Citations

Abstract Objective Genicular nerve radiofrequency (gRF) treatment is a widely used intervention for chronic pain from knee osteoarthritis (KOA). This systematic review and meta-analysis focuses on RCTs utilizing image guidance to address inconsistencies in previous reviews and provide higher-quality evidence. Design, Setting, and Methods This study included RCTs that compared gRF techniques (conventional, cooled, pulsed, bipolar) to non-gRF treatments, including sham procedures, intra-articular injections, ozone therapy, and oral medications. Primary and secondary outcomes were changes in pain and total WOMAC scores at 3, 6, and 12 months post-gRF treatments. Subgroup analyses explored differences by lesion size, use of prognostic blocks, industry sponsorship, and study location. Statistical heterogeneity was assessed via I 2 statistics. Results Eleven RCTs with 868 knee osteoarthritis patients (435 gRF, 433 non-gRF) were included. At 3 months, gRF significantly reduced pain (SMD -1.65, 95% CI: -3.20 to -0.10, I 2 = 98%, P = 0.040), but not at 6 months or 12 months. Secondary analyses showed no significant differences in total WOMAC scores between the gRF and control groups at 3, 6, and 12 months. Subgroup analysis showed that industry-sponsored studies reported significant 3-month pain reduction, whereas non-sponsored studies did not. This effect was independent of study location. Conclusions GRF provides short-term pain relief (up to 3 months) but neither functional improvement nor sustained pain reduction compared to non-gRF treatments. Our findings do not support the routine use of gRF for long-term chronic pain due to KOA.

Abstract Introduction The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. Methods This study involved 56 PDs of ACGME‐accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow‐up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. Results Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry‐related and professional society‐related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long‐term success. Fifty‐four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. Conclusion This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12‐month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Background Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective and durable metabolic and bariatric surgery to achieve a target weight loss. However, many surgeons are hesitant to adopt BPD-DS due to a lack of training, technical complexity, and long-term nutrition deficiencies. This meta-analysis aimed to investigate long-term nutrition outcomes after primary BPD-DS in the management of obesity. Methods Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023391316). Results From 834 studies screened, 8 studies met the eligibility criteria, with a total of 3443 patients with obesity undergoing primary BPD-DS. At long-term follow-up (≥5 years), 25.4% of patients had vitamin A deficiency (95% CI: -.012, .520, I 2 = 94%), and 57.3% had vitamin D deficiency (95% CI: .059, 1.086, I 2 = 86%). Calcium deficiency was observed in 125 patients (22.2%, 95% CI: .061, .383, I 2 = 97%), and 69.7% had an abnormal parathyroid hormone level (95% CI: .548, .847, I 2 = 78%). Ferritin level was abnormal in 30 patients (29.0%, 95% CI: .099, .481, I 2 = 79%). Conclusions Despite displaying comparable nutrition-related outcomes to mid-term follow-up, our study demonstrated that BPD-DS could result in a high level of long-term nutrition deficiency after BPD-DS for selected patients. However, further randomized controlled studies with standardized supplementation regimens and improvement in compliance are necessary to evaluate and prevent long-term nutritional deficiencies after BPD-DS.

AbstractBackgroundThis is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.MethodsExperts in management of the high‐risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta‐analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.ResultsComponents of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.ConclusionsThese guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end‐of‐life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high‐risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Abstract Background This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra‐ and postoperative aspects of care. Methods Experts in aspects of management of high‐risk and emergency general surgical patients were invited to contribute by the International ERAS ® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta‐analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS ® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Results Twenty‐three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. Conclusions These guidelines are based on best available evidence for an ERAS ® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high‐risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Abstract Background Asymptomatic patients colonized with Clostridioides difficile are at risk of progressing to C. difficile infection (CDI), but the risk factors associated with progression are poorly defined. The objectives of this study were to identify the prevalence and risk factors to progression of hospital-onset CDI (HO-CDI) among colonized patients. Methods This was a retrospective cohort study conducted at a large academic medical center. Patients were included if they were ≥ 18 years of age and colonized with C. difficile, detected via polymerase chain reaction (PCR) on a rectal swab collected on admission from 2017 to 2020. Patients were excluded if they had prior CDI, CDI symptoms on admission, neutropenia, prior rectal surgery, or were hospitalized for less than 24 hours. CDI toxin positive patients were matched 1:3 to CDI negative patients using PCR colonization test date. The primary endpoints were the prevalence of HO-CDI and the risk factors for progression to HO-CDI. Descriptive analyses were used to describe the population and univariate analysis was used to determine risk factors associated with HO-CDI. Results A total of 2,150 patients were colonized with C. difficile; 109 CDI toxin positive patients were matched to 327 CDI toxin negative patients. 134 patients were included and 3.2% (69/2150) developed HO-CDI. The median age was 64 and 68 patients (50.7%) were male. Malignancy (OR 2.89, 95% CI: 1.24-6.75; P = 0.01), hospitalization within one month (OR 2.2, 95% CI: 1.1-4.38; P = 0.03), antibiotic use within one month (OR 3.23, 95% CI: 1.59-6.56; P = 0.001), antibiotic use within three months (OR 2.16, 95% CI: 1.07-4.35; P = 0.03), intensive care unit (ICU) admission (OR 5.14, 95% CI: 2.47-10.73; P < 0.0001), immunosuppressant use (OR 3.33, 95% CI: 1.14-9.78; P = 0.03), and use of a third generation cephalosporin within three months (OR 4.5, 95% CI: 1.12-18.13; P = 0.03) were associated with HO-CDI. Conclusion Progression to HO-CDI was uncommon among colonized patients at our institution. This data suggests that in hospitalized patients colonized with C. difficile, malignancy, hospitalization within one month, antibiotic use within one or three months, ICU admission, receipt of immunosuppressants, and use of a third generation cephalosporin within three months are associated with HO-CDI. Disclosures All Authors: No reported disclosures.

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity. Methods: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521). Results: From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=−10.16%, 95% confidence interval: −11.80, −8.51, I2=0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=−1.36 d, 95% CI: −2.39, −0.33, I2=86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I2=20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I2=0%) values than the BPD-DS group. Conclusions: SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

Introduction Applicants to chronic pain medicine fellowship programs often express confusion regarding the importance of various selection criteria. This study sought to elucidate program directors’ considerations in applicant selection for fellowship interviews and ranking and to correlate these criteria with match statistics to provide a guide for prospective candidates. Methods An electronic survey was sent to all Accreditation Council for Graduate Medical Education-accredited chronic pain fellowship directors. The importance of various applicant characteristics were evaluated and compared with recent match data. Results Fifty-seven program directors completed the survey. The most important factors involved in applicant interview selection were perceived commitment to the specialty, letters of recommendation from pain faculty, scholarly activities, and leadership experiences. Although completion of a pain rotation was valued highly, experience with procedures was of relatively low importance. There was no preference if rotations were completed within the responders’ department. Variability was noted when considering internal applicants or the applicant’s geographic location. When citing main factors in ranking applicants, interpersonal skills, interview impression and applicant’s fit within the institution were highly ranked by most responders. Discussion Assessment of an applicant’s commitment to chronic pain is challenging. Most responders prioritize the applicant’s commitment to chronic pain as a specialty, scholarly activity, participation in chronic pain rotations, pain-related conferences and letters of recommendation from pain faculty. Chronic pain medicine fellowship candidates should establish a progressive pattern of genuine interest and involvement within the specialty during residency training to optimize their fellowship match potential.

Abstract Background: An elevated risk of developing non-Hodgkin's lymphoma (NHL) has been associated with a family history of NHL and several other malignancies, but the magnitude of risks and mechanisms are uncertain. Methods: We used self-reported family history data from a recent multicenter U.S.-based case-control studies of NHL to evaluate familial aggregation of NHL with various hematolymphoproliferative and other cancers. Estimates of familial aggregation were obtained as hazard ratios (HR) that compare incidence of different cancers in first-degree relatives of NHL cases with that in the first-degree relatives of NHL controls. Limitations of the study included low participation rates (76% for cases and 52% for controls) and potential differential accuracy of recall. Results: Risk of NHL was elevated in relatives of NHL cases [HR, 2.9; 95% confidence interval (95% CI), 0.95–8.53]; the aggregation seems to be stronger for siblings (HR, 7.6; 95% CI, 0.98–58.8) and for male relatives (HR, 6.2; 95% CI, 0.77–50.0). Risk of Hodgkin's lymphoma seems to be also elevated among relatives of early-onset (<50 years) NHL cases (HR, 3.2; 95% CI, 0.88–11.6). Evaluation of family history of other cancers provided modest evidence for an increased risk of melanoma of the skin (HR, 2.9; 95% CI, 1.08–7.75), pancreatic cancer (HR, 2.1; 95% CI, 0.96–4.43), stomach cancer (HR, 1.8; 95% CI, 0.91–3.63), and prostate cancer (HR, 1.3; 95% CI, 0.87–1.99). Conclusions: These results are consistent with previous findings of familial aggregation of NHL, Hodgkin's lymphoma, and a few other cancers. The pattern of male-specific and sibling-specific familial aggregation of NHL we observed, if confirmed, may shed new light on the possible mechanisms that underlie familial aggregation of the disease.

Abstract Background Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high‐risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods Experts in aspects of management of the high‐risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta‐analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non‐emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high‐risk patients.