搜索结果：Anesthesiology and Pain Medicine

Chronic knee (CK) pain has various underlying etiologies with several available therapeutic options that differ in effectiveness, duration, and complication rate. For the past decade, a minimally invasive ablation relying upon genicular radiofrequency has been gaining popularity as a treatment for the condition. To date, however, the literature contains only limited data supporting the effectiveness of this procedure, leading to insurance companies labeling it as "experimental" and denying claims. Benefits described include reduced adverse outcomes and complications, quicker recovery and longer duration of analgesia, and broader scope of applicability when compared to other, traditional treatments. The present investigation focused on genicular radiofrequency ablation (GRFA) and its outcomes, including disability (e.g., stiffness, physical function), pain, and improvement in patients' quality of life. This retrospective, single-center study was conducted to evaluate the safety and effectiveness of GRFAs, plus their associated radiofrequency generators and electrode systems. The equipment consisted of the MultiGen® 2 Radiofrequency Generator (Stryker Corporation) and the RFA Solutions Generator System (Avanos Medical, Inc.). Selected patient age ranged between 26 and 92 years, with a mean age of 56.5 years. Thirty-four (34) individuals were enrolled at LSU Health Shreveport, which was the sole investigational site, between March 2021 and 2025. The Stryker SERFAS Energy Platform (Stryker Corporation) was the primary radiofrequency generator selected for genicular ablation (61.9%), with the Avanos RFA Solutions Generator System (Avanos Medical, Inc.) selected for the remaining cases. As for the outcome measures, scores on the visual analog scale (VAS), disability changes measured on the Western Ontario and McMaster Universities Arthritis Index (WOMAC), adverse outcomes, quality of improvement, and ratings recorded in the Quality of Life subsection of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were compared after GRFA. Mean VAS scores for CK pain intensity decreased significantly, dropping by 3.1 cm from a baseline score of 9.0 cm by the specified end (March 18th, 2025). Furthermore, 66.7% of the patients experienced a 20% or greater improvement in pain, 33.3% of the patients experienced a 40% or greater improvement in pain, and 19.1% of the patients experienced a 60% or greater improvement in pain. Zero (0) procedure-related adverse events or intra- or post-procedural complications occurred during the investigation. The study was retrospective and had no sham operation to determine placebo response. The relatively small sample size (34 total ablations, 21 patients) could have limited the generalizability of the results. Furthermore, the withdrawal rate was 38%, thereby limiting the certainty of the treatment's long-term duration. Results should be considered hypothesis-generating, not confirmatory, but they align well with the growing body of corroborating literature. The results of this study substantially reinforce GRFA as a safe, effective, and minimally invasive treatment option for patients experiencing CK pain over a 6-month period.

Cervical radicular pain is a common chronic pain syndrome, typically managed with conservative treatments. In patients unresponsive to conservative management, minimally invasive interventions, such as an interlaminar cervical epidural steroid injection (ICESI), are employed. The cervical erector spinae plane block (ESPB), initially utilized at the upper thoracic level, has shown promise for managing cervical radicular pain and may serve as an alternative to an ICESI. Our study compared the efficacy of ICESIs and cervical ESPBs in patients with cervical radicular pain that was refractory to conservative treatment. A randomized, double-blind, controlled trial. Rasool Akram Hospital, pain clinic and pain operating room, Department of Anesthesia and Pain Medicine, Iran University of Medical Science, Tehran, Islamic Republic of Iran. In this randomized clinical trial, 30 patients with cervical radicular pain that was unresponsive to conservative therapy were randomized into 2 groups: ICESI Group and ESPB Group. Outcomes were assessed at baseline, and at the 2- and 8 weeks postprocedure follow-ups using the Neck Disability Index (NDI) and the Numeric Rating Scale (NRS-11). Both groups demonstrated significant reductions in pain intensity and improvements in functional status (P < 0.05). No significant differences in mean (SD) NRS-11 scores were recorded between the groups at 2 weeks (ICESI: 3.93 [1.87] vs. ESPB: 3.73 [1.98], P = 0.778) and 8 weeks (ICESI: 3.53 [2.92] vs. ESPB: 4.93 [3.06], P = 0.211). However, the ICESI group showed significantly greater improvement in mean (SD) NDI scores at both follow-up intervals (11.870 [6.812] vs 19.670 [7.715], P = 0.007, at 2 weeks; 10.070 [8.216] vs 19.000 [9.577], P = 0.011, at 8 weeks follow-up). The limitations of this study are its short follow-up times and small sample size. Cervical ESPBs are as effective as ICESIs in reducing pain and improving function in patients with cervical radicular pain. Given its comparable efficacy and potentially fewer adverse effects, ESPBs may be considered a suitable alternative to ICESIs in this patient population.

In this double-blind, randomized controlled trial, we compared the efficacy of perineural 2 &#xb5;g/kg dexmedetomidine and 5 mg dexamethasone as adjuvants to bupivacaine for postoperative pain control in patients undergoing arthroscopic shoulder surgery. We hypothesized that the combination of bupivacaine with dexmedetomidine would prolong analgesia compared with dexamethasone. One hundred twelve patients scheduled for arthroscopic shoulder surgery were randomized to receive 15 mL of 0.33% bupivacaine with either 2 &#xb5;g/kg of dexmedetomidine or 5 mg of dexamethasone during ultrasound-guided interscalene brachial plexus block (ISB). The primary outcome was the duration of analgesia (DOA), analyzed as a time-to-event variable using Kaplan-Meier survival curves with log-rank testing. Secondary outcomes included the duration of sensory block (DOS) and motor block (DOM), pain scores, incidence and severity of rebound pain, opioid consumption, patient satisfaction, and adverse effects. Longitudinal pain scores were evaluated using a regression model. Of 112 randomized patients, 107 were included in the primary analysis. Dexmedetomidine and dexamethasone produced a similar DOA (median, 16.77 vs 12.48 h; median difference in location 5.24 h, 95% CI -0.47 to 9.17; p&#x2009;=&#x2009;0.655). The dexmedetomidine group had a significantly longer DOS (19.8 vs. 17.3 h; mean difference 2.45 h, 95% CI 0.23 to 4.65; p&#x2009;=&#x2009;0.031) and DOM (19.9 vs. 17.8 h; median difference in location 2.23 h, 95% CI 1.02 to 3.60; p&#x2009;=&#x2009;0.008). Postoperative pain score at 6, 12, 18, and 24 hours were comparable, as were rebound pain, postoperative nausea and vomiting (PONV), patient satisfaction, and opioid consumption. The dexmedetomidine group had a higher incidence of intraoperative hypotension (risk difference [RD] 44.4%, 95% CI 30.0% to 59.9%; p&#x2009;<&#x2009;0.001), bradycardia in the block room (RD 17.9%; p&#x2009;=&#x2009;0.010) and intraoperatively (RD 27.6%; p&#x2009;=&#x2009;0.004), and postoperative sedation (RD 10.9%; p&#x2009;=&#x2009;0.027); however, all hemodynamic events were transient and did not require intensive care admission. Perineural dexmedetomidine (2 &#xb5;g/kg) was not shown to be superior to dexamethasone (5 mg) in prolonging analgesia when added to bupivacaine for ISB in arthroscopic shoulder surgery. Although dexmedetomidine prolonged sensory and motor block duration, this did not translate into a longer DOA and was associated with higher rates of hemodynamic instability and sedation. These findings suggest limited clinical benefit and raise safety concerns regarding higher dexmedetomidine doses.

Neuropathic pain is a chronic pain disorder refractory to conventional analgesics. Iron-dependent neuronal ferroptosis has been implicated in its pathogenesis. G protein-coupled receptor 4 (GPR4), a proton-sensing receptor, is involved in inflammation and ferroptosis, but its role in neuropathic pain and spinal neuronal ferroptosis remains unclear. Neuropathic pain was induced in rats using the spared nerve injury (SNI) model, and GPR4 expression and its effects on pain behaviors, neuronal ferroptosis, and spinal inflammation were examined. GPR4 was inhibited by a selective antagonist or small interfering RNA (siRNA), while Ras homolog family member A (RhoA) and Yes-associated protein (YAP) were activated via intrathecal injection of specific agonists. Spinal GPR4 expression was significantly upregulated and neuronal ferroptosis was induced by SNI, as evidenced by increased iron accumulation, lipid peroxidation, and dysregulated ferroptosis-related protein expression. SNI-induced mechanical allodynia, cold hyperalgesia, neuronal ferroptosis, and spinal inflammation were attenuated by GPR4 inhibition or knockdown. Mechanistically, the spinal RhoA/YAP signaling pathway was activated by SNI, and this activation was reversed by GPR4 inhibition. Furthermore, the analgesic and anti-ferroptotic effects of GPR4 inhibition were abolished by RhoA or YAP activation. It is demonstrated that GPR4 regulates neuropathic pain, neuronal ferroptosis, and spinal inflammation via the spinal RhoA/YAP signaling pathway, suggesting that GPR4 inhibition may represent a promising novel therapeutic strategy for neuropathic pain.

Chronic widespread pain (CWP) is a debilitating condition characterized by persistent pain, yet objective biomarkers based on electroencephalography (EEG) remain elusive. This exploratory study aimed to identify neurophysiological correlations related to the sensory and affective dimensions of CWP using resting-state EEG data analyzed with exact low-resolution electromagnetic tomography (eLORETA). We analyzed data from 20 CWP patients and 22 healthy controls, calculating current source density (CSD) and functional connectivity (FC) in key brain networks and correlating them with pain scores from the numerical rating scale and short-form McGill Pain Questionnaire. While no significant CSD or FC differences emerged between the groups, analysis within the CWP group yielded two preliminary associations. First, current pain intensity was negatively correlated with CSD values in the &#x3b3; bands of the precuneus/posterior cingulate cortex (PCC) (r = -0.743). Second, the affective pain component was positively correlated with &#x3b4; band FC between the anterior cingulate cortex (ACC) and the right anterior insula (r = 0.647). These results suggest that EEG-derived neurophysiological correlations can offer insights into individual differences in the CWP experience. The findings in the precuneus/PCC may reflect exploratory correlations associated with sensory pain intensity, while the salience network connectivity may be linked to the affective dimension of pain. Future research with larger, homogeneous samples and longitudinal designs is needed to evaluate the potential clinical relevance of these electrophysiological correlations.

AI adoption in health care has accelerated rapidly, with ambient documentation tools, diagnostic imaging AI, and clinical decision support systems (CDSSs) entering routine practice. However, the cognitive demands placed on clinicians supervising these systems remain understudied. Specifically, the concept of verification burden requires closer examination. Consequently, institutional decision-makers lack a structured, certainty-graded evidence base regarding the true impact of AI on clinician workload and burnout. This study aimed to systematically review evidence on cognitive workload and burnout in health care professionals that use AI-powered clinical tools, quantify pooled effects under a conservative inferential framework, and assess certainty of evidence by AI category. The study was registered in PROSPERO (CRD420261284298) and reported per PRISMA 2020 and PRISMA-S guidelines. We searched MEDLINE, Embase, Web of Science, and Cochrane CENTRAL (January 2015-2026) for studies measuring cognitive workload or burnout using validated instruments (NASA Task Load Index [NASA-TLX] and Professional Fulfillment Index [PFI]) among health care professionals using clinical AI. Risk of bias was assessed using ROB 2.0 and ROBINS-I; certainty was rated using GRADE. Meta-analyses applied Hartung-Knapp-Sidik-Jonkman adjustment with restricted maximum likelihood estimation, incorporating prediction intervals (PIs). We included 21 studies representing 2885 health care professionals across 7 countries. The synthesis demonstrated that the cognitive impact of clinical AI varies according to its specific application. Pooled analyses of ambient AI documentation showed statistically significant reductions in NASA-TLX temporal demand (SMD -1.46, 95% CI -2.81 to -0.11; k=2; I2=31.1%) and effort (SMD -1.29, 95% CI -2.16 to -0.42; k=2; I2=0%), PFI work exhaustion (MD -0.35, 95% CI -0.58 to -0.12; k=3; I2=0%; 95% PI -1.03 to 0.33), and burnout prevalence (OR 0.47, 95% CI 0.25-0.86; k=3; I2=0%; 95% PI 0.06-3.82). Two pools favored ambient AI but did not reach significance at k=2: NASA-TLX mental demand (SMD -1.29, 95% CI -3.64 to 1.07) and documentation time (SMD -0.24, 95% CI -1.10 to 0.61). Diagnostic imaging AI and CDSS showed mixed or paradoxically increased workload. GRADE certainty was moderate for cognitive workload reduction with ambient AI, low for burnout reduction with ambient AI, and very low for imaging AI and CDSS outcomes. This review combines validated workload instruments, meta-analysis, and PIs in health care AI, delivering a GRADE certainty assessment across 5 AI categories that prior accuracy- or efficiency-focused reviews have not provided. Ambient AI documentation was associated with reduced cognitive workload and burnout, but only in voluntary early-adopter cohorts and based on few studies; the conservative CIs were wide and, where estimable, PIs crossed the null. Findings inform institutional pilots with prospective workload measurement, regulatory human-factors evaluation of AI medical devices, and human-centered AI design. Net benefit on the health care workforce remains an open empirical question.

Pain management is a core ethical principle in emergency medicine, yet gender-related differences in analgesic treatment have been reported. This study examines whether patient and emergency physician gender influence prehospital pain management. This retrospective observational cohort study included all primary helicopter emergency medical service missions conducted by DRF Stiftung Luftrettung in Germany between January 2012 and June 2025. Adult patients (&#x2265;&#x2009;18 years) with a Glasgow Coma Scale score&#x2009;&#x2265;&#x2009;11 and without airway management were analyzed. Pain severity was assessed using the Numeric Rating Scale (NRS). Patient characteristics, analgesic treatment, and emergency physician gender were analyzed using descriptive statistical methods. The study was approved by the Ethics Committee Freiburg (25-1272-S1, August 19th 2025). A total of 106,888 cases was included, of which 38.5% were female and 61.5% male. Initial pain severity was comparable between genders, with a similar distribution across NRS categories. Despite this, women received analgesic treatment less frequently than men (62.0% vs. 66.9%; p&#x2009;<&#x2009;0.001), whereas a greater effect is seen when particularly examining the use of opioid analgesics (50.0% vs. 57.1%; p&#x2009;<&#x2009;0.001). This finding is consistent across all pain severity subgroups. Pain scores at patient handover were similar for women and men, indicating comparable pain levels at the end of prehospital care. Despite comparable pain intensity, women received analgesic and opioid treatment less frequently than men in prehospital care, indicating potential gender-based inequalities in pain management. These findings underscore the need for strategies to ensure equitable analgesic treatment.

Background Onboarding in anesthesiology varies widely across institutions and often emphasizes logistics over clinical workflow integration, contributing to cognitive load and inconsistent early practice. These challenges may be amplified in thoracic anesthesia, where complex perioperative management requires specialized skills and coordinated workflows. Although structured perioperative pathways, such as Enhanced Recovery After Surgery (ERAS) protocols, improve outcomes when consistently implemented, adherence depends on reliable, accessible clinical guidance. This quality improvement needs assessment evaluated thoracic anesthesia practitioners' perceptions of standardized, workflow-integrated templates to support onboarding and protocol adherence. Methods A pre-implementation needs assessment was conducted among anesthesia residents, fellows, and faculty to evaluate the perceived usefulness of standardized template systems for thoracic cases, with a primary focus on the ERAS protocol. The survey assessed anticipated effects on confidence and clinical focus (e.g., shifting effort from learning local norms to patient optimization and patient-centered care) and identified perceived barriers and concerns to implementation. Results Most respondents were staff anesthesiologists. Exposure to thoracic anesthesia varied. Most participants reported prior experience with ERAS protocols. Participants perceived that access to a standardized thoracic ERAS protocol would increase confidence in managing cases and facilitate more rapid integration into new clinical environments. Respondents also reported that standardized protocols would support greater focus on patient optimization rather than determining local standards of care. Reported concerns included potential reductions in clinical flexibility and the need for regular protocol updates, while integration within the electronic health record was identified as the preferred mode of access. Conclusion Respondents perceived standardized thoracic ERAS protocols as useful for improving confidence, integration, and clinical focus, with EHR integration preferred. Concerns centered on flexibility and protocol updates. Findings support implementation feasibility and inform a post-implementation evaluation.

Epigenetics, the study of heritable changes in gene expression that occur without altering the underlying DNA sequence, has emerged as an important conceptual framework for anesthesiology. The epigenome is organized into three mechanistic tiers: cytosine methylation in DNA, chemical modification of histone proteins, and gene regulation by non-coding RNA molecules. Unlike a relatively stable genome, epigenetic patterns vary between cell types, change throughout the lifespan, and are modifiable by environmental exposures, including surgical stress and anesthetic drugs. These properties make epigenetic mechanisms particularly relevant to several problems encountered in anesthetic practice. For example, interindividual variability in responses to analgesics and anesthetics, pathophysiology of chronic pain and opioid tolerance, immune dysregulation in critical illness, and long-term cognitive consequences of perioperative exposure in vulnerable populations. This review aimed to explore the fundamental concepts of epigenetics for anesthesiologists; established roles in disease conditions relevant to anesthesiology, including pain, neurodegeneration, and inflammation; and the key considerations for designing and interpreting epigenetic research in the perioperative context. Understanding the epigenome offers both a new lens through which to view the clinical phenomena encountered daily in anesthetic practice, and a potential avenue toward more individualized, mechanism-informed patient care.

Laparoscopic surgery has become the mainstream approach for gynecological procedures. However, postoperative pain, particularly visceral pain, remains a major obstacle to achieving enhanced recovery after surgery. Therefore, this study aimed to observe the clinical effects of opioid-sparing anesthesia combined with a quadratus lumborum block (QLB) in patients undergoing gynecological laparoscopic surgery to provide a reference for clinical practice. A total of 80 female patients (aged 18 to 65 years, body mass index 18 to 28&#x2009;kg/m2, American Society of Anesthesiologists I-II) scheduled for elective gynecological laparoscopic surgery under general anesthesia were enrolled and randomly assigned to 2 groups (n&#x2005;=&#x2005;40 each): the control group (Group C) and the treatment group (Group T). All patients received general anesthesia. In Group T, a bilateral QLB was additionally performed under ultrasound guidance after the induction of general anesthesia. The following parameters were recorded for both groups: general demographic data and perioperative parameters; total intraoperative remifentanil consumption; postoperative analgesic pump consumption at 0 to 24 hours and 24 to 48 hours; the number of effective presses and total presses of the analgesic pump during 0 to 24 hours and 24 to 48 hours postoperatively; numerical rating scale (NRS) scores at rest and during movement at 2 hours, 6 hours, 12 hours, 24 hours, and 48 hours postoperatively; the rescue analgesia rate within 48 hours postoperatively; and the incidence of adverse reactions (hypotension, respiratory depression, postoperative nausea and vomiting [PONV], somnolence). Compared with Group C, patients in Group T had significantly reduced the following parameters: total intraoperative remifentanil consumption (P&#x2005;<&#x2005;.05); analgesic pump consumption at 0 to 24 hours and 24 to 48 hours postoperatively (P&#x2005;<&#x2005;.05); the number of effective presses and total presses of the analgesic pump during 0 to 24 hours and 24 to 48 hours postoperatively (P&#x2005;<&#x2005;.05); resting NRS scores at 12 hours, 24 hours, and 48 hours postoperatively (P&#x2005;<&#x2005;.05); and movement NRS scores at 6 hours, 12 hours, 24 hours, and 48 hours postoperatively (P&#x2005;<&#x2005;.05). Furthermore, the rescue analgesia rate within 48 hours postoperatively was significantly lower in Group T compared to Group C (P&#x2005;<&#x2005;.05). Regarding adverse reactions, the incidence of PONV in Group T was considerably lower than that in Group C (P&#x2005;<&#x2005;.05). For gynecological patients undergoing laparoscopic surgery, the application of opioid-sparing anesthesia combined with a QLB provides effective analgesia, reduces intraoperative opioid consumption, prolongs the duration of postoperative analgesia, lowers the incidence of PONV, and promotes enhanced postoperative recovery.

To investigate the associations between the use of epidural analgesia (EA) and intrapartum care, labour, birth and neonatal outcomes in uncomplicated pregnancy low-risk women, to inform evidence-based intrapartum practices and support informed maternal choice. Retrospective cohort study. Single maternity hospital in Northern Italy. A total of 3406 uncomplicated pregnancy low-risk women who gave birth between 2019 and 2023 were included. Participants were grouped according to whether they received EA (n=417) or not (n=2989). Labour progression, intrapartum care practices, maternal and neonatal outcomes were evaluated according to exposure to EA. Associations between EA and the study outcomes were assessed using descriptive and inferential statistics and multivariable logistic and linear regression analyses, adjusted for maternal age, parity and other outcome-specific confounders. Women receiving EA experienced higher rates of prolonged first and second stage of labour (adjusted OR (aOR) 24.3 and 5.0, 95%&#x2009;CI 17.8 to 33.6&#x2009;and 3.8 to 6.6, respectively), amniotomy and oxytocin use (aOR 7.7 and 17.8, 95%&#x2009;CI 5.7 to 10.6&#x2009;and 12.9 to 24.6, respectively), caesarean section (aOR 7.2, 95%&#x2009;CI 3.1 to 17.1), lithotomy position at birth (aOR 2.3, 95%&#x2009;CI 1.7 to 3.0)&#x2009;and urinary retention (aOR 6.0, 95%&#x2009;CI 3.1 to 11.5). No differences were observed in neonatal outcomes. In uncomplicated pregnancy low-risk women, EA during active labour was associated with increased rates of clinical interventions and altered labour patterns, with no differences in neonatal outcomes. These findings underscore the importance of the midwife's role in promoting physiological labour while ensuring effective pain management.

An association between personality factors and pain experience has been investigated. However, the direct contributions of personality traits by the Maudsley Personality Inventory to clinical pain outcomes in patients with chronic pain remain unclear. The Maudsley Personality Inventory is a self-report questionnaire used to assess extroversion, neurotic tendencies, and lying or exhibitionistic tendencies. The present study aimed to investigate whether personality traits influenced with the pain-related psychological variables in patients with chronic secondary low back pain (CLBP). One hundred fifteen consecutive outpatients with CLBP were included. Personality traits were measured by using the Maudsley Personality Inventory to assess extroversion, neurotic tendencies, and lying or exhibitionistic tendencies. The association of Maudsley neurotic tendency score and pain-related variables was analyzed and then performed a path analysis. Eleven patients (9%) were the biased persons with frequent lying. The pain-related variables showed no significant differences between the persons with frequent lying and those with normal. The Maudsley neurotic tendency score was significantly associated with Pain Catastrophizing Scale, Hospital Anxiety and Depression Scale, Pain Self-Efficacy Questionnaire, Athens Insomnia Scale, and EuroQol-5 Dimensions-3 level. The unstandardized coefficients for Maudsley neurotic tendency score were small, compared to pain-Numerical Rating Scale in each outcome. These results suggest the presence of neurotic tendency could have an impact on the health outcomes in patients with CLBP, but the impact was small.

It is only through the advent of extended release/long-acting opioids that the concept of breakthrough pain emerged. The concept suggests that if pain emerges through satisfactory analgesia achieved by an extended release/long-acting opioid, then additional dosing with a short-acting opioid is needed. The concept therefore suggests that breakthrough pain is due to inadequate dosing of opioid. A different explanation, that of drug opposite neuroadaptation or tolerance, turns this thinking on its head. Suppose inadequate analgesia while receiving opioids is not due to an inadequate dose, but rather due to the rebound pain of tolerance. As such, the need to increase the dose sets up further need for pain relief by increasing the dose, the hallmark of negative reinforcement. Negative reinforcement, continued use to avoid negative effects (in this case withdrawal pain), then drives the unhappy state of needing higher doses in a futile attempt to relieve the pain created by the drug itself. PERSPECTIVE: This article describes the neurobiological basis for tolerance to opioid analgesics and highlights the ultimate futility of dose increase as a means of overcoming tolerance. The article argues that so called breakthrough pain could equally be withdrawal hyperalgesia demanding a different response. SUMMARY: Could neuroadaptation explain breakthrough pain, and what would this mean in terms of optimizing opioid efficacy and reducing risk of dependence on opioids.

We sought to synthesize and evaluate evidence for the overuse of vascular diagnostic imaging tests and procedures in high-income countries as they may be overused in asymptomatic, minimally symptomatic, and/or high-risk patients with limited life expectancy. After protocol registration (CRD42021257490), we searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1st, 2010-May 14th, 2025) for English-language studies that reported the incidence/prevalence of overuse of vascular diagnostic imaging tests and/or procedures in high-income countries; adjusted predictors of overuse; or adjusted associations between overuse and outcomes. Three investigators independently reviewed titles/abstracts and full-texts, extracted data, and assessed risk of bias. Data were pooled using random-effects models. GRADE was used to assess estimate certainty. Among 11,748 citations, we included 14 studies (n=16,706,904 patients) that examined two unique vascular diagnostic imaging tests and eight unique procedures. The most frequently overused vascular imaging tests included carotid (pooled-cumulative incidence=19%; 95% confidence interval [CI]=10-30%; moderate-certainty) and venous duplex (cumulative incidence=46%; 95% CI=43-48%; moderate-certainty). The most frequently overused vascular procedures included renal artery angioplasty (pooled-cumulative incidence=92%; 95% CI=85-97%; low-certainty) and inferior vena cava filter placement (pooled-cumulative incidence=72%; 95% CI=0-100%; low-certainty). Adjusted-risk factors for carotid duplex overuse included increasing age and higher median neighborhood income quartile. Adjusted risk factors for overuse of endovascular intervention for claudication included ever smoking and end-stage renal disease. Overuse was associated with increased healthcare costs in all studies examining this outcome. Overuse of vascular diagnostic imaging tests and procedures may be common in high-income countries and associated with increased healthcare costs. However, because the included studies had important limitations, our findings should be confirmed before methods to reduce the above overuse are developed.

Pudendal neuralgia (PN) severely impacts quality of life, particularly sitting. Uncertainty exists whether catheter-based sacral nerve block with daily intermittent bolus (SNB) or pudendal nerve block (PNB) is more effective. This trial compared their efficacy over 6&#x2009;months. A prospective, randomized, double-blinded trial in China enrolled 90 PN patients. Patients were randomized to CT-guided catheter-based PNB near the pudendal nerve or SNB through the third posterior sacral foramen. In both groups, the catheter remained in place for 7&#x2009;days, and 10&#x2009;mL of 0.2% ropivacaine was administered once daily as an intermittent bolus, with compound betamethasone administered on Day 7. Primary outcome was pain intensity (VAS) over 6&#x2009;months; secondary outcomes included patient-reported global outcomes and maximum sitting time at 6&#x2009;months. The SNB group had significantly lower VAS scores at 1&#x2009;month (2.98&#x2009;&#xb1;&#x2009;1.47 vs. 3.72&#x2009;&#xb1;&#x2009;1.08, p&#x2009;=&#x2009;0.04), 3&#x2009;months (3.36&#x2009;&#xb1;&#x2009;1.14 vs. 4.17&#x2009;&#xb1;&#x2009;1.19, p&#x2009;=&#x2009;0.02), and 6&#x2009;months (3.85&#x2009;&#xb1;&#x2009;1.04 vs. 4.95&#x2009;&#xb1;&#x2009;1.08, p&#x2009;<&#x2009;0.0001). Significantly more SNB patients reported excellent/good outcomes at 1&#x2009;month (83.88% vs. 63.40%, p&#x2009;=&#x2009;0.04) and 6&#x2009;months (75.61% vs. 37.50%, p&#x2009;=&#x2009;0.002). Maximum sitting time at 6&#x2009;months was longer with SNB (68.56&#x2009;&#xb1;&#x2009;21.61 vs. 37.65&#x2009;&#xb1;&#x2009;16.25&#x2009;min, p&#x2009;<&#x2009;0.0001). No severe complications occurred. SNB provided superior and sustained pain relief, functional improvement, and patient satisfaction compared to PNB over 6&#x2009;months in PN patients. Broader sacral root (S2-4) coverage by SNB may enhance efficacy by targeting pudendal neuropathy and central sensitization. SNB may be considered as an intermediate minimally invasive option for selected refractory PN patients in experienced centers, pending larger safety and feasibility studies. This first RCT directly comparing catheter-based nerve blocks for pudendal neuralgia demonstrates that sacral nerve block (SNB targeting S2-4) provides significantly superior and sustained pain relief, functional gains (doubled sitting tolerance), and patient satisfaction over pudendal nerve block (PNB) at 6 months. Its broader root coverage likely addresses central sensitization alongside neuropathy. Catheter-based sacral nerve block with daily intermittent bolus may represent an intermediate minimally invasive option for selected patients with refractory PN in experienced centers capable of structured catheter monitoring. Because this trial was not powered to estimate rare infectious complications and required a 7-day inpatient protocol, larger multicenter studies are needed to define safety, feasibility, cost-effectiveness, and the potential for outpatient adaptation.

Ultrasound-guided regional anesthesia (UGRA) requires knowledge of anatomy, hand-eye coordination, and safe needling techniques. Extended reality (XR), including augmented reality, virtual reality (VR), and mixed reality, is an emerging simulation modality for UGRA training. We sought to conduct a systematic review to evaluate the current evidence on the effectiveness of XR for UGRA training. We searched MEDLINE, Embase&#xae;, the Cochrane Library, Web of Science&#xae;, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to 15 November 2024. We included randomized controlled trials, observational studies, and case series. We categorized outcomes by Kirkpatrick levels and assessed risk of bias. From 1,703 articles, we included seven studies (N = 137 participants). Four studies reported participant reactions. One trial (n = 29) found higher self-confidence in anatomical landmark identification and procedural performance (P < 0.001). One study assessed knowledge, reporting a score increase (P < 0.001). Augmented reality head-mounted display studies found shorter procedure times (10 vs 7&#x2009;sec; P = 0.03 and 18 vs 12&#x2009;sec; P = 0.002), higher needle visibility (34% vs 57%; P < 0.001 and 20% vs 38%; P = 0.001), and fewer head movements (P = 0.02). Immersive VR trials found no between-group differences in ratings or error scores (mean difference, -3.3; 95% confidence interval, -12.7 to 6.1; P = 0.51). The only randomized controlled trial was a pilot study that was terminated early and was underpowered for outcomes. We found substantial variability in XR definition, study design, methodologic rigour, and study quality. The current evidence does not conclusively support widespread adoption of XR for UGRA training, owing to heterogeneity, small samples, and underpowered studies. Currently, XR remains at an early and experimental stage in development. PROSPERO ( CRD42023424194 ); first submitted 18 May 2023. R&#xe9;SUM&#xe9;: OBJECTIF: L&#x2019;anesth&#xe9;sie locor&#xe9;gionale &#xe9;choguid&#xe9;e requiert des connaissances en anatomie, de la coordination main-&#x153;il et la ma&#xee;trise de techniques d&#x2019;insertion d&#x2019;aiguille s&#xe9;curitaires. La r&#xe9;alit&#xe9; &#xe9;tendue, qui englobe la r&#xe9;alit&#xe9; augment&#xe9;e, la r&#xe9;alit&#xe9; virtuelle (RV) et la r&#xe9;alit&#xe9; mixte, constitue une modalit&#xe9; de simulation &#xe9;mergente pour la formation en anesth&#xe9;sie locor&#xe9;gionale &#xe9;choguid&#xe9;e. Nous avons cherch&#xe9; &#xe0; mener une revue syst&#xe9;matique afin d'&#xe9;valuer les donn&#xe9;es probantes actuelles sur l&#x2019;efficacit&#xe9; de la r&#xe9;alit&#xe9; &#xe9;tendue dans la formation dans ce domaine. Nous avons effectu&#xe9; des recherches dans MEDLINE, Embase&#xae;, la biblioth&#xe8;que Cochrane, Web of Science&#xae; et le r&#xe9;pertoire CINAHL (Cumulative Index to Nursing and Allied Health Literature), depuis leur cr&#xe9;ation jusqu&#x2019;au 15 novembre 2024. Nous avons inclus des &#xe9;tudes randomis&#xe9;es contr&#xf4;l&#xe9;es, des &#xe9;tudes observationnelles et des s&#xe9;ries de cas. Nous avons class&#xe9; les crit&#xe8;res d'&#xe9;valuation selon les niveaux de Kirkpatrick et &#xe9;valu&#xe9; le risque de biais. Sur 1703 articles recens&#xe9;s, sept &#xe9;tudes ont &#xe9;t&#xe9; retenues (n = 137 personnes). Quatre &#xe9;tudes faisaient &#xe9;tat des r&#xe9;actions des personnes participantes. Une &#xe9;tude (n = 29) a relev&#xe9; une plus grande confiance en soi dans l&#x2019;identification des rep&#xe8;res anatomiques et dans l&#x2019;ex&#xe9;cution des gestes (P < 0,001). Une &#xe9;tude a &#xe9;valu&#xe9; les connaissances, rapportant une d&#x2019;une am&#xe9;lioration du score (P < 0,001). Les &#xe9;tudes sur les afficheurs t&#xea;te-haute en r&#xe9;alit&#xe9; augment&#xe9;e ont mis en &#xe9;vidence des dur&#xe9;es d&#x2019;intervention plus courtes (10 vs 7&#x2009;s; P = 0,03 et 18 vs 12&#x2009;s; P = 0,002), une meilleure visibilit&#xe9; de l&#x2019;aiguille (34 % vs 57 %; P < 0,001 et 20 % vs 38 %; P = 0,001) et moins de mouvements de t&#xea;te (P = 0,02). Les essais de RV immersive n&#x2019;ont r&#xe9;v&#xe9;l&#xe9; aucune diff&#xe9;rence entre les groupes quant aux scores d'&#xe9;valuation ou d&#x2019;erreur (diff&#xe9;rence moyenne, &#x2212;3,3; intervalle de confiance &#xe0; 95 %, &#x2212;12,7 &#xe0; 6,1; P = 0,51). Le seul essai randomis&#xe9; contr&#xf4;l&#xe9; &#xe9;tait une &#xe9;tude pilote interrompue pr&#xe9;matur&#xe9;ment et dont la puissance &#xe9;tait insuffisante pour &#xe9;valuer ces crit&#xe8;res. Nous avons constat&#xe9; une variabilit&#xe9; importante dans la d&#xe9;finition de la r&#xe9;alit&#xe9; &#xe9;tendue, la conception des &#xe9;tudes, la rigueur m&#xe9;thodologique et la qualit&#xe9; des &#xe9;tudes. Les donn&#xe9;es actuelles ne permettent pas de conclure en faveur d&#x2019;une adoption g&#xe9;n&#xe9;ralis&#xe9;e de la r&#xe9;alit&#xe9; &#xe9;tendue dans la formation en anesth&#xe9;sie locor&#xe9;gionale &#xe9;choguid&#xe9;e, en raison de l&#x2019;h&#xe9;t&#xe9;rog&#xe9;n&#xe9;it&#xe9; des &#xe9;tudes, de la petite taille des &#xe9;chantillons et de la puissance insuffisante. &#xc0; ce jour, la r&#xe9;alit&#xe9; augment&#xe9;e en est encore &#xe0; un stade pr&#xe9;coce et exp&#xe9;rimental de d&#xe9;veloppement. ENREGISTREMENT DE L&#x2019;&#xe9;TUDE: PROSPERO ( CRD42023424194 ); premi&#xe8;re soumission le 18 mai 2023.

Hyaluronidase is an enzyme that degrades hyaluronic acid within the extracellular matrix, thereby increasing tissue permeability and facilitating the dispersion of injected agents. Hyaluronidase has been used as an adjunct in spinal interventions to improve drug delivery, enhance adhesiolysis, and overcome therapeutic limitations imposed by epidural fibrosis and scar tissue. This review summarizes the pharmacological properties, clinical evidence, safety considerations, and practical applications of hyaluronidase in spinal pain management. The available evidence suggests that hyaluronidase enhances the distribution of local anesthetics, corticosteroids, and other therapeutic agents within fibrotic or compartmentalized tissues. Clinical studies have demonstrated improved pain relief and functional outcomes when hyaluronidase was incorporated into lumbar interlaminar, caudal, and transforaminal epidural injections, particularly in patients with failed back surgery syndrome. However, evidence regarding its role in percutaneous epidural neuroplasty and adhesiolysis remains inconsistent, with some studies reporting sustained benefits, whereas others have not demonstrated significant independent effects beyond mechanical adhesiolysis. In trigger point injections for myofascial pain syndrome, hyaluronidase has been associated with a faster onset and longer duration of analgesia. Although generally well-tolerated, rare hypersensitivity reactions, including anaphylaxis, have been reported, necessitating careful patient selection and monitoring. Current evidence supports the use of hyaluronidase as a valuable adjunct rather than a stand-alone therapeutic option in selected spinal interventions. Future well-designed prospective studies are needed to clarify its independent therapeutic contribution, optimize dosing strategies, and establish evidence-based clinical guidelines for its use in interventional pain management.

Propofol-based total intravenous anesthesia (TIVA) with remifentanil is widely used for general anesthesia but is frequently associated with hypotension and bradycardia. Remimazolam, an ultra-short-acting benzodiazepine, provides rapid onset and offset, with the additional advantage of reversal by flumazenil, and may result in less hemodynamic depression. Previous randomized studies have largely focused on the induction phase or the incidence of hypotension, with limited data on continuous intraoperative hemodynamic changes during laparoscopic gynecologic surgery. The study is designed to compare prospectively the intraoperative hemodynamic profiles of remimazolam-based versus propofol-based TIVA in patients undergoing robotic gynecologic surgery in the Trendelenburg position. This prospective, single-center, randomized, single-blind, parallel-group superiority trial will be conducted at CHA Ilsan Medical Center, a secondary care university-affiliated hospital. In total, 58 adult patients (aged 19-65 years, American Society of Anesthesiologists physical status I-II) scheduled for elective robotic laparoscopic hysterectomy under general anesthesia will be enrolled and randomly assigned (1:1) to receive either remimazolam- or propofol-based total intravenous anesthesia, both in combination with remifentanil. Continuous invasive mean arterial pressure (MAP) will be monitored using a FloTrac&#x2122; sensor (Edwards Lifesciences, Irvine, CA, United States). The primary outcome will be the time-weighted average MAP (TWA-MAP), analyzed using analysis of covariance adjusted for baseline MAP. Secondary outcomes will include the area under the curve for hypertensive and hypotensive burden, as well as the incidence of adverse hemodynamic events, including hypotension, hypertension, bradycardia, and tachycardia. Generalized estimating equations (GEE) will be used to evaluate hemodynamic and respiratory parameters across predefined time points. This trial is expected to provide prospective, randomized evidence to compare continuous intraoperative blood-pressure trajectories between remimazolam- and propofol-based TIVA during robotic gynecologic surgery. It is anticipated that the findings will clarify the relative hemodynamic stability of these anesthetic agents under the combined physiological challenges of Trendelenburg positioning and pneumoperitoneum. The findings may inform anesthetic drug selection and intraoperative blood pressure management strategies, enhancing cardiovascular stability and improving postoperative outcomes. ClinicalTrials.gov, identifier NCT07251101.

To compare clinical outcomes between urinary and non-urinary tract sepsis in nonagenarians and centenarians admitted to intensive care units (ICUs). Retrospective propensity score-matched multicentre cohort study. Adult ICUs participating in the Australian and New Zealand Intensive Care Society Adult Patient Database across Australia and New Zealand (2010-2023). We included all ICU admissions for sepsis in patients aged 90 years or older, classified as urinary or non-urinary tract sepsis using Acute Physiology and Chronic Health Evaluation III-J diagnostic codes. After 1:1 nearest neighbour propensity score matching, 1130 patients (565 per group) were included. The primary outcome was all-cause mortality within 180 days and beyond 180 days. Secondary outcomes included ICU mortality, hospital mortality, ICU length of stay and hospital length of stay. Of 1669 patients, 573 had urinary tract sepsis and 1096 had non-urinary tract sepsis. After matching, 1130 patients were included (565 per group). In the matched cohort, non-urinary tract sepsis was associated with higher mortality within 180 days than urinary tract sepsis (HR 1.67, 95% CI 1.33 to 2.09, p<0.001), whereas mortality beyond 180 days did not differ (HR 1.03, 95% CI 0.80 to 1.34, p=0.816). ICU and hospital length of stay were similar between groups. Among nonagenarian and centenarian ICU patients with sepsis, infection source was an important determinant of early but not late mortality, with non-urinary tract sepsis conferring a higher risk than urinary tract sepsis. Incorporating infection source and simple physiological markers alongside illness severity scores may improve prognostication and support shared decision-making in this very old population.