Brain corticostriatal circuits are important for understanding chronic pain and highly relevant to motivation and cognitive processes. It has been demonstrated that in patients with chronic back pain, altered nucleus accumbens (NAcc)—medial prefrontal cortex (MPFC) circuit fMRI-based activity is predictive of patient outcome. We evaluated the NAcc-MPFC circuit in patients with another chronic pain condition, fibromyalgia, to extend these important findings. First, we compared fMRI-based NAcc-MPFC resting-state functional connectivity in patients with fibromyalgia (N = 32) vs. healthy controls (N = 37). Compared to controls, the NAcc-MPFC circuit’s connectivity was significantly reduced in fibromyalgia. In addition, within the fibromyalgia group, NAcc-MPFC connectivity was significantly correlated with trait anxiety. Our expanded connectivity analysis of the NAcc to subcortical brain regions showed reduced connectivity of the right NAcc with mesolimbic circuit regions  in fibromyalgia. Lastly, in an exploratory analysis comparing our fibromyalgia and healthy control cohorts to a separate publicly available dataset from patients with chronic back pain, we identified reduced NAcc-MPFC connectivity across both the patient groups with unique alterations in NAcc-mesolimbic connectivity. Together, expanding upon prior observed alterations in brain corticostriatal circuits, our results provide novel evidence of altered corticostriatal and mesolimbic circuits in chronic pain. Such processes involve brain regions including the nucleus accumbens (NAcc), amygdala, hippocampus, thalamus, anterior cingulate cortex (ACC), and medial prefrontal cortex (MPFC)5. Connections between these regions form a complex cortico-basal ganglia network to support human behaviors and cognition5. Chronic pain is often comorbid with dysfunctional cognitive and motivation processes7, and the cortico-basal ganglia network plays an important role in chronic pain9.Motivation and cognitive processes are central to human survival10 to investigate circuits within the cortico-basal ganglia network11, with a specific focus on corticostriatal circuits13. Studies using such methods have shown that patients with chronic pain demonstrate evidence of dysfunctional corticostriatal  circuits13. For example, when patients with chronic back pain receive thermal stimulation and perform a coinciding self-report pain-monitoring task, compared to healthy controls, patients exhibit greater functional connectivity between the NAcc and MPFC regions12. As revealed in another study when patients with sub-acute back pain performed a continuous self-report pain-monitoring task during an otherwise resting-state fMRI scan, functional connectivity between the NAcc and MPFC predicts pain chronification. 13. However, no studies have evaluated this specific NAcc-MPFC circuit in patients with back pain (or other types of chronic pain) during resting-state fMRI with no task involved.Prior functional magnetic resonance imaging (fMRI) studies have used a measure of functional connectivity 14. Compared to healthy controls, patients with fibromyalgia demonstrate greater MPFC activity during avoidance of punishment, and reduced MPFC activity during anticipation of reward16. Similarly, patients with fibromyalgia demonstrate reduced midbrain activity both during anticipation of pain  and pain relief 17. Likewise, in patients with chronic pain , the right striatum shows reduced response during anticipation of reward and loss18. Thus, based on these multiple lines of evidence of altered activity within corticostriatal brain regions, it follows that corticostriatal circuits, specifically of the NAcc-MPFC, would be altered in patients with fibromyalgia, as similar to patients with chronic back pain.In addition to such findings in patients with back pain, corticostriatal activity is similarly altered in other chronic pain conditions, including fibromyalgia. Fibromyalgia is a condition of widespread chronic pain, that is typically accompanied by cognitive-, mood-, and fatigue-related symptomshttps://osf.io/cj9u8), we hypothesized that resting-state corticostriatal circuits  are altered in patients with fibromyalgia. Therefore, to test our hypothesis, we first examined corticostriatal connectivity strength of the NAcc-MPFC circuit in patients with fibromyalgia compared to healthy controls. Additionally, in our fibromyalgia cohort, we probed relationships between NAcc-MPFC connectivity and clinical measures of mood, affect, and symptom severity. Then, we conducted an expanded analysis of NAcc resting-state functional connectivity to mesolimbic  circuit regions in fibromyalgia. In addition, as an exploratory analysis, we compared our findings  with another chronic pain condition, chronic back pain (CBP), using publicly available dataset (openpain.org).To extend prior evidence of altered corticostriatal circuits to new cohorts of chronic pain patients, in the present study, we aimed to evaluate the NAcc-MPFC circuit in patients with fibromyalgia and to further evaluate activity within subcortico-striatal networks. Importantly, we evaluated these circuits by analyzing resting-state fMRI with no task involved. As outlined in our pre-registered plan on the Open Science Framework  We provide the demographic data in Supplementary Table 16. However, we have not previously described the resting-state fMRI data from the Stanford and Duke data sets other than in the preprint. In an exploratory analysis, we included resting-state fMRI data from a cohort of 31 chronic back pain patients . From the chronic back pain data set (openpain.org), demographic and clinical data were only partially available at the time of analysis  and Duke University  by the same investigator at each site (K.T.M.).  = 3.34, p = 0.002), we also included age as covariate. For healthy controls, no significant age difference across the two sites was observed (p = 0.38). When combining the two datasets, no significant difference in age was observed between patients and controls (p = 0.09).Our a-priori hypothesis was that NAcc-MPFC resting-state functional connectivity would be altered in patients with fibromyalgia (as demonstrated in prior investigations of patients with chronic back pain). Therefore, we first aimed to identify group differences in NAcc-MPFC connectivity in patients with fibromyalgia compared to healthy controls Fig. A,B. SincIn both patients with fibromyalgia and healthy controls, robust NAcc-MPFC connectivity was demonstrated  = 5.1, p < 0.0001 and t(36) = 8.28, p < 0.0001, respectively). Further, when comparing across fibromyalgia and control groups, NAcc-MPFC connectivity was significantly lower in fibromyalgia (t(64) = − 2.91, p = 0.005; Fig.  = 5.1, p15. As both Martucci et al. and our present study have strong predetermined hypotheses , we followed this previous approach in creating the right NAcc ROI and bilateral MPFC VOI . To determine whether a slightly different ROI may lead to different patterns of results, we created two more bilateral MPFC VOIs  and the same VOIs used by Baliki et al.13  as an exploratory analysis  was observed, t(64) = − 1.76, p = 0.083.The right NAcc region of interest  and bilateral MPFC volume of interest  were predetermined based on the approach used in Martucci et al.https://osf.io/cj9u8), we re-tested the primary hypothesis  comparing connectivity with the bilateral MPFC in patient vs. healthy control groups. While no group difference was shown with the left NAcc-bilateral MPFC connectivity, as compared to controls, patients showed significantly reduced bilateral NAcc-bilateral MPFC connectivity (t(64) = − 2.41, p = 0.018).For exploratory analyses using the left NAcc and bilateral NAcc as alternative NAcc ROIs  BAS fun, BAS reward, BAS drive, and BIS (p ≤ 0.001), (2) STAI-trait, STAI-state, BDI, and POMS (p ≤ 0.036), (3) pain severity and pain interference (BPI) (p = 0.004), (4) PROMIS Fatigue and PAS subscale (p = 0.003), and (5) NAS subscale. Accordingly, the NAcc-MPFC connectivity vs. clinical measures correlational analyses were Bonferroni corrected for a total of 6 independent comparisons  and determined to be significant at the level of p < 0.008 (corrected threshold). Within the fibromyalgia patient cohort only, correlational analysis of connectivity vs. questionnaire measures showed a significant positive relationship between NAcc-MPFC connectivity and anxiety,  , three BAS subscales , behavioral inhibition , positive affect , negative affect , trait anxiety (STAI Trait), state anxiety (STAI State), total mood disturbance (POMS), depression (BDI), pain severity (BPI), and pain interference (BPI). As similarly performed in Martucci et al.22 . In this analysis, age and pain duration were included as covariates. Due to unstated information for the chronic back pain dataset regarding the number of study sites involved, study site was not included as covariate. As revealed by one-way analysis of covariance (ANCOVA), a NAcc-MPFC connectivity across three groups was significantly different, . Further, as revealed by post-hoc t-test, NAcc-MPFC connectivity in patients with chronic back pain and fibromyalgia was significantly decreased as compared to controls (chronic back pain > controls: t(95) = − 2.16, p = 0.032; fibromyalgia > controls: t(95) = − 2.95, p = 0.004)  during resting-state may influence corticostriatal connectivity in chronic pain.We conducted an additional analysis to compare our NAcc-MPFC connectivity results from patients with fibromyalgia and healthy controls to a separate dataset from a cohort of patients with chronic back pain . Of note, these patients with chronic back pain underwent similar resting-state fMRI procedures, which did not involve any task during the scanhttps://osf.io/cj9u8, we measured resting-state functional connectivity between the right NAcc and several regions within the expanded mesolimbic circuit  = − 2.4, p-uncorrected = 0.019, p-FDR corrected = 0.104), left thalamus (t(64) = − 2.28, p-uncorrected = 0.026, p-FDR corrected = 0.104), and left ventral pallidum (t63) = − 2.8, p-uncorrected = 0.006, p-FDR corrected = 0.081)  Additionally, differences in clinical status may have contributed to study differences . More importantly, however, while administration of noxious thermal stimuli or a self-report pain-rating task were used during fMRI scans in previous functional connectivity analyses13, no task and/or stimulation experience was involved during the acquisition of resting-state fMRI data in our fibromyalgia cohort nor (to the best of our knowledge) in the publicly available chronic back pain cohort dataset. As methodologic differences may impact our comparative results, pain stimulation and/or monitoring may drive increased NAcc-MPFC functional connectivity in chronic pain conditions vs. healthy controls12. Consistent with this observation, in another study which demonstrated greater NAcc-MPFC functional connectivity in patients with sub-acute back pain (SBP) whose pain persisted vs. patients with SBP who recovered13, a self-report pain-monitoring task was involved. In line with these methodologic differences which parallel differences in results, it is reasonable to suspect that concurrent cognitive evaluation/experience with ongoing chronic pain may influence NAcc-MPFC functional connectivity. Specifically, NAcc-MPFC connectivity appears to be reduced in chronic pain states during task-free resting state, but is heightened in chronic pain conditions during self-monitoring and pain tasks13. Indeed, several research studies have identified intrinsic differences between task-based and resting-state fMRI when characterizing and differentiating brain signals and networks30. Our present results underscore that these nuanced differences  are essential to consider in future evaluations of brain circuit connectivity in chronic pain.Notably, in contrast to previous findings34. Previous functional connectivity studies have revealed a critical role for thalamic projections in shaping and supporting motivational and reward processing within the NAcc among both healthy adults and adolescents35. Reduced connectivity between the putamen and NAcc has been demonstrated in patients with anorexia nervosa36, a condition highly related to brain subcortical system alterations39. Furthermore, patients with chronic back pain  demonstrated reduced connectivity between the NAcc and the right caudate  in patients with major depressive disorder while performing a reward task42. Similar to these prior studies in other healthy and clinical populations, our findings of reduced connectivity within mesolimbic circuits lend further support to the clinical relevance of subcortical system alterations among patients with fibromyalgia as well as patients with chronic back pain. Indeed, as changes in connectivity predict and track with treatment response44, alterations in corticostriatal and subcortical-striatal circuits in chronic pain may provide crucial information for development and tracking of effective clinical treatments.Within the broader mesolimbic system, analysis of NAcc-subcortical circuits revealed novel significant differences in both groups of patients with fibromyalgia and patients with chronic back pain. Specifically, patients with fibromyalgia demonstrated significantly reduced connectivity between the NAcc and the left ventral pallidum, left putamen, and left thalamus. All of these brain regions play essential roles in motivational/reward processing47. To our knowledge, no prior studies have specifically examined potential relationships between NAcc-MPFC connectivity and various clinical, affective, and cognitive measures in fibromyalgia. As shown in our exploratory correlational analysis within the fibromyalgia group, NAcc-MPFC connectivity was positively correlated with anxiety (STAI-Trait measure). At first glance, the positive correlation is counterintuitive. However, as the overall functional relationship between NAcc and MPFC is reduced in chronic pain, anxiety may be enhancing NAcc-MPFC connectivity in fibromyalgia by engaging MPFC processes of cognition and attention49. Indeed, the MPFC projects to NAcc and modulates its activity51—thus, increased NAcc-MPFC connectivity may coincide with enhanced corticostriatal modulation in patients with higher anxiety. In general, striatal dysfunction is related to cognitive deficits and emotional disorders56. For example, as compared to controls, adolescents with anxiety show hypersensitive striatal response to high-value rewards and greater striatal activity to low-value rewards when unexpected52. Complementing such a relationship between dysregulated striatal response and anxiety, our data suggest a relationship between a corticostriatal circuit and anxiety regulation in chronic pain.As demonstrated in several previous studies in patients with fibromyalgia, relationships exist between altered resting-state fMRI activity and clinical status/affective measures57. Future studies examining the extent to which altered corticostriatal resting-state functional connectivity predicts sex-specific altered striatal activity during reward processing may provide critical scaffolding for more carefully tailored chronic pain treatments. In addition, effects of medications need to be considered. Indeed, chronic pain patients on long-term opioid therapy demonstrate disrupted functional connectivity between spinal cord dorsal horns58 and within corticostriatal circuits59. Notably, the patients included in the present study were opioid naïve , however, other medications may similarly contribute to individual changes in corticostriatal and/or subcortical-striatal circuits60. Finally, through future investigation of how altered striatal circuits influence and interact with other central nervous system (CNS) circuits such as those supporting attention61 and expectation63, the broadening field of functional connectivity may help to clarify the complex neurobiology of chronic pain and thereby potentially aid clinical treatment.As our analyses of NAcc connectivity to other regions within mesolimbic circuits were exploratory, our findings were limited in that they were not corrected for multiple comparisons, and as such should be evaluated prospectively in future investigations. By examining altered connectivity between all 13 regions ), and at Duke University . Of these study participants, 1 patient with fibromyalgia was excluded due to a registration issue . In addition, 1 patient with fibromyalgia and 2 healthy controls were excluded due to excessive motion. Thus, a total of 32 patients with fibromyalgia and 37 healthy controls were included in the present study. An additional set of data from a cohort of patients with chronic back pain was acquired from the Open Pain repository (openpain.org). The Open Pain dataset (when accessed in March 2021) contained 34 patients with chronic back pain; data from 3 patients was excluded after preprocessing because their scans could not be aligned .64. Other patient inclusion criteria were: pain in all 4 quadrants of the body, an average pain score of at least 2  over the previous month, and no uncontrolled anxiety or depression. Because opioids can have dramatic and long-lasting effects on brain neurophysiology66, all patients with fibromyalgia were relatively opioid naïve, in that they had not taken any opioid medications within 90 days prior to study participation, and their opioid usage was less than 1 month within their lifetime. Healthy controls reported no history of chronic pain, took no pain medications at the time of the study visit, and did not have depression, anxiety, or major ongoing health conditions.All patients with fibromyalgia were required to meet the modified American College of Rheumatology 2011 criteria for fibromyalgia: (1) a widespread pain index (WPI) score ≥ 7+ a symptom severity (SS) score ≥ 5, or WPI score 3–6+ SS score ≥ 9; (2) comparable symptoms present for at least 3 months; and (3) no diagnosis that would otherwise explain the painTen patients reported taking no mood-altering or pain medications. The 22 remaining patients reported taking nonsteroidal anti-inflammatory drugs , gamma-aminobutyric acid (GABA) analogs , serotonin-norepinephrine reuptake inhibitors , tricyclic antidepressants , selective serotonin reuptake inhibitors , low-dose naltrexone , anticonvulsant drugs (N = 2), muscle relaxants (N = 4), other anxiolytics , medical cannabis (N = 1), triptans , other serotonin reuptake inhibitors , benzodiazepine , and using topical lidocaine patches (N = 1). We retained data from the participant taking medical cannabis in our final analysis as excluding this data did not significantly change the group results.Thirty-four healthy controls were taking no mood-altering or pain medications. One healthy control participant took gabapentin (100 mg/day) and fluoxetine (40 mg/day) to treat premenstrual symptoms (2 days/month). Another healthy participant took celecoxib (200 mg) 3 weeks prior to study participation due to an ankle injury, and one control took escitalopram (5 mg). We retained data from these 3 participants in our final analysis as excluding them did not significantly affect group results. All participants were required to have no MRI contraindications and not be pregnant or nursing. All study procedures were approved by the Stanford University and Duke University Institutional Review Boards for data collection and analysis, and were performed in accordance with all relevant guidelines and regulations with informed consent obtained from all participants.https://osf.io/cj9u8). Figure 13, which described functional connectivity (NAcc-MPFC) between patients with and without persistent pain, served as the input for our power analysis calculations. Results showed that we were well powered to detect group differences such that 17 participants per group would provide ≥ 80% power at alpha = 0.005 to detect a difference in mean connectivity of 0.05 between 2 groups of interest, and we have more than 30 participants in each group.Before our analyses, we performed a power analysis for our main study hypothesis to determine the sample size required to detect differences in NAcc-MPFC connectivity between patients with fibromyalgia and healthy controls 68, Behavioral Inhibition System/Behavioral Approach System Scales (BIS/BAS)69, Profile of Mood States (POMS)70, Positive and Negative Affect Schedule (PANAS)71, Brief Pain Inventory-Short Form (BPI)72, and PROMIS Fatigue 73. After completing the questionnaires, MRI scans were conducted. Additional questionnaires and brain scans74 were collected but were not included in the analyses for this study.Data collection was obtained from patients with fibromyalgia and healthy controls following informed consent at the Richard M. Lucas Center for Imaging at Stanford University and at the Duke-UNC Brain Imaging and Analysis Center (BIAC). As part of the study, patients with fibromyalgia and healthy controls completed clinical questionnaires including the Beck Depression Inventory (BDI)75, and acquisition of medial prefrontal and orbitofrontal cortices was improved. The resting-state scan consisted of 360 volumes.Neuroimaging data were acquired on a 3 T General Electric scanner using an 8-channel head coil . One T1 anatomic scan (3D FSPGR [fast spoiled gradient-echo] Irprep BRAVO) was performed for anatomic information. The image covered the whole brain, which included the brainstem and cerebellum, and parameters were as follows: 1-mm slice thickness, 22-mm frequency field of view (FOV), frequency direction anterior/posterior, number of excitations (NEX) 2, flip angle 11°, TR 6.8, TE 2.6, frequency 256, phase 256, and bandwidth 50.00. Functional scans consisted of a Gradient Echo Pulse Sequence using spiral in–out acquisition with 32 oblique slices acquired in a sequential descending slice order. The in-plane resolution was 2.0 mm × 2.0 mm, and slice thickness was 4.0 mm with 0.5-mm slice spacing . By using the spiral in–out scan sequence, orbitofrontal signal drop-out was reduced74, T1 anatomical scan, and a resting-state scan. The fMRI scan parameters were as follows: Gradient Echo Pulse Sequence, echo time (TE) 25 ms, repetition time (TR) 2 s, interleaved slice order, 46 slices, flip angle 77°, 2.9 mm slice thickness, pixel size 2.9 mm. Unlike data collected at Stanford University, a spiral in–out scan sequence was not used in this dataset. A T1 anatomical scan (MPRAGE sequence) was acquired with parameters as follows: whole-brain coverage including the brainstem and cerebellum, 1 mm slice thickness, TR 2.2 s, TE 3.2 ms, 256 mm frequency field of view (FOV), frequency direction anterior/posterior, flip angle 8°. The resting-state scan consisted of 360 volumes.Scans were conducted on a 3 T GE Premier UHP system with a 48-channel coil at the Duke-UNC Brain Imaging and Analysis Center. The scan sessions consisted of the initial preparatory localizer, asset calibration scans, task fMRI scans76 running in MATLAB v. R2020a and SPM12. Functional data underwent realignment, and no slice-timing correction was applied, as data from different sites have different slice order information. Outliers were identified based on the observed global blood oxygenation level-dependent (BOLD) fMRI signal and the amount of subject motion. The intermediate outlier identification setting in the CONN toolbox was used to identify framewise displacement . T1-weighted structural images and functional images were segmented into grey matter (GM), white matter (WM), and cerebrospinal fluid (CSF) tissue classes, and normalized to Montreal Neurologic Institute (MNI) space. Lastly, functional data were smoothed using spatial convolution with a Gaussian kernel of 4 mm full width half maximum.All resting-state fMRI data were preprocessed using the default preprocessing pipeline in the CONN Toolbox v.20b76. This step included an anatomic component-based noise correction procedure, corrections for potential confounding effects of WM and CSF, estimated subject-motion parameters, identified outlier scans or scrubbing, and bandpass filtering to 0.008–0.09 Hz. The number of outlier volumes detected ranged from 0 to 18.89% of the total volumes per participant. Rates were comparable to other published analyses77.We then followed CONN’s default denoising pipelinehttp://www.openpain.org; all participants in this dataset consented to participate in the study approved by the Institutional Review Board at Northwestern University.)We analyzed fMRI scan data from the “cbp_resting” project provided by the Open Pain Project (OPP) database  and 305 volumes (14 patients), and study site(s) information was not reported for the dataset. The number of outlier volumes detected ranged from 0.1 to 14% of the total volumes per participant.The same right NAcc ROI and bilateral MPFC VOI described above were used for NAcc-MPFC connectivity analysis of this comparison dataset. Data were preprocessed using the default preprocessing pipeline in the CONN Toolbox v.20b13, 2 seed regions were defined: the right NAcc and the bilateral MPFC. The right NAcc region of interest  was created from the Desai Atlas included in Analysis of Functional NeuroImages (AFNI)15. The size of the bilateral MPFC volume of interest  was fixed at 10-mm diameter spheres centered at  , affect (PANAS), and fatigue (PROMIS Fatigue). For the correlation analysis, the NAcc-MPFC connectivity data were Fisher-transformed correlation coefficient values from the first-level analysis . We also performed, additional exploratory correlational analyses between NAcc-MPFC connectivity and depression (BDI), anxiety (State-Trait Anxiety), reward-related behavioral inhibition/activation , and total mood disturbance (POMS).For determining group differences in our primary endpoint of NAcc-MPFC connectivity, we used an unpaired two-sample t-test of correlation coefficients, thresholded for significance at p < 0.05. For the correlational analyses, Bonferroni correction . The chronic back pain cohort underwent similar resting-state fMRI, which did not involve any task during the scan. For the analysis across the 3 groups, as in our primary analysis, the same 2 seed regions were used and analysis was conducted using the CONN toolbox Fig. A. Again,78. The coordinates were determined based on previous findings of activation likelihood estimation and parametric voxel-based meta-analysis23 , insula, thalamus, and ventral pallidumIn a separate analysis using CONN Toolbox, we evaluated connectivity of the right NAcc with the 12 mesolimbic circuit regions across (1) fibromyalgia vs. chronic back pain, and (2) healthy control vs. chronic back pain (Supplementary Fig. Supplementary Information.


Various maneuvers have been introduced to address anterior shoulder dislocations. Chair method allows the patient to sit comfortably and feel less pain during the reduction procedure. However, the rarity of comparative studies led to a lack of evidence to popularize. The present study aimed to introduce a modified chair (MOC) reduction method for anterior shoulder dislocation and explore its effectiveness compared with the traditional Hippocratic approach.This is a single-center retrospective study of 257 patients with anterior shoulder dislocation from September 2020 and July 2021. Patients were divided into two groups according to the reduction method they received (either the Hippocratic method or the MOC method). Success rate, reduction time, visual analog scale (VAS) pain score, satisfaction level, and a new indicator, pain index (reduction time (s)* VAS/ 10), were compared.p = 0.002). Pain index of the patients in the MOC group was much lower than that in the Hippocratic group  vs. 36.70 , p <  0.001). The reduction time, VAS pain score, and satisfaction level also favored the MOC method.One hundred sixteen patients  underwent the Hippocratic method, and 141  MOC method. A significantly higher success rate was seen in the MOC group (96.5%(136/141) vs. 84.5%(98/116) in the Hippocratic group; OR 5, 95%CI 1.79 ~ 13.91; The MOC method is an easy and efficient reduction method with minimum assistance for anterior shoulder dislocations. Physicians can skillfully perform this procedure with the help of their body weight. The MOC method could be attempted for shoulder dislocations in the emergency department. Acute shoulder dislocation is a widespread problem encountered in the Emergency Department (ED) . There aWhite  first inThe present study aimed to introduce a modified chair (MOC) reduction method for anterior shoulder dislocation and explore its effectiveness compared with the traditional Hippocratic way.Between September 2020 and July 2021, this retrospective study enrolled 302 patients aged 14 years or over and presented with anterior shoulder dislocation in the emergency department in a level-1 trauma center. Patients who were treated with either the Hippocratic method or MOC method were included. The exclusion criteria included multiple trauma, noncooperation (as it may complicate the procedure), and concomitant glenoid fracture or surgical neck fracture of the proximal humerus. Patients who asked for anesthesia or oral analgesics prior to the reduction maneuver were also excluded. All patients gave written informed consent before reduction, and the Institutional Review Board approved the study of the Beijing Jishuitan Hospital .Anteroposterior (AP) and lateral radiographs were obtained from all patients before and after the reduction to confirm the diagnosis, and neurovascular status was reassessed. Computed Tomography (CT) was also obtained if necessary to exclude occult surgical neck fracture. Reduction procedures were performed by six junior residents who were in their second or third year in orthopedic surgery. Three junior residents were trained for MOC methods, while three were for the Hippocratic method. Patients were divided into two groups according to the reduction method (Hippocratic or MOC group).MOC method is performed with the patient sitting in a chair sideways. The patient is guided to abduct the upper arm slightly and then use the chair’s backrest as a fulcrum in the axilla. In order to maximize the comfort level and minimize the risks of nerve injury, a pillow or cushion or folded clothing is used as a pad on the backrest Fig. A. With tThe Hippocratic method was conducted as in other literature described before , 14. CouIn patients who failed two attempts with the same reduction maneuver, we recorded it as failures and employed other reduction methods or further anesthesia like sedation and nerve block to accomplish the reduction procedure. All patients were immobilized in internal rotation with a shoulder/arm sling for 4 weeks. After 4 weeks, the patients underwent rehabilitation.Data regarding demographic information, injury mechanism, the time interval between injury and presentation, history of the previous dislocation, neurovascular assessment, the presence of a greater tubercle fracture, reduction method, reduction time, success or not, complications, visual analog scale (VAS) and satisfaction level were recorded and collected for all patients. In our study, we introduced a variate called pain index, taking both reduction time and pain score into account to judge the efficiency of a reduction maneuver (pain index = reduction time (s)* VAS/ 10), and the higher the pain index, the worse the outcome).The success rate and pain index were regarded as the primary outcome. The duration of reduction was accepted as the time between the patient being placed in the reduction position and the completion of reduction. The time was recorded with a stopwatch. VAS from 0 (no pain) to 10 (intolerable pain) was used to rate the amount of pain felt during the process. Satisfaction level was documented as very dissatisfied, dissatisfied, general, satisfied, and very satisfied. The same orthopedic surgeon who had performed the reduction asked and assessed the patients VAS pain scores and satisfaction level.http://www.R-project.org, The R Foundation) and Free Statistics software version 1.4. A two-tailed test was performed, and p <  0.05 was considered statistically significant.Missing data in the time interval between injury and reduction (33(13%) were randomly missing, 8(7%) and 25(18%) in the Hippocratic group and MOC group, respectively) were filled with the median. Data are presented as means and standard deviations for parametric data or as medians and interquartile ranges when the data are not normally distributed. Categorical variables are described using frequencies and numerical distributions. The Chi-squared test was used to assess the differences between the two groups for categorical variables and Student’s t-test or the Mann-Whitney U-test for continuous variables, as appropriate . With pain index as the outcome, stratified analysis was further conducted according to age grouping (above and below 60 years), sex, the time interval between injury and reduction (over and within 6 hours), recurrent dislocation, and fracture of the greater tubercle. The analyses were performed with the statistical software packages R  were ultimately compared. The flow is shown in Fig. p = 0.002) (Table p <  0.001) (Table p <  0.001) (Table A significantly higher success rate was seen in the MOC group (96.5%136/141) vs. 84.5%(98/116) in the Hippocratic group; OR 5, 95%CI 1.79 ~ 13.91; 6/141 vs.In this present retrospective study, a comparison between the MOC method and the Hippocratic method was conducted to assess its effectiveness and safety. The study results demonstrated that the MOC method had an advantage over Hippocratic in terms of all the outcome parameters, especially in the pain index, which combined the two biggest concerns of dislocated patients - time and the VAS pain score. In the MOC group, 105/141(74.5%) patients felt a pain level of less than 4, indicating the reason behind the phenomenon that 125/141(88.7%) patients felt more than satisfied.p < 0.001). Ten patients (7.1%) received reduction within 5 s. This is the shortest duration of reduction ever reported to the best of our knowledge. Mahiroğulları [The reduction time in the MOC group ranged from 3 s to 30s with a median of 12 s, which was significantly shorter than the Hippocratic group  were concluded and compared in a meta-analysis conducted by Dong et al. . HoweverMuscle contraction was often reported to cause difficulty, pain, and even iatrogenic fracture during reduction , 18. In The main limitation of the present study was its retrospective design. Lack of quality control, like data missing, was inevitable, resulting in selection bias. However, the missing data in our study were randomly distributed, and the sample size was large enough to reflect the differences. Another limitation is that some of the patients came to our hospital after several failed attempts in other hospitals. This kind of data was not documented and collected due to its retrospective nature as well. In addition, the pain index introduced in our study was an attempt to reflect both aspects of reduction time and pain level, and to some degree, it may overstate the differences between the two methods. Future studies could further explore the value of such an indicator. Last, we only compared the MOC method with the Hippocratic method because these two were the main reduction methods conducted in our ED. Further well-designed prospective trials are needed to compare MOC with other methods. Further well-designed prospective trials are required to compare MOC with other methods to better evaluate its effectiveness.In conclusion, the MOC method is an easy and efficient reduction method with minimum assistance for anterior shoulder dislocations. Physicians can skillfully perform this procedure with the help of their body weight. The MOC method could be attempted for shoulder dislocations in the emergency department.


PPT changes significantly differed between primary headache and post-traumatic headache (PTH) (p = 0.019–0.026). Change in headache frequency was significantly higher in patients with than without neck pain (p = 0.032). A total of 60% of patients with neck pain responded to rNMS (≥25%), while 20% of patients without neck pain responded (p = 0.048). 60% of patients receiving rNMS twice a week were responders, while 33% of patients receiving rNMS less or more frequently responded to treatment, respectively. Alleviation of muscular hyperalgesia was demonstrated sustaining for 3 months, which was emphasized in PTH. The rNMS sessions may positively modulate headache symptoms regardless of headache diagnosis. Patients with neck pain profit explicitly well. Two rNMS sessions per week led to the highest reduction in headache frequency.Repetitive neuromuscular magnetic stimulation (rNMS) for pediatric headache disorders is feasible, safe, and alleviates headache symptoms. This study assesses muscular effects and factors affecting response to rNMS. A retrospective chart review included children with headaches receiving six rNMS sessions targeting the upper trapezius muscles. Pressure pain thresholds (PPT) were measured before and after rNMS, and at 3-month follow-up (FU). Mean headache frequency, duration, and intensity within the last 3 months were documented. In 20 patients (14.1 ± 2.7 years), PPT significantly increased from pre- to post-treatment ( Primary headache disorders like migraine and tension-type headache (TTH) are highly prevalent in kids and adolescents, and they represented the second most disabling conditions in 10- to 24-year-old individuals in 2019 ,4. HowevIn the pathophysiology of these headache disorders, the trigemino-cervical complex (TCC) plays an important role ,16. UppeWithin this concept, muscular involvement accompanying headache disorders comprises reports of neck pain or tension as well as findings during manual palpation of the short neck and upper trapezius muscles (UTM) ,22,23,24A multimodal therapeutic strategy approaching the burdensome migraine, TTH, and PTH in children, calls for non-invasive, non-pharmacological, safe, and well-accepted treatments . NeurostThe aims of this retrospective analysis were (1) to assess the local effects on the  muscular level of this rNMS treatment, and (2) to investigate whether the specific headache disorder (primary headache or PTH), the presence of neck pain, and the time frame rNMS is delivered in, may affect the response with regard to muscular and headache symptoms.The study was approved by the institutional review board of the medical faculty of the University of Munich .During chart review, 23 patients were identified, who had a diagnosis of (1) episodic migraine, (2) episodic TTH, (3) mixed-type headache , or (4) All patients received rNMS delivered by an eMFieldPro system . Stimulation was targeted to the UTM bilaterally in 6 consecutive sessions during two to three weeks. Each side was stimulated for 15 min consisting of 7420 pulses  with a duration of 250 μs by a coil creating a magnetic field of 2.5 T maximum (7.6 cm diameter of the copper winding). The starting side was alternated in each session and the stimulation intensity was individually set to a comfortable level. Detailed descriptions of the rNMS setup and stimulation protocol have been recently published .Before and after each rNMS session, mechanical algometry was performed using a hand-held analogous algometer  to determine the patient’s pressure pain thresholds (PPT) above the UTM. The PPT is defined as the cut-off weight between the perception of pressure and the perception of pressure-induced pain ,48. PatiHeadache frequency, headache intensity (minimum and maximum), and headache duration regarding the headaches in the last 3 months were documented before treatment and at FU. Patients were classified according to responder rates  based on their relative reduction in headache frequency. While headache changes in the total sample have been previously analyzed , this ma2. If no pain was indicated when that pressure was reached, 10 kg/cm2 was defined as the PPT [Paper-based clinical report forms and customized questionnaires were used to document rNMS interventions and FU examinations. Data were anonymized, entered into Microsoft Excel data sheets , and plausibility of data was checked by at least two independent analysts. The algometer’s maximum pressure was 10 kg/cm the PPT . HeadachMicrosoft Excel  and SPSS  were used for statistics. The level of statistical significance was set at α = 0.05. Shapiro–Wilk tests checked for normality of the headache variables and PPT measurements. The Pearson correlation between the time from treatment to FU examinations and the PPT at FU examinations above each reference point were calculated. Since no correlations were observed , time from treatment to FU examinations was not considered as a covariate for the following analyses.Differences in the PPT between pre-, post-, and FU assessments in the total sample were assessed with a repeated-measures analysis of variance (ANOVA). The homogeneity of variances at different time points was assessed by Mauchly’s test and was given for all analyses. Bonferroni corrections were used for adjustment for multiple comparisons. Effect sizes were calculated using eta squared.t-tests and Mann–Whitney U tests. Differences in the relative change in headache characteristics and PPT from baseline to FU examinations between the treatment time frame groups were assessed using one-way ANOVA. Pearson correlations between the time since headache onset or trauma and the relative change in headache frequency were calculated for the headache diagnosis, neck pain, and treatment time frame comparisons. Sample sizes for the comparisons are listed in In addition, the following subgroup analyses were performed: (1) primary headache group vs. PTH group, (2) neck pain group vs. no neck pain group, and (3) different treatment time frame groups . Comparisons of the PPT above each reference point between the groups were calculated with two-way repeated measures ANOVA with time as within-factor and group as between-factor. Bonferroni (within) and Tukey (between) corrections were used for adjustment for multiple comparisons. Differences in the relative change of headache characteristics and the PPT from baseline to FU examinations between the headache diagnosis groups as well as the neck pain groups were assessed using two-samples A total of 23 patients completed the rNMS intervention, of whom 5 patients received a second block of rNMS on average 104.2 ± 32.8 days (range: 73–167 days) after the first intervention, resulting in 28 rNMS interventions in total. Two patients were lost to FU and one patient was identified as an outlier based on a late FU as the FU time (210 days after intervention) lied more than 3 standard deviations above the mean FU time of the sample (91.7 ± 26.7 days). Therefore, data from 20 patients receiving 25 rNMS interventions were analyzed. Since three patients received FU examination via telephone calls, data from 17 patients receiving 22 rNMS interventions were included in the PPT analysis. Details on the sample sizes for analysis are given in Patients were on average 14.1 ± 2.7 years old, and 12 patients were females (60%). Diagnoses included migraine without aura and TTH , migraine with aura , migraine without aura , migraine with aura and TTH , and PTH . Acute medication was used by patients in 12 cases (48%) and a pharmacoprophylaxis with magnesium in 11 (44%). In the 3 months before the intervention, physiotherapy was obtained in 12 cases (48%), and was continued during the intervention in 5 (20%). During the 3 months after the intervention, in 4 cases (16%) physiotherapy was continued, and in 5 cases (20%) started. Neck pain as a general complaint besides headaches was indicated 15 times (60%) at the beginning of a rNMS treatment block. For the left UTM, mean stimulation intensity was 25.0% ± 11.6 of the maximum stimulator output and for the right UTM 25.8% ± 11.3 of stimulator output. A detailed description of the study population can be found in Staisch et al. (2022) .p < 0.001, η2 = 0.318; left medial: p < 0.001, η2 = 0.351; right medial: p < 0.001, η2 = 0.363; right lateral: p < 0.001, η2 = 0.311). PPT were increasing from pre- to post-treatment assessments and did not significantly change from post-treatment to FU examinations . Regarding the comparison of different treatment time frames, PPT changes over time did not significantly differ between the three groups .Comparisons of the PPT above each reference point resulted in significant differences for all reference points over time  and duration (p = 0.511) did not significantly differ between these groups. No significant differences were observed for the changes in headache characteristics in the headache diagnosis  and treatment time frame comparisons .When comparing patients with and without neck pain at baseline, the change in headache frequency was significantly higher in the neck pain group . In addition, 60% of patients receiving rNMS twice a week were responders (≥25%), while 33% of patients receiving rNMS less or more than twice a week responded to treatment (≥25%), respectively.Regarding the responder rate classification , 43% of patients with primary headaches were responders (≥25%) with 14% being classified as 75% responders . In the p = 0.857), nor in headache frequency in the PTH group  ,57,58, tIn comparison to the above-mentioned techniques that stimulate cranial nerves directly, rNMS is not only safe but also well accepted among patients, which is an important factor especially in the pediatric field ,41. The Some limitations apply to the current study. First, it reports data collected during everyday routines within our clinical setting. Patients could have received other therapies like physiotherapy or psychological interventions in parallel to the rNMS intervention within the multimodal treatment regimen. As the setting/placebo effects might be increased in the pediatric field and for medical device treatments, this may have influenced the effects as well ,66. ThusReduced muscular hyperalgesia after rNMS was demonstrated in pediatric patients with headache disorders, which was sustained up to weeks to months. This effect was particularly emphasized in patients with PTH. In addition, rNMS seems to positively modulate headache symptoms regardless of the specific headache diagnosis. Patients with neck pain profit explicitly well from the intervention. Regarding treatment time frame, two rNMS sessions per week led to the highest reduction in headache frequency. Given the framework of the trigemino-cervical complex, rNMS targeting the UTM most likely acts via neuromodulation of nociceptive processing at the central level.


Background and Objectives: Pain during and after the procedure remains the leading concern among women undergoing cesarean section. Numerous studies have concluded that the type of anesthesia used during a cesarean section undoubtedly affects the intensity and experience of pain after the operation. Materials and Methods: This prospective cohort study was conducted at the Clinic for Gynecology and Obstetrics, Clinical Center “Dragisa Misovic—Dedinje”, Belgrade, Serbia. Patients at term pregnancy (37–42 weeks of gestation) with an ASA I score who delivered under general (GEA) or regional anesthesia (RA) by cesarean section were included in the study. Following the procedure, we assessed pain using the Serbian McGill questionnaire (SF–MPQ), Visual Analogue Scale (VAS) and the pain attributes questionnaire at pre-established time intervals of 2, 12, and 24 h after the procedure. Additionally, time to patient’s functional recovery was noted. We also recorded the time to the first independent mobilization, first oral intake, and lactation establishment. Results: GEA was performed for 284 deliveries while RA was performed for 249. GEA had significantly higher postoperative sensory and affective pain levels within intervals of 2, 12, and 24 h after cesarean section. GEA had significantly higher postoperative VAS pain levels. On pain attribute scale intensity, GEA had significantly higher postoperative pain levels within all intervals. Patients who received RA had a shorter time to first oral food intake, first independent mobilization, and faster lactation onset in contrast to GEA. Conclusions: The application of RA presented superior postoperative pain relief, resulting in earlier mobilization, shorter time to first oral food intake, and faster lactation onset in contrast to GEA. Despite the effort and recommendations, almost one in five children are born in an operating room . Pain duAcute pain after a cesarean section leads to a delayed recovery of patients, as well as a longer hospital stay . In addiNumerous studies have concluded that the type of anesthesia during a cesarean section undoubtedly affects the intensity and experience of pain after the operation . AnestheThis prospective cohort study was conducted at the Clinic for Gynecology and Obstetrics, Clinical Center “Dragisa Misovic-Dedinje”, Belgrade, Serbia. Institutional Review Board (IRB) of Medical Faculty, University of Belgrade (29/IX-9) and IRB of Clinical Center “Dragisa Misovic-Dedinje” (01-8127/16) approved the study. Every patient gave informed consent before the surgery. Patients at term pregnancy (37–42 weeks of gestation), with ASA II score , who delivered by cesarean section, were included in the study. Type of anesthesia used for cesarean section was determined either based on anesthesiologist’s judgment or patient’s preference. Both scheduled and emergent cesarean sections were included in the study. If patients did not receive standard anesthetic protocol, had some form of complicated pregnancy, were transferred to the intensive care unit, were diagnosed with chorioamnionitis , or did not provide the written consent, they were excluded.The anesthesiologist monitored non-invasive blood pressure, electrocardiogram, and pulse oximetry for all patients during the procedure. Before the induction of anesthesia, every patient received Ringer lactate solution (500 mL).GEA protocol: After the adequate preoperative preparation for the cesarean section, and before the induction in GEA, patients were adequately positioned to avoid aortocaval compression and its effect on hemodynamics. We placed a high-flow peripheral line and, in case of potential massive bleeding, several venous lines. Non-invasive basic monitoring included blood pressure measurement, ECG monitoring, pulse oximetry, and capnography. We performed preoxygenation to increase the oxygen reserve in the lungs during apnea . After preoxygenation, we started administering the induction drug propofol in a dose of 2.3 mg/kg intravenously. As a muscle relaxant for induction, we used succinylcholine (a depolarizing muscle relaxant for rapid induction in a dose of 1.5 mg/kg). Laryngoscopy was performed using direct laryngoscopes or video laryngoscopes. Smaller diameter tubes with inner diameter of 6–7 mm were placed. After induction and intubation, anesthesia was maintained with a mixture of inhalational anesthetic gases and oxygen. Nitric oxide, which serves to maintain GEA, was made up 50% of the pre-extraction mixture and 67% of mixture after the baby was extracted. In cases of emergencies and fetal endangerment, 100% oxygen mixed with sevoflurane was applied until the moment of extraction. Sevoflurane was applied in dose of 0.6 MAC-A so that it would have no effect on the relaxation of the uterus and the occurrence of atony. Fentanyl 3 µ/kg and rocuronium 0.5 mg/kg were applied after baby extraction and umbilical cord clamping for placenta extraction. After surgery, the neuromuscular block reversal was performed with a mixture of prostigmine and atropine. We did not use sugammadex in any patient. After careful planning and preparation, extubation was performed in a fully awake patient who responded to voice commands, maintained adequate blood oxygen saturation, and had satisfactory respiratory volume and protective reflexes. Postoperative monitoring was mandatory.Spinal anesthesia (SA) protocol: The spinal anesthetic (SA) was induced by hyperbaric bupivacaine 12 mg and fentanyl 0.01 mg. After the spinal injection, blood pressure was measured every minute for the first 10 min and then every 3 min until the end of the procedure. By protocol, any reduction in systolic pressure by at least 10% from preoperative pressure or below 100 mmHg would be treated with intravenous ephedrine (3–6 mg).Epidural anesthesia (EA) protocol: After the insertion of the epidural catheter and the application of the test dose, isobaric bupivacaine 0.5% (0.5 mg per 10 cm height) and fentanyl 0.05 mg were injected. Removal of the epidural catheter was performed 24 h after its placement. Epidural catheter was used only in patients where cesarean section was performed under EA and a combined SA-EA approach was not used.In the recovery room, the patients stayed for an hour after the cesarean section. A non-invasive blood pressure, heart rate, and pulse oximetry measurement was taken every 15 min for the first hour, and every 30 min for the second hour, within the postoperative observation area. Details regarding non-invasive measurements have been described in detail elsewhere [Postoperative pain therapy was managed by multimodal approach using intravenous analgesics . All patAfter the surgery, an independent anesthesiologist interviewed each patient at pre-established time intervals of 2, 12, and 24 h. Analgesics were always prescribed only after patients had assessed their pain. Following the study design, we assessed pain using the shortened version of the Serbian McGill questionnaire (SF–MPQ) . To compTime to patient functional recovery was noted, including time to the first independent mobilization, time to the first oral intake, and lactation establishment. Additionally, we recorded the personal demographic  and obstetric characteristics (parity and type of cesarean section) of every patient.p-value < 0.05 was considered to be statistically significant. Statistical analysis was performed using IBM SPSS statistical software .Descriptive statistics were presented as mean values with standard deviation (SD) for numerical variables, or as absolute numbers with percentages for categorical variables. Differences between the GEA and RA (SA + EA groups) were presented as difference means with 95% confidence intervals and compared by Student’s t and chi-square test, for numerical and categorical data, respectively. Postoperative changes in pain characteristics were determined by repeated measurements ANOVA. The internal consistency of the SF–MPQ was assessed for multiple item scales by using Cronbach’s alpha coefficient . In all tests, the The study included 533 women that delivered by cesarean section. GEA was performed for 284 deliveries while RA was performed for 249 (SA for 162 and EA for 87). The mean age in the GEA group was 32.4 ± 4.5, while in the RA group, the mean age was 31.7 ± 4.8. Patients who underwent cesarean section under GEA were in gestational age of 38.4 ± 1.23 compared with 38.5 ± 1.35 in patients from the RA group. A total of 62 patients (21.8%) from the GEA group went to primary or secondary school, while the same number from the RA group was 46 (18.5%). Cesarean section was classified as urgent in 56 patients (19.7%) from the GEA group compared with 57 (22.9%) in the RA group. Age, gestational age, education level, and type of cesarean section did not differ between the groups. More details regarding study population has been described in detail elsewhere .p < 0.001 for all respective intervals), with the GEA group having higher postoperative sensory and affective pain levels. Pain characteristics represented by the VAS scale showed significant differences regarding the type of anesthesia within all assessed intervals after cesarian section , with the GEA group having higher postoperative VAS pain levels. A Pearson correlation coefficient higher than 0.8 showed a strong correlation between the SF-MPQ questionnaire with VAS for all three measurements. Both groups differed on the pain attribute scale intensity, with the GEA group having higher postoperative pain levels within intervals of 2, 12, and 24 h after cesarean section (p < 0.001). Postoperative pain characteristics in relation to applied GEA and RA are shown in In the GEA group, 86.3% of women established lactation 36 to 48 h after cesarean section, in contrast to the RA group, where 56.2% and 28.9% of women established lactation after 18 and 24 h, respectively. In the GEA group, 95.8% of women had their first peroral intake 24–36 h after birth, in contrast to the RA group, where 86.7% of women had peroral intake after 18 h. Additionally, the application of GEA resulted in 85.9% of women taking their first independent mobilization 24–48 h postoperatively, in contrast to the group receiving RA, where 29.7% of women established their first independent mobilization after 12 h, and 50.6% of them after 18 h .In this study, we aimed to compare the effects of RA and GEA on postoperative analgesic requirements and pain relief in women delivering by cesarean section. GEA had higher postoperative pain levels on SF–MPQ, VAS, and the pain attribute scale. Additionally, RA was associated with faster first independent mobilization and faster establishment of lactation.Even though it is not considered a major procedure, the cesarean section is ranked ninth among 179 different procedures according to a recent study assessing postoperative pain intensity ,17. AnesKessous et al.  found thUsage of GEA for cesarean sections has significantly declined in recent years ,20,21. TTo promote early recovery and optimize the parturient’s ability to care for her newborn baby, high-quality pain relief is of great importance after a cesarean section procedure. Postpartum pain is composed of not only nociceptive and neuropathic pain, but also four other components: sensory, affective, cognitive, and behavioral. We primarily examined the sensory and affective dimensions of pain at predetermined intervals of 2, 12, and 24 h postoperatively, using the VAS and SF-MPQ. Both sensory and affective characteristics differences were present between the GEA and RA across all time intervals. Furthermore, pain characteristics based on VAS scales within the same intervals showed significant differences. Almost three decades ago, Wang et al.  concludeEven though different methods of analgesia are currently in use, pain relief and patient satisfaction are still inadequate in many cases ,32,33. BAnother controversial topic with unclear results concerns breastfeeding after cesarean delivery. In the early postpartum period, the time of lactation establishment is vital for both mother and newborn. A recent Swedish study marked cesarean delivery as one of the main factors for exclusive breastfeeding lasting less than two months after delivery . MoreoveA recent meta-analysis showed that early oral feeding after cesarean section is not associated with the risk of postoperative complications, while also supporting a return to normal bowel function. In this meta-analysis, oral intake was provided within 6–8 h after the procedure . The impOur study has some limitations. Firstly, the results of this study represent a single-center experience. Since the University of Belgrade consists of two University Clinics for Obstetrics and Gynecology, further research should include the participants from these two centers. Moreover, research should include smaller Serbian hospitals for more representable and applicable results. We think that the inclusion of both University Clinics and local obstetric departments would significantly affect the percentage of GEA usage, since SA or EA is not available in many smaller hospitals with obstetrical departments. Another limitation is the lack of exact diagnosis as an indication for emergency cesarean section. Inclusion of these indications would allow us to re-evaluate the decisions for urgent procedures, thus providing a better insight into possible unnecessary usage of GEA.To our knowledge, this is the first study of its kind in Serbia. Its results support the PROSPECT (systematic review utilizing procedure-specific postoperative pain management) recommendations for postoperative analgesia after cesarean section, which propose a multimodal pre-, intra- and postoperative analgesic strategy, while balancing the degree of pain after surgery and the invasiveness of the analgesic intervention . Given tDespite major efforts, post-cesarean pain remains the greatest concern among women undergoing cesarean delivery, closely followed by the adequate and immediate care of the newborn. In this study, the application of RA presented superior postoperative pain relief, resulting in earlier mobilization, shorter time to first oral food intake, and faster lactation onset in contrast to GEA. Further research on this topic is essential to provide optimal and individual pain management after a cesarean section.


Background: Persistent Idiopathic Facial Pain (PIFP), previously named Atypical Facial Pain (AFP) is a poorly understood condition, often diagnosed after several inconclusive investigations. The aim of this retrospective study was to evaluate the demographic and clinical characteristics of patients with PIFP referred to a Facial Pain Center. Methods: Between May 2011 and September 2014, data on 41 PIFP patients were analyzed regarding temporal, topographical and descriptive pain features, including onset, localization, pain descriptors and intensity. Pharmacological pain treatments were also registered. Finally, the presence and type of previous minor oro-surgery procedures in the painful area were investigated. Results: Demographic and clinical characterization were similar to PIFP patients reported in literature. The presence of previous minor oro-surgery procedures in the painful area was reported in most of these patients, in particular endodontic treatments and tooth extractions. Conclusions: This retrospective analysis showed a high prevalence of minor oro-surgery procedures in our population, while its role in PIFP pathophysiology remains unknown. A new classification of PIFP built around the main discriminant factor of presence of these procedures in the painful area could be considered while available data were still insufficient to define specific diagnostic criteria. Persistent Idiopathic Facial Pain (PIFP), previously termed Atypical Facial Pain (AFP), is a poorly understood painful condition often diagnosed after several inconclusive clinical investigations. According to the last International Classification of Headache Disorders ICHD third edition 2018, PIFP is defined as persistent facial and/or oral pain, with varying presentations but recurring daily for more than 2 h/day over more than 3 months, in the absence of clinical neurological deficit. Pain must be hardly localized, not following the distribution of a peripheral nerve, dull or aching or nagging in quality. Clinical neurological examination must be normal, and a dental cause must be excluded by appropriate investigations . HoweverIn this retrospective observational study, performed according to the STROBE statement , we analFrom CRF we extracted demographic and clinical data regarding temporal, topographical and descriptive features of patient’s pain, including onset, localization, type, and intensity. Pharmacological pain treatments at the time of evaluation were also registered. Moreover, presence and type of minor oro-surgical procedures in the painful area and their temporal relationship with pain onset were investigated.https://www.medcalc.org (accessed on 18 May 2022)).All the available data were collected and analyzed. Demographic, medical, and clinical characteristics were summarized by descriptive statistics. Data collected in this study were retrospectively analyzed using MedCalc Statistical Software version 14.8.1 .Between May 2011 and September 2014, a diagnosis of PIFP was given to 41 patients.A significant prevalence of female gender was highlighted . The mean age was 53.8 years (±13.68), with no significant gender difference. Complete demographic characterization is summarized in Most patients reported episodic pain feature , with at least one daily episode in 25 patients (60.9%). Eight patients (19.5%) reported continuous pain, sometimes with intermittent exacerbations. The most reported pain descriptors, often in association, were burning (46.3%), lancinating (41.5%), electric shock-like (36.6%), pulsating (31.7%) and gnawing (24.4%). In four patients (9.8%), the pain was described generically as “aching”. The mean daily pain intensity assessed by NRS scale (0–10) was 6.35 (±2.54). Pain characterization is summarized in Pain location was unilateral in 27 patients (65.8%) and bilateral in 14 patients (34.1%). In patients with unilateral pain, location was reported in maxillary , mandibular  or in frontal/periocular region . Intraoral pain was reported by 32 patients (78.04%), while extraoral and intra/extra-oral pain was reported in six (14.63%) and in three patients (7.31%), respectively. Pain location is summarized in p = 0.031). Patients with previous minor oro-surgical procedures reported predominantly episodic pain . The duration of daily pain episode was reported as a few seconds or minutes  or hours . Patients with continuous daily pain  also reported transient intermittent pain exacerbations. In 27 patients (79.41%), pain was described with a unilateral location. In most of these patients , pain disappeared during night sleep. Oro-surgical procedures are summarized in In most patients , the pain disappears during night sleep. Regarding neurological assessment, none of the 41 PIFP patients reported neurological impairment such as hyperalgesia, allodynia, paresthesia, or anesthesia in the painful area. Active oro-facial tissue modifications were excluded by the maxillo-facial evaluation. Regarding pharmacological treatment at the time of evaluation, the majority of patients were undergoing NSAIDs treatment  alone or in combination with antibiotics . Anticonvulsant drugs were administered in four patients (10.8%), weak or strong opioids in two patients (5.4%), tricyclic antidepressants (TCA) in two patients (5.4%). Only four patients (9.7%) were drug-free at the time of evaluation. Pharmacological treatment is summarized in This retrospective observational study on a population of 41 patients diagnosed with Persistent Idiopathic Facial Pain (PIFP) showed a prevalence of female gender, with a main age of 53 years, a prevalence of episodic daily pain, and heterogeneity in pain-type descriptors, with a slight prevalence of burning and lancinating pain and a more frequent unilateral pain location in superior maxilla. Moreover, the clinical evaluation showed the complete absence of any kind of neurological or tissue impairment in the painful area. Most of the patients reported pain freedom during night sleep. The pharmacological pain treatment at the time of evaluation showed a prevalent use of NSAIDs and/or antibiotics while other analgesics, commonly used in chronic pain, were administered only in a minority of patients. Similar results were reported in other epidemiological observations, where a prevalence of female gender and a mean age of 40 years at pain onset were evidenced . The anaEven though it requires further data collection, this small retrospective observation provided further evidence of a possible distinction between PIFP patients based on the presence of oro-surgery procedures in the painful area prior to pain onset. A new classification based on the presence of these procedures could represent a consistent tool for all specialists involved in diagnosis and treatment of this rare form of pain disorder. Lastly, our data collection could represent a useful tool for future research purposes.


In conclusion, both groups showed significant improvement in all characteristics of the pain scales; however, the improvement of the second group was significantly higher.Exercise is often recommended for fibromyalgia. The aim of this study was to investigate the possible influence and change in the pain characteristics of fibromyalgia patients when breathing exercises were added to their exercise program. A total of 106 patients were included and randomly divided into two groups. Τhe first group of patients followed a program of active exercises up to the limits of pain, lasting 30 min with a repetition of two times a week. Patients of the second group followed the same program with the addition of diaphragmatic breaths when they reached the pain limit. The patients completed three questionnaires: the Fibromyalgia Rapid Screening Tool (FiRST), the Brief Pain Inventory (BPI), and the Pain Quality Assessment Scale (PQAS)—once at the beginning, once again after three weeks of exercise, and again 3 months since the beginning of the program. Independent  Fibromyalgia is a complex syndrome, with its etiology still under debate . SuffereVarious pharmacological or non-pharmacological treatments are recommended for the treatment of fibromyalgia . FibromyAmong the latest revised recommendations for fibromyalgia management by EULAR, the type of exercise was among the key research priorities . TherefoThis was a double-blind (participants and assessor) randomized controlled trial. The sample included 143 outpatients with fibromyalgia, and physical therapy was recommended by the orthopedic referral. There were 112 patients in all who received trial information, and six of them were excluded ; therefore, 106 patients were finally included in the trial. Equal 1:1 randomization was utilized for allocation in either of the two groups based on the patient order of entry to the study. An independent research assistant was involved in the allocation process. The treatment interventions were carried out by the same physiotherapist. All patient examination data were documented by a physiotherapist who was blind to the study and independent.All patients were recruited from the orthopedic clinics of the 401 General Military Hospital of Athens. All patients provided written informed consent prior to their participation to the study. The study protocol received approval from the bioethics committee of the hospital and followed the principles of the Declaration of Helsinki. The study excluded patients with open wounds, pregnant women, those with any form of neoplastic disease, those with respiratory, metabolic, or rheumatic diseases, as well as those with pacemakers or major cardiovascular diseases .The pain characteristics of included patients were recorded through the completion of 3 questionnaires: once before starting the exercise, once again after a three-week period of exercise, and again 3 months later after the initiation of the program.The Fibromyalgia Rapid Screening Tool (FiRST) is a self-report scale used to identify fibromyalgia syndrome in people with diffuse persistent pain. The highest rate of accurate patient identification was achieved with a cut-off score of 5, which corresponds to the number of affirmative items ,7.The Brief Pain Inventory (BPI) is a self-report tool that has evolved into a standard for evaluating pain and its effects. The seven interference items are presented on a scale of 0 to 10, with 0 denoting no interference and 10 denoting complete interference. A recent consensus panel advised that the two BPI domains—pain intensity (severity) and the interference of pain with functioning—should be included as assessment criteria in all therapeutic studies for chronic pain . If moreThe Pain Quality Assessment Scale (PQAS) is a 20-item scale, with individual items scored between 0 and 10, except for the last item that is scored on a three-level categorical scale. It is not advised to compute a “global” PQAS scale score, as this would likely omit crucial information about certain aspects of pain. Each item can be separately rated to better understand the types of pain the patients feel. Item 20 describes the temporal pain characteristics and is scored categorically . The mean score of the items related to each subscale  is usually separately presented. Only respondents who have responded to every item should have their sub-scale scores calculated . No itemAll questionnaires were translated and validated in the Greek language ,8, excepThe same 10-min warm-up routine was applied to both groups, consisting of active mobilization and 30-second-long stretches for the spine, hips, knees, ankles, shoulders, elbows, and wrists ,10,11. TParticipants of the second group followed the program of the first group exactly, and diaphragmatic slow breaths were additionally performed, where the pain limit was reached each time. Patients performed the first exercise, discovering what the end of their range was (the point when the movement became painful) . At thisAn a priori power analysis was performed, aiming at estimating the patient sample size required for results to have adequate power for the between-group comparisons. The parameters of the power analysis included were: (a) an alpha level of 0.05 for the appropriate statistical tests for comparative analysis; and (b) a statistical power of at least 80%. (c) The effect size for the evaluation of the change between time points  was assigned to be small (f = 0.23) due to the short duration of the interventions, and medium (f = 0.55) for the difference between two independent means (depending on the program they followed) in order to reduce the probability differences due to chance. The required number of participants was calculated using the software G*Power 3.0.10 by entering the above-mentioned parameters. The calculator indicated that by using 53 patients in each group, a statistical power level of more than 80% could be achieved for all assessments performed.The effect of both exercise programs  on clinical pain characteristics  was examined with a mixed-model ANOVA analysis, with repeated measures for the within-subjects time factor  and a between-subjects factor between the two different groups.Independent t-tests were initially carried out for all the mentioned variables to assess whether the two groups were comparable at baseline. Furthermore, in order to investigate the differences in total improvement between the two programs of exercise after the completion of the intervention, independent t-tests were performed at the end of the intervention for each pain scale.2).Possible dependencies between qualitative variables and categorical pain characteristics of the two different exercise groups were investigated by the use of Pearson’s chi-squared test  or percentages (%), while data of descriptive statistics are presented as mean ± standard deviation (SD). Statistical analysis was performed using IBM SPSS Statistics v.28 for Windows , and statistical significance for all tests was set at 0.05. The study involved a total of 106 patients with chronic pain, diagnosed with fibromyalgia, aged 35 to 57 years (46.83 ± 5.991). Of these patients, 45.3% (n = 48) were male and 54.7% (n = 58) were female, where about half of them were receiving some kind of treatment or medication. The majority of patients 72.7% (n = 77) indicated that they felt pain in the back area. Similarly, 77.4% (n = 82) described their pain as deep, as opposed to 22.6% (n = 24) who rated it as superficial. Regarding the different time qualities of pain, 66% (n = 70) had stable pain, 23.6% (n = 25) had variable pain, and only 10.4% (n = 11) felt pain intermittently. In addition, the FiRST self-questionnaire score for the detection of FM showed that about 60% (n = 63) of the patients met the cut-off score ≥ 5/6 criterion. Mean and categorical scores for all patients in pain subscales are presented in p-values for the respective tests.The results of the independent t-tests and chi-squared tests revealed that there were no statistically significant between-group differences before the implementation of the exercise programs. p < 0.05). The mixed-model ANOVA results within the three time-points showed statistically significant differences for both groups between the mean values of all variables examined  = 29.42, p < 0.001), the FiRST scale F = 37.14, p < 0.001 and for two out of the three PQAS subscales  = 8.43, p = 0.005 and Surface F = 13.08, p < 0.001), but the difference between the two groups for the PQAS subscale of Deep Pain was not statistically significant  = 0.59, p < 0.446).The results of multiple comparisons per pair of assessment time-points (Bonferroni post hoc tests) showed that this significant improvement appears to take place immediately after the three-week intervention and is of equal amount for both of the two groups and remains constant until the last assessment three months from baseline (as attested by the non-significant interaction effect). The results of the between-group comparisons (between-subjects factor) performed for the two different exercise programs showed statistically significant differences in mean scores for BPI subscales  = 37.8, p ≤ 0.001) for all pain scales, except for the PQAS Deep Pain subscale (p = 0.38), as depicted in Furthermore, the results from independent t-tests for the mean total change improvement in each pain scale showed that the second group registered a greater change improvement in all pain scales. These differences were statistically significant (According to recommendations for the effective management of fibromyalgia, exercise has a prominent and advantageous role . TherefoCompared to other types of exercise, aerobic exercise has been preferred . AerobicIn our study, aerobic exercise appeared to have a beneficial impact in both groups, since we found statistically significant differences in all scales, between baseline and after the completion, for each group. In people suffering from fibromyalgia, it is often observed that complete rest, as well as a small daily amount of movement, can lower painful sensations . InductiBoth groups showed significant improvement in all characteristics of the pain scales, but the improvement of the second group was significantly higher. The recommendation of the aerobic exercise and breathing combination is not only to increase fitness, but also to provide a way of controlling allodynia and hyperalgesia, which we are aware exists in patients with fibromyalgia. Controlling the pain limit with breathing seems to have an effect because patients who suffer from central pain, such as fibromyalgia , learn tPeople with chronic pain have a wrong perception of the force they have to exert for exercise performance, resulting in increased sensory feedback . The recAny potential threat to the body can increase pain . Thus, aA significant difference in pain reduction appeared to emerge after the three-week intervention for both groups, and remained significant until the last assessment, three months from baseline. Both groups showed significant improvement in all characteristics of the pain, as measured by three relevant pain scales, but the improvement of the second group was significantly higher. It is worth mentioning that this greater improvement in the pain characteristics of the second compared to the first group occurred in a short period of only three weeks.


Adjunctive hyaluronidase has been widely used for ophthalmic anesthesia; however, in Dentistry, very few studies are available so far. Thus, the present study aimed to evaluate anesthetic outcomes of adjunctive hyaluronidase administration following buccal infiltration of articaine with epinephrine for anesthesia of mandibular first molars. Twenty-eight patients received a buccal supraperiosteal infiltration of 4% articaine with 1:100,000 epinephrine for anesthesia of the mandibular first molars, in a split-mouth approach. Afterward, randomly and using the same technique, they received either 1.0 mL of hyaluronidase (150 UTR/mL) or a placebo solution. Considering patients’ pain perceptions provoked by electric and mechanical stimulations, as well as using a pain scale, success rate, action onset time, duration of both pulpal and soft tissue anesthesia, and pain immediately after both punctures and on the 2nd day were assessed. The pulpal anesthetic success rate was 85.7% for hyaluronidase and placebo groups. Soft tissue anesthesia showed a shorter action onset time and a longer duration when hyaluronidase was used; however, there was no difference between the groups regarding action onset time and duration of pulpal anesthesia. Pain at the puncture sites did not differ between the groups, regardless of the time point evaluated. Adjunctive hyaluronidase following buccal infiltration of articaine with epinephrine for mandibular first molars seems not to provide any advantage in anesthetic outcomes in which the nerve fibers are intraosseous . On the other hand, soft tissue anesthesia may be improved substantially by using this pharmacological strategy. Key words:Hyaluronidase, local anesthesia, dentistry. Hyaluronidase is an enzyme that exhibits exceptional tissue penetration, and is used as an adjunct to improve the absorption and dispersion of other injected drugs. Its mechanism is based on reversible hydrolysis of the β-1,4-glycosidic linkages of hyaluronic acid, a constituent of the extracellular matrix composed primarily of proteoglycans and glycoproteins synthesized by fibroblasts and their derived cells .Before modern eye surgery techniques were developed, the associations of local anesthetic agents with bovine hyaluronidase had been commonly used in ophthalmic surgery to achieve less akinesia, leading to greater comfort and better patient and surgical satisfaction scores ,4. The rAs traditional techniques for mandibular anesthesia are occasionally confounded by anatomical variations  and impoAlso regarding the adjunctive use of hyaluronidase in Dentistry, the few studies conducted so far have yielded conflicting results. Whereas some authors have reported no benefit when hyaluronidase is injected during inferior alveolar nerve block , others Taking into consideration the lack of studies on the late use of hyaluronidase in infiltrative terminal mandibular anesthesia, the present study aimed to evaluate the anesthetic outcomes of adjunctive hyaluronidase following buccal infiltration of articaine with epinephrine for mandibular first molars.This split-mouth, double-blind, placebo-controlled randomized clinical trial was conducted at the Dental Clinic of the Faculty of Dentistry of the University of São Paulo (FOUSP) with a convenience sample, from February to November 2011. Sixty healthy outpatients, 18 years of age or older, who would receive resin composite restorations for two contralateral mandibular first molars  were selected.Exclusion criteria consisted of systolic or diastolic arterial blood pressure >130 and >90 mmHg, respectively; heart rate <50 or >110 beats per minute; smoking; current pregnancy or lactation; systemic diseases or medications known to affect collagen or pain pathophysiology/perception; bone disorders; allergy or hypersensitivity to any drug used in the study protocol; previous radiotherapy of the head and neck; and local infection or inflammation.All procedures were double-blinded and performed by a single researcher. Randomization was performed using a computer-generated Table, and both codes for each patient  were then allocated into numbered, opaque, sealed envelopes by another researcher. According to the split-mouth study design, each patient attended clinical appointments twice (at least 7 days apart) and always in the same morning period.Following a blood aspiration test to avoid accidental intravascular injection, the patients received a slow buccal supraperiosteal infiltration of 1.7 mL of 4% articaine hydrochloride with 1:100,000 epinephrine  for anesthesia of a mandibular first molar. Shortly thereafter, either 1.0 mL of hyaluronidase (150 UTR/mL) or a placebo solution (distilled water), which were previously handled and placed into cartridges coded as A and B by the manufacturer, was injected at the same puncture area of the first injection and using the same buccal technique.The success and duration of pulpal anesthesia were assessed according to the pain perception provoked by an electrical pulp stimulator  applied to the buccal surface of the tooth. Considering that the voltage of this device corresponds to values on a 0-80 scale and that vital lower molar teeth present a sensibility response in the range of 30-70 , the basIn contrast, buccal soft tissue anesthesia was assessed using nociceptive mechanical stimulation by introducing a dental explorer into the buccal mucosa until periosteal contact near the target lower molar tooth every 2 minutes. Soft tissue anesthesia and the action onset time were both considered achieved when there was no pain response to the mechanical stimulus. After reaching successful anesthesia, the above-mentioned procedure was repeated every 10 minutes to ascertain the duration of action, considering the period between the total loss of painful sensation and its partial recovery (pain reported to any degree).A pain scale presenting values from 0 (no pain) to 5 (the worst pain imaginable) and written instructions on its use were provided to the patients at the first appointment. The patients were asked about pain from the anesthetic infiltration site immediately after the first (solution of articaine with epinephrine) and second  injections and asked again on the 2nd day by phone call.This study was previously approved by the local Research Ethics Committee, School of Dentistry of the University of São Paulo (FOUSP) . The patients received information regarding the study before being submitted to any procedure, and those who agreed to participate read and signed the informed consent form.Data were analyzed both descriptively and inferentially in the BioEstat 5.0™ software . The differences between hyaluronidase and placebo groups were analyzed by the paired samples T-test for continuous data and by the Wilcoxon test for discrete ordinal data. Moreover, effect sizes were determined using G*Power 3.197™ software . The observed power for each parameter was calculated also by the same software and adopting α = 0.05, as follows: soft tissue latency, 91.6%; soft tissue duration, 72.7%; pulpal latency, 14.7%; pulpal duration, 20.8%; pulpal anesthetic success, undetermined; pain after the first puncture, 5.2%; pain after the second puncture, undetermined; pain on the second day, 6.7%.P undetermined). A statistically significant shorter action onset time (P = 0.0018) and a longer duration (P = 0.0130) were observed in soft tissue anesthesia when hyaluronidase was used (P = 0.3584) or duration (P = 0.2467) of pulpal anesthesia (P = 0.1698) and on the 2nd day (P = 1.0). In all cases, the patients reported the same score immediately after both second punctures (P undetermined)  .This study evaluated the success rate, action onset time, and duration of both pulpal and soft tissue anesthesia and pain at puncture sites when hyaluronidase was used following buccal infiltration of articaine with epinephrine for mandibular first molars. To the best of the authors’ knowledge, this is the first paper addressing the adjunctive hyaluronidase with articaine and epinephrine for buccal mandibular anesthesia, as well as multiple anesthetic outcomes.Buccal infiltrations with articaine are more effective than lidocaine ones for posterior mandibular teeth ,25. Its The results of this study indicate that adjunctive hyaluronidase significantly prolonged the duration of soft tissue anesthesia, and also shortened its action onset time; however, no additional benefit to pulpal anesthesia was observed. The osseous extracellular matrix is calcified due to the deposition of hydroxyapatite crystals  on collagen fibrils and by condensation of existing components  during osteogenesis ,29. ThisA certain degree of discomfort at the puncture sites was expected among patients in the hyaluronidase group, because of catabolism of connective tissue components that may remain incompletely restored for up to 48 hours ,31. CuriBecause few studies on the use of hyaluronidase in dentistry have been completed, the present results are encouraging and can be considered a relevant contribution to the literature; however, these findings should be interpreted with caution. Firstly, the sample size was not determined statistically before patient enrollment, which may have yielded biased results, especially on the likelihood of failing to detect true differences between groups (type-2 error). Because statistical power and P-values depend simultaneously on sample and effect sizes, the convenience sample used herein could not provide sufficient power to detect some significant differences between both groups , as noteSumming up, within the limitations of this study, adjunctive hyaluronidase following buccal infiltration of articaine with epinephrine for mandibular first molars seems not to provide any advantage in anesthetic outcomes in which the nerve fibers are intraosseous . On the other hand, soft tissue anesthesia may be improved substantially by using this pharmacological strategy.


IntroductionRezum is a minimally invasive, outpatient procedure using convective water vapor to relieve outlet obstruction from benign prostatic hyperplasia (BPH). Evidence on the technical approach of Rezum therapy, particularly pain control, is lacking. The purpose of this study was to evaluate the efficacy of utilizing a local anesthetic prostate block for postoperative pain control during Rezum therapy for BPH. A multimodal approach is typically utilized for pain control during and after Rezum. However, little is known about which elements are most critical.MethodsThis is a single-center retrospective study of 109 patients who underwent Rezum for BPH. Patients were then divided into two groups: Local anesthetic prostatic block verse no local anesthetic prostatic block for the procedure. A phone survey was performed to assess the patients' subjective pain scores and postoperative analgesics usage. A comparison of reported pain scores on a 0-10 Likert scale as well as usage of prescription and non-prescription analgesics medications was performed.ResultsThere were 109 patients who underwent Rezum therapy, and 86 (79%) of patients responded to phone surveys. There was no significant difference in postoperative pain scores between patients who received local anesthetic prostatic block vs those who did not (2.10 vs 3.03). Similarly, there were no significant differences in postoperative narcotics or non-prescription analgesic medications usage.ConclusionOur data suggest that when performing Rezum using conscious sedation in the operating room or cystoscopy suite, it is unnecessary to perform a local anesthetic prostate block as it has no significant effect on patient-reported pain or the use of analgesics in the postoperative period. Approximately 70% of men have some evidence of benign prostatic hyperplasia (BPH), by the age of 70 . The degRezum using convective water therapy is a minimally invasive, outpatient procedure designed to relieve obstructive symptoms associated with BPH . Rezum iEvidence on the best technical approach to managing pain related to Rezum therapy is lacking. Currently, large variations in pain management exist amongst practitioners when performing Rezum. Published recommendations are based on urologist experience, without a comparison of the efficacy of opposing methods -5. We soData and study populationFollowing the approval of the institutional review board, a single-institution retrospective chart review accompanied by a phone survey of 109 men was performed who underwent Rezum therapy between January 1, 2017, and April 20, 2019. Data pertaining to age, BMI, prostate size, international prostate symptoms scores, post-void residuals on bladder scans, and a number of treatment sites were gathered by retrospective chart review. Foley size, length of time, and median lobe were not recorded from the scan. Pain scores and medication usage was obtained by the phone survey.A total of 86 patients out of 109 willingly provided verbal informed consent and participated in the phone survey. During the survey, the surveyor read the patient the pain scale and the patient reported their pain level. Data on prescriptions filled and usage of pain medication post-operatively were collected through retrospective chart review and survey questions. The patients were divided into two groups: one was with local anesthetic prostatic block prior to Rezum therapy and the control group was without local anesthetic prostatic block prior to therapy. This study was non-blinded and included no use of placebos. Survey questions can be found in the first table of the Appendices section. Statistical analysisComparison of reported pain scores   and usagProstate block procedureThe local anesthetic prostatic block was performed via a transperineal route employing a transperineal access system  . The traOf the 109 patients who underwent Rezum therapy, 86 (79%) of patients responded to phone surveys. The following means were reported: mean age of patients participating in this study was 68.5 years (48-95), mean BMI was 29.4 kg/m2 (18-39.7), mean prostate size was 51.5 g (18-170), mean pre-treatment was IPSS 10 (0-31), mean pre-treatment was PVR 141 mL (0-990 mL), and the mean number of treatments was five (2-10). No significant differences in age (69.2 vs. 67.8 years) or BMI (28.95 vs. 29.84 kg/m2) exist between groups who did and did not receive a local anesthetic prostatic block. Similarly, no differences existed in prostate size (49.47 vs. 47.12 g), treatment number (5.02 vs. 4.4), pre-treatment IPSS (10.2 vs. 9.4), or pre-treatment PVR (146.9 vs. 135.9 mL) between groups  pain medication were compared between groups. All patients received the same narcotic and dosage. No significant differences in prescription or usage of medication were shown between patients who did and did not receive local anesthesia prior to Rezum therapy Table .Many different combinations of pain management have been described in the literature -5. PriorThe current literature suggests that the decisions to perform Rezum in the office versus an ambulatory surgery setting and management of pain and anxiety should be joint between the patient and his provider -12. A muOur data suggest using local anesthetic block has no correlation with patient-reported pain or the prescription or use of analgesics (prescription or OTC) post-operatively, suggesting the use of local anesthetic block is extraneous when used in adjunct with IV sedation. Therefore, local anesthesia has limited utility when performed under IV sedation with regard to postoperative pain in patients undergoing Rezum. It is reasonable to assume that a local prostatic block in the absence of IV sedation would reduce postoperative pain; however, this wasn’t assessed in this study. Local anesthetic prostate block has been well-established for pain control for prostate biopsies . ProstatAnother interesting point is that no patients who received a local block reported a 10 out of 10 pain while four patients in the group without a block reported 10 out of 10 pain. The two groups were not significantly different but clearly, four patients didn’t have a positive experience. As urologists are consistently evaluating ways to improve the patient experience, performing a prostatic block comes at minimal risk and may spare a patient from reporting 10 out of 10 pain, so it does not appear unreasonable to perform a prostatic nerve block.Overall, 60% of our patients who responded to our survey were prescribed pain medication by their surgeon. Interestingly, only 23% of patients reported using narcotics, and 27% reported using OTC analgesics. The data suggests that we overprescribed narcotics following Rezum, and we have changed our prescribing patterns based on this survey. No statistically significant differences were seen in prescription/use of pain medication or patient-reported pain scores between groups who did and did not receive local anesthetic prostatic block prior to the procedure. The survey data suggested there was a lack of utilization of pain medication post-operatively in both groups. This suggests that perioperative pain is not a big problem with or without local anesthetic blocks.There are certainly limitations to the study. This was a non-randomized retrospective study and the decision to perform prostatic nerve block was based on surgeon preference. The study may also introduce recall bias as many patients were being surveyed regarding pain that generally resolves quickly in the post-operative period. However, despite the possible recall bias, there is value in reporting how patients’ remember their postoperative experience. Additionally, not all sources of pain were addressed by the survey questions. For example, bladder spasm pain was not discussed.Our study suggests that when performing Rezum under IV sedation, it is unnecessary to perform a local anesthetic prostatic block as it has no significant effect on patient-reported pain or the prescription or usage of analgesics post-operatively. The Rezum procedure has been shown to be well tolerated post-operatively. Only 23% of patients used the prescribed narcotics and 27% used OTC pain medications, suggesting that prescribing narcotics following Rezum could be avoided. Rezum appears to provide a reasonable minimally invasive therapy for BPH management.