednisolone (44.2 %) was preferred over dexamethasone (32.6 %). The majority of providers performing ILESI's (91.7 %) preferred a Tuohy/Weiss needle while only a small fraction preferred the Quincke needle (7.2 %). Sedation practices were more varied with only about half of providers (47.6 %) offering medications. Furthermore, a great fraction of providers continue to use contrast for LIESIs (97.9 %) and CIESIs (89.6 %)., Discussion: Our survey suggests that despite updated consensus recommendations, variability continues to exist in procedural practice patterns. Highlighting areas of variable adherence to current safety guidelines can assist with what is emphasized in the generation of future evidence-based guidelines. Though our survey was conducted in the context of the COVID-19 pandemic with resultant supply chain shortages, more research is needed to elucidate what variables may factor into why proceduralists may stray from guideline concordant care., Competing Interests: None., (© 2023 The Authors.)

Introduction Pain management is a crucial aspect of patients' perioperative journey and a fundamental duty of every anesthetist. Throughout anesthesia training, there is an emphasis on the management of critical incidents, several of which surround pain management. With changes to the anesthesia curriculum over recent years, variable exposure to training opportunities, and a reduction in clinical hours during training, many trainees report feeling underprepared for their future roles as consultants. However, pain management remains a small fragment of the core anesthesia curriculum with no pain-focused simulation courses currently available across the UK. Simulation has proven to aid learning transfer in complicated and stressful scenarios with a substantial improvement in knowledge retention and prevention of skill loss while eliminating the risk of harm to patients. Aim A novel perioperative pain management simulation course was designed and implemented in the East of England to equip junior anesthesia trainees with the knowledge, skills, and confidence to manage perioperative pain and the associated critical incidents. Methods A multidisciplinary team (MDT) was involved in the course design. The faculty consisted of anesthesia consultants, trainees, pain nurses, and simulation technicians. The course ran twice over a six-month period both locally and regionally. A blended learning approach was adopted where 17 trainees attended PowerPoint presentations providing an overview of basic pain theories, perioperative pain management, regional anesthesia, and labor analgesia. Trainees then underwent telecasted simulation training using replicated patient notes, imaging, blood gas analysis, and a high-fidelity SimMan®. A debriefing period followed each scenario using Pendleton's model. An anonymized questionnaire was completed by all trainees before and after the course to assess improvement in their knowledge and confidence levels across four domains covering the management of perioperative pain. Results All 17 trainees completed the questionnaire; therefore, the entire dataset was analyzed. The pre-course questionnaire showed that using a scale of zero to 10, the vast majority of trainees reported low levels of confidence (<6/10) in the management of chronic pain during the perioperative period (82%), intraoperative pain management (76%), regional anesthesia (88%), and labor analgesia (65%). Following the simulation training, the results showed an overwhelmingly positive improvement in all 17 trainees' knowledge and confidence across all four tested domains. All 17 trainees (100%) also showed an improvement in their understanding of local pain protocols. The subjective feedback was positive, highlighting the overall usefulness of the course and that the tailored complexity of each simulation scenario was appropriate to each candidate's prior level of experience. Trainees also reported feeling more confident in starting their anesthesia on-calls. Conclusion This novel simulation course is the first of its kind in pain management. It has shown great improvements in trainee confidence in managing perioperative pain and the associated critical incidents. Subjective feedback has also been positively reassuring. Its inclusion into the East of England anesthesia training program and national training curriculum would greatly enhance trainee's knowledge and experience in pain management in the perioperative setting., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Afzaal et al.)

One of the ACGME's six core competencies, systems-based practice (SBP), is difficult to interpret and developing proficiency over a one-year fellowship poses a challenge. Given the implications that successful SBP can have on pain medicine, it is especially important for fellows to focus on this competency during their training. Here, we propose a way to implement effective SBP into a pain medicine fellowship and the impact it may have within the larger health care system., (© The Author(s) 2023. 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.)

Introduction: The evolution of treatment options for painful spinal disorders in diverse settings has produced a variety of approaches to patient care among clinicians from multiple professional backgrounds. The American Society of Pain and Neuroscience (ASPN) Best Practice group identified a need for a multidisciplinary guideline regarding appropriate and effective informed consent processes for spine procedures., Objective: The ASPN Informed Consent Guideline was developed to provide clinicians with a comprehensive evaluation of patient consent practices during the treatment of spine pathology., Methods: After a needs assessment, ASPN determined that best practice regarding proper informed consent for spinal procedures was needed and a process of selecting faculty was developed based on expertise, diversity, and knowledge of the subject matter. A comprehensive literature search was conducted and when appropriate, evidence grading was performed. Recommendations were based on evidence when available, and when limited, based on consensus opinion., Results: Following a comprehensive review and analysis of the available evidence, the ASPN Informed Consent Guideline group rated the literature to assist with specification of best practice regarding patient consent during the management of spine disorders., Conclusion: Careful attention to informed consent is critical in achieving an optimal outcome and properly educating patients. This process involves a discussion of risks, advantages, and alternatives to treatment. As the field of interventional pain and spine continues to grow, it is imperative that clinicians effectively educate patients and obtain comprehensive informed consent for invasive procedures. This consent should be tailored to the patient's specific needs to ensure an essential recognition of patient autonomy and reasonable expectations of treatment., Competing Interests: Dr Timothy Deer reports personal fees for consulting, research and/or stock options from Abbott, Vertos, SpineThera, Saluda, Mainstay, Nalu, Cornerloc, Ethos, SPR Therapeutics, Medtronic, Boston Scientific, PainTeq, Tissue Tech, Spinal Simplicity, Avanos, and Biotronik, outside the submitted work; In addition, Dr Timothy Deer has a pending patent to Abbott. Dr Ashley Bailey-Classen reports personal fees for consulting or speaker’s bureau from Nevro, Medtronic, Biotronik, and Spinal Simplicity, outside the submitted work. Ms Ashley Comer reports personal fees for consulting from Abbott, NALU, PainTEQ, Saluda, SPR Therapeutics, and Vertos, outside the submitted work. Ms Zohra Hussaini reports consulting fees from Nevro, SPR, PainTeq, Averitas; advisory board for Vertos, outside the submitted work. Dr Nasir Khatri reports personal fees for consulting from Saluda Medical; personal fees, non-financial support for advisory board from Vertos Inc., outside the submitted work. Dr Melissa Murphy reports personal fees for speaking, research and/or consulting from Medtronic and Relievant, outside the submitted work. Dr Morteza Rabii reports personal fees from InFormed consent, LLC, Abbott, Spinal Simplicity LLC, Flowonix Medical, and Southern Spine, outside the submitted work. Dr Douglas Beall reports personal fees from Medtronic, Spineology, Merit Medical, Johnson & Johnson, IZI, Techlamed, Peterson Enterprises, Medical Metrics, Avanos, Boston Scientific, Sollis Pharmaceuticals, Simplify Medical, Stryker, Lenoss Medical, Spine BioPharma, Piramal, ReGelTec, Nanofuse, Spinal Simplicity, Pain Theory, Spark Biomedical, Micron Medical Corp, Bronx Medical, Smart Soft, Tissue Tech, RayShield, Stayble, Thermaquil, Vivex, Stratus Medical, Genesys, Abbott, Eliquence, SetBone Medical, Amber Implants, Cerapedics, Neurovasis, Varian Medical Systems, Companion Spine, DiscGenics, Discure, SpinaFX, PainTEQ, outside the submitted work. Dr Michael E Schatman is a research consultant for Modoscript, Scientific Steering Committee for Collegium Pharma, and AdComm for Syneos Health, outside the submitted work. Dr Timothy Lubenow reports personal fees from Abbott Labs, Boston Scientific, Nevro, and Pain Teq, outside the submitted work. The authors report no other conflicts of interest in this work., (© 2023 Deer et al.)

This retrospective cohort study describes the utilization of opioids and gabapentin among patients with diabetic neuropathy who were gabapentin and opioid naïve, and assesses predictors of concomitant use of opioids and gabapentin. Using Medicare claims data (2012-2016), 22 037 patients were identified, of whom 23.42% (N = 5161) initiated opioids without concomitant gabapentin, 4.56% (N = 1004) initiated gabapentin without concomitant opioids, and 3.87% (N = 852) had concomitant use of gabapentin and opioids 12 months following their index date (date of earliest diagnosis). Concomitant gabapentin and opioid use were more common for lower doses of both drugs and for 15 days or more cumulatively. Compared to individuals aged 65-74, those aged 75-84 (OR: .759; 95% CI: 0.653-.882) or ≥ 85 years (OR: .586, 95% CI: 0.462-.743) had lower odds of concomitant use. People residing in the Northeast had lower odds of concomitant use, compared to those residing in the South (OR: .646 95% CI: 0.535-.779). Females compared to males (OR: 1.185, 95% CI: 1.027-1.367), people with higher Charlson's Comorbidity Index (CCI) scores (OR: 1.085, 95% CI: 1.037-1.135) or those having anxiety (OR: 1.462, 95% CI: 1.131-1.889) had higher odds of concomitant use. Concomitant prescriptions of opioids and gabapentin were more common for longer durations, indicating the need for interventions aimed at minimizing this prescribing practice.

Introduction: Throughout its history, there have been significant advances in pain control of inguinal hernia repairs. One of the most recent developments is locoregional pain blocks. There is a multitude of literature available on laparoscopic inguinal hernia repair and transversus abdominis plane (TAP) blocks., Objectives: This paper seeks to provide a thorough and systematic literature review on the role of TAP blocks in laparoscopic inguinal hernia repairs., Methods: PubMed and Google Scholar were searched for relevant literature using predetermined medical subject heading (MeSH) terms: "(TAP block)" AND "(Laparoscopic inguinal hernia repair)"., Results: A total of 166 publications were identified, from which 18 publications were included in the final review after eligibility criteria were applied., Conclusion: The majority of studies conclude that TAP blocks performed in the setting of laparoscopic inguinal hernia repair improve post-operative pain and mobility, decrease opiate analgesic usage, and are superior in pain control compared to other modalities of regional anesthesia. Thus, to improve post-operative outcomes and patient satisfaction, TAP blocks should be heavily considered for routine use in surgical practice for laparoscopic inguinal hernia repair., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Unlike traditional video games developed solely for entertainment purposes, game-based learning employs intentionally crafted approaches that seamlessly merge entertainment and educational content, resulting in captivating and effective learning encounters. These pedagogical methods include serious video games and gamification. Serious games are video games utilized as tools for acquiring crucial (serious) knowledge and skills. On the other hand, gamification requires integrating gaming elements (game mechanics) such as points, leaderboards, missions, levels, rewards, and more, into a context that may not be associated with video gaming activities. They can be dynamically (game dynamics) combined developing various strategic approaches. Operatively, gamification adopts simulation elements and leverages the interactive nature of gaming to teach players specific skills, convey knowledge, or address real-world issues. External incentives stimulate internal motivation. Therefore, these techniques place the learners in the central role, allowing them to actively construct knowledge through firsthand experiences.Anesthesia, pain medicine, and critical care demand a delicate interplay of technical competence and non-technical proficiencies. Gamification techniques can offer advantages to both domains. Game-based modalities provide a dynamic, interactive, and highly effective opportunity to learn, practice, and improve both technical and non-technical skills, enriching the overall proficiency of anesthesia professionals. These properties are crucial in a discipline where personal skills, human factors, and the influence of stressors significantly impact daily work activities. Furthermore, gamification can also be embraced for patient education to enhance comfort and compliance, particularly within pediatric settings (game-based distraction), and in pain medicine through stress management techniques. On these bases, the creation of effective gamification tools for anesthesiologists can present a formidable opportunity for users and developers.This narrative review comprehensively examines the intricate aspects of gamification and its potentially transformative influence on the fields of anesthesiology. It delves into theoretical frameworks, potential advantages in education and training, integration with artificial intelligence systems and immersive techniques, and also addresses the challenges that could arise within these contexts., (© 2023. Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care.)

Introduction: Acute cholecystitis is a painful inflammatory disease of the gallbladder. The Low Cervical-2 Plane Block is a retrolaminar block that targets the C3, C4, and C5 spinal nerves, which provide sensory innervation to the gallbladder, in order to potentially provide analgesia to patients with pain associated with acute cholecystitis., Methods: In this brief report, a softly embalmed cadaver was injected with a dye mixture bilaterally., Results: Subsequent cadaveric dissection revealed spread of the injectate deep to the prevertebral fascia to the C4 lamina on the right side and the C5 lamina on the left side. Also, diffusion of the anesthetic over the ligamenta flava could spread inferiorly and laterally to the spinal nerve roots of C3-C5 and thus potentially target the direct sensory innervation of the gallbladder., Conclusion: The Low Cervical-2 Plane Block is a potentially effective modality for treating intractable pain from acute cholecystitis. However, further cadaveric injections are needed to confirm the exact extent of spread of anesthetic. Clinical application of the Low Cervical-2 Plane Block in patients with acute cholecystitis is needed to establish the efficacy of this theoretical technique., Competing Interests: Declaration of Competing Interest None. The authors declare no competing interests. Support was provided solely from institutional and/or departmental sources., (Copyright © 2023 Elsevier Inc. All rights reserved.)