Pain Practice最新文献

Objectives: Artificial intelligence (AI) represents an exciting and evolving technology that is increasingly being utilized across pain medicine. Large language models (LLMs) are one type of AI that has become particularly popular. Currently, there is a paucity of literature analyzing the impact that AI may have on trainee education. As such, we sought to assess the benefits and pitfalls that AI may have on pain medicine trainee education. Given the rapidly increasing popularity of LLMs, we particularly assessed how these LLMs may promote and hinder trainee education through a pilot quality improvement project.

Materials and methods: A comprehensive search of the existing literature regarding AI within medicine was performed to identify its potential benefits and pitfalls within pain medicine. The pilot project was approved by UPMC Quality Improvement Review Committee (#4547). Three of the most commonly utilized LLMs at the initiation of this pilot study - ChatGPT Plus, Google Bard, and Bing AI - were asked a series of multiple choice questions to evaluate their ability to assist in learner education within pain medicine.

Results: Potential benefits of AI within pain medicine trainee education include ease of use, imaging interpretation, procedural/surgical skills training, learner assessment, personalized learning experiences, ability to summarize vast amounts of knowledge, and preparation for the future of pain medicine. Potential pitfalls include discrepancies between AI devices and associated cost-differences, correlating radiographic findings to clinical significance, interpersonal/communication skills, educational disparities, bias/plagiarism/cheating concerns, lack of incorporation of private domain literature, and absence of training specifically for pain medicine education. Regarding the quality improvement project, ChatGPT Plus answered the highest percentage of all questions correctly (16/17). Lowest correctness scores by LLMs were in answering first-order questions, with Google Bard and Bing AI answering 4/9 and 3/9 first-order questions correctly, respectively. Qualitative evaluation of these LLM-provided explanations in answering second- and third-order questions revealed some reasoning inconsistencies (e.g., providing flawed information in selecting the correct answer).

Conclusions: AI represents a continually evolving and promising modality to assist trainees pursuing a career in pain medicine. Still, limitations currently exist that may hinder their independent use in this setting. Future research exploring how AI may overcome these challenges is thus required. Until then, AI should be utilized as supplementary tool within pain medicine trainee education and with caution.

Introduction: The fields of anesthesiology and pain medicine are experiencing significant changes driven by market forces and professional preferences. While demand for anesthesiologists is rising, pain medicine is facing a decline in fellowship applications.

Methods: This study analyzed data from the Electronic Residency Application Service (ERAS) and the National Resident Matching Program (NRMP) from 2019 to 2023, focusing on trends in fellowship applications to pain medicine programs. Additionally, preliminary data from the 2024 match cycle were examined.

Results: There has been a notable decrease in anesthesiology residents applying to pain medicine fellowships, with applications dropping from 351 in 2019 to 193 in 2023. The overall decline in anesthesia-based applicants to pain medicine fellowships was 45%, signaling the highest detriment among anesthesiology applicants compared to other specialties. Gender disparities have been prevalent, with the absolute number of female applicants decreasing every year since 2019. Additionally, the 2023 match saw a significant number of unfilled programs, with 35 out of 115 programs failing to fill all positions. Preliminary data from the 2024 match cycle suggest this downward trend is continuing.

Conclusion: The decline in pain medicine fellowship applications, particularly among anesthesiology residents, signals potential future workforce shortages and challenges in patient care. Recruitment strategies should include early exposure to pain medicine during residency, enhanced mentorship programs, and robust recruitment efforts (including virtual options). Addressing these issues is essential to ensure enough trained specialists to meet the growing need for pain specialists nationally.

Background: Long-term use of opioids does not result in significant clinical improvement and has shown more adverse than beneficial effects in chronic pain conditions. When opioids cause more adverse effects than benefits for the patient, it may be necessary to initiate a process of deprescribing.

Aim: To explore the perceptions of French pain physicians regarding the process of opioid deprescribing in patients experiencing chronic non-cancer and to generate an understanding of the barriers and levers to the deprescribing process.

Methods: We conducted a multicentric observational study with qualitative approach. Individual semi-structured interviews exploring pain physicians' perceptions, beliefs, and representations to assess the determinants of opioid deprescribing with an interview guide were used. After checking the transcripts, an inductive and independent thematic analysis of the interviews was to extract meaningful themes from the dataset.

Results: Twelve pain physicians were interviewed. The main obstacles to deprescribing revolved around patient-specific attributes, characteristics of the opioids themselves, and limitations within the current healthcare system, that hinder optimal patient management. Conversely, patient motivation and education, recourse to hospitalization in a Pain Department with multidisciplinary care, follow-up by the general practitioner, and training and information dissemination among patients and clinicians emerged as facilitative elements for opioid deprescribing.

Conclusion: This study underscores the needs to improve the training of healthcare professionals, the effective communication of pertinent information to patients, and the establishment of a therapeutic partnership with the patient. It is therefore essential to carry out the deprescribing process in a collaborative and interprofessional manner, encompassing both pharmaceutical and non-pharmaceutical strategies.

Introduction: Pain is a very common complaint among patients with hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSDs). Often challenging to treat, insights into the underpinnings of pain in this population have been fleeting. Central sensitization (CS) has been postulated as a potential etiological factor.

Methods: In this retrospective study, 82 consecutive patients with hEDS/HSDs were reviewed. Demographic information and Central Sensitization Inventory (CSI) results were collected.

Results: 71 of 82 (86.5%) patients demonstrated CS. Scores ranged from 12 to 94 with a median of 56. Pain scores as measured on the numerical rating scale (NRS) ranged from 2 to 10 with a mean and median of 6.

Conclusion: A large percentage of patients with pain and a diagnosis of hEDS/HSDs demonstrated evidence of central sensitization as measured using the CSI. The CSI is simple to administer. The CSI may provide clinical insights that are key to successfully managing patients with hEDS/HSDs. Further research is needed to explore the ability to classify pain phenotypes in this patient population and the impact on precision medicine.

Background: Although long-term opioid therapy (LTOT) for chronic pain has declined, it remains common in the U.S. Providers do not have clinical practice guidelines for vulnerable LTOT patients, in whom both LTOT continuation and tapering to discontinuation pose risks of harm and in whom opioid use disorder (OUD) is absent.

Methods: To begin to meet the gap in guidelines, the study used a multiple case study approach. Five cases were constructed to systematically vary key elements of LTOT continuation and discontinuation harms among patients reporting LTOT's lack of efficacy (experience of pain and poor function). For each, treatment approaches were collected from 28 opioid safety experts identified through their participation in a national policy panel (19 were physicians) and analyzed using template analysis.

Results: For patients receiving LTOT with harms of continuation and discontinuation, experts recommended attempting a slow taper (even with a prior unsuccessful taper, possibly with adjuvant medications to manage withdrawal) and not maintaining opioid therapy. Experts considered switching to buprenorphine, especially if the patient had aberrant behaviors. They also considered adding non-opioid pain therapies (especially re-trying such therapies if they were unhelpful before) and engaging in shared decisionmaking, although with little consensus on specific approaches. Some experts would address co-occurring conditions related to patient safety (alcohol use, mental health symptoms, opioid side effects). Few experts referenced assessing or addressing OUD or overdose risk. In quantitative data, 36% of experts agreed LTOT is beneficial, 36% agreed most LTOT patients should be discontinued, and 57% agreed patients experience harm from tapering and from discontinuation.

Discussion: Evidence is needed to build on and test these experts' recommendations to attempt tapering and add non-opioid pain therapies for patients reporting harms of continued LTOT who may experience harms from tapering. Such evidence informs the development of clinical practice guidelines that provide comprehensive protocols to support the safety and functioning of this group of patients.

Objective: The objective of this study was to evaluate the effect of outpatient celiac plexus block on acute pain reduction in patients with suspected median arcuate ligament syndrome.

Methods: This is an Institutional Review Board approved, retrospective chart review. Data were collected and analyzed from patients who received celiac plexus blocks from November 1, 2021 through April 6, 2023. The primary outcome was pain reduction, determined by the change in numerical pain rating scale (NPRS) from pre-procedure to post-procedure. Additional data collected include patient demographics, comorbidities, preoperative symptoms and duration of symptoms.

Results: There were 33 patients identified in this study. Thirty-one patients were included in the data analysis. The median age of the cohort was 29 years, and the median BMI was 20.4. 94% of the cohort was female. These patients were referred as part of an evaluation for symptomatic vascular compression disorders. For many patients, positive response to celiac plexus block was used as an indication to proceed with surgical MALS resection. We provide a diagnostic algorithm for MALs. All patients endorsed preoperative symptoms. Patients experienced a median pain reduction of -4 from baseline to immediately post-procedure.

Conclusions: Celiac plexus blocks continue to be a tool for ruling out neurogenic median arcuate ligament syndrome in patients who have undergone extensive previous imaging and assessments for vascular compression disorders. Our data suggest that patients with suspected MALS may experience substantial immediate pain relief from temporary blocks of the celiac ganglion as guided by fluoroscopy in an outpatient setting.

Introduction: To determine the frequency of superior cluneal nerve entrapment (SCN-E) in patients who applied to our outpatient clinic with low back pain.

Methods: Two hundred patients with mechanical low back pain persisting more than 3 months were included in our study. All patients were evaluated with detailed clinical history and physical examination. Ultrasound-guided diagnostic injection was performed in patients who had tenderness on the posterior iliac crest and whose main complaint emerged by pressing on this point. Patients with 70% or greater pain relief 1 h after the injection were considered as SCN-E. The frequency and clinical features of SCN-E were determined and compared with other mechanical low back pain.

Results: The mean age of the patients included in our study was 48.56 ± 14.11 years, with 138 female and 62 male patients. The diagnostic injection was performed on 31 patients and considered positive in 24 of them. The frequency of SCN-E was determined as 12%. The Hip-Knee Flexion Test was determined to be more specific for SCN-E than other causes of low back pain, the sensitivity and specificity of the test were 41.67% and 88.64% (p = 0.001; p < 0.01). In addition, all demographic and clinical features in patients diagnosed with SCN-E were found to be similar to other mechanical low back pain cases.

Conclusions: In patients with chronic low back pain, SCN-E is not a rare cause and is often overlooked. Increasing the awareness and experience of physicians on SCN-E will prevent patients from being exposed to unnecessary surgical or non-surgical treatments.