Pain Practice最新文献

Background: Gabapentinoids are commonly prescribed to control neuropathic pain of lumbar radiculopathy. Few trials have compared the efficacy of gabapentin (GBP) and pregabalin (PGB). Therefore, the authors conducted a meta-analysis to compare the difference in effect between GBP and PGB in lumbar radiculopathy patients.

Methods: Articles which were published between January 1, 1960 and May 31, 2023 were investigated via Cochrane Central Register of Controlled Trials, Embase, Google Scholar, and MEDLINE. This meta-analysis was conducted on patients with lumbar radiculopathy. Gabapentin was used as an intervention, and pregabalin as a comparison. As outcomes, pain rating scales including visual analog scale (VAS) and numeric pain rating scale (NRS), and number of adverse events (dizziness and sedation) were obtained.

Results: PGB showed statistically significant improvement in pain scale (VAS and NRS) in short-term follow-up (6 weeks or less) compared to GBP. (Total mean difference of -0.31) However, in the long-term follow-up (6 weeks to 12 weeks), there was no difference in pain reduction effect between two groups. The incidence of AEs showed no difference between two groups.

Conclusion: Based on this article, the existing evidence suggests that PGB was more effective in reducing pain of lumbar radiculopathy compared to GBP at the short-term follow-up, but there was no difference in the long-term follow-up. Physicians should consider this finding in prescribing medications for patients with lumbar radiculopathy.

Objectives: Letters of recommendation (LORs) are an important part of pain medicine fellowship applications that may be subject to implicit bias by the letter's author. This study evaluated letters of recommendation for applications to pain medicine fellowships in the United States to characterize biases and differences among applicants over four application cycles.

Methods: This was a retrospective single-site cohort study. De-identified LORs were collected from 2020 to 2023 from one institution. The Valence Aware Dictionary and sEntiment Reasoner (VADER) natural language processing package scored positive LOR sentiment. In addition, the deep learning tool, Empath, scored LORs for 15 sentiments. Wilcoxon rank-sum and one-way ANOVA tests compared scores between applicant demographics: gender, race, medical school type, residency specialty, and chief resident status, as well as letter writers' academic position.

Results: Nine hundred and sixty-four applications were studied over four application cycles. Program directors wrote fewer words (p = 0.020) and less positively (p < 0.001) compared to department chairs and letter writers with neither position. Department chairs wrote with less "negative emotion" compared to both program directors and writers with neither position (p < 0.001). Anesthesiologist applicants received more letters highlighting "achievement" (p < 0.001) while PM&R applicants submitted letters with less "negative emotion" (p < 0.001) compared to other specialties. Chief residents' letters scored higher in "leader" sentiment (p < 0.001) and lower in "negative emotion" (p < 0.001).

Discussion: Linguistic content did not favor certain genders or races over others. However, disparities in LORs do exist depending on an applicant's specialty and chief resident status, as well as the academic status of the letter writer.

Introduction: Patients suffering from postherpetic neuralgia (PHN) report unilateral chronic pain in one or more dermatomes after an acute herpes zoster (HZ) infection. The incidence of acute HZ ranges between three and five patients per 1000 person-years. In one out of four patients, acute HZ-related pain will transition into PHN. PHN can be very disabling for patients and reduce quality of life. Additionally, the treatment of PHN is characterized by high failure rates. The aim of this review is to give an update on the previous practical guideline published in 2011 and revised in 2015 (published in 2019) and to provide an overview of current interventional treatment options for HZ infection and PHN.

Methods: The literature on the diagnosis and treatment of HZ and PHN was systematically reviewed and summarized.

Results: The most important treatment for acute HZ-related pain is antiviral therapy within 72 h of symptom onset. Additional symptomatic treatment options are analgesic drugs according to the WHO pain ladder, tricyclic antidepressants (eg, nortriptyline), and antiepileptic drugs (eg, gabapentin). If pain is not sufficiently reduced, interventional treatment such as an epidural injection with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion (DRG) are options. Treatment for PHN is preferably transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics.

Conclusions: Treatment of acute HZ-related pain especially PHN is challenging. Besides the conventional treatment for PHN, interventional management is considered a new treatment option. PRF of DRG seems to be the most promising interventional management.

Introduction: Pain management in late-stage cancer patients is a complex clinical problem. The historical guidelines were from the World Health Organization (WHO). Recently, ESMO produced guidelines consistent with 52 recommendations applicable to the entire period of disease since the pain appears.

Aim: To evaluate the appropriateness and applicability of ESMO guidelines (EGL) in advanced cancer patients admitted to palliative care.

Method: An observational, prospective, multicentric study conducted by specialist palliative care centers on cancer patients in the advanced stage. The 52 recommendations were divided into eight macro areas. The adherence levels were expressed as a percentage for each recommendation and have been broken down as high (>75%), medium (50%-75%), and low (<50%). In the case of not adhering to a recommendation, the comment was "not applicable" (NA) or not evaluable (NE).

Results: Four hundred seventy-six patients were enrolled in the study. Thirty-five recommendations were considered NA or NE, especially because their application took too long to achieve clinical results, given the condition of the patients. Some interesting opinions on the choice of drugs emerged. At the end of the study, pain dropped from 5.0 to 2.6, patients' satisfaction increased from 3.3 to 4.6, and quality of life improved from 4.4 to 5.5.

Conclusions: Palliative physicians' adherence to EGL was medium. The main contribution of this study was to evaluate their applicability and clinical results in far-advanced patients assisted by palliative care. The selection of useful recommendations and expert opinions can make a contribution to clinical practice.

Introduction: Peripheral artery diseases (PAD) and Raynaud's syndrome are associated with substantial morbidity. PAD, through the restriction of blood flow to the extremities, may lead to critical limb ischemia with symptoms of pain at rest which may eventually progress to severe limb ischemia with gangrene. This serious and painful clinical condition requires extensive medical care, is limb-threatening and, in case of delayed or unsuccessful treatment, is associated with a high mortality rate. In Raynaud's syndrome, the blood supply to certain parts of the body, usually the fingers and toes and less frequently the nose or ears, is restricted because of vasculopathy of the smaller vessels at acral sites. Under certain circumstances, with cold as the most well-known provoking factor, blood flow restriction occurs, leading to demarcated color changes and symptoms such as pain, paresthesia, and numbness. In severe cases of Raynaud syndrome tissue ischemia may lead to necrosis and the need for amputation of the affected area.

Methods: In this narrative review, the literature on the diagnosis and interventional pain treatment of PAD and Raynaud's syndrome was updated and summarized.

Objectives: This review focused on interventional pain treatment. In PAD, the effects of the intervention on limb salvage, ulcer healing, and ischemic pain were summarized. Additionally, results with respect to skin microcirculation and quality of life were reported if available. In Raynaud's syndrome, we focused on the effect of the intervention on peripheral blood flow metrics and pain intensity during attacks.

Results: In PAD, prevention and treatment of risk factors are important. Initially, conservative treatment and pharmacological therapy are preferred first-line therapies. However, when disease progression occurs, interventional management may be considered. The literature search yielded conflicting evidence for sympathectomy as a treatment for PAD. Spinal cord stimulation (SCS) as a treatment modality for advanced PAD had high-quality evidence for limb salvage in subgroups of patients but conflicting evidence for other outcome measures such as pain, wound healing, and quality of life. The literature search for interventional pain management in Raynaud's syndrome was limited to only one randomized controlled trial (RCT) studying the effect of thoracic sympathectomy. This study had several limitations and hence the level of evidence for this interventional treatment is very low. No RCTs studying SCS in patients with Raynaud's syndrome were found.

Conclusions: In both PAD and Raynaud's syndrome, additional RCTs are needed to substantiate interventional (pain) management and bolster the evidence base for sympathectomy and SCS as treatment options.