Non-opioid psychiatric medications for chronic pain: systematic review and meta-analysis.

Background: The escalating number of deaths related to opioid usage has intensified the pursuit of non-opioid alternatives for managing chronic pain. It's often observed that psychiatric comorbidities coexist in patients suffering from chronic pain. There are a variety of psychotropic medications that have demonstrated effectiveness in treating both psychiatric symptoms and pain. This systematic review and meta-analysis aim to assess the effectiveness of various psychiatric drugs in managing specific types of chronic pain, including fibromyalgia, neuropathic pain, and chronic low back pain. Methods: A comprehensive search of five major databases was conducted through February 2023 to identify randomized controlled trials (RCTs) that met our inclusion criteria, focusing on outpatients Over 18 years of age with chronic pain. The study assessed the effectiveness of duloxetine, mirogabalin, pregabalin, gabapentin, and tricyclic antidepressants (TCAs), including serotonin-norepinephrine reuptake inhibitors (SNRIs), across various chronic pain conditions such as fibromyalgia, neuropathic pain, and chronic low back pain. The primary outcome measures included pain reduction, improvement in function, and quality of life. Of the 29 RCTs in the systematic review, 20 studies qualified for the meta-analysis. The analysis was stratified by pain type and treatment duration (short-term ≤14 weeks vs. long-term >14 weeks), using Hedge's g standardized mean differences and a random-effects model, along with sensitivity and subgroup analyses. Results: The overall short-term intervention effect across all studies was significant (SMD -1.45, 95% CI -2.15 to -0.75, p < 0.001), with considerable heterogeneity (I2 = 99%). For fibromyalgia, both duloxetine and mirogabalin demonstrated substantial efficacy with SMDs of -2.42 (95% CI -3.67 to -1.18, p < 0.0001) and -2.10 (95% CI -3.28 to -0.92, p = 0.0005), respectively. Conversely, treatments for neuropathic pain and chronic low back pain, including those with amitriptyline and desipramine, did not show significant benefits. The effectiveness of gabapentin could not be conclusively determined due to limited representation in the data. Additionally, no consistent long-term benefits were observed for any of the medications. Conclusions: While the results of this study underscore the importance of exploring non-opioid alternatives for chronic pain management, particularly in light of the opioid crisis, it is crucial to interpret the findings carefully. Our analysis suggests that certain psychiatric medications, such Duloxetine and mirogabalin demonstrated significant short-term efficacy in fibromyalgia patients. However, their effectiveness in treating neuropathic pain and chronic low back pain was not statistically significant. Additionally, the effectiveness of gabapentin and other medications, such as pregabalin for neuropathic pain, could not be conclusively determined due to limited data and high study heterogeneity. No consistent long-term benefits were observed for any of the drugs studied, raising questions about their sustained efficacy in chronic pain management. These findings highlight the need for further research to understand better the role of psychiatric medications in managing specific chronic pain conditions without prematurely concluding that they are ineffective or unsuitable for these purposes.

Therapeutic Potential of Buprenorphine in Depression: A Meta-Analysis of Current Evidence.

Background: Emerging research indicates buprenorphine, used in management of opioid use disorder, has attracted interest for its potential in treating a variety of psychiatric conditions. This meta-analysis aimed to determine the efficacy of buprenorphine in treating symptoms of depression. Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a search was conducted of several databases until April 25, 2022, for English language articles related to buprenorphine and its use in treating various mental health conditions. Standardized mean differences (SMDs) and its 95% confidence intervals (CIs) were reported for the Hamilton Rating Scale for Depression (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS) scores. Statistical analyses were performed using Cochrane RevMan 5. Results: Of the 1,347 identified studies, six clinical trials were included. MADRS-10 least square mean difference (LSMD) inter-group assessment favored buprenorphine over placebo, but it lacked statistical significance. Similarly, MADRS scores as well as HAM-D inter-group assessment were in favor of buprenorphine, however, were not statistically significant. These findings suggest a potential therapeutic role for buprenorphine in treating depression, albeit with caution due to the observed lack of statistical significance and the potential for confounding factors. Conclusions: Preliminary evidence suggests potential efficacy of buprenorphine at lower doses in improving improving outcomes specifically related to depression. However, due to limitations in statistical significance and possible confounding factors, entail cautious interpretation. Further rigorous research is needed to investigate the long-term effects, optimal dosing, and determine the role of adjuvant drug therapy.

Good manufacturing practice production of human corneal limbus-derived stromal stem cells and in vitro quality screening for therapeutic inhibition of corneal scarring.

BACKGROUND: Mesenchymal stem cells in the adult corneal stroma (named corneal stromal stem cells, CSSCs) inhibit corneal inflammation and scarring and restore corneal clarity in pre-clinical corneal injury models. This cell therapy could alleviate the heavy reliance on donor materials for corneal transplantation to treat corneal opacities. Herein, we established Good Manufacturing Practice (GMP) protocols for CSSC isolation, propagation, and cryostorage, and developed in vitro quality control (QC) metric for in vivo anti-scarring potency of CSSCs in treating corneal opacities. METHODS: A total of 24 donor corneal rims with informed consent were used-18 were processed for the GMP optimization of CSSC culture and QC assay development, while CSSCs from the remaining 6 were raised under GMP-optimized conditions and used for QC validation. The cell viability, growth, substrate adhesion, stem cell phenotypes, and differentiation into stromal keratocytes were assayed by monitoring the electric impedance changes using xCELLigence real-time cell analyzer, quantitative PCR, and immunofluorescence. CSSC's conditioned media were tested for the anti-inflammatory activity using an osteoclastogenesis assay with mouse macrophage RAW264.7 cells. In vivo scar inhibitory outcomes were verified using a mouse model of anterior stromal injury caused by mechanical ablation using an Algerbrush burring. RESULTS: By comparatively assessing various GMP-compliant reagents with the corresponding non-GMP research-grade chemicals used in the laboratory-based protocols, we finalized GMP protocols covering donor limbal stromal tissue processing, enzymatic digestion, primary CSSC culture, and cryopreservation. In establishing the in vitro QC metric, two parameters-stemness stability of ABCG2 and nestin and anti-inflammatory ability (rate of inflammation)-were factored into a novel formula to calculate a Scarring Index (SI) for each CSSC batch. Correlating with the in vivo scar inhibitory outcomes, the CSSC batches with SI < 10 had a predicted 50% scar reduction potency, whereas cells with SI > 10 were ineffective to inhibit scarring. CONCLUSIONS: We established a full GMP-compliant protocol for donor CSSC cultivation, which is essential toward clinical-grade cell manufacturing. A novel in vitro QC-in vivo potency correlation was developed to predict the anti-scarring efficacy of donor CSSCs in treating corneal opacities. This method is applicable to other cell-based therapies and pharmacological treatments.

Access challenges to opioid use disorder treatment among individuals experiencing homelessness: Voices from the streets.

BACKGROUND: Achieving equitable access to medications for opioid use disorder (MOUD) such as buprenorphine is a pressing issue. Evidence suggests disparities in MOUD access based on race and socioeconomic status, further exacerbated by the COVID-19 pandemic. However, the drivers behind this access gap remain poorly understood. This study explores barriers to treatment access among individuals with opioid use disorder (OUD) experiencing homelessness. METHODS: We interviewed 28 individuals in and around the Boston Public Health Commission (BPHC) Engagement Center, an area known for its high density of active substance use and homelessness. We asked about people's experiences, perceptions, and attitudes toward OUD treatment. We conducted a thematic analysis of our interview data. RESULTS: Fifty-four percent of participants sampled were not prescribed MOUD. None of the participants reported having an active prescription of sublingual buprenorphine or buprenorphine/naloxone. White participants were more likely to have been prescribed buprenorphine in the past compared to participants of other races even in this socioeconomically homogeneous sample. Themes that emerged in our data included challenges to accessing MOUD due to reduced services during the COVID-19 pandemic, lost or stolen medications, fewer inpatient withdrawal management beds for women, transportation challenges, fear of adverse effects of MOUD, the perception that taking MOUD replaces one addiction for another, and community disapproval of MOUD. Participants also reported stigma and discrimination based on race, gender, and socioeconomic status. CONCLUSION: Systems and individual-level factors contribute to the MOUD treatment gap across race and socioeconomic status. The COVID-19 pandemic posed additional access challenges. This study provides important, actionable insights about the barriers faced by a particularly vulnerable population of individuals with OUD experiencing homelessness.

Medication treatment for alcohol use disorder in special populations.

BACKGROUND AND OBJECTIVES: Alcohol use disorder (AUD) is a significant public health concern, with underutilized effective treatments, particularly in special populations. This article summarizes the current evidence and guidelines for treating AUD in special populations. METHODS: This article is a literature review that synthesizes the latest research on AUD treatment for special populations. We screened 242 articles and included 57 in our final review. RESULTS: There are four food and Drug Administration-approved medications for AUD (MAUD): disulfiram, oral naltrexone, extended-release injectable naltrexone (XR-NTX), and acamprosate. Naltrexone and disulfiram have the potential to cause liver toxicity, and acamprosate should be avoided in patients with severe kidney disease. Psychosocial treatments should be considered first-line for pregnant and nursing patients. Naltrexone is contraindicated in patients on opioids, as it may precipitate acute withdrawal. For patients experiencing homelessness, nonabstinent treatment goals may be more practical, and XR-NTX should be considered to improve adherence. Limited evidence suggests medication can improve AUD treatment outcomes in adolescents and young adults. For patients with poor treatment response despite adequate medication adherence, switching to a different medication and augmentation with psychosocial treatments should be considered. DISCUSSION AND CONCLUSIONS: Understanding the unique considerations for special populations with AUD is crucial, and addressing their special needs may improve their treatment outcomes. SCIENTIFIC SIGNIFICANCE: Our study significantly contributes to the existing literature by summarizing crucial information for the treatment of AUD in special populations, highlighting distinct challenges, and emphasizing tailored approaches to improve overall health and well-being.

The association between workload, alcohol use, and alcohol misuse among psychiatrists in China.

Aim: Survey alcohol use and workload among Chinese psychiatrists and explore their associations. Methods: We conducted an online questionnaire among psychiatrists working in large psychiatric institutions across the country. We collected data including demographic factors, alcohol use, and workload. Alcohol use was assessed using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C), and workload-related questions included working hours, night shifts, and caseloads. Results: In total, 3,549 psychiatrists completed the survey. Nearly half (47.6%) reported alcohol use, and the percentage of alcohol use in males (74.1%) was significantly higher than in females. 8.1% exceeded the AUDIT-C cutoff scores for probable alcohol misuse (19.6%in males and 2.6%in females). AUDIT-C scores were significantly correlated with working hours per week (p = 0.017) and the number of outpatient visits per week (p = 0.006). Regressional analysis showed that alcohol use was significantly associated with the following factors: longer working hours (Working more than 44 h/week, OR = 1.315), having an administrative position (OR = 1.352), being male (OR = 6.856), being single (OR = 1.601), being divorced or widowed (OR = 1.888), smoking (OR = 2.219), working in the West (OR = 1.511) or the Northeast (OR = 2.440). Regressional analysis showed that alcohol misuse was significantly associated with the following factors: fewer night shifts (Three to four night shifts/month, OR = 1.460; No more than 2 night shifts/month, OR = 1.864), being male (OR = 4.007), working in the Northeast (OR = 1.683), smoking (OR = 2.219), frequent insomnia (OR = 1.678). Conclusion: Nearly half of the psychiatrists in China reported alcohol use and 8.1% had probable AUD. Alcohol consumption is significantly associated with several workload-related factors, such as long working hours, heavy caseload, and administrative duties. Alcohol misuse was inversely associated with the number of night shifts per month. While the direction of causality is unclear, our findings may help identify vulnerable professional groups and develop more targeted interventions to improve healthcare professionals' well-being.

Alcohol misuse, health-related behaviors, and burnout among clinical therapists in China during the early Covid-19 pandemic: A Nationwide survey.

Objectives: This study aimed to assess the extent of alcohol use and misuse among clinical therapists working in psychiatric hospitals in China during the early COVID-19 Pandemic, and to identify associated factors. Methods: An anonymous nationwide survey was conducted in 41 tertiary psychiatric hospitals. We collected demographic data as well as alcohol use using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and burnout using the Maslach Burnout Inventory Human Services Survey. Results: In total, 396 clinical therapists completed the survey, representing 89.0% of all potential participants we targeted. The mean age of participants was 33.8 years old, and more than three-quarters (77.5%) were female. Nearly two-fifths (39.1%) self-reported as current alcohol users. The overall prevalence of alcohol misuse was 6.6%. Nearly one-fifth (19.9%) reported symptoms of burnout with high emotional exhaustion in 46 (11.6%), and high depersonalization in 61 (15.4%). Multiple logistic regression showed alcohol use was associated with male gender (OR = 4.392; 95% CI =2.443-7.894), single marital status (OR = 1.652; 95% CI =0.970-2.814), smoking habit (OR = 3.847; 95%CI =1.160-12.758) and regular exercise (OR = 2.719; 95%CI =1.490-4.963). Alcohol misuse was associated with male gender (OR = 3.367; 95% CI =1.174-9.655), a lower education level (OR = 3.788; 95%CI =1.009-14.224), smoking habit (OR = 4.626; 95%CI =1.277-16.754) and high burnout (depersonalization, OR = 4.848; 95%CI =1.433-16.406). Conclusion: During the COVID-19 pandemic, clinical therapists' alcohol consumption did not increase significantly. Male gender, cigarette smoking, and burnout are associated with an increased risk of alcohol misuse among clinical therapists. Targeted intervention is needed when developing strategies to reduce alcohol misuse and improve clinical therapists' wellness and mental health.

Reactive Green 19 dye-ligand immobilized on the aminated nanofiber membranes for efficient adsorption of lysozyme: Process development and optimization in batch and flow systems.

The performance of lysozyme adsorption by the aminated nanofiber membrane immobilized with Reactive Green 19 (RG19) dyes was evaluated in batch and flow systems. The physicochemical properties of the dye-immobilized nanofiber membrane were characterized. The parameters of batch-mode adsorption of lysozyme (e.g., pH, initial dye concentration, and lysozyme concentration) were optimized using the Taguchi method. In a flow process, the factors influencing the dynamic binding performance for lysozyme adsorption in the chicken egg white (CEW) solution include immobilized dye concentration, adsorption pH value, feed flow rate, and feed CEW concentration. The impact of these operating conditions on the lysozyme purification process was investigated. Under optimal conditions, the recovery yield and purification factor of lysozyme achieved from the one-step adsorption process were 98.52% and 143 folds, respectively. The dye-affinity nanofiber membrane also did not exhibit any significant loss in its binding capacity and purification performance after five consecutive uses.

Mental health symptoms and their associated factors among pharmacists in psychiatric hospitals during the early stage of the COVID-19 pandemic.

As frontline workers, pharmacists often face significant work stress, especially in psychiatric settings. A multicenter cross-sectional design was conducted in 41 psychiatric hospitals. The Depression, Anxiety and Stress Scale-21 (DASS-21) was used to measure the mental health of 636 pharmacists. We also collected demographic data and work-related variables. The prevalence of depression, anxiety and stress was 20.60%, 22.96% and 8.96%, respectively. Multivariate logistic regression showed that several common factors were associated with depression, anxiety and stress, including professional identity (odds ratio [OR] = 0.132, 0.381 and 0.352) and verbal violence (OR = 2.068, 2.615 and 2.490). Those who were satisfied with their job were less likely to develop depression (OR = 0.234) or anxiety (OR = 0.328). We found specific factors associated with mental health. Older age (OR = 1.038) and perceived negative impact (OR = 2.398) of COVID-19 on medical work were associated with anxiety, and those with frontline experience with COVID-19 patients (OR = 2.306) were more likely to experience stress. More than one-fifth of pharmacists in psychiatric hospitals experienced symptoms of depression or anxiety during the pandemic, highlighting the need for policy change to improve workplace conditions and psychological well-being for this professional group.

Incidental Findings from Deep Phenotyping Research in Psychiatry: Legal and Ethical Considerations.

Substantial advancement in the diagnosis and treatment of psychiatric disorders may come from assembling diverse data streams from clinical notes, neuroimaging, genetics, and real-time digital footprints from smartphones and wearable devices. This is called "deep phenotyping" and often involves machine learning. We argue that incidental findings arising in deep phenotyping research have certain special, morally and legally salient features: They are specific, actionable, numerous, and probabilistic. We consider ethical and legal implications of these features and propose a practical ethics strategy for managing them.

Epigenetic remodeling by vitamin C potentiates plasma cell differentiation.

Ascorbate (vitamin C) is an essential micronutrient in humans. The severe chronic deficiency of ascorbate, termed scurvy, has long been associated with increased susceptibility to infections. How ascorbate affects the immune system at the cellular and molecular levels remained unclear. From a micronutrient analysis, we identified ascorbate as a potent enhancer for antibody response by facilitating the IL-21/STAT3-dependent plasma cell differentiation in mouse and human B cells. The effect of ascorbate is unique as other antioxidants failed to promote plasma cell differentiation. Ascorbate is especially critical during early B cell activation by poising the cells to plasma cell lineage without affecting the proximal IL-21/STAT3 signaling and the overall transcriptome. As a cofactor for epigenetic enzymes, ascorbate facilitates TET2/3-mediated DNA modification and demethylation of multiple elements at the Prdm1 locus. DNA demethylation augments STAT3 association at the Prdm1 promoter and a downstream enhancer, thus ensuring efficient gene expression and plasma cell differentiation. The results suggest that an adequate level of ascorbate is required for antibody response and highlight how micronutrients may regulate the activity of epigenetic enzymes to regulate gene expression. Our findings imply that epigenetic enzymes can function as sensors to gauge the availability of metabolites and influence cell fate decisions.

Studies of Protein Wastes Adsorption by Chitosan-Modified Nanofibers Decorated with Dye Wastes in Batch and Continuous Flow Processes: Potential Environmental Applications.

In this study, reactive green 19 dye from wastewater was immobilized on the functionalized chitosan nanofiber membranes to treat soluble microbial proteins in biological wastewater. Polyacrylonitrile nanofiber membrane (PAN) was prepared by the electrospinning technique. After heat treatment, alkaline hydrolysis, and chemically grafted with chitosan to obtain modified chitosan nanofibers (P-COOH-CS), and finally immobilized with RG19 dye, dyed nanofibers were generated (P-COOH-CS-RG19). The synthesis of P-COOH-CS and P-COOH-CS-RG19 are novel materials for protein adsorption that are not deeply investigated currently, with each of the material functions based on their properties in significantly improving the adsorption efficiency. The nanofiber membrane shows good adsorption capacity and great recycling performance, while the application of chitosan and dye acts as the crosslinker in the nanofiber membrane and consists of various functional groups to enhance the adsorption of protein. The dyed nanofibers were applied for the batch adsorption of soluble protein (i.e., lysozyme), and the process parameters including chitosan's molecular weight, coupling pH, chitosan concentration, dye pH, dye concentration, and lysozyme pH were studied. The results showed that the molecular weight of chitosan was 50 kDa, pH 5, concentration 0.5%, initial concentration of dye at 1 mg/mL dye and pH 12, lysozyme solution at 2 mg/mL at pH 8, and the maximum adsorption capacity was 1293.66 mg/g at a temperature of 318 K. Furthermore, thermodynamic, and kinetic studies suggested that the adsorption behavior of lysozyme followed the Langmuir adsorption isotherm model and the pseudo-second-order kinetic model. The optimal adsorption and desorption conditions based on batch experiments were directly applied to remove lysozyme in a continuous operation. This study demonstrated the potential of dyed nanofibers as an efficient adsorbent to remove approximately 100% of lysozyme from the simulated biological wastewater.

Successful Management of a Patient With a History of Postoperative Delirium Undergoing Cardiac Surgery With an Erector Spinae Plane Block and Multimodal Analgesia: A Case Report.

Perioperative delirium is an acute confusional state with fluctuating levels of consciousness, which can be precipitated by opioid-based anesthetics and inadequate pain control, especially in patients undergoing cardiac surgery. We seek to minimize opioid usage to avoid postoperative delirium in a patient with multiple risk factors undergoing aortic valve replacement. We used cardiac enhanced recovery after surgery protocols (ERAS-C), which include multimodal analgesia and regional anesthesia via bilateral erector spinae plane (ESP) blocks. Our observations suggest that bilateral ESP blocks and cardiac ERAS protocols offer a potential option to manage pain and control risk factors in patients at high risk of postoperative delirium undergoing cardiac surgery.

Smartphone Ownership, Smartphone Utilization, and Interest in Using Mental Health Apps to Address Substance Use Disorders: Literature Review and Cross-sectional Survey Study Across Two Sites.

BACKGROUND: In recent years, there has been increasing interest in implementing digital technologies to diagnose, monitor, and intervene in substance use disorders. Smartphones are now a vehicle for facilitating telepsychiatry visits, measuring health metrics, and communicating with health care professionals. In light of the COVID-19 pandemic and the movement toward web-based and hybrid clinic visits and meetings, it has become especially salient to assess phone ownership among individuals with substance use disorders and their comfort in navigating phone functionality and using phones for mental health purposes. OBJECTIVE: The aims of this study were to summarize the current literature around smartphone ownership, smartphone utilization, and the acceptability of using smartphones for mental health purposes and assess these variables across two disparate substance use treatment sites. METHODS: We performed a focused literature review via a search of two academic databases (PubMed and Google Scholar) for publications since 2007 on the topics of smartphone ownership, smartphone utilization, and the acceptability of using mobile apps for mental health purposes among the substance use population. Additionally, we conducted a cross-sectional survey study that included 51 participants across two sites in New England-an inpatient detoxification unit that predominantly treats patients with alcohol use disorder and an outpatient methadone maintenance treatment clinic. RESULTS: Prior studies indicated that mobile phone ownership among the substance use population between 2013 and 2019 ranged from 83% to 94%, while smartphone ownership ranged from 57% to 94%. The results from our study across the two sites indicated 96% (49/51) mobile phone ownership and 92% (47/51) smartphone ownership among the substance use population. Although most (43/49, 88%) patients across both sites reported currently using apps on their phone, a minority (19/48, 40%) reported previously using any apps for mental health purposes. More than half of the participants reported feeling at least neutrally comfortable with a mental health app gathering information regarding appointment reminders (32/48, 67%), medication reminders (33/48, 69%), and symptom surveys (26/45, 58%). Most patients were concerned about privacy (34/51, 67%) and felt uncomfortable with an app gathering location (29/47, 62%) and social (27/47, 57%) information for health care purposes. CONCLUSIONS: The majority of respondents reported owning a mobile phone (49/51, 96%) and smartphone (47/51, 92%), consistent with prior studies. Many respondents felt comfortable with mental health apps gathering most forms of personal information and with communicating with their clinician about their mental health. The differential results from the two sites, namely greater concerns about the cost of mental health apps among the methadone maintenance treatment cohort and less experience with downloading apps among the older inpatient detoxification cohort, may indicate that clinicians should tailor technological interventions based on local demographics and practice sites and that there is likely not a one-size-fits-all digital psychiatry solution.

Phase 2 Assessment of a New Functional Pain Scale by Comparing It to Traditional Pain Scales.

Background Assessment of pain has always been subjective and is commonly assessed using a numeric pain scale (NPS) or Wong-Baker faces scale. The pain intensity score is not standardized and relies on individuals' past experiences. The disadvantage of using such pain assessment scales and treating the numbers can lead to overdosing on analgesics leading to unwanted side effects. The Robert Packer Hospital/Functional Pain Scale (RPH/FPS) was developed as a tool for the objective assessment of pain and its impact on a patient's function.  Aim The study aimed to validate the RPH/FPS scale against NPS and Wong-Baker faces scale in medical, surgical, and trauma patients. The patients' were also asked to rank the scales as one (1) being the most preferred to three (3) being the least preferred. Design This prospective, observational cohort study compares the two most common pain scales, the NPS and the Wong-Baker Faces, to the RPH/FPS. Methods Spearman correlation was used to test for correlation between the three scales, and Wilcoxon rank-sum test was used to compare means between the RPH/FPS and NPS. The study participants were also asked to rate their preferences for the scales by rating the most preferred of the three scales as one (1) and the least preferred number three (3).  Results The RPH/FPS had a strong correlation with both the NPS and Wong-Baker Faces scales (RPH/FPS vs. NPS R=0.69, p<0.001: RPH-FPS vs. Wong-Baker Faces R=0.69, P<0.001). As for preferences, the RPH/FPS was ranked first on 36.9% of the surveys followed by NPS on 35.9%, and the Wong-Baker Faces on 22.3%. There were 4.9% of the surveys missing the preference rankings. Conclusion The results validate the RPH/FPS scale against the NPS and Wong-Baker Faces scales. This gives the clinicians a tool for objective assessment of pain and its effect on the recovery process, thereby minimizing the observed disconnect that sometimes happens between the reported pain intensity level and the providers' observation of the patient.

Retraction: Phase 2 Assessment of a New Functional Pain Scale by Comparing It to Traditional Pain Scales.

[This retracts the article DOI: 10.7759/cureus.24522.].

Pectointercostal fascial plane block for rescue pain management of traumatic sternal fracture following inadequate thoracic epidural block: a case report.

Adequate pain control after multisystem trauma including the chest wall is essential for improved patient outcomes, especially with sternum and rib fractures. The thoracic epidural is considered the gold standard in pain management of thoracic injury; however, failure or patchy epidural is not uncommon. Pectointercostal fascial plane block (PIFB) is regularly used in cardiac surgery to provide analgesia to the anterior chest wall; however, there are few reports of PIFB being used as a primary block for the management of thoracic injuries. We present a case in which PIFB was used as a rescue block for the successful management of sternal pain following patchy thoracic epidural block in a patient with thoracic polytrauma.

Micro but mighty-Micronutrients in the epigenetic regulation of adaptive immune responses.

Micronutrients are essential small molecules required by organisms in minute quantity for survival. For instance, vitamins and minerals, the two major categories of micronutrients, are central for biological processes such as metabolism, cell replication, differentiation, and immune response. Studies estimated that around two billion humans worldwide suffer from micronutrient deficiencies, also known as "hidden hunger," linked to weakened immune responses. While micronutrients affect the immune system at multiple levels, recent studies showed that micronutrients potentially impact the differentiation and function of immune cells as cofactors for epigenetic enzymes, including the 2-oxoglutarate-dependent dioxygenase (2OGDD) family involved in histone and DNA demethylation. Here, we will first provide an overview of the role of DNA methylation in T cells and B cells, followed by the micronutrients ascorbate (vitamin C) and iron, two critical cofactors for 2OGDD. We will discuss the emerging evidence of these micronutrients could regulate adaptive immune response by influencing epigenetic remodeling.

Clinical and laboratory parameters in blunt pelvic trauma not associated with subsequent positive conventional angiography in patients with positive CTA.

PURPOSE: This study evaluates clinical and laboratory parameters, as well as extravasation and hematoma size on CTA as potential predictors of conventional angiogram (CA) results. METHODS: This is a retrospective study of 380 adult patients presenting with pelvic trauma over a 9-year period. Of these patients, 91 were found to have active arterial extravasation on initial CTA. Statistical analysis between the two groups +CA versus -CA was performed to determine whether clinical and laboratory parameters, as well as extravasation size and hematoma size could predict CA results. RESULTS: There were no significant differences in all clinical and laboratory data, including hemodynamic instability (defined as systolic blood pressure < 90 mmHg) on presentation (22.2% vs. 21.4%), except for Glasgow Coma Scale (p = 0.015) when comparing the two groups. Extravasation size and hematoma size as continuous or categorical variables were not predictive of subsequent positive CA. Secondary analysis demonstrated no association between select parameters (i.e., hematocrit, systolic blood pressure, and lactate) and subsequent positive CA while controlling for extravasation size or hematoma size. CONCLUSION: Clinical and laboratory parameters in blunt pelvic trauma with arterial hemorrhage were not significantly associated with subsequent conventional angiography results, once accounting for degree of hemorrhage. The area of the foci of active extravasation and hematoma size in the axial plane were not significantly associated with the need for embolization. We conclude from these findings that catheter angiography should be considered in patients with blunt pelvic trauma found to have active arterial extravasation, regardless of size of bleed or the patient's clinical or laboratory values.