Morphine Equivalent Dose Research Articles

Short-term pain control after palliative radiotherapy for uncomplicated bone metastases: a prospective cohort study.

This study aimed at evaluating the efficacy of different radiotherapy (RT) fractionation regimens in managing uncomplicated painful bone metastases (BM) and identifying predictive factors for pain control. Patients with 1 to 4 symptomatic BM from any primary solid tumors and a life expectancy exceeding 3months were included in the study and received palliative RT, with SBRT restricted in the context of oligometastatic disease or in patients with good prognosis. Pain analysis using the Brief Pain Inventory (BPI) tool was conducted at baseline, 1 and 3months after RT. Analgesic intake was recorded as morphine-equivalent doses (OME). Pain response was assessed using the International Consensus on Palliative Radiotherapy Endpoint (ICPRE). Multivariate logistic regression analyzed patient-related, tumor-related, and treatment-related factors predicting BM pain control at 3months post-RT. From Feb 2022 to Feb 2023, 44 patients with 65 symptomatic BM were investigated. Breast (32%) and lung (24%) tumors were the most common primary tumors. Treatment plans included 3DCRT (60%) and VMAT (40%), with a median biological effective dose for tumors (BED) of 29Gy [14-108]. All patients completed the 3-month follow-up. Pain response rates were 62% at 1month and 60% at 3months. Responders had better PS ECOG scores (67%; P = 0.008) and received active systemic therapies (67%: P = 0.036). Non-responders had lower pretreatment BPI (mean: 13.7 vs. 58.2; P = 0.032), with significantly higher values after 1month (mean: 9.1 vs. 5.3, P = 0.033). Baseline BPI (OR: 1.17; 95% CI: 1.032-1.327; P = 0.014) and BPI at 1month (OR: 0.83; 95% CI: 0.698-0.976; P = 0.025) were independent predictors of pain response at 3months. Our findings show that palliative RT ensured short-term pain control in patients with BM, regardless of tumor type and dose-fractionation regimen. A larger sample size and a longer follow-up could potentially identify which patients are likely to benefit most from RT, and which fractionation might be indicated for achieving a durable pain relief. A multidisciplinary approach is paramount to provide a better care to BM patients.

Sex Differences in Opioid Administration After Cardiac Surgery

ObjectivesAre there sex-based differences in the administration of opioid analgesic drugs among inpatients after cardiac surgery? DesignThis is a retrospective cohort study. SettingA tertiary academic referral centre. ParticipantsAdult patients who underwent cardiac surgery from 2014 to 2019. InterventionsNone Measurements and Main ResultsThe primary outcome was the cumulative oral morphine equivalent dose (OMED) for the post-operative admission. Secondary outcomes were the daily difference in OMED and the administration of non-opioid analgesics. We developed multivariable regression models controlling for known confounders, including weight and length of stay.A total of 3,822 patients (1,032 women and 2,790 men) were included. The mean cumulative OMED was 139 mg for women and 180 mg for men, and this difference remained significant after adjustment for confounders (adjusted mean difference [aMD], -33.21 mg; 95% confidence interval [CI], -47.05 to -19.36 mg; p < 0.001). The cumulative OMED was significantly lower in female patients on postoperative days 1 to 5, with the greatest disparity observed on day 5 (aMD, -89.83 mg; 95% CI, -155.9 to -23.80 mg; p = 0.009). By contrast, women were more likely to receive a gabapentinoid (OR, 1.91; 95% CI, 1.42 to 2.58; p < 0.001). We found no association between patient sex and the administration of other non-opioid analgesics or specific types of opioid analgesics. We found no association between patient sex and pain scores recorded within the first 48 hours following extubation, or the amount of opioid administered in close proximity to pain assessments. ConclusionsFemale sex was associated with significantly lower amounts of opioid administered after cardiac surgery.

The Impact of Enhanced Recovery After Surgery Protocol Implementation on Postoperative Pain Management in the Era of Opioid Crisis: The Post- Chemotherapy Open RPLND Experience.

Enhanced Recovery After Surgery (ERAS) protocols have been proven to optimize postoperative outcomes; however, misuse of opioid analgesics can still hinder postoperative recovery due to related side effects and potential complications. To determine if the implementation of ERAS protocol in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) patients could help with reducing postoperative pain and opioid use. A case-control study of consecutive testicular cancer patients with indications for PCRLPND, who were offered Conventional Post-operative Management (CPM) or ERAS protocol. Outcomes of interest included Visual Analogue Scale (VAS)-assessed pain level at postoperative days 3, 7, and 30, and Morphine-Equivalent Doses (MEDs)/postoperative day. Intraoperative parameters and postoperative complications were recorded. Parametric and non-parametric tests were used for statistical analysis. In total, 100 opioid-naïve PC-RPLND patients were studied. CPM and ERAS groups (36 and 64 patients, respectively) had similar demographic and baseline clinical characteristics). ERAS group patients had significantly lower blood loss (p = 0.005), blood transfusion rate (p < 0.001), and duration of the procedure (p < 0.001). Post-operative complications were comparable between groups. Nausea and bowel disorders were numerically but not statistically more frequent in the CPM group. ERAS patients had shorter mean hospital stay (5.3 ± 1.4 vs. 7.4 ± 1.6 days, p < 0.001), lower daily MEDs (4.73 ± 2.63 vs. 7.04 ± 2.29, p < 0.001), and lower VAS scores on post-operative day 7 (3.89 ± 1.07 vs. 4.67 ± 1.17, p = 0.001). Post-operative pain was similar between groups on post-operative days 3 and 30. Systematic implementation of ERAS protocol after PC-RPLND improves pain management, optimizes patient recovery, and prevents over-prescription of opioid analgesics.

Sickle Cell Disease and Comorbid Psychiatric Conditions: A Single-Center Retrospective Study

Introduction: It is established that patients with various chronic disease states are predisposed to psychiatric comorbidities. However, in the sickle cell disease (SCD) patient population, psychiatric comorbidities have been uniquely shown to exacerbate disease through a psychosomatic component. A co-existing diagnosis of depression is found in 1 of 3 patients with SCD, and they are more than 5 times as likely to suffer from a mood disorder than the general population. SCD patients with psychiatric illnesses have significantly worse physical and mental health outcomes. Additionally, healthcare costs are more than double for SCD patients with depression than for those without. Thus, SCD patients with psychiatric comorbidities have unique challenges and are an important population to study. Methods: This was a retrospective single-center study of patients with SCD, all genotyped and ≥16 years old, who were treated at UT Physicians Comprehensive Sickle Cell Center during the study period (March-July 2023). The demographics, clinical characteristics, psychiatry history, initial and recent PHQ-9 results, and laboratory findings were collected and analyzed. Descriptive statistics were obtained and analyzed between SCD patients with and without psychiatric disorders and are presented in percentages, medians, and interquartile ranges. Data analysis was completed using a p value &amp;lt; 0.05 to indicate statistical significance, using an independent group unpaired t-test for continuous variables and Chi-square and Fisher's exact tests for categorical data, respectively. Data was analyzed using GraphPad Prism version 9.0.2. Results: Patient sex was 45% male and 55% female; 73% of patients had the HbSS genotype. Of the studied cohort, 33% were affected by at least one psychiatric disorder. The most common psychiatric disorder was depression, which occurred in 26% of patients, followed by anxiety (21%). The most common pharmacotherapy for psychiatric conditions was tricyclic antidepressants (TCAs), followed by SSRIs and SNRIs. There was no significant difference in ED visits or hospitalization rates between patients with known psychiatric disorders versus those without. Common laboratory markers used to assess SCD (LDH, total bilirubin, reticulocyte count) were overall higher in the subset with psychiatric illnesses, but only LDH was statistically significantly higher. Surprisingly, SCD patients with psychiatric disorders used fewer opioids than those without with a lower Morphine Equivalent Daily Dose (although this was not statistically significant). Conclusion: Although it is known that psychiatric illnesses in SCD patients are prevalent, exacerbate disease, and pose a cost burden, in our study there was nosignificant increase in hospitalizations or ED visits. However, it is notable that our study patient population was an outpatient population that is compliant and generally has access to resources including a robust behavioral health team and regular psychotherapy sessions. Due to these factors, ourdata may not be generalizable to the entire SCD patient population. Additionally, althoughlaboratorymarkers were overall poorer in the psychiatric population, they were not statistically significant, perhaps owing to the small sample size. Our study calls for a broader look at SCD patients with psychiatric illness, perhaps also to review these variables in SCD patients in the inpatient setting. A future direction could also be to evaluate the efficacy of psychiatric pharmacotherapy versus cognitive behavioral therapy in this patient population. Word count: 518 words

Perioperative Opioid Use and Dosage Trajectories Vary Depending on Pain Outcome Classification and Bodily Pain in Patients who Catastrophize About Their Pain: A Secondary Analysis of a Randomized Trial in Knee Arthroplasty

Opioid use and dosage following knee arthroplasty (KA) has not been reported for subgroups with persistent moderate pain versus rapidly improving mild pain, externally validated from prior work. We determined if opioid use and dosage varied for persons classified into these externally validated subgroups. A secondary purpose determined if bodily pain scores are associated with the outcome subgroup. This was a secondary analysis of a prospective no-effect randomized clinical trial conducted on 384 participants with pain catastrophizing and scheduled for KA. Data were collected preoperatively and at 2-, 6-, and 12-month following surgery. Two-piece latent class growth curve analyses applied previously validated pain outcomes to determine subgroup outcome trajectories for the proportion of opioid users and oral morphine equivalent (OME) dosages. Substantial trajectory separation was found for opioid use and OME. Specifically, the average OME dosage for the persistent moderate pain subgroup was more than double that for the other outcome subgroup. The average preoperative opioid daily OME dosage for 170 patients reporting opioid use was 24.94 (95% [confidence interval] CI = 20.52, 29.38). Bodily pain was consistently higher for the persistent moderate pain subgroup compared to the other subgroup. Outcome subgroups in patients with pain catastrophizing demonstrated substantial differences in opioid use and dosage and were predicted by high pain catastrophizing, more bodily pain, and changes in bodily pain over time. The persistent moderate pain subgroup is at greater risk of opioid use and greater opioid dosages and should be targeted for preoperative screening and interventions to reduce opioid use and potential opioid misuse. PerspectiveMore frequent and higher opioid dosage following KA was found for the persistent moderate pain subgroup compared to the other subgroup. Patients with persistent pain had worse catastrophizing, contralateral and ipsilateral lower extremity pain, low back pain, and whole body pain compared to the rapidly improving mild pain subgroup.

Comparison of different sustained-release opioids and acute respiratory conditions in patients with cancer and chronic kidney disease.

Few data are available on the association between the use of oxycodone in patients with chronic kidney disease (CKD) and acute respiratory conditions. The aim of this study was to investigate whether oxycodone is associated with an increased risk of acute respiratory conditions in patients with cancer and CKD compared with other opioids. The data were obtained from a claims database in Japan. Patients with cancer and CKD who had received sustained-release opioids, including oral oxycodone, oral morphine, or transdermal fentanyl, between April 2014 and May 2021 were selected. The primary outcome was defined as an acute respiratory condition. Data for age and sex, morphine equivalent daily dose, concomitant use of specified medications, comorbidities defined based on the modified Charlson comorbidity index, substance use disorder, and lung cancer or metastatic lung cancer were investigated as covariates. Distribution of acute respiratory conditions was compared among the three sustained-release opioid groups using the log-rank test. Estimates of the incidence of acute respiratory conditions were compared among the groups using a Cox proportional hazards model with time-varying variables. A significant difference in the distribution of acute respiratory conditions was found among the three groups (p < 0.01). Cox regression analysis showed a significantly higher risk of acute respiratory conditions with morphine (hazard ratio [HR]: 3.04, 95% confidence interval [CI]: 1.07-8.65, p = 0.04) compared with oxycodone but no significant difference in risk with oxycodone (HR 0.67, 95% CI: 0.32-1.38, p = 0.27) compared with fentanyl. The findings suggest that the risk of acute respiratory conditions may be lower in patients with CKD who use oxycodone for cancer pain than in those who use morphine. Additionally, no difference in the risk of acute respiratory conditions was found between oxycodone and fentanyl use.

Intrathecal cervical analgesia for cancer pain: a 12-year follow-up study in a comprehensive cancer center

BackgroundIntrathecal analgesia plays a key role for patients suffering refractory cancer pain. Nevertheless, intrathecal drug delivery systems (IDDS), requiring a cervical catheter tip implantation, have been poorly described in medical...

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial.

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Opioid dose titration for cancer pain.

Opioid dose titration is a fundamental process of opioid therapy in cancer pain. To assess data opioid dose titration. The principal opioid dose titration methods, outcomes, and modalities of administration regarding the different opioid preparations were examined in different clinical contexts. Most studies suggested that opioid-naive patients should be started at doses of 15-30 mg/day of oral morphine equivalents. Opioid-tolerant patients may receive low or higher doses of oral morphine equivalents, depending on the level of opioid tolerance. Generally, dose increments of 30%-50% seem to be indicated to start dose titration. Some patients with severe excruciating cancer pain may present as an emergency requiring a rapid application of powerful analgesic strategies. The intravenous use of opioids may circumvent this problem providing a faster pain relief, due to the large availability and rapid achievement of effective plasma concentrations. Opioid dose titration is a delicate passage in patients with cancer pain. This approach may be different according to different clinical conditions. Opioid dose titration requires expertise to optimize cancer pain management while minimizing the development of adverse effects. While most approaches are meaningful and partially supported by existing literature, more studies are necessary to establish advantages and disadvantages in different clinical conditions. Optimization of opioid dose titration is of paramount importance. This review provides the most recent insights on the different modalities of opioid dose titration in cancer pain management.

Appendectomy Pain Medication Prescribing Variation inthe U.S. Military Health System.

Post-appendectomy opioid prescription practices may vary widely across and within health care systems. Although guidelines encourage conservative opioid prescribing and prescribing of non-opioid pain medications, the variation of prescribing practices and the probability of opioid refill remain unknown in the U.S. Military Health System. This retrospective observational cohort study evaluated medical data of 11,713 patients who received an appendectomy in the Military Health System between January 2016 and June 2021. Linear-mixed and generalized linear-mixed models evaluated the relationships between patient-, care-, and system-level factors and the two primary outcomes; the morphine equivalent dose (MED) at hospital discharge; and the probability of 30-day opioid prescription refill. Sensitivity analyses repeated the generalized linear-mixed model predicting the probability of opioid (re)fill after an appendectomy, but with inclusion of the full sample, including patients who had not received a discharge opioid prescription (e.g., 0 mg MED). Discharge MED was twice the recommended guidance and was not associated with opioid refill. Higher discharge MED was associated with opioid/non-opioid combination prescription (+38 mg) relative to opioid-only, lack of non-opioid prescribing at discharge (+6 mg), care received before a Defense Health Agency opioid safety policy was released (+61 mg), documented nicotine dependence (+8 mg), and pre-appendectomy opioid prescription (+5 mg) (all P < .01). Opioid refill was more likely for patients with complicated appendicitis (OR = 1.34; P < .01); patients assigned female (OR = 1.25, P < .01); those with a documented mental health diagnosis (OR = 1.32, P = .03), an antidepressant prescription (OR = 1.84, P < .001), or both (OR = 1.54, P < .001); and patients with documented nicotine dependence (OR = 1.53, P < .001). Opioid refill was less likely for patients who received care after the Defense Health Agency policy was released (OR = 0.71, P < .001), were opioid naive (OR = 0.54, P < .001), or were Asian or Pacific Islander (relative to white patients, OR = 0.68, P = .04). Results from the sensitivity analyses were similar to the main analysis, aside from two exceptions. The probability of refill no longer differed by race and ethnicity or mental health condition only. Individual prescriber practices shifted with new guidelines, but potentially unwarranted variation in opioid prescribing dose remained. Future studies may benefit from evaluating patients' experiences with pain management, satisfaction, and patient-centered education after appendectomy within the context of opioid prescribing practices, amount of medications used, and refill probability. Such could pave a way for standardized patient-centered procedures that both decrease unwarranted prescribing pattern variability and optimize pain management regimens.

Melatonin Use in Infants Admitted to Intensive Care Units.

Sleep deprivation is a risk factor for delirium development, which is a frequent complication of intensive care unit admission. Melatonin has been used for both delirium prevention and treatment. Melatonin safety, efficacy, and dosing information in neonates and infants is lacking. The purpose of this study was to describe melatonin use in infants regarding indication, dosing, efficacy, and safety. This descriptive, retrospective study included infants <12 months of age admitted to an intensive care unit receiving melatonin. Data collection included demographics, melatonin regimen, sedative and analgesic agents, antipsychotics, and delirium-causing medications. The primary objective was to identify the melatonin indication and median dose. The secondary objectives included change in delirium, pain, and sedation scores; change in dosing of analgesic and sedative agents; and adverse event identification. Wilcoxon signed rank tests and linear mixed models were employed with significance defined at p < 0.05. Fifty-five patients were included, with a median age of 5.5 months (IQR, 3.9-8.2). Most (n = 29; 52.7%) received melatonin for sleep promotion. The median body weight-based dose was 0.31 mg/kg/dose (IQR, 0.20-0.45). There was a statistical reduction in cumulative morphine equivalent dosing 72 hours after melatonin administration versus before, 17.1 versus 21.4 mg/kg (p = 0.049). No adverse events were noted. Most patients (n = 29; 52.7%) received melatonin for sleep promotion at a median dose was 0.31 mg/kg/dose. Initiation of melatonin was associated with a reduction of opioid exposure; however, there was no reduction in pain/sedation scores.

Intensive Care Unit Analgosedation After Cardiac Surgery in Children with Williams Syndrome : a Matched Case-Control Study.

Cardiovascular abnormalities are common in patients with Williams syndrome and frequently require surgical intervention necessitating analgesia and sedation in a population with a unique neuropsychiatric profile, potentially increasing the risk of adverse cardiac events during the perioperative period. Despite this risk, the overall postoperative analgosedative requirements in patients with WS in the cardiac intensive care unit have not yet been investigated. Our primary aim was to examine the analgosedative requirement in patients with WS after cardiac surgery compared to a control group. Our secondary aim was to compare the frequency of major ACE and mortality between the two groups. Matched case-control study. Pediatric CICU at a Tertiary Children's Hospital. Patients with WS and age-matched controls who underwent cardiac surgery and were admitted to the CICU after cardiac surgery between July 2014 and January 2021. None. Postoperative outcomes and total doses of analgosedative medications were collected in the first six days after surgery for the study groups. Median age was 29.8 (12.4-70.8) months for WS and 23.5 (11.2-42.3) months for controls. Across all study intervals (48h and first 6 postoperative days), there were no differences between groups in total doses of morphine equivalents (5.0mg/kg vs 5.6mg/kg, p = 0.7 and 8.2mg/kg vs 10.0mg/kg, p = 0.7), midazolam equivalents (1.8mg/kg vs 1.5mg/kg, p = 0.4 and 3.4mg/kg vs 3.8mg/kg, p = 0.4), or dexmedetomidine (20.5 mcg/kg vs 24.4 mcg/kg, p = 0.5 and 42.3 mcg/kg vs 39.1 mcg/kg, p = 0.3). There was no difference in frequency of major ACE or mortality. Patients with WS received similar analgosedative medication doses compared with controls. There was no significant difference in the frequency of major ACE (including cardiac arrest, extracorporeal membrane oxygenation, and surgical re-intervention) or mortality between the two groups, though these findings must be interpreted with caution. Further investigation is necessary to elucidate the adequacy of pain/sedation control, factors that might affect analgosedative needs in this unique population, and the impact on clinical outcomes.

Opioid tapering after surgery and its association with patient-reported outcomes and behavioral changes: a mixed-methods analysis

IntroductionOpioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was...

Transdermal Rotigotine at End-of-Life for Parkinson's Disease: Association With Measures of Distress

BackgroundEnd-of-life (EOL) care for Parkinson's disease (PD) can be challenging when oral medications are no longer tolerated. MeasuresTo assess EOL prescribing for people with PD (PWP), focusing on rotigotine dosing and proxy measures of distress: benzodiazepine and opioid use. InterventionA retrospective audit of patient records from PWP who died between January 2019 and May 2022 at the Royal Hobart Hospital (RHH), Australia, was conducted. Data was systematically collated on demographics, symptoms, levodopa equivalent daily dose (LEDD) and rotigotine, oral morphine equivalent (OME) and benzodiazepine doses in the last 72 hours of life . OutcomesPain (72%), respiratory secretions (66%) and agitation (66%) were the most documented EOL symptoms. 83% (n = 52) of PWP were eligible for rotigotine and, of those, 13% (n = 7) received the correct dose, 38% (n = 20) a lower dose, 12% (n = 6) a higher dose and 37% (n = 19) did not receive any. Rotigotine dose was positively associated with total (P = 0.016) and PRN (P = 0.037) benzodiazepine dose. LEDD was positively associated with total benzodiazepine (P = 0.018) and total OME dose (P = 0.046). Contraindicated dopamine antagonists were prescribed for 43% of PWP and administered in 31% of those cases. ConclusionsRotigotine dose and admission LEDD were both associated with proxy measures of distress in the last 72 hours of life. This suggests cautious use of rotigotine at EOL. LEDD may help identify patients at risk of distress. Rates of inappropriate prescribing and symptom prevalence were high, indicating a need for further staff education to optimize the care of PWP.

The contribution of pain catastrophizing, depression and anxiety symptoms among patients with persistent pain and opioid misuse behaviours.

Anxiety, depression and pain catastrophizing are independently associated with risk of opioid misuse in patients with persistent pain but their relationship to current opioid misuse, when considered together, is poorly understood. This study will assess the relative contribution of these modifiable, and distinct psychological constructs to current opioid misuse in patients with persistent pain. One hundred and twenty-seven patients referred to a specialized opioid management clinic for prescription opioid misuse within a tertiary pain service were recruited for this study. The Pain Catastrophizing Scale, Depression, Anxiety and Stress Scales and the Current Opioid Misuse Measure were administered pre-treatment. Pain severity and morphine equivalent dose based on independent registry data were also recorded. Higher levels of pain catastrophizing, depression, and anxiety were significantly associated with higher current opioid misuse (r = .475, 0.599, and 0.516 respectively, p < .01). Pain severity was significantly associated with pain catastrophizing (r = .301, p < .01). Catastrophizing, depression, and anxiety explained an additional 11.56% of the variance (R2 change = 0.34, p < .01) over and above age, gender, pain severity and morphine equivalent dose. Depression was the only significant variable at Step 2 (β = 0.62, p < .01). Findings show that in a sample of people with persistent pain referred for treatment for opioid misuse, depression contributes over and above that of anxiety and pain catastrophizing. Theoretical and clinical practice implications are presented.

Long Term Outcomes of Conventional Palliative Radiotherapy in Bone Metastases of Lung Cancer: A Prospective Study

Bone metastases (BM) are highly prevalent in metastatic lung cancer (LC) leading to consequential morbidity and a decline in quality of life. The identification of oncogenes mutation and introduction of targeted therapy has prolonged the survival and therefore evaluation of long-term pain response rates, durability and re-irradiation (Re-RT) with conventional radiotherapy (RT) is crucial, especially in LMIC where penetration of stereotactic body radiotherapy for BM is poor. This prospective observational study included consecutive patients with histologically proven LC with radiologically confirmed BM. The primary objective was to evaluate the pain response rates in lung cancer patients with bone metastases treated with palliative RT. Palliative RT to BM was delivered using a conventional/conformal technique. The International Bone Metastases Consensus response criteria using Numeric Pain Rating Scale (NPRS) and Oral Morphine Equivalent Dose (OMED) was used to evaluate the pain response at 12, 24, and 52 weeks. Assuming the worst-case scenario, pain progression-free survival (PPFS) was calculated from the date of baseline assessment to the date of pain progression (PP) or death using Kaplan-Meier survival analysis. Known prognostic factors were evaluated using Cox regression analysis. From June 2020 to August 2022, 250 patients of NSCLC (94%) were accrued. The majority were male (66%), smokers (35%), lytic lesions (75%) and in the axial skeleton (82%). The oncogenic mutation was seen in 123 (49%) patients. At baseline, the mean OMED was 20mg/day (SD-21), and the mean pain score was 6 (SD-2.3). The majority (66%) received an 8 Gy single fraction with only 3% treated with SBRT. In evaluable patients, the CR and PR rates at 12 (n-161) and 24 weeks (n-121) were 34%, 40%, and 44%, 35% respectively. The indeterminate response rate (IRR) at 3 and 6 months were 18% while the rate of PP was 6%. On multivariate analysis, negative oncogene mutation {HR-0.34 (CI 0.22- 0.50), p<0.0001} and soft tissue mass {HR-0.46 (CI 0.31- 0.68) p<0.0001} were significant prognostic factors for pain progression. Of 71 evaluable patients at 1 year, 56% had a complete response with an ORR of 87%. In patients with oncogene mutation, the CR rates at 12 (n-101), 24 (n-77), and 52 weeks were 40%, 47%, and 60% with an ORR of 86%. PP is observed in less than 4%. Pain response was significantly more durable than mutation negative (8 vs 3 months, p-0.003). Re-RT rate was overall 11% (n = 27) and 8.2% in oncogene mutation patients. Re-RT rate with single-fraction was 8% and 3% with fractionated RT. The median time to Re-RT was 9.7 weeks. The PPFS was 70% and 60% at 12 and 24 weeks, respectively. This prospective study in an LC-specific population demonstrated excellent CR and PR rates with conventional RT. Durable pain relief with modest Re-RT rates with single fraction, particularly in oncogene mutation compels us to evaluate the role of SBRT for BM, especially in LMIC in a randomized setting.

Phase II Multi-Institutional Study of a Low-Dose (4 Gy) Palliative Response-Adapted Radiotherapy Regimen for Symptomatic Bone Metastases from Multiple Myeloma: Planned Interim Analysis of First 40 Patients

Painful bone lesions are common in patients with multiple myeloma (MM). Radiotherapy (RT) is effective in providing pain relief from MM bone lesions in over 80% of patients. There is no consensus as to the most effective dose or fractionation for palliation. Shorter courses of therapy are not only more convenient for patients, but they also have less impact on timing of systemic therapies. There is precedent for using 4 Gy in the palliation of lymphomas, which have similar radiosensitivity to myeloma. The primary objective of this trial is to determine whether treatment with a total dose of 4 Gy to a painful myeloma bone lesion achieves patient-reported pain reduction comparable to historical controls at 4 weeks. Patients with a known diagnosis of MM and a painful bone lesion that was not at the base of skull, in need of stabilization, or causing cord compression were treated with 4 Gy (2 Gy x 2 or 4 Gy x 1). Patients' pain was measured using the brief pain index (BPI) prior to treatment and at 2, 4, 8 weeks and 6 months following treatment. Pain response was determined by the international consensus on palliative radiotherapy and considered change in BPI and oral morphine equivalent dose (OMED). A planned interim analysis for futility was completed after 40 patients. Reirradiation with clinician choice regimens could be considered at ≥4 weeks following initial treatment for indeterminate pain response or pain progression. Forty patients were treated at 6 institutions between 2019 and 2022. Median age was 65 years with 40% women and 88% with an ECOG of 0-1. A complete response (CR) was defined as a BPI score of 0 with no concomitant increase in OMED. A partial response (PR) was defined as BPI reduction in 2 or more without analgesic increase, or an OMED reduction of 25% or more without an increase in pain. An indeterminate response (IR) was any response that is not captured by a CR, PR or pain progression. A CR was achieved in 48%, a PR in 38% of patients, an IR in 13% with 1 patient who refused participation. Pain response was achieved in 86% of patients. Seven patients (18%) requested reirradiation at ≥4 weeks. Median BPI at baseline and 4 weeks after RT for patients with CR, PR, and IR were 3.75 and 0, 4.00 and 1, and 5.25 and 4.75, respectively. Median change of BPI between baseline and 4 weeks after RT for all responders (CR and PR) was -3.25. The median PTV volume (cc) for patients with CR, PR and IR were 81, 140 and 226, respectively. Based on these results, the futility threshold was not met, and the recommendation by the DSMC is to continue the trial. In the first 40 patients who received 4 Gy palliation for painful bone lesions from multiple myeloma, there were 86% that had a pain response (48% CR, 38% PR). This low dose, response-adapted treatment, led to reirradiation in less than 20% of patients.

Catheter-based serratus anterior plane block vs. continuous wound infiltration for postoperative pain control following minimally invasive atrioventricular valve surgery : a randomized, prospective trial

Background: Minimally invasive cardiac surgery via mini-thoracotomy reduces surgical trauma compared to full sternotomy. However, thoracotomy can cause severe postoperative pain. Managing postoperative pain is challenging but critical for fast rehabilitation and avoidance of chronic pain. Our objective was to compare the efficacy of analgesia of a bolus in combination with continuous local anaesthetics using a serratus anterior plane block (SAPB) catheter versus a wound infiltration catheter (CWI) in patients after minimally invasive cardiac surgery. Design and setting: We conducted a monocentric, prospective, randomized controlled trial between January 2021 and August 2022. The study was performed at Ghent University Hospital, Belgium. Methods: Patients scheduled for minimally invasive cardiac surgery via thoracoscopy and mini-thoracotomy were randomized to receive either a SABP or a CWI catheter. Postoperatively, continuous ropivacaine 0.2% was started at 10ml/h, and a supplementary bolus of 30ml ropivacaine 0.5% was administered one hour before detubation. The catheter remained in place for at least 24 hours. The primary endpoint was opioid consumption during the first 48 hours postdetubation. Secondary endpoints were anti-emetic consumption, Numerical Analogue Score for 48 hours, length of stay in the Intensive Care Unit and hospital, and incidence of chronic pain. Qualitative data were compared using the Chi – Square test, quantitative data were analyzed with the Student’s t-test. Results: During the study period, a total of 21 patients received a SAPB catheter and 26 patients received a CWI catheter. No statistical significant differences were seen in baseline characteristics. In the first 48 hours postdetubation, morphine equivalent consumption was similar in both groups (p= 0.52), with no differences observed in the early, mid- or late postoperative phases. The total morphine equivalent dose was 21.8 mg in the SAPB and 18.6 mg in the CWI group. There were no significant differences in postoperative vomiting and nausea, length of stay in the Intensive Care Unit and in the hospital and chronic thoracic pain (23% and 33% for the SAPB and CWI group, respectively, p=0.54). Conclusion: This prospective study found no significant difference in postoperative opioid consumption between patients who received a serratus anterior plane block catheter and those who received a wound catheter with bolus and continuous ropivacaine, following minimally invasive cardiac surgery via right thoracoscopy and mini-thoracotomy.

THE EFFICACY OF CT-GUIDED PERCUTANEOUS CORDOTOMY ON INTRACTABLE PAIN IN PATIENTS WITH LUNG CANCER

ABSTRACT&#x0D; &#x0D; Aim&#x0D; This study was carried out to evaluate the efficacy of CT-guided percutaneous cordotomy and postoperative complications in the treatment of intractable pain associated with lung cancer. &#x0D; &#x0D; Material &amp;Method&#x0D; Computed tomography (CT) guided-cordotomy was performed on 10 lung cancer patients unresponsive to medical and interventional pain management methods.&#x0D; &#x0D; Results&#x0D; The mean pretreatment and post treatment visual analogue scale (VAS) scores of the patients were determined as 10 ± 0.0001 and 1.00 ± 0.67, respectively. Additionally, the mean pretreatment and posttreatment Karnofsky Performance Scale (KPS) scores of the patients were calculated as 40± 9.42 and 73±10.59, respectively. Accordingly, there was a statistically significant difference between the pretreatment and posttreatment VAS and KPS scores. Furthermore, the mean pretreatment and posttreatment morphine equivalent dose of the patients were found as 860.2±199.8 mg and 220.7±69.08 mg, respectively.&#x0D; &#x0D; Conclusion&#x0D; The findings of this study suggest that cordotomy is a valuable treatment option for intractable pain problems in patients suffering from lung cancer.

Comparison of the analgesic effect of intrathecal morphine between laparoscopic and open living donor hepatectomy: Propensity score matching analysis.

Laparoscopic donor hepatectomy is being increasingly adopted in transplant programs due to its numerous advantages. However, the role of intrathecal morphine (ITM) in laparoscopic donor hepatectomy has not been thoroughly investigated. This study aimed to compare the analgesic effects and safety of ITM between laparoscopic and open donor hepatectomy. This retrospective study included 742 donors who underwent hepatectomy with ITM between April 2007 and June 2019. Among them, 168 and 574 donors underwent laparoscopic hepatectomy (LH) and open hepatectomy (OH), respectively. Propensity score matching yielded two comparable groups of 168 donors each. The primary endpoint was the incidence of moderate-to-severe pain (maximum numerical rating scale [NRS] pain score ≥ 4) within 24 postoperative hours. The LH group had a significantly lower incidence of moderate-to-severe pain within 24 postoperative hours than the OH group (16.1% vs 64.3%, P < .001). Moreover, the cumulative rescue intravenous opioids (in morphine-equivalent dose) on postoperative day (POD) 1 was lower in the LH group than in the OH group (3.3 [0-8.3] mg vs 10 [3.3-17.3] mg; P < .001). There were no significant between-group differences in the incidence of respiratory depression (2.4% vs 0.6%; P = .371) and prescriptions for pruritus (14.3% vs 15.5%; P = .878). However, the prescriptions for postoperative nausea and vomiting (PONV) was significantly higher in the LH group than in the OH group (64.9% vs 41.7%; P < .001). The predictors of antiemetic agent prescription included the use of laparoscopic procedure (adjusted odds ratio [OR], 2.05; 95% confidence interval [CI], 1.11-3.79; P = .021) and female sex (adjusted OR, 5.63; 95% CI, 3.19-9.92; P < .001). Preoperative ITM administration resulted in a significantly lower incidence of moderate-to-severe pain within 24 postoperative hours after laparoscopic donor hepatectomy than after open donor hepatectomy.