Maximum Pain Research Articles

Posterior Hip Pericapsular Block (PHPB) with pericapsular nerve group (PENG) block for hip fracture: a case series

BackgroundPain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function.MethodsThis case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded.ResultsThey experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients.ConclusionsUltrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.

Levonorgestrel 52 mg intrauterine device placement without uterine sounding: A feasibility study

ObjectivesTo evaluate feasibility of levonorgestrel 52 mg intrauterine device (IUD) placement without uterine sounding. Study designWe performed a three-phase feasibility study from February 2023-May 2024. In phase one, participants had levonorgestrel 52 mg IUD placement with sounding. In the experimental phases, placement occurred without sounding and with (phase two) or without (phase three) concurrent transabdominal sonography and participants had 3-month follow-up. We defined feasibility as successful IUD placement without uterine sounding based on ultrasound confirmation. We measured total instrumentation time from the sound or inserter touching the cervix to inserter removal. Participants reported maximal pain experienced using a 100-mm Visual Analog Scale when the inserter was removed. We calculated a sample size of 30 per phase so that if there was one failed placement, the lower 95% confidence interval of the successful placement rate would be no less than 90.0%. ResultsSuccessful placement without sounding occurred in 30(100%) participants in phase two and 28(93.3%) in phase three. Median instrumentation was longest in phase one (49.5 [interquartile range (IQR) 42.3–55.0] seconds) compared to phases two (16.0 [IQR12.0–28.0] seconds, p < 0.0001) and three (25.0 [IQR 18.5–32.2] seconds, p < 0.0001). Participants’ median placement pain was 21.0 (IQR 10.3–32.8) mm in phase one with no difference in phase two (25.5 [IQR 14.3–47.0] mm, p = 0.35), but was higher in phase three (36.0 [IQR 22.8, 61.0] mm, p = 0.01). ConclusionsLevonorgestrel 52 mg IUD placement without sounding is feasible with concurrent sonography. Placement without sounding results in shorter instrumentation time but does not decrease maximum placement pain.

Could temporomandibular joint arthroscopic discopexy with resorbable pins or disc mobilisation influence mandibular condyle marrow?

The aim of this study was to evaluate the relationship between arthroscopic discopexy with resorbable pins or disc mobilisation and its effect on the bone marrow of the mandibular condyle. An observational analytical retrospective cohort study was conducted. The inclusion criteria comprised adult patients with Wilkes IV and V with MRI in T2 sequence undergoing TMJ arthroscopy. The first group included subjects who received discopexy with pins (Level III Arthroscopy), and the second included subjects who underwent disc mobilisation without any fixation (Level IIb Arthroscopy). Variables studied were maximum interincisal opening (MIO), pain, and Signal Intensity Ratio (SIR) index. Data were analysed using the chi-squared test, Fisher’s exact test, the Mann Whitney U test, and the Shapiro-Wilk test. To establish the relationship between the variables and SIR ≥ 2, a multivariate analysis was performed using unconditional logistic regression. A total of 50 joints were divided in two groups. In the multivariate logistic regression analysis, discopexy surgery with pins (Odds Ratio OR = 0.03, 95% [CI] 0.02 to 0.69, p = 0.027) was identified as an independent predictor for the non-development of a high SIR score (≥2.0) after adjusting preoperative covariates. This study shows changes in the medullary signal in patients undergoing discopexy with resorbable pins. However, more studies are required that correlate quantitative measures.

Comparative evaluation of various biomaterials as pulpotomy agents in molars with symptomatic irreversible pulpitis: A randomized single-blinded single-center control trial.

Untreated tooth decay in mature permanent dentition is a prevalent global issue, affecting 34.1% of people with 2.5 billion cases annually. Extensive decay often leads to irreversible pulpitis, characterized by pulp inflammation and pain. Pulpectomy, the standard treatment, involves complex procedures with potential complications. Modern endodontics favors minimally invasive treatment such as pulpotomy, which preserves pulp vitality. This study aims to compare the clinical as well as radiographic outcomes of different pulpotomy agents: Biodentine, mineral trioxide aggregate (MTA), Bio-C repair, and Endosequence Bio-ceramic root repair material (BCRRM) in mature permanent molars. This single-blind, single-center study involved 80 participants randomly assigned to four groups, each receiving one of the biomaterials. Ethical approval was obtained. Participants aged 14-60 years with symptomatic irreversible pulpitis were selected. Pulpotomy procedures were performed, and follow-up evaluations occurred at 24 h, 1 week, 4 weeks, 3, 6, and 12 months. Clinical success was measured by the absence of pain, sensitivity, and tenderness. Radiographic evaluation used the periapical index (PAI) scoring system. Pulpotomy significantly reduced postoperative pain in all groups. Endosequence BCRRM showed the maximum pain reduction at 24 h with a statistically significant difference from all the groups (at 1% probability level), followed by Bio-C repair, Biodentine, and MTA. At 1 week, Bio-C repair led in pain reduction with statistically nonsignificant results. All groups reported no pain at 3, 6, and 12 months. Endosequence BCRRM had the highest improvement in periapical findings at 1 year. Sensitivity to hot and cold improved significantly in all groups, with Endosequence BCRRM performing best. Endosequence BCRRM provided the best overall outcomes, emphasizing the importance of material choice in pulpotomy treatments. Further research on biomaterials' long-term clinical and radiographic outcomes is needed to enhance treatment efficacy.

Efficacy of virtual reality therapy versus pharmacological sedation for reducing pain and anxiety during coronary catheterisation procedures: A prospective randomised controlled trial.

The use of virtual reality (VR) therapy has grown considerably, as it is effective for reducing pain and anxiety in different clinical areas. However, it has not been well evaluated for coronary angiography and angioplasty. This study aimed to compare VR therapy with pharmacological sedation (Sedation) for reducing pain in patients undergoing a planned coronary angiography or coronary/peripheral angioplasty. In this prospective randomized controlled trial, patients were randomly allocated to one of two groups before catheterization: a Sedation group (injection of midazolam and fentanyl) or a VR group (Deepsen VR headset). The primary outcome measure was the maximum pain during the procedure (visual analogue scale: 0-10). The secondary outcome measures were anxiety following the procedure (Spielberger State Anxiety Inventory: 20-80), the occurrence of arterial spasm, the haemodynamic profile and patient satisfaction. The VR group (n = 63) had a mean pain rating of 2.5; for the Sedation group (n = 59) this was 1.0. This did not meet the criterion for non-inferiority. Anxiety was comparable between the two groups (VR: 25.4; Sedation: 24.7), as was the occurrence of arterial spasm (VR: 7.9%; Sedation: 8.5%; p = 0.91), but blood pressure was higher in the VR group (140.2/71.7 mmHgvs. 121.8/64.7 mmHg). There were no VR-related adverse effects, and patient satisfaction was high for both groups. Virtual reality therapy was not non-inferior to pharmacological sedation for reducing pain during coronary angiography or angioplasty. However, it reduced anxiety to a comparable level. Virtual reality therapy represents an alternative to pharmacological sedation, which is well accepted by patients.

Transcutaneous Tibial Nerve Stimulation for Pain Management in Women with Primary Dysmenorrhea: A Randomized Clinical Trial.

Primary dysmenorrhea is considered one of the main causes of pelvic pain during a woman's childbearing years, resulting in poor quality of life. The objective was to evaluate the effectiveness of transcutaneous tibial nerve stimulation (TTNS) in painful symptomatology improvement and non-steroidal anti-inflammatory drug (NSAID) intake reduction in women with primary dysmenorrhea (PD) compared with a control group in the short, medium, and long terms. A single-blind, controlled clinical trial was developed. Participants were randomized to the experimental (TTNS) and control group (sham TTNS). Both groups received 12-weekly 30-min sessions with a NeuroTracTM PelviTone electrostimulation device. The intensity and severity of pain and non-steroidal anti-inflammatory drug (NSAID) intake were evaluated in the short-term (after treatment), medium-term (1-3 months), and long-term (6 months). A total of 61 participants were randomized, with a split of 31 (experimental group) and 30 (control group), but 55 participants completed the study and were analyzed. Statistically significant differences between both groups in the maximum pain intensity decrease (F = 4.88, p = 0.0043) measured with the visual analogue scale, as well as NSAID intake decrease (F = 4.68, p = 0.011) and days of their ingestion (F = 4.57, p = 0.012) occurred in the short term. Furthermore, significant decreases in the total number of NSAIDs ingested during the cycle (F = 3.82, p = 0.011) and the number of days on which patients ingested NSAIDs (F = 3.59, p = 0.015) in the medium-long term occurred. TTNS could be an effective and safe strategy to reduce pain caused by PD, which could reduce or complement the use of pharmacological techniques and other more invasive methods.

Intraoperative magnesium sulfate is not associated with improved pain control after urologic procedures

ObjectiveTo evaluate effects of intraoperative magnesium sulfate infusion on pain control and analgesic use in the postanesthesia care unit (PACU).MethodsThis is a retrospective review of patients undergoing robot-assisted radical prostatectomy (RARP) and endoscopic procedures of the bladder, prostate, and urethra from 2/2021 to 12/2021. Patients receiving Mg infusion (Mg group) received an intravenous 2-g bolus of Mg at anesthesia induction, followed by infusion of 1 g/h until procedure end. Outcomes were compared with patients who underwent similar procedures during this timeframe without Mg (Control). Endpoints were use of anticholinergic (AC) and belladonna and opium suppositories (BO), maximum pain score, and morphine milligram equivalents (MME) in PACU.ResultsThere were 182 patients, with 89 (48.9%) patients in the Mg group and 93 (51.1%) in the Control. Significantly, fewer patients in the Mg group were given AC/BO in PACU (9.0% vs. 21.7%, p = 0.02), with odds of using AC/BO which was 0.36 (95% CI 0.14, 0.83). No differences were found in pain score (p = 0.62) or MME administration (p = 0.94). In subgroup univariate analysis, only those who underwent bladder procedures had a significant difference in use of AC/BO (9.5% vs. 30.2%; p = 0.02). Across all surgeries, Mg infusion was associated with decreased use of AC/BO in the PACU (OR 0.34, p = 0.02); however, stratifying by procedure type did not find a difference in AC/BO use postoperatively.ConclusionIntravenous infusion of magnesium was found to decrease use of AC/BO in the PACU; however, this significance was lost after multivariable analysis stratifying by procedure type.

Characterization of Oral Ketamine Use: A Retrospective Review

Ketamine is an N-methyl D-aspartate (NMDA) receptor antagonist used to treat pain at subanesthetic doses. Ketamine is beneficial for pain control in patients who have a high tolerance to opioids and are experiencing opioid-induced hyperalgesia. This study characterizes oral ketamine use for analgesia at a large academic hospital and reports safety outcomes for hospitalized patients. This study was a retrospective electronic health record (EHR) review of patients ≥ 18 years or older receiving oral ketamine. The primary endpoint was median ketamine starting dose and maximum dose (mg/kg/day) during treatment duration. Secondary outcomes included oral Morphine Milligram Equivalents (MMEs), buprenorphine dose, minimum and maximum pain scores on the first and last day of therapy. Safety endpoints were reported. The median starting dose was 1 mg/kg/day, and the median maximum dose was 1.6 mg/kg/day. Median MMEs decreased from the first day to the last day of oral ketamine therapy. The study population experienced a low incidence of safety events overall. Oral ketamine was administered safely for analgesia, with patients receiving ketamine doses that were on the lower end of the established therapeutic range. Evaluation of the efficacy and safety of oral ketamine use for analgesia should be further studied.

Sex-Differences in Post-Procedural Pain Experiences After Thermal Liver Ablations for Liver Tumors: A Retrospective Study

IntroductionLiterature shows differences in pain experiences between sexes. The exact influence of thermal liver ablation on experienced pain is still not well-known. This study aims to investigate the maximum pain intensity at the recovery between men and women after percutaneous thermal liver ablation.MethodsPatients treated with percutaneous thermal liver ablation (radiofrequency or microwave ablation) in Maastricht University Medical Center + between 2018 and 2022 for primary or secondary liver tumors were included retrospectively. Outcomes included maximum numerical rating scale (NRS, scale:0–10) score at the recovery room, prevalence of post-procedural pain (defined as NRS score ≥ 4), duration of anesthesia, length of stay at recovery, and complications. Regression analyses were adjusted for age, ASA-score, BMI, tumor type, maximum diameter of lesion, chronic pain in patients’ history, and history of psychological disorder.Results183 patients were included of which 123 men (67%). Results showed higher average maximum NRS scores in women patients compared to men (mean:3.88 versus 2.73), but not after adjustments (aß:0.75, 95%CI:−0.13–1.64). Women suffered more from acute post-procedural pain (59% versus 35%; aOR:2.50, 95%CI:1.16–5.39), and needed analgesics more often at the recovery room (aOR:2.43, 95%CI:1.07–5.48) compared to men. NRS score at recovery arrival did not significantly differ (aß:0.37, 95%CI:-0.48–1.22). No differences were seen in the length of stay at the recovery, duration of anesthesia, procedure time, and complication rate. Location of the tumor (subcapsular or deep), total tumors per patient, and distinction between primary and secondary tumors had no influence on the NRS.ConclusionThis retrospective single-center study shows higher post-procedural pain rates after thermal liver ablation in women, resulting in higher analgesics use at the recovery room. The results suggest considering higher dosage of analgesics during thermal liver ablation in women to reduce post-procedural pain.Level of Evidence 3Non-controlled retrospective cohort study.Graphical

EFFICIENCY OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION AND PIROXICAM TO ALLEVIATE PAIN DURING ORTHODONTIC TOOTH SEPARATION - A PROSPECTIVE STUDY

Objective: This study was conducted to assess the effectiveness of TENS in comparison with TENS-Placebo and prophylactic Piroxicam (20 mg) for pain control before orthodontic tooth separation by Elastomeric separators, Brasswire and Kesling separators. Study design: 108 patients seeking orthodontic treatment were categorically administered extraoral TENS, TENS-Placebo and Piroxicam (20 mg) using Elastomeric, Kesling and Brasswire separators prior to their orthodontic treatment. The subjects were instructed to rate their pain 2, 6, 12, 24 and 48 hours after the procedure on a Visual Analog Scale. Results: No statistically significant difference was found in the mean VAS scores when TENS group was compared with Piroxicam. However, significant differences were found between the mean VAS scores when placebo TENS group was compared to the aforementioned groups. Maximum pain was perceived at 24 hours with elastomeric and Kesling springs, but brasswire separators were most painful 6 hours after placement altogether. At all time stamps, pain felt was significantly less with brasswire separators than elastomeric separators and Kesling springs. Conclusion: TENS was found to be equally effective in reducing pain as Piroxicam. TENS could be thus stated as an effective pain management modality which is safe, comfortable and easy to use and also eliminates adverse drug effects of NSAIDs like GI irritation and reduced orthodontic tooth movement.

Specific therapeutic methods in lumbar facet syndrome tratment: prliminary study

Introduction: Specific therapeutic methods (STM) are manual techniques used to treat tissue blockade.Aim of this research is to determine efficacy of STM in treatment of lumbar facet syndrome (LFS).Patients and methods. The study included 60 patients suffering from LFS (65% women) aged ~47. The patients were treated ~24 days with the following 2-8 procedures: osteopathy, “myofascial release”, acupuncture, acupressure, “cupping”, neurodynamic, proprioceptive neuromuscular facilitation, kinesiotherapy, “kinesio-type taping”, homeopathy and electrotherapy. All patients were evaluated at admission and discharge through: a. pain scale with visual analogue scale (VAS) marked with numbers 1 to 10 (1 being state of no pain, 10 being state of maximum pain); b. disability with so-called Oswestry index (ODI) expressed in percentages (0-20% being minimum, 80-100% being complete disability); c. quality of sleep, rated through modified Pittsburgh index of sleep quality (PSQI) expressed between 0 (very poor) and 4 (very good). The assessment of improvement in pain intensity and level of disability was conducted via subtraction of values noted before treatment from values at the end of treatment, while the assessment of sleep quality improvement was conducted via subtraction of values noted at the end of treatment from the values noted before treatment. Non-parametric statistical analyses were used. Results: significantly lower values of VAS (p&lt;0.0001) and ODI (p?0.0001), significant increase in PSQI (p?0.0001) at the end in relation to the beginning of treatment, as well as significant correlation between decrease in pain and disability (r=0.3292, p=0.0105). No significant difference in pain (p=0.9856) and disability (p=0.9171 decrease was noticed between sexes.Conclusion: STM is efficient in the treatment of pain attacks in patients of both sexes suffering from LBS.

Quality of Life and Symptomatology in Neuropathic Corneal Pain in Comparison With Dry Eye Syndrome.

To investigate and compare the quality of life (QoL) and symptomatology between neuropathic corneal pain (NCP) and dry eye disease (DED). We recruited 150 patients, comprising 50 patients with NCP and 100 patients with DED. Patients' symptoms and QoL were evaluated using the Ocular Pain Assessment Survey and Ocular Surface Disease Index questionnaires. Ocular surface assessments were also performed. Patients with NCP demonstrated significantly lower Oxford and National Eye Institute scores for ocular surface and corneal staining, respectively, and a better tear break-up time than patients with DED. However, patients with NCP reported significantly worse scores on most of the Ocular Pain Assessment Survey questions and significantly more severe overall pain (P = 0.019), maximal and average ocular pain and nonocular pain (all P < 0.05). The NCP group reported significantly worse QoL in all aspects of daily living (all P < 0.001). Patients with NCP spent more time thinking about their eye pain and reported significantly higher pain intensities than patients with DED when exposed to chemical and mechanical stimuli (all P ≤ 0.008). Burning sensation and photophobia were significantly more frequent in patients with NCP (P = 0.032 and P = 0.012, respectively). Similarly, the NCP group reported significantly worse total Ocular Surface Disease Index scores, significantly more frequent vision-related function impairment and painful or sore eyes than the DED group (P = 0.029, P = 0.031, and P = 0.014, respectively). Compared with DED, NCP is more debilitating, leading to more severe and frequent symptoms, and greater negative impact on all aspects of QoL.

Ultrasound-guided supraclavicular block versus Bier block for emergency reduction of upper limb injuries: statistical analysis plan

BackgroundUltrasound-guided supraclavicular block (UGSCB) is an emerging technique gaining interest amongst emergency physicians that provides regional anaesthesia to the upper limb to tolerate painful procedures. It offers an alternative to the more traditional technique of a Bier block (BB). However, the effectiveness or safety of UGSCB when performed in the emergency department (ED) is unclear.MethodsSUPERB (SUPraclavicular block for Emergency Reduction versus Bier block) is a prospective open-label non-inferiority randomised controlled trial comparing the effectiveness of UGSCB versus BB for closed reduction of upper limb fractures and/or dislocations. Adult patients presenting with upper limb fracture and/or dislocation requiring closed reduction in ED were randomised to either UGSCB or BB. Once regional anaesthesia is obtained, closed reduction of the injured part was performed and immobilised. The primary outcome is maximal pain experienced during closed reduction measured via a visual analogue scale (VAS). Secondary outcomes include post-reduction pain, patient satisfaction, total opioid requirement in ED, ED length of stay, adverse events and regional anaesthesia failure.ResultsPrimary outcome analysis will be performed using both the intention-to-treat and per-protocol populations. The between-group difference in maximum pain intensity will be assessed using linear regression modelling with trial group allocation (UGSCB vs BB) included as a main affect. A pre-specified non-inferiority margin of 20 mm on the VAS scale will be used to establish non-inferiority of UGSCB compared to BB.ConclusionSUPERB is the first randomised controlled trial to investigate the effectiveness and safety of UGSCB in the ED. The trial has the potential to demonstrate that UGSCB is an alternative safe and effective option for the management of upper extremity emergencies in the ED.

Oral resveratrol in adults with knee osteoarthritis: A randomized placebo-controlled trial (ARTHROL).

Resveratrol is a natural compound found in red wine. It has demonstrated anti-inflammatory properties in preclinical models. We compared the effect of oral resveratrol in a new patented formulation to oral placebo for individuals with painful knee osteoarthritis. ARTHROL was a double-blind, randomized, placebo-controlled, Phase 3 trial conducted in 3 tertiary care centers in France. We recruited adults who fulfilled the 1986 American College of Rheumatology criteria for knee osteoarthritis and reported a pain intensity score of at least 40 on an 11-point numeric rating scale (NRS) in 10-point increments (0, no pain, to 100, maximal pain). Participants were randomly assigned (1:1) by using a computer-generated randomization list with permuted blocks of variable size (2, 4, or 6) to receive oral resveratrol (40 mg [2 caplets] twice a day for 1 week, then 20 mg [1 caplet] twice a day; resveratrol group) or matched oral placebo (placebo group) for 6 months. The primary outcome was the mean change from baseline in knee pain on a self-administered 11-point pain NRS at 3 months. The trial was registered at ClinicalTrials.gov: (NCT02905799). Between October 20, 2017 and November 8, 2021, we assessed 649 individuals for eligibility, and from November 9, 2017, we recruited 142 (22%) participants (mean age 61.4 years [standard deviation (SD) 9.6] and 101 [71%] women); 71 (50%) were randomly assigned to the resveratrol group and 71 (50%) to the placebo group. At baseline, the mean knee pain score was 56.2/100 (SD 13.5). At 3 months, the mean reduction in knee pain was -15.7 (95% confidence interval (CI), -21.1 to -10.3) in the resveratrol group and -15.2 (95% CI, -20.5 to -9.8) in the placebo group (absolute difference -0.6 [95% CI, -8.0 to 6.9]; p = 0.88). Serious adverse events (not related to the interventions) occurred in 3 (4%) in the resveratrol group and 2 (3%) in the placebo group. Our study has limitations in that it was underpowered and the effect size, estimated to be 0.55, was optimistically estimated. In this study, we observed that compared with placebo, oral resveratrol did not reduce knee pain in people with painful knee osteoarthritis. ClinicalTrials.gov ID: NCT02905799.

Breastfeeding Success With Use of Electric Breast Pump Versus Inverted Syringe Technique in Lactating Women With Inverted Nipple: Open Labelled Randomized Control Trial.

Background Inverted nipple is a commonly encountered impediment to proper attachment and latch establishment. Correction of inversion using a disposable syringe represents the conventional method of management. However, it is understudied, cumbersome, and inconvenient. Using electric breast pump represents a more physiological method to achieve correction of inversion. This open-label, randomized control trial investigated syringing versus electric breast pump both in terms of effectiveness in achieving correction of inversion of nipple and patient satisfaction with the use of the assigned intervention. Objectives The primary objective of this study was to compare breastfeeding success by Day 3 postnatal age (achieving correction of inversion of nipple and establishment of direct breastfeeding) in syringing versus electric breast pump in mothers with inverted or flat nipples. The secondary objective was to compare the two methods for the pain experienced by the mother while using syringing versus an electric breast pump. Methodology/Design This was a single-center, open-label randomized control trial performed at a tertiary care neonatal unit in Eastern India, from December 2022 to September 2023. 60 healthy mothers with inverted nipples were randomly allocated to one of two interventions: Group A (n=30, syringing); or Group B (n=30, electric breast pump). Both groups were compared for the establishment of breastfeeding by Day 3 postnatal age and daily maximum pain scores till Day 3 (visual analogue scale). Multivariable logistic regression was used to look for factors independently associated with establishment of breast feeding by Day 3 postnatal period. Chi square test was used to compare the proportions of different outcomes between the groups. Results The primary outcome of establishment of breastfeeding by Day 3 postnatal period was achieved in 18 (60%) mothers in syringe group vs. 17 (56.67%) in the breast pump group, with no statistically significant difference (p=0.793). In the first two days the pain score differences were not statistically significant, but on Day 3, 28 (93.99%) mothers in the electric breast pump group had no/mild pain compared to 22 (73.33%) mothers in the syringe usage group. This difference was statistically significant (p= 0.038). Conclusion In hospital settings where electric breast pump is easily available, the same may be preferred over inverted syringe technique for achieving establishment of breastfeeding by Day 3 postnatal period with minimal nipple pain in mothers. However, further large scale studies will be required to confirm these findings.

Exploring the Analgesic Efficacy and mechanisms of low-dose esketamine in pregnant women undergoing cesarean section: A randomized controlled trial

BackgroundPostoperative pain is a prevalent concern following a cesarean section. This study aimed to investigate the effect and mechanism of low-dose (0.1 mg/kg) esketamine on postoperative pain management in pregnant women undergoing cesarean sections, specifically in cases where both patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) were employed. MethodsPregnant women intending to undergo elective cesarean section were divided into four subgroups based on the intravenous administration of esketamine and the specific analgesia methods employed: E1 (0.1 mg/kg esketamine + PCEA), E2 (0.1 mg/kg esketamine + PCIA), C1 (saline + PCEA), and C2 (saline + PCIA). The primary outcome was the maximum pain score within 24 h postoperatively. Secondary outcomes included the pressure pain threshold and tolerance at 30 min and 24 h postoperatively, along with the inflammation and adverse event index scores. ResultsA total of 118 pregnant women were assigned to the four groups: E1 (n = 29), E2 (n = 29), C1 (n = 30), and C2 (n = 30). Compared with those in the control groups (C1 + C2), the maximum postoperative pain scores within 24 h in the esketamine groups (E1 + E2) were significantly lower (4 [2–5] vs. 4 [4–6], P = 0.002), and the E1 group exhibited superior analgesic effects compared with other groups. No significant differences were observed in postoperative hyperalgesia or inflammation across the four groups. Notably, esketamine combined with PCIA increased the incidence of postoperative nausea and vomiting (7 [25 %] vs. 0 [0 %]; P = 0.005). ConclusionThe administration of low-dose (0.1 mg/kg) esketamine effectively alleviates pain following cesarean section, and the analgesic effect is notably enhanced in combination with PCEA. Importantly, these effects do not appear to be mediated through anti-inflammatory mechanisms or the inhibition of hyperalgesia. Clinical trial registration numberNCT05414006.

EVALUATION OF CLINICAL RESULTS OF SURGICAL RESECTION OF SYNOVIAL OSTEOCHONDROMATOSIS IN THE SHOULDER: A RETROSPECTIVE STUDY

Synovial osteochondromatosis of the shoulder is a rare condition and its details remains unclear. Aim of this study was to evaluate the clinical results of surgical resection and histopathological characteristic of SOC of the shoulder. Ten shoulders with SOC were retrospectively assessed for demographic characteristic, history of trauma, presence of osteochondral loose bodies, inferior humeral osteophytes and acromial spurs. Visual analog scores for pain and functional scores using Constant scores were compared pre and post operatively. Resected lesions were histo-pathologically differentiated between primary and secondary SOC. The average age of patients was 39.8+/- 15.7 year; four female and six patients was male in our study. Average duration of symptoms was 11.5+/-8.11 months. Three shoulders has osteochondral lesion in subacromial space (30%) and seven in glenohumeral joint (70%). Five shoulders (71%) show inferior humeral osteophytes out of seven shoulders with lesion in glenohumeral joint. All three shoulder (100%) with SOC in the subacromial space had spur formation. One shoulder have primary SOC while other nine had secondary SOC. Average Visual analog scale pain score graded from 0 (no pain) to 100 mm( maximal pain) was 47.5+/-11.32 mm. The Constant score was improved from preoperative score 51.6+/-8.34 points to postoperative score 78.7+/-11.62. No case show recurrence of new loose bodies, acromial spur and inferior humeral osteophytes. Our study showed that resection of SOC successfully relieved the pain and clinical symptoms. Primary SOC is less common than secondary SOC and histopathological identification is needed to differentiate between both types. Thus further investigations required to determine long term prognosis SOC in the shoulder. KEYWORDS: osteochondromatosis, shoulder joint, synovium

Clinical evolution of patients with lower extremity peripheral artery disease during the COVID-19 pandemic (the COVID-PAD study).

Background: The COVID-19 pandemic has led to significant disruptions in chronic disease care and forced people to stay at home. The effects of such issues on outpatients with lower extremity peripheral artery disease (PAD) remain unknown. Patients and methods: Single-centre, retrospective-prospective study conducted in a Swiss University Hospital. Patients with PAD were included between May 1 and July 31, 2020, with a follow-up visit at 12 months. Upon both visits, the Leriche-Fontaine PAD stage was recorded, and study participants underwent ankle-brachial index (ABI) calculation to assess limb perfusion. Functional capacities were assessed through the 6-minute walking and treadmill tests. Major adverse cardiovascular (MACE) and limb events (MALE) were recorded. Data collected during the pandemic were compared with the pre-pandemic period (January 1, 2019-April 30, 2020). Results: Overall, 259 patients were included. Mean age was 69 years and male sex was prevalent (69.1%). Odds of experiencing a degradation in PAD stage were lower during the pandemic than before (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21-0.87; p = 0.018). No significant difference was found between periods in terms of ABI trends. Both pain-free walking time at treadmill test (p = 0.003) and maximal pain intensity at 6-minute walking test (p = 0.001) significantly improved during the pandemic. Compared with the pre-pandemic period, during the pandemic patients were hospitalized less frequently (p = 0.028) and were less likely to undergo elective limb revascularization (p<0.001). No significant difference was found between periods in terms of MALE (p = 0.311), whereas non-fatal strokes were less frequently reported during the pandemic (p = 0.043). Conclusion: In a cohort of outpatients with PAD, we found no evidence of clinical deterioration during the pandemic compared with the pre-pandemic period, though rates of adverse events were nonnegligible in both periods. In case of future pandemics, patients with PAD should be encouraged to maintain an active lifestyle while being closely monitored to avoid clinical worsening.

Clinical efficacy of the bared external anal sphincter (BEAS) in high horseshoe-shaped anal fistulas: Protocol for a real-world, prospective cohort study

BackgroundHigh horseshoe-shaped anal fistula (HHAF) is a complex disease that manifests in the perianal region and typically requires surgical intervention for treatment. However, the current therapeutic approaches are limited by the high rates of postoperative recurrence and anal incontinence. To overcome the limitations of traditional surgical approaches, we introduce the bared external anal sphincter (BEAS) technique. Our study aims to compare the clinical efficacy of BEAS surgery with that of the modified Hanley procedure in a real-world setting. Materials and methodsThis single-centre, prospective cohort study will be conducted in a tertiary hospital in China and aims to evaluate the short-term clinical efficacy and safety of BEAS surgery and modified Hanley surgery in HHAF patients from March 2024 to March 2026. Data from the prospective database of this tertiary referral hospital will be used to obtain insights into the clinical outcomes of these surgical treatments. The primary outcome of this study will be the wound healing rate within six months, while the secondary outcomes will include the time to return to work, the maximum visual analogue scale pain score (VAS-PS) within 1–5 days postsurgery, and the Cleveland Clinic Florida Incontinence Score (CCF-IS) and Quality of Life in Anal Fistula Questionnaire Score (QoLAF-QS) at 1, 3, and 6 months postsurgery. Moreover, logistic regression analysis will be used to explore the risk factors for anal fistula recurrence after the BEAS procedure. DiscussionThis will be the first cohort study to evaluate the differences in therapeutic outcomes between patients who undergo BEAS surgery and patients who undergo surgery via the modified Hanley procedure. By conducting a detailed observation of the efficacy and treatment results of these two surgical methods, this study aims to reveal the differences the clinical effectiveness of these approaches and to provide evidence-based support for future randomized controlled trials (RCTs).

Implementation of a Multimodal Enhanced Recovery Protocol in Ambulatory Anorectal Surgery: A Randomized Trial.

Few studies report outcomes for enhanced recovery pathways in ambulatory anorectal surgery. We hypothesize that an ambulatory anorectal enhanced recovery pathway with multimodal analgesia can reduce postoperative opioid use. To compare postoperative opioid use in patients undergoing ambulatory anorectal surgery who receive multimodal analgesia vs. standard of care without multimodal analgesia. A prospective randomized trial of patients undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022. Urban teaching hospital. Adults aged 18 to 70 undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022. Multimodal enhanced recovery pathway including pre- and postoperative non-opioid analgesia with oral acetaminophen, gabapentin and ketolorac. Primary endpoint was oral opioid use during the first postoperative week. Secondary endpoints included maximum pain and nausea scores, adverse events and emergency room or hospital admissions during the first 30 days postoperatively. Of the 109 enrolled patients, 20 were lost to follow-up. The remaining 89 patients had a median age of 38 (range, 20-67) years and included 41 (46%) females. There were no significant differences between the enhanced recovery protocol (Arm E) and non-enhanced recovery protocol (Arm NE) groups in terms of preoperative and surgical characteristics. The study primary endpoint, oral MME use during the first week, was significantly higher among patients in the NE arm (79 mg; range, 0-600) than patients in the E arm (8 mg; range, 0-390) (p = 0.002). On subgroup analysis, both fistula and hemorrhoid surgery patients assigned to the NE arm took significantly higher oral MME in the first week than patients in the E arm. There was no significant difference in secondary endpoints. Patients and providers were not blinded. Our findings are limited to hemorrhoid and fistula surgery and may not be applicable to other anorectal procedures. Enhanced recovery protocols including multimodal analgesia should be used in elective anal fistula and hemorrhoid surgery to decrease postoperative opioid use. See Video Abstract . ClinicalTrials.gov ID NCT03738904.