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Methotrexate (MTX) is a chemotherapeutic agent that acts primarily by inhibiting the folic acid cycle. In addition to its application for treating malignancies, MTX is also used to treat chronic inflammatory diseases including psoriasis. Adverse effects have been reported even at low doses (up to 25 mg/week), and there is risk of toxicity in the form of myelosuppression, hepatotoxicity, or pulmonary fibrosis.

To compare local anesthetic wound infiltration with intraperitoneal instillation of local anesthetic for analgesia after cesarean section under spinal anesthesia.

CKD is associated with decreased anabolic response to insulin contributing to protein-energy wasting. Targeted metabolic profiling of oral glucose tolerance testing (OGTT) may help identify metabolic pathways contributing to disruptions to insulin response in CKD.

To the Editor, We read the article "Integrating IPACK (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) Block in an Enhanced Recovery after Surgery Pathway for Total Knee Arthroplasty-A Prospective Triple-Blinded Randomized Controlled Trial" by Pai et al in the Journal for Knee Surgery (2022) with great interest1. We applaud the authors in finding that when added to an enhanced recovery after surgery pathway consisting of a spinal anesthetic, adductor canal nerve catheter, and surgeon-administered periarticular joint infiltration (PAI), the IPACK block did not significantly impact postoperative opioid consumption or measured functional outcomes on postoperative day 1. Interestingly, the authors found that addition of the IPACK block did significantly decrease posterior knee pain. We found this notable as both the IPACK block and PAI target the posterior knee capsule. Innervation of the posterior knee capsule is complex and includes branches of the obturator, sciatic, common fibular, and tibial nerves2. PAI has variable effectiveness in this anatomical area3. Prior studies have shown that addition of the IPACK and adductor canal blocks to PAI provides superior analgesia and decreases opioid consumption in TKA4. This study found that the IPACK block resulted in improved posterior knee analgesia compared to PAI. This could signify that an ultrasound-guided approach may be more consistent in targeting the posterior knee capsule. The authors also astutely mention concern for local anesthetic toxicity (LAST). Peripheral nerve blocks, especially in the lower extremity, have a decreased risk of LAST compared to PAI5. Further study of the effectiveness of the IPACK block compared to PAI may show that the IPACK is a reasonable replacement of PAI, while also potentially decreasing the risk of LAST. We greatly appreciate the work Dr. Pai and team performed to further our understanding of posterior knee analgesia and its contribution toward the creation of patient care pathways that target analgesia and prioritize patient safety.

Altered lumbar multifidus (LM) activation has been found in populations with non-specific chronic low back pain (NSCLBP).

Opioids are commonly prescribed beyond what is necessary to adequately manage postoperative pain, increasing the likelihood of chronic opioid use, pill diversion, and misuse. We sought to assess opioid utilization and patient-reported outcomes (PROs) in patients undergoing ventral hernia repair (VHR) following the implementation of a patient-tailored opioid prescribing guideline.

The interest in Para athletes' health continues to increase. Still, there are few studies that have evaluated health parameters beyond injury and illness in this athlete population.

Patients with severe burn injuries often require split thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 to May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African American males, but mechanism of injury varied. Over half had a neurologic (17 %) or psychiatric history (34 %) outside of substance use. Almost three-quarters had a history of substance use with 17 % being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < 0.001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

In this issue of Anesthesia & Analgesia, Lim and colleagues offer a scoping review of the available literature encompassing opioid use disorder (OUD) in pregnant patients. As discussed in their review, opioid use and abuse in pregnant patients have increased four-fold in the past decade. As such, these patients can present significant challenges with respect to pain management during labor and delivery. A baseline habituation to opioids can render patients resistant to conventional pain management plans. Those who are additionally prescribed opioid agonist-antagonists or other maintenance medications for OUD such as buprenorphine or methadone have even more complex pharmacologic considerations that make pain management unpredictable. As detailed in their analysis, there is a paucity of literature surrounding optimal management strategies in this population of patients. Reports are increasing over time, however, most publications are of lower tier evidence, with very few randomized trials and systematic reviews to inform practitioners. It becomes plainly evident that this is an area of clinical science that demands greater attention. Specific areas of focus elaborated by the authors include: better characterization of opioid selection and dosing in managing labor analgesia, effectiveness of different regional anesthetic techniques, non-pharmacologic management, and psycho-social support for these patients. The reader is strongly encouraged to review the cited article for an in-depth understanding of the concepts summarized in this infographic.