Using joint probability density to create most informative unidimensional indices: a new method using pain and psychiatric severity as examples.

BACKGROUND: Dimension reduction methods do not always reduce their underlying indicators to a single composite score. Furthermore, such methods are usually based on optimality criteria that require discarding some information. We suggest, under some conditions, to use the joint probability density function (joint pdf or JPD) of p-dimensional random variable (the p indicators), as an index or a composite score. It is proved that this index is more informative than any alternative composite score. In two examples, we compare the JPD index with some alternatives constructed from traditional methods. METHODS: We develop a probabilistic unsupervised dimension reduction method based on the probability density of multivariate data. We show that the conditional distribution of the variables given JPD is uniform, implying that the JPD is the most informative scalar summary under the most common notions of information. B. We show under some widely plausible conditions, JPD can be used as an index. To use JPD as an index, in addition to having a plausible interpretation, all the random variables should have approximately the same direction(unidirectionality) as the density values (codirectionality). We applied these ideas to two data sets: first, on the 7 Brief Pain Inventory Interference scale (BPI-I) items obtained from 8,889 US Veterans with chronic pain and, second, on a novel measure based on administrative data for 912 US Veterans. To estimate the JPD in both examples, among the available JPD estimation methods, we used its conditional specifications, identified a well-fitted parametric model for each factored conditional (regression) specification, and, by maximizing the corresponding likelihoods, estimated their parameters. Due to the non-uniqueness of conditional specification, the average of all estimated conditional specifications was used as the final estimate. Since a prevalent common use of indices is ranking, we used measures of monotone dependence [e.g., Spearman's rank correlation (rho)] to assess the strength of unidirectionality and co-directionality. Finally, we cross-validate the JPD score against variance-covariance-based scores (factor scores in unidimensional models), and the "person's parameter" estimates of (Generalized) Partial Credit and Graded Response IRT models. We used Pearson Divergence as a measure of information and Shannon's entropy to compare uncertainties (informativeness) in these alternative scores. RESULTS: An unsupervised dimension reduction was developed based on the joint probability density (JPD) of the multi-dimensional data. The JPD, under regularity conditions, may be used as an index. For the well-established Brief Pain Interference Inventory (BPI-I (the short form with 7 Items) and for a new mental health severity index (MoPSI) with 6 indicators, we estimated the JPD scoring. We compared, assuming unidimensionality, factor scores, Person's scores of the Partial Credit model, the Generalized Partial Credit model, and the Graded Response model with JPD scoring. As expected, all scores' rankings in both examples were monotonically dependent with various strengths. Shannon entropy was the smallest for JPD scores. Pearson Divergence of the estimated densities of different indices against uniform distribution was maximum for JPD scoring. CONCLUSIONS: An unsupervised probabilistic dimension reduction is possible. When appropriate, the joint probability density function can be used as the most informative index. Model specification and estimation and steps to implement the scoring were demonstrated. As expected, when the required assumption in factor analysis and IRT models are satisfied, JPD scoring agrees with these established scores. However, when these assumptions are violated, JPD scores preserve all the information in the indicators with minimal assumption.

A Functional Restoration Program for Active Duty Service Members With Chronic Pain: Examining the Impact of Co-occurring PTSD on Treatment Response.

INTRODUCTION: Standard medical intervention for chronic pain may be less effective in the presence of co-occurring PTSD. Functional restoration programs (FRPs), which combine psychological interventions and progressive exercise rehabilitation, represent an alternative to standard medical intervention for chronic pain. The objective of the current study is to evaluate a FRP serving Active Duty Service Members with chronic pain and to examine whether co-occurring PTSD symptoms are associated with differential treatment response. METHODS: This is a retrospective observational study of data previously collected at Naval Medical Center San Diego approved by the Naval Medical Center San Diego Institutional Review Board. The study included 81 Active Duty Service Members, primarily Sailors and Marines, who completed a FRP, and examined pre- to post-treatment changes in Pain Impact Score-a composite measure of pain intensity, pain interference, and physical functioning-as well as measures of mental health and pain cognitions. Co-occurring PTSD symptoms were examined as a potential moderator of treatment response. RESULTS: Twenty-three patients (28.4%) screened positive for PTSD during baseline assessments. Repeated measures analysis of variance showed statistically significant improvement in Pain Impact Score for the full sample (P <.001). Although no significant interactions with probable PTSD were demonstrated for measures of pain intensity and physical functioning (both Ps >.05), patients screening positive for PTSD demonstrated a lesser decrease in pain interference compared to patients screening negative for PTSD (P <.01). Improvements in measures of mental health and pain cognitions were also statistically significant for the full sample (all P values <.05) and did not differ as a function of PTSD symptoms (all P values >.05). CONCLUSION: This FRP primarily serving Sailors and Marines contributed to broad overall improvements in the domains of pain and functioning as well as mental health and pain cognitions. Co-occurring PTSD symptoms were not associated with poorer treatment response on most measured outcomes.

Improving door-to-analgesia timing in musculoskeletal injuries in an academic emergency department in India: a quality improvement project.

INTRODUCTION: Pain, more frequently due to musculoskeletal injuries, is a prevalent concern in emergency departments (EDs). Timely analgesic administration is paramount in the acute setting of ED. Despite its importance, many EDs face challenges in pain management and present opportunities for improvement. This initiative aimed to expedite the administration of the first analgesic in patients with musculoskeletal pain in the ED. LOCAL PROBLEM: Observations within our ED revealed that patients with musculoskeletal injuries triaged to yellow or green areas experienced prolonged waiting times, leading to delayed analgesic administration, thereby adversely affecting clinical care and patient satisfaction. SPECIFIC AIM: The aim of our quality improvement (QI) project was to reduce the time to administration of first analgesia by 30% from baseline, in patients with musculoskeletal injuries presenting to our academic ED, in a period of 8 weeks after the baseline phase. METHODS: A multidisciplinary QI team systematically applied Point-of-Care Quality Improvement and Plan-Do-Study-Act (PDSA) cycle methodologies. Process mapping and fishbone analyses identified the challenges in analgesia administration. Targeted interventions were iteratively refined through PDSA cycles. INTERVENTIONS: Interventions such as pain score documentation at triage, fast-tracking of patients with moderate-to-severe pain, resident awareness sessions, a pain management protocol and prescription audits were executed during the PDSA cycles. Successful elements were reinforced and adjustments were made to address the identified challenges. RESULTS: The median door-to-analgesia timing during the baseline phase was 55.5 min (IQR, 25.75-108 min). During the postintervention phase, the median was significantly reduced to 15 min (IQR, 5-37 min), exceeding the anticipated outcomes and indicating a substantial 73% reduction (p value <0.001) from baseline. CONCLUSION: Implementing simple change ideas resulted in a substantial improvement in door-to-analgesia timing within the ED. These findings significantly contribute to ongoing discussions on the optimisation of pain management in emergency care.

Effect of Humor on Pain and Anxiety in Patients With Rheumatoid Arthritis: A Prospective, Randomized Controlled Study.

Humor can contribute to nursing practices for relieving pain and anxiety in patients with rheumatoid arthritis (RA) during intravenous (IV) biologic treatment. This study used a prospective, randomized controlled study design to investigate the effect of humor on pain and state anxiety in patients with RA receiving IV infusion therapy. Two sample groups were formed: the intervention group (watching a comedy movie) (n = 18) and the control group (usual care) (n = 18). Both groups received IV biologic therapy. A significant difference was found between the groups' pain mean scores, but the effect size was small (P < .001, η² = 0.032). The mean visual analog scale scores decreased in both groups after the treatment; however, it decreased more in the intervention group (P < .001, Md = 2.44) than in the control group (P = .017, Md = 0.83). No significant difference was found between the groups' mean state anxiety scores, and the effect size was irrelevant (P > .05, η² = 0.001). There was a significant decrease in the anxiety levels of both groups (P < .001). During IV biologic infusion therapy, watching comedy movies is recommended as a nursing care intervention for reducing pain in patients with RA in cooperation with other health professionals.

Incidence and Risk Factors of Chronic Postoperative Pain in Same-day Surgery: A Prospective Cohort Study.

BACKGROUND: The amount of same-day surgery has increased markedly worldwide in recent decades, but there remains limited evidence on chronic postsurgical pain in this setting. METHODS: This study assessed pain 90 days after ambulatory surgery in an international, multicenter prospective cohort study of patients at least 45 yr old with comorbidities or at least 65 yr old. Pain was assessed using the Brief Pain Inventory. Chronic postsurgical pain was defined as a change of more than 1 point in self-rated average pain at the surgical site between baseline and 90 days, and moderate to severe chronic postsurgical pain was defined as a score greater than 4 in self-rated average pain at the surgical site at 90 days. Risk factors for chronic postsurgical pain were identified using multivariable logistic regression. RESULTS: Between November 2021 and January 2023, a total of 2,054 participants were included, and chronic postsurgical pain occurred in 12% of participants, of whom 93.1% had new chronic pain at the surgical site (i.e., participants without pain before surgery). Moderate to severe chronic postsurgical pain occurred in 9% of overall participants. Factors associated with chronic postsurgical pain were active smoking (odds ratio, 1.82; 95% CI, 1.20 to 2.76), orthopedic surgery (odds ratio, 4.7; 95% CI, 2.24 to 9.7), plastic surgery (odds ratio, 4.3; 95% CI, 1.97 to 9.2), breast surgery (odds ratio, 2.74; 95% CI, 1.29 to 5.8), vascular surgery (odds ratio, 2.71; 95% CI, 1.09 to 6.7), and ethnicity (i.e., for Hispanic/Latino ethnicity, odds ratio, 3.41; 95% CI, 1.68 to 6.9 and for First Nations/native persons, odds ratio, 4.0; 95% CI, 1.05 to 15.4). CONCLUSIONS: Persistent postsurgical pain after same-day surgery is common, is usually moderate to severe in nature, and occurs mostly in patients without chronic pain before surgery.

Pain Intensity and Satisfaction of Pain Relief in Discharged Cancer Patients: A Large Sample Study in China.

BACKGROUND: Many studies have focused on the quality of pain management in hospitalized patients with cancer pain, while what happens after discharge remains unclear. AIM: The purpose of this study was to investigate the pain intensity and satisfaction of pain relief among a large sample of Chinese patients with cancer pain after discharge. DESIGN: Cross-sectional, descriptive, correlational research. SETTINGS AND SAMPLE: ABOUT: 1,013 patients were recruited in a tertiary cancer hospital, and their residence addresses were distributed in 6 geographical regions, including 26 provinces, municipalities, and autonomous regions. METHODS: The 1,013 patients with cancer pain were discharged from the wards of a national cancer hospital in China from July 2020 to October 2021. A nurse in the pain clinic followed the patients based on a whole-process information system and collected the data after the cancer pain patients were discharged. The study methods followed the STROBE guidelines. RESULTS: The average age of 1,013 discharged patients was 61.30 (±12.56) years. Moderate and severe background pain (BGP) was reported in 749 patients (73.94%), and more than 3 instances of breakthrough pain (BTP) in the past 24 hours were reported in 541 patients (53.41%). More severe BGP was associated with more frequent BTP (p < .01). In addition, there were 572 patients (56.47%) whose satisfaction with pain relief was lower than 70%. More severe BGP was associated with a lower satisfaction degree (r = -0.796, p < .01). CONCLUSIONS: Pain among discharged Chinese patients with cancer is poorly managed, and there is a low degree of satisfaction with pain relief. Nurses can do more work to assist cancer patients in managing pain more effectively by ensuring they have a plan to report and manage pain after discharge.

Effect of postoperative intermittent boluses of subcostal quadratus lumborum block on pulmonary function recovery and analgesia after gastrectomy: a randomized controlled clinical trial.

BACKGROUND: Following the gastrectomy, the reduction in pulmonary function is partly attributed to postoperative pain. Subcostal quadratus lumborum block (QLB) has recently emerged as a promising component in multimodal analgesia. We aimed to assess the impact of intermittent boluses of subcostal QLB on pulmonary function recovery and analgesic efficacy after gastrectomy. METHODS: Sixty patients scheduled for gastrectomy were randomly assigned to either control group (multimodal analgesia) or intervention group (intermittent boluses of subcostal QLB plus multimodal analgesia). Two primary outcomes included the preservation of forced expiratory volume in the first second (FEV1) and the pain scores (0-10 cm visual analog score) on coughing 24 h postoperatively. We assessed the pulmonary function parameters, pain score, morphine consumption and number of rescue analgesia at a 24-h interval up to 72 h (Day1, Day2, Day3 respectively) as secondary outcomes. RESULTS: 59 patients were analyzed in a modified intention-to-treat set. The preservation of FEV1 (median difference: 4.0%, 97.5% CI: -5.7 to 14.9, P = 0.332) and pain scores on coughing (mean difference: 0.0 cm, 97.5% CI: -1.1 to 1.2, P = 0.924) did not differ significantly between two groups. In the intervention group, the recovery of forced vital capacity (FVC) was faster 72 h after surgery (interaction effect of group*(Day3-Day0): estimated effect (ß) =0.30 L, standard error (SE) =0.13, P = 0.025), pain scores at rest were lower in the first 3 days (interaction effect of group*(Day1-Day0): ß = - 0.8 cm, SE = 0.4, P = 0.035; interaction effect of group*(Day2-Day0): ß = - 1.0 cm, SE = 0.4, P = 0.014; and interaction effect of group*(Day3-Day0): ß = - 1.0 cm, SE = 0.4, P values = 0.009 respectively), intravenous morphine consumption was lower during 0-24 h (median difference: -3 mg, 95% CI -6 to -1, P = 0.014) and in total 72 h (median difference: -5 mg, 95% CI -10 to -1, P = 0.019), and the numbers of rescue analgesia was fewer during 24-48 h (median difference: 0, 95% CI 0 to 0, P = 0.043). Other outcomes didn't show statistical differences. CONCLUSION: Postoperative intermittent boluses of subcostal QLB did not confer advantages in terms of the preservation of FEV1 or pain scores on coughing 24 h after gastrectomy. However, notable effects were observed in analgesia at rest and FVC recovery.

Prevalence of Pain With Movement in Active Duty US Army Soldiers.

INTRODUCTION: Soldiers must be able to perform a multitude of physically demanding tasks as part of their regular duty, but their physical readiness is often degraded due to pain and musculoskeletal injury (MSKI). The presence of pain with movement has been associated with increased MSKI risk in Soldiers. Improved awareness of the prevalence of painful movements in uninjured Soldiers could help inform Army injury mitigation efforts. The purpose of this study was to identify the prevalence of pain with movement in a population of healthy active duty Soldiers. MATERIALS AND METHODS: The Selective Functional Movement Assessment-Top Tier Movements (SFMA-TTM), active range of motion (AROM) of the hips and shoulders, and the elicitation of pain with movement were measured in 268 healthy US Army Soldiers. Descriptive statistics were generated for the number of painful movements for each measure and inferential statistics; independent t-test and one-way independent analysis of variance (ANOVA) were used for analysis of the other measures. RESULTS: Greater than half (59%) of the participants reported pain with at least 1 movement and more than 41% reported pain with 2 or more movements. Soldiers reported a mean of 1.35 painful movements on the SFMA-TTM assessment and a mean of 1.54 painful AROM movements. CONCLUSIONS: Pain with functional movement patterns was common across a sample of uninjured Soldiers. The presence of pain with movement warrants further evaluation as it may impact a Soldier's physical performance, risk for future injury, and overall quality of life.

Quadratus lumborum block vs. transversus abdominis plane block for postoperative pain control in patients with nephrectomy: A systematic review and network meta-analysis.

STUDY OBJECTIVE: This systematic review and network meta-analysis aimed to compare the analgesic efficacy of transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) on nephrectomy. DESIGN: Systematic review and network meta-analysis. PATIENTS: Patients undergoing nephrectomy. INTERVENTIONS: TAPB and QLB for postoperative analgesia. MEASUREMENTS: The primary outcome was 24 h morphine-equivalent consumptions after surgery. Secondary outcomes included postoperative pain scores, postoperative opioid consumption, postoperative rescue analgesia, postoperative nausea and vomiting (PONV), length of hospital stay after surgery, and patient satisfaction. MAIN RESULTS: Fourteen studies involving 883 patients were included. Seven studies compared TAPB to control, six studies compared QLB to control, and one study compared TAPB to QLB. For direct meta-analysis of the post-surgical 24 h morphine-equivalent consumption, QLB was lower than control (mean difference [95%CI]: -18.16 [-28.96, -7.37]; I2 = 88%; p = 0.001), while there was no difference between TAPB and control (mean difference [95%CI]: -8.34 [-17.84, 1.17]; I2 = 88%; p = 0.09). Network meta-analysis showed similar findings that QLB was ranked as the best anesthetic technique for reducing postoperative 24 h opioid consumption (p-score = 0.854). Moreover, in direct meta-analysis, as compared to control, the time of first postoperative rescue analgesia was prolonged after QLB (mean difference [95%CI]: 165.00 [128.99, 201.01]; p < 0.00001), but not TAPB (mean difference [95%CI]: 296.82 [-91.92, 685.55]; p = 0.13). Meanwhile, QLB can effectively reduce opioid usages at intraoperative period, as well as at postoperative 6 h and 48 h, while TAPB can only reduce opioid consumption at 6 h after surgery. As compared to control, both TAPB and QLB exhibited the reduction in PONV and pain scores at post-surgical some timepoints. Also, QLB (mean difference [95%CI]: -0.29 [-0.49, -0.08]; p = 0.006) but not TAPB (mean difference [95%CI]: 0.60 [-0.25, 1.45]; p = 0.17) exhibited the shorter postoperative length of hospital stay than control. CONCLUSIONS: QLB is more likely to be effective in reducing postoperative opioid use than TAPB, whereas both of them are superior to control with regard to the reduction in postoperative pain intensity and PONV. TRIAL REGISTRATION: PROSPERO identifier: CRD42022358464.

Depressive Symptoms, Sleep Quality, and Pain Are Associated With Frailty in Nursing Home Residents During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has caused severe effects on older adults. Depressive symptoms, poor sleep quality, and pain are common in older adults with frailty. However, it is unknown the relationship between these symptoms and frailty in nursing home residents and the difference of importance between pain intensity and pain impact on frailty during the COVID-19 Pandemic. Therefore, this study aims to explore the associations between depressive symptoms, poor sleep quality, pain intensity, and pain impact with frailty in older adults living in nursing homes. METHODS: In this cross-sectional population-based study, 172 older adults living in nursing homes from Changsha in China were included. We collected data on depressive symptoms, sleep quality, pain, and frailty using the Patient Health Questionnaire, the Pittsburgh Sleep Quality, the Brief Pain Inventory-short form, and the FRAIL-NH Scale. Generalized linear regression models were used to explore the interaction association between these symptoms with frailty. RESULTS: Most older adults were between 80 and 90 years old. Approximately 11.6% of older adults experienced one of the following symptoms: depressive symptoms, poor sleep quality, pain intensity, or pain impact. Moreover, 76.7% of older adults experienced at least two of these symptoms. The most common overlapping symptoms were depressive symptoms and poor sleep quality (14.5%). Among nursing home residents, the most common sites of pain were the lower limbs, followed by the back. There was a strong correlation between depressive symptoms, sleep quality, pain intensity, pain impact, and frailty. After adjusting for covariates, the interaction term between any two or three symptoms of depressive symptoms, poor sleep quality, pain intensity, and pain impact was found to be associated with a higher likelihood of frailty in older adults residing in nursing homes (p< .05). CONCLUSIONS: Depressive symptoms, poor sleep quality, pain intensity, and pain impact are common among nursing home residents. Furthermore, these symptoms interacted with each other. In future studies, multidisciplinary interventions aimed at releasing these symptoms and reducing the adverse outcome of frailty are needed.

The management of paediatric acute pain in Spain in 2021: Results of a national survey among paediatric anaesthesiologists.

OBJECTIVE: To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain. METHODS: A 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. RESULTS: The 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. CONCLUSIONS: The survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients.

Pain Predictors in Patients in the Postanesthesia Care Unit.

PURPOSE: To analyze the effects of pain-predicting factors on patients in the postanesthesia care unit (PACU). DESIGN: This is an observational and prospective study. METHODS: This study was conducted at a University Hospital in the state of Minas Gerais (Brazil). To collect data on demographic, clinical, and surgical factors, a collection instrument was devised. The verbal numerical scale was employed to measure pain levels before and after surgery in the PACU. A path analysis was used to assess a predictive model. FINDINGS: A total of 226 patients were included in this study. The incidence of pain in the PACU was 31.9%. A model with demographic, clinical, and surgical variables was tested. The final model, after including modification indices, obtained results that indicated an acceptable data fit (comparative fit index = 0.996; root mean square error of approximation = 0.08). Age (being young), sex (being a woman), oncological diagnosis as an indication for the surgical procedure, type of surgery (surgery of the digestive system), duration of surgery (longer surgeries), and high intraoperative doses of opioids were predictive variables for pain in the PACU. CONCLUSIONS: This study's findings provide support for pain management in the PACU. Furthermore, the results of this research can be used to anticipate the occurrence of acute postoperative pain and personalized perioperative analgesia needs.

Relation of Early Mobility With Gastrointestinal Symptoms and Pain in Patients Undergoing Abdominal Surgery.

PURPOSE: The purpose of this study was to examine the relation of mobility with abdominal symptoms and pain in patients undergoing abdominal surgery. DESIGN: The study has a prospective, correlational design. METHODS: The study sample included 130 patients who underwent abdominal surgery. Data were gathered with a sociodemographic and clinical features form, the Patient and Observer Mobility Scale, a patient mobility checklist, the Gastrointestinal Symptom Rating Scale, and the Numeric Pain Rating Scale. Higher scores on the Gastrointestinal Symptom Rating Scale show more severe symptoms (max scores: 21 on abdominal pain, 14 on reflux, 21 on diarrhea, 28 on distension, and 21 on constipation). The frequency of mobility and the severity of pain was evaluated from the postoperative first day until discharge. Gastrointestinal symptoms were evaluated on the postoperative seventh day. FINDINGS: The mean time elapsing till the first postoperative mobility was 22.13 ± 0.57 hours. The mean score was 7.61 ± 0.19 on abdominal pain, 11.94 ± 0.23 on distension, 2.04 ± 0.32 on reflux, 5.02 ± 0.32 on diarrhea, and 4.65 ± 0.24 on constipation. As the difficulty in mobility increased, the frequency of patient mobility decreased, and pain severity increased. As the difficulty in mobility increased, so did the duration of abdominal pain, diarrhea, indigestion, reflux, and time elapsing until the first intestinal gas passed after surgery. As the frequency of mobility increased, abdominal pain, diarrhea, and time elapsing till the first intestinal gas after surgery decreased. CONCLUSIONS: The results of the study showed that increased mobility had a positive relationship with the reduction of gastrointestinal symptoms and pain. Therefore, interventions directed toward increasing patient mobility should be performed.

Patient Expectations of Pain Versus Experienced Expectations of Pain Following Shoulder Injection.

PURPOSE: Corticosteroids, platelet-rich plasma, and hyaluronic acid injections to either the subacromial space (SAS) or the glenohumeral joint (GHJ) of the shoulder are commonly used for diagnostic and therapeutic purposes in outpatient settings. The first aim of this study was to determine whether the anticipated pain level differed significantly from the actual pain level experienced by patients who underwent shoulder injections. The second aim was to determine whether there was a significant difference in these pain levels between SAS and GHJ injections. The secondary goal was to investigate the correlation between patients' demographic data, anxiety characteristics, and pain scores. DESIGN: Prospective clinical study. METHODS: This study involved patients who completed a three-part questionnaire prior as well as following an injections to the GHJ\SAS. FINDINGS: Sixty-three patients (28 males; 35 females), mean age of 54.28 years (standard deviation 13.95, range 25 to 84) met the inclusion criteria. There was a significant difference between the anticipated and the experienced pain (visual analog score 6.03 vs 3.17, P < .001). Experienced pain of the GHJ injections (n = 34) was rated as being greater than that of the SAS injections (n = 29) with borderline significance (visual analog scale 3.79 vs 2.36; P = .05). Forty-five patients (71.42%) reported a decrease in at least one pain category between anticipated and experienced pain compared to an increase reported by two patients (3.17%). CONCLUSIONS: Injections to the GHJ and SAS were shown to be significantly less painful than anticipated by the patients. GHJ injections were perceived as more painful than SAS injections. Communicating this evidence-based reassuring information with patients prior to an injection may alleviate fear of the procedure, reduce the perception of pain, and ultimately improve compliance with the procedure.

Full endoscopic versus open discectomy for sciatica: randomised controlled non-inferiority trial.

OBJECTIVE: To assess whether percutaneous transforaminal endoscopic discectomy (PTED) is non-inferior to conventional open microdiscectomy in reduction of leg pain caused by lumbar disc herniation. DESIGN: Multicentre randomised controlled trial with non-inferiority design. SETTING: Four hospitals in the Netherlands. PARTICIPANTS: 613 patients aged 18-70 years with at least six weeks of radiating leg pain caused by lumbar disc herniation. The trial included a predetermined set of 125 patients receiving PTED who were the learning curve cases performed by surgeons who did not do PTED before the trial. INTERVENTIONS: PTED (n=179) compared with open microdiscectomy (n=309). MAIN OUTCOME MEASURES: The primary outcome was self-reported leg pain measured by a 0-100 visual analogue scale at 12 months, assuming a non-inferiority margin of 5.0. Secondary outcomes included complications, reoperations, self-reported functional status as measured with the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery. Outcomes were measured until one year after surgery and were longitudinally analysed according to the intention-to-treat principle. Patients belonging to the PTED learning curve were omitted from the primary analyses. RESULTS: At 12 months, patients who were randomised to PTED had a statistically significantly lower visual analogue scale score for leg pain (median 7.0, interquartile range 1.0-30.0) compared with patients randomised to open microdiscectomy (16.0, 2.0-53.5) (between group difference of 7.1, 95% confidence interval 2.8 to 11.3). Blood loss was less, length of hospital admission was shorter, and timing of postoperative mobilisation was earlier in the PTED group than in the open microdiscectomy group. Secondary patient reported outcomes such as the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery, were similarly in favour of PTED. Within one year, nine (5%) in the PTED group compared with 14 (6%) in the open microdiscectomy group had repeated surgery. Per protocol analysis and sensitivity analyses including the patients of the learning curve resulted in similar outcomes to the primary analysis. CONCLUSIONS: PTED was non-inferior to open microdiscectomy in reduction of leg pain. PTED resulted in more favourable results for self-reported leg pain, back pain, functional status, quality of life, and recovery. These differences, however, were small and may not reach clinical relevance. PTED can be considered as an effective alternative to open microdiscectomy in treating sciatica. TRIAL REGISTRATION: NCT02602093ClinicalTrials.gov NCT02602093.

Subgrouping of Peripheral Neuropathic Pain Patients According to Sensory Symptom Profile Using the Korean Version of the PainDETECT Questionnaire.

BACKGROUND: A culturally validated Korean version of the PainDETECT Questionnaire (PD-Q) was used to identify neuropathic pain components (NeP) in patients suffering from chronic pain. The purpose of this study was to determine if the Korean PD-Q can be used to subgroup patients with peripheral NeP according to sensory symptom profiles. METHODS: This study included 400 Korean patients with peripheral neuropathic pain diagnosed as probable or definite NeP. The total scores and subscores for each item in PD-Q were transformed into a Z-score for standardization. Hierarchical cluster analysis was performed to identify clusters of subjects by PD-Q scores. RESULTS: The mean total PD-Q score of the study participants was 14.57 ± 6.46. A hierarchical cluster analysis identified 5 clusters with distinct pain characteristic profiles. Cluster 1 had relatively severe burning and tingling sensations. The mean total PD-Q score for cluster 2 was the lowest of the 5 clusters. Cluster 3 tended to be vulnerable to pain in response to cold/heat stimulation. Cluster 4 showed relatively severe pain induced by physical stimuli, such as light touch or slight pressure. Cluster 5 had high scores for all NeP symptoms. CONCLUSION: This study demonstrates the ability of patients to cluster by symptoms using the Korean PD-Q. Subgrouping of peripheral neuropathic pain by sensory symptom profile may be useful in making effective drug treatment decisions.

Effects of rTMS and tDCS on neuropathic pain after brachial plexus injury: a randomized placebo-controlled pilot study.

Neuropathic pain after brachial plexus injury (NPBPI) is a highly disabling clinical condition and is increasingly prevalent due to increased motorcycle accidents. Currently, no randomized controlled trials have evaluated the effectiveness of non-invasive brain stimulation techniques such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) in patients suffering from NPBPI. In this study, we directly compare the efficacy of 10-Hz rTMS and anodal 2 mA tDCS techniques applied over the motor cortex (5 daily consecutive sessions) in 20 patients with NPBPI, allocated into 2 parallel groups (active or sham). The order of the sessions was randomised for each of these treatment groups according to a crossover design and separated by a 30-day interval. Scores for "continuous" and "paroxysmal" pain (primary outcome) were tabulated after the last stimulation day and 30 days after. Secondary outcomes included the improvement in multidimensional aspects of pain, anxiety state and quality of life from a qualitative and quantitative approach. Active rTMS and tDCS were both superior to sham in reducing continuous (p < 0.001) and paroxysmal (p = 0.002; p = 0.02) pain as well as in multidimensional aspects of pain (p = 0.001; p = 0.002) and anxiety state (p = < 0.001; p = 0.005). Our results suggest rTMS and tDCS are able to treat NPBPI with little distinction in pain and anxiety state, which may promote the use of tDCS in brachial plexus injury pain management, as it constitutes an easier and more available technique.Clinical Trial Registration: http://www.ensaiosclinicos.gov.br/, RBR-5xnjbc - Sep 3, 2018.

ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries.

OBJECTIVES: To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment" (ABCDEF) bundle. DESIGN: Online surveys conducted between 2017 and 2019. SETTING: One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. CONCLUSIONS: ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.