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Background Patients and clinicians can choose from several treatment options to address acute pain from non-low back, musculoskeletal injuries. Purpose To assess the comparative effectiveness of outpatient treatments for acute pain from non-low back, musculoskeletal injuries by performing a network meta-analysis of randomized clinical trials (RCTs). Data sources MEDLINE, EMBASE, CINAHL, PEDro (Physiotherapy Evidence Database), and Cochrane Central Register of Controlled Trials to 2 January 2020. Study selection Pairs of reviewers independently identified interventional RCTs that enrolled patients presenting with pain of up to 4 weeks' duration from non-low back, musculoskeletal injuries. Data extraction Pairs of reviewers independently extracted data. Certainty of evidence was evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Data synthesis The 207 eligible studies included 32 959 participants and evaluated 45 therapies. Ninety-nine trials (48%) enrolled populations with diverse musculoskeletal injuries, 59 (29%) included patients with sprains, 13 (6%) with whiplash, and 11 (5%) with muscle strains; the remaining trials included various injuries ranging from nonsurgical fractures to contusions. Topical nonsteroidal anti-inflammatory agents (NSAIDs) proved to have the greatest net benefit, followed by oral NSAIDs and acetaminophen with or without diclofenac. Effects of these agents on pain were modest (around 1 cm on a 10-cm visual analogue scale, approximating the minimal important difference). Regarding opioids, compared with placebo, acetaminophen plus an opioid improved intermediate pain (1 to 7 days) but not immediate pain (≤2 hours), tramadol was ineffective, and opioids increased the risk for gastrointestinal and neurologic harms (all moderate-certainty evidence). Limitations Only English-language studies were included. The number of head-to-head comparisons was limited. Conclusion Topical NSAIDs, followed by oral NSAIDs and acetaminophen with or without diclofenac, showed the most convincing and attractive benefit-harm ratio for patients with acute pain from non-low back, musculoskeletal injuries. No opioid achieved benefit greater than that of NSAIDs, and opioids caused the most harms. Primary funding source National Safety Council. (PROSPERO: CRD42018094412).

Patients undergoing bariatric surgery present unique analgesic challenges, including poorly controlled pain, increased prevalence of obstructive sleep apnea, and opioid-induced respiratory depression. The transversus abdominis plane (TAP) has been demonstrated to be a safe and effective component of multimodal analgesia for a variety of abdominal surgeries.To determine the benefits of the TAP block on postoperative analgesia and recovery in patients undergoing bariatric surgery.Systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies.We conducted a comprehensive search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to April 2020 for studies using TAP block in bariatric surgeries and reporting postoperative pain, opioid consumption, and recovery-related outcomes. Primary outcomes included postoperative pain scores, opioid consumption, and recovery-related outcomes (e.g., length of stay, time to ambulation). Outcomes were pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI).Twenty-one studies (15 RCTs [n = 1410] and 6 nonrandomized studies [n = 1959]) were included. Among RCTs, the TAP block group required fewer opioid rescues (RR 0.28; 95% CI 0.18 to 0.42, P0.001) (moderate quality); reduced total opioid use over 24 hours (MD -8.33; 95% CI -14.78 to -1.89, P = 0.01); decreased time to ambulation (MD -1.12 hours; 95% CI -1.50 to -0.73, P0.001) (high quality); and had significantly lower pain scores at 6 hours (MD -1.52; 95% CI -1.90 to -1.13, P0.01) and 12 hours (MD -0.95; 95% CI -1.34 to -0.56, P0.001) on a 0-10 pain scale (moderate quality). No difference was observed for nausea and vomiting, or hospital length of stay. Meta-analyzed outcomes from observational studies supported these results, suggesting decreased postoperative pain and opioid consumption.Studies varied with respect to type of surgery and components of comparator multimodal analgesia, likely contributing to heterogeneity. Subgroup analyses by type of comparator group were conducted to address these differences. We were unable to extract data from all trials included due to variability in outcomes reporting, such as non-opioid drugs for postoperative pain management or invalid dosages. Pain-related outcomes may be affected by operative differences leading to variation in visceral pain. Observational studies have their inherent limitations, such as confounding due to lack of participant randomization and intervention blinding, potentially affecting subjective outcomes, such as pain scores, as well as provider-dependent outcomes, such as hospital length of stay. Lastly, there was significant variation of TAP block technique across all studies.TAP block is an effective, safe modality that can be performed under anesthesia. It decreases pain, opioid use, and time to ambulation after bariatric surgeries and should be considered in multimodal analgesia for enhanced recovery in this high-risk surgical population.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The objective of this review is to assess the effects of various preoperative fasting regimens (i.e. the duration of fasting from liquids and solids and the type and volume of permitted intake) on perioperative complications, including aspiration, aspiration‐related morbidity (e.g. aspiration pneumonia), and mortality in children undergoing general anaesthesia. We will also assess the effect of preoperative fasting regimens on other perioperative outcomes and complications, including length of hospital stay, risk of unplanned intubation and intensive care unit (ICU) admission, risk of unplanned oxygen administration, risk of unplanned admission, thirst, hunger, pain, risk of vomiting, and anxiety. We will also use subgroup analyses to assess whether the risk of perioperative complications with various preoperative fasting regimens differ for children with a comorbidity (e.g. obesity, diabetes, respiratory, or digestive) or for children of different ages (e.g. infants, children, adolescents).

Background The prevalence and intensity of persistent post-surgical pain (PPSP) after breast cancer surgery are uncertain. We conducted a systematic review and meta-analysis to further elucidate this issue. Methods We searched MEDLINE, Embase, CINAHL, and PsycINFO, from inception to November 2018, for observational studies reporting persistent pain (≥3 months) after breast cancer surgery. We used random-effects meta-analysis and the Grading of Recommendations, Assessment, Development and Evaluations approach to rate quality of evidence. Results We included 187 observational studies with 297 612 breast cancer patients. The prevalence of PPSP ranged from 2% to 78%, median 37% (inter-quartile range: 22–48%); the pooled prevalence was 35% (95% confidence interval [CI]: 32–39%). The pooled pain intensity was 3.9 cm on a 10 cm visual analogue scale (95% CI: 3.6–4.2 cm). Moderate-quality evidence supported the subgroup effects of PPSP prevalence for localized pain vs any pain (29% vs 44%), moderate or greater vs any pain (26% vs 44%), clinician-assessed vs patient-reported pain (23% vs 36%), and whether patients underwent sentinel lymph node biopsy vs axillary lymph node dissection (26% vs 43%). The adjusted analysis found that the prevalence of patient-reported PPSP (any severity/location) was 46% (95% CI: 36–56%), and the prevalence of patient-reported moderate-to-severe PPSP at any location was 27% (95% CI: 10–43%). Conclusions Moderate-quality evidence suggests that almost half of all women undergoing breast cancer surgery develop persistent post-surgical pain, and about one in four develop moderate-to-severe persistent post-surgical pain; the higher prevalence was associated with axillary lymph node dissection. Future studies should explore whether nerve sparing for axillary procedures reduces persistent post-surgical pain after breast cancer surgery.

Objective To determine the benefits and harms of medical cannabis and cannabinoids for chronic pain. Design Systematic review and meta-analysis. Data sources MEDLINE, EMBASE, AMED, PsycInfo, CENTRAL, CINAHL, PubMed, Web of Science, Cannabis-Med, Epistemonikos, and trial registries up to January 2021. Study selection Randomised clinical trials of medical cannabis or cannabinoids versus any non-cannabis control for chronic pain at ≥1 month follow-up. Data extraction and synthesis Paired reviewers independently assessed risk of bias and extracted data. We performed random-effects models meta-analyses and used GRADE to assess the certainty of evidence. Results A total of 32 trials with 5174 adult patients were included, 29 of which compared medical cannabis or cannabinoids with placebo. Medical cannabis was administered orally (n=30) or topically (n=2). Clinical populations included chronic non-cancer pain (n=28) and cancer related pain (n=4). Length of follow-up ranged from 1 to 5.5 months. Compared with placebo, non-inhaled medical cannabis probably results in a small increase in the proportion of patients experiencing at least the minimally important difference (MID) of 1 cm (on a 10 cm visual analogue scale (VAS)) in pain relief (modelled risk difference (RD) of 10% (95% confidence interval 5% to 15%), based on a weighted mean difference (WMD) of −0.50 cm (95% CI −0.75 to −0.25 cm, moderate certainty)). Medical cannabis taken orally results in a very small improvement in physical functioning (4% modelled RD (0.1% to 8%) for achieving at least the MID of 10 points on the 100-point SF-36 physical functioning scale, WMD of 1.67 points (0.03 to 3.31, high certainty)), and a small improvement in sleep quality (6% modelled RD (2% to 9%) for achieving at least the MID of 1 cm on a 10 cm VAS, WMD of −0.35 cm (−0.55 to −0.14 cm, high certainty)). Medical cannabis taken orally does not improve emotional, role, or social functioning (high certainty). Moderate certainty evidence shows that medical cannabis taken orally probably results in a small increased risk of transient cognitive impairment (RD 2% (0.1% to 6%)), vomiting (RD 3% (0.4% to 6%)), drowsiness (RD 5% (2% to 8%)), impaired attention (RD 3% (1% to 8%)), and nausea (RD 5% (2% to 8%)), but not diarrhoea; while high certainty evidence shows greater increased risk of dizziness (RD 9% (5% to 14%)) for trials with Conclusions Moderate to high certainty evidence shows that non-inhaled medical cannabis or cannabinoids results in a small to very small improvement in pain relief, physical functioning, and sleep quality among patients with chronic pain, along with several transient adverse side effects, compared with placebo. The accompanying BMJ Rapid Recommendation provides contextualised guidance based on this body of evidence. Systematic review registration https://osf.io/3pwn2

Introduction/Aim: Persistent post-surgical pain (PPSP) is a common complication after breast cancer surgery; but reported prevalence rates range from 10% to 69%. We conducted a systematic review to address this uncertainty. Methods: We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to October 2018, to identify observational studies that reported the prevalence and intensity of PPSP after breast cancer surgery. We performed random effects meta-analysis with Freeman-Tukey transformation for overall, moderate and severe PPSP prevalence, and pooled pain intensity after converting all pain scales to the 10cm VAS. Results: We included 188 observational studies with 300,025 patients. The overall prevalence of any PPSP was 34.5% (95%CI 30.1% to 39.2%). The pooled prevalence of moderate and severe pain was 14.9% (95%CI 11.5% to 18.7%) and 4% (95%CI 2.7% to 5.5%) respectively. The average pain intensity on a 10cm VAS was 2.7 (95%CI 2.2 to 3.1). We are completing analyses to inform PPSP prevalence and intensity at 3 years, and prevalence of neuropathic pain. We will also perform subgroup analyses for risk of bias, any pain vs. specific pain, axillary lymph nodes dissection and radiotherapy, and meta-regression for the association between PPSP and length of follow-up and proportion of loss to follow-up. Discussion/Conclusions: PPSP after breast surgery is common and affects approximately 1 in 3 women undergoing this procedure. Of those who develop persistent pain, 43% will report at least moderate pain and 12% will experience severe pain although the average pain is mild.

Background Canadian rheumatologists' attitudes toward and management of fibromyalgia remain uncertain. Objective The aim of this study was to explore management strategies and attitudes of Canadian rheumatologists toward fibromyalgia and concordance with guideline recommendations. Methods We administered a 17-item cross-sectional survey to Canadian rheumatologists and explored the concordance between respondents' management practices with the 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia. Results Among 331 Canadian rheumatologists who were approached, 140 returned the survey for a 42% response rate. The majority felt that fibromyalgia was a useful clinical diagnosis (110/138 [80%]) but was divided as to whether fibromyalgia was objectively defined (75/138 [54%]) or a psychosocial condition (42/138 [30%]) or could result in an inability to work (37/138 [27%]). Contrary to guideline recommendations, most (82/134 [61%]) endorsed that tender points were useful for diagnosis. Half endorsed potentially refusing consultations with fibromyalgia patients, and only 42% (59/139) agreed that there were effective therapies for this syndrome. Consistent with the guideline, most respondents managed fibromyalgia with education, exercise therapy, antidepressants, and nonnarcotic analgesics (≥89% for all); however, fewer than half agreed that any of these modalities were effective (endorsement ranged from 9% to 47%). Assessment of the 2012 guideline revealed a number of important limitations. Conclusions Canadian rheumatologists largely do not provide primary care for fibromyalgia. Most adhere to guideline recommendations for management of fibromyalgia, but few endorse these interventions as effective. Further research, including updating of the 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia, is required to inform this disconnect.

IntroductionAcute, non-low back-related musculoskeletal pain is common and associated with significant socioeconomic costs. No review has evaluated all interventional studies for acute musculoskeletal pain, which limits attempts to make inferences regarding the relative effectiveness of treatments.Methods and analysisWe will conduct a systematic review of all randomised controlled trials evaluating therapies for acute musculoskeletal pain (excluding low back pain). We will identify eligible, English-language, trials by a systematic search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline, Physiotherapy Evidence Database (PEDro) and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to February 2018. Eligible trials will: (1) enrol patients presenting with acute, non-low back-related musculoskeletal pain (duration of pain ≤4 weeks), and (2) randomise patients to alternative interventions or an intervention and a placebo/sham arm. Fractures will be considered ineligible, unless they are non-surgical and therapy is directed at pain relief. Pairs of reviewers will, independently and in duplicate, screen titles and abstracts of identified citations, review the full texts of potentially eligible trials and extract information from eligible trials. We will use a modified Cochrane instrument to evaluate risk of bias. Disagreements will be resolved through discussion to achieve consensus. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence supporting treatment effects. When possible, we will conduct: (1) in direct comparisons, a random-effect meta-analysis to establish the effectiveness of therapeutic interventions on patient-important outcomes; and (2) multiple treatment comparison meta-analysis to assess the relative effects of treatments. We will use a priori hypotheses to explain heterogeneity between studies. We will use STATA V.14.2 for all analyses.Ethics and disseminationNo research ethics approval is required for this systematic review, as no confidential patient data will be used. The results of this systematic review will be disseminated through publication in a peer-reviewed journal, conference presentations and will inform a clinical practice guideline.PROSPERO registration numberCRD42018094412.