Cannabis use and acute postoperative pain outcomes in older adults: a propensity matched retrospective cohort study.

INTRODUCTION: Cannabis use is increasing among older adults, but its impact on postoperative pain outcomes remains unclear in this population. We examined the association between cannabis use and postoperative pain levels and opioid doses within 24 hours of surgery. METHODS: We conducted a propensity score-matched retrospective cohort study using electronic health records data of 22 476 older surgical patients with at least 24-hour hospital stays at University of Florida Health between 2018 and 2020. Of the original cohort, 2577 patients were eligible for propensity-score matching (1:3 cannabis user: non-user). Cannabis use status was determined via natural language processing of clinical notes within 60 days of surgery and structured data. The primary outcomes were average Defense and Veterans Pain Rating Scale (DVPRS) score and total oral morphine equivalents (OME) within 24 hours of surgery. RESULTS: 504 patients were included (126 cannabis users and 378 non-users). The median (IQR) age was 69 (65-72) years; 295 (58.53%) were male, and 442 (87.70%) were non-Hispanic white. Baseline characteristics were well balanced. Cannabis users had significantly higher average DVPRS scores (median (IQR): 4.68 (2.71-5.96) vs 3.88 (2.33, 5.17); difference=0.80; 95% confidence limit (CL), 0.19 to 1.36; p=0.01) and total OME (median (IQR): 42.50 (15.00-60.00) mg vs 30.00 (7.50-60.00) mg; difference=12.5 mg; 95% CL, 3.80 mg to 21.20 mg; p=0.02) than non-users within 24 hours of surgery. DISCUSSION: This study showed that cannabis use in older adults was associated with increased postoperative pain levels and opioid doses.

Critical Assessment of the Neurological Complications during High-Risk Anesthesia Procedures.

Damage to the peripheral and central nervous systems is frequently irreversible. Surgically induced neurological damage and anesthesia may result in catastrophic situations for patients and their families. The incidence of significant neurological complications during the perioperative period is examined in this article. In contrast to other organs like the kidney, heart, liver, lungs, and skeletal system, native neurological function cannot be replaced with artificial parts or devices soon. Ignoring brain function during the perioperative period has been a systemic problem in anesthesiology, even though the central and peripheral nervous systems are crucial. This bold claim is intended to draw attention to the fact that, unlike the circulatory and respiratory systems, which have been routinely monitored for decades, the brain and other neural structures do not have a standard monitoring during surgery and anesthesia. Given that the brain and spinal cord are the principal therapeutic targets of analgesics and anesthetics, this deficiency in clinical care is even more alarming. Organs that are notoriously hard to repair or replace after damage have, up until now, received comparatively little attention. In this article, a succinct overview of five neurological complications associated with surgery and anesthesia is presented. After critically reviewing the literature on the subject, the article is focused to common (delirium), controversial (postoperative cognitive decline), and potentially catastrophic (stroke, spinal cord ischemia, or postoperative visual loss) adverse events in the neurological surgery setting. The findings will increase awareness of major neurological complications to the involved surgical and anesthesia team and enhance preventive and treatment strategies during the perioperative period.

Transforming Growth Factor-ß-Activated Kinase 1 (TAK1) Alleviates Inflammatory Joint Pain in Osteoarthritis and Gouty Arthritis Preclinical Models.

Purpose: Joint pain is one of the most commonly reported pain types in the United States. In the case of patients suffering from inflammatory diseases such as osteoarthritis (OA) and gout, persistent inflammation due to long-term overexpression of several key cytokines has been linked to neuronal hypersensitivity and damage within the joints. Ultimately, a subset of patients develop chronic pain. Pharmacologic treatment of joint pain involves the use of analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antidepressants, as well as intra-articular injections of corticosteroids and hyaluronic acid. However, NSAIDs are short-acting and fail to alleviate severe pain, opioids are generally ineffective at managing chronic pain, and all therapeutic options involve increased risks of serious side effects. Methods: We explored the therapeutic and analgesic effects of transforming growth factor-ß-activated kinase 1 (TAK1) inhibition in both the monoiodoacetate (MIA) and monosodium urate (MSU) models of joint pain as an innovative strategy for alleviating chronic inflammatory pain. Mechanical allodynia (Von Frey), weight-bearing and histological changes were measured in separate groups of rats receiving either the selective TAK1 inhibitor, HS-276, gabapentin or vehicle. Results: Our data support that TAK1 inhibition effectively prevented the development of mechanical allodynia and differential weight-bearing in the MIA model. In the MSU model of gouty arthritis, treatment with HS-276 significantly reduced mechanical allodynia and knee edema in female rats, but not male rats. Histological evaluation of effected joints in both models showed that HS-276 treatment significantly reduced disease-induced degradation of the joint. Conclusion: Our results support that TAK1 is a critical signaling node in inflammatory joint diseases such as OA and gouty arthritis. Selective pharmacological inhibition significantly attenuated several aspects of the disease, including joint degeneration and mechanical pain. Thus, TAK1 is a novel therapeutic target for the treatment of painful inflammatory joint diseases. Perspective: This article reports on the therapeutic potential of TAK1 in the treatment of chronic inflammatory joint diseases such as OA and gout. Using the selective TAK1 inhibitor, HS-276, we show the therapeutic and analgesic effects of TAK1 inhibition in two preclinical murine models of inflammatory joint pain.

Preoperative Acetaminophen For Microsuspension Laryngoscopy Reduces Postoperative Opioid Use.

OBJECTIVES: The opioid crisis has prompted consideration of analgesic prescriptions. This study explored the value of preoperative acetaminophen for pain control following microsuspension laryngoscopy (MSL) and compared the results with a previous study of pain and opioid use following MSL (Tsang et al.). METHODS: A prospective open-label clinical trial was conducted in patients undergoing MSL. All patients were administered preoperative acetaminophen. Short-form McGill Pain Questionnaire (SF-MPQ), pain visual analogue scale (VAS), and present pain intensity (PPI) scores were collected preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. Statistical analysis identified variables associated with opioid use or increased pain scores, and compared outcomes with Tsang et al. RESULTS: Eighty-nine patients were included (mean age 52.8 ± 17.3 years, 40 males). All patients received preoperative 1 g acetaminophen (77 (86.5%) orally) with no adverse effects. On POD1, opioid usage was 10%. Median [IQR] pain scores were 5 [2-11], 21 [12.3-56.8], and 3 [2-3.3] on SF-MPQ, VAS, and PPI, respectively. Post-Anesthesia Care Unit (PACU) opioid requirements significantly correlated with POD1 opioid consumption (τb = 0.214; p ≤ 0.05), and significant associations with PACU opioid administration were found for total anesthesia time (OR (95%CI) = 1.271 (1.043-1.548), p = 0.017) and total laryngoscope suspension time (OR (95%CI) = 0.791 (0.651-0.962, p = 0.019)). This cohort demonstrated reduced opioid usage on POD1 compared with Tsang et al (23%). CONCLUSIONS: Preoperative acetaminophen is a safe intervention, resulting in decreased postoperative opioid use following MSL. Anesthesia time correlated with need for postoperative opioids. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon.

BACKGROUND: A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. OBJECTIVE: To examine the effect of the policy on prescribing, health outcomes, and health service utilization. DESIGN: Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. SUBJECTS: Adult Medicaid patients with back pain enrolled between 2014 and 2018. INTERVENTION: The Oregon Medicaid back pain policy. MAIN MEASURES: Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. KEY RESULTS: The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01 pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4 days [95% CI - 0.53, - 0.26] slope), receipt of more than 7 days of short-acting opioids (- 2.36 pp [95% CI - 2.76, - 1.95] level, - 0.91 pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27 pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. CONCLUSIONS: A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

A comprehensive review of the typical and atypical side effects of gabapentin.

BACKGROUND: Gabapentin, a widely prescribed medication for various neuropathic pain conditions, has demonstrated efficacy in managing diverse neurological disorders. While conventional side effects are well-documented, a growing body of evidence suggests the existence of atypical side effects, necessitating comprehensive exploration. This paper aims to systematically review and summarize the literature on the atypical side effects of gabapentin, shedding light on manifestations beyond the conventional spectrum. METHODS: A systematic review was conducted, encompassing peer-reviewed articles published up to the knowledge cutoff date in November 2023. Databases, specifically PubMed, were searched for relevant studies, focusing on atypical side effects such as myoclonus, ataxia, pediatric aggression, respiratory depression, pneumonia, pregnancy complications, sleep interference, encephalopathy, peripheral edema, suicidal ideation, dyskinesia, anorgasmia, and myopathy. Inclusion criteria comprised studies with a focus on gabapentin-related atypical side effects, published in recognized journals and involving human subjects. RESULTS: The review identified a spectrum of atypical side effects associated with gabapentin use, ranging from neurological manifestations like myoclonus and ataxia to behavioral changes such as pediatric aggression and suicidal ideation. Additionally, respiratory complications, pregnancy-related issues, sleep disturbances, and rare complications like encephalopathy and myopathy were observed. Literature synthesis provided insights into the incidence, clinical presentation, and potential mechanisms underlying these atypical side effects. CONCLUSION: This comprehensive review highlights the diverse range of atypical side effects associated with gabapentin use, expanding beyond conventional knowledge. Healthcare practitioners must be cognizant of these manifestations, recognizing their potential impact on patient well-being. As clinical decision-making relies on a thorough understanding of a medication's side effect profile, this review contributes to enhancing awareness and fostering informed practices in the prescription and management of gabapentin. Further research is warranted to elucidate the mechanisms and risk factors associated with these atypical side effects, refining our understanding of gabapentin's safety profile.

SGIP1 Deletion in Mice Attenuates Mechanical Hypersensitivity Elicited by Inflammation.

Background: Activation of cannabinoid receptor 1 (CB1R) in the nervous system modulates the processing of acute and chronic pain. CB1R activity is regulated by desensitization and internalization. SH3-containing GRB2-like protein 3-interacting protein 1 (SGIP1) inhibits the internalization of CB1R. This causes increased and prolonged association of the desensitized receptor with G protein-coupled receptor kinase 3 (GRK3) and beta-arrestin on the cell membrane and results in decreased activation of extracellular signal-regulated kinase 1/2 (ERK1/2) pathway. Genetic deletion of SGIP1 in mice leads to altered CB1R-related functions, such as decreased anxiety-like behaviors, modified cannabinoid tetrad behaviors, reduced acute nociception, and increased sensitivity to analgesics. In this work, we asked if deletion of SGIP1 affects chronic nociception and analgesic effect of Δ9-tetrahydrocannabinol (THC) and WIN 55,212-2 (WIN) in mice. Methods: We measured tactile responses of hind paws to increasing pressure in wild-type and SGIP1 knock-out mice. Inflammation in the paw was induced by local injection of carrageenan. To determine the mechanical sensitivity, the paw withdrawal threshold (PWT) was measured using an electronic von Frey instrument with the progression of the applied force. Results: The responses to mechanical stimuli varied depending on the sex, genotype, and treatment. SGIP1 knock-out male mice exhibited lower PWT than wild-type males. On the contrary, the female mice exhibited comparable PWT. Following THC or WIN treatment in male mice, SGIP1 knock-out males exhibited PWT lower than wild-type males. THC treatment in SGIP1 knock-out females resulted in PWT higher than after THC treatment of wild-type females. However, SGIP1 knock-out and wild-type female mice exhibited similar PWT after WIN treatment. Conclusions: We provide evidence that SGIP1, possibly by interacting with CB1R, is involved in processing the responses to chronic pain. The absence of SGIP1 results in enhanced sensitivity to mechanical stimuli in males, but not females. The antinociceptive effect of THC is superior to that of WIN in SGIP1 knock-out mice in the carrageenan-induced model of chronic pain.

Relationships of self-reported opioid and benzodiazepine use with health-related quality of life among adults with spinal cord injury.

BACKGROUND: There is limited understanding of the relationships between prescription opioid and benzodiazepine use and indices of health-related quality of life (HRQOL) among those with spinal cord injuries (SCI). OBJECTIVE: To identify the relationships between self-reported prescription opioid and benzodiazepine use and two indicators of HRQOL, number of days in poor physical health and poor mental health in the past 30 days among adults with SCI. METHODS: A cross-sectional cohort study of 918 adults with chronic (>1 year), traumatic SCI living in the Southeastern United States was conducted. Participants completed a self-report assessment (SRA). RESULTS: In the preliminary model, both opioid and benzodiazepine use were associated with a greater number of days in poor physical health and poor mental health in the past month. After controlling for health conditions (pain intensity, spasticity, anxiety and perceived sleep insufficiency), opioid use was associated with 2.04 (CI = 0.69; 3.39) additional poor physical health days in the past 30 days, and benzodiazepine use was associated with 2.18 (CI = 0.70; 3.64) additional days of poor mental health. Age was associated with greater number of poor physical health days and fewer poor mental health days. Lower income was associated with poor mental health days. Most of the health conditions were significantly related to the number of past month poor physical and mental health days. CONCLUSIONS: Opioid and benzodiazepine use are associated with poor physical and mental HRQOL, even after controlling for health conditions. Treatment strategies should consider potential unanticipated negative consequences of pharmacological interventions.

Comparison of 2% lidocaine infiltration and eutectic mixture of local anesthetics cream application before spinal needle insertion for pain reduction and assessment of maternal satisfaction levels in women undergoing cesarean section at a tertiary care se.

Background: This study aimed to compare two analgesic pretreatment techniques for assessing pain reduction before spinal needle insertion and the subsequent patient satisfaction levels in pregnant women undergoing cesarean sections. Methods: Sixty pregnant women scheduled for elective cesarean section under spinal anesthesia were randomly assigned to two groups. The Lidocaine group received local skin infiltration with 2% lidocaine pretreatment before spinal needle introducer insertion, whereas the eutectic mixture of local anesthetics (EMLA) group received EMLA (lidocaine 2.5% and prilocaine 2.5%) cream pretreatment for at least 30 min before spinal needle introducer insertion. Subjective and objective pain scores, procedure duration, number of attempts, maternal satisfaction, and decisions regarding future numbing procedures and regional anesthesia were assessed. Results: The demographic characteristics of the patients were similar between groups. The mean visual analogue scale (VAS) pain score was significantly lower in the EMLA group compared to the lidocaine group (1.2 ± 1.1 vs. 2.8 ± 1.7, estimated difference 1.6; 95% confidence interval [CI], 0.8-2.3; P < 0.05). Additionally, the objective pain score was significantly lower in the EMLA group (P < 0.05). The duration of spinal block placement was significantly longer in the lidocaine group than in the EMLA group (estimated difference, 0.74; 95% CI, 0.50-1.00; P < 0.05). The number of attempts to perform the spinal block placement was similar in both groups. However, women in the EMLA group expressed greater overall satisfaction than those in the lidocaine group (76.7% vs. 20%, P < 0.05). Conclusions: Analgesic pretreatment with EMLA cream is superior to local skin infiltration with lidocaine in pregnant patients undergoing elective cesarean section under spinal anesthesia.

Individuals With Prior Chronic Pain and Long-Term Opioid Treatment May Experience Persistence of That Pain Even After Subsequent Complete Cervical Spinal Cord Injury: Suggestions From a Prospective Case-Controlled Study.

Objective: To determine whether chronic pain persists after complete spinal cord injury (SCI). Design: Prospective observational study regarding the outcome of pre-existent chronic pain of inpatients admitted with new clinically diagnosed complete cervical SCI. For patients who acknowledged chronic pain of ≥3 years duration before the SCI, further questions explored whether they still experienced that pain, whether they were experiencing current posttraumatic pain, and whether they had any past exposure to opioids. The included patients were identified during the initial consultation in the trauma center for treatment of the SCI. Setting: Level I trauma center. Participants: From a total of 49 participants with acute cervical SCI with clinically diagnosed complete motor and sensory tetraplegia admitted between 2018 and 2020, 7 were selected on the basis of a history of chronic pain. Intervention: Collected complete history and performed physical examination with serial follow-ups during the acute hospital stay until death or discharge. Main Outcome Measures: The primary outcome was a finding of chronic pain experienced before new clinical diagnosis of complete SCI, compared with whether or not that pain continued after the SCI injury. The secondary outcome was the relation of persistent pain with opioid use; it was formulated after data collection. Results: Among 49 patients with clinically diagnosed complete cervical SCIs, 7 had experienced prior chronic pain. Four participants experienced a continuation of the prior pain after their complete tetraplegia (4/7), whereas 3 participants did not (3/7). All the participants with continued pain had been previously treated with opioids, whereas those whose pain ceased had not received chronic opioid therapy. Conclusions: There may be a unique form of chronic pain that is based in the brain, irrespective of peripheral pain or spinal mechanisms. Otherwise healthy people with longstanding antecedent chronic pain whose pain persists after acute clinically complete SCI with tetraplegia may provide a new model for evaluation of brain-based pain. Opioids may be requisite for this type of pain.

Effects of popliteal plexus block after total knee arthroplasty: a randomized clinical trial.

BACKGROUND AND OBJECTIVES: Motor-sparing peripheral nerve blocks enhance multimodal opioid-sparing strategies after total knee arthroplasty. We hypothesized that adding a popliteal plexus block to a femoral triangle block could reduce 24-hour opioid consumption after total knee arthroplasty, compared with standalone femoral triangle block or adductor canal block. METHODS: This patient- and assessor-blinded, randomized controlled trial allocated 165 patients into three equally sized parallel groups, receiving either 1) popliteal plexus block+femoral triangle block, 2) femoral triangle block, or 3) adductor canal block. Intravenous oxycodone was administered via patient-controlled analgesia pumps. The primary outcome was 24-hour postoperative opioid consumption. Secondary outcomes were preoperative maximum voluntary isometric contraction and manual muscle tests of knee and ankle movement assessed before and after the nerve block procedure together with postoperative pain scores, mobilization, and 12-hour opioid consumption. RESULTS: 24-hour postoperative intravenous oxycodone consumption varied significantly between groups (p<0.01), with medians (IQR) of 6 mg (2-12) in the popliteal plexus block+femoral triangle block group, 10 mg (8-16) in the femoral triangle block group, and 12 mg (6-18) in the adductor canal block group. Median consumption in the popliteal plexus block+femoral triangle block group was reduced by -4 mg (95% CI -7.4 to -1.0, p<0.01) and -6 mg (95% CI -8.3 to -1.3, p=0.01) compared with groups of femoral triangle block and adductor canal block, respectively. No differences were found in pain scores, mobilization, or changes in preoperative muscle strength. Post hoc analysis revealed successful 24-hour opioid-free postoperative care among 12 patients with popliteal plexus block+femoral triangle block, as compared with two with femoral triangle block and six with adductor canal block. CONCLUSION: Adding a popliteal plexus block to a femoral triangle block resulted in a statistically significant reduction of 24-hour postoperative opioid consumption after total knee arthroplasty. However, no differences were found in pain scores. Popliteal plexus block did not impair the lower leg muscles.

Opioid and non-opioid analgesic regimens after fracture and risk of serious opioid-related events.

Background: Non-opioid analgesics are prescribed in combination with opioids among patients with long bone fracture to reduce opioid prescribing needs, yet evidence is limited on whether they reduce the risk of serious opioid-related events (SOREs). We compared the risk of SOREs among hospitalized patients with long bone fracture discharged with filled opioid prescriptions, with and without non-opioid analgesics. Design: We identified a retrospective cohort of analgesic-naïve adult patients with a long bone fracture hospitalization using the Merative MarketScan Commercial Database (2013-2020). The exposure was opioid and non-opioid analgesic (gabapentinoids, muscle relaxants, non-steroidal anti-inflammatory drugs, acetaminophen) prescriptions filled in the 3 days before through 42 days after discharge. The outcome was the development of new persistent opioid use or opioid use disorder during follow-up (day 43 through day 408 after discharge). We used Cox proportional hazards regression with inverse probability of treatment weighting with overlap trimming to compare outcomes among those that filled an opioid and a non-opioid analgesic to those that filled only an opioid analgesic. In secondary analyses, we used separate models to compare those that filled a prescription for each specific non-opioid analgesic type with opioids to those that filled only opioids. Results: Of 29 489 patients, most filled an opioid prescription alone (58.4%) or an opioid and non-opioid (22.0%). In the weighted proportional hazards regression model accounting for relevant covariates and total MME, filling both a non-opioid analgesic and an opioid analgesic was associated with 1.63 times increased risk of SOREs compared with filling an opioid analgesic only (95% CI 1.41 to 1.89). Filling a gabapentin prescription in combination with an opioid was associated with an increased risk of SOREs compared with those that filled an opioid only (adjusted HR: 1.84 (95% CI1.48 to 2.27)). Conclusions: Filling a non-opioid analgesic in combination with an opioid was associated with an increased risk of SOREs after long bone fracture. Level of evidence: Level III, prognostic/epidemiological. Study type: Retrospective cohort study.

The Essential and Optimal Analgesic and Anti-Inflammatory Medicines for Athletes at the Olympic Games.

BACKGROUND: In 2019, the International Olympic Committee published the first Olympic and Paralympic Model Formulary (OPF), which defined the standardised set of medications required at every Olympic and Paralympic Games for the treatment of athletes. This study aimed to test the OPF to determine whether it meets the clinical needs of the athlete population with respect to medications used for pain and/or inflammation (PI), and to present a revised set of essential PI medications for the OPF based on prevalence of athlete use. Medication-use data of athletes at the Tokyo 2020 and Beijing 2022 Olympic Games (n = 6155) from three sources were used to establish prevalence of PI medicine use and to revise the OPF: (i) doping control forms, (ii) pharmacy dispensing reports, and (iii) injection declaration forms. This revised list was further validated through (iv) medication importation declarations by teams (n = 156), and (v) survey of team physicians (n = 382). RESULTS: Overall prevalence of PI medication use was 36.7%, with higher use by female athletes (female: 44.1%; male: 30.0%; p < 0.001), with non-steroidal anti-inflammatory drugs being the most used class (27%). Use of medications with safety risks were identified, including nimesulide, piroxicam and metamizole. A revised list of 48 PI medications was recommended for the OPF. CONCLUSION: The research led to a revised set of essential medications for the treatment of pain and inflammation to be available for athletes at the Olympic Games, which would lead to a 7% improvement in the numbers of athletes who could have their exact PI medication requirements met by the OPF.

Pain after oocyte retrieval in women with endometriosis undergoing fertility preservation or IVF.

RESEARCH QUESTION: Do women with endometriosis undergoing oocyte retrieval for fertility preservation experience the same level of pain as women undergoing oocyte retrieval for IVF? DESIGN: This retrospective cohort study included 796 cycles in women with endometriosis undergoing oocyte retrieval for fertility preservation (n = 401) or IVF (n = 395) between January 2020 and October 2022. Post-operative pain assessments were compared between the two groups using a numeric rating scale (NRS). RESULTS: Women in the fertility preservation group were younger (32.1 ± 4.2 years versus 35.1 ± 4.1 years; P < 0.001), had a lower body mass index (22.8 ± 3.9 kg/m2 versus 24.6 ± 4.4 kg/m2; P < 0.001) and had a lower concentration of anti-Müllerian hormone (1.8 ± 1.5 ng/ml versus 2.15 ± 2.11 ng/ml; P = 0.026) in comparison with women in the IVF group. The oestrogen concentration on the day of ovulation trigger was higher in women in the fertility preservation group (2188 ± 1152 pg/ml versus 2081 ± 995 pg/ml; P = 0.004), and the prevalence rates of adenomyosis and digestive endometrial lesions were lower in women in the fertility preservation group (14% versus 29%, P < 0.001; 16% versus 25%, P = 0.003, respectively) compared with women in the IVF group. After oocyte puncture, more women in the fertility preservation group had an NRS pain score >3 (moderate to severe pain) compared with women in the IVF group (20% versus 14%; P = 0.018). The progestin-primed ovarian stimulation (PPOS) protocol was identified as an independent predictive factor of greater post-operative pain (adjusted OR 2.30, 95% CI 1.06-5.15; P = 0.039). CONCLUSION: Women with endometriosis undergoing fertility preservation reported more intense post-operative pain in the recovery room than women undergoing IVF. The PPOS protocol was an independent risk factor of intense pain (NRS pain score >3) in women with endometriosis, but further studies are needed to confirm this result.

Opioid-Related Emergency Department Visits Before and During COVID-19: Association with Community-Level Factors.

Background: The purpose of the study was to investigate the relationship between community-level variables and emergency department (ED) visit rates before and during COVID-19. The focus was on opioid-related ED visits. Despite large declines in overall ED visits during COVID-19, opioid-related visits increased. While visits for avoidable conditions decreased, the opposite was true for opioid-related visits. Methods: We combined data from Florida EDs with community-level variables from the 2020 American Community Survey. The outcome measures of the study were quarterly ZIP code tabulation-area-level ED visit rates for opioid-related ED visits as well as visit rates for all other causes. Associations with opioid-related visit rates were estimated before and during COVID-19. Results: The associations between community-level variables and opioid-related visit rates did not match those found when analyzing overall ED visit rates. The increase in opioid-related visits during COVID-19 was not unique to or more prevalent in areas with a larger percentage of racial/ethnic minority populations. However, socioeconomic status was important, as areas with higher unemployment, lower income, lower home ownership, and higher uninsured had higher overall ED visit rates and opioid visit rates during the pandemic. In addition, the negative association with income increased during the pandemic. Conclusion: These results suggest socioeconomic status should be the focus of prevention and treatment efforts to reduce opioid-related visits in future pandemics. Healthcare organizations can use these results to target their prevention and treatment efforts during future pandemics.

Analysis of Two Treatment Modalities for Post-surgical Pain after Hemorrhoidectomy.

Background: This non-randomized study aimed to compare the efficacy of two pharmacological treatments, "around-the-clock" analgesic treatment (ACAT) and "on-demand" analgesic treatment (ODAT), for managing postoperative pain following hemorrhoidectomy. Material and Methods: The study, conducted from July 2016 to December 2020, included 5335 hemorrhoidectomy patients. Participants were divided into ACAT (3767) and ODAT (1568) groups. The study was registered at clinicaltrials.gov (NCT04953182). Results: Patients had a mean age of 47.47 years, with 59.98% males. Postoperatively, 14.13% reported severe pain, 36.49% moderate, 34.28% mild, and 15.09% no pain. ACAT group's maximum pain was 3.04 (VAS), ODAT 4.95 (p; average pain was 0.79 (ACAT) and 1.45 (ODAT). Discharge pain was 0.42 (ACAT) and 0.63 (ODAT) VAS. The ACAT group consistently reported lower levels of pain across all measured instances. Higher BMI and younger age were pain risk factors (p=.049, p .001 respectively). ACAT administration resulted in reduced opioid usage, with meperidine showing a 68.38% decrease, morphine 43.57% less, tramadol 46.82% less, oxycodone reduced by 38.74%, and codeine by 53.40%. Additionally, the use of non-opioid analgesics was notably lower in the ACAT group, ranging from 16% to 59% less compared to the ODAT group. Conclusion: Hemorrhoidectomy induces moderate postoperative pain, with only 14% experiencing severe pain. A fixed schedule multimodal pain regimen, regardless of procedure and anesthesia type, reduces pain from moderate to mild post-hemorrhoidectomy. This approach also decreases opioid and non-opioid analgesic requirements. Higher BMI and younger age are identified as risk factors for elevated postoperative pain.

Attenuation of acute postoperative pain and opioid requirement with the use of magnesium sulfate in patients undergoing limb amputations.

OBJECTIVE: To compare the effects of magnesium sulphate on the total dose of intravenous morphine consumption postoperatively following limb amputations along with rescue analgesia requirement, pain scores and side effects. METHODS: This prospective, triple-blinded, randomised controlled study was conducted from October 2021 to May 2022 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised of patients scheduled for limb amputations. They were randomised into 2 equal groups. The anaesthesia protocol was uniform for all patients. Intervention group A was administered 30mg/kg loading dose and 10mg/kg/hr maintenance dose of magnesium sulphate intravenously, while patients in control group B received the same amount of plain isotonic saline. Morphine consumption, including that used for rescue analgesia and patient-controlled analgesia, was measured for 24 hours postoperatively. Numeric rating scale was used for the evaluation of postoperative pain in both groups at 15min, 1h, 2h, at discharge from the post-anaesthesia care unit and at 12h and 24h in the ward. Data was analysed using SPSS 23. RESULTS: Of the 24 patients enrolled, the study was completed by 20(83.33%). There were 10(50%) patients in group A; 8(40%) males and 2(20%) females with mean age 24.8±14.14 years and mean surgery time 130.5±47.86 minutes. There were 10(50%) patients in group B; 8(40%) males and 2(20%) females with mean age 23.2±7.4 years and mean surgery time 117±23.85 minutes (p>0.05). Total morphine used over 24 hours in group A was 16±3.1 mg compared to 29.6±11.2 mg in group B (p<0.05). The time for first use of patient-controlled analgesia after arriving in the postanaesthesia care unit was significantly delayed in group A (72.2±24.95 minutes) compared to that in group B (25±26.68 minutes) (p<0.05). Pain scores were significantly higher in the group B at 15min compared to group A (p<0.05), but not at the rest of the time points (p>0.05). CONCLUSIONS: Intravenous magnesium sulphate proved to be effective in lowering postoperative opioid requirement following limb amputations.

Access to care for patients with chronic pain receiving prescription opioids, cannabis, or other treatments.

Changes in chronic noncancer pain treatment have led to decreases in prescribing of opioids and increases in the availability of medical cannabis, despite its federal prohibition. Patients may face barriers to establishing new care with a physician based on use of these treatments. We compared physician willingness to accept patients based on prescription opioid, cannabis, or other pain treatment use. This study of 36 states and Washington, DC, with active medical cannabis programs surveyed physicians who treat patients with chronic noncancer pain between July 13 and August 4, 2023. Of 1000 physician respondents (34.5% female, 63.2% White, 78.1% primary care), 852 reported accepting new patients with chronic pain. Among those accepting new patients with chronic pain, more physicians reported that they would not accept new patients taking prescription opioids (20.0%) or cannabis (12.7%) than those taking nonopioid prescription analgesics (0.1%). In contrast, 68.1% reported willingness to accept new patients using prescribed opioids on a daily basis. For cannabis, physicians were more likely to accept new patients accessing cannabis through medical programs (81.6%) than from other sources (60.2%). Access to care for persons with chronic noncancer pain appears to be the most restricted among those taking prescription opioids, although patients taking cannabis may also encounter reduced access.

Parabolic Changes in Pain Scores Among Partial Herpes Zoster Patients: A Retrospective Study.

Background: Herpes zoster (HZ) typically manifests in the acute phase with distinct blisters and severe neuropathic pain. Remarkably, a subset of patients initially presents with only a mild skin rash and moderate pain that gradually intensifies, following a parabolic pattern. Despite being frequently observed in clinical settings, the underlying causes of this trajectory and its potential connection with post-herpetic neuralgia (PHN) remain unclear. Methods: To investigate this phenomenon in-depth, we conducted a meticulous retrospective study involving 529 eligible HZ patients. All these patients sought medical care at the Third Central Hospital of Tianjin, China, between January 2020 and December 2023. Results: The research identified that 14.6% of the sample (77 patients) experienced pain scores aligning with a parabolic curve. This trend was significantly more prevalent in patients aged 60 and above, accounting for 90.9% of this group, and demonstrated a positive correlation with age. Moreover, 87.0% of these patients had pre-existing medical conditions, highlighting the potential role of comorbidities in influencing the pain trajectory. A concerning 45.5% of patients sought medical attention more than seven days after the onset of symptoms, a delay that could exacerbate neurological damage. Notably, among those following a parabolic pain pattern, 66.2% eventually developed PHN, a considerably higher rate compared to the broader patient population. Conclusion: We emphasize that healthcare practitioners meticulously assess patients who initially report lower pain scores for high-risk factors potentially leading to parabolic pain increases, including being over 60 years old, having comorbid conditions, and delaying medical consultation beyond seven days from symptom onset. Early implementation of supplementary pain management therapies may mitigate the risk of PHN development and enhance the quality of life for patients. This study furnishes clinicians with a deeper understanding of the variations in HZ-related pain trajectories, promising to improve treatment approaches and prognoses for HZ patients while paving the way for enriched clinical practice in the future.

A Comprehensive Meta-Analysis on the Role of Analgesics and Anti-Inflammatories in Pan-retinal Photocoagulation.

PURPOSE: Pan-retinal photocoagulation (PRP) is the mainstay of treatment for proliferative diabetic retinopathy (PDR), reducing the risk of severe vision loss. Pain poses a potential obstacle to effective laser delivery and patient compliance. Therefore, implementing pain relief strategies can enhance both treatment efficacy and patient comfort. DESIGN: A systematic review and meta-analysis. METHODS: We conducted a systematic review and meta-analysis according to PRISMA guidelines. The PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that enrolled patients undergoing PRP due to DR and compared analgesics or non-steroidal anti-inflammatory drugs (NSAID) to placebo. Pain was evaluated with the visual analogue scale. The version 2 of the Cochrane Collaboration's Risk of Bias in Randomized Controlled Trials tool and its version for crossover trials were used to assess the risk of bias. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used to measure the certainty of evidence. RESULTS: A total of 13 studies were included, comprising 1404 eyes from RCTs, nine of which were crossover. Patients who were administered analgesia reported a significantly lower pain sensitivity compared to those who received placebo (Standardized mean difference [SMD] -0.38; 95% confidence interval [CI] -0.58, -0.17; P<0.01; I2=69%). Subgroup analysis of systemic administration of analgesics/NSAIDs (metamizole, Entonox, acetaminophen, ibuprofen, caffeine, mefenamic acid, intramuscular ketorolac tromethamine, and potassium diclofenac) also showed a statistically significant reduction in pain when compared to placebo (SMD -0.28; 95% CI -0.50, -0.07; P<0.01; I2=43%). Exclusive eye drops administration (ketorolac tromethamine 0.5% and sodium diclofenac 0.1%) also showed a significant difference in pain sensitivity (SMD -0.46; 95% CI -0.88, -0.05; I2=83%), however with a more significant heterogeneity. CONCLUSION: The results of this meta-analysis including over 1000 patients demonstrated that the use of analgesics significantly reduced pain sensitivity during PRP, and systemic analgesia is potentially better than topical administration when compared to placebo.