decrease children’s pain during painful procedures. Diversion therapy protocols differ in various ways, most notably in the attention required by the participant to engage in the distraction. Many studies have proved effectiveness of active distraction, based upon this the current study aimed to assess the effectiveness of active distraction, to increase children’s pain tolerance during painful medical procedures and achieve children comfort as much as possible. The child who experiences pain in an unsecure environment (i.e., away from his or her family) can suffer from a lack of confidence and stress. If the child has experienced a prior painful event, exposure to a similar situation can lead to severe anxiety that even renders the application of topical analgesics ineffective in preventing fear of the pain. Thus, inadequate relief of pain and distress during painful childhood medical procedures may have long-term negative effects on future pain tolerance and pain responses.
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neonates (< 28 weeks) undergoing as many 700 painful procedures during their hospital stay . Recently, Car- bajal  conducted a 2-week prospective chart review of 431 infants in 13 European NICUs. These infants endured 60, 969 painful procedures and a mean of 16 exposures (range 0 to 62) of painful or stressful procedures per day. Pain management for infants undergoing procedural pain associated with most frequent procedures such as tracheal suctioning, heelstick, tape removal, venepuncture and intravenous line insertions, although improved in recent years, was suboptimal. Almost 40% of infants undergoing heelstick for blood collections, the most commonly per- formed tissue breaking procedure in the NICU setting, did not receive any form of non-pharmacologic or pharmaco- logic intervention and 41% of infants underwent tracheal intubation without the benefit of any pain relieving strat- egies . In a similar 1-week prospective chart review of pain practices in 14 tertiary level NICU's in Canada, John- ston and colleagues  reported that 582 infants under- went a total of 30,416 procedures. Thirty-five different procedures were identified with 3553 (11.7%) being clas- sified as tissue breaking (i.e. skin-breaking or endotra- cheal intubation or an ophthalmologic examination). On average infants had 26 exposures (0-469) per week, just less that 4 per day. Although these findings support a slight reduction in previously reported average number of daily painful procedures that infants in the NICU endure, pain relieving strategies were still not routinely used. Forty-six percent (tissue) and 57% (non-tissue) damaging procedures performed were not accompanied by any form of pain relieving treatment.
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in 1995, that pain induced by procedures in the emer- gency department was unacceptably high. They noted that 44% of children cried during procedures, 16% fought against being restrained, and in 24% of the cases, the child was judged to be in a state of panic. Painful procedures are part of routine medical care of children in the pediatric or emergency depart- ments. In these settings, aggressive procedures in- clude venipunctures, bladder catheterizations, lum- bar punctures, bone marrow aspirations, nasogastric tube placement, laceration repairs, and others. The physical restraint usually applied to perform these procedures intensifies the child’s feelings of insecu- rity, powerlessness, and helplessness. The recent un- derstanding of the long-lasting effects of pain in children 3 underlines the necessity of providing opti-
Neonates were taken from warm, quiet nursery for venepuncture for sampling. Before skin preparation a pulse Oxymeter was applied to the baby’s foot to measure changes in heart rate and Oxygen saturation during the study. A trained nurse gave the selected interventional drug in a dose of 0.2 mL/kg, two minutes before the painful prick in the baby’s mouth, sublingually, with a syringe.A non-nutritive sucking followed the administration of drug. The baby was pricked on the dorsum of hand 2min after the selected intervention had been given. Only 1 prick was permissible for sample collection. Squeezing was done not more than 3 times to collect the sample.Blood Sample was collected after 1 minute of administration of drug and before completion of 3 minutes. NIPS and PATS Scale were used for assessment of severity of pain. After the commencement of intervention heart rate, respiratory rate, blood pressure and SPO2 were recorded 30seconds before pricking the baby. NIPS score was assessed at 2-3 min after the prick. Heart rate, respiratory rate, blood pressure and SPO2 were recorded again from the pulse oxymeter at 2 and 4 minutes after pricking the new-born. A number of tools to evaluate children's pain have been developed and are currently in use throughout the world. Neonatal Infant Pain Scale(NIPS)is a pain scale base on behavioural changes, a suitable instrument for assessment of neonatal pain. NIPS is composed of six indicators which use the behaviours that clinicians have described as being indicative of pain or distress in infants, i.e. facial expression, crying pattern, breathing pattern, arms and legs position and state of arousal. The minimum value of pain score in each group could be 0 or the maximum value of pain score in each group could be 7.
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Methods: The study is a retrospective review of 74,276 procedures performed at two pedi- atric hospitals in an integrated academic children’s health system between 2013 and 2016. We compared three comfort measures most frequently offered: positions of comfort (POC), distraction (DIST), and pharmacological (PHARM). These methods were compared in the set- ting of four procedures: peripheral intravenous (PIV) catheter insertion, gastrointestinal tube placement, incision procedures, and bladder catheterization. We used the number of attempts needed to complete a procedure as a measure of efficacy minimizing distressing experience in an acutely painful setting (single attempt vs repeat attempts).
The neonatal period is recognized as a brief, critical time that requires focused interventions. Neonates routinely undergo painful invasive procedures even after uncomplicated birth. Treating procedural pain has become a crucial part of neonatal care. In the past it was believed that neonates do not feel pain because of incomplete myelination of peripheral nerves. This is no longer believed to be true, because myelination is not necessary for pain perception. Hence Pain among ed and untreated, producing untoward consequences. In one word assessment of pain in babies is a persistent, unresolved problem that has serious implications for The objective of the study was to evaluate the effect of facilitated tucking in terms of variations in physiological and behavioural responses by comparing experimental The data was collected from 50 neonates (experimental =25, control =25) neonates underwent routine procedure with facilitated tucking and control group neonates underwent routine procedure without facilitated The mean NIPS score following the routine procedure with facilitated tucking was error of 0.245 and the same following the routine procedure without facilitated tucking was 5.12 with a standard error of 0.279 The NIPS scores of these two procedures were test, which revealed that there is a statistically significant difference in NIPS score (mean difference 3.520) between them. The result also showed that there is no significant association between the physiological and behavioural changes with demographic variables. -pharmacological measure to reduce procedural pain in neonates demonstrated by significantly lower NIPS scores.
1. Ghadami Yazdi A, Ayatolahi V, Hashemi A, Behdad SH, Ghadami yazdi E. Effect of two Different concentration of propofol and ketamine combinations (ketofol) in pediatric patients under lumbar puncture or bone marrow aspiration. Iran J Ped Hematol Oncol 2013;3(1):187-192. 2. Abdolkarimi B, Zareifar S, Golestani Eraghi M, Saleh F. Comparison effect of intravenous ketamine with pethidine for analgesia and sedation during bone marrow procedures in onchologic children: A Randomized, double-Blind, Crossover Trial. Iran J Hematol Oncol Stem Cell Res 2016;10(4):206-211.
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The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor, yet painful procedures. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures.
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A state of equipoise relating to analge- sic beneﬁts of sucrose or glucose in healthy term and preterm infants dur- ing single episodes of heel lancing, ve- nipuncture, or intramuscular injection no longer exists. Therefore, it is uneth- ical to conduct additional placebo- controlled or no-treatment trials in this population, and sucrose or glu- cose should be considered standard care for these procedures in future studies. Uncertainties remain with re- spect to outcomes after long-term use of sucrose during painful procedures for very preterm and sick infants, ef- fectiveness of concomitantly adminis- tered sweet solutions and opioid anal- gesics, effectiveness during longer procedures, and effectiveness for in- fants ⬎ 12 months of age. Future inves- tigations should focus on addressing these important research gaps re- garding sucrose analgesia for our youngest patients.
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Pharmacologic agents that have been examined for redu- cing procedural pain in neonates include topical anesthetics and systemic drugs, such as opioids or acetaminophen. Topical anesthetics, while effective for pain management during circumcision [16-20], have been shown to be ineffective for heel lance, venipuncture, and insertion of intravenous lines [21-25]. Systemic drugs, specifically opiates, are highly sensitive to the developmental stage of the infant [26,27]. Therefore, rapid changes in require- ments make effective and safe dosing a challenge. In addition, opiates have significantly slower clearance in neonates [28-32], and have not necessarily been demon- strated as effective for managing procedural pain . Trials of acetaminophen for procedural pain control have demonstrated that it is not effective, and may even be no better than placebo for heel lance procedure [34,35]. Thus, pharmacological management for common, repeated, painful procedures in preterm neonates is not an option. Given the frequency of painful procedures in NICUs, the short and long term negative effects of repeated pain expos- ure in this population, and the ethical imperative to manage this pain, other approaches are required.
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Procedural sedation is an emerging cornerstone in pediatrics aiming to control pain, decrease fear and emo- tional response when immobility is required or during painful procedures. The ideal sedative drug should have a prompt onset of action, be easy to administer, with a short elimination half time, offering efficacious pain re- lief without side effects. Particular attention is required when procedural sedation is needed in patients with disabilities associated with specific genetic disease or neurologic impairment. These patients present reduced communicative and expressive skills which reduce pain recognition and cooperation and they experience more pain and distress when compared to healthy peers . Therefore, they are frequently candidates for sedation, which is a challenge due to their comorbidities, which cause increased sedation-related risk. For example,
impairments . The consequences of untreated procedural pain in neonates can be both severe and long term. It is believed that exposing preterm neonates to pain negatively affects their ability to cope with pain and stress in later childhood [5, 8]. There is growing awareness that pain following a painful procedure should be treated appropriately and adequate soothing by parents or nurses is advocated. Neonates show many different responses to pain and stress. These responses can be of both physiological and behavioural nature, and can be used to detect discomfort of a neonate. Physiological responses include an increased heart and respiratory rate, increased or decreased blood pressure, decreased oxygen saturation, vagal tone and skin temperature. Behavioural responses are even more varied. Examples include vocalizations like crying and whimpering, facial expressions like grimacing with eyes squeezed shut or a stretched open mouth, and body movements like finger and toe splaying and trunk arching [5, 9]. It is worth noting that a change in any of these responses does not always imply that the neonate is experiencing stress or discomfort. Several pain-scoring systems have been developed to aggregate the behavioural signs, providing a reliable and structured tool for pain measurement. The past two decades have seen an increase in interest in neonatal pain treatment . Pharmacological solutions remain popular and are the most used method for pain treatment. Non-pharmacological methods of providing comfort and pain relief do exist and some have proven to be effective. The most popular techniques include: non-nutritive sucking, offering a sweet solution, facilitated tucking and skin-to-skin care. Non-nutritive sucking was one of the first non pharmacological comforting techniques to be studied and refers to offering a pacifier for the neonate to suck on . A sucrose solution can be provided as an extra means of comfort during more painful procedures. A syringe is used to gently squeeze some sucrose on the inside of the neonate's cheek. A pacifier is offered after the delivery of the sucrose, distracting the infant with something sweet to suck on . One of the most successful comforting techniques is skin-to-skin care (SSC), otherwise known as kangaroo mother care . Other comforting techniques include presenting the neonate with an audible heartbeat  or music  and aromatherapy . If possible, breastfeeding can also be used as a non-pharmacological comforting technique, although its effect was demonstrated on term neonates .
The first description of sarcoidal thyroid involvement was in 1938 (11). Although, thyroid involvement is rare (12), variable clinical presentations have been reported including painful enlargement of the gland, painful nodule, multinodular goiter with hyperthyroidism, diffuse toxic goiter, euthyroid goiter, cold thyroid nodule, graves`disease, and subclinical hypothyroidism (12- 19). Thyroid involvement in sarcoidosis most commonly is associated with intrathoracic findings but isolated thyroidal sarcoidosis has also been reported (20, 21).
Data from paper surveys was input into a spreadsheet (Microsoft Excel 2016; Microsoft Corp.) and merged with data from online respondents. Error checking and data audit was carried out at this stage. For pain score data, the distributions of scores across conditions and procedures were presented as boxplots. Pairwise associations between pain score assigned and various demographic factors were tested using Mann-Whitney U tests for factors with two categories, and Kruskal-Wallis tests for factors with more than two categories. As there were substantial correlations within some of these demographic factors (for example, the higher proportion of female graduates in later years), a multivariable linear regression model was constructed with pain score as the outcome variable, using a respondent-level random effect to account for repeated scores within individuals. The model was built using forward selection, and visual assessment of distribution of residuals and influence plots was used to assess model fit.
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“Don’t think I intended this to hurt you in any way, but I did what I had to do at the time. I love you no less because of it, but have grown to understand and appreciate things without harkening back to painful memories. Give me the time I need to speak, and I’ll reciprocate with ev- erything you’d like to know. Can I please have that?”
Vedānanupassanā: In Tathagatha Meditation, Vedānanupassanā is the mindfulness of feeling. The Buddha taught this in Satipatthana Sutta as follows: “There is the case where a monk, when feeling a painful feeling, discerns that he is feeling a painful feeling. When feeling a pleasant feeling, he discerns that he is feeling a pleasant feeling. When feeling a neither-painful-nor-pleasant feeling, he discerns that he is feeling a neither-painful-nor-pleasant feeling. “When feeling a painful feeling of the flesh, he discerns, ‘I am feeling a painful feeling of the flesh.’ When feeling a painful feeling not of the flesh, he discerns, ‘I am feeling a painful feeling not of the flesh.’ When feeling a pleasant feeling of the flesh, he discerns, ‘I am feeling a pleasant feeling of the flesh.’ When feeling a pleasant feeling not of the flesh, he discerns, ‘I am feeling a pleasant feeling not of the flesh.’ When feeling a neither-painful-norpleasant feeling of the flesh, he discerns, ‘I am feeling a neither-painful-norpleasant feeling of the flesh.’ When feeling a neither-painful-nor-pleasant feeling not of the flesh, he discerns, ‘I am feeling a neither-painful-norpleasant feeling not of the flesh.’ In Patriarch Meditation, one learns to just observe emotions and sensations come and go, without judgments and without identifying with them. In other words, it is not “my” feelings, and feelings do not define who you are. There are just feelings. Sometimes this can be uncomfortable. What can come up might surprise us. We humans have an amazing capacity to ignore our own anxieties and anger and even pain, sometimes. But ignoring sensations we do not like like is unhealthy. As we learn to observe and fully acknowledge our feelings, we also see how feelings dissipate. Some Zen masters beat or shout his disciples. Some pushes his students to be broken in feet or hand. It is regarded as a method to help meditators recognize the mindfulness of feeling. In this manner, contemplation on feeling between these two traditions is same in a certain level.
From the research that has been obtained indicates that as many as 18 students (72.0%) of respondents sufficient level of knowledge in the handling of dysmenorrhea causing increased pain. This is because in the handling of dysmenorrhea done by students is not based on the way of thinking and a positive attitude about the complaints that happened, thus forming behavior in an effort to handle to prevent the state of dysmenorrhea increased pain, and there are some businesses that are not made to reduce the incidence of dysmenorrhea such as the provision of warm compresses, regular exercise and rest, eat nutritious foods, taking analgesics. And lack of awareness of students to always pay attention to the pain he felt when menstruation. Menstrual pain is a normal thing to happen in women adolescence, menstrual pain clarified into two parts, namely primary menstrual pain and menstrual pain secondary. According Anurogo (2011) primary menstrual pain is pain that occurs without any abnormalities in the genital or uterine, but due to the excessive production of prostaglandin hormone secretion phase which causes stimulation of the smooth muscles of the endometrium. Painful menstruation (dysmenorrhea) at the moment are menstruating are included into the physical state of a person so when seoarang students to experience painful menstruation (dysmenorrhea) without any effort good handling it causes impaired activities of daily living in the study because the majority of students while experiencing menstrual pain concentration learning and in its activities will be focussed to control the pain.
Challenging experiences during early life can have profound long-term effects on an individual’s phenotype and, in some cases, on that of its offspring. Effects of early stress on later metabolic function and stress reactivity, including across generations, have been studied in detail [1,2]. Early life influences on later pain sensitivity also warrant attention because variation in sensitivity may affect an individual’s ability to cope with injury or disease and hence its vulnerability to suffering and poor welfare. There is evidence that painful neonatal experiences can influence the development of nociceptive systems and associated behaviour although, depending on the specifics of the early experience and the readout measures used , the direction of effects may vary (e.g. increased pain sensi- tivity in injured neonates (humans  and rats ); increased  and decreased  pain sensitivity in rats exposed to neonatal inflammatory pain). Perinatal experience of both central and peripheral lipopolysaccharide (LPS)-induced inflammation in the absence of overt pain, as may occur during infectious disease, also results in later changes in pain responsiveness, often hyperalgesia [8,9]. Thus, both painful and non-painful early life challenges can alter subsequent nocicep- tive processing. However, whether such effects carry over across generations is, to our knowledge, currently unknown.
In this ancillary pilot study, we assessed whether changes in serum levels of cytokines, chemokines and Substance P from baseline to 2-month post-injection were associ- ated with clinically meaningful pain relief at 2-month post-injection. We performed a mechanistic study and used data from our randomized study of intra-articular injection for painful TKA . In many patients, the pain improvement lasted through the 6-month follow-up period, indicating that the joint pain relief was somewhat durable . We found that several cytokine levels, includ- ing IL-7, IL-10, IL-12 (p70), eotaxin, IFN- γ and TNF-α, changed significantly more in WOMAC pain responders compared to pain non-responders (responders defined as those with pain decrement of 20 points or more on 0-100 scale). Correlation analyses identified additional cytokines with moderate correlations with WOMAC pain scores (baseline to 2-month change in cytokine level with baseline to 2-month change in WOMAC pain) in addition to these, including IL-2, IL-8, IL-9, IL-16, GCSF, IP-10, MCP, MIP1b and VEGF. In sensitivity analysis using a smaller dataset, serum substance P level reduction was greater in pain responders using the 0 – 10 daytime NRS pain than pain non-responders (pain decrement of two points or more o 0–10 scale). The direction and magni- tude were similar to the responder analysis by WOMAC pain, however, standard deviations were larger in WOMAC pain analysis, leading to the difference in sub- stance P levels being non-significant ( p = 0.32) in the main analysis, but significant in sensitivity analysis ( p = 0.023). This is a hypothesis-generating study and therefore, these findings need to be replicated in future studies.
We determined that the findings of these systematic reviews are not consistent across all patients or all surgi- cal procedures. We have previously identified patient characteristics and surgical procedures that may benefit from pregabalin . Through this systematic review, we would like to carefully explore the findings of the more recent perioperative clinical trials that have studied the use of pregabalin for acute pain. We will comment on the implications of the findings and provide further dir- ection for the appropriate use of pregabalin in acute pain. This protocol will attempt to bridge the growing gap between clinical practice and emerging evidence. Fi- nally, this systematic review has the potential to aid fu- ture guideline development in the perioperative use of pregabalin.