In our study, there were no differences observed in pain intensity relative to level of anxiety. Coping style is an important concept in the management of anxiety and pain experienced by patients undergoing chest surgery. Therefore, a multidisciplinary approach should be considered in clinical practice.Stress, anxiety, and post-surgical chest pain are common problems among patients with thoracic surgical pathology. The way in which psychological distress is managed—the coping style—can influence the postsurgical evolution and quality of life of patients. In our study, we monitored the influence of coping style on patients’ anxiety and the intensity of post-operative chest pain. We conducted a cross-sectional study on 90 subjects with thoracic surgical pathology. One month after their surgeries, patients completed the following scales and questionnaires, translated, adapted, and validated for the Romanian population: COPE scale inventory, Generalized Anxiety Disorder-7 Questionnaire, McGill Pain Questionnaire, and Numeric Pain Rating Scale. Anxiety  and postoperative thoracic pain intensity  were significantly higher in patients exhibiting social-focused coping than in patients presenting emotion-focused or problem-focused coping as their main coping style (Kruskal–Wallis,  Stress is a common interdisciplinary problem in medicine when patients are faced with serious medical problems, especially when discussing major surgeries . Its negAmong patients with an increased level of psychological distress are those with thoracic surgical pathology. Patients tend to overestimate their risk of lung cancer . A patiePreoperatively, psychological distress can lead to worsening pain, decreased postoperative cognitive function, and increased expenditure on medical services . AnxietyFurthermore, stress during surgery can generate anxiety; its presence has a negative impact on patients’ quality of life, as well as on their postoperative recovery. Many studies have indicated that more anxious patients have poorer outcomes, longer hospital stays, higher rate of complications, and prolonged convalescence . Hence, Postoperative chest pain also has a negative impact upon postoperative evolution, both in developing and maintaining anxiety . In the The exact mechanism underlying the development of chronic pain after thoracotomy is currently unknown, except for intraoperative nerve injuries. Otherwise, the age, sex, operative technique, existence of preoperative pain, genetic and psychosocial factors, and/or analgesic management are taken into consideration in the development of such chronic pain .In fact, thoracotomy is considered one of the most painful medical procedures, and the pain resulting from it has been reported as acute, traumatic, and severe ,19. TherPsychological rehabilitation in thoracic surgical patients is still a concern for doctors, due to the psychological challenges generated by diagnosis, surgical treatment, and socio-professional reintegration. However, high-quality communication strategies have been demonstrated to improve patients’ knowledge of the risk of malignancy and to reduce emotional distress .Coping is a psychological process that takes place consciously and is used to manage stressful life situations. Some coping styles may prove appropriate and adaptive in a stressful situation, while others may prove maladaptive to the same stressful situation and even have a seriously negative impact upon it. Recently, an increased interest in understanding the correlation between stress, symptom severity, and patient well-being has emerged in the literature . While pStarting from the above-mentioned aspects, in our study we aimed to identify the main coping styles exhibited by patients with thoracic surgical pathology and their influence upon anxiety and on the intensity of chest pain felt by them in the postoperative period.In this cross-sectional, non-interventional study, we examined 90 patients with thoracic surgical pathology prior to and 1 month following their surgery. They were hospitalized and operated on in the Thoracic Surgery Department of the Municipal Emergency Hospital of Timisoara, Romania, between November 2018 and November 2019. Subjects were included in the study according to consecutive-case criteria and using a population-based approach. They were informed about the objectives and methods of the research and agreed to take part by providing written informed consent before and after surgery . The resPatients over 18 years of age at the moment of inclusion in the research;Patients hospitalized at least 1 day before surgery;Patients diagnosed by imaging through chest CT that require a scheduled thoracic surgery;Patients who understood study procedures and agreed to take part and sign the Informed Consent Form (ICF).Subjects were included in the study based on the following criteria:Patients suffering from mental disorders that may interfere with the research methods and results;Patients unable to understand the research procedures or give written consent;Patients with stage IV lung neoplasm;Patients with multiple comorbidities and limited life expectancy;Thoracic surgical emergency.The following were excluded from the study:Socio-demographic data of the patients were requested on the first day of hospitalization.We offered all patients the opportunity to be included in our study according to the inclusion criteria presented. Postoperatively, we had 7 cases that refused, for various personal reasons, to complete the questionnaires; they were withdrawn from the study.We used the COPE questionnaire to assess coping. Developed by Carver, Scheier, and Weintraub in 1989, the COPE scale is a self-report tool that evaluates the coping strategies of people to stress . The queThe four coping styles analyzed with this tool were: coping focused on emotion, problem-focused coping, coping focused on social support, and avoidant coping. Each coping style included three coping mechanisms. For each patient, the coping style that presented the highest value compared to the other three was considered the dominant coping style.2.The GAD-7  Questionnaire was employed to assess anxiety. The questionnaire includes seven items, with the answer from each item rated on a scale from 0 to 3. The final score is obtained by summing the scores of the seven items, with a higher score indicating greater anxiety severity. The sum of the seven items, and therefore the GAD-7 total score, will be a value between 0 and 21, with a total score of 5 representing mild anxiety, 10 representing moderate anxiety, and 15 representing severe anxiety .3.(a)The McGill Pain Questionnaire scale was utilized for the quantitative and descriptive assessment of the subjective sensation of pain. It consists of three major classes of words describing the painful experience . It also contains a clinical pain intensity scale and other items to describe the painful sensation (miscellaneous). Pain intensity was rated on a scale from 0 to 5, whereby 0 represents the absence of pain and 5 is maximum intensity. The subscale Number of Words Chosen (NWC) was recorded following Melzack’s instructions .(b)The Numeric Pain Rating Scale (NPRS) is frequently applied in measuring the intensity of pain, with patients asked to select a number from 0 to 10 to indicate the severity of their pain .The characteristics of pain were evaluated using the McGill Pain Questionnaire and Numeric Pain Rating Scale (NPRS).p < 0.05.Statistical data were presented using SPSSv17. In the analysis of numerical variables, average, minimum, and maximum values were estimated, as well as the variables’ standard deviations. The non-parametric Kruskal–Wallis test was applied for comparisons between more than two numerical series. For comparisons between two sets of values with no Gaussian distribution, the Mann–Whitney test was applied. The Student’s t-test was used in the case of two series of normally distributed values, while the chi-square (χ2) test was used for comparisons between nominal variables. The results were considered significant for a value of Of the 90 patients, 24 were diagnosed with primary lung cancer and 16 had a history of cancer. Twenty-six patients presented benign tumor formations of variable size and were operated on by using a variety of minimally invasive or classic surgical procedures. Twenty-four patients were included postoperatively due to presenting inflammatory conditions. We analyzed the questionnaires, with the demographic characteristics of the 90 patients shown in Depending on the type of surgical incision, patients were divided into three categories: thoracoscopic incision, mini-thoracotomy incision, and thoracotomy incision.p < 0.001).n = 37), coping focused on emotion (n = 33), and coping focused on social support (n = 20) data summarized in Following the data obtained with the COPE scale, we analyzed the patients’ scores and grouped them into three categories, depending on the dominant coping type that they presented. Thus, patients were divided into those with coping focused on the problem (p > 0.05) and are represented by their mean plus or minus one standard deviation: problem-oriented coping (35.87 ± 7.58), emotion coping (34.99 ± 5.94), and social-oriented coping (32.40 ± 6.78).The coping scores showed a normal distribution for the entire study group . Comparisons between the coping styles (p = 0.644);The GAD-7 anxiety values were insignificantly higher for problem-focused coping than for emotional-focused coping ;Problem-focused coping had significantly lower GAD-7 scores than coping centered upon social support .Emotion-focused coping presented significantly lower GAD-7 values than social-support coping  and for pain intensity . We refined the comparisons between the coping styles and obtained the following results (p = 0.458) and for the intensity of the pain ;The differences between the scores obtained for the predominantly problem-centered coping style and predominantly emotion-centered coping style were insignificant, both in the case of “total words” . The intensity of pain was significantly higher in the social-support-oriented coping cases as opposed to the problem-oriented coping cases ;The scores for “total words” were significantly increased in the predominantly social-support-centered coping cases in contrast to the problem-focused coping cases  and the intensity of the pain  were significantly higher in the predominant social-support-oriented cases compared with the emotion-focused coping cases.The scores for “total words” . We compared the three coping styles (p = 0.362);The NPRS pain values were insignificantly lower for problem-directed coping in comparison to emotion-directed coping ;The problem-focused coping NPRS scores were significantly lower than the social-support-directed coping scores .The emotion-focused coping values were significantly lower than the social-support-oriented coping values , 5–9 mild anxiety (33 cases), 10–14 moderate anxiety (8 cases), and 15–21 severe anxiety (6 cases) .There were no differences observed in pain intensity assessed one month postoperatively, relative to the intensity of anxiety.The results of our study indicate that any surgical approach  generates postoperative pain of variable intensity depending upon the coping mechanism. Preoperative psychological evaluation of patients should be done regardless of the type of coping. Our study showed that patients with social-support-oriented coping had both a higher anxiety score and an increased intensity of post-surgical chest pain.Furthermore, the intensity of pain felt by patients was not influenced by the intensity of anxiety, unlike most existing studies that conclude that a higher intensity of pain is dependent upon the presence or intensity of anxiety ,33,34. IOne possible explanation is that in the above-mentioned studies, the selected groups were much more homogeneously outlined, such as groups of patients with coronary artery bypass graft or lung cancer. Conversely, our study presented a more diverse group of patients with thoracic-pulmonary pathology. Our research indicates that the way in which subjects handle stress—that is, the main coping style they use—influences both the intensity of anxiety and the intensity of pain they experience.It is known that a patient’s distress may relate to their coping style when faced with challenging life events . There aOur research used coping levels based upon an adaptation of the COPE scale on the Romanian population . TherefoThere have been situations described in the literature where the different styles of coping have influenced the pain in various analyzed aspects. Gil et al. (1989) observed a difference between patients with passive coping and active coping. The patients presenting a passive style of coping (catastrophizing) have asserted a higher intensity and frequency of pain than patients with active coping . Hence, passive coping is maladaptive, while patients with active coping adapt better to painful situations and experience decreased pain intensity . In PolaMoreover, Polanski et al. (2018) demonstrated that lung cancer patients with coping mechanisms that focused on the problem experienced less pain .In our study, we observed that the intensity of pain did not differ significantly relative to the surgical approach performed. In addition, there were no significant differences between groups in terms of surgery time, taking the three surgical approach methods  into consideration. Hence, the influence of the dominant coping style is even more pertinent in understanding differences between patients in terms of anxiety and pain.Regarding patients with non-small-cell lung carcinoma (NSCLC), studies indicate that focusing on emotions contributes to psychological distress. Consequences include both physical symptoms  and mental symptoms  ,47. On tIn this research, the intensity of anxiety varied depending upon the dominant coping style. In our studied cases, the level of anxiety in patients with social-support-directed coping significantly surpassed that found in the other two coping categories (problem-centered coping and emotion-oriented coping).There are extensive studies showing that coping has a significant role in handling anxiety ,33,49. ICumulating our results with those mentioned in other studies, we suggest that for patients with somatic thoraco-pulmonary pathology, the coping style focused on social support has been most closely associated with high-intensity anxiety symptoms. There were no significant differences between those with emotion-centered coping and those with coping focused on the problem in terms of intensity of anxiety.Coping may further impact the anxiety and pain experience associated with chest surgery pathology. According to our study, coping focused on social support is a less-adaptive coping mechanism than emotion-oriented or problem-focused coping types, both in terms of anxiety and pain.The creation of a predictive preoperative algorithm could be an invaluable tool in quantifying the psychological impact upon the patient, while highlighting the need for tailored psychological care according to the subject’s coping mechanism. Future research shall demonstrate the need for the inclusion of psychotherapy in the “team board”.Given their vulnerability, we recommend special care for patients exhibiting social-focused coping mechanism. Information about the surgical procedure and what to expect after the operation should be tailored according to the patient’s preferences regarding the type and amount of information.


The substitution of reference drugs for similar, new or existing drugs in the market is a dilemma present in daily dental procedures. In order to decide whether or not to adopt a new drug in relation to the reference, a clinical trial can provide the necessary evidence.A total of 179 healthy volunteers (18–25 years) requiring extraction of mandibular third molars completed the study. Subjects were randomized into 4 groups: right, left, Arteek-SP and Septanest. Allocations consisted of 4% Articaine hydrochloride with 1:10000 epinephrine. The primary aim of this randomized controlled trial was to determine whether the test drug Arteek-SP was noninferior by a margin of 10% in the proportion of patients with total absence of pain, compared to the reference drug Septanest in the extraction of mandibular third molars using inferior alveolar nerve blocks. Secondary outcomes included, hemodynamic parameters, volume (mL), pain scores assessed during one visit and reported postoperative discomfort assessed during 8 days. Noninferiority was declared if total absence of pain for both groups was equal to 0.9, with a significance level of 5% (P < 0.05) and power at 90% (β = 0.1) at 95% confidence level.Arteek-SP was applied during the first surgery to 90 volunteers (50.28%) and Septanest was applied to 89 subjects (49.72%). Less than 10% difference was identified, in the proportion of patients with total absence of tooth pain P < 0.05 and in the gum P < 0.1, at 95% CI, when Arteek-SP was applied first in comparison with Septanest, establishing noninferiority.The clinical performance of the test drug Arteek-SP is noninferior to the reference drug Septanest. They can be considered interchangeable in terms of cost or convenience.ClinicalTrials.org, number NCT4166890. Local anesthetics, amides, pain, oral surgery, nerve block, clinical studies. This siThe most common local anesthetic used in dentistry is Articaine, a tertiary amine. Articaine has good liposolubility properties that diffuse easily through soft and hard tissue, exerting adequate pain control , 7. ArtiThe primary aim of this study was to compare non-inferiority of the test formulation Arteek-SP produced by NewStetic, Colombia, on the assumption, it was at least as effective, following IANBs, gum flap, osteotomy, tooth section, extraction and suture, to the reference formulation Septanest produced by Septodont, France. Reported outcomes were on the basis of time, injected volume of solutions and pain. A secondary objective of this study was to evaluate the safety of the test drug compared to the reference drug, regarding hemodynamic parameters, adverse effects, and postoperative complications. Our null hypothesis stated that the sensitivity of pain in patients with the application of the tested drug Arteek is not inferior to the effect of the active control Septanest in the up to 10%.2A randomized, triple blind, controlled, crossover clinical trial was carried out on 179 subjects, in compliance with the CONSORT guidelines  , 11. EliExclusion criteria included medical history suggestive of known or suspected allergies to amides, systemic disease, pregnancy/lactation, subjects who took analgesics 24 h before and presented an episode of infection in the past 6 months.ClinicalTrials.gov (NCT04166890). All volunteers provided written informed consent after attending the study presentation and before any procedure was performed.This study was approved by the School of Dentistry ethics committee (02/2017), University of Antioquia, in accordance with Article 67 of the resolution 008430/93 of the Ministry of Health and Social Protection of the Republic of Colombia and registered in The sample size per group (n = 155) was calculated with the two-sample proportion test for Non-Inferiority function (TwoSampleProportion.NIS) of TrialSize Package version 1.4 for R . Based oThe subjects randomly received a combination of IANBs: 4% articaine HCL with 1:100,000 epinephrine  against 4% articaine HCL with 1:100,000 epinephrine  . The stuAn independent dentist blinded to the groups, prepared the treatments, color coded the anesthetics and marked them A or B. A pair of cartridges (blue-green) were labeled with the specified side (right or left) and packed in a numbered envelope (1–196); they were then delivered to each patient in order of arrival to the appointment. The treatment groups can be seen in Participants were asked to be present 30 min before the scheduled procedure to record baseline values regarding safety of the solutions. Heart rate (HR), blood pressure (BP) and oxygen saturation (SO2) were recorded before the administration of the anesthetic, 4 min after the injection, when pain was reported and after completion. The participants were instructed to self-report the pain intensity using their hands, when requested during the procedure, following the Heft-Parker visual analog scale (VAS). A scale from 0 to 10 was used, where 0 corresponded to no pain and 10 to unbearable pain .The same surgeon (C–P.L.) performed all the inferior alveolar nerve blocks (IANB). According to the randomization, molar 38 was extracted first followed by molar 48 in the second surgery. Volunteers received 1.8 mL of anesthetic solution (either NewStetic or Septodont). After this injection, every volunteer received an additional injection of 0.7 mL of the same articaine solution into the area to guarantee complete anesthesia of the area. The procedure commenced, when VAS scored 0 for gum, tongue and lip, following a standard protocol , 17, 18.The primary outcome of the study was to measure the onset of the anesthesia when the tactile and painful sensitivity were blocked (2–6 min after administration of the anesthetics). When the inability to block tactile sensitivity or painful sensitivity after 10 min occurred, or there was a need to use more than two cartridges or reach a dosage of 120 mg of articaine per procedure, it was considered as a failure.The secondary outcomes were assessed evaluating the dose-response values, injected volume (mL) and time, simultaneously with the visual analog pain scale. Duration of the anesthetic effect was measured 4 min after the initial administration of the anesthetic solutions, until the volunteers expressed sensitivity and pain to stimuli. The safety of Articaine solutions was evaluated by the recording of hemodynamic parameters, and self-reported postoperative discomfort.Statistical comparisons between the surgery duration, time of latency, onset of the anesthesia, and vital signs were tested non-parametrically using the Kruskal-Wallis test. Differences in the proportions of patients that required complementary anesthesia or reported pain sensation between the anesthetics were evaluated with a two-proportions Z-test. The Wilcoxon test was used to compare the mean VAS score. All statistical tests were carried out at P < 0.05 significance level in R version 1.4 .3A total of 179 healthy volunteers needing bilateral extraction of mandibular third molars with no clinical sign of eruption were included in the study. Ninety-six percent of the participants (both genders) came from low-income socioeconomic backgrounds . The sumThe duration (latency) of both anesthetics showed very similar and non-significant results (P > 0.05) in different mouth zones – gum, lip, tongue, and tooth as depicted in However, the average of injected volume of anesthetic revealed a significant difference between Arteek-SP and Septanest (0.131 mL) E, where During tooth section, 74% of volunteers reported pain and 58% of them in the gum at 9.08 ± 0.19 min for Arteek-SP and 8.94 ± 0.17 min for Septanest A, 3B. Av4Most of the participants of this study were considered as vulnerable students needing extra support with a higher number of females participating in the study , howeverIn the present study, the hemodynamic parameters were statistically insignificant before and after the completion of extraction (P > 0.05). There was a heart rate increase during the first 10 min caused by the application of both brands and gradually decreased to the initial values after the completion of the procedure. These results were congruent to previous studies reported by other authors , 23, 24 As previously reported by other authors, there was a sudden hypotension recorded soon after the administration of the Articaine solutions (Arteek-SP and Septanest). It returned to baseline values within an hour after the injection. There were no statistical differences in the values of the systolic and diastolic blood pressure 1 h after (P > 0.05) , 25. ThePain measurement is always difficult to establish, because its perception and intensity are multifactorial, however the direct self-report is the most common in clinical practices . The cliThe onset of the anesthesia and pain control are consistent with other reports evaluating 4% Articaine , 28. TheFurthermore, the use of the visual analog scale, which is a widely used and proven method, still presents challenges to measure pain, due to its individual perception and multifactor causes C. Thus, The proportion of patients with total absence of pain, showed less than 10% difference. In conclusion, the results of this study showed that the test drug Arteek-SP was within the margin calculated compared to the reference drug Septanest establishing noninferiority. This study provides valuable information to make an evidence-based decision to adopt or substitute anesthetic brands in daily clinical practice for effective management of surgical tooth extraction, in terms of availability, cost or convenience.David Arboleda-Toro: Conceived and designed the experiments; Wrote the paper.Liliana Castrillon-Pino: Performed the experiments.Yuliana Andrea Osorio Osorno: Contributed reagents, materials, analysis tools or data.Lenka Toro: Analyzed and interpreted the data; Wrote the paper.Nathalia Maria Vanessa Florez-Zapata: Analyzed and interpreted the data.New Stetic S.A., Guarne, Colombia.This work was supported by Data will be made available on request.The authors declare no conflict of interest.ClinicalTrials.gov under the registration number NCT04166890.The clinical trial described in this paper was registered at No additional information is available for this paper.


In patients with contracture-related pain, the average NRS score was 3.53 before BT injection, and 0.41 one month after BT injection (p = 0.0001). Conclusions: Juvapen is a less-painful injection technique than the standard one. BT reduces contracture-related pain one month after injection.It is well-established that botulinum toxin (BT) injections improve quality of life in patients with postparalytic hemifacial spasm. Nevertheless, injection-related pain and contracture-related pain have not yet been studied. The primary objective of our study was to evaluate injection-related pain in patients with facial palsy sequelae, and to compare the standard technique (syringe) with the Juvapen device. The secondary objective was to evaluate the improvement of contracture-related pain one month after BT injection. Methods: We conducted an observational, prospective, monocentric study based on 60 patients with facial palsy sequelae who received BT injections in our university ENT  department. There were 30 patients in the Juvapen group (J) and 30 in the standard technique group (ST). All patients completed Numerical Rating Scale (NRS) questionnaires immediately after the injections and one month later. Results: The average NRS score was 1.33/10 with Juvapen and 2.24/10 with the standard technique ( Peripheral facial palsy incidence is about 0.2 per 1000 per year. One third of patients with peripheral facial palsy do not fully recover and have chronic sequelae, particularly postparalytic hemifacial spasm [Juvapen is a cordless motorized injection system produced by Juvaplus and intended to assist practitioners with injecting botulinum toxin. Both techniques, standard and Juvapen, use the same 30-gauge needle. Juvapen can be operated in two specific positions due to its ergonomic handle. Gentle pressure on its plastic button delivers a selected volume of botulinum toxin at a controlled speed. The speed and the depth are calculated in order to decrease the injection-related pain [The primary objective of our study was to evaluate injection-related pain in patients with facial palsy sequelae, and to compare the standard technique (syringe) with the new Juvapen device. The secondary objective was to evaluate the improvement of contracture-related pain one month after BT injection.Sixty-two patients with post-paralytic hemifacial spasm received BT injections in our university ENT department between February and April 2021. All patients had either postparalytic hemifacial spasm , flaccid palsy , or both. We excluded two patients: one with facial diplegia and another who was treated for Frey syndrome. Thirty patients were injected with the standard technique (ST) and 30 patients were injected with the Juvapen device (J). The two groups were comparable . There wn = 9 in J group; n = 7 in ST group). The average NRS score was 3.53/10 before the injection in patients who reported contracture-related pain. No difference between the two groups was found: the average NRS score was 3.42/10 in the J group and 3.64/10 in the ST group.Before injection, 16 patients reported pain related to muscle contractures  . On the healthy side there was no significant difference between the two injection techniques.During the injection, the global average NRS score was 1.30/10 in the J group and 2.04/10 in the ST group ( = 2.58) . On the On the affected side the NRS score with J was significantly lower than with ST on peribucal and periocular territories . There wp = 0.0001; Z = 7.96). A total of 88.8% of patients with contracture-related pain before the injection reported being satisfied after BT administration.Eighteen patients (30%) had contracture-related pain before botulinum toxin injections. Their average NRS-score was 3.53/10 before injection and 0.41/10 one month after injection  vs. the Juvapen device. The first thirty patients were injected using the standard technique and the last thirty received Juvapen. The BT used in the study were Botox 100, Botox 50 , Xeomin 100 and Xeomin 50 .We included patients older than 18, with synkinesis sequelae of facial palsy or post-paralytic hemifacial spasm. We excluded patients with Frey syndrome or hemifacial spasm due to vascular-nervous conflict, and patients with facial diplegia. All patients gave their informed and written consent according to IRB approval number 20210322165101 (APHP registry).The following data were collected: demographics  and etiology of facial palsy); BT injection territories ; and Numerical Rating Scale (NRS) pain score from 0 to 10 before, during, and after (one day and one month) injections. Patients were specifically queried about their contracture pain. Patients were also asked if they would desire analgesic drugs for their next injections. Patients were blinded to the injection technique and, in fact, were not aware there were different injection techniques being used in the department. During the collection of the NRS, double-blindness was not an option as the injector was aware of the injection technique.The Juvapen is a cordless, motorized injection system produced by Juvaplus for use by practitioners to inject botulinum toxins. It can be used with a traditional 0,5 mL syringe and 30 to 35-gauge needles. Juvapen can be operated in two specific positions due to its ergonomic handle. Gentle pressure on its plastic button delivers a selected volume of BT at a controlled speed. The speed can be adjusted in order to decrease the injection-related pain and minimize toxin loss.p < 0.001 and suggestive if p < 0.05 [Our main objective was to compare the pain during injection using the standard technique relative to the pain experienced using the Juvapen device. For this, we compared the pain’s global score by averaging the NRS of all injected territories. Therefore, we had two independent samples that did not follow a normal distribution. The data were nonparametric, and we used a Wilcoxon test to compare the two groups. We then compared the two groups based on the average pain in the affected areas after injection, and subsequently in healthy areas that underwent injection. On affected territories that had been injected, we also compared the pain by region . The secondary objective was to compare contracture pain before injection versus pain one month after injection. For this, we used a Wilcoxon test for paired magnitudes. For all tests, significance was considered if p < 0.05 .


BackgroundWe hypothesize that revision surgery that includes soft tissue releases for patients with residual pain and reduced range of motion following rotator cuff repair can provide pain relief and improvement of motion and function.MethodsPatients were identified via a retrospective chart over a 10-year period who had a history of previous rotator cuff repair and had revision surgery with or without a rotator cuff repair and soft tissue release. Changes in visual analog scores (VAS) pain score on a 10-point scale and shoulder motion including forward flexion and external rotation were evaluated from the preoperative visit to the postoperative visit.ResultsIn total, 73 patients underwent procedures to address their symptoms following failed rotator cuff repair. Patients that underwent soft tissue release with revision rotator cuff repair and those who underwent isolated soft tissue release had decreased postoperative VAS pain scores  and improved postoperative forward flexion (15.3° and 13.6° respectively). Patients that have had one previous surgery had decreased pain (absolute reduction of 3.2 points), increased forward flexion and external rotation (16.2° and 4.9°). Patients that underwent two or more previous surgeries had decreased pain (absolute reduction of 1.8 points) and increased forward flexion (12.7°). Patients who were filing a Worker’s compensation claim also had decreased pain (absolute reduction of 2.2 points) and increased forward flexion (14.9°). Overall, there was a VAS pain scores absolute reduction of 2.6 points or 49.5% when examining the entire patient population.ConclusionOperative management by performing soft tissue release with or without concurrent revision rotator cuff repair is successful for both decreasing pain as well as improving motion. This effect was noted both in patients with commercial insurance and worker’s compensation claims. Improvements of pain and motion were more significant in patients who had undergone one prior surgery compared to those who have had multiple prior procedures. Rotator cuff tears are a common cause of pain and disability, with a prevalence of approximately 20% in the general population and >50% in patients greater than eighty years old -4. WhileRisk factors for failure of tendon healing include age, size of the tear, amount of tendon retraction, chronicity of the tear, and fatty degeneration ,13,14. TAs the authors gained more experience with treating patients referred for a failed rotator cuff surgery, the importance of recognizing and treating the postsurgical joint contracture that often was associated with these cases became apparent. We hypothesized that patients who underwent a revision surgery following a failed rotator cuff surgery also required soft tissue releases. We also hypothesized that patients with residual pain and decreased range of motion will see improved pain relief and range of motion, both when the previous rotator cuff repair is intact and when a revision repair is indicated. We believe that pain can be improved independent of whether a revision rotator cuff repair is indicated and that soft tissue release alone can be effective to improve pain control. We aim to determine the effects of soft tissue releases as part of the operative management for patients in the setting of failed rotator cuff surgery with residual shoulder pain and stiffness and examined patients who underwent a soft tissue release after failed rotator cuff surgery with or without a revision rotator cuff repair.Patient selectionPatients surgically treated by a single surgeon were identified via a retrospective chart review of cases from Institutional Review Board (IRB) study 00011713 which identified patients from our institution’s enterprise information management system with the Current Procedural Terminology (CPT) code 29825 from 01/01/2010 to 01/01/2019. Inclusion criteria consisted of patients with prior rotator cuff repair who presented with continued pain and stiffness and who subsequently underwent revision surgery to manage their symptoms. The procedures performed were categorized as soft tissue release with revision rotator cuff repair and soft tissue release without revision rotator cuff repair. Patients who were incarcerated, <18 years old at the time of surgery, or pregnant were excluded. Of note, patients with arthritis were not excluded.Information obtained from chart review included preoperative and postoperative visual analog scale (VAS) pain scores, preoperative and postoperative shoulder flexion, preoperative and postoperative external rotation, number of prior surgeries performed, the surgery performed, and Worker’s compensation status. Utilizing this information, we classified the patients into sub-groups to analyze the effectiveness of surgical intervention based on: Number of prior surgeries, surgery performed (soft tissue release with revision rotator cuff repair vs soft tissue release without revision rotator cuff repair), and insurance status .AnalysisChanges in VAS pain score as well as shoulder motion measurements, including forward flexion and external rotation were calculated. Improvement in pain scores was reported as both percentage of pain relief and absolute VAS reduction from the preoperative visit to the postoperative visit. Paired t-tests and descriptive statistics were performed using Graphpad Prism8 .Preoperative clinical assessmentWhen evaluating patients in clinic with continued pain after rotator cuff repair, it is critical to observe range of motion, particularly forward flexion and external rotation. While it is important to assess active range of motion, perhaps more important in the case of continued pain after repair is the active-assisted or passive range of motion. Patients with persistent pain and reduced range of motion compared to the contralateral shoulder and limited function underwent magnetic resonance imaging (MRI) to evaluate the integrity of the healing repair as well as for other potential pathology such as arthritis at the glenohumeral joint. Patients that had evidence of a recurrent rotator cuff tear >50% thickness on MRI who had persistent symptoms were considered candidates to undergo soft tissue releases with revision rotator cuff repair. Patients that had either <50% thickness tear on MRI or an intact rotator cuff were considered candidates to undergo soft tissue release without revision rotator cuff repair.ProcedureAll surgeries were performed by the senior author. An examination under anesthesia was performed prior to incision to provide a baseline range of motion. Standard anterior, posterior, and lateral arthroscopic portals were utilized. After the initial diagnostic arthroscopy, including evaluation of the rotator cuff tendon, attention was turned to release of the soft tissue structures. This begins while intraarticular with lysis of adhesions, release of the rotator interval and anterior capsule until normal compliance of soft tissues, and release of scarring about the biceps tendon. It is critical to debride the synovium in the rotator interval and work medially toward the coracoid process. The rotator interval adhesions contribute most significantly to the loss of external rotation with the arm in adduction. Often there is synovitis posteriorly in the joint around the posterior labrum which can be debrided. In some cases, the rotator cuff is also scarred to the superior labrum and this can be carefully released to avoid iatrogenic injury to the suprascapular nerve and re-create the normal “gutter” between the labrum and the rotator cuff. Range of motion can be reevaluated intraoperatively with a gentle manipulation to complete the effects of the release. Caution must be taken when debriding anteriorly around the subscapularis to avoid iatrogenic injury of the tendon. When releasing the capsule, particular attention should be taken to the superior and anterior capsule. After completing the anterior release intraarticularly, the subacromial space was entered. A thorough subacromial and subdeltoid decompression including bursectomy was performed with removal of adhesions. Often the normal space between the humeral head/rotator cuff and acromion is obliterated and the surgeon takes time to re-create the normal space between the undersurface of the deltoid and the rotator cuff, particularly if the previous surgery was performed with an open deltoid splitting approach. Finally, the rotator cuff was evaluated. Repair was performed based on surgeon preference depending on the size and repairability of the tear. There was not a standardized protocol for repair, but left to the surgeon’s experience. In general, tears were repaired with suture anchors in a simple fashion. Repairs were performed to avoid significant tension at the time of the repair. Postoperatively, patients that only underwent soft tissue release without a rotator cuff repair started an early range of motion rehab protocol that began on postoperative day one. Patients that underwent a rotator cuff repair had limited weightbearing for six weeks followed the standard rotator cuff repair rehab protocol and began strengthening exercises at three months.Patient cohort and demographicsSeventy-three patients were identified and included for analysis. Average age at the time of procedure was 53 years old (range: 25-74 years old). Fifty-five of the 73 patients had a recurrent rotator cuff tear >50% thickness identified on MRI prior to revision surgery and underwent soft tissue release with revision rotator cuff repair. There were no patients in our cohort that had an irreparable tear. The remaining eighteen patients either had an intact or healed rotator cuff or partial thickness tear <50% thickness which was not indicated for repair and underwent soft tissue release without revision rotator cuff repair or debridement. The majority of patients had right-sided repair (n = 43). Average postoperative follow-up time was eight months with a range of three to 29 months. Only one patient had the minimum follow-up of three months and was then lost to follow up for other medical issues. Sixty-nine of the patients included in this study identified as white, two identified as black, and two identified as Hispanic. Forty-six were male and 27 were female  as well as with other insurance payers (n = 38) . The average improvement of forward flexion was 14.7° (P < 0.0001) and external rotation was 4.8° (P = 0.007).Performing a soft tissue release was effective in improving pain as a primary surgical intervention when a patient had residual pain and stiffness without a recurrent tear. Soft tissue release was likely an important adjunctive intervention for patients with residual pain and stiffness in conjunction with a revision rotator cuff repair, but it is hard to know how much the soft tissue release or the rotator cuff repair helped in alleviating pain. This effect was most significant in patients who had fewer previous surgeries (most significant with one previous surgery) where results demonstrated both decreased pain scores and improved range of motion. While there was not a statistically significant change in pain reduction and shoulder motion, there was a general trend showing improvement in both pain and range of motion in patients that had underwent three or four previous procedures. A notable finding was performing soft tissue releases with or without concurrent rotator cuff repair lead to decreased pain scores and improved range of motion in patients with Worker’s compensation claims, as well as those with commercial insurance. We would propose that patients who have failed previous rotator cuff surgery often present with a concomitant shoulder contracture and can benefit from soft tissue release procedures alone. When describing the effectiveness of performing soft tissue release with or without RCR, patients demonstrated approximately 50% reduction in pain.The effectiveness of soft-tissue releases can be attributed to the broad statement that stiff shoulders are painful shoulders. While patients with pain after rotator cuff surgery do not have the same pathophysiology as patients with adhesive capsulitis, they both often present with pain, specifically worsened at the extremes of motion, and limited range of motion. Postoperative stiffness after RCR differs from adhesive capsulitis as the pathology is the result of contracture from surgical scaring, subacromial scaring, or tightness from tendon repair. While adhesive capsulitis often resolves with non-operative management, post-surgical shoulder stiffness is not as likely to resolve with nonoperative management. Once a patient develops a chronic postsurgical rotator interval contracture, it can be very difficult for them to gain this motion back with therapy alone, and perhaps operative soft tissue releases should be considered for these patients.Areas that were targeted for postoperative shoulder stiffness were the rotator interval, the capsule, the subacromial space, and the subdeltoid space. These areas were debrided to mobilize the surrounding soft tissues and address limitations with external rotation and forward flexion. Our results show that revision rotator cuff repair is only part of providing patients with clinical improvement following previous failed rotator cuff surgery.Almost half of the patients included in this study were receiving care under a Worker’s compensation claim (n = 35). Prior studies have shown patients with worker’s compensation claims undergoing revision rotator cuff repairs have worse clinical outcomes when compared to patients with commercial insurance ,17. OverSome other alternatives have been suggested for managing failed rotator cuff repairs. Many methods focus on addressing the rotator cuff tear itself, such as performing tendon transfers; however, most do not address managing pain or range of motion specifically. One method focused on addressing pain and movement is Matsen et al. smooth and move procedure. The focus of this procedure is to smooth the proximal humerus and coracoacromial arch and then working with physical therapy to make gains in range of motion which helps patients stay mobile and limit pain ,19.One limitation to this study is that data were obtained retrospectively. Method of measurement of range of motion was not always recorded, and unable to be determined if they were obtained through visual inspection or use of a goniometer. Range of motion angles were obtained by two different observers (the attending surgeon and an advanced practice provider) and no interobserver reliability was assessed at the time of obtaining values. These factors could have led to an underestimated or overstated range of motion change.Another limitation to this study is the small sample size. We could not sufficiently support statistical significance for patients with two, three, or four previous surgeries. However, there was a trend in the data where most patients had substantial pain reduction and improved range of motion. The few outliers that were present in the small group size had a substantial effect on the results. When examining the entire cohort of patients that had underwent ≥2 surgeries (n = 28), soft tissue release did have statistically and clinically significant improvement in pain and shoulder flexion. This supports that soft tissue release with or without revision rotator cuff repair for residual pain and stiffness could potentially be effective for this population, but would require a larger analysis.Performing soft tissue release with or without concurrent revision rotator cuff repair improves pain and motion for patients with residual pain and stiffness after previous rotator cuff repair. It is important to note that those patients with a healed rotator cuff repair also benefitted from surgery, and thus these patients should not be ignored. This was demonstrated for both insured and worker’s compensation patients. Performing soft tissue releases for these patients may be an answer to improve their symptoms. We recommend that patients with persistent pain and decreased range of motion in the setting of previous rotator cuff may benefit from operative soft tissue release. This procedure could be beneficial with or without revision rotator cuff repair and should also be considered in symptomatic patients with healed rotator cuff tendon repairs.


Chronic inflammatory joint diseases (CIJD) have been linked to increased cardiovascular morbidity and mortality. A decisive reason could be a dysregulation of the autonomic nervous system, which is responsible for the control of cardiovascular function. So far, the cause of changes in autonomic nervous system functions remains elusive. In this study, we investigate the role of chronic pain and the insular cortex in autonomic control of cardiac functioning in patients with CIJD.We studied the autonomic nervous system through the assessment of heart rate and heart rate variability (HRV) at rest and under cognitive stimulation. Furthermore, we investigated insular cortex volume by performing surface-based brain morphometry with FreeSurfer. For this study, 47 participants were recruited, 22 individual age- and sex-matched pairs for the magnetic resonance imaging analyses and 14 for the HRV analyses. All available patients’ data were used for analysis.n = 20). In a multiple linear regression model including only CIJD patients with heart rate at rest as a dependent variable, we found a significant positive relationship between heart rate at rest and the volume of the left insular cortex and a significant negative relationship between heart rate at rest and the volume of the right insular cortex. However, we found no significant differences in HRV parameters or insular cortex volumes between both groups.Pain duration was negatively correlated with the resting heart rate in patients with chronic inflammatory joint diseases .The study was preregistered with the German Clinical Trials Register ( Chronic inflammatory joint diseases (CIJD), such as rheumatoid arthritis (RA) and ankylosing spondylitis, are commonly associated with disability and pain . CIJDs hThe function of the ANS can be assessed by measuring heart rate and calculating heart rate variability (HRV), i.e. the variation of the length of the R-to-R-wave time interval , 9. In pHowever, the reasons for these changes in ANS function in CIJD remain elusive. In 2006, Dunn and Croft for instance showed the importance of pain duration in patients suffering from chronic low back pain. According to their results, the prognosis of chronic back pain was dependent on pain duration. It therefore seems feasible to hypothesize that pain duration might also impact bodily systems like the ANS, represented by changes in HRV .The ANS is controlled by centers in the brainstem, the hypothalamus, and, ultimately, by several cortical regions, including the insula, anterior cingulate gyrus, and medial frontal cortex , 14. TheWartolowska and colleagues have investigated morphological changes in the brains of patients with rheumatic diseases. Although they did not investigate cortical regions, they described morphological changes in subcortical areas, including the caudate nucleus, putamen, and nucleus accumbens . SimilarThe aims of the present study hence were a) to evaluate differences in HRV at rest and under stimulation between the CIJD and control groups, b) to test whether pain duration might be associated with changes in heart rate and heart rate variability in patients with chronic inflammatory joint diseases, and c) whether altered HRV is associated with structural changes in ANS-controlling cortical areas such as the insular cortex.https://www.drks.de; DRKS00012791). All participants gave written informed consent prior to participating in this study. Participants  were recruited between July 2017 and March 2019. All measurements were performed at the Neuroimaging Unit, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg. All data were collected as a part of a larger study, which, in addition to the data evaluated here, included functional magnetic resonance imaging (MRI) and behavioral tests [The study was approved by the Medical Research Ethics Board of Carl von Ossietzky University of Oldenburg, Germany (#2017–059) and was preregistered with the German Clinical Trials Register .Pregnant women and participants with contraindications for MRI were excluded, in addition to participants with conditions that could have had an influence on HRV or cerebral functions: previous heart surgeries; heart failure stage > 2 of the New York Heart Association’s classification ; peripheFirst, each participant completed a questionnaire including information about demographic and clinical characteristics, such as pain, co-morbidities, and suitability for MRI-examinations. Next, structural and functional MRI was performed while the measurements of HRV at rest and under cognitive stimulation were carried out.Information about the diagnosis, pain intensity, duration of pain, and medications were collected in the CIJD group. Pain intensity was assessed using an 11-point numerical rating scale  . PhotoplThree functional MRI experiments were performed: an arithmetic experiment with two subtraction tasks, a number line identification experiment, and a resting-state measurement. Here, the HRV signals recorded during the arithmetic experiment and the resting-state measurement were analyzed as a marker of autonomic function . The anahttps://www.mccauslandcenter.sc.edu/crnl/tools/part) was used to link the starting points of the MRI tasks and pulse oximetry measurements. The MRI measurements included 205 volumes each in the arithmetic task and resting state. For the analysis of the pulse oximetry measurements, the first 4 volumes were deleted. This led to a duration of 6 min and 42 s for each HRV measurement.The Physiological Artifact Removal Tool , which is an established software for assessing ANS function [2/Hz. The frequency ranges for the absolute power measurements were as follows: LF = 0.04–0.15 Hz and HF = 0.15–0.4 Hz [Data processing and calculation of the HRV via pulse oximetry measurements were performed with Kubios HRV standard  on Mac OS high sierra (Version 10.13.6), started with the extraction of the cortical  surface. Due to the hybrid watershed/surface deformation procedure, non-brain tissues were removed [The image analysis, performed with FreeSurfer  [p <  0.00625 was considered significant. The obtained correlation coefficients were interpreted according to Cohen as small (r = 0.1), medium (r = 0.3), or large (r = 0.5) [n = 20) was computed with SDNN and HR at rest as dependent variables. The model corresponded to the regression model described above, only that the variable age was exchanged for pain duration and the variable group was deleted. Results were considered statistically significant if p <  0.05.All statistical analyses were performed using SPSS 25 . Data were analyzed for normal distribution employing Shapiro-Wilk tests. SDNN, LF, and HF were logarithmically transformed to approximate normal distribution. Demographic data were first analyzed descriptively. To determine possible differences between the demographic data of the groups, an independent samples t-test (age) and Chi-Square tests  were used. Mixed-effects analyses of variance (ANOVA) was employed to evaluate possible differences between the HRV parameters in the different measurements and between the matched groups (C = 14 vs. CIJD = 14). Results were considered statistically significant if  effect) . Next, p effect) . After Br = 0.5) . IndepenFigure p = 0.896), smoking status  = 0.990, p = 0.605), or formal education  = 2.109, p = 0.550). No participants were taking opioids, benzodiazepines, or anticonvulsants at the time of the study. Seven CIJD patients were taking glucocorticoids at the time of the study; four CIJD patients had taken glucocorticoids previously. No control participant had ever taken glucocorticoids. Antidepressants had been taken previously by one person in each group. One CIJD patient was taking a low-dose tetracyclic antidepressant at the time of the study, and none control participant. No included participant was on antihypertensive medication that could have influenced the autonomic nervous system.Table https://github.com/RainCloudPlots/RainCloudPlots) [Mean heart rate and heart rate variability at rest and under cognitive stimulation are demonstrated in Table udPlots) . Furthern = 20) demonstrated a significant negative correlation between heart rate at rest and pain duration independent of age and sex , there was no correlation between the heart rate and pain duration .CIJD patients (p = 0.832) and the right insula (t (42) = 0.165, p = 0.870). The general linear regression model including both groups  with HR as dependent variable showed no significant differences . The SDNN model including group, age, sex, and insula volume in both hemispheres showed significant results and explained 23% of the variability . However, the only relevant variable was sex. The second subgroup regression model (n = 20) was used to predict HR with pain duration, sex, and volume of the insular cortices in both hemispheres. The subgroup regression explained 66% of the HR and 39% of the SDNN variability . Tables Employing independent t-tests of insula volume with eTIV normalization , we found no significant differences between the matched groups in the left (t (42) = 0.214, Our results provide evidence for an inverse correlation between HR and pain duration in patients with chronic inflammatory joint disease at rest. Moreover, both healthy volunteers and patients with CIJD showed a similarly adequate cardiovascular response during cognitive stimulation . Finally, our data suggest that structural changes in the insular cortices are related to changes in heart rate in CIJD patients.r = − 0.743) at rest, while controlling for the influence of age and sex. To the best of our knowledge, this is the first report of an association between resting HR and pain duration in patients with CIJD. The dependence of age and HR decrease was already reported in previous studies [The present data provide evidence for a negative association between HR and pain duration with a large effect size ( studies , but cou studies . In an a studies . One pos studies . This noIn humans, studies on HR in chronic pain caused by CIJD provided mixed results. For example, Rensburg and colleagues found a significantly higher basal HR in women with RA , whereasSimilarly, studies on heart rate variability in patients with chronic pain are inconclusive and the selected HRV parameters differ . For exaIn our study, we not only measured HR and HRV at rest but also during cognitive stimulation. As expected, HR increased in healthy controls during serial subtraction . InteresProcessing of nociceptive input is a highly complex function of the brain, involving multiple brain regions as well as excitatory and inhibitory mechanisms. Structural MRI studies in chronic pain patients have been inconclusive so far with some showing increased and others, decreased cerebral gray matter density , 73. ForOne of the major strengths of this study is the matching of patients and controls on an individual basis. Further, this study examined diseases that are based on similar pathophysiology. Nevertheless, further research and longitudinal studies are needed to investigate the influence of chronic pain in patients with rheumatic diseases. There is some evidence that changes in brain areas caused by chronic pain were reversible after pain relief . It is pIn summary, our results suggest that HR at rest is negatively associated with the pain duration of CIJD patients, independent of the participants’ age and sex. Further, our data established the possibility of insular cortex involvement in the process of ANS changes.


Knee osteoarthritis is a common arthritic disease which mainly affects the elderly (≥65 years old) population. As a result of the cartilage degeneration, it can cause a significant amount of pain and functional limitation. In patients who are refractory to conservative management, total knee arthroplasty is being utilised as the last resort in management. In this review, we discuss the perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty. Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 3 June 2020.Osteoarthritis (OA) is a degenerative disease which affects the weight-bearing joints, preventing individuals from participating in activities of daily living and work . OA of tThere is currently no treatment that can adequately halt or reverse the progress of OA, with the mainstay of treatment being conservative lifestyle advice, pharmacological analgesia and appropriately timed surgical interventions . In patiDespite its success in improving the quality of life in patients, TKA is associated with considerable acute postoperative pain, which if unrelieved may result in prolonged hospital stay and poorer functional outcomes . FurtherThe final objective for patients after TKA is to lead an active life, free from pain. This outcome is dependent on the operation along with the steps taken before and after the surgery in the perioperative phase to minimise any complications as well as to speed up the recovery process . TherefoPatient education is a crucial component of preoperative management, which involves informing patients about the physical effects of TKA, changes to anatomical ability post-surgery as well as the benefits and risks of TKA . FurtherObesity is a prominent risk factor for developing osteoarthritis by exerting deleterious effects on joints through both biomechanical and systemic inflammatory changes . It alsoThe systematic use of validated scales preoperatively such as the Oxford Knee Score, which is a patient-reported outcome measure specifically designed to assess knee function and pain before and after TKA, should be encouraged as it enables assessment of outcomes after TKA (BOA 2017).Preemptive analgesia is an analgesia strategy that uses analgesics before operation, which has been demonstrated to decrease postoperative analgesic consumption while exhibiting better analgesic effects . PreoperThe increased utilisation of opioids has been accompanied by concerns about their adverse effects on surgical outcome when taken prior to surgery. High doses of opioids have been associated with the development of opioid dependence and hyperalgesia, which could contribute to intractable pain . PatientThe administration of multiple doses of preoperative dexamethasone has been shown to improve clinical outcomes after TKA . MultiplPrehabilitation, which is the concept of preoperative physiotherapy and exercise programmes has been proposed as a potential way to expedite recovery times . It has Aside from mechanically based strength training, it has been shown that metabolic stimuli have the ability to counteract skeletal muscle atrophy . TherefoBefore carrying out any surgical procedure, it is imperative that the World Health Organization (WHO) checklist is performed in the anaesthetic room as well as the operating room where the identity of the patient is confirmed along with the surgical site marking as per documentation (WHO 2009). Planning and discussion of TKA among every member of the operative team are imperative to allow the procedure to proceed as smoothly as possible. This includes checking that the knee implant is specific to the patient before beginning the surgery and making sure that the implant is firmly in place by requesting postoperative X-rays to identify periprosthetic loosening.There are both advantages and disadvantages to the use of a tourniquet in TKA: tourniquets allow surgeons to obtain a clear visualisation of the operative field, reduce intraoperative blood loss and provide a cleaner field for cement penetration and fixation. However, the use of tourniquets may cause extensive rhabdomyolysis due to local muscle damage, nerve damage, delayed recovery, acute pain and need for analgesia .Non-tourniquet TKA surgeries are beneficial in preventing adverse effects such as DVT/PE, support early recovery of patients by maintaining muscle strength as well as decreasing pain and opioid consumption: more so in females compared to males . TherefoLarge blood loss after TKA remains a concern of surgeons, with total blood loss reaching 1.5 L on average, which then requires transfusions . AllogenThe use of intravenous tranexamic acid has been found to reduce the need of blood transfusions, as it decreases postoperative blood loss and reduces swelling . On the Managing a patient’s response to the stress of surgery can increase the chance of a favourable postoperative outcome. Acute postoperative pain may be a direct consequence of the operation or anaesthetic protocol; therefore, a multimodal drug cocktail injection which includes gabapentin, paracetamol and oxycodone as proposed by the ERAS protocol to the periarticular region can assist with analgesia in the initial postoperative period . PeripheLocal anaesthetics are also a core component of the multimodal pain management pathway, which seeks to relieve postsurgical pain with fewer side effects to facilitate recovery . ConventPlatelet-rich plasma injections that stimulate the natural healing cascade at the site of treatment were found to promote a favourable environment for joint tissue healing after TKA with a reduction in pain and improvement in knee function . HoweverAccelerated physiotherapy regimens, where the patient is mobilised within 24 hours of surgery are the most beneficial active physiotherapy interventions during the acute hospital stay following TKA . It reduIt is well known that muscle strength and function are reduced for a long period postoperatively with a reduction of up to 80% in knee extension strength after TKA . QuadricPostoperative limb positioning has been found to be a simple way to reduce blood loss and improve range of motion following TKA. Compared to other methods to reduce bleeding, which requires the use of dedicated instrumentations and risk of adverse drug reactions, a consistent limb position regime for 48–72 hours postoperatively represents an inexpensive and simple approach. Placing the knee in a flexion position has been shown to be effective in reducing total blood loss compared to when in extension; however, there is still no consensus regarding the optimal flexion position. Mild-flexion positions were superior in decreasing hidden blood loss, while high-flexion positions were superior in reducing transfusion requirements and improving postoperative range of motion . HoweverEarly anti-coagulation is essential for the prevention of thrombosis, but the benefits may be offset by an increased risk of bleeding because of the hyperfibrinolysis . In hospOther complications include postoperative delirium, nausea, vomiting, periprosthetic loosening and joint infections. A special emphasis should be placed on the early detection of infection as it can compromise the viability of the implant as well as cause chronic pain . TherefoTo conclude, knee osteoarthritis causes significant pain which requires surgical intervention when non-responsive to conservative management. Optimal perioperative management of these patients has the potential to improve recovery and prevent the development of chronic pain, which is crucial to ensure a successful outcome and to limit complications.Knee osteoarthritis causes significant pain and is commonly found in the elderly population.Total knee arthroplasty is indicated in patients who do not respond to conservative management.Prehabilitation found to expedite recovery time.Intravenous tranexamic acid administration reduces the need for blood transfusion.Accelerated physiotherapy regimens are effective in improving outcomes.


NCDs tend to be long-term and are caused by genetic, physiological, environmental, and behavioral factors. Currently, NCDs account for 71% of deaths globally. The current study aimed to explore whether patients with NCDs receive advice on health behaviors from healthcare professionals in the PHCs in the Gaza Strip, Palestine.This research applied a cross-sectional survey design in five PHCs from October 2019 to December 2019, with 360 patients selected using a convenience sampling technique. A structured questionnaire on sociodemographic, history and patients' views on receiving advice on health behaviors from health care professionals was developed and collected. Data were analyzed using descriptive analyses and a One-way ANOVA test through SPSS-v22.The patients reported receiving advice as follows: in terms of regular physical activity (54.5% ±13.6), in terms of eating a heart-healthy diet (49.3% ±11.5), in terms of treatment adherence (86.1% ±8.1), and in terms of stop tobacco for smokers' patients (43.9% ±16.8). Statistically significant differences were found between the five Gaza strip governorates in terms of regular physical activity, eating heart-healthy, and treatment adherence .Participants claimed that the vast majority of them had received advice from healthcare professionals regarding attending regular follow-up and treatment adherence. In contrast, participants reported receiving advice from health care professionals regarding regular physical activity, eating a healthy diet, and stopping tobacco are suboptimal. There is a need to develop a strategy to ensure that healthcare professionals are committed to providing advice on health behaviors. Non-communicable diseases (NCDs), or chronic diseases, tend to be long lasting and caused by genetic, physiological, environmental, and behavioral factors , 2. It iBesides, WHO-PEN protocol 2 is an essential tool in the implementation process, which is concerned with health education and counseling on healthy behaviors. The main instructions including progressively increasing physical activity to moderate levels; at least 150 minutes per week, restricting salt to less than 5 grams per day, five servings of fruits and vegetables per day, strongly advising all smokers to stop smoking and support them in their efforts, teach the patient how to take prescribed medications at home, and check the patient's understanding , 12. In Study designs: This cross-sectional study conducted from October 2019 to December 2019 in Gaza Strip, Palestine, used a convenience sampling technique.Study settings: The study was conducted in five government primary health care centers. The participants were selected from the five Gaza Strip governorates based on the population density. The Gaza Strip is divided into five governorates, including North Gaza, Gaza, Deir Al Balah, Khan-Yunis, and Rafah., both genders, aged ≥ 18, registered and receiving treatment in the five selected MOH-PHCs in Gaza Strip were taken as inclusion criteria. And the exclusion criteria were patients who did not receive treatment in the five selected PHCs or their medical files are not available, aged < 18 years old.Sample size: The traditional equation (Cochran) was used to calculate the sample size, the estimated sample size according to the equation is 384 cases, with a margin of error of 5% and confidence level of 95%. were used to represent continuous variables. A One-way ANOVA test was used to compare means between the five Gaza strip governorates. P-values of less than 0.05 were considered statistically significant.Ethics approval and consent to participate: The study protocol was approved by the Palestinian Health Research Council . Second, official letters were obtained from the MoH-General Directorate of Human Recourses Development. In addition, orally informed consent was also obtained from each participant.Three hundred and sixty patients with noncommunicable diseases agreed to participate in the study during the data collection period with a response rate of 93.7%. The study sample was distributed in each governorate as follows:  71, 124, 52, 69, and 44 patients respectively.Characteristics of the Study ParticipantsA total of 360 patients with NCDs were included in this study. The characteristics of the study participants are summarized in Patients with NCDs received advice on health behaviors from healthcare professionals: Data are expressed as Mean Percentages ±SD for continuous variables and as percentage for categorical variables. M±SD: Mean Percentages ± Standard Deviation.Patients with NCDs received advice on taking regular physical activity: The Mean percentages in terms of taking regular physical activity was reported as 54.5% ±13.6. Only 8.9% of the study participants claimed that they always or often received advice from healthcare professionals in the last twelve months to progressively increase physical activity to moderate levels ; at least 150 minutes per week. Patients with NCDs received advice in terms of eating a heart-healthy diet: Patients with NCDs received advice in terms of treatment adherence: Patients with NCDs received advice in terms of stop tobacco:Globally, the four major NCDs (cardiovascular diseases (CVDs), cancers, chronic respiratory diseases, and diabetes) account for the majority of deaths. These four NCDs share common behavioral risk factors including tobacco use, unhealthy diet, physical inactivity, and alcohol use. There is an extensive scientific agreement that these factors contribute significantly to NCDs morbidity and mortality , 4.Many studies were conducted by researchers worldwide and focus on healthcare professionals' adherence to counseling on healthy behaviors for NCDs patients from healthcare professionals' perspectives, as well as, from the patients' perspectives , 19, 20.Possible limitations are this study is a cross-sectional study and use a convenience sample technique, and it asked about the advice without considering who provide this advice (Physician or Nurse). Besides, the study focused on advice only and did not observe the exact time spend in the advice sessions, and it is based on self-reported data, which could lead to recall bias.In conclusion, Participants claimed that the vast majority of them had received advice from healthcare professionals regarding attending regular follow-up and treatment adherence. In contrast, participants reported receiving advice from health care professionals regarding regular physical activity, eating a healthy diet, and stopping tobacco are suboptimal. There is a need to develop a strategy to ensure that healthcare professionals are committed to providing advice on health behaviors for patients with non-communicable diseases. The results could help the decision-maker to plan for review the present way used by healthcare professionals to advising NCDs patients on healthy behaviors at the PHCs. Further future studies are required to confirm these findings.


The opioid epidemic continues to be a significant public health concern. On the surface, it appears difficult to understate the profound consequences and unnecessary loss of life at the hands of the opioid crisis throughout the 2010s. This reality should not dissuade rigorous attention toward those who have suffered unnecessarily due to an overreaching backlash toward the opioid crisis.Oncology patients have been significantly impacted on both ends of the opioid crisis. Like other populations, cancer patients were first affected during the initial surge of opioid availability, prescription, and use at the beginning of the crisis, where opioid abuse and overdose negatively impacted cancer patient populations at similar rates as the general population. Yet, cancer patients were perhaps even more heavily affected during secondary events after the initial crisis, as opioid restrictions and the stigmatization, undoubtedly beneficial in many spaces, of opioid use became prevalent across the American society. During this second period of the opioid crisis , restrictions on opioids have significantly decreased the use and access of opioids for cancer patients.Management of pain, in general, is a complex topic, and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, its treatment, or other comorbidities. This review aims to clarify the impact of reducing opioid use on cancer patients over the past eight years. We summarize the challenges facing providers as they attempt to manage cancer-related pain. Additionally, we propose tools for best practices to reduce the unnecessary suffering of cancer patients and protect against the overuse and abuse of opioids. The opioid crisis continues to be a significant public health concern. According to the Centers for Disease Control and Prevention (CDC), in 2019, there were nearly 50,000 deaths attributed to opioid overdose in the United States -6.In the era of novel targeted therapeutics and immunotherapy with the increasingly recognized diseases and diagnosing patients in the earlier stages of incurable cancers, the need for adequate pain management is expected as many patients experience a more chronic course. Currently, in the United States, there are approximately 15.5 million cancer survivors, and, of these, more than two-thirds have lived five years or more after their diagnosis, and 44% have survived 10 years or more .Globally, 8.2 million people die of advanced cancer each year. Interestingly, World Health Organization (WHO) estimates that around 6 million of these patients have inadequate or no access to strong opioids because of no increase in the availability of opioids for decades among the world’s poorest but most populated countries due to strict government regulations .Even in developed countries, at least 32% of cancer patients remain undertreated due to concern about abuse and increased restrictions of prescribing regulations for opioids ,11. OnlyThis restrictive attitude toward opioids exists due to the potential harms of these drugs; however, an extensive systematic review of 52 studies confirmed that 53% of people at all stages of cancer experienced pain, affecting approximately 64% of patients with advanced cancer . OncologDespite the known efficacy of opioids in relieving cancer-related pain, routine screening for the risk of aberrant opioid behaviors is not performed in common clinical practice. Limited published data on the frequency of aberrant drug use make this challenging for prescribers. This obstacle limits clinicians’ ability to determine the frequency and factors predicting the risk of drug misuse behaviors among patients in the outpatient setting, limiting pharmacologic therapies prescribed. Moreover, some formulations may aggravate the potential harms of addiction and mortality with other medications patients may be on such as benzodiazepines .Management of pain, in general, is complex and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, treatment, or from other comorbidities . Opioid Identifying the impact of opioid use on cancer patients is crucial; it is prudent to review the progress made in tackling the opioid crisis. In the United States, the 2000s and early 2010s marked a sharp increase in adverse outcomes related to opioids. This culminated in medication-focused guidelines such as the Veterans Health Administration Opioid Safety Initiative  and the CDC Guideline for Prescribing Opioids for Chronic Pain. Since then, there has been a decrease in the overall number of opioid prescriptions. Likely, this can be attributed to not only educating prescribers on this issue but also raising public awareness . There iOn the surface, reducing opioid prescriptions is encouraging, but it begs the question of whether cancer pain is adequately treated. It is important to note that the opioid prescribing guidelines by the CDC, for example, specifically do not pertain to cancer patients . A retroTherefore, the purpose of this review article is to identify the challenges facing the oncology population regarding opioid therapy. Additionally, we aim to provide a framework for treating cancer-related pain by reviewing tools useful for assessing cancer pain and general principles for prescribing, titration, maintenance, and safety of opioid use among cancer patients.Definitions and terminology of cancer-related painopioid use disorder as a pattern of opioid use leading to significant impairment or distress. Non-medical use includes using these prescription drugs by someone other than the intended patient and/or deviating from the deliberate regimen or reason. To achieve an intentional response, one must also identify if a patient has opioid tolerance, increasing doses to achieve the required effect [It is essential to be familiar with the terminology of opioid abuse or, more appropriately, opioid use disorder. The CDC defines d effect . Opioid d effect ,24.Screening for opioid misuseScreening can help clinicians tailor treatment options and monitoring strategies for patients. It is also essential to identify patients at risk of substance dependence. Genetics, drug availability, peer substance use, social norms about substance use, family history of drug use, and poor educational attainment are risk factors associated with opioid dependence.Opioid therapy is an effective treatment for pain among many patients, especially oncology patients. However, opioid misuse puts the patients at risk for addiction, overdose, and non-medical opioid use (NMOU). Using high opioid doses is more acceptable among oncology patients with short life expectancy than patients with non-malignant pain ,26.Risk factors of NMOU include a family history of drug abuse, poor social support, personal history of drug abuse, history of sexual abuse, and psychiatric illnesses such as major depression, bipolar disorder, or personality disorders ,27-29.Patients with chronic pain and a history of substance use may develop substance use disorder. Some patients with no prior substance use history may develop aberrant drug-related behaviors . AssessmProposed assessment toolsCancer pain comprises multiple pain syndromes with different etiologies. This pain may be a consequence of the malignancy itself, therapeutic interventions, or other comorbidities. No pain classification system is universally accepted as a standard. An example is the Edmonton Classification System for Cancer Pain. This tool can assess the complex nature of cancer pain by prompting the practitioner to review, albeit simplistically, the mechanism of the pain, whether addictive behavior is present, and the impact the pain is having psychologically and cognitively. In general, when assessing cancer pain, one should incorporate pain intensity, which can be measured on a scale of 1-10, the location, timing, and temporal variation. Timing distinguishes the pain as acute or chronic, with the caveat that it can be challenging to distinguish the two. Temporality assesses whether the pain is intermittent or continuous. The latter category serves to identify breakthrough pain episodes that can occur over a background pain level ,31.Though all assessment tools are imperfect, the details of the proposed assessment tools remain consequential. Uncontrolled cancer pain can lead to psychosocial consequences and poor quality of life. It can also cause distress and hopelessness and can impact a patient’s compliance with a treatment plan . When asPsychiatric diagnoses, substance misuse disorder or risk factors, medical comorbidities, and potential adverse drug interactions must be closely monitored. A multidisciplinary approach is beneficial and provides further insight into the obstacles of opioid use and misuse. This team includes, but is not limited to, medical and interventional pain specialists, physical and occupational therapy, psychiatrists and psychologists, and palliative care specialists. Safe opioid prescribing and monitoring techniques need to be implemented.1. Current Opioid Misuse Measure is a nine-question patient assessment tool designed to identify drug misuse during chronic opioid therapy; it is commonly used for long-term opioid treatment -35.2. Opioid Risk Tool is a five-question screening tool to predict the risk of drug misuse; it is widely used and included in smartphone apps, increasing its accessibility -38.3. Screener and Opioid Assessment for Patients with Pain-Revised is a 24-question tool used to predict drug misuse before initiation of long-term opioid therapy but has lower sensitivity than other tools ,39-42. P4. Urine Drug Monitoring is one of the few measuring tests available to assess opioid misuse. The test includes point of care testing, which is a dipstick; this testing is readily available and inexpensive .Universal precautions to limit non-medical opioid useEfforts to address the opioid epidemic require proactive partnerships, including healthcare providers, pharmaceutical industries, judicial personnel, emergency management personnel, and government agencies. Addressing the opioid epidemic requires a multidisciplinary approach to increase community knowledge and awareness, educate, and screen to help identify those at risk .Patients and caregivers need to be well informed about treatment with opioids, especially their side effects. Adverse effects may cause opiophobia among patients and caregivers and can trigger misunderstanding of the indications, resulting in inadequate use and/or misuse ,45. With1. Pain diagnosis: assess the pain intensity, location, and causes to determine the need for opioid therapy .2. Screening: using the risk assessment questionnaires to identify the risk of misuse before starting therapy .3. Informed consent: review, in detail, the risks, benefits, and side effects of opioid therapy . The inf4. Treatment agreement: obtain a verbal or written agreement on the therapy plan -52. One 5. Review and consider applying adjuvant analgesics to optimize the pain plan better.6. Implement a multimodal approach, including specialist referral: consider referral of patients at high risk of substance abuse -56.7. Subsequent monitoring: conduct follow-up, urine dipsticks, behavioral assessment, and therapeutic decision-making support ,58.8. Pain outcome assessment: assess the effect of the therapy plan.General principles for prescribingPain is the most frequent indication for opioid use in cancer patients; cancer-related pain is reported in 30-50% of patients who receive cancer therapy and 70% of patients suffering from advanced cancer.Pain in cancer patients is caused by metastasis, chemotherapy-induced neuropathy or mucositis, radiation-related adverse events such as dermatitis, or local mass effect. Moderate-to-severe pain is considered an indication of opioid use. Providers should assess the pain frequency, intensity duration, and site, as well as evaluate patients to avoid NMOU . PatientGeneral principles for titration and maintenanceMu-agonist opioids are the most used in cancer pain because of the absence of ceiling effects. There is no standard or fixed dose of opioids, with the dosing depending on patients’ needs, tolerability, pain frequency, and age. Younger patients need higher doses than older patients. Titration is necessary during treatment depending on the patient’s response and risk for NMOU.Parenteral Dose TitrationWhen using morphine, the previous total dose of morphine given in the last 24 hours is divided by three, and then divided by 24 to provide a continuous hourly infusion. Twice the calculated amount is administered initially, and the hourly dose is repeated every 15 minutes until the pain is controlled.Oral Dose TitrationThe last 24-hour doses are totaled and divided by the preferred frequency in 24 hours -62. DosiCancer patients who receive long-term opioid therapy are at risk of developing tolerance, dependence, and NMOU; hence, they need opioid maintenance therapy. Methadone and buprenorphine can be used. Buprenorphine is a semisynthetic opioid, highly bound and partial agonist on Mu receptors, and can be used in renal impairment. Methadone is a synthetic opioid agonist therapy that has an analgesic effect with controlling side effects.Buprenorphine/naloxone is another combination at a ratio of 4:1 to maintain the therapeutic effect and have some opioid antagonism effect of naloxone, which at a low dose controls the side effects without significant reversal of analgesia -67. PainGeneral principles for safetyOpioids have common side effects such as constipation, nausea, sedation, respiratory distress, and opioid-induced neurotoxicity (OIN). OIN consists of sedation, cognitive impairment, delirium, hallucinations, myoclonus, and opioid-induced hyperalgesia. Elderly patients or those using sedatives such as benzodiazepines or antihistamines are at a higher risk of OIN. Considering the side effects and dangers of NMOU and abuse, monitoring must be done frequently using assessment tools, urine drug tests, and routine lab work, as well as reducing daily doses when the pain is controlled ,68,69.Opioid misuse is a common challenge during the management of cancer-related pain during an opioid epidemic. However, it can be monitored and modified. It requires a multidisciplinary approach to pain management, increased awareness and education about opioid therapy, and screening to help identify those at risk for opioid misuse. We propose a multimodal approach involving psychiatry teams and interventional pain management for managing cancer-related pain. Utilizing general pain assessment and prescribing, titration, and maintenance strategies is key to successful pain management and limiting NMOU in the cancer population.