Rejected

Genicular artery embolization (GAE) has emerged as a treatment option to improve quality of life in patients suffering from moderate-to-severe pain refractory to conservative treatment of knee osteoarthritis, with encouraging results. This paper describes the study protocol of a single-center, double-blind, randomized controlled trial designed to evaluate and compare the safety and efficacy of GAE using imipenem/cilastatin vs. microspheres for the treatment of moderate-to-severe pain associated with knee osteoarthritis. We hypothesized that there will be no difference in safety and efficacy outcomes. The study received ethics approval of the institutional review board with number 4.364.391 / CAAE: 37590820.3.0000.5342 and is registered onto the Registro Brasileiro de Ensaios Clinicos (ReBEC), with number RBR-2h5rwgb. Technical success was defined as embolization of at least 1 feeding artery supplying the hyperemic synovium of the knee joint. Primary outcome: clinical success was defined as improvement in symptoms, 50% reduction in Western Ontario and McMaster Universities Osteoarthritis Index pain scores or an increase of at least 10 points in the Knee Injury and Osteoarthritis Outcome Score from baseline to 3 months of follow-up. Secondary outcome: radiological success was defined as significant improvement in the Whole-Organ Magnetic Resonance Imaging Score for knee synovitis considering the embolized areas at 12 months of follow-up after GAE and a reduction in the analgesia or other conservative therapies for knee pain used by the patient at 3 and 12 months of follow-up. Clinical assessments will be performed before GAE, during GAE and at hospital discharge (for Visual Analog Scale of pain), and at 30 days, 3 months, and 12 months after GAE.

Background Most adults presenting with chest pain will not receive a diagnosis and be recorded with unattributed chest pain. The objective was to assess if they have increased risk of cardiovascular disease compared with those with noncoronary chest pain and determine whether investigations and interventions are targeted at those at highest risk. Methods and Results We used records from general practices in England linked to hospitalization and mortality information. The study population included patients aged 18 years or over with a new record of chest pain with a noncoronary cause or unattributed between 2002 and 2018, and no cardiovascular disease recorded up to 6 months (diagnostic window) afterward. We compared risk of a future cardiovascular event by type of chest pain, adjusting for cardiovascular risk factors and alternative explanations for chest pain. We determined prevalence of cardiac diagnostic investigations and preventative medication during the diagnostic window in patients with estimated cardiovascular risk ≥10%. There were 375 240 patients with unattributed chest pain (245 329 noncoronary chest pain). There was an increased risk of cardiovascular events for patients with unattributed chest pain, highest in the first year (hazard ratio, 1.25 [95% CI, 1.21-1.29]), persistent up to 10 years. Patients with unattributed chest pain had consistently increased risk of myocardial infarction over time but no increased risk of stroke. Thirty percent of patients at higher risk were prescribed lipid-lowering medication. Conclusions Patients presenting to primary care with unattributed chest pain are at increased risk of cardiovascular events. Primary prevention to reduce cardiovascular events appears suboptimal in those at higher risk.

Physical activities, such as resistance training and walking, are known to be effective against chronic low back pain (CLBP). However, few studies have examined the associations of walking and resistance training with CLBP in the general older population. Therefore, this study analyzed these relationships in the older Korean population (aged ≥65 years), with the goal of determining which exercise is better for CLBP.This cross-sectional study analyzed Korean National Health and Nutrition Examination Survey data for the period 2012 to 2015. The Korean National Health and Nutrition Examination Survey, which provides representative data for the Korean population, uses a clustered, multistage, random sampling method with stratification based on geographic area, age, and sex. Three multiple logistic regression models were generated in this study to determine the associations of walking and resistance training with CLBP.A total of 5233 participants were enrolled, 3641 (69.6%) of whom were free from CLBP; the remaining 1592 (30.4%) had CLBP. 78.4% and 64.8% of the non-CLBP and CLBP group patients, respectively, walked at least once a week. Also, 23.5% and 11.6% of the participants in the non-CLBP and CLBP groups, respectively, engaged in resistance training at least once a week. In the multiple logistic regression analysis, which was adjusted for all potential confounders, walking was significantly associated with a lower risk of CLBP (1-2d/wk: odds ratio [OR] = 0.65, P = .002; 3-4d/wk: OR = 0.69, P = .004; ≥5 d/wk: OR = 0.57, P < .001). However, resistance training showed no association with the risk of CLBP.In this cross-sectional study, walking was associated with a lower risk of CLBP. In particular, walking >5days per week had the maximum benefit in a lower risk of CLBP. Therefore, clinicians can consider recommending walking to patients with CLBP for optimal pain improvement.

At teaching hospitals, consultants must provide effective supervision, including appropriate selection of teaching cases, such that the outcomes achieved by trainees are similar to that of consultants. Numerous studies in the surgical literature have compared patient outcomes when surgery is performed by consultant surgeons or surgical trainees but, to our knowledge, none exist in the field of anaesthesia. We aimed to compare analgesia outcomes of regional anaesthesia when performed by supervised trainees versus consultants. We designed a retrospective observational study using registry data. The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS) for pain >5 reported at any time in the post-anaesthesia care unit (PACU). Secondary outcomes included the maximum pain NRS, pain experienced in the PACU, and the requirement for systemic opioid analgesia in the PACU. Of the 1814 patients analysed, the primary proceduralist was a consultant for 514 (28.3%) patients and a trainee for 1300 (71.7%) patients. All trainees were supervised by an on-site consultant. There were no statistically significant differences between consultants and supervised trainees in terms of the primary outcome (NRS >5 in 24.9% and 24.5% of patients, respectively;  = 0.84) and secondary outcomes. Compared to trainees, consultants had a slightly higher rate of patients with a body mass index >30 kg/m, an American Society of Anesthesiologists Physical Status Classification of 3 or 4, nerve blocks performed under general anaesthesia, paravertebral/neuraxial blocks and blocks with perineural catheter placement. Regional anaesthesia performed by supervised trainees can achieve similar analgesia outcomes to consultant-performed procedures.

Pulsed radiofrequency (PRF) is a commonly used method for the treatment of zoster-related pain in the clinic. However, PRF therapy has a high recurrence rate and many adverse reactions. Recent studies have shown that short-term spinal cord stimulation (stSCS) can effectively alleviate zoster-related pain. Due to the lack of evidence, it is unclear whether stSCS is superior to PRF in the efficacy of treating zoster-related pain.

Superior mesenteric artery syndrome (SMAS), also known as Wilkie's syndrome, is a rare cause of upper gastrointestinal tract obstruction. We report a case of a 10-year-old girl with persistent abdominal pain for over 3 months, who on extensive investigations was diagnosed with SMAS. She underwent a surgical procedure to bypass the obstructed portion of the intestine for relief of her symptoms.

BACKGROUND We emphasize the utility of focusing on patient medical history and concerns rather than anchoring on data sent from referral institutions, which is often qualitative and devoid of useful patient-driven information. CASE REPORT A 21-year-old man was referred to our hospital with persistent back pain, hypoalbuminemia, and C-reactive protein (CRP) elevation after prolonged hospitalization for a UTI at another hospital. A review of systems (ROS) revealed chronic diarrhea and colonoscopy revealed Crohn's disease. Colonoscopy was followed by worsening back pain. Intestinal perforation was ruled out by X-ray, and analgesics were prescribed for long-standing scoliosis. The patient returned several days later with a recurrent UTI; a vesicointestinal fistula was identified, a known complication of Crohn's disease. This case involved diagnostic errors due to the doctors' faulty cognitive process. Also, in retrospect, we needed to be aware that the CT at the time of referral showed free air in the bladder and not uncomplicated pyelonephritis. The diagnostic errors were related to both satisfaction bias (finding one disease that prevents the accurate and timely diagnosis of another) and lack of awareness of epidemiology. To prevent errors like these, it is important to first conduct a careful interview and physical examination, as if the patient were a first-time patient, in order to eliminate the influence of bias. Next, epidemiological possibilities should be considered and differentiation made between physical and epidemiological issues. CONCLUSIONS It is important to treat referral patients as if they were first-time patients and to give due consideration to diagnostic biases and epidemiology.

The aim of this study is to retrospectively analyze and evaluate the effect of transverse thoracic muscle plane (TTP) block as a routine analgesic strategy for cardiac enhanced recovery after surgery in sternotomy.Patients received TTP block after general anesthesia and tracheal intubation were included in this study. The baseline clinical data of the patients, intraoperative use of sufentanil, internal mammary artery separating time, the postoperative duration of invasive ventilation, visual analogue scale, the compression times of patient-controlled intravenous analgesia in the first 3 days after surgery, and postoperative nausea and vomiting were recorded.A total of 104 cases was included and divided to G group (without TTP block) and TTP group (with TTP). Sufentanil use (sufentanil dose/min, sufentanil dose/kg body weight, sufentanil dose/[min kg]) in TTP group was significantly lower than that of G group. In G group, intraoperative use of sufentanil was correlated to the duration of anesthesia (P = .035). The postoperative visual analogue scale pain scores and the compression times of patient-controlled intravenous analgesia in the TTP group were significantly decreased compared with G group (P < .01). The postoperative duration of invasive ventilation of patients with normal and mildly impaired pulmonary function was significantly correlated to the use of sufentanil (P = .027, .009).TTP block has certain analgesic effect and can reduce sufentanil use in medium-length cardiac surgery and postoperative use of opioids. It is indicated that TTP block can be used as a routine enhanced recovery after surgery strategy for sternotomy in cardiac surgery.

Anesthetic agents are mandatory in colorectal cancer patients undergoing surgery. Studies published so far have shown that anesthetic drugs and intervention may have different impacts on patient's outcome. Among these drugs, propofol and, more recently, local anesthetics have been mostly targeted.