Need For Pain Medication Research Articles

Edukasi Penanganan Nonfarmakologi Nyeri Otot Kronis

Chronic pain can result from various clinical conditions and may persist for more than three months. The symptoms can range from mild to severe. While chronic pain can be associated with various diseases, its exact cause sometimes remains unclear. In 2019, data from the National Health Interview Survey in the United States indicated that approximately 1 in 5 adults experienced chronic pain, with over 7% frequently limiting their activities due to this condition. However, there is no comparable data available for Indonesia. Chronic pain restricts activities and can decrease a person’s quality of life. Various options are available for pain management, one of which is non-pharmacological therapy, including hot-cold compresses, massage and stretching techniques, music therapy, and aromatherapy. These therapies aim to improve bodily function, regulate emotions, reduce weakness, stress, and anxiety, and decrease the need for pain medication. Gout is among the most common causes of chronic pain, with a prevalence of 3.9% in the US, 2.5% in Europe, and 7.3% in Indonesia, according to Riskesdas (2018). Based on this, local citizens were provided with education about pain management. This community service activity involved educating citizens on non-pharmacological treatments for chronic pain management and offering health services to residents of Angke. The purpose was to increase knowledge about non-pharmacological treatments for managing chronic pain. This activity was conducted on April 27th, 2024, from 07.00 to 12.00 at the Dhammasavana School in the Angke sub-district area, West Jakarta. The activities proceeded smoothly and in an orderly manner. A comparison of citizens’ knowledge before and after the education revealed a 58.18% increase in knowledge, contributing to improved welfare among the local residents.

Efficacy and safety of neridronate in paediatric type I complex regional pain syndrome: a multicentre experience.

Evidence regarding the efficacy of neridronate in the treatment of complex regional pain syndrome type I (CRPS I) is increasing, however, very little data are available in paediatric age. Our aim was to analyse the safety and the efficacy of neridronate in a case series of children with CRPS I, according to the Budapest criteria, who did not respond to previous pharmacological and physical therapy. We collected data of children affected by CRPS I from three paediatric rheumatology centres who received neridronate. Efficacy was evaluated by changes in pain intensity, vasomotor changes, physical function, need for pain medications and MRI findings. Adverse effects were also documented. Five children (3 females and 2 males, mean age 10.4 years, range 7-13 years) who received neridronate (4 intravenous, 1 intramuscular) were included. All patients had failed previous medical treatments (NSAIDs in 4, local steroids in 2, gabapentin, vitamin D and calcium supplementation in 1) and non-medical therapies (physiotherapy in 4, magnetotherapy in 2, laser in 1). Four out of five patients reported a significant improvement in pain (average VAS pre-treatment 9.6, post-treatment 2.6), recovery of physical function, and a reduced need for pain medications. Before treatment, all patients underwent MRI which revealed bone oedema that disappeared in the three of them after treatment. Neridronate was well-tolerated as only one patient experienced mild flu-like symptoms. Our data suggest that in children as in adults with CRPS I, neridronate may represent an effective and safe treatment option, particularly in those who do not respond to other pain treatments.

Knowledge and Perceptions about Curative Therapies for Sickle Cell Disease and Hydroxyurea Among Caregivers and Patients at a Large Tertiary Care Center: A Survey Study

Background: Sickle Cell Disease (SCD) affects approximately 100,000 individuals in the United States. Patients require regular follow-up and monitoring to prevent serious complications. Even with rigorous monitoring, health outcomes can be poor due to pain-seeking stigma and other social determinants of health, namely racial, social, and economic disparities. According to the National Assessment of Health Literacy published in 2006, 36% of adults have limited health literacy in the United States. Among SCD populations, disease-specific knowledge can play a vital role in improving pain control and access to appropriate maintenance therapies. Aims:The purpose of this study is to investigate the knowledge and perceptions of patients with SCD and their caregivers attending The Valerie Fund Pediatric Hematology-Oncology Center at the Children's Hospital of New Jersey in Newark, NJ regarding their disease, complications, genetic impact, general anticipated course of treatment or natural history of disease. Hydroxyurea (HU) and curative therapies include bone marrow transplant (BMT) and gene therapy (GT). Methods: We surveyed 85 participants, accounting for 79 patients as some surveys were completed by each the patient and caregiver. Sixty-six (83.5%) participants were caregivers and 13 (16.5%) were children with sickle cell disease between 12- and 20-years-old. Most patients identified as black, African, or African American (76; 96.2%) with 2 (2.5%) Hispanic patients, and 1 (1.3%) white patient. Forty-three patients (54.4%) were female and 36 (45.6%) were male. The average age of the patients was 10.9 years with a standard deviation of 5.7 years. More than half of patients were HbSS genotype (51; 64.6%). Remaining genotypes were HbSC (21; 26.6%), HbS-β 0-thalassemia (5; 6.3%), and HbS-β +-thalassemia (2; 2.5%). Forty-six (58.2%) of patients had received HU and 33 (41.8%) had not. Results: When assessing background knowledge of sickle cell and heritable risk, most participants could correctly identify the patient's sickle cell genotype (74; 87.1%) and most caregivers could correctly identify their own genotype (49; 74.2%). However, many caregivers exhibited limited understanding of genetic risk with only 18 (27.2%) correctly identifying the one in four chance of having a subsequent child with SCD when both parents are carriers. The results revealed participants could not distinguish between treatment for SCD and sickle cell trait; few participants correctly identified that sickle cell trait is not an indication for treatment with HU (8; 10.1%), BMT (4; 5.1%) or GT (6; 7.6%). Baseline knowledge about BMT and GT was limited. Only 27 (34.1%) participants correctly identified that BMT is indicated for treating patients with HbSS or HbS-b 0-thalassemia, and only 9 (11.4%) participants correctly identified this treatment population for GT. BMT knowledge was slightly greater than GT knowledge, namely that 60.1% (48) correctly identified the benefits of BMT for SCD patients, including decreased pain, decreased need for pain medication, decreased length of hospital stay, and cure, and that either bone marrow, stem cells, or blood could be transplanted materials. Most patients did not correctly identify these benefits of GT (55; 70%), nor could they identify the source of blood or stem cells for GT (65; 82.3%). The ability to correctly identify the benefits of HU for sickle cell disease (48; 60.8%) was positively associated with the ability to correctly identify the benefits of BMT (p-value 0.0091) and GT (p-value 0.0438) using Fisher's exact test with 95% confidence interval. Conclusion: These results suggest that dedicated teaching about HU, a common treatment for SCD, can result in greater patient knowledge about newer and curative treatment options of bone marrow transplant and gene therapy. These findings underscore the necessity of implementation of comprehensive patient teaching that is inclusive of population education levels, literacy rates, health literacy rates, and other cultural and societal factors.

Sickle Cell Disease and Hydroxyurea Knowledge, Views and Perceptions Among 400 Sickle Cell Patients and Caregivers at Mulago Hospital Sickle Cell Clinic: A Global Health Study in Kampala, Uganda

Background: In 2017, hydroxyurea was approved for the treatment of all sickle cell patients with genotype HbSS in Uganda following overwhelming support from the NOHARM trial conducted in a malaria endemic region at Mulago National Referral Hospital's Sickle Cell Clinic. Between January 2019 and June 2022, immediately following nationwide approval and distribution of hydroxyurea, hydroxyurea was prescribed a total of 4017 (51.2%) times out of the 7851 HbSS patient visits to the clinic according to data available from the clinic. Aims:The purpose of this study is to investigate the knowledge, perceptions, and beliefs of patients with sickle cell disease and their caregivers attending this clinic in Kampala regarding their disease, complications, genetic impact, general anticipated course of treatment or natural history of disease, and hydroxyurea. Methods: A total of 400 (56%) out of 713 patients were surveyed over a 3-week period using standardized, pretested questionnaires administered orally by trained research personnel in both English (253, 63%) and Luganda (147, 36.8%), which are the most common local languages and dialects spoken by patients in Kampala. Three-hundred and twenty-one (80.3%) participants were caregivers and 79 (19.8%) were children with sickle cell disease between 12- and 17-years-old. Results: Most participants reported receiving counseling about sickle cell disease (333; 83.3%) largely by hematologists (286; 85.9%), however, several knowledge gaps were identified. Two-hundred and ninety-seven (74.3%) participants reported not knowing the type of sickle cell or genotype of the patient. Moreover, presentation of various options did not significantly improve recognition of the correct genotype, with only 121 (30.3%) participants correctly identifying HbSS. Three-hundred and twenty-eight (82%) participants correctly identified the heritable transmission of the disease from both parents; however, caregivers exhibited limited understanding of genetic risk with only 31 (9.7%) correctly identifying the one in four chances of having a subsequent child with sickle cell disease when both parents are carriers. Hydroxyurea counseling was reported by 326 (81.5%) of participants, and 307 (76.7%) participants reported that the patient received hydroxyurea, with most patients taking the medication for at least 1 year. Of the 93 (23.5%) participants who identified the patient had never received hydroxyurea, 32 (34.4%) were uncertain if the patient would be eligible and 56 (57%) believed the patient was eligible to take the medication. Participants identified hydroxyurea benefits as decreases in pain (332; 83%), hospitalization (162; 40.8%), need for blood transfusion (148; 37%), need for pain medication (87; 21.8%), infections (42; 61%), weight loss (22; 31.9%), length of hospital stay (18; 4.5%), and incidence of stroke (10; 2.5%). Slightly more than half of patients had no concerns about hydroxyurea (218; 54.5%). Most patients with concerns (182; 45.5%) identified hydroxyurea's high cost as their main concern (141; 77.5%). Other rumors and fears about hydroxyurea included: negative affects on internal organs such as the liver or kidneys (54; 29.7%), other negative side effects (27; 14.8%), inaccessibility in pharmacies and remote areas (18; 10%), harm due to stopping or missing doses (16; 8.8%), ineffectiveness (16; 8.8%), additional indications as a cancer medication (9; 4.9%), and younger children's difficulty swallowing pills (6; 3.3%). Conclusion:Given the significantly improved morbidity and mortality of sickle cell patients who are adherent to hydroxyurea, it is necessary to address the rumors, misconceptions, and gaps in understanding of the genetic impact of the disease as well as the risks and benefits of hydroxyurea therapy. At the population level, learning is impacted by education levels, literacy rates, health literacy rates, and other cultural and societal factors, thus teaching should be culturally competent and inclusive with verbal and visual methods. The high cost of the medication and lack of consistent supply seem to be the most prohibitive factors in patient acceptance and adherence to take hydroxyurea. With only 1% of Uganda's population covered by health insurance, it is imperative for system-wide changes to address the affordability and accessibility of hydroxyurea and/or to extend the coverage of health insurance to those in need.

Efficacy of Cervical Facet Joint Radiofrequency Ablation Using a Multitined Cannula, a Technical Note, and Observational Study

BACKGROUND: Chronic cervical facet joint pain is a leading cause of pain and disability. In patients nonresponsive to conservative treatment, cervical facet radiofrequency ablation (RFA) has shown to be efficacious. However, the conventional RFA technique can be cumbersome. A novel RFA technique with a multitined cannula allows for a lateral approach and represents an attractive alternative option for cervical facet RFA. It offers a potentially shorter, less cumbersome procedure, with consequently less x-ray exposure and patient discomfort than the conventional cervical RFA. OBJECTIVES: To describe the novel RFA technique using the lateral approach with the multitined cannula at the cervical facet joints and to assess its efficacy in chronic cervical facet joint pain. STUDY DESIGN: This is a single-center observational study. SETTING: Interventional Pain Management Center, Switzerland. METHODS: The aim of this study is to describe the RFA technique using the lateral approach with the multitined cannula at the cervical facet joints and to assess its efficacy in chronic cervical facet joint pain. Eligible adult patients with chronic (> 3 months) cervical facet joint pain refractory to conservative treatment and confirmed by dual positive medial branch blocks, received a fluoroscopic-guided cervical facet RFA treatment using the multitined cannula. The primary outcome was pain relief. Secondary outcome measures included the proportion of patients reporting a >= 30% reduction of pain intensity 2 months after RFA, patient global impression of change (PGIC), need for pain medication, sleep quality, and patient satisfaction. RESULTS: We included 26 patients. The patients showed a clinically meaningful and significant pain relief at 2 months after cervical facet RFA (mean Numeric Rating Scale of 7.5 [1.9] at baseline to 4.2 [2.4]) and 58% of the patients reported >= 30% reduction of pain. An improvement on the PGIC was reported by 88.2% of the patients. No severe side effects or complications were observed. LIMITATIONS: Key limitations of our study were the relatively small sample size, the lack of a control group, and a relatively short-term follow-up duration. CONCLUSIONS: Our results suggest that cervical facet joint RFA using the novel technique with the multitined cannula results in significant pain reduction and improvement on the PGIC. While the conventional technique requires multiple ablations at each target level, the RFA with the multitined needle requires only a singular ablation, likely sparing time, radiation dose, discomfort, and costs. Our results merit consideration of replacement of the conventional technique with the novel technique using the multitined cannula. However, larger-scale clinical trials with an adequate long-term follow-up period are needed to prove the efficacy of RFA using the multitined cannula in cervical facet joint pain. KEY WORDS: Neck pain, facet joint pain, cervical, radiofrequency, ablation, denervation, multitined cannula, lateral approach, observational study

The Effects of Electrode Placement on Analgesia Using Transcutaneous Electrical Nerve Stimulation for Primary Dysmenorrhea: A Single-Blind Randomized Controlled Clinical Trial.

Background Primary dysmenorrhea (PD) refers to the occurrence of painful menstrual crampswithout pathological involvement of the pelvic organs, with considerable morbidity and high prevalence among females of reproductive age. Objective The objective of this study is to present and test the efficacy of an innovative method of interactive transcutaneous electrical nerve stimulation (iTENS) for PD. Methods and materials This study is a single-blind controlled clinical trial. This was conducted at the outpatient clinic of the faculty of physical therapy. Females with PD (n=124) were divided into the treated group (transcutaneous electrical nerve stimulation {TENS} group {TG}, n=62) and the placebo group (PG, n=62). A single session of either iTENS or placebo intervention was used for 35 minutes. Pain, the duration of analgesia, and the use of pain medication were assessed before and after the intervention. Data from before and after the treatment were compared between groups (Student's t-test). The level of significance was set at 5%. Results A significant decrease in pain (p<0.001) was observed after the intervention for the TG, with a more long-lasting analgesia (p<0.001) and decreased need for pain medication (p<0.001). Conclusions The proposed method of transcutaneous electrical nerve stimulation (TENS) application showed positive results for pain management on females with PD, with no reported adverse effects. The new proposed TENS application takes into account the preferences of the patient regarding positioning and the number of channels needed to cause analgesia. This application was able to promote almost complete analgesia in females with primary dysmenorrhea, and the analgesia persisted for more than one menstrual cycle.

Femoral nerve blockade during endovenous laser ablation of great saphenous vein decreases pain but does not affect the use of opioids during the procedure

BackgroundEndovenous laser ablation (EVLA) using tumescent anesthesia for treatment of an insufficient great saphenous vein (GSV) can be painful and require intravenous pain management and, sometimes, sedation with propofol. Femoral nerve blockade (FNB) anesthetizes the femoral nerve distribution and is usually used for anterior thigh and knee procedures. It is easy to inject with ultrasound guidance because the nerve is easy to visualize in the groin. The aim of the present double-blind, randomized controlled trial was to determine whether FNB before tumescent anesthesia decreases the pain of GSV EVLA combined with local phlebectomy. MethodsEighty patients who underwent GSV EVLA combined with local phlebectomy under tumescent anesthesia were randomized into two groups. The placebo group (control group; 40 patients) was given placebo FNB with 0.9% saline before tumescent injection. The FNB group (intervention group; 40 patients) received 1% lidocaine with adrenaline for FNB before tumescent injection. Only the study nurse, who performed the randomization, knew which patients were in which group. The patients and operating surgeon were unaware of the randomization group. FNB was performed under ultrasound guidance. The effectiveness of anesthesia was tested 10 minutes after injection using the pin-prick test and a numeric rating scale (NRS). The NRS was completed before and during tumescent anesthesia and during EVLA ablation and local phlebectomy. The motor function of the femoral nerve was tested at the end of the procedure and 1 hour after using the Bromage method. Patients had a follow-up visit 1 month after the procedure, and their need for pain medication and the duration of sick leave were recorded. ResultsNo differences were found in the gender distribution, age, or GSV dimensions at baseline. The mean length of the treated GSV segment was 28 cm and 30 cm and the mean energy used was 1911 J and 2059 J in the placebo and FNB groups, respectively. The median NRS score for pain during tumescent injection around the GSV was 2 (interquartile range [IQR], 1-4) in the placebo group compared with 1 (IQR, 1-3) in the FNB group. Very little pain was experienced during laser ablation. The median NRS score was 0 (IQR, 0-0) and 0 (IQR, 0-0.75) in the placebo and FNB groups, respectively. The most painful stage was injection of tumescence to the local phlebectomy sites in both groups. The median NRS score was 4 (IQR, 3-7) in the placebo group and 2 (IQR, 1-4) in the FNB group (P = .01). During local phlebectomy, the NRS score was 2 (IQR, 0-4) vs 1 (IQR, 0-3) in the placebo and FNB groups, respectively. Only the difference in pain during injection of tumescence before local phlebectomy was significant. ConclusionsFNB seems to decrease pain during EVLA combined with local phlebectomy. Patients experienced the highest pain when tumescence was injected before local phlebectomy, and those in the FNB group experienced significantly less pain than the placebo group. No indication for routine use of FNB is indicated. However, it could be used to decrease the pain for patients who experience strong pain during varicose vein surgery, especially if extensive local phlebectomies are required.

Observation of Child Experience During Discontinuing of Medically Provided Nutrition and Hydration.

Ethical and professional guidelines support withholding/discontinuing medically provided nutrition and hydration (MPNH) for children in specific scenarios yet literature shows many providers do not support this practice. One reason clinicians continue MPNH is worry about child suffering. This study was designed to assess clinician observations of infant/child experience following withholding/discontinuing MPNH. This study is a national survey of clinicians who had personally medically-managed an infant/child during the process of withholding/discontinuing MPNH. Survey disseminated via Twitter, email, and Facebook. Descriptive and content analyses were performed. Responses from 195 clinicians represented experiences with 900+ children, with over half of those experiences occurring within the prior year. Palliative care was consulted in 76% of cases. Most clinicians reported that in their patients, comfort (80/142, 56%) and peacefulness (89/143, 62%) increased during withholding/discontinuing MPNH, as did dry lips/mouth (109/143, 76%). Most observed decreased work of breathing (58/142, 63%) and respiratory secretions (90/142, 63%). The perceived need for pain medication typically remained unchanged (54/142, 38%). When asked to describe the dying process during withholding/ discontinuing MPNH, the most common response was "peaceful." Clinicians also observed increasing levels of parent relief (78/137, 57%), peace (77/137, 56%), as well as anxiety (74/137, 54%). Respiratory, gastrointestinal symptoms, signs of peacefulness, and comfort improved for most infants and children during withholding/withdrawing MPNH. Aside from dry lips/mouth, fewer than 10% of children were perceived to have increased symptom distress. This study's findings are consistent with adult data and failed to detect a compelling reason to forgo withholding/discontinuing MPNH solely due to concern about child comfort.

Healthcare is Demanding: Patience is a Virtue!

Healthcare is Demanding:Patience is a Virtue! Andrea Torrence Nursing is a rewarding career, but it can also be extremely challenging, depending on the type of patient you are assigned to. In my career, I have had a number of "difficult" patients, and every situation required a specific type of approach. Understanding how to interact with a difficult patient is a talent and requires a level of patience that exceeds the normal amount one may have. As a nurse, if you want to be successful, you must have patience. Along with many natural characteristics required to be successful in nursing, patience, in my opinion, is the most required quality required for nursing. The difficult patient can be an emotional burden to the care provider. These burdens are not always related to the tasks associated with care. The patient that is emotionally exhausting is far more complex than a patient who requires physical work. Nursing is a trying and risky career, but the nurse is obligated to provide the best care possible to all patients regardless of how difficult that person may be. Our cardiac surgical telemetry unit received a patient from the emergency room diagnosed with a minor psychiatric problem and tachycardia (a fast heart rate). This patient required medical clearance before going to the psychiatric unit for further evaluation. At our facility, this frequently happens, depending on how many psychiatric beds are available and on the patient's medical status. There were no clinical indications for this patient to require a bedside caregiver—a bedside caregiver is assigned to a patient that may somehow be classified as a danger to themselves or others—and the patient was not "pink-slipped." Patients who may not be safe to leave the hospital once they've been evaluated in the emergency room will be pink-slipped for an inpatient evaluation. Also, suicidal or homicidal patients are pink-slipped until they undergo an extensive evaluation and are deemed safe to leave on their own. A pink slip is a legal hold document. The patient that we received at the time of her admission required neither. The initial description of the patient revealed that she was a young, pleasant, ambulatory (able to walk with no problems) woman and completely oriented (understands and can comprehend). This patient did not have any pain or complaints documented on her emergency room assessment. She was corporative and followed instructions. As soon as we received the patient to the unit, she began to protest the need for pain medication. There were no orders for pain medication because there was no notation of pain in the emergency room. The nurse addressed the patient's pain with the admitting physician and Tylenol was ordered. When the patient heard that the physician ordered Tylenol, she became very angry. The patient wanted a stronger medication. I have a reputation for connecting with patients who become angry, and those who are classified as difficult, so the primary nurse asked me to speak to this patient. After a brief conversation, I was able to calm the patient, and she returned to her room quietly. The patient was apologetic and sincere. I used a calm approach, reassuring words of affirmation, and the perfect body language to de-escalate this patient. I was pleased with myself because only a simple combination of techniques was used to resolve the patient's anger, and at that time, a therapeutic connection was made. The nurse entered the patient's room and noticed that the roommate looked somewhat bewildered, [End Page E11] but she did not address the roommate. The nurse was focused on completing her patient's admission assessment. After the nurse completed the assessment, the order for the patient to wear telemetry was discussed. Telemetry is a physician's order to continuously monitor the heart's function while hospitalized. Because the patient was mildly tachycardic, telemetry was ordered. The patient immediately refused the order and told the nurse that she was not going to wear the monitor. The nurse explained the need and informed the patient that she would not be confined to the bed while wearing it. The nurse left the room to find me to discuss the...

Is There a Relationship Between Waking Up from Sleep and the Onset of Testicular Torsion?

Testicular torsion is a serious urologic emergency that can present with unusual or atypical history and examination. Classical pain from testicular torsion is of sudden onset, significantly severe, and is accompanied by nausea and vomiting. However, in some patients, the initial scrotal pain appears to considerably subside within the next few hours. In others, testicular torsion tends to occur while sleeping, and many patients recount a history of being woken up from sleep by intense pain. Furthermore, some patients in this subset can resume normal activities and even sleep through the night with little or no discomfort, without a perceived need for pain medications. Other patients initially experience mild pain, which worsens over time. Consequently, these patients are less likely to be evaluated immediately. In view of these atypical cases, the question remains unanswered regarding sleep as a predisposing factor for testicular torsion. This narrative review focuses on exploring the association between sleep and testicular torsion.

Pain Reduction Using Ropivacaine in Tumescent Solution following Lipoaspiration.

Tumescent solution utilizing dilute epinephrine and a local anesthetic agent injected into a fat compartment has been shown to effectively minimize blood loss and postoperative pain in liposuction. Ropivacaine has a longer duration of action compared to lidocaine and is a potential analgesic in tumescent solution. We sought to explore the effect of using ropivacaine in a tumescent technique with a focus on its efficacy for pain control postoperatively. The formula for the tumescent technique used combined 1 mL of epinephrine with 30 mL of ropivacaine into 500 mL of injectable saline. Tumescent solution was injected manually into fat donor sites of 10 consecutive patients followed by a 20-minute waiting period before beginning fat aspiration with liposuction cannula. Patients were seen immediately following their surgery and on postoperative day 1 and reported their pain using a numerical scale. Data gathered included the amount of ropivacaine used, average pain rating, and the average amount of fat removed. On average, participants reported little to no pain at the donor sites immediately following surgery and on postoperative day 1. Based on the low need for pain medication, we believe that ropivacaine may be successfully used in tumescent solution to reduce postoperative pain.

Policy Proposals for Infection Control in Patients with Chronic Wounds

South Korea is seeing a steady increase in its aging population. One in five people in the Republic of Korea will be at least 65 years old by 2025, putting more pressure on healthcare and social spending. Various geriatric diseases such as cancer, arthritis, and stroke are major contributors to disabilities in aging populations. Compounded with an increase in diabetes mellitus, the number of patients with pressure ulcers and diabetic foot ulcers is growing. Therefore, considerations for treating chronic wounds such as pressure ulcers and diabetic wounds are emerging as an urgent public health need in South Korea. The treatment of chronic wounds increases medical expenses, placing a significant social, economic, and practical burden on individuals. When complications related to chronic wounds occur, the patient’s quality of life deteriorates, threatening public health. Therefore, strategies for managing chronic wounds are clinically important; South Korea should begin to recognize the importance of chronic wound care. Social attention and government support with the establishment of proper medical insurance policies, as well as efficient medical expense budget execution, are essential for the management of chronic wounds. Silver has been known to inhibit infections for many centuries and is widely used around the world. Previous studies reported the clinical and cost-effectiveness of silver-impregnated dressings. The majority of randomized controlled studies found the positive effects of silver-impregnated dressings on chronic wound healing. A number of studies found that silver-impregnated dressings reduced wound healing time, dressing change frequency, the need for pain medication during dressing changes, and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia resulting from MRSA-infected wounds, thereby shortening hospital stays. Despite evidence of the positive effects of silver-impregnated dressings on chronic wound healing, medical insurance policies and government support fall far short of expectations. This is because government officials, who often lack the required knowledge and understanding of chronic wound care, impose impossibly strict regulations on the use of silver-impregnated dressings. The regulations that enable use of silver-impregnated dressings only on major burns prohibitively limit the use of silver-impregnated dressings to a few indications and low-volume uses. Currently, silver-impregnated dressings cannot be used for chronic wounds such as pressure ulcers, diabetic wounds, venous ulcers, and cancerous wounds, even though patients are willing to bear the full costs without any government subsidies. As South Korea has one of the fastest rates of population aging in the world, a continued rise in the economic, clinical, and social impacts of chronic wounds warrants a more structured approach and proportionate investment in chronic wound care. Medical expense budget providers should be encouraged to think broadly about the potential for wider cost savings in terms of reducing wound healing time, hospital stays, and nursing time by using appropriate dressings. Therefore, there is an urgent need for better communication and mutual understanding among wound specialists, policy makers, and working-level public servants on insured dressings for chronic wound care. This white paper is a policy proposal composed by senior members of the Board of Directors of the Korean Wound Management Society for chronic wound care using silver-impregnated dressings and will hopefully contribute to a better understanding of silver-impregnated dressings for chronic wound care.

Association of Radial Head Fracture Treatment With Long-Term Function.

Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures. A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings. Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.

More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Opioids Long-term After Spinal Fusion: A Systematic Review.

A common expectation for patients after elective spine surgery is that the procedure will result in pain reduction and minimize the need for pain medication. Most studies report changes in pain and function after spine surgery, but few report the extent of opioid use after surgery. This systematic review aims to identify the rates of opioid use after lumbar spine fusion. PubMed, CINAHL, Cochrane Central Register of Controlled Trials, and Ovid Medline were searched to identify studies published between January 1, 2005 and June 30, 2020 that assessed the effectiveness of lumbar fusion for the management of low back pain. Of 6872 abstracts initially identified, 329 studies met the final inclusion criteria, and only 32 (9.7%) reported any postoperative opioid use. Long-term opioid use after surgery persists for more than 1 in 3 patients with usage ranging from 6 to 85.9% and a pooled mean of 35.0% based on data from 21 studies (6.4% of all lumbar fusion studies). Overall, opioid use is not reported in the majority of lumbar fusion trials. Patients may expect a reduced need for opioid-based pain management after surgery, but the limited data available suggests long-term use is common. Lack of consistent reporting of these outcomes limits definitive conclusions regarding the efficacy of spinal fusion for reducing long-term opioid. Patient decisions about undergoing surgery may be altered if they had realistic expectations about rates of postsurgical opioid use. Spine surgery trials should track opioid utilization out to a minimum of 6 months after surgery as a core outcome.

Development and validation of the Gynecologic Oncology Predictor Of Postoperative opioid use (GO-POP) model

<h3>Objectives:</h3> With increasing use of minimally invasive surgical techniques and same-day discharges, the need to predict pain medication use on the day of surgery is critical to post-operative pain control, patient satisfaction and public health concerns. Our goal was to develop and externally validate a statistical model for predicting postoperative opioid use following gynecologic surgery in an increasingly minimally invasive surgical population, incorporating patient-reported surgical concerns. <h3>Methods:</h3> We prospectively enrolled 382 women scheduled for abdominal surgeries (including laparotomies and minimally invasive approaches [MIS]) in an academic gynecologic-oncology practice to a study to develop and validate a predictor of outpatient opioid pill use. Negative binomial, zero-inflated negative binomial, and ordinal regression models were developed using an initial cohort of 216 women enrolled from February 2018-March 2019 and followed for 6 weeks postoperatively. A total of 39 candidate predictors were considered, including preoperative assessments of anxiety and anticipated pain as well as intra-operative factors. The primary model outcome was the number of opioid pills used postoperatively. After fitting models using best predictors, all models were internally validated with 1000 bootstrap samples to obtain bias-corrected accuracy using ordinal concordance index and calibration curves. All models' predictions were then externally validated using a second cohort (n=166) enrolled from May 2019-February 2020. The best model (GO-POP) was updated by combining cohorts and an online calculator and nomogram were created. GO-POP included 7 predictors: age, total operating time, patient's self-reported pre-operative anticipated need for pain medication, whether pregabalin was administered preoperatively, patient educational attainment, smoking history and patients' self-reported preoperative anxiety. <h3>Results:</h3> Most surgeries were performed using MIS approaches (276; 72.3%) while 52 (13.6%) patients underwent planned laparotomies and 14.1% had planned MIS approaches converted to laparotomies. Median total number of opioid pills was 7 in the combined cohort. Nearly 40% of subjects used 0 pills after hospital discharge. After external validation, an updated combined model had the best fit, with ordinal concordance of 0.646 (95% CI:0.615, 0.679). Over 1/3rd of patients were either not planning to dispose of unused opioids or had not yet decided how to handle unused pills. A nomogram was created to facilitate clinical use of the model. <h3>Conclusions:</h3> A prospectively constructed and validated model accurately estimates the number of opioid pills used by women after gynecologic surgery. Use of the GO-POP nomogram enables providers to tailor prescriptions using information available immediately following surgery. More work is needing to educate patients on the importance of disposal of unused opioids post-operatively to protect our communities.

Osteoarthritis-Related Knee Pain Treated With Genicular Artery Embolization: A Systematic Review and Meta-analysis.

Background:Genicular artery embolization (GAE) is an innovative technique that has been investigated as a supplementary treatment method for chronic pain secondary to knee osteoarthritis (OA).Purpose:To evaluate the current evidence on the effectiveness and safety of GAE for OA-related knee pain.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic literature search was conducted in the PubMed, Web of Science, EMBASE, and Scopus databases to identify studies related to knee OA treated with GAE. Treatment agents were categorized as Embozene, imipenem/cilastatin, resorbable microspheres, and polyvinyl alcohol. The main outcomes were the mean difference (MD) in pre- and postembolization pain based on the visual analog scale (VAS) or the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores as well as changes in the need for pain medication. Random- and fixed-effects models were applied for data analysis.Results:Of 379 initially inspected publications, 11 (N = 225 patients; 268 knees) were included in the final review. The quality of the studies was fair in 8 and poor in 3—categorized according to the National Institutes of Health quality assessment tool. Overall, 119, 72, 13, and 21 patients were treated with imipenem/cilastatin, Embozene, resorbable microspheres, and polyvinyl alcohol, respectively. Symptomatic improvement was reported in all studies. The pooled effect size, characterized by MD, showed a significant improvement in the VAS and WOMAC pain scores, with better functional status after GAE. Pre- versus postembolization MDs in VAS scores ranged from 32 within the first week to 58 after a 2-year follow-up (equivalent to 54% and 80% improvement, respectively). There was a similar trend in the overall WOMAC scores, with MDs ranging from 28.4 to 36.8 (about 58% and 85% improvement, respectively). GAE resulted in a decreased need for pain medication for knee OA, with a 27%, 65%, and 73% decline in the number of patients who used opioids, nonsteroidal anti-inflammatory drugs, and intra-articular hyaluronic acid injection, respectively (P < .00001 for all). No significant difference between embolic agents was seen with regard to post-GAE pain reduction. No severe or life-threatening complications were reported.Conclusion:OA treated by GAE using different embolic particles can be considered generally safe, with good efficacy and no reported serious complications.

Use of bisphosphonates in a retrospective case series of children and adolescents with complex regional pain syndrome.

There is increasing evidence for the use of bisphosphonates to treat Complex Regional Pain Syndrome in adults. However, there are scarce data for their use in children with Complex Regional Pain Syndrome. This retrospective case series aimed to analyze the effects of intravenous bisphosphonate use in children and adolescents with Complex Regional Pain Syndrome enrolled in a multidimensional pain treatment program. We analyzed the data of 16 patients (15 females and 1 male, mean age 14±3years) who received infusions of zoledronic acid (0.015±0.0044mg/kg), pamidronate (0.72±0.17mg/kg), or both depending on their initial response between October 2014 and December 2019. The primary endpoint of the study was the patient's global impression of change. Secondary outcomes included pain intensity, physical function, role function (school attendance), need for pain medications, and adverse effects. Nine of 16 patients reported meaningful improvements (global impressions of change of 84% or higher) at a median follow-up time of 16 (8-21) months after their last infusion of bisphosphonates. There were also meaningful reductions in pain intensity and the need for pain medications. There was an increase in the proportion of patients with minimal or without physical disability, and almost all patients normalized their school activities. Thirteen patients (81%) reported adverse effects, mostly flu-like symptoms, for a few days after the infusion. The use of bisphosphonate infusions may represent an effective treatment option for children with Complex Regional Pain Syndrome, not responding to multidisciplinary pain treatment programs.

Robotic-assisted, laparoscopic, and open incisional hernia repair: early outcomes from the Prospective Hernia Study.

To provide a comparative analysis of short-term outcomes after open, laparoscopic, and robotic-assisted (RAS) ventral incisional hernia (VIH) repairs that include subject-reported pain medication usage and hernia-related quality of life (QOL). Subjects were ≥ 18years old and underwent elective open, laparoscopic or RAS VIH repair without myofascial release. Perioperative clinical outcomes through 30days were analyzed as were prescription pain medication use and subject-reported responses to the HerQLes Abdominal QOL questionnaire. Observed differences in baseline characteristics were controlled using a weighted propensity score analysis to obviate potential selection bias (inverse probability of treatment weighting, IPTW). A p value < 0.05 was considered statistically significant. Three hundred and seventy-one subjects (RAS, n = 159; open, n = 130; laparoscopic, n = 82) were enrolled in the study across 17 medical institutions within the United States. Operative times were significantly different between the RAS and laparoscopic groups (126.2 vs 57.2, respectively; p < 0.001). Mean length of stay was comparable for RAS vs laparoscopic (1.4 ± 1.0 vs 1.4 ± 1.1, respectively; p = 0.623) and differed for the RAS vs open groups (1.4 ± 1.0 vs 2.0 ± 1.9, respectively; p < 0.001). Conversion rates differed between RAS and laparoscopic groups (0.6% vs 4.9%; p = 0.004). The number of subjects reporting the need to take prescription pain medication through the 2-4weeks visit differed between RAS vs open (65.2% vs 79.8%; p < 0.001) and RAS vs laparoscopic (65.2% vs 78.75%; p < 0.001). For those taking prescription pain medication, the mean number of pills taken was comparable for RAS vs open (23.3 vs 20.4; p = 0.079) and RAS vs laparoscopic (23.3 vs 23.3; p = 0.786). Times to return to normal activities and to work, complication rates and HerQLes QOL scores were comparable for the RAS vs open and RAS vs laparoscopic groups. The reoperation rate within 30days post-procedure was comparable for RAS vs laparoscopic (0.6% vs 0%; p = 0.296) and differed for RAS vs open (0.6% vs 3.1%; p = 0.038). Short-term outcomes indicate that open, laparoscopic, and robotic-assisted approaches are effective surgical approaches to VIH repair; however, each repair technique may demonstrate advantages in terms of clinical outcomes. Observed differences in the RAS vs laparoscopic comparison are longer operative time and lower conversion rate in the RAS group. Observed differences in the RAS vs open comparison are shorter LOS and lower reoperation rate through 30days in the RAS group. The operative time in the RAS vs open comparison is similar. The number of subjects requiring the use of prescription pain medication favored the RAS group in both comparisons; however, among subjects reporting a need for pain medication, there was no difference in the number of prescription pain medication pills taken. While the study adds to the body of evidence evaluating the open, laparoscopic, and RAS approaches, future controlled studies are needed to better understand pain and QOL outcomes related to incisional hernia repair. ClinicalTrials.gov identifier: NCT02715622.

Response of Severe Osteomalacia to High Dose Vitamin D3 Replacement in a Patient With Ulcerative Colitis and Liver Transplantation on Immunosuppressive Therapy

Background: Bone disease is common in inflammatory bowel disease (IBD), more frequently in Crohn’s disease than ulcerative colitis (UC). We present the case of a patient with prior history of ulcerative colitis with severe 25 OH vitamin D deficiency and metabolic bone disease. Case: 67 year old male with h/o ulcerative colitis, colon cancer s/p proctocolectomy and ileostomy, chemo-radiation, h/o primary sclerosing cholangitis (PSC) and orthotopic liver transplantation (OLT) 20 years prior presented with presented with severe muscle aches, severe limitation in mobility and severe vitamin D deficiency. He had been on chronic prednisone and tacrolimus, mycophenolate. Three years after OLT, he had fragility fractures at different times in both hips requiring hip arthroplasty. Labs were significant for persistently elevated alkaline phosphatase (ALP) up to 1569 U/L for last 10 years, bone specific ALP at 423.6 mcg/L, Calcium 9 mg/dl, phosphorus 2 mg/dl, 25 OH vitamin D was 4 ng/ml, 1, 25-hydroxy vitamin D (25-OHD) was 34 ng/ml, PTH was 189 pg/ml, urine calcium/creatinine ratio was 50 mg/g and urine NTX at 223 nM BCE/mM. Celiac screen was negative and tacrolimus levels were within normal range. Patient had extensive workup by gastroenterology for elevated ALP including three liver biopsies which were unrevealing. A bone scan showed increased uptake in thoracic region and metaphyses of large joints. A diagnosis of osteomalacia and secondary hyperparathyroidism was made and he was started on high dose vitamin D gradually increased to 8000 units thrice a day. Within few weeks, he noted marked improvement in mobility, bone pain and need for pain medications. In few months, BSAP decreased to 144.9 mcg/l, NTX and PTH also improved. 25 OH has also increased slightly to 13. He continues on high dose vitamin D and 1200mg of calcium daily. Discussion: Our patient likely had severe osteomalacia due to prolonged vitamin D deficiency, caused by multiple etiologies. Firstly, poor absorption in UC might lower 25-OHD levels. Secondly CYP3A enzymes are involved in the metabolism of calcineurin inhibitor tacrolimus as well as vitamin D, this could result in enhanced vitamin D metabolism, which would explain persistently low vitamin D level despite replacement with such high doses. The significant improvement in his symptoms with supplementation resulting in increased mobility despite not having a normal vitamin D level suggest other pleiotropic effects of vitamin D on muscle and bone as well. Additionally effects of liver transplantation on vitamin D metabolism need to be explored further.

Perceptions of nonopioid treatment for pain in a homeless population.

Opioid abuse has developed into a public health emergency within the last decade because opioid medications, while addictive, are effective and commonly used for pain management. In 2016, over 42,000 deaths were attributed to opioids. Chronic pain affects about 50% of people experiencing homelessness in the US, and they have a higher overall rate of chronic pain than the general population; opioids are among the methods they might use to manage that pain. Complementary and alternative therapies for pain management have largely gone unexplored in the homeless population. To determine, among people experiencing homelessness, the willingness to use and current use of complementary and alternative treatments (physical and massage therapy, chiropractic treatments). A secondary objective was to investigate awareness and perception of osteopathic manipulative treatment (OMT) as a complementary treatment for chronic pain among the homeless population. A 32 question survey was administered verbally to guests of True Worth Place Homeless Shelter in Fort Worth, Texas in three 4hour sessions from February 2019 to April 2019. If participants gave verbal consent, a researcher read the questionnaire, one question at a time, and recorded the participant's responses. The survey included queries for opioid and nonopioid treatment modalities (physical and massage therapy, chiropractic, and OMT) to assess the perception of and current use of each among the population. Appropriate nonparametric statistical analysis was conducted to assess significance and correlations among the treatment groups. Of the 200 survey participants, 126 (91.3%) reported a history of opiate use for pain, but 136 (68.0%) believed that a nondrug pain intervention could better treat their pain. Additionally, 150 participants (75.0%) believed that regular manipulation, including OMT, would decrease their need for pain medications. Participants with a history of opioid use for pain were more likely to believe that the availability of regular manipulation, including OMT, at True Worth Place could decrease their need for pain medication (odds ratio=3.7143; 95% confidence interval=1.6122-8.5572; p=0.0009). Moreover, some participants (141; 70.5%) were already pursuing nondrug pain management modalities such as PT, massage therapy, and chiropractic care. The greatest barriers to receiving OMT were transportation and cost. This survey study was conducted to determine whether a homeless population would be willing to use nonopioid treatment, particularly OMT, for chronic pain management. Results revealed both a willingness to use and a previous use of nonopioid treatments for pain, along with a high prevalence of opiate use. Despite limited exposure to OMT, this population reported being potentially willing to pursue manipulation, including OMT, as a complementary treatment for pain relief alongside opioids if readily available.