Pain is considered as the fifth vital sign, and the need to control pain after surgery emphasizes its importance. Pain after surgery leads to unpleasant outcomes and effects on different mechanisms thus causes fundamental changes in the metabolism of the body of susceptible people. Accordingly, the current article aimed to compare two methods of pain control by the patient using PCA pumps compared to medicine injection to ease the pain by nurses.Methodology: In the current research, a single-blind clinical trial of 70 patients as nominees of undergoing open-heart surgery at Shiraz Ordibehesht Hospital during 12 months was examined. The patients randomly divided into two groups of 35 patients with pain control by analgesia pumps of PCA and by NCA. The pain intensity was analyzed by visual analog scale (VAZ) and the sedation degree was examined based on the factors such as the Richmond sedation, nausea and vomiting and respiratory depression induced by opioids and analgesic effects, arterial oxygen saturation, patient satisfaction, ventilation duration for up to 48 hours after surgery. For data analysis, statistical software SPSS was used.Results: No statistically clear distinction was seen in the status of nausea and vomiting as well as in the length of ventilation and the oxygen saturation status between the two groups. In none of the two groups, respiratory depression was observed. There was a statistically notable variation between the two teams regarding satisfaction level. Also, an increasing significant decline in pain intensity was noted in both groups at consecutive times. There was an experimentally meaningful distinction between the two teams regarding degree of sedation (P < 0.001), such that the level of sedation in NCA group was higher (P < 0.001).Conclusion: The use of PCA pump in acute pain control after open cardiac surgery was better than the NCA. In the case of using the PCA pump, in addition to the psychological effect, the pump could control pain. Thus, the side effects of high dose injections would be reduced, and the increased use of the dose of drugs would not be detected. Pain is considered as the fifth vital sign, and the need to control it after surgery emphasizes its importance. Pain after surgery leads to unpleasant outcomes and affects different mechanisms, thus causing fundamental changes in the metabolism of the body of the susceptible people.Given the large open-heart surgery and the extreme anatomical and physiological changes that are unique in their kind, patients after surgery undergo severe and intolerable pains due to cuts in skin, muscle and bone that are especially done on the chest. Pain can not only lead to the recurrence of a heart attack but may also cause problems such as the reduction in the operational capacity of the lungs, the lack of an effective cough due to the pain and subsequently lung secretions accumulation, the atelectasis, pneumonia, and lung infection. Also, it may lead to tachycardia, hypertension, cardiac arrhythmias, thrombotic complications like (DVT), pulmonary embolism, pain, anxiety, insomnia, fear, dissatisfaction of patients with the operation, nausea, repeated vomiting, constipation, and flatulence, which should be eased by analgesics and particularly opioids. In pain management by nurses, high dose of narcotic medications is injected in the form of a bolus that causes some complications such as respiratory depression, hypotension, nausea, and vomiting.1]. PCA pumps operates the same as a lock and prevent excessive doses of drugs from entering the body. The patient pushes the control button to get the drug into the body, but the pump only injects the programmed amount [2]. In using the PCA pump, due to the continued injection of a little amount of drug (yet in a continuous manner), the beneficial effects of opioid analgesics can be observed, while their side effects are not observed. An effective method of pump pain relief is the use of PCA , which includes parts of a bolus dose, the required dose, and the intervals when the pump is locked, and continuous injection of a tranquilizer [3]. Daniel et al. (2005) presented a precise study and meta-investigation to evaluate whether or not PCA has a better clinical outcome than NCA. The results showed that in patients undergoing cardiac surgery by PCA method, the cumulative dose of morphine could be increased in 24-48 hours and therefore result in an improvement in VAS 48 hour compared to the NCA [4]. Also, the research conducted by Peterson et al. (2000) revealed that the treatment with PCA after coronary vein detour grafting surgery is preferably better in the treatment of the pain and more use of drugs externally an improvement in side impacts, related to conventional methods of pain control by NCA [5].Sima Lakdizaji et al. (2012) carried out a research entitled “the impact of pain control method by the patient on the relief of postoperative pain of coronary artery bypass surgery”. The results indicated that PCA method, with continuous infusion of morphine, leads to an increase in morphine consumption and a reduction in patient’s pain, and it seems that this method would be more efficient than NCA, and PCA method would be used in coronary artery graft bypass surgery [The current research aimed to analyze pain control in two groups of PCA and NCA in the patients of Ordibehesht Hospital in Shiraz. The present research was an interventional study and of a type of single-blind interventional randomized clinical trial, that tried to examine the benefits of pain control by using the PCA pump compared to drug injection to ease the pain by nurses.The target population included all the patients undergoing open-heart surgery during the 12-months period in 2015, who underwent the surgery in Ordibehesht Hospital in Shiraz. Exclusion criteria included: age more than seventy years, BUN ˃ 40 mg/ dl, Cr ˃ 2mg/ dl, EF < 30% (poor left ventricular function), drug allergy, drug or alcohol addiction, and withdrawal patients every time. In this study, 70 patients were randomly divided into two groups of 35 people of PCA and 35 people of NCA.In the control group, after being extubated, the patient’s expression of pain is controlled by routine medication injection procedures and by a nurse, and in PCA, the pain is controlled by continuous injections and bolus of PCA device.In PCA group, one day before the surgery, the patient was informed of the use of pumps and his consent to perform such act asked, and he was also trained how to push the button related to the pain pump. In this group, when the patient felt a new pain, he could press the button, and the pump infused an additional pre-determined dose of the bolus to the patient, and the patient’s pain reduced in this way.In this group, immediately after surgery and by entering the ICU, the pain pump was placed for 48 hours. The volume of PCA pump  was 100cc and lock time set 15 minutes, the duration of which was designed to prevent the patient’s overdose. Also, the infusion rate 4cc/ hr and bolus dose of 0.5 ccs/ every time (bolus dose by each time pushing the button is 0.5cc) were formulated. The pump contained morphine, midazolam, Apostle, and Ketamin. The dose of medication was such that in the first 24 hours, morphine 10 mg, midazolam 5 mg, Apostle 3 grams, 50 mg ketamine; and in the second 24 hours, morphine 5 mg, midazolam 5 mg, Apostle 2 grams, and ketamine 25 mg. Each one cc of the pump solution, at the first 24-hour, contained 0.1 mg of morphine, 0/ 05 mg of midazolam, 30 mg Apostle, and 0.5 Ketamine. In the 24 hours, each single cc of the pump solution included 0.05 mg morphine, 0.05 mg midazolam, 20 mg Apostle, and 0.25 mg ketamine.In NCA group, the patient’s pain was controlled by the nurse. Whenever the patient felt pain, the nurse administered analgesic medication as an IV based on the ward’s routine. The routine of the ICU ward of Ordibehesht Hospital used midazolam, diazepam, morphine, pethidine, Apostle, and the use of NSAID's medications. The nurses administered one of these drugs for pain relief based on the pain intensity. When the patient was on a ventilator, some medications such as midazolam, diazepam, morphine, pethidine were administered, and when the patient was intubated, Apostle and NSAIDs were used.In both groups, the used anesthetic medications were the same and included Midazolam, Morphine, Pavilion, Fentanyl, and Pentothal. The table on the visual analog pain scale (VAS) was based on some shape presented to the patients and patients expressed the degree of their pain and then they were recorded. The patients were asked about the amount of the pain every 6 hours of extubation until they admitted to ICU. Some recommendations were presented to the patients regarding the research at hand and how the visual scale analyzed the pain, and they were asked to reply to some questions on pain at regular intervals after surgery. VAS ranges from 0 to 10; in which 0 is no pain, and 10 is the maximum pain, i.e. the worst pain felt by the patient. The degree of patient’s sedation in PCA group was measured every six hours. The variables of the present research were nausea and vomiting, duration of ventilation, visual analog pain scale (VAS), sedation rate, artery oxygen saturation, and respiratory depression, and also patient satisfaction about the amount of pain that. In this study, the patient’s satisfaction was gained by orally asking some questions. Based on the questions, the patients were to rate their satisfaction on the tolerable level of pain, and the replies ranged from bad, not good, average, good and very good.n′=n × 11−pand the losing of 10%, and the final sample size that was 35 in each group, a total of 70 patients being needed.Sample size: according to the objectives and the type of the study, and based on the previous research in this regard, and also considering assumptions that included an error of 5%, capability of 80%, and the effect rate of 60%, using the formula,Block design permutations were used as a randomized method. After selecting each sample, the sample was assigned to treatments A and B by using the random number table. The numbers 0 to 4 were assigned to AB permutation, and 5 to 9 assigned to BA permutation. After completing a questionnaire and its thorough investigation, the data were inserted in the form of code in Code Sheet. The existing problems were rectified by using a review of the survey. Then, the coded data were entered into SPSS. After preparing data in SPSS, the data were once considered to ensure their authenticity.Data analysis was done by using descriptive statistics methods and independent t-test and analysis of variance with repeated measures, chi-square tests, McNemar’s tests, or nonparametric tests at 5% level of significance. To analyze the data, EXCELL and SPSS statistical software was used.Table 1.N this study, 70 patients in two groups of 35-subject PCA and NCA were reviewed. For comparing the Nausea/ Vomit (N/ V) in both groups, Chi-square was used. Based on this analysis, 45.7% of PCA and 54.3% of the NCA, had positive N/ V. However, the observed difference was not considered statistically significant (P = 0.473) Table 2, Fig. 1).There was no statistically significant difference regarding the status of nausea and vomiting of the two groups. To compare the satisfaction score in the two groups, Mann-Whitney U Test was used. Based on this test, a statistically significant difference was observed between the satisfaction scores of the two groups of patients (P < 0.001) (Table 3).To compare the length of ventilation (L/ V)) in two groups, a t-test was used. Accordingly, there was no clear distinction between the 2 teams (P = 0.401) , and PCA group had lower scores than the NCA . Also, a significant decline in pain intensity was observed in both groups at consecutive times .To compare the score VAS , at various times between the two groups, the analysis of variance with repeated measures was used, the analysis results being given in Table 5, Fig. 4).To compare the degree of sedate in the two groups, the analysis of variance with repeated measures was used. The findings indicated that there was a clear difference between the 2 teams (P < .001). Also, at various times, the difference between the two groups was compared by using a t-test, whose difference was not initially significant, but it was great at time 2 (1st post op day am) and 5 (1st post op day pm) was significant) . However, significant differences could be observed between the two groups, so that the degree of the sedate in the group NCA was at a higher state (P < 0.001).A diagram was used to show the trend of changes in the degree of sedation in both groups. Based on this diagram, in both groups, NCA and PCA had an increasing trend, while changes in PCA were at a lower level. Fig. 5,6).To compare the percentage of oxygen saturation in the group, ANOVA test was used with repeated measures. The results revealed that there was not a statistically clear variation between the 2 teams. This meant that at any time, no clear distinction was observed between the 2 teams, and both groups were statistically identical all the time (In none of the two groups, respiratory depression was observed. The length of stay in ICU was of 48 hours, and the duration of hospital stay was of five days; this was identical and did not differ in the two groups.Finally, it was found that the application of the PCA pump and keeping on infusion via small amounts of drugs after open-heart surgery could improve pain control and the side effects of drugs and an increased dose of drugs would not be seen.


To assess the correlation of symptoms with findings on esophageal high-resolution manometry (HRM) in Indian patients.Prospective data collection of all patients undergoing esophageal manometry was done at two centers in India—Indore and Chennai—over a period of 18 months. Symptom profile of the study group was divided into four: Motor dysphagia, noncardiac chest pain (NCCP), gastroesophageal reflux (GER), and esophageal belchers. The symptoms were correlated with manometric findings.Of the study group (154), 35.71% patients had a normal study, while major and minor peristaltic disorders were noted in 31.16 and 33.76% respectively. In patients with symptoms of dysphagia, achalasia cardia was the commonest cause (45.1%), followed by ineffective esophageal motility (IEM) (22.53%) and normal study (19.71%). In patients with NCCP, normal peristalsis (50%) and ineffective motility (31.25%) formed the major diagnosis. Of the 56 patients with GER symptoms, 26 (46.4%) had normal manometry. An equal number had ineffective motility. Of the 11 esophageal belchers, 7 (63.6%) of these had a normal study and 3 had major motility disorder. Dysphagia was the only symptom to have a high likelihood ratio and positive predictive value to pick up major motility disorder.Dysphagia correlates with high chance to pick up a major peristaltic abnormality in motor dysphagia. The role of manometry in other symptoms in Indian setting needs to be ascertained by larger studies.The present study highlights lack of symptom correlation with manometry findings in Indian patients.How to cite this article: Jain M, Srinivas M, Bawane P, Venkataraman J. Does Chicago Classification address Symptom Correlation with High-resolution Esophageal Manometry? Euroasian J Hepato-Gastroenterol 2017;7(2):122-125. Mikaeli et al3 have reported a good correlation between the intensity of the motor abnormality and symptom severity in achalasia.4 Fakhre Yaseri et al5 found HREM to be a useful tool in diagnosis of achalasia. It could differentiate achalasia from those who had normal esophageal motility.The esophageal motor function is evaluated using various techniques, including barium radiography, radionuclide transit studies, manometry with or without impedance testing, and more recently impedance planimetry.5 In our day-to-day practice, we encounter difficulty in correlating HREM findings with the clinical presentation. We therefore retrospectively correlated the HREM findings with symptoms in patients with dysphagia, NCCP, and GER disease.The diagnostic value of water perfusion HREM for indications other than achalasia, e.g., esophageal symptoms like dysphagia, GER disease is still unknown.In this study, 187 patients from two centers—Choithram Hospital and Research Centre, Indore (MJ) and Gleneagles Global Health City, Chennai — who had HREM between July 2014 and December 2015 were analyzed. Patients with one or more combination of symptoms of dysphagia, NCCP, regurgitation, and heartburn were included.Demographic data including age, gender, and symptoms of the patients were noted in detail. High-resolution manometry was done and reported by gastroenterologists with more than 2 years of experience with HRM. Manometry was done in supine position using 16-channel water perfusion systems . The studies were conducted with the patient in the supine position after at least a 6-hour fast, and medications that could affect the esophageal motor function  were discontinued for 5 to 7 days prior to the study. After application of topical anesthetic into the nostril, the manometry catheter was passed transnasally and the sensors were positioned to record from the hypo pharynx to the stomach. After the lower esophageal sphincter (LES) was detected via the stationary pull-through method, the catheter was fixed in place by taping it to the nose. Basal LES pressures were recorded for 1 minute. Wet swallows were done using ten swallows of 5 mL each. The data were reported as per Chicago Classification v 3.0. Patients below 18 years of age, previous foregut surgery, large hiatus hernia, esophagitis of grade C or D, eosinophilic or candidal esophagitis, Barrett’s esophagus, and cardiovascular disease were excluded.The correlation of following symptoms was assessed with the final manometry diagnosis: Dysphagia for both solids and liquids with or without weight loss, suggestive of motor dysphagia; NCCP; reflux symptoms; regurgitation and/or heartburn with or without NCCP; GER; and esophageal belchers; belchers.The correlation of above-mentioned symptoms to an identifiable manometric abnormality  was assessed by calculating sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and positive and negative predictive values.A total of 187 patients from two centers underwent HRM during the study period. Based on the fulfilment of inclusion criteria, 154 patients were included in the study. The male:female ratio was 1.32:1 and median age was 45.5 years (18-77 years). Of the study group, 55 (35.71%) patients had a normal study, while major and minor peristaltic disorders were noted in 31.16 and 33.76% respectively. Seventy-one patients presented with motor dysphagia. Achalasia cardia was the commonest cause (45.1%), followed by IEM (22.53%) and normal study (19.71%).Sixteen patients presented with NCCP. Among these patients, normal peristalsis (50%) and ineffective motility (31.25%) formed the major diagnosis after manometric evaluation. Major motility disorders, like achalasia cardia and absent peristalsis, were noted in three cases (18.75%). Of the 56 patients with GER symptoms, 26 (46.4%) had normal manometry. An equal number had ineffective motility. Fragmented peristalsis and absent contractility were noted in two cases (3.5%) each. None of these patients had dysphagia. Of the 11 esophageal belchers, 7 (63.6%) of these had a normal study. However, 2 patients had achalasia cardia (18.18%) and 1 each (9.1%) had ineffective motility and absent contractility. The manometry diagnosis with respect to the major symptoms studied is shown in 6 However, numerous factors that may affect transit and motility, such as bolus shape, surface, and consistency cannot be measured with manometry.7 Dysphagia and NCCP are considered to be the predominant symptoms in motility disorders. Regurgitation, heartburn, hoarseness, and asthma are hallmark of reflux disease.8 The present study was done to ascertain the correlation of symptoms and findings noted in esophageal manometry in Indian setting. While most patients presenting with dysphagia had a demonstrable abnormality of manometry, most patients with NCCP had a normal study. In patients with reflux symptoms, minor peristaltic abnormalities and normal manometry were the common reported findings. Interestingly, in the subset of esophageal belchers, we picked up major motility disorders in one-third of cases. In our group of patients, dysphagia for solids and liquids was the only symptom to have a higher likelihood of showing peristaltic abnormality. Symptoms of dysphagia had a high positive predictive value for detecting dysmotility. None of the other symptoms assessed showed a good positive predictive value or likelihood for detection of peristaltic abnormality. There are a few reports of symptom correlation with esophageal manometry outcomes. Saha et al9 reported that manometry showed abnormalities in 54.83, 68.42, and 38.70% of patients with reflux, dysphagia, and NCCP respectively. In reflux group, the most common abnormalities were hypoperistalsis (22%), followed by hypotensive LES (29.67%). In patients with dysphagia, the most common motor abnormality was achalasia cardia (55.26%), whereas in case of chest pain, hypotensive LES was frequently noted.10 Our study findings are similar to reported in other studies where it was noted that manometry yields a higher diagnostic value in patients with dysphagia. Manometry is not a first-choice functional diagnostic test in the study of patients with GER or NCCP.10 Gambitta et al,11 however, highlighted the role of manometry in symptoms of dysphagia, chest pain, and refractory reflux disease. Ineffective esophageal motil-ity is an important cause of symptoms in patients with chest pain, dysphagia, and reflux symptoms. It is also a minor esophageal motility disorder characterized by weak esophageal contractions that may result in abnormal esophageal bolus clearance. The clinical significance and outcome of this subgroup is not clearly known. However, few case reports of progression to major peristaltic abnormalities like esophageal spasm and achalasia have been reported in the literature.12 The changes of IEM are persistent even on long-term follow-up.13 Other authors have reported that esophageal symptoms may be secondary to esophageal hypersensitivity14 or to factors beyond the circular muscle contraction patterns,15 which at present cannot be fully estimated using HRM. The present study highlights the role of manometry in our setting in India. While HRM seems to have a definite role in evaluation of dysphagia, its role in evaluation of NCCP and belching remains to be studied. In reflux patients, we did not find any major peristaltic abnormality and this affirms our belief that esophageal manometry may not be required for all reflux patients. However, its role in refractory cases and prior to fundoplication remains to be studied in our setting. Our study has few limitations in view of small sample size and the fact that motility patterns may differ between liquid and solid boluses.Manometry is regarded as gold standard investigation of motility disorders in the esophagus. The transport of bolus is successful when minimal bolus material is retained within the esophageal body.Dysphagia correlates with high chance to pick up a major peristaltic abnormality in motor dysphagia. The role of manometry in other symptoms in Indian setting needs to be studied further. The significance of these manometry findings in terms of patient care and pharmacotherapy needs an in-depth evaluation. So the final question remains: Do we treat symptoms or do we treat the physiological changes at HRM which do not have significant correlation with patients symptoms? It is time that Chicago classification dwells and addresses these issues.Apart from dysphagia, none of the other common symptoms predict the presence of a major peristaltic abnormality in Indian patients.


Various pain management strategies for patients undergoing open excisional hemorrhoidectomy have been proposed, yet postoperative pain remains a frequent complaint.  To determine whether mesoglycan  would reduce the edema of the mucocutaneous bridges and thus improve postoperative pain symptoms.  For this prospective observational multicenter study, 101 patients undergoing excisional diathermy hemorrhoidectomy for III-IV degree hemorrhoidal disease were enrolled at 5 colorectal referral centers. Patients were assigned to receive either mesoglycan (study group SG) or a recommended oral dose of ketorolac tromethamine of 10 mg every 4–6 hours, not exceeding 40 mg per day and not exceeding 5 postoperative days according to the indications for short-term management of moderate/severe acute postoperative pain, plus stool softeners (control group CG). p < 0.001) and pain after rectal examination (p < 0.001) were significantly reduced at 7–10 days after surgery in the mesoglycan-treated group, permitting a faster return to work (p < 0.001); however, in the same group, the incidence of postoperative bleeding, considered relevant when needing a readmission or an unexpected outpatient visit, was higher, possibly owing to the drug's antithrombotic properties.  Postoperative thrombosis (SG 1/48 versus CG 5/45) ( The administration of mesoglycan after an open diathermy excisional hemorrhoidectomy can reduce postoperative thrombosis and pain at 7–10 days after surgery, permitting a faster return to normal activities. Hemorrhoids are a common, multifactorial benign but bothersome condition . Among tOpen excisional hemorrhoidectomy remains the gold standard technique despite the risk of postoperative bleeding and associated sequelae such as anal stenosis and fecal incontinence. Its main drawback is the frequent severe postoperative pain caused by postoperative scars, hygiene/social habits, hard stools, and diet, particularly by the edema of the mucocutaneous bridges, especially if a local thrombosis develops –12. StraThe aim of this prospective comparative observational multicenter study was to determine whether the administration of mesoglycan in patients undergoing hemorrhoidectomy would reduce postoperative pain.Mesoglycan belongs to a broad class of compounds called glycosaminoglycans that are amino hexose polysaccharides contained in mucoproteins, glycoproteins, and blood group substances. It is composed of dermatan sulfate, heparan sulfate, electrophoretically slow-moving heparin, and minimal quantities of chondroitin sulfate, hyaluronic acid, and related hexosaminoglycans . MesoglyOur hypothesis was that for the anti-inflammatory and profibrinolytic activities of the mesoglycan, its use could improve the postoperative pain due to edema and thrombosis of the mucocutaneous bridges.The study was approved by the local ethical committee of each site, and written informed consent was obtained from all patients.One hundred and one consecutive patients submitted to open diathermy excisional hemorrhoidectomy for grade III-IV hemorrhoids were enrolled at five colorectal referral centers from January 2016 to April 2016. The exclusion criteria were age < 18 or >80 years; history of coagulopathy, cardiac diseases, anticoagulant therapies, colorectal or anal neoplasms and/or inflammatory bowel disease (IBD) and/or other proctological diseases , and pelvic radiotherapy; previous anal surgical procedures; inability to return for postoperative control visits; and known allergy to mesoglycan. Proctological examination and proctoscopy were performed to grade hemorrhoid disease and to exclude any associated proctological or rectal pathologies. Patients aged more than 50 years or with symptoms suggestive of IBD underwent a preoperative pancolonoscopy.Patients were, alternatively, assigned to receive mesoglycan  or standard postoperative therapy, as established before the beginning of the study . Mesoglycan i.m. was always administered by a nurse on postoperative day 1 and then for the next 4 days by the same home-care nurse.All patients underwent an open diathermy excisional hemorrhoidectomy, under spinal or general anesthesia, with removal of the three classical piles. At each of the five centers, the procedure was carried out by a surgeon with at least 200 previous hemorrhoidectomies. Three v-shaped incisions were placed on the mucocutaneous border, leaving a skin bridge in between to avoid anal stenosis. No ligation of the vascular pedicle was applied and no contemporary internal sphincterotomy was performed. Discharge was planned the day after surgery.Patients were followed up by the same surgeon who had performed the procedure and were scheduled for a control visit at the first postoperative day (T1), at 7 to 10 days (T2), 20 days (T3), and 40 days after discharge (T4). The follow-up assessment comprised clinical external evaluation at T1, clinical evaluation with rectal digital exploration at T2, and clinical evaluation and proctoscopy at T3 and T4. Postoperative pain was evaluated using a visual analog scale (VAS) for pain in which 0 indicates no pain and 10 the worst possible pain.The presence of thrombosis, defined as one or more swollen painful piles at the site of mucocutaneous bridges, was assessed at T2, T3, and T4.A postoperative bleeding was considered relevant when needing a readmission or an unexpected outpatient visit.We considered autonomy as the return to normal activity: it includes also the return to work apart from cases of retired patients in which we considered it as the complete return to daily activities.The following data were collected: the name of the study site/surgeon; VAS at rest (VAS-sp), VAS after defecation (VAS-def), and VAS after rectal examination (VAS-espl); complications ; evaluation of surgical scars ; and possible autonomy and time of return to work.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.Due to the explorative, nonconfirmative nature of this research, no formal sample size determination was performed.Patient characteristics were analyzed using Fisher's exact test for categorical variables and either Mann–Whitney and Kruskal-Wallis tests (for independent measures) or Wilcoxon and Friedman tests (for repeated measures) for continuous variables. Descriptive results for continuous variables are expressed as the median (interquartile range [IQR]). For the continuous variables , the primary outcomes were their independent trends over time and the potential effects of mesoglycan therapy. These three variables were longitudinally measured at the four time points and then used as dependent variables in three independent univariate and multivariate mixed-effects linear model (MLM) series. Since the distributions of the VAS-sp, VAS-def, and VAS-espl time series by single time points were Gaussian, no log-transformation was needed. The three multivariate mixed-effects linear models for the repeated measures of VAS-sp, VAS-def, and VAS-espl were estimated by the restricted maximum likelihood method, using a first-order autoregressive covariance matrix: for every covariate, the variances at each time point were considered comparable and constant, while the correlations between subsequent measures were considered similar.p-values were obtained by the two-sided exact method at the conventional 5% significance level. Data were analyzed as of December 2016 using R version 3.3.2 .For the four categorical variables , the primary outcomes were their independent trends over time and the potential effects of mesoglycan therapy. The frequencies of these covariates are reported at the same four time points. The changes noted at the follow-up examination and the effects of mesoglycan were evaluated by the generalized estimating equations model (GEE for repeated measures logistic regression). GEE extends GLM  to longitudinal data, with correlated outcomes; the first-order autoregressive correlation matrix was used to represent the within-subject dependencies. Their trends over time  were estimated in four independent GEE models, analyzing the follow-up time after surgery (independent continuous variable) and the effects of mesoglycan  as its determinant. All reported n = 54, 21 women and 33 men) or standard postoperative therapy . The two groups were similar for sex, age, and grade of disease  (p = 0.332), except at T2, when a significant reduction in postoperative thrombosis was observed in the mesoglycan-treated group (p < 0.001) (p = 0.457). The time to return to work or normal daily activities was significantly shorter (p = 0.009) in the mesoglycan-treated group (= 0.488) . No pati= 0.488)  was simi< 0.001) . As expeed group .p = 0.033) for the mesoglycan-treated group (ed group . Also, tPostoperative pain is the most common complaint after an excisional hemorrhoidectomy, and it can be the reason for prolonged hospital stay and time off work , 6. WhilPostoperative pain after excisional hemorrhoidectomy generally results from a spasm of the internal anal sphincter and/or from a secondary infection of the surgical site, and many attempts have been proposed to reduce these possible etiopathogenetic factors. Metronidazole has been successfully used since 1998 for treating internal anal sphincter spasm , and itsLa Torre and Nicolai demonstrated a significant advantage in terms of postoperative comfort and reduction of pain and bleeding using a combination of micronized purified flavonoid fraction plus short-term antibiotic and anti-inflammatory treatment compared with an antibiotic and anti-inflammatory treatment alone .Owing to its analgesic and anti-inflammatory activities, atorvastatin can reduce the inflammation and irritation of the perianal skin , as seenThe aim of the present study was to determine whether the use of a product containing mesoglycan could reduce the local thrombosis and edema of the mucocutaneous bridges after an open excisional hemorrhoidectomy, with a consequent improvement of the postoperative pain.To our knowledge, this is the first report on the use of mesoglycan in the postoperative treatment of hemorrhoids. Only two old studies reported the use of mesoglycan in patients with acute hemorrhoidal disease , 42.The severe standardization of the pre-, intra- and postoperative managements of the patients is the main strength of our prospective comparative observational multicenter study, limiting the bias of the nonrandomization of the study.Our results indicate that mesoglycan therapy can reduce postoperative thrombosis and edema after an open diathermy excisional hemorrhoidectomy, with decreased postoperative pain symptoms, statistically significant at T2 after rectal examination. Even though this is the only significant result, we consider the possibility to return to work after 7–10 days after surgery as the main benefit of the mesoglycan from a socio-economical point of view, with a real faster return to work.In our opinion, these advantages depend on the initial postoperative intramuscular administration of a high dose of the drug. Of note, we also found a trend for a higher rate of postoperative bleeding at T2, probably due the well-known antithrombotic properties of the mesoglycan.A further interesting result was that mesoglycan was not inferior to standard treatment in controlling postoperative pain at any T.This study has several limitations. The number of patients is small and may not have sufficient power to reveal small difference in outcomes, but the major methodological flaw is the lack of a uniformed and standardized thrombosis-measuring tool. The different number of patients in the two groups depends on the strength of recruitment of the single centers.In our small series of patients, mesoglycan has been useful in reducing the incidence of thrombosis and the severity of pain at digital rectal examination after an open diathermy excisional hemorrhoidectomy at 7–10 days postop.This has allowed a faster return to normal daily activities. Further studies on larger patient samples are needed to confirm our results.


Patient satisfaction with postoperative pain management is an important quality indicator in patient health care, but its determinants are poorly understood. Here, we examined the contribution of the discrepancy between an individual’s estimated acceptable and actual postoperative pain scores to the overall satisfaction with pain treatment.A total of 93 surgical patients were included in this study. Preoperatively, the subjects were asked to rate their estimated acceptable postoperative pain using a numerical rating scale (NRS). One day after the surgery, the patients were again asked to give NRS ratings of the overall actual pain intensity they had experienced, as well as their satisfaction with the provided pain treatment. The median estimated acceptable and actual NRS values for postoperative pain were 4.0 (3.0–5.0) and 4.0 (2.0–5.0), respectively. Although there was no correlation between the degree of patient satisfaction and preoperative estimated acceptable pain intensity, there was a significant negative correlation between the degree of patient satisfaction and postoperative actual pain intensity. When the preoperative estimated acceptable NRS value was compared with the postoperative actual value for each individual, postoperative NRS was greater in 34 cases (36.6%), less in 43 cases (46.2%), and equal in 16 cases (17.2%). The degree of patient satisfaction was not significantly correlated with the magnitude of difference between preoperative estimated acceptable NRS and postoperative actual NRS.Our findings suggest that inquiring about the estimated acceptable pain before surgery may not help anesthesiologists to understand the patient’s goal of pain management for improving patient satisfaction. Patient satisfaction is widely used as an index to evaluate the quality of medical approaches and hospital services , 2. The In order to increase patient satisfaction with postoperative pain management, multimodal approaches are currently thought to be the most effective . The goaPain has been defined as an unpleasant sensory or emotional experience, and thus, self-report is considered to be the most valid measure of pain intensity . In thisThe study protocol was approved by the ethics committee of Kochi Medical School. The included subjects were scheduled to undergo benign elective surgery under general anesthesia: ASA classes 1–2, age 18–65 years, and those who have the capacity to understand the content of the questionnaire. Participants were excluded if they had previous history of surgery, diagnosed chronic pain, or currently uncontrolled pain. There were no other restrictions with regard to perioperative management, including type of analgesic intervention. The subjects of this study were limited to the patient undergoing benign elective surgery to minimize the possible confounding influence regarding psychological status associated with malignant conditions.One day before surgery, the patients were asked to estimate their acceptable levels of postoperative pain using a numerical rating scale (NRS) from 0 to 10, where 0 represents no pain and 10 the worst pain imaginable. Postoperative pain controls were conducted by anesthesiologists based on the standard manual of Kochi Medical School Hospital, e.g., non-steroidal anti-inflammatory drugs, intravenous patient-controlled analgesia with fentanyl, or epidural analgesia with local anesthetics and/or fentanyl, according to the type of surgery. One day after surgery, the patients were again asked to rate the average postoperative pain intensity (NRS 0–10) that they had experienced, as well as their overall satisfaction with the provided pain treatment  . The difα error of 0.05). With a 10% allowance for missing data, a sample size of 96 was obtained for this study. Correlation coefficients and p values were determined by using the Spearman rank correlation test, and p < 0.05 was considered statistically significant. Data were analyzed using the statistical software SPSS .The results of non-parametric data are presented as medians and interquartile ranges. Sample size calculation based on the results obtained from a previous study  indicater = 0.126, p = 0.227). On the other hand, as expected, there was a significant negative correlation between the degree of patient satisfaction and postoperative actual pain intensity . Thirty-four (36.6%) patients rated their actual NRS greater than estimated acceptable NRS, 43 (46.2%) patients rated their actual NRS less than estimated acceptable NRS, and 16 (17.2%) patients rated their actual NRS equal to estimated acceptable NRS. The degree of patient satisfaction was not significantly correlated with the magnitude of difference between preoperative estimated acceptable NRS and postoperative actual NRS .In this study, among the 96 patients eligible to participate, complete data could be obtained from 93 postoperative patients (97% response rate) and their demographic characteristics are shown in Table Successful pain management may be associated with an increase in patient satisfaction . HoweverSimilar to our findings, Gerbershagen and colleagues  previousIt is now well recognized that comprehensive approaches with multidisciplinary perioperative care teams including anesthesiologists, surgeons, pharmacists, and nurses could improve postoperative pain management . AdditioThere are some limitations in our work which should be addressed. First, patients’ satisfaction was measured by NRS, rather than the commonly applied dichotomous method. However, this allowed us to evaluate the correlation between pain intensity and the degree of satisfaction. Second, in order to investigate the surgical-type dependent impacts, it would be better to ask how much pain a patient expected for the scheduled surgery, rather than the estimated acceptable pain level. Third, in this study, we did not include the elderly population to avoid the potential confounding factor of cognitive impairment. Therefore, further research works including surgery-type and age-specific effects should be conducted.In conclusion, inquiring about a preoperative patient’s estimated acceptable pain level may not help anesthesiologists set the patient’s goal of pain management to improve their satisfaction.


Background. Validity of pain recall is questioned in research. Objective. To evaluate the reliability of pain intensity recall for seniors in an emergency department (ED). Methods. This study was part of a prospective multicenter project for seniors (≥65 years old) treated in an ED for minor traumatic injury. Pain intensity  was evaluated at the initial ED visit, at one week (baseline), and 3 months. At three months, patients were asked to recall the pain intensity they had at baseline. Results. 482 patients were interviewed  and 72.8% were female. Intraclass correlation coefficient between pain at baseline and its recall was 0.24 (95% CI: 0.14–0.33). Senior patients tended to overestimate their pain intensity by a mean of 1.2 (95% CI: 0.9–1.5) units. A stepwise multiple regression analysis showed that the variance of baseline pain recall at 3 months was explained by pain at ED visit (11%), pain at 3 months (7%), and pain at baseline (2%). Conclusion. The accuracy of pain intensity recall after three months is poor in seniors and seems to be influenced by the pain experienced at the time of injury. Pain intensity is a common outcome in pain management studies but pain intensity diaries are difficult for patients to complete reliably; therefore they are not usually used . To evalBeese and Morley demonstrated only fair accuracy of pain recall at two weeks postdental surgery . Dunn etMost studies define chronic pain as pain persisting for more than 3 months, so recall of pain in this setting can also be seriously questioned. Furthermore, in all these studies, seniors are poorly represented or not included. Age could be an important contributing factor since it is associated with a reduction in semantic memory for pain which can translate in a decline in reported pain .The primary objective of the study was to evaluate the reliability of pain intensity recall in senior ED patients with minor trauma after a three-month follow-up period and identify factors associated with the recall of pain.This was a planned substudy of a larger prospective multicenter cohort study of functional decline experienced by seniors following a minor traumatic injury treated in an ED. Patients were recruited from April 2011 to January 2014 across seven ED teaching hospital centres of five Canadian cities . To be included, patients had to be aged 65 years or older, had to be treated in an ED within two weeks of a minor traumatic injury , had to be independent in their daily living activities prior to the injury (score on ADLs of 13 or 14), had a pain intensity score of at least 1 on a 0–10 numeric rating scale (NRS) at baseline, and had to be discharged from the ED within 24 hours of arrival. Hospitalized patients, patients living in a long-term establishment, patients unable to give verbal consent, patients unavailable for follow-up, or patients unable to communicate in French or English were excluded.The study was approved by the ethics review board of each participating institution. Potential patients were recruited 24 hours a day, seven days a week by emergency physicians or research assistants. After completing a screening questionnaire to evaluate inclusion and exclusion criteria, cause of the injury, description of trauma, pain intensity assessment, loss of consciousness, and treatment plan, physicians asked the patients if they accepted to be contacted by research staff to be offered to participate in our study. After obtaining consent to participate in the study, the research staff interviewed the patients in a face-to-face meeting or by telephone within seven days of the ED visit (baseline) and then again at three and six months following the initial interview. For the present study, to insure consistency in interview quality (some measures were differently assessed by phone compared to face-to-face interviews), we selected only patients who had been contacted by phone after the ED visit (baseline) and at three-month follow-up (majority of patients). All research staff was trained on the standardized administration of the tools and questionnaires.We recorded sociodemographic variables: age, sex, race, education level, and living arrangements . We used the Older American Resources and Service  scale toWe assessed pain intensity with a NRS ranging from 0 to 10, 0 indicating no pain and 10 indicating the worst pain imaginable. We evaluated pain intensity during the ED visit (by the triage nurse), during the initial phone interview (baseline pain intensity) and at three months. Recall of baseline pain intensity was done at three months. The three-month interview included other questions to evaluate functional decline.t-tests) to compare the characteristics of the included and excluded patients and the intraclass correlation (ICC) to determine the agreement between the recall of baseline pain intensity (at three months) and baseline pain intensity . A paired t-test was used to compare pain intensity at baseline and its recall at 3 months to evaluate the general direction of the difference. Mean (±95% CI) absolute pain intensity difference between pain at baseline and its recall at 3 months was also performed since there were both positive and negative differences. To better study changes in the recall of pain intensity, we divided the sample into three distinct “recall of pain intensity” groups, patients who, at recall, underestimated their pain at baseline, patients who overestimated the pain they felt at baseline, and patients who recalled correctly their pain at baseline. Bijur et al. [We used univariate statistics  as per the TICS scores compared to included patients. Mean age was 76.6 years (SD ± 7.3), and a majority of patients (72.8%) were female.At baseline (less than one week from ED visit), we interviewed 1070 patients by phone and 757 of those had pain score of at least 1 on a 0 to 10 NRS. Finally, 482 were interviewed again by phone after the three-month follow-up period .  Table p < 0.001). Mean absolute pain intensity difference between pain at baseline and its recall at 3 months was 2.6 (95% CI: 2.4–2.8). Using the 1 point error tolerance (on 0–10 NRS) between baseline and recall of pain, 37.1% of patients correctly estimated their pain at baseline (1 point difference or less), 44.4% overestimated their pain (at least 2 points more), and 18.5% underestimated it (at least 2 points less).The intraclass correlation coefficient between recall of pain and pain at baseline was 0.24 (95% CI: 0.14–0.33) indicating a poor agreement  between p < 0.01). Patients who tended to overestimate their baseline pain at recall had significantly higher pain intensity at ED presentation than the two other groups (p < 0.001). No other variables including age, sex, education level, cognitive status, or pain at three months were associated with the ability to remember pain.Results of the multiple regression analysis with recall of pain as the dependent variable and pain at ED presentation, pain at baseline, pain at three months, number of medications, age, cognitive status at three months, and education level as predictor variables are presented in We demonstrated that only 37.1% of patients reliably recall their baseline pain intensity, whereas 44.4% overestimate it and 18.5% underestimate it after a three-month follow-up. We also found that pain intensity at ED presentation, pain at three months, and pain at baseline (first interview less than one week after ED visit) significantly predicted pain recall . These results are in keeping with most of the literature for a recall delay of more than one week –22.As in our study, overestimated pain at recall is frequently reported in the literature , 32, 33 Pain intensity recall has also been linked to pain intensity experienced during the time of recall, such that higher pain intensity at time of recall is associated with exaggerating baseline pain intensity and lower pain intensity at time of recall with underestimation of baseline , 33, 34.Surprisingly, cognitive function did not influence pain recall. However, in the laboratory setting, Rainville et al. demonstrated that recalled pain ratings obtained even after very short delays are transformed into a less precise categorical format which is easier to memorize and which is possibly resistant to cognitive impairments .Using only a relief scale for clinical research is also problematic, Feine et al. showed that almost all patients report relief even those whose pain had increased during the study period . This alOur study has some limitations that need to be considered. We lost 36% of patients at follow-up, however these patient's characteristics were similar to those of included patients . The iniIn conclusion, the accuracy of pain intensity is poor in senior after three months and seems mostly influenced by the pain experienced at the time of injury. The reliability of the long-term recall of pain in clinical research is thus brought into question. This emphasizes the importance of immediate assessment of pain intensity in clinical research and the need for development of tools that facilitate reliable and accurate pain recording.


P < 0.001) in both hepatitis B e antigen-positive (HBeAg [+]) and HBeAg-negative (HBeAg [−]) CHB patients. CHB patients with no to mild inflammation (G0–1) had significantly lower serum qAnti-HBc levels than patients with moderate to severe inflammation (G2–4) (P < 0.001). Receiver operating characteristic analysis suggested that a serum qAnti-HBc cut-off value of 4.36 log10 IU/mL provided a sensitivity of 71.68%, specificity of 73.81%, positive predictive value of 78.43%, and negative predictive value of 66.24% in HBeAg (+) CHB patients with moderate to severe inflammation (G≥2). A cut-off value of 4.62 log10 IU/mL provided a sensitivity of 54.29%, specificity of 90.00%, positive predictive value of 95.00%, and negative predictive value of 36.00% in HBeAg (−) CHB patients with moderate to severe inflammation (G≥2). Serum qAnti-HBc levels were positively associated with liver inflammation grade. Furthermore, we identified optimal serum qAnti-HBc cut-off values for the prediction of inflammation activity in both HBeAg (+) and HBeAg (−) treatment-naïve CHB patients.Previous studies have shown that hepatitis B core antibody (anti-HBc) levels vary during different phases of disease in treatment-naïve chronic hepatitis B (CHB) patients and can be used as a predictor of both interferon-α and nucleoside analogue therapy response. However, there is no information on the association between the quantitative serum anti-HBc (qAnti-HBc) level and liver inflammation in CHB patients. Therefore, we investigated these relationships in a large cohort of treatment-naïve CHB patients. A total of 624 treatment-naïve CHB patients were included in the study. The serum qAnti-HBc level was moderately correlated with ALT and AST levels ( In 1979, HBV DNA was first sequenced by Galibert, which initiated HBV genomic research. Researchers have been making great progress in elucidating the constitution of the HBV genome, the life cycle of HBV, and the structural and biological traits of HBV antigens.Hepatitis B virus (HBV) is one of the major human pathogens that cause severe liver disease, including liver cirrhosis and hepatocellular carcinoma. Approximately 2 billion people are infected with HBV worldwide, 350 million of whom are chronic HBV carriers, and HBV infection causes over 600,000 deaths each year. anti-HBc has been widely used in clinical diagnosis or blood screening combined with HBsAg. One positive attribute of anti-HBc is that it is considered to be an indicator of both past and persistent HBV infection. Due to the limitation of quantitative detection technology and the lack of international standardization, the clinical significance of the anti-HBc quantitative (qAnti-HBc) level remains largely unknown.HBV consists of an external envelope (HBsAg) and an inner core . Hepatitis B core antibody (anti-HBc) is generally formed during an infection with HBV, which often persists throughout the lifetime. As one of the most classical serological markers of HBV infection, Based on the new quantitative method and standard information derived from World Health Organization reports, it was reported that qAnti-HBc levels vary during different phases of chronic hepatitis B (CHB) in treatment-naïve patients.,9 Furthermore, it was demonstrated that the baseline levels of qAnti-HBc represented a new potential predictor of treatment response in both interferon-α and nucleoside analogue therapies.,11 These findings highlight the clinical value of qAnti-HBc levels in CHB patients. However, the relationship between qAnti-HBc and liver inflammation activity in treatment-naive CHB patients remains unknown.Recently, a novel diagnostic immunoassay procedure for qAnti-HBc using homogeneous purified full-length HBcAg capsids obtained from Escherichia coli was developed to quantify serum anti-HBc levels.22.1From 2012 to 2015, consecutive CHB patients were assessed at the Fifth Hospital of Shijiazhuang, Hebei, China. The inclusion criteria were as follows: HBsAg-positive for at least 6 months, treatment-naïve, and scheduled for liver biopsy. The exclusion criteria were as follows: decompensated liver cirrhosis, hepatocellular carcinoma, liver transplantation, coinfections , causes of liver disease other than HBV, and immunosuppressive treatment. Liver biopsies and serum samples were obtained on the same day in all cases.The study was in compliance with the Helsinki Declaration and was approved by the Medical Ethics Committee of The Fifth Hospital of Shijiazhuang. All the enrolled patients gave their written informed consent.2.2Serum ALT levels were determined using a Hitachi 7600  automated biochemistry analyzer. Serum HBV DNA levels were measured by real time fluorescence quantitative polymerase chain reaction assays on an ABI 7500 (Applied Biosystems), and the lowest limit of detection was 500 IU/mL. Serum HBsAg titers were quantified using an Elecsys HBsAg II quant assay , with a dynamic range from 0.05 to 130000 IU/mL. Hepatitis B e antigen (HBeAg) and anti-HBe were detected using Architect assays . The serum qAnti-HBc level was measured using a newly developed double-sandwich immunoassay  that was calibrated using the World Health Organization standard . The HBV genotype was assessed by sequencing. Liver inflammatory was assessed using the Scheuer scoring system, with the inflammatory grade measured on a scale of 0–4.2.32 or Fisher's exact test. Continuous variables are presented as the means ± standard deviation (SD) or median (interquartile range). Student t test, 1-way analysis of variance or the Mann–Whitney U test was used for statistical comparisons where appropriate. Correlations of qAnti-HBc with ALT, HBV DNA, and other parameters were assessed using Spearman's method. Receiver operating characteristic (ROC) curves and areas under the ROC (AUROC) curves were calculated to evaluate the diagnostic accuracy of qAnti-HBc for liver inflammation activity. P values of less than 0.05 were considered statistically significant. Statistical analyses were performed using SPSS ver. 17.0 software .Categorical variables were expressed as counts and percentages and were analyzed using the χ33.1P < 0.001). Compared with the HBeAg (−) patients, the HBeAg (+) patients had significantly higher platelet (PLT), HBV DNA, and HBsAg values but had significantly lower total bilirubin and qAnti-HBc levels. HBeAg (+) patients exhibited similar serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) to HBeAg (−) patients. HBV genotype C was significantly more prevalent among all patients, and there were no significant differences in the frequency of the HBV genotype between HBeAg (+) and HBeAg (−) patients (P = 0.23). There were significant differences in the frequency of the different grades of liver inflammation between the two patient groups. The proportion of patients with severe portal/periportal inflammation and lobular inflammation in the HBeAg (−) group was greater than that in the HBeAg (+) group.A total of 624 treatment-naïve CHB patients were enrolled in the study, 489 of whom were HBeAg-positive (HBeAg [+]) and 135 of whom were HBeAg-negative (HBeAg [−]). The demographic, clinical, and histological characteristics of the patients are presented in Table 3.2R = 0.559, P < 0.001) and AST . Additionally, there was a positive correlation observed in the HBeAg (−) CHB subjects between serum qAnti-HBc and ALT  and between serum qAnti-HBc and AST .The correlation of serum qAnti-HBc with ALT and other clinical parameters is shown in Table P < 0.05). When the ALT level reached 5 times the ULN, it plateaued (P = 0.65) , the mean qAnti-HBc level successively increased with increasing ALT level (65) Fig. .3.3P > 0.05). The distributions of HBV genotypes were stratified according to liver inflammation grade. The frequencies of the different portal/periportal inflammation grades between the 2 groups were significantly different (P = 0.003), and the proportion of patients with severe portal/periportal inflammation in the genotype C group was greater than that in the genotype B group. However, the frequencies of the different lobular inflammation grades between the two groups were similar (P = 0.19) , G1 (3.84 ± 1.07 log10IU/mL), G2 (4.43 ± 0.77 log10IU/mL), and G3–4 (4.90 ± 0.61 log10IU/mL); the mean levels of qAnti-HBc for different grades of lobular inflammation were as follows: G0 (3.53 ± 1.13 log10IU/mL), G1 (3.84 ± 1.10 log10IU/mL), G2 (4.53 ± 0.77 log10IU/mL), and G3 (4.90 ± 0.60 log10IU/mL). The mean qAnti-HBc level in G0/G1 subjects was significantly lower (P < 0.001) than that in G2 and G3/G3–4 subjects, and there was also a significant difference between G2 and G3/G3–4 subjects (P = 0.001) , G2 (4.56 ± 0.54 log10IU/mL) and G3–4 (4.86 ± 0.54 log10IU/mL); the mean levels of qAnti-HBc for different grades of lobular inflammation were as follows: G0–1 (4.22 ± 0.60 log10IU/mL), G2 (4.64 ± 0.50 log10IU/mL), and G3–4 (4.97 ± 0.51 log10IU/mL). The trend in qAnti-HBc levels among different grades of liver inflammation was similar between the HBeAg (−) and HBeAg (+) CHB patients  and HBeAg (−) patients were stratified according to the level of liver inflammation. Among the HBeAg (+) CHB patients, the mean levels of qAnti-HBc for different grades of portal/periportal inflammation were as follows: G0 (3.10 ± 1.30 log3.5P < 0.001). However, HBV DNA was significantly higher in HBeAg (+) patients with no to mild inflammation (P < 0.001). Among the HBeAg (−) patients, the no to mild inflammation group had significantly lower serum qAnti-HBc and ALT as well as HBV DNA, compared with the patients in the moderate to severe inflammation group (P < 0.001).Based on the grade of portal/periportal and lobular inflammation, data from the HBeAg (+) and HBeAg (−) CHB patient groups were stratified into two groups: no to mild inflammation (G0–1) and moderate to severe inflammation G2–G4) groups. HBV markers and ALT were calculated for the 2 groups (Table  groups. P < 0.01). In contrast, the HBV DNA levels were significantly higher in HBeAg (+) patients compared with HBeAg (−) patients, regardless of inflammation grade (P < 0.001). There was no significant difference in serum qAnti-HBc in the G2–G4 group or ALT levels in both the G0–1 and G2–G4 groups between HBeAg (+) and HBeAg (−) patients (P > 0.05).Compared with the corresponding ranges in HBeAg (−) patients, HBeAg (+) patients with G0–1 liver inflammation exhibited a significantly lower serum qAnti-HBc level  CHB patients, the AUROC curve was 0.755 (95%CI: 0.659–0.851). The cut-off value was 4.62 log10 IU/mL, with a sensitivity of 54.29%, specificity of 90.00%, positive predictive value of 95.00%, and negative predictive value of 36.00%  and HBeAg (−) CHB patients. In HBeAg (+) CHB patients, the area under the receiver-operating characteristic (areas under the ROC) curve of qAnti-HBc was 0.779 (95%CI: 0.738–0.820) for moderate to severe inflammation. The cut-off value of 4.36 log4 Previous studies revealed that serum qAnti-HBc levels are closely related to the host immune status and are strongly associated with hepatitis activity in CHB patients. Song LW et al showed that the mean qAnti-HBc levels in patients in the immune clearance phase and HBeAg-negative hepatitis phase were significantly higher than those in patients in both the immune tolerance phase and the low-replicative phase. They also demonstrated that serum qAnti-HBc levels were positively correlated with ALT levels. Another study showed similar results. However, there is a lack of direct evidence from liver biopsies to confirm these results. In the present study, we investigated the relationship between serum qAnti-HBc levels and liver inflammation grades.Qualitative detection of the five serological markers of HBV is routinely used as diagnostic and/or prognostic indicators of acute or chronic HBV infection. The presence of HBsAg is the most common marker of HBV infection, and HBeAg is used as an ancillary marker, primarily to indicate active HBV replication associated with progressive liver disease, whereas the presence of anti-HBc is considered to be an indicator of both past and persistent HBV infection. Along with the development of quantitative technology, researchers investigated the new clinical significance of HBV serological markers. The quantification of serum HBsAg titers could add value to HBV DNA quantification and could improve treatment monitoring.To our knowledge, this is the first study to investigate the relationship between serum qAnti-HBc levels and liver inflammation activity in treatment-naïve CHB patients. All of the included patients were treatment-naïve. The results showed that serum qAnti-HBc levels, ALT, and liver inflammation activity were closely related to each other. First, we found that serum qAnti-HBc levels were moderately correlated with ALT and AST levels in both HBeAg (+) and HBeAg (−) CHB patients. Furthermore, we found a significantly lower level of qAnti-HBc in patients with no to mild inflammation (G0–1) than in those with moderate to severe inflammation (G2–4). We also observed increased serum levels of ALT to be associated with increased inflammation severity. While the exact underlying mechanism of the positive correlation between serum qAnti-HBc level, serum ALT level, and inflammation severity remains to be examined, a possible mechanistic explanation for this association is that all of these features are determined by the host's immune responses. HBV is not directly cytopathic to hepatocytes, and hepatocellular damage observed during chronic HBV infections appears to be primarily caused by the host's immune responses to the virus. Tissue-damaging inflammation occurs when the host's immune system attacks liver cells. ALT and HBcAg can be released from damaged infected hepatocytes into the bloodstream. An increase in the serum ALT level causes potent antigenic stimulation of B cells, resulting in an increase in the serum qAnti-HBc level. and suggest that the immune system may not be overactivated without limitation when ALT is higher than 5 × ULN.However, serum qAnti-HBc titers reached a plateau and no longer showed a correlation with ALT levels when ALT levels were greater than 5 × ULN. These results are consistent with those of a previous study,15 However, liver biopsy is an invasive procedure. Therefore, we identified the grade of liver inflammation according to qAnti-HBc level. Our analyses established a qAnti-HBc level of 4.36 log10 IU/mL or more as an optimal cut-off value for identifying HBeAg (+) subjects with moderate to severe inflammation and 4.62 log10 IU/mL or more for HBeAg (−) subjects. The above results revealed a potential role of qAnti-HBc levels in reflecting different levels of liver inflammation in chronic HBV infection. The baseline qAnti-HBc levels would be convenient for application in clinical practice, especially for subjects with ALT 2 × ULN or less before initiating antiviral treatment to optimize the antiviral treatment. However, qAnti-HBc alone is not sufficient to accurately predict liver inflammation grade, and it should be combined with other parameters. These issues will be addressed in our future studies.Treatment guidelines for CHB by international liver associations (American Association for the Study of Liver Diseases and Asian Pacific Association for the Study of the Liver) recommend that CHB patients begin antiviral treatment when ALT is consistently more than 2 × ULN. When serum ALT levels range between normal and 2 × ULN, liver inflammation activity should be moderate to severe.Our study also had a few limitations. Only 4 patients with G4 inflammation were included, and they were merged into the G3 group for the data analysis. In cases of severe inflammation in clinical practice, most physicians would first choose general liver protection therapy and then consider liver biopsy. The level of serum qAnti-HBc in CHB patients with G4 inflammation requires further study. Additionally, our study only included patients with genotypes B and C, while data for patients with genotypes A and D, which are prevalent in Europe, need to be further investigated.In conclusion, our study demonstrated that serum qAnti-HBc levels were significantly correlated with liver inflammation grade in treatment-naïve CHB patients. Furthermore, we defined a serum qAnti-HBc cut-off for the identification of moderate to severe inflammation in HBeAg (+) and HBeAg (−) CHB patients.


There are several surgical treatment options for inguinal hernia; however, there is no consensus on the literature identifying which surgical technique promotes less postoperative pain.  To compare the intensity of postoperative pain between the surgical techniques Lichtenstein and transabdominal pre-peritoneal laparoscopy for the treatment of unilateral primary inguinal hernia.  Were included 60 patients, of which 30 were operated through the Lichtenstein technique and 30 patients through the transabdominal pre-peritoneal laparoscopy. The pain levels were evaluated through the analogue visual scale for 2, 10 and 30 days after the surgery. Additionally, the recurrence rate and the presence of chronic pain and paresthesia were evaluated 12 months after the surgery.  Overall, the data analysis showed significant differences on pain levels between the surgical techniques. There were no significant differences between the pain levels for day 2. However, for 10 and 30 days after the surgery, the pain levels were significantly lower for the patients operated through the transabdominal pre-peritoneal laparoscopy technique compared to the Lichtenstein technique. Furthermore, despite no recurrent hernias for both surgical techniques, 32 % of patients operated through the Lichtenstein technique reported chronic pain and paresthesia 12 months after the surgery, compared with 3,6% of patients operated through the transabdominal pre-peritoneal laparoscopy technique.  There are differences between the surgical techniques, with the transabdominal pre-peritoneal laparoscopy procedure promoting significantly lower postoperative pain (10 and 30 days) and chronic pain (12 months) compared to the Lichtenstein procedure. This study was approved by the Ethics Committee of the Santa Casa de Misericórdia de Goiânia - GO hospital (Project number 28150514.2.3001.5081) and was performed according to the 466 Resolution. Appropriate informed consent was obtained from all participants.This was a prospective clinical study to evaluate pain levels following the surgical repair of unilateral primary inguinal hernia. Overall, 60 patients were enrolled. The choice of surgical procedure was randomized, with the first 30 patients evaluated at the Santa Casa da Misericórdia de Goiânia, Brazil, booked through the Municipal Health Office, were operated through the open LC technique and the 30 following patients operated through the TAPP technique. The inclusion criteria were: age between 18-70 years, Goldman surgical risk level I or II and the diagnosis of unilateral primary inguinal hernia. The exclusion criteria were: previous abdominal surgeries, susceptible individuals such as native Brazilians, army and prisoners, not completing the postoperative following at any stage, urgent surgeries and additional surgical procedures such as umbilical hernioraphy, prostatectomy, cholecystectomies and other surgical procedures. Among all patients, two were excluded from the LC group as they did not complete the 12 months postoperative and two from the TAPP group for not completing the 30 days postoperative examination. Data concerning gender, age, body mass index (BMI) and Nyhus classification of the hernia, as well as duration of the surgery, edema occurrence and pain medication use, were recorded for each patient. All surgical procedures were performed by the same surgeon. The patients underwent standard routine preoperative examination including. All patients were discharged one day after the surgical procedure, with the exception of one patient that remained in the hospital for two days to drain a scrotal sac seroma. The patient was laid down in the supine position under raquianesthesia. After the asepsis using clorexidine, an oblique incision of approximately 7 cm, on the bisectrix of the angle formed between the inguinal fold and the external edge of the rectus abdominis muscle, with the opening of the pars plana until the inguinal canal. It was dissected laterally until de inguinal arcade and medially until the abdominal rectus. Subsequently, the spermatic funiculus was isolated using Penrose drains number 1, as well as identification, isolation and treatment of the hernia sac. The inguinal canal posterior wall reinforcement was made below and above the internal inguinal ring, using a polypropylene mesh of 12x4 cm, fixed using nylon 2-0 on the pubic tubercle, inguinal arcade and the conjoined tendon. The synthesis of the planes wall was made on the roof of the inguinal canal with nylon 2-0, subcutaneous with regular catgut 3-0 and on the skin using nylon 4-0.For the TAPP procedure, the patient laid down in the Trendelenburg position under general anesthesia. Subsequently, a pneumoperitoneum was created using a Veress needle around the umbilical region inserting three trocars, a 10 mm at umbilical level and two 5 mm at the hemiclavicular level on the left and right sides. An incision was made on the peritoneal membrane above the upper side of the internal ring. The peritoneal membrane was incised just above the superior edge of the inguinal ring and, mobilized laterally until the anterior superior iliac spine, medially until the pubic tubercle, and inferiorly until the ductus deferens. A piece of mesh with 18x12 cm was inserted through the 10 mm trocar and fixed on the superior region of the pubic area, using polyester thread 2-0. Once de mesh was applied, the peritoneum was sewed with the same polyester, in order to induce local reperitonealization.The pain intensity was evaluated through the visual analogue scale (AVS) for three postoperative days: 2, 10 and 30 after the surgery. The recurrence of the hernia, presence of chronic pain and paresthesia were also evaluated 12 months after the surgical procedure.The information about postoperative pain was recorded by the patient two days after the surgery, and the surgeon performed the 10 and 30 days and 12 months follow-up and the 12 months follow-up after the surgery. The recurrence rate was determined through physical examination and the chronic pain was determined as present or absent, without measuring intensity.First, was performed a descriptive analysis using the variables gender, age, BMI, Nyhus classification, duration of the surgery, edema occurrence and pain medication use. For the categorical variables, was used the chi-squared test and for the numeric variables the Student´s t-test. A repeated measures ANOVA was used to compare the postoperative pain levels 2, 10 and 30 days after the surgery. The significant interactions were further analyzed using the post-hoc test Tukey´s HSD. For the ANOVA, the assumptions of homogeneity of variance and normality were assessed by scatter plots and normal curves of the residuals, respectively. All statistical analyses were performed using the IBM SPSS Statistics software version 20 .Overall, from the total number of 56 patients, 51 were male and five female aged between 26-69 years. There were no significant differences in gender, age, BMI, and duration of the surgery between the patient groups . There wThe ANOVA demonstrated that the patients operated through the TAPP had pain levels significantly lower than the patients operated through the LC procedure p<0.05, . There wPostoperative pain is one of the major factors concerning the choice of a surgical technique for the repair of inguinal hernia. This study determined that patients subjected to the TAPP procedure presented significantly lower levels of postoperative pain compared to the LC, for 10 and 30 days after the surgery. Chronic pain and paresthesia were also present in a lower percentage on patients that underwent the TAPP procedure (3.6%) compared to the LC (32%). Additionally, for the TAPP surgical procedure, the edema incidence and the use of analgesic medication was significantly lower. However, no cases of recurrent hernia were reported for both techniques 12 months after the surgery.,In Brazil, almost 100% of the surgical procedures for inguinal hernia repair from the National Health System (SUS) in 2015/2016 were performed through the open Lichtenstein technique,1 and was also lower for different laparoscopic techniques such as the total extra-peritoneal repair and transinguinal pre-peritoneal repair,Chronic pain is defined as an AVS score above zero which lasts for more than three months after a surgical procedure and is described by patients as an ongoing awareness of pain. Chronic pain may be caused by nerve damage during surgery. It may also be related to the positioning of the mesh in the inguinal canal,The recurrence rate was, for many years, the main factor used to determine the surgical technique to repair inguinal hernias. The incorporation of the tension-free prosthetic mesh by Lichtenstein was the sole responsible for the significant decrease in the rate of recurrent herniaThe TAPP technique promoted less postoperative and chronic pain. The laparoscopic procedure TAPP hernia repair was safe and reliable, with a similar recurrence rate to the open Lichtenstein repair. Additionally, the laparoscopic procedure showed clear advantages such as less postoperative and chronic pain, paresthesia and lower incidence of edema and use of pain medication. Therefore, the laparoscopic TAPP procedure should be considered as an appropriate approach for the surgical treatment of unilateral primary inguinal hernia.


To evaluate the role of botulinum toxin type A (BTX-A) in the treatment of pain associated with nocturnal bruxism.Fifty subjects reporting nocturnal bruxism were recruited for a randomized clinical trial. Twenty five bruxers were injected with botulinum toxin in both masseters, and twenty five were treated with traditional methods of treating bruxism. Patients were evaluated at 3rd week, 2nd and 6th month and one year after injection and then used to calculate bruxism events. Bruxism symptoms were investigated using questionnaires.P =0.000, highly significant). However, in the conventional treatment group, mean pain score does not show improvement with time (p>0.05).Mean pain score due to Bruxism events in the masseter muscle decreased significantly in the botulinum toxin injection group A (Our results suggest that botulinum toxin injection reduced the mean pain score and number of bruxism events, most likely by decreasing the muscle activity of masseter rather than affecting the central nervous system. Key words:Temporomandibular pain, nocturnal bruxism, botulinum toxin. Bruxism, which includes clenching or grinding of the teeth, or both, affects from 50% to 95% of the adult population -3. BruxiAccording to the American Sleep Disorders Association, the diagnosis of nocturnal bruxism is based on the reports of tooth grinding or clenching and one of the following signs: abnormal tooth wear, sounds associated with bruxism, and jaw muscle discomfort. Bruxism can also produce an increase in dental wear and temporomandibular dysfunction. Delaying treatment, in some cases, may result in luxation and degenerative arthritis of the temporomandibular joint . In ordeA prospective, randomized, controlled, parallel group design study was conducted with the approbation of the Department of Dentistry, Alyamamah Hospital, Riyadh, Saudi Arabia over the period of a year from December, 2010 to December, 2011. The study protocol was reviewed and approved by the Institutional Ethical Committee, and the Helsinki guidelines were followed. The procedures were explained to the patients verbally and in writing, and informed consent was taken before enrolment. Those who were not ready or fail to report according to the set criteria were excluded from the study. The patients were randomly allocated to two group’s i.e. experimental group I using BTX-A administration group and control group II that used traditional methods of treatment of Bruxism.All patients  with bruxism associated with chronic pain in masseter muscles bilaterally participated in this study. The mean ages were 45.5± 10.8 years.et al. , and the use of a lower soft bite-raising appliance for a minimum of 8 weeks. Those who did not respond to conservative measures on subsequent review were given the following options: persevere with conservative measures; or have botulinum injections into the masseter muscle bilaterally.Outcomes for injections were assessed using 10 cm visual analogue pain scores (VAS) at 0, 3rd week, 2 months 6 months and 1 year. Once patients had consented to treatment with botulinumtoxin, they indicated their average pain for the previous weekon a VAS sliding ruler for both sides of the face. They then had up to 20 units of BOTOX injected into masseter muscles bilaterally. All patients were reviewed 3 weeks after injection and then again recorded their average pain levels for the previous week using the same VAS ruler. If free from pain they were discharged to primary care and told to return to clinic if unprecedented events occurs. We considered our true primaryend point to be a reduction in pain of 90% or more. The outcome was the proportion of patients whose pain had reduced at one year review, which was measured by taking the difference in the four scores (VAS) as a percentage of the score before injection.All patients were evaluated at 3 weeks, 2 months, 6 months, and 1 year.-Statistical analysisP< 0.05 consider statistically significant.Evaluation of the data was done using the statistical package for the social science  using student unpaired t- test and Wilcoxon sign rank test. The present study was done in order to estimate the improvement in pain score related to the bruxism patients especially in the masseter muscles, when treated with BOTOX and traditional methods. The results were evaluated using student unpaired t test and Wilcoxon sign rank test.p= 0.000). The mean pain score at 2nd month post-operatively in group I was 2.5 ± 0.59 and in group II was 4.3 ± 0.48. There was highly significant difference in mean pain score at post-operative 2nd month in group I and group II. Mean pain score at 6th month and 1 year post-operatively in group I was 0.2 ± 0.51 and in group II was 2.1 ± 0.74. There was highly significant difference in mean pain score post-operatively at 6th month and 1 year in group I and group II .Guarda-Nardini et al.  comparedet al. (Lee et al.  comparedThe above mentioned studies were the only randomized clinical trial till now available in the literature, however, our study is the only study on the Saudi female population as it was tertiary referral centre for females only. Further, larger sample sized, meta-analysis studies are required to validate the findings of our study for the treatment of Bruxism associated with myofascial and TMD pain.Several complications after botulinum toxin injection into the masticatory muscles have been reported, including mastication difficulties, muscle pain, speech disturbance, and unnatural facial appearance. But these complications are reported to be transient, usually lasting from 1 to 4 weeks after injection . Immunol20 UI per side Botulinum toxin injection in the masseter muscles is an effective and safe means of intervention in cases of moderate to severe chronic myofascial and TMJ pain associated with bruxism. The patient should be evaluated 15 days after the application and return for control after three or four months after the application for a new evaluation and another application, if needed. In this way, the treatment of bruxism with botulinum toxin type A can present itself as a possible treatment for bruxism patients. More studies are needed that follow the quality criteria to reach a definitive conclusion on safety and efficacy.