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Objective:To investigate the effects of hypertensive disorders during pregnancy (HDP) on preterm newborns in terms of umbilical cord blood serum ferritin (SF), hemoglobin (Hb) at birth and outcome.Methods:Among inpatients of the First Maternity and Infant Health Hospital Affiliated to Tongji University from October 1, 2015 to December 31, 2016, totally 1 419 cases of preterm newborns were prospectively collected.Preterm infants whose mothers with diagnosis of HDP were recruited as the HDP group.Meanwhile, premature newborns whose mothers without HDP were recruited as the control group.Umbilical cord blood SF levels, Hb levels at birth, outcome of preterm newborns and the basic information for maternity were compared between the two groups.The data of normal distribution between the two groups were compared by independent sample t test.The count data was tested by χ2, and the count data with frequency <5 was tested by Fisher′ s exact test. Results:SF levels of HDP group were significantly lower than the control group [(85.6±67.2) μg/L vs. (103.9±95.5) μg/L]. But Hb levels of HDP group were much higher than the control group [(206.2±33.8) g/L vs. (193.2±31.9) g/L]. The difference between two groups was statistically significant ( t=2.791, 4.825 all P<0.05). Umbilical cord blood SF levels were negatively correlated with Hb levels at birth ( r=-0.120, P<0.001). Moreover, compared to the control group, statistically significant lower incidence of neonatal respiratory distress syndrome (NRDS), pneumonia and bronchopulmonary dysplasia (BPD) in HDP group was observed (all P<0.05). Conclusions:HDP was correlated with umbilical cord blood SF levels and Hb levels at birth in premature newborns.Higher Hb levels and relatively lower incidences of NRDS, pneumonia and BPD were observed in these newborns delivered by mothers with diagnosis of HDP.
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To compare the performance of self-inflating bag (SIB) with T-piece resuscitator (TPR) in neonatal resuscitation.Methods:This study involved the trainees participating in a Neonatal Resuscitation Simulation Camp (NRSC) organized by Shanghai First Maternity and Infant Hospital in December 2019. They were trained to provide positive pressure ventilation with the two devices on artificial lungs. Ventilation parameters including peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), PIP in pulmonary alveoli (PIP alv), mean airway pressure (MAP), frequency, inspiratory time (Ti), tidal volume and minute ventilation volume were recorded and analyzed by independent sample t-test or rank sum test. Results:The PIP alv, PIP, oxygen flow rate, tidal volume and minute ventilation volume delivered by TPR were significantly lower than those by SIB [(17.18±1.61) vs (24.05±4.29) cmH 2O (1 cmH 2O=0.098 kPa), t=－6.87; (17.91±1.35) vs (29.97±4.50) cmH 2O, t=－14.06; (3.65±0.25) vs (6.88±1.59) L/min, t=－11.33; (15.90±1.81) vs (24.02±4.29) ml/min, t=－10.99; (664.71±88.94) vs (1 069.49±205.68) ml/min, t=－9.89; all P<0.001]. However, compared with SIB, the PEEP in pulmonary alveoli, Ti, duration of ventilation, inspiratory to expiratory ratio were increased when using TPR [(4.76(4.69-5.57) vs 0.19(0.12-4.10) cmH 2O, T=1 190.00; (0.59±0.15) vs (0.43±0.09) s, t=5.01; (1.46±0.23) vs (1.36±0.11) s, t=2.15; 0.71±0.22 vs 0.47±0.13, t=5.14; all P<0.05]. Conclusion:TPR could deliver more stable and safer PIP, PEEP and tidal volume than SIB and keeping MAP at a stable level during positive pressure ventilation on artificial lungs.
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Team training significantly affects the performance of clinicians in neonatal resuscitation, which plays an important role in improving outcomes of asphyxiated newborns. Since 2016, team training was formally described in the Textbook of Neonatal Resuscitation, including 10 key points, which were summarized into three core elements in this review: teamwork, communication, and leadership. We review the application of these three elements in current team training and the main training approaches, aiming to offer a framework for standardized team training and to improve the success rate of neonatal resuscitation.
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Objective To study the perinatal outcomes of monochorionic diamnionic ( MCDA ) twins.Method A retrospective study had been conducted to analyze the outcomes of MCDA twins delivered in Hospital from Jan 2011 to Dec 2012.According to whether complicated with twin to twin transfusion syndrome ( TTTS, n=14 ) and/or selective intrauterine growth restriction ( sIUGR, n=41 ) , the infants enrolled in the study were assigned into complicated group (n=55) and uncomplicated group (n=90).The infants with sIUGR were further subdivided into three groups .The outcomes of the neonates were compared between the groups.Result A total of 145 pairs of MCDA twins were delivered , 285 neonates (12 of them died after birth ) and 5 cases of stillbirth. The gestational age at delivery in complicated group were significantly lower than those in uncomplicated group (33.8 ±2.8weeks vs.35.5 ±1.6weeks, P<0.001);The birth weight in complicated group ( the birth weight of the bigger baby was 2072 ±460 g vs.2520 ± 383 g, the smaller one 1620 ±477 g vs.2320 ±373 g ) were significantly lighter than those in uncomplicated group;The incidence of fetal death in complicated MCDA twin pregnancies (7.3% vs.0) was significantly higher than controls .Neonatal outcomes of fetuses complicated with sIUGRⅠ ( n=23 ) were similar to controls.Neonates complicated with TTTS, sIUGRⅡ(n =6) or sIUGRⅢ (n =12) had significantly increased incidence of respiratory distress syndrome , asphyxia, cardiac disorders, retinopathy of prematurity and neonatal death compared with controls .Conclusion Neonates of MCDA with TTTS or sIUGR had more complications compared with uncomplicated MCDA twins .The fetuses with abnormal umbilical artery Doppler blood flow are more vulnerable to stillbirth , neonatal death and other serious adverse outcomes .
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Objective@#To investigate the incidence and pathogen distribution of ventilator-associated pneumonia (VAP) among preterm infants admitted to level Ⅲ neonatal intensive care units (NICU) in China.@*Method@#A prospective study was conducted in 25 level Ⅲ NICU, enrolling all preterm infants <34 weeks gestational age admitted to the participating NICU within the first 7 days of life from May 2015 to April 2016. Chi-square test, t test and Mann-Whitney U test were used for statistical analysis.@*Result@#A total of 7 918 patients were enrolled, within whom 4 623(58.4%) were males. The birth weight was (1 639±415) g and the gestational age was (31.4±2.0) weeks; 4 654(58.8%) infants required non-invasive mechanical ventilation and 2 154(27.2%) required intubation. Of all the mechanically ventilated patients, VAP occurred in 95 patients. The overall VAP rate was 7.0 episodes per 1 000 ventilator days, varying from 0 to 34.4 episodes per 1 000 ventilator days in different centers. The incidence of VAP was 9.6 and 6.0 per 1 000 ventilator days in children′s hospitals and maternity-infant hospitals respectively, without significant differences (t=1.002, P=0.327). Gram-negative bacilli (76 strains, 91.6%) were the primary VAP microorganisms, mainly Acinetobacter baumannii (24 strains, 28.9%), Klebsiella pneumonia (23 strains, 27.7%), and Pseudomonas aeruginosa (10 strains, 12.0%).@*Conclusion@#The incidence of VAP in China is similar to that in developed counties, with substantial variability in different NICU settings. More efforts are needed to monitor and evaluate the preventable factors associated with VAP and conduct interventions that could effectively reduce the occurrence of VAP.
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Objective To establish a reference range of cancellous bone ultrasonic backscatter coefficient (BSC) in term neonates,and to determine the significance of BSC in bone nutritional status in term newborns and infants.Methods Six hundred and sixty-five term newborns,who were born in Shanghai First Maternity and Infant Hospital from July 2014 to August 2014,were enrolled.On the third day and the 42nd day after birth,all infants underwent ultrasonic measurement of the calcaneum bone using a broadband-non-focus ultrasonic transducer at three frequencies (2.25,3.5 and 5 MHz).MATLAB software was used to analyze the backscatter signals.Clinical data of the infants,including gestational age,birth weight and birth age,were recorded at the same time.Statistical analyses of the data included variance analysis,Tukey's test,rank sum test,Dunn test and Pearson or Spearman correlation analysis.Results (1) Of the 665 infants,335 were male.The mean gestational age at birth was (38.0± 1.9) weeks,and the mean birth weight was (3 1524±226) g.(2) On the third day,there were significant differences in BSC values acquired at 2.25 and 3.5 MHz among the groups with different gestational ages or birth weights (2.25 MHz:H=9.842 and 17.271;3.5 MHz:H=6.275 and 21.450,respectively,all P＜0.05).At 3.5 and 2.25 MHz,BSC values were positively correlated with gestational age (r=0.047 and 0.035,respectively,both P＜0.05) and birth weight (r=0.125 and 0.186,both P＜0.05).(3) On the 42nd day,significant differences in BSC were observed at each frequency among the groups with different gestational ages or birth weights (gestational age:H=76.832,16.498 and 32.756;birth weight:H=70.014,18.095 and 34.126;all P＜0.01).Gestational age and birth weight were positively correlated with BSC value acquired at each frequency (r=0.397,0.286 and 0.272 for gestational age,0.451,0.223 and 0.196 for birth weight;all P＜0.01).Conclusions A preliminary BSC reference percentile in term-born infants is established.There are positive correlations between BSC value and newborn gestational age and birth weight at certain frequencies,which can reflect the status of the newborn's cancellous bone.Determination of BSC value should be performed during the follow-up period to assess the nutritional status of neonatal bone.
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Objective To investigate the early changes of cardiac output and vital signs in term neonates shortly after born from gestational diabetic women.Methods From January 2015 to April 2015, 22 term neonates of gestational diabetes mellitus (GDM) women with euglycemia during pregnancy (GDM group) and 20 term neonates of non complicated gravidas (control group) in Shanghai First Maternity and Infant Hospital were enrolled.Neonates in both groups were measured by ultrasonic cardiac output monitor (USCOM) for cardiac hemodynamics index, including aortic peak flow velocity, pulmonary artery peak flow velocity, left cardiac output, right cardiac output and Smith Madigan inotropy index at one and two hours after birth.Vital signs including heart rate, respiratory rate, blood pressure and peripheral blood glucose were measured as well.Two independent sample t-test and Chi square test were used for statistical analysis.Results The peripheral blood glucose of neonates in GDM group was significantly lower than that of the control [(3.0±0.4) vs (4.0± 0.4) mmol/L, t=8.400, P ＜ 0.01), but all within normal range.Vital signs including heart rate, respiratory rate, mean blood pressure showed no differences between the groups (all P ＞ 0.05).In GDM group, aortic peak flow velocity were (1.230±0.160) and (1.210±0.220) m/s, left ventricle cardiac output was (0.867±0.196) and (0.859±0.193) L/min, Smith Madigan inotropy index was (0.846±0.180) and (0.823±0.189) W/m2 at one and two hours after birth, respectively, which were significantly higher than those in the control group [aortic peak flow velocity: (1.080±0.130) and (1.090± 0.120) m/s;left ventricle cardiac output: (0.754±0.098) and (0.757 ± 0.099) L/min;Smith Madigan inotropy index: (0.746 ± 0.097) and (0.725 ± 0.086) W/m2;t=3.464, 2.265, 2.296, 2.187, 2.263 and 2.202, respectively, all P ＜ 0.05].But no statistically significant differences was found on pulmonary artery peak flow velocity and right cardiac output between the two groups.Cardiac hemodynamics index had no difference between one and two hours within each group (all P ＞ 0.05).Conclusion The left ventricular contractility and left cardiac work are increased in neonates of gestational diabetes mellims women with good sugar control during pregnancy.
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Objective To investigate the hemodynamic changes and their association with the expression of β 1 and β 2 adrenoceptors after hypoxia-reoxygenation injury in a neonatal swine model of asphyxia.Methods One to four day-old piglets were randomly assigned to control group (n=6),acute hypoxia group (n=8) and subacute hypoxia group (n=8).The piglets in the control group were observed for 50 h under normoxic mechanical ventilation; while the acute and subacute hypoxia groups were subject to two hours of hypoxic injury induced by ventilation with 0.10-0.15 oxygen followed by 4 or 48 h of observation under normoxic mechanical ventilation,respectively.Blood gases were analyzed and the mean arterial blood pressure,heart rate,and cardiac output were recorded at different time points during the experiment.Tissues from the left ventricle were also harvested to assay lactate,glutathione and β adrenoceptors at the end of the experiment.Analysis of variance,the Tukey test and Pearson correlation analysis were used for statistical analysis of the data.Results Two hours after hypoxia,pH,HCO3-and partial pressure of oxygens (PO2) in the acute hypoxia group and subacute hypoxia group were lower than in the control group,however,pH and HCO3-in animals in the subacute hypoxia group recovered to 7.38 ± 0.05 and (23.04± 2.40)mmol/L,respectively,after reoxygenation,which was similar to those in the control group,and higher than in the acute hypoxia group [7.25±0.07 and (16.88±2.40) mmol/L,respectively,q=6.76 and 7.81,both P＜0.01].Mean arterial pressure,cardiac output and stroke volume in the acute group and subacute group were lower than those in the control animals following two hours of hypoxic injury (all P＜0.01).After reoxygenation,the mean arterial pressure in the acute hypoxia group and subacute group recovered to (42.17±6.14) and (43.19± 5.55) mmHg (1 mmHg=0.133 kPa),cardiac output recovered to (150.04± 56.17) and (169.75 ± 37.85) dl/min,respectively,and there were no differences compared with the control group (all P＞0.05).Expressions of β 1 and β 2 adrenoceptors in the left ventricle in the subacute hypoxia group (1.51 ±0.51 and 2.14±0.66,respectively),were higher than those in the control group (0.56±0.24 and 0.38±0.21,q=7.02 and 10.97,both P＜0.01) and the acute hypoxia group (0.65±0.20 and 0.45±0.11,q=6.86 and 11.38,both P＜0.01).The lactate level in the acute hypoxia group and subacute hypoxia group was higher than that in the control group [(6.95±0.32) and (6.92±0.40) vs (5.03±0.19) μ mol/mg protein,respectively,q=15.43 and 15.19,both P＜0.01].The level of glutathione in the subacute hypoxia group was lower than the control group and acute hypoxia group [(352.00± 16.51) vs (438.35±33.66) and (464.66±52.65) nmol/mg protein,respectively,q=6.00 and 8.46,both P＜0.01).In the subacute hypoxia group,the expressions of β 1 and β 2 adrenoceptors were negatively correlated with the changes in cardiac output (r=-0.60 and-0.59,respectively,both P＜0.05).Conclusions Severe metabolic acidosis and cardiac dysfunction resulting from perinatal asphyxia may recover after reoxygenation,which may be associated with the enhanced expression of β adrenoceptors in the left ventricle during the subacute phase.
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To assess the effects of resuscitation with oxygen or room air on the cardiac circulation and the activity of superoxide dismutase (SOD) in a hypoxic newborn piglet model. Methods Newborn piglets(1.6-2.5 kg) were randomly assigned into three groups:control group (n=8) with no hypoxic insult;room air group (n=12) resuscitated with room air for 240 min after 120 min hypoxia;and oxygen group (n=12) resuscitated with 100% oxygen for 30 min followed by 210 min with room air after 120 min hypoxia. Blood gas analysis, blood pressure and hemodynamic parameters were recorded at 0, 10, 30, 60, 120, 180 and 240 min of resuscitation. The activity of superoxide dismutase (SOD) in the left ventricle was measured at 240 min of resuscitation using enzyme method . One-way analysis of variance, two-way analysis of variance measured repeatedly and Student-Newman-Keuls test were applied as statistical methods. Results Severe metabolic acidosis, hypotension and hypoxemia were caused by hypoxia.(1)Arterial oxygen partial pressure(PaO2):At 10 min of resuscitation, PaO2 of control group, room air group and oxygen group was (67±4), (78±12) and (409±42)mmHg(1 mmHg=0.133 kPa) (F=580.19, P0.05). (3)Arterial oxygen content (CaO2):At 10 min of resuscitation, CaO2 of control group, room air group and oxygen group was(87.0±16.1), (76.9±13.2) and (102.2±15.9) ml O2/dl (F=8.64, P0.05). (4)Oxygen delivery (DO2): At 10, 30, 60, 120, 180 and 240 min of resuscitation, there were no statistical significance among DO2 of control group, room air group and oxygen group [10 min:(16.5±3.3), (15.7±9.9) and (16.9±4.2)L O2/(kg·min), F=0.10;30 min:(16.2±4.1), (15.1±5.5) and (14.5±3.3) L O2/(kg·min), F=0.38;60 min:(16.1±4.2), (14.9±4.0)and(13.3±3.8)L O2/(kg·min), F=1.28;120 min:(15.5±3.7),(15.6±6.1)and(13.4± 4.6) L O2/(kg·min), F=0.66;180 min:(15.4±3.1), (15.3±9.3) and (11.9±5.0) L O2/(kg·min), F=0.97;240 min:(14.7±3.4), (13.4±6.7) and (9.3±5.2) L O2/(kg·min), F=2.84;all P>0.05]. (5) SOD activity in the left ventricle:At 240 min of resuscitation, SOD activity of control group (n=6), room air group (n=8) and oxygen group (n=8) was (289±107), (210±75) and (142±61)U/mg protein, F=5.75, P0.05). Conclusions Despite higher oxygen content in the blood, resuscitation with oxygen is not beneficial to recovery from metabolic acidosis in newborn hypoxic piglets. Oxygen supplementation does not increase oxygen delivery but reduces SV compared to resuscitation with room air. Resuscitation with oxygen may impair the oxidative stress defense.
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Objective To investigate the effect of persistent hypoglycemia on the cerebral oxidative stress and matrix metalloproteinase-2 (MMP-2) activity of newborn rats and to explore the potential mechanism of hypoglycemia-induced brain injury of newborn.MethodsSeven-day-old rats were injected insulin subcutaneously to induce persistent hypoglycemia.Cerebral cortex,hippocampus and thalamus were collected after 36 hours' observation and stored in -80 ℃.Glutathione (GSH)and glutathione disulfide (GSSG) were detected by commercial kit and GSSG/GSH was calculated.MMP-2 activity was detected by gelatin zymography. The data were analyzed by t test,one or two-wayanalysis of variance and Pearson correlation analysis.Six rats were set as the normal glucose group. ResultsThirty-six hours after induction of hypoglycemia, the cerebral GSSG and GSSG/GSH of hypoglycemic pups elevated about 1.5 times higher than those of control group [GSSG:(15.89 ± 5.46) vs (6.15 ± 3.42) mg/g protein,t =3.704,P =0.004; GSSG/GSH:(5.58± 1.79) ％ vs (2.79±1.76) ％,t =2.712,P=0.022].The GSSG and GSSG/GSH in thalamus of hypoglycemia were significantly higher than those of control [GSSG:(15.93 ± 5.75) mg/g protein vs (5.03±5.14)mg/g protein,P＜0.05; GSSG/GSH:(6.50±3.25) ％ vs (2.41±3.12) ％,P＜0.05],whereas there were no significant differences in the cortex ard hippocampus.The total MMP-2 activity of hypoglycemic animals (2.22±0.59) was significantly higher than that of control (1.21± 0.17)(t=4.064,P=0.002),and significant differences were found between the two groups in cortex (2.14 ± 0.5 vs 1.17± 0.27),hippocampus (2.31± 0.72 vs 1.22 ± 0.37) and thalamus (2.22±0.68 vs 1.24±0.18) with all P＜0.01].The activity of MMP-2 was positively related to GSSG (r=0.575,P=0.0002) and GSSG/GSH (r=0.484,P=0.0003).ConclusionsOxidative stress might play an important role in the persistent hypoglycemia induced brain injury of 7-day-old rat pups and thalamus might be most vulnerable to hypoglycemia.Hypoglycemia might also elevate MMP-2 activity which is positively related to GSSG level and GSSG/GSH of the brain.
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ObjectiveTo investigate the selection of dilivery of pregnant women and related factors.MethodsThe selection of delivery modes for pregnant women was investigated by analyzing the associated factors of the infants registered into a computerized health care managing system from January 1,2008 to December 31,2010 at a local community of Shanghai.The information associated with delivery modes of their mothers was collected and the choice of delivery modes investigated through a standardized questionnaire by interviewing the mothers at two months after birth.ResultsThe cesarean section (C/S)rate of pregnant women residing in this local area was 58.3 ％ (224/384).In the C/S group,the percentages of delivery age ≥24 yr,white-collar workers,education level at high school and above and monthly income ≥ 3000 yuan were 73.2％ ( 164/224 ),38.4％ ( 86/224 ),79.5％ ( 178/224 ) and 80.8％ ( 181/224 )respectively.And they were all higher than those of vaginal delivery (63.1％,n =101; 32.5％,n =52;69.4％,n =111; 70.6％,n =113 ).The choices of C/S depended on the existences of maternal,fetal,social-psychological and others factors during pregnancy.Most pregnant women and families who chose C/S without medical indications were afraid of pain ( 33.9％ ) or a failure of vaginal delivery ( 30.5％ ).ConclusionsThe social-psychological factors of pregnant women are important in the choices of delivery modes.Unnecessary C/S could be reduced by improving their knowledge of delivery with meticulous prenatal health care consultations.
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@# Objective To explore the effects of static wrist on radial nerve palsies. Methods 60 patients with radial nerve palsies were devided into wrist group (n=20), acupuncture group (n=20) and intermediate-frequency (IF) group (n=20), who accepted static wrist wearing, electroacupuncture, and intermediate-frequency electro-stimulation respectively. Results The efficacy was not significantly different among these groups, but the time out of working and the cost for the management were the least in the wrist group. Conclusion Wearing static wrist is not only effective on radial nerve palsies, but also reduce the loss of working time and cost of treatment
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Objective To investigate the activation of apoptotic genes of the brain with hypoxia- ischemia (HI) in newborn SD rats, and MRI changes and memory and learning ability in adulthood. Methods HI was induced by right carotid artery ligation followed by 2.5 h of hypoxia (6% O2) on 3-day-old SD rats (n=36). Control pups were sham-operated (n = 27). Right brain hemisphere was collected at 12 h and 7 d after HI and subjected to an apoptosis Oligo GEArrayR. MRI and Morris water maze test were performed on both groups at 42 and 44 days old, respectively. Results Comparing to 12 h after HI, up-regulated apoptotic genes included TNF, Caspase and pro-apoptotit genes of Bcl2 families, whereas the anti-apoptotic genes of Bcl2 family were down-regulated at 7 d after HI. The MRI assessment of the rats in HI group demonstrated that the area of the right cerebra l cortex was significantly smaller than the left side and control [periventricular layer: (23.5±3.6) mm2 vs (33.0±4.3) mm2, (34.5±3.9) mm2; hippocampus layer: (18.9±4.4) mm2 vs (29.1±5.0) mm2,(30.8±4.5) mm2, both P<0.01]. During the navigation trial, the HI rats demonstrated longer escape latency (4th day: (52.7±35.9) vs (17.8±8. 9) s, P<0.01). HI rats passed the platform less times than the control ones (T= 292.5, P<0.05) in space probe trial. Conclusions The activation of apoptotic genes induced by HI brain injury remains until 7 days later, involving intrinsic and extrinsic apoptotic pathway. The apoptosis of neural cells may lead to poor development of the cortex and impair the memory and learning ability in the adult rats after neonatal hypoxia- ischemia injury.
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Objective To investigate the effect of syndecan-4 on the proliferation and extracellular matrix (ECM) secretion of human mesangial cells(HMC) stimulated by basic fibroblast growth factor (bFGF) and to evaluate the role of syndecan-4-PKCα pathway. Methods The expression of syndecan-4 in HMC was observed by immunofluorescence. After the down-regulation of syndecan-4 in HMC by RNA interference, the cell proliferation was detected by MTT. The secretion of fibronectin (FIN), type IV collagen, type Ⅰ collagen was assessed by ELISA. The copy number of syndecan-4 and PKCα was measured by fluorescent quantitation PCR at different time points. Results Syndecan-4 was expressed in HMC. bFGF could promote the cell proliferation and ECM secretion together with the PKCα copy number per million house-keeping genes of HMC, which could be reversed by the syndecan-4 siRNA transfection (MtT: 48-60 h, P<0.01; FiN: 24 h, P<0.01, 48-96 h, P<0.05; type Ⅳ collagen: 72-96 h, P<0.05; PKCa: 0 h, P<0.05, 12-48 h, P< 0.01). Conclusion Syndecan-4 may regulate the proliferation and ECM secretion of HMC stimulated by bFGF through syndecan-4-PKCα pathway.
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Objective Compare the analgesia effects of using different intervention method among neonatal infants, and then find out the most effective method. Methods Divided 120 neonatal infants into the control group, the NNS group and the position group, there were 40 cases in every group. Using the N-PASS scale evaluated the pain degree at the points of 1 and 5 minutes respectively after stimulation among the 3 groups. Results There was significant difference between the 3 groups on the pain degree,P