Median Visual Analogue Scale Score Research Articles

A clinical study to optimise a sand fly biting protocol for use in a controlled human infection model of cutaneous leishmaniasis (the FLYBITE study)

Background: Leishmaniasis is a globally important yet neglected parasitic disease transmitted by phlebotomine sand flies. With new candidate vaccines in or near the clinic, a controlled human challenge model (CHIM) using natural sand fly challenge would provide a method for early evaluation of prophylactic efficacy. Methods : We evaluated the biting frequency and adverse effects resulting from exposure of human volunteers to bites of either Phlebotomus papatasi or P. duboscqi, two natural vectors of Leishmania major. 12 healthy participants were recruited (mean age 40.2 ± 11.8 years) with no history of significant travel to regions where L. major-transmitting sand flies are prevalent. Participants were assigned to either vector by 1:1 allocation and exposed to five female sand flies for 30 minutes in a custom biting chamber. Bite frequency was recorded to confirm a bloodmeal was taken. Participant responses and safety outcomes were monitored using a visual analogue scale (VAS), clinical examination, and blood biochemistry. Focus groups were subsequently conducted to explore participant acceptability. Results: All participants had at least one successful sand fly bite with none reporting any serious adverse events, with median VAS scores of 0-1/10 out to day 21 post-sand fly bite. Corresponding assessment of sand flies confirmed that for each participant at least 1/5 sand flies had successfully taken a bloodmeal (overall mean 3.67±1.03 bites per participant). There was no significant difference between P. papatasi and P. duboscqi in the number of bites resulting from 5 sand flies applied to human participants (3.3±0.81 vs 3.00±1.27 bites per participant; p=0.56) . In the two focus groups (n=5 per group), themes relating to positive participant-reported experiences of being bitten and the overall study, were identified. Conclusions: These results validate a protocol for achieving successful sand fly bites in humans that is safe, well-tolerated and acceptable for participants. Clinicaltrials.gov registration: NCT03999970 (27/06/2019)

Comparing N-acetylcysteine with sodium thiosulfate for relieving symptoms caused by Lugol’s iodine chromoendoscopy: a randomized, double-blind trial

Lugol's iodine chromoendoscopy is an important method to detect esophageal squamous cell carcinoma. Sodium thiosulfate solution (STS) has been used to neutralize iodine after Lugol's chromoendoscopy; however, it is not available in many medical centers. The aim of the current study was to assess the efficacy of N-acetylcysteine solution (NAC) for relieving symptoms caused by Lugol's iodine chromoendoscopy. Patients were randomized to receive either STS or NAC after spraying Lugol's iodine solution on the esophagus. The neutralizing effects for residual iodine in the esophagus and gastric mucous pool were observed. The primary endpoint was the intensity of retrosternal pain and/or heartburn measured by a visual analog scale (VAS) score 30 minutes after chromoendoscopy. Secondary endpoints were the rate of patients with any adverse symptom, rate of moderate to severe retrosternal discomfort occurring, and heart rate variability between time points before and after chromoendoscopy. The neutralization rates for residual iodine between the NAC and STS groups were not significantly different (P > .999). The difference of median VAS scores between the NAC and STS groups 30 minutes after chromoendoscopy was .0 (P= .719; 95% confidence interval, .0-.0), and the 95% confidence interval higher limit was .0, which was less than our prespecified margin of .5, concluding an noninferiority of NAC with regard to STS. There was no significant difference between the 2 groups regarding the rate of patients with any adverse symptom, rate of moderate to severe retrosternal discomfort, or heart rate variability at 5 minutes or 30 minutes after chromoendoscopy. As a very easily accessible reagent in clinical circumstances, NAC can also alleviate mucosal irritation symptoms induced by Lugol's chromoendoscopy at similar efficacy as STS and can be routinely recommended. (Clinical trial registration number: NCT04764643.).

COVID-19 confinement and related well being measurement using the EQ-5D questionnaire: A survey among the Palestinian population.

PurposeThis study aims to assess the effect of the COVID‐19 confinement on the population wellbeing using the EQ‐5D questionnaire.MethodsAfter receiving the written permission from the EuroQol Research Foundation, an online‐based survey was prepared and a total of 1380 participants were recruited via social media. The relationships of all the factors were studied as well as the scores of the EQ‐5D including EQ‐5D Index, Visual Analogue Scale (VAS), and each of the EQ‐5D dimension. Linear regression for the Index and VAS and Logistic regression model was used to examine each dimension.ResultsThe median EQ‐5D Index and VAS scores were 0.65 (0.5‐0.75) and 80 (60‐90), respectively. The most frequently reported problem was anxiety/depression (67.3%), followed by usual activities (48.6%). The statistical analysis showed that factors significantly associated with more reported problems in at least one EQ‐5D dimension (P < .05) were: females, ageing, being unmarried, low income, school studies, living in refugee camps, and villages, unemployment, having chronic diseases or pain, and obesity. It is important to note that participants who responded in November showed more problems compared with December 2020. On the other hand, more problems were reported by participants who were infected, had known affected persons, had no enough information, perceived negative effect of confinement, and indicated having a high infection chance (P < .05).ConclusionsThis work provides important evidence on the health status and wellbeing during the COVID‐19 confinement in a sample of the Palestinian population, affecting almost all the aspects of the health state and wellbeing. This effect could be minimised by improving the COVID‐19 preventive education and monitoring that can play an important role in all health and life aspects among the Palestinian population in facing this pandemic.

Effect of focal and diffuse hypervascularization as cystoscopic findings on predicting intravesical therapy response in patients with bladder pain syndrome.

To define the relationship between cystoscopic findings, including novel findings such as the hypervascularization, of bladder pain syndrome/interstitial cystitis (BPS/IC) and the response to intravesical therapy. We retrospectively evaluated cystoscopy findings in patients who had a preliminary diagnosis of BPS/IC. All patients received early intravesical combined therapy (ICT), ie, within 2 hours after hydrodistention. Additionally, ICT was continued according to our protocol. Cystoscopic findings were classified as glomerulations, hypervascularization, and Hunner's lesion (HL). The therapy responses were evaluated at 1st, 3rd, 6th, and 12thmonths using the visual analog scale (VAS), O'Leary/Sant interstitial cystitis symptom index (ICSI), and interstitial cystitis problem index (ICPI) scores. Out of 61 patients, HL was diagnosed during cystoscopy in six (9.8%) patients, glomerulations in 35 (57.4%) patients, and hypervascularization in 15 (24.6%) patients. No pathological findings were defined in five (8.2%) patients. In the glomerulation and hypervascularization group, the median VAS, ICSI, and ICPI scores were lower than those in the preoperative period in the follow-up. In patients with HL, the median VAS scores were lower in the entire follow-up compared to the preoperative period, with an increase at 1st year compared to 6th month, and ICSI scores were lower than preoperative period in the entire follow-up, with an increase at 3rd month and 1st year. ICPI scores were also lower during the follow-up, with an increase observed in the 1st year. The presence of hypervascularization should be defined since it might show different characteristics that may affect the ICT response. Patients with glomerulations might be good candidates for early combined intravesical therapy.

English

BACKGROUND Scoliotic spine puts undue strain on the back musculature which may lead to the production of myofascial pain syndrome (MPS). The purpose of this study was to find out the association of myofascial pain of iliopsoas and quadratus lumborum in scoliotic patients and to look for any correlation between the degree of deformity (Cobb’s angle) and severity of myofascial pain. METHODS A total of 60 patients of low back pain with spinal deformity were enrolled in the study. The severity of the spinal deformity and pain was calculated with Cobb’s angle and visual analogue scale (VAS) pain scale (0 - 100) respectively. Patients with iliopsoas and quadratus myofascial pain underwent trigger point therapy along with regimen of stretching exercises. VAS scores were recorded at 0 - hour, 2 - hour, 2 - weeks, 1 month and 3 months after the procedure. RESULTS Forty-four patients out of 60 had myofascial pain of iliopsoas or quadratus lumborum or both. 15, 31 and 12 patients had Cobb’s angle of 10 - 20, 21 - 30 and 31 - 40 degree, respectively. Trigger point injections were performed in 38 patients. The pre-procedure median VAS score was 70, at 0 hour 45, at 2 hour 40, at 2 weeks 30, at 1 month 30 and at 3 months 30. A significant reduction (P &lt; 0.001) in VAS score was observed till 3 months. CONCLUSIONS The myofascial pain of iliopsoas and quadratus lumborum is an important source of low back pain in patients with scoliosis. There is no correlation between the degree of scoliosis and severity of low back pain. KEYWORDS Scoliosis, Kyphoscoliosis, Thoraco-Lumbar Spinal Deformity, Myofascial Pain, Iliopsoas, Psoas Major, Quadratus Lumborum, Low Back Pain

A clinical study to optimise a sand fly biting protocol for use in a controlled human infection model of cutaneous leishmaniasis (the FLYBITE study).

Background: Leishmaniasis is a globally important yet neglected parasitic disease transmitted by phlebotomine sand flies. With new candidate vaccines in or near the clinic, a controlled human challenge model (CHIM) using natural sand fly challenge would provide a method for early evaluation of prophylactic efficacy. Methods : We evaluated the biting frequency and adverse effects resulting from exposure of human volunteers to bites of either Phlebotomus papatasi or P. duboscqi, two natural vectors of Leishmania major. 12 healthy participants were recruited (mean age 40.2 ± 11.8 years) with no history of significant travel to regions where L. major-transmitting sand flies are prevalent. Participants were assigned to either vector by 1:1 allocation and exposed to five female sand flies for 30 minutes in a custom biting chamber. Bite frequency was recorded to confirm a bloodmeal was taken. Participant responses and safety outcomes were monitored using a visual analogue scale (VAS), clinical examination, and blood biochemistry. Focus groups were subsequently conducted to explore participant acceptability. Results: All participants had at least one successful sand fly bite with none reporting any serious adverse events, with median VAS scores of 0-1/10 out to day 21 post-sand fly bite. Corresponding assessment of sand flies confirmed that for each participant at least 1/5 sand flies had successfully taken a bloodmeal (overall mean 3.67±1.03 bites per participant). There was no significant difference between P. papatasi and P. duboscqi in the number of bites resulting from 5 sand flies applied to human participants (3.3±0.81 vs 3.00±1.27 bites per participant; p=0.56) . In the two focus groups (n=5 per group), themes relating to positive participant-reported experiences of being bitten and the overall study, were identified. Conclusions: These results validate a protocol for achieving successful sand fly bites in humans that is safe, well-tolerated and acceptable for participants. Clinicaltrials.gov registration: NCT03999970 (27/06/2019).

Comparing tolerability of local anaesthetic transperineal and transrectal prostate biopsies

Objectives: Local anaesthetic transperineal prostate biopsies have been demonstrated as tolerable. However, to date, the tolerability has not been directly compared to the standard of care for transrectal biopsy. We set out to prospectively compare the tolerability of local anaesthetic transperineal and transrectal prostate biopsies. Patients and methods: All patients between 3 April 2019 to 6 December 2019 undergoing local anaesthetic transperineal / transrectal ultrasound biopsy were prospectively asked to complete a questionnaire using visual analogue scales assessing the tolerability of their biopsy. Results: 108 patients were included. Baseline characteristics (mean): age 66.4 years, prostate-specific antigen 13.7 ng/dl, prostate volume 48 ml. Of the patients 51% had ⩾ Gleason 3+4 prostate cancer. 56 patients had transperineal and 52 patients had transrectal biopsy. Median visual analogue scale scores (0–9: transperineal vs transrectal) for probe insertion, probe presence, local anaesthetic injection and taking biopsy were 3 vs 4 ( p=0.66), 3 vs 3 ( p=0.91), 3 vs 2 ( p=0.15) and 3 vs 3 ( p=0.18), respectively. Median visual analogue scale scores (0–3) for overall pain, embarrassment and how they would describe it to a friend were 1 vs 1 ( p=0.17), 0 vs 0 ( p=0.34) and 1 vs 1 ( p=0.2), respectively (transperineal vs transrectal ultrasound). 42 of the 56 patients in the transperineal group had prior transrectal biopsy. 24/42 patients described local anaesthetic transperineal biopsy as the same or better than transrectal; 15/42 described it as a little worse. Conclusion: Tolerability of local anaesthetic transperineal biopsy is comparable to transrectal biopsy. As such, we advocate the routine use of transperineal biopsy and to phase out the transrectal approach where possible. Level of evidence: 2b

Silver Ion Hydrocolloid Gauze and Self-Adhesive Polyurethane Foam Dressing Combination Therapy Can Better Promote Healing of Skin Graft Donor Area Than Traditional Therapy: A Case Control Study

The management of skin graft donor area has been a troublesome problem in reconstructive surgery. Currently, no guidelines exist for the management of skin graft donor areas, and the disposal methods vary from clinician to clinician. With the goal of providing a better basis for improved patient care, the authors conducted a case control study to investigate whether a combination of silver ion hydrocolloid gauze and self-adhesive polyurethane foam dressing (AG+foam group) was effective in healing skin graft donor sites. Forty-eight patients requiring intermediate-thickness skin graft between January 2014 and December 2015 were included in the study. Inclusion criteria included a skin graft measuring at least 40 cm2 to be harvested from the ipsilateral thigh and patient age of 14 years to 60 years. All patients were treated differently according to the experience of their own doctor. Donor sites were covered with silver ion hydrocolloid gauze and self-adhesive polyurethane foam dressing (AG+foam group, n = 23]) or petrolatum gauze, sterile gauze, and compression bandage (control group, n = 25]). Wounds healed faster (mean, 12.7 days ± 2.4 standard deviation vs 22.0 days ± 5.8; P < .001), with fewer dressing changes (median [interquartile range, IQR], 2 [IQR, 2-3] vs 4 [IQR, 2.5-5]; P = .002), and with reduced pain on first dressing change (median visual analog scale score, 5 [4-6] vs 7 [6-7.5]; P < .001) in the AG+foam group compared with the control group. The Patient and Observer Scar Assessment Scales and overall scar ratings were better in the AG+foam group than in the control group (P < .001 for all). The AG+foam group had no infections; 2 infections occurred in the control group. Combined use of AG+foam dressing may enhance skin graft donor site healing, alleviate pain, and require fewer dressing changes.

Comparison of effects of low-level laser therapy and extracorporeal shock wave therapy in calcaneal spur treatment: A prospective, randomized, clinical study.

Objectives In this study, we aimed to evaluate and compare the efficacy of low-level laser therapy (LLLT) and extracorporeal shock wave therapy (ESWT) in the treatment of calcaneal spurs. Patients and methods A total of 62 patients (14 males, 48 females; mean age: 47.6±11.7 years; range, 18 to 70 years) who were diagnosed with calcaneal spurs based on clinical examination and plain radiography between April 2019 and September 2019 were included in this study. A total of 15 sessions of plantar fascia gastroc-soleus stretching exercises and cold pack treatments were given to both groups. The LLLT (904 nm wavelength, 3,000 Hz, 8 J/cm2 dose to the painful heel area and insertion of the plantar fascia on the medial calcaneal area, five points for a total of 5 min for three weeks) was applied to the first group (n=31), whereas ESWT (10 Hz, 2,000 shock waves with a 2.5 bar pressure into the areas of the painful heel, insertion of the plantar fascia on the medial calcaneal area) was applied the second group (n=31). All patients were evaluated using the Visual Analog Scale (VAS) and Foot Function Index (FFI) before and after treatment. Results In both groups, the median VAS and FFI scores after treatment showed a significant improvement, compared to pre-treatment scores (p=0.001). There was no significant difference between the groups in terms of the median post-treatment VAS scores (p>0.05). In the ESWT group, the median FFI pain and total scores after treatment were significantly lower than in the LLLT group (p=0.033). The change in the median FFI pain and total scores were significantly higher in the ESWT group (p=0.046). Conclusion Both treatment modalities are effective and not superior to each other in terms of disability and activity limitation reduction, although a greater improvement in the FFI pain and total scores can be achieved with the ESWT. Based on these findings, we recommend both non-invasive treatment methods to be used in the treatment of calcaneal spurs in the clinical practice.

Prospective, Multicenter Evaluation of a Polyherbal Supplement alongside Standard-of-Care Treatment for Mild Knee Osteoarthritis.

Background This study aimed to provide clinical information on general and joint performance from individuals taking Tregocel® (containing curcuminoid and extracts of the herbs Harpagophytum procumbens, Boswellia serrata, Apium graveolens, and Zingiber officinale) alongside a standard therapy of symptomatic mild knee osteoarthritis (OA). Methods This was a multicenter, open-label, prospective, single-arm study, in which Tregocel® was supplemented for 36 weeks. Participants with symptomatic mild knee OA requiring pharmacologic treatment for pain were enrolled. Physical performance (6-minute walk test, WOMAC-pain and functional domain, and heel-thigh distance flexion test), general performance (WOMAC questionnaire), and VAS (Visual Analogue Scale) assessment of knee pain, as well as anti-inflammatory and analgesic medication consumption, were assessed. Results Between January and April 2019, 107 participants were enrolled and analysed in per protocol population. Mean age was 59.7 (SD 10.8) years, and there were 68.2% women. Mean observation time was 291.1 (SD 7.7) days. Mean increase in 6MWT result observed at the end of the study was 26.0 (SD 30.4) m (p < 0.001). Median VAS score decreased from 60.0 (IQR 50–72) mm at the beginning of the study to 21.0 (IQR 14–30) mm after 36 weeks of product administration (p < 0.001). Regular knee OA medications were taken in 99.1% of subjects at baseline decreasing to 55.1% at the end of the Tregocel® supplementation. Conclusions During Tregocel® supplementation, participants observed improved functional capacity confirmed in the distance in 6MWT and in the heel-thigh distance flexion test, decreased level of pain, and improved WOMAC scores for all domains.

Anxiety and stress in women with suspected endometrial cancer: Survey and paired observational study.

To determine the anxiety and stress levels of women with suspected endometrial cancer and factors affecting this. Prospective survey and paired observational study of consecutive women with suspected endometrial cancer in a rapid access gynaecology clinic. Structured questionnaire including a GAD-7 anxiety test and a modified stress thermometer were used. Patients ranked their perception of a cancer diagnosis on 0-5 Likert scale (0=confident not cancer and 5=cancer). Patients requiring an endometrial tissue biopsy were asked to rank their pain on a visual analogue scale (VAS), this was paired with the survey results. 250 patients completed the study and 23 of which underwent an endometrial tissue biopsy. The median age was 50-59 years old and 59% of women spoke English as their first language. 32% of patients had significant levels of anxiety with GAD-7 score ≥10. The median stress score was three out of five on Likert scale. GAD-7 anxiety scores were higher in women who perceived that they received insufficient information prior to clinic (sufficient information 5 vs. insufficient information 9.5, P=0.00036) or had a disability (disability 9 vs. no disability 5.5, P=0.00374). The median VAS score from the biopsies was seven out of 10 (range 1-10). Patients with higher anxiety levels (GAD-7 scores) were more likely to believe they had cancer P <0.00001. These findings confirm high levels of anxiety and stress in women with suspected endometrial cancer. Adequate pre-clinic information is essential, particularly for minority groups.

Outcomes of posterior labral repair with or without concomitant high-grade glenohumeral chondral pathology: a retrospective cohort with minimum 2-year follow-up.

The purpose of this study was to compare outcomes of patients who underwent posterior labral repair with and without concomitant glenohumeral chondral pathology. A retrospective review was performed on patients aged ≥18 years who underwent primary posterior labral repair over 5 years. Charts were reviewed to determine the presence and location of high-grade (Outerbridge grade III or IV) pathology. Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Western Ontario Stability Index (WOSI), visual analog scale (VAS), and Simple Shoulder Test (SST) scores were collected at median 71.5-month follow-up and compared between patients with and without concomitant chondral pathology during the index procedure. Of 100 patients who underwent primary posterior labral repair, 43% had glenoid and/or humeral-sided high-grade chondral pathology. Patients with chondral pathology were older than those without (P < .001). A higher proportion of patients with chondral pathology underwent concomitant biceps tenodesis (19.3% vs. 37.2%, P = .046). The type of anchor (all-suture or solid body, P = .010) used was different between patients with and without chondral pathology at time of posterior labrum repair. There was no difference in reoperation rates at final follow-up between patients with and without chondral damage at time of index procedure (P = .200). All outcome scores were similar between all comer patients with and without chondral pathology. Isolated glenoid pathology was significantly associated with lower QuickDASH (P = .018), higher SST (P = .013), lower VAS (P = .016), and lower WOSI scores (P = .046) compared to patients with bipolar lesions. After stratifying by age, there was an association between chondral pathology and lower VAS and WOSI scores in patients aged <35 years, and there was an association between chondral pathology and lower SST scores in patients aged ≥35 years. Based on median QuickDASH, SST, WOSI, and VAS scores, subjective and functional outcomes after primary arthroscopic posterior labral repair were not negatively influenced by the presence of concomitant chondral damage at the time of surgery for patients aged <35 years at minimum 2-year follow-up. Although our primary outcome score, the QuickDASH, was not significantly associated with the presence of chondral damage in patients aged >35 years, SST scores were negatively influenced by concomitant chondral damage in this older cohort, but this may not be adequately powered. It appeared that patients with chondral damage localized to the glenoid tended to have better outcomes scores that those with bipolar damage.

Implant survival and functional results of endoprosthetic reconstruction for proximal femoral metastases with pathological fractures.

This study aimed to evaluate the patient and implant survival, clinical and functional outcomes, and the rate of complications resulting in reconstruction failure following endoprosthetic reconstruction (EPR) of extensive proximal femoral metastases associated with actual or impending pathological fractures. A total of 111 patients with actual or impending pathological fractures due to metastatic disease of the proximal femur were treated with EPR between 2003 and 2018. Staged surgery, bilateral EPR, was performed in 3 cases. The patients comprised 51 females and 60 males with a mean age of 52.1 ± 12.3 years. The patient and implant survival were recorded. Clinical and functional outcomes were assessed by using the visual analogue scale (VAS), Musculoskeletal Tumour Society (MSTS) functional scoring, and Karnofsky Performance Scale (KPS). The different types of abductor mechanism repair were evaluated by functional tests and existence of Trendelenburg gait at postoperative follow-ups. The complications resulting in reconstruction failure were investigated. The mean follow-up was 23.1 ± 17.9 months. The overall survival of patients after EPR was 89% at 6 months, 72% at 1 year and 10% at 5 years. The estimated 1- and 5-year overall implant survival was 100% and 97.3% (95% CI, 0.95-0.98), respectively, as the endpoint was defined as complete removal of the prosthesis. Median VAS score before endoprosthetic replacement was 8 and after 3 months 4. Before surgery, the median MSTS score was 40 (30-56.6%) and the median KPS score was 40 (30-50). Postoperative third month, the median MSTS score was 56.6 (53.3-86.6%) and the median KPS score was 60 (40-70). Functional scores were superior in trochanter major split osteotomized group compared to trochanter major removed group. Trendelenburg gait was seen in 20 (17.5%) patients postoperatively. There were 10 (8.7%) complications resulting in reconstruction failure. Endoprosthetic replacement can provide a durable fixation with high implant survival rate and good clinical and functional results in extensive proximal femoral metastases associated with a pathological fracture.

Continuous Pectoral Nerve Block Compared With Continuous Thoracic Paravertebral Block and Intravenous Opioid Analgesia for the Postoperative Analgesic Efficacy in Patients Undergoing Modified Radical Mastectomy: A Prospective Randomized Trial.

Postoperative pain following mastectomy is often severe and pain management is necessary. We evaluated the analgesic efficacy of continuous pectoral nerve block (PEC) in comparison with that of the continuous thoracic paravertebral block (TPVB) and the intravenous opioid analgesia in patients scheduled for modified radical mastectomy (MRM). A total of 90 female patients aged 20 to 70 years, American Society of Anesthesiologists (ASA) I to III, undergoing unilateral MRM were randomly allocated into 3 groups. All patients received postoperative morphine patient-controlled analgesia (PCA). Continuous TPVB and continuous PECs were added in group II and group III, respectively. Postoperative morphine consumption during the first 48 hours and postoperative visual analog scale were recorded. The cumulative morphine consumption in the first 24 hours postoperative was higher in the PCA-M group (27.47±4.95 mg) than that of the TPVB group (8.43±2.67 mg) and PEC group (13.47±3.89 mg) (P<0.001, confidence interval: 16.6-21.5 and 11.6-16.4, respectively). It was significantly higher in the PEC group as compared with the TPVB group (P<0.001, confidence interval: 2.6-7.5). On admission to postanesthesia care unit till 2 hours postoperative, the median visual analog scale score at rest was higher in the PCA-M group than that of the TPVB group (P<0.05) and PEC group (P<0.05) without statistical difference between the TPVB group and PEC group. Continuous PEC and continuous TPVB reduced the postoperative morphine consumptions as compared with the intravenous opioid analgesia in patients undergoing MRM with greater reduction in TPVB and without increased adverse effects.

Analysis of pain perception associated with urodynamic testing in children over 3 years old

ObjectiveTo measure the tolerance of urodynamic testing (UDT) in the pediatric patient by means of the Visual Analog Scale (VAS). To analyze which clinical and UDT-related variables influence pain perception. Material and methods. Cross-sectional study of 139 pediatric patients undergoing UDT (December 2013 - May 2018). Inclusion criteria: understanding and expressing their experience after UDT (preschool and school age). No adolescents were included.Measurement instrument Visual Analog Scale (0−10). Other clinical and UDT-associated variables were obtained. Statistical analysis: Mann-Whitney U test, Kruskal Wallis test. Spearman’s rank correlation analysis (rs). Multivariate analysis through ordinal logistic regression. Significance p < 0.05. ResultsMean age 7.7 years (SD 2.4), median VAS score, 2 (2–6). In 41% (n = 57), the score was ≥ 4 (moderate pain). Multivariate analysis. Explanatory variables for obtaining a high VAS score: high APUDT score (identifying patient anxiety prior to UDT), sensory-motor alteration in the lower limbs, difficult bladder catheterization and the appearance of pain during the filling phase. Age and duration of the UDT have not influenced the VAS score. ConclusionsAlthough the UDT has resulted in 40% of the pediatric patients in our study expressing discomfort or pain, it is a well-tolerated test.The variables that have influenced on pain perception were patient’s anxiety prior to UDT, a sensory-motor alteration located in the lumbosacral metameres, difficult bladder catheterization and the appearance of pain during bladder filling.

Arthroscopic Reduction and Fixation With a Knotless Double-Row Construct Provides Good Results for Displaced Greater Tuberosity Fractures

PurposeThe purpose of the study is to describe the functional and structural outcomes of the arthroscopic 4-strand, knotless, double-row construct with suture tapes for the surgical treatment of displaced and/or comminuted greater tuberosity fractures of the humerus.MethodsPatients were enrolled between December 2012 and January 2018. The main inclusion criteria were a comminuted and/or displaced tuberosity fracture with a displacement of at least 5 mm in any plane fixed under arthroscopy using a 4-strand, knotless, double-row construct. The technique involves reducing the displaced fragment with 2 medially placed, transtendinous anchors and compressing the greater tuberosity using the tapes from these medial anchors in 2 laterally placed anchors. The exclusion criteria were a fracture that was more than 10 days old at the time of surgery or a history of shoulder surgery and 3- or 4-part fractures. The postoperative rehabilitation protocol was similar for all patients. Constant scores, Quick Dash, return to work and sport, and complications were reported after a minimum follow-up period of 24 months. Bone healing was systematically evaluated on standardized radiographs, including lateral scapula view and anteroposterior views.ResultsTwenty-one patients were enrolled in this study. One patient did not complete the follow-up examination period and thus was excluded, leaving 20 patients in this study. At a median (SD) follow-up of 32 (9) months, the median (SD) Constant score was 94.7 (7.3) points, the median (SD) Quick Dash was 1.7 (4) points, and median (SD) visual analog scale score was 0.5 (1.4). All patients returned to previous work and sport level. No malunions or nonunions were seen. One conversion to open surgery was required for failure of the lateral row during surgery in a 62-year-old woman with osteopenic bone. Two patients experienced complex regional pain syndrome in the postoperative period that resolved after nonoperative treatment.ConclusionsIn this series, the use of arthroscopy combined with the biomechanical properties of knotless double-row constructs contributed to postoperative satisfactory functional results and healing of greater tuberosity fracture. In addition, range of motion was early, and no hardware removal was required. However, care should be taken with osteopenic bone where anchorage can fail.Level of EvidenceLevel IV, case series.

Simple Anal Fistula: Clinical Criteria for Diagnosis and Local Anesthesia with Conscious Sedation for Surgery -an Observational Study

ABSTRACT PURPOSE: To evaluate (i) acceptability of surgery for simple anal fistula under local anesthesia with conscious sedation by the patients and (ii) accuracy of a set of clinical criteria for diagnosis of simple anal fistula. METHODS: A set of clinical criteria based on physical findings was used to diagnose patients with simple anal fistula. These patients were operated under local anesthesia with conscious sedation. Intravenous paracetamol, diclofenac sodium, and midazolam were administered as adjuvants. Fistulotomy with/without marsupialisation was performed in most patients. Clinical diagnosis was matched with operative findings. RESULTS: Among 193 patients presenting with anal fistula, 61 patients were diagnosed as simple anal fistula and were scheduled for surgery under local anesthesia with conscious sedation. One patient was found to have complex anal fistula during intraoperative assessment and surgery was deferred. Surgery could be completed under local anesthesia with conscious sedation for 58/60 (96.7%) patients. Acceptability of the procedure was assessed with two parameters: the patients’ satisfaction score on visual analogue scale and their willingness to undergo fistula surgery under local anesthesia again, if required. Median (interquartile range) visual analogue scale score for patients’ satisfaction was 10 (9-10). All the patients expressed their willingness to undergo fistula surgery under local anesthesia again, if required. The clinical criteria was successful in diagnosing simple anal fistula in 58/61 (95.1%) patients. The remaining three patients had high intersphincteric fistula (1) and blind sinus (2). CONCLUSIONS: Acceptability of surgery for simple anal fistula under local anesthesia with conscious sedation was excellent. The proposed clinical criteria were highly accurate in diagnosing simple anal fistula.

Análisis de la percepción del dolor asociado al estudio urodinámico en niños mayores de tres años

ObjectiveTo measure the tolerance of urodynamic testing (UDT) in the pediatric patient by means of the Visual Analog Scale (VAS). To analyze which clinical and UDT-related variables influence pain perception. Material and methods. Cross-sectional study of 139 pediatric patients undergoing UDT (December 2013 - May 2018). Inclusion criteria: understanding and expressing their experience after UDT (preschool and school age). No adolescents were included.Measurement instrument Visual Analog Scale (0-10). Other clinical and UDT-associated variables were obtained. Statistical analysis: Mann-Whitney U test, Kruskal Wallis test. Spearman's rank correlation analysis (rs). Multivariate analysis through ordinal logistic regression. Significance p < 0.05. ResultsMean age 7.7 years (SD 2.4), median VAS score, 2 (2-6). In 41% (n = 57), the score was ≥ 4 (moderate pain). Multivariate analysis. Explanatory variables for obtaining a high VAS score: high APUDT score (identifying patient anxiety prior to UDT), sensory-motor alteration in the lower limbs, difficult bladder catheterization and the appearance of pain during the filling phase. Age and duration of the UDT have not influenced the VAS score. ConclusionsAlthough the UDT has resulted in 40% of the pediatric patients in our study expressing discomfort or pain, it is a well-tolerated test.The variables that have influenced on pain perception were patient's anxiety prior to UDT, a sensory-motor alteration located in the lumbosacral metameres, difficult bladder catheterization and the appearance of pain during bladder filling.

Comparison of intravenous ketorolac at three doses for treating renal colic in the emergency department: A noninferiority randomized controlled trial.

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that is extensively used for the management of renal colic in the emergency department (ED). It has been proposed that ketorolac is used at doses above its analgesic ceiling with no more advantages and increased risk of adverse effects. In this study, we compared the analgesic effects of three doses of intravenous ketorolac in patients with renal colic. This noninferiority, randomized, double-blind clinical trial evaluated the analgesic efficacy of three doses of intravenous ketorolac (10, 20, and 30mg) in adult patients presenting to the ED with renal colic. Exclusion criteria consisted of age > 65 years, active peptic ulcer disease, acute gastrointestinal hemorrhage, renal or hepatic insufficiency, NSAID hypersensitivity, pregnancy or breastfeeding, unstable vital signs, and patients who had received analgesics in the past 24 hours. Pain was recorded every 15minutes from baseline up to 60minutes, and the primary outcome was pain reduction at 30minutes. If patients still required additional pain medications at 30minutes, they would receive 0.1mg/kg intravenous morphine sulfate as a rescue analgesic. A total of 165 subjects enrolled in this study, 55 in each group. The median visual analog scale score in 30 minutes was improved from 90 at baseline to 40 among subjects who were randomized to 30-mggroup. This improvement was 40and 50mm in 20- and 10-mg ketorolac treatment arms, respectively, with no significant difference between the three doses (p<0.05). Secondary outcomes showed similar rescue analgesic administration and adverse effects. There was no serious adverse event. Ketorolac at 10-, 20-, and 30-mg doses can produce similar analgesic efficacy in renal colic.

Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome.

Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4–5 mL of an O2-O3 mixture (24 μg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman’s rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.