Pain Control Research Articles

The role of methadone in cardiac surgery for management of postoperative pain

BackgroundThis retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids. MethodsPatients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M). ResultsPatients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0–POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07–5.12), 6.82 (IQR=3.52–12.98), and 7.0 (IQR=3.82–12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups. ConclusionsIntraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.

A Pharmacotherapeutic Approaches for Managing Labour Pain using Synthetic Drugs and Natural Therapies.

The birth of a child is a critical and potentially traumatic experience for women, entailing multiple physiological and psychosocial changes. The psychological effects of childbirth pain can have both immediate and long-term effects on the mother's health and her bond with her child. Many studies investigated the different ranges of synthetic drugs available for pain control in labour, inclusive of neuraxial analgesics, inhaled analgesics, and various opioids. The inadequate efficacy and unfavourable side effects of these synthetic drugs prevent appropriate pharmacotherapy, resulting in a quest for natural therapies for reducing labour pain. Herbal therapies (aromatherapy) using several essential oils obtained from various natural plants are another alternative that calms and manages the mind and body through aromatic compounds that have neurological and physiological effects. The review discussed the safety profile of various synthetic drugs with their dosage information and also deliberated on the mechanism and safety profile of various natural plants that are used in aromatherapy. The review also briefly highlighted the other non-pharmacological miscellaneous techniques such as TENS, hypnosis, immersion in water, acupuncture, massage, and different other tactics that aim to assist women in coping with pain in labour.

Usability of a telehealth-nurse supported home-based walking training for peripheral arterial disease - The Keep Pace! pilot study.

Background: Guidelines recommend walking trainings for peripheral arterial disease (PAD) management. Supervised walking training is superior to walking advise to improve the walking distance. Telehealth service with nurse support may close this gap. Patients and methods: This study introduces a telehealth service, "Keep pace!", which has been developed for patients with symptomatic PAD (Fontaine stage IIa and IIb), enabling a structured home-based walking training while monitoring progress via an app collecting unblinded account of steps and walking distance in self-paced 6-minute-walking-tests by geolocation tracking to enhance intrinsic motivation. Supervision by nurses via telephone calls was provided for 8 weeks, followed by 4 weeks of independent walking training. Patient satisfaction, walking distance and health-related quality of life were assessed. Results: 19 patients completed the study. The analysis revealed an overall high satisfaction with the telehealth service (95.4%), including system quality (95.1%), information quality (94.4%), service quality (95.6%), intention to use (92.8%), general satisfaction with the program (98.4%) and health benefits (95.8%). 78.9% asserted that the telehealth service lacking nurse calls would be less efficacious. Pain-free walking distance (76.3±36.8m to 188.4±81.2m, +112.2%, p<0.001) as well as total distance in 6-minute-walking test (308.8±82.6m to 425.9±107.1m, +117.2%, p<0.001) improved significantly. The telehealth service significantly reduced discomfort by better pain control (+15.5%, p=0.015) and social participation (+10.5%, p=0.042). Conclusions: In conclusion, patients were highly satisfied with the telehealth service. The physical well-being of the PAD patients improved significantly post vs. prior the telehealth program.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review.

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures. Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Postoperative pain control and opioid use with transversus abdominis plane block and scheduled multimodal pain management in patients undergoing cesarean section.

The impact of a transversus abdominis plane (TAP) block in patients undergoing cesarean section requires further evaluation. The aim of this study was to compare postoperative pain scores and opioid use in cesarean surgery patients undergoing either a TAP block and scheduled multimodal pain management (SMPM) or SMPM alone. In this retrospective, dual cohort study, cesarean surgery patients underwent neuraxial anesthesia and a TAP block (SMPM/TAP) or SMPM; the TAP block incorporated ropivacaine (20-30 mL) administered bilaterally. The group analyses involved a comparison of postoperative pain scores using the visual analog scale and opioid consumption at 24 and 24-48 h. There were 94 (52.8%) patients in the SMPM/TAP group and 84 (47.2%) subjects in the SMPM alone group. At 24 h postoperatively, the SMPM/TAP group exhibited significantly lower pain scores (4.07 vs 4.54) than the SMPM group (P < 0.001) and reduced opioid consumption (2.29 vs 3.28 mg; P < 0.001). However, at 24-48 h, the SMPM group demonstrated lower pain scores (5.46 vs 5.98) compared to the SMPM/TAP group (P < 0.001) and reduced opioid consumption (8.75 vs 10.21 mg; P < 0.001); overall opioid consumption was higher (12.50 vs 12.02 mg) in the SMPM/TAP group (P < 0.001). The TAP block improved cesarean surgery patients' pain scores and reduced opioid consumption at 24 h postoperatively but the effect of the TAP block was ephemeral as the SMPM/TAP group exhibited inferior pain scores and greater opioid consumption compared to the SMPM group at 24-48 h postoperatively.

Bladder Cancer Invading the Prostate and Penis and Multiple Bone Metastases Showing Significant Improvement after a Short-Term Pembrolizumab Therapy following Radiation and Gemcitabine and Cisplatin Therapy Leading to a Pathologically Complete Remission

A 65-year-old man was diagnosed with bladder cancer invading the prostate and penis and multiple bone metastases. He underwent palliative radiation (30 Gy/10 fr) through vertebral bones (Th3 and Th12-L5) and pelvic bones for pain control. The patient received pembrolizumab therapy after three courses of gemcitabine and cisplatin therapy. CT four weeks after starting pembrolizumab therapy showed that both the primary and metastatic lesions had notably reduced in size, and no new lesion was detected. He subsequently fell, resulting in a femoral neck pathological fracture, and underwent hemiarthroplasty. Pathological examination of the pathological fracture site revealed no residual tumor tissue.

Use of CYP2D6 Inhibitors with CYP2D6 Opioids: Association with Emergency Department Visits for Pain.

Hydrocodone, tramadol, codeine, and oxycodone are commonly prescribed opioids that rely on activation by cytochrome P450 2D6 (CYP2D6). CYP2D6 inhibitors can significantly decrease CYP2D6 activity, leading to reduced generation of active metabolites, and impairing pain control. To understand this impact, we assessed emergency department (ED) visits in patients initiating these CYP2D6-dependent opioids while on CYP2D6-inhibitor antidepressants vs. antidepressants that do not inhibit CYP2D6. This retrospective cohort study included adult patients prescribed CYP2D6-dependent opioids utilizing electronic health records data from the University of Florida Health (2015-2021). The association between ED visits and inhibitor exposure was tested using multivariable logistic regression. The primary analysis had 12,118 patients (72% female; mean (SD) age, 55 (13.4)) in the hydrocodone/tramadol/codeine cohort and 5,547 patients (64% female; mean (SD) age, 53.6 (14.2)) in the oxycodone cohort. Hydrocodone/tramadol/codeine-treated patients exposed to CYP2D6-inhibitor antidepressants (n = 7,043) had a higher crude rate of pain-related ED visits than those taking other antidepressants (n = 5,075) (3.28% vs. 1.87%), with an adjusted odds ratio (aOR) of 1.75 (95% CI: 1.36 to 2.24). Similarly, in the oxycodone cohort, CYP2D6-inhibitor antidepressant-exposed individuals (n = 3,206) had a higher crude rate of ED visits than individuals exposed to other antidepressants (n = 2,341) (5.02% vs. 3.37%), with aOR of 1.70 (95% CI: 1.27-2.27). Similar findings were observed in secondary and sensitivity analyses. Our findings suggest patients with concomitant use of hydrocodone/tramadol/codeine or oxycodone and CYP2D6 inhibitors have more frequent ED visits for pain, which may be due to inadequate pain control.

P.150 Effect of postoperative pain control and other perioperative risk factors on length of stay after elective spine surgery

Background: Prolonged length of stay (LOS) after elective spine surgery increases patients’ risk for in-hospital complications and contributes significantly to healthcare costs. Here we explored the role of pain control and other perioperative factors on LOS. Methods: Consecutive adult patients undergoing elective spine surgery were enrolled. The primary outcome was in-hospital LOS following surgery. The primary independent variable was poor pain control on postoperative day 1 (POD1). Univariable analyses followed by multivariable regression analysis were used to investigate the relationship between poor pain control and LOS. Results: 1305 patients were enrolled. Mean LOS was 4.38 days. Incidence of poor pain control was 56.9%. Multivariable analysis revealed poor POD1 pain control was significantly associated with increased LOS (p=0.03), after adjusting for other significant predictors of increased LOS including perioperative hemodynamic instability (p=0.001), perioperative blood transfusion (p=0.000), delirium (p=0.000), POD1 morphine equivalent dose (p=0.000), urinary tract infection (p=0.000), urinary retention (p=0.003), surgical site infection (p=0.000), wound complication (p=0.000), neurologic deterioration (p=0.000), surgical levels (p=0.016), operative time (p=0.007), ASA score (p=0.000), preoperative disability score (p=0.001). Conclusions: Poor pain control on POD1 was an independent predictor of increased LOS after elective spine surgery, highlighting the importance of a proactive approach to addressing pain in the immediate postoperative period.

Pain control during intrauterine device insertion: Transcutaneous electrical nerve stimulation.

Current practice lacks effective periprocedural pain management during common gynecological procedures such as intrauterine device insertion, increasing the possibility of significant pain and adverse reaction to such procedures. Because of this, pain can often be a barrier for a patient in choosing a form of contraception that best serves them. Transcutaneous electrical nerve stimulation offers an option for effective pain control during intrauterine device insertion. This case review characterizes five cases where patients were offered transcutaneous electrical nerve stimulation for pain control during intrauterine device insertion. The patients reported a range of no pain to moderate pain during intrauterine device insertion and rated their pain experience as better compared with prior insertions. Although limited to a case review, our findings suggest a promising clinical indication for transcutaneous electrical nerve stimulation as a pain management strategy for intrauterine device insertion.

Optimal Perioperative Pain Management of the Transgender Patient for Gender Affirming Surgery: A Scoping Review.

As we increasingly encounter transgender patients in the perioperative setting, it is important to be cognizant of appropriate medical management of the transgender patient. There is limited literature on the appropriate perioperative techniques to implement for adequate pain control in the transgender patient presenting for gender affirming procedures. In this scoping review, the authors identify publications that address perioperative pain control techniques that can be implemented by the anesthesiologist such as regional anesthesia, multimodal medications, or non-pharmacologic modalities. This scoping review included two retrospective reviews, two case reports, and one letter to the editor. There are no prospective, randomized controlled trials on this topic. The limitations of this scoping review include the limited publications that are available to analyze as this is a growing area of medicine. There are numerous variables that may play a factor in the pain experience of the transgender patient including biological factors, psychological and social factors. Techniques that are necessary for comprehensive pain management include pharmacologic, injections, physical therapy, acupuncture, massage, and more. There are limited publications on the comprehensive pain management of the transgender patient; therefore, the authors advocate that as perioperative physicians, anesthesiologists implement comprehensive preemptive analgesia techniques to avoid progression to chronic pain. Clearly more research is necessary to standardize acute pain management techniques in the transgender patient.

Early Utilization of Ketorolac in Cleft Palate Repair.

To determine the effect of ketorolac on opiate requirement and hospital length of stay after palatoplasty. This was a retrospective chart review. This study was completed at an urban tertiary medical center. Those who underwent palatoplasty with a pediatric otolaryngologist between 2010-2020. Incorporation of standing Ketorolac into the immediate post-operative pain regimen. T-test analysis was performed to determine whether initiation of ketorolac within 24 h post-palatoplasty was correlated with shorter length hospitalization or reduced opiate requirement. A total of 55 pediatric subjects (49.1% female) were included in this study. Average age at time of surgery was 13 months (range 9.9-33.9 months). On two tailed t-test, use of ketorolac within the first 24 h after palatoplasty was associated with shorter length of stay (mean of 1.68 vs 2.57 days, t = 2.58, P = .01) and lower total opiate dosage during hospitalization (mean of 2.8 vs 9.16 morphine milligram equivalents, t = 3.37, P = .001). Among patients undergoing palatoplasty, there is a significant relationship between the early utilization of ketorolac and decreased length of hospitalization as well as decreased opiate requirement. This has important consequences to help improve pain control with reduced opiates requirement as well as length of stay. Future prospective studies can help elicit the causative effect of Ketorolac on these parameters and can investigate whether use of Ketorolac has an effect on long term recovery and post-discharge opiate requirements as well.

Pain treatment individualization in patients with advanced cancer using immediate release morphine

Adequate pain relief through individual tailoring of the basic analgesic in suited dose and drug formulation, as well as the use of adjuvant and supportive therapy, relieves the suffering of patients with advanced cancer in most cases. Noninvasive opioids in immediate and modified release formulations play a key role in treating severe chronic pain syndrome. We present a series of case studies to illustrate morphine tablet and oral solution administration as part of an individual pain therapy regimen, such as opioid dose titration, treatment of breakthrough pain, and around-the-clock pain control.

Application of ultrasound-guided single femoral triangle and adductor canal block in arthroscopic knee surgery: a prospective, double-blind, randomized clinical study

PurposeTo compare the difference in analgesic effect between femoral triangle block (FTB) and adductor canal block (ACB) during arthroscopic knee surgery.MethodsPatients who underwent arthroscopic knee surgery were randomized preoperatively to FTB group or ACB group. For each group, 20 mL of 0.1% ropivacaine was injected. Primary outcomes: The numeric rating score (NRS) at 12 h after surgery at rest and during movement. Secondary outcome: (1) The NRS at post anesthesia care unit (PACU) and 2, 24 h after surgery at rest and during movement; (2) The quadriceps muscle strength at PACU and 2, 12, 24 h after surgery; (3) Consumption of Rescue analgesia; (4) Incidence of adverse reactions.ResultsThe NRS at 12 h after surgery at rest and during movement of ACB group were higher than FTB group. Among secondary outcomes, the NRS at PACU at rest and during movement, 2 h after surgery during movement of FTB group lower than ACB group; the quadriceps muscle strength at 2 h after surgery of FTB group stronger than ACB group. After multiple linear regression model analysis, the data showed additional statistically significant reduction NRS at 24 h after surgery at rest (0.757, p = 0.037) in FTB group. Other outcomes were similar between two groups.ConclusionsThe FTB appears to provide superior pain control after knee arthroscopy than ACB, the FTB is superior to the ACB in quadriceps muscle strength at 2 h after surgery.Trial registrationThe trial was registered in the Chinese Clinical Trial Registry (ChiCTR2300068765). Registration date: 28/02/2023.

Factors conditioning pain control and reduction in post-cesarean section parturients: a cross-sectional study.

Pain experienced by women in the perinatal period constitutes a complex and multifaceted phenomenon. The aim of the study was to assess conditions of pain locus of control and pain reduction in post-cesarean section parturients. A cross-sectional quantitative study with convenience sampling was performed among 175 hospitalized post-cesarean section women in hospitals in Eastern Poland in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement. A self-design questionnaire regarding general information and obstetrics/gynaecology medical interview, The Pain Coping Strategies Questionnaire (CSQ) and The Beliefs about Pain Control Questionnaire (BPCQ) were used. The inclusion criteria were as follows (1) age of ⩾18 years old; (2) cesarean section (CS); (3) period from the 13th hour to the end of the 72nd hour after the procedure; and (4) informed consent. The data was analyzed with IBM SPSS Statistics. Internal locus of control (M = 14.02) was provided the highest value by the parturients and followed by chance events (M = 12.61) and doctors' power (M = 12.18). Dominant coping with pain strategies in the post-cesarean parturients were coping self-statements (M = 19.06), praying or hoping (M = 18.86). The parturients assessed their pain coping (M = 3.31) strategies along with pain reduction (M = 3.35) at the moderate level. Higher pain control was correlated with cognitive pain coping strategies (β = 0.305; t = 4.632; p < 0.001), internal pain control β = 0.191; t = 2.894; p = 0.004), cesarean section planning (β = -0.240; t = -3.496; p = 0.001) and past medical history of CS (β = 0.240; t = 3.481; p = 0.001). The skill of reduction of pain was positively associated with cognitive pain coping strategies (β = 0.266; t = 3.665; p < 0.001) and being in subsequent pregnancy (β = 0.147; t = 2.022; p = 0.045). Catastrophizing and hoping were related to lower competences of coping with pain (B = - 0.033, SE = 0.012, β = - 0.206, T = -2.861). The study allowed for identification and better comprehension of factors conditioning pain control and pain reduction in parturients after the cesarean section. Furthermore, a stronger belief that pain can be dealt with is found in the parturients characterized by cognitive pain coping strategies and internal pain locus of control. The skill of reduction of pain is related to cognitive coping strategy and procreation status.

Advanced Pelvic Girdle Reconstruction with three dimensional-printed Custom Hemipelvic Endoprostheses following Pelvic Tumour Resection.

Resection of pelvic bone tumours and subsequent pelvic girdle reconstruction pose formidable challenges due to the intricate anatomy, weight-bearing demands, and significant defects. 3D-printed implants have improved pelvic girdle reconstruction by enabling precise resections with customized guides, offering tailored solutions for diverse bone defect morphology, and integrating porous surface structures to promote osseointegration. Our study aims to evaluate the long-term efficacy and feasibility of 3D-printed hemipelvic reconstruction following resection of malignant pelvic tumours. A retrospective review was conducted on 96 patients with primary pelvic malignancies who underwent pelvic girdle reconstruction using 3D-printed custom hemipelvic endoprostheses between January 2017 and May 2022. Follow-up duration was median 48.1 ± 17.9months (range, 6 to 76months). Demographic data, imaging examinations, surgical outcomes, and oncological evaluations were extracted and analyzed. The primary endpoints included oncological outcomes and functional status assessed by the Musculoskeletal Tumor Society (MSTS-93) score. Secondary endpoints comprised surgical duration, intraoperative bleeding, pain control and complications. In 96 patients, 70 patients (72.9%) remained disease-free, 15 (15.6%) had local recurrence, and 11 (11.4%) succumbed to metastatic disease. Postoperatively, function improved with MSTS-93 score increasing from 12.2 ± 2.0 to 23.8 ± 3.8. The mean operating time was 275.1 ± 94.0min, and the mean intraoperative blood loss was 1896.9 ± 801.1ml. Pain was well-managed, resulting in substantial improvements in VAS score (5.3 ± 1.8 to 1.4 ± 1.1). Complications occurred in 13 patients (13.5%), including poor wound healing (6.3%), deep prosthesis infection (4.2%), hip dislocation (2.1%), screw fracture (1.0%), and interface loosening (1.0%). Additionally, all patients achieved precise implantation of customized prosthetics according to preoperative plans. T-SMART revealed excellent integration at the prosthesis-bone interface for all patients. The use of a 3D-printed custom hemipelvic endoprosthesis, characterized by anatomically designed contours and a porous biomimetic surface structure, offers a potential option for pelvic girdle reconstruction following internal hemipelvectomy in primary pelvic tumor treatment. Initial results demonstrate stable fixation and satisfactory mid-term functional and radiographic outcomes.

Dexmedetomidine in Palliative Care: A Versatile New Weapon Against Delirium and Pain-Systematic Review.

Introduction: At the end of life, the prevalence of delirium and pain is high. Current therapy is not satisfactory. Dexmedetomidine could be useful in the control of delirium and pain but is not approved outside of intensive care setting. Our objectives are to evaluate existing evidence in the literature that assessed the efficacy of dexmedetomidine in pain and delirium control and its safety in palliative care patients outside intensive care units. This systematic review was prospectively registered with PROSPERO and included a risk of bias assessment. Methods: PubMed and SCOPUS were examined for literature published until 2023. Experimental, cohort, cross-sectional, case-control studies, and case series/reports were included if they evaluate the use of dexmedetomidine in delirium and/or pain management in hospitalized palliative care adult patients. Studies were excluded if they were carried out in intensive care units. Results: Of the initial 529 records, 14 were included. Although only two studies were randomized trials, most were small and only one had low risk of bias. In most case reports and in the two retrospective cohort studies, dexmedetomidine appears to be a better option for these symptoms, although differences were not significant in the randomized trials. Discussion: Dexmedetomidine seems to be a promising option for refractory pain and delirium and may contribute to a reduction in opioid administration to control pain. This is the first systematic review of dexmedetomidine in palliative care. Quality evidence is limited, but clinical properties of dexmedetomidine justify the conduction of controlled trials in palliative care.

Case report: CBD: THC medical cannabis in the treatment of neuropathic pain

Chronic neuropathic pain affects millions of adults worldwide, creating a direct impact on quality of life. The control of neuropathic pain is a challenge in daily clinical practice. Current pharmacological treatment options for neuropathic pain afford substantial benefit for only a few people, often with adverse effects that outweigh the benefits. There is a need to explore other treatment options, with different mechanisms of action for treatment of this pathology. The use of cannabis and cannabinoid products is a growing area of research for the treatment of different pathologies including neuropathic pain. The studies developed so far and what is observed in the clinical practice, demonstrate the importance of this medication in a pathology of such complexity and difficult control, besides of that, more randomized controlled studies are needed to confirm medical cannabis an adjunct medication in the treatment of neuropathic pain. This case report aims to demonstrate the validity of joining GMP cannabis products as an adjuvant therapy for an effective with low profile side effects treatment leading to an improvement in quality of life.

Ultrasound-Guided Hydrodistention with Corticosteroid Instillation in Glenohumeral Joint for Relief in Frozen Shoulder: A Case Series

Abstract The frozen shoulder (FS) also known as adhesive capsulitis is one of the most common causes of shoulder pain and disability. It is marked by pain and limitation of movement resulting in progressive deterioration of quality of life. Although a few patients with an FS recover without any intervention, the majority of patients have persistent pain with or without movement restriction. Ultrasound (USG)-guided hydrodistension of the shoulder joint is an upcoming mode of treatment for FS which can theoretically lead to pain relief, functional improvement, and a better quality of life, especially if combined with the anti-inflammatory effects of intra-articular corticosteroids. Here, we are presenting our experience with USG-guided hydrodistention of the shoulder joint along with intra-articular corticosteroid in cases of FS both in terms of objective indices of shoulder functionality and subjective outcomes of pain. Eight patients who presented to the outpatient department of pain medicine in our hospital having FS (stage 2/3) were selected. Outcome measures included pain score, Shoulder Pain and Disability Index (SPADI) and Shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Visual Analogue Scale, and range of movement. Data were collected at baseline, as well as at 6 weeks, 12 weeks, and 6 months. We performed hydrodistension with 30 ml of volume constituted by adding lignocaine and triamcinolone acetate to normal saline immediately, followed by physiotherapy of the shoulder joint and cryotherapy. We found promising results with all our patients both in the short term as well as long term with both SPADI and QuickDASH scores as well as the range of motion of the shoulder joint improving significantly in all eight patients at 6 weeks and 12 weeks. This improvement notably persisted in all the patients when reassessed at 6 months indicating a long-term benefit of the intervention.

Perioperative Opioid Stewardship Program: Barriers and Promotors of Implementation and Sustainability

AbstractPerioperative opioid stewardship programs aim to harness the benefits of opioid analgesia for managing acute post-surgical pain whilst mitigating potential harm. Healthcare worker stakeholders are vital for the effective program introduction and continuation. However, their perceptions of program barriers and promotors are underexplored. We conducted twenty semi-structured interviews with healthcare workers across three health services that introduced a perioperative opioid stewardship program. The participants included specialist pain medicine physicians, anaesthetist managers, pain nurses, pharmacists and Junior Medical Officers. Interviews were transcribed and coded both inductively and deductively against the Consolidated Framework of Implementation Research. Key themes from the data were reviewed, refined and reported. Participants were generally aware of perioperative opioid stewardship principles but senior clinicians reported greater specific program knowledge. Adherence to the discharge opioid prescription guideline was promoted by hospital leadership endorsement and workflow integration. A universal barrier to program adherence was inadequate resourcing. Lack of role clarity was a barrier to patient discharge opioid education. Hospital-community prescriber communication was variable but generally limited to written discharge summaries rather than a comprehensive, personalised approach. Introducing an Electronic Medical Record was universally seen as an opportunity to promote better program integration and sustainment. This study deepens our current understanding of the drivers of observed perioperative opioid stewardship program outcomes from the perspective of healthcare worker stakeholders. The findings could be used to optimise existing programs or to guide the implementation of new programs to achieve effective clinical change.

A Comparative Study of Endoscopic versus Percutaneous Epidural Neuroplasty in Lower Back Pain: Outcomes at Six-Month Follow Up.

Background and Objectives: Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods: This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results: The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions: EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.