Effectiveness of theta burst versus high-frequency repetitive transcranial magnetic stimulation in patients with depression (THREE-D): a randomised non-inferiority trial.

BACKGROUND: Treatment-resistant major depressive disorder is common; repetitive transcranial magnetic stimulation (rTMS) by use of high-frequency (10 Hz) left-side dorsolateral prefrontal cortex stimulation is an evidence-based treatment for this disorder. Intermittent theta burst stimulation (iTBS) is a newer form of rTMS that can be delivered in 3 min, versus 37·5 min for a standard 10 Hz treatment session. We aimed to establish the clinical effectiveness, safety, and tolerability of iTBS compared with standard 10 Hz rTMS in adults with treatment-resistant depression. METHODS: In this randomised, multicentre, non-inferiority clinical trial, we recruited patients who were referred to specialty neurostimulation centres based at three Canadian university hospitals (Centre for Addiction and Mental Health and Toronto Western Hospital, Toronto, ON, and University of British Columbia Hospital, Vancouver, BC). Participants were aged 18-65 years, were diagnosed with a current treatment-resistant major depressive episode or could not tolerate at least two antidepressants in the current episode, were receiving stable antidepressant medication doses for at least 4 weeks before baseline, and had an HRSD-17 score of at least 18. Participants were randomly allocated (1:1) to treatment groups (10 Hz rTMS or iTBS) by use of a random permuted block method, with stratification by site and number of adequate trials in which the antidepressants were unsuccessful. Treatment was delivered open-label but investigators and outcome assessors were masked to treatment groups. Participants were treated with 10 Hz rTMS or iTBS to the left dorsolateral prefrontal cortex, administered on 5 days a week for 4-6 weeks. The primary outcome measure was change in 17-item Hamilton Rating Scale for Depression (HRSD-17) score, with a non-inferiority margin of 2·25 points. For the primary outcome measure, we did a per-protocol analysis of all participants who were randomly allocated to groups and who attained the primary completion point of 4 weeks. This trial is registered with ClinicalTrials.gov, number NCT01887782. FINDINGS: Between Sept 3, 2013, and Oct 3, 2016, we randomly allocated 205 participants to receive 10 Hz rTMS and 209 participants to receive iTBS. 192 (94%) participants in the 10 Hz rTMS group and 193 (92%) in the iTBS group were assessed for the primary outcome after 4-6 weeks of treatment. HRSD-17 scores improved from 23·5 (SD 4·4) to 13·4 (7·8) in the 10 Hz rTMS group and from 23·6 (4·3) to 13·4 (7·9) in the iTBS group (adjusted difference 0·103 [corrected], lower 95% CI -1·16; p=0·0011), which indicated non-inferiority of iTBS. Self-rated intensity of pain associated with treatment was greater in the iTBS group than in the 10 Hz rTMS group (mean score on verbal analogue scale 3·8 [SD 2·0] vs 3·4 [2·0] out of 10; p=0·011). Dropout rates did not differ between groups (10 Hz rTMS: 13 [6%] of 205 participants; iTBS: 16 [8%] of 209 participants); p=0·6004). The most common treatment-related adverse event was headache in both groups (10 Hz rTMS: 131 [64%] of 204; iTBS: 136 [65%] of 208). INTERPRETATION: In patients with treatment-resistant depression, iTBS was non-inferior to 10 Hz rTMS for the treatment of depression. Both treatments had low numbers of dropouts and similar side-effects, safety, and tolerability profiles. By use of iTBS, the number of patients treated per day with current rTMS devices can be increased several times without compromising clinical effectiveness. FUNDING: Canadian Institutes of Health Research.

Differences in Sensory Pain, Expectation, and Satisfaction Reported by Outpatients with Cancer or Sickle Cell Disease.

BACKGROUND: Patients with sickle cell disease (SCD) report pain scores that appear greater than those reported in a meta-analysis for patients with cancer, but statistical comparisons of the pain scores from both populations have not been published. AIMS: The goal of the study described here was to compare pain outcomes reported by outpatients with cancer or SCD. DESIGN: Descriptive comparative study. SETTING: Outpatient oncology or sickle cell clinics. SUBJECTS: The participants were outpatients (N = 415) from three studies: (1) 106 patients with SCD, 93% African-American (referent group); (2) 140 patients with cancer, 90% Caucasian (race discordant); (3) 169 patients with cancer, 20% Caucasian, 65% African-American (race concordant). METHODS: Patients completed the PAINReportIt including pain location, quality, pattern, intensity, expectation, satisfaction, and demographic questions. Analyses included the χ2 test, analysis of variance, and regression. RESULTS: Outpatients with SCD reported more pain location sites than the race-discordant (p < .001) and race-concordant (p < .001) cancer groups; higher pain quality than the race-discordant (p < .001) and race-concordant (p < .001) groups; and greater pain pattern scores than the race-discordant (p < .001) and race-concordant (p < .001) groups. The race-concordant group reported higher worst pain intensity than the SCD (p < .001) and race-discordant (p = .002) groups. The three groups did not differ significantly on pain expectation (p = .06). Regarding satisfaction with pain level, there was a significant difference between the race-concordant and SCD (p = .006) groups, but not between the race-discordant and SCD (p = .12) groups or between the race-discordant and race-concordant (p = .49) groups. CONCLUSIONS: Outpatients with SCD reported three of four sensory pain parameters that were greater than those reported by outpatients with cancer. A better understanding of these differences is pertinent to improving pain outcomes.

Ranking of dental and somatic pain sensations among paediatric dental patients.

BACKGROUND: Children suffer from somatic and dental pain, which may interfere with their everyday life. Pain self-report tools are available for children. Research is needed to better understand the perception of dental pain in comparison with pain in other organs. AIM: To investigate relations between the perceptions of dental and somatic pain complaints among school-age children. DESIGN: One hundred and two children, aged 7-17 years (mean age, 11.5 ± 2.65 years), completed questioners regarding their somatic and dental: 1. Memory pain rank (MPR) and 2. Wong-Baker FACES Pain Rating Scale (FRS). RESULTS: Children reported increased dental pain after school in both scales (P = 0.015 in MPR). In both MPR and FRS, the pattern of pain ranking was similar: Abdominal pain was scored highest (2.75 ± 1.4 and 1.56 ± 1.63, respectively), followed by headache, ear, dental and TMJ (Temporomandibular joint). CONCLUSION: There was a strong correlation between pain perception and current pain scores in every organ. Somatic pain, namely head, abdomen and ears, was ranked significantly higher than dental and TMJ pain. School-aged children rank current pain and pain experience significantly lower while they are pre-occupied (school time) in comparison with times when they are less busy (after school time).

Differences in pain perception in children reporting joint and orofacial muscle pain.

PURPOSE: To determine changes in orofacial pain perception in community-based children by assessing the pressure pain threshold (PPT) with an algometer and pain intensity by manual palpation (MP). METHODS: A total of 100 children from the community aged 7 to 12 years were assessed. Thirty-eight children reported pain in the orofacial region. Of these children,10 reported joint pain (GJ), 12 reported joint and muscle pain (GJMM), 5 reported muscle pain (GMM), 11 reported pain during mastication (GMAST), and 62 reported no pain. An ANOVA (p < 0.05) was used to determine the differences in pain intensity and PPT among groups. RESULTS: Significantly higher pain intensity upon MP was observed for the temporalis muscle in the GJMM, GMAST and GJ groups compared to the remaining groups. The PPT values were significantly lower in the masseter temporalis muscles, TMJ and thenar region in the GJMM group compared to the other groups. CONCLUSION: MP more accurately differentiated symptomatic subjects from symptom-free TMD subjects, and PPT values were more sensitive to the discrimination of pain in the orofacial sites assessed. In addition, the changes in perception at a larger number of sites among children reporting mixed pain may suggest the presence of a possible mechanism of central sensitization.

Percepción del dolor según el modo de punción de la fístula arteriovenosa en pacientes sometidos a hemodiálisis. Revisión sistemática / Pain perception according to manner of arteriovenous fistula cannulation in patients undergoing hemodialysis. Systematic review

Objetivo: Valorar la posible asociación entre la forma de punción de la fístula arteriovenosa y el dolor que siente el paciente por la inserción de la aguja. Metodología: Se ha seguido la declaración PRISMA para revisiones sistemáticas. Se han consultado 6 bases de datos; Medline, Scopus, Cuiden, CINAHL, SciELO, y Cochrane PLUS. Además, se realizó una búsqueda secundaría manual para detectar literatura gris no encontrada en las bases de datos o mediantes las estrategias definidas. Criterios de inclusión; estudios de nivel de evidencia 1 en la escala Scottish Intercollegiate Guidelines Network, publicados en los últimos 10 años, idiomas español/inglés, y temática relacionada con las técnicas utilizadas en hemodiálisis para el abordaje de la fistula. Los artículos se evaluaron de forma crítica para detectar cualquier riesgo de sesgo mediante el instrumento CASPe y el manual Cochrane para Revisiones Sistemáticas de Intervenciones. Resultados: Se identificaron un total de 150 resultados, seleccionándose finalmente 9 estudios. Los resultados han sido muy heterogéneas, encontrándose resultados para el dolor, tasas de infección, número de intentos de canalización, flujo sanguíneo, presión venosa, tiempo de hemostasia, seguridad, dilataciones aneurismáticas, estética del brazo portador de la fístula y calidad de vida del paciente. Conclusiones: La evidencia no respalda el uso preferencial de la técnica del ojal sobre la canalización tradicional. Por tanto, se necesita mejorar el rigor metodológico y un mayor tamaño muestral para dilucidar que técnica da mejores prestaciones respecto al dolor, permitiendo por tanto mejorar la calidad de vida de los pacientes de hemodiálisis

Aims: To assess the possible association between the manner of arteriovenous fistula cannulation and the patient pain related to the insertion of the needle for the hemodialysis session. Methodology: The PRISMA statement for systematic reviews has been followed. Six databases have been consulted: Medline, Scopus, Cuiden, CINAHL, SciELO, and Cochrane PLUS. In addition, a secondary manual search was performed to detect grey literature not found in databases or through defined strategies. Inclusion criteria: studies of level of evidence 1 on the Scottish Intercollegiate Guidelines Network scale, published in the last 10 years, Spanish/English languages, and topics related to the techniques used to canalize the hemodialysis fistula. The articles were critically evaluated to detect any risk of bias using the CASPe instrument and the Cochrane Handbook for Systematic Reviews of Interventions. Results: A total of 150 results were identified, 9 of which were finally selected. The results have been very heterogeneous, finding results for pain, infection rates number of attempts of channalization, blood flow, venous pressure, time of hemostasis, safety, aneurysmal dilations, esthetics of the fistula-carrying arm and quality of life of the patient. Conclusions: The evidence does not support the preferential use of the buttonhole technique over traditional channeling. Therefore, it is necessary to improve the methodological quality and a larger sample size to elucidate which technique gives better benefits with respect to pain, thus allowing to improve the quality of life of hemodialysis patients

Valoración del dolor. Revisión comparativa de escalas y cuestionarios / Pain assessment. Comparative review of scales and questionnaires

El dolor se define como una experiencia sensorial o emocional desagradable, asociada a daño tisular real o potencial. Se trata en todo caso de un concepto subjetivo y existe siempre que un paciente diga que algo le duele. Es una patología prevalente en población general y que adquiere especial relevancia entre la población laboral por sus implicaciones socioeconómicas. Es objetivo de este trabajo revisar los distintos baremos, escalas y cuestionarios utilizados para la valoración del dolor y sus limitaciones para su posterior uso, tanto con fines médicos como laborales o periciales. Se realizó una búsqueda de las escalas, cuestionarios y baremos de discapacidad e incapacidad para la valoración del dolor realizando una comparativa entre ellos y revisando la consideración del dolor como objeto de calificación en distintos países. La comparativa de escalas y cuestionarios reafirma la complejidad de la valoración del dolor, especialmente para su posterior calificación con finalidad pericial ante la inexistencia de la valoración del dolor en los baremos. Como conclusión se consideran de utilidad las escalas y cuestionarios, todas ellas válidas y ninguna concluyente, siendo el investigador quien debe decidir cuál utilizar en cada caso en función de su experiencia y del objetivo buscado

Pain is defined as an unpleasant emotion, experience, or sensation, associated with potential or the general population, but it acquires special relevance among the working-class population, because of its socioeconomic implications. The objective of this work is to perform a review of the different scales and questionnaires used for the assessment of pain and its limitations, for their later use in medical, professional, and research purposes. An investigation of the different scales, questionnaires, disability and incapacity concept for the assessment of pain was carried out, comparing them and reviewing the consideration of pain as an object of qualification in different countries. The results reaffirm the complexity of the assessment of pain, especially for its future use, quantification, and qualification when those did not previously existed. Conclusion: All kinds of measurement scales and questionnaires are considered very useful, all beign valid, but none finally conclusive; The researchers must decide which method they will apply in each different case, based on their experience and the goal they try to achieve

Dolor y simulación: reto diagnóstico y terapéutico / Pain and simulation: diagnostic and therapeutic challenges

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Perception of discomfort during injection and the need for supplemental anesthesia in the intraosseous technique using 4 per cent articaine / Percepción de incomodidad durante la inyección y necesidad de anestesia suplementaria en anestesia intraósea usando articaína al 4

The authors conducted an experimental study to determine patient perception of discomfort during injection and the need for supplemental anesthesia using the intraosseous technique with 4% articaine with 1:100,000 epinephrine in patients with symptomatic pulpitis in mandibular molars. At different clinical sessions, researchers used 4% articaine with 1:100,000 epinephrine to apply intraosseous injection (Group 1) or inferior alveolar nerve block (Group 2). Each technique was applied in 35 patients. In each group, the need for additional anesthesia was determined and patient discomfort during injection was assessed with a Visual Analogue Scale (VAS) test. In the intraosseous group, no supplemental technique was needed in 22 patients (62.85 %), and results were similar for the inferior alveolar technique (n: 23 65.71%). The intraosseous technique proved to be more comfortable than the mandibular technique (18 patients - 25.7%). This study found that the use of intraosseous technique with 4% articaine shows promising results regarding patient comfort and reducing the need for additional anesthesia.

Los autores condujeron un estudio experimental para deter minar la eficacia de la técnica anestésica intraósea usando articaína al 4% con epinefrina 1:100.000, en pacientes con pulpitis aguda en molares mandibulares. En diferentes sesiones clínicas, los miembros del equipo de investigadores usaron articaína al 4% con epinefrina 1:100.000 para inducir anestesia mandibular con la técnica intraósea (Grupo 1) o con el bloqueo del nervio alveolar inferior (Grupo 2), se aplicó cada técnica en 35 pacientes con diagnóstico de pulpitis aguda en molares inferiores. En cada grupo, se determinó la necesidad de hacer anestesia complementaria y la comodidad del paciente con un test Escala Visual Analoga. Un total de 70 pacientes fueron enrolados en este estudio (35 sujetos por grupo). En el grupo de intraósea no fue necesaria la aplicación de técnicas complementarias en 22 pacientes (31.4%), resultados similares en la técnica alveolar inferior (n: 23 32.8%). La técnica intraósea demostró ser más cómoda al compararla con técnica mandibular (18 pacientes 25.7%). Este estudio demostró que el uso de la técnica intraósea conarticaína al 4%, arrojó resultados prometedores en lo que a comodidad y reducción en la anestesia complementaria hace referencia.