Coplen Bs Johnson

Purpose of review The present investigation is the first systematic review and meta-analysis assessing analgesic efficacy of erector spinae plane blocks (ESPB) in patients undergoing nephrectomies. ESPBs have shown promise in various surgeries, but their efficacy in nephrectomy has not been comprehensively evaluated. This study compares patients that underwent nephrectomies with ESPBs and general anesthesia versus patients that had general anesthesia only. We performed a systematic search for studies from PubMed, Google Scholar, Embase, and Cochrane. Sources were considered for inclusion in the review if they were randomized controlled trials published from July 2014 to present in English. Data on postoperative opioid consumption, intraoperative opioid use, pain scores, and time to first analgesic request was extracted. The data was analyzed using EndNote, Rayyan, and RevMan software. Recent findings Our analysis included 7 studies with a total of 352 patients. ESPBs significantly reduced postoperative opioid consumption (mean difference = -11.28 mg IV (intravenous) morphine equivalents; 95% CI (confidence interval), -15.33 to -7.22; P < 0.00001) and intraoperative opioid use (mean difference = -0.08 mg IV fentanyl equivalents; 95% CI, -0.09 to -0.08; P < 0.00001). Also, the time to the first analgesic request was significantly longer in the ESPB group (mean difference = 52.86 min; 95% CI, 50.24 to 55.48; P < 0.00001). Pain scores were consistently lower in the ESPB group at various postoperative intervals. Summary ESPBs effectively reduce both opioid consumption and pain scores in nephrectomy patients. This approach can minimize opioid-related side effects and improve recovery.

Background Robot-assisted prostatectomy (RAP) can cause significant post-operative pain. Opioids are commonly used for relief, but they pose risks such as side effects and potential dependence. To reduce opioid usage, regional anesthesia approaches, especially various nerve block techniques, have been developed. However, evidence comparing the effectiveness of these different nerve blocks remains limited. Methods A systematic review was conducted to evaluate the effectiveness of different nerve block techniques on post-operative pain control after RAP. Databases were searched for randomized controlled trials (RCTs) that compared nerve blocks with either standard care or other regional anesthesia techniques. The primary outcomes assessed were pain scores, opioid consumption, recovery metrics, and treatment-related adverse effects. Results Eight studies comprising 696 participants were included. Intrathecal morphine consistently demonstrated the most significant reduction in post-operative pain and opioid use, though with increased incidence of pruritus and other side effects. Erector spinae plane blocks (ESPB) and rectus sheath blocks (RSB) were also effective, offering a favorable balance of analgesia and safety. Quadratus lumborum blocks (QLB) and pudendal nerve blocks (PNB) were found to effectively reduce pain, opioid usage, and side effects when they were used in a multimodal analgesic protocol. Alternatively, transversus abdominis plane blocks (TAPB) and caudal blocks were found to have mixed or no opioid-sparing effects. Because of methodological heterogeneity between studies, direct comparisons between blocks were limited. Conclusion Regional anesthesia techniques improve post-operative pain control and reduce opioid use after RAP. Given the lack of definitive superiority among techniques, analgesia should be individualized and incorporated into multimodal, opioid-sparing protocols. More large-scale, head-to-head trials are needed to guide optimal nerve block selection.

Purpose of Review Managing pain after hip surgery can be challenging, especially with the need to balance effective relief and early movement. Traditional pain management methods, such as opioids and nerve blocks, have been demonstrated to be efficacious but come with risks, including side effects, potential for opioid dependency, and the possibility of delays in mobility. Recent Findings The erector spinae plane block (ESPB) has recently gained attention as a newer option that may offer unique benefits. ESPB is an ultrasound-guided technique targeting nerves along the spine, providing broad and long-lasting pain relief without significant muscle weakness. This allows patients to start moving sooner, which is critical to recovery. Studies suggest ESPB can reduce opioid use and maintain motor strength better than other approaches, although more research is needed to confirm these findings across larger groups. Conclusion ESPB’s technique, however, still needs standardization to ensure consistent results, as variations in dosage and application can impact its effectiveness. Further research focusing on larger, controlled studies could better clarify ESPB’s role compared to traditional methods, especially regarding long-term recovery and quality of life. As more evidence accumulates, ESPB may become a valuable addition to pain management plans for hip surgery, especially for patients needing effective, low-risk analgesia.

Abdominal abscesses are commonly treated using percutaneous abscesses drainage (PAD). Despite PAD becoming commonplace in clinical practice, there are still unanswered questions and absent formal guidelines regarding its use. This narrative review discusses the evolution and different features of PAD, including the imaging modalities used in the process, catheter anatomy and sizes, placement techniques, the quantity of catheter side holes, and factors that determine the length of catheter stay and the usage of antibiotics for treating abdominal abscesses. Based on a retrospective review of the existing literature, this work is presented with an intent of identifying the most efficient design aspects and indications to optimize clinical success when performing PAD. This manuscript shows that there are still many unanswered questions and room for improvement regarding percutaneous drainage of abscesses.

Objective: Postoperative peri-lead edema (PLE) is an increasingly recognized complication of deep brain stimulation (DBS), a therapeutic intervention commonly used for neurological conditions such as Parkinson’s disease (PD), essential tremor (ET), intractable focal epilepsy, and dystonia. In this study, we conducted a retrospective chart review to evaluate the incidence of PLE and explore potential clinical and demographic risk factors. Methods: A single physician performed DBS electrode placements. To check for complications, postoperative computed tomography (CT) scans were conducted on the day of surgery and approximately 12–15 days afterward. Data on age, gender, complications, edema size, electrode laterality, lead target, lead brand, indication, and use of robotic assistance versus Starfix were collected and analyzed statistically. Results: 133 leads were implanted in 63 patients, with peri-lead edema (PLE) observed in 65 electrodes (48.87%). Minor postoperative complications, such as subarachnoid hemorrhage (SAH) and subdural hematoma (SDH), were noted in some patients. A few cases of severe PLE were recorded, with the most significant volume of edema reaching 85.11 cm³. No statistically significant differences were found between PLE-positive and PLE-negative patients based on age, sex, lead target, indication, or robotic assistance versus Starfix. However, the use of Boston Scientific electrodes was significantly associated with PLE, with a p-value of 0.047. A logistic regression model (p = 0.013, R² = 0.219) correctly classified 63.2% of cases, with no significant predictors of PLE, but imaging complications (p = 0.057) and electrode brand (p = 0.086) approached significance, with Boston Scientific electrodes linked to higher PLE risk compared to Abbott electrodes (p = 0.027, OR = 3.729). Conclusions: PLE appears more prevalent than previously reported and generally presents with delayed onset post-surgery. This retrospective analysis identified the use of Boston Scientific electrodes as a potential risk factor for PLE. Further research, particularly more extensive studies, is necessary to clarify the underlying mechanisms of PLE, improve prevention strategies, and enhance our understanding of this complication.

Purpose of Review Complex Regional Pain Syndrome (CRPS) is a neuropathic pain disorder characterized by pain disproportionate to the inciting event that is constant for an extended duration. Numerous treatment options for this condition have been explored with unsatisfactory results in many cases. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist typically used as an anesthetic and analgesic, presents a promising potential treatment for CRPS in patients who fail to respond to traditional therapies. Recent Findings Numerous studies report significant improvement in the degree of pain, mobility of extremities, and other parameters after ketamine infusion in patients with CRPS. Although adverse effects were not reported often, some subjects experienced nausea, vomiting, headache or psychotropic or psychomimetic symptoms which could be mitigated with cessation of the drug. Although more research is needed to determine optimal dosing and duration, ketamine seems to be a safe and effective treatment for refractory cases of CRPS. Conclusion The present investigation summarizes existing knowledge and research surrounding ketamine infusions for CRPS to provide a well-rounded depiction of advantages and disadvantages for physicians who may be considering it for patients with this challenging and complex condition.

Purpose of Review Chronic low back pain (LBP) is a prevalent and debilitating condition affecting millions worldwide. Among emerging interventions, spinal cord stimulation (SCS) has gained attention as a potential alternative for managing chronic LBP, particularly when alternative approaches fail to provide adequate relief. Recent Findings This systematic review focuses on both residual pain levels and ability to perform daily tasks after treatment with SCS. The present investigation includes a systematic search for studies from PubMed, Google Scholar, and Cochrane, and Embase. Sources were eligible for inclusion in the review if they were published from 2010 to present (May 1, 2024). 8 studies involving a total of 1,172 patients were evaluated. Summary This systematic review demonstrated that SCS is superior to conventional medical management (CMM) for both short and long-term pain relief, functionality, psychological well-being, and opioid dependency. Furthermore, newer SCS approaches, such as high frequency (HF), differential target multiplexed (DTM), and multiphase SCS all demonstrated improved efficacy over traditional SCS for pain relief and functionality scores. Adverse event rates for all trials were low and represent the safety of SCS treatments. The present investigation provides insight into the capabilities of both traditional SCS and HF SCS, DTM SCS, and multiphase SCS as compared to baseline pain and functionality as well as conventional medical management (CMM). This review grants physicians a broader picture of the applicability of SCS, its safety profile, and the opportunities it offers for pain reduction and functionality over CMM.

Tacrolimus and mycophenolate are important immunosuppressive agents used to prevent organ rejection in post-transplant patients. While highly effective, their use is associated with significant toxicity, requiring careful management. Tacrolimus, a calcineurin inhibitor, is linked to nephrotoxicity, neurotoxicity, metabolic disturbances such as diabetes mellitus and dyslipidemia, and cardiovascular complications such as hypertension and arrhythmias. Mycophenolate, a reversible inhibitor of inosine monophosphate dehydrogenase, frequently causes gastrointestinal disturbances, including diarrhea and colitis, as well as hematologic side effects like anemia and leukopenia, which increase infection risk. Therapeutic drug monitoring (TDM) and pharmacogenomics have emerged as essential strategies for mitigating these toxicities. TDM ensures tacrolimus trough levels are maintained within a therapeutic range, minimizing the risks of nephrotoxicity and rejection. Pharmacogenomic insights, such as CYP3A5 polymorphisms, allow for personalized tacrolimus dosing based on individual metabolic profiles. For mycophenolate, monitoring inosine monophosphate dehydrogenase activity provides a pharmacodynamic approach to dose optimization, reducing gastrointestinal and hematologic toxicities. Emerging tools, including dried blood spot sampling and pharmacokinetic modeling, offer innovative methods to simplify monitoring and enhance precision in outpatient settings. Despite their utility, the toxicity profiles of these drugs, including those of early immunosuppressants such as cyclosporine and azathioprine, necessitate further consideration of alternative immunosuppressants like sirolimus, everolimus, and belatacept. Although promising, these newer agents require careful patient selection and further research. Future directions in immunosuppressive therapy include integrating individual pharmacogenetic data to refine dosing, minimize side effects, and improve long-term graft outcomes. This narrative review underscores the importance of personalized medicine and advanced monitoring in optimizing post-transplant care.

Hepatic encephalopathy (HE) is a neuropsychiatric condition frequently associated with cirrhosis and portosystemic shunting (PSS). It imposes a significant clinical and economic burden, with increasing attention toward identifying modifiable factors that could improve outcomes. Emerging evidence suggests that vitamin D deficiency (VDD), prevalent in patients with cirrhosis, may contribute to the development and severity of HE. This review explores the association between VDD and HE by analyzing the underlying pathophysiology, including oxidative stress, ammonia accumulation, and impaired hepatic function. Additionally, we summarize recent studies highlighting the correlation between low serum 25-hydroxy vitamin D (25-OHD) levels and worsening grades of HE. Despite strong observational data, interventional studies on vitamin D (VD) supplementation for HE remains limited. Current evidence suggests that VD’s antioxidant properties may alleviate oxidative stress in HE, with potential benefits in mitigating disease severity. Future research should focus on longitudinal studies and randomized controlled trials to evaluate the clinical impact of VD supplementation on HE outcomes and explore VD’s role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedures. Understanding the therapeutic potential of VD could lead to improved management strategies for HE and cirrhotic patients at large.

Primary Ewing sarcoma of the kidney (ESK) is a rare and aggressive malignancy often misdiagnosed as renal cell carcinoma (RCC) due to non-specific radiological features. Accurate diagnosis requires histology, immunohistochemistry (IHC) and molecular studies. We report the case of a female in her 20s presenting with abdominal pain, haematuria and weight loss, initially diagnosed with RCC. Imaging revealed a large renal mass and pulmonary embolus. Mechanical thrombectomy (MT) was performed, and biopsy of the pulmonary thrombus confirmed metastatic ESK through IHC and next-generation sequencing, identifying the EWSR1–FLI1 gene fusion. The patient was treated with neoadjuvant chemotherapy (NAC) and interventional procedures. This case highlights the importance of considering ESK in differential diagnoses of renal masses and the utility of MT in obtaining diagnostic tissue, which allowed for the timely initiation of NAC and improved clinical management.