Pain Research Articles

Objective: To investigate the clinicopathological characteristics of type 2 autoimmune pancreatitis (AIP) and to explore its relationship with inflammatory bowel disease (IBD). Methods: AIP cases confirmed by pathology in the First Affiliated Hospital of Zhejiang University School of Medicine from 2009 to 2024 were collected. According to the International Consensus Diagnostic Criteria (ICDC) for AIP, 11 patients were identified as histological level 1 (definite) or level 2 (probable) type 2 AIP. Their clinical manifestations, laboratory test results, imaging features, and histopathological characteristics were analyzed, and a follow-up was conducted. Meanwhile, 130 patients with type 1 AIP diagnosed in our hospital during the same period were selected as control group. Results: Among 141 AIP patients, 11 cases (7.8%, 11/141) were diagnosed with type 2 AIP, including 7 cases of histologically level 1 and 4 cases of level 2. There were 10 male patients and 1 female patient, with a median age of 37(31,46) years (range: 25-47 years). Three patients were complicated with ulcerative colitis (UC). Compared with type 1 AIP patients, type 2 AIP patients were younger, often presented with acute pancreatitis or abdominal pain as the initial symptom, and had a close association with IBD (P<0.05). Laboratory tests showed that only 1 patient had slightly elevated serum IgG4, while the other 10 patients had normal serum IgG4 levels. Serum CA19-9 was elevated in 8 patients, and the percentage of peripheral blood neutrophils was increased in 9 patients. Imaging findings revealed diffuse pancreatic enlargement in 8 patients and localized enlargement in 3 patients (2 cases in the pancreatic head and 1 case in the pancreatic body-tail). Magnetic resonance cholangiopancreatography (MRCP) showed main pancreatic duct stenosis in 5 cases (5/7). Histopathological features included 7 cases of level 1 type 2 AIP that showed neutrophilic infiltration in the pancreatic duct epithelium and massive neutrophilic infiltration between the acini. Immunohistochemistry showed that only 1 case had <5 IgG4-positive plasma cells per high-power field (HPF), while the other 10 cases were negative. All 11 patients with type 2 AIP received steroid therapy, and no recurrence was observed during the follow-up period of 5 to 174 months. Conclusions: Type 2 AIP has unique clinicopathological characteristics. It is more commonly found in young patients and often presents with manifestations similar to acute pancreatitis. Histologically, neutrophilic infiltration in the ductal epithelium is the common feature. Type 2 AIP is closely associated with IBD, especially UC.

Despite advancements in acute pain management and minimally invasive surgical techniques, persistent postsurgical pain can occur in up to 30% to 50% of patients. Psychological and social factors are increasingly recognized as contributors to pain outcomes, yet the impact of specific social determinants of health on persistent postoperative pain remains unclear. We conducted a retrospective observational study using the All of Us Research Program database. Adults who underwent surgical procedures after the year 2000 were included if they had available social determinants of health (SDoH) survey data and no prior diagnosis of persistent postoperative pain. Persistent postoperative pain was defined via SNOMED codes as a diagnosis occurring at least 1 year after the surgery date. Multivariable logistic regression was performed to assess the association between 21 independent variables derived from All of Us SDoH survey items and persistent postoperative pain, controlling for age, sex, race, ethnicity, and surgery type. A Bonferroni-corrected significance threshold (P < .002) was applied. There were 8065 participants included in the final analysis with 641 (7.9%) developing persistent postoperative pain. Food insecurity had the strongest association with persistent postoperative pain (odds ratio [OR] = 1.83, 95% confidence interval [CI], 1.45-2.30, P < .001). Having greater social support (OR = 0.96, 95% CI, 0.94-0.99, P = .002) and lower residential density (OR = 0.72, 95% CI, 0.61-0.85, P < .001) was protective. These findings underscore the importance of routinely assessing and addressing socioeconomic and psychosocial factors in perioperative care to help prevent long-term pain.

Abstract Introduction The treatment of acute pain is essential to facilitate recovery from surgery or trauma by enabling early mobilisation and avoiding complications, including the bed-bound risks of venous thromboembolism, pulmonary embolus, pressure sores and pneumonia. Severe, untreated acute pain may also predispose to the development of chronic pain [1]. Opioid toxicity whilst in hospital can be fatal and requires strict adherence to good prescribing guidance. Also, opioid-induced constipation is the most common adverse effect associated with prolonged use of opioids [2]. Aim To ascertain compliance with the Trust’s “Adult Opioid Prescribing Guide” [3] in adult patients in the Princess Royal University Hospital (PRUH) surgical wards. Objectives To determine if all patients prescribed opioids had naloxone 100 micrograms PRN (when required) prescribed. To determine if all patients prescribed opioids had at least one laxative prescribed (if not contraindicated). To assess if both naloxone and a laxative were prescribed concurrently with opioids. Methodology Standards Ethics approval was not required. The audit was approved by the KCH Pharmacy Research and Audit Group. On 23rd August 2023, data was collected prospectively from surgical wards S3 and S6 (20 beds each, all occupied) using Electronic Patient Records (EPR). The Raosoft sample size calculator was used [4]. It recommended 37 patients. However, the total number of patients was included. Data was analysed using Microsoft Excel®. Inclusions: all admitted patients on S3 and S6 on the audit date. Exclusions: opioid/laxative use as part of drug history and contraindications (e.g. allergy, bowel perforation). Results Of the 40 patients, 4 were excluded (2 had opioids as regular medication, 2 had contraindicated laxatives), leaving 36 patients. Of these, 22 were prescribed opioids for acute pain. Only 6 (27%) had naloxone prescribed, 10 (45%) had at least one laxative, and 4 (18%) had both prescribed as per the Trust’s Guidelines [3]. Discussion This was the first audit at this Trust, so no previous data was available for comparison. Compliance with guidelines was poor. Contributing factors included staffing shortages, limited audit resources, lack of awareness among new doctors due to reduced induction time, and junior doctors' and consultants' strikes shortly before the audit. Study limitations included small sample size due to resource constraints, inability to automate data collection, recent staff changes and shortages across the hospital, and limited time for pharmacists to support daily prescribing reviews. There is inadequate compliance with the Trust’s opioid prescribing guidelines (1) in surgical wards at PRUH, increasing the risk of opioid toxicity and constipation-related complications [1,2]. Recommendations are to: 1) Include pharmacists in induction sessions for new prescribers to introduce Trust guidelines, 2) Provide refresher training to surgical doctors during monthly audit days, 3) Email consultants audit findings and guideline reminders, 4) Plan a re-audit in three months, 5) Introduce EPR prompts or protocols to co-prescribe naloxone and laxatives with opioids.

Practice variations in pharmacological management of acute renal colic pain: A cross-sectional survey study.

Autonomic Parameters Correlated to Acute Postoperative Pain in the Postanesthesia Care Unit: A Systematic Review.

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a transient cardiac condition characterized by acute but reversible left ventricular dysfunction, typically triggered by emotional or physical stress. While Takotsubo cardiomyopathy usually occurs in the absence of significant coronary artery disease, its coexistence with severe coronary artery disease is uncommon and presents diagnostic and therapeutic challenges. We report the case of a 56-year-old Asian woman with a history of hypertension and diabetes who presented with acute chest pain following an intense emotional and physical altercation. On admission, she was hemodynamically stable, with electrocardiogram showing minor ST-segment elevation in the anterior leads and modest troponin rise. Bedside echocardiography revealed apical akinesia suggestive of Takotsubo cardiomyopathy. Coronary angiography demonstrated high-risk multivessel coronary artery disease, including significant left main disease. Cardiac function rapidly improved within 5 days, with normalization of left ventricular ejection fraction and global longitudinal strain, consistent with Takotsubo cardiomyopathy. Given her refusal of coronary artery bypass grafting, percutaneous coronary intervention to the left main and left anterior descending was successfully performed. She was discharged home on optimal medical therapy in stable condition. This case highlights the diagnostic complexity when Takotsubo cardiomyopathy coexists with severe coronary artery disease. It emphasizes the importance of considering Takotsubo cardiomyopathy in patients with acute chest pain even in the presence of significant coronary lesions, as Takotsubo cardiomyopathy may unmask otherwise silent but clinically important coronary artery disease.

Recurrent fever and acute abdominal pain are common reasons for emergency visits, particularly in adolescents. These symptoms often lead to misdiagnosis and unnecessary surgeries like appendectomy. Familial Mediterranean fever (FMF), arare autoinflammatory disorder, should be considered in patients with periodic febrile abdominal episodes, especially in those with amigration background. A19-year-old male of Syrian origin presented with acute right lower quadrant abdominal pain, fever, arthralgia, and pleuritic chest pain. Similar episodes had occurred in the past and resolved spontaneously. Physical examination revealed signs of peritonism; laboratory results showed elevated C‑reactive protein (CRP; 35 mg/L) with normal white blood cell counts. Abdominal ultrasound excluded appendicitis. Conservative treatment (fluids, analgesics, dietary rest) led to full symptom resolution within 2days. After recovery, adetailed family history revealed consanguinity and arelative with similar symptoms. The diagnosis of FMF was made based on the Tel Hashomer criteria. Colchicine therapy (1.0 mg/day) was initiated. This report illustrates acase of late-onset FMF in amigrant adolescent, with typical symptoms but without definitive serositis or confirmed genetic diagnosis at the time of treatment. The case underscores the importance of thorough history-taking and highlights the need to avoid unnecessary CT scans in similar settings. Awareness of FMF is crucial in nonendemic regions experiencing increased migration from high-incidence countries.

Despite optimized therapy, up to 30% of patients with trigeminal neuralgia (TN) experience treatment failure. To date, there is limited and low-quality data available on rescue strategies for this subset of patients. This study describes clinical outcomes associated with intravenous (IV) magnesium sulfate and methocarbamol, with or without adjunctive antiseizure medications (ASMs), in the management of acute, refractory TN pain crises. This was a single-center, retrospective cohort study conducted at the Cleveland Clinic Headache and Facial Pain Section from January 2015 to 2024. We analyzed adults (≥18 years) with treatment-refractory TN who received a standardized 3-day infusion regimen of magnesium sulfate and methocarbamol, with or without IV ASMs (levetiracetam, lacosamide, or valproic acid). Each encounter represented a distinct TN pain crisis treated with 3 consecutive days of infusion therapy. Infusions were administered specifically during acute exacerbations of pain that occurred despite ongoing or previously attempted maintenance treatment. Pain intensity was assessed using the 11-point numerical rating scale before and after each infusion day. The primary outcome was the proportion of encounters achieving a ≥50% reduction in NRS score from day 1 preinfusion to day 3 postinfusion. A total of 170 patients were included. The patient encounters analyzed in this study had an overall mean age of 57.0 years and consisted mostly of females (n = 130, 76.5%). A ≥50% reduction in pain score was achieved in 86.9% of encounters. The largest reduction occurred on day 1, with diminishing but continued improvements on days 2 and 3. Adjunctive IV ASMs were not associated with improved response compared to the magnesium and methocarbamol alone (72.4% vs. 75.8%, respectively; p = 0.740). Pain Disability Index scores also improved among patients with follow-up data. A 3-day IV infusion protocol combining magnesium sulfate and methocarbamol, with or without adjunctive ASMs, was associated with rapid, meaningful pain relief in most patients with acute TN pain crises. Larger, prospective studies are warranted to further investigate and confirm the effectiveness of this IV treatment strategy for managing this challenging neurological condition.

Post-traumatic renal artery embolism (RAE) represents a rare vascular emergency with diagnostic challenges due to its nonspecific presentation. This study aims to enhance clinical recognition through a comprehensive analysis of a bilateral RAE case and contemporary management strategies. A 23-year-old male was admitted to the Emergency Department of the Second Affiliated Hospital, Zhejiang University School of Medicine, with acute chest and back pain and disturbance of consciousness following blunt abdominal trauma. The diagnostic workup included contrast-enhanced computed tomography angiography and serum biomarkers. Upon admission to the Emergency Intensive Care Unit, the patient underwent immediate continuous renal replacement therapy, vasoactive drugs, fluid replacement, alkalization of urine, and symptomatic treatment. After the patient's condition improved, the spinal surgery performed thoracic vertebra reduction and internal fixation surgery. Serial renal function monitoring demonstrated complete functional recovery. In the evaluation of post-traumatic abdominal pain, RAE should be systematically considered in the differential diagnosis following exclusion of acute surgical abdomen.

Cerebellar vermis and somatosensory-motor cortex differentially contribute to sex differences in acute pain perception in rats.

While the risks and benefits of autologous breast reconstruction have been widely examined, nationally representative, longitudinal data on complication burden, flap utilization trends, and patient-level risk factors remain limited. The NIH All of Us Research Program provides an opportunity to address these gaps using a diverse, population-scale cohort. We identified 260 patients who underwent autologous breast reconstruction using CPT codes within the All of Us Registered Tier Dataset (1995-2025). Complications were tracked at 30 days and 1 year postoperatively. Logistic, multivariate regressions and Kaplan-Meier analyses evaluated predictors and timing of complications. Unsupervised machine learning via K-means clustering was utilized to uncover phenotypic subgroups by age and BMI. DIEP flap utilization increased over time, particularly among younger patients. Complication rates did not significantly differ across flap types. BMI >32.7 kg/m² was associated with increased 30-day complications, while age and race were not independent predictors. Chronic pain and persistent postoperative pain were the most common 1-year complications. Flap failure occurred in fewer than 2% of cases. Clustering revealed three patient subgroups with distinct complication profiles; older patients and those with higher BMI experienced greater morbidity but maintained high flap success rates. Autologous breast reconstruction is broadly effective across diverse patient populations. Complication risk is more strongly influenced by BMI than age or race. Chronic pain emerged as a common long-term morbidity, underscoring the need for improved detection and management efforts. The diversity, depth, and follow-up available through All of Us enable nuanced insights into reconstructive outcomes not possible with traditional datasets.

Morphine remains a first-line analgesic for both acute and chronic pain. However, its prolonged use often results in the development of tolerance, diminishing its analgesic efficacy and limiting its long-term clinical utility. Emerging evidence highlights the pivotal role of microglial activation in the central nervous system as a key contributor to morphine tolerance. Phytochemicals, natural metabolites derived from plants, have garnered attention for their multi-target mechanisms, low toxicity, and broad biological activities, positioning them as promising candidates for mitigating morphine tolerance. This review systematically explores the key receptors and signaling pathways involved in microglial activation during morphine tolerance, and elucidates how various phytochemicals modulate these pathways to attenuate tolerance. Furthermore, it discusses the translational challenges associated with phytochemical-based interventions and outlines future directions for their clinical application. The aim is to provide a theoretical framework to support translational research and the development of novel adjunct therapies for opioid analgesia.

ABSTRACT Pseudoprogression is characterised by an increase in tumour size, driven by an influx of inflammatory cells, followed by regression. This phenomenon has rarely been reported in multiple myeloma (MM), despite increased use of immunotherapy approaches that have been associated with pseudoprogression in other malignancies. We report a case of pseudoprogression in a female in her early seventies with relapsed/refractory MM who was treated with the BCMA×CD3 bispecific antibody linvoseltamab. At study Day 28, she was hospitalised with acute bone pain and a new fracture, and a positron emission tomography/computed tomography scan suggested disease progression. However, biochemical markers of disease burden (serum M‐protein, kappa light chain) had decreased from baseline, and therefore linvoseltamab was continued. At Day 77, M‐protein was absent and the patient had achieved complete biochemical response, but she had to discontinue linvoseltamab due to infectious complications. A subsequent scan on Day 86 demonstrated marked improvement in osseous lesions. Despite being off therapy, the disease did not progress for 2 years. Assessment of T‐cell activation and proinflammatory cytokine production indicated increased T‐cell activation concurrent with onset of radiologic pseudoprogression. To our knowledge, this is the first description of radiologic pseudoprogression in MM with anti‐BCMA bispecific antibody therapy.

Ibuprofen and ketorolac are nonsteroidal anti-inflammatory drugs (NSAIDs) commonly used to treat acute back pain in the Emergency Department (ED). Data comparing pain relief between oral and intramuscular administration at their proposed ceiling doses is lacking. The aim of this study was to compare oral (PO) ibuprofen 400mg to intramuscular (IM) ketorolac 10mg for the treatment of acute, atraumatic, musculoskeletal back pain. This single-center, double-blind, double-placebo, randomized study compared PO ibuprofen 400mg to IM ketorolac 10mg for acute, atraumatic musculoskeletal back pain in adult patients presenting to an urban ED. Subjects were randomized to receive PO ibuprofen 400mg suspension plus IM placebo injection or IM ketorolac 10mg plus PO placebo suspension. The primary outcome was absolute reduction in pain score 1 hour after medication administration, as measured by visual analog scale (VAS). Secondary outcomes included rescue analgesia administration at 60minutes and adverse drug reactions. The author's enrolled 93 patients; 47 in the ibuprofen group and 46 in the ketorolac group. VAS score reduction from baseline to 1hour with ibuprofen or ketorolac was 35 vs 32, respectively (95% Confidence Interval: -8.03 to 15.03). Rescue analgesia administration at 60minutes was similar between both groups; adverse reactions were reported in the ketorolac group only as pain at injection site in two patients. In this prospective analysis, PO ibuprofen 400mg and IM ketorolac 10mg provide comparable pain relief for the treatment of acute, atraumatic, musculoskeletal back pain.

Objective To compare three therapeutic strategies in the management of acute post-traumatic pain at emergency department (ED) discharge. Methods We conducted a prospective, randomized, controlled trial including patients ≥18 years with acute post-traumatic pain. They were randomized to receive oral paracetamol (n = 506), paracetamol-codeine (P-Cod group; n = 489) and paracetamol-caffeine (P-Caf group; n = 505) for 7 days. The primary endpoint was the rate of participants achieving at least 50% reduction in Numerical Rating Scale (NRS) from baseline by the 7th day after ED discharge. Secondary endpoints included the need for rescue analgesics, adverse effects, and patient satisfaction. Results At day-7, success rate were 85.8%, 93.9%, and 90.1% in paracetamol, P-Cod, and P-Caf groups, respectively. The differences were statistically significant between the paracetamol and P-Caf groups (p = .02), the paracetamol and P-Cod groups ( p ≤ .001); and the P-Cod and P-Caf groups ( p = .04). The need for rescue analgesics was significantly higher in paracetamol group (47.6%) compared to P-Caf (7.5%) and P-Cod group (7.4%); whereas, no significant difference was found between P-Cod and P-Caf groups. Most of the adverse effects (95.7%) were observed in P-Cod group. Finally, patients treated with paracetamol alone were the least satisfied. Conclusion The combination of codeine or caffeine with paracetamol was equally effective and superior to paracetamol alone. If we consider the better tolerance, paracetamol combined with caffeine appears to be a suitable analgesic option for post trauma patients.

Single-injection superficial parasternal intercostal plane (SPIP) blockade provides an effective and low-risk analgesic option for patients undergoing cardiac surgery with sternotomy, but their duration is limited. We sought to evaluate whether continuous SPIP blockade, compared with single-injection SPIP blockade, reduces acute sternal pain on coughing at 24 hours after cardiac surgery. We conducted a randomized controlled parallel-arm superiority trial at a tertiary care center in Vancouver, BC, Canada. We included English-speaking adult patients undergoing scheduled cardiac surgery with full median sternotomy. We randomized participants in a 1:1 ratio to intervention or control groups, stratified by sex, using permuted block randomization with variable block sizes of 4 or 6. Patients in both study groups received bilateral SPIP catheters, with a 20 mL bolus of ropivacaine 0.2% through each catheter followed by a 3 mL/hour infusion of study solution (ropivacaine 0.2% in the intervention group and normal saline in the control group) for 48 hours. All patients received standardized multimodal analgesia. The primary outcome was the numeric rating scale (NRS) sternal pain score on standardized coughing at 24 hours. Secondary outcomes included sternal pain within 48 hours, opioid use, quality of recovery, postoperative nausea or vomiting and chronic sternal pain. Patients, healthcare providers, outcome collectors and data analysts were blinded to group allocation. Eighty patients were randomized (n=40 per group). Mean (SD) sternal pain (NRS) scores on coughing at 24 hours were 4.0 (2.2) in the intervention group versus 3.9 (2.2) in the control group. The adjusted mean difference was -0.2 (95% CI -1.7 to 1.3; p=0.79). There were no differences between the groups in secondary outcomes. One patient in the intervention group experienced suspected local anesthetic systemic toxicity requiring unblinding. No other major complications were noted. Continuous SPIP blockade did not demonstrate superiority over single-injection SPIP blockade in reducing acute sternal pain on coughing at 24 hours after cardiac surgery. NCT05054179.

Background The scaphoid is the most frequently fractured carpal bone, yet its diagnosis remains a significant clinical challenge. A substantial percentage of non-displaced fractures are missed on initial radiographs, leading to delays in treatment and an increased risk of serious long-term complications such as non-union and avascular necrosis. While advanced imaging like CT and MRI are highly accurate, they are associated with higher costs, radiation exposure (CT), and limited immediate availability. High-resolution musculoskeletal ultrasound has emerged as a rapid, non-invasive, and cost-effective alternative. Its unique ability to perform dynamic, real-time assessment of fracture stability offers a significant advantage over static imaging modalities. Case presentation A 29-year-old woman presented to our outpatient clinic with acute left wrist pain following a traction-fall injury. An initial four-view radiographic series of the wrist revealed no definitive evidence of a fracture. Despite the negative imaging, clinical suspicion remained high due to persistent, exquisite point tenderness over the anatomical snuffbox. A point-of-care musculoskeletal ultrasound examination was performed, which revealed a clear hypoechoic cortical breach at the scaphoid waist. To assess mechanical stability, a dynamic stress maneuver—defined as a gentle, controlled “heel-toe” probe rocking that applies focal pressure across the fracture—was performed under real-time sonographic visualization. Gentle probe pressure combined with passive ulnar deviation of the wrist demonstrated visible gapping and micromotion at the fracture site, confirming it as mechanically unstable. Based on this definitive finding, the diagnosis was revised to an unstable occult scaphoid waist fracture, and the management plan was immediately upgraded to a rigid thumb spica splint. Long-term follow-up over 2 years showed radiographic and sonographic evidence of a stable fibrous union. Conclusion This case report highlights the pivotal role of dynamic musculoskeletal ultrasound as an adjunct in the diagnostic algorithm for acute wrist trauma. It demonstrates its ability not only to identify a radiographically occult scaphoid fracture but, more critically, to provide immediate functional information about mechanical stability. This information is paramount for guiding appropriate and timely management to mitigate the risk of long-term complications. We advocate for the broader integration of dynamic ultrasound into the initial assessment of suspected scaphoid fractures.

Background/Objectives: This exploratory systematic review aims to analyze the influence of isolated muscle flexibility training on the reduction of chronic pain symptoms in older adults aged 65 years or more. Articles were selected from the Web of Science, PubMed, and Scopus databases, using the EndNote software for reference management. The selection process followed the PICOS framework and the PRISMA 2020 guidelines, and the review protocol was registered in the PROSPERO database. Methods: The inclusion criteria comprised randomized controlled trials with participants aged 65 or older, evaluating the effect of flexibility training as a standalone intervention on chronic pain, and published in English or Portuguese. Studies were excluded if they involved multimodal training, did not specify participants’ ages, evaluated only acute or postoperative pain, or were not peer-reviewed articles. Results: From an initial pool of 1390 articles, only three met all criteria and were included in the final analysis. These studies—conducted in China (n = 2) and the United States (n = 1)—showed moderate methodological quality (PEDro score = 7/10). Two trials applied Proprioceptive Neuromuscular Facilitation (PNF) in participants with knee osteoarthritis, while the third compared a flexibility-based program to combined strength and aerobic training in a healthy elderly population. All studies reported significant reductions in chronic pain symptoms following flexibility training interventions. Conclusions: The reviewed evidence suggests that muscle flexibility training, particularly using techniques like PNF, may be a promising therapeutic strategy to mitigate specific chronic pain-related symptoms in older adults, particularly reductions in joint stiffness, movement discomfort, and pain intensity associated with osteoarthritis. However, the limited number of high-quality trials and heterogeneity in protocols and pain assessment tools highlight the need for further research.

In the age of the opioid epidemic and a widespread desire to reduce opioid prescriptions, both in outpatient practices and hospitals, we have welcomed non-opioid medications as one possible strategy to reduce the reliance on opioids for the treatment of pain. For anesthesiologists, surgeons, and other perioperative physicians, minimizing exposure to opioids in the perioperative period has been a focal point for several decades now and countless protocols have been described, adopted, and studied. Gabapentin and pregabalin, known collectively as gabapentinoids, have been included in many of these protocols and it is not difficult to see why. They have predictable pharmacokinetics, are one of the only medication classes to treat neuropathic pain, and have sizeable literature support for their ability to reduce pain and opioid consumption. Their use for acute perioperative pain remains off-label. As with many drugs, we have learned more over time and now have a fuller picture of the benefits and risks associated with gabapentinoids. In particular, the central nervous system adverse effects, including dizziness and sedation, are now well established and can be especially problematic in the elderly. Synergistic respiratory depression when combined with opioids and even possible cognitive deficits from prolonged use have been described, forcing some perioperative physicians to rethink their inclusion in enhanced recovery and other perioperative protocols. In this pro-con discussion, we debate the merits of perioperative gabapentinoids in 2025, relying on published evidence for our positions, and ultimately call for a nuanced approach that considers the individual patient before us.

Complete coronary artery occlusion causes acute coronary syndrome, which includes ST-segment elevation myocardial infarction (STEMI). Rapid reperfusion therapy greatly reduces mortality. Initial treatment with acetylsalicylic acid and a P2Y12 inhibitor, dual antiplatelet therapy (DAPT), prevents thrombosis by inhibiting platelet aggregation. A 50 years old woman had diaphoresis, vomiting, and acute chest pain radiating to her left arm. Sinus rhythm with ST-segment elevation in leads V2–V6, I, and aVL indicated anterior widespread STEMI on her ECG. Nasal oxygen, 320 mg aspirin, 180 mg ticagrelor, and sublingual isosorbide dinitrate were administered quickly. The patient declined fibrinolytic treatment and requested primary PCI at a tertiary hospital. She was surprised that her symptoms improved after a short monitoring period. ST-segment elevation dropped significantly on a repeat ECG, indicating reperfusion. Patient's vital signs stabilized and he was diagnosed with total reperfusion post-DAPT before transfer. Early administration of DAPT can lead to effective reperfusion in anterior STEMI, even prior to mechanical intervention. This case highlights the potential of DAPT as a vital initial strategy in the management of early-onset STEMI, especially when timely PCI access is limited.