Tracheal airway pressure in tracheostomy tube capping trials: an experimental study.

BACKGROUND: Tracheostomy tube capping is a commonly used test to determine if the tracheostomy tube can be removed. The success of the capping trial depends on the patient's ability to maintain sufficient spontaneous breathing with an occluded tracheostomy tube. The impact of an occluded tracheotomy tube on airway resistance is currently unknown. The aim of this study was to investigate tracheal pressure during capping or stoma button insertion and potential determinants concerning cuff. METHODS: Eight cuffed and uncuffed tracheostomy tubes and three stoma buttons of various manufacturers and sizes were inserted into the trachea model. Cuffs were completely deflated or contained atmospheric pressure. The trachea was ventilated bidirectional with a respirator in volume-controlled mode and volume flows 15-60 L/min. Tracheal pressure drop during inspiration as a parameter of pressure required to move gas through the airway was measured. RESULTS: Tracheal pressure drops occurred linearly or irregularly during capping trials to a maximum of 4.2 kPa at flow rates of 60 L/min for atmospheric pressure cuffs. In tracheostomy tubes with completely deflated cuffs, pressure drop in the trachea reaches a maximum of 3.4 kPa at a flow rate of 60 L/min. For tracheostomy tubes with cuff smaller inner or outer diameters do not regularly result in lower tracheal pressure drop. The pressure drop varies between different tracheostomy tubes depending on the manufacturer. In cuffed tracheostomy tubes, we observed three phenomena: sail-like positioning, folding over, and tightening of the cuff during flow. The maximum tracheal pressure drop during stoma button insertion reaches 0.014 kPa. CONCLUSIONS: The cuff is a central element for the pressure drop in the airway and thus airway resistance during spontaneous translaryngeal breathing with a capped TT. Complete deflation reduces the pressure drop in the trachea. Due to deformation of the cuff, measured pressures are irregular as the volume flow is increased. Incomplete deflated cuffs and material characteristics of tracheostomy tubes and cuffs in addition to anatomical and clinical variables may cause unsuccessful capping trials due to increased airway resistance. All stoma buttons showed that pressure drop and thus airway resistance due to stoma buttons has no clinical relevance.

Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial.

IMPORTANCE: A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements. OBJECTIVE: To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone. DESIGN, SETTING, AND PARTICIPANTS: This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019. INTERVENTIONS: In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles. MAIN OUTCOMES AND MEASURES: The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain. RESULTS: A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups. CONCLUSIONS AND RELEVANCE: Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02364167.

Stimulation of Lactation Using Acupuncture: A Case Study.

INTRODUCTION: Breastfeeding is a recognized preferred method of infant feeding; however, for many women, difficulties in breastfeeding result in termination before the recommended period of time. Acupuncture is suggested to be a promising option to treat lactation insufficiency and enhance the production of maternal milk. MAIN ISSUE: We have reported the case of a woman with lactation insufficiency due to Caesarean section and congenital unilateral invaginated nipple. Milk production started on the 3rd day following delivery. The newborn was not provided with any food or fluids other than mother's milk. At 5 days of life, the newborn required long feeding periods and lost 4% of his birth weight, with the participant reporting lactation insufficiency described by the perception of inadequate milk production. MANAGEMENT: Despite the implementation of conventional measures to improve lactation, the difficulties in breastfeeding persisted. Acupuncture was tried on Day 6 of life, and enhanced milk production was observed, which could be measured as the volume of residual milk extracted using the breast pump each time after the newborn achieved satiety. After acupuncture treatment there was an augmentation of maternal milk production from both breasts and successful lactation. CONCLUSION: This case study provides information that might be useful for prospective investigation of acupuncture's efficacy in women with lactation insufficiency.

Auricular stimulation for preoperative anxiety - A systematic review and meta-analysis of randomized controlled clinical trials.

STUDY OBJECTIVE: Previous randomized controlled trials (RCTs) suggest that auricular stimulation (AS) is safe and effective in treatment of preoperative anxiety; however, a systematic evaluation is lacking. The aim was to summarize the evidence on efficacy and safety of AS for preoperative anxiety, as well as for other outcomes. DESIGN: We conducted a systematic review of RCTs including patients from all available populations. The search was done through MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science and Scopus Database from inception to June 2020. Study selection and data extraction were performed in by 2 independent reviewers with ability to resolve disagreements by a third author. Meta-analyses as well as the risk of bias and evidence quality assessments were performed according to the Cochrane 6.2, 2021 handbook recommendations. INTERVENTIONS: We compared AS with pharmacological and non-pharmacological interventions for different outcomes. MEASUREMENTS: We assessed the repercussion of the evaluated interventions over anxiety scores and their safety, physiological parameters, perioperative medications requirement and intensity of postoperative pain. MAIN RESULTS: We have included 15 studies with 1603 patients. AS has presented reduced anxiety scores as compared to the sham control (Standardized Mean Difference (SMD) -0.72, 95% confidence interval (CI) -1.09 to -0.36, p < 0.0001; 8 trials; 701 patients; heterogeneity: I2 80%; GRADE: moderate certainty) and to no intervention (SMD -1.01, 95% CI -1.58 to -0.45, p = 0.0004; 4 trials; 420 patients; heterogeneity: I2 84%; GRADE: very low certainty). There was no difference between AS and benzodiazepines (SMD -0.03; 95% CI: -0.34 to 0.28; p = 0.84; 3 trials; 158 patients; heterogeneity: I2 0%; GRADE: very low certainty). No trials reported serious adverse effects of AS. CONCLUSIONS: AS may be useful in treatment of preoperative anxiety. Due to heterogenous certainty in effect estimates, further research is needed to clarify the actual efficacy of AS for preoperative anxiety.

Pain perception during injection of local anesthesia in pedodontics.

OBJECTIVE: Few studies have examined pain levels for the injection of local anesthesia in children, though it is a routine technique in pediatric dentistry. The objective of the study was to evaluate the difference in the assessment of procedural pain by the child, parent, dental practitioner, and independent observers during injection of local anesthesia for dental treatment in pediatric dentistry. METHOD AND MATERIALS: In total, 27 male and 22 female children (5 to 17 years of age, mean ± SD 9.8 ± 4.0 years) received local anesthesia (LA) via infiltration or mandibular alveolar blocks according to a standard protocol. After the dental treatment, the children assessed the pain levels for the procedures on a visual analog scale (VAS), while their parents and the dental practitioner used a numeric rating scale (0 to 10). Independent observers also assessed pain via video tape for an evaluation after blinding. The heart rate was monitored continuously during the procedure. The Bland-Altman method was used to quantify the comparison between pain ratings. RESULTS: The assessed level of pain by dental practitioner, parent, and child during injection of LA differed clearly (child: 3.94 ± 2.71; parent: 3.31 ± 2.60; dental practitioner: 3.02 ± 1.98; video observer 1: 1.76 ± 2.56; video observer 2: 1.89 ± 2.55). In 42.9% of cases the dental practitioner's rating and the self--reported pain by the child during injection of LA differed by ≥ 2 on the numeric rating scale, which is clinically a highly different and relevant assessment. CONCLUSION: As pain perception in children during the injection of local anesthetic and its assessment varies considerably depending on the assessing person and the treated child, dental practitioners and researchers should be cautious in interpreting the patient's pain perception.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation.

BACKGROUND: The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. METHODS: One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. RESULTS: Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). CONCLUSION: The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Auricular Acupuncture for Preoperative Anxiety-Protocol of Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Preoperative anxiety causes profound psychological and physiological reactions that may lead to a worse postoperative recovery, higher intensity of acute and persistent postsurgical pain and impaired quality of life in the postoperative period. Previous randomized controlled trials (RCTs) suggest that auricular acupuncture (AA) is safe and effective in the treatment of preoperative anxiety; however there is a lack of systematic evidence on this topic. Therefore, this protocol was developed following the PRISMA guidelines to adequately evaluate the existing literature regarding the value of AA for the reduction in anxiety in patients in a preoperative setting, compared to other forms of acupuncture, pharmacological, or no control interventions and measured with questionnaires regarding anxiety and fear. Methods: The following databases will be searched: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. RCTs will be included if an abstract is available in English. Data collection and analysis will be conducted by two reviewers independently. Quality and risk assessment of included studies will be done using the Cochrane 5.1.0 handbook criteria and meta-analysis of effectiveness and symptom scores will be conducted using the statistical software RevMan V.5.3. Conclusions: This systematic review will evaluate the efficacy and safety of AA for preoperative anxiety. Since all data used in this systematic review and meta-analysis have been published, this review does not require ethical approval. The results may be published in a peer-reviewed journal or be presented in relevant conferences. Registration number: PROSPERO ID CRD42020.

Acupuncture for Relief of Gag Reflex in Patients Undergoing Transoesophageal Echocardiography-A Protocol for a Randomized Placebo-Controlled Trial.

Background: Gagging during transesophageal echocardiography examination (TEE) can be distressing and even dangerous for patients. The needling of acupuncture point CV24 was described to be effective in reducing the gag reflex during TEE in patients with ischemic stroke or transient ischemic attack. Methods: We describe a proposal for a prospective, randomized, patient, practitioner and assessor-blinded, single-center trial with two arms/groups; real acupuncture will be compared to placebo acupuncture. A total of 60 (30 per group) patients scheduled for elective TEE in order to exclude a cardiac embolic source, endocarditis or for valve failure evaluation will be recruited according to patients' selection criteria and receive either indwelling fixed intradermal needles at acupoints CV24 and bilateral PC6 or placebo needles at the same areas. Patients, the practitioners who will perform the TEE procedure, and the assessor of the outcome measures will be unaware of the group's (real or placebo) allocation. Results: The primary outcome is the intensity of gagging, measured using verbal rating scale (VRS-11) from 0 = no gagging to 10 = intolerable gagging. Secondary outcomes include the incidence of gagging, the use of rescue medication, patients' satisfaction with relief of unwanted side effects during TEE procedure, success of patients' blinding (patients' opinion to group allocation), heart rate and oxygen saturation measured by pulse oxymetry. Conclusions: To study the effects of acupuncture against gagging during TEE, we test the needling of acupoints CV24 and PC6 bilaterally. A placebo acupuncture is used for the control group. Trial registration number: NCT NCT0382142.

Computerized 4-choice reaction time test for the measurement of psychomotor recovery after general anesthesia.

The recovery of patients after general anesthesia is usually estimated by using clinical scores. Since there is a lack of objective methods for assessing psychomotor recovery, the aim of this study was to evaluate three psychological tests for this purpose. Patients, scheduled for ambulatory gynecological surgery, underwent 3 standard psychological tests before (T1), 15 min after the surgery (T2) and on discharge from the recovery room (T3). The tests used were Wechsler memory scale (test 1, working memory capacity), d2-test (test 2, concentration endurance) and computer-based 4-choice-reaction time (4CRT, test 3, reaction time) as well as Postanesthesia Discharge Scoring System (PADSS). The same test battery was used in healthy female volunteers, all test results were compared at the different time points. In 109 patients, working memory capacity and concentration (tests 1 and 2) decreased, the reaction time (test 3) was prolonged at T2 in comparison with T1 and T3 (P < 0.01). PADSS increased from 8 (T2) to 10 (T3) (medians, P < 0.001). Fifty-seven healthy volunteers demonstrated a practice effect in all 3 tests through the course of the study (P <0.01). 4CRT test had shortest duration and enabled computerized data processing. All three tests objectively assess the recovery of psychomotor function in patients after general anesthesia, the computer-based 4CRT seems to be the most convenient for the clinical routine.

Mechanisms of "Cough-Trick" for Pain Relief during Venipuncture: An Experimental Crossover Investigation in Healthy Volunteers.

Objectives: The easily performed "cough-trick" (CT) reduces pain during venipuncture (VP), although the underlying mechanism remains unclear. The aim was to investigate the pain-reducing effect of CT during VP in comparison with two distraction methods, as well as under the influence of naloxone. Methods: 54 healthy male volunteers participated in 3 investigations. Pain during standardized VP with CT was compared to a "weak" distraction (squeezing a rubber ball; investigation 1; n=20) and to a "strong" distraction (inflating a tourniquet to a given pressure; investigation 2; n=21). In investigation 3 (n=13), pain at a VP without intervention was compared to pain at VP with CT under naloxone; pressure pain thresholds before and after naloxone administration were also measured. Pain was assessed using a 100 mm visual analogue scale. Data were compared within each sample using Student's t-test for paired samples. Results: Pain intensity at VP with CT was lower than under "weak" distraction (mean difference 5 mm; 95% CI: 0.5 to 9.6; P=0.03). Pain levels under CT and "strong" distraction were comparable. There was no difference between pain under CT after naloxone infusion and pain without intervention. Pressure pain threshold decreased (mean difference 1 mm; 95% CI: 0.1 to 1.0 mm; P=0.02) after naloxone administration. Conclusion: Pain-reducing effect of CT during VP is superior to that of simple motor distraction and equivalent to a complex distraction method. This might be due to the activation of segmental pain inhibitory pathways during coughing indicated through the lack of pain reduction due to CT under opioid antagonist blockage.

Auricular acupuncture for treatment of preoperative anxiety in patients scheduled for ambulatory gynaecological surgery: a prospective controlled investigation with a non-randomised arm.

OBJECTIVE: Auricular acupuncture (AA) is a promising alternative treatment for situational anxiety. The aim of this pilot investigation was to test the acceptability and feasibility of AA as a treatment for preoperative anxiety (PA) in preparation for a subsequent randomised controlled trial. METHODS: AA was offered for treatment of PA to female patients who were scheduled for ambulatory gynaecological surgery. In patients who agreed, indwelling fixed needles were applied bilaterally at the points MA-IC1, MA-TF1, MA-SC, MA-AH7 and MA-T the day before surgery. Patients who declined AA but agreed to be examined constituted the control group (no intervention). State anxiety (primary outcome) was measured using the State-Trait-Anxiety Inventory (STAI) before AA (time I), the evening before surgery (time II) and immediately before surgery (time III). Anxiety was measured with a 100 mm visual analogue scale (VAS-100); heart rate, blood pressure and serum cortisol were also quantified. RESULTS: Data from 62 patients (32 with AA and 30 with no intervention) were analysed. Whereas preoperative anxiety was reduced after AA the evening before surgery (P<0.01), anxiety levels in the control group increased from the first to the last measurement (P<0.001). Secondary outcomes were comparable between the patients from both groups. CONCLUSIONS: AA was acceptable and feasible as a treatment for preoperative anxiety. The results were used for the sample size calculation of a subsequent randomised controlled clinical trial. TRIAL REGISTRATION NUMBER: NCT02656966; Results.

Disparity between High Satisfaction and Severe Pain in Patients after Caesarean Section: A Prospective Observational-Controlled Investigation.

OBJECTIVES: Recent advances in the treatment of postoperative pain (POP) have increased the quality of life in surgical patients. The aim of this study was to examine the quality of POP management in patients after CS in comparison with patients after comparable surgical procedures. METHODS: This was a prospective observational analysis in patients after CS in comparison with the patients of the same age, who underwent comparable abdominal gynaecological surgeries (GS group) at the university hospital. A standardised questionnaire including pain intensity on the Verbal Rating Scale (VRS-11), incidence of analgesia-related side effects, and incidence of pain interference with the items of quality of life and patients' satisfaction with the treatment of POP was used. RESULTS: Sixty-four patients after CS reported more pain on movement than the patients after GS (N=63): mean 6.1 versus 3.6 (VRS-11; P < 0.001). The patients after CS reported less nausea (8 versus 41%) and vomiting (3 versus 21%; P < 0.001) and demonstrated better satisfaction with POP treatment than the patients after GS: 1.4 (0.7) versus 1.7 (0.7) (mean (SD); VRS-5; P=0.02). CONCLUSION: The disparity between the high level of pain and excellent satisfaction with POP treatment raises the ethical and biomedical considerations of restrictive pharmacological therapy of post-CS pain.

Effects of Electrical Transcutaneous Vagus Nerve Stimulation on the Perceived Intensity of Repetitive Painful Heat Stimuli: A Blinded Placebo- and Sham-Controlled Randomized Crossover Investigation.

BACKGROUND: Transcutaneous vagus nerve stimulation (TVNS) is a promising treatment for acute and chronic pain. However, experimental studies yielded controversial results. We examined if TVNS reduces the perceived intensity of repetitive painful heat stimulation and temporal summation of pain (TSP) in healthy volunteers in comparison with placebo and sham stimulation, as well as no intervention. METHODS: In 4 sessions, 90 heat pulse stimuli at individual pain tolerance temperature were applied to the ventral forearm of 49 healthy volunteers (25 women) using a Contact Heat Evoked Potential Stimulator thermode (Medoc, Ramat Yishai, Israel). Pain intensity was assessed with verbal ratings on a numeric pain scale (0-100) at every tenth heat pulse. After the first session in which pain intensities without intervention were evaluated, participants completed 3 sessions in a single-blinded randomized crossover manner: (1) sham stimulation applied at the earlobes, (2) placebo stimulation (inactive device), or (3) TVNS applied at the cymbas conchae. Primary data were analyzed using analysis of variance for repeated measures and t test for paired samples. RESULTS: Pain intensity decreased during all interventions as compared to no intervention (ηp = 0.22, P < .001; mean difference TVNS versus no intervention 9.5; 95% confidence interval [CI], 3.6-15.4; P < .001). Hypoalgesic effect of TVNS was better than that of placebo and sham in men before the onset of TSP (mean differences for TVNS versus placebo 6.2; 95% CI, 0.2-12.1; TVNS versus sham 6.2; 95% CI, 0.2-12.1; P < .05). In women, TSP response under TVNS was decreased if compared to no intervention (median difference, 7.5; 95% CI, 3.5-15.0; P = .003). CONCLUSIONS: TVNS, placebo, and sham stimulation exerted comparable effects under experimental heat pain stimulation. Only in male participants, TVNS was superior to sham and placebo conditions in the reduction of heat pain before the onset of TSP.

Auricular Acupoints with Reduced Skin Resistance: Detection in Patients Scheduled for Hip Arthroplasty.

Objective: The detection of auricular acupuncture (AA) points by measuring electrical skin resistance (ESR) is often used in diagnostics and therapy; however, systematic investigations of ESR in AA points are rare. The aim of this study was to examine the frequency of detection of AA points with reduced ESR in patients scheduled for unilateral hip arthroplasty. Materials and Methods: Data were obtained from 2 prospective clinical trials, which studied the perioperative analgesic effects of AA in patients with unilateral degenerative hip osteoarthritis. Three AA points (MA-TF1, MA-AH4, and MA-IC1) were examined in these patients before arthroplasty surgery using a SVESA (Neuralstift SVESA 1070, SVESA, Muenchen, Germany) neural pen. The frequency of AA points detection on the ipsi- and contralateral sides of the affected hip joint was registered and analyzed with a χ2 test. Results: The data of 114 patients (60 females) were available for analysis. AA points with lower ESR were detected more frequently on the side ipsilateral to the affected joint rather than on the contralateral side: 81% versus 37% of patients (P < 0.0001). None of the AA points could be identified at all in 13% of patients with diabetes mellitus versus 3% of patients without diabetes mellitus (P = 0.07). Conclusions: AA points with low ESR were detected more frequently on the side ipsilateral to the underlying pathology. This finding is in agreement with neurophysiologic data. The therapeutic value of this finding should be clarified in future studies.

Feasibility and safety of dilatational tracheotomy using the rigid endoscope: a multicenter study.

BACKGROUND: Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED). METHODS: In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant. RESULTS: PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%). CONCLUSION: The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible.

Acupuncture Reduces Pain and Autonomic Distress During Injection of Local Anesthetic in Children: A Pragmatic Crossover Investigation.

OBJECTIVES: Stimulation of acupoint LI4 has been shown to result in analgesic effects in patients experiencing acute pain. We aimed to study the effectiveness of LI4 stimulation for pain relief in children receiving an injection of a local anesthetic (LA). MATERIALS AND METHODS: Children scheduled for dental treatment using LA received bilateral acupuncture at LI4 using indwelling fixed needles. During the treatment, the parents of the patients stimulated the needles by massage. Two different treatment regimes were compared: a standardized LA injection given 5 minutes after acupuncture, and an LA injection without acupuncture. The order of treatment was randomized, with the 2 treatments performed in a crossover manner on different days. Pain intensity during LA injection, assessed by the patient with the Verbal Rating Scale or Faces Pain Scale (0 to 10), was used as the primary endpoint. Parent-assessed and dentist-assessed pain intensity and agitation, heart rate, and the patients' satisfaction with the therapy were also recorded. RESULTS: Data were obtained from 49 patients (22 female; mean age 10 y). Patients reported less pain when acupuncture was used: mean 2.3 (95% confidence interval, 1.5-3.1) versus 3.9 (95% confidence interval, 3.0-4.7); P<0.001. The patients' heart rate remained low throughout the dental treatment after LI4 stimulation, when compared with treatment without acupuncture (P<0.05). LI4 stimulation was safe and increased satisfaction levels in both the patients and their parents, when compared with LA injection alone (P<0.05). DISCUSSION: Stimulation of acupoint LI4 reduces pain and autonomic distress in children during LA injection in dental procedures.

Acupuncture for pain control after Caesarean section: a prospective observational pilot study.

OBJECTIVE: Options for pharmacological analgesia in patients who have undergone Caesarean section (CS) are often restricted. Acupuncture is a promising tool for treating postoperative pain. We aimed to study the feasibility and acceptability of acupuncture as an additional method of analgesia in CS patients in a prospective observational pilot investigation. METHODS: Twenty-two patients scheduled for elective CS under spinal anaesthesia were enrolled according to set inclusion criteria. Each patient received auricular and body acupuncture with 20 indwelling fixed needles according to previously validated protocols of acupuncture for postoperative analgesia. Pain intensity on an 11-point verbal rating scale (VRS-11, where 0=no pain and 10=maximal pain), analgesia-related side effects, time to mobilisation and Foley catheter removal after CS, and patients' compliance and satisfaction with treatment of pain on a 5-point VRS (VRS-5, where 1=excellent; 5=bad) were recorded. RESULTS: Twenty patients were included in the final analysis. One patient was disturbed by paraesthesia at the site of needling. All other patients tolerated acupuncture well. Pain intensity on movement on the first postoperative day was 4.3±2.4 (mean±SD; VRS-11) and decreased to 2.2±1.2 on the day of discharge. Patient satisfaction was 1.9±0.8 (mean±SD; VRS-5) and compliance (rated by their nurses) was 1.5±0.5 (mean±SD; VRS-5). CONCLUSIONS: Acupuncture for additional analgesia after CS was well accepted. The primary outcome measurement was feasible and allowed the sample size to be calculated for a future randomised controlled trial.

Verum and sham acupuncture exert distinct cerebral activation in pain processing areas: a crossover fMRI investigation in healthy volunteers.

Although acupuncture is effective for treating pain, its site-specificity is questioned. The aim was to compare the cerebral responses of needling applied to an acupuncture point to the needling of a sham point, using functional magnetic resonance imaging (fMRI). Twenty-one healthy male volunteers were enrolled. Manual stimulation of the acupuncture (ST44) and sham points on the dorsum of the left foot was applied during fMRI in a crossover manner. fMRI data analysis was performed contrasting the ST44 and the sham conditions. Stimulation intensity, subjective discrimination of the needling site and the incidence of "Qi" sensation were additionally recorded. Stimulation of ST44 acupoint, in comparison to the sham procedure, was associated with an increased fMRI-activation in the primary somatosensory, the inferior parietal and the prefrontal cortex and the posterior insula. Sham needling was associated with increased activation in the anterior cingulate cortex and the anterior insula. Verum acupuncture increased the activity of discriminative somatosensory and cognitive pain processing areas of the brain, whereas sham needling activated the areas responsible for affective processing of pain. This may explain favorable effects of verum acupuncture in clinical studies about treatment of chronic pain patients.