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In the quest for sustainable waste management solutions, this study explores the integration of ultrasonic pretreatment as a preparatory step for the anaerobic digestion of landfill leachate. Employing response surface methodology (RSM) coupled with central composite design (CCD), we systematically optimize the process parameters, including pH, inoculum volume, and ultrasonic pretreatment duration, to maximize the yield of bio-methane potential (ml CH4/g VS). The results demonstrate the effective application of RSM-CCD for predicting and modelling methane generation, with a highly significant model (R2 = 0.899). The optimized conditions reveal a remarkable biomethane potential of 177 ml CH4/g VS. Additionally, this study contributes to the understanding of the positive effect of ultrasound pretreatment on the anaerobic digestion of landfill leachate, and the quality of the digestate obtained after anaerobic digestion was studied and different valorisations were proposed.

Water scarcity remains the main obstacle to sustainable development in regions under arid and semiarid climate conditions. This study focuses on the assessment of groundwater potentiality in the Middle Moulouya and the higher part of Lower Moulouya, Morocco, by using remote sensing (RS) and geographical information system (GIS) techniques. This is a multicriteria approach, based on the analysis of five principal factors controlling the existence of groundwater resources, namely fracturing, lithology, drainage, topography and rainfall, and their comparison with the hydrogeological data of 179 boreholes. The use of a dynamic parameter weighting algorithm allowed to obtain a Groundwater Potential Index model with considerable correlation coefficient (r= 0.73) between calculated values of GPI, from considered factors and observed water yields in boreholes.

Al–Li–Cu–Mg–Zr alloys are widely used in the aerospace industry for different applications and make an excellent concurrent to high-performance composites. This family of alloys has remarkable properties like low density, high elastic modulus, high strength and specific stiffness, fracture toughness, fatigue crack growth resistance, and improved corrosion resistance.The present work aims to investigate a family of Al–Li alloys by employing suitable characterization techniques such as computer-aided cooling curve analysis and thermal dilatometry to characterize the as-cast alloy. The characterization temperatures of the alloy were obtained and the phase transformation temperatures were concluded as thermal expansion inflection points as well. Furthermore, the homogenization heat treatment effect of the alloy is examined through optical microscopy (OM), scanning electron microscopy (SEM), Energy-dispersive X-ray spectroscopy (EDS), X-ray diffraction (XRD) and Vickers microhardness testing to determine the optimum heat treatment time. The results reveal the formation of δ′, δ and β’ precipitates in the alloy after different hours of homogenization heat treatment. Notably, our investigation identifies the optimum heat treatment time for the alloy as 26h at 515 °C, resulting in reduced hardness and barely any chemical segregation. These findings contribute to the characterization of as-cast Al–Li alloys and the understanding of microstructure evolution and mechanical properties during homogenization heat treatment that offer a valuable insight for enhancing their performance in aerospace applications.

Introduction: Several studies have highlighted the importance of these 3 concepts, which are probiotics, prebiotics and symbiotic in daily clinical practice. They play an important role in the treatment/prevention of several diseases and contribute to the proper functioning of the digestive and immune systems. Objective:The objective of our study is to describe and compare the evolution of the use of symbiotic by the Moroccan population based on the sales rate between the year 2020 and 2021.Methods:Data collection was carried outby a means of a questionnaire concerning 15 symbiotic products most used by the Moroccan population. Results: Our study suggests that some products have seen an increase in sales between 2020 and 2021, such as Lactobaciluscasei which reached 95,500 products in 2021 instead of 69,500 products in 2020,while the sale of the products decreased such as Bifidobacteriumlongum which reached 0 products in 2021 instead of 300 products in 2020, and according to the student test there is a significant difference between the average sales during the two successive years of 2020 and 2021(p=0,037).Conclusion:Ourresults show that the consumption and the use of symbiotic products by Moroccan populationhave shown significant differences. Keywords: Symbiotic, prebiotics, probiotics, sales, Moroccan population.

INTRODUCTION: Nul ne peut nier les résultats protecteurs satisfaisants de la vaccination contre plusieurs maladies graves dans le monde et particulièrement au Maroc. L´extension de la pandémie Covid-19 dans notre pays a entrainé une baisse importante de la vaccination des enfants, ce qui pourrait causer des flambées épidémiques dans le futur. D´où l´intervention du ministère de la santé pour pallier à cette situation. L´objectif était de montrer l´ampleur du relâchement de la vaccination en temps COVID-19 et sortir avec des recommandations visant à rétablir ce changement. METHODES: il s´agit d´une étude transversale sur l´impact de cette pandémie sur le suivi vaccinal des enfants. Nous avons mené une enquête nationale auprès des pédiatres sous forme d´un questionnaire électronique via Google Forms. Nous avons procédé à la collecte, l´analyse et l´interprétation des résultats. RESULTATS: cent trois pédiatres marocains ont répondu au questionnaire. Plus de 2 tiers des pédiatres exercent au secteur privé et pratiquent tout le calendrier vaccinal. La majorité des pédiatres (95%) ont reçu des questions émanant des craintes des parents sur la vaccination. Nous avons noté que 82,5% des parents hésitent à venir au cabinet et 5,8% refusent de faire la vaccination pendant cette période. Environ 22% des pédiatres ont arrêté totalement la vaccination et 72,8% ont décalé les vaccins d´un mois. CONCLUSION: il est essentiel de maintenir la confiance de la population dans la vaccination. Une évaluation continue de la couverture vaccinale, des recommandations claires et une large sensibilisation du grand public seront nécessaire pour répondre aux changements vaccinaux durant la pandémie de COVID-19.

Background and Aims. There is growing evidence that the 2019 coronavirus disease (COVID-19) is emerging as a potential trigger virus for the development of diabetes mellitus in children. This can occur even in patients without factors predisposing to impaired glucose metabolism. Here, we report two rare cases of diabetic ketoacidosis revealing new-onset diabetes and precipitated by COVID-19. These cases are reported in view of their rarity and originality. The relationship between type 1 diabetes mellitus and COVID-19 is discussed. Results. Two children developed symptoms suggestive of diabetic ketoacidosis preceded by polyuria, polydipsia, and asbestos. There is a documented COVID-19 infection in the parents of the 2 children. An asymptomatic infection was detected in the 2 patients on the basis of a reverse transcription polymerase chain reaction (RT-PCR) test. Thoracic imaging and inflammatory workup were negative in both cases. Both patients responded well to treatment, including rehydration regimens and intravenous insulin. On the 2nd day of their hospitalization, they were transferred to several injections of subcutaneous insulin with therapeutic and nutritional education from the parents. After about 4 weeks, their insulin requirements probably decreased due to the diabetes honeymoon. Conclusion. COVID-19 can induce acute onset diabetes and diabetic ketoacidosis in children. More research data are needed to improve our knowledge of this constellation and to guide the most appropriate therapies.

The physicochemical and biological sludge (PCS and BS) from a Moroccan dairy industry, constitute a source of organic matter that is ranging respectively between 58.67 to 90.6% and 18.85 to 92.5%. The composition of these sludges is very specific because they are derived from an effluent mixture (milk, orange, whey, …) witch varied according to production of this industry. As results, the physicochemical and microbiological characteristics of these sludges fluctuate according to time. The pH of biological sludge varied between 7.35 to 8.85 while the pH of physicochemical sludge fluctuated between 5.32 to 7.5. In addition the microbial germs is represented by total coliforms (3.95.107 and 2.02.1011UFC.ml-1), total germs (1.61.109 and 2.36.1012 UFC.ml-1), sulphate-reducing bacteria (1.55.108 and 5.72.109 UFC.ml-1), lactobacillus (2.15.108 and 9.37.1011 UFC.ml-1) and streptococcus (1.05.109 and 2.46.1011UFC.ml-1) (respectively for BS and PCS). Assessment of anaerobic digestion for treating these wastes in batch reactor at mesophilic condition (38°C) show the promising results in terms of methane production and organic pollution removal. Indeed, the methane yields were 5.601 and 20.79 mlSTP.gVS-1 gave respectively by BS and PCS for the maximal load (100% of substrate) which is the optimal load. The total solid and volatile solid reduction reached 79.63 and 83.60% for biological sludge while it reached 87.06% and 89.16% for physicochemical sludge for the same load (100% of sludge).

La maladie de Weber-Christian ou panniculite idiopathique est une affection rare, caractérisée par une inflammation du tissu adipeux sous-cutané; il s'agit d'une entité pathologique non spécifique qui reste toujours un sujet de débat et dont l'évolution est imprévisible. Nous rapportons dans cet article le cas d'un nourrisson de sexe féminin de 9 mois, admise dans un tableau de sepsis précédé d'une symptomatologie respiratoire et suivi de l'apparition de nodosités sous cutanées érythémateuses, de petite taille, dures, sensibles, asymétriques et situées au niveau des bras et des membres inférieurs, la biopsie cutanée a montré une hypodermite lobulaire avec infiltration des polynucléaires neutrophiles. La maladie de Weber-Christian a été retenue après avoir éliminé les autres diagnostics différentiels. Notre patiente a été traitée par la prednisone avec une bonne évolution initiale. Durant le suivi et au cours de la dégression, le diagnostic d'une leucémie aigue lymphoblastique type B a été posé. Cette évolution atypique à notre connaissance n'a jamais été décrite dans la littérature. Nous allons discuter à travers ce cas les différentes situations similaires où un autre diagnostic a été fait après avoir pris en charge les malades comme ayant une panniculite lobulaire idiopathique, en concluant de la nécessité d'une enquête étiologique exhaustive et d'une surveillance prolongée afin de rechercher une éventuelle pathologie associée.

INTRODUCTION: Evaluer la consommation quotidienne des produits laitiers dans une population d'enfants marocains et déterminer les facteurs associés pouvant influencer cette consommation. METHODES: étude prospective du 1 er octobre 2013 au 31 avril 2014. Les enfants âgés entre 2 et 16 ans ont été inclus. Le recrutement a eu lieu dans la ville de Fès. Le recueil des données s'est fait à l'aide d'un questionnaire fréquentiel. Les parents et les enfants inclus ont été interrogés sur la consommation des produits laitiers et les facteurs socio-démographiques avec une évaluation anthropométrique des enfants. L'association des variables à la consommation des produits laitiers a été analysée en analyse univariée et multivariée par un modèle de régression logistique. RESULTATS: l'enquête alimentaire avait intéressé 286 enfants dont 151 filles (52,8 %) et 131 garçons (45,8%). Les enfants âgés de 2 à 3 ans représentaient 26,4 %, ceux âgés de 4 à 7 ans 28,9 %, ceux âgés de 7 à 9 ans 18,3 % et les adolescents âgés de 10 à 16 ans 26,4 %. Les enfants consommaient en moyenne 2.5'1 produits laitiers par jour. Les enfants consommaient au moins 3 produits laitiers par jour dans 57,8% chez les enfants âgés de 2 à 3 ans, 53,6% chez les enfants âgés de 4 à 6 ans, 40% chez les enfants âgés de 7 à 9 ans et 41.2% chez les enfants âgés de 10 à 16 ans. Les facteurs associés à la consommation de trois produits laitiers minimum par jour en analyse univariée étaient le niveau d'instruction maternel analphabète p = 0.001 OR = 0.1 et primaire p=0.002 OR=0.1, le niveau socioéconomique familial moyen p = 0.001 OR = 3, l'âge p= 0.01 OR = 0.9 et l'indice de masse corporelle normal p = 0.01 OR = 2.5 et = 90, percentiles p = 0.001 OR = 6. Il existe un lien positif entre l'indice de masse corporelle = 90 percentiles p = 0.01 OR=3.9 est et la quantité consommée des produits laitiers et négatif avec le faible niveau de scolarité maternel analphabète p = 0.008 OR = 0.1 et primaire p=0.009 OR= 0.1. CONCLUSION: la consommation du lait et des autres produits laitiers était inappropriée en particulier chez l'enfant âgé de 7 à 9 ans et l'adolescent de 10 à 16 ans. Le faible niveau d'éducation maternel et un indice de masse corporelle supérieur au 90, percentiles était des facteurs indépendamment associés à la consommation de moins de 3 produits laitiers par jour. La sensibilisation des parents et des enfants sur l'intérêt du lait et de ses dérivés dans l'alimentation de l'enfant est indispensable.

The Oum Er-Rbia estuary is located on the Atlantic littoral of Morocco. It undergoes severe clogging due to the sand deposition in its outlet. The current study examined the indicators of the morphodynamic evolution in the littoral system including the Oum Er-Rbia estuary and the neighboring beaches over 1970−2017. The methodology adopted was based on the analysis and the interpretation of aerial photographs and Google Earth images under a GIS environment and field work. The morphodynamic evolution was discussed by taking into account the evolution of hydraulic facilities installed in the watershed area, especially the construction of dams, as well as the dredging works in the Oum Er-Rbia estuary. The results highlight the morphologic evolution estimated in terms of surface units observed in the estuary and the neighboring beaches. The evolution of the littoral system was mainly influenced by the closest dam location and by the dredging works, in addition to the regulation of the river flow by the installation of hydraulic facilities upstream.

Background: Closantel is a veterinary drug used as anthelmintic for ruminants while it is contraindicated for humans. This report describes a rare case of blindness, increased liver enzymes and coagulopathy following closantel poisoning. Case report: A 5-year-old girl was presented with acute blindness following closantel poisoning. She was given mistakenly a dose of 500 mg/day (25mg/kg/day) for 8 days. Clinical examination revealed a well-appearing child with bilateral mydriasis, loss of pupillary light reflex and absence of blinking to threat. Fundoscopic exam revealed bilateral pre-atrophic papilledema. Electroretinogram showed a highly significant decrease in retinal activity. Laboratory examinations revealed 52% increase in prothrombin time, prolongation of activated partial thromboplastin time to 1.3 times the normal and rise of aspartate aminotransferase to 120 IU/L. In addition, creatine kinase peaked at 904 IU/L. Moreover, normocytic normochromic anemia with hemoglobin at 10.7 mg/L and leukocytosis with lymphocytic predominance was noted. The patient received glucocorticoids, vitamin B12 and vitamin K and was discharged after correction of blood and coagulation parameters and normalization of liver enzymes. Partial recovery in visual acuity was found two months after ingestion of the last dose. Discussion:Closantel can cause significant spongiform change (intra-myelin vacuolation) in the white matter of the cerebrum and the cerebellum. It can also induce optic nerve damage as a result of Wallerian degeneration, fibrosis and atrophy. On the retina, closantel leads to papilledema, necrosis of the outer layers, and retinal detachment. It can also cause fatty change and hydropic degeneration in the liver and hepatocellular degeneration. Conclusion: Closantel is a toxic drug for humans causing blindness, hematologic and hepatic disorders. Public awareness should be raised regarding the risks of use of unapproved drugs for human.

Gaucher's disease (GD) is a lysosomal storage disorder due to glucocerebrosidase deficiency; it's one of the rare genetic diseases for which therapy is now available. The purpose of this work is to study the epidemiological features of the disease and to highlight the diagnostic difficulties. We performed an 11-year retrospective study of 11 patients with GD followed-up in the department of paediatric hepatology gastroenterology and nutrition of Rabat children's Hospital. We observed 11 patients with GD: 6 males and 5 females. Age at onset ranged from 3 months to 10 years with an average of 3.41 years. Mean age at diagnosis was 4 years (range 3months-14years).Parental consanguinity was noted in 85% cases. According to the clinical presentation, we classified our patients into: 9 cases of type 1 (81%) and two cases of type 2 (19%), none of the patients presented GD type 3. GD type 1: The age at diagnosis ranged from 2 years to 14 year with an average of 6 years. Main symptoms were: splenomegaly, hepatomegaly , pallor, haemorrhagic appearance (40%), bone pain (40%). The diagnosis was based on histology showing the Gaucher's cells in various tissues (100%). Enzymatic activity dosage confirmed the diagnosis of GD for 4 patients (44.5%). The treatment was always symptomatic (analgesics, transfusion). A splenectomy was performed in one case presenting with multiple splenic abscesses and high transfusion requirements. None of the patients received a specific treatment (substitutive enzymotherapy). The follow-up period ranged from 3 months to 6 years with an average follow-up of 4 years. We noticed stability in 4 cases, 2 worsening cases with bone and spleen complications. Three patients were lost to follow-up. GD type 2: we observed two cases of GD type 2 diagnosed at 3 and 18 months. The visceral symptoms were serious and the neurological features included seizures, hypertony, squint, physical developmental milestones delay. Both of them died. Gaucher's disease is not exceptional in Morocco. Type 1 is the most common type. We noted through this study some diagnostic difficulties as the diagnosis was delayed and the enzymatic dosage was performed in only 42% of the cases as well as therapeutic difficulty with no prescription of the specific treatment given the high cost of the enzyme.

INTRODUCTION: to determine the metabolic profile in a group of obese children in Morocco. METHODS: the BMI, the waist circumference, the blood pressure and metabolic parameters in 73 children (37 obese and 36 normal) were compared. RESULTS: 80% of obese children had abdominal obesity (p =0.0001). For systolic blood pressure among children who have a higher value than the 95th percentile, 85.7% were obese and 14.3% children are normal children. For diastolic blood pressure, 83.34% of obese children had higher diastolic blood pressure values in the 95th percentile and 16.6% of normal children have a higher value than the 95th percentile (p = 0.013). No obese child had hyperglycemia. The prevalence of metabolic syndrome was 21.6%. CONCLUSION: obesity is number one risk of cardiovascular disease for children. Early detection can help for an appropriate care.

Malignant Infantile Osteopetrosis (MIOP) is a rare genetic disorder due to osteoclast abnormal activity.We report a thirteen month-old male patient, diagnosed as MIOP while investigating the cause of hepatosplenomegaly associated with hydrocephalus. His medical history revealed non consanguineous parents and one brother's death at the same age of unknown etiology (similar symptoms).Systemic examination showed hepatosplenomegaly, growth failure, developmental milestones delay, and rickets features. Ophthalmic exam yielded bilateral optic atrophy. Skeleton radiographs detected generalized dense bone and rickets. Cerebral CT scan revealed hydrocephalus. Histological examination showed hypoplastic bone marrow and extra-medullary hematopoeisis. Diagnosis was confirmed by genetic testing that showed two heterozygote mutations within the TCIRG1 gene. The patient received supportive treatment. He died from an acute respiratory distress.MIOP should be kept in mind as a rare cause of hepatosplenomegaly. Early diagnosis and timely Hematopoietic stem cell transplantation are the only curative approach for an otherwise fatal disease.

Les banques tunisiennes mettent à la disposition de leurs clients un ensemble des services bancaires électroniques. Si les recherches ayant étudié les antécédents de l’adoption de l’e-banking par les clients particuliers sont assez nombreuses, peu est connu sur les prédispositions des entreprises tunisiennes à intégrer l’e-banking comme une procédure fiable leur permettant de gérer les différentes opérations financières. L’objectif de cette recherche est d’expliquer dans quelle mesure les intentions d’utilisation régulière de l’e-banking par les responsables des petites entreprises tunisiennes sont déterminées par la sécurité, la qualité de service, les valeurs et la confiance. La collecte des données est effectuée par un questionnaire remplis par les responsables financiers ou chefs de 104 petites entreprises tunisiennes. L’analyse des données par la méthode PLS montrent un effet significatif et positif de la confiance sur les intentions d’utilisation régulière de l’e-banking. La confiance est déterminée par les valeurs fonctionnelles de l’e-banking. Les valeurs fonctionnelles et les valeurs monétaires sont expliquées par la qualité des services et la sécurité. Les implications managériales et théoriques de ces résultats ainsi que les voies futures de recherche sont examinées.

Background: Percutaneous auricular nerve stimulation (neuromodulation) involves implanting electrodes around the ear and administering an electric current. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial; and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following two ambulatory surgical procedures., Methods: Within the recovery room following cholecystectomy or hernia repair, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied. Participants were randomized to 5 days of either electrical stimulation or sham in a double-blinded fashion., Results: In the first 5 days, the median (IQR) pain level for active stimulation (n=15) was 0.6 (0.3-2.4) vs 2.6 (1.1-3.7) for the sham group (n=15) (p=0.041). Concurrently, the median oxycodone use for the active stimulation group was 0 mg (0-1), compared with 0 mg (0-3) for the sham group (p=0.524). Regarding the highest pain level experienced over the entire 8-day study period, only one participant (7%) who received active stimulation experienced severe pain, versus seven (47%) in those given sham (p=0.031)., Conclusions: Percutaneous auricular neuromodulation reduced pain scores but not opioid requirements during the initial week after cholecystectomy and hernia repair. Given the ease of application as well as a lack of systemic side effects and reported complications, a definitive clinical trial appears warranted., Trial Registration Number: NCT05521516., Competing Interests: Competing interests: BMI, WBA, BA, JFS, ETS, BA, and JJF—the University of California San Diego has received funding and/or product from the following companies for other research studies of these authors: Epimed International (Dallas, Texas, USA), SPR Therapeutics (Cleveland, Ohio, USA), Infutronix (Natick, Massachusetts, USA), Avanos Medical (Irvine, California, USA), Masimo (Irvine, CA, USA), and Varian Medical Systems (Palo Alto, California, USA). Th remaining authors have no conflicts to disclose., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Background: Pectoralis-II and paravertebral nerve blocks are both used to treat pain following breast surgery. Most previous studies involving mastectomy identified little difference of significance between the two approaches. Whether this is also accurate for non-mastectomy procedures remains unknown., Methods: Participants undergoing uni- or bilateral non-mastectomy breast surgery anticipated to have at least moderate postoperative pain were randomized to a pectoralis-II or paravertebral block (90 mg ropivacaine/side for both). Surgeons and recovery room staff were masked to treatment group assignment, and participants were not informed of their treatment group. Injectate for pectoralis-II blocks was ropivacaine 0.3% (30 mL) per side. Injectate for paravertebral blocks was ropivacaine 0.5% (9 mL in each of 2 levels) per side. We hypothesized that pectoralis-II blocks would have noninferior (1) analgesia [Numeric Rating Scale] and (2) cumulative opioid consumption within the operating and recovery rooms combined (dual primary outcomes). The study was adequately powered with n=100, but the target enrollment was raised to n=150 to account for higher-than-anticipated variability., Results: The trial was ended prematurely with 119 (79%) of the original target of 150 participants enrolled due to (masked) surgeon preference. Within the recovery room, pain scores were higher in participants with pectoralis-II (n=60) than paravertebral blocks (n=59): median [IQR] 3.3 [2.3, 4.8] vs 1.3 [0, 3.6]; 95% CI: 0.5 to 2.6; P < 0.001. Similarly, intravenous morphine equivalents were higher in the pectoralis-II group: 17.5 [12.5, 21.9] vs 10.0 mg [10, 20]; 95% CI: 0.1 to 7.5; P = 0.004. No block-related adverse events were identified in either group., Conclusions: Following non-mastectomy breast surgery, 2-level paravertebral blocks provided superior analgesia and opioid sparing compared with pectoralis-II blocks. This is a contrary finding to the majority of studies in patients having mastectomy in which little significant difference was identified between the two types of blocks., Competing Interests: Conflicts of Interest (previous 3 years): Drs. Gabriel, Curran, Sztain, Tsuda, Said, Alexander, Finneran, Abramson, Black, Abdullah, and Ilfeld: The University of California San Diego has received funding and/or product from the following companies for other research studies of these authors: Epimed International (Dallas, Texas, USA), SPR Therapeutics (Cleveland, Ohio, USA), InfuTronix (Natick, Massachusetts, USA), Avanos Medical (Irvine, California, USA), Masimo (Irvine, CA, USA), and Varian Medical Systems (Palo Alto, California, USA). Dr. Swisher: The University of California San Diego has received funding and/or product from the following companies for other research studies of this author: Vertex Pharmaceuticals (Boston, Massachusetts, USA), Epimed International (Dallas, Texas, USA), SPR Therapeutics (Cleveland, Ohio, USA), InfuTronix (Natick, Massachusetts, USA), Avanos Medical (Irvine, California, USA), Masimo (Irvine, CA, USA), and Varian Medical Systems (Palo Alto, California, USA). Dr. Wallace: None. Dr. Blair: None. Dr. Donohue: Dr. Donohue’s spouse is a full-time employee of Janssen Pharmaceuticals (Beerse, Belgium) and he has consulted for Roche (Basel, Switzerland). Ms. Xu: None. Mr. Cha: The University of California San Diego has received product from Masimo (Irvine, CA, USA) for other research studies of this author., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Anesthesiologists.)

Prolonged acute postsurgical pain (PAPSP) contributes to the development of chronic postsurgical pain, impaired rehabilitation, longer hospital stays, and decreased quality of life. For upper extremity analgesia, the duration of postoperative pain management with continuous brachial plexus peripheral nerve blocks is limited due to the risk of infection. Ultrasound-guided percutaneous cryoneurolysis provides extended analgesia and avoids the risks and inconveniences of indwelling catheters. We present 2 cases of PAPSP of the forearm effectively managed by the use of ultrasound-guided percutaneous cryoneurolysis to treat the medial, lateral, and posterior antebrachial cutaneous nerves., Competing Interests: Conflicts of Interest: The University of California San Diego has received funding and/or product from the following companies for other research studies of E. T. Said: Epimed International, SPR Therapeutics, Infutronix, Avanos Medical, Masimo, and Varian Medical Systems. Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Introduction: Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions., Methods: All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared., Results: Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01)., Conclusions: This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use., Methods: This was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24-48 h and 48-72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series., Results: There were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] (p < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort (p = 0.005)., Conclusions: The implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy., (© 2024. The Author(s).)

Background: Percutaneous auricular nerve stimulation (neuromodulation) is an analgesic technique involving the percutaneous implantation of multiple leads at various points on/around the ear followed by the delivery of electric current using an external pulse generator. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized, controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following total knee arthroplasty., Methods: Within the recovery room following primary, unilateral, total knee arthroplasty, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied using three percutaneous leads and one ground electrode. Participants were randomized to 5 days of either electrical stimulation or sham stimulation in a double-masked fashion. Participants were discharged with the stimulator in situ and removed the disposable devices at home. The dual primary treatment effect outcome measures were the cumulative opioid use (oral oxycodone) and the mean of the "average" daily pain measured with the Numeric Rating Scale for the first 5 postoperative days., Results: During the first five postoperative days, oxycodone consumption in participants given active stimulation (n=15) was a median (IQR) of 4 mg (2-12) vs 13 mg (5-23) in patients given sham (n=15) treatment (p=0.039). During this same period, the average pain intensity in patients given active stimulation was a median (IQR) of 2.5 (1.5-3.3) vs 4.0 (3.6-4.8) in those given sham (p=0.014). Awakenings due to pain over all eight postoperative nights in participants given active stimulation was a median (IQR) of 5 (3-8) vs 11 (4-14) in those given sham (p<0.001). No device-related localized cutaneous irritation, systemic side effects, or other adverse events were identified., Conclusions: Percutaneous auricular neuromodulation reduced pain scores and opioid requirements during the initial week after total knee arthroplasty. Given the ease of application as well as the lack of systemic side effects and reported complications, a definitive clinical trial appears warranted., Trial Registration Number: NCT05521516., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Competing Interests: Competing interests: BMI, JJF, ETS, and BA: The University of California San Diego has received funding and/or product from the following companies for other research studies of these authors: Epimed International (Dallas, Texas, USA), SPR Therapeutics (Cleveland, Ohio, USA), InfuTronix (Natick, Massachusetts, USA), Avanos Medical (Irvine, California, USA), Masimo (Irvine, CA, USA), and Varian Medical Systems (Palo Alto, California, USA). BJC: The University of California San Diego has received product from Masimo (Irvine, CA, USA) for other research studies. ANQ: No conflicts to disclose.

Introduction: Regional anesthesia has been shown to be efficacious for analgesia in patients who underwent thoracotomies. The objective of this study was to analyze the association of epidurals and peripheral regional anesthesia with time to hospital discharge for these patients., Methods: This was a retrospective cohort study using National Surgical Quality Improvement Program dataset from 2014 to 2020. Propensity-matched cohorts were assembled based on use of regional anesthesia, peripheral regional anesthesia, or epidural. Fine-Gray competing risk regressions were used to explore the association between regional anesthesia use and rate of discharge. The subdistribution hazard ratio (HR) represented relative discharge rates, and in-hospital death was a competing event. A sensitivity analysis was subsequently performed in which patients with American Society of Anesthesiologists score ≥4 were removed., Results: There were 4350 patients included in this analysis, in which 472 (10.8%) received a peripheral regional anesthesia nerve block and 565 (13.0%) received thoracic epidural analgesia. The subdistribution HR for rate of discharge in the epidural versus non-epidural cohort was 1.09 (95% CI 1.01 to 1.18), thus epidurals were associated with an increased rate of discharge over time. However, this benefit was no longer apparent with the sensitivity analysis. The subdistribution HR for rate of discharge in the peripheral regional anesthesia versus no regional anesthesia cohort was 1.26 (95% CI 1.15 to 1.39), thus peripheral regional anesthesia was associated with an increased rate of discharge over time. This benefit remained even with the sensitivity analysis., Conclusions: Thoracic epidural use when compared with no regional anesthesia was associated with decreased length of stay following thoracotomy in our primary analysis. The difference was no longer apparent with the sensitivity analysis. Peripheral regional anesthesia was associated with decreased length of stay even after sensitivity analysis., Competing Interests: Competing interests: The University of California has received funding and product for other research projects from Epimed International (Farmers Branch, TX); Infutronics (Natick, MA); Precision Genetics (Greenville County, SC); and SPR Therapeutics (Cleveland, OH) for the following author: RG. The University of California San Diego is a consultant for Avanos (Alpharetta, GA), in which RG represents., (© American Society of Regional Anesthesia & Pain Medicine 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Ultrasound-guided percutaneous cryoneurolysis provides analgesia using cold temperatures to reversibly ablate peripheral nerves. Cryoneurolysis probes pass a gas through a small internal annulus, rapidly lowering the pressure and temperature, forming an ice ball to envelope the target nerve. Analgesia is compromised if a nerve is inadequately frozen, and laboratory studies suggest that pain may be paradoxically induced with a magnitude and duration in proportion with the incomplete ablation. We therefore investigated the relative effects of various factors that may contribute to the size of the ice ball and the effective cryoneurolysis zone., Methods: A cryoprobe was inserted into a piece of meat, a gas was passed through for 2 min, and the resulting ice ball width (cross-section) and length (axis parallel to the probe) were measured using ultrasound, with the temperature evaluated in nine concentric locations concurrently., Results: The factor with the greatest influence on ice ball size was probe gauge: in all probe types, a change from 18 to 14 increased ice ball width, length, and volume by up to 70%, 113%, and 512% respectively, with minimum internal temperature decreasing as much as from -5 to -32 °C. In contrast, alternating the type of meat (chicken, beef, pork) and the shape of the probe tip (straight, coudé) affected ice ball dimensions to a negligible degree. The ice ball dimensions and the zone of adequate temperature drop were not always correlated, and, even within a visualized ice ball, the temperature was often inadequate to induce Wallerian degeneration., Conclusions: Percutaneous probe design can significantly influence the effective cryoneurolysis zone; visualizing a nerve fully encompassed in an ice ball does not guarantee adequate treatment to induce the desired Wallerian degeneration because ice forms at temperatures between 0 and -20 °C, whereas only temperatures below -20 °C induce Wallerian degeneration. The correlation between temperatures in isolated pieces of meat and perfused human tissue remains unknown, and further research to evaluate these findings in situ appears highly warranted., (© 2023. The Author(s).)

Background Gender-affirming pelvic surgery (GAPS) can be associated with significant postoperative pelvic pain. Given the lack of available peripheral nerve blocks to the perineum, intrathecal morphine (ITM) injection could offer a potent analgesic modality for this patient population. No prior studies to date have been performed examining the analgesic effects of intrathecal morphine for these patients. Methods This retrospective case-control study aims to understand the postoperative analgesic effects of intrathecal morphine for these patients with a historical comparison group of patients who did not receive intrathecal morphine. Results Fourteen patients presented for gender-affirming pelvic surgery over an eight-month period at a single institution and were offered intrathecal morphine for postoperative analgesia. Their analgesic results were compared to a similar historical group of 13 patients who were not offered or declined intrathecal morphine. Conclusions Intrathecal morphine injection is a potent analgesic modality for patients presenting for gender-affirming pelvic surgery., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Swisher et al.)

Background: Expansion of clinical guidance tools is crucial to identify patients at risk of requiring an opioid refill after outpatient surgery., Objective: The objective of this study was to develop machine learning algorithms incorporating pain and opioid features to predict the need for outpatient opioid refills following ambulatory surgery., Methods: Neural networks, regression, random forest, and a support vector machine were used to evaluate the data set. For each model, oversampling and undersampling techniques were implemented to balance the data set. Hyperparameter tuning based on k-fold cross-validation was performed, and feature importance was ranked based on a Shapley Additive Explanations (SHAP) explainer model. To assess performance, we calculated the average area under the receiver operating characteristics curve (AUC), F1-score, sensitivity, and specificity for each model., Results: There were 1333 patients, of whom 144 (10.8%) refilled their opioid prescription within 2 weeks after outpatient surgery. The average AUC calculated from k-fold cross-validation was 0.71 for the neural network model. When the model was validated on the test set, the AUC was 0.75. The features with the highest impact on model output were performance of a regional nerve block, postanesthesia care unit maximum pain score, postanesthesia care unit median pain score, active smoking history, and total perioperative opioid consumption., Conclusions: Applying machine learning algorithms allows providers to better predict outcomes that require specialized health care resources such as transitional pain clinics. This model can aid as a clinical decision support for early identification of at-risk patients who may benefit from transitional pain clinic care perioperatively in ambulatory surgery., (©Rodney Allanigue Gabriel, Sierra Simpson, William Zhong, Brittany Nicole Burton, Soraya Mehdipour, Engy Tadros Said. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 08.02.2023.)

Percutaneous peripheral nerve stimulation is used to provide analgesia for weeks or even months. While infection of any percutaneously implanted object is a concern, it is exceedingly rare for helically coiled leads, with a reported incidence of less than 1 infection for every 32,000 indwelling days. We now report an infected helically coiled lead requiring sedation for extraction and complicated by lead fracture during removal, leaving a remnant in situ. The infection was successfully treated with oral antibiotics. We speculate on the cause of this infection and propose steps to prevent this complication, including the avoidance of sling-to-lead insertion site overlap., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Background: Ultrasound-guided percutaneous cryoneurolysis is an analgesic technique in which a percutaneous probe is used to reversibly ablate a peripheral nerve(s) using exceptionally low temperature, and has yet to be evaluated with randomized, controlled trials. Pain after mastectomy can be difficult to treat, and the authors hypothesized that the severity of surgically related pain would be lower on postoperative day 2 with the addition of cryoanalgesia compared with patients receiving solely standard-of-care treatment., Methods: Preoperatively, participants at one enrolling center received a single injection of ropivacaine, 0.5%, paravertebral nerve block at T3 or T4, and perineural catheter. Participants subsequently underwent an active or sham ultrasound-guided percutaneous cryoneurolysis procedure of the ipsilateral T2 to T5 intercostal nerves in a randomized, patient- and observer-masked fashion. Participants all received a continuous paravertebral block with ropivacaine, 0.2%, until the early morning of discharge (usually postoperative day 2). The primary endpoint was the average pain level measured using a 0 to 10 numeric rating scale the afternoon of postoperative day 2. Participants were followed for 1 yr., Results: On postoperative day 2, participants who had received active cryoneurolysis (n = 31) had a median [interquartile range] pain score of 0 [0 to 1.4] versus 3.0 [2.0 to 5.0] in patients given sham (n = 29): difference -2.5 (97.5% CI, -3.5 to -1.5), P < 0.001. There was evidence of superior analgesia through month 12. During the first 3 weeks, cryoneurolysis lowered cumulative opioid use by 98%, with the active group using 1.5 [0 to 14] mg of oxycodone compared with 72 [20 to 120] mg in the sham group (P < 0.001). No oral analgesics were required by any patient between months 1 and 12. After 1 yr chronic pain had developed in 1 (3%) active compared with 5 (17%) sham participants (P < 0.001)., Conclusions: Percutaneous cryoneurolysis markedly improved analgesia without systemic side effects or complications after mastectomy., (Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved.)

We present a case series to demonstrate proof-of-concept for the off-label use of an auricular neuromodulation device-originally developed to treat symptoms associated with opioid withdrawal-to instead provide analgesia and opioid-sparing following knee and hip arthroplasties. Within the recovery room, an auricular neuromodulation device (near-field stimulator system 2 [NSS-2] Bridge, Masimo) was applied to 5 patients. Average daily pain at rest and while moving was a median of 0 to 2 as measured on the 0 to 10 numeric rating scale, while median daily oxycodone use was 0 to 2.5 mg until device removal at home on postoperative day 5. One patient avoided opioid use entirely., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Background: The potential benefit of regional interventions for simple lumpectomy breast cancer surgeries has not been well investigated. Understanding which patients to not offer a regional intervention to can be just as important as knowing which would benefit. It is unclear whether fascial plane blocks, such as serratus anterior plane (SAP) block, should be routinely performed for less extensive breast surgeries. Therefore, our goal in this retrospective cohort study was to evaluate the association of integrating SAP blocks into a standard perioperative multimodal analgesia plan in patients undergoing simple lumpectomies (without node biopsies) with perioperative opioid consumption. As secondary outcomes, we also analyzed postoperative pain scores and post-anesthesia care unit (PACU) length of stay., Methods: This was a single institution retrospective cohort study (surgical site infiltration only versus SAP block cohorts) assessing the association of SAP blocks to our outcomes of interest. In the adjusted analysis, we created matched cohorts using 1:1 (surgical site infiltration only: SAP block) propensity-score matching using nearest neighbor-matching without replacement. To compare the primary and secondary outcomes in the matched cohorts, we used the Wilcoxon signed rank test. A P-value of < 0.05 was considered statistically significant., Results: There were 419 patients included in the analysis, in which 116 (27.7%) received a SAP block preoperatively in addition to our standard perioperative analgesia plan. In an unadjusted analysis, no differences were seen in perioperative opioid consumption, PACU pain scores, and PACU length of stay. Among the matched cohorts, the median [quartile] perioperative opioid consumption in the surgical site infiltration only versus SAP block cohorts were 10 mg [10, 13.25 mg] and 10 mg [7, 15 mg], respectively (P = 0.16). No differences were seen in the other outcomes., Conclusions: In this study, we evaluated the impact of SAP blocks on patients undergoing simple lumpectomies, which are relatively less involved breast surgeries. We concluded that routine use of preoperative regional anesthesia is not beneficial for these specific patients. Future studies should focus on identifying patients that would directly benefit from regional interventions., (© 2022. The Author(s).)

Background: There are few effective pain treatments following trauma on the battlefield other than opioids, which are limited by respiratory depression. Ultrasound-guided percutaneous peripheral nerve stimulation ("neuromodulation") has been proposed as an analgesic, but requires physician-level skills, advanced equipment, and an hour to administer. In contrast, percutaneous auricular neuromodulation may be placed by a medic in the field under nonsterile conditions in a few minutes, theoretically provides analgesia for any anatomic location, has no side effects, and no significant risks. It therefore offers the potential to be applied quickly on the battlefield without any of the limitations of opioids. We propose total joint replacement as a surrogate for battlefield trauma and here present a case report to demonstrate proof of concept., Methods: Following open total knee or hip arthroplasty under spinal anesthesia, two patients had an auricular neuromodulation device applied within the recovery room. Patients were discharged with the unit and contacted daily for 7 days., Results: The devices were each applied in under 3 minutes without difficulty, were well tolerated during use, and removed without complication at home on Day 5. During use, neither patient experienced pain while lying, sitting, or ambulating. Neither required analgesics other than scheduled celecoxib; and a single tablet (50 mg) of tramadol for one patient on postoperative Days 3 and 4 for pain while lowering herself to a seated position. On Days 6 and 7, both patients experienced an increase in pain, one of whom required around-the-clock tramadol., Conclusion: Ambulatory postoperative percutaneous auricular neuromodulation is feasible. In these two cases, it appears to have markedly reduced pain scores and opioid requirements free of systemic side effects during the week following major orthopedic surgery. Considering the potential of this modality to treat trauma on the battlefield without systemic side effects, additional investigation appears warranted., Level of Evidence: Therapeutic/care management; Level V., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Background: Following outpatient surgery, it is often difficult to provide adequate analgesia while concurrently minimizing opioid requirements. Ultrasound-guided percutaneous peripheral nerve stimulation has been proposed as an analgesic, but requires physician-level skills, advanced equipment, up to an hour to administer, and is frequently cost prohibitive. In contrast, percutaneous auricular neuromodulation may be placed by nursing staff in a few minutes without additional equipment, theoretically provides analgesia for nearly any anatomic location, lacks systemic side effects, and has no significant risks. We now present a case report to demonstrate proof of concept for the off-label use of an auricular neuromodulation device-originally developed to treat symptoms associated with opioid withdrawal-to instead provide analgesia following outpatient surgery., Case Presentation: Following moderately painful ambulatory orthopedic and breast surgery, seven patients had an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) affixed within the recovery room in approximately 5 min and discharged home. Average resting and dynamic pain scores measured on the 0-10 Numeric Rating Scale were a median of 1 over the first 2 days, subsequently falling to 0. Five patients avoided opioid use entirely, while the remaining two each consumed 5 mg of oxycodone during the first 1-2 postoperative days. After 5 days, the devices were removed at home and discarded., Conclusions: These cases demonstrate that ambulatory percutaneous auricular neuromodulation is feasible and may be an effective analgesic and decreasing or even negating opioid requirements following outpatient surgery. Considering the lack of systemic side effects, serious adverse events, and misuse/dependence/diversion potential, further study with a randomized, controlled trial appears warranted., Competing Interests: Competing interests: The University of California San Diego has received funding and/or product from the following companies for other research studies of the authors: Epimed International (Farmers Branch, Texas, USA), SPR Therapeutics (Cleveland, Ohio, USA), Infutronix (Natick, Massachusetts, USA), and Avanos Medical (Irvine, California, USA)., (© American Society of Regional Anesthesia & Pain Medicine 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The common technique using a basal infusion for an ambulatory continuous peripheral nerve blocks frequently results in exhaustion of the local anesthetic reservoir before resolution of surgical pain. This study was designed to improve and prolong analgesia by delaying initiation using an integrated timer and delivering a lower hourly volume of local anesthetic as automated boluses. The hypothesis was that compared with a traditional continuous infusion, ropivacaine administered with automated boluses at a lower dose and 5-h delay would (1) provide at least noninferior analgesia (difference in average pain no greater than 1.7 points) while both techniques were functioning (average pain score day after surgery) and (2) result in a longer duration (dual primary outcomes)., Methods: Participants (n = 70) undergoing foot or ankle surgery with a popliteal-sciatic catheter received an injection of ropivacaine 0.5% with epinephrine (20 ml) and then were randomized to receive ropivacaine (0.2%) either as continuous infusion (6 ml/h) initiated before discharge or as automated boluses (8 ml every 2 h) initiated 5 h after discharge using a timer. Both groups could self-deliver supplemental boluses (4 ml, lockout 30 min); participants and outcome assessors were blinded to randomization. All randomized participants were included in the data analysis., Results: The day after surgery, participants with automated boluses had a median [interquartile range] pain score of 0.0 [0.0 to 3.0] versus 3.0 [1.8 to 4.8] for the continuous infusion group, with an odds ratio of 3.1 (95% CI, 1.23 to 7.84; P = 0.033) adjusting for body mass index. Reservoir exhaustion in the automated boluses group occurred after a median [interquartile range] of 119 h [109 to 125] versus 74 h [57 to 80] for the continuous infusion group (difference of 47 h; 95% CI, 38 to 55; P < 0.001 adjusting for body mass index)., Conclusions: For popliteal-sciatic catheters, replacing a continuous infusion initiated before discharge with automated boluses and a start-delay timer resulted in better analgesia and longer infusion duration., (Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved.)

Background: The objective of this study is to develop predictive models for persistent opioid use following lower extremity joint arthroplasty and determine if ensemble learning and an oversampling technique may improve model performance., Methods: We compared various predictive models to identify at-risk patients for persistent postoperative opioid use using various preoperative, intraoperative, and postoperative data, including surgical procedure, patient demographics/characteristics, past surgical history, opioid use history, comorbidities, lifestyle habits, anesthesia details, and postoperative hospital course. Six classification models were evaluated: logistic regression, random forest classifier, simple-feedforward neural network, balanced random forest classifier, balanced bagging classifier, and support vector classifier. Performance with Synthetic Minority Oversampling Technique (SMOTE) was also evaluated. Repeated stratified k-fold cross-validation was implemented to calculate F1-scores and area under the receiver operating characteristics curve (AUC)., Results: There were 1042 patients undergoing elective knee or hip arthroplasty in which 242 (23.2%) reported persistent opioid use. Without SMOTE, the logistic regression model has an F1 score of 0.47 and an AUC of 0.79. All ensemble methods performed better, with the balanced bagging classifier having an F1 score of 0.80 and an AUC of 0.94. SMOTE improved performance of all models based on F1 score. Specifically, performance of the balanced bagging classifier improved to an F1 score of 0.84 and an AUC of 0.96. The features with the highest importance in the balanced bagging model were postoperative day 1 opioid use, body mass index, age, preoperative opioid use, prescribed opioids at discharge, and hospital length of stay., Conclusions: Ensemble learning can dramatically improve predictive models for persistent opioid use. Accurate and early identification of high-risk patients can play a role in clinical decision making and early optimization with personalized interventions., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2022. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Introduction: The use of opioids in mastectomy patients is a particular challenge, having to balance the management of acute pain while minimizing risks of continuous opioid use postoperatively. Despite attempts to decrease postmastectomy opioid use, including regional anesthetics, gabapentinoids, topical anesthetics, and nonopioid anesthesia, prolonged opioid use remains clinically significant among these patients. The goal of this study is to identify risk factors and develop machine-learning-based models to predict patients who are at higher risk for postoperative opioid use after mastectomy., Methods: In this retrospective cohort study, we collected data from patients that underwent mastectomy procedures. The primary outcome of interest was defined as oxycodone milligram equivalents (OME) greater than or equal to the 75% of OME use on a postoperative day 1. Model performance (area under the receiver-operating characteristics curve (AUC)) of various machine learning approaches was calculated via 10-fold cross-validation. Odds ratio (OR) and 95% confidence intervals (CI) were reported., Results: There were a total of 148 patients that underwent mastectomy and were included. The medium (quartiles) postoperative day 1 opioid use was 5 mg OME (0.25 mg OME). Using multivariable logistic regression, the most protective factors against higher opioid use was being postmenopausal (OR: 0.13, 95% CI: 0.03-0.61, p = 0.009) and cancer diagnosis (OR: 0.19, 95% CI: 0.05-0.73, p = 0.01). The AUC was 0.725 (95% CI: 0.572-0.876). There was no difference in the performance of other machine-learning-based approaches., Conclusions: The ability to predict patients' postoperative pain could have a significant impact on preoperative counseling and patient satisfaction., Competing Interests: Rodney Gabriel serves on the advisory board for Avanos and Acacia Pharmaceuticals. Rodney Gabriel and Engy Said’s institution has received research funding from Epimed, Teleflex, and SPR Therapeutics., (Copyright © 2022, Dolendo et al.)

Introduction: In an effort to decrease physician contribution to the opioid crisis, we utilized a narcotic free pathway (NFP) after urethroplasty. Our objectives were to demonstrate feasibility of a NFP and identify patients at higher risk for requiring postoperative narcotics., Materials and Methods: We implemented a NFP for patients undergoing urethroplasty. Pain was assessed using the Likert scale (1-10). Narcotic use was quantified using oral morphine equivalents (OMEs)., Results: Forty-six patients underwent urethroplasty following the NFP over a 7-month period. Fifteen patients were excluded, leaving 31 patients in the final analysis. Postintervention data was compared to 30 patients who underwent urethroplasty prior to implementation of the NFP. The groups had similar demographics except for a history of heroin abuse (0% preintervention, 12.9% postintervention, p = 0.04). Surgical characteristics were not statistically different aside from length of surgery (183.6 minutes preintervention, 145.5 minutes postintervention, p = 0.01). The mean [SD] perioperative OME use preintervention was 194.9 [151] mg, compared to 40.4 [111.9] mg postintervention (p < 0.001). Six patients postintervention were discharged with a narcotic prescription (mean 27.5 mg OME) compared to 26 patients preintervention (mean 76 mg OME) (p < 0.001). There was no difference in pain scores at any time interval. Patients with a history of chronic opioid use were more likely to require narcotics (OR 5.33, CI 1-28.44)., Conclusions: The narcotic free pathway resulted in a dramatic reduction in narcotic prescriptions without a significant difference in postoperative pain scores. Opioid use can be minimized following urethral and perineal surgery.

Background: Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique., Methods: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior., Results: Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0-5.5) vs 0 (0-3.0) for those with paravertebral blocks (n=51): 0.95% CI -3.00 to -0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10-19) vs 10 mg (10-16) for the paravertebral group: 95% CI -4.50 to 0.00, p=0.123. Since the 95% CI lower limit of -4.5 was less than our prespecified margin of -2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption., Conclusions: Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery., Trial Registration Number: NCT03860974., Competing Interests: Competing interests: The University of California has received funding and product for other research projects from Epimed International (Farmers Branch, Texas, USA); Infutronics (Natick, Massachusetts, USA); and SPR Therapeutics (Cleveland, Ohio, USA) for the following authors: RG, MWS, JFS, ETS, BK, JJF, AMW and BMI. RG is a consultant for Avanos (Alpharetta, Georgia, USA)., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We examined the association of body mass index (BMI) with sociodemographic data, medical comorbidities and hospital admission following ambulatory foot and ankle surgery. We conducted an analysis utilizing data from the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016. Adult patients who underwent ankle surgery defined as ankle arthrodesis, ankle open reduction and internal fixation, and Achilles tendon repair in the outpatient setting. We examined 6 BMI ranges: <20 kg/m 2  underweight, ≥20 to <25 kg/m 2  normal weight, ≥25 to <30 kg/m 2  overweight, ≥30 to <40 kg/m 2  obese, ≥40 kg/m 2 to <50 kg/m 2  severely obese, and ≥50 kg/m 2 extremely obese. The primary outcome was hospital admission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p value of <.05 as statistically significant. Data extraction yielded 13,454 adult patients who underwent ambulatory ankle surgery. We then performed listwise deletion to exclude cases with missing observations. After excluding 5.4% of the data, the final study population included 12,729 patients. The overall rate of hospital admission was in the population was 18.6% (2,377/12,729). The overall rate of postoperative complications was 0.03% (4/12,729). We found no significant association of BMI with hospital admission following multivariable logistic regression. We recommend that BMI alone should not be solely used to exclude patients from having ankle surgery performed in an outpatient setting, especially since this patient group makes up a significant proportion of orthopedic surgery., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Angiomyomatous hamartomas are mixed-tissue benign lymphatic tumors that typically occur in the inguinal or axillary lymph nodes. These lesions may cause local lymphedema and painful compression neuralgias. Ultrasound-guided percutaneous cryoablation is an interventional technique that has been shown to provide sustained pain relief for peripheral neuropathies and neuralgias. Previously, our group published a case report of a patient with an inguinal angiomyomatous hamartoma causing a compression neuralgia, whose pain was temporarily alleviated after blockade of the femoral branch of the genitofemoral nerve. We present a follow-up case report describing this patient's sustained pain relief after cryoablation therapy., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)