Abdominal Pain in Inflammatory Bowel Disease: An Evidence-Based, Multidisciplinary Review.

Abdominal pain is one of the most common and impactful symptoms associated with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. A great deal of research has been undertaken over the past several years to improve our understanding and to optimize management of this issue. Unfortunately, there is still significant confusion about the underlying pathophysiology of abdominal pain in these conditions and the evidence underlying treatment options in this context. There is also a relative paucity of comprehensive reviews on this topic, including those that simultaneously evaluate pharmacological and nonpharmacological therapeutic options. In this review, our multidisciplinary team examines evidence for various currently available medical, surgical, and other analgesic options to manage abdominal pain in IBD.

Preparing for the future of medical education: A case series of traditional and virtual clinical rotations in addiction medicine spanning the COVID pandemic.

Background: Substance use accounts for more than 400,000 deaths annually in the United States and overdose rates surged during the COVID pandemic. While the pandemic created increased pressure for better prepared providers, it simultaneously placed restrictions on medical training programs. The purpose of this educational case series is to assess the feasibility of a virtual addiction medicine training program and conduct a qualitative evaluation of medical student attitudes toward caring for people with substance use disorders, both before and after their addiction medicine training experience. Methods: We conducted a qualitative analysis related to course content focused on strengths and limitations of in-person and virtual training modalities. Individual quotes were evaluated and content themes were developed after a thorough review of all codes and detailed examination of interviewee quotes. Results: The primary themes that emerged were (1) Addiction medicine content is important to improve care of patients with substance disorders and is not fully addressed in undergraduate medical education (2) In-person and virtual training contain unique strengths and weaknesses and (3) Students perceived that both experiences provided positive and needed training in addiction medicine that shifted perspective and enhanced confidence to practice. Conclusions: Remote training via virtual lectures and patient visits may enhance training opportunities for students with limited exposure to addiction medicine patients and faculty with addiction medicine expertise. There is a need to further refine virtual care for patients with SUDs and virtual training to meet the needs of patients and learners across the country.

Effect of a Prescription Drug Monitoring Program on Emergency Department Opioid Prescribing.

INTRODUCTION: Our goal was to determine whether implementation of a prescription drug monitoring program (PDMP) altered emergency department (ED) opioid prescription rates overall and in patients of different pain severities. METHODS: We conducted this single-center, retrospective review at an academic ED. The study examined patients discharged from the ED who received opioid prescriptions, before and after the state's implementation of a PDMP (August 25, 2016). The monthly rate was a ratio of the patients given ≥ 1 opioid prescription to the ED patients with a numeric pain rating scale (NPRS) > 0. We performed an interrupted time series analysis on each demographic. RESULTS: The overall ED opioid prescription rate decreased from 51.3% (95% confidence interval [Cl], 50.4%-52.2%) to 47.9% (95% Cl, 47.0%-48.7%). For males, this decreased from 51.1% to 46.7% (P < 0.0001), while in females it did not significantly change (51.6% to 49.7% [P = 0.0529]). For those with mild pain, the rate increased from 27.5% to 34.3% (P < 0.0001), while for those with moderate pain, it did not significantly change (42.8% to 43.5% [P = 0.5924]). For those with severe pain, the rate decreased from 66.1% to 59.6% (P < 0.0001). CONCLUSION: We found that PDMP implementation was associated with an overall decrease in opioid prescription rates, and that patients with mild pain were prescribed opioids more often while severe pain patients were prescribed opioids less often.

The Effect of Propofol on Chronic Headaches in Patients Undergoing Endoscopy.

Objective: This study determined acute and long-term effects of propofol administration in patients with severe headaches undergoing endoscopic procedures. Background: Approximately 13% of the US population is affected by migraines or severe headaches. The effect of propofol on headaches more than a few days after the intervention has not been explored. Methods: We employed a nonrandomized, prospective observational study that recruited patients with chronic headaches who received propofol from an outpatient endoscopy center for either upper or lower endoscopies. Patients completed the six-item Headache Impact Test (HIT-6) questionnaire prior to the procedure and 30 days after endoscopy. Additionally, the patients' response to propofol two days after endoscopy was assessed via phone. Results: The age of the participants (n=31) ranged from 20 to 70 years. The mean HIT-6 composite scores were significantly lower (p < 0.05) 30 days after propofol administration when compared to baseline scores. Upon stratification, 23 patients indicated an improved condition, 7 a worsened outcome, and 1 showed no change. Furthermore, mean scores were significantly lower (p < 0.05) in three HIT-6 questions pertaining to the severity of pain, daily activity, and frequency of lying down. Finally, the mean pain score obtained was significantly lower (p < 0.05) two days after procedure. Conclusions: The results of this suggest that propofol administration should be considered in treating chronic headaches. Double-blind studies are necessary to confirm these results.

Fluoroscopically-guided epidural blood patch for spontaneous intracranial hypotension.

We present three patients with spontaneous intracranial hypotension who failed conservative treatment and were treated with image-guided epidural blood patch close to the cerebrospinal fluid (CSF) leak site. Each patient achieved significant long-term improvement of clinical symptoms and CSF leak related image findings.

A Survey of Ultrasound Training in U.S. and Canadian Chronic Pain Fellowship Programs.

OBJECTIVE: To assess the current state of ultrasound training in U.S. and Canadian Chronic Pain Fellowship programs. DESIGN: U.S. as well as Canadian chronic pain fellowship programs were contacted via email and program directors were asked to complete a survey. The surveys were completed online using a questionnaire. SETTING: Questionnaire via email. PATIENTS: None. INTERVENTIONS: None. OUTCOME: To assess the current state of ultrasound training in U.S. and Canadian Chronic Pain Fellowship programs. MEASURES: Current teaching structure, types, and numbers of ultrasound-guided interventional pain procedures. RESULTS: Thirty-one responses (30.7%) from the 97 U.S. and four Canadian programs surveyed. Of the 31 programs that responded, 26 offered ultrasound training; five did not. These 31 programs averaged 4.1 fellows per year, majority 96.2% of the 26 programs taught ultrasound throughout the fellowship year. The type of ultrasound training varied, with the large majority 96.2% being patient based. Among 26 programs, 96.2% used ultrasound for peripheral nerve blocks, 76.9% used ultrasound for non-axial musculoskeletal injections, and 53.8% used ultrasound for axial nerve blocks. CONCLUSIONS: Chronic pain fellowships were teaching ultrasound-guided procedures to their fellows. The majority of the fellowships offered ultrasound training throughout the fellowship year. A majority of training was accomplished via hands-on experience with patients. Chronic pain fellows were receiving a majority of ultrasound training for peripheral nerve blocks, followed by nonaxial musculoskeletal blocks, with few axial nerve blocks being taught.

Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study.

BACKGROUND: Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy. METHODS: A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received nortriptyline and/or gabapentin plus physical therapies, up to three cervical epidural steroid injections (ESI) or combination treatment over 6 months. The primary outcome measure was average arm pain on a 0 to 10 scale at 1 month. RESULTS: One-month arm pain scores were 3.5 (95% CI, 2.8 to 4.2) in the combination group, 4.2 (CI, 2.8 to 4.2) in ESI patients, and 4.3 (CI, 2.8 to 4.2) in individuals treated conservatively (P = 0.26). Combination group patients experienced a mean reduction of -3.1 (95% CI, -3.8 to -2.3) in average arm pain at 1 month versus -1.8 (CI, -2.5 to -1.2) in the conservative group and -2.0 (CI, -2.7 to -1.3) in ESI patients (P = 0.035). For neck pain, a mean reduction of -2.2 (95% CI, -3.0 to -1.5) was noted in combination patients versus -1.2 (CI, -1.9 to -0.5) in conservative group patients and -1.1 (CI, -1.8 to -0.4) in those who received ESI; P = 0.064). Three-month posttreatment, 56.9% of patients treated with combination therapy experienced a positive outcome versus 26.8% in the conservative group and 36.7% in ESI patients (P = 0.006). CONCLUSIONS: For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed.