An evaluation of impact factor bias of clinical trials published in pain journals.

BACKGROUND AND OBJECTIVE: Studies with nonsignificant results are less likely to be published or published in lower impact factor journals. To determine whether a similar phenomenon occurs in pain literature, we explored impact factor bias in peer-reviewed pain journals. METHODS: A PubMed search involving randomized controlled trials in pain journals during 2012 through 2018 was performed. The primary outcome was the publication impact factor. Exclusion criteria included commentaries, editorials, meta-analyses, reviews, and animal studies. The average impact factor for each journal was determined. The primary independent variable was a study with a positive outcome. RESULTS: Of the 9 journals evaluated, 1108 articles met our inclusion criteria and were included in our analysis. The quartiles for the impact factor for the journals included were 2.5, 2.9, and 3.6. A multivariate analysis identified sample size greater than 100, description of a sample size calculation, presence of a stated hypothesis, and presence of sponsorship funding as independent predictors of publication in a journal with greater impact factor. In contrast, positive results were not associated with publication in a greater impact factor journal, even when forced into the model, P = 0.49. CONCLUSIONS: After adjusting for study factors associated with publication, there is no evidence of impact factor bias within the pain literature. The lack of impact factor bias in the pain literature is a positive finding for the field and should benefit scientific development and the clinical care of patients.

A Case of Prolonged Angioedema After Cardiac Surgery.

Angioedema (AE) is a transient capillary leak syndrome, caused by either histamine or bradykinin, that presents as an acute nonpitting swelling of the skin, subcutaneous tissues, and mucous membranes of the face, lips, tongue, upper airways, and gastrointestinal tract, with or without a rash. A lack of response to antihistamines, steroids, and epinephrine suggests a bradykinin-mediated AE. Bradykinin-AE may be inherited, acquired, or drug related. Mechanism of increased bradykinin can include decreased C1-esterase inhibitor (C1-INH) levels or activity, increased bradykinin production, or decreased bradykinin breakdown, the latter occurring during angiotensin converting enzyme inhibitor (ACEi). A 65-year-old woman had coronary artery bypass grafting, which was complicated by prolonged bradykinin-AE owing to ACEi, requiring prolonged endotracheal tube intubation. Treatment with a C1-esterase inhibitor (Berinert) on postoperative day 7 resulted in a dramatic improvement in airway edema and tongue swelling within 7 hours, and the patient was subsequently extubated. The case is unusual because of the prolonged course of AE and the benefit of late administration of C1-INH concentrate.

Outcomes After Injection-Based Therapy: A Pain Outcomes Questionnaire for Veterans Univariate Analysis.

Background: The Pain Outcomes Questionnaire-For Veterans (POQ-VA) was developed within the Veterans Health Administration (VHA) as a brief but psychometrically sound pain outcomes instrument that assesses key domains. In routine clinical practice, it is valid and reliable for evaluating effectiveness of treatment of chronic noncancer pain in veterans. We hypothesized that POQ-VA scores would improve across multiple domains in the veteran population following injection-based interventional treatment for chronic pain. Methods: We aggregated all available POQ-VA reports from veterans who underwent ≥ 1 interventional pain procedures between April 1, 2009 and April 1, 2019. Patients were included who had pre- and posttreatment POQ-VA results separated by ≤ 6 months (N = 112). A paired-samples t test was used to compare means, standard deviations, and ranges for each POQ-VA domain. Individual question responses were analyzed using a nonparametric Wilcoxon matched-pairs signed-rank test. Results: All POQ-VA domains showed a statistically significant decrease posttreatment (P ≤ .03). Directionally, the responses to 17 of 20 individual POQ-VA questions reflect a small but statistically significant positive treatment response (P < .04). Conclusions: Most veterans undergoing injection therapy for chronic pain had statistically significant improvements in POQ-VA measures within a 6-month period. To conduct more rigorous, multivariate studies, continued and widespread use of the POQ-VA instrument is warranted.

Receipt of Physical Therapy and Chiropractic Care by Adults Diagnosed with Chronic Pain: Analysis of the 2016-2018 Rhode Island All Payer Claims Database.

OBJECTIVE: To examine trends and factors associated with physical therapy (PT) and chiropractic care use among Rhode Islanders with private or publicly-funded health insurance who were diagnosed with chronic pain from 2016-2018. METHODS: We measured monthly PT and chiropractic care use from the RI All Payer Claims Database, and conducted logistic regression to identify factors associated with utilization. RESULTS: There were 284,942 unique adults with chronic pain representing over one-quarter of insured persons in the state. Chiropractic care use remained unchanged but was more prevalent (7.2%) than PT whose use increased minimally from 4.0% (2016) to 4.5% (2018). Traditional Medicare or Medicaid enrollment was associated with lower odds of receiving PT and chiropractic care than in private plans. CONCLUSIONS: PT and chiropractic care use varied across payers; however, there were little to no changes in their use over time despite clinical guidelines that encourage non-pharmacologic options to manage chronic pain.

Flip Your Perspective: Dextrocardia and its Effect on Monitoring and Management.

Dextrocardia is a rare congenital disorder characterized by an anatomically flipped heart that is positioned in the right instead of the left side of the thorax. Anatomical variants, such as this, are vital to be aware of as they can alter patient monitoring and management. In this case report, we describe a patient with dextrocardia whose anatomy affected intraoperative monitoring while undergoing a successful aortic valve replacement surgery.

An Evaluation of the Online Quality of Content of United States Accredited Pain Medicine Fellowship Training Programs.

BACKGROUND: Pain medicine fellowship applicants often seek information about programs from the Internet, which is becoming even more relevant with the transition to virtual interviews as a consequence of the global pandemic. Previous literature has revealed the significance of training program websites as part of the application process in other specialties. OBJECTIVES: The objective of this cross-sectional study was to evaluate the content, design, organization, and user friendliness by using a composite score to determine the quality of the pain medicine fellowship websites (PMFW). METHODS: Accredited pain medicine fellowship programs was queried from three databases for pain medicine education: (1) Electronic Residency Application Service (ERAS); (2) the Fellowship and Residency Electronic Interactive Database (FREIDA); and (3) the National Resident Matching Program (NRMP). Programs that appeared within one and/or more databases were eligible for study inclusion. PMFW were evaluated for the accessibility of recruitment and education content items. The quality of PMFW was determined as multifactorial composed of four dimensions: content, design, organization, and user friendliness. RESULTS: For program recruitment, PMFW contained an average of 12 ± 4.0 of 32 content items (38%) for fellowship programs: (1) 83% of fellowship programs specified the number of positions available for the 2021 Match; (2) 17% indicated alumni career placement; (3) 6.8% supplied interview dates; and (4) merely 4.9% detailed the selection process. For program education, PMFW contained an average of 7 ± 3.4 of 16 content items (44%): (1) 70% of programs provided a rotation schedule; (2) 49% detailed operative experiences; and (3) just 16% included simulation training. Regarding the quality based on content, design, organization, and user friendliness, the average PMFW was not "good" with only 1% of PMFW meeting "great" standards. A kappa value of 0.92 was calculated for inter-rater reliability. CONCLUSIONS: The web presence of pain medicine fellowship programs falls short of providing essential accessibility, content, design, organization, and user friendliness to allow applicants to adequately access information about program characteristics. There are ample opportunities to increase the effectiveness of PMFW to benefit training programs and to inform prospective applicants, especially given the rise of virtual applications and interviews.

Safety and outcomes of outpatient compared to inpatient total knee arthroplasty: a national retrospective cohort study.

BACKGROUND: Many factors are driving total knee arthroplasty to be performed more commonly as an outpatient (<24 hour discharge) procedure. Nonetheless, the safety of total knee replacements performed in the outpatient setting is not well established when compared with inpatient setting. The purpose of this study is to compare the postoperative outcomes of outpatient and inpatient total knee arthroplasties. METHODS: The 2015 and 2016 American College of Surgeons National Surgical Quality Improvement Program data sets were queried to extract patients who underwent primary, elective, unilateral total knee arthroplasty. The primary outcome was serious adverse events defined by a composite outcome including: return to operating room, wound-related infection, thromboembolic event, renal failure, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, cerebrovascular accident, use of ventilator >48 hours, unplanned intubation, sepsis/septic shock, and death. Propensity matched analysis was used to adjust for potential confounding covariates. RESULTS: 1099 patients undergoing outpatient total knee arthroplasty (1% of total cases) were successfully matched to 1099 patients undergoing inpatient surgeries. The composite rate of serious adverse events was greater in outpatient procedures compared with inpatient procedures (3.18% vs 1.36%, p=0.005). In contrast, failure to rescue and readmission rates were not different between groups. CONCLUSIONS: Outpatient total knee arthroplasty is associated with a higher composite risk of serious adverse events than inpatient procedures. Anesthesiologists and surgeons should inform patients and discuss this information when obtaining consent for surgery and planning for discharge timing.

The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials.

METHODS: We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases. Meta-analysis was performed using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals, and sample size. Methodological quality was evaluated using Cochrane Collaboration's tool. RESULTS: Seven randomized controlled trials evaluating 337 patients across different surgical procedures were included. The aggregated effect of intraoperative methadone on postoperative opioid consumption did not reveal a significant effect, WMD (95% CI) of -0.51 (-1.79 to 0.76), (P=0.43) IV morphine equivalents. In contrast, the effect of methadone on postoperative pain demonstrated a significant effect in the postanesthesia care unit, WMD (95% CI) of -1.11 (-1.88 to -0.33), P=0.005, and at 24 hours, WMD (95% CI) of -1.35 (-2.03 to -0.67), P < 0.001. CONCLUSIONS: The use of intraoperative methadone reduces postoperative pain when compared to morphine. In addition, the beneficial effect of methadone on postoperative pain is not attributable to an increase in postsurgical opioid consumption. Our results suggest that intraoperative methadone may be a viable strategy to reduce acute pain in surgical patients.