Median Pain Score Research Articles

Clinical utility of trans-sacral magnetic stimulation-evoked sphincter potentials and high-density electromyography in pelvic floor assessment: Technical evaluation.

Faecal incontinence is common and of multifactorial aetiologies, yet current diagnostic tools are unable to assess nerve and sphincter function objectively. We developed an anorectal high-density electromyography (HD-EMG) probe to evaluate motor-evoked potentials induced via trans-sacral magnetic stimulation (TSMS). Anorectal probes with an 8 × 8 array of electrodes spaced 1 cm apart were developed for recording HD-EMG of the external anal sphincter. These HD-EMG probes were used to map MEP amplitudes and latencies evoked via TSMS delivered through the Magstim Rapid2 (MagStim Company). Patients undergoing pelvic floor investigations were recruited for this IDEAL Stage 2a pilot study. Eight participants (median age 49 years; five female) were recruited. Methodological viability, safety and diagnostic workflow were established. The test was well tolerated with median discomfort scores ≤2.5/10, median pain scores ≤1/10 and no adverse events. Higher Faecal Incontinence Severity Index scores correlated with longer MEP latencies (r = 0.58, p < 0.001) and lower MEP amplitudes (r = -0.32, p = 0.046), as did St. Mark's Incontinence Scores with both MEP latencies (r = 0.49, p = 0.001) and MEP amplitudes (r = -0.47, p = 0.002). This HD-EMG probe in conjunction with TSMS presents a novel diagnostic tool for anorectal function assessment. Spatiotemporal assessment of magnetically stimulated MEPs correlated well with symptoms and offers a feasible, safe and patient-tolerable method of evaluating pudendal nerve and external anal sphincter function. Further clinical development and evaluation of these techniques is justified.

Comparison of ultrasound-guided transversalis fascia and posterior transversus abdominis plane block for postoperative analgesia following caesarean delivery: A double-blinded randomised controlled trial.

Posterior-transversus abdominus plane (TAP) block and transversalis fascia plane (TFP) block have been used for postoperative analgesia following caesarean delivery. We compared the analgesic efficacy of the TAP vs TFP plane blocks in patients undergoing elective caesarean delivery. We randomised 90 women undergoing caesarean delivery under spinal anaesthesia to receive either a posterior-TAP (Group-TAP), TFP (Group-TFP) or no block (Group-C) postoperatively. The primary objective was the postoperative analgesic requirements. Secondary objectives were duration of analgesia, pain scores and infra-umbilical sensory loss, which were recorded at specific intervals for 24 h. Statistical analysis was carried out using Statistical Package for Social Sciences version 16.0 software. The patients requiring one, two or nil rescue analgesics were comparable between the interventions and the control (P = 0.32). The duration of analgesia was longer in Group-TAP when compared to Group-C, 4.76 (1.2) vs. 6.89 (2.4); P < 0.001, whereas Group-TFP, 5.64 (2.1) h, was not significantly different from Group-C. The static pain score in Group-TAP was significantly less than that in Group-C at 4 h and beyond 12 h (P < 0.001), whereas Group-TFP was comparable with Group-C at all time points except at 4 h and 24 h (P = 0.002). Only Group-TAP demonstrated midline infraumbilical sensory loss. TAP and TFP blocks did not decrease the rescue analgesic requirement compared with the control group. The posterior-TAP block prolonged the duration of analgesia by 2 h, maintained the median static pain score at 0 beyond 12 h, and demonstrated sensory loss at the infraumbilical dermatomes.

Impact of Dosimetric Parameters on Local Control and Toxicity of Head and Neck SBRT

SBRT is potentially useful as a local therapy for head and neck cancer patients who require re-irradiation, as well as those who may not be candidates for surgical resection or a lengthy course of conventionally fractionated radiation therapy. The objective of this study was to assess rates of local control with SBRT, as well as the impact of mucosal dosimetric parameters on rates of grade 3 or higher toxicity in patients treated with head and neck SBRT. We retrospectively reviewed patients within our institution who underwent SBRT for cancers of the oral cavity and oropharynx between 2013 and 2022. Primary endpoints were local control (LC) and grade 3 or higher toxicity potentially attributable to SBRT, based on CTCAE 5.0. We analyzed the following endpoints as potential predictors of toxicity: 1) ratio of total oral mucosal volume/oral mucosal volume outside of PTV, 2) mean dose to oral mucosa, and 3) maximum dose to oral mucosa. We conducted regression analysis to determine predictors of local failure and severe toxicity. We estimated local control using Kaplan-Meier analysis. We treated 66 tumors in 60 patients with a median age of 71 years. 41 patients (68.3%) had oral cavity cancer and 19 (31.6%) had oropharynx cancer. 64 tumors (97.0%) were squamous cell carcinomas. 32 tumors (48.5%) were previously irradiated. Mean PTV volume was 55 cc (range: 39.4-74.1 ccs). Median prescribed radiation dose was 40 Gy given in 5 biweekly fractions. A total of 51 patients received systemic therapy (platinum-based chemotherapy in 52%, Cetuximab in 38%). 10 patients (16.7%) additionally received immunotherapy, constituting 56% of 18 patients treated from 2019-2022. Median pain score at presentation was 3/10. Oral pain non-significantly increased between 3 weeks and 3 months after starting treatment and subsequently returned to baseline after SBRT (P = 0.227). Local control was 68.5%, at a median follow up of 9.8 months. In oral cavity tumors, 1- and 2-year local control rates were 78.7% and 43.1% respectively. 1- and 2-year rates of LC were 78.9% and 50.2% in oropharynx tumors. Grade 3 or higher toxicities were present in 18 patients (30.0%), including osteonecrosis in 6 (10.0%) and ulceration or extensive tissue necrosis in 12 (20.0%). No significant relationship was present between mucosal surface radiation doses and acute oral mucosa toxicity. On regression analysis for both local control and grade 3 or higher toxicity, we did not find any significant association with prior radiation, disease site, age, or PTV volume. SBRT provided comparable local control for tumors of the oropharynx and oral cavity, with slightly higher 2-year local control in tumors of the oropharynx, and comparable rates of toxicity. We appreciated increased use of immunotherapy in our study population from 2019 onwards. We did not find any relationships between dosimetric parameters and rates of grade 3 or higher toxicity, or local control, though our analysis is limited by a small sample size.

Disparities in Acute Radiation-Related Pain and Dermatitis between Black and White Patients with Early-Stage Breast Cancer Receiving Adjuvant Radiation Following Breast Conserving Surgery

Historically, black patients with cancer experience poor clinical outcomes and low quality of life due to inadequate screening and management of cancer-related treatment toxicities. There are limited data documenting racial disparities in acute radiation-related toxicities (ARRTs) for patients with early-stage breast cancer. Therefore, we compared ARRTs between Black (B) and White (W) patients receiving adjuvant radiation following breast conserving surgery (BCS). This retrospective analysis included 317 patients with stage 0/1 breast cancer treated with adjuvant radiation between October 2019 and February 2022. 29% (N = 81) were B and 71% (N = 236) were W, with an average age of 65 (range: 32-88) for both. We abstracted weekly on-treatment-visit clinical notes (OTVs) completed by a nurse and radiation oncologist who utilized the Common Terminology Criteria for Adverse (CTCAE) v4.0 to evaluate each patient's pain score (scaled 0-10, 0 = no pain and 10 = worst), radiation dermatitis (RD; Grade 0-4), as well as non-CTCAE descriptors of pain and presence of hyperpigmentation or pruritus. We compared onset and severity of pain and rates of RD and pruritus between B and W patients. The proportion reporting pain was significantly lower among B vs. W patients (43.8% vs. 63.6%; P = 0.002). Of patients qualitatively reporting pain, B patients were significantly more likely to have their pain scored as 0 than W patients (24.3% vs. 11.7%; P = 0.024). B patients had significantly lower median pain scores than W patients (P = 0.010), with a median score of 3 (interquartile range [IQR]: 0-5.5) vs. 5 (IQR: 4-8). B patients had a significantly longer time to pain identification than W patients (P = 0.027), with median time to pain of 10th fraction (IQR: 4-13.5) vs. 8th fraction (IQR: 4-11). Radiation dermatitis was graded as 0 (50.6% vs 8.5%; P<0.001), 1 (44.4% vs 82.6%; P<0.001), 2 (14.8% vs 15.3%, P = NS), and 3 (3.7% vs 0.4%; P = 0.023), with no grade 4 RD, amongst B and W patients, respectively. Of note, B patients experiencing mild hyperpigmentation were graded as 0. We found no statistically significant differences in incidence of pruritus. Qualitative and quantitative analyses of ARRTs based on CTCAE v4.0 show discordance in pain scores and radiation dermatitis. The underscoring of pain amongst B patients suggests possible cultural hesitancy to report pain or implicit biases in evaluating pain suggesting the need for alternative ways to discuss and score pain in B patients. Our data suggests that CTCAE does not effectively assess radiation dermatitis in B patients. There are no descriptors of hyperpigmentation in grading of radiation dermatitis in CTCAE, which may lead to underreporting in dark-skinned individuals. Better assessment tools are needed to document ARRTs to ensure appropriate evaluation and treatment across all racial groups.

Effect of low-pressure pneumoperitoneum on pain and inflammation in laparoscopic cholecystectomy: a randomized controlled clinical trial

ObjectiveWe aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers.BackgroundThe standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12–14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines.MethodsA prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8–10 mmHg) vs. standard-pressure (12–14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed.Resultsone hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs. 6, p-value = 0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons.Conclusionlow-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022).

Optimization of Radiofrequency Needle Placement in Percutaneous Cordotomy Using Electromyography in the Deeply Sedated Patient.

Cordotomy, the selective disconnection of the nociceptive fibers in the spinothalamic tract, is used to provide pain palliation to oncological patients suffering from intractable cancer-related pain. Cordotomies are commonly performed using a cervical (C1-2) percutaneous approach under imaging guidance and require patients' cooperation to functionally localize the spinothalamic tract. This can be challenging in patients suffering from extreme pain. It has recently been demonstrated that intraoperative neurophysiology monitoring by electromyography may aid in safe lesion positioning. The aim of this study was to evaluate the role of compound muscle action potential (CMAP) in deeply sedated patients undergoing percutaneous cervical cordotomy (PCC). A retrospective analysis was conducted of all patients who underwent percutaneous cordotomy while deeply sedated between January 2019 and November 2022 in 2 academic centers. The operative report, neuromonitoring logs, and clinical medical records were evaluated. Eleven patients underwent PCC under deep sedation. In all patients, the final motor assessment prior to ablation was done using the electrophysiological criterion alone. The median threshold for evoking CMAP activity at the lesion site was 0.9 V ranging between 0.5 and 1.5 V (average 1 V ± 0.34 V SD). An immediate, substantial decrease in pain was observed in 9 patients. The median pain scores (Numeric Rating Scale) decreased from 10 preoperatively (range 8-10) to a median 0 (range 0-10) immediately after surgery. None of our patients developed motor deficits. CMAP-guided PCC may be feasible in deeply sedated patients without added risk to postoperative motor function. This technique should be considered in a group of patients who are not able to undergo awake PCC.

Patient-reported outcomes after free muscle flap coverage for therapy-resistant neuropathic pain from the ulnar nerve.

Extensive microsurgical neurolysis followed by free gracilis muscle flap coverage can be performed as a last resort for patients with persistent neuropathic pain of the ulnar nerve. All patients who had this surgery between 2015 and 2021 were identified. Data were collected from the medical records of 21 patients and patient-reported outcomes were collected from 18 patients, with a minimum follow-up of 12 months. The median visual analogue pain score decreased significantly 8 months postoperatively from 8.0 to 6.0 and stabilized to 5.4 at the 3-year follow-up. Health-related quality-of-life scores remained diminished compared to normative data. In the treatment of therapy-resistant neuropathic pain of the ulnar nerve, extensive neurolysis with a subsequent free gracilis muscle flap coverage shows a promising reduction of pain that persists at long-term follow-up.Level of evidence: IV.

The Wound Express System, A Potential Treatment for Patients with Ulcers and Non-Operable Arterial Disease: A Pilot Safety Study

Background: Intermittent pneumatic compression (IPC) devices apply intermittent compression to the thigh, which is thought to facilitate wound healing by improving wound perfusion in patients with chronic limb-threatening ischemia and no option for revascularization. Wound Express is an IPC device but its safety and efficacy are currently unclear. In this study, we aimed to determine the safety of the Wound Express IPC system in this high-risk cohort.Methods: This was a prospective, non-controlled, non-randomized pilot safety study. In total, 19 patients were screened for inclusion and 10 were recruited. IPC was applied for 2 hours per day for 12 weeks. The primary endpoint was any treatment-related adverse event in the first 3 months. Secondary endpoints included pain using the visual analogue scale, limb status assessed using the Wound, Ischemia, Foot Infection (WIFi) score and quality of life using the Vascular Quality of Life Questionnaire (VASUQOL) score.Results: Of the 10 patients who were enrolled, eight completed the 12-week course. There were no treatment-related adverse events. One patient died from coronavirus disease 19-related disease and two withdrew for reasons unrelated to treatment. Median pain scores were reduced from 6 to 0, while median VASUQOL increased from 10 to 16.5. WIFi scores were reduced in three out of eight of participants (37.5%).Conclusion: Wound Express appears to be safe and may decrease pain, improve wound healing and improve quality of life for chronic limb-threatening ischemia patients. Adequately powered, prospectively randomized trials of the Wound Express system to assess its efficacy and safety are warranted.

A single-center prospective study on pain alleviation during peroral upper endoscopy with an ultrathin endoscope

BackgroundThe efficacy of transnasal endoscopy using an ultrathin endoscope has been reported in several studies. However, few studies regarding peroral endoscopy with ultrathin endoscopes with high resolution have been reported. This study investigates the pain alleviation of peroral endoscopy with an ultrathin endoscope.MethodsPatients with a history of peroral endoscopy using a conventional, normal-diameter scope with no sedation who underwent peroral esophagogastroduodenoscopy (EGD) using a thin scope between April-July 2022 were included in this study. After the procedure, the patients completed a questionnaire evaluating pain during the examination and willingness to repeat the procedure. The physicians were surveyed regarding their level of satisfaction. The primary endpoint was patient satisfaction, which corresponded to the rate of patients who rated the thin endoscope as more comfortable or somewhat more comfortable than the previously-used, conventional endoscope.ResultsOne hundred and forty-five patients were included in the analyses. Patient satisfaction was achieved in 86.2% (125/145) of patients. The median visual analog scale pain score was 3 (0–7) points in this study, which is significantly lower than the pain score after the previous endoscopy (5 (0–10) points; p < 0.001). In addition, 96% (24/25) of patients who underwent EGD by an expert and 95.8% (115/120) who underwent EGD by a non-expert were willing to repeat endoscopy using the thin scope (p = 0.69).ConclusionPeroral endoscopy using a thin scope reduces patient pain regardless of the endoscopist’s experience.

Best analgesia control in pancreatic adenocarcinoma study: justification and feasibility of a randomised trial of early EUS-CPN versus standard care—a prospective observational study (The BAC-PAC study)

IntroductionLimited and conflicting trial data is available on the efficacy of Endoscopic Ultrasound-guided Coeliac Plexus Neurolysis (EUS-CPN). This study aimed to assess the feasibility, justification and to inform design considerations of a randomised trial of early EUS-CPN versus standard care.MethodsThis was a questionnaire-based prospective observational study of patients with inoperable pancreatic adenocarcinoma who were self-reporting their performance status, pain levels, analgesic use, quality of life (QoL) and healthcare resource use, on a monthly basis.ResultsOver a total period of twelve months 143 patients were screened for eligibility, of which 56 met the criteria. In total, 12 (21%) patients were recruited. The median survival from the first record of pain was 5.2 (IQR 2.46–5.9) months. In total, 80% of the questionnaires were completed. The median Visual Analogue Score for pain was 2.6 (0.8–5.1) and the median daily morphine dose was 36 (20–48) mg.DiscussionRecruitment rates remained low throughout this study. Despite these limitations, overall, this study supports the justification of trial administering endoscopic analgesia. However, uncertainties remain with regards to its feasibility. In a future trial, data collection procedures need to minimise burden to patients. Further observational research with a larger sample size, longer follow-up and refined procedures is required.

Loop Excision for Precancers of the Uterine Cervix: Local or General Anaesthetic?

In Germany, treatment of HSIL or AIS of the uterine cervix by loop excision is performed almost exclusively under general anaesthesia (GA). International studies and guidelines show high acceptance of local anaesthesia (LA) due to hermeneutic, medical, and economic factors. We performed an observational comparative study aiming to prove advantages of local anaesthesia within the German health system. In a prospective observational study, patients diagnosed with HSIL or AIS of the uterine cervix were treated at the Institute for Cytology and Dysplasia, Berlin, by loop excision in 2021. We started with a feasibility study : 303 patients diagnosed with HSIL/AIS of the uterine cervix and her colposcopist answered an electronic questionnaire with respect to loop excision under LA. Since we found a high acceptance for LA in patients and colposcopists, we initiated a comparative study LA vs. GA: 322 patients underwent loop excision and selected their mode of anaesthesia: n=206 LA vs. n=116 GA. 114 patients of the feasibility study had to undergo loop excision and became part of the comparative study (n=79 for the LA group, n=35 for the GA group). All patients received a standardised questionnaire to document their pain score within 24h after treatment on a visual analogue scale, i.e. VAS, between 0 and 100. 178 patients of the LA group and 80 patients of the GA group completed and returned the questionnaire and form the cohort for our comparison of LA vs. GA. With 191 of these 258 patients, i.e. 74%, a telephone survey was performed to ask for patient satisfaction and the rates of recurrence after a mean interval of 1 year post surgery. We postulate that there will be no clinically relevant significant difference in satisfaction and postoperative pain between patients in the LA group and the GA group. In the feasibility study , 90% (272 of 303) of patients diagnosed with HSIL or AIS were considered eligible for LA by their colposcopists. 75% (227 of 303) of patients were open to loop excision under LA. In the comparative study , 63 of 206 women of the LA group were interviewed preoperatively: 89% would accept a pain score above 20 during the procedure, 33% a pain score above 50 and 11% of max. 20. Postoperatively, the median VAS pain score for loop excision under local anaesthesia was 13.1 in 178 patients, and pain during injection of local anaesthesia was 20.9 (p<0.001). The VAS pain score 20 minutes post surgery did not differ significantly between 178 patients after local anaesthesia versus 80 patients after general anaesthesia (p=0.09). The surgeons estimated the patient's pain significantly less than the patients themselves with an underestimate of -14.63 points on the VAS (p<0.001). Within 7 days following loop excision under LA, 95.5% of 178 patients would choose local anaesthesia as their preferred method for a potential repeat loop excision, 8.8% of which would like additional painkillers, and 4.5% would choose general anaesthesia.In a telephone follow-up survey of 133 women from the LA group after a mean of 12 months post surgery, 97% were "satisfied" or "very satisfied" with the treatment carried out. For patient satisfaction and postoperative pain, no clinically relevant significant difference was seen between the LA and the GA group.The rate of secondary bleeding (6.7% vs. 8.1%, p=0.72), recurrence of HSIL/AIS (3.6% vs. 5.2%, p=0.62), and the distribution of the histopathological R status (R0 89.5% vs. 81.1%, p=0.73; R1 5.3% vs.12.2%, p=0.57, Rx 4.1% vs. 5.4%, p=0.65) showed no significant difference when comparing the LA group versus the GA group. Following loop excision under local anaesthesia, more than 95% of patients would choose this method again for repeat surgery. One year post surgery, 97% of the patients were "satisfied" or "very satisfied" with the treatment under local anaesthesia. Offering local anaesthesia for loop excision to patients should be mandatory and included in current guidelines.

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

Temporal characterization of acute pain and toxicity kinetics during radiation therapy for head and neck cancer. A retrospective study.

Pain during Radiation Therapy (RT) for oral cavity/oropharyngeal cancer (OC/OPC) is a clinical challenge due to its multifactorial etiology and variable management. The objective of this study was to define complex pain profiles through temporal characterization of pain descriptors, physiologic state, and RT-induced toxicities for pain trajectories understanding. Using an electronic health record registry, 351 OC/OPC patients treated with RT from 2013 to 2021 were included. Weekly numeric scale pain scores, pain descriptors, vital signs, physician-reported toxicities, and analgesics were analyzed using linear mixed effect models and Spearman's correlation. Area under the pain curve (AUCpain) was calculated to measure pain burden over time. Median pain scores increased from 0 during the weekly visit (WSV)-1 to 5 during WSV-7. By WSV-7, 60% and 74% of patients reported mouth and throat pain, respectively, with a median pain score of 5. Soreness and burning pain peaked during WSV-6/7 (51%). Median AUCpain was 16% (IQR (9.3-23)), and AUCpain significantly varied based on gender, tumor site, surgery, drug use history, and pre-RT pain. A temporal increase in mucositis and dermatitis, declining mean bodyweight (-7.1%; P < 0.001) and mean arterial pressure (MAP) 6.8 mmHg; P < 0.001 were detected. Pulse rate was positively associated while weight and MAP were negatively associated with pain over time (P < 0.001). This study provides insight on in-depth characterization and associations between dynamic pain, physiologic, and toxicity kinetics. Our findings support further needs of optimized pain control through temporal data-driven clinical decision support systems for acute pain management.

Efficacy, Safety, and Pain Level of Subcutaneous Catheter Use for Administration of Granulocyte Colony-Stimulating Factor (G-CSF) in Children With Cancer: A Randomized Pilot Study.

Background: The aim of this study was to explore the efficacy, safety, and pain level of granulocyte colony-stimulating factor (G-CSF) administration via a subcutaneous catheter compared with direct injection in children with cancer. Method: This was a pilot randomized controlled trial of standard G-CSF administration versus subcutaneous catheter administration. Children 2-15 years of age who were beginning G-CSF after their first chemotherapy cycle and anticipated to receive G-CSF following the next three cycles of chemotherapy were eligible. Efficacy, safety, and pain were as outcomes of the study. Results: Twenty-nine children with cancer (median age 12 years) were enrolled in the study (16 children in the subcutaneous catheter group and 13 children in the direct injection group). During Cycle 2, the median number of days to reach absolute neutrophil count (ANC) ≥ 500/mm3 was greater among those in the subcutaneous catheter group (12 vs. 10; p = .02). In Cycle 3, however, the subcutaneous catheter group received fewer doses of G-CSF (8 vs. 12; p = .004). No complications related to subcutaneous catheter use were observed. No differences in the visual analog scale pain score were observed between groups in Cycles 1 to 3; however, in Cycle 4, children in the subcutaneous catheter group had lower median pain scores than those in the direct subcutaneous injection group (Mdn = 0, [IQR] = 0-2 vs. Mdn = 1, IQR = 0-6; p < 0.01). Conclusion: Results demonstrated administering G-CSF via a subcutaneous catheter enables ANC to recover with no pain or complications associated with its use. Thus, oncology teams may consider this administration method to be used in children with cancer.

It's Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate.

Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established. A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined. Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery. The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.

Safety and feasibility of percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting: a pilot study.

The objective of this study is to evaluate the safety and feasibility of the combined simultaneous percutaneous needle tunneling coupled with injection of platelet-rich plasma in the outpatient department for the treatment of Peyronie's disease. This prospective, non-randomized, cohort and preliminary study included patients who underwent this procedure from November 2020 to July 2022. The main outcome was an improvement in penile curvature. Fifty-four patients were enrolled and underwent 6 sessions under local anesthesia followed by vacuum therapy for the treatment of Peyronie's disease in our outpatient unit. The amendment of the curvature angle was significant with a median correction percentage of -44.40% interquartile range (-66.70 to (-39.70)), [p-value = 0.001, 95% CI (-29.76 to (-18.02)), paired Student's t-test]. The median pre-treatment curvature angle was 45° (40-75), and the median post-treatment was 30° (20-40). The median score for pain during the procedure was 3 (0-4.25) according to a 10-point visual analogic scale. After two hours, 20.37% of patients still had pain but none required any pain medication. 50% of patients had a minor hematoma and 75.93% patients reported penile ecchymosis. A single patient reported an injection site skin infection. In our experience percutaneous needle tunneling with platelet-rich plasma injections for Peyronie's disease in the outpatient setting is a safe, effective, and feasible treatment of penile deformity for PD.

Transvaginal natural orifice specimen extraction surgery for 3D laparoscopic radical cystectomy: A cohort study.

Transvaginal natural orifice specimen extraction surgery (NOSES) has been widely used in laparoscopic surgery due to its benefits. However, laparoscopic radical cystectomy (LRC) with NOSES has rarely been reported. A retrospective analysis of 25 patients who underwent 3D LRC with NOSES from November 2014 to November 2019 was performed. The clinical and perioperative related data, peri and postoperative complications, and oncologic outcomes were recorded. Surgery was successfully completed in 25 patients, and none were converted to open surgery. Mean total operative time was 294.1 ± 48.80 min. Mean NOSES time was12 ± 6.48 min. The median post-op hospital stay was 10.5 d (range 6-27 d). The median visual analog pain score on post-op day 1, 2, and 3 was 2, 2, and 1, respectively. Thirteen patients had 30-day complications (3 had Clavien grade I and 11 had Clavien grade II). Pelvic floor distress inventory-short form 20 (PFDI-20) was 9.8 ± 1.9 after three months (compared with pre-PFDI-20, P = 0.06) and 9.3 ± 1.2 after six months (compared with pre-PFDI-20, P = 0.15). At the mean follow-up of 24.7 ± 12.05 months (range 11-60 months), one patient (4%) had recurrence, two (8%) had metastasis, and one (4%) died. Transvaginal NOSES in 3D LRC is safe and feasible. Understanding the female vagina anatomy and comprehending the techniques is conducive to avoid incision-related complications. NOSES is minimally invasive with good cosmetic outcomes with few surgical complications or affecting pelvic floor function.

Effectiveness of Infrared and William Flexion Exercise on Reducing Pain and Increasing Flexibility in Patients with Low Back Pain

Introduction: The condition of low back pain is a musculoskeletal problem without age limit. Patients with lower back pain tend to take analgesic drugs to reduce pain. Apart from pharmacological consumption, the tendency for low back pain sufferers to seek other alternatives, namely; physiotherapy treatment. One of the physiotherapy treatments for low back pain is giving infrared and William flexion exercise or a combination of both. This study aims to determine the effectiveness of infrared and William flexion in reducing pain and flexibility of the lumbar muscles. Method: The research design is quasi experimental pre-posttest with control group. The study population consisted of 44 patients with low back pain at Physiomar Clinic by dividing 40 samples into intervention groups (William flexion exercise) and control group (Infrared and William Flexion Exercise) 2 times/week for 1 month. The pain level measured by using the Visual Analog Scale (VAS) and flexibility using the Modified Schober Test (MST). The data was analyzed by Wilcoxon and Mann Whitney (α≤0.05). Results: This study in intervention group showed a median pre-post pain score of 6.00-5.00 and a median pre-post flexibility value of 3.00-3.00 (p=0.000); while control group showed a median pre-post pain score of 6.00-2.00 and a median pre-post flexibility value of 2.50-10.00 (p=0.000). The combination of infrared and William flexion exercise is better than William flexion exercise for changes in pain and flexibility in low back pain patients at the physiomar clinic

The Efficacy of Pericapsular Nerve Group Block Versus Facia Iliaca Block on Immediate Postoperative Pain and Opioid Consumption After Hip Arthroscopy Randomized Trial

BACKGROUND: Postoperative pain after hip arthroscopy remains a major cause of patient dissatisfaction in the immediate postoperative period. Adequate postoperative analgesia is associated with increased patient satisfaction, earlier mobilization, and decreased opioid consumption. OBJECTIVES: Therefore, there is a need for safe, reliable, and opioid- and motor-sparing methods of achieving postoperative analgesia following hip arthroscopy. We evaluated the efficacy of pericapsular nerve group (PENG) block vs fascia iliaca block (FIB) in reducing postoperative pain and analgesic consumption in the first 24 hours following hip arthroscopy. STUDY DESIGN: A prospective randomized double-blinded control clinical trial. SETTING: At the arthroscopy unit of the orthopedic department of Assiut University Hospitals, Assiut, Egypt from 2019 to 2022. METHODS: Forty-three patients comprising 18 women and 25 men scheduled for hip arthroscopy were randomized to receive a preoperative block with PENG or FIB from March 2019 to March 2022. The mean age was 27.9 years (standard deviation [SD], 6.2 years; range, 18-42 years) and the mean body mass index was 25.13 kg/m2 (SD, 5.08 kg/m2). Patients were randomized into 2 groups: group A comprising 20 patients that received FIB; and group B comprising 23 patients that received PENG block. The efficacies of FIB and PENG block were evaluated using Visual Analog Scale scores. RESULTS: Statistically significant differences in median pain scores and mean at rest pain scores were observed between the 2 groups at all measured time points following surgery (i.e., 6, 12, 18, and 24 hours). Further, dynamic pain scores (with hip flexion) scores significantly differed between the 2 groups at 24 hours postoperatively (P = 0.001). PENG block significantly decreased postoperative opioid use compared to FIB. Total opioid use in the 24-hour postoperative period was lower in the PENG group compared to the FIB group (16.5 ± 9.9 vs 27.5 ± 9.6; P &lt; 005). LIMITATIONS: Different hip pathologies and different interventions lead to different outcomes. Also, a larger sample size and longer follow-up duration are required. CONCLUSIONS: PENG block may represent the ideal regional anesthesia modality for hip arthroscopy as an alternative to more conventional regional nerve blocks, such as FIB, femoral nerve block, and lumbar plexus block. PENG block is reproducible, easily performed in the preoperative setting, and appears to spare motor function while providing prolonged sensory analgesia. KEY WORDS: Pericapsular, nerve group block, fascia iliaca block, peripheral nerve blocks, hip arthroscopy

Oral versus intravenous acetaminophen for perioperative pain management in adult patients undergoing non-cardiac surgery: A quantile segmented regression analysis

Study objectiveDetermine whether preferential use of perioperative enteral acetaminophen is associated with changes in perioperative pain, narcotic administration, or time to meeting criteria for post anesthesia care unit (PACU) discharge, compared to preferential parenteral administration. DesignRetrospective Cohort with quantile segmented regression analysis. Groups determined by date of surgery, one year pre-initiative and one year post-initiative. SettingOperating room and PACU of a tertiary academic medical center. PatientsAdult (age > 18 years), ASA status 1–5, non-pregnant patients undergoing non-cardiac surgery of less than six hours duration admitted to the PACU postoperatively. InterventionsA multidisciplinary initiative to preferentially utilize enteral over parenteral acetaminophen. MeasurementsThe primary outcome was narcotic consumption in the PACU. Secondary outcomes were intraoperative narcotic administration, pain score on PACU admission and discharge, and time to meeting criteria for PACU discharge. Results24,701 patients were included in the analysis; 12,379 had surgery prior to the initiative and 12,322 after. Enteral acetaminophen administration increased preoperatively from 13.49% to 26.84%, and postoperatively from 43.16% to 51.45%, while intraoperative parenteral APAP use dropped from 43.23% to 6.81%. Quantile Segmented regression analysis after adjusting for period (pre versus postintervention), day, age, gender, inpatient status, and ASA class demonstrated a decrease in adjusted median perioperative acetaminophen dose (−175 mg P < 0.001), with no significant difference in level change of intraoperative or PACU narcotic administration. There was no significant difference in median time to meet criteria for PACU discharge, though there was a significant change in the slope, (−0.36, p = 0.007.)Median pain scores measured on a standard 0–10 numeric rating scale at PACU admission did not change, while median pain scores at PACU discharge decreased slightly (−0.24 p < 0.001). There was no change in the probability of PONV. Conclusion: In adult patients undergoing non-cardiac surgery of <6 h duration, preferential use of enteral rather than parenteral acetaminophen is associated with non-inferior outcomes in narcotic requirements, pain scores, time to PACU discharge, and probability of PONV when compared with routine parenteral administration. Further studies are needed to validate these findings.