Audio-Visual Distraction- A Non-Pharmacological Approach to Alleviate Pain in Pediatric Vaccine Administration: An Observational Study

Atypical site of myocardial infarction pain

Non-pharmacologic analgesia has been demonstrated to alleviate pain and distress in invasive procedures. Nevertheless, the practice has not been adopted widely in paediatric departments because nurses are often too busy to perform a time consuming procedure. Three hundred patients (8-9 years) requiring venepuncture for intravenous treatment were randomized into audiovisual distraction group (n = 100, watching cartoon films), intervention group (n = 100, receiving psychological intervention) and control group (n = 100, without any intervention). There was no significant difference (P>0.05) between the audiovisual distraction and the intervention groups for cooperation, venepuncture times and pain intensity (assessed with visual analogue scale, VAS). However, cooperation in the control group was more passive than in the intervention group (P <0.05) but not apparently different to the audiovisual distraction group (P >0.05). Venepuncture time was significantly higher in the control group than in the other two groups (P <0.05). Venepuncture caused moderate pain in children (VAS score: 5.22 +/- 2.53 in the control group). VAS scores indicated that procedures were more painful in the control group than in the audiovisual distraction or the intervention group (VAS score: 4.55 +/- 2.26 and 4.38 +/- 2.32 in the audiovisual distraction and intervention groups respectively, P <0.05). Audiovisual distraction was demonstrated to be effective in reducing self-reported pain, improving patient cooperation and increasing success rate in venepuncture procedures and was as successful as routine psychological intervention. It is highly recommended as an effective, labour saving and easy to administer analgesia and should be used to help prevent pain from venepuncture in school age children.

Local anaesthesia (LA) administration provokes dental anxiety in children. BrightHearts is a biofeedback relaxation application designed to reduce anxiety in children during painful procedural interventions. To compare the effectiveness of biofeedback relaxation (BR) and audio-visual (AV) distraction on dental anxiety among 7- to 12-year-old children while administering LA. A total of 70 children requiring dental treatment under LA for three visits were recruited for this single-blinded randomized control trial. They were randomly divided into two equal groups. Group A received BR and Group B received AV distraction during LA delivery in the first two visits, and both groups did not receive any intervention during LA in third visit. Outcomes were measured using heart rate and a cartoon-based anxiety measuring scale (Chotta Bheem-Chutki (CBC) scale). AV group had statistically significant higher mean heart rates than BR group (P<.001) during needle penetration and post-intervention, respectively. CBC scale showed no statistical differences between the groups. Both the interventions are effective in reducing dental anxiety during LA administration. Based on objective measures, BR is found to be better than AV distraction. Subjective scores, however, show no differences between the two.

Hospitalized children often describe needle-related procedures as the worst pain possible and such procedures may be emotionally traumatic. The use of hospital clowns (HCs) related to painful medical procedures in children may offer pain relief, but this has not been systematically evaluated. The objective of this study was to assess the effect of a therapeutic clown in comparison with standard care on the experience of pain in children receiving venipuncture. A sample of 116 children aged 4 to 15 years consecutively admitted to the hospital was allocated to either the experimental (presence of HC) or control group (standard care) before venipuncture. Self-reported pain after the procedure was assessed using the Faces Pain Scale combined with a 0 to 10 Numerical Rating Scale. Separate analysis was conducted in age groups from 4 to 6 (N=37) and 7 to 15 (N=74) years. Without the clown present, the mean pain score (2.7±2.8) was not significantly different between the 2 age groups. Children aged 7 to 15 years had lower pain scores when the clown was present compared with the control group (P=0.025). Children aged 4 to 6 years had higher pain scores with the clown present, although the difference was not statistically significant (P=0.054). Children with pain (N=49) or previous experiences with venipuncture (N=56) did not score pain significantly differently. Assessing the pain experience of children receiving venipuncture with the presence of an HC indicates a pain relieving effect for children older than 6 years. However, future studies should carefully study the effects on younger children where mixed effects may be present.

The assessment of ice pack effect in pain reduction during digital nerve block: A randomized clinical study

(396) Pregabalin is effective irrespective of antidepressant class in fibromyalgia patients currently receiving antidepressant medication for comorbid depression

Background Transcatheter mitral-valve repair is increasingly performed under conscious sedation to minimize the risks associated with general anesthesia, particularly in patients with advanced cardiovascular conditions. However, patient discomfort, anxiety, and management of sedation levels can be challenging. Whether audiovisual distraction (AVD) techniques can reduce sedative requirements and enhance patient satisfaction in patients undergoing transcatheter mitral-valve repair is unclear. Methods We conducted a single-center, randomized controlled trial to assess whether AVD with video glasses and headphones can lower the sedation dose needed during mitral transcatheter edge-to-edge repair (M-TEER) and improve the overall procedural experience for patients. Patients were assigned in a 1:1 ration either to inactive video glasses (control group) or active video glasses (AVD group) during M-TEER. The primary outcome was the dosage of administered propofol. Secondary outcomes included procedural time, patient satisfaction (ZUF-8 score), anxiety, and pain levels before and after M-TEER. Results A total of 56 patients undergoing M-TEER underwent randomization: 26 were assigned to the control group and 30 to the AVD group. The AVD group required significantly less propofol (4.6 ± 1.6 mg/kg/h vs. 5.8 ± 1.4 mg/kg/h, p=0.005) and reported higher comfort levels during the procedure. Procedural time did not differ significantly between groups (102.2 ± 36 min vs. 91.0 ± 32.7 min, p=0.24). The ZUF-8 scores indicated a significant increase in patient satisfaction in the AVD group (24.7 ± 3.0 vs. 22.5 ± 3.0, p=0.008). Anxiety levels were significantly lower in the AVD group immediately after the procedure compared with the control group (Numeric Rating Scale , NRS 1.1 ± 1.0 vs. 2.6 ± 1.8; p=0.001). Pain levels remained low in both groups without significant intergroup differences. Conclusion AVD via video glasses effectively reduces sedative requirements and improves patient satisfaction and anxiety management in patients undergoing M-TEER under conscious sedation. This technique holds potential as a non-invasive adjunct to enhance procedural comfort and reduce pharmacological sedation in interventional cardiology. Further studies with larger samples could provide additional insights into its benefits for patient-centered care in interventional cardiology.Audiovisual distraction in M-TEER

Introduction: Circumcision is one of minor surgery that usually done for school age children. Most of the children appear to be anxious enough. Audio-visual distraction is one of the methods that researcher want to applied to decrease children’s anxiety level during circumcision. The objective of this study was to identify the effect of audio-visual distraction to decrease children’s anxiety level during circumcision. Method: Non randomized pretest-posttest control group design was used in this study. There were 21 children divided into two groups, control group (n=13) receive intervention as usual, otherwise the intervention group (n=8) receive audio-visual distraction during circumcision. By using self report (scale of anxiety) and physiological measures of anxiety (pulse rate per minute), children are evaluated before and after the intervention. Result: The result showed that audio-visual distraction is efective to decrease the anxiety level of school age children during cicumcision with significance difference on the decrease of anxiety level between control and intervention group (p=0.000) and significance difference on the pulse rate per minute between control and intervention group (p=0.006). Discussion: It can be concluded that by applying the audio-visual distraction during circumcision could be minimized the children’s anxiety. The audio visual is needed for children to manage and reduce anxiety during invasive therapy through mecanism of distraction.

Foot and mouth disease and lumpy skin disease of cattle is a common disease on commercial cattle farms which associated with changes in behavior, blood parameters, pain related behaviors and pain scale measurements, but little is known about this effect. The objectives of the present study were to test 2 hypotheses. First, investigate these changes; second, explained the effect of different treatment strategies (analgesic with Flunixin meglumine) or non-analgesic on lameness and pain scale. 125 bull cows were enrolled in the study based on visual observation of abnormal behavior the present study was done in Assiut governorate in Egypt was divided in three groups, which 25 clinically healthy bull (control group), FMD clinically infected group (25 analgesic + 25 non-analgesic and LSD (25 analgesic + 25 non analgesic). Obtained data illustrated that; there are significant increase physiological parameters (rectal temperature, heart rate and respiratory rate), lying behavior and total pain scale, while, there are significant decrease in feeding, drinking, rumination and standing behaviors, activity of exploration and activity of body care which may be corrected by Flunixin using. Conclusion: Flunixin injection may help in decreasing the negative pain behaviors and physiological changes caused by LSD or FMD

The aim of this study was to determine the association of postoperative dexmedetomidine with markers of pain in children undergoing Chiari malformation decompression. The authors hypothesized that patients receiving dexmedetomidine postoperatively would have decreased cumulative opiate use. They further hypothesized that there would be no difference in median pain scores, outcomes, or medication adverse events. An IRB-approved retrospective cohort study of patients undergoing Chiari malformation decompression from December 1, 2015, to December 31, 2018, was performed. Patients aged 0-21 years who underwent intradural Chiari malformation decompression at a single institution were included. Data for those who used dexmedetomidine postoperatively were compared with those who did not use dexmedetomidine. The primary outcome was cumulative opiate use throughout hospitalization. Secondary outcomes included pain scores, ancillary medication use, adverse events, hospital and ICU length of stay, readmission rates, and hospital cost. The authors reviewed the records of 172 patients who underwent Chiari malformation decompression. Of those patients, 86 received dexmedetomidine postoperatively and 86 did not. Demographics were not different between the groups. Patients who received dexmedetomidine postoperatively received more doses of dexamethasone and were also more frequently exposed to dexmedetomidine intraoperatively (p = 0.028). Patients who received dexmedetomidine postoperatively used fewer morphine equivalents during their admission (1.02 mg/kg vs 1.43 mg/kg, p = 0.003). The patients who received dexmedetomidine postoperatively also had lower median pain scores on postoperative day 0 (0 vs 2, p < 0.001), lower median pain scores throughout the entire admission (1 vs 2, p < 0.001), and lower maximum pain scores recorded (6 vs 8, p = 0.005). Adjusting for steroid dose number and intraoperative dexmedetomidine exposure, postoperative dexmedetomidine remained associated with lower opiate dosing, lower pain scores on postoperative day 0, lower scores throughout hospital stay, and lower maximum pain scores. Patients who received dexmedetomidine had shorter hospital lengths of stay by 19 hours (p < 0.001). There were no statistically significant differences in medication adverse events or hospital costs between the two groups. Postoperative dexmedetomidine use was associated with decreased opiate use, lower pain scores, and shorter hospital length of stay in this cohort. Dexmedetomidine may be considered as a safe adjuvant medication that may have opiate-sparing effects for this patient population.

The efficacy of LED phototherapy for reducing orthodontic pain during anterior retraction was evaluated. Fourteen patients (mean age, 15.2 years) underwent extraction of their four first premolars and were randomly divided into LED group (LEDG): seven patients (five males, two females) who performed self-application of Biolux LED device (850 nm, 60 mW, 10.8 J/cm2) daily for 5 min to the maxillary and 5 min to the mandibular arches during the anterior retraction phase and control group (CG): seven patients (five males, two females) who did not use LED therapy. All patients completed a survey for seven consecutive days after every retraction activation for a period of 4 months (T1, T2, T3, and T4) to quantify the pain experienced using a score from 0 to 10. There was a significant difference (P < 0.05) in pain score between the two groups on days 1 and 2 at T3 and in the overall mean pain score, based on the four surveys, with significantly lower values in the LEDG. Friedman’s test and Tuckey’s post hoc analysis showed a reduction in the pain score for both groups over time, and although the difference was not significant between the groups at T1, T2, or T4, the pain scores were numerically lower in the LEDG than in the CG at all evaluated time points, but mainly during the first 2 days after orthodontic activation. In conclusion, use of the 850-nm LED device after anterior retraction activation resulted in lower pain scores at all time points, indicating that LED therapy should be considered a good alternative to reduce orthodontic pain during the first 2 days postprocedure.

To determine whether audio and visual distraction can affect the pain perception of a patient undergoing endovenous thermal ablation under tumescent anesthesia. Patients underwent an endovenous thermal ablation procedure and were randomized into two groups: non-distraction (AVD-) and with distraction (AVD+). Visual analogue scale pain score and hospital anxiety depression scale scores were used to measure outcome. The recruited patients were asked to submit an anticipated visual analogue scale pain score prior to treatment as well as the actual experienced post-operative visual analogue scale pain score. There was no significant difference between the AVD- and AVD+ groups post-operative pain score 2.85 (SD 1.7) versus 2.60 (SD 2.3), p = 0.68. Pain score in women with distraction (AVD+) decreased from 3.81 to 2.42. The pain score in men with distraction (AVD+) increases from 1.88 to 2.82. In the AVD- group, a significant difference was found between men and women (p = 0.014). Disregarding gender, a significant difference was found between the anticipated pain score and the actual pain score in both the AVD- group (p = 0.009) and AVD+ group (p = 0.021). There was a correlation between depression and the pain score, which was not seen between pain and anxiety score. The results suggested that audiovisual distraction has no influence on the visual analogue scale pain score during endovenous thermal ablation under tumescent anesthesia. Despite this, patients appreciate and evaluate audio and visual distraction as pleasant to extremely pleasant when applied.

Background Alopecia areata is a common disease that affects the psychological well-being of the affected individuals. No single treatment option is proved to be effective and safe in its management. Laser-assisted drug delivery is a new method for the management of different dermatological diseases. Objective To evaluate the effectiveness of fractional carbon dioxide laser-assisted topical steroid delivery in the management of alopecia areata. Patients and methods A total of 30 patients with alopecia areata with two or more nonadjacent patches were included. Patients were randomized and given two separate treatment modalities in two different patches in the same individual. One patch was treated with fractional carbon dioxide laser followed by topical triamcinolone acetonide (group I), and the other was treated with intralesional triamcinolone acetonide (group II). Follow-ups by MacDonald Hull and Norris grading were done every 3 weeks for 3 months. Results The mean grading score in group I patches treated with ablative fractional CO2 laser followed by the topical steroid application at fourth follow-up was 3.37±0.76, and the mean grading score in group II patches treated with intralesional steroid at fourth follow-up was 3.73±0.58. There was significant improvement in the MacDonald Hull and Norris grading score every follow-up in both groups. However, group II patches showed significantly higher mean grading score as compared with group I patches. The mean pain score in group II patches was significantly higher than that in group I patches. Conclusion The use of fractional carbon dioxide laser to assist topical steroid delivery is a promising, safe, and effective method for the treatment of alopecia areata. Although intralesional steroid treatment showed more significant results, we thought that the low pain score in patients treated with laser-assisted drug delivery is more advantage, which increases their compliance to treatment.

Venepuncture in chronically-ill patients is one of the invasive procedures most frequently repeated during the day. Most children are frightened and anxious before this procedure, and during venepuncture they cry, suffer pain and refuse to cooperate, whereas parents are often worried and do not know how to help. Studies suggest that the first experiences of pain in neonatal age can be associated with altered reactions to pain during childhood and in adulthood. Our sample included 203 patients aged between 2 and 15 years. During venepuncture a video was shown to the patient. Pain and parent collaboration were measured using validated scales. Significant differences were observed between the mean score of pain in patients undergoing venepuncture with audiovisual distracting technique (2.53 +/- 1.76) and the mean score obtained in those undergoing venepuncture without this technique (5.22 +/- 2.53). In the group with audio-video distractors, the mean level of cooperation was 0.38 (SD = 0.63) compared to 0.20 (SD = 0.54) in the control group. In relation to the presence of parents, no significant differences were found in the mean pain scores (P = 0,5 > 0,05), whereas the mean scores of cooperation were significantly different (P = 0.0076 < 0.05) Audio-visual distraction effectively improved pain management and favoured children's cooperation during venepuncture. This technique is cost-effective, so it can be widely used for pain management and to promote cooperation with the child, two aspects that are of key importance in building a relationship of trustworthiness

Posterior spinal fusion (PSF) and hip reconstruction are commonly indicated surgeries in children with cerebral palsy (CP), particularly those functioning at GMFCS levels IV and V. These are large and often painful procedures, and previous literature suggests that hip surgery is more painful than spine surgery in this patient population. The purpose of this study is to investigate pain scores and opioid use following hip and spine surgery in a large cohort of children with CP, including many patients who have undergone both types of surgery. A retrospective chart review was performed to identify children with CP who underwent hip reconstruction and/or PSF at a tertiary children's hospital between 2004 and 2022. Charts were reviewed for demographic data, pain scores, pain medication usage, duration of hospital stay, and complications. Data were collected for 200 patients (101 male, 99 female) who met inclusion criteria. Eighty-seven patients underwent hip reconstruction, 62 spinal fusion, and 51 both hip and spine surgery asynchronously. Median (interquartile range) age at the time of surgery was significantly older for spinal fusion compared with hip surgery [13.1 (4.9) vs. 8.1 (5.7) y, P <0.0001]. Length of stay was significantly longer after PSF, with a median of 6 (4) days compared with 2 (1) days after hip surgery ( P <0.0001). Both maximum and average daily pain scores were similar following hip and spine surgery, with the exception that average pain scores for hip surgery were slightly higher on postoperative day 1, hip=1.73 vs. spine=1.0 ( P <0.0001). The amount of opioids used, expressed as morphine milligram equivalents (MME)/kg were similar in the hip and spine surgery groups; however, it was significantly lower in the hip surgery group on postoperative day 0, hip=0.06 versus spine=0.17 ( P <0.0001). For the 51 patients who underwent both hip and spine surgery, the amount of opioids used mirrored that for the entire group (similar MME/kg, though only statistically significantly less on POD 0 and 3), and pain scores were not significantly different between the 2 groups except in 2 circumstances. The 2 exceptions in these 51 patients both demonstrated lower pain scores in patients after hip surgery, including lower maximum pain scores on POD 1 ( P =0.041), and lower average pain scores on POD3 ( P =0.043). This is the largest series to date comparing postoperative pain in children with CP after hip and spine surgery, including 51 of 200 patients who underwent both types of surgery. The results of this study demonstrate that hip surgery is not more painful than spine surgery in children with CP, and conflict with the traditional belief that hip surgery is more painful. This is important information for health care providers when counseling patients and families regarding these surgeries in children with CP. Level 3.