Facial Pain Scores Research Articles

Comparison Of The Effect Of Two-dose And One-dose Dexamethasone On Post-inflammatory Complications In Third Molar Surgery

Objective: This study aimed to compare the effects of administration of both preoperative and postoperative dexamethasone with that of only preoperative dexamethasone, and with that of a no dexamethasone (control) on reduction of pain, trismus and swelling following lower impacted 3rd molar surgery.
 Methods: A prospective randomized controlled double blinded study at the dental clinic of Babcock University Teaching Hospital on 84 subjects that were divided into 3 groups. Group A had both preoperative and postoperative dexamethasone, while group B had only preoperative dexamethasone and group C was a 'no dexamethasone' group. Differential mean facial swelling, mouth opening and pain scores were compared within the three groups.
 Results: The pattern of postoperative swelling, pain and trismus showed a general decrease from day 1 to 7, with group A showing the highest rate of decrease. On postoperative day 1, there was a difference between the swelling of groups A and C (p =0.01) and groups B and C (p = 0.02) and also between the pain scores of group A and group C (p = 0.01). On postoperative day 3, there was only a difference between the swelling of groups A and C (p = 0.02), but not in pain and trismus and no difference was seen in all the measured variables on postoperative day 7.
 Conclusion: Administration of a combination of both preoperative and post operative dexamethasone to reduce the postoperative inflammatory sequelae that follows lower third molar surgery gave better results than administration of only a single preoperative dose.

Effect of cryotherapy on pain management at the puncture site of arteriovenous fistula among children undergoing hemodialysis

ObjectiveTo evaluate the effectiveness of cryotherapy in managing the pain at the puncture site of Arterio-Venous Fistula (AVF) among children undergoing maintenance hemodialysis (HD). MethodsA one-group pre-post quasi-experiment was performed in two HD centers affiliated with Cairo University. The experiment involved 40 children with AVF undergoing HD. Before puncturing, cryotherapy was applied using 2 cm–3 cm pieces of frozen distilled water in a plastic bag. Pain was assessed subjectively and objectively in two dialysis sessions before and after cryotherapy. A part from a physiological assessment of vital signs, pain was assessed using the Wong–Baker Faces Pain and the Observed Pain Behavior rating scales. All research ethics were applied. ResultsHD had a median duration of four years, while cryotherapy had a median application time of 8.8 min. The Wong–Baker Faces Pain score and almost all observed pain behaviors significantly decreased after cryotherapy. Significant improvements were observed in respiratory rate before and after needle puncture and in oxygen saturation after needle puncture. A lower skin dryness was observed after cryotherapy (12.5%) than before cryotherapy (52.5%; p < 0.001). ConclusionsCryotherapy can effectively reduce the venipuncture pain among children with AVF undergoing maintenance HD. However, the confounding effects of distraction and the non-randomized design used must be both considered when interpreting the findings. This study recommends the use of cryotherapy in managing needle puncture pain. Further research must adopt a randomized trial design with a placebo to support further the benefits of this procedure.

Effect of Different Sedation Regimes on Cognitive Functions in Colonoscopy.

Aim:To compare the effects of propofol/remifentanil and meperidine/midazolam on postprocedure cognitive function.Materials and methods:A total of 100 American Society of Anesthesiologists (ASA) score I to III patients undergoing elective colonoscopy were taken into the study and divided into two groups. Exclusion criteria were patient refusal, mini mental test (MMT) <26, The Amsterdam Preoperative Anxiety and Information Scale (APAIS) >10, advanced cardiopulmonary or psychiatric disease, chronic alcohol abuse, morbid obesity, and known allergy to study drugs. In group MM, 2 mg midazolam and 20 mg meperidine was given intravenously and additional 1 to 2 mg midazolam and 20 mg meperidine (with a maximum total of 5 mg midazolam and 50 mg meperidine) was given when bispectral index (BIS) was >80. In group RP, 100 μg/kg/minute propofol infusion and 1 μg/kg remifentanil bolus was administered and additional 0.5 μg/kg remifentanil bolus was given when BIS was >80. Observer’s Assessment of Alertness/Sedation scale (OAA/S) and Facial Pain Score (FPS) values were recorded. Cognitive function was measured by Trieger Dot Test (TDT) and Digit Symbol Substitution Test (DSST).Results:The study was concluded with 100 patients. Heart rate was slower and BIS values were lower in group RP throughout the procedure. Blood pressure was lower in group RP without clinical significance. There was no difference concerning recovery time and visual analog scores (VASs). In group MM, TDT scores were higher and DSST scores were lower. Satisfaction was higher in group RP.Conclusion:Propofol/remifentanil combination is better than meperidine/midazolam combination concerning cognitive function in sedation for colonoscopy.Clinical significance:The addition of BIS monitorization to evaluate the depth of sedation and the negative effects of midazolam meperidine combination on postprocedural cognitive function.How to cite this article: Ekmekci P, Erkan G, Yilmaz H, Kazbek BK, Koksoy UC, Doganay G, Tüzüner F. Effect of Different Sedation Regimes on Cognitive Functions in Colonoscopy. Euroasian J Hepato-Gastroenterol 2017;7(2):158-162.

Pain management assessment in children with limb fractures in an emergency service

IntroductionThe tool most widely used for measuring the intensity of pain in children is the Faces Pain Score – Revised (FPS-R). Pain management depends on the level of care and the knowledge of the physician regarding dosing, indications and side effects of the medications available for use. ObjectiveTo assess pain management in patients 3–17 years of age with limb fractures using the FPS-R within the first 6h. Materials and methodsObservational cohort of patients 3–17 years of age presenting with limb fractures between October 2013 and January 2014. Patients with comorbidities associated with chronic pain were excluded. The tool was administered four times in accordance with the validated instructions – on admission, at first hour, at three hours and at six hours. ResultsOverall, 60 patients were assessed and 4 pharmacological regimens were identified: dipyrone alone (63.3%), combined therapy with dipyrone plus tramadol (10%), tramadol alone (8.3%), acetaminophen alone (6.6%).The mean pain intensity reduction with the use of dipyrone was 1.7 points on the FPS-R within the first hour, with a mean reduction of 4 points by the end of the six hours of follow-up. With tramadol, pain reduction was 1.6 points and 4.6 points, respectively. The combined use of dipyrone plus tramadol did not result in significant pain reduction within the first hour. ConclusionFracture immobilization is the mainstay for analgesia but it does not suffice as a form of pain management. Monotherapy with dipyrone or tramadol resulted in the best pain reduction, whereas the combined use of dipyrone plus tramadol was not better than the use of either medication alone.

Evaluación del manejo de dolor en niños con fractura en extremidades en un servicio de urgencias

IntroductionThe tool most widely used for measuring the intensity of pain in children is the faces pain score - revised (FPS-R). Pain management depends on the level of care and the knowledge of the physician regarding dosing, indications and side effects of the medications available for use. ObjectiveTo assess pain management in patients 3 to 17 years of age with limb fractures using the FPS-R within the first 6hours. Materials and methodsObservational cohort of patients 3-17 years of age presenting with limb fractures between october 2013 and january 2014. Patients with comorbidities associated with chronic pain were excluded. The tool was administered four times in accordance with the validated instructions – on admission, at first hour, at three hours and at six hours. ResultsOverall, 60 patients were assessed and 4 pharmacological regimens were identified: dipyrone alone (63.3%), combined therapy with dipyrone plus tramadol (10%), tramadol alone (8.3%), acetaminophen alone (6.6%).The mean pain intensity reduction with the use of dipyrone was 1.7 points on the FPS-R within the first hour, with a mean reduction of 4 points by the end of the six hours of follow-up. With tramadol, pain reduction was 1.6 points and 4.6 points, respectively. The combined use of dipyrone plus tramadol did not result in significant pain reduction within the first hour. ConclusionFracture immobilization is the mainstay for analgesia but it does not suffice as a form of pain management. Monotherapy with dipyrone or tramadol resulted in the best pain reduction, whereas the combined use of dipyrone plus tramadol was not better than the use of either medication alone.

Transdermal Fentanyl for Cancer Pain Management in Opioid-Naive Pediatric Cancer Patients.

Transdermal therapeutic system fentanyl with a drug release rate of 12 µg/h should be of special value in pediatric cancer pain control. Such a fentanyl formulation allows for a stepwise dose increase, similar to that reported for sustained-release morphine. Sixty-four male and female pediatric patients with moderate to severe chronic cancer pain, ages ranging 2-14 years, were included. Patients did not receive opioids prior to enrollment. Patients were observed for pain relief using the Visual Analog Scale and the Wong-Baker FACES Pain Rating Scale, play performance score, and for side effects. There was significant improvement of visual analog scale and FACES pain scores from the baseline to the second day of application (P < 0.001). By the 15th day, scores reached 1.18 ± 0.393 and 1.13 ± 0.35, respectively (P < 0.001). Play performance scale improved from the third day of application of the patch when compared with the baseline (P < 0.001), reaching 55.02 ± 8.35 (P < 0.001) at the end of the study. The sedation score increased on the second day to 2 in 10 patients and to 3 in 54 patients. By the seventh day, 56 patients had a sedation score of 1. All patients returned to baseline by the 15th day. Itching was reported in 16 cases, and erythema occurred in 10 cases. No significant side effects were reported. Transdermal fentanyl was found to be an effective, safe, and well-tolerated treatment for pediatric cancer-related pain in opioid-naive patients with chronic moderate to severe pain. In this study population, evaluation of vital signs and physical examination did not suggest any safety concerns while using transdermal fentanyl.

Conchopexy of middle turbinate versus bolgarization in endoscopic sinus surgery

Abstract The aim of this study is to assess the role of simple conchopexy suture in maintaining a widely patent middle meatus during the phase of postoperative healing (and its effect on olfaction); this enables delivery of topical medication and sinus aeration compared with functional endoscopic sinus surgery (ESS) with and without bolgarization of the middle turbinate (MT). This study included 39 patients. Patients were divided into three equal groups randomly; each group included 13 patients. Group A underwent ESS with suture medialization of the MT (method), group B underwent ESS with bolgarization of the MT, and group C underwent normal ESS. Items of comparison between the three groups included both subjective and objective parameters such as symptoms (nasal obstruction, facial pain, and smell) and endoscopy findings. All the patients underwent preoperative and 2-month postoperative assessment with a questionnaire, smell test, and endoscopic examination. In terms of nasal obstruction in all three groups, there was a statistically significant improvement (P = 0.001, 0.001, and 0.002, respectively). Improvement in facial pain was statistically highly significant in group A (P = 0.0007), whereas it improved significantly in groups B and C (P = 0.001 and 0.002, respectively). Improvement in smell was statistically insignificant in all three groups (P = 0.4). The postoperative endoscopy findings improved compared with the preoperative findings in all three groups. MT conchopexy and bolgarization of the MT have no detectable adverse effects on olfaction. No lateral synechia was detected, and there was a highly significant improvement in facial pain scores were observed in patients who underwent concopexy; patients who underwent middle turbinate bolgarization also showed improvement in both aspects, but in a lower percent. Both conchopexy and bolgarization of the MT after conventional ESS may help improve postoperative ostiomeatal complex patency, mucosal healing, and minimize adhesions, with no adverse effect on olfaction.

The revised FLACC score: Reliability and validation for pain assessment in children with cerebral palsy

Background and aimsPain in children with cerebral palsy (CP) is difficult to assess and is therefore not sufficiently recognized and treated. Children with severe cognitive impairments have an increased risk of neglected postoperative, procedural and chronic pain resulting in decreased quality of life. The r-FLACC (revised Face, Legs, Activity, Cry and Consolability) pain score is an internationally acclaimed tool for assessing pain in children with CP because of its ease to use and its use of core pain behaviours. In addition the r-FLACC pain score may be superior to other pain assessment tools since it includes an open-ended descriptor for incorporation of individual pain behaviours. The COSMIN group has set up three quality domains, which describe the quality of Health-Related Patient-Reported Outcomes (HR-PROs). These are reliability (internal consistency, reliability and measurement error), validity (content validity, construct validity and criterion validity) and responsiveness. The r-FLACC score has only been assessed for reliability and validity in the original English version by the developers of the score. The aim of this study is to assess reliability and validity of the r-FLACC pain score for use in Danish children with CP. MethodsTwenty-seven children aged 3–15 years old with CP were included after orthopaedic surgery. Two methods for assessment of postoperative pain were used. Pain intensity was assessed by r-FLACC, with a 2min standardized video recording of the child, and the Observational Visual Analogue Score (VAS-OBS) assessed by the parents. The COSMIN checklist was used as a guideline in the reliability and validity testing of the r-FLACC score. ResultsReliability was supported by three measurement properties. Internal consistency was excellent with a Cronbachs alpha of 0.9023 and 0.9758 (two raters). A factor analysis of the subgroups in the r-FLACC score showed unidimensionality. A test–retest showed excellent intra-rater reliability with an intraclass correlation (ICC) of 0.97530. Inter-rater reliability was acceptable with an ICC of 0.74576. Validity was supported by three measurement properties. Content validity was tested by the originators of the r-FLACC. Construct validity was supported by a significant increase in r-FLACC scores following surgery (n=17; difference 2.23; p=0.0397). Criterion validity was acceptable with Pearson's correlation coefficients of 0.76 and 0.59 when comparing r-FLACC scores and VAS-OBS scores. Conclusion and implicationsThis study benefits from a systematical approach to the validation and reliability parameters by using the COSMIN checklist as a guideline. It is evident that the r-FLACC pain score maintains its psychometric properties after translation. In conclusion, the r-FLACC pain score is valid and reliable in assessing postoperative pain in children with CP not able to self-report pain. With the r-FLACC pain score clinicians have a valid tool for assessing postoperative pain, hence increasing the quality of pain management in children with CP. In addition the validated r-FLACC score has the potential for use in interventional research regarding pain management in this vulnerable group of patients. Future perspectives include validation of the r-FLACC score for procedural and chronic everyday pain and implementation into daily practice.

VPLIV TRAMADOLA NA ZDRAVLJENJE POOPERATIVNE BOLEČINE PO ODSTRANITVI ŽRELNICE IN NEBNIC PRI OTROCIH

Background: Tonsillectomy is one of the most commonly performed surgical prcedures in childhood. Acute pain after tonsillectomy and adenoidectomy can be treated with non-opioid and opioid analgesics. Our hypothesis stated that tramadol iv after induction of anaesthesia has superior analgesic effect compared to acetaminophen.Methods: In a prospective, randomised study we compared analgesic efficacy of tramadol (group T: 2 mg/kgBW iv) and acetaminophen (group A: elixir 15 mg/kgBW before op. procedure) in a group of 108 children (age 3-7 years). Exclusion critheria: allergy, liver or kidney failure, epilepsy, febrile convulsions. A standard anaesthetic technique was used: propofol, alfentanil, vecuronium, positive pressure ventilation with 60% nitrous oxide in oxygen. After the procedure each child received acetaminophen suppositories (10 mg/kgBW/4-6h) and combined suppositories. Monitoring: vital signs during and after op. procedure, pain intensity on the ward (facial pain score). Results: There were no significant differences between the two groups in age distribution (mean age 5,2 years), ASA physical status, body weight, operative procedure, pain scores (VAS 6h after operative procedure; group T: 4,21±1,45; group A: 4,06±1,33), oxygen saturation, pulse frequency and the consumption of acetaminophen suppositories. Significant difference was in the consumption of combined suppositories (group T: 1,85±0,79; group A: 1,43±0,69, p=0,003). Conclusion: Our study has shown, that tramadol is not a superior analgesic for the relief of posttonsillectomy pain in children compared to acetaminophen.

Dexmedetomidine versus ketofol for moderate sedation in Endoscopic Retrograde Cholangiopancreatography (ERCP) comparative study

BackgroundRecently dexmedetomidine had been successfully used in conscious (moderate) sedation as a good competitive to popular agent (midazolam). Different concentrations of ketamine and propofol combinations (ketofol) were used for procedural sedation and analgesia.ObjectivesThe study was conducted to compare two techniques of moderate sedation for patients undergoing ERCP, using either dexmedetomidine or ketofol as regards hemodynamic, sedation, pain, respiratory effect, recovery time, patients’ and endoscopists’ satisfactions, and complications during and after the procedure.Patients and methodsFifty patients were randomly allocated in one of two groups; dexmedetomidine group D (n = 25) received 1 μg/kg i.v. bolus over 10 min followed by 0.5 μg/kg/h or ketamine/propofol (ketofol) group KP (n = 25) received 1 mg/kg i.v. bolus followed by 50 μg/kg/min. The level of sedation was adjusted to achieve a Ramasy sedation scale (RSS) score of 4 in both groups of patients. Mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation (SPO2), and facial pain score (FPS) were compared. Time to achieve RSS, modified Aldrete’s score (MAS) of 9–10 and the related complications were compared between groups. Patients’ and endoscopists’ satisfactions were compared. Total amount of rescue sedation was recorded.ResultsAfter loading dose HR and MAP were significantly lower in group D as compared with group KP (p < 0.05). HR was significantly lower in group D during the recovery (p < 0.05). No significant difference between both groups as regards time to achieve RSS, MAS, FPS and total dose of rescue sedation. Personnel restraint was significantly lower in group KP (8% versus 20%) than in group D. Endoscopists’ satisfaction was significantly higher in group KP than D group (92% and 80%) respectively.ConclusionKetofol (1:1) provided better hemodynamic stability than dexmedetomidine and standard alternative to it in moderate sedation during ERCP.

Laryngeal Mask Airway versus Endotracheal Tube Intubation for Repairing of Nasal bone Fracture: A 7 Year Single Institution Case-Control Study

Introduction: Closed reduction nasal fracture is a common and well established procedure in the otolaryngology literature. The Laryngeal mask airway (LMA) is being used more frequently for otolaryngologic procedures in recent years because it has been proven safe for select procedures especially in the pediatric population. The frequency of closed reduction nasal fracture repair and the increased propensity to use LMA anesthesia for otolaryngologic cases warrants investigation. Objective: We sought to investigate the benefits, risks and safety of using LMA anesthesia for pediatric patients during closed reduction nasal fracture compared to case controlled equivalents that underwent ETT intubation. Methods: We performed a retrospective case-control study in which all cases of closed reduction nasal fracture at a single pediatric institution by a single surgeon were studied. This included patients from 2007 to 2013 at Ann & Robert H Lurie Children’s Hospital of Chicago. The primary outcomes assessed were postoperative VAS and FACES pain scores, blood loss, cough, stridor and aspiration. Secondary outcomes assessed included timing data to determine if one technique led to greater optimization of operating room (OR) time and/or total hospital stay. The timing data included overall OR duration, prep to cut time, cut to close time, non-operative OR time and the total hospital stay in minutes. Results: Fifty patients met the inclusion criteria. Of the 50 patients included an endotracheal tube was used in 16 patients and a LMA was used for 34 patients. Two of the LMA group 2/34 (6%) had aspiration documented compared to zero of the ETT group. The average total length of hospital stay was 268.5 m when both groups were included. The average total hospital stay was 252.6 minutes for the LMA group and 312.4 for ETT group. The average postoperative VAS pain score, as documented 0-10 by the RN, was 0.47 for the LMA group as opposed to 0.56 for the ETT group. A total of 24 patients had cough noted, 15/34 (44%) of the LMA group and 9/16 (56%) of the ETT group. Ten patients had stridor noted, 5/34 (15%) of the LMA group and 5/16 (31%) of ETT group. Conclusion: These results support the hypothesis that using an LMA versus an ETT for short procedures does save time when assessing overall hospital stay. Additional benefits of the LMA are reduced cough, pain, stridor and ease of placement. The data also supports our second hypothesis that using an LMA for close reduction nasal fracture can lead to more frequent post operative airway obstruction when compared to the ETT. Our data and review suggest that it is the combination of deep extubation (lack of airway protection) and the use of an LMA (allows for blood accumulation) that result in the increase risks of airway obstruction postoperatively. For operations in the pediatric population with a significant risk of bleeding into the pharynx we recommend using an ETT due to the risks of aspiration. If an LMA is used we recommend to only removing the LMA after the patient has been deemed in the state of anesthesia which is awake. For short cases with a low risk of immediate post operative bleeding into the pharynx, we are proponents of the LMA due to its’ time saving effect.

English

Propofol is commonly used newer induction agent of choice with smooth and rapid recovery from anaesthesia. It has one adverse effect which is restricting its use i.e. pain during injection. We in present study are comparing Ondansetron with Lignocaine to alleviate pain during injection of Propofol, as ondansetron is routinely used to prevent post-operative nausea and vomiting, so it can have both effects viz prevention of pain on injection of Propofol and prevention of post-operative nausea and vomiting. The aims of study were to evaluate incidence to alleviate pain during injection of propofol, efficacy of Ondansetron & Lignocaine to alleviate pain during injection of propofol, incidence and severity of pain in Ondansetron and Lignocaine group, incidence of side effects in both groups. MATERIAL AND METHODS: The present study was carried out in S.R.T.R. Govt. medical college and hospital Ambajogai after ethical committee approval. 120 patients of ASA grade I and II of either sex undergoing short surgical procedures requiring general anaesthesia without endotracheal intubation were randomly allocated to three equal groups of 40 patients each :Group I: Received 0.9% Normal saline (2ml) as pretreatment, Group II: Received 2% lignocaine hydrocloride (2ml) as pretreatment, Group III: Received 4mg ondansetron (2ml) as pretreatment. EXCLUSION CRITERIA: patients with history of allergy to propofol, neurological disorders or altered sensorium or those on anti-psychotropic medication and patient with cardiac conduction abnormalities. It was pre decided that patients with sedation score of >3 would be excluded from study, however none of the patients in our study had sedation of >2 with 1/4 th calculated dose of propofol. Assessment of pain was done using Verbal Pain score and Face pain score. OBSERVATION: Statistical analysis was done by ANOVA test while comparing 3 groups and by Z test while comparing group II & III. Incidence of pain was more in control group than study groups & difference was statistically significant. There was no significant difference in adverse effects. CONCLUSION: Pretreatment with either Lignocaine or Ondansetron can be used to alleviate incidence of pain on Propofol injection with cardiovascular stability and minimal side effects.

Dexmedetomidine versus midazolam for conscious sedation in endoscopic retrograde cholangiopancreatography: An open-label randomised controlled trial

Background:Traditionally, midazolam has been used for providing conscious sedation in endoscopic retrograde cholangiopancreatography (ERCP). Recently, dexmedetomidine has been tried, but very little evidence exists to support its use.Objective:The primary objective was to compare haemodynamic, respiratory and recovery profile of both drugs. Secondary objective was to compare the degree of comfort experienced by patients and the usefulness of the drug to endoscopist.Study Design:Open-label Randomised Controlled Trial.Methods:Subjects between 18 and 60 years of age with American Society of Anaesthesiologist Grade I-II requiring ERCP were enrolled in two groups (30 each). Both groups received fentanyl 1 μg/kg IV at the beginning of ERCP. Group M received IV midazolam (0.04 mg/kg) and additional 0.5 mg doses until Ramsay Sedation Scale (RSS) score reached 3-4. Group D received dexmedetomidine at loading dose of 1 μg/kg over 10 min followed by 0.5 μg/kg/h infusion until RSS reached 3-4. The vital parameters (heart rate (HR), blood pressure (BP), respiration rate, SpO2), time to achieve RSS 3-4 and facial pain score (FPS) were compared during and after the procedure. In the recovery room, time to reach modified Aldrete score (MAS) 9-10 and patient and surgeon's satisfaction scores was also recorded and compared. Any complication during or after the procedure were also noted.Results:In Group D, patients had lower HR and FPS at 5, 10 and 15 min following the initiation of sedation (P<0.05). There was no statistically significant difference in BP and respiratory rate. The procedure elicited a gag response in 29 (97%) and 7 (23%) subjects in Group M and Group D respectively (P<0.05). MAS of 9-10 at 5 min during recovery was achieved in 27 (90%) subjects in Group D in contrast to 5 (17%) in Group M (P<0.05). Dexmedetomidine showed higher patient and surgeon satisfaction scores (P<0.05).Conclusion:Dexmedetomidine can be a superior alternative to midazolam for conscious sedation in ERCP.

Palatal Injection: A Myth or a Reality in Maxillary Third Molar Extraction

ABSTRACT Introduction Palatal injection, in spite of many modernized injection techniques, remains a painful experience for the patient. The aim of this study was to demonstrate if maxillary third molars could be extracted using only buccal infiltration of 2% lignocaine hydrochloride (HCl) with adrenaline 1:80,000 without the need for supplemental palatal injection. Materials and methods Three hundred patients were selected randomly and divided into two groups of 150 each. In the experimental group, 2 ml of 2% lignocaine hydrochloride with 1:80000 adrenaline was injected into the buccal vestibule of the tooth to be extracted. Extraction was performed after a waiting period of 7 minutes postinjection. Equal number of 150 patients were used as control and were subjected to the same protocol, with additional palatal injection. Pain experienced during extraction of both groups were recorded using visual analog scale and faces pain scale. Mann-Whitney test was used to analyze pain between both the groups. Results Statistical analysis of the two groups, experimental and control groups do not defer with respect to visual analog and faces pain score. Conclusion Palatal injection for extraction of maxillary third molar is not mandatory. How to cite this article Pawar S, Desai RA, Padhye M, Shevale V, Khosa R, Keswani E, Thakker S, Shah V. Palatal Injection: A Myth or a Reality in Maxillary Third Molar Extraction. World J Dent 2014;5(1):28-32.

Bedside Ultrasound Diagnosis of Nonangulated Distal Forearm Fractures in the Pediatric Emergency Department

Ultrasound (US) may be a useful tool for rapidly diagnosing fractures. Our objective was to determine the accuracy of US as compared with radiographs in the detection of nonangulated distal forearm fractures. Distal forearm US was performed and interpreted at the bedside by a pediatric emergency medicine physician before radiography in a prospective sample of children with possible nonangulated distal forearm fractures. A second pediatric emergency medicine physician with extensive US experience gave a final interpretation of the images. This second reviewer was blinded to both clinical and radiographic findings. The primary outcome was accuracy in the detection of fracture via the blinded reviewer's US interpretation when compared with the radiologist's clinical radiography results. Patient-reported FACES pain scores (range, 0-5) associated with both US and radiography were compared. Of 101 enrolled patients, 46 had a fracture detected by the radiologist. When compared with radiographs, the blinded US interpretation had an overall accuracy of 94% (95% confidence interval [CI], 88%-99%). Sensitivity and specificity were 96% (95% CI, 85%-99%) and 93% (95% CI, 82%-98%), respectively. Positive predictive value was 92%, and negative predictive value was 96%. Mean FACES pain scores were higher following radiography than US (1.7 vs 1.2, respectively; P = 0.004). For the diagnosis of nonangulated distal forearm fractures in children, bedside US holds promise as a diagnostic modality, particularly with appropriate training. Ultrasound is at least no more painful that traditional radiographs. Pediatric emergency medicine physicians should consider becoming proficient in this application.

Quality-of-life outcomes after Gamma Knife surgery for trigeminal neuralgia

Gamma Knife surgery (GKS) is an important part of the neurosurgical armamentarium for treatment of patients with trigeminal neuralgia (TN) and is regarded as the first-line treatment in patients with TN who have serious medical comorbidities. In this study, the authors investigated the efficacy of GKS on TN in patients with serious medical comorbidities. Between May 2004 and September 2007, 52 severely ill patients who also had TN with Barrow Neurological Institute (BNI) facial pain scores of IV or V were entered into this study. The patients' medical records and imaging findings were reviewed by an anesthesiologist and neurosurgeons to determine whether GKS was a reasonable approach to palliate the patient's pain. All patients underwent GKS, in which a maximum dose of 80 Gy was targeted to the trigeminal nerve with or without plugging to keep the dose received by the brainstem at less than 16 Gy. After treatment, every patient had clinical follow-up every 1-3 months and filled out questionnaires designed to assess BNI facial pain and numbness scores, visual analog scale scores, and 36-Item Short Form Health Survey (SF-36) scores every 3 months until the end of the study. Statistical analysis was performed to find favorable prognostic factors related to pain relief and changes in quality of life. The median age of the patients was 71 years, and the male/female ratio was 30:22. The median follow-up period was 54 months (at least 2 years). All patients had a positive initial response to GKS, with BNI facial pain scores at least 1 point less than respective pre-GKS scores. Three patients (5.7%) obtained BNI facial pain Score I. Twenty-three patients (44.2%) experienced pain recurrence at a median follow-up of 33 months. One patient suffered from angina and required time in an intensive care unit; another patient had bleeding from a pin wound that required suturing. Alterations in BNI scores were highly correlated to visual analog scale scores (R(2) = 0.978). In both univariate and multivariate analyses, a decreased BNI facial pain score at different time points was significantly (p < 0.05) related to younger patient age, no previous treatment, evidence of vessel compression on MR imaging, time of first GKS ≤ 24 months, physical function (SF-36), role limitation due to a physical problem (SF-36), role limitation due to an emotional problem (SF-36), mental health (SF-36), social functioning (SF-36), bodily pain (SF-36), and general health (SF-36), but was not related to vitality (SF-36). Five patients (9.6%) experienced facial numbness at a mean of 13.2 ± 3.1 months after GKS (4 patients with BNI facial numbness Score II and 1 with BNI facial numbness Score III). Post-GKS MR imaging changes, including focal contrast enhancement or T2-weighted signal alterations, were identified in 3 patients (5.7%). Gamma Knife surgery produced significant pain relief in severely ill patients who had TN without causing appreciable morbidity. The effect of reduced pain significantly paralleled an improvement in SF-36 quality-of-life indices.

Global Osteitis Scoring Scale and chronic rhinosinusitis: a marker of revision surgery

Determine the incidence and severity of osteitis in patients with chronic rhinosinusitis using a new Global Osteitis Scoring Scale. Validation and prospective case-control study. Academic Tertiary Otolaryngology Department (Academic Medical Centre, Amsterdam). A prospective series of 102 patients undergoing a computed tomography (CT) sinuses as part of their evaluation for chronic rhinosinusitis between January and May 2008 (study group) and an age- and gender-matched control group of 68 non-rhinosinusitis patients. Seventy-eight of the chronic rhinosinusitis patients completed the nasal subset of the RhinoSinusitis Outcome Measure (RSOM-31) and visual analogue scales. Their CT scans were assessed for osteitis using a newly developed Global Osteitis Scoring Scale. A subsample of 35 scans were additionally scored by a second otolaryngologist and a radiologist. Global Osteitis Scoring Scale. The interrater variability of Global Osteitis Scoring Scale was low (average intraclass correlation coefficient: 0.94). Forty per cent of the chronic rhinosinusitis group and none of the control group had evidence of clinically significant osteitis. In the chronic rhinosinusitis group (102 patients), the severity of osteitis was correlated with Lund-Mackay (L-M) score (P<0.001), duration of symptoms (P<0.01) and previous surgery (P<0.001), rising in incidence with increasing number of previous operations. There was no association between osteitis and age, gender, smoking, co-existing asthma, allergy or Sumpter's triad. Additionally, there was no correlation between osteitis and symptom burden including headache, facial pain and nasal subset score of the RhinoSinusitis Outcome Measure. In patients with recalcitrant chronic rhinosinusitis who have undergone multiple surgeries in the past, the incidence of osteitis can be as high as 64%. It does not seem to be associated with more troublesome symptoms; however, it is strongly associated with previous sinus surgery, which may be a manifestation of a shared endpoint (underlying recalcitrant disease).

Bedside Ultrasound Diagnosis of Clavicle Fractures in the Pediatric Emergency Department

Clavicle fractures are among the most common orthopedic injuries in children. Diagnosis typically involves radiographs, which expose children to radiation and may consume significant time and resources. Our objective was to determine if bedside emergency department (ED) ultrasound (US) is an accurate alternative to radiography. This was a prospective study of bedside US for diagnosing clavicle fractures. A convenience sample of children ages 1-18 years with shoulder injuries requiring radiographs was enrolled. Bedside US imaging and an unblinded interpretation were completed by a pediatric emergency physician (EP) prior to radiographs. A second interpreter, a pediatric EP attending physician with extensive US experience, determined a final interpretation of the US images at a later date. This final interpretation was blinded to both clinical and radiography outcomes. The reference standard was an attending radiologist's interpretation of radiographs. The primary outcome was the accuracy of the blinded US interpretation for detecting clavicle fractures compared to the reference standard. Secondary outcome measures included the interrater reliability of the unblinded bedside and the blinded physicians' interpretations and the FACES pain scores (range, 0-5) for US and radiograph imaging. One-hundred patients were included in the study, of whom 43 had clavicle fractures by radiography. The final US interpretation had 95% sensitivity (95% confidence interval [CI] = 83% to 99%) and 96% specificity (95% CI = 87% to 99%), and overall accuracy was 96%, with 96 congruent readings. Positive and negative predictive values (PPVs and NPVs, respectively) were 95% (95% CI = 83% to 99%) and 96% (95% CI = 87% to 99%), respectively. Interrater reliability (kappa) was 0.74 (95% CI = 0.60 to 0.88). FACES pain scores were available for the 86 subjects who were at least 5 years old. Pain scores were similar during US and radiography. Compared to radiographs, bedside US can accurately diagnose pediatric clavicle fractures. US causes no more discomfort than radiography when detecting clavicle fractures. Given US's advantage of no radiation, pediatric EPs should consider this application.

Evidence of descending inhibition deficits in atypical but not classical trigeminal neuralgia

Trigeminal neuralgia (TN) is a rare neuropathic facial pain disorder. Two forms of TN, classical TN (CTN) and atypical TN (ATN), are reported and probably have different aetiologies. The aim of the present study was to evaluate the functional integrity of the diffuse noxious inhibitory controls (DNIC) in (1) a group of patients with classical trigeminal neuralgia (CTN), (2) a group of patients with atypical trigeminal neuralgia (ATN), and (3) a group of healthy controls in order to determine if a descending pain modulation deficit could participate in the pathophysiology of TN pain. DNIC responses of 14 CTN patients, 14 ATN patients and 14 healthy controls were obtained by comparing thermode-induced facial heat pain scores before and after activating DNIC. DNIC was triggered using a standard counter–irritation paradigm (i.e., immersion of the arm in painfully cold water). General sensitivity to pain was also evaluated by measuring mechanical pain thresholds over 18 points located outside the trigeminal territory. Healthy participants and CTN patients showed a 21% and 16% reduction in thermode-induced pain following the immersion, respectively (all p-values <.01), whereas ATN patients experienced no change (p=.57). ATN patients also had more tender points (mechanical pain thresholds<4.0kg) than CTN and healthy controls (all p-values <.05). Taken together, these results suggest that the underlying physiopathology differs between CTN and ATN and that a deficit in descending inhibition may further contribute to the pain experienced by patients with ATN.

Lidocaine Jelly and Plain Aqueous Gel for Urethral Straight Catheterization and the Q-tip Test

To compare the pain perception between lidocaine and plain aqueous gel during assessment of postvoid residual volume and the Q-tip test. : Patients were randomly assigned to either to 2% lidocaine hydrochloride jelly or plain aqueous gel. The allocated gel was first used to lubricate a catheter that was inserted into the bladder to measure the postvoid residual volume. After removal of the catheter, a cotton swab, coated with the same allocated gel, was advanced to the urethrovesical junction until resistance was felt. The angle of the swab with the horizontal plane was measured at rest and with Valsalva maneuver. Relevant baseline characteristics and the Wong-Baker FACES pain scores (where 0 is for no pain and 5 for worst pain) were compared. After randomization, lidocaine and the plain aqueous gel arms consisted of 69 and 68 women, respectively. Baseline characteristics of the groups were similar. Significantly fewer women in the lidocaine group (62.3%) reported any pain than those allocated to plain aqueous gel (80.9%) (odds ratio 0.39, 95% confidence interval 0.18-0.85). The median pain score was significantly lower in the lidocaine group (1, range 0-5) compared with 2 (range 0-4), P<.001). When compared with plain aqueous gel, 2% lidocaine jelly significantly reduces pain perception during evaluation of postvoid residual volume and the Q-tip test. I.