According to the European Association of Urology bladder cancer is the seventh most commonly diagnosed malignancy in the world's male population. Despite its high incidence, papers evaluating psychological state in those patients' group are lacking. The purpose of the study was to evaluate pain management, disease acceptance, and adjustment to cancer in homogenous group of patients diagnosed with nonmuscle-invasive bladder cancer (NMIBC). Group of 252 male patients who were scheduled for NMIBC treatment were prospectively evaluated. Patients fulfilled Acceptance of Illness Scale (AIS), Mini-Mental Adjustment to Cancer (Mini-MAC) and Coping Strategies (CSQ) questionnaires before treatment introduction. Highest CSQ score was achieved by the coping self-statements subscale . The catastrophizing subscale score was the lowest . Place of residence affected results of CSQ statement about pain control. Catastrophizing and coping self-statements strategies were associated with matrimonial status. In the Mini-MAC questionnaire the fighting spirit way of coping had the highest  and the helplessness-hopelessness subscale had the lowest mean value . Matrimonial status was strongly associated with anxious preoccupation, fighting spirit, and helplessness – hopelessness way of coping. The mean AIS test score was 28.8. AIS result was influenced by patient's marital status, yet not by education, place of residence, nor any clinical factor. In the examined group, the level of acceptance of the disease reached values that were slightly higher than the average. It indicated a fairly good adaptation to cancer. Among the methods of coping with cancer, the constructive style is definitely dominant with a high intensity of the fighting spirit strategy. The destructive style of cancer coping reached low values with a low intensity of helplessness/hopelessness strategy. From pain coping strategies, self-statements and praying/hoping were the most commonly chosen ways, whereas catastrophizing was the rarest. Many associations between various questioners' results were also observed. According to the European Association of Urology (EAU) bladder cancer (BC) is the seventh most commonly diagnosed malignancy in the world's male population . In the Despite the fact that NMIBC represents majority of BC cases, papers evaluating psychological state in those patients' group are lacking. Available studies concerning BC cases apply solely to muscle invasive BC and its extensive mutilating proceedings –5.The purpose of the study was to evaluate pain management, disease acceptance, and adjustment to cancer in homogenous group of patients diagnosed with NMIBC. We also analysed the effect of socioeconomic and clinical variables on the above mentioned issues.An institutional ethics committee approved the study and all patients gave written informed consent.We prospectively evaluated pain management, disease acceptance, and adjustment to cancer in 367 male patients with NMIBC who were scheduled for a transurethral resection of bladder tumour (TURB) procedure. The patients were recruited during 12 months' period (11.2016- 11.2017) in 3 polish centres: the Urology and Urologic Oncology Department of Wroclaw Medical University, Department of General, in the Oncological and Functional Oncology of Medical University of Warsaw, and in the Department of Urology and Oncologic Urology of Lower Silesian Specialistic Wrocław Hospital.Due to the fact that this analysis is a part of a study analysing TURB influence on patient psychological well-being following exclusion criteria were adopted. Patients with age under 18 years old enable to understand the information about the study or to cooperate with psychological evaluations and taking medications that could affect their mental status were disqualified.From the initially qualified population (367 pts.) 68 patients, who did not fulfil the questionnaires, were not included in analyses (drop-out). Those, who did not provide or did not correctly fulfil the Mini-Mental Adjustment to Cancer questionnaire (Mini-MAC) (17 pts.) and/or Coping Strategies Questionnaire (CSQ) (49 pts.) but filled completely Acceptance of Illness Scale (AIS) were included in analysis. Finally, data from 252 patients were included in the analysis . Additionally, as a part of bigger study, results of other questionnaires were available  and 196 of The Sexual Satisfaction Questionnaire (SSQ) and the simplified International Index of Erectile Function (IIEF-5)).The questionnaires were completed after admission to the departments, yet, before surgical treatment , in a space that provided privacy. The investigating urologist explained to each patient the purpose of the study, the protection of participant confidentiality, and the participants' freedom to drop out at any time. The study included individuals who gave informed, written consent to participate.Demographic , clinical, and psychometric data were collected. Clinical details such as ASA score, body mass index (BMI), nicotine abuse, history of previous TURB, recurrence/year index, previous intravesical chemotherapy, and/or BCG immunotherapy were recorded. Blood and urine laboratory analysis components were also documented as well as tumour features. Pathological stages were evaluated for all the patients according to the TNM staging system.Psychometric tools used in the study included the Acceptance of Illness Scale, the Mini-Mental Adjustment to Cancer questionnaire, and the Coping Strategies Questionnaire.The Acceptance of Illness Scale is a questionnaire designed for measuring any disease acceptance in adult individuals . The tooThe Mini-Mental Adjustment to Cancer (Mini-MAC) is a 29-statements questionnaire, which analyses four methods of cancer coping . When put together, anxious preoccupation and helplessness-hopelessness form the passive (destructive) style of coping and the fighting spirit and positive re-evaluation form active (constructive) way of coping. Each statement is scored on a four-point scale ranging from 1 (definitely not) to 4 (definitely yes). The points in each strategy are summed separately resulting in final range of 7-28 points. The higher the score, the more intense the behaviour patterns typical for a given coping strategy [The Coping Strategies Questionnaire was designed by Rosenstiel and Keefe to assess patient pain coping strategies and their effectiveness in pain alleviation and control . TechniqIn the statistical analysis, Pearson's r linear correlations between continuous outcome variables were calculated. Statistical differences of means between considered groups of patients were estimated based on the t-Student's test and one-way analysis of variance. The computation was performed in the R platform .The study involved 252 male NMIBC patients , who were scheduled for the TURB procedure because of proven or suspected BC. The mean scores of each scales are presented in In the Mini-MAC questionnaire the fighting spirit way of coping had the highest  and the helplessness-hopelessness subscale had the lowest mean value  .When analysing demographic features, it was shown, that matrimonial status was strongly associated with anxious preoccupation, fighting spirit, and helplessness – hopelessness way of coping. Influence of individual clinical features were minor.The mean AIS test score was 28.8. Amounts and percent of patients who have chosen answer 4 and 5 are also listed in the What is more, Pearson's r linear correlations between questionnaire's scores and risk factors and between each questionnaire's results were performed. Because of the fact that this paper is a part of a bigger study evaluating TURB impact on patients psychological well-being, preoperative scores of SSQ, HADS, and IIEF was also available and therefore analysed. From risk factors only a number of previous TURBs were positively correlated with CSQ ignoring pain strategy. Results of correlations between each questionnaire's scores are presented in In one-way ANOVA analysis CSQ pain reduction subscale result was associated with place of residence with higher score for smaller district. T-Student's test results are presented in Tables In the majority of cancer patients, emotions such as anxiety, restlessness, helplessness, and weakness are commonly present. Those negative feelings in addition to long, burdensome, and often mutilating treatment influence significantly patients' quality of life , 12.Being diagnosed with malignant disease is an emotional, psychological, and physical traumatic experience. In the best part of cases it is associated with considerable life changes and necessity to adapt to new circumstances. Many studies prove that these changes are often negative and are connected to stress caused by the diagnosis, fear of the disease, and fear of death.It is widely known that coping strategies, illness acceptance and adjustment to cancer have a substantial impact on the treatment of malignant disease , 13–15. Coping is an essential process that involves an individual's cognitive and behavioural efforts to manage a stressor . In the In this study population constructive style of coping with illness scored higher than destructive, with fighting spirit mean score of 21,73 and helplessness-hopelessness of 13,3 points. Those observations are similar to other papers evaluating cancerous patients in polish population , 25 espeOther authors observed that adopted strategies of coping with disease may change with time from diagnosis and treatment. The change was more evident for constructive models , 28, 29.It was previously proved, that physical activity has impact on one's attitude to the illness , 31. In When analysing demographic features, it was shown that matrimonial status is strongly associated with almost all types of disease coping. Patients living in active relationships obtained significantly higher score in fighting spirit strategy and lower in both destructive models. It is possible that lone patients have a greater tendency to implement destructive styles of coping. Yet, it was not confirmed in study on females with breast cancer, however some statistically insignificant trends were noticed .In other papers influence of place of residence was noted, with the anxious preoccupation score decreasing along the size of the place of residence , 33. In Upwards of half of cancerous patients experience pain associated with the disease. Nevertheless, the pain assessment and its treatment may be very difficult due to its subjectivity, presence of emotional components, and the fact that not only pain intensity but also degree of reaction to stimuli vary from one person to another , 36. AvaIn this population, coping self-statements and praying/hoping where the most commonly chosen pain coping strategies, whereas catastrophizing was the rarest. Those observations are in accord with other paper on cancerous patients in polish population , 45, 46.Malignant disease affects various aspects of one's life and, for that reason, acceptance of the illness is a serious issue for patients with cancer. From a simpler perspective, acceptance of the illness may be considered as an approval to life changes. It is proven that higher level of cancer acceptance prevents negative emotions intensification, is correlated with symptom severity, facilitates acceptance of disease-induced limitations and leads to greater motivation to fight disease –50. FromIn the analysed population mean score of Acceptance of Illness Scale was 28,8. More than 55% of patients have chosen answers 4 and 5 declaring that one disagrees or definitely disagrees with the AIS statements. This is all indicative for relatively good disease acceptance. Those results seem to be higher when compared with other, noncancerous patients analysed by Juczyński . In his Negative emotions triggered by malignant disease might make a person feel redundant. What is more, pain, therapeutic proceedings, and/or frequent and prolonged hospitalizations make patient feel submissive, dependent, or incompetent. When analysing meticulously the particular statements scores it could be noted that more than 60% of the study population strongly contradicts the fact feeling unneeded or being dependent on others. Those numbers are similar when comparing to majority of papers on various malignancies in polish population. In contrast, patients with leukaemia scored significantly lower .Evaluation of sociodemographic factors influence on AIS was also performed. In opposite to other authors, we have shown that matrimonial status had significant impact on AIS . Single It has to be kept in mind that the AIS values may differ with time after cancer treatment. , 57. As To analyse associations between each questionnaire's results Pearson's r linear correlations were performed. Pre-TURB scores of SSQ, HADS and IIEF were also available and therefore analysed. It was showed that there were strong correlations between various scales, especially between each score within one tool. It suggests consistent structure of questionnaires and appropriate selection of questions. What is worth noticing is that depressive and anxiety HADS scores were strongly negatively correlated with acceptance with illness, pain control, and pain reduction scores and positively with catastrophizing coping strategy. Also, solid correlations between HADS and Mini-MAC scores may be observed, as well as between Mini-MAC and some CSQ scores. This is especially evident when catastrophizing coping strategy is compared to anxious preoccupation and helplessness-hopelessness Mini-MAC strategies.Data analysis allows assuming that the higher the AIS score, the more often the constructive way of coping is used. AIS was also positively associated with pain control and pain reduction scores, emphasizing earlier observations that patients who accept their illness cope better with the pain and with the disease itself. Opposite conclusions can be drawn for catastrophizing and praying/hoping pain coping strategies as well as for destructive style of disease coping. What is more, SSQ and IIEF scores were strongly linked with AIS scores. This one more time accentuates the fact that good disease acceptance has positive influence on various sections of patient's mental well-being.Our study has some limitations. Firstly, there might have been some qualification bias, as we included only patients that were able to fill out surveys completely without the help of third parties. Some were unable to fill the initial questionnaires, which might have resulted from strong anxiety at the admission for operation. For that reasons, the paper possibly does not include a complete cross-section of NMIBC patients. Secondly the study includes only male patients.Despite limitation our report has some clear strengths. Study was conducted in high-volume oncology-orientated centres, which certifies the quality and repeatability of the procedures. Secondly the study sample was homogenous and significantly bigger than in other papers evaluating other malignancies. Thirdly we present analysis of the problem that was not addressed previously in available literature.In the examined group, the level of acceptance of the disease reached values that were slightly higher than the average. It indicated a fairly good adaptation to cancer. Among the methods of coping with cancer, the constructive style is definitely dominant with a high intensity of the fighting spirit strategy. The destructive style of cancer coping had reached low values among the respondents with a low intensity of helplessness/hopelessness strategy. From pain coping strategies, self-statements and praying/hoping were the most commonly chosen ways, whereas catastrophizing was the rarest. Many associations between various questioners' results were also observed.In modern medicine, the proceedings of medical personnel should include both proper therapy and ensuring the best possible patients' psychological well-being. The results of this study emphasise the significance of personalized medicine based on the work of a multidisciplinary team. Therapeutic groups ought to include individuals who routinely evaluate patients' mental state and patients' adaptation to one's health situation.


IntroductionWe report our initial series of terminally ill cancer patients treated with radiosurgery to the pituitary gland to alleviate pain.MethodsA fully automated rotating gamma ray unit was used to deliver a high dose of radiation (150Gy) using an 8 mm collimator to the neurohypophysis in 11 patients suffering from opioid-refractory pain deriving from cancer.ResultsFrom November 2016 to November 2018, 11 patients were treated, and 10 were eligible for follow-up evaluation. Pain from bone metastases was present in 70%; others suffered from neuropathic and visceral pain. The median survival was 119.7 days (range: 32 to 370). The visual analogue scale (VAS) was nine (7-10) and standardized to 10; eight patients (80%) responded. The average VAS at the time of response was three (range: 1-6), and the average time to response was 2.8 days (range: 2-5). In the first week, 40% of the patients categorized the result as 'excellent', 30% deemed the result 'good', and 20% reported the result as 'poor'. One patient (10%) referred to the result as 'regular'. Those who responded were able to reduce their medications by at least 25%. The one-month average VAS score was five (range: 1-6), 60% reported a 'good' effect, 20% reported 'excellent' results, and 20% had no response. Of the study participants, 60% maintained their level of medicine consumption at lower than baseline. At the end of life, five patients (50%) presented substantial pain, two (20%) never had a therapeutic effect, and three (30%) died without substantial pain. There were no clinical complications that could be attributed directly to the treatment. ConclusionRadiosurgery to the pituitary gland is effective and safe and warrants further investigation to understand its potential role in palliative care in cancer patients. Pain derived from cancer represents a heavy burden on patients, their families, and healthcare systems worldwide; even in economically advanced countries, refractory oncological pain is a challenge for palliative care -2. AlthoHypophysectomy or induced lesions to the pituitary gland and the stalk have historically demonstrated adequate pain reduction in advanced cancer patients. Initially performed to prolong survival in hormonodependent metastatic cancer patients, more contemporary indications were focused mainly on alleviating pain -11. The We report the first series of terminally ill patients that were treated for refractory oncological pain using stereotactic radiosurgery with a fully automated rotating gamma ray unit in a country categorized as a limited resource setting.Patient selectionWe conducted a prospective non-randomized trial of radiosurgical hypophysectomy for patients in palliative care suffering from cancer pain, refractory to opioid therapy in whom no reasonable alternative intervention therapy  was feasible. The trial was approved by the hospital’s ethical committee in November 2016. The inclusion criteria were patients with cancer-related pain categorized as severe (scoring 7-10) on the visual analog scale (VAS) despite the best medical algology practice and optimal opioid dosing, were 18 years or older with a life expectancy under six months, and their pain could derive from bone metastases or other organs affected by the disease. The cases were reviewed and approved by an ad-hoc committee that included a palliative care specialist and an algologist, oncologist, and radiation therapy and neurosurgery staff. The main endpoints of the study were the reduction of the VAS score by at least 50% and a reduction in opioid or pain medicine consumption.Radiosurgical techniquePatients fasted six hours on the day of the procedure and were prepared for sedation by the anesthesiologist using local anesthesia. An Infini stereotactic frame  was placed by a neurosurgeon, and the magnetic resonance imaging (MRI) acquisition was performed with a 1.5-tesla Avanto . Normally, only one volumetric T1 of 1 mm to 1.5 mm slice thickness with no spacing of the head (apex to foramen magnum) was acquired; a contrast was added in one patient where metastatic lesions to the brain were also found. Images were transferred to the treatment planning station . The organs at risk, which included the visual pathway and the brainstem, were contoured by neurosurgery; a single 8 mm collimator shot was placed to focus the isocenter of the shot on the neurohypophysis. Due to safety mechanisms specific to Superplan and the use of the prescribed high dose, we needed to place two shots in the same coordinates. The prescribed dose of 150 Gy to Dmax was administered to all patients with a gamma angle regularly fixed at 70°. The target was moved anteriorly or inferiorly as needed to comply with the organs at risk restrictions as stated by the American Association of Physicists in Medicine Task Group 101 Report [Patients did not receive more than 8 Gy as a threshold dose to more than 0.2 cc of the visual pathway. Patients did not receive a maximum point exceeding 10 Gy, nor did they receive over 10 Gy as a threshold dose to more than 0.5 cc of the brainstem or a maximum point exceeding 15 Gy.Patient follow-upPatients were contacted 72 hours after the procedure and every 15 days until the time of death. The VAS was standardized with patients and caregivers to 10 on the day of treatment to facilitate registry. Expected complications such as severe electrolytic variations, increased urine output, or visual disturbances were explained to caregivers as reasons to consult in case of an event. We used Wilcox signed rank test to determine p-values.From November 2016 to November 2018, 11 patients were enrolled and treated with radiosurgical hypophysectomy for intractable pain (Table The average treatment time was 68.9 minutes (range: 63 to 89 minutes). One patient’s treatment lasted 159 minutes as multiple posterior fossa metastases where treated. The median survival was 119.7 days . Mean VAS before treatment was nine (range: 7-10) and was standardized to 10 on the day of treatment. Eight patients (80%) presented a reduction of at least 50% of their initial pain, and the average VAS at the time of response was three . The average time to response was 2.8 days (range: 2-5 days) after treatment, and 40% of the series categorized their result as 'excellent' , 30% considered the treatment as 'good' , and 20% rated the treatment as 'poor' (no response). One patient (10%) referred to the treatment as 'regular' because the pain was alleviated less than 50% and there was significant pain despite the medications. Of those who responded, all reduced medications to five daily intakes  by at least 25% .After 30 days, the VAS was five , and 60% categorized the effect as 'good'. Among participants, 20% reported 'excellent' results, and 20% did not respond. At that time, 60% of the patients maintained their level of medicine consumption lower than baseline  from the time of treatment, with at least a 25% reduction and an actual reduction from baseline at 41% for one month  presented substantial pain (VAS 7-10), three of these patients presented it during the last days before death, two during the last weeks, two (20%) never had a therapeutic effect, and three (30%) patients died without substantial pain according to caregivers , we could not use hormonal screening to detect more subtle alterations that may result in potential adverse effects. Given this study limitation, further investigations warrant adequate laboratory studies attributed to opioid function and, eventually, posttreatment imaging.Although rotating gamma ray units as a technique are lesser known than their original counterpart, the Gamma Knife, dosimetry studies have proven them to be equivalent . These sThis is the first series to describe the clinical results of radiosurgical hypophysectomy using a fully automated rotating gamma ray unit. The results as described by previous authors seem useful as an ancillary technique in the palliative care setting where every other alternative to alleviate pain is not viable. This procedure seems safe, and its effect over pain seems prolonged enough until weeks or days before death. Therefore, pain specialists should work closely with palliative care specialists to provide optimal care for these patients.


Individuals were recruited at an oncology center and a psychiatry clinic in Istanbul. The main focus of the study has been on existential meaning-making coping, which is characterized by finding power inside oneself, altruism, family love, a search for meaning by contemplating philosophical issues, and having a positive life perspective (shukran—thankfulness). In contrast to findings from similar studies conducted in other countries (studies included in the same project), in Turkey religious belief directly determines the coping methods used, including the non-religious methods.The present paper looks at the influence of culture on Turkish cancer patients’ use of meaning-making coping, paying particular attention to religious, spiritual, and existential coping methods. Data were collected using an interview study ( To look more closely at the role of culture in cancer patients’ use of meaning-making coping, an international project has been conducted in five countries . The purpose of the project has been to focus on different forms of meaning-making coping  among people diagnosed with cancer and to try to understand the influence of culture on the use of these coping methods. In the present study, we refer to culture as a system of beliefs, traditions, customs, art, history, folklore, institutions, norm and values and their explicit expression as shared by members of a society, a community, or a group.Which of the religious and spiritually oriented coping methods used by cancer patients can be categorized as religious coping, as defined by the Many Religious Coping Methods (RCOPE)?What has the role of culture been in the choice of religious and spiritually oriented coping methods?Our specific questions were:In the current article, which is based on a study carried out in Turkey, we present results on religious, spiritual, and existential meaning-making methods of coping with cancer. A detailed discussion on the religious coping methods has already been presented in another paper .Interview questions for the study in Turkey were mainly constructed based on the results from the Swedish study Ahmadi . Two psyFor the present qualitative study, we chose a convenience sample. A total of 25 participants (18 women and 7 men) were recruited in Istanbul. Psychologists at an oncology center and a psychiatry clinic informed their patients about the study. These patients had either survived cancer or were still undergoing chemotherapy and/or radiotherapy. Upon receiving the patients’ consent to participate in the study, the interviews were conducted.Prior to each interview, the participants read and signed an informed consent form explaining the study purpose and ensuring confidentiality. Face-to-face interviews in Turkish were conducted at the hospital or the clinic, by the same interviewer; they lasted from 40 to 60 min, and a semi-structured questionnaire was used. The interviews were conducted from April 2015 through July 2015; the transcriptions were completed by the end of November 2015. The interviews were transcribed verbatim by the same interviewers to avoid divergence in the interpretations. Once all the interviews had been completed, the same person translated them to English.The group of participants included both men and women, between 20 and 71 years of age. Among the 25 participating patients, the number of women far exceeded the number of men . They identified themselves as non-religious, spiritual, or religious. Two people reported not having a religion, though this does not mean they deprecated spiritual or existential coping. The participants had various types of cancer. Their stage of cancer varied from earliest to severe; their social status also varied, including housewives, retirees, and the currently employed. Most participants were living with their spouse and had children; 5 were 20–39 years of age, 14 were 40–59 years, and 6 were 60 + . Ten participants were high school graduates or less, and 15 college graduates or higher. Concerning employment status, 1 participant was a housewife, 11 were not working , 10 worked, and 3 were retired or on leave. With regard to their religious affiliation, 21 were Muslims, 2 believed in God but did not have any religious affiliation, and 2 were atheists.Following transcription, the interview data were coded based on the themes found in the study using a template analysis style, a theory-driven analysis Malterud . CategorWithin the framework of the present study, we gathered data on the meaning-making coping strategies used by people who are very vulnerable given that they are facing life-threatening disease. It is clear that bringing these issues to the fore, which is related to very fundamental layers of an individual’s ego, is of ethical relevance.This being the case, it is essential to establish a cooperative relationship with potential respondents—one that is based on trust. Here, we made it clear to potential respondents that: participation was voluntary; data would be treated with confidentiality and not made available to anyone outside the research team; agreement to participate could be canceled at any time without any consequences for the respondent; and the results obtained from the study would be published such that identification of individual respondents would be impossible.This study was approved by the Regional Ethics Board in Uppsala (Reg. no. 2015-126).Below, we provide a concise list and brief discussion of the meaning-making coping methods the Turkish participants reported using during their illness.Proceeding from our definition of religion, spirituality, and existential meaning-making coping and based on previous studies in Sweden, South Korea, and China, we have observed the use of several meaning-making coping methods among our interviewees in Turkey see “”.The present results show that the RCOPE methods seem to be highly relevant for the Turkish interviewees. This can be explained by the fact that, for these interviewees, religion is a “larger part of [their] orientation system” Ahmadi : 28. In Using the coping method benevolent religious reappraisal, the individual tries to find a lesson from God in the event or to see how the situation could be spiritually beneficial. In the present study, we found two patterns. In the first pattern, we can see the act of talking with God, prayer itself, as a way of dealing with the stressor and feeling relaxed. In the second pattern, praying seems to have helped the interviewees reexamine their past life and find a lesson there .This method involves passively waiting for God to control the situation. Regarding illness as a test that God imposes on us is an old idea. In our study  and being patient (Sabr), i.e., the idea that the problems of this world are intended to test people and encourage them to have patience when facing problems, is quite influential among Muslims, including those in Turkey.Passively facing one’s illness and totally relying on God is, according to some researchers  all that has happened and will happen. This means that God has dictated everything that happens in the world (cosmos) on the basis of his prior knowledge and the states of his wisdom. Here we are not dealing with interviewees who passively accept their destiny. Instead, they actually do their best, but nonetheless know that, ultimately, everything is in God’s hands.This method entails actively giving up control to God . Among our interviewees, we saw belief in the idea of This method refers to seeking control indirectly by pleading to God (praying). The study indicates that some interviewees tried to gain comfort by pleading to God to make things turn out positively .theodicy problem. They wonder why God, who is supposed to love his children, would expose them to such a terrible illness.By questioning the existence of God, some interviewees showed their discontent with religion and faith. The problem these interviewees faced is called the Besides these religious and spiritual methods, we also found several existential meaning-making coping methods. In the following, we will discuss the methods of existential meaning-making coping we found most interesting.self-realization when he discusses “humanistic religion.” Through realization of the self when facing a stressful situation caused by illness, some of our informants found a way to give meaning to their life and, thereby, cope with their illness.Some interviewees have used existential meaning-making coping, finding power inside oneself, as a way to deal with the stressors brought about by cancer. As the same study conducted in Sweden Ahmadi  also conAltruism, expressed by informants as “being a good person,” was found to be one of the existential meaning-making coping methods used by some informants.“Human altruism is not only an act, but is interwoven with an emotion: empathy. Altruism is then as a prosocial behaviour a voluntary intention/act to help others at some cost to oneself ” (ibid.).Ahmadi : 139 expA similar coping method was found in the study among Swedes Ahmadi : 139–141la Condition Humaine .fasting,1zakat,sadageh,Another factor that should be taken into consideration here is religion. In societies where religion plays a significant role in the interrelation between people, any sense of altruism may be related to religious belief and duties. In Islam, altruism takes the form of hospitality and generosity, which are foundational virtues. There are several duties like In a collectivistic society like Turkey, the importance of family gives rise to another coping method: “Family love.”“For many people, family relationships involve more than biological, psychological, and social processes; people often believe these bonds tap directly into the spiritual realm…in short, people often view family relationships as sacred.”As Mahoney et al. : 222 maiAccording to these authors, people can sanctify the entire family system (ibid.).As our study among cancer patients in Turkey shows, sanctification of the family may serve as a coping method. Actively trying to get better and not allowing the problems of illness to disturb family relations or make family members unhappy can be a potent method of dealing with the psychological problems brought about by cancer. In this connection, religion may play an important role. According to Zimmerman : 6, “theGiven that our interviewees, cancer patients in Turkey, were socialized in a group-oriented society, where religion is an important component of the dominant culture, it is understandable that “love of family” seems to have played a role in their existential meaning-making coping.We found that, for some of our interviewees, the search for existential meaning, i.e., thinking about the meaning of life and death, has functioned as an existential meaning-making method of coping with their illness.In the Turkish case, the interviewees were believers who were contemplating existential issues in the context of religiosity.We found that going through the painful journey of having cancer caused some interviewees to appreciate their present life and the moments they experienced in everyday life. This brought about “a turning point” that caused them to change their proprieties in life. This new attitude has helped them cope with their illness, called “positive life perspective coping method” , here we found a great impact of religion on the selection of meaning-making coping methods, concerning not only the religious coping methods, but also the non-religious ones. The two following examples clearly illustrate this difference.As explained before, in the Turkish study, the search for existential meaning, i.e., thinking about the meaning of life, was found to be an existential meaning-making method of coping with their illness.The same study conducted in Sweden Ahmadi  also shoAnother example concerns the positive life perspective (finding new meaning in life by changing priorities). As mentioned above, in the Turkish study, we found that, for some informants, being hit by cancer was “a turning point” that caused them to begin to appreciate their life and everyday life events. This has helped them cope with their illness.In the project, the same coping method was found among Korean informants .As the above presentation of the non-religious coping methods used by our Turkish interviewees indicates, in all non-religious coping—i.e., finding power inside herself, altruism (being a good person), family love, search for meaning by pondering philosophical issues, and positive life perspective (finding new meaning for life by changing priorities)—the interviewees who chose these coping methods had been influenced by Islamic beliefs. These beliefs have an obvious impact on the everyday life of Turkish people, despite the fact that the state has, until recently, played an assertive role in confining religion to the private sphere (also referred to as “one reason people turn to religion in a time of crisis is that religion is more accessible in their sociocultural context than are other resources. In other words, people have more access to religion as a tool for coping with difficult situations when their religious beliefs, feelings and practices are a part of their culture, and therefore a part of their orienting system.”To understand such a direct convergence of religion and coping, we should remember that, as Pargament : 144 menAlthough Turkey is at the intersection of strong religiosity and secularism, according to the World Values Survey, this country, with its 99.9% Muslim population, is characterized by a highly homogenous culture, traditional values, and strong religious commitment, all of which impact the way people deal with their everyday life, including their life crises.


Patients with lumbar disc herniation (LDH) may present with motor disorders and various sensory disorders, among which pain and numbness are the most common ones. Percutaneous endoscopic lumbar discectomy (PELD) is reported to be both safe and effective. However, most of the previous studies focused on the recovery of pain, and the relief extent of numbness and weakness has rarely been reported. The Sciatica Bothersomeness Index (SBI) is a self-assessment tool for LDH patients. It has demonstrated acceptable reliability, construct validity, and responsiveness.  Our aim was to explore the curative effect of percutaneous endoscopic lumbar discectomy and to compare the various extent of relief among pain, numbness, and weakness. p value less than 0.05 was considered significant.  The medical records of patients admitted for LDH from September 2016 to December 2018 were collected, and the patients were followed up for 3 months to evaluate the relief of their clinical symptoms. Preoperative and postoperative total scores and subitem scores of SBI were compared to evaluate the relief of pain, numbness, and weakness. Surgical outcomes of PELD were evaluated by the Nakai score, and patients were divided into two groups accordingly, which were the relief group (excellent and good in the Nakai score) and the less relief group (fair and poor in the Nakai score). Risk factors for PELD outcomes and preoperative presence of numbness and/or weakness were analyzed by the logistic model, and p=0.002; OR: 1.647 (1.199–2.261)) was a relatively independent risk factor for PELD outcomes, and multiplicativity of duration of preoperative symptoms and imaging grade  was a relatively independent risk factor for preoperative presence of numbness and/or weakness.  A total of 86 patients met the inclusion criteria and acquired 3 months follow-up. Relief extent of pain, numbness, and weakness, was 82%, 41%, and 21%, respectively. There were 71 cases in the relief group and 15 cases in the less relief group. Results of the logistic regression analysis showed that the preoperative pain score of SBI ( PELD had a good curative effect in the treatment of LDH. Patients of LDH recovered best from pain, followed by numbness and weakness after PELD. Higher level of patients self-reported preoperative pain indicated a better surgical outcome for LDH patients, and preoperative long duration of symptoms together with a severe compression of nerve root significantly increased the risk of presenting numbness and/or weakness. Patients with lumbar disc herniation (LDH) usually present with symptoms like pain, numbness, and weakness, which have a negative influence on their social functions , 2. PercSciatica Bothersomeness Index (SBI) is a self-assessment tool to assess the severity of sciatica. It contains four items, which can evaluate the main symptoms of LDH patients quantitatively, such as pain, numbness, and weakness . It has LDH patients admitted for PELD from September 2016 to December 2018 were enrolled in this study. The criteria for inclusion were as follows: (1) complained of unilateral lower limb radiating pain, numbness, weakness, or other symptoms caused by single nerve root compression; (2) with symptoms consistent with preoperative imaging; and (3) with no significant relief of symptoms after 6 weeks of regular conservative treatment. The exclusion criteria were as follows: (1) with lumbar spinal stenosis; (2) and/or with lumbar instability; and (3) with spondylolisthesis or deformity.Two approaches for PELD were selected according to disk segments of herniation, which were transforaminal approaches for L45 and interlaminar approaches for L5S1. Surgical procedure was performed by one doctor under local anesthesia with 1% lidocaine, and the patients were laid in the prone position. A cannula was inserted into the spinal canal under the guidance of the C-arm X-ray machine. Free disk fragments were removed as much as possible. Microscopically, free movement of the nerve root and dural sac with the change of abdominal cavity pressure during breathing indicated that the goal of nerve decompression had been achieved.All patients were treated with neurotrophic drugs routinely after operation and were able to get out of bed with a brace 24 hours after operation. After 3 weeks postoperation, the patients were instructed to return to everyday activities gradually.(1) Demographic data included gender, age, and body mass index (BMI); (2) clinical data included duration of preoperative symptoms, the SBI scores for evaluating preoperative symptoms, and the ODI score for evaluating social dysfunction. The SBI score is a patient self-rated instrument usually applied to evaluate the severity of sciatica, which contains 4 items and includes the most common symptoms of LDH patients, such as pain, numbness, and weakness. Each item has a range of score from 0 to 6. The index has labels at the categories 0 (not bothersome), 3 (somewhat bothersome), and 6 (extremely bothersome), which provides a total score from 0 to 24 when summing up the ratings across the 4 items . (3) Imap values less than 0.2 as covariates, which were further assessed together by the logistic regression. p value less than 0.05 was taken as the criterion for covariates being significant risk factors.All data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 22 . For all qualitative variables, the total number of patients and the percentage were provided. For quantitative variables, the mean and standard deviation were provided. To reveal the relationship between social dysfunction and different symptoms like pain, numbness, and weakness, correlations between preoperative ODI and the SBI score and its subitem scores were analyzed by the Pearson correlation analysis. The risk factors for curative effect and preoperative presence of numbness and/or weakness were analyzed by the logistic regression model. Factors according to its clinical significance were first assessed individually as predictive variables by the logistic regression analysis, and the final model included all the predictive variables with A total of 87 patients were enrolled in this study, and one case was lost to follow-up. The 86 enrolled patients included 44 males and 42 females, aged from 21–80, with an average age of 49. Demographic and clinical characteristics of the study patients are listed in Proportions of pain, numbness, and weakness are shown in Results of the Pearson correlation analysis showed that the ODI score displayed a positive correlation with the preoperative SBI total score, pain score, and weakness score, while no significant correlations were found between the ODI score and the numbness score .p < 0.001. The mean SBI total score was decreased to 3.2 (2.32), p < 0.001, with a symptom relief rate of 65%. The mean pain score was decreased to 0.6 (0.82), p < 0.001, with a symptom relief rate of 82%. The mean numbness score was decreased to 1.6 (1.34), p < 0.001, with a symptom relief rate of 41%. The mean weakness score was decreased to 0.5 (0.85), p < 0.001, with a symptom relief rate of 21% , e of 21% .According to the Nakai score, 11 (12.7%) cases had achieved excellent surgical outcomes, while good, fair, and poor were 60 (69.8%), 12 (14.0%), and 3 (3.5%), respectively. Patients were divided into two groups based on the Nakai score, which were the relief group with excellent or good in the Nakai score and the less relief group with fair or poor in the Nakai score. There were 71 cases in the relief group and 15 cases in the less relief group.p=0.193), BMI (p=0.184), preoperative SBI pain score (p=0.002), preoperative SBI numbness score (p=0.08), preoperative SBI weakness score (p=0.186), preoperative SBI total score (p=0.05), and preoperative ODI score (p=0.007) were included as covariates in the final model of surgical outcomes. Among them, preoperative SBI pain score  significantly increased the probability of relatively good surgical outcomes, while gender (p=0.242), BMI (p=0.175), preoperative SBI numbness score (p=0.302), preoperative SBI weakness score (p=0.126), preoperative SBI total score (p=0.525), and preoperative ODI score (p=0.059) were found to be nonsignificant predictors of the relatively good surgical outcomes and were excluded from the model.Demographics, preoperative clinical data, and imaging grade stratified by surgical outcomes are shown in p=0.006), imaging grade (p=0.123), and joint effect of duration of preoperative symptoms and imaging grade (multiplicativity) (p=0.004) were included as covariates in the final model of presence of numbness and/or weakness. Among them, joint effect of duration of preoperative symptoms and imaging grade  significantly increased the probability of presence of numbness and/or weakness, while duration of preoperative symptoms (p=0.633) and imaging grade (p=0.341)individually were found to be nonsignificant predictors and were excluded from the model.To further explore the risk factors for preoperative presence of numbness and/or weakness, we divided the patients into the numbness and/or weakness group and the pain alone group based on the SBI subitem scores. Patients with SBI numbness and/or weakness scores greater than 2 points were grouped into the numbness and/or weakness group while the rest were in the pain alone group. Demographics, preoperative ODI score, duration of preoperative symptoms, and imaging grade stratified by presence of numbness and/or weakness are shown in Patients with lumbar disc herniation usually present symptoms like pain, numbness, and weakness, which have a negative influence on their social functions , 16. OurA great number of studies in the previous literature have reported significant relief of symptoms after decompression surgery –20. Endoβ fibers conducting feeling vibrations and touch may result in a general sense of numbness [α fibers may result in weakness [α and Aβ fibers as the process of remyelination requires more time [However, previous studies mainly provided evidence about patients' postoperative overall functional recovery by employing outcome measurements like JOA, VAS, ODI, or SF36 –9. Varionumbness , 23, andweakness , 25. Botweakness . Nerve rore time .The SBI scores have been used in the previous studies about lumbar disc herniation and have demonstrated acceptable reliability, construct validity, and responsiveness , 13. ThrThis study has some limitations. The reason for following up patients at 3 months after operation was that most symptoms of LDH recovered the fastest at the first 6 weeks and plateaued at 3 months postoperatively according to the previous literature . The resIn patients with LDH, pain was the most common symptom, followed by numbness and weakness. PELD had a good curative effect in the treatment of LDH. Patients recovered best from pain, followed by numbness and weakness. Higher level of patients' self-reported preoperative pain indicated a better surgical outcome for LDH patients, and preoperative long duration of symptoms together with a severe compression of nerve root significantly increased the risk of presenting numbness and/or weakness.


Salvage autologous stem-cell transplantation (sASCT) in patients with multiple myeloma (MM) relapsing after a prior autologous stem-cell transplantation leads to increased remission duration and overall survival. We report a comprehensive study on patient-reported outcomes, including quality of life (QoL) and pain in sASCT.Patients were randomly assigned to either sASCT or nontransplantation consolidation (NTC). Pain and QoL were assessed as secondary outcomes using validated QoL instruments .P = .0496), but not at later time points. Pain interference was higher (worse) in the sASCT group than in the NTC group at 6 months after random assignment (P = .0267), with patients with sASCT reporting higher scores for Pain interference with daily living for up to 2 years after random assignment. Patients reporting lower concerns about adverse effects of treatment after sASCT had a time to progression advantage.A total of 288 patients (> 96%) consented to the QoL substudy. The median follow-up was 52 months. The European Organisation for Research and Treatment of Cancer QLQ-C30 Global health status scores were higher (better) in the NTC group at 100 days after random assignment (Patients with sASCT with relapsed MM demonstrated a comparative reduction in QoL and greater impact of treatment adverse effects lasting for 6 months and up to 2 years for pain, after which patients who had received sASCT reported better outcomes. Patients who experienced lower adverse effects after sASCT had longer time to progression and overall survival, showing the need to improve symptom management peritransplantation. To our knowledge, this study provides the most comprehensive picture of QoL before and after sASCT in patients with relapsed MM. A cumulative burden of symptoms and treatment adverse effects, including various forms of pain, all affect health-related quality of life (QoL).14 There has been growing interest in the methodology of evaluating patient-reported outcomes (PROs) to measure the impact of both novel agents and autologous stem-cell transplantation (ASCT) on QoL in patients with MM.18 Studies have also reported on PROs in larger cohorts of patients undergoing ASCT and allogeneic transplantations for other conditions and in older populations.23 However, few studies have examined the years after transplantation that patients with MM can now expect to survive.With improving survival, MM is being experienced by an increasing proportion of patients as a chronic illness.A secondary aim of Myeloma X was to evaluate the impact of sASCT compared with nontransplantation consolidation (NTC) with oral cyclophosphamide once per week on PROs relating to QoL and pain at first relapse after a prior ASCT and after reinduction chemotherapy. The hypothesis was that ASCT was expected to be superior to NTC in terms of TTP. Therefore, ASCT-related toxicity in the short term and its potential impact on QoL, as well as patients’ long-term QoL, were of interest. Furthermore, we sought to evaluate the association of QoL at random assignment with subsequent clinical outcomes and to identify patient subgroups that may gain most QoL benefit from sASCT.24 at least 18 months after a prior ASCT). Inclusion and exclusion criteria and the trial procedures have been described in detail previously10 and are summarized in the trial CONSORT diagram  pain scale was administered as a diagnostic tool to assess the extent to which the pain was neuropathic.26The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the EORTC myeloma-specific module (EORTC QLQ-MY20), were used to assess QoL during reinduction and randomized treatment (Data Supplement). Pain experience was captured using the Brief Pain Inventory (Short Form) [BPI-SF], which assesses the severity of pain and its impact on aspects of daily living in patients with chronic pain.Questionnaires were administered before registration and after completion of reinduction. For randomly assigned patients, the questionnaires were administered before randomization, unless within 2 weeks of the previous questionnaires. These questionnaires were administered in the clinic. Questionnaires were then sent by mail at 100 days after random assignment, 6 and 12 months after random assignment, and then annually until the last randomly assigned patient was 2 years after random assignment  in the a10 The cutoff date for this analysis was July 14, 2015. The intention-to-treat population for the QoL substudy included all consenting patients who had completed at least one questionnaire. All statistical analyses were undertaken in SAS . All statistical tests were two-sided and were considered significant at the 5% level.Sample size and trial details have been described previously.sASCT was expected to be superior to NTC in terms of TTP. Therefore, ASCT-related toxicity in the short term and its potential impact on QoL, as well as patients’ long-term QoL, were of interest. EORTC QLQ-C30, EORTC QLQ-MY20, the S-LANSS pain scale, and the BPI-SF were used to measure temporal changes in patient-assessed QoL and pain, and their association with treatment. Of individual interest were the QLQ-C30 Global health status score, BPI-SF Pain interference scale, and MY20 Side effects of treatment subscale. Adjustments to the 5% significance level were not made for repeating the analysis for these scales because they were defined prospectively as being of individual interest in the study Statistical Analysis Plan, which was finalized before any analysis was undertaken. No power calculations were prespecified for these prospectively defined scales. For all other QLQ-C30, QLQ-MY20, BPI-SF subscales, and the S-LANSS, no statistical hypothesis testing was performed to compare between treatment groups.QoL subscales were summarized using means, 95% CIs, and differences between the two groups. For randomly assigned patients, multilevel repeated mixed model analyses, which allowed for randomized treatment, time effects, treatment-time interactions, and baseline QoL (fixed effects), and patient and patient-time interaction (random effects) were used. Additional details are given in the Data Supplement.Between April 16, 2008, and November 19, 2012, 288 of the 297 patients registered consented to the QoL substudy; 174 patients were subsequently randomly assigned to receive sASCT  or NTC . Baseline demographic and disease characteristics were well balanced between the treatment groups , except Compliance was good, with 76.1% of all expected questionnaires returned among consenting patients and similar rates of compliance comparing randomly assigned groups (Data Supplement). The greatest rate of noncompliance for EORTC QLQ-C30 and QLQ-MY20 questionnaires was at the randomization baseline time point . For the S-LANSS and BPI-SF questionnaires, compliance was slightly less .v 11 months; 95% CI, 9 to 12 months]; hazard ratio [HR], 0.45; 95% CI, 0.31 to 0.64; log-rank P < .001; Data Supplement).Subsequently, among the randomly assigned QoL population, more patients in the sASCT group completed the QLQ-C30, MY20, and other questionnaires at later time points, owing to the increased TTP .The adjusted means and 95% CIs (Data Supplement) with baseline mean scores  show thaP = .0496; 27 This deterioration in Global health status for patients receiving sASCT compared with NTC dissipated to a trivial27 difference at 6 months and a smaller trivial difference at 1 year. The difference at 2 years favored sASCT but was still trivial. The Side effects of treatment subscale was higher in the sASCT group of the trial at 100 days and 6 months after random assignment  showed no significant heterogeneity of treatment effect on subscales of special interest: Global health status (Data Supplement), Side effects of treatment (Data Supplement), and BPI-SF Pain interference score (Data Supplement). The greatest variability in estimates was observed in the adverse cytogenetics risk group, which was small for the intersection of patients with completed questionnaires and available cytogenetics.P = .006). However, with multivariable Cox regression analysis accounting for stratification factors, this difference was not significant. Patients who reported a lower than median score on the Side effects of treatment subscale randomization and who received sASCT had a significant TTP advantage over those receiving NTC . This survival difference was maintained with multivariable Cox regression analysis . Pain scores were not found to be strongly predictive of outcome .Post hoc exploratory analysis of TTP by randomly assigned allocation suggested that patients with Global health status greater than median at randomization (Data Supplement) and who received sASCT had a significant TTP advantage over those receiving NTC  and symptom scales. They found that levels of physical and functioning well-being were already low, and fatigue, anxiety, and depression pain were prevalent at the pretransplantation assessment. After ASCT, there was a worsening of transplantation-related concerns, depression, and life satisfaction. Pain and physical functioning did not deteriorate. Older patients were no more compromised than younger ones, confirmed in another study of mixed hematologic malignancies.15Several studies have sought to describe the process of MM treatment, including adverse effects of ASCT in terms of PROs and overall QoL. Morbidity during ASCT is high, with mucositis, emesis, and complications of bone marrow depletion and sepsis. Many patients find this period acutely distressing and may display long-term psychological changes. Sherman et al23 described the QoL effects of ASCT in MM in a sample of 701 participants in the Blood and Bone Marrow Transplantation Clinical Trials Network 0902 trial. Using the Medical Outcomes Study Short Form (a generic instrument describing key dimensions of daily life), they were able to describe four trajectories for physical and mental aspects of QoL 100 days and 6 months after ASCT: low and stable; average and declining, then stable; higher than average and stable; and average and stable. They also concluded that attrition in post-ASCT studies could give rise to overestimates of QoL, but these are slight and consistent over time.Jim et al30 ixazomib,31 and elotuzumab,32 where 43% to 62% of patients in these studies were treated for first relapse. Baseline and long-term on-treatment scores for the scales of key interest were similar to those observed in this study. Each novel agent improved PFS and showed no detrimental long-term impact on Global health status. These findings are important because others have shown that baseline psychosocial factors and QoL after induction and before ASCT, and the extent of treatment adverse effects during ASCT, could be predictive of post-transplantation adverse changes, including the finding of post-traumatic stress disorder in some patients.35 Most recently, O’Sullivan et al36 confirmed that higher pretransplantation pain predicted lower physical well-being and QoL. However, it should be noted that these studies included a variety of hematologic malignancies, both autograft and allograft, and a range of QoL measures.Novel agents in triplet combinations and their impact on PROs have recently been reported in relapsed patients for carfilzomib,Although the questionnaire compliance was good, a limitation of this report is the low compliance at randomization baseline for all questionnaires, which leads to a subsample of data used in statistical models. In addition, there was an imbalance in the QoL scores at randomization baseline, with most scores better in the cyclophosphamide once-per-week group. There was no reason identified for the reduced compliance nor the baseline imbalance, with no significant differences identified in the time between trial registration, randomization, and questionnaire completion, or an imbalance in the same subsample of patients at trial registration or the end of reinduction. However, sensitivity analysis found no evidence to reject an assumption of missing at random, and multiple imputation provided broadly similar results, with potentially a nonsignificant difference in Global health status at 100 days post-ASCT.33 In the early postrandomization period, patients who had undergone sASCT showed evidence of a small reduction in aspects of QoL. At 100 days, only Role functioning and Global health status were significantly higher in the NTC arm, with a magnitude indicating a small clinical difference. However, by 1 year after random assignment, this difference in Global health status was not observed.We found that after entering the trial and after reinduction with bortezomib, doxorubicin, and dexamethasone, there were adverse changes in many aspects of QoL reflecting the intensity of treatment; these were of medium clinical significance only for Global health status, Fatigue, and Diarrhea. Importantly, psychological aspects were not compromised, because these have been shown to predict worse outcomes after hematopoietic stem-cell transplantation (HSCT) elsewhere.37 We have shown in another cohort study of patients with MM in remission that pain level as measured by BPI-SF was correlated with circulating interleukin-6.38 In sASCT, the increased risk of systemic inflammation, including sepsis, could condition patients with existing neural damage to express more pain. Prolonged increased pain after HSCT has not been reported previously, possibly because others have not used a standardized pain measure such as BPI-SF, with its more sensitive, specific Pain interference scale.There was evidence from the S-LANSS scale that the neuropathic component of pain was increased at 100 days after transplantation, but not later. Pain interference with daily living using the BPI-SF also increased in patients with sASCT and was seen until 2 years after random assignment. Drugs used in the ASCT process are not usually associated with direct neuropathic changes. However, systemic inflammation can give rise to increased pain sensitivity, probably because of the effect of proinflammatory cytokines directly sensitizing peripheral pain pathways.39 reported on the effect of a randomized trial of in-patient palliative care on QoL of patients with HSCT. This novel intervention led to a smaller increase in depression, lower anxiety, and less increase in symptom burden at 2 weeks post-HSCT and also a smaller reduction in QoL at 2 weeks, with higher QoL at 3 months.The MY-20 module has a specific scale for detecting concerns about Side effects of treatment. Although this score was increased in patients randomly assigned to sASCT at 100 days and 6 months, the magnitude of this change was small and disappeared subsequently. Patients with sASCT who reported a lower (ie better) than median level of concern about adverse effects had significant TTP and OS advantages, even after adjustment in a multivariable Cox regression analysis. One likely interpretation of this in patients undergoing ASCT is that maximal efforts should be made to minimize the emergence of adverse effects of the procedure and to optimize their management. El-Jawahri et al23 This is perhaps relevant in this study, where PROs were collected up until the time of disease progression.This study is subject to several limitations, including an open-label design, in which lack of blinding could be relevant where subjective end points such as pain, other symptoms, treatment adverse effects, and QoL are of interest. We relied on patient reports using paper-based questionnaires. These are subject to problems related to adherence, especially when patients are experiencing periods of increased illness. We found the adherence and missing data rates to be comparable to other studies in this population, using the same or similar instruments. Attrition rates are possibly a source of bias if they occur differentially in allocated treatment arms. It has been shown that attrition can overestimate QoL scores, but this effect can be consistent over time and between allocated treatment arms.The small and diminishing differences in Global health status and Side effects of treatment need to be considered alongside the results of Myeloma X, which showed a significant benefit of sASCT on OS. The benefits of sASCT should be considered alongside the relatively short-term negative effects on QoL and pain when making patient treatment decisions and further support the use of sASCT.


Hip fracture causes moderate to severe pain and while fascia iliaca block has been reported to provide analgesic benefit, most previous trials were unblinded, with subsequent high risks of performance, selection and detection biases. In this randomized, control double-blind trial, we tested the hypothesis that a fascia iliaca block provides effective analgesia for patients suffering from hip fracture.Thirty ASA I-III hip fracture patients over 70 years old, who received prehospital morphine, were randomized to receive either a fascia iliaca block using 30 ml of bupivacaine 0.5% with epinephrine 1:200,000 or a sham injection with normal saline. The fascia iliaca block was administered by emergency medicine physicians trained to perform an anatomic landmark-based technique. The primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45 min following the procedure . Secondary outcomes included the longitudinal pain score profiles on movement and the comparison over 4 h, 8 h, 12 h, and 24 h after the procedure, along with cumulative intravenous morphine consumption at 24 h.p = 0.53 and on movement p = 0.45). The same parallel change in pain scores over time was observed over 24 h of follow-up . These results were confirmed after adjustment for gender, ASA score, and cumulative sums of intravenous morphine received pre-procedure and during-follow-up. In addition, there was no difference between the two groups in total cumulative intravenous morphine consumption at 24 h.At baseline, the fascia iliaca group had a lower mean pain score than the sham injection group, both at rest  and on movement . These differences remained 45 min after the procedure and the two longitudinal pain score profiles were parallel both for patients at rest and on movement (test of parallelism for patients at rest Fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach definitive conclusion.NCT02433548. The study was registered retrospectively.Clinicaltrials.gov –  Hip fracture is very common in the elderly, with an incidence of 4.6 per 1000 adults over 50 years old . Hip fraThe hip joint is innervated by the femoral and obturator nerves anteriorly, and the sciatic nerve posteriorly . The fasIn this randomized, controlled double-blind trial, we tested the hypothesis that landmark-based FIB for hip fracture, performed by emergency medicine physicians, provides effective analgesia.Ethical approval was granted by the ethics committee of the Lausanne University Hospital, Switzerland  on October 10, 2014, and the trial was registered on Clinicaltrials.gov NCT02433548) on October 20, 2014. The CONSORT statement was followed in reporting this trial [33548 on www.randomization.com, seed 20,388). Assignments were concealed in a sealed opaque envelope. An emergency medicine physician, who was not responsible for the patient’s care, prepared the study drugs in syringes and performed the block procedure. A blinded study nurse collected the data. The physicians and nurses responsible for the patient’s care in the emergency department and on the ward were all blinded to the group allocation.After written informed consent was obtained, subjects were randomly allocated to either the experimental group (FIB group) or the control group (sham injection group) according to a computer-generated list of random numbers  was treated with intravenous morphine as needed. After transfer to the orthopaedic ward, patients were prescribed acetaminophen 1000 mg every 6 h and subcutaneous morphine 0.1 mg.kgWe originally planned to compare the two mean pain scores (fascia iliaca block versus sham injection groups) at 45 min. However, given that, despite randomisation, the two groups had different mean baseline scores, we elected to evaluate the longitudinal pain trajectories and tested for parallelism instead. Therefore, the primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45 min following the procedure. Pain intensity was assessed with an 11-point numeric rating scale (NRS), ranging from 0 (no pain) to 10 (worst imaginable pain). Secondary pain-related outcomes included comparison of the longitudinal pain score profiles on movement over the first 45 min following the procedure; longitudinal pain score profiles at rest and during movement (standardized gentle 15°-elevation of the leg) 4 h, 8 h, 12 h and 24 h after the injection ; and cumulative intravenous morphine consumption at 24 h after the injection (mg). Other outcomes were length of stay, and mortality at 3 months. The between group difference in NRS score over time was analysed as a post hoc addition to the protocol in order to explore the potential impact of baseline pain score differences between groups.p < 0.05. Statistical analyses were performed using the Stata 14.2 statistical package .Based on published data, mean NRS pain score at rest when patients are untreated was anticipated to be 8/10 with a variance of 2 . We deteThirty patients were recruited, and all completed the follow-up for the primary outcome. Figure p = 0.53, Fig. p = 0.45; Fig. p = 0.50 for the test of equality of the two differences  at rest and p = 0.45 on movement). Likewise, analyses over the periods of 4 h, 8 h, 12 h and 24 h after the procedure showed parallelism in the longitudinal pain scores at rest .At baseline (before the injection) the mean pain score at rest was lower in the FIB group . The difference between groups remained unchanged 45 min after the injection : .2; diffep = 0.63), despite an apparent higher pre-procedure dose for the FIB group , and an apparent lower cumulative dose during-follow-up .Over the 24-h follow-up period, cumulative intravenous morphine consumption was similar between groups . Three patients in the FIB group, and one in the sham injection group died at 3 months (p = 0.28).Finally, the fascia iliaca block did not impact on the length of stay . Nevertheless, the original sample size calculation did not factor in this design and the risk of a type II error cannot be excluded. Although we adjusted for baseline characteristics such as gender, ASA score and pre-procedure intravenous morphine consumption, there may have been other unmeasured baseline characteristics, which should have been adjusted for. Our data should therefore be considered as preliminary and we suggest further research would add additional value. Finally, the choice of an anatomic landmark-based approach makes extrapolation of the study results to ultrasound-guided techniques uncertain. There is some evidence that incorporation of ultrasound may have a positive impact on the sensory blockade territory  and therIn conclusion, fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach more definitive conclusions.


Hysterosalpingography is one of the essential diagnostic methods for examining women who have difficulty becoming pregnant. This procedure is somehow invasive and is associated with numerous complications such as allergic sensitivity, pain, abdominal cramps and shock. Therefore, this study aimed to investigate the effect of evening primrose on cervical length and pain during and after hysterosalpingography. In this double-blind clinical trial, 66 candidates for hysterosalpingography were randomly divided into two groups. A group received 1000 mg of evening primrose orally for two days prior to hysterosalpingography, while the control group received a placebo drug similar in size to evening primrose three days prior to hysterosalpingography. The pain level was recorded based on the Visual Analogue Scale (VAS), during tenaculum placement but also immediately and four hours after hysterosalpingography. Finally, the data were analyzed using SPSS (version 20). There was a significant difference between the two groups in terms of pain during insertion of speculum and injection of the contrast medium (p <0.05). Less pain was reported in the evening primrose group compared to placebo. There was no significant difference between the two groups in terms of the length and diameter of the cervix (p <0.05). Given the fact that it is a medicinal plant with no complications and can reduce pain during speculum insertion and during contrast medium injection, evening primrose seems to be a good drug for managing pain during hysterosalpingography. Oenothera L., growing in the temperate and tropical climate zones of North and South America. Some species have adapted to new areas, inhabiting the countries of the European continent, and about 70 species are now present in Europe. The most numerous species in the Oenothera L. family is Oenothera biennis, which also has the best-studied biological activity. It has been indicated that Oenothera biennis is beneficial in the treatment of many diseases. Therefore, research is ongoing to determine the chemical composition of these plants and how it relates to the biological activity of evening primrose. This research mainly concerns extracts from various parts of evening primrose  [Infertility is one of the most common problems in women. This complication involves a heterogeneous group of patients, and infertility-related assessments are required to investigate its causes. Hysterosalpingography (HSG) is one of the important diagnostic methods for assessing the openness of the uterus and uterine tubes . Uterined seeds) . Eveningd seeds) . Many wod seeds) , 14. Alvd seeds)  and Prutd seeds)  argued tIn this double-blind clinical trial, 66 candidates for hysterosalpingography were randomly divided into two groups. A group received 1000 mg of evening primrose orally two days prior to hysterosalpingography, while the control group received a placebo drug similar in size to evening primrose three days prior to hysterosalpingography.Infertility; patients aged 19 to 42 years; candidate for hysterosalpingography.Severe dysmenorrhea; pelvic infections; drug sensitivity; duration of HSG for more than 45 minutes; hemodynamic instability during HSG; unwillingness to participate in the study; vaginal delivery; secondary infertility.A demographic questionnaire including age, parity, history of dysmenorrhea , history of hysterosalpingography in the past, and history of endometrial biopsy was recorded for all patients. Patients were randomly divided into two groups. A group received 1000 mg of evening primrose orally for two days prior to hysterosalpingography, while the control group received a placebo drug similar in size to evening primrose three days prior to hysterosalpingography. Afterward, all patients underwent hysterosalpingography. A metal cannula was gently inserted into the external cervical canal, the cannula and tenaculum were secured together, and the speculum was removed. Once the cervix was detected, betadine solution was used to probe the area. The anterior and posterior lips of the cervix were held with the tenaculum, and the cannula was inserted through the cervical canal. The speculum was then removed.The patient was asked to assess pain intensity using the visual analogue scale. A Visual Analogue Scale (VAS) is a measurement instrument that tries to measure a characteristic or attitude that is believed to range across a continuum of values and cannot easily be directly measured. It is often used in epidemiology and clinical research to measure the intensity or frequency of various symptoms. After insertion into the vagina, the tenaculum allows healthcare professionals to grasp the cervical tissue, pull and stabilize the external part of the cervix. Tenaculum consists of a slender sharp-pointed hook, and it causes pain and bleeding. Based on HSG findings, the presence or absence of spasm of the fallopian tubes was determined. Having the patient empty her bladder prior to positioning may ease discomfort from the speculum, which should be warmed prior to insertion. Supporting the patient’s hips on a short stack of towels or an overturned bedpan often aids in the visualization of the cervix.As with any pelvic examination, the operator should attempt to drape as much of the patient’s lower body as possible, have a female chaperone, and explain to the patient each step of the procedure. At the end of the procedure, all instruments were removed, and the patient was observed and monitored for half an hour in the clinic. The pain level was recorded based on the Visual Analogue Scale (VAS) during tenaculum placement but also immediately and four hours after hysterosalpingography. In this scale, zero and ten represent the lowest and the highest amount of pain, respectively. Then, the pain was compared in the two groups. Pain intensity was compared between the two groups at the time of fallopian tube and abnormalities in the uterine cavity. Accordingly, the anomalies of the uterine cavity were also compared.Moreover, vasovagal responses were recorded and compared in patients of both groups. The vasovagal response is the development of inappropriate cardiac slowing and arteriolar dilatation. Vasovagal responses reflect autonomic neural changes: bradycardia results from sudden augmentation of efferent vagal activity, and hypotension results from sudden reduction or cessation of sympathetic activity and relaxation of arterial resistance vessels. Two different neural pathways are thought to be involved, one originating in the hypothalamus, the other in the heart.It should be noted that neither the radiology assistants nor the patients had access to the data. Finally, the data were analyzed using SPSS. The ethical committee code is: IR.ARAKMU.REC.1396.42This double-blind clinical trial included 66 patients undergoing hysterosalpingography in Radiology Clinic of Arak University of Medical Sciences. The patients were randomly divided into two groups. The minimum and the maximum was 19 years and 42 years, respectively. The mean age of the patients was 27.74 ± 4.77 years. The duration of infertility was 2.65 ± 3.17 years. Accordingly, the duration of infertility in the evening primrose group and the placebo group was 3.36 ± 4.9 and 2. 04 ± 1.71, respectively. There was no significant difference between the two groups (p = 0.20). According to the results, there was no significant difference between the two groups in terms of age (p = 0.939). The results showed that there was no significant difference between the two groups in terms of parity, dysmenorrhea, history of dyspareunia, history of hysterosalpingography and history of endometrial biopsy (p> 0.05) .The results showed that there was no significant difference between the two groups in terms of vasovagal responses, fallopian tube spasm and uterine cavity anomalies .According to According to As a low-priced and simple method, hysterosalpingography is used to detect these abnormalities. This invasive method is associated with several complications such as increased sensitivity, pain, abdominal cramp and even shock . Recent Szymusik et al. investigated the factors influencing pain during hysterosalpingography. In their study, 89 patients were assigned to the ketoprofen group and received 0.1 g of ketoprofen. Likewise, 89 patients were assigned to the metamizole group and received 2.5 g of metamizole. The pain level was measured using the visual analogue scale. There was no significant difference between the two groups regarding the type of infertility or previous delivery [Alvandipour et al. compared the effect of evening primrose and vitamin E in the treatment of periodic mastalgia. The results indicated that vitamin E and evening primrose extract have similar therapeutic effects for the treatment of breast pain and can be used as therapeutic alternatives . AccordiPruthi et al. examined the effect of vitamin E and evening primrose oil on pain control in women with mastalgia. They argued that vitamin E and evening primrose extract have similar therapeutic effects for the treatment of pain in the breast and can be used as therapeutic alternatives . These rAccording to the results, the pain during insertion of the speculum and during contrast medium injection was lower in the evening primrose group compared to placebo. Moreover, there was no difference between the two groups in terms of the length and diameter of the cervix. Therefore, evening primrose is capable of managing pain in hysterosalpingography.This dissertation was approved with the code IR.ARAKMU.REC.1396.42. The registration code is IRCT2017070520258N52 in the Iranian Center for Clinical Trials. We need to express our sincere gratitude to the Clinical Research Council of Valiasr Hospital and the Deputy of the Arak Medical University Research Center for their assistance in conducting this research.The authors confirm that there are no conflicts of interest.


Rheumatoid arthritis (RA) is a long-term disorder significantly impairing the somatic, emotional, and psychological functioning of its sufferers. Previous research has shown that affected individuals are characterized by an increased level of anxiety and depression. Currently, there are two main treatment schemes for RA; the first uses anti-inflammatory drugs, and the second utilizes biologic agents. This begs the question whether sufferers differ in intensities of pain, anxiety, and depression depending on the type of treatment and what the determinants of these affective states in patients treated using different methods are. The study comprised 85 patients affected by RA . Research participants filled out a set of questionnaires measuring levels of anxiety and depression, intensity of experienced pain, strategies of coping with pain, and ego resiliency. The collected data was analyzed through intergroup comparisons, calculating simple correlation coefficients, developing and solving regression equations. The results imply that the choice of treatment differentiates the intensity of pain experienced by patients. Those receiving biologic agents reported lower levels of pain compared to those taking anti-inflammatory medication. It has also been noted that there are distinct configurations of conditions conducive to anxiety and depression in both anti-inflammatory and biologic agent groups. The observed constellation of dependencies between variables indicates that the choice of treatment scheme differentiates pain levels. This confirms the assumption that pain intensity, coping strategies, and ego resiliency depend on the severity of anxiety and depression. Chronic illness is indicated by the World Health Organization as the leading cause of premature death in the world. According to WHO's estimates, it is responsible for 63% of all fatalities . ChronicOne chronic illness severely altering its sufferers' ability to function is rheumatoid arthritis (RA). RA is the most common rheumatic disorder among connective tissue disorders. It is a persistent, progressive inflammatory process beginning in the synovial membrane, leading to the deformation and destruction of articular tissues, and the impairment of articulatory function . TypicalThe theoretical approach based on which we can understand the processes of adaptation to chronic disease is the Transactional Model of Stress and Coping . This apA basic problem that RA patients must cope with is pain. As the disorder advances, pain levels usually increase . The unpAmong the psychological consequences of RA, in the foreground are changes in the sufferer's emotional life, considered an effect of pain and growing impairment . IndividResearch on the consequences of depression in RA patients indicates that individuals exhibiting complex depressive symptoms are more susceptible to repeated recurrence of intense pain –18. ExpeAnother emotional state typical for RA is anxiety. The proportion of individuals with an increased level of anxiety stands between 21% and 70% of sufferers . Some reUsing the transactional model of stress , 26, potOne classification of strategies of coping with pain was proposed by Rosenstiel and Keefe . They diEgo resiliency is another potentially significant condition. It is the individual's ability to adapt their level of control over internal impulses to the requirements of the current situation . Ego resThe pathogenesis of rheumatoid arthritis is not fully identified. RA is treated as an autoimmune disorder, wherein white blood cells attack the organism's own tissues. This process manifests in the presence of immune complexes in the synovial fluid, synthesized with the involvement of the rheumatoid factor (RF), that is, antibodies against IgG. It is assumed that the rheumatoid factor initiates and maintains the inflammatory process in joints, though how and why it starts and sustains the course of illness remains an unknown. One popular hypothesis is that of viruses or bacteria triggering , 32.Because the primary cause of rheumatoid arthritis has not been discovered, treatment is symptomatic. The goal of pharmacological therapy is to halt the progress of disease and so induce remission. The drugs used over the course of RA largely have analgesic, anti-inflammatory, or immunosuppressive properties. They can modify the course of the underlying condition (most desirable) or merely ease the symptom-related pain, providing relief to patients. There are two basic groups of medication. The first are analgesic and anti-inflammatory drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticosteroids (GCs). The second are drugs modifying the course of the illness, including biologically active substances. Biologic agents are currently the newest and most advanced form of treatment. They are characterized by a decidedly increased efficacy compared to nonbiologic drugs, as they can more effectively thwart the organism's immunological response, leading to remissions which last several years.Because there are currently two main methods of pharmacologically treating RA, i.e., using either anti-inflammatory or biologically active drugs, an interesting question arises: does the pharmacotherapy used differentiate patients' pain and levels of anxiety and depression? Additionally, is the level of anxiety and depression determined by a different configuration of psychological variables?M=48.94; SD=14.31). An average of 14.86 years has passed since the initial diagnosis (SD=9.31). Women, numbering at 68 (80%), dominated the research group which is consistent with epidemiological data. The participants were treated using biologic agents  and standard anti-inflammatory drugs . A difference in age has been noted between the treatment groups , which was expected, as biological treatment is suggested for younger patients. However, no difference was noted in illness duration  nor in gender (womenNB 25 (29.21%); menNB 3 (3.53%); womenB 43 (50.56%); menB 14 (16.50%); chi2=2.250; p=0.134).85 rheumatoid arthritis patients hospitalized on rheumatoid wards took part in the study. They were aged between 29 and 76  , the EgoHospital Anxiety and Depression Scale (HADS) [ “I look forward with enjoyment to things), 7 regarding anxiety and 7 regarding depression. The study participants respond to each statement by choosing one of four possible answers .e (HADS) : it is mThe Ego-Resiliency Scale by Block & Kremen [ I like to take different paths to familiar places). Participants estimate how much each statement applies to them and choose the most appropriate response on a four-point scale, where 1 indicates it does not apply at all and 4 indicates it applies very strongly.& Kremen ; Polish & Kremen : the scaThe Pain Coping Strategies Questionnaire (CSQ) by Rosenstiel & Keefe; Polish adaptation: Juczyński [ I don't think about the pain). Due to the large number of measured coping strategies, in order to conduct detailed analyses the strategies were reduced to three general factors isolated by the method's authors: cognitive coping and suppression, diverting attention and substitute activities, catastrophizing and hoping.uczyński : the scaA Visual Analogue Scale (VAS) [ intensity of pain. Patients estimated what intensity of pain they felt during the day and at night using two 10-point scales. They marked the appropriate pain level on a horizontal 10-centimeter-long line marking the space between 1 no pain and 10 worst pain imaginable.le (VAS)  was used t-test  and daytime pain , as well as with ego resiliency . For patients in the nonbiological treatment group, depression correlates with four variables: positively with daytime  and nighttime pain , but negatively with ego resiliency  and cognitive coping strategies   . z=.57; p=.028; ego resiliency z=.52; p=.030)  .β=-.41; p<.001) and daytime pain levels . These two variables combined account for 22% of the variance of depression (F=8.72∗∗). For patients in the nonbiological treatment group, cognitive  and nighttime pain  were significant, accounting for 35% of the variance of depression (F=8.24∗∗).Solving the regression equation for the biological treatment group pointed to the importance of two variables: ego resiliency , as well as its daytime  and nighttime  components. Negative correlations, on the other hand, were found for cognitive coping strategies   .r=.41; p=.032). Experiencing daytime pain turned out to be the only anxiety predicate shared by both treatment groups   .β=.36; p=.003), cognitive coping strategies , and coping through catastrophizing . This set of three variables accounts for 31% of anxiety variance (F=9.53∗∗). For patients in the nonbiological treatment group, only daytime pain proved significant , accounting for 13% of anxiety variance (F=5.14∗)  .The first conclusion that can be drawn from the analyses relates to differences found in pain experienced by patients treated with biologic agents and anti-inflammatory drugs. Analysis results showed that patients receiving biologic agents experience lower levels of pain, both during the day and at night. The noted differences were strong. This shows that using biologically active medication alleviates one of the main symptoms of rheumatoid arthritis, pain, which lets it be assumed that a deferred consequence may be a decrease in depressive symptoms. This assumption is founded on the observation made by Zautra and collaborators , who notNo differences were noted, however, between patients in biological and nonbiological treatment groups regarding their levels of negative affect, anxiety, and depression. This may be related to the study taking place during the treatment process, while changes in mood could be delayed. As such, it has been suggested that future studies on the topic be longitudinal in nature. A different analysis approach may also be considered; namely, the dependency between pain and negative affect could be moderated by the time passed since initiating biological treatment.The second explored issue dealt with indicators of anxiety and depression in the two treatment groups. A low pain level, personality traits, and strategies of coping with pain were considered potentially beneficial in adapting to chronic illness , 36.It is assumed that pain, one of the most distressing symptoms of RA, has critical influence over the experience of negative emotions, anxiety, and depression. This thesis has been confirmed in previous research . In the Ego resiliency, understood as a set of subjective properties governing the ability to flexibly adapt the level of self-control to existing circumstances , was takStrategies of coping with pain were the third factor considered as a potential determinant of anxiety and depression. Coping is defined as the individual's efforts to manage arising demands . PreviouThe analysis of relationships between variables showed that the strongest protective function against symptoms is provided ego-resilience and cognitive coping. Probably the role of mental resilience is related to the characteristics of rheumatoid arthritis, which is a very changeable condition. It is not clear which group of strategies for dealing with anxiety and depression symptoms will be effective at a particular stage of the disease, so it is important to be able to adapt to changing conditions, including the flexible use of those strategies. For these reasons, it seems particularly important to develop mental resilience in this group of patients, regardless of the chosen treatment method. Moreover, it seems worthwhile to design and conduct experimental studies in which patients will develop resistance as a result of psychological interventions and check whether its development will help to reduce the symptoms of the disease.Despite their scientific value, our research has a number of limitations that need to be taken into account when interpreting the results. The limitations of the studies are that they were conducted on a very specific group of hospitalized patients. This implies that the results of the study can only be applied to a group of patients with acute symptoms of rheumatoid arthritis. In future studies, analyses should also be carried out on other groups of patients, i.e., outpatient clinics. In addition, patients were treated as a homogeneous group in regard to the severity of the disease. In future studies, it would be worth taking into account the severity of the disease estimated, e.g., by means of the DAS—Disease Activity Score—a scale for assessing the level of activity of symptoms of rheumatoid arthritis. As well as check if the disease activity interacts with the other variables studied.