Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review.

INTRODUCTION: Group A streptococcus (Streptococcus pyogenes) is one of the most lethal bacterial pathogens of humans, with increased risk of progression to septic shock and multiorgan failure in the pregnant population. The objective of this study is to systematically review the outcomes and management strategies for pregnancy and puerperal group A streptococcus infections in an effort to provide further guidance for prevention and treatment of a rare but lethal infection worldwide. MATERIAL AND METHODS: A comprehensive search using puerperium and streptococcus pyogenes terms was completed across several registered databases. A total of 902 articles investigating pregnancy and puerperal group A streptococcus infection were identified, with 40 studies fulfilling inclusion criteria of original research articles in humans published from 1990 onwards reporting four or more unique cases of group A streptococcus in pregnancy or postpartum. This study was registered in PROSPERO: CRD42020198983. RESULTS: A total of 1160 patients with pregnancy and puerperal group A streptococcus infection were identified. Most infections occurred postpartum (91.9%), with 4.7% reported antepartum and 0.6% intrapartum. Bacteremia was present in 49.0% of patients and endometritis in 45.9%. Puerperal sepsis was described in 28.2% of cases and progressed to streptococcal toxic shock syndrome in one-third of such cases. Overall, the case fatality ratio was 2.0%, with one-third of the deaths from antenatal cases including 3/22 (13.6%) cases of septic abortion and 10/46 (21.7%) antenatal cases of group A streptococcus infection. CONCLUSIONS: Group A streptococcus infection remains an important contributor to pregnancy and puerperal morbidity and mortality. Early recognition, diagnosis and aggressive management are important for favorable outcomes given the serious risk of sepsis and streptococcal toxic shock syndrome.

Antibiotic Use and Surgical Site Infections in Immunocompromised Patients After Mohs Micrographic Surgery: A Single-Center Retrospective Study.

BACKGROUND: As Mohs micrographic surgery becomes more widely used in immunosuppressed patients, it is important to understand the risks in this unique population. OBJECTIVE: To determine whether immunosuppressed patients are at an increased risk for surgical site infection and evaluate the utility of postoperative antibiotics for the prevention of surgical site infection. MATERIALS AND METHODS: A single-center retrospective review of patients who underwent Mohs micrographic surgery between October 9, 2014, and August 20, 2021, was performed. RESULTS: Five thousand eight hundred eighty-six independent cases were identified. Factors associated with an increased incidence of antibiotic use included preoperative lesion size >40 mm (86.7%, n = 13; p < .01) and high-risk lesion location (46.4%, n = 1,268; p < .01). Patients were not more likely to be prescribed antibiotics if immunosuppressed (37.0%, n = 269 vs 34.2%, n = 1765; p = .14), and immunosuppression was not independently associated with antibiotic use on multivariate analysis (odds ratio 1.2, 95% confidence interval 1.0-1.5). Infection rates were similar between immunocompromised patients and immunocompetent patients (2.1%, n = 15 vs 1.6%, n = 80, respectively; p = .30). In immunosuppressed patients, antibiotic use did not decrease the likelihood of infection (3.0%, n = 8 vs 1.5%, n = 7; p = .19). CONCLUSION: There was no association between immunosuppression and surgical infection rate. Furthermore, postoperative antibiotics should not be indicated in these patients unless other high-risk criteria exist.

Screening for Gonococcal and Chlamydial Infections in the Third Trimester.

A retrospective study was conducted at our institution of all patients who delivered between May 2016 and April 2017. A change of practice had been instituted, which involved obstetricians testing for Neisseria gonorrhoeae and Chlamydia trachomatis universally in the first and third trimesters. Medical records were reviewed for N. gonorrhoeae and C. trachomatis results and for risk factors traditionally associated with sexually transmitted infections (STIs). A substantial proportion of patients (10.7%) had not undergone screening during pregnancy. We also identified third-trimester cases of infection in asymptomatic patients who had no traditional risk factors STI acquisition, which raised the question of optimal timing for STI screening during pregnancy.

Development and validation of patients' surgical safety checklist.

BACKGROUND: Poor uptake and understanding of critical perioperative information represent a major safety risk for surgical patients. Implementing a patient-driven surgical safety checklist might enhance the way critical information is given and increase patient involvement in their own safety throughout the surgical pathway. The aim of this study was to develop and validate a Surgical Patient Safety Checklist (PASC) for use by surgical patients. METHOD: This was a prospective study, involving patient representatives, multidisciplinary healthcare professionals and elective surgical patients to develop and validate PASC using consensus-building techniques in two Norwegian hospitals. A set of items intended for PASC were rated by patients and then submitted to Content Validation Index (CVI) analyses. Items of low CVI went through a Healthcare Failure Mode and Effect Analysis (HFMEA) Hazard Scoring process, as well as a consensus process before they were either kept or discarded. Reliability of patients' PASC ratings was assessed using Intraclass Correlation Coefficient analysis. Lastly, the face validity of PASC was investigated through focus group interviews with postoperative patients. RESULTS: Initial development of PASC resulted in a checklist consisting of two parts, one before (32 items) and one after surgery (26 items). After achieving consensus on the PASC content, 215 surgical patients from six surgical wards rated the items for the CVI analysis on a 1-4 scale and mostly agreed on the content. Five items were removed from the checklist, and six items were redesigned to improve PASCs' user-friendliness. The total Scale-level index/Average (S-CVI/Ave) before revision was 0.83 and 0.86 for pre- and post-operative PASC items, respectively. Following revision, these increased to 0.86 and 0.93, respectively. The PASC items reliability score was 0.97 (95% confidence interval 0.96 to 0.98). The qualitative assessment identified that patients who used PASC felt more in control of their situation; this was achieved when PASC was given to them at what they felt was the right time and healthcare professionals took part in its usage. CONCLUSION: Multidisciplinary perioperative care staff and surgical patients agreed upon PASC content, the checklist ratings were reliable, and qualitative assessment suggested good face validity. PASC appears to be a usable and valid checklist for elective surgical patients across specialties.

HIV Infection in Pregnant Women: A 2020 Update.

Acquired immunodeficiency syndrome (AIDS) was first described in 1981, and continues to be one of the worst global health pandemics in recorded history. Concerted international efforts have helped to increase awareness of human immunodeficiency (HIV) status, improve access to treatment and continuation of therapy to achieve viral suppression with a goal of ending the AIDS epidemic by 2030. The clinical outcomes for patients living with HIV on combined antiretroviral therapy are considerably improved with prolonged life expectancy and superior quality of life. Further, perinatal transmission rates have dramatically decreased with elimination of mother to child transmission of HIV in a growing number of countries worldwide. However, there have been significant reductions in the pace of progress in treatment expansion for pregnant women with failure to meet global targets in 2018. In this review, we will highlight recent advances and challenges ahead in 2020 for three areas of perinatal care for women with HIV in developed countries: (a) pregnancy planning considerations, (b) impact of antiviral medications on perinatal outcomes, and (c) infant feeding practices. The promise of a HIV-free generation is on the horizon and continued international efforts in preventing perinatal transmission are an important component of this achievement.

BI-RADS 3 (short-interval follow-up) assessment rate at diagnostic mammography: Correlation with recall rates and utilization as a performance benchmark.

The purpose of this study was to identify a correlation between the screening BI-RADS 0 (recall) rates and diagnostic BI-RADS 3 (short-interval follow-up) rates of individual interpreting radiologists, with the goal of utilizing the BI-RADS 3 rate as an acceptable performance metric in the diagnostic population. A multicenter retrospective analysis of medical audit statistics was conducted on annual radiologist performance data collected over a 14-year period in a community hospital-based practice. Mixed regression models were used to estimate the association between screening BI-RADS 0 and diagnostic BI-RADS 3 examinations while adjusting for calendar year, annual radiologist screening volume, annual radiologist diagnostic volume, and diagnostic examination indication. A moderate statistically significant positive correlation was established between the screening BI-RADS 0 rates and Diagnostic BI-RADS 3 rates (Pearson correlation coefficient + 0.349, P ≤ .001). Furthermore, when utilizing a national benchmark range of 8%-12% as an acceptable BI-RADS 0 rate within a screening population, the correlative BI-RADS 3 assessment rate was demonstrated to be approximately 16%. We propose that this BI-RADS category 3 rate may represent an additional acceptable performance metric in the diagnostic population. Routine inclusion of an interpreting mammographer's diagnostic BI-RADS 3 rate in the annual medical audit may help reduce inappropriate and/or excess use of the BI-RADS 3 category, which may lead to significant potential reductions in follow-up examinations with their associated healthcare-related costs, resource expenditure, and induced patient anxiety.

Safety of Cabergoline for Postpartum Lactation Inhibition or Suppression: A Systematic Review.

This study sought to perform a systematic review of adverse events reported with the use of cabergoline for postpartum lactation inhibition or suppression in women aged 15 to 50. Following registration with PROSPERO (CRD42017049894), a comprehensive search of the Ovid databases Medline, Embase, and CENTRAL, along with PubMed, was conducted from January 1, 1985 to January 25, 2018. All study designs investigating cabergoline use for postpartum lactation inhibition or suppression in women aged 15 to 50 were included. A total of 695 articles were retrieved, and 25 articles were eligible for inclusion. Adverse events were then reported in terms of frequency, with percentages calculated according to the total number of women exposed to the intervention. A bias assessment of the articles was also performed. Among a total of 757 women, 108 adverse events were observed in 96 women (14.2%). The most common adverse events were dizziness (35 of 757), headache (30 of 757), and nausea or vomiting (19 of 757). These events were described as short-lived, self-resolving, and dose dependent. One pharmacovigilance study reported 29 "serious" events from a total of 175 events in 72 case reports, which included thromboembolic and neurologic events. Four case studies specifically addressed the psychiatric population, with one half reporting psychiatric symptoms following administration of cabergoline. In conclusion, this systematic review demonstrates that adverse events were generally benign and tolerable following the administration of cabergoline. However, pharmacovigilance data reveal that vigilance is still needed given the occurrence of rare but serious events.

Patients' and healthcare workers' recommendations for a surgical patient safety checklist - a qualitative study.

BACKGROUND: Patients' involvement in patient safety has increased in healthcare. Use of checklists may improve patient outcome in surgery, though few have attempted to engage patients' use of surgical checklist. To identify risk elements of complications based on patients' and healthcare workers' experiences is warranted. This study aims to identify what the patients and healthcare workers find to be the risk elements that should be included in a patient-driven surgical patient safety checklist. METHOD: A qualitative study design where post-operative patients, surgeons, ward physicians, ward nurses, and secretaries from five surgical specialties took part in focus group interviews. Eleven focus groups were conducted including 25 post-operative patients and 27 healthcare workers at one tertiary teaching hospital and one community hospital in Norway. Based on their experiences, participants were asked to identify perceived risks before and after surgery. The interviews were analysed using content analysis. RESULTS: Safety risk factors were categorised as pre-operative information: pre-operative preparations, post-operative information, post-operative plans and follow-up. The subcategories under pre-operative information and preparations were: contact information, medication safety, health status, optimising health, dental status, read information, preparation two weeks before surgery, inform your surgical ward, planning your own discharge, preparation on admission and just before surgery. The subcategories under post-operative information, further plans and follow-up were: prevention and complications, restriction and activity, medication safety, pain relief, stomach functions, further care and appointments. Both healthcare workers and patients express the need for a surgical patient safety checklist. CONCLUSION: A broad spectre of risk elements for a patient safety checklist were identified. Developing a surgical safety checklist based on these risk elements might reduce complications and unwanted errors. TRAIL REGISTRATION: The study is registered as part of a clinical trial in ClinicalTrials.gov: NCT03105713.

Is self-screening for 'at risk of malnutrition' feasible in a home setting?

INTRODUCTION: Despite malnutrition being established as a well-known risk for postoperative complications, the lack of screening for nutritional risk remains a challenge. The aim of this study was to investigate whether self-screening for nutritional risk prior to surgery is feasible in a home setting and if it will increase number of patients screened for nutritional risk, and secondly, to compare their screening results with the "in-hospital assessments" conducted by healthcare professionals. MATERIALS AND METHODS: This was a prospective study involving patients from six randomly selected surgical wards at two Norwegian hospitals as a part of the "Feasibility study of implementing the surgical Patient Safety Checklist the (PASC)". This checklist included a self-reported screening tool based on the Nutritional Risk Screening tool (NRS 2002) to identify "at risk of malnutrition" in patients that will undergo surgery the next 3 months or less. The original screening tool (NRS 2002) was used as a standard routine to identify "at risk of malnutrition" by healthcare professionals at hospital. The interrater reliability between these results was investigated using Fleiss multi rater Kappa with overall agreement and reported with Landis and Koch's grading system (poor, slight, fair, moderate, substantial, and almost perfect). RESULTS: Out of 215 surgical patients in the home setting, 164 (76.7%) patients completed the self-reported screening tool. A total of 123 (57.2%) patients were screened in-hospital, of whom 96 (44.7%) prior to surgery and 96 (44.7%) were screened both at hospital (pre- and post-surgery) and at home. Self-screening at home improved malnutrition screening participation by 71.9% compared to hospital screening prior to surgery (165 (76.7%) and 96 (44.7%), respectively) and by 34.1% compared to pre- and postoperative in-hospital screening, 165 (76.7%) and 123 (57.2%), respectively). The degree of agreement between patients identified to be "at risk of malnutrition" by the self-reported screening tool and healthcare professionals was poor (κ = - 0.04 (95% CI: -0.24, 0.16), however, the degrees of agreement between the patients and healthcare professionals answers to the initial NRS 2002 questions "low BMI", "weight loss", and "reduced food intake" were almost perfect (κ = 1.00 (95% CI: 0,82, 1.18)), moderate (κ = 0.55 (95% CI: 0.34, 0.75)), and slight (κ = 0.08 (95% CI: - 0.10, 0.25) respectively. CONCLUSIONS: Three out of four patients completed the self-screening form and the preoperative screening rate improved with 70%. Preoperatively self-screening in a home setting may be a feasible method to increase the number of elective surgical patients screened for risk of malnutrition. TRIAL REGISTRATION: The trial is registered in ClinicalTrials.gov ID NCT03105713. https://classic.clinicaltrials.gov/ct2/show/NCT03105713.

Meta-Analysis of Long-Term (>1 Year) Cardiac Outcomes of Peripartum Cardiomyopathy.

Peripartum cardiomyopathy is the development of heart failure toward the end of pregnancy or in the months after delivery in the absence of other attributable causes, with left ventricular systolic dysfunction and a left ventricular ejection fraction (LVEF) generally <45%. Given that patients are relatively young at the time of diagnosis, this study was performed to summarize current evidence surrounding the long-term cardiac outcomes. MEDLINE, Embase, Cochrane CENTRAL, and CINAHL were searched for original studies that reported long-term (>1 year) patient outcomes. Of the 3,144 total records identified, 62 studies involving 4,282 patients met the selection criteria. The mean LVEF was 28% at diagnosis and 47% at the time of the last follow-up. Approximately half of the patients achieved myocardial recovery (47%), most commonly defined as an LVEF >50% (n = 21). The prevalence of implantable cardioverter-defibrillator use, left ventricular assist device implantation, and heart transplantation was 12%, 7%, and 11%, respectively. The overall all-cause mortality was 9%, and despite having more cardiovascular risk factors, patients residing in high-income countries had superior outcomes, including reduced rates of mortality.

Feasibility of implementing a surgical patient safety checklist: prospective cross-sectional evaluation.

BACKGROUND: The World Health Organization's Global Patient Safety Action Plan 2021-2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients' involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients' completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial. METHODS: This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis. RESULTS: Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway. CONCLUSIONS: Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03105713. Registered 10.04.2017.

Recently-Arrived Afghan Refugee Parents' Perspectives About Parenting, Education and Pediatric Medical and Mental Health Care Services.

Refugee children are at risk for mental/behavioral health problems but may not receive timely diagnosis or care. Parental experiences and perspectives about resources in the US may help guide interventions to improve mental/behavioral health care. In a community-academic partnership, we performed a qualitative study of recently-arrived Afghan refugee parents, using in-depth, semi-structured interviews to characterize experiences with parenting, education, and health care services. A four-person coding team identified, described, and refined themes. We interviewed 19 parents from ten families, with a median residence in the US of 24 months. Four themes emerged; parents described: (1) shifting focus as safety needs changed, (2) acculturation stress, (3) adjustment to an emerging US support system, and (4) appreciation of an engaged health care system. Health and educational providers' appreciation for the process of acculturation among newly-arrived refugee Afghan families may facilitate screening, diagnostic, and intervention strategies to improve care.

Patient-completed safety checklists as an empowerment tool for patient involvement in patient safety: concepts, considerations and recommendations.

The application of safety checklists to healthcare settings to help systematise routines and improve communication between healthcare professionals has proven to be effective in reducing errors, complications, mortality and hospitalisation time. There is a new call to extend the checklist concept to develop safety checklists that can be used by patients to help empower their involvement in safety practices. Only a handful of studies around patient-completed checklists exist, but those that do indicate a positive impact on patient empowerment and involvement in safety-related behaviours. In this article, we present the concept of patient-completed checklists and provide a review of the existing evidence, highlighting important design and implementation considerations, and making recommendations for future research and development.

Obesity in pregnancy: a comparison of four national guidelines.

BACKGROUND: Obesity in pregnancy has become one of the most important challenges in obstetrical care given its prevalence and potential adverse impact on both mother and fetus. The primary objective of this descriptive review is to identify common themes and distinctions within the current recommendations for maternal obesity in the most updated version of four published national guidelines. METHODS: We reviewed the following guidelines for obesity in pregnancy: American College of Obstetricians and Gynecologists (ACOG) 2015, Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) 2013, Royal College of Obstetrics and Gynecology (RCOG) 2010, and Society of Obstetrics and Gynecologists of Canada (SOGC) 2010. RESULTS: There were no major contradictions between the guidelines, however, variations did exist. Recognition of overweight and obese populations prenatally was uniformly emphasized, so that appropriate nutrition and exercise counseling could be provided prior to pregnancy. Obesity in pregnancy was consistently defined as a body mass index of 30 kg/m2 or more, and weight gain recommendations were in line with the Institute of Medicine guidelines. Counseling patients regarding the specific maternal and fetal complications in pregnancy, delivery, and postpartum which are associated with obesity was consistently emphasized. Most guidelines recommended early screening for gestational diabetes, however, specific details were not provided. All guidelines stressed the importance of available resources in clinics and the operating room specific to the obese population. Disparities were found regarding recommendations for high-dose folic acid, vitamin D supplementation, and low-dose aspirin. Thromboprophylaxis is a matter of debate, with most guidelines recommending use on an individual patient basis. CONCLUSIONS: In general, the guidelines emphasized the importance of counseling women regarding the risks associated with obesity in pregnancy, and stressed the necessity of screening for these adverse outcomes. Initiatives to develop common terminology and reporting of outcomes in women's health are important for the development of cohesive and uniform recommendations for patient care. Disparities existed with respect to management strategies and where the further research and systematic reviews should be targeted, to allow clinicians to provide an appropriate obstetrical care pathway for obese women.

Oncologic Trends, Outcomes, and Risk Factors for Locoregional Recurrence: An Analysis of Tumor-to-Nipple Distance and Critical Factors in Therapeutic Nipple-Sparing Mastectomy.

BACKGROUND: Oncologic outcomes with nipple-sparing mastectomy continue to be established. The authors examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance, in therapeutic nipple-sparing mastectomies. METHODS: Demographics, outcomes, and overall trends for all nipple-sparing mastectomies performed for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including tumor-to-nipple distance. RESULTS: A total of 496 therapeutic nipple-sparing mastectomies were performed, with an average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4 percent) and ductal carcinoma in situ (50.4 percent). Sentinel lymph node sampling was performed in 79.8 percent of nipple-sparing mastectomies; 4.1 percent had positive frozen sentinel lymph node biopsy results, whereas 15.7 percent had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5 percent) followed by stage 0 (31.3 percent). The rate of local recurrence was 1.6 percent (n = 8), and the rate of regional recurrence was 0.6 percent (n = 3). In all, 171 nipple-sparing mastectomies had magnetic resonance imaging available with which to assess tumor-to-nipple distance. Tumor-to-nipple distance of 1 cm or less (25.0 percent versus 2.4 percent; p = 0.0031/p = 0.1129) and of 2 cm or less (8.7 percent versus 2.0 percent; p = 0.0218/p = 0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, tumor-to-nipple distance of 1 cm or less was the only significant risk factor for recurrence (OR, 13.5833; p = 0.0385). No factors were significant in regression analysis. CONCLUSIONS: In early stage and in situ breast carcinoma, therapeutic nipple-sparing mastectomy appears oncologically safe, with a locoregional recurrence rate of 2.0 percent. Tumor-to-nipple distances of 1 cm or less and 2 cm or less trended to higher recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Sulforaphane and erucin increase MRP1 and MRP2 in human carcinoma cell lines.

Multidrug resistance (MDR) transporters have been termed the Phase III detoxification system because they not only export endogenous metabolites but provide protection from xenobiotic insult by actively secreting foreign compounds and their metabolites from tissues. However, MDR overexpression in tumors can lead to drug resistance, a major obstacle in the treatment of many cancers, including lung cancer. Isothiocyanates from cruciferous vegetables, such as sulforaphane (SF) and erucin (ER), are known to enhance the expression of Phase II detoxification enzymes. Here we evaluated the ability of SF and ER to modulate MDR mRNA and protein expressions, as well as transporter activity. The expression of P-glycoprotein (P-gp), multidrug resistance protein 1 (MRP1) and multidrug resistance protein 2 (MRP2) in liver (HepG2), colon (Caco-2) and lung (A549) cancer cells treated with ER or SF was analyzed by Western blotting. Neither SF nor ER affected P-gp expression in any of the cell lines tested. Both SF and ER increased the protein levels of MRP1 and MRP2 in HepG2 cells and of MRP2 in Caco-2 cells in a dose-dependent manner. In A549 lung cancer cells, SF increased MRP1 and MRP2 mRNA and protein levels; ER caused a similar yet smaller increase in MRP1 and MRP2 mRNA. In addition, SF and ER increased MRP1-dependent efflux of 5-carboxyfluorescein diacetate in A549 cells, although again the effect of SF was substantially greater than that of ER. The implication of these findings is that dietary components that modulate detoxification systems should be studied carefully before being recommended for use during chemotherapy, as these compounds may have additional influences on the disposition of chemotherapeutic drugs.

What should be the optimal cut points for mild, moderate, and severe pain?

PURPOSE: Grouping patients' rating of pain intensity from 0 to 10 into categories of mild, moderate, and severe pain is useful for informing treatment decisions, interpreting study outcomes, as well as aiding policy or clinical practice guidelines development. In 1995, Serlin and colleagues developed a technique to establish the cut points for mild, moderate, and severe pain by grading pain intensity with functional interference. Since then, a number of studies attempted to confirm these findings in similar or different populations but had different results. Such inconsistencies in the literature prompt for more research to establish the definition of mild, moderate and severe pain. Thus, the purpose of the current study was to identify optimal cut points (CP) of the three pain severity categories for worst, average, and current pain. PATIENTS AND METHODS: The study population (n = 199) was patients with symptomatic bone metastases referred to a palliative radiotherapy clinic. Using the Brief Pain Inventory (BPI), patients reported their worst, average, and current pain intensity, as well as the degree of functional interference due to pain. All possible combinations for the CPs, between 2 and 8, were created and related to the set of 7 interference items from the BPI using the multivariate analysis of variance (MANOVA). The criteria used to determine the optimal set of cut points for mild, moderate and severe pain was a MANOVA among pain severity categories that yielded the largest F ratio for the between-category effect on the 7 interference items as indicated by Pillai's trace, Wilk's lambda, and Hotelling's trace F statistics. RESULTS: Results confirmed a non-linear relationship between cancer pain severity and functional interference. The optimal CP for worst and average pain was CP4, 6 (mild = 1-4, moderate = 5-6, and severe = 7-10), confirming Serlin and colleagues's findings. CONCLUSION: These findings are pivotal in further understanding the meaning of pain intensity levels and the assessment of pain in patients with metastatic cancer. However, further research in alternative methods of defining the optimal CP and clinically important change should be considered.