FACES Score Research Articles

B-45 | The Use of Virtual Reality to Optimize Patient Comfort During Transcatheter Aortic Valve Replacement

The use of sedating anxiolytic and pain medications is ubiquitous in the United States in patients undergoing transcatheter aortic valve replacement (TAVR). We hypothesize the use of a virtual reality headset (VRH) can lower patient perception of anxiety and pain and improve overall patient experience whilst limiting the use of sedating medications. A feasibility study was performed among patients undergoing TAVR. Use of sedating medications was managed by an anesthesiologist. Patients underwent pre and post procedure surveys with State-Trait Anxiety Inventory 6 Score to assess anxiety and the Wong-Baker FACES Score to assess pain. During the procedure, patients had the option to choose their preferred environment from immersive beach, space, underwater, or nature experiences. In total, 14 patients were enrolled in our study with 4 opting to discontinue the VRH for various reasons including claustrophobia and weight of the headset. For the 10 patients who completed the study, 7 had improvement in their anxiety scores post TAVR (Figure 1, Panel C). The average overall patient experience was excellent at 8.45/10. Post procedural pain scores for the majority of patients was 0 and the most severe pain score 4/10. All 10 patients stated they would use the technology again in future procedures. Use of a VR headset by patients undergoing TAVR appears feasible and does not interfere with care provided by the medical team. Future study will focus on comparisons of anesthetic use and patient satisfaction with vs without use of VRH.

Nonpharmacological pain management in vaccination. Perception of paediatricians, patients and guardians

IntroductionThe use of nonpharmacological measures to reduce pain during vaccination has been studied extensively in infants, but there are fewer studies on its effectiveness in older children and on the parental perception of pain in children. MethodsWe conducted a multicentre, quasi-experimental interventional study with a control group. Patients: infants aged 2–11 months and children aged 4 years that attended routine vaccination appointments. Setting: Primary care. Intervention during vaccination: infants were breastfed and 4-year-old children blew a party horn. Control: vaccination performed following routine practice. Measurement: NIPS (Neonatal Infant Pain Scale) and duration of crying in infants, Wong-Baker FACES pain rating scale in older children and parents. ResultsThe study included 125 children (intervention: 60; control: 65). There was a significant decrease in perceived pain in the intervention groups: NIPS score in infants, 3.8 ± 1.1 compared to 5.2 ± 0.7 (P < .001); Wong-Baker FACES score at 4 years of 3.3 ± 1.7 compared to 4.2 ± 1.6 (P = .042). These same differences in support of the intervention were reflected in the parental assessments (3.4 ± 1.3 vs 4.5 ± 1.5; P < .001). The correlation between child and parent scores was strongly positive: 0.7 (95% CI, 0.59−0.78). However, the duration of crying was longer in the intervention group. ConclusionThe use of distraction techniques reduces pain in children and the pain perceived by parents in their children, thus increasing their satisfaction with the procedure.

Number of Episodes Can Be Used as a Disease Activity Measure in Familial Mediterranean Fever.

ObjectiveTo evaluate the number of episodes in the past 12 months as an indicator of the overall disease activity status in Familial Mediterranean fever (FMF).MethodsIn this cross-sectional study, patients were recruited from tertiary pediatric hospitals. Demographic data, main clinical symptoms of the episodes, treatment modalities, and genetic mutations were recorded. The patients were grouped as no episodes (Group 1), 1–4 episodes (Group 2), and more than 4 episodes (Group 3) according to the number of episodes in the past 12 months. The Pediatric Quality Life Inventory (PedsQL), the Children’s Depression Inventory (CDI), and the Wong-Baker FACES Pain Rating Scale (FACES) scores were compared between groups. Concurrent validity between the number of episodes and the patient-reported outcome measures (PROMs) was assessed using Spearman’s rank correlation coefficient (ρ).ResultsA total of 239 patients were included. There were 74 patients (31%) in Group 1, 99 (41.4%) in Group 2, and 66 (27.6%) in Group 3. Groups were similar according to age, age at diagnosis, gender, consanguinity, family history, history of amyloidosis, clinical symptoms, and in terms of allele frequency (p > 0.05). According to PROMs completed by parents, moderate correlations were found between the number of episodes and the PedsQL score (ρ = −0.48; 95% CI = −0.58 to −0.35, p < 0.001) and between the number of episodes and the Wong-Baker FACES score (ρ = 0.47, 95% CI = 0.35–0.57, p < 0.001).ConclusionThe number of episodes was positively and moderately correlated with patient- and parent-reported outcomes in our cohort. The number of episodes in patients with FMF can be used as a single measure to assess disease activity.

Analgesia no farmacológica en la vacunación. Valoración de pediatras, pacientes y tutores

IntroductionThe use of nonpharmacological measures to reduce pain during vaccination has been studied extensively in infants, but there are fewer studies on its effectiveness in older children and on the parental perception of pain in children. MethodsWe conducted a multicentre, quasi-experimental interventional study with a control group. Patients: Infants aged 2 and 11 months and children aged 4 years that attended routine vaccination appointments. Setting: Primary care. Intervention during vaccination: infants were breastfed and 4-year-old children blew a party horn. Control: vaccination performed following routine practice. Measurement: NIPS (Neonatal Infant Pain Scale) and duration of crying in infants, Wong−Baker FACES pain rating scale in older children and parents. ResultsThe study included 125 children (intervention: 60; control: 65). There was a significant decrease in perceived pain in the intervention groups: NIPS score in infants, 3.8±1.1 compared to 5.2±0.7 (P<.001); Wong−Baker FACES score at 4 years of 3.3±1.7 compared to 4.2±1.6 (P=.042). These same differences in support of the intervention were reflected in the parental assessments (3.4±1.3 vs 4.5±1.5; P<.001). The correlation between child and parent scores was strongly positive: 0.7 (95% CI, 0.59–0.78). However, the duration of crying was longer in the intervention group. ConclusionsThe use of distraction techniques reduces pain in children and the pain perceived by parents in their children, thus increasing their satisfaction with the procedure.

ARE SELF-REPORTED PAIN SCALES IN PEDIATRICS VALID?

Background: Pain is the most common symptom for presentation to an orthopaedic practice and orthopedists rank 4th among top prescribers of opiates. Pain acuity, etiology and severity have been published as guiding factors for pain assessment and management. In an attempt to address the underassessment and undertreatment of pain, pain was even considered the 5th vital sign for a period of time. Assessment of pain using validated severity assessment instruments including the Visual Analogue Scale and the Wong-Baker FACES® Scale, is common in orthopaedic practices. The purpose of this study is to evaluate the validity and sensitivity of self-reported pain assessment tools administered to pediatric and adolescent patients presenting with a primary complaint of knee pain. Methods: A retrospective review of 211 patients with a primary complaint of knee pain in a single practice over a nine-month period was completed. Medical records were reviewed for demographics, sport, laterality, symptoms, and factors described as influencing the pain. Prior to orthopaedic evaluation, patients were given an electronic tablet to complete patient reported outcomes measures and the visual analog scale (VAS). Patients were asked, electronically, “Do you have pain today?” and to verbally rate the pain using a Wong-Baker FACES® Pain Rating Scale (FACES). The FACES scale, typically a 0-5 rating, was normalized to a 0-10 scale for comparison to both the VAS and the pain component of the pedi-IKDC (Pain-pIKDC). A Pearson’s correlation was used to compare the VAS and the Pain-pIKDC with the FACES scores to determine validity. A paired t-test was used to identify differences between the three measures. Results: Of the 211 subjects, 112 were females and 99 were males, with a mean age of 13.9 years (range 7-18). 82% of patients reported presenting for pain due to a specific injury and not of spontaneous origin. The mean FACES score was 1.26 (normalized to 2.52) with a median score of 0. Compared to the FACES, the mean VAS was 4.22 (p&lt;0.001) and Pain-pIKDC was 3.66 (p&lt;0.001) noted to be both a statistically and clinically significant difference. When comparing the FACES to VAS, a weak correlation was noted (0.360, p&lt;0.001). A stronger correlation was noted between the VAS and the Pain-pIKDC (0.752, p&lt;0.001). 66.4% of patients reported no pain on the FACES but reported pain &gt;1 on the Pedi-IKDC. 80.5% of patients reported no pain on FACES but pain of &gt;1 on the VAS. Only 12.2% on VAS and 16.2% on Pain-pIKDC reported no pain . For both the VAS and Pain-pIKDC, the sensitivity of detecting “no pain” is low at 19.2% and 30.2% respectively. Conclusion: Though pain is widely accepted as an important factor for patient care management, clinicians should be aware that self-reported pain assessment tools in pediatrics and adolescents, without verbal confirmation, may inflate reported pain intensity and lead to possible overtreatment.

Differences in Facial Emotion Recognition between First Episode Psychosis, Borderline Personality Disorder and Healthy Controls.

BackgroundFacial emotion recognition (FER) is essential to guide social functioning and behaviour for interpersonal communication. FER may be altered in severe mental illness such as in psychosis and in borderline personality disorder patients. However, it is unclear if these FER alterations are specifically related to psychosis. Awareness of FER alterations may be useful in clinical settings to improve treatment strategies. The aim of our study was to examine FER in patients with severe mental disorder and their relation with psychotic symptomatology.Materials and MethodsSocio-demographic and clinical variables were collected. Alterations on emotion recognition were assessed in 3 groups: patients with first episode psychosis (FEP) (n = 64), borderline personality patients (BPD) (n = 37) and healthy controls (n = 137), using the Degraded Facial Affect Recognition Task. The Positive and Negative Syndrome Scale, Structured Interview for Schizotypy Revised and Community Assessment of Psychic Experiences scales were used to assess positive psychotic symptoms. WAIS III subtests were used to assess IQ.ResultsKruskal-Wallis analysis showed a significant difference between groups on the FER of neutral faces score between FEP, BPD patients and controls and between FEP patients and controls in angry face recognition. No significant differences were found between groups in the fear or happy conditions. There was a significant difference between groups in the attribution of negative emotion to happy faces. BPD and FEP groups had a much higher tendency to recognize happy faces as negatives. There was no association with the different symptom domains in either group.ConclusionsFEP and BPD patients have problems in recognizing neutral faces more frequently than controls. Moreover, patients tend to over-report negative emotions in recognition of happy faces. Although no relation between psychotic symptoms and FER alterations was found, these deficits could contribute to a patient’s misinterpretations in daily life.

Validity and sensitivity of 6 pain scales in critically ill, intubated adults.

Self-report is the best indicator of pain; however, pain is more difficult to assess in noncommunicative patients who may be receiving mechanical ventilation or sedated and unable to report pain. To evaluate the validity and sensitivity of 6 pain scales (Adult Nonverbal Pain Scale; Behavior Pain Scale [BPS]; Comfort Scale; FACES; Face, Legs, Activity, Cry, and Consolability scale; Pain Assessment Behavioral Scale with Numeric Rating Scale [NRP]) to identify the best measure of pain in noncommunicative patients. Fifty communicative and 100 noncommunicative patients receiving mechanical ventilation were observed before and during routine physical examination and endotracheal tube suctioning. All pain scales had moderate to high correlations with the patient's self-report during suctioning. The FACES score reported by the patient had the highest correlation with the patient's NRP score (r = 0.76, P < .001) during suctioning; associations between the BPS and NRP scores during physical examination were the weakest (r = 0.21, P = .20). All scales were sensitive in capturing the patient's pain response in all phases (P < .001); sensitivity was higher during suctioning (P < .001). Both participants and investigators rated pain higher on the FACES scale. These pain scales commonly used in noncommunicative critically ill adult patients are valid and sensitive for capturing changes in pain response during suctioning in both communicative and noncommunicative patients. However, caution must be used when using the FACES scale because subjectivity may lead to overtreatment or undertreatment of pain.

Use of string test and stool specimens to diagnose pulmonary tuberculosis.

SUMMARYBackgroundThe Xpert MTB/RIF (MTB/RIF) test has advanced the field of tuberculosis (TB) diagnostics; however, depending on age and HIV status, 10–85% of individuals with presumed pulmonary TB (PTB) are unable to produce sputum.MethodsThe feasibility of using MTB/RIF and culture on stool and string test specimens from 13 adult patients with presumed PTB was studied.ResultsThe string test was well tolerated with a median Wong Baker Faces score of 2. The string test had 100% sensitivity and specificity by MTB/RIF and 87.5% sensitivity and 100% specificity by culture. In stool, Mycobacterium tuberculosis DNA was detected in all cases of culture-confirmed PTB.ConclusionThe string test and stool provide diagnostic specimens that warrant further investigation.

Pain during office removal of K-wires from the elbow in children.

Closed reduction and K-wire fixation is standard treatment for displaced supracondylar fractures in children. The purpose of this study is to evaluate pain using 2 pediatric pain scales when removing K-wires from the distal humerus in children in the office setting. A total of 98 percutaneous smooth K-wires were removed from 47 patients who had sustained displaced supracondylar fractures of the elbow. Pain was measured using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The maximum score is 13 and the minimum score is 4 points. In addition, after K-wire removal, each child indicated on a numbered pain-face diagram (Wong-Baker FACES: a scale consisting of faces with varying emotional expressions and corresponding numbers on a scale from 0 to 5) the amount of pain that they felt. The average age of the patients treated was 7.1 years (range, 2 to 14 y). There were 28 males and 19 females. Thirty patients (64%) had a CHEOPS score of ≤6. The average CHEOPS was 6 (range, 4 to 10). Seventeen patients (37%) had a FACES score of ≤1. The average FACES score was 2 (range, 1 to 5). Higher CHEOPS and FACES scores correlated with younger patient age and higher number of K-wires removed. K-wire removal in the clinic is common practice. The pain associated with K-wire removal and the safety of this practice has received minimal previous study in the literature. In the present manuscript, 64% of patients had little or no pain measured by the CHEOPS scale--score of ≤6 and 36% had little or no pain self-reported by the FACES scale--score of ≤1. No patient reported severe pain by the CHEOPS scores (CHEOPS 11 to 13) and only 1 patient reported having severe pain with a FACES of 5. No complications occurred. The results of this study suggest that the removal of K-wires in the office setting is safe and acceptable. Retrospective analysis.

Clinical Application of the FACES Score for Face Transplantation

This study aimed to systematically evaluate all reported outcomes of facial allotransplantation (FT) using the previously described FACES scoring instrument. This was a retrospective study of all consecutive face transplants to date (January 2012). Candidates were identified using medical and general internet database searches. Medical literature and media reports were reviewed for details regarding demographic, operative, anatomic, and psychosocial data, which were then used to formulate FACES scores. Pre-transplant and post-transplant scores for "functional status", "aesthetic deformity", "co-morbidities", "exposed tissue", and "surgical history" were calculated. Scores were statistically compared using paired-samples analyses. Twenty consecutive patients were identified, with 18 surviving recipients. The sample was composed of 3 females and 17 males, with a mean age of 35.0 ± 11.0 years (range: 19-57 years). Overall, data reporting for functional parameters was poor. Six subjects had complete pre-transplant and post-transplant data available for all 5 FACES domains. The mean pre-transplant FACES score was 33.5 ± 8.8 (range: 23-44); the mean post-transplant score was 21.5 ± 5.9 (range: 14-32) and was statistically significantly lower than the pre-transplant score (P = 0.02). Among the individual domains, FT conferred a statistically significant improvement in aesthetic defect scores and exposed tissue scores (P ≤ 0.01) while, at the same time, it displayed no significant increases in co-morbidity (P = 0.17). There is a significant deficiency in functional outcome reports thus far. Moreover, FT resulted in improved overall FACES score, with the most dramatic improvements noted in aesthetic defect and exposed tissue scores.

The assessment of dyspnea during the vigorous intensity exercise by three Dyspnea Rating Scales in inactive medical personnel.

It is well recognized that exercise is good for health especially as it’s known to prevent metabolic syndromes such as diabetes, hypertension and heart disease. To reap the benefits from exercise the most appropriate level of intensity must be determined, the level of intensity ranging from low, low to moderate to hard (vigorous).This study is aimed to 1. To investigate and evaluate 3 subjective rating scales. The Borg scale, the Combined Numerical Rating Scale (NRS) + FACES Dyspnea Rating Scale (FACES) and the Likert scale, during hard (vigorous) exercise. 2. To compare the effectiveness of the Borg scale and Combined Numerical Rating Scale (NRS) + FACES Dyspnea Rating Scale during the hard (vigorous) intensity exercise. This study uses a descriptive methodology.The sample group was 73 medical personnel that were leading an inactive life style, volunteers from Phramongkutklao Hospital. Participants were randomly divided into 3 groups. Group 1, those to report using the Borg Scale, group 2 using NRS + FACES, and group 3 to subjectively assess the intensity of the exercise using the Likert scale during a treadmill Exercise Stress Test (EST) using the Bruce protocol. The upper limit of the intensity in the study was equal to 85% of the maximal heart rate of all participants. The subjective reporting of the experienced level of dyspnea was undertaken immediately after the completion of exercise.The average age of participants was 23.37 years old. The 26 participants reporting using the Borg scale had mean Borg scale score of 13.46+1.77, a mode score of 15. The 24 participants reporting intensity levels through NRS +FACES had a mean NRS + FACES score of 6.83+1.09 and mode on the NRS + FACES scale equal to 7. The Likert scale group evaluated 23 participants with a mean Likert scale score of 2.74. That is those choosing Levels 2 and 3 were 6 (26.9%) and 17 participants (73.95%), respectively. Comparing the two groups with the Borg scale at equal to or greater than 15 and NRS + FACES greater than or equal to 7 using a Chi-square test showed that there were no statistical significant differences at p = 0.084. Using Spearman’s rank correlation coefficient it was found that the subjective rating of intensity in the 3 different groups was not statistically significantly related to heart rate at 85% of maximal heart rate (P> 0.05). NRS + FACES, the evaluation of the intensity of exercise at the hard (vigorous) level, was not statistically significantly different from the Borg scale.

G242(P) Regular Education and Audit Improves the Management of Pain in Children

AimsAll children have the right to appropriate prevention, assessment and control of pain yet the assessment and management of pain in children is often inadequate1,2. We therefore set out to...

Clinical application and validation of the FACES score for facial transplantation

Clinical application and validation of the FACES score for facial transplantation

The Cleveland Clinic FACES Score

In lieu of limited resources, our multidisciplinary face transplant team requires a preliminary, supplemental objective grading scheme for identifying the optimal face transplant candidate. Therefore, our objective was to develop an effective method for evaluating "facial deficit," which could also be used in the future for the allocation of limited facial organs, analogous to liver transplantation.Each candidate is screened using our institutional review board-approved protocol's current inclusion/exclusion criteria. Five categories were conceptualized to be of significance in evaluating patients in pursuit of facial allotransplantation as per our recent experience, as determined by the face transplant team. All patients with unfavorable characteristics such as evidence of poor medical compliance, an unsatisfactory psychosocial evaluation by our team's transplant psychiatrist, and/or end-stage organ disease suggestive of significant comorbidity were excluded.This study resulted in a reproducible scoring system allowing our team the unprecedented ability to stratify facial deficit in a standardized fashion. The FACES scores ranged from 10 (minimum) to 60 (maximum). Besides being used as a supplemental prescreening and/or postscreening tool, the FACES score has also provided an unprecedented framework for establishing a face transplant candidate registry within our institution, with the optimal recipients receiving the highest of scores.This FACES score objectively stratifies face transplant candidates for their facial deficit during multiple steps throughout the screening process and affords our institution the means of creating a registry. If substantiated, this supplemental score may ultimately predict successful outcomes, determine optimal utility, and provide insight toward prognosis with respect to facial composite tissue allotransplantation.

Comparing the Effectiveness of Modified Forearm and Conventional Minidose Intravenous Regional Anesthesia for Reduction of Distal Forearm Fractures in Children

Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. Level I, therapeutic study.