Purpose. To study the correlation between ocular parameters and subjective pain that patients perceived during phacoemulsification. Methods. Medical records of 142 patients who underwent standard phacoemulsification under topical anesthesia between March and August 2016 were retrospectively reviewed. The pain during phacoemulsification and 1 h after surgery was assessed and compared using a visual analog scale. In addition, demographic data, preoperative biometric parameters, and intraoperative surgical parameters were recorded. Results. Mean age of patients was 67.49 ± 12.50 years. The mean pain score was 2.26 ± 0.85 during phacoemulsification and 0.40 ± 0.69 postoperatively. Intraoperative pain was significantly associated with higher preoperative intraocular pressure , greater anterior chamber depth , and greater axial length . Conclusions. To reduce the subjective pain when patients have high preoperative intraocular pressure, large anterior chamber depth, or great axial length, supplementary procedures may be required. Phacoemulsification under topical anesthesia, first described by Fichman in 1992, has become the standard care for routine cataract surgery .Patient cooperation is a must for the success and ease of phacoemulsification surgery under topical anesthesia. Perceived pain directly affects the patient's cooperation and has been reported to vary with age, sex, and whether the surgery is being performed for the first time , 5. HoweIn this study, we analyzed parameters contributing to pain in patients having phacoemulsification and intraocular lens implantation under topical anesthesia alone.Medical records were retrospectively reviewed after approval was received from the Institutional Review Board of Kyungpook National University Hospital. The review was conducted in accordance with the tenets of the Declaration of Helsinki.Patients scheduled for elective phacoemulsification and intraocular lens implantation (IOL) with the Infiniti Vision System  were included. Because undergoing secondary eye surgery has been reported to cause more severe pain, only patients having their first operation were evaluated . CataracPatients who needed general anesthesia or were taking medications capable of affecting perceived pain were excluded from this study. Patients who had traumatic cataract and/or conditions likely to require vitrectomy and transscleral fixation of posterior chamber intraocular lens were also excluded.Topical anesthesia (0.5% proparacaine HCl) eye drops were administered into the lower conjunctival sac three or four times in the 10 min preceding surgery. Clear corneal phacoemulsification was performed through a 2.2 mm incision using standard surgical parameters . CataracA third person assessed intraoperative and postoperative subjective pain using a pain visual analog scale  ranging The primary outcome measures at baseline were best-corrected visual acuity using the Snellen chart converted to the logarithm of the minimum angle of resolution (logMAR) and intraocular pressure (IOP) measured with the Goldmann applanation tonometry. Axial length (AL) and anterior chamber depth (ACD) were measured using partial coherence interferometry . A noncontact specular microscope  was used to measure corneal endothelial cell density, and a rotating Scheimpflug camera  was used to measure central corneal thickness.The duration of surgery, recorded by the staff, was considered as the time from when the eye was covered with a drape to the extraction of the lid speculum. Ultrasound time, cumulative dissipated energy, and mean volume of balanced salt solution used were recorded. When adjuvant procedures were performed during surgery , these were also recorded.t-test and the Pearson correlation coefficients were used to compare the pain score between intraoperative and postoperative periods. Univariate linear regression analysis was performed to compare intraoperative pain and clinical factors. A multiple linear regression analysis including variables with P values < 0.05 in the univariate analysis was performed to assess the effect of each variable on intraoperative pain score. For all statistical tests, a P value < 0.05 was considered significant.Statistical analyses were performed using SPSS statistical software 20.0 . Paired A total of 142 eyes of 142 patients were reviewed in this study. Their clinical characteristics are shown in Tables P < 0.001). The mean intraoperative and postoperative pain scores were significantly correlated .The mean pain score was 2.26 ± 0.85 during phacoemulsification and 0.40 ± 0.69 at 1 h after completion of the procedure, with a significant difference between the two periods , AL , ACD , and cataract grade , were significantly associated with intraoperative pain in the univariate analysis. In the multivariate analysis, however, pain during phacoemulsification was significantly associated with higher preoperative IOP , larger ACD , and greater AL .Phacoemulsification under topical anesthesia is preferred due to the safety and efficacy of this method as compared with other types of anesthesia. However, patient cooperation is directly related to perceived pain, and pain management may significantly influence the success of surgery and the occurrence of postoperative complications. Moreover, our results show that a patient who experienced more pain during surgery also has more postoperative pain, so the management of postoperative pain is also important in these cases.O'Brien et al. reported that the highest mean pain score was at the phacoemulsification stage during cataract surgery procedures . During In our study, patients with higher baseline IOP had more pain during surgery. Higher baseline IOP could contribute to the elevation of IOP during cataract surgery and increase intraoperative pain. IOP fluctuations during phacoemulsification also could affect the elevation of intraoperative pain. Thus, it is essential to understand pharmacodynamics and widely used IOP control techniques, such as decreased bottle height or infusion pressure. Moreover, there are several reports of medications that lower IOP to prevent IOP spikes and to control IOP elevation , 11.β = 0.432, P < 0.001) [In addition, patients with larger ACD or greater AL had increased subjective pain during surgery. Hou et al. reported that in most patients pain was increased when the anterior chamber was extended by irrigation . Particu< 0.001) , 14. ThuPatients with lens-iris diaphragm retropulsion syndrome, first described by Wilbrandt and Wilbrandt in 1994, have anterior chamber deepening, pupil dilation, posterior iris bowing, and discomfort during phacoemulsification . This syPatients who had higher preoperative IOP, larger ACD, and/or greater AL experiencing more surgical pain and additional strategies for reducing pain should be considered in these cases. There are two strategic approaches for relieving surgical pain. One is adding another anesthetic or analgesic treatment, and the other strategy is reducing lens-iris diaphragm fluctuation.The use of intracameral lidocaine can be effective to relieve discomfort, especially during iris manipulation, although its use is controversial. Studies showed that the use of supplementary intracameral lidocaine injection with topical anesthesia is an effective and safe adjunct for decreasing intraoperative pain , 19, wheTopical nonsteroidal anti-inflammatory drugs (NSAIDs) also can be an alternative option in these patients. According to Price and Price, applying ophthalmic ketorolac 0.4% solution for 3 days prior to and 1 day following surgery was an effective treatment to control discomfort associated with cataract surgery . In addiSurgical techniques or modification of surgical parameters to avoid overextension of the anterior chamber were necessary in patients with larger ACD or greater AL. Management options include reducing the height of the infusion bottle and adding a second infusion line to relieve overextension of the anterior chamber by decreasing the infusion pressure . IntraopWe designed this study to use topical anesthesia alone and did not use additional anesthesia, as we thought it unnecessary. However, the mean pain scores were higher than those reported in other researches. However, all patients in those studies also received additional preoperative intravenous or oral sedation, which likely explains the discrepancy.In summary, we found that patients with higher preoperative IOP, larger ACD, and/or greater AL experienced more pain during and after phacoemulsification under topical anesthesia alone. Although the use of topical anesthesia is safe in cataract surgery, patients should be informed about the perceived pain preoperatively, and additional procedures can be used as needed to relieve discomfort and to improve cooperation during surgery and postoperatively.


Assessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear.Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur.Semi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients.145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value.The incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness.The online version of this article (10.1186/s12875-018-0771-0) contains supplementary material, which is available to authorized users. In general practice, chest pain as a reason for encounter is common  and differential diagnosis is broad . Yet, inMost guidelines clearly state that general practitioners (GPs) should refer every patient suspected of an ACS to secondary care facilities as soon as possible, or GPs should even be bypassed to prevent loss of time and, consequently, myocardial cell necrosis . HoweverNotwithstanding this strategy to work with low thresholds for referral to maintain the number of missed cases of ACS low, uncertainty among GPs has been a part of dealing with chest pain in general practice for decades –18. GPs Several developments in the field of chest pain in general practice have been described. First, an altering presentation of ACS in general practice has been reported, whether or not due to sex differences in presentation , 23–25. Do GPs experience a changing incidence and presentation of chest pain and / or ACS in daily practice, and if so, what changes do GPs observe?Which considerations are important to GPs and how do they deal with uncertainty  in the management of chest pain patients?Which thoughts, demands and doubts concerning new diagnostic tools can be extracted from GPs’ reflections on managing patients with chest pain? .Studies on GPs’ contemporary perceptions, attitudes and experiences in dealing with chest pain patients regarding uncertainty and developments in presentation, incidence and diagnostic tools as described above are mainly dealing with specific diseases, are focussing on out of office hours working situations or are lacking , 17, 32.145 GPs were selected from a list of GPs who had indicated earlier they were interested in participating in scientific studies. We invited 15 Flemish GPs by phone and 30 per e-mail. 100 Dutch GPs were invited per e-mail and were phoned shortly afterwards to inquire possible participation. We included general practitioners willing to participate, with at least 5 years of working experience. No further selection criteria were used.The semi-structured face-to-face interview, composed by the Flemish researchers, consisted of five main subjects to answer the objectives of the study: 1) recently experienced changes in the prevalence of chest pain and ACS, (2) management of chest pain patients in daily practice, (3) dealing with uncertainty, (4) the GPs’ approach in referring chest pain patients, and (5) their attitude towards - in the light of the final diagnosis - ‘unnecessary’ referrals. The second subject (2) was approached by letting the GPs imagine a chest pain patient and thereby reflect on their diagnostic steps and decision to refer. An additional subject was added in the Dutch interview: (6) the GP’s own suggestions for improving the management of chest pain patients in general practice. The interview protocol was piloted with a Flemish and a Dutch GP who both had over 25 years of working experience. Flaws were discussed by the researchers and two GPs, which resulted in an adapted version of the interview. The pilot interviews were not included in the final research sample. The main questions, used as starting points of different phases of the interview are given in Additional file  recentlyData were collected through face-to-face interviews. Flemish interviews were carried out by LB, as part of her research thesis completing her GP education, between June and October, 2015. Dutch interviews were carried out by LC and BH, both fulfilling their research internships during the master phase of their medical school, between April and June, 2016. All interviews were audio-recorded and transcribed verbatim. Data were collected until saturation was achieved. Saturation was defined as the identification of no new nodes in the last two interviews in the Flemish, or the Dutch part of the study, respectively.Thematic analysis was used to bring forth answers to the main objectives of this study. All Flemish interview transcripts were analysed independently by two researchers in a process of inductive line-by-line coding. LB coded all transcripts, and four GP residents and one anesthesiology resident coded three transcripts each. Afterwards, differences were discussed and further analysis was assisted by FB and WR. Thereafter, the initial codebook was established, which was adjusted after every four interviews. In a second step the codes were refined, resulting in the development of descriptive themes. Finally, a thematic analysis was performed by all researchers to generate new analytical themes.Each Dutch interview was analysed and coded independently using the Flemish codebook by LC and BH. Conflicts were solved by discussion. During the analysis of subsequent interviews, the initial code list was further refined by adding new codes under the pre-existing themes, when confronted with relevant data that could not be linked to an existing code. Finally, a framework analysis was performed by LC, BH, and RW to generate new hypotheses. Ultimately, Flemish and Dutch results were independently analysed and discussed by LB, LC and RW to uncover similarities and differences in outcomes. Subsequently, these findings were documented when applicable in the results section of this paper. NVivo 11 pro software was used to facilitate coding.All participants were informed about the aims of the study and the recording of the interviews. The study was approved by the Medical Ethical Committees of the University of Leuven and of Maastricht University.145  GPs were invited to participate, 27 GPs (15 Flemish and 12 Dutch) were interviewed. The main reason for declining our invitation was a lack of time. GP characteristics are presented in Table “Hm, I think we are confronted with this complaint weekly, maybe even multiple times a week.” [NL GP 12]“Yes, the lion’s share here, of people presenting with chest pain, is not of cardiac origin.” [NL GP 8]Most GPs stated that they are confronted with chest pain at least once every week. Chest pain can have a wide variety of causes, of which the majority is not of cardiac origin.“Then I think it is more or less the same … if you don’t only count cardiac but also other types of chest pain like respiratory infections or indeed psychosomatic symptoms. Then I think it [the frequency of chest pain] is comparable to before.” [BE GP 4]“I think that the frequency with which we see a grave acute infarction nowadays is a lot lower than it was twenty years ago.” [BE GP 7]Although some Dutch GPs experienced an evident increase in the prevalence of chest pain in their practice, the majority of GPs did not experience a change in frequency over time. However, most GPs experienced a change in the clinical spectrum of chest pain. GPs claimed to encounter less cases of ACS, due to improved cardiovascular risk management in general practice, and more atypical thoracic complaints, due to a growing awareness on chest pain in the general population. The anxiety accompanying this awareness, combined with the continuously available health care in large out-of-hours general practice facilities, lower the threshold to consult a GP.“Of course raising public awareness is helpful, but it can also cause more unnecessary consultations. Not everyone is good at assessing their own situation. And people are worried when they feel something.” [NL GP 12]Most GPs believed raising awareness in the general population on the possible consequences of chest pain is important. However, Dutch GPs stated it can result in an increase in patient anxiety, leading to more uncertainty and consultation of a GP.“Outside office hours people often call, saying: “I experience an acute severe pressure on my chest”, and according to the current guidelines, the ambulance will leave for this patient. In such case we don’t assess the patient ourselves.” [NL GP 8]“We have a varied patient population here. We are on the verge of a rural area where most people still obediently go to the GP. On the other hand, in the city of Mechelen e.g., the citizens – and certainly the immigrants – go to the emergency department much easier and will thus pass us by.” [BE GP6]Especially in out-of-hours general practice facilities in the Netherlands, new triage guidelines with a low threshold for directly sending out an ambulance in case of chest pain, are causing Dutch GPs to encounter less chest pain patients. Some Flemish GPs stated that recently more patients go directly to the emergency room, especially in urban areas with a high number of immigrants.“Yes, you first try to determine in which framework the pain fits. (…) Are the lungs causing the problems, or is it the heart or is it something less serious? So that’s what you try to assess first and foremost.” [BE GP10]“But I taught myself, if I have a certain gut feeling that something isn’t right, yes, then I just refer them. I’m not going to take the risk behind the patient’s back.” [NL GP 11]When confronted with a chest pain patient, GPs quickly attempt to distinguish between acute and non-acute pathology. The most important tools in assessing chest pain are history taking, clinical evaluation and gut feeling. The language used by GPs suggests a feeling of responsibility.“Especially because you have to assess the value of an ECG. I mean that an ECG can be negative despite the fact that the clinical presentation is very suspicious. Then you have to follow your clinical judgment. The technicalities can be an affirmation of your clinical assessment but not vice versa.” [BE GP8]“It also helps to reassure people that are not expected to have a serious condition, then you’ll have an additional confirmatory tool [ECG].” [NL GP 12].Most GPs questioned the value of diagnostic tools such as ECG or troponin in ruling out ACS at first assessment. However, a few GPs felt confident enough to not refer a patient based on a negative ECG. In non-acute situations, these diagnostic tools are mostly used to take away any doubt, experienced by the GP, and to reassure the patient. GPs regard personal judgment, not advanced diagnostic tools, as the main instrument to rely on.“But when someone has acute chest pain suspected of ACS, that goes with getting picked up by an ambulance with the highest urgency.” [NL GP 8].When a patient is suspected of ACS, GPs immediately refer them to the emergency department, transported by ambulance with the highest level of urgency.“Or it is a semi-acute problem and the person can go to the hospital by their own means of transportation, transported by someone else. They shouldn’t drive themselves.” [NL GP 2]Some GPs considered it acceptable for a patient to leave for the hospital on their own, if the patient is in a stable condition. However, they should never drive themselves.“Imagine if you had to suddenly give an injection urgently: (...) If you haven’t done any of that in twenty years, or haven’t received any information about it anymore, you won’t start doing it again that easily, right?” [BE GP10]Before the ambulance arrives, some GPs administer medication and accomplish intravenous access. However, a few Flemish GPs felt insecure about their knowledge on acute interventions and their necessity in urgent situations.“Unless I have to drive for fifteen minutes, some of our patients live quite far off, and I am really busy with other obligations. But in principle I do both [send an ambulance and leave for the patient].” [NL GP 2]When patients call their GP because of chest pain and their situation seems to be unstable, it depends on the amount of time available, whether the GP heads to the patient himself, sends an ambulance directly, or does both.In non-urgent cases patients are referred to the hospital cardiology department for a consultation on a following day.“Because a woman often has atypical complaints regarding cardiovascular conditions. You have to be more careful, which means you maybe have to look a little closer.” [NL GP 7]To GPs, the greatest difficulties in the assessment of chest pain are atypical symptoms, expressed – according to Dutch GPs – mainly by women.“I think when people keep consulting you with a certain complaint, not just chest pain, even if they have already consulted you about this complaint earlier, that’s an indication to refer the patient anyway.” [NL GP 2]Some GPs feel the need to refer anxious patients, for their own and the patient’s peace of mind.“But my rule is: when I’m uncertain, I always refer the patient.” [NL GP 10]In urgent cases, most GPs feel no insecurity in choosing to refer a patient or not. However, when GPs experience uncertainty, it is mainly due to doubt as to which condition is causing the chest pain, sometimes leading to more referrals.“Yes, I try to rule out some things myself, those things that are really easy to rule out. (…) And subsequently, because of these possibilities, you refer less often.” [NL GP 10]In less urgent cases some GPs try to perform most diagnostics themselves, start a test treatment, or opt for the approach of watchful waiting, to make a more targeted referral.“I think that we are in a luxury position because we work here with three GPs in a group. There is always someone you can immediately ask for a second opinion. That helps a lot. A short discussion is often enough to be able to make a decision.” [BE GP5]To diminish uncertainty, GPs stated they could consult colleagues or a cardiologist. However, not all GPs feel the need to do so. Mainly Flemish GPs stated they rarely ask for advice on managing chest pain patients.“Yes, if you have a feeling that you’ve made a mistake somewhere or that you’ve misjudged something it certainly keeps…lingering in your head for a while, keeps bothering you for a while.” [BE GP14]Sometimes, uncertainty remains after a consultation with a chest pain patient. To reduce this uncertainty, some GPs tend to refer more patients.“It helps me that I can debrief about it … eh … in a safe environment. I think that that is one of the most important things a GP – and actually any doctor – can attain: safe situations. I’ve been working now for twenty years and I have finally found safety. (…) I think that that’s important for every doctor, that he has the opportunity to talk about his uncertainties with his peers.” [BE GP1]Afterwards, some GPs like to debrief cases they were uncertain about, both on medical and personal aspects, either through the cardiologist’s letters or through discussion with colleagues. However, some Flemish GPs find it difficult to find a safe environment to talk about their uncertainty.“I think the experience and the development of the gut feeling plays a role in becoming more confident. So, I think that I was more insecure 15 years ago, and because of that I may have referred more patients wrongly.” [NL GP 2]“It is like that, when you get a claim or you think: “Oops, did I miss that?” then you will pay more attention to those complaints for a period of time. Absolutely.” [NL GP 5]“Sometimes you have to make a risk assessment. Sometimes you are right and sometimes you are wrong. But there’s no dishonour in that. I would rather refer one patient too many than one too few. Because then you are going to have to come up with a really good explanation.” [BE GP3]Nonetheless, all GPs believed that insecurity and mistakes are part of their profession and that GPs must learn to handle these situations. Most GPs believed they became more confident in assessing chest pain during their career, due to experience and development of their gut feeling, causing them to refer less patients unnecessarily. Still, GPs stated they refer quite a large part of chest pain patients because they do not want to risk missing ACS. Looking back after obtaining the final diagnosis, some of these referrals were unnecessary. However, GPs believed this is due to a lack of diagnostic tools to initially rule out ACS. Critical incidents of missing ACS cause GPs to be more cautious, either temporarily or permanently. GPs judge their referral decisions as right or wrong in the light of a final diagnosis. This is remarkable, since a referral decision based on considering a severe disease can essentially not be wrong.“I have assessed the patient, so I have to take responsibility and I have to make the decision on my own.” [NL GP 1]“That is your autonomous decision. He wasn’t there at the moment you called. And if you say in that moment ‘I want an emergency doctor here’, then it has to be there, end of story! Ten minutes later, the situation is different, the insight is different, the patient is different and so on. And then maybe the decision would be different. But they can never judge you for that!” [BE GP 1]Referrals of patients that eventually appear to have no severe disease can be unfavourable, leading to high health care costs, an overload of the hospital staff and a stressful experience for patients. However, some GPs never let their referral decision depend on such possible thresholds. Others stated they try to prevent medicalisation and somatisation in low-risk patients. GPs sometimes get criticised on their referral decisions by hospital physicians. Most GPs claim not to be affected by this criticism, however, their language to express their feeling of making autonomous referral decisions is rather explicit. Thus, GPs seem to define their position in a difficult field where colleagues and patients might judge the GP’s decisions.“Look, if you just… Independently of what it says, and I think the patient’s situation is not looking good based on the clinical assessment, then I’ll refer him anyway. Then I don’t let it depend on a biomarker.” [NL GP 12]“It [PoCT] might contribute something in case of doubt. Then of course it also depends on the sensitivity and the cost price. You have to be quite sure when you use such a thing and it comes out positive, that you won’t make big effort which in the end turns out to be futile.” [BE GP8]“If a clinical decision rule will be designed (...) those are really helpful. You count the points and then you get yes, no, or an intermediate. Yes, if you add a troponin test to that (...) then I think it will contribute of the quality of health care.” [NL GP 8]Most GPs stated they are satisfied with the current diagnostic options for chest pain patients in general practice and some believe that clinical assessment will remain the most important tool in assessing chest pain patients. Others do believe an additional diagnostic tool such as a biomarker PoCT would be useful. Yet, usability strongly depends on indications and diagnostic accuracy. A few Dutch GPs suggested to combine such test with a clinical decision rule. In general, new diagnostic tools are considered to be of a certain degree of added value, with a remaining central role for clinical judgment by the GP.First, when suspecting an ACS, GPs base their suspicion mainly on history taking and gut feeling. Second, recent findings in literature are endorsed by the interviewed GPs: chest pain is still a common reason for consulting a GP, the relative number of ACS patients among chest pain patients seems decreasing, whereas the presentation of atypical complaints increases, leading to more uncertainty. Third, GPs compensate for the experienced feeling of uncertainty by referring patients, performing additional tests or discussing cases with colleagues. Besides, GPs regard uncertainty as a substantial part of their profession and they feel more certainty when working experience increases. Still, some GPs use explicit language to express their certainty, possibly reflecting an ongoing struggle to keep patients and colleagues in secondary care satisfied. Overall, GPs feel relatively comfortable with a certain degree of over-referral of chest pain patients, as over-referral is regarded as a safe strategy in dealing with a potentially life threatening condition. An ongoing and substantial role for clinical judgment by the GP is expected. Fourth, new diagnostic tools in general practice are anticipated with cautiousness. Proper clinical embedding of such tools is obligatory according to the interviewed GPs.Before interviewing the GPs, an extensive tryout of the interview with an experienced GP, observed by another experienced GP, was carried out. Two pilot interviews were performed. All Flemish interviews were carried out by LB, a GP in training. Her own experience from working in general practice might have had an impact on the interviews. There might have been bias due to her own opinion on subjects that were discussed. On the other hand, her own learning process as a GP might have lead to a curious attitude. The Dutch interviews were carried out by LC and BH, both master’s students in medicine. They had no experience in managing chest pain patients themselves, possibly leading to a certain degree of open-mindedness although the lack of experience could have prevented them from thinking of all possible in-depth questions.n = 18) than women (n = 9). However, differences of the answers between sexes or years of experience as a GP were not observed. All participating GPs seemed motivated to respond extensively to our questions. Theoretical data saturation was reached in the Flemish and Dutch interviews separately.The population of interviewed GPs contained a good variety in area, type of practice and age Table . They miThe incidence of chest pain in general practice has not changed remarkably. However, most GPs do experience a change in the clinical spectrum of chest pain, encountering less cases of ACS, and in its presentation. These findings are in line with various epidemiological studies, although data of these studies were partially obtained in a hospital setting , 27. TheGPs’ judgment of chest pain is based mainly on history, physical examination and gut feeling. Indeed, it is known that GPs use additional tools for assessment, such as background knowledge about patients and gut feeling , 33. MosGPs sometimes experience uncertainty in the management of chest pain patients, during or after the consultation. GPs tend to reduce this uncertainty by easily referring patients or performing additional tests. Some GPs consult their colleagues or a cardiologist to diminish uncertainty, though mainly Flemish GPs rarely ask for advice on managing chest pain. When uncertainty persists after the consultation, most GPs seek confirmation either through the cardiologist’s letters or through discussion with colleagues. GPs overall become more confident in assessing and managing chest pain patients during their career.GPs mainly feel comfortable with their diagnostic assessment, management and possible over-referral of chest pain patients, stating that sometimes referral is necessary to get confirmation of the diagnosis. For most GPs the unfavourable consequences of ‘unnecessary’ referrals and criticism by secondary care physicians are not influencing their decisions. Several studies indeed indicate that GPs’ clinical judgment is quite accurate and that they succeed in managing chest pain patients well , 13, 36.Though most GPs agree that clinical assessment will remain the most important tool in diagnosing chest pain patients, some GPs think that reliable new diagnostic tools (such as PoCTs) could be a useful addition to improve diagnostic accuracy. The general attitude towards such tools seemed more conservative than in recent questionnaire based studies , 37. GPsGPs feel that the incidence of chest pain in general practice is not decreasing. However, the number of patients having an acute coronary syndrome among patients presenting with chest pain is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. Yet, uncertainty is regarded as a substantial element of their profession.GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe.New diagnostic tools are awaited with cautiousness: GPs rely on their own judgment, and desire new diagnostic tools only when these tools are of clear added value.Additional file 1:Semi-structured interview. (DOCX 27 kb)


Various therapeutic approaches have been proposed for the treatment of pediatric patients with eosinophilic granuloma (EG) of the cervical spine. Our aim was to discuss and present our experience with the individualized surgical intervention of pediatric cervical EG complicated with neurologic deficits and/or spinal instability.We retrospectively analyzed the clinical data of 19 children who were diagnosed with cervical EG comor spinal/or spinal instability  and treated surgically in our institution.Lesions involved C1–2 in 7 patients and C3–7 in 12 patients. Anterior tumor resection combined with posterior pedicle screw fixation, anterior approach of excision and instrumentation, and posterior tumor resection combined with pedicle screws instrumentation were selected according to the different locations of tumors. Frankel scale and Oucher scale improved significantly after surgery. There was no morphologic alteration of the neck at follow-up.Surgery can significantly improve the neurologic status and symptoms. Surgical decision-making must be individually tailored to minimize the influence of surgery on spine growth. Langerhans-cell histiocytosis (LCH) is a complicated disease entity that can result in either benign or devastating outcomes. Among the clinical spectrum of LCH, eosinophilic granuloma (EG) is the most benign and predominant condition, featured by a clonal proliferation of Langerhans-type cells with bone involvement. In children and young adolescents with this tumor, about 80% of patients are reported to be younger than 20 years .Although thoracic segments is the most preferential spine localization in EG patients of all ages with vertebral involvement , 2, dataThe typical vertebral lesion of EG is composed of an osteolytic area causing complete or incomplete collapse and flattening of vertebrae, known as vertebra plana. The bony destruction of vertebral EG might lead to spinal instability with severe mechanical back pain and even a pathological fracture. Pediatric patients with cervical EG can present with symptoms including acute onset of neck pain with/without history of trauma and torticollis or neck stiffness due to restricted motion , 6. VertVarious therapeutic approaches have been proposed for the treatment of pediatric patients with EG of the cervical spine. For most cases without neural deficits or spinal instability, it is often sufficient to palliate symptoms and induce the lesion regression by conservative treatment and biopsy with cervical collar immobilization in view of the possibility of spontaneous resolution. Surgical intervention should be considered to relieve pain, maintain spinal stability, and preserve neural function in the presence of neurologic compromise, spinal instability, and severe deformity . It has To discuss the most suitable surgical management of pediatric patients with cervical EG, a retrospective study was undertaken reviewing 19 cases of cervical EG complicated with neurologic deficit and/or spinal instability. Herein, we reviewed the clinical features of pediatric cervical EG and presented our experience with the surgical intervention of the disease Figs. .Fig. 1CaThis study was approved by the ethics committee of the Changzheng Hospital of Second Military Medical University. We retrospectively reviewed cases in 19 children (≤15 years) who were diagnosed with cervical EG complicated with neurological deficits and/or spinal instability  and treThe surgical approach was tailored for each patients depending on Weinstein-Boriani-Biagini (WBB) surgical staging system, including posterior approach, anterior approach, or a combination. The instrumentation method (anterior miniplate and screws or posterior pedicle screws) was also individualized in consideration of minimizing motion scarification and influence on growth. All surgeries were performed in one stage.2/day orally days 1–5 every 3 weeks for a total treatment duration of 6 months. To reinforce the stability of the cervical spine, patients were immobilized with neck collars for at least 6 months until the fusion of the bones.Postoperatively, patients were prescribed with prednisone 40 mg/mAll patients were followed up in the outpatient clinics at 3-, 6-, and 12-month postoperatively and annually for life thereafter. Outcome including radiographic image  was investigated at each visit, and pubertal status  was evaluated every 6 months. The neurologic status and pain were also assessed by Frankel scale and Oucher scale, respectively.t test was used. Statistical differences are presented at when p values were <0.05.All data were analyzed using SPSS 18.0 analysis software. To compare the pre- and postoperative clinical parameters and outcome, the paired-sample The cohort consists of 15 boys and 4 girls. The average age of diagnosis was 9.9 ± 3.1 years  with mean height and weight being 143.0 ± 21.2 cm and 36.8 ± 13.3 kg, respectively. The basic clinical data were summarized in Table The initial clinical presentation was retrieved from the medical records. The most common initial symptoms were, in descending order, restricted cervical motion 100%), neck pain (94.7%), neurological symptoms (84.2%), and torticollis (26.3%). The average SINS score was 11.8 ± 2.5. Oucher scale for pain was obtained, with the mean score being 8.1 ± 1.5. The neurological status of all the patients was accessed and classified according to Frankel scale. The result reveals 3 patients with Frankel grade C, 14 with grade D, and 2 with grade E , and magnetic resonance image (MRI). In 7 patients, lesions involved the upper cervical spine (C1–2) and in 12 patients, lesions involved the lower cervical spine (C3–7). The distribution of the tumors was evaluated using the Weinstein-Boriani-Biagini (WBB) classification on the basis of layers and zones on CT and MRI findings. In most cases, the tumors involved layers A–D, with only six lesions extended to layers B–D. It is found that tumors were located majorly in the anterior column (zones 4–9) in 15 cases and the posterior column (zones 10–5) in 4 cases.The customized surgical strategy was designed for each patients depending on the location and extension of the lesion. For the atlantoaxial tumor, anterior tumor resection combined with posterior pedicle screws fixation was performed (seven cases). We selected anterior approach of excision and instrumentation for tumors majorly located on the anterior column (eight cases), and posterior tumor resection combined with pedicle screws instrumentation for those involved posterior elements (four cases).p < 0.001). Pain was significantly released by treatment, with average Oucher score decreasing from 8.1 ± 1.5 to 0.3 ± 1.4 (p < 0.001) , with a median follow-up time of 41 months. The average height and weight at the last follow-up were 158.1 ± 14.9 cm and 50.3 ± 14.4 kg, respectively (Table LCH can occur in any age groups but is more common in the pediatric population, with the estimated incidence ranging from 2 to 10 per million children , 10. AltGiven the general benign prognosis of spinal EG , variousSurgical modalities for cervical EG may vary with the extent and location of the disease. For EG of the atlas and axis in adult patients, we have previously reported that anterior tumor resection and posterior reconstruction by posterior occipitocervical fixation or upper cervical fixation can offer eradication of the lesion, decompression of nerve, and immediate atlantoaxial stability . HoweverIn comparison, more reports focused on the surgical procedures for lower cervical EG, which included curettage and fusion with or without instrumentation. Denaro et al.  describeThere has been no definitive evidence-based conclusion yet to guide the adjuvant therapy after surgical intervention of spinal EG. Opinions vary from only observation to low-dose standard chemotherapy. On the basis of the experience drawn from our clinic and previous report , desirabThere is an obvious demand for a full assessment of each pediatric cervical EG patient with a rational surgical procedure tailored to the extension and location of the lesion. Limitations of the current study are common to retrospective research in which the data are only as precise as available medical records. Besides, our study has limited power as a result of small numbers and uncontrolled variables. Despite the limitations, our results strongly suggest the application of aforementioned procedures on the specific site of cervical spine and contribute to the individualized surgical treatment of pediatric cervical EG patients complicated with neurologic deficit and/or spinal instability, which is characterized by minimal surgical trauma and effects on spine growth without recurrence. The neural status and symptoms of these patients were significantly improved by the surgical intervention and EG-related cervical deformity was corrected by instrumentation. After all, surgeries for pediatric cervical spine is demanding and require thorough pre-operative planning and special technical expertise to supply an ensurance for the safety and effectiveness both in the operation and in the long term.


To evaluate the use of infiltration of periarticular analgesic agents intraoperatively in total knee arthroplasty (TKA), with regard to benefits, reduction of pain, opioid consumption, improvement of range of motion and early ambulation.  To analyze the benefits of periarticular drug infiltration, the patients submitted to TKA were evaluated, being separated into two groups. One group received the local periarticular infiltration protocol containing 0.5% bupivacaine (400mg/20ml), 1/1000 epinephrine (0.3ml), triamcinolone hexacetonide (20mg/1ml), clonidine (150mcg/1ml) and 20 ml of saline (0.9% SS) and, the other group underwent conventional intravenous analgesia. The results were compared and the variables analyzed were age, sex, BMI, comorbidities, postoperative complications, pain, functional capacity, range of motion, transfusion and rescue opioids for analgesia.  The mean age of the patients was 68 years and most were female and presented involvement of the left knee. Postoperatively, patients who had received periarticular infiltration showed improvement of pain as well as functional capacity. Level of Evidence II, Prospective Comparative Study. The analysis of data obtained demonstrated that the periarticular infiltration of analgesic agents is significantly effective for pain control and functional recovery. One of the main goals of postoperative analgesia is improvement in functional results and early return to routine activities, improving patient quality of life.,,,The growing number of total knee arthroplasties and increased life expectancy reinforce the need for early rehabilitation to completely restore function in the operated joint and improve pain with the fewest complications.Our objective was to assess postoperative improvement after total knee arthroplasty by comparing the use of multimodal periarticular infiltration with analgesic agents with conventional analgesia. More specifically, the objective of this study was to compare the postoperative analgesia obtained through periarticular infiltration of a solution containing 0.5% bupivacaine (400mg/20ml), 1/1000 epinephrine (0.3ml), triamcinolone hexacetonide (20mg/1ml), clonidine (150mcg/1ml), and 20ml of 0.9% saline solution with the use of intravenous analgesia utilizing opiates and painkillers (tramadol 100mg and dipyrone 1g) according to the assessment of opioid analgesic consumption, function , and evaluation of pain .To evaluate the results, we conducted a prospective and comparative study from March 2008 to December 2014. We selected 59 patients with a diagnosis of primary osteoarthritis of the knee who underwent elective surgeries for TKA, and separated them into two groups using permuted block randomization.The study began after approval by the institutional review board, and was registered under process number CAAE 38426214.5.0000.5032. All patients signed an informed consent form before being included in the study.Participants were male and female patients aged 60 to 80 years, with grade 3 or above according to the Kellgren and Lawrence classification,We excluded patients with psychiatric disorders, dependence on alcohol or illegal drugs, allergies to morphine, dipyrone or any local anesthetic, previous infection in the knee or other joints, systemic inflammatory diseases, congenital deformities or neurological disorders, and arthroplasty revision.The variables evaluated were: age, sex, body mass index (BMI), post-surgical complications, pain level evaluated by the analog pain scale (VAS), ability to ambulate, time to begin walking, range of motion, and the need for transfusion and oral and intravenous rescue opioid analgesia.The patients who underwent TKA were divided into two groups: Group 1  received spinal anesthesia as well as the trans-operative analgesia protocol using infiltration of multimodal periarticular analgesic drugs. Group 2 (30 subjects) received only conventional intravenous analgesia using opiates and painkillers (tramadol 100mg and dipyrone 1g) and morphine sulfate (4mg every 2 hours) as required by the patient, which was similar in both groups. The drugs used in the spinal anesthesia were the same for all patients according to the anesthesia team protocol, namely 0.5% isobaric bupivacaine (5mg) and morphine hydrochloride (0.1mg), and were administered by the same anesthesia team. All patients who required medications outside the anesthesia team protocol for TKA were excluded from the study.All patients received the same pre-emptive analgesia containing dipyrone (1g every 6 hours), tramadol (100mg every 8 hours), and pregabalin (75mg every 12 hours). The patients were oriented on the use of medications 24 hours prior to the surgery, and the drugs were maintained during hospitalization.The medications used for intraoperative analgesia by the individuals in Group 1 are listed in The drugs used for periarticular infiltration were based on the studies by Ranawat.The medications used in the postoperative period for both groups were: dipyrone (1g IV every 6 hours), tramadol  as needed, and morphine sulfate (4mg every 2 hours) as requested for persisting pain above 7 on the visual analog scale (VAS). Extra rescue doses of opioids were recorded (usage and frequency).Pain intensity was evaluated in three periods: prior to surgery, 24 hours after the procedure, and 48 hours after the procedure.A pneumatic tourniquet at 100 mmHg above systolic blood pressure was used to control bleeding during the surgical procedure in all cases. A suction drain was used for 24 hours. After cementing and placement of the implants, periarticular infiltration was conducted using the drugs listed in Before placement of the polyethylene component, periarticular infiltration was performed in the following order: posterior capsule, posterior-lateral and posterior-medial structures, patellar ligament and quadriceps tendon, synovia, capsule, pes anserinus, periosteum, iliotibial band, and tibial and fibular collateral ligaments at their origins. Rehabilitation began on the first day after surgery and the protocol was identical in both groups. Assessment began 6 hours after the end of the procedure.The quantitative variables were presented as means and their standard deviations, medians, and interquartile ranges. Categorical variables were represented using frequencies and percentages. Numerical variables were compared between groups using Student's T test for variables that assumed normal distribution and the Mann-Whitney U test for variables with non-normal distribution. Proportions were compared using the chi-squared test or Fisher's test (when necessary), and ANOVA was conducted on repeated measurements considering the VAS score at three points in time  between the groups (with or without periarticular infiltration), analyzing the clinically significant variables and/or those which exhibited significant differences or trends in univariate analysis: preoperative WOMAC and opioid rescue dose at 48 hours. The analyses were conducted using IBM Statistical Package for the Social Sciences software version 20.0  and the R programming language and environment.A total of 59 patients were selected, 36 (61%) females and 23 (39%) males. Mean patient age was 68, (65.0-75.0) and mean patient BMI was 27.0 (65.0-75.0).The results of this prospective randomized clinical study showed significant pain reduction as assessed by the VAS with statistically significant data, especially in the first 24 hours post-procedure, showing the benefit of periarticular anesthetic infiltration in pain reduction in the immediate postoperative period up to 48 hours post-procedure. Pain relief and functional recovery after surgery using the protocol described presented excellent security for pain control and functional recovery.Superior pain relief provided by infiltration of analgesics for pain control over exclusively intravenous analgesia was demonstrated in a systematic review conducted by Jiang et al.Vendittoli et al.,,,Currently, multimodal management of perioperative pain has been the most common means of reducing the incidence of persistent postoperative pain. It should be noted that intra-articular analgesia has a fleeting effect and is not a substitute for other therapies after hospital discharge.Nevertheless, intra-articular intraoperative injection of multimodal analgesics has shown significant results in enhancing the analgesic effect without increased complications resulting from the use of oral or intravenous opioids. This control may significantly reduce the need to use opioids, and may improve patient satisfaction without apparent risks in the period following TKA surgery.-).Pharmaceutical synergy produces more effective analgesia by addressing pain through all its mechanisms. Epinephrine prolongs the action of local agents by decreasing absorption via vasoconstriction through its α-adrenergic effects. It can also reduce bleeding and postoperative hematoma. Morphine has central, regional, and local effects via its effect on opioid receptors. Local administration yields reduces the frequency of typical opioid side effects  which occur through the opioid receptors. Clonidine works through its α2-adrenergic actions. This strengthens the action of local anesthetics and opioids through synergistic effects. By suppressing these physiological responses to surgery, pain and functional recovery are improved.Limitations of this study include the sample in comparison with multi-center studies, and the focus on a specific and homogenous population. Further studies should be conducted in order to compare the analgesic drugs, defining the best protocol.Use of periarticular infiltration in total knee arthroplasty reduces pain and improves functional capacity in the 48-hour period immediately following surgery when compared to oral and intravenous analgesia alone. We did not observe an increase in the incidence of side effects when the multimodal drug protocol was used on periarticular infiltration.


Migraine patients usually report a high prevalence of neck pain preceding or during the migraine attack. A recent investigation of musculoskeletal dysfunctions in migraine patients concluded that neck pain is not simply a symptom of the migraine attack but corresponds to identifiable muscle and joint alterations. Particularly pain provocation using palpation of the joints in the upper cervical spine was significantly more prevalent in patients with migraine than in headache-free participants.One hundred seventy-nine migraineurs (diagnosed according to IHS classification criteria version III beta) and 73 age- and gender-matched healthy controls were examined by a physiotherapist blinded towards the diagnosis, using a palpation technique over the upper cervical spine. The palpation combined oscillating movements and sustained pressure.Using simple palpation of the upper cervical spine, migraine patients can be stratified into three groups: painfree (11%), local pain only (42%), and pain referred to the head during sustained pressure (47%). Combining both test components  has a high sensitivity and specificity for migraine.The response to palpation of the upper cervical spine may indicate migraine subtypes. The presence of musculoskeletal dysfunctions of the upper cervical spine should be identified and treated to avoid ongoing nociceptive input into the trigeminocervical complex.DRKS00009622.German Clinical Trial Register DRKS-ID:  The influence of peripheral structures such as neck muscles or cervical joints on migraine and associated symptoms is the topic of an ongoing scientific debate. The generally accepted hypothesis, that migraine is mainly a disease of the central nervous system  is challIf there is a causal relationship between peripheral, i.e. cervical structures and migraine, there should be identifiable dysfunctions that are more common in patients with migraine than in headache-free participants. To investigate the frequency and the type of musculoskeletal findings in patients with migraine we recently published a Delphi survey reporting headache assessment tests (HATs) that reached international consensus amongst international experts in physical therapy and headaches, as the most useful for the evaluation of musculoskeletal dysfunctions in patients with headaches . The HATThese results are in line with publications on smaller migraine populations reporting higher numbers of trigger points , 10–12 aThe aim of this short report is to evaluate the response of migraine patients compared to healthy controls to palpation of the upper cervical spine (with and without sustained pressure). We hypothesize that this easy procedure will clearly distinguish between patients and controls and will further allow the definintion of clinical subtypes. Potential implications for the underlying pathophysiology and for the clinical management are discussed.The data presented here are based on 252 participants . Procedures are described in detail elsewhere . In summPalpation of the upper cervical spine was conducted with the patient positioned in prone, with his/her hands supporting the head. Manual pressure was applied over the midline of C1 and the spinuous processes of C2 and C3. Subsequently pressure was applied over the area of the joint C0/1 and C1/2 on the right and on the left hand side. The exact testing procedure was described by Maitland  to test 2 Test.To distinguish subgroups of migraineurs responding differently to palpation of the upper cervical spine, the analysis focused on the number and percentage of patients, who reported either local pain provocation during the manual examination and/or pain referred to the head during sustained pressure. Results across groups were tested for statistical significance using the ChiTest results were evaluated for a correlation with age using biserial point correlation to accommodate for undiagnosed age-related changes. Pearson’s corrlelation was also calculated for the number of headache days per month. A further correlation was conducted with the reported side of the headache symptoms using Cramer’s V for nominal data. The sensitivity and specificity of both components of the test as well as the positive and negative predictive values were calculated using cross-tabulation. All analyses were conducted in SPSS Version 24 (IBM).One hundred ninety-five of the 252 participants  or for referral to the head (p = 0.846) but a significant correlation with headache days per month (p = 0.027 for pain provocation and p = 0.019 for referred pain).There was no significant correlation of the test result with age for local pain provocation  with the side of the pain provocation  was not significant with Patients who did not report any pain during palpation,Patients who reported only local pain,Patients who additionally reported referred pain to the head during sustained pressure.Pain provocation during palpation of the upper cervical spine was significantly more present in migraine patients than in healthy controls. Pain during palpation and sustained pressure classified migraine patients into 3 subtypes:Approximately 80% of the migraine patients reported local tenderness during palpation; half of these also had referred pain to the head. The sensitivity and specificity for the two tests in combination is high. These findings confirm the result of a previous smaller scale study on head pain referral in patients with tension-type headache and migraine reporting that 14/14 patients with tension-type headache and 19/20 patients with migraine showed the same phenomenon of head referral during sustained pressure over the upper cervical spine . An earlManual examination of the C0/1 and the C1/2 joint regions on either side, requires pressure through the suboccipital muscles rectus capitis posterior major (and possibly minor) and obliquus capitis inferior , hence pain provocation during palpation could either indicate muscle or joint changes. While joint changes have not been investigated in migraine patients, upper cervical MRI changes in patients with cervicogenic headaches could not be confirmed . Muscle The sensitivity to palpation in our patients was not correlated to the dominant side of headache. This could be explained by the fact that only approximately 15% of our participants suffered from side-locked headache, while the majority had migraine that could change sides during or across attacks. The obvious non-mechanical explanation for bilateral pain provocation is, that local tenderness and referred pain indicate a generalised hypersensitivity of the suboccipital region due to central sensitisation in this particular subgroup of migraine patients . HoweverWhether peripheral tissue such as joints or muscles can indeed trigger migraine attacks and/or contribute to the transition to chronic migraine remains to be investigated. If this hypothesis is confirmed, it is essential to detect and treat musculoskeletal dysfunctions appropriately to reduce incoming nociceptive signals. It is therefore proposed to include manual joint examination into the routine physical examination procedure of migraine patients and to use both components  of the tests in combination to reach a high specificity and sensitivity.


The purpose of this study was to introduce a technique to extract the remaining peritoneal gas in order to improve the post-laparoscopic shoulder pain.This study included 12 patients undergoing laparoscopic gynecologic procedures between February and March 2016 in Minimally Invasive Techniques Research Center, Pars Hospital, Tehran, Iran. For complete suction of the air from abdominal cavity, the air was first vacuumed from the pelvic cavity in Trendelenburg position and then the patients were put in anti-Trendelenburg position. In this position, as the remaining gas was shifting toward subdiaphragmatic area, the suction tube was shifted to a position next to the camera canal and the remaining air was suctioned. A 10 point visual analogue scale was used to measure the severity of patients’ post-operative shoulder pain.hr post-surgery. At 12 hr post-surgery, the mean VAS was 0.8±1.5. At 24 hr post-surgery, the mean VAS for shoulder pain was 0.3±0.8. Finally, 48 hr post-surgery, the VAS score for all patients was zero.The mean VAS for shoulder pain was 0.8±1.7 4 Our approach for emptying the abdominal cavity from residual gas after laparoscopic procedures seems to be useful in preventing post-operative shoulder pain among patients undergoing gynecological laparoscopic surgeries. Further studies are suggested to compare the effect of our proposed method with other methods. Several studies have shown a relation between the residual gas volume and the severity of post-operative shoulder pain  following induction of the general anesthesia as a prophylactic antibiotic. Laparoscopy was performed by direct trocarization and CO2 insufflation. Two 5 mm ports were inserted through outer upper margins of bilateral rectus muscle sheaths, a 10 mm port through umbilicus for telescope insertion, and then a suprapubic trocar as described before , nausea and/or vomiting, and the time to first gas passing. Also, the duration of laparoscopic procedure, post-operative hospital stay and any complications were recorded as well. A 10 point visual analogue scale (VAS) was used to measure the severity of patients’ post-operative shoulder pain at 4, 12, 24 and 48 hr post-operatively. The score 0 in VAS scale indicated “no pain” and the score 10 indicated the worst pain possible and patients were asked to give a score from 0 to 10 based on their severity of pain. The pain score was assessed by nursing staff, who were blinded regarding the aims and design of the study. The main objectives of the present study were to evaluate shoulder pain at 4, 12, 24 and 48 hr after the surgery and the demand for analgesic medications.The Minimally Invasive Techniques Research Center, Pars hospital ethics committee approved this case series study and informed written consent for conducting and later publication of the study results was obtained from all participants before the start of study. The study was conducted in Minimally Invasive Techniques Research Center, Pars hospital, Tehran, Iran, from February to March 2016 and included twelve patients with age range of from 17 to 59 years who underwent uncomplicated gynecological laparoscopic procedures. Patients with any history of pre-operative shoulder pain were excluded from the study. Also, patients with a history of pulmonary disorder, abdominal or pelvic pain, tubo-ovarian abscess and severe adhesions in abdominal or pelvic regions were excluded from the study. All patients entering the study were operated by the same surgical team. All patients were given intravenous Cefazolin  in abdominal cavity is considered to be the main cause of post-operative shoulder pain and some researchers have indicated a relation between the residual gas volume and the severity of post-operative shoulder pain  and none of patients needed repeating of surgery.A main limitation of many previous studies examining the effectiveness of drainage in reducing post-laparoscopic shoulder pain is the inclusion of patients with a wide range of surgical indications . Our stuOur approach for emptying the abdominal cavity from residual gas after gynecologic laparoscopic procedures seems to be useful in preventing post-operative shoulder pain and also reducing the duration of post-laparoscopic hospital stay. It is probable that this method could be used as a non-invasive technique for reducing post-laparoscopic shoulder pain. Further prospective studies are suggested to compare the effect of our proposed method with previous methods of pain reduction with or without drain placement to confirm its usefulness.


This paper aims to examine the relationship between different characteristics of pain and stiffness and the functional status of patients with newly diagnosed polymyalgia rheumatica (PMR). Baseline analysis of an inception cohort study was conducted. Patients aged ≥18 years, with a new diagnosis of PMR were recruited from 382 English general practices. Participants were mailed a baseline questionnaire, including separate pain and stiffness manikins and numerical rating scales (NRS), a question on their ability to raise their arms above their head and the modified Health Assessment Questionnaire (mHAQ) to examine participants’ functional status. Linear regression analysis, reported as regression co-efficients ), was used to assess the association of pain and stiffness with function, initially unadjusted and then adjusted for age, gender, deprivation status, smoking status, BMI, anxiety and depression. Six hundred fifty two patients responded to the baseline survey (88.5%). The majority (88.2%) reported no, or mild impairment in their functional status. Adjusted linear regression analysis demonstrated that high (NRS ≥8) pain (0.20 (95% CI 0.10–0.28)) or stiffness (0.18 (0.09–0.26)) ratings, an increasing number of sites of pain (0.18 (0.06–0.29)) or stiffness (0.19 (0.08–0.31)) and shoulder pain (0.18 (0.05–0.31)), stiffness (0.10 (0.01–0.20)) and difficulty raising arms above one’s head (0.19 (0.10–0.28)) were all associated with increased functional impairment. The majority of newly diagnosed PMR patients reported no or minimal functional difficulty. However, those who experience severe or widespread pain or stiffness often have significant functional limitation in performing their daily activities and may be a subset worthy of additional focus in primary care. Polymyalgia rheumatica (PMR) is an inflammatory condition seen in patients aged over 50 years, with incidence increasing with age and peaking between 70 and 80 years. PMR is characterised by bilateral pain and stiffness in the shoulders, upper arms or pelvic region, with raised inflammatory markers and a rapid response to glucocorticoid treatment (commonly prednisolone in the UK). It is also often associated with constitutional symptoms such as fatigue, malaise and weight loss , 2.Pain and stiffness are common in patients with PMR, and these symptoms are frequently used to denote the ‘classical’ presentation description of bilateral involvement of the shoulders and hips. Pain and stiffness can also be an indirect marker of functional ability, an outcome measure reported as more important to some patients than either specific pain or stiffness symptoms . FunctioThough pain, stiffness and functional limitations are not uncommon in patients with PMR, there is limited research into the relationship between these during the early stages of PMR. In a sample of patients with PMR from secondary care, Hutchings et al. found there to be a major reduction in the functional status of this group, as measured by the Health Assessment Questionnaire (HAQ) . They shOur aim was to examine the relationship between different characteristics of pain and stiffness and the functional status of newly diagnosed patients with PMR, hypothesising that increased pain or stiffness would be associated with a reduced ability to perform daily activities.We examined patient reported baseline data from an inception cohort study of patients with newly diagnosed PMR in general practice. The methods of the PMR cohort study have been described elsewhere , but in Participants were asked to rate the severity of their pain and stiffness using two separate 0–10 numerical rating scales (NRS), with 0 indicating no pain/stiffness and 10 the worst pain/stiffness imaginable. The anatomical location of pain and stiffness were elicited using two separate body manikins . ParticiThe baseline questionnaire also collected information on sample characteristics, including age, gender, body mass index  and neighbourhood level of deprivation was reported using the indices of multiple deprivation (IMD) . The 7-iDescriptive statistics were used to summarise the characteristics of the study sample. The mean age (standard deviation (SD)) and gender were reported. Pain and stiffness were dichotomised at the median (inter-quartile range (IQR)) into low (NRS score 0–7) and high (NRS score 8–10) severity. Using manikin data, participants were categorised by quartiles into the number of painful body sites , and patients with bilateral shoulder and/or hip pain also identified. Through the same methods, the number of stiff sites was categorised , and participants with bilateral hip and/or shoulder stiffness identified . PatientTo assess the association between pain, stiffness and mHAQ scores, we used linear regression analysis. The relationship between each pain characteristic and functional status (mHAQ score) was initially examined, followed by each stiffness characteristic and functional status. Associations were reported as the regression co-efficient of the mean mHAQ score with 95% CI. Each association was examined through unadjusted analysis, followed by adjustment for age, gender, deprivation status, smoking status, BMI, anxiety and depression.IMD was categorised into three groups . BMI was categorised into four groups: (i) <24.9 , (ii) 25.0–29.99 (over weight), (iii) 30.0–34.9 (obese) or (iv) ≥35.0 (severely obese). Smoking status was categorised by those who had never smoked, were ex-smokers or current smokers. Anxiety was categorised as none (GAD7 score 0–4), mild (5–9), moderate (10–14) or severe (15–21). Depression was categorised as none (PHQ8 score 0–4), mild (5–9), moderate (10–14), moderately severe (15–19) or severe (20–24) , 13.A total of 739 patients with PMR were invited into the study, with 652 responding to the baseline survey (adjusted response rate 88.5%). The mean age of responders was 72.6 years (SD 9.0), the majority were female (62.0%), and a quarter were obese (25.8%) Table .Table 1PThe median NRS severity score for both pain and stiffness was 8 . Approximately half of newly diagnosed PMR patients reported pain (47.1%) in ≥16 body sites or stiffness (47.1%) in ≥12 sites. Nearly two-thirds of responders were unable to raise their arms above their head (64.2%).The mean mHAQ score was 0.57 (SD 0.57), with 269 (42.8%) responders categorised as having normal functioning with no impairment, 285 (45.4%) had a mild functional deficit, 50 (8.0%) had moderate and 24 (3.8%) had a severe functional deficit. The percentage of responders with a score denoting moderate or severe clinically defined anxiety was 13.1%, those with moderate or severe depression was 21.8%.In the unadjusted model, the mean mHAQ score was 0.24 (95% CI 0.15–0.34) points higher (indicating poorer functioning) in those with a high pain severity (NRS >8) compared to those with a low pain severity. When linear regression analysis was adjusted for age, gender, BMI, deprivation status, smoking status, anxiety and depression, this was attenuated to 0.20 (0.10 to 0.28) and remained significant ; 23–44 sites (0.27 (0.15 to 0.39)) and poorer functional status compared to those with 0–9 pain sites. When adjusted, this was attenuated to 0.13 (0.01 to 0.25) for 16–22 sites and 0.21 (0.06 to 0.29) for 23–44 sites, though remained significant.The relationship between bilateral shoulder pain and function also showed a significant association. In the unadjusted model, the mean mHAQ score was 0.22 (0.09 to 0.36) points higher in those with bilateral shoulder pain compared to those without. When linear regression analysis was adjusted, this was attenuated, but remained significant (0.18 (0.05 to 0.31)). There was no statistically significant association between bilateral hip pain and functional status after adjustment.In the unadjusted model, the mean mHAQ score was 0.23 (95% CI 0.14 to 0.32) points higher (poorer functioning) in those with a high stiffness severity (NRS >8) compared to those with a low stiffness severity. When linear regression analysis was adjusted, this remained significant 0.18 (0.09 to 0.26). We also found that as the number of stiffness sites increased, there was an association with poorer function. In the unadjusted analysis, there was an association between 6 and 11 stiff sites (0.18 (0.06 to 0.30)), 12–19 stiff sites (0.22 (0.09 to 0.34)) and 20–44 stiff sites (0.31 (0.19 to 0.43), which remained significant after adjustment (6–11 sites 0.14 (0.03 to 0.26); 12–19 stiffness sites 0.17 (0.05 to 0.29) and 20–44 stiffness sites to 0.19 (0.08 to 0.31) ) or bilateral hip stiffness (0.12 (0.03–0.20)) and the functional status of patients with PMR, this was only retained for bilateral shoulder stiffness after adjustment.Finally, an association was examined between the PMR patients’ ability to raise their arms above their head and functional status. Unadjusted analysis showed that those unable to raise their arms above their head were significantly more likely to have poorer mHAQ scores than those who could raise their arms above their head (0.28 (0.18–0.38) and this association was retained after adjustment (0.19 (0.10 to 0.28)).Our research used baseline data from an inception cohort of primary care patients with newly diagnosed PMR to better understand the relationship between pain, stiffness and the patients’ ability to function in their daily activities. Our results demonstrate that in the earliest stages of PMR, over half of patients have some degree of functional limitation. Those PMR patients with high pain or stiffness severity, a high number of painful or stiff body sites and those with limitations in the shoulders report significantly poorer functional status.n = 85) [n = 125) [The ability of newly diagnosed PMR patients to conduct their daily activities has not previously been examined within a primary care population. However, two prospective cohort studies recorded baseline mHAQ scores in secondary care populations of patients with new-onset PMR. Matteson et al. reported a median (IQR) mHAQ score of 1.1 0.8, 1.7) in a US sample (n = 85)  and Dasgn = 125) . Our sam in a US Our sample of patients with PMR also has improved functional capacity compared to patients with other rheumatic conditions. Pincus et al. 1999) reported mean mHAQ scores for patients with RA, fibromyalgia, osteoarthritis or vasculitis from secondary care to be 1.73, 1.64, 1.52 and 1.39, respectively. These scores suggest that patients with prevalent rheumatological conditions are experiencing a “moderate” impact on function, compared to the “mild” impact seen within our sample, even though these samples were generally 20 years younger than our participants . Therefo99 reportThis study is the first inception cohort study in primary care to examine newly diagnosed PMR patients. Response rates were excellent and as this data is based on incident PMR patients, recall bias is minimised. We were also able to recruit a large sample of patients across a wide geographical area and therefore our results are generalisable to PMR patients from across England who consult in primary care.Our limitations include the use of routinely collected data, including the diagnosis of PMR. It is possible that some people referred into the study may not have been considered to have PMR given time or if reviewed by a rheumatologist and therefore includes the possibility that some of our PMR patients were later re-diagnosed with a different condition. However, our provision of information to GPs through the recruitment template, the balance of our samples’ demographics, in addition to large proportions with bilateral shoulder and/or hip pain and stiffness, adds further confidence of the accuracy of the PMR diagnosis, rather than alternative conditions where patients’ experience widespread pain or stiffness. Furthermore, this sample represents the cross-section of individuals that GPs diagnose and manage with PMR in UK primary care.Our study demonstrates that the majority of patients with polymyalgia rheumatica experience no, or mild functional limitations when newly diagnosed in primary care. However, a significant association does exist between widespread, severe pain and stiffness and functional status. As the ability to function in daily activities is so important to patients, primary care is well placed to examine this subset further. At the point of diagnosis, early specific assessment of function  may be needed to help to prioritise and assess patients further for more intensive support and treatment.


To analyse the overall cosmetic outcome according to patient self-assessment in relation to the fractionation received.A questionnaire, drawn up on the basis of subjective rating scales of cosmesis and of acute and late toxicity RTOG/EORTC, EORTC QLQ-C30 (v3) and LENT SOMA, was applied to patients with early-stage breast cancer who received radiotherapy with tangential fields between June 2014 and July 2015. Self-perception of cosmesis, changes in the treated breast, pain and fractionation used (hypofractionation (HF) 42.56 Gy in 16 fractions or conventional fractionation (CF) 50 Gy in 25 fractions) were evaluated.p = 0.6).Three hundred and fifty-two questionnaires were obtained. The median age was 58 years. 45% of patients reported ‘excellent’ cosmesis, 53% ‘good’, and 2% ‘poor’ cosmesis. Cosmesis was considered ‘excellent/good’ by 98% of patients. No statistically significant difference was found in overall cosmesis according to fractionation received , and 48% reported change in normal breast colour.p = 0.04).Fifteen percent of patients who are younger than 58 years reported a change of normal breast colour affecting cosmesis compared to 9% of patients older than 58 years (in situ (DCIS) (p = 0.04); 14% in stages I-II referred colour change affecting cosmesis compared to 6% of those with DCIS (p = 0.03).Complications affecting breast cosmesis were reported by 9% of patients with stages I-II compared with 2% with cancer Ninety-four percent of patients stated that they would accept treatment again.No difference in cosmetic results was found between HF and CF in our patients. Great satisfaction regarding cosmetic outcome of cancer treatment was reported, given by 98% of excellent/good cosmesis, and 94% of patients who would receive treatment again. Adjuvant radiation therapy after conservative breast surgery represents the standard treatment to improve loco-regional control and survival . Since sThe treatment of breast cancer can result in discomfort such as pain and alterations in cosmesis by disturbances in the volume of the breast, scars and skin changes. These changes result from both surgery and adjuvant treatments. Radiation therapy can cause both acute and chronic damages, while the effects of the surgery are usually more immediate . Radiatiet al . (p = 0.9).Pain was reported by 68% (190/279) of the patients. Most of them reported occasional pain , whereas only 6% (18/279) reported permanent pain. The rest of the patients reported no presence of pain . There were no statistically significant differences in the presence of pain between hypofractionated treatment and conventional treatment , while 3% and 4% reported poor cosmesis at the beginning and at discharge, respectively.Both before the start of radiation therapy and at the end of it, the frequency described above is maintained, the alteration referred with greater frequency was ‘difference between both breasts’ (66% before and 80% after RT), and in most, without affecting cosmesis. Colour change of the breast upon discharge was reported by 68% (54/80) of the patients and 26% (21/80) claimed that it affected their cosmesis. Thirty-three percent pointed out no change of normal breast colour after RT. Regarding pain, most patients reported occasional pain at the beginning and at the end of RT, no statistically significant difference was found between both time points. Thirty-three patients had questionnaire both before RT and at discharge . FinallyThis study demonstrates that aesthetic result after conservative surgery and RT in patients with early-stage breast cancer is generally good as perceived by patients, given by 98% of them who refer excellent/good cosmesis, 46% excellent cosmesis, 52% good and only 2% poor results, which is comparable with data reported in previous literature where excellent or good assessment is described in 66% , and in The alteration most frequently described was difference between both breasts, both globally and before the beginning and at discharge of RT. This is probably the most frequent alteration given the broad meaning that this question may have and it may also be valued differently by each patient. The percentage of patients who reported ‘difference between both breasts’ was 66% before the start of RT, confirming what was mentioned above, sequelae of treatment begin with surgery and then remain or could be increased with adjuvant treatments.The alteration ‘change in normal breast colour’ affected cosmesis in only a quarter of the patients at discharge, this could be due to management of patient expectations with respect to outcome and treatment toxicity, and that change in colour, either erythema and/or hyperpigmentation, is frequent and usually transient.There was no statistically significant difference in overall aesthetic result according to the fractionation used, consistent with that reported by other studies , 3. As met al [The randomized study by Shaitelman et al  presentsp = 0.003), higher frequency of moderate or severe pain, grade 2 dermatitis, induration, chest wall pain, and moist and dry desquamation. According to the evaluation by the patients, there was greater frequency of pain, moist and dry desquamation, oedema and fatigue with CF [In addition to this, a multicentre, observational study , which s with CF . This stThe choice between one fractionation schedule over another in our institution is based, beside disease and patient characteristics, on the capacity of obtaining the best dosimetric parameters possible. The use of modern techniques of 3D conformal RT has led to lower treatment toxicity . In our Regarding pain, most patients had occasional pain, both before the start of RT and at the end of it, and the minimum percentage described constant pain. Analgesia requirements were not assessed. Dose inhomogeneity has been described as a predictor of pain after breast RT . The dosPatient age and tumour size are among the factors affecting cosmetic outcome . In thisOne of the limitations of this study is the subjective nature of the questionnaire that is also not validated. This questionnaire was made based on other scales most widely used in the literature –10, althIn conclusion, this study found no difference between hypofractionated regimens compared with CF of radiation therapy in our patients in terms of cosmetic results, with no differences in the different variables measured with respect to fractionation received. Great satisfaction regarding the cosmetic outcome of cancer treatment has been reported, given by 98% of excellent/good cosmesis, and 94% of patients who would agree to receive the treatment again.