Mean Pain Score Research Articles

Comparison Between Short Term Outcomes of Lichtenstein and Desarda Repair for Inguinal Hernia

Desarda repair for inguinal hernia repair came into being in 2001 and was an alternative to the Lichtenstein repair where mesh placement is necessary. The procedure is thought to be simple, reproducible and avoids the complications of a mesh and thus favorable for resource limited countries. Aim of the study was to compare short term outcomes of Lichtenstein versus Desarda repair for inguinal hernia in terms of mean post-operative pain and frequency of post-operative wound infection, scrotal edema and hematoma. Methodology: This RCT was conducted at Surgical Unit I, Fatima Jinnah Medical University, Lahore. Diagnosis of inguinal hernia was confirmed on clinical examination and per-operative findings. Two groups were formed with one undergoing Desarda repair and one Lichtenstein repair. Post-operative scrotal edema and hematoma formation, pain scores and wound infection were recorded and evaluated for both groups. Results: The overall incidence of scrotal edema was 5.0% (n=3) with 6.7% in Lichtenstein group and 3.3% in Desarda repair group. The overall incidence of hematoma formation was 0% (n=0), and the overall wound infection rate was also 0%. The overall mean for pain score for all study participants was 2.73 S.D 1.36. Mean pain score in Desarda repair was 2.13 S.D 1.30 and 3.33 S.D 1.15 for Lichtenstein group (p-value 0.001). Conclusion: Desarda repair is an economical repair especially for resource-limited countries and should be undertaken in place of a Lichtenstein repair where mesh cost and availability poses a problem. The Desarda repair has a better morbidity profile than the Lichtenstein repair and with more data generation may have a place to become the standard open inguinal hernia repair technique. Keywords: Desarda Repair; Lichtenstein Repair; Short-term outcomes

Effect of intraurethral instillation of cooled versus room temperature lignocaine gel on pain perception during outpatient rigid cystoscopy

Background: Reducing temperature of topically applied lignocaine gel for maximal anesthesia during cystoscopy in conscious patients have yielded mixed results. This prospective randomised controlled study was undertaken to compare pain mitigating effect of lignocaine gel at 4°C versus at room temperature during rigid cystoscopy in male patients. Methods: The study consists of 126 consecutive patients (n=126) who were randomly assigned into two groups: Group 1 (control, n1=63) received 2% topical lignocaine at room temperature, Group 2 (L4, n2=63) received topical lignocaine cooled to 4°C prior to insertion of rigid cystoscope. Pain during instillation of lignocaine and during performance of rigid cystoscopy was measured by independent evaluator on non-graphical 100-mm visual analogue scale (VAS). Results: Mean pain score for cystoscopy in L4 was lower (46.69±10.38) than that in CONTROL (49.19±12.47), this difference was statistically not significant (p value, one tail =0.11, >0.05). Mean pain score for instillation in L4 was 14.80±6.00 and that for control was higher at 17.04±6.54 with difference in pain scores being statistically significant (p value, one tail =0.02, <0.05). Conclusions: With regard to reducing pain perception during rigid cystoscopy, cooled lignocaine gel at 4°C has no benefit over room temperature lignocaine gel, however cooling lignocaine gel to 4ºC does significantly decrease pain of instillation of gel into urethra.

Perichondrium-Cartilage Inlay Butterfly Myringoplasty: An Office-Based Procedure for Closing Small- to Medium-Sized Tympanic Membrane Perforations.

Objective: The objective of this study was to assess the graft and functional outcomes of inlay butterfly cartilage-perichondrium graft myringoplasty in an office setting. Material and Methods: Adult patients with chronic perforations underwent inlay butterfly cartilage-perichondrium graft myringoplasty under local and topical anesthesia. The graft and functional outcomes, intraoperative pain score, and complications were evaluated at 6 months postoperatively. Results: A total of 39 patients (39 ears) were included in this study. All patients completed 6 months of follow-up. The mean operation time was 26.5 ± 3.2 (ranged from 21 to 32) minutes. The intraoperative mean pain score was 0.61 ± 0.28. The graft success rate was 97.4% (38/39) at 6 months postoperatively. The mean preoperative air-bone gap (ABG) was 19.18 ± 4.01 dB, while the mean postoperative ABG at 6 months was 10.56 ± 2.27 dB (P < .05; Paired-Samples T Test). The functional success rate was 100.0% (38/38). Endoscopic examination showed that the transplanted perichondrium graft gradually atrophied, flattened, and became indistinguishable from the surrounding tympanic membrane 2 to 3 months following surgery, the superficial layer of perichondrium graft formed the crust and migrated into the external auditory canal at 3 to 6 months postoperatively. Conclusions: Perichondrium-cartilage inlay butterfly myringoplasty is a highly successful and minimally invasive procedure well tolerated by adults for closure of small- and medium-sized perforations in an office setting.

The Effect of Video Streaming With Virtual Reality on Anxiety and Pain During Bone Marrow Aspiration and Biopsy Procedure

BackgroundPain and anxiety are among the most common symptoms in patients undergoing invasive procedures. Increased pain levels tend to worsen anxiety, and anxiety often leads to more frequent or severe pain. AimsThe study was conducted to determine the efficacy of virtual reality goggles (VRG) on pain and anxiety during bone marrow aspiration and biopsy (BMAB) procedure. DesignA randomized controlled experimental study. SettingsThe outpatient unit of an adult hematology clinic of a tertiary care university hospital. Participants/SubjectsThe study was conducted in patients aged 18 years and older who underwent a BMAB procedure. Thirty-five patients in the experimental (VRG) group and 40 patients in the control group. MethodsPatient identification form, visual analogue scale (VAS), state and trait anxiety inventory (STAI), and VRG were used to collect the data. ResultsPostprocedural state anxiety mean scores were found to be statistically significantly higher in the control group than in the VRG group (p = .022). A statistically significant difference was found between groups in terms of procedure-related pain (p = .002). The postprocedural mean pain scores were found to be statistically significantly higher in the control group than in the VRG group (p < .001). A statistically significant but moderate positive correlation was found between the postprocedural pain and preprocedural state anxiety variable (r = 0.477). A statistically significant and strong positive correlation was found between the postprocedural pain and the postprocedural state anxiety variable (r = 0.657). A statistically significant but moderate positive relationship was found between preprocedural and postprocedural state anxiety variables (r = 0.519). ConclusionsWe determined that video streaming with VRG reduces pain and anxiety felt by adult patients during the BMAB procedure. VRG can be recommended to use in controlling pain and anxiety in patients undergoing a BMAB procedure.

Effect Of Flippits Versus Virtual Reality On Pain, Fear, And Satisfaction During Phlebotomy Among Children.

To determine the effect of flippits versus virtual reality on pain, fear and satisfaction among children during phlebotomy. The quasi-experientialstudy was conducted at the Paediatric Medical Department of Kafrelsheikh University Hospital, Egypt, from November 2021 to April 2022, and comprised children of either gender aged 6-12 years. The subjects were randomised into flippits group A, virtual reality group B and control group C in which only traditional care was provided. Data was collected using a structured interview, Wong-Baker Faces Pain Rating Scale, Children's Fear Scale, and Blood Specimen Collection Satisfaction Evaluation Scale. Data was analysed using SPSS 20. Of the 120 children, 40(33.3%) were in each of the three groups. There were 21(52.5%) boys and 19(47.5%) girlsin group A with mean age 8.2±1.6 years, 22(55%) boys and 18(45%) girlsin group B with mean age 7.8±1.7 years, and 27(67.5%) boys and 13(32.5%) girls in group C with mean age 7.9±1.9 years (p>0.05). Mean pain and fear scores were significantly lower and mean satisfaction score was higher in groups A and B than group C (p<0.05). There was no significant difference in the mean pain scores of group A and group B (p>0.05). Flippits and virtual reality interventions had a positive effect on pain, fear and satisfaction levelsin children during phlebotomy.

Efficacy of inferior alveolar nerve block and intraligamentary anesthesia in the extraction of primary mandibular molars: A randomized controlled clinical trial

ObjectiveThe study aims to compare the effectiveness and quality of intraligamentary anesthesia (ILA) and inferior alveolar nerve block (IANB) for primary mandibular molar extraction. MethodsThis prospective, randomized clinical study included patients aged 5 to 13 years scheduled for primary mandibular molar extraction. A total of 208 participants were randomly allocated into two groups (n = 104 each group), IANB and ILA, who were administered 2% lignocaine with epinephrine 1:100,000. Patients rated their pain during injection and extraction (VAS pain score). Frankl’s behavior rating score, quality of anesthesia as perceived by clinician, and duration of procedure were recorded. Demographic and other variables were analysed using Pearson x2 test, Pearson correlation coefficient, Fisher exact test, or an analysis of variance, as appropriate. ResultsIn patients who received IANB, the clinician reported a slightly better quality of anesthesia (p = 0.19) than those who received ILA (VAS score 1.3 ± 0.7 Vs 1.6 ± 0.4). Mean (±SD) score for pain during extraction were found be 1.7 (±0.6) for the IANB group and 1.8 (±0.5) for the ILA group. The clinician observed 46.2% of patients in the IANB group and 39.4% of patients in the ILA group had no discomfort during extraction. Frankl’s behavior score was negatively correlated with the quality of anesthesia and the time taken to complete the extraction (p = 0.017 and p = 0.053, respectively). ConclusionThe efficacy of conventional ILA was similar to IANB, and thus ILA might be a good alternative to the IANB while extracting primary mandibular molars.

(085) Topical Capsaicin for Provoked Vestibulodynia

Abstract Introduction Provoked vestibulodynia (PVD), occurs when pain is localized in the vulvar vestibule and triggered by any vestibular contact (sexual or otherwise). PVD is the most common form of vulvodynia and there is currently no approved treatment. Capsaicin cream is hypothesized to improve vestibular allodynia in patients with neuroproliferative PVD by binding to the vanilloid receptor (TRPV1) on the C- afferent nociceptors and thereby causing defunctionalization of the TRPV1. Although capsaicin has been utilized as a treatment for vulvodynia, very little is known about its effectiveness in improving vestibular pain and sexual function. Objective Investigate the therapeutic potential of capsaicin cream as treatment for PVD. Methods Patients who were prescribed 0.025% capsaicin compounded in VersaBase cream were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed with a prescription list from a compounding pharmacy. Adult patients with documented vulvodynia were included. Female Sexual Dysfunction (FSD) was measured before and after treatment with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Results Twenty-five patients responded to the follow-up questionnaire. Average age at presentation was 30 years (range 18-52 years). Self-reported ethnicity of the study population was 76% White, 4% Latina, 4% Asian, 4% Mixed, and 4% Middle Eastern, with no response from 8% of participants. After consistent daily usage, 80% of patients were able to tolerate capsaicin application for the full 20 minutes. Washing the cream off with cold water was helpful for tolerating capsaicin application for 72% of patients, and 8% of patients found applying a topical anesthetic such as lidocaine helpful. The median amount of time required to increase tolerance to the full 20 minutes was 1-2 weeks. On a VAS scale, the mean pain score while initially applying capsaicin was 8.96, and the median was 10. While 48% of patients found capsaicin improved their vulvar pain, 56% of patients would recommend capsaicin as a treatment for vulvar pain. The mean FSDS score was 35.96 at baseline compared to 25.09 at follow-up (p &amp;lt; 0.0001). On a VAS scale, the mean self-reported vulvar pain score was 8.2 at baseline compared to 5.35 when using capsaicin consistently (p &amp;lt; 0.0001). The mean FSFI pain domain score was 0.98 at follow-up compared to 2.45 at baseline (p = 0.005). While not statistically significant, the mean total FSFI score was 15.44 at baseline compared to 17.84 at follow-up. Conclusions Capsaicin cream is a promising treatment for PVD. Among patients who are able to tolerate consistent daily usage, capsaicin cream significantly decreases vulvar pain. Patients should be counseled that topical capsaicin is initially severely painful, even with the use of topical anesthetics such as lidocaine. Emotional distress and trauma were reported among patients who were not able to tolerate capsaicin application. However, patients who were able to tolerate capsaicin reported feeling “grateful” and “satisfied” with the treatment. Capsaicin cream should be considered for patients who have failed more conservative treatments and proper counseling regarding application should be reviewed. Disclosure No

Evaluation of microMend wound closure device in repairing skin lacerations

BackgroundmicroMend, a novel microstaple skin closure device, may be able to close simple lacerations. This study aimed to evaluate the feasibility and acceptability of using microMend to close these wounds...

Postoperative effects and complications of intrathecal morphine compared to epidural analgesia in patients undergoing intracorporeal robot-assisted radical cystectomy: a retrospective study

BackgroundAnalgesia after robot assisted radical cystectomy aims to reduce postoperative pain and opioid consumption, while facilitating early mobilization and enteral nutrition and minimizing complications. Epidural analgesia is currently recommended for an open radical cystectomy, but it is unclear if intrathecal morphine is a suiting, less-invasive alternative for a robot-assisted radical cystectomy.MethodsThe analgesic method of choice changed from epidural anesthesia to intrathecal anesthesia for patients undergoing a robot-assisted radical cystectomy. This single-center retrospective study aims to investigate if there is a difference between epidural and intrathecal analgesia in postoperative pain scores, opioid consumption, length of hospital stays and postoperative complications. An Propensity Matched Analysis was added to conventional analysis to consolidate the findings.ResultsThe study population consisted of 153 patients of whom 114 received an epidural catheter with bupivacaine/sufentanil and 39 received a single shot of intrathecal bupivacaine/morphine. Mean pain scores on the first two postoperative days (POD) were slightly higher in the intrathecal analgesia group (epidural versus intrathecal analgesia, NRS POD0: 0(0–2)[0–8] versus 1(0–3)[0–5], p = 0.050; POD1: 2(1–3)[0–8] versus 3(1–4)[0–7], p = 0.058; POD2: 2(0–3)[0–8] versus 3(2–4)[0–7], p = 0.010). Total postoperative morphine consumption was similar over the first seven days: 15 mg (5–35)[0–148] in the epidural group versus 11 mg (0–35)[0–148] in the intrathecal morphine group, p = 0.167. Length of hospital stay and time until fit for discharge where slightly higher in the epidural group (respectively 7 days (5–9)[4–42] versus 6 days (5–7)[4–38], p = 0.006, and 5 days (4–8)[3–30]) versus 5 days (4–6)[3–34], p = 0.018). There was no further difference in postoperative course.ConclusionsThis study showed that the effects of epidural analgesia and intrathecal morphine are comparable and that intrathecal morphine may be a suiting alternative for epidural analgesia.

Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial

Background and purposeRadiotherapy is considered a treatment option for Ledderhose disease. However, its benefits have never been confirmed in a randomised controlled trial. Therefore, the LedRad-study was conducted. Materials and methodsThe LedRad-study is a prospective multicentre randomised double-blind phase three trial. Patients were randomised to sham-radiotherapy (placebo) or radiotherapy. The primary endpoint was pain reduction at 12 months after treatment, measured with the Numeric Rating Scale (NRS). Secondary endpoints were pain reduction at 6 and 18 months after treatment, quality of life (QoL), walking abilities and toxicity. ResultsA total of 84 patients were enrolled. At 12 and 18 months, patients in the radiotherapy group had a lower mean pain score compared to patients in the sham-radiotherapy group (2.5 versus 3.6 (p = 0.03) and 2.1 versus 3.4 (p = 0.008), respectively). Pain relief at 12 months was 74% in the radiotherapy group and 56% in the sham-radiotherapy group (p = 0.002). Multilevel testing for QoL scores showed higher QoL scores in the radiotherapy group compared to the sham-radiotherapy group (p < 0.001). Moreover, patients in the radiotherapy group had a higher mean walking speed and step rate with barefoot speed walking (p = 0.02). Erythema, skin dryness, burning sensations and increased pain were the most frequently reported side effects. These side effects were generally graded as mild (95%) and the majority (87%) were resolved at 18 months follow-up. ConclusionRadiotherapy for symptomatic Ledderhose disease is an effective treatment resulting in a significant pain reduction, improvement of QoL scores and bare feet walking abilities, in comparison to sham-radiotherapy.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

Pre-operative sciatic nerve block vs postoperative surgeon-placed perineural stump catheter for prevention of phantom limb pain after below-knee amputation.

A comparison of coblation and modified monopolar tonsillectomy in adults

ObjectiveTo compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.Materials and methodsAdult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.ResultsPain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).ConclusionAlthough pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

Comparing Tubeless and Tubed Approaches in Percutaneous Nephrolithotomy for Moderate Renal Calculi: Outcomes on Safety, Efficacy, Pain Management, Recovery Time, and Cost-Effectiveness.

Introduction This study focuses on investigating the effect of routine nephrostomy tube placement in patients with moderate renal calculi of size 2.5 cm or less who undergo uncomplicated percutaneous nephrolithotomy (PCNL) procedures. Previous studies have not specified whether only uncomplicated cases were included in the analysis, which may affect the results. This study aims to provide a clearer understanding of the effect of routine nephrostomy tube placement on blood loss in a more homogeneous patient population. Materials and methods A prospective randomized controlled trial (RCT) was conducted at our department over 18 months, dividing 60 patients with a single renal or upper ureteric calculus of size ≤2.5 cm into two groups: 30 patients in each group (group 1: tubed PCNL, group 2: tubeless PCNL). The primary outcome was the drop in perioperative hemoglobin leveland the number of packed cell transfusions necessary. The secondary outcome included the mean pain score, analgesic requirement, length of hospital stay, time to return to normal activities, and the total cost of the procedure. Results The two groups were comparable in age, gender, comorbidities, and stone size. The postoperative hemoglobin level was significantly lower in the tubeless PCNL group (9.56 ± 2.13 gm/dL) compared to the tube PCNL group (11.32 ± 2.35 gm/dL) (p = 0.0037), and two patients in the tubeless group required blood transfusion. The duration of surgery, pain scores, and analgesic requirement were comparable between the two groups. The total procedure cost was significantly lower in the tubeless group (p = 0.0019), and the duration of hospital stay and time to return to daily activities were significantly shorter in the tubeless group (p < 0.0001). Conclusions Tubeless PCNL is a safe and effective alternative to conventional tube PCNL, with the advantages of shorter hospital stay, faster recovery, and lower procedure costs. Tube PCNL is associated with less blood loss and the need for transfusions. Patient preferences and bleeding risk should be considered when choosing between the two procedures.

Analgesic stewardship in Australian residential aged care facilities: Retrospective audit of a collaborative approach to optimising opioid use.

To evaluate retrospectively an analgesic stewardship role of a non-dispensing pharmacist as part of a general practice team providing primary care services to residential aged care facilities (RACF). Our general practice implemented an analgesic stewardship program to optimise and monitor opioid usage for our patients located across 12 RACF in Canberra from March 2019 to September 2020. The primary objective was the development of a multidisciplinary chronic pain care plan to document treatment and monitoring strategies for optimising pain control. The pharmacist reviewed and documented existing pain management strategies in a care plan for each patient and discussed recommendations for optimisation with the general practitioner. The general practitioner implemented accepted recommendations and distributed finalised care plans to the RACF. A retrospective audit of care plans was undertaken to assess the outcomes: mean daily oral morphine equivalence to monitor opioid usage, and pain scores to monitor for any potential harm associated with analgesic stewardship. One hundred and sixty-seven residents received an initial care plan. Residents were scheduled for a follow-up care plan after 6 months, which was achieved for 100 residents (60%). Scope for optimising opioid therapy was identified for 47 residents (28%) at baseline and 23 residents (23%) at follow-up. Mean opioid usage and pain scores were reduced at follow-up; 19.4 mg (SD 40.8) versus 13.4 mg (SD 22.8), and 4.2 (SD 2.3) versus 3.9 (SD 2.0), respectively. A systematic, multidisciplinary analgesic stewardship approach may optimise pain management plans and reduce opioid usage in RACF residents.

The Prevalence of Low Back Pain Among Medical Students: A Cross-Sectional Study From Saudi Arabia.

Low back pain is a prevalent and debilitating condition that affects a significant proportion of the adult population. Medical students are particularly vulnerable due to the demands of their rigorous curriculum. Therefore, this study aims to investigate the prevalence and risk factors associated with low back pain among medical students. A cross-sectional survey was conducted among medical students and interns at King Faisal University in Saudi Arabia using a convenience sampling technique. An online questionnaire was distributed via social media applications to explore the prevalence and risk factors for low back pain. Out of 300 medical students who participated in the study, 94% reported experiencing low back pain, with a mean pain score of 3.91 ± 2.0 out of 10. The most common factor that aggravated the pain was prolonged sitting. Logistic regression analysis revealed that sitting for more than eight hours(OR=5.61; 95% CI: 2.92-21.42) and not engaging in physical exercise(OR=3.10; 95% CI: 1.34-6.57) were independently associated with a higher prevalence of low back pain. These findings highlight the increased risk of low back pain among medical students due to prolonged sitting and a lack of physical activity. This study provides evidence of the high prevalence of low back pain among medical students and identifies significant risk factors that exacerbate the condition. It emphasizes the need for targeted interventions to promote physical activity, reduce prolonged sitting, manage stress, and encourage good posture among medical students. The implementation of such interventions could help alleviate the burden of low back pain and improve the quality of life for medical students.

O115 Is humeral head resurfacing still a valid treatment for younger patients? 10-15-year patient follow up data for the global conservative anatomic prosthesis

Abstract Introduction Humeral head resurfacing has fallen out of favour owing to high reported revision rates. We present 10-15 year follow up data for the Global Conservative Anatomical Prosthesis (CAP). Methods Patients who underwent humeral head resurfacing using the Global CAP between March 2005 and May 2010 were contacted via telephone. All operations were performed by a single surgeon. Patients rated pain and satisfaction on a 11-point numerical scale (0-10). Oxford shoulder scores (OSS) and Quick-DASH scores were also completed. Results Some 46 patients (49 resurfacings) were identified. 20 patients were deceased, 3 had been revised, 3 were uncontactable and 1 developed dementia. Complete data was obtained for 19 patients (73% response rate). The mean respondent age at time of surgery was 68.8 years. 68% were female. The principal indication was osteoarthritis (74%). The mean pain score was 2.2 with a mean satisfaction score of 6.9. The mean OSS was 43.1 and mean Quick-DASH 14.1 indicating good shoulder function. When stratified according to age at time of surgery, younger patients (&amp;lt;65) were found to have higher OSS (p=0.036) and lower Quick-DASH scores (p=0.029) at follow up (Mann-Whitney U Test). Conclusion At 10 year follow up, patients who underwent humeral head resurfacing had low pain scores, high satisfaction scores and good patient reported outcome measures. We propose that humeral head resurfacing retains value, particularly for painful osteoarthritis in younger patients who do not wish to undergo total shoulder replacement. The operation is simple and preserves humeral bone stock for future surgery.

Effectiveness of Bromelain in the control of postoperative pain after periodontal surgery: A crossover randomized clinical trial.

This study aimed to compare the analgesic effects of Ibuprofen and bromelain after periodontal surgery. A double-blinded crossover clinical trial was conducted on 22 patients needing two crown lengthening surgeries without bone surgery or with limited bone surgery on two quadrants of the maxilla, with control and test sides. Each quadrant was randomly assigned to bromelain (500 GUD) or ibuprofen (400 mg). Immediately after the surgery and 6 hours after it, the first dose of the drugs was packaged in the same capsules in A and B. Postoperative pain was evaluated during the first 8 hours and on the following day using a visual analog scale (VAS). Using the VAS, the Ibuprofen group showed significantly lower mean pain scores than the bromelain group at 4 hours (P=0.047). In contrast, there were no significant differences between the two groups at 2, 6, 8, 10, 12, 24, and 48 hours (P>0.05). The effectiveness of bromelain for pain control following periodontal surgery was comparable to that of Ibuprofen. Therefore, bromelain can be an efficient replacement for ibuprofen in managing pain after periodontal surgery, especially in patients with gastric ulceration and increased bleeding tendency.

Antepartum depressive symptoms are associated with significant postpartum opioid use

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant. This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization. This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome. The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms. Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

Additive Value of Intranasal Fentanyl on Ibuprofen for Pain Management of Children With Moderate to Severe Headaches: A Randomized Controlled Trial

BackgroundFew studies have evaluated the rapid pain improvement provided by medications for children presenting to an emergency department (ED) with headaches. ObjectiveOur aim was to evaluate pain reduction provided by intranasal fentanyl (INF) compared with placebo in addition to ibuprofen. MethodsA single-center, double-blinded, randomized, placebo-controlled clinical trial was conducted in a tertiary care pediatric ED. All children aged 8–17 years presenting with a moderate to severe headache were eligible. Study participants were randomly allocated to receive INF 1.5 µg/kg (maximum dose of 100 µg) or similar placebo solution. Co-administration of oral ibuprofen 10 mg/kg (maximum dose of 600 mg) was also provided. The primary outcome was the mean pain rating reduction at 15 min. ResultsAmong the 62 participants, the median age was 14 years (interquartile range [IQR] 12–16 years in both groups) and the median initial visual analog scale (VAS) score was 64 (IQR 55–72 in the intervention group; IQR 50–81 in the control group). There was no difference in the mean pain score reduction at 15 min between the two groups (mean difference 2 mm; 95% CI –7 to 11 mm). Mean VAS score reductions were also similar at 30 and 60 min. Adverse events were more frequent in the INF group (risk ratio 2.8; 95% CI 1.29 to 6.22), but all events were minor and transient. No significant differences were found in other outcomes. ConclusionsThis study did not find a benefit from INF for providing additional pain relief in children presenting to ED with headaches.

The bidirectional relationship between chronic joint pain and frailty: data from the Investigating Musculoskeletal Health and Wellbeing cohort

BackgroundPain and frailty are associated, but this relationship is insufficiently understood. We aimed to test whether there is a unidirectional or bidirectional relationship between joint pain and frailty.MethodsData were from Investigating Musculoskeletal Health and Wellbeing, a UK-based cohort. Average joint pain severity over the previous month was assessed using an 11-point numerical rating scale (NRS). Frailty was classified as present/absent using the FRAIL questionnaire. Multivariable regression assessed the association between joint pain and frailty, adjusted for age, sex, and BMI class. Two-wave cross-lagged path modelling permitted simultaneous exploration of plausible causal pathways between pain intensity and frailty at baseline and 1-year. Transitions were assessed using t-tests.ResultsOne thousand one hundred seventy-nine participants were studied, 53% female, with a median age of 73 (range 60 to 95) years. FRAIL classified 176 (15%) participants as frail at baseline. Mean (SD) baseline pain score was 5.2 (2.5). Pain NRS ≥ 4 was observed in 172 (99%) of frail participants.Pain severity was associated with frailty at baseline (aOR 1.72 (95%CI 1.56 to 1.92)). In cross-lagged path analysis, higher baseline pain predicted 1-year frailty [β = 0.25, (95%CI 0.14 to 0.36), p < 0.001] and baseline frailty predicted higher 1-year pain [β = 0.06, (95%CI 0.003 to 0.11), p = 0.040]. Participants transitioning to frailty over one year had higher mean pain scores (6.4 (95%CI 5.8 to 7.1)) at baseline than those who remained non-frail (4.7 (95%CI 4.5 to 4.8)), p < 0.001.ConclusionsThe bidirectional relationship between pain and frailty could lead to a vicious cycle in which each accelerates the other’s progression. This justifies attempts to prevent frailty by addressing pain and to include pain measures as an outcome in frailty studies.