To test our hypothesis that a new modified VAS (mVAS) is superior and more objective than VAS in evaluating pain perception and treatment response between genders who have renal colic pain.IV score). Then the patients with renal colic were asked to mark the pain they experienced before treatment (VASRC score) and at 15 and 30 minutes after the administration of the first analgesic drug. The modified VAS scores (mVAS score) were obtained by subtracting the VASIV score from VASRC score.The individuals in patient and control groups were first asked to mark the pain perceived during access of IV line . However, there was not any significant difference at 0 and 30th min between sexes while female patients had significantly higher level of pain scores only at 15th minute according to mVAS scores (p = 0.027).When VAS was used, the female patients had significantly higher level of pain at 0, 15, and 30We think that the mVAS is superior and more objective than VAS in evaluating pain perception and abolished the difference in the perceived level of pain due to gender. Pain is an alarming symptom that develops in response to numerous clinical conditions and causes discomfort in patients. The incidence of patients with pain has been on the rise in recent years, and a greater number of patients have sought care in emergency departments (EDs) due to acute pain.4The VAS is a scoring system that requires patient compliance describes the level of pain from zero to ten. It was claimed that the VAS is more useful in evaluating the effectiveness of pain treatment than in the evaluation of acute pain.8Another major discussion point on pain perception is whether gender affects pain perception or not. While a majority of the studies support the assumption that women experience pain more frequently and more severely than men, others conclude that there is essentially no difference about the perception of pain and the response to pain treatment between the sexes.In the present study, VAS was thought to be modified with threshold level by determining pain perceived during access of intravenous (IV) line. Our hypothesis is that a new modified VAS (mVAS) is superior and more objective than VAS in evaluating pain perception and treatment response between genders who have renal colic pain.This single-center prospective clinical study was conducted on consenting adults  who presented to Emergency Department (ED) of a university hospital and were diagnosed with and treated for renal colic pain between March 2010 and September 2011. The diagnosis of acute renal colic was made based on the findings of the patient history, physical examination, complete urinalysis, direct urinary system radiography, and if required, renal ultrasonography and non-contrast abdominal tomography. In order to standardize the study protocols, patients with acute pain other than renal colic were excluded from the study. The control group consisted of adult patients that presented to the ED for complaints other than pain. Approval for the study was obtained from the local ethics committee (ECN: 2011-111), and written consent was obtained from all patients enrolled in the study.The same nurse performed access of IV line with a 20G catheter on the antecubital regions of individuals on the patient and control groups. In patient group, hydration with 500 mL of a 0.9% NaCl solution was provided together with a single dose of a non-steroid anti-inflammatory drug (NSAID) delivered intravenously. An additional dose of the same agent or a different type of analgesic was given 30 minutes after the initial dose of the IV NSAID to patients for whom an adequate analgesia could not be achieved. The patients on the control group, who presented to the ED for complaints other than acute pain, were also started on IV lines using the same size catheters and with the same nurse.IV score) on the VAS card. Then the patients with renal colic were asked to mark the pain they experienced before treatment (VASRC score) on the VAS card. Finally, the patients marked their pain levels at 15 and 30 minutes after the administration of the first analgesic drug. The patients of the control group were just asked to mark their VASIV scores on the VAS cards.A 100-mm VAS  was used to assess the pain perceived by the study groups. Those patients in both groups were first asked to mark the pain perceived during access of IV line (VASIV score were assumed as the standard to establish the patients’ pain thresholds. The modified VAS scores (mVAS score) were obtained by subtracting the VASIV score from VASRC score, and were considered the true indication of pain perception:The pain levels marked as VASRC score - VASIV score][mVAS score = VASWe evaluated the differences for the pain perceived during access of IV line between patient and control group. Further, we grouped the patients based on gender and evaluated the changes in VAS and mVAS scores over time in order to evaluate differences between sexes.t-tests. Variations in VAS scores over time were tested using Dependent two-sample t-tests and Wilcoxon tests.All data were evaluated using SPSS . The data were presented as the median (minimum (min) – maximum (max)), mean and standard deviation. Differences in VAS scores between groups were tested using the Mann Whitney U and independent two-sample A total of 96 patients were included in the study. Of those, 63 (65.6%) were in the patient group and 33 (34.3%) were in the control group. The average age of the patient group was 37.8±13.8, while it was 49.8±20.4 for the control group. Forty-two members (66.7%) of the patient group were males, whereas 16 members (48.5%) of the control group were males.IV score is taken into account, the patient group reported significantly less pain during access of IV line than did the control group (p < 0.001)  (When VAS< 0.001) , Fig.1. < 0.001) , Fig.2.RC score over time according to gender, the female patients had significantly higher level of pain at 0, 15, and 30th minutes than men   , Fig.3.th min between sexes while female patients had significantly higher level of pain only at 15th minute (p = 0.027)  , Fig.4.With this study, we wanted to show that modified VAS method is more objective in evaluating pain perception and eliminates gender differences in pain perception. In order to find the ideal method in our study, we assumed that different scores reported by individuals after the standard procedure like accessing IV line were actually the same. By aligning the different scores reported for standard procedure on the same line, we aimed to determine the actual level of pain perceived by the patients experiencing more severe pain. We think that such an adjustment is a simple yet valuable method to standardize and establish the pain threshold of an individual.numeric rating scale.Pain is a subjective finding. Even though people perceive same level of pain, their expression of pain can be different among individuals. Ideally, clinicians wish to have a method that overcomes differences in expression so that the perception of pain can be described more objectively. Research has been conducted for years for the purpose of developing an ideal pain expression method. VAS has been reported as a simple yet effective methodology for the assessment of acute and chronic pain in the studies.Patients with renal colic pain expressed significantly less pain during acess of IV line than the control group , Fig.1. RC scores, women perceived renal colic pain more severely than men, and that they got less relief from analgesic treatments after 15 and 30 minutes  in order to objectify the expression of pain, as we did in our study, are needed to optimize the VAS scale. Furthermore, asking patients on whom the VAS scale was used to quantify a previous pain experience on the VAS scale may further assist in optimizing the objectivity of the VAS scale.This was a single center study with a limited number of patients. The accuracy of mVAS also should be tested on cases with different racial groups and different source of acute pain. The previous experience of patients about pain was not considered.


Little is known regarding the burden of opioid-induced constipation (OIC) among patients who suffer from cancer-related pain.A prospective longitudinal study was conducted among cancer patients in the United Kingdom (UK), Canada, and Germany, which included medical record data abstraction, Internet-based patient surveys, and physician surveys. Patients on daily opioid therapy (≥30 mg for ≥4 weeks) for treatment of cancer pain with self-reported OIC were recruited. Response to laxatives was defined by classifying participants into categories of laxative use and evaluating the prevalence of inadequate response. Descriptive statistics were used to evaluate outcomes, including the patient assessment of constipation-symptom (PAC-SYM), patient assessment of constipation-quality of life, EuroQOL-5 dimensions, and global assessment of treatment benefit, satisfaction, and willingness to continue.n = 16) of participants were male, and all were White. Breast , pancreatic , and multiple myeloma  were the most common cancers. Mean duration of chronic pain and opioid use were 2.3 and 1.3 years, respectively. Participants reported having a mean of 4.4 bowel movements/week in the 2 weeks prior to baseline, of which a mean of 0.9 were spontaneous. Most participants  were using at least 1 lifestyle approach to manage their constipation; 65% (n = 20) were taking ≥1 over-the-counter laxative; 19% (n = 6) were taking ≥1 prescription laxative; 23% (n = 7) reported no laxative use in the prior 2 weeks. Moderate-to-severe constipation symptoms on the PAC-SYM were common, and mean scores on health-related quality of life outcomes were comparable to chronic pain populations.Recruitment was difficult for this study with only 31 participants completing the baseline survey and meeting criteria for opioid use and OIC . Fifty-two percent (In this primarily UK sample, there appears to be considerable unmet OIC treatment needs among cancer patients. At present, there is no consensus definition of opioid-induced constipation (OIC) to guide clinical and epidemiological research or to inform treatment recommendations . DependiLittle is known about the decision tree by which cancer patients and their physicians manage OIC. Available management options include lifestyle strategies, such as exercise, increased intake of fiber and fluids, and probiotics, followed by use of laxatives [both over-the-counter (OTC) and prescription treatments] . HoweverIn order to better understand OIC among cancer patients, a hybrid, prospective longitudinal study was designed to generate real-world empirical evidence of the patient burden and experience of OIC. Difficulties were encountered when recruiting sites and patients with cancer pain. The recruitment for this patient cohort was truncated after 13 months where 31 patients were enrolled. The objective of this paper is to present the completed baseline data to characterize demographics, clinical characteristics, constipation symptoms, pain management, OIC treatments, rate of inadequate response to laxatives, and the impact of OIC on HRQL in this small convenience sample of patients with cancer pain and OIC.This analysis focuses on baseline data from a patient survey conducted among patients with cancer pain and is part of an ongoing longitudinal study evaluating clinical characteristics and burden of OIC among patients with cancer and non-cancer pain using a combination of patient surveys, retrospective data abstraction from medical records, and physician surveys , 9.The study received institutional review board approval and was executed in accordance with the Canadian regulation known as the Personal Information Protection and Electronic Documents Act, Health Insurance Portability and Accountability Act of 1996, European Union Data Protection Directive, and Safe Harbor agreement. The protocol (NCT01928953) was also reviewed and endorsed by the Anesthetics Pain Subgroup and the Primary Care Research Network.via the Internet at baseline and again at the end of the study period (Week 24) for each patient who completed a baseline survey. The Internet-based patient-specific physician survey was completed at baseline and at Week 24 for each patient who completed the baseline survey. Data from the chart review and physician survey are still being collected.The Internet-based patient-reported component includes the baseline survey and eight follow-up Internet surveys conducted over 24 weeks . The retrospective chart review was completed by the clinical sites Additional details about participant recruitment and data collection procedures are described elsewhere in the manuscript summarizing the study methodology and descriptive analysis of baseline study outcomes in the non-cancer pain study sample .Briefly, participants were patients with cancer who were recruited from oncology clinics, primary care clinics, pain management clinics, and clinical research sites affiliated with primary care networks who had chart confirmation of daily opioid therapy lasting ≥4 weeks for the treatment of chronic cancer pain and who self-reported OIC during their screening interview. Clinical site staff identified a preliminary cohort of potentially eligible patients by review of the medical charts at their site. Staff then described the study and the informed consent process to each identified patient. Following completion of the baseline survey, participants were compensated for their time in the form of an electronic gift card in the country’s currency, with values ranging from the equivalent of 15 to 25 USD.The initial recruitment target for cancer pain patients was 150 patients. However, due to extensive difficulties in recruiting clinical sites to recruit patients and in recruiting cancer pain patients to participate in this OIC burden of illness study, recruitment was truncated after 13 months with only 31 patients enrolled. No sites were activated in the US.The patient survey included demographic questions regarding gender, age, race, education, marital status, employment status, and insurance type. The survey also included questions about clinical characteristics, including rating of overall health, duration, type, and severity of chronic pain, and duration of opioid use including changes in opioid pain medications to have a bowel movement (BM).Opioid-induced constipation status was confirmed during the survey by patients meeting one of the following criteria: responding “yes” to question “Since starting the opioid pain medication, have you been experiencing constipation or worsening of current constipation? Yes/No”; OR reporting fewer than three BMs per week, OR reporting laxative use if more than three BM per week, OR report at least one symptom of OIC on the patient assessment of constipation-symptom (PAC-SYM) in the past 2 weeks. Participants’ answered questions about their history of constipation, including questions about the duration of constipation symptoms and health-care seeking in relation to constipation symptoms, as well as questions about which therapies the health-care provider (HCP) suggested for constipation. Information about participants’ bowel symptoms, including BM frequency, spontaneity, and preferences, were collected in addition to which therapies they used to relieve their constipation. Management options included lifestyle approaches , OTC therapies , and prescription laxatives.The PAC-SYM questionnaire  was desiThe patient assessment of constipation-quality of life (PAC-QOL): a 28-item measure designed to capture four QOL domains: physical discomfort, psychological discomfort, worries and concerns, and satisfaction (which was not measured in this study) with a recall period of 2 weeks. Similar to the PAC-SYM, participants are asked to rate themselves over the previous 2 weeks on a five-point Likert scale ranging from 0 to 4, where higher scores indicate worse QOL.The EuroQOL-5 dimensions (EQ-5D) is a five-item health state descriptive system where full health is 1 and 0 is equivalent to death (EQ-5D index), and a visual analog scale . There is extensive evidence supporting the reliability and validity of the EQ-5D , and it The global assessment of treatment benefit, satisfaction, and willingness (BSW) to continue consists of three single-item measures that are designed to capture patients’ perception of the effect of their treatment in terms of benefits, satisfaction, and willingness to continue treatment . The BSWFinally, participants also completed patient-reported questionnaires assessing condition-specific and general HRQL, includingAnalyses were performed using SAS version 9.4  following a statistical analysis plan approved prior to receipt of the locked and clean dataset. The data were analyzed as observed, without imputation for missing responses. Descriptive statistics were used to evaluate outcomes. For continuous variables, the mean and SD were described and rounded to one decimal for all data. For categorical variables, the number and percent distribution by category were described.Participants who completed the baseline survey were further evaluated for presence of OIC in order to confirm study eligibility, which included the following criteria.Participants who responded “Yes” to the baseline question: “Since starting opioid pain medication, have you been experiencing constipation or worsening of current constipation? Yes/No”; OR participants who reported laxative use if the number of BMs in the past 2 weeks is ≥3/week; OR participants who reported <3 BMs/week in the past 2 weeks were eligible, regardless of whether they reported laxative use; OR participants who did not report laxative use but reported at least one symptom of OIC at least “moderate” or more often on the PAC-SYM screening questions in the past 2 weeks .®, Ducolax® stool softener), mineral oil], osmotics , stimulants , salines [magnesium hydrochloride ], rectal options , and prescription therapies .Participants were classified into groups based on their use of laxatives, which included the following: stool softeners [e.g., docusate sodium  were from the United Kingdom (UK), 3% (N = 1) was from Canada, and 13% (N = 4) were from Germany. Just over half  were male, and all were White (Table n = 28) and unable to work due to disability or handicap (n = 11) or retired (n = 16).All 31 (100%) participants completing the baseline survey met criteria for opioid use and OIC. Eighty-four percent (n = 24) reported discussing their OIC with their HCP during an office visit (Table Most participants n = 4 reporten = 13) or poor (n = 13). The mean (±SD) duration of pain was 2.3 ± 3.6 years, and the mean (±SD) duration of opioid medication use was 1.3 ± 1.3 years. In addition to pain related to their cancer, patients commonly reported back pain (n = 15), joint pain (n = 10), and pain syndrome (n = 10). Many participants (n = 12) reported that their constipation moderately or completely interfered with the ability of their opioid medication to control pain.Most patients reported that their health was fair (n = 15) were on more than one opioid, with morphine being the most frequently prescribed opioid (n = 13) followed by oxycodone (n = 12). The mean morphine equivalent dose (MED) at baseline was 183.3 ± 185 mg, and five patients had a MED of ≥200 mg/day. Nine patients discontinued use of their opioids over the course of the study and mean MED at week 24 for remaining patients was 251.3 ± 313.4 mg.Nearly, half (n = 26) reported wanting to have a BM at least once a day or more. Thirty participants reported at least 1 of the 12 PAC-SYM symptoms as moderate or greater in intensity (Table n = 27), pain in abdomen (n = 24), bloating in abdomen (n = 23), painful BM (n = 21), incomplete BM (n = 22), BMs too hard (n = 19), straining/squeezing to pass BM (n = 22), and feeling like had to pass BM but could not (n = 19).Participants reported 4.4 ± 2.5 BMs on average per week, with 0.9 ± 1.5 BMs being spontaneous. Eighty-seven percent of participants  used a combination of at least one natural or behavioral therapy and one OTC therapy.The most frequently utilized OIC management options in the past 2 weeks were natural or behavior therapies, including dietary changes, increased fluids or exercise, probiotics, and fiber supplements  PAC-QOL physical discomfort, psychosocial discomfort, and worries and concerns domain scores were 1.7 ± 1.0, 1.2 ± 1.1, 1.9 ± 1.1, respectively  was higher than what was found among patients with OIC and non-cancer pain . This may be due to the higher rates of discussion regarding OIC between the physicians and patients in the cancer cohort  than non-cancer cohort . Participants with cancer pain also reported a greater number of BMs per week on average (4.4) as compared to those with non-cancer pain (3.7), though fewer of these were spontaneous , and the majority of patients in both samples  reported wanting to have a BM at least once a day or more. Interestingly, the proportion of participants reporting PAC-SYM constipation symptoms at least moderate or more often tended to be higher among participants in the cancer pain cohort compared to those with non-cancer pain. Patients in the non-cancer cohort reported significantly longer durations of pain  and opioid use , which may have contributed to this difference in results as the non-cancer pain patients have been coping with OIC for much longer and have developed a new “normal” with OIC.The prevalence of sufficient laxative use reported in this descriptive sample of cancer patients with OIC .In terms of constipation-specific quality of life, participants with cancer pain in this study had PAC-QOL scores that were similar to those reported among patients with constipation and cancer pain in the DYONISOS study . As expen = 12) of cancer pain patients in this study reported that OIC at least moderately interfered with their pain management.Taken together, these findings suggest that patients with cancer pain commonly experience burdensome constipation symptoms despite being more likely to proactively treat their OIC using sufficient laxatives as compared to patients with non-cancer pain. Previous publications evaluating laxative management in ambulatory cancer patients also suggest substantial unmet treatment needs . Wirz etAlthough most patients with cancer pain and OIC are willing to continue their current laxative treatment regimen, there is a need for viable treatment alternatives with less burdensome side effect profiles and better efficacy. Novel peripherally acting μ-opioid antagonists may be useful in reversing opioid agonist-induced actions, including bowel dysfunction .There are a number of limitations to this study. First, as noted above, recruitment was prematurely terminated due to the difficulty encountered when recruiting sites and cancer patients with OIC. Reasons for recruitment difficulties were thought to be due to cancer pain patients being burdened with research and other treatment considerations, which reduced the likelihood and interest to participate in non-interventional, observational research.n = 31) is limited in its generalizability and precision with respect to point estimates on the characteristics reported. The cohort is composed of patients with a range of different cancer diagnoses, levels of disease severity, and other health problems leaving this a descriptive analysis of the burden of OIC in a small number of cancer pain patients. Second, bowel habits in this study were not able to be compared to those prior to opioid use, so patients with a long-standing history of constipation could not be differentiated from those who had OIC. Third, the use of an Internet-based survey may have biased the study sample to those with higher levels of education and socioeconomic status. Finally, most of the study questions used a 1-week (7-day) recall period, which may have resulted in recall bias in reporting symptoms that vary from day to day. These limitations aside, the study does highlight the burden of OIC among patients with cancer pain.Thus, the small sample size (Although most patients with cancer pain and OIC in this predominantly UK sample were willing to continue their current laxative treatment regimen, there appears to be a need for viable treatment alternatives with better efficacy. Further research on OIC burden and management of the condition is needed. To do so, challenges in recruiting sites and patients need to be elucidated and resolved, so that future research design for studies related to OIC in cancer pain can generate point estimates with acceptable precision. Increased awareness of OIC and its persistence among this already burdened patient cohort may be needed among HCPs.All authors participated in the conceptualization and writing of this paper, have seen and approved the final manuscript, meet the criteria for authorship, and approved its submission to Frontiers in Oncology.SA is affiliated with the University of Sheffield. FK and RL are employed by AstraZeneca. KC is employed by Evidera, which provides consulting and other research services to pharmaceutical, device, government and non-government organizations. MM and CS were employed by Evidera at the time the study was completed and during the writing of this manuscript. As Evidera employees, they work with a variety of companies and organizations and are expressly prohibited from receiving any payment or honoraria directly from these organizations for services rendered. MM, CS, and KC have received consultancy fees from AstraZeneca.


During 2000–2012, most patients with AS were diagnosed outside of rheumatology practices. The delay before referral to rheumatology was 10 months; AS diagnosis generally followed within a month. Earlier referral of patients with AS signs and symptoms may lead to more timely diagnosis and appropriate treatment.This study aimed to identify providers involved in diagnosing ankylosing spondylitis (AS) following back pain diagnosis in the USA and to identify factors leading to the delay in rheumatology referrals. The Truven Health MarketScan® US Commercial Database was searched for patients aged 18–64 years with back pain diagnosis in a non-rheumatology setting followed by AS diagnosis in any setting during January 2000–December 2012. Patients with a rheumatologist visit on or before AS diagnosis were considered referred. Cox regression was used to determine factors associated with referral time after adjusting for age, sex, comorbidities, physician specialty, drug therapy, and imaging procedures. Of 3336 patients included, 1244 (37 %) were referred to and diagnosed by rheumatologists; the others were diagnosed in primary care (25.7 %), chiropractic/physical therapy (7 %), orthopedic surgery (3.8 %), pain clinic (3.6 %), acute care (3.4 %), and other (19.2 %) settings. Median time from back pain diagnosis to rheumatology referral was 307 days and from first rheumatologist visit to AS diagnosis was 28 days. Referred patients were more likely to be younger  contains supplementary material, which is available to authorized users. The delay between symptom onset and diagnosis of ankylosing spondylitis (AS) has been estimated at approximately 8 to 11 years in Europe  and apprIn the USA, the majority (approximately 60 %) of patients with low back pain consult with general practitioners, whereas 35–37 and 24–30 % of patients seek care from the orthopedists and chiropractors, respectively , 13. HowStrategies for appropriate and timely referral to rheumatologists aimed at shortening the diagnostic delay in AS have been described , 7, 16. The current study sought to identify the health care providers who make the diagnosis of AS in patients with chronic back pain in the USA, to assess treatment and referral patterns, and to identify factors associated with diagnostic delay in a large sample of patients who initially presented in non-rheumatology settings including primary care. In particular, we aimed to describe patterns of prescription drug therapy, use of diagnostic imaging, and rheumatology referral during the period from back pain diagnosis to AS diagnosis.International Statistical Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9] code = 720.0) in any clinical setting  or rheumatologist referral (for referred patients) and prescribing/referring physician specialty. The outcome of interest was time to referral, defined as time from the first non-rheumatologist visit for back pain to the first rheumatologist visit, at or before the time of AS diagnosis. This study included time-independent (those that could not randomly change with time) and time-dependent (those that could randomly change with time) factors that could influence the time to rheumatologist referral in AS patients. Age, sex, and comorbidities as assessed at back pain diagnosis date were considered time-independent variables. Comorbidities assessed included diabetes mellitus, cardiovascular disease, hypertension, renal disease, cancer (any), and uveitis. Time-dependent variables were captured from index date to AS diagnosis date and included physician specialty, prescription drug therapy, and diagnostic imaging procedures carried out. Physician specialty under which all prescription drug and health care service claims were provided included primary care, orthopedic surgery, pain management, chiropractic/physical therapy, acute care, and “other” . Prescription drugs assessed included NSAIDs, disease-modifying antirheumatic drug (DMARDs), corticosteroids, opiate pain medications, and anti-TNF therapy. Diagnostic imaging procedures assessed included X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scans of the spine and pelvis.p < 0.05.Demographic and clinical characteristics, patterns of prescription drug use, and diagnostic imaging procedures received were compared between referred and non-referred patients using descriptive statistics. A time-dependent Cox proportional hazard model was used to determine factors associated with time to referral. The model was adjusted for age, sex, comorbidities, physician specialty, drug therapy, and imaging procedures; time-dependent variables were adjusted annually in the model. A stepwise selection method was used to determine statistically significant predictors of referral time. Hazard ratios with 95 % confidence intervals (CI) were reported. Data management and analysis was accomplished via PC-SAS® version 9.2 , with an a priori alpha set at n = 2092; 63 %) were diagnosed with AS outside of rheumatology practices  patients were referred to rheumatologists for AS diagnosis and the remaining ; approximately half of patients in each group were women.A comparison of demographic and clinical characteristics between the 1244 referred and 2092 non-referred patients at the index date is shown in Table p < 0.0001 each) prior to AS diagnosis or rheumatologist referral. As shown in Table Patterns of prescription drug use and diagnostic imaging procedures ordered by non-rheumatology providers in the period between back pain diagnosis and AS diagnosis (for 2092 non-referred patients) or rheumatologist referral (for 1244 referred patients) are summarized in Fig. n = 2450) of all patients received at least one diagnostic imaging procedure  of the spine and/or pelvis in the period between back pain diagnosis and either AS diagnosis or rheumatologist referral  and MRI . Referred patients were more likely than non-referred patients to have received imaging procedures specific to the pelvis  days, and median time from referral to AS diagnosis was 28 (interquartile range 0–194) days. Factors associated with referral time are presented in Table This large, retrospective analysis of the administrative claims data of 127 million individuals over a 10-year period provides several unique observations regarding the diagnosis of AS in the USA. First, of all patients with an initial diagnosis of back pain who subsequently were diagnosed with AS, only 37 % were referred to rheumatologists. The remaining 63 % were diagnosed by non-rheumatologists. Previous studies have shown that non-rheumatology providers see most patients with chronic back pain. For example, an analysis of data from the National Health and Nutrition Examination Survey NHANES 1976–1980) showed that patients with low back pain most commonly sought care from PCPs (approximately 60 %), followed by orthopedists (30 %) and chiropractors (30 %) . In addi76–1980 sSecond, the median delay from back pain diagnosis to rheumatologist referral was approximately 10 months, but following consultation with a rheumatologist, patients were generally diagnosed with AS within 1 month. Predictors of shorter time to referral included younger age, male sex, presence of uveitis, increased use of prescription drug therapy, use of X-ray imaging, and PCP as the referring physician specialty. These results suggest that referral decisions may be driven both by appropriate recognition of AS features  and by a continued misperception among non-rheumatologists that AS is rarely seen in women . IncreasThird, of patients who were initially diagnosed with AS by a non-rheumatologist and then referred to a rheumatologist, only 42 % were confirmed to have AS, and the diagnosis was changed in 58 % of the patients—mostly to a non-inflammatory condition—by the rheumatologists. Among many other possible reasons, inappropriate use of imaging modalities by non-rheumatologists may have contributed to misdiagnosis. In particular, only 21 % of non-referred and 45 % of referred patients received pelvic X-rays by non-rheumatologists, which are essential for the diagnosis of AS . MRI of Our results are generally consistent with previous studies showing insufficient awareness of AS in the primary care setting. In a study of 807 patients with AS in the UK, the mean diagnostic delay was 8.6 years, yet a majority of patients (62.1 %) reported consulting a health care practitioner within 1 year of symptom onset. Because most of these patients were ultimately referred to rheumatologists, the authors suggested that the diagnostic delay was associated with inadequate recognition of signs and symptoms by primary care physicians . In anotdiagnosis to AS diagnosis, rather than delay between back pain onset to AS diagnosis. Therefore, it was not possible to compare our results directly to studies that determined diagnostic delay relative to symptom onset. Additionally, patients with chronic back pain who were not ultimately diagnosed with AS are not included in this dataset and it is not known how these patients are managed. In addition, due to limitations in ICD-9 coding, our data set included both acute and chronic back pain prior to AS diagnosis and also included patients with diagnoses of back pain arising from a variety of non-inflammatory or mechanical etiologies, including spondylosis, spinal stenosis, spondylolisthesis, lordosis, sprains and fractures, sciatica, and others Below is the link to the electronic supplementary material.


Background. Chronic pain is prevalent, disabling, costly, and undertreated. There is clearly a need to improve patient understanding of ways to manage their pain. Internet-based programs are continually being developed to facilitate mental health improvement, providing tailored content for patients to manage their pain, anxiety, and depression. Objective. To evaluate the impact of Internet-based patient self-management education and activities on patients' pain, anxiety, and quality of life in patients who could not access multidisciplinary pain management. Design. Observational study. Subjects. Two hundred (200) patients  from one community pain clinic in Toronto, Canada (Toronto Poly Clinic), participated. Patients had moderate to severe pain, depression, and anxiety. These patients committed to study from a group of 515 patients with chronic noncancer pain of different origins who were stable on their levels of pain, anxiety, and depression for 12 consecutive months before start of study and could not afford noninsured treatment modalities like physiotherapy, psychology, nutrition, or exercise therapy consultation. Methods. Patients were encouraged to visit two Internet sites (a blog and Twitter postings) for educational postings written by the author about exercise, nutrition, mindfulness meditation, disease management methods, evidence-based supplements, daily relaxation exercises, and overall self-management methods 15 minutes per day for six months. Patients were also encouraged to share their ideas and comments on a blog. Activity logs were kept by patients and reviewed by physician at follow-up visits. Compliance was encouraged via weekly email reminders and phone calls during the observation period. Results. Modest improvements were noted in pain, anxiety, depression, and quality of life. Of the patients with moderate or severe pain before treatment, 45% reported mild levels of pain after treatment, with a reduction of severe pain from 40% before treatment to 25% after treatment . Conclusion. Self-management support interventions, such as Internet-based educational tools, can be considered to help patients manage their chronic pain, depression, and anxiety and may be helpful to improve the treatment outcome in patients who could not otherwise afford noninsured services. Chronic diseases, including chronic pain, affect a large portion of the population worldwide . AlthougPain medicine experts agree that the successful management of chronic pain requires a multidisciplinary approach . In an eIn this observational study, we used an Internet patient education blog and Twitter postings to provide free, accessible patient self-management education for a group of chronic pain patients and evaluate the impact of these tools on patients' levels of pain, anxiety, depression, and quality of life. The goal was to observe if using Internet-based patient self-management education would improve measurable outcomes in chronic noncancer patients who were stable on their severity of pain, depression, anxiety, and impact on quality of life for one year and were not able to access noninsured services otherwise.As a community chronic pain management center, this clinic treats a large group of patients who try many different treatment modalities alone or combined in different treatment plans for chronic noncancer pain. Some of these treatment modalities are not covered by their provincial health insurance plan and this becomes a barrier to care for patient who cannot afford them. This can impact their treatment outcomes. We measure the levels of pain and comorbid conditions of depression and anxiety along with impact on quality of life through standardized questionnaires  for all patients before treatment and in follow-up visits to monitor our treatment outcomes. Many of these patients do not have access to noninsured treatment services like physiotherapy, psychology, nutrition, or exercise therapy consultations. We identified a group of 515 of this group of patients who despite trying all treatments available to them through insured services  had significant pain (moderate or severe pain), anxiety, depression, and poor quality of life. These patients had plateau levels of their pain and limitations for at least 12 months. These patients had no prior training or education in self-management techniques. This group of patients were provided with the opportunity to participate in this observation for six months. For inclusion 18 to 75 years old patients who had at least moderate levels of pain, depression, and anxiety with quality of life level of less than five for a period of at least twelve months and had no plan or financial possibility of changing any of their concurrent treatments for the period of study (six months) were considered. Patient who had plans to add noninsured services like physiotherapy, psychological therapy, nutrition, and exercise therapy consultation to their current treatments were excluded. Patients with concurrent conditions of cancer, psychosis, unstable bipolar affective disorder, lack of proper command of English language, and inability to access or use Internet for education and patients with possibility of being scheduled for any surgery were excluded. Ethics board approval was obtained for this observational study on effects of online patient self-management education. Patients of this group were provided with possibility of and education about participation in this study and the informed consent process. We anticipated having at least 15% improvement in different measurable scales of pain, depression, anxiety, and quality of life.http://mypain.ca/) and Twitter postings under the title #ZENDOSE (https://twitter.com/search?q=zendose&src=typd/) to learn how to be safely active, improve eating habits, manage stress, learn mindfulness skills, and review proper medication and supplement use. The online materials were provided by the author based on the current evidence-based literature in the related fields. Patients were encouraged to read the educational postings (http://mypain.ca/) about exercise, nutrition, meditation, disease management methods, evidence-based supplements, daily relaxation exercises, and overall self-management methods and the mindfulness postings on Twitter under #ZENDOSE and reflect on the sites materials for a minimum of 15 minutes a day. Patients were encouraged to share ideas and comments on the blog by logging in with their Facebook, Google, or Twitter accounts. The #ZENDOSE posts were updated daily, and patients were encouraged to reflect on the messages for 15 minutes each day. No other elements of their treatments (medications and limited counselling and injections) were changed, and patients were still following up with their usual clinic visits. To encourage compliance, email and phone reminders were made on a weekly basis. Patients kept logs to record time spent on the sites to assure a minimum of 15 minutes of reading and reflection. Patient logs were reviewed by treating physician on their regular follow-up visits. We noticed marked changes as described in the study results. The 315 patients who did not participate continued to have the same plateau level on all levels of outcome measurements through this six months' period of time.Two hundred (200) chronic pain patients  agreed to participate in this 6-month study (from the fourth quarter of 2014 to the first quarter of 2015). The main reasons for declining to take part in the study were lack of consistent access to Internet, not being familiar enough with Internet, or not being able to commit to regular daily 15 minutes' activities. Patients had access to a patient educational blog , Hamilton Depression Rating Scale (HDRS), Hospital Anxiety and Depression Scale (HADS), and Quality of Life Scale (QOLS) have been previously used in different research studies, and their validity as research scale tools has been demonstrated –15. We uAll patients who were enrolled had at least a moderate level of pain on the NPRS  ; at leasCompliance and support emails were sent to all patients on a weekly basis during the six-month observation period. Patient compliance logs were reviewed by treating physician on regular follow-up visits. All other elements of treatment were kept the same as baseline without any changes during the observation.A sample size of 200 patients achieves 84% power to detect a difference of 0.10 after treatment using a 2-sided binomial test with an alpha = 0.05. This assumes that the pretreatment population proportion under the null hypothesis is 0.40.The proportion of patients with moderate or severe pain, depression, and anxiety was calculated by taking the number of subjects scoring in the respective categories using the standard questionnaires and dividing by 200 patients. The proportion of patients with the ability to function in daily activities before and after treatment was also calculated. The change in proportion of subjects from the period before to the period after treatment was reported as the improvement.z-test [The significance level of the improvement in pain, depression, and anxiety was assessed using a general z-test  to test The proportion of patients with a global impression of change after treatment was also calculated.e pain before treatment, 45% reported mild levels of pain after treatment, with a reduction of severe pain from 40% before treatment to 25% after treatment  of patients reported much improved results on the PGIC scale after treatment .Chronic pain comes at a cost whether from lost wages, social stigma, or ineffective health care coverage. One study found that the annual cost of pain was greater than the annual costs of heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion) . For exaRehabilitation in chronic disease like chronic pain requires a multidisciplinary approach. Self-management support interventions are becoming more common as a structured way of helping patients learn to better manage their chronic diseases, including chronic pain. Because chronic diseases affect the whole person, patient-centered complementary and integrative medicine therapies that acknowledge patients' roles in their own healing processes have the potential to provide more efficient and comprehensive pain management , 25.N = 952) 40 years of age or older with heart disease, lung disease, stroke, or arthritis demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations, demonstrating that an intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care [There is evidence that patient education for self-management can improve the outcomes in chronic diseases. A report of 10 studies involving 6074 people with various chronic diseases, such as arthritis, depression, and chronic pain revealed that self-management programs led to modest, short-term improvements in pain, disability, fatigue, self-rated health, depression, and quality of life when compared to usual care [ual care .Mindfulness based cognitive therapy (MBCT) is a form of Mindfulness Based Stress Reduction (MBSR) that includes information about depression as well as cognitive therapy-based exercises linking thinking and its resulting impact on feeling. MBCT demonstrates how participants can best work with these thoughts and feelings when depression threatens to overwhelm them and how to recognize depressive moods that can bring on negative thought patterns . MindfulThe effect of mindfulness training has also been shown for the treatment and relapse prevention of anxiety and depression in a variety of baseline medical conditions , 31, sucAlthough there are effective multidisciplinary treatments available, they are often not easily accessible and designed for patients with severe long-lasting problems who are able to cover the costs of these programs. However, the field of Internet interventions is growing , and theOver the past decade, researchers worldwide have been using the Internet for online treatment programs, usually behavioral –46. The Internet-based cognitive behavioral therapy serves as a complement for those with chronic pain who prefer this treatment and have difficulties accessing specialty treatment facilities. In one such study that assessed whether Internet-based intervention would have an effect on the symptoms of chronic back pain, the results showed that the treatment had an effect on catastrophizing and quality of life . This sun = 7, 77.8%), activity limitation , and costs associated with treatment , whereas effects on depression  and anxiety  were less consistent. There was limited (n = 2 from same research group) but promising evidence that Internet-based peer support programs can lead to improvements in pain intensity, activity limitation, health distress, and self-efficacy; there were limited (n = 4 from same research group), promising evidence that social networking programs can reduce pain in children and adolescents and insufficient evidence on Internet-based clinical support interventions. Internet-based interventions seem promising for people in pain, but it is still unknown what types of patients benefit most [Whether pain can be managed through the Internet was examined in a systematic review of randomized controlled trials from 1990 to 2010. The studies evaluated the effects of interventions that provided cognitive and behavioral therapy, moderated peer support programs, or clinical visit preparation or follow-up support on 2503 people in pain. Six studies (35.3%) received scores associated with high quality. Most cognitive and behavioral therapy studies showed an improvement in pain , research health social network websites (n = 3), and multicomponent interventions delivered in part via preexisting popular online social network websites (Facebook: n = 4 and Twitter: n = 1). The review revealed significant improvements in outcome measures related to health behavior change (effect sizes ranging from −0.05 (95% CI −0.45 to 0.35) to 0.84 (95% CI 0.49–1.19) [In the present study of the patients with moderate or sever49–1.19) . Althoug49–1.19) .The impact of brief but ongoing online patient self-management educations on chronic pain patients who cannot access the conventional multidisciplinary pain programs has not been well explored yet and there is more room for investigation in this area. Our current study is an observational study with the inherent limitations of observational studies, compared to double blind controlled clinical trials. The results can be considered as stepping stones for better designed studies that would allow higher level of statistical rigor with better comparison with control groups and exploring the length of the period of effect for positive changes.There is evidence that brain hard wiring can change with meditation rather quickly through process of neuroplasticity, suggesting that it may serve as an effective adjunct therapy –64. In oBecause there was no control group, statistical comparisons were made to an expected improvement. Also, there may have been particular characteristics about the 200 of 515 patients who agreed to participate that made them more receptive to this type of treatment and thus resulted in a bias in the result. A more robust study would randomize participants to either treatment or control, thereby using outcomes from the two groups for the statistical comparison.The Internet is changing the way people are experiencing illness and Internet-based self-management patient education may serve as a complement for chronic pain patients who prefer this treatment or have difficulties accessing specialized treatment facilities. This observation, using Twitter and a blog, showed modest improvement in patients' chronic pain, anxiety, depression, and quality of life using Internet-based patient self-management education tools. These results highlight the need for more studies in this area. Further investigations in this area as an accessible treatment modality that would help to remove the barriers to care seem warranted.


A minority of patients with incurable and advanced disease receive specialised palliative care. Specialised palliative care services that complement the care of difficult and complex cases ought to be integrated with services that deliver general care for most patients. A typical setting in which this integrative concept takes place is the hospital setting, where patients suffering from incurable and advanced disease are treated in many different departments.The aim of the study is to investigate the profile and spectrum of a palliative care consultation service (PCCS) at a German university hospital with special reference to pain therapy.We retrospectively analysed the PCCS documentation of three years.Most patients were referred from non-surgical departments, 72% were inpatients, and 28% were outpatients. 98% of the patients suffered from cancer. Counselling in pain therapy was one of the key aspects of the consultation: For 76% of all consulted patients, modifications of the analgesic regimen were recommended, which involved opioids in 96%. Recommendations on breakthrough-pain medication were made for 70% of the patients; this was an opioid in most cases (68%). The most commonly used opioid was morphine. For 17% of the patients, additional diagnostic procedures were recommended. Besides pain management palliative care consultation implied a wide range of recommendations and services: In addition to organising home care infrastructure, palliative care services supported patients and their families in understanding the life-limiting diseases. They also coordinated physical therapy and social and legal advice.This survey clearly shows that for a consultation service to support patients with incurable or advanced disease, a multi-disciplinary approach is necessary to meet the complex requirements of a needs-adapted palliative care in inpatient or outpatient settings. Timely integration of palliative expertise may support symptom control and may give the required advice to patients, their carers, and their families. It is recognized increasingly more often that comprehensive care of cancer patients includes not only life-saving or life-prolonging anticancer treatment, but also palliative care, which focuses on symptoms and other physical, psycho-social, or spiritual needs. Palliative and hospice care are thus evolving into an established feature in the overall medical system. Still, a minority of patients will actually receive specialised palliative care services during the course of their disease. Thus, sPrevalence of pain in cancer patients varies depending on the different types and stages of cancer. Even at early stages 33% of the patients suffer pain, which increases to 59% during anticancer treatment and to up to 64% for patients with metastatic or advanced stages of disease. Overall, more than 80% of cancer patients experience pain caused by their disease, its treatment, or treatment-related complications. BetweenPalliative care consultation services (PCCS) seem to be an adequate approach to improve the care of patients with complex palliative care needs in hospitals and, depending on structural preconditions, even in outpatient care. Previous studies have shown that PCCS improve the quality of life, quality of care, and satisfaction of patients with advanced illness and their families,13,14.Even if structures and involvement of PCCS have been examined in other studies, little is known about the working profile of these services in German hospitals,15-17. PThe purpose of this study is therefore to determine the characteristics and needs of the patients that are being seen by PCCS, the reasons why PCCS became involved, and an analysis of the recommendations made by the PCCS. The surveyed PCCS is provided by the Department of Palliative Medicine of Göttingen University Hospital, which provides counselling in cancer-related pain syndromes and all other matters of physical, psycho-social, or spiritual palliative care.We retrospectively and anonymously analysed all patient contacts of the PCCS at Göttingen University Hospital between January 2008 and December 2010 with a standardized protocol. The analysis included only contacts with a palliative care physician, contacts with nurses were excluded. We included all patients that were referred from departments other than the Department of Palliative Medicine. Most patients were seen as inpatients, but outpatient referral was possible . This survey was approved by the local ethics authorities . Theses routine and anonymous data-analysis was performed without an additional informed consent, according to the local ethical standard.The analysis included the actual request and problem as described by the referring department, information on the medical history as documented on the request form, an assessment of the documented problems, the recommended medical treatment (e.g. substances and preparations), and further recommendations. We focused here on pain and the recommended pain therapy. For comparison, opioid doses were expressed as oral morphine equivalent . Previous medications were not explicitly recorded, but the extent to which opioid doses were adapted was compared with the medication prescribed before the PCCS intervention , no change, a reduction, or an increase in pain medication. Data on length of stay of inpatients were taken from the electronic clinical information system.We anonymised the data, and the analysis was performed primarily descriptively. Percentages were related to the total number of surveyed patients unless stated otherwise. We statistically analysed the differences between patients of surgical and non-surgical departments using the chi-square test according to Pearson. Continuous variables were compared with a t-test for dependent samples. The level of significance was set to p <0.05. The p-value was not adjusted for multiple testing for groups because of the explorative character of the study. The three pediatric patients were included in the descriptive results, but their data were not used for group comparisons because of the small-number statistics.273 patients during the time of January 2008 to December 2010 were included . Table The average length of hospitalization for inpatients was 14,4 ± 16,8 days ; the time from admission to hospital to the first contact with the palliative care consultation service was 7,7 ± 13,6 days  for inpatients without significant difference between patients from the various departments.Almost all PCCS patients suffered from cancer 98%, n = 267), the most common cancer entity was lung cancer, followed by colorectal cancer  was pain in 64% of all PCCS patients. In 5% of all consultations, the side effects of pain treatment were reasons for a palliative care consultation. The dominating type of pain was somatic pain , followed by visceral (21%), neuropathic (15%) and mixed types of pain (15%). Underlying causes included chronic pain syndromes related to cancer (67%), acute pain syndromes presumably related to cancer in the presence of pre-existing chronic cancer pain (22%), acute post-operative pain in addition to chronic cancer pain syndromes (4%), both cancer pain and chronic (non-cancer) pain (4%), acute non-surgical pain syndromes (2%), and chronic pain (1%).In 35% of cases, the PCCS was involved in order to induce a transfer of the patient to the palliative care unit (15%) or to establish contact to the palliative home-care team (20%). In 46% of cases, an overall assessment of palliative care needs or a general consultation was requested. In 5% of cases, no specific request or aim of the consultation could be identified on the consultation form. In 17% of the requests, the PCCS was explicitly asked for a follow-up visit.For 76% (n = 208) of all PCCS-patients, modifications of the analgesic regimen were recommended. Of these consultations concerning analgesics in 96% (n = 197) opioids were used. Comparing the patients’ previous opioid dose with the recommended dose , it was recommended to increase the opioid dose in 32% of patients, to limit the dose in 1%, and to reduce the dose in 6% of all consultations addressing analgesics. In 15% of patients, an opioid rotation was recommended.70% (n = 186) of all patients were recommended to receive an on-demand/breakthrough-pain analgesic, which was an opioid in most cases . The average equivalent daily dose of morphine of the recommended baseline opioid was 107.3 ± 90.8 mg. The most often used opioid was morphine (Table multiple options). In 71% of the patients with opioids, other routes were additionally recommended . A dedicated invasive technique, such as patient-controlled analgesia or epidural analgesia, was recommended for 2% of all patients.The oral route was the most often recommended route of application for opioid drugs , followed by ibuprofen (13%), diclofenac (5%), paracetamol (4%), and selective COX-2-inhibitors (1%).54% of all patients received at least one non-opioid drug. The most frequently used non-opioid drug was dipyrone (metamizol)  and initiated different modes of support options for 26% of the patients. These additional recommendations included applications for professional nursing-home care for 14%, assisting devices for 15%, suggesting the implementation of a health care power of attorney for 1%, and completing an advance directive for 2% of the PCCS patients.Other PCCS tasks were to explain the different options for comprehensive support, such as the different levels of specialised palliative care (65%). General counselling about the disease, the current situation, and prognosis took place by addressing the patient by himself (21%), solely addressing the family members (6%), or addressing both patient and family (35%).2 = 0.001), as was the frequency of adverse events of pharmacological pain treatment  or pain type . As expected, more acute and post-operative pain syndromes were seen in surgical departments . This had no consequences for the frequency of analgesic recommendations, however  , special analgesic techniques (Chi2 = 1.771), further diagnostics , social support , psychological support , counselling of family members , or organisational efforts . Similar numbers of patients were recommended to receive the benefit of other specialised palliative care structures involved .No significant differences between surgical and non-surgical departments were detected in the recommendations for physiotherapy , which resulted in various possible acute, chronic, or cancer pain phenomena. Such multiple causes of pain were also found in other settings, for instance, in patients seen by a specialised pain consultation service of a university hospital,19. Pre-It is difficult to compare these results with other studies on PCCS because medical care, hospital systems, and palliative care structures differ. In addition, the term "consultation service" is not used homogeneously in the context of the palliative care,17,22,23Considering the fact that PCCS patients suffered from complex problems, and the broad spectrum of relevant recommendations and actions observed following the consultation, it is interesting to see that it took on average about 7–8 days in hospital before contact to the PCCS was sought. This shows that a PCCS referral may be preceded by a period of consideration and observation by both the treating oncological discipline and/or the patient, and that referral is not established as a clinical routine. This also suggests that cooperation between departments and the PCCS can be further improved. Information on the PCCS needs to be readily available and accessible for staff and patients throughout the hospital[In a proportion of patients (approximately 17%) further diagnostic investigations for palliative care reasons were recommended. These recommendations demonstrate that palliative care is not just "symptom palliation", but also contributes to the overall medical management. The broad range of recommendations is in line with this viewpoint because the recommendations included approaches to physical, nursing-related, and psycho-social problems.A number of limitations of our study need be mentioned. This study was based on data from a university hospital and did neither intend to assess symptom prevalence or intensity, nor was the actual implementation of the recommendations and their effects evaluated. All patients seen by the PCCS were included, without classification of disease severity, other symptoms, or side effects. A statement on the influence of PCCS on the resulting overall quality of care or the severity of the palliative status is thus not possible here.Another question is the financial setup of such services in German hospitals. The discussion about the cost effectiveness of care and support of other departments provided by an acute pain service is well-known,27. SeveOur results show that the PCCS has an important role in facilitating consecutive inpatient or outpatient guidance and acquisition of patients. A future challenge will be to reduce departmental and sectorial boundaries to achieve an integrated care for the patients who suffer from complex needs.Finally, this analysis of a PCCS supports two important statements about palliative care. A multi-professional approach that requires a team with the respective qualifications is necessary to meet the complex needs in the end-of-life care and to adequately support the patients, their families, and the referring departments. Timely and possibly early integration of palliative expertise may lead to improved symptom control and advice to patients, their carers, and their families.Our survey clearly showed that to support patients with incurable or advanced disease by a consultation service, a multi-disciplinary approach is necessary. Only this service can properly meet the complex requirements of a needs-adapted palliative care in inpatient or outpatient settings. Pain is one of the common topics, in some cases even complex pain-problems that include acute or chronic pain, but typically, these patients have several other needs in addition to this, including psycho-social or social work. Especially the planning of further care provision, including discharge planning, is an important need.Timely integration of palliative expertise may support symptom control and may give the required advice to patients, their carers, and their families. Our study reflects clinical practice; this may limit it somewhat because we did not assess symptom prevalence or intensity or evaluated the implementation of the recommendations of the PCCS and their effects.The authors declare that they have no competing interests.JE, AG, and JS collected the data; JE, FP, BA-E, and FN conceived the study and participated in its design and coordination; JE, FP, and BA-E performed the statistical analysis; JE, AG, FP, and BA-E drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-684X/13/45/prepub


P = 0.98). The incidence of post-operative anterior knee pain was 4.5 versus 3.8 % for group I and group II patients, respectively (P = 0.88). The pain scores and functional scores had not exhibited any differences. However, the knee scores of patients with severe arthritis of the lateral facet of the patella was worse than those seen in patients without severe arthritis of the lateral facet of the patella with a statistical significance. It was scored as 96.78  versus 94.43  for group I and group II patients, respectively (P = 0.02). Anterior knee pain, pain scores, and functional scores were not different between the two groups following a medial Oxford UKA. However, the knee scores of patients with severe arthritis of the lateral facet were worse than those in patients without severe arthritis of the lateral facet of the patella.In the past, medial osteoarthritis (OA) knee with symptomatic patellofemoral (PF) arthritis has not been recommended for a unicompartmental knee arthroplasty (UKA). However, recent studies have reported that UKA has shown good results in patients with medial OA of the knee, including those with PF arthritis. The purpose of this study is to compare the results between patients with medial OA knees; those with severe arthritis of the lateral facet of the patella and patients without severe arthritis of the lateral facet of the patella following mobile bearing UKA. We have prospectively evaluated 104 patients (114 knees) who had undergone an Oxford mobile bearing UKA. The mean follow-up was 19.05 months (range 12.30–29.70 months). The patients were divided into two groups: group I consisted of eighty patients (88 knees) who did not have severe arthritis of the lateral facet (Outerbridge grade 0–2) and group II had twenty-four patients (26 knees) who had severe arthritis of the lateral facet . We recorded the incidence of anterior knee pain, knee scores, pain scores, and functional scores in comparison of the two groups. The visual analog scale (VAS) and incidence of post-operative anterior knee pain had not shown any significant differences. The VAS for post-operative anterior knee pain was 0.11  versus 0.12  for group I and group II patients, respectively ( Medial unicompartmental knee arthroplasty (UKA) has shown good long-term results  knees with symptomatic patellofemoral (PF) arthritis were not recommended for UKA in the past . The patients who have undergone a medial Oxford UKA , performed by a single surgeon (BP), were included in this study. The inclusion criteria were patients who were diagnosed with medial osteoarthritis (OA) of the knee with an Alhback score of 2, 3 and 4 Ahlback  and withAll surgical procedures were performed by the same surgeon with the Oxford Phase III UKA . All patients had received a spinal block with morphine, 0.1–0.2 mg. The patients were then given 1 g of Cefazolin intravenously. A tourniquet was inflated to 300 mm Hg in all cases prior to the skin incision. The anteromedial skin incision was performed from the upper pole of the patella to the medial aspect of the tibial tubercle. A mini-midvastus approach was used in all cases for the prevention of patellar maltracking and the possible resulting, subsequent anterior knee pain  was removed at 24 h post op and blood loss from the drain was recorded. Both groups of patients had received the same discharge instructions and rehabilitation protocols.We followed patients at 6 weeks, 3 months, 6 months, 1 year, and 2 years post operatively. At each visit, the anterior knee pain was assessed by use of a visual analog scale. Our research assistant asked the patients while performing low chair rising activities and stair climbing. If the patient presented with anterior knee pain, the assistant had them score the pain using a 10-point VAS with 0 representing no pain and 10 representing maximum pain. The number of patients who had anterior knee pain was also recorded. The Knee Society Score© (KSS)  was assessed .We have performed a sample-size estimation based on the incidence of anterior pain experienced with the UKA which has shown that 25 patients from each group would be required to exhibit a difference with a risk difference of 20 % (5 vs 25 %) at a significant level of 0.05 and power of 80 %. The VAS for anterior knee pain, pain scores, functional scores, KSS, ROM, knee alignment, tibial slope, operative time, blood loss, BMI, femoral and tibial component alignment were calculated using the Independent Student’s A total of 105 patients (115 knees) were recruited for this study. One patient did not complete the study due to a medial tibial plateau fracture suffered at 3 months postoperatively. This patient had undergone a revision TKA and had shown good results after the surgery. Therefore, a total of 104 patients (114 knees) were included in the final analysis. Group I consisted of 80 patients (88 knees) who had non severe arthritis of the lateral facet of the patella (Outerbridge grade 0–2). Group II consisted of 24 patients (26 knees) who had severe arthritis of the lateral facet of the patellar .The preoperative patients’ demographics have shown that the patients in group II had a lower range of motion, a greater tibiofemoral angle, a greater ratio of females to males, and a higher VAS for pre-operative anterior knee pain than the patients in group I with a statistical significance. However, there were no differences in age, ratios of site, BMI, flexion contractures, recurvatum deformities, and incidence of pre-operative anterior knee pain Table .The incidence anterior knee pain and the VAS for post-operative anterior knee pain were not significantly different between the two post-operative groups. The incidence of post-operative anterior knee pain was 4.5 versus 3.8 % in group I and group II patients, respectively (P = 0.88). The VAS for post-operative anterior knee pain was 0.11  versus 0.12  in group I and group II patients, respectively (P = 0.98)  versus 94.43  in group I and group II patients, respectively (P = 0.02). However the pain scores and functional scores were not different between the two groups  were normal, seventy-two knees (81.8 %) had shown medial patellar joint space narrowing, six knees (6.8 %) had narrowing of the medial and lateral facets, and four knees (4.6 %) had an obliteration of the medial patellar joint space. Of the 26 pre-operative skyline views of the group II patients; nineteen knees (73.1 %) had shown a narrowing of the medial and lateral facets, two knees (7.7 %) had an obliteration of the medial facet, four knees (15.4 %) had exhibited an obliteration of the lateral facet, and one knee (3.8 %) had obliteration of the medial and lateral facets.The post-operative skyline views at the 2 week follow up of the group I patients; seventy-nine knees (89.8 %) were normal, and nine knees (10.2 %) were with medial patellar joint space narrowing. The post-operative skyline view at 2 weeks follow up of the group II patients; eighteen knees (69.2 %) were normal, eight knees (30.8 %) had shown a narrowing of the medial and lateral facets. No patients in either group have developed progressive narrowing of the medial and lateral facets of the patella at the final follow-up.The blood loss measured from the drains, operative time, and the alignment of the prosthesis were not different between the two groups Table . The posWe have not seen any complications such as patellar crepitation, patellar fractures, infections, dislocation of the mobile polyethylene, lateral compartment arthritis, and component loosening in our study.The patients who had progressive arthritis of the patellofemoral compartment and needed a revision TKA following UKA was minimal. Parrette et al. has shown that the mode of failure of a fixed bearing UKA in long-term follow up was from polyethylene wear, they found that only one patient had symptomatic patellofemoral arthritis and needed a revision TKA . Kang et al. have also shown that the patients with patellofemoral arthritis at medial and lateral facets on preoperative radiographies had shown good results following a medial Oxford UKA. Beard et al. have shown that preoperative anterior knee pain and intra-operative full thickness cartilage loss of the medial and lateral facet of the patella were not contraindications for the Oxford UKA. However, all of the previous studies did not include patients with ebernation of the lateral facet of the patella. In contrast, our study had 3 patients who presented with ebernation. Two patients had not experienced anterior knee pain following the surgery. Another one had anterior knee pain, but described it as only an occasional pain, mild in intensity.Our study has also shown that the pain scores and functional scores were the same between the two groups but the knee society scores of patients in group II were worse than the patients in group I and this has shown a statistical significance. The reasons for lower knee society scores in group II patients in our study resulted from lower post-operative ROM and lower tibiofemoral angles. However, the post-operative pain scores and functional scores were similar. Therefore the group II patients also had good clinical outcomes that were not different from the group I patients. Bread et al. has also shown the similar results to those found in our study. They found that the Oxford knee score of patients with full-thickness cartilage loss of lateral facet of the patella had lower scores than the patients without. However these patients have shown good clinical outcomes. Kang et al. has shown that the Oxford knee score, SF-12 in patients with arthritis of the lateral facet and both patellar facets in preoperative radiographic results were the same as seen in patients without preoperative radiographic PF arthritis.There are some limitations in our study. First, the subjects in our study were not randomized into the two groups as the finding of arthritis of the lateral facet of the patella would have been evaluated during surgery and thus the patients were classified into one or another group. However we were blinded in the evaluation of the anterior knee pain, pain scores and functional scores of the patients, post operatively. Second, the preoperative demographic data was not the same between the two groups. The patients with arthritis of the lateral facet of the patella have shown a lower ROM, lower knee scores, and more varus deformity than had been seen in patients without arthritis of the lateral facet of the patella. Third, we decided to determine the arthritis of the lateral facet of the patella through direct observation during the surgical procedure. There is a study from Koike et al. that had demonstrated that determining patellofemoral arthritis by a skyline view radiograph has shown to be inaccurate and it was technically demanding (Koike et al. In conclusion, the medial OA knee patient with or without severe arthritis of the lateral facet of the patella has shown good clinical outcomes following a medial Oxford UKA.


Thalamic pain syndrome, a type of central post-stroke pain (CPSP), may develops after a hemorrhagic or ischemic stroke and results in impairment of the thalamus. There is limited experience about gabapentin in treatment of central pains like CPSP. In a prospective observational study, the intensity of pain was recorded using the Numeric Rating Scale (NRS) at the entrance to the study. Patients eligible for treating with gabapentin, received gabapentin 300 mg twice-daily. The pain intensity was measured at entrance to the study and after one month using NRS. Decrease of 3 points from the initial NRS considered being clinically significant. From a total of 180 primarily screened patients, 84 (44 men and 40 women) were recruited. There was a significant difference between pre-treatment and post-treatment NRS . Fisher's exact test showed no statistically significant effect of clinical and demographic characteristics of patients on their therapeutic response to gabapentin.Given the safety, efficacy, well tolerability and lack of interaction with other drugs we suggest gabapentin to be more considered as a first line therapy or as add-on therapy for reducing the pain severity in patients with thalamic syndrome. Central post-stroke pain (CPSP) can be defined as a central neuropathic pain condition occurring after stroke characterized by pain and sensory abnormalities where other causes of obvious nociceptive, psychogenic, or peripheral pain have been excluded , 2. The Although it is more than a century after the first description of the thalamic syndrome, the evidence for treatment of this pain syndrome is still extremely diminutive. Pain medications often provide some reduction of pain, but not complete relief of pain, for those affected by central pain syndrome. Opioids, tricyclic antidepressants such as amitriptyline or anticonvulsants such as lamotrigine and gabapentin have been used in patients with CPSP , 8. Becaneuropathic pains . It has been approved as adjunctive therapy in the treatment of partial seizures and for the management of postherpetic neuralgia  and curric pains  and reliic pains . et al. in a randomized, placebo-controlled trial of 305 patients with chronic pain, 9 of whom had CPSP, evaluated the efficacy and safety of gabapentin in the treatment of neuropathic pain. But the effect of gabapentin was not significant in patients suffering CPSP .Study design and settingThis was a prospective observational study conducted in multi centers at Tehran, Iran. Participating centers were two outpatient clinics from two different educational hospitals and three private neurology clinics in Tehran, Iran. Approval of this study was conducted by the institutional review board of all of the participating centers. All patients were given a written informed consent before entering the study, and the study was performed in accordance with the declaration of Helsinki.All patients with stroke in the thalamic area admitted to each center between January 7, 2010 and June 30, 2011 were evaluated. Patients documented as being diagnosed with CPSP and who found to be eligible for treating with gabapentin as their standard therapy, entered to the study and demographic information , stroke type, NRS on day of diagnosis, and NRS 30-day after treatment initiation were documented.Management of the patients was based on EFNS  guidelines on the pharmacological treatment of neuropathic pain . AccordiIf a patient with an initial treatment other than gabapentin had no clinical response to the drug, a proper response was defined as at least three points decline in NRS, the therapeutic course was discontinued. NRS was recorded again and gabapentin was started for the patient. Finally, one month after initiation of gabapentin, the NRS of the patients were documented. Study populationPatients were qualified for the study on the basis of these inclusion criteria: (I) positive history of hemorrhagic or ischemic stroke in the thalamic area proved by computed tomography or magnetic resonance imaging of the brain; (II) presence of signs and symptoms in accordance with a decrease in pain and heat sensations in the affected part of the body; (III) presence of spontaneous or stimulated pain in the affected side  which could be smaller or the same in size as the sensory impairment area; and (IV) a pain onset after a thalamic stroke. Exclusion criteria comprise lack of imaging findings compatible with stroke and other imaging abnormalities including tumors in the thalamus area; absence of sensory impairment in the affected side of the body; therapeutic response to other treatments of thalamic syndrome; and previous hypersensitivity to gabapentin. Women were excluded if they were pregnant or lactating during the study. Eligible patients received gabapentin 300 mg twice daily for one month.Outcome measuresThe primary outcome in this study was the change in the NRS from the baseline through the fourth week of treatment and the secondary outcome was the proportion of patients with a clinically significant change in NRS (three-point decrease). Statistical analysisComparison was done using the paired sample t-test. Two-sided 95% confidence interval (CI) for the difference in response rates was calculated. A p-value of < 0.05 was needed for a result to be considered statistically significant. In the second step of our analysis, patients with a proper response and those who did not response to the suggested treatment were compared with regard to their baseline characteristics to find any probable correlation. To perform this comparison, unpaired t-test was used for interval variables and Chi-square or Fisher's exact test was used for nominal data. Study patientsOf all 180 primarily screened patients, 93 patients entered to the study of whom 9 did not complete the study during the follow up period, and 84 patients successfully completed the study .Among patients 44 (52.4%) men and 40 (47.6%) women completed the study. Type of underlying stroke that caused thalamic syndrome was ischemic in 76 (90.5%) patients and hemorrhagic in 8 (9.5%) patients. Concurrent hyperlipidemia, hypertension and diabetes mellitus as coexistent diseases were present in 9 (10.7%), 54 (64.3%) and 17 (20.2%) of the included patients, respectively. NRS score change from day one to day thirty was significantly different between pre-treatment (6.7 ± 2.51) and post-treatment (3.4 ± 3.01), .Comparing patients with adequate and inadequate responsesOur results found that 50 patients (59.5%) showed a clinically significant improvement according to NRS scores (3 points decline in post-treatment NRS). In the second step of our analysis we tried to find probable effects of patients` demographics and clinical characteristics on their response to the suggested regimen.Our findings revealed that distribution of gender, age category, previous history of diabetes mellitus; hypertension; hyperlipidemia, and stroke-type were not statistically different between the responders and non-responders. These findings are presented in In this multicenter study we showed that in more than half of patients with central post stroke pain, the NRS pain score was reduced after a month of therapeutic course with gabapentin.For patients with thalamic syndrome due to severity and chronicity, like other types of chronic pain, reduction of pain intensity, instead of pain elimination, should be considered as the goal of the treatment strategy. Hence, in the present study and in order to perform a better evaluation of pain intensity we used NRS. By NRS, patients will be asked about their pain and this individualized scoring can help physician make a better assessment.Central pain syndrome is a neurological condition that originates from damage to the central nervous system (CNS) or may happen due to impairment of the function of CNS. Many conditions such as stroke, tumors of CNS and spinal cord, multiple sclerosis, epilepsy, brain or spinal cord trauma or can be served as an underlying process and induce this pain syndrome.The probable pathophysiology of thalamic syndrome includes a post-stroke lesion of thalamus that results in toxic, anatomical and inflammatory changes which simultaneously ruins the inhibitory mechanisms of the sensory thalamus and its related neuronal pathways and also can destruct the afforestation of the sensory pathways and eventually results in neuronal hyper excitability above the level of differentiation (-). This hyperactivity can result in central sensitization, which in turn leads to chronic pain .The diversity and convolution of damages affected multiple parts of the spinothalamocortical pathway, indicates the intricate pathophysiology of this pain and clarifies the challenge of its effective treatment.Gabapentin (Neurontin), 1–(aminomethyl) cyclohexane–acetic acid, is an antiseizure drug primarily approved for treatment of partial seizures with an undocumented mechanism of action, however recent studies have reported that probably gabapentin elevates gamma-Aminobutyric acid (GABA) levels in the different parts of the brain including the thalamus as well as inducing GABA release from glial cells. Although, the action sites of gabapentin for pain reduction has not been well clarified but both animal (-) and human  studies Several reports have been demonstrated gabapentin as a first line treatment (-) or as an add-on therapy in combination with other drugs  in patieet al. (In a case report published by Chen et al. , gabapenSimilarly, in our study all of the patients tolerated the drug well and no one discontinued the therapeutic course because of the adverse events of the drug.Previously, gabapentin has been shown as an effective second line medication to decrease the pain intensity in cases who failed to achieve a proper response after standard treatment with first line agents like lamotrigine and amitriptyline .Amitriptyline, from the antidepressants group, was among the first drugs proven to be effective in central post stroke pain syndrome in a double-blind placebo-controlled study . LamotriDue to possible dose dependent adverse effects of gabapentin, this study tried low doses of this drug. In our study, the proposed daily dosage of 600 mg yielded a significant clinical improvement with no adverse effects. Serpell and colleagues have evaluated clinical efficacy of higher doses of gabapentin titrated to 2400 mg/day in 9 patients with central post stroke pain over an eight weeks period . Clinicaet al. (et al. (Usual analgesics, including opioids, are generally ineffective in treatment of central post stroke pain and due to their possible adverse events; it is generally recommended that they should be avoided. In a study published by Attal et al. , there w (et al. . The stuWe also attempted to determine the probable influence of baseline characteristics on the therapeutic response, and found that baseline type of stroke, age, gender, positive history for hyperlipidemia; hypertension and diabetes mellitus did not have a statistically significant effect on response to treatment. Further baseline characteristics analyses are needed to help identify probable gabapentin response factors.In conclusion, the findings of this study show gabapentin as an effective and well tolerable treatment for patients with thalamic syndrome. There is a paucity of data toward the efficacy of this drug in pain relief in patients with thalamic syndrome, so we suggest more clinical trials to be conducted to evaluate various aspects of using gabapentin in treating patients with thalamic syndrome. Given the safety and lack of interaction with other drugs we suggest gabapentin to be considered as a first line therapy or as add-on therapy for reducing the pain severity in patients with thalamic syndrome. A randomized controlled trial with a larger sample size may attenuate methodological weaknesses of the present trial and open new avenues for a successful usage of gabapentin in these patients.


Opioids have been traditionally used for postoperative pain control, but they have some unpleasant side effects such as respiratory depression or nausea. Some other analgesic drugs like non-steroidal anti-inflammatory drugs (NSAIDs) are also being used for pain management due to their fewer side effects.The aim of our study was to compare the analgesic effects of paracetamol, an intravenous non-opioid analgesic and morphine infusion after elective laparotomy surgeries.This randomized clinical study was performed on 157 ASA (American Society of Anesthesiology) I-II patients, who were scheduled for elective laparotomy. These patients were managed by general anesthesia with TIVA technique in both groups and 150 patients were analyzed. Paracetamol (4 g/24 hours) in group 1 and morphine (20 mg/24 hours) in group 2 were administered by infusion pump after surgery. Postoperative pain evaluation was performed by visual analog scale (VAS) during several hours postoperatively. Meperidine was administered for patients complaining of pain with VAS > 3 and repeated if essential. Total doses of infused analgesics, were recorded following the surgery and compared. Analysis was performed on the basis of VAS findings and meperidine consumption.There were no differences in demographic data between two groups. Significant difference in pain score was found between the two groups, in the first eight hours following operation , but not after 12 hours (P = 0.14) .The total dose of rescue drug (meperidine) and number of doses injected showed a meaningful difference between the two groups (P = 0.00). Also nausea, vomiting and itching showed a significant difference between the two groups and patients in morphine group, experienced higher levels of them.Paracetamol is not enough for postoperative pain relief in the first eight hour postoperatively, but it can reduce postoperative opioid need and is efficient enough for pain management as morphine after the first eight hours following surgery. Management of pain, especially postoperative pain, is a major concern for anesthetists in patients undergoing surgery. There are many ways for managing the postoperative pain. The most common way used after most surgeries is injecting analgesic drugs specially opioids. Excessive opioids administration is associated with a variety of side effects including ventilatory depression, drowsiness and sedation, nausea and vomiting, pruritus, ileus, urinary retention and constipation . UnpleasThe aim of our study was to compare the analgesic effects of paracetamol  and morphine  after elective laparotomy surgeries.The study was approved by the legal and ethics committee of Iran University of Medical Sciences in March 2011 and registered at Iranian Registry Clinical Trials site (IRCT ID: IRCT201203114969N6). This double-blinded study which in, patients and evaluators were unaware of group assignments was performed on 159 ASA (American Society of Anesthesiology) class I-II patients aged between 25-85 years. Patients scheduled for elective laparotomy  were selected by block randomization in two groups. Patients with psychiatric illnesses, addiction, allergic reactions to opioids or paracetamol (or other NSAIDs) severe renal or hepatic disease and BMI ≥ 30 were excluded from the survey. Technique of general anesthesia was similar in both groups. After establishment of IV access and monitoring, midazolam (0.02 mg/kg) and fentanyl (2 µg /kg) was injected as premedication, and propofol (2 mg/kg) and atracurium (0.5 mg/kg) for Induction of anesthesia.Propofol (100-150 µg/kg/min) as needed and remifentanil (0.4 µg/kg/min) were infused as maintenance and atracurium (0.15 mg/Kg) was injected every 30 minutes. Fifteen minutes before end of the surgery, fentanyl (1 µg /kg) was injected and at the end of the operation muscle relaxant effects was reversed by neostigmine (0.04 mg/kg) and atropine (0.02 mg/kg) .At the end of the surgery paracetamol, UniPharma, Greece (4 g/24 hours) or morphine sulphate, Daroupakhsh, Iran (20 mg/24 hours) injection would start through IV infusion pump. Visual analog scale (VAS) from 0 to 10 (with 0 representing no pain and 10 representing the worst imaginable pain) for postoperative pain was used in a time schedule  after surgery.For Any patient complaining of pain on with a score more that 3 on VAS 0.3 mg/kg of meperidine was injected and if demanded, the same dose was repeated until VAS ≤ 3. The total dose and number of doses injected was recorded. Postoperative nausea, vomiting, pruritus and respiratory rate were recorded throughout the study period. Data were registered in checklists including demographic characteristics  and nausea, vomiting, pruritus, respiratory rate and urinary retention, patient’s complaints, visual analog scale score and meperidine dose were analyzed. Numerical variables were reported as mean ± standard deviation (SD). Quantitative and qualitative variables were measured by independent t-test, and ANOVA test respectively. P value ≤ 0.05 was considered to be statistically significant. All analyses were performed using SPSS for Windows version 19 .Among all patients included in the study, 4 people in morphine group and five in paracetamol group were excluded due to different reasons and analysis was performed on the basis of VAS findings on the rest of the patients . Mean age of patients was 54 ± 15.45 years. The data analysis showed both groups were similar regarding age, sex, BMI and duration of surgery . The paiin vivo  and morphine infusion may be beneficial in the management of acute pain after major surgery in patients, prone to opioid-related complications. Although, it is acceptable that paracetamol overall is an effective postoperative sole analgesic, it is recommend on the basis of this study findings, if it is used for pain killing after laparotomy surgeries, small amounts of opioids are essential for the first eight hours after operation.Studying on various types laparotomy techniques was the limitation to this study; therefore it is better to repeat the study on specialized operations.