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Introduction: Despite the newer innovation and recent technological advances in modern dentistry, fear and anxiety constitute an important theme in dentistry. They are a usual reaction to stressful conditions that help children while staying alert in situations of an impending threat. Aim: To evaluate the effect of deep breathing exercise in reducing dental anxiety, behaviour and pain using smartwatch during maxillary buccal infiltration in children aged 7-11 years. Materials and Methods: A prospective interventional and single-blinded randomised clinical trial conducted in the Department of Paediatric and Preventive Dentistry, NDCH, Nellore, Andhra pradesh, India, from November 2019 to October 2020. A total of 70 children of age between 7-11 years. They were randomly allocated into two groups, 35 in each. Children in group I were trained for deep breathing exercise using smartwatch and group II (control group) was traditional tell show do technique. The reaction of children during maxillary buccal infiltration anaesthesia was recorded in terms of behaviour (Frankl behaviour rating scale), anxiety {Facial Image Scale (FIS) and pulse rate}, and pain perception (Wong-Baker FACES pain rating scale and face, leg, activity, cry and consolability scale). Data was tabulated using Kolmogorov-Smirnov test and Kruskal-Wallis for data distribution. Independent Student’s t-test or Mann-Whitney test (Quantitative variables) and Chi-square test or Mann-Whitney test (Qualitative variables) were used to test statistical significance using Statistical Package for Social Sciences (SPSS) version 25.0. Results: The mean age of children in smartwatch group was 8.9±1.4 years and in control group was 8.9±1.6 years with no statistical significant difference. Statistically significant decrease in pulse rate was observed in smartwatch group (p=0.003), subjective anxiety and pain was lowered in intervention group. Objective pain was decreased significantly in smartwatch group (p=0.007). Conclusion: Children performing deep breathing exercise using smartwatch had efficiency to reduce dental anxiety and pain perceived during maxillary buccal infiltration anaesthesia.

Background and Aim: Treatment of acute postoperative pain is one of the most important measures to improve recovery. Different methods of local and regional anesthesia, and also numerous intravenous drugs have been used. In this study, the analgesic effect ketorolac, paracetamol and pethidine in the postoperative pain control of outpatient transurethral lithotripsy was evaluated. Materials and Methods: This clinical trial was performed on 96 patients who were candidates for outpatient transurethral lithotripsy in Mashhad Imam Reza Hospital. In randomized double blinded study, at the end of the operation, 30 mg of intravenous ketorolac to the first group, 1 gram paracetamol in half an hour to the second group and 50 mg of pethidine to the third group were injected. Pain was assessed every 10 minutes to half an hour and then, every half an hour to 4 hours by numerical rating scale )NRS(. Finally, the data were analyzed by SPSS v16 software. The relationship between quantitative variables was analyzed by analysis of variance and the qualitative variables was assessed by Chi-square test and P<0.05 was considered significant. Results: There was no significant difference between three groups in demographic information. The pain intensity in the first 10 minutes after surgery was the same between the groups (P=0.372), but the pain intensity at 20, 30 and 60 minutes after surgery was significantly different in the three groups )P.values 0.005, 0.006, and 0.001 respectively(, and was lower in the pethidine group. In other hours after surgery, no significant difference in pain control was observed between the three groups. The need for additional analgesia was higher in the paracetamol group than in the other two groups (P=0.025) in the first hour. Hemodynamic changes and surgical complications such as nausea and vomiting were the same in both groups. Conclusion: The present study showed that pethidine causes better pain relief than ketorolac and paracetamol in the first hour after surgery, but after 60 minutes there is no significant difference between these three groups. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate and compare the efficacy of the hands–eyes–mouth distraction technique (HEM-DT) in reducing anxiety and pain levels and improving the behaviour of pre-school children during inferior alveolar nerve block (IANB) administration to that of the covering patient's vision technique (CPV-T). Methods: This study included 52 children aged 3–5 years old with primary dentition, no history of receiving local anaesthesia, and whose treatments required an IANB. These children were randomly assigned into two groups: HEM-DT (G1; n = 26) and CPV-T (G2; n = 26). Anxiety and pain levels were assessed using the Facial Image Scale and the Wong–Baker Scale, respectively, while the patient's behaviour was evaluated using the Frankl Behaviour Scale. This study was divided into two sessions including the treatment session (administration of IANB) and the control session (7 days after anaesthesia). Chi-square test, the Mann–Whitney U test and Wilcoxon test were used for statistical analyses. Results: The patients' anxiety levels did not increase 7 days after IANB in G1 (p value = 0.798); however, higher anxiety levels were observed in the G2 group (p value = 0.039). No significant differences in pain levels and behaviour were observed between the groups during administration of anaesthesia (p value > 0.005). Conclusion: HEM-DT and CPV-T showed efficacy in terms of pain and behaviour during IANB administration. Pre-school children in the HEM-DT group exhibited lower anxiety levels in the control session. Trial registration number and date of registration: ClinicalTrials.gov (NCT02591797). October 28, 2015. [ABSTRACT FROM AUTHOR]

PURPOSE: The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. METHODS: This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children's Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number of days on oral narcotics, and cumulative dose of oral narcotic. RESULTS: Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). CONCLUSION: Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively. [ABSTRACT FROM AUTHOR]

Background. Pain after periodontal surgeries is one of the most common complications. Echium amoenum is among the important therapeutic herbs in Iranian traditional medicine. Various studies have shown its pain control properties. This study aimed to evaluate this herb's efficacy in controlling pain after periodontal surgeries. Methods. In this randomized clinical trial, 50 patients referred to Tabriz Dental School for clinical crown lengthening surgery were divided into two equal groups: control and test. In the test group (using E. amoenum), 24 hours before surgery, E. amoenum was administered to the patient at home every 12 hours, and a dose of E. amoenum was administered one hour before the procedure. The postoperative pain was assessed using VAS 30 minutes, 1 hour, and 3 hours after the surgery and verbal rating scale (VRS) 24, 48, and 72 hours postoperatively. A chi-square test was used to compare the pain severity between the two groups. Results. The VAS index was significantly lower in the E. amoenum group compared to the control group (30 minutes, 1 hour, and 3 hours after the procedure) (P < 0.05). In both groups, pain severity increased significantly up to 3 hours postoperatively (P < 0.05). In the first 24 hours, the VRS index of the E. amoenum group was significantly lower than that of the control group (P < 0.05), with no significant differences between the two groups at 48 and 72 hours (P > 0.05). Conclusion. The E. amoenum herb reduced the pain severity after clinical crown lengthening surgeries. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the duration and effect of superior hypogastric nerve block (SHNB) with ropivacaine and clonidine on postinterventional pain levels and opioid requirements in patients undergoing uterine artery embolization. Materials and Methods: Postinterventional pain levels (numeric rating scale, NRS 0–10) and opioid doses were retrospectively analyzed in 53 patients undergoing transfemoral uterine artery embolization and intraprocedural superior hypogastric nerve block during 24 h. A mixture of 150 mg of ropivacaine and 150 µg of clonidine was used for the block. Results: Postinterventional pain averaged between 1.4 and 2.0 during the first 9 h, after which a small but significant increase was observed (NRS 1.7 ± 1.6 vs. NRS 2.6 ± 2.2, p < 0.001). 70% of patients did not exceed a tolerable pain threshold of NRS 4 during the first 9 h after the intervention. Thirty-three patients (62%) did not require any opioid medication. Mean iv morphine dose was 3.1 ± 4.7 mg, whereas 71% of opioid doses were administered after 9 h. Conclusion: Superior hypogastric nerve block using a mixture of ropivacaine and clonidine provides good pain relief for 9 h after uterine artery embolization requiring only very low amounts of additional opioids. [ABSTRACT FROM AUTHOR]

Objective: To determine whether an inpatient post-cesarean analgesic regimen which separated oxycodone and acetaminophen resulted in less inpatient opioid use, when compared to a regimen using combination medications containing both acetaminophen and oxycodone in a cohort including patients of all gestational ages, acuity levels, and modes of operative anesthesia. Methods: This is a retrospective cohort study which was conducted at a single tertiary care center Labor and Delivery unit. Data were collected via retrospective chart review, and a total of 170 records were examined with a final N= 150. Inclusion criteria were all patients over the age of 18, and >23.0 weeks gestational age, who had a singleton or twin cesarean delivery regardless of their mode of operative anesthesia and whether or not they received intrathecal opioid at time of delivery. Exclusion criteria were pregnancies of higher-level multiples (triplets or greater), prolonged intensive care unit (ICU) stay, and patients who received both combination oxycodone-acetaminophen and separately administered oxycodone. For analysis patients were classified into two groups: the “Combined Medication” group representing patients who received combination oxycodone-acetaminophen medication only (n= 83) and the “Separate Medication” group representing patients who received oxycodone and acetaminophen separately (n= 67). Differences between the groups with respect to opioid use and acetaminophen use were assessed. Results: The primary outcome was inpatient opioid medication use per 12-h period in intravenous morphine mg equivalents (MME). Patients received an average of 4.6 ± 3.5 MME IV morphine per 12 h in the Separate Medication group and 5.7 ± 3.7 MME IV morphine per 12 h in the Combined Medication group. When controlled for several covariates, the Separate Medication group took significantly fewer MME per 12-h period (mean difference = 1.2, 95% CI: (2.3, 0.1), p= .04). There was no appreciable difference in acetaminophen utilization between groups. Conclusions: An analgesic regimen where oxycodone is ordered separately from acetaminophen is associated with reduced inpatient opioid medication use in patients of all gestational ages, acuity levels, and modes of operative anesthesia. [ABSTRACT FROM AUTHOR]

Objectives: To prospectively analyse robotically administered transperitoneal transversus abdominis plane (robot‐assisted transversus abdominis plane [RTAP]) compared with both ultrasonography‐guided transversus abdominis plane (UTAP) and local anaesthesia (LA) with regard to pain control and narcotic use in patients undergoing robot‐assisted prostatectomy (RARP) or robot‐assisted partial nephrectomy (RAPN). Subjects/Patients and Methods: Patients undergoing RARP or RAPN were randomized in a single‐blind 2:2:1 fashion to RTAP:UTAP:LA, with the study powered to evaluate superiority of UTAP to LA and non‐inferiority of RTAP to UTAP. We compared time to deliver the block, operating room time, postoperative pain scores using the visual analogue scale, and intra‐operative and postoperative analgesia consumption. Results: A total of 143 patients were randomized and received treatment. There was no significant difference in patient baseline characteristics. UTAP did not demonstrate superiority to LA in terms of pain control. RTAP and LA were faster to administer than UTAP (time to perform block 2.5 vs 2.5 vs 6.25 min; P < 0.001). There was no difference in postoperative narcotic, acetaminophen, ketorolac or ondansetron requirements among the three groups (P > 0.05). The study was terminated early due to the unexpected efficacy of LA. Conclusion: This study showed that UTAP and RTAP do not provide superior pain control to LA. The efficiency, effectiveness, and ease of administration of LA make it an excellent option for first‐line therapy for postoperative analgesia. [ABSTRACT FROM AUTHOR]

Background: Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non‐opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults. Methods: We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013–2018. We included patients >65 years old without prior gabapentinoid use who underwent common non‐cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity. Results: Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non‐White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin. Conclusions: More than one‐fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy. [ABSTRACT FROM AUTHOR]

Introduction: The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores.Methods: Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union.Results: The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance.Discussion: The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings.Level Of Evidence: Therapeutic Level 1. [ABSTRACT FROM AUTHOR]

Pain is the predominant symptom of many clinical diseases and is frequently associated with neurological and musculoskeletal problems. Chronic pain is frequent in the elderly, causing suffering, disability, social isolation, and increased healthcare expenses. Chronic pain medication is often ineffective and has many side effects. Nonsteroidal over-the-counter and prescription drugs are frequently recommended as first-line therapies for pain control; however, long-term safety issues must not be neglected. Herbs and nutritional supplements may be a safer and more effective alternative to nonsteroidal pharmaceuticals for pain management, especially when used long-term. Recently, topical analgesic therapies have gained attention as an innovative approach due to their sufficient efficacy and comparatively fewer systemic side effects and drug–drug interactions. In this paper, we overview the main natural herbal pain relievers, their efficacy and safety, and their potential use as topical agents for pain control. Although herbal-derived medications are not appropriate for providing quick relief for acute pain problems, they could be used as potent alternative remedies in managing chronic persistent pain with minimal side effects. [ABSTRACT FROM AUTHOR]

Purpose: In this meta-analysis, we aim to compare ketamine use versus a control group (saline solution) during induction of anesthesia in adolescent idiopathic scoliosis patients undergoing fusion surgery in terms of postoperative opioid consumption, pain control, and side effects. Methods: A PubMed search of studies published over the last 20 years using the descriptor/terms "ketamine AND scoliosis" was performed. Baseline characteristics of each article were obtained and efficacy measures analyzed (morphine equivalent treatment at 24, 48, and 72 h postoperatively, complications (vomiting/nausea and pruritus), length of hospital stay (days); and pain score (VAS)) (Review Manager 5.4 software package). Results: Five randomized clinical trials were included. Morphine administration showed statistically significant differences at 24 and 48 h (MD − 0.15, 95% CI − 0.18 to − 0.12) and (MD − 0.26, 95% CI − 0.31 to − 0.21) between the ketamine and control (saline solution), respectively. No intergroup differences were found regarding nausea/vomiting and pruritus (OR 0.77, 95% CI 0.35 to 1.67) and (OR 0.71, 95% CI 0.31 to 1.62), respectively, same as for the pain score (MD − 0.75, 95% CI − 1.71 to 0.20). Conclusions: The use intraoperative and postoperative continuous low doses of ketamine significantly reduces opioid use throughout the first 48 h in patients with AIS who undergo posterior spinal fusion. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to compare the efficacy of mirabegron plus tamsulosin to tamsulosin monotherapy in terms of ureteral stent-related discomfort after ureteroscopic lithotripsy. Methods: A total of 102 patients undergoing ureteroscopic lithotripsy and silicone ureteral stent placement were enrolled in this study. Patients were randomized 1:1 to receive either tamsulosin 0.4 mg once daily or mirabegron 50 mg + tamsulosin 0.4 mg once daily during the stenting period. Before the operation, the IPSS, QOL, and pain score were collected. On the day of ureteral stent removal, the USSQ, analgesic usage amount was collected and recorded. Results: The median USSQ-body pain score in the tamsulosin group and tamsulosin + mirabegron group was 15 and 16, respectively (p = 0.530). The median analgesic usage in the two groups was 3 and 2, respectively (p = 0.170). The median USSQ-urinary symptoms, USSQ-general health, USSQ-work performance, USSQ-sexual matters, and USSQ-additional problems in the two groups were 26 and 26 (p = 0.194), 11 and 12 (p = 0.068), 12 and 13 (p = 0.105), 2 and 2 (p = 0.437), 9 and 9 (p = 0.533), respectively. The international patients used more analgesics than Chinese patients (6 vs. 1, p = 0.015). Conclusion: Compared to tamsulosin alone, tamsulosin + mirabegron showed no additional benefit on the ureteral stent-related pain control after ureteroscopic lithotripsy and silicone stent placement. There was no significant difference on the analgesic usage and USSQ scores between the two groups. Chinese patients request fewer analgesics than international patients. [ABSTRACT FROM AUTHOR]

The United States is in a prescriptive opioid crisis, and physicians have a responsibility to their patients and the healthcare system to mitigate irresponsible prescriptive practices. A patient's preoperative opioid status and brief resilience score (BRS) may be used to individualize analgesic protocols and reduce opioid overprescription. The purpose of this study is to evaluate the relationship between preoperative resilience scores and patient-reported pain control after total shoulder arthroplasty (TSA). This study also examines reported pain control in patients with or without preoperative narcotic use 30 days before their procedure. Patients undergoing elective primary anatomic total shoulder arthroplasty (aTSA) or primary reverse total shoulder arthroplasty (rTSA) were asked to complete the BRS survey before their procedure and postoperative narcotic pain medication surveys at 1, 4, and 12 weeks after their operation. The patients were then stratified into 2 cohorts based on preoperative opioid usage status. Two-sample equal-variance t -tests were used to test for differences between resilience score group means and adequate pain control after TSA. The differences between preoperative opioid and no preoperative opioid usage cohorts, and perceived pain control and the number of oxycodone pills taken were analyzed for direction and statistical significance using t -tests for continuous variables and chi-squared tests for categorical variables. The study cohort consisted of 218 patients, of whom 74 had preoperative opioid use (group O). Patients who reported inadequate pain control after TSA had consistently lower resilience scores at baseline. The BRS group means ± standard deviations after TSA for the adequate vs. inadequate pain control groups respectively were 3.84 vs. 3.48 (P =.010) at week 1, 3.83 vs. 3.53 (P =.055) at week 4, and 3.84 vs. 3.36 (P =.002) at week 12. Of the patients in group O (n = 74), a consistently smaller proportion of patients reported adequate pain control after TSA. Pain control rates among group O vs. nonusers/opioid-naïve patients (group N) respectively were 81.1% vs. 89.6% (P =.080) at week 1, 83.8% vs. 92.4% (P =.055) at week 4, and 82.4% vs. 93.0% (P =.016) at week 12. A patient's resilience score and preoperative opioid consumption are associated with postoperative pain control. Physicians may be able to use these 2 preoperative measures to better individualize postoperative narcotic prescriptive practices and reduce the number of unused opioids. [ABSTRACT FROM AUTHOR]

Outpatient (OP) total shoulder arthroplasty (TSA) with same-day discharge can now be performed safely in appropriately selected patients. Patient knowledge and perspectives regarding OP TSA are yet unknown and such information may inform surgeon decision-making and provide a framework for addressing patient concerns. The goal of this study was to understand and quantify patient knowledge of and concerns for OP TSA, with a working hypothesis that majority of patients are unaware of OP TSA as a realistic option and that their primary concern would be postoperative pain control. This was a retrospective cohort study at a tertiary care academic medical center including patients who underwent anatomic or reverse shoulder arthroplasty and completed an OP TSA expectations questionnaire/survey. This survey was provided preoperatively and included demographic factors, self-rated health evaluation, and perioperative expectations. Surveys evaluated whether patients undergoing TSA had any prior awareness of OP TSA and evaluated their primary concern with same-day discharge. Secondary questions included an assessment of patient expectations of outcomes of outpatient vs. inpatient surgery as well as their expected length of inpatient stay. A total of 122 patients who underwent anatomic and reverse shoulder arthroplasty completed the questionnaire and comprised the study cohort. Fifty-two (42.6%) of the patients were unaware that OP TSA was an option, and 26 (50%) of these were comfortable with the idea of OP TSA. Comfort with OP TSA was significantly associated with higher subjective patient-reported health status. Fifty-eight patients (47.5%) expected that following TSA they would require <24 hours of in-hospital postoperative care. The primary concern for patients considering OP TSA was postoperative pain control, endorsed by 44.3% of patients, compared with 13.1% of patients stating this would be their primary concern if admitted as an inpatient postoperatively. Pain control being a primary concern was significantly different between those considering outpatient vs. inpatient TSA. Most patients anticipated that OP shoulder arthroplasty would lead to a better (36%) or comparable (53%) outcome, whereas only 11% had concerns that it would lead to a worse outcome. Expanding OP TSA crucially depends on awareness and education. Perceived ability to control pain is an important concern. Patients may benefit from preoperative counseling, including emphasizing a comprehensive postoperative pain management strategy. [ABSTRACT FROM AUTHOR]

In recent years, opioid misuse has resulted in much scrutiny on providers' prescribing habits. The purpose of this study was to analyze prescribing habits in the context of third molar extractions as a model for promoting better postsurgical pain management. This was a cross-sectional survey of oral maxillofacial surgeons in Connecticut and New Jersey. A total of 291 practitioners were contacted to complete an online survey using Qualtrics Research Services to determine prescribing habits following third molar extractions. The most common approach for postoperative analgesia was nonsteroidal anti-inflammatory drugs (NSAIDs) and an opioid/acetaminophen (APAP) combination as 2 separate prescriptions, reported by 36% of participants. The combination of hydrocodone/APAP was the most common opioid formulation, and an average of 10.93 ± 4.51 opioid pills were prescribed with a maximum of 20 pills reported. Most providers (79%) consistently provided patients with opioid information. Only 22% reported always checking opioid-monitoring programs; however, providers were more likely to check if prescribing more than ∼11 opioid pills (P =.0228). Most reported using dexamethasone (82%) and bupivacaine (56%) intraoperatively, while ketorolac was less common (15%). No association was found between the quantity of opioids prescribed and the use of intraoperative ketorolac, steroids, or bupivacaine (P >.05). There remains to be a universal standard for using opioids for postoperative pain management in dentistry. Providers should be mindful when prescribing opioids and consider using NSAIDs and APAP for baseline pain plus a separate opioid prescription for breakthrough pain. Additional focus on minimizing the quantity of opioids prescribed and self-reflecting on prescribing and practice habits to further reduce opioid-related complications is warranted. [ABSTRACT FROM AUTHOR]

Summary: Background: Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. Methods: A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. Results: A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time. Conclusions: ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.

Marco Mazzotta,1 Marco Filetti,2 Marta Piras,2 Sebastiano Mercadante,3 Paolo Marchetti,2,4 Raffaele Giusti5 1Department of Oncology and Hematology, Medical Oncology Unit, Central Hospital of Belcolle, Viterbo, Italy; 2Department of Clinical and Molecular Medicine, Oncology Unit, “La Sapienza” University of Rome, Azienda Ospedaliera Sant’Andrea, Rome, Italy; 3Anesthesia and Intensive Care & Pain Relief and Supportive Care, La Maddalena, Palermo, Italy; 4Medical Oncology Unit, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy; 5Medical Oncology Unit, Sant’Andrea Hospital of Rome, Rome, ItalyCorrespondence: Raffaele Giusti, Medical Oncology Unit, Sant’Andrea Hospital of Rome, via di Grottarossa, 1035/1039, Rome, 00189, Italy, Email raffaelegiusti@yahoo.itBackground: Cancer pain is one of the most important symptoms for patients. Pharmacological control is central for clinical management and to ensure well-being. In cancer patients, the management of breakthrough cancer pain (BTcP) is also crucial. This study aims to identify factors that can predict patients’ satisfaction with pain relief for BTcP.Methods: This was a secondary analysis of the IOPS-MS study, a large, observational, multicenter, national study where thirty-two Italian centers were involved to explore BTcP management. Clinical and pathologic features were recorded, as well as the patients’ degree of satisfaction with BTcP medications classified as dissatisfied (not or indifferent satisfied) versus satisfied (or very satisfied). Frequency distributions and the chi-squared test of independence were performed. A multivariate model was carried out by selecting significant variables upon univariate analysis using logistic regression.Results: From the original 4016 patients enrolled, 3840 were available for the study purpose. Seventy-one per cent of patients declared satisfaction with BTcP medications. Young age [odds ratio (OR) 1.29 (95% confidence interval, CI: 1.12– 1.50)], non-metastatic cancer stage [OR 1.53 (95% CI: 1.22– 1.91)], high Karnofsky performance status [OR 1.63 (95% CI:1.33– 1.99)], the absence of anticancer treatment [OR 1.42 (95% CI: 1.19– 1.69)], the NSAIDs/paracetamol use for background pain [OR 1.56 (95% CI: 1.34– 1.82)] and a high BTcP interference in activities of daily living [OR 2.34 (95% CI: 1.81– 3.01)] resulted positively correlated with dissatisfaction in the multivariate analyses. Also, the setting of care was related to difference in BTcP therapy satisfaction.Conclusion: This study proposes several key points to be considered in the pharmacological management of BTcP, useful to ensure patients’ satisfaction and optimal quality of life.Keywords: breakthrough cancer pain, opioids, pain control, patient satisfaction, quality of life

Pei-Shan Chen, Fu-Shan Xue, Cheng-Wen Li Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of ChinaCorrespondence: Fu-Shan Xue, Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People’s Republic of China, Tel +86-13911177655, Fax +86-10-63138362, Email xuefushan@aliyun.com; fushanxue@outlook.com

The aim of this systematic review and meta-analysis was to evaluate the analgesic effect of different doses of tapentadol immediate release (IR) and its adverse effects after a bunionectomy. Pubmed, Cochrane, Lilacs, Medline, and Imbiomed were used to identify abstracts of scientific publications related to the keywords of this systematic review (PROSPERO ID CRD42023437295). Moreover, the risk of bias in all included articles was assessed using the Cochrane Collaboration risk of bias tool. Data on the sum of pain intensity, total pain relief, global assessment, and adverse effects were extracted. The statistical method of inverse variance with means difference was used to evaluate the numerical data and the Mantel–Haenszel and Odd Ratio test to analyze the dichotomous data. In addition, the number needed to treat, the number needed to harm, and the 95% confidence intervals were calculated. A qualitative evaluation (n = 2381) was carried out according to the conclusions of the authors. Tapentadol (n = 1772) was more effective in relieving postoperative pain than the placebo (n = 609) after a bunionectomy. In addition, the analgesic efficacy of IR tapentadol (n = 1323) versus the placebo (n = 390) was evaluated in a total of 1713 patients using a global evaluation of the treatments. All three doses of IR tapentadol showed better results compared to the placebo after a bunionectomy. Finally, the adverse effects have a direct relationship with the dose, and the greatest number of adverse effects are most observed with tapentadol IR 100 mg (n = 2381). It is concluded that tapentadol IR (100 mg) leads to the best satisfaction score in this meta-analysis.

Specialized palliative care (SPC) is a multidisciplinary need-based approach from the time a life-threatening disease is diagnosed. Patients with multiple myeloma (MM) will, at the time of diagnosis, often present with symptoms and needs that require a multidisciplinary approach. This case describes the course of a patient with newly diagnosed MM, involving all vertebrae and with no common analgesic treatment providing sufficient relief. High symptom burden and psychosocial and existential factors contribute to his total suffering. SPC, anesthesiological, and radio-oncological disciplines are integrated early, and the multidisciplinary approach includes support from social worker, psychologist, and physiotherapist. The needs and distress of the patients' wife are addressed. Barriers for further integration and the role of standardized care pathways are discussed, and the importance of systematic screening for symptoms and needs is highlighted. Integrating several disciplines may be a prerequisite for antineoplastic treatment being initiated for patients with newly diagnosed malignant disease.

Background Controlling postoperative pain after posterior lumbar spine surgeries is necessary to achieve patient satisfaction and good outcome after successful surgical intervention. Preoperative erector spinae block (ESB) technique is considered a recently evolved tool to achieve these goals. Purpose The aim of this study was to evaluate the efficacy of the bilateral ESB technique in pain management after lumbar spinal fusion surgery for degenerative spine diseases. Patients and methods Patients who underwent lumbar spinal fusion surgery for degenerative pathologies in 2019and 2020 were enrolled in the study. The patients were assessed according to pain score experienced postoperatively at different times till the end of the first postoperative day by numeric rating scale, amount of analgesics received, and drug-related complications noticed in the first postoperative day. Results The data of 60 patients who had lumbar spinal fusion surgery were collectively analyzed. Of these, 30 received only general anesthesia (group A), whereas the other 30 patients received the ESB in addition to general anesthesia (group B). The numeric rating scale pain scores and the amount of intravenous postoperative analgesia received were lower in group B than in group A at all the measured time points (P < 0.05). There was no significant difference in the incidence of complications between the two groups. Conclusion Bilateral ESB is an effective tool in controlling postoperative pain after posterior spinal fusion surgeries in both pain intensity and postoperative-received analgesics.

Purpose: Total knee arthroplasty (TKA) is one of the most performed procedures. Postoperative pain control is an important factor for the improvement of patient's quality of life. The aim of this study is to report pain control results and functional outcome scores associated with adductor canal blockade (ACB) usage post-TKA. Methods: A prospective case series study of patients who underwent TKA for degenerative osteoarthritis with ACB postoperatively from 2018 to 2019 in a single center in Saudi Arabia, Riyadh. Assessment of functional outcome scores and pain level were measured preoperatively and postoperatively respectively using Knee injury and Osteoarthritis Outcome Score (KOOS) and the Visual Analog Scale (VAS). Results: Average KOOS score preoperatively for all 5 domains showed a marked improvement at 3 months compared to preoperative values. Pain score postoperatively was measured at 12, 24, and 48 h with an average of 0.7, 1.2, and 0.6 out of 10 on the VAS scale, respectively. The incidence of associated common side effects with the use of analgesic use was included as an add-on in the postoperative questionnaire. Conclusion: In conclusion, by comparing preoperative and postoperative pain levels and functional outcome scores, our study showed a significant pain control and improved functional outcome scores following TKA using ACB.

Abstract Background Pain symptoms in the upper abdomen and back are prevalent in 80% of patients with metastatic pancreatic ductal adenocarcinoma (mPDAC), where the current standard treatment is a systemic therapy consisting of at least doublet-chemotherapy for fit patients. Palliative low-dose radiotherapy is a well-established local treatment option but there is some evidence for a better and longer pain response after a dose-intensified radiotherapy of the primary pancreatic cancer (pPCa). Stereotactic body radiation therapy (SBRT) can deliver high radiation doses in few fractions, therefore reducing chemotherapy-free intervals. However, prospective data on pain control after SBRT of pPCa is very limited. Therefore, we aim to investigate the impact of SBRT on pain control in patients with mPDAC in a prospective trial. Methods This is a prospective, double-arm, randomized controlled, international multicenter study testing the added benefit of MR-guided adaptive SBRT of the pPca embedded between standard of care-chemotherapy (SoC-CT) cycles for pain control and prevention of pain in patients with mPDAC. 92 patients with histologically proven mPDAC and at least stable disease after initial 8 weeks of SoC-CT will be eligible for the trial and 1:1 randomized in 3 centers in Germany and Switzerland to either experimental arm A, receiving MR-guided SBRT of the pPCa with 5 × 6.6 Gy at 80% isodose with continuation of SoC-CT thereafter, or control arm B, continuing SoC-CT without SBRT. Daily MR-guided plan adaptation intents to achieve good target coverage, while simultaneously minimizing dose to organs at risk. Patients will be followed up for minimum 6 and maximum of 18 months. The primary endpoint of the study is the “mean cumulative pain index” rated every 4 weeks until death or end of study using numeric rating scale. Discussion An adequate long-term control of pain symptoms in patients with mPDAC is an unmet clinical need. Despite improvements in systemic treatment, local complications due to pPCa remain a clinical challenge. We hypothesize that patients with mPDAC will benefit from a local treatment of the pPCa by MR-guided SBRT in terms of a durable pain control with a simultaneously favorable safe toxicity profile translating into an improvement of quality-of-life. Trial registration German Registry for Clinical Trials (DRKS): DRKS00025801. Meanwhile the study is also registered at ClinicalTrials.gov with the Identifier: NCT05114213.

Background: The aim of the study was to assess whether a quality improvement project focused on providers’ education of responsible opioid prescribing, creating order sets to facilitate pre- and post-operative adjunct use, and decreasing the number of opioids prescribed following elective outpatient surgery affected opioid prescribing habits and the use of adjunct pain medication on the inpatient Emergency General Surgery (EGS) service. Methods: Inpatient EGS opioid prescribing habits following laparoscopic cholecystectomy, laparoscopic and open inguinal hernia repair, or open umbilical hernia repair during the pre- and post-Acute Care Surgery Division-Quality Improvement (QI) periods were recorded retrospectively. Demographics, type and dose of opioids, and non-opioid adjuncts prescribed were collected. Opioids were converted to oral morphine equivalents (OME). Pre- and post-QI data were compared. Post-QI discharge opioids prescribed were compared to reported use of opioids. Patients’ rating of pain management is reported. Results: One hundred twenty-two and 62 patients were included during the pre- and post- QI periods, respectively. Post-QI, opioid prescribing decreased, and adjunct prescribing increased (31.1% vs. 72.6%; p

Background: Nociceptive and neuropathic post-operative discomfort of moderate severity is related to inguinal hernia operations. The Wong-Baker FACES pain rating scale, the McGill Pain Questionnaire (MPQ), the Visual Analogue Scale (VAS), and the Numeric Rating Scale (NRS) for pain are all used to measure pain. Objective: To control the postoperative pain in patients undergoing open inguinal hernia. Methods: Pain Control, Undergoing Open Inguinal Hernia and Visual Analogue Scale were searched for in PubMed, Google Scholar, and The Egyptian Knowledge Bank. Systemic analgesic methods (such as opioids and nonsteroidal anti-inflammatory drugs), localised analgesic methods (such as quadratus lumborum block (QLB)), and a multimodal approach to perioperative recovery were used to control postoperative pain. High postoperative pain scores were seen in patients with high pain levels in the first week following surgery, patients who had recurrent hernia repairs, patients who had high levels of pain prior to surgery, and patients who had outpatient surgery were all risk factors for inguinal hernia postoperative pain. Only the most current or comprehensive studies were included after the authors thoroughly filtered references from the pertinent literature, which comprised all the recognised studies and reviews. Conclusion: After open inguinal hernia surgery, a multimodal analgesic strategy (a mix of localised and systemic analgesia) is particularly successful at reducing postoperative discomfort and promoting early mobilisation. [ABSTRACT FROM AUTHOR]

Introduction: Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for postoperative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics after infant robotic pyeloplasty. Methods: We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes, and unscheduled health care encounters within 30 postoperative days. Results: Sixty-three percent (15/24) of patients were male and average age was 12.1 months (range 4–34 months). Fifty-eight percent (9/15) underwent surgery on the left, and 16.7% (4/24) of patients received a single postoperative dose of narcotics in the postanesthesia care unit. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related unscheduled visits or phone calls after discharge. Conclusions: This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Postprocedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use. [ABSTRACT FROM AUTHOR]

The efficacy of intra-arterial lidocaine for pain control of uterine artery embolization remains controversial. We conduct a systematic review and meta-analysis to explore the influence of intra-arterial lidocaine versus placebo on the postoperative pain intensity of uterine artery embolization. We searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials (RCTs) assessing the effect of intra-arterial lidocaine versus placebo on pain control of uterine artery embolization. This meta-analysis is performed using the random-effect model. Three RCTs were included in the meta-analysis. Overall, compared with control group for uterine artery embolization, intra-arterial lidocaine was associated with substantially reduced pain scores at 4 h (SMD = −0.85; 95% CI = −1.31 to −0.38; p =.0003) and analgesic consumption (SMD = −0.84; 95% CI = −1.26 to −0.42; p <.0001), but has no obvious influence on pain scores at 7 h (SMD = −0.19; 95% CI = −0.63 to 0.25; p =.40) or pain scores at 24 h (SMD = −0.55; 95% CI = −1.25 to 0.16; p =.13). Intra-arterial lidocaine is effective for pain control after uterine artery embolization. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to evaluate the effect of paracervical block (PCB) on endometrial sampling procedures, to assess the effect on pain of waiting between PCB and intervention, and to compare the effectiveness of PCB with oral non-steroidal anti-inflammatory drugs (NSAID) for decreasing the pain levels associated with endometrial biopsy. Material and methods: A total of 123 participants were divided into four groups as Group 1: Waiting 1 minute after PCB, Group 2: Waiting 3 minute after PCB, Group 3: Control group, and Group 4: Waiting 60 minute after taking oral NSAIDs. The success of analgesic measures used for endometrial biopsy during and 30 minutes after the procedure was compared with the Numeric Pain Rating Scale (NPRS) system. Results: The Numeric Pain Rating Scale (NPRS) 0 score was 2.60 (± 2.42) in Group 1; 1.60 (± 1.73) in Group 2; 5.30 (± 2.10) in Groups 3; 5.63 (± 1.99) in Groups 4. NPRS 30 score was 0.80 (± 0.88) in Group 1; 0.43 (± 0.81) in Group 2; 1.90 (± 1.32) in Groups 3; 2.70 (± 1.41) in Groups 4. The pain was significantly less in the paracervical block groups compared to control and oral NSAIDs groups. However, there was no significant difference in NPRS 0 (p = 0.196) and NPRS 30 (p = 0.191) scores between Group 1 and Group 2. There was no significant difference in NPRS 0 and NPRS 30 scores between control group and oral NSAID group. Conclusions: Paracervical block (PCB) is an effective method and superior to oral NSAIDs. Waiting 1 minute or 3 minutes after PCB were equally effective. [ABSTRACT FROM AUTHOR]

Background: Craniosynostosis is a condition characterized by a premature fusion of one or more cranial sutures. The surgical repair of craniosynostosis causes significant pain for the child. A key focus of craniosynostosis repair is developing effective strategies to manage perioperative pain. This study aimed to review perioperative pain control strategies for craniosynostosis repair systematically. Methods: Guidelines for reporting systematic reviews and meta-analyses were used in the design of this review. In May 2022, the following databases were used to conduct the literature search: MEDLINE, Cochrane, EMBASE, and Google Scholar. A search was performed using MeSH terms "craniosynostosis," "pain management," and "cranioplasty." Results: The literature review yielded 718 publications. After applying our inclusion criteria, 17 articles were included, accounting for a total of 893 patients. During the postoperative period, most studies used multimodal analgesia, primarily opioids, and acetaminophen. In the postoperative period, oral ibuprofen was the most commonly used NSAID, rectal codeine, and acetaminophen were the most commonly used weak opioids, and continuous remifentanil infusion was the most commonly used potent opioid. Conclusion: The authors determined the best pain management options for pediatric patients undergoing cranioplasty by analyzing the most commonly used analgesics. A high-quality clinical trial comparing different types of analgesic combinations would be a valuable addition to the present literature. [ABSTRACT FROM AUTHOR]

Transcutaneous electric nerve stimulation (TENS) is a non-pharmacological method, which isused widely for the management of acute and chronic pain in a variety of conditions. This review aims to provide an insight into orthodontic pain, its etiology and management, andclinical research evidence available on TENS in managing pain in the field of dentistry. The paper briefly discusses the mechanism of action of TENS, the advantages, and contradictions of TENS, and its use in the field of orthodontics. [ABSTRACT FROM AUTHOR]

Introduction & Objective: Pain is the most important stressor in the intensive care unit (ICU). The use of pain management protocols in the ICU, in addition to reducing anxiety and stress, lowers the duration of hospital stay. Therefore, this study was conducted to investigate the effect of implementing pain control guidelines on the pain of patients admitted to the intensive care unit (ICU). Methods: This quasi-experimental study was conducted on 54 patients admitted to the ICU, who had been non-randomly allocated into two intervention and a control groups. The data collection tool was the Behavioral Pain Scale (BPS). The pain control guidelines were implemented for patients in the intervention group according to the pain pattern. Results: Repeated measures test showed a significant difference between the intervention and control groups (P <0.01) in terms of pain score, and the highest difference was observed at 1 hour after intervention, where the severity of pain in the intervention group was less than the control group. Discussion and Conclusion: Based on the results of present study, it can be said that the implementation of pain control guidelines has an important role in relieving patients' pain in the ICUs. Therefore, educating and encouraging nurses to use pain control guidelines has an important role in reducing drug side effects and hospitalization time, and also increasing patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: Effective symptom control is a stated goal of palliative care (PC) to improve quality of life for terminally ill patients. Virtual reality (VR) provides temporary escapes from pharmacologically resistant pain and allows for experiences and journeys patients may not access in any other way. Enabling wishes through virtual worlds may also offer additional benefits such as controlling psychological and physical symptoms. Aims: We investigated the feasibility of a single VR experience as a viable, satisfying, and effective tool for end-of-life pain relief for inpatients presenting palliative needs. Design: This is an observational, single-arm and national single-center feasibility trial. Methods: A one-time VR experience with a selection of several videos and games was offered to 45 inpatients receiving PC at Muenster University Hospital. Patients with brain tumors, brain metastases, seizures, motion sickness, claustrophobia, vertigo, hearing or visual impairment, or unable to consent were excluded. Primary outcome measured patient reported pain on a visual analogue scale (VAS). We also measured Karnofsky performance status, health-related quality of life (HRQOL) using the EQ-5D-5 L questionnaire, and the Pain Out Questionnaire for postoperative pain. Results: We analyzed data from 21 women (52.5%) and 19 men (47.5%) at an average age of 51.9 (SD: 15.81) years. The mean Karnofsky score among the sample was 45.5 (SD: 14.97) and the HRQOL was 41.9 (SD: 23.08). While no serious side effects were reported during the intervention, three patients experienced nausea (7%), two headaches (5%), and three reported dry eyes (7%) afterwards. Significant pain reduction (baseline VAS 2.25 (SD: 0.4399)) was demonstrated during (VAS 0.7 (SD: 0.2983, p < 0.0001)), immediately after (VAS 0.9 (SD: 0.3354, p = 0.0001)) and one hour after the intervention (VAS 1.15 (SD: 0.4163, p = 0.0004)). More than 80% rated the VR experience as very good or good (85%, n = 34) and intended to make use of the device again (82.5%, n = 33). However, two participants (5%) also expressed sadness by becoming aware of old memories and previous opportunities that are gone. Discussion: The present pilot study suggests that VR seems to be a feasible and effective tool for pain relief in PC. Its use encompasses the approach of a total pain and symptom therapy and enhances patients' dignity and autonomy. Future research ought to include if and to what extent VR could reduce the necessity of pharmacological pain relief. [ABSTRACT FROM AUTHOR]

Over the last several decades, rates of opioid use and associated problems have dramatically increased in the United States leading to laws limiting prescription duration for acute pain management. As a result, orthopedic surgeons who perform total hip arthroplasty (THA), a procedure that often leads to significant postoperative pain, have been faced with substantial challenges to adequately mitigate patient pain while also reducing opioid intake. Current strategies include identifying and correcting modifiable risk factors associated with postoperative opioid use such as preoperative opioid use, alcohol and tobacco abuse, and untreated psychiatric illness. Additionally, recent evidence has emerged in the form of Enhanced Recovery After Surgery (ERAS) protocols suggesting that a multidisciplinary focus on patient factors perioperatively can lead to reduced postoperative opioid administration and decreased hospital stays. A cornerstone of ERAS protocols includes multimodal pain regimens with opioid rescue only as needed, which often includes multiple systemic pain therapies such as acetaminophen, gabapentin, non-steroidal anti-inflammatory drugs, as well as targeted pain therapies that include epidural catheters and ultrasound-guided nerve blocks. Many hospital systems and states have also implemented opioid prescribing limitations with mixed success. As the opioid epidemic continues in the United States, while contributing to poor outcomes following elective surgeries, further research is warranted to identify multidisciplinary strategies that mitigate opioid use while also allowing for adequate pain control and rehabilitation. [ABSTRACT FROM AUTHOR]

Introduction: The Transversus Abdominis Plane (TAP) block is a relatively simple technique that provides analgesia that, as part of a multimodal analgesic treatment, may be useful in the prevention of postoperative pain. Ultrasound (USG) versus Peripheral Nerve Stimulator (PNS) guided TAP blocks are being frequently given postoperatively for pain these days in laparoscopic cholecystectomy. Aim: To assess the analgesic efficacy of USG guided and PNS guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy. Materials and Methods: The randomised clinical study was conducted in the Department of Anaesthesiology, Shyam Shah Medical College, Rewa, Madhya Pradesh, India, from March 2020 to June 2021. Ninety adult patients were enrolled and randomly allocated into three groups. Group 1 (n=30) received bilateral USG-guided TAP block with 20 mL of 0.375% ropivacaine along with standard postoperative analgesia regimen. Group 2 (n=30) received bilateral PNS-guided TAP block with 20 mL 0.375% ropivacaine along with standard postoperative analgesia regimen. Group 3 (Control) (n=30) received standard postoperative analgesia regimen consisting of inj. paracetamol iv 1 gm (6 hourly) and inj. diclofenac 75 mg i.v. (12 hourly). Each patient was assessed for VAS score, duration of analgesia, total analgesic consumption and patient satisfaction for 24 hours postoperatively. Results: The average mean VAS score in first 24 hrs was 2.04±0.80 in group 1, 2.10±0.70 in group 2 and 3.18±0.63 in group 3. The duration of analgesia was least in group 3 (5.8±2.31 hrs) followed by group 2 (9.67±2.47 hrs) and maximum in group 1 (11.87±2.97 hrs). The total tramadol requirement in first 24 hrs postoperatively was 126.67±44.98 mg in group 1, 140±62.15 mg in group 2 and 226.67±63.97 mg in group 3. Conclusion: Postoperative analgesia with USG and PNS guided TAP block enables better pain control and less analgesic consumption. PNS guided TAP block is good alternative when compared with control for postoperative analgesia when USG machine is not available. [ABSTRACT FROM AUTHOR]

Both iliopsoas (IL) and quadratus lumborum (QL) muscle tightness are associated with lower back pain, which limit activities of daily life, such as squatting and walking. High-frequency diathermy (HFD) treatment generates heat as a result of molecular vibrations in deep soft tissues. HFD increases blood flow and tissue flexibility following muscle relaxation, and improves pain thresholds by lessening pain and facilitating maximum muscle stretch without destruction. We examined the effectiveness of HFD therapy on pain in the IL and QL in nonsymptomatic participants with IL tightness. A convenience sample of 15 nonsymptomatic participants with IL tightness (n (females) = 4 , 2 3. 5 ± 2. 9 years) was recruited, based on participants obtaining a positive value on the Thomas test. The treatment was applied to each muscle (IL and QL) for 15 min: 5 min of capacitive mode was applied, and 10 min of resistive mode was subsequently applied using the WINBACK tool. The whole participants were assessed pre- and post-intervention. Clinical variables contained visual analog scale (VAS) scores. The Wilcoxon signed-rank test was used to analyze the VAS scores, to determine whether HFD influenced pain control. The alpha value was set at 0.05. A significant reduction in IL and QL pain was observed when HFD was applied to participants (P < 0. 0 5). Our findings offer therapeutic proof that HFD is effective in controlling IL and QL pain in participants with IL tightness. [ABSTRACT FROM AUTHOR]

Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA. This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization. The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P =.99) and race (P =.81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P <.001) and 36 hours (3 vs. 2, P <.001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P =.001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P <.001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P =.002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P =.01) and more 30-day emergency department visits (5% vs. 2%, P =.038). LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs. [ABSTRACT FROM AUTHOR]

Symptomatic irreversible pulpitis is a painful clinical condition with a broad inflammatory component. Dental anesthesia in these patients is affected by the inflammatory process, reporting a high incidence of anesthesia failure. The aim of this systematic review and meta-analytical evaluation was to determine the effect of pre-treatment with tramadol in patients with symptomatic irreversible pulpitis, as well as for pain control and adverse effects. This study was registered in PROSPERO (ID: CRD42021279262). PubMed was consulted to identify clinical investigations comparing tramadol and placebo/local anesthetics in patients with symptomatic irreversible pulpitis. Data about the anesthesia, pain control, and adverse effects were extracted. Both the anesthetic success index and the adverse effects of local tramadol and placebo were compared with the Mantel–Haenszel test and odds ratio. Data analysis showed that the local administration of tramadol increased the anesthetic success rate when compared to placebo in patients with symptomatic irreversible pulpitis (n = 228; I2 = 0; OR = 2.2; 95% CIs: 1.30 to 3.79; p < 0.004). However, local administration of tramadol increased the risk of adverse effects when compared to placebo/local anesthetics (n = 288; I2 = 0; OR = 7.72; 95% CIs: 1.37 to 43.46; p < 0.02). In conclusion, this study shows that the local administration of tramadol increases the anesthetic success index when compared to placebo in patients with symptomatic irreversible pulpitis. [ABSTRACT FROM AUTHOR]

Interventional radiology is an evolving field that treats a variety of diseases. Local anesthetics is an important component of pain management during interventional radiologic procedures. It is highly effective and generally safe for routine procedures. However, local anesthetics can be associated with painful initial injection, allergic reactions, and rare but potentially devastating systemic toxicities. Recent evidence has shown that buffered solution and warm local anesthetics may reduce injection discomfort and improve clinical efficacy. Sensible safety practices and prompt recognition/treatment of the systemic toxicity are of paramount importance to provide safe local anesthesia. Interventional radiologists should be familiar with the basic pharmacology, common local anesthetics, optimizing strategies, complications, and management to provide safe and effective local anesthesia for patients. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To recognise the importance of providing rapid and effective pain relief for patients presenting to emergency departments (EDs) with traumatic injuries • To learn about the potential benefits of using methoxyflurane for patients with traumatic injuries in the ED • To understand how methoxyflurane is administered and the need for emergency nurses and ED clinicians to undergo training in its use Evidence suggests that pain is highly prevalent among patients with traumatic injuries who attend emergency departments (EDs), yet accurate assessment and management of patients with acute pain can be challenging in this setting. Effective and rapid pain management is beneficial for patients and can support timely discharge from the ED, which is particularly important in the context of the coronavirus disease 2019 (COVID-19) pandemic. This article describes a service development project that introduced the use of a patient-administered analgesic, methoxyflurane, for patients with traumatic injuries with moderate to severe pain in one ED. The author outlines the benefits and rationale for using methoxyflurane as a first-line analgesic in this patient group and describes the main elements of training sessions for emergency nurses and other ED clinicians in the administration and supervision of patient-administered methoxyflurane. [ABSTRACT FROM AUTHOR]

Background: To determine the prevalence of opioid use in Australian hip (THA) or knee (TKA) cohort, and its association with outcomes. Methods: About 837 primary THA or TKA subjects prospectively completed Oxford Scores, and Knee or Hip Osteoarthritis Outcomes Score(KOOS/HOOS) and opioid use in the previous week before arthroplasty. Subjects repeated the baseline survey at 6 months, with additional questions regarding satisfaction. Results: Opioid use was reported by 19% preoperatively and 7% at 6 months. Opioid use was 46% at 6 weeks and 10% at 6 months after TKR, and 16% at 6 weeks and 4% at 6 months after THR. Preoperative opioid use was associated with back pain(OR 2.2, P = 0.006), anxiety or depression(OR 1.8, P = 0.001) and Oxford knee scores <30(OR 5.6, P = 0.021) in TKA subjects, and females in THA subjects(OR 1.7, P = 0.04). There was no difference between preoperative opioid users and non‐users for satisfaction, or KOOS or HOOS scores at 6 months. 77% of patients taking opioids before surgery had ceased by 6 months, and 3% of preoperative non users reported opioid use at 6 months. Opioid use at 6 months was associated with preoperative use (OR 6.6–14.7, P < 0.001), and lower 6 month oxford scores (OR 4.4–83.6, P < 0.01). Conclusion: One in five used opioids before arthroplasty. Pre‐operative opioid use was the strongest risk factor for opioid use at 6 months, increasing odds 7–15 times. Prolonged opioid use was rarely observed in the opioid naïve (<5% TKA and 1% THA). Preoperative opioid use was not associated with inferior outcomes or satisfaction. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine if laparoscopically guided transversus abdominis plane block (Lap-Tap) with liposomal bupivacaine provides superior postoperative pain control when compared to ultrasound-guided block (US-Tap) with liposomal bupivacaine at the time of robotic surgery for gynecology oncology patients. This was a prospective randomized controlled trial assigning patients to one of two cohorts: Cohort 1 consisted of US-Tap administered before the procedure using liposomal bupivacaine, Cohort 2 consisted of Lap-Tap administration with laparoscopic visualization using the medication above. Primary outcomes were pain scores and total opioid use in Oral Morphine Equivalents (OME) during the first 72 h after surgery. Secondary outcomes were postoperative pain satisfaction and oral narcotic requirements. There was a significant increase in oral narcotic use in the first 24 h in the US-Tap cohort compared to the Lap-Tap cohort: Lap-Tap mean = 6.73 ± 8.22 OME versus US-Tap mean = 12.69 ± 12.94 p = 0.018 OME. The increase was equivalent to one additional Hydrocodone-Acetaminophen 7.5 mg/325 mg in the first 24 h after surgery. However, total oral narcotic use over the first 72 h was not significantly different between the two cohorts: Lap-Tap mean = 21.73 ± 19.83 OME, US-Tap mea n = 32.50 ± 29.47, p = 0.062 OME. In addition, there was no significant difference in satisfaction or pain scores between the US-Tap and Lap-Tap groups at 24, 48, or 72-hours. Lap-Taps are comparable to US-Tap for postoperative analgesia during the first 72-h after surgery when performing robotic-assisted gynecologic oncology surgery. • Laparoscopically guided TAP blocks are a useful and effective alternative to US guided TAP blocks. • There was no significant difference in total oral narcotic use in either group over the first 72 h. • Total oral narcotic use in the L-TAP group was increased in the first 24 h when compared to the US-TAP group. • Pain and satisfaction scores were not significantly different in either cohort. • There was a significant increase in pain scores among those with a history of pain or psychiatric medication use. [ABSTRACT FROM AUTHOR]

Objective: Total hip replacement (THR) is associated with severe postoperative pain. In this study, we aimed to compare fascia iliaca compartment block (FICB) with epidural block in the prevention of postoperative pain. Material and Method: Our study included 40 patients; who underwent epidural analgesia and FICB. At the end of the operation, (Group FICB) who underwent ultrasound-guided FICB for postoperative analgesia and received 100 milligrams Bupivacaine hydrochloride +250 micrograms fentanylcitrate. Patients in Group EPI were given 100 milligrams bupivacaine hydrochloride and 250 micrograms fentanyl citrate an elastomeric pump containing 100 milligrams Bupivacaine hydrochloride +250 micrograms fentanylcitrate with 75 cc saline added, giving a total of 100 ml and infusing 2 cc/hour continuously for 48 hours was installed through an epidural catheter to obtain postoperative analgesia. Time to first analgesia request after the operation, total milligrams of meperidine received in the postoperative 24 hours, postoperative VAS scores at the 30th minute, 2nd hour, 6th hour, 12th hour, and 24th hour and patient satisfaction levels were evaluated. Results: VAS scores at the postoperative 2nd, 6th, 12th, and 24th hours were statistically significantly higher in Group FICB compared to Group EPI (p <0.001). In addition, it was observed that the total analgesic consumption in the postoperative period was statistically significantly higher in Group FICB compared to Group EPI (p <0.001). The evaluation of patient satisfaction levels revealed that patients in Group EPI were very much satisfied (p <0.001). Conclusion: In our study; we found out that postoperative pain levels and analgesic consumption were lower in epidural anaesthesia patients compared to the patients, who underwent fascia iliaca compartment block. [ABSTRACT FROM AUTHOR]

Studies investigating preoperative use of opioid medication and early postoperative outcomes are lacking in reverse total shoulder arthroplasty (RTSA), findings that would be relevant in the setting of bundled payment plans. This study compared patients with chronic preoperative opioid use with patients who were opioid naïve in regard to pain, opioid use, length of hospital stay, and complications after RTSA. Patients using opioids chronically (>3 months) preoperatively and those not using opioid medications before RTSA were identified through an institutional database. Visual analog scale (VAS) pain scores were recorded at the preoperative visit and 12 weeks after surgery. Oral morphine equivalents (OME) were recorded from in-hospital use, discharge, and subsequent opioid prescriptions, and a search of a statewide controlled substances monitoring database was performed during the 3-month postoperative period. The hospital length of stay and complications also were recorded. Statistical analyses for preoperative and postoperative measurements were performed using Mann-Whitney testing. Differences with P <.05 were considered statistically significant. There were 55 patients with chronic preoperative opioid use and 134 nonusers included in the study. Preoperative VAS scores (6.7 vs. 5.6; P =.01) were found to be higher for the opioid group. At 3 months postoperatively, VAS (3.5 vs. 1.9; P =.04) was again found to be higher for the opioid group. However, the degree of improvement in VAS (4.1 vs. 3.6; P =.65) was similar between groups. The amount of inpatient OME (66.6 vs. 55; P =.76) and postdischarge OME (606 vs. 559; P =.76) consumed were similar between groups. The cumulative 3-month postoperative OME use (1457 vs. 569; P =.07) was higher in the opioid group and trended toward statistical significance. No differences were noted in the length of stay between the 2 groups, with each averaging 2.3 days. Complication rates were similar between the 2 groups in the 90-day episode of care (9.1% vs. 10.4%). These results indicate that chronic preoperative opioid use is associated with increased postoperative pain after RTSA, although VAS improvement was similar to narcotic-naïve patients. Furthermore, cumulative OME usage only trended toward statistical significance but, nevertheless, reflected an over 2.5-fold increased requirement in the group of patients using opioids preoperatively. Although opioid users did not require substantially more perioperative resources, these data can be used to further counsel patients regarding opioid use, manage postoperative expectations, and aid in risk stratification during the evolution of bundled payments and the transition to value-based care. Level III; Retrospective Case-Control Treatment Study [ABSTRACT FROM AUTHOR]

Objectives: Judicious opioid use is important for balancing patient comfort and safety. Although opioid use is well studied in adult populations, pediatric opioid prescription practices are less understood and there are very few guidelines regarding its usage. The purpose of this study was to investigate pediatric opioid prescription trends by emergency medicine physicians over the last ten years, including assessing proxies for the adequacy of pain control and risk of any opioid-related adverse events including overdose.Methods: A retrospective analysis was performed of all patients age 0 to 18 who presented to an urban county hospital emergency department (ED) between 2007 and 2017 for acute fracture care. Data collected included age, opioids given in the ED, opioid prescriptions from the ED, adverse events, and secondary opioid prescriptions. Opioid prescription quantities were assessed in morphine equivalents (Meqs).Results: Out of 4713 patients diagnosed with acute fracture, opioid prescriptions from the ED were given to 1772 patients (37.6%), with a mean quantity of 107.0 Meqs (SD = 69.1). Over the ten-year period studied, prescription rates declined from 54.8% in 2007 to 13.6% in 2017. Although 201 (4.3%) fracture patients had a second fracture-related ED visit, only 27 visits (0.57%) were for inadequate pain control, with no significant differences in year-to-year analysis. During the ten-year study period, there were zero opioid overdoses reported among pediatric fracture patients.Conclusions: A major shift has occurred in the last ten years, as emergency medicine physicians now favor non-opioid pain management regimens over opioids for the majority of pediatric fracture patients. There was no increase in the rate of inadequate pain control requiring a return to the ED, even as opioid prescription rates declined during the study period. [ABSTRACT FROM AUTHOR]

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period. This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal. Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group. There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain. Therapeutic II. [ABSTRACT FROM AUTHOR]

Background: Controversy exists on the acceptability of medical immobilization (MI). Aim: To identify regulations, professional conventions, and opinions on the acceptability of MI and to identify practice patterns through a pilot study of members of the International Association of Paediatric Dentistry (IAPD) and their colleagues. Design: A 22‐item questionnaire was developed and electronically distributed to 1191 members of the IAPD. Results: Responses were received from 182 dentists in 45 countries. The majority (74.9%) of respondents use MI, and 29.1% use an immobilization device. MI with an immobilization device was reported as professionally acceptable (58.1%) and permitted by medicolegal regulations (70.8%) in their countries of practice. Dentists rated acceptability of MI higher than they perceived parents would overall and perceived MI to be more acceptable by parents for emergency situations and for children with special healthcare needs but 19.8% of respondents found it totally unacceptable in all scenarios. Use and opinions of acceptability varied by geographical location with respondents from North America being more accepting of MI. Most dentists felt that the use of an immobilization device could lead to lasting psychological trauma (72.3%) and violation of the rights of the child (55.4%) but that it improves access to care (58.5%). Conclusion: The acceptability of MI remains an area of controversy for paediatric dentists internationally. [ABSTRACT FROM AUTHOR]

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