This decision analytical model study uses survey responses to investigate the importance patients gave to attributes of postoperative pain management after hand surgical procedures. Which attributes of pain control are most important to patients after surgical treatment?In this decision analytical model study of survey responses from 321 patients who underwent elective hand surgical procedures, risk of addiction and pain relief were the aspects of postoperative pain control with the highest attribute importance scores.These findings suggest that a multimodal pain control regimen that is associated with sufficient pain relief and decreased risk of addiction may be ideal for the treatment of postoperative pain. Opioids are often prescribed after elective surgical treatment despite the potential for misuse. Although various pain control regimens exist, patient preferences for acute postoperative pain management are unknown.To describe patient-reported key attributes of postoperative pain management.This decision analytical model used responses from a survey based on conjoint analysis to investigate the value patients placed on different aspects of postoperative pain management. Participants were patients aged 18 years or older who underwent elective hand surgical procedures between July 1, 2018, and July 23, 2019, at a single academic center. The survey was completed on a web-based platform and took place between November 2019 and January 2020. Data were analyzed from May through July 2021.Participants were presented with a series of discrete-choice tasks and asked to select between 2 postoperative medication options that changed from question to question and had varying characteristics.Attribute importance scores and part-worth utility values for the queried aspects of pain control were calculated.Of 710 individuals invited, 321 (45.2%) completed the survey; there were 212 (66.0%) women and 108 (33.6%) men, and the most common age category was 60 to 69 years (102 participants [31.8%]). Most patients reported previous opioid use . Factors in the decision-making process with the highest attribute importance scores (SDs) were risk of addiction (26.3% [13.0%]) and amount of pain relief (25.6% [14.6%]). Adverse effects 13.9% (7.2%), functional independence 11.8% (7.3%), and level of trust in the prescriber 11.4% (5.8%) had intermediate attribute importance scores (SDs). Cost 7.9% (4.4%) and stigma 3.1% (1.3%) had the lowest attribute importance scores (SDs) in patient decisions.These findings suggest that multimodal pain control regimens that are associated with optimized pain relief and minimized risk of addiction are preferable to treat acute postoperative pain. The results suggest that identifying procedures for which patients prioritize minimizing risk of addiction over pain relief and incorporating patient preferences into decision-making may be associated with decreased postoperative opioid prescribing. Therefore, health systems, government organizations, and surgical societies have established guidelines aimed at limiting the number of opioid pills prescribed after surgical treatment.2 Despite these efforts, studies have found substantial variation in postoperative opioid prescriptions and an association between opioid prescription and morbidity and mortality.5 It has become apparent that existing opioid reduction policies do not take a patient-centered approach and instead tend to focus on clinician behaviors. A more holistic strategy encompassing patient, clinician, and health system factors is needed to combat the opioid epidemic.Acute postoperative pain is commonly treated with opioids.6 For advanced cancer pain in particular, Meads and colleagues7 found that patients preferred optimal pain control, low out-of-pocket medication costs, and adequate control of adverse effects. These studies highlight the importance of an individualized approach for chronic pain management. It is unknown whether patients with acute postoperative pain have similar preferences. Given the potential for opioid misuse and poor pain control after surgical treatment, further investigation is warranted.Patient preferences for postoperative pain control are poorly understood and missing from the literature. Little is known regarding the trade-offs patients make for acute pain management, including the positive attributes of pain relief and potential negative consequences of opioid use, such as adverse effects and addiction potential. However, research on management of chronic pain suggests that patients prioritize avoiding opioid-related adverse effects, such as nausea and vomiting, which may also eliminate the net benefits of pain relief associated with opioid use, and that patients are often less concerned with risk of addiction.We sought to use discrete choice experiments (DCEs) to investigate which attributes of pain control, such as risk of addiction and potential for adverse effects, were most important to patients after surgical treatment. DCEs use surveys to evaluate trade-offs and quantify the relative preference that responders have for various attributes of a product or service. Findings from this study may provide insight into patient perspectives on the relative importance of analgesic characteristics and may inform prescription decisions.CHEERS) reporting guideline for decision analytical models given that this survey methodology can be used to identify aspects of postoperative pain control that are most important to patients who underwent surgical treatment and had acute pain.The Michigan Medicine Institutional Review Board (IRB) determined that this decision analytical model study was exempt from IRB review because we collected the data anonymously  and separately from the monetary compensation list that contained patient contact information. Informed consent for the voluntary study was obtained using an IRB-approved consent prompt and template , which is a survey methodology that originated in market economics to determine which elements of a product are most valuable and evaluate the trade-offs consumers consider during product selection.g values .12 When performing conjoint analysis, it is assumed that a product can be described based on a limited number of attributes and that individuals are more likely to choose the option that has greater utility.Through a series of DCEs and CA, we sought to calculate patient-perceived utility associated with different attributes of postoperative pain control.9 A preliminary list of attributes was made from a comprehensive literature review and consultation of the hand surgeons at our institution. Subsequently, we conducted qualitative interviews with 30 patients to confirm that all relevant attributes had been identified.13 The final list included 7 attributes: amount of pain relief, adverse effects, risk of addiction, functional independence, stigma, level of trust in the prescriber, and cost. Of these attributes, 3 attributes had 3 value levels , and the remaining 4 attributes had 4 value levels   . Using tWe used QCAST to distribute the online survey. At the start, participants were introduced to the study purpose and estimated time needed for completion of the survey. Informed consent was obtained. Next, participants were asked to imagine that they’d just had elective, outpatient surgical treatment and were presented with a series of DCEs asking them to select their preferred pain medication . Each quAfter completing the DCE portion of the survey, participants were asked to select the type of surgical treatment they had undergone. We also collected participant demographic characteristics, including sex, age, race, ethnicity, employment status, household income, and education level. We collected self-reported race and ethnicity (participants selected their race and ethnicity on the survey) to assess the diversity of the cohort and identify differences in pain control preferences based on patient characteristics.We used Qualtrics software to calculate participant part-worth utilities, which are a quantification of patient preferences for each value level of the 7 attributes . QualtriAfter calculating individual participants’ part-worth utilities, we determined mean part-worth utility for each attribute value level across the study population using QCAST. Specifically, attribute importance =  × 100. We determined SDs for attribute importance scores and 95% CIs for part-worth utility values using Microsoft Excel version 2108. We also conducted subgroup analyses for the most common hand conditions in our study population , as well as sex, age, race, ethnicity, and previous opioid use. We did not conduct subgroup analysis if fewer than 5 responders met subgroup criteria. In addition, we compared demographic characteristics of survey responders and nonresponders. Data were analyzed from May to July 2021.We collected 321 completed surveys from 710 invited participants  between November 2019 and January 2020. There were 212 (66.0%) women, 108 (33.6%) men, and 1 individual who responded other to sex; the most common age category was 60 to 69 years (102 participants [31.8%]). There were 3 Asian individuals (0.9%), 5 American Indian or Alaska Native individuals, 18 Black individuals (5.6%), 1 Native Hawaiian or other Pacific Islander individual, 2895 White individuals (90.0%), and 5 individuals with other race. There were 8 Hispanic individuals (2.5%). Participants self-selected other if their race or ethnicity was not listed; we did not ask them to specify their race or ethnicity, so groups in other are unknown. Most participants were employed full time  or retired . Responders most frequently underwent surgical treatment for carpal tunnel syndrome (CTS) , carpometacarpal (CMC) arthritis , or trigger finger . Most responders  reported previous opioid use .Part-worth utility values and attribute importance scores for the entire patient sample are reported in When we analyzed the CTS, CMC arthritis, and trigger finger samples separately, risk of addiction and amount of pain relief remained the attributes with the highest attribute importance scores . Meanwhile, there was a decreased proportion of Black and Hispanic individuals in the responder cohort . Demographics of nonresponders are displayed in eTable 22 in the Quantifying patient preferences in postoperative pain control may help surgeons gain a robust understanding of patient decision-making processes. Using DCE and CA in this decision analytical model study of patient preferences for postoperative opioid use, we observed that risk of addiction and amount of pain relief were the most important factors in decisions for pain control among patients who underwent elective surgical treatment. Patient level of trust in clinicians, cost, and stigma were less influential attributes. These results suggest that a multimodal approach to pain control that is associated with adequate pain relief and minimized risk of addiction may be preferable for treatment of acute postoperative pain. Identifying procedures for which patients prioritize minimizing risk of addiction over pain relief, such as trigger finger release in this study, may present an opportunity for decreased postoperative opioid prescribing.17 For example, in a DCE of patients with chronic osteoarthritis, the highest-ranking attribute was symptom control, followed by risk of addiction.17 Meanwhile, our study of acute pain control found that the potential for adverse effects was less important than pain relief or risk of addiction. Furthermore, unlike patients with chronic pain, who may use opioids after finding other treatment modalities ineffective, patients with acute postoperative pain are often prescribed opioids despite the availability of effective, yet less addictive medications. For instance, a randomized controlled trial18 found that acetaminophen or ibuprofen can provide comparable if not better pain relief than oxycodone after carpal tunnel release. These findings suggest that guidelines are necessary to ensure that patients receive adequate pain control and minimal exposure to addictive substances after surgical treatment.Our findings contrast with research on chronic pain, for which patients often rank avoidance of adverse effects as one of the most important factors when devising pain control regimens.19 such as laparoscopic cholecystectomy and thyroidectomy, found that patients were satisfied after using acetaminophen and ibuprofen rather than opioids to control their pain. This opioid-sparing approach may be beneficial considering that up to 10% of patients who are opioid-naive who receive an opioid prescription after surgical treatment may develop physical dependence.20 Furthermore, 3 studies23 found that local anesthesia is associated with decreased severity of postoperative pain relative compared with general anesthesia and nerve blocks. Identifying procedures for which local anesthesia or multimodal pain regimens can be used may provide an additional avenue to decrease the need for postoperative opioids.Determining procedures for which patients prioritize minimizing risk of addiction may aid in decreasing postoperative opioid prescribing, especially given the increasing body of research on multimodal treatments for postoperative pain. In addition to the aforementioned study on CTR, an investigation into patient satisfaction after general surgical procedures,24 Shared decision-making, in particular, may facilitate patient-physician discussions of pain control. For example, Vilkins et al25 used a visual decision aid to ensure that patients received uniform education on posthysterectomy pain management. This intervention was associated with decreased opioid prescribing without a decrease in patient satisfaction. However, similar interventions are needed across surgical treatments to substantially curb unnecessary opioid use.When patients have a history of opioid misuse or opioid-seeking behavior, clinician expertise is essential to prevent or treat addiction. Meanwhile, in situations in which the risk of addiction is less obvious, patients often receive opioids without consideration of their personal preferences or alternative pain control options. This suggests that patient-centered guidelines for use of multimodal pain control are necessary to ensure that decisions are made in patients’ best interest. Our study findings suggest that patients may desire different attributes of pain control depending on age, race, and ethnicity. For example, Hispanic patients and those aged 20 to 29 years ranked the attribute importance of risk of addiction higher than other subgroups did. It is inappropriate to use demographic characteristics alone to determine pain levels, as various studies have found racism and other forms of discrimination in pain management.26 However, a comparison of responder and nonresponder cohorts found no substantial differences by key demographic characteristics. Furthermore, research indicates that individuals tend to put less emphasis on future payoffs, in what is known as hyperbolic discounting.27 This may have been associated with an overemphasis on value-levels that provided short-term benefits, such as high pain relief over low pain relief or unlikely chance of adverse effects over likely chance of adverse effects. Additionally, we could not determine which medications responders received at discharge, which could have influenced their preferences.This study has several limitations, including selection bias, given that responders were recruited from a single institution and underwent hand procedures. However, the findings may be generalized to other outpatient procedures that require medical intervention for pain control. Considering that most responders were White, were not Hispanic, and were college educated, the findings may be less applicable in a more diverse population. Furthermore, given that participants were recruited using email, we likely selected against individuals who are unfamiliar with web-based technology. Given that individuals increasingly seek health information online, it is possible that responders to our survey were more familiar with pain control options than the general population.28 However, it did not provide measures of variance that may be used to gauge the true value of attribute importance or part-worth utilities across subgroups.It is also important to consider the limitations inherent to the survey, given that survey fatigue may have prevented responders from fully considering advantages and disadvantages of the choices. Additionally, it was not feasible to test every attribute or value level that may have been relevant. However, we relied on the literature and conducted a qualitative study of perspectives on postoperative opioid use among patients who underwent hand surgical treatment to identify the most important attributes. Additionally, Qualtrics software facilitated complex analysis of survey data.13Although this study provided a quantitative assessment of patient preferences for aspects of pain control, it is not meant to replace evaluations necessary to determine a unique patient’s postoperative needs. Nevertheless, these findings may lay the foundation for surgeon-patient discussions and support the development of decision-aids that incorporate important attributes associated with pain control, such as risk of addiction and adverse effects. Research has found that many patients undergoing surgical treatment depend on their personal beliefs and understanding of opioid addiction when deciding whether to take opioid pills postoperatively; however, these considerations are not consistently taken into account when opioids are prescribed.Quantifying patient preferences may help surgeons devise pain control regimens that are evidence-based, safe, and effective for individual patients. This study found that patients undergoing elective surgical treatment considered risk of addiction and pain relief the most important aspects of pain control, although their preferences varied based on specific condition or procedure. These findings suggest the importance of using multimodal regimens associated with minimized risk of addiction with sufficient pain relief.


Material and Methods. One hundred patients who received only orthodontic treatment are the nonsurgical group. One hundred other patients were separated equally into the following four orthognathic surgical subgroups. The visual analog scale (VAS) score was used to measure postoperative pain. Patient- and operation-related factors were compared among the four surgical subgroups. The null hypothesis was that there was no difference between orthodontic treatment and orthognathic surgery in terms of posttreatment pain.  The purpose of this study was to compare postintervention pain related to orthodontic treatment and orthognathic surgery. P = 0.780) or age (P = 0.473). The VAS scores of the nonsurgical group (mean: 3.59) were significantly (P = 0.007) higher than those of the surgical group (mean: 3.06). The null hypothesis was rejected. Within the surgical subgroups, no significant differences were observed between the men and women for age, operation time, blood loss volume, or blood laboratory values.  There were no significant differences between the nonsurgical and surgical groups for gender  group were significantly higher than those of the surgical group. No significant differences in VAS scores were found between the four surgical subgroups. Deformities in the maxillary and mandibular bones, including variations in form, size, and position, can cause abnormalities in the jaw relationship, resulting in malocclusion and other problems associated with facial deformities. Prognathism refers to protrusion of the maxilla or mandible or to protrusion of both jawbones concomitantly . The twoOrthognathic surgery (OgS) is widely used to improve the appearance of facial protrusion and malocclusion. Although surgical precision is important, clinicians should also consider other factors  to minimize the occurrence of subsequent complications and other sequelae –6. Most Patients who received orthodontic treatment without surgery were selected to form the control group , whereas other patients who underwent orthognathic surgery were selected as the surgical group. The variables assessed were sex, age, operation time, perioperative blood loss, and the postoperative change in blood components. The null hypothesis of this study proposed that the visual analog scale (VAS) scores of the first day posttreatment would be the same in the control group as in the surgical group. This study further compared the differences in perceived postoperative pain and other relevant variables for treating mandibular and bimaxillary prognathism by 4 surgical subgroups.The sample is comprised of 100 patients who underwent only orthodontic treatment as the controls  and 100 patients who underwent orthognathic surgery . Patients in the nonsurgical group received a fixed orthodontic appliance without being given any analgesics for pain management, and their VAS scores were recorded on the first day postintervention. The surgical group is comprised of 50 patients with mandibular prognathism and 50 patients with bimaxillary prognathism. The surgical procedures included intraoral vertical ramus osteotomy (IVRO), anterior segmental osteotomy of the mandible (ASO Md) and maxilla (ASO Mx), and genioplasty (GeP). The surgical group was further divided into four groups of 25 patients. The patients with mandibular prognathism formed Group 1  and Group 2 (IVRO+GeP). Those with bimaxillary prognathism formed Group 3 (ASO Mx+ASO Md) and Group 4 (ASO Mx+ASO Md+GeP). Groups 1 and 2 received six weeks of intermaxillary fixation treatment, whereas Groups 3 and 4 did not.P value < 0.05 was considered significant. Scores in the control and surgical groups were compared using t-tests; the null hypothesis was that there would be no differences in VAS scores on the first day posttreatment between these two groups. In addition, the VAS scores of 4 surgical subgroups were analyzed using t-tests, and Tukey's HSD (honest significant difference) test was used for post hoc analysis. Pearson's correlation coefficients were used to evaluate the correlations for the variables of sex, age, operation time, blood loss volume, and changes in blood components. The purpose of the present study is to compare the pain severity between the nonsurgical orthodontic group without pain medication and the orthodontic-OgS group with pain medication on day one after the initial treatment either via orthodontic force application or surgical intervention.All patients underwent orthognathic surgery under hypotensive anesthesia. Data on the operation time, perioperative blood loss, and postoperative changes in blood components were examined. Postoperation pain management is based on a standardized protocol regarding the schedule of medicine administration. During hospitalization, an intravenous nonsteroidal anti-inflammatory drug  was prescribed for pain control at 6-hour intervals. The dose of NSAID is equally applied to the gender and surgical subgroups. On the first day posttreatment, the VAS scores (0–10 cm) of the nonsurgical group and the surgical group were recorded. SPSS Statistics, version 20 , was used for statistical analysis, and a The values in Within the surgical group, no significant differences were observed between the sexes in terms of age, operation time, blood loss volume, or reduction in postoperative hemoglobin (Hgb) and hematocrit (Hct) levels, as shown in Tables Over the past decade, there has been an increasing trend emerging in the number of patients opting for surgical treatment to improve their malocclusion, a trend which may have been due to improved surgical techniques which alleviate perioperative and postoperative discomfort arising from the surgery. However, patients with maxillofacial abnormalities are often required to accept combination therapy with both orthodontic and orthognathic surgeries, which may involve different degrees of pain. Pain represents a highly complex response to intense stimuli and is accompanied by various effects on functioning. Importantly, pain is a highly subjective perception that differs significantly from person to person, and pain management has thus been a topic of considerable interest across the field of medicine.During orthodontic treatment, pain is commonly observed as a side effect that varies according to the sex and age of patients, the magnitude and method of orthodontic force, and individual emotional responses to pain and tolerance of stress –10. In tBecause the two groups in this study showed no significant differences in sex or age, the results may be applicable to the general population. Notably, the first-day postintervention VAS scores of the nonsurgical group indicated that this group perceived a significantly higher level of pain than those who underwent orthognathic surgery. The possible reason for this outcome might be that no analgesic was given to the nonsurgical group, whereas the patients in the surgical group were periodically prescribed medication for pain relief. Another possible reason might be that the patients in the nonsurgical group may not have anticipated the degree of pain associated with fixed orthodontic appliances, which exert continuous force on the periodontal ligament through orthodontic tooth movement. This might suggest that the patients in the surgical group, who had undergone orthodontic treatment, were more mentally prepared for postoperative pain because they anticipated it prior to their surgery.When stratified by sex, further analysis of the two groups revealed no difference in female : male ratios or age; however, differences in the VAS scores were noted between the two sexes in the nonsurgical group, where women perceived a significantly higher level of pain than did the men. Conversely, in the surgical group, no differences were observed in perceived pain levels between the sexes. Furthermore, when men and women in the nonsurgical group were compared with men and women in the surgical group, the analysis of the first-day posttreatment VAS scores revealed that women in the nonsurgical group reported a significantly higher level of pain than women in the surgical group, whereas the men in the surgical group reported a significantly higher level of pain than the men in the nonsurgical group.Numerous studies , 13 haveNiederhagen et al.  suggest Where the operation time and relevant blood components among the four groups were concerned, Group 4 demonstrated the largest and most significant changes. Comparisons of the operation time and blood loss during GeP surgery revealed that GeP surgery for mandibular prognathism had an operation time which was approximately 70 min longer and a 80 cc increase in blood loss; similarly, GeP surgery for bimaxillary protrusion showed an increase of approximately 50 min in operation time and a 140 cc increase in blood loss. The results of our study also demonstrated that there was greater blood loss during ASO for bimaxillary protrusion than that observed in bilateral IVRO. This might be because more bone marrow is involved in surgery to the maxillary and mandibular bones during ASO. No significant difference was observed in first-day postoperative pain between the four surgical groups.The results of Pearson's correlation analysis of postoperative pain in each group challenged the generally held belief that first-day postoperative VAS scores correlate positively with operation time and blood loss; indeed, the results of the present study revealed no significant correlation in these variables among the four subgroups. This might be related to the sites of surgery. We presume that the prevalence of postoperative lower lip numbness in Groups 2, 3, and 4 may have been higher than that in Group 1 . Lower lip numbness may relieve perceived pain even when considerable blood loss occurs, which may reduce the likeliness of observing a significantly positive relationship with the level of pain; by contrast, although the lowest amount of blood loss and lowest level of postoperative numbness were observed in Group 1, blood loss correlated significantly and positively with the level of pain.Because tissue-level injury, inflammation, facial edema, and other harmful perioperative stimuli can affect the central nervous system, a variety of different methods and techniques can be used to control postoperative pain. Various research , 16 repoThe VAS is a unidimensional tool to measure pain intensity. However, pain is a multidimensional nature, made up of unpleasant sensory, emotional experience, cognitive, and behavioral elements. Therefore, VAS cannot reflect the overall aspects of a patient's pain experience. Without comparing the VAS baseline of a patient's pain tolerance, the present study revealed a weak point to interpret the difference of VAS scores between the control group and the surgical subgroups.The results of this study demonstrate that the pain after orthognathic surgery, when appropriate analgesia is administered, is significantly lower than that from orthodontic treatment. Consequently, attaining a more complete understanding of orthognathic-orthodontic treatment with improved surgical techniques is expected to help meet patients' needs for preoperative psychosocial support and to reduce their postoperative pain.


This quality improvement (QI) project tracks a series of 2 Plan-Do-Study-Act (PDSA) cycles as we standardized and refined an ambulatory pediatric anesthesia strabismus protocol. We aimed to provide effective pain relief, reduce postoperative nausea and vomiting (PONV) rates, and be cost-efficient while minimizing perioperative opioids over 5 years.We used statistical process control (SPC) charts to analyze real-world data captured from the medical record. We chose the following outcome and process measures to evaluate effectiveness: postoperative morphine rescue rate, maximum pain score in the postanesthesia care unit (PACU), and PONV rescue rate. We also used 2 balancing measures: postoperative length of stay (LOS) and total anesthesia time. We standardized our anesthesia protocol for our first PDSA cycle (April 2017) by removing intraoperative intravenous acetaminophen and utilizing fentanyl only. For the second PDSA cycle (January 2019), we replaced intraoperative fentanyl with dexmedetomidine.There was a total of 325 pediatric strabismus repair surgeries performed between April 2015 and July 2020. There was no special cause variation detected in the SPC charts for the family of measures chosen to measure effectiveness: postoperative morphine rescue rate, maximum pain score in the PACU, or the PONV rescue rate. The PONV rescue rate was 0 with the removal of opioids. Also, there was no special cause variation for the balancing measures: postoperative LOS or total anesthesia time.Throughout 2 PDSA cycles, this QI project enabled our team to standardize an opioid-free and cost-efficient anesthesia protocol for pediatric strabismus surgery over 5 years. Analgesia is typically achieved with intravenous (IV) opioids. Administration of dexamethasone, ondansetron, and liberal IV fluids are common prophylaxis measures for nausea and vomiting.5 Treatment of ED includes benzodiazepines and dexmedetomidine.6Strabismus surgery is a common pediatric ophthalmologic surgery. Risk factors for strabismus include prematurity, low birth weight, and a history of retinopathy of prematurity.7 The use of dexmedetomidine in the current pediatric literature focuses upon treatment of ED,10 sedation for the intensive care unit,11 and preoperative anxiety.12 A tonsillectomy and adenoidectomy (T&A) quality improvement (QI) project at BCSC demonstrated similar pain scores and postanesthesia care unit (PACU) length of stay (LOS) when utilizing dexmedetomidine and ketorolac as compared to morphine and acetaminophen, as well as improved PONV rescue rates.13 Based upon the T&A QI project findings, the BCSC facility expanded its protocols to utilize dexmedetomidine, which minimizes opioids’ use for all its pediatric ambulatory surgeries.14 The expansion of dexmedetomidine use was implemented in a phased manner to track its effectiveness.At Seattle Children’s Bellevue Clinic and Surgical Center (BCSC), approximately 90 strabismus repairs are performed annually. Due to the opioid shortage in 2017–2018, BCSC anesthesiologists explored methods to conserve the opioid supply by pivoting to opioid-sparing pain management strategies. One methodology utilized dexmedetomidine, a highly selective alpha-2-agonist with analgesic and anxiolytic properties but without the respiratory depressant effects of opioids.We aimed to standardize an anesthetic protocol to optimize pain management and PONV in a multimodal approach for pediatric strabismus surgery over 5 years. We selected maximum PACU pain score, postoperative morphine rescue rate, and PONV rescue rate as primary outcome measures.BCSC is an ambulatory outpatient facility where clinicians incorporate standardized clinical pathways into their practice. Anesthesiologists and certified registered nurse anesthetists can track the adoption and effectiveness of protocol changes due to the healthy patient population, low acuity, high-volume caseload, and the informatics infrastructure built around real-world electronic medical record (EMR) data starting in 2015.In this QI project, we included the American Society of Anesthesiologists class 1–3, patients 1–17 years old of age undergoing strabismus surgery at BCSC from April 1, 2015, through July 30, 2020. We chose this time frame due to the variability of strabismus cases performed and to encourage adherence to multiple concurrent protocol changes at the BCSC facility.Since 2010, the anesthesia protocol for strabismus surgery included the following: fentanyl IV (1–2 µg/kg) and ketorolac IV (0.5 mg/kg) for pain control, and dexamethasone IV (0.15 mg/kg), ondansetron IV (0.15 mg/kg), and IV fluids (20 mL/kg) for PONV  (cohort D) replaced fentanyl IV (1–2 µg/kg) in the strabismus protocol. The average wholesale cost of dexmedetomidine IV is $17 per vial. However, the BCSC pharmacy can partition a single dexmedetomidine vial into 10 single-use syringes, thereby decreasing the cost to approximately $2 per syringe, which is equivalent to 1 vial of fentanyl. From January 1, 2019, to July 30, 2020, 2% of strabismus cases received intraoperative acetaminophen, 5% of strabismus cases received intraoperative fentanyl, and 99% of strabismus cases received intraoperative dexmedetomidine.16 We converted each pain assessment tool into an 11-point (0–10) score for the analyses.The PACU maximum pain score was a primary outcome measure used to assess the effectiveness of the different protocols. The PACU nurses record pain scores using assessment tools at their discretion. For patients 1–3 years old, the nurses use the Faces, Legs, Activity, Cry, Consolability scale . For patients 3–6 years old, the nurses use the Faces Pain Scale-Revised . The nurses use the numerical 0–10 visual analog scale  for patients 7 years old and older.Another primary outcome measure was the postoperative morphine rescue rate. PACU nurses administer oral acetaminophen for mild pain (score 1–3). Morphine is the first-line rescue analgesia for moderate (score 4–6) to severe (score 7–10) pain in the PACU.The PONV rescue rate was an additional outcome measure. Nurses administer PONV rescue medications if the patient is vomiting or if the patient or caregiver notes that the patient is feeling nauseated.17 which is not preferable in a high turnover ambulatory surgical center. Patients and families were discharged directly from PACU to home once they returned to their preoperative baseline or met discharge criteria based upon the Aldrete scoring system.18We studied PACU LOS and total anesthesia time as balancing measures. Dexmedetomidine can delay arousal and increase time to discharge,20 SPC methodology enables clinicians to distinguish between common cause variation (random variation intrinsic to the system), from nonrandom variation or special cause variation (SCV), such as improvements in protocol changes monitoring a process over time and combining sequential, time-based analyses.19 The goal is to see either no SCV (interventions did not worsen postoperative pain score or increase PONV) or a change indicating improvement.MDmetrix OR Advisor  is a software system that extracts continuously updated, aggregated, and de-identified health information from the hospital’s EMR. It then presents the data as statistical process control (SPC) charts.20 We utilized a P-chart for postoperative rescue morphine administration in the PACU. An X-bar chart displays continuous data for subgroups with more than one data value per subgroup.20 We utilized an X-bar chart for maximum pain score, PACU LOS, and total anesthesia time. We set the upper and lower control limits at three sigmas above and below the mean, respectively. We identified SCV in the case of the following criteria: (1) a single point located outside the control limits; (2) a run of 8 or more points in a row above or below the mean centerline; or (3) 2 out of 3 consecutive points located near the outer one-third of the control limit. A run of 12 points without SCV is representative of a stable process.19In this QI project, we used 2 types of SPC charts. The P-chart displays dichotomous data as a percentage or proportion of the total data count.We submitted this QI project to the Seattle Children’s Institutional Board Review. The board did not deem it as a research study, and there was no further review.There were 82 patients in the acetaminophen/fentanyl (A/F) cohort, 130 patients in the fentanyl (F) cohort, and 113 patients in the dexmedetomidine (D) cohort. Table The X-bar chart in Figure Figure Only three patients required a PONV rescue medication . No patients required PONV rescue medication in the opioid-free protocol (D cohort).Figure Figure This project consisted of 2 PDSA cycles, assessing the comparative effectiveness of three protocols utilizing intravenous acetaminophen, fentanyl, and/or dexmedetomidine over 5 years.We did not see a notable change in PACU maximum pain scores, morphine rescue requirements, PONV rescue medication rates, or LOS in all 3 protocols. Most importantly, the final protocol successfully reduced opioid use without increased pain scores and achieved a zero PONV rescue rate. This information can help clinicians tailor an effective and cost-efficient protocol for pediatric patients undergoing strabismus surgery.The first PDSA intervention of removing IV acetaminophen from anesthesia protocols (protocol F), primarily as a cost-reduction strategy , demonstrated no detectable change in PACU maximum pain score or morphine rescue rates. Additionally, there was no increase in PONV or PACU LOS. It is important to weigh the risk and benefit of each medication, including the cost of medications. A case-by-case administration of IV acetaminophen may be more appropriate since its addition did not alter morphine rescue rates. Evidence-based care plans are crucial for establishing best practices.22 Administration of opioids for pain control is not without consequence. Common side effects include nausea, vomiting, itching, and potential respiratory depression. Our goal of effective discontinuation of opioids while maintaining low rates of moderate-to-severe pain is a crucial component in determining an effective anesthesia protocol’s viability. Dexmedetomidine has been well established as an analgesic adjunct and can reduce the need for opioids.23 This study demonstrated similar results. From a cost analysis perspective, the use of one vial of fentanyl is similar to one pharmacy partitioned syringe of dexmedetomidine at our facility.The second PDSA intervention of removing fentanyl and adding dexmedetomidine (protocol D) showed similar results. PACU maximum pain scores, morphine rescue rates, PONV rates, and LOS were all unchanged. Postoperative pain from strabismus surgery has been reported as high as 65%.24 Previous studies have suggested that dexmedetomidine can reduce PONV.25 We used PONV rescue administration in the PACU as a surrogate for PONV rates. This study showed no change in PONV rescue medication requirements with A/F, F, or D protocols. Our historical PONV rates, with the administration of two prophylactic antiemetic medications, were already very low (<1%). This finding would explain why we did not detect a further reduction. In the opioid-free group (protocol D), the PONV rate was zero. Removing opioids and reducing an additional risk factor for PONV is very beneficial in high-risk patients. PONV increases PACU LOS; it also correlates with patient satisfaction and is an essential component of patient care plans.Strabismus surgery is highly emetogenic, with PONV rates ranging from 30% to 80%.Dexmedetomidine has the potential to prolong emergence and LOS in the perioperative period. The stability in our total anesthesia time and PACU LOS X-bar chart indicated no deterioration of this measure. The utilization of dexmedetomidine is common in several other protocols at BCSC. Therefore, we speculate that practitioners are already comfortable with the use and pharmacokinetics of this medication. This possibility may account for the lack of significant change in these measured outcomes.This study did have limitations. We did not isolate the effect of acetaminophen on pain control. In the initial protocol (A/F), only 26% of patients received acetaminophen. The fentanyl group (F) had 18% of cases still receiving intraoperative acetaminophen. Removal of acetaminophen from the protocols did not produce a change in pain scores or morphine use rates. At the time of the study, the focus was to remove opioids safely and decrease patients’ costs. A future PDSA intervention worth exploring is the administration of preoperative oral acetaminophen and intraoperative dexmedetomidine.We screen the patient population for BCSC to ensure the appropriateness of outpatient surgery, and thus, it is a predominantly American Society Of Anesthesiologists class 1 and 2 pediatric population. We are not attempting to make gross generalizations about populations outside the facility. Recommendations should be considered for appropriate patient populations.Through QI methodology, leveraging PDSA cycles and SPC charts, we optimized an anesthesia protocol for strabismus surgery that eliminated the need for intraoperative opioids without increasing postoperative morphine requirements and achieved zero PONV rescue medication administration. We present our methods of using real-world data to improve our pediatric population’s outcome measures and successfully established an opioid-free, nausea-free protocol for strabismus surgery not previously published.Dr. Low is the Chief Medical Officer and founder of MDmetrix, and Dr. Martin is a shareholder in MDmetrix. The other authors have no financial interest to declare in relation to the content of this article.


Abdominal pain after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common and unwanted complication that typically leads to further exploration through radiology. Concerns have been raised regarding the consequences of this radiation exposure and its correlation with the lifetime risk of cancer. The aim of this study was to evaluate the differences in computed tomography (CT) use between LRYGB patients with open and closed mesenteric defects and to assess the radiological findings and radiation doses.n = 150) or nonclosure (n = 150) of mesenteric defects during LRYGB. The total number of CT scans performed due to abdominal pain in the first 5 postoperative years was recorded together with the radiological findings and radiation doses.This subgroup analysis included 300 patients randomized to either closure (p = 0.014). The other pathological and radiological findings were infrequent and not significantly different between groups. At the 5-year follow-up, the total radiation dose was 82,400 mGy cm in the nonclosure group and 85,800 mGy cm in the closure group.A total of 132 patients (44%) underwent 281 abdominal CT scans, including 133 scans for 67 patients with open mesenteric defects (45%) and 148 scans for 65 patients with closed mesenteric defects (43%). Radiological findings consistent with small bowel obstruction or internal hernia were found in 31 (23%) of the scans for patients with open defects and in 18 (12%) of the scans for patients with closed defects (Closure of mesenteric defects did not influence the use of CT to assess abdominal pain. Obesity is associated with a wide range of negative health effects such as sleep apnea, hypertension, depression, diabetes, cardiovascular disease, and cancer . This coAcute, intermittent, and chronic abdominal pain after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common complication that has been reported to require healthcare contacts for as many as 1 out of 3 patients after gastric bypass surgery . The evaThe causes of abdominal pain in this population are diverse and range from benign to potentially life-threatening conditions. Small bowel obstruction (SBO) due to internal hernia (IH) is a particularly sinister condition that has become a major concern over the past decades. If no measures are taken to reduce the risk of SBO, the incidence may be as high as 10%, of which IH is the predominant cause , 6.Acute incarceration of an IH can cause necrosis and a significant loss of small bowel with a nonnegligible risk for mortality . While rWhen confronted with abdominal pain in LRYGB patients, physical examination alone is often inconclusive, and the results are hard to interpret. Clinical assessments are therefore often combined with radiological examinations. Currently, computed tomography (CT) is the preferred modality, with a reported sensitivity of 83–85% [The use of various medical imaging examinations has expanded in the last couple of years, with an increase outpacing that of all other categories of physician services except laboratory tests , 10. ConThe aim of the present study was to investigate if there is a difference in the use of CT for abdominal pain depending on whether the mesenteric defects are closed during LRYGB and to assess the radiological findings and radiation doses.This study represents a subgroup analysis of patients included from one surgical center in an original multicenter randomized clinical trial (RCT) comparing mesenteric closure with running nonabsorbable sutures to nonclosure during LRYGB surgery. The enrollment, inclusion, and randomization processes have previously been reported in detail . In brieAll CT scans acquired for any symptoms of abdominal pain within the first 5 postoperative years were obtained from the regional hospital database and collected together with the indications for the examination, radiological findings, and radiation exposure, as measured by dose-length product  and computed tomography dose index . Follow-up imaging performed due to the findings on the primary scan was included, as they were also considered a consequence of abdominal pain. Scans acquired to assess multiple traumas were excluded. The effective dose (E) was calculated using a conversion factor (k) specific for the anatomic region: E = k*DLP . The priThe power calculation for the main study has been presented previously. For the present study, a power calculation was conducted assuming a risk reduction in CT usage equivalent to the described reduction in risk for small bowel obstruction. To detect a difference with a power of 80% at the 5% significance level, a minimum of 108 patients were needed in each group.t tests for continuous numeric variables with a normal distribution and Mann–Whitney U tests for data without a normal distribution. A skewness between − 0.5 and 0.5 was considered a normal distribution. Pearson’s χ2 test was used for dichotomous nominal variables. Statistical significance was set at p < 0.05, and two-tailed tests were applied. All data analysis was performed using IBM SPSS Statistics version 25.0 .The results were analyzed on an intention-to-treat basis. Variables were compiled with standard descriptive statistics and presented in terms of frequency, mean, standard deviation, and/or percentage, if suitable. The study arms were compared using independent-samples The trial is registered in ClinicalTrial.gov, number NCT01137201.The study was approved by the Regional Ethics Board (DNR:2009/415/3) and followed the standards of the 1964 Helsinki declaration and its later amendments.During the inclusion period, 300 patients agreed to participate in the study and were randomized in equal proportions for either mesenteric defect closure using running nonabsorbable sutures or nonclosure. Five patients in the group randomized to nonclosure of the mesenteric defects did not fully receive the allocated intervention: one had neither of the mesenteric defects closed (due to adhesions), 3 had only the defect beneath the jejunojejunostomy closed, and 1 had only the defect at Petersen’s space closed. All of these patients were included in the analyses in accordance with the intention-to-treat principle  were examined with at least one CT scan, compared to 43.3% of patients with closed mesenteric defects . The highest number of scans per patient was 7 in the nonclosure group and 16 in the group randomized to mesenteric defect closure. There was no significant difference regarding the total number of postoperative CT scans between the two groups . Some 44.7% of patients in the nonclosure group (p = 0.017). The other findings explaining the pain were infrequent and not significantly different between groups. For the majority of patients, no radiologic explanations were found for their abdominal pain (Table CT signs of SBO and IH were more common in the group with open mesenteric defects (23.3% versus 12.2%). Twelve patients with open mesenteric defects suffered from SBO compared to 3 with closed defects (p = 0.909). The average effective dose was estimated to be 9 mSv.The total radiation dose measured as DLP was 168,200 mGy cm for the entire cohort, with a distribution of 82,400 mGy cm in the nonclosure group and 85,800 mGy cm in the closure group. The mean CTDI during examinations was 10.3 ± 4.71 mGy with a mean radiation dose per patient for those with open mesenteric defects of 500 mGy cm ± 1100 (DLP) and for those with closed mesenteric defects 10.5 ± 5.41 mGy during examinations with a mean radiation dose of 600 mGy cm ± 1100 (DLP) per patient (In this post hoc analysis of a subgroup of patients randomized to mesenteric defect closure or nonclosure, no significant difference in terms of CT use for abdominal pain or radiation exposure during the first 5 postoperative years after surgery was seen.In all, 43% of patients with closed mesenteric defects and 45% of those without closure underwent at least one abdominal CT scan to evaluate abdominal pain. These numbers are well in line with those reported previously for patients who underwent laparoscopic gastric bypass surgery , 17. WhiThe large number of cases of abdominal pain in which no explanation could be seen on abdominal CT conforms with the high prevalence of chronic abdominal pain as well as irritable bowel syndrome after gastric bypass surgery . In addiThe large number of patients evaluated with CT scans and the large number of scans for certain patients may reflect the current practice for evaluating patients with abdominal pain who have previously undergone gastric bypass surgery. These patients generally present abdominal pain in the emergency department where they may be evaluated by physicians or surgeons with limited experience in bariatric surgery. While early consultations with surgeons with extensive experience in bariatric surgery are warranted, difficulties in reaching such colleagues in combination with pressure on a daily basis from various authorities, such as the legal system, the department of finance, and the public, to write prescriptions and order imaging examinations may in part explain the common use of CT scans in the evaluation of acute abdominal pain among these patients –25. It iThe cancer risk associated with radiation exposure from any given CT scan can be estimated theoretically by either measuring or calculating the doses to the organ involved and then applying organ-specific cancer incidence/mortality data from atomic bomb survivors . AccordiHowever, the concern regarding radiation-induced cancer due to CT scans is due to not only a single examination but rather the current rapid increase in CT usage and the overall effect of this increase. Individual cases of low risk applied to a fast-growing population may very well result in a potential public health issue in some years in the future. In our study, 132 patients underwent a total of 281 CT scans, which led to an overall radiation dose of 168 200 mGy cm for the entire group. This equals a collective dose of approximately 2800 manSv. Using the risk factor 5%/Sv for fatal cancer  would imThe major strengths of this study include the randomized design with high rates of inclusion and follow-up after 5 years. Despite these strengths, the study has several limitations that must be acknowledged. First, although the original study was a registry-based nationwide multicenter RCT, the present post hoc analysis merely included a subpopulation from a single center. Local practices and resources along with geographical location may influence the use of imaging services. Therefore, the generalizability to other regions and countries may be limited. Second, as described previously, mesenteric defects closure is associated with a learning curve during which the risk for bowel obstruction in the early postoperative phase is increased , 30. ThiAlmost half of the patients who underwent LRYGB underwent a CT scan for abdominal pain within 5 years of surgery. Closure of the mesenteric defects did not influence the use of CT for abdominal pain.


Gray-scale, B-mode ultrasound (US) imaging is part of the standard clinical procedure for evaluating thyroid nodules (TNs). It is limited by its instrument- and operator-dependence and inter-observer variability. In addition, the accepted high-risk B-mode US TN features are more specific for detecting classic papillary thyroid cancer rather than the follicular variant of papillary thyroid cancer or follicular thyroid cancer. Quantitative ultrasound (QUS) is a technique that can non-invasively assess properties of tissue microarchitecture by exploiting information contained in raw ultrasonic radiofrequency (RF) echo signals that is discarded in conventional B-mode imaging. QUS provides quantitative parameter-value estimates that are a function of the properties of US scatterers and microarchitecture of the tissue. The purpose of this preliminary study was to assess the performance of QUS parameters in evaluating benign and malignant thyroid nodules.Patients from the Thyroid Health Center at the Boston Medical Center were recruited to participate. B-mode and RF data were acquired and analyzed in 225 TNs  from 208 patients. These data were acquired either before (167 nodules) or after (58 nodules) subjects underwent fine-needle biopsy (FNB). The performance of a combination of QUS parameters (CQP) was assessed and compared with the performance of B-mode risk-stratification systems.CQP produced an ROC AUC value of 0.857 ± 0.033 compared to a value of 0.887 ± 0.033 (p=0.327) for the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS) and 0.880 ± 0.041 (p=0.367) for the American Thyroid Association (ATA) risk-stratification system. Furthermore, using a CQP threshold of 0.263 would further reduce the number of unnecessary FNBs in 44% of TNs without missing any malignant TNs. When CQP used in combination with ACR TI-RADS, a potential additional reduction of 49 to 66% in unnecessary FNBs was demonstrated.This preliminary study suggests that QUS may provide a method to classify TNs when used by itself or when combined with a conventional gray-scale US risk-stratification system and can potentially reduce the need to biopsy TNs. Thyroid nodules (TNs) occur in 50% of the older adult population; however, only about 5% of TNs are malignant , 2. CurrHigh-risk B-mode-image features used for risk-stratification are more specific for hypoechoic classic papillary thyroid cancer (cPTC) rather than the follicular variant of papillary thyroid cancer (fvPTC) or follicular thyroid cancer (FTC), which tend to be isoechoic and are not associated with microcalcification. Finally, the sensitivity and specificity of FNB cytology in conjunction with commonly used, costly, and time-consuming molecular genomic and gene-expression testing  range from 91 to 94% and 68 to 82%, respectively  echo signals reflected back from tissue and discard much of the information that is present in the raw RF echo signal. QUS uses the normalized power spectrum of the raw RF signal, and extracts discarded RF-signal information to obtain parameter-value estimates that are a function of effective scatterer size and effective scatterer acoustic concentration  as described in detail for clinicians in prior publications  produced a receiver operating characteristics (ROC) area under the curve (AUC) value of 0.93.Quantitative ultrasound (QUS) is a non-invasive method of analyzing microarchitectural tissue properties ications –13. Whilications , 15. Smaications , 17. Theications . A combiThis is the first large-scale, single-institution, clinical-use study evaluating the utility of QUS in human subjects for cancer risk-stratification of TNs. The aim of this preliminary study is to determine if QUS US can stratify the risk of malignancy of TNs that is similar to the ACR-TIRAD and ATA Risk Assessment systems for reducing the number of thyroid biopsies while not missing a significant number of malignancies of TNs with definitive cytology or pathology results. Since the QUS and B-mode-US characteristics depend on different aspects of the US RF echo from a TN, we explored the potential of QUS in combination with an existing TN risk-stratification system to determine if the number of biopsies could have been further reduced in this cohort.The study was approved by the Boston University Medical Center institutional review board. Patients, 18 years and older, were recruited from the Thyroid Health Center at Boston Medical Center if they were scheduled for an FNB of one or more TNs based on the 2015 ATA TN guidelines or at the discretion of the treating provider. Patients were recruited when referred to the research team by a member of the Thyroid Health Center. The gray-scale images archived in the Boston Medical Center picture and archiving and communications system (PACS) and reviewed by an investigator (SLL) with considerable experience in thyroid US to determine the cancer risk according to the ATA risk-stratification system and ACR TI-RADS. A GE LOGIQ-E9 US scanner  modified for RF-data acquisition was used to acquire conventional gray-scale and QUS data. QUS data were acquired by either of two study investigators (SLL or PNG). Following research US data acquisition, patients underwent an US-guided FNB of one or more TNs per standard of care. The biopsy material was acquired for cytopathology and for additional molecular analysis with ThyroSeq genomic classifier (v2 or v3)  if required. A second set of patients who had a prior TN FNB  was recruited during a routine follow up visit when the research US data were acquired. TNs were excluded for analysis if a significant cystic region was present or macrocalcification existed superficial to the regions of interest in the TN.The final categorization of the TN was based on FNB cytology and surgical pathology results. A TN was classified as benign if its cytology was unequivocally cancer free (Bethesda II) or surgical pathology showed no evidence of malignancy. If a biopsy specimen had an indeterminate cytology (Bethesda III or IV), it was considered benign if molecular testing was negative or if the positive result was associated with a low risk for cancer . Molecular testing was not used in TNs with Bethesda V cytology according to the recommendations of the molecular test manufacturers, and surgical-pathology results served as the basis for final categorization. A classification of cancer was determined either by a cytology category of Bethesda VI or by a definitive diagnosis based on surgical pathology. In one subject, a TN was determined to be malignant based on the presence of classic high-risk gray-scale US features and cervical adenopathy. Although the TN was not biopsied, the FNB of the suspicious cervical lymph node was positive for metastatic thyroid cancer.0) were obtained from the linear model. The fifth QUS estimate was the Nakagami shape parameter (µ), which was computed using a maximum-likelihood estimator to fit the probability density function of the envelope-detected RF signals to the probability density function of the Nakagami distribution.Each RF data set was manually segmented by an investigator (PNG) for QUS processing by identifying the TN in B-mode images and overlapping rectangular regions of interest (ROI) were applied to ten cross-sectional planes of the nodule. Spectral-parameter estimation techniques have been described in prior publications . The bacA linear-discriminant classifier was trained and tested to assess the ability of the QUS parameters to differentiate malignant and benign TNs. Classification performance was expressed using standard ROC methods as the AUC. The ROC AUC values and 95%-confidence intervals (CIs) were obtained using 10-fold cross validation to guarantee that the classifier was not overtrained and able to independently assess previously unseen cases. The mean and standard-deviation values for each QUS parameter were calculated. Initially, the classification performance for each feature was tested alone and then linear combinations of features were tested. To linearly combine the features, the standard Fisher linear discriminant approach was used to test all possible combinations of the five QUS parameter means and standard deviations. Statistical analysis was performed using the MATLAB statistics toolbox .309 patients with 333 TNs were recruited for the study. Fourteen TNs were not included in the analysis because the data could not be recovered from the US instrument. Thirty-four TNs were excluded when the signal-processing software detected an error in the data being analyzed and blocked further processing. These data errors occurred randomly, and were not associated with any nodule pathology or sonographic appearance. In five TNs, difficulty existed in identifying the region of interest (ROI) during analysis , and in 19 TNs, significant cystic areas or macrocalcifications existed that interfered with the propagation of the US beam and with the analysis and, therefore, these TNs were excluded. Thirty-one TNs were excluded because cytopathology results were insufficient or incomplete at the time of analysis, and three were excluded because non-thyroid pathology was present . Only two non-invasive follicular tumors with papillary like features (NIFTPs) were present with analyzable data confirmed after surgery. NIFTPs were excluded from analysis because it has been considered to be a pre-malignant lesion that cannot be classified as completely benign or malignant. Consequently, the final analysis included 225 TNs from 208 patients. Of these, 167 patients had RF echo-signal data acquired immediately prior to the biopsy being performed. The remaining 58 patients had RF data acquired after an FNB with an interval of 26 days to 85 months. 0 with a ROC AUC value of 0.742 +/- 0.046 and ESC with an AUC value of 0.702 +/- 0.049 as shown. The normalized standard deviation of selected QUS parameters showed improved performance with an AUC of 0.769 +/- 0.047 and 0.72 +/- 0.064 for I0 and ESC respectively. Linear discriminant analyses revealed that the optimal linear combination of QUS parameters (CQP) was [(0.143 x ESC) + (0.018 x ESS) + (3.198 x µ) - (0.391 x σESC) - (14.896 x σESS/mean of ESS) - 3.062], which produced an AUC value of 0.857 +/- 0.033 as shown in We examined the utility of QUS compared with ACR TI-RADS and the ATA nodule classification systems to reduce FNBs of benign TNs. When applied by an experienced thyroid sonographer the ACR TI-RADS system produced an AUC value of 0.887 +/- 0.033 and the ATA system produced an AUC value of 0.880 +/- 0.041. There were no statistically significant differences when comparing these values with the ROC performance of CQP (p=0.327 and p=0.367 respectively). In this cohort of TNs that have been selected for biopsy by the treating providers, ACR TI-RADS would not have recommended a biopsy in 89 (39.6%) TNs, with a single false-negative determination. The ATA system would have prevented 14 biopsies (6.2%) with no false-negative determinations. The ATA system is used by our endocrine clinicians to determine the need for FNB, and hence there was a lower number of TNs excluded for biopsy when reviewed by investigators. In comparison, if a CQP value of 0.263 or less was used to recommend tissue sampling, while providing a zero percent false negative rate, a biopsy would be avoided in 98 TNs (43.6%) Table 4.The single missed cancer when applying the traditional ACR TI-RADS criteria to the cohort was nodule A (Bethesda III cytology with NRAS mutation), which was a low-risk, 1-cm, encapsulated fvPTC with minimal focal capsular invasion without lymphovascular invasion, extra-thyroidal extension, or abnormal lymph nodes on surgical pathology as shown in The use of a B-mode, risk-stratification systems in combination with QUS was explored to determine if additional FNBs or molecular testing could be reduced as summarized in TNs are a common occurrence in the adult population. The ACR-TIRAD and ATA Risk Assessment systems based on high-risk sonographic characteristics have very high negative predictive value (NPV) but low positive predictive value (PPV) resulting in unnecessary biopsy of benign nodules. Even when combined with fine needle biopsy, 20-30% of biopsies will have an indeterminate cytology that results in expensive molecular marker testing or surgery for pathological diagnosis. We anticipate that QUS, an US technology that allows a noninvasive method of investigating microarchitectural structures that cannot be assessed by conventional B-mode imaging, will provide additional information to improve the discrimination between benign and malignant thyroid nodules to reduce the number of biopsies of benign nodules and reduce the molecular marker testing and surgery of nodules with an indeterminate  cytology.The study cohort had a Bethesda cytology category distribution that is typical of this institution including the indeterminate rate (Bethesda III and IV) of 26%. The overall cancer prevalence was 10.7% in nodules that were selected for biopsy and is also typical of our academic tertiary care referral center. The cancer prevalence is higher in this study cohort compared to the 5% prevalence in all TNs as some nodules are not biopsied because of small size or benign sonographic characteristics (completely cystic or spongiform). The study cohort in which research data were acquired after the FNB was completed had a higher proportion of Bethesda II cytology (76%) as they did not have surgery or refused surgery based on the prior FNB results.The ACR-TIRADS and the ATA systems are used to determine if a TN can be excluded from biopsy based on size and the absence of high-risk sonographic features. The AUC for ACR TI-RADS and the ATA system to identify cancer in prior published data has a wide range of values between 0.76 to 0.88 and 0.77 to 0.89, respectively –22. In tThere were several limitations and aspects of QUS application in TN assessment that were not evaluated in this study. Factors affecting the reproducibility of results that are operator-dependent, such as defining the ROI, were not addressed in the current study. Given limited numbers, individual cancer subtypes were analyzed together rather than separately. NIFTPs, which currently are considered a pre-malignant lesion and are a clinically relevant subtype of thyroid tumors, were not included in the current study because of the low prevalence in this cohort of TNs and uncertainty whether to consider this a benign or malignant in the classification for this study. Although NIFTP are considered a benign lesion, resection is recommended because of the potential of future malignant behavior. Since the recommendation is for surgical removal, it would be an error to categorize it as benign requiring no further characterization in the analysis of this data. Identifying isoechoic cancers has traditionally been difficult due to the lack of specificity of this B-mode feature and the frequent absence of an association with other high-risk US features. While QUS appeared to show an encouraging degree of separation between malignant and benign isoechoic TNs Figure 2The cohort included a total of 225 nodules, with US data being collected either before or after FNB completion, as this was a preliminary study. The 33 patients in our pilot study (ROC AUC 0.93) are a subset of the nodules included in this study . With a Future prospective studies are required to validate the findings from the current study and further explore the role of QUS in the evaluation of TNs to reduce biopsies of benign TN, possibly reduce the use of expensive molecular testing and reduce unnecessary surgery of benign TNs with indeterminate cytology . The currently available molecular testing for FNB are “rule out” tests with low positive predictive values because of overlapping molecular findings in benign and malignant nodules. The results of this initial study justify a larger prospective study examining the benefits of combining QUS with other US risk-stratification methods, such as TI-RADS, to further enhance TN-classification.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Boston University Medical Campus and Boston Medical Center. The patients/participants provided their written informed consent to participate in this study.PG, JM, DR, KW, EF, and SL conceived and planned the study design. PG and SL collected data and all authors contributed towards processing and analyzing data. All authors contributed to the article and approved the submitted version.The research reported in this publication was supported by the National Institutes of Health grant R21 CA212744 awarded to the Boston Medical Center, SL, Principal Investigator.Author DR is an employee of Versonics, Inc. and KW is an employee of the General Electric Research Center.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This scoping review with narrative synthesis aimed to analyze scholarly peer-reviewed articles reporting on improving communication with patients discharged from the emergency department with noncardiac chest pain and qualitatively narrate on and summarize items that can be used in guiding communication with patients discharged from the emergency department with noncardiac chest pain.  The databases of EMBASE/PubMed, Scopus, COCHRANE, CInAHL/EBESCO, UW libraries, and Google Scholar were searched using relevant MeSH and key terms up to February 06, 2020. The selected articles were analyzed for their contents. Items guiding discharge communication were summarized qualitatively.  Twenty-five articles were eligible for full review. These were published in between 1994 and 2020. Of those, 16 (64.0%) originated from the United States and 4 (16%) used some interventional design. A total of 45 different items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain were identified from the studies included in this review. Items were grouped under 6 categories that were related to initial assessment (8 items), information on diagnosis (7 items), information on discharge (9 items), follow-up suggestions (7 items), symptoms that promote return to the emergency department (7 items), and treatment plan (7 items).  Communication with patients discharged from the emergency department with noncardiac chest pain can be improved. Results of this investigation might be helpful in guiding quality improvement projects aimed for further improvement of communication with patients discharged from the emergency department with noncardiac chest pain. Despite the advancements and innovations in diagnostic and interventional methods, evaluation of patients who present to the emergency department with chest pain is still challenging –3. PatieImproving quality of care, patient experiences, and patient satisfaction are high priorities in all healthcare settings , 9. ImprDespite the importance of communication between patients and their healthcare providers in the emergency department articulated in previous research, little scoping and narrative synthesis of scholarly peer-reviewed articles reporting on improving communication with patients who present to the emergency department with noncardiac chest pain was conducted before.Scoping reviews with narrative analysis have evolved as useful tools in analyzing the contents of scholarly peer-reviewed literature on a particular subject . In thisThis scoping review with narrative synthesis is being reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR) . AdherenA systematic search for articles was conducted to identify and select studies reporting on improving discharge communication with patients who present to the emergency department with chest pain. The following databases were searched: Excerpta Medica database (EMBASE) through PubMed, Scopus, COCHRANE, Cumulative Index to Nursing and Allied Health Literature (CInAHL) hosted by EBESCO, and UW libraries. The databases were searched using medical subject headings (MeSH) and key terms relevant to improving discharge communication with patients who present to the emergency department with chest pain: “patient discharge,” “patient discharge summaries,” “communication,” “teach-back communication,” “health communication,” “hospital communication systems,” “communication barriers,” “physician-patient relations,” “therapeutic alliance,” “patient satisfaction,” “emergency service, hospital,” “emergency medical services,” “emergency treatment,” and “chest pain.” MeSH and key terms were combined using the Boolean operators “AND” and “OR” , 24–29. A manual search was performed using the titles and abstracts of the articles identified through the search to decide on which studies will be selected for full-text review.Three researchers  independently performed the literature search. The literature search was supervised by RS (PhD) who had prior knowledge and experience in searching the databases used in this study . ResultsIn this study, articles were included when they reported original studies on communication with patients who present to the emergency department with chest pain. The search was not restricted to any particular country, year of publication, and/or publication status. Articles were included regardless of the methods used. Articles with mention of discharge communication, emergency department, and chest pain were given a priority for inclusion in the full-text review.Articles published in languages other than English were not included. Editorials, commentaries, letters to the editor, and review articles were excluded. Studies that were not related to communication in emergency department in relation to chest pain were also excluded.In this study, a form was created in Excel spreadsheet (Microsoft Inc.) to collect the data. Three researchers  independently reviewed the full text of the selected articles. Items relevant to communication with patients complaining of chest pain within the full text of each article were highlighted using Adobe Acrobat Pro  by each researcher independently. The researchers extracted items independently into the data collection form. Items were then shared between all researchers, and results were compared. Conflicting results and discrepancies were resolved by discussion and consensus. The extracted items were analyzed and organized thematically , 30.In this study, data relevant to name of author (s), year of publication, country/setting in which the study was conducted, aims of the study, design of the study, study participants, method data collection, main findings, and funding were collected. The data collection form is found in Supplementary Materials (Supplementary Table S2).Due to the nature and heterogeneity of the results, a narrative synthesis was used to present the results of the scoping part of this study. Items that can be used in guiding discharge communication with patients presenting to the emergency department with chest pain were qualitatively synthesized. From the synthesized items, the authors selected the most important key messages that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain. Discussions, deliberations, and consensus were used to select the most important key messages.The literature search in the databases yielded a total of 54,542 documents. When the duplicates were removed, 54,325 documents were retained. Upon applying the inclusion and exclusion criteria, 194 documents were retained. Of those, 45 were eligible for full-text review. Of those, 25 articles were included in the narrative synthesis. Of the selected articles, 10 (40.0%) were open access and 15 (60.0%) were accessible by subscription. Details of the search strategy are shown in The selected studies were published in the years 1994 to 2020. Of all studies, 4 (16.0%) were published in the year 2018. Details of the year of publication are shown in Of the selected studies, 16 (64.0%) were conducted in the United States and 3 (12.0%) were conducted in Switzerland. Details of the countries in which the selected studies were conducted are shown in Of the studies selected, 4 (16%) used some interventional design. The rest of the studies were observational or qualitative. Details of the study design and tools used in the selected articles are shown in Supplementary Materials (Supplementary Table S3). Narrative summaries of the selected articles are shown in Supplementary Materials (Supplementary Table S4).Of the studies selected for this scoping review, 5 (20.0%) were funded by a research institution, 4 (16.0%) were funded by a professional association, and 3 (12.0%) were funded by Agency for Health Care Research and Quality. Details of the funding bodies are shown in The most important key messages that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain that were selected by the authors are shown in The studies included reported different methods that can be used to assess the level of patient satisfaction with discharge communication. These methods included interviews with the patients, using questionnaires/surveys/checklists, reviewing patient records, using some sort of electronic communication portal, and listening to audio recordings of the emergency department. In modern healthcare systems, communication between healthcare providers and patients has received considerable attention. Additionally, there has been more emphasis on improving satisfaction of patients being discharged after receiving necessary healthcare services. The purpose of this scoping with narrative synthesis was to identify, analyze, and summarize peer-reviewed articles published on improving discharge communication with patients who presented to the emergency department with chest pain. Findings of this study portrayed the scholarly literature on improving discharge communication with patients who presented to the emergency department with chest pain and summarized items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain. To our knowledge, this study is the first appraisal of peer-reviewed scholarly articles reporting on improving discharge communication with patients who presented to the emergency department with chest pain. Additionally, this is the first study to summarize items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain.In this study, original articles were selected and included. In scholarly peer-reviewed publications, the majority of the articles are published as original articles , 32. Of The articles selected in this study were retrieved through a thorough search of 5 main large databases of scholarly published peer-review literature. The search engine Google Scholar was also used to supplement the search. The databases used in this study are known for the quality of the journals indexed in each database. Additionally, these databases are commonly used in scoping and systematic reviews , 34.The articles selected in this study were published over the year span of 1994–2020, and the majority of the articles (76.0%) were published beyond the year 2010. Growth of the number of articles in recent years could have indicated more emphasis on improving communication with and satisfaction of patients with chest pain being discharged from emergency departments.In the present study, the majority (64.0%) of the articles reported studies conducted in the Unites States. Articles also reported studies conducted in the United Kingdom, Canada, Australia, Switzerland, and Norway. In this study, none of the studies included originated from a developing country. Our findings could have been explained by the high productivity of developed countries compared to productivity of developing countries in terms of research and scholarly peer-reviewed literature . It has Of the studies selected, 15 (60.0%) declared receiving funds from research institutions, professional associations, or agencies for healthcare research and quality. Funding could be crucial in supporting and sustaining scientific/academic research and productivity of scholarly peer-reviewed literature productivity –40.Items guiding discharge communication with patients presenting to the emergency department with chest pain were summarized and grouped under 6 categories: initial assessment, information on diagnosis, information on discharge, follow-up suggestions, symptoms that prompt return to the emergency department, and information on treatment. In emergency department, assessment of patients complaining of chest pain should be initiated in a timely manner in quiet places to preserve the privacy and confidentiality of the patient . Recent Patient satisfaction with discharge communication can be measured using different methods. Healthcare providers/stakeholders can conduct face-to-face or phone interviews with the patients , 43–45. This scoping with narrative synthesis provided adequate coverage of scholarly peer-reviewed research on improving discharge communication with patients who presented to the emergency department with chest pain and summarized items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain. The main databases indexing the largest number of peer-reviewed literature were used in the search . FindingFindings of this study could be interpreted taking into consideration the following limitations. First, articles published in languages other than English were excluded from this study. As we restricted the search to articles published in English, we could have missed some interesting findings in articles published in languages other than English. Second, a scoping method was used for the literature search and review. Compared to other review approaches including the scoping approach, the systematic approach has been advertised as the most robust in preserving rigor and reproducible results. However, in this study we did not opt for a systematic review approach because the nature, aims, questions, problem, intervention, comparison, outcome, study design (PICOS), and number of articles needed for this study encouraged a scoping approach –63. ThirIn summary, effective communication and patient satisfaction are major concerns in the emergency department, especially those presenting with chest pain. Poor communication between patients and healthcare providers could have devastating consequences on the quality of healthcare services provided and health outcomes of the patients. This scoping study provided insights into the width and depth of scholarly peer-reviewed documents on improving discharge communication with patients presenting to the emergency department with chest pain. Results of this investigation might be helpful in directing future research for further improvement of discharge communication with patients presenting to the emergency department with chest pain. More studies are still needed to address poor communication and improve satisfaction of patients presenting to the emergency department with chest pain.


Background and Objectives: The current options for acute pain control of vertebral compression fracture include hard brace, vertebroplasty, early surgery, and analgesic injection. We hypothesize that the gray ramus communicans nerve block (GRNB) controls the acute pain experienced during vertebral compression fractures. This study assessed the time course of pain control after injection and evaluated the risk factors affecting pain control failure. Materials and methods: Sixty-three patients  with a thoracolumbar vertebral fracture at the T10-L5 spine, who presented to our hospital from November 2018 to October 2019, were included in this retrospective cohort study. GRNB was performed within 1 week of the trauma. The patients were followed up on days 3, 14, 30, 90, and 180 and assessed with the serial visual analog scale , Oswestry Low Back Disability (ODI) questionnaire, and Roland–Morris Disability Questionnaire (RDQ). The failure group was defined by the need for an additional block or cement injection after a single GRNB. The failure group’s risk factors, such as body mass index, initial thoracolumbar injury classification and severity score, Kummel’s disease, age, bone marrow density (BMD), and underlying disease, were analyzed. Results: The motion VAS score improved from preoperative to three months post-procedure, but the resting VAS was affected by the procedure for only three days. The quality of life index improved at postoperative six months. A lower BMD was the only risk that affected treatment failure in the logistic regression analysis (p = 0.0038). Conclusion: The effect of GRNB was maintained even at three months after trauma based on motion VAS results. The only risk factor identified for GRNB failure was lower BMD. As we have entered an aging society, osteoporotic vertebral fractures are on the rise, and the number of patients with traumatic vertebral fractures is increasing . The preThe primary goal of this study was to analyze the time course of pain control after GNRB. Secondary goals were to evaluate the risk factors for failing pain control after GNRB. We defined ‘pain control failure’ as requiring additional procedures such as a repeated block or vertebroplasty or kyphoplasty.The Institutional Review Board at Hallym University reviewed and approved this retrospective study. We found spinal fracture patients admitted to the neurosurgery department between 1 November 2018 and 1 November 2019 through electronic medical record (EMR) system. As inclusion criteria, patients had an index thoracolumbar fracture from T10 to L5, adult patients over 18 years of age were included, and patients who underwent computed tomography (CT)or magnetic resonance imaging (MRI) for fracture evaluation were included. The exclusion criteria were as follows: visual analog scale (VAS) score was 3 or less; no acute fracture on CT or MRI; spine fracture which needs fixation surgery; spine fractures other than T10-L5 fractures; multiple trauma combined T10-L5 fractures; pathologic fractures such as tumor, infection, etc.; severe soft tissue injury such as multiple burn injuries .For all patients, thoraco-lumbo-sacral orthosis braces were worn, and conservative treatment for pain relief was started. Oral tapentadol 50 mg was taken twice a day for 7 days, then tramadol 37.5 mg + acetaminophen 325 mg combination was prescribed twice a day. To patients who did not improve their pain with oral mediation, additional intravenous analgesics were given such as ketorolac 30 mg or tramadol 50 mg. Additionally, osteoporosis was evaluated and treated. Within three days after trauma, GRNB was performed under fluoroscopy under local anesthesia.The sex, age, body mass index (BMI), bone marrow density (BMD), underlying disease, and medications, such as steroids, were analyzed in all patients.The procedure was performed in a biplane angiography room. Patients were placed in a prone position with a soft bed table and arms hanging over the table. Under the fluoroscopic images, a 23 gauge spinal needle was laterally inserted toward the center of the fractured vertebral body. Approximately 3.5~5.0 cm from the midline of the vertebral body just inferior to the transverse process, usually 1.5~2.0 cm lateral to the inferior endplate in case of the thoracic region. The needle was then advanced through just inferior to the pedicle and advanced into a slightly anterosuperior aspect of the foramen. The needle tip was positioned approximately 5–10 mm anterior to the foramen and just above the foramen roof, where the most proximal portion of gray ramus communicans is known to be located . After gDuring the nerve block procedure, the patient’s vital signs were checked, and after the procedure, we monitored for any signs of complications. .The same questionnaire was administered to all fracture patients, such as VAS (divided into motion and resting score) for pain intensity and characteristics. The Oswestry Low Back Disability (ODI) and Roland–Morris Disability Questionnaire (RDQ) assessments for quality of life were analyzed pre-procedure and at three days, 14 days, 30 days, 90 days, and 180 days post-procedure. The dose of analgesics was monitored for their effect of GRNB before and after the procedure.The patients were divided into two groups: success and failure groups. We defined ‘treatment failure’ as either the absence of pain improvement or the need for another procedure, such as repeat GRNB or vertebroplasty. Sex, age, smoke, alcoholics, bone marrow density (BMD), BMI, Kummel’s disease, thoracolumbar injury classification and severity score (TLICS), underlying illnesses , and medications  were analyzed as risk factors of GRNB failure.Data were analyzed using SPSS . The primary outcome measures were changes in the VAS, ODI, and RDQ scales over time as determined by using a repeated measure ANOVA. The model included the pattern of covariance between repeated observations to account for correlations between observations within each patient. For the secondary outcome analysis, unpaired Student t-tests or Mann–Whitney tests were used for continuous variables, and chi-square tests or Fisher’s exact test was used for categorical variables. The following baseline characteristics of patients experiencing treatment failure after GRNB were examined for statistically significant differences: The sex, age, BMI, BMD, underlying disease, and medications, such as steroids.Of the 483 patients with vertebral fracture during that period, 94 patients declined the procedure, and 312 patients were excluded due to mild pain of VAS score 3 or less, no acute fractures, or pathological fractures. Finally, 63 patients underwent the gray ramus nerve block procedure .The characteristics of the 63 study patients are summarized in p = 0.0088). The treatment failure group’s average BMD was −3.31, which was lower than the average BMD of the treatment success group  . There were no significant differences between the two groups, with an average duration of 5 days after fracture. The treatment failure group’s average age was 72.86 years, which was higher than the average age of the treatment success group, 64.26 years ( 0.0003) .p < 0.0001), 14 days , 30 days , 90 days . After 90 days, the pain score change did not differ significantly at 180 days (0.27 ± 0.19). The pattern of resting VAS change was different from that of motion VAS. The resting VAS score was 4.37 ± 0.38. Symptom improvement was seen at three days , but was then unremarkable at 14 days , 30 days , 90 days  and 180 days .Pre-procedure motion VAS was 7.88 ± 0.31. After the procedure, the pain score was serially improved at 3 days , 14 days , 30 days , 90 days  and 180 days . The initial RDQ, a life quality index, was 19.59 ± 3.57 and improved at 3 days , 14 days , 30 days , 90 days , and 180 days  over 6 months  to 3 day .The frequency of analgesic injection use during hospitalization decreased in the GRNB treatment group. The average number of analgesic administrations decreased from 1.571 pre-GRNB to 0.265 post-GRNB in the success group. However, comparing to failure group, the number of analgesic injections was not significant different , and underlying disease, were analyzed.p = 0.0088). The average BMD of the treatment success group was −1.79, which was significantly different from the treatment failure group (−3.31). (p = 0.0003). Using a logistic regression model, BMD was a significant risk factor for treatment failure . We think that in osteoporotic vertebral fracture patients, the vertebral body’s stability was decreased, leading to persistent and longtime back pain after the injection. In previous GRNB-related papers, no risk analysis was performed for the patient group with a low treatment effect.In our research, satisfactory pain improvement over three months, without additional treatments, was confirmed in 78% of patients. These were similar results to the study on GRNB in another study, Choi et al . In anotThe strength of our study is that the same treatment protocol for acute fractures was applied to all patients. The treatment effect was recorded through the same questionnaire survey at pre-procedure and on the 3rd, 14th, 30th, 90th, and 180th days after the GRNB block, allowing us to evaluate the effect over time. Our study’s other strength is that we define the treatment failure group and analyze the risk factors in this group.A limitation of our study is that it was a retrospective study, and there was no control group. Compared to conservative treatment alone or shame procedure or cement augmented procedure such as vertebroplasty or kyphoplasty, we may identify the effective time point and period compared to control group. And without a control group, the effect of GRNB may be minimal clinical differences. Another limitation is that the acting time of the drugs used in the block is short acting agent. Various block regimens, such as triamcinolone and RF, were used in other studies. To date, there have been no studies on the difference between these drugs. If a paper that addresses these problems is published in the future, it is believed that a reliable verification of the effect of GRNB treatment will be possible. The other limitation is that, radiologic factors such as changes in the morphology of fractures have not been analyzed as risk factors for treatment failure. The kyphotic angular change of the patient’s body shape due to fractures over time may affect treatment failure.The GRNB could relieve acute pain and improve quality of life. The motion pain decreased rapidly for three days and was maintained for 90 days after the procedure. Decreased BMD is a risk factor for GRNB treatment failure.