Local anesthetics and regional anesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children: A Cochrane systematic review and meta-analysis update.

BACKGROUND: Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017. METHODS: We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias. RESULTS: 40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence). CONCLUSIONS: Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children.

BACKGROUND: Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES: To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA: We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS: In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS: We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children.

BACKGROUND: Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES: To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA: We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS: In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS: We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

A noninvasive biomechanical treatment as an additional tool in the rehabilitation of an acute anterior cruciate ligament tear: A case report.

OBJECTIVES: Conservative treatments for anterior cruciate ligament (ACL) tears may have just as good an outcome as invasive treatments. These include muscle strengthening and neuromuscular proprioceptive exercises to improve joint stability and restore motion to the knee. The Purpose of the current work presents was to examine the feasibility of a novel non-invasive biomechanical treatment to improve the rehabilitation process following an ACL tear. This is a single case report that presents the effect of this therapy in a patient with a complete ACL rupture who chose not to undergo reconstructive surgery. METHODS: A 29-year old female athlete with an acute indirect injury to the knee who chose not to undergo surgery was monitored. Two days after injury the patient began AposTherapy. A unique biomechanical device was specially calibrated to the patient's feet. The therapy program was initiated, which included carrying out her daily routine while wearing the device. The subject underwent a gait analysis at baseline and follow-up gait analyses at weeks 1, 2, 4, 8, 12 and 26. RESULTS: A severe abnormal gait was seen immediately after injury, including a substantial decrease in gait velocity, step length and single limb support. In addition, limb symmetry was substantially compromised following the injury. After 4 weeks of treatment, patient had returned to normal gait values and limbs asymmetry reached the normal range. CONCLUSIONS: The results of this case report suggest that this conservative biomechanical therapy may have helped this patient in her rehabilitation process. Further research is needed in order to determine the effect of this therapy for patients post ACL injuries.

Differences in gait pattern parameters between medial and anterior knee pain in patients with osteoarthritis of the knee.

BACKGROUND: Patients with osteoarthritis of the knee have unique spatiotemporal gait alterations. These gait changes have not yet been differentiated according to the location of knee pain. The purpose of this study was to compare the gait patterns of patients with symptomatic knee osteoarthritis that exhibit either anterior or medial joint pain. METHODS: 240 Patients with knee osteoarthritis were evaluated at one therapy center. Patients were divided into two groups according to the location of greatest pain in their worse knee. Patients underwent a computerized spatiotemporal gait analysis. Differences in gait patterns between the two knee pain locations were also examined within each gender. FINDINGS: Compared with patients with pain in the anterior knee compartment, those with pain in the medial knee compartment exhibited a significantly slower walking speed (P<0.01), shorter step length (P<0.01), lower single-limb-support phase (P<0.01). These differences are witnessed mainly between the females in each group, whereas males differed only in single-limb-support. INTERPRETATION: The results of this study suggested underlying gait differences in the nature of medial and anterior knee pain. Furthermore, gender differences in gait may exist between patients with medial knee pain compared to patients with anterior knee pain.

Robotic microsurgery 2011: male infertility, chronic testicular pain, postvasectomy pain, sports hernia pain and phantom pain.

PURPOSE OF REVIEW: The use of robotic assistance during microsurgical procedures has evolved from its early beginnings in the early 2000s. Currently, its use is expanding in the treatment of male infertility and patients with chronic testicular or groin pain. The addition of this technology may allow an improvement in outcomes as when the operating microscope was introduced in microsurgery. However, this is yet to be proven. RECENT FINDINGS: This review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, microsurgical denervation of the spermatic cord for chronic testicular or groin pain, post-vasectomy pain, sports hernia pain, postnephrectomy, donor nephrectomy and phantom groin pain. Preliminary animal studies show an advantage in terms of improved operative efficiency and improved surgical outcomes. Preliminary human clinical studies appear to support these findings. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve early postoperative sperm counts compared to the pure microsurgical technique. SUMMARY: Long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising and evidence is mounting, but further evaluation is warranted.

Video technique for human robot-assisted microsurgical vasovasostomy.

Previous studies have shown that robot-assisted microsurgical vasovasostomy (RAVV) has technical advantages over pure microscopic vasovasostomy (MVV) in animal and human models. This study presents a video technique and initial results for RAVV in 20 human cases compared with 7 MVV cases by a single fellowship-trained microsurgeon from July 2007 to June 2009. A three-layer 10-0 and 9-0 suture anastomosis was performed with up to 22 months follow-up (mean 3 months). Mean operative duration for the RAVV cases was 109 and 128 minutes for MVV (p = 0.09). At 2 months postoperatively, all patients were patent. Mean sperm count was 54 million in RAVV and 11 million in MVV (p = 0.04). The use of robotic assistance in microsurgical vasovasostomy may have potential benefit over MVV in decreasing operative duration and significantly improving early semen analysis measures. Further evaluation and longer follow-up is needed to assess its clinical potential.

Robotic surgery in male infertility and chronic orchialgia.

PURPOSE OF REVIEW: The use of robotic assistance during microsurgical procedures is currently being explored in the treatment of male infertility and patients with chronic testicular pain. Whether the addition of this technology would allow a corresponding improvement in outcomes as when the operating microscope was introduced in microsurgery is yet to be seen. RECENT FINDINGS: The present review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, denervation of the spermatic cord for chronic testicular pain and microsurgical vascular anastomosis. Preliminary animal studies appear to show an advantage in terms of improved operative efficiency and improved surgical outcomes. Preliminary human clinical studies appear to support these findings. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and significantly improve early postoperative sperm counts compared with the pure microsurgical technique. SUMMARY: As with any new technology, long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.

Evidence-based medicine training in residency: a survey of urology programme directors.

OBJECTIVE: To investigate whether and in what format urology residents receive formal training in evidence-based clinical practice. METHODS: In 2007 we conducted a survey of the Accreditation Council for Graduate Medical Education (ACGME)-accredited urology residency programmes in the USA. The survey instrument was sent to all programmes, using postal mailing, e-mail and a web-based interface. Programme director and coordinator names and basic demographic information such as programme size and length were retrieved from the institutions' websites and the ACGME database. RESULTS: Of 117 ACGME-accredited urology programmes, 108 responded (92.3%). Most respondents either agreed or strongly agreed with statements that formal evidence-based medicine (EBM) training was valuable to urology residents (97, 89.8%) and should be part of all residency programme curricula (91, 84.3%). Eighty-four programmes (77.8%) indicated that their curricula included formal educational activities related to EBM. These programmes provided a median (interquartile range) of 10 (4.8-25.0) h of EBM teaching per academic year. Most programmes (65.9%) provided fewer hours of EBM training than programme directors perceived as ideal. Asked what would make it easier to integrate EBM into the programme, respondents identified urology-specific educational materials (33.3%), a formal curriculum (24.4%) and faculty development (16.3%) as central needs. CONCLUSION: In this survey we found that most programme directors recognize formal EBM teaching as an important aspect of urology residency training. However, most programmes devote less time to EBM training than they would like, and urology-specific resources have been lacking. These findings support increased efforts to provide urology residents with opportunities to learn EBM-related knowledge and skills in a variety of educational formats.

Use of MP3 players to increase asthma knowledge in inner-city African-American adolescents.

BACKGROUND: Low-income African-American adolescents suffer a disproportionate burden of asthma morbidity. PURPOSE: To evaluate the ability of our intervention, the Adolescents' Disease Empowerment and Persistency Technology (ADEPT) for asthma, to increase asthma knowledge in our target population. METHODS: This was a 14-week (2-week run-in and 12-week treatment) randomized, double-blind, placebo-controlled pilot study in which 28 inner-city African-American adolescents with asthma, between 10 and 18 years of age, were randomized to receive (1) celebrity asthma messages (experimental group), or (2) general health messages (control group) between music tracks on an MP3 player. The asthma messages were recorded by famous athletes, musicians, and other celebrities popular among this group of teenagers. Asthma knowledge, assessed by the ZAP Asthma Knowledge instrament, was collected pre- and post-intervention. RESULTS: Mean improvement in ZAP score was significantly higher in the experimental group (8.1%, SD 7.2%) than the control group (0.4%, SD 7.2%) (p = 0.05). CONCLUSION: These findings suggest that this may be an innovative and promising new approach to improving asthma outcomes in this difficult-to-reach population.

Comparing interpersonal interactions with a virtual human to those with a real human.

This paper provides key insights into the construction and evaluation of interpersonal simulators--systems that enable interpersonal interaction with virtual humans. Using an interpersonal simulator, two studies were conducted that compare interactions with a virtual human to interactions with a similar real human. The specific interpersonal scenario employed was that of a medical interview. Medical students interacted with either a virtual human simulating appendicitis or a real human pretending to have the same symptoms. In Study I (n = 24), medical students elicited the same information from the virtual and real human, indicating that the content of the virtual and real interactions were similar. However, participants appeared less engaged and insincere with the virtual human. These behavioral differences likely stemmed from the virtual human's limited expressive behavior. Study II (n = 58) explored participant behavior using new measures. Nonverbal behavior appeared to communicate lower interest and a poorer attitude toward the virtual human. Some subjective measures of participant behavior yielded contradictory results, highlighting the need for objective, physically-based measures in future studies.