Optimal Perioperative Pain Management of the Transgender Patient for Gender Affirming Surgery: A Scoping Review.

INTRODUCTION: As we increasingly encounter transgender patients in the perioperative setting, it is important to be cognizant of appropriate medical management of the transgender patient. There is limited literature on the appropriate perioperative techniques to implement for adequate pain control in the transgender patient presenting for gender affirming procedures. METHODS: In this scoping review, the authors identify publications that address perioperative pain control techniques that can be implemented by the anesthesiologist such as regional anesthesia, multimodal medications, or non-pharmacologic modalities. RESULTS: This scoping review included two retrospective reviews, two case reports, and one letter to the editor. There are no prospective, randomized controlled trials on this topic. The limitations of this scoping review include the limited publications that are available to analyze as this is a growing area of medicine. CONCLUSION: There are numerous variables that may play a factor in the pain experience of the transgender patient including biological factors, psychological and social factors. Techniques that are necessary for comprehensive pain management include pharmacologic, injections, physical therapy, acupuncture, massage, and more. There are limited publications on the comprehensive pain management of the transgender patient; therefore, the authors advocate that as perioperative physicians, anesthesiologists implement comprehensive preemptive analgesia techniques to avoid progression to chronic pain. Clearly more research is necessary to standardize acute pain management techniques in the transgender patient.

The Use of Telemedicine in Outpatient Pain Management: A Scoping Review.

BACKGROUND: Telemedicine is an increasingly important tool in outpatient pain management. Telemedicine can be implemented through various strategies and a multitude of approaches have been described in existing literature. OBJECTIVES: This scoping review aims to survey how telemedicine has been approached in published literature, providing insight for continued implementation. STUDY DESIGN: Scoping review. SETTING: Outpatient pain management. METHODS: Ovid MEDLINE and Embase databases were queried. Two board-certified pain management physicians screened search results for relevant publications based on predetermined criteria. Included publications focused on outpatient pain management via live video or telephone and reported empirical outcomes. Publications were excluded that focused on acute pain, progressive muscle relaxation, physical therapy, or psychiatry, including cognitive behavioral therapy, or that primarily described educational modules, apps, mobile tracking, or automated calls. Nonfull publications (abstracts) and articles not available in English were also excluded. A third reviewer performed full-text screening, extracting variables of interest. Systematic reviews and meta-analyses were excluded from final selection. RESULTS: Text and abstract screening of 3,302 results yielded 88 publications. Upon full-text screening, 64 additional publications were excluded, yielding 24 publications. High-quality randomized controlled trials (RCTs) were described in 5 (21%) publications, pilot RCTs in 4 (17%), prospective studies in 1 (4%), retrospective studies in 5 (21%), survey-based studies in 7 (29%), and other types of studies in 2 (8%). Cancer pain was the focus of 3 (13%) studies, headache/facial pain the focus of 4 (17%), musculoskeletal the focus of 3 (13%), and unspecified chronic pain the focus of 14 (58%). Patient experiences were the focus of 18 (75%) publications, provider experiences the focus of 2 (8%), and both patient and provider experiences the focus of 4 (17%). Outcome improvement measures were studied in 17 (71%) publications, process improvement measures in 5 (21%), and both types of measures in 2 (8%). Standard visits without on-site support were described in 4 (17%) publications, while standard visits with on-site support were described in 9 (38%). The remaining 11 (46%) described structured/integrated pain management programs. Positive pain-related outcomes were reported in 9 (38%) studies. Increased access or decreased barriers to care were reported in 9 (38%). Patient satisfaction was reported in 12 (50%) publications, with 10 (42%) describing positive results. LIMITATIONS: This scoping review focused on telemedicine delivered via telephone or live video communication, excluding a substantial body of literature focused on virtual courses, modules, and other telehealth programs not involving live communication. CONCLUSIONS: Current literature describes telemedicine implementation with various levels of technological and logistical support. Models of telemedicine represented in current literature include: standard visits with on-site support, standard visits without on-site support, and structured/integrated pain management programs. Presently, no literature has directly compared outcomes from these different approaches. Choice of model will depend on the specific goals and available resources. Patient satisfaction was studied most frequently and generally demonstrated positive results. Though current literature is heterogeneous and lacks RCTs, it consistently demonstrates benefits of telemedicine to patient satisfaction, pain, and access to care.

Chronic opioid use and mortality outcomes in patients admitted with COVID-19: A retrospective cohort study.

BACKGROUND: We hypothesized that chronic opioid users would likely have worse outcomes with COVID-19 infection. METHODS: A retrospective review of electronic medical records was conducted for all COVID-19 patients admitted in two large academic hospitals in New York City from March 1, 2020 to June 30, 2020 during the onset of the COVID-19 pandemic. A total of 1,361 patients (1,289 opioid naïve patients, 72 with chronic opioid use) were included. A propensity score matched analysis was used to create a dataset. A logistic regression using the generalized estimating equations method was used to evaluate oxygen requirements including bilevel positive airway pressure (BiPAP), high flow nasal cannula (HFNC), and mechanical ventilation (MV). Cox models with random match pairs were fitted for time spent until hospital discharge and in-hospital mortality. RESULTS: The propensity score matched analysis did not demonstrate a significant difference between the chronic opioid use group vs the opioid naïve group for the use of oxygen support (p = 0.439), BiPAP (p = 0.377), HFNC (p = 0.978), or MV (p = 0.080), and length of stay (LOS) (p = 0.950). There was also no statistically significant finding for reduced need for MV (odds ratio 0.42, 95 percent CI: 0.16-1.11, p = 0.080) and lower in-hospital mortality (hazard ratio 0.75, 95 percent CI: 0.39-1.43, p = 0.378) in the chronic opioid use group; however, future larger studies will be needed. CONCLUSIONS: Our study did not demonstrate a significant difference in outcomes in patients with COVID-19 with preadmission chronic opioid use vs opioid naïve patients in oxygen requirements, LOS, MV, or mortality. Future studies are needed to further illustrate the impact of opioids on COVID-19 outcomes.

Sentiment analysis of pain physician reviews on Healthgrades: a physician review website.

INTRODUCTION: There are currently no published studies using patient reviews of pain physicians to quantitatively assess patient preferences for pain physician attributes. The aim of the present study was to use natural language processing to quantitatively analyze patient reviews of pain physicians by determining the effect of physician demographics and word frequency on positive review outcomes. METHODS: Using a peer-reviewed algorithm, online Healthgrades reviews of pain physicians practicing in the USA were scored according to their positive sentiment from -1 to 1. These sentiment scores and star ratings were used to compare physicians by age, gender and region of practice. Frequency analysis of words and bigrams was performed for all reviews. RESULTS: There were 15 101 reviews collected among 1275 pain physicians which showed male physicians received higher star ratings and review sentiment scores than female physicians. Pain physicians younger than 55 years received higher star ratings and sentiment scores than those of 55 years and older. Frequency analysis revealed that words most commonly used in the more positive patient reviews included 'care', 'professional', 'patient', 'help' and 'kind'; the words most commonly used in less positive reviews included 'pain', 'back', 'office', 'time' and 'years'. CONCLUSIONS: Male and/or younger pain physicians receive more positive reviews. Patients highly rate pain physicians who are perceived as personable. Patients lowly rate physicians who are perceived as providing ineffective treatment of their pain as well as when they experience barriers to their access to care.

A Cross-sectional Study of the Social Media Presence of ACGME-Accredited Pain Medicine Fellowship Programs: Time to Get Online?

BACKGROUND: Approximately 70% of Americans use social media platforms, and use of specific platforms, such as Instagram, Twitter, Snapchat, and TikTok, is especially common among adults under 30. The presence of social media accounts among residency and fellowship programs in academic medicine has been used to connect with other specialties, highlight achievements and research, disseminate information to the general public, and as a recruiting tool for applicants. OBJECTIVES: The objective of this cross-sectional study was to evaluate the social media presence, specifically on Twitter and Instagram, of the Accreditation Council for Graduate Medical Education (ACGME)-accredited Pain Medicine fellowship programs. We hypothesized that programs with more fellows were more likely to have a social media presence, as well as more content pertaining to branding for recruitment purposes. STUDY DESIGN: A cross-sectional study observing the social media presence of ACGME- accredited Pain Medicine fellowship programs. METHODS: Two independent reviewers conducted searches for corresponding official pain programs and departmental accounts on Twitter and Instagram over the period of July 1, 2020 to June 31, 2021. For all social media accounts identified, number of posts (total and within the study period), followers, and date of first post were recorded. Each post was categorized as medical education, branding, or social. RESULTS: Of the 111 ACGME-accredited Pain Medicine fellowship programs, 4 (3.6%) had both Twitter and Instagram accounts,10 (9%) only Twitter, 7 (6.3%) only Instagram, and 90 (81.1%) had neither. A significant association between the number of fellows and the odds of having an Instagram, but not Twitter, fellowship account was found (odds ratio 1.38, 95% confidence interval [CI]: 1.02,1.88; P = 0.038). Also, a linear relationship existed between the number of followers and tweets (B coefficient 3.7, 95% CI: 3.6, 3.8; P < 0.001). LIMITATIONS: Limitations include that the data were collected during the COVID-19 pandemic, which may correlate to increased likelihood of social media usage. We were also limited by our ability to find all of the pain management fellowship program accounts on social media. CONCLUSIONS: Less than 20% of the pain fellowship programs are currently utilizing Twitter and/or Instagram. When compared to primary anesthesiology residencies, social media presence among pain fellowships is much lower. By utilizing basic social media strategies, including image-based content posting, hashtags, and videos, programs can increase their engagement with the social media community, and increase their overall number of followers, thus expanding their potential reach to prospective applicants. Although social media can be an effective tool for branding purposes, it is vital to address the safe use of social media among all trainees.

Preoperative Renal Insufficiency: Underreporting and Association With Readmission and Major Postoperative Morbidity in an Academic Medical Center.

BACKGROUND: Making a formal diagnosis of chronic kidney disease (CKD) in the preoperative setting may be challenging because of lack of longitudinal data. We explored the predictive value of a single reduced preoperative estimated glomerular filtration rate (eGFR) value on adverse patient outcomes in the first 30 days after elective surgery. We compared the rate of major postoperative adverse events, including 30-day readmission rate, hospital length of stay, infection, acute kidney injury (AKI), and myocardial infarction across patients with declining preoperative eGFR values. We hypothesized that there is an association between decreasing preoperative eGFR values and major postoperative morbidity including readmission within 30 days of discharge and that the reasons for unplanned readmissions may be associated with poor preoperative renal function. METHODS: This was a retrospective analysis of the electronic health record of 39 989 adult patients who underwent elective surgery between June 2011 and July 2013 at our institution. Patients with reduced eGFR (<60 mL/min/1.73 m) were identified and categorized by the stages of CKD that correlated with the preoperative eGFR value. Odds of readmission to our hospital within 30 days, as well as new diagnosis of AKI, myocardial infarction, and infection, were determined with multivariate logistic regression. The subset of patients who were readmitted within 30 days also were subdivided further into patients who had an eGFR <60 mL/min/1.73 m and those with an eGFR ≥60 mL/min/1.73 m, as well as whether the readmission was planned or unplanned. RESULTS: Of the 4053 patients with eGFR <60 mL/min/1.73 m, 3290 (81.2%) did not carry a preoperative diagnosis of CKD. Adjusted odds ratios of being readmitted were 1.48 (99% confidence interval [CI], 1.18-1.87; P < .001) for eGFR 30 to 44 mL/min/1.73 m to 2.06 (99% CI, 1.32-3.23; P < .001) for eGFR <15 mL/min/1.73 m compared with patients with a preoperative eGFR value ≥60 mL/min/1.73 m. Patients with a lower eGFR also demonstrated increasing odds of AKI from 2.78 (99% CI, 1.86-4.17; P < .001) for eGFR 45 to 59 mL/min/1.73 m to 3.81 (99% CI, 1.68-8.16; P < .001) for eGFR <15 mL/min/1.73 m. CONCLUSIONS: This study highlights that preoperative renal insufficiency may be underreported and appears to be significantly associated with postoperative complications. It extends the association between a single low preoperative eGFR and postoperative morbidity to a broader range of surgical populations than previously described. Our results suggest that preoperative calculation of eGFR may be a relatively low-cost, readily available tool to identify patients who are at an increased risk of readmission within 30 days of surgery and postoperative morbidity in patients presenting for elective surgery.

Analgesic Effect of Recombinant GABAergic Cells in a Model of Peripheral Neuropathic Pain.

Chronic neuropathic pain represents a clinically challenging state with a poor response to current treatment options. Long-term management of chronic pain is often associated with the development of tolerance, addiction, and other side effects, reducing the therapeutic value of treatment. Alternative strategies based on cell therapy and gene manipulation, balancing the inhibitory and excitatory events in the spinal cord, may provide sustained pain relief in the long term. Transplantation of GABAergic cells has been successfully used to enhance inhibition and to restore physiological spinal pain processing. However, since the underlying mechanism of chronic pain development involves changes in several pain-signaling pathways, it is essential to develop an approach that targets several components of pain signaling. Recombinant cell therapy offers the possibility to deliver additional analgesic substances to the restricted area in the nervous system. The current study explores the analgesic potential of genetically modified rat embryonic GABAergic cells releasing a peptidergic NMDA receptor antagonist, Serine(1)-histogranin (SHG). Overactivation of glutamate NMDA receptors contributes to the hyperexcitability of spinal neurons observed in chronic pain models. Our approach allows us to simultaneously target spinal hyperexcitability and reduced inhibitory processes. Transplantable cells were transduced by viral vectors encoding either one or six copies of SHG cDNAs. The analgesic potential of recombinant cells after their intraspinal transplantation was evaluated in a model of peripheral nerve injury. Enhanced reduction of hypersensitivity to thermal and mechanical stimuli was observed in animals treated by recombinant cells compared to the nonrecombinant group. The recombinant peptide was detected in the spinal tissue, suggesting its successful production by transplanted cells. Our results demonstrate the feasibility of using recombinant cells releasing adjunct analgesic peptides in the therapy of neuropathic pain.