The Ilioinguinal/iliohypogastric nerve block has been shown to significantly decrease opioid analgesic requirements and side effects after inguinal herniotomy. We compared the effect of pre-incisional field block with 0.25% bupivacaine and post-incisional wound infiltration with 0.25% bupivacaine for postoperative pain control after inguinal herniotomy.This was a randomized controlled double blind study in 62 ASA I and II children aged 1-7 years scheduled for inguinal herniotomy. They were assigned to receive either pre-incision field block (group I) or post-incision wound infiltration at the time of wound closure (group II). The pain score was assessed in the recovery room using mCHEOPS score and VAS or FLACC score at home by the parents for 24 hours.The mean pain scores during the 2 hour stay in the recovery room, at 12 and 18 hours at home were similar in both groups, p > 0.05. However, the mean pain scores were significantly lower at 6 hours at home in group I (1.22 ± 0.57) than in group II (1.58 ±0.90), p <0.001, but significantly higher at 24 hours at home in group I (3.29 ± 0.46) than in group II (2.32 ± 0.24), p = 0.040. There was no difference in mean paracetamol requirement, and in the number of patients who required paracetamol for pain relief at home in both groups, p > 0.05.We have demonstrated that both pre-incisional ilioinguinal/iliohypogastric field block and post incisional wound infiltration provided adequate postoperative analgesia for 24 hours after inguinal herniotomy. Ilioinguinal/iliohypogastric field block appears to be the technique of choice in many paediatric institutions in Europe and America because it is usually effective with minimal risk, and low cost . The supUncontrolled pain can induce tachycardia, raised blood pressure, insomnia and behavioural disorders . In viewThe use of pre-emptive analgesia may involve pre-incisional nerve blocks, injection of local anaesthetic agents to the site of the incision or regional blocks like caudal block. This study investigated the effectiveness of pre-emptive analgesia using pre-incisional field block for herniotomy with 0.25% plain bupivacaine compared with post incisional wound infiltration with 0.25% plain bupivacaine on the pain scores in paediatrics patients in the immediate postoperative period.This was a prospective, double blind randomised controlled trial in 62 American Society of Anesthesiologist (ASA) physical status I or II subjects aged 1-7 years scheduled for ambulatory inguinal herniotomy. The institution Human Research Ethics Committee approval and informed consent were obtained from subject’s parents/relatives. The recovery room nurse was educated on the use of the modified Children’s Hospital of Eastern Ontario Pain Scale (mCHEOPS) . The parThe patients were randomly allocated by blind balloting to one of the two groups by using a sealed envelope technique. Group I received 1 ml/kg of 0.25% bupivacaine 20 minutes before surgical incision, and equal volume of normal saline infiltration at skin closure. Group II received 1 ml/kg of normal saline 20 minutes before surgical incision and 1 ml/kg of 0.25% bupivacaine at skin closure. The surgeon who was blind to the type of solution in the syringes performed the field block.Patients with sickle cell disease, liver, renal, respiratory or cardiovascular diseases, those on chronic analgesic therapy, ASA III and IV and BMI > 85 percentile for age and sex were excluded from the study.Routine electrolytes/urea/creatinine, haemoglobin electrophoresis and packed cell volume were done at the surgical outpatient unit at least one week before surgery. Preoperative assessment was conducted on the morning of surgery; fasting guideline was 6 hours to solid food, 4 hours to breast milk and 2 hours to clear fluid. No premedication was administered. The weight and height were taken on the morning of surgery.2) was measured after insertion of laryngeal mask airway (LMA).On arrival in the theatre, multiparameters monitor (Datex Ohmeda Cardiocap 7100) Metropolitan Medical Services of NC. Inc. 15 Westside Drive, Asheville North Carolina] was attached. Intraoperative monitoring included precordial stethoscope, non-invasive blood pressure, and electrocardiogram (ECG), heart rate and oxygen saturation. End tidal carbon dioxide  incremental doses in 100% oxygen via Mapleson D Bains Circuit) for patients > 25 kg or Mapleson F breathing circuit (Jackson Rees modification of the Arye T piece), Flexicare, Mid Glamorgan; CF45 4ER UK, for patients < 25kg weight. When anaesthesia was considered adequate, intravenous (IV) access was secured with a 20-22 gauge cannula, and the airway was secured with an appropriate sized LMA.The first infiltration was done after confirming adequacy of ventilation. The attending anaesthetist was responsible for preparing and labelling the solutions for infiltration. The surgeon was blinded to the type of solution in the syringe.The field block was performed using a 21G hypodermic needle, the local anaesthetic agent was divided into four equal volumes of 5 ml each. Four sites were infiltrated viz 1-2 cm medial to the anterior superior iliac spine and to the external oblique aponeurosis, 1.5 cm above the midpoint of inguinal ligaments, the subcutaneous tissue from the pubic tubercle towards the umbilicus and the subcutaneous tissue along the line of the skin incision.Anaesthesia was maintained with Isoflurane (1-2.5%) in 100% oxygen which was adjusted to achieve stable intraoperative haemodynamic measurements. All patients received intravenous paracetamol 15 mg/kg and diclofenac 1 mg/kg 20 minutes after the field block was performed before surgical incision. The administration of intravenous fluids in the operating room followed standard guidelines for paediatric patients.At the end of surgery, the second infiltration was performed by the same surgeon. Anaesthesia was discontinued and the LMA was removed in all patients when they were fully awake. The children were continuously monitored in the recovery room every 15 minutes for 2 hours, after which they were discharged home if they were fit for discharge. During this time, a nurse blinded to the two groups assessed the pain score using mCHEOPS on arrival in the recovery room at 0 minute and at 15, 30, 45, 60, and 120 minutes post-operatively. A score of < 6 was taken to be satisfactory pain control. A score of > 6 was taken as moderate to severe pain and IV pentazocine 0.5 mg/kg was given as the supplemental analgesia. The time of first analgesic requirement was noted. Parents were instructed on how to assess pain using VAS or FLACC scales at home every six hours for 24 hours after discharge. Oral paracetamol 15 mg/kg was given at home for severe pain (> 6) in ages 4-7 years and those between ages 1-3 years who refused food and could not be consoled following crying. The frequency of use of additional paracetamol, and the total analgesic used at home was obtained by the researcher via a phone call.The following data were recorded: Pain scores assessed at 0, 15, 30, 45, 60 and 120 minutes in the recovery room. The incidence of vomiting, the use and timing of supplemental analgesic (pentazocine) in the recovery room, the time to first micturition and the time to first analgesic requirement.Parents were contacted the day after surgery and asked to report the following: The pain score since discharge from the hospital every 6 hours, the occurrence of vomiting, the time to first micturition and total amount of additional paracetamol given at home. The primary outcome compared the effect of pre-emptive analgesia of pre-incisional field block using 0.25% bupivacaine for postoperative pain control with postincisional infiltration of 0.25% bupivacaine at the time of wound closure, in patients aged 1-7 year old scheduled for elective unilateral herniotomy. The secondary outcome determined the pain scores, the time to first administration of analgesia and the frequency of administration of oral paracetamol in patients scheduled for herniotomy with pre-incisional field block or post-incisional infiltration of 0.25% bupivacaine wound infiltration. We tested the alternate hypothesis, that the pain relief obtained with pre-incisional ilioinguinal/iliohypogastric field block using 0.25% bupivacaine was significantly superior to that obtained with post-incisional wound infiltration using 0.25% bupivacaine in children scheduled for unilateral inguinal herniotomy.Data collection was done by the researcher who was blinded to the groups. Data were presented as mean ±SD, frequencies, and percentile, and the differences between the two groups were analysed using the student t-test for or chi-square as considered appropriate, p ≤ 0.05 was considered significant. All analysis was performed using the Statistical Package for Social Sciences for Windows version 17 .Sixty-two patients, (31 in each group) were recruited for the study. There was no significant difference in the mean age, weight, height, BMI duration of surgery, the time of first analgesic requirement, total dose of paracetamol consumed, and the time of first micturition between the groups . There wThe distribution of pain within 24 hours of surgery and the mean pain scores at rest after surgery in the two groups are shown in Tables The mean paracetamol consumption at home was similar in both groups; group I (316.07 ± 99.15) mg versus group II (318.52 ± 115.28) mg, p = 0.497. However, the number of patients who required paracetamol in group II (24) was less than in group I (27) though this was not significantly different, p = 0.167.There were significant differences in the number of patients who had pain between the groups at 6 and 12 hours, (p <0.05), We have demonstrated that either pre-incisional ilioinguinal/iliohypogastric nerve block or post-incisional wound infiltration using 0.25% bupivacaine were effective in relieving postoperative inguinal herniotomy pain in children. There was no significant difference in mean pain scores in the first 2 hour (mean score of both were zero) period of admission in the recovery room. We observed that the mean pain scores at home in both groups were <6, which was taken to be a reflection of satisfactory pain control. This may suggest that both techniques of analgesia were effective in the control of postoperative herniotomy pain. This is agreement with observation made by Sajedi et al.  which weIn contrast, Sajedi et al.  reportedThe mCHEOPS appears to be more complex and therefore the interpretation may be guarded, unlike the Oucher pain scale that uses a numerical scale or facial expression index.On arrival in the recovery room, none of the patients in our study experienced pain using the mCHEOPS score (score of 0) during their two hour stay. In contrast, Reid et al.  observedThe number of subjects who complained of pain in our study was significantly lower in the pre-incisional field block group than the post-incisional group. Reid et al.  in a simIn contrast to our observation, Saejdi et al.  reportedSimilarly, Dahl et al.  observedThe mean time to first postoperative analgesic requirement in this study is similar to that reported with postincisional wound infiltration after herniotomy . Unlike The mean time of micturition in our study was similar in both groups; unlike observations made with caudal block by Edomwonyi et al.  when theNone of our cohort experienced fever and wound dehiscence, a similar observation was made by like Reid et al.  the obseThe use of ultrasound guided ilioinguinal block has been reported to provide a better quality of analgesia than the standard “fascial click” method . In addiThe study has some limitations, in the pre-incisional nerve block group, there was no ultrasound available in our institution during the study period. An ultrasound guided nerve localisation technique will ensure proper identification and blockade of the ilioinguinal/iliohypogastric nerves. The nerve block and local infiltration was done by different surgeons with varied experience, this may constitute bias and increase the chance of a failed block. Similarly, variation in pain assessment by parents at home might have influenced the pain score assessment, future studies using domiciliary nurses will help to eliminate the bias.We have demonstrated that either pre-incisional ilioinguinal/iliohypogastric nerve block or post-incisional wound infiltration with bupivacaine (0.25%) was effective for postoperative pain management following paediatric herniotomy. These techniques are very simple, cost effective with minimal time taking. This seems to be the best method of pain management in children for day case surgery. When a child is playful; the parents are also satisfied physically as well as psychologically.


Post-sternotomy pain often causes patients discomfort and delays recovery. Consecutive pulmonary complications, in particular infections, as well as adverse effects of pain killers and addiction to pain killers lead to a significant increase of postoperative complication rates.In order to prevent postoperative pain and subsequently impaired inspiration enhancing the risk of pulmonary complications, sufficient analgesia is essential in patients after sternotomy. The present prospective randomized pilot study aimed at investigating the influence of Kinesio taping on the post-sternotomy pain levels.Fifty elective cardiosurgical patients at the age of 66 ± 10 years undergoing sternotomy between 09/2014 and 11/2014 at the University Hospital Duesseldorf were enrolled in the trial. All patients were randomly assigned to either group TAPE (n = 25), receiving Kinesio taping after discharge from the intensive care unit, or group CONTROL (n = 25) without any taping. In each group, two drop-outs occurred. Until discharge from the hospital, the pain level of all patients was daily assessed using a standardized pain measurement scale ranging from 0 to 10 points. Moreover, the need for additional analgesic therapy was documented.The mean hospitalization period in group TAPE was 10.1 ± 2.2 days versus 11.4 ± 4.4 days in group CONTROL. Patients treated with Kinesio tapes had significantly lower pain scale levels as compared to controls (1.7 ± 0.7 versus 3.3 ± 1.7 with p < 0.0001). The dose of administered opioids (piritramide) as well as of non-opioid analgesics (paracetamol) were significantly reduced in group TAPE . The percentage of patients presenting with unimpaired breathing amounted to 96% in group TAPE and 22% in group CONTROL (p < 0.0001).Kinesio taping seems to be a safe and promising approach to reduce postoperative pain and the dose of analgesic drugs to be administered after cardiac surgery via sternotomy. The results of this pilot study warrant a clinical trial with a higher number of participants.


Neck pain is a common musculoskeletal condition with a point prevalence of around 15 % in males and 23 % in females that often presents in physiotherapy practice.Physical therapy and/or manipulation therapy is generally the first management option for patients with mechanical neck pain. Physical therapists treat mechanical neck pain with a number of interventions including joint mobilization and/or manipulation, therapeutic exercises or education. However, manipulation of the cervical spine carries some risks. Treating the thoracic spine for neck pain is an alternative approach. Emerging evidence suggests that it may be effective for treating neck pain without the risks associated with cervical spine manipulation. A new electromechanical device has recently been developed and tested for delivering multiple high velocity, low amplitude thrust manipulations to the spine. This device incorporates both auditory and visual systems that provide real time feedback on the applied treatment. The objective of this study is to compare the short- and long-term effects of manual versus mechanically assisted manipulations of the thoracic spine for neck pain patients.A 6-month, randomized controlled trial consisting of 54 patients with acute or chronic neck pain patients will be conducted. Patients with no signs of major pathology and with little or no interference with daily activities will be recruited. Three treatment sessions with 4-day intervals will be carried out. The patients will be randomly assigned to receive either manually performed manipulations or electromechanical manipulations at the thoracic spine. The primary outcome is pain intensity as measured by the Visual Analogue Pain Rating Scale. The secondary outcome measures are neck physical disability using the Neck Disability Index, quality of life measured by the European Quality of Life 5 Dimensions 5 Levels and patients’ improvement using the Patient’s Global Impression of Change Scale.It is expected that both interventions will improve neck pain. This would be a significant finding, as thoracic spine manipulation for neck pain does not carry the same risk of injury as cervical spine manipulation. In addition, the results may provide useful information about therapeutic options for health care providers and patients for the problem of neck pain.ISRCTN88585962, registered January 2013Current Controlled Trials The online version of this article (doi:10.1186/s13063-015-0763-5) contains supplementary material, which is available to authorized users. The burden of musculoskeletal disorders is increasing rapidly, using a high percentage of health care resources . Neck paGrade I: no signs of major pathology and little or no interference with daily activities. This is frequently the caseGrade II: no signs of major pathology, but with an interference with daily activities. This occurs less frequentlyGrade III: neck pain with neurological signs or symptoms (radiculopathy)Grade IV: neck pain with signs of major pathology  Neck pain is generally described as pain perceived in the posterior region of the cervical spine. It is distributed between the superior nuchalline down to the first thoracic spinous process and may radiate into the head, shoulders, arms and chest . The TasCurrent opinion regarding the etiology and onset of neck pain and how it is best managed varies widely, and often seems to be associated with the background and beliefs of the clinician , 7. TreaAlthough cervical spinal manipulation is still recommended for the treatment of neck pain, there is a small risk of possible serious side-effects such as cervical artery dysfunction (CAD), lesions of the brain stem, Wallenberg syndrome or ischemic stroke –11. AlthPre-manipulative testing and screening procedures were introduced to minimize the risk of side-effects in cervical spinal manipulations . UnfortuWithin the last few years several intervention studies, systematic reviews, and meta-analyses have been conducted investigating thoracic spinal manipulations , 24–30. A manipulation may be delivered manually  or mechanically using spring-loaded or electromechanical devices  –35. ForcA new electromechanical device for manipulations has recently been developed, which purports to give objective feedback to the practitioner, using an audible sign (beep) Fig. . The devTherefore, the purpose of this study is to compare the effects of manually performed manipulations and electromechanical manipulations to the thoracic spine in neck pain patients. Short- and long-term clinical outcomes, such as neck pain and function and overall improvement, will be assessed.The aim of this study is to compare the short and long-term treatment outcomes for neck pain patients using an instrument-assisted mechanical manipulation with feedback versus manual manipulations of the thoracic spine.This study is a randomized trial comparing the treatment effects of manual versus instrument- assisted mechanical manipulations of the thoracic spine for neck pain patients. The study has received ethical approval from the Ethics Commission of the Canton of Zurich (2012-0248).Participants will be recruited by registered chiropractors and physical therapists in private practices in the canton of Zurich. A test group of 54 participants will be recruited based on the following inclusion criteria: 1) presence of acute or chronic neck pain, Grade I or II ; 2) agedIf and when the participant qualifies based on the above criteria and has signed the informed consent form, the recruiting chiropractor or physical therapist will inform the research assistant of their suitability for the study. The research assistant will verify the inclusion and exclusion criteria and invite the participant for the baseline assessments.There will be 3 treatment sessions and an additional training program for 6 weeks. Follow-up assessments will take place after 6 weeks, 3 months and 6 months. The 3 treatment session will always be 4 days apart. At baseline the participant will fill out the Visual Analogue Pain Rating Scale (VAS), the Neck Disability Index (NDI) and the European Quality of Life 5 Dimensions 5 Levels (EQ-5D-5 L) –45. At tBaseline measurements as stated above, will be followed by a history taking and physical examination (P/E). History taking includes questions referring to the onset, episode, nature and location, as well as factors that increase or decrease the pain, medication use, occupation, sick leave and other treatments that have already been tried. The P/E will start with a neurological screening  followed by Spurling’s test, cervical distraction test and neurodynamic upper limb test –50. ThesA clinician, who is not involved in the study, will independently conduct the randomization procedure. A block randomization (20 blocks of 4) using a computer-based randomization program will be conducted. The original randomization list will be stored in an opaque and sealed envelope not accessible to the therapist conducting the manipulations. Eighty sequentially numbered, sealed, opaque envelopes, containing the randomized group allocation will be prepared. At the time of treatment, these envelopes will be given to the therapist applying the manipulation, immediately prior to the execution of the manipulation. The patient will be unaware of the technique that will be applied, only that the technique may either be delivered manually or with an electromechanical instrument . To minimize any possible effects of expectations of treatment, each participant will be asked prior to the first treatment about their expectations regarding new and conventional treatments.To minimize performance bias, the therapist who is conducting the treatment will be kept unaware of the treatment method until the manipulation is applied. Additionally, the questionnaires that are filled out by the patient are put inside sealed, opaque envelopes. The therapist is unaware of the patient-assessed outcome. When data is entered into the database the researcher will be unaware of the associated participant due to de-personalization/anonymity of the questionnaires.Additionally, the expectations of the patient regarding the new and conventional treatments are retrieved beforehand and taken into consideration during the evaluation of the data.After the initial P/E the first manipulation will be applied to the thoracic spine either manually or by using the Impulse iQ®  and the training program, consisting of four different exercises, will be instructed.For the manually performed manipulations the patient is lying supine. The therapist’s hand is under the thoracic spine using a pistol grip (the fingers are positioned with the index finger straightened and fingers 3 to 5 flexed). The patient’s forearms are crossed in front of their chest. The force is applied against the therapist’s flexed fingers, the thenar eminence and slightly cranial to the transverse process of the caudal vertebra of the treatment segment  Figs. 3.Fig. 3HaFor the Impulse iQ®  the patient lies prone on a treatment table, with arms next to the body, in a relaxed position. Before the treatment begins, the patient is instructed that they will hear a rattling sound that indicates the thrusts conducted by the device and a beep at the end of the treatment. The Impulse iQ®  is then put onto the vertebra that has been identified as a painful segment. A double stylus and middle force setting (peak force = 200 N), as recommended by the manufacturer for the treatment of the thoracic spine, will be used . The devTraining the holding capacity of the deep neck flexors Head Lift Retraining the cranio-cervical musclesRetraining scapular muscles Eye/Head coordination After the first treatment session the patients will all be introduced to the home exercise program and asked to perform this program once a day for 6 weeks, while compliance with the home exercise program is assessed using a training journal:A detailed exercise-program may be found in Additional file The primary outcome measure is the VAS before and after every treatment, after 6 weeks, 3 months and 6 months. The VAS has shown to be a valid and reliable outcome measure –41.The VAS tries to assess a person’s pain intensity level. The patient is asked to place a mark on a 100-mm long line with the question ‘how much pain do you have at this moment’. The beginning of the line illustrates ‘no pain’ the end of the line ‘extreme pain’. To extract the data the researcher measures the distance in millimeters between ‘no pain’ and the mark set by the participant.Secondary outcome measures are the NDI, EQ-5D-5 L and the PGIC.The German version of NDI is a questionnaire to assess self-rated disability in neck pain patients. It is a short paper-pencil instrument, which is based on a similar instrument used for patients with lower back pain, the Oswestry Low Back Pain Questionnaire. It consists of ten items: for example, working and driving. Each item has a score up to 5 with a total score of 50. The lower the score the less the self-rated disability , 43.The EQ-5D-5 L is a valid and reliable self-report questionnaire that measures patient’s health status for clinical and economic appraisal using a descriptive system and a VAS , 45. TheThe PGIC is a valid outcome measure that is based on a seven-point Likert scale . The purThe sample size was calculated with the formula:2 × 152]/122 = 24.53 0.05). Secondary outcome variables will be compared using the Wilcoxon test for matched pairs including confidence intervals. Participants will be sub-grouped into acute and chronic to compare the outcomes. To analyze the outcome of the PGIC, patients will be split into 2 groups (dichotomized): improved (6 and 7) and not improved (1 to 5). With the help of logistic regression, the predicted probability of the outcome will be assessed using the PGIC as dependent variables (improved/not improved). Independent variables will be age, sex, expectations, manipulation and duration of complaints. Missing data will be analyzed using an intention-to-treat method. The data will be collected, stored and analyzed in the IBM-SPSS 22  statistics program.This trial has been approved by the Ethics Committee of the Canton of Zurich (KEK-ZH-number 2012-0248). All patients will be asked to provide written informed consent prior to participating in this study. This trial is registered at Current Controlled Trials (ISRCTN 88585962). The collected data will be locked in a secure cabinet and saved at Balgrist University Hospital for 20 years.The purpose of this study is to compare treatment outcomes for neck pain patients using manual versus instrument-assisted mechanical manipulation at the thoracic spine. For this aim, a randomized clinical trial is the appropriate study. There are already existing trials and reviews that have investigated the treatment of the thoracic spine in neck pain patients , 24–30. One of the trial’s weaknesses might be regarding blinding. We addressed this issue in different ways. To minimize performance bias, the therapist who is conducting the treatment will be unaware of the treatment method until the manipulation is applied. Additionally, the filled-in questionnaires are put inside a sealed, opaque envelop by the patient. The therapist is unaware of the outcome. When the data is put into the database the therapist will be unaware of the associated participant due to de-personalization/anonymity of the questionnaires. Additionally, the expectations of the patient regarding the new and conventional treatment are retrieved beforehand and taken into consideration during the evaluation of the data..The results of this study may provide useful information for clinicians and patients in terms of effective therapeutic options for treating neck pain patients without the risk of cervical spine manipulation. The outcomes of the research will be published in a timely manner after the completion of this studyRecruitment of study participants is currently ongoing.Written informed consent was obtained from the patient(s) for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process. Critical Care, Chanques and colleagues [In the previous issue of lleagues  evaluatelleagues  - that illeagues  and the lleagues  - and a lleagues .Assessing pain in non-communicative adult patients in the ICU must rely on the observation of behavioral indicators of pain. Selection of pain assessment tools in clinical practice must be done with rigor. Indeed, an assessment tool can be shown to be valid only for a specific purpose and a given group of respondents and context of care. All steps of scale development are important. The first step, selection of items and scale scoring, can be done by using a combination of various strategies, including an in-depth literature review, consultation of end users , and direct clinical observation and other sources. Content validation is a method of examining the content and relevance of the items that are useful for selecting or revising them. Once developed, reliability and validity of the scale use must be tested with the targeted patient group . ReliabiEvaluation of the psychometric properties of behavioral pain scales in ICU patients unable to self-report has been recently performed ,8. Of thWhat are the next steps in relation to pain assessment in the ICU? First, there is a clear need to better evaluate the impact of pain assessment and management on patient outcomes. Few studies have shown that evaluating pain was associated with positive outcomes such as a shorter duration of mechanical ventilation and ICU length of stay and reduced adverse events -11. WhetAssessing pain in non-communicative ICU patients is challenging. The BPS and the CPOT have shown the strongest psychometric properties for this purpose. These scales should be incorporated into pain management protocols to target the desired levels of analgesia in order to optimize inter-professional practices and to achieve better patient outcomes.


Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care.n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention.A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22–76 years, were randomized to intervention  contains supplementary material, which is available to authorized users. More than 50 % of patients seeking hospital care because of chest pain are diagnosed as having “non-cardiac” symptoms , 2. ManyTargeting cardiac anxiety with psychological interventions might break the vicious circle and improve patient outcomes. Patients need to evaluate the way they perceive and handle their chest pain; this can be achieved using cognitive behavioural therapy (CBT) . There iFace-to-face CBT can be effective when delivered by experts, but it is time-consuming , 28 and The study was designed as a pilot randomized controlled study and registered at Clinicaltrials.gov, no. NCT02336880. The study is reported in accordance with the CONSORT 2010 checklist of information to include when reporting a randomized trial , and who had cardiac anxiety (≥24 points on the Cardiac Anxiety Questionnaire), or fear of body sensations (≥28 on the Body Sensations Questionnaire). These cut-off scores were based on results from our earlier study [The CBT-based program contained four sessions, focusing on the behavioural aspects of CBT, intended to be completed in four weeks. The program was influenced by the intervention by Jonsbu et al.  and inclPsychoeducation has shown to be effective in the treatment of many conditions, including health anxiety and depressive symptoms , 36. TheExposure to tasks that the individual misinterprets as threatening is a central component to treat anxiety and relieve fear avoidance . ExposurPhysical Activity in the Prevention and Treatment of Diseases [The patients received psychoeducation about physical activity according to Diseases . They weThe Breathing Anchor [Breathing technique has demonstrated a positive impact on the experience of anxiety, depressive symptoms, and the thinking pattern in relation to stress, thus leading to chest pain prevention , 39, 40.g Anchor . The patThe patients were guided and supported through the program by the first author, who is a cardiac nurse with several years of teaching experience, and they received responses to their questions by email, text messages, and sometimes phone calls within 24 hours. Reminders and encouraging messages were also sent by email and text messages to motivate the patients to complete the intervention , 42. PatThe control group received usual care, meaning that they could seek healthcare within primary and secondary care settings whenever needed.Study patients were recruited using a regional care database run by the County Council of Östergötland, Sweden. A list of names of patients fulfilling the inclusion criteria was given to the first author, who contacted the patients by phone and informed them of the study. Written study information, an informed consent form, and a pre-stamped envelope were sent to patients who were interested in participation. Patients who returned a signed written informed consent form were screened for cardiac anxiety or fear of body sensations before randomization.Data were collected before randomization  and after the CBT program. All data were self-reported and collected using secure web-based questionnaires requiring both username and password for login. All questions were mandatory, resulting in no missing values.Feasibility of the study concerned recruitment and randomization of study participants for sufficient sample size, testing the study protocol, data collection, and evaluation of selected outcomes. Feasibility of the intervention, however, concerned the user-friendliness of the Internet platform, the time and amount of guidance needed to manage the program, the accessibility of the content, and the patients’ perception of the program. Feasibility data were collected after the end of the program using a self-developed questionnaire containing 18 questions and statements regarding the aforementioned parts of feasibility and how this could be enhanced.α coefficients in this study were, at baseline, 0.83 for the total scale, and 0.83, 0.87, and 0.65 for the three subscales.The Cardiac Anxiety Questionnaire was used to assess cardiac anxiety. This questionnaire comprises 18 items, each scoring between 0 and 4 points and consists of three subscales for fear, avoidance, and heart-focused attention. A sum and a mean total score can be calculated for the Cardiac Anxiety Questionnaire. For the subscales, the mean score of the items included in each subscale is preferable, since these differ in number. Higher scores indicate greater cardiac anxiety and, for the subscales, greater fear, avoidance and heart-focused attention. The Cardiac Anxiety Questionnaire has demonstrated good psychometric properties . Cronbacα coefficient was 0.92 in this study.Fear of body sensations was measured with the Body Sensations Questionnaire, comprising 17 items, each scoring between 1 and 5 points. Total score is computed as the mean value of all items, with higher scores indicating more fear of body sensations. The Body Sensations Questionnaire is reliable and valid . Cronbacα coefficient was 0.85.Depressive symptoms were measured with the Patient Health Questionnaire-9. This is a nine-item questionnaire, with items scoring between 0 and 3 points. A score of 10 or higher indicates at least moderate depressive symptoms. The Patient Health Questionnaire-9 has demonstrated good psychometric properties . In this“During the last month, how often have you experienced non-cardiac chest pain?”Chest pain frequency was determined by asking the patients the following self-developed question: U test. Mean values and standard deviations were used to report the scores of the measurements. To determine the differences between groups, Mann–Whitney U test was used to analyze mean differences in cardiac anxiety, fear of body sensations, and depressive symptoms between baseline and the end of the program. All analyses were based on intention to treat. Differences were considered significant at P < 0.05.IBM SPSS Statistics 22 was used in all statistical analysis. Non-parametric statistics were used, owing to the small sample and skewed variables. Categorical variables are described in numbers and percentages, and were analyzed with chi-square tests. Continuous variables are described in medians and ranges, and analyzed with the Mann–Whitney A total of 101 patients were assessed for eligibility . Non-participants (n = 125) consisted of 71 men and 54 women and had a median age of 68 years (range 23–98). These did not differ significantly regarding sex and age, compared with study participants.The intervention group consisted of five men and two women with a median age of 65 years (range 22–76). The control group was equal with regard to sex, and had a median age of 66 years (range 53–75). The intervention group only differed from the control group regarding number of exercise hours per week, as the intervention group exercised more hours , the participant did not become more active. Another participant who had been very active during the start of the intervention dropped out after 1.5 weeks (sessions), owing to difficulties with the technology.The study protocol was easy to follow and all patients were guided by the same person. Patients reported working between 30 minutes and 90 minutes per day on the program, with a median of 60 minutes. On average, about 22 minutes’ weekly therapist time was required to guide, support, and give feedback to each patient through the program. Two of the patients required about 35 minutes each, owing to inactivity, which resulted in repeated contacts.The program was evaluated as user-friendly, with comprehensible language, adequate and varied content , and manageable homework assignments, but could benefit from more tailored exercises and assignments. Furthermore, there was a need for some technology support, i.e. how to handle the two-factor authentication, switching between the different parts of the program, and filling in the forms.Almost all patients thought that the program had met their expectations and provided valuable knowledge and tools, and they thought it was worth the time and effort they invested in the program. Four of the patients reported that the program helped them reach their goals to a great extent. Getting reassured that their hearts tolerated physical activity made some patients less worried and anxious about their chest pain. Participation in the program, and particularly being guided and supported, motivated and empowered some patients to be active, despite cardiac anxiety. Some patients felt an obligation to complete the program because they were surveyed, which they did despite sometimes feeling tired and not in the mood. Anyway, patients were in general satisfied with the overall program and were willing to recommend it to others.Cardiac anxiety, fear of body sensations, and depressive symptoms decreased in patients in both intervention and control groups Table . There wFive patients in the intervention group reported lower Body Sensations Questionnaire scores  at the end of the program and two reported higher scores. In the control group, seven patients reported lower scores and one reported higher scores. Regarding depressive symptoms, four patients in the intervention group reported lower Patient Health Questionnaire-9 scores at the end of the program, two reported higher scores, and one did not change. In the control group, five patients reported lower scores, two reported higher scores, and one did not change. With regard to minimal significant change of five points on the Patient Health Questionnaire-9, two patient scores decreased by nine points in the intervention group, whereas in the control group, one person’s score decreased by five points.At baseline, three patients in the intervention group reported daily chest pain and two reported chest pain at least twice per week. The rest had chest pain sporadically. At the end of the program, one patient reported daily chest pain and three reported chest pain at least twice per week. The rest had chest pain sporadically. Compared with baseline, two patients had less chest pain and five did not change at the end of the program. In the control group, four patients reported daily chest pain and one reported chest pain at least twice per week, both at baseline and at the end of the program. The other patients had chest pain sporadically. At the end of the program, one patient had less chest pain, one had more chest pain, and six did not change, compared with baseline.This is the first study assessing the feasibility and effects of a short guided Internet-delivered CBT program in patients with non-cardiac chest pain. Patients perceived the program to be feasible and user-friendly, with comprehensible language, adequate and varied content, and manageable homework assignments, although some patients needed support with the technology. The program showed the potential to help patients with non-cardiac chest pain improve regarding cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain frequency, but this was not significantly different from the control group. The results of this study can contribute to the design of future interventions to test the effectiveness of Internet-delivered CBT programs in these patients.Regarding treatment and technology, our patients’ levels of knowledge, needs, and preferences varied. One participant only completed parts of the program, despite repeated phone and email contacts. Another participant had technology-related difficulties and dropped out of the program. This problem has been pointed out as one of the disadvantages with Internet-delivered treatments . More suOn average, only 22 minutes’ therapist time per week was needed to guide, support, and give feedback to an ordinary patient through the program. Other Internet-delivered CBT studies have reported feedback times of between 9 and 20 minutes , 49, 50,With regard to the effects of the intervention, some patients reported being reassured by the bicycle stress test that their hearts tolerated physical activity, which made them less worried and anxious about chest pain. This is an important finding, since modification of thoughts and behaviors can lead to decreased avoidance of physical activity, less anxiety, and also chest pain in these patients , 52. SinSince Internet-delivered CBT has demonstrated a potential to decrease anxiety, depression, and pain in various patient groups , 53, 54,Our results are comparable with results from a previous study by Sanders et al. , using aRecruitment to this study was a challenge. One of the reasons might be that patients may have considered their pain to have cardiac or other physical causes and therefore declined participation, since they perceived our intervention as too psychological and not really addressing their perceived physical cause of their chest pain, as previously reported by Sanders et al. . AdditioThe study is a pilot and based on a small sample with differences in length of chest pain experience between the intervention and control groups, although these were not significant. However, the results should be interpreted with caution. There might also have been a selection bias, since those interested in participation were more healthy and receptive to this kind of psychological treatment. Some of the barriers for participation were that some patients did not have access to the Internet or did not feel comfortable handling computers. Only pain frequency was measured. We suggest that pain intensity should be included in future studies.A short guided Internet-delivered CBT intervention was perceived to be feasible. The CBT intervention was found to decrease cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain frequency, but no significant differences were found compared with the control group. Larger studies with longer follow-up are needed to further evaluate both the short- and long-term effects of Internet-delivered CBT in patients with non-cardiac chest pain.CBT, cognitive behavioural therapy; CONSORT, Consolidated Standards of Reporting Trials


The overarching goals of treatments for orthopedic conditions are generally to improve or restore function and alleviate pain. Results of clinical trials are generally used to determine whether a treatment is efficacious; however, a statistically significant improvement may not actually be clinically important, i.e., meaningful to the patient. To determine whether an intervention has produced clinically important benefits requires a two-step process: first, determining the magnitude of change considered clinically important for a particular measure in the relevant population and, second, applying this yardstick to a patient’s data to determine whether s/he has benefited from treatment. Several metrics have been devised to quantify clinically important differences, including the minimum clinically important difference (MCID) and clinically important difference (CID). Herein, we review the methods to generate the MCID and other metrics and their use and interpretation in clinical trials and practice. We particularly highlight the many pitfalls associated with the generation and utilization of these metrics that can impair their correct use. These pitfalls include the fact that different pain measures yield different MCIDs, that efficacy in clinical trials is impacted by various factors , that the MCID value is impacted by the method used to calculate it , by the type of anchor chosen and by the definition (threshold) of improvement. The MCID is also dependent on the population characteristics such as disease type and severity, sex, age, etc. For appropriate use, the MCID should be applied to changes in individual subjects, not to group changes. The MCID and CID are useful tools to define general guidelines to determine whether a treatment produces clinically meaningful effects. However, the many pitfalls associated with these metrics require a detailed understanding of the methods to calculate them and their context of use. Orthopedic surgeons that will use these metrics need to carefully understand them and be aware of their pitfalls. Th. Th23]. There are two methods of estimating SDD/MDC which are purely statistical : SDD is There are four methods to calculate the MCID: consensus, anchor-based, distribution-based, or a combination of anchor- and distribution-based methods.In the consensus method, a panel of expert is convened and each expert provides his/her best estimate of the MCID until a consensus is achieved. For instance, the consensus method was used to define a decrease in PI from a baseline of ≥20% (moderate improvement) as a MCID and a decrease of ≥30% or ≥50% as a CID . A ≥50% In the anchor-based method, the pain scores are compared with an external, independent, face valid criterion (termed “anchor”) to determine a MCID in pain. The anchor is generally a questionnaire in which patients report their level of improvement, chosen based on its good reliability and validity. Examples of anchors include the PGIC, a “transition” question, the Patient Global Assessment (PGA) of treatment effectiveness Tables  and 3. UThe anchor can be used to create a receiver operated characteristics (ROC) curve, a common approach for determining the performance of diagnostic tests. The ROC cutoff is the value for which the sum of % of false positives and false negatives is the smallest  the anchors used often measure “improvement,” which is a composite endpoint of pain and other factors, such as function; and (iii) patients may have difficulty to recall their initial status to accurately report their level of improvement between pre- and post-treatment. Finally, and most importantly, the degree of change in the anchor that is meaningful to patients is usually uncertain, defeating the purpose of the anchor.There are several problems associated with anchor-based approaches. First, they are not suitable for conditions where most patients will improve and only a few remain unchanged. Second, they do not take into account the variability of the sample. The optimal cutoff is an average; some patients require smaller or larger changes in PI, for example, to feel “much improved.” Third, there are inherent problems associated with anchors for pain: (i) there is no Distribution-based methods use a statistical method to measure the variability of a variable  within the sample and determine what degree of change in that variable is generally of clinical importance. One distribution-based approach uses the SEM: because the SEM value reflects the imprecision of the measurement, an MCID value below the SEM does not reflect a true change. Another distribution-based method is the MDC, where MDC is the smallest change above the measurement error. In this approach, the MCID value is defined as the upper value of the 95% confidence interval (CI) for the average change score in non-responders. The basis of using the SEM as MCID is supported by the fact that MCIDs often turn out to be around 1 SEM or ½ SD .A few studies in painful orthopedic conditions have used distribution-based methods to calculate the MCID ,18; Tabl.Distribution-based approaches have two important limitations. First, they allow calculation of the MCID, but not the CID. Second, they only define the minimum value below which a change in pain score is hopefully not due to measurement error.One approach that combines both methods consists of (i) defining responders/non-responders using an anchor for improvement and then (ii) calculating the MCID based on the MDC: the MCID is then equal to the upper value of the 95% CI for the average change in pain score seen in non-responders with the anchor. Using this combined method, Parker et al. found a MCID of 2.6 points for neck pain on VAS, compared to 4.1 points for the ROC method ; the MCIThe CID value is dependent on the methodology used to calculate it. One study used a variety of anchor-based  and combination (anchor + SEM or MDC) methods and found that the MCID could vary by seven- to eightfold for the same anchor depending on the method used Table  20]. An. An20]. The MCID calculation using the anchor-based method may also depend on the anchor type . Various studies have compared the MCID values with two anchors Tables  and 4. WFinally, the CID value depends on the threshold of improvement. For instance, selecting patients “much improved” versus “very much improved” on PGIC (anchor) doubled the CID value from 2 to ≥4 points .very similar context to the trial, i.e., for the same pain measure, in a similar patient population , and using a similar trial design because the MCID is dependent on all these factors, as discussed above. In addition, one should be mindful of how the MCID was calculated, as many factors influence the MCID value, as discussed above . MCIDs values for a variety of pain measures, painful conditions, and patient populations have been calculated and published. To find the appropriate MCID yardstick to use among these publications, clinicians should search through publication databases using search words such as “MCID,” “pain,” accompanied with the treatment of interest , and the measurement of interest . Then, it requires sorting through these publications to find the most appropriate one . For instance, if one is interested in finding the MCID value for VAS neck pain in a population of patients undergoing anterior cervical discectomy and fusion, a type of search as described above retrieved a very appropriate article from Parker et al. [To appropriately use the MCID to determine the efficacy of a treatment in a trial, one must use MCID values that were calculated in a r et al. , which sChoice of pain measure: different pain measures yield different MCIDsEfficacy in clinical trials is impacted by various factors Pitfalls in generating efficacy data to calculate metrics of clinically important differencesPitfalls in calculating the metrics of clinically important differencesThe method used to calculate it The type of anchor chosenThe definition (threshold) of improvementThe population characteristics such as disease type and severity (baseline pain score)The MCID value is impacted by:The appropriate MCID value has to be found or calculated for the specific applicationIn clinical trials, the MCID yardstick should be applied to changes in individual subjects, not to group changes; applying individual CIDs on a group level is misleadingPitfalls in applying the metrics of clinically important differences to clinical trial dataPitfalls in calculation and interpretation of clinically important differenceswithin the same clinical trial. In other words, the same clinical trial data serve to calculate the MCID value, which is then applied to each patient of the trial to determine which patient met the MCID threshold. For instance, a clinical trial of lumbar discectomy was used (i) to calculate the MCID of leg and back pain  and (ii) to determine the proportion of patients with improved leg and back pain  [If the appropriate MCID value cannot be found, one approach is to calculate the MCID he MCID) . Using tindividual patients for whom the difference between pre- versus post-treatment pain score is equal to or greater to the MCID threshold. Then, the treatment groups can be compared for the proportion of patients who meet the MCID using a standard statistical method. For instance, a study evaluating transsacral axial interbody fusion found that only 50% of patients met the MCID of the VAS score for back pain [The MCID can be used to determine treatment efficacy or to compare the efficacy of two active treatments in clinical trials. To do so, first, one has to calculate the proportion of patients in each treatment group that meet the MCID, defined as ack pain . Anotherack pain .mean difference (pre- versus post-treatment) pain score for the treatment group and comparing it to the MCID . The MCID is a metric that is based on longitudinal differences in individual patients and should be used in the same context.One important error that is made when determining treatment efficacy in clinical trials is to calculate the average decrease in PI scores of 0.5 to 1 point on a 0–10 NRS compared to placebo, which means that MCID values tend to be small  analgesics that are known to be effective only result in an change in pain score between pre- versus post-treatment. Figure The SDD/MDC and MCID can be used by orthopedic practitioners in the clinical setting to determine whether an individual patient has responded to treatment based on the patient’s There are important caveats to applying the MCID, which is determined in clinical trial, to the clinical setting . First, the MCID is derived in a homogeneous population in clinical trial, while patients in the clinical setting are heterogeneous. Second, categorizing patients as responder/non-responder can negatively affect patient management as it does not take into account the category of patients who are borderline responders or poor responders. For these suboptimal responders, making an appropriate treatment decision will require additional clinical information regarding treatment effect.in pain but may have substantial improvements in function, sleep, or other clinical benefits. Thus, applying only MCID in painful orthopedic indications where function and other outcomes are important to make treatment decisions may not be the best approach, i.e., may have negative implications for patient management. Other domains including physical functioning, emotional functioning, and overall improvement, for which an MCID can be calculated, should be considered. Adverse effects, burden to patient, and cost should also be taken into consideration when making treatment choices .One key problem in using the MCID in the clinical setting is that patients may not have clinically important changes The MCID ) derived from clinical trials is used to inform guidelines. For example, in the OA treatment guidelines , clinicaThe use of the MCID or MCII as the cornerstone to determining treatment efficacy in guidelines has many caveats . First, The MCID and CID are useful tools to determine whether a treatment produces clinically meaningful effects in a patient. However, these metrics have many pitfalls, requiring a good understanding of the methods to calculate them and their context of use. Orthopedic surgeons that will use these metrics need to carefully understand them and be aware of their pitfalls.


To compare the open Lichtenstein repair and laparoscopic mesh repair for direct inguinal hernias in terms of immediate post operative pain and length of hospital stay.This randomized control trial was conducted at Benazir Bhutto Hospital Rawalpindi from January 2009 to June 2010. All patients presenting in the surgical OPD with direct inguinal hernia, ASA I/II, were randomly divided in two equal groups. Group-I, patients underwent Lichtenstein’s repair and Group-II had hernioplasty by laparoscopic method (TAPP). Post operative pain intensity assessed by VAS and hospital stay measured in hours.A total 60 patients of direct inguinal hernia were studied. The mean age was 61.48±7. The range of postoperative pain experienced was 5.55 as per VAS among all patients. In group-I (open hernioplasty) majority of patients  experience severe type of pain where as in group-II, moderate severity of pain was reported by large number of patients . The mean post operative pain intensity as per VAS was 6.23 in group-I and 4.43 in group-II patients. The mean length of hospital stay was slightly less (35.10 hrs) in group-I as compared to group-II (38.70 hrs).There is definitely less post operative pain after laparoscopic repair but hospital stay is same in both the procedures but laparoscopic procedure does increase the cost. History of hernia repair is very rich and since ancient times surgeons have tried to improve it bit by bit. It is in fact a game of surgical anatomy, the one who understands the anatomy of Groin, can succeed in a way or the other to do a perfect repair. Herniorrhaphy is one of the commonest general surgical procedures performed and about 700,000 hernia operations are performed each year in the United States which is still on rise.2Success of groin hernia repair is measured primarily by the permanence of the operation, fewest complications, minimal costs, and earliest return to normal activities. This success largely depends upon the surgeon’s competencies, preoperative patient selection and preparation, knowledge and experience of effective use of surgical techniques and currently available materials for repair.The objective of the study was to compare the open Lichtenstein repair and laparoscopic mesh repair for direct inguinal hernias in terms of immediate post operative pain and length of hospital stay. This Randomized controlled trial was conducted in Surgical Unit–I at Rawalpindi General Hospital, Rawalpindi for one year from January to December 2009. A total of 60 patients were studied and divided between the 2 equal groups. Patients were selected through Simple random sampling (computer generated) technique. Inclusion Criteria consist of male presenting to general-surgery clinic which are above thirty years of age with a diagnosis of direct inguinal hernia , Patients of ASA I & II category. Exclusion Criteria comprised of Patients with contraindications to pelvic laparoscopy, history of repair with mesh, recurrent inguinal hernia, previous pelvic surgery, history of Transvesical prostatectomy or patients having Hepatitis B or C positive. Routine baseline of all patients was checked. After obtaining approval by the hospital ethical committee, informed consent was taken from each patient. Pre-anesthetic evaluation was done before operation. All the procedures were performed by a single selected team of surgeons and assistants of the same surgical Unit. The patients were divided in two groups by simple random sampling (computer generated) to minimize the selection bias. No blinding possible.Patients underwent hernioplasty by open method (Lichtenstein’s repair).Patients underwent hernioplasty by laparoscopic method (TAPP).st at the umbilicus, and the other two at lateral border of Rectus muscle at the level of umbilicus on both sides. Classical Open Lichtenstein’s repair was performed in the other group.Laparoscopic repair was performed by Transabdominal preperitoneal (TAPP) approach by 3 port technique, 1Postoperatively, patient’s perception of pain was assessed by Visual Analogue Scale (VAS) about four hours after surgery. All patients received analgesia in the form of Inj. Diclofenic sodium 75mg I/M immediately after surgery and it was repeated only after 06 hours. No preoperative or peroperative analgesia was given to any patient. All the patients were given standardized postoperative instructions not to restrict their activities unless the activities cause pain. All patients were assessed for postoperative analgesia requirements and hospital stay. Length of postoperative hospital stay was calculated in terms of hours after surgery till the time when patient was discharged. The discharge time was the time mentioned in patients’ notes.All the data was entered on SPSS for windows version 10. Mean and standard deviation will be were calculated for all quantitative data . Frequencies and percentages were calculated for qualitative data (age). Comparison of Quantitative data in both groups was analyzed by student T- test. Comparison of Quantitative data in both groups was analyzed by chi-square test in both groups. A p-value ≤ 0.05 was considered statistically significant.A total of 60 patients having direct inguinal hernia admitted through the surgical OPD from January to December 2009. The age varies between 35-75 years with a mean age of 61.48±7 years . PatientThe conventional surgery of groin hernias has been to ligate or reduce the hernia sac and reconstruct the posterior wall through an open incision. Although this operation can be performed as day care procedure in selected cases with the use of local anesthesia but it has been presumed that open hernioplasty is associated with increased postoperative pain, prolonged hospital stay, more recurrence and a delayed return (four to six weeks) to full physical activity and employment. The rates of hernia recurrence after open repair reported in literature are low (less than 2 percent) in specialized centers, but recurrence rates in regionalized studies of heterogeneous populations have averaged 5 to 10 percent for primary hernias and 5 to 30 percent for recurrent hernias.7In contrast with the open repair, Laparoscopic repair of inguinal hernias is performed with the use of general anesthesia and three laparoscopic ports. Several techniques for laparoscopic herniorrhaphy have been used, including closure or plugging of the hernia and various types of patch repairs. Patch repair is currently the most common method and entails placing a large prosthetic patch internally to cover the hernia and inguinal floor.Regarding post operative pain, it is reported in literature that the laparoscopic repair is associated with less pain as compared to open herniorrhaphy. The p value for postoperative pain is 0.005 in our study which is quite significant and concludes that the patient who had laparoscopic hernioplasty experienced less pain postoperatively as compared to those having open herniorrhaphy. The same results were also concluded from the review of 41 Cochrane studies,18Regarding hospital stay, our results shows that there is no significant statistical difference regarding postoperative hospital stay in either open or laparoscopic hernia repair. These findings are consistent with the many other studies carried out at different centers.20To date, recurrence rates with the laparoscopic preperitoneal prosthetic-patch operation have been low, but the follow-up has been short.Laparoscopic hernia repair also requires a general anesthesia, with its associated risks, for a procedure that can be done conventionally with local anesthesia in selected cases. There is a small but definite risk of serious injury to intra-abdominal organs that is not associated with traditional inguinal herniorrhaphy. Also, costs may be higher because of the need for expensive equipment and other supplies related to laparoscopic instrumentation.22The safety and efficacy of laparoscopic inguinal hernia repair have recently been evaluated in two multi-institutional reports.25There is less post operative pain after laparoscopic repair but hospital stay is same in both the procedures. Keeping in view the limitations of Laparoscopic repair the choice between them should be made on a case to case basis depending on patient preference and other characteristics such as age, work, health status and cost etc.


Most patients with chest pain have nothing wrong with their cardiac function. Psychological forms of treatment for this condition are more likely to be successful than others.A two-arm parallel controlled randomized trial of standard care versus a modified form of cognitive behaviour therapy for chest pain (CBT-CP) in patients who have attended emergency hospital services. Inclusion criteria include (i) emergency attendance more than once in the previous year with chest pain when no physical pathology has been found, (ii) aged between 16 and 75, (iii) signed consent to take part in the study. Exclusion criteria are (i) under current psychiatric care, (ii) those who have had new psychotropic drugs prescribed within the last two months, (iii) are receiving or about to receive a formal psychological treatment. Those satisfying these criteria will be randomized to 4–10 sessions of CBT-CP or to continue with standard care.Participants are randomized using a remote web-based system using permuted stacked blocks stratified by study centre. Assessment is carried out at baseline by researchers subsequently masked to allocation and at 6 months and 1 year after randomization. The primary outcome is the Health Anxiety Inventory score at 6 months, and secondary outcomes are generalised anxiety and depressive symptoms, the Lucock Health Anxiety Questionnaire adapted for chest pain, visual analogue scales for chest pain and discomfort , the Schedule for Evaluating Persistent Symptoms (SEPS), health related quality of life, social functioning and medical resource usage. Intention to treat analyses will be carried out with clinical and functioning data, and a cost-utility analysis will compare differences in total costs and differences in quality of life using QALYs derived from the EQ-5D. The data will also be linked to another parallel study in New Zealand where 126 patients with the same inclusion criteria have been treated in a similar trial; the form of analysis of the combined data has yet to be determined.The morbidity and costs of non-cardiac chest pain are substantial and if a simple psychological treatment given by health professionals working in medical departments is beneficial it should prove to be of great value. Combining data with a similar study in New Zealand is an additional asset.ISRCTN14711101 (registered 05/03/2015) Chest pain is one of the most common reasons for attending an Accident & Emergency Department. This is understandable as cardiac conditions often present with chest pain and many sufferers require emergency interventions to save life. However, only a minority of patients presenting with chest pain have a demonstrated physical cause for their conditions. The experience of chest pain, even if not related to cardiac pathology, is often alarming and frightening, and if inadequately managed, tends to reinforce rather than resolve the problems.Atypical, better termed non-cardiac, chest pain, can have a number of underlying pathologies. Most importantly, it can be an indicator of genuine myocardial disease. A recent study of the outcome of 8762 patients attending rapid access chest pain clinics showed that of 599 patients who reached the primary end-point  after a mean of 2.6 years, 194 32 %) had non-cardiac chest pain. However, this represented only 2.7 % of the population (6396 people) with non-cardiac chest pain whereas 16.5 % of those with angina reached the primary end-point [2 % had nCognitive behaviour therapy and related psychological treatments are normally effective in the treatment of anxiety and depressive disorders but have not shown quite such success in the treatment of non-cardiac chest pain. Kisely et al , 5 have Examination of the reasons for the relatively poor performance of psychological treatments for this condition suggest three factors handicap progress; (i) the resistance of patients to the notion of a psychological explanation for their condition, (ii) the confidence of the therapists in dealing with a condition that mimics major cardiac pathology, and (iii) the ability of therapists to deliver treatment well to such patients. Most well-trained CBT therapists are psychologists but they do not have the background knowledge of medicine that helps to reassure the patients with non-cardiac chest pain that they understand their ‘medical’ problems; conversely, cardiac support nurses are excellent in this latter understanding but not so skilled in the former . In the A recent pilot study in this population  has alsoThe design is a two-arm parallel design randomized controlled trial carried out in three centres that compares a modified form of cognitive behaviour therapy for chest pain (CBT-CP) that also includes elements of a similar successful treatment for health anxiety  or standard treatment (ST) in patients presenting with non-cardiac chest pain to cardiology settings who have presented at least once before in the previous year and do not have cardiac pathology of sufficient severity to explain the symptoms.Our previous work has suggested that most of these patients can be treated successfully in a relatively short number of sessions with an adapted form of cognitive behaviour therapy (CBT), although a minority of handicapped patients may need more. The randomisation was carried out by an independent Clinical Trials Unit  will consist of normal management at the clinics concerned, consisting of investigative procedures to exclude pathology and feedback to patients about the findings.Assessments of outcome include reduction in health anxiety recorded with the Health Anxiety Inventory  . Using data from a similar randomised controlled trial  we demonAll patients recruited to the study are initially referred by clinical staff involved in their care and are then seen by a research assistant who gives each person a participant information sheet and explains the study. If, after getting appropriate answers to questions, patients agree to take part in the randomised study, they sign a declaration of informed consent. The study has been approved by the NRES  Committee East Midlands, Northampton, UK (11/EM/0376).The patients seen are those satisfying the criteria below who presented with chest pain to either cardiology clinics and/or accident and emergency departments at three hospitals, King's Mill Hospital, Sutton-in-Ashfield, Nottinghamshire, the Hillingdon Hospital, Middlesex and the Royal Berkshire Hospital, Reading. Two other centres were included but the lack of a local principal investigator prevented recruitment. The procedures for the chest pain pathway are not the same at these three hospitals but are likely to be representative of the UK as in most hospitals there is no standard pathway for the assessment of non-cardiac chest pain.The criteria for inclusion are (a) significant chest pain on at least two separate occasions in the past year in which no significant pathology explaining the symptoms was found, (b) signed consent to take part in the study, (c) age between 18 and 75. The exclusion criteria are (a) under active psychiatric care, (b) having received a prescription of a new psychoactive drug within the previous two months, (c) receiving, or on waiting list for, a formal psychological treatment. Those who are currently stable and on regular psychoactive medication (for more than 2 months) are eligible for the study.Patients who are identified as eligible for the trial by cardiology and accident and emergency staff, and willing to take part, were first assessed by an independent research assistant. After baseline assessment all ratings and demographic details are recorded on a secure on-line data base, initially Open-CDMS in London and from 2014, CHaRT in the Health Services Research Unit, University of Aberdeen. Patients are then allocated to either CBT-CP or standard care in permuted stacked blocks (do we specify numbers) stratified by study centre. The allocated treatment is then passed to the trial coordinator (SC) who, if the patient is allocated to CBT-CP, informs the next available therapist at the centre concerned and then the patient, GP and consultant. Patients allocated to standard care are informed by letter or phone call and the GP and hospital team also notified. Follow up assessments are carried out by research assistants ignorant of original allocation after 6 and 12 months. All data are kept by CHaRT until the termination of the trial.Adapted CBT-CP (CBT for Chest Pain)(i) A formulation made for a recent episode of chest pain with its central fear associations and possible consequences (by end of first session),(ii) assessment of the behaviours that are maintaining the chest pain,(iii) introducing the Beck equation of likelihood times awfulness divided by coping skills times rescue factors (a much larger issue for chest pain than for most other symptoms),(iv) building up a model of the cognitive theory of emotion with illustrations where necessary of the nature of symptoms,(v) introducing the model of fear of having heart disease/more serious heart disease (in those with pre-existing cardiac pathology) versus actually having heart disease/more serious heart disease,(vi) introducing the pie chart and pyramid systems for interpreting other worrying but innocuous symptoms,(vii) trying to influence the over-developed sense of responsibility that the patient feels is necessary to monitor the progress of, and likely interventions for, the chest pain,(viii) using the patient's strengths in finding alternative strategies of dealing with chest pain,(ix) developing a strategy for managing risk (highly important in this population),(x) diary homework to illustrate the relationship between symptoms and events likely to provoke anxiety.This will be given by staff trained and supervised by HT. This is similar in several ways to cognitive behaviour therapy for health anxiety (CBT-HA)  and its In preliminary work we have found in some cases only one or two sessions of 50–60 min are needed to complete treatment but in others many more sessions are needed, particularly if the chest pain has become chronic.This constitutes the care that is currently given to patients in primary and secondary care at present; this involves appropriate testing, explanation of findings, reassurance of the implications of these and the opportunity for the patient to ask questions about the symptoms and the test results.The economic evaluation will take a health care perspective and, using the service use data collected over follow-up, will calculate the total cost of the services used by each study participant. These costs will be taken together with the cost of the CBT to generate average costs for each randomised group. These costs will be compared using standard t-tests, which are recommended for economic analysis because they allow for analysis of mean costs without transformation. The robustness of this approach will be checked through the calculation of bootstrapped confidence intervals , 19. A cThe primary outcome is the reduction in scores on the Health Anxiety Inventory between baseline and 6 months, Secondary outcomes are (i) the reduction in visual analog scores of frequency and intensity of chest pain, (ii) reduction in Lucock scores, (iii) reduction in the total SEPS score,  the number of attendances at Accident & Emergency Departments after 6 months and one year, (iii) total health service costs in primary and secondary care at 6 and 12 months, (iv) reduction in generalised anxiety symptoms  reduction in depressive symptoms on the HADS-Depression Scale at the same time points, and (vi) change in mean Lucock scores from baseline after one year.All analyses will be by intention to treat, analysed as randomised. The primary analysis will compare mean change scores of the Health Anxiety Inventory scale from the baseline to 6 months between the treatment and control groups. We shall conduct sensitivity analyses to examine data missing mechanism to decide whether imputation approaches are necessary. Random effects regression model will be used to estimate and test differences of mean change scores between the two comparison groups at 6 and 12 months simultaneously with adjustment for baseline score and key variables used for minimisation procedure. We shall also examine distribution of the outcome score. If a skewed distribution such as a Poisson one was shown, data transformation such as logarithmic transformation of raw data will be carried out before any statistical analysis.Analyses of secondary outcomes will follow the same analytic procedure and statistical approaches. Economic analysis will follow a similar methodology except that wherever possible data will be analysed without transformation and using bootstrapping techniques for skewed data , 19.Each therapist will be trained by HT and assessed in vivo at interviews with patients using an adaptation of the Cognitive Therapy Rating Scale (CTRS), a necessary change for a population that largely regards its anxiety as an appropriate mood to monitor health . SuperviRecruitment to the study began in July 2012 and the last patient was recruited in January 2015. No data have currently been examined. The CONSORT diagram illustrates the high numbers of people who present with potential non-cardiac chest pain  after passing through all other part of the assessment process. This reluctance to take part in psychological interventions has been noted by others in this field  and will


DAs) are useful in Parkinson′s disease (PD), they are not frequently used in elderly patients due to adverse effects. However, there is a lack of evidence because few elderly PD patients are enrolled in clinical trials.Although dopamine agonists  in a group of PD patients in clinical practice and to identify the related factors. Specifically, we studied the effect of age, comorbidity, and polypharmacy as potential risk factors for DAW.The aims of this study were to analyze the reasons of PD patients receiving a DA  from a cohort (n = 150) previously studied in detail in 2012 was used to identify predictive factors of DAW.A retrospective chart review of the follow‐up  of a subgroup of DAW percentage was 18.2% . DAW causes were cognitive impairment (3), reduction therapy (3), hallucinations (2), dyskinesia (2), and excessive diurnal somnolence (2). Only a higher levodopa daily dose  was an independent predictor of DAW after adjustment for other explanatory variables.The DAW was low. Advanced age alone is not a contraindication to the administration of DAs.The frequency of  Levodopa is the gold standard symptomatic treatment in Parkinson′s disease (PD), although its long‐term use is associated with the development of motor complications. Alternatively, dopamine agonists (DAs) have shown to be effective, both as monotherapy in the early stages of PD or in association with levodopa in advanced PD  to determine the reasons of DA withdrawal (DAW) in a group of PD patients in clinical practice; and (2) to identify the predictive factors of DAW. Specifically, we studied the effect of age, comorbidity, and polypharmacy as potential risk factors for DAW.n = 68; 60.3% males, 69.3 ± 9.2 years old) from a cohort (n = 150) previously studied in detail . The follow‐up period was from the baseline evaluation (between 11 May and 24 December 2012 depending on the case) to 23 March 2015. The reason for DAW, age at DAW, follow‐up time, time until DAW , time taking DA therapy (time taking the DA before baseline) and DA dose : (1) patients who discontinued DA therapy during follow‐up (DAW group); and (2) patients who did not discontinue DA therapy (non‐DAW group). Univariate and multiple regression analyses were performed to evaluate predictors of DAW. Specifically, we studied the effect of age, comorbidity, and polypharmacy as potential risk factors for DAW. The number of drugs different of antiparkinsonian agents taken at baseline was considered a surrogate marker of comorbidity. Polypharmacy was assessed by counting the total number of pills at baseline. Values of p < 0.05 were considered significant.Data were processed using SPSS 21.0 for Windows. Proportions between groups were compared using the chi‐square test. Continuous variables are expressed as the mean ± SD or median and quartiles, depending on whether they were normally distributed and were compared using the Student′s n = 150) (Santos‐García and de la Fuente‐Fernández Sixty‐eight PD patients from the cohort n = 50 (SantoAs shown in Table P = 0.006). The levodopa daily dose HR was 1.003  after adjustment for covariates. As expected, when PD patients were classified according to the levodopa daily dose, a significantly higher percentage of DAW was observed in those receiving more than 750 mg per day  . Fourth, some information may have been missed due to the methodology used (chart review). However, the findings are novel and have practical applicability in clinical practice. Fifth, a cognition assessment using a specific scale at baseline was not conducted. Finally, follow‐up information on adverse events was not collected in patients who continued receiving DA therapy at the end of the follow‐up. Nevertheless, this study was not designed to evaluate tolerability and effectiveness. Thus, we can assume that patients continued taking the medication in clinical practice because it is useful and well tolerated.In conclusion, our study shows that DA therapy is generally well tolerated by nondemented PD patients in clinical practice. Advanced age alone is not a contraindication to the administration of DA therapy. We must keep in mind that the probability of successful treatment when we use DA therapy is lower in PD patients with a longer disease duration, polypharmacy, and a higher daily dose of levodopa.None declared.