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Objective To assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE). Methods 30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities (Numeric Rating Scale – NRS: 0–10) on PODs 1–3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures. Results Average pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects. Conclusion The PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE.

Background Use of popliteal nerve blocks (PNBs) as an alternative or adjunctive therapy to traditional methods of pain control (e.g., systemic or spinal anesthesia and opioids) is increasingly popular in foot and ankle surgery. Methods We reviewed online databases for literature on PNBs in foot and ankle surgery to analyze the various techniques and positioning used, the influence of drugs on their efficacy, and possible complications associated with their use. Thirty articles were identified with a predefined search criteria, followed by a review process for relevance. Results Patient demographics, procedure specifics, and block techniques, such as anesthetic used, can impact the duration and success of a PNB. Administration with ultrasound guidance proved superior to nerve stimulation, and preoperative administration was superior to postoperative administration. Conclusions PNBs are an effective method to control postoperative pain with minimal complications, leading to decreased analgesic use, earlier discharge, and higher patient satisfaction. Level of evidence Level III, retrospective comparative study

Summary Background Pediatric thoracoscopic lobectomy is a technically challenging procedure that may result in better pain control, better cosmetic results, and shorter hospital stay. However, data describing the learning curve of total thoracoscopic lobectomy (TTL) have yet to be obtained. To evaluate our learning curve for TTL in children, we reviewed the safety and efficiency of our initial experiences with TTL in pediatric patients with congenital lung malformation. Methods This was a retrospective study of all pediatric patients undergoing TTL between March 2011 and January 2017. Cumulative summation (CUSUM) analysis of operative time (OT) was used. Results One hundred patients were retrospectively analyzed and chronologically divided into three phases: the ascending (A), plateau (B), and descending (C) phases of CUSUM of OT. Phases A, B, and C comprised 35, 22, and 43 cases, respectively. OT decreased significantly from phases A to B (P = 0.035) and B to C (P = 0.019). Age and weight of patients both reduced significantly from phase A to B (p = 0.017 and p = 0.012, respectively), while the two measures did not vary from phase B to C (p = 0.987 and p = 0.874, respectively). Chest tube duration and length of hospital stay had similar trend. All complications occurred in five cases in phase A (5/35). Six cases were converted to open surgery (6%). Four conversions occurred within phase A and two in phase C (4/35 vs 2/43, p = 0.490). There were no mortalities. Conclusions Repeated standardized training plays a role in overcoming the learning curve for thoracoscopic lobectomy in children, and CUSUMOT indicates that a learning curve of approximately 57 cases is required in our institute.

OBJECTIVE Precise and accurate targeting is critical to optimize outcomes after stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). The aim of this study was to compare the outcomes after SRS for TN in which two different techniques were used: mask-based 4-mm cone versus frame-based 5-mm cone. METHODS The authors performed a retrospective review of patients who underwent SRS for TN at their institution between 1996 and 2019. The Barrow Neurological Institute (BNI) pain score and facial hypesthesia scale were used to evaluate pain relief and facial numbness. RESULTS A total of 234 patients were included in this study; the mean age was 67 years. In 97 patients (41.5%) radiation was collimated by a mask-based 4-mm cone, whereas a frame-based 5-mm cone was used in the remaining 137 patients (58.5%). The initial adequate pain control rate (BNI I–III) was 93.4% in the frame-based 5-mm group, compared to 87.6% in the mask-based 4-mm group. This difference between groups lasted, with an adequate pain control rate at ≥ 24 months of 89.9% and 77.8%, respectively. Pain relief was significantly different between groups from initial response until the last follow-up (≥ 24 months, p = 0.02). A new, permanent facial hypesthesia occurred in 30.3% of patients (33.6% in the frame-based 5-mm group vs 25.8% in the mask-based 4-mm group). However, no significant association between the BNI facial hypesthesia score and groups was found. Pain recurrence occurred earlier (median time to recurrence 12 months vs 29 months, p = 0.016) and more frequently (38.1% vs 20.4%, p = 0.003) in the mask-based 4-mm than in the frame-based 5-mm group. CONCLUSIONS Frame-based 5-mm collimator SRS for TN resulted in a better long-term pain relief with similar toxicity profiles to that seen with mask-based 4-mm collimator SRS.

Background Given the national opioid crisis, postoperative analgesia at discharge must be thoughtfully prescribed. Data specifically related to thoracic procedures remain scarce. This study assessed adequacy of pain control with standardized and limited opioids after thoracic procedures. Methods A standardized prescription comprised 15 hydromorphone tabs, 7 days of acetaminophen, and 3 days of ibuprofen was provided on discharge to elective thoracic surgery patients. On the first postoperative visit, patients completed a questionnaire regarding the number of hydromorphones used, use of additional opioids, pain-related limitation to function, and adequacy of pain control. Results A total of 122 patients undergoing thoracic surgery procedures were surveyed. Twelve underwent open procedures and were excluded. An additional 6 patients who used opioids chronically preoperatively were also excluded. The remaining 104 patients were included in the study. Median age was 66 years (age range, 17-90 years) and median length of stay was 2 days (range, 1-15 days). Seventeen (16%) patients used all prescribed hydromorphone and 56 (54%) used none, 18 (17%) asked for additional or other opioid, and 14 (13%) felt that their pain significantly limited their function. Nine (9%) felt that that their pain was inadequately controlled. Conclusions Pain after thoracic procedures, especially video-assisted thoracoscopic surgery, is adequately controlled with minimal opioid doses (combined with adjuncts), with less than 1 in 5 patients requiring additional prescriptions and very few patients complaining of pain that significantly limited their function. This study shows that a standardized limited opioid prescription is safe, is adequate, and can easily be implemented for the majority of thoracic surgery patients.

Objective The reconstruction of large scalp defects poses both functional and cosmetic challenges. While free tissue transfer remains the standard for defects larger than 30 cm2, prolonged anesthesia and postoperative complications remain significant limitations. The purpose of this study is to evaluate the use of O-Z flaps for the reconstruction of large scalp defects and to describe the techniques employed. Methods This is a retrospective analysis of ten patients who underwent reconstructive surgery using an O-Z flap approach for large scalp defects between July 2017 and June 2019. The parameters included in this study were patient demographics, tumor characteristics, and postoperative management, collected for at least a year after surgery. Results In this cohort, the mean age was 76.1 years and 90% were male. All patients were treated for neoplastic skin lesions, with 70% located on the vertex and 30% located on the temporoparietal region. The mean size of defect was 52.0 cm2 (range: 38.6–63.8 cm2). The maximum hospital stay was two days, and no patients were readmitted within 30 days of surgery. There were no cases of wound infection or flap necrosis. All patients reported pain control with acetaminophen and ibuprofen. Four patients received adjuvant radiation, and there was no delay to receiving treatment following surgery. Conclusions The O-Z flap is a reliable alternative for the reconstruction of non-irradiated scalp defects in the vertex and temporoparietal regions up to 63 cm2. This technique provides advantages for patients, including hairline preservation, shorter hospital stays, and decreased postoperative complications.

A quality assurance study was completed following the implementation of a standardized opioid prescribing and education protocol post cesarean delivery. The primary goal was to determine the need for a policy on postpartum opioid prescribing practices and whether the protocol worked. There was a decrease in the number of tablets provided post intervention and no statistically significant maternal or neonatal readmissions for suspected opioid toxicity or pain control. Combination prescribing of Tylenol 3 and/or tramadol and another opioid occurred in both groups. Our results show a need for concise guidelines regarding opioid prescribing following cesarean delivery.

Background: Mindfulness meditation has been shown to alleviate pain and may be an appealing adjunctive pain management option. Objective: To compare measures of pain, mindfulness, and opioid usage, and collect evaluative feedback among patients undergoing septorhinoplasty with and without guided meditation. Methods: Patients undergoing septorhinoplasty were randomized to online-guided meditation postoperative days 0-3 versus standard care; all received the same pain medications. Primary outcome measures included pain intensity, opioid consumption, mindfulness scores, and evaluative feedback. Results: Twenty-one patients received guided meditation and 24 received standard care. No significant difference in opioid consumption or pain scores was seen with the exception of higher opioid use in patients with intranasal splints in the standard care group. Twenty out of 21 patients provided evaluative feedback; all recommended mindfulness meditation to friends undergoing nasal surgery, 90% reported it was beneficial, 85% believed it eased pain/discomfort, and 80% believed it aided with sleep. Conclusion: Although no objective difference was found in opioid consumption or pain scores, most patients reported that guided mindfulness meditation was beneficial to their recovery following septorhinoplasty.

OBJECTIVE To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. MATERIALS AND METHODS The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (

Background Acute aortic syndromes comprise a spectrum of diseases including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcers. Early diagnosis, rapid intervention, and multidisciplinary team care are vital to efficiently manage time-sensitive aortic emergencies, mobilize appropriate resources, and optimize clinical outcomes. Objective This comprehensive review outlines the multidisciplinary team approach from initial presentation to definitive interventional treatment and post-operative care. Discussion Acute aortic syndromes can be life-threatening and require prompt diagnosis and aggressive initiation of blood pressure and pain control to prevent subsequent complications. Early time to diagnosis and intervention are associated with improved outcomes. Conclusions A multidisciplinary team can help promptly diagnose and manage aortic syndromes.

Nerve block showed some potential in alleviating pain after mammaplasty. This systematic review and meta-analysis was conducted to investigate the efficacy of nerve block for pain control after mammaplasty.The databases including PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases were systematically searched for collecting the randomized controlled trials (RCTs) regarding the impact of nerve block on pain intensity after mammaplasty.This meta-analysis included 4 RCTs. Compared with control group after mammaplasty, nerve block resulted in remarkably reduced pain scores at 1 hour (mean difference [MD] = -1.84; 95% CI = -2.49 to -1.20;Nerve block was associated with substantially reduced pain intensity after mammaplasty.Le bloc nerveux a un certain potentiel pour soulager la douleur après la mammoplastie. La présente analyse systématique et méta-analyse a été réalisée pour examiner l’efficacité du bloc nerveux afin de contrôler la douleur après une mammoplastie.Les chercheurs ont fouillé systématiquement les bases de données PubMed, EMbase, Web of Science, EBSCO et de la Bibliothèque Cochrane pour en extraire les essais aléatoires et contrôlés (EAC) sur les effets du bloc nerveux sur l’intensité de la douleur après la mammoplastie.La présente méta-analyse comprenait quatre EAC. Par rapport au groupe témoin après la mammoplastie, le bloc nerveux favorisait une diminution remarquable des scores de douleur au bout d’une heure (différence moyenne [DM]=-1,84; intervalle de confiance [IC] à 95 %=-2,49 à -1,20; p0,00001), de trois heures (DM=-1,04; IC à 95 %=-1,47 à -0,62; p0,00001), de six heures (DM=-0,96; IC à 95 %=-1,48 à -0,43; p=0,0004) et la consommation d’analgésiques (différence moyenne type=-1,27; IC à 95 % =-1,73 à -0,82; p0,00001), mais n’avait pas d’effets significatifs sur les scores de douleur au bout de 24 heures (DM=-0,31; IC à 95 %=-1,05 à 0,43; p=0,41).Le bloc nerveux est associé à une diminution substantielle de l’intensité de la douleur une mammoplastie.

Analgesic options for surgical abortion (also called procedural abortion) beyond local anesthesia and minimal sedation include moderate sedation, deep sedation and general anesthesia. These clinical recommendations review the effectiveness of various moderate sedation, deep sedation, and general anesthesia regimens for pain control during abortion; medication regimens used to induce analgesia and anesthesia; patient factors affecting anesthesia safety; preoperative and intraoperative protocols to reduce anesthesia risks; personnel qualifications for administration; recommended patient monitoring protocols; and general risks of anesthesia in the context of abortion care. The scope of these recommendations is based on limited available evidence and considerably relies on existing professional society guidelines and recommendations developed by content experts and reviewers. Further research to compare the efficacy and safety of different regimens is needed.

Many male dairy calves are castrated when reared for beef production, but for dairy breeds the assessment of the longer-lasting pain associated with this procedure has received little scientific attention. In this study we assessed 2 methods: surgical (n = 10 calves) and rubber ring (n = 11). All calves were castrated at 28 d of age using multimodal pain control. During the 8 wk that followed, we recorded wound healing, local inflammation, body weight, milk and calf starter intake, lying time, and wound-directed behavior. Surgical wounds were fully healed on average 4 wk after the procedure, but only 1 calf in the rubber ring treatment fully healed within the 8-wk study. Inflammation was greater after rubber ring castration; skin temperature in the area around the lesion was 1.7 ± 0.35°C (mean ± standard deviation) higher than for the surgical treatment. Compared with surgically castrated calves, those castrated by rubber ring gained less weight over the study period (on average 11.9 ± 5.1 kg less), a difference due in part to lower intake of calf starter (on average 1.8 ± 0.6 kg less). Calves in the rubber ring treatment spent less time lying down (on average 4.2 ± 1.2% fewer scans per day) and licked their lesions more frequently (on average 16.0 ± 3.3 more licks per day). We conclude that the rubber ring calves experienced more pain in the weeks following the procedure and thus recommend that surgical castration be favored for preweaning dairy calves.

Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery.This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared.Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019).ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

Transcutaneous electrical nerve stimulation (TENS) is one of the non-pharmacological methods of pain relief that has been able to reduce pain by 70 to 90% in postoperative pain control. This study aimed to determine the effect of TENS on pain control after cesarean section and its effect on PNMT gene expression. For this purpose, a double-blind randomized clinical trial was performed on 70 Chinese patients with elective cesarean section. Patients were divided into case and control groups. In the case group, TENS and analgesic drugs were used to relieve pain, and in the control group, the only analgesic drug was used. Then the severity of pain, recurrence of pain attacks, the number of analgesic drugs used and the amount of analgesic drug used in the first 24 hours after surgery were evaluated and compared. Blood samples were also taken from patients to evaluate PNMT gene expression. The semi-quantitative RT-PCR was used to study changes in gene expression. The results showed that the group treated with TENS had less pain intensity and less recurrence of pain attacks than the group that received only analgesic medication. Also, the frequency of analgesic drug use and its dose in the TENS group were significantly lower than in the control group. TENS, on the other hand, has been able to greatly reduce the expression of the PNMT gene, which is produced during times of stress. Therefore, it is recommended that TENS be used as a non-invasive and non-pharmacological adjuvant effective in reducing pain after cesarean section.

Intra-articular injections with hyaluronic acid are recommended in the treatment of knee osteoarthritis; however, hypertonic dextrose prolotherapy has been reported as effective and safe. The aim was to evaluate the effectiveness of hypertonic dextrose prolotherapy for pain reduction and improvement of function in individuals with knee osteoarthritis in comparison with hyaluronic acid by meta-analysis. The search was performed in electronic databases. Six studies were included (395 participants). No statistically significant differences were found between prolotherapy and hyaluronic acid in pain control in the short-term; however, in the subanalysis that included only the studies that used intra-articular injection within the prolotherapy scheme, an effect was found in favor of the prolotherapy groups ( d = -1.33; 95% confidence interval, -2.50 to -0.16; P ( z ) = 0.03). Also, an effect was found in favor of the prolotherapy group in the improvement in function ( d = -1.05; 95% confidence interval, -2.03 to -0.08; P ( z ) = 0.03). No major adverse reactions or side effects were reported in any of the studies. Hypertonic dextrose prolotherapy seems to be an effective intervention to decrease pain and improve function in knee osteoarthritis, with efficacy similar to intra-articular injections with hyaluronic acid in the short-term follow-up. Nonetheless, better-quality clinical trials are necessary.

Virtual reality therapy has been shown to be an excellent alternative to non-pharmacological treatment for the control of burn pain. The objective was to evaluate the effects of virtual reality therapy on pain control in people who have suffered burns published in the scientific literature. Systematic review carried out as recommended by Cochrane. The search was carried out in the Embase, PubMed, Lilacs, and Cochrane Library databases, in the period from March 2021. Randomized clinical trials were included without language restriction and year of publication. The risk of bias was assessed using the Cochrane tool. Of the 3755 articles found, only 17 articles were selected for reading in full. Of these, only four articles met the inclusion criteria. The results of the studies showed that the use of virtual reality therapy reduced the intensity of pain in children and adolescents with burns, despite the fact that most results are not statistically significant. No selected study had a high risk of bias. Virtual reality therapy has been shown to be effective in controlling pain, reducing the time spent thinking about it and greater distraction during the procedures. However, most randomized clinical trials results were not statistically significant in at least one of the moments when pain was assessed. It is noteworthy that randomized clinical trials are still necessary to administer virtual reality therapy, especially in adults.

OBJECTIVE To prospectively analyze pain and pain medication use following otologic surgery. STUDY DESIGN Prospective cohort study with patient reported pain logs and medication use logs. SETTING Tertiary academic hospital.Patients: Sixty adults who underwent outpatient otologic surgeries. INTERVENTIONS Surveys detailing postoperative pain levels, nonopioid analgesic (NOA) use, and opioid analgesic use. MAIN OUTCOME MEASURES Self-reported pain scores, use of NOA, and use of opioid medications normalized as milligrams morphine equivalents (MME). RESULTS Thirty-two patients had surgery via a transcanal (TC) approach, and 28 patients had surgery via a postauricular (PA) approach. TC surgery had significantly lower reported pain scores than PA surgery on both postoperative day (POD) 1 (median pain score 2.2, IQR 0-5 vs. median pain score 4.8, IQR 3.4-6.3, respectively; p = 0.0013) and at POD5 (median pain score 0, IQR 0-0 vs. median pain score 2.0, IQR 0-3, respectively; p = 0.0002). Patients also used significantly fewer opioid medications with TC approach than patients who underwent PA approach at POD1 (median total MME 0, IQR 0-5 vs. median total MME 5.0, IQR 0-15, respectively; p = 0.03) and at POD5 (median total MME 0, IQR 0-0 vs. median total MME 0, IQR 0-5, respectively; p = 0.0012). CONCLUSIONS Surgery with a postauricular approach is associated with higher pain and opioid use following otologic surgery. Patient- and approach-specific opioid prescribing is feasible following otologic surgery.

Os alimentos ou ingredientes funcionais são, todo aquele que contribui beneficamente dentro do estado fisiológico e metabólico para a saúde do indivíduo a que consomem. O cacau é uma cultura importante do ponto de vista social para a agricultura familiar, tem origem nas regiões tropicais da américa central, seu fruto possui compostos bioativo funcionais, o qual atua na prevenção e redução do risco de determinadas doenças, especialmente em relação à saúde cardiovascular. O seu cultivo cresceu na floresta amazônica brasileira, especialmente no estado do pará. O presente trabalho vem ser uma revisão de literatura, como objetivo apresentar os benefícios proveniente desde fruto e seus componentes nutricionais e funcionais na saúde dos consumidores. Com base nos resultados da pesquisa literária, comprovaram que produtos à base de cacau, associado a uma dieta equilibrada e práticas físicas, tem efeitos benéficos a saúde de que o consomem. Portanto consumido de forma adequada com alimentação balanceada pode trazer benefícios para o sistema do coração, ter influência em várias outras patologias e retardar o envelhecimento precoce.

INTRODUCTION We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries. METHODS All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data. RESULTS After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p

Background Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated. Objective of the Review To provide an evidence-based review of clavicle fracture management in the emergency department. Discussion Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults. Conclusions When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Calfhood morbidity is an important issue on commercial dairy operations, with substantial production and welfare impacts. The objective of this observational study was to evaluate potential risk factors for morbidity, including disbudding, disbudding pain control, serum total protein (STP) concentrations, and haptoglobin concentrations in young dairy calves. A total of 140 heifer calves from a commercial dairy farm in southwestern Ontario, Canada, were enrolled at 1 to 9 d of age and followed for 1 wk. Calves were scored at enrollment for several health parameters using a scale from 0 to 3, with 0 representing normal and 3 representing severely abnormal. Calves were only included if they were considered healthy enough to participate using cut points of3 for rectal temperature and fecal score; ≤2 for nasal discharge, ocular discharge, and cough score; and 1 for ear position, navel score, and joint score. To ensure that only calves that were considered healthy on the baseline day were included, 17 calves were excluded from analysis, resulting in a total of 123 calves. These calves were a part of a disbudding trial, with 100 disbudded using a commercial caustic paste and 23 sham disbudded with a placebo paste. The disbudding paste (commercial or sham) was applied to calves on enrollment day (baseline) with health scoring at baseline and 3 and 7 d later. The following health outcomes were analyzed: diarrhea (a fecal consistency score of ≥2), respiratory disease (a total respiratory score of ≥5), and general sickness [suffering from either diarrhea, respiratory disease, or a navel or joint infection (joint or navel score of ≥2)]. The following variables were assessed for association with the outcomes: STP, inadequate transfer of passive immunity (5.2 g/dL STP), pain control treatment for disbudding (lidocaine nerve block alone, meloxicam alone, lidocaine nerve block and meloxicam, no pain control, sham), disbudding (disbudded or sham), and haptoglobin concentrations (taken on the baseline day, +3 d and +7 d). We did not detect any relationship between the development of a health outcome of interest (diarrhea, respiratory, or sick) and disbudding or pain control on any of the days following disbudding. However, for every 1 g/dL increase in STP concentration, calves had 0.24 and 0.33 times the odds of suffering from diarrhea or any sickness event, respectively, 3 d after disbudding. At 3 d after disbudding, for every 0.1 mg/mL increase in haptoglobin concentration on that day, calves had 1.34 and 1.20 times the odds of having diarrhea or a general sickness, respectively. These findings suggest that disbudding itself or the pain control method does not appear to influence health after the procedure when healthy calves are disbudded. Calves developing an illness 3 d after disbudding were more likely to have had lower STP concentrations and increased haptoglobin concentrations.

Many dairy farmers in North America disbud or dehorn their cattle to improve human and animal safety. The Farmers Assuring Responsible Management (FARM v. 4.0) program requires that disbudding be performed before 8 wk of age with pain-control medication. The objective of this observational cross-sectional study was to quantify disbudding and dehorning practices of Wisconsin dairy producers to target future extension programming. Responses from 217 Wisconsin dairy producers and calf raisers were collected via digital surveys distributed at extension events and through industry contacts. Of the 217 respondents, 188 performed on-farm disbudding themselves. Most respondents (61%) used caustic paste as their primary method, which was most commonly applied on the day the calf was born (53%). Hot iron was used by 32% of respondents, and surgical methods (gouge, scoop, or wire saw) were used by 6% of respondents. Hot-iron disbudding was most commonly performed at 4 to 8 wk of age (41%) and 1 to 4 wk of age (33%), whereas surgical methods were most commonly performed at 8 wk or older (73%). Pain-control medication was used by 43% of respondents. Specifically, 35% used an anti-inflammatory, and 21% used a local nerve block. Veterinary involvement in creating the disbudding protocol was associated with increased odds of using pain control. Respondents with a target weaning age of ≥10 wk had greater odds of complying with FARM disbudding requirements and were also more likely to use polled genetics. Respondents aged 18 to 34 and respondents with >60 calves were more likely to have made changes to their disbudding or dehorning protocol in the last decade. Although use of pain control was higher than in previous US studies, full adoption of pain management requires further extension efforts. Veterinarians appeared influential on adoption of pain control, and their involvement may encourage adoption of pain management. Further research should investigate how the implementation of new FARM v. 4.0 standards will change the disbudding and dehorning practices of American dairy producers.

Resumen: La artropatía de Charcot en el raquis es una afectación neuropática de la columna, es considerada una coindición inusual, tiene una evolución destructiva y progresiva. Habitualmente suele ser debida a una lesión traumática previa, pero también se ha descrito secundaria a otros procesos infecciosos, tumorales. Inicialmente siempre se ha planteado un tratamiento quirúgico para las posibles complicaciones como son el control del dolor y la inestabilidad del tronco. Se presenta una serie de 13 casos diagnosticados de artropatía de Charcot en el Institut Guttmann, donde se describen como variables: la etiología (traumática, infecciosa, iatrogénica), la clínica (dolor, pérdida de control de tronco, vegetatismo, espasticidad), el intervalo de aparición de la clínica, la localización (L2-L3), el tratamiento (quirúrgico o conservador) y la evolución que presentaron, y se pretende valorar el tratamiento conservador como primera opción, en lugar de la opción quirúrgica. En nuestra muestra, el 61,5% (8/13) fueron tratados quirúrgicamente con instrumentación posterior (7/8), salvo un caso que fue anterior y posterior; el 38,5% (5/13) fueron tratados de manera conservadora y ninguno necesito una cirugía posterior. En conclusión, nuestra línea de actuación sería inicialmente contemplar un tratamiento conservador, y utilizar la cirugía para casos en los que la evolución de la clínica no fuera la esperada, bien por un mal control del dolor y/o la limitación de la movilidad secundaria a la deformidad del tronco, o cuando la afectación raquídea o la clínica que presenta el paciente no fuera tolerada y necesitara de una solución más rápida y agresiva. Abstract: Charcot arthropathy of the spine is a neuropathic affectation of the spine, it is considered rare, has a destructive and progressive evolution. It is usually due to a previous traumatic injury, but it has also been described as secondary to other infectious or tumoural processes. Initially, surgical treatment has always been considered for possible complications such as pain control and trunk instability. We present a series of 13 cases diagnosed with Charcot arthropathy at the Institut Guttmann, in which the following variables are described: aetiology (traumatic, infectious, iatrogenic), clinical features (pain, loss of trunk control, vegetatism, spasticity), interval of onset of the clinical features, location (L2-L3), treatment (surgical or conservative) and the evolution they presented, with the aim of evaluating conservative treatment as the first option, instead of surgery. In our sample, 61.5% (8/13) were treated surgically with posterior instrumentation (7/8), except for one case which was anterior and posterior; 38.5% (5/13) were treated conservatively and none required subsequent surgery. In conclusion, our line of action would initially be to consider conservative treatment, and to use surgery for cases in which the clinical evolution was not as expected, either due to poor pain control and/or limitation of mobility secondary to the deformity limitation of mobility secondary to the deformity of the trunk, or when the spinal involvement or the patient's symptoms are not tolerated and require a quicker and more aggressive solution.

Rib fractures represent a significant cause of morbidity and mortality in trauma patients. The erector spinae plane block has come to the forefront as a potential safe and effective option for analgesia in painful conditions of the thorax over multiple dermatomal levels. Given the high morbidity associated with rib fractures, the inadequacy of opioid analgesia and the strong safety profile of the erector spinae plane block, this pilot study sought to address whether this block can be used to safely and effectively provide analgesia in emergency department (ED) patients with acute rib fractures.A total of nine patients underwent the procedure successfully. Patients were found to have a significant reduction in their pain score pre- and post-block. The reduction in mean pre- and post-block pain scores was 9.89 vs 3.56 which was statistically significant (p 0.0001).In a pilot sampling of emergency department patients with acute fractures who failed traditional analgesic therapy, the erector spinae plane block performed by emergency physicians provided safe and effective pain control. Further research is needed to fully establish the clinical benefit and safety of this procedure.RéSUMé: OBJECTIFS: Les fractures des côtes représentent une cause importante de morbidité et de mortalité chez les patients traumatisés. Le bloc du plan des muscles érecteurs du rachis est apparu comme une option potentiellement sûre et efficace pour l’analgésie dans les états douloureux du thorax sur plusieurs niveaux dermatomiques. Compte tenu de la morbidité élevée associée aux fractures des côtes, de l’insuffisance de l’analgésie opiacée et du profil d’innocuité solide d'un bloc du plan des muscles érecteurs du rachis, cette étude pilote visait à déterminer si ce bloc peut être utilisé pour fournir une analgésie sûre et efficace aux patients des urgences présentant des fractures aiguës des côtes. MéTHODES: Au total, neuf patients ont subi l’intervention avec succès. On a constaté que les patients avaient une réduction significative de leur score de douleur avant et après le blocage. La réduction des scores moyens de la douleur avant et après le blocage était de 9.89 contre 3.56, ce qui était statistiquement significatif (p 0.0001). CONCLUSION: Dans le cadre d’un projet pilote d’échantillonnage de patients des services d’urgence ayant subi des fractures aiguës et ayant échoué à la thérapie analgésique traditionnelle, le bloc du plan des muscles érecteurs du rachis effectué par les médecins urgentistes a permis de contrôler efficacement et en toute sécurité la douleur. Des recherches supplémentaires sont nécessaires pour établir pleinement les avantages cliniques et la sécurité de cette procédure.

The use of stereotactic body radiation therapy (SBRT) to treat non-spine bone metastases (NSBM) is becoming increasingly common in clinical practice. The clinical advantages of SBRT include good pain control and high local control rates, although only limited data are available. The Spanish Society of Radiation Oncology (SEOR) SBRT group recently convened a task force of experts in the field to address key questions related to SBRT for NSBM, including treatment indications, planning, techniques, and dose fractionation. The task force reviewed the available literature to develop evidence-based recommendations for the safe application of NSBM SBRT and to standardize and optimize SBRT processes. The present document provides a comprehensive analysis of the available data, including ongoing clinical trials and controversies, providing clinically applicable recommendations.

Background Alveolar Osteitis (AO) is one of the most common complications of tooth extraction. Several therapeutic interventions have been described for the treatment of AO, however, there are no treatment standardized protocols. The aim of this study was to conduct a systematic review on the efficacy in pain control of the different treatments for AO. The feasibility of the application of these interventions is also discussed. Material and Methods A structured electronic and hand search strategy was applied to PubMed, Scopus, Cochrane Library, OpenGrey, and Google Scholar between January 2010 and July 2020 to identify studies according to PRISMA guidelines. The inclusion criteria were original English and Spanish clinical trials that analyzed pain-control parameters according to visual analog scale (VAS, 0-10 scale), or pain relief patients’ percentages. Those treatments that reach VAS ≤ 4 on day 2 or before; or ≥ 85% of patients with absence of pain symptoms at day 7 or before were considered accepTable for their recommendation. Results The final review included 17 clinical trials. Among them, there were analyzed a total of 39 different AO treatments. 53,8% of the treatments fulfill the proposed parameters for pain control. Conclusions Treatment alternatives are multiple, heterogeneous, and difficult to compare. The management of AO is summarized in basic (intra-alveolar irrigation) and specific procedures (Alveogyl®, Neocones®, SaliCept Patch®, Low-Level Laser, Platelet-Rich Fibrin) that reach pain control success. They could be selected according to their availability and advantages or disadvantages. Key words:Dry socket, alveolar osteitis, treatment, management, pain control, pain relief.

ResumoQuase 90% dos casos de coccigodínia podem ser tratados por meio de tratamento clínico conservador; os 10% restantes precisam de outras modalidades invasivas para o alívio da dor, como o bloqueio do gânglio ímpar (BGI) ou ablação por radiofrequência (ARF) do gânglio ímpar. Com o objetivo de avaliar a eficácia do BGI e ARF do gânglio ímpar no controle da dor em pacientes com coccigodínia, foi realizada uma pesquisa sistemática no PubMed, MEDLINE e Google Scholar, a fim de identificar estudos que relatam o alívio da dor, em termos de Escala Visual Analógica (EVA) ou dos seus homólogos, após o BGI ou ARF em pacientes com coccigodínia por 2 autores diferentes, de acordo com as diretrizes PRISMA. Foram definidos sete estudos com um total de 189 pacientes (104 no grupo BGI e 85 no grupo ARF). No grupo BGI, a média da pontuação EVA melhorou de 7,83 no início do estudo para 3,11 no acompanhamento de curto prazo, 3,55 no acompanhamento de médio prazo e 4,71 no acompanhamento de longo prazo. No grupo ARF, a média da pontuação EVA melhorou de 6,92 no início do estudo, 4,25 no acompanhamento de curto prazo e 4,04 no acompanhamento de longo prazo. No grupo BGI foram relatadas 13,92% de falhas (11/79) e complicações de 2,88% (3/104), enquanto que no grupo ARF foram relatadas 14,08% de falhas (10/71) e nenhuma complicação (0%). A taxa total de êxito foi >85% em qualquer uma das modalidades. O BGI e ARF do gânglio ímpar fornecem um método confiável e provavelmente excelente no controle da dor, em pacientes com coccigodínia que não respondem ao tratamento médico conservador. No entanto, deve ser estabelecido um limite entre os que responderam, os que não responderam e aqueles não respondedores tardios, sendo necessários estudos mais amplos com acompanhamento mais longo (>1 ano).

Minimally invasive repair of pectus excavatum (Nuss procedure) is associated with significant pain, and efforts to control pain impact resource utilization. Bilateral thoracic intercostal nerve cryoablation has been proposed as a novel technique to improve post-operative pain control, though the impact on hospital cost is unknown.We conducted a retrospective study of patients undergoing a Nuss procedure from 2016 to 2019. Patients who received cryoablation were compared to those that received traditional pain control (patient-controlled analgesia or epidural). Outcome variables included postoperative opioid usage (milligram morphine equivalents, MME), length of stay (LOS), and hospital cost.Thirty-five of 73 patients studied (48%) received intercostal nerve cryoablation. LOS (1.0 vs 4.0 days, p 0.01) and total hospital cost ($21,924 versus $23,694, p = 0.04) were decreased in the cryoablation cohort, despite longer operative time (152 vs 74 min, p 0.01). Cryoablation was associated with decreased opioid usage (15.0 versus 148.6 MME, p 0.01) during the 24 h following surgery and this persisted over the entire postoperative period, including discharge opioid prescription (112.5 vs 300.0 MME, p 0.01).Bilateral intercostal nerve cryoablation is associated with decreased postoperative opioid usage and decreased resource utilization in pediatric patients undergoing a minimally invasive Nuss procedure for pectus excavatum.Retrospective comparative study, level III.

Introduction Bone metastases are frequent in patients with cancer. Electrochemotherapy (ECT) is a minimally invasive treatment. Preclinical and clinical studies supported the use of ECT in patients with metastatic bone disease (MBD). The purposes of this multicentre study are to confirm the safety and efficacy of ECT, and to identify appropriate operating procedures in different MBD conditions. Materials and methods 102 patients were treated in 11 Centres and recorded in the REINBONE registry (a shared database protected by security passwords): clinical and radiological information, ECT session, adverse events, response, quality of life indicators and duration of follow-up were registered. Results 105 ECT sessions were performed (one ECT session in 99 patients, two ECT sessions in 3 patients). 24 patients (23.5%) received a programmed intramedullary nail after ECT, during the same surgical procedure. Mean follow-up was 5.9 ± 5.1 months (range 1.5–52). The response to treatment by RECIST criteria was 40.4% objective responses, 50.6% stable disease and 9% progressive disease. According to PERCIST criteria the response was: 31.4% OR; 51.7% SD, 16.9% PD with no significant differences between the 2 criteria. Diagnosis of breast cancer and ECOG values 0–1 were significantly associated to objective response. A significant decrease in pain intensity and significant better quality of life was observed after ECT session at follow-up. Conclusion The results are encouraging on pain and tumour local control. ECT proved to be an effective and safe treatment for MBD and it should be considered as an alternative treatment as well as in combination with radiation therapy.

Hip resection arthroplasty is a useful procedure for the management of complex hip problems and in patients with high surgical and anesthetic risk factors. Unilateral procedures performed for failed total hip arthroplasty have been shown to be successful for pain relief with acceptable functional outcomes; however, to our knowledge, no research exists on simultaneous bilateral hip resection arthroplasty for femoral head osteonecrosis. We present two cases of single-stage bilateral hip resection arthroplasty performed under singular anesthetic procedures for femoral head osteonecrosis. The patients were each able to stand for transfers postoperatively and had no deterioration in pain or function. These two cases demonstrate that satisfactory pain control with preservation of function may be achievable with bilateral hip resection arthroplasty procedures in patients who are not a candidate for more advanced reconstructive procedures.

Flail chest is associated with high rates of morbidity and mortality and management of such condition is a multidisciplinary task that should be based on pain control, judicious fluid administration, adequate pulmonary hygiene and management of the paradoxical movements of the thoracic wall. Many methods of treating rib fractures and flail chest have been developed over the years. Our aim was to evaluate a novel method of flail chest stabilization using negative vacuum pressure and compare it to a traditional method. Material and methods: 10 patients with flail chest from trauma admitted in Thoracic Surgery Clinic from Clinical County Emergency Hospital of Craiova and County Emergency Hospital of Targoviste were submitted to stabilization using Vacuum Assisted Closure kit. This series of patients were compared with 10 patients in whom a traditional method of stabilization was used, selected from the database of patients from the Thoracic Surgery Clinic of Clinical Emergency Hospital of Craiova, used as control group. Results: The 2 groups were comparable as no statistically significant differences were found regarding the gender, mean age, type of trauma, associated trauma, preexistent conditions, number of rib fractures, presence of pulmonary contusion, thoracic deformity. The parameters investigated: number of days with mechanical ventilation, number of days spent in ICU, total hospital stay, mortality didn’t reach statistically significant differences. The only significant results found were for the pain scores recorded at 2 weeks and 1 month after discharge, the VAC stabilization being significantly better than traditional method. Conclusions: A larger study is required to establish if the advantages of the VAC assisted stabilization of the flail chest are superior to traditional treatment.

One of the priority tasks in the management of patients in the intraoperative and early postoperative period is appropriate pain control, which provides not only a smooth clinical course of the disease and quality of life of patients, but also the success of surgical treatment in general by reducing the number of stress complications. Prolonged postoperative acute pain can cause the development of functional disorders of the lungs, cardiovascular system, gastrointestinal tract, central nervous system, hemostasis system, etc. The use of opioids increases the number of complications in the early postoperative period. Therefore, today a promising area is the use of multimodal analgesia, which promotes better pain relief, a smoother clinical course, early mobilization of patients by minimizing the number of complications caused by opioids. The choice of an adequate model of postoperative analgesia should be based on an understanding of the multifaceted nature of the pain syndrome, which may include both the somatic component due to surgical trauma and neuropathic one caused by chronic inflammation, neuropathy, ischemic disorders. The article presents data from current researches on the concept of multimodal analgesia, which shows that the use of dexketoprofen (Dexpro) as its part promotes better and longer analgesia, prevents the development of chronic postoperative pain, reduces the need for narcotic analgesics., Одной из первоочередных задач ведения больных в интраоперационном и раннем послеоперационном периоде является соответствующее обезболивание, которое обеспечивает не только гладкое клиническое течение заболевания и качество жизни пациентов, но и успех хирургического лечения в целом благодаря снижению количества стресс-реализованных осложнений. Длительная послеоперационная острая боль может быть причиной развития функциональных нарушений со стороны легких, сердечно-сосудистой системы, желудочно-кишечного тракта, центральной нервной системы, системы гемостаза и др. Применение опиоидов увеличивает количество осложнений в раннем послеоперационном периоде. Поэтому сегодня перспективным направлением является применение схем мультимодальной аналгезии, что способствует лучшему обезболиванию, более гладкому клиническому течению заболевания, ранней мобилизации больных благодаря минимизации количества осложнений, вызванных опиоидами. Выбор адекватной модели после­операционного обезболивания должен основываться на понимании многоплановости болевого синдрома, который может включать как соматический компонент, обусловленный хирургической травмой, так и нейропатический, вызванный хроническим воспалением, нейропатией, ишемическими расстройствами. В статье приведены данные современных исследований относительно концепции мультимодальной аналгезии, которые показывают, что применение в ее составе декскетопрофена (Декспро) способствует более качественной и длительной аналгезии, предотвращает развитие хронической послеоперационной боли, уменьшает потребность в применении наркотических анальгетиков., Одним із першочергових завдань ведення хворих в інтраопераційному та ранньому післяопераційному періоді є відповідне знеболювання, що забезпечує не тільки рівний клінічний перебіг захворювання та якість життя пацієнтів, а й успіх хірургічного лікування в цілому завдяки зниженню кількості стрес-реалізованих ускладнень. Тривалий післяопераційний гострий біль може бути причиною розвитку функціональних порушень із боку легень, серцево-судинної системи, шлунково-кишкового тракту, центральної нервової системи, системи гемостазу тощо. Застосування опіоїдів збільшує кількість ускладнень у ранньому післяопераційному періоді. Тому на сьогодні перспективним напрямком є застосування схем мультимодальної аналгезії, що сприяє кращому знеболюванню, більш рівному клінічному перебігу, ранній мобілізації хворих завдяки мінімізації кількості ускладнень, спричинених опіоїдами. Вибір адекватної моделі післяопераційного знеболювання повинен ґрунтуватися на розумінні багатоплановості больового синдрому, який може включати як соматичний компонент, зумовлений хірургічною травмою, так і нейропатичний, спричинений хронічним запаленням, нейропатією, ішемічними розладами. У статті наведені дані сучасних досліджень щодо концепції мультимодальної аналгезії, які демонструють, що застосування в її складі декскетопрофену (Декспро) сприяє більш якісній та тривалій аналгезії, запобігає розвитку хронічного післяопераційного болю, зменшує потребу в застосуванні наркотичних анальгетиків.

Blunt trauma patients commonly present with multiple rib fractures, which increases overall morbidity and mortality due to pulmonary complications. Effective chest wall analgesia may be challenging due to positioning difficulty, body habitus, anticoagulation issues with neuraxial interventions, etc. Serratus anterior plane block has been shown to be beneficial in anterior and lateral rib fractures in recent studies. We propose the efficacy of this block in posterior rib fractures as well, through this small case series of blunt trauma patients with posterior rib fractures, reporting significant pain relief after the block.

An abuse-deterrent, microsphere-in-capsule extended-release formulation of oxycodone myristate (Xtampza® ER, Collegium Pharmaceutical Inc, Canton, Massachusetts), was approved by the FDA in 2016 for the management of pain. The advantage of this formulation of oxycodone is that the microspheres can be administered via enteral tubes without compromising the long-acting formulation. This case series characterizes the experiences of five head and neck cancer patients initiated on oxycodone myristate through enteral tube administration for control of cancer-related pain. The primary outcome of patient reported subjective improvement in pain within one week occurred in all five patients. The median time to pain control was 4 days. The safety profile of oxycodone myristate was consistent with the package insert with no new findings reported. Oxycodone myristate can be an appropriate long-acting opioid analgesic option for patients requiring enteral tube administration of medications to achieve adequate cancer-related pain control.

Objective: To evaluate the healing of open upper lip vermillion wounds irradiated with CO2 laser immediately after injury. Background: There are reports of using CO2 laser therapy on healed wounds for scar tissue reduction. However, limited data exist regarding its use immediately after an injury. Thus, the role of CO2 laser in wound healing remains unclear. Methods: Two patients with open upper lip vermillion wounds were treated using CO2 laser irradiation to the area postsuturing. Results: Good functional and aesthetic results were obtained from the therapy, with no postoperative pain complaints or infection. Conclusions: CO2 laser irradiation, performed immediately after an injury, could be an effective treatment option for open vermillion wounds.

Background: Tumor Necrosis Factor -a (TNF-a) and Interleukin-113 (IL-113) are among the cytokines released secondary to the surgical stress response. The objective of this study was to investigate the effect of a Transversus Abdominis Plane (TAP) block on postoperative pain and its immunomodulatory activity through proinflammatory cytokines. Methods: TAP (study group; n = 40) or p-TAP (placebo group; n = 40). Patients in the TAP group underwent an Ultrasound (US) guided unilateral TAP block using 20-cc 0.5% bupivacaine solution. Patients in the p-TAP group underwent a sham block using 20-cc isotonic solution. The TNF-a and IL-113 levels were measured three times at preoperative hour-0 and postoperative hours 4 and 24. Visual Analog Scale (VAS) scores were recorded at 0-hours, 30-minutes, 4-hours, and 24-hours. Analgesic use within the first 24-hours following surgery was monitored. Results: The postoperative VAS score was decreased in the TAP group at all time points (0, 4, and 24 hours), and the differences between groups were statistically significant (p < 0.001 for all comparisons). In the TAP group, the TNF-a and IL-113 levels at 4 and 24 hours post operation were significantly lower than the preoperative levels (p < 0.001 for all comparisons). Conclusion: The TAP block for pre-emptive analgesia enabled effective hemodynamic control during the intraoperative period, provided effective pain control in the postoperative period, and decreased inflammation and surgical stress due to the decreased levels of the proinflamma-tory cytokines TNF-ec and IL-1 beta in the first postoperative 24 hours, indicating immunomodulatory effect. (c) 2021 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Objective: The aim of the study is the assessment of the analgesic efficacy of transversus abdominis plane block in patients undergoing general abdominal surgery. Methods: Pubmed, Scopus, and Medline databases were searched for papers evaluating the effect of transversus abdominis plane block. The primary and secondary outcomes of the studies were analyzed. Results: A total of 10 studies were analyzed, including 717 patients. Studies revealed that transversus abdominis plane block was associated with significantly reduced postoperative discomfort and reduced opioid consumption. Conclusion: The present study shows the clear benefit brought by the transversus abdominis plane block as part of multimodal analgesia, with a significant reduction of pain and higher comfort scores.

Clinicians struggle to manage pain in pediatric patients, challenged by developmental constraints, nonlinear physiology, and uncertainty about pharmacological risks, all in the context of the decision pressure of trauma. This review describes means to mitigate these uncertainties. In the past 5 years, focus of investigations has been on pediatric burn patients and using new technologies, such as virtual reality, to provide distraction during painful procedures. Further evidence demonstrates that the setting in which trauma patients receive initial pain control is important, as many children do not receive adequate analgesia in the prehospital setting. Pain management in trauma can be approached as special instances of validated principles applied to adults but requires knowledge of adjunct therapeutic options and special consideration of both patient and caregiver anxiety.

Background Satisfaction measures such as Press Ganey (PG) scores are increasingly used to determine reimbursement. Purpose To investigate the relationship between PG satisfaction scores and perioperative opioid use in patients undergoing anterior cruciate ligament reconstruction (ACLR). Methods Patients undergoing ACLR were retrospectively identified. Perioperative opioid prescription data were collected using the electronic medical record. Results Positive correlations existed between immediate preoperative total morphine equivalents (TMEs) and PG scores. There was a negative correlation between “Pain Control” and preoperative TMEs. Conclusion PG scores were correlated with preoperative and intraoperative opioid administration but not postoperative opioid administration.

PURPOSE: This study examined the influence of treadmill exercise with initial pain control using transcutaneous electrical nerve stimulation (TENS) on induced pain of knee osteoarthritis in rats. METHODS: Thirty adult male Sprague - Dawley rats were divided randomly into the TENS Group (TG, n = 10), Treadmill Exercise Group (TEG, n = 10), and Treadmill with TENS Group (TTG, n = 10). In the TG, TENS was performed for 20 min per day for two weeks with a TENS program at the knee joint. The TEG performed treadmill exercise 15 m/min for 20 min per day for two weeks. The TTG performed initial pain control by TENS program during the 1st ~ 3rd days, and treadmill exercise was performed using the TEG methods from the 4th day. The lumbar spine was extracted and processed using western blot analysis to evaluate pain (c-fos expression). RESULTS: The results showed that c-fos expression was decreased significantly in all groups after each intervention (p < .05). In particular, TTG produced the most significant decrease compared to the other groups. CONCLUSION: These results suggest that treadmill exercise with initial pain control using TENS is a suitable method for relieving pain in knee osteoarthritis.

BACKGROUND Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery. METHODS An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers. RESULTS A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions. CONCLUSIONS There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery. LEVEL OF EVIDENCE Level IV-literature review.

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared.Of 2340 women who underwent cesarean birth during the study period (1 July 2017 - 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

AIM: The aim of the study was to investigate whether chewing gum (CG) can reduce pain as compared to non-CG (NG) after orthodontic elastomeric separators placement. MATERIALS AND METHODS: Sixty patients were randomly allocated in a ratio of 1:1 to CG group (mean age = 21.82 ± 0.87 years) and NG group (mean age = 22.31 ± 1.09 years). Patients in the CG group were instructed to chew sugar-free gum for 10 min immediately after separators placement and then at 8-h intervals for 1 week, while the patients in the NG group were instructed not to chew any type of gum for the duration of the study. Patients in the two groups were asked not to use any type of analgesics. The patients were asked to register their pain level using a 10-cm horizontal line visual analog scale at 2 h, 6 h, bedtime, 24 h, and then daily for 1 week after separators placement. RESULTS: The data from 53 patients (27 in the NG group and 26 in the CG group) were analyzed. The pain scores were significantly lower in CG as compared to NG at 2 h, 6 h, bedtime, 24 h, and 2 days after separators placement. From day 3 to the end of the week duration of the study, the pain scores stayed lower in the CG group, but the difference was not statistically significant. CONCLUSION: CG significantly reduced pain resulting from orthodontic elastomeric separators placement as compared to non-CG controls.

Background: Patients commonly visit the emergency department for pain after musculoskeletal injury, but the problem of oligoanalgesia is prevalent. Methoxyflurane (Penthrox®) is an inhalational analgesic for moderate to severe trauma-associated pain in stable and conscious patients. It is a fast-acting, effective analgesic that can be readily administered via a non-invasive route, making it an attractive agent for managing acute pain in the emergency departments. Objectives: The aim was to assess the analgesic efficacy of methoxyflurane in patients with acute traumatic pain by comparing it to ketorolac, a standard analgesic treatment for moderate pain in emergency departments in Hong Kong. Methods: This was a single-center, open-label, randomized controlled, parallel-group, non-inferiority pilot study that enrolled adult patients with moderate trauma-associated pain in an emergency department in Hong Kong. Patients were randomized 1:1 to the methoxyflurane group or the ketorolac group. The primary outcome was the change in pain intensity measured by visual analogue scale from baseline to 5, 15, 30, and 60 min after drug administration. Results: Twenty patients received methoxyflurane, and twenty patients received ketorolac. There were significant reductions in pain score over 60 min in both groups. The pain reduction at 5 min was significantly greater for the methoxyflurane group (−13.912 mm; 95% confidence interval = −20.008 to −7.817) than for the ketorolac group (−4.888 mm; 95% confidence interval = −10.983 to 1.208), with the treatment effect (−9.025 mm; 95% confidence interval = −17.656 to −0.393; p = 0.041) demonstrating superiority of methoxyflurane. The treatment effect at 15 and 30 min demonstrated non-inferiority of methoxyflurane versus ketorolac. Conclusion: Methoxyflurane provided non-inferior analgesia in the first 30 min with a faster onset of action when compared with ketorolac in moderate traumatic pain. It can be considered a non-invasive, rapid-acting, and effective first-line alternative to currently available analgesics for traumatic pain in emergency settings.

BACKGROUND Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. METHODS Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. RESULTS Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. CONCLUSION Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. LEVEL OF EVIDENCE Collected case series, level V.

A significant amount of empirical progress has been made in the management of pain over the last century,largely as a result of the introduction of a more effective pharmacological agent and the developmentof a better understanding of the principle of molecular development that governsits use. Much remains to be learned from the mechanisms and treatment of pain by researchers and practitioners. This review article will discuss regarding the important aspects of pain control in oral and maxillofacial facial surgery.