Worst Imaginable Pain Research Articles

Addition of nitrous oxide and oxygen to carbon dioxide pneumoperitoneum during laparoscopic surgery for pain reduction: A double-blinded randomized controlled trial.

To examine if peritoneal conditioning with an altered insufflation gas mixture is associated with reduced postoperative pain intensity compared to the standard insufflation gas (i.e., 100% CO2). A prospective, single-centre, randomized, double-blind, superiority trial was performed. This study was conducted between 4 April 2019 and 10 February 2022 at the Jessa Hospital, Hasselt, Belgium. Patients scheduled for elective gynaecologic laparoscopic surgery. Seventy-four patients scheduled for elective gynaecologic laparoscopic surgery were randomised to receive either the standard insufflation gas with 100 CO2 (n = 37; control group) or the altered gas mixture of 86% CO2, 10% N2O and 4% O2 (n = 37; experimental group). Postoperative pain was assessed at 4, 8 and 24 hours after surgery and on postoperative day (POD) 7 by an 11-point Numeric Rating Scale, with 0 indicating no pain and 10 indicating worst imaginable pain. No significant differences were found between the control and experimental groups regarding postoperative pain at 4, 8 and 24 h after surgery, as well as on POD7. In addition, the median (25% and 75%) total amount of IV piritramide consumption during the first 24 h after surgery was not significantly different between groups (control group: 18.0 [10.0, 27.0] mg vs. experimental group: 17.0 [10.0, 34.0] mg, p = 0.62). The alternative insufflation gas mixture comprising 86% CO2, 10% N2O and 4% O2 used for the pneumoperitoneum during gynaecologic laparoscopic surgery does not appear to reduce postoperative pain compared to the standard insufflation gas of 100% CO2.

Perioperative and postoperative pain in patients undergoing subcutaneous implantable cardioverter-defibrillator placement

Abstract Funding Acknowledgements Type of funding sources: None. Background The recent Avoiding Transvenous Leads in Appropriate Subjects (ATLAS) Trial demonstrated that the subcutaneous implantable cardioverter–defibrillator (S-ICD) reduces lead-related complications without significantly compromising the effectiveness of ICD shocks, but with more early postoperative pain. Purpose To assess the perioperative and postoperative pain during S-ICD implantation in current clinical practice and evaluate the influence of implantation techniques. Methods We analyzed 255 consecutive patients (84% male, 52±16 years, body mass index 26±4 Kg/m², ejection fraction 42±16%) who had undergone S-ICD implantation from 2017 to 2022. The primary endpoint was pain during S-ICD placement. The secondary outcome measure included static and dynamic pain intensity 6 hours after the end of the procedure. Patients were asked to rate pain intensity on a 10-point visual analogue scale from 0 (no pain) to 10 (worst imaginable pain). Results The mean procedure duration was 62±22 minutes. The serratus anterior plane block (SAPB) was performed in 161 (63%) patients for anesthesia/analgesia, and 161 (63%) patients underwent the defibrillation testing. Implantation success was reported in all patients with no operative complications. In the overall group, the pain intensity was 2 [range: 1-8] during the implantation procedure, and 1 [1-7] for both static and dynamic pain, 6 hours after the end of the procedure. Significantly lower values were recorded during implantation in the SAPB group (p=0.010) and among those who did not undergo the defibrillation testing (p=0.008). The adoption of the SAPB (coefficient: -0.54, p=0.047) and the omission of defibrillation testing (coefficient: -0.70, p=0.028) remained associated with less pain during implantation after correction for age, sex, body habitus, ejection fraction. Six hours after the end of the procedure the static and dynamic pain intensity remained lower among those with omitted testing (p=0.018 and 0.004, respectively). Conclusions In current clinical practice, S-ICD implantation is associated with very little discomfort. The adoption of novel anesthetic techniques and the omission of defibrillation testing is associated with lower pain levels.

Postoperative Pain after Different Transscleral Laser Cyclophotocoagulation Procedures.

As the number of surgical options in glaucoma treatment is continuously rising, evidence regarding distinctive features of these surgeries is becoming more and more important for clinicians to choose the right surgical treatment for each individual patient. For this retrospective data analysis, we included glaucoma patients treated with either continuous wave (CW-TSCPC) or micropulse transscleral cyclophotocoagulation (MP-TSCPC) in an inpatient setting. Pain intensity was assessed using a numeric rating scale (NRS) ranging from 0 (no pain) to 10 (worst imaginable pain) during hospitalization. CW-TSCPC was performed using OcuLight® Six (IRIDEX Corporation, Mountain View, CA, USA) and MP-TSCPC was performed using the IRIDEX® Cyclo-G6 System (IRIDEX Corporation, Mountain View, CA, USA). A total of 243 consecutive cases of TSCPC were included. Of these, 144 (59.26%) were treated with CW-TSCPC and 99 (40.74%) with MP-TSCPC. Using the univariable model, the risk for postoperative pain was observed to be lower in MP-TSCPC compared with CW-TSCPC (unadjusted: OR 0.46, 95% CI 0.24-0.84, p = 0.017), but this did not hold using the multivariable model (adjusted: OR 0.52, 95% CI 0.27-1.02, p = 0.056). Simultaneously conducted anterior retinal cryotherapy was associated with a higher risk for postoperative pain (OR 4.41, 95% CI 2.01-9.69, p < 0.001). We found that the occurrence of postoperative pain was not different in CW-TSCPC compared with MP-TSCPC in a multivariable model. In cases of simultaneous anterior retinal cryotherapy, the risk for postoperative pain was significantly higher.

The temporal expression of circulating microRNAs after acute experimental pain in humans.

MicroRNAs (miRNAs) can modulate several biological systems, including the pain system. This study aimed to evaluate the temporal expression of circulating miRNAs in the plasma of healthy volunteers as a marker for epigenetic changes before and after an acute, experimental, pain provocation by intramuscular hypertonic saline injection. Twenty volunteers were randomly allocated into two groups and received either hypertonic (pain) or isotonic (control) saline injection in the first dorsal interosseous muscle of their dominant hand. Pain intensity was continuously recorded for 20minutes after injection on a VAS scale from 0 to 100 (0 indicates no pain and 100 the worst imaginable pain). Blood samples were taken at baseline, 30minutes, 3hours, and 24hours post-injection, and plasma was separated. MiRNA extracts were used for RNA sequencing with the Illumina NextSeq platform. MiRNA transcripts were compared between the pain and the no-pain, control group at every time point. Significant differences were considered when folds were >2 and the False Discovery Rate was p< 0.05. After 30minutes, 4 miRNAs were significantly altered in the pain group compared to controls, which increased to 24 after 3 hours and to 42 after 24hours from baseline (p< 0.0001). Two miRNAs were consistently upregulated throughout the experiment. Enrichment analysis showed significant miRNAs involved in brain perception of pain, brain signalling and response to stimuli. This exploratory study is the first to report on the temporal expression of circulating miRNAs after an acute, human experimental muscle pain model. This exploratory study evaluated the temporal profile of circulating miRNAs in the plasma of healthy subjects after acute experimental pain. Several miRNAs were altered in subjects at the times of follow-up after the acute pain model when compared to controls. MiRNAs previously associated with pain processes were altered in the pain group. Our results, by showing the fast and prolonged modifications of miRNA elicited by the acute experimental pain model, add new perspectives to the topic of epigenetics and pain.

Healthy ageing: Herpes zoster infection and the role of the adjuvanted recombinant zoster vaccine

Abstract Background Increases in life expectancy over the last 50 years has been matched by an increase in the burden of diseases (e.g. herpes zoster (HZ)) in adults ≥50 years of age (YOA). Without intervention, around 30% of individuals can expect to develop HZ in their lifetime, which would impact their daily activities and healthy ageing. Methods We conducted a narrative review on published literature on the impact of developing HZ on healthy ageing and the ability of vaccination to prevent the burden of disease due to HZ. Specifically, we describe HZ impact on quality of life (QoL), and impact of the adjuvanted recombinant zoster vaccine (RZV) on reducing the burden of HZ in adults ≥50 YOA. Results In adults ≥50 YOA with HZ, 65.1% and 15.8% reported severe pain and worst imaginable pain, respectively. Pain persisted for up to 90 days (defined as post-herpetic neuralgia) in 10-20% of HZ patients, and occasionally for years after initial symptoms. Pain due to HZ impacted all domains of QoL (psychological, physical and social). Evidence suggested that RZV reduced HZ burden of illness and burden of interference on daily activities by &amp;gt; 90%. Reports also suggested that RZV retained vaccine efficacy of &amp;gt; 90% in all frailty subgroups, who typically respond poorly to other vaccinations. Long-term follow-up data reported vaccine efficacy against HZ of 84.1% (95% confidence interval, 64.4% - 94.0%), 8 years post-vaccination. Modelling studies demonstrated that vaccination resulted in reduced hospitalization and other healthcare visits related to HZ. Conclusions Vaccination with RZV can protect older adults from HZ, thus maintaining QoL and promoting active and healthy ageing. Key messages • There is significant burden of disease due to HZ among adults ≥50 YOA due to ageing and immunosenescence. • Vaccination can reduce burden of disease among the elderly and frail individuals and maintain QoL.

Incidence and predictors of priapism events in sickle cell anemia: a diary-based analysis

AbstractWe conducted one of the first prospective studies to test the hypothesis that the clinical history of priapism underestimates priapism incidence compared with a priapism pain diary. Eligibility criteria were men with sickle cell anemia (SCA) between 18 and 40 years of age who have had at least 3 episodes of priapism in the past 12 months. Seventy-one men with SCA completed the diary for at least 3 months. The first 3 months of the priapism diary were included in the analysis. A total of 298 priapism episodes were recorded, and 80% (57 of 71) of the participants had at least 1 priapism event. Priapism severity was reported in the range of moderate to the worst imaginable pain in 81.5% (263 of 298), and a total 57 participants (80%) had a median pain rating of 6 (interquartile range: 5-8) on a scale from 1 to 10. The monthly incidence rate of priapism per participant based on history versus self-report pain diary was 2.0 (95% confidence interval, 1.9-2.1) and 1.4 (95% confidence interval, 1.2-1.6), respectively (P < .001). For participants that had a prior priapism episode, 80% had another episode during the 3-month interval follow-up. The median time to that second episode was 27.5 days. Major priapism occurred in 9.9% of episodes and was associated with the sum of all prospective priapism events. Men with SCA and at least 3 priapism episodes in the past 12 months are at significant risk for recurrent priapism in the following 3 months.

Long-Term Follow-Up Safety and Effectiveness of CT-Guided Radiofrequency Thermocoagulation of Sphenopalatine Ganglion in Refractory Headache Treatment.

ObjectiveThe purpose of this study was to evaluate the effectiveness and safety of computed tomography (CT)-guided radiofrequency thermocoagulation (RFTA) of the sphenopalatine ganglion (SPG) for patients with refractory headache.MethodsA total of 14 patients with refractory migraine and 10 patients with cluster headache (CH) who underwent CT-guided SPG RF between May 2019 and August 2021 at the Jiaxing First Hospital, located in Jiaxing City, Zhejiang Province, China, were included and analyzed in this retrospective cohort study. Pain score, sleep quality scores, and treatment effects were observed before operation as well as 1 day and 1, 3, 6, 12, and 24 months after surgery. Also, the incidence of facial numbness at different timepoints after operation was evaluated.ResultsThe frequency and duration of attacks decreased after treatment in patients with migraine, and the shortening of the cluster period and the prolongation of the remission period after treatment in patients with CH indicated that the treatment was effective. The numeric rating scale (NRS) ranged from 0 to 10, where 0 meant no pain and 10 meant the worst imaginable pain. The NRS of patients at 1 day and 1, 3, 6, 12, and 24 months after surgery was significantly lower than before operation (P < 0.05). The treatment of patients with migraine and CH was effective. The overall incidence of numbness in patients with migraine and the total incidence of numbness in patients with CH was recorded. The total incidence of numbness decreased gradually, but no significant difference was detected in the incidence of numbness between the two groups (P > 0.05). No serious adverse reactions, such as orthostatic hypertension, intracranial infection, and visual disturbance, occurred in the patients after operation.ConclusionCT-guided RFTA of the SPG significantly relieves headache symptoms in patients with refractory migraine and CH. It has the advantages of rapid onset, long duration, and a safe and reliable treatment process, making it worthy of clinical application.

Impact of endometriosis on women’s life decisions and goal attainment: a cross-sectional survey of members of an online patient community

ObjectivesTo examine women’s perceptions of endometriosis-associated disease burden and its impact on life decisions and goal attainment.DesignAn anonymous online survey was distributed in October 2018 through the social media network...

The Effectiveness of Perioperative Parecoxib Intravenous Administration in Foot and Ankle Surgery: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

Category:Trauma; AnkleIntroduction/Purpose:Parecoxib is indicated for the short-term treatment of postoperative pain in adults. A systematic review assessed the analgesic efficacy of single dose intravenous (IV) or intramuscular (IM) parecoxib in acute postoperative pain and concluded that parecoxib is an effective analgesic in the postoperative setting in adults. However, little is known about its effectiveness in the perioperative intravenous administration in foot and ankle surgery. The present study conducts a double- blinded prospective randomized controlled trial via an 'intention-to-treat analysis' principle to compare the effectiveness of perioperative parecoxib versus placebo in patients with unstable ankle fractures who have surgical indications.Methods:A total of 40 patients undergoing open reduction and internal fixation of the unstable ankle fractures were randomly allocated either to Group A (parecoxib 40 mg IV 30 min before surgery and then an additional 40 mg every 12 hours for 48 hours after surgery [n=20]) or Group B (placebo (saline) [n=20]). The baseline data were recorded in each patient. The efficacy of pain control was assessed by total morphine used, pain intensity (at rest/ambulation) and pain relief (at rest/ambulation) using the verbal numerical rating score (VNRS) from 0 (no pain) to 10 (worst imaginable pain) and the verbal numerical rating percentage (VNRP) from 0 (no relief) to 100 (best relief) respectively, as well as each patient's subjective rating of the medication. The patients' subjective rating of the medication used the classifications of 'excellent', 'good', 'fair', or 'poor'. When the patients were moved to the post-anesthesia care unit (PACU) after surgery, the study procedure was to record the time as 0. The data were then recorded at 0, 4, 12, 24, and 48 hours after surgery by trained personnel. The overall adverse effects experienced by patients were reported in both groups. All outcomes were recorded by trained personnel who were blind to the patient group allocation. All surgeons, anesthesiologists, and patients involved in the process were also blind to the group allocations. The outcomes including efficacy, patients' subjective ratings of the medication, and overall adverse effects were statistically compared between the two groups.Results:From a total of 40 patients in the study, four patients were excluded by the study criteria. The remaining 36 patients continued in the study. The mean age of patients was 49.3 +/- 18.0 years. No significant difference was found regarding the mean age of patients between the two groups (p-value > 0.05). Male patients appeared more frequently in the saline group than the parecoxib group (p-value = 0.018). For the main outcomes, there were no significant differences between the two groups in terms of the pain intensity, pain relief, patients' subjective ratings of the medication at both preoperative and postoperative periods, total quantity of morphine used, and side effects and acute complications of surgery (p-values > 0.05).Conclusion:Based on the results of the present study, the perioperative administration of parecoxib could not significantly improve postoperative pain control as defined by the reduction in opioid requirements, lower pain scores, higher pain relief, and higher patients' subjective ratings of the medication when compared to the placebo. Male predominance was significantly found in the placebo group. This may have influenced the level of pain tolerance between the two groups. This may also affect the results as no significant differences of pain parameters between the two groups in the study. Further study with larger numbers of patients is still necessary to clarify the role of preemptive parecoxib on ankle fracture surgery.

Pain Assessment during Gnathological Treatment of Temporomandibular Myofascial Pain through Mandibular Repositioning Splints Designed after a Posture-Stabilometric Evaluation

The aim of the study is to evaluate the effectiveness of two complementary mandibular repositioning splints (SVED and MORA) designed after a preliminary patients’ posture-stabilometric evaluation in treatment for temporomandibular myofascial pain (TMP) using the Pain-Intensity Numeric Rating Scale (PI-NRS) assessment. Eighty-six consecutive sportive non-agonistic subjects with TMP were randomly divided in two groups. Forty-two wear mandibular repositioning splints designed by a posture-stabilometric evaluation, thus constituting the test group. The other 44 subjects were not subjected to any treatment, thus represented the control group. To record pain intensity, subjects in both groups were asked to fill in a PI-NRS which ranged from 0 (no pain) to 10 (worst imaginable pain). In the test group, PI-NRS was assessed three times: before starting therapy (t0), after 4 months (t1) and after 8 months (t2) of treatment. Instead, in the control group PI-NRS was recorded during the first visit (t0) and after 8 months (t2). The Friedman test showed a statistically significant decrease in PI-NRS mean scores after 4 (t1) and 8 (t2) months from the start of the gnathological therapy with mandibular repositioning splints, (p &lt; 0.001) in test group. There is enough evidence to assess that occlusal splint therapy for mandibular repositioning (MORA and SVED) designed through a posture-stabilometric evaluation could be considered in the treatment of temporomandibular myofascial pain.

157. Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: roles of psychological distress and patient activation

157. Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: roles of psychological distress and patient activation

O-168 Chronic pelvic pain is the most troublesome endometriosis pain symptom for women’s quality of life

Abstract Study question Which pre-operative endometriosis pain symptom is most troublesome for the quality-of-life of women assessed at different meta-levels? Summary answer Of five pain symptoms chronic pelvic pain is most troublesome or has the strongest correlation to women’s overall quality-of-life and overall and endometriosis-specific health status. What is known already Endometriosis affects women’s quality of life negatively, and its impact seems to depend more on women’s symptoms than on their degree of endometriosis. Experts proposed to include ‘the most troublesome symptom’ and ‘overall pain’ as core outcomes but did not define how to assess these outcomes. It would be interesting to find out which pain symptom (i.e. assessed for presence and intensity) has most impact on women’s quality-of-life assessed at different meta-levels, including: overall quality-of-life (depending on amongst others one’s professional and relational life besides health), general health status and endometriosis-specific health status. Study design, size, duration A prospective survey addressed 277 adult women scheduled for diagnostic and/or therapeutic surgery in a University endometriosis clinic between October 2016 and November 2019. Women were reminded twice of our request to fill out the coded but anonymous questionnaire package assessing five pain symptoms (i.e. chronic pelvic pain, dysmenorrhea, dyspareunia, dysuria and dyschezia) and assessing quality-of-life at three different meta-levels. Participants/materials, setting, methods Women scored five endometriosis symptoms between 0 (no pain) and 10 (worst imaginable pain), combined into ‘overall pain’ (0-50). ‘Overall quality-of-life’ was assessed with the Linear Analogue Scale (LAS; the higher, the better). General and endometriosis-specific health status were assessed with the overall scores of the EuroQol-5D and the Endometriosis-Health-Profile-30 (the higher, the better). Pearson correlation coefficients between the six pain scores and three measures of quality-of-life were computed (p = 0.003; 0.05/18 as Bonferroni correction). Main results and the role of chance A total of 227 women took part (participation rate=82%) and the data of 202 women (mean age 31±5 years old) with surgically confirmed endometriosis were analysed. In the previous six months, the majority of women reported chronic pelvic pain (56%), dyspareunia (55%), dysmenorrhea (56%) and/or dyschezia (58.4%), while only some reported dysuria (25%). Women’s mean overall pain score was 20 (±12). Women’s mean overall quality-of-life was 65 (±16). On average women rated their general health status to be 62 (±18) and their mean endometriosis-specific health status was 53 (±18). Only the pain symptom chronic pelvic pain was correlated (p &amp;lt; 0.001) to assessments of quality-of-Life at all three meta-levels. The correlation for endometriosis-specific health status was large (r= -0.574), while the others were medium (r= -0.343 &amp; r= -0.324). After taking account of the Bonferroni correction for multiple testing the remaining four pain symptoms only had a medium correlation (p &amp;lt; 0.001) to endometriosis-specific health status (r= -0.356 – -0.265; p &amp;lt; 0.001) and they were not correlated to overall quality-of-Life or general health status. Overall pain had a medium correlation (p &amp;lt; 0.001) to Overall quality-of-Life (r= -0.270) and general health status (r= -0.259) and a strong correlation (p &amp;lt; 0.001) to endometriosis-specific health status (r= -0.529). Limitations, reasons for caution The majority of patients (60%) of the recruiting University endometriosis clinic had severe endometriosis (AFS-IV) and this study could be repeated in another setting. Directly asking women which pain symptom is most troublesome to them would be interesting besides exploring correlations between pain symptoms and quality of life. Wider implications of the findings Nurses, midwives and other health care professionals should devote attention to chronic pelvic pain during the anamnesis and women-centred care as this pain symptom is most troublesome for women’s quality of life. Whether surgery decreases chronic pelvic pain and overall pain is currently followed-up in the studied prospective cohort. Trial registration number Not applicable

Assessment of Health-Related Quality of Life in Adults Hospitalized with Sickle Cell Disease Vaso-Occlusive Crisis

Background: Sickle cell disease (SCD) is a chronic condition characterized by painful vaso-occlusive (VOC) episodes which lead to poor health-related quality of life (HRQL) and premature mortality. As curative treatment with hematopoietic stem cell transplant is only an option for a minority of adult patients, current treatments are palliative with focus on pain management. Clinically, pain assessment is commonly performed by the Numeric Rating Scale (NRS), where patients rate the intensity of pain from 0 (no pain)-10 (worst imaginable pain). However, the incorporation of HRQL through the use of newer patient-reported outcome measures (PROs) into the assessment of pain and the care of patients with SCD is evolving. As these newer measures were developed in ambulatory populations, to date, they have not been studied among adults with SCD hospitalized for painful VOC.Objective: To describe the VOC pain experience and its effect on HRQL in hospitalized adults with SCD, using two PRO measures, the Patient-Reported Outcomes Measurement Information system (PROMIS) Global Health and the Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me).Methods: Adults with SCD hospitalized at a US-based academic medical center with VOC were eligible. Following study enrollment at hospital admission (T1), participants completed the ASCQ-Me Pain Episode assessment, which yields a Frequency score (range 0-11) and Severity score (range 0-22), where higher scores reflect worse disease over the prior year. Participants also complete PROMIS Global and ASCQ-Me at T1. Seven days after hospital discharge (T2), participants again completed PROMIS Global and ASCQ-Me questionnaires. These measures yield scores in domains of global physical and mental health, and SCD-related domains of emotional, social functioning, pain, stiffness, and sleep impact, respectfully. Standardized domain scores have a mean of 50 (SD=10) where higher scores indicate better functioning. Changes of 3 points (0.3 SD) are considered clinically meaningful. We calculated means and standard deviations for the NRS and domain scores at T1 and T2. One sample t-tests were used to compare domain change scores from Admission to Discharge+7, restricted to respondents with complete follow-up.Results: We report preliminary results from our larger inception cohort. To date, 28 of 29 eligible patients consented and completed T1 assessments (97%). 18 also completed T2 assessments. Of the 10 participants who did not complete T2 assessments, 50% were readmitted within 1 week and 20% within one month; the remainder (n=3) were non-respondents at T2.The mean age was 30.6 years (SD 9.9) with 57% females and 71% self-identified as black, non-Hispanic. The remainder was Hispanic. The most common genotype was HbSS (57%). T1 mean ASCQ-Me Pain Episode Frequency score was 9 (SD 2.2, range 4-11) and Severity score was 18 (SD 3.1, range 8-22), reflecting recurrent and prolonged painful VOC episodes over the prior year.At hospital admission, 66% of patients had 4 or more pain crises in the last 12 months. The mean score for the most severe pain during the last pain attack was 8.8 (SD = 1.4) on a scale from 0-10. The most recent pain crisis for 66% of patients lasted at least 1 week; 26% reported crisis lasting longer than 2 weeks.The table presents mean domain scores at each assessment period and the change scores. All domain scores on ASCQ-Me and PROMIS Global were well below population norms. There was statistically significant and clinically meaningful improvement in pain intensity and the domains of physical health, emotional impact and sleep impact by 7 days after discharge (p<0.05).Conclusions: Administering both general and disease-specific PROs at the point-of-care is feasible and informative. Among this cohort of hospitalized patients with VOC, baseline ASCQ-Me Pain Episode scores reflect recurrent and prolonged painful VOC episodes over the prior year. All ASCQ-Me domain and PROMIS Global scores were well below population norms, indicating substantial suffering from the multidimensional impact of the VOC pain experience both upon admission and following discharge. Despite the intensity of the patients' condition, we demonstrate successful enrollment (97%) and data collection on admission. 64% data completeness at T2 indicates some degree of non-ignorable missing data, which will be addressed in final data analysis. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Comparative Study of Valsalva Maneuver, Lidocaine, and Valsalva Maneuvers with Administration of Lidocaine to Reduce the Pain Associated with Administration of Etomidate During General Anesthesia.

ObjectivesThe purpose of this study is a comparison of Valsalva, lidocaine, and Valsalva with administration of lidocaine to reduce the pain associated with administration of etomidate.MethodsThe present study is a clinical trial study. The number of samples in each group was 30 and a total of 90 people were selected. This study was a clinical trial and the subjects were randomly divided into three groups: Group 1: Valsalva, 2: Lidocaine, 3: Valsalva and Lidocaine. Pain due to etomidate was rated on a VAS from 1 (painless) to 3 (worst imaginable pain) and their information was recorded. The collected information was entered into SPSS 22 and analyzed with appropriate statistical tests.ResultsA total of 90 subjects participated in the present study and were divided into 3 groups: Valsalva, lidocaine, and Valsalva with lidocaine. No significant difference was observed between demographic variables in the study groups. There was a significant relationship between severity of pain in the three groups. According to the results, the highest pain intensity was in the Valsalva group and the lowest pain intensity was in the Valsalva with lidocaine group.ConclusionsValsalva with lidocaine reduces the severity of pain caused by etomidate to a greater extent than other groups.

Clinical Relevance of Changes in Pain Intensity in Patients with Specific Back Pain.

Pain intensity is frequently measured on the 11-point numerical pain rating scale (NRS-PI), ranging from 0 (no pain) to 10 points (worst imaginable pain). However, it is difficult to interpret the clinical importance of changes from baseline to endpoint on this instrument. To estimate the minimal detectable change (MDC) and the minimal clinically important difference (MCID) for average pain intensity in patients with specific back pain. Data on 1232 subjects with specific back pain from a German hospital were included in this study. A score combining the patient's (PGIC) and the physician's global impression of change (CGIC) over the in-patient length of stay was used as an external criterion. A priori, we considered the score value "slightly improved" as the MCID. MDC was calculated using the standard error of measurement (SEM) and the standard deviation (SD) of the sample. MCID was estimated by the mean value of PI-NRS change in patients who self-assess as "slightly improved", and by sensitivity/specificity analyses, computed by the receiver operating characteristic method (ROC). MDC was 1.77. The MCS and ROC methods consistently showed an MCID of 2 for the total sample. Both methods showed the dependence of the MCID on the initial pain: 1 for mild to moderate pain at baseline (1 - 4 NRS points), 2 for moderate to severe pain (5 - 7) and 3 - 4 for very severe to extreme pain (8 - 10). For patients with lumbosacral intervertebral disc disorders and patients in the acute phase (duration of pain < 6 weeks), the ROC method resulted in a higher limit than the MCS method. In order to facilitate the interpretation of changes and to take into account the patient's perspective, the global assessment of the success of treatment should be used as an anchor criterion. In addition to dealing with pain measurement, function-related and psychosocial aspects of pain symptoms should be kept in mind.

A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department

We compare the efficacy and adverse effects of 5 oral analgesics in emergency department (ED) patients aged 21 to 64 years with acute musculoskeletal pain. This was a randomized clinical trial conducted in 2 urban EDs. Patients received 400 mg ibuprofen/1,000 mg acetaminophen, 800 mg ibuprofen/1,000 mg acetaminophen, 30 mg codeine/300 mg acetaminophen, 5 mg hydrocodone/300 mg acetaminophen, or 5 mg oxycodone/325 mg acetaminophen. The primary outcome was change in pain before administration of medication (baseline) to 1 hour postbaseline. A numeric rating scale was used, varying from 0="no pain" to 10="worst imaginable pain." Secondary outcomes included receipt of rescue medication and adverse effects at 1 and 2 hours postbaseline. ANOVA was used to test differences in the primary outcome between treatment groups. Six hundred participants, predominantly men and Latino, were enrolled. Change in pain from baseline to 60 minutes did not differ by treatment (P=.69). The mean change in pain in numeric rating scale units was 400 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% confidence interval [CI] 2.6 to 3.5); 800 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% CI 2.5 to 3.5), 30 mg codeine/300 mg acetaminophen 3.4 (95% CI 2.9 to 3.9), 5 mg hydrocodone/300 mg acetaminophen 3.1 (95% CI 2.7 to 3.5), and 5 mg oxycodone/325 mg acetaminophen 3.3 (95% CI 2.8 to 3.7). Rescue medication was received before 1 hour had elapsed by 2 patients receiving 400 mg ibuprofen/1,000 mg acetaminophen (1.7%), 3 patients receiving 800 mg ibuprofen/1,000 mg acetaminophen (2.5%), zero patients receiving 30 mg codeine/300 mg acetaminophen (0.0%), 3 patients receiving 5 mg hydrocodone/300 mg acetaminophen (2.5%), and zero patients receiving 5 mg oxycodone/325 mg acetaminophen (0.0%) (P=.21). More patients who received opioids were nauseated or vomited compared with those who did not: 6.7% versus 1.7% (5.0% difference; 95% CI 1.7% to 8.2%). The findings at 2 hours were similar. No analgesic was more efficacious than others 1 or 2 hours after baseline. There was significantly more nausea and vomiting among patients treated with opioids.

Assessment of Awareness, Attitude and Desire for Labor Analgesia and Associated Factors Among Pregnant Women in Ethiopia: A Cross-Sectional Study.

IntroductionLabor pain is the worst imaginable pain that women experience during their childbearing years. Untreated labor pain has numerous negative consequences, for both the mother and her fetus. Low levels of awareness and attitudes among pregnant women about labor analgesia is a major challenge that affects outcomes for both the mother and fetus. Therefore, this study aimed to assess the awareness of, attitude towards and desire for labor analgesia and its associated factors among pregnant women who visited an antenatal care facility.MethodsAn institution-based, cross-sectional study was conducted from February to March 2019. Data were collected using semi-structured questionnaires by a convenience sampling technique. Data were entered using EpiData 4.2 and exported to SPSS version 20 software for analysis. Both bivariate and multivariate binary logistic regression analysis were used to identify factors associated with awareness, attitude and desire for labor analgesia among pregnant women. Crude odds ratio (COR) and adjusted odds ratio (AOR) were calculated to show the strength of association.ResultsA total of 410 participants were included. Thirty-three (8%) of the pregnant women who visited the antenatal care facility were found to have an awareness of labor analgesia. In multivariate analysis, the likelihood of having awareness of labor analgesia was 7.227 times (AOR: 7.227, 95%, CI 2.406–21.720) greater among parous versus nulliparous mothers. The odds of having awareness of labor analgesia were 3.133 times (AOR: 3.133, 95%; CI 1.144–8.581) greater among government employees than among housewives. The odds of having a good attitude towards labor analgesia were 6.488 times (AOR: 6.488, 95% CI 1.894–22.227) higher in government employees than in farmers. Women in the age group of 25–31 years were 1.815 times more likely to want labor analgesia for their next delivery (AOR: 1.815, 95% CI 1.103–2.989).ConclusionsThe awareness of labor analgesia among pregnant women was low. There is a need for teamwork by all stakeholders in health sectors to improve attitudes and increase the desire for labor analgesia among pregnant women who visit antenatal care facilities.Electronic supplementary materialThe online version of this article (10.1007/s40122-020-00212-1) contains supplementary material, which is available to authorized users.

Sternal reconstruction using locking compression plates (LCP): our experience in Egypt, a case series

BackgroundSternal fractures are rare accounting for about 3–8% of traumatic chest. There are many lines of treatments for sternal fractures which can be classified as conservative or surgical. Surgical techniques include wire fixation and sternal plating. There are no standardization of indications for each line of management.We explore if sternal reconstruction using locking titanium plates and self-tapping screws provide the patient with the best chance of proper sternal healing avoiding chronic pain and its complications and allow the patient early mobilization and rapid restoring of his normal life at its maximum.MethodsOur inclusion criteria are patients of both gender from 20 to 60 years of age presented with traumatic sternal fracture at any site or pathological fracture due to metastatic or primary tumors infiltrating the sternum. High Associated Injury Scale scores were excluded. Exclusion criteria also included patients younger than 20 years or older than 60 years. Primary outcome is post-operative pain score and is measured using numerical pain scale ranging from zero to 10 where zero means there is no pain at all and ten is the worst imaginable pain ever.ResultsSternal reconstruction using titanium plates has proven to be an efficient method of stabilization with tremendous immediate relief of pain showed by the differences between pre-operative and post-operative pain scale scores in our patients (n = 5) with Median scores being 7 and 1.5 with range being from 7 to 9 and 1 to 3 respectively (p-value = .039). Operative time range between 150 min and 90 min with median of 120 min. Extubation of patients was smooth with no events with median time of extubation being 120 min. From our experience, there were no observed wound complications except at the third patient who suffered a small wound hematoma that was resolved by gentle compressing only and needed no further intervention.ConclusionWe recommend adopting sternal reconstruction using titanium plating systems more readily encouraging even larger clinical trials on the way to a clear guidelines. Plating systems show promising results with least pain, better stability, less complications and rapid, smooth recovery.Trial registrationNCT04092374

Preoperative Osteopathic Manipulative Therapy Improves Postoperative Pain and Reduces Opioid Consumption After Total Knee Arthroplasty: A Prospective Comparative Study.

Pain is a therapeutic challenge after total knee arthroplasty (TKA), and it could lead to the overuse of opioids. Few methodologically robust clinical studies have been performed to assess the effectiveness of osteopathic manipulative therapy (OMTh; manipulative care performed by non-US-trained osteopaths) for postsurgical pain. To evaluate the effectiveness of standardized preoperative OMTh on early postoperative pain and opioid consumption after TKA. This comparative, nonrandomized study took place from 2013 to 2015 and included patients who had primary unilateral TKA for osteoarthritis in a knee that had not undergone any previous surgery. Patients were divided into 2 consecutive groups: 1 group received traditional preoperative management, and the other group received associated preoperative OMTh (general OMTh [rhythmic mobilization of all the body joints, from the ankles to the skull, using long-lever manipulation] and myofascial relaxation). The primary evaluation criterion was knee pain at rest 1 month after surgery: 0 (no pain) to 100 (the worst imaginable pain). The secondary evaluation criteria were: (1) knee pain while walking 1 month after surgery, (2) average weekly knee pain during the first month after surgery, (3) the presence of night pain and the consumption of sleeping pills and opioids or morphine at least once per week, (4) the International Knee Society scores and the Western Ontario and McMaster University Osteoarthritis index at postoperative 6 months and 1 year. The number of patients needed for a superiority trial was determined. No eligible patient refused OMTh when proposed. Seventy patients were evaluated (mean [SD] age, 75 [8] years; 47 women and 23 men). The 2 treatment groups contained 35 patients each. At postoperative month 1, the OMTh group had significantly less pain at rest (mean [SD], 6.8 [6] vs 20.9 [17.3]; P=.00001) and while walking (7.9 [9.4] vs 23.5 [20.6]; P=.0001) compared with the group that received traditional preoperative management. The consumption of opioids during the first postoperative week was significantly lower in the OMTh group (P=.0001). No statistically significant difference was found in the International Knee Society or Western Ontario and McMaster University Osteoarthritis scores between the 2 groups at 6 months and 1 year of follow-up. Standardized preoperative OMTh was found to be effective in reducing pain in the first month after TKA for osteoarthritis and significantly reduced opioid consumption during the first postoperative week.

Patient-Physician Interactions Regarding Dyspareunia with Endometriosis: Online Survey Results.

IntroductionDyspareunia can be a debilitating symptom of endometriosis. We performed this study to examine women’s experiences with painful sexual intercourse, the impact of dyspareunia on patients’ lives, and perceptions of interactions with healthcare practitioners.MethodsAn anonymous 24-question online survey was provided through the social media network MyEndometriosisTeam.com and was available internationally to women aged 19–55 years who were self-identified as having endometriosis and had painful sexual intercourse within the past 2 years.ResultsFrom June 13 to August 20, 2018, 860 women responded and 638 women completed the survey (United States, n = 361; other countries, n = 277; 74% survey completion rate). Respondents reported high pain levels (mean score, 7.4 ± 1.86; severity scale of 0 [no pain] to 10 [worst imaginable pain]), with 50% reporting severe pain [score of 8 to 10]). Nearly half (47%) reported pain lasting ≥24 hours after intercourse with the pain often leading to avoiding (34%) or stopping (29%) intercourse. Pain impacted patients’ lives, causing depression (61%), anxiety (61%), low self-esteem (55%), and relationship strain. Many women feared to seek help (10%). Of those women who approached practitioners, many (36%) did not receive effective treatments.DiscussionWomen with dyspareunia related to endometriosis experience severe pain that can negatively impact patients’ lives. Dyspareunia may be a challenging topic for discussion for both patient and practitioner, leading to a suboptimal treatment approach and management. Results suggest that practitioners need improved education and training regarding dyspareunia to evaluate and treat patients’ sexual pain caused by endometriosis.