The treatment of acute pain in the emergency department is not always optimal. Peripheral nerve blocks using “blind” or nerve stimulator techniques have substantial disadvantages. Ultrasound-guided regional anesthesia may provide quick, safe, and effective pain relief in patients with proximal femoral fractures with severe pain. However, no evidence exists on emergency physician-performed ultrasound-guided regional anesthesia in these patients in Dutch emergency departments. We hypothesized that emergency physicians can be effectively trained to safely perform and implement ultrasound-guided femoral nerve blocks, resulting in effective pain relief in patients with proximal femoral fractures.In this prospective observational study, emergency physicians were trained by expert anesthesiologists to perform ultrasound-guided femoral nerve blocks during a single-day course. Femoral nerve blocks were performed on patients with proximal femoral fractures. A system of direct supervision by skilled anesthesiologists and residents was put in place.p <  0.001).A total of 64 femoral nerve blocks were performed. After 30 min, blocks were effective in 69% of patients, and after 60 min, in 83.3%. The mean reduction in pain scores after 30 and 60 min was 3.84 and 4.77, respectively . No adverse events occurred.Ultrasound-guided femoral nerve block is an effective, safe, and easy to learn (single-day course) procedure for emergency physicians to implement and perform in the emergency department. Patient satisfaction was high. The treatment of acute pain in emergency department (ED) patients is not always optimal , 2. FortNerve blocks in femoral neck fracture patients can be achieved using different techniques. The FICB is a “blind” technique in which surface anatomy landmarks are used to determine the needle insertion point, and tactile feedback guides the correct needle position. Techniques based on surface landmarks have a higher incidence of paresthesia during performance of the block . FurtherUltrasound-guided nerve blocks may overcome the aforementioned drawbacks. Ultrasonography allows identification of relevant anatomical structures and continuous needle tip visualization, and even the spread of local anesthetic (LA) may be observed. Ultrasonography in regional anesthesia has increased the success rate and reduced the complications of peripheral nerve blocks .Traditionally, only anesthesiologists performed ultrasound-guided regional anesthesia (UGRA). In recent years, though, emergency physicians (EPs) have been adopting this technique –16. HoweAn ultrasound-guided femoral nerve block and FICB appears to provide quick, safe, and effective acute pain relief and could therefore be a valuable tool adding to current pain management regimes in Dutch EDs , 17. HowA prospective observational study in ED patients with proximal femoral fractures was conducted from June 2014 until June 2017. The aim of the study was to evaluate the effectiveness, safety, and satisfaction of EP-performed ultrasound-guided nerve blocks in the emergency department.Adult patients admitted to the Radboud university medical center ED with a proximal femoral fracture, including trochanteric and femoral neck fractures, in whom an ultrasound-guided femoral nerve block or FICB was planned in the ED were included. Exclusion criteria were any sign of infection at the injection site, hemorrhagic diathesis  > 2.0), an allergy to ropivacaine, and multiple traumata.A 1-day course and an e-learning module were developed by a collaboration of anesthesiologists with extensive experience in UGRA and EPs experienced in general ultrasound. Every EP and EP in training participated in this hands-on course focusing on UGRA of the femoral nerve and FICB. The online pre-course e-learning module and course lectures dealt with basic theory of ultrasound, pharmacology of local anesthetics, indications, relevant anatomy, block techniques, complications and their treatment, and follow-up. Live anatomy and practical block techniques were taught on human cadavers at the Radboud Anatomy Department. Scanning techniques and sonoanatomy were taught and practiced on the participants themselves. Ultrasound-guided needle handling was practiced on blocks of tofu with tiny artifacts inserted.The UGRA-trained EPs were supervised by skilled (resident) anesthesiologists for five, or more if desired, ultrasound-guided femoral nerve blocks or FICBs until the EPs had gained the knowledge, expertise (as judged by the anesthesiologist), and confidence to perform the procedure independently. A dedicated pool of anesthesiologists and residents with extensive experience in UGRA provided immediate and direct supervision on weekdays during regular business hours. Outside of these hours, supervision was provided depending on the availability of a skilled anesthesiologist or resident.Before the ultrasound-guided femoral nerve block or FICB was performed, oral informed consent was obtained as part of the standard operating procedure (SOP). No sedative premedication was administered prior to the procedure.− 1 body weight of ropivacaine, injected in 1–2 ml increments under direct ultrasound guidance to confirm the optimal spread of LA around the femoral nerve or below the iliac fascia (FICB). Negative aspiration is confirmed at least every 5 ml to prevent intravascular injection.The ED SOP was jointly written by anesthesiologists and EPs, in accordance with the existing SOP for ultrasound-guided femoral nerve blocks performed by anesthesiologists in the operating room. It prescribes a sterile procedure and a conservative maximal LA dosage to minimize risks of local anesthetic systemic toxicity (LAST). Vital parameters  are monitored and continued for 30 min after the procedure. The skin is prepped and draped, and face masks, caps, sterile gloves, and a sterile probe cover are donned. Sterile ultrasound transmission gel and a Stimuplex® Ultra 22G 0.64 × 50 mm, 30°, short bevel  non-traumatic needle are used. The LA consists of ropivacaine 0.375%, in (four) labeled 10-ml syringes, to allow for a high-volume block without exceeding the maximum dosage. Alternatively, ropivacaine 0.75%, which is also used by anesthesiologists for providing surgical pain relief, can be used. The maximum allowed dose of LA is 2 mg · kgIn addition to the EPs and EPs in training, all ED nurses were trained to be familiar with the SOP and to be able to assist in the procedures.The procedure was recorded in the electronic medical record (EMR) according to the SOP. Relevant and additional data were recorded on a dedicated case report form, including gender, age, fracture type and location, and prehospitally administered analgesics . The indication and type of the nerve block, LA dosage, scores on physician and patient satisfaction, pain scores, any rescue medication, adverse events, and any reason to abandon the procedure were also recorded. Vital signs were recorded only in the EMR.Pain scores were taken in rest on a numeric rating scale  on arrival at the ED (t0) and after the procedure at 30, 60, and 120 min , but only if still in the ED. We considered a nerve block to be successful whenever there was a pain reduction of at least two points after 30 min compared to baseline. We considered a pain reduction of at least 33% to be clinically important, as inspired by the work of Farrar et al. . An absoJust before discharge from the ED, patients were asked about the level of (dis)comfort they experienced and if they were motivated to undergo a similar procedure in the future. In addition, EPs self-reported five attributes of the procedure. These attributes were scored on a 1–10 rating scale as shown in Table t test and a one-way ANOVA was used. Pearson correlation was calculated for the influence of age and injected volume of LA. Statistical significance was considered at P <  0.05. For statistical analysis, IBM SPSS Statistics for Windows, version 22.0 , and GraphPad Prism version 5.00 for Windows  were used.Normally distributed data are reported as mean ± standard deviation (SD) or 95% confidence interval (CI), and data with a skewed distribution, including absolute pain scores, are reported as median with an interquartile range (IQR). A one-tailed paired Wilcoxon test was used to test for differences in pain scores within subjects because these are ordinal values, not normally distributed. To test for differences between subgroups in relative and absolute pain score changes , a In total, 64 patients  received UGRA by EPs in the ED for a proximal femoral fracture. Demographics, types of fractures, and prehospitally administered analgesics are displayed in Table Fourteen EPs and EPs in training performed on average 4.6 (CI 3.1–6.0) ultrasound-guided nerve blocks of which 13 (20.3%) were FICBs and 51 (79.7%) femoral nerve blocks.Ropivacaine 0.375% was used in 28 (43.8%) patients with a mean volume of 22.8 ml . Ropivacaine 0.75% was used in 36 (56.3%) patients with a mean volume of 18.9 ml . All blocks proceeded uneventfully, although one patient with mild pain on injection and one event of transient periprocedural hypotension, unrelated to LA injection, were reported.P <  0.001). The pain was significantly reduced even further to 2 (IQR 0–4) at t60 and to 1 (IQR 0–1) at t120. Relative and absolute pain reductions are shown in Table The median pain score on an NRS at baseline (t0) before UGRA was 8 (IQR 5–9). At 30 min (t30) after the nerve block, the median score was significantly reduced to 3 . When asked if they were motivated to undergo a similar procedure in the future, the score was 9 .Patient-reported (dis)comfort was scored a median of 8  of analgesics, the two block types, the two different concentrations of ropivacaine, or volume of injected LA. Also, we found no significant difference in pain reduction at t30, t60, and t120, whether the EPs performed the blocks with or without supervision. As shown in Table n = 59) were ease of procedure 8 (7–9), success of procedure itself, regardless of the effect 9 (8–10), visibility of anatomical structures on ultrasound 8 (7–9), spread of local anesthetic 9 (8–10), and subjective added value of the procedure to patient care 9 (8–10).The 1-day course was very well received, and the EPs were enthusiastic about starting to perform the nerve blocks after the course. The median scores, IQR in parentheses, of the self-reported qualifications of the procedure  and 4.77 (64.4%). A pain score of 4 or less was reported by 69 and 83.3%, respectively, of the patients. The EPs thought the procedure was easy to perform, and they were able to obtain a good visualization of the relevant anatomy and LA spread. This means that performing a peripheral nerve block is an effective pain relief strategy provided by the very first physician they encounter upon admittance in the hospital.To date, there are only few similar reports of EPs performing UGRA in the ED. At 30 and 60 min after the nerve block, we found a meaningful pain reduction, respectively, in 70.7 and 80.0% of the patients. We could confirm the results reported by Groot et al. who reported that on a Dutch ED, EP-performed blind FICBs were safe and effective. In 26 of 34 patients (76%), they found a clinically meaningful pain score reduction after 120 min . An explt = 30 and pain scores of 4 or less were comparable .Dochez et al. described the effect of blind FICBs performed by EMS nurses in 100 patients with suspected proximal femoral fractures. After 30 min, they reported a successful block in 96% and median pain scores were reduced from 8 to 3, and on arrival at the ED, 75% had a pain score of 4 or less . Median Gozlan et al. described prehospital EP-performed blind FICBs in 52 patients with femoral fractures and reported a success rate of 94% and pain reduction comparable to Dochez and the present study . MorrisoA study by Beaudoin et al. reported similar results to our study . Thirty-We showed EPs and EPs in training can be taught to effectively and safely perform UGRA in the ED. In addition, they experienced the procedure to be relatively easy and successful, represented by the high EP-reported scores for success, easiness, visibility of the anatomy, and quality of LA spread. These findings implicate that (Dutch) EPs should consider the introduction of ultrasound-guided regional anesthesia in proximal femoral fracture patients in the ED to provide superior pain management as compared to conventional systemic analgesics. Such a program should preferably be introduced in cooperation with their colleagues from the anesthesiology department. Once a successful UGRA program for these patients is implemented, it can be extended to other indications in need of excellent pain management.journey cannot start at home, adequate pain relief needs to be taken care of by the first care provider they encounter in the hospital.With this project, we followed the recommendation by Wu et al. that anesthesiologists with extensive experience in regional anesthesia should introduce these techniques into settings outside the operating room and in the early treatment phases of trauma patients to provide the benefits of regional anesthesia . AlthougThis study adds to the literature because we took a unique approach in the introduction and execution of these blocks on our ED through a productive collaboration between the two (ED and anesthesiology) departments.Furthermore, to date, there have been no published reports of effective and safe UGRA in a Dutch ED.This study has several limitations. The observational study design is not optimal to answer the main question. A relatively small number of patients was included based on convenience sampling. The aim was to treat proximal femoral fracture patients with ultrasound-guided nerve blocks as the treatment of choice. Although UGRA was recently introduced in our ED, its effectiveness has been proven extensively , 13, 25.In conclusion, this study demonstrates that, through close cooperation between EPs and anesthesiologists, after a 1-day training (Dutch), EPs can learn to safely perform ultrasound-guided nerve blocks in proximal femoral fracture patients in the ED, resulting in effective acute pain relief.


Background: The implementation of primary healthcare-based screening and advice that is effective in reducing heavy drinking can be enhanced with training.Objectives: Undertaking secondary analysis of the five-country ODHIN study, we test: the extent to which practice, provider and patient characteristics affect the likelihood of patients being screened and advised; the extent to which such characteristics moderate the impact of training in increasing screening and advice; and the extent to which training mitigates any differences due to such characteristics found at baseline.Methods: A cluster randomized factorial trial involving 120 practices, 746 providers and 46 546 screened patients from Catalonia, England, the Netherlands, Poland, and Sweden. Practices were randomized to receive training or not to receive training. The primary outcome measures were the proportion of adult patients screened, and the proportion of screen-positive patients advised.Results: Nurses tended to screen more patients than doctors . Screen-positive patients were more likely to be advised by doctors than by nurses , and more liable to be advised the higher their risk status . Training increased screening and advice giving, with its impact largely unrelated to practice, provider or patient characteristics. Training diminished the differences between doctors and nurses and between patients with low or high-risk status.Conclusions: Training primary healthcare providers diminishes the negative impacts that some practice, provider and patient characteristics have on the likelihood of patients being screened and advised.Trial registration ClinicalTrials.gov. Trial identifier: NCT01501552 KEY MESSAGESTraining and support given to primary health care providers obviate to varying extents the detrimental impacts that patient and provider characteristics have in decreasing the likelihood of heavy drinking patients being screened and advised to reduce their drinking.Within Europe, one-quarter of adults are heavy drinkers  . While pIn this paper, we report novel secondary analyses of the ODHIN data to explore: the extent to which practice, provider and patient characteristics affect the likelihood of patients being screened and advised; the extent to which such characteristics moderate the impact of training in increasing screening and advice; and the extent to which training mitigates any differences due to such features found at baseline. A priori, we expect patients’ gender and level of alcohol consumption to affect the proportion of patients screened and advised ,6.Details of the trial protocol and the primary results have been published ,7. The fPractices were recruited during 2013. After formal agreement of the practice to take part, a four-week baseline measurement period occurred. After a two-to-six-week gap, the 12-week implementation intervention period occurred. Controls were given printed national guidelines on conducting screening and brief advice to reduce heavy drinking. Training consisted of two initial one-to-two hour’s face-to-face educational inputs and one (10–30 min) telephone support call during the 12-week implementation period. Using computerized randomization the ODHIN coordinating centre randomly allocated practices stratified by country. After the baseline measurement period, the practices and investigators were not blind to group allocation.Practices were asked to screen all adult patients aged 18 + years) who consulted the practice for whatever reason, using AUDIT-C [ + years The two primary outcomes were the proportion of consulting adult patients screened, calculated in this paper at the level of the provider; and the proportion of screen-positive patients advised, calculated in this paper at the level of the patient. The distribution of the proportion screened per provider was highly positively skewed. For analyses, the proportion screened was dichotomized at the median of the whole provider sample (0.031). It was estimated that 120 practices (24 per country) would be needed for an 80% chance of detecting an increase in the proportion of consulting adult patients screened and screen-positive patients advised intervened from four to six per cent (ICC = 0.029)  . One praSix practice variables were examined: practice type ; practice setting (exclusively urban or other); number of registered patients; number of providers per practice; ratio of doctors to non-doctors in the practice; and, screening method used . Four provider variables were examined: profession (nurses as opposed to doctor); gender; age and, number of adult consultations during the measurement period. Three patient variables were examined: gender; age; and AUDIT-C score, dichotomized to 8 + and less than 8 .A generalized linear model was used employing a multi-level approach using country, PHCU, and provider, as appropriate, with random intercepts and slopes. Odds ratios (OR) are presented for dichotomous variables and regression coefficients (B) for continuous variables, both with 95% confidence intervals (95%CI). Analyses were conducted using IBM SPSS V23, procedure GENLIN.The practice, participating provider and patient data are summarized in During the four-week baseline period, of the six practice variables entered simultaneously in the model, only screening method was related to screening. The odds ratio (OR) for a provider being above the median of the proportion of consulting adult patients screened was 3.1  for providers whose practices undertook screening by both doctors and nurses as opposed to doctors alone. Of the four provider variables entered simultaneously in the model, only provider profession was related to screening. The odds ratio for a provider being above the median of the proportion of consulting adult patients screened was 3.1  for providers who were nurses as opposed to doctors.Training was related to higher screening during the 12-week implementation period, with baseline screening, and the two other interventions  added as covariates. The odds ratio for a provider being above the median of the proportion of consulting adult patients screened was 2.7  for providers who had received training, compared to those who had not. The impact of training was unaffected when the six practice variables were added to the model  or when the four provider variables were added to the model .Training reversed the impact of practice screening method, but not the impact of the profession of the provider at baseline. In the presence of training during the 12-week implementation period, the odds ratio for a provider being above the median of the proportion of consulting adult patients screened was 4.3  for providers whose practices undertook screening by doctors alone as opposed to by both doctors and nurses.During the four-week baseline period, 1202/1626 screen-positive patients (73.9%) were given advice. Of the six practice variables entered simultaneously in the model, only screening method was related to advice giving. The odds ratio for a screen-positive patient being given advice was 3.8  for providers whose practices undertook screening by doctors alone as opposed to by both doctors and nurses. Of the four provider variables entered simultaneously in the model, only provider profession was related to advice giving. The odds ratio for a screen-positive patient being given advice was 2.3  for providers who were doctors as opposed to non-doctors. Of the three patient variables entered simultaneously in the model, only AUDIT-C score was positively related to advice giving. The odds ratio for a screen-positive patient being given advice was 1.9  for patients with an AUDIT-C score of 8 + compare to less than 8.Training was related to higher advice giving during the 12-week implementation period, with the two other interventions  added as covariates. The odds ratio for a screen-positive patient being given advice was 2.6  for providers who had received training, compared to those who had not. The impact of training was no longer significant when, of the six practice variables, screening method (but not any other practice variables) was added to the model. The impact of training was no longer significant when, of the four provider variables, the number of adult consultations (but not any other provider variables) was added to the model. The impact of training was not affected when adding the three patient variables to the model.Training did not influence the impact of practice screening method on advice giving that was present at baseline but did affect the impact of the profession of the provider at baseline. In the presence of training during the 12-week implementation period, the odds ratio for a screen-positive patient being given advice was no longer significant  for providers who were doctors as opposed to nurses. Training did affect the impact of a screen-positive patient’s AUDIT-C score on advice giving that was present at baseline. Screen-positive patients with an AUDIT-C score of less than eight were more likely to be given advice in the presence of training than in the absence of training , whereas this was not the case for screen-positive patients with an AUDIT-C score of eight plus, who were equally likely to be given advice, independent of training .During the four-week baseline period, we found that higher levels of screening were found in practices in which screening was undertaken by both nurses and doctors, rather than doctors alone and for providers who were nurses rather than doctors. We also found that screen-positive patients were more likely to be advised in practices in which screening was undertaken by doctors alone rather than by both nurses and doctors, by providers who were doctors rather than nurses, and in patients whose AUDIT- C score was eight plus, rather than less than eight.We found that training led to higher screening and advice giving, with the impact of training largely unaffected by the practice, provider and patient variables that we analysed. Training tended to lessen the differences between nurses and doctors in screening and advice giving and mitigated the dichotomy in advice giving that was mediated by the AUDIT-C score.A strength of the present study is the large number of practices, providers, and patients included, giving confidence in the findings across five different European countries. One weakness of the study is that the involved practices were volunteers. Previously, we indicated that providers from the volunteer practices seemed more motivated to work with drinkers than providers from the same country in general . A seconTwo English studies found that the likelihood of screen-positive patients receiving advice to reduce their drinking was greater if patients were male, the higher the level of risky drinking, the longer the average consultation time, and if providers received training ,6. In thAt baseline, the only practice and provider characteristics that influenced screening and advice were professional roles. Nurses tended to screen more than doctors; doctors tended to advise screen-positive patients more than nurses. At baseline, screen-positive patients with higher risk were more likely to receive advice than those with lower risk. These differences due to practice, provider, and patient characteristics were largely mitigated by training.


Background. Oxycodone, a semisynthetic opioid, has been widely used for acute and chronic pain. Objectives. The aim of this study was to compare the analgesic and adverse effects of oxycodone and alfentanil on postoperative pain after laparoscopic cholecystectomy. Methods. This was a prospective, randomized, double-blind study. A total of 82 patients undergoing laparoscopic cholecystectomy were randomly assigned to receive either oxycodone or alfentanil using intravenous patient-controlled analgesia (PCA). PCA was administered as a time-scheduled decremental continuous infusion based on lean body mass for 48 hours postoperatively. Patients were assessed for pain with a visual analogue scale (VAS), the cumulative PCA dose, adverse effects, sedation level at 1, 4, 8, 16, 24, and 48 hours postoperatively, and satisfaction during the postoperative 48 hours. Results. There were no significant differences (p < 0.05) between the two groups in VAS score, cumulative PCA dose, adverse effects, sedation level at 1, 4, 8, 16, 24, and 48 hours postoperatively, and satisfaction during the postoperative 48 hours. Conclusions. Our data showed that the analgesic and adverse effects of oxycodone and alfentanil were similar. Therefore, oxycodone may be a good alternative to alfentanil for pain management using intravenous PCA after laparoscopic cholecystectomy when used at a conversion ratio of 10 : 1. This trial is registered with KCT0001962. Laparoscopic cholecystectomy (LC) is often accompanied by severe postoperative pain, although it has the advantages of fast recovery and short hospital stay . Postopeμ-agonist, with a potency comparable to that of morphine [Oxycodone, a semisynthetic opioid synthesized from thebaine, is used to manage moderate to moderately severe acute or chronic pain. It is a potent morphine . Many stmorphine , 6, and morphine , 7, 8. Rmorphine –11. AlthAlfentanil has a rapid onset of action and appropriate pharmacokinetic properties in continuous infusion , and it Intravenous (IV) PCA has not always provided reliable and adequate analgesia. The analgesic concentration in the body might be insufficient for the severity of the early postoperative pain during fixed-rate infusion of the recommended regimen . Fixed hVarious studies have compared the effects of oxycodone, morphine, and fentanyl on postoperative pain. However, no studies have compared the effects of oxycodone and alfentanil on postoperative pain, and there is no published study of the efficacy and side effects of oxycodone and alfentanil.In this randomized, prospective, double-blind study, we compared the analgesic and side effects of oxycodone and alfentanil on postoperative pain in patients who were given IV PCA in a time-scheduled decremental mode after laparoscopic cholecystectomy.This prospective, randomized, double-blind study was conducted between August 2014 and September 2015. The study protocol was approved by our Institutional Review Board (IRB) and all patients provided informed consent before surgery.We enrolled 90 patients who underwent laparoscopic cholecystectomy and belonged to the American Society of Anesthesiologists (ASA) physical status class I or II. Both men and women aged 18–70 years were included. Exclusion criteria were patients who had used preoperative acetaminophen or nonsteroidal anti-inflammatory drugs or opioids, patients who could not describe their pain using the visual analogue scale (VAS), patients who had abnormal liver and kidney function, and pregnant patients.We referred to references on the conversion of oxycodone to morphine that suggest a potency ratio of 1 : 1 because there were no recommendations concerning the direct conversion factor of IV oxycodone and IV alfentanil dosages , 18. AlfPatients were randomized to either Group A  or Group O (oxycodone) by a simple randomization method using Excel . Group A received IV PCA with 10 mg of alfentanil , 0.6 mg of ramosetron , and 76 mL of normal saline. Group O received IV PCA with 100 mg of oxycodone , 0.6 mg of ramosetron, and 86 mL of normal saline. The rate of PCA, loading dose, and demand dose were calculated based on the lean body mass (LBM), which was calculated using Hume's formula .(1)Men: 2O. Then, 0.3 mg of ramosetron was injected intravenously and a loading dose of PCA was administered 15 minutes before the end of the operation. Immediately after the loading doses, the background infusion was started. Neuromuscular blockade was reversed with 0.4 mg of glycopyrrolate and 10 mg of pyridostigmine. After surgery, patients were extubated, provided their vital signs were within normal limits, and were transferred to the postanesthesia care unit.The patients provided informed consent on the day before the operation and were instructed on the use of PCA. Anesthesia was performed in the same manner in both groups and all patients received 0.2 mg of intramuscular (IM) glycopyrrolate 30 minutes preoperatively. After entering the operating room, patients were monitored using standard monitoring devices. Anesthesia was induced with 2 mg/kg of propofol and 0.6 mg/kg of rocuronium and maintained with desflurane and NPain level, cumulative doses, sedation scale, and adverse effects were measured at 1, 4, 8, 16, 24, and 48 hours postoperatively. The severity of the patients' pain was evaluated using the visual analogue scale (VAS), with scores ranging from 0 (no pain) to 10 (worst pain possible). The VAS was evaluated when coughing and resting. Sedation was scored using the Inova Sedation Scale (ISS): 1, alert; 2, occasionally drowsy, easy to rouse; 3, dozing intermittently; 4, asleep, easy to wake; 5, difficult to wake; 6, unresponsive .Any nausea, vomiting, dizziness, headache, respiratory depression, pruritus, or difficulty voiding was recorded as an adverse effect. The patient's satisfaction with PCA during the 48 hours postoperatively was assessed according to the following scale: 1, very satisfactory; 2, satisfactory; 3, neutral; 4, unsatisfactory; 5, very unsatisfactory.t-test and chi-square test. Comparison analysis of the incidence of postoperative nausea, vomiting, and other adverse effects was performed using the chi-square test and Fisher's exact test. The cumulative PCA dose and the sedation scale were assessed using the Mann-Whitney U test, while the VAS was assessed by repeated-measures analysis of variance (ANOVA). The satisfaction score of the two groups was assessed via the chi-square test. A probability of <0.05 was considered to indicate statistical significance. All data were analyzed using SPSS ver. 22 .Data are expressed as the mean ± standard deviation (SD). The demographic data of the two groups were analyzed with Student's α = 0.05. Therefore, we enrolled 90 subjects into our study considering 10% as the exclusion rate.Based on previous similar studies, the sample size was 41 patients per group. The cumulative PCA dose difference between the two groups was 5 mL and the standard deviation was 8.0 with power of 80% and n = 43) or oxycodone (n = 43). Two patients in Group A and one patient in Group O were excluded because they ultimately underwent open laparotomy. One patient in Group O was excluded due to incorrect operation of the PCA device. In total, 41 patients were left for analysis in each group  than Group A (6 patients), but the difference was not statistically significant. One patient in each group experienced urinary retention. Although the incidence was very low and statistically insignificant, both patients also complained of lower abdominal discomfort and severe incisional pain concurrent with urinary retention.The VAS score decreased gradually over time and changes of VAS are not different over time when resting and when coughing in both groups. However, one patient in each group had flatulence and was not discharged until 24 hours postoperatively. Both patients complained of abdominal discomfort and maintained a high VAS score until discharge. Opioids tend to inhibit intestinal propulsion and increase gut transit time, which can lead to postoperative ileus . TherefoThere are many studies comparing the effects of different opioids on acute postoperative pain. To the best of our knowledge, no previous study has compared intravenous oxycodone and intravenous alfentanil. We hypothesized that alfentanil would be superior to oxycodone in terms of the adverse effects of postoperative PCA. However, alfentanil and oxycodone did not differ significantly in terms of pain control and adverse effects in our study. These results may indicate that oxycodone had comparable effects compared to alfentanil at a conversion ratio of 10 : 1 with a time-scheduled decremental infusion mode of PCA based on the LBM. Therefore, using a conversion factor of 10 : 1, oxycodone is a useful alternative to alfentanil for IV PCA after laparoscopic cholecystectomy. Further studies in various clinical settings will be needed to determine the adequate potency ratio.Intravenous oxycodone produces similar analgesic and adverse effects to intravenous alfentanil in the treatment of postoperative pain after laparoscopic cholecystectomy when used at a conversion ratio of 10 : 1. Based on these results, we conclude that oxycodone may be used as a good alternative to alfentanil in pain management after laparoscopic cholecystectomy without increasing adverse effects.


The aim of this randomized clinical trial split-mouth study was to compare the postoperative pain following use of mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement as pulpotomy agents in carious primary molars. Forty-seven children aged between 6-10 years old were enrolled in this study. Each child had two cariously involved primary molar in need of pulpotomy. After caries removal and preparing access cavity in one of the carious teeth, either MTA or CEM cement was randomly used as the pulpotomy agent, while the other cariously involved primary molar tooth was capped with the other material in a separate visit. After covering the radicular pulp with one of the capping materials the teeth were permanently restored with stainless steel crown (SSC). Postoperative pain was recorded by using Wong-Baker faces pain rating scale (Wong-Baker FPRS) up to seven days following the treatment. Data was analyzed using the Wilcoxon, McNemar, and chi square tests. P=0.805, P=0.942, P=0.705, respectively) following the procedure. The trend of the pain scores showed decreasing manner during the study period for the teeth in either groups of MTA or CEM cement. There was no significant difference between the two groups in the number of analgesics used following the treatment (P>0.05).Forty-five patients fulfilled the treatment procedure and returned the Wong-Baker FPRS forms. Overall 65.6% of the patients reported pain irrespective of the pulpotomy agents used. There was no significant difference in postoperative pain between the teeth that received either MTA or CEM cement as pulpotomy agents in the first, second and the third day (The findings of the present study showed that a majority of the children felt pain following pulpotomy and SSC placement; however, there was no significant difference in pain reported when either MTA or CEM cement was used as pulpotomy agents. Each year, a large number of primary molars receive pulpotomy treatment because of extensive caries and pulp exposure . Most peSeveral systematic reviews and meta-analyses have shown that MTA could be named as one of the most suitable materials for pulpotomy in primary molars because of high clinical and radiographic success rate compared to other pulpotomy agents -8. CEM cOne of the important points in performing dental procedures for the children is the amount of pain they may suffer from that whenever the dental pulp has involved. A few investigations regarding prevalence of postoperative pain in pediatric dentistry have been published. The results of these studies have shown that both pulpotomy and stainless steel crown (SSC) placement procedures, are among the most prevalent dental procedures that may cause post-treatment pain in children -13. So fTherefore, the aim of the present study was to compare postoperative pain and number of analgesic consumption following use of two different pulpotomy agents namely MTA and CEM cement in primary carious molars.α=5% and power of 80%, the sample size of 46 patients was calculated.This split mouth randomized clinical trial study was approved by the Ethics Committee of Kerman University of Medical Sciences in Kerman, Iran (Grant No.: KA/91/267) the procedure was also registered online . Considering A total of 47 patients aging between 6 to 10 years old from both genders who referred to the postgraduate clinic of the Pediatric Department of Kerman Dental School in Kerman, Iran from October 2012 to March 2013 could participate in this study.The patients’ parents were comprehensively informed about the aim and method of the study and an informed consent has been obtained from all of them. The inclusion criteria were: 6-10 year-old patients having bilateral primary molars with carious lesion with restorable crown, no tenderness to percussion and no pain except after eating, teeth without clinical and/or radiographic signs or symptoms of pulp degeneration, presence of sinus tract, no physiologic resorption (less than two-thirds of the root length were affected) and presence of active bleeding at the time of the access cavity preparation indicating a vital pulp .Based on the Frankl Behaviour Rating Scale (FBRS) , all parExclusion criteria were any systemic diseases that should not receive vital pulp therapy such as leukemia and some types of malignancies, radiographic findings such as internal resorption, widening of periodontal ligament (PDL), furcation and apical radiolucency, and root canal calcifications , 18.Based on a random selection (by using table of random numbers) each tooth randomly received either one of the pulpotomy agents, MTA  or CEM cement  in a split mouth design. After application of local anesthesia using 2% lidocaine with 1:80000 epinephrine  and rubber dam isolation, pulpotomy was performed with a round bur  by a high-speed handpiece with copious water irrigation. Then the rest of coronal pulp was removed by a sharp excavator. After full pulpotomy the cavity was rinsed with 0.9% normal saline and hemostasis was tried to achieve by a wet cotton pellet . If the All dental procedures including anesthesia, pulpotomy and placement of the SSC were performed by a second year postgraduate pediatric dentistry student. Patients’ parents were asked to complete a Wong-Baker faces pain rating scale (Wong- Baker FPRS) questionnaire by asking their children’s pain and rate their pain intensity up to 7 days after the treatment and bring that questionnaire back after seventh day. The Wong-Baker FPRS consists of a row of 6 numbered faces ranging from “no hurt” to “hurts worst” , 13.Scoring of pain severity was outlined as follows; 0: no pain, 1-3: mild pain, 4-6: moderate pain and 7-9: severe pain . AccordiThe data were analyzed by using the Wilcoxon, McNemar and chi square tests. The level of significance was set at 0.05.From the 47 patients who met the inclusion criteria and their parents agreed to enroll in the study, 2 subjects were excluded because one patient did not return the Wong-Baker PRFS after the second visit and one patient used ibuprofen syrup as an analgesic for pain relief. The rest (45 patients with the mean age of 7.1±1.006 years) completed the forms and returned it to the department. The patients’ demographic data is presented in P=1.00). Data analysis showed that as time passed, patients reported lower pain rate irrespective of the pulpotomy agent used . There was a significantly higher analgesic consumption in patients who reported pain compared to the patients that had not pain following the treatment (P>0.05)  .In the resent study no significant difference was found in pain following pulpotomy using two pulpotomy biomaterials including MTA and CEM cement. Both American academy of pediatric dentistry (AAPD) and British society of pediatric dentistry (BSPD) recommended placement of the SSC after pulpotomy in primary molars and have described SSC as a durable, relatively inexpensive treatment with minimal technique sensitivity during placement as well as an advantage of full coverage crown. Therefore, in the present study SSC was used as final restoration , 22.et al. [et al. [Previous investigations have shown that 33 to 95% of children reported pain following dental procedures. These investigations either evaluated postoperative pain in children following dental procedures that had been performed under general anesthesia or local administration of the anesthetic agents , 13, 23. [et al.  reportedNo significant relationship was found between the patients’ gender, type of the treated tooth and post-operative pain. This was consistent with another study . Regardlet al. [The reason that MTA and CEM cement had been compared in the present study was the successful outcome of vital pulp therapy investigations that used these biomaterials in primary molars , 10. Asget al.  in an inet al. , placingIn the present study, the trend of pain showed that only during early post-treatment phase the patients experienced pain. Therefore, it would be reasonable to give some information to the parents that their children received pulpotomy and SSC treatment regarding a possibility of pain until the third day after the treatment and prescribe on-demand mild analgesic.Fortunately, severe and moderate pain was reported only at the first and the second day following treatment . The autThe present study was designed as split-mouth randomized clinical trial because each patient received both pulpotomy agents for different primary molars in need of vital pulp therapy. The advantage of split-mouth randomized clinical trial is the fact that each patient served as his/her own control and the results would be more reliable as individual differences had the least effect on the outcome of the study; however, a new investigation could not find significant differences in intervention effect between parallel-arm randomized clinical trials compared to those with split mouth design . Nowadays acetaminophen is the most common analgesic used in pediatrics in the US. Acetaminophen is an effective safe analgesic for mild to moderate pain relief and for these reasons had been prescribed as the analgesic in the present study . The impPain assessment following pulpotomy and SSC placement could be a limitation for our study. In future, it is suggested to accomplish these two treatments separately so that the precise evaluation of post-operative pain could be readily obtained after each step.No significant difference was found in pain levels following pulpotomy with either of cements as pulp capping agents in carious primary molars. Meanwhile prescribing analgesic at least for a few days following treatment should be considered.


The management of pain and anxiety in dentistry encompasses a number of procedural issues, including the delivery of anesthetic solution. One of the most important ways to manage the behavior of children is pain control. Trypanophobia is very common among dental patients and the most important goal of guidelines on behavior guidance for pediatric dental patient is to ease fear and anxiety in dental procedures in children. For the stated reasons, the purpose of the present study was to record child’s pain sensation both objectively and subjectively while receiving dental local anesthesia using conventional syringes and diabetic needles.Twenty children of age group 6 to 12 years undergoing routine dental procedures participated in the study. Every child acted as one’s own control, while receiving treatment on the opposite side of the same arch. Each patient was randomly assigned to receive the injection either with conventional syringe or diabetic needle for the first visit, while the injection with the other needle was administered during the second visit. Rating scales were used for objective and subjective evaluations.Statistical analysis of the measurements were made using Wilcoxon signed U test and Mann-Whitney U test which showed the mean sound, eye, motor (SEM) score difference using insulin syringe. The outcome was statistically significant when compared using the mean ranks between male and female patients with that of control group.It can be concluded that diabetic syringes exhibit clinical advantage and its use in pediatric dentistry for local anesthetics (LA) infiltration can prove beneficial.How to cite this article: Kour G, Masih U, Singh C, Srivastava M, Yadav P, Kushwah J. Insulin Syringe: A Gimmick in Pediatric Dentistry. Int J Clin Pediatr Dent 2017;10(4):319-323. The most difficult aspect of patient management that can be a barrier to good care and treatment is fear-related behavior.2As quoted by Dean Koontz, “Pain can be endured and defeated only if it is embraced. Denied or feared, it grows in perception if not in reality.” Pain is a complex and multidimensional construct that involves sensory, emotional, and cognitive processes.3 Not just the pain and discomfort, the prospect of injection and just looking at a syringe can provoke anxiety particularly in children.4Patients who fear dental treatment can induce anxiety and harm the smooth delivery of dental care.1 In surgical and dental procedures, they prevent nociception. The only perceived painful part of dental procedures is the injection of LA.2 The field of dental medicine has always been trying to create a painless experience for the patients. Anesthetic needle injection attributes to the fear of pain, which has been a problem in providing appropriate dental care.256 In an attempt to improve patient comfort during dental anesthetic administration, smaller gauge needles, slow computer-regulated administration, distraction techniques, vibrating devices, and topical agents (refrigerants and anesthetics) have been used.Most widely used drugs in dentistry are LA.The major issues in delivering dental treatment to children are anxiety and phobia. So reducing the anxiety level even before giving a LA injection is necessary, especially in children and this can be done by using a syringe, which is smaller in size, colorful, and less frightening than the usual conventional syringes used.Therefore, the purpose of this study was to evaluate pain perception in children, while providing LA with 26 gauge conventional syringe and 30 gauge insulin syringe .in vivo study was undertaken in the Department of Pedodontics and Preventive Dentistry in K.D. Dental College & Hospital, Mathura, Uttar Pradesh, India, to compare the pain perception of children to LA using two different syringe designs.The present Twenty children who met the inclusion criteria were selected for participation in this study. Children from 6 to 12 years of age with treatment needs in two different quadrants either in maxillary or mandibular arch. A minimum of two clinical appointments of similar operative procedures on both sides of the same jaw preceded by LA injection. Children who demonstrated positive or definitely positive behavior during pretreatment evaluation . Children having their first dental visit.Children with emergency treatment needs, such as abscess, cellulitis and space infection, and those who needed premedication for receiving dental treatment. All parents were informed about treatment procedures and an informed consent was obtained. The study was performed using two types of syringe designs. Local anesthetic solution used was 2% lidocaine and 1:100,000 epinephrine. Every child acted as one’s own control, while receiving treatment on the opposite side of the same arch. Patients were randomly assigned to receive the injection either with a conventional syringe or insulin syringe for the first visit, while the injection with the other syringe was administered during the second visit. Objective and subjective evaluations were done using two rating scales.7For objective evaluation during the injection procedure, the response of the child was noticed with SEM scale designed by Wright et al in 1991.Immediately after injections, children were asked to complete the Wong-Bakers faces rating scale (FRS) for subjective evaluation of pain perception after the injection. Verbal instructions were given to the child on how to utilize the FRS. The values for this scale range between 0 and 5, where 0 is no hurt and 5 is hurt very much. The data were collected and analyzed using Statistical Package for Social Sciences version 17.0 for Windows. The level of statistical significance was set as 95% (p = 0.05).The objective and subjective behavioral parameters were evaluated by Wilcoxon signed rank test and Mann-Whitney U test.The mean pain score using FRS scale for 26 gauge conventional syringe was found to be 3.25, whereas mean pain score for 30 gauge insulin syringe was found to be 1.35 . The meaThe mean pain score in male patients using conventional syringe was 2.0 and score using insulin syringe was 1.20. The difference was statistically significant . The meaThe mean pain score in female patients using conventional syringe was 3.40 and score using insulin syringe was 1.40 . The difThe mean SEM score difference using insulin syringe was statistically significant when comparing the mean ranks between male and female children using Mann-Whitney U test . The mea4 Any measure used to potentially minimize the pain during dental treatment can help in reducing the anxiety and fear of our child patient.The present study was undertaken to evaluate and compare the pain perception using two different syringe designs with different needle gauges while giving LA using local infiltration technique. Dental treatment demands a good response of a child patient and his cooperative behavior.4 To influence the objective behavior of the child, insulin syringes (U-40) were used in this study.Behavioral management, distraction techniques, topical anesthetic agents prior to injections have been suggested to reduce pain during injection.189Infiltration technique has been used in this study because of various factors like direct vision of practitioner on it, less depth penetration of needle, less technical errors, less amounts of anesthetic solution, easier application, limited anesthesia of soft-tissues outside the operation field, and shorter duration of being anesthetized and might be used as an alternative to block.10 compared the effectiveness of infiltration technique with block technique and concluded that mandibular infiltration as a possible alternative to mandibular block anesthesia in young children.Donohue et al11 in a study on 308 patients, inferior dental nerve blocks were rated significantly more painful than buccal infiltrations. The visual analog pain scale was found to be unsuitable for use by children under 7 years of age, and keeping it in view, the age group was selected for this study.Jones et al12 evaluated the efficacy of block and infiltration injections anesthetizing mandibular first molars and concluded faster appearance of anesthesia with infiltration injection compared to block with same efficacy.Jung et al1Dental needles are available in three lengths: Long (32 mm), short (20 mm), and ultrashort (10 mm). Needle gauges range from size 23 to 30. Needle breakage is a rare occurrence and its primary cause is weakening the needle due to bending it before insertion into the soft tissues and patient movement after the needle is inserted.1Short needles may be used for any injection in which the thickness of soft tissue is less than 20 mm. Any 23- through 30-gauge needle may be used for intraoral injections, since blood can be aspirated through all of them. Aspiration can be more difficult, however, when smaller gauge needles are used but an extra-short, 30-gauge is appropriate for infiltration injections.Various studies have been done and published by various authors to find the difference in pain perception using different needle gauges:4 concluded a significant difference concerning pain when 27 and 30 gauge needles were used and said that 30 gauge needle exhibited clinical advantage when used to give inferior alveolar nerve block in children. Ram et al13 also reported a significant difference concerning pain when mandibular nerve block was provided using 27 and 30 gauge needles. Ghasemi et al14 did a comparative evaluation of the 30-gauge dental needle and quoted that even under the extreme manipulations and stresses, the physical properties of these needles proved them to be tough, durable, and surprisingly resistant to breakage. Cooley and Robison15 and Lehtinen16 have reported no significant differences in pain perception using different gauge needles. Some authors like Fuller et al17 compared inferior dental nerve block injections in child patients using 30-gauge and 25-gauge short needles, and it was concluded that 25- and 30-gauge needles do not differ significantly with respect to efficacy, pain, or aspiration. Brownbill et al18 have concluded that the pain due to injection penetration may be controlled using thinner gauge needles. AsokanThe syringe to be used in first appointment was randomly selected to discard the effect of notion that the young patient brings to the initial dental experience, which might either facilitate or impede his adaptation to the stress.No study to the best of our knowledge has been conducted till date, to check the influence of different syringe designs on the anxiety and fear psychosis of the pediatric patients, which in turn can influence the pain perception in our child patients while receiving the LA injection.In this study, insulin syringes were compared with the conventional syringes. Insulin syringe with its miniature needle, bright color, and slim look appears like a toy to the child patient till our job of infiltration anesthesia is over. This study overwhelmingly justifies its use in pediatric patients as supported by the child. The use of insulin syringe for injecting LA solution also helps in curtailment of dental appointments in child patients as less time is required for convincing them to receive the injection and gaining their confidence as the syringe looks less menacing.19The calibrations in insulin syringe are marked at 0.025 mL intervals and so there is a controlled and fractionated administration of drug not requiring excessive force on the plunger, which can be monitored visually.The study justifies the use of diabetic syringe with 30-gauge needle to be used for the delivery of LA using infiltration technique in child patients because smaller gauge needle is less painful; the size and the color of the syringe is such that it does not scare the child patient, cost-effective, and the calibrations at 0.025 mL intervals in insulin syringe provide a drug delivery control, which in turn reduces the pain caused and there is less tissue distension, less chances of local ischemia and necrosis.It can be concluded that diabetic syringes exhibit clinical advantage and its use in pediatric dentistry for LA infiltration can prove beneficial for patients as well as for dental caregiver. There is scope of introducing toy syringes in market for the use by pediatric dentists.


High resolution anoscopy (HRA) examination is regarded as the best method for the management of anal high grade squamous intraepithelial lesions to prevent anal squamous carcinoma. However, little is known about the acceptability of this procedure. This analysis looks at patient experience of HRA examination and ablative treatment under local anaesthetic.Patients took part in anonymised feedback of their experience immediately after their HRA examinations and/or treatments. A standard questionnaire was used that included assessment of pain and overall satisfaction scores as well as willingness to undergo future HRA examinations.p < 0.0001] and 3 (IQR 4.5) in treatment cases. Problematic pain defined as a pain score of ≥7 occurred more frequently in women (14%) than in men (6%), . Patient satisfaction with the care they received, measured on a scale of 0 (not happy) to 10 (very happy) found the median score to be 10 with 76% reporting a score of 10. Out of 360 responses, 98% of women and 99% of men said that they would be willing to have a future HRA examination.Four hundred four (89.4%) responses were received and all responses were analysed. The group consisted of 119 females (29.4%) and 261 males (64.6%) with median age of 45 years (IQR = 19) and 45 years (IQR = 21) respectively, and included 58 new cases, 53 treatment cases and 202 surveillance cases. 158 patients (39.1%) had at least one biopsy during their visits. The median pain score was 2 [Inter Quartile Range (IQR) 3] on a visual analogue scale of 0 to 10, where 0 indicated no pain / discomfort and 10 indicated severe pain. The median pain score was 2 (IQR 2) in men and 4 (IQR = 3) in women [Dunn’s Test = 4.3, In this cohort, the overall pain scores were low and similar across appointment types. However, women had a higher pain score, including troublesome pain levels. Despite this, both women and men were equally satisfied with their care and were willing to have a future examination. The results of the analysis show that the procedure is acceptable to patient groups. A small number of women may need general anaesthesia for their examinations/treatment. High risk human papillomavirus (HPV) infections are associated with lower anogenital tract cancers . Rates oWe conducted a study of patient experience at Homerton anal neoplasia service (HANS), a tertiary referral unit, run by a multidisciplinary team in the United Kingdom. Patients are referred from across the UK for anal and perianal HSIL diagnosis and treatment. Additionally, women with lower anogenital tract HSIL or suspected HSIL are referred to HANS for further management. The aim of the study was to establish if HRA, including biopsy and HRA-guided treatment, is acceptable as a procedure to a UK population of men and women.2 laser ablation  or diode laser ablation . Outpatient-based treatments were limited to disease involving no more than 2 quadrants (50%) of the circumference. Using a pre-formatted feedback form  setting in the dorsal lithotomy position with an adjustable bed. Patient assessments were made after 5% acetic acid applications to the zones to be inspected. Women had multizonal assessments that included examination of the cervix, vagina, vulva, perianus and the anal canal. Men had examination of the perianus and anal canal, unless they had genital symptoms or previous history of penile neoplasia, in which case genital examinations were additionally conducted. All biopsies were obtained after the administration of Citanest 3% with octapressin  by injection, by using a Tischler biopsy forceps. Ferric subsulphate (Monsel’s solution) was then applied to the biopsy site for haemostasis. Patients attending for treatment with laser ablation applied EMLA™ cream 5% (contains lidocaine and prilocaine) to the treatment areas prior to arrival in the office. Treatment patients underwent HRA assessments to mark out the areas for treatment, then received local anaesthetic as above via submucosal or subcutaneous injections, and underwent treatment with COThe forms were given immediately after the procedure to all consecutive patients during the study period by the nurse. The forms had a visual analogue scale of 0 to 10, where 0 indicated no pain or discomfort at all, and 10 indicated severe pain. The independent clinician and nurse scores of patient experience of pain were recorded. The nurse also made a note of the type of patient visit (assessment vs. follow-up vs. treatment) and the number of biopsies, if taken. The feedback form also included an overall satisfaction score; a visual analogue scale with 0 indicating ‘not happy’ and 10 indicating ‘very happy’. Patients were also asked about their willingness to undergo HRA examination in the future. Patients were asked to fill the form in privacy at the Unit’s reception and post them into a box kept at the reception. The forms were anonymous and had no patient identifiers other than age and sex. A retrospective analysis of the data was conducted after Institutional approval .During the period of October 2015 and August 2016, 452 patient attendances were recorded and 404 responses (89.4%) were received. Of the 404, 119 (29.4%) were females while 261 (64.6%) were males (24 missing gender). The median age was 45 years (IQR = 19) in females and 45 (IQR = 21) in males. There were 58 new cases, 53 treatment cases and 202 surveillance cases in the study population (data not entered in 101). 158 cases (39.1%) had at least one biopsy during their visits and amongst these patients 85 (54%) had 2 or more.p < 0.0001]. Overall, 57 patients (14.3%) reported a zero (0) pain score. In 157 cases who had biopsies during their visit the pain score was 3 (IQR 3). From 52 patients who had treatment under local anaesthesia, the pain score was 3 (IQR 4.5). Problematic pain, defined as a pain score of ≥7, occurred in a small number of cases (9%). More women (14%) reported problematic pain compared to men (6%) . Further analysis of problematic pain by visit type did not show significant differences . The pain score values appeared consistent across patients and clinicians  on a pain scale of 0 to 10, where 0 indicated no pain or discomfort and 10 indicated severe pain. The median pain score amongst men was 2 (IQR 2) while in females was 4 (IQR 3) [Dunn’s Test = 4.3, Feed-back on overall satisfaction with care received was obtained on a scale of 0 to 10, where 0 meant ‘not happy’ with the service while a score of 10 indicated ‘very happy’ with the care. The median score from 368 responses (91.1%) was 10, with 76% reporting a score of 10. Although 24% reported a score of less than 10, only 4% scored 7 or less on happiness with their care. There were no differences noted between men and women. A further patient response, that related to ‘the willingness to a future HRA examination’, was collected. 44 patients (10.9%) did not answer this question. Of those that answered, 99% were willing to re-attend. 4 patients were not . This enables the analysis of health care provision from the patients’ rather than healthcare providers’ perspective.There is an increasing trend in healthcare evaluation to ensure that patients’ views and opinions are taken into account The team at Homerton anal neoplasia service (HANS) consists of a number of HRA practitioners and this study reflects the overall performance of the whole team at HANS. It may be possible for us to bench-mark patient initiated scores of pain and overall satisfaction of care for our service, for comparison with other services, as well as individual practitioners in the future. Patients at high-risk of anal carcinoma include HIV-positive men and women , those oRates of overall questionnaire answering were high but not all patients completed all the questions. This was the price of anonymity which we felt was important, in order to encourage truthful answers. HRA involves intimate examination and biopsy under local anaesthetic.Treatment with laser ablation is one form of ablative treatment for anal HSIL. In a randomised controlled study comparing 3 different treatments for anal neoplasia, pain was assessed as a side effect to treatment . This stIn our study, pain scores were essentially similar between the new cases, treatment cases and those attending for surveillance. Although ‘problematic pain’ defined as a pain score of ≥7 was uncommon in this cohort of patients, a relatively larger number of women reported ‘problematic pain’. This may relate to the fact that women have multizonal assessment which includes examination of the cervix, vagina and vulvar regions at the same visit as high resolution anoscopy. Previous anecdotal observations suggest that the duration of examination may determine the level of pain or discomfort experienced by the patient. The guidelines for international practice standards recognises the duration of HRA examination to be important . In the We compared nurse and physician assessment of pain with patients’ own pain Table . There wIn our cohort of patients, women were equally satisfied with the care they received as men and almost all men and women were willing to return for a future examination. In a study looking at the psychological impact of being screened for anal cancer in HIV-positive men who have sex with men, patients were more likely to have higher negative impact scores immediately after being screened, compared to at other time points such as pre-screen and post-results . This suHRA examination is thought to be the ideal method for the diagnosis of high grade anal neoplasia, through directed biopsies . It enabThis study has several limitations. The National Health Service in the UK advocates routine collection of patient feed-back on services. We obtained patient feed-back over a 10-month period, from patients seeing different members of staff. Due to the anonymous nature of the survey, we could not stratify the results according to the clinician who saw the patient. A small number of patients (~ 5%) may have attended twice and filled out two separate forms. This may have ‘amplified’ feed-back results. Our patient cohort consisted of those who had HRA only, those who had one or more biopsies, and those who received treatment. The patients undergoing treatment and surveillance were by definition groups who had already attended at least once previously and thus may bias the results in favour of patients willing to return for a further examination. However, there were no significant differences between these three groups in terms of willingness to return.No sample size calculations were conducted but we found a difference in pain scores between men and women; further studies and replication of the findings are necessary. The overall response rate was high it was not 100%, and not all patients answered all questions. This may have reflected a failure of trust in the anonymization process, leading to a refusal to fill out any deemed to be a critical or negative response. Both these factors could bias the results in favour of those who experienced less pain/were more willing to return. Finally, the feedback audit was conducted in a tertiary referral unit, and thus the results may not be generalizable to other populations.Our results are encouraging in that due to low pain scores and a high proportion of patients being willing to return for further visits, we feel that HRA can be supported as an outpatient procedure, including for small volume ablative treatments. Access to general anaesthetic or sedation may be required for patients, particularly women, who may experience pain during examination and for larger volume ablative treatments.High resolution anoscopy (HRA) in the outpatient setting including biopsy and ablative treatment under local anaesthetic is well-tolerated in men and women in a tertiary referral centre in the UK. Treatment and biopsies did not impact on the acceptability and pain scores of the procedure. A small number of people may require general anaesthetic or sedation in order to undergo the procedure in comfort. We propose that units currently carrying out non-high resolution anoscopy with mapping biopsies under GA consider training in HRA and transferring surveillance of anal intraepithelial neoplasia (AIN) to this less invasive outpatient-based modality.


The aim of the article is to investigate the efficacy of ultrasound (US)-guided Caudal Epidural Steroid Injection (CESI) compared with fluoroscopy (FL)-guided CESI in patients with unilateral lower lumbar radicular pain.This case-controlled, retrospective, comparative study was done at the university hospital. A total of 110 patients treated with US- or FL-guided CESI were administered a mixture of 20 cc (0.5% lidocaine 18.0 mL + dexamethason 10 mg 2 mL). Outcome measurement was assessed by Oswestry Disability Index (ODI), verbal numeric pain scale (VNS) before injections and at 3, 6, and 12 months after the last injections. Successful outcome was defined as measured by >50% improvement in the VNS score and >40% improvement in the ODI.P < 0.05). No significant differences in the proportion of patients with successful treatment were observed between the groups from the 3-month to 6-month to 12-month outcomes.ODI and VNS showed improvement at 3, 6, and 12 months after the last injection in both groups. No statistical differences in ODI, VNS were observed between groups (US-guided CESI is deserving of consideration in conservative management of unilateral lower lumbar radicular pain. Because the injection is administered close to the gonadal area, treatment of patients of reproductive age should be considered with caution.7 And the high cost of FL must be considered.Caudal epidural steroid injection (CESI) can be helpful in the symptomatic treatment of lumbar radicular pain due to spinal canal stenosis or herniated disc.3 showed the practicability of ultrasound (US) in locating the sacral hiatus and guiding the needle into the caudal epidural space. Chen et al3 also described using FL after contrast injection to confirm the position of a caudal needle placed under US guidance and reported a 100% success rate. Blanchais et al,8 who assessed the safety of US-guided CESI, reported that no cerebrospinal fluid reflux occurred. In addition, heme with aspiration was noted in 9/29 patients and resolved in 8 upon needle repositioning. No complications were recorded during the first month.8 In terms of treatment effect, Park et al9 demonstrated that US- and FL-guided CESI provided adequate pain reduction and improvement of function for 3 months when performed in patients with unilateral lower lumbar radicular pain, and no statistical differences in the verbal numerical rating scale (VNS), the Oswestry Disability Index (ODI), or the effectiveness of the procedure were observed between groups.Chen et alIn previous studies, only the location of the needle, safety, and short-term treatment effect were observed. One of the main limitations of US-guided CESI is that we cannot confirm that medication is delivered to the exact target site. And this limitation can have an influence on long-term treatment effects. Hence, the aim of this study was to evaluate long-term pain reduction and functional improvements of US-guided CESI compared with FL-guided CESI in the case of unilateral lower lumbar radicular pain through a retrospective study with 1-year follow-up.This study is a retrospective comparative study of chart review. All the patients’ privacy and data were maintained confidentially throughout the research process. No direct contact with the study population was included in this study, and all patient identifiers were removed from the data set on initial collection. Approval from the Institutional Review Board of Sanggye Paik hospital was obtained including a waiver of informed consent.Between January 2012 and December 2013, 362 patients with unilateral lower lumbar radicular pain due to spinal canal stenosis or herniated disc were referred to our pain clinic. Diagnosis of unilateral lower lumbar radicular pain was based on the clinical pain profiles, physical examinations, and CT or MRI. Clinical pain profiles mean lancinating and traveled along the length of the lower limb, in a band no more than 2 to 3 inches wide. The EMG test was used to rule out other disease such as other peripheral neuropathy, progressive motor deficit or significant sensory deficit, and cauda equina syndrome, and so on.Those who met the following inclusion criteria were selected: aged 18 or older, received US- or FL-guided CESI. Further inclusion criteria included patients who had experienced chronic radicular pain for at least 3 months and had failed to respond to anti-inflammatory medications, analgesics or physical therapy of at least 4 weeks. Patients with sacroiliac joint or facet joint pain based on clinical or radiological evaluation, psychiatric disorders, bleeding disorders, infection sign, inflammatory disease, or rheumatoid disorders were excluded in this study. Patients who have previous lumbar surgery, progressive motor deficit or significant sensory deficit, cauda equina syndrome were also excluded. We permitted only acetaminophen and nonsteroid anti-inflammatory drugs (NSAIDs) for the pain control.FL- or US-guided CESI to treat unilateral lower lumbar radicular pain due to spinal canal stenosis or herniated disc was a common practice in our service. Patients were informed of the potential risks associated with the procedure, and the benefits and risks of using corticosteroid mixed with contrast media, and then were asked to provide consent. The choice whether to use US or FL was made by the patient.®  with a linear probe at 6 to 12 MHz as the US instrument. First, US probe was placed transversely at the midline to obtain the sacral hiatus transverse image with the patient in prone position.10 Two sacral cornua were seen as hyper-echogenic structures with an inverted U shape, and then, sacral hiatus could be identified easily. Before CESI, blood vessels were identified by power doppler imaging. With the help of an assistant, an interventionalist, wearing sterilegloves, set up the equipment needed for the injection on a table covered with a sterile drape. The sacrococcygeal area was prepared using an iodine-based povidone solution and an alcohol solution. The interventionalist then used the middle finger of the dominant hand to localize the tip of the coccyx through palpation. Finally, the interventionalist inserted the needle in the direction of the affected side in order to deliver the medication toward the affected side and to increase the chance of the medication reaching the site of the anomaly.11 A spinal needle  of 22-gauge and 3.5-inch was then inserted into the sacral hiatus through the 2 cornua , was injected after confirming the absence of abnormal findings.We checked the absence of blood in the syringe before furthering the needle advancement, and then performed an aspiration test to check for the presence of blood and cerebrospinal fluid. If either method identified blood or cerebrospinal fluid, the needle was repositioned. After confirming the absence, first 1 to 2 mL of 1% lidocaine test dose was injected. The flow was observed using color Doppler mode of US  with the image intensifier. We checked the absence of blood in the syringe before the needle advancement. The inhalation test was performed to check cerebrospinal fluid leakage. We injected ∼1 mL of contrast media  before drug injection to confirm epidural flow and to avoid intravascular, intradural, or soft tissue infiltration.For FL-guided CESI, the patients were asked to lie on a fluoroscopic table with their abdomen side down. A pillow was placed under the hips to tilt the pelvis and bring the sacralhiatus into greater prominence. The sacrococcygeal area was prepared using an iodine-based povidone solution and an alcohol solution. The interventionist then localized coccyx tip through palpation with sterilized middle finger. We used a 22-gauge, 3.5-inch length spinal needle . We injected 20 cc of the treatment drug (0.5% lidocaine 18.0 mL + dexamethason 10 mg 2 mL) in the absence of such abnormal findings.In both groups, patients received 2 consecutive injections 2 weeks apart. The second injection proceeded conditionally. If the initial injection resulted in significant symptom reduction (VNS ≥ 50%), the second injection was omitted with a progression to follow-up. If no pain relief or pain deterioration was observed, a second injection or re-evaluation was not considered. If the patients experienced pain relief of <50% reduction in VNS, a second injection was scheduled. Because none of the patients had shown any improvement by medications such as anti-inflammatory drugs and physical therapy for 4 weeks, we did not set any limit on the continuation of previous exercise programs, drug therapy, and work. There were no specific additional interventions.13 ODI is one of the most commonly used disease-specific measures for patients with LBP.14 ODI ranges from 0 to 100 is one of the most common measures when we assess outcome of LBP patients.14 ODI is composed of 10 items. Each item is scored from 0 to 5, and the total score is calculated by added of each item and multiplied by 2.Of the 178 CESIs, US (n = 86) or FL n = 92) performed during the interval encompassed by this study, the inclusion criteria were met for 110 (62%) injections. Fifty-six (31%) injections were excluded because the patient did not complete and return follow-up's survey. Twelve (7%) of the injections were excluded because of exclusion criteria. Finally, 58 patients in the US group and 52 patients in the FL group were left in this study , pain duration, sex, and age were from medical records. Predictive variables were measured as follows:15We grouped patients as 5 according to their age: <39 years old, 40 to 49, 50 to 59, 60 to 69, and >70. The duration of radicular pain was analyzed as a potential predictive value, and classified as acute of subacute (< 6 months) or chronic (≥6 months).16 Patients who did not satisfy these conditions were considered as ineffective treatment. Patients who were treated by repeated CESI or surgical treatment were also considered as ineffective treatment.We defined effective treatment as a reduction in the VNS score of 50% or more, and ODI of 40% or more at 3, 6, and 12 months.We checked immediate adverse events such as vasovagal reaction, facial flushing, or severe back pain within a few minutes after the injection. Every patients were asked to complete a questionnaire within 48 h. After the procedure to evaluate the occurrence of side effects including headaches, fever, transient pain exacerbation, hematoma, or loss of control of heart disease, hypertension, or diabetes.17 Previous studies of interventional techniques identified 50 to 60 patients as appropriate.20The sample size was calculated based on significant pain relief. Considering a 2-sided significance level of 0.05, a power of 80%, and an allocation ratio of 1:1, it was estimated that 55 patients were required for each group.U test was used to evaluate for age, body mass index (BMI), and pain duration difference between the 2 groups. Repeated measure analysis of variance (ANOVA) was done to compare VNS and ODI at each time point and Bonferroni's correction for post-hoc comparison. The chi square test was used to analyze the correlation of possible outcome predictors with the therapeutic effect. Logistic regression modeling was performed to determine the influence of injection methods, patients’ age, gender, and pain duration on successful outcome. Statistical analyses were performed using SAS Enterprise Guide 4.1. The level of statistical significance was set as P < 0.05.Pearson's chi square test was used to compare the characteristics of the 2 groups in variables such as sex difference, target nerve root, cause, and number of injection. Mann–Whitney The mean age of the patients was 56.3 ± 9.7 in the FL group and 57.9 ± 9.9 in the US group, without a significant difference. No significant differences were observed in the general characteristics of sex, BMI, pain duration, injection number, lesion location, and topographical comparisons Table .ODI and VNS showed significant improvement at 3, 6, and 12 months after the last injections in both groups. No significant differences in ODI and VNS at the point of baseline, 3, 6, and 12 months after the last injections were observed between the groups . These results are summarized in Tables Injection method, gender, age, pain duration, cause, and number of injection were not found to be statistically related to the effectiveness of CESI. Injection method, gender, age, pain duration, cause, and number of injection were not independent predictors of effectiveness of CESI by using univariate and multiple logistic regression analyses in 53.4% to 51.9% of patients in both groups at the end of the 1-year period. Successful treatments did not differ significantly between the groups or from the 3-month to 6-month to 12-month outcomes. Consequently, pain reduction and functional improvement were similar for US-guided CESI and FL-guided CESI.23 Therefore, local delivery of corticosteroid with both anti-inflammatory and local anesthetic properties to the affected nerve root appears to be a reasonable option.25 The epidural corticosteroid injection may be classified as interlaminar, caudal, or transforaminal, depending on the approach to the epidural space.9 CESI is an easy and safe way to administer drug in the outpatient setting with a lower risk of thecal sac puncture and intrathecal injection.26 However, inaccurate needle location has been reported in 25% to 36% of cases in unaided procedures.27 The FL-guided procedure is commonly used for the spinal intervention procedures and recommended for the confirmation of the correct caudal epidural needle placement.29 But the radiation exposure has been the major concern in clinical fields. The advantages of US are that it is easy to use, radiation-free, and can be used in virtually any clinical setting.30 Most significantly, US can provide real-time and continuous needle guiding images without radiation exposure.3Various experimental studies have shown that radicular pain occurs as a result of both mechanical compression and chemical radiculitis.7 first reported the use of US during CESI and particular advantages in moderately obese patients or patients with difficulty in prone positioning. Chen et al,3 who evaluated US-guided CESI in 70 patients with radicular pain, reported a 100% success rate in needle placement using a high-frequency transducer to identify the sacral hiatus during injection. In addition to accuracy and feasibility, US can provide clear images of the sacral hiatus and detect the anatomic variations of the sacrum and sacral hiatus that make CESI difficult or impossible.26 In the previous studies, ∼2% to 3% of the studied population have closed sacral canals, thus making CESI impossible for these subjects.31 Measurement of the diameter of the sacral canal at the apex of the sacral hiatus is also important. Sekiguchi et al 31 reported that the diameter of the sacral canal was <2 mm in 1% of cases. Another study reported such a diameter in 6.25% of cases.32 In cases of <2 mm, patients complained of severe soreness and pain at the injection site when CESI was attempted after the injection needle just penetrated through the sacrococcygeal ligament.27 Strong resistance was felt during the injection procedure, and injection of the medication into the sacral canal was nearly impossible.27 Additionally, a needle >22 gauge may cause insertion failure through the sacreal hiatus in the case of narrow sacral hiatus <2 mm diameter. Chen et al 27 reported 4 cases of injection failure when the sacral hiatus diameter was between 1.2 and 1.6 mm. Park et al 9 reported 4 cases of injection failure with FL-guided CESI and all of their sacral hiatus diameters measured by US were under 2 mm.9 Thus, obtaining of anatomical information such as sacra hiatus shape and diameter before CESI is important in terms of reducing patient discomfort and saving procedure time.Klocke et al 35 Manchikanti et al 33 reported that CESI led significant pain relief (≥50%) in 55% to 65% of patients with LBP due to spinal stenosis after CESI. Botwin et al34 reported 65% of patients showed a successful outcome  in 6 weeks after CESI, 62% in months, and 54% in 12 months. In cases of radicular pain due to disc herniation, Manchikanti et al35 reported proportion of patients with significant pain relief of 50% or greater and/or improvement in functional status with 50% or more reduction in ODI scores of 77% and 75% in patients receiving steroids with average number of procedures per year of 3.8. As illustrated in the present study, the proportion of patients with successful outcome is showing 53.4 % in US groups and 51.9 % in FL groups at 12 months.Despite widespread use and numerous publications there is controversy with regards to the medical necessity and indications for lumbar epidural injections. Multiple previous studies have identified indications for caudal epidural injections in positive reports to treat radicular pain from herniated lumbar intervertebral disc or spinal stenosis.35 Despite using this method, Lee et al 36 reported that 13.6% of the studied patients had a greater amount of the drug on the opposite side of the lesion. Positioning the patient in the lateral decubitus on the side of their leg pain results in accumulation of the injected drugs on the dependent side due to gravity and can solve the problem. Makki et al 37 reported that laying a patient on the side of their leg pain after CESI has a beneficial effect on the degree of pain relief. We expect that the combination method of needle insertion direction to the affected side and patient positioning can result in a more accurate US-guided procedure.Compared to the FL-guided procedure, the US-guided procedure has several limitations. Faulty injections resulting in low effectiveness cannot be detected during the US-guided procedures. In the case of unilateral radicular pain, a diminished therapeutic effect could be expected, if a drug might be administered to the opposite site. On the other hand, FL-guided procedure has advantage that adjusting needle direction is possible in the case of detecting incorrect drug administration. In order to overcome the limitation of the US-guided procedure, experts in CESI have recommended inserting the needle in the direction of the affected side in order to deliver the medication toward the affected side and to increase the chance that the medication will reach the site of the anomaly.38 The needle aspiration test before drug injection is helpful for the prevention of intravascular injection, but is neither sufficiently sensitive nor specific to avoid an intravascular needle position.9 Color Doppler and lidocaine test dose injections were used to protect intravascular injections. According to Yoon et al 10 if the injection flow was not detected as being mainly in the cephalic direction and vascular flow was detected by the Doppler as having multicolored spectrums, it was considered that the medication was injected into the vessel. In such cases, the needle tip must be relocated. Using such an identification method, Yoon et al 10 reported a successful injection rate of 94% and in 3 other failure cases, they presumed that the cause was positional changes of the needle after exchanging the syringe.10 Park et al 9 used live FL during injection of 1 to 2 cc contrast media with color Doppler mode. They could obtain an accurate contrast media dye position in the epidural space and no case of intravascular injection in all 60 subjects by using the color Doppler spectrum confirmation method during live FL.9 It reveals that the application of color Doppler during the injection procedure could significantly reduce the intravascular injection rate. In addition, we recommend lidocaine test dose injections to rule out the possibility of intravascular injections. Using 1cc, 1% lidocaine as an anesthetic test dose was recommended for the prevention of intravascular drug injection during the transformianal injection.12 We also used 1 cc, 1% lidocaine as a test dose before drug injections. Patients were monitored for any special reaction for 1 to 2 min after the test dose injections before proceeding to the actual treatment injections. Although positive findings of intravascular injection were not observed, a confirmation step with the test dose provided reassurance regarding the absence of intravascular injections.A second limitation is that the inadvertent intravascular injection cannot be detected during US-guided CESI. The frequency of accidental intravascular injections during CESI was reported to range from 2.5% to 9%.2 in this study. Since visualization of small vessels or radicular arteries by US may be difficult in obese patients, there can be some different results in the study including obese patients. Additional studies may be required in order to improve such limitations of this study.The present study had several limitations. First, this study was retrospective in design. Although subjects were selected according to the inclusion and exclusion criteria, there could have been heterogeneity among the subjects included in this study. In addition, other treatments such as medication or physical therapy during follow-up period might have influenced to outcomes. However, we thought that these effects were very limited because patients refractory to these treatments were included in this study. Second, both procedures were performed by 1 physician, reflecting the experience of 1 practitioner and limiting the generalization of the study results. Third, the US-guided approach was performed in patients with a BMI <30 kg/mIn conclusion, pain reduction and functional improvement were similar for the US-guided procedure and the FL-guided procedure without the risk of radiation exposure. Therefore, by considering our data from this retrospective study, US-guided CESI is deserving of consideration for conservative management of unilateral lower lumbar radicular pain.In this study, US-guided CESI showed similar improvement in pain relief and function as the FL-guided injection for the treatment of unilateral lower lumbar radicular pain. Therefore, based on our data from this retrospective study, US-guided CESI deserves to be considered among the conservative managements of unilateral lower lumbar radicular pain.