Greater Reduction In Pain Scores Research Articles

Assessing the effects of prehabilitation protocols on post-operative outcomes in adult cervical deformity surgery: does early optimization lead to optimal clinical outcomes?

To investigate the effect of a prehabilitation program on peri- and post-operative outcomes in adult cervical deformity (CD) surgery. Operative CD patients ≥ 18years with complete baseline (BL) and 2-year (2Y) data were stratified by enrollment in a prehabilitation program beginning in 2019. Patients were stratified as having undergone prehabilitation (Prehab+) or not (Prehab-). Differences in pre and post-op factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales. 115 patients were included (age: 61years, 70% female, BMI: 28kg/m2). Of these patients, 57 (49%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI, and frailty. Surgically, Prehab+ were able to undergo longer procedures (p = 0.017) with equivalent EBL (p = 0.627), and shorter SICU stay (p < 0.001). Post-operatively, Prehab+ patients reported greater reduction in pain scores and greater improvement in quality of life metrics at both 1Y and 2Y than Prehab- patients (all p < 0.05). Prehab+ patients reported significantly less complications overall, as well as less need for reoperation (all p < 0.05). Introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling patients to undergo longer surgeries with lessened risk of peri- and post-operative complications.

P100 The Impact of Intensive Management on Pain Intensity in Patients with Rheumatoid Arthritis and Psoriatic Arthritis: Secondary Analysis of Three Clinical Trials

Abstract Background/Aims Pain remains a common, life-changing symptom for patients with rheumatoid (RA) and psoriatic arthritis (PsA). Its current care focuses on prescribing analgesics, particularly opioids, despite minimal supportive trial evidence and potential associated harms. Intensive management with disease-modifying anti-rheumatic drugs (DMARDs) reduces disease activity and improves function in RA and PsA. Its impacts on pain are less well established. We examined the impact of varying intensities of DMARD treatment on pain in patients with RA/PsA in a secondary analysis of three trials. Methods The trials comprised MIPA in PsA (methotrexate vs. placebo), CARDERA in early RA (triple therapy vs. monotherapy), and TITRATE in established RA (monthly assessments with DMARD uptitration and psychosocial support vs. standard care). All measured 100mm pain intensity visual analogue scores. Regression models evaluated the relationship between active vs. control treatment and: (a) achieving “low” endpoint pain scores of ≤ 34, (b) changes in pain scores between baseline and endpoint, (c) achieving ≥30% reductions in pain scores between baseline and endpoint. Results We evaluated 765 patients (from 1,023 [75%]) with endpoint pain intensity scores available. In all trials more patients achieved low endpoint pain scores (≤34) with active than control treatment (MIPA 70% vs. 42%, P=0.003; CARDERA 71% vs. 56%, P=0.011; TITRATE 67% vs. 50%; P=0.008). Multivariable models showed the associations remained significant after treatment effects were adjusted for age, sex, and baseline pain: odds ratios (ORs) 2.8 (P=0.012), 1.9 (P=0.019) and 2.1 (P=0.006) in MIPA, CARDERA, and TITRATE. The trials differed in the impact of intensive treatment on changes in pain scores. In MIPA mean changes in pain intensity scores over the trial period were similar with active and control treatment. In CARDERA (P=0.019) and TITRATE (P=0.004) mean changes in pain scores were significantly greater with active than control treatment in multivariable models (estimated differences of 6.8 and 9.4 units). The trials also differed in the impact of treatment on the proportion of patients having large reductions in pain scores (≥30). In MIPA proportionally more patients achieved this with active vs. control treatment but this was not statistically significant. In CARDERA (P=0.009) and TITRATE (P=0.002) a significantly greater proportion of patients achieved large reductions in pain scores in multivariable models with active treatment (ORs 1.9 and 2.2). Conclusion In our secondary analysis all forms of intensive management provided beneficial effects on pain in active RA and PsA. More patients achieved “low” endpoint pain scores with active treatment in all trials. In the two trials employing the most intensive management strategies (CARDERA/TITRATE) significantly greater reductions in pain scores and a greater proportion achieving substantial pain improvements with active treatment were seen. Our results support the use of intensive management to improve pain in patients with active RA/PsA. Disclosure I.C. Scott: None. D.L. Scott: None. F. Ibrahim: None.

Effectiveness of precooling with ethyl chloride versus honey in alleviating intra-oral injection pain in adult patients: A randomized controlled trial

The objective of the study was to assess and compare the effectiveness of precooling with ethyl chloride versus honey in alleviating the pain of dental injection. About 90 patients were recruited for this randomized controlled trial. In each of the following three groups, 30 patients were allocated: Group 1, precooling with ethyl chloride; Group 2, honey; and Group 3, control. The pain score of patients in each group was measured after injecting the dental local anesthesia using a visual analog scale. Paired t-test and multiple linear regression tests were used for statistical analysis. A p value of ⩽0.05 was considered to be as significant. The mean pain scores of participants residing in different groups were as follows: Group 1: 2.83 ± 1.46, Group 2: 4.33 ± 1.62, and Group 3: 7.80. After administrating ethyl chloride, the majority of the 18 (60%) patients reported to suffer from "mild pain." Furthermore, in patients who were given honey in Group 2, most of the 21 (70%) patients reported suffering from "moderate pain." In Group 3 (control) where no anesthetic modality was used, the majority of the 25 (83.33%) patients experienced "severe pain." A significant difference was noted among the pain scores of three groups (p = 0.001). The administration of local anesthetic is part of almost all dental procedures. Precooling with ethyl chloride resulted in a greater reduction in pain scores than honey upon administration of local anesthesia injection.

Comparative Efficacy of Analgesics for Pain Relief in Patients with Symptomatic Irreversible Pulpitis Prior to Emergency Endodontic Treatment: A Randomized Controlled Trial.

This study aimed to compare the efficacy of ibuprofen, Novafen, mefenamic acid (MA), and celecoxib for pain relief in patients with symptomatic irreversible pulpitis prior to emergency endodontic treatment. This clinical trial was conducted on 120 patients with moderate to severe pain due to symptomatic irreversible pulpitis seeking emergency endodontic treatment. The patients were randomly divided into 4 groups to receive Novafen, MA, Celecoxib, and ibuprofen. The pain score of patients was measured before and 1 hour after analgesic intake using a visual analog scale (VAS). The success of analgesic treatment was analyzed by the binary logistic regression model. A total of 117 patients including 76 females and 41 males with a mean age of 30.29 years completed the study and were statistically analyzed. Ibuprofen had the highest analgesic efficacy followed by Novafen, and caused a significantly greater reduction in pain score compared with MA and celecoxib [OR (Ibuprofen vs MA)=1.28, OR (Ibuprofen vs Celecoxib)=3.74, OR (Novafen vs MA)=2.94, OR (Novafen vs Celecoxib)=2.94, P<0.05]. Ibuprofen and Novafen had no significant difference in analgesic efficacy (P>0.05). Baseline pain score was a predictive factor for the success of analgesics (P<0.05). The success of analgesic treatment decreased by 0.68 times with each unit increase in pain score (P<0.05). Gender and age of patients had no significant effect on success of analgesics (P>0.05). Both ibuprofen and Novafen can serve as the analgesics of choice for pain relief in patients with symptomatic irreversible pulpitis with moderate to severe pain when emergency endodontic treatment cannot be immediately performed.

811: EVALUATION OF SUBDISSOCIATIVE-DOSE KETAMINE FOR PROCEDURAL SEDATION IN THE EMERGENCY DEPARTMENT

Introduction: Recent literature has shown efficacy of sub-dissociative dose ketamine (< 0.5 mg/kg) for acute pain management while also minimizing its adverse event profile; however, the advantages and disadvantages of sub-dissociative dose ketamine for indications other than analgesia is unknown. This study evaluated the safety and efficacy of sub-dissociative dose ketamine (SDK, < 0.5 mg/kg) compared to dissociative dose ketamine (DK, ≥0.5 mg/kg) for procedural sedation and analgesia (PSA) in the emergency department (ED). Methods: This was a two-center, retrospective, case-matched cohort study of adult patients admitted to the ED between 2016-2021 who received intravenous push ketamine for PSA. Patients were stratified into two cohorts based on ketamine dose and case-matched 1:1 based on age, mean arterial pressure, and procedure type. The primary outcome was the comparative differences in adjunctive analgosedative requirements at 2 hours. Secondary outcomes included the change in numeric rating scale pain scores before versus after ketamine, PSA success rates, incidence of adverse events, and risk factor determination for PSA failure. Results: Sixty-two patients per group were case-matched and included. Demographics were similar between groups. Median ketamine PSA dose was lower in the SDK group (0.3 [IQR 0.27-0.3 mg/kg] vs 1.1 [IQR 0.98-1.5 mg/kg], p< 0.001). Greater reductions in pain scores were seen in the DK group (-3 [IQR -6 to 0] vs -5.5 [IQR -8 to -1], p=0.03), with similar median morphine milligram equivalent requirements (SDK, 0 [IQR 0-8 mg] vs DK, 0 [IQR 0-0 mg], p=0.17). However, patients receiving SDK required less median lorazepam milligram equivalents (0 [IQR 0-0 mg] vs 0 [IQR 0-0.5 mg], p< 0.001). PSA success rates were similar between groups, with decreased adverse events in the SDK group (28 [45.2%] vs 57 [91.9%], p< 0.001). Comorbidities of hypertension and diabetes, and procedures performed by the orthopedic surgery team were identified as independent risk factors for PSA failure. Conclusions: Sub-dissociative dose ketamine administration for PSA in the ED provided comparable procedural sedation and analgesia success at lower doses compared to dissociative dose ketamine along with a significant reduction in adverse events.

Multicenter, Double-Blinded, Randomized, Active-Sham Controlled Clinical Study Design to Assess the Safety and Effectiveness of a Novel High Frequency Electric Nerve Block System in the Treatment of Post-Amputation Pain (The QUEST Study).

BackgroundChronic pain that follows amputation of a limb is reported as “one of the most severe pains in the human experience,” due to the magnitude of tissue injury and the multiple potential of pain generators at the local peripheral, spinal, and cortical levels. The Altius® System was developed to deliver high-frequency nerve block (HFNB) therapy via a cuff electrode applied to the peripheral nerve(s) and an implantable pulse generator. We report a novel clinical trial design for the first study of an active-implantable medical device in subjects with lower-limb post-amputation pain utilizing a multicenter, double-blinded, randomized, active-sham controlled clinical study protocol called QUEST, which is an ongoing investigational device exemption study to support United States Food and Drug Administration approval.MethodsThe study enrollment of 180 subjects was completed in September 2021. Subjects were randomized 1:1 to the treatment group or the active-sham control group for the 3-month primary effectiveness and safety endpoints. After month 3, the active-sham control program group crossed over to the treatment program group and all subjects continued to the 12-month study endpoint. Study effectiveness success is determined by a superiority test between responder rates in the treatment and control groups at 3 months. A responder is defined as someone who experiences a 50% or greater reduction in pain scores – after a 30-minute treatment session – for more than 50% of all pain episodes in which the treatment was used.DiscussionThe QUEST study design employs an active-sham control group to objectively assess the effectiveness of HFNB therapy. Additionally, the electronic diary repeated measures data collection in QUEST is expected to reduce the intra-subject variation typically observed in pain treatment studies. Finally, the longitudinal measurement of health-related quality of life and use of pain medication may, for example, show effectiveness in reducing opioid use over time.

Virtual reality for pain management in advanced heart failure: A randomized controlled study

Background: Hospitalized patients with advanced heart failure often experience acute and/or chronic pain. While virtual reality has been extensively studied across a wide range of clinical settings, no studies have yet evaluated potential impact on pain management on this patient population. Aim: To investigate the impact of a virtual reality experience on self-reported pain, quality-of-life, general distress, and satisfaction compared to a two-dimensional guided imagery active control. Design: Single-center prospective randomized controlled study. The primary outcome was the difference in pre- versus post-intervention self-reported pain scores on a numerical rating scale from 0 to 10. Secondary outcomes included changes in quality-of-life scores, general distress, and satisfaction with the intervention. Setting/participants: Between October 2018 and March 2020, 88 participants hospitalized with advanced heart failure were recruited from an urban tertiary academic medical center. Results: Participants experienced significant improvement in pain score after either 10 minutes of virtual reality (change from pre- to post −2.9 ± 2.6, p < 0.0001) or 10 minutes of guided imagery (change from pre- to post −1.3 ± 1.8, p = 0.0001); the virtual reality arm experienced a 1.5 unit comparatively greater reduction in pain score compared to guided imagery (p = 0.0011). Total quality-of-life and general distress scores did not significantly change for either arm. Seventy-eight participants (89%) responded that they would be willing to use the assigned intervention again. Conclusion: Virtual reality may be an effective nonpharmacologic adjuvant pain management intervention in hospitalized patients with heart failure. Trial Registration: ClinicalTrials.gov database (NCT04572425).

Effect of photobiomodulation therapy on painful temporomandibular disorders

To evaluate the effect of photobiomodulation therapy (PBMT) on painful temporomandibular disorders (TMD) patients in a randomized, double-blinded, placebo-controlled manner. Participants were divided into a masseter myalgia group (n = 88) and a temporomandibular joint (TMJ) arthralgia group (n = 87) according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Both groups randomly received PBMT or placebo treatment once a day for 7 consecutive days, one session. The PBMT was applied with a gallium-aluminum-arsenide (GaAlAs) laser (wavelength = 810 nm) at pre-determined points in the masseter muscle (6 J/cm2, 3 regions, 60 s) or TMJ region (6 J/cm2, 5 points, 30 s) according to their most painful site. Pain intensity was rated on a 0–10 numerical rating scale (NRS) and pressure pain thresholds (PPT) and mechanical sensitivity mapping were recorded before and after the treatment on day 1 and day 7. Jaw function was assessed by pain free jaw opening, maximum unassisted jaw opening, maximum assisted jaw opening, maximum protrusion and right and left excursion. Data were analyzed with a mixed model analysis of variance (ANOVA). Pain intensity in arthralgia patients decreased over time (P < 0.001) for both types of interventions, however, PBMT caused greater reduction in pain scores than placebo (P = 0.014). For myalgia patients, pain intensity decreased over time (P < 0.001) but without difference between interventions (P = 0.074). PPTs increased in both myalgia (P < 0.001) and TMJ arthralgia patients over time (P < 0.001) but without difference between interventions (P ≥ 0.614). Overall, PBMT was associated with marginally better improvements in range of motion compared to placebo in both myalgia and arthralgia patients. Pain intensity, sensory function and jaw movements improve after both PBMT and placebo treatments in myalgia and arthralgia patients indicating a substantial non-specific effect of PBMT.

Trans-nasal high-flow dehumidified air in acute migraine headaches: A randomized controlled trial.

Intranasal high flow of dehumidified (dry) air results in evaporative cooling of nasal passages. In this randomized clinical trial, we investigated the effect of dry gas induced nasal cooling on migraine headaches. In this single-blind study, acute migraineurs were randomized to either nasal high-flow dry oxygen, dry air, humidified oxygen or humidified air (control) at 15 L/min for 15 min. All gases were delivered at 37°C. Severity of headache and other migraine associated symptoms (International Classification for Headache Disorders, 3rd edition criteria) were recorded before and after therapy. The primary endpoint was change in pain scores, while changes in nausea, photosensitivity and sound sensitivity scores served as secondary endpoints. A linear regression model was employed to estimate the impact of individual treatment components and their individual interactions. Fifty-one patients (48 ± 15 years of age, 82% women) were enrolled. When compared to the control arm (humidified air), all therapeutic arms showed a significantly greater reduction in pain scores (primary endpoint) at 2 h of therapy with dry oxygen (-1.6 [95% CI -2.3, -0.9]), dry air (-1.7 [95% CI -2.6, -0.7)]), and humidified oxygen (-2.3 [95% CI -3.5, -1.1]). A significantly greater reduction in 2-h photosensitivity scores was also noted in all therapeutic arms (-1.8 [95% CI -3.2, -0.4], dry oxygen; -1.7 [95% CI -2.9, -0.4], dry air; (-2.1 [95% CI -3.6, -0.6], humidified oxygen) as compared to controls. The presence of oxygen and dryness were independently associated with significant reductions in pain and photosensitivity scores. No adverse events were reported. Trans-nasal high-flow dry gas therapy may have a role in reducing migraine associated pain.Clinical Trial registration: NCT04129567.

Comparing Nonopioids Versus Opioids for Acute Pain in the Emergency Department: A Literature Review.

Pain is the most common reason for patient visits in the emergency department (ED). Opioids have been long considered the standard of care for acute pain in the ED. Because of the opioid crisis, investigation and implementation of novel practices to manage pain is needed. The use of various nonopioids has been suggested as a plausible alternative to opioids, with emerging literature to support its use for acute pain in the ED. To evaluate the safety, efficacy, opioid-sparing effects of nonopioids in patients who present with acute pain in the ED. We systematically searched PubMed and EMBASE (July 1970 to January 2019). Randomized controlled trials that evaluated nonopioids versus opioids in the ED were eligible. The clinical outcomes measured were change in pain scores compared with baseline, the incidence of adverse events, and use of rescue analgesia. Twenty-five randomized controlled trials that evaluated the use of nonopioids in 2323 patients [acetaminophen (APAP) (n = 651), diclofenac (n = 547), ketamine (n = 272), ketorolac (n = 225), lidocaine (n = 219), ibuprofen (n = 162), ibuprofen & APAP (n = 162), hydroxyzine & dihydroergotamine (n = 85)] met inclusion criteria. Four trials found significant greater reductions in pain scores, favoring nonopioids. In all trials, the duration of pain relief provided by nonopioids was not sustained over an extended period. Eighteen trials reported no significant differences in reduction of pain scores. Two trials reported improved pain reduction with opioids and one trial reported noninferiority. Evidence from primary literature suggests that nonopioids could be a feasible alternative to opioids for management of acute pain in the ED as it is effective, safe, and decreases the need for rescue analgesia.

Ketamine Infusions for Chronic Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

IV ketamine is widely used to treat patients with chronic pain, yet the long-term impact remains uncertain. We synthesized evidence from randomized control trials to investigate the effectiveness of IV ketamine infusions for pain relief in chronic conditions and to determine whether any pain classifications or treatment regimens are associated with greater benefit. We searched Medline, Embase, and Google Scholar, as well as the clinicaltrials.gov website from inception through December 16, 2017 for randomized control trials comparing IV ketamine to placebo infusions for chronic pain that reported outcomes for ≥48 hours after the intervention. Three authors independently screened the studies, pooled the data, and appraised risk of bias. Random-effects model was used to calculate weighted mean differences for pain scores and secondary outcomes. Our primary outcome was the lowest recorded pain score ≥48 hours after cessation of treatment. Secondary outcomes included responder rate and adverse effects. Among 696 studies assessed for eligibility, 7 met inclusion criteria. All studies except one were at high risk of bias. These studies randomly assigned 211 patients with neuropathic (n = 2), mixed (n = 2), and nonneuropathic (nociplastic or nociceptive) (n = 3) pain. Three studies reported significant analgesic benefit favoring ketamine, with the meta-analysis revealing a small effect up to 2 weeks after the infusion (mean difference in pain scores, -1.83 points on a 0-10 numerical rating scale; 95% CI, -2.35 to -1.31 points; P < .0001). In the 3 studies that reported responder rates, the proportion with a positive outcome was greater in the ketamine than in the placebo group (51.3% vs 19.4%; relative risk, 2.43; 95% CI, 1.10-5.40; P = .029; I = 0.0%). No differences were noted based on pain classification or condition. Compared to low-dose ketamine studies and investigations that evaluated non-complex regional pain syndrome conditions, a small but nonsignificant greater reduction in pain scores was found among studies that either utilized high-dose ketamine therapy (P = .213) or enrolled complex regional pain syndrome patients (P = .079). Evidence suggests that IV ketamine provides significant short-term analgesic benefit in patients with refractory chronic pain, with some evidence of a dose-response relationship. Larger, multicenter studies with longer follow-ups are needed to better select patients and determine the optimal treatment protocol.

Hormone treatment as first line therapy is safe and relieves pelvic pain in women with bowel endometriosis.

ABSTRACTObjective:To evaluate clinical features and complications in patients with bowel endometriosis submitted to hormonal therapy.Methods:Retrospective study based on data extracted from medical records of 238 women with recto-sigmoid endometriosis treated between May 2010 and May 2016.Results:Over the course of follow-up, 143 (60.1%) women remained in medical treatment while 95 (39.9%) presented with worsening of pain symptoms or intestinal lesion growth (failure of medical treatment group), with surgical resection performed in 54 cases. Women in the Medical Treatment Group were older (40.5±5.1 years versus 37.3±5.8 years; p<0.0001) and had smaller recto sigmoid lesions (2.1±1.9 versus 3.1±2.2; p=0.008) compared to those who had failed to respond to medical treatment. Similar significant reduction in pain scores for dysmenorrhea, chronic pelvic pain, cyclic dyschezia and dysuria was observed in both groups; however greater reduction in pain scores for dyspareunia was noted in the Surgical Group. Subjective improvement in pain symptoms was also similar between groups (100% versus 98.2%; p=0.18). Major complications rates were higher in the Surgical Group (9.2% versus 0.6%; p=0.001).Conclusion:Patients with recto-sigmoid endometriosis who failed to respond to medical treatment were younger and had larger intestinal lesions. Hormonal therapy was equally efficient in improving pain symptoms other than dyspareunia compared to surgery, and was associated with lower complication rates in women with recto-sigmoid endometriosis. Medical treatment should be offered as a first-line therapy for patients with bowel endometriosis. Surgical treatment should be reserved for patients with pain symptoms unresponsive to hormonal therapy, lesion growth or suspected intestinal subocclusion.

Lornoxicam with Low-Dose Ketamine versus Pethidine to Control Pain of Acute Renal Colic.

Objectives This study was established to compare single-dose lornoxicam 8 mg (NSAID) in addition to 0.15 mg.kg−1 ketamine with single-dose pethidine 50 mg, both administered intravenously (IV), on the quickness and extent of analgesia, disadvantage, and consequence on utilitarian situation. Patients and Methods One hundred and twenty patients with acute renal colic pain received in emergency room were included in this prospective, randomized, and double blind clinical study. They were aimlessly designated into one of two groups using a computer-generated table. Group L received lornoxicam 8 mg IV plus 0.15 mg.kg−1 ketamine and Group P received pethidine 50 mg IV. Parameters were noticed at baseline and after 0, 15, 30, and 45 minutes and 1 hour after drug administration. The efficiency of the drug was determined by observing: patient rated pain, time to pain relief, rate of pain recurrence, the need for rescue analgesia, adverse events, and functional status. Results The visual analogue scale was significantly lower in Group L after 30 minutes in comparison to Group P. In addition, there was statistically significant increase in Group P regarding their need for rescue analgesia after 30 min in comparison to Group L. Group P showed nonsignificantly increased sedation score compared to Group L. Conclusion Patients receiving lornoxicam-ketamine attained greater reduction in pain scores and less side effects with better functional state and also are less likely to require further analgesia than those administered pethidine to control acute renal colic pain.

Chemical coping and efficacy of buprenorphine for cancer pain.

200 Background: The management of cancer-related pain is challenging in the age of the opioid epidemic. Patients who struggle with substance misuse or chemical coping use these substances to dull emotional and or existential suffering. Buprenorphine is often used for cancer pain due to less reported euphoria when compared to other opioids. Methods: We conducted a retrospective review of patients in an outpatient palliative care clinic at a tertiary comprehensive cancer center who were prescribed buprenorphine for cancer pain. Total oral morphine equivalent (OME), as well as use of adjuvant non-opioid neuropathic pain medication, were assessed prior to transition to buprenorphine. Chemical coping behavior was defined as patients taking opioids for emotional pain in excess of the maximum prescribed amount. Pain scores were reported before and after buprenorphine administration using a Likert pain scale (0-10). Patients were also assessed for the presence of withdrawal symptoms after transition to buprenorphine. Results: Patients were predominantly female (75%), slightly more than half had a psychiatric diagnosis (56%), a majority were on non-opioid neuropathic pain medication (93%), and the majority were identified as chemical copers (75%). For all patients, the mean pain score prior to buprenorphine (pain pre) was 8.3 and the mean pain score on follow up post buprenorphine (pain post) was 6.1, with a reduction in mean pain score (pain change) of -2.0 (p = 0.059). Patients without chemical coping behaviors reported a significantly greater reduction in pain scores compared to patients with chemical coping (pain change -5.0 vs -1.3, p = 0.02). Illicit drug use and psychiatric co-morbidity were not associated with differences in reported pain scores. Only a small number of patients reported withdrawal symptoms (6%) during buprenorphine transition. Conclusions: Rotation to buprenorphine led to a trend of reduction in pain score, though not statistically significant. Patients without chemical coping experienced greater reductions in pain score than those with chemical coping behavior. Illicit drug use and psychiatric co-morbidity were not associated with differences in reported pain.

Can Epidural Contrast Dispersal Pattern Help to Predict the Outcome of Transforaminal Epidural Steroid Injections in Patients with Lumbar Radicular Pain

To investigate the relationship between epidurographic contrast dispersal patterns and both immediate and short-term clinical effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) in patients with radicular back pain. A digital database of 64 patients who underwent single-level lumbar TFESI for unilateral lumbar radicular pain was scanned. The type of contrast pattern was analyzed by 1 physiatrist and defined as follows: type 1 (tubular appearance), type 2 (nerve root visible as a filling defect), or type 3 (cloud-like appearance). Pain was evaluated with a visual analog scale (VAS) and recorded before injection and 2 days, 2 weeks, and 3 months after injection. The mean age was 45.9 ± 13.5 years (range, 22-80 years), and the mean duration of symptoms was 5.7 ± 4.2 months. Contrast distribution patterns were as follows: type 1 in 33 patients (51.6%), type 2 in 18 patients (28.1%), and type 3 in 13 patients (20.3%). Mean decrease in VAS scores at all time points was statistically significant in 3 types of contrast dispersal patterns (P < 0.05). Differences in improvements of VAS scores obtained at any assessment period and success rates were not statistically significant between groups. However, the ratio of patients who achieved 50% or greater reduction in pain scores was higher in type 1 and type 2 than type 3 at each follow-up point. TFSEIs have a beneficial effect in managing lumbar radicular pain regardless of contrast pattern type. Success rates were higher in type 1 and type 2 than type3.

Efficacy of Bacillus coagulans Unique IS2 in treatment of irritable bowel syndrome in children: a double blind, randomised placebo controlled study.

The efficacy of the probiotic strain, Bacillus coagulans Unique IS2 in the treatment of Irritable Bowel Syndrome (IBS) was evaluated in children. A total of 141 children of either sex in the age group 4-12 years, diagnosed with IBS according to the Rome III criteria, participated in the double-blind randomised controlled trial. Children received either B. coagulans Unique IS2 chewable tablets or placebo once daily for eight weeks followed by a two week follow-up period. Reduction in pain intensity as well as other symptoms associated with Irritable Bowel Syndrome like abdominal discomfort, bloating, distension, sense of incomplete evacuation, straining at stool, urgency of bowel movement, passage of gas and mucus, and bowel habit satisfaction were assessed. B. coagulans Unique IS2 treated group showed a greater reduction in pain scores as evaluated by a weekly pain intensity scale. There was a significant reduction (P<0.0001) in pain intensity in the probiotic treated group (7.6±0.98) as compared to the placebo group (4.2±1.41) by the end of the treatment period (8 weeks). There was also a significant improvement in stool consistency as well as reduction in abdominal discomfort, bloating, staining, urgency, incomplete evacuation and passage of gas. Bowel habit satisfaction and global assessment of relief was also observed in the B. coagulans Unique IS2 treated group as compared to the placebo group. This study demonstrates the efficacy of B. coagulans Unique IS2 in reducing the symptoms of Irritable Bowel Syndrome in children in the age group of 4-12 years.

Subanesthetic ketamine for pain management in hospitalized children, adolescents, and young adults: a single-center cohort study.

BackgroundSubanesthetic doses of ketamine, an N-methyl-d-aspartate receptor antagonist used as an adjuvant to opioid for the treatment of pain in adults with acute and chronic pain, have been shown, in some instances, to improve pain intensity and to decrease opioid intake. However, less is known about the role of ketamine in pain management in children, adolescents, and young adults.PurposeWe examined the effects of subanesthetic ketamine on pain intensity and opioid intake in children, adolescents, and young adults with acute and chronic pain syndromes treated in an inpatient setting.MethodsThis is a longitudinal cohort study of patients treated with subanesthetic ketamine infusions in regular patient care units in a tertiary pediatric hospital. Primary outcomes included changes in pain scores and morphine-equivalent intake.ResultsThe study cohort included 230 different patients who during 360 separate hospital admissions received subanesthetic ketamine infusions for pain management. Overall, ketamine infusions were associated with significant reductions in mean pain scores from baseline (mean pain scores 6.64 [95% CI: 6.38–6.90]) to those recorded on the day after discontinuation of ketamine (mean pain scores 4.38 [95% CI: 4.06–4.69]), p<0.001. Importantly, the effect of ketamine on pain scores varied according to clinical diagnosis (p=0.011), infusion duration (p=0.004), and pain location (p=0.004). Interestingly, greater reductions in pain scores were observed in patients with cancer pain and patients with pain associated with pancreatitis and Crohn’s disease. There were no records of psychotomimetic side effects requiring therapy.ConclusionThese data suggest that administration of subanesthetic ketamine for pain management is feasible and safe in regular inpatient care units and may benefit children, adolescents, and young adults with acute and chronic pain. This study is informative and can be helpful in determining sample and effect sizes when planning clinical trials to determine the role of subanesthetic ketamine infusions for pain management in pediatric patients.

AUDIT OF PAEDIATRIC SICKLE PAIN MANAGEMENT AND CODEINE USE IN CHILDREN

Aim To evaluate incidences and management of acute paediatric sickle cell pain, and outcomes of safety and efficacy of codeine in patients at North Middlesex University Hospital (NMUH). Method A retrospective audit was performed on all admissions with diagnosis of sickle cell pain from January to December 2013. Case notes of 54 patients were reviewed using pre-specified audit criteria in a data collection tool. Types of analgesics administered at home and in the accident and emergency (A&E) department and pain scores were recorded where available from the case notes. Particular attention was paid to the use of codeine and outcomes of efficacy and safety. Results Over the one-year period, 91 admissions were recorded. The average age of the population was 6.6 years (±4.1), with the majority (45%) of the population aged between 1 and 5 years. The most prevalent haemoglobinopathy was HbSS (82%), followed by HbSC (13%) and β-thalassemia (4%). The majority of patients (61%) had a single painful crisis admission, 33% had 2–3 admissions, and the remainder presented with four or more admissions in the year. The audit revealed that most patients (93%) received one or more analgesics prior to admission, although the drug of choice varied, with paracetamol and ibuprofen been the most frequently utilised combination (43%) and 22% received opioids (20% had codeine). Similar to the pre-admission trends, a wide range of analgesics were utilized at the Trust, with the majority of patients receiving paracetamol and ibuprofen combination. However, the doses utilized at home were significantly less than those given on admission, suggesting inadequate pain management at home. Codeine was given in 37% of the cases after admission and it was observed that patients who received codeine had significantly higher initial pain scores on admission compared with those who did not receive codeine. There were also greater reductions in pain scores recorded post analgesia although accurate inferential statistics could not be carried out due to incomplete documentation of pre and post medication pain scores. In addition, the audit revealed compliance with guidelines was poor, particularly as documentations were mostly incomplete/not done. Although up to 82% documented fluid balance, only 7.7% recorded pain scores appropriately on the assessment scale, while 36.3% and 28.6% utilised the first hour sheet and fast track forms respectively (local assessment documentation sheets). Similarly, the time of assessment, analgesia and reassessment were recorded in 29%, 36% and 5.5% of cases respectively. Conclusion The current audit revealed that only 2% of the admissions for sickle cell pain crisis at the Trust in 2013 met all criteria specified in the local and national guidelines for management of the condition. This was mostly attributed to poor documentation of assessments. In addition, clear analgesic benefits could not be demonstrated for codeine use with regards to the outcome of efficacy. According to the main outcome of the audit, efforts need to focus on increasing awareness of the objectives of utilisation of Trust documentation sheets to facilitate prompt and appropriate management.

Intranasal fentanyl for the management of acute pain in children.

Pain is the most common symptom in the emergency setting; however, timely management of acute pain in children continues to be suboptimal. Intranasal drug delivery has emerged as an alternative method of achieving quicker drug delivery without adding to the distress of a child by inserting an intravenous cannula. We identified and evaluated all randomized controlled trials (RCTs) and quasi-randomized trials to assess the effects of intranasal fentanyl (INF) versus alternative analgesic interventions in children with acute pain, with respect to reduction in pain score, occurrence of adverse events, patient tolerability, use of "rescue analgesia," patient/parental satisfaction and patient mortality. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 1); MEDLINE (Ovid SP, from 1995 to January 2014); EMBASE (Ovid SP, from 1995 to January 2014); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host, from 1995 to January 2014); the Latin American and Caribbean Health Science Information Database (LILACS) (BIREME, from 1995 to January 2014); Commonwealth Agricultural Bureaux (CAB) Abstracts (from 1995 to January 2014); the Institute for Scientific Information (ISI) Web of Science (from 1995 to January 2014); BIOSIS Previews (from 1995 to January 2014); the China National Knowledge Infrastructure (CNKI) (from 1995 to January 2014); International Standard Randomized Controlled Trial Number (ISRCTN) (from 1995 to January 2014); ClinicalTrials.gov (from 1995 to January 2014); and the International Clinical Trials Registry Platform (ICTRP) (to January 2014). We included RCTs comparing INF versus any other pharmacological/non-pharmacological intervention for the treatment of children in acute pain (aged < 18 years). Two independent review authors assessed each title and abstract for relevance. Full copies of all studies that met the inclusion criteria were retrieved for further assessment. Mean difference (MD), odds ratio (OR) and 95% confidence interval (CI) were used to measure effect sizes. Two review authors independently assessed and rated the methodological quality of each trial using the tool of The Cochrane Collaboration to assess risk of bias, as per Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions. Three studies (313 participants) met the inclusion criteria. One study compared INF versus intramuscular morphine (IMM); another study compared INF versus intravenous morphine (IVM); and another study compared standard concentration INF (SINF) versus high concentration INF (HINF). All three studies reported a reduction in pain score following INF administration. INF produced a greater reduction in pain score at 10 minutes post administration when compared with IMM (INF group pain score: 1/5 vs IMM group pain score: 2/5; P value 0.014). No other statistically significant differences in pain scores were reported at any other time point. When INF was compared with IVM and HINF, no statistically significant differences in pain scores were noted between treatment arms, before analgesia or at 5, 10, 20 and 30 minutes post analgesia. Specifically, when INF was compared with IVM, both agents were seen to produce a statistically significant reduction in pain score up to 20 minutes post analgesia. No further reduction in pain score was noted after this time. When SINF was compared with HINF, a statistically and clinically significant reduction in pain scores over study time was observed (median decrease for both groups 40 mm, P value 0.000). No adverse events (e.g. opiate toxicity, death) were reported in any study following INF administration. One study described better patient tolerance to INF compared with IMM, which achieved statistical significance. The other studies described reports of a "bad taste" and vomiting with INF. Overall the risk of bias in all studies was considered low. INF may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children. However, this review of published studies does not allow any definitive conclusions regarding whether INF is superior, non-inferior or equivalent to intramuscular or intravenous morphine. Limitations of this review include the following: few eligible studies for inclusion (three); no study examined the use of INF in children younger than three years of age; no study included children with pain from a "medical" cause (e.g. abdominal pain seen in appendicitis); and all eligible studies were conducted in Australia. Consequently, the findings may not be generalizable to other healthcare settings, to children younger than three years of age and to those with pain from a "medical" cause.

Low-Dose Propofol for the Abortive Treatment of Pediatric Migraine in the Emergency Department

Limited progress has been made in the past decade for abortive treatment of migraine headache in the pediatric emergency department (PED). Propofol, a general anesthetic, has been reported to be effective in the treatment of refractory headaches in adults at subanesthetic doses but never in the pediatric population. The goal of this study was to review our institution's experience with subanesthetic doses of propofol for the abortive treatment of pediatric migraine and compare propofol with standard abortive therapy in the PED. Retrospective review of all patients discharged from the Oregon Health and Science University PED with a diagnosis of migraine headache from January 2010 to July 2011. Patients treated with subanesthetic doses of propofol were compared with matched controls who received standard abortive migraine therapy, defined as the combined use of a nonsteroidal anti-inflammatory medication, diphenhydramine, and prochlorperazine. Outcome variables of interest included reduction of pain as measured on a self-reported visual analog scale and length of stay after administration of initial abortive medication. Patients who received subanesthetic doses of propofol achieved significantly greater reduction in pain scores (80.1% vs 61.1%; P < 0.05) compared with matched controls as well as shorter stay (122 minutes vs 203 minutes; P = 0.2) after treatment. No adverse effects (hypotension, respiratory depression, or hypoxia) were recorded in either group. Propofol seems to be effective for the abortive treatment of pediatric migraine headache in the PED. Further prospective trials are warranted to either support or refute these initial findings.