OBJECTIVE: This study aims to evaluate emotional factors such as anxiety and depression, and the Quality of Life of individuals with chronic persistent pain after amputation in order to identify the interindividual variation in response to pain. METHODS: This was a descriptive, exploratory and cross-sectional study with quantitative approach. Twenty seven patients were interviewed. The instruments have rated the sociodemographic, clinical and economic profile (semistructured interview) and the Quality of Life  and emotional factors  of the interviewed patients. RESULTS: It was identified that the most frequent amputations occur in males aged 18-38 years and are related to occupational accidents. The Quality of Life was compromised in both components of physical and mental health. Furthermore, anxiety levels were more prevalent in the range from aged 18 to 38 years old, while the levels of depression were most prevalent among the elderly (60 to 80 years old). CONCLUSION: The impairment of Quality of Life and change in the perception of body image has a major impact on adherence to the rehabilitation program and the functional prognosis. Therapeutic orientation is, therefore, critical after this type of surgery. Level of Evidence II, Descriptive and Exploratory Study. Amputations are characterized by the removal of an organ/limb or part thereof located at the end of the human body.This type of surgical procedure aims to consider what it is available to replace the function of that limb, preferably to its aesthetics. However, amputation and any other surgical procedure can lead to complications, such as bleeding, infection, skin tear, joint contracture and especially phantom limb pain. Furthermore, we must consider the psychological trauma since the patients are faced with a situation that involves a change in their locomotion, work and social living.Phantom limb pain (PLP) refers to the sensation of pain in the missing part of the amputated limb, presenting in different ways such as a burning sensation, a grip, or a pain which may vary in intensity and frequency.There are two theories that explain its pathophysiology. The first considers that this pain is a phenomenon that occurs from top to bottom, i.e. it is triggered by the reorganization of the mapping of structures depicted in the cerebral cortex, in a sensory and motor plasticity process. The second considers that this phenomenon occurs from the bottom up, i.e. it occurs by excessive stimulation and not by its loss, ectopically generated in the primary afferent neurons in the dorsal root ganglion, that before enervated the amputated limb. Among these theories, the first is the most widely accepted.This kind of pain occurs in 50-80% of amputation cases and can occur days after surgery for reasons not yet fully understood.It should be noted that phantom limb pain differs from pain in the stump, or residual limb, which is due to skin complications, vascular compromise, inappropriate healing, painful neuromas, excess soft tissue and bone irregularities.The impact of amputation in the experience of any individual translates into changes in his body image, beyond that, it infers on the psychosocial adjustment of individuals who experience the phenomenon, with influence on their self-esteem and the possible emergence of psychopathological symptoms and on social functioning.Within this context, this study aims to assess emotional factors such as anxiety and depression and quality of life of individuals with post-amputation persistent chronic pain in order to identify the interindividual variation in response to pain and contribute to knowledge and practice of health professionals involved in assisting this population.Hospital de Base (FUNFARME/FAMERP). Inclusion criteria were patients of both genders aged over 18 years old that have had persistent pain postoperatively to independent amputation whichever body part or level, with cognitive level sufficient to understand the assessments and consent to participate in the study by signing the Post-Informed Consent Term. This is a descriptive, exploratory, cross-sectional study with a quantitative approach. The research project was approved by the Research Ethics Committee of FAMERP (2384/2010) and held at the Pain Clinic Outpatient and Orthopedics and Traumatology Service, The evaluation of the subjects was performed using primarily a semi-structured interview with sociodemographic, economic and clinical characteristics , followed by a characterization instrument regarding the amputation surgery . Subsequently an instrument for the analysis of daily activities and practice was applied  which were marked with the corresponding values: (1) No alteration (2) Partially compromised. (3) Fully compromised (4) does not apply. Pain was assessed using a visual analog scale (VAS),The descriptive analysis was performed in the Excel software. Qualitative data were analyzed by odds ratio and ordinals by nonparametric tests. All statistical analysis was performed using significance level at 0:05.Hospital de Base (FUNFARME/FAMERP) participated in this study, 16 of them being male (59%) and 11 female (41%). Among the patients, 38% (n=10) were young adults (from 18 to 38 years old), 33% (n=9) were elderly (60-80 years old) and 29% (n=8) were in the range 39-59 years old. Mean education was 6.5±3.0 years. Of the participants 48% (n=13) were married, 22% (n=6) were single, 22% were widowed and 8% (n=2) divorced. Most were still working (n=15/55%).Twenty-seven patients from the Pain Clinic Outpatient and Orthopedics and Traumatology Service, As for the self perception of the familiar aspects 77% (n=21) believed they have a good relationship with their family, while 9% (n=2) considered having a bad relationship. Among the subjects evaluated 22% (n=6) were smokers and 18% (n=4) were drinkers. The main diseases that have been reported are associated with diabetes mellitus and hypertension (both with n=3/11%). Other diseases reported were cirrhosis (n=1/3%) and chronic renal failure (n=1/3%). Most respondents own their house (n=13/44%), while 40% (n=12) pay rent and 6% (n=2) live with relatives. Sociodemographic and clinical characteristics are summarized in Chi square test - * p <0.05: significant statistical difference.Regarding daily activities 44.4% (n=12) of subjects reported sleeping was partially compromised after amputation surgery, while 25.9% (n = 7) reported no change in this regard. Regarding appetite mostly (n=19 / 70.3%) reported no change and only 7.4% (n=2) of patients reported to have partially compromised appetite. As for deambulation 40.7% (n=11) of patients reported partial impairment, 14.8% (n=4) of patients reported total impairment and 25.9% (n=7) had no effect in this regard. One third  of the subjects reported no changes in household activities, while 29.6% (n=8) reported partial impairment of these activities and 11.1% (n=3) reported total impairment. Regarding work limitation was greater, 29.6% (n=8) of patients were totally impaired in this regard, 25.9% (n=7) had milder impairment and only 22.2% (n=6) were not impaired at all. As for personal hygiene 29.6% (n=8) of the subjects reported having partial impairment, while 44.4% (n=12) reported no change. Fourteen point eight percent (n=4) of the subjects reported total impairment of bowel habits, 22.2% (n=6) reported partial impairment and 33.3% (n=9) had no alteration whatsoever. Interpersonal relationships were partially deteriorated to 29.6% (n=8) of individuals, totally deteriorated to 11.1% (n=3) and not affected to 40.7% (n=11) of them.Concentration was abnormal in 29.6% (n=8) of patients and in 48.1% (n=13) it was not altered. Regarding sexual activity 29.6% (n=8) of respondents reported partial impairment, 14.8% (n=4) reported total impairment and 25.9% (n=7) reported no alteration. Humor was the aspect that was most altered, since 40.7% (n=11) evaluated the reported partial impairment, 22.2% (n=6) reported total impairment and only 14.8% (n=4) reported no change at all. Regarding the pain sensation, burning was the most common type (42% - n=11) followed by "needle type" (36% - n=9) and burning feeling (22% - n=7). Only seven patients (25%) and wore prosthesis. Regarding medication adherence, 51% (n=14) used medications such as anticonvulsants, antidepressants and anesthetic blocks. Thirteen patients (49%) reported use of anti-inflammatory or analgesic drugs, without improvement. There were no reports of use of regular or intermittent analgesia prior to amputation. Rehabilitation was done in 70% (n=18) with orientation such as stump lifting, percussion and massage. Regarding anxiety and depression the number of patients ranked by the level of severity of symptoms of depression with their mean scores on the Hospital Anxiety and Depression Scale (HAD) are shown in It has been noted that anxiety levels were higher (18/27) than depression (11/27), and the quality of life was compromised in both components (<50), where the physical health component was 42 and the mental health component 40.The study also included associations between the individual's age and the presence of anxiety and depression. Importantly, the anxiety levels were more prevalent in the age group of 18-38 years old, while the levels of depression were more prevalent among the elderly (60-80 years old).Hospital de Base (FUNFARME/FAMERP) who presented phantom limb pain after amputation surgery, as well as the impairment of daily activities and quality of life of these individuals, besides depressive and anxiety symptoms.This study investigated the sociodemographic and clinical characteristics of patients from Pain Clinic Outpatient and Orthopedics and Traumatology Service, The loss of a limb disrupts the integrity of the body and affects physical and psychological conditions of patients who undergo amputation surgery. This type of surgery means a huge impact, not only for the patient's body and the way he notices it, as well as the perception of the environment around him.et al.17 the majority of respondents were married (47.6%), as well as in the present study (48%). In both studies, most patients remain employed and in the cited study 71.4% had their own income, as compared with 55% in this study. Compared to the study of Resende et al.Regarding to clinical aspects, in both studies, the major cause of amputation were accidents (81% and 37%). However, most of amputations in this study was of the lower limbs (55%), while in the study of Resende et al.As to daily living activities, this study reveals that most of them are partially or totally compromised, except appetite. Activities such as working and humor proved to be the most affected. According to the study of Batista The phantom limb pain it is a type of chronic post-surgical pain, whose incidence is high and that affects qualitatively the patients' lives, though often neglected by the medical team. It is a morbidity difficult to treat, and prevention is the most effective measure.This type of pain is manifested in various ways, it may be characterized as mild to severe, intermittent or constant, like a stab, a shot, a tingle, a colic, a punch by a needled, and/or a burning feeling.et al.The results of the study indicate that patients with phantom limb pain have a lower quality of life, mainly related to the impairment of daily activities and an increase in anxiety levels, especially among young people (18-38 years) and depression in the elderly (60-80 years old). In the study by Vaz As well as the perception of body image, phantom limb pain leads to changes in the psychosocial profile, which result in a major impact on adherence to the rehabilitation program, the functional outcome and quality of life. Therefore, its evaluation and therapeutic management should be part of the approach of patients undergoing amputation surgery, giving the importance this type of clinical condition deserves to have.


Uterine artery embolization (UAE) is usually a very painful procedure. Although pain after the procedure can occur as a single symptom, it usually is associated with other symptoms such as nausea, vomiting, pelvic pain, general malaise, fever and leukocytosis that characterize the post-embolization syndrome. Management of the post-embolization symptoms and of pain in particular, is paramount if UAE is to be performed as an outpatient procedure. Different protocols have used analgesic and/or anti-inflammatory agents to control these symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in association with analgesic drugs to control post-embolization symptoms. In our institution the patients start oral medication with NSAIDs the day before the procedure and continue it during and after UAE. We also mix NSAIDs with the embolizing particles. This enables a reduction in the inflammation present in the uterine fibroids and helps controlling the pain. The purpose of this paper is to review the importance of NSAIDs in the management of the post-embolization symptoms. We describe the protocol that we use in our institution that enables us to perform the procedure on an outpatient basis with same day discharge and good control of the post-embolization symptoms with oral NSAIDs and analgesics. Uterine artery embolization (UAE) is usually a painful procedure. In the first hours after the procedure many patients suffer from post-embolization syndrome, consisting of nausea, vomiting, pelvic pain, low grade fever, fatigue, general malaise and leukocytosis . The paiManagement of these post-embolization symptoms and of the associated pain in particular, is paramount if UAE is to be performed as an outpatient procedure . SeveralBesides pain and the other post-embolization symptoms associated with UAE in the first hours after the procedure, other symptoms such as abdominal swelling, constipation, fever, vaginal bleeding, pain, nausea/vomiting, anorexia or fatigue can occur on the following days. As most patients will experience 4 to 5 days of post-procedural symptoms, most centres where UAE is performed admit their patients in the hospital for 1 to 2 days after the procedure for abdominal pain or vomiting control [et al. [et al. [et al. [et al. [et al. [Many different agents such as fentanyl, ibuprofen, promethazine, acetaminophen, codeine, meperidine, ketorolac, cefazolin, hydroxyzine, oxycodone, morphine, droperidol, ondasetron, midazolam and hydrocodone have been used in more or less complex associations with variable results ,4,5,6. Bet al.  used mor [et al.  used sup [et al.  reinforcAnother agent that has been previously used is ketoprofen . KetoproDifferent strategies have used analgesic and/or anti-inflammatory agents along with the embolizing agents. Pain control has also been addressed using ibuprofen-loaded microspheres for uterine artery embolization ,11; mixiDespite the different combinations of medications used, most institutions rely on morphine/morphine-derived analgesics through a PCA pump to control post-UAE pain and admit their patients overnight in order to better control the symptoms. NSAIDs are usually used as a second hand drug to treat pain after intravenous narcotics. We have shown that using prophylactic pre-embolization medication with NSAIDs for pain, allows UAE to be performed safely as an outpatient procedure with high patient satisfaction rates, good post-embolization symptom control, without risking the medium-term results   with an acid suppressing drug (omeprazole 20 mg—Bluepharma), an anti-inflammatory , an anti-histaminic  and a stool softener . They repeat the medication at home on the day of UAE (at breakfast).Patients are usually admitted to the hospital on the morning of embolization. They are first directed to the hospital ward were a receiving nurse checks vital signs and applies an i.v. access. Before the procedure a saline drip infusion is started. Still in the ward room, just before embolization the patients have an anxiolytic , an acid suppressing drug (omeprazole 20 mg i.v), analgesics  antiemetics  an anti-inflammatory , and an antibiotic .The patients are then directed to the angiography suite and the procedure is started. Both uterine arteries are embolized with nonspherical polyvinyl alcohol (PVA) particles mixed with ketoprofen 100 mg. During embolization an anti-inflammatory  is administered twice before the embolization of each uterine artery . Midazolam 1 mg i.v. is given if necessary for anxiety control. When the procedure is finished, the patients are redirected to the ward room where a dedicated nurse checks for vital signs and post-embolization symptoms. Medication is continued using an acid suppressing drug (omeprazole 20 mg i.v.) analgesics (paracetamol 1g i.v. and metamizol 2 g i.v.), anti-inflammatory (ketorolac tromethamine 30 mg i.v. and piroxicam 20 mg i.v.) and antiemetics . Two to three hours after the procedure, all asymptomatic patients and those with mild symptoms, without nausea or vomiting have a light meal, start oral medication with tramadol 37.5 mg plus paracetamol 325 mg  and are discharged from the hospital, 4 to 8 hours after the procedure. Just before discharge, tramadol 100 mg i.v. plus metoclopramide 25 mg i.v. are given to every patient. Four to eight hours post-embolization patients with no symptoms, mild to severe pain, only light fatigue, anorexia, abdominal swelling or minor vaginal bleeding are considered for discharge.The night of embolization, at home, the patients have omeprazole 20 mg, hydroxyzine 25 mg and naproxen 500 mg. As on-demand medication, the patients are given tramadol 37.5 mg plus paracetamol 325 mg  and codeine 30 mg plus paracetamol 500 mg  by mouth for pain and dimenhydrinate 100 mg  as suppositories for vomiting. The day after the procedure the patients start oral medication with omeprazole 20 mg twice a day, naproxen 500 mg twice a day and Clyss Go (as suppositories) and are advised not to stay in bed. We measure pain using a numeric pain score scale rated from 0 (sensation of no pain) to 10 (the worst pain). The patients are asked to rate verbally their pain severity. During embolization there is a mean pain score of 0.9, after embolization and before discharge the mean pain score is 2.5. At discharge the mean pain score is 0.9. At home, on the night of discharge, the mean pain score is 1.1. On the morning following embolization the mean pain score is 0.7. We have treated over 900 patients using this protocol and currently perform the procedure on an outpatient basis in the vast majority of cases. Only patients with persisting pain and/or vomiting 6–8 hours after UAE are admitted overnight. The use of oral NSAIDs is cornerstone in the pain management before and after UAE allowing us to treat patients without relying on morphine PCA pumps. As shown, we rely on NSAIDs before, during and after UAE to control symptoms. We only rely on analgesic drugs in the immediate time before and after UAE. Afterwards, the NSAIDs play a major role in symptom control. We only use analgesic drugs as on-demand medication when symptoms persist. NSAIDs include a vast variety of different agents with three main effects—anti-inflammatory, analgesic and antipyretic. Most NSAIDs act as nonselective inhibitors of the enzyme cyclooxygenase (COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), which decreases production of pro-inflammatory prostaglandin precursors. In our pain management protocol we use four different NSAIDs—naproxen, piroxicam, ketorolac and ketoprofen.Naproxen is a NSAID that works by inhibiting both the COX-1 and COX-2 enzymes, with a bioavailability of 95% , 99% protein binding, with hepatic metabolism, renal excretion and a half life of 12–24 hours. It is commonly used for the reduction of pain, fever, inflammation and stiffness. We use oral naproxen 1,000 mg on the day before and on the morning of UAE and continue it on the night of UAE and on the following days (500 mg). Piroxicam is a non-selective COX inhibitor possessing both analgesic and antipyretic properties. It undergoes enterohepatic circulation, with 4–10% renal metabolism and excretion, with a half life of 30–86 hours. It is used to relieve the symptoms of rheumatoid and osteoarthritis, primary dysmenorrhoea, and postoperative pain, acting as an analgesic, especially where there is an inflammatory component. Piroxicam 20 mg is administered i.v. immediately before and after UAE, based on the good analgesic effects when managing inflammation-associated pain as in post-UAE. Ketorolac or ketorolac tromethamine is a non-selective COX inhibitor in the family of heterocyclic acetic acid derivatives, often used as an analgesic, antipyretic, and anti-inflammatory, with a bioavailability of 100% by all routes, with hepatic metabolism, renal and biliary excretion and a half life of 3.3–9.2 hours. We use ketorolac trometamine i.v. during and immediately after UAE based on its rapid acting time, excellent bioavailability and short half life, enabling good pain control, quickly and for short periods of time. Ketoprofen is a propionic acid-derived non steroidal anti-inflammatory drug employed as an analgesic and anti-inflammatory agent that can be given by mouth, topically, i.v. or i.m. with anti-inflammatory, analgesic and antipyretic effects. Ketoprofen is a non-selective COX inhibitor, inhibiting COX-1 and COX-2 enzymes reversibly, with 99% protein binding and a half life of 2–2.5 hours. Based on its rapid acting time and short half-life we use it for intra-procedural pain control mixed with the embolizing agent (PVA) in the embolizing solution cup.We also use paracetamol, that could be considered a NSAID, but paracetamol has very little anti-inflammatory effect in many tissues. We use it based on its analgesic properties and not on the anti-inflammatory effects. It is commonly used for the relief of headaches, and other minor aches and pains. In combination with opioid analgesics, paracetamol can be used also in the management of more severe pain as in post-UAE. In medical procedures there is a trend to shift toward ambulatory care, both to increase patient satisfaction and to reduce health care costs. To perform UAE as an outpatient procedure it is important to control the post-embolization symptoms, particularity pain and vomiting and the patients should be informed about those symptoms and the corresponding medication, thus, an effective post-embolization medication must be provided . et al. [We agree with Lampmann et al.  in that et al. [et al. [During and just after UAE one of the chosen NSAIDs is ketorolac. As suggested by Siskin et al. , ketorol [et al.  administAnother agent used during UAE is ketoprofen. We found that combining the strong anti-inflammatory activity of ketoprofen and the ability to mix it with the PVA particles in the embolizing solution could be used to relieve pain after UAE. We described this new form of use of a NSAID that allows good control of pain during and after UAE  , which is significantly lower than the 5.7 mean pain score reported by Siskin Patients start anti-inflammatory drugs before embolization to decrease the inflammation that is present in almost all fibroids and thus the post-embolization symptoms. Besides that, the anti-inflammatory drugs have some analgesic action. We believe that continuing the anti-inflammatory medication with naproxen after discharge is paramount in order to avoid late development of pain in the night after UAE. As we have shown mean pain score at discharge is usually low (0.9), but at home, on the night of discharge, the mean pain score increases slightly (1.1). Discontinuation of medication has leaded some patients to late night hospital readmissions due to intense pain. When patients are compliant with the medication, there is usually good pain control at the hospital during and after UAE and at home after UAE. In order to reduce vomiting the patients start an acid-suppressing drug (omeprazole) that is a proton pump inhibitor before embolization. Vomiting is due to embolization but also to the effect of analgesic and anti-inflammatory drugs in gastric mucosa even if they are administered i.v. We use the acid suppressing medication on the day before UAE to decrease the effects of the anti-inflammatory on gastric mucosa and the vomiting that may be associated with the anti-inflammatory when administered by mouth or i.v. For further reduction of vomiting, omeprazole is associated with metoclopramide and droperidol (injected i.v.) before embolization and with metoclopramide and ondasetron (injected i.v.) after finishing UAE. After discharge the vomiting is controlled by dimenhydrinate (suppositories) as on-demand medication. Further studies are required in order to achieve optimal post-embolization pain control. In spite of good overall pain control achieved with this protocol, there is still great variability of pain experienced between different patients. The many NSAIDs and analgesics used with strong dosages require active gastric protection to reduce vomiting and may have some additional side affects. More so, the relatively complicated and long list of different drugs used make it difficult to achieve correct and timely administration in all patients and nurse staff must be at all times available to assist the patients after UAE. Forgetting even just one of the medications may have disastrous implications on the post-embolization symptoms, and patient compliance is paramount. We have used alternative pain-management protocols based on acupuncture , achieviMost centres perform UAE with overnight hospital admission using morphine/morphine-derived analgesics through a patient-controlled analgesic pump in order to control post-UAE pain. We rely on NSAIDs before, during and after UAE to control symptoms, combining different types of NSAIDs and administering them in different ways . In this way we are able to deliver the anti-inflammatory and analgesic effects of NSAIDs before, during and after UAE and in both a systemic and localized fashion. This new form of treatment enables UAE to be performed on an outpatient setting with less pain and fewer post-embolization symptoms.


The benefit of the post-anaesthesia care unit (PACU) with respect to an early detection of postoperative complications is beyond dispute. From a patient perspective, prevention and optimal management of pain, nausea and vomiting (PONV) are also of utmost importance. The aims of the study were therefore to prospectively measure pain and PONV on arrival to the PACU and before discharge and to determine the relationship of pain and PONV to the length of stay in the PACU.Postoperative pain was assessed over 30 months using a numeric rating scale on admittance to the PACU and before discharge; in addition, PONV was recorded. Statistical analysis was done considering gender, age, American Society of Anesthesiologists (ASA) classification, surgical speciality, anaesthesia technique, duration of anaesthesia, intensity of nursing and length of stay.Data of 12,179 patients were available for analysis. The average length of stay in the PACU was 5.7 ± 5.9 h, whereas regular PACU patients stayed for 3.2 ± 1.9 h and more complex IMC patients stayed for 15.1 ± 6.0 h. On admittance, 27% of patients were in pain and the number decreased to 13% before discharge; 3% experienced PONV. Risk factors for increased pain determined by multivariate analysis were female gender; higher ASA classification; general, cardiac and orthopaedic surgery and prolonged case duration. In more complex IMC patients, pain scores were higher on arrival but dropped to similar levels before discharge compared to regular PACU patients. Female gender and postoperative pain were risk factors for postoperative vomiting. Pain and PONV on arrival correlated with length of stay in the PACU. Pain- or PONV-free patients stayed almost half of the time in the PACU compared to patients with severe pain or vomiting on arrival.The majority of PACU patients had good pain control, both on admittance and before discharge, and the overall incidence of PONV was low. Managing patients in the PACU could achieve a significant reduction of pain and PONV. The level of pain and presence of PONV on admittance to the PACU correlate with and act as predictors for increased length of PACU stay. Today, post-anaesthesia care units (PACUs) are a standard and integral part of daily anaesthesia practice in most developed countries. Their main purpose is to safely recover patients from surgical and interventional procedures with concomitant anaesthesia. Through structured and tight clinical observation combined with continuous patient monitoring, discomfort and complications can be identified and treated early, thereby reducing adverse outcomes and increasing efficacy . SeveralThe benefit of a PACU service with respect to early detection of postoperative complications is beyond dispute. From a patient perspective, however, prevention and optimal management of pain, nausea and vomiting are of utmost importance as well. Therefore, the degree of pain, quantity of pain relief over time and the presence of postoperative nausea and vomiting (PONV) are being used as popular quality indicators for anaesthesia and postoperative care in PACU audits ,4.first aim of the present study was to prospectively measure pain and PONV at two defined time points: on arrival to our PACU and before discharge to the ward. As a quality management project, we wanted to specifically monitor these indicators and to compare our results to published reports. The second aim of the study was to determine if pain and PONV on arrival correlate with the length of stay in our PACU. It is important to early identify patients at risk for unplanned, prolonged PACU stay for optimal perioperative efficiency . Th. Th11]. An increased incidence of PONV was observed in patients with higher pain scores on PACU admittance. This finding may be explained by a higher use of opioids in order to control postoperative pain. Only recently, a study evaluating the relationship between postoperative opioid administration and PONV has been published and a logarithmic dose-effect relationship could be established . In the A limitation of the present investigation is the heterogeneity of the studied patient population with regard to the surgical specialities and the intraoperative anaesthetic technique. On the other side, by representing daily clinical reality, this heterogeneity could also be interpreted as strength. Additionally, our pain scores were not compared to preoperative values and both pain and PONV were just measured in the PACU period. To get more detailed information and to increase validity, it would be interesting for future studies to compare pain levels to baseline levels before and to add a follow-up on pain and PONV experience several weeks after their PACU stay.We conclude that the majority of PACU patients had good pain control, both on admittance and before discharge and that the overall incidence of PONV was low. Managing patients in the PACU could achieve a significant reduction of pain and PONV. The level of pain and presence of PONV on admittance to the PACU correlate with and act as predictors for increased length of PACU stay.


Background and Aims. The exploration of an individualised protocol of radial extracorporeal shock wave therapy (rESWT) for plantar fasciopathy, assessing success rates and the recurrence rate over a 1-year period after treatment, is not yet identified in literature. Methods and Results. Between 2006 and 2013, 68 patients (78 heels) were assessed for plantar fasciopathy. An individualised rESWT treatment protocol was applied and retrospectively analysed. Heels were analysed for mean number of shock wave impulses, mean pressure, and mean frequency applied. Significant mean pain reductions were assessed through Visual Analogue Scale (VAS) after 1-month, 3-month, and 1-year follow-up. Success rates were estimated as the percentage of patients having more than 60% VAS pain decrease at each follow-up. 1-year recurrence rate was estimated. The mean VAS score before treatment at 6.9 reduced to 3.6, 1 month after the last session, and to 2.2 and 0.9, after 3 months and 1 year, respectively. Success rates were estimated at 19% (1 month), 70% (3 months), and 98% (1 year). The 1-year recurrence rate was 8%. Moderate positive Spearman's rho correlation  was found between pretreatment pain duration and the total number of rESWT sessions applied. Conclusions. Individualised rESWT protocol constitutes a suitable treatment for patients undergoing rESWT for plantar fasciitis. Plantar fasciopathy (PF) is a common cause of heel pain and many treatment options are available . The plaPF is frequently self-limiting. There are certain factors that can predispose to its development. Risk factors usually reported in the literature as leading to an increased risk of PF include high body mass index or anatomical abnormalities such as pes cavus or leg length discrepancy –7. ProloThere are many treatment options available for PF, ranging from the conservative stretching and orthotics to the more invasive injections and, in recalcitrant cases, surgery . ESWT isESWT can be separated into two different types, radial and focused. With regard to focused extracorporeal shock wave therapy (fESWT) the waves are targeted specifically onto the affected area, whereas the waves produced by radial extracorporeal shock wave therapy (rESWT) do not concentrate on the area but instead disperse to the surrounding tissue too . rESWT hSome studies do not provide follow-up data up to a year or more after treatment, which would help support or dismiss rESWT as a viable treatment option , 21. Mor0) that there is no relationship between pretreatment pain duration and the number of rESWT treatment sessions applied was also stated.The aim of this study was to report the protocol used and the recurrence rate of PF after a “flexible/individualised” treatment with rESWT. The hypothesis  and consented after having visited a sport and exercise medicine clinic between 2006 and 2013. All patients had a comprehensive history taken and clinical examination performed. Examination includes observation for any swelling and palpating the anatomical site of pain. This is to exclude partial plantar fascia tear , stress fracture of the calcaneus, and medial calcaneal nerve entrapment. The other useful examination is percussing (Tinel test) the inferior aspect of medial malleolus to look for tarsal tunnel syndrome . UltrasoExclusion criteria were as follows: less than eighteen years of age, those who had undergone surgery for PF, any history of malignancy, a history of radicular back pain, any fractures in the foot, ankle, and tibia, and previous ESWT treatment.Sixty-eight individuals  were finally retrospectively analysed, 29 males (43%) and 39 females (57%) whose age ranged from 18 to 75 years with an average age of 47 ± 11 years. PF emergence differentiated in means of pain duration experienced by patients until the initialization of the treatment. We found that 21 patients (31%) experienced pain for less than three months, 14 patients (21%) experienced pain from three to six months, 18 patients (26%) experienced pain from six to 12 months, six patients experienced pain from 12 to 24 (9%) months, and nine patients (13%) experienced pain more than 24 months .Ultrasound gel was applied to the affected area. The rESWT machine used was the Storz Medical Masterpuls MP 200 . Application of rESWT was performed by a trained physiotherapist.Patients were treated with an individualised protocol also dependent on their tolerance to treatment. The number of sessions, the number of impulses, the pressure, and the frequency varied between the subjects depending on the healing process and the severity and insistence of symptoms. The protocols were analysed retrospectively. However, all patients were treated for a minimum of four to six sessions. Six to eight sessions were recommended if pain existed for more than three months. One treatment was performed per week.The working pressure was influenced by the patient's pain tolerance. If the patient was unable to cope with the set pressure due to pain, then the pressure was lowered until found acceptable by the patient. Therefore, the higher the degree of pain, the lower the pressure, although it was always set at a minimum of 1 bar.The effects of the rESWT were evaluated in all 68 patients (78 heels) over a period of one year via follow-ups arranged at 1 month, 3 months, and 1 year after treatment. Patients recorded the level of pain felt through the Visual Analogue Score (VAS) self-evaluation tool, after viewing a straight line separated in equal intervals of 1 cm, ranging from 0 to 10, where 0 represents “no pain” and 10 “worst imaginable pain” . VAS scoOne-year follow-up for any recurrence of symptoms was assessed during a clinic appointment. Recurrence of symptoms was defined as a painful event requiring additional cycles of treatment, or anyone with a one-year follow-up VAS score over and including four .The statistical analysis was performed using Microsoft Excel and SPSS 20. The frequency of the number of rESWT sessions was assessed, as well as mean shock wave impulses, mean pressure, and mean frequency applied. It was also tested as to whether the pretreatment VAS scores (baseline) were statistically significantly different from the posttreatment VAS scores with Wilcoxon Signed Ranks Test and Monte Carlo simulation to test statistical significance –29.Success rates were assessed as the percentage of those having more than 60% VAS pain decrease from baseline scores . Mean VAα = 0.05) for all statistical tests performed.Recurrence rate was assessed and Spearman's rho correlation was performed in order to test if there are grounds of approving a relationship between pain duration and the number of rESWT sessions needed. The confidence level was set at 95%  dropped out of the study group in the very early sessions due to financial or transportation issues, not because of the treatment itself. There were no adverse effects reported by the patients.The number of rESWT sessions per patient ranged from 4 to 11 with a mean of 7 ± 1.6. A total of seventy-eight (78) heels were treated with an average of 2000 impulses per session at a mean pressure of 1.7 ± 0.2 bar (ranged from 1.3 to 2.2) and a mean frequency of 5 ± 0.2 Hz (ranged from 5 to 6) .From the total of 68 patients, 9 (13%) received 4 sessions, 10 (15%) received 5 sessions, 21 (31%) received 6 sessions, 5 (7%) received 7 sessions, 17 (25%) received 8 sessions, 2 (3%) received 9 sessions, 3 (4%) received 10 sessions, and 1 (1%) received 11 sessions.z = −7.809, p = 0.000), between baseline and 3-month follow-up , and between baseline and 1-year follow-up . 3 patients did not contribute in the 1-year VAS follow-up and recurrence examination . One year after treatment VAS was also significantly correlated with pretreatment pain duration  and with the number of rESWT sessions  performed. A positive Spearman's rho correlation was found in both cases, moderate and strong, respectively.Spearman's rho correlation was positive and moderate  between U test was used to assess continuous variables between the group of patients with or without pain recurrence and Monte Carlo simulation to test statistical significance.The Mann-Whitney The recurrence rate was 8% accounting for 6 heels from the 74 assessed at the one-year follow-up (5 out of 65 patients). Specifically, there was one male patient with unilateral recurrence (1.4% of the feet) and four  female patients (6.8% of the feet) .U = 46, p < 0.001), in the total number of rESWT sessions applied , and in baseline VAS score .Statistically significantly differences between the recurrence and the nonrecurrence group were found in pretreatment pain duration  include ESWT as an option, although stating that “sistent” . Howeversistent” .When looking specifically at rESWT though, there is still some debate as to its efficacy. Whilst many studies have found rESWT highly beneficial and conclude it to be a creditable treatment option , 32–34, Possible reasons for the conflicting findings may include the different protocols used. The protocol used in this study is as follows: a thorough patient examination including ultrasonography prior to treatment; a minimum of four to eight treatments spaced one week apart depending on patients' response and the duration of the symptoms; a mean pressure of 1.7 bar, guided by the patient's pain; a mean frequency of 5 Hz; a mean total number of impulses of 2000; in our case only means and ranges are retrospectively examined. Therefore other studies which have variable numbers of treatment sessions, pressures, frequencies, and total impulses may have different outcomes to this study. Other studies have shown that multiple applications of ESWT produce better short- and long-term results than single session alone . AccordiSummarising the differing protocols with regard to the ESWT settings, there are no standardised recommendations on the treatment parameters  other thIn 2007 a review  found ESWhat appears to have been concluded, however, is that there has to be a balance between pressure and time: the higher the pressure the less the sessions required, but the risk of damage increases, whilst the lower the pressure the more the sessions required to see any effects . TherefoWith regard to the 8% recurrence rate, this study found three key factors for recurrence: female sex, pretreatment pain duration, and the number of ESWT sessions received. With regard to the pretreatment pain duration, it is thought that recalcitrant PF could be caused by “plantar fascia thickening and loss of normal tissue elasticity,” that is, tissue degeneration over a period of time . TherefoCorticosteroid injections are another treatment modality recommended for PF, but there are no studies directly comparing rESWT and corticosteroid injections for the treatment of PF. Many compare injections with ESWT as a whole and have found injections more beneficial and more cost-effective , 47. Howt-tests repeated measurements.Limitations of the present study may be found in the fact that patients were not standardised in terms of age, sex, BMI, or occupation, which could lead to analysis exploring possible correlations or depopulation. Prior to commencing the study, a sample size calculation was not performed also bringing a limitation although anticipated by a post hoc power analysis of VAS scores This study reports the recurrence rate, the mean VAS reductions, and success rates of the intervention, something not widely done in the literature. The protocol is tailored to the individual patient's needs and is hence much more flexible than other protocols used. By adapting the programme to the patient, it allows for better results as the treatment programme can progress at a rate suitable to the patient, due to the ability to allow for patient-guided feedback.Nonetheless, this study has shown encouraging results, and therefore this rESWT protocol can be recommended for the treatment of PF. More research should be conducted with more flexible protocols such as this, in order to corroborate this study. They should also look at the implications of other variables such as gender and age, in order to assess whether programmes of rESWT can be further tailored. Apparently, meta-analysis techniques as well as the development of current good practice guidelines may assist in the fields of bringing together different outcome measures and rESWT treatment protocols on PF.


The study included 48 women (aged 22–42) with varying degrees of endometriosis of the lesser pelvis. The Numeric Rating Scale (NRS) was used to evaluate pain intensity before the surgery in all patients, followed by either laser ablation or electroablation of the endometriotic foci. The results of the laparoscopic treatment were monitored after 3 and 6 months postoperatively. p value of 0.05 was considered to be statistically significant. Patients from both groups reported less intensive pain before/during menstruation (dysmenorrhea) 6 months postoperatively, with more distinct tendency in the electroablation group (p = 0.004) as compared to the laser ablation group (p = 0.025). Despite the initial improvement reported at the 3-month checkup (p = 0.008), 6 months postoperatively, a statistically significant increase in pain intensity was noted in both groups . Both surgical methods seem to be effective only in the treatment of endometriosis-related dysmenorrhea, whereas the intensity of other pain complaints ) has remained on the same level.Endometriosis is a chronic disease affecting mainly women of the reproductive age. Its most common manifestations include impaired fecundity, pelvic pain, and dyschezia. Laparoscopic removal of endometriotic foci remains to be the gold standard for the treatment of endometriosis. More effective techniques of endoscopic approach—among others, laser application—are continually being developed. The aim of the study was to evaluate the efficacy of laparoscopic treatment with the use of CO Endometriosis is an estrogen-dependent chronic disease with the incidence of 30–40 % in women with pain complaints of the lesser pelvis , 2. The Endometriosis is clinically graded into four stages of advancement according to the revised American Society of Reproductive Medicine classification. The Chapron classification (2003) is an example of another system, which introduced the deep infiltrating endometriosis (DIE) term as the main cause of pain complaints, depending on the location within the organs of the lesser pelvis . Apart fThe consequences of the disease are a serious and complex social issue, although it is often underestimated or ignored. Endometriosis is a multifactorial disease  and exte2 laser ablation seems to be the most beneficial of them all, as it allows for a precise vaporization of endometriotic lesions with good homeostasis and minimal damage to surrounding tissue. The latter is especially important in the event of a removal of the endometrial cysts within the ovary, as it allows preservation of the ovarian reservoir [Laparoscopy remains to be the gold standard in the diagnosis and treatment of endometriosis . Enucleaeservoir , 14.The efficacy of laser ablation of endometrial implants to reduce pain is estimated at almost 65 % . However2 laser ablation, to reduce a variety of pain complaints in the affected individuals.The aim of the study was to evaluate the therapeutic effect of two laparoscopic techniques, electroablation of endometriosis vs. COlight amplification by stimulated emission of radiation.A laser is a device that emits electromagnetic radiation in various ranges of wavelengths: visible light, ultraviolet, or infrared radiation, by using stimulated emission. The name is an acronym of the 2 laser is a gas laser based on a gas mixture of carbon dioxide, nitrogen, hydrogen, and helium. The main spectral lines are within the wavelength of 9.4 and 10.6 μm, and the emitted power reaches 100 kW at continuous and 1013 pulsed operation. The AcuPulse CO2 laser of 30–40 W , connected to a laparoscope , and Aida software  to archive data were used in the study.Laser radiation is coherent, usually polarized, and the beams have very small divergence. Narrow emission linewidth, which corresponds to a high power in a selected, narrow spectrum range, may be easily generated. The COn = 0), II (n = 4), III (n = 37), and IV (n = 7) according to rARSM, prepared for laparoscopic removal of endometriotic lesions at the Clinic of Gynecology and Oncology, Kraków, between 2011 and 2012, were recruited for the study. Exclusion criteria were the following: pregnancy, history of surgery within the abdominal cavity, history of pelvic inflammatory disease, and prolonged use of oral contraceptives. Before the surgery, all patients filled a questionnaire on pain complaints during the 3 months preceding the study. Numerical Rating Scale (NRS) was used in the questionnaire, with 0 for “no pain” and 10 for “unbearable pain,” to evaluate the intensity of five types of pain during menstruation, urination, defecation, sexual intercourse, as well as noncyclic pelvic pain syndrome (PPS). The respondents were also asked to submit information on their use of painkillers. Patients deemed eligible for the study underwent a gynecological examination and an ultrasound test with the use of transvaginal probe, 2D/3D/4D 5–9 MHz, Voluson E6 . All women underwent laparoscopic destruction of the endometriotic foci. The subjects were randomized into the laser ablation (n = 15) and electroablation (n = 33) groups. At the 3- and 6-month checkup, the patients completed the pain questionnaire again. Additionally, changes in painkiller use were also investigated. At the first visit, when patients deemed eligible for the study were selected and all control checkups, the subjects were examined with the use of a transvaginal ultrasound to evaluate the presence of endometrioid lesions. The tests were performed by the same experienced and certified  doctor, Agnieszka Nocuń.A total of 48 patients with ovarian endometriosis and DIE, grades I  and nonparametric Wilcoxon test  were used to evaluate changes in pain intensity. McNemar’s test was used to analyze the percentage of patients using antispasmodic drugs  and nonsteroidal anti-inflammatory drugs (NSAIDs) (the most commonly used). Student’s t test for independent groups and Mann-Whitney U test for nonnormally distributed variables were used for the comparison between changes in pain intensity inpatients with disease recurrence vs. no recurrence. p < 0.05 was accepted as statistically significant. Microsoft Office Excel and SPSS Statistics 17.0 were used for the calculations. The study was approved by the Ethics Committee of Collegium Medicum, Jagiellonian University.Student’s 2 laser ablation  woman conceived and five (14.7 %) resigned from the 6-month checkup.A total of 48 patients were deemed eligible for the study, with 33 women who underwent electroablation . Pain threshold increased in one (6.67 %), decreased in nine (60 %), and remained on the same level in five (33.3 %) patients. In the electroablation group, the 3-month checkup revealed statistically significant pain relief during menstruation (p = 0.01), urination (p = 0.037), and sexual intercourse (p = 0.008). Dysuria decreased from seven to four points in 7 (28 %), remained on the same level in 16 (64 %), and increased in 2 (8 %) patients, whereas 12 (50 %) subjects reported complete resolution of pain symptoms.The statistical analyses generated diversified results. In the CO2 laser group, dysmenorrhea significantly subsided (p = 0.025), but dyschezia intensified (p = 0.018). Fifteen (100 %) patients presented no dyschezia complaints before the surgery, but after 6 months, seven (50 %) patients reported pain of mild intensity. Interestingly, after the initial improvement observed at the 3-month checkup, the 6-month checkup revealed significantly intensified dyspareunia (p = 0.016). Mean values increased from 3.75 to 9.38   in that group. Seventeen (50 %) patients reported dyspareunia at the level of greater than or equal to two points before the surgery, but greater than or equal to ten points at the 6-month checkup.The 6-month checkup revealed further changes. In the COd p = 0.08. Fifteep > 0.05) were observed in either of the investigated groups. The frequency of the use of painkillers and antispasmodic drugs was also analyzed in both groups. NSAIDs  and antispasmodic drugs (No-Spa) were most often used. Statistical analysis was carried out for both of these groups of drugs, and statistically significant decrease in the use of NSAIDs was noted in both study groups (p = 0.008 for electroablation and p = 0.031 for laser ablation), but not sooner than 6 months postoperatively. The frequency of postoperative use of antispasmodic drugs was comparable to preoperative values (p > 0.05).No statistically significant changes in terms of PPS (n = 7) was investigated. Recurrence was noted only in the laser ablation group. A statistically significant correlation (p = 0.02) was found between intensified dyschezia and disease recurrence at the 6-month checkup  with regard to the remaining types of pain were found.No correlations between changes in pain intensity and disease recurrence on ultrasound within the lesser pelvis 2 laser ar et al.  and Jacor et al.  review, Similar results have been reported by Radosa et al., who investigated the effectiveness of electroablation , in theip < 0.08 after 6 months).Also, it is noteworthy that the use of NSAIDs, associated mostly with dysmenorrhea-related pain, was also statistically significantly decreased (2 laser ablation and electroablation resulted in intensified dyspareunia 6 months postoperatively (Fig. 2 laser, believed to be the essential factor for preservation of the ovarian reserve in the treatment of ovarian endometriosis, may have a less beneficial therapeutic effect in DIE therapy of the Douglas pouch and promotes earlier recurrence of endometriosis and, consequently, pain complaints, especially dyspareunia [2 laser, but the study included patients with DIE of the rectosigmoid area and management consisting of segmental colon resection with the additional use of CO2 laser.Regardless, changes in the intensity of the remaining types of pain do not allow for unambiguous assessment of the positive effects of laparoscopic treatment. Both COpareunia , 35. Meupareunia  obtained2 laser, believed to be its advantage in the treatment of ovarian endometriosis, might not correspond to the long-term therapeutic effect in pain management of extra ovarian endometriosis, i.e., DIE.Evaluation of partial therapeutic effect ought to take into account hyperalgesia of the nerve endings of tissues theoretically neighboring DIE lesions , which i2 laser ablation and electroablation is short-term and incomplete. Precision of the CO2 laser and relatively limited tissue damage during electroablation seem to be irrelevant when it comes to their practical application in treating pain related to extra ovarian endometriosis. Owing to a short postoperative observation period, our results should be regarded as a preliminary evaluation of treatment efficacy for pain complaints [Pain relief in patients after laparoscopic COmplaints . Furthermplaints .


Further studies on the potential of text messages to improve adherence are needed.Artemisinin combination therapies are available in private outlets, but patient adherence might be compromised by poor advice from dispensers. In this cluster randomized trial in drug shops in Tanzania, 42 of 82 selected shops were randomized to receive text message reminders about what advice to provide when dispensing artemether-lumefantrine (AL). Eligible patients purchasing AL at shops in both arms were followed up at home and questioned about each dose taken. Dispensers were interviewed regarding knowledge of AL dispensing practices and receipt of the malaria-related text messages. We interviewed 904 patients and 110 dispensers from 77 shops. Although there was some improvement in dispenser knowledge, there was no difference between arms in adherence measured as completion of all doses (intervention 68.3%, control 69.8%,  Plasmodium falciparum malaria in the public sector of most malaria-endemic countries, with patient adherence reported to range widely from 39% to 100%.10Patient adherence to treatment is an important step in ensuring the effectiveness of artemisinin-based combination therapies (ACTs) for malaria.Although access to effective antimalarials in the private sector may have increased, drug sellers may not always provide patients with appropriate doses or advice, raising concerns about patient adherence, though evidence is very limited. Only five studies have specifically assessed patient adherence to antimalarials obtained in the private retail sector.Mobile phones are a promising tool for the delivery of healthcare interventions as coverage of mobile networks and handset ownership increases.23Given the concerns over inadequate patient adherence to ACTs delivered through the private retail sector, and the potential benefit of text-message interventions to enhance adherence, we designed and completed a cluster randomized trial in southern Tanzania to assess the effect of text message reminders to drug shop workers on patient adherence to artemether-lumefantrine (AL). We also evaluated the effect of text messages on dispenser knowledge and advice.The private retail sector in Tanzania is an important source of treatment of malaria,27The study was conducted in Mtwara, a rural region in southeastern Tanzania with 35.5% of the population in the lowest national wealth quintile.31In Mtwara, ADDO accreditation commenced in 2006, and officially only accredited drug stores are allowed to function. In reality, a large number of non-accredited shops exist because of a lack of training, unpaid fees, or administrative delays. These shops are tolerated by regulating authorities and considered “prospective ADDOs.” Before AMFm, ACTs were not commonly available in ADDOs in Mtwara, and dispenser training on ACTs was limited, but ACT availability significantly increased after AMFm implementation, with 88% of ADDOs stocking ACTs in Mtwara in August 2011.We based the sample size for this two arm cluster randomized trial on data from the public sector in Tanzania, where patient adherence to AL was 65–98%.In May 2012, we conducted a census of all drug shops in Mtwara (ADDOs or prospective ADDOs). Data were collected on the characteristics of owners and dispensers, ACT stocks and sales, and global positioning system (GPS) coordinates. ADDOs were excluded from the sampling frame if they had sold fewer than five antimalarial treatments in the previous week, no dispensers used a mobile phone, the shop was located on the border with Mozambique or was not accessible, or the owner refused to participate . The finWe designed seven content messages about advice that dispensers should provide when dispensing AL . The mesBefore sending the first message, the 42 ADDOs in Mtwara randomized to the intervention arm were visited to invite participation and collect an updated list of mobile numbers for all dispensers. Messages began in July 2012 and were sent in random order once per day Monday–Friday for the first 4 weeks, followed by once per day Monday, Wednesday, and Friday for the next 10 weeks. Messages were written in Swahili and scheduled in advance on an automated platform, with each message paired with a different complementary component each time to promote interest. Complementary components consisted of inspirational quotes or proverbs or, once per week, a quiz question on message content that earned correct respondents free air time (500 TSH or $.30). Over the 14-week period, 49 messages were sent to each of 60 dispensers, and detailed delivery reports were kept for each message.From September through November 2012, dispensers at ADDOs in the intervention and control arms were visited by study supervisors and given a standard introduction about study objectives. To limit patients' awareness of our primary interest in adherence, which could have led to a biased assessment, dispensers were told we were studying how patients chose to treat fever and would visit some, but not all, patients at their homes. They were asked to fill out a registration form for all patients purchasing any treatment of fever, including the day and time of their ADDO visits, the patients' names, the drugs purchased, and a description of where the patients lived. Dispensers were provided with blister packs of AL that they could then sell to patients needing treatment of malaria. Study staff visited ADDOs every day to check and collect registration forms for 1–3 weeks, or until 12–15 patients purchasing AL were registered if quicker.Eligible patients who obtained AL were identified from the registration forms and assigned patient identification numbers (recorded on follow-up forms). Patients were followed up ∼68–72 hours after their ADDO visit, according to a predefined schedule, and all attempts to locate and interview patients were recorded. Where written informed consent was given, patients or their caregivers were asked about demographic and socioeconomic characteristics, treatment-seeking history, illness symptoms, detailed information about each dose of AL taken and the advice provided by the ADDO dispenser. Blister packs were requested for a pill count, and blood samples were collected for a blood smear and a malaria rapid diagnostic test (mRDT) . Blood smears were stained in the field and transported to the Ifakara Health Institute, where they were double-read by two microscopists blinded to results from each other and the mRDT, with discrepant results read by a third microscopist.Adherence was defined in two ways.After completion of patient interviews, dispensers working at the study ADDOs were interviewed on ADDO characteristics, demographics, receipt of study text messages, and advice they would give to patients when dispensing AL. To assess knowledge corresponding with message content, we used an open-ended question, e.g., “I would like to ask about which advice you think you should provide to a person of any age taking treatment for malaria. For the following topics  tell me if advice on this topic is important or not, and if so, what advice you would provide.” Responses were recorded verbatim and evaluated by the study leader using predetermined criteria based on message content.t test of the proportion adherent in each cluster. A list of potentially important confounders was identified a priori consisting of ADDO accreditation certificate, number of customers purchasing ACTs in the previous week, dispenser medical qualification, dispenser training on ACTs, patient age, and patient education. Adjustment for variables on this list found to be unbalanced between arms was performed by fitting a logistic regression model to the individual data and performing analysis on the aggregated residuals, as described by Bennett and colleagues.37All patient and dispenser interview data were collected using personal digital assistants, and data extracted from study forms  were double entered into Microsoft Access databases . Data were analyzed in Stata 11.0 . Primary outcomes were analyzed by intention-to-treat. Comparison of adherence was based on a All questionnaires, consent forms, and other study documents were translated into Swahili and piloted before use. Written informed consent was collected from dispensers before census, patient registration and interview, and from patients or their caregivers prior to interview. The study protocol was approved by the ethical review boards of Ifakara Health Institute and London School of Hygiene and Tropical Medicine. The Centers for Disease Control and Prevention (CDC) investigators provided technical assistance in design and analysis but were not engaged in data collection. The trial is registered with Current Controlled Trials, ISRCTN83765567.Characteristics of patients were well balanced between arms . A high p [adjusted] = 0.0748), though knowledge of the correct regimen for a child aged four weighing 20 kg was lower than for adults in both arms . Dispenser knowledge was considerably higher in the intervention arm than the control arm on advice to take AL with fatty food  and to continue to take AL if minor side effects occur . However, surprisingly high dispenser knowledge (87–99%) was recorded in both arms on advice to complete treatment even if feeling better, advice to return to the ADDO or go to a health facility if the condition worsens, and advice to take the second dose after 8 hours , with a similar percentage of patients adherent to each of the four age-appropriate blister packs and no important differences between arms. The mean number of doses taken by non-adherent patients was four in both arms, and the most common reported reasons for non-adherence included planning to take the medication later, forgetting to take the tablets, feeling better, and other reasons 34Although the text message intervention targeting dispensers was not effective at improving patient adherence, there was a marked increase in dispenser knowledge of advising patients to take AL with fatty foods or milk and to continue AL even if minor side effects occurred. However, knowledge in both arms was surprisingly high, particularly on advising patients to take the second dose after 8 hours, to complete treatment even if feeling better, and to seek further care if the condition worsens. This could reflect the recent ADDO trainings in Mtwara, raising the possibility that the intervention's impact could have been different in the absence of recent training.Knowledge did not necessarily result in the provision of advice, even though some advice was provided. For example, 98% of dispensers in both arms knew it was important to advise patients to complete treatment even if feeling better, but only 60% of patients reported receiving this advice. Other advice was much less commonly provided, with < 5% of patients in both arms reporting being advised on what to do in case of minor side-effects or vomiting, even though dispenser knowledge of this advice was much higher. This may be because the dispensers did not deem the advice helpful to their business or to the patients, as it could heighten a negative perception about the effects of their products. Dispensers may have also perceived that clients were in a hurry or not receptive to advice. Alternatively, patients or caretakers may not have recalled the advice given to them several days before. Exit interviews or mystery shopper surveys may have been useful in assessing whether advice was communicated, but these methods also have limitations, such as greater potential for a Hawthorne effect and ethical challenges.We intentionally avoided telling dispensers that the purpose of our study was to improve patients' adherence. Although dispensers receiving text messages were aware that the content focused on advising patients about the correct use of AL, we did not mention the objective to dispensers in either arm to avoid this information being relayed to patients, who might then change their behavior because they expected their adherence to be monitored.The evaluation of patient adherence relied on self-reported data from patients or their caregivers, which may be subject to recall and social desirability bias. We inspected blister packs for the 80% of patients who could provide them and identified only 10 patients (1%) that had reported completing all doses but had pills remaining. On the other hand, patients may have removed pills from the packaging to consume at a later time. Even though Swahili times of day, based on sunrise and sunset, were used to assess timely completion, patients or their caregivers may not have remembered when each dose was taken or may have provided the expected responses to avoid being seen as negligent.A similar text message intervention targeting health workers in public health facilities in Kenya found significant improvements in health worker case management of pediatric malaria.37Interventions involving training of dispensers in the private retail sector, although limited in number, have improved dispenser knowledge across a range of diseases and settings, but the impact of improved knowledge on dispenser and patient behavior has been mixed.5The private retail sector is likely to continue to be an important source of treatment of malaria and there is a need to maximize patient adherence to ACTs. Given the effectiveness of text message reminders on health worker case management in Kenya and the low cost of this intervention, there is potential for further evaluations of text message interventions targeted at dispensers in the private retail sector to improve dispenser knowledge, advice provided, and patient adherence, particularly in settings where dispensers have not received recent training on malaria. Such interventions should ensure message content addresses gaps in dispenser knowledge and would benefit from additional research on dispenser readiness to provide advice, and client receptivity to their advice. There should also be further consideration of how best to design the evaluation so that dispensers are motivated to communicate the importance of adherence without biasing study results.The double gap between dispenser knowledge and providing advice and then patients receiving advice and being adherent may also call for other interventions to enhance adherence. Text message reminders to patients have been shown to be a low-cost approach to improve patient adherence to antiretroviral therapy for HIVOther interventions that have been shown to improve patient adherence to antimalarial drugs include packaging and community education.5Text message reminders improved some aspects of dispenser knowledge of advice to provide to patients when dispensing AL in the private sector. However, patients in the intervention arm were not more likely to report receiving improved advice and did not have higher adherence than patients in the control arm. Adherence to AL among patients in both arms was suboptimal, highlighting the need for studies evaluating other interventions to improve adherence to ACTs obtained in the private retail sector.


Dear Editor,I have recently reviewed the interesting article by Farzanegan et al. , publishLumbar radiculopathy is a disease, and lumbar discectomy is the most common surgical procedure for patients who are experiencing back and leg pain as a result of herniated discs. It is well-known that surgical procedures such as; percutaneous endoscopic discectomy, lumbar microdiscectomy, or spinal fusion, improve the patients’ QOL after 6 months. Also QOL improves more quickly in surgically treated patients, then in those treated conservatively. The results of this article are consistent with previous studies.Depression plays a role in pain; it is a major contributor to how pain is processed and coped with, affecting QOL and disability after back surgery. Patients with more depressive symptoms preoperatively, were less likely to achieve clinically significant improvements in disability and QOL following lumbar discectomy . Hence, In the present study, the Short Form 36 (SF-36) questionnaire was used to assess QOL after lumbar surgery. The SF-36 consists of eight sections, which are; vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social functioning, and mental health. Despite the fact that the SF-36 has a number of advantages for the evaluation of QOL, there is still a need for greater precision in measuring QOL. In addition, this article lacks an interpretation of why educational levels and BMI do not affect the SF-36. In chronic low back pain patients, pain severity is more strongly related to being overweight and psychological factors than to pathophysiological changes (Although, this study has a few demerits, Farzanegan et al. have provided evidence that lumbar discectomy is a safe and effective technique to improve both the physical and mental health subscales of the QOL in patients with chronic disc herniation.


This dose decreased with patient’s age and duration of operation and increased with patient’s weight. OPRM1 and ABCB1 polymorphisms were significantly associated with administered dose of morphine (p = 0.038 and 0.012 respectively). Patients with at least one G allele for c.118A>G OPRM1 polymorphism (AG/GG) needed 4 times the dose of morphine of AA patients. Additionally, patients with ABCB1 CT and CC genotypes for c.3435C>T polymorphism were 5.6 to 7.1 times more prone to receive higher dose of morphine than TT patients. Our preliminary results support the evidence that OPRM1/ABCB1 genotypes along with age, weight and duration of operation have an impact on morphine consumption for acute postoperative pain treatment.Individualization of acute postoperative pain treatment on an evidence-based decision process is a major health concern. The aim of this study is to investigate the influence of genetic and non-genetic factors on the variability of response to morphine in acute postoperative pain. A group of nighty-five patients undergoing major surgery were included prospectively. At 24 h, a logistic regression model was carried out to determine the factors associated with morphine doses given by a Patient Controlled Analgesia device. The dose of morphine was associated with age ( Management of acute postoperative pain is a major challenge. Studies suggest that only 25% of postoperative patients receive appropriate analgesic treatment ,2. Pain Patient controlled analgesia (PCA) is a frequently used system to manage post-operative pain. It relies on the use of a pump that allows patients to self-administer morphine according to their subjective evaluation of pain. Consequently, the administered morphine doses vary greatly among patients.Many studies have investigated the association between genetic and non-genetic factors and the variability of response to opioids .Genetic factors are thought to be responsible for approximately 12% to 60% of response variability in opioid treatment, as evaluated by twin studies .OPRM1) and pharmacokinetics (such as ABCB1) that can modulate nociception and analgesic dose requirement.Many genes have been studied to identify pharmacogenetic markers in morphine treatment, including genes implied in pharmacodynamics (such as OPRM1 encodes for the Mu opioid receptor (MOR). Studies on mice with targeted inactivation for Oprm1 established this receptor as essential for morphine analgesia, physical dependence, and reward process [OPRM1 [N-terminal domain of the receptor associated with a modification of responses to opiates [in vitro [ process . More ths [OPRM1 . The coms [OPRM1 . This po opiates . Indeed,in vitro . c.118A>in vitro .ABCB1 (former MDR1 for multi-drug resistance protein). The c.3435C>T (rs1045642) variant is a result of a C-to-T substitution at nucleotide 3435 and has been associated with a reduced expression of duodenal P-gp in homozygous TT patients [In addition, numerous studies have shown that some opioids, in particular morphine, are substrates for the P-glycoprotein (P-gp) ,12,13. Tpatients . It has patients .As for non-genetic factors, numerous studies have shown that age, gender, hepatic or renal failure, anxiety, and duration of surgery are predictive factors of morphine requirements in the post-operative period ,17,18.The aim of this study was to investigate the association between genetic or non-genetic factors and morphine requirements using PCA in the 24 h post-operative period. Therefore, we evaluated the allelic frequencies of two SNPs  in a Lebanese population of patients undergoing orthopedic or major abdominal surgeries. We then assessed the relationship between these genetic and demographic/clinical factors on one hand, and pain perception and morphine doses and side effects on the other hand.A total of 100 patients  were enrolled in this study. Out of these patients, five were then excluded: three patients having received remifentanyl during surgery and one having refused the installation of PCA. In addition, in one patient, a desaturation with hypovolemia and postoperative bleeding occurred 2 h postoperatively. The PCA was stopped and the patient was sent to the intensive care unit. Consequently, only 95 patients completed the study. The main clinical and demographic characteristics of patients are presented in Patients were admitted for urogynaecology (47.4%), orthopaedic (40%) or gastroenterology (12.6%) surgeries.p24 = 0.53) nor the VAS on movement (p24 = 0.22) was significantly different between the various surgery groups.The mean pain scores evaluated by the visual analog scale (VAS) at rest and on movement were relatively low at 24 h . Neither the VAS at rest (Morphine doses administered by PCA were highly variable within the population: 4 to 227 mg per 24 h. The median doses (±SD) were 40.5 ± 34.9 mg.OPRM1 c.118A>G, the allelic frequencies were 0.89 for 118A and 0.11 for 118G. For ABCB1 c.3435C>T, allelic frequencies were 0.55 for 3435C and 0.45 for 3435T (n = 192 chromosomes). The population was in Hardy-Weinberg equilibrium for both SNPs.Results of genotyping and allele distribution are summarized in In order to explore the variables associated with morphine doses, a univariate analysis was conducted after dichotomization of the doses of morphine using the 50th percentile. The comparison of the distribution and mean values of patient socio-demographic and genetic characteristics as well as surgery parameters are presented in p < 0.25 in this univariate analyses (in bold in The explanatory variables that showed associations to the doses of morphine with p = 0.011), weight (p = 0.025) and the duration of operation (p = 0.030) (The 24 h morphine dose was associated with age (= 0.030) . The meaOPRM1 and ABCB1 SNPs were significantly associated with morphine doses at 24 h (p = 0.038 and 0.012 respectively). Patients with at least one G allele for c.118A>G OPRM1 (AG/GG) needed 4 times the dose of morphine of AA patients. Additionally, patients with ABCB1 CT and ABCB1 CC genotypes were 5.6 to 7.1 times more likely to receive a higher dose of morphine than ABCB1 TT patients (patients .24 score 0.13 (0–2)) and 14 patients had at least one episode of nausea/vomiting in the first post-operative 24 h ).Side effects reported postoperatively were sedation and nausea/vomiting. However, the overall incidence of these adverse events remained low; only 11 patients out of 95 had sedation . No other association was found with the VAS scores at rest or on movement  were associated with sedation nor nausea/vomiting scores at 24 h . Howevermovement .Postoperative pain management remains a challenge for clinicians due to unpredictable patient’s response to opioid therapy. Morphine is the most widely used drug for postoperative pain treatment. Inter-individual variability in response to morphine is a significant challenge in the management of pain. A PCA morphine administration usually guarantees an optimal analgesia. However, some studies have shown that this technique is also associated with a risk of complications, even serious ones such as respiratory depression which was estimated at 0.25%–7% ,22,23.Indeed, some errors have been reported such as incorrect programming of the pump, wrong understanding or reproduction of the physician’s prescription and finally errors in monitoring and system malfunction leading to overdoses. In addition, some patients with psychomotor delay or suffering from psychiatric disorders, non-cooperative patients, and in particular elderly ones may be unable to adopt the technique or even understand its concept .This study was conducted in order to evaluate the added value of determining some genetic and non-genetic factors in optimizing postoperative pain treatment. Rational doses of standard (morphine) or minor analgesics treatment might be sufficient for patients requiring low doses, whereas patients requiring high doses of morphine would be ideal candidates for a PCA-morphine based on a “multimodal” analgesia, combined with loco-regional or peripheral nerve blocks analgesia techniques.In this study, patient age and weight were significant predictors of morphine consumption during the 24 h after surgery.Elderly patients appeared to be more sensitive to the analgesic effect of morphine than younger patients. The association between increased patient’s age and reduction of morphine requirement for postoperative analgesia has been previously published ,24,25. EAs for weight, patients with higher weight seem to have higher postoperative morphine consumption. Whereas the anesthetic opioid doses are “partly” adapted to the patient’s weight, the postoperative dose of morphine is mainly based on the level of pain and initial titration dose. However, our current observation is probably related to a higher volume of distribution.A significant influence of surgical factors (duration of operation) on both VAS scores and morphine doses was found. Hence, the longer the duration of the operation, the more it was associated with high VAS scores but lower morphine doses. This result is not in agreement with previous work that reported an increase in postoperative opioid requirements with increased post-operative pain levels .Genetic factors appear to influence both sensitivity to pain, and analgesic requirement for effective pain control.n = 113; OPRM1 c.118A>G or to those of Asian populations for ABCB1 c.3435C>T (Chinese HapMap).The Lebanese population is an admixture of Ancient Phoenician pooled with Arabian and Western European lineages . Indeed,OPRM1 c.118A>G and ABCB1 c.3435C>T polymorphisms with morphine response [Previous studies have produced inconsistent results regarding the association of OPRM1 received significantly higher doses of morphine than AA patients and those with at least one 3435C allele (CC or CT) for ABCB1 received significantly higher doses of morphine than TT patients. Hence, 118AA and 3435TT patients may be considered as “good responders” to morphine.In our study, patients with at least one 118G allele (AG and GG) for OPRM1 indicates a change from an asparagine to an aspartic acid residue in amino acid position 40 (p.N40D). Studies have shown that 118G allele expression in stably transfected cells results in a reduced expression of MOR at the cell surface due to both transcriptional and post-transcriptional effects [in vitro [OPRM1 needs larger doses of morphine to compete for opioid receptors. Hence, in this patient, MOR with an aspartate at residue 40  would control analgesia less efficiently.Indeed, as previously described the c.118A>G SNP in  effects ,27, suggin vitro  and reduin vitro . Howeverin vitro . This isOPRM1 c.118A>G and the doses required for pain relief . As r review ,31,32,33ABCB1 c.3435C>T, our results are in agreement with previously published data. Campa et al. (n = 145 Caucasians) showed that ABCB1 TT patients were “good responders” compared to CC patients [Concerning patients ,37. HumaWe did not detect any association between genetic or non-genetic factors with the occurrence of morphine side effects, probably due to the small sample size.It is noteworthy to add that the results presented in this article might be considered as preliminary results. In fact, this is the first pharmacogenetic study conducted in Lebanon for pain management and it is very motivating to compare our results with other populations. Our aim was to determine the genetic and demographic factors associated with the dose of morphine in a homogeneous sample of Lebanese patients. We acknowledge however that it is a relatively small study for genetic associations and further studies are consequently needed on a larger sample to confirm and generalize our results on Lebanese patients as well as other populations.OPRM1 and ABCB1 and other genes such as those encoding glucuronidases ex. UGT2B7) contribute to the response variability to morphine.Finally, we cannot exclude that other genetic effects . Patients chosen to be enrolled in this study were candidates for orthopaedic or major abdominal surgeries requiring parenteral analgesia in the post-operative period and were supposed to experience the same levels of pain. Inclusion occurred after patients had provided a written informed consent. Patients were not eligible if their calculated creatinine clearance (estimated by the Cockcroft-Gault formula) was less than 40 mL/min. In addition, patients treated with opioid analgesics, corticosteroids or non-steroidal anti-inflammatory drugs in the preoperative period, or those taking on a regular basis co-analgesics such as benzodiazepines or antidepressants were also excluded because these drugs may alter pain perception.This prospective study was conducted between 20 October 2009 and 6 June 2011 and was approved by the ethical committee of the hospital .Clinical and demographic information including age, gender, weight, height, ethnicity, duration of the operation and co-medication were collected.2 and N2O, sevoflurane, fentanyl and muscle relaxant for the maintenance of anesthesia. They received morphine intravenously (IV) before extubation (0.05–0.1 mg/kg), followed by titration in the post-anesthesia care unit (PACU) until VAS ≤ 3 and acetaminophen 1 gr q6 IV for 48 h. PCA was started in PACU with 2 mg/10 min for 48 h with possibility to raise bolus to 3 mg/10 min if the VAS was ≥5.During surgery, all patients had a standard general anesthesia using propofol and muscle relaxant for the induction and OPain was self-rated by the patients using the item of “average pain” by the VAS during 24 h. Patients rated pain on a numeric scale, where 0 represents “no pain” and 10 “pain as bad as you can imagine” as recommended for use in clinical studies of pain. The pain scores were reported in integer number.The cumulative 24 and 48 h doses of morphine were collected, including morphine administered peroperatively, in the PACU, and those administered by PCA.Side effects commonly associated with morphine treatment were also assessed. Sedation was evaluated on a scale going from (0–4) , as well as nausea and vomiting from (0–2) . Respiratory depression (respiratory rate less than 10/min) and bradycardia (pulse less than 45/min) were evaluated according to the qualitative criteria Presence/Absence (yes/no: Y/N). Anxiety was evaluated in the PACU using a 0 to 100 scale, where 0 represents “no anxiety” and 100 represents “very severe anxiety”.® Blood  as recommended by the manufacturer.DNA was extracted from blood cells using the QIAamp DNA Mini® 2.0 .Genotyping for the two SNPs was performed using the Lightcycler2 (10 mM); Lightcycler Fast Start DNA Master Hybridization Probes Kit® catalogue no. 03 003 248 001, Roche Diagnostics GmbH, Mannheim, Germany), and 0.2 μL of each primer (20 mM) and fluorescent probes  . The samples were then loaded into composite plastic/glass capillaries , centrifuged, and placed in the LightCycler sample carousel.In summary, the reaction was carried out using 25 ng of DNA (10 ng/μL solution or 2.5 µL) in a final volume of 10 µL. The reaction mixture (10 μL) contained Fast Start Taq polymerase (10×), buffer and dNTPs, MgClOPRM1 (rs1799971) and ABCB1 (rs1045642) were performed according to previously published methods [OPRM1 c.118A>G, primer forward 5'-GCTTGGAACCCGAAAAGT-3', primer reverse 5'-GTAGAGGGCCATGATCGTGA-3', probes CCCGGTTCCTGGGTCAACTTGTCC-FL and 640-CTTAGATGGCAACCTGTCCGACC-PH and for ABCB1 c.3435C>T, primer forward 5'-TGTTTTCAGCTGCTTGATGG-3', primer reverse 5'-AAGGCATGTATGTTGGCCTC-3', probes 640-GACAACAGCCGGGTGGTGTCA and GGAAGAGATCGTGAGGGCAG-PH.Genotyping of  methods ,39. PrimPositive heterozygous and homozygous controls (defined by direct sequencing) and negative controls (water) were systematically included in experiments.The genotyping was conducted on patients following their surgery. The genotyping was performed in the laboratory and none of the investigators, clinical care providers or observers of this study were aware about the genotyping results. Therefore, the genetic testing could not have biased the pain assessment process.Clinical data are presented as mean ± standard deviation (SD). The statistical analysis was performed using a software program . The alpha error was set at 0.05.N = 50 + 8 m (m is the number of independent variables); given that m = 5, at least 90 subjects have to be included in the present study.The formula for calculating sample size requirements was the one published by Tabachnick and Fidell  that tak2 analysis with one degree of freedom.Deviation from the Hardy-Weinberg equilibrium was tested using χ2 independence tests and the Student’s t-test or the analysis of variance, respectively. A logistic regression model was carried out with one categorical dependent variable (doses of morphine) and the explanatory independent variables. Explanatory variables, that showed associations to the doses of morphine with p < 0.25 in univariate analyses, were candidates for the multivariate model according to the Enter method.To determine the genetic and non-genetic factors associated with the morphine doses at 24 h, the doses were dichotomized using the 50th percentile. In the initial stage, the univariate analyses of categorical and continuous variables were carried out using the χOPRM1 c.118A>G and ABCB1 c.3435C>T genotypes influence postoperative morphine doses required by PCA for good pain relief during the 24 h after major painful surgeries.Our study adds to the evidence that age, weight, duration of the operation, It would be of interest in future studies to evaluate the added value of a preoperative genotype testing for acute pain management. Hence, if our results are confirmed on a larger cohort, it will emphasize the importance of individualizing analgesic therapy to optimize medical treatment, in terms of efficacy, safety and cost. A preoperative genotyping could determine acute pain management strategies. Rational doses of standard (morphine) or minor analgesics treatment might be sufficient for 118AA and 3435TT patients to have good analgesia, while patients with at least 118G or 3435C alleles (either 118AG or GG and 3435CC/CT) would be ideal candidates for a PCA-morphine based on a “multimodal” analgesia, combined with local regional or peripheral nerve blocks analgesia techniques. This could provide adequate pain relief as well as a reduction in the occurrence of analgesic side effects after major surgeries.Ideally, in the future, it would be interesting to elaborate a guided dosing algorithm incorporating genotypes in addition to some clinical and demographic factors such as age, weight and duration of the operation. This algorithm would improve treatment outcomes of acute postoperative pain management strategies.


We tested the hypothesis that nocturnal hypoxemia, quantified by sleep time spent at an arterial saturation  the minimum nocturnal SaO2, and (c) the number of apnea/hypopnea episodes per hour of sleep. We used multivariable regression models to adjust for both clinical and sleep-related confounders.With Institutional Review Board approval, we examined the records of all patients who underwent laparoscopic bariatric surgery between 2004 and 2010 and had an available nocturnal polysomnography study. We assessed the relationships between the time-weighted average of pain score and total opioid consumption during the initial 72 postoperative hours, and: (a) the percentage of total sleep time spent at SaO2 < 90% was inversely associated with total postoperative opioid consumption; a 5-%- absolute increase in the former would relatively decrease median opioid consumption by 16% . However, the percentage of total sleep time spent at SaO2 < 90% was not associated with pain. The minimum nocturnal SaO2 was associated neither with total postoperative opioid consumption nor with pain. In addition, neither pain nor total opioid consumption was significantly associated with the number of apnea/hypopnea episodes per hour of sleep.Two hundred eighteen patients were included in the analysis. Percentage of total sleep time spent at SaOPreoperative nocturnal intermittent hypoxia may enhance sensitivity to opioids. Sleep disruption and recurrent nocturnal hypoxemia are distinct pathophysiological components of obstructive sleep apnea (OSA), and both are thought to influence pain processing –3 and op2) < 85% required half the dose of morphine after adenotonsillectomy than those with a nadir SaO2 ≥ 85% , . The obsectively . The una2 < 90% (P = 0.006). The adjusted estimated ratio of medians of total opioid consumption was 0.84 (98.75% CI: 0.72 to 0.98) for a 5-%-absolute increase in the percentage of total sleep time spent at SaO2 < 90%  for a 10-%-absolute increase, and so forth. However, the time-weighted average of pain score during the same postoperative period was not associated with the total sleep time spent at SaO2 < 90% (P = 0.18). The adjusted increase in the time-weighted average of pain score was 0.04 (98.75% CI: -0.03 to 0.10) for a 5-%-absolute increase in the percentage of total sleep time spent at SaO2 < 90%. The sensitivity analysis provided consistent results  nor time-weighted average of pain score (P = 0.17) was associated with the minimum nocturnal SaOanalysis . Similar2 (P = 0.03). These results are almost identical with the results of our primary analysis.There were 119 (55%) patients who were discharged on postoperative day 1 or 2. Among these patients, 32 (27%) had no pain at discharge (pain score of 0), 45 (38%) had mild pain (pain score 1 to 3), 31 (26%) had moderate pain (pain score 4 to 6), and 11 (9%) had severe pain (pain score 7 to 9) at discharge, respectively. In order to examine the possibility of underestimating the total opioid consumption during the first 72 hours postoperatively , we conducted a sensitivity analysis where we used the total opioids consumption up to 48 hours as the outcome. We found that the estimated ratio of medians of total opioid consumption was 0.84 (0.72 to 0.98) for a 5-%-absolute increase in the percentage of total sleep time spent at SaO2 < 90% (P = 0.005) and 0.94 (0.88 to 1.01) for a 1-%-absolute decrease in the minimum nocturnal SaOSecondly, we found that neither time-weighted average of pain score nor total opioid consumption was significantly associated with apnea /hypopnea index or a preoperative diagnosis of OSA .2 < 90%) in patients suffering from OSA. Patients with longer arterial desaturations in polysomnography consumed significantly less opioid for postoperative pain management.We found that total opioid consumption in the first 72 hours after laparoscopic bariatric surgery was significantly associated with nocturnal intermittent hypoxia , [2 were predictive vs. those with less 4%), [2 tripled the risk for atrial fibrilation), [2 < 94% and more than 2.17% of total sleep time at SaO2 < 90% predicted insulin resistance), [2 from 92 to 75% approximately doubled the odds for pain), [Attended preoperative polysomnography showed that approximately 60% of our bariatric patients were suffering from moderate-to-severe OSA (apnea /hypopnea index ≥ 15 events per hour of sleep), which agrees with the current epidemiological profile of the disease in this age and BMI range . A mediastroke), ; cardiovlation), ; insulinr pain), .2 in polysomnography) in adults suffering from OSA, is associated with an increased analgesic sensitivity to short-acting opioids [Our findings support previous evidence from both the clinical ,26 and e opioids . Further opioids , is asso opioids .Seemingly in contrast to our findings, a prospective study cohort evaluating the effect of race on postoperative pain in children undergoing adenotonsillectomy, showed that African American children with OSA required more opioids for pain management and experienced longer post-anaesthetic recovery due to inadequate pain control than Caucasian children suffering from OSA. Interestingly, Caucasian children (with or without OSA) experienced a higher incidence of opioid-related side effects . But becCollectively, clinical ,26,33 anThe bariatric patients included in our analysis had a nocturnal polysomnography evaluation performed in the past and, presumably, all carried certain risk markers for OSA . This might have reduced a potential bias associated with withholding opioids for postoperative pain management in patients with certain OSA-related phenotypes. But it is also possible that OSA patients with more severe arterial desaturations in the nocturnal polysomnography were more sensitive to the sedative effect of opioids and, compounded with the residual effect of general anaesthetics, more likely to present with airway obstruction and /or desaturation events in the PACU. However, we believe that the potential for such a bias in our analysis is rather minimal because: a) opioid administration at the Clinic is titrated to analgesia, defined by a specific pain score, making dose adjustments in response to baseline characteristics less likely, b) symptoms of excessive daytime sleepiness in OSA patients, even in the presence of nocturnal hypoxemia, have been associated with the sleep fragmentation and chronic sleep deprivation phenotypes of the disease  rather, than the severity of arterial desaturations per se ,36, c) iAlthough the predominant perioperative analgesia regimen was opioid-based, the total amount of opioids  consumed by our patients in the first 48 hours postoperatively, was similar to that observed in other bariatric surgery populations . DexametIn conclusion, we found that recurrent nocturnal hypoxemia in bariatric surgery patients was significantly associated with decreased opioid consumption for postoperative pain management. To the extent that these findings are confirmed by prospective investigations in various surgical settings may indicate that in patients suffering from OSA, nocturnal intermittent hypoxia should be considered as a determinant of postoperative opioid pharmacology.S1 Dataset(SAS7BDAT)Click here for additional data file.S2 Dataset(CSV)Click here for additional data file.S1 Fig2 = arterial oxygen saturation by pulse.The first quartile, median, and third quartile comprise the boxes; whiskers extend to the most extreme observations within 1.5 times the interquartile range of the first and third quartiles, respectively; points outsides these whiskers are displayed individually. SaO(TIF)Click here for additional data file.