Serratus Anterior Plane Block Versus Intercostal Block with Incision Infiltration in Robotic-Assisted Thoracoscopic Surgery: A Randomized Controlled Pilot Trial.

OBJECTIVES: Patients undergoing robotic video-assisted thoracoscopic surgery (rVATS) report significant postoperative pain. Both the serratus anterior plane block (SAPB) and the surgical intercostal block (IB) (performed by a surgeon from within the thorax), along with incision infiltration (II), are distinct modalities that target the lateral cutaneous branches of intercostal nerves and are acceptable analgesic modalities in an enhanced recovery after rVATS surgery. DESIGN: Prospective, double-blinded, randomized, controlled pilot trial with 65 patients to assess the difference in analgesia quality between the SAPB and IB+II in rVATS. SETTING: Major academic teaching hospital. PARTICIPANTS: The inclusion criteria included ASA physical status I-IV, ages 18-to-75 undergoing an elective, unilateral rVATS procedure. INTERVENTIONS: Patients were randomized to receive either an ultrasound-guided SAPB at the end of their surgery, using a 20-mL mixture consisting of 10 mL of liposomal bupivacaine (133 mg) and 10 mL 0.25% bupivacaine, or IB+II, using a 20-mL mixture consisting of 10 mL of liposomal bupivacaine (133 mg) and 10 mL 0.5% bupivacaine prior to skin closure by the surgeon. RESULTS: The primary outcome was the amount of postoperative opioid consumption in morphine milliequivalents [MME] during the first 24 hours after surgery. Secondary outcomes were time to first analgesic request, VAS scores at zero, two, six, 18, or 24 hours at rest, and PACU, ICU, or hospital lengths of stay (LOS). There were no differences in any outcomes between the groups. CONCLUSIONS: Both SAPB and IB+II are comparable analgesic modalities for rVATS procedures.

Use and Clinical Relevancy of Pericapsular Nerve Block (PENG) in Total Hip Arthroplasty: A Systematic Review and Meta-analysis.

BACKGROUND: Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip arthroplasties (THA). There are clinical studies comparing this fascial plane block to other established methods; however, evidence on the actual efficacy of this block for THA continues to evolve. OBJECTIVE: Available clinical studies conducted over the past 4 years were reviewed to evaluate the analgesic efficacy and effectiveness of PENG block in patients undergoing THAs. METHODS: A meta-analysis of randomized controlled trials (RCTs) in patients undergoing THA, where PENG block was compared to no block, placebo/sham block (injection with saline), or other analgesic techniques including suprainguinal fascia iliaca block (FIB), or periarticular infiltration (PAI) was performed. Our primary outcome was opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, block performance time, sensory-motor assessment, quadriceps weakness, the incidence of postoperative falls, first analgesic request, block and opioid-related complications, surgical complications, patient satisfaction scores, postanesthesia care unit length of stay, hospital length of stay, and functional and quality of life outcomes. RESULTS: We included 12 RCTs with a total of 705 patients. Data showed that PENG block decreased 24-hour oral morphine milligram equivalent consumption by a mean difference (MD) of 3.75 mg (95% CI: -5.96,-1.54; P =0.0009). No statistically significant differences in rest or dynamic pain were found, except for a modest MD reduction in dynamic pain score of 0.55 points (95% CI: -0.98, -0.12; P =0.01), measured 24 hours after surgery in favor of PENG block. CONCLUSIONS: Our systematic review and meta-analysis suggest that PENG block provides better analgesia, measured as MME use, in the first 24 hours after THA, with no real impact on postoperative VAS scores. Despite statistical significance, the high heterogeneity across RCTs implies that PENG's benefits may not surpass the minimal clinically important difference threshold for us to recommend PENG as best practice in THA.

Emotional, informational, and decision-making support needs among people seeking abortion in the US: perspectives from All-Options Talkline callers.

People seeking abortion may need or want emotional or informational support before, during, and after their abortion. Feeling supported and affirmed contributes to perceptions of quality care. The All-Options Talkline offers free, telephone-based, peer counselling to callers anywhere in the United States. This study aimed to explore the types of support received through the Talkline and the ways it supplemented other forms of support received by people who obtained an abortion. Between May 2021 and February 2022, we conducted 30 interviews via telephone or Zoom with callers recruited through the Talkline. We coded the interviews and conducted thematic analysis, focusing on themes related to gaps of support from family, friends, and healthcare professionals, as well as types of support received through the Talkline. We identified four key motivations for calling the Talkline, including the need for (1) decision-making support and validation, (2) a neutral perspective, (3) emotional support to discuss negative or complex feelings, and (4) information about the abortion process. Participants indicated that interactions with family, friends, and healthcare professionals ranged from unsupportive and negative, to substantially supportive. Access to the Talkline was particularly useful prior to clinical interactions and in the weeks or months after an abortion. We found that the All-Options Talkline provided person-centred, remote support for callers, filling gaps or supplementing support from one's community or healthcare professionals. Abortion support from non-medically trained support people contributes to high-quality abortion care, especially in a time of increasing abortion restrictions and use of remote abortion services.

Effect of body mass index on outcome in patients with suspected coronary artery disease referred for stress echocardiography.

In patients with hypertension, heart failure, or coronary artery disease (CAD), obese patients have been shown to have a lower cardiac event rate compared with normal weight counterparts. This phenomenon has been termed the "obesity paradox." We sought to determine whether the obesity paradox exists in a cohort of patients referred for stress echocardiography. We evaluated 4,103 patients with suspected CAD (58 ± 13 years; 42% men) undergoing stress echocardiography (52% exercise and 47% dobutamine). Patients were divided into 3 groups on the basis of body mass index (BMI): 18.5 to 24.9, 25 to 29.9, and >30 kg/m(2). During the follow-up of 8.2 ± 3.6 years, there were 683 deaths (17%). Myocardial ischemia was present in 21% of the population. Myocardial ischemia was more prevalent in patients with a BMI of 18.5 to 24.9 kg/m(2) (26%) than those with a BMI of 25 to 29.9 kg/m(2) (21%) and >30 kg/m(2) (18%). Patients with a BMI of >30 kg/m(2) had the lowest death rate (1.2%/year) compared with those with a BMI of 25 to 29.9 kg/m(2) (1.75%/year) and 18.5 to 24.9 kg/m(2) (2.9%/year; p <0.001). After adjusting for significant clinical variables including exercise capacity, patients with higher BMI (>30 kg/m(2) and 25 to 29.9 kg/m(2)) had less risk of mortality compared with those with a BMI of 18.5 to 24.9 kg/m(2) (hazard ratio 0.58, 95% confidence interval 0.47 to 0.72, p <0.0001 and hazard ratio 0.69, 95% confidence interval 0.57 to 0.82, p <0.0001, respectively). In conclusion, higher survival rate in patients with higher BMI as previously described in patients with hypertension, heart failure, and CAD extends to patients with suspected CAD referred for stress echocardiography, independent of exercise capacity.