More than 90% of patients with hidradenitis suppurativa (HS) report that pain interferes with their quality of life (QoL) and pain may have a larger impact on QoL than disease severity alone.The purpose of this study was to understand the impact of pain on the daily lives of patients with Hurley stage III HS.≥ 18 years old with Hurley stage III HS in at least one area of the body were prospectively invited to participate in this study. The study consisted of survey questions on patients’ demographic information, past medical histories, HS-related pain histories, and previous therapies for pain management. Additionally, patients completed a series of standardized rating scales on their pain and overall QoL.This was a single-center, prospective cross-sectional study that was conducted at Beacon Dermatology in Calgary, AB. Patients Of the 10 patients that participated in the study, 90% (9/10) expressed a desire for more counselling on pain management options. Many patients  reported routine use of over-the-counter pain medications and 70% (7/10) used complementary and alternative medicines (CAMs) to manage their pain. Patients’ efficacy ratings of HS treatments in controlling their pain revealed that topical treatments provided minimal or no relief, while surgical interventions had the highest efficacy for reducing pain. Patients’ average worst pain over the preceding 24 hrs was 6.3 +/- 2.5 (2-9) on the Numerical Rating Scale for pain and the mean Dermatology Life Quality Index score was 19.5 +/- 8.2 (5-29).Patients with Hurley stage III HS report high levels of daily pain and QoL impairment and many individuals use over-the-counter treatments and CAMs to manage their pain. Physicians involved in the care of HS patients should consider implementing routine counselling on pain management into their clinical practices, especially for patients with severe HS. Over time, sinus tracts can form underneath the skin between individual HS lesions, leading to significant pain, drainage, scarring and mobility restriction. As a result, more than 90% of HS patients report that pain interferes with their quality of life (QoL). Previous studies have demonstrated that pain may have a more substantial impact on QoL than HS severity alone. Pain can adversely impact sleep, ability to attend work or school, social relationships, and other activities of daily living.Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease that can be extremely painful and debilitating for many patients. HS is characterized by inflammatory nodules and abscesses that develop in intertriginous areas, such as the axilla, inframammary folds, groin and buttocks. In the interim, patients may receive suboptimal management, leading to disease progression. Once a diagnosis of HS is made, support offered for pain management may also be limited. Factors that limit patients’ access to pain management include lack of provider training and comfort in prescribing pain medication, poor access to outpatient clinics during flare-ups, and patients’ fears of stigmatization and being labelled as ‘drug-seeking’ by healthcare providers (HCPs). Suboptimal pain management in outpatient settings may lead to frequent emergency department visits and an increased risk of substance use disorder. Thus, it is essential that physicians provide thorough counselling on pain management to HS patients who are significantly impacted by pain.However, pain is a frequently overlooked aspect of HS management and there are many barriers to effective pain management in HS. Often, it may take years for patients to receive a formal diagnosis of HS after symptom onset, due to a lack of awareness of HS within the medical community. Nociceptive pain occurs during acute flare-ups of HS, due to tissue damage and inflammatory cytokine release in HS lesions, with subsequent activation of nociceptors in the skin. Nociceptive pain tends to be well-localized to the area of skin injury and presents with ‘throbbing,’ ‘aching’ or ‘constant’ pain at the area of tissue damage. Neuropathic pain tends to be more chronic in nature and is the result of direct nervous system injury, leading to pain that may be described as ‘burning,’ ‘tingling’ or ‘shooting’ and it may also present with allodynia or numbness. This type of pain often occurs in the absence of noxious stimuli and may be diffuse or may be localized to the region that is innervated by a damaged nerve. Patients may respond differently to pain medications based on whether they have nociceptive, neuropathic, or mixed-type pain. Therefore, it is important to assess both quantitative intensity of pain and qualitative symptoms when taking a pain history from HS patients.HS patients may experience both nociceptive and neuropathic pain.The purpose of this study is to highlight the challenges faced by HS patients with severe disease with respect to pain from their condition and to understand if pain management is an unmet need from the perspectives of a group of Canadian HS patients with Hurley stage III disease.This was a single-center study that utilized a cross-sectional design. Eligible participants were prospectively enrolled and asked to complete a paper-based survey, which included a standardized set of questionnaires. A retrospective review of patients’ electronic medical record charts was also completed. Ethics approval was obtained from the University of Calgary’s Conjoint Health Research Ethics Board.Patients with Hurley stage III HS who had ≥1 active HS lesion in at least one area of the body and were over the age of 18 years were prospectively invited to participate in the study during routine clinic appointments. All participants were patients of a dermatologist at Beacon Dermatology in Calgary, Alberta, Canada. Patients who attended an appointment at the clinic between September and December 2022 were provided with an information handout on the study and asked to follow-up with the study co-ordinator (LJ) if they were interested in study participation. Participants were informed that study participation was voluntary and written informed consent was obtained for all participants. Participants were provided with paper copies of the survey and were instructed to either complete the survey on-site or scan and email the completed survey to the study co-ordinator.The survey was comprised of 4 main sections: (1) Demographic Information and Medical History (2) Previous HS Treatments (3) HS-Related Pain History and Pain Management (4) Standardized Pain and Quality of Life Rating Scales. The first 3 sections included a combination of open-ended questions and Likert rating scales on past medical history, co-morbidities, HS severity and symptoms, previous HCPs seen for their HS, and previous and current treatments for HS lesions and for managing pain. Patients’ self-reported medical histories and physical exam findings were verified using data from previous clinic visit notes in Beacon Dermatology’s electronic medical record system.Participants were asked to rate both changes in HS disease activity and changes in pain for a set of common treatments for HS as well as changes in pain levels for a set of pain remedies. Efficacy in improving symptoms was rated on a scale of 1-5, with 1 = no change in symptoms, 2 = minimal improvement, 3 = moderate improvement, 4 = excellent improvement, 5 = complete improvement.In Part 4 of the survey, participants were asked to complete a series of standardized rating scales to capture the impact of their HS on their overall QoL and provide data on the quantitative severity of their pain and specific pain sensations that they experience. In the NRS, patients are asked to provide a quantitative measure of their pain during the past 24 hrs on a scale that ranges from 0 to 10, with 0 indicating no pain and 10 indicating the most severe pain possible. The DLQI is used to assess QoL impairment for a variety of dermatologic conditions. Questions included in the DLQI do not ask about the impact of specific symptoms on patients’ daily lives and only provide a general overview of the impact of HS on QoL.The Numerical Rating Scale (NRS) for pain and Dermatology Life Quality Index (DLQI) are commonly used in clinical trials of biologic therapies for HS. The BPI measures interference of pain with general activity, mood, walking ability, work, housework, social relationships, sleep, and enjoyment of life. The Short-Form McGill Pain Questionnaire 2 (SF-MPQ-2) asks patients to rate the intensity over the preceding week for a series of 22 different descriptive terms for pain sensations. SF-MPQ-2 items are rated on a scale of 0 (none) to 10 (worst possible level). Each descriptive item is associated with one of four pain categories: 1) Continuous 2) Intermittent 3) Affective and 4) Neuropathic.The Brief Pain Inventory (short form) is used to evaluate both pain intensity and the impact of pain on daily functioning.The primary outcome measures aimed to capture both quantitative and qualitative aspects of HS patients’ pain. Additionally, information was also gathered on the impact of pain on HS patients’ daily lives, the impact of previous HS treatments on their pain, the efficacy of over-the-counter and prescription pain therapies, and previous experiences seeking support for pain management from a HCP.Data from standardized surveys and patient charts in Beacon Dermatology’s electronic medical record system  was compiled into a centralized, secure database. Descriptive analysis was used to summarize study data and analyzed data were reported in data tables. Categorical data were reported with frequencies of each score and relative frequencies. Continuous variables were reported with statistics such as mean, median, mode and/or standard deviation.Supplemental Table 1. All patients were returning patients who had been seen previously by a dermatologist at Beacon Dermatology. Six patients presented for routine follow-up visits, while four patients had booked urgent fit-in appointments for management of HS flare-ups.A total of 10 patients with Hurley stage III HS met inclusion criteria for participation and were enrolled in the study. Patient characteristics, clinical features of HS, and HS symptoms in these patients is summarized in The study cohort included 8 females and 2 males, with a median age of 37 years (range: 28-51 years). The mean age of onset of HS was 19.6 years (range: 8-44 years) and at the study enrolment visit, patients had lived with HS for an average total duration of 18.7 years (range: 2-34 years). All patients had HS in 2 or more areas of the body, with a median of 3 different anatomic locations affected by HS lesions. The most frequently affected site was the groin (9/10 patients), followed by the axilla (8/10), inframammary folds and chest (7/10), buttocks (5/10), abdominal pannus (3/10), inner thighs (2/10), and the anterior neck in one patient.The patient-reported frequency of flare-ups was weekly in five patients, weekly to monthly in two, monthly in two, and every few months in one patient. All patients  reported both pain and pruritus as symptoms of their HS.Supplemental Table 2). However, 90% (9/10) of patients expressed a desire for more counselling on pain management options. Three patients (30%) had been previously prescribed pain medication by a physician. Eighty percent of patients (8/10) reported the use of over-the-counter pain medications and 70% (7/10) indicated that they routinely use complementary and alternative medicines (CAMs) to manage their pain. Specific CAMs included cannabis products  and dietary supplements .Thirty percent of patients had previously discussed pain management with a HCP, while 70% had not received any pain management counselling  for both procedures. Most patients  were currently on or had previously utilized one or more biologic therapies, which had a median pain improvement rating of 3 (moderate improvement). Oral antiandrogens and intralesional corticosteroids also had moderate median ratings for pain improvement.HS patients’ self-ratings of the efficacy of different treatments for managing both their HS lesions and their pain are depicted in One patient reported use of a gabapentinoid, and two patients had been previously prescribed opioids during acute HS flare-ups or following surgical procedures. No patients reported use of a selective-serotonin reuptake inhibitor or a selective-norepinephrine reuptake inhibitor. Patients reported pain relief scores for the following over-the-counter treatments and CAMs: topical lidocaine creams, acetaminophen, non-steroidal anti-inflammatory drugs such as ibuprofen, hot compresses, and cannabis. Patients’ mean and median ratings for improvement in pain were in the minimal to moderate improvement range for these therapies.Supplemental Table 4. The mean NRS score for worst pain over the past 24 hrs was 6.3 +/- 2.5 (2-9) and patients’ least pain was 3.8 +/- 2.4 (0-7). Patients’ average daily pain was 4.9 +/- 2.4 (0-8) and their current pain while completing the survey was 4.9 +/- 2.9 (0-9). The mean DLQI score was 19.5 +/- 8.2 (5-29) and 90% of patients’ DLQI scores corresponded to the ‘large’  or extremely large  impact on QoL categories for DLQI scores. The mean score on the BPI interference items was 5.6 +/- 3.0 (0.6- 10), which corresponded to the ‘high level of interference with daily activities’ category.HS patients’ scores on standardized pain and QoL rating scales are depicted in Supplemental Table 5).The mean total score on the SF-MPQ-2 was 3.4 +/- 2.1 (0.6-6.3). Mean scores on the SF-MPQ-2 subdomains were 3.1 +/- 2.1 (0.3-6.3) for continuous pain, 3.5 +/- 2.2 (0.3-6.0) for intermittent pain, 2.9 +/- 1.9 (0.3-6.0) for neuropathic pain, and 4.4 +/- 4.1 (0.0-10.0) for the affective dimension of pain. The top five rated descriptive terms for pain were ‘tender,’ ‘itching,’ ‘pain caused by light touch,’ ‘stabbing pain,’ and ‘tiring-exhausting’  of dermatologists mentioned pain management in their interview answers, highlighting the importance of focused counselling on pain management when discussing treatment plans with HS patients.Only a few patients had previously received a prescription for pain medication. This study revealed a substantial discrepancy between the number of patients who had previously discussed pain management for their HS with a HCP (30%) and the number of patients who desired more counselling on this topic (90%). This indicates that patient counselling on pain management may be an unmet need in the HS patient population, particularly for patients with severe disease. A recent study that interviewed 12 HS patients on their treatment priorities showed a similarly high desire for pain management, with 83% (10/12) of patients mentioning that pain control was an important goal in their treatment plans. In this study, surgical interventions for HS, including incision and drainage and deroofing, had the highest patient-reported efficacy in reducing pain severity. These results highlight the importance of prioritizing surgical procedures in the management of patients with Hurley stage III HS, as they may have several areas of skin that are covered with sinus tracts, which are often refractory to systemic medical therapy alone. At Beacon Dermatology, a modified deroofing surgical technique is utilized to thoroughly excise the fibrotic tissue lining sinus tracts, providing a low rate of disease recurrence. However, wait times for surgical procedures may be months’ long in some geographic areas and the number of areas that can be treated during one surgical appointment may be limited. Therefore, interim pain management may be essential for improving patients’ QoL prior to their scheduled surgeries.Patient ratings of the efficacy of HS treatments in controlling their disease activity and pain revealed that topical treatments provided minimal or no improvement of both outcomes. Biologic therapies, intralesional corticosteroids, and oral antiandrogens provided the most pain relief out of the medical therapies that were included in the survey. However, ratings for these medication classes indicated that many patients experienced only minimal to moderate relief of their pain with medical therapies. This data is consistent with results from clinical trials for biologic therapies, which showed that patients with Hurley stage III HS had poorer responses to biologics due to their advanced disease. However, this study found that many self-initiated treatments had minimal success in improving patients’ pain. Similarly, a 2022 survey also found that most CAMs used by HS patients only had mild to moderate efficacy. Additionally, previous studies have found that patients with poorly controlled pain may use dangerously high doses of over-the-counter therapies or may misuse prescription medications that were prescribed for a different indication or to a family member. This further highlights the importance of discussing pain management with HS patients, to increase patients’ access to pain management options that are both safe and effective.A notable consequence of the lack of provider-initiated pain management counselling and limited efficacy of medical therapies in improving HS patients’ pain is that many patients use over-the-counter medications and CAMs to self-manage their pain. The sample size was also limited by single-center recruitment and prospective enrolment of patients who attended clinic visits during the study enrolment period. Additionally, although previous studies have found that pain was highly correlated with disease severity, inclusion of patients based on clinical Hurley staging alone may be a less accurate representation of the pain experienced by patients with acutely active disease. Recent studies have found ultrasonography may be beneficial in detecting sonographic features that are associated with increased disease activity and pain, such as intense vascularization, and classification of Hurley stage based on ultrasonography may result in upstaging compared to clinical staging alone. Finally, as this study predominantly focused on HS patients’ experiences with pain, the impact of other symptoms on patients’ QoL, such as pruritus and wound drainage, was not explored in-depth. However, all patients in this study reported experiencing pruritus as a HS symptom and this attribute had the second highest severity rating out of all 22 pain descriptors on the SF-MPQ-2. A previous systematic review of itch in HS found that between 35-82.6% of HS patients experienced pruritus on a regular basis and that pruritus has been associated with impaired QoL and psychiatric co-morbidities in HS patients. Further study on the impact of pruritus on HS patients’ daily lives may be beneficial.A limitation of this study was the small sample size of the study cohort (n = 10). To understand the challenges faced by patients with the most severe stage of HS, the study was restricted to patients with Hurley stage III disease, which comprises only about 4% of the total HS patient population.In conclusion, patients in this study with Hurley stage III HS reported high levels of daily pain and QoL impairment and many individuals reported self-directed use of over-the-counter treatments and CAMs to manage their pain. Most patients expressed a desire for increased counselling on pain management options. Therefore, physicians involved in the care of HS patients should consider implementing routine counselling on pain management into their clinical practices, especially for patients with severe HS. Strong interdisciplinary collaboration between primary care providers, dermatologists, and chronic pain specialists is essential to address the unmet need for pain management in the HS patient population.Click here for additional data file.Supplemental material, Table S1, for Understanding Hurley Stage III Hidradenitis Suppurativa Patients’ Experiences With Pain: A Cross-Sectional Analysis by Leah Johnston, Elaine Dupuis, Lauren Lam and Susan Poelman in Journal of Cutaneous Medicine and Surgery


For patients with severe hip osteoarthritis without clinical or socioeconomic conditions for total hip replacement, the obturator nerve block may serve for pain control and functional improvement. Either lidocaine or phenol are used, although the latter is expected to last longer. Objectives: Compare hip pain and functional performance after obturator nerve block with phenol versus lidocaine in patients with severe hip osteoarthritis who failed conservative treatment.Forty-four patients scheduled for total arthroplasty due to severe osteoarthritis were randomized to the anterior branch of the obturator nerve with phenol (PG) or 1% lidocaine (LG), guided by electrical stimulation. Patients were evaluated with VAS, WOMAC, and pressure pain dolorimetry before the procedure and in the first and fourth months afterward.Both groups improved significantly in pain control, pressure dolorimetry and functioning in the first month with reduced effect after 4 months, although the scores were still better than baseline. No statistical difference could be noticed between the groups. Severe adverse effects were not reported.Evidence Level I; Randomized control trial, double-blind .Both lidocaine and phenol are equally effective and safe in the obturator nerve block for the control of pain and improvement in functioning in patients with severe hip OA.  The main symptom of osteoarthritis (OA) is joint pain, tipically worsened by movement or load, but also present at rest, and accompanied by joint stiffness that lasts less than thirty minutes or joint instability, limitation of the range of motion, and physical disability. These may lead to a compromised functional capacity of the affected individual and give rise to changes in gait and activities of daily living (ADLs). Despite not being present in the therapeutic guidelines for this clinical condition, nerve blocks are a valuable interventionist resource, particularly when clinical treatment fails and the surgical indication for total hip arthroplasty is restricted due to the clinical conditions related to high surgical risk in the elderly patient with multiple comorbidities,2 or socioeconomic conditions.3 In this context, the obturator nerve block can be an analgesic therapeutic alternative that enables the rehabilitation process.Comprehensive rehabilitation therapy aims to control pain, improve mobility, and bring functional restoration. Therapeutic resources may include non-pharmacological strategies such as exercise, modalities, walking aids, and drugs such as analgesics, anti-inflammatories, opiates, capsaicin cream, injections with glucocorticoids or hyaluronic acid. Among the substances used in the practice of these blocks are lidocaine and phenol, which share the immediate local anesthetic action, which is more prolonged in the later due to their immediate selective effect on smaller nerve fibers, resulting from the destruction of small vessels, which initially saves large fibers. John Monagle and Joanne Ee described the use of intra-articular phenol in hip osteoarthritis, where they achieved better pain control and improved functioning and a previous study by our group, carried out only with the use of phenol in a series of patients,4 there was an improvement in pain, especially during the first two months after the block.Nerve blocks interrupt the nociceptive input at its origin, blocking conduction by the spinal, cranial nerves, or afferent fibers that accompany the autonomic nerves. It is an indication for the relief of multiple painful syndromes, of nociceptive or neuropathic nature.This study aims to evaluate the effectiveness of a pain treatment done by applying phenol to the anterior branch of the obturator nerve in comparison with the application of lidocaine in patients with hip osteoarthritis, who did not improve with the conservative treatment.This study was approved by the institution Internal Review Board (CAAE: 66553517.8.0000.5440), all subjects were instructed on the risks and benefits and signed an informed consent form prior to the start of the study.This was a randomized, double-blind clinical trial. Participants were recruited from the rehabilitation center of a tertiary general hospital from Brazil's public health system. Inclusion criteria for this study were: 1) both sexes, 2) adults, 3) diagnosis of severe hip OA, based on the stage of joint degeneration(Kellgren Lawrence class 3 or 4), 4)failed conservative treatment such as drugs, physical therapy exercises, injections with glucocorticoids or hyaluronic acid, pain intensity assessed by the Visual Analog Scale (VAS) greater than six, 5) no known phenol allergy or uncontrolled coagulopathy. Exclusion criteria consisted of the presence of generalized pain, inability to undergo the block procedure under electrical stimulation guidance, due to pacemakers or other implanted devices sensitive to electrical currents, and difficulty in understanding the assessment instruments. Forty-four severe hip OA patients were randomized in blocks of four participants with a computer-generated list (website www.randomization.com)for the blockade in the anterior branch of the obturator nerve (BABON)either with phenol (group PG) or lidocaine (group LG). – the painful pressure threshold indicate the sensibilization of that specific trigger point, thus lower scores indicated more sensitive points which needed less pressure to cause pain. The questionnaire Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used to assess pain, stiffness, and physical function specifically for hip conditions, having already been used in several RCTs for drug and surgical treatment of hip OA.In this study, patients were evaluated immediately after randomization and before the nerve block, follow up assessments were done one and four months after the intervention. Assessment used pain intensity VAS, which consisted of a 100 mm straight line anchored at the extremities to the expressions ‘no pain’ and ‘worst possible pain’ on which the patient is asked to indicate the intensity of the painful symptom during the day of evaluation. Dolorimetry consisted in the use of a pressure dynamometer with a cylindrical and rubberized tip of 1 cm2 to inflict progressive pressure on myofascial trigger points until the patient manifested painUsing manual palpation, the interval between muscles adductor longus and brevis was identified, and needles were inserted 3 to 5 centimeters distal to their upper extremity. The anterior branch of the obturator nerve could be localized with 100mm-long isolated needles connected to an electrostimulator.Both lidocaine and phenol solutions are transparent liquids, but the later exhalates a pungent smell and could be easily differentiated from the first. To warrant blinding, the therapeutic solutions were prepared by a research nurse who was the only one in contact with the randomization sequence. She would bring the syringes with an open bottle of phenol, thus the injection would always be performed in a phenol smelling environment.The sample size calculation was based on the result of a previous study published by Crema et al., in which a series of patients with severe hip OA underwent neurolysis in the anterior branch of the obturator nerve to control pain, having the mean pain intensity (VAS) varied from 8.2 ± 0.9 at baseline to 6.6 ± 1.7 at the end of one month, 6.5 ± 1.7 at the end of two months, and 7.3 ± 1 at six months (p= 0.0094). Considering an effect size of 10%, the statistical power of 80% and the significance level of 0.05, twenty participants would be needed in each study group, to which a margin of 10% was added (four more participants) for the case of follow-up losses. Quantitative variables were evaluated with mean and standard deviation, whereas in categorical variables, percentages were evaluated. After verifying the normality of the distribution of variables, the evaluation of the results of pain assessment in patients with the VAS (primary outcome), WOMAC and its subscales and dolorimetry, the ANOVA test for repeated measures was used to assess the evolution of the values of these variables. As the dolorimetry was always evaluated in a group of six muscles, adductor magnus, short and long, gluteus minimus, medius and piriformis, we preferred to create an index of mean value of these points rather than study them individually. The analysis of the results was based on the intention to treat.Forty-four patients were included in the study according to the flowchart shown in Idiopathic hip OA was responsible for 50%, followed by avascular necrosis of the femoral head (22.7%). Other etiologies of hip disease were Legg-Perthes and rheumatoid arthritis.Similar results concerning functioning can be observed in Mean dolorimetry values were calculated from the pain pressure theshold obtained in the medial gluteus medius, lateral gluteus medius, gluteus minimus, and piriformis. Although the curves in Patients did not report adverse effects after the procedure, such as paresthesia, bruising or pain.This randomized controlled trial was successful in comparing the effect of blocking the anterior branch of the obturator nerve with lidocaine and phenol in patients with severe hip OA. Overall, it was possible to demonstrate a reduction of about 33% in pain intensity assessed by the VAS for up to sixteen weeks in these patients who were candidates for surgical treatment, accompanied by an improvement in quality of life and functioning measured by WOMAC. However, there was no significant change in pressure dolorimetry. The two pharmacological agents produced very similar results in all parameters evaluated, with minimal differences. Alternatively, Silva et al. describe a case report in which they performed an obturator nerve block with 10 ml of 0.25% bupivacaine, resulting in 100% improvement of pain and improvement in the patient's functioning, who started presenting independence for daily activities. The analgesic effect persisted for 40 days. The effects of chemical neurolysis with phenol are not permanent, since functional reinnervation may occur in a period of months. or years. The time of action of this procedure may vary with the concentration of phenol, injected volume, duration of exposure, and injection technique. In a study carried out by Felsenthal, the degree of conduction block differed with different concentrations and volumes of phenol injected up to eight weeks after the nerve block, which could explain the variation in duration.The initial hypothesis that the effects of phenolblock would last longer was not confirmed. Contrasting to lidocaine, which effect of neural block lasts 2 to 4 hours, the effects of phenolic blocks are based in the local anesthetic action on gama fibers, reducing the spastic reflex associated to pain. Also, this substance can produce axoniotmesis, which is the disorganization of the structure of myelin sheath of axons, without injury to endoneural tubes, which may reduce motor inputs and cause relaxation. Its effect in muscle relaxation and spasticity control is well known.The WOMAC questionnaire showed that, in an unified way, up to the fourth month there was an improvement of joint stiffness, feeling of instability or joint insecurity, limited range of motion, and physical incapacity leading to impairment of activities such as walking, sitting, standing, and performing physical activities.None of the individuals in this study developed sensory changes or neuropathic pain pattern in the sensory territory of this nerve branch - the medial face of the thigh, although it is expected that, when injected close to nerves with a predominance of sensory fibers, phenol may cause dysesthesia or anesthesia for up to four months, and eventually this sensation can be described as neuropathic pain, with terms such as shock and burning and with constant or paroxysmal presentation. The most frequent adverse effects in phenolysis are: dysesthesia and pain resulting from a local inflammatory process, ranging from 0.4% to 5% in children and 2-32% in adults. The most frequently involved muscles are the piriformis, iliopsoas, adductor longus, gluteus medius and minimus, adductors, and the piriformis muscle, which is related to pain over the buttock, along with its insertion in the greater trochanter and radiating to the posterior surface of the thigh. The iliopsoas muscle, in turn, presents a distribution of pain associated with its trigger points on the anterior and proximal surface of the thigh, as shown in an unpublished study by Magário et al.This study has some limitations, such as the evaluation of functionality through a questionnaire to be answered by the patient and not through physical tests; the patients had multiple comorbidities and presented arthritis in other joints as a confounding factor in the perception of improvement; and also the presence of periarticular pain pathologies should be investigated. Special attention should be directed to muscular affections, such as myofascial pain, as its treatment can represent a significant symptomatic relief.Given that there is a lack of studies on blocks aimed at improving pain in hip osteoarthritis, the positive aspects of this study include the assessment of methods based on blocks to relieve pain and improve the quality of life or functionality for patients with few resources.The application of phenol or lidocaine in the anterior branch of the obturator nerve can alleviate pain and improve the functionality of patients with hip OA, and may be an alternative treatment for patients who have not undergone THA surgery, either because they are not in clinical condition or because of the queue waiting for the procedure.


First time examination of the physical and psychological long-term outcome following traumatic hemipelvectomy.In this study, all patients suffering from traumatic hemipelvectomy that were treated in a level-A trauma center since 1988 were retrospectively evaluated. The authors aimed to compare the physical and psychological outcome following primary amputation (A) vs. limb-preservation (LP) procedures. The patients were examined with a focus on pain, function, mobility and general health. As part of this examination, various scores were recorded, i.e., Majeed Score, Time up & Go or SF-36.The following work showed 13 patients who had suffered a traumatic hemipelvectomy, 8 of whom survived. Five of these were available for subsequent clinical re-examination; of these, three patients underwent an amputation, while limb preservation was performed on two patients. Mean follow-up of the amputee group was after 12 years compared to 6.5 years following limb preservation. After limb preservation, both patients reported phantom limb pain at the affected leg, despite pain medication. The general state of health was assessed as 82/100 (A) and 45/100 (LP). The Majeed score was 61 (A) vs. 45 (LP). In the clinical examination, three out of five patients  showed peroneal palsy (PP). In the quality-of-life analysis based on the SF12/36 and the NHP, amputees scored higher than the patients who underwent limb preservation surgery.In our small patient cohort, satisfaction, pain and mobility tend to be better following primary amputation compared to limb preserving surgery. Traumatic hemipelvectomy (THP) is a rare injury to the pelvis, accounting for only 0.6% of all pelvic fractures , 34, 42.In 1989, Beal et al. described THP in a larger patient cohort for the first time. During a three-year period, eight patients sustained a traumatic hemipelvectomy, of whom three survived , 44, 45.A retrospective analysis of all patients with pelvic fractures, that were treated in a level-one trauma center since 1988, was performed. All patients that met the definition of a traumatic hemipelvectomy were selected for evaluation.The analysis includes demographic data, mechanism of the injury, vital parameters, the Glasgow Coma Scale (GCS) and laboratory parameters at arrival in emergency room, microbiological contamination of the wound and the clinical course.At a follow-up visit of patients that had survived the long-term functional outcomes, current intake of pain medication and QoL were analyzed.To evaluate the functional long-term outcome, follow-up examinations were organized, including standardized scores, as: Timed Up and Go Test (TUG-T), Majeed Score, Merle D’Aubigne Score (MDA Score) and Harris Hip Score (HHS).The range of motion of the large lower joints was examined using the neutral-zero method. Muscle strength was examined according to Janda , 29, 40.The health-related quality of life and the psychosocial conditions were analyzed using the 36/12-Item Short-Form Health Survey (SF-36/SF-12) measuring with following eight scales: physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH) a physical dimension, represented by the Physical Component Summary (PCS), and a mental dimension, represented by the Mental Component Summary (MCS) , 24. TheCollected data were managed with Microsoft Excel for Mac 2011 , and, after further processing, analyzed with the statistics program IBM SPSS® Statistics® . However, no statistical analysis was included into this manuscript due to the small patient sample.From the pelvic ring fractures treated in a level-A trauma center between 1988 and 2019, 13 patients suffered from THP of whom eight patients survived and five patients died. Detailed medical information of patients are summarized in Table In five of thirteen patients’ treatment included surgically completion of the traumatic hemipelvectomy resulting in amputation of the affected leg for primary life rescue. Three patients were treated with external fixator; five patients received a plate osteosynthesis. In three cases, control of bleeding was the main reason for amputation. Two patients received a hemipelvectomy because of septical complications.The most common accompanying injuries were anorectal and urogenital injuries (11/13). Microbiological swabs of the wounds detected gastrointestinal pathogens such as enterococci and enterobacteriacae. Ten patients suffered from septic complications during the following clinical course.After primary hemipelvectomy all patients suffered septic complications Table . Due to Five out of 13 patients were available for the follow-up visit on average 11.8 years after the accident. Two patients were treated without amputation (LP) whereas three patient’s emergency surgery included amputation of the affected leg (A). Mean follow-up in the group A was 12 years, in the group LP 6.5 years after traumatic hemipelvectomy.The evaluation of the collected data showed with A: 48; LP: 40) on average poor results in the Harris Hip Score for both groups . Evaluat; LP: 40 The daily pain medication intake and their substance class (opioids/non-opioids) were also analyzed. No patient in group A was taking opioids. In group LP, both patients took opioid analgesics daily.Non-opioid analgesics were taken as concomitant medication in both patients in group LP. In group A, one patient regularly took nonsteroidal anti-inflammatory drugs (NSAID) for pre-existing headaches. Two amputated patients frequently used a wheelchair. One limp preservation and the third amputated patient were able to walk with crutches. One patient after limp preservation needed an ankle foot orthosis (AFO) to walk Table .Table 4MMuscle strength at the big muscle groups in hip and knee joint and in the upper ankle joint (UAJ) was balanced in both groups, the different values are summarized in Table See Table The analysis of the SF-12/36 demonstrated that the patients who underwent amputation were able to achieve higher values in all recorded sub-areas. Not only did they rate their physical resilience or their social functioning higher, at the same, time they also reported less pain and greater emotional satisfaction. Accordingly, the aggregated total scores (KSK and PSK) of group A were higher than in the LP group Figs. , 5.Fig. The analysis of the NHP- results revealed differences Fig. , for lesThe existing literature reports the results of case reports and small patient cohorts primarily targeting the survival-rate after traumatic hemipelvectomy, wound healing and related pain following traumatic hemipelvectomy , 46. HerThe results of specific hip and pelvic scores were comparable in both groups. The mean Merle d’Aubigne score was better within the LP group. With 10.5 points, the value can nevertheless be assessed as “moderate” . The MajThe range of motion and muscle strength measurements for the hip and knee joints and the upper ankle joint revealed no differences in either group. Within the LP and A group abnormal results for ROM of the ankle joint can be related to co-existing peroneal palsy of the contralateral leg (A) and the affected leg (LP) Table  20, 41], 4120, 4Furthermore, the follow-up examination demonstrated that after amputation, the daily mobility seems less restricted according to the results of TUG test . In compDespite daily intake of opioid medication, the reported pain at the pelvic area and the foot could not be controlled sufficiently for the LP subjects. Surprisingly, expecting phantom limb pain, none of the amputees take daily pain medication.Reference groups from the manual by Bullinger and Kirchberger can be used to compare the quality of life of the analyzed two groups to each other and to further musculoskeletal diseases and degenerative diseases as arthritis . In the The results for physical function (PF) of group A (50) were superior to the group LP (22) and were similar to the control group of musculoskeletal diseases (51).Like the SF-36, the results in the SF-12 on both the physical and psychological total scales for group LP are inferior compared to group A and the control groups. The NHP was used and evaluated as an additional screening tool. The Nottingham Health Profile (NHP), together with the SF-36, is one of the standard international instruments for recording quality-of-life .SF-12 results are in concordance with the prior assessed a higher quality of life in the SF-36 for the A group. The individual analysis revealed differences between the two groups in three dimensions. The sleep quality, the general energy level and the level of pain were also better after amputation.Of clinical interest is the question of post-THP pain . The stuFurthermore, developments in modern prosthetics, socket technologies and assistive devices might allow wider possibilities for those patients regarding pain free mobility and related QoL even in very proximal amputation levels than in the past , 37.The decision on whether to perform a (delayed) primary amputation following THP or not is a very difficult one to make. In contrast to open fractures of the legs there are no scores. But the scores available can possibly help in the decision-making process in traumatic hemipelvectomies. Reconstruction is always the primary aim in trauma surgery, with amputation reserved for exceptional cases as traumatic hemipelvectomy might belong to as nerve and vessels in the pelvis are major injured. In severe open fractures of the leg, there is no difference in outcome between primary and delayed primary amputation, but the prognosis is noticeably worse for secondary than for primary amputations especially regarding development of chronic pain and social consequences related to the high number of revision surgeries during limb salvage and chronification of pain .Once a traumatic hemipelvectomy has been diagnosed, surgical completion could ensure the survival of patients and could presumably cause fewer septic complications. Long-term quality of life after amputation also appears to be good , 35, 38.


Few studies on adolescents have investigated intelligence quotient (IQ) in mood disorders. Evidence on Disruptive Mood Dysregulation Disorder (DMDD), a controversial entity among depressive disorders, is more limited.We performed an exploratory study on adolescent inpatients with unipolar mood disorders to test specific impairment in cognitive and adaptive profile. We also considered common psychopathological comorbidities. We retrospectively collected data on inpatients with a diagnosis of major depressive disorder (MDD), DMDD or Depressive Disorder – Not Otherwise Specified (DD-NOS) evaluated with Wechsler Scales of Intelligence, Adaptive Behavior Assessment System (ABAS-II), and Children’s Global Assessment Scale (C-GAS).p = 0.001) and ABAS-II scores  than other groups. In linear regression analysis, DMDD retained a significant correlation with lower IQ and adaptive abilities when controlling for sex, and comorbidities. Among comorbidities, LD correlated with lower perceptual reasoning and IQ, and ADHD with lower conceptual adaptive abilities. In all diagnosis groups, working memory and processing speed were lower than verbal comprehension and perceptual reasoning.Out of 198 inpatients , 33.3% had MDD, 60.1% DD-NOS and 6.6% DMDD. DMDD patients had higher rates of ADHD (15.4%) and learning disorders , a lower mean IQ (87.8 ± 10.7; While impairment in working memory and processing speed is a non-specific correlate of active mood disorder, DMDD is burdened by lower general intelligence and adaptive abilities and higher rate of neurodevelopmental comorbidities. Lower IQ in the normal range is a correlate of DMDD among variables examined, not explained by the effect of neurodevelopmental comorbidities. These findings are discussed with regards to possible implications for the consideration of DMDD as a bridge condition between neurodevelopmental disorders and mood disorders. UnipCognitive domain is underinvestigated in mood disorders of adolescents in comparison to adults, and evidence on DMDD is particularly limited. A cognitive symptoms cluster is relevant in depression  and maniThere is some evidence that a lower Intelligence Quotient (IQ) is a nonspecific correlate across all psychiatric diagnoses , 27. WitStudies on cognition in adolescents with mood disorders are fewer and report less remarkable differences in neuropsychological profiles, compared to those on adults. Lower premorbid IQ in developmental age has also been described as a risk factor for MDD . A studyAssociation between DMDD and lower school functioning is remarkable , 36, andIn a transdiagnostic approach, irritability has been shown to impact the association between inattention symptoms and difference in processing efficiency between conflict and non-conflict conditions in ADHD . This fiAdaptive abilities and functioning show a grade of correlation with intelligence  but reprDifferent unipolar disorders  are characterized by distinctive impairment in cognitive and adaptive profile and functioning.The diagnosis of mood disorder accounts for a difference in cognitive and adaptive profile and functioning among the different groups studied when controlling for neurodevelopmental and other psychopathological comorbidities.We performed an exploratory study on cognitive, adaptive ability and general functioning in a cohort of adolescent inpatients with unipolar mood disorders, admitted in our psychiatry inpatients unit for acute decompensation, to better describe consistency of these different phenotypes. We aim to test two hypotheses:22.1We conducted a retrospective study on inpatients admitted from 2020 to 2022 to the Child Neuropsychiatry Unit of a referral center for children and adolescent psychiatry. We collected data on consecutive patients admitted for the first time, referred by either our own or regional emergency departments, secondary care  or our own outpatient service. We included children and adolescents of both sexes aged ≥11 to <18 years at admission with a diagnosis of DMDD, MDD or DD-NOS. We excluded patients with intellectual disability of mild to profound severity and/or full-scale IQ <70, patients with a diagnosis of (hypo)manic/mixed episode, patients with a diagnosis of substance-induced mood disorder and/or mood disorder due to another medical condition according to DSM-5 , patient2.2Sociodemographic data were collected on clinical records on admission. Neuropsychological and psychopathology assessment was completed within 48 hours of admission. Diagnoses were assessed with the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-aged Children, Present and Lifetime version (K-SADS-PL) , followiAll diagnoses were reviewed before discharge by two independent expert clinicians (M.A. and R.A.) and agreement was reached in every included case.Measures of cognitive profile were Wechsler intelligence batteries. WISC-IV  was usedAdaptive abilities were assessed with the Adaptive Behavior Assessment System, Second Edition (ABAS-II) , which wThe Children’s Global Assessment Scale (C-GAS)  was used2.3Categorical variables are presented as number and percentage. Continuous variables are presented as mean and standard deviation (SD). In the section on the description of the cohort characteristics, association between variables was tested with Pearson’s or Fisher’s test, as appropriate. The Bonferroni correction for multiple comparisons was applied.st hypothesis, means of cognitive, adaptive abilities and general functioning scores were compared in the different diagnosis groups by a multivariate analysis of variance (MANOVA). Mean IQ, Wechsler scale indexes , adaptive behavior general composite score and scales  and C-GAS score were compared between the 3 diagnosis groups. Variance–covariance homogeneity assumption was tested with Box’s test and was not violated. Pillai’s trace was chosen to assess the significance of the model. Eta squares (η2) were reported as a measure of effect size of the model. Post-hoc analyses were performed using Fisher’s LSD test. Odds ratios (OR) with 95% confidence intervals were reported. SPSS generalized linear model for repeated measures was used to test differences between VCI, PRI, WMI and PSI within patients with the same mood disorder diagnosis. VCI, PRI, WMI and PSI were computed as repeated measures and the three mood diagnosis disorder groups were tested independently.To test the 1To test the 2nd hypothesis, linear regression modeling was used to test the effect of mood disorder diagnosis controlling for potential confounding effect of age, sex and comorbidities known to potentially affect cognitive functioning, adaptive abilities and general functioning. Among these, we tested the variables which were found to be significantly different among mood disorder diagnoses in the previous analyses as predictors. FSIQ and indexes  were tested as predicted variables in repeated analyses. Furthermore, mood disorder diagnosis FSIQ and indexes, sex and comorbidities , were tested as predictors and ABAS-II general composite score and subscales as predicted variables. Lastly, mood disorder diagnoses, FSIQ and indexes, ABAS-II general composite score and subscales age, sex, comorbidities , were tested as predictors of C-GAS score.p value of 0.05 or less was considered significative. Analyses were conducted with Microsoft Office 365 – Excel and IBM SPSS Statistics V26 software.A 33.1p = 0.012). DMDD patients had higher rates of ADHD (15.4%), LD (23.1%) and CD (7.7%) than other mood disorder groups and lower rates of current (n = 0) or past anxiety disorders (23.2%) or eating disorders (n = 0). Difference in prevalence of comorbid eating disorder was not significative after applying Bonferroni correction for multiple comparisons.During the study period, data on 198 patients  were collected. The diagnosis was of MDD in 33.3% (number = 66), DMDD in 6.6% (number = 13) and DD-NOS in 60.1% (number = 119). UHR for psychosis was present in 22.7% of patients. Patients had a mean 0.62 active comorbidities . Female prevalence was lower in DMDD  and DD-NOS (102.1).VCI and PRI were significantly lower in DMDD than in MDD and DD-NOS. WMI was significantly higher in MDD than in DD-NOS and DMDD, while in DMDD it was not significantly lower than in DD-NOS. Significant differences in PSI were found on post-hoc analysis in all comparisons between group, and PSI in MDD was significantly higher than in DD-NOS and in DMDD. Additionally, PSI in DD-NOS was significantly higher than in DMDD.F = 18.6, p < 0.001, partial 2η = 0.47 in MDD group; F = 55.3, p < 0.001, partial 2η = 0.59 in DD-NOS group; F = 6.5, p = 0.01, partial 2η = 0.66 in DMDD group;). Pairwise comparisons of VCI vs. WMI, VCI vs. PSI, PRI vs. WMI, and PRI vs. PSI were significant with p ≤ 0.001 in MDD group and in DD-NOS group. In DD-NOS, VCI was also significantly higher than PRI . In DMDD group, pairwise comparisons of VCI vs. WMI and VCI vs. PSI were significant with p = 0.001, pairwise comparison of PRI vs. WMI was significant with p = 0.002 and pairwise comparison of PRI vs. PSI was significant with p = 0.008.With regard to within-group difference between indexes, WMI and PSI were significantly lower than VCI and PRI in all diagnosis groups .Global functioning measured with C-GAS was not significantly different among mood disorder diagnosis groups  were set as predicted variables and mood disorder diagnosis, together with female sex, comorbid anxiety disorders, comorbid ADHD, comorbid LD and comorbid CD as predictors in five consecutive regression analyses. Results are shown in Thereafter, we tested the effect of mood disorder diagnosis in predicting adaptive abilities scores, controlling for the effect of FSIQ and indexes, female sex, comorbid anxiety disorders, comorbid ADHD, comorbid LD and comorbid CD in four consecutive regression analyses. Results are shown in Lastly, we tested the effect of mood disorder diagnosis in predicting general functioning, controlling for the effect of adaptive abilities, FSIQ and indexes, female sex, comorbid anxiety disorders, comorbid ADHD, comorbid LD and comorbid CD in a regression analyses. Results are shown in 4We analyzed a cohort of adolescents with depressive disorders to identify relevant differences in cognitive, adaptive profile and functioning between the different groups of mood disorder diagnoses. Participants were selected from an inpatient setting, where they were admitted for acute decompensation of current psychopathology. All participants were in an active phase of the psychiatric disorder and a degree of impairment was evident in all.In patients with DMDD, general intelligence and adaptive abilities were significantly lower. Furthermore, patients with DMDD were characterized by a higher rate of neurodevelopmental comorbidities. In more detail, patients with DMDD had more comorbid ADHD and LD, as well as CD, and lower lifetime and present anxiety comorbidities. WMI and PSI were significantly lower than VCI and PRI in all patients, as a nonspecific signature of mood disorder.In regression analyses, the effect of DMDD on lower IQ, VCI, PRI and PSI was significant; an effect of LD on IQ and PRI was significant too. The effect of DMDD on lower adaptive abilities was significant and more marked in the social adaptive domain, while ADHD had a significant effect on conceptual adaptive domain. Functioning was low on average in all groups, and not significantly affected by specific mood disorder diagnoses. It was slightly higher, however, in patients with anxiety comorbidities.DMDD is a debated entity among depressive disorders, however our exploratory findings on cognition and adaptive impairment relative to psychopathological comorbidities, in the landscape of previous literature, may point toward its conceptualization as a distinct disorder, whose features cannot be exhaustively included in the mood disorder chapter. We contemplate a reconsideration of DMDD as a bridge entity between neurodevelopmental and mood disorders.We assessed comorbidities systematically and analyzed their possible impact on cognition, adaptive abilities and functioning in regression analyses. This was particularly relevant for ADHD and LD, which are known to influence Wechsler scales examination scores. The effect of bidirectional interaction between neurodevelopmental and mood disorders on cognition is an under investigated issue, which is worth exploring in future studies. ADHD and LD affected cognitive profiles more than anxiety, depression, and behavior disorders in one study , while ADMDD in our cohort appears distinct from pediatric bipolar disorders , 56 sincThese considerations are also interesting in light of recent studies on “emotional dysregulation” construct, conceptualized as a distinct neurodevelopmental, early-onset disorder . DMDD maOur patients with DMDD had higher rates of ADHD, LD and CD, which is consistent with the studies of Benarous et al. , 37, butWe also analyzed MDD, DD-NOS and DMDD to find differences in cognitive performance in different domains within each group to identify distinctive profiles. Impairment in working memory and processing speed appeared as a non-specific correlate of current mood disorder across all diagnoses. Literature on adults , 64, 65 PSI was the most discriminant index between groups. It was higher in females, consistently with literature , and sinGeneral functioning in our study was low on average in all groups, due to the inpatient setting of our study, where patients are admitted for acute decompensation of their psychopathology. Previous studies report mixed findings on functioning. A study on depressive disorders did not find differences in global functioning but reported more school and peer-relationship difficulties in DMDD compared to MDD . A studyA strength of our study is providing data on cognitive and adaptive profile of DMDD, whereas literature is limited. The evaluation procedure was standardized, providing a synoptic overview on cognition, adaptation and functioning, and all patients were evaluated in an early and acute phase of their psychopathological trajectory. There are, however, considerable limitations. Firstly, the study was exploratory, DMDD patients were a minority, and the sample size was underpowered. Chronic irritability is more often managed in outpatient units, limiting the number of our observations of DMDD to patients needing prompt start of a pharmacological treatment. Furthermore, due to the cross-sectional design of the study, some patients may have been provisionally classified as DD-NOS for not meeting the criteria for a diagnosis of another mood disorder  at first clinical observation. Excessive prevalence of females in our cohort is consistent with differential incidence of mood disorders between sexes but limits the detection of sex differences in the outcomes studied. Finally, our cohort is made of inpatients, which are all characterized by higher severity of current psychopathology. These limitations are worth addressing in specifically designed perspective studies.The datasets presented in this article are not readily available because of the nature of the research, due to ethical reasons. Further inquiries can be directed to the corresponding author.The studies involving humans were approved by Ospedale Pediatrico Bambino Gesù. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.MA: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. MCP: Data curation, Methodology, Writing – review & editing. RA: Conceptualization, Investigation, Methodology, Writing – review & editing. ML: Data curation, Investigation, Writing – review & editing. MP: Methodology, Supervision, Writing – review & editing. SV: Conceptualization, Investigation, Supervision, Writing – review & editing.


Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy.Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery.p = 0.868), at 6 months (9.4 vs. 12.4%) (p = 0.785), and at 12 months (3.3 vs. 5.9%) (p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant (p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain (p = 0.03), while cardiac disease (p = 0.6), perioperative morbidity (p = 0.228), prolonged air leak (p = 0.057), and repeat drainage (p = 0.626) were not.Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) (Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain. The point prevalence is nearly 25%, and one-third of these patients have a neuropathic component . ApproxiIn the last few decades, VATS has shown unquestionable surgical advantages over open thoracotomy, including early removal of chest tube, faster functional recovery, a shorter hospital stay  and imprIn our study, we compared the presence of persistent pain up to 12 months after surgery as defined by differences in analgesic consumption in patients who underwent lobectomy using the iVATS and NITS techniques.2.2.1.U test. From these patients, 35 iVATS and 32 NITS patients had complete documentation of postoperative pain and use of analgesic medications, and only their data were used in this study. All patients underwent the same preoperative pulmonary examinations and none of them had chronic chest pain before the surgery. All patients who were selected in this study had BMI less than 30 or close to it, in both groups. Between July 02, 2015,  and January, 24, 2017  all the patients underwent iVATS. The NITS was started at January, 24, 2017. After the start of the NITS till the end of the study , if the anesthesiologist in charge was familiar with the NITS procedure, the lung resection was performed with NITS, but in the other cases the traditional iVATS was our choice. Age-adjusted Charlson Comorbidity Index was calculated with regard to comorbidities and weighted it based on patient age. The exclusion criteria were similar: tumors greater than 7 cm, cN2 lymph node stage, previous thoracotomy, therapeutic –dose anticoagulation, unstable cardiac disease, psychiatric disorders, or severe obesity with 35 <body mass index (BMI). The patients who underwent conversion from NITS to IVATS or from VATS to open method were excluded from this study. Additionally, the possibility of difficult intubation was excluded in cases of NITS.Using propensity score matching, we selected 70 iVATS and 70 NITS patients who underwent surgery between July 3, 2015, and November 27, 2018, in the Department of Thoracic Surgery at the Szeged University Hospital. The following factors were used for propensity score match: age, sex, BMI, Charlson Comorbidity Index, histology, type pf lobectomy and FEV1. We compared the differences between two groups with Mann-Whitney 2.2.Although the anesthetic considerations were different, the number of surgical incisions was the same in both groups: All patients were operated via uniportal technique, and an utility incision was performed in the 5th intercostal space without any additional port. All the skin incisions were less than or equal to 4 cm. Local anesthesia with nerve blockade is crucial in NITS. Before the incision, the skin was infiltrated with local anesthetic  between the 5th and 6th rib on the middle axillary line. After the utility incision was completed, vagus nerve blockade was performed with 0,5% bupivacaine (0.5 ml/kg) on the right upper mediastinum or on the aortopulmonary window. The paravertebral blockade was administered with 4–5 ml of bupivacaine alongside the thoracic spine, blocking the 2nd to the 5th intercostal nerves.Subsequently, the surgical steps were similar; however, the non-intubated patients were able to breathe spontaneously under the procedure. All the patients underwent uniportal VATS lobectomy and radical lymph node dissection. Finally, a plastic chest tube was placed through the utility incision, and the wound was closed. None of the patients underwent intraoperative conversion from video-assisted thoracoscopy to open thoracic surgery or from NITS to iVATS.The duration of paravertebral blockade was 24 h. After that we used intravenous Neodolpasse (diclofenac) and Paracetamol infusion on the first postoperative day to reduce acute postoperative pain. On the next day we switched to oral diclofenac therapy.2.3.The Human Investigation Review Board of University Szeged approved and reviewed the study. All patients were informed and gave written consent. All patients were assessed during follow-up visits in our pulmonology department at 3, 6, and 12 months after the surgery. General conditions, pain status, type of pain medication, analgesic consumption, and current wound healing status were recorded. In our study the severity of acute pain and and the related painkiller consumption in the early postoperative period were not recorded. Chronic pain was defined as pain that develops or increases in intensity after a surgical procedure and persists beyond the healing process for at least 3 months after the surgery, according to the International Association for the Study of Pain  or diffusing lung capacity for carbon monoxide (DLCO) were not significantly different in patients who underwent intubated and non-intubated VATS lobectomies. Patient demographics and preoperative pulmonary evaluation are presented in p-values showed no statistically significant differences in the mean operation time, mean day of chest tube removal, prolonged air leak, number of repeat drainages, reoperation, or morbidity. The mean total operation time among the patients with chronic pain was 100 min (85–125), which was 7 min longer as in the total cohort. This difference was not significant. No perioperative mortality was observed in the follow-up period. Pathological types and stages showed also not significant differences between the groups. Surgical data, pathological types, and staging are listed in The p-value = 0.616), both sexes reported chronic pain during the initial 2 follow-up periods (16.7% vs. 16% at 3 months and 11.9% vs. 8% at 6 months). Surprisingly, after 1 year, no men reported the presence of chronic pain (7.9% vs. 0%).With female predominance, although statistically not significant .p-value = 0.228), perioperative morbidity also appeared to be a risk factor in the first 2 follow-up periods , but after 12 months, no patient with morbidity reported any chronic pain (0% vs. 5.2%).Although statistically not significant . Interestingly, none of the two patients who underwent repeat drainage reported chronic analgesic consumption .Only one patient required reoperation, and this patient suffered from chronic pain during follow-up . In terms of cardiac disease, the results were similar , but not significant . Patients with diabetes mellitus had a higher chance of long lasting pain than non-diabetics , and this difference was statistically significant . After 6 months, both rates were reduced, with 9.4% of NITS and 11.4% of iVATS patients needing regular pain medications. The difference was 2%, which was again not significant . There was a further reduction in pain at 12 months, with only 3.3% of NITS and 5.9% of iVATS patients reporting analgesic use. The difference was 2.6% but was again not significant .During follow-up at 3 months, 15.6% of NITS and 17.1% of iVATS patients reported the use of pain medications. These data showed a 1.5% difference between the two groups, which was not statistically significant  function . TherefoThe secretion of neuroinflammatory mediators facilitates neuroimmune activation, sensitizes primary afferent neurons, and contributes to the various symptoms of neuralgia . The actThe interruption of tissue continuity indicates an increase in inflammatory mediator level. Prostaglandin, histamine, and bradykinin can stimulate the nociceptors and lead to an increased activation and reduction in pain threshold. This primary sensitization leads to acute postoperative pain. The permanent activation of sensory receptors after the surgery provokes excessive sensibility of dorsal horn neurons and the central nervous system amplifies its response. Finally, the increased neural reactivity lead to central sensitization and with neuropathic component can transform to persistent, chronic pain .+, CD4+, and CD8+ T cells  compared to VATS , 32–36.  T cells , 39 whil T cells . Less T- T cells .In contrast, other studies have shown no differences between the VATS and thoracotomy approaches  in the onset and intensity of chronic pain after the surgery –45.Theoretically, a smaller incision reduces immune activation and pain. There are slight differences in the postoperative systemic inflammatory response in UniVATS compared to multiportal VATS , but theImmune activation appeared to be affected by the type of anesthesia used as well. NITS has a lower negative effect on the activation of the cellular and humoral immune systems, which tend to be important in postoperative infections, pain, and tumor progression –53.In our study the inflammatory and anti-inflammatory markers of the patients were not measured. We based our study on previous studies in connection with inflammatory response. Our initial hypothesis was that the non-intubated surgical approach reduces immune activation and causes a milder immune response, consequently lowering the presence of chronic pain in comparison to that in patients subjected to general anesthesia. This hypothesis has been confirmed in association with acute postoperative pain. Apart from the number of incisions, the intensity of pain is low in patients who undergo thoracic surgery without intubation –56. PompSome authors have drawn different conclusions; Kocatürk et al. found no significant difference at 4, 8, 12, and 24 h between awake and intubated patients who underwent diagnostic operations for pleural disease . Yang etTo our knowledge, our study is the first to examine the differences in chronic pain between patients who underwent intubated and non-intubated lobectomy with a follow-up period of 1 year. We evaluated the presence of chronic pain based on analgesic consumption at 3, 6, and 12 months after surgery. No pain scales were used. We hypothesized that patients who continue to use pain medications months after surgery experience significant pain levels, causing limitations in daily life activities. All patients underwent single-incision VATS lobectomy, and there were no statistically relevant differences in the demographic, pulmonary, surgical, or pathological parameters. The main difference between the 2 groups was the anesthetic management; therefore, theoretically, all the resulting differences in connection with long-lasting pain originate from the anesthetic assessment and the type of ventilation  used. Based on our results, there was no significant difference between the two groups, although a higher number of the iVATS patients needed pain medications at home after surgery . This finding is similar to that of Yang et al., but our follow-up time was 9 months longer. In addition, we found no statistically significant differences in the onset of chronic pain between female and male patients; however, in our cohort, more female patients had long-lasting symptoms. Furthermore, none of the male patients reported analgesic use 12 months after surgery. Neuropathy and neuropathic pain are one of the most common complication of diabetes. The pathophysiology is not clear put hyperglycemia, oxidative stress, metabolic and microvascular changes seem to be important . The sta


Chronic musculoskeletal pain (CMP) is a complex condition that is mainly treated with analgesic drugs. However, antidepressant intervention is also an important factor in the treatment of CMP. Duloxetine is an effective treatment option for patients with CMP as its antidepressant effect. The purpose of this article is to evaluate the efficacy and safety of duloxetine in treating CMP.We searched PubMed, Web of Science, Embase, Cochrane Library from inception to May, 2022. Randomized controlled trials (RCTs) evaluating the efficacy and safety of duloxetine versus placebo in patients with CMP were included. We identified 13 articles and studied a population of 4201 participants in 4 countries.This meta-analysis showed that the duloxetine has statistically significant compared with the placebo control, benefits on 24-hour average pain, living quality, physical function, and global impressions and there was no difference in the incidence of serious adverse event. In general, duloxetine can improve mood and pain level at the same time.This review shows a significant contribution of duloxetine to CMP symptom relief. This meta-analysis improved that duloxetine can significantly reduce the pain level of patients, improve depressive symptoms and global impression, and has no obvious serious adverse reactions. However, additional studies are required to confirm the relationship between psychological diseases and chronic pain and explore their internal links.The online version contains supplementary material available at 10.1186/s12891-023-06488-6. Chronic musculoskeletal pain (CMP) is a persistent pain that affects muscles, joints, bones and other parts of the human body. CMP encompasses a wide range of motor system diseases, including osteoarthritis, neck pain, low back pain and fibromyalgia syndrome. About 20-33% of the global population suffers from CMP. With the increasing of population aging and social pressure, the incidence of CMP has increased significantly . In addiCurrently, treatment of CMP relies on analgesic drugs such as non-steroidal anti-inflammatory drugs (NSAIDs), antipyretics, opioids, and muscle relaxants. However, NSAIDs will increase the risk of peptic ulcer, gastrointestinal bleeding, cardiovascular adverse events and have poor efficacy –6. AntipDuloxetine, a potent and selective serotonin and norepinephrine reuptake inhibitor (SNRI), is the only antidepressant drug approved by Food and Drug Administration (FDA) to treat CMP . DuloxetWe searched PubMed, Cochrane Library, Medline, Web of Science from inception to May, 2022 by using a combination of abstract and key words, such as “duloxetine”, “chronic musculoskeletal pain”, “osteoarthritis”, “fibromyalgia”. We limited the literature what was published but did not place any limits on language or publication date.The title and abstract were obtained by two independent researchers, and we used EndNote to manage the retrieved literature. After reading the title, abstract and full text, the literature was screened and checked. If there was any disagreement, the third researcher would decide. The literature we included had to meet the following criteria: (1) study type: RCTs of efficacy and safety of duloxetine in the treatment of CMP, such as knee osteoarthritis (KOA) or fibromyalgia; (2) study group: Patients diagnosed as KOA or fibromyalgia and the course of disease was more than 3 months; (3) interventions: Duloxetine was used in the test group, placebo was used in the control group, and NSAIDs were allowed to be used together; (4) the outcome indicators included at least one of the following: Brief Pain Inventory-Severity(BPI-S)、Brief Pain Inventory-Interference(BPI-I)、Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC)、36-Item Short-Form Health Status Survey(SF-36)、Clinical Global Impressions of Severity(CGI-S)、Patients’ Global Impression of Improvement(PGI-I)、Serious Adverse Events(SAEs), and data were extracted at the end of follow-up for each outcome.Two researchers  screened and extracted the data independently, reviewing the title, abstract, and full text of each article, and consulted a third researcher (Yang Guo) when disputations arose. The extracted data mainly includes the following contents: (1) basic information of each study including first author, country, publication year, study design, etc.; (2) age of patients, sample size, interventions, period of treatment; (3) the data of case and control groups; (4) potential sources of biases.We assessed the risk of bias for each study using the items in Cochrane Collaboration’s tool  for asse2 statistic. If I2 < 50%, the heterogeneity of articles was considered to be small, and the fixed effects model was used. Otherwise, the random-effects model was used [In this study, we tried to contact the authors to obtain the original data when the data were missing or incomplete. For data that were not available, the investigators used the evidence-based transformation formula to obtain means and other corresponding data . Pooled was used . In addiwas used . Besideswas used . Forest As is briefly illustrated in Fig. The baseline characteristics and treatment regimens of the 13 eligible studies with a total sample size of 4201 patients are displayed in Table The quality assessment of the trials was performed using the Cochrane Collaboration’s risk-of-bias tool. Two studies , 26 explIn the 13 eligible RCTs, 12 trials , 24–31 mTwelve trials contributed to the meta-analysis of pain relief based on the BPI-S. Compared with the placebo control groups, the meta-analysis results indicated that patients in the duloxetine groups had significant reductions in the average pain within 24 h      Fig. .To validate the reliability of results, each of the 13 studies was sequentially eliminated one by one, and sensitivity analysis of the remaining studies was conducted at each step. The sensitivity analysis showed that no individual study significantly influenced the results, indicating the robust result of this meta-analysis. Sensitivity analysis images can be found in the Additional file We used funnel plot and Egger’s test to detect publication bias in the outcome of the BPI-S 24 h average pain. No distinct asymmetry could be observed from the shape of funnel plot, suggesting no proof of publication bias (p = 0.492) Fig. .Consistent with previous studies, the results of this meta-analysis showed that duloxetine can significantly reduce the patient’s pain level. It can also effectively improve patient’s mood and quality of life, which may be related to its pain relief effect, and delay the progress of chronic musculoskeletal diseases such as knee osteoarthritis and fibromyalgia syndrome and ameliorate the limb function of patients. Thus, duloxetine had a definite efficacy in the treatment of patients with CMP, and the incidence of SAEs was no statistically different compared with placebo control.Today, CMP has become one of the major problems faced by the older people, which affects their normal work and life seriously. Long-term chronic pain is unfavorable to the patients’ psychology and mood, and may even induce depression, anxiety, Alzheimer or other diseases , 33. TheMore and more studies –44 reporThe reduction of patients’ pain is conducive to the improvement of patients’ global impression. This study found that the evaluation of patients’ global efficacy and global evaluation showed the same trend as the pain score, indicating that duloxetine has obvious efficacy for CMP and can effectively improve patients’ global impression. There is a significant difference between the experimental group and the control group.NSAIDs are currently the first-line treatment for the pain with CMP. However, Enthoven  demonstrThere are several limitations of meta-analysis that should be taken into account. First, the meta-analysis only included English literature, and based on a relatively small number of RCTs, which may lead to bias risk. Fortunately, the quality of trials we included was relatively high. Second, the included RCTs lack long-term follow-up studies, so the long-term efficacy and safety of duloxetine are still unclear. The included RCTs mostly used placebo as a control and lacked comparison with NSAIDs. Also, the current systematic review was not registered, which is a deficiency of this study. Lastly, in this study and most of the current meta-analyses, the statistical model of Meta-analysis (fixed or random effect method) is based on the results of statistical test of heterogeneity, which has certain shortcomings.In conclusion, antidepressant drugs like duloxetine, is an effective treatment option for patients with CMP. Antidepressant treatment is a non-negligible factor in the treatment of CMP. This study improved that duloxetine can significantly reduce the pain level of patients, improve depressive symptoms and global impression, and has no obvious serious adverse reactions.Any drug has two sides, and we should explore the potential issues of duloxetine in the treatment of CMP in the future. Further studies should confirm the relationship between psychological diseases and CMP, explore its internal relationship, and verify the efficacy and safety of antidepressant drugs for musculoskeletal Diseases.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3


Pain management at the end of life is a fundamental aspect of care and can improve patients' quality of life. Interventional approaches may be underutilized for pediatric cancer patients.To describe a single institution's 10 years of experience with regional pain management at the end of life in pediatric oncology.A retrospective cohort study of 27 patients with pediatric cancer who died between April 2011 and December 2021 and received continuous nerve block (CNB) catheters or single-shot nerve blocks (SSBs) during their last three months of life. The type of blocks, analgesic efficacy, and palliative care involvement were evaluated.Twenty-two patients (81.5%) had solid tumor diagnoses, including carcinomas, sarcomas, and neuroblastoma. Most (59%) patients received CNB catheters, and 12 patients (44%) received SSBs for pain control. The mean pain score decreases for CNB catheters and SSBs after interventions were −2.5 and −2.8, respectively, on an 11-point scale. Decreases in opioid patient-controlled analgesia dosing requirements were noted in 56% of patients with CNB catheters; likewise, in 25% of patients with SSBs at 24 h and in 8% at 5 days after interventions. Nearly all patients had PC involvement and received care from pain specialists . Twenty-three (85%) had physician orders for scope of treatment orders completed before death.Regional pain control interventions can be effective and safe for relieving regional pain and suffering in dying children and young adults. The collaboration between palliative care and pain management specialists at the end of life can help alleviate suffering and improve quality of life. Pain management during end-of-life (EoL) care remains important to optimize a patient's overall quality of life (QoL). Up to 50% of patients undergoing cancer treatment experience pain secondary to their disease. This increases to 76% during the EoL period and can be as high as 90% for pediatric patients with advanced cancer , 2. In aStrategies to enhance QoL and relieve suffering due to pain are multimodal and multidisciplinary and include the following: (1) pharmacological therapy including but not limited to NSAIDs, acetaminophen, opioids, methadone, and gabapentinoids, (2) physical and occupational therapy, (3) advanced infusions such as low-dose ketamine or lidocaine infusions, and (4) interventional approaches such as peripheral nerve blocks and central neuraxial blocks  . AdditioMorphine is the most commonly used drug for pain control in the EoL period (reported in 60%–90% of patients) ; opioidsIn this Institutional Review Board–exempt retrospective review, we evaluated pediatric patients from a single academic institution who were treated with CNB catheters or SSBs as part of regional pain control regimens during the EoL period [defined as the three months before the documented date of death (DOD)]. The study institution is a 78-bed facility that cares for over 500 new pediatric patients with oncology diagnoses each year, comprising patients from the Mid-South as well as national and international patient referrals. Pediatric patients were defined as those who received their primary diagnosis before the age of 21 years or received a diagnosis of pediatric primary cancer. Patient data were obtained from the electronic medical record database PowerChart P134 from CernerWorks. The study review period included patients who died between April 2011 and December 2021, a timeframe during which patients would have all pertinent data for this study placed into the electronic medical record system. Demographic information  was collected. The following pain characteristics were collected at the interventional procedure for pain: (1) location of pain; (2) type of pain ; (3) medications for pain management ; and (4) pain scores (PS) collected 24 h before and 24 h after the interventional procedure, and, as applicable, 5 days after the procedure. For the PS assessment, age-appropriate pain assessment tools were used, including the FACES Revised pain scale , FLACC s3·1−1) and the platelet count (×10−1·1−1). Adverse effects following the pain blocks were evaluated.The data collected regarding pain management interventions included intervention type ; device location; tunneling technique ; local anesthetic and/or ablative agent, concentration, and rate of infusion at day of insertion and by day 5 after insertion (if applicable); duration of the device in relation to the patient's lifespan (measured in days); outpatient status with device; and reason for device removal (if applicable). Potential limiting factors for assessing a patient's candidacy for the interventional pain blocks were collected, specifically the absolute neutrophil count (ANC) (×10−1·day−1), using the following equianalgesic rations: 100:1 for fentanyl:morphine and 5:1 for hydromorphone:morphine.The change in PS before and 24 h after the pain intervention, as well as the change in opioid patient-controlled analgesia (PCA) requirement before intervention, 24 h post, and at day 5 after intervention were used to analyze the effectiveness of the pain block interventions. Patients who did not receive PCA before or after the intervention were evaluated using only the change in PS before and 24 h after the intervention. When PS were not documented within a 24 h interval, this was counted as missing data. To facilitate comparison of different intravenous opioids used for PCA, the doses were calculated as mean intravenous morphine equivalent (mg·kgn = 5), with most patients  having solid tumor diagnoses. The most common site of pain was the abdominal region , and most patients  had a documented nociceptive type of pain.Altogether, 2,151 patients died during the study period; 415 of them (19%) engaged with the pain medicine team. Of those who received subspecialty pain care, 27 (6.5%) received interventional pain management procedures during the EoL period and were reviewed for this study; of them, 4 patients had multiple interventional procedures reported. n = 16) received CNB catheters, 62% (n = 10) of which were epidural catheters (n = 3) received multiple CNB catheter infusions: one patient had two peripheral nerve block catheters placed on the same day in two different locations, and two patients had dislodged catheters replaced. The average use of a CNB was 6 days  for peripheral nerve block, 16 days (range 5–24 days) for intrathecal catheters, and 11 days (range 2–56 days) for epidural catheters (n = 12) of the catheters were placed using a tunneling technique, and 62% (n = 10) remained in place on the DOD. Most patients  using CNB catheters were receiving opioids (excluding methadone) prior to catheter insertion.Most patients  resulted in decreasing PS, with a mean decrease of 2.15 (n = 12) had an opioid PCA as part of their pain management regimen. After CNB intervention, 37% (n = 6) had decreased PCA dosing requirements 24 h after catheter placement; 37% had decreased PCA dosing requirements 5 days after catheter placement.The mean PS was 5  before catheter insertion and 3  24 h after insertion. Nearly all catheter-based interventions  of patients received a SSB intervention for pain control, mainly celiac plexus blocks .Nearly half  had a documented decrease in PS at 24 h after the SSB intervention; the mean change in PS was −2.8, with a median change of −3 (n = 3) had a decreased PCA requirement at 24 h, and 17% (n = 2) had no change in the PCA requirement. Five days after the intervention, 17% (n = 2) had decreased PCA requirements, and another 17% had an increased or new PCA requirement  had PC involvement, with an average of 40 visits, not limited to the EOL period, throughout their care journey . Similarly, 93% (n = 25) of patients received care from a pain medicine specialist, with an average of 37 visits spanning the course of their clinical care . Of the patients who received a CNB catheter, 2 (7.4%) used their devices in the outpatient setting. The mean lifespan following regional pain control intervention was 34 days .Nearly all patients in this study  had POST orders completed before the DOD: 70% (n = 16) indicated limited additional interventions, and 22% (n = 5) specified comfort measures only (n = 16) died in a hospital setting although only 5 of the 11 patients who specified a preferred LOD chose a hospital setting. Of the patients who set a preferred LOD, 64% (n = 7) died at their preferred location  and two patients had platelet counts <50k. Four adverse events were reported in our patient cohort: ventricular tachycardia, bleeding, leaking of the catheter, and a temporary discontinuation of catheter infusion due to a surgical procedure. Of note, the reporting of potential complications spans the time period of date of regional pain intervention until the day of death, to ensure potential procedural complications were not inadvertently missed.This single-institution retrospective study reports on a decade of regional pain management interventions for pediatric oncology patients during the EoL period and represents the largest known cohort to date. Historically, regional pain management interventions have been underutilized during the EoL period because of concerns about procedural complications, such as infection and bleeding, patient distress/discomfort during the procedure, and the time requirements for patient assessment . LikewisDespite leukemias remaining the most prevalent pediatric cancer type , 81% of Case reports and case series in adults and pediatrics emphasize that CNB catheters can mitigate pain for patients with advanced cancer pain , 14, 26;Similar to CNB, little has been published about the role of SSBs as pain management for EoL care. One study reported SSB of the brachial plexus to be useful for adults , with paClinicians may avoid regional pain control interventions at the EoL for fear of procedural complications such as bleeding and infection or for worries that it may interfere with patient and family EoL preferences, such as dying at home , 31. FewFinally, the importance of collaboration between interdisciplinary teams to ensure the needs of the patient and family are being met is evident. Nearly all patients in this study received consultation from the PC and pain medicine specialists. This is significant because delayed PC involvement is linked to a greater chance of dying in the intensive care unit and more intensive interventions that may contribute to increased suffering during the EoL –37. EarlThe limitations of this study are those inherent to retrospective studies. First, this was a single-institution study with a relatively small cohort of eligible patients. To our knowledge, this is the largest sample size describing regional pain control interventions at the EoL in pediatric oncology. Additionally, retrospective data collection prohibits the procurement of dynamic information related to pain, so we ascertained pain intensity and relief through objective PS documentation and opioid dosing requirements. Given the overall sample size, intercomparison analyses between the types of blocks performed were not powered accordingly and thus not performed and reported. Lastly, our comparison of opioid doses before and after regional pain intervention excluded the use of sustained-release oral or transdermal opioids. We analyzed PCA-delivered opioids exclusively because it is the most “titratable” component of a pain management regimen and likely reflects the change in opioid need in our clinical practice; catheter placements were unaltered during the remaining pain treatments. One may also argue that the lack of evaluation of non-pharmacological interventions for pain and psychology support represents a limitation of this study. Indeed, in the difficult and complex context of EOL, this type of data may have been a valuable component to reflect the multidisciplinary approach to pain management in view of the bio-psycho-social model of pain.Our study highlights the analgesic efficacy and safety of regional interventions for relieving pain-related suffering in children dying with progressive cancer and suggests that interventional approaches remain underutilized in this clinical context. The coordinated efforts of the primary oncology service, pain and PC services, and home hospice agencies enabled the implementation of regional pain interventions and their continuation in the outpatient setting. This collaboration is important to help relieve suffering during EoL care and enable preferred location of death. Future prospective studies to investigate the analgesic efficacy and the safety of CNB and SSB in children at the end of life are necessary.