The long head of biceps tendon is frequently involved in degenerative rotator cuff tears. Therefore, this study explored the clinical results of an isolated biceps tenotomy and identified prognostic factors for improvement in pain and function.Between 2008 and 2017, an arthroscopic isolated biceps tenotomy was performed on 64 patients with a degenerative rotator cuff tear (> 65 years). Primary outcome was patient-perceived improvement in pain and function. Potential prognostic factors for improvement in pain and function were identified.n = 55). A perceived improvement in function was observed in 49% of patients at three months and in 76% of patients at follow-up. Patients with a preoperatively normal acromiohumeral distance (> 10 mm) reported an improvement in pain and function significantly more often. Retraction of the supraspinatus tendon Patte 3 was significantly associated with worse functional outcome.A perceived improvement in pain was reported in 78% of the patients at three months after surgery and in 75% at a mean follow-up of 4.2 years . Degenerative rotator cuff tears are common in the aging population, and most tears are asymptomatic. Some patients may develop symptoms, but conservative treatment is still effective in most cases –3. When The aim of this study was to explore the clinical results of isolated LHB tenotomy in patients with degenerative rotator cuff tears and to identify potential prognostic factors.This is a retrospective longitudinal cohort study.Patients with a degenerative rotator cuff tear treated with an arthroscopic LHB tenotomy between 2008 and 2017 were included. Minimal follow-up was 12 months. Indications for an arthroscopic LHB tenotomy in these patients were a clinically and radiologically confirmed symptomatic degenerative rotator cuff tear, and age above 65 years, and failure of conservative treatment (of at least 6 months) including physiotherapy and cortisone injections, or patients with a symptomatic irreparable rotator cuff tear and failure of conservative treatment (of at least 6 months). Patients with a pseudoparalysis were excluded. Rotator cuff repair was not considered standard treatment for patients above age of 65 years with degenerative rotator cuff tears in our clinic during the study period. Other reconstructive options were considered not suitable, for this, often retired, patient population. If a cuff arthropathy was seen, a RSA was performed. Surgery was performed in a general teaching hospital by two dedicated shoulder surgeons . Patients were excluded when glenohumeral osteoarthritis was observed on plain radiographs, in the case of symptomatic osteoarthritis of the acromioclavicular joint, and if a fracture/dislocation of the operated shoulder occurred during the follow-up period. Approval of the Medical Ethical Committee was obtained (no: 180446), and all patients gave written informed consent. The STROBE guidelines were followed .Arthroscopic surgery was performed in beach-chair position under an interscalene block of the brachial plexus. A posterior portal was used to enter the glenohumeral joint, and routine diagnostic arthroscopic evaluation was performed. An anterior working portal was used for instrumentation. Specific details of the rotator cuff and LHB were recorded for each patient. LHBT tenotomy was performed by sectioning the tendon at the origin at the superior labrum with an ablation device. We noted that in hypertrophic LHBs the tendon did not retract out of the glenohumeral joint after sectioning. In those cases, the intra-articular portion of the tendon was resected. No additional surgery was performed in any of the cases. Postoperatively patients wore a collar and cuff for two days, and passive range-of-motion exercises were started immediately. Active mobility exercises were started two days after surgery, as tolerated.Primary outcome was patient-perceived improvement in pain and function after shoulder surgery, measured with two anchor questions in which patients were asked to indicate on a global rating scale how much their pain (pain anchor) or function  had changed after surgery , 17. TheTwo weeks prior to elective shoulder surgery, orthopedic patients were seen at an outpatient clinic by an independent physiotherapist. The following preoperative demographic and clinical variables were prospectively collected: age, gender, dominant shoulder and duration of shoulder complaints. The DASH score and the VAS pain score at rest and during activity were scored. After surgery, the following data were recorded: classification of type of LHB lesion  and whetThe patients received a print questionnaire at follow-up containing anchor questions about improvement in pain and function, DASH score, VAS pain at rest and during activity, patient satisfaction and the EQ-5D. All follow-up data were collected independently by the research unit of our orthopedic department using standardized case report forms and a study-specific database. If patients were re-operated, they filled in a questionnaire just before the second surgery, including anchor questions about improvement in pain and function, DASH score and VAS pain at rest and during activity. All second surgeries were considered the endpoint of the follow-up for these patients and were subsequently included in the analysis.A standard measurement was performed of the acromiohumeral interval on an anteroposterior radiograph with the arm in neutral position. In this study, a modified classification of the acromiohumeral distance according to Saupe et al.  was usedRetraction of the supraspinatus tendon was scored on an MRI scan using the Patte classification , and fatp values of < 0.05 were considered significant.Patient characteristics are presented as frequency counts and percentages for categorical variables and as mean and standard deviation (SD) for continuous variables. Differences between categorical variables were tested using the Chi-square test and dependent samples t test for continuous variables. IBM SPSS 24 was used for statistical analyses, and Five potential prognostic factors were investigated: retraction of the supraspinatus tendon, fatty infiltration of the infraspinatus tendon, presence of LHB lesion, anterosuperior cuff tear, acromiohumeral interval. Potential prognostic factors were first explored using cross tables and Chi-square tests. For comprehensibility and clinical applicability, categorical variables were computed into dichotomous variables. Variables that had significant associations with outcome measures were tested in multiple regression analyses.The study period included 64 patients. Nine patients were excluded from follow-up: one patient had a traumatic shoulder dislocation with a permanent lesion of the axillary nerve three years after surgery, and one patient sustained a fracture of the proximal humerus one year after surgery. Four patients died before follow-up, and three patients were not able to fill in a postoperative questionnaire due to a cognitive disorder. Figure Of the 55 patients included in the long-term follow-up, mean age was 72.1 years (SD 5.9) at the time of surgery. Demographic, clinical and radiological data at baseline are presented in Table Mean follow-up of these 55 patients was 4.2 years . The clinical outcomes of this study are depicted in Table p < 0.001). Preoperative and postoperative VAS pain scores were available for 40 patients. Pain during activity improved from VAS 8.2 (SD 1.3) preoperative to VAS 3.0 (SD 3.0) at follow up; 65% of patients were satisfied or very satisfied with the result of surgery, with 15% somewhat satisfied. The EQ-5D score was 0.792 (0.157).Both the preoperative and the long-term follow-up DASH scores were available for 30 patients. A significant improvement in DASH score from 46.1 (SD 17.1) preoperative to 26.5 (SD 22.8) postoperative was observed after an arthroscopic LHB tenotomy (p = 0.014 and p = 0.042). For pain, there was major improvement or complete recovery in 90% of patients with a normal acromiohumeral distance (> 10 mm) and in 59% of patients with an acromiohumeral distance ≤ 10 mm.Exploratory analysis showed that patients with an acromiohumeral distance of more than 10 mm reported significantly more often an improvement on the anchor questions for both pain  and function  at long-term follow-up (Retraction of the supraspinatus tendon Patte grade 1/2 (versus grade 3) was significantly associated with functional improvement . Hence, retraction of the supraspinatus tendon negatively influences outcome. No associations between presence of LHB lesion, fatty infiltration of the infraspinatus or anterosuperior cuff tear and anchor questions on pain and function were found. Groups were too small to provide sufficient power for multiple logistic regression analysis. All analyzed factors are depicted in Table Our study shows good short- and mid-term pain relief was observed after arthroscopic LHB tenotomy in most of the elderly patients with degenerative rotator cuff tears and a failed conservative treatment with improvement on both functional and pain specific questionnaires. Acromiohumeral distance and retraction of the supraspinatus tendon were identified as prognostic factors for pain and function at mid-term follow-up. This is the first study assessing the clinical results after isolated LHB tenotomy in patients with a degenerative cuff rupture. This procedure can be a viable option for patients who are not candidate or do not have access to reconstructive surgery such as rotator cuff repair, superior capsular reconstruction or RSA.Walch et al. reported satisfactory results in 87% of 307 patients with degenerative rotator cuff tears after arthroscopic LHB tenotomy at 4.7 years follow-up . In thatThe role of the LHB in shoulder pain has been debated for a long time. Boileau et al. described entrapment of the LHB in patients with degenerative cuff ruptures . They noAcromiohumeral distance appeared to be of great importance in treating patients with symptomatic degenerative rotator cuff tears. Patients in the current study with a normal acromiohumeral distance > 10 mm) reported significantly better improvement in pain and function after LHB tenotomy than patients with a shorter acromiohumeral distance (≤ 10 mm), irrespective of type of LHB lesion. Saupe et al.  studied  mm reporLimitations were the retrospective study design and the absence of a control group. The pain relief observed after LHB tenotomy could be the result of the tenotomy but might also be attributable to a surgical placebo effect, to the postoperative treatment of the physiotherapist or to a benign natural course. Patients included in this study had symptoms for a long period (mean duration of 19.9 months), and most patients were already being extensively treated by a physiotherapist before surgery. Interestingly, the pain relief after LHB tenotomy was already observed within three months postsurgery and was maintained at longer follow-up. This supports the concept of the LHB as a pain generator in patients with a degenerative cuff tear. Furthermore, the improvement in 19.6 points on the DASH score exceeds the minimal important clinical difference (MICD) of 10.8 points . In thisArthroscopic long head of biceps tenotomy in patients with degenerative cuff tears and failed conservative treatment can be a reliable treatment option when the acromiohumeral distance is normal (> 10 mm), with both good short- and mid-term pain relief and functional outcomes. Other treatment options should be considered when the acromiohumeral distance is shorter in patients with degenerative cuff tears.


Both groups also performed eccentric exercises. The main outcome to be measured was the Numerical Pain Rating Scale (NPRS), but the shoulder range of motion (ROM) and trigger point pressure pain threshold (PPT) were also considered. A one-year follow-up was conducted. Significant differences favoring the PE group were found regarding pain at one-year follow-up (p = 0.002). The improvement achieved in the PE group was greater in the NPRS (p < 0.001), proximal PPT, middle PPT, distal PPT  and ranges of movement. PE seems to be more effective than TDN in relieving pain and improving ROM and PPT supraspinatus values in patients with supraspinatus tendinopathy, both right after treatment and at one-year follow-up.Supraspinatus tendinopathy is one of the most common causes of shoulder pain. Many studies support conservative treatments such as exercise, trigger point dry needling or corticosteroid injections. Otherwise, a minimally invasive approach with percutaneous electrolysis (PE) has also been used successfully in shoulder pain, although evidence about its long-term effects is scarce. The aim of this trial was to determine the effects of PE on supraspinatus tendinopathy compared with trigger point dry needling (TDN). Thirty-six patients with supraspinatus tendinopathy were randomly assigned to either a PE group ( Up to 64.3% of disorders of the shoulder area are caused by tendinopathies of the rotator cuff . Among tRegarding evidence on treatment for supraspinatus tendinopathy, eccentric exercises are considered the gold standard followed by manual therapy , althougAbdulla et al. suggests that supervised and home-based progressive shoulder strengthening and stretching are effective for the management of subacromial pain . EccentrAnother technique currently recommended for the management shoulder pain in supraspinatus tendinopathy is Trigger point Dry Needling (TDN). This technique involves dry needling a taut band of a muscle in order to cause a “local twitch response”, which is an involuntary local muscle contraction induced by a spinal reflex . The effPercutaneous electrolysis (PE) is an electrotherapy technique that applies galvanic current through the skin using an echo-guided acupuncture needle . This acThere are few studies on the effectiveness of PE ,17,18,20PE seems to be a clinically effective tool when combined with eccentric exercise to rapidly and durably reduce symptoms ,20, as iFor these reasons, the aim of this trial was to compare the effects of PE with those of a well-established technique such as trigger point dry needling for the management of supraspinatus tendinopathy in patients treated with eccentric exercises. The hypothesis of our work was that treatment by PE is better than TDN in relieving pain and increasing the pressure pain threshold (PPT) and range of motion (ROM) of patients with supraspinatus tendinopathy who are concurrently subjected to eccentric exercise.ClinicalTrials.gov: identifier, NCT03184181; registry completion, April 2019. The reporting of data complies with the Consolidated Standards of Reporting Trials (CONSORT) statement.The study was a single-blinded, prospective and longitudinal randomized clinical trial, conducted in accordance with the Helsinki Declaration and approved by the Ethics Committee of Servicio Andaluz de Salud. The trial is registered at 2) in the insertion zone of the tendon and the humerus when compared with the other side. This pain did not improve when using pharmacology or manual therapy. Patients who had previously undergone any surgical intervention at the arm were excluded from the study, as were those presenting any antecedents of fracture or luxation, those who had suffered from any severe disorder in the month prior to this study, those who had with bilateral affectation, and those who suffered from any cervical radiculopathy or fibromyalgia or who presented any contraindication related to the use of any of the techniques described in this study .In this study, from a selection of 40 adults, finally, 36 participants aged 25–60 fulfilled the following inclusion criteria: they were diagnosed with supraspinatus tendinopathy by obtaining positive results in the Hawkins–Kennedy test, a painful arc test during abduction ,21 and uParticipants were recruited from November of 2017 to January of 2018 in Clínica Santa María, Cádiz, Spain. One of the physiotherapists and the traumatologists held an informative session with all potential candidates in a physical medicine and rehabilitation center where the treatments took place. There, they received comprehensive information about the specifics of the study, as well as about the possible benefits and risks of the interventions. Once informed, participants signed an informed consent form that contained the previously mentioned information as well as their right to withdraw from the study at any moment and without having to justify their reasons.Participants were randomized and assigned to either group, using the Epidat 4.1 software program, with an equal distribution (1:1). The assessing physician remained blind to this allocation (TDN or PE) thanks to the help of opaque envelopes prepared by a different researcher who was at the same time blinded for data collection and intervention. Follow-up was performed at one month and at one year.Calculation of the sample size was based on the data provided for Arias-Buría et al. . From thPain: This was the main outcome of this study. This was measured using the Numeric Pain Rating Scale (NPRS), which assigns a number between 0 (lack of pain) and 10 (the worst pain) to quantify its intensity . The NPRPressure pain threshold: The amount of pressure applied until the subject referred to pain for first time . Accordi®, India), which is a tool validated for this purpose [Range of motion: Another variable measured was shoulder joint motion. For this purpose, a digital inclinometer was used  at an intensity of 350 μA for 1.2 min [®, Boston, MA, Massachusetts, USA)  using a percutaneous electrolysis EPTE 1.2 min  was perfts, USA) . For thiTrigger point dry needling group: A weekly session for four weeks  of dry needling of the upper trapezius muscle towards supraspinatus muscle was held. A different researcher from the one of PE groups performed dry needling according to Hong’s fast-in and fast-out technique with the patient in the decubitus prone position. The upper member to be treated remained in a relaxed position along the body. A dermographic pencil was used to mark the location of the hyperalgesic points on the upper trapezius  that reproduced familiar pain to the patient and where pressure produced the characteristic local twitch response . After tExercise program: As there is not a consensus about exercises for shoulder pain , patientExercise for the supraspinatus: from standing position, the patient performed a shoulder abduction (concentric phase), followed by a slow shoulder adduction (eccentric phase). The patient used elastic bands to achieve proportional resistance. These were fixed to the floor using one foot .Exercise for the infraspinatus: from the seating position and with the elbow resting on the treatment table, the patient performed an external rotation of the shoulder (concentric phase). The initial position was then slowly restored towards an inner rotation (eccentric phase). Resistance was provided by an elastic band, fixed to the floor with one foot .Exercise for scapular global stabilization: in a quadruped position, the patient performed maximal shoulder flexion with an extended elbow (concentric phase) and returned to rest (eccentric phase) .Patients were instructed for 15 min in the first intervention session and were then supervised and corrected when necessary in the following treatment sessions so as to ensure an adequate performance of the exercises mentioned above. They were told not to exceed three points on numeral pain rating scale  while performing the exercises. Whenever pain exceeded three points on the scale during the exercise, a softer elastic band was used.t test were used to analyze the baseline comparability of the groups. A 2X4 mixed-model analysis of variance (ANOVA) was used to examine the effects of the treatment conditions (PE versus TDN), as the between-subjects variable, and time  on the outcome variables. The NPRS at baseline was used as a covariable. The hypothesis of interest was the time-by-group interaction. Eta-squared was calculated to determine the effect size of the group-by-time interaction. Eta-squared is the equivalent in experimental studies of the coefficient of determination R2 and could be interpreted as the proportion of the between-groups differences dues to the effect of the differing treatments. According to Cohen, eta-squared can be deemed insignificant when <0.02, small if between 0.02 and 0.15, medium if between 0.15 and 0.35, and large if >0.35 [Data were described using means and standard deviations for the continuous variables and by frequencies and percentages for the categorical ones. The Kolmogorov–Smirnov test was used to measure the normality of the distributions of the continuous variables. The chi-squared test and Student’s if >0.35 . AdditioOf the 36 participants randomized, all completed the treatment and the follow-up .p = 0.025), and for height, which shows differences in the limit of significance (p = 0.046).The groups were comparable concerning demographic, morphologic and outcome variables at baseline except for NPRS , which sA linear mixed model revealed a significant time-by-group interaction that favored the PE group for flexion, extension, external rotations, NPRS, and all PPTs. There were no significant differences in abduction or internal rotation of the shoulder . The effp < 0.001). As for the TDN Group, there were no significant changes at several time-point measurements concerning the mechanosensibility at hyperalgesic points of both middle and distal supraspinatus region PPTs.This work aimed to analyze the differences between PE and TDN for the improvement of pain, PPTs and ROM in patients with supraspinatus tendinopathy undergoing treatment with eccentric shoulder exercises. The results of our study show more significant improvements in the group treated with PE than in that treated with TDN, with a large effect size for the differences in the PPTs of the proximal and middle hyperalgesic regions of the supraspinatus, and medium, for the pain measured with the NPRS and for shoulder flexion and the distal trigger point PPT. Despite some variables, including pain, showing between-group significant differences, the magnitude of these differences was not very high, being close to the MDC. It also must be considered that the decision of only needling the supraspinatus to obtain a greater comparability among interventions could have reduced the effects of TDN from those obtained in clinical practice, with the additional needling of other trigger points in related muscles.Although the results of the present study seem to be encouraging, studies on PE are still scarce, and we must exert caution before generalizing ,17,18,20The results of this study support those observed by Arias et al. . A similRegarding function, both TDN and PE produced significant improvements in the range of motion in patients with supraspinatus tendinopathy. A comparison between both groups showed significant higher improvements for PE in flexion, extension and external rotation. Patients in the PE group reached the necessary 130° in abduction and 142° in flexion to perform most of daily activities [The data yielded by this study are similar to those obtained when using ultrasound-guided PE to treat other disorders such as epicondylitis  and pateThere are several studies that include information on the potential risk of possible vasovagal reactions ,32,33. SFinally, this study presents several limitations. Firstly, a placebo group would be required to measure any improvement. However, there are remarkable methodological and ethical difficulties in applying invasive interventions as placebo, and for that reason, the comparison with a placebo group has not been considered viable. Additionally, a higher number of result variables would reveal more valuable information on the effects of this treatment, especially those related to shoulder function. Future studies should include other measures of function and pain as outcomes to check the effect of this treatment on these variables. Moreover, recording the exercise that participants performed along the follow-up period would have been useful to assess its relation to the improvements obtained and the adherence. It also must be considered that in clinical practice, not only the supraspinatus muscle is needled; other rotator cuff muscles are also treated, which could present trigger points. Regarding medication intake, participants were asked to avoid any change in their common treatments in order to avoid possible side effects and/or alterations in their usual pain. Finally, it must be kept in mind that both groups performed an eccentric exercise protocol and that further studies should look into how much of the improvement is due to that intervention.Eco-guided percutaneous electrolysis may be more effective, both in the short- and long-term, than trigger point dry needling in improving the shoulder pain, range of motion and PPTs of a group of supraspinatus tendinopathy patients treated with eccentric exercise.


Median VAS score for the maximum remembered pain measured after 30 min was 0. Median differences in angulation between proximal and distal bone fragments before and after the intervention were 0° (p < 0.0001) in the a.p. view and 8.4° (p < 0.0001) in the lateral view. Conclusion: Cast wedging improved the position of forearm fracture fragments at the expense of minimal short-term pain.Background: Although fracture displacement in children is easily treated by cast wedging, no data on pain associated with the procedure are available. We hypothesized that there is no clinically relevant difference in pain before and after cast wedging in children between 3 and 12 years of age. Patients and Methods: This international, multicenter, prospective, observational study included 68 children  aged 3 to 12 years (median age 8 years) with forearm fractures. Cast wedging was performed 5 to 10 days after the injury. Before starting the procedure, we administered a single oral dose of sodium metamizole (10 mg/kg body weight), and the children inhaled a nitrous oxide/oxygen mixture (50%/50%) during the wedging procedure. Pain was rated on a visual analog scale (VAS) 5 to 10 min before incision of the cast as well as 3 to 5 min and 30 min (maximum remembered pain) after inhalation stop. The degree of bending was judged either by the surgeon or was determined on the basis of first signs of pain expressed by the patient. We assessed the effectiveness of the procedure by obtaining X-ray images in two planes after 3 to 9 days. Results: Among the 68 patients, median VAS score before cast wedging was 0. This increased to a score of 1 ( One third of all pediatric fractures involve the forearm ,2,3,4. UIn principle, any axial deviation in the frontal and sagittal plane of the forearm or lower leg can be reduced by cast wedging, so that the remaining angulation resides within the limits of spontaneous correction ,7,8,9,10Fracture treatment under general anesthesia is an alternative technique to reduce residual malalignment of long-bone fractures. However, treatment of these frequent fractures under general anesthesia is questionable because it is associated with several risks, especially in children . To the This international, multicenter, prospective, observational study included 68 children  aged 3 to 12 years  with forearm fractures. The study participants were recruited from outpatients who were followed up after primary conservative treatment of forearm fractures immobilized with a cast.First, we aimed to examine whether there is a clinically relevant difference in pain perception before forearm cast wedging compared to pain perceived 3 to 5 min after forearm cast wedging in children aged 3 to 12 years. Second, we recorded the maximum pain during cast wedging as remembered by the child (maximum remembered pain) 30 min after the wedging procedure. We also compared the radiologic angles measured between the proximal and distal bone fragments before and after cast wedging to determine treatment success.In line with usual procedures, the indication for cast wedging was established by a senior pediatric surgeon or pediatric orthopedic surgeon after obtaining a.p. and lateral radiographs 6 to 10 days after the injury.We included children who suffered fractures with rotational malalignment, shortening, and fracture instability requiring operative stabilization. Patients aged 3 to 12 years were selected for the cast wedging procedure by a senior pediatric or orthopedic surgeon. Written informed consent was obtained from parents or caregivers before entering the child into the study. We included only children in good physical condition according to classification I or II defined by the American Society of Anesthesiologists .Children with intolerance to nitrous oxide or metamizole sodium and/or pre-existing neuromuscular, rheumatic, or musculoskeletal disease were excluded from this study.The study, which was approved by the local Ethics Committee (protocol number: BASEC 2017-02247), was performed at the University Children’s Hospital Basel (UKBB), Switzerland, and the communal Hospital St. Elisabethen, Lörrach, Germany. These centers were selected because the two departments of pediatric surgery employ identical treatment strategies for forearm fractures and have been entertaining a well-established cooperation in clinical and scientific activities. We hypothesized that there is no clinically relevant difference in pain perception before and after cast wedging.The primary study endpoint was the maximum pain experienced 5 min before (PainBE) and 5 min after (PainAF) cast wedging to assess the influence of cast wedging on pain perception. Pain was recorded with a validated visual analog scale (VAS ), where Secondary endpoints of the study included the assessment of maximum remembered pain during the procedure (PainOv) as elicited at 30 min after the intervention. This time interval was selected because some children reported drowsiness shortly after stopping inhalation of the nitrous oxide/oxygen mixture. In addition, angle differences in a.p. and lateral views between the proximal and distal bone fragments before and 3 to 9 days after the wedging procedure were assessed as the secondary study endpoint. Angle differences in a.p. and lateral views before (Angap/lat_1) and 3 to 9 days after (Angap/lat_2) the wedging procedure were measured electronically by two independent, nonblinded radiologists at each study center. To obtain comparable radiographic views, X-ray imaging was standardized by drawing a cross on the cast in line with the laser cross of the radiographic device to ensure consistent rotational position of the forearm and cast. Blinding was not possible because of the radiologically visible gap in the cast. For ethical considerations, necessary actions were taken after each pain measurement, depending on the step within the study .Approximately 30 to 60 min before starting the wedging procedure, we administered a single oral dose of metamizole sodium (10 mg/kg body weight). Split casts were closed before the wedging procedure. The wedging line on the cast was defined by the senior attending physician by clinical judgment , the data were analyzed as a noninferiority trial. The difference between perceived pain after and before wedging was estimated using paired analysis and 95%, confidence intervals (CIs) were calculated. Noninferiority was concluded if the 95% CI did not cross the predetermined noninferiority margin (δ). A clinically relevant noninferiority margin was defined as 1 VAS unit. For meaningful clinical use, the measured number was rounded to the next lower integral number.Our study hypothesis H0 was as follows: Maximum pain 3 to 5 min after wedging (PainAF) is inferior  by at least δ compared to maximum pain before wedging (PainBE), where δ is the clinically relevant noninferiority margin.Data from pilot measurements were used to calculate the sample size. We simulated data for each sample size based on multivariate truncated distributions (truncated to lie between 0 and 10) and analyzed the data according to the primary analysis described below. For each sample size, simulation and analysis were performed 1000 times; the proportion of cases in which noninferiority was shown was taken as the power of the study with the relevant sample size. Sample sizes from 30 to 90 were simulated. With a sample size of 64 participants, the simulation showed an 80% power to determine noninferiority of pain after wedging compared to pain before wedging with a difference margin (δ) of 1 point and significance level of 0.05.Nonadherence to the protocol was expected to be low. Because very few variables were measured and a single visit was necessary during the study, loss of data was expected to be negligible. Therefore, the difference between the intention-to-treat and per-protocol analyses was not taken into account. For missing values, the reasons were recorded.t-test using JMP© Software . The following parameters were recorded and described by summary statistics: age, sex, body height, body weight, pain before wedging, pain 3 to 5 min after stopping inhalation of nitrous oxide/oxygen mixture, maximum pain perception during the whole procedure (secondary endpoint), and angle of the radius fracture before and after wedging of the cast (secondary endpoint). A p-value of ≤0.05 was considered significant.Procedural data were analyzed for normal distribution using the Shapiro–Wilk test. To test for noninferiority of pain after wedging compared to pain before wedging, the differences of pain scores after and before wedging therapy were compared to the noninferiority margin by a paired From June 2018 to April 2020, we enrolled 68 children  with forearm fractures of various types .One additional patient with complete distal diaphyseal radius fracture was excluded because a painful cast had to be removed one day after cast wedging, and this patient could not be followed up. After removal of the cast, the pain subsided, and there were no other complications in this patient.p = 0.015) (Median VAS score 5 min before cast wedging was 0 (IQR 0). This increased to a VAS score of 1 at 3 to 5 min after stopping the inhalation of nitrous oxide/oxygen mixture (IQR 2). This difference was significant (= 0.015) .The median VAS score for the maximum pain remembered 30 min after stopping inhalation of nitrous oxide/oxygen mixture was 0 (IQR 1).One (1.5%) patient achieved a VAS score >4  3–5 min after stopping the inhalation of nitrous oxide/oxygen mixture. The pain subsided to below 4 after oral administration of ibuprofen. Another 2 (2.9%) patients reported a VAS score of 6 for maximum remembered pain as elicited 30 min after stopping nitrous oxide/oxygen inhalation, but these patients did not have a VAS score >4 measured 3–5 min after the wedging procedure .Among patients with marked displacement of bone fragments, 5 of 15 (33.3%) patients with overall angular correction of >15° reported a VAS score of ≥4 measured 3–5 min after stopping nitrous oxide/oxygen inhalation .Maximum remembered pain recorded 30 min after stopping the inhalation dropped to ≤2 in 12/15 (80%) patients. The remaining three patients reported a VAS score of ≤4 at 30 min after stopping nitrous oxide/oxygen inhalation.p = 0.023 vs. p = 0.200 in the preschool group). In school age children, the initial median VAS score of 0 increased to 2 at 3 to 5 min after cast wedging (p = 0.023). Median fracture angulation in these two groups improved by 8.4° on lateral view and 0° on a.p. view (IQR −7° (lat) and −3.9° (a.p.)) (p = 0.67).We grouped our patients into a younger “preschool” group (aged 3–7 years) and older “school age” group (aged 8–12 years). Both groups experienced a change between the VAS scores before and 3 to 5 min after the wedging procedure, although the change was significant only in the school age group ( (a.p.)) . RegardiDespite the current trend towards surgical treatment of forearm fractures in children living in developed countries , cast weCast wedging was first reported in the first half of the 20th century, but studies on cast wedging are sparse. A meta-analysis identified only three studies including a total of 325 patients . AccordiWe performed radiographic controls 5 to 10 days after trauma and decided whether to perform cast wedging or not. Our indications for cast wedging followed the guidelines published by von Laer [We did not notice any angle correction failures after wedging. However, the cast of one patient had to be replaced one day after the wedging procedure due to persisting pain.Samora et al. investigated 61 cast wedging procedures in forearm fractures but applied cast wedging up to the age of 16 years for males and 14 years for females . They obImmobilization for fracture healing in children is not a static process, and changes in alignment can occur over time once tissue swelling decreases, especially if the position of immobilization is not corrected or has been modified. Therefore, even a small correction in alignment during the first 2 weeks after injury can be the decisive factor for fracture healing in acceptable alignment of the bone fragments .Our study had a number of limitations. First, we did not consistently document the wedging site and were thus unable to correlate wedge position with outcome. The wedging procedure used was based on previous experience gained in a pilot study . The pilSecond, we did not assess long-term function of the upper extremity of the children in our study. Thus, we cannot prove that the wedging therapy was necessary in all cases, although we achieved good radiologic outcomes. We successfully shifted most fracture displacements into the range of angulations known to permit spontaneous correction of the deformity. Nonetheless, we were not able to answer the question whether the seven patients in whom only minimal angular correction (≤3°) was achieved would have had a similarly favorable outcome in the absence of cast wedging.Third, due to ethical concerns we were not able to include a control group to prove the superiority of our therapy over cast therapy alone or surgical treatment.Finally, in the absence of a control group, it remains uncertain whether inhaling nitrous oxide/oxygen mixture (50%/50%) was the decisive factor for reducing pain during cast wedging.The strengths of this study include the use of a standardized wedging procedure at both centers and involvement of a small specialist team. Cast wedging therapy is a standardized and well-defined procedure and is part of current pediatric surgical training. Use of the pain VAS according to Hicks  is estabWe showed that cast wedging in children improved the alignment of fracture fragments in distal metaphyseal and diaphyseal forearm fractures with axial deviation at the expense of minimal transient pain. Although we were able to show a significant difference in pain before and after treatment according to our hypothesis, the actual increase from a median VAS score of 0 before to a median VAS score of 1 after treatment was minimal. Moreover, maximum pain remembered by the children at 30 min after the intervention showed no relevant increase of pain compared to the pain they perceived before the intervention.In conclusion, we consider cast wedging an effective and child-friendly therapy of bone fragment misalignment in radius and forearm fractures requiring reduction or prevention of further displacement in the first 10 days after trauma.


Shaping was performed with ProGlider and ProTaper Next, and irrigation was performed with 5% NaOCl and 10% EDTA. Intracanal samples for culture tests were collected before and after irrigation. The microbiological analysis was evaluated by the Kolmogorov–Smirnov normality and Mann–Whitney tests (p < 0.05). A self-assessment questionnaire was used to evaluate the QoL during the 7 days after treatment; differences were analysed with Student’s t-test. Irrigation with the PIPS device was significantly effective in reducing bacterial counts, which were higher for facultative than obligate anaerobic strains, particularly for Gram-negative bacteria, without statistical significance (p > 0.05). There were no significant differences among the QoL indicators, except for the maximum pain (p = 0.02), eating difficulty (p = 0.03) and difficulty performing daily functions (p = 0.02) in the first few days post-treatment. PIPS may represent an aid to root canal disinfection not affecting the patients’ QoL, particularly for the first day after treatment.The aim of this study was to evaluate the ability of a PIPS (photon-induced photoacoustic streaming) Er:YAG laser to reduce the root canal system bacterial count in vivo in comparison to the traditional irrigation technique. The post-operative patients’ quality of life (QoL) after endodontic therapy was evaluated through a questionnaire. Fifty-four patients affected by pulp necrosis with or without apical periodontitis biofilm disease were selected for endodontic treatment and randomly assigned to Group A ( Streptococcus anginosus, S. constellatus, S. intermedius, enterococci and Lactobacillus spp.) are often resistant to chemo-mechanical instrumentation and root canal dressings. In particular, Enterococcus faecalis can frequently be isolated from root canals in the case of failed root canal treatments [Apical periodontitis biofilm disease is a periradicular inflammatory disease related to the presence of bacteria and toxins within the root canal system ,2. Diffeeatments . The onleatments . Previoueatments ,8. Howeveatments . Therefoeatments . The cureatments . Severaleatments ,12. The eatments . Recentleatments . A photoeatments ,15,16. Teatments . Howevereatments ,19,20. TThis randomized controlled clinical trial  was prepared following the CONSORT guidelines  and was Eligibility criteria. Consenting and healthy subjects of both genders were enrolled until the required sample size was reached. The patients presented a first or second maxillary or mandibular molar with a diagnosis of pulp necrosis with or without symptomatic or asymptomatic apical periodontitis biofilm disease. Patients with a sinus tract, periapical abscess or facial cellulitis were not enrolled due to the possibility of confounding the QoL perception regardless of the treatment. Patients with physical or psychological disabilities or an inability to understand the study instructions were excluded. Additionally, patients who had received emergency endodontic care were not included in the study.Interventions. The medical and dental status and history of each patient were collected. Intraoral examination was performed with 3.5× dental loupes. The pulpal and periradicular statuses were assessed with thermal and electric pulp tests , palpation and percussion. The periodontal status was also recorded. Preoperative periapical radiographs were obtained using a Rinn XCP  and a digital Photostimulable Phosphor Plates (PSP) system. The data were processed and archived by a dedicated scanner . Teeth with a loss of lamina dura and periodontal ligament enlargement >2 mm were classified as having lesions of endodontic origin (LEOs). The clinical and radiological data were analyzed by three blinded Assistant Professors within the Endodontic Department, and their concordance was analyzed according to the Fleiss’ K score until inter-examiner reliability (K > 0.70) was expected. Only teeth with primary root curvatures between 0° and 40° in bucco-palatal or lingual vision were included according to the Schneider method, and teeth with excessive calcification were excluded. The American Association of Endodontists (AAE) difficulty form was filled out for every clinical case .All treatments were performed by a single expert clinician with more than 3 years of experience. After local anesthesia, the teeth were isolated with a rubber dam, and the dental surface was disinfected with a 30% hydrogen peroxide solution. After the removal of the carious tissue, an endodontic pre-treatment with composite was carried out, in order to ensure an adequate irrigation reservoir.After the access cavity preparation, each canal was irrigated with saline solution, and the pre-shaping microbial sample was taken using sterile paper cones inserted inside the canal up to the point of engagement with the walls . The first file to bind the canal walls was a K-File with a minimum size #15 up to the root canal middle third, in order to standardize the canal width. Afterwards, for all the canals, a manual canal scouting was performed with K-File #10 (Dentsply Maillefer), a mechanical glide path using ProGlider (PG) (Dentsply Maillefer) and mechanical shaping using ProTaper Next (PTN) X1 and X2 (Dentsply Maillefer) up to the working length (WL). Apical patency was established and confirmed with a size #10 K-File 0.5 mm beyond the apex. The electronic WL (EWL) was recorded with an apex locator  three times: during canal scouting, with a #10 size stainless-steel K-File; at the end of the glide path, with a #17 size stainless-steel K-File; and during shaping after X1, with a #17 size stainless-steel K-file. At the end of the glide path, a radiographic check of the WL was performed, using a #17 size stainless steel K-File. All the canals in both groups were instrumented to the working length with each instrument, except for the ProTaper Next X2, which was kept 0.5 mm shorter than the working length, to reduce the risk of debris extrusion and to ensure homogeneous study conditions between the traditional irrigation group and the PIPS irrigation group. The apical finishing was then completed with K-Files NiTiFlex #25 at the WL.-Thirty seconds of PIPS with a continuous flow of 10% EDTA (5 mL);-Thirty seconds of PIPS with a continuous flow of sterile distilled water (5 mL);-Thirty seconds of PIPS three times with a continuous flow of 5% NaOCl (5 mL) with 30 s pauses between cycles;-Thirty seconds of PIPS with a continuous flow of sterile distilled water (5 mL) as a final step.Irrigation protocol. Before the second sampling after instrumentation, the patients were randomly assigned to one of the two irrigation groups (Group A or Group B) by a single-blinded operator, and the root canals were irrigated in the two groups with alternating 5% NaOCl and 10% EDTA solutions for a total of 10 mL for each. Standard endodontic manual irrigation (Group A) was performed using a 30 G side-vented steel needle  after every instrument before apical finishing. The needle was positioned inside the canal without engagement with the walls and about 3 mm from the working length during the whole process. For the activation of the irrigation solutions, the needle moved with an amplitude of approximately 2 mm. The PIPS group (Group B) was exposed to laser irradiation with an Er:YAG laser , characterized by a wavelength of 2940 nm in exposure intervals of 30 s. The laser was set with frequency values of 15 Hz and an energy of 20 mJ, guaranteeing a total power of 0.30 W. The pulse duration was set to the Super Short Pulse (SSP), equal to 50 μs. During use, the air/water spray of the handpiece was deactivated. The control panel had standard PIPS parameters of 20 mJ and 15 Hz in SSP mode (50 μs), resulting in an average power of 0.30 W . A standThis irrigation protocol was performed after having instrumented the canal with ProTaper Next X2 0.5 mm shorter than the WL, but before the completion of the apical finishing with K-Files NiTiFlex #25, to reduce the risk of the apical extrusion of debris.For all the groups, after a final profuse irrigation with saline solution, the post-treatment microbial sample was taken with sterile paper cones and inserted within the canal up to 2 mm from the WL (2nd sample). Finally, the canals were re-irrigated with 5% NaOCl and dried with paper cones, and the access cavity was sealed with a temporary filling . No occlusal adjustments were performed.Microbiological analysis. Microbial samples collected before (1st sample) and after irrigation treatment (2nd sample) were placed in a sodium thioglycolate broth  and sent to the Bacteriology and Microbiology Laboratory, Department of Public Health and Pediatrics, University of Turin. All the samples were serially diluted 1:10 in normal saline (0.9% NaCl) and plated on selective and differential media to quantify the total microbiota and the number of obligate and facultative anaerobic bacterial strains: in detail, Brain Heart Infusion Agar  was used to determine the number of facultative anaerobic strains, Columbia CNA Agar with 5% Sheep Blood  was used to determine the total number of Gram-positive anaerobic (obligate and facultative) bacterial strains, and Schaedler Agar with Vitamin K1 and 5% sheep blood  and Schaedler Kanamycin-Vancomycin Agar with 5% Sheep Blood  were used for Gram-positive and Gram-negative obligate anaerobes, respectively. All plates were incubated at 37 °C: BHA plates for 24–48 h under aerobic conditions, and the other ones, for about two weeks under anaerobic conditions in an anaerobic system . All the aerobic cultures were examined after 24 and 48 h of incubation, whereas the anaerobic cultures were examined for growth every 3 days. The microbial counts are reported as colony-forming units/mL (CFU/mL).TM technique (Dentsply Maillefer) in association with the use of a eugenol-based canal sealer . A final post-operative radiograph was performed, and a follow-up was established after 3, 6 and 12 months.Post-operative pain self-assessment questionnaire. All the patients were scheduled for a subsequent appointment after 7 days to fill the root canals, and they were dismissed with post-operative instructions and a prescription for optional analgesics. The patients’ post-operative pain (mean and maximum) was assessed through a visual analogue scale (VAS) made of a 10 cm line, where 0 = no pain and 10 = unbearable pain. The patients also received a self-assessment questionnaire, in order to evaluate post-operative QoL within the following 7 days after shaping. The following indicators of the patient’s QoL were used: difficulty in chewing, speaking, sleeping, performing daily functions and social relations and overall QoL. A Likert scale (LS) was used with a numerical value from 0 (none) to 10 (very much). In addition, the analgesic intake, evaluated by the number of analgesic tablets taken in the post-operative period, and the number of days to complete pain resolution were also evaluated. The progressively numbered questionnaires were returned anonymously in a collecting box. Only the principal investigator was aware of the correspondence between the codes and patients and was excluded from the data analysis. The root canal obturation was completed in the second appointment after 7 days with the ThermafilSample size. To detect a difference of 5%  in the post-operative pain values between groups, an alpha-error of 0.05 and a power (1-beta) of 80% were considered, requiring a sample size of 23 patients for each group. In the present study, 27 patients for each group were analyzed.Randomization. The randomized order was obtained using computer-generated tables. The following parameters were considered for randomization to control for potential confounders: the prevalence of pain before treatment, mean pain before treatment and clinical diagnosis. An operator, external from the clinical treatment, prepared blinded envelopes containing the randomized allocation for each patient. The same operator communicated the allocation to the clinician after the initial patient assessment and before root canal instrumentation. The operator was not blinded to the allocation group, as each instrument required a specific technique. However, the randomization, allocation and statistical analysis were performed by blinded operators.p < 0.05). The variation in the QoL indicators in the 7 post-treatment days was assessed using a specific variance analysis model for repeated measures (two groups compared). Student’s t-test was used for the amount of painkillers taken. All the statistical analyses were performed with the SPSS statistical software, version 17.0.Statistical analysis. The obtained data were analyzed descriptively and inferentially. The randomization, group assignment and statistical analysis were performed by a blinded operator. The distribution of the microbial analysis data was evaluated by means of the Kolmogorov–Smirnov normality test. The differences between the groups were analyzed by the Mann–Whitney test (n = 30) and PIPS irrigation . The distributions of occupation, education and socio-economic background between the groups were uniform. Three patients in Group B and two in Group A were lost to follow-up before the second visit, while one patient in Group A required an unscheduled intervention during the observation period, due to a post-operative flare-up. Finally, data analysis was performed on 27 patients for each group . The patient flow and the patients’ baseline characteristics are presented in p > 0.05).A total of 80 subjects were selected for inclusion, and 60 patients were finally enrolled and randomized between traditional endodontic irrigation . The correspondence between the BLR and mean and maximum post-operative pain on Day 1 in both groups is reported in p > 0.05).Microbiological analysis. The results obtained from the microbiological analysis are shown in p > 0.05). Significant results were found between Groups A and B for the following indicators on Day 1 post-operation: maximum pain (p = 0.02), eating difficulty (p = 0.03) and difficulty performing daily functions (p = 0.02) (p > 0.05).Post-operative pain and quality of life indicators. The baseline QoL indicators did not show statistically significant differences between the groups ( = 0.02) . These iThe laser energy exploited with the LAI (laser-activated irrigation) methods has been claimed to improve the effectiveness of endodontic irrigants ,24,25. THowever, a correlation between residual bacteria at the end of the instrumentation and the post-operative pain did not emerge. Therefore, it can be assumed that the presence or absence of residual bacteria in the canal is not the direct cause of post-operative pain and worse QoL perception. It is likely that the onset of post-operative pain may be related to the extrusion of debris or irrigant solution beyond the apex ,36. TherBased on the present results, the PIPS method could be considered a viable system for endodontic disinfection, especially in the case of simplified operational protocols and reduced instrumentation times. The improvement of endodontic disinfection systems is a key step for an ever increasingly modern, easy, fast and minimally invasive treatment plan, despite the traditional irrigation protocol, which continues to be extremely competitive with regard to effectiveness in reducing bacterial infections.


Postoperative pain is the most prominent concern among surgical patients. It has previously been reported that venous cannulation-induced pain (VCP) can be used to predict postoperative pain after laparoscopic cholecystectomy within 90 mins in the recovery room. Its potential in predicting postoperative pain in patients with patient-controlled intravenous analgesia (PCIA) is worth establishing. The purpose of this prospective observational study was to investigate the application of VCP in predicting postoperative pain in patients with PCIA during the first 24 h after laparoscopic nephrectomy.One hundred twenty patients scheduled for laparoscopic nephrectomy were included in this study. A superficial vein on the back of the hand was cannulated with a standard-size peripheral venous catheter (1.1 × 3.2 mm) by a nurse in the preoperative areas. Then the nurse recorded the VAS score associated with this procedure estimated by patients, and dichotomized the patients into low response group (VAS scores < 2.0) or high response group (VAS scores ≥2.0). After general anesthesia and surgery, all the patients received the patient-controlled intravenous analgesia (PCIA) with sufentanil. The VAS scores at rest and on coughing at 2 h, 4 h, 8 h, 12 h, 24 h, the effective number of presses and the number of needed rescue analgesia within 24 h after surgery were recorded.rs = 0.64) and during coughing (rs = 0.65), effective times of pressing (rs = 0.59), additional consumption of sufentanil (rs = 0.58). Patients with venous cannulation-induced pain intensity ≥2.0 VAS units reported higher levels of postoperative pain intensity at rest (P < 0.0005) and during coughing (P < 0.0005), needed more effective times of pressing (P < 0.0005) and additional consumption of sufentanil (P < 0.0005), and also needed more rescue analgesia (P = 0.01) during the first 24 h. The odds of risk for moderate or severe postoperative pain  was significantly higher in patients with venous cannulation-induced pain intensity ≥2.0 VAS units compared to those <2.0 VAS units.Peripheral venous cannulation-induced pain score was significantly correlated with postoperative pain intensity at rest  center on July 6 2019 and received the registration number:  Postoperative pain is the most prominent concern among surgical patients. If not adequately controlled, it will affect postoperative rehabilitation, health-related quality of life, and may develop into persistent long-term pain –3.Current postoperative pain management strategies apply a standardized, one-size-fits-all approach to all patients. These standardized protocols are not suitable for the significant difference in patient’s pain and may lead to insufficient analgesia in patients with high analgesic needs, or excessive analgesia, which is accompanied by increasing analgesic-related side effects. The ability to preoperative predict who is at risk for developing moderate or severe postoperative pain might allow anaesthetists to optimize pain management by offering personalized, stratified or targeted analgesic treatment protocols. Preoperative pain prediction methods are highly relevant in this regard.Numerous studies have tried to identify patients who are at risk for postoperative pain in the preoperative period and evaluated the role of psychological factors and experimental pain tests or quantitative sensory tests (QST) –8. HowevPeripheral venous cannulation, a routine procedure of preoperative preparation, induced pain intensity could be assessed easily and rapidly before surgery without specific equipment or training. It was recently shown that peripheral venous cannulation-induced pain (VCP) intensity could be used to predict the risk of postoperative pain. Patients with VCP score at or above 2.0 VAS units reported higher levels of acute postoperative pain intensity and more often have moderate or severe postoperative pain within 90 mins in the recovery room [chictro.org .This prospective clinical observational study was approved by the Institutional Scientific Research and Clinical Trials Ethics Committee of the First Affiliated Hospital of Zhengzhou University (ref.: 2019- KY-120) and registered at 2, and scheduled to undergo laparoscopic nephrectomy under general anaesthesia, agree to use postoperative analgesia pump for 48 h after surgery, agreed to cooperate and signed the informed consent were recruited.Patients who were classified as American Society of Anesthesiologists (ASA) physical status I-II, aged between 18 and 65 years, all genders, BMI 18 to 28 kg/mPatients with the following conditions were excluded: severe heart, lung and metabolic diseases, hepatic or renal dysfunction, a history of neuromuscular system disease, mental illness, and a tendency to malignant hyperthermia, preoperative existing pain, long-term use of sedative and analgesic drugs (> 3 months), drug or alcohol abusers, or severe hypertension, poor understanding or communication difficulty, failed venous cannulation, changed in surgical approach  for them and instructed on the use of PCIA bump. On the day of surgery, an experienced nurse inserted a peripheral venous catheter  with a standard-size (1.1 × 3.2 mm inner diameter) into a superficial vein on the back of the patient’s hand in the preoperative preparation room. The patients were asked to estimate, on a horizontal VAS ruler, their maximum pain intensity associated with this procedure, recorded to one decimal point (0.0–10.0). Then the nurse recorded the VAS score estimated  by the patients, and dichotomized the patients into low response group (VCP score < 2.0 VAS units) or high response group (VCP score ≥ 2.0 VAS units). The nurse was aware of whether the patient was to take part in the study.2, noninvasive blood pressure was established. Before the induction of anaesthesia, the patients were given IV Penehyclidine Hydrochloride 0.5 mg, and a loading dose of dexmedetomidine with 0.5 μg kg− 1 was infused over 10 min. The bispectral index (BIS) was used to monitor the depth of anaesthesia. Then anaesthesia was induced with midazolam 2 mg, sulfentanil 0.5 μg kg− 1, etomidate 2–3 mg kg− 1. Cisatracurium 0.2 mg kg− 1 was given to facilitate endotracheal intubation. Anaesthesia was maintained with sevoflurane (1–2%), remifentanil 0.1–0.3 μg kg− 1 min− 1. The cisatracurium was used to provide a satisfactory level of muscle relaxation. The BIS value was maintained between 40 to 60. The pneumoperitoneum pressure with carbon dioxide was set at 13–15 mmHg, and the EtCO2 was maintained at 35 to 45 mmHg. Thirty minutes before the end of the surgery, sulfentanil 10 μg and flurbiprofen axetil 100 mg were given as postoperative analgesia, and tropisetron 5 mg was given to prevent postoperative nausea and vomiting. At the end of the surgery, sevoflurane and remifentanil were stopped. Immediately after surgery, the PCIA pump was attached to the peripheral venous line by the anaesthetist. Then the patients were sent to the post anaesthetic care unit for anaesthetic resuscitation. All patients were sent to the general ward after being fully awake. Upon arrival in the general ward, all the patients were once again instructed on the use of the PCIA pump and VAS.All patients were anaesthetized by anaesthetists who were blinded to study and did not participate in data collection. Once in the operating room, the standardized monitoring of ECG, SpO− 1 and 5 mg tropisetron, mixed with 0.9% normal saline to a total volume of 150 ml. The PCIA was programmed to deliver a 2 ml bolus on demand, with a lock-out interval of 10 min, and a background infusion rate of 2 ml h− 1. In the ward, patients pressed PCA when VAS score at rest > 3.0. If patients still reported pain or the VAS scores ≥4.0, supplemental rescue boluses of intravenous flurbiprofen axetil injection of 50 mg were administered. The complete history of continuous infusion, bolus infusion, and bolus demand for the PCIA device was downloaded after surgery.The PCIA with sulfentanil regimen was applied to 48 h after surgery. The PCIA regimen consisted of sulfentanil 3.0 μg kgThe study outcomes variables and the vital parameters were recorded at 2, 4, 8, 12 and 24 h after surgery. During the studied period, pain intensity, sulfentanil consumption, pressing times of the PCIA, and the number of rescue analgesia were recorded at above time points. Overall satisfaction index of the patients was recorded at 24 h. Pain intensity was assessed with VAS at rest and during coughing.The primary outcome was maximum postoperative pain scores at rest and during coughing within the first 24 h. The secondary outcome was effective times of pressing, additional consumption of sulfentanil and satisfaction index at 24 h. Also, the number of rescue analgesia within the first 24 h was also measured.Postoperative data collector was blinded to the preoperative peripheral venous cannulation-induced pain score of the patients.The sample size was based on a pilot experiment of 20 cases resulted in our observation that patients with VCP score ≥ 2.0 VAS units was present in 8 out of 20 patients and that mean maximum postoperative pain score (VAS) at rest within 24 h after surgery was 3.9 (± 1.3). Therefore, in order to show a 20% difference between the patients with VCP score ≥ 2.0 VAS units and the patients with VCP score ≥ 2.0 VAS units, the number of patients in each group was expected to be 41 . Since the groups are unequal, assuming a 40% of patients with VCP score ≥ 2.0 VAS units, and allow for up to 15% dropouts, a total of 120 patients (48 patients with VCP score ≥ 2.0 VAS units and 72 patients with VCP score < 2.0 VAS units) would be sufficient to test our hypothesis.t-test. IF the distribution was not normal, the median with inter-quartile range (IQR) were expressed, and a Mann–Whitney U-test was used. Categorical data were expressed as frequency (n) and percentage (%) and were statistically tested using the chi-square or Fisher’s exact test. Correlations between variables were assessed with Spearman’s rank correlation coefficients. Logistic regression analysis was used to evaluate the predictive abilities of cannulation-induced pain intensity. All P values <0.05 were considered to be statistically significant.The IBM SPSS version 22.0 software packages were used for statistical analyses. The normality of the continuous data was tested by the Shapiro-Wilk test. Normally distributed continuous variables were expressed as mean ± SD and compared between groups using a two-sample Student A total of 139 patients undergoing laparoscopic nephrectomy were screened between August and October 2019, of which 19 were excluded because they did not meet the inclusion criteria, refused to participate in the trial, and failed venous cannulation. Among the remaining 120 patients, some were eliminated due to transferred to ICU, converted to open surgery, surgery duration over 3 hours, or incomplete recording, and 106 study patients were available for analysis   , additional consumption of sulfentanil  were statistically significantly correlated with peripheral venous cannulation-induced pain score, respectively.Bivariate correlations between peripheral venous cannulation-induced pain score and outcome variables are shown in Fig. 01) Fig. a, postop01) Fig. b, effectP < 0.0005) and during coughing , needed more effective times of pressing  and additional consumption of sulfentanil , and also needed more rescue analgesia  during the first 24 h. While the satisfaction index was significantly lower .Patients’ demographic characteristics and perioperative data between the two groups are shown in Table P = 0.01).The number of patients experiencing maximum pain (at rest) exceeding 4.0 VAS units during the first 24 h between high response group and low response group were shown in Table After controlling for possible factors affecting postoperative pain , the odds of risk for moderate or severe postoperative pain  was significantly higher in patients with venous cannulation-induced pain intensity ≥2.0 VAS units compared to those < 2.0 VAS units (Table This study shows that peripheral venous cannulation-induced pain score is positively correlated with postoperative maximum pain and addition consumption of sulfentanil during the first 24 h after laparoscopic nephrectomy. Patients with VCP score ≥ 2.0 VAS units are more likely to report higher postoperative pain scores and additional consumption of sulfentanil. Furthermore, patients with VCP score ≥ 2.0 VAS units have a 3.5 times higher risk for moderate or severe postoperative pain.Peripheral venous cannulation, is a routine practice before surgery, has been reported by patients to be painful. The pain intensity is associated with cannula site, cannula size, failed venipuncture attempts and process times , 11. In Prior researchers have also reported similar results to ours. Persson et al.  study reNumerous studies have been developed to predict postoperative pain in the last decade. The pain intensity of QST stimuli, including pressure, electric, and thermal stimulus, have been reported to correlate with the intensity of postoperative pain –8, 14–17Our finding has important clinical implications since pain management in the postoperative period still present a challenge. There is large individual variability in response to opioids and the potential side effects such as respiratory depression, nausea, vomiting and constipation. The ability to preoperative identification of patients at greater risk for moderate or severe postoperative pain and having higher opioids requirements is very beneficial. Using peripheral VCP intensity as a predictor of postoperative pain may allow anaesthetists more convenient to adjust the dosage of opioids and can potentially improve postoperative pain management.There are some limitations to the present study. Known risk factors of postoperative pain are female gender, lower age, preoperative pain, intraoperative factors and psychological factors, and so on , 19–21. In conclusion, peripheral venous cannulation-induced pain score was associated with postoperative pain and addition consumption of sulfentanil during the first 24 h after laparoscopic nephrectomy. Patients with VCP score ≥ 2.0 VAS units had higher postoperative pain scores, additional consumption of sulfentanil and risk for moderate or severe postoperative pain. Therefore, peripheral venous cannulation-induced pain intensity can be considered as a simple and useful method to predict postoperative pain in patients with PCIA during the first 24 h after laparoscopic nephrectomy.


Background: Pain is a core symptom of hidradenitis suppurativa (HS) and is of complex, multifactorial origin. HS patients frequently report typical neuropathic pain qualities, but its prevalence has been poorly described. Methods: In this cross-sectional study, we examine the prevalence of neuropathic pain (NP) component and related pain-characteristics of a hospital-based cohort of patients with symptomatic HS. We administered the pain-DETECT tool (PDQ), a validated screening tool for NP, collecting clinical and patient-reported data on pain, pruritus and pain-management. We obtained 110 complete datasets from symptomatic HS patients –II (45.5%)–III (27.3%)). According to the PDQ tool, 30% of patients were classified with a high probability (>90%) of neuropathic pain (LNP). LNP status was significantly associated with increased pain severity, disease activity, pruritus intensity and use of pain medication. Regression analysis showed a significant impact of the PDQ score on patient-reported outcomes, including pain severity and the dimensions of activity and affective pain interference. HS patients may present a mixed chronic pain phenotype with a neuropathic component, thus requiring additional pain-assessments. A multi-modal approach to pain management, in combination with disease-specific treatment, should be implemented in future interventional studies. Hidradenitis suppurativa (HS) is a chronic, auto-inflammatory skin disease characterized by painful, deep seated, highly inflamed nodules and draining tunnels in the intertriginous areas of the body ,2,3. PaiAmong licensed therapies for HS, only adalimumab, a TNF-alpha antagonist, has been shown to reduce HS-related skin pain both in the short and long-term . PatientDuring a six months period, all patients with a diagnosis of HS attending the specialized outpatient clinics of the Dermatology units of Fondazione Policlinico A. Gemelli IRCCS, Rome and Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, were evaluated for this cross-sectional study. Inclusion criteria for cases were the following: male or female adult patients diagnosed with painful HS disease, presenting active, painful clinical lesions and/or at least one inflammatory episode in the last 24 weeks, undergoing regular follow-up and already enrolled in ongoing institutional patient registries for HS.Patients with long-term stable disease (no flares or pain-free for at least six months) and with a diagnosis of neurologic/psychiatric conditions or in stable treatment with psychoactive medications  were excluded. Disease-specific data were retrieved from the local patient-registry, including standard demographic information, HS-specific clinical information and outcome measures , concomitant medication, including pain-specific medication, and comorbidities . HS sevePain-DETECT questionnaire (PDQ) —The painBrief Pain inventory short form (BPI) is a self-administered questionnaire designed to evaluate pain severity and its functional consequences. Items of the BPI are scored on a numerical rating scale (0 to 10), measuring the level of pain intensity and related interference with general activity  ,20,21. TNumerical rating (NRS) intensity scale for pain and pruritus—Pain and pruritus intensity were evaluated by the patient using a numerical rating scale (NRS), at baseline (at the time of consultation) and with a recall period of seven days for the worst, mean and weakest intensities .Number of skin areas involved by HS and symptomatic body regions, with patient-reported pain and/or pruritus, were also recorded and captured during routine clinical activities. The patients completed a series of validated patient-reported clinical outcome measures (PROMs) to collect information on skin-related neuropathic pain and pruritus. These PROMs are already in use during regular patient consultations, capturing baseline symptoms with a seven days-recall period, and include:Additional information on pain-specific aspects was collected, including pain history/duration, frequency/duration of pain attacks, number of “bed days”  due to HS-related pain in the last 12 weeks, use of pain medication, self-reported non-pharmacologic measures of pain management, referral to a pain specialist, use of conservative-medical treatments for management of HS disease, and use of surgery for HS. Information on pain course  and presence of radiating pain was extracted from the PDQ and reported for descriptive statistics.Because the study was based on an observational design with collection of routine clinical data in local HS-patient registries only, a notification to the Ethical Committee of the two centers was requested.Continuous data were reported with median and interquartile range (IQR), and categorical data were reported with a frequency distribution. The data was tested for normality using Shapiro-Wilk. Differences among PDQ groups-responders, for continuous variables, were tested using the parametric and non-parametric Kruskall-Wallis one-way analysis of variance on ranks, followed by a Dunn’s post-hoc test. Differences in distribution of categorical variables were tested with Chi-square test. Spearman coefficient correlation testing was carried out to analyze correlation between the PDQ-score and clinical parameters  as well as between PDQ-score and PROMs of interest . The effect of the PDQ-score was determined using multivariable linear regression models, with the outcomes of the BPI questionnaire as dependent variables: pain severity, activity interference and affective interference. In the multivariable models, the effect of the PDQ-score was adjusted by sex, age, Hurley stage, extent of painful diseased body areas (> three disease body areas involved), use of any HS-specific medication  and use of biologic treatment . Selection of these co-factors was based on clinical significance and previous evidence from studies on HS-related pain and pruritus. Independent variables were entered in the model with a backwards approach. Multivariable linear regression was used to assess the effect of PDQ score on baseline pruritus intensity score as the dependent variable, adjusting for the cofactors: sex, age, IHS4 score, extent of painful diseased body areas (>3 body areas), use of any HS-specific medication  and use of biologic treatment .During the time period from 1 February 2019 to 30 July 2019, and during the routine clinical care of 380 patients, we enrolled 110 patients with active-symptomatic disease and with complete datasets: 54 (49.1%) females; 30 Hurley I patients (27.3%), 50 Hurley II (45.5%) and 30 Hurley III patients (27.3%). Demographic and clinical characteristics of the enrolled patient cohort are summarized in p = 0.015). Clinical characteristics such extent of disease involvement and disease duration were not different between PDQ groups (p = 0.066). Disease severity, as measured by the IHS4 score, was significantly different across PDQ groups (p = 0.037), with the LNP group presenting an higher disease severity (median IHS4 = 12) than the PNP group (median IHS4 score = 6.5).According to the PDQ, 33 (30%) of 110 patients were classified as “likely neuropathic pain (LNP)”, presenting a PDQ score greater than 18. Thirty-two (29.1%) of 110 patients were classified as having a “possible neuropathic pain” (PNP) component (PDQ score range 13–18), while 45 (40.9%) patients, scoring less than 13 in the PDQ, were considered as having “unlikely neuropathic pain” (UNP) see . There wQ groups . DiffereMore than 80% of patients reported a year-long pain history, in line with the long disease duration of HS and with the chronic pain phenotype. Descriptive features of pain course and pain attacks are summarized in In patients experiencing pain attacks, frequency or duration of episodes were not different between PDQ groups. Notably, 73.7% of patients in the LNP group presented pain attacks with duration of 1–3 or more days, possibly indicating disease flares.p < 0.001) in comparison to the PNP- and UNP-groups (see p < 0.001) than the PNP- and UNP- groups. Both activity and affective pain interference results were higher in the LNP group (p < 0.001) versus the other PDQ groups, pointing at a marked impact on the two dimensions of pain interference. Pruritus was reported by 85 (77.3%) of patients, with no difference between PDQ classes. LNP responders presented higher pruritus intensity scores than PNP and UNP groups (p < 0.001). . .p < 0.0001), activity pain interference , affective pain interference , baseline pruritus intensity scores , but not with disease activity (IHS4) (p = 0.125) and disease duration (p = 0.8595)  see .p = 0.001) (p < 0.001) (p < 0.001) (p = 0.012), activity interference , and affective interference . Hurley stage remained a significant cofactor in the models for the outcomes pain severity  and activity interference .Multivariate regression analysis revealed PDQ-score to be an independent predictor of the outcomes of the BPI pain severity score   and on t< 0.001)  and affe< 0.001) . Of notep < 0.001) and disease activity (IHS4 score)   of patients reported the use of pain-relief medications and only 10% (n = 11) reported a referral to pain specialty clinics. The LNP group was associated with the use of pain-medication (p = 0.013) (n = 23), followed by combination of COX-inhibitors and weak opioid preparations (n = 10) and topical anesthetics (n = 5). Use of strong opioids  for HS-related pain was reported only by two patients. Sixteen patients reported the use of adjunctive pain-medication, including low-dose systemic steroids (n = 14) and anti-convulsivants  (n = 2). Use of specific systemic antipruritic drugs (antihistamines) was not reported. Of note, among self-reported pain management strategies for HS-pain, 24.5% of patients employed cold-based compresses or applications of icepacks. Patients in the LNP group reported less pain-relief from any type of intervention (pain-specific or HS-specific therapeutics) than UNP group (p = 0.0254).In our cohort, 34.5% (= 0.013) . Among pThe results of this study point at a substantial prevalence of a neuropathic-like pain component in patients with active HS disease. Neuropathic pain is initiated or caused by a primary lesion or dysfunction in the central and/or peripheral nervous system and can be induced in chronic pain states by inflammatory and neuroplastic mechanisms . HS is aThe prevalence of a neuropathic pain component in almost one-third of HS patients in our study is in line with the results of a previous retrospective study, also using the PDQ tool. In the study of Huilaja et al. the presence of a “likely” neuropathic pain status was reported in 31.5% of HS patients, especially in cases with psychiatric comorbidities, higher QoL impairment and with moderate-severe pain ratings . In the In our study, the presence of a “likely” neuropathic pain (LNP) component presented a significant association with validated patient-reported outcome measures of pain and pruritus. Patients classified as LNP-PDQ reported increased pain and pruritus scores as well as a pronounced interference in daily activities and affective dimension due to chronic pain. Functional impairment, measured as forced bed-rest days, was also markedly increased in patients with LNP status. Subgrouping HS patients on the basis of the PDQ and thus on their individual pain phenotype helped identify cases with a higher burden of pain and pruritus.The importance of skin-related pain as one of the main outcome measures in HS has been reported only in few observational studies and interventional studies ,27. SkinThe concept of a complex pain phenotype in HS patients, which encompasses a “neuropathic” pain component other than inflammatory-nociceptive, may fit well with the progressive, complex pathogenesis of this disease. Furthermore, in chronic pain states, pain and pruritus can be perceived in parallel or can interact with each other, as both sensations are conveyed by the excitation of cutaneous C-nerve fibers . In our A better understanding of the pathophysiology of pain and pruritus in HS could also improve clinical management, as the use of adjunctive pain medication is poorly described in current CPGs . DiffereThere are several limitations to our study design, including the enrolment of a hospital-based cohort of patients, with selection of more severe cases of HS. Furthermore, we did not explore the role of chronic fatigue, psychiatric comorbidity and diminished quality of life in our patient cohort, as these factors could contribute to the disease burden and modulate pain/itch perceptions in these patients. We excluded patients with comorbid neurological/psychiatric conditions and related medications, in order to minimize the role of concomitant medications and other chronic pain states. On the other hand, psychiatric comorbidity, especially mood, bipolar disorder and schizophrenia, has been increasingly linked to HS in population-level studies and may negatively impact on pain and itch perceptions ,44 ExcluHS patients may present a complex pain phenotype with a neuropathic pain component, thus requiring additional pain-assessments. HS patients should be screened for skin-related neuropathic pain with a clinometric tool, and eventually undergo additional clinical and neurophysiological assessments to confirm the presence of neuropathic pain. Subgrouping of patients on their basis of their pain phenotypes might improve the management of HS disease, identifying patients in need of adjunct pain medication other than HS-specific therapeutics. Longitudinal follow-up studies in HS patients should also explore the stability of pain-phenotypes and evaluate the role of peripheral or central sensitization to pain and pruritus. A multi-modal approach to pain and pruritus management, in combination with disease-specific treatment, should be implemented in future interventional studies for HS.


Background and purpose — Indication for lumbar disc herniation (LDH) surgery is usually to relieve sciatica. We evaluated whether back pain also decreases after LDH surgery.back) and leg pain (Nleg) and by negative binomial regression relative risk (RR) for gaining improvement exceeding minimum clinically important difference (MCID).Patients and methods — In the Swedish register for spinal surgery (SweSpine) we identified 14,097 patients aged 20–64 years, with pre- and postoperative data, who in 2000–2016 had LDH surgery. We calculated 1-year improvement on numeric rating scale (rating 0–10) in back pain (Nleg was preoperatively (mean [SD]) 6.7 (2.5) and Nback was 4.7 (2.9) (p < 0.001). Surgery reduced Nleg by mean 4.5 (95% CI 4.5–4.6) and Nback by 2.2 (CI 2.1–2.2). Mean reduction in Nleg) was 67% and in Nback 47% (p < 0.001). Among patients with preoperative pain ≥ MCID , the proportion who reached improvement ≥ MCID was 79% in Nleg and 60% in Nback. RR for gaining improvement ≥ MCID in smokers compared with non-smokers was for Nleg 0.9 (CI 0.8–0.9) and Nback 0.9 (CI 0.8–0.9), and in patients with preoperative duration of back pain 0–3 months compared with > 24 months for Nleg 1.3 (CI 1.2–1.5) and for Nback 1.4 (CI 1.2–1.5).Results — Nleg and Nback.Interpretation — LDH surgery improves leg pain more than back pain; nevertheless, 60% of the patients with significant back pain improved ≥ MCID. Smoking and long duration of pain is associated with inferior recovery in both N The most common indication for lumbar disc herniation (LDH) surgery is persistent sciatica that does not respond to nonoperative treatment  Weber . A few sIt would also be of clinical interest to identify preoperative factors that are associated with favorable reduction of back pain following LDH surgery such as age, sex, smoking, preoperative health, and duration of pain  evaluated whether back pain is reduced after LDH surgery and if so, to what extent compared with the reduction in leg pain and (ii) what proportion of patients gain improvement in back and leg pain exceeding minimum clinically important difference (MCID). The secondary aim was to identify factors associated with improvement in back pain exceeding MCID. www.swespine.se). In the register the patient reports preoperative anthropometric, lifestyle, and disease-related data such as age, gender, smoking habits (yes/no), numeric rating scale (NRS) for pain in the back (Nback) and leg (Nleg), duration of pain symptoms  and the PROM Short Form Health Survey 36 (SF-36) (rating from 0 to 100). The outcome after the operation is evaluated after 1 year by a similar questionnaire including current NRS pain level in back and leg and SF-36. The surgeon reports data concerning diagnosis, procedure, level of surgery, side of operation, and peri- and postoperative complications. SweSpine has previously been described in detail, including validation, with adequate results , which is a patient register with prospectively collected data. The register covers 98% of all clinics performing lower back surgery in Sweden and has a completeness of 75% . The included patients had undergone open discectomy with or without microscope (87%), decompression with or without microscope (6%), various other types of surgeries (6%), or with type of surgery not reported (0.4%). 5,718/19,815 patients had not responded with postoperative NRS back pain data and were therefore excluded . PatientIBM SPSS Statistics version 26  was used for statistical analysis. Descriptive data are presented as numbers and means with standard deviations (SD) and inferential statistics as proportions (%) or means with 95% confidence intervals (CI). For group comparisons we used a paired Student’s t-test between means for continuous data and a chi-square test for categorical data. MCID was defined as an improvement by at least 2.5 units in NRS back pain and 3.5 units in NRS leg pain . Data sharing plan: the data is available from SweSpine upon request and approval by the registry board. No specific funding has been received for this study. No conflict of interest was declared. leg was before surgery (mean [SD]) 6.7 (2.5) and Nback 4.7 (2.9) (p < 0.001), and 1 year after surgery 2.1 (2.7) and 2.5 (2.7) (p < 0.001) (leg by 4.5 (CI 4.5–4.6) and Nback by 2.2 (2.1–2.2). The relative Nleg reduction was 67% and relative Nback reduction 47% (leg and 2.5 for Nback), that is, patients with significant baseline pain and with hypothetical possibility to improve ≥ MCID, 79% of the patients improved ≥ MCID in leg pain and 60% in back pain (p < 0.001) (N< 0.001) . This cotion 47% . The pro< 0.001) .leg of 0.9 (CI 0.8–0.9) and in Nback of 0.9 (0.8–0.95). Older age (per year increment) had RR of gaining improvement ≥ MCID in Nleg of 0.995 (0.993–0.998) and in Nback of 1.00 (0.99–1.00). Duration of symptom 0–3 months had, compared to > 24 months, RR of gaining improvement ≥ MCID in Nleg 1.3 (1.2–1.5) and for Nback 1.4 (1.2–1.5), and 3–12 months compared with > 24 months for Nleg 1.2 (1.1–1.3) and for Nback 1.3 (1.2–1.4). Sex and quality of life by SF-36 was not associated with either outcome  and successful outcome. Peul et al. (2007) have found a similar 1-year outcome for those operated on early (6–12 weeks’ duration) and those who waited another 6 months.We highlight that our study design could draw inferences only as regards associations. Our results do not motivate LDH surgery on the basis of back pain. We can only use these data to inform patients scheduled for LDH surgery that they have a probability of 60% of having a reduction of clinical significance if they have back pain ≥ MCID. Our view is supported by another registry study that included 2,262 patients, which reported that patients with baseline back pain NRS ≥ 5 (out of maximum 10), also had significant improvement in the back pain by discectomy . However, that study did not evaluate the proportion of patients who reached the MCID level of pain reduction. Further studies should examine whether it is possible to identify sub-groups of patients that will specifically benefit from back-pain reduction by discectomy.Strengths in our study include a large study population, prospectively collected data, and reports of outcome on a national level that identify the results in the general health care system rather than in highly specialized spinal units. Another strength is the absence of exclusion criteria, rendering the actual outcome within general health care, in which patients with comorbidities and relative contraindications for surgery are included. This should be compared with studies that show what it is possible to achieve in selected defined patient cohorts in specialized units with highly trained surgeons (Kotilainen et al. In conclusion, both leg and back pain improve after LDH surgery, leg pain more than back pain. In patients with preoperative pain ≥ MCID, leg pain level was reduced at this level or above in 79% of the patients and back pain in 60%. The preoperative factors that in our model were associated with back pain reduction ≥ MCID by LDH surgery were virtually the same as those associated with leg pain reduction ≥ MCID. Our results improve the ability to provide accurate preoperative information as regards the probability of reaching clinically significant reduction in back and leg pain by LDH surgery.