Aims and Objective. Pain is a common problem associated with postoperative orthopedic patients; the current study is aimed at evaluating music intervention as an alternative method to control pain. Methodology. The experimental design of the current study was comparative, descriptive, and quasi-experimental. 38 postoperative orthopedic patients were equipped with pocket-size MP3 players with prerecorded music tracks  in Hindi, English, and Urdu. After that, pre-post-pain scores were recorded with the help of designed brief patient logs. Ultimately, a satisfactory survey was completed at discharge. Major Findings. It was found that during the intervention of music, the pain was significantly reduced from 5.40 to 2.98. There was a slight relationship between listening time and pain relief. It was also found that the feedback was extremely positive and each patient suggested the use of music to others with 96.6% recommendation. Conclusion. From the current study, it was found that music intervention can be beneficial to postoperative patient pain control. Further, it is hoped that the findings of the current experimental work will lead to improvements in the care of postoperative patients. Nowadays, nurses are facing challenges to provide a better environment to patients in order to enhance patient outcomes and should be more observant of the needs of patients . PatientThe current study is aimed at evaluating the role of listening to music in reducing pain in the postoperative period of orthopedic surgery patients. The subjective data was collected through a survey of satisfaction at discharge to determine the interference of music in the control of orthopedic pain. Moreover, this study is also aimed at assessing and evaluating music as an alternative method to control pain.The experimental work was carried among 38 patients from the orthopedic ward and trauma center, with the help of a quasi-experimental design. And this study was approved by the ethical committee of the hospital. Experimental logs were designed under the supervision of a trained statistician, and it was determined that approximately 30 to 45 patients and 90 logs would be ideal to achieve a power of >0.8.Individual small pocket-size MP3 players were given to each patient along with a headphone. The MP3 player has very few functional buttons and was easy to operate . Music wAfter assessing the inclusion criteria, informed signed consent was obtained from each eligible individual. The inclusion criteria of the study comprise the following points: age limits 18 or older, with more than 24 hours of hospital stay, fond of music, able to understand the nature of the study, and filled and completed the listening logs designed by the researchers  by applying the descriptive statistics (frequency and percentage) and paired sample n = 28 (73.68%) were female and n = 10 (26.31%) were male. The average age group was 31-45 years. The average length of hospital stay was 3.2 days. The most common surgery was total hip replacement , followed by fractured hip repair , andn = 3(7.89%) were admitted for total knee replacement. Further,n = 2(5.26%) were admitted for the repair of ankle fractures andn = 1(2.63%) was admitted for fractured hip repair.A total of 38 patients participated in the study, and 65 total logs were completed by all of these patients. The number of completed logs was less than projected because some patients forgot to fill the logs or fell asleep during music listening. In addition, among these participants, T value is 2.390. The result can be seen in After comparing findings from the logs, it was found that during the intervention of music, the pain was significantly reduced from 5.40 to 2.98. The At discharge, only 30 patients return the satisfaction logs (return rate 79%). From these 30 logs, it was found that the feedback was extremely positive and each patient suggested the use of music to others with 96.6% recommendation. The average of each response is depicted in Moreover, faculty members particularly nurses stated that it was very simple for the nurse to intervene in the music therapy to their nursing practices. It was also observed that they recommend music to confused or agitated patients. There are several other studies that are consistent with our findings such as –15.Though this study gives wonderful outcomes, it still has certain limitations; for example, the sample size of the study was so small, coming from only one unit (orthopedics); therefore, its result cannot be generalized. Further, in the hospital, it is difficult to avoid the interruption of the busy environment during music listening. Thus, a calm and silent environment should be preferred. The researcher should find a better approach to convince and guide patients to fill logs.From the current study, it can be concluded that patients benefited from music therapy. The further intervention of music into nursing care is the holistic approach. It is relatively inexpensive, possesses no risks, and can be administrated without the prescription of doctors. Busy nurses and patients can both work together towards pain control with the help of this method. Both nurses and patients should be trained enough to use this alternative method to achieve positive feedback.


In the face of the opiate addiction epidemic, there is a paucity of research that evaluates limitations for our current pain rating methodologies for patient populations at risk for drug seeking behavior.We hypothesized that VAS scores would be higher and show less serial improvement for patients with a history of frequent ED use.This was a prospective, observational cohort study of a convenience sample of adult ED patients with chief complaint of pain. Initial VAS scores were recorded. Pain scores were subsequently updated 30–45 min after pain medication administration. ED frequenter defined as having >4 ED visits over a 1-year time period. Categorical data analyzed by chi-square; continuous data analyzed by t-tests. A multiple linear regression performed to control for confounding.125 patients were enrolled; 51% ED frequenters. ED frequenters were similar to non-ED frequenters with respect to gender, mean age, Hispanic race, educational level, chief complaint type, and initial pain medication narcotic. ED frequenters more likely to have higher initial VAS score  and higher second VAS scores  and significantly lower mean change in first to second VAS scores . Within our multiple linear regression model, only ED frequenter group (p < 0.001) and private insurance status (0.04) were associated with differences in mean reduction in pain scores.We found that ED frequenters had significantly less improvement between first and second VAS measurements. Pain; Analgesics; Visual analog scale; Pain scores; Pain medications; Emergency department; Opioids; Opioid epidemic; Patient satisfaction In 2015With this backdrop, regulatory agencies including the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Centers for Medicare and Medicaid (CMS) have increasingly emphasized pain management in their assessment of health facility and provider competence. In 2012, CMS created an “Incentive Fund” which partially based hospital reimbursement off of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey which directly asks patients how well their pain was controlled .While attempting to improve the comfort of patients in pain, it is less clear what role regulatory forces may have unwittingly served in leading physicians to overprescribe narcotics. Unintentional opioid overdoses have now become a national epidemic with the majority being related to prescription oral forms, surpassing motor vehicle crashes as the leading cause of death in the United States . In 2008Competing pressures to control pain in the face of a growing opioid addiction epidemic place emergency physicians in a precarious position for many of the patients treated in the ED. Oligoanalgesia may lead to diminished reimbursement and lower satisfaction scores with potential administrative ramifications, while overly generous prescribing may have regulatory consequences for the physician , 6. EmerRelevant to this concern, investigators have previously described that there are significant pain score reporting differences between subsets of ED patients , 8. For As a consequence of poor access to alternative sites for pain and other medical care, emergency physicians encounter a large number of patients who utilize the emergency department frequently. Our literature search did not reveal prior studies that evaluate whether or not frequent users of the ED are a higher risk to have poor response to analgesic therapy. In view of this knowledge gap, we initiated a prospective study to examine the relationship between frequent ED utilization and patients' reports changes in pain score during serial assessments.We hypothesized that VAS scores would be higher and show less serial improvement as reported by patients with a history of frequent ED use.22.1We conducted a prospective, observational cohort study during a nine-month period from January 5, 2017 through September 28, 2017.2.2The study was based in the ED of a 275-bed community hospital with an annual census of approximately 45,000 patient visits. The study was approved by our hospital's Institutional Review Board prior to the initiation of data collection.2.3Patients presenting with a chief complaint of abdominal pain, back pain, flank pain, or headache were consented for enrollment at point of care by emergency physicians with the aid of trained research associates (convenience sample). We excluded pregnant females, prisoners, patients less than 18 years old, or any patient that ultimately was admitted and required a surgical intervention for their condition. Consistent with the methods of Locker et al., we defined an ED frequenter as a patient who within a 1-year period look-back from the current visit was found to have greater than or equal to 4 visits to any one of the 6 EDs within our southern Texas hospital system . Prior E2.4Consenting participants completed a brief survey providing demographic, chief complaint and historical information. We recorded pretreatment pain scores that were reported by patients to their treating physician based on a 0–10 visual analog scale (VAS). Pain medication was administered at the discretion of the treating physician, and, within 30–45 min of medication administration another pain score reported to the treating physician was recorded on the same scale previously utilized. If subsequent VAS scores were taken during the patients stay in the ED, these were also recorded.2.5The Anderson-Darling test was utilized to assess the data for normality. Continuous data are presented as frequency of occurrence and were analyzed by t-tests (parametric data) or the Wilcoxon rank sum test (non-parametric data). Categorical data are presented as a means +/- standard deviation and were analyzed using chi-square. Alpha was set at 0.05. JMP v14 SAS Institute software was utilized for the analysis. We performed a multiple linear regression to control for possible confounding. The dependent variable was the change in initial VAS scores, and we included in the multiple regression model 7 main factors , higher second VAS scores , and lower mean change from 1st to 2nd VAS scores  compared to patients who did not frequently visit the ED. 32 patients (22 frequenters) received a second dose of analgesic. There were no significant differences in mean pain score change for ED frequenters vs. non-frequenters .To control for possible confounding, we performed a multiple linear regression that included all clinical and historical variables collected for the study. Within our model, the association between ED frequenter status and mean pain score reduction remained significant (p < 0. 001). With respect to other patient characteristics, only private insurance status was associated with differences in mean reduction in pain scores (p = 0.04).4In this prospective, observational cohort study, we sought to determine if patients that frequently utilize the ED (ED frequenters) had less serial change in their VAS scores after pain management when compared to patients without a pattern of high ED utilization. We found that ED frequenters were significantly more likely to have higher initial VAS scores, higher second VAS scores, and less serial improvement in their VAS scores following analgesic administration.Our findings raise some new concerns for regulators and administrators who wish to assess the adequacy by which emergency physicians treat their patients reporting pain. If our results are validated in other populations, we have identified a subset of patients for which there is lower likelihood that the provision of analgesics will result in end-of-visit improvements. Unfortunately, current evaluation methods do not control for such variables both within institutions and between institutions respectively. Thus, EDs with higher recidivism rates may be at risk for scoring poorly on key pain control and patient satisfaction metrics based on census characteristics that are, clearly, outside the sphere of physician influence.Investigators previously have evaluated the assessment and treatment of pain in the ED from a variety of perspectives Noting the poor treatment improvement in our ED frequenter study group and that observed by Todd et al. for chronic and recurring pain sufferers, we can speculate that these and other patient subgroups likely contribute significantly to the observations by other investigators that interventions to improve pain management often do not result in increasingly satisfied patients , 13. In As much as patient characteristics may play a role in ED pain management challenges, Sampson et al. explored ED staff factors that might contribute to poor satisfaction reporting by patients despite recorded serial pain score improvements . They coOur findings and the aforementioned reports outline significant challenges for emergency physicians when one considers the significant potential for patient and staff factors outside of the physician domain of control to influence pain score reporting and satisfaction. We believe additional research is warranted to validate our findings and to identify additional patient characteristics that may be associated with low likelihood of serial pain score reporting improvement.5Our study has several limitations that warrant discussion. First of all, we did not enroll patients consecutively, and we did not track patient refusals to participate, which raises concern for selection bias. We attempted to mitigate this risk by utilizing research associates who had highly varied service hours that crossed all days and times of the week. ED frequenter and non-frequenter groups within our study sample were found to be similar across most characteristics. We acknowledge that our patient population, which has a high proportion of Hispanics from lower socioeconomic status, is dissimilar from that observed in other settings/regions of the country, thus, raising external validity concerns. However, in our regression model to attempt to control for confounding, we did not find any association between our primary outcome parameter and the variables race, income, and educational level.Another limitation of our investigation was the lack of a standardized treatment protocol for patients in the two comparison groups. Physicians, at their discretion, treated patients with analgesics and chose the type of medication provided. Fortunately, we found that patients in the two groups were provided narcotics with similar frequency suggesting some degree of uniformity in therapy. Physicians and patients alike were not blinded to the medication administered, but it is unclear how blinding might have impacted our outcome parameter when such a high percentage of patients in both groups received narcotics.We also allowed for a broad array of patients with a variety of chief complaints to be enrolled. However, we note that the distribution of chief complaints was not significantly different between ED frequenters and non-frequenters. Thus, we do not believe that inclusion of a diverse group of patients with pain confounded our results. We do think future investigators should consider larger studies that focus on patients solely with a specific type/location of pain  to evaluate whether our findings are consistent across chief complaints.Finally, while our results seem to support a widely held belief by emergency physicians that patients who frequently visit the emergency department are more likely to not improve with initial analgesic administration, our study does not specifically identify factors that contribute to this phenomenon. Grover et al. observed, “drug seeking patients exhibit classically described drug-seeking behavior  with only low to moderate frequency . Thus, i6We found that ED frequenters had significantly less improvement between first and second VAS measurements than those observed for patients who had prior history of infrequent visits. Future investigators should conduct studies to confirm our findings in other settings as well as to identify other high-risk groups/patient characteristics for poor reported pain treatment response.Ryan Joseph and Peter Richman: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.Alainya Tomanec and Thomas McLaughlin:Conceived and designed the experiments; Performed the experiments; Wrote the paper.Jose Guardiola: Conceived and designed the experiments; Analyzed and interpreted the data; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


To investigate the effectiveness of pre-procedural oral mefenamic acid compared with placebo in women undergoing Loop Electrosurgical Excision Procedure (LEEP) with intracervical lidocaine injection. A prospective double-blinded randomized control trial. Women undergoing LEEP for any indications were asked to participate in the study. The participants were randomly allocated into two groups. In group 1 , the participants were offered oral mefenamic acid (500 mg) for 30 minutes before procedures. In group 2 (placebo), the patients were given oral placebo  for 30 minutes before operation. All participants received immediate 10 mL of 2% lidocaine with 1:100,000 of epinephrine intracervical injection before undergoing the LEEP. All participants were excised in one piece of LEEP. No top-hat excision in this study. The patients graded their pain on a 10-cm visual analog scale (VAS) at different points during the procedure, including speculum insertion, at starting excision, and 30 minutes post excision. Primary outcomes revealed the difference of VAS during all steps of LEEP by generalized estimating equations procedure. Sixty participants (30 in mefenamic group and 30 in placebo group) participated in this study. The study did not find differences of VAS during all steps of LEEP and analgesic drug requirement at 30 minutes after LEEP procedure. All patients reported no immediate complications and no intervention-related adverse events were observed. Using pre-procedural oral mefenamic acid before LEEP procedure was not associated with pain reduction during all steps of excision. The Loop Electrosurgical Excision Procedure (LEEP) is widely used to treat high-grade cervical intraepithelial neoplasia (CIN2-3) to prevent invasive cervical diseases . These procedures are usually performed in the outpatient setting, during which intracervical submucosal injection of lidocaine is generally performed to reduce pain. The other modalities of anesthesia for pain control during LEEP have been proposed in previous studies such as lidocaine spray, lidocaine gel, and oral analgesic. However, mild to moderate pain from patients who underwent LEEP are currently reported in speculum insertion, excision and post excision periods.To reduce mild to moderate pain, Mefenamic acid, a Nonsteroidal anti-inflammatory drug (NSAIDs), is widely used mostly in postoperative pain control . The actions of Mefenamic acid are achieved by blocking the effect of COX enzymes and decreasing prostaglandin products, which results in reduction of pain and inflammation . Mefenamic acid is rapidly absorbed via oral administration and has half-life of action of two hours . Single dose of 500 mg oral mefenamic acid is commonly used before minor gynecologic procedure such as hysteroscope, fractional and curettage for intraoperative and postoperative pain control and complication avoidance . Due to insufficient data regarding whether adding pre-procedural oral analgesic medication can diminish pain in women undergoing the LEEP procedure, the aim of this study was to compare the effectiveness of pre-procedural additional mefenamic acid with the standard intracervical lidocaine injection for pain control in all steps of the procedure. Setting and populationThis double-blind, parallel-group, randomized controlled trial was conducted at Srinagarind Hospital between July 2019 and February 2020. Women who were diagnosed as abnormal cervical cancer and planned to undergo LEEP procedure at our center were asked to participate in this trial. As for inclusion criteria, the participants were to be 18-60 years of age and able to communicate well in Thai; meanwhile, those who had pregnancy, history of allergy to NSAID or lidocaine injection, peptic ulcer disease, coagulopathy, chronic kidney disease, and pelvic infection were excluded from the study. Participants were withdrawn from the analysis once found to have anaphylaxis signs and symptoms such as exacerbated respiratory symptoms  and mucocutaneous reactions  after receiving the pre-procedural oral medication. Ethical oversight was approved by the Khon Kaen University Ethics Committee for Human Research (HE611536). Written informed consent was obtained from all of the participants. This trial was performed and reported in compliance with the CONSORT statement  and was registered with the Thai Clinical Trial Register (TCTR20190307001). Sample size calculationThe mean ± SD of pain score (VAS) from all steps of LEEP, including speculum insertion, excision, and 30-minute post excision were the primary outcome. Sample size in this study was calculated for analysis of generalized estimating equations based on a study by Vanichtantikul et al., 2013). We hypothesized that a combination of pre-procedural oral mefenamic acid with intracervical lidocaine injection before LEEP (group1) would achieve a higher score of pain reduction in all stages of LEEP procedure compared to that of group receiving placebo (group2). Based on a power of 80%, a type I error of 0.05 and the sample size needed for testing our primary outcome was 60 women, 30 of whom were assigned in each group. Randomization and intervention The participants who met the inclusion criteria were randomly allocated to one of the comparison groups using computer generated block randomization of varying block size. The assigned adjuvant treatment was noted on cards, which were sealed in secure opaque envelopes. The envelopes were then numbered in sequence, kept and opened by an independent researcher in an office outside the hospital. All LEEP procedures were performed by five gynecologic oncologists. The surgeon, participants and investigator involved in this study were blinded to the intervention allocated. Before performing LEEP procedures, participants having been allocated to the intervention group (group1) were given oral mefenamic acid (500 mg) at 30 minutes before LEEP procedures. Meanwhile, the participants having been allocated to the control group (group2) received oral placebo at 30 minutes before LEEP procedure. Oral placebo was prepared with the appearance similar to that of Mefenamic acid. All participants received the same operative excision procedure with local anesthesia under 10 mL of 2% lidocaine with 1:100,000 of epinephrine intracervical injection. All participants were excised in one piece of LEEP. No top-hat excision in this study. To minimize the effects of other variables, oral administration of others analgesic drugs or injected analgesic drugs before excision were not allowed.Outcomes and measurements According to the primary outcomes, VAS was different in all steps of LEEP procedures between two groups. Secondary outcomes were additional analgesic required at 30 minutes after LEEP procedure and adverse events. Pain scores were assessed by 10-cm visual analogue scale from 0 (no pain) to 10 (a maximum level of experienced pain). An investigator asked all individual participants to point their pain score based on a standard 10-cm visual analogue scale. Pain score assessments were recorded before speculum examination, at starting excision and at 30 minutes after LEEP procedure. The participants were instructed to inform nurses or investigators if analgesic drug was required at 30 minutes after LEEP procedure and if single dose of 500 mg oral paracetamol was given. Safety assessments were then recorded, including adverse events and immediate complications within 30 minutes after LEEP.Statistical analyses Statistical analyses were performed using Stata 10 . Descriptive statistics were used to report participants’ baseline characteristics. Student t-test was used to compare continuous variables. In addition, the Chi-square or Fisher-exact test were employed to compare categorical variables. Differences between the comparison groups were measured, including mean difference (MD) or relative risk (RR) with their associated 95% confidence interval (CI). Statistical analysis was conducted using generalized estimating equations. P-value < 0.05 was considered to be clinically significant. All analyses were carried out based on the intention-to-treat principle.Of the study population, 66 women were assessed for eligibility, 60 of whom met the inclusion criteria and were randomly allocated to either the mefenamic group (n = 30) or the control group (N = 30). According to the When subgroup analysis was applied, the size of the loop diameter did not affect the pain score in both groups . MoreoveThe results of this study demonstrated that the administration of pre-procedural Mefenamic acid 30 minutes before LEEP procedure did not result in statistically significant relief pain score in women who underwent LEEP procedures compared with placebo. Moreover, no differences in analgesic drug required at 30 minutes after LEEP procedure were observed. Furthermore, pre-procedural Mefenamic acid before LEEP was considered safe as no intervention-related adverse events took place. Preinvasive cervical cancer especially high-grade lesion are usually treated with excision procedures; thus, most tertiary hospitals performed LEEP excision in the outpatient setting (colposcopy clinic). Moreover, several guidelines recommended the analgesic prior to excisional procedures. Indeed, multiple anesthetic modalities for pain control during LEEP are available such as lidocaine gel, lidocaine spray, intracervical lidocaine injection, paracervical block . Premedical with NSAID can be used adjuvant with anesthetic block for additional pain control  . A previous study reported that premedication with oral Mefenamic acid 500 mg significantly reduced pain in 30 and 60 minutes after hysteroscopy . However, using oral Mefenamic acid 500 mg did not show the significant difference of pain score in fractional and curettage compared with paracervical block . Two small RCTs was used to evaluate oral naproxen before carbodioxide laser vaporization for preinvasive cervical cancer. Al-Kurdi et al., 1985 reported that premedication oral NSAIDs (Naproxen sodium) used in carbondioxide laser treatment of uterine cervix has minimal effect on the pain and causes discomfort during laser treatment. The likely explanation for the failure of naproxen sodium to relieve the pain during laser application may be that transmitting nerves are stimulated directly during applying the laser. To illustrate, naproxen sodium is not a centrally acting analgesic and would not be expected to reduce this sort of pain. However, naproxen sodium appears to have some advantages over placebo in the period following treatment when a response to tissue damage takes place. Therefore, if being routinely given naproxen sodium before laser treatment, patients may be prevented from distress after treatment. Frega et al., (1994) evaluated pain score during carbon dioxide laser vaporization for cervical intraepithelial neoplasia (CIN) among 3 groups; naproxen, placebo and no treatment. It may be argued from the study that analgesia before laser surgery for CIN is not required. In the present study, we reported pre-procedural Mefenamic acid before LEEP and we also found that it was not necessary either to relieve pain in women undergoing LEEP. A Cochrane review conducted by Gajjar et al., (2016) revealed that there was no difference in pain score in women receiving oral analgesics compared with placebo or no treatment during colposcopy treatment and in the postoperative period . The authors suggested that the evidence to be of a low to moderate quality and required further high quality, adequately powered trials to provide the data necessary to estimate the efficacy of oral analgesics, the optimal route of administration and dose of local anesthetics. Similarly, our study confirms that pre-procedural oral Mefenamic acid before LEEP is unlikely to significantly reduce pain during LEEP excision and post LEEP at 30 minutes. Al-Kurdi et al., 1985 reported that patients suffered from some pain during laser treatment particularly from dysmenorrhea, dental drilling and parturition. However, our study indicated that the factors such as the size of loop diameter, parity, menopausal status, cervical cytological and final histological type are not associated with pain score during excision and post LEEP 30 minutes by subgroup analysis. Moreover, in this study, a total of 70% of participants were performed LEEP by using 1 cm of loop diameter if using larger loop, it possible to be showed the different result.The strength of this study is that it was a prospective double-blinded randomized control trial, in which we used placebo prepared in similar appearance as Mefenamic acid. Another strength of this current study was that no participants dropped out from the study. The LEEP excision was performed in the standard technique by the same level of operators. In addition, as for postoperative pain evaluation, we applied analgesic using pain scores in order to address the bias of individual experience pain. Furthermore, this study is the first trial that evaluated the difference of pain scores in each time points and both groups were evaluated using generalized estimating equations. In conclusion, using pre-procedural oral Mefenamic acid before LEEP procedure is unlikely required. Further larger investigation with different approach in higher dose of Mefenamic acid and other pre-procedural oral analgesic administration would be explored to optimize pain during LEEP procedures.


The need for meaning in life is a key aspect of being human, and a central issue in the psychology of religion. Understanding experience of meaning for persons with severe dementia is challenging due to the impairments associated with the illness. Despite these challenges, this article argues that meaning in life is as important for a person with severe dementia as it is for everyone else. This study was conducted in a Norwegian hospital and nursing home context and was part of a research project on meaning in life for persons with severe dementia. The study builds on two other studies which focused on how meaning-making and experience of meaningfulness appeared in patients with severe dementia. By presenting the findings from these two studies for a group of healthcare professionals and introducing them to research on meaning in life, the aim of this study was to explore how healthcare professionals interpret the patients' experience of meaning in life in practise for patients with severe dementia in a hospital and nursing home context, and to highlight its clinical implications. The study was conducted using a qualitative method with exploratory design. The data were collected at a round table conference, a method inspired by a mode of action research called “co-operative inquiry.” Altogether 27 professional healthcarers, from a variety of professions, with high competence in dementia care participated together with six researchers authoring this article. This study revealed that healthcare professionals were constantly dealing with different forms of meaning in their everyday care for people with dementia. The findings also showed clear connexions between understanding of meaning and fundamental aspects of good dementia care. Meaning corresponded well with the principles of person-centred care, and this compatibility allowed the healthcare professionals to associate meaning in life as a perspective into their work without having much prior knowledge or being familiar with the use of this perspective. The study points out that awareness of meaning in life as an integrated perspective in clinical practise will contribute to a broader and enhanced repertoire, and hence to improved dementia care. Facilitating experience of meaning calls for increased resources in personnel and competence in future dementia care. The participants considered the moments as tiny bits of a bigger picture of meaning, where it was possible to see patterns and resources to build on. The importance of knowing the background and life-story of the patients was a common feature. This was described as deep diving or signing into the patient's life-story. By signing or inviting oneself into the life-story of the person with dementia, the participants observed that there was meaning in the patients' activity. This made it possible to understand their behaviour, and thus to participate in creating and confirming a coherence for the patients. One of the participants illustrated this point by telling a story about one of the patients who spent much time crawling on the ward floor at the hospital. The healthcare workers felt sorry for the man and were worried about what his family would say if they found him crawling on the floor. But when they tried to help the man onto his feet, he became very distressed. However, the crawling on the floor all gave more sense when his family told them that the man had been a professional floor layer in his working years. While crawling on the floor he was actually at work. In this case, catching the moment was not sufficient to understand the meaning there and then. However, the patient's background provided a context for meaning that was not evident out of the situation but had to be searched for. Knowing the patient's background made it possible to interpret the crawling on the floor as a meaningful moment. The story showed that it is important to not only consider the moments isolated but seeing them as a part of a bigger picture. Seeing the moments as pieces of a whole story was also seen to give a sense of orientation as described by one of the participants:Unlike the patients with dementia where it was the here and now that counted, the participants had the possibility of a broader perspective; But I think that maybe we easily think that setting direction and goals, we can't do that. But we are doing it all the time because it's in small pieces.”“creating these moments. The participants used different milieu-therapy tools, such as reminiscence activities or music, to achieve meaningful moments. Creating moments is related to the former category of being on a treasure hunt where everyday activities were used in search of meaning. As the everyday activities were initiated by the participants, one could also say that they were created moments.In addition to enlarging potentially meaningful moments for the patients in everyday situations, the participants also worked on The third main category relates to the assignment of roles and responsibilities between participants and patients. The participants described the relationship between themselves and the patients as asymmetrical and they emphasised the need for taking leadership. However, the participants made nuanced descriptions of the components of this leadership.Some of the participants described their role as being a “guide.” This role was seen as encompassing a number of responsibilities; including getting a grasp of the here and now situation of the person, simplifying or adapting choices in order to make them manageable for the person with dementia, offering opportunities for relief of pain and unease, as well as incorporating differentness and odd behaviours. In this way, the participants saw themselves as someone the patients could “lean on,” providing safety and meaning.Taking leadership involved a demanding balancing act related to the participants' preservation of the personal integrity of the patient as described below:It becomes such a delicate balance of taking leadership, but at the same time exercising or showing respect. They are persons who need management very much and guidance from the caregiver.”“The participants identified certain characteristics of taking leadership. This was related to the participant's presence; of being attentive and physically present in order to be able to interpret non-verbal signals and behaviour. Some participants expressed the importance of “silent presence,” emphasising that being physically close to someone had a value in itself, without having to talk or do anything. By being present in silence the participants were taking responsibility for the relation to the patients through their presence.tuning in. “Tuning in” was characterised as the responsibility to “tune in on” the reality and situation of the person with dementia. However, the term was also used in reference to the task of preserving the demanding balance between leadership and personal integrity and dignity of the person with dementia. One of the participants used the word resonance as an expression of two-way communication based on observation of how the communication is received in the patient.The participants also described that taking leadership was about equal collaborators. This seemingly contradictory understanding of balancing responsibility with collaboration was expressed in the following quote:A common feature among the participants was to describe the relations between the participants and the patients as asymmetrical. This was partly done in reference to their role and responsibility as healthcare professionals. However, at the same time the participants expressed that the relationship between healthcare professionals and patients had changed compared to the past in terms of talking about the patients as We have to regard them as equal partners, and we are the ones who are going to make them equal.”“Here, in this context the notion of equal collaborators was used primarily as a stance towards recognising the identity and humanity of the patients, and in this way to the principles of human rights, emphasising the equal worth of all humans.This study revealed that healthcare professionals were constantly dealing with different forms of meaning in their everyday care for patients with dementia. This finding corresponds to other research in the field Haugan, , 2015. WThe aim of this study was to explore how healthcare professionals interpret the patients' experiences of meaning in life in practise for patients with severe dementia in a hospital and nursing home context, and to highlight its clinical implications. The findings of the study are important because they show how meaning in life can be facilitated into dementia care, and hence accommodate the Norwegian government's aim of facilitating experience of meaning as one of the measures to promote mental and physical health in society  means to see again, to see once more. The participants' respect for the patients seemed to be about not underestimating them but look once more to confirm their significance as persons, and also about showing respect for the patients' autonomy through balancing between support and preservation of the personal integrity. In line with Schnell's  in April 2016 (#47488). Registered by the Data Protection Office at Innlandet Hospital Trust 2020. The patients/participants provided their written informed consent to participate in this study.T-AI: conceptualisation , methodology—data collection , transcribing data, analysis (lead), writing—original draught preparation (lead), and writing—review and editing . SH, HS-H, LD, LØ, and HT: conceptualisation , methodology—data collection , analysis , and writing—review and editing . All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


PurposeTrigger finger is a commonly occurring hand condition that presents with symptoms of pain, clicking, locking, and catching of the finger. A common non-operative management option is corticosteroid injection. The purpose of this study was to evaluate the short-term patient response to corticosteroid injections for trigger finger. MethodsThe patients of six fellowship-trained orthopedic hand surgeons who underwent a corticosteroid injection for trigger finger between June 2019 and October 2019 were invited to participate in this study. Patients were contacted by phone at one week, two weeks, and three weeks after the injection to complete a questionnaire regarding their pain and triggering symptoms. Medical records were also reviewed to collect basic demographic data.ResultsA total of 452 patients were included in the study. At the final follow-up, 82.4% of patients reported complete pain relief, 16.3% had partial relief, and 1.2% had no relief from their pain. For their triggering symptoms, 65.9% reported complete triggering relief, 30.4% had partial relief, and 3.5% had no triggering relief. It took an average of 6.6 days following injection for patients to experience complete pain relief, and an average of 8.1 days for patients to experience complete triggering relief.ConclusionsThis analysis found that most patients experience relief of pain and triggering at three weeks following corticosteroid injection. The majority of patients experienced some pain relief within the first week following corticosteroid injection, while improvement in triggering appeared to lag behind pain relief. Trigger finger or stenosing tenosynovitis is a common hand condition with a prevalence of 2-3% in the general population -4. TypicBunnell described corticosteroid injection for trigger finger as early as 1953 . While tThe purpose of the present study was to evaluate the short-term patient response to corticosteroid injections for trigger finger. We hypothesized that single corticosteroid injection is an effective first-line treatment that would provide pain relief within one week and mechanical relief within three weeks. After obtaining institutional review board approval , we identified the patients of six fellowship-trained orthopedic hand surgeons who were treated only with a corticosteroid injection for nodular trigger finger. This was achieved by querying our medical database each week using Current Procedural Terminology (CPT) code 20550, “injection(s) single tendon sheath, or ligament, aponeurosis .”Patients who received a corticosteroid injection for trigger finger during the data collection period from June 4, 2019, to October 17, 2019, were invited to participate in the study. Patients who declined to participate or who did not respond to the survey were excluded. The injections were performed sterilely in the clinic setting using a 25 gauge needle and a combination of 1 cc of corticosteroid and 1 cc of 1% lidocaine without epinephrine. The injections were administered directly into the palm of the hand over the A1 pulley in the palm of the hand. During the data collection period, 672 patients received injections. Three patients declined to participate in the study, and 217 patients did not respond to the survey. Therefore, a total of 452 patients made up the cohort. The average age of the cohort was 66 years (range 25-91). Two hundred sixty-one (58%) of the patients were women, 373 (83%) were right-hand dominant, and two patients were ambidextrous. There were 119 thumbs, 42 index, 144 middle, 121 ring, and 26 little fingers included.Patients were contacted by phone at one week (W1), two weeks (W2), and three weeks (W3) after the injection to complete a questionnaire regarding their symptoms of pain and triggering. During each phone call, the caller asked a series of standardized questions. For the pain section of the questionnaire, patients were asked: (1) whether they had complete, partial, or no pain relief; (2) for those who had complete or partial pain relief, how many days post-injection did improvement begin. Similarly, for the triggering section of the questionnaire, patients were asked: (1) whether they had complete, partial, or no triggering relief; (2) for those who had complete triggering relief, how many days post-injection did improvement begin. No further calls were made once the patients reported full resolution of pain and triggering. In addition, the electronic medical records were reviewed to collect demographic data including age, sex, handedness, smoking status, medical comorbidities, laterality of injection, and finger affected, and the type of corticosteroid used.A statistical power analysis, with power set to 80%, was performed prior to the study to determine the number of subjects needed to detect a difference (p<0.05), yielding 385 patients. Two separate logistic regressions were analyzed for this study. The first one evaluated whether or not pain was relieved, and the second one evaluated whether or not triggering was relieved. Significance was determined by any p-value <0.05. All statistical analyses were done using R Studio Version 3.6.1 .Patient demographics are provided in Table PainOf the 452 patients, 431 patients reported pain in their finger prior to injection. Overall, at W3, 328 (82.4%) patients reported complete pain relief, 65 (16.3%) had partial pain relief, and five (1.2%) had no pain relief  patients had complete pain relief, 199 (46.2%) had partial pain relief, and 27 (6.3%) had no pain relief. At W2, 206 of the 226 patients who still had pain after W1 reported data. Eighty-four (19.4%) had complete pain relief, 114 (26.4%) had partial pain relief, and eight (1.9%) had no pain relief. At W3, 109 of the 122 patients who still had pain after W2 reported data, with 39 (9.0%) had complete pain relief, 65 (15.0%) had partial relief, and 5 (1.2%) had no pain relief. Pain relief in patients who did not experience complete pain relief in week 1 is given in Figure In patients who experienced partial pain relief, the average time post-injection was 2.9 days (range 0-20). Patients that experienced complete pain relief did so at an average of 6.6 days (range 0-20) post-injection. For these patients, the average pain level (VAS 0-10) was 0.8 (range 0-5) at W1, and 0 at W2 and W3 post-injection. Patients that experienced partial pain relief did so at an average of 2.9 days (range 0-20) post-injection. For these patients, the average pain level was 4.6 (range 1-10) at W1, 3.4 (range 1-6) at W2, and 2.7 (range 1-7) at W3 post-injection.From W1 to W2, 11 patients reported a worsening in pain level (on average 2.7 W1 vs. 4.8 W2). From W2 to W3, eight patients reported a worsening in pain level (on average 2.8 W1 vs. 4.1 W2). Four patients who did not report pain worsening between W1 and W2 reported worsening on W3. None of the patients who experienced partial relief regressed to no relief over the study period.TriggeringOf the 452 patients, 440 patients reported triggering in their finger prior to injection. Overall, at W3, 258 (65.9%) patients reported complete triggering relief, 119 (30.4%) had partial triggering relief, and 14 (3.5%) had no triggering relief. There were 40 patients who did not complete all surveys at the third week of follow-up. At W1, 137 (31.1%) patients had complete trigger relief, 259 (58.8%) had partial trigger relief, and 44 (10.0%) had no trigger relief. At W2, 276 of the 303 patients still had triggering after W1 reported data. 74 (16.8%) had complete trigger relief, 181 (41.1%) had partial trigger relief, and 21 (4.7%) had no trigger relief. At W3, 180 of the 202 patients still had triggering after W2 reported data, with 47 (10.6%) had complete trigger relief, 119 (27.0%) had partial relief, and 14 (3.1%) had no trigger relief. Triggering relief in patients who did not experience complete pain relief in week 1 is given in Figure Patients who experienced complete relief of pain did so at an average of 8.1 days (range 0-22) post-injection. From W1 to W2, 3 patients who initially had partial improvement reported no longer having improvement, and this regression of improvement continued into W3 for two of the patients, with the third patient reporting improvement in W3. There was one patient who reported having improvement W1 and W2 who subsequently reported no further improvement in W3.Consistent with our hypothesis, we found that the majority of patients experienced some pain relief within the first week following corticosteroid injection, with approximately half achieving complete pain relief. It appears that the extent to which patients experience pain relief during this first week is predictive of the rapidity of their response to the injection. If patients do not experience any relief of pain during that first week, they are much less likely to have complete relief of pain during week 2. Furthermore, patients who do not have complete relief by the end of week 2 are unlikely to have relief by three weeks. Conversely, patients who experience a partial relief of symptoms by the end of week 1 are much more likely to have an improvement over the ensuing weeks.In contrast to the trend seen in pain relief, the improvement in triggering seems to lag - fewer patients had an early (week 1) response and fewer patients had complete resolution of the trigger by week 3. Additionally, early improvement in triggering (or lack thereof) does not seem to be predictive of the speed of resolution. Even among the patients who did not experience complete triggering relief during the first one to two weeks, the vast majority had a partial or complete response by week 3.While there are many studies demonstrating the long-term effectiveness of corticosteroid injections for trigger finger, there is little prospective data that documents the time course of symptom improvement ,16,17-24Given the paucity of data on this topic, our results are valuable in counseling patients prior to their corticosteroid injection. Setting appropriate expectations has the potential to increase patient satisfaction while decreasing unnecessary phone calls and/or follow-up visits in the early post-injection period. Moreover, realistic expectations are important for the injecting surgeon as well. In a study of treatment strategies for trigger fingers, Zyluk and Jagielski found that early post-injection reevaluation led to increased surgery as compared to delayed or as-needed reevaluation . The oveThere are several limitations to our study. First, the volume of injectate was not standardized or recorded across all surgeons. While the surgeons in the study tend to use a total of 1-2 mL of injectate (combination of lidocaine and corticosteroid), we did not specifically record the volume injected into each patient so there may have been some variability. However, given that the volumes injected were relatively small, we doubt that some minor variability would have had a substantial impact on the results. Second, the type of injectate was not standardized across all surgeons. Given that corticosteroids vary in their rapidity of action and duration of effect, it is possible that this may have impacted our results . Third, We found that most patients experience relief of pain and triggering by week 3 after corticosteroid injection, though pain improved more rapidly and reliably than triggering within this time interval. We counsel patients that improvements in symptoms after corticosteroid injection for trigger finger can be delayed and that they should not be surprised if it takes a few weeks to see an effect. Understanding the timing of the effect of the injection may help to counsel the surgeon on the timing of surgical intervention.


Breast cancer surgery frequently causes deficiencies in shoulder functioning. The study pourpode is to identify risk factors for prolonged pain, reduction in function, and decrease in range of motion (ROM) in BC patients.A prospective cohort study was designed in a private hospital; between October 2018 and April 2019 with a follow-up of 6 months. Patients following BC surgery, were divided by arm morbidities, and the different risk facrors were evaluated using univariate analysis and logistic regression.p = .006), the size of tumors more than 1.4 ± 0.8 cm. compared with no morbidities 0.8 ± 0.9 cm. (p = .046), and breast reconstructions (p = .030). Risk factors for prolonged pain includes mastectomy (p = .006), breast reconstruction (p = .011), more than three dissected lymph nodes (p = .002), the presence of preoperative pain (p < .001), in-hospital pain (p < .001), axillary web syndrome (p < .001) and lymphedema (p < .001). Risk factors for decreased ROM were more than three dissected lymph nodes (p = .027), radiation (p = .018), and the size of dissected tissue (p = .035). Postoperative physical therapy appears to reduce the incidence of prolonged pain (p = .013) and regular physical activity may reduce long term functional disabilities (p = .021).A total of 157 patients were included in the study. Risk factors for functional disabilities included; pain levels during hospitalization NPRS 1.2 (±0.8) compared to patients with no disabilities 0.5 ± 0.7 (Upper arm morbidity following BC treatments affect up to 70% of the patients. Identifying the different risk and beneficial factors may improve awareness among physicians to refer patients to early rehabilitation programs and thus avoid chronic morbidity and improve the course of recovery.NCT03389204.The study was registered in Clinical trial with the ID number: The online version contains supplementary material available at 10.1186/s12885-021-08891-5. Breast cancer (BC) surgeries and treatments can cause arm morbidity that can progress beyond 2.5 years . The mosRisk factors for prolonged pain, functional and movement disabilities, can be varied including factors associated with the type and extent of surgery, as mastectomy and breast reconstructive surgeries cause more pain and limitations than lumpectomies . Non-surUpper arm morbidity significantly affects BC survivors’ ability to return to work , to fullThe treatment is usually combined according to complex decongestant therapy, from components of physical activity, adapted exercises, and for lymphatic patients elastic bandaging and lymphatic massage , 21..The aim of this study is to identify risk factors affecting the recovery of the arm in BC survivors, enabling a personalized treatment plan for patients at risk for arm morbidityClinicalTrials.gov; study identifier NCT03389204). All patients provided written informed consent before enrollment.A prospective trial was conducted in a single medical center in women that underwent BC surgery between October 2018 and April 2019. The trial was approved by the Institutional Helsinki Review Board- Assuta Medical Center  and was registered on the National Institutes of Health’s website , factors related to the type of surgical procedure performed, such as; the size and stage of the tumor, number of lymph nodes dissected, in addition to the effect of the different oncologic treatment administrated.The data collection and analysis were conducted by a single investigator and therefore without blindness.Primary outcome measures- The QuickDASH instrument  . Risk factors from the surgical report, the pathological report, oncological treatments and pain levels during hospitalization were taken from the medical record.p < .05.Statistical analysis was performed using the SPSS statistical package, Version 21 . The significance level was set at Sample size estimation was calculated using the PS Power and Sample Size Calculations software . QuickDASH instrument was the main outcome measure used to evaluated shoulder functional disability. QuickDASH score after BC surgery  . Nominal variables were evaluated by the chi-squared test; cancer grade, physical activity, job status, family status, type of surgery, type of oncological treatment, presence of lymphedema and AWS. Logistic regression was used in three different models to evaluate associations between the three outcome measures and a set of covariate variables as risk and beneficial factors. The three regression models examined the adjusted odds ratios (ORs) with confidence intervals (CIs) of 95%.A total of 188 patients were recruited to the study, of them 28 were excluded; one (3.6%) had a nonmalignant tumor, 17 women (60.7%) had previous breast surgery, five (17.9%) had limited shoulder ROM mostly rotator cuff tears, two (7.1%) had lymphedema, and three (11%) had fibromyalgia. Of 160 remaining patients, three did not complete the follow-up and therefore only 157 patients entered the study cohort.The patients mean age was 52.2 ± 12.9, with a mean BMI of 25.0 ± 4.4. Patients in both groups, with and without arm morbidity, were similar in values of age, BMI, cancer grade, level of physical activity family status, and type of job (Table p = .046). A higher percentage of patients after breast reconstructions had reported decreased function, nine (55.6%) compared with patients that did not undergo reconstructions 141 (33.3%), p = .030. In addition, patients with function disabilities 6 months postoperatively had reported higher pain levels during hospitalization, 1.2 ± 0.8, compared to patients with no disabilities, 0.5 ± 0.7 (p = .006), shown in Table Seven participants out of 157 lacked data and were therefore not included in the analysis. Risk factors for functional disabilities of the upper arm were found to be attributed to the tumor size, as patients with arm morbidity had bigger tumors 1.4 ± 0.8 compared to patients with no morbidities, 0.8 ± 0.9 (p = .006. Patients after breast reconstruction reported prolonged pain in higher percentage (45.3%) compared with patients without pain (25.3%), p = .011. In addition, patients that had reported prolong pain had a higher number of dissected lymph nodes 3.7 ± 3.0, compared to patients that did not report pain, 6 months postoperatively 2.4 ± 2.7 (p = .002) (Supplementary Table p = .026) (Supplementary Table p < .001). The two common side effects of surgery and treatments are lymphedema and AWS, when patients who suffered from these pathologies, reported prolonged pain in higher percentages compared to patients without these complications, p < .001 and p = .001, respectively.Ten patients had missing data and therefore not included in this analysis. The risk factors included mastectomy procedure in (46.9%) patients compared to lumpectomy (25.3%), p = .027). Radiation therapy resulted in a greater decrease in ROM 72.9%, compared with women who were not treated with radiation 53.7% (p = .018). The size of dissected tissue may be an additional factor as patients with decrease ROM underwent a bigger dissection 520.6 ± 662.7 compared to women without decrease ROM 389.6 ± 449.4 (p = .035).Two participants were not included in this analysis due to missing data. Relevant decreased ROM was contributed to a higher number of lymph nodes dissected 3.4 ± 2.8 compared to patients without movement limitation 2.6 ± 2.9 .Physical active patients had less functional disabilities, as only (33.3%) of the patients who reported functional impairment exercised routinely compared with (70.3%) women who had no functional impairment (p = .013).Providing physical therapy treatment during hospitalization and after discharge, might have a beneficial effect on arm function and pain, as from the painful women 64 (35.9%) received physical therapy treatments compared to 83 (56.6%) patients who receive treatment and had no pain (When we examined the three models in logistic regression very few factors were found to be significant in predicting risk for upper arm morbidity Table . Furtherp = .005) and preoperative function . Moreover, physical therapy may help reduce disability .The risk factors found for functional disabilities were preoperative pain , decreased function at 6 months , lymphedema  and AWS . Physical therapy may be beneficial in reduction of prolonged pain incidences .The risk factors found for prolonged pain were in-hospital pain higher than NPRS 1  radiation therapy , preoperative decreased ROM , preoperative decreased function  and at 6 months . Physical therapy as a beneficial factor . The different risk factors are summarized in Table Risk factors found for decreased ROM were lymphedema , instead of volume measurement and clinical diagnosis might not provide the precise prevalence of these diseases.The strengths of the study are in the broad examination of different risk factors that may affect recovery and, in an attempt, to bind the risk factors into models that were intended to predict risk for each morbidity separately .The morbidity of the arm 6 months after BC treatments affects up to 70% of the patients. In-hospital pain, breast reconstructions, and tumour size were correlated with long-term functional disabilities. Mastectomy, the number of lymph nodes removed, pain values in hospital, amount of drain secretion, preoperative pain, lymphedema, and AWS were found to be correlated with prolonged pain. Radiation therapy, the number of lymph nodes removed, and the size of the tissue were found to be correlated with a decrease in ROM. Furthermore, physical therapy may reduce incidence of prolonged pain and physical activity may reduce long term functional disabilities. Consequently, identifying risk factors with an early start of comprehensive physical therapy rehabilitation programs can improve the recovery process of BC patients.Additional file 1: Table 5. Risk factors of any arm morbidities using Mann Whitney and chi-squared test.Additional file 2: Table 6. Crosstab and OR divide by two age groups.Additional file 3: Table 7. Crosstab and OR divide by two BMI groups.Additional file 4: Table 8. Crosstab and OR divide by the mean amount in the drains.Additional file 5: Table 9. Crosstab and OR divide by the size of the tumor.Additional file 6: Table 10. Crosstab and OR divide by the number of dissected lymph nodes.Additional file 7: Table 11. Crosstab and OR divide by the mean pain reported during hospitalization.Additional file 8.


Treatment-resistant depression (TRD) and pain frequently coexist clinically. Ketamine has analgesic and antidepressant effects, but few studies have evaluated individual differences in antidepressant outcomes to repeated ketamine in TRD patients with comorbid pain. Our aims were to determine the difference in ketamine’s antidepressant effects in TRD patients with or without pain and then to examine whether inflammatory cytokines might contribute to ketamine’s effect.Sixty-six patients with TRD received six infusions of ketamine. Plasma levels of 19 inflammatory cytokines were assessed at baseline and post-infusion (day 13 and day 26) using the Luminex assay. Plasma inflammatory cytokines of sixty healthy controls (HCs) were also examined.χ2 = 4.062, P = 0.044) and remission rate  than patients without pain. Before ketamine treatment, GM-CSF and IL-6 levels were higher in the pain group than in the non-pain and HC groups. In the pain group, levels of TNF-α and IL-6 at day 13 and GM-CSF, fractalkine, IFN-γ, IL-10, MIP-3α, IL-12P70, IL-17α, IL-1β, IL-2, IL-4, IL-23, IL-5, IL-6, IL-7, MIP-1β, and TNF-α at day 26 were lower than those at baseline; in the non-pain group, TNF-α levels at day 13 and day 26 were lower than those at baseline. In the pain group, the changes of IL-6 were associated with improvement in pain intensity  and depressive symptoms  at day 13. Path analysis showed the direct  and indirect  effects of changes of IL-6 on improvement in depressive symptoms both were statistically significant.TRD patients with pain had a higher antidepressant response rate (This study suggested that an elevated inflammatory response plays a critical role in individual differences in TRD patients with or without pain. Ketamine showed great antidepressant and analgesic effects in TRD patients with pain, which may be related to its effects on modulating inflammation.ChiCTR, ChiCTR-OOC-17012239. Registered on 26 May 2017The online version contains supplementary material available at 10.1186/s12974-021-02245-5. Depression and pain frequently coexist clinically –4. The pAlthough patients with comorbid depression and pain are common in clinics, the pathogenesis remains unclear. The mechanism of the interaction between depression and pain is likely more complex than that of a single disorder and suggests that the overlapping pathogenesis might have a role in the development of these two common disorders, including abnormal glutamate signaling, excessive activation of inflammation, and decreased brain-derived neurotrophic factor (BDNF) –8. An abN-methyl-d-aspartic acid receptor antagonist with anesthetic and analgesic effects and has been used for acute pain for several decades. Recently, an increasing number of clinical studies have identified that a single subanesthetic dose of ketamine has a fast and robust antidepressant effect in patients with treatment-resistant depression (TRD) [Currently, some analgesics and antidepressants are being used to treat this comorbidity; however, sometimes, there is limited clinical remission , 18. Keton (TRD) , 20. Ouron (TRD) , consiston (TRD) . Ketaminon (TRD) , 24 and on (TRD) . In addion (TRD) .Based on evidence from previous studies, ketamine may be ideal for the treatment of comorbid chronic pain and TRD; however, few clinical studies have evaluated individual differences in antidepressant outcomes to repeated ketamine infusions in TRD patients with pain. Moreover, although plasma levels of inflammatory cytokines decreased after six infusions of ketamine administration based on our previous results from a patient cohort with TRD and/or suicidal ideation , the rolWe present a post hoc analysis of an original study designed to assess the antidepressant response of six adjunctive ketamine infusions in patients with TRD and/or suicidal ideation , 28. ThiThis study included 66 patients with TRD who received six doses of ketamine, along with 60 healthy controls (HCs) matched with patients for age and sex. The main inclusion criteria for TRD patients were as follows: diagnosis of major depressive disorder (MDD) established using the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria, age between 18 and 65 years, 17-item Hamilton Depression Rating Scale (HAMD-17) score ≥ 17 at screening without hallucination or delusion, and treatment resistance defined as the failure of two adequate antidepressant trials. The exclusion criteria included the presence of alcohol or substance dependence or any serious or unstable medical conditions, including neurological, endocrine, rheumatic, and infective diseases. Taking anti-inflammatory agents  also was an exclusion criterion in the current analysis, but there was no participant taking anti-inflammatory agents in the original study. Current psychotropic medication had to be stable for ≥ 4 weeks, and the same dose was maintained during the six-infusion period. Additional detailed information regarding these participants has been described in our previous studies , 28, 29.TRD patients received ketamine three times weekly for 2 weeks. The detailed study design and methods have been previously published , 28, 29.Depressive symptoms were assessed using the Montgomery-Asberg depression rating scale (MADRS) by clinicians at the pretreatment baseline, 24 h after each infusion, and again 14 days after the 6th infusion (day 26). A response was conventionally defined as a 50% or more reduction from baseline in MADRS score at 24 h after the 6th infusion (day 13). Remission was defined as a MADRS total score ≤ 10 at day 13.Pain intensity was measured using the Short-Form McGill Pain Questionnaire (SF-MPQ). The main component of the SF-MPQ consists of the sensory index, affective index, present pain intensity (PPI) index, and visual analog scale (VAS). The VAS was assessed at the same time point as the MADRS, but the sensory index, affective index, and PPT were assessed at baseline, day 13, and day 26. Based on the presence or absence of pain using the SF-MPQ, 33 (50.0%) TRD patients had pain symptoms at baseline.TRD patients provided blood samples at baseline, day 13, and day 26, and HCs provided only a single blood sample. Blood samples were collected into EDTA tubes between 8:00 and 10:00 AM after an overnight fast. The tubes were immediately stored at + 4 °C and then centrifuged (3000 rpm/min at + 4 °C) for 10 min within 1 h. The plasma was obtained and stored at − 80 °C.Plasma inflammatory cytokine levels were detected using the Human High Sensitivity T Cell Magnetic Bead Panel  performed with a Luminex 200 multiplex immunoassay system based on the manufacturer’s instructions. Nineteen cytokines, including interferon-inducible T cell alpha chemoattractant (ITAC), granulocyte-macrophage colony stimulating factor (GM-CSF), fractalkine, interferon (IFN)-γ, IL-10, macrophage inflammatory protein (MIP)-3a, IL-12P70, IL-13, IL-17A, IL-1β, IL-2, IL-4, IL-23, IL-5, IL-6, IL-7, IL-8, MIP-1β, and TNF-α, were quantified twice. The detailed detection process and interassay coefficients of variability have been described in our previous studies .Of the 66 TRD patients included, 5 (7.6%) lacked blood sample at day 26, three of them were in the non-pain group and two in the pain group. Thus, these data were analyzed based on the intent-to-treat with expectation-maximization algorithm interpolation method.t-test for continuous variables with a normal distribution and the chi-square test for categorical variables.First, baseline demographic variables and clinical symptoms between the groups (pain vs. non-pain) were statistically evaluated using Student’s d was calculated to measure their difference.Next, changes in MADRS scores, VAS, sensory index, affective index, and PPT over time and group differences were assessed using linear mixed models with group (pain vs. non-pain) and time  as factors. Baseline demographic and clinical variables that differed between the groups were entered as covariates. Bonferroni-corrected post hoc comparisons were used to calculate the group differences at each follow-up point. Cohen’s Then, group comparisons of baseline cytokine levels among the pain group, non-pain group, and HC group were examined using multivariate analysis of covariance (MANCOVA), with age, gender, and body mass index as covariates. Post hoc analysis was used to compare the differences within each group. We further compared the changes of cytokine levels from baseline to day 13 and day 26 between the two patient groups using linear mixed models, with their baseline levels as covariates. Bonferroni-corrected post hoc comparisons were used to calculate the group differences at day 13 and day 26, as well as the differing levels between baseline and day 13 as well as day 26 within each group. Prior to the analyses, data for inflammatory cytokines were natural log-transformed.Finally, linear regression analyses were used to further test whether the changes in depressive symptoms individually correlated with the changes in cytokine levels within each group and whether changes in pain symptoms correlated with the changes in inflammatory cytokine levels in the pain group. A mediation analysis using the process v2.15 in SPSS was used to investigate whether the relationships between changes in cytokine levels and changes in MADRS scores were mediated by the changes in VAS scores in the pain group.P-values < 0.05 were considered statistically significant. P-values were adjusted for multiple comparisons using false discovery rate correction.All statistical analyses were performed using IBM SPSS Statistics version 22, and At baseline, body mass index and years of education in the pain group were significantly greater than that in the non-pain group; other baseline demographic or clinical characteristics showed no statistically significant differences between the groups Table .Table 1t = 2.130, P = 0.037) and to depression remission  and had a higher response rate  and remission rate  than the patients without pain , time main effect , and group-by-time interaction . Significant reductions in MADRS scores were found at 24 h after the first infusion compared to baseline scores, and these reductions were maintained over the subsequent infusion period as well as on day 26 in both groups . The largest significant differences in MADRS scores between the pain group and the non-pain group were observed at the 3rd infusion (Cohen’s d = 0.490).The linear mixed model with MADRS scores showed a significant group main effect , sensory index , affective index , and PPI . In the pain group, large and significant reductions in VAS scores were found at 24 h after the first infusion compared to baseline and were maintained over the subsequent infusion period as well as on day 26 .The VAS, sensory index, affective index, and PPI scores at baseline are summarized in Table P < 0.05). Post hoc analyses showed GM-CSF, fractalkine, IL-10, MIP-3α, IL-13, IL-17α, IL-2, IL-6, and MIP-1β levels were significantly higher in both the pain and non-pain groups than in the HC group, but IL-4 levels were significantly lower in both the pain and non-pain groups than in the HC group (P < 0.05); IL-7 levels were observed to be lowly expressed in the non-pain group as compared to the HC group; GM-CSF and IL-6 levels were significantly higher in the pain group than in the non-pain group (P < 0.05), while there was no significant difference in the other 17 inflammatory cytokines between the pain and non-pain groups  and significant group-by-time interaction on GM-CSF, fractalkine, IL-1β, and IL-6 (P < 0.05), while no significant group main effects on any of cytokines . In the pain group, levels of TNF-α and IL-6 at day 13 and GM-CSF, fractalkine, IFN-γ, IL-10, MIP-3α, IL-12P70, IL-17α, IL-1β, IL-2, IL-4, IL-23, IL-5, IL-6, IL-7, MIP-1β, and TNF-α at day 26 were lower than those at baseline (P < 0.05); in the non-pain group, only TNF-α levels at day 13 and day 26 were lower than those at baseline . In the pain group, the changes of IL-6 levels were associated with the reductions in VAS  and MADRS  scores at day 13 and associated with the reductions in VAS scores at day 26 . Thus, the mediation model in the pain group was further explored at day 13. Path analysis showed the direct  and indirect  effects of the changes of IL-6 levels on reductions in MADRS scores both were statistically significant, indicating improvements in depressive symptom severity were partly dependent of the improvements in pain symptoms.In the non-pain group, linear regression analyses showed that none of the cytokine alterations was associated with the reductions in MADRS scores following ketamine treatment at day 13 or day 26 (all Three important findings of the present study are as follows: First, repeated subanesthetic doses of ketamine had significantly superior antidepressant effects in TRD patients with comorbid pain compared with patients without pain. Second, before ketamine treatment, TRD patients with comorbid pain had an elevated inflammatory response compared with patients without pain and healthy controls. Third, ketamine exerted greater effects on modulating inflammation in TRD patients with pain than in patients without pain.The present study showed that 50% of TRD patients had comorbid pain, consistent with previous reports that the comorbidity rate of chronic pain and depression was approximately 40 to 60% , 4. Our Pain adversely affects the treatment response and prognosis of depression and vice versa. Patients with comorbid pain and depression were reported to experience a worse response to analgesic therapy than those without depressive symptoms . PatientKetamine showed analgesic effects in patients suffering from acute and chronic pain, as well as rapidly robust antidepressant effects in patients with TRD. Several clinical studies have supported that subanesthetic doses of ketamine may be ideal for the treatment of pain and depression comorbidities. Subanesthetic ketamine can reduce depressive symptoms in chronic pain patients, even in patients with refractory neuropathic pain syndromes , 24. DaiA wealth of evidence supports the hypothesis that excessive activation of inflammation contributes to the pathophysiology of the comorbidity of pain and depression. Microglial activation in the hippocampus and thalamus was found in patients suffering from chronic fatigue syndrome who exhibited pain and depression using positron emission tomography scans , and micFurthermore, plasma levels of GM-CSF and IL-6 in TRD patients with pain were higher than those in patients without pain, reflecting that these patients are much more likely to suffer an elevated inflammatory response. A preclinical study also reported increased levels of the inflammatory cytokines IL-6, IL-1β, TNF-α, IL-4, and IL-10 in spared nerve ligation rats with a depression-like phenotype but not rats without a depression-like phenotype . Thus, aThen, we further analyzed whether alterations in inflammatory cytokines were related to individual differences in ketamine’s effects on comorbid TRD and pain. Results of the linear mixed model showed no significant group main effects on any of cytokines, while most of the 19 inflammatory cytokine levels decreased after six infusions of ketamine in TRD patients as reflected by their significant time main effects, consistent with our previous findings in depressed patients without controlling pain . These aNotably, anti-inflammatory IL-10 and IL-4 levels also decreased 2 weeks after the final ketamine infusion, which were significantly elevated in the pain group before ketamine treatment compared with healthy controls. These changes in IL-10 and IL-4 levels after ketamine treatment may be a result of the weakening of the CIRS response caused by decreased IRS activity. Similarly, our previous study found a significant decreased in a broad range of cytokines, also including anti-inflammatory IL-10 and IL-4 after 4 weeks of antidepressant treatment in patients with first-episode drug-naive MDD . A recenInterestingly, correlations between changes in IL-6 levels and both antidepressant and analgesic effects were found in TRD patients with pain at day 13; however, further analysis showed that ketamine’s analgesic effect mediated the association between decreases of IL-6 levels and its antidepressant effect. Previous studies have also suggested that ketamine can decrease the expression of inflammatory cytokines in MDD patients, but the results regarding the relationship between the changes in cytokine levels and antidepressant efficacy have been inconsistent , 47. CheThis study was associated with several limitations. First, the small patient sample size meant that it is impossible to perform subgroup analyses by the exact area of pain. Second, seven participants lacked inflammatory cytokine data at 2 weeks after ketamine treatment. The third limitation was that inflammatory cytokines were measured only in the peripheral blood, which does not directly reflect the inflammatory response in the brain. Finally, the absence of cytokine data in healthy volunteers at days 13 and 26 meant that we could not know how the inflammatory signatures of patients compare to healthy volunteer values at these points.Our study suggested that an elevated inflammatory response plays a critical role in the individual differences among TRD patients with or without pain. Ketamine showed great antidepressant and analgesic effects in TRD patients with pain, which may be related to its effect on modulating inflammation. Further preclinical studies to address the precise modulating inflammation mechanism of ketamine and future therapies based on such a mechanistic understanding can be developed to better serve those with TRD and pain comorbidity.Additional file 1: Table S1. Change in depressive symptoms and pain intensity in pain group and non-pain group. Abbreviations: MADRS, Montgomery-Asberg Depression Rating Scale; VAS, Visual Analogue Scale; PPI, Present Pain Intensity. Table S2. Baseline plasma levels of inflammatory cytokines in pain group, non-pain group and healthy controls. Abbreviations: ITAC, interferon-inducible T cell alpha chemoattractant; GM-CSF, granulocyte macrophage colony-stimulating factor; IFN, interferon; IL, interleukin; MIP, macrophage inflammatory protein; TNF, tumor necrosis factor; HCs, healthy controls. Table S3. Comparison of inflammatory cytokines levels between groups using linear mixed model analysis. Abbreviations: ITAC, interferon-inducible T cell alpha chemoattractant; GM-CSF, granulocyte macrophage colony-stimulating factor; IFN, interferon; IL, interleukin; MIP, macrophage inflammatory protein; TNF, tumor necrosis factor.


To investigate what effect decreased opioid prescribing following hip arthroscopy had on Press–Ganey satisfaction survey scores.A retrospective review of prospectively collected data was conducted on patients who underwent primary hip arthroscopy for femoroacetabular impingement between October 2014 and October 2019. Inclusion criteria consisted of complete Press–Ganey survey information, no history of trauma, fracture, connective tissue disease, developmental hip dysplasia, autoimmune disease, or previous hip arthroscopy. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy that occurred in October 2018. Prescriptions were converted to milligram morphine equivalents (MME) for direct comparison between different opioids.P > .05). Average opioid prescription dropped from 249.6 ± 152 MME  preprotocol to 108.6 ± 84.7 MME  postprotocol; P = .0002. There were no statistically significant differences in Press–Ganey survey scores between pre- and postprotocol groups (P > .05).A total of 113 patients met inclusion criteria, 88 preprotocol and 25 postprotocol. There were no statistically significant differences between groups with respect to patient demographics or intraoperative pathologies (A reduction in opioids prescribed after a hip arthroscopy is not associated with any statistically significant difference in patient satisfaction with pain management, as measured by the Press–Ganey survey.Level III, retrospective comparative study. The opioid epidemic was responsible for more than 46,000 deaths in the United States in 2018.,Existing literature has suggested that overprescribing is linked, at least in part, to a physician desire to mitigate poor patient satisfaction ratings, despite providing otherwise positive health care.Previous research by Kohring et al.The purpose of this study was to investigate what effect decreased opioid prescribing following hip arthroscopy had on PG satisfaction survey scores. We hypothesize that patient satisfaction would not change, despite patients being prescribed less opioid pain medication.This single-center, institutional review board–approved study involved the query of this institution’s electronic medical record for all patients who underwent primary hip arthroscopy for femoroacetabular impingement between October 1, 2014 and October 1, 2019.Inclusion criteria for this study were as follows: patients aged ≥18 years old on day of surgery who underwent primary hip arthroscopy for femoroacetabular impingement with an associated PG survey were included. Patients were excluded if they were outside the inclusion age limit, revision cases, had a connective tissue disorder, or whose hip problems were related to traumatic fracture. Patients were similarly excluded if they were enrolled in any research studies involving pain management, opioid consumption, anesthesia, or rheumatology. In addition, patients were excluded if data to be analyzed were missing. Following preliminary chart review, demographic information  was recorded. In addition, any information regarding previous surgery on an upper extremity was recorded.All patients were placed under general anesthesia before the start of the procedure. Surgery was performed by 1 of 3 authors . All patients underwent hip arthroscopy in traction, in the supine position. Typically, an anterolateral portal was made with fluoroscopy before a second, mid-anterior portal was made under direct visualization. Then, an interportal capsulotomy was performed to allow access to the central compartment for chondrolabral debridement or repair.When needed, an anterolateral accessory portal was made distally to assist in anchor placement for the purposes of labral repair. Cam-type lesion osteochondroplasty or acetabular rim trimming was performed if needed. Rarely, loose body removal or subspine impingement resection was performed, and only if needed. Chondral debridement was performed with electrocautery or shaver. Microfracture was not performed in any of these patients. At the conclusion of the procedure, capsular repair was conducted.Patients underwent hip arthroscopy in an outpatient setting. They were given a hip abduction brace so as to limit both hyperextension and external rotation and restricted to flat-foot weight-bearing on their operative extremity with crutch-support for the first 3 to 4 weeks postoperatively. Patients were discharged with 12 tablets of 500 mg cephalexin, taken every 6 hours for the first 3 days for infection prophylaxis. They were also given 7 tablets of 81 mg aspirin for venous thromboembolism prophylaxis, and they were given a 14-day supply of either Celebrex (200 mg daily) or Naproxen (500 mg daily) for heterotopic ossification prophylaxis. Patients were prescribed physical therapy with the goal of return to sports at 6 months after surgery.An opioid-sparse institutional protocol for perioperative pain management was enacted in October 2018, and before that, opioid prescriptions were surgeon-specific. In October 2018, a formal protocol was enacted, which included giving patients up to 20 tablets of oxycodone/acetaminophen 5 mg/325 mg.Patients responded to surveys, administered postoperatively by PG, via mail or e-mail. If surveys were not returned within 1 month, a second questionnaire was sent. These surveys consisted of a modified version of the Hospital Consumer Assessment of Healthcare Provider and Systems questionnaire survey. This survey is a multi-item, patient-focused instrument administered to evaluate patient satisfaction with their perioperative experience, which includes pain management.There were 4 survey questions of interest: (1) “degree to which your pain was controlled”; (2) “Nurses’ concern for your comfort after the procedure”; (3) “Explanation the physician gave you about what the surgery or procedure would be like”; and (4) “Information the physician provided you about what was done during your procedure.” These questions were scored in a Likert-type fashion, from 1 (lowest) to 5 (highest).The primary outcomes of interest in this study were the following: (1) Discharge opioid prescription quantity and (2) patient satisfaction with pain control, as determined by a Likert-type scaled response to the survey question “rate the degree to which your pain was controlled (1-5).” PG data were obtained from our institution’s PG representative. Postoperative opioid prescriptions were converted from milligrams or milliliters to milligram morphine equivalents (MME) for direct comparison between different opioids and were obtained from direct institutional electronic medical record chart review.Demographic data were analyzed and recorded from additional chart review, intraoperative pathology was similarly recorded from operative notes, and several other survey questions were analyzed for statistical significance. Patients were divided into 2 chronological groups, before and after protocol commencement, for comparison. These intervals included October 31, 2014 (date of first surgery) to October 1, 2018 , and October 2, 2018, to September 6, 2019. To add further validity to our data and existing body of literature on the subject, we duplicated the methods of Daniels et al.For the determination of clinical significance, the minimum detectable change (MDC) was calculated. The MDC value, the smallest difference in 2 scores that is considered larger than measurement error, is considered the most conservative estimate of minimal clinically important difference.2 analysis was used for dichotomous outcome analysis. χ2 analysis also was used to when Likert-type satisfaction data were reanalyzed as a dichotomous outcome. All statistical analysis was performed using GraphPad Prism 8.4 . Statistical significance was set at P < .05.All continuous data were initially tested for normality via a D’Agostino-Pearson test. Direct group comparisons for pain control and MME were performed with the nonparametric Mann–Whitney test, as the groups failed a D’Agostino-Pearson test for normality. In addition, χMDC was calculated with the accepted formula of standard error of measure × 1.96 × √2 where the standard error of measure is calculated as standard deviation × √(1 – r), where “r” is the test–retest reliability coefficient.2. Average opioids prescribed at discharge were 218.4 ± 151 MME over the study period. Average patient satisfaction with pain control was 4.77 ± 0.60 of a possible 5.A total of 115 patients were identified who underwent hip arthroscopy and had an associated, complete postoperative PG survey. Of those, 2 were excluded based on demographic information, medical history, or surgical indication. Average age of the overall cohort was 40.33 ± 13.1 years, with an average BMI of 25.33 ± 4.7 kg/mP > .05) between pre- and postimplementation of the formalized pain protocol.P > .05 for all). In addition, 89.8% (79) of patients preprotocol underwent labral repair, compared with 88.0% (22) postprotocol (P = .726). 12.5% (11) of patients preprotocol underwent labral debridement, compared with 16.0% (4) postprotocol (P = .739).P = .0002, power (1 – β) = 0.99. This was equivalent to a 56.5% reduction in average postoperative opioid prescription following hip arthroscopy.As seen by P > .05). The results of this analysis can be seen in When PG scores were separated into preprotocol and postprotocol cohorts and analyzed for statistical significance via Mann–Whitney test, there were no statistically significant differences in scores between groups  served as an ideal period because it allowed comparison before and after the implementation of institutionally imposed postoperative opioid prescribing guidelines. During the pre-protocol period, both federal and state regulations were instituted to reduce opioid prescribing. The New York State government passed legislation in 2016, which prevented providers from prescribing more than a 7-day supply of an opioid medication for acute pain. The United States government passed the 21st Century Cure Act in 2017, officially naming the ongoing opioid epidemic a national public health emergency.This institution’s protocol appears to have been very effective, as the mean volume of opioids prescribed significantly decreased after implementation. It is also important to recall the duration of study period, which suggests that these decreased prescribing patterns are durable, having persisted for at least 1 year.Previous research has suggested that one obstacle to the widespread implementation of decreased opioid-prescribing protocols is concern that narcotic reduction may lead to lower patient satisfaction scores.,Value-based purchasing initiatives incorporate patient perception of care into a reimbursement algorithm that then determines provider and hospital level compensation. The implicit relationship between patient pain, functional outcome scores, and patient satisfaction surveys has been previously researched. Rane et al.This is of substantial clinical significance to practicing hip arthroscopists for at least 2 reasons. First, previous work by Westermann et al.The results of our study demonstrate a 56.5% reduction in average postoperative opioid prescribing, somewhat larger than the 36.0% reduction associated with a study by Stepan et al.It is important to note that many studies are able to demonstrate a decrease in opioid use through a growing emphasis and implementation of multimodal pain management techniques as well as perioperative interventional pain management. In a systemic review published in 2018, Shin et al. analyzed published randomized controlled trials and comparative studies on pain control after hip arthroscopy.Thus, it stands to reason that there are viable alternatives to the opioid-predominant pain regimens, and that reductions in opioid-prescribing have no statistically significant impact on increasingly important patient satisfaction surveys. In addition, provider-focused opioid education may be a viable option to further reduce overall opioid prescribing at the institutional level and should be pursued. In addition, investigation regarding a multimodal and multidisciplinary approach to pain management after hip arthroscopy may potentially curtail opioid consumption even further, without jeopardizing patient satisfaction with pain control.This study is not without limitations. First is its retrospective nature. Second, our results are at risk for responder bias. Patients did not keep a diary nor record the actual consumption of narcotics. Next, there are possible ceiling effects of the survey. It is unclear how sensitive the survey would be to small changes in only the one domain, and how that could affect the results and analysis. Finally, we did not control for confounding variables  that are known to influence PG scores.A reduction in opioids prescribed after a hip arthroscopy is not associated with any statistically significant difference in patient satisfaction with pain management, as measured by the PG survey.