The Landscape of Pain Medicine for Women Physicians: A Perspective.

BACKGROUND: The gender bias in academic anesthesiology is well known. Women are not only a minority in the field but also underrepresented in leadership positions. Reported reasons for this underrepresentation include barriers to career advancement, lack of mentorship, and differences in compensation, among others. Interventional pain, a competitive procedural subspecialty of anesthesiology, sees the trickle-down effects of this disparity. According to a report from the ACGME that sorted medical subspecialties by number of female trainees, pain medicine ranked in the bottom quartile across all disciplines from 2008-2016. OBJECTIVES: To better understand the landscape for women physicians in the field of pain medicine, we undertook this investigation to review the knowledge about the topic and what questions remain unanswered. STUDY DESIGN: This study is a review of the current literature and aims to summarize and describe the landscape of pain medicine for women physicians. SETTING: All literature review and manuscript preparation took place at the Yale University School of Medicine. METHODS: We performed a comprehensive search using the PubMed, Scopus, and Cochrane databases for the combined terms "gender disparity," "pain medicine," and "anesthesiology," limiting our search to the year 2000 onward for the most recent literature on the topic. Our initial search retrieved 38 articles. All relevant articles pertaining to this perspective piece were collated. The available literature is discussed below. RESULTS: Women are underrepresented in interventional pain. The grim scarcity of female pain physicians is unlikely to improve soon, since while the number of Accreditation Council for Graduate Medical Education pain fellowship programs continues to grow, women trainees comprise only between 22-25% of all pain medicine fellows. Additionally, although studies have compared the numbers of male interventional pain faculty to their female counterparts in academic hospitals and shown the ratio to range from 71.84-82% to 18-28.52%, respectively, no studies have truly explored the landscape for women physicians in private practice. Patients prefer and have better experiences with physicians who are racially and ethnically like themselves. In fact, the preference for and the lack of female clinicians have been associated with delayed pursuit of care and adverse health outcomes. The consequences of the burnout and attrition caused by the gender disparity, especially in a field like pain medicine, cannot be understate. LIMITATIONS: The review might not have been comprehensive, and relevant studies might not have been included. CONCLUSION: While the gender disparity in academia is well documented for both anesthesiology and pain medicine, the reasons for this disparity have not been fully explored. Moreover, it is also unknown whether the minority of female physicians who select pain medicine as a subspecialty gravitate toward an academic or a private-practice path. To address the existing gender disparity, it is necessary to explore the landscape of interventional pain medicine in both academic and private practices and understand pain physicians' beliefs and sentiments regarding their subspecialty.

Trainee Insight into Pain Fellowship Programs: A Critical Evaluation of the Current Educational System by the APPD.

BACKGROUND: Since 1992, when the Accreditation Council of Graduate Medical Education (ACGME) acknowledged pain medicine as a subspecialty, the field has experienced significant growth in its number of programs, diversity of sponsoring specialties, treatment algorithms, and popularity among applicants. These shifts prompted changes to the educational model, overseen by program directors (PDs) and the ACGME. The pool of pain fellowship applicants also changed during that period. OBJECTIVES: This study aims to investigate trainees' reasons for applying to pain medicine fellowship programs as well as the applicants' specific expectations, interests, and motivations, thereby contributing to the remodeling and universal improvement of programs across the country. STUDY DESIGN: Online survey via SurveyMonkey. The online questionnaire targeted pain fellowship applicants in 2023 and current fellows in the US. METHODS: Our study was designed by board members of the Association of Pain Program Directors (APPD). The board disseminated a survey to those who applied to ACGME Pain Medicine fellowships in 2023 as well as to existing fellows. The survey was emailed to residency and fellowship PDs for dissemination to their trainees. The participants answered a 12-question survey on their reasons for pursuing pain medicine fellowships, expectations of and beyond those fellowships, and educational adjustments. RESULTS: There were 283 survey participants (80% applicants in residency training and 20% fellows). Participants ranked basic interventional procedures and a strong desire to learn advanced procedures as the most significant factors in pursuing a pain fellowship. Most trainees (70%) did not wish to pursue a 2-year fellowship, and 50% desired to go into private practice. LIMITATIONS: The relatively small number of respondents is a limitation that could introduce sampling error. Since most of the respondents were from the fields of physical medicine and rehabilitation (PM&R) and anesthesia, the use of convenience sampling reduced our ability to generalize the results to the wider community. Furthermore, approximately 80% of the trainees were residents, who might have had less experience in or knowledge of the survey's particulars than did the fellows. CONCLUSION: This survey demonstrated that procedural volume and diversity were important factors in trainees' decisions to apply to the field of pain medicine; however, extending the duration of a pain fellowship was not an option survey participants favored. Therefore, PDs and educational stakeholders in pain fellowship training need to develop creative strategies to maintain competitive applicants' interest while they adapt to our evolving field.

Comparing the Effectiveness and Safety of Dexamethasone, Methylprednisolone and Betamethasone in Lumbar Transforaminal Epidural Steroid Injections.

BACKGROUND: Particulate steroids are thought to exert their effects for long durations at injection sites. However, these types of steroids carry higher risks when used in epidural steroid injections. Catastrophic spinal cord complications, including sudden-onset paraplegia, have been reported due to intravascular particulate steroid preparations that cause embolisms and occlusion of blood vessels, resulting in spinal cord infarctions. Clinicians, therefore, recommend nonparticulate steroids to mitigate these adverse events. To our knowledge, this is the first retrospective study that addresses the effectiveness and safety of methylprednisolone, dexamethasone, and betamethasone when used in transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar radiculopathy. OBJECTIVES: The primary goal of this study was to compare the proportion of patients who received injections of particulate steroids and required zero repeat injections within 12 months of their initial injection to the proportion of patients who received injections of nonparticulate steroids and also required zero repeat injections, as well as to compare the number of patients in the particulate cohort who required one or more repeat injections within 12 months of their initial injection to the number of patients in the nonparticulate cohort who required the same. The secondary goal was to evaluate the proportion of patients ultimately requiring surgery. STUDY DESIGN: This is a single-center, IRB-approved, retrospective study evaluating the safety and effectiveness of nonparticulate as compared to particulate steroid medications when used in TFESIs as minimally invasive treatments for chronic lumbar radiculopathy. SETTING: This study captured data (n = 1717) over a 4-year time frame (01/15/2018 to 01/15/2022). METHODS: The following data were collected from each patient's chart: age, gender, BMI, race, date of initial injection, number of repeat injections at the same lumbosacral level and on the same side within 12 months of the initial injection, and lumbar surgery date (if applicable). Inclusion criteria included: 1) having chronic low back pain of radicular etiology; 2) being at least 18 years old; 3) having experienced the failure of conservative therapy after 12 weeks (including physical therapy and/or medications); 4) having positive physical exam findings supporting nerve impingement (straight leg raise, slump test); and 5) showing lumbar MRI evidence of nerve impingement from disc herniation. Exclusion criteria included: 1) having received prior lumbar surgery at any level (L1-S1); 2) having been given prior TFESIs fewer than 6 months prior to initial injection; 3) having contracted a systemic infection at the proposed injection site; 4) undergoing active cancer treatment; and 5) having gotten any other spine injections. RESULTS: A significantly greater proportion of patients in the nonparticulate steroid cohort received 0 repeat injections (87.5% vs 71.4%, P < 0.001). The particulate steroid cohort demonstrated a significantly greater proportion of patients who received repeat injections within 12 months after the initial injections (12.5% vs 29.6%, P < 0.001). There were no significant differences among patients requiring surgery between the 2 cohorts. Other outcome measures included the identification of risk factors significantly associated with repeat injections. There was a statistically significant weak positive correlation between age and repeat injections (Pearson corr = 0.102; P < 0.001) and a weak negative correlation between ethnicity/race and repeat injections (point-biserial corr = -0.093; P < 0.001).  No adverse events were reported. LIMITATIONS: Not all clinicians included in this study used each of the 3 steroid types, and all clinicians used either particulate or nonparticulate steroids exclusively. CONCLUSIONS: Our study demonstrates that the clinical outcomes associated with TFESIs of nonparticulate steroids are superior to those associated with TFESIs of particulate steroids when either variety of medication is used to treat lumbar radiculopathy. This is the first study to include a clinically useful predictive model using information on laterality, age, and steroid type.

Efficacy of parasternal peripheral nerve catheters versus no block for median sternotomy: a single-centre retrospective study.

Background: Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h. Methods: We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery. Results: Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (-62, 95% confidence interval -108 to -16; P<0.01) and 48 h (-50, 95% CI -97 to -2.2; P=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC. Conclusions: This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.

External Oblique Intercostal Plane Block: A Case Report and Review of Literature.

Chronic low back pain (CLBP) and post-laminectomy syndrome (PLS) can pose significant therapeutic challenges, often refractory to conservative management. We present a case of a 52-year-old male with refractory CLBP and PLS who underwent spinal cord stimulation (SCS) lead placement, and subsequently developed chronic right anterior chest wall and upper abdominal pain. Despite using SCS and opioid therapy, the pain persisted until an ultrasound-guided external oblique intercostal plane block (EOIPB) was administered, resulting in complete pain relief. This case highlights the efficacy of EOIPB in managing chronic post-surgical neuropathic pain, underscoring its potential as a valuable intervention in such cases.

Publications Among Pain Medicine Fellowship-Trained American Board of Anesthesiology Diplomates.

American Board of Anesthesiology (ABA) diplomates who pursue clinical fellowship training in pain medicine may be better suited to lead scholarly projects and serve as first authors of publications in peer-reviewed journals given their additional training and clinical expertise. The primary aim of this study was to determine whether ABA certification in pain medicine is associated with a greater number of peer-reviewed publications. The secondary aim included assessments of whether pain medicine fellowship training is associated with a higher publication rate (publications per year) or publication in a larger number of peer-reviewed journals. A literature search was conducted in December 2023 using the Scopus database for publications related to anesthesiology and pain medicine in the United States between 2013 and 2023. First authors identified through the search were then individually searched within the ABA physician directory. The following data were collected: author name and identification number, year of publication, publication type (article or review), year of primary anesthesiology certification, and year of fellowship, if applicable. This study identified 9,612 publications and 6,924 unique first authors. Pain medicine fellowship training was associated with a statistically significant increase (p-value < 0.001) in the number of publications (0.546; 95% confidence interval {CI}, 0.386-0.707), publications per year (0.140; 95% CI, 0.121-0.159), and publication in a larger number of peer-reviewed journals (0.256; 95% CI, 0.182-0.330) in regression models adjusted for the number of years from certification. This query of the Scopus database and ABA physician directory indicates that pain medicine fellowship training is associated with statistically significant increases in research productivity, as defined by the number of publications, publications per year, or the number of publications in peer-reviewed journals. However, these increases in research output would not lead to a marked increase in scholarship productivity to justify pursuing a fellowship for this purpose.

Analysis of Top 100 Articles Cited in Top Pain Journals: A Comprehensive Two Decade Bibliometric Analysis.

PURPOSE OF REVIEW: A bibliometric analysis was performed to analyze and compare the top 100 articles from the most well-known five pain journals: Pain, Pain Physician, Pain Medicine, Regional Anesthesia & Pain Medicine, and Journal of Pain. A query of the Scopus database was performed to filter the top 200 most cited articles from each journal. CY score was calculated for the top 200 articles from each journal by dividing the total number of citations by the number of years the article has been published. RECENT FINDINGS: All articles had a collective analysis of the top CY scores, the top 100 of which were further analyzed. The pain subtype, type of publication, country of origin, and senior author were extrapolated from these top 100 articles. Frequency tables were organized, revealing Pain Journal as the highest publishing journal out of the top 100 articles. Chronic pain was the most studied subtype of pain and narrative reviews were the most common type of evidence. Studies were also organized in five-year epochs to analyze the frequency of publications in these intervals. Results show that 2010-2014 had the highest frequency of articles published overall. Journal Impact Factor (JIF) is also an objective indicator of the average number of citations per published article from each journal. The journal with the highest JIF was Pain with an impact factor of 7.926. (6).

An acute phase reaction from zoledronate mimicking symptoms seen in opioid withdrawal: a case report.

BACKGROUND: Zoledronate, a bisphosphonate, is a potent first-line treatment for osteoporosis. It is also a preferred treatment for hypercalcemia especially when unresponsive to intravenous fluids. Bisphosphonates can cause acute phase reactions that mimic opioid withdrawal symptoms, which can confound provider decision-making. Our case highlights cognitive bias involving a patient with opioid use disorder who received zoledronate for hypercalcemia secondary to immobilization and significant bone infection. CASE PRESENTATION: A 41-year-old male is admitted with a past medical history of active intravenous opioid use complicated by group A streptococcal bacteremia with L5-S1 discitis and osteomyelitis, L2-L3 osteomyelitis, and left ankle abscess/septic arthritis status post left ankle washout. His pain was well-controlled by acute pain service with ketamine infusion (discontinued earlier), opioids, acetaminophen, buprenorphine-naloxone, cyclobenzaprine, gabapentin, and naproxen. Intravenous opioids were discontinued, slightly decreasing the opioid regimen. A day later, the patient reported tachycardia, diaphoresis, myalgias, and chills, which the primary team reconsulted acute pain service for opioid withdrawal. However, the patient received a zoledronate infusion for hypercalcemia, on the same day intravenous opioids were discontinued. He had no other medications known to cause withdrawal-like symptoms per chart review. Therefore, it was suspected that an acute phase reaction occurred, commonly seen within a few days of bisphosphonate use. CONCLUSION: Zoledronate, well known for causing acute phase reactions, was likely the cause of withdrawal-like symptoms. Acute phase reactions with bisphosphonates mostly occur in the first infusion, and the incidence decreases with subsequent infusions. Symptoms typically occur 24-72 h post-infusion, and last at most for 72 h. Cognitive bias led the primary team to be concerned with opioid withdrawal rather than investigating other causes for the patient's presentation. Therefore, providers should thoroughly investigate potential etiologies and rule them out accordingly to provide the best care. Health care providers should also be aware of the implicit biases that potentially impact the quality of care they provide to patients.

Narrative review of radiofrequency ablation applications in peripheral nerves.

BACKGROUND AND OBJECTIVE: Chronic pain is a pervasive and often-complex condition that can severely detract from an individual's quality of life. When conservative measures of treatment fail, radiofrequency ablation (RFA) has emerged as a potential alternative. This narrative review subsequently explores recent advancements in the use of RFA on peripheral nerves as a means of attenuating chronic pain and providing relief to patients. METHODS: A comprehensive literature search was conducted on the PubMed database using the keywords "Radiofrequency", "Ablation", "Pain", "Chronic", "Peripheral", and "Nerve". The search focused on articles published between 2018 to 2023 that discussed an application of RFA in a peripheral nerve. In total, 30 articles were selected for inclusion in this review. KEY CONTENT AND FINDINGS: Results indicate the successful use of RFA in an array of chronic pain conditions and anatomical sites. Applications include the treatment of trigeminal neuralgia (TN), occipital neuralgia, cluster headaches, knee pain derived from osteoarthritis (OA), hip pain, abdominal pain associated with pancreatic cancer, and several other chronic pain conditions. CONCLUSIONS: These findings suggest RFA is a viable option for reducing patient's pain scores and improving quality of life. Future research should build off extensive case reports/series with double-blind, randomized controlled studies to further investigate anecdotal successes.

Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey.

CONTEXT: Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists. OBJECTIVES: To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness. METHODS: A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs. RESULTS: The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians. CONCLUSION: This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.

The Utility of an Epidural Steroid Injection for the Treatment of Idiopathic Brachial Neuritis.

Idiopathic brachial neuritis is an uncommon disorder that predominately affects the superior and middle trunks of the brachial plexus. Severe throbbing and aching shoulder pain is initially present for a period of days to weeks, followed by severe weakness and atrophy that can develop for an extended period of months to years. There are currently no known treatments for brachial neuritis, with the standard of care consisting of analgesics and corticosteroids, which typically provide minimal to no benefit in most cases. In this case, we will present a case of a patient who was diagnosed with idiopathic brachial neuritis and underwent an interlaminar epidural steroid injection (ESI) for treatment. Following treatment with the ESI, the patient had a subsequent resolution of symptoms. This case underscores the value of early recognition for the diagnosis of brachial neuritis and the utility of an ESI as a treatment option, thus preventing long-term pathological sequalae. To our knowledge, this is the first known reported case to have successfully cured brachial neuritis.

Examining disparities in regional anaesthesia and pain medicine.

In high-resource countries, health disparities exist in both treatment approaches and health outcomes. Race and ethnicity can serve as proxies for other socioeconomic factors and social determinants of health such as income, education, social support, and residential neighbourhood, which strongly influence health outcomes and disparities. In regional anaesthesia and pain medicine, disparities exist across several surgical specialties including obstetrics, paediatrics, and orthopaedic surgery. Understanding these disparities will facilitate development of solutions aimed at eliminating disparities at the patient, physician/provider, and healthcare system levels.

The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Applications of Artificial Intelligence in Pain Medicine.

PURPOSE OF REVIEW: This review explores the current applications of artificial intelligence (AI) in the field of pain medicine with a focus on machine learning. RECENT FINDINGS: Utilizing a literature search conducted through the PubMed database, several current trends were identified, including the use of AI as a tool for diagnostics, predicting pain progression, predicting treatment response, and performance of therapy and pain management. Results of these studies show promise for the improvement of patient outcomes. Current gaps in the research and subsequent directions for future study involve AI in optimizing and improving nerve stimulation and more thoroughly predicting patients' responses to treatment.

Factors Associated With Same Day Discharge Post-Spinal Cord Stimulator Placement.

BACKGROUND: Spinal cord stimulator (SCS) surgeries, whether performed using the open or percutaneous approach, are becoming increasingly common for a range of neuropathic pain conditions, including post-laminectomy syndrome and complex regional pain syndrome. However, there is limited knowledge regarding the factors linked to same-day discharge patterns following SCS. OBJECTIVE: The purpose of this study was to identify factors associated with same-day discharge after SCS placement. The primary outcome was same-day discharge. STUDY DESIGN: Retrospective, cohort study using a nationwide database. METHODS: Inclusion criteria included patients who underwent percutaneous or open SCS from January 1, 2014 through December 31, 2021. Exclusion criteria included patients with missing data (n = 178) and those with SCS implants for unlisted indications (n = 1,817). A multivariable analysis was conducted on the outcome data and co-variates associated with same-day discharge after SCS. RESULTS: After applying inclusion and exclusion criteria, a total of 18,058 patients remained in the final data set, including 7,339 patients who underwent percutaneous SCS and 10,719 patients who underwent open SCS procedures. After analysis, factors associated with increased rates of same-day discharge after SCS included men (odds ratio [OR] 1.16; 95% CI, 1.09 -1.24;  P < 0.001), patients on Medicaid (OR 1.64; 95% CI, 0.1.34 - 2.01; P < 0.001), and hospitals in the US Midwest (OR 1.66; 95% CI, 1.45 - 1.90; P < 0.001) and hospitals in the US West (OR 1.32; 95% CI, 1.20 - 1.46; P < 0.001). Factors associated with decreased rates of same-day discharge after SCS included the open approach (OR 0.21; 95% CI, 0.19 - 0.23; P < 0.001), Hispanic ethnicity (OR 0.61; 95% CI, 0.54 - 0.69; P < 0.001) and increased age (OR 0.99; 95% CI, 0.98 - 0.99; P < 0.001). LIMITATIONS: Since our study is retrospective, the data are subject to various biases, including variable confounding, human error in data entry, and generalizability of the results. CONCLUSION: These results can be used to help determine hospital bed needs post-SCS surgery. Future research should focus on identifying the specific reasons certain demographic and geographic factors might influence same-day discharge rates. Our study provides important insights into the factors associated with same-day discharge rates post open and percutaneous SCS implant and highlights the need for patient-centered, evidence-based approaches to health care delivery.

Artificial Intelligence and Pain Medicine: An Introduction.

Artificial intelligence was introduced 60 years ago and has evolved immensely since that time. While artificial intelligence is found in nearly all aspects of our life, the use of artificial intelligence in the healthcare industry has only recently become apparent and more widely discussed. It is expected that artificial intelligence will allow improved disease recognition, treatment optimization, cost and time savings, product development, decision making, and marketing. For pain medicine specifically, these same benefits will be translatable and we can expect better disease recognition and treatment selection. As adoption occurs with this impressive technology, it will be imperative for the pain medicine community to be informed on proper definitions and expected use cases for artificial intelligence. Our objective was to provide pain medicine physicians an overview of artificial intelligence, including important definitions to aid understanding, and to offer potential clinical applications pertinent to the specialty.

Medical students' attitudes and perceived competence regarding medical cannabis and its suggestibility.

INTRODUCTION: The global trend of legalizing medical cannabis (MC) is on the rise. In Germany, physicians have prescribed MC at the expense of health insurers since 2017. However, the teaching on MC has been scant in medical training. This study investigates medical students' attitudes and perceived competence regarding MC and evaluates how varying materials (videos/articles) impact their opinions. METHODS: Fourth-year medical students were invited to participate in the cross-sectional study. During an online session, students viewed a video featuring a patient with somatoform pain discussing her medical history, plus one of four randomly assigned MC-related materials (each an article and a video depicting a positive or negative perspective on MC). Students' opinions were measured at the beginning [T0] and the end of the course [T1] using a standardized questionnaire with a five-point Likert scale. We assessed the influence of the material on the students' opinions using paired-sample t-tests. One-way analysis of variance and Tukey post-hoc tests were conducted to compare the four groups. Pearson correlations assessed correlations. RESULTS: 150 students participated in the course, the response rate being 75.3% [T0] and 72.7% [T1]. At T0, students felt a little competent regarding MC therapy (M = 1.80 ± 0.82). At T1, students in groups 1 (positive video) and 3 (positive article) rated themselves as more capable in managing MC therapy [Formula: see text], and students in groups 3 (positive article) and 4 (negative article) felt more skilled in treating patients with chronic pain [Formula: see text]. Compared to the other groups, group 2 students (negative video) felt significantly less competent. They perceived cannabis as addictive, hazardous and unsuitable for medical prescription. DISCUSSION: This study showed that medical students lack knowledge and perceived competence in MC therapy. Material influences their opinions in different ways, and they seek more training on MC. This underlines that integrating MC education into medical curricula is crucial to address this knowledge gap.

Use of artificial intelligence in the field of pain medicine.

In this editorial we comment on the article "Potential and limitations of ChatGPT and generative artificial intelligence in medial safety education" published in the recent issue of the World Journal of Clinical Cases. This article described the usefulness of artificial intelligence (AI) in medial safety education. Herein, we focus specifically on the use of AI in the field of pain medicine. AI technology has emerged as a powerful tool, and is expected to play an important role in the healthcare sector and significantly contribute to pain medicine as further developments are made. AI may have several applications in pain medicine. First, AI can assist in selecting testing methods to identify causes of pain and improve diagnostic accuracy. Entry of a patient's symptoms into the algorithm can prompt it to suggest necessary tests and possible diagnoses. Based on the latest medical information and recent research results, AI can support doctors in making accurate diagnoses and setting up an effective treatment plan. Second, AI assists in interpreting medical images. For neural and musculoskeletal disorders, imaging tests are of vital importance. AI can analyze a variety of imaging data, including that from radiography, computed tomography, and magnetic resonance imaging, to identify specific patterns, allowing quick and accurate image interpretation. Third, AI can predict the outcomes of pain treatments, contributing to setting up the optimal treatment plan. By predicting individual patient responses to treatment, AI algorithms can assist doctors in establishing a treatment plan tailored to each patient, further enhancing treatment effectiveness. For efficient utilization of AI in the pain medicine field, it is crucial to enhance the accuracy of AI decision-making by using more medical data, while issues related to the protection of patient personal information and responsibility for AI decisions will have to be addressed. In the future, AI technology is expected to be innovatively applied in the field of pain medicine. The advancement of AI is anticipated to have a positive impact on the entire medical field by providing patients with accurate and effective medical services.

Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review.

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.