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The 2023 iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimated prevalence, incidence, and health burden for 375 diseases and injuries, including 12 mental disorders. We assess past, current, and emerging trends in the prevalence and burden of mental disorders across sexes and age groups, for 21 regions, 204 countries and territories, and by Socio-demographic Index (SDI) quintile, from 1990 to 2023. Mental disorders included in GBD 2023 were anxiety disorders, major depressive disorder, dysthymia, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, idiopathic developmental intellectual disability, and a residual category of other mental disorders. A literature review identified epidemiological data for each disorder. These were analysed via a Bayesian meta-regression to estimate prevalence by disorder, sex, age, location, and year. Disorder-specific prevalence was multiplied by disability weights representing the severity of health loss associated with each disorder to estimate years lived with disability (YLDs). Deaths due to anorexia nervosa were assessed with a Cause of Death Ensemble modelling strategy to estimate deaths by sex, age, location, and year, and then multiplied by the standard life expectancy at age of death to estimate years of life lost (YLLs). YLDs equalled disability-adjusted life-years (DALYs) for all mental disorders except anorexia nervosa (the only mental disorder considered as an underlying cause of death in GBD), for which DALYs represented the sum of YLDs and YLLs. We presented prevalence, deaths, YLDs, YLLs, and DALYs as counts, age-specific rates per 100 000 population, and age-standardised rates per 100 000 population. We estimated 1·17 billion (95% uncertainty interval 1·06-1·31) prevalent cases of mental disorders globally in 2023, equivalent to an age-standardised prevalence rate of 14 210·7 cases (12 849·5-15 940·1) per 100 000 population. These estimates represented a 95·5% (75·0-121·2) increase in prevalent cases and 24·2% (11·4-41·4) increase in age-standardised prevalence rate between 1990 and 2023. All mental disorders showed increases in prevalent cases between 1990 and 2023, while notable increases were seen in age-standardised prevalence rates for anxiety disorders, major depressive disorder, dysthymia, anorexia nervosa, bulimia nervosa, schizophrenia, and conduct disorder. There were an estimated 171 million (127-228) DALYs due to mental disorders globally across sex and age in 2023, equivalent to an age-standardised DALY rate of 2070·5 DALYs (1519·1-2750·5) per 100 000 population. Mental disorders contributed to 6·1% (4·8-7·6) of all-cause DALYs in 2023, making them the fifth leading cause of global DALYs (up from 12th in 1990). DALYs were almost entirely composed of YLDs. Mental disorders were the leading cause of YLDs in 2023 (up from second in 1990), explaining 17·3% (14·8-20·6) of all-cause global YLDs. Leading causes of mental disorder DALYs were anxiety disorders (ranked 11th among the 304 diseases and injuries at Level 4 of the GBD cause hierarchy), major depressive disorder (15th), and schizophrenia (41st). Globally in 2023, mental disorder age-standardised DALY rates were higher among females (2239·6 [1643·7-3014·1] per 100 000) than among males (1900·2 [1399·8-2510·8] per 100 000), and peaked in the 15-19 years age group (2617·3 [1850·6-3696·8] per 100 000). All locations showed increased mental disorder DALY rates in 2023 compared with 1990, ranging across countries and territories from 1302·4 (952·7-1683·7) per 100 000 in Viet Nam to 3555·8 (2661·9-4715·0) per 100 000 in the Netherlands. Across SDI quintiles, DALY rates ranged from 1853·0 (1352·1-2469·3) per 100 000 for middle SDI to 2184·1 (1606·1-2890·3) per 100 000 for high SDI. A significant health burden was imposed by mental disorders in all countries and territories in 2023, irrespective of the health resources available. In some instances, this burden has increased over time and is unevenly distributed across populations. Stronger surveillance systems, particularly in low-income and middle-income countries, are required. Additionally, we need more coordinated and inclusive policies to reduce the burden through early treatment and prevention, tailored to sex and age differences across locations. Responding to the mental health needs of our global population, especially those most vulnerable, is an obligation, not a choice. Gates Foundation, Queensland Health, and University of Queensland.
Botulinum toxin type A (BoNT-A) intramuscular injections are commonly administered for neck pain unresponsive to other therapies, but the benefit-harm profile remains uncertain. To assess the benefits and harms of intramuscular BoNT-A injection for people with subacute to chronic neck pain. We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registers, together with reference checking, citation searching and contact with study authors up to 4 March 2026. Randomised controlled trials (RCTs), including cross-over, pragmatic, or cluster designs, were included for adults with subacute to chronic neck disorder without radicular findings, with or without cervicogenic headache, and compared BoNT-A to placebo or no-treatment. Our outcomes were pain, function-disability, health-related quality of life, participant-reported treatment success, adverse events and costs at both short-term (< 24 weeks) and long-term (≥ 24 weeks) follow-up. We assessed the risk of bias (RoB) using the ROB 2 tool. We synthesised results using meta-analyses with random-effects models to calculate mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CIs), or using SWiM (Synthesis Without Meta-analysis) methods. We assessed certainty with GRADE. This update included 16 trials (855 participants) compared to six (252 participants) in the previous review: 13 parallel RCTs and three cross-over RCTs. One other trial is awaiting classification. Short-term follow-up ranged from 3 to 12 weeks post-treatment, and long-term follow-up was six months. Participants (mean age 45 years; 64% female; pain severity 56 on the Visual Analogue Scale (VAS 0 to 100)) were from ambulatory care settings in North America (five trials), Central America (one trial), Europe (six trials), the Middle East (one trial), Central Asia (one trial), and the East Asia & Pacific region (two trials), from upper (12 trials) or upper-middle (four trials) income economies. Disorder classifications included non-specific neck pain - myofascial (eight trials), whiplash-associated disorder (four trials), and cervicogenic headache (four trials). Overall, 88% of participants had chronic pain. The dose varied from 10 to 400 units over 1 to 10 trigger points. The RoB was high or raised some concern across all outcomes. Since 2011, evidence has shifted from no benefit to a potentially slight-to-small short-term benefit for BoNT-A compared with placebo. No trials compared BoNT-A with no treatment, and evidence was limited by bias (no studies with an overall low RoB), imprecision, and potential publication bias. For pain intensity measured on the VAS (scale 0 to 100), BoNT-A may result in a slight-to-small improvement in the short term (MD 5.95 points lower, 95% CI 10.89 lower to 1.02 lower; I2 = 0%; 12 studies, 393 participants; low-certainty evidence; downgraded two levels due to high overall RoB and indirectness), but not in the long term (MD 11.74 points lower, 95% CI 35.63 lower to 12.16 higher; I² = 50%; 2 studies, 43 participants; low-certainty evidence; downgraded two levels due to high RoB and imprecision). Mean pain in the placebo group was 46.66 points compared to 40.71 in the BoNT-A group, representing an absolute improvement of 6% (95% CI 11% better to 1% better). Additionally, there may be a moderate risk reduction in pain events in the short term (RR 0.68, 95% CI 0.56 to 0.83; I² = 0%; 2 studies, 292 participants; low-certainty evidence; downgraded two levels due to high overall RoB and dissemination bias, including potential conflict of interest from funding sources that may overestimate effects). Assuming a 70% risk with placebo, the corresponding risk with BoNT-A is 47%, representing a 23% absolute risk reduction. Five people (95% CI 3 to 9) would need BoNT-A treatment for one person to benefit. For physical function measured on the Neck Disability Index (scale 0 to 100), BoNT-A may have little to no effect in the short term, but the evidence is very uncertain (MD 2.49 points higher, 95% CI 9.72 lower to 14.70 higher; I² = 0%; 3 studies, 76 participants; very low-certainty evidence; downgraded three levels due to high overall RoB, indirectness, and wide confidence intervals). For health-related quality of life (change score), BoNT-A may make little to no difference in the short term (MD 2.30 points higher, 95% CI 12.57 lower to 17.17 higher; 1 study, 28 participants; low-certainty evidence; downgraded two levels due to imprecision). For participant-reported treatment success, BoNT-A may provide a small improvement in the global rating of change. Short-term results: MD 1.16 points lower on a 1 to 5 Verbal Rating Scale (95% CI 1.86 lower to 0.46 lower; 1 study, 31 participants; low-certainty evidence), corresponding to an absolute improvement of 20% (95% CI 10% to 36%). Long-term results were similar: MD 2.00 points lower on a 0 to 10 Patient Global Assessment (95% CI 3.80 lower to 0.20 lower; 1 study, 19 participants; 20% absolute risk reduction, low-certainty evidence). Evidence was downgraded by two levels for RoB and imprecision. No studies evaluated participant satisfaction or serious adverse events. For non-serious adverse events, participants treated with BoNT-A may have a small, negligible increased risk (RR 1.51, 95% CI 1.04 to 2.20; I² = 28%; number-needed-to-treat for an additional harmful outcome (NNTH) 6, 95% CI 4 to 12; 7 studies, 489 participants; low-certainty evidence; downgraded two levels due to RoB and indirectness). Participants treated with BoNT-A have a 16% increased absolute risk of experiencing non-serious adverse events lasting up to three weeks, such as injection soreness, muscle fatigue, and headache. BoNT-A may provide slight-to-small short-term pain relief (6%) and perceived treatment success (20%) for subacute and chronic neck pain, but may offer no long-term physical function or health-related quality of life benefits. The moderate (23%) risk reduction in pain events may be overestimated due to publication bias. Non-serious adverse events are 16% more frequent. Uncertainty remains due to wide confidence intervals, short-term single-dose trials, and dose variation, highlighting the need for larger, high-quality studies with comprehensive adverse event reporting. This Cochrane review had no dedicated funding. Protocol and previous versions available via doi.org/10.1002/14651858.CD008626, doi.org/10.1002/14651858.CD008626.pub2 and doi.org/10.1002/14651858.CD008626.pub3 (withdrawn).
To summarise the evidence on long-term and infrequent harms following selected spinal and paraspinal injections and denervation procedures for chronic non-cancer spine pain. Systematic review and meta-analysis. MEDLINE, EMBASE and Cumulative Index to Nursing and Allied Health Literature from inception to October 2023. Non-randomised studies reporting on harms of selected interventional procedures administered to adults living with chronic axial or radicular non-cancer spine pain with ≥4 weeks of follow-up. A parallel guideline panel provided input on the scope, design and interpretation of this systematic review, including selection of adverse events for consideration. Systematic literature screening, data abstraction and risk of bias appraisal were conducted independently and in duplicate by pairs of reviewers. We used random-effects models for all meta-analyses and the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of evidence. We included 60 longitudinal studies (56 non-comparative, 4 comparative) that enrolled 4966 patients with chronic non-cancer spine-related pain. 31 studies investigated radiofrequency ablation or denervation, 22 epidural injections and 11 joint injections or nerve blocks. Low certainty evidence suggests that joint targeted steroid injection and epidural steroid injection for chronic spine pain may result in temporary altered level of consciousness (incidence: 2.1%; 95% CI 1.1% to 4.0%), joint radiofrequency nerve ablation, joint targeted steroid injection and epidural injection of local anaesthetic and steroids may result in deep infection (incidence: 0.7%; 95% CI 0.3% to 2.0%), epidural steroid injection, joint radiofrequency nerve ablation and joint targeted injection of local anaesthetic and steroids may result in dural puncture (incidence: 1.4%; 95% CI 0.5% to 4.3%), and dorsal root ganglion radiofrequency and joint radiofrequency nerve ablation with or without joint-targeted injection of steroids may result in prolonged pain or stiffness (incidence: 8.6%; 95% CI 6.3% to 11.6%). Several interventional procedures may result in metabolic complications and prolonged sensory deficits, but the supporting evidence was only very low certainty. Most complications resolved spontaneously or with conservative management. Low certainty evidence suggests that several common interventional procedures for chronic spine pain show risk of deep infection, dural puncture, temporary altered level of consciousness and prolonged pain or stiffness. Other harms are uncertain due to very low certainty evidence, and catastrophic outcomes were not reported in the small studies that contributed to our analyses.
The co-occurrence of chronic pain and trauma symptoms is prevalent; thus treatment approaches that address both are required. This systematic review of non-randomized studies aims to describe available psychotherapeutic interventions that concurrently target chronic pain and trauma-related symptoms for adults. Five databases (MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PsycINFO) were searched from date of inception until October 8th, 2025. Eligible studies featured a psychological intervention addressing chronic pain and trauma-related symptoms. We screened 12,597 articles at the title and abstract phase, with 23 full-text studies meeting our eligibility criteria to be included in this review. Risk of Bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Eight studies assessed pain as the primary outcome, with five showing a significant improvement in both pain and trauma outcomes. Seven studies assessed trauma-symptoms as the primary outcome with three finding significant improvement in both pain and trauma-related outcomes. Eight studies assessed both pain and trauma-related symptoms as primary outcomes, with six showing an improvement in both categories. Due to the heterogeneity of the interventions and inconsistency of the results, it remains unclear which intervention approach(es) are effective to manage co-morbid chronic pain and trauma-related symptoms. However, overall, the synthesis underscores that psychological therapies can improve both pain and trauma symptoms; thus, advancing the field will require rigorous study designs that can delineate which specific therapies and mechanisms of action are most effective in treating individuals living with these comorbid conditions. PERSPECTIVE: Our results highlight the inconsistency in how chronic pain, trauma-related symptoms, psychological interventions and related outcomes are assessed in the current landscape. There is a necessity to streamline and standardize trial design and reporting in this field to improve knowledge acquisition and translation.
Postoperative pain remains a major challenge following major abdominal surgery. Noise in the operating room is a modifiable stressor, and the efficacy of targeted noise isolation requires prospective investigation. This study investigated the effects of intraoperative noise isolation on the incidence of moderate-to-severe postoperative pain. This multicentre randomized clinical trial assessed patients who underwent elective major abdominal surgery under general anaesthesia in four medical centres in China between April, 2024 and May, 2025. Following anaesthesia induction, patients were randomized to either wear noise-cancelling headphones or not (control). The primary outcome of this study was the incidence of moderate-to-severe pain (numeric rating scale (NRS) score ≥ 4) within the 24-hour (h) period after surgery. Secondary outcomes included the incidence of moderate-to-severe pain, cumulative postoperative pain NRS scores within 48 h after surgery, and the consumption of analgesic drugs within 24 and 48 h after surgery. In all, 304 patients were enrolled and randomized; 302 patients were included in the final analysis (150 in the noise isolation group, 152 in the control group). The incidence of moderate-to-severe pain was higher in the control than noise isolation group within 24 h after surgery (49 versus 23%, respectively; relative risk (RR) 0.47; 95% confidence interval (c.i.) 0.33 to 0.65; P  < 0.001) and within 48 h after surgery (51 versus 25%, respectively; RR 0.48; 95% c.i. 0.35 to 0.66; P < 0.001). During the 24-h and 48-h periods after surgery, the number of patient-controlled intravenous analgesia boluses was significantly higher in the control group, which also had a higher extra analgesia requirement and increased total analgesic consumption compared with the noise isolation group. The cumulative and maximum rest and movement pain scores were higher in the control than noise isolation group during the 48-h period after surgery. Intraoperative noise isolation was found to be an effective, safe, and non-invasive preventive intervention that significantly lowered the incidence of moderate-to-severe pain after major abdominal surgery, arguing for its integration into standard multimodal analgesic strategies. Registration number: NCT06316440 (http://www.clinicaltrials.gov).
Cannabis use, both medical and recreational, is increasing and poses a growing challenge for anesthesiologists, given the scarcity of specific clinical data. The main phytocannabinoids, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), interact with CB1 and CB2 receptors, affecting cardiovascular, respiratory, neurological, and immune systems, as well as the metabolism of several anesthetic drugs. Chronic or high-dose use can alter anesthetic requirements, increase risk of perioperative complications, and modify postoperative pain responses, often leading to greater opioid consumption. ASRA and PAIN guidelines recommend universal preoperative screening, assessment for cannabis use disorder, dose tapering or discontinuation in high-use patients, and postponement of elective procedures in the presence of acute intoxication. Differentiating medical use - characterized by standardized formulations and titrated dosing - from recreational use, which is more variable and often associated with polysubstance use, is essential. Cardiovascular (tachycardia, hypotension, arrhythmias), respiratory (bronchitis, airway hyperreactivity), and neurological (cognitive impairment, delirium risk) effects require targeted intra- and postoperative monitoring. Multimodal analgesic strategies, opioid-sparing approaches, and postoperative nausea/vomiting prevention are recommended. The pain specialist plays a key role in managing chronic therapy patients, avoiding abrupt discontinuation and preventing withdrawal syndrome, including through oral cannabinoid substitution. A multidisciplinary approach involving anesthesiologists, pain specialists, and pharmacologists, integrating thorough history-taking, risk assessment, and personalized perioperative planning, is essential to optimize safety and outcomes in surgical patients who consume cannabis.
The current study aimed to evaluate the efficacy of vibration and external cooling in contrast to counter-stimulation with audiovisual (AV) distraction in reducing pain and anxiety during inferior alveolar nerve block (IANB). The participants in the study included 36 children aged 6-10 years who needed dental work on their mandibular posterior teeth that called for IANB usage. A pulse oximeter was used for the objective measure, which was pulse rate. The patient selected the Wong-Baker FACES Pain Rating Scale (WBFPRS), and the observer recorded the face, leg, activity, cry, and consolability (FLACC) scale among the subjective measures. The participants were randomly assigned to three groups: Group A: Buzzy, group B: Counter-stimulation with AV distraction group, and group C: Control group (IANB without intervention). Comparison between groups revealed that the differences in pulse rates between the groups were statistically significant during the procedure (p = 0.035). Group B showed the highest mean pulse during the procedure. Regarding Wong-Baker scale results, after the procedure, group A (Buzzy) showed the lowest mean pain score, followed by group C, while group B showed the highest mean pain score, but the difference between groups did not reach a level of statistical significance (p = 0.19). Group B had the highest mean FLACC score, but the groups did not differ significantly. Buzzy was more successful in lowering pediatric dental patients' perceptions of IANB pain as compared to counter-stimulation with AV distraction and conventional technique, but this effect was not statistically significant. Children with dental anxiety have exaggerated expectations of pain. The use of the Buzzy device during IANB aids in improving comfort and cooperation in pediatric dental patients, supporting effective chairside pain and anxiety management. How to cite this article: Abdel Lattif NA, Abd-Alla NF, Alfadhli HA, et al. Buzzy vs Counter-stimulation with Audiovisual Distraction for Pain and Anxiety Control during Inferior Alveolar Nerve Block in Children: A Randomized Controlled Trial. J Contemp Dent Pract 2026;27(2):117-123.
BACKGROUND The Halstead inferior alveolar nerve block (IANB) is the standard local anesthetic method for mandibular dental procedures, but it can fail due to anatomic variations. A modified mylohyoid anesthesia (MMA) block can be used as a supplemental injection technique for the surrounding tissues. Therefore, this study included patients undergoing mandibular molar surgery and aimed to compare outcomes following a modified mylohyoid nerve block with 4% articaine with epinephrine and dexamethasone, 4% articaine with epinephrine, and 2% lidocaine with epinephrine. MATERIAL AND METHODS Sixty patients were equally allocated into 3 groups (n=20). Group 1 received 4% articaine with epinephrine plus dexamethasone via modified mylohyoid anesthesia (MMA). Group 2 received MMA with 4% articaine and epinephrine alone. Group 3 (control) received 2% lidocaine with epinephrine using Halstead's inferior alveolar nerve block. Pain intensity was assessed using a visual analog scale (VAS). Secondary outcomes included quality of anesthesia score (QAS) and duration of anesthesia (DOA). RESULTS Groups were comparable in age (P=0.958). Median VAS scores were 3.5, 5.5, and 8 mm for Groups 1, 2, and 3, respectively, with no significant differences (P=0.232). Median QAS was 2 in all groups (P=0.168). Mean DOA was 189.2, 216.5, and 219 min, respectively. CONCLUSIONS MMA demonstrated clinical outcomes comparable to the conventional inferior alveolar nerve block, although no statistically significant differences were observed among groups.
Radical gastrectomy is associated with trauma and severe pain. We examined whether oxycodone could improve postoperative analgesia and early recovery compared with sufentanil in patients undergoing radical gastrectomy. Patients who underwent radical gastrectomy with patient-controlled intravenous analgesia (PCIA) based on sufentanil or oxycodone for postoperative pain management from January 2022 to December 2023 were included in this study. We used a 1:1 ratio propensity score matching (PSM) in our study to adjust for confounding factors and differences between groups. Patient demographics, surgical and anesthesia details, analgesic effects, and recovery profiles were recorded and analyzed. After PSM, 224 patients were included in each group. Oxycodone treatment was associated with improved pain scores at rest and during movement at 2 h postoperatively (P<0.001), fewer rescue analgesics (P=0.005), shorter time to first flatus and defecation (P=0.030; P=0.016), reduced indwelling nasogastric tube time (P=0.043), shorter length of hospital stay (P=0.031), and lower incidence of nausea in the matched cohort (P=0.049). There were significantly higher lymphocytes (POD1 and POD3: all P<0.001), CD4+ T cells (POD1: P=0.003; POD3: P<0.001) and CD4+/CD8+ T cell ratio (POD1 and POD3: all P<0.001), and lower CD8+ T cells (POD1: P=0.001; POD3: P<0.001). Subgroup analysis stratified by age, surgical technique, and resection extent demonstrated no significant interaction effects across all variables (P-interaction > 0.05). Compared with sufentanil, oxycodone-based PCIA was associated with lower early postoperative pain scores, reduced immune suppression and fewer adverse reactions, and faster gastrointestinal function recovery.
This study aims to compare the analgesic efficacy and procedural efficiency of pectoral (PECS II) blocks performed using artificial intelligence (AI)-integrated ultrasonography (USG) versus conventional USG in patients undergoing modified radical mastectomy (MRM). Between November 2021 and March 2023, a total of 70 female patients scheduled for unilateral MRM under general anesthesia were included in this randomized study. The patients were randomly allocated into two groups: USG group (n = 35) and AI-USG group (n = 35). A fourth-year anesthesiology resident performed the PECS II blocks under the supervision of a senior anesthesiologist. The primary outcome was the postoperative pain score as assessed by Visual Analog Scale (VAS) at 12 hours. Secondary outcomes included pain scores at other postoperative time points, total opioid consumption, time first to rescue analgesia request within 24 hours, and the resident's skill development at the end of the study. The mean age was 55.3±11.4 (range, 35 to 75) years. Intraoperative remifentanil consumption was higher in USG group than in AI-USG group; however, the difference was not statistically significant (p > 0.05). The durations of anesthesia and surgery were shorter in AI-USG group (p = 0.005 and p = 0.008, respectively). A comparison of local anesthetic injection times between the first 35 and the last 35 patients revealed a statistically significant decrease in the USG group (4.0 min vs. 3.0 min, p = 0.014). The VAS pain scores in the post-anesthesia care unit were initially higher in the AI-USG group (p = 0.05); however, at 12 and 24 postoperative hours, VAS scores were significantly lower than those in the USG group (p = 0.005 and p < 0.001, respectively). There was no significant difference in total tramadol consumption via PCA during the first 24 hours postoperatively (p > 0.05). Surgeon satisfaction scores were lower in the AI-USG group (p = 0.037). Our study results suggest that AI-enhanced USG guidance is associated with improved analgesic outcomes and may offer clinical and educational advantages in the performance of PECS II blocks, particularly for residents in training. The integration of AI into routine USG-guided regional anesthesia practice holds promise for improving procedural consistency and supporting novice practitioners.
Breast cancer remains the most frequently diagnosed malignancy among females worldwide. Surgical management is the cornerstone of the therapeutic strategy, however associated with multiple postoperative complications, particularly acute pain and shoulder mobility limitations. Regional anesthetic techniques have been proposed to counteract this phenomenon, such as the modified pectoral plane block (PECS II) and erector spinae plane block (ESPB). This systematic review and meta-analysis aims to compare between ESPB and PECS II in managing post-operative pain in modified radical mastectomy patients. We conducted a systematic search of PubMed, Web of Science, and Scopus up to July 2025. According to our eligibility criteria, randomized controlled trials comparing PECS II and ESPB techniques in modified radical mastectomy patients were included. Our primary outcomes were post-operative analgesia duration, postoperative morphine use in the first 24 h, and postoperative pain scores. Quality assessment was conducted using the Cochrane risk of bias assessment tool 2 (RoB2). Analysis of relevant outcomes was conducted using R software Version 4.4.2. The literature search identified 697 studies, of which 11 trials, involving 790 patients, were analyzed. Compared to ESPB, PECS II was associated with a significantly longer analgesia duration [MD = -3.16, 95%CI (-6.11; -0.21), P = 0.0361], and fewer rescue analgesia requirement [RR = 1.37, (95%CI; 1.01, 1.87), P = 0.0437]. Pain assessment at 24 h, using the numerical rating scale (NRS) or the visual analogue scale (VAS), was comparable between the two techniques. Intraoperative fentanyl consumption was comparable, whereas postoperative morphine use in the first 24 h was significantly lower following PECS II [MD 2.96, 95%CI (2.43, 3.48), P < 0.0001]. PECS II was superior to ESPB, with a longer analgesia duration, reduced rescue analgesia requirement, and postoperative morphine consumption in the first 24 h. Overall, PECS II may offer modest analgesic advantages in modified radical mastectomy patients.
BackgroundIn this study we investigated the effect of adding dexmedetomidine to fascia iliaca compartment block on postoperative analgesia in patients undergoing femoral fracture surgery.MethodsIn this double-blind randomized clinical trial study, 70 patients aged 20-75 years, classified as American Society of Anesthesiologists physical status I and II who were scheduled to undergo femoral fracture surgery under spinal anesthesia were included. Patients were divided into intervention and control groups using the block randomization method (35 patients in each group). In the intervention group, fascia iliaca block was performed using 20 cc of 0.25% bupivacaine with 0.5 cc of 50 μg dexmedetomidine (fascia iliaca compartment block + dexmedetomidine group), and in the control group, the block was performed using 20 cc of 0.25% bupivacaine alone (fascia iliaca block group). The outcomes, including the average time to achieve sensory block, analgesia duration, number of times rescue analgesia was needed, time to first rescue analgesia, and pain severity assessed using the visual analog scale within 24 h postoperatively, were measured and compared between the two groups.ResultsThe demographic data and time to reach sensory block were not significantly different between the two groups (p > 0.05). The mean analgesia duration in the fascia iliaca compartment block + dexmedetomidine group was significantly longer than that in the fascia iliaca block group (11.42 ± 1.65 vs. 9.26 ± 1.39 h; p = 0.001). An analgesic was prescribed for 11.4% and 31.4% of the patients 2-6 h postoperatively and for 54.3% and 77.1% at 6-12 h postoperatively in the fascia iliaca compartment block + dexmedetomidine and fascia iliaca block groups, respectively, representing a statistically significant difference between the two groups (p = 0.03). The visual analogue scale scores while in recovery, at 2 h postoperatively, and at 12-24 h postoperatively did not show a statistically significant difference between the two groups (p > 0.05); however, patients in the fascia iliaca compartment block group had significantly higher pain scores than those in the fascia iliaca compartment block + dexmedetomidine group at 2-6 h and 6-12 h postoperatively (p < 0.05).ConclusionAddition of dexmedetomidine to bupivacaine in the fascia iliaca block in femoral fracture surgeries reduces the severity of postoperative pain and need for analgesics and increases the analgesia duration.
Neuropathic pain arises from an intricate network of interconnected pathophysiological mechanisms, yet the arsenal of effective therapeutic strategies remains frustratingly limited. Accumulating evidence has linked mitochondrial dysfunction to the progression of neuropathic pain. C1q‑tumor necrosis factor‑related protein‑3 (CTRP3), a newly identified adipokine with diverse cytoprotective capacities, has not been previously explored for its role in nociceptive processing. To explore the role of CTRP3 in pain hypersensitivity, pain‑related behavioral assessments were conducted using von Frey filaments and acetone drop method in male rats subjected to spared nerve injury (SNI). To unravel the underlying mechanisms, spinal cord tissues were subjected to western blotting, reverse transcription‑quantitative PCR, immunofluorescence staining, dihydroethidium staining, small interfering RNA (siRNA) technologies and biochemical assays for quantifying oxidative markers. The findings showed that SNI markedly reduced endogenous CTRP3 expression in spinal neurons. Intrathecal administration of recombinant CTRP3 (rCTRP3) alleviated mechanical allodynia and cold hyperalgesia in SNI‑induced rats. Additionally, rCTRP3 treatment enhanced PGC‑1α‑mediated mitochondrial biogenesis, ATF5‑triggered mitochondrial unfolded protein response (UPRmt), and mitigated spinal oxidative stress. Mechanistically, pharmacological inhibition of SIRT1 with EX‑527, or siRNA‑mediated silencing of PGC‑1α or ATF5, reversed the effects of CTRP3 on pain hypersensitivity, mitochondrial biogenesis, UPRmt and oxidative stress. The present study demonstrates that CTRP3 mitigates mechanical allodynia and cold hyperalgesia in male SNI rats by activating spinal SIRT1, thereby enhancing PGC‑1α‑mediated mitochondrial biogenesis and ATF5‑induced UPRmt. CTRP3 may therefore represent a novel therapeutic target for the management of neuropathic pain.
Anesthetic agents can cause hypotension, and patients with severe aortic stenosis (AS) require special attention. This study compared the effects of remimazolam versus sevoflurane anesthesia on hemodynamics in patients with severe AS undergoing minimally invasive aortic valve replacement (AVR). Patients were assigned to the remimazolam (R) or sevoflurane (S) group. Group R received remimazolam 6 mg/kg/h for induction and 1-2 mg/kg/h for maintenance with remifentanil. Group S received 1% propofol at 1-2 mg/kg for induction and sevoflurane with remifentanil for maintenance. Vasopressor requirement and hypotensive events were compared. Sixty-four patients were enrolled, and one patient was excluded from the study. The infusion rate of norepinephrine was lower in group R during post-cardiopulmonary bypass (CPB) (0.040±0.051 vs. 0.085±0.080 mcg/kg/min, P=0.03). The proportion of hypotension was lower in group R during post-CPB (80.2%±21.5% vs. 91.9%±25.2%, P=0.04), and the entire duration of anesthesia (66.5%±16.9% vs. 76.0%±16.2%, P=0.03). Compared to conventional sevoflurane anesthesia, remimazolam-based total intravenous anesthesia was associated with more stable hemodynamics and reduced vasopressor requirement during pre-CPB, and post-CPB in patients with severe AS undergoing minimally invasive AVR. The clinical research was registered at ClinicalTrials.gov (Ref: NCT05864625).
Conventional radiotherapy for bulky tumors is often limited by normal tissue tolerance, restricting dose escalation and increasing toxicity. Spatially Fractionated Radiation Therapy (SFRT), including GRID and Lattice Radiotherapy (LRT), delivers intentionally heterogeneous dose distributions to overcome these limitations. This systematic review summarizes the clinical application, outcomes, and dosimetric variability of SFRT in the treatment of bulky tumors. A systematic literature search of the MEDLINE database was performed for studies published between January 2010 and June 2025. Eligible English-language studies reporting original clinical data on SFRT, including case reports, case series, retrospective analyses, and prospective trials, were included. Data on patient and tumor characteristics, treatment intent, SFRT technique, clinical response, and toxicity were extracted, and methodological quality was assessed using the ROBINS-I framework. Twenty-nine studies involving 513 patients and 553 lesions were included. The most commonly treated sites were the thorax (28.8%), pelvis (24.7%) and abdomen (23.3%), with sarcomas (48.0%) carcinomas (14.5%) and non-small cell lung cancer (10.4%) being the predominant histologies. SFRT was mainly delivered with palliative intent (216 cases). Tumor shrinkage was reported in approximately 80% of lesions, with consistent symptom relief. Treatment-related toxicity was generally mild, with most adverse events graded as 1-2; severe toxicities (Grade ≥ 3) were rare. Despite favorable clinical outcomes and an acceptable safety profile, substantial heterogeneity in dosimetric parameters, including valley-to-peak dose ratio and fractionation schemes, was observed across studies. SFRT appears to be a feasible and effective option for bulky tumors, particularly in the palliative setting. However, the lack of dosimetric standardization and prospective data highlights the need for harmonized protocols and well-designed clinical trials.
Ex-premature infants have a high risk of postoperative apnea and bradycardia. This study aimed to develop a predictive model for postoperative desaturation and bradycardia in infants who underwent laparoscopic inguinal hernia repair (IHR) under general anesthesia based on identified risk factors. The retrospective cohort included infants who underwent laparoscopic IHR under general anesthesia at Severance Hospital in Korea between February 2013 and September 2019. Collected data included sex, gestational age (GA), postnatal age and post-conceptual age at surgery, birth weight, body weight at surgery, medical history and comorbidities, urgency of surgery, preoperative hemoglobin, anesthetic agents used, operation time, anesthesia time, intraoperative opioid dose, length of hospital stay, operation to discharge time, and postoperative ward. Feature selection was applied, and a machine learning model was developed to predict postoperative desaturation and bradycardia. Three features for desaturation (cardiac comorbidities, GA, and body weight at surgery) and two features for bradycardia (GA and cardiac comorbidities) were selected for multivariate logistic regression analysis. Cardiac comorbidities were the most significant predictor for desaturation and bradycardia with odds ratios (95% confidence intervals) of 5.112 (1.881-13.888) and 26.597 (3.190-221.850), respectively. Preterm infants with cardiac comorbidities and lower GA may be more susceptible to postoperative desaturation or bradycardia.
Sternotomy causes substantial postoperative pain. Recently, several less invasive nerve blocks have been described that are safer to use even on anticoagulated patients. This study aims to evaluate early pain management using ultrasound-guided superficial parasternal intercostal plane block (SPIP) in patients undergoing aortic valve replacement via full sternotomy. This was a randomized, placebo-controlled trial performed in a tertiary referral hospital. Seventy-four elective patients scheduled for aortic valve replacement via full sternotomy were included. Patients were randomized to receive a preoperative SPIP block using either 40 mL of ropivacaine 7.5 mg/mL or 40 mL of 0.9% saline. Cumulative oxycodone consumption during the first 24 postoperative hours was recorded and analyzed as the primary outcome. Pain at rest was assessed using the numerical rating scale (NRS) scores 48 h postoperatively. Additional secondary outcomes included the need for vasopressors and antiemetics, recovery of bowel function, time spent in the intensive care unit (ICU), and nerve block-related complications. The 24-h cumulative consumption was not significantly different between groups (93.8 mg ± 33.3 vs. 109.4 mg ± 37.9, p = 0.066). NRS pain scores at rest were reduced in the patients with SPIP at 4 (5.0 ± 1.8 vs. 3.3 ± 2.4, p = 0.002). No differences were found in additional secondary outcomes. In this randomized controlled trial a single-shot SPIP block did not reduce the 24-h cumulative opioid consumption after cardiac surgery. This trial in a cardiac surgical cohort tested for possible benefit of a single injection superficial parasternal intercostal plane block for post-operative analgesia for post-sternotomy pain. The study found no post-op opioid treatment reduction with the treatment, but some analgesia effect cannot be ruled out.
Neuromuscular blocking agents (NMBAs) are the leading cause of perioperative anaphylaxis. In confirmed cases with limited non-cross-reactive options, safe anesthesia requires coordination and muscle relaxant-free strategies. A 64-year-old woman with confirmed rocuronium-induced anaphylaxis and multiple comorbidities-including poorly controlled diabetes, coronary artery disease, chronic obstructive pulmonary disease, and obesity-underwent laparoscopic anterior resection of the sigmoid colon. General anesthesia was induced and maintained without muscle relaxants using total intravenous anesthesia and regional blocks. Airway topicalization and deep anesthesia enabled smooth intubation. Bilateral transversus abdominis plane and rectus sheath blocks provided effective somatic analgesia and abdominal relaxation. Ventilation and hemodynamic parameters remained stable throughout. The patient recovered uneventfully, without agitation or delayed arousal, and was discharged uneventfully on postoperative day 5. This report describes the feasibility of NMBA-free general anesthesia using intravenous agents and targeted regional blocks in high-risk patients with confirmed anaphylaxis, even in laparoscopic procedures.
The coronavirus disease 2019 (COVID-19) pandemic has profoundly influenced surgical practice and perioperative care, but its impact on postoperative pneumonia incidence remains unclear. We conducted a retrospective cohort study using the Observational Medical Outcomes Partnership-Common Data Model databases from 17 Korean hospitals. Based on the inpatient surgery date, patients were classified into prepandemic (January 2018-December 2019) and postpandemic groups (January 2020-December 2021). Postoperative pneumonia was identified within 30 days after surgery. Logistic regression analysis assessed the independent effects of the pandemic, age, anesthetic technique, and their interaction. The overall incidence of postoperative pneumonia per 10,000 persons changed slightly from 12.38 prepandemic to 12.99 postpandemic (+4.94%). Younger patients (< 70 years) demonstrated decreased incidence (8.47→7.97, -5.81%), whereas older patients (≥ 70 years) demonstrated increased incidence (28.97→31.97, +10.36%). Considerable interhospital variation was observed, with some hospitals reporting increases exceeding 100%, while others reporting declines exceeding 80%. Overall postoperative pneumonia risk was similar between the pre- and postpandemic periods (odds ratio [OR], 0.893; 95% confidence interval [CI], 0.787-1.015). Older age (≥ 70 years) was strongly associated with higher risk (OR, 2.816; 95% CI, 2.383-3.328), and a significant postpandemic×age interaction indicated that older patients were disproportionately affected (OR, 1.385; 95% CI, 1.145-1.675). The COVID-19 pandemic did not substantially change the overall incidence of postoperative pneumonia, although variations existed across hospitals and age groups. Older age remained the strongest risk factor. Further studies are warranted to clarify the underlying causes and optimize perioperative infection control.
Postoperative neurocognitive disorders, including delirium and longer-term cognitive decline, are among the most common and costly complications of surgery in older adults, yet effective preventive strategies remain limited. Insomnia and sleep-circadian disruption are highly prevalent in this population, affecting up to one-third of older adults undergoing elective surgery and represent potentially modifiable risk factors that are rarely addressed in perioperative care. Cognitive Behavioural Therapy for Insomnia (CBT-I) is the first-line, evidence-based treatment for insomnia; however, its feasibility and efficacy have not been systematically evaluated for perioperative implementation. This protocol describes a pilot randomised controlled trial designed to evaluate the feasibility and acceptability of a condensed CBT-I intervention in the perioperative setting. The study will also explore its potential effects on insomnia and postoperative outcomes. The SLEEP-BOOST study is a single-site, randomised controlled pilot trial conducted at Massachusetts General Hospital. The study will enrol 50 older adults (≥65 years) undergoing elective orthopaedic surgery with insomnia symptoms (Insomnia Severity Index≥10). Participants will be randomised 1:1 to either a condensed CBT-I intervention or a patient contact-matched Sleep Hygiene Education control group. All participants will complete 3 weeks of preoperative actigraphy and daily sleep diaries, with follow-up assessments at 2 weeks, 1 month and 3 months after surgery. The primary outcome is feasibility, assessed through adherence metrics, protocol engagement and acceptability. Secondary outcomes will be treated as exploratory including insomnia severity, sleep quality, actigraphy-derived sleep and circadian metrics, cognitive trajectories, postoperative pain, mood, functional status and incidence of postoperative neurocognitive disorders. This protocol has received ethics approval from Massachusetts General Hospital Institutional Review Board (Protocol #2024P000780). Dissemination is expected to include peer-reviewed journal articles, reports, conference presentations as well as websites or social media platforms of relevant sleep treatment organisations. Participants will receive a summary of the study results. NCT06375265.