Total Knee Arthroplasty (TKA) is offered to patients with knee osteoarthritis (OA) in the oil-rich countries in the Gulf region without adequate understanding of their perceptions, preferences or pain experiences. This study aimed to explore the pain experience and mobility limitation as well as the patient’s decision making process to undertake TKA among women with knee pain in the waiting list for surgery.Five focus group discussions were conducted comprised of 39 women with severe knee OA from the waiting list for TKA in the only orthopaedic hospital in Kuwait. Discussions were recorded, transcribed and coded for themes to identify the factors considered to be important in decision-making for TKA.Experiencing knee pain was central to daily living and affected patients and their families. Mobility limitation was shaped by a strong sense of expected obligation to take care of the family. Two major sources of TKA delay were identified; one was due to late clinical advice to undergo TKA which was the result of receiving several consultations from different clinicians each of whom tried the medical management for OA. The second delay occurred after the clinical advice for TKA and was mainly due to ambivalence of patients because of fear of the operation and the lack of information about TKA that resulted in unclear expectations of the surgery.Both verbal and written information about TKA should be provided as part of preoperative rehabilitation. This is critical to improve doctor-patient interactions and facilitate informed decision about the procedure and thus achieve patient-centered healthcare. Knee pain is a major public health problem that causes considerable disability and impact on quality of life, particularly among elderly people. Most cases occur as a result of osteoarthritis (OA), a disease that is diagnosed mostly on clinical ground and is more common among women -3. It isCurrently there is no evidence-based medical treatment to stop or reverse the progression of knee OA and thus the available treatments focus on managing the pain and disability. Elective surgery of total knee arthroplasty (TKA) is recommended for patients with moderate to severe pain who do not respond to symptomatic therapy . The benTKA has been offered to patients in many countries in the Middle East and the Gulf region without adequate understanding of patients’ perceptions and preferences, and thus health care professionals may lack the contextual perspective necessary to identify what implications of disease and treatment outcomes are most important to patients with knee OA. Exploring pain experiences of patients with knee OA, as well as their perceptions and expectations of TKA would potentially improve the ability of health care professionals to provide effective and relevant care for the growing number of patients with knee pain in the Middle East and Gulf region. We aimed to conduct focus group discussions to study the pain experience and mobility limitation of patients as well as to investigate patient decision making to undertake TKA among women with knee pain in the waiting list for surgery. It was anticipated that this methodology would generate revealing comments and insights about the decision-making process as well as the social contexts in which patients make decisions, which are critical information to improve the outcome of the surgery.The study was conducted in Kuwait, a small-country in the Gulf region with a population of 3.5 million, two thirds of whom are non-Kuwaitis. Public health services are easily accessible particularly for Kuwaitis. There is one public orthopaedic hospital  that performs TKA with approximately 120 surgeries per year but there is also unknown numbers of TKA that are conducted abroad and small number in the private sector.Five focus group discussions were conducted in the orthopaedic hospital with female patients selected from the waiting list for TKA. Discussions were conducted sequentially in the hospital and were led by a local female facilitator who is a clinical psychologist and proficient in both English and the local Arabic dialect. The note taker was also a local Kuwaiti female. It was important to have a gender-matched facilitator since older women in this conservative society are unlikely to share their experiences in the presence of males. The group discussions were focused on the pain experience of patients and its impact on their social, emotional and physical lives as well as on the factors considered to be important in the decision-making process to undergo TKA. A question guide including eighteen questions with probes were developed in Arabic for use in the group discussions but one question was removed after the first group discussion due to redundancy (See the list below). The groups discussed the impact of knee OA in broad terms and then turned to the process of decision-making about the surgery.uestion guide used in focus group discussionsQElements of decision making /Perception of risk of surgery (Risk of complications/fear of surgery)Q13. Who suggested knee replacement as a treatment for your knee-pain?Probes: Doctor , friend, family members?Q14. Do you know anyone who has had knee replacement surgery?Probes: if so, how has talking with that person made you feel about knee-replacement?Q15. Other than your doctor, who else did you talk (consult) with on whether to undergo the surgery?Q16. What would you need to hear from your doctor that would make you agree to undergo a Knee replacement?Q17. When do you think a person with knee pain should decide to undergo knee replacement surgery?Knowledge and expectation of Knee arthroplastyQ8: What can clinicians/doctors do to help you with your knee pain?Q9: How successful do you think knee replacement is in terms of pain relief?Q10: How successful do you think knee replacement in terms of improved function/mobility?Q11: How long do you believe the prosthesis will last for?Q12: Where did you get your information about knee replacement?Living with knee pain/ impact of knee pain on patients and their relativesQ1: How do you feel about your knee pain?Q2: How has having knee pain interfered with your life?Probes: social, emotional, and physical?Q3: From what we have discussed so far, what bothers you the most about having knee pain?Q4: Is any member of your family affected by you having knee pain?Probes: If yes, who and how?Q5: What do you personally do to deal with your knee pain?Q6: How do you cope with your knee pain?Q7: Who do you think can help you with the knee pain?All focus group discussions were audio-recorded and transcribed verbatim using the audio-records and supplemented by the notes. The transcripts were checked against the audio-tapes for completeness and accuracy by another person. Each transcript was coded for themes by two researchers (AT and RS) who then met to compare themes and their organization, working out a set of final themes and subthemes by consensus. Analysis began with identification of key themes and patterns from the data using the process of coding that involved assigning labels to the different themes that emerged from each question. Transcripts were coded by assigning labels to segments of text in themes and then writing descriptive accounts based on these themes . Coding Before the start of each focus group discussion, permission to tape-record the interview was taken and a written informed consent was obtained from each participant. The study was approved by the ethics committee at The Faculty of Medicine, Kuwait University.A total of 39 patients participated in the group discussions; with a mean age of 62.5  years. The demographic characteristics of the participants in group discussions are illustrated in Table Pain was a predominant feature of daily living and many participants talked at length about their pain experiences. Participants described their knee pain more than any other issue using such strong expressions as “horrible” or “a complete destruction”. One participant noted, “Horrible pain, you cannot imagine it, I mean unbearable I live only on painkillers which started to hurt my stomach but without these painkillers I just cannot live.” (77-years-old woman).The use of painkillers and other methods of pain relief were mentioned in every group discussion, most of the time linked with the participants’ fear of the side effects of these analgesics on their stomach, blood pressure, and kidneys, or even fear from becoming dependent on the analgesics. Participants described all kinds of pain management from using tablets and injecting medicines into their knees to acupuncture, and electrical therapy or seeking help from traditional healers. The duration of knee pain was very long for many patients who reported having pain for more than 20 years. Many participants described how pain has interfered with their sleep (14 participants in five groups) and that they must take large amounts of painkillers in order to have a restful sleep. The psychological impact of knee pain was obvious among participants many of whom started crying when they described their pain experiences (six participants in four groups). Some participants described how they turned to religion and reading Holy Quran. They asked God for help, and when they felt hopeless about improvements in their pain asked God to take their lives. Some participants felt more reassured explaining their belief that God would reward them because of their suffering. Participants also described how they distract their attention away from their pain by talking with relatives over the phone or requesting the company of their grandchildren. As one participants said,“I ask my grandsons to come, I call my daughters and ask them to bring their kids, I try to distract my attention from pain with them. The daughter of my son is 2 month old I want her to be beside me so that I forget the pain.” (48-years-old woman)Of note is that most of the participants viewed knee pain as an illness that has its causes about which they asked the moderator. They talked about possible causative factors such as obesity (two participants in one group), food (one participant in one group), sedentary life style (one participant in one group), genetics (one participant in one group) or even evil eye (two participants in one group). Only one participant cited that her pain has increased with age but none described their knee pain as part of normal ageing.Pain was strongly related to mobility restriction, which was a major theme in all group discussions. Mobility restriction was severe among these groups of patients, has lasted for a long period, and affected their daily activities and social life such as attending social events like weddings. Some participants have not climbed a flight of stairs at their homes for more than 10 years and many were unable to go to the bathroom alone. Fear of falling was also common among participants (eight participants in five groups) who refrained from movement because they had experienced falling several times. Although many participants have domestic helpers, inability to do the household chores was a concern for several participants (nine participants in four groups).The experience of mobility restriction was shaped by their feeling about their roles as housewives or mothers who are expected to take care of the family. One participant noted while she was crying, “I have a 19-year old disabled son whom I used to take care of; now I sit helpless beside him; now we are both disabled”. Another participant was in sorrow as her two disabled children stay at home because she is physically unable to take them out. Another participant was not happy because her husband started helping her and she is not able to pick her children up from school. Despite their pain and mobility limitation, participants continued serving their husbands and taking care of their children but felt helpless or less valuable when describing their failure to fulfill their felt obligations towards their husbands or children; with two participants expressed their acceptance for their husbands to remarry. The other activity, which participants valued most, was praying which all participants continued to perform albeit sitting down on a chair.Family was an important element in both pain experience and mobility limitation of patients. When participants were asked about persons who help them whenever they experience knee pain, all participants mentioned their sons, daughters or husbands. Participants described in detail how their daughters and sometimes husbands persistently offer help. Participants also described how their sons and daughters or even grandchildren react every time they saw them suffering from knee pain. Sons and daughters bring them everything they need without request and grandchildren urge their parents to take the participants to the doctor. Some participants reported that their sons and daughters do not go to work when the participants have a lot of pain and another participant described how her daughter withdrew from her university course so as to be available for her care. Two participants talked at length about the support they received from their husbands while another participant was in sorrow because her husband let her down and did not support her. Furthermore, social life and leisure activities of the whole family were affected because families opted against going out and leaving the participants at home alone. Participants described how their young children and teenagers cannot go out without supervision and thus had to stay at home most of the time; with girls who prefer to go out with their mothers, are particularly affected. What can be drawn from this is that pain and mobility limitation experienced by participants affected their families; and that family support was a critical factor in the coping with the pain.Participants brought up their past-medical treatment several times during the discussions. They mentioned all different kinds of pain management from tablets to acupuncture. Some participants described taking expensive injections. Participants judged their past-medical treatment as an overuse of painkillers and pain management procedures and as a waste of time and money. Pathways of care in this group of patients also included consultation in neighboring countries including Bahrain, Syria, Dubai, Saudi Arabia, Jordan and other countries. Nine participants in four groups talked about at least one consultation abroad. Most of these consultations occurred when patients accompanied their families for holiday abroad; and resulted in receiving recommendation for TKA but none of the patients followed the recommendation at that time. As one participant said “I have only one son who took me almost to every country. He took me to Syria, Bahrain, Jordan, German Hospital in Jeddah and wanted to take me to Dubai to have the operation done”.Pathway of care showed that participants had received the advice to undertake TKA at least once locally and once abroad but this was very late and came after a long and unnecessary suffering from their perspective. There was consensus that the medical advice to undertake TKA was very late. One participant said "they wasted our life, they should have told us to have the operation from the beginning" while another noted “doctor do not advise their patients to undertake the operation until the knee is completely destroyed then they give their advice”. More illustrative quotes on the doctors’ advice are shown below. Part of the delay in medical advice to have TKA came from the fact that patients sought second, third and probably fourth opinion on their OA from different clinicians who failed to consider the treatment which patients had received from previous clinicians and thus started another trial of painkillers; as one of the patients put it “every doctor wants to try from the beginning to see if we need surgery”.Although there was delay in clinicians’ recommendation for surgery, further and even longer delay was caused by the participants’ deliberation on whether to undergo the operation. Factors that caused this delay are interlinked and include: a) Fear of the operation b) Seeking the encouragement and approval of family members on whether to have the operation, and if so, abroad or locally c) Lack of information about the procedure and the outcome d) Frequent consultations whereby every clinician tried medical treatment without considering the outcome of past medical treatment.Participants’ fear of the operation was a strong reason for delaying the operation even after they received the clinical advice for arthroplasty. Twenty-six participants in five groups have mentioned fear of the operation which was either related to fear of the operation itself, the anesthesia, pain after the surgery or fear that the operation may not produce the hoped outcome. One participant described how her excessive fear of undergoing a previous surgery to remove a tumor caused her blood pressure to be extremely high and as a result, was sent home without having the surgery. Fear of the operation was exacerbated by the fact that some clinicians advised against knee arthroplasty because they wanted patients to exhaust all possible non-invasive medical treatments (See quotes below). As a result, patients remained anxious and doubtful about the surgery, even though clinicians changed their minds and recommended the surgery when patients did not respond to the medical treatment.Facilitator: Is there anything that doctors can do to help?W1: They do not recommend the operation! They don’t recommend the operation! Straightaway physiotherapy, go and do electrical massage or injections; can you imagine I feel I am dying.W2: Four years ago I consulted a private doctor, first he advised me not to have the operation and to be away from it, my family wanted to take me to Germany ….he advised me not to have the operation even if I have to walk on cane stick when he realized there is no hope he said now you have nothing other than the operation!W1: For 20 years he has not recommended the operation!W3: For 30 years he has not recommended the operation!W4: No he advised me to have the operation from the beginning, the visiting doctor said it is necessaryQuotes from another focus group:W1: Doctor does not recommend the operation, he does not say straightaway to the operation!W2: Yes, he does not say straightaway to the operation!W3: We recommend this, they should recommend the operation before other disease comesW1: Yes. . .yesFacilitator: Do you agree …W3: ExactlyW1: Yes rightW4: wait until our life is over!When the participants were asked about those with whom they had discussed the possibility of having TKA, the majority of the participants mentioned their sons, daughters and husbands. One participant said her sons were not happy that she was going to have the operation because they believed she is too old. Another participant said that initially her husband was against the operation asking her to wait until new advancements in medicine occur but changed his mind when he saw the successful outcome among those who had TKA. There was a long debate within the participants’ families on whether to have the surgery at all and, if so, whether to have it done locally or abroad.Many participants knew someone who had TKA and some of whom were their own relatives (23 participants in five groups). People who had the operation were mentioned as a source of information and their experience was brought up several times. All participants cited positive experiences of people who had undergone the operation. A participant described a success story of a woman who, after the operation, is now able to climb the stairs to reach her flat on the fifth floor while another participant cited a story of a woman who is able to walk around the Ka'aba in Mecca (i.e. some of the steps involved in the Islamic Pilgrimage to Mecca). Many others cited positive and encouraging experiences of other patients. Of note is a participant who was advised against having TKA from a lady in a wheelchair who had the prosthesis that failed after 20 years. Instead of being discouraged, the participant became more positive about having the surgery because of her new understanding that the prosthesis lasted for 20 years. Knowing someone who had knee arthroplasty increased the knowledge of the participants about the procedure and raised their expectations about the positive outcome of the surgery.As mentioned above, there was a delay of years between the clinical recommendation for TKA and the decision to undertake the procedure because patients were ambivalent about TKA. Participants attributed this indecisiveness to the poor quality of clinical advice, which did not include explanations of the expected outcome in terms of pain relief, improved mobility or the life-expectancy of the prosthesis. Some participants noted a difference between private and public sector doctors in the way they explain treatment options to patients. They explained how clinicians in the public sector simply ask "do you want the surgery or not", and do not provide any written or verbal information about the surgery. Most participants gleaned their information on TKA from those who had previously experienced it and this took time to occur and caused substantial delay. Participants on the waiting list had many unanswered questions about their upcoming surgery and sought the answers from the moderator. It was surprising to find that participants expressed full trust in their surgeons but at the same time expressed a strong sense of dissatisfaction with the insufficient amount of information provided by their surgeons. One participant said “you have to ask and persist in order to get any piece of information”.When the participants were asked about their expectations from the surgery, their answers ranged from “Do not know” to “God knows”, or citing the positive experiences of those who had TKA. The experience of those who had TKA appeared to improve the participants' expectations of surgery. As mentioned above one participant knew a patient who is able to climb stairs and another knew someone who went to Mecca and were able to complete their religious practices. Other participants had modest expectations from surgery such as walking short distances without pain or going to the bathroom alone. One participant had asked the surgeon about whether she can pray-which requires kneeling- after the operation without siting on a chair. Overall, lack of information has contributed to poor and non-specific expectations of TKA among the participants.This is the first qualitative study that has attempted to describe the pain experiences of women with advanced OA and their expectation of TKA in the Middle East or the Gulf Region. Given the ageing population and the increasing prevalence of obesity in the area, the morbidity associated with knee osteoarthritis is expected to increase. It has also been suggested that women delay seeking arthroplasty until a later point in the process of functional loss ,29. Our Unlike the underlying cultural concept of ageing in the Western societies, which accepts knee pain as an inevitable part of the normal ageing process that does not require professional medical treatment , our parPatients described their pain experiences showing that pain has interfered with their sleep which is consistent with previous studies that showed sleep disturbance is common among patients with OA ,36. It hIn the current study, patients’ pain experiences and mobility limitation was shaped by strongly felt obligation towards their families. Participants felt less valuable or helpless when they thought they failed at their obligations towards their husbands or children. Like other studies that described the desire of patients with knee OA to carry on with valued activities even with the presence of pain , particiThe pathway of care showed the presence of two major delays with distinct causes before the participants were able to reach a final decision to undergo TKA. The first delay was caused by late medical advice to undertake TKA. There was a consensus that the medical advice was late and came after a long time of unnecessary suffering. Participants felt that the threshold of pain and loss of function at which the knee surgery should be done- described sometimes as breakpoint experience - had beeThe second delay came after the medical advice to undergo TKA due to the patients’ extended period of indecisiveness regarding the procedure. Patients attributed this lengthy time of thinking to the poor quality of advice that was not accompanied by explanation about the procedure and its outcome. Fear of the operation itself and fear of poor outcome which has been described to be common among women , has conDoctor competency or doctor trust was not an issue in deciding to undergo TKA although this may be because of selection bias as all participants were from the waiting list for TKA. Despite the complete trust in their surgeons, participants expressed dissatisfaction with the insufficient amount of information they were given or that they were not listened to. Women elsewhere have emphasized good listening as a quality of a good doctor . Unlike The purpose of focus group discussions is usually to generate revealing comments and insights about a topic in a spontaneous but focused conversation among strangers. Our findings cannot be generalized to all patients with knee pain in Kuwait because the study focused on a relatively homogenous group of Kuwaiti female patients living with advanced OA recruited from a specialized orthopedic hospital. They cannot also be generalized to patients with early symptoms of knee OA or those who seek TKA in private hospitals or abroad.Our findings emphasize the need for improved doctor-patient interactions and highlighted several factors in the pathway of care of patients with chronic knee pain including seeking multiple clinical opinions both locally and abroad and the lack of patient education, which is a significant part of preoperative rehabilitation. The provision of both verbal and written information around TKA seems to be critical to improve patient understanding of the risks and benefits of TKA and allows patients to make an informed decision about the procedure and thus achieve patient-centered healthcare.The authors declare that they have no competing interests.AT: Designed the study, wrote the grant protocol, analyzed the data and drafted the paper. RS: Contributed to the study design, data collection, data analysis and revised the manuscript for important intellectual content. ES: Contributed to data collection, data collection, data analysis and revised the manuscript for important intellectual content. DS: Contributed to data collection, data collection, data analysis and revised the manuscript for important intellectual content. SM: Contributed to data collection, data collection, data analysis and revised the manuscript for important intellectual content. All authors read and approved the final manuscript.


Assessment of pain in children is an important aspect of pain management and can be performed by observational methods or by self-assessment. The Faces Pain Scale-Revised (FPS-R) is a self-report tool which has strong positive correlations with other well established self-report pain intensity measures. It has been recommended for measuring pain intensity in school-aged children (4 years and older). The objective of this study is to compare the concordance and the preference for two versions, electronic and paper, of the FPS-R, and to determine whether an electronic version of the FPS-R can be used by children aged 4 and older.The study is an observational, multicenter, randomized, cross-over, controlled, open trial. Medical and surgical patients in two pediatric hospitals  provided self-reports of their present pain using the FPS-R on a personal digital assistant (PDA) and on a paper version. Paper and electronic versions of the FPS-R were administered by a nurse in a randomized order: half the patients were given the PDA version first and the other half the paper version first. The time between the administrations was planned to be less than 30 minutes but not simultaneous. Two hundred and thirty-seven patients were enrolled; 35 were excluded from analysis because of misunderstanding of instructions or abnormal time between the two assessments.s = 0.911 (p < 0.0001). The mean difference of pain scores was less than 0.1 out of 10, which was neither statistically nor clinically significant; 83.2% of children chose the same face on both versions of the FPS-R. Preference was not modified by order, sex, age, hospitalization unit , or previous analgesics. The PDA was preferred by 87.4% of the children who expressed a preference.Final population for analysis comprised 202 children. The overall weighted Kappa was 0.846  and the Spearman correlation between scores on the two versions was rThe electronic version of the FPS-R can be recommended for use with children aged 4 to 12, either in clinical trials or in hospitals to monitor pain intensity. The advantages of data collection in health care using hand-held and notebook computers and personal digital assistants (PDA) are now widely recognized and exploited. These advantages include their ability to capture and transmit immediate (momentary) rather than remembered ratings, reducing recall bias; elimination of the common tendency to omit ratings and backfill them later; a built-in timestamp to ensure accurate recording of the time each rating was made; and preference on the part of most patients for electronic compared with paper-and-pencil measures -3. ElectWithin the specialized field of pediatric pain assessment, several research groups have independently programmed electronic devices to obtain patients' self-reports of pain intensity -12. Somehttp://www.painsourcebook.ca is a self-report scale to measure pain intensity in children aged 4 years or older. To use a faces scale, children need not be able to estimate quantities using numbers  or distances , but must simply be able to match their pain intensity to one of several pictures of a face showing expressions of varying degrees of pain [To evaluate these electronic pain scales, a starting point is to compare them with their non-electronic versions. The Faces Pain Scale - Revised (FPS-R) ,14http:/ of pain ,16 The F of pain .In the present study, hospitalized children rated their own post-surgical or disease-related pain using the original paper-and-pencil FPS-R, as well as an electronic version of the FPS-R. Concordance and preference for the two versions were compared and associations of scores on the respective versions with age and sex were assessed.Faces scales are well-established for children 5 years and older. There is debate about whether preschool-age children can give meaningful self-reports on pain scales ,19. ThusThis is an observational, multicenter, randomized, cross over, controlled, open trial. In France, ethical approval for this type of study , is still not legally required. Nevertheless this study was conducted following ethical rules with respect to parental consent, voluntary participation and confidentiality.Participants were recruited from two hospitals in Paris, France. Inclusion criteria were as follows: age 4 to 12 years; hospitalized in surgical or medical wards; presenting a pain condition (post-operative or disease-related pain); no analgesics administered within 30 min before assessment (except constant infusion); willing to participate. Exclusion criteria were as follows: not able to communicate verbally about their pain; too sedated to respond to questions; emergent or unstable acute pain .http://www.painsourcebook.ca. The original scale on paper consists of 6 drawings of faces, arranged in a horizontal row, with a neutral face at the left (scored 0) and the maximum pain face at the right (scored 10).The patients were instructed by a pain specialist nurse using standard French language instructions on how to use the Faces Pain Scale - Revised  as shownThe six faces were reproduced in the same size in a paper version and in an electronic version on a personal digital assistant (PDA), a PalmOne Zire™, as shown in Figure When the child was first presented with the electronic version, a small version of the six FPS-R faces could be seen at the bottom of the screen but no large face was displayed. When the child pressed (with a finger or stylus) one of the small faces at the bottom, that face was displayed in larger format, together with a plus sign at the right (except for face 10/10) and a minus sign at the left (except for face 0/10). In a 1- to 3-minute period of familiarization with the device, the child was asked to scroll back and forth through the faces by touching the plus and minus symbols on the screen or the small faces in the 6-face display at the bottom. In the present study there was no specific requirement that all of the 6 large versions of the faces be displayed before the actual pain ratings were made, but the full FPS-R scale was visible continuously in the small version, providing a reference to the anchor points. When they said they were ready, participants chose one face corresponding to their current pain intensity. The screen then requested confirmation of the face selected, and a reply (yes or no) had to be given.Following information and consent of the study, parents were permitted to stay in the room if they wished, but were asked not to discuss the pain ratings with their child. Other persons were asked to leave the room during data collection. The paper and electronic versions of the FPS-R were administered by a nurse in a randomized order: half the patients were given the PDA version first and the other half the paper version first. The time between the administrations was planned to be less than 30 minutes but not simultaneous. The PDA directly recorded the child's response on the electronic version. For the paper version of the FPS-R, after the child indicated a choice of face, the nurse recorded that response. For both versions, the child was asked to point out the face that showed no pain and the face corresponding to maximum pain, in order to ensure that the child could understand the scale; if they did not, the instructions were repeated as needed. The PDA recorded the time for each score. The nurse then asked the child which version she or he preferred, and recorded the preference.Participants were required to be stable with respect to pain management. In those cases where self-reports indicated severe pain, rescue analgesia or stepped up analgesia was administered as soon as possible while the second assessment was done.In the present study, hospitalized children rated their own post-surgical or disease-related pain using the original paper-and-pencil FPS-R, as well as an electronic version of the FPS-R. Concordance and preference for the two versions were compared and associations of scores on the respective versions with age and sex were assessed.N = 204.A calculation of power and sample size was performed for the difference between paired mean scores on the electronic and paper versions of the FPS-R. Assuming a minimum difference of 1 out of 10  in the mThe random allocation sequence was generated by computer on block size of 4.Statistical analysis was carried out using using SAS version 9.2. Patients' characteristics were tested by non-parametric tests. The difference between PDA and Paper scores was calculated and compared to 0 using a non-parametric test. Agreement between the two methods was assessed by a Kappa statistic weighted by Cicchetti-Allison's procedure. Symmetry for cell proportions used Bowker's test (extending McNemar's test for tables larger than 2 × 2). General characteristics and results on scores were compared for factors likely to impact the results: assessment order, patient's origin (surgery or medicine), sex, and age.The study, including 237 patients, was performed in two pediatric hospitals in France. Thirty-five patients were lost to analysis because of the following reasons: time intervals between the two assessments exactly equal to 0 min. or exceeding 30 min.; misunderstanding of the instructions to use the scale .n = 60 (29.7%); 7 to 9 years, n = 66 (32.7%); and 10 to 12 years, n = 76 (37.6%). Most of the patients came from the surgical department (82.2%). The remainder were medical patients. Eighty percent (80.2%) of the patients were receiving analgesics, without statistical difference between randomized order (p = 0.48) when they were assessed.The final population comprised 202 children: 104 started with the electronic version and 98 with the paper version. Patients' characteristics are displayed in Table The mean time interval between assessments was 13.1 ± 5.5 minutes (range: 1 - 28).There were no statistical differences in patients' characteristics between the two randomized groups whether they were first assessed by paper or with the PDA device, except for patients treated in the surgery ward who received significantly more level 3 analgesics.The mean levels of the pain scores were 3.1 ± 2.3 and 3.2 ± 2.3 for paper and PDA scores respectively, with no difference related to the assessment order. The mean absolute discrepancy between the two versions was not statistically different significant from zero .The relationship between scores on the paper and electronic versions of the FPS-R is depicted in Figure To analyse preference, 20 patients who did not express a preference between electronic versus paper forms were excluded from the analysis for this specific issue. For the other 182 patients, the PDA was preferred over the paper version by 87.4% , preference, status, age group, and sex. The results are presented in Table Significant statistical differences in the level of pain scores were observed in some subgroups of patients without difference between the two methods: patients hospitalized in medical wards had higher pain intensities  than those in surgical wards . Older patients had higher pain intensities than younger patients.A post hoc analysis was carried out to assess the ability of 4 year olds to assess their pain with the FPS-R. For the 13 patients of the study aged 4 years, the kappa reflecting agreement between electronic and paper version was 0.861, while for children over 4 years (n = 189) it was 0.844.The mean score on the PDA was 3.54 for the 4 year olds while for the older children it was 3.19. The mean scores for the paper version were 3.38 versus 3.11 for the younger and the older children, respectively. These differences were not significant.Among the 4-year-olds in the sample, 77% (10/13) had exact agreement of the paper with the electronic scores, compared with 84% (158/189) for all other ages combined.The object of this study was to compare an electronic and paper version of the FPS-R as measures of pain intensity in hospitalized children aged 4 to 12 in medical and surgical departments. Validation of the electronic version of the FPS-R as a measure of pain intensity was not carried out.The Faces Pain Scale - Revised was adapted for administration using a personal digital assistant . The electronic and paper versions were administered to hospitalized children. In all age groups and in both sexes, scores on the two versions were similar. The mean difference of 0.08 between pain scores on the two instruments fell far below the minimum clinically significant difference of approximately 1 out of 10 reported for children using visual analog scales by Powell et al. . MedicalIn all age groups and in both sexes, the electronic version was preferred to the paper version by most patients. Does children's strong preference for the PDA over the paper version translate into better compliance with the PDA? A randomized experiment by Palermo et al.  showed tOf particular interest is that the concordance between the electronic and paper versions, both in terms of Kappa value and low mean difference, was as strong among 4-year-olds as among all other ages within the sample, suggesting that even the youngest children utilized the two versions as reliably as older children.The results are consistent with those of other investigators. Specifically, Gulur et al.  comparedThus the present data provide further evidence for the concordance between the two versions and acceptability of an electronic version of the FPS-R based on high Kappa values (> 0.80), and low mean differences , and strong preference in comparison with the paper version. Separate studies are needed to establish its usability  and feasA principal limitation of the current study is that data on the underlying clinical conditions of the participants and their previous experience with pain and with pain rating scales were not collected. Such data would establish more clearly the generalizability of the findings, and could help to understand the difference in mean pain scores between medical and surgical patients. A further possible limitation is the restricted range of pain intensity. Most patients (80.2%) were receiving analgesics which could explain the relatively low pain scores . However, pain intensity did not affect concordance between the PDA and paper versions of the FPS-R. Implementation of PDA-based clinical data collection is not without some perceived and real disadvantages . PDAs arPending further evidence of usability and feasibility, some practical advantages of the PDA scale can be summarized. Clinicians can carry a PDA in their pocket and it can contain many other resources such as medication dosage charts and other reference information. Individual patient pain trajectories over time can be recorded and displayed on the PDA, allowing clinicians and patients to identify patterns of pain requiring analgesic adjustments. Direct access to recorded pain scores would eliminate the bias to report greater pain in retrospective reports for pain over past time periods, which is an important consideration during clinical consultations.A promising development which may occur in the near future would be adaptation of the FPS-R and other scales for use on cellular telephones, which are increasingly being designed with PDA features ('smartphones'). This would enable patients who are at home with longer-term pain (post-operative or chronic) to have pain diaries and to transmit the information easily by telephone to the clinic ,26. An aValidation would include showing expected response to pain-producing and pain-relieving events, showing concordance with other self-report and observational pain scales, and showing the expected trajectory of healing over time . These rBased on the present results, the electronic version of the FPS-R can be recommended for use in clinical trials of analgesics and other pain-related variables in children from 4 through 12 years of age. The advantages of electronic administration, in terms of technical reliability, reduced recall bias, convenience of data acquisition and processing, and patient preference, are expected to be seen with use and further adaptation of this new technology.PDA: personal digital assistant; FPS-R: Faces Pain Scale-Revised; CI: Confidence Interval; WHO: World Health Organization.The authors declare that they have no competing interests.CW had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study design: CW, SF, CvB. Acquisition of data: CW, DA. Analysis and interpretation of the data: DM, CvB, CW, SF, DA. Manuscript preparation: CvB, CW, VL, DM. All authors read and approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/11/87/prepub


Acute pain after axillary lymphadenectomy is often related mainly to axillary surgery. The aim of the prospective randomized study was to find out if continuous wound infusion of local anaesthetic reduces postoperative pain, consumption of opioids and the incidence of chronic pain compared to the standard intravenous piritramide analgesia after axillary lymphadenectomy in breast carcinoma patients.Altogether 60 patients were enrolled in the prospective randomized study; half in wound infusion of local anaesthetic and half in the standard (piritramide) group.In the recovery room and on the first day after surgical procedure, the wound infusion of local anaesthetic group reported less acute and chronic pain, a lower consumption of piritramide and metoclopramide, but their alertness after the surgical procedure was higher compared to the standard group.After axillary lymphadenectomy in breast carcinoma patients, wound infusion of local anaesthetic reduces acute pain and enables reduced opioid consumption, resulting in less postoperative sedation and a reduced need for antiemetic drugs. After wound infusion of local anaesthetic there is a statistical trend for reduction of chronic pain. The sense of pain is an individual experience; it depends on pain memories and present circumstances.i.e. vomiting, respiratory depression or cardiovascular instability, compared to morphine.Patients who develop pain or paraesthesia are at risk of progression to chronic pain syndromes. Five years after axillary dissection, as many as 30% of patients continue to experience symptoms.Patients listed for axillary dissection because of breast cancer were screened preoperatively during the routine anaesthetic assessment. Allergies to local anaesthesia, male gender or dependence on analgesics were the criteria excluding patients from our study. Female patients undergoing breast cancer surgery with axillary dissection were randomized into a group having a wound catheter with elastomeric pump, or into the standard piritramide treatment group. From December 2010 to July 2011, a total of 60 patients were enrolled: 30 patients in the test group and 30 in the standard group.The study was reviewed by the appropriate Ethics Committee and performed in accordance with the ethical standards laid down in an appropriate version of the 1964 Declaration of Helsinki. Our study was approved by the Institutional Review Board and conducted with the understanding and consent of the involved human subjects.The surgical procedure was performed during general anaesthesia. Anaesthetic technique for all the patients was the same. All of them received a single prophylactic dose of antibiotic before the beginning of the surgical procedure. Patients without diabetes received 4 mg of dexamethasone. All patients were given 1 mg of granisetron in order to prevent nausea. Before the end of the surgical procedure, all patients received our standard analgesic infusion mixture, which contained 7.5 mg of piritramide, 2.5 g metamizole and 10 g of metoclopramide.Before wound closure, 30 patients, who were randomized into the test group, received a fenestrated wound catheter, which was placed into their wound cavity near to the axillary vein and upon the whole length over the upper side of the wound. The wound catheter was fenestrated in the distal part, 15 cm in length. A bolus of 15 ml of 0.25% levo-bupivacaine was injected in the wound through the catheter immediately after wound closure. Soon after the administration of bolus, the elastomeric pump was connected to the wound catheter.Surgical drains and the fenestrated catheter were clamped for five minutes after the administration of levo-bupivacaine in order to enable the absorption of levo-bupivacaine from the bolus. After five minutes, clamps on surgical drains were released in order to evacuate seroma. After another 15 minutes, the clamp on fenestrated catheter was also released, enabling a continuous infusion of levo-bupivacaine. The amount of the local anaesthetic in the elastomeric pump was 100 mL at the flow rate of 2 mL per hour. The catheter was removed 50 hours later, when the elastomeric pump reservoir was empty.i.e. those who received the standard intravenous piritramide treatment, were on a continuous intravenous infusion with piritramide (30 mg), metoclopramide (20 mg) and metamizole (2.5 g) in total amount of 100 mL of saline until the next morning. The rate of infusion was between 3 mL/h and 6 mL/h. The nursing staffs were instructed to maintain the lowest rate of drip infusion, which relieved the patient of her pain. The volume of infusion has been registered.The control patients, Both groups of patients could get the intravenous bolus of a rescue analgesic or an antiemetic drug whenever needed. In a case of severe pain, the patient received a bolus of 3 mg of piritramide. A total consumption of all intravenous drugs used during the first 24 hours after the surgical procedure was registered.Pain was measured using a standard visual analogue scale (VAS) score in ranging from 0 to 10. The first measurement was made in the recovery room. Thereafter, pain was measured three, six and nine hours after the surgical procedure. Over the next two days, pain was measured every eight hours. Six hours after the surgical procedure, we measured their alertness using the Observer’s Assessment of Alertness/Sedation Scale  in a composite way.In case of nausea or vomiting, the patient received a bolus of an antiemetic drug, the first one being metoclopramide. If no relief was achieved, 1 mg of granisetron or, with persistent nausea, 1.25 mg of droperidol was administered intravenously. On the first postoperative day, all patients received analgesics in the form of tablets. They were administered 100 mg of diclofenac, a combination of paracetamol and tramadol and, in case of nausea, an antiemetic drug. The consumption of drugs during hospitalization was registered.After surgical procedure the majority of patients had adjuvant treatment: chemotherapy (67%), irradiation (63%) and/or hormone therapy (82%).All complications  were recorded. Three months after the surgical procedure the patients were asked about pain in the postoperative area or the upper extremities. All patients were examined and asked about neuropathic pain in the axilla, shoulder, arm or chest wall six months after the surgical procedure.2 or Fisher’s exact test, as appropriate. All comparisons were two-sided and a p-value of ≤ 0.05 was considered statistically significant. Statistical packages PASW 18  and R 2.11.1  were used for the analysis.The student t-test or the Mann-Whitney U test was conducted according to the data distribution. The association between categorical variables was tested by chiThe mean age of patients was 60 years (range 30–84), height 163 cm (range 150–176), weight 73 kg (range 43–114), and body mass index (BMI) 27.4 (range 15.4–41.4). There were no significant differences between both study groups either in BMI, American Society of Anaesthesiology (ASA) score, comorbidities , length All lymphadenectomies were performed by eleven experienced surgeons. There were no significant differences between various surgeons either in VAS score during hospital stay (p = 0.66) or in rate of chronic pain after six months (p = 0.32).Consumption of piritramide during the first 24 hours after the surgical procedure was smaller in the test group compared to the control group (p < 0.0001) . AlertnePatients in the test group reported less nausea than patients in the standard group. Consumption of metoclopramide during the first 24 hours  after thNo local signs of infection were observed in the area, where the wound catheter was inserted. All microbiological samples taken were negative. There were no significant differences in the complications following the surgical procedure between the two groups. Altogether three patients (5%) underwent another surgical procedure because of haematoma: two cases from the test group and one case from the standard group. Inflammation after the surgical procedure occurred in nine cases (15%): five cases (17%) in the test group and four cases (13%) in the standard group.The average postoperative hospital stay was 1.7 days. There was no significant difference in the duration of the hospital stay between the two groups.Questionnaire about pain was answered by patients three months after lymphadenectomy. Pain was reported by 17% and 50% of patients from test and control group (p = 0.01), respectively. Six months after surgical procedure patients from test and control group had neuropathic chronic pain in 20% and 40% (p = 0.09), respectively. Oedema of the arm was present in 21 patients, 10 from the control group and in 11 from the test group. Limited shoulder movement was present in 14 patients (23.3%), 7 from each group. Chronic pain after 6 month was present in 18 patients (30%). There were no differences in both arms of our study in frequency of chronic pain after adjuvant treatment .et al. performed a prospective, double-blind, randomized, placebo controlled trial on 42 patients after a modified radical mastectomy.29Axillary lymph node dissection is a standard surgical procedure in case of positive lymph nodes in breast cancer or melanoma.In our study a cost-benefit analysis was not done. The costs of drugs were almost the same in both study arms. So, the cost of treatment with elastomeric pain pump is bigger than standard pain treatment for a price of elastomeric pain pump and perforated catheter, which is 175 Euros in our country. But, we proved that patients with a continuous infusion of local anaesthetic had a lower sedation rate compared to the standard opioid-based analgesia group of patients as a consequence of a reduced use of opioids. Almost all patients from the test group had an excellent alertness OAA/S score already on the day of the surgical procedure. Therefore, we believe that a continuous infusion of a local anaesthetic represents a very good pain management option for patients who underwent axillary lymph node dissection and are thus treated as a day case, which has already become a standard of care in some hospitals, for example in the Memorial Sloan-Kettering Cancer Centre in New York.et al. identified age, marital status, employment status and housing as risk factors for post-mastectomy pain syndrome.vs. 50%; p = 0.01).Another very important issue of breast cancer treatment after axillary surgery is the incidence of chronic pain. Many factors are involved in the development of chronic pain after a surgical procedure: genetic susceptibility, psycho-social background, age and gender.vs. 40%; p = 0.09). Similar outcome on occurrence of post-mastectomy pain syndrome was reported by Fassoulaki et al.38However, six months after lymphadenectomy there was just a trend for lower pain in continuous infusion of local anaesthetic group of patients in comparison to opioid-based analgesia (20% To conclude, our prospective randomized study confirmed that the application of a wound catheter with an elastomeric pump with a local anaesthetic is safe, easy and effective for reducing acute postoperative pain. Continuous infusion of a local anaesthetic into the wound reduces opioid consumption and results in less postoperative sedation and a reduced need for antiemetic drugs. The elastomeric pump is comfortable for both the patients and a nursing stuff. Thus, the patients are more alert, do not feel pain and, consequently, do not need intensive monitoring and nursing care.


The incidence of transient neurologic symptoms (TNS) after spinal anesthesia with lidocaine is reported as high as 40%.This prospective clinical trial was designed to determine the incidence of TNS in patients who underwent spinal anesthesia with two different needles, in two different surgical positions.The present randomized clinical trial was conducted on 250 patients (ASA I-II), who were candidates for surgery in supine or lithotomy positions. According to the needle type (Sprotte or Quincke) and local anesthetics (lidocaine and bupivacaine) all patients were randomly divided into four groups. After performing spinal anesthesia in sitting position, the position was changed into supine or lithotomy, according to surgical procedure. The patients were observed for complications of spinal anesthesia during the first five post-operative days. The primary end-point for this trial was to recognize the incidence of TNS among the four groups. Our secondary objective was to evaluate the effect of patient's position, needle type, and duration of surgery on the development of TNS following spinal anesthesia.TNS was most commonly observed when lidocaine was used as anesthetic drug (P = 0.003). The impact of needle type, was not significant (P = 0.7). According to multivariate analysis, the duration of surgery was significantly lower in cases suffering from TNS (P = 0.04). Also, the risk of TNS increased following surgeries performed in lithotomy position (P = 0.00).According to the results of this clinical study, spinal anesthesia with lidocaine, and the lithotomy position in surgery increased the risk of TNS. Following spinal anesthesia, some neurologic complications are expected to occur. Low back pain, radiating to the buttock and lower extremities, is the major symptom of such neurologic complications. The pain is mostly transient and usually fades within 24-48 hours. In 1993, Schneider et al.  was designed to evaluate 250 candidates of elective surgeries from January 2011 to December 2011. The approval of the Ethics Committee of Tehran University of Medical Sciences was obtained and randomization was achieved by a computer-generated block of numbers and sealed envelope technique. All patients were between 18 to 60 years old and their ASA score was I or II. Subjects suffering from neuromuscular disease, spinal canal stenosis or vertebral disc disease, femur fracture or the fracture of pelvis, diabetes mellitus, morbid obesity, and those having history of neurologic complications following spinal anesthesia were excluded from the study. Various stages of study were explained meticulously to all patients and written consent was obtained from them .All cases were randomly divided into four groups according to the needle type (25 gauge Sprotte or Quincke) and local anesthetics (lidocaine or bupivacaine). In the first and second groups, 1.5-2mL from 5% hyperbaric lidocaine (Orion Pharma) was used for spinal anesthesia, and the third and fourth groups received 2.5-3mL from 0.5% isobaric bupivacaine (MYLAN) for the same purpose. Based on described style and through Sprotte needle, 62 patients received lidocaine, and another 62 received bupivacaine. Through Quincke needle, bupivacaine was injected in 63 patients and lidocaine in the other group of 63 cases. After EKG monitoring, non-invasive blood pressure measurement, pulse oximetry, and infusion of 8 mL/kg from normal saline, spinal anesthesia was performed in sitting position at L2-L3 or L3-L4 levels by the same anesthesiologist. The dose of anesthetic drug was tailored by the height of patients. Intra-operative hypotension (MAP reduction more than 20% of the baseline) was treated with injection of 5-10 mg from ephedrine and infusion of 200 mL from Ringer's solution. Bradycardia (heart rate < 50  bpm) was treated with 0.5 increments of atropine, and hypotension (systolic BP < 90  mmHg) with 5  mg increments of ephedrine. According to the type of surgery, the operation was performed in the supine or lithotomy positions. All cases were ambulatory within the first post-operative day. The potential neurologic complications were monitored every eight hours within the first two post-operative days, and every 24 hours for the following three days. During each post-operative control, the patients were asked to report any of the following symptoms, which were considered as the criteria for TNS development: any type of bilateral or unilateral pain, numbness, or hyperalgesia in the back; or radiating pain to waist, buttock, hip, or anterior or posterior regions of leg or thigh. The severity of pain was assessed by Visual Analogue Scale (VAS). All patients were remained hospitalized for at least 48 hours after the operation. The symptoms of TNS and any other complications were observed by a neurosurgeon that was blinded to surgical position of patients and the type of drugs and needles used for spinal anesthesia. Additional investigations for whom complaining from TNS, such as MRI and infection workup, were only performed when neurologic deficit or any sign of infection was discovered by the neurosurgeon through his detailed physical examination to rule out other etiologies. In patients with VAS score more than three, administration of pethidine and NSAID was considered. After discharge, the patients were visited for at least three consecutive days and any symptoms of TNS were evaluated. The sample size of the study was calculated according to the report of Hampl et al. (250 patients with mean age of 46.4 ± 15, consisting of 45 women and 205 men, were included in this study. Demographic characteristics and important risk factors, especially position of the patients during the surgery, age, sex, and duration of procedure, were not significantly different between the four groups . Type ofSeveral factors influenced on the development of low back pain and neurologic complications following spinal anesthesia. The type of drug used for anesthesia was a particularly important factor in this regard, especially when the injected agent was lidocaine. Risk of neurologic complications following the injection of other drugs has been reported to be less than that of lidocaine , 5. In t


Due to a lack of prospective studies, which are difficult to perform, bracing adolescent scoliosis is discussed from 30°, and sometimes surgery is proposed at this angulation. It seems interesting to study the results of scoliosis over 40° with the Lyon brace, and to present the criteria for successful treatment.To prove the effectiveness of the Lyon conservative treatment in the most difficult conditions. If treatment is effective for scoliosis over 40°, it is even more so for lower angulations.We selected in our prospective database a cohort of 176 adolescent scoliosis patients with curves over 40° seen between 1998 and 2007. At this angulation, the Lyon management involves 2 plaster casts, each worn for two months, and a full time Lyon brace up to 18 months after the end of the growth, and a specific program of physiotherapy (Lyon method).24 patients (13.6%) did not accept the protocol and chose surgery. 11 patients (6.25%) discontinued during the treatment. 136 patients  can be studied statistically. Mean initial angulation is 45.4° (+-6.33); reducibility in plaster cast and brace is 50%. At follow up 2 years after weaning, angulation is 40.5° (+-13.1). 61 patients (45%) improved by more than 5°, 27 patients (20%) are stable, 48 (35%) are worsening by more than 5°. The results are worse in boys (57% failure). 21 patients were evaluated 10 years after weaning of the brace. Mean progression during this period is 5° (0.5°/year) identical to that of the general adult scoliotic population. The best results are obtained when the lower vertebra is L3 (89%); the worst when the lower vertebra is T12 (53%). The two significant predictors of failure of conservative treatment are:- A prior treatment .- Early onset scoliosis (EOS) and non-idiopathic scoliosis .Conservative treatment with Lyon brace and physiotherapy was effective in halting scoliosis progression in 65% of patients including prior treatments. The results of this study confirm that bracing is effective even after 40°. For EOS and non idiopathic, it allows waiting until end of growth for surgery.


Root canal treatment (RCT) success criteria inform us of the path to bony healing and of prognostic factors, but tell little about how the patient perceives, feels, or values RCT. Patients choose, undergo, and pay for RCT, they live with the result, and inform their community. The purpose of this narrative review was to appraise patient-centered outcomes of initial non-surgical RCT and nonsurgical retreatment, in adults.Patient-centered RCT outcome themes were identified in the extant literature: quality of life, satisfaction, anxiety, fear, pain, tooth survival and cost. Narrative review was applied because the disparate themes and data were unsuited to systematic review or meta-analysis.Application of the Oral Health Impact Profile (OHIP) demonstrated that disease of pulpal origin affects quality of life with moderate severity, primarily through physical pain and psychological discomfort, and that RCT results in broad improvement of quality of life. Satisfaction with RCT is extremely high, but cost is the primary reason for dissatisfaction. Anxiety and fear affect RCT patients, profoundly influencing their behaviors, including treatment avoidance, and their pain experience. Fear of pain is “fair” to “very much” prior to RCT. Pain is widely feared, disliked, and remembered; however, disease of pulpal origin generally produces moderate, but not severe pain. RCT causes a dramatic decrease in pain prevalence and severity over the week following treatment. Survival rates of teeth after RCT are very high; complication rates are low. Cost is a barrier to RCT, but initial costs, lifetime costs, cost effectiveness, cost utility, and cost benefit all compare extremely well to the alternatives involving replacement using implants or fixed prostheses.Dentists must strive to reduce anxiety, fear, experienced and remembered pain, and to accurately inform and educate their patients with respect to technical, practical and psychosocial aspects of RCT. Endodontic outcomes have been long and widely studied in terms of root canal treatment (RCT) case success. Instruments such as the Strindberg Criteria or Orstavik’s Periapical Index have been widely used to measure treatment outcomes. These instruments are extremely helpful in studying prognostic indicators and in measuring the long and irregular pathway towards radiographic bony healing -3. Even Patients’ pretreatment decisions and post treatment satisfaction may be strongly influenced by social, psychological, and behavioral dimensions including knowledge, beliefs, attitudes, preferences and behaviors . PatientThe study of endodontic patient-centered outcomes is a rapidly expanding area, but one that has not yet received broad review or overall synthesis in the dental literature. The purpose of this narrative review was to appraise patient-centered outcomes of initial non-surgical root canal treatment, initial treatment and nonsurgical retreatment, in adults.Patient-centered RCT outcome themes were identified in the extant literature: quality of life, satisfaction, anxiety, fear, pain, tooth survival and cost.Narrative review, rather than systematic review, was chosen because the studied topic was broad-reaching, contained disparate data types, was heterogeneous, and identified data was not conducive to meta-analysis. Wherever possible, higher forms of clinical evidence, such as systematic reviews, were referenced. For convenience, we have grouped patient-centered outcomes into the common themes represented in the extant literature.Quality of life is concerned with the degree to which a person enjoys the important possibilities of life . FactorsDugas et al., studied the patients who had received RCT within the last 2 years, using a modified seven-question version of OHIP, emphasizing on diseases of pulpal origin .Physical pain, psychological discomfort, and psychological disability highly influenced postoperative quality of life; social disability and handicap moderately influenced postoperative quality of life; functional limitation had little influence on postoperative quality of life . PhysicaIn two subcategories, the ability to perform usual jobs  and temperature sensitivity , RCT which was provided by endodontists produced significantly more improvement than by generalists . For theHamasha and Hatiwsh used the OHIP questionnaire, as used by Dugas et al. with 17 questions , before Gatten et al. used a 14-question shortened version of the OHIP questionnaire delivered at least one year after RCT or implant and coronal restoration , 11. TheLiu et al. used the 14-question shortened version of the OHIP questionnaire  to compaYu et al. studied painful exacerbations of persistent periapical lesions using a modified Oral Impacts on Daily Performances (OIDP) quality of life questionnaire . The vasLobb et al. studied patients’ perceptions of their RCT. They reported that the majority of patients who received endodontic treatment would undergo this treatment again if their dentist recommended it; for those few who would not, pain and expense appeared to be the greatest deterrents .Gorduysus and Gorduysus studied expected and experienced pain, satisfaction of RCT, and economics . Almost Jimena studied geriatric patient attitudes and RCT satisfaction; patients generally reported a positive attitude to RCT, reporting relief of pain, better appreciation of food and improved self-esteem .In summary, disease of pulpal origin affects quality of life with moderate severity, primarily through physical pain and psychological discomfort. Provision of RCT resulted in broad improvement of quality of life, especially in physical pain, psychological discomfort, psychological disability, and social disability. Some provider and patient differences were noted. Satisfaction with RCT was extremely high but cost was the primary reason for dissatisfaction.Anxiety and fear are certainly felt by RCT patients; this may be expressed in a variety of different ways ranging from physiologic responses such as hyperventilation or fainting, to simple verbal expression, and to silence or loquaciousness . PatientDental anxiety, fear and phobia are known to profoundly influence patients’ behaviors and felt experiences -22. FearAlthough anxiety has been well studied with respect to the general field of dentistry, less has been reported specifically concerning RCT. This is surprising because RCT appears to carry a special stigma beyond all other dental disciplines and feature prominently in patients’ life stories .There is no doubt that RCT can increase patients’ physiologic and psychological stress levels . PatientPhysiologic stress peaks early in a RCT appointment, around the time of local anesthesia delivery and initial instrumentation , 33. PatPatients may avoid RCT due to anxiety and fear of pain, resulting in treatment avoidance and eventual tooth loss through extraction . Half ofAccurately informing patients about pain associated with RCT reduces fear of pain . FortunaPain is widely feared and disliked by the public , 38, 39.It appears that patients often remember a connection between pain and RCT, rather than a connection between pain and extant disease of pulpal origin or its predominant cause, caries. Unfortunately, RCT appears less frequently remembered for relief of pain. However, RCT definitely causes a dramatic decrease in pain , 40. PrePain is frequently experienced during RCT, but generally only at low levels of severity , 41. PaiMany studies have attempted to identify predictive factors for post treatment pain. However, results have often been unclear, inconsistent, or lacking obvious mechanistic cause , 43. It The influence of single versus multiple appointments on post treatment pain has been widely studied, subjected to systematic reviews and meta-analysis. Although patients undergoing single-visit RCT reported a higher frequency of pain medication use, compelling evidence for a difference is lacking , 46. LikFlare ups resulting in pain, swelling, and unscheduled attendance following a RCT appointment generally have a low incidence , 47-50. Long term persistent pain following RCT is rare , but of Pain of pulpal origin is best managed by RCT and non-steroidal anti-inflammatory drugs; antibiotics should not be prescribed to treat pain or the expectation of pain , 54. DenThe survival of a treated tooth is of obvious importance to the patient. Little in life is certain, but patients may reasonably expect a high probability for long-term retention of their treated teeth . Long-teThe endodontic literature is distinguished by studies with unusually large sample size. These include: Lazarski et al., 94% functional survival for 44,613 cases at 3.5 years in the USA; Salehrabi and Rotstein 97% survival for 1.1 million patients at 8 years in the USA; and Chen et al., 93% survival for 1.5 million teeth at 5 years in Taiwan , 56, 61.Complications also have obvious impact on patients. Complications following RCT may include slow or inadequate healing, new disease, symptoms, swelling, tooth fracture, extraction, caries and periodontal disease. However, the complication and additional intervention rates for RCT are low, several times lower than for single tooth implants -68.Teeth with RCTs have remarkably high long-term survival rates as measured longitudinally. However, cross-sectional data of the prevalence of disease in community populations presents a less positive picture; periradicular disease in both treated and untreated teeth is surprisingly common and technical quality of community RCT is broadly decried ; room foCost is a significant barrier to receiving care for toothache and a very important factor in patients’ treatment choices . InitialThe social impact, or quality of life impact, of RCT was investigated by several authors who used shortened versions of the OHIP , 10-12. OHIP metrics are not the only outcomes valued by patients. Anxiety, pain and cost appear to be of preeminent concern to patients facing the choice among RCT and tooth retention, tooth extraction without replacement, and tooth extraction with replacement. The pain and economic data reviewed in this paper are extremely supportive of the RCT option. However, people possess complex sets of emotions, beliefs, behaviors and values. Anxiety and fear play important roles in our behaviors and remembered experiences. Appearance is also of tremendous importance, patients place a high value on the appearance of their anterior teeth , 76. DenSuccess was not included as a theme in this narrative review because differing criteria produce different results; furthermore most success/failure instruments are radiograph-based, not patient-centered. It is important to note that radiographically evident periapical disease, a usual determinant of failure, is often not painful or symptomatic. The authors suggest that comprehensive new endodontic outcome assessment indices, including patient-centered metrics, should be developed.Previous narrative and systematic reviews have contrasted RCT with its alternatives, notably implants , 77. LikPatient education is critically important. Patients disproportionally fear RCT. However, compared to its alternatives such as extraction and replacement, RCT is less invasive, less costly, less time consuming, with low levels of intraoperative pain, and causes a greater reduction in pain felt by patients. Acceptance of this knowledge can reduce anxiety, fear, experienced, and remembered pain.1.Disease of pulpal origin affects quality of life, with moderate severity, primarily through physical pain and psychological discomfort; RCT results in broad improvement of quality of life.2.Satisfaction with RCT is extremely high; cost is the primary reason for dissatisfaction.3.Anxiety and fear affect RCT patients, profoundly influencing their behaviors, including treatment avoidance, and felt pain.4.Pain is widely feared, disliked, and remembered; RCT causes a dramatic decrease in pain prevalence and severity over the week following treatment.5.Survival rates of teeth after RCT are very high; complication rates are low.6.Cost is a barrier to RCT, but initial costs, lifetime costs, cost effectiveness, cost utility, and cost benefit all compare extremely well to the alternatives of extraction and replacement using implants or fixed prostheses.


Pain management with the use of sedatives and analgesics has several advantages and few complications or side effects.In this study, we planned to evaluate the effects of pain control on oxygen saturation independent of other factors, such previous cardio-pulmonary conditions or respiratory rate.Sixty-seven adult patients with direct trauma to extremities, who were referred to Imam Hossein Educational Hospital emergency room were enrolled in this study. Exclusion criteria were trauma to parts of the body other than extremities, and comorbidity with cardiovascular, pulmonary, or other disorders. Pain was evaluated using a numerical rating scale and scored between 0-10. Patients’ respiratory rates (RR) were recorded by a physician and blood oxygen saturations were measured using a pulse oximeter. Then, fentanyl 1 μg/kg was administered under direct supervision of a physician. After five minutes, pain score, oxygen saturation, and RR were measured in the above-mentioned order.2 saturation differentiation showed no significant relation between these variables. There were no side effects or complications of fentanyl observed in these patients.The data from 67 patients with a average age of 30 years were collected: 77% were male and 23% were female. The average pain score of these patients was 7.3 at the time of admission, which significantly decreased to 3.8 after fentanyl administration (P < 0.001). Upon arrival in emergency department the mean oxygen saturation and RR were 97.1% and 21.5/minute, respectively. After pain control, mean oxygen saturation and RR were 94.9% and 19.2 /minute, respectively, showing a significant decrease only for RR in comparison with that at the time of admission (P < 0.001). Regression analysis of pain score and OThe results of our study revealed no independent causative relationship between pain control and oxygen saturation. Fear of respiratory depression often causes pain to be left undertreated and patients experience unnecessary pain . In spitIn this study, we evaluated the effects of pain control on oxygen saturation independent of other factors such as cardio-pulmonary conditions or respiratory rate.2 saturation and pain scores) during, before, and following fentanyl administration. A stepwise linear regression model was developed to identify the association between O2 saturation and pain severity scores. P < 0.05 was considered statistically significant.In this study, 67 adult patients with isolated and direct trauma to extremities referred to the emergency department of our hospital were studied. The study protocol was accepted by the ethics committee of Shahid Beheshti University of Medical Sciences and the principles of the Declaration of Helsinki were observed throughout the study. Patients with trauma to any part of the body other than the extremities, and those suffering from cardiovascular, pulmonary, or other co-morbid disorders were excluded from the study. A data collection sheet was designed to gather demographic data as well as pain score, respiratory rate (RR), and blood oxygen saturation which were checked by a physician before and after analgesic administration. Pain was evaluated using a numerical rating scale and scored 0-10. Patient’s respiratory rate was recorded by a physician and blood oxygen saturation was measured using a finger pulse-oximeter (Nonin 9550). Afterwards, fentanyl 1 μg/kg was administered under direct supervision and observation of a physician. After five minutes (when fentanyl effect reached its peak level), pain score, oxygen saturation, and RR were measured in the aforementioned order. Any decrease in the level of conciouseness, appearance of side effects, or complications were deemed reasons to stop the assessment. Since we only selected patients with direct trauma to the extremities, supplemental oxygen was not administered. Data analysis was performed using SPSS 18.5 . Paired t test was used to compare continuous variables . The mean pain score of these patients at the time of admission was 7.3 , which significantly decreased to 3.8  after fentanyl administration (P < 0.001). The mean respiratory rate before and after pain control were 21.5/minute  and 19.2 /minute , respectively, showing a significant decrease in comparison at the time of admission (P < 0.001) . The mean oxygen saturation was 97.1%  upon arrival in the emergency department. After pain control, mean oxygen saturation was 94.9% . In spite of significant decrease in post-analgesic RR, arterial blood saturation did not show a significant decrease (P > 0.05). Regression analysis of pain score and oxygen saturation differentiation showed no significant correlation between these variables . No side2) is determined mainly by arterial partial pressure of oxygen (PaO2). The relationship between these two variables is the known oxygen dissociation curve, which was determined experimentally by in vitro titration of the blood while increasing oxygen partial pressures. At low oxygen pressures, there is relatively little increase in SaO2 for a given change in PaO2. For PaO2 above 20 mmHg, the rate of SaO2 change increases markedly and then drops beyond PaO2 of 60 mmHg. PaO2 is the most important (but not the only) determinant of SaO2. Boom and colleagues in a recent study mentioned that fentanyl causes marked respiratory depression and analgesia  and capnography  in hospitalized patients receiving opioid for pain therapy . Macintynalgesia . The phanalgesia . In our nalgesia . Hence, nalgesia , 9. Subsnalgesia . It is analgesia . The cli


CM is a complex neurological disorder affecting approximately 2% of the general adult population. CM sufferers experience a broad range of debilitating symptoms.To assess the daily headache symptoms of chronic migraine (CM) patients over a 4-week period.PREEMPT  evaluated onabotulinumtoxinA for prophylaxis of headaches in CM (>15 days/month with headache lasting >4 hours/day). A total of 1384 CM patients daily reported their headache symptoms for a 28-day baseline period using an interactive voice response telephone diary. The baseline frequencies of various headache features and associated symptoms were computed.Of 38,752 total days, patients reported 27,483 (70.9%) days with >4 hours of headache. Patients classified their pain as moderate/severe on 90.9% of their headache-days. The most common associated symptoms patients described experiencing on headache-days were photophobia (81.2%), phonophobia (80.2%), exacerbation with physical activity (80.0%), pulsating quality (70.8%), unilateral pain (63.6%), and nausea (59.8%). Vomiting (13.8%) was reported infrequently.These CM patients experienced severe headache symptoms throughout the 28-day baseline period. The overwhelming majority of headaches were characterized as moderate/severe pain intensity, which were often accompanied with sensitivity to both light and sound and aggravated by routine physical activity. The majority of patients also reported pulsating pain quality, unilateral headache, and nausea. The heavy burden of illness suffered by CM patients emphasizes the necessity of prophylactic treatment for their headaches.Allergan, Inc.