Intolerable Pain Research Articles

Lumbar disc herniation

The most common cause of disc herniation is the degeneration of the intervertebral disc. Consequently, lumbar disc herniations are amongst the most common pathologies of the lumbar spine. Factors that can increase the risk of disc herniation include genetics, weight, occupational risk factors, smoking, as well as apredominantly sedentary profession. Pathognomonic symptoms of aherniated disc include sciatica, caused by the compression of one or more spinal nerve roots. The clinical sequelae of lumbar disc herniations range from mild low back and buttock pain to severe, immobilising cases of sciatica to cauda equina compression syndromes. In 1-1.5% of cases, acauda equina syndrome may occur. This cauda equina syndrome may be considered an emergency situation that requires immediate attention and surgical decompression. The same applies to significant and rapidly deteriorating neurological deficits (< 24 h). In all other cases, which represents the majority of all patients,substantial pain relief can be achieved with nonsurgical measures. If an adequate and intolerable pain relief cannot be achieved despite intense conservative treatment measures after an extended period of 6-12weeks, surgical removal of the disc herniation may be indicated. Lumbar disc herniations may be addressed surgically with minimally invasive techniques. The goal of the surgery is full and sufficient safe removal of the herniated disc fragments in order to decompress the spinal nerves as well as the cauda equina. The two most commonly used surgical techniques (endoscopic/microsurgical) entail fivedifferent approaches (endoscopic: interlaminar, transforaminal; microsurgical: interlaminar, translaminar, extraforaminal). Patients are generally fully mobilized within hours after the surgery without any further restrictions. Postoperative rehabilitation measures are often carried out, but have no scientifically proven influence on the outcome of the operation. This article sheds light on the diagnostic and therapeutic procedures, techniques and special features of this socio-medically very important clinical picture.

Improving Pain Assessment After Inpatient Orthopedic Surgery: A Comparison of Two Scales.

In pain assessment, the commonly used Numeric Rating Scale (NRS) offers an incremental 0-to-10 range of response options. But this broad range often leads to discordant evaluations between nurses and their patients. This study aimed to compare the NRS to the three-category Interventional Pain Assessment (IPA) scale, validate the IPA scale in an inpatient setting, and determine RN and patient scale preferences. This prospective study enrolled 122 postoperative orthopedic patients and their designated 104 RNs at a level 1 trauma center in the midwestern United States. Patients were asked to verbally rate their pain from 0 to 10 using the NRS and from 0 to 2 on the IPA scale. Patients were also asked which scale best conveyed their pain. The RNs were asked which scale best informed them of their patient's pain situation and which scale they preferred. To establish a correlation between the two scales, we considered NRS values of 0 to 7 (signifying no pain to moderate pain) to correspond to IPA scale values of 0 to 1 (signifying no pain to tolerable pain). NRS values of 8 to 10 (signifying severe pain) were considered to correspond to IPA scale values of 2 (signifying intolerable pain). Responses in which patients reported IPA scores indicating no pain to tolerable pain but NRS scores above 7 or IPA scale scores indicating intolerable pain but NRS scores of 7 or below were defined as discordant answers. Data analysis revealed a strong significant correlation between the NRS and IPA scale (τ = 0.597), with an 82.7% concordance rate. Once an NRS score rose above 7, more discordance between the two scales became increasingly prevalent, as evidenced by the 45% of patients who also reported tolerable pain on the IPA scale. Significantly more patients (89.3%) preferred the IPA scale to communicate their pain level than the NRS (10.7%). Significantly more RNs (76%) felt the IPA scale best informed them of their patient's pain and was a better guide for treatment than felt the NRS did so (24%). The IPA scale asks about pain tolerability and thus has a direct role in the management of pain medications. Both patients and nurses felt they were better able to convey and understand pain when using the IPA scale than when using the NRS. There was consensus regarding pain scale preference among patients and their RNs, with both groups preferring the IPA scale due to its simplicity and, among the RNs, its usefulness in guiding treatment. The IPA scale may be a much better tool for accurately assessing a patient's pain experience and needs, with the potential to change practice and improve pain management.

Assessing pain management in total joint arthroplasty using the Detroit interventional pain assessment scale—A prospective cohort study

BackgroundTotal joint arthroplasty (TJA) is an effective treatment for end-stage osteoarthritis, but postoperative pain has been poorly managed. The purpose of this study was to (1) assess how much narcotic medication was prescribed after TJA; (2) assess if patients were satisfied with their pain management; (3) compare these same data between total hip arthroplasty (THA)/total knee arthroplasty (TKA); (4) compare these same data between preoperative opioid users/opioid-naïve patients.MethodsAn IRB-approved prospective study was conducted at a US academic joint replacement practice. Patients were evaluated by an independent observer at three weeks, three months, and six months postoperatively using the Detroit Interventional Pain Assessment (DIPA) scale. Patients verbally rated their pain with their current medication regimen as 0 (no pain), 1 (tolerable pain), or 2 (intolerable pain) on the DIPA scale. Narcotic usage was verified by the Michigan Automated Prescription System (MAPS). Patients were divided into THA, TKA, previously on opioids, and opioid-naïve groups. Provider efficiency scores reflected pain management satisfaction and were calculated as the percentage of patients reporting no pain or tolerable pain.ResultsOut of 200 patients, the percentage of patients using narcotics and their daily usage (MMEs) significantly decreased from 75.5% (27.5 MMEs) at three weeks to 42.9% (5.3 MMEs) at six months (P < 0.001). In 80% of patients, narcotics taken at six months were prescribed by outside providers. Significantly fewer patients used narcotics at six months for THA (15.4%) compared to TKA (52.7%) (P < 0.021). There was a significant difference in daily narcotic usage between patients who took narcotics preoperatively (22.9 MMEs) and opioid-naïve ones (13.4 MMEs) (P < 0.001). Provider efficiency scores were best at three weeks (76.6%) and three months (70%) but declined at six months (57.2%).ConclusionsNarcotic tapering practices were observed as postoperative daily narcotic intake decreased across six months. However, outside providers prescribed 80% of narcotics at six months, necessitating a better-coordinated practice with surgeons. Patients taking preoperative narcotics experienced higher daily MME requirements than their opioid-naïve counterparts. In terms of the percentage of patients on narcotics, THA is a better procedure for tapering patients off narcotics by six months.

Evaluating Repetitive Transcranial Magnetic Stimulation for Neuropsychiatric Symptoms in Long COVID: A Case Series.

To describe the immediate clinical outcomes of repetitive transcranial magnetic stimulation (rTMS) in treating long COVID symptoms. Long COVID currently impacts approximately 5.3% of US adults, presenting with persistent fatigue, depression, anxiety, cognitive impairments, and social function decline. Repetitive transcranial magnetic stimulation targeting the left dorsolateral prefrontal cortex has improved these symptoms in some studies. Five patients (ages 52-63 years, 3 female patients) underwent accelerated rTMS using intermittent theta burst stimulation (600 pulses over 3 minutes 20 seconds, 80%-120% of resting motor threshold) to the left dorsolateral prefrontal cortex. The treatment consisted of twice-daily sessions over 20-30 treatments. Outcomes were measured using the Patient-Reported Outcomes Measurement and Information System (PROMIS) questionnaires, assessing fatigue, depression, anxiety, cognitive function, and social function at baseline and immediately posttreatment. One patient discontinued immediately due to intolerable scalp pain. Posttreatment PROMIS scores showed the following: fatigue decreased from 74.5 to 61.8, depression from 60.3 to 51.5, and anxiety from 62.0 to 54.0. Scores increased for cognitive (26.8 to 32.3) and social (31.0 to 32.5) function. These changes, although not statistically significant, indicate a trend toward symptom reduction. Subjectively, 3 of 4 patients who completed the rTMS course reported improvements. This case series suggests that rTMS may offer symptomatic relief in long COVID patients. Although the observed improvements in PROMIS were not statistically significant, even minimal improvements are clinically significant for patients enduring prolonged suffering. These preliminary findings are encouraging and underscore the need for further research with larger cohorts to validate the efficacy of rTMS in long COVID symptom relief.

Pacing sensation with a second generation intercostal extravascular ICD lead

Abstract Background/Introduction An investigational intercostal extravascular ICD lead (EV-ICD Lead) has been developed to provide antitachycardia pacing and shock treatment of ventricular tachyarrhythmias when connected to a commercially available ICD pulse generator. Unlike other available extravascular ICD systems that achieve pacing with ring electrodes which transmit undirected current to cardiac and non-cardiac tissue alike, the intercostal EV-ICD Lead uses button-shaped electrodes backed by an insulative paddle to direct current toward excitable myocytes while minimizing undesired excitation of the adjacent tissues. Purpose The purpose of this analysis was to evaluate pacing sensation with the intercostal EV-ICD Lead connected to a commercially-available ICD pulse generator programmed to the maximum voltage output and pulse width settings. Methods In the STEP ICD Study (n=20), pacing sensation was evaluated at the pre-discharge visit while pacing at the maximum programmable voltage output (7.5 or 8.0 V, depending on manufacturer) and pulse width (1.5 or 2.0 ms). Sensation was reported by the patient as one of four choices: No Sensation, Sensation Only, Tolerable Pain or Intolerable Pain. Results Pacing sensation was assessed in 18 of 20 patients. One (1) patient did not undergo a pacing evaluation due to atrial fibrillation with rapid ventricular response. Responses were as follows: No Sensation in 4 (22%) patients, Sensation Only in 10 (56%) patients, Tolerable Pain in 3 (17%) and Intolerable Pain in 1 (6%). In no patient was the pain so severe that pacing capture threshold testing could not be completed. Of note, the single report of intolerable pain was only reported in the sitting posture. When tested supine, the patient reported sensation only. Conclusion(s) The design of the investigational intercostal EV-ICD Lead, with button-shaped electrodes backed by an insulative paddle, produced low levels of patient sensation at maximum output and pulse width. These sensation levels represent an improvement over designs that employ ring electrodes and indicate that antitachycardia pacing will be well tolerated with the novel EV-ICD Lead. These results corroborate the predictions about patient discomfort from in silico models.

Photodynamic therapy light’: An enhanced treatment protocol for actinic keratoses with minimal pain and optimal clinical outcome by combining laser-assisted low irradiance PDT with shortened daylight PDT

BackgroundBetween 2003 and 2016, 546 patients in our clinic discontinued outpatient treatment for actinic keratoses (AKs) using conventional photodynamic therapy (PDT) because of intolerable pain, thereby necessitating the use of a less painful procedure. Therefore, we developed a novel off-label PDT protocol: ‘PDT light’. MethodsLaser-assisted low irradiance PDT (li-PDT) was performed beginning in 2014. The dosage was gradually lowered to 8-12 J/cm² in 2018, so that we achieved considerable pain reduction while maintaining comparable therapeutic efficacy. A further considerable reduction in pain was achieved from 2018 onwards by combining the advantages of li-PDT with daylight PDT (DLPDT), thereby resulting in 2018 in the new technique ‘PDT light’. Patients with AK Olsen grades 1 or 2 and field cancerization initially received a mild-fractionated CO2 laser pretreatment prior to MAL-incubation (methyl aminolaevulinate, Metvix ®) under occlusion for 1.5-3 h. Then, patients were illuminated on average for 1.02 min with the Aktilite-LED and, after application of an UV-screen on the illuminated area, sent out into daylight for 1 h. ResultsBetween March and November 2019, we successfully treated 152 cases using the enhanced ‘PDT light’ procedure, with 137 cases achieving at follow-up 1 (on average after 8.14 months) good-to-excellent clearance rates (CLA and CLB together 90%) and minimal adverse effects. ConclusionsThe novel ‘PDT light’ protocol proved to be an excellent and nearly painless method with an average visual-analogue scale (VAS) score of 1.19. Additional advantages included reduced illumination time, shorter outpatient stays in the clinic, fewer adverse effects, and better patient compliance than with DLPDT alone.

Evaluating the Efficacy of Pre-Emptive Peribulbar Blocks with Different Local Anesthetics or Paracetamol Using the Adequacy of Anesthesia Guidance for Vitreoretinal Surgeries: A Preliminary Report.

Precisely selected patients require vitreoretinal surgeries (VRS) performed under general anesthesia (GA) when intravenous rescue opioid analgesics (IROA) are administered intraoperatively, despite a risk of adverse events, to achieve hemodynamic stability and proper antinociception and avoid the possibility of intolerable postoperative pain perception (IPPP). Adequacy of anesthesia guidance (AoA) optimizes the titration of IROA. Preventive analgesia (PA) techniques and intravenous or preoperative peribulbar block (PBB) using different local anesthetics (LAs) are performed prior to GA to optimize IROA. The aim was to analyze the utility of PBBs compared with intravenous paracetamol added to AoA-guided GA on the incidence of IPPP and hemodynamic stability in patients undergoing VRS. A total of 185 patients undergoing vitreoretinal surgery (VRS) were randomly assigned to one of several anesthesia protocols: general anesthesia (GA) with analgesia optimized through AoA-guided intraoperative remifentanil opioid analgesia (IROA) combined with a preemptive single dose of 1 g of paracetamol (P group), or PBB using one of the following options: 7 mL of an equal mixture of 2% lidocaine and 0.5% bupivacaine (BL group), 7 mL of 0.5% bupivacaine (BPV group), or 7 mL of 0.75% ropivacaine (RPV group). According to the PA used, the primary outcome measure was postoperative pain perception assessed using the numeric pain rating scale (NPRS), whereas the secondary outcome measures were as follows: demand for IROA and values of hemodynamic parameters reflecting quality or analgesia and hemodynamic stability. A total of 175 patients were finally analyzed. No studied PA technique proved superior in terms of rate of incidence of IPPP, when IROA under AoA was administered (p = 0.22). PBB using ropivacaine resulted in an intraoperative reduction in the number of patients requiring IROA (p = 0.002; p < 0.05) with no influence on the dose of IROA (p = 0.97), compared to paracetamol, and little influence on hemodynamic stability of no clinical relevance in patients undergoing VRS under AoA-guided GA. PA using paracetamol or PBBs, regardless of LAs used, in patients undergoing VRS proved no advantage in terms of rate of incidence of IPPP and hemodynamic stability when AoA guidance for IROA administration during GA was utilized. Therefore, PA using them seems no longer justified due to the potential, although rare, side effects.

RNA-seq revealed the protective effect of Huangqi Guizhi Wuwu Decoction against cisplatin induced PC12 cell injury

Background Chemotherapy-induced peripheral neuropathy (CIPN) not only affects the tolerability of chemotherapy, but also causes intolerable and prolonged neuropathic pain in cancer patients. Currently, duloxetine is the only drug used to treat CIPN. However, the clinical use of this drug still faces several challenges. Therefore, we focused on traditional Chinese medicine (TCM) to find an effective and safe alternative medicine. Huangqi Guizhi Wuwu Decoction (HGWD) is a traditional Chinese medicine that has been clinically used for treating nerve pain for thousands of years. This study aimed to investigate the neuroprotective effect of HGWD on cisplatin-induced nerve injury in PC12 cells and to elucidate its potential mechanism of action. Methods HGWD-containing serum and blank serum were prepared from a rat model. The protective effects of HGWD on cisplatin (10 µmol/L)-induced PC12 cell injury were assessed by a Cell Counting Kit-8 (CCK-8) assay. RNA expression in HGWD-protected PC12 cells was analyzed using RNA-seq, and subsequently, differentially expressed genes (DEGs) were further analyzed using Gene Ontology (GO) and Gene Set Enrichment Analysis (GSEA). Results The CCK-8 results showed that pretreatment of PC12 cells with HGWD-containing serum (5%, 10%, 15%) significantly increased cells' viability to 10 µmol/L cisplatin-induced cell death. RNA-seq analysis revealed 843 DEGs in the CIPN group and 249 in the HGWD group. The GSEA results in this study suggest that HGWD may treat CIPN by enhancing axon guidance. Conclusions This study provides valuable evidence for using HGWD in treating CIPN, partially achieved by improving axon guidance pathways.

The Effect of Antinociceptive Dose of Morphine on Cell Therapy in Rats with Spinal Cord Injury.

Spinal cord injury (SCI) is a sensory-motor injury. Today, combined treatments such as cell therapy along with drug therapy and their interactions are of interest. Morphine is an opioid drug used to relieve intolerable pain. This study aims to evaluate the impact of an antinociceptive dose of morphine (with minimal tolerance/dependence but effective pain relief) on cell therapy in SCI. The antinociceptive dose of morphine was determined in rats with SCI through the Hargreaves and naloxone-induced morphine withdrawal tests. The rats were then allocated to 5 groups: laminectomy, SCI, SCI + Morphine, SCI + cell therapy, SCI + Morphine + cell therapy. The antinociceptive dose (5 mg/kg) was administered on days 1, 4, 10, and 13 (i.p.) post-SCI. On day 7, Neural-like stem cells derived from adipose tissue were transplanted intraspinally into the injured animals, and they were monitored for 12 weeks. The outcomes were assessed using the BBB test, somatosensory evoked potential (SSEP), and histology. The BBB test indicated that morphine significantly hindered functional recovery post-cell transplantation compared to animals receiving only cell therapy (p < 0.05). In the SSEP test, the analysis of amplitude and latency of waves did not reveal a significant difference (p > 0.05). The histological results showed that cell therapy reduced the cavity size post-SCI, while morphine had no significant impact on it. Morphine at the antinociceptive dose significantly impairs motor recovery despite cell therapy. Nonetheless, there was no significant difference between groups in terms of sensory pathway outcomes.

Comparing the Efficacy of US Guided Pudendal Nerve Block plus Periprostatic Nerve Block versus Periprostatic Nerve Block Alone for Pain Control of Patients During and After Transrectal Biopsy of the Prostate Gland

Abstract Background Cancer prostate is considered one of the most common cancers among male population. Trans rectal ultrasound (TRUS) guided biopsy has become the main procedure for diagnosing prostate carcinoma, In order to definitively diagnose prostate carcinoma, (TRUS)-guided prostate biopsy is needed. Aim of the Work To compare the efficacy, safety of Pudendal nerve block plus periprostatic nerve block with the standard technique (periprostatic nerve block). Patients and Methods during a period of 6 months duration A total of 30 patients (group 1 [Pedundal nerve block plus periprostatic nerve block], n = 15; group 2 [periprostatic nerve block], n = 15) were included in the study. all patients were instructed about how to assess pain and discomfort level using a visual analog scale (VAS) from 0 to 10, with an 11-point score (0 = no pain, 10 = intolerable pain). Results in our study 30 male patients were divided into 2 groups, group 1 underwent to (PPNB) and group 2 (PPNB + pudendal block). The mean age of the studied group was 58.8 ± 10 years old. All patients hadn’t previous history for prostate surgery nor for rectoanal disease. In our study we evaluated pain scores immediately after the procedure. Regarding the relation between VAS and two studied group, there was an increase in VAS in group 1 more than group 2 along the three sets of follow up with statistical difference between two studied groups in all follow ups as p-Value was &amp;lt;0.05. Conclusion our data suggest that combined bilateral pudendal nerve block plus periprostatic nerve block is more effective than periprostatic nerve block alone in reducing the pain during TRUS guided prostate biopsy.

Hydroxypropyl Cellulose-Based Orally Dissolving Film Loaded with Insoluble Dexamethasone for Treatment of Oral Ulcers.

Oral ulcers present as recurrent and spontaneous lesions, often causing intolerable burning pain that significantly disrupts patients' daily lives and compromises their quality of life. In addressing this clinical challenge, oral dissolving films (ODFs) have emerged as promising pharmaceutical formulations for oral ulcer management due to their rapid onset of action, ease of administration, and portability. In this study, ODFs containing the insoluble drug dexamethasone (Dex) were formulated for the treatment of oral ulcers in rabbits using a solvent casting method with ethanol as the solvent. To optimize the composition of the ODFs, a Box-Behnken Design (BBD) experiment was employed to investigate the effects of varying concentrations of hydroxypropyl cellulose (HPC), low-substituted hydroxypropyl cellulose (L-HPC), and plasticizer (glycerol) on key parameters, such as disintegration time, tensile strength, and peel-off efficiency of the films. Subsequently, the film properties of the Dex-loaded ODFs (ODF@Dex) were thoroughly assessed, revealing favorable attributes, including homogeneity, mechanical strength, and solubility. Notably, the use of ethanol as the solvent in the ODF preparation facilitated the homogeneous distribution of insoluble drugs within the film matrix, thereby enhancing their solubility and dissolution rate. Leveraging the potent pharmacological activity of Dex, ODF@Dex was further evaluated for its efficacy in promoting ulcer healing and mitigating the expression of inflammatory factors both in vitro and in vivo. The findings demonstrated that the ODF@Dex exerted significant antiulcer effects by modulating the PI3K/Akt signaling pathway, thus contributing to ulcer resolution. In conclusion, our study underscores the potential of HPC-based ODFs formulated with ethanol as a solvent as a promising platform for delivering insoluble drugs, offering a viable strategy for the clinical management of oral ulcers.

Value of PET/CT Scanning in Detection of Osseous and Marrow Metastatic Lesions in Cancer Patients

Abstract Background Early diagnosis of cancer remains to be of paramount importance to maximize a patient’s long-term survival and reduce various neurological, hematological, and orthopedic complications that may arise. Skeletal metastasis (SM) is a frequently encountered and important complication of cancer which can lead to intolerable pain. Objectives The goal of the study was to illustrate the value of combined 18F-FDG PET/CT over isolated CT for detection of osseous metastases in cancer patients. Patients and Methods The study included 75 patients. 18F-PET/CT scans were performed. In this study, a lesion-based analysis was performed in detailed retrograde manner. Statistical analysis including specificity, Sensitivity, negative predictive value (NPV) and positive predictive value (PPV) of each of these modalities were calculated. A final diagnosis of metastasis was confirmed by biopsy. Results Combined PET-CT examination is highly sensitive imaging modality in detection of early bone marrow metastatic lesions which are not yet evident on conventional CT study. Conclusion Combined 18-F FDG PET/CT significantly improves the sensitivity and specificity of isolated CT for the detection of osseous and bone marrow metastases. Thus, it adds a significant value that can detect lesions and consequently start a treatment course and improve the overall outcome of the disease process.

The new proposal of the relationship between axial pain and hinge fracture and facet involvement after open-door laminoplasty with titanium spacers.

This was a retrospective, observational study. Postoperative axial pain (AP) is a well-known complication of cervical posterior surgery. It can be caused by various reasons, but the etiology remains unclear. This study aimed to investigate risk factors for postoperative AP after open-door laminoplasty. A previous meta-analysis revealed muscle damage, female, age of <60 years, and longer collar application as possible risk factors for postoperative AP after cervical posterior procedures. However, the postoperative AP etiology, specifically for open-door laminoplasty, has been inconclusive and remains conflicting. This retrospective study included 129 adult patients who underwent open-door cervical laminoplasty for degenerative diseases in our single institution from January 2015 to October 2021. Postoperative AP was defined as intolerable pain on the neck or shoulder that lasted for >1 month postoperatively. We compared the demographic and radiographic characteristics of AP and non-AP groups. Postoperative AP developed in 62 (48.1%) patients. Intraoperative hinge fracture (HF) and facet involvement by miniscrews were significantly greater in the AP group than in the non-AP group (P < 0.05). Using a logistic regression model, multivariate analysis revealed that HF was significantly associated with postoperative AP (odds ratio = 2.83, 95% confidence interval = 1.28-6.44, P = 0.011). HF and facet involvement were risk factors for postoperative AP after open-door laminoplasty with titanium spacers. Careful surgical manipulation is required to prevent postoperative AP.

Application of Recombinant Human Superoxide Dismutase in Radical Concurrent Chemoradiotherapy for Cervical Cancer to Prevent and Treat Radiation-induced Acute Rectal Injury: A Multicenter, Randomized, Open-label, Prospective Trial

PurposeTo evaluate the efficacy of recombinant human superoxide dismutase (rhSOD) enemas in radiation-induced acute rectal injury (RARI) in patients with locally advanced cervical cancer. MethodsIn this phase III, randomized, open-label trial (NCT04819685) conducted across 14 medical centers in China from June 2021 to August 2023, all patients received concurrent chemoradiotherapy (CCRT). The experimental group was treated with a rhSOD enema during chemoradiotherapy, and the control group had no enema. The Common Terminology Criteria for Adverse Events (version 5.0) was used to evaluate radiotherapy-induced side effects. Endoscopic appearance was assessed using the Vienna Rectoscopy Score. The primary endpoint in the acute phase was the occurrence rate and duration of grade ≥1 (≥G1) diarrhea during CCRT. Secondary endpoints included the occurrence rate and duration of ≥G2 and ≥G3 diarrhea; ≥G1 and ≥G2 diarrhea lasting at least 3 days; and damage to the rectal mucosa due to radiotherapy measured by endoscopy. ResultsTwo-hundred-and-eighty-three patients were randomly divided into the experimental (n = 141) or control group (n = 140). The mean number of ≥G1 and ≥G2 diarrhea days were significantly lower in the experimental group than in the control group (3.5 and 0.8 days vs. 14.8 and 4.5 days, respectively; P<0.001). The incidence of ≥G2 diarrhea decreased from 53.6% to 24.1% when rhSOD enemas were used. Use of antidiarrheals was lower in the experimental group (36.2% vs. 55.7%, P<0.001). Three patients felt intolerable or abdominal pain following rhSOD enema. RARI grades in the experimental group tended to be lower than those in the control group (P=0.061). Logistic regression analysis revealed that rhSOD enema was associated with a lower occurrence rate of ≥G1/2 diarrhea for at least 3 days (P<0.001). ConclusionThe results of this study suggest that rhSOD enema is safe and significantly reduces the incidence, severity, and duration of RARI, protecting the rectal mucosa.

VIRTUAL-REALITY PAIN SCIENCE POSITIVELY IMPACTS PAIN AND FUNCTION, RETURN TO WORK, CUSTOMER EXPERIENCE AND RETURN ON INVESTMENT: A CASE STUDY

CASE SETTING 52-year-old male client referred for post-operative cervical-spine two-level fusion rehabilitation, two-years following a motor accident. History of prior motor accident five-years earlier with cervical-spine discectomy resolving symptoms. Referred under compensable insurance policy with 13-years claim benefit remaining. Referral objective to restore health and function for return-to-work (RTW). Experiencing intolerable neck pain with reduced left arm function, pain medication side effects, and low mood. Loss of hope resulting from significant pain post-operatively, whereas prior surgery resolved similar symptoms. Not working at referral. Pre-disability work was full-time self-employed barista. TREATMENT/REHABILITATION PROVIDED Six hours of EXPHYS BETTER Pain VR program, consisting of virtual-reality (VR) pain science coached by an exercise physiologist (AEP) over 10-weeks, face-to-face, within the pain mechanism and bio-psycho-social models. Learning consisted of VR modules and workbook with practical application of six key target pain concepts: pain is always real, doesn’t accurately measure tissue health, relies on context, is a protector, has a buffer zone, and can be retrained. Two functional goals of self-care and cooking were established, and RTW. RESULTS Validated inventories demonstrated self-reported improvements in; pain intensity: 11 item numerical pain rating scale, range: 0-10 points [8 referral; 1 closure]; and function; two 11-item patient-specific functional scale [self-care, cooking], range: 0-20 points) [2 referral; 16 closure]. Work mindset improved from pre-contemplation [referral] to maintenance [closure]. Work capacity improved from no capacity to full capacity. Work status improved from not working to working pre-disability hours and duties. Insurance claim closed. Direct return-on-investment of $300 for every $1 spent on the EXPHYS BETTER Pain VR Program. Client net promotor score (NPS) was promoter (10/10), and customer satisfaction (CSAT) was very satisfied (5/5). REFLECTIONS/LEARNINGS Virtual-reality pain science, delivered by an AEP within the pain mechanisms model, positively impacts pain and function, RTW, and customer experience, with demonstrated return-on-investment.

Efficacy of neuroendoscopic-assisted surgery in the management of symptomatic sacral perineural (Tarlov) cysts: a technical report.

The Tarlov cysts are pathological enlargements of the cerebrospinal fluid spaces between the endoneurium and perineurium, which can cause intolerable sciatic pain, motor impairment of lower limbs, and bladder/bowel dysfunction. Currently, the treatment results are unsatisfactory due to the low cure rates and extensive surgical trauma. Thus, there is an ongoing exploration of surgical techniques for Tarlov treatment. In the current study, we present a novel neuroendoscopic-assisted technique that combines the fenestration, leakage sealing, and tamponade of the Tarlov cyst. Between January 2020 and December 2021, a total of 32 Tarlov patients were enrolled and received neuroendoscopic-assisted surgery. Their pre- and post-surgical Visual Analogue Scale (VAS) scores, major complaints, and MR imaging were recorded for comparison. 27 of 32 patients (84.4%) patients demonstrated immediate pain relief as their VAS scores decreased from 5.6 ± 1.5 to 2.5 ± 1.1 (p < 0.01) on the first day after surgery. At the 3-month follow-up, the patients' average VAS score continued to decrease (1.94 ± 0.8). Meanwhile, saddle paresthesia, urinary incontinence, and constipation were relieved in 6 (50%), 4 (80%), and 5 (41.7%), respectively, according to patients self-report. No surgical-related complication was observed in any of the cases. We conclude that neuroendoscopic-assisted surgery is an effective surgical method for symptomatic Tarlov cysts with minimized complications.

Possibility of Using Surgical Pleth Index in Predicting Postoperative Pain in Patients after Vitrectomy Performed under General Anesthesia.

Adequacy of anesthesia concept (AoA) in the guidance of general anesthesia (GA) is based on entropy, and it also reflects the actual depth of anesthesia and the surgical pleth index (SPI). Therefore, this study aimed to analyze the potential existence of relationships between SPI values at certain stages of the AoA-guided GA for vitreoretinal surgeries (VRS) and the incidence of intolerable postoperative pain perception (IPPP). A total of 175 patients were each assigned to one of five groups. In the first, the VRS procedure was performed under GA without premedication; in the second group, patients received metamizole before GA; in the third, patients received acetaminophen before GA; in the fourth group, patients received Alcaine before GA; and, in the peribulbar block group, the patients received a peribulbar block with a mix of the solutions of lignocaine and bupivacaine. Between the patients declaring mild and statistically significant differences in the IPPP in terms of SPI values before induction (52.3 ± 18.8 vs. 63.9 ± 18.1, p < 0.05) and after emergence from GA (51.1 ± 13 vs. 68.1 ± 8.8; p < 0.001), it was observed that the patients postoperatively correlated with heart rate variations despite the group allocation. The current study proves the feasibility that preoperative SPI values help with predicting IPPP immediately after VRS under AoA guidance and discrimination (between mild diagnoses and IPPP when based on postoperative SPI values) as they correlate with heart rate variations. Specifically, this applies when the countermeasures of IPPP and hemodynamic fluctuations are understood to be of importance in reducing unwelcome adverse events.

Presence of manubrium-sternum joint does not assure sufficient elevation of sternum in Nuss procedure for pectus excavatum patients.

The manubrium and body of the sternum are connected by the manubrium-sternum joint (MSJ). In performing the Nuss procedure for pectus excavatum patients, the body of the sternum is elevated as the operator flips correction bars upside down. Theoretically, the presence of the MSJ should allow elevation of the sternum body. However, does the MSJ secure sufficient elevation of the sternum? This study aims to elucidate this clinical question. Seventy-four adult pectus excavatum patients with moderate to serious deformity (with Haller Index being equal to or greater than 5) were included in the study. The MSJ was open in all patients. For 29 patients, the sternum was elevated by only bar flipping (Non-Separation Group); for 45 patients, the sternum was horizontally separated after bar flipping (Separation Group). Whether or not additional elevation for Separation Group patients results from the division was observed, and the degree of the additional elevation was evaluated. Furthermore, 74 patients subjectively evaluated postoperative pain and gave scores with a Visual Analog Scale ranging from 0 (no pain) to 10 (intolerable pain). The VAS scores were compared between the two groups. In the Separation Group, the sternums of all patients achieved additional elevation from sternum separation. The pain scores were lower for the Separation Group than for the Non-Separation Group. Even when the MSJ is present, horizontal separation enhances the elevation of the sternum. Furthermore, horizontal separation of the sternum reduces postoperative pain.

Efficacy of Qingpeng ointment (a Tibetan medicine) for acute gouty arthritis: a multi-center, randomized, double-blind, placebo-controlled trial

BackgroundThis study aims to assess the efficacy and safety of Qingpeng ointment (QPO), a Tibetan medicine for alleviating symptoms in individuals with acute gouty arthritis (AGA).MethodsThis study was a randomized, double-blind, placebo-controlled trial that involved individuals with AGA whose joint pain, as measured on a visual analog scale (VAS) from 0 to 10, was equal to or greater than 3. The participants were randomly assigned to either the QPO or the placebo group and received their respective treatments twice daily for seven consecutive days. In case of intolerable pain, the participants were allowed to use diclofenac sodium sustained-release tablets as a rescue medicine. The primary outcomes measured were joint pain and swelling, while the secondary outcomes included joint mobility, redness, serum uric acid levels, C-reactive protein levels, and the amount of remaining rescue medicine. Any adverse events that occurred during the trial were also recorded.ResultsA total of 203 cases were divided into two groups, with balanced baselines: 102 in the QPO group and 101 in the placebo group. For joint pain, differences between the groups were notable in the VAS scores [1.75 (0, 3.00) versus 2.00 (1.00, 3.50); P = 0.038], changes in VAS [5.00 (3.00, 6.00) versus 4.00 (2.00, 6.00); P = 0.036], and disappearance rate [26.47% compared to 15.84%; P = 0.046] after treatment. Concerning joint swelling, significant between-group differences were observed in the VAS scores [1.00 (0, 2.30) versus 2.00 (0.70, 3.00); P = 0.032] and disappearance rate [33.33% compared to 21.78%; P = 0.046] at treatment completion. The QPO group exhibited a statistically significant mobility improvement compared to the placebo group (P = 0.004). No significant differences were found in other secondary outcomes. Five patients, four from the QPO group and one from the other, encountered mild adverse events, primarily skin irritation. All of these cases were resolved after dosage reduction or discontinuation of the medication.ConclusionsCompared to the placebo, QPO exhibits positive effects on AGA by alleviating pain, reducing swelling, and enhancing joint mobility, without causing significant adverse effects.Trial RegistrationISRCTN34355813. Registered on 25/01/2021.

Honey in Alleviating Severe Oral Mucositis Among Head and Neck Cancer Patients Undergoing Radiation Therapy.

Aiming to resolve debates on honey's efficacy for radiotherapy-induced severe oral mucositis in head and neck cancer, we conducted a meta-analysis focused on randomized trials, primarily assessing severe mucositis incidence. Secondary outcomes included weight loss, pain management, and honey types. A comprehensive literature search was conducted in PubMed, Embase, WOS, and the Cochrane Library up to December 2023. The analysis concentrated on randomized controlled trials that assessed the efficacy of honey, targeting the incidence of mucositis as the main outcome. Additional outcomes explored were weight loss, intolerable pain, and the specific types of honey used in interventions. Data analysis was performed using CMA software, and a funnel plot was employed to identify publication bias. The analysis of 176 records resulted in the inclusion of 10 studies with 599 patients receiving radiotherapy. The research showed that honey significantly reduced the occurrence of grade 3-4 mucositis (severe mucositis), provided significant pain relief, and had a positive effect on reducing weight loss. Regarding the type of honey used, no significant differences were found in their effectiveness in alleviating severe mucositis. Honey serves as an effective intervention for individuals with oral mucositis. It can be considered as an adjuvant in the management of clinical radiotherapy-associated oral mucositis, particularly for patients requiring prolonged use of anti-analgesic or antifungal medications.