Publications by authors named "Alan D Kaye"

544 Publications

Structural Heart Issues in Dextrocardia: Situs Type Matters.

Ochsner J 2021 ;21(1):111-114

Department of Anesthesiology, Louisiana State University Health-Shreveport, Shreveport, LA.

Patients who are diagnosed with dextrocardia, a rare congenital heart condition in which the heart points toward the right side of the chest, need their specific situs classification (eg, solitus, inversus, ambiguus) ascertained to optimize their care and outcomes. In this report, we discuss the perioperative anesthetic management of a patient presenting with dextrocardia. A 44-year-old African American female with a history of hypertension, hyperlipidemia, gastroesophageal reflux disease, and diabetes mellitus type 2 was admitted for shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. The patient had been diagnosed with dextrocardia in 2003 at an outside hospital and was asymptomatic prior to this presentation. Chest x-ray revealed bilateral perihilar vascular congestion with bibasilar atelectasis and suspected small bilateral pleural effusions consistent with new-onset congestive heart failure. Preoperative 2-dimensional transthoracic echocardiography revealed an ostium secundum-type atrial septal defect (ASD) with mild left-to-right atrial shunting. The patient's ASD was repaired using a pericardial patch. The anesthetic management of patients presenting with dextrocardia is complex. Preoperative cardiac transthoracic echocardiography can identify cardiac lesions or aberrant anatomy associated with dextrocardia. Proper placement of electrocardiogram electrodes is necessary to avoid false-positive results for perioperative ischemia. Central line access must be adjusted to anatomic variations. Clinicians should have high suspicion for associated pulmonary hypertension and should limit sedatives preoperatively to minimize the cardiovascular effects of hypoxia and/or hypercarbia on the pulmonary vasculature. Finally, high clinical suspicion for respiratory complications should be maintained, as dextrocardia has been associated with respiratory complications secondary to primary ciliary dyskinesia in approximately 25% of patients.
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http://dx.doi.org/10.31486/toj.19.0119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993426PMC
January 2021

Synergistic Effects of Dexamethasone and Dexmedetomidine in Extending the Effects of Pectoral I and Pectoral II Blocks for Postoperative Analgesia Following Total Mastectomy with Lymph Node Dissection.

Clin Pract 2021 Mar 30;11(2):190-192. Epub 2021 Mar 30.

Anesthesiology and Pain Medicine, Portsmouth Anesthesia Associates, Portsmouth, VA 23707, USA.

Regional anesthesia is an important aspect of the overall anesthetic plan for patients. It has the potential to offer superior benefits compared to opioid-based treatment and is an important component of Enhanced Recovery after Surgery (ERAS) protocols. The use of the pectoral type I (PECS I) and pectoral type II blocks (PECS II) has been shown to reduce postoperative pain and opioid consumption in patients undergoing complete mastectomy and breast surgery. We describe the use of dexamethasone and dexmedetomidine to prolong the analgesic effects of these regional blocks in a patient undergoing total mastectomy with lymph node dissection.
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http://dx.doi.org/10.3390/clinpract11020027DOI Listing
March 2021

Thoracic Outlet Syndrome: A Narrative Review.

J Clin Med 2021 Mar 1;10(5). Epub 2021 Mar 1.

Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA.

Thoracic outlet syndrome comprises a group of disorders that result in compression of the brachial plexus and subclavian vessels exiting the thoracic outlet. Symptoms include pain, paresthesia, pallor, and weakness depending upon the compromised structures. While consensus in diagnostic criteria has not yet been established, a thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis. General first-line therapy for thoracic outlet syndrome is a conservative treatment, and may include physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids. Patients who have failed conservative therapy are considered for surgical decompression. This article aims to review the epidemiology, etiology, relevant anatomy, clinical presentations, diagnosis, and management of thoracic outlet syndrome.
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http://dx.doi.org/10.3390/jcm10050962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957681PMC
March 2021

A prediction model for delirium after cardiac surgery: Another step towards prevention?

J Clin Anesth 2021 Mar 23:110238. Epub 2021 Mar 23.

Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110238DOI Listing
March 2021

Effects of Premedication With Midazolam on Recovery and Discharge Times After Tonsillectomy and Adenoidectomy.

Cureus 2021 Feb 3;13(2):e13101. Epub 2021 Feb 3.

Anesthesiology, Children's National Medical Center, Washington, D.C., USA.

Background Midazolam is commonly used preoperatively for anxiety. Adverse effects data in pediatric patients with obstructive sleep apnea (OSA) undergoing tonsillectomy and adenoidectomy (T&A) is limited. Aims We hypothesized that preoperative midazolam increases the time to emergence from anesthesia and postoperative discharge. Secondary objectives assessed if patients receiving midazolam experienced increased side effects or complications from treatment. Methods This study was a retrospective chart review of patients undergoing T&A from July 2014 to December 2015. Midazolam receiving patients (midazolam group: MG) were compared to patients who did not (non-midazolam group: NMG). Multivariable analyses were performed and adjusted for predefined potential cofounder variables. Results Emergence and discharge times were 5.2 minutes (95% CI [-7.1, 17.4]; p=0.41) and 10.1 minutes (95% CI [-6.7, 26.8]; p=0.24) longer in MG. These results were not statistically significant. Comparing by OSA status, there was no statistical difference in emergence and discharge times between mild, moderate and severe OSA groups or between MG and NMG within each OSA group. Emergence and discharge times in moderate OSA was 6.1 minutes (95% CI [-17.6, 29.8]; p=0.61) and 18.8 minutes (95% CI [-16.4, 53.9]; p=0.29) longer than mild OSA, and in the severe OSA group, 2.6 minutes (95% CI [-19.9, 25.1]; p=0.82) shorter and 2.8 minutes (95% CI [-30.3, 35.9]; p=0.87) longer. The incidence of postoperative complications was comparable between MG and NMG groups. Conclusions Premedication with midazolam was not associated with prolonged emergence or discharge time or higher incidence of complications after anesthesia for T&A in patients with OSA.
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http://dx.doi.org/10.7759/cureus.13101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935262PMC
February 2021

COVID-19 and the Opioid Epidemic: Two Public Health Emergencies That Intersect With Chronic Pain.

Pain Ther 2021 Mar 14. Epub 2021 Mar 14.

Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

The COVID-19 pandemic has affected the entire world and catapulted the United States into one of the deepest recessions in history. While this pandemic rages, the opioid crisis worsens. During this period, the pandemic has resulted in the decimation of most conventional medical services, including those of chronic pain management, with the exception of virtual care and telehealth. Many chronic pain patients have been impacted in numerous ways, with increases in cardiovascular disease, mental health problems, cognitive dysfunction, and early death. The epidemic has also resulted in severe economic and physiological consequences for providers. Drug deaths in America, which fell for the first time in 25 years in 2018, rose to record numbers in 2019 and are continuing to climb, worsened by the coronavirus pandemic. The opioid epidemic was already resurfacing with a 5% increase in overall deaths from 2018; however, the preliminary data show that prescription opioid deaths continued to decline, while at the same time deaths due to fentanyl, methamphetamine, and cocaine climbed, with some reductions in heroin deaths. The health tracker data also showed that along with an almost 88% decline in elective surgeries, pain-related prescriptions declined 15.1%. Despite increases in telehealth, outpatient services declined and only began returning towards normal at an extremely slow pace, accompanied by reduced productivity and increased practice costs. This review, therefore, emphasizes the devastating consequences of concurrent epidemics on chronic pain management and the need to develop best practice efforts to preserve access to treatment for chronic pain.
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http://dx.doi.org/10.1007/s40122-021-00243-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955940PMC
March 2021

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review.

Cardiol Ther 2021 Mar 11. Epub 2021 Mar 11.

Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Purpose Of Review: Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease.

Recent Findings: Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.
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http://dx.doi.org/10.1007/s40119-021-00213-xDOI Listing
March 2021

Recent Advances in the Treatment of Opioid Use Disorder.

Curr Pain Headache Rep 2021 Mar 11;25(4):23. Epub 2021 Mar 11.

Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.

Purpose Of Review: Opioid use disorder (OUD) remains a national epidemic with an immense consequence to the United States' healthcare system. Current therapeutic options are limited by adverse effects and limited efficacy.

Recent Findings: Recent advances in therapeutic options for OUD have shown promise in the fight against this ongoing health crisis. Modifications to approved medication-assisted treatment (MAT) include office-based methadone maintenance, implantable and monthly injectable buprenorphine, and an extended-release injectable naltrexone. Therapies under investigation include various strategies such as heroin vaccines, gene-targeted therapy, and biased agonism at the G protein-coupled receptor (GPCR), but several pharmacologic, clinical, and practical barriers limit these treatments' market viability. This manuscript provides a comprehensive review of the current literature regarding recent innovations in OUD treatment.
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http://dx.doi.org/10.1007/s11916-021-00941-8DOI Listing
March 2021

Disinfectants In Interventional Practices.

Curr Pain Headache Rep 2021 Mar 11;25(4):21. Epub 2021 Mar 11.

Department of Anesthesiology, Mount Sinai Medical Center, Alton Road Miami Beach, FL, 4300, USA.

Purpose Of Review: This review aims to provide relevant, aggregate information about a variety of disinfectants and antiseptics, along with potential utility and limitations. While not exhaustive, this review's goal is to add to the body of literature available on this topic and give interventional providers and practitioners an additional resource to consider when performing procedures.

Recent Findings: In the current SARS-CoV2 epidemiological environment, infection control and costs associated with healthcare-associated infections (HAIs) are of paramount importance. Even before the onset of SARS-CoV2, HAIs affected nearly 2million patients a year in the USA and resulted in nearly 90,000 deaths, all of which resulted in a cost to hospitals ranging from US$28 billion to 45 billion. The onset SARS-CoV2, though not spread by an airborne route, has heightened infection control protocols in hospitals and, as such, cast a renewed focus on disinfectants and their utility across different settings and organisms. The aim of this review is to provide a comprehensive overview of disinfectants used in the inpatient setting.
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http://dx.doi.org/10.1007/s11916-021-00938-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946573PMC
March 2021

Intravenous Lidocaine Infusion for the Management of Early Postoperative Pain: A Comprehensive Review of Controlled Trials.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):216-259

Chu, Roberts, Johns Hopkins School of Medicine, Baltimore, MD, USA. Umukoro, Department of Anesthesia, Riley Hospital for Children, Indiana Health, Indianapolis, IN, USA. Greer, MD, Department of Transitional Year Residency Program, HCA Houston Healthcare, Kingwood, TX, USA. Adekoya, MD, Department of Anesthesia and Critical Care Medicine, Baltimore, MD, USA. Odonkor, MD, Department of Orthopedics and Rehabilitation, Division of Physical Medicine and Rehabilitation, Yale Medicine, Yale New Haven Health System, New Haven, CT, USA. Hagedorn, MD, Olatoye, MD, Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Hasoon, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. Salisu Orhurhu, MD, MPH, Orhurhu, MD, MPH, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. Umukoro, MD, Department of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA.

Previously used as anti-arrhythmic, intravenous lidocaine infusion is becoming popular for use in management of acute pain. There is still much to be understood about its pharmacokinetics and pharmacodynamics, especially with regard to optimal dosing to avoid side effects. In this article, we selected and reviewed randomized controlled trials to summarize the pharmacokinetics, antinociceptive effects, anti-hyperalgesic effects, anti-inflammatory effects, side effects, and role of intravenous lidocaine in the management of early postoperative pain. The mechanisms of action of lidocaine are still unclear but there are many theories postulated. Optimal dosing of lidocaine is not known but general consensus indicates that a loading dose of 1-2 mg/kg, followed by 1-2 mg/kg/hr continuous infusion during early postoperative pain control while recovering from anesthesia to achieve therapeutic levels of 0.5-5 mcg/kg clearly improves analgesia in the immediate postoperative period. Although lidocaine was initially studied and proven to have clear analgesic effects following laparoscopic and open abdominal surgeries, it has now been shown to be applicable in different clinical settings perioperatively including following spinal, breast, ENT and other surgeries. It is generally safe, with hypotension, headache and vomiting being the more common side effects. Serious adverse effects include cardiovascular block and arrhythmias, neuro-excitability and hypersensitivity, although the frequency of these are not known.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901134PMC
October 2020

An Evidence-Based Review of Elagolix for the Treatment of Pain Secondary to Endometriosis.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):197-215

Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Adamian, BS, Creighton University School of Medicine-Phoenixix Regional Campus, Phoenix, AZ. Miro, BS, Callan, BS, M. Patel, BS, Patel, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Purpose Of Review: This is a review of elagolix use for pain related to endometriosis. It summarizes the background and recent data available about the pathogenesis of endometriosis and pain that is secondary to this syndrome. It then reviews the evidence to support the use of elagolix and the indications for use.

Recent Findings: Endometriosis occurs in 10% of reproductive-age women and is a common source of chronic pelvic pain, infertility, and co-morbid disorders. It usually presents with some combination of dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Treatment options may be surgical or hormonal. Traditional treatment is divided into medical and surgical. The latter, though effective, is reserved for surgical emergencies and patients failing medical management. Medical management with NSAIDs is usually limited in efficacy. It is generally based on hormonal suppression leading to atrophy of endometrial lesions. Elagolix (Orlissa) is a GnRH antagonist that suppressed the entire hypophysis-gonadal axis. Reduced levels of estrogen and progesterone lead to involution of the endometrial lesions and improvement in symptoms. Clinical trials showed that elagolix is effective in treating dysmenorrhea and non-menstrual pain that is secondary to endometriosis. It is well tolerated and has a relatively safe usage profile. Studies up to 12 months long showed continued efficacy and reduction in dysmenorrhea of up to 75%, with 50%-60% reduction in non-menstrual pain. Elagolix was found effective when compared to both placebo and alternative treatments.

Summary: Endometriosis is a common syndrome that causes significant pain, morbidity, and disability, as well as financial loss. Elagolix is an effective drug in treating the symptoms of endometriosis and is a relatively safe option. Phase 4 studies will be required to evaluate the safety and efficacy of long term chronic use.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901127PMC
October 2020

A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):189-196

Gress, BS, Charipova, BS, Georgetown University School of Medicine, Washington, DC. Kassem, MD, Schwartz, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Berger, MD, PhD, Hasoon, MD, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Cornett, PhD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Purpose Of Review: This is a comprehensive review and update on advances in the understanding and treatment of slipping rib syndrome. It covers the physiology and pathophysiology at the basis of the syndrome, epidemiology and clinical presentation as well as diagnosis. It goes on to review the available literature to provide description and comparison of the available methods for alleviation.

Recent Findings: Slipping rib syndrome stems from irritation of intercostal nerves. It is caused by slipping of the costal cartilage and the resulting displacement of a false rib and pinning underneath the adjacent superior rib and nerve irritation. It is rare and spans genders and ages; most evidence about epidemiology is conflicting and mostly anecdotal. Risk factors include trauma and high intensity athletic activity. Presentation is of a sudden onset of pain with jerking motion; the pain can be localized, radiating or diffuse visceral. It is often alleviated by positions that offload the impinged nerve. Diagnosis is clinical, and can be aided by Hooking maneuver and dynamic ultrasound. Definitive diagnosis is with pain relief on nerve block, visualization of altered anatomy during surgery and relief after surgical correction. Initial treatment includes rest, ice and NSAIDs, as well as screening for co-morbid conditions, as well as local symptomatic relief. Injection therapy with local anesthetics and steroids can provide a diagnosis as well as symptomatic relief. Surgical correction remains the definitive treatment.

Summary: Slipping rib syndrome is a rare cause of chest pain that could be perceived as local or diffuse pain. Diagnosis is initially clinical and can be confirmed with nerve blocks and surgical visualization. Initial treatment is symptomatic and anti-inflammatory, and definitive treatment remains surgical. More recently, advanced surgical options have paved way for cure for previously hard to treat patients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901126PMC
October 2020

Lasmiditan for the Treatment of Migraines With or Without Aura in Adults.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):163-188

Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Winnick, MA, Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; School of Optometry, University of California, Berkeley, Berkeley, CA. Popovsky, MS, Kaneb, BA, Berardino, BS, Georgetown University School of Medicine, Washington DC. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA.

Migraines are a common form of primary headache, affecting women more than men (17.4% and 5.7% of US population, respectively, a total of 12%) that carry significant morbidity and disability, as well as a hefty healthcare price tag. They are most prevalent in women of reproductive ages and are estimated to be the 6th disease in order of causing global burden. They are estimated to cause 45.1 million years lived with disability, or 2.9% of global years lost to disability. Migraine treatment divides into acute, abortive treatment for relief of an ongoing migraine attack, and prophylactic therapy to reduce the occurrence of migraines, specifically for patients suffering from chronic and frequent episodic migraines. Traditional abortive treatment usually begins with NSAID and non-specific analgesics that are effective in curbing mild to moderate attacks. 5HT-agonists, such as triptans, are often used for second-line and for severe attacks. Triptans are generally better tolerated in the longterm than NSAIDs and other analgesics, though they carry a significant side-effect profile and are contraindicated in large parts of the population. Prophylactic therapy is usually reserved for patients with frequent recurrence owing to medication side effects and overall poor adherence to the medication schedule. Importantly, medication overuse may actually lead to the development of chronic migraines from previously episodic attacks. Recent research has shed more light on the pathophysiology of migraine and the role of CGRP in the trigeminovascular system. Recent pharmacological advances were made in developing more specific drugs based on this knowledge, including CGRP neutralizing antibodies, receptor antagonists, and the development of ditans. These novel drugs are highly specific to peripheral and central 5-HT receptors and effective in the treatment of acute migraine attacks. Binding these receptors reduces the production of CGRP and Glutamate, two important ligands in the nociceptive stimulus involved with the generation and propagation of migraines. Several large clinical studies showed Lasmiditan to be effective in the treatment of acute migraine attacks. Importantly, due to its receptor specificity, it lacks the vasoconstriction that is associated with triptans and is thus safer is larger parts of the population, specifically in patients with cardiac and vascular disease. Though more research is required, specifically with aftermarket surveillance to elucidate rare potential side effects, Lasmiditan is a targeted anti-migraine drug that is both safe and effective, and carries an overall superior therapeutic profile to its predecessors. It joins the array of medications that target CGRP signaling, such as gepants and CGRP-antibodies, to establish a new line of care for this common disabling condition.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901123PMC
October 2020

Oral Muscle Relaxants for the Treatment of Chronic Pain Associated with Cerebral Palsy.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):142-162

Peck, MD, Noor, BS, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Crane, BS, McNally, BS, Georgetown University School of Medicine, Washington, DC. Patel, BS, University of Arizona College of Medicine-Phoenix, Phoenix, AZ. Cornett, MD, Louisiana State University Health Sciences, Department of Anesthesiology, New Orleans, LA. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Purpose Of Review: This is a comprehensive literature review of the available for treatment of oral muscle relaxants for cerebral palsy (CP) and associated chronic pain. It briefly describes the background and etiology of pain in CP and proceeds to review and weigh the available evidence for treatment for muscle relaxants.

Recent Findings: CP is a permanent, chronic, non-progressive neuromuscular and neurocognitive disorder of motor dysfunction that is diagnosed in infancy and is frequently (62% of patients) accompanied by chronic or recurrent muscular pain. Treatment of pain is crucial, and focuses mostly on treatment of spasticity through non-interventional techniques, surgery and medical treatment. Botulinum toxin injections provide temporary denervation, at the cost of repeated needle sticks. More recently, the use of oral muscle relaxants has gained ground and more evidence are available to evaluate its efficacy. Common oral muscle relaxants include baclofen, dantrolene and diazepam. Baclofen is commonly prescribed for spasticity in CP; however, despite year-long experience, there is little evidence to support its use and evidence from controlled trials are mixed. Dantrolene has been used for 30 years, and very little current evidence exists to support its use. Its efficacy is usually impacted by non-adherence due to difficult dosing and side-effects. Diazepam, a commonly prescribed benzodiazepine carries risks of CNS depression as well as addiction and abuse. Evidence supporting its use is mostly dated, but more recent findings support short-term use for pain control as well as enabling non-pharmacological interventions that achieve long term benefit but would otherwise not be tolerated. More recent options include cyclobenzaprine and tizanidine. Cyclobenzaprine carries a more significant adverse events profile, including CNS sedation; it was found to be effective, possible as effective as diazepam, however, it is not currently FDA approved for CP-related spasticity and further evidence is required to support its use. Tizanidine was shown to be very effective in a handful of small studies.

Summary: Muscle relaxants are an important adjunct in CP therapy and are crucial in treatment of pain, as well as enabling participation in other forms of treatments. Evidence exist to support their use, however, it is not without risk and further research is required to highlight proper dosing, co-treatments and patient selection.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901132PMC
October 2020

A Comprehensive Review and Update of the Use of Dexmedetomidine for Regional Blocks.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):121-141

Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Virgen, BS, Alattar, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Shehata, MD, Ain Shams University, Department of Anesthesiology, Cairo, Egypt. Elhassan, MD, Desert Regional Medical Center, Department of Anesthesiology, Palm Springs, CA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Purpose Of Review: This evidence-based systematic review will focus on the use of dexmedetomidine and its role as adjuvant anesthetics in regional blocks to help better guide physicians in their practice. This review will cover background and mechanism of dexmedetomidine as well as the use in various regional blocks.

Recent Findings: Local anesthetics are preferred for nerve blocks over opioids; however, both due come with its own side effects. Local anesthetics may be toxic as they disrupt cell membrane and proteins, but by using adjuvants such as dexmedetomidine, that can prolong sensory and motor blocks can reduce total amount of local anesthetics needed. Dexmedetomidine is an alpha-2-adrenergic agonist used as additive for regional nerve block. It has a relatively low side effect profile and have been researched in various regional blocks (intrathecal, paravertebral, axillary, infraclavicular brachial plexus, interscalene). Dexmedetomidine shows promising results as adjuvant anesthetics in most regional blocks.

Summary: Many studies have been done and many show promising results for the use of dexmedetomidine in regional blocks. It may significantly increase in duration of sensory and motor blocks that correlates with lower pain scores and less need of morphine in various regional blocks.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901136PMC
October 2020

Interventional Approaches to Pain and Spasticity Related to Cerebral Palsy.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):108-120

Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Purpose Of Review: This review will cover seminal and emerging evidence on interventional therapy chronic pain in cerebral palsy (CP). It will cover the background and burden of disease, present the current options, and then weigh the evidence that is available to support interventional therapy and the current indications.

Recent Findings: CP is a permanent posture and movement disorder from in-utero brain development defects with a 3-4/1,000 incidence in the US. The cost of care for each child is estimated at $921,000. Pain in CP is attributed to musculoskeletal deformities, spasticity, increased muscle tone, dislocations, and GI dysfunction. First-line treatments include physical and occupational therapy and oral pharmacological agents; however, a significant amount of patients remain refractory to these and require further therapy. Injection therapy includes botulinum toxin A (BTA) injections and intrathecal baclofen. BTA injections were shown to control chronic pain effectively and are FDA approved for spastic pain; intra-thecal baclofen, in contrast, was only shown to improve comfort and quality of life with a focus on the pain. Surgical intervention includes selection dorsal rhizotomy (SDR). It may increase range of motion and quality of life and reduce spasticity and pain; however, most evidence is anecdotal, and more research is required.

Summary: Interventional therapy, including injection and surgical, is the last line of therapy for chronic pain in CP. It extends the possibility of therapy in hard-to-treat individuals; however, more data is required to provide strong evidence to the efficacy of these treatments and guide proper patient selection.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901135PMC
October 2020

A Comprehensive Update of Adhesive Capsulitis and Minimally Invasive Treatment Options.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):91-107

Patel, MD, Wolf, BS, Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Murthy, MS, BS, Georgetown University School of Medicine, Washington, D.C. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Ngo, MD, MBA, Pain Specialty Group, Department of Pain Medicine, Newington, NH; Harvard Medical School, Boston, MA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Background: Adhesive capsulitis of the shoulder (AC) is characterized by fibrosis and contracture of the glenohumeral joint capsule, resulting in progressive stiffness, pain, and restriction of motion of the shoulder. The prevalence of AC is estimated to be 2-5% of the general population. Patients with AC typically have an insidious onset of pain and can progress to severe limitation of the shoulder leading to significant disability and decreased quality of life.

Objectives: The objective of this manuscript is to provide a comprehensive review of AC with a focus on clinical presentation, natural history, pathophysiology, and various treatment modalities.

Study Design: A review article.

Setting: A review of literature.

Methods: A search was made on the Pubmed database using the keywords of adhesive capsulitis, frozen shoulder, shoulder capsulitis, arthrofibrosis, shoulder pain, shoulder stiffness.

Results: Our search identified numerous studies in order to provide a comprehensive review of the current understanding of the treatment and management of AC.

Limitations: There remains limited evidence in literature about the understanding of AC and optimal treatment.

Conclusion: AC is an important cause of chronic pain and disability. There is currently no consensus on treatment. Initial treatment modalities revolve around conservative measures as well as aggressive physical therapy. Further treatment options include intraarticular injections, hydro-dilation, nerve blocks, and for more refractory cases, surgical interventions such as arthroscopic capsulotomy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901130PMC
October 2020

An Evidence Based Review of Epidurolysis for the Management of Epidural Adhesions.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):74-90

Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE.

Purpose Of Review: This review presents epidurolysis as a procedure to alleviate pain and disability from epidural adhesions. It reviews novel and groundbreaking evidence, describing the background, indications, benefits and adverse events from this procedure in an effort to provide healthcare experts with the data required to decide on an intervention for their patients.

Recent Findings: Epidural adhesions (EA) or epidural fibrosis (EF) is defined as non-physiologic scar formation secondary to a local inflammatory reaction provoked by tissue trauma in the epidural space. Often, it is a sequelae of surgical spine intervention or instrumentation. The cost associated with chronic post-operative back pain has been reported to be up to nearly $12,500 dollars per year; this, coupled with the increasing prevalence of chronic lower back pain and the subsequent increase in surgical management of back pain, renders EF a significant cost and morbidity in the U.S. Though risk factors leading to the development of EA are not well established, epidural fibrosis has been reported to be the culprit in up to 46% of cases of Failed Back Surgery Syndrome (FBSS), a chronic pain condition found in up to 20-54% of patients who receive back surgery. Moreover, EF has also been associated with lumbar radiculopathy after lumbar disc surgery. Epidurolysis is defined as the mechanical dissolution of epidural fibrotic scar tissue for persistent axial spine or radicular pain due to epidural fibrosis that is refractory to conservative therapy Endoscopic lysis of adhesions is a procedural technique which has been shown to improve chronic back pain in one-third to one-half of patients with clinically symptomatic fibrous adhesions. Here we review some of the novel evidence that supports this procedure in EA and FBSS.

Summary: The literature concerning epidurolysis in the management of epidural adhesions is insufficient. Prospective studies, including randomized controlled trials and observational studies, have suggested epidurolysis to be effective in terms of pain reduction, functional improvement, and patient satisfaction scores. Observational studies report epidurolysis as a well-tolerated, safe procedure. Current evidence suggests that epidurolysis may be used as an effective treatment modality for epidural adhesions. Nonetheless, further high quality randomized controlled studies assessing the safety and efficacy of epidurolysis in the management of epidural adhesions is needed.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901122PMC
October 2020

Intrathecal Morphine Delivery at Cisterna Magna to Control Refractory Cancer-Related Pain: A Prospective Cohort Study.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):48-66

Dr. Sun, Department of Orthopedics, General Hospital of the PLA Airforce, Beijing, China. Liu, Yang, Zhao, Lu, Anesthesia and Operation Center, Department of Anesthesiology, Chinese PLA General Hospital, Beijing, China. Wang, Department of Emergency, Xijing Hospital, The Fourth Military Medical University (Air Force Medical University), China. Dai, Department of Clinical Nutrition, Xijing Hospital, The Fourth Military Medical University (Air Force Medical University), China. Cheng, Jin, Department of Anesthesiology, Pain Medicine Center Jinling Hospital, Nanjing, China. Dong, Wang, Song, Department of Pain medicine, The First Affiliated Hospital of Chinese Medical University, China. Sun, Department of Neurology, Xijing Hospital, The Fourth Military Medical University (Air Force Medical University), China. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE. Prof. Sun, Department of Comprehensive treatment, the second Medical Center of the Chinese People's Liberation Army General Hospital, Beijing, China.

Background: For patients suffering from primary or metastatic cancer above the middle thoracic vertebrae, refractory pain management still remains a great challenge. Theoretically, inserting a catheter tip into the cisterna magna may be a promising solution. However, at present, there have been no reliable data regarding this novel technique. We therefore investigated the efficacy and safety of an advanced approach for pain relief in a specific population.

Methods: Thirty participants from two hospitals received the intrathecal deliveries of opioid to either one of two sites: cisterna magna (n = 15) or lower thoracic region (n = 15). Pain relief (visual analogue scale, VAS), quality of life (short form (36) health survey, SF-36) as well as depression (self-rating depression scale, SDS) were assessed in the follow-up visits and compared between the two groups.

Results: Patients receiving intrathecal morphine delivery to cisterna magna achieved greater pain improvement indicated as significant decrease of VAS scores at day 1 and 7, and achieved better improvement in physical function (day 7 and 30), role physical (day 7 and 30), body pain (day 7, 30 and 90), general health (day 7, 30 and 90), vitality (day 7, 30 and 90), social function (day 90), role emotional (day 7 and 90), mental health (day 7, 30 and 90) and SDS (day 1 and 7).

Conclusions: Intrathecal morphine delivery to cisterna magna might be an effective and safe technique for patients suffering from cancer at the middle thoracic vertebrae or above to control refractory pain. Trial registration: No. ChiCTR-ONN-17010681.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901124PMC
October 2020

Epidural Analgesia in Ventral Hernia Repair: An Analysis of 30-day Outcomes.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):33-47

Jones, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Brovman, MD, Wagenaar, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Whang, MD, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, New York. Ang, MD, Department of Surgery, Brigham and Women's Hospital, Boston, MA. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Urman, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA.

Background: Ventral hernia repair (VHR) is a common procedure associated with significant postoperative morbidity and prolonged hospital length of stay (LOS). The use of epidural analgesia in VHR has not been widely evaluated.

Purpose: To compare the outcomes of general anesthesia plus epidural analgesia (GA + EA) versus general anesthesia alone (GA) in patients undergoing ventral hernia repair.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify elective cases of VHR. Propensity score-matched analysis was used to compare outcomes in GA vs GA + EA groups. Cases receiving transverse abdominus plane blocks were excluded.

Results: A total of 9697 VHR cases were identified, resulting in two matched cohorts of 521 cases each. LOS was significantly longer in the GA + EA group (5.58 days) vs the GA group (5.20 days, p = 0.008). No other statistically significant differences in 30-day outcomes were observed between the matched cohorts.

Conclusion: Epidural analgesia in VHR is associated with statistically significant, but not clinically significant increase in LOS and may not yield any additional benefit in cases of isolated, elective VHR. Epidural analgesia may not be beneficial in this surgical population. Future studies should focus on alternative modes of analgesia to optimize pain control and outcomes for this procedure.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901129PMC
October 2020

Long-Term Outcomes of Post Dural Puncture Headache Treated With Epidural Blood Patch: A Pilot Study.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):25-32

Hasoon, MD, Cai, MD, Aner, MD, Rana, MD, Simopoulos, MD, Gill, MD, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. AL-Jumah, MD, Baylor College of Medicine, Department of Anesthesiology, Houston, TX. Burroughs, MD, Methodist Dallas Medical Center, Department of Surgery, Dallas, TX. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA.

Background: Post dural puncture headache (PDPH) is a known complication which may occur in the setting of patients undergoing lumbar punctures (LP) for diagnostic or therapeutic purposes. The gold standard for treating a PDPH is an epidural blood patch (EBP). There have been few publications evaluating the long-term outcomes of PDPH treated with EBP. The aim of this pilot study was to examine the incidence of chronic headaches in dural puncture patients who received EBP versus those who did not.

Methods: A retrospective case control study was performed at a single large center institution. Forty-nine patients who had intentional dural puncture were identified on chart review and completed a survey questionnaire via phone interview: twenty-six of these patients required a subsequent EBP, while twenty-three did not. The primary outcomes were the development and prevalence of chronic headaches after the procedures. There was no statistically significant difference in the prevalence of current headaches between the EBP group and Non-EBP group (54% vs. 52% p = 0.91). There were no significant differences in the rates of severity and descriptive qualities of headache between the EBP and non-EBP groups. There was higher incidence of tinnitus in the PDPH patients.

Summary: This pilot study demonstrates that patients who received an EBP for treatment of a PDPH following LP are no more likely to experience chronic headaches compared to patients who do not receive an EBP. However, both the EBP group and Non-EBP group had high incidence of chronic headaches which may be related to dural puncture or a baseline trait of this cohort given the recall bias. There is a suggestion that tinnitus could be a long-term residual symptom of PDPH treated with EBP.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901131PMC
October 2020

Epidural Blood Patch does not Contribute to the Development of Chronic Low Back Pain in Patients who Undergo Lumbar Punctures: A Pilot Study.

Psychopharmacol Bull 2020 Oct;50(4 Suppl 1):17-24

Hasoon, MD, Cai, MD, Aner, MD, Yazdi, MD, Simopoulos, MD, Hess, MD, Gill, MD, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Burroughs, MD, Methodist Dallas Medical Center, Department of Surgery, Dallas, TX. Orhurhu, MD, MPH, Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA.

Purpose Of Review: Post dural puncture headache (PDPH) is a known and relatively common complication which may occur in the setting of patients undergoing lumbar punctures (LP) for diagnostic or therapeutic purposes, and is commonly treated with an epidural blood patch (EBP). There have been few publications regarding the long-term safety of EBP for the treatment of PDPH.

Recent Findings: The aim of this pilot study was to examine any association of chronic low back pain (LBP) in patients who experienced a PDPH following a LP, and were treated with an EBP. A total of 49 patients were contacted and completed a survey questionnaire via telephone. There was no increased risk of chronic LBP in the dural puncture group receiving EBP (percentage difference 1% [95% CI -25% - 26%], RR: 0.98 [95% CI 0.49 - 1.99]) compared to the dural puncture group not receiving EBP. There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Both groups had higher prevalence of back pain compared to baseline.

Summary: Our findings suggest that dural puncture patients undergoing EBP do not experience low back pain with increased frequency compared to dural puncture patients not undergoing EBP. Higher prevalence of LBP compared to baseline and compared to general population was seen in both groups. However, this pilot study is limited by a small sample size and no definitive conclusion can be drawn from this observation. The findings of this study should spur further prospective research into identifying potential associations between LP, EBP and chronic low back pain.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901133PMC
October 2020

A Comprehensive Update of the Superior Hypogastric Block for the Management of Chronic Pelvic Pain.

Curr Pain Headache Rep 2021 Feb 25;25(3):13. Epub 2021 Feb 25.

Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA, USA.

Purpose Of Review: This is a comprehensive review of the superior hypogastric block for the management of chronic pelvic pain. It reviews the background, including etiology, epidemiology, and current treatment available for chronic pelvic pain. It then presents the superior hypogastric block and reviews the seminal and most recent evidence about its use in chronic pelvic pain.

Recent Findings: Several definitions exist for chronic pelvic pain (CPP), making the diagnosis more challenging for the clinician; however, they commonly describe continuous pain lasting 6 months in the pelvis, with an overwhelming majority of patients being reproductive-aged women. This pain is often one of mechanical, inflammatory, or neuropathic. It is generally underdiagnosed and affects anywhere between 5 and 26% of women. The diagnosis of chronic pelvic pain is clinical, consisting of mainly of a thorough history and physical and ruling out other causes. The pathophysiology is often endometriosis (70%) and also includes PID, adhesions, adenomyosis, uterine fibroids, chronic processes of the GI and urinary tracts, as well as pelvic-intrinsic musculoskeletal causes. Treatment includes physical therapy, cognitive behavioral therapy, and oral and parenteral opioids. Interventional techniques provide an added tier of treatment and may help to reduce the requirement for chronic opioid use. Superior hypogastric plexus block is one of the available interventional techniques; first described in 1990, it has been shown to provide long-lasting relief in 50-70% of patients who underwent the procedure. Two approaches described so far, both under fluoroscopy, have seen similar results. More recently, ultrasound and CT-guided procedures have also been described with similar success. The injectate includes local anesthetic, steroids, and neurolytic agents such as phenol or ethanol. CPP is a common debilitating condition. It is diagnosed clinically and is underdiagnosed globally. Current treatments can be helpful at times but may fall short of satisfactory pain relief. Interventional techniques provide an added layer of treatment as well as reduce the requirement for opioids. Superior hypogastric plexus block provides long-lasting relief in many patients, regardless of approach. Evidence level is limited, and further RCTs could help provide better tools for evaluation and patient selection.
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http://dx.doi.org/10.1007/s11916-020-00933-0DOI Listing
February 2021

HTX-011 (bupivacaine and meloxicam) for the prevention of postoperative pain - clinical considerations.

Pain Manag 2021 Apr 23;11(4):347-356. Epub 2021 Feb 23.

Provost & Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA.

HTX-011 is an extended-release, dual-acting local anesthetic consisting of bupivacaine (sodium-channel blocker) and low-dose meloxicam (non-steroidal anti-inflammatory drug [NSAID]) applied needle-free during surgery. Introducing low-dose meloxicam addresses the limited efficacy of liposomal bupivacaine in acidic inflamed tissues and allows enhanced analgesic effects over three days. It has great promise to be an extremely effective postoperative pain regimen and produce an opioid-free surgical recovery, as it has consistently significantly reduced pain scores and opioid consumption through 72 h. This manuscript provides an updated, concise narrative review of the pharmacology, clinical efficacy, safety and tolerability of this drug and its applications to prevent postoperative pain.
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http://dx.doi.org/10.2217/pmt-2020-0097DOI Listing
April 2021

Erector Spinae Plane Block for the Treatment of Post Mastectomy Pain Syndrome.

Cureus 2021 Jan 12;13(1):e12656. Epub 2021 Jan 12.

Pain Management, Louisiana State University Health Sciences Center, Shreveport, USA.

Postmastectomy pain syndrome (PMPS) is a common complication after breast cancer surgery and is often challenging to manage. Treatment options include medication management, physical therapy, and interventional procedures. The erector spinae plane block (ESPB) is a regional technique proven to help both acute postoperative analgesia and chronic neuropathic pain conditions. This block is becoming more popular in the chronic pain setting for neuropathic thoracic pain conditions. We describe the utilization of the ESP block for significant neuropathic breast pain after total mastectomy. Our case demonstrates the utility of this block for women suffering from severe PMPS.
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http://dx.doi.org/10.7759/cureus.12656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872866PMC
January 2021

Preoperative Anemia Treatment with Intravenous Iron Therapy in Patients Undergoing Abdominal Surgery: A Systematic Review.

Adv Ther 2021 03 12;38(3):1447-1469. Epub 2021 Feb 12.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Introduction: Preoperative anemia is associated with increased morbidity, mortality, and healthcare costs. As a result of the increased incidence of chronic blood loss and iron deficiency anemia in abdominal surgery patients and its impact on patient outcomes, we systematically evaluated the quality of evidence for preoperative intravenous (IV) administration of iron to patients with anemia undergoing major abdominal surgery with the focus on clinical outcomes.

Methods: In this systematic review, PubMed, Cochrane, The Cumulative Index to Nursing and Allied Health Literature, Web Of Science, and Excerpta Medica Database databases were searched up to 2019 using specific keywords. Inclusion criteria were patients that were over 18 years of age, underwent abdominal surgery, and received an IV iron treatment in the preoperative setting.

Results: The nine studies included in the final systematic review do not provide consistent evidence of a reduced incidence of allogeneic blood transfusions with preoperative IV iron administration. However, IV iron administration did consistently cause a significant increase in hemoglobin levels relative to oral iron therapy or no iron.

Conclusion: Overall, these findings are consistent in that IV iron administration is highly effective at rapidly increasing hemoglobin levels in patients with iron deficiency anemia undergoing major abdominal surgery. Unfortunately, there is currently no evidence of reduced incidence of allogeneic blood transfusions or other enhanced outcomes.
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http://dx.doi.org/10.1007/s12325-021-01628-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932933PMC
March 2021

Does an individualized goal-directed therapy based on cerebral oxygen balance benefit high-risk patients undergoing cardiac surgery?

J Clin Anesth 2021 Jun 6;70:110189. Epub 2021 Feb 6.

Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, United States of America; Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, United States of America.

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http://dx.doi.org/10.1016/j.jclinane.2021.110189DOI Listing
June 2021

A Comprehensive Review and Update of Post-surgical Cutaneous Nerve Entrapment.

Curr Pain Headache Rep 2021 Feb 5;25(2):11. Epub 2021 Feb 5.

Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.

Purpose Of Review: This is a comprehensive review of the literature regarding post-surgical cutaneous nerve entrapment, epidemiology, pathophysiology, and clinical presentation. It focuses mainly on nerve entrapment leading to chronic pain and the available therapies.

Recent Findings: Cutaneous nerve entrapment is not an uncommon result (up to 30% of patients) of surgery and could lead to significant, difficult to treat chronic pain. Untreated, entrapment can lead to neuropathy and damage to enervated structures and musculature, and significant morbidity and financial loss. Nerve entrapment is defined as pressure neuropathy from chronic compression. It causes changes to all layers of the nerve tissue. It is most significantly associated with hernia repair and other procedures employing a Pfannenstiel incision. The initial insult is usually incising of the nerve, followed by formation of a neuroma, incorporation of the nerve during closing, or constriction from adhesions. The three most commonly involved nerves are the iliohypogastric, ilioinguinal, and genitofemoral nerves. Cutaneous abdominal nerve entrapment could occur during thoracoabdominal surgery. The presentation of nerve entrapment usually involved post-surgical pain in the territory innervated by the trapped nerve, possibly with radiation that tracks the nerve course. Once a suspected neuropathy is identified, it can be diagnosed with relief in pain after a nerve block has been instilled. Treatment is usually started with pharmaceutical solutions, topical first and oral if those fail. Most patients require escalation to a second line of treatment and see good result with injection therapy. Those that require further escalation can choose between ablation and surgical therapies. Post-surgical nerve entrapment is not uncommon and causes serious morbidity and financial loss. It is underdiagnosed and thus undertreated. Preventing nerve entrapment is the best treatment; when it does occur, options include topical and oral analgesics, nerve blocks, ablation therapy, and repeat surgery.
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http://dx.doi.org/10.1007/s11916-020-00924-1DOI Listing
February 2021

Successful Reimplantation of Spinal Cord Stimulator One Year after Device Removal Due to Infection.

Surg J (N Y) 2021 Jan 1;7(1):e11-e13. Epub 2021 Feb 1.

Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Spinal cord stimulation is an effective treatment modality for patients with numerous pain conditions. Although proven to be highly successful, device implantation does come with some inherent risks. One of the most challenging complications is perioperative infection. For most patients, a simple trial of oral antibiotics and in-office drainage of any superficial infectious material may be sufficient. Deeper infections with wound dehiscence necessitate device removal and intravenous antibiotic therapy. The question remains, if the device was previously providing pain relief for the patient, when is the appropriate time to reimplant the device after the infection has cleared? We describe the case of explantation of an infected device and successful reimplantation after 1 year.
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http://dx.doi.org/10.1055/s-0040-1722179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850884PMC
January 2021

Adrenal Ganglioneuroma: A Rare Tumor of the Autonomic Nervous System.

Cureus 2020 Dec 31;12(12):e12398. Epub 2020 Dec 31.

Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA.

Ganglioneuromas (GNs) are benign, differentiated tumors that are derived from neural crest sympathogonia. They can be found anywhere in the body along autonomic ganglia. These tumors are seen most often in individuals over 10 years of age and are usually asymptomatic. However, GNs can grow large and cause symptoms due to mass effect. GNs are rarely located within the suprarenal gland and are benign tumors that are often diagnosed late in their course due to mass effect or found incidentally on imaging studies. We describe a case of a 22-year-old female who presented to clinic with vague abdominal pain. She underwent an extensive workup which ultimately revealed a rare presentation of a left suprarenal GN that required surgical removal. She underwent an extensive workup which ultimately revealed a left suprarenal GN that required surgical removal. The patient underwent laparotomy and surgical excision of the mass and made a full recovery.
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http://dx.doi.org/10.7759/cureus.12398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845755PMC
December 2020