To compare the clinical characteristics of dry eye patients with ocular neuropathic pain features according to the types of sensitization based on the Ocular Pain Assessment Survey (OPAS).Cross-sectional study of 33 patients with dry eye and ocular neuropathic pain features. All patients had a comprehensive ophthalmic assessment including detailed history, the intensity and duration of ocular pain, the tear film, ocular surface, and Meibomian gland examination, and OPAS. Patients with < 50% improvement in pain intensity after proparacaine challenge test were assigned to the central-dominant sensitization group  and those with ≥50% improvement were assigned to the peripheral-dominant sensitization group . All variables were compared between the two groups.p > 0.05). Ocular pain and non-ocular pain severity and the percentage of time spent thinking about non-ocular pain were significantly higher in the central group than in the peripheral group . Central group complained more commonly of a burning sensation than did the peripheral group (p = 0.01).No significant differences were observed in age, sex, underlying diseases, history of ocular surgery, duration of ocular pain, tear film, ocular surface and Meibomian gland parameters (all Patients with central-dominant sensitization may experience more intense ocular and non-ocular pain than the others and burning sensation may be a key symptom in those patients. Dry eye disease (DED) is a multifactorial disease and the management of DED is often complicated because the disease varies from patients to patients, both in severity and in character . DEWS IIThere is no gold standard for diagnosing ocular neuropathic pain. Owing to the scarcity of available signs, the diagnosis mainly depends on clinical history, symptoms, and ophthalmologic examination results , 12. ManIn this study, we collected clinical data and the OPAS questionnaires from three eye centers to investigate the characteristics of patients with DED and ocular neuropathic pain features, the association of ocular neuropathic pain features with pre-existing medical conditions, and the clinical differences between groups classified according to the dominant types of sensitization.A multicenter, cross-sectional study was performed between January 2, 2018 and June 30, 2019, at the outpatient departments of three eye centers in Korea, namely, Chonnam National University Hospital, Konyang University Hospital, and Chonbuk National University Hospital. Informed consent was obtained from each patient. Ethical approval was obtained from the ethical committees of all participating hospitals, and the study protocol followed the guidelines of the Declaration of Helsinki.Patients complaining of continuous severe ocular pain or burning sensation of pain score 7 or more using the Wong-Baker FACES® Pain Rating Scale with little or no corneal staining were included. The diagnosis of DED was made based on DEWS II criteria . PatientPatients were divided into two subgroups according to their response to the proparacaine challenge test , 10. As TBUT, Schirmer test score, and corneal staining score (CSS) were evaluated by three cornea specialists  at the first visit. TBUT was assessed three times after the instillation of fluorescein dye, and the mean TBUT recorded in seconds was used for analysis. CSS was evaluated subsequently by employing a white light and cobalt blue filter, using the area-density index, scoring the area (0–3) and density (0–3) of the superficial punctate corneal lesion, and multiplying the area and density scores (0–9) . The SchThe Meibomian gland (MG) expressibility was assessed by applying digital pressure onto the lower central eyelid and counting the number of expressed gland orifices within the central eighth of the lower eyelid and was scored on a 0–3 grading scale . MG secrAll patients completed the OPAS, which is a validated questionnaire for neuropathic pain that combines patient responses regarding ocular and non-ocular pain intensity, impact on QoL, aggravating factors, associated factors, and symptomatic relief . The quep value < 0.05 was considered statistically significant. The sample size of 17 subjects in the central group and 16 subjects in the peripheral group provided approximately 88% of power to show a significant difference with the independent t-test.SPSS Statistics for Windows, Version 23.0  was used for statistical analysis. All data are shown as the mean ± standard deviation. The Kolmogorov-Smirnov test was performed for continuous variables, and the normally distributed variables were age, OPAS ocular pain intensity score, impairment in walking score, pain-associated redness, and burning sensation score. The independent t-test was used to identify between-group differences in the mean values of these variables. For other variables that were not normally distributed, the Mann-Whitney U-test was performed. Pearson’s correlation analysis between the Wong-Baker FACES® Pain Rating Scale and the ocular pain severity score of OPAS was conducted. A p > 0.05).A total of 33 patients were analyzed. On the basis of the proparacaine challenge test results, 17 patients were assigned to the central group and 16 patients to the peripheral group; their mean ages were 59.12 ± 11.58 and 58.13 ± 12.86 years, respectively. There were more women than men in both groups. Table P > 0.05) (Table p = 0.69).The mean values for TBUT, Schirmer test score, CSS, and MG quality and expressibility in patients with ocular neuropathic pain were 4.67 ± 2.01 s, 7.22 ± 5.09 mm, 0.42 ± 0.75, 1.21 ± 0.82, and 0.61 ± 0.79, respectively. No significant differences were found in tear film, ocular surface, and MG parameters between the central and peripheral groups . The pain scale assessed by the Wong-Baker FACES® Pain Rating Scale was also significantly higher in the central group  and the Pearson’s correlation coefficient between the Wong-Baker FACES® Pain Rating Scale and the OPAS score was 0.78 (p < 0.001). Non-ocular pains, such as headache, backache, and arthralgia, scored higher in the central group (6.12 ± 3.12) than in the peripheral group , and patients in the central group spent more time thinking about non-ocular pain than did those in the peripheral group (0.56 ± 0.35 vs. 0.27 ± 0.26) (p = 0.01). The scores regarding QoL were highest for reading impairment in both groups, but no significant differences were observed between groups. Although the difference was not statistically significant, most of the QoL scores were higher in the central group  than in the peripheral group. The aggravating factors were scored by the percentage of worsening of ocular pain according to mechanical stimuli, such as wind, dry air, heat, and air conditioning, and chemical stimuli, such as volatile chemicals, fumes, and cosmetic fragrances. The associated factors were scored as a percentage of the frequency with which each symptom was accompanied by ocular pain. The percentage values were later divided by 100 for analysis. The values of aggravating and associated factors did not differ significantly between the two groups, except for burning sensation .Table In the present study, dry eye patients with ocular neuropathic pain features were divided into two groups on the basis of proparacaine challenge test results. Although clinical parameters associated with the tear film and ocular surface, such as TBUT, basal tear secretion, CSS, and MG parameters, were not significantly different between the two groups, the central group complained of more severe ocular pain and non-ocular pain than did the peripheral group. In addition, we noticed that patients in the central group complained of a burning sensation more commonly than did those in the peripheral group.The underlying mechanisms of DED is ocular surface inflammation and damage induced by tear hyperosmolarity . Tear hyIt is well established that structural and functional changes occur in ocular surface sensory nerves in DED. Reduced tear secretion causes stress on ocular mucosal epithelium, leading to local inflammation and peripheral nerve damage . Long-teIn vivo confocal microscopy (IVCM) visualizes microstructures, including corneal nerve plexus –30. SomeThe 0.5% proparacaine challenge test is a useful method to assess the central sensitization of ocular pain in a general clinical setting which does not provide research equipments such as esthesiometry or confocal microscopy . In prevPrevious studies have attempted to evaluate patients with ocular pain by using dry eye-related questionnaires, such as the Ocular Surface Disease Index, Dry Eye Questionnaire, and Dry Eye–Related Quality-of-Life Score –15. In mKalangara et al.  used theOur study has several limitations. First, the sample size may not be enough to prove the clinical significance of results. Further studies with larger sample sizes that provide greater power could advance the results of this study. Second, because this study is a multicenter study, subtle bias may be present in conducting clinical examinations. Third, corneal esthesiometry or IVCM imaging were not obtained in this study. Fourth, we used an arbitrary 50% cut-off value in the proparacaine challenge test for the analysis and it might not be a validated value for determining the types of sensitization. Further studies with more precise diagnostic equipment are warranted in the future.In conclusion, dry eye patients with central-dominant sensitization may experience more intense ocular and non-ocular pain than the others. Burning sensation may be a key symptom in ocular neuropathic pain. The OPAS questionnaire can be a good option for evaluating whether patients have ocular neuropathic features. Further investigations on corneal nervous system and peripheral and central sensitization associated with dry eye may give clue to the management of patients with ocular neuropathic pain features.


Background. It is difficult to achieve successful pulpal anesthesia in mandibular posterior teeth with symptomatic irreversible pulpitis. The present study aimed to compare the effect of articaine/epinephrine anesthesia with articaine/epinephrine at acombination of 0.5 mol/mL of mannitol for the inferior alveolar nerve block (IANB) in patients presenting with symptomaticirreversible pulpitis in the mandibular first molar tooth.Methods. One hundred patients with symptomatic irreversible pulpitis in the mandibular first molar tooth were selected andrandomly divided into two groups based on the injection method. The first group underwent an IANB technique with 1.8 mLof articaine, whereas the second group received 2.9 mL of a formulation, consisting of 1.8 mL of articaine plus 1.1 mL of 0.5mol/L of mannitol. Fifteen minutes after injections and anesthesia of the lip, the access cavity was prepared. According to thevisual analog scale (VAS) criteria, no pain or mild pain for caries removal, pulp exposure and canal instrumentation wereregarded as success. Chi-squared test was used for the analysis of data. The level of significance was set at 0.05.Results. The success rate in the group with articaine/epinephrine anesthesia plus mannitol was higher than that in the groupwith articaine/epinephrine anesthesia, with no significant difference between the two groups (P>0.05).Conclusion. It was concluded, under the limitations of this study, that adding mannitol to articaine/epinephrine anesthesiadid not increase the success of IANB in mandibular posterior teeth with symptomatic irreversible pulpitis. Antonijevic et al13 concluded that 0.5 mol/mL of mannitol is very effective in opening the membrane surrounding each nerve, resulting in the penetration of more macromolecules and pumping of ions into the nerve. In addition, hyperosmolar solutions, like mannitol, have been shown to block the release of action potentials in type A neurons in mice.17In this regard, mannitol has been recently used. Mannitol is a hexose sugar alcohol with a molecular weight of 182.17 g/mol. It can be naturally found in fruits and vegetables and is an osmotic diuretic.20 Compared with lidocaine, articaine induces faster and more durable anesthesia.23 Available studies indicate that articaine has equal effects in comparison with other local anesthetics in the IANB and maxillary infiltration; however, it is more successful than lidocaine in mandibular first molar infiltration technique.27Articaine, after lidocaine, is the most widely used anesthetic agent in dentistry. Articaine is a dental amide-type local anesthetic agent, and instead of the benzene ring in lidocaine, it contains a thiophene ring, which increases its solubility in fat and accelerates its penetration through the membrane and bone.Recent studies have shown that mannitol plus lidocaine increases anesthesia in the IANB; however, there is a lack of studies on the effect of mannitol plus articaine on the induction of anesthesia in IANB in patients with symptomatic irreversible pulpitis. Therefore, this study investigated the efficacy of adding mannitol to articaine to increase the success rate of IANB in patients presenting with symptomatic irreversible pulpitis in the mandibular first molar teeth.The protocol of this study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Ethics code: IR.TBZMED.REC.1396.1269) and registered at the Iranian Registry of Clinical Trials .10 considering a success rate of 39% in the group with a combination of lidocaine/epinephrine and mannitol and 13% in the group with lidocaine/epinephrine with a difference of 26% in the success rate, α = 0.05, a study power of 80% and an error rate of 10%.The sample size was estimated at 50 samples in each group according to the results of a study by Kreimer et al,The current randomized controlled clinical trial was carried out on 100 patients referring to the Endodontic Department of Tabriz Faculty of Dentistry. The inclusion criteria consisted of systemically healthy patients, an age >18 years, no use of beta-blockers, no treatment with different types of opioids, no drug abuse, no pregnancy and lactation, no allergy to the materials used in the study, and no oral inflammation, or infection.The patients included in this study had permanent mandibular first molar teeth with vital pulps and mature roots (confirmed by radiography), spontaneous pain, more severe and prolonged pain response, compared with the adjacent control tooth, to the cold testing with Endo-Ice  due to the decay, and normal periapical status. To avoid bias, the diagnostic steps were performed by an individual blinded to the injection of anesthetic solutions, and pain registration procedures.The exclusion criteria of the study included patients with the following characteristics: no response to the cold test, teeth with widening of the periodontal ligament (PDL), and teeth with no vital coronal pulp tissue during access cavity preparation .One hundred patients, including 50 females and 50 males, were selected (n = 50 for each group) and randomly divided into two subgroups composed of 25 men and 25 women. The randomization was implemented with the Randlist software. A code from 1 to 50  was assigned to each patient.A standard injection of IANB, using conventional injection by a syringe with a 27-gauge needle with a length of 3.6 cm, was conducted in group one. The injection point was determined and aspiration was conducted, followed by the injection of 1.8 mL of 4% articaine solution with an epinephrine concentration of 1:200,000  in one minute.The anesthetic solution for group two was prepared immediately before injection according to the following steps.Under a sterile condition, 1.8 mL of 4% articaine solution with 1:200,000 epinephrine concentration  from a standard dental cartridge plus 1.1 mL of 0.5 mol/L of 20% mannitol (200 mL)  was taken into a 3-mL sterile Luer-lok tip syringe . The mixture was shaken 20 times to achieve a uniform mix. The mannitol solution was placed in water at 80°C before mixing for 15‒20 minutes to remove any crystals in the solution. The standard injection and the remaining steps were similar to those in the first group.10 Fourteen patients did not have lip anesthesia and were excluded, whereas 86 patients had lip anesthesia and were enrolled in the study.Fifteen minutes after injection, the patients were asked about lip anesthesia.The patients were informed about the stages of the study and informed consent was obtained. The teeth were isolated with a rubber dam and the access cavity was prepared. The patients were asked to raise their hand when they felt any pain and record their pain severity on VAS. Pain sensation steps were recorded separately using the following methods: upon dentin entry, upon the pulp chamber entry, and initial canal instrumentation.10 in which according to the location of pain, the pain level is classified into 4 categories: no pain (0 mm), mild pain (1‒54 mm), moderate pain (55‒112 mm), and severe pain (113‒170 mm).The 170-mm Heft-Parker visual analog scale (VAS) was employed to assess pain,Successful anesthesia was defined according to the VAS criteria representing no pain (0) or mild pain (1‒54 mm).In this study, diagnostic tests of pulp status and IANB injection were performed by an operator, and the access cavity preparation and recording of the possible pain during operation were carried out by another operator.Repeated-measures ANOVA was used to determine statistical differences in the means of pain intensity between the two groups through three stages of evaluation; chi-squared test was used to assess the relationship between gender and the study groups. The level of significance was defined at P<0.05.The results of repeated-measures ANOVA showed no significant differences in the means of pain intensity between the two groups (P>0.05) . In addiAccording to the results of chi-squared test, there was no statistically significant relationship between gender and the study groups (P>0.05).4 The causative factors for the failure to achieve sufficient anesthesia in the IANB technique in the presence of inflammation include neurodegenerative changes throughout the inflamed nerve away from the inflammation site and the presence of amino acids produced by the lysosomal activity of proteolytic enzymes.8 Recent studies have assessed the use of auxiliary substances, such as meperidine, diphenhydramine, hyaluronidase, and sodium bicarbonate to enhance the success of the IANB technique. It has been indicated that none of these substances, compared with lidocaine/epinephrine, increase the success rate of IANB significantly.28Favorable pain control is essential in the treatment of painful endodontic diseases. The low success rate of IANB injection and poor control of pain in patients with irreversible pulpitis has resulted in an increase in the use of supplementary substances to increase the anesthetic success.16 Moreover, it changes or interrupts the action potential in neurons.17 Accordingly, in this study we studied the effect of mannitol. Studies have indicated that mannitol is a non-reactive substance,16 which is widely used in medicine. No study has yet compared the effect of articaine anesthetic solution with that of a combination of articaine and mannitol in patients with symptomatic irreversible pulpitis. In this regard, this study compared the success rate of articaine/mannitol with that of articaine for IANB injection in patients with symptomatic irreversible pulpitis. In the present study, the male and female patients were divided and analyzed equally, andsince the tooth type affects the IANB success rate, mandibular first molar teeth were selected. Gender and age of the patients did not result in a significant difference between the two study groups. In previous endodontic studies, IANB success rate was 19‒57% in patients with irreversible pulpitis.12 In this research, we used lip anesthesia as a clinical indicator of IANB success, ignoring the electric pulp testing (EPT) since Nasstein et al29 showed that in 42% of the cases which responded negatively to the EPT test, there was pain during endodontic procedures. Lip anesthesia does not guarantee a successful anesthesia of the pulp. Therefore, no pain (VAS = 0) or mild pain (VAS = 1‒54 mm) were considered as a success upon dentin entry, upon the pulp chamber entry, and initial canal instrumentation. The low success rate of articaine in the IANB technique for the patients presenting with symptomatic irreversible pulpitis was consistent with other studies.30 Since adequate pulpal anesthesia cannot be achieved by these formulations in patients with symptomatic irreversible pulpitis, supplementary injection techniques, such as intraosseous or intraligamentary, must be considered to provide favorable anesthesia.2 Further studies are recommended to increase the success rate of the IANB technique in patients with symptomatic irreversible pulpitis.The failure of inferior alveolar anesthesia can be caused by the membrane surrounding the nerve, through which the anesthetic solution cannot fully penetrate to reach the nerve tract. It has been reported that mannitol increases the permeability of the membrane surrounding each nerve.10 examined the effect of mannitol on the success rate of IANB for mandibular molars and showed significant differences in terms of success rate between the group with lidocaine/epinephrine plus mannitol and the group with lidocaine/epinephrine.It can be concluded that articaine itself has a high tissue and osseous penetration and diminishes the effect of mannitol, which increases the permeability of the nerve membrane.The results of this study showed that the articaine/epinephrine solution plus mannitol resulted in a higher success rate compared with articaine/epinephrine without mannitol; however, the difference was not statistically significant. Unlike the current study, Kreimer et alUnder the limitations of this study, it was concluded that adding mannitol to articaine/epinephrine anesthetic agent did not increase the success rate of the IANB technique in mandibular posterior teeth with symptomatic irreversible pulpitis.SS was responsible for the idea of the research, study design and observing the procedure of the study. MG was responsible for data collection and conducting the practical steps of the study. AAA carried out the data analysis and edited the manuscript. NG prepared the final manuscript.The authors wish to thank the Research Vice Chancellor and Dental and Periodontal Research Center of Tabriz University of Medical Sciences.None declared.Not applicable.This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (Ethics code: IR.TBZMED.REC.1396.1269) and registered at the Iranian Registry of Clinical Trials .


A collaborative research team lead by an investigator from the Lyon Neuroscience Research Center and Lyon University Hospital and Lyon 1 University studied epileptogenicity of tuber and its surrounding cortex using stereoelectroencephalography (SEEG) in patients diagnosed with tuberous sclerosis complex (TSC) . A collaborative research team lead by an investigator from the Lyon Neuroscience Research Center and Lyon University Hospital and Lyon 1 University studied epileptogenicity of tuber and its surrounding cortex using stereoelectroencephalography (SEEG) in patients diagnosed with tuberous sclerosis complex (TSC) . A study cohort of eighteen patients (11 children) who underwent presurgical SEEG evaluation between 2004 and 2018 was identified from four French tertiary epilepsy centers. The electrodes were implanted bilaterally in 14 patients, and the total number of electrodes ranged from 8 to 16 per patient. The total number of tubers in each patient ranged from 3 to 30 [Epileptogenicity Index (EI)  was usedThe dominant tuber was the most epileptogenic P < .001) of the five ROI. Seven patients with a focal tuber EZ organization had 80% Engel IA postsurgical outcome and the following 4 tuber characteristics: continuous interictal discharges (100%), fluid-attenuated inversion recovery (FLAIR) hypointense center (86%), stimulation – induced seizures (71%), and center-to-rim EI gradient. A combination of the first three characteristics showed a 98% specificity for a focal tuber EZ organization. Six patients with a complex EZ organization showed 40% Engel IA outcome with nearby cortex (4 patients) and distant cortex (1) as the most epileptogenic region. The authors concluded that tubers with focal EZ organization are much like type II focal cortical dysplasia, and that identification of these tubers relate to EZ hypothesis generation and invasive EEG/resection strategies. [ of the fCOMMENTARY. Talarirach and Bancaud developed “stereoencephalographie” in the 1960s as a tool to aid in defining the EZ. Their definition of EZ was an ictal electro-clinical concept based on SEEG recordings. Over the past 50 years, the concept of EZ has evolved due to invention of sophisticated localizing tools. Hans Lüders et al. (2006) defined EZ as “the minimum amount of cortex that must be resected to produce seizure freedom .” UltimaThe authors reported the following results in consideration of EZ identification in TSC: 1. A combination of the three characteristics - continuous interictal discharges, FLAIR hypointense center, and stimulation-induced seizures, showed a 98% specificity in localizing the dominant tuber; 2. Nearby cortex (4 of 6 patients) was the most epileptogenic  in the presence of a dominant tuber that lacked center-to-rim gradient in EI. Importantly, these results may contribute to development of an effective implantation strategy of intracerebral electrodes in further defining EZ in TSC, as one of the challenges of using SEEG is determining targets and trajectories based on presurgical data and EZ hypothesis. Experience and skill of a functional neurosurgeon who places intracerebral electrodes to confirm/modify/reject the hypothesis of EZ may also influence outcome. The current work is a welcome and laudable contribution to further our understanding of epileptogenicity in TSC.The authors have declared that no competing interests exist.


Milligan Morgan Hemorrhoidectomy is one of the most commonly performed surgeries. Post-operative pain is the major cause of morbidity in post hemorrhoidectomy patients. Metronidazole has an established role in relieving post hemorrhoidectomy pain. The objective was to evaluate the pain score by using topical and oral metronidazole in post Milligan Morgan hemorrhoidectomy patients.rd and 4th degree hemorrhoids were presenting in surgical OPD and who underwent Milligan Morgan hemorrhoidectomy between July 2018 and December 2018 were included in the study. Patients allocated in two groups, Group-A received topical metronidazole 10% post hemorrhoidectomy for seven days and Group-B were given oral metronidazole 400mg for 07 days. Analgesics were given on patient’s requirement. Patients post hemorrhoidectomy pain was recorded by using VSA scale at baseline (1st day) and on 7th post-operative day. Data analysis was done by using SPSS 21. Pain calculated by compared in terms of mean, standard deviation between groups and independent sample T test was used. Association between demographic details like gender and ages of the patients with pain scale on 7th day was measured and chi-square distribution was used.A prospective randomized controlled trail was done in surgical departments of Akbar Niazi Teaching Hospital, Islamabad. A total of 166 consecutive patients with 3p=0.001). Association of pain with respect to ages was insignificant (p=0.202) whereas between genders inside the groups showed significant difference (p=0.028).Total 166 patients were included in this study. The mean ages of the patients were 44.07±10.62 years with minimum 20 and maximum 60 years. Out of 166 patients, female were 55 (33.1%) and male were 111 (66.9%). Results showed significantly lower pain in patients using topical metronidazole as compared to oral metronidazole (These results showed that topical metronidazole significantly reduces pain in post hemorrhoidectomy patients as compared to oral metronidazole overall and even when data stratified among age, gender and type of hemorrhoids. Secondary hemorrhoids are between them. Patients present with complaints of fresh bleeding per rectum, mucous discharge, pain rectal discomfort and swelling. There are four degrees of hemorrhoids. In 1rd and 4th degree are treated surgically by hemorrhoidectomy, stapler hemorrhoidopexy.p0.004, p0.0011)Hemorrhoids not responding to non-operative management, recurrent after banding and sclerotherapy and 3The rationale behind doing this study was that limited data was available regarding the use of topical metronidazole for post hemorrhoidectomy pain. And topical metronidazole has less systemic side effects so the patient’s compliance was improved. Topical metronidazole is not frequently used in our setup. So this study provided us with fresh first hand and local evidence about mean pain score by using topical and oral metronidazole. The objectives of this study are to investigate and compared whether mean pain score after topical metronidazole 10% was equal or less than oral metronidazole.rd, 4th degree hemorrhoids and age 20 to 60 years presenting in OPD were admitted for Milligan Morgan hemorrhoidectomy to be performed by consultant with 05 years’ experience. Patients with diabetes mellitus, chronic liver disease and ASA III, IV were excluded from study. Patients with mental incompetence and patients refusing informed consent were also excluded from study. 83 Patients were randomly allocated to Group-A  and 83 to Group-B  by non-probability consecutive sampling. Two groups were made by computer to received either topical metronidazole or oral metronidazole. Randomization numbers were placed inside sequentially numbered opaque envelopes.After approval from ethical committee  of the hospital, this prospective randomized controlled trial was carried out in surgical department of Akbar Niazi Teaching Hospital (ANTH) from July 2018 to December 2018. After informed written consent a total of 166 patients st post-operative day) and on 7th post-operative day pain was measured and the score of VAS was calculated. After surgery pain is aggravated due to incisions and hemorrhoidectomy. All patients received their first dose of infusion metronidazole preoperatively. Patients in Group-A received topical metronidazole 10%, 06 hours postoperatively then 08 hourly for 07 days and Group-B received oral metronidazole 400mg, 08 hourly for 07 days. Patients in both groups were advised sitz bath for 15 minutes three times a day and analgesics advised on patient’s requirement. Patient discharged next day. Pain on defecation and during preceding 24 hours was recorded in both groups by using visual analogue scale VAS in centimeters as a single value on 7th post-operative day (follow up visit).The following procedure was done for evaluation of the patients; patients were familiarized with visual analogue scale and test reading was taken preoperatively. At baseline  were evaluated for post hemorrhoidectomy. Mean age in Group-A was 44±10.45 and mean age in Group-B was 43±10.84. Out of 83 patients in Group-A 55 (66.27%) were male and 28 (33.73%) were female. In Group-B male and female ratios were 56 (67.47%), 27 (32.53%) respectively.rd degree hemorrhoids and 17 (20.5%) 4th degree hemorrhoids. In Group-B 68 (81.9%) out 83 patients were with 3rd degree and 15 (18.1%) with 4th degree hemorrhoids. The pain range in 3rd and 4th degree hemorrhoids were 5-7 and 6-7 on 1st operative day and 3-5 & 4-6 on 7th operative day on VAS scale respectively.Out of 83 patients in Group-A 66 (79.5%) had 3st day before surgery and at 7th day after surgery, pre and post interventions were applied of topical and oral metronidazole compared between two groups , so there was a significant reduction in pain on 7th postoperative day. Stratification of mean pain with respect to ages was insignificant whereas between genders inside the groups showed significant difference.This study showed that in Group-A mean pain was 3.04±1.41 on 7The reasons of topical metronidazole were local effects and quick action with better compliance as compared to oral metronidazole with delayed onset and decreased drug provision due to first pass effect while direct vascular permeability and access locally for topical metronidazole at the site of application. Looking at the above statistics and results of this study, we strongly advocate to use topical metronidazole as it improved the patients post-operative pain and reduced morbidity. In our country it is not widely used too.Studies show that metronidazole reduces postoperative pain13p≤0.04) as compared to placebo.The study by Neogi P et al. indicates that metronidazole  significantly reduces postoperative pain on day 3, 7 but showed no difference in between oral and topical metronidazole.More male patients (66.9%) were included than females (33.1%). This is because of the social norms where female are reluctant to talk about their disease. Topical metronidazole 10% ointment was not available in our setup and had to be prepared by a local pharmacist.The study concluded that mean pain score after topical metronidazole is less than oral metronidazole in post Milligan Morgan hemorrhoidectomy patient.STA provided concept/research design and did data collection, subjects & editing of manuscript.AR, NA did statistical analysis and manuscript writing.IC did editing of manuscript and project management.TH, NH did data collection, subjects and provision of facilities/equipment.AR, NA takes the responsibility and is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


Pain is the primary symptom of chronic pancreatitis (CP) and remains a considerable therapeutic challenge. In patients with obstruction of the pancreatic duct, including stones and strictures, endoscopic treatment with or without preceding extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct decompression. The rationale for these procedures is based on the assumption that obstruction of the pancreatic duct leads to ductal hypertension and pain. However, clinical pain symptoms correlate poorly with pancreatic duct morphology, and the evidence for pancreatic duct decompression as an effective treatment for pain is based on case series and comparison between different procedures. No randomized, prospective, sham-controlled trials are currently available. The SCHOKE  trial is a randomized, sham-controlled trial designed to determine if pancreatic duct decompression is an effective treatment for pain in patients with CP.The SCHOKE trial is a randomized, single-blind, parallel-group, sham-controlled trial designed to evaluate the effect of combined ESWL and endoscopic treatment for pain in patients with CP. In total, 106 adult patients with painful CP and pancreatic duct obstruction will be randomized to combined ESWL and subsequent endoscopic treatment or corresponding sham procedures. The primary outcome is pain relief during the 3-month postrandomization period as documented in a pain diary. Secondary outcomes include quality of life and functional scores, patient global impression of change, change in use of analgesics, frequency of hospitalization, and complications. Standard follow-up is at 3 and 6 months after randomization. In an experimental substudy, quantitative sensory testing obtained before and after intervention will be used to obtain information on central pain processing and to develop models for prediction of treatment outcome.The SCHOKE trial investigates if pancreatic duct decompression, obtained by combined ESWL and endoscopic treatment, is effective for pain treatment in patients with CP.ClinicalTrials.gov, NCT03966781. Registered on May 25, 2019.Protocol date and version identifier: March 1, 2020; version 3.0.Sponsor: Rupjyoti Talukdar, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India. Pain is the primary symptom of chronic pancreatitis (CP) and remains a considerable therapeutic challenge . In patiRecent meta-analyses have documented that nonspecific effects of invasive procedures are generally large, particularly in the field of pain-related conditions and for endoscopy-based therapies , 16. ForAlbeit endoscopic treatment or surgery is widely used for pain in CP, these treatments are only effective in a subset of patients , 19, 20.Quantitative sensory testing (QST) can be used to investigate the state of the pain system. The technique is based on the rationale that different neural pathways and networks can be explored using standardized stimulation with simultaneous recording of the evoked pain response by psychophysical and/or objective methods . Due to The study protocol is reported in accordance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines  and midterm (6 months) pain relief in patients with CP compared with a sham procedure. In addition, we hypothesize that QST can be used to predict the outcome of treatment. Hence, patients with evidence of widespread sensitization of central pain pathways are hypothesized to have a worse outcome after ESWL and endoscopic treatment than patients with no evidence of widespread sensitization.We are conducting a randomized, single-blind, single-center, parallel-group, sham-controlled, prospective trial designed to evaluate the effect of combined ESWL and endoscopic treatment for pain in adult patients with CP. The study will be conducted at the tertiary care academic Asian Institute of Gastroenterology in Gachibowli, Hyderabad, India.A diagnosis of chronic calcific pancreatitis diagnosed using the Mayo Clinic diagnostic criteria . Both diAge ≥ 18 years.Chronic abdominal pain characteristic for CP with a pain intensity > 3 on a 0–10 visual analogue scale (VAS) and meeting the criteria for chronic pain (pain ≥ 3 days per week for ≥ 3 months).Obstruction of the pancreatic duct due to intraductal stones with dilation of the duct proximal to the obstruction, as determined by magnetic resonance cholangiopancreatography (MRCP) or abdominal computed tomography (CT).The patients must be able to read and understand the provided informed consent form.Patients must personally sign and date the informed consent document, indicating that he/she has been informed of all pertinent aspects of the trial.Patients should be willing to comply with the scheduled visits, clinical and experimental assessment plans, and other trial procedures.Patients with any clinically significant laboratory abnormalities that, in the opinion of the investigator, may increase the risk associated with trial participation or may interfere with the interpretation of the trial results.Previous history of pancreatic surgery, ESWL, or ERCP.Patients with a pancreatic stricture on cross-sectional imaging prior to study enrollment.Active alcohol or illicit drug dependency.Patients with evidence or history of medical or surgical disease of importance for this study as judged by the investigator.Patients must not have painful conditions other than CP that make them unable to distinguish the pain associated with CP from chronic pain of other origin.Presence of pancreatic head mass, multiple strictures, large ascites, and/or large fluid collections.Patients will be randomly allocated to either combined ESWL and endoscopic treatment or sham treatment.Patients enrolled in the active treatment group will be subjected to ESWL followed by ERCP. In India, patients with CP typically present with large pancreatic stones that tend to be dense and spiculated. In order to ensure complete stone clearance, ESWL and ERCP are therefore performed together and in agreement with clinical practice in most centers , 31.ESWL will be conducted with the patient under epidural anesthesia. For epidural anesthesia, bupivacaine will be used to block the T6–T12 thoracic spinal segments. The patient’s eyes will be lightly covered during the procedure. Once epidural anesthesia is achieved, the patient will be given a light sedation, and ESWL will be performed using a third-generation Dornier dual focus lithotripsy system , providing a maximum of 5000 shocks at the rate of 90 shocks per minute. If complete stone clearance is not achieved during the first ESWL session, a second session will be scheduled the following day.After lithotripsy, stone fragments will be removed during an ERCP procedure. An endoscopic pancreatic sphincterotomy will be performed, and complete stone removal will be attempted with registration of pancreatic duct clearance. If cannulation fails after a maximum of five attempts, the patient will be subjected to precut sphincterotomy. In case a pancreatic duct stricture is identified during the ERCP procedure that was not detected by MRCP prior to enrollment, the stricture is dilated and followed by pancreatic stent insertion. A pancreatic duct stent will also be inserted in case of incomplete stone removal during the ERCP procedure.Patients undergoing pancreatic duct stenting will be referred for a new ERCP procedure after 6 months for stent exchange or removal . When complete runoff of contrast material is observed after removal of the stent and an extraction balloon can be passed through the pancreatic duct, endoscopic treatment is considered completed, and further stenting will be stopped. Persistent strictures will be treated by repeated endoscopic dilations and sequential insertion of new stents in agreement with the European Society of Gastrointestinal Endoscopy guidelines .In the sham/control group, patients will be given a transient superficial pinprick sensation to give the feeling of epidural anesthesia prior to sham ESWL. Subsequently, the lithotripsy machine will be switched on, without establishing any form of contact with the patient’s body. The patient’s eyes will be lightly covered during the entire procedure. Following sham ESWL, patients will be subjected to sham ERCP with duodenal intubation of the endoscope and examination of the papillary area, but no pancreatic ductal intervention will be performed.Patients will be instructed not to change their regular pain treatment during the trial period. Regular pain treatment will be recorded twice: at the screening visit and at the last visit. Rescue pain medication, taken on an “as needed basis,” is allowed throughout the trial period, and its use will be documented and quantified in the pain diary. Patients with exocrine pancreatic insufficiency will remain on enzyme replacement therapy during the trial period and follow-up.The study consists of a clinical part and an experimental part. The clinical part of the study aims to investigate the pain-relieving effects of combined ESWL and endoscopic treatment in patients with painful CP in comparison with sham treatment. The experimental part of the study aims to evaluate if QST profiles obtained prior to ESWL and endoscopic intervention can be used for prediction of treatment outcome.The primary clinical endpoint is pain relief. Average and maximal daily clinical pain intensity scores will be recorded in a patient pain diary based on a 0–10 VAS, with registration of the baseline pain intensity scores done in the week prior to intervention and weekly recordings continued for a 3-month period after intervention. Mean values of pain scores will be calculated over 1 week to adjust for day-to-day variability in pain intensity. The difference in pain scores between patients receiving active treatment (ESWL and ERCP) and sham treatment are compared, with the primary comparison of average pain scores 3 months after intervention. Weekly telephone interviews from a study coordinator will be undertaken to facilitate accurate registration and compliance pain score.Difference between groups in pain scores after 6 months.The ratio of responders versus nonresponders defined by a decrease in the average clinical pain score (VAS) of 30% after 3 and 6 months compared with baseline.Difference between groups in number of pain-free days after 3 and 6 months.Change in analgesic consumption (if used) after 3 and 6 months compared with baseline.Difference between groups in total number of hospitalizations during the study period.Difference between groups in total duration of hospital stays during the study period.Difference in total loss of working days due to CP between groups during the study period.Difference between groups in cumulative cost attributed to CP-related treatment and disability (loss of working days) during the study period.Difference between groups in quality of life using the European Organization for Research and Treatment of Cancer Quality of Life questionnaire after 3 and 6 months .Difference between groups in pain and physical functioning composite scores of the modified Brief Pain Inventory–short form after 3 and 6 months .Difference between groups in depression and anxiety scores of the Hospital Anxiety and Depression Scale after 3 and 6 months .Patient global impression of change after 3 and 6 months .Assessment of complications resulting from interventions during the study period.Muscle pressure stimulation Bone pressure stimulation (tibia bone)Temporal summation to repetitive pinprick stimulations of the pancreatic area (T10) and control area [dominant forearm])Conditioned pain modulation (CPM)The following experimental pain measures will be employed prior to intervention as well as 24–48 h and 3 months after intervention to characterize changes in pain processing induced by the assigned procedures:The study is powered to detect a minimal difference between groups of 30% in the average clinical pain score 3 months after intervention . On the Randomization is performed using an automatic assignment system that conceals allocation. Block randomization is employed with randomization of six patients per block to equal proportions for sham procedures or combined ESWL and endotherapy. No stratification of randomization based on demographic or clinical variables will be applied. The allocation sequence will be generated by a biostatistician who will not be involved in the administration of treatment or recording of data. Randomization of patients into the two groups will be done by a physician who will not have access to the clinical data of the patients.The patients will be blinded to the treatment received. The patients in the sham procedure will be provided a superficial needle prick with a sterile needle to mimic epidural anesthesia. Then the ESWL instrument will be started so that the patients get an auditory perception that the treatment is being provided. The patient’s eyes will be covered, and if the patient wishes, he or she will be given light sedation. The operator cannot be blinded, owing to the nature of the study. However, the principal investigator and the statistician will be blinded to the treatment arms.In case of an emergency that necessitates knowledge of the procedure allocation, the individual procedure assignment for each patient will be available. The codes will be available at the study center in sealed envelopes that are stored in a locked and secured area accessible only to those individuals authorized by the investigator. This procedure allows unblinding of individual subjects, without revealing codes of the entire study. The investigator will be able to determine which procedure a patient was given by opening the sealed envelope with the corresponding randomization number. The investigator must state the reason why the code was broken on the envelope and must date and sign it. At the end of the study, all sealed and unsealed envelopes must be accounted for.At baseline, the following assessment parameters will be registered Fig. : age andThe follow-up duration is 6 months from randomization with scheduled visits after 3 months (primary study period) and 6 months (follow-up). The questionnaires and pain diary used for collection of clinical endpoints are described in the previous sections on primary and secondary clinical endpoints. In addition, QST profiles will be recorded prior to intervention as well as 24–48 h after and 3 months after intervention. A schedule for the study assessment parameters is provided in Fig. Recording of temporal summation to repetitive pinprick stimulations in the pancreatic and control areas (midline volar site of dominant forearm) will be employed using a 256-nm von Frey hair . Pain ratings using a 0–10 numerical rating scale will be obtained after a single application and after the last application in a series of ten repetitive stimuli with an interstimulus interval of 1 s. For accurate timing of the stimuli, the procedure is guided by an auditory signal using a metronome. The difference between the last and the first pain ratings of the ten stimuli will be recorded as the temporal summation score.2 will be used for the pressure stimulations. Pressure will be increased in two separate sessions at a rate of 30 kPa/s until the PDT or PTT is reached. The assessment parameter is the pressure at the predefined sensory threshold measured in kilopascals.The pressure pain detection threshold (PDT) and pain tolerance threshold (PTT) will be determined for the following skin dermatomes: C5 (clavicula), T10 ventral , T10 back (pancreatic viscerotome), L1 (anterior superior iliac crest), and L4 (the quadriceps 15 cm above the patella). All lateralized pressure stimulations will be applied on the patient’s dominant side. An electronic pressure algometer  with a probe surface area of 1 cmThe dominant hand is immersed in an ice-chilled water bucket (2.0 °C ± 0.3 °C). The patient will be told to remove the hand from the water after 2 min of immersion or sooner if the pain is intolerable. The patients rate the pain intensity for every 10 s during the cold pressor test using a 0–10 VAS. If the patient withdraws their hand sooner than 2 min because of intolerable pain, the VAS will be considered to be 10 for the remaining period of time, and the time for withdrawal of the hand will be noted.CPM is a clinically measurable form of descending pain modulation that can be induced experimentally by a conditioning stimulus (the cold pressor test) and quantified by applying a “test pain” (pressure stimulation on the nondominant quadriceps musculature 4 cm above the patella) before and after the conditioning stimulus . The difCross-sectional imaging (CT and MRCP) will be used to evaluate the pancreatic morphology prior to study enrollment based on usual clinical practice. All patients enrolled in the study will have their imaging parameters reviewed and described by an expert radiologist (Dr. Ashirwad).t tests or Wilcoxon rank-sum tests as appropriate. The predictive value of the QST profiles will be analyzed using logistic regression models.The primary analysis of clinical endpoints will be by intention to treat, meaning that all randomized patients are included in their initially assigned study arm, regardless of adherence to the study protocol. Experimental endpoints will be evaluated by per-protocol analysis, meaning that only patients completing the experimental setup will be included. A repeated measures linear mixed effects model will be used for the primary analysis and will include terms for treatment group, assessment time point (week), and the interaction of treatment with assessment time point. Summary statistics of pain scores will be provided for the individual time points, and the difference in pain scores between groups after 3 months is considered the primary efficacy parameter. Subgroup and covariate analyses will be performed if applicable and in case differences in patient subgroups deemed clinically relevant are evident. Subsequent analyses directed at the secondary, experimental, and safety endpoints are analyzed using appropriate statistics, including mixed effect models, Fisher’s exact tests, and Student’s n = 40) have been randomized and have completed 6 months of follow-up, using a two-sided significance test with the O’Brien–Fleming spending function and a type I error rate of 5%. An independent statistician, blinded to the treatment allocation, will perform the interim analysis. The statistician will report to an independent data and safety monitoring board (DSMB). The DSMB will have unblinded access to all data and will decide on the continuation of the trial and report to the internal review board of the Asian Institute of Gastroenterology. If there is a highly significant difference in improvement in pain in the treatment arm, then all subsequent patients will be subjected to this. The trial will not be stopped in case of futility, unless the DSMB advises otherwise during the course of safety monitoring.We plan to conduct an interim analysis after approximately one-third of patients  will be constituted. The DSMB will conduct periodic monitoring to ensure that the protocol and good clinical practice standards are followed. The monitors may review source documents to confirm that data recorded on case report forms are accurate. The investigator and institution will allow the DSMB and appropriate regulatory authorities direct access to source documents to perform this verification. The trial site may be subject to review by the institutional review boards, and/or to quality assurance audits performed by the DSMB, and/or to inspection by appropriate regulatory authorities. The DSMB will also conclude on the planned interim analysis.There is no anticipated harm or compensation for trial participation. The ESWL and ERCP procedures on patients with CP are currently used in daily clinical practice, and participation in the study is not expected to be associated with an increased risk of adverse events compared with standard clinical care. Following ESWL, we have observed mild erythema at the site of stimulation. There has been a very infrequent incidence of acute pancreatitis after the procedure. Because ERCP is associated with an increased risk of post-procedure acute pancreatitis, means to decrease this risk  will be used in high-risk patients.Pain is the primary symptom of CP and is associated with poor health-related outcomes, including reduced life quality, disability, and increased health resource use –39. PainThe mechanisms responsible for pain in patients with CP are multifactorial, and thus it is to be expected that no treatment can effectively relieve pain in all patients . IdentifIn conclusion, the SCHOKE trial is a randomized, sham-controlled trial that investigates whether pancreatic duct decompression is effective for obtaining pain relief in patients with painful CP.ClinicalTrials.gov on May 25, 2019 (NCT03966781). The first patient was randomized by January 4, 2020, and recruitment is expected to be completed July 1, 2021.Ethical approval has been obtained, and the trial was registered with Additional file 1. SPIRIT 2013 checklist: recommended items to address in a clinical trial protocol and related documents.


To assess the efficacy of healing touch (HT) for reducing pain and promoting wound healing in patients undergoing total knee replacement (TKR).The experiment will be implemented from December 2020 to December 2021 and was granted through the Research Ethics Committee of Huaihua First People's Hospital (3928/823). 60 patients are included in the study. The recruitment criteria of patients includes:1.the willingness and ability to finish the anxiety and pain questionnaires;2.the clinical indication of TKR on the basis of medical history and physical examination; and3.above the age of 60 years.The exclusionary criteria includes1.unable to cooperate with the postoperative evaluation and treatment;2.revision of TKR;3.diagnosis of the rheumatoid arthritis; and4.having surgical complications.The measurement of pain is conducted by the visual analog scale, while the levels of anxiety is measured with the State-Trait Anxiety Inventory. For all data, they are analyzed through using the software of IBM SPSS Statistics for Windows, version 20 .Table 1 indicates the comparison of clinical outcomes between the control group and study group.HT appears to reduce the postoperative pain and improve patient satisfaction after TKR. More than half a million TKRs were reportedly completed in the United States in 2016, which indicated the growing demand in the future. TKR can improve the function of knee joint and relieve pain. Nevertheless, it is related to the early postoperative pain owing to extensive soft tissue manipulation and bone resection.,5 In addition, impaired wound healing is also a severe postoperative complications which can cause surgical site infection. Recently, more and more articles have concentrated on the role of nursing in TKR.,8 Nurses are the major link in the assessment of individual impact of interventions, intervention management and pain evaluation.Total knee replacement (TKR) is a kind of surgical method to treat the degenerative joint disease of knee. The addition of biofield energy healing therapies such as HT that affect intentionally the patients energy field and environmental energy field can be incorporated into care, offering the healing atmosphere, helping to manage a variety of negative symptoms, and then generally supporting the process of healing. The goal of HT is to accelerate the rehabilitation process of the patient through restoring the balance of the environmental and patients energy system. It is utilized to relieve anxiety and pain, reduce depression, speed the healing of wound, promote relaxation, and increase the well-being of patients. HT is a kind of non-invasive treatment method with no known side effects. Some evidence have suggested that HT may possess some positive effects.,12 However, few articles have introduced the HT in TKR. Thus, we conduct this randomized controlled study protocol to evaluate the influence of HT on pain relief and wound healing in patients undergoing TKR.Healing touch (HT) provides the nurses with a non-pharmacological technology to improve the prognosis of patients and establish contact with patients.2The experiment will be implemented from December 2020 to December 2021 at Huaihua First People's Hospital. The experiment was granted through the Research Ethics Committee of Huaihua First People's Hospital (3928/823) and recorded in research registry (researchregistry6253). Before the registration, the patients who are recruited receive written informed consent. Sequence of random numbers is generated by a computer. Sequentially numbered sealed opaque envelopes are used for the concealment of random numbers. All the patients participating in this study are randomly divided into control group and study group, with 30 patients in each group.2.1Sixty patients are included in the study. The recruitment criteria of patients includes:1.the willingness and ability to finish the anxiety and pain questionnaires;2.the clinical indication of TKR on the basis of medical history and physical examination; and3.above the age of 60 years.The exclusionary criteria includes1.unable to cooperate with the postoperative evaluation and treatment;2.revision of TKR;3.diagnosis of the rheumatoid arthritis; and4.having surgical complications.2.2All patients receive a fully cemented posterior stabilized TKR with patellar resurfacing. All TKRs are performed by a single orthopedic surgeon. In study group, the patients are given 4 HT sessions through 1 of 2 certified practitioners of HT. Although HT intervention aims at reducing the postoperative anxiety and pain, in HT group, the patients receive analgesic opioids in a same way as the control group patients. HT practitioner utilizes the light touch to carry out the techniques of HT. Each HT treatment lasts about 45 minutes. The first treatment is conducted immediately after the operation in postanesthesia care room. The following HT courses are performed once a day in care unit, between 2 daily physiotherapy courses, within about 2 hours after the administration of pain medication. In post-anaesthesia care room, all the patients receive the patient-controlled analgesia (PCA) at a demand morphine dose of 1 mg with an interval of 6 minutes for atresia. The follow-up adjustments of PCA setting are not limited via the research scheme. And in control group, the patients do not receive the HT courses.2.3The visual analogue scale is utilized for the measurement of pain and it is expressed as the 10 cm long line with “LEAST Possible Pain” on the left and “WORST Possible Pain” on the right. The levels of anxiety are measured with the State-Trait Anxiety Inventory. It is widely utilized in the clinical practice and investigation, and it is designed for the self-management. Opioid consumption is also recorded.2.4t-tests and χ2-tests are respectively utilized to analyze the categorical variable and continuous variable. P value less than .05 indicates that there is statistical significance.The analysis of all the data are conducted with the software of IBM SPSS Statistics for Windows, version 20 . Afterwards, all the data acquired are represented through the appropriate characteristics, e.g., standard deviation, and mean, median as well as percentage. And independent 3Table 4,14 The management of postoperative pain remains a fascinating topic for decades. Opioids are generally utilized as the adjunctive therapy for postoperative pain. Nevertheless, side effects associated with opioids are often occurred such as hypotension, respiratory depression, nausea and vomiting, increasing the hospital stays.,16 Proper control of postoperative pain is beneficial to early postoperative recovery and better functional prognosis. HT is a kind of treatment initiated by nurses. It may improve the control of postoperative pain, restore the balance of the energy field of patient, and then promote the self-healing. It utilizes the non-invasive technology that uses the gentle touch and hand to clean, stimulates and balances the energy fields of human and environment, thereby affecting emotional, physical, spiritual and mental health for healing.,18 As a complement to traditional health care, it is utilized in collaboration with other health and therapeutic approaches. This protocol may guide the subsequent randomized trial to investigate the effect of HT in patients with TKR.As far as we know, this is the first randomized control study aiming to assess the safety and effectiveness of HT on the pain relief and the improvement of patient satisfaction in primary TKR. With the population ages, the occurrence of knee osteoarthritis is increasing, and TKR is a successful treatment which is widely performed.5HT appears to reduce the postoperative pain and improve patient satisfaction after TKR.Pingfang Liu plans the study design and writes the manuscript. Chengfeng Qiu reviews the protocol. Juan Yao collects data. All authors approve the submission.Conceptualization: Juan Yao.Data curation: Juan Yao.Funding acquisition: Pingfang Liu.Investigation: Chengfeng Qiu.Methodology: Chengfeng Qiu.Writing – original draft: Pingfang Liu.Writing – review & editing: Chengfeng Qiu.


Treatment of postoperative pain remains a significant clinical problem, and prediction of patients with a risk of higher postoperative pain levels is an important focus. We aimed to identify patients undergoing total hip arthroplasty (THA) with risk of higher pain levels at 24 h postoperatively by using four simple and easily available clinical tools.p-value < 0.01 as statistically significant and for other outcomes a p-value of 0.05.This prospective observational cohort study included 102 patients having THA at Zealand University Hospital in Denmark. The following predictive tools were investigated for identifying patients with higher postoperative pain levels at 24 h postoperatively, both at rest and during mobilization: preoperative pain by peripheral venous cannulation (PVC)  (primary outcome); the post anesthesia care unit (PACU) nurses’ expectations of patients pain levels; patients early pain levels at the PACU; and patients own forecast of postoperative pain levels. The Mann-Whitney U test was used to analyze comparisons between prediction groups. For the primary outcome we considered a p = 0.10; and for pain at rest: PVC-Low 2 (0–3) ) versus PVC-High 3 (2–5) ), p = 0.12. Other comparisons performed between predictive groups did not differ significantly.We found no significant differences between the PVC groups for pain during mobilization at 24-h postoperatively: PVC-Low: 6 (4–8) ) versus PVC-High: 7 (5–8) ), In this prospective cohort study of 102 THA patients, we did not find that preoperative pain by PVC, when using a cut-off point of NRS ≤ 2, were able to predict postoperative pain at 24 h postoperatively. Neither did PACU nurses’ prediction of pain, patients forecast of pain, nor did maximum pain levels at the PACU.NCT03439566).Retrospectively registered 20th February 2018 at ClinicalTrials.gov ( Despite considerable efforts in optimizing postoperative pain, this clinically important symptom remains a major challenge . It is tA newer study indicated that pain intensity by preoperative peripheral venous cannulation (PVC), using a grouping according to numerical rating scale pain (NRS) ≤ 2 and > 2, was associated with pain levels at the post anesthesia care unit (PACU) . This stNurse’s prediction of patient outcomes has been investigated in different settings but with varying results , 6. TherAs patients may be predisposed to certain levels of postoperative pain due to e.g. sex, preoperative pain, genetic variations , anxietyA recent study reported that 47% of patients correctly predicted their pain levels 2 weeks after hand surgery, but they did not investigate the prediction of acute postoperative pain . A subseTotal hip arthroplasty (THA) is a surgical procedure of which patients’ have reported moderate to severe postoperative pain . TherefoThis prospective observational cohort study was approved by the Danish Data Protection Agency (REG-158-2017) and first posted at ClinicalTrials.gov (NCT03439566) on 20th February 2018. The Research Ethics Committee of the Capital Region was consulted, but approval was not needed according to Danish law (Reg. nr. J.nr. 17–000048). Consecutive data was collected at Zealand University Hospital, Koege (ZUHK) in the period from January 2018 to February 2019. The head nurse and chief physician from the orthopaedic department at ZUHK accepted departmental participation in the study, including the collection of patient data. The manuscript follows the STrengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines . The parThe participants were enrolled after giving verbal and written informed consent when attending the pre-scheduled surgical and anesthetic information meeting about 2 weeks before to surgery.Inclusion criteria were: age ≥ 18 years old, speaking Danish and/or English, and scheduled for primary elective THA in spinal anesthesia. Exclusion criteria were: not able to-cooperate according to investigators judgement, alcohol or drug abuse, or if correct placement of the PVC was impossible. No investigational intervention was initiated during the study. The department followed the usual local protocols for postoperative pain treatment and standard of care. Two surgical specialists performed all the THA procedures. The lateral surgical approach was used for all patients.Primary outcome was: numeric rating scale (NRS) pain (0–10) during mobilization at 24 h postoperatively.Secondary outcomes were: NRS-pain at rest at 24 h postoperatively, and 24 h intravenous morphine equivalent consumption, mg.A correctly placed PVC was defined as a cannula placed in a vein on the dorsum part of the dominant hand. The NRS score was performed during the first attempt otherwise the patients were excluded. The allowed cannula sizes were 20G or 22G.All patients received spinal anesthesia (10–15 mg bupivacaine). The standard analgesic treatment that was provided for patients at the hospital was: perioperative methylprednisolone IV 125 mg (after induction of anesthesia). At the POTA patients were supplied with opioids as needed, according to usual practice. At the ward, postoperatively, paracetamol 1000 mg OR every 6 h, and slow-release oxycodone 10 mg OR administrated twice a day, supplemented with oxycodone IV as needed.Patients’ psychological profile and relation to pain were tested using the validated self-administered questionnaire, Pain Catastrophizing Scale (PCS). The scale includes 13 items and assesses the extent of the patient’s catastrophizing thoughts and emotions associated with pain. Such thoughts or feelings are rated from zero  to five . The PCS has a maximum score of 52. A clinically relevant cut off for being a pain catastrophizer was considered as numbers above 30 .When PACU nurses were asked to state if they predicted a patient to be a high pain responder or not, they were also asked to tick a box with the following statements underpinning their choice: patients’ appearance, patients’ pain intensity, my own intuition, patients’ need of opioids, the patient’s expression of concern and anxiety, or optional additional information – described in their own words.For evaluation of pain, the NRS-scale was used, 0 to 10 (0 = no pain and 10 = worst imaginable pain). All patients were instructed preoperatively in how to use the NRS tool . The patAt inclusion, patients completed the PCS questionnaire and provided information about years of education after high school, civil status, employment, as well as their forecast of pain levels. The anesthesia nurse at the operation theater, who performed the peripheral cannulation, asked patients’ about the levels of NRS pain after placement of the PVC. The nurses on the PACU collected data on NRS pain after the spinal anesthesia had ceased, as well as performed a prediction of which patients they believed would experience moderate or severe pain at 24 h during mobilization. The primary investigator, a project nurse or research assistants performed the data collection at the ward at 24 h +/− 2 h postoperatively for pain and opioid consumption.The following information was registered from the electronic patient records. Preoperative data: height, weight, sex, American Society of Anesthesiologists physical score (ASA), usual preoperative analgesic consumption and pre-medication. Perioperative data: analgesic and antiemetic treatment, duration of surgery. Postoperative data: analgesics used from 0 h to 24 h postoperatively, and length of stay (LOS). All data were registered in the CRF, imported to the statistical package IBM SPSS version 25, and the final data set was double-checked for errors.The patients also filled out a diary from postoperative day one to five at home regarding pain, side effects, use of analgesics and quality of sleep. These data will be reported elsewhere.A sample size estimation was performed for NRS pain during mobilization based on data from a prior study that investigated a similar patient population . To reduPain by preoperative PVC dichotomized to NRS ≤ 2 (PVC-Low) or NRS > 2 (PVC-High)PACU nurses’ prediction of patients being a high pain responder or not Maximum NRS pain at the PACU dichotomized to NRS ≤ 3 / > 3  Patients reporting of being a high pain responder or not For comparisons we defined groups based on the following:p-value < 0.01, and for other outcomes, a p-value < 0.05, as statistically significant. Bonferroni correction was used to counteract for mass-significance where relevant.Normal distribution was tested visually in histograms and Q-Q plots and quantitatively with Kolmogorov-Smirnov test. Data are presented with either numbers or percentages, median (IQR), mean (SD), and 95% CI, where relevant. Mann-Whitney U test (for non-parametric data) was used to analyze all comparisons between groups: PVC-High versus PVC-Low, Nurse-Low versus Nurse-High, Forecast-Low versus Forecast-High, and PACU-NRS ≤3 versus PACU-NRS > 3. For the primary outcome we considered a We performed an exploratory multiple linear regression, both adjusted an unadjusted analyses, using a dependent variable, NRS pain at 24 h during rest or mobilization, and adjusting for the following pre-defined covariates: sex, age, patients pain threshold, marital status, education, daily analgesic consumption, PCS, and employment status. To test for the possibility of multicollinearity, Pearson r for parametric data and Spearman rho for non-parametric data was used.For evaluating and comparing predictive models we calculated Receiver Operating Characteristic curves (ROC). The true positive rate in the model (sensitivity) was plotted against the false positive rate (1 – specificity) for a given cut-off value of the predictive variable, thus aiming to determine the optimal cut-off value. Areas in the interval 0.9–1 represented excellent prediction, 0.8–0.9 good prediction, 0.7–0.8 fair prediction and 0.6–0.7 poor prediction , 17. StaOne hundred and fifty patients scheduled for THA were assessed for eligibility. After exclusions, 102 patients were included in the study for evaluation of the primary outcome. For further information see Fig. The study included 35 males and 67 females, mean age was 69 19) ) years, the surgery lasted in 53 (46–63) ) min, and median LOS was 1  day. For further information, see Table 9   (median (IQR)) mg and Group PVC-High 23 (15–28) (median (IQR) mg (median (IQR), p = 0.20  (median (IQR)) and PVC-High 7 (5–8) (median (IQR)) (p = 0.10) between groups defined by PVC pain. When adjusted for sex, age, patient’s forecast of own pain, marital status, education, daily analgesic consumption, PCS, and employment status, we found a significant difference in standardized Beta NRS (95% CI) 0.24  (p = 0.03) between the groups defined by pain during PVC (Table p = 0.11)  NRS (95% CI)  and Nurse-high: 6 (4–7) (median (IQR)), p = 0.74. No significant differences between groups were found for pain at rest. For 24 h morphine consumption, we found a significant difference between group PACU-NRS ≤ 3: 20 (15–25) mg and PACU-NRS > 3: 26 (18–33) mg (median (IQR)), p = 0.03, Bonferroni adj. See Table For groups based on NRS pain ≤ 3 and NRS pain > 3 at the PACU, we found no significant differences between groups, for pain during mobilization at 24 h postoperatively, PACU-NRS ≤ 3: 5 (4–8) and PACU-NRS > 3: 7 (6–8) (median (IQR)), p = 0.79. No significant differences between groups for NRS pain 24 h during rest and opioid consumption was detected. For further information see Table We found no significant differences between groups Forecast-Low and Forecast-High regarding NRS pain during mobilization at 24 h postoperatively; Forecast-Low: 6 (4–8) and Forecast-High 6 (4–8) (median (IQR)), We performed ROC curves for groups PVC-Low and PVC-High, and its capability of predicting pain during rest and mobilization 24 h, as well as 24 h opioid consumption. Since all ROC had AUC values less than 0.60, we did not consider these to be reliable predictors  for prediction of postoperative pain in a study with 180 patients undergoing laparoscopic cholecystectomy. Here, Persson and colleagues (3) reported that patients with NRS pain > 2 by PVC reported higher pain scores at rest and received more opioids within the first 90 min at the PACU, compared to those with NRS ≤ 2. Furthermore, in a newer and larger study, Persson and co-workers , 20. HowIn a recent study in 563 women having breast cancer surgery, Sipilä and colleagues  found thIn this prospective study it was a strength that all patients had spinal anesthesia and underwent the same surgical procedure, which was performed by the same two orthopaedic surgeons, and with all patients receiving a standardized perioperative pain treatment. This minimizes variations and bias. Furthermore, PVC was performed by experienced anesthesia nurses, and all were placed in the patients’ dominant hand. Also, data at the ward were collected by a limited group of four investigators, reducing observer bias.We used a cut-off point of NRS 2, for the division of groups, based on the study by Persson et al. . The ROCIn perspective, the prediction of postoperative pain levels continues to be an important focus for future research, as individualized pain treatment has the potential to improve patient courses. Such research may well be based on the collection of big data including new types of analyses hereof, biomarkers, neuroimaging, physiological and psychological variables, and clinical data as well. It is possible, that results of studies using simple clinical tools, in the future, might be included in such big data in the guidance of pain treatment. Until then, the focus must be on effective pain treatment, regular assessment of pain with frequently monitoring of patients and their needs.In this prospective cohort study of 102 THA patients, we did not find that preoperative pain by PVC, when using a cut-off point of NRS ≤ 2, were able to predict postoperative pain at 24 h after THA postoperatively. Neither did PACU nurses’ prediction of pain, patients forecast of pain, nor did maximum pain levels at the PACU.Additional file 1. Supplemental Digital Content 1: Opioid conversion.Additional file 2.


Therapeutic radiographers (TRs) are well placed to deliver health behaviour change advice to those living with and beyond cancer (LWBC). However, there is limited research on the opinions of TRs around delivering such advice to those LWBC. This study aimed to explore TRs’ practices and facilitators in delivering advice on physical activity, healthy eating, alcohol intake, smoking and weight management.Fifteen UK-based TRs took part in a telephone interview using a semi‐structured interview guide. Data was analysed using the framework analysis method.Emergent themes highlighted that TRs are mainly aware of the benefits of healthy behaviours in managing radiotherapy treatment related side effects, with advice provision lowest for healthy eating and physical activity. Participants identified themselves as well placed to deliver advice on improving behaviours to those LWBC, however reported a lack of knowledge as a limiting factor to doing so. The TRs reported training and knowledge as key facilitators to the delivery of advice, with a preference for online training.There is a need for education resources, clear referral pathways and in particular training for TRs on delivering physical activity and healthy eating advice to those LWBC. This study provides an insight in therapeutic radiographers’ views on all key modifiable health behaviours for those living with and beyond cancer.The participants worked in different radiotherapy departments, offering insight into the practices among therapeutic radiographers in the delivery of healthy behaviour advice from a wide range of hospitals.Whilst data saturation was reached, the sample size was small and therefore the findings may not be representative of the views of the wider therapeutic radiography workforce.The response rate was low (20.8%), therefore the participants might be more interested in the role of health behaviours in cancer survivorship, which might bias the responses towards a positive view on the role of therapeutic radiographers in delivering advice within their role.It is estimated that 40% of cancer cases are linked to unhealthy behaviours.2–8Despite the potential benefits of healthy behaviours, few people LWBC are meeting the WCRF recommended health behaviour recommendations.13–21Reported barriers among HCPs in providing health behaviour advice for those LWBC, include believing that giving advice was not part of their role, lack of time with patients, lack of referral programmes, lack of resources such as education leaflets for those LWBC and lack of knowledge regarding guidelines and research findings.22TRs are the only health professionals qualified to deliver radiotherapy and play a central role in supporting cancer patients.However, despite these opportunities one survey in the UK among 102 TRs identified that TRs rarely advise patients on the key modifiable health behaviours including smoking, alcohol, healthy eating and exercise.28Challenges remain in translating behaviour change interventions into existing care pathways and practices in a way that is appropriate for use by health professionals.Participants were TRs working in the UK in a clinical role. They had provided their contact details on a previous online survey investigating TR’s practices in delivering health behaviour advice agreeing to be invited for a follow-up telephone interview. An email was sent with an information sheet explaining the research and inviting these TRs. Those who agreed to take part signed a consent form prior to the telephone interview.th interview.Semi-structured individual telephone interviews were carried out between April and May 2019 by a lecturer in therapeutic radiography with an MSc who had completed qualitative interviewing as part of their training (NP). The interviewer had no previous relationship with the study participants. The topic guide see  was base10.1136/bmjopen-2020-039909.supp1Supplementary dataPatient input was not used in the design of the research methods. However, the topic guide was piloted with TRs in the academic setting. Additionally, the topic guide was piloted with two participants and these were included in the analysis.The interview transcripts were analysed using the framework analysis method.10.1136/bmjopen-2020-039909.supp2Supplementary dataThe radiotherapy radiography workforce census in the UK only reports the workforce’s professional grade, and no other demographics.Five main themes were identified: (1) TRs provide behaviour change advice to manage radiotherapy-related side effects; (2) TRs make judgements about when it is appropriate to deliver health behaviour advice; (3) Knowledge and training are key facilitators in the delivery of health behaviour advice; (4) TRs feel patients undergoing radiotherapy treatment seek guidance on health behaviours; and (5) TRs identify themselves as well placed to give health behaviour advice to patients.Most respondents reported that they only provided advice on health behaviours that they believed would minimise radiotherapy-related side effects. This meant smoking cessation and alcohol intake were the two health behaviours TRs mainly advised on.With head and neck patients, we give advice, particularly on smoking and drinking, obviously get worse side effects (TR 6).The only thing we do generally say is about drinking plenty of fluids, avoiding alcohol. But that’s more to do with prostate side effects, bladder reactions and reducing gas (TR 14).Radiographers are comfortable talking about alcohol when it comes to managing side effects (TR 12).No TRs reported advising patients on healthy eating. Some TRs mentioned advising patients on dietary intake but this is to patients who are at risk of losing weight, for side effect management and potential impact on accuracy of radiotherapy treatment delivery.Healthy eating, I don’t tend to discuss too much. A lot of patients have difficulty eating and we are encouraging maintaining weight while on treatment (TR 5).I’m not very sure if healthy eating is important. Any patients where we’re treating, lower GI or pelvis, we would advise them to avoid very high-fibre foods, spicy foods, that might make them have very loose bowels, but other than that we say more or less keep on your same diet. We wouldn’t generally discuss a healthy diet as a standard for all patients. No (TR 15).Some TRs mentioned they advise patients to be physically active, however this was only in the context of managing radiotherapy and cancer-related fatigue.So exercise is one of my main ones that I focus on with all patients, particularly to help with their fatigue (TR 9).Exercise, I say that’s its quite beneficial to help with fatigue (TR 12).I guess when we have patients come in, fatigue is one of the side effects, so we encourage our patients to remain active (TR 15).TRs explained only discussing health behaviours, particularly smoking and alcohol with patients if there were evident indications of a problem. TRs also often reported making a judgement of whether appropriate to advise a patient on a particular health behaviour.So, quite often you can tell if a patient is a smoker, you can smell it, or you can tell by their skin (TR 11).I tend to give advice when you make a judgement of when it’s appropriate, an example might be if a patient smelt of smoke (TR 12).Had patients come in and will smell of alcohol and at that time I’ll say to the patient that it can exacerbate side effects (TR 15).This meant TRs did not provide advice on health behaviours to every patient.But for those patients where it’s not clearly going to benefit them to stop drinking, you would just mention it very briefly. Not every patient will have that information (TR 5).The reported delivery of advice on health behaviours appeared to be matched by knowledge of the benefits among those LWBC.One participant explained how he only appreciated the importance of physical activity in cancer survivorship after attending a talk and being made aware of the evidence.My experience of appreciating the role exercise was from attending a talk. I suppose it was really just highlighting in the studies the benefits obviously of a healthy lifestyle and introducing physical activity for patients on treatment (TR 15).Healthy eating was a topic the participants felt particularly unqualified to deliver advice on, and reported lack of knowledge as a barrier to the delivery of advice on healthy eating.It’s a difficult one, diet, I think. It’s more a knowledge thing. If you don’t have the knowledge about what you can and can’t say, you’re just not going to approach the subject (TR 12).All interviewed said they would welcome postgraduate training on delivering health behaviour advice. The majority expressed a preference for online training to help overcome the barrier of limited time among TRs to attend training.Online, you’re not having to take time out of clinical practice, online is more accessible (TR 6)Participants also mentioned that online training allows for yearly updates and continuous professional development.I think it’d be good (online training) because you can do it in your own time. Because I think that’s sometimes the problem. You have this training once and then maybe it never gets brought up again. So it would be quite handy to have something small, every year, alongside all your other mandatory training (TR 12).Participants did acknowledge that face-to-face training allows for further questioning that’s not possible with online training.I think one-to-one training, because you can ask questions that may not be covered within the online training (TR 1).To overcome the barrier of not all staff being able attend face-to-face training participants suggested it would be useful to train some TRs through face-to-face methods that they could then cascade to other TRs within the radiotherapy department.Maybe some face-to-face with some staff, that they could cascade down, might be useful as well (TR 4).It was also suggested to incorporate training on delivering lifestyle advice into the undergraduate education programme.Certainly, get it into the undergraduate course to start with, making them aware it is part of the role (TR 9).It’s still not something that I can say was primarily covered in the undergraduates’ training about the benefits of healthy lifestyle, you know, there’s no real formal education that I can see (TR 15).Participants also felt knowledge of how to refer patients onto further support would enable them to have conversations on improving health behaviours. With some TRs reporting that lack of knowledge of resources and referral pathways are barriers to initiating a conversation on behaviour change.There needs to be more information available to professionals of where exactly you can refer patients to, whether that be website, whether that be an app (TR 13).That’s the only reason why they [therapeutic radiographers] don’t want to open these conversations up, because they don’t know where to go with it or how to refer on (TR 9).They also acknowledge that in the short time they have with patients if they had a resource then would be more inclined to advise.Having something on a piece of paper, education and having the resources, if you can do it in 2 min you should be able to slip that in (TR 2).You don’t always have that information at hand, so if it was readily available, I think we’d give out a bit more [health behaviour information] if it was just the case of pointing them in the right direction that would be a quick and easy thing to do (TR 3).Participants also mentioned that getting patients’ perspectives on receiving advice on improving health behaviours should be incorporated into training.I think that would be better coming from the patients themselves, rather than just feedback from what journals, and other literature says (TR 7).If there’d even be patients that would be willing to maybe just even be involved with staff training (TR 3).Many of the TRs also described that patients often ask them for guidance around health behaviour changes, particularly on diet and exercise. This shows that patients see TRs as credible sources of information on health behaviours.We are getting asked the question more and more about weight loss, healthy living, wanting to exercise more (TR 4).It is quite a common thing to be asked at the end of treatment, not so much the smoking and alcohol, I have to say, but diet and exercise is certainly something that people commonly ask (TR 3).TRs acknowledged that they are a consistent healthcare member for patients undergoing radiotherapy and have many opportunities to deliver lifestyle advice. Therefore, TRs recognised that they are well placed to deliver health behaviour advice to patients.We’re in a unique position because we do see the same patient day after day and you do kind of start to develop a relationship with them (TR 10).I think we’re well placed to help influence patients’ behaviours and it’s something we should be seen to encourage and report (TR 7).We’re in the best position where we see the patients, for a number of weeks every day to encourage any changes (TR 8).From the interviews it appeared that many patients undergoing radiotherapy, excluding those at risk of malnutrition or significant weight loss, are primarily reviewed and assessed by TRs. This highlights that TRs are in an ideal position to deliver advice on health behaviours, particularly when asked about nutrition advice delivery.They routinely see the specialist radiographer, for the breast patients. But they don’t have a dietitian appointment (TR 12).Prostate and breast are two tumour groups that are fully radiographer-led review and about 70% to 80% of our work load. They generally wouldn’t be sent to a dietician (TR 15).Only have a dietitian on board for the head and necks (TR 9).TRs in this study saw themselves as well placed to deliver health behaviour advice, but also reported that they do not routinely provide advice to all patients. TRs were particularly unlikely to provide advice on healthy eating and physical activity, and were more likely to provide advice on those behaviours they believed would minimise radiotherapy or cancer-related side effects. This is in line with previous research among TRs.In some studies, oncology HCPs have reported they do not self-identify as the right person to provide lifestyle advice.15–17et al17All interviews demonstrated that TRs would welcome training on delivering health behaviour advice and recommended it as a key facilitator in delivering advice, in addition to incorporating it into the undergraduate setting. The need for postgraduate training among TRs in delivering health advice has also recently been reported by Charlesworth Those LWBC wish to receive advice on health behaviours from their healthcare teamTRs have a responsibility to educate patients on the importance of following healthy behaviours given the increasing evidence showing implementing healthy behaviours improve a number of physical and psychosocial outcomes after a cancer diagnosis.51 52Of those interviewed in this study it appeared that those with breast, prostate and colorectal cancer are primarily reviewed and assessed by TRs. Therefore, it is the responsibility of TRs to deliver advice on improving health behaviours to these patients. This is also particularly important because the strongest evidence for the benefits of diet and exercise is currently in breast, prostate and colorectal cancer survivors.46This is the first qualitative study among TRs to explore the provision of advice on all key modifiable lifestyle behaviours for those LWBC as per recommendations.This study highlights the need for training and education among TRs on the delivery of health behaviour advice to cancer patients, both in the undergraduate and postgraduate setting. Particularly on the topics of physical activity, healthy eating and weight management. Higher Education Institutions have a responsibility in educating the Allied Health Professional workforce on implementing health promotion within their role.In conclusion, while the majority of TRs delivered some advice on health behaviours as part of their role, advice was mainly on smoking and alcohol intake. Most believed in the value of this advice in managing radiotherapy and cancer-related side effects. Provision of advice was lowest for weight management, healthy eating and physical activity. The findings show a need for training among TRs in delivering advice on improving health behaviours among those LWBC, with TRs reporting a preference for online training in the postgraduate setting.