Single incision laparoscopic cholecystectomy has become more popular recently. Because it yields shorter hospitalization, less postoperative pain, and better cosmetic outcomes. As it minimizes the number of incisions, it causes less trauma to the anterior abdominal wall and this decreases the operative mortality and morbidity. In this study, our aim is to share our results from the procedure so that surgeons in the field may consider adopting this approach when performing a laparoscopic cholecystectomy.This is a retrospective study of 125 patients that underwent single-incision cholecystectomy. These patients underwent the procedure in a specialized center. We extracted data and surveyed patients who underwent the procedure between 2017 and 2019, and that were performed by the same consultant using the standard tools of laparoscopic surgery. All patients were followed for 12 months. The postoperative survey includes; the cosmetic appearance of the surgical site, pain management after the procedure, and patient satisfaction with this experience.2 and the mean operative time was 25.56 ± 10.42 min.Most of the patients were satisfied with postoperative pain management and their cosmetic appearance. Most of the patients were females diagnosed with cholelithiasis preoperatively. The mean age of the patients was 37.43 ± 10.72 years, the mean BMI of the participants was 29.68 ± 6.51 kg/mSingle incision laparoscopic cholecystectomy has the potential to become the procedure of choice for cholecystectomy. •Single incision laparoscopic cholecystectomy has become more popular recently. Because it yields shorter hospitalization, less postoperative pain, and better cosmetic outcomes.•Single incision laparoscopic cholecystectomy has shown exceptional post outcome patient satisfaction, and reduced operative time.•Single incision laparoscopic cholecystectomy might soon become the procedure of choice for cholecystectomy. . A considerable number of studies in various medical centers have concluded that single-incision laparoscopic cholecystectomy (SILC) results in shorter hospitalization, less postoperative pain, and better cosmetic outcomes ,2. Since2researchregistry8115.This is a retrospective cohort study for patients who underwent cholecystectomy in a specialized center between 2017 and 2019. Institutional review board approval was waived for the study. This study is reported in line with the STROCSS criteria . Researc2.1All patients undergoing single-incision laparoscopic cholecystectomy were eligible for the study. The inclusion criteria included all patients with sufficient demographic and follow-up data. Patients with missing data or a follow-up period of less than 12 months were excluded from the analysis. Patient data was collected from the SMC electronic medical record system. These include age, sex, body mass index (BMI), presenting complaints, diagnosis, operative time, operative blood loss and perioperative complications .2.2After obtaining anesthesia clearance, all patients were kept NPO for 6–8 h before the operation. All surgeries were performed under general anesthesia. In addition, the incision site was shaved and sterilized with a chlorhexidine-based or alcohol-based povidone-iodine solution.A standard surgical technique was applied for all procedures using standard laparoscopic instruments (Storz). The abdomen was accessed through a 2 cm supraumbilical incision. After abdominal insufflation using the Veress pneumoperitoneum needle, three 5 mm ports (Covidien) were inserted through the incision. In 23 of the patients, the Veress needle was inserted into the right upper quadrant through a 2 mm incision to facilitate liver retraction. Dissection was started in the neck of the gallbladder until a critical view of safety was achieved. 5 mm clips were used to ligate the cystic duct and cystic artery. The gallbladder was then extracted through the right port after being dissected from the liver bed. Following successful extraction, hemostasis was secured. CO2 was released. Finally, the skin is closed using 4-0 Monocryl subcuticular suture. The dressing was done with steristreps and waterproof dressing.Postoperatively, paracetamol was used for pain management in all patients. Opioids were used in cases of severe pain. The patients were kept in NPO until flatus was passed, after which clear liquid was started. A low-fat diet was administered before the patients were discharged.2.3During the follow-up in the clinic for a period of 2 weeks and one month after operative, the patients completed a short survey. The elements of the survey are: 1) cosmetic appearance of the incision site; 2) postoperative pain; 3) general patient satisfaction. For each of these elements, a satisfaction scale  is provided.2.4The data was analyzed using Microsoft Excel. Central tendency measures and variance measures were calculated for the different parameters that were analyzed.32. Of the 125 patients, 114 patients were diagnosed with cholelithiasis, 9 patients with acute calculous cholecystitis, and 2 patients with hydrops of the gallbladder. Most of the patients (80%) presented typical symptoms of biliary colic, mainly pain in the pain in the right upper quadrant exacerbated by fatty food intake. The mean operative time was 25.56 ± 10.42 min, with a maximum operating time of 65 min and a minimum of 12 min. The estimated blood loss was minimal in all operations. The rate of postoperative complications was 0%.After excluding patients with insufficient data, 125 patients who underwent SILC were included in the analysis . All patThe results of the satisfaction survey are shown in 48 reported 50 cases who were operated using SILC with minimal blood loss and no postoperative complications. Similarly, Ersin et al. , n et al.  successfThe operative technique we followed has been described in other studies in which SILC was successfully performed using conventional laparoscopic instruments . A noticOne of the main variables that determines operational efficiency is operative time. As operative time decreases, the surgeon's and hospital performance capacity will increase. Therefore, our study considers the tangible reduction in operation time as an independent factor that favors SILC. Interestingly, the mean operative time in our study was 24.6 min, while other studies have reported a mean operative time ranging from 47.31 to 93.16 min with conventional laparoscopic cholecystectomy . AlthougRegarding postoperative patient satisfaction, our study shows that SILC is an excellent alternative to conventional laparoscopy. The cosmetic outcome, which is the patient's perception of their body image after the procedure, points to higher satisfaction rates. This is consistent with several other studies that have also reported a better cosmetic outcome in SILC compared to conventional laparoscopy ,13.As pain and wound infection are significant causes of patient morbidity, results from various studies corroborate our findings of less postoperative pain and less incidence of surgical wound infection . In our One limitation of this study is that it does not compare SILC with any other surgical technique, and that we only demonstrated our criteria. Therefore, it cannot be concluded that this technique is the gold standard of treatment. This necessitates the need of further studies to be done on the procedure, so that practicing surgeons may have an improved scope of what to employe in their practice.5The field of minimally invasive surgery is expanding rapidly, and in order to steer these expansive efforts in the appropriate direction, the safety and satisfaction of patients should be of the utmost importance. In this study, we have demonstrated that the use of SILC is in fact an optimal, minimally invasive, and promising procedure that will greatly add on to this field. The pain control and cosmetic appearance of the patients in our study exceeded our expectations, as the level of satisfaction obtained was truly rewarding.Specialized Medical Center (SMC) waived IRB approval for this study.No funding was provided.K.T., M.B., R.A., B.N.S., A.A., S.A., S.A.S. drafted the manuscript K.T. contributed to reviewing and finalizing the manuscript. All authors reviewed the manuscript for intellectual content and approved the submission.The authors declare no conflicts of interest.1.Name of the registry:2.Unique Identifying number or registration ID:3.Hyperlink to your specific registration (must be publicly accessible and will be checked):N/A.Khalil Terro, MD.N/A.N/A.Not commissioned, externally peer reviewed.Not applicable.Not applicable.Not applicable.


Few reports address post-procedural pain after interventional radiology in oncology. All patients treated from 2015 to 2019 in interventional radiology were included in a retrospective cohort study. In an additional case-control study, patients reporting strong or intolerable pain were compared to those with no pain. From 4411 procedures, severe pain was more frequent in women (6% vs. 4%) and the youngest patients, after general anesthesia, arterial embolization, limb cementoplasty, osteosynthesis, and abdominal tumor ablation. In the case-control study, long-term opioid use, duration >160 min, and high-dose remifentanil were risk factors for a high pain level. Intraoperative ketoprofen was associated with a decreased high pain level incidence. Immediate severe post-procedural pain was a risk factor for severe pain in wards until discharge. Severe post-procedural pain was observed, particularly after specific interventional radiology procedures, and may be prevented by injecting intraoperative analgesics.p < 0.04) and the youngest patients (p < 0.0001), after general anesthesia (p < 0.0001). Higher pain levels were associated with certain procedures, such as arterial embolization, limb cementoplasty, osteosynthesis, and abdominal tumor ablation, and when the intervention duration exceeded 160 min (p = 0.038). In the cohort study, high-dose remifentanil (≥0.055 µg/kg/min) was a risk factor for post-procedural high pain levels (p < 0.001). Intraoperative ketoprofen was associated with a decrease in high pain level incidence (p < 0.0001). Severe pain in PACU was a risk factor for severe pain in wards from day 0 until discharge. Conclusion: Severe pain depends on the type and duration of interventional radiology, type of anesthesia, and preoperative use of opiates. Limiting doses of remifentanil and injecting intraoperative analgesics, especially ketoprofen, may reduce the incidence of post-intervention severe pain.Background: Interventional radiology plays a major role in oncology both for curative and palliative treatment, but few reports address post-procedural pain. The purpose of this study was to quantify postoperative pain after interventional radiology procedures in oncology and to identify major pain-associated pre and intraoperative factors. Methods: From 2015 to 2019, all patients treated with interventional radiology were included retrospectively in a cohort study. Anesthetic protocols were standardized by the type of radiological procedure. Demographic data, preoperative treatments, analgesic agents, pain score levels, and morphine consumption from the post-anesthesia care unit (PACU) to hospital discharge were collected from databases. In an additional case-control study, patients reporting strong or intolerable pain in PACU were compared to those with no pain. Matching to control cases was based on the type of intervention, sex, and age. Results: From 4411 procedures, severe pain in PACU was more frequent in women ( Interventional radiology (IR) is increasingly being offered to high-risk patients as an alternative to surgery . These mThe scope of IR in oncology includes diagnostic (biopsies) or therapeutic procedures, both guided by imaging methods . It can be used for direct destruction of tumors by radiofrequency, cryotherapy, laser, microwave, treatment of complications , adjuvant treatment, such as regional chemotherapy injection, and palliative or symptomatic therapy, such as pain treatment or dilation of stenosis ducts.Modalities of anesthesia vary by procedure, whether local anesthesia, sedation, general anesthesia (GA), or regional anesthesia (RA). There is no consensus in the literature regarding the use of a particular anesthesia technique for a specific IR procedure, and each team of radiologists and anesthetists must determine its own anesthesia protocol.Published studies addressing post-procedural pain control and its effect on the oncology patient are uncommon in IR. One study evaluated 150 patients for objective pain scores 24 h before and after nine different interventional procedures, observing significant increases in pain after some procedures .Few studies have focused on determining associated factors for postoperative pain and their prevention by intraoperative injection of pain medication, as for surgery . When suThe purpose of the first part of this work, a cohort study, was to assess retrospectively the incidence of postoperative pain after IR by the type of intervention, demographic characteristics, and anesthesia procedures from a structured database in a cancer center. In a second part, a case-control study, we compared patients reporting the most pain with those reporting none in the post-anesthesia care unit (PACU) regarding pre and intraoperative risk factors and the course of their pain until hospital discharge.We performed a cross-sectional observational study using medical data from a comprehensive cancer center. All patients who underwent an IR procedure during January 2015 to December 2019 were included. Patients under the age of 18 years and those who had an associated surgical procedure at the same time were excluded. Each patient gave written consent to authorize health care teams to use anonymized data from their medical records for investigation. This current analysis was approved by the French Ethics Committee for Research in Anesthesiology and Intensive Care with IRB approval n° IRB 00010254-2021-094.Data were analyzed only for patients who had received GA, RA, sedation, or monitored care. Procedures under local anesthesia without anesthetic supervision were not included. The anesthesia technique was standardized and varied according to the IR procedure: simple monitoring, RA, sedation , and GA. The standard analgesia protocol included intraoperative injection of paracetamol and tramadol in all patients, and nefopam was added in all patients under GA. Ketamine (bolus and/or infusion), ketoprofen, and morphine were injected according to the anesthesiologist’s choice. GA was begun with propofol bolus (2–2.5 mg/kg), and maintenance was carried out by halogenated agents (sevoflurane or desflurane), and rarely by TCI propofol. Atracurium was adjusted according to monitoring. The same analgesic protocol was used for surgical and IR patients and was adapted to the types of intervention.All procedure data for patients aged 18 years and older were included in the cohort study. From the cohort, patients assessing their pain at 3 (strong) or 4 (intolerable) using an analog or subjective scale from 0 to 4  were compared as cases to patients reporting no pain in the PACU (score 0) as controls in a case-control study. Cases and controls were matched by the type of intervention and then by sex and age.Demographics, age, weight, height, and preoperative analgesic treatments , and benzodiazepine treatments) were extracted from the anesthesia consultation.Intraoperative and PACU medical data were collected on Centricity Anesthesia software , for both IR and surgical patients. This tool has been described in detail previously . Events,The following data were collected from the Centricity software: age, weight, height, American Society of Anesthesiologists class, type of anesthesia, and amounts of morphine and other analgesic agents  injected during the procedure and in the PACU, as well as the duration of the procedure. The doses of ketamine and remifentanil were transmitted through an interface with an infusion pump.NVS from 0 to 4  was measured in the PACU at least on arrival and exit, and the maximum score was retained for this study . If the After leaving the PACU, the consumption of morphine and other analgesic agents, pain intensity as measured by a numerical rating scale of 0–10 was collected from the medical data management software DxCare  at D0, D1, and hospital discharge. The numerical rating scale was only available on this software and the values from the pain assessment scales were converted to the 0–4 scale to homogenize them with the pain scale used in the PACU and on the wards.2 test for categorical variables. The influence of the interventional procedure was analyzed by technique type and target organ. Finally, we analyzed more specifically the relationship between pain level in the PACU and the amount of remifentanil, expressed as µg/kg/min, to identify a possible threshold at which the pain would be increased.In the cohort study, the categorical variables are reported as numbers and percentages; the continuous variables are expressed as means and standard deviations. For comparisons between different pain groups (score 0 vs. score 1 vs. score 2 vs. scores 3 or 4), we used analysis of variance for continuous variables and the chiIn the case-control study, we performed bivariate then multivariate analyses (logistic regressions) to determine which factors were associated with the main outcome . All of the variables significantly associated with the outcome at a threshold of 0.2 in bivariate analyses were included in the multivariate models. We then used a backward stepwise regression procedure to exclude variables from the model.p < 0.05. All analyses were carried out using SAS version 9.4 software .Differences were considered statistically significant at For this 5-year period, 4891 IR procedures under anesthesia were extracted. We removed 569 procedures from the study for patients who did not switch to the PACU (a direct transfer to ward or intensive care unit), 20 because no pain score was recorded, and 2 because pain remained non-evaluable during the stay in the PACU . A totalIn the cancer patients, the incidence rates of the most important pain (score 3–4) were comparable for IR and surgery  during the same period (5.0% for IR and 4.9% for surgery), and lower than for abdominal surgery (9.7%). Only 17 patients rated their maximum pain at level 4 (0.4%) and 194 patients at level 3 (4.6%) during their stay in the PACU. To ensure enough patients for analyses, we grouped these patients into the same class “group 3–4.”p < 0.04; p < 0.0001). NVS was higher after GA than after other types of anesthesia . Compared with patients reporting lower pain levels, those with a score of 3–4 in the PACU received significantly less analgesia (except for tramadol) preventively during the procedure.The cohort characteristics are described in p < 0.001). Patients with NVS 3 and 4 had a higher average infusion rate of remifentanil. As The incidence of pain 3–4 was less than 5% for most procedures and exceeded 5% for several types of procedures, however, included arterial embolization, bone treatment (cementoplasty and osteosynthesis), and tumor ablation . The posIn PACU, patients with a high pain level received more rescue analgesics than patients reporting no pain. Among patients rating pain 3–4, 90% received morphine in the PACU versus 0.6% of patients with a score of 0. Those with pain at 3–4 also had more nonsteroidal anti-inflammatory drug (NSAID) use at 24% versus 4% for those with a score of 0 and more ketamine use at 25% versus 0.3% with a score of 0.n = 194) and 4 (n = 17) were matched to 211 patients with NVS 0, according to the type of procedure, sex, and age. The number of patients for whom the indication for IR was justified to treat cancer pain was comparable in the two groups, at 39 in the case group and 28 in the control group (p > 0.1).The 211 patients with NVS 3  except for ketamine. Despite the application of this analgesic treatment, pain scores measured at PACU exit and in the wards until hospital discharge was lower (p < 0.02) in the control group (NVS 0) than in the case group (NVS 3–4)  and more NSAIDs (54 vs. 32). The difference was significant for all analgesics (NVS 3–4) .This large database study, with 4211 enrolled patients, is the first to explore postoperative pain after IR for multiple types of cancer procedures. Despite the minimally invasive nature of IR, some patients experienced severe pain in the PACU. As has been widely reported, the incidence of severe pain was higher in women and men than in  and relaThe incidence of severe pain was not higher in patients for whom the radiological procedure was indicated to treat pain or to treat cancer. The likely reason is the delayed analgesic efficacy of these treatments .We found greater pain in patients with preoperative opiates, as already seen for surgical patients, possibly because of opioid-induced hyperalgesia (OIH) . This reThe type of procedure performed influenced the intensity of postoperative pain. Based on an arbitrarily set incidence threshold of 5%, cementoplasties, osteosynthesis, tumor ablations, and arterial embolizations led to more intense postoperative pain.The incidence of post-IR pain in cancer patients has not been studied in large cohorts. However, some studies have evaluated pain treatment after cementoplasties , embolizAccording to our protocols, almost all patients on GA or sedation received remifentanil. Remifentanil, at high doses, is deemed to increase postoperative pain by a dose-dependent OIH mechanism . This hyIn both the cohort and case-control studies, intraoperative injection of ketoprofen significantly decreased the incidence of major pain. NSAIDs use is highly recommended for the prevention of postoperative pain . PeriopeIn the cohort study, patients with a score of 3–4 received more intraoperative morphine than patients reporting no pain. This pattern was not confirmed in the case-control study, where this factor became insignificant. The discrepancy may be explained by the more frequent preoperative opioid use in the case group, as these patients usually need more intraoperative morphine to control postoperative pain, as recommended during surgery .No definitive conclusion could be established for the efficacy of other intraoperative analgesic drugs because of the discrepancy between the statistical results of the cohort and case-control studies. The small number of patients in the case-control study may have reduced statistical power in comparison with the cohort study.Our clinical protocol in the PACU recommended using analgesic agents that were not administered during the procedure. Postoperative administration of ketamine, morphine, and ketoprofen in the PACU helped to control pain and very few patients (three with NVS 2 and none with a score of 3–4) were experiencing pain when discharged from the PACU. A total of 90% of patients with an NVS score of 3–4 received morphine in the PACU versus 0.6% of patients with a score of 0.As shown in This retrospective study involved many patients whose management followed a pre-established protocol. The small amount of missing data attests to good patient follow-up. The case-control analysis mitigates the negative aspects of this type of retrospective study by weighting several variables, such as sex or intervention. The advantage of a retrospective study using a structured database including many interventions is to reflect day-to-day practice and highlight outlier patients, such as those with excruciating pain in the PACU (17 patients with NVS 4 during the 5-year period).This study focused on postoperative pain after IR in a cancer treatment context. Pain was more significant after certain types of procedures, including tumor ablation, treatment of limb bone lesions, and arterial embolization. The incidence of severe pain after IR was close to 5% and increased in patients with preoperative opiates. High remifentanil doses were associated with a higher risk of developing severe pain in the PACU. Intraoperative administration of analgesics, particularly ketoprofen, reduced this incidence. Beyond the PACU until hospital discharge, patients with scores of 3–4 remained more painful than others despite the painkillers’ administration. This pattern encourages the adoption of a preventive approach, such as the limitation of remifentanil doses, more systematic use of NSAIDs and RA, and improved postoperative follow-up in the wards for patients with a high level of pain in the PACU.


To evaluate how radiographic damage, overall and measured as joint space narrowing score (JSNS) and erosion score (ES), as well as other clinical and laboratory measures, relate to disability and pain in early rheumatoid arthritis (RA).An inception cohort of 233 patients with early RA, recruited in 1995–2005, was followed for 5 years. Disability was assessed with the Health Assessment Questionnaire (HAQ), and pain with a visual analogue scale . Radiographs of hands and feet were evaluated using the Sharp-van der Heijde score (SHS), including JSNS and ES. The relation for radiographic scores and other clinical parameters with pain and HAQ were evaluated cross-sectionally by multivariate linear regression analysis and over time using generalized estimating equations.p<0.001 at all visits).ES was significantly associated with HAQ cross-sectionally at inclusion, after 2 and after 5 years, and over time. Associations for HAQ with SHS and JSNS were weaker and less consistent compared with those for ES. There was no association between radiographic scores and pain at any visit. Both HAQ and pain were associated with parameters of disease activity. The strongest cross-sectional associations were found for the number of tender joints (adjusted Joint damage was associated with disability already in early RA. Erosions of hands and feet appear to have a greater influence on disability compared with joint space narrowing early in the disease. Pain was associated with other factors than joint destruction in early RA, in particular joint tenderness—suggesting an impact of pain sensitization.The online version contains supplementary material available at 10.1186/s13075-023-03015-9. Rheumatoid arthritis (RA) is a disease characterized by inflammation of joints, which in time may result in joint destruction. Irreparable damage may occur to affected joints and can lead to increased disability. The Health Assessment Questionnaire (HAQ) is a validated measure for disability in RA . Pain isJoint destruction in RA includes damage to periarticular bone and articular cartilage, which can be identified by radiographs of hands and feet. Radiographic scoring can be used to assess the level of joint destruction and is often evaluated with composite measures like the Sharp-van der Heijde score (SHS) . In the RA-related disability is complex and could be explained both by current inflammation, which is known to fluctuate over time, and by joint destruction, which is more progressive and permanent. Several studies in established RA have shown that joint damage is associated with increased disability –13. In pSeveral studies have assessed the association between disability and composite radiographic measures like the SHS, but only a few have investigated the effects of ES and JSNS separately. In these studies, disability displayed a stronger association with JSN than with erosions , 18.Like disability, pain is a multifactorial experience, associated partly with disease activity, but also with central sensitization of the nervous system and psychologic factors . It woulFurther insight into the relation for joint damage and other clinical measures with pain and disability in early disease could aid in early treatment decisions, with the goal of improving patient outcome. The purpose of this study was therefore to evaluate how joint damage, measured as SHS, as well as JSNS and ES separately, and other clinical and laboratory parameters, relates to pain and disability in early RA.An inception cohort of 233 patients with early RA with a symptom duration ≤12 months was investigated. Patients were recruited in 1995–2005 from the rheumatology outpatient clinic of Malmö University Hospital, the only hospital serving the city, and from the four rheumatologists in private practice in Malmö. The patients were diagnosed by a specialist in rheumatology and fulfilled the 1987 American College of Rheumatology (ACR) classification criteria for RA . Post hoPatients were followed according to a structured program with clinical examinations, laboratory tests, and radiographs of hands and feet at inclusion and 12, 24, and 60 months. All clinical examinations at all visits were performed by the same experienced rheumatologist for all patients. Patients were managed according to standard care with no pre-specified protocol for anti-rheumatic treatment. Assessment of pain  and C-reactive protein (CRP) were measured with standard methods at the Department of Clinical Chemistry at Malmö University Hospital. IgM rheumatoid factor (RF) was analyzed using ELISA, which was calibrated against the World Health Organization RF reference preparation. Anti-cyclic citrullinated peptide (anti-CCP) antibodies were analyzed using the Quanta Lite CCP IgG ELISA .Radiographs of hands and feet were scored according to the SHS , as prevp-value ≤0.10 were considered for inclusion. In case of collinearity (bivariate correlation between covariates with r > 0.3), only the covariate with the strongest association with the outcome variable was included in the multivariate linear regression model. Sensitivity analyses were also performed with adjustment for the year of inclusion.Normality distribution of descriptive data was assessed with the Shapiro-Wilk test. Descriptive data was presented as mean (standard deviation) or median (interquartile range) depending on the distribution. Potential associations between each independent variable at inclusion and 1, 2, and 5 years and the outcome variables VAS pain and HAQ, at the same time points, were estimated with univariate linear regression analysis. Normality distribution of residuals was also evaluated with the Shapiro-Wilk test. All analyses were, in addition, performed with adjustment for sex and age. For the multivariate models, covariates were chosen based on the age- and sex-adjusted analysis, where covariates with a In addition, the longitudinal relation between radiographic and clinical parameters and outcomes was modeled using generalized estimating equations (GEE). With repeated measures of VAS pain or HAQ as the dependent variable, we investigated whether time-varying SHS, JSN, ES, and clinical variables were associated with worse pain or greater disability over time. These analyses were adjusted for age at inclusion and sex. Multivariate models were constructed based on principles similar to the linear regression analyses. All statistical analyses were performed using IBM SPSS statistics version 26.A total of 233 patients (median symptom duration 7 months) were investigated in this study Table . VAS paiIn univariate linear regression analysis, there were no significant associations between radiographic scores and pain at any visit. However, positive significant associations between pain and SJC28, TJC28, ESR, and CRP were present at inclusion and at follow-up visits at 1, 2, and 5 years , rather than for JSNS or total SHS. The results were similar in the age- and sex-adjusted analysis  in the multivariate analyses. In longitudinal analyses, using GEE, significant associations were found for ES with HAQ over time, but not with pain over time.The stronger and more consistent association for ES with HAQ, as compared to JSNS with HAQ that was found in this study, contrasts with a report from Smolen et al. where JSN progression was the only damage score found to be associated with physical function in patients with early RA (<3-year disease duration) . As theiIn contrast with several studies which have demonstrated joint damage to be related to disability only later during the disease course , 15, we The clinical relevance of the association between ES and HAQ should also be discussed. For example, a one-unit increase in ES at 5 years was associated with a 0.009 increase in HAQ, and ES in the highest quartile at 5 years ranged from 10 to 94. The minimum clinically important difference for HAQ has been reported to be 0.22 . An incrThe lack of association between radiographic damage and pain indicates that other factors are responsible for pain in early RA. Based on the results from this study, factors associated with current joint inflammation seem to play a more important role in explaining pain. The tender joint count on the other hand, which had the strongest cross-sectional association with pain throughout the study, does not necessarily reflect only inflammation, but could also represent other pain mechanisms such as central sensitization, often present in chronic pain conditions like fibromyalgia. Coury et al. found that patients with RA and concurrent fibromyalgia were less likely to experience joint destruction . These pr-square ranged from 0.24 to 0.39 in the multivariate models. Furthermore, the study only evaluated radiographic damage of the hands and feet, and joint damage of larger joints might also have an impact on disability and pain.Limitations of the study include the relatively small sample size which affects statistical power, especially for the analyses at 5 years where more patients have been lost to follow-up. Additionally, the majority of patients were included before the implementation of a treat to target strategy and before the use of biologic DMARDs became the standard of treatment in severe RA. The results of this study may therefore not be fully applicable to patients diagnosed after this period, although the association at inclusion should be less period-sensitive. Another limitation was that the scoring of the radiographs was performed by one single reader, increasing the risk for misclassification, although good reproducibility was demonstrated in a subset of the cohort . Such miStrengths of this study include the systematic longitudinal follow-up from a defined period of time and a defined catchment area. Consequently, selection bias should not be a major issue in this study, and the results could be generalized to patients seen in clinical practice.In this cohort of patients with early RA, statistically significant associations were found between bone damage and disability, measured by HAQ, already at inclusion. Disability was more strongly and consistently associated with erosions, and less so with cartilage destruction, demonstrated by JSN. This suggests that erosions have a greater influence on disability in early disease, although cartilage damage also appears to have an impact on function in the longer run. Joint damage was not associated with patient-reported pain at any point during the 5-year follow-up, suggesting that other factors play the main role in the multifactorial pain spectrum seen in RA—for example the potential development of a coexisting chronic pain syndrome. Both pain and disability were associated with increased laboratory markers of inflammation at all time points, but even more so with joint tenderness—compatible with a role for pain sensitization.Additional file 1. Question for pain.Additional file 2. Relation for clinical and radiographic parameters with VAS pain; linear regression, adjusted for age and sex.Additional file 3. Relation for clinical and radiographic parameters with VAS pain; multivariate linear regression. Sensitivity analysis, including inclusion calendar year as covariate.Additional file 4. Relation for clinical and radiographic parameters with HAQ; linear regression, adjusted for age and sex.Additional file 5. Relation for clinical and radiographic parameters with HAQ; multivariate linear regression. Sensitivity analysis, including inclusion calendar year as covariate.


Trigeminal neuralgia (TN) is a unilateral, paroxysmal, sharp, shooting, or jabbing pain that occurs in the trigeminal nerve divisions, including the ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves. Typically, an episode is triggered by anything touching the face or teeth. TN is a clinical diagnosis with no specific diagnostic test; it is determined by the patient's medical history and pain description. Imaging is necessary to exclude secondary causes. The precise reason for TN is uncertain, but it is commonly believed to result from vascular compression of the trigeminal nerve root, typically near its origin in the pons. There are numerous surgical and medical treatment options available. The most frequently applied medical treatment therapies are carbamazepine and oxcarbazepine. Surgical alternatives are reserved for patients who do not respond to medical treatment. Botulinum toxin A (BTX-A) has emerged as a novel and promising alternative to surgery for individuals whose pain is unresponsive to medication. Multiple studies have established the safety and usefulness of BTX-A in treating TN, with the most significant benefits occurring between six weeks and three months after the surgery. This article reviews various studies published in the last 10 years regarding the therapeutic use of BTX-A in TN. These studies include various observational, clinical, pilot, and animal studies. The International Headache Society defines trigeminal neuralgia (TN) as a disease characterized by recurrent unilateral, brief electric shock-like pains that are abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve, and triggered by innocuous stimuli . IdiopatThe three types of TN are classical, secondary, and idiopathic. The classical type, which is the most prevalent, accounts for 75% of all cases of TN. It is diagnosed when trigeminal neurovascular compression results in morphological changes ipsilateral to the side of the compression, demonstrated with magnetic resonance imaging or surgery . The secThe diagnosis of TN is based solely on the clinical presentation as no particular diagnostic test exists. TN is characterized by a sharp, shooting, stabbing pain that is unilateral, abrupt in onset, and can persist for a fraction of a second to up to two minutes. These paroxysmal episodes are frequently precipitated by non-noxious stimuli, such as tooth or facial contact .There are numerous surgical and medical treatment options available. Carbamazepine and oxcarbazepine are first-line therapy options, whereas lamotrigine and baclofen are second-line alternatives. However, medical treatments have their associated adverse effects . GuideliClostridium botulinum, an anaerobic gram-positive bacteria. There are eight distinct antigenic types A-G with type A having the most potent effect. Botulinum toxin primarily acts by preventing the release of acetylcholine at the neuromuscular junction. The toxin prevents the release of acetylcholine by cleaving critical proteins involved in its release [The Food and Drug Administration (FDA) initially approved botulinum toxin to treat strabismus . BTX-A i release . The mecThe efficacy of BTX-A in TN is usually measured on a visual analog scale (VAS), which is commonly used in epidemiological and clinical research to measure the frequency and intensity of symptoms. The VAS is depicted in Figure Even though the initial results regarding the use of BTX-A in TN seem promising, various factors limit its widespread use in real-world clinical practice. The clinical trials conducted so far have a small sample size limiting the clinical usefulness of the conclusions drawn regarding its use.The patients selected for studies have intractable TN restricting the efficacy of conclusions that we can draw from these studies regarding the use of BTX-A as a first-line treatment option for TN. There is a shortage of evidence regarding the optimal dose, route, depth of injection, onset of action, and period of effectiveness of BTX-A. Information regarding the safety of BTX-A in pregnancy, nursing, and patients planning on becoming pregnant is unknown. There is also insufficient evidence regarding the clinical use of BTX-A on TN in patients with neuromuscular disorders and medically unstable patients. Patients taking medications that affect neuromuscular junctions, e.g., aminoglycosides and quinine, were excluded from the studies due to the possible interaction of these medications, limiting the clinical usefulness of conclusions drawn from these studies. Information regarding the long-term effectiveness of BTX-A in patients with TN remains to be known since most studies conducted so far have had a short follow-up period. There is a requirement for well-designed randomized, double-blind placebo-controlled trials to overcome these limitations. Even though there has not been a report in the clinical trials assessing the efficacy of BTX-A in TN, there is a concern regarding the risk of possible hypersensitivity reaction with BTX-A administration. There have been reports of hypersensitivity reactions and long-term adverse effects with BTX-A administration when used for cosmetic and therapeutic purposes, necessitating a much more cautious approach toward the therapeutic use of BTX-A in TN ,20.MethodDatabases such as PubMed, PubMed Central (PMC), ResearchGate, and Google Scholar were searched. They were extensively searched using relevant keywords and medical subject heading (MeSH) to identify all the relevant articles that discuss the role of BTX-A in the management of TN. Both the MeSH terms "botulinum toxin" and "trigeminal neuralgia" were included in the search. We included articles from 2012 to 2022 and included reviews, clinical trials, pilot studies, animal studies, and retrospective studies. We included only those studies for which complete text was available for free and was in English.ResultsAn advanced MeSH on PubMed and Google Scholar yielded 1,143 articles at first. All papers not directly related to the research topic were manually omitted, leaving 18 articles for our review.DiscussionFollowing are the findings regarding the clinical use of botulinum toxin in the management of TN.Observational Studies/Clinical TrialsAn open-labeled clinical trial with 27 patients treated with maxillary/mandibular injections of BTX-A showed significant improvement in pain and attack frequency in the first week, second month, and sixth month after treatment. In the second and sixth months, 74.1% and 88.9% of patients, respectively, responded to the treatment. At the sixth-month interval, 44% of the patients did not experience pain attacks. The severity and frequency of pain attacks decreased after each injection administration. Two patients remained recurrence-free after two years of treatment with BTX-A. The success rate of 88.9% achieved with this different injection technique was slightly higher than that attained from other injection methods . An openA randomized, single-blind controlled trial conducted on 20 patients with intractable TN showed a significant reduction in their pain assessed using the VAS with a decrease of 6.5 in the BTX-A group versus 0.3 in the placebo group. There was also a reduced need for acute medications and improved quality of life functioning with BTX-A. No significant relationship was found between total injected dosage and endpoint VAS or pain attack frequency . A randoA clinical trial assessing the safety and efficacy of BTX-A in the management of older patients showed no difference in patients above 80 years and below 60 years of age, with efficacy and dosages comparable between the two age groups. The VAS scale for the older patient group decreased from a baseline of 8.5 to 4.5 after treatment with BTX-A, while for the younger patient group, the VAS decreased from a baseline of 8.0 to 5.0 after treatment with BTX-A . In anotPilot StudiesA pilot study with 100 patients assessing the efficacy of single and repeated doses of BTX-A in the management of TN showed no difference in frequency, the time between treatment and effect, VAS, and adverse effects. The single-dose group reported a significantly longer duration of effects. This study indicates no significant advantage of repeat doses with BTX-A when compared with a single dose of BTX-A . A studyAnimal StudiesAn animal study involving purified BTX-A to treat experimental trigeminal neuropathy in rats demonstrated significant improvement in the head withdrawal threshold as compared to saline-injected rats, demonstrating the possible efficacy of BTX-A in TN. Although the exact mechanism behind the effect of BTX-A is unclear, possible axonal transport is thought to play a role . A studyReview ArticlesIn a randomized, double-blind placebo-controlled study with 42 patients, intradermal/subcutaneous injection of BTX-A resulted in more than 50% reduction of pain in the VAS in 68.18% of patients. In a class IV, open-ended study with eight patients, all patients reported beneficial effects with BTX-A. In a class IV, open-label study with 13 patients, four patients were pain-free, and nine patients reported more than 50% pain reduction on the VAS with BTX-A, which lasted for 60 days. Transcutaneous injection of BTX-A in 11 patients resulted in more than 50% reduction in pain frequency and intensity in eight patients, with beneficial effects lasting for two to four months. In a class IV, open-label study with 12 patients with TN, 10 patients reported significant improvement in their pain on the VAS with BTX-A with effects lasting for 60 days. Similar results were seen in another class IV, open-label study with 15 patients, with all 15 patients reporting an improvement in pain frequency and intensity with BTX-A with effects lasting up to six months. Although the beneficial effects of BTX-A in TN are reported in several case reports and open-label studies including class IV studies, there has only been a single class I study establishing the therapeutic efficacy of BTX-A in TN .In an open-label study with 12 patients, 83% of patients reported pain relief within a few minutes of injection with BTX-A. Higher doses of BTX-A were associated with a faster onset of action, and mixing BTX-A with lidocaine resulted in the prolonged action of lidocaine, helping in the management of acute exacerbations . The useLimitationsThis review is limited to studies in the English language, so we may have missed important studies that were published in other languages. This review is limited to studies published after 2012, which may have also caused a similar limitation.The clinical efficacy of BTX-A in TN possibly stems from the inhibition of the release of inflammatory mediators and peripheral neurotransmitters from sensory nerves. Our review has shown that the studies conducted regarding the clinical use of BTX-A in TN have demonstrated its clinical efficacy, with patients reporting improvement in their pain frequency and intensity. In some cases, long-term benefits with BTX-A are also seen, with patients reporting prolonged pain-free periods. The side effects observed with BTX-A were mild and self-limited in most cases, with no significant systemic side effects reported in most studies. However, several factors limit the clinical use of BTX-A; these include a lack of specific guidelines about optimal dose and injection techniques. Patients included in studies have intractable TN, limiting the usefulness of the conclusions drawn regarding the use of BTX-A as a possible first-line therapy. Safety of BTX-A in patients who are medically unstable, pregnant, or planning to become pregnant remains yet to be determined. There is also a concern regarding the possible drug interaction in patients taking other medications. These concerns necessitate well-designed randomized controlled trials with a large patient sample to fully establish its safety, efficacy, and other parameters, including dosing, route, the onset of action, and effective period. BTX-A can be an effective and viable alternative, especially in patients with intractable TN.


In order to better alleviate the pain symptoms of patients with advanced cancer, this study adopts image detection and analysis and hospice nurse mediated aromatherapy, so as to comprehensively understand the physical condition of patients with advanced cancer and finally implement the nursing scheme of aromatherapy.  Sixty advanced cancer patients admitted to a tertiary and grade A oncology hospital in Jiangxi Province from December 2020 to March 2022 were selected. This study was randomized into trial and control groups. The control group contained 30 regular treatment patients and 30 regular nursing patients for advanced cancer patients, and the trial group performed a 28-day hospice care specialist nurse-mediated aromatherapy based on the control group. Pain and quality of life scores were measured before and after the intervention in both groups. The experimental group consisted of 30 cases, with the mean age of 58.2 years; the control group consisted of 30 cases, with the mean age of 58.6 years.  60 patients with advanced cancer were selected for group comparison. The results showed that the effect of aromatherapy mediated by hospice nurse on pain score, QLQ-C30, index value of patients with advanced cancer  was better than that of patients with advanced cancer (the control group).  Through retrospective analysis, we investigated the patients with advanced cancer and discussed the difference between conventional therapy and aromatherapy. The results showed that aromatherapy based on image detection and analysis and mediated by Anning nurses was helpful to alleviate the physical function of patients with advanced cancer and improve their quality of life, which provided a reference for clinical application. With the rapid development of high technologies such as artificial intelligence and sensing technology, smart medicine rises. It is to build a regional medical information platform for health records and use the most advanced Internet of things technology to realize the interaction between patients and medical personnel, as well as between medical institutions and medical equipment, so as to gradually achieve informatization and make the medical service intelligent in the real sense. In the intelligent medical environment, the method based on image detection and analysis has also been widely used in medical treatment. At present, with the increasing global cancer incidence rate, cancer has become the “number one killer” threatening human life and health. The first problem that scientists have not yet solved is the problem of cancer treatment. In particular, patients with advanced cancer suffer from psychological and mental torture in addition to physical pain. It has seriously affected the physical and mental health and quality of life of patients. Previously, most of the patients were relieved by taking drugs. Now, safe and effective nursing methods are encouraged. Aromatherapy can relieve the cancer pain of patients and provide reference for the care of patients with pain. Therefore, Tang et al. pointed out that, due to the disease itself or treatment, cancer patients will be accompanied by physiological, psychological, spiritual, and other symptoms throughout the course of the disease, which seriously affect the quality of life of patients . AromathAromatherapy originated from ancient civilizations such as ancient Egypt and prevailed in Europe in modern times. It can relieve mental stress and improve physical health by using essential oils. In 1928, the French chemist “Gatfersey” first used the name of aromatherapy, and some began to use it in the scientific journal of aromatherapy. By chance, he found that peppermint or lavender oil has special therapeutic power. The essential oil distilled from aromatic plants is used to obtain the integrated curative effect of body, heart, and spirit. It is an adjuvant therapy. Essential oil contains ketones, esters, and other chemical components, which determine its therapeutic characteristics. It can be used by direct inhalation, bathing, and massage to improve anxiety, pain, fatigue, and wound healing. Like drugs, essential oils mainly affect the limbic system of the brain through sniffing and penetrate into the body through the skin, so as to achieve the purpose of treatment. Cancer is one of the main diseases that human beings are difficult to overcome at this stage, and, globally, the number of people living with cancer is still increasing. Long-term radiotherapy and chemotherapy have led to a significant decline in their quality of life. Li et al. found that cancer can bring many uncomfortable symptoms to patients, such as pain, fatigue, anxiety, and fear. Therefore, cancer pain is considered to be one of the most common and fearful symptoms. Therefore, pain treatment is an indispensable and important part of comprehensive treatment of cancer . Chen etWith the increasing refinement of the computer age, image detection extends the idea of edge detection to identify the entire image, usually to judge whether the detected image belongs to an image in the known image database, or infer that the image is most similar to a known image after comprehensive discrimination. Based on image detection and analysis, it is found that the current situation and application of hospice nurse mediated aromatherapy in patients with advanced cancer are reducing pain, which is usually caused by noxious stimulation, accompanied by a feeling of unpleasant emotional experience, and the stimulation can come from the outside and act on the body surface. According to the survey, more than 50% of cancer patients will have cancer pain of different degrees, which will bring serious negative emotions. Severe cancer pain will seriously affect the quality of life of patients. Through the grouping experimental study, the researchers randomly selected cancer patients and then compared them with essential oil massage combined with hospice care, simple massage, and no other special treatment. The results showed that the analgesic effect of essential oil massage combined with hospice care was better than that of other groups, with higher quality of life and less emotional fluctuation. Based on the analysis of the current situation, emotional relief can reduce the generation of negative emotions, which can better illustrate that aromatherapy can be widely used in medicine and has reference significance. Therefore, aromatherapy can be used as one of the adjuvant therapies to control pain. Secondly, aromatherapy can alleviate the nausea and vomiting of cancer patients. Cancer patients will have different degrees of nausea and vomiting after chemotherapy and drug treatment. Some researchers found that inhaling ginger, mint, and lemon compound essential oil and smelling sliced lemon fragrance can effectively alleviate the nausea and vomiting of patients. Therefore, in clinical intervention, we can try to choose the method of aromatic inhalation, combined with essential oil acupoint massage, so as to effectively alleviate the nausea and vomiting of tumor patients. In addition, aromatherapy can relieve the mood of cancer patients. By diverting attention from their own symptoms, cancer patients will not only suffer physical pain but also suffer psychological and mental torture. The intervention of aromatherapy can reduce the physical discomfort of patients. In addition, many cancer patients will have emotional problems such as anxiety and depression, which will affect the quality of life of patients. Studies have found that lavender essential oil has analgesic, anticonvulsant, antidepressant, and sedative effects. In aromatherapy, it is often used to balance emotions and improve anxiety, depression, and other problems and can bring positive effects to patients. Aromatherapy can also improve sleep disorders and improve sleep quality. Sleep disorder is one of the most common symptoms of cancer patients, which can be caused by adverse reactions such as pain, radiotherapy, and chemotherapy, as well as factors such as anxiety and depression. Insomnia can hinder the recovery of cancer patients, which directly affects the changes of patients' diseases. Therefore, effective sleep nursing intervention is necessary. Some researchers have found that the use of lavender essential oil and mint essential oil can help to improve the symptoms of insomnia. Therefore, as a low-risk, low-cost, low adverse reactions, and simple and easy to operate complementary therapy, aromatherapy can be used as a nondrug method for the treatment of sleep disorders, and, combined with acupoint massage, it can better solve the sleep disorder of cancer patients and improve their sleep quality.Sixty patients with advanced cancer admitted to a tertiary A oncology hospital in Jiangxi Province from December 2020 to March 2022 were selected. This study was randomized into trial and control groups. The control group consisted of 30 regular treatment patients and 30 regular nursing patients for advanced cancer patients, and the trial group performed a 28-day hospice care specialist nurse mediated aromatherapy based on the control group. Pain and quality of life scores were measured before and after the intervention in both groups. The experimental group consisted of 30 cases, with the mean age of 58.2 years; the control group consisted of 30 cases, with the mean age of 58.6 years;.Inclusion criteria were as follows: cancer diagnosed by pathology or cytology, pathological stage IV, and estimated survival time ≤6 months, patient with a complaint of pain, visual analogue score ≥1, age ≥18 years old, normal sense of smell, no history of allergy to the drugs and essential oils used in this study, and the patient knowing the condition and voluntarily participating in the study and signing the informed consent form. Exclusion criteria were as follows: coma or other serious diseases, such as heart failure, renal failure, respiratory failure, liver failure, and brain metastasis, consciousness disorder or cognitive dysfunction, which is unable to cooperate with this study, discharge or death during the study period, and withdrawal from the study.Using random number table method, 60 patients were randomly divided into test group and control group with 30 patients in each group. The grouping situation was put into an opaque envelope and the corresponding sequence number was marked on the envelope. When the subjects were included in the study, the envelopes were opened in sequence, and they were divided into different groups according to the grouping conditions in the envelopes. Different groups were arranged in different wards as far as possible. In order to avoid measurement bias, a trained nurse evaluated and collected data for all subjects, and another researcher conducted statistical analysis. This study has been reviewed and approved by the hospital ethics committee.The patients in the control group were given routine treatment and routine nursing. Cancer is a systemic epidemic disease. Now it is in an advanced stage and there is no way to make radical surgery. Systemic adjuvant chemotherapy can be considered. In addition, cancer patients rely on controlling the development of the disease. In order to prolong the survival time in the case of poor physical condition, patients with advanced cancer have strong pain and can be treated with powerful analgesics. In the case of poor nutrition and inability to eat, they can be treated with infusion nutrition.Angelica dahurica, clove, frankincense, benzoin, white rosin, Acanthopanax senticosus, sandalwood, aloes, and musk, are made into drug types with different odors by appropriate methods. The drugs are used by burning, wearing, rubbing, or taking through the nose, mouth, and skin to penetrate into the body, improve anxiety, pain, fatigue, and other conditions, and make patients with advanced cancer happy, excited, or have mysterious feelings. It has the functions of warming the meridians, harmonizing Yin and Yang, and unblocking Qi. It has the dual functions of helping sleep and relieving pain. The personal system of patients with advanced cancer is different, which may cause skin allergy or discomfort. It is recommended to use it under the guidance of hospice nurses to avoid the side effects and contraindications of aromatherapy and drugs for cancer patients. The patients in the control group were given routine treatment and routine nursing. The patients in the observation group were given aromatherapy intervention mediated by hospice nurses on the basis of the control group. The intervention was conducted at 13:00 p.m. every day and 30 min before going to bed every night for 28 days. Before and after the intervention, the pain and quality of life of the two groups were evaluated by visual analog score and EORTC QLQ-C30.On the basis of routine treatment and routine care, the patients in the observation group continued to intervene with aromatherapy mediated by hospice nurses. The aromatherapy mediated by hospice nurses is an alternative therapy that uses the pure essential oil of aromatic plants to assist medical work according to the pain grade characteristics of physical diseases of patients with advanced cancer. The role of aromatherapy is to enable patients to obtain the integrated curative effect of body, heart, and spirit. Medicinal materials with aromatic smell, such as p value of the statistical data is considered to be in the confidence space when p < 0.05.The clinical data were analyzed by IBM SPSS 24.0 data analysis platform. Observe the distribution law of the data, discuss the correlation between the data by using Spearman correlation analysis method, and analyze the statistical significance of the observed data by linear regression. In all data analysis, the significance Cancer can bring many uncomfortable symptoms to patients, such as pain, fatigue, anxiety, and fear. Cancer pain is considered to be one of the most common and fearful symptoms. Cancer pain is often accompanied by involvement pain in other parts. In the process of advanced treatment, most of the pain parts are not clear, and the scope is relatively broad and even covers the whole body. Pain management is based on image detection and analysis. An important part of hospice nurse mediated aromatherapy can use effective pain management techniques for patients with advanced cancer. Hospice nurses should also pay attention to educating patients about cancer pain and clarify their cognition of cancer pain, so that patients with advanced cancer can comfort themselves when they encounter pain and enhance their tolerance to pain, so as to reduce the pain of patients with advanced cancer. Now, the scores of the two groups of subjects in the total scores of sensory items, emotional items, pain, VAS, and PPI are analyzed, respectively, and In In order to better observe and analyze the effects of the scores of patients with advanced cancer before and after the two different treatment interventions, the score data of patients in the above table are visualized, as shown in As shown in After standardized treatment, the pain symptoms of patients were relieved, especially in patients with advanced cancer. They are weakness, lack of appetite for food, fatigue, inability to take care of themselves, and other systemic symptoms. With the pain of the whole body, even the use of painkillers cannot completely relieve the pain. Most branches have metastasis and damage to adjacent organs and tissues, decreased activity tolerance, decreased physical function, and psychological anxiety, depression, and fear. With the sudden change of roles during the disease, social activities also decrease, and loneliness during hospitalization has seriously affected the quality of life of late-stage cancer patients. Now, the physical function, role function, emotional function, cognitive function, social function, fatigue, nausea, and vomiting of the two groups of subjects are analyzed, and In In order to better observe and analyze the effect of EORTC QLQ-C30 score of patients with advanced cancer before and after the intervention of two different therapies, the EORTC QLQ-C30 score data of patients in the above table are visualized, as shown in As shown in p < 0.05). Consistent with the results of Qian and Chen [With the emergence of various new drugs and treatment modalities, the number of patients living with cancer is constantly increasing, but the number of patients experiencing a series of uncomfortable symptoms is also increasing, seriously affecting the quality of life of patients . Pain, aand Chen , Wang anand Chen  study reand Chen . Qualityand Chen .Panning care specialist nurses assume the role of assessor, educator, and implementer in hospice care practice, including . Nurses In this study, based on image detection and analysis and hospice nurse mediated aromatherapy in the intelligent medical environment, the impact of pain on patients with advanced cancer was studied. Through the comparative analysis of aromatherapy and conventional therapy, using statistical methods and simulation verification, aromatherapy, as an auxiliary therapy, can achieve the purpose of improving mental state; it provides more comprehensive and accurate condition data in the nursing process of patients with advanced cancer based on image detection and analysis and hospice nurse mediated aromatherapy than conventional therapy. Image detection and analysis can make patients have a deep understanding of the condition, which is conducive to alleviate the pain of patients, relieve the discomfort of the body, and provide a good foundation for follow-up treatment. The final results showed that the effect of the observation group in pain score, QLQ-C30, value was better than that of the control group of advanced cancer patients with conventional therapy. Aromatherapy can reduce pain and muscle tension, reduce neuropathic pain scores, help to enhance self-acceptance, and cope with physical changes and improve patients' quality of life. The application of aromatherapy has a deep impact on the medical field, so that patients can improve the quality of life at the end of life, so as to further improve the core competence of hospice nurses and provide theoretical basis and practical guidance for the research and development of hospice in the future. In this study, aromatherapy based on image detection analysis and hospice care nurses in a smart medical environment is a safe, economical, and simple nonpharmacological therapy that can effectively relieve pain and improve the quality of life in cancer patients. However, there are some deficiencies in this study, and the patients' psychological mood and sleep quality were not included in the analysis. Then, the sample size will be expanded to evaluate the effect on psychological and sleep consumption.


We aimed to compare the levels of pain and salivary α‐amylase (SAA) in patients before and after mandibular third molar surgery.Patients were divided into asymptomatic and symptomatic groups and were then identified by the analgesic drug taken throughout the 2‐week study. The visual analog scale (VAS) was employed to evaluate the severity of pain experienced by a given subject before treatment, when the anesthetic wore off, in the morning, and at night for a period of 1 week. Saliva was collected from the mouth floor of the subjects and the levels of SAA activity were measured at indicated times.p < 0.05), but were not necessarily different between the two groups. The pain levels were positively correlated with SAA activities in both groups (p < 0.05). There was no difference between the number of analgesics taken by the two groups and the postoperative complications observed during the study. A significant correlation was observed between the VAS pain scale and SAA activities.The levels of postoperative pain were higher than those of pretreatment pain (SAA would be a simple effective biomarker for the objective assessment of pain intensity in patients who have undergone mandibular third molar surgery. SAAsalivary α‐amylaseSDstandard deviationVASvisual analog scale1Acute pain experienced as a result of symptomatic wisdom teeth has been identified as a significant problem in the field of maxillofacial surgery. This type of pain is complicated and can be difficult to treat as patients experience extreme discomfort. There are many options for the management of pain in patients with symptomatic wisdom teeth. These options include supportive types of treatments that include antibiotic treatment, the removal of opposing teeth, irrigation around the affected tooth, curettage, excision of the operculum, or the surgical removal of the third molar to remove the source of the infection Frew, . LeavingThe visual analog scale (VAS) score is a common and reliable assessment used for measuring postoperative pain during dental treatments  which consists of 496 amino‐acid residues, one calcium ion, one chloride ion, and 170 water molecules  was calculated using the method employed in a previous study  of VAS = 3.0, standard deviation  = 3.6, confidence level = 95%, power of test = 80, alpha (α) = 0.05, and beta (β) = 0.20. According to the above calculation, the sample size required for the present study was 10 subjects per group. Subsequently, 32 subjects were further divided into two groups: asymptomatic and symptomatic groups (n = 16 each). This study was then divided into two parts in which the clinical part involved an assessment of pain level using VAS and the second part involved the collection of saliva specimens for the measurement of SAA activity.The sample size (2.2https://docs.google.com/forms/d/1QLkQ8mR5eeoxDL1Wk0bWH7FgxSvyb0MFcnkyD6A_cWw/viewform?edit_requested=true/accessed on 22 September 2019) before treatment. Local anesthesia was then administered to the subjects by intramuscular injection of 4% articaine hydrochloride/epinephrine solution . Following that, flushing was achieved with an inferior alveolar nerve block (1.8 ml) and buccal infiltration (0.5 ml). All surgeries were done by the same surgeon who administered either a simple extraction or surgical removal without bone removal or tooth section. The duration of the course of treatment was recorded after initiating the extraction or after the first incision was made. The treatment then lasted until the placement of the last suture but did not exceed 20 min. All subjects were given the same postoperative instructions and received the same type of analgesic paracetamol (500‐mg tablet) when necessary every 6 h, and ibuprofen (400‐mg tablet) when their pain was not relieved after taking the paracetamol. The VAS score was then recorded for both groups after the anesthetic wore off, in the morning at 8.00 am, and before bedtime at 8.00 pm for a period of 1 week after surgery. Notably, when the subjects used analgesic drugs, they were required to record the type, dosage, and duration of time that the drugs were taken.The subjects in both groups were evaluated in terms of their pain levels using the VAS scoring tool accessible on the Google document online site . The color intensity of the p‐nitrophenol formed was directly proportional to the α‐mylase activity.Subjects in both groups were instructed to neither eat nor drink within 1 h before saliva specimens were collected in order to avoid contamination. Nonstimulated saliva was collected from the floor of the mouth before treatment when the anesthetic wore off and on Days 1 and 7 after surgery, with the use of a sterile plastic pipette. Saliva specimens were spun using a bench‐top fixed‐angle centrifuge  at 3500 rpm, 25°C for 5 min, and the clear saliva supernatant was kept in sterile microcentrifuge tubes  at −20°C until the day of SAA analysis. SAA activity was determined using a coupled enzymatic colorimetric assay kit  that was run according to the manufacturer's operating instructions at the Center for Medical Excellence, Faculty of Medicine, Chiang Mai University . Data are expressed as mean ± standard deviation values (SD) with the significance level indicated by a 33.1n = 16, 2 male and 14 female) or the symptomatic group  according to their perceptions of pain. Demographic data and the characteristics of the symptomatic and asymptomatic subjects are summarized in Table n = 7) and surgery (n = 9), while the symptomatic patients were treated by simple extraction (n = 8) and surgery (n = 8). Interestingly, with the use of VAS assessment, preoperative pain levels in the symptomatic group (5.50 ± 1.87) were significantly higher than those in the asymptomatic group (1.00). However, no significant differences were observed in terms of the postoperative pain levels for members of both groups. In findings, preoperative levels of SAA activity were not different between male and female asymptomatic patients, and they were increased in symptomatic patients whom the male subjects showed higher than the female subjects but not significantly.Thirty‐two patients  within the age range of 18–37 years old (24.5 ± 4.7 years) were enrolled in this study and were classified into either the asymptomatic group (3.2p < 0.05). Furthermore, the pain levels of both groups were found to have decreased gradually after the treatment. Accordingly, the members of the symptomatic group did not experience postoperative pain after Day 4 and members of the asymptomatic group did not experience postoperative pain after Day 6. However, on Day 7 of the postoperative period, the level of pain in the symptomatic group was found to have dramatically decreased (p < 0.05) when compared to their level of preoperative pain. This value of pain was even lower than it was in the asymptomatic group.As is shown in Figure 3.3p > 0.05) and declined gradually until postoperative Day 7. Obviously, the SAA levels on postoperative Day 7 were significantly lower than the preoperative levels for both groups.The results shown in Figure In addition, Spearman correlation analysis revealed a positive correlation between pain levels and the levels of SAA activities for members of each group and among both groups of asymptomatic and symptomatic patients before and after mandibular third molar extraction Figure .Analgesic drugs (in terms of tablets per day) taken by asymptomatic and symptomatic patients for all periods are shown in Table p < 0.05), for which the dosage of the analgesic drug increased along with the severity of pain   who felt uncomfortable after the treatment. Subjects claimed to experience postoperative pain, a limited ability to open their mouths, and difficulties in eating or swallowing Table ; however4The controversial topic in the field of oral maxillofacial surgery is whether or not to extract teeth immediately in cases of acute infection or for symptomatic patients. Previous studies have shown that the extraction of the presence of acute infection may induce the bacteria to seed into the fascia space, potentially resulting in a life‐threatening infection  and the additional requirements, if any, of the country where the research has been carried out. The study has been independently reviewed and approved of by the Local Human Experimentation Committee of the Faculty of Dentistry, Chiang Mai University (Study Code No. 39/2018).


The patients with CGD showed higher depression and kinesiophobia values compared to the MCNP and TTH groups (p < 0.05). No differences were found for cervical flexion, extension, lateral flexion, or rotation ROM (p > 0.05). The CGD and MCNP groups found a moderate positive correlation between psychological distress and kinesiophobia (p < 0.05). The patients with TTH and MCNP showed a moderate positive correlation between pain intensity, psychological distress and kinesiophobia (p < 0.05). Conclusion: Pain intensity, psychological distress and kinesiophobia should be considered in the three groups. Psychological distress was correlated with kinesiophobia in the CGD and MCNP groups. The MCNP group showed a correlation between pain intensity, psychological distress and kinesiophobia.Background: The objectives of this study were: (1) to compare the pain intensity, cervical range of motion (ROM), psychological distress and kinesiophobia in patients with cervicogenic dizziness (CGD), tension-type headache (TTH), and mechanical chronic neck pain (MCNP); and (2) to investigate the relationships between pain intensity and cervical ROM and between psychological distress and kinesiophobia. Methods: a cross-sectional and correlational study was designed. In total, 109 patients  were included. Pain intensity, cervical ROM, psychological distress and kinesiophobia were assessed. Results: Statistically significant differences were found between the groups in pain intensity, psychological distress and kinesiophobia. The patients with MCNP showed higher pain intensity compared to the other groups ( Symptoms related to the cranial and neck areas are among the most prevalent reasons for consultation in primary care and they are important causes of disability in the United States, creating significant socioeconomic costs ,2,3. TheThe causes of CP are diverse, which makes it challenging for clinicians to locate the source of the symptoms . The symIn clinical practice, patients usually complain about dizziness, headache and mechanical pain ,12,13. DThe clinical characteristics are different in each group. The primary symptoms of patients diagnosed with CGD are dizziness and neck pain; in patients diagnosed with TTH, the main symptoms are headaches and neck pain; and patients diagnosed with MCNP solely experience neck pain. To assess the symptoms, clinicians usually use valid and reliable instruments to measure these outcome variables, such as the visual analogue scale (VAS) and goniometers or inclinometers. The VAS is a low-cost and easy-to-use tool for patients with CP in clinical practice . GoniomeHowever, the increasing evidence about the relationship between CP prognosis and other psychosocial factors ,19 has eSome authors suggest that psychosocial factors are frequent findings in patients with CP. Some of these variables may be predicted in patients with CP based on pain intensity. For this reason, it is suggested that psychological distress and kinesiophobia may be pain mediators in patients with CP ,23,24,25This cross-sectional and correlational study was performed between February 2019 and March 2021. The Research Ethics Committee of Aragón (PI15/229) approved the study protocol, which followed the Strengthening the Reporting and Observational Studies in Epidemiology (STROBE) guidelines . AccordiOne hundred and nine female participants were included in the study . The inclusion criteria in the CGD group were dizziness, neck pain and age > 18 years. The inclusion criteria in the TTH were: TTH diagnosis according to the ICHD-III  and agedBefore the enrolment, all the participants were diagnosed with CGD, TTH or MCNP by medical doctors from primary-care centers in Delicias Norte and Delicias Sur, Zaragoza (Spain).Demographic variables  were assessed for descriptive purposes. The outcome variables considered in this study were pain intensity, cervical ROM, psychological distress and kinesiophobia. Two blinded examiners who did not know the assigned group measured all the outcome variables. The procedure process is shown in the Pain intensity was measured using the 100-mm Visual Analog Scale (VAS), in which 0 represented no pain and 100 represented the most intense pain imaginable. The VAS has been shown to be a valid and reliable instrument for the measurement of pain in patients with CP .Active cervical flexion, extension, lateral flexion and rotation ROM were registered using the Cervical Range of Motion Instrument . The patients were placed with the cervical spine in a neutral position. The examiner recorded the initial angle in the selected plane of the CROM. Next, the patients were asked to perform flexion, extension, lateral flexion, or rotation without pain and avoiding trunk or shoulder movement. The examiner ensured the correct running of the test. This protocol was used for all movements and repeated three times for each . The tesPsychological distress was assessed using the Spanish version of the Hospital Anxiety and Depression Scale (HADS). The HADS questionnaire includes 14 items to assess anxiety and depression symptoms. Each item is rated from 0 (no distress) to 3 (maximum distress). The cut-off score for the presence of psychological distress is >8 points. The cut-off scores for the anxiety and depression subscales are as follows: normal (0 to 7 points), borderline abnormal (8 to 10 points) and abnormal (>11 points) . The senKinesiophobia was registered with the Spanish version of the TKS-11 questionnaire. TSK-11 includes 11 items to assess fear of movement. Each item was rated from 1 (strongly disagree) to 4 (strongly agree). The test–retest reliability of this questionnaire has shown an ICC of 0.95 .Statistical Package for the Social Sciences (SPSS) software version 20.0 for Windows was used for statistical analysis . ContinuOne-hundred and forty-five participants were recruited for the study. Thirty-six were excluded for not meeting the three groups’ eligibility criteria. One-hundred and nine female patients with CGD, TTH or MCNP were finally included in the study. The demographic variables are shown in p < 0.05) (p < 0.001) and to the TTH group . The CGD group showed higher values of psychological distress  and depression  compared to the MCNP group and higher values of kinesiophobia compared to the TTH group .The analysis of the variance (ANOVA) showed statistically significant differences between the three groups for pain intensity and psychological distress ( < 0.05) . The MCNConcerning the psychological-distress cut-offs, 84.37% of the patients in the CGD group, 63.63% in the TTH group and 68.12% in the MCNP group presented symptoms of psychological distress. The frequencies of the HADS total scale and anxiety and depression subscales are presented in p = 0.014) and the MCNP group .The correlation analysis showed a moderate positive correlation between psychological distress and kinesiophobia in the CGD group with a 95% confidence interval and a sample of 109 participants showed estimated differences between the groups of 87.2% to 99% for pain intensity, psychological distress and kinesiophobia. The statistical power obtained for the correlation was 99% for psychological distress and kinesiophobia and for pain, psychological distress and kinesiophobia correlation.The statistical power was calculated with G*Power version 3.1 (The aims of this study were: (1) to compare the pain intensity, ROM, psychological distress and kinesiophobia in female patients with CGD, TTH and MCNP in females; and (2) to investigate the relationships between psychological distress and kinesiophobia and between pain intensity and cervical ROM in females. Concerning the first objective, the results of the present study showed that the patients with MCNP presented higher pain-intensity values than those with CGD and TTH. The patients with CGD presented higher values of psychological distress and depression compared to the patients with MCNP and higher values of kinesiophobia compared to the patients with TTH and MCNP. Regarding the second objective, the CGD and MCNP groups demonstrated a moderate positive correlation between psychological distress and kinesiophobia. The MCNP group presented a positive moderate correlation between pain intensity, psychological distress and kinesiophobia.Statistically significant differences were found in pain intensity, depression and kinesiophobia. The mean values displayed for each group in pain intensity were similar to the values reported in other studies that included the same populations ,35. The No statistically significant differences were found in any group’s three planes of ROM. Cervical ROM restriction is common in most patients with CP ,43,44. PAccording to the cut-off points proposed by Zigmond et al. , more thThe three groups showed a positive moderate correlation between psychological distress and kinesiophobia. This means that higher values of psychological distress were related to higher values of kinesiophobia and vice versa. It is important to note that the correlations were found in the three groups, which means that the correlations were independent of the type of diagnosis received by the patient. To the best of our knowledge, this is the first study to investigate the relationship between psychological distress and kinesiophobia in patients with CP. Therefore, these results are not comparable to those of similar studies.In addition, the TTH group and the MCNP group showed a positive moderate correlation between pain intensity, psychological distress and kinesiophobia. However, the CGD group did not show a correlation. This means that higher pain intensity values are related to higher values of psychological distress and kinesiophobia in patients with TTH and MCNP. Pain is the most common reason for seeking medical attention in patients with TTH and MCNP ,13. FurtThe prevalence of CP has increased in recent years in Spain. The prevalence and intensity of chronic pain are higher among women. In addition, it has been observed that women use more medication for symptoms of pain, anxiety and depression than men . SeveralThis study has some limitations that should be described. First, since only three groups were included, the results cannot be extrapolated to other subgroups with cervical or cranial disorders. Second, the study took into account only women and the results were compared with those of other studies that did not differentiate groups of patients by sex; therefore, the patients in this study may not have been representative of the population. Third, of the pain conditions that may have influenced the status of the patients , only pain intensity was recorded. Finally, the study design allowed us to establish a correlation but not a cause–effect association for the differences found.The present study was conducted on females. Future studies should investigate differences between genders and ages in the three groups. In addition, the design of prospective or retrospective studies may allow to describe casual associations.Pain intensity, psychological distress and kinesiophobia are parameters to consider in patients with CD, TTH and MCNP. Psychological distress and kinesiophobia were shown to be positively correlated in the three groups. Pain intensity was shown to be correlated with psychological distress and kinesiophobia in the TTH and MCNP groups.