We reviewed the referral pattern of children with chronic pain to a specialized pediatric pain clinic. Data were obtained from referring physicians and medical records and during an interview with patients and their parents by physicians and a psychologist. We analyzed the following: referral diagnosis, demographics, duration of symptoms, number of physicians previously consulted, school attendance, sports activities, presence of psychological disorders, final team diagnosis, and outcomes. Children had been experiencing pain for 34 ± 55 months. Patients had consulted on average 3 physicians in addition to their pediatrician. 32% of the patients had missed at least 10 days of school in a calendar year, and 47% had stopped playing sports. 15% had an operation because of pain that had been unsuccessful. The most common missed diagnosis was anxiety (25%) and depression (13%). 69% of the patients were back to school and/or playing sports within 4 months from our initial consultation. 32% of the patients did not make any progress during the follow-up period. The most common reasons for failure to improve were no compliance with the recommended treatments and poorly controlled major mood disorder. The time to refer children with chronic pain for specialized care could be extremely long causing significant social and psychological consequence. Literature data show that children with chronic pain often encounter significant delays between their initial pain complaints and the time they eventually consult a pain specialist –3. ZerniThe reasons for these findings are still unclear. The current literature does not address how often an accurate diagnosis is made by general practitioners and nonpain specialist and whether the psychological and social components of pain are taken in consideration in the care plan. It is also unclear how the evaluation by a pain specialist can affect patients' outcomes, particularly in the presence of data showing that adherence to pain physicians' recommendations is inconsistent in part due to a negative attitude towards specific recommendations, in particular psychological interventions , 8.The aim of this retrospective review was twofold. We analyzed the referral history for pediatric patients seen at our pain clinic, looking at the time interval between initial pain complaints and pain clinic consultation, including the number of physicians who consulted these patients and the referral diagnosis. We then analyzed the results of a multimodal approach to manage patients' symptoms and examined patients' compliance with the recommended treatments.The study was reviewed and approved by the Institutional Review Board. We reviewed the medical record of patients seen in the pain clinic of an academic institution between October 2014 and June 2016. The inclusion criteria were children aged 3–20 years diagnosed with chronic headaches, neuropathic pain, and muscle-skeletal and chronic abdominal pain and patients whose prior medical record and note from the referring physicians were available. We excluded patients with cancer pain or acute onset pain defined as any pain lasting less than 12 weeks  and whosThe pain clinic was staffed by a physician (anesthesiologist), a psychiatrist, a nurse practitioner, and a psychologist. A physical therapist and an occupational therapist were available for consultation as needed.The duration of the initial encounter ranged between 90 and 120 minutes. During this time, Complete past medical, surgical, and family history were taken. This was followed by a psychological evaluation and a physical examination. Patients with neuromuscular deficits were also evaluated by physical therapists. The following data were extracted from the patients' electronic medical record: sociodemographic data, race and ethnicity, diagnoses, history of health care contacts including a list of consulting physicians, therapeutic procedures including surgeries, and ability of patient to practice sports and attend classes at school on regular basis.We defined patients as unable to attend regular school classes when they were homeschooled because of pain symptoms and enrolled in online school or home-hospital programs and those who had missed more than 10% of school days during the previous school year, based on the California Department of Education policy [Patients were asked about the time interval between the onset of pain symptoms and the referral to this pediatric pain clinic. A review of the patients' prior medical records and referral documentation confirmed the data's accuracy. We documented the type and number of providers consulted because of pain and we recorded whether patients were referred by a practitioner working at this institution or a physician practicing in the community.Every patient was evaluated by a psychologist following a clinical interview assessing mental disorder classes and subcategories according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR)  includinThe recommendations made to patients and families included medications, psychotherapy, and Complementary and Alternative Medicine (CAM) interventions including acupuncture, yoga, biofeedback, massage therapy, and occupational therapy interventions. Nerve blocks and local or joint steroid infiltrations were also recommended when clinically indicated. Patients with Complex Regional Pain Syndrome and those unable to ambulate for chronic pain were admitted in the hospital rehabilitation unit for intense physical and occupational therapy. Patients with history of opioid abuse were referred to the hospital substance abuse program specialists.Patients were asked to follow up with the clinic within a month after the initiation of the recommended treatments. The following appointments were scheduled based on the response to the treatments. Phone calls were made to remind patients of their clinical appointments. Treatments including psychotherapy and physical and occupational therapy as well as CAM interventions were done at this institution or in the community based on patients' insurance requirements and their physical address.We defined clinical improvement in our population as the ability of patients to go back to school full time as well as being able to resume sport activities that were interrupted because of pain , 13.p values < 0.05 were considered statistically significant.STATA/IC 14 software was used for data analysis . Chi-square analysis was conducted to compare categorical data after verification of their normal distribution using the Silk-Wilk test. A multivariable least square regression model was used to analyze the independent relationship between duration of symptoms and potential different predictors of delayed referral to our pain clinic including distance from our hospital, type of insurance, referral diagnosis, and race. A similar analysis was conducted to determine whether any of variables could predict the number of doctors' visits done prior to our evaluation. p < 0.01), during the study period, there were fewer Hispanic patients compared to non-Hispanic patients (p < 0.001), and only 5% of the families did not speak English and needed a translator during the visit (p < 0.001). Thirty-nine children (52%) were not able to attend regular classes because of pain and 35 (47%) were unable to continue playing sports because of pain (Seventy-five patients were included in the review. Demographic data are shown in  of pain .p < 0.05). The longest duration of symptoms prior to the referral to our pain clinic was observed in patients with headaches (61 ± 58 months), followed by abdominal pain (39 ± 33 months) and back pain (37 ± 55 months). Patients diagnosed with dystonia and fibromyalgia had the shortest referral time (8 ± 5 months).Patients had been reporting pain for an average of 34 ± 55 months. The duration of symptoms was twice as long in patients who had a Health Maintenance Organization (HMO) insurance plan and Medi-Cal compared to patients who had a Preferred Provider Organization (PPO) or Kaiser insurance plan , and only 4 patients never saw their pediatrician (5%). The most commonly consulted specialists were as follows: orthopedic surgeons (41%), rheumatologists (27%), and neurologists and gastroenterologists (24%). Ten percent of the patients had at least one emergency room visit since the pain symptoms had started with 2 visits (range 1–4) on average prior to the referral to our clinic. There was no correlation between the number of specialists consulted and the delay to refer patients to this clinic. The multivariate regression analysis identified distance to our clinic and type of health insurance as the variables that predicted a delay in referring patients to our pain clinic .Sixteen patients (21%) had consulted a psychologist prior to visiting our pain clinic. Four patients were seen for anxiety, 5 for depressive symptoms, and 6 either after parents divorced or after episodes of trauma . In only one of these patients psychotherapy had been recommended to help manage chronic pain symptoms.Eleven patients (15%) underwent an operation because of pain complaints prior to the referral to the pain clinic. The list of procedures includes 2 appendectomies, 1 Nissen fundoplication and 1 cholecystectomy done for complaints of chronic abdominal pain, 2 foot surgeries for pain thought to be related to feet deformities, and 1 resection of a small leg osteochondroma for chronic leg pain. All of these patients continued to report pain after the aforementioned operations similar in intensity and quality to that experienced prior to their operation.The types of interventions recommended by our team are shown in We prescribed SSRI antidepressants to 7 patients. Six of them improved during the follow-up period. The patient who failed the recommended treatment also had a diagnosis of opioid abuse. We recommended psychotherapy in conjunction with CAM therapies in 24 patients. Three of them did not come back to the clinic, 14 followed the recommendations, and all of them improved during the follow-up period. Seven patients chose not to consult a psychologist; subsequently, none of these patients reported improvements in their pain symptoms.Our team misdiagnosed a patient. He was initially diagnosed by surgeons with chronic functional abdominal pain. Because of negative physical findings we recommend CAM. However, after further investigations conducted by his surgeon, he was found to have an intra-abdominal neuroblastoma 6 months later.p < 0.0001). Similarly, 62% of our patients were practicing a sport activity after having followed our treatment plan compared to 20% prior to it (p < 0.0001). It should be noticed that 36% of the children who were not interested in practicing any sport at the time of the initial clinic visit started practicing some sport as part of our overall recommendations.The length of the follow-up was 11 ± 10 months. Twelve patients (16%) decided not to come back to this pain clinic and were lost to follow-up. The average number of follow-up visits was 3 (range 1–20). Of those who returned to the clinic for follow-up, 17 patients (27%) did not follow up with the recommended treatments. Of those who adhered to the treatment plan, 43 patients (68%) were functional and had returned to their daily activities either pain-free or able to cope with their symptoms. In particular, there were a significant higher number of children who were able to go back to regular classes during the follow-up period compared to the time prior to our evaluation and recommendations  reported no improvement in their symptoms. This lack of improvement has been attributed to one of the following: wrong diagnosis in 1 patient made by this team, drug abuse and dependence in 2 patients, lack of insurance for 2 patients, no compliance with the recommended treatment in 7 patients, and major depression or generalized anxiety poorly controlled by psychotherapy and medications in 7 patients.This review highlights two important aspects of the care delivered to children with chronic pain: the delay to refer these patients to a pediatric pain specialist and the failure to recognize psychological disorders as an important comorbid condition in chronic pain in children and adolescents.We found that the delay to refer children with chronic pain to our clinic was significantly longer than what has been reported in other studies , 6. The We have confirmed literature data  suggestiLack of specialized care and low household income are other major barriers to access specialized care in general , 18. TheAlthough the type of insurance and distance were significantly correlated to the delayed referral to the clinic, the model accounted only for 10% of the findings. When looking at other potential reasons for the delayed referral it is important to consider the pediatricians', specialists', and families' biases towards the search for an organic cause of pain in children. It is difficult to quantify how much inappropriate referral practices can be attributed to the belief that there are definitive tests for every specific disease and that causal determinism can be explained with certitude in medicine . It is qWith respect to health care utilization, our data are consistent with other reports. While a study found that higher income, more severe pain scores, and activity limitations were significant predictors of the number of doctors' visits , we coulEven though the biopsychosocial model of chronic pain is widely accepted by chronic pain practitioners, it is often difficult for families to accept that psychological and social factors intricately interrelate to affect pain perception, coping with symptoms, engagement with providers, and, ultimately, clinical outcomes. We identified anxiety and/or depression in 45% of our patients. Longitudinal studies have clearly indicated that depression and anxiety are risk factors for developing chronic pain , 27. At Not only is it important to recognize the appropriate time to refer a child with chronic pain to a pain specialist but also it is important to identify what kind of pain practice the child should be referred to. There are different types of pain clinics, those where symptom control is the priority and others that focus on improving patients' functional activities. It is rare that both approaches are used .Adherence with physicians' recommendations is often a major obstacle to clinical improvement. The number of patients who did not come back to the clinic or did not adhere to the treatment plan (36%) was slightly lower than what has been reported in other studies focused on chronic pain (47%) . SurprisThere are multiple reasons why we observed a poor compliance as well as a relatively high number of patients who did not follow up with the recommended treatments. Patients may have faced problems obtaining insurance coverage for some of the CAM interventions we recommended. Opposite to data obtained in the adult population where a recent study has shown that 30–40% of adults in the United States use some form of CAM intervention every year , a signiThis study has several limitations. This was a retrospective analysis and we could not report on the recommended outcomes proposed by the PedIMPACT  focus grIn conclusion, our data support the notion that there is a significant delay in referring children with chronic pain to pediatric pain specialists. The psychological component of pain is often missed, and this results in multiple doctor and emergency room visits, multiple laboratory and radiologic tests, and unnecessary operations with consequences on the quality of life of children. A multidisciplinary evaluation and a broad range of interventions including CAM techniques, psychotherapy, and referral to appropriate pediatric specialists could significantly expedite the return to a functional life with well managed pain symptoms. Although some of the academic pediatric pain clinics housed in large medical centers utilize a multidisciplinary or interdisciplinary approach, our data support the need for providing mental and behavioral health services as part of a primary care model as psychologists play a key role in integrated health care by helping people modify their behavior to prevent and recover from health problems.


Chronic inguinodynia (groin pain) is a common complication following open inguinal hernia repair or a Pfannenstiel incision but may also be experienced after other types of (groin) surgery. If conservative treatments are to no avail, tailored remedial surgery, including a neurectomy and/or a  meshectomy, may be considered. Retrospective studies in patients with chronic inguinodynia suggested that spinal anaesthesia is superior compared to general anaesthesia in terms of pain relief following remedial operations. This randomised controlled trial is designed to study the effect of type of anaesthesia  on pain relief following remedial surgery for inguinodynia.A total of 190 adult patients who suffer from unacceptable chronic (more than 3 months) inguinodynia, as subjectively judged by the patients themselves, are included. Only patients scheduled to undergo a neurectomy and/or a meshectomy by an open approach are considered for inclusion and randomised to spinal or general anaesthesia. Patients are excluded if pain is attributable to abdominal causes or if any contraindications for either type of anaesthesia are present. Primary outcome is effect of type of anaesthesia on pain relief. Secondary outcomes include patient satisfaction, quality of life, use of analgesics and (in)direct medical costs. Patient follow-up period is one year.The first patient was included in January 2016. The expected trial deadline is December 2019. Potential effects are deemed related to the entire setting of type of anaesthesia. Since any setting is multifactorial, all of these factors may influence the outcome measures.This is the first large randomised controlled trial comparing the two most frequently used anaesthetic techniques in remedial surgery for groin pain. There is a definite need for evidence-based strategies to optimise results of these types of surgery. Besides pain relief, other important patient-related outcome measures are assessed to include patient’s perspectives on outcome.NL54115.015.15) is approved by the Medical Ethics Committee of Máxima Medical Centre, Veldhoven, The Netherlands. The study protocol was registered at www.trialregister.nl (NTR registration number: 5586) on 15 January 2016.The protocol (protocol number The online version of this article (doi:10.1186/s13063-016-1746-x) contains supplementary material, which is available to authorized users. Chronic postoperative groin pain (inguinodynia) is defined as pain beyond 3 months after inguinal surgery. In the majority of patients, inguinodynia develops following open inguinal hernia repair . One third of patients with chronic postherniorrhaphy pain experience impairment of daily activities , 2. ThisThe SolviMáx Centre of Excellence is a third-line referral centre for abdominal wall and groin pain. Experience with a spectrum of surgical procedures for inguinodynia is growing. One retrospective study in patients with inguinodynia suggested that spinal anaesthesia is associated with a superior outcome in terms of pain relief when compared to general anaesthesia . A more www.trialregister.nl (NTR registration number: 5586). The present paper is written according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statement for reporting a clinical trial protocol [This monocenter, nonblinded, randomised controlled trial is performed in the SolviMáx Centre of Excellence for Abdominal Wall and Groin Pain. SolviMáx is a subdivision of the Surgical Department of Máxima Medical Center (MMC), a teaching hospital situated in the southern part of The Netherlands serving a population of approximately 200,000 inhabitants. The study aims at investigating a potential difference in pain relief following remedial surgery that is performed in two different settings, spinal anaesthesia versus general anaesthesia. The present trial is not considered a drug study as other variables associated with type of anaesthesia are not under control of the investigators. The present trial follows guidelines of the declaration of Helsinki (version 19 October 2013). The protocol (protocol number NL54115.015.15) is approved by the Medical Ethics Committee of Máxima Medical Centre, Veldhoven, the Netherlands. The study protocol (version 1) is registered at protocol . The SPIPatient enrolment started in January 2016. Chronic inguinodynia that is unacceptable as subjectively judged by patients themselves is a prerequisite for inclusion. Only patients scheduled to undergo remedial surgery including a neurectomy and/or a meshectomy (if patients have mesh) by an open approach are considered for inclusion  is left to the discretion of the attending anaesthesiologist. Consequently, the setting of the two types of anaesthesia rather than the actions of the anaesthetic drugs are investigated. It is allowed for patients who are randomised to the spinal anaesthesia group to receive midazolam during the procedure. Midazolam has no effect on perception of pain so no drug-related sequelae on the primary outcome measure are expected. If requested, midazolam will be administered in a dose of 1 mg (if aged over 65 years) or 2 mg (if ASA class below III).If a patient receives spinal anaesthesia but intrathecal articaine has insufficient effect, the patient will undergo surgery under general anaesthesia. Subsequently, this will be considered as a protocol violation and the particular patient will be excluded from further analysis.t0), Fig. t1–t3) and long-term results .Primary outcome is the effect of type of anaesthesia on pain relief after surgery. Patients are asked to score their pain using the Numerical Rating Scale . The first pain score is obtained in the preoperative phase . To avoid confusion, satisfaction is also measured by a NRS-like method, using an 11-point rating scale.www.imta.nl) are used [Other secondary endpoints include differences in pain medication and both direct and indirect medical costs. Two different validated questionnaires, developed by the institute for Medical Technology Assessment . Results from previous retrospective studies were used as criteria for eligibility were similar . Additional literature regarding anaesthesia on remedial surgery is not available. Previously demonstrated success rates were 77% in the spinal anaesthesia group and 58% in the general anaesthesia group . Based on these data, a sample size of 190 patients is calculated to demonstrate a potential effect of either type of anaesthesia on pain relief. This volume of patients is attained after three years as based on the number of included patients in previously performed studies . No blocked randomisation or prestratification is performed. The decision to execute a neurectomy and/or mesh removal depends on patient history, physical examination and intraoperative findings [Patients will be electronically randomised by the web-based research software Research Manager  anaesthesia assignments by the investigators is secured. Consequently, bias due to improper randomisation techniques is minimised.Blinding of anaesthesiologists, surgeons and patients is not possible. Since the study is designed to investigate the setting of type of anaesthesia, where all factors associated with anaesthesia are of interest, blinding is not conditional for a robust conclusion on efficacy of either anaesthetic technique setting.©) for Windows. Digital data are easily exported from RM to SPSS. The primary outcome measure is pain relief using NRS as compared to the preoperative pain levels (t0). Pain reduction is calculated by using the following formula:Data analysis will be performed using SPSS version 22  will be compared to preoperative data within groups. The Student’s t test or the Wilcoxon signed rank test will be used as appropriate. P values ≤ 0.05 are considered statistically significant. Intention-to-treat analysis will be applied on the primary outcome measure.Secondary outcome measures will be compared between groups at the various postoperative follow-up points. In addition, outcomes at each evaluation time  of hernia operations . Spinal a repair , 22. In eadiness . Only reeadiness . This isConsidering groin pain relief following remedial surgery for groin pain, spinal anaesthesia is hypothesised to be superior to general anaesthesia. The assumed beneficial effect is possibly associated with the spinal block itself diminishing transmission of nociceptive signals from the operation site toward the nervous system , 25. Howprimary herniorrhaphy [In 2004, Burney and coauthors performed a randomised trial on the effects of anaesthesia in orrhaphy . A disaporrhaphy . It is torrhaphy –29. Whenorrhaphy –32. By aThe majority of studies on chronic postoperative pain lack sufficient data to draw any robust conclusions. Previously, authors have claimed that extensive preoperative data, detailed characteristics of surgical procedures and measures of acute and chronic postoperative pain (up to 1 year) are essential for a proper evaluation of effects on pain . The preA potential limitation of the present study is its nonblinded design. Blinding of patients is, in our opinion, unethical and hardly practicable. Moreover, the main outcomes of the present trial are subjective. Consequently, these outcomes may be contaminated by recall bias if patients enrolled in the trial are not blinded to their treatment allocation .This is the first large randomised controlled trial comparing two routinely used anaesthetic techniques in remedial surgery for groin pain. There is a definite need for evidence-based strategies to optimise the results of these types of surgery. Besides pain relief, other patient-related outcome measures are assessed to include patient’s perspectives on outcome. The first study results are expected in 2019 and will be communicated via publication.Period of patient recruitment.


Motor cortex stimulation (MCS) was introduced as a last-resort treatment for chronic neuropathic pain. Over the years, MCS has been used for the treatment of various pain syndromes but long-term follow-up is unknown.This paper reports the results of MCS from 2005 until 2012 with a 3-year follow-up. Patients who suffered from chronic neuropathic pain treated with MCS were studied. The analgesic effect was determined as successful by decrease in pain-intensity on the visual analog scale (VAS) of at least 40%. The modifications in drug regimens were monitored with use of the medication quantification scale (MQS). Stimulation parameters and complications were also noted. Interference of pain with quality of life (QoL), the Quality of Life Index (QLI), was determined with use of a specific subset of questions from the MPQ-DLV score.P < 0.0001). A successful outcome was achieved in seven responders (38.9%). All patients in the responder group suffered from pain caused by a central lesion. With regard to all the patients with central pain lesions (n = 10) and peripheral lesions (n = 8), a significant difference in response to MCS was noticed (P = 0.002). MQS scores and QLI-scores diminished during the follow-up period .Eighteen patients were included. Mean pre-operative VAS changed from 89.4 ± 11.2 to 53.1 ± 25.0 after three years of follow-up (MCS seems a promising therapeutic option for patients with refractory pain syndromes of central origin. In the early 1990s, Tsubokawa and colleagues presented that chronic motor cortex stimulation (MCS) was effective in treating thalamic pain syndromes, 3. The In 2003, an observational study protocol was set up in the university medical centers of Nijmegen and Groningen, the Netherlands, in order to study the effects of MCS in patients that suffered from chronic neuropathic pain. PatientMedtronic Inc., Minneapolis, MN, USA) to visualize the cortical areas and determine the central sulcus and the motor cortex, which then was marked on the skin by using neuronavigation. All patients were operated under general anesthesia without muscle relaxation. A small craniotomy (approximately 4 × 4 cm) was carried out over the central sulcus. An electrode was placed perpendicular to the central sulcus in the epidural space . The central sulcus was identified using the phase reversal of the somatosensory evoked potential recorded with an eight-contact electrode strip during median nerve stimulation. Consequently, monopolar anodal train-of-five stimulation was used to map motor function at different locations in the precentral gyrus. Stimulation intensity was increased until a reproducible motor evoked potential was found in the muscle of interest . Results from electrophysiological testing were taken together with intraoperative neuronavigation to determine the optimal cortical target for MCS. The MCS electrode was sutured to the dura mater. After placement of the electrode, the electrode was tunneled subcutaneously and connected with an internalized pulse generator (IPG) (Medtronic Versitrel and later Prime Advanced) that was implanted in the subclavian space or in a subcutaneous abdominal pocket.The pre-operative fMRI was fused with the neuronavigation MRI. For this purpose, cortex surface rendering technique was performed using the Stealthviz software (An independent researcher (D.H.), who was blinded to the stimulation conditions, investigated the patient records in this observational study. Only patients who were treated in accordance to the aforementioned treatment protocol and with a minimal follow-up of three years in whom the effect of MCS, occurrence of complications, daily intake of medication and change in quality of life was complete, were analyzed.S1 File).This observational study was performed under the approval of the medical ethical committee of the region Arnhem–Nijmegen. All patients, after extensive pre-operative information, gave written informed consent due to the experimental nature of this treatment at that time. This clinical trial was not registered in 2003 due to the fact that, in The Netherlands, MCS was not an experimental method at that moment. The authors confirm that all ongoing and related trials for this intervention are registered . The TREND Statement Checklist was added to this paper in order to contribute to the standardization of the reporting of non-randomized trials , the intake of pain medication is thought to be a valid tool of measuring pain relief, 36. AddIBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). The differences in VAS-scores MQS-scores and QoL-indices over time were analyzed using a mixed model analysis. To determine differences between groups in MQS-scores, the Mann-Whitney U test was used. In order to correlate the applied stimulation parameters, the Spearman rank correlation coefficient was conducted. To determine the complication rate across time, a Poisson regression analysis was conducted. Values are represented as mean ± standard deviation (minimum- maximum). Statistical tests were two sided and with a significance level of P < 0.05 .IBM SPSS Statistics version 22 was used for statistical analyses of the retrieved data . The mean age was 59.0 ± 7.3 years (41–72 years), and 10 of them were females. The mean duration of pain was 7.7 ± 6.1 years (2–26 years). Tables 2 summarize the baseline surgery-related characteristics and the outcomes of MCS and the complications due to surgery. The complete, anonymized database has been made available; see S1 Database).Eighteen patients were included (P < 0.0001). A clinical relevant pain relief (level 1 and 2) was observed in 38.9% of the patients after 1 month. After 6 months, a mean VAS score of 58.3± 20.9 was observed (P < 0.0001). After 1 year, the most optimal results were observed with a clinical relevant pain relief in 44.4% of the patients and a mean VAS score of 56.1 ± 29.6 (P < 0.0001). After 3 years of MCS, a mean VAS score of 53.1 ± 25.0 was observed (P < 0.0001).The mean pre-operative VAS was 89.4 ± 11.2. A mean VAS score of 59.2 ± 21.4 was observed after 1 month (P = 0.002). As many of the patients suffered from orofacial pain, this group was also reviewed separately. When the orofacial pain candidates and the site of the lesion were reviewed, MCS showed to have a significant favorable outcome (P = 0.003) in the treatment of proximal  lesions (Table 3).A clinical relevant pain relief was observed in 38.9% of the described population after 3 years of follow-up and a mean VAS reduction of 36.4 points. This indicates seven responders (R) to MCS and eleven non-responding patients (NR). All responders to MCS (n = 7) showed to be suffering pain due to lesions in the central nervous system. In the non-responder group (n = 11), central lesions were seen in three cases. With regard to all the patients with central pain lesions (n = 10), a clinical relevant pain relief was observed in 70% of the cases and a mean VAS reduction of 54.5% ± 23.9 could be observed. All the patients with a peripheral lesion (n = 8) showed a mean VAS reduction of 16.7% ± 10.0. This indicated a significant difference in response to MCS . Responders showed a median MQS score before and after MCS of 6.3 and 5.4, respectively, ranging from 0 to 14.1 before MCS and 0 to 20.7 after MCS . The non-responders had a median MQS score of 11.5 and 5.4 before and after MCS, respectively, ranging from 5.4 to 26.1 before and 0 to 15.6 after MCS .At baseline, 16 patients used pain medication. P = 0.007). Responders and non-responders to MCS did not show a significant different preoperative QoL-index (P = 0.249), whereas the postoperative QoL-index showed significant differences in favor of the group responders (P = 0.002).The QoL-index was used in order to measure the impact of MCS on the pain-related quality of life. QoL-indices were retained from thirteen patients. Three patients were lost during follow-up of QoL due to recurrent infections and removal and re-implantation of MCS electrodes . The mean pre- and postoperative QoL-index showed to be 11.9 ± 3.5 and 7.7 ± 4.4, indicating a significant improvement in QoL .Complications occurred in nine patients (50%). In three patients, an infection of the electrode and the extension wire occurred and the electrodes were removed . One patient (#10) experienced a short-lasting, intra-operative epileptic seizure during intra-operative stimulation of the motor cortex. One patient suffered from an IPG hardware malfunctioning (#13). In four cases, the system was explanted on request of the patient due to an unsatisfactory pain relief . After it was observed that some patients suffered from local pain after implanting the IPG in the subclavian area, the IPG implantation area was switched to the subcutaneous abdominal space . The complication rate across time showed to be 0.16 events per person years (Table 4). No correlation between the applied intensities or pulse widths and the pain relief at last follow-up could be observed . A significant correlation (P = 0.035), however, was observed between the applied frequencies and the pain relief at the last follow-up (Spearman correlation = 0.498).The intensity of the stimulation varied between 1.5 V and 5.0 V. The frequencies ranged from 40 Hz to 60 Hz, and the pulse width ranged from 60 μs to 120 μs (This paper reports that the positive effects of MCS are associated with a decrease in pain scores (VAS), improved quality of life and a diminished consumption of pain medication. Various reports in chronic pain management show that the improvement that patients experience after MCS takes place in numerous domains. Therefore, the analgesic effects must be registered using pain intensity scores, quality of life assessments and a medication intake score . For exaTable 3). Possibly, the combination of a clear anatomical region with detectable changes on neuro-imaging, combined with a relatively large somatotopic area to be stimulated, is key to these findings. However, classifying this anatomical diagnosis in a mechanism-based way remains difficult.As mentioned, a significant difference in response to MCS between the central and peripheral pain patients was observed. This phenomenon could be the result of a hypothesized double projection of body regions to the thalamus and the somatosensory cortical areas, 46. If The various stimulation parameters  in combination with the anatomical position  of the electrode and per-operative neurophysiological measurements, all influence the effects of MCS. RegardiAll patients were seen by a team of anesthesiologist-pain specialists, neurosurgeons, and clinical psychologists preceding the operation and during the treatment process. Since it is known that an evaluation by the operator involved creates bias, the participation of an independent observer adds to the strength of the results. The absence of a control group forms an important limitation of this study. Nevertheless, this lack of a control group can be explained by the unacceptable safety aspects of performing a sham surgical intervention and limited trustworthiness of a control group in MCS studies. A double blinded on/off-phase trial could be a valuable addition with regard to the lack of a control group. Second, as over the years new insights in neurophysiological features of chronic pain and MCS were gained, important diagnostic steps were not included in this protocol. For example, Rasche and Tronnier suggested that a double-blinded test trial with an external stimulation device could identify non-responders and placebo responders, hence improving the results of MCS. They alNowadays, all ongoing and related trials for MCS must be registered, but just like this study, some studies might not have been registered as this was not common practice at that time. For studies that were started at the time when the registration of trials started and of which the results currently can be presented, this might offer a problem. Strict adherence to this policy might introduce loss of a huge amount of valuable data that could be used to raise questions and help to develop or refute treatments.Furthermore, more sophisticated imaging techniques such as diffusion tensor imaging, at higher resolutions, could contribute to our understanding of nociceptive pathways in humans. For example, as this report shows, different forms of orofacial pain, conducted by different nociceptive pathways  respond differently to MCS. A stricter guideline or protocol of selecting and treating patients with MCS seems to be of great importance in order to optimize the efficacy.MCS shows to be promising with regard to the long-term effects in patients suffering from chronic, intractable, neuropathic pain, especially in patients who suffer from pain, caused by a central lesion. Optimizing the pre-operative diagnostic procedure and careful patient selection can increase the success rate of MCS. Second, the effect of MCS should not only be evaluated by measuring pain scores alone, but also by alterations in daily intake of pain medication and quality of life.S1 FileThe Transparent Reporting of Evaluations with Non-randomized Designs (TREND) group aimed to improve the reporting standards of non-randomized evaluations of behavioral and public health interventions. The TREND statement checklist is a 22-item checklist that was specifically developed to guide standardized reporting of non-randomized trials. The TREND statement checklist complements the widely adopted CONsolidated Standards Of Reporting Trials (CONSORT) statement, which was developed for randomized controlled trials.(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.S1 Database(XLSX)Click here for additional data file.


Earlier small case series and clinical observations reported on chronic pain playing an important role in facioscapulohumeral dystrophy (FSHD). The aim of this study was to determine the characteristics and impact of pain on quality of life (QoL) in patients with FSHD.We analyzed patient reported outcome measures collected through the U.K. FSHD Patient Registry.Of 398 patients, 88.6% reported pain at the time of study. The most frequent locations were shoulders and lower back. A total of 203 participants reported chronic pain, 30.4% of them as severe. The overall disease impact on QoL was significantly higher in patients with early onset and long disease duration. Chronic pain had a negative impact on all Individualised Neuromuscular Quality of Life Questionnaire domains and overall disease score.Muscle Nerve57: 380–387, 2018Our study shows that pain in FSHD type 1 (FSHD1) is frequent and strongly impacts on QoL, similar to other chronic, painful disorders. Management of pain should be considered when treating FSHD1 patients.  FSHDfacioscapulohumeral muscular dystrophyFSHD1facioscapulohumeral muscular dystrophy type 1INQoLIndividualised Neuromuscular Quality of Life QuestionnaireIRinterquartile rangeJWMDRCJohn Walton Muscular Dystrophy Research CentreNSAIDsnonsteroidal anti‐inflammatory drugsQoLquality of lifePROMpatient reported outcome measuresSF‐MPQShort Form of the McGill Pain QuestionnaireSMCHD1structural maintenance of chromosomes flexible hinge domain containing 1SMCHD1) gene are found. The D4Z4 methylation status changes in FSHD and the D4Z4 hypomethylation leads to chromatin relaxation of D4Z4 and expression of DUX4.Facioscapulohumeral muscular dystrophy (FSHD) is the second most common muscle condition in adults, with an overall incidence of 1:20,000.FSHD symptoms usually start around the second decade and are most commonly characterized by asymmetric weakness affecting the face, shoulder, and arms, followed by the distal lower extremities and pelvic girdle. Not all patients have the complete phenotype of FSHD, and clinical severity varies widely among patients, including great variability of weakness within families. Chronic pain is a significant problem in different neuromuscular conditions,Recent studies have suggested that pain may be present in the majority of FSHD patients, ranging from 76% to more than 80% of the FSHD population, with 19% reporting severe pain.The aim of the study was to determine the frequency, localization, and intensity of pain in the FSHD1 population registered in the U.K. FSHD registry; and to evaluate the influence of pain, age, sex, disease duration, and ambulatory status on QoL.https://www.fshd-registry.org/uk/participants/questionnaires/index.en.html). The Registry started in May 2013. A cutoff point for data analysis was established in February 2017. This patient driven registryWe have analyzed data obtained from the U.K. FSHD Patient Registry that is curated from the John Walton Muscular Dystrophy Research Centre (JWMDRC) at Newcastle University (The Short Form of the McGill Pain Questionnaire (SF‐MPQ) was used to report pain. The SF‐MPQ is widely used, well‐validated, and reliable and has previously been used in FSHD1.Patients completed the Individualised Neuromuscular Quality of Life Questionnaire (INQoL), a widely used and well‐validated neuromuscular disease specific measure of QoL.U test, and Kruskal‐Wallis test were used, as appropriate. Correlations were calculated using nonparametric Spearman's coefficient. To evaluate influence of age, age of onset, disease duration, gender, D4Z4 repeat, SF‐MPQ total score, and chronic pain on INQoL we performed a multivariate linear regression. Differences were considered significant at P < 0.05, and all statistical tests were two tailed. All data were analyzed with IBM SPSS Statistics 22.Location and dispersion indexes of noncontinuous variables were used to describe the sample with median and interquartile range (IR). Categorical variables were described as percentages. All statistics discussed here are presented as percentages of the total patient answers and not as percentages of the whole cohort unless otherwise stated. For comparison between groups, Chi‐square tests, Mann‐Whitney Four hundred and two genetically confirmed FSHD1 patients were included in this study. Figure EcoRI fragments was > 39 kb ; although, they have neither SMCHD1 test nor methylation studies. These 6 patients were included in the study because all reported symptoms and the treating neuromuscular specialist confirmed clinical features consistent with FSHD. There was no EcoRI fragment information in 45 of the cases.The median age of the entire cohort was 47.0 (interquartile range: 60.6) years. Demographic data is presented in Table P < 0.05) than in males (Table P < 0.05). No significant differences were observed regarding current pain localization across EcoRI fragments size, age of onset or motor function as showed in Table P < 0.05). The most common location of chronic pain was the shoulder joint in 165 patients (45%). No association was seen between chronic pain and EcoRI fragments size, age of onset, or motor function.Of those completing the SF‐MPQ, 339 patients (88.5%) reported experiencing pain to some degree. The sensory score in females was significantly higher (es Table . Three hMedication to manage pain was taken by 367 (92.2%) patients. When specified, nonsteroidal anti‐inflammatory drugs (NSAIDs) were the most frequent drugs used followed by opioids as described in Figure P < 0.01). No other domain was affected by gender (Table EcoRI fragment (P < 0.05). The overall INQol increases with statistical significance with younger age of onset (rho = ‐0.22) and longer disease duration (rho = +0.23) (P < 0.05).The median overall INQoL score was 53.1 (IR: 34.3) suggesting relatively moderate sickness‐related dysfunction in this group of FSHD1 patients. The sub‐domains with the highest median scores, indicating the greatest impact on QoL were muscle weakness, body image, and activities. The least impact on QoL is in the areas of muscle locking and relationships. The weakness score in males was significantly higher than in females (P < 0.01).SF‐MPQ sensory, affective, and total pain scores correlated with INQoL pain score , and INQoL total score . On the other hand, the presence of severe pain in the shoulders, severe lower back pain, chronic pain, and severe chronic pain correlated with the INQoL pain score , and the INQoL total score . Multiple regression analysis showed that longer disease duration was related to greater deterioration on INQol; interestingly, the total SF‐MPQ score and presence of chronic pain was also directly related to an increase in total INQoL scores as showed in Table The pain INQoL score is higher in ambulant populations  has not yet been validated; however, there was a good correlation with the well‐validated SF‐MPQ. In answering the universal pain assessment tool, it is important to clarify that patients have to recognize the pain as a result of their FSHD, and that it may be difficult to differentiate this pain from other types of pain.In conclusion, pain is a frequent symptom in FSHD1 that negatively impacts QoL. Studies have demonstrated that pain in FSHD1 is an inherent feature of the condition that requires further investigations to understand the pathophysiology, to study the relation with disease severity and functional disability.Additional supporting information may be found in the online version of this article.Supporting Information Table S1Click here for additional data file.


Operations performed with local anesthesia can sometimes be extremely painful and uncomfortable for patients. Our aim was to investigate the optimal analgesic method in saline infusion sonograms.This study was performed in our Clinic of Obstetrics and Gynecology between March and August 2011. Ninety-six patients were included. Patients were randomly divided into groups that received saline , paracervical block (group 2), or paracervical block + intrauterine lidocaine (group 3). In all groups, a visual analogue scale score was performed during the tenaculum placement, while saline was administered, and 30 minutes after the procedure.When all the patients were evaluated, the difference in the visual analogue scale scores in premenopausal patients during tenaculum placement, during the saline infusion into the cavity, and 30 minutes following the saline infusion sonography were statistically different between the saline and paracervical block groups, and between the saline and paracervical block + intrauterine lidocaine group. However, there was no statistically significant difference between paracervical block and paracervical block + intrauterine lidocaine groups.As a result of our study, paracervical block is a safe method to use in premenopausal patients to prevent pain during saline infusion sonography. The addition of intrauterine lidocaine to the paracervical block does not increase the analgesic effect; moreover, it increases the cost and time that the patient stays in the dorsolithotomy position by 3 minutes. Pre and post-menopausal bleeding, endometrial lesions found with ultrasound, and evaluation of endometrial cavity before performing hysterectomy are some indications that may require saline infusion sonography (SIS). In sum, SIS is a valuable and indispensable method in gynecology practice.The specificity and sensitivity of SIS for detecting endometrial pathology were 81-100% and 85-100%, respectively. For detecting submucosal myoma, it has sensitivity of 57-100% and specificity of 96-100%. For detecting endometrial hyperplasia or cancer it has sensitivity of 29-80% and specificity of 82-100%,6,7,8,9.Unfortunately, SIS may cause pain and discomfort depending on the technique and methods of anesthesia. Grasping the cervix with a tenaculum, movement of cannulas in the uterus, and distention of the uterine cavity with saline may cause pain in the procedure. Hence, active cooperation of patients is highly desirable to obtain maximum efficacy, and effective anesthesia becomes very important. Paracervical block (PCB) is the most frequently used method to prevent pain in the procedure. Previous reports showed that intrauterine lidocaine (IUL) is also a safe and effective method for preventing pain in outpatient gynecologic proceduresWe designed a randomized controlled trial to compare the efficacy of PCB vs. IUL, and also with placebo.We conducted this study between March 2011 and August 2011 in a tertiary reference center. The study was approved by our ethical committee. All participants gave their written informed consent for the study. We included 120 women who underwent SIS for various reasons. We excluded women with severe systemic medical conditions such as heart failure and uncontrolled severe hypertension, and cervical stenosis, acute cervicitis and/or vaginitis, and lidocaine allergy. The remaining 96 women were randomized into three groups: saline controls (group 1), PCB (group 2), and PCB + IUL (group 3); randomization was performed using computer-generated random number tables.We collected data about patient characteristics including age, gravidity, parity, history of abortion, any known allergy, current drug use, and medical and gynecologic history from patient records.All women underwent a bimanual pelvic examination to determine the size and position of the uterus. The cervix was exposed using a bivalve speculum and washed with povidone-iodine solution. In the PCB group, 2 mL 2% lidocaine  was injected into the cervix at 4- and 8 o’clock positions at a depth of 2-3 cm after confirming the tip of needle was not inside a vessel lumen. Five minutes were allowed to pass to ensure the anesthetic effect of lidocaine had started. In the PCB + IUL group, an 18-gauge intravenous catheter was gently inserted into the cervical canal up to the internal os. Two milliliters of 2% lidocaine was injected into the uterine cavity. Again, 5 minutes were allowed to pass to ensure that the anesthetic effect of the lidocaine had begun. All forms of anesthetic methods were applied before grasping the cervix with a tenaculum. We used no anesthetic in the control group. Two milliliters of 0.9% saline solution was injected into the cervix at 4- and 8 o’clock positions instead of lidocaine. Five minutes were allowed to pass to create similar circumstances with the other groups. The cervix was grasped with a tenaculum at 11- and 1 o’clock positions. A number 4 carmen cannula was inserted in the uterine cavity. The uterine cavity was filled with 50 mL of normal saline solution. The same operator performed all SIS procedures in the same way with help of the same nurse. Therefore, other variables that may affect pain score were controlled. A tenaculum was used in all patients in the standard procedure technique. Difficulty during passing the cervix and SIS findings were not recorded in our study.We evaluated pain scores using a 10-cm visual analogue scale (VAS), where 0 cm represented no pain and 10 cm represented worst pain imaginable. We evaluated pain scores at three different points: Immediately after installation of normal saline, at the end of the procedure, and 30 minutes after the procedure. All patients were prescribed 500 mg azithromycin as prophylaxis.Statistical calculations were performed using the Statistics Package for the Social Sciences (SPSS) for Windows version 13.0. Descriptive data are presented as mean ± standard deviation or standard error. One-way ANOVA and Post-hoc Tukey tests were used to compare parametric variables and to compare differences between groups, respectively. A value of p<0.05 was accepted as statistically significant.The ages of the 96 patients who participated in the study ranged from 23 to 62 years. The mean age of group 1 was 38.38±7.48 years, group 2 was 35.25±8.08 years, group 3 was 37.03±7.27 years. There was no statistically significant difference between the mean ages of the groups (p>0.05).Of the patients included in the study, 16 were postmenopausal and 80 were premenopausal; group 1 (n=32) 26 premenopausal, 6 postmenopausal patients; group 2 (n=32) 27 premenopausal, 5 postmenopausal; and group 3 (n=32) 27 premenopausal, 5 postmenopausal patients.The median scores of the groups were gravida , living child , abortion , and curettage  respectively. It has been found to disperse in accordance with the average of all these groups.We found significant differences between groups at tenaculum placement. We used the Post-hoc Tukey test to determine which group had the statistically significant score. We found that pain scores were significantly higher in the control group (p=0.002), but there was no significant difference between either study group (p=0.596).After the injection of sterile saline solution, the control group had significantly increased pain scores, different from both study groups (p=0.045). We found no significant difference between either study group at this point p=0.835). During tenaculum use, the mean pain in the group 1 was 27.40±25.58, group 2 was 21.74±23.25, and group 3 was 11.74±11.54 . During 5. DuringPatients experience pain in gynecologic outpatient diagnostic interventions. We aimed to determine whether it was correct to use different anesthetic methods in daily clinical practice, and thus we compared PCB and PCB + IUL with placebo., IUL that was applied just after buccal misoprostol was found effective preventing pain. IUL failed to prevent pain in procedures such as endometrial biopsy or hysterosalpingograhy in other studies,7. Guney et al. attributed this difference to the combined use of lidocaine with other drugs. Though there was no significant difference between study groups, we also find that lidocaine decreased pain with statistical significance. The reason of this result may be the limited local effect of lidocaine. Patients feel pain the most at the time of grasping the cervix with a tenaculum and the insertion of a carmen cannula. Lidocaine shows its anesthetic effect through free nerve endings as described in previous studies. Guney et al. found that pain was decreased in their IUL group during endometrial curettage. We did not perform endometrial biopsy, instead only the uterine cavity was distended in our study. We found no significant differences, probably because we performed a less painful procedure than that of Guney et al..In the study of Guney et al. noted that combined use of IUL and misoprostol was effective at preventing pain in premenopausal women, whereas it was not effective in postmenopausal women. More randomized studies are warranted to determine which anesthetic method would be appropriate for postmenopausal women in outpatient gynecologic procedures.PCB and PCB + IUL were effective at preventing pain in all premenopausal women in our study. The same effect could not be shown in postmenopausal women. To our knowledge, no studies have compared pain scores of women according to their menopausal status. Only Guney et al. compared gel infusion sonography with SIS in their study of 2009. They found both methods were similar in use but pain caused by the procedure was heightened in SIS. They attributed this difference to the lubricant effect of gel, which made it easier to pass the instrument through the cervix. In their second study, they compared gel infusion sonography alone with gel infusion sonography plus IUL. The authors could not show significant differences in the mean VAS scores. Performing SIS is much easier than gel infusion sonography in outpatient settings. Moreover, the long-term effect of gel use remains unknown.Van den Bosch et al.The effect of different anesthetic methods on endometrial curettage, hysterosalpingograhy, and hysteroscopy has been extensively studied. The results are conflicting because of the different natures of the procedures. We think our study will help those who need an effective method to prevent pain in SIS.In conclusion, paracervical block is effective at preventing pain in premenopausal women undergoing SIS. The addition of IUL to PCB does not decrease pain but increases both the time and cost of the procedure.


Background Analgesics are used in the management of chronic non-malignant pain (CNMP), a condition which is highly prevalent among older adults. CNMP may not only be physically distressing but also complicated by psychosocial and economic factors. An individual’s perception and use of analgesics may be influenced by a range of factors such as perceptions of risk or benefits, ability to purchase medication or access to non-pharmacological therapies or specialist care. Objective The aim of this study was to describe the perceptions and experiences of analgesics by ageing and elderly individuals with CNMP and identify factors that influence their use. Setting Telephone interviews with 28 members of Chronic Pain Ireland aged ≥50. Method In-depth semi-structured interviews; audio-recorded, transcribed verbatim, and thematically analysed. Main outcome measure Experiences and perceptions of ageing and elderly individuals with CNMP taking analgesics. Results A combination of factors specific to the patient and arising from outside influences informed perceptions and experiences of analgesics. Pain severity, perceived efficacy of analgesics, occurrence of adverse-effects and concerns about addiction/dependence were identified as internal factors influencing medication use. External factors included views of family members, access to specialised care and the individual’s interaction with healthcare professionals (HCPs). Conclusion Individuals with CNMP regard analgesics as an important method for managing pain and are relied upon when other interventions are difficult to access. HCPs in primary care, who are the main point of contact for patients, need to take into account the various factors that may influence analgesic use when consulting with this patient group. While analgesics are an important method of pain control, patients attempt to offset use through nonpharmacological management strategies, but limited access to physical and psychological interventions contributes to increased reliance on analgesics for pain management.Primary care physicians must be offered opportunities to engage in continuing professional education on the subject of analgesia as new therapies are licensed and concerns about existing medications emerge.Patients have concerns about long-term use of strong opioids which is perceived to be inherently linked with addiction. Before starting treatment, these concerns should be discussed with patients who need strong pain-control.Chronic non-malignant pain (CNMP) is defined as pain that exists beyond 3 months or the expected timeframe for healing . It is pAnalgesics such as non-opioids [e.g. paracetamol and non-steroidal anti-inflammatories (NSAIDs)] or opioids are commonly used to manage CNMP. A recent European survey suggested that two-thirds of individuals with CNMP were taking some form of analgesic , 5. DepeThe pattern and extent of analgesic use is also influenced by the patient’s perceived need for, efficacy of, and concerns about the medication, some of these concerns particular to older patients , 10. StoThe NICE Medicines Adherence guideline (2009) details recommendations for the involvement of patients in decisions about prescription medications . The guiThis study aimed to examine the experiences of ageing and elderly individuals with CNMP with analgesics, and to describe the factors that influence the way these medications are used by this group.Ethical approval was granted by the Health Sciences Research Ethics Committee, Trinity College Dublin (TCD).® and Twitter® pages and in the quarterly newsletter. Individuals aged >=50 years were eligible to partake in this study. Individuals of this age are classified as ‘ageing’, as they may have retired, are no longer of child-bearing potential and will be considered elderly within a number of years  … I think if I was dealing with somebody else, I would be telling them for God’s sake [sic] come off that medication, and here I am. I am caught up in it. I have osteoarthritis, a pain in my back, then eventually I got a stomach ulcer from taking DifeneAdverse effects were described for NSAIDs, opioids and adjuvants however, those arising from opioids appeared to cause most distress. Participants appeared to be aware of the adverse gastrointestinal (GIT) effects of NSAIDs, however, no one discussed the potential adverse cardiovascular effects. One participant described the development of a stomach ulcer which she stated was caused by diclofenac: P9, female, rheumatic condition)The other side effect … is that I am overweight, and that is because of the increased appetite or things like that things, cravings for sweet foods because of medication, again that is to do with side effects. I was told to try amitriptyline … now that [pause] even the smallest amount of that would have me asleep for 24 h so I decided not to. That would have been the main reason I would have taken a break from them. I found that I was too sedated [pause] not so much sedated more that I felt maybe a detached, like feeling like the world was going on around me. Even the children were saying that my favourite hobby was sleeping! What I have learned is the opiates are only [pause] I understand people take them for a long time but there should be something that stops you, because you eventually reach the stage where you need more and more to get the same effect. Addiction would be of a concern for me and with the family here and you’re concerned about things like this. And they are very much aware of what they do. And they’re concerned that I might be dependent too much on them. It was going to relieve me of my pain, but really the end result would be that it would damage my system. I was speaking to a colleague at work about the very same thing, we were sitting on night duty talking about it and she said, now you might die younger, but at least you won’t be in as much pain. [Laughter] Now one thing I was doing which was wrong, I was watching the clock and saying, oh I can take another tramadol, you know what I mean, I’d say every 4 h. [pause] With the pain programme I stopped doing that. I’d normally start with one [tramadol tablets] and hope it works, but I do usually end up having to take a second one [tramadol tablets] and I kind of, try and use heat or a TENS machine or something else rather than take anymore . Some were using one or more of these interventions to minimise or offset the need for an analgesic: P3, male, chronic back pain)If I go to somebody and they prescribe something, the first thing I do is go to the internet and look it up. And, what tends to be on the internet…is quite a lot of negative stuff. And again you’re starting off with a negative base… Probably my family would be different because they’ve actually seen me and seen me in pain and they would be very much inclined to say look you know you’re going to end up taking it, why don’t you just take it now instead of in 4 h time when you’re much worse. They would try to encourage me to take it much more. I suppose what I would find about the community in general is that nobody understands the word chronic… So when people see you and you are looking well and tanned… you must be better. The GPs, there is a real need for more training and up-skilling in the area, with me they just don’t know what to do anymore and they haven’t known what to do for a good while really. My doctor… she is excellent… and she kept going until she got a diagnosis, and she is proactive in looking up new medication and trying to get it right, you know, get it sorted, and as I said I always get her to check what the hospital say. The way I have sort of gone paying, not that I can afford it, but paying you will get in somewhere much quicker anyway and you sort of have to weigh up things. I know there were doctors who were writing out things but no one was paying any attention to what the other fella [sic][Participants were asked to comment on their experience of interdisciplinary co-operation in the management of their condition. While participants tended to praise the care received in primary care, and acknowledged the expertise of specialists, the connectivity of these domains clearly remains an issue: This study highlights the multiple complex factors that can influence the use of analgesics by ageing and elderly individuals with CNMP. These factors can be mapped onto those identified within Horne’s model of adherence, this framework is of particular importance to clinicians seeking to optimise analgesic use among patients with CNMP in accordance with the NICE Medicines Adherence guideline (2009) , 24.Ability to undertake daily activities or engage in social or leisure pursuits appears to be an implicit measure employed by patients to establish the efficacy of the analgesic regimen . HoweverExternal factors can exert effects on the management of the patient with CNMP. HCPs and social support networks can influence the patient’s approach to coping with the condition . PositivSeveral participants in this study described a concern that GPs lack sufficient knowledge on CNMP to provide effective management in primary care. This concern is echoed in empirical studies which have highlighted insufficient focus on pain education within undergraduate medicine curricula leading to a lack of confidence when managing patients with CNMP –51. EngaPatients are becoming an increasingly empowered group with access to information independent of HCPs, mainly via the internet . ParticiThere are several limitations to this study. Participants were members of CPI and self-selected into the study which demonstrates a degree of self-empowerment and interest in their condition. Such self-empowerment may not be representative of the general ageing and elderly population with CNMP . InterviThis study described the factors affecting the use of analgesics by ageing and elderly adults with CNMP. Internal factors including efficacy of the analgesic together with the perceived risks of the medication are specific to the patient and influence the nature and extent of analgesic use. External factors, such as poor access to pain specialists, physiotherapists or other allied healthcare professionals, affect the quality of management of the condition. Awareness of these factors is of value to HCPs when seeking to optimise analgesic use within this patient group.


Thyroid cysts are usually benign lesions that when voluminous may induce cosmetic concerns or local discomfort. Percutaneous ethanol injection (PEI) has been demonstrated to be effective for shrinkage of such cysts. In this retrospective study, we evaluated the efficacy, pain perception, and health-related quality of life (HRQL) in patients submitted to PEI for pure cystic lesions. We reviewed the data of 101 patients who underwent ≤3 PEI. In the whole group of patients, the volume reduction was 66% after the first, 74.4% after the second, and 79.4% after the third PEI treatment. 55.4% had a cystic volume ≤ 10 ml; 85.7% of cysts ≤ 10 ml were cured by just one PEI. The number of PEI was significantly higher in the >30.0 ml group; this latter group obtained the smallest percent reduction versus baseline after the first PEI when compared with smaller cysts. The sensation of pain reported during PEI was absent in 78.3% of cases, and HRQL significantly improved from pre- to the posttreatment. PEI is a safe and effective technique for pure cystic lesions. In addition, HRQL significantly improves, providing a further support for this procedure. Thyroid cysts, that is, a thyroid lesion having a delimiting wall with a fluid content, are more rare than thyroid nodules but may induce cosmetic concerns and compressive symptoms as well. They are benign by definition, and after the advent of percutaneous ethanol injection (PEI), in most cases they do not require surgical treatment. Indeed, it is more than 20 years that PEI is successfully used as a safe, cheap, and effective treatment to significantly and permanently reduce the cystic volume, with a consequent relief for the patient –3. WhereIn this report, we retrospectively evaluated the outcome, the pain perception, and the HRQL of a hundred of patients suffering from pure thyroid cysts who were submitted to PEI at our Institution.D1 × D2 × D3 × 0.52).We reviewed the data of patients treated in our Institution from 2012 to 2016. Criteria of inclusion were euthyroid patients who underwent PEI for a simple cystic lesion and having complaints for aesthetic or compressive troubles, negative cytologic result, and any cystic volume, but a number of PEI ≤ 3. Cystic volume was calculated using the ellipsoid formula  and excruciating pain (10) in which each 1/3 of the scale corresponded, from the lowest to the highest, to the following categories: mild pain, moderate pain, and severe pain (the pain reported by the patient was the one in relation to the procedure and not the one experienced during the extraction of the needle). HRQL was assessed using the SF-12 Health Survey. The SF-12 Health Survey is a reduced form of the more extensive SF-36 questionnaire but is reliable as well, is more simple, and requires only a few minutes to complete it. The SF-12 uses 12 questions to cover 8 health domains: physical functioning, role limitations due to physical health, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. The results can be summarized as a physical component summary (PCS-12) and a mental component summary (MCS-12). Higher scores indicate better health status.t-test and nonparametric variables with the Mann–Whitney U test. Qualitative variables were evaluated with the chi-square test. The comparison of volumes at different periods was conducted with the Friedman test, confirmed with nonparametric multiple comparison for dependent data. Multiple linear regression analysis was used to determine factors independently predictive of the percent nodule volume reduction. Factors entered into the model included age, sex, and basal nodule volume. Statistical Package for the Social Sciences (SPSS) version 16 was used for statistical analysis.The comparison of parametric quantitative variables between groups was analyzed with Student's P < 0.01). The baseline volume was significantly different among the four groups (P < 0.01). The number of PEI was significantly higher in the >30.0 ml group versus the other groups (P < 0.05). As expected, the higher the fluid drained was, the larger the cyst was , whereas the alcohol injected was significantly higher only at the first PEI in the >30 ml group (P < 0.05). The >30.0 ml group obtained the smallest percent reduction versus baseline after the first PEI (P < 0.05), whereas the ≤10.0 ml obtained the greatest percent reduction versus baseline after the third PEI (P < 0.05) (P < 0.01 versus baseline) (P < 0.01) (P < 0.01).In the study period, 101 patients were collected ; mean age was 42.3 ± 12.9; mean cystic volume was 14.8 ± 15.5. Each patient underwent 1.4 ± 0.7 PEI. 56/101 (55.4%) of cysts had volume ≤ 10 ml, 23 (22.8%) 10.1–20.0 ml; 13 (12.9%) 20.1–30.0 ml, 9 (8.9%) > 30.0 ml  . In the aseline) . A posit < 0.01) . MultiplP < 0.01).The sensation of pain reported during PEI was virtually absent (78.3%), mild (17.4%), or moderate (4.1%). In all cases, this was a transient sensation of pain with relief within minutes. No patient felt intense pain and none suffered other complications. PCS-12 and MCS-12 both significantly improved from pre- to the posttreatment  effective in cyst ≤ 10 ml, where a single PEI treatment is able to definitely eliminate the cyst. In more than half of cases, a single PEI is also effective for cysts of 10–30 ml, whereas, for those >30 ml, three PEI are necessary in 2/3 of cases. From these few figures, one would argue that considering PEI, as soon as cosmetic concerns or local discomfort appears, is a reasonable choice. PEI is also confirmed to be a safe procedure that is usually practiced in an office setting and does not require high-tech or expensive equipment; in skilled hands, it does not entail specific dangers, and the occasional pain felt by the patient due to ethanol leakage into subcutaneous tissues is usually mild and transient . In relaA limitation of the study is that the follow-up time was quite short (≤4 weeks). A longer follow-up could have shown an even better result than that observed in cystic shrinkage. Several studies demonstrated, although in solid nodules, that when the follow-up time is long , the effect in terms of shrinkage is increased, probably due to a continuous sclerosing effect induced by ethanol over the time , 15.In conclusion, PEI is effective for pure cystic thyroid lesions. In addition to that, PEI represents a safe treatment, with minimal, transient, and self-limited adverse events. The larger the cyst is, the greater the number of PEI needed to obtain a definitive result is. A significant improvement of HRQL in such treated patients provides a further support for this procedure.


The aim of this retrospective study was to compare immediate postoperative pain scores and need for rescue analgesia in children who underwent pulpotomies and restorative treatment and those who underwent restorative treatment only, all under general anaesthesia.t-tests, chi-square tests, and Pearson's correlation analysis. Ninety patients aged between 3 and 7 years who underwent full mouth dental rehabilitation under general anaesthesia were enrolled in the study and reviewed. The experimental group included patients who were treated with at least one pulpotomy, and the control group was treated with dental fillings only. The Wong-Baker FACES scale was used to evaluate self-reported pain and need for rescue analgesia. The data were analysed using the Kruskal-Wallis test, two sample x2 = 24.82, p < 0.01). In the experimental group, 48% of the children needed rescue analgesia, compared with only 13% of the children in the control group . Ninety percent of the children experienced postoperative pain in varying degrees of severity. Immediate postoperative pain scores in experimental group were found to be significantly higher than in control group ( Children who underwent pulpotomy treatment had higher postoperative pain scores and greater need for rescue analgesia than control group who underwent only dental fillings. Dental caries remains a global public health problem. Young children who are frequently exposed to sugary liquids, poor oral hygiene, breast feeding, fruit juices, and other sweet liquids for long periods are particularly at risk of suffering from extensive caries. Children with untreated caries may experience infection, pain, disturbed sleep, speech and communication problems, and inability to eat leading to weight loss .Treatment of young children frequently requires a multidisciplinary treatment plan that includes general anaesthesia (GA) because they may be unable to cooperate in a dental clinic setting. Despite the fact that GA is an accepted behavior management technique according to the American Academy of Pediatric Dentistry, this procedure has some morbidity or mortality risks. Postoperative pain is the most common morbidity after GA for dental rehabilitation in children .Tooth extraction and pulp therapies of primary teeth (pulpotomy and pulpectomy) have been designated as painful dental procedures (PDPs) in previous studies, and postoperative pain may occur after these procedures . PulpotoEffective postoperative pain management is important in reducing the recovery time, improving patient outcomes, and decreasing the length of hospital stays . There hFor this reason, this study was undertaken to compare the postoperative pain scores of children who underwent primary molar pulpotomy that is a vital endodontic treatment under GA with those of children in the control group who underwent only regular restorative treatment under GA and to evaluate the need for rescue analgesia during the postoperative period. An additional purpose of this study was to investigate the effects on the recovery time of the two treatment types (fillings and pulpotomies) performed under GA.NCT03142672) at http://www.clinicaltrials.gov.This retrospective cohort study was conducted on children who underwent full mouth dental rehabilitation under general anaesthesia between July 2015 and January 2016. The study was approved (2016/764) by the Research and Ethics Committee of the Adnan Menderes University and registered  according to World Health Organization (WHO) criteria ; type ofn = 45), and patients treated with dental fillings only were included in the control group (n = 45); a total of 90 patients were eligible for the study.Patients with at least 1 primary molar pulpotomy and tooth filling were included in the experimental group  and had discomfort except postoperative dental pain were excluded from the study. Patients who received pulpectomy and/or extraction were excluded from the study. All patients were elective cases; those preoperative pain scores were “0.”All children were examined and verified as fit for GA by a pediatrician on the day before the anaesthesia procedure. On the morning of the treatment, the patients were not allowed to eat or drink for at least six hours before the GA commenced. No premedication was given. All patients were intubated by the same anaesthetist. Induction was carried out via a facemask with 8% sevoflurane in 100% oxygen.μg/kg, rocuronium  0.5 mg/kg were given via nasotracheal intubation. Heart rate, respiratory rate, noninvasive blood pressure, oxygen saturation, and end-tidal carbon dioxide were recorded.Following loss of consciousness, an intravenous line was established through which propofol 1%  2 mg/kg, fentanyl  1 Anaesthesia was maintained with sevoflurane 2% in a mixture of 50% oxygen and nitrous oxide. All the children received tenoxicam  0.4 mg/kg for analgesia 15 min before the end of the surgery. Patients were extubated and transferred to the postanesthesia care unit (PACU).After transfer to PACU, patients were monitored by a registered nurse. The nurse evaluated the patient at 5-minute intervals using the Aldrete scale. Patient pain was self-assessed using the Wong-Baker FACES scale immediately, after one hour, and after two hours postoperatively. This scale, which is validated for children aged 3 to 7 years, includes six cartoon faces with varying expressions ranging from very happy to very sad  Figure .μg/kg dose.When the Wong-Baker FACES score was 4 points or greater during the postoperative period, pain intensity was assessed as moderate-severe, and this was recorded on the patient sheet as a rescue analgesia need . PatientAll dental treatment was performed by the same paediatric dentist (SK). All restorative and pulpal treatments were completed in a single session under GA. Local analgesia was not used prior to pulpotomies and fillings. After caries removal, all of the primary teeth  were restored with compomer resin  according to the manufacturer's recommendations. The pulps of teeth (only primary molars) with extensive caries were removed and bleeding was arrested with gentle pressure from a sterile cotton pledget moistened with saline. Ferric sulfate pulpotomies were performed and primary teeth were restored with compomer resin according to the manufacturer's recommendations. The occlusion was checked in all patients after compomer resin restoration and final finishing and polishing of the restoration was performed using soflex disks . The duration of the dental operations was recorded in the patient's file.t-tests were used to compare normal continuous variables in independent groups, and chi-square tests were used to compare numerical and categorical variables between the two groups. A 5% type-1 error level was used to infer statistical significance.All numerical and categorical data saved into a database and the reports created in Microsoft Excel format were exported into Statistical Package for Social Science program for Windows  for statistical analysis. All data were subjected to the Kolmogorov-Smirnov test for normality. For data which were not normally distributed, the Kruskal-Wallis test for independent groups was used for statistical analysis. Pearson's correlation analysis was used to detect the relationship between pain scores and the number of dental procedures performed for each group . Two sample p > 0.05). The average dmft of the experimental group was 8.3 ± 3.2 and the average dmft of the control group was 6.6 ± 3.1. In the experimental group, the average number of pulpotomies was 2.6 ± 1.4 and the number of fillings was 5.7 ± 3.3, while in the control group the average number of fillings was 6.6 ± 3.1.The mean age of the participants was 4.6 ± 1.7; 38 were female and 52 were male. No significant differences were found between the two groups for the age and gender parameters . Statistically significant differences were determined between experimental and control groups in terms of immediate, 1-hour, and two-hour postoperative pain scores (p < 0.01). The immediate, 1-hour, and 2-hour postoperative average pain scores of the experimental and control groups are shown in Overall 90% of all patients experienced varying degrees of postoperative pain. Immediate postoperative pain scores in the experimental group were significantly higher than those in the control group . Similarly, in the intragroup comparison in the control group, no significant relationship was observed between the number of fillings and the postoperative pain score .In the intragroup comparison in the experimental group, no significant relationship was found between the number of pulpotomies and the postoperative pain score . However, no significant differences were observed between the two groups at the 1-hour postoperative and 2-hour postoperative time points (p > 0.05). While rescue analgesia was required for 49% of the children in the experimental group during the immediate postoperative period, only 13% of the children in the control group needed rescue analgesia, and this difference was found to be significant .The average recovery time was 17 ± 6.8 minutes for the experimental group and 13.2 ± 5.6 minutes for the control group, and this difference was found to be significant (p < 0.05)  see .p < 0.05). However, there was a significant relationship between the duration of the dental procedures and the immediate postoperative pain scores  and the rescue analgesic need .There was no significant relationship between the duration of the dental procedures and the recovery time  were found in patients who underwent primary molar pulpotomies (49%) than in patients who underwent regular restorative treatment (13%), regardless of the number of procedures performed. Rescue analgesia was given according to the postoperative pain scores; however no local anesthesia was performed intraoperatively in any of the patients. This may be the cause of the high pain scores observed in pulpotomy cases, which is a painful dental procedure.Although our study found that 90% of the groups experienced immediate postoperative pain, other researchers have reported levels of 86% and 70% of postoperative pain following dental extraction under GA , 12. ThiLocal anesthetic injections are frequently used during procedures performed under GA, especially tooth extraction, because the local anaesthetic assists with both bleeding control and postoperative pain relief . HoweverIn our study, although IV analgesia was given in the intraoperative period, postoperative pain was reported in both groups but in children who underwent vital endodontic procedures higher pain scores were noted than control group. El Batawi  reportedProlonged recovery time in children causes increased postoperative anxiety and treatment costs because of the need for prolonged stays in hospital , 19. PatThere are several different methods for evaluating the pain of children in clinical studies such as self-reporting scales, behavioral assessment, and physiologic measurements . In our The ideal restorative material to be used after a primary molar pulpotomy is reported to be a stainless steel crown. However, stainless steel crowns do not meet today's rapidly increasing aesthetic demands. Other aesthetic crown coatings produced as alternatives to stainless steel crowns are not routinely used in clinical settings because of their high cost. For this reason, compomer resin was used to restore the pulpotomised teeth in the present study . PreviouThis study is significant in that it indicates the need for effective postoperative pain control after vital endodontic treatment in comparison with the patients having restorative treatment only under GA. Postoperative pain control could be provided by giving additional postoperative analgesics following the intraoperative analgesics given to the patient. Postoperative pain results in a prolonged recovery period. Effective pain control is necessary to provide patients with a comfortable and fast recovery following vital pulp treatments performed under GA.