Chronic low back pain (CLBP) is challenging to treat with its significant psychological and cognitive behavioural element involved. Mindfulness meditation helps alter the behavioural response in chronic pain situations. Significant body of research in the filed of mindfulness meditation comes from the work of Dr Kabat-Zinn. The current evidence in the field, though not grade one, shows that there is a place for mindfulness meditation in managing chronic pain conditions including CLBP. Further research to test the usefulness of mindfulness in CLBP should involve good quality randomized controlled trials of pure mindfulness based technique in matched subjects. Chronic low back pain is challenging to treat with its significant economical burden, and very few effective treatment options. Psychological and cognitive factors are very important contributors to the pain intensity & disability associated with chronic pain. They may create a vicious cycle in which pain causes stress, and the stress, in turn, increases pain.Various authorities have defined mindfulness in different ways, but the core of all of them is- mindfulness meditation is being alert and awake about the every present moment. The meditator concentrates on his/ her own breath in its entirety. Once he/ she becomes expert in it, he then starts body scan from head to toe and feels the body sensations with equanimous mind (non-reacting).Kabat-ZinnThe aim of this review is to evaluate the available scientific evidence for effectiveness of mindfulness meditation in the management of CLBP.There has been an extensive research in the field of management of CLBP. But meditation, in particular mindfulness meditation, as a tool to tackle CLBP associated problems has not been studied much. In this review, randomised clinical trials, systematic reviews, surveys and expert opinions have been examined for usefulness of mindfulness meditation for the management of CLBP.Kabat-ZinnFollow up showed statistically significant progress towards greater energy, less pain and improved coping. The main limitations of the study were lack of control group, reliance on patient's subjective experiences for data collection, no observer blinding and non–rigorous selection process. But, this was a landmark study in the field of mindfulness meditation in chronic pain conditions. Being a nonrandomized, non blinded study it can not be accepted as very good research evidence, despite significant improvement in patients' condition.In subsequent study Kabat-Zinn et alKabat-Zinn et alBerman and SinghWolf E et alThis was a randomized control trial in which participants were allocated into two groups: breath therapy and physical therapy. The measurements were done in a complex way (difficult to interpret easily). Baseline, six week and six months pain intensity (VAS), pain specific functional disability and overall health status (SF-36) were assessed. There was significant number of drop outs from the beginning, which has been described clearly in the study. The breath therapy group showed significant improvement over physical therapy in pain intensity, back pain related functional disability and emotional components of Short Form-36 score for functional health status(SF-36). The authors also conclude that breath therapy is safe in CLBP and it might teach coping skills and provide insight into the effects of stress on the body and low back pain.M J OttPlews-Ogan et alThe participants were randomized into three groups by computer generated randomization- standard care, mindfulness meditation (MBSR) and massage. The study was not observer blinded. There was also a high drop out rate amongst the MBSR arm subjects. None of the MBSR participants completed 8-weeks course. The pain outcome for MBSR was not significantly different from standard care. MBSR group had a statistically significant improvement in mental health scores over standard care group. Overall, this study was not very well conducted, so can not be graded as good evidence.Carson et alMorone et alRoy C GThe author has concluded that relaxation techniques can aid in the rehabilitation of the patients with chronic pain in following ways. Minimum staff support is needed, usually just one therapist. Once the participants understand technique, they are encouraged to practice it independently. Meditation experience changes the attitude towards the pain. Thirdly, alteration of pain experience facilitates adjustment and rehabilitation, such as the partial relief from hopelessness and depression.In a special communication of JAMAMorone et alMorone et alThey followed the patients for three months and found sustained benefit from program as measured by continued meditation (MBSR) by the participants and improvement in physical function and pain acceptance. Nearly one half of the participants reported reduction in pain and sleep medications 3 months after completing the study. Overall, this is well-conducted study with good quality.Randolph el alThey carried out nonrandomized, prospective investigation in multidisciplinary chronic pain management clinic in West Texas. The patients initially had extensive psychological and medical assessment, during which, baseline data was gathered. As per their need, the patients then received combination of medical, physical and psychological therapies before participation in mindfulness training- Pain and Stress Management Program (P&SMP).Most (95%) of the sample subjects reported to be affiliated with Christianity. The patients were allocated to P&SMP when they fulfilled the criteria and agreed to commit the time and efforts for mindfulness meditation. This means there was no strict selection criteria (selection bias). The study results showed significant improvement in sensory, affective and cognitive measures of chronic pain after 8-weeks mindfulness meditation program. The results were sustained at 1-year follow up. The authors also conclude that mindfulness meditation might act as a catalyst for positive response to medical treatment.Sherman et alAs mentioned above in the study by Berman and SinghThe researchers may accept the technique of mindfulness meditation with different perspective, and this might over/under estimate the effects of the study involving mindfulness meditation.Kwee et alKabat-ZinnThe actual group intervention with mindfulness technique can meet with lots of challenges. The trainer competencies and beliefs may affect the progress of the participants significantly. Kabat-ZinnApart from one patient in a study by Wolf E et alThe traditional pain therapies have their limitations and side effects. Mindfulness meditation is an inexpensive, non-invasive method which can be taught without any special equipment. There is definite evidence in favour of mindfulness meditation and its modifications in the management of CLBP. But we still need more good quality studies to justify the use of mindfulness meditation in CLBP patients on routine basis.The future research should involve well designed randomised blinded control studies comparing CLBP patients in control group with standard therapy, against mindfulness meditation in intervention group. Obviously, it is not possible to conduct a double blind control trial due to the nature of the mindfulness intervention. Also, the structure of the meditation program needs a proper attention. It must be a pure mindfulness based program, rather than a combination of mind-body interventions. Most of the studies in this review involved combination of patients with chronic pain from various body parts, apart from CLBP. To be more specific to CLBP, the inclusion and exclusion criteria for study samples need to be strict.Though there is no grade 1 evidence for mindfulness meditation in the management of CLBP, it is quite cheap, harmless and still effective to certain extent in improving affective component of chronic pain. Also, it may lead to more pain acceptance, improved global health, and possibly improved compliance with current medical therapy.


Sixty-one laparoscopic presacral neurectomies were performed in Chang Gung Memorial Hospital, Keelung Center over a 1-year period for patients with primary dysmenorrhea who failed to respondto medical management. Eighty-three percent (50) had complete relief of pain, 10% (6) had significant relief, 3.5% (2) had moderate relief, and 3.5% (2) had no relief from their dysmenorrhea at their first menstruation after the procedure. One vascular complication requiring laparotomy occurred. Average total operation time was 24 minutes, and the average hospital stay was 2 days. Six monthsfollow-up was done in 35 patients with complete symptom relief, and all reported continued reliefof menstrual pain. The efficacy of laparoscopic presacral neurectomy for the pain relief of primarydysmenorrhea is justified in this report.


Injection of these platelets in the attachment of the fascia to the os calcis might induce a healing rate.If conservative treatment for chronic plantar fasciitis fails, often a corticosteroid injection is given. Corticosteroid injection gives temporarily pain reduction, but no healing. Blood platelets initiate the natural healing rate. GPSA randomized controlled multi centre trial will be performed. The study population consists of 120 patients of 18 years and older. Patients with chronic plantar fasciitis will be allocated randomly to have a steroid injection or an autologous platelet concentrate injections. Data will be collected before the procedure, 4,8,12,26 weeks and 1 year after the procedure.The main outcome measures of this study are pain and function measured with questionnaires.Recent literature show positive effects for the treatment of tendinosis with autologous platelet injections. The forthcoming trial will compare treatment for chronic plantar fasciitis with a steroid injection versus an autologous platelet injection. Our results will be published as soon as they become available.http://www.clinicaltrials.gov NCT00758641.Trial registration number:  Chronic plantar fasciitis is the most common cause of foot complaints in the United States, making up 11 to 15% of the foot symptoms requiring professional care among adults . The incThe underlying condition that causes plantar fasciitis is a degenerative tissue condition that occurs near the site of origin of the plantar fascia at the medial tuberosity of the calcaneous . In acutIn an animal model the addition of growth factors to the ruptured tendon has been shown to increase the healing of the tendon ,15. In hPRP is promoted as an ideal autologous biological blood-derived product, which can be exogenously applied to various tissues where it releases high concentrations of platelet derived growth factors that enhance wound healing, bone healing and also tendon healing. In addition PRP possesses antimicrobial properties that may contribute to the prevention of infections . When plWe will evaluating the effects of PRP injections on "self-reported function and pain" in a double-blind randomized trial.Randomization will be performed after patients are deemed eligible and have provided informed consent. Patients will be randomly allocated to the concentrated autologous platelet group (PRP group) or to the corticosteroid group (control group). A computer using block randomisation of 10 patients will be used to create a randomization schedule. Treatment assignments  will be assigned by the trial managers  who will also arrange the facilities needed for the procedure.All patients with a plantar fasciitis who are admitted to one of the participating hospitals and meet the inclusion criteria are asked to join the study.Plantar fasciitis was defined as pain at the point of the fascia plantaris origin at direct palpation. All affected patients were screened with X-ray of the calcaneus for bony abnormalities and to difentiate for subtalar arthritis. Sonography and MRI were not used standardly.The Medical Ethical Committee of The Netherlands approved the study design, procedures and informed consent.http://www.clinicaltrials.gov NCT00758641.Trial registration number: The study will be conducted at the Orthopaedic Departments of the HAGA Ziekenhuis Den Haag, St. Antonius Ziekenhuis Nieuwegein, Diaconessenhuis Leiden and St. Elisabeth Ziekenhuis Tilburg between November 2008 and December 2010. Authors JP and TG will be responsible for the data and safety monitoring. Inclusion criteria: patients aged > 18 years, with plantar fasciitis (6-12 months duration), who failed conservative treatment are included. They have to be able to understand the informed consent and have a VAS pain score in the morning by first steps higher as 5 .Patients will be excluded from the study when they received local steroid injections within 6 months, physical/occupational therapies within 4 weeks, or non-steroidal anti-inflammatory within 1 week prior to randomization. Also patients will be excluded with the inability to fulfil follow-up criteria, significant cardiovascular, renal or hepatic disease, pregnancy,  malignancy, history of amenia (hemoglobin < 5.0), previous surgery for plantar fasciitis, active bilateral plantar fasciitis, diagnosis of vascular insufficiency or neuropathy related to heel pain, hypothyroidism and diabetics.Fifty-five milliliters whole blood is collected from the uninvolved arm into a 60-mL syringe that contained 5 mL sodium citrate. A peripheral complete blood count is also collected at the time of the initial blood draw. The blood is then prepared according to the GPS System instructions . This device is a desktop-size centrifuge with disposable cylinders for the blood approximately 0.05cc Platelet concentrate is obtained for each patient.Autologous platelet concentrate contains concentrated white blood cells and platelets that are suspended in plasma. Since an acidic anticoagulant is introduced to the whole blood used to produce the platelet concentrate, the platelet concentrate must be buffered to increase the pH to normal physiologic levels. This is accomplished with 8.4% sodium bicarbonate solution added at a ratio 0.05cc of sodium bicarbonate solution to 1 cc of platelet concentrate.The resulting buffered platelet concentrate contains approximately a 6 to 8 times concentration of platelets compared to baseline whole blood. No activating agent is used. The total time from blood draw to injection in the patients is about 30 minutes. No specialized equipment, other than the GPS machine, is required.Initially, bupivacaine is infiltrated into the skin and subcutaneous tissue of both groups as a local field block. Approximately 0.05cc is also injected directly into the area of maximum tenderness. Then, either 5 to 6 cc platelet concentrate or 5 to 6cc corticosteroid is injected using a 22-g needle into the plantar fasciitis using a peppering technique. This technique involved a single skin portal and then 5 penetrations of the fascia.Immediately after the injection, the patient is kept in sitting position without moving the foot for 15 minutes. Patients will go to the physiotherapist to obtain stretching exercises. Patients are sent home with instructions to limit their use of the feet for approximately 48 hours and use hydrocodone or acetaminophen for pain. The use of nonsteroidal medication is prohibited. After 48 hours, patients are given a standardized stretching protocol to follow for 2 weeks. A formal strengthening program is initiated after this stretching. At 4 weeks after the procedure, patients are allowed to proceed with normal sporting or recreational activities as tolerated. Any type of foot orthoses will not be allowed.The type of steroid that is used during the study is kenacort 40 mg/ml triamcinolon acetonide.Pain will be measured using a visual analogous scale at all time points. The VAS score of the Foot Function Index will be used.The score records the patient's reported pain using a scale of 0-10, where 0 is pain-free and 10 is the worst pain imaginable. The scale will be a 10 centimeter line beginning with 0 and ending with 10, the score will be marked at the point on the line that corresponds with the patient response.Each patient randomly assigned to a treatment and with at least one non-missing pre- and post-baseline measurement, will be classified at each visit, as either a treatment success or failure. Patients with a score reduction of 25% compared to baseline, did not require pain medication beyond the protocol defined allowable period, and did not require escape therapy will be considered a treatment success.The absolute change from baseline to endpoint means the baseline value is subtracted from the endpoint value. Percent change is defined as the absolute change multiplied by 100 divided by the baseline value. For patients whose pain improves, these values will be less than zero.The treatment is defined as successful if the pain reduction after 6 months is over 25%. If the patient is lost to follow-up, the last measurement will be carried forward. If the patient has obtained a different treatment, the subject is classified as unsuccessful.The function and satisfaction will be measured using the AOFAS foot questionnaire ,19, the All patients will be followed up at 4, 8, 12, 26 and 52 weeks. All patients will complete AOFAS and VAS scores at all follow up momentsThis study has two main parameters: number of patients with 25% pain reduction after 6 months and the average pain reduction;Corticosteroids and stretching have a recurrence of pain after 6 months ,25. PrevConservative treatment with taping or stretching shows a 30 ± 24 points decrease in VAS pain at walking ,27. CortTo be able to measure a difference in average pain reduction, the largest number of patient is needed 55 patients in both groups. To compensate for possible lost to follow-up, 60 patients will be included in each group Figure .This is a double blind randomized and prospective study. Patients will be randomized in equal proportions to either autologous platelet concentrate or corticosteroid injections. The primary endpoint of the trial is treatment success at 6 months. The other measurements are to measure the speed of recovery and the re-occurrence of pain.Statistical analyses will test the null hypotheses of no differences between patients treated with autologous platelet concentrate and those treated with corticosteroid in the proportion of the protocol defined, successfully treated patients.All tests of treatment effect will be made using a one-sided alpha level of 0.025, unless otherwise specified. Tests for the interaction between treatment and a blocking factor will be made at the alpha level of 0.10. All p-values will be rounded then quoted to 3 decimal places, unless the true p-value is less than 0.001 whereby the notation (p < .001) will be used or if the true p-value is greater than 0.999, in which case the notation (p > .999) will be used. Confidence intervals, where indicated for the difference between the two treatment groups, will be calculated at the 95% level. All data will be analyzed by a blinded researcher.This randomized study is designed to test the use of concentrated autologous platelets in patients with plantar fasciitis. Plantar fasciitis is a common problem with many available treatment methods. When conservative treatment results in a non-satisfactory outcome, the patient is often interested in treatment options other than surgery. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree . TreatmeIn a recent study of Peerbooms et al.  a positiThe injection of platelet-rich-plasma (PRP) into the effected tissue addresses the healing stages necessary to reverse the degenerative process which are going on in the base of the plantar fascia. The individual cytokines present in the platelet α-granules have been shown to enhance fibroblast migration and proliferation, up-regulate vascularization, and increases collagen deposition in a variety of in vitro and in vivo settings . The cytThe treatment of tendinosis with an injection of concentrated autologous platelets may be a nonoperative alternative. Utilising the Recover system the patient's own platelets can be collected into a highly concentrated formula. This treatment concept directly addresses the existing condition and should prove to be a superior alternative to current conservative treatments for chronic plantar fasciitis.We postulate that the concentrated growth factors work in a synergetic manner to initiate a tendon healing response. This hypothesis is supported by in vitro research in the literature. Transforming growth factor β1 is shown to significantly increase type I collagen production by tendon sheath fibroblasts. This same mechanism is likely to be active in chronic plantar fasciitis .The authors declare that they have no competing interests.TG originated the idea for the study, led its design and will supervise the project. TG and JP will coordinate the trial and are responsible for data acquisition. JP, WL, FF, HS and HH provided extra protocol information in order to expand the original study design from single-centre to multi-centre. TG, JP, WL, FF, HS, and HH are responsible for data collection at their respective locations. All authors have read and corrected draft versions of the manuscript and have approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/11/69/prepub


For adult scoliosis patients with chronic low back pain bracing is initially indicated before spinal surgery is considered. Until recently there has been a lack of research into the effect upon pain reductions in the mid and long-term. Promising results have been documented in short-term studies for the application of a sagittal re-alignment brace in patients with spinal deformities and along with pain; however mid-term and long-term results are not yet available. The purpose of this study is to investigate the mid-term effects of this brace with respect to pain control.67 patients  with chronic low back pain (> 24 months) and the diagnosis of scoliosis or hyperkyphosis were treated with a sagittal re-alignment brace (physio-logic brace™) between January 2006 and July 2007. The indication for this kind of brace treatment was derived from a positive sagittal re-alignment test (SRT) and the exclusion of successful conservative treatment during the last 24 months. The aim of this type of conservative intervention was to avoid surgery for chronic low back pain.The average pain intensity was measured on the Roland and Morris VRS (5 steps) before treatment. This was 3.3 (t1), at the time of brace adjustment it was 2.7 (t2) and after at an average observation time of 18 months it was 2.0 (t3). The differences were highly significant in the Wilcoxon test.Short-term measurements showed that a significant pain reduction is possible in chronic postural low back pain using a sagittal re-alignment brace inducing lumbar re-lordosation. In a preliminary report at adjustment (t2), highly significant improvements of pain intensity have also been demonstrated. At 6 months of treatment however, no improvement was measured. The improvement of the mid-term effects (18 months) found in this study compared to the preliminary report may be due to the changed approach to compliance: whilst the bracing standard was not changed; the patients in this study were obligated to wear the brace for a minimum of 20 hrs per day for the first 6 months of treatment.The effect of the sagittal re-alignment brace leads to promising short-term improvements in patients with chronic low back pain and spinal deformities. Contrary to unspecific orthoses, which after a short period without persistent pain reduction are omitted by the patients, the sagittal re-alignment brace (physio-logic™ brace) leads to an effective reduction of pain intensity in mid-term even in patients who have stopped brace treatment after the initial 6 months of treatment. In conservative treatment of chronic low back pain specific approaches such as the sagittal re-alignment brace are indicated prior to considering the surgical options. Loss of lumbar lordosis correlates well with the incidence of chronic low back pain in adulthood ,2. SedenFor adult scoliosis patients with chronic low back pain bracing should be indicated before spinal surgery is considered, but until now no investigations have established the effects upon pain reductions in the mid or long-term application of these treatments.The success rate of such a treatment in general does not appear to be high and compliance is generally described as moderate or poor -5, howevThe treatment with the "sagittal re-alignment brace"   it can be expected, that the sagittal deformity has been mobilised enough to gain the desired functional improvement and (2) for the patient to have learnt to cope with the brace during activities of daily living and the impairment of posture and movement whilst wearing the brace. The expectation provided to the patient was that after the initial 6 months the patient may decide by himself to have a first brace-free interval, if the result finally was a consistent pain relief without the brace.If pain increased in the brace-free interval, the initial procedure of brace treatment would re-start once again.The purpose of this study was to investigate as to whether a change in the approach to the patients' education would improve the compliance in order to allow better treatment results in the mid-term. In the latter case a prescription of this brace would be justified in order to attempt to prevent surgery.67 patients  with chronic low back pain (> 24 months) and the diagnosis scoliosis  or kyphosis (n = 11) were treated with a sagittal re-alignment brace (physio-logic brace™) between January 2006 and July 2007. The distribution of diagnoses can be seen in figure st week after brace adjustment (t2) and at follow-up, at average 18 months after brace adjustment (t3) using the Roland and Morris VRS [Before brace prescription the brace action was simulated and pain reduction was tested . Brace trris VRS .The physio-logic™ brace Figure . is manuAfter the anthropometrical data  are registered, the foam model is milled from a blank hard foam block. This hard foam model is wrapped in a heated PE-plate, which is vacuumed to the models surface. The brace parts are cut from the PE-model and adjusted to the patient -9 Figur..In principle the brace provides a crosswise ventral pressure area of 3 cm directly sub-pectoral, caudally followed by a void. The caudal ventral pressure point is supra-pubical. The dorsal pressure zone is situated at the waist level allowing an apical pressure at the level of L2. This dorsal pressure leads to a mass movement also ventralising the lower ribs into the ventral void of the brace. As there is a slight compression of the trunk unavoidable, lateral voids are necessary to give room for the shifted regions of the trunk there as well. If these voids are omitted the compression forces generated will inhibit breathing and make brace wearing impossible.The Roland and Morris questionnaire used for this study is a verbal rating scale (VRS) providing certain steps of subjective pain judgements recorded by the patients themselves . It contWhile the bracing standard was not largely changed in comparison to the preliminary series , the patShort-term = directly upon application to 14 daysMid-term = 6 months to 24 months of follow-upLong-term = > 24 months of follow-upThe average pain intensity recorded on the Roland and Morris VRS (5 steps) before treatment was 3.3 t1), at the time of brace adjustment was 2.7 (t2) and after an average observation time of 18 months was 2.0 (t3). The differences were highly significant in the Wilcoxon test  highly significant improvements of pain intensity have been shown, however at 6 months of treatment no significant improvement was retained .The improvement of the mid-term effects in this study, when compared to the preliminary report, may be due to the change in the approach patient education. Whilst the bracing standard was not largely changed, the patients were obligated to wear the brace at minimum 20 hours per day for the first 6 months. After this period the individual patients decided upon the brace wearing times by themselves. With this new approach to compliance we can predict a successful outcome using the sagittal re-alignment brace (physio-logic™ brace) in this specific patient population.The brace should not be used in patients with chronic low back pain due to lumbo-sacral instability (e.g. spondylolisthesis), even if the SRT measured a pain reduction . As withThe beneficial effects of this brace in patients with lumbar scoliosis and the symptoms of spinal claudication has also been demonstrated ; therefoThe effects of the sagittal re-alignment brace leads to promising short-term improvements in patients with chronic low back pain and spinal deformities. Contrary to unspecific orthoses, which after a short period without persistent pain reduction are omitted by the patients, the sagittal re-alignment brace (physio-logic™ brace) leads to an effective reduction of pain intensity at 18 months even in patients who have stopped brace treatment after the initial 6 months of treatment. Therefore in conservative treatment of chronic low back pain, specific approaches such as the sagittal re-alignment brace are indicated initially that aim to prevent spinal surgery.HRW is a consultant for Koob-Scolitech. MW does not declare any competing interests related to this paper.HRW contributed to patient acquisition, manuscript writing and statistics. MW contributed to patient acquisition and technical support.


Renal colic (RC), is one of the most severe pain patterns which is most commonly diagnosed and managed in the emergency department (ED). This study is designed to evaluate the characteristics of adult patients presenting with pain and diagnosed with RC in the ED, length of stay in the ED and hospital and factors affecting these variables.All consecutive adult patients who presented with side pain, flank pain, abdominal or groin pain and consequently diagnosed with urolithiasis or RC were analyzed retrospectively. Sociodemographic data, times of admission into and discharge from the ED, adjunctive complaints, results of laboratory investigations, findings on examination, treatment and drugs administered were noted.A total of 235 patients with a diagnostic code of urolithiasis were enrolled. Physicians were more likely to order radiological and laboratory investigations for female patients and those without hematuria in urinalysis. The peak incidence of patients diagnosed with RC (p = 0.001) was noted in August, while the winter had the lowest frequency of relevant admissions. The peak frequency was between 06:00 and 08:00. Women stayed longer in the ED (p = 0.001). Absence of hematuria in urinalysis was associated with increased length of stay (p = 0.007).Although RC is a common ED presentation for which the emergency physician has no guidelines in terms of diagnosis and management, there is no exact pattern to guide ordering investigations. Patients with atypical presentations stay longer in the ED and are likely to undergo additional tests in management. Colicky pain originating from kidneys in flank area, namely renal colic (RC), is one of the most severe pain patterns which is commonly diagnosed and managed in the emergency department (ED). Severely increased intraluminal pressure following augmented blood flow with resultant ureteral smooth muscle contraction is accused in the mechanism of the pain. In addition, overt sensitivity of nociceptive receptors to mediators such as histamine and bradykinin are also implicated .Most common manifestations of patients with renal colic in the ED are side pain or flank pain followed by abdominal pain, back pain, and groin pain . Turkey The evaluation and treatment of patients with nephrolithiasis is rapidly changing. New imaging modalities have emerged and have changed the way we evaluate patients with flank pain. Although a myriad of diagnostic tools including ultrasonography (USG), computed tomography (CT), kidney, ureter, and bladder radiograph (KUB) are useful aids in the diagnosis, clinical presumptive diagnosis generally direct treatment in the emergency setting.This study evaluates the clinical and demographic characteristics of adult patients presenting with pain and diagnosed with RC in the ED, length of stay in ED and hospital and third factors affecting these variables.The present study was conducted in an industrialized middle-sized city of western Turkey, Denizli, in a University-based hospital. The hospital is one of the biggest hospitals in the city with an annual census of 24.000 patients. All consecutive adult patients presenting with side pain, flank pain, abdominal or groin pain and diagnosed with urolithiasis or RC by the emergency physicians between February 2005 and February 2007 were analyzed retrospectively. Patients with primary complaints other than pain such as nausea/vomiting, painless hematuria, etc. were excluded from the analysis. Also excluded were patients admitted into other healthcare institutions before being transferred to the study center with the consideration of confounding factors.Patients younger than 15 years of age, patients with other complaints and those who had been previously diagnosed with RC and treated accordingly were excluded from the analysis. Detailed data relating to a total of 266 patients who received the code of urolithiasis (N20-23) in accord with International Classification of Diseases (ICD-10) were abstracted from the hospital information system.Sociodemographic variables, times of admission and discharge from the ED, adjunctive complaints other than pain, results of laboratory and radiological investigations, findings on physical examination, treatment and drugs administered were noted and analyzed. Formally recorded entrance times were considered the starting point of stay in ED, and were calculated till discharge from ED or admission to the hospital wards.Urinalysis was performed with IRIS iQ 200 Automated Urine Microscopic Analyzer  in the hospital laboratory.All data obtained in the study were recorded and analyzed using the Statistical Package for Social Sciences for Windows, Version 11. Numerical variables were given as mean ± standard deviation (SD), and categorical variables were noted as N and percentages. Categorical variables regarding RC, length of stay, time of presentation and sociodemographic variables were compared to each other using chi-squared test. P values below .05 were considered statistically significant.A total of 235 patients have received the diagnostic code of urolithiasis (N20-23) in accord with ICD-10 system and were considered eligible for the study. Male patients constituted 75.7% (n = 178) with a mean age of 31.7 ± 6.5 vs. a mean of 29.1 ± 8.2 for females. The ages of the samples averaged to 31.1 ± 7.0 years (range:16 and 66).The presenting symptoms of the patients were side pain in 81.7% (n = 192), abdominal pain in 10.6% (n = 25), back pain in 5.9% (n = 14) and groin pain in 1.7% (n = 4).Table Table Physicians were found to be more likely to order radiological and laboratory investigations for female patients and those without hematuria (<5 RBC/HPF) in urinalysis Table . IntramuOnly 36 (15.3%) patients were consulted with other disciplines and more than four-fifth of this subgroup (n = 28) were hospitalized with the resultant hospitalization rate of 11.9% for the whole sample. Of those admitted to the wards, 17 had pain or vomiting despite analgesics and antiemetics, whereas 13 (5.5%) suffered from infected hydronephrosis. Mean length of stay in hospital was 4.2 ± 1.9 days.As far as the patterns and times of presentations to the ED, August had the peaked rate of patients diagnosed with RC (p = 0.001) Table . Winter Mean length of stay in ED was found to be 87.6 min (± 42.4 min) (range: 41 and 487 min). Seventy-eight patients (33.2%) stayed in ED for longer than two hours, 101 (43.0%) patients for 1 to 2 hours, while 56 (23.8%) stayed for shorter than one hour. Female patients tended to stay longer in the ED when compared to males (p = 0.001)  followed by abdominal pain (16.2%) [% followeOur results indicate that female patients with RC were more likely to stay in ED longer, to go to radiology suit and to have their blood drawn for laboratory tests when compared to males. Abdominal complaints were also noted more frequently in females. It can be concluded that emergency physicians tend to order more tests to consider a clinical diagnosis of RC in females possibly due to a broad list of differential diagnoses in females.The most common finding in patients with ureterolithiasis is FT due to the dilation and spasm of the ureter from transient obstruction as the stone passes from the kidney to the bladder . The preThe urinalysis is the investigation most commonly ordered in patients with presumptive diagnosis of RC and reveals hematuria in 90% of patients with stones. On the other hand, one-tenth of patients with RC would not exhibit hematuria . One retAdmission times in the current study suggest that the weather affects the frequency of referrals with RC. This is due to dehydration in hot weather from increased perspiration resulting in concentrated and acidified urine. These changes could lead to crystallization with a higher likelihood to form stones. There are concrete data reporting higher incidence of admissions due to RC in hotter climates and in summer ,9. ThereThe current data also showed that most patients visited the ED in the morning hours. According to anecdotal evidence people are more at risk of renal colic during the night. Nonetheless, recent data suggested a circadian variability for the occurrence of renal colic, with a pattern characterized by a morning peak, independent of gender and presence or not of demonstrable kidney stones ,14. ManfThe data derived from the present sample showed the lowest incidence of admissions with RC on Sundays, which is difficult to interpret. Engagement with other activities and/or consumption of larger amounts of liquids might be responsible for the decreased rate of referral for holiday makers.When faced with the patient who has symptoms consistent with acute RC, the physician must decide if the patient needs emergent imaging. It can be discussed that the physicians underutilized the radiological investigations to diagnose RC in the current study when compared to literature data.CT is generally the preferred imaging modality to diagnose renal colic. Ultrasound is preferred in pregnant women to minimize radiation exposure in the western world . Brown cAlthough RC is a common ED presentation for which the emergency physician has no guidelines in terms of diagnosis and management. Physicians usually perceive presumptive diagnoses sufficient to start treatment. There is no exact pattern to guide the art of ordering laboratory and radiological investigations, with resultant variations in approach to patients. Patients with atypical presentation patterns stay longer in the ED and are likely to undergo additional tests in management.


The necessity to fight against cancer pain has only recently become a priority. In 1996 a working group, set up by the French National Federation of Cancer Centres , published clinical practice guidelines for pain management in adult and paediatric patients with cancer (Société d'Etude et de Traitement de la Douleur) French section of the International Association for the Study of Pain (IASP) subgroup on cancer pain).All patients have the right to expect to receive the best therapeutic means available to reduce their suffering. Recent evaluation of the French ministerial 3-year plan for the fight against pain by the French Society of Public Health , pain evaluation, the use of coanalgesics and pain management requiring specialist teams, will be covered in the updates currently being developed from the original document published in 1996  with an indication of the level of evidence. These recommendations help clinicians to select an appropriate option. Thus, clinicians can make choices for the management of patients using this information and taking into consideration local circumstances, skills, equipment, resources and/or patient preferences. The adaptation of the SOR to the local situation is allowable if the reason for the choice is sufficiently transparent and this is crucial for successful implementation. Inclusion of patients in clinical trials is an appropriate form of patient management in oncology and is recommended frequently within the SORs, particularly in situations where only weak evidence exists to support a procedure or an intervention.When all the members of the working group agree, based on the best available evidence, that a procedure or intervention is beneficial, inappropriate, or harmful, it is classified as a ‘Standard’, ‘Option’ or ‘Recommendation’ is indicated using a classification developed by the FNCLCC based on previously published methods. The level of evidence depends not only on the type and quality of the studies reviewed, but also on the concordance of the results (The type of evidence underlying any ‘ in 1986 .http://www.fnclcc.fr). A summary version was prepared in French  based on the full text version, and this is the English version of that summary.The integral version of this document was peer reviewed by independent experts, and their comments were taken into consideration in the preparation of the final document. The SOR guidelines are considered to be validated when the members of the working group give their agreement for publication. This integral version is available on the FNCLCC web site . In addition to the criteria used to choose the appropriate treatment , an understanding of the physiopathological mechanisms of the pain is essential .oral drug administration;drug administration at regular intervals;drug administration conforming to the three-step WHO ladder ;personalised administration;constant attention to detail.The WHO analgesic ladder is used to classify three levels of pain as summarised in Figure 1The planned treatment should be written down and explained to the patient. It should anticipate breakthrough pain and side effects. It should be re-evaluated regularly .The timing of progression from one step of the therapeutic ladder to the next is dependent on the duration of action of the analgesic and the intensity of the pain .Two products of the same pharmacological class, with the same kinetics , should not be prescribed together .Coanalgesics can be used concurrently at each level in the WHO analgesic ladder .The prescription of strong opioids as first-line analgesia should be considered in patients with very severe pain .Nonopioid analgesics should be used for mild to moderate pain . Nonopioid analgesics (WHO level 1) can be combined with opioid analgesics (WHO levels 2 and 3) .Acetaminophen (1 g every 4–6 h) is recommended as first-line treatment for mild to moderate pain . The maximum dose in the French product licence is 4 g/day. Acetaminophen can cause hepatic toxicity if the daily recommended dose is exceeded. This justifies cautious use in patients with liver failure .The use of nonsteroidal anti-inflammatory drugs (NSAID) is recommended for treating inflammatory pain, particularly bone pain . NSAIDs should not be used with methotrexate . When NSAIDs are prescribed, the potential risk when used in conjunction with nephrotoxic (particularly cisplatin) or myelotoxic chemotherapy should not be ignored . If gastrointestinal symptoms develop in patients taking NSAIDs, the necessity to use an NSAID at all and/or the need for gastroscopy and/or the prescription of a proton pump inhibitor should be reviewed .COX2 inhibitors have not been evaluated in clinical trials of patients suffering from cancer pain and they are not licensed for use in cancer patients in France. Nefopam and floctafenin are not indicated as first-line treatments for chronic cancer pain .Dipyrone is not advised, except in specific situations, because of the serious, unpredictable side effects that have been reported .Based on their analgesic efficacy, opioids are classed as ‘weak’ for moderate pain (WHO level 2 — classified as prescription drugs in France) and ‘strong’ for moderate to severe pain .Opioids can be classed into three categories based on the type of action they have on receptors: pure agonist, partial agonist–antagonist or mixed agonist–antagonist. Drugs in different categories should not be prescribed at the same time .‘Weak’ opioid analgesics should be used in patients with moderate pain .Weak opioid analgesics can be used alone or in combination with a level 1 analgesic . The following products can be used: codeine, dextropropoxyphene, dihydrocodeine, tramadol . There are no absolute criteria to guide the selection of the different drugs.Tramadol should not be combined with monoamine oxidase inhibitors . Tramadol should be used with caution in patients with a risk of epilepsy and when used in combination with antidepressants .Dextropropoxyphene should not be used in combination with carbamazepine as it will induce an increase in the plasma concentration of carbamazepine .Constipation should always be anticipated in patients receiving codeine .Strong opioid analgesics should be used in patients with moderate to severe pain .Except in specific situations, oral morphine is the first-line WHO level 3 opioid of choice . Oral morphine should be given without delay to patients whose pain is uncontrolled by step 1 and 2 treatments .Morphine should be prescribed in an oral form, either as tablets or capsules of immediate-release morphine sulphate, as tablets or capsules of sustained-release morphine sulphate, or as morphine hydrochloride solution .In all patients treated previously with another strong opioid, the starting dose for morphine should be calculated using equianalgesic dose ratios .In patients receiving baseline treatment with opioids, an immediate-release formulation must be prescribed concurrently for the treatment of breakthrough or incident pain .It is advisable to be cautious by prescribing doses at the lower end of the equianalgesic dose range and providing rescue doses as needed, rather than immediately subjecting the patients to doses at the upper limit of the range .When oral administration is impossible, the preferred routes are transdermal (e.g. fentanyl), or continuous parenteral administration with patient-controlled analgesia (e.g. morphine) . The choice of dose should take into consideration equianalgesic dose ratios .The other routes of administration for morphine and the other opioids are rarely indicated. They should be used taking into consideration the benefit to risk ratio, the training of the personnel involved (including close family and friends), and the constraints of the follow-up, particularly for patients at home .Treatment with opioids  should never be stopped abruptly . No specific protocol for reducing the dose of opioids has been validated. Dose reduction should be in steps of 30–50% over about a week, depending on the clinical situation  .Although buprenorphine is used in some countries, it cannot be recommended as a WHO level 3 opioid since other opioids have become available .μg h−1 is one therapeutic option for the initiation of opioid treatment in patients with stable pain. This is appropriate for patients who do not need frequent breakthrough doses and do not have intense pain that requires parenteral dosing because of the faster onset of action. It can be useful in the following situations :oral administration impossible because of uncontrolled nausea and vomiting;risk of bowel obstruction;poor digestive absorption: fistula; short or irradiated small intestine; gastrointestinal damage following surgery; severe diarrhoea; etc.;moderate chronic renal failure (fentanyl is mainly metabolised through a hepatic route);to reduce the number of tablets in patients distressed by a large number of medications.The use of fentanyl patches at 25 Hydromorphone is indicated for patients with severe cancer pain when there is resistance or intolerance to morphine .Oxycodone is another alternative to oral morphine for the treatment of severe cancer pain when there is resistance or intolerance to morphine .Pethidine has no place as a WHO level 3 opioid since other opioids have become available .Transmucosal fentanyl should only be used to treat breakthrough pain as a complement to baseline opioid analgesia in patients with chronic cancer pain. The high cost of this treatment should be taken into consideration .The initial and subsequent dose titration (dose readjustment) of WHO level 3 opioids can be undertaken with a sustained-release preparation in combination with an immediate-release form, or with an immediate-release form only, particularly in ‘frail’ patients .At the time of initial titration, at least once-daily self-assessment (particularly for patients at home) or assessment by a health professional is necessary to judge the analgesic efficacy and to detect any side effects .There is no upper limit to the dose of a pure agonist opioid as long as the side effects can be controlled .Rescue doses should be calculated based on the daily opioid dose .Each immediate-release opioid rescue dose should correspond to 10% of the daily dose of sustained-release opioid .Patients who have uncontrolled pain can take a rescue dose every hour for up to 4 h, before consulting a physician. If pain relief is not obtained after the four consecutive doses, the patient should be reassessed, in a hospital if necessary .Outside the hospital setting, prescriptions for opioids should be written out in full on security prescription forms. All oral forms of morphine and most opioids can be prescribed for a maximum of 28 days. For injectable forms, the prescription is restricted to 7 days or to 28 days when used in an infusion system.In hospital, it is not obligatory to write the prescription on a security prescription form. In practice, the procedure will vary depending on local practice.The loss or theft of a security prescription form should be declared. In France, this declaration should be made to the departmental medical supervisory council, the regional pharmacy inspectorate as well as to the local police.All opioids have similar side effects. The ‘Standards, Options, and Recommendations’ below relate to oral morphine.There is wide inter- and intrapatient variation in the occurrence of side effects. The occurrence of side effects is not necessarily related to an overdose. Miosis is a sign of morphine usage, but it is not a sign of overdosage. The risk of overdose is low in patients with cancer pain, when they are followed-up and evaluated regularly and when they receive morphine continuously for a long period. Psychological dependence is rare in patients with cancer.Tolerance and physical dependence are not problems in patients treated with oral morphine for cancer pain. The prescription should be uninterrupted. The coprescription of an opioid receptor agonist and an antagonist should be avoided to prevent physical dependence. Drowsiness occurs principally during the treatment titration phase and usually disappears within a few days. In patients with persistent or recurrent drowsiness, the presence of metabolic disorders or potentiation by other drugs should be considered . However, if the morphine is found to be the cause, its dose should be reduced or the drug changed (rotation) . Dose reduction should be preferred if the pain is well controlled .With the exception of constipation, other side effects tend to disappear in the first few days or weeks of treatment with oral morphine. The patient should be informed about the possibility of side effects, particularly the most frequent: constipation, nausea, drowsiness .A laxative, to prevent constipation, should be prescribed during the treatment period and this should be associated with advice on diet and hydration .In patients with nausea and vomiting during treatment, other possible causes should be excluded first. If this persists, an antiemetic should be prescribed for a few days .There is no contraindication for the prescription of opioids in patients with asthma and/or respiratory failure .in the presence of very unstable, intense pain, preference should be given to intravenous or subcutaneous patient-controlled analgesia ;in other situations (stable and/or moderate pain), rotation and/or intravenous or subcutaneous patient-controlled analgesia are possibilities .In patients receiving oral morphine who have resistant side effects, the options are either to change the administration route or to change the opioid :Opioid rotation is defined as the substitution of one opioid by another and is justified if this results in an improved benefit to risk ratio. The main indication for opioid rotation is the occurrence of resistant side effects , despite adequate symptomatic treatment  .Another indication for opioid rotation is the rare occurrence of resistance to opioids, defined not only by an absence of efficacy, but also by an absence of side effects despite a rapid increase in opioid dose .Opioid rotation is possible between all the pure agonists: morphine, fentanyl, hydromorphone, oxycodone .There are no validated criteria to guide drug selection when undertaking an opioid rotation, apart from the individual precautions for use of each drug and the relative contraindications for each individual opioid .The occurrence of side effects in patients in whom the dose is increased does not always necessitate opioid rotation .Opioid rotation should take into consideration equianalgesic doses, but it is always advisable to favour safety over rapid action by using the lowest value of the conversion range .When administering opioids parenterally, the physicochemical compatibility with all other drugs needs to be taken into consideration, as well as the risk of side effects arising from the combination .In the event of metabolic failure, particularly liver or renal, the same precautions should be taken for WHO level 2 and 3 opioids .selection of opioids taking into consideration their preferential metabolic pathway and active metabolites;administration of oral or parenteral immediate-release forms;administration of lower doses (much lower doses may be appropriate depending on the extent of the metabolic failure);cautious titration taking into consideration the efficacy and duration of action of the first dose to calculate the subsequent doses and intervals. After a few days of a stable dose, it may be possible to consider using a sustained-release formulation with adjustment, if necessary, of the rescue dose.In the event of metabolic failure, opioids should be prescribed with caution taking the following into account :Rapid or immediate release formulations should be used initially in patients with a short or irradiated small intestine . In elderly patients, lower doses and/or longer intervals between the doses is recommended. Dose titration, following the above rules, will facilitate pain control .Overdosage with oral morphine, and with opioids in general, is characterised mainly by increasing drowsiness. This is accompanied by respiratory failure, seen as respiratory depression and an increased expiratory pause (risk of apnoea).−1) principally involves stopping opioid treatment, stimulating the patient, oxygen therapy, and the injection of an opioid-antagonist . Constant surveillance is required. Transfer to a medical intensive care unit may be necessary, particularly if the patient is at home .Treatment of severe respiratory depression (respiratory frequency less than about 8 minprepare an ampoule of 1 ml (0.4 mg) diluted to 10 ml with a 5% saline or glucose solution;−1. This titration aims to eliminate the respiratory depression, but not the analgesia;give an intravenous injection of 1 ml every 2 min until the respiratory frequency increases to 10 mininfuse two ampoules diluted in 250 ml over 3–4 h, repeat if necessary, depending on the respiratory frequency and taking into consideration the elimination time of the drug responsible for the overdosage.In the absence of a published, validated administration protocol for naloxone, the following protocol is recommended :In other situations of overdosage, a ‘therapeutic window’, adapted to the drug's half-life and the intensity of the symptoms, should be identified .If in the slightest doubt, the patient should be referred to an anaesthetist for supervision of treatment and follow-up .


Background and purpose The degree of lumbar lordosis and reduced lumbar mobility are regarded as important clinical features in patients with low back pain, and in lumbar disc herniation A more stiff back preoperatively in a proportion of patients has been shown to be associated with sequestered disc herniation. The main aim of this study was to investigate whether there was any correlation between lumbar lordosis and flexion on the one hand in patients with lumbar disc herniation who were scheduled for surgery, and postoperative pain and disability on the other. Our second aim was to determine the patterns of postoperative improvement in pain, perceived disability, and flexion/lordosis for 2 years after surgery.Methods Pain (VAS), disability (DRI), lumbar flexion and lordosis (Debrunner's kyfometer) were measured pre- and postoperatively in 80 patients who underwent microscopic lumbar disc surgery.Results Patients with preoperative hyperlordosis had more severe pain and more disability postoperatively than patients with hypolordosis. The level of pain did not change much from 2–6 weeks postoperatively until 2 years, while the perceived disability did not reach a steady state until 6 months after surgery.Interpretation Patients with a stiff and flat back have a good prognosis after lumbar disc surgery, and in most cases the pain will reach the 2-year level during the first 2–6 weeks, while the physical restoration measured by the lumbar flexion and lordosis, and the perceived disability, will continue to improve over the first 6 months after surgery. The degree of lumbar lordosis and reduced lumbar mobility are regarded as important clinical features in patients with low back pain, and in lumbar disc herniation. For example, the range of motion of the lumbar spine has been shown to be predictive of the type of disc herniation found at surgery. Those with a stiff back preoperatively was associated to have a sequestered disc herniation. Also, a subset of patients with sequestrated hernias, who had a good clinical outcome, increased both their lumbar flexion and their lordosis postoperatively . In addiThe main aim of this study was to investigate any correlation between the degree of lumbar lordosis/flexion in patients with lumbar disc herniation who were scheduled for surgery, and postoperative pain and perceived disability. Our second aim was to determine at which time point after surgery the 2-year results can be predicted.The study population consisted of 80 patients (44 men) who underwent microscopic lumbar disc surgery to determine the effect of peroperatively administered corticosteroids from October 1994 through November 1998 . The incThe mean age was 42 (18–65) years. The median duration of sciatica was 4.5 (0–12) months and the median duration of back pain was 5 (1–24) months.Pain was assessed by the patients on a visual-analog scale ranging from 0 (no pain) to 100 (worst pain possible) documenting pain just now (VAS-N) and worst pain during last week (VAS-W). Impairment was assessed with the Disability Rating Index (DRI) , which cWe used the Debrunner's kyphometer ; this has been tested by Öhlen et al. (1989a), who found a mean standard deviation of 2.7° for lordosis and 3.6° for lumbar flexion in their analyses of variance. We measured the lumbar lordosis between T11-T12 and S1-S2. The degree of lordosis is read directly on the instrument. The patient was told to stand relaxed and then to bend forward as much as possible. The degree of flexion is the difference between the value at the starting position and that at the maximum forward bending, in absolute numbers.We dichotomized the patients based on lumbar flexion  into hypo- and hyperflexion, and in the same manner based on lordosis into hypo- and hyperlordosis. The median was used as a cut-off value: a patient with a more negative value than the median of lordosis was categorized arbitrary as having a hyperlordosis, and a patient with a more positive value (closer to zero) was categorized as having a hypolordosis.Severe pain was defined as VAS-W or VAS-N of more than 54 mm on the VAS scale according to the study of Preoperatively, the mean pain measured as VAS-N was 51 (SD 25) and as VAS-W it was 82 (SD 20). The mean DRI was 69 (SD 17). 91% of patients had a positive Laségue's sign and 25% had positive crossed Laségue's sign.There was one drop-out because of such severe pain preoperatively that the patient could not perform standing and flexion maneuvers. The median of lordosis in the remaining 79 patients was –20º (–42 to 30).The median of flexion in the same 79 patients was 24º (0–76). Patients with higher values than the median were categorized arbitrary as having a hyperflexion, and patients with lower values were categorized as having a hypoflexion.Preoperatively, a somewhat higher proportion of patients with hyperlordosis had severe pain (51% VAS-N) compared to patients with hypolordosis 34% VAS-N), while VAS-W and DRI were about the same –3. Simil4% VAS-N,Neither the preoperative degree of flexion (p = 0.8) nor lordosis (p = 0.5) was statistically significantly associated with severe pain postoperatively . The staThere was a tendency for patients with hypolordosis preoperatively to have less severe pain postoperatively than patients with hyperlordosis  . The difA lower proportion of patients with preoperative hypolordosis compared to patients with hyperlordosis had DRI > 40 postoperatively  . No statIt may be concluded that level of pain did not change much between 2–6 weeks postoperatively and 2 years, while the perceived disability did not reach a steady state until 6 months after surgery –3. The pIn 6 patients, we found the following complications. There was 1 discitis 6 months postoperatively, which was successfully treated with antibiotics. There were 3 relapses of disc herniation (1 of these patients was operated on 10 months after the primary surgery). 1 patient received a herniation at a new level but had no further surgery. 1 patient developed a post-discectomy syndrome and went through a fusion 20 months after the disc surgery. According to the study design, the analyses included all these patients.We found that a stiff and flat back preoperatively is associated with a good outcome 2 years after lumbar disc surgery. One explanation might be that this lumbal configuration is one way to diminish the mechanical pressure from the herniated disc . To achiThe pattern of reduction in pain after surgery indicates that a steady state will be reached in the period between 2 and 6 weeks, somewhat earlier than shown by Measurement of pain in 2 ways (VAS-N and VAS-W) did not give identical results, but the tendency was the same. One explanation for this discrepancy might be that VAS-W estimates the pain in a more comprehensive way, similar to DRI, while VAS-N describes the daily variation in pain. In order to analyze pain (VAS) and disability (DRI) as ordinal data, as recommended by some authors  we stratWe found a pattern of continuous improvement in the degree of flexion and in restitution of lordosis. This finding disagrees somewhat with the results of One weakness of our study was that the data was collected from a study designed for another purpose. Despite this we believe that it is of clinical interest to describe the pattern of the patients suffering from disc herniation.


Pain is a common condition among prehospital patients. The present study is designed to determine whether adding low-dose ketamine as additional analgesia improves the pain/nausea scores and hemodynamic parameters compared to morphine sulphate alone among patients with bone fractures.Prospective, prehospital clinical cohort study. Twenty-seven patients were included with acute pain. Eleven patients received morphine sulphate 0.2 mg/kg (M-group) and 16 patients received morphine sulphate 0.1 mg/kg combined with 0.2 mg/kg ketamine (MK-group). Scores for pain, nausea, sedation (AVPU) and the haemodynamic parameters (systolic blood pressures (BP), heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded at rescue scene before the start of analgesia and subsequently to admission at hospital.P < 0.05). All patients were Alert or respond to Voice and the results were similar between the groups. One patient versus 4 patients reported nausea in the M- and MK-group, respectively, and 3 patients vomited in the Mk-group (ns).Mean treatment time 46 ± 17 minutes in the M-group and 56 ± 11 minutes in the MK-group, respectively (ns). Mean doses of morphine sulphate in the M-group were 13.5 ± 3.2 mg versus 7.0 ± 1.5 mg in the MK-group. The mean additional doses of ketamine in the MK-group were 27.9 ± 11.4 mg. There were significantly differences between the M- and the MK-group according to NRS scores for pain (5.4 ± 1.9 versus 3.1 ± 1.4) and BP (134 ± 21 mmHg versus 167 ± 32 mmHg) at admission at hospital, respectively (We conclude that morphine sulphate with addition of small doses of ketamine provide adequate pain relief in patients with bone fractures, with an increase in systolic blood pressure, but without significant side effects. In Sweden since 2005, there is a requirement of at least one licensed nurse per emergency ambulance. It appears in the skill description of nurses in Sweden, that specialised ambulance nurses must have extended knowledge in medicine and nursing care . A speciPain is a common condition among prehospital patients. A literature review 2008 by Thomas and Shewakramani confirmed that there is evidence supporting the safety of prehospital analgesia, however they also conclude that different providers should assess available information to further improve pain relief . AnalgesDrug options generally available in the prehospital area include morphine, fentanyl, tramadol, ketorolac and ketamine . For simThe present study is designed to determine whether adding low-dose ketamine as additional analgesia improves the pain/nausea scores and hemodynamic parameters compared to morphine sulphate alone in a prehospital setting among patients with bone fractures.n = 11), and the other group MK (n = 11) received morphine sulphate plus ketamine. To possibly detect other (not known-) effects in the MK-group an extra 5 patients were included in this group . Exclusion criteria include the inability to use the rating scale, long-term use of opioids, history of chronic pain, history of/or acute myocardial infarction and unconsciousness. Every five minutes monitoring includes pulse oximetry, automated blood pressure, heart rate (HR), breathing frequencies (AR) and lead II electrocardiogram. The breathing frequencies were measured during 60 seconds every five minutes.Following ethics committee approval this study was carried out in (Region of Skane) southern Sweden, for the period of spring and autumn 2008. Study design was a prospective, clinical cohort study with a random inclusion. Patients with bone fractures were randomly assigned to one of two treatments (11 patients in each group), to receive morphine sulphate intravenously in M-group  Numeric Rating Scale (NRS) was used for pain and nausea assessment . In all patients, when the NRS scores for pain were four (≥ 4) or greater, a standardized (0.1 mg/kg) loading dose of morphine sulphate was given. Subsequently (every five minutes), if patients still report NRS scores four or greater, the patients in the M-group received a supplementary dose of morphine sulphate to a total dose of 0.2 mg/kg. In the MK-group the patients received 0.2 mg/kg ketamine doses instead of the supplementary dose of morphine sulphate in the M-group, to maintain NRS scores below four.Scores for pain, nausea, sedation (AVPU) and the haemodynamic parameters (systolic blood pressures (BP), heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded at rescue scene before the start of analgesia and subsequently to admission at hospital.During the evaluations of the pain/nausea scores, the nurses documented if the treated patients could respond adequately. This was done using a 4- point sedation scale  . TreatmeP < 0.05 is considered statistically significant [The results are presented as mean, standard deviations (SD), median and quartiles. Demographic data were analysed using parametric t-test. Pain and nausea scores were analysed using non-parametric test (Mann-Witney) and sedation, nausea and vomiting scores were analysed using Chi-Square tests. An initial power analysis showed that with a clinical relevant difference in NRS-scores of 1 for pain, with a SD of 0.75, reaches a power-value of 0.8 with 9 patients included in each group against a p-value of 5%. The data collection included 27 patients, 11 patients in the M-group versus 16 patients in the MK-group. Demographic data, type of fractures and treatment times are shown in Table P < 0.05)  is satisfying since the Swedish Association of Anaesthesia and Intensive care (SFAI) has set a benchmark that no patient should have to experience pain estimated to NRS ≥ 4. Equally frustrating is the M-group NRS values at admission to hospital. Since the maximum dose morphine sulphate per kg body weight was given  and led to a NRS value at arriving to hospital of 5.4 ± 1.9, this indicates that these patients with bone fractures are delivered to hospital with moderate to severe pain. This cannot be considered acceptable in modern ambulance care. According to the American Pain Society's (APS) Guidelines for the Treatment of Pain, each patient should receive individual optimal doses of pharmacological pain relief [Heart rate, SpOn relief . The resThis study also demonstrates a significant difference in blood pressure between the times of initial treatment to admission to hospital Table . This inThere are some limitations in the present study. First, if the study had been blinded it could have increased the strength of the results. Second, some findings may be due to the given doses and time intervals. However, we believe that the doses are adequate due to previous experiences from emergency care in patients with bone fractures. Third, the sample size might be questionable. Not according to the described power analysis but the limited number of patients might not be sufficient in arguing about unknown safety issues combining the two drugs. Finally, this study does not evaluate whether adding an antiemetic can mitigate the side effects of nausea and vomiting. This question together with the limitations mentioned above should stimulate further studies in this field.We conclude that morphine sulphate with the addition of small doses of ketamine provide safe adequate pain relief in patients with bone fractures, with an increase in systolic blood pressure, but without significant side effects.The authors declare that they have no competing interests.PJ made substantial contribution to conception and design to the study. PK participated in data analysis and interpretation. AJ made statistical analysis and substantial contribution to conception and design to the study. All authors read and approved the final manuscript.


Chronic abdominal pain is a difficult complaint. It leads to evident suffering and disability, both physically and psychologically. Many diagnostic and therapeutic procedures have been described in literature, but with little proof or evidence of success. Laparoscopy is one of the modalities that could be of benefit in such cases. We aim to evaluate the diagnostic and therapeutic value of laparoscopy in cases with chronic abdominal pain.Thirty patients with chronic abdominal pain were included in this prospective descriptive cross-sectional study. The pain in all patients was of unclear etiology despite all the investigative procedures. All patients were subjected to laparoscopic evaluation for their conditions. The findings and outcomes of the laparoscopy were recorded and analyzed.The most common site of pain was the periumbilical region (30%). A definitive diagnosis was made in 25 patients (83.3%), while five patients (16.7%) had no obvious pathology. Adhesions were the most common laparoscopic findings (63.3%) followed by appendiceal pathology (10%), hernia (3.3%), gall bladder pathology (3.3%), and mesenteric lymphadenopathy (3.3%). Postoperatively, pain relief was achieved in 24 patients (80%) after two months.Laparoscopy is an effective diagnostic and therapeutic modality in the management of patients with chronic abdominal pain. Chronic abdominal pain is a common disorder both in general practice and in hospitals. Although patients with this type of pain may have undergone numerous diagnostic workups, including surgery, their pain remains a challenge to all known diagnostic and treatment methods. After all, more than 40% of the patients presenting with chronic abdominal pain had no specific etiological diagnosis at the end of their diagnostic workup.–4 Chroni7915423Between February 2008 and January 2009, a total number of 30 consecutive patients with chronic abdominal pain were enrolled in this prospective descriptive cross-sectional study. They were recruited from the Outpatient Clinic of the Surgery Department, Suez Canal University Hospital. Ismailia, Egypt. After approval of our Ethics Committee, all the patients underwent laparoscopic surgery for evaluation and management of their chronic abdominal pain. We defined chronic abdominal pain as a continuous or intermittent abdominal pain with daily intake of analgesics, and a duration of at least three months.26In all the patients, the pain was of unclear etiology, despite physical, laboratory, and radiographic evaluation. The patients who presented with acute abdominal pain were excluded from the study. Also patients with known abdominal malignancy, patients being treated by psychiatrists, and patients under the age of 18 years were excluded.All of the studied patients were subjected to a complete preoperative evaluation through a medical history and an abdominal examination to find out if there were any organic diseases of the alimentary tract or the abdomen. Special concern was given to any past history of abdominal operations. Associated symptomatology, such as vomiting, fever or abdominal distention, were noted and recorded. Routine preoperative laboratory investigations including coagulation profile and complete blood count were performed. A total of 57 imaging studies (excluding plain films) had been done before laparoscopy, including 27 abdominal ultrasounds, 15 computed tomographies, (CT), 10 barium enemas, and five upper gastrointestinal endoscopiesThe procedure was entirely performed with the patient under general anesthesia. If there was a previous upper midline incision or massive intra-abdominal adhesions were suspected, the Veress needle was passed through the abdominal wall in an area with no scars, most often in the left upper quadrant of the abdomen, a few centimeters below the costal margin. After establishment of the pneumoperitoneum, a standard three-trocar technique was used . A fourth 5-mm trocar was inserted in a few cases. The whole abdominal cavity was inspected carefully starting from the liver, gallbladder, anterior surface of the stomach and spleen. With fine smooth graspers, these structures could be touched safely and elevated for further inspection. The small bowel was examined using these atraumatic graspers. It was inspected thoroughly from the ligament of Treitz to the ileocaecal valve, keeping in mind the fact that the loops with the large bit had to be grasped as much as possible to avoid the pinpoint fixation of the bowel with its perforation risk. The colon including the appendix was inspected in the same manner as the small bowel. Finally, the gynecological organs and peritoneal surfaces were inspected. If adhesions were seen between the intestinal loops and the abdominal wall or between the abdominal organs, they were dissected with a scissors in a vast majority of patients. Electrocautery was used mainly for hemostasis and as a dissection technique in few cases. The dissection was made close to the abdominal wall to avoid injury to the bowel loops. Other laparoscopic procedures such as appendectomy, cholecystectomy, hernia repair, and biopsies were performed according to the patient’s condition.After the laparoscopy, postoperative hospital stay was recorded. Standard diclofenac sodium 75 mg was used for postoperative pain relief. All the patients were re-evaluated after two months, six months, and one year. The pain in the late postoperative period was classified into: worse, unchanged, less pain, and disappearance of pain. Less pain and disappearance of pain were referred to as positive outcomes, while unchanged and worse pains were referred to as negative outcomes.t test was used to test the significance of difference for quantitative variables, while Chi Square and Fisher’s exact tests were used to test the significance of difference for qualitative variables. A probability value  < 0.05 was considered statistically significant.Gathered data were processed using the SPSS version 15 . A Student The studied patients were in the age group ranging from 20 – 68 years, with a mean age of 36 years. More than half of the patients studied were females (60%). The mean duration of pain was nine months with the range of duration from three to fifteen months. The most common site of pain was the periumbilical region (30%) followed by the right lower abdominal quadrant (23.3%). Twenty patients were using either non-steroidal drugs or pain killers to relieve the pain, and six patients were using proton pump inhibitors. Seventeen patients (56.7%) had undergone at least one previous surgical abdominal procedure. All patient characteristics are summarised in The average length of the operative time was 58.7 minutes with the range from 30 to 120 minutes. There were no cases converted to open procedures. Out the 30 patients with chronic abdominal pain, a definitive diagnosis was established in 25 patients (83.3%), while no identifiable cause could be reached in five patients (16.7%).The most common laparoscopic findings were adhesions (63.3%). Other findings included appendiceal pathology (10%), hernia (3.3%), gall bladder pathology (3.3%), and mesenteric lymphadenopathy (3.3%). All patients with adhesions had undergone previous abdominal surgery, except for two patients who had local adhesions of unknown origin. Three patients showed appendiceal pathology; one of them showed adhesions from the appendix to the adjacent structures and the other two showed thickened appendix and their pathology revealed evidence of chronic appendicitis. Other pathological diagnoses such as small ventral hernia, chronic acalcular cholecystitis, and multiple enlarged mesenteric lymph nodes were found in one patient. Laparoscopic management included adhesiolysis (19), appendectomy (3), hernia repair (1), cholecystectomy (1), and lymph node biopsy (1). Five patients had no interventions performed.Postoperative hospital stay ranged from two to nine days with a mean of 3.6 days.In most cases no postoperative complications had been reported except in five cases (two cases showed bleeding and three cases showed infection). The bleeding could be dealt with through electrocautary and postoperative transfusion of packed cells with no necessity for laparotomy, while the wound infection responded well to oral antibiotic and daily dressing.During the time of follow up, all patients were re-evaluated for pain. After two months, positive outcome (less pain or disappearance of pain) was achieved in 24 patients (80%), in 21 patients (70%), after six months, and in 19 patients (63%) after one year; while negative outcome (unchanged or worse pain) was noted in six patients (20%) in the first two months, in nine patients (30%) after six months, and in 11 patients (27%) after one year .Chronic idiopathic pain syndromes are among the most challenging and demanding conditions to treat across the whole age spectrum. Potentially it can be unrewarding for both the patients and the medical team. Studies All patients included in the study had chronic abdominal pain, and they were subjected to laparoscopic evaluation after exclusion of all organic causes of the pain by radiographic and laboratory tests. Also when abdominal wall pain was suspected, injections of bubivacaine were administered into the trigger-points in 12 patients. The study confirmed that in this difficult patient group, laparoscopy could safely identify abnormal findings and can improve the outcome in a majority of cases.A majority of patients had undergone previous abdominal surgery, and not surprisingly, in a majority, adhesions were found. However, a significant number were found to have a variety of other conditions to which their pain could be attributed, while a less number were found to have no clear pathology, during laparoscopy. The overall outcome in this series was positive; most of the patients found significant relief from their chronic pain, postoperatively.The use of laparoscopy in patients with ill-defined chronic abdominal pain remains controversial. While we418et al.[et al.[Whether laparoscopic adhesiolysis is preferable to laparotomy or not is a matter of debate. Some authors believe et al. have foul.[et al. have fouUnlike Salky and Edye, we have 419We found that in a selected patient group, laparoscopic evaluation of chronic abdominal pain is usually associated with a positive outcome (80%) in terms of less or no pain, after two months of laparoscopy, and in 70 and 63% of the patients, after six months and one year, respectively. This finding is justified in many previous studies,2132 howe2123In conclusion, laparoscopy has an effective diagnostic role in evaluating patients with chronic abdominal pain, in whom conventional methods of investigations have failed to elicit a certain cause. The therapeutic value of laparoscopy is also accepted and appreciated.