Low Pain Research Articles

Evaluation of minimally invasive esthetic crown lengthening using an open flap versus flapless surgical approach: A randomized controlled clinical trial.

Esthetic crown lengthening (ECL) is commonly advocated to treat patients with altered passive eruption (APE). Since the introduction of the minimally invasive surgical concept, a limited number of studies have investigated this technique in a standardized manner, with further studies required to verify the validity and predictability of the minimally invasive FL-technique. The current randomized trial compares a minimally invasive (ECL), using piezosurgery with flapless-approach (FL), versus an open-flap (OF) approach in the management of patients with APE Type 1B. Twenty-four patients diagnosed with APE Type 1B were randomly assigned into test (FL) with tunneling approach or control (OF) group with minimally invasive flap reflection (n = 12/group). Postoperative pain was assessed during the first 48 h. Gingival margin (GM) level relative to a custom-made stent (rGM) and patient satisfaction were assessed preoperative, immediately after surgery, at 3 and 6 months postsurgically. Postoperative swelling was reported for the first week postsurgically. Plaque index (PI), bleeding on probing (BoP), clinical attachment level (CAL), pocket depth (PD) and pink esthetic score (PES), were evaluated at baseline and 6 months. Linear regression analysis was conducted for pain. OF-group reported significantly higher pain and swelling scores than FL-group during the first 48 h (p < 0.05). FL-group showed no significant differences regarding rGM between 3 and 6 months, in contrast to OF-group, where a significant decrease in rGM was notable (p < 0.05). No significant differences in PI, BoP, CAL, PD, PES, and patient satisfaction scores were evident between groups (p > 0.05). Regression analysis demonstrated that treatment and gender were significant predictors for pain (p < 0.05). Within the current study's limitations, piezo-surgical ECL with FL-approach presented significantly lower postoperative pain, swelling, and early GM stability compared to OF-approach. Piezosurgical ECL with a FL-approach can be considered a predictable technique with advantages over the OF-approach in the management of patients with APE Type1B.

Percutaneous Foraminal Neuroplasty Using Reference Spinal Needles: Technical Description.

Lumbar foraminal stenosis is a common cause of chronic lower back pain and radiculopathy often treated by epidural steroid injections. In the absence of imaging findings with a positive physical exam demonstrating symptoms, percutaneous neuroplasty (PNP) may be an alternative to transforaminal epidural steroid injections that have otherwise failed. We present two cases (55-year-old man and 65-year-old woman) with chronic low back pain and radiculopathy with otherwise normal imaging demonstrating no lumbar foraminal stenosis refractory to transforaminal epidural steroid injections. PNP was performed using reference spinal needles with both patients achieving sustained > 50-75% pain relief. PNP offers interventional chronic pain physicians and patients with refractory chronic low back pain with lumbar radiculopathy due to fibrosis an alternative, safe treatment that offers sustained results. Furthermore, this is the first of its kind to offer a step-by-step procedural step of PNP using a reference spinal needle.

Colonic diverticular bleeding due to a rupture of an ileocolic artery pseudoaneurysm secondary to colonic diverticulitis.

A 53-year-old woman with a history of recurrent right lower quadrant pain presented with slightly bloody stools in April 2023. She was initially diagnosed with acute diverticulitis using an abdominal computed tomography (CT) scan and was treated conservatively. On the second day, however, she reported significant hematochezia. A subsequent contrast-enhanced CT scan revealed an extravasation in the ascending colon, which was promptly managed with colonoscopy. Despite initial hemostasis, she experienced recurrent bleeding. Another contrast-enhanced CT scan revealed a pseudoaneurysm with ongoing extravasation in the same area. Angiography confirmed a pseudoaneurysm in a branch of the ileocolic artery, which was successfully treated by embolization. She was discharged after an 18day hospital stay. This case highlights a pseudoaneurysm caused by diverticulitis.

Removal of Complete Spontaneous Migration of an Intrauterine Contraceptive Device to the Bladder by Cystoscopy

Intrauterine contraceptive devices (IUCD) are widely used as a reversible method of contraception. Although uterine perforation caused by an IUCD is rare, in some cases, the device may migrate to the pelvic/abdominal cavity or nearby structures. When the IUCD migrate to the bladder, it can lead to various symptoms. These include pain or discomfort in the lower abdomen, difficulties or pain during urination, frequent urinary tract infections, and the development of bladder stones. This article presents a case report of a 24-year-old woman with an intrauterine contraceptive device (IUCD) that had migrated completely into the bladder. She had an IUCD inserted by a midwife four years earlier and became pregnant a year later, unaware of the IUCD’s presence. She later presented with lower abdominal pain, hematuria, and dysuria three months before being admitted to our hospital. Imaging confirmed the intravesical location of the IUCD. She underwent successful cystoscopy treatment to remove the migrated IUCD. Prompt diagnosis and appropriate management are crucial in preventing complications and improving patient outcomes. Clinicians should be aware of this potential complication and consider it when patients present with symptoms or complications after IUCD insertion. Regular monitoring and timely intervention can help detect and address IUCD migration effectively.

Prevalence of Current Chronic Pain in Royal Canadian Mounted Police Cadets

ABSTRACT Background Nearly half of active duty Royal Canadian Mounted Police (RCMP) officers (i.e. 43%) report experiencing current chronic pain (i.e. pain lasting longer than 3 months). Most RCMP officers (i.e. 91%) who report chronic pain indicate that the pain started after working as RCMP officers. Baseline data on chronic pain prevalence among RCMP cadets has not been available. Aims The current study was designed to provide cross-sectional estimates of chronic pain prevalence among RCMP cadets starting the Cadet Training Program and to assess for sociodemographic differences among participants. Methods The RCMP Study uses a longitudinal prospective sequential experimental cohort design to create a clustered randomized trial that engages individual participants for 5.5 years. The current manuscript provides cross-sectional associations between chronic pain prevalence and sociodemographic characteristics. Participants were RCMP cadets (n=770) starting the Cadet Training Program. Location, intensity (i.e. on a 0-10 scale, and days per week experienced), and duration (i.e. number of months) of chronic pain was reported. Differences across sociodemographic characteristics were examined. Results Few RCMP cadets reported experiencing chronic pain (i.e. 10%); lower back pain was rated as the most severe in terms of intensity and duration, and second most frequently reported in number of days experienced per week. Prevalence of chronic pain was lower among RCMP cadets than RCMP officers. Conclusions Chronic pain prevalence among active duty RCMP officers may result from or be moderated by operational duties, as well as routine aging. Future researchers could examine ways to mitigate chronic pain development during RCMP officer careers.

Robotic-arm-assisted lateral unicompartmental knee arthroplasty leads to high implant survival and patient satisfaction at mean 10-year follow-up.

There is a lack of literature reporting on long-term outcomes following robotic-arm-assisted lateral unicompartmental knee arthroplasty (UKA). This study assessed the long-term survivorship, patient-reported satisfaction and pain scores following robotic-arm-assisted lateral UKA for lateral compartment osteoarthritis (OA). A single surgeon's database was reviewed to identify all patients who underwent robotic-arm-assisted lateral UKA with a cemented, fixed-bearing prosthesis prior to May 2015. Patients were contacted to determine implant survivorship, satisfaction and pain. Kaplan-Meier models were applied to analyse survival. A total of 77 knees (70 patients) with a mean follow-up of 10.2 ± 1.5 years (range: 8.1-13.3) were included. Five knees were revised, corresponding to a 10-year survivorship of 96.1% and estimated survival time of 12.7 ± 0.3 years (95% confidence interval: 12.2-13.2) with all-cause revision as the endpoint. Unexplained pain (40.0%) and progression of OA (40.0%) in contralateral compartments were the most reported reasons for revision. Among patients without revision, 94.4% were either satisfied or very satisfied with their lateral UKA and the average pain score was 1.1. Robotic-arm-assisted lateral UKA led to high implant survivorship and patient satisfaction, and low pain scores at long-term follow-up. Progression of OA in contralateral compartments and unexplained pain were the most frequent reasons for revision. These findings support the continued use of robotic-arm-assisted lateral UKA for lateral compartment OA; however, its clinical value over conventional techniques remains to be established in prospective comparative studies. Therapeutic Level IV.

Virtual reality vs. tablet for procedural comfort using an identical game in children undergoing venipuncture: a randomized clinical trial

IntroductionRecent research has explored the effectiveness of interactive virtual experiences in managing pain and anxiety in children during routine medical procedures, compared to conventional care methods. However, the influence of the specific technology used as an interface, 3-dimensions (D) immersive virtual reality (VR) vs. 2D touch screens, during pediatric venipuncture, remains unexamined. This study aimed to determine if immersive VR is more effective than a tablet in reducing pain and anxiety during short procedures.MethodsAn interactive game was designed by clinicians and psychologists, expert in pain theory, hypnosis, and procedural pain and anxiety relief, and was tailored for both VR and tablet use. Fifty patients were randomly assigned to either the Tablet or VR group. The primary outcome measures were pain and anxiety levels during the procedure. Secondary outcome measures included the need for physical restraint, duration of the procedure, enjoyment levels, and satisfaction ratings from both parents and nurses.ResultsParticipants, in both groups, had low levels of pain and anxiety. Physical restraint was infrequently used, procedures were brief, and high satisfaction levels were reported by patients, parents, and nurses.DiscussionThis study suggests that the type of technology used as a support for the game has a minimal effect on the child's experience, with both groups reporting low pain and anxiety levels, minimal physical restraint, and high enjoyment. Despite immersive VR's technological advancements, this study underscores the value of traditional tablets with well-designed interactive games in enhancing children's wellbeing during medical procedures.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT05065307].

Caudal Regression Syndrome First Diagnosed in Adulthood: A Case Report and a Review of the Literature

Caudal regression syndrome (CRS) is a rare congenital malformation characterized by incomplete development of the lower spine and spinal cord. Its estimated incidence ranges from 1 to 2 per 100,000 live births, leading to a spectrum of clinical presentations. Although most cases are diagnosed during childhood, only a small number of cases have been documented in adults in the medical literature. Case Report: A 27-year-old woman underwent an outpatient magnetic resonance imaging (MRI) of the thoracolumbar spine due to severe lower back pain experienced for the first time. Despite congenital leg abnormalities and multiple childhood surgeries, no further investigations were conducted at that time. MRI revealed congenital anomalies consistent with CRS, including coccygeal agenesis, L5 sacralization, and spinal cord defects. The patient also had a long-standing pilonidal cyst treated conservatively, now requiring operative treatment due to an abscess. Conclusions: This report underscores a rare case of CRS initially misdiagnosed and mistreated over many years. It emphasizes the importance of considering less common diagnoses, especially when initial investigations yield inconclusive results. This clinical case demonstrates a highly valuable and educative radiological finding. In the literature, such cases with radiological findings in adults are still lacking.

Exercise as an anti-inflammatory Therapy in Axial Spondyloarthritis Therapeutic Intervention (EXTASI study): a randomised control trial

Abstract Objectives Axial Spondyloarthritis (AxSpA) is a chronic inflammatory disease, yet despite known anti-inflammatory effects of exercise, the effect of exercise on inflammatory immune cell populations and associated inflammatory profiles in AxSpA is unknown. This randomised-control trial investigated the effect of 12-weeks of walking on symptom severity, cardiometabolic health, inflammatory biomarkers, and immune cell populations. Methods Twenty people (60% male) living with AxSpA who were on stable dose non-steroidal anti-inflammatory (NSAIDs) medication participated. Participants were randomly assigned to control or exercise (30 min of walking five x per week). Participants were invited back every four-weeks for assessment. Results There was a 0% drop out and no adverse events in the exercise group showing walking exercise was well tolerated. Home-based walking for 12-weeks lowered the proportion of pro-inflammatory monocytes, whereas they increased in the control group. Changes were associated with lower interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations, lower spinal pain, and lower systolic blood pressure in the exercise group, whereas these markers increased in the control group. Reductions in IL-6 and pro-inflammatory monocytes with exercise were independent of lower body fat percentage. Conclusion Supplementing NSAID therapy with walking exercise can improve inflammatory immune profiles in people with AxSpA coinciding with reductions in spinal pain. Importantly, the exercise was well tolerated, suggesting walking exercise can be used as an adjuvant anti-inflammatory therapy for NSAID treatments. This should now be explored in people living with AxSpA who have had high enough disease activity to necessitate the prescription of biologic or synthetic DMARD treatments. Clinical trials registration ClinicalTrials.Gov, NCT04368494

Causal associations between sarcopenia-related traits and intervertebral disc degeneration: a two-sample mendelian randomization analysis.

Sarcopenia (SP) and intervertebral disc degeneration (IVDD) have a higher incidence in the elderly population. Previous studies have indicated a potential association between SP and IVDD. The objective of this study is to elucidate the potential causal relationship between sarcopenia-related traits and IVDD through Two-sample Mendelian randomization (MR) analysis. We utilized a genome-wide association study conducted on the European population to collect aggregated data on sarcopenia and IVDD. Inverse variance weighting was primarily employed, supplemented by MR Egger, weighted median, simple model, and weighted model methods. Additionally, sensitivity analysis was performed to assess the robustness of the findings. Appendicular lean mass is positively associated with "Other intervertebral disc disorders" (OIDD) and "Prolapsed or slipped disc" (POSD) (OIDD: p = 0.002, OR = 1.120; POSD: p < 0.001, OR = 1.003), while grip strength (GS) is positively associated with POSD (left: p = 0.004, OR = 1.008; right: p < 0.001, OR = 1.010). It is worth mentioning that walking pace has significant causal relationship with "Low back pain" (LBP), "Lower back pain or/and sciatica" (LBPOAS), "Sciatica with lumbago" (SWL) and OIDD (LBP: p < 0.001, OR = 0.204; LBPOAS: p < 0.001, OR = 0.278; SWL: p = 0.003, OR = 0.249; OIDD: p < 0.001, OR = 0.256). The present study revealed the causal relationship between SP-related traits and IVDD and recommended to prevent and treat sarcopenia as a means of preventing IVDD in clinic practice.

Positive Deviance and Exploring the Role of Mental Health on Early Postoperative Recovery After Total Hip Arthroplasty: A Retrospective Analysis Using the PROMIS-10 Global Health.

Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT. This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition. A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group. The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT. Diagnostic study-retrospective cohort study.

Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation: a technical note

BackgroundThe traditional surgical procedures for upper lumbar disc herniation (ULDH) usually lead to frequent complications. We aim to investigate the clinical efficacy of the unilateral biportal endoscopy (UBE) technique in treating upper lumbar disc herniation (ULDH).MethodsFrom January 2020 to December 2021, the clinical data of 28 patients with ULDH treated with the UBE technique were collected and analyzed for surgery time under UBE, postsurgical drainage, postsurgical hospital stay, and complications. The clinical efficacy was evaluated according to the modified MacNab score, Oswestry disability index (ODI), and visual analogue scale (VAS) of low back pain and lower limb pain before the surgery; one week, one month, and three months after the surgery; and at the last follow-up.ResultsAll patients underwent the UBE surgery successfully. The surgery time under UBE for non-fusion cases was 47.50 ± 11.84 min (monosegment) and 75.00 ± 20.66 min (two segments), while that for fusion cases was 77.50 ± 21.02 min. The postsurgical drainage for non-fusion cases was 25.00 ± 13.94 mL (monosegment) and 38.00 ± 11.83 mL (two segments), while that for fusion cases was 71.25 ± 31.72 mL. The postsurgical hospital stay was 8.28 ± 4.22 days. The follow-up time was 15.82 ± 4.54 months. The VAS score for each time period after the surgery was significantly lower (P < 0.05), while the ODI was significantly higher than that before the surgery (P < 0.05). According to the modified MacNab scoring standard, the ratio of excellent to good was 96.43% at the last follow-up. Two patients experienced transient numbness and pain in their lower limbs and no activity disorder after the surgery, and they recovered after conservative treatment.ConclusionsThe clinical effect of UBE technique in treating ULDH was reliable. According to the needs of the disease, the interlaminar approach or paraspinal approach of the UBE technique was selected. This technique took into account the effect of treatment, achieved the purpose of minimal invasiveness, and did not require special instruments. Therefore, it has the potential for clinical application.

Comparison of short‑term outcomes and 3-year overall survival between robotic and laparoscopic gastrectomy for gastric cancer: a propensity score matching analysis

Background Despite the increasing use of robotic gastrectomy (RG) as an alternative to laparoscopic gastrectomy (LG) in treating gastric cancer, controversy remains over the advantages of RG compared to LG and there is a paucity of studies comparing the two techniques regarding patient survival. Methods In this retrospective cohort study, 675 patients undergoing minimally invasive gastrectomy were recruited from January 2016 to January 2018 (LG: n = 567; RG: n = 108). A one-to-one propensity score matching (PSM) analysis was applied to minimize the selection bias due to confounding factors, yielding 104 patients in each of the RG and LG groups. After matching, the short-term outcomes and 3-year overall survival were compared in the two groups. Results The PSM cohort analysis showed a similar 3-year overall survival between RG and LG groups (p = .249). Concerning the short-term outcomes, the RG compared to LG resulted in lower blood loss (p = .01), lower postoperative complications (p = .001), lower postoperative pain (p = .016), earlier initiation of soft diet (p = .011), shorter hospital stay ‌(p = .012), but higher hospitalization expenses (p = .001). Conclusion Our findings suggest that RG may offer advantages in terms of blood loss, surgical complications, recovery time, and pain management compared to LG while maintaining similar overall survival rates. However, RG is associated with higher hospital costs, potentially limiting its wider adoption. Further research, including large, multi-center randomized controlled trials with longer patient follow-up, particularly for advanced gastric cancer, is needed to confirm these findings.

Prescription drug monitoring programs and prescription pain medication misuse among U.S. high school students—2019

BackgroundPrescription drug monitoring programs (PDMPs) are state-level databases that track and inform prescribing practices to reduce prescription drug diversion and misuse. To our knowledge, only three studies have examined the impact of PDMPs on opioid-related outcomes among adolescents, and none have focused on prescription pain medication misuse among adolescents.MethodsThis study leveraged data from the 2019 National Youth Risk Behavior Survey (YRBS) to explore the associations between five categories of PDMP dimensions and the prevalence of self-reported prescription pain medication misuse. Demographic factors’ associations with self-reported prescription pain medication misuse were also examined.ResultsIn 2019, none of the PDMP dimensions were associated with self-reported prescription pain medication misuse among U.S. high school students, adjusting for gender, grade, race/ethnicity, and sexual orientation.ConclusionsNone of the five PDMP dimensions were associated with lower prescription pain medication misuse, however further research is needed, especially as new YRBS data become available.

Enhanced external counterpulsation treatment improves multi-organ hemodynamics for postoperative liver transplantation patient. A case report

IntroductionPost liver transplantation (LT) patients endure high morbidity rate of multi-organ ischemic symptoms following reperfusion. We hypothesize that enhanced external counterpulsation (EECP) as a typical non-invasive assisted circulation procedure, which can efficiently inhibit the relative ischemic symptoms via the systemic improvement of hemodynamics.Case presentationA 51-year-old male patient, 76 kg, 172 cm, received orthotopic LT surgery for viral hepatitis B induced acute-on-chronic liver failure hepatic failure. His medical records revealed ischemic symptoms in multi-organ at the time of hospital discharge, including headache, refractory insomnia, abdominal paralysis, and lower limb pain. The EECP treatment was introduced for assisted rehabilitation and to improve the postoperative quality of life. Doppler Ultrasound examination showed significant augmentation of blood flow volume in the carotid arteries, the hepatic artery, the portal vein and the femoral artery during EECP intervention. A standard 35-hour EECP treatment led to significant improvement in quality of life, e.g. sleep quality and walking ability.ConclusionWe report a case of multi-organ ischemic symptoms in a post LT patient. EECP treatment can significantly improve the quality of life via the systematic promotion of hemodynamics.

Effects of automatic heel lancet on invasiveness in neonates: A systematic review and meta-analysis.

We conducted a meta-analysis comparing the invasiveness of automatic lancet devices, which can collect adequate amount of blood at shallow puncture depths, with conventional manual lance devices (lancet or needle) to statistically identify less invasive instruments for neonatal heel lance. We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and Ichushi databases for studies comparing the invasiveness between automatic lancet and manual lancet or needle in term and preterm neonates in neonatal intensive care unit. This review included 9 out of 449 searched articles, with 673 neonates. Automatic lancet had significantly lower pain scores (standardised mean difference: -2.0, 95% confidence interval: -3.3 to -0.7), heart rate (mean difference: -8.0, 95% confidence interval: -13.8 to -2.1), cry duration (mean difference: -21.5, 95% confidence interval: -32.5 to -10.4), number of punctures (mean difference: -0.6, 95% confidence interval: -1.1 to -0.2), and duration of procedures (mean difference: -37.7, 95% confidence interval: -75.2 to -0.2) than manual lancet or needle. Furthermore, peripheral oxygen saturation was significantly higher in automatic lancet than in manual lancet or needle (mean difference: 4.5, 95% confidence interval: 0.5-8.5). Automatic heel lancet devices were less invasive than manual heel lance devices (lancet or needle).

A clinical evaluation of low-level laser therapy for pain reduction in early treatment stages: A pilot study

Objectives: This study aimed to clinically evaluate the efficacy of low-level laser therapy (LLLT) in reducing pain associated with orthodontic movement during the early stages of treatment. Material and Methods: A randomized controlled trial was conducted with 20 participants undergoing non-extraction orthodontic treatment. The laser group (LG, n = 10) received LLLT (808 nm, 100 mW) immediately after appliance installation, while the control group (CG, n = 10) received no pain control intervention. Pain levels were assessed using a visual analog scale (VAS) at 6, 24, 48, and 72 h till 7 days with an interval of 24 h. Statistical analyses included Chi-square tests and Mann–Whitney tests. Results: The LG consistently demonstrated significantly lower pain scores during chewing and at rest compared to the CG. After 6 h post-treatment, the median pain score on chewing in the LG was markedly lower than the CG (P &lt; 0.001), a trend observed at each subsequent interval till 7 days. The comparison of spontaneous pain also favored the LG at various time points. Lower median VAS scores for pain on chewing among the LG and CG were zero and two, respectively, with a significant difference. The maximum median VAS scores for pain on chewing among the LG and CG were five and seven, respectively, with a significant difference. Conclusion: This study provides robust evidence supporting the effectiveness of LLLT in reducing orthodontic pain during the early stages of treatment. The sustained and significant reduction in pain scores, coupled with rigorous statistical analyses, emphasizes the potential of LLLT as a valuable adjunctive therapy in orthodontic practice.

Peripheral nerve blocks for analgesia following cesarean delivery A narrative review

Abstract Spinal and epidural blocks are commonly employed for pain relief during and following cesarean section. Intrathecal morphine (ITM) has been the gold standard for the same for many years. In recent times, many peripheral nerve blocks (PNBs) have been tried for postoperative analgesia following cesarean delivery (PACD). This article has reviewed the common PNBs used for PACD. The role of PNBs along with ITM has been studied and the current best strategy for PACD has also been explored. Currently, Ilio-inguinal nerve and anterior transversus abdominis plane block in conjunction with intrathecal morphine have been found to be the most effective strategy, providing lower rest pain at 6 hours as compared to ITM alone. In patients not receiving intrathecal morphine, recommended PNBs are lateral transversus abdominis plane block, single shot local anesthetic wound infiltration, or continuous wound infiltration with catheter below rectus fascia. PNBs are recommended for PACD. They have an opioid-sparing effect and are devoid of adverse effects associated with central neuraxial blocks such as hypotension, bradycardia, and urine retention. However, caution must be observed with PNBs for possible local anesthetic toxicity due to the large volumes of drug required. Key Messages: Peripheral nerve blocks form an effective component of multi-model analgesic regimens for pain control following cesarean section. Ilio-inguinal nerve and anterior transversus abdominis plane block in conjunction with intrathecal morphine is the most effective strategy. In the absence of intrathecal morphine, lateral transversus abdominis plane block or local anesthetic wound infiltration should be administered.

Woman with lower abdomen and flank pain

Woman with lower abdomen and flank pain

Decision-Making Confidence of Clinical Competency Committees for Entrustable Professional Activities

A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs' clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known. To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions. This cohort study used deidentified data from the EPA Pilot Study, with participating sites at 28 general surgery residency programs, prospectively collected from July 1, 2018, to June 30, 2020. Data were analyzed from September 27, 2022, to February 15, 2023. Microassessments of resident entrustment for pilot EPAs (gallbladder disease, inguinal hernia, right lower quadrant pain, trauma, and consultation) collected within the course of routine clinical care across four 6-month study cycles. Summative entrustment ratings were then determined by program CCCs for each study cycle. The primary outcome was CCC decision-making confidence rating (high, moderate, slight, or no confidence) for summative entrustment decisions, with a secondary outcome of number of EPA microassessments received per summative entrustment decision. Bivariate tests and mixed-effects regression modeling were used to evaluate factors associated with CCC confidence. Among 565 residents receiving at least 1 EPA microassessment, 1765 summative entrustment decisions were reported. Overall, 72.5% (1279 of 1765) of summative entrustment decisions were made with moderate or high confidence. Confidence ratings increased with increasing mean number of EPA microassessments, with 1.7 (95% CI, 1.4-2.0) at no confidence, 1.9 (95% CI, 1.7-2.1) at slight confidence, 2.9 (95% CI, 2.6-3.2) at moderate confidence, and 4.1 (95% CI, 3.8-4.4) at high confidence. Increasing number of EPA microassessments was associated with increased likelihood of higher CCC confidence for all except 1 EPA phase after controlling for program effects (odds ratio range: 1.21 [95% CI, 1.07-1.37] for intraoperative EPA-4 to 2.93 [95% CI, 1.64-5.85] for postoperative EPA-2); for preoperative EPA-3, there was no association. In this cohort study, the CCC confidence in EPA summative entrustment decisions increased as the number of EPA microassessments increased, and CCCs endorsed moderate to high confidence in most entrustment decisions. These findings provide early validity evidence for this novel assessment framework and may inform program practices as EPAs are implemented nationally.