Both treatments were efficient, whatever the age or sex of the patient, the initial pain level, and the causal tooth. Conclusion: Pulpotomy is an efficient way to relieve pain, using either articaine or eugenol. When choosing a pulp dressing, eugenol should be the first choice.Irreversible pulpitis is an extremely painful dental pathology. Its emergency treatment, pulpotomy, should include the use of a pulp dressing in the pulp chamber until the final treatment. Various antalgic products have been suggested as efficient medications to relieve the patient’s pain and are commonly used, but data for scientific validation are scarce. Objective: We evaluated the efficacy of articaine or eugenol in the diminution of pain after pulpotomy. Design: We included 100 patients with irreversible pulpitis and evaluated their initial pain levels. Pain was measured using a 0–10 numeric rating scale. After treatment through pulpotomy, we randomized them into two groups using either articaine or eugenol as a pulp dressing and evaluated their pain level at 1, 3 and 7 days. Results: Initial pain levels were severe (7.53). The use of painkillers was not associated with lower levels of pain. Both treatments showed great efficiency on day 1, with stronger efficiency of eugenol than articaine, showing a decrease of 6.24 versus 4.89 ( Irreversible pulpitis is a frequent oral pathology that leads to dental pulp destruction. It accounts for up to 35% of painful dental emergencies, with an elevated prevalence among young adults ,2,3.ArouVarious products have been used as temporary pulp dressings over the years ,13. AssoThe evaluation of various medications used as pulp dressings has shown no difference in the efficiency of the evaluated products , all of them being highly efficient in relieving pain . HoweverWith the disappearance of some medications, we wanted to validate and compare the efficiency of two inexpensive, easy-to-use and easily available products used for analgesia, which are present in every dental office: articaine and eugenol. Pulpotomy by itself seems to be an efficient treatment even without using any active pulp dressing ,13. HoweArticaine is an anesthetic drug commonly used for local and loco-regional anesthesia and, as such, available during the procedure. Its efficiency as an anesthetic has been extensively studied and seems slightly superior to other dental anesthetic drugs in some situations, like inferior alveolar nerve block ,17, but Eugenol (4-Allyl-1-hydroxy-2-methoxybenzene) has complex dose-dependent effects on inflammation, apoptosis and anesthesia and is widely used for its antibacterial, antiviral, antioxidant, anti-inflammatory and analgesic properties, per se or as part of more complex materials such as zinc-oxide–eugenol cements . Its useThe aim of this study is to evaluate the efficacy of articaine and eugenol as pulp dressings for pain control by comparing pain diminution after a pulpotomy following a diagnosis of irreversible pulpitis in a double-blind (blind patient and phone investigator) randomized clinical trial.The study protocol, written with respect of the declaration of Helsinki, was validated by an ethics committee according to French law (Patient Protection Comity CPP): “Comité de protection des personnes Est IV”; N° IDRCB: 2017-A03416-47/RIPH3 2017-HUS N°6953, on 14 March 2018. The study was also approved by the institutional review board of Strasbourg’s Hospital: The scientific council of the Direction of Clinical Research and Innovation (DRCI) and registered as “HUS N°6953”. The trial was registered with the clincialtrials.gov identifier NCT03472456 (21 March 2018). The National Commission for data processing and Freedom (CNIL) and the National Health and Drug Association (ANSM) were, respectively, informed of the data collection and of the study protocol. We followed the CONSORT Guidelines  of the Strasbourg (France) University Hospital (HUS).The null hypothesis was “articaine and eugenol have a similar efficacy on pain diminution after treatment on day 1, 3 and 7”.Our main judgment criterion was the evolution of pain measured using the 0 to 10 numeric rating scale for pain (NRS) score 24 h after treatment. We also measured NRS scores 3 and 7 days after treatment.Our inclusion criteria were: informed and willing adult (>18 years old) patient with social insurance, a sufficient understanding of the French language to answer our questions with no risk of error, not undergoing antalgic treatment for another pathology, diagnosed with an irreversible pulpitis (see below) on any mature permanent tooth and for which pulpotomy was indicated and achievable. We did not include patients on whom we were not able to perform the pulpotomy , patients whose pain was caused by two or more teeth and patients undergoing chronic antalgic medical treatment.Diagnosis of irreversible pulpitis was performed by a senior dental surgeon on the following criteria: Spontaneous, severe and prolonged pain, exaggerated following cold exposure on a single tooth, presenting a logical etiology (such as carious disease) and no sign of infection nor pulp necrosis. Radiographs were used to confirm the presence of a logical etiology and eliminate teeth with signs of necrosis, such as visible periapical radiolucent lesions. We explained the protocol and anonymity to eligible patients. Signed consent was obtained before we started the treatment procedure. Due to the risk of procedure or anesthetic failure, patients were considered, as included only after the success of the pulpotomy procedure, just before the randomization. On day 0 before the treatment, included patients answered a questionnaire in which we recorded the spontaneous pain level using NRS and the phone number of the patient. Other evaluated variables were age, sex, treated tooth, consumption of painkillers in the past 24 h, medical conditions and treatments. -Anesthesia using articaine from a 40 mg/mL anesthetic cartridge with 1/200,000 vasoconstrictor . The Inferior Alveolar Nerve Block technique was used in the first intention for mandibular molars, and vestibular infiltration for other teeth. If not enough, intra-ligamentary anesthesia was performed, or intra pulpal if the pulp was exposed.-The tooth was isolated from the saliva using a rubber dam when the use of a clamp was possible. If using a rubber dam was impossible  and since pre-endodontic restoration was not manageable in an emergency, and isolation was obtained using cotton rolls and dental aspirator.-Access to the pulp chamber was achieved using a diamond bur; destruction of the whole pulp in the pulp chamber using an Endo-Z bur. Sodium hypochlorite on a cotton pellet was used to clean the chamber for a few seconds. Complete pulpotomy was confirmed by the end of any bleeding and the visualization of the root canal entrances. In case of persistent bleeding, compression using a dry cotton pellet was performed for 2 min.Patients were then treated for irreversible pulpitis using the standard pulpotomy procedure performed by two dental students in their 5th of 6th year of studies who undertook theoretical and practical courses about endodontics and pulpotomy, supervised by a senior investigator (D.O. or G.FdG.) using the following steps: After a senior confirmed the success of the pulpotomy procedure, patients were included in the study and were randomly and blindly  assigned a medication: either a drop of articaine from a 40 mg/mL anesthetic cartridge with 1/200,000 vasoconstrictor  commonly used for anesthesia  or a drop of pure eugenol  on a cotton pellet covered by a temporary filling material without eugenol . Failure to perform the pulpotomy procedure did not lead to inclusion.No painkiller or any other drug was prescribed, but patients were informed that they were allowed to use painkillers if needed. A blind investigator called them back by phone on day 1, Day 3 and Day 7 to evaluate pain and the use of painkillers. At day 0, patients were offered an appointment to perform the full endodontic treatment if it was deemed possible or an extraction if it was not after a one-month delay after the last phone call.We evaluated the necessary number of patients to 100 to assess a difference in pain relief of 2 on the NRS between the two groups, with less than 10% of patients lost to follow-up, using the standard risks α = 0.05 and β = 0.10 and estimating the standard deviation for pain to be of 3 at most based on a previous study . The flow diagram of this study is shown in Statistical analysis was made using the software R   and the worst (no diminution of pain) situations for the missing data of those two patients, which made no statistical difference. We thus excluded them from the final analysis concerning the evolution of pain at the 7th day only .No adverse effects were reported during or after the study outside those three exclusions: one diagnostic failure and two for where the treatment was inefficient and likely failed.The sample used for baseline and day 1 analysis is composed of 86 patients , while tOur 86-patient sample was composed of 46 women (53%) and ranged from 18 to 71 years old (mean 31). Among them, 33 (37%) took painkillers before inclusion. Causal teeth were mostly mandibular molars and maxillary molars, followed by other maxillary teeth and other mandibular teeth. Initial pain levels were not significantly different between groups .p = 0.157) difference between the two groups: 7.29 CI95% [6.73–7.95] for the eugenol group and 7.77 CI95% [7.37–8.17] for the articaine group , with a small non-significant . Most patients (91.9%) experienced a decrease in pain, 75.6% of the patients had a pain score under 3, and 45.3% had no more pain at all. Pain intensity on day 1 was not correlated with pain intensity on day 0 (p = 0.43).On day 1, pain among the whole group significantly dropped from 7.53 (±1.57) to 1.99 (±2.47) (p < 0.001 in both groups) as well as a significantly higher decrease (p = 0.025) and a significantly lower pain perceived on day 1 (p < 0.001) among the eugenol group (Pain decreased by 6.24 (±2.68) to 1.05 CI95% [0.51–1.58] among the eugenol group and by 4.89 (±2.81) to 2.89 CI95% [2.05–3.72] among the articaine group, showing a significant decrease in both groups , 4.47 vs. 0.71 on day 3 (p < 0.001) and 4.60 vs. 0.43 on day 7 (p < 0.001), in both articaine and eugenol groups.The consumption of painkillers on days 1 (24% of the population), 3 (20%) and 7 (13%) was significantly associated with a higher level of pain: 4.05 vs. 1.32 on day 1 (p = 0.22) nor sex (p = 0.63) nor the type of causal tooth (p = 0.29) was associated with the changes in pain levels between day 0 and day 1. Similar results were obtained on days 3 and 7.Neither age , Opium (3%) and Caffeine (9%). Those four patients still evaluated their pain at 8 on the NRS. This confirms the low efficiency of painkillers on pain associated with irreversible pulpitis and the need for an emergency treatment such as pulpotomy . It shouUse of painkillers after treatment was associated with higher pain levels, which is quite logical since patients were advised to stop taking painkillers once free of pain. This once again assesses the low efficiency of painkillers, even in post-treatment residual pain ,24.The main strengths of this study are (1) the large sample when compared to similar studies, (2) the strict, detailed protocol including a reproducible method for pulpotomy and a seven-day follow-up, and (3) the use of the NRS for pain recording, allowing for a more precise description of pain-levels evolution than the qualitative scales found in other studies ,14.The main limitation of this study is the lack of a placebo control. Our results are thus limited to a comparison of pulpotomy + eugenol vs. pulpotomy + articaine, allowing us to conclude on the efficiency of eugenol vs. articaine but not on the specific effect of each product independently of the pulpotomy. As stated in the introduction, we had to comply with national recommendations and were not able to use an inactive product as a control. We chose to evaluate two products that are cheap, widely available, and traditionally used for short-term pain management. We did not evaluate the most recent but experimental procedures, such as long-term pulpotomy, using MTA or Biodentine whose goal is mostly long-term survival, which was not the purpose of this study. However, the higher efficiency of eugenol compared to articaine and the overall excellent efficiency of the procedures are still important and valid results. Other studies could evaluate the efficiency of different dressings, such as zinc oxide–eugenol cements, which could deliver eugenol while ensuring the temporary filling of the tooth, or even the absence of any dressing since pulpotomy seems to be efficient in itself due to the removal of the coronal pulp and independently of any pulp dressing . As an eWe also experienced a major attrition of our sample over only seven days, close to the anticipated 10% on day 1 but much higher (32%) on day 7, despite several tries to reach the patients back by phone. This may be due to the specific population attending the emergency dental care unit in Strasbourg, which consists mainly of needy patients with social difficulties and low motivation once the emergency is treated. The missing patients did not display any specific characteristics compared to the rest of the sample and were likely missing at random, not leading to any bias outside a loss of statistical power.The interventions were performed by supervised dental students in their last or second-to-last year of study. Despite supervision by a senior investigator, this may have introduced variability in the results while also confirming that pulpotomy can be performed with high efficiency and good reproducibility, even by young practitioners.Only a few recent studies about pulpotomy as a treatment for irreversible pulpitis were found, and even fewer detailing the possible procedures ,14,21. TIrreversible pulpitis is a painful dental pathology. We confirmed that pulpotomy is an efficient alternative emergency treatment of irreversible pulpitis to relieve the patient’s pain when a full endodontic treatment cannot be immediately performed. While pulpotomy using either articaine or eugenol is always efficient, using eugenol as a pulp dressing seems to be slightly more efficient than using articaine to ensure lower pain levels on days 1, 3 and 7 after treatment and should be preferred if available.


Background and Objectives: Available data with regard to the outcomes of patients with severely calcified left main (LM) lesions after revascularization by percutaneous coronary intervention (PCI) when compared to non-calcified LM lesions is unclear. Materials and Methods: The present study sought to retrospectively investigate in hospital and 1 year post-intervention outcomes of patients with extremely calcified LM lesions after PCI facilitated by calcium-dedicated devices (CdD). Seventy consecutive patients with LM PCI were included. CdD requirement was based on suboptimal results after balloon angioplasty. Results: Twenty-two patients (31.4%) required at least one CdD, while nine patients (12.8%) required at least two. Intravascular lithotripsy and rotational atherectomy were the predominantly used methods, while ultra-high pressure and scoring balloons contributed the least to lesion preparation (9%). In 20 patients (28.5%), severe or moderate calcifications were angiographically identified, but non-compliant balloon predilation was adequate and CdD were not necessary. Total procedural time was significantly higher in CdD group . Procedural and clinical success were obtained in 100% of cases. There were no major adverse cardiac and cerebrovascular events (MACCE) recorded during hospitalization. MACCE at 1 year post-procedure were recorded in three patients . All three events were documented in the control group (6.2%), and no events were recorded in CdD group . There was one cardiac death at 10 months and two target lesion revascularizations for side-branch restenosis. Conclusions: Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using calcium-dedicated devices. Significant unprotected left main (LM) coronary disease is frequently encountered, with a reported prevalence ranging from 3.6%  up to 12Coronary artery calcification (CAC) represents a frequent finding in patients with CAD . Even wiSimilar to severe CAC at any location, LM lesion preparation using calcium-dedicated devices (CdD) is known to be both feasible and technically effective. Nonetheless, in real-world practice, a notable level of reluctancy might be observed with regard to CdD employment in LM located lesions. This can be explained by several factors, including the higher-risk location, increased complexity due to the presence of a critical bifurcation, insufficient operator expertise, higher costs, and lack of dedicated studies to validate the (long-term) risk-benefit ratio.Thus, the present study sought to retrospectively investigate the in hospital and 1 year post-procedure clinical outcomes of patients with extremely calcified LM lesions after PCI facilitated by CdD.We retrospectively included all consecutive patients who underwent LM PCI at a single center in Belgium during a 12 month period (January 2021 to December 2021). Outcomes were evaluated during index hospitalization and at 12 months post-procedure using data from in hospital visits, telephone interviews , or national data registries for death occurrence, if necessary, in particular cases. The study included a total of 70 patients. All the LM procedures were performed by a single experienced operator. There were no exclusion criteria.Significant LM CAD was defined as ≥50% diameter stenosis in any segment of the LM. Other vessel significant CAD was defined as stenosis of >70% or 40–70% with invasive or non-invasive proof of ischemia. Protected LM was defined when at least one patent graft to the left coronary system was present. Ad-hoc procedures were performed in patients with acute coronary syndrome and ongoing ischemia. Patients with stable clinical status and high anatomical complexity were discussed in the local heart team. The decision to perform either PCI or CABG was based on anatomic complexity, surgical risk, comorbidities, the possibility of maintaining dual-antiplatelet therapy for at least 6 months, and patients’ informed preference.The diagnostic and PCI procedures were performed as per conventional and local practices. During the PCI procedure, unfractionated heparin was administered to obtain an activated clotting time of 250–300 s. The antiplatelet regimen included administering aspirin with a thienopyridine at the operator’s discretion  for a period of at least 12 months. The type of stent, intravascular imaging, circulatory mechanical support, and the intraprocedural usage of GP IIb/IIIa antagonists were all left at the discretion of the operator.®, SIS Medical AG, Frauenfeld, Switzerland), intravascular lithotripsy (IVL), or rotational atherectomy (RA). RA was also utilized as a primary strategy in cases where the operator’s judgement deemed initial balloon dilatation as futile. NC balloon post-dilatation was used at the discretion of the operator. Procedural details of the CdD techniques are described in the Supplementary Data.As per local protocols, all LM lesions were predilated before stent implantation using non-compliant (NC) balloons (with or without semi-compliant (SC) balloon dilatation as a first step). Insufficient plaque preparation was considered, by visual inspection, as >20% under-expansion of a 1:1 sized NC balloon . In the scenario of insufficient plaque preparation, additional plaque modification maneuvers were used according to operator judgement: scoring balloon, cutting balloon, ultra-high-pressure balloon  and a second group used as control (regular LM PCI—rLM Group). It should be noted that the dividing factor—necessity of CdD—was independent of the degree of calcification severity. as assessed angiographically.Procedural success was defined as final residual diameter stenosis <20% with TIMI 3 flow. Clinical success was defined as procedural success and hospital discharge without death, stroke, or urgent repeat revascularization. Death was classified as either cardiac  or non-cardiac (confirmation of any other cause). For myocardial infarction (MI), the fourth universal definition was used . Peri-prThe SYNTAX Score was used to quantify the anatomical severity of the lesions . Diseaset or Mann–Whitney–Wilcoxon U test were used. All the reported p-values are two-sided, and values of <0.05 were considered significant. Data analysis was performed using IBM SPSS Statistics for Windows, version 20 .Categorical data are shown as absolute and relative frequencies. Continuous variables are shown as mean ± standard deviation if normally distributed, or as median and interquartile range (IQR) if non-normally distributed. Normality tests were performed using histograms and the Shapiro–Wilk test. Inter-group comparison for categorical variables was performed using chi-square test . For continuous data, Student’s p = 0.49). Multivessel coronary disease was a frequent finding in both groups, with three-vessel disease observed in 14 (63.6%) in the CdD Group and 26 (54.1%) in the rLM Group (p = 0.20). The mean SYNTAX score for the entire population was 28.45 ± 8.89, with no significant difference between the two groups . The total number of patients with SYNTAX score >32 was 22 (31.4%), with numerically more in the CdD group (36.3%) when compared to the rLM group .During the analyzed period, a total of 870 PCI procedures were performed at our center, of which 70 involved LM angioplasty and were included in the present analysis. The baseline characteristics of the study population are presented in p-value = 0.03). Overall, the preferred access site was radial in 61 patients (87.1%) from the total population, with no significant differences between groups. Distal radial access was performed in 45 (64.2%) of the total cases, and the usage of CdD created no significant difference with regard to the distal approach. A sheathless vascular system was used to facilitate transradial access in 47 cases (67.1%), of which 36 cases required a 7F Sheathless system. Distal radial access was performed exclusively using the RailTracking technique, as was previously described [Procedural details and angiographic characteristics with inter-group comparisons are detailed in escribed . Pharmacp = 0.38). The ostium of the LM was found to be involved in two cases (9.1%) in the CdD Group, and four cases (8.3%) in the rLM Group (p = 0.91). There were no calcified lesions observed angiographically in two patients from the CdD Group, while severe and moderate calcifications were identified in four (8.3%), and sixteen (33.3%), respectively, in the rLM Group.LM stenosis ≥ 70% was observed in 36 patients (51.1%) of the total population, numerically more in the CdD Group , while a drug-eluting balloon was used in one case (1.4%) as treatment for LM in-stent restenosis. LM non-bifurcation stenting was performed in one case (1.4%). The up-front two-stents technique was used 17 cases (24.3%) from the total (intergroup comparisons and detailed techniques used are shown in p = 0.40), nor for the LM stent length . However, there was a significant tendency for increased LM final stent diameter through proximal optimization technique (POT) balloon diameter in the CdD Group . Overall, final kissing balloon optimization was performed in 67 cases (95.7%). Only one case with provisional strategy required side-branch (SB) bail-out stenting.There were no significant differences between the two groups with regard to the LM stent diameter . Multi-vessel PCI was performed during index procedure for 41 patients (58.6%), with at least one other complex lesion (B2/C by ACC/AHA classification) treated in 23 patients (32.8%), with no significant differences between groups (p = 0.85).Complete revascularization during index procedure was achieved in 53 patients (75.7%), with no significant differences between groups . Details with regard to the procedural phase in which intravascular imaging was used were not recorded, nor were the morphological lesion details. No additional steps were required for stent optimization following intravascular imaging.Intravascular imaging was used in five cases from the CdD group (22.7%) and nine cases (18.8%) in the rLM group , and coronary balloon perforation during non-LM vessel PCI in one patient (treated successfully with covered stent). Procedural success was obtained in all patients.Clinical success was obtained in all 70 cases (100%). During index hospitalization, the incidence of in-hospital morbidity was 2.9% (two cases): one case of minor gastro-intestinal bleeding in the CdD Group, and one case of contrast-induced nephropathy in the rLM Group. Both cases were managed with a conservative approach. In-hospital outcomes are shown in Clinical data and patient status at 12 months were available for 68 patients (97.1%). Survival status at 12 months was available for 70 patients (100%). Clinical events at follow-up are described in p = 0.18). Median time to repeat angiography was 44.4 weeks with no significant differences between groups. Relevant findings at repeat angiography are shown in p = 0.87). There were no statistically significant differences between groups with regard to the outcomes . Accordingly, repeat coronarography was available 43 patients from the entire study population (61.4%), with 15 patients from the CdD group (68.1%) and 28 patients from the rLM group  patients with extremely calcified LM lesions appeared to have a good prognosis after PCI facilitated by CdD; (ii) aggressive lesion preparation strategies appear safe, as they added no notable immediate complications when compared to standard lesion preparation; (iii) the overall incidence of adverse clinical outcomes in the total LM population was unexpectedly low at 1 year post-procedure when compared to available data in the literature.The existence of calcifications in LM location represents a strong predictor of mortality . Additiop = 0.50); however, a higher numerical tendency of stent thrombosis was noted in the RA and CSB groups [Available data for proper interpretation of our results is scarce and consists of mostly retrospective studies or post-hoc analyses from several registries. Regarding RA performed for severely calcified LM lesions, a post-hoc examination of the ROTATE registry revealed an in-hospital MACE rate of 5.8%, and 26.4% rate at 12-months follow-up, driven mostly by TVR 20.3%) . These r.3% . TheThe available data are even less robust when it comes to other CdD used in LM disease. Lesion preparation with scoring or cutting balloons in LM calcified lesions is proved to be feasible, but available data on clinical impact are limited ,28. ConcThe present analysis might be regarded as revealing a more favorable clinical outcome of this high-risk patient population with extremely calcified LM lesions in which at least one dedicated device was required. There were no events recorded during hospitalization or at 1 year follow-up in the CdD Group. In comparison to what is currently described, the results become additionally relevant and they can be explained by several factors. First, in our study there was possibly a lower threshold for the use of CdD. This would result in a better plaque preparation if compared to exclusively NC balloon preparation. These additional procedural steps might have determined a better stent apposition and higher final stent areas. Additionally, 40% of the patients in this group had plaque preparation with more than one dedicated device. The algorithm used in the selection of the CdD was based on operator preference, anatomical features, plaque morphology, and anticipated deliverability. It is noticeable that RA and, in particular, Shockwave IVL represented the main pillars in the CdD group , with only a small gap outside the RA-IVL scope . The higFurthermore, in the present analysis there were no significant device-related complications that otherwise might have offset the outcomes. One other notable aspect was the significant tendency towards higher POT balloon diameter in the CdD group. A final stent area obtained in these patients could partly explain the better outcomes.The overall MACCE event rate for the entire LM population in our study was 4.2% at 12 months post-procedure. This is substantially less that what was anticipated using available data from LM PCI RCTs ,37,38,39Several studies demonstrated the positive clinical impact that IVUS has in LM PCI ,41,42,43In the present analysis, the usage of intravascular imaging was relatively low (20% of cases); as such. the final clinical outcomes cannot be significantly attributed to imaging. Nevertheless, it becomes noticeable that our technical approach bears resemblance to IVUS-related approaches in which high(er) balloon sizes were used for post-dilation ,41,43. FOne other important feature of our study is related to the high use of transradial approach, and particularly distal radial approach  using the RailTracking technique . The ratCompleteness of revascularization is a known prognostic factor after PCI, particularly in the case of three-vessel or LM CAD ,46. In tLimitations of this study are first related to the small sample size. In addition, the absence of a methodical pre-specified plan for the employment of a particular CdD (or their association) could be considered as another limitation. The 1 year outcomes data period might be regarded as insufficient, and a threshold of 3 or 5 years could be more reliable.Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using CdD. A lower threshold for device employment and their association did not represent a trigger for significant peri-procedural adverse events when compared to conventional PCI. Clinical outcomes at 1 year post-procedure were similar between groups and presented with a low incidence of adverse events overall. The results might contribute to the difficult decision-making process regarding the risks and benefits of using debulking tools for optimal plaque preparation in LM PCI.


The objective of the present study is to understand the symptomatology of endometriosis in patients across various countries and to assess whether the severity of symptoms correlates with the diagnosed stage of disease. (2) An international online survey collected self-reported responses from 2964 participants from 59 countries. Finalization of the questionnaire and its distribution was achieved by cooperation with various organizations and centers around the globe. (3) Chronic pain presentation remarkably increased between Stage 1 and 2 . The prevalence of pain only around and during menstruation was negatively correlated to the stage, presenting with 15.4% and 6.9% in Stages 1 and 4, respectively. Atypical presentation of pain was most commonly reported in stage 4 (11.4%). Pain related solely to triggering factors was the most uncommon presentation of pain (3.2%). (4) Characteristics of pain and quality of life tend to differ depending on the reported stage of the endometriosis. Further research may allow a better stage estimation and identification of patients with alarming symptomatic presentation indicative of a progressive stage, even those that are not yet laparoscopically diagnosed. Endometriosis is a chronic, inflammatory disease characterized by the presence of functional endometrial tissue outside of the uterine cavity, most commonly involving the ovaries. It is one of the most common gynecological diseases among all ethnicities and social groups , and affAmong the symptoms presented in endometriosis, varying manifestations of pain are one of the most prominent. Pain constitutes the three frequently primary symptoms: dysmenorrhoea, lower abdominal pain, and pelvic pain . Deep dyAdditional major symptoms associated with endometriosis include impaired fertility, which affects up to 50% of patients .Endometriosis also impairs patients’ mental and physical well-being and has a significant impact on patients’ quality of life . FurtherThis study aimed to explore the relationship between the clinical presentation of endometriosis, namely pain and quality of life, to the current surgical staging of the disease. Given that there are currently no clear unified guidelines on placing patients with alarming symptoms into later stages of the disease, the intent of this study is to identify such symptoms with the aim of identifying patients who will most likely benefit primarily from surgical and/or fertility treatments. The prioritization of such patients for these treatments will help to avoid the possible delays associated with the wait for laparoscopic diagnosis and the initiation of hormonal treatments that are currently the first line of treatment offered for patients without definitive (laparoscopic) diagnosis.An international cross-sectional survey was employed for this study, created along an initial qualitative phase that consisted of a scoping literature review, created with the purpose of identifying globally accepted characteristics of pain and related symptoms of endometriosis. A computerized search of PubMed Central-US National Library of Medicine (PMC), the Biomed Central Women Health (BMC), coherence library, and Health Affairs resources was performed to identify relevant articles. Data was pulled from articles about endometriosis and its management in the field of obstetrics and gynecology, focusing on the different symptomatic manifestations of the condition as well as its impact on quality of life and healthcare management. The search was conducted using the following terms: ‘Endometriosis and quality of life’; ‘endometriosis and infertility’; ‘endometriosis and pain’; and ‘endometriosis and symptoms’.Information from qualitative studies, multicentre studies, comparative studies, controlled and randomized controlled trials, and clinical trials was included in the resulting literature review. The following inclusion criteria were used to choose the articles: they had to have been published within the last five years, be written in English and published in peer-reviewed journals, and had to involve questionnaire studies on endometriosis consisting of self-reported surveys. The results of the review will not be further explored in this manuscript, as the qualitative phase did not produce the analysis that is necessary for the interpretation of the findings.The survey was created using a methodologic approach in which questions aimed to investigate selected factors that may or may not affect women’s suffering from endometriosis and their quality of life. The initial survey was first finalized in English and later translated into 15 languages, which included Arabic, Farsi, Finnish, French, German, Greek, Hebrew, Italian, Norwegian, Polish, Portuguese, Russian, Spanish, Swedish, and Turkish, in accordance with the World Health Organization (WHO) recommendations for medical translation. Translations were aimed at the conceptual equivalent of relevant phrases and words, as recommended by the WHO , yet avoided a ‘word-for-word’ or literal translation. It aimed for all three phases of forward translation, expert panel, and back translation for every language. Distributed through different platforms, this survey provided data from 2964 respondents with a self-reported endometriosis diagnosis.The questionnaire was divided into four sections. The first section included an informed consent paragraph and collected demographic information from respondents, including questions on age, nationality and country of residence. The second section investigated the health-related quality of life (HRQoL) in women with endometriosis. Based on a review of EHP-30  questionThe third and fourth sections of the questionnaire focused on the effects of the COVID-19 pandemic on women with endometriosis. These parts were excluded in the present article and are discussed more thoroughly in a different paper .For the purpose of analyzing the results, the research team created questions that enabled the division of participants into different groups that were later co-analyzed with their stage and additional factors. The questionnaire was validated for content and construct, reviewed by an expert panel, and piloted on endometriosis patients before administration.The questionnaire, being an online self-administered survey, was distributed using social media channels provided by the cooperating organizations and centers. The participants reported back voluntarily, without any form of compensation. Because the study did not employ pre-existing databases of patient histories, the respondents were not recruited at health care centers. The material collected from these self-reported data was subsequently interpreted for further analysis. Surgical diagnosis based on ASRM staging was a selective criterion for patients reporting to be diagnosed with a specific stage.Patients participating in the study were divided into five groups according to their diagnosis based on the ASRM (The American Society of Reproductive Medicine) classification: Stage 1; Stage 2; Stage 3; Stage 4, and undiagnosed patients. Due to the international nature of this study, the research team aimed to employ a criterion that is used internationally and that patients are familiar with. As the ASRM criteria has been accepted globally and has been widely used in recent years, it was therefore selected . An analThe effect on quality of life was classified as: (A): severe long-term effect; (B): severe short term effect; (C): mild effect and (D): no effect. Different manifestations of pain were also investigated and groupings were created; (1): chronic pain throughout the menstrual cycle (2): pain only around and during menstruation, (3): pain related to trigger factors, (4): pain related only to sexual intercourse, (5): mixed presentation of pain (selected multiple options), (6): other experiences of pain, and (7): little to no experience of pain.The Bioethics Committee of the Pomeranian Medical University in Szczecin provided an exemption from ethical consent (case number: KB-0012/34/03/2021/Z). Additionally, this study was granted an ethical approval from the Turkish Ministry of Health .p values of <0.05 were considered nominally significant . Chi-square tests for independence were carried out for everyday experience and stage, pain experience and stage, and pain experience and the frequency of visits to medical institutions. shown in .For added clarity into the correlation of pain and stage of endometriosis, another graph was plotted  showing Out of 3024 participants from 59 countries who submitted the questionnaire between November 2020 and January 2021, 2964 (98.01%) provided information that enabled the proper analysis of the results . The meap << 0.001). The resulting groups were compared based on stages of endometriosis, as seen in p-value << 0.001.) Groups A (severe long-term effect) and B (severe short- term effect), were the most highly impacted groups, respectively. The incidence of severe effect on quality of life increases in proportion to the diagnostic stage. This is in contrast to groups C (mild effect) and D (no effect), where there is an inverse proportion to the diagnostic changes.In p: <<0.001). A total of 95.55% (n = 2889) of participants provided information that enabled an analysis of the results.Stage 1 was the stage most associated with pain related to triggering factors (6.6%) and least associated with chronic pain throughout the entire menstrual cycle (16.2%). It was also the stage with the largest number of respondents reporting little to no experience of pain (9.6%). Chronic pain throughout the entire menstrual cycle was reported with the highest extent in patients diagnosed with Stage 2 disease (32.2%). Similarly, among patients that were not yet diagnosed with a specific stage of disease (patients who did not undergo laparoscopic diagnosis), 28.8% reported pain throughout the entire menstrual cycle. Patients in Stage 3 (27.8%) and Stage 4 (27.7%) were fairly comparable in their experiences of chronic pain. Other  pain presentations were most pronounced in patients diagnosed with Stage 4 disease (11.4%). Pain related solely to sexual intercourse (dyspareunia) was the most uncommon pain presentation of endometriosis, with the highest reports being in patients with Stage 2 disease (5.0%). Group 2 (pain only around and during menstruation) is negative correlated to stage of disease, starting at 15.4% of the participants in Stage 1, continually decreasing to 6.9% of the participants in Stage 4. Group 6 (other experiences of pain) is positively correlated with stage; in other words, ‘other experiences of pain’ were more prevalent in patients with later stages of the disease (Stage 1 to Stage 4: 2.9% -> 2.7% -> 6.6% -> 11.4%).p-value << 0.001. There is a positive correlation between chronic pain and the frequency of medical appointments from Stage 1 through Stage 3, yet it flattens between Stage 3 and 4. In contrast, there is a negative correlation between pain only during menstruation and frequency of visits. Patients most commonly attend a medical appointment once every six months for mixed pain presentation (47.2% n = 513). Chronic pain was found to be the predominant type of pain presentation that causes patients to seek medical attention multiple times during half of a year (36.5% n = 270). Chronic pain was the second most predominant type of pain presentation that causes multiple visits per month (34.3%), after the mixed presentation of pain (44.4%).p-value: <<0.001). There is a correlation between higher stages of disease and difficulty conceiving, with 23.9% of patients affected by infertility in Stage 1 of the disease, growing to 36.4% in Stage 4. The greatest variation exists between Stage 2 (25.5%) and Stage 3 (34.7%), while no remarkable difference in fertility hardship is seen between Stage 3 and Stage 4 . As the purpose of this analysis was to identify fertility hardship, it did not include the analysis of patients reporting that they had not been trying to conceive or are not currently trying to conceive.This study portrays the symptomatology of endometriosis as described by women suffering from the disease and its effects on their quality of life. According to priorities established following the World Congress on Endometriosis, further research should collect and evaluate data across populations and specifically focus on the symptomatology of the disease with the attempt to finalize characterization beyond the staging system that is currently used . This stDespite the availability of medical care and mental support for people with endometriosis in many countries, 92% of the women reported an effect on their quality of life. Of those, more than half (50.7%)] reported this effect to be severe in both the short and long-term. 75.1% reported that the severe effect on their quality of life was long-term. Various factors may influence the quality of life, but these findings suggest a need for improved treatment and follow-up across all stages, as well as the need to prioritize the long-term quality of life in patients living with endometriosis.A study , which iNearly half of the patients (44.7%) that were not yet diagnosed with a specific stage of disease describe severe long- and short-term effects on their quality of life, which may indicate that a considerable amount of the patients who are undiagnosed suffer from advanced stage endometriosis. For the purpose of comparison, only about a third of the patients suffering from stage 1 (30.5%) reported these severe effects on their quality of life, as compared to the reports of 45.7% of patients in Stage 3. As such, undiagnosed patients seem to have results more consistent with patients in later stages of the disease, namely Stages 2 and 3.It is possible that the large incidence of undiagnosed patients noticing severe effects on their quality of life could be the result of a negative impact on their mental and physical state due to diagnostic delay. A negative effect on health-related quality of life and its relationship with diagnostic delays was discussed in several studies. Among those, a multinational study that included 1418 premenopausal women undergoing laparoscopy demonstrated that health-related quality of life scores were lower among those who experienced a longer diagnostic delay [The pathophysiology of pain in endometriosis is still unclear, as a complex interaction between physical and psychosocial factors is suggested ,16,17. IA mixed presentation of when pain occurred  was the most common pain manifestation. The resulting data are in accordance with other researchers who reported that endometriosis commonly presents with a variety of pain characteristics. In this view, clinicians with the responsibility to diagnose and treat endometriosis should be aware of the possibility of multiple pain features presenting simultaneously. For instance, patients may report that at times pain appears only around or during menstruation, while others may report pain that is constantly present. Specific symptoms, such as dyspareunia or limitation in daily activities should also be considered, as well as the general effect of pain symptoms on patients’ well-being .Nevertheless, our results reveal that the occurrence of pain episodes and their frequency appear to be a major factor to consider when suspecting an alteration in patients’ disease course. In our study, it was evident that patients suffering from stage 1 endometriosis experienced less constant pain throughout the menstrual cycle (16.2%), as compared with those diagnosed with other stages. This is notably lower than that which was reported by patients diagnosed with other stages, with those with Stage 3 and 4 disease having an incidence of 27.8% and 27.7%, respectively, and those in stage 2 having an incidence of 32.2%. These findings suggest that a patient is more likely to report chronic pain if they are diagnosed at Stage 2 or higher.The prevalence of pain only around and during menstruation was reported in stage 1 significantly more than in the other stages. In fact, this pain manifestation was shown to be remarkably underrepresented among patients suffering from stage 4 disease .The findings, which show that patients in Stage 4 have the highest incidence of special pain characteristics, are of high clinical value due to the fact that such patients may be less likely to present with common pain symptoms of endometriosis. In addition, future research must be corrected to include length of pain episodes as well as more detailed characteristics, rather than focusing only on pain presence and intensity.Pain related solely to triggering factors was the lowest reported pain manifestation, with an incidence of 3% of all patients, a finding that can also serve as a tool under the clinical interview of a patient with a suspicion of endometriosis. Triggering factors may include pain only during sexual intercourse or pain only during menstruation or ovulation. As such, complaints may be indicative of other conditions such as pelvic adhesions, adenomyosis, and gastrointestinal or urologic disorders, and thus a differential diagnosis is important and should be carefully considered as a gold standard [As endometriosis is a progressive disease in many cases, symptomatic observations such as those described above are essential . PreviouUnderstanding the relationship between endometriosis and fertility is challenging. Our findings are consistent with the previous literature, which states that the more severe the stage is, the more difficult it is for a patient to conceive . RegardlBearing these challenges in mind, undiagnosed patients who most likely suffer from an advanced stage based on other findings might significantly benefit from early referral to fertility treatments.While the present study was designed to minimize limitations, some did arise. Firstly, issues regarding cultural differences as well as subjective answers are likely inevitable with an international questionnaire. The research team ensured, in most cases, to incorporate two people who spoke the targeted language during the translation. However, the team could not always ensure that two translators with English as their mother tongue were also fluent in the target language in the backward translation.Furthermore, the questionnaire was anonymous, and was not monitored for multiple responses from a singular participant. However, there is little reason to suspect otherwise, as no incentive to participate was given. The same might apply for the diagnostic credibility of the participants. This does, however, not exclude the possibility of self-selection bias among the responders. The context of the study did not permit the verification of self-reported histological data; however, there was no incentive for the participants to misrepresent their answers. Moreover, as an endometriosis diagnosis is conducted differently around the world, the questionnaire did not investigate the means of diagnosis in depth.With the help of national and international endometriosis organizations, the distribution of the survey through various platforms led to varying levels of success, and in some countries the questionnaire was not released at all. South America and Europe were the most represented areas, comprising 90% of the respondents.Finally, the study surveyed a large population size of women affected by endometriosis; however, it lacks a control group. Future studies should compare symptoms in women with and without endometriosis to assess the incidence of pain and related symptoms in the general population and in the studied populations.Endometriosis is a chronic disease that can lead to a significant decrease in quality of life, namely in terms of pain and fertility. Therefore, it is imperative to further understand how its clinical presentation relates to its surgical staging. The diagnostic lag time of endometriosis must be shortened in order to provide patients with proper and suitable treatment options prior to disease progression and/or symptomatic deterioration. Although endometriosis presents with a variety of symptoms, in this study we demonstrated that the characteristics of pain and quality of life tend to differ depending on the stage of the disease. Previous studies focused mainly on where and how pain is felt. Our aim was to investigate the timing of pain and how it affects quality of life. It is our belief that differentiating between the nuances of the timing of symptoms experienced provides more clinical context to identify the most probable corresponding stage of endometriosis when laparoscopy is not easily accessible or desired, which can therefore lead to a more accurate diagnostic evaluation and subsequent choice of treatment. This could lead to a shorter diagnostic lag and earlier treatment that is tailored to the patients’ needs, improving quality of life and fertility for those with endometriosis .


Reasons for prolonged hospital stay include postoperative headache and protracted nausea with or without vomiting. Bilateral superficial trigeminal nerve blocks of the supra-orbital V1 and infra-orbital V2 (SION) nerves performed intra-operatively as a regional anesthetic adjunct to general anesthesia were hypothesized to decrease 6 hours postoperative morphine PCA  use by patients.Pituitary neurosurgery executed Forty-nine patients, following induction of general anesthesia for their transsphenoidal surgery, were prospectively randomized in a double-blinded fashion to receive additional regional anesthesia as either a block  or placebo/sham . The primary endpoint of the study was systemic morphine PCA opioid consumption by the two groups in the first 6-hours postoperatively. The secondary endpoints included (1) pain exposure experienced postoperatively, (2) incidence of postoperative nausea and vomiting, and (3) time to eligibility for PACU discharge.Of the 49 patients that were enrolled, 3 patients were excluded due to protocol violations. Ultimately, there was no statistically significant difference between morphine PCA use in the 6 hours postoperatively between the block and placebo/sham groups. There was, however, a slight visual tendency in the block group for higher pain scores, morphine use p=0.046, and delayed PACU discharge. False discovery rate corrected comparisons at each time point and then revealed no statistically significant difference between the two groups. There were no differences between the two groups for secondary endpoints.It was found that a 6-hour postoperative headache after endoscopic trans-sphenoidal pituitary surgery likely has a more complicated mechanism involving more than the superficial trigeminovascular system and perhaps is neuro-modulated by other brain nuclei.NCT04670614. The goal of this approach is to reduce pain and promote rapid recovery .If regional anesthesia facilitates the administration of less systemic pain medications, patients could benefit in several ways: (1) reduced postoperative discomfort and opioid use, (2) decreased postoperative nausea and vomiting, (3) shortened PACU (post-anesthesia care unit) stay time, and (4) shortened time to discharge from hospital. A more streamlined, shorter, and more pleasant hospital course for the patient could lead to increased patient satisfaction and potential economic gains for the hospital.Pituitary tumor surgery is primarily executed through a minimally invasive approach through the nose and sinuses as an endoscopic procedure called the: “Trans-Sphenoidal Hypophysectomy”. More recently, it has been performed entirely endoscopically through the nose as the earlier modification, the “Caldwell Luc” approach, involved opening a bony window through a sub-labial oral (at the upper gum line under the top lip), leading to the maxillary sinus and then ultimately to the sellar cavity housing the pituitary tumor. Patients who undergo this endonasal endoscopic trans-sphenoidal pituitary surgery are usually same-day admission patients who, following their operation, stay in a hospital up to 24 hours postoperatively. Prolonged post-op admissions are often caused by persistent headaches or nausea with or without vomiting . By admi2Following Institutional Review Board approval at the University of California, San Francisco, USA (UCSF), study enrollment was offered to adult patients  (aged 18-65) having an ASA (American Society of Anesthesiologists) physical status I or II scheduled for same day admit endoscopic endo-nasal trans-sphenoidal hypophysectomy to be performed by a single surgeon (SK).p < 0.05 was considered to indicate a statistically significant difference.This is a prospective, randomized, double-blinded sham-controlled  regional anesthetic ) study to compare the systemic postoperative pain medication requirements in patients having trans-sphenoidal endoscopic, endo-nasal pituitary surgery under general anesthesia. The study protocol was performed in accordance with the relevant guidelines and is included in detail below. The primary endpoint was systemic morphine sulfate PCA  opioid consumption by the 2 groups during the first 6 hours postoperatively . The secondary endpoints included: (1) pain exposure experienced by the patients postoperatively, (2) incidence of PONV, (3) time to eligibility for PACU discharge, and (4) length of hospital stay/discharge. To our knowledge, this is the first published clinical trial examining the use of SION block to control postoperative pain after endonasal pituitary surgery. The results from the two groups were compared using an unpaired Student t-test. etc.) as per the patient report, and (7) no herbal medications for pain in the last 1 month prior to surgery as per the patient report. Urine or blood testing was not used to confirm opioid use preoperatively. Exclusion criteria included: (1) patients less than 18 yo, (2) non-English speaking and unable to consent, (3) known allergy to ropivacaine, (4) chronic pain conditions, including idiopathic migraine as defined by the ICHD  II criteria, requiring the use of pain medications, or (5) inability to comprehend or adhere to the study protocol .Additional inclusion criteria were: (1) elective pituitary surgery for tumors less than or equal to 2 cm diameter within the sella turcica and without cavernous sinus invasion, (2) both male or female patients, (3) English-speaking patients providing informed consent, (4) not on chronic pre-op pain medications (non-narcotics) in the last week prior to surgery as per the patient report, (5) no opioid pain medications pre-op in the last month before surgery as per the patient report, (6) no abuse of recreational drugs .After written informed consent, the subjects were randomly assigned to 1 of 2 groups using randomization envelopes in 3 blocks of 20. A “triple mask design” was used: the subjects, healthcare providers (including the anesthesiologist in the operating room and anesthesiologist administering the SION blocks), randomization consent nurse, and data collection nurse, as well as the statistician, were all blinded to the treatment groups assigned  received SION blocks with 0.5% ropivacaine with epinephrine 1:200 000 following induction of general anesthesia, and the placebo group (P) received the same volume SION blocks using sterile, preservative-free normal saline. Following general anesthetic induction and endotracheal intubation, supra-orbital and infra-orbital (SION) injections with study medication were performed. Supra-orbital nerve blocks were performed bilaterally using 3 cc  of the study solution. A percutaneous technique was used to block both bilateral supra-orbital and supra-trochlear nerves. A 27 gauge, 1.5 needle attached to a 10-cc syringe was used. Then, the infra-orbital nerves were blocked intra-orally following retraction of the upper lip and using a 27-gauge, 2.54 cm needle attached to a 10-cc syringe inserted anterior to the ipsilateral canine tooth that runs along the maxilla. Here, 3 cc of the study drug was placed bilaterally for a total of 6 cc. The needles were directed superiorly toward the infra-orbital foramen on the ipsilateral side, as was described in the “Lynch” method . Correct2.2Following pre-medication with midazolam 1-2 mg IV, anesthesia was induced with lidocaine 1 mg/kg IV, propofol 1-2 mg/kg IV, fentanyl 1 mcg/kg IV, and rocuronium 0.6 mg/kg IV.via the sphenoid sinus and then via the sellar floor. Following removal of the sellar floor, the dura was opened, and the pituitary tumor was resected using a series of micro-dissectors and curettes. CSF leaks were then repaired, and fat was placed in the free intra-sellar space. The sellar floor was repaired, and the sphenoid sinus and nostrils were packed temporarily to close the sellar space. We removed the nasal packing just prior to extubation.The surgeon then administered standard topical intranasal anesthesia with lidocaine and epi-soaked pledgets on the inner nasal mucosa. Less than 10 cc of 1% lidocaine with epi 1:200 000 was used to ensure hemostasis. Access to the pituitary gland was obtained transnasally with an endoscope 2/air mixture with 80% inspired O2 was administered to provide anesthesia and maintain the blood pressure within 20% of baseline. Fentanyl was infused at 1 mcg/kg/hr from induction of anesthesia to the end of surgery. Dexamethasone 10 mg IV or hydrocortisone 100 mg IV was administered at the beginning of surgery as directed by the surgeon. An end-tidal CO2 of 30-35 mmHg was maintained. The patients were relaxed with rocuronium as needed to maintain 1-2 twitches by an NMT (neuro-muscular twitch) monitor. On emergence from anesthesia, ondansetron 4 mg IV was administered, and residual muscle relaxation was reversed with neostigmine 0.07 mg/kg and glycopyrrolate 0.01 mg/kg IV.Following induction of anesthesia, the local injection study block drug/placebo was administered, and the patients were maintained on a balanced anesthetic technique using intravenous agents, inhaled gas, and a neuro-muscular relaxant. Desflurane in OPost-operatively, a morphine PCA (1mg IV every 6 min lock-out time) to a max of 10 mg IV morphine sulfate per hour, without a basal rate, was administered. For pain ranked at > 4/10, rescue pain medicine of morphine 1 mg IV was administered by the PACU recovery room nurses every 5-10 min until the pain was < 4/10 or acceptable to the patient. Blood pressure was maintained with a systolic BP < 140 mmHg using . Following intraoperative treatment of nausea with ondansetron and dexamethasone/hydrocortisone, the following escalating rescue algorithm was used for PONV:1) Additional ondansetron 4 mg IV for 1 dose, then2) Prochlorperazine 5-10 mg IV, then3) Scopolamine patch 1.5 mg topical .The primary outcome of the study was to compare the total amount of morphine (in mg) used postoperatively (for 6 hours) in the 2 study groups from T0-T6 time from PACU entry (T0) to 6 hours post PACU entry (T6). Study data were collected for 5 data time points: T0 (PACU entry), T1, T2, T4, and T6 . Pain scores (P0-P6) were collected using the Wong-Baker FACES Pain Rating Scale at times T0-T6 in the scale (0-10/10), with 10/10 being the worst imaginable pain. Nausea score N0-N6 was collected using the Baxter retching faces (BARF) nausea scale (0-10/10), with 10/10 being the worst nausea imaginable with or without vomiting. Other secondary data collected included Tr , Th , and Tn (time from surgery start to last dose of narcotics). Modified UCSF Aldrete PACU score in PACU assesses individual scores for vital signs, activity, mental status, pain, nausea, blood loss, and intake/output. At one-week post-op, patients were contacted by phone and asked about potential study complications.A research assistant collected all study data and was blinded to the assigned treatment group.3st, 2017 to Dec 31st, 2018, 175 patients were screened for the study using the inclusion and exclusion criteria . Based on clinical experience, we considered an effect size of 0.5 to be clinically significant. With this assumption, 64 patients were randomized into two equal groups for a statistical power of 0.8 for the main outcome. Of those, 49 patients were enrolled and randomized into the study. Although the original sample size was estimated at 64 patients, study enrollment was stopped after 49 subjects for administrative reasons.From Jan 11 report Absolute Standardized Differences defined as differences in means or proportions divided by the standard deviation (SD) and are used to assess the imbalance between the 2 groups. Established guidelines that interpret Standardized Differences describe the magnitude of the difference as: 0.2 = small, 0.5 = medium, and 0.8 = large. Comparisons between groups were performed with unpaired t-tests, Mann-Whitney u-tests, and Fisher’s exact test as appropriate. Parametric data are presented as means , while nonparametric data are presented as medians (95% CI). Opioid consumption, pain exposure, and incidence of nausea over time were analyzed with a repeated measure mixed effects model. Groups were compared post hoc at each time point, correcting for multiple comparisons using the two-stage linear step-up procedure of Benjamini, Krieger, and Yekutieli to control the false discovery rate. Results with a p < 0.05 or a false discovery rate q < 0.05 were considered statistically significant. All analyses were performed using Prism 8.4.2 for MacOS .Demographics and opioid consumption results are presented as means with 95% confidence intervals. Baseline variables presented in Table The False Discovery Rate correction for multiple comparisons was chosen in order to preserve greater statistical power compared to the more often used Bonferroni correction  850-857).41). Baseline variables reported as standardized differences were not substantially different between the 2 groups. They showed a possible small to a medium imbalance between the 2 groups (0.2-0.48). Height, weight, and BMI, which were more clinically relevant (as pain medication dosing was based on weight), showed a small or approximately 0.2 standardized difference.A total of 49 patients were randomized. Three of the randomized patients subsequently had to be disqualified from the study due to protocol violations. There was no statistically significant difference between groups in demographic variables (Table p = 0.22). As analyzed over time , there was a significant difference between groups (p = 0.046). Although there was a tendency towards higher morphine doses in the block group, false discovery rate corrected comparisons at each time point revealed no statistically significant differences between groups.The median (95% CI) total postoperative morphine dose was 0.21 mg/kg (0.19 - 0.35 mg/kg) in the block group and 0.21 mg/kg (0.12 - 0.23 mg/kg) in the placebo group (4) showed a significant difference between groups (p = 0.0021), with false discovery rate corrected comparisons at each time point showing a significant difference 1 hour after PACU entry and 2 hours after PACU entry. At 1 hour after PACU entry, the mean pain score was 7 (6 - 8) in the Block group and 4 (3 - 6) in the placebo group (q = 0.006). At 2 hours after PACU entry, the mean pain score was 6 (5 - 7) in the block group and 4 (3 - 5) in the placebo group (q = 0.03).Analysis of pain exposure over time . Examining both groups combined, compared to PACU arrival, patients experienced significantly more nausea at 1 hour after PACU entry .The median PACU stay duration was 128 minutes (110 - 158 minutes) in the block group and 113 minutes (98 - 143 minutes) in the placebo group , or median time from surgery start to last in-hospital narcotic dose . Just prior to hospital discharge, but before the last dose of narcotics, the block group had significantly higher median pain scores (Block 2 [1 - vs. Placebo 1 [0 - p = 0.03).There was no difference in either median time from surgery start to hospital discharge  fibers in V1  and V2 (maxillary branch) sensory distribution of the face by the surgical endoscope and surgical trauma may lead to extravasation and release of inflammatory mediators (Substance P (SP), calcitonin gene-related peptide (CGRP), and Vasoactive Intestinal Peptides (VIPs)) from the local area via the trigemino-vascular system. This “sterile neurogenic peri-vascular inflammation” can ultimately cause meningeal blood vessel vasodilation, increased cerebral blood flow, and migraine-type post-op headaches . It has These study results showed that the addition of supra-orbital and infra-orbital sensory trigeminal nerve blocks intra-operatively to general anesthesia during transsphenoidal, total endo-nasal pituitary surgery does not appear to reduce postoperative headache and thus, 6-hour post-op morphine PCA consumption as compared to patients receiving only general anesthesia. In fact, the placebo group had less postoperative pain and morphine use, along with a shorter median PACU stay. As the standard deviations in both groups were varied, this effect was not clinically significant. Possible explanations for this unexpected pain and morphine consumption post-op response in the block group may include:(1) It may be more difficult to accurately execute the supra-orbital V1 and infra-orbital nerve V2 blocks under general anesthesia than expected. The terminal sensory nerve anatomy of patients may vary, and so the block, placed using landmarks, may not actually capture all branches of the trigeminal nerves V1 and V2, which may then eventually trigger the trigeminovascular effects, leading to post-op headaches. As the patients were under general anesthesia, the presence/absence and extent of numbness were not evaluated prior to surgery. Post-op evaluation of this would have led to unblinding the patient and the data collection nurse, so this was not performed. Thus, the two groups showed similar postoperative pain exposure data and morphine use.(2) It is possible that the administration of normal saline solution used in the placebo group may have some analgesic properties, resulting in similar pain exposure and 6-hour post-op morphine use data.6). Both the sphenopalatine and trigeminal nerve ganglia have been extensively studied in migraine [(3) Most surprisingly/unexpectedly, there was a tendency for slightly paradoxically increased pain exposure, morphine usage, and median time of PACU stay in the block group. One possible explanation for this could be the influence of another mechanism in addition to the sensitization of the trigeminal ganglion in the production of post-op headaches. The sphenopalatine ganglion (SPG), a primarily parasympathetic ganglion, located in the pterygopalatine fossa , is known to communicate directly with the trigeminal ganglion via several branches of the infra-orbital or maxillary V2 nerve  invasive and riskier  than the(5) Perhaps future studies should focus on randomized, controlled data using both the trigeminalnerve blocks combined with the sphenopalatine ganglion block as a multimodal regional adjunct to general anesthesia for transsphenoidal pituitary resection.(6) As there appeared to be little difference in pain exposure and morphine consumption post-op, no significant difference was reported in post-op nausea over time between the block and placebo groups.(7) In addition to the pain complexity described, it is possible that patients may have had variable amounts of preoperative anxiety and associated sleep disturbance, which may variably amplify/ affect their perceived postoperative surgical pain experience. All patients received midazolam 1-2 mg IV pre-operatively as a premedication prior to surgery based on their subjective reported level of preoperative anxiety. A total of 81% of placebo (P) patients received 2 mg of midazolam IV, and 78% of block (B) patients received 2 mg of midazolam IV. We recorded baseline preoperative pain data prior to surgery, which was considered in our statistical calculations related to pain exposure. We did not gather data on sleep disturbance and anxiety.The postoperative time to discharge and time to last dose of narcotics from the start of surgery for the block and placebo groups did not have statistically significant differences. Considering pain on discharge, the placebo group had less pain, although the final median pain scores of 1/10 for placebo and 2/10 for block did not seem to have clinical significance. However, examining the individual pain scores, the block group was found to have greater pain data, showing some patients with significant pain on discharge.In conclusion, the mechanism of the pain response to pituitary surgery via the total endo-nasal endoscopic technique appears to be more complex than expected. Likely, several nerves and ganglia interact via a complex mechanism of neuromodulation to determine the final post-op headache intensity experienced by the patient. Simple peripheral sensory nerve supra-orbital V1 and infra-orbital V2 nerve blocks, in addition to general anesthesia, do not decrease pain exposure or 6-hour post-op morphine PCA consumption compared to general anesthesia alone.


Oral lichen planus with exclusive keratotic reticular, papular, and/or plaque-like lesions (K-OLP) is a clinical pattern of OLP that may be associated with a complex symptomatology and psychological alteration. The aim of the study was to evaluate the prevalence of anxiety (A) and depression (D) in patients with K-OLP, analyzing the potential predictors which can affect mental health status.Three hundred K-OLP patients versus 300 healthy controls (HC) were recruited in 15 Italian universities. The Numeric Rating Scale (NRS), Total Pain Rating Index (T-PRI), and Hamilton Rating Scales for Depression and for Anxiety (HAM-D and HAM-A) were administered.p-value < 0.001**). A and D were found in 158 (52.7%) and 148 (49.3%) K-OLP patients. Strong linear correlations were identified between HAM-A, HAM-D, NRS, T-PRI, and employment status and between HAM-D, HAM-A, NRS, T-PRI, employment status, and female gender. Multivariate logistic regression revealed that HAM-D and HAM-A showed the greatest increase in the R2 value for A and D in the K-OLP patients, respectively .The K-OLP patients showed statistically higher scores in the NRS, T-PRI, HAM-D, and HAM-A compared with the HC (The prevalence of A and D is higher in the K-OLP patients compared with the HC, also found in K-OLP subjects without pain, suggesting that the processing of pain may be in a certain way independent of the processing of mood.Mood disorders and pain assessment should be carefully performed in relation to K-OLP to obtain a complete analysis of the patients.The online version contains supplementary material available at 10.1007/s00784-023-04909-3. Oral lichen planus (OLP) is a chronic immune-mediated, inflammatory disease of the oral mucosa, affecting 1.01% of the population with a higher prevalence in Europe 1.38%) . The pat8% . The OLP may present with different clinical patterns, ranging from keratotic manifestations , usually symmetrical and bilateral, to predominantly non-keratotic OLP  , 4. MoreDespite the OLP with exclusive keratotic manifestations (K-OLP) being usually considered asymptomatic compared with non-keratotic OLP, recent studies have suggested a high prevalence of oral discomforts, a burning sensation and pain with additional oral symptoms such as taste disturbance, xerostomia, and globus pharyngeus (a non-painful sensation of a lump or foreign body in the throat). Such symptoms are not related to clinical features because they have been revealed also in oral sites without lesions –8.The oral symptomatology associated with the fear of cancer development may contribute to emotional and mood changes , 10, as Despite recent studies have suggested a strong association between OLP and mood disorders , 15, 16,This study is a descriptive secondary analysis of a multicentric clinical observational study which was conducted between January 2019 and February 2020, involving fifteen Italian University departments of Oral Medicine belonging to the Italian Society of Oral Pathology and Medicine  (SIPMO) .The study was previously approved by the Ethics Committee of Federico II University of Naples,  and conducted in accordance with the ethical principles of the World Medical Association Declaration of Helsinki. The adopted methods conformed with the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies .As described in our previous research,  all poteAdditionally, the procedures used to enlist the patients in the group and the screening process conformed with those adopted in the other studies, involving expert clinicians in oral medicine and psychiatry for the psychological assessment. Sociodemographic characteristics were formerly recorded, such as the anamnestic evaluation . The acrQuestionnaires were administered to the K-OLP patients and HC in order to completely analyze the intensity of pain, through the Numerical Rating Scale (NRS) , 19; thep-values less than 0.05 or 0.01 were considered moderately or strongly significant, respectively. The non‐parametric Mann‐Whitney U test was employed to evaluate differences between the median scores of the HAM-A, HAM-D, NRS, and T-PRI in the groups. P‐values < 0.05 were considered to reflect a statistical significance. The Spearman test was used to analyze the correlation between the qualitative and quantitative predictors and HAM-A and HAM-D median scores.The statistical analysis was performed using the SPSS software v. 23. Descriptive statistics, including means, standard deviations, medians, and interquartile range (IQR), were used to analyze the socio-demographic and clinical characteristics of the groups. The Pearson chi-square test and Fisher’s exact test were used to assess the significant differences between the percentages, and the differences associated with To identify potential predictors of A and D in K-OLP, multiple linear regression analyses were performed, considering sociodemographic parameters  and intensity and quality of pain (NRS and T-PRI). Full models, when all the parameters were entered simultaneously, were used to evaluate the relative contributions of these variables to pain.In detail, a sequential regression model analysis including predictors, one by one, to obtain unadjusted coefficient estimations was performed. Moreover, in a final step, we performed a full model analysis considering all predictors, simultaneously, to estimate adjusted coefficients. In all steps, we provided standard errors of model coefficients which measure the statistical precision of inference estimation of the model parameters.The sample size, namely 300 subjects, was set by fixing a test power of no less than 90% associated with a significance of no more than 5% (software G*Power 3.1.9.7 by Dusseldorf University). This sample size calculation was performed using the effect size estimation from a previously published research study regarding scales of mood disorders and pain .p-value: 0.597). Statistically significant differences were found in relation to employment and marital status. A lower proportion of K-OLP patients were employed  compared to the HC  . In contrast, a statistically significant higher percentage of K-OLP patients were married  in comparison to the HC  . In addition, the HC presented a higher education  and were characterized by a significantly higher percentage of smokers (32.0%) . No differences were detected in terms of BMI and alcohol consumption between the groups .A total of 600 participants were enrolled, 300 K-OLP patients and 300 HC. The sociodemographic characteristics of both groups are shown in Table p-values: 0.024* and 0.021*). Further, a moderately significant difference was observed with respect to the intake of levothyroxine sodium, which was more prevalent among the K-OLP group . No further differences were recorded for all the other comorbidities and drugs.Table p-value: < 0.001**) and dysosmia  in comparison with the HC. A moderately significant difference was found with respect to sialorrhea , and occlusal dysesthesia  while no difference was revealed with regard to oral dyskinesia  and a change in the tongue morphology .Table Table p-values: < 0.001**). Additionally, there was a significantly different frequency distribution between the K-OLP patients and the HC with respect to the NRS categories , as only 39.7% (119) of the K-OLP group presented no pain compared to 80.7% (242) of the HC. In detail, 30.3% (91), 17% (51), and 13% (39) of the K-OLP patients presented mild, moderate, and severe pain, respectively, compared to 12% (36), 4.7% (14), and 2.7% (8) of the HC. Statistically significant differences in the frequency distributions were also detected when analyzing the severity scores of the HAM-A and HAM-D . Indeed, no A was reported in 47.3% (142) of the K-OLP patients compared to 62% (186) of the HC. A was found in 52.7% (158) of the K-OLP group; 40.7% (122) presented mild A, 7.7% (23) moderate A, and 4.3% (13) severe A in comparison with 32% (96), 5% (15) and 1% (3) of the HC, respectively. With regard to the HAM-D score categories, instead, 50.7% (152) of the K-OLP patients reported no D compared with 64% (192) of the HC. D was found in 49.3% (148) of the K-OLP group; 39.3% (118) presented mild D, 7.7% (23) moderate D, and 2.3% (7) severe D, compared with 31% (94), 3% (9), and 1.7% (5) of the HC.Overall, the K-OLP patients presented statistically significantly higher median total scores for the NRS, T-PRI, HAM-A, and HAM-D in comparison to the HC , while no correlation was found with age, education, and BMI . Similarly, a positive correlation was also found between the HAM-D scores and the HAM-A, NRS, and T-PRI scores . Furthermore, both the HAM-A and HAM-D scores were positively correlated with the female gender and with unemployment status .Tables p-value 0.046*). Instead, the addition of D (model 2) resulted in a significant increase in the R2 value for HAM-A , similar to the addition of pain intensity (NRS) (model 3)  and the addition of pain quality (T-PRI) (model 4) . The final full model (model 5) in which all of the variables were entered simultaneously could explain 59.8% of the variance in the total scores of the HAM-A for the K-OLP patients . With respect to D (HAM-D), no demographic variables (model 1) were found to be statistically significant in the increase in the R2 value, while the addition of A (HAM-A) contributed to a significant increase in the R2 value . The addition of pain intensity (NRS) and pain quality (T-PRI) in models 3 and 4, respectively, resulted in an increase in the R2 value for the HAM-D scores . The final full model (model 5) could explain 58.7% of the variance of the HAM-D total scores for the K-OLP patients. .The results of the simultaneous multiple linear regression analyses for the K-OLP group, predicting A and D (HAM-A and HAM-D) are shown in Table The bidirectional link between mood disorders and OLP is well recognized in the literature in that patients with A and D had an almost three or four times greater risk of developing OLP compared with subjects without any psychological impairment , 25. On A and D are the most common medical comorbidities associated with OLP, as suggested by several studies , 28 and The results of this study showed a higher prevalence of A and D in patients with K-OLP compared with HC. Indeed, A and D, respectively, were found in 52.7% 158) and 49.3% (148) of K-OLP patients, with the majority showing mild A  and mild D . The prevalence of A in K-OLP found in this study is in line with the data of a recent systematic review and meta-analysis of De Porras-Carrique T et al. [58 and 49p-value < 0.001**), from the analysis of multiple linear regression, NRS and T-PRI could explain only 6.2% and 20% and 3.9% and 17.2% of the variance of A and D, respectively. In addition, it is interesting to highlight that A and D were reported in K-OLP without pain, as well as severe pain being reported also in K-OLP without A and D. Instead, A and D were strictly interconnected in patients with K-OLP as shown both by the dependence and multiple regression analyses. Indeed, D could explain 55.5% of the variance of A and A contributed to 56.2% of the variance of D. In contrast, the other variables considered together could increase the R2 value by only 4.3% and 2.5% for A and D, respectively.Burning sensation was reported by 58.3% (149) of K-OLP patients and in 15.3% 46) of these cases, this was diffused to the whole oral mucosa, reported also in sites without any lesions [ of theseTherefore, from this analysis, it is possible to suppose that the symptomatology was not consistently interconnected with A and D, as shown in a previous study where the worsening of symptoms was directly associated with an increase in psychological distress.  Instead,In the current study, the disease onset was at about 4.5 years. Therefore, it is not possible to exclude the possibility that the fear of cancerization of the disease has had an impact on susceptible patients in terms of the development of psychological distress over time. Indeed, in line with previous studies , 33, in The similarity in the biological pathways between A, D, and OLP may be explained by the involvement of the serotonergic system, which could be implicated also in the pathogenesis of OLP, as described by Kurmus et al.  Another Interestingly, recent researches have suggested the potential role of vitamin D in reducing the expression of some pro-inflammatory cytokines . SpecifiMoreover, recent studies have suggested a possible role of the imbalance of the oral microbiota and host response in the development of neurodegenerative and immune diseases , 44. TheThe results of this study have confirmed that patients with K-OLP may suffer from A and D and a complex symptomatology that may potentially influence the clinical course and the evolution of the disease. Therefore, dentists, frequently consulted by such patients initially, must be aware of these comorbidities and should carefully and routinely evaluate emotional disorders, pain/burning, and additional symptoms in the assessment of all subtypes of OLP, at the first diagnosis and during follow-up. The evaluation of the psychological profile of the patient is complex in a dental setting and requires a learning curve on the part of clinicians since the majority of K-OLP patients are unaware that they are suffering from A or D and have never been specifically examined for mood disorders.Further prospective studies using a structured clinical psychiatric interview should be carried out to assess the specific prevalence of A, D, and others psychiatric comorbidities in order to confirm our data and to better understand the cause-effect role between mood disorders and K-OLP.The results of the present study should be interpreted in light of certain limitations. Indeed, due to the cross-sectional nature of the study, it is not possible to deduce any cause-effect relationship between mood disorders (A and D) and OLP, although their strong association is suggested.Moreover, the recruitment of the participants was undertaken in tertiary referral Oral Medicine Units, with the result that potential confounding factors may have been introduced due to the heterogeneity of the different centers. Finally, the differential diagnosis between OLP and oral lichenoid drug reactions (OLDR), which also may appear at any time even years after the drug administration, was not feasible, as at the present there are no available diagnostic tests for OLDR .In this large multicentric Italian study, the prevalence of A and D in relation to K-OLP was significantly higher in comparison to the control group, suggesting a strong association between A, D, and K-OLP.Moreover, almost 60% of K-OLP patients reported oral pain/burning and additional symptoms, also in sites without any lesions. As expected, patients suffering from higher levels of A and D, also reported higher scores of pain. Despite this positive correlation, A and D have been interestingly reported in relation to K-OLP without pain, as well as severe pain being reported also in K-OLP without A and D, suggesting that the oral discomfort may be predominantly related to the peripheral neuropathy, independently of the clinical form of the disease.These findings may suggest that, although the neurological pathways of pain modulation and mood disorders (A and D) are similar and to some extent overlap and despite the well-established link between OLP, A, and D, there are probably other separate pathogenetic mechanisms implicated in pain perception and in the development of mood disorders which should be further elucidated.In conclusion, any improvement in the psychological status of K-OLP patients, through appropriate treatment, may prevent the progression of the lesions and reduce the associated symptoms, thereby contributing to promote the patient’s recovery and improve the prognosis.Supplementary file1 (DOCX 31 KB)Below is the link to the electronic supplementary material.


Neuropathy of the lateral femoral cutaneous nerve, also known as meralgia paresthetica, causes pain and paresthesia to the anterolateral thigh. It commonly results from nerve irritation from extrinsic compression; however, it may occur spontaneously. Symptoms from this condition can be debilitating, and the pain may be ascribed to other conditions leading to delays in diagnosis. Peripheral nerve blockade can be useful both diagnostically and therapeutically for meralgia paresthetica.Two female patients in their sixties presented to the emergency department for chronic, atraumatic, left upper thigh pain. In both cases the patients had hyperalgesia and paresthesia to the anterolateral, upper thigh. The emergency physician performed an ultrasound-guided nerve block of the lateral femoral cutaneous nerve for each patient, which resulted in temporary, complete resolution of their pain.Meralgia paresthetica is an uncommon but painful condition that can elude diagnosis. Physical exam findings such as allodynia and hyperalgesia of the anterolateral thigh in the absence of back pain is suggestive of the diagnosis. Utrasound-guided nerve blockade can be helpful to the emergency physician to confirm the diagnosis and provide non-opioid pain relief to the patient. Meralgia paresthetica (MP) also referred to as lateral femoral cutaneous nerve (LFCN) neuropathy is characterized by painful paresthesia and numbness of the anterolateral thigh. The incidence of this disorder is 4.3 per 10,000 person per year and usually presents in the third or fourth decade of life but can occur at any age. Causes of MP are grouped into spontaneous and iatrogenic categories. In spontaneous cases, external compression from tight clothing or belts can irritate the nerve. Compression may also result from intra-abdominal or pelvic processes, such as obesity, pregnancy, and uterine tumors. Spontaneous neuropathy can be caused by metabolic abnormalities such as diabetes, hypothyroidism, and nutritional deficiencies.2Typically, patients will present with unilateral symptoms, but bilateral symptoms occur in 20% of patients.Lumbar radiculopathy may mimic symptoms of MP, but in cases of isolated MP, back pain is absent. Muscle strength and deep tendon reflexes should be normal as the LCFN is a purely sensory nerve. Patients may have an antalgic gait.Meralgia paresthetica can cause significant patient distress and disability. Clinician unfamiliarity with this condition may lead to delay in diagnosis, leading to prolonged patient discomfort and unnecessary workup for other conditions.2) 98%. On physical examination, she had hyperalgesia and allodynia of the skin of her proximal, left anterolateral thigh. Tenderness and paresthesia to palpation inferior to the ASIS was present. She had normal strength to hip flexion, knee extension, and ankle dorsiflexion/plantarflexion and palpable ankle pulses.A 67-year-old female presented to the ED for left thigh pain worsening over the course of one month. The pain began after abdominal aortic aneurysm surgery three months prior. She had one ED presentation for severe pain as well as several clinic visits with workup including CT angiogram of the abdominal aorta with iliofemoral run-off and Doppler ultrasound for venous thrombosis without any surgical complications or venous thrombosis noted. Her vital signs on presentation were blood pressure (BP) of 183/88 millimeters of mercury (mm Hg), temperature 36.4°Celsius (C), heart rate 67 beats per minute (bpm), respiratory rate 20 breaths per minute, and oxygen saturation , we performed an ultrasound-guided LFCN block on the patient with seven milliliters (mL) of 0.25% bupivacaine after obtaining consent. On re-evaluation 10 minutes later, the patient reported complete resolution of the pain. She was given the diagnosis of MP and recommended to see pain management. On chart review follow-up, the initial block gave her two days of symptom relief. She received another block with pain management that lasted two days. She was started on pregabalin with improvement of symptoms over the next several weeks.CPC-EM CapsuleWhat do we already know about this clinical entity?Meralgia paresthetica (MP) is an uncommon cause of upper thigh pain. While not life-threatening, it can be distressing for patients and difficult to diagnose.What makes this presentation of disease reportable?Because it is uncommon, pain from MP may be ascribed to other conditions leading to negative workups and repeat patient presentations for pain.What is the major learning point?Ultrasound-guided lateral femoral cutaneous nerve blockade is a low-risk option that can aid physicians in correctly diagnosing MP and provide non-opioid pain control.How might this improve emergency medicine practice?Correct diagnosis of MP in the emergency department allows physicians to initiate specific therapy and plan appropriate outpatient follow-up for MP patients.2 100% (besides mildly elevated heart rate of 99 bpm). On physical examination she had an antalgic gait, but a negative, straight-leg raise test bilaterally and normal strength to hip flexion, knee extension, and ankle movement bilaterally. She had normal ankle pulses. Skin examination was notable for hyperesthesia and allodynia to the region of the left, anterolateral thigh without erythema, induration, or rashes.A 60-year-old female presented to the ED for acute worsening of a five-month history of atraumatic left thigh pain. The patient had multiple ED, primary care, and specialty care visits for the pain without definitive diagnosis. She had been worked up previously with negative Doppler ultrasound for venous thrombosis and MRI of the lumbar spine showing only mild neuroforaminal stenosis. On presentation she had normal vital signs: temperature 36.7°C, BP 128/73 mm Hg, respiratory rate 18 breaths per minute, and SPOAfter consenting the patient, we performed an ultrasound-guided LFCN block with the X-Porte using six mL of 0.25% bupivacaine with four milligrams of preservative-free dexamethasone. After 10 minutes, the patient was pain-free and ambulated out of the ED with a normal gait. She was recommended to continue following up with her primary care physician; however, because they were outside our health system we could not perform chart follow-up.The LFCN is a purely sensory nerve originating from the posterior divisions of L2 and L3 of the lumbar plexus. The nerve courses in the retroperitoneal space through the psoas muscle and over the iliacus muscle in the region of the inguinal ligament .3 The mo4To perform the block, expose the affected thigh and inguinal area with the patient in a supine position. A high frequency linear transducer should be used to visualize the nerve and surrounding structures. The probe can initially be placed just inferior to the ASIS in a transverse orientation . Scannin3Once the nerve is identified, the patient should be prepped in an antiseptic fashion. A probe cover and sterile conduction medium should be used. A small gauge needle is then guided to the soft tissue surrounding this nerve, and local anesthetic is deposited after negative aspiration of blood . An in-p11Meralgia paresthetica is an uncommon entity that can cause significant discomfort. Conservative treatment of MP consists of addressing any extrinsic causes of compression like tight clothing and weight loss and use of non-steroidal anti-inflammatory drugs (NSAID). Persistent neuropathic pain may be treated with tricyclic antidepressants or anticonvulsants such as gabapentin.In both cases, the patients had undergone multiple comprehensive imaging studies and specialist evaluation without a diagnosis or improvement in symptoms. Performance of the LFCN block in the ED was diagnostic and therapeutic without any additional imaging studies or specialty consultation. In both cases our patients experienced great satisfaction with the result of the block. The first patient was able to be transitioned off opioid therapy for symptom control.Limited studies of ultrasound-guided nerve blocks in MP patients show that some require only a single injection to improve symptoms. Tagliafico et al. showed symptom improvement in 16 out of 20 MP patients with a single injection. They also demonstrated a significant mean improvement of patient-reported quality of life.Ultrasound-guided nerve blocks have been shown to be efficacious for the treatment of musculoskeletal pain and neuropathic pain.Meralgia paresthetica, although uncommon, can be a painful and chronic condition that may go misdiagnosed. Ultrasound-guided peripheral nerve blockade performed in the ED can help the emergency physician differentiate MP from other entities, which can improve diagnostic confidence and avoid potentially unnecessary workups. Ultrasound-guided LFCN blockade also provides the emergency physician an opioid-sparing option for treatment of MP in ED patients.