Propellant Free Pressurized Spray System of Etodolac to Manage Acute Pain Conditions: In Vitro and In Vivo Evaluation.

This study aimed to develop a propellant-free topical spray formulation of Etodolac (BCS-II), a potent NSAID, which could be beneficial in the medical field for the effective treatment of pain and inflammation conditions. The developed novel propellant-free spray formulation is user-friendly, cost-effective, propellant-free, eco-friendly, enhances the penetration of Etodolac through the skin, and has a quick onset of action. Various formulations were developed by adjusting the concentrations of different components, including lecithin, buffering agents, film-forming agents, plasticizers, and permeation enhancers. The prepared propellant-free spray formulations were then extensively characterized and evaluated through various in vitro, ex vivo, and in vivo parameters. The optimized formulation exhibits an average shot weight of 0.24 ± 0.30 ml and an average drug content or content uniformity of 87.3 ± 1.01% per spray. Additionally, the optimized formulation exhibits an evaporation time of 3 ± 0.24 min. The skin permeation study demonstrated that the permeability coefficients of the optimized spray formulation were 21.42 cm/h for rat skin, 13.64 cm/h for mice skin, and 18.97 cm/h for the Strat-M membrane. When assessing its potential for drug deposition using rat skin, mice skin, and the Strat-M membrane, the enhancement ratios for the optimized formulation were 1.88, 2.46, and 1.92, respectively against pure drug solution. The findings from our study suggest that the propellant-free Etodolac spray is a reliable and safe topical formulation. It demonstrates enhanced skin deposition, and improved effectiveness, and is free from any skin irritation concerns.

Acute, Chronic, and Everyday Physical Pain in Borderline Personality Disorder.

PURPOSE OF REVIEW: Physical pain is an underrecognized area of dysregulation among those with borderline personality disorder (BPD). Disturbances are observed within the experience of acute, chronic, and everyday physical pain experiences for people with BPD. We aimed to synthesize research findings on multiple areas of dysregulation in BPD in order to highlight potential mechanisms underlying the association between BPD and physical pain dysregulation. RECENT FINDINGS: Potential biological mechanisms include altered neural responses to painful stimuli within cognitive-affective regions of the brain, as well as potentially low basal levels of endogenous opioids. Emotion dysregulation broadly mediates dysregulation of physical pain. Certain psychological experiences may attenuate acute physical pain, such as dissociation, whereas others, such as negative affect, may exacerbate it. Social challenges between patients with BPD and healthcare providers may hinder appropriate treatment of chronic pain. Dysregulated physical pain is common in BPD and important in shaping health outcomes including elevated BPD symptoms, chronic pain conditions, and risk for problematic substance use.

Sex moderates the association between quantitative sensory testing and acute and chronic pain after total knee/hip arthroplasty.

OBJECTIVES: Acute postsurgical pain (APSP) may persist over time and become chronic. Research on predictors for APSP and chronic postsurgical pain (CPSP) has produced inconsistent results. This observational study aimed to analyze psychological and psychophysical variables associated with APSP and CPSP after total knee or hip arthroplasty, and to explore the role of sex. METHODS: Assessments were conducted before surgery, 48 h, and 3 months postsurgery, including questionnaires (sociodemographic, pain related, and psychological) and quantitative sensory testing (QST). Hierarchical linear regression models analyzed potential predictors of APSP and CPSP, and moderation analyses evaluated the role of sex. RESULTS: The study included 63 participants undergoing total knee (34, 54%) or hip (29, 46%) arthroplasty. Thirty-one (49.2%) were female and 32 (50.8%) were male. APSP (48 h) was associated with impaired conditioned pain modulation (CPM) (ß = 0.301, p = 0.019). CPSP (3 months) was associated with being female (ß = 0.282, p = 0.029), longer presurgical pain duration (ß = 0.353, p = 0.006), knee arthroplasty (ß = -0.312, p = 0.015), higher APSP intensity (ß = 373, p = 0.004), and impaired CPM (ß = 0.126, p = 0.004). In multivariate analysis, these clinical variables were significant predictors of CPSP, unlike sex, and CPM (adj. R 2 = 0.349). Moderation analyses showed that wind-up ratio (WUR) was a significant predictor of APSP in men (WUR × sex: b = -1.373, p = 0.046) and CPM was a significant predictor of CPSP in women (CPM × sex: b = 1.625, p = 0.016). CONCLUSIONS: Specific QST parameters could identify patients at risk for high-intensity APSP and CPSP, with sex as a moderator. This has important clinical implications for patient care, paving the way for developing tailored preventive pain management strategies.

El tratamiento del dolor agudo pediátrico en España EN 2021: resultado de una encuesta nacional entre anestesiólogos pediátricos / The management of paediatric acute pain in Spain IN 2021: Results of a national survey among paediatric anaesthesiologists

Objetivo: Mejorar el conocimiento acerca de la práctica clínica habitual en el tratamiento del dolor agudo pediátrico en España.MétodosSe llevó a cabo una encuesta telemática a través de Internet en una muestra representativa de profesionales sanitarios involucrados en el tratamiento del dolor agudo pediátrico (concretamente anestesiólogos) en España. La encuesta incluyó 28 cuestiones acerca de su práctica clínica habitual en la valoración y el tratamiento del dolor agudo, así como aspectos formativos y organizativos en el dolor agudo pediátrico.ResultadosLa encuesta fue completada durante el mes de marzo de 2021 por 150 especialistas en anestesiología. Los encuestados presentaron una amplia experiencia en el tratamiento del dolor agudo pediátrico (media de años de experiencia: 14,3; DE: 7,8) y básicamente en dolor agudo postoperatorio (97% casos). Aunque el 80% de los mismos utilizaba de modo habitual escalas validadas de valoración de dolor agudo pediátrico, solo el 2,6% utilizaba las específicas adaptadas para pacientes con discapacidad cognitiva. La mayoría de los encuestados empleaba habitualmente fármacos analgésicos como el paracetamol (99%) o el metamizol (92%), pero solo el 84% los complementaba con alguna técnica de bloqueo loco-regional u otra medicación tipo antiinflamatorio no esteroideo (62%). Además, únicamente un 62,7% reconocía haber recibido formación específica en dolor agudo pediátrico, solo un 45% seguía protocolos institucionales hospitalarios y un escaso 28% lo hacía a través de unidades de dolor infantil.ConclusionesLa encuesta identificó importantes puntos de mejora en la formación y organización del tratamiento del dolor agudo de los pacientes españoles en edad pediátrica. (AU)

Objective: To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain.MethodsA telematic survey was conducted via the Internet on a representative sample of healthcare professionals involved in the management of paediatric acute pain (specifically anaesthesiologists) in Spain. The survey included 28 questions about their usual clinical practice in the assessment and treatment of acute pain, and also training and organisational aspects in paediatric acute pain.ResultsThe survey was completed during March 2021 by 150 specialists in anaesthesiology. The respondents widely experienced in the management of acute paediatric pain (mean years of experience: 14.3: SD: 7.8), essentially in acute postoperative pain (97% of cases). Although 80% routinely used validated paediatric acute pain assessment scales, only 2.6% used specific scales adapted for patients with cognitive impairment. Most of the respondents routinely used analgesic drugs such as paracetamol (99%) or metamizole (92%), but only 84% complemented these drugs with a loco-regional blocking technique or other non-steroidal anti-inflammatory drugs (62%). Furthermore, only 62.7% acknowledged having received specific training in paediatric acute pain, only 45% followed hospital institutional protocols, and a scant 28% did so through paediatric pain units.ConclusionsThe survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients. (AU)

Gestión del dolor agudo postoperatorio: condiciones para garantizar la seguridad y la efectividad de los tratamientos analgésicos / Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments

La evidencia sobre la gestión del dolor postoperatorio presenta un grado de calidad bajo o insuficiente. El Grupo de Trabajo del Dolor Agudo SEDAR ha elaborado este documento-guía para aplicar la mejor evidencia científica disponible a la práctica clínica habitual, individualizándolo en función de factores propios del paciente y del procedimiento, y englobando las distintas opciones organizativas del control de dolor.El documento profundiza y actualiza conceptos y requisitos mínimos necesarios para una analgesia óptima postoperatoria, el abordaje multidisciplinar y la gestión del dolor agudo postoperatorio. Se definen y se describen líneas estratégicas y los distintos modelos de gestión. Se establece un plan de actuación general perioperatoria basado en la colaboración con los servicios quirúrgicos implicados, en la revisión conjunta de la evidencia y en la elaboración de protocolos por procedimiento. Finalmente, se presenta un plan de seguimiento y los indicadores mínimos necesarios para un control de calidad del dolor postoperatorio. (AU)

The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control.The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of acute postoperative pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented. (AU)

Effects of (2R,6R)-hydroxynorketamine in assays of acute pain-stimulated and pain-depressed behaviors in mice.

Ketamine has been shown to produce analgesia in various acute and chronic pain states; however, abuse liability concerns have limited its utility. The ketamine metabolite (2R,6R)-hydroxynorketamine (HNK) has been shown to produce antidepressant-like effects similar to ketamine without abuse liability concerns. (2R,6R)-HNK produces sustained analgesia in models of chronic pain, but has yet to be evaluated in models of acute pain. The present study evaluated the efficacy of acute (2R,6R)-HNK administration (one injection) in assays of pain-stimulated (52- and 56-degree hot plate test and acetic acid writhing) and pain-depressed behavior (locomotor activity and rearing) in male and female C57BL/6 mice. In assays of pain-stimulated behaviors, (2R,6R)-HNK (1-32 mg/kg) failed to produce antinociception in the 52- and 56-degree hot plate and acetic acid writhing assays. In assays of pain-depressed behaviors, 0.56% acetic acid produced a robust depression of locomotor activity and rearing that was not blocked by pretreatment of (2R,6R)-HNK (3.2-32 mg/kg). The positive controls morphine (hot plate test) and ketoprofen (acetic acid writhing, locomotor activity, and rearing) blocked pain-stimulated and pain-depressed behaviors. Finally, the effects of intermittent (2R,6R)-HNK administration were evaluated in 52-degree hot plate and pain-depressed locomotor activity and rearing. Intermittent administration of (2R,6R)-HNK also did not produce antinociceptive effects in the hot plate or pain-depressed locomotor activity assays. These results suggest that (2R,6R)-HNK is unlikely to have efficacy in treating acute pain; however, the efficacy of (2R,6R)-HNK in chronic pain states should continue to be evaluated.

Transcutaneous electrical nerve stimulation for reducing postoperative acute pain after hip fracture surgery: a double-blinded randomized clinical trial.

OBJECTIVE: The aim of this study was to assess the effects of two different applications of transcutaneous electrical nerve stimulation (TENS) on the reduction of postoperative acute pain after hip fracture surgery. PATIENTS AND METHODS: In this study, 120 patients undergoing hip surgery were divided into three groups. The first group received patient-controlled analgesia (PCA) with epidural fentanyl and additional medications. The second group received lumbar plexus and sciatic nerve transcutaneous electrical nerve stimulation (LS-TENS) along with the same medication protocol as the first group. The third group received the same medication protocol as the first group, as well as surgical wound transcutaneous electrical nerve stimulation (SW-TENS). Pain levels were measured using a Visual Analog Scale (VAS) score, and the number of opioid analgesics used by each patient was recorded. VAS score and the total consumption of opioid analgesics were meticulously documented. RESULTS: VAS scores were higher in the control group than in the SW-TENS group at 30 min (1.58±2.49 vs. 0.70±2.15, p<0.05) and in the SW-TENS group than in the LS- TENS group at 24 h postoperatively (2.33±1.29 vs. 1.63±1.05, p<0.05). The 48-h total analgesic consumption level of the control group was higher than that of the LS-TENS group (p<0.05). CONCLUSIONS: The findings of this study indicate that TENS application to the surgical wound, lumbar plexus, and sciatic nerve using anatomical landmarks can significantly reduce postoperative pain, as demonstrated by the higher VAS scores, higher total analgesic consumption and high additional analgesic need in the control group after hip fracture surgery. CLINICALTRIALS: gov ID: NCT02642796.

Challenges of acute pain management in older patients.

Adequate management of acute pain in the older population is crucial. However, it is inherently complex because of multiple physiological changes that significantly impact both the pharmacokinetics and pharmacodynamics of medications. Current guidelines promote paracetamol as the first-line analgesic for acute pain in older adults, whereas opioids are advised cautiously for moderate to severe acute pain. However, opioids come with a significant array of side effects, which can be more pronounced in older individuals. Ketamine administered via intranasal (IN) and nebulised inhalation in the emergency department for managing acute pain in older patients shows promising potential for improving pain management and reducing opioid reliance Kampan, Thong-on, Sri-on (2024, Age Ageing, 53, afad255). Nebulised ketamine appears superior in terms of adverse event incidence. However, the adoption of IN or nebulised ketamine in older adult acute pain management remains unclear because of the lack of definitive conclusions and clear guidelines. Nevertheless, these modalities can be valuable options for patients where opioid analgesics are contraindicated or when intravenous morphine titration is impractical or contraindicated. Here, we review these concepts, the latest evidence and propose avenues for research.

Sex differences in pain catastrophizing and its relation to the transition from acute pain to chronic pain.

BACKGROUND AND IMPORTANCE: Differences exist between sexes in pain and pain-related outcomes, such as development of chronic pain. Previous studies suggested a higher risk for pain chronification in female patients. Furthermore, pain catastrophizing is an important risk factor for chronification of pain. However, it is unclear whether sex differences in catastrophic thinking could explain the sex differences in pain chronification. OBJECTIVES: The aim of this study was to examine sex differences in pain catastrophizing. Additionally, we investigated pain catastrophizing as a potential mediator of sex differences in the transition of acute to chronic pain. DESIGN, SETTINGS AND PARTICIPANTS: Adults visiting one of the 15 participating emergency departments in the Netherlands with acute pain-related complaints. Subjects had to meet inclusion criteria and complete questionnaires about their health and pain. OUTCOMES MEASURE AND ANALYSIS: The outcomes in this prospective cohort study were pain catastrophizing (short form pain catastrophizing) and pain chronification at 90 days (Numeric Rating Scale ≥ 1). Data was analysed using univariate and multivariable logistic regression models. Finally, stratified regression analyses were conducted to assess whether differences in pain catastrophizing accounted for observed differences in pain chronification between sexes. MAIN RESULTS: In total 1,906 patients were included. Females catastrophized pain significantly more than males (p < 0.001). Multiple regression analyses suggested that pain catastrophizing is associated with pain chronification in both sexes. CONCLUSIONS: This study reported differences between sexes in catastrophic cognitions in the development of chronic pain. This is possibly of clinical importance to identify high-risk patients and ensure an early intervention to prevent the transition from acute to chronic pain.

Noninferiority trials in acute pain research: a valid approach or a slippery slope?

The conduct and reporting of studies with a noninferiority hypothesis is challenging because of the complexity involved in their design and interpretation. However, studies with a noninferiority design have increased in popularity. A recently published trial reported on the noninferiority of lidocaine infusion to epidural analgesia in major abdominal surgeries. Apart from needing a critical appraisal, this draws attention to improve our understanding of noninferiority study framework and its unique features. Given the increasing focus on using various analgesic adjuncts and multiple approaches to fascial plane blocks to avoid more definitive and standard approaches, it is imperative that particular attention is paid to appropriate execution and reporting of noninferiority studies.

Long-Acting Drug Delivery Technologies for Meloxicam as a Pain Medicine.

Meloxicam, a selective COX-2 inhibitor, has demonstrated clinical effectiveness in managing inflammation and acute pain. Although available in oral and parenteral formulations such as capsule, tablet, suspension, and solution, frequent administration is necessary to maintain therapeutic efficacy, which can increase adverse effects and patient non-compliance. To address these issues, several sustained drug delivery strategies such as oral, transdermal, transmucosal, injectable, and implantable drug delivery systems have been developed for meloxicam. These sustained drug delivery strategies have the potential to improve the therapeutic efficacy and safety profile of meloxicam, thereby reducing the frequency of dosing and associated gastrointestinal side effects. The choice of drug delivery system will depend on the desired release profile, the target site of inflammation, and the mode of administration. Overall, meloxicam sustained delivery systems offer better patient compliance, and reduce the side effects, thereby improving the clinical applications of this drug. Herein, we discuss in detail different strategies for sustained delivery of meloxicam.

Evoked oscillatory cortical activity during acute pain: Probing brain in pain by transcranial magnetic stimulation combined with electroencephalogram.

Temporal dynamics of local cortical rhythms during acute pain remain largely unknown. The current study used a novel approach based on transcranial magnetic stimulation combined with electroencephalogram (TMS-EEG) to investigate evoked-oscillatory cortical activity during acute pain. Motor (M1) and dorsolateral prefrontal cortex (DLPFC) were probed by TMS, respectively, to record oscillatory power (event-related spectral perturbation and relative spectral power) and phase synchronization (inter-trial coherence) by 63 EEG channels during experimentally induced acute heat pain in 24 healthy participants. TMS-EEG was recorded before, during, and after noxious heat (acute pain condition) and non-noxious warm (Control condition), delivered in a randomized sequence. The main frequency bands (α, ß1, and ß2) of TMS-evoked potentials after M1 and DLPFC stimulation were recorded close to the TMS coil and remotely. Cold and heat pain thresholds were measured before TMS-EEG. Over M1, acute pain decreased α-band oscillatory power locally and α-band phase synchronization remotely in parietal-occipital clusters compared with non-noxious warm (all p < .05). The remote (parietal-occipital) decrease in α-band phase synchronization during acute pain correlated with the cold (p = .001) and heat pain thresholds (p = .023) and to local (M1) α-band oscillatory power decrease (p = .024). Over DLPFC, acute pain only decreased ß1-band power locally compared with non-noxious warm (p = .015). Thus, evoked-oscillatory cortical activity to M1 stimulation is reduced by acute pain in central and parietal-occipital regions and correlated with pain sensitivity, in contrast to DLPFC, which had only local effects. This finding expands the significance of α and ß band oscillations and may have relevance for pain therapies.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update.

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Low-dose ketamine safely reduces acute pain in the ED with a more rapid and shorter effect than morphine.

SOURCE CITATION: Guo J, Zhao F, Bian J, et al. Low-dose ketamine versus morphine in the treatment of acute pain in the emergency department: a meta-analysis of 15 randomized controlled trials. Am J Emerg Med. 2024;76:140-149. 38071883.

Opioids for Acute Musculoskeletal Pain: A Systematic Review with Meta-Analysis.

OBJECTIVE: To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo. STUDY DESIGN: Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h). DATA SOURCES: Multiple databases were searched from their inception to February 22nd, 2023. DATA SYNTHESIS: Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed. RESULTS: We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%). DISCUSSION: Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits. PROSPERO REGISTRATION: CRD42021249346.

Gastrointestinal adverse effects associated with the use of intravenous oliceridine compared with intravenous hydromorphone or fentanyl in acute pain management utilizing adjusted indirect treatment comparison methods.

Background: In the absence of head-to-head comparative data from randomized controlled trials, indirect treatment comparisons (ITCs) may be used to compare the relative effects of treatments versus a common comparator (either placebo or active treatment). For acute pain management, the effects of oliceridine have been compared in clinical trials to morphine but not to fentanyl or hydromorphone. Aim: To assess the comparative safety (specifically differences in the incidence of nausea, vomiting and opioid-induced respiratory depression [OIRD]) between oliceridine and relevant comparators (fentanyl and hydromorphone) through ITC analysis. Methods: A systematic literature review identified randomized clinical trials with oliceridine versus morphine and morphine versus fentanyl or hydromorphone. The ITC utilized the common active comparator, morphine, for the analysis. Results: A total of six randomized controlled trials (oliceridine - 2; hydromorphone - 3; fentanyl - 1) were identified for data to be used in the ITC analyses. The oliceridine data were reported in two studies (plastic surgery and orthopedic surgery) and were also reported in a pooled analysis. The ITC focused on nausea and vomiting due to limited data for OIRD. When oliceridine was compared with hydromorphone in the ITC analysis, oliceridine significantly reduced the incidence of nausea and/or vomiting requiring antiemetics compared with hydromorphone (both orthopedic surgery and pooled data), while results in plastic surgery were not statistically significant. When oliceridine was compared with hydromorphone utilizing data from Hong, the ITC only showed a trend toward reduced risk of nausea and vomiting with oliceridine that was not statistically significant across all three comparisons (orthopedic surgery, plastic surgery and combined). An ITC comparing oliceridine with a study of fentanyl utilizing the oliceridine orthopedic surgery data and combined orthopedic and plastic surgery data showed a trend toward reduced risk that was not statistically significant. Conclusion: In ITC analyses, oliceridine significantly reduced the incidence of nausea and/or vomiting or the need for antiemetics in orthopedic surgery compared with hydromorphone and a non-significant trend toward reduced risk versus fentanyl.

REKOVER study protocol: a pRospective patient treatment rEgistry of tramadol and dexKetoprofen trometamol oral fixed-dose combination (SKUDEXA) in mOderate to seVere acutE pain in Real-world setting in Asia.

INTRODUCTION: Satisfactory management of acute pain remains a major medical challenge despite the availability of multiple therapeutic options including the fixed-dose combination (FDC) drugs. Tramadol and dexketoprofen trometamol (TRAM/DKP) 75/25 mg FDC was launched in 2018 in Asia and is widely used in the management of moderate to severe acute pain. There are limited data on its effectiveness and safety in Asian patients, and therefore, a need to better understand its usage patterns in clinical practice. We aim to understand the usage pattern of TRAM/DKP FDC, its effectiveness and tolerability in patients with moderate to severe acute pain in Asia. METHODS AND ANALYSIS: REKOVER is a phase-IV, multicountry, multicentre, prospective, real-world observational study. A total of 750 postsurgical and non-surgical patients (male and female, aged 18-80 years) will be recruited from 13 tertiary-care hospitals (15 sites) in Singapore, Thailand, the Philippines and Malaysia. All patients prescribed with TRAM/DKP FDC and willing to participate in the study will be enrolled. The recruitment duration for each site will be 6 months. The severity of pain will be collected using Numeric Pain Rating Scale through the treatment period from day 1 to day 5, while satisfaction with the treatment will be evaluated using Patient Global Evaluation Scale at the end of treatment. Any adverse event reported during the study duration will be recorded for safety analysis (up to day 6). The study data will be entered into the ClaimIt portal and mobile application (app) (ObvioHealth, USA). All the inpatient data will be entered into the portal by the study site and for outpatient it will be done by patients through an app. ETHICS AND DISSEMINATION: The study has been approved by the local ethics committee from each study sites in Singapore, Thailand, the Philippines and Malaysia. Findings will be disseminated through local and global conference presentations, publications in peer-reviewed scientific journals and continuing medical education.

Transforaminal Epidural Block and Erector Spinae Plane Block to Manage Acute Zoster-Associated Pain: A Retrospective Case-Control Study.

Background and Objectives: Achieving adequate pain reduction in the acute phase of herpes zoster is essential for preventing postherpetic neuralgia (PHN). For this purpose, appropriate antiviral medications, oral analgesic medications, and various nerve block methods could be applied. Erector spinae plane block (ESPB) is a simple, novel ultrasound-guided block technique, and its use has increased because the procedure is convenient and relatively safe. Although several cases have reported the zoster-associated pain (ZAP) control effect of ESPB, the efficacy of ESPB has not been compared with that of other types of nerve blocks for managing ZAP. This study aimed to compare the efficacy of ESPB with that of other types of nerve blocks for managing ZAP. Study Design: Retrospective case-control study. Materials and Methods: Medical records of 53 patients with acute thoracic herpes zoster were reviewed. We divided the participants into two groups: patients who received transforaminal epidural injection (TFEI) (n = 32) and those who received ESPB (n = 21). The efficacy of the procedure was assessed by a numerical rating scale (NRS) and by recording patient medication doses before the procedure and at 1 week, 1 month, 2 months, and 3 months after the procedure. Results: The time required for pain intensity to decrease to NRS ≤ 2 was not significantly different between the groups. The rate of medication discontinuation also was not different between the groups. There was no significant difference between the two groups in the proportion of clinically significant PHN (NRS ≥ 3) at any time point. Limitations: The relatively small sample size from a single center and the retrospective nature of the study served as limitations. Conclusions: The clinical effects of ESPB and TFEI were similar in patients with acute thoracic herpes zoster. ESPB could be considered an interventional option for ZAP management.

The acute pain crisis in sickle cell disease: What can be done to improve outcomes?

The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.