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      Evaluation of association factors for labor episodic pain during epidural analgesia

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          Epidural analgesia provides safe and effective labor pain relief. However, labor episodic pain can occur during epidural analgesia, requiring epidural top-ups, and may result in decreased patient satisfaction. The primary aim of our study was to investigate the factors associated with labor episodic pain during epidural analgesia.

          Patients and methods

          Electronic and hardcopy records of labor deliveries between January 2012 and December 2015 were reviewed at KK Women’s and Children’s Hospital, Singapore. The primary outcome was the prevalence of episodic pain. Demographic, clinical and anesthetic data were retrieved. Univariate and multivariate logistic regression analyses were used to identify associated risk factors for labor episodic pain experienced by parturients while receiving epidural analgesia. Model performance was assessed by area under the curve (AUC) from the receiver operating characteristic curve.


          The prevalence of labor episodic pain was 14.2% (2,951 of 20,798 parturients). The risk factors associated with labor episodic pain, which are given here as factor (OR, 95% CI), are the following: need for epidural resiting (11.4, 7.53–17.28), higher pain scores intrapartum (1.34, 1.32–1.36), higher Bromage scores (1.12, 1.02–1.22), the need for instrumental delivery (1.32, 1.16–1.52), the need for cesarean delivery (1.41, 1.26–1.59), the presence of venous puncture (1.29, 1.03–1.62), the presence of dural puncture (14.28, 5.92–34.43), the presence of high block (6.05, 1.39–26.35), the need for a urinary catheter (1.17, 1.17–1.34), larger volumes of local anesthetics used (1.01, 1.01–1.01) and higher body mass index (1.01, 1.01–1.02), and decreased maternal satisfaction (0.97, 0.97–0.98). The AUC was 0.80.


          Knowledge of these factors may allow for future interventions in management to prevent labor episodic pain. Further research is needed to validate these association factors.

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          Most cited references 30

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          The use of receiver operating characteristic curves in biomedical informatics.

          Receiver operating characteristic (ROC) curves are frequently used in biomedical informatics research to evaluate classification and prediction models for decision support, diagnosis, and prognosis. ROC analysis investigates the accuracy of a model's ability to separate positive from negative cases (such as predicting the presence or absence of disease), and the results are independent of the prevalence of positive cases in the study population. It is especially useful in evaluating predictive models or other tests that produce output values over a continuous range, since it captures the trade-off between sensitivity and specificity over that range. There are many ways to conduct an ROC analysis. The best approach depends on the experiment; an inappropriate approach can easily lead to incorrect conclusions. In this article, we review the basic concepts of ROC analysis, illustrate their use with sample calculations, make recommendations drawn from the literature, and list readily available software.
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            Genetic influence on variability in human acute experimental pain sensitivity associated with gender, ethnicity and psychological temperament.

            While a variety of cultural, psychological and physiological factors contribute to variability in both clinical and experimental contexts, the role of genetic factors in human pain sensitivity is increasingly recognized as an important element. This study was performed to evaluate genetic influences on variability in human pain sensitivity associated with gender, ethnicity and temperament. Pain sensitivity in response to experimental painful thermal and cold stimuli was measured with visual analogue scale ratings and temperament dimensions of personality were evaluated. Loci in the vanilloid receptor subtype 1 gene (TRPV1), delta opioid receptor subtype 1 gene (OPRD1) and catechol O-methyltransferase gene (COMT) were genotyped using 5' nuclease assays. A total of 500 normal participants (306 females and 194 males) were evaluated. The sample composition was 62.0% European American, 17.4% African American, 9.0% Asian American, and 8.6% Hispanic, and 3.0% individuals with mixed racial parentage. Female European Americans with the TRPV1 Val(585) Val allele and males with low harm avoidance showed longer cold withdrawal times based on the classification and regression tree (CART) analysis. CART identified gender, an OPRD1 polymorphism and temperament dimensions of personality as the primary determinants of heat pain sensitivity at 49 degrees C. Our observations demonstrate that gender, ethnicity and temperament contribute to individual variation in thermal and cold pain sensitivity by interactions with TRPV1 and OPRD1 single nucleotide polymorphisms.
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              Failed epidural: causes and management.

              Failed epidural anaesthesia or analgesia is more frequent than generally recognized. We review the factors known to influence the success rate of epidural anaesthesia. Reasons for an inadequate epidural block include incorrect primary placement, secondary migration of a catheter after correct placement, and suboptimal dosing of local anaesthetic drugs. For catheter placement, the loss of resistance using saline has become the most widely used method. Patient positioning, the use of a midline or paramedian approach, and the method used for catheter fixation can all influence the success rate. When using equipotent doses, the difference in clinical effect between bupivacaine and the newer isoforms levobupivacaine and ropivacaine appears minimal. With continuous infusion, dose is the primary determinant of epidural anaesthesia quality, with volume and concentration playing a lesser role. Addition of adjuvants, especially opioids and epinephrine, may substantially increase the success rate of epidural analgesia. Adjuvant opioids may have a spinal or supraspinal action. The use of patient-controlled epidural analgesia with background infusion appears to be the best method for postoperative analgesia.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                15 February 2019
                : 12
                : 679-687
                [1 ]Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, Singapore, sng.ban.leong@ 123456singhealth.com.sg
                [2 ]Duke-NUS Medical School, Singapore, sng.ban.leong@ 123456singhealth.com.sg
                [3 ]Division of Clinical Support Services, KK Women’s and Children’s Hospital, Singapore
                [4 ]Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
                Author notes
                Correspondence: Ban Leong Sng, Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore, Tel +65 6 394 1077, Fax +65 6 291 2661, Email sng.ban.leong@ 123456singhealth.com.sg
                © 2019 Chan et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Anesthesiology & Pain management

                model, epidural, anesthesia, factors, labor pain, labor


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