P=0.013), but not at T2 (P=0.059). Adverse effects were comparable and were not significantly related with the IV-MO and OTFC doses. Intravenous morphine and OTFC in doses proportional to the scheduled daily dose of opioids were both safe and effective, IV-MO having a shorter onset than OTFC. Future comparative studies with appropriate design should compare titration methods and proportional methods of OTFC dosing.The use of supplemental doses of opioids is commonly suggested to manage breakthrough pain. A comparative study of intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) given in doses proportional to the basal opioid regimen was performed in 25 cancer patients receiving stable opioid doses. For each episode, when it occurred and 15 and 30 min after the treatment, pain intensity and opioid-related symptoms were recorded. Fifty-three couples of breakthrough events, each treated with IV-MO and OTFC, were recorded. In episodes treated with IV-MO, pain intensity decreased from a mean of 6.9 to 3.3 and to 1.7 at T1 and T2, respectively. In episodes treated with OTFC, pain intensity decreased from a mean of 6.9 to 4.1 and to 2.4 at T1 and T2, respectively. Statistical differences between the two treatments were found at T1 ( Patients with chronic cancer pain often report wide fluctuations in pain intensity. In the cancer population, breakthrough pain (or episodic pain) is a transitory flare of pain superimposed on an otherwise stable pain pattern in patients treated with opioids (Intravenous morphine (IV-MO) has been found to be highly effective and safe, as only a low intensity of opioid-induced adverse effects was observed, even when administering large doses  have shown that this approach produces a faster onset of relief and a greater degree of pain relief than the oral morphine, at 15, 30, and 60 min . Patients with predominant incident pain or with short-lived episodes of neuropathic pain resolving spontaneously in few minutes were also excluded. Finally, patients receiving oral morphine equivalents in a dose range of 270–330 mg (see below), and patients who presented more than two episodes or just one episode during the daily hours (from 0700 to 1900), or pain flares repeating after with short intervals (less than 6 h) were also excluded (see the protocol described below).Forty patients met the inclusion criteria and gave their informed consent. According to the department policy, an intravenous line was established for emergency treatment of symptoms. Increases of pain intensity were considered only if patients felt that there was a clear difference with basal pain and required a medication as needed. Patients were encouraged to call when their pain got severe.Patients were planned to receive IV-MO and OTFC for each couple of breakthrough pain events. The order of administration was computer-generated to produce equivalent sequence orders, 50–50%, and the wash out period between the pain flares was at least 6 h. Patients who repeated the sequence on another day received the opposite sequence. Only patients presenting a couple of episodes occurring between 0700 and 1900 were taken into consideration. Thus, patients received both treatments, serving as their own control. Patients who presented more than two episodes or just one episode during the daily hours (from 0700 to 1900) were excluded, so that only days in which two episodes occurred within this interval of 12 h were considered, to assure the presence of physicians in the unit, and minimise the occurrence of possible complications.μg OTFC should be administered in patients receiving at least 60 mg day−1 of oral morphine or 25 μg h−1 (0.6 mg day−1) of transdermal fentanyl .The IV-MO dose was administered for about 5 min at 1/5 of the oral daily dose, converted using an equianalgesic ratio of 1/3  , 15 min after (T1), and 30 min after (T2) the study of drug administration, patients were asked about the following parameters, which were recorded: pain intensity, using a numerical scale from 0 to 10, and opioid-related symptoms, using a scale from 0 to 3 . These scales have been reported in several previous papers on same subject , 2006, aDaily doses of oral morphine equivalents and basal pain intensity were also recorded. A decrease in pain intensity of at least >33% at T1, not requiring further treatment for the next 2 h, was considered as an effective treatment of each episode. Patients were offered the common prescription used in the unit, that is IV-MO, but at half dose, if they were not satisfied with the treatments within T1.P<0.05, power=0.8). This computation assumes that the mean difference is 0.20 with a 95% confidence interval (CI) of 0.07–0.33 and the common within-group standard deviation of 0.28.A power analysis indicated that a sample size of 25 episodes per group would allow to detect a 20% difference ) was used to compare the scores or the means of non-parametric and parametric variables, respectively, at different time intervals. The one-way ANOVA and Mann–Whitney U statistic test were used to compare the different parametric or non-parametric variables. All P-values were two-sided and P-values less than 0.05 were considered statistically significant.Frequency analysis was performed with Patients' characteristics are listed in Twenty-five patients completed 53 couples of breakthrough events , each randomly treated with IV-MO and OTFC, during admission. A total of 25 couples were IV-MO/OTFC sequences, and 28 couples were OTFC/IV-MO sequences.In episodes treated with IV-MO, pain intensity decreased from 6.9 (95% CI 6.6–7.2) to 3.3 (95% CI 2.7–3.8) and 1.7 (95% CI 1.2–2.3) at T1 and T2, respectively. This reduction was more than 33% in 39 (74%) and in 46 episodes (87%) at T1 and T2, respectively, and more than 50% in 29 (55%) and in 40 episodes (75%), at T1 and T2, respectively.In episodes treated with OTFC, pain intensity decreased from 6.9 (95% CI 6.6–7.2) to 4.1 (95% CI 3.6–4.7) and 2.4 (95% CI 1.8–2.9) at T1 and T2, respectively. This reduction was more than 33% in 30 (57%) and 45 episodes (85%) at T1 and T2, respectively, and more than 50% in 20 (38%) and in 40 episodes (75%) at T1 and T2, respectively.P=0.013, univariate repeated measures analysis ANOVA), whereas at T2 the difference did not attain a statistical significance . Three patients and one patient who had received OTFC and IV-MO, respectively, required an additional  dose of IV-MO, as a further rescue dose. When excluding these patients with the intention for protocol analysis, a statistical difference was similarly found at T1 (P=0.049), but not at T2 (P=0.124).A statistical difference between the two treatments was found at T1 (P=0.026). At T2, a decrease of 65.9 and 73.8% in pain intensity was recorded after OTFC and IV-MO, respectively (P=0.136). No differences between the two groups were observed in the number of episodes with a reduction of more than 33 and 50% at T1 (P=0.66 and 0.39) and T2 (P=0.23 and 0.20), respectively.At T1, a decrease of 41.4 and 51.7% in pain intensity was observed after OTFC and IV-MO, respectively .The outcome was not related to the basal regimen, and as a consequence to IV-MO and OTFC doses. Statistical tests with exact critical values were performed to evaluate differential carryover effect and period effect between treatments. There were no statistically significant period or carryover effects . Moderate adverse effects in episodes treated with OTFC were: nausea (four episodes), drowsiness (seven episodes), and confusion (one episode). Moderate adverse effects in episodes treated with IV-MO were: nausea (two episodes), drowsiness (10 episodes), confusion (three episodes) see . No seveDespite the growing interest on breakthrough or episodic pain in the last 10 years, few prospective comparison studies have been performed. Oral transmucosal fentanyl citrate was compared with the standard treatment used in the unit, which is an intensive acute pain relief and palliative care unit, where strict monitoring is essential and an intravenous line is commonly inserted to achieve rapidly pain and symptom control. We have also chosen IV-MO as a control, as this modality could better fit the onset of OTFC for comparison, although the use of IV-MO is often restricted to selected palliative care units. While subcutaneous route is more frequently used in the setting of hospice care, probably, it would result in an expected delay in the onset of the effect in comparison with OTFC.μg of OTFC or more in the first instance, producing acceptable adverse effects, which occurred equally, independently of the dose. This observation contrasts with almost all studies of OTFC  were treated with doses of 600 The aim of the present study was not to compare effective titrated doses with doses proportional to the scheduled daily doses, but two fast methods for treating breakthrough pain were compared, using a similar approach that is providing opioids at a dose proportional to the basal regimen.μg per hour of fentanyl . Eligible patients were defined as having their basal pain no more than moderate, and presenting no more than four episodes per day. On the other hand, some patients could not be universally considered  as having well-controlled pain, especially if matched with a pain intensity of breakthrough events of 6.8 on average (with some patients at the lowest extremes). No distinction was made between incident pain, dependent on activity, and other mechanisms, which can have a different temporal pattern. Finally, almost no adverse effects were reported with usual breakthrough medication in comparison with OTFC, which doses were titrated in patients apparently responsive to their usual medication, suggesting that probably most patients were undertreated either with basal or ‘as needed’ medication.Some issues gathered by these previous studies should be pointed out. As 66% of the episodes treated with placebo did not require an additional dose of medication, the episodes recorded were possibly short-lived or not too much severe, and possibly spontaneously resolved. This can also explain why minimal doses of oral morphine equivalents (about 20 mg) were effective in patients taking a mean basal dose of 100 Of interest, in previous studies of OTFC, up to four episodes per day were treated, suggesting that the treatment was sometime repeated more frequently than every 6 h. Six hours should be a sufficient interval to avoid overlapping of effects between OTFC and IV-MO administration and vice versa. On the other hand, the increase in pain intensity, typical of the breakthrough event, which triggers drug administration, gives evidence that the effect of the previous medication is evanished.In this study, criteria for selecting breakthrough events were strict. Adequate pain levels (about 3/10 intensity) and severe pain intensity of the episodes (about 7/10 intensity) were chosen to make a clear distinction between basal pain intensity and pain flare intensity. We also selected patients having no more than two episodes per day, to avoid possible inclusion of patients with disputable pain control. Specifically, for inclusion, we have chosen only days when both randomised treatments were used, facilitating also patients' compliance for comparison, but at a distance of at least 6 h, to avoid overlapping effects. Given that the study was not blinded, a learning effect in using OTFC cannot be excluded in subsequent administrations, but this was inevitable. However, no particular differences between subjects who received one or more OTFC treatments were found. When evaluating differential carryover effect and period effect between treatments, there were no statistically significant period or carryover effects. Of interest, previous studies did not take into consideration an acceptable time interval between events  after a preliminary testing, also considering that in previous studies the starting dose of OTFC for patients receiving equivalent doses of oral morphine was 200 μg  the efficacy of OTFC compared to IV-MO. This means that OTFC doses of 400 Owing to lack of blindness of the study, the results should be interpreted carefully. No placebo control was considered for such patients requiring immediate pain relief and having available effective medication, and who were considered not amenable ethically with placebo, also given the exploratory use of OTFC at doses equivalent to the basal opioid regimen, never tested in previous OTFC studies where no correlations were found. The double-dummy technique requiring simultaneous treatments was unfeasible in this clinical context. The low number of patients is of concern, and probably owing to dropout rate. However, the strict selection criteria adopted  should limit this bias. In any case, the meaning of this study should be interpreted as a preliminary experience for evaluating the feasibility of such an approach, rather than proposing a standard treatment, particularly given the peculiarity of the setting where the study was performed. To collect such acute data in real time, it was preferred to use very simple tools and specific time intervals, avoiding other instruments, such as pain relief intensity, which would have confused the monitoring, introducing a further burden for patients. Fifteen minutes was considered an acceptable interval to evaluate the treatment of pain flares. Another possible concern is about the use of different opioids as basal medication, which were compared in an equianalgesic range. In previous studies and a subsequent experience, this problem did not arise specific problems in response to OTFC or IV-MO (In conclusion, IV-MO and OTFC were equally effective for treating breakthrough pain episodes, the effect of IV-MO being faster. As IV-MO, OTFC used at a dose proportional to the basal opioid regimen was safe and effective in the majority of patients experiencing pain exacerbation, confirming figures reported previously, but contradicting previous OTFC studies. Adverse effects were compatible and not troublesome. Should data regarding the risks confirmed in a larger number of patients, this treatment could be feasible even for outpatients or home patients, without requiring complex titration procedures.


The aim of the study was to achieve earlier diagnosis of malignant cord compression (MCC) using urgent magnetic resonance imaging (MRI) for selected patients. A comparison was carried out of the current prospective audit of 100 patients referred by a general practitioner or a consultant over 32 months with both a previous national Clinical Research and Audit Group (CRAG) prospective audit (324 cases of MCC) and an earlier retrospective audit of 104 patients referred with suspected MCC. A telephone hotline rapid-referral process for patients with known malignancy and new symptoms (severe nerve root pain ± severe back pain) was designed. Patients were considered for urgent MRI after discussion with a senior clinician responsible for the hotline. Appropriate referrals were discussed with radiology and oncology ensuring timely MRI reporting and intervention. The main outcome measures are as follows: time from referral to diagnosis; time from the onset of symptoms to diagnosis; and mobility at diagnosis. A total of 50 patients (52%) of those scanned had either MCC (44) or malignant nerve root compression (6) compared with the earlier rate of 23 out of 104 patients (22%). Ten out of 44 MCC patients (23%) were paralysed at diagnosis, compared with 149 out of 324 (46%) in the CRAG audit. Time from reporting pain to diagnosis was 32 days compared with 89 days in the CRAG audit. Median time from referral to diagnosis was 1 day, again considerably shorter than the CRAG audit time of 15 days (interquartile (IQ) range: 3–66). In patients at risk of MCC, fast-track referral with rapid access to MRI reduces time between symptom onset and diagnosis, improves mobility at diagnosis and reduces the number of negative MRI scans. Numerous retrospective studies have reported that most patients with malignant cord compression (MCC) have experienced pain for a number of weeks and lost the ability to walk by the time a diagnosis is established  scanners have limited capacity, and urgent MRI scans should be reserved for those patients who will benefit the most or have the most to lose if diagnosis is delayed. Within the National Health Service (NHS) open access, MRI scanning is not available because of scarce resources. However, if it were possible to identify a group of patients with cancer and back pain whose symptoms were significantly more likely to be associated with epidural disease or early cord compression, then selective, urgent MRI scanning within 24 h would be justified. The clinical benefits that might be expected would be improved mobility at diagnosis, reduced dependency, reduced pain, reduction in the number of patients who require diagnosis and treatment as an in-patient and a reduced proportion of negative (for MCC) MRI studies.If diagnosis is to be confirmed before weakness becomes permanent, then selection for scanning needs to be based on clinical symptoms or signs that occur before weakness has the opportunity to develop. Patients usually have a history of severe and worsening pain for weeks or months before the diagnosis is established . SelectiThe development of nerve root pain usually prompts the patient to seek medical advice. Root pain is particularly unpleasant and is generally unresponsive to conventional analgesics. In general practice, the most likely cause of L5/S1 root pain is degenerative disc disease; hence, at the time of the study, plain X-ray of the lumbar spine was a common initial investigation. However, in patients with cancer, the development of new pain, and in particular nerve root pain, is likely to be related to tumour progression  study from several Scottish centres  reportedreduce time interval between a GP or a hospital doctor referral and radiological diagnosis;reduce the number of patients unable to walk at diagnosis; andreduce overall time interval between the onset of symptoms and the diagnosis of malignant cord or root compression.A MCC group, with representation from oncology, radiography, radiology, neurology, neurosurgery, palliative medicine, general practice and physiotherapy, was established in 2003 to re-design the service for patients with suspected MCC. The three main aims included one to improve the effectiveness of the referral system (A) and two to improve the clinical outcome (B and C) and are as follows:We based our re-design on the lessons learnt from an earlier audit , our pooEthics approval was obtained from the NHS Tayside Ethics Committee. A rapid referral system was designed for GPs, community nursing staff and hospital clinicians to refer patients with suspicious symptoms directly to a senior hotline clinician.patient known to have, or strongly suspected to have, cancer;and/or new severe localised vertebral pain, especially thoracic; andnew severe nerve root pain  any new difficulty in walking.Referral criteria are as follows:The referring GP or a hospital doctor speaks directly with a senior clinician, currently a specialist in palliative medicine, by a dedicated phone number. After further discussion, usually between the hotline clinician and the patient's oncologist, the hotline clinician decides whether an MRI is required within 24 h. Alternatively, the hotline clinician or the patient's oncologist may arrange to examine the patient before determining whether an urgent scan is required.ad hoc on-call service is available at weekends and public holidays.An MRI slot is reserved at the end of each day's list for hotline referrals. If, by midday, the slot has not been allocated to a patient with suspected MCC, it is re-appointed to an urgent in-patient or an outpatient. Patients with probable MCC presenting after this time are scanned first thing the next morning. An Scans are immediately reported on a dedicated proforma  by radioThe results are immediately communicated to the clinical team caring for the patient and the appropriate management is instituted.Data were prospectively collected using a Microsoft Access database. All analyses were carried out with Minitab .Data were compared with (a) pre-hotline analysis of referrals in Tayside for MRI for possible cord compression (unpublished audit data) and (b) CRAG data from several Scottish centres, which included information on mobility at presentation, the presence of back and neuropathic pain, duration of symptoms, underlying diagnosis and MRI findings , 16 were referred from the hospice and 68 from the hospital. Of the hospital referrals, 51 were referred by a hospital doctor or a nurse and 17 by the hospital palliative care team. In one case referred from the community, the diagnosis was suggested by an oncologist's secretary on receiving a request from a GP for an early outpatient appointment.P=0.041, two-sided Fisher's exact test (2FET)). Analyses were therefore carried out for the population as a whole and for subgroups (patients with lung cancer vs the rest). A total of 94 patients referred to the hotline had localised back pain, 89 had nerve root pain and 84 had both.Underlying malignancies included lung (31), breast (13), prostate, (18), colorectal (7), upper GI (6), myeloma (6), kidney (3), lymphoma (2), other (10) and unknown (4). There were proportionally more patients with lung cancer in the hotline group  than in the CRAG reference group , a statistically significant difference . If we include those with MCC or malignant nerve root compression (MNRC) in the comparison, then the rates are 23 out of 104 patients (22.1%) before the introduction of the hotline and 50 out of 95 patients (52.6%) afterwards .A total of 44 out of 95 patients (46.3%) referred via the hotline had MCC compared with 18 out of 104 patients (17.3%) referred before the hotline system was introduced. This is a statistically significant difference . The frequency of major pathology, unrelated to cancer, seen on MRI reduced dramatically with the introduction of the hotline process from 15.4 to 0% .The frequency of patients having normal or benign degenerative changes on MRI results decreased markedly on the introduction of the MCC hotline from 42.3% (pre-hotline) to 14.7% (hotline), and this change was statistically significant  for each subgroup: overall (15 days vs 1 day), lung cancer (20 days vs 1 day) and non-lung cancer (14.5 days vs 1 day).The time from the GP or a hospital doctor referring the patient to the hotline, to diagnosis, was a median of 1 day (range: 0–21). One patient waited 9 days – this was a clinical decision by the palliative medicine/hotline consultant. One patient with claustrophobia needed three scans to establish a diagnosis 21 days later. Two patients waited 7 days (one had claustrophobia and the other patient's scan was delayed). This was considerably shorter than the median time of 15 days from referral to diagnosis in the CRAG audit (IQ range: 3–66 days); and significant at P=0.003, 2FET). Thirty-four patients had some mobility and 15  were able to walk unaided compared with only 18.8% in the CRAG audit, and once again this difference is statistically significant . In the subgroup of patients with lung cancer, there was no statistically significant difference in the rate of ability to walk unaided  between patients referred via the hotline and those analysed as part of the CRAG audit; this lack of statistical significance is probably because of the small numbers involved in the comparison. In the subgroup of patients who did not have lung cancer, the difference in rates was statistically significant .Of the 44 patients with proven MCC, all of whom had mobility recorded at diagnosis, 10 patients (22.7%) were unable to walk at the time of MRI diagnosis compared with 46.0% in the CRAG audit . The oveP=0.002, MW).Back pain: All 44 patients with diagnosed MCC reported back pain. For 41 of the patients, we had information on the date of onset of the back pain. The median length of time patients reported back pain before a diagnosis was established was 32 days . This waP=0.001, MW). Patients with cancers other than lung cancer had back pain for a median of 41.5 days, and although this was shorter than in the CRAG study (72 days), it did not reach statistical significance .Patients with lung cancer diagnosed with MCC via the hotline had back pain for a median of 18 days, and this was significantly shorter than the length of time (113 days) for which the corresponding patients in the CRAG study experienced back pain .Root pain: Forty-one out of 44 (84%) patients who had an MRI diagnosis of MCC via the Tayside hotline reported nerve root pain. For one patient no data regarding root pain were recorded, for another a report of root pain was given but no date to calculate duration of pain. The median duration of nerve root pain in the 39 patients for whom information was available was 28 days, and this compares favourably (and significantly) with a median of 89 days in the CRAG audit . For patients with cancers other than lung cancer, the reported median time of root pain before diagnosis was 30 days via the hotline and 72 days in CRAG, and was, again, statistically significant .In the lung cancer subgroup, the mean time from reporting root pain to diagnosis was 17.2 days in the hotline and 181.2 days in the CRAG audit, and this difference was statistically significant . The improved clinical results were achieved without applying any additional pressure to the MRI service.We would suggest that a key component of this was the educational process that preceded the introduction of the hotline. By assembling a multi-professional group, we were able to contact, both directly and indirectly, those health-care professionals who would be involved in implementing the new procedures. Incorporating their views and listening to their opinions throughout the whole of the re-design process provided a two-way channel of communication: consultation and education became simply two aspects of the same enterprise. This meant that when it came to implementing the intervention, the staff involved  were motivated, aware and well disposed to ensuring the success of the enterprise. This intervention was seen as an initiative developed by front-line clinicians with immediate and visible benefits for both patients and staff.We were fortunate with our first patient referred via the hotline. This patient was walking without any help and the MRI confirmed extensive compression at T7. This helped modulate the perceptions of staff in the MRI unit. Their previous experience had led them to believe that MRI findings of MCC were invariably associated with paralysis. As a consequence, staff believed that they could make a major contribution in getting patients treated sooner. The cycle of despondency was broken. As the majority of patients accrued via the hotline were mobile, the process of scanning was physically easier, and less moving and handling were required. This contrasted with the previous experience in the scanning unit where the majority of patients with MCC had established paralysis, and all that this implies in terms of handling and dignity by the time they were scanned.Symptoms in patients known to have active cancer have a different diagnostic interpretation than similar symptoms in patients not known to have cancer. In patients with cancer, new or escalating pain, in particular new nerve root pain, is associated with disease progression and strongly suggestive of the involvement of the spinal cord or cauda equina. One feature of the hotline system was that it afforded GPs, who may have been concerned about how to interpret worrying symptoms, the opportunity to have immediate discussions with a senior clinician and to make a plan.Our initial efforts were concentrated on ensuring that the referral system worked smoothly within the hospital before advertising it more widely. Once the hotline was embedded within the hospital, we set out actively to increase the involvement of the wider community. A review of 42 patients subsequent to those included in this paper already shows an increase in community referrals  (unpublished audit 2008).Early MRI examination and reporting is feasible for carefully selected patients. There has been minimal impact on other imaging services and no noticeable effect on overall waiting times for investigation.More patients were referred from within hospital than from the community. However, this paper reports the first results from the hotline, and during that period, we concentrated on establishing an effective process of selection and scanning. With time, the number of referrals from the community has increased, as GPs and community-based nurses are becoming more aware of the service.A telephone hotline offers a simple, affordable and practical method whereby MCC can be diagnosed earlier and, in this study, we have clearly shown that earlier diagnosis improves outcome, in particular patients’ mobility.


Recently, dexamethasone has been found to have a prophylactic effect on postoperative vomiting and pain in children undergoing tonsillectomy. However, few studies have examined the preemptive analgesic effects of dexamethasone after tonsillectomy. The aim of this study was to evaluate the effect of pre-incisional infiltration of tonsils with dexamethasone on the incidence and severity of postoperative pain and vomiting in children undergoing tonsillectomy under general anesthesia.In a double blinded study, 62 patients were randomly allocated to infiltrate dexamethasone  or an equivalent volume of saline at the peritonsillar region. All infiltrations were performed following the induction of general anesthesia and 5 minutes prior to the onset of surgery. Anesthetic agents, end-tidal carbon dioxide levels, and the administration of intravenous fluids were carefully regulated. Surgery was performed by one attending otolaryngologists using the same dissection and snare technique. The incidence of pain and vomiting, need for rescue antiemetics, and analgesic consumption were compared in both groups. Pain scores used included Children's Hospital Eastern Ontario Pain Scale, “faces”, and a 0-10 visual analogue pain scale.Demographics of dexamethasone and placebo groups were similar. No statistically significant difference was found between the dexamethasone and placebo groups in pain score, nausea, vomiting, irritability, or analgesic requirement postoperatively.Preincisional infiltration of the tonsils with dexamethasone play a limited role in the recovery phase from tonsillectomy, but further prospective, randomized studies are needed to support it. Tonsillectomy is one of the most frequently performed ambulatory surgical procedures in children and is associated with an incidence of postoperative vomiting ranging between 40% and 73%. The intr792 O in 50% oxygen under mechanical ventilation adjusted to maintain heart rate and blood pressure values within 20% of the baseline induction. Muscle paralysis was maintained with atracurium. The patients were given intravenous morphine 0.1 mg/kg for intraoperative analgesia. During anesthesia, the heart rate (ECG), arterial oxygen saturation (SpO2), blood pressure, temperature and end-tidal CO2 were monitored. Following the induction of general anesthesia, but prior to the onset of surgery, the peritonsillar regions were infiltrated. The same surgeon, using an electrodissection technique, performed all operations. The patients were randomized to infiltrate dexamethasone  or an equivalent volume of saline at peritonsillar region. Study drugs were marked only with a coded number label. A computer-generated table of numbers guided randomization. All infiltration was performed in the same manner. The needle was inserted superficially into the tonsillar pillar, and following aspiration the pillar was ballooned. Three injections into both pillars were made on every patient: At superior pole, at the inferior pole, and between the poles. A reversal dose of neostigmine 40 μg/kg with atropine 20 μg/kg was administered at the completion of surgery. At the end of surgery, gastric contents were suctioned via an orogastric tube before extubation. The trachea was extubated when the child was awake. All children were transferred to the (PACU). Each patient was assessed by a single-blinded observer measuring postoperative pain in the recovery room prior transfer to the ward and then again at four and eight hours. In patients aged 12 years and older, we used a simple linear analog pain scale from 0 = no pain to 10 = most severe.[®, Gerot, Iran) was administered in increments of 5 mg  every 5 min until the child was comfortable. Water was offered to children one hour after arrival in the PACU and at the child's request. Intravenous fluid infusion was continued until adequate oral intake . The nurse recorded the incidence of vomiting. For the purpose of this study, vomiting was defined as ‘the forceful expulsion of liquid or solid gastric contents’. Retching and nausea were not considered vomiting. Repeated vomiting within a one-to two-minute period was recorded as a single emesis. Vomiting occurring more than twice was treated with metoclopramide 0.15 mg·kg–1 i.v. The presence or absence of any side effect such as bleeding, fever, flushing or headache was noted.A randomized, double-blind, placebo-controlled clinical trial was conducted at the Alzahra Hospital following approval by the Hospital Ethics Committee. Informed written consent was obtained from the parents of 62 ASA I and II children aged between three and 15 years scheduled for elective inpatient tonsillectomy with or without adenoidectomy. Exclusion criteria included a known allergy to dexamethasone, any patient with a known contraindication to steroid use, an ASA physical status III or greater, a history of severe postoperative vomiting, children who received antiemetics, steroids, anti-histaminic, or psychoactive drugs during the week before surgery, patients who need additional analgesic during surgery, and children with sever postoperative bleeding who were reoperated. In both groups, no oral premedication was administered before surgery. After IV infusion of acetated Ringer's solution 10 mL/kg, anesthesia was induced with fentanyl 1-2 μg/kg and thiopental 5 mg/ kg IV, and the trachea was intubated after the administration of atracurium 0.5 mg/kg IV. Anesthesia was maintained with halothane 1.0% and Nt severe. This cont severe. Each patt test or Chi-squared test for contingency tables as appropriate. Visual analogue scores were analyzed using Mann-Whitney U test. Differences within groups were subjected to the Wilcoxon signed rank test. A P value < 0.05 was considered statistically significant.A sample size calculation performed before the commencement of the study revealed that 31 patients per group would be required to detect a 30% reduction in the incidence of postoperative pain, assuming a 40% baseline incidence of pain after tonsillectomy in the control group (α ≤ 0.05 and β = 0.20). Data were analysed using the statistical program SPSS for window, Release 11. Parametric data including patient demographics of age and weight were analyzed using Student's The two groups did not differ significantly with respect to age, sex, weight, length of operation, and fluid required during the operation . The incResearch into the physiology of pain has delineated 2 distinct pain mechanisms that result from the stimulus of surgical trauma. There is inflammatory pain, a local effect produced by the surgical trauma, and there is physiologic or functional pain, a central effect produced by stimulation of the central nervous system. It follows that the use of anti-inflammatory agents, such as acetaminophen, would successfully treat pain and, in fact, is standard practice in the treatment of postsurgical pain. Likewise many surgeons use “preemptive analgesia,” the use of local anesthetics at a surgical site before a surgical procedure is commenced, because this blocks the development of hypersensitivity and hyperalgesia, which are important mechanisms in the promotion central sensitization (physiologic pain).16 The us77179101017This study has shown that a course of dexamethasone injection before incision of tonsils may offer limited improvement in the recovery phase from tonsillectomy. It is possible that a beneficial effect was masked by insufficient sample sizes. We believe additional research is needed to find additional treatments to improve the recovery for these children.


Abdominal pain is a common cause for emergency admission. While some patients have serious abdominal pathology, a significant group of those patients have no specific cause for the pain. This study was conducted to identify those who have non-specific abdominal pain who can be either admitted short term for observation or reassured and discharged for outpatient management.A prospective documentation of clinical and laboratory data was obtained on a consecutive cohort of 286 patients who were admitted to a surgical unit over a nine month period with symptoms of abdominal pain regarded severe enough for full assessment in the casualty department and admission to a surgical ward. The patients were followed until a definite diagnosis was made or the patient's condition and abdominal pain improved and the patient discharged. The hospital where the study took place is a small peripheral general hospital draining a population of 120,000 people in a rural area in New Zealand.There were 286 admissions to the emergency department. Logistic regression multivariate statistical analysis showed that guarding raised white cells count, tachycardia and vomiting were the only variables associated with significant pathology.Patients with no vomiting, no guarding, who have normal pulse rates and normal white cell counts are unlikely to have significant pathology requiring further active intervention either medical or surgical. Abdominal pain is very common presentation to emergency department. It is vital that the physician has an understanding and be familiar with the presentations of common diseases that cause abdominal pain ,2. PatieWomen of childbearing age commonly present with right iliac fossa pain, most of them do not have appendicitis . Those wPatients assessed at the emergency department at Rotorua Public Hospital with acute abdominal pain requiring admission to the surgical unit were enrolled in the prospective study.Patients were examined by the admitting surgical team after taking a thorough history, Relevant points in the history included the patient's gender, duration of pain, site of pain, character of pain, fever, loss of appetite, change in bowel habit, vomiting, abdominal distension and urinary or genital symptoms.Factors in the clinical examination that were considered of significant contribution to the final diagnosis included temperature, tachycardia, and abdominal tenderness and localized guarding.Data was collected prospectively on an electronic database. Patients were followed up with further investigations that included ultrasound scan, CT scan and diagnostic laparotomy as was clinically indicated to ascertain the final diagnosis. All patients were admitted for observation or surgery if indicated.Non-specific abdominal pain was defined as an abdominal pain in right iliac or hypogastric area lasting more than 6 hours and less than 8 days, without fever, leukocytosis, or obvious peritoneal signs and uncertain diagnosis after physical examination and baseline investigations including abdominal sonography; provide they have totally settled or underwent diagnostic laparoscopy that proved to be normal.® version 10.5. Univariate analysis was performed using simple linear regression; multivariate analysis was performed using logistic regression analysis.Analysis was performed to evaluate the relative contribution and specificity of each individual factor to a definitive final diagnosis that led to identification those who had no definitive diagnosis. The data analyzed using SPSSThere were 286 patients over three months period of the study, 201(70%) females). Median age is 37 years. The causes of abdominal pain are shown in , raised WBC (p = <0.0001), tachycardia (pulse rate greater than 100 per minute) (p < 0.0001), temperature (p < 0.0001), rigors (p = 0.0008), lack of appetite (p < 0.0001) and vomiting (p < 0.0001). Table 3Multivariate analysis was conducted using logistic regression; it showed he only significant predicting factors for acute surgical diagnosis are Heart rate p = 0.048), guarding (p = 0.0009), WBC (p = 0.016) and vomiting (p = 0.008). Table 8, guardiThe current study shows that patients who present with abdominal pain with no vomiting, guarding or raised white cell count are unlikely to have significant intra abdominal pathology and therefore can be considered for early discharge back to the community. Abnormal liver function test was helpful to point out the possibility of biliary colic, so was microscopic hematuria that may reflect urinary tract pathology.Complaints of acute abdominal pain are common emergency department presentations. Many of these conditions prove to be benign and self-limiting illness, which has no clear explanation. Tenderness and peritonism in the right iliac fossa are not specific for appendicitis but may help to narrow the differential diagnosis in patients with right iliac fossa pain ,7. HowevIn females of childbearing age, the presence or absence of bilateral tenderness pain migration and vomiting may help to differentiate acute appendicitis from acute pelvic inflammatory disease  where paImaging such as ultrasound  is helpfEarly diagnostic laparoscopy and treatment results in accurate, prompt, and efficient management of acute abdominal pain. This technique reduces the rate of unnecessary laparotomy and right iliac fossa gridiron incisions and increases the diagnostic accuracy in these patients; however this approach is expensive with significant use of the resources and potential morbidity . DiagnosThe current study shows the likely groups of patients with non-specific abdominal pain are those with normal white cell count, no history of vomiting and absent signs of peritoneal irritation with normal heart rate. Patients who fulfill those findings are suitable for early discharge, which may help to reduce the health care cost for those patients. All patients admitted to emergency department with abdominal pain should be referred for surgical opinion and the diagnosis of nonspecific abdominal pain should only be made after thorough assessment, definite pathology excluded and the patient does not return with the same complaint.The author(s) declare that they have no competing interests.


Myofascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the general population. Current guidelines for the management of myofascial pain are not available. In this study we investigated how physicians on the basis of prescription behaviour evaluate the effectiveness of treatment options in their management of myofascial pain.We conducted a cross-sectional, nationwide survey with a standardized questionnaire among 332 physicians  experienced in treating patients with myofascial pain. Recruitment of physicians took place at three German meetings of pain therapists, rheumatologists and orthopaedists, respectively. Physicians estimated the prevalence of myofascial pain amongst patients in their practices, stated what treatments they used routinely and then rated the perceived treatment effectiveness on a six-point scale (with 1 being excellent). Data are expressed as mean ± standard deviation.The estimated overall prevalence of active myofascial trigger points is 46.1 ± 27.4%. Frequently prescribed treatments are analgesics, mainly metamizol/paracetamol (91.6%), non-steroidal anti-inflammatory drugs/coxibs (87.0%) or weak opioids (81.8%), and physical therapies, mainly manual therapy (81.1%), TENS (72.9%) or acupuncture (60.2%). Overall effectiveness ratings for analgesics (2.9 ± 0.7) and physical therapies were moderate (2.5 ± 0.8). Effectiveness ratings of the various treatment options between specialities were widely variant. 54.3% of all physicians characterized the available treatment options as insufficient.Myofascial pain was estimated a prevalent condition. Despite a variety of commonly prescribed treatments, the moderate effectiveness ratings and the frequent characterizations of the available treatments as insufficient suggest an urgent need for clinical research to establish evidence-based guidelines for the treatment of myofascial pain syndrome. Myofascial pain syndrome is a chronic muscular pain disorder in one muscle or groups of muscles accompanied by local and referred pain, decreased range of motion, weakness, and often autonomic phenomena. It is a primary cause of health-care visits, absenteeism and invalidity pensions .Myofascial pain affects up to 85% of the general population . MyofascTreatment approaches in myofascial pain range from analgesics to various physical modalities. These approaches include combined techniques (e.g. spray and stretch), manual techniques, transcutaneous electrical stimulation (TENS), frequency-modulated neural stimulation, ultrasound or massage, injections, acupuncture and dry needling -14. AnalIn conclusion there is not sufficient clinical evidence to incorporate evidence-based guide treatments.We therefore evaluated the distribution of the usage and physicians rating of effectiveness for frequently prescribed treatments amongst German physicians with experience in treating patients with myofascial pain.We conducted a cross-sectional, nationwide survey among German physicians involved in the management of patients with myofascial pain. Participants were recruited at the annual meetings of the German Society for the Study of Pain, German chapter of the IASP [Deutsche Gesellschaft zum Studium des Schmerzes], the Professional Organisation of German Rheumatologists [Berufsverband Deutscher Rheumatologen] and the Association of Southern German Orthopaedists [Vereinigung Süddeutscher Orthopäden]. Participants completed a standardised questionnaire.A subgroup analysis was performed within three groups of all physicians. We chose pain therapists, orthopaedists and rheumatologists as they were thought to be the ones with most experience in attending and treating myofascial pain syndrome.http://www.wma.net/en/30publications/10policies/b3/index.html. Written consent was not sought from each participant for use of survey data, but consent of respondents was assumed if they completed and returned the questionnaire.In this trial we consider the ethical, legal and regulatory norms and standards for research involving human subjects in Germany. As this study did not involve patient data and the research did not involve humans, ethical approval was not necessary In the first part we assessed the following demographic data: age, gender, field of specialisation , subspecialisation , employment centre , and status of specialisation (resident and consultant). We asked for the physician's average number of treated myofascial pain patients and the number of patients referred to specialised pain centres.Secondly we wanted the physicians to estimate the importance of myofascial pain in the general population on a six-point scale (with 1 being a very common problem). Additionally the physicians had to estimate the prevalence of active trigger points in the population and their respective patients in percent.Physicians were asked to choose their routinely prescribed therapeutic options in the treatment of myofascial pain syndrome from a list of prespecified options. Afterwards they had to rate the effectiveness of the approaches chosen based on their own experience on a six-point scale (with 1 being "excellently effective" and 6 being "ineffective"). We asked for analgesics , physical medicine  and injections . In each category, physicians had the opportunity to name additional treatment approaches (free text). Finally, we asked for the opinion regarding the sufficiency of available treatment options.All statistical analysis was carried out using the SPSS statistical software system . Data were expressed as mean ± SD. Between-group differences were examined with Kruskal-Wallis tests, using the Mann-Whitney U tests for post-hoc two-group comparisons. Two-sided p < 0.05 were considered statistically significant. Due to the exploratory nature of our analyses, no alpha adjustments for multiple testing were undertaken.Three hundred thirty-two physicians with a mean age of 47.5 ± 9.6 years  responded to the questionnaire. Among all physicians, 146 (44.0%) were orthopaedists, 97 (29.2%) internists and 63 (19.0%) anaesthetists. Out of these groups, 90 (27.1%) were sub-specialised in rheumatology and 50 (15.1%) in pain therapy. Thirty-seven (11.1%) doctors worked at a university hospital, 113 (34.0%) at a county hospital, 160 (48.2%) in a private clinic, 2 (0.6%) in a pain centre and 20 (6.0%) did not specify their place of work. Forty-one (12.3%) physicians were residents and 281 (84.6%) consultants. The detailed affiliations and professional status of the respondents are shown in Table S1  of all physicians attended more then four patients a week, 87 (26.1%) between one and three patients a week, 39 (11.7%) between one and three patients per month, 36 (10.8%) up to ten patients a year and 6 (1.8%) physicians never saw myofascial pain patients. There were no intergroup differences regarding those distributions (p = 0.801).When we asked how often patients were referred to special pain centres, we found the following distribution: 82 (24.6%) of physicians never did, 89 (26.7%) up to ten patients per year, 96 (28.8%) up to three patients per month, 25 (7.5%) between one and three patients a week and 26 (7.8%) referred more than four patients a week to a specialised pain centre. Pain therapists rarely refer their patients to another centre (p < 0.001). For detailed information see Table S1 . There were no significant differences among the respective groups (p = 0.803), specialities (p = 0.578), genders (p = 0.294) or other demographic data.Physicians estimated the prevalence of active trigger points to 46.1 ± 27.4% n = 329) in the overall population and 52.8% ± 26.9 (n = 330) in their own patients. Subjects from the pain congress rated these frequencies higher than other physicians; 55.4 ± 22.2% in the overall population (p < 0.001) and 63.4 ± 21.7% in their own patients (p = 0.001). For detailed information see Table S2 . Non steroidal anti-inflammatory drugs or coxibs were the main analgesics , followed by metamizol and paracetamol , weak opioids , antidepressants , strong opioids  or anticonvulsants . Other drugs were rarely used , physicians named especially muscle relaxants  and flupirtine . Detailed intra- and inter-group values are shown in Figure Physical therapies were prescribed one-third less often than analgesics . Manual therapy was prescribed most often, i.e. by 270 (81.1%) of all physicians, followed by TENS  and acupuncture . Ultrasound , percussion waves  or dry needling  were prescribed less often. Additional treatments were chosen by 72 (21.7%) of all physicians. These treatments were rather specified e.g. chiropractics (n = 8), cryotherapy (n = 3) and osteopathy (n = 3) as other physical therapy. Detailed intra- and inter-group values are shown in Figure The use of injection techniques is less important in the overall therapeutic concept . Injection of local anaesthetics was mainly used . Spinal interventions  was used by 102 (30.7%) whereas injection of botulinum toxin was used by 41 (12.3%) of physicians. Additional techniques  were not specified. Detailed intra- and inter-group values are shown in Figure A 6-point scale (with 1 being excellent effective and 6 being worst) allowed physicians to rate the effectiveness of the used treatment approaches. 54.3% of all physicians surveyed stated current symptom-based treatment options being insufficient. This opinion was more pronounced in the rheumatologists group (77.3%) than anaesthetists (49.2%) or orthopaedists (45.8%).Muscle relaxants 2.1 ± 0.5) and flupirtine (1.6 ± 0.7) are estimated as most effective analgesics. They form part of additional assignable drugs . They were followed by antidepressants (2.6 ± 1.0), non-steroidal anti-inflammatory drugs or coxibs (2.7 ± 1.0), metamizol or paracetamol (3.1 ± 1.0), weak opioids (3.1 ± 1.1), strong opioids (3.2 ± 1.5) and anticonvulsants (3.2 ± 1.2). Detailed intra- and intergroup data are shown in Figure .1 ± 0.5 There were significant intragroup differences regarding the rating of treatment options for non-steroidal anti-inflammatory drugs or coxibs (p = 0.002), weak and strong opioids (p < 0.001), anticonvulsants (p = 0.024) and additional pharmacologic approaches (p = 0.006). Non-steroidal anti-inflammatory drugs or coxibs were rated better by orthopaedists when compared to pain therapists (p = 0.018) or to rheumatologists (p = 0.001); weak and strong opioids were rated less effective by pain therapists than orthopaedists (p < 0.001) or rheumatologists (p < 0.01); pain therapists rated anticonvulsants worse than orthopaedists (p = 0.008); Other pharmacologic treatments scored better in the pain group then with orthopaedists (p = 0.007) or rheumatologists (p = 0.018).Manual therapy was rated with an average of 2.3 ± 0.9. Dry needling (2.4 ± 1.1) and acupuncture (2.4 ± 1.0) were estimated with a similar effectiveness. TENS (2.6 ± 0.9) scored better than percussion waves (2.8 ± 1.2). Ultrasound techniques were estimated being the less effective therapeutic option (3.0 ± 1.2). Additional treatments  were rated 2.0 ± 0.9. Detailed intra- and intergroup data are shown in Figure There were intragroup differences regarding the rating of TENS (p = 0.001), manual therapy (p = 0.002) and acupuncture (p = 0.006). TENS got a better ranking by orthopaedists (p = 0.001) and pain therapists (p < 0.001) when compared to rheumatologists. The same held for manual therapy  and acupuncture . Ultrasound was rated better by orthopaedists than pain therapists (p = 0.033); Dry needling was rated better by pain therapists than orthopaedists (p = 0.039) or rheumatologists (p = 0.044).Injection of local anaesthetics was rated with an average of 2.3 ± 1.0 and injection of botulinum toxin scored 2.8 ± 1.4. Spinal interventions scored worst (2.9 ± 1.8). Additional but unspecified injections scored 1.9 ± 0.5. Detailed intra- and intergroup data are shown in Figure There were intragroup differences regarding the rating of injection of local anaesthetics (p = 0.008). This concerned the rheumatologists group when compared to pain therapists (p = 0.032) or orthopaedists (p = 0.002). Injections were rated differently by orthopaedists and rheumatologists (p = 0.021).A gender effect could be demonstrated for the use of spinal interventions (p = 0.049), which is rarely used by women, while they prefer manual therapy (p = 0.019).Physicians younger than 35 years rated the use of weak (p = 0.002) and strong opioids (p = 0.009) less effective than those older than 65 years.Working place-related effects appeared different: physicians employed at district hospitals (n = 113) estimated non-steroidal anti-inflammatory drugs or coxibs more effective than physicians working in a private practice .Comparing the ratings of residents and consultants, it became evident that residents evaluated weak (p = 0.004) and strong opioids (p = 0.001), antidepressants (p = 0.049) and dry needling (p = 0.042) less effective.To our knowledge, the present study is the first physicians survey that estimates the prevalence and clinical importance of myofascial pain and the utilization rate and physician rated effectiveness of the most common treatment options. Our data suggests that German physicians that treat various pain issues considered myofascial pain a highly prevalent condition. Though, prescription rate and estimated effectiveness of prescribed treatments showed significant discrepancies: the most frequently prescribed treatments were not rated the most effective Figures , 2. In aThis current survey demonstrates that physicians estimated the effectiveness of frequently prescribed analgesics as unsatisfactory. For example commonly used analgesics such as NSAID and coxibs, metamizol and paracetamol and weak opioids were estimated moderately in their effectiveness. This lack of concordance between frequently prescribed treatments and perceived effectiveness reflects the lack of scientific evidence and available treatment guidelines. Consensus is also requisite among researchers to define and describe myofascial pain using standard terminology and validated examination techniques . In partSimilar observations have been made by Tsang and her colleagues in the treatment of chronic vascular disease. A knowledge gap caused by lack of awareness of the evidence or familiarity with current treatments leads to a so called evidence-to-practice care gap .We observed that the perceived effectiveness of some treatments that require specialized education and additional experience, including acupuncture, TENS, dry needling or injections varied among specialist. In general, these techniques were rated to be controversial; especially by physicians not familiar with these practical treatments. For example, ratings for injection techniques  differed in between groups, what could be explained by a particular enhanced use of invasive methods in the respective clinical fields. The choice of treatment might depend on the professional career of the physicians. For example orthopaedists, by specialisation familiar with surgical techniques, were estimating injections better. In contrast, rheumatologists, familiar with pharmacologic treatments, estimated pharmacologic approaches better. There were also differences regarding the rating of group related treatments such as ultrasound and percussion waves that could be due to different educational access. Taken together these data suggest that the estimated efficacy of treatment options for myofascial pain syndrome is mostly influenced by the speciality-related training and education of the physicians.In addition our data show that other physician-related parameters may influence the choice of treatment. We analysed the impact of working place or status of specialisation. While physicians in the pain congress group mainly worked in hospitals, those members that had chosen a private practice as their working place rated treatments differently, which might reflect the differences in work experience in these groups. It might also influence the choice and rating of treatments. We could also demonstrate that use and evaluation of treatments are influenced by the status of specialisation. It might also be possible that previously learned strategies are kept out of mind. It has been shown that physicians reconsider the use of evidence-based treatments by simple patient-specific prompting .Access to education in the treatment of myofascial pain seems to be an important fact whilst improving diagnosis and treatment of myofascial pain. Bishop et al. could recently demonstrate diversity of the attitudes of general practitioners and physiotherapists in the United Kingdom (UK) towards low back pain patients. Against the line of clinical guidelines a quarter of respondents believed in avoidance of physical activity or the need to be off work as part of treatment regimen . This suIt remains interesting why physicians estimated seldom used pharmacologic remedies as very effective, e.g. muscle relaxants, chiropractics or flupirtine. Flupirtine for example appeared as a scientifically promising but not yet prevalent treatment option . Large cThe majority of physicians, even whilst prescribing, characterized the available symptomatic treatment options as insufficient. This might also reflect the challenge to understand the sophisticated pathogenic pathways that may lead to myofascial pain syndromes. The complexity of pathogenesis might also be expressed regarding the multitude of different available treatment approaches. This survey did e.g. not approach the psychosocial aspects of treatments event though it is supposed that the occurrence of depression has been related to pain syndromes of the joints and musculoskeletal system . It is cIn addition, physicians estimated the prevalence of active trigger points. Almost every second person is considered having active trigger points, thus supporting physicians opinion considering myofascial pain a highly prevalent condition. Myofascial trigger points have been described as a 'common cause of pain in clinical practice' and an 'extremely common, yet commonly overlooked' source of musculoskeletal disorders . The eviClinically, an active (symptom-producing) central myofascial trigger point can be defined as a hyperirritable nodule of spot tenderness in a palpable taut band of skeletal muscle. The spot is a site of exquisite tenderness to palpation from which a local twitch response can be elicited when appropriately stimulated, that refers pain to a distance, and that can cause distant motor and autonomic effects.These clinically findings have not been proven to be reliable, as stated in a recent review by Lucas et al. .However there is no validated list of diagnostic criteria for mTrPs. Two pilot studies with a small number of subjects evaluating various diagnostic tests ,34 reporOur data demonstrate that active myofascial trigger points are considered prevalent and related to myofascial pain by the physicians. Hence, the lack of concordance in this field is limiting the conclusion how far this observation may contribute to the thesis that trigger point diagnosis is reliable.It is commonly understood that chronic myofascial pain may be a consequence of a complex stress response that extends beyond the nervous system and contributes to the experience of pain.As we chose personal contact instead of postal distribution almost everyone asked responded to the questionnaire (response-rate > 95%).In any attempt to examine the clinical practice of myofascial pain syndrome management for an entire population of physicians in a country, a questionnaire study is the most feasible method. However, we do not know to what extent the physicians' responses represent their actual practice, or whether is their perception of professional behaviour. It remains an open question whether the physicians' skills and abilities to treat myofascial pain syndrome are reflected in the answers and ratings to the questions. It is our belief that the questionnaire addresses central elements in myofascial pain management. The only reliable way to measure prescribing practices is to analyse the actual process in detail. But even then, this approach would not provide an understanding of the perceived effectiveness of the prescribed treatments.Our questionnaire regarded the myofascial pain syndrome as a single entity. One reason was the current lack of strict classification criteria for distinct clinical entities. The participants of this study might handle different aspects of the myofascial pain syndrome and therefore choose different treatments. We took the approach on introducing questions on myofascial trigger points at the beginning of the questionnaire to help ensure that the physicians responses related to the treatment of myofascial pain syndrome rather than other soft tissue pain conditions such as fibromyalgia.The questionnaire has not undergone formal validation. The objective of this study was to analyse and provide an overview of the diversified customs of German physicians in the treatment of myofascial pain syndrome. Given the purpose of the questionnaire, validation is not necessary.The results of this survey demonstrate that there is no agreement amongst German specialist in the utilization and perceived effectiveness of the various common treatment options for myofascial pain. In view the low rating of effectiveness, physicians seem to be aware of this drawback. We believe that guidelines for the treatment of myofascial pain syndrome are necessary. Neither standard diagnostic procedures to identify myofascial pain nor discriminating variables to distinguish the different entities of myofascial pain syndrome are available. Therefore we conclude that multiple diagnostic approaches may lead to therapeutic confusion.All things considered, beside education in the management of myofascial pain syndrome and enhancing manual skills, clinical investigation is necessary to develop standard guidelines in the diagnosis and treatment of myofascial pain syndrome.The authors declare that they have no competing interests.JF conceived the study, performed the statistical analysis and drafted the manuscript. DZ, LL and FF recruited and assessed participants. LJR and PML participated in the design of the study and helped drafting the manuscript. DI participated in the design and coordination of the study and supervised drafting the manuscript. All authors read, and approved of, the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/11/32/prepubQuestionnaire on myofascial pain. Please find detailed description of the questionnaire within the manuscript.Click here for fileTable S1 - Demographic and participants characteristics (mean ± SD or in %). Table S1 provides the demographic data of physicians dealing with myofascial pain: age, gender, field of specialisation, subspecialisation, employment centre and status of specialisation. We asked for the physician's average number of treated myofascial pain patients (Treatment ratio) and the number of patients referred to specialised pain centres . Data are expressed as mean ± SD or as total count (n) and in percent (%).Click here for fileTable S2 - Estimated prevalence (mean ± SD). Table S2 provides the physician estimated importance of myofascial pain in the general population on a six-point scale (with 1 being a "very common problem"). Additionally the physician estimated prevalence of active trigger points in the general population and their respective patients in percent (%) is given. Data are expressed as mean ± SD.Click here for fileTable S3 - Prescription Rate of Treatment Options (in %). Table S3 indicates the physician estimated prescription rate of different therapeutic options in the treatment of myofascial pain. Data are expressed in percent (%). TENS: transcutaneous electrical stimulation.Click here for fileTable S4 - Ratings (1-6) of treatment options (mean ± SD). Table S4 indicates the physician estimated efficacy of different therapeutic options in the treatment of myofascial pain on a 6-fold scale (with 1 being "excellently effective" and 6 being "ineffective"). Data are expressed as mean ± SD. TENS: transcutaneous electrical stimulation.Click here for file


Methylergonovine is an ergot alkaloid widely used in postpartum women. It is also an active metabolite of methysergide and previous studies suggest that it could be effective against refractory headache and cluster headache. The purpose of the present study was to assess the potential therapeutic effectiveness of methylergonovine in the emergency treatment of severe migraine.One hundred and twenty five female patients with migraine attending the emergency department received 0.15 mg of methylergonovine intravenously. Pain intensity, heart rate, blood pressure, and methylergonovine side effects were checked 5, 10, 15, 30 and 60 minutes after drug administration. An additional 0.075 mg dose of methylergonovine was administered to those patients who did not experienced relevant pain relief 15 minutes after dosing. Pain intensity decreased markedly from the first minutes after dosing, the 74.4% of patients being pain free at 60 minutes. Only seven patients required an additional dose of methylergonovine. Nausea and vomiting were the most relevant side effects related with methylergonovine administration (84% of patients). A substantial decrease (10 to 25 mmHg) in systolic blood pressure values was observed in 56% of the patients. A significant correlation (p < 0.0001) was found between the decrease in pain intensity and the reduction of systolic blood pressure.Although limited by the non-controlled design of the study, our data suggest that intravenous methylergonovine can be an effective and safe drug in the management of severe migraine attacks in the emergency room. The treatment of migraine attacks in the emergency room includes the use of several kind of drugs, usually administered by parenteral route, namely non-steroidal antiinflamatory drugs (NSAIDs), opioids, glucocorticoids, neuroleptics, ergot alkaloids and triptans . Among eMethylergonovine, also called methylergometrine, is another ergot alkaloid, a semisynthetic derivative of LSD, widely used in the postpartum for its uterotonic properties. Additionally, methylergonovine is also a major active metabolite of methysergide whose area under the curve after oral administration of methysergide is substantially higher than the one of the parent drug . MethyleThe purpose of the present study was to evaluate the potential effectiveness of intravenous methylergonovine in the acute treatment of severe migraine previously refractory to non-steroidal analgesic drugs (NSAID).The study was done in the Emergency Departments of two hospitals of the district of Santa Marta, in Colombia. Inclusion criteria were female adult patients experiencing migraine with or without aura according to the IHS diagnostic criteria , and sufWomen experiencing current or previous cardiovascular disease, morbid obesity, epilepsy, serious (DSM IV Axis I) psychiatric disease, known intolerance to ergot alkaloids, pregnant or lactating were excluded from the study, as well as those who have received ergotamine or triptans in the previous twenty four hours.Pain intensity was assessed by means of a Visual Analog Scale (VAS) just before drug administration and 5, 10, 15, 30 and 60 minutes after. Arterial blood pressure and heart frequency were measured, and emergent drug adverse reactions were recorded at the same time points. Methylergonovine was administered intravenously diluted in 5 ml of saline at an initial dosage of 0.15 mg. If pain intensity was still above 5 in pain VAS, an additional dose of 0.075 mg of methylergonovine was administered 15 minutes after the first one. Analgesic drug intake before admission was recorded. In fourteen (11%) patients, randomly selected, continuous monitoring of the ECG was performed during the all the observation period.http://www.graphpad.com.). Repeated measures analysis of variance was applied to analyze the evolution of pain severity, systolic and diastolic blood pressure, and heart rate. Effects sizes were caluculated according to the Cohen's formula and considered large when equal or higher than 0.80 [t test for unpaired data. The Spearmen correlation coefficients were used to evaluate the potential relationship between systolic blood pressure and pain intensity.Data were analyzed by means of GraphPad Prism version 5.0  suffered migraine without aura and 14 (11.2%) migraine with aura. Their age ranged from 25 to 45 years (45 ± 7). All patients reported photophobia, phonophobia, nausea and vomiting at baseline. Previous analgesic intake included paracetamol (55%), aspirin (16%), ibuprofen (16%), metamizole , diclofenac (8%), and combined analgesics (6.4%).Pain intensity subsided quickly after methylergonovine administration until reaching a mean value of 0.46 ± 1.1 60 minutes after dosing. As it can be seen in Figure Only seven (5.6%) patients required a second additional dose of methylergonovine 15 minutes after the initial one. As it is shown in Figure Complete disappearance of pain was reached by 66 (52.8%) patients 30 minutes after dosing and by 93 (74.4%) patients 60 minutes after dosing. Only one of the patients requiring an additional dose of methylergonovine was pain free at 60 minutes.Table Nausea (84.8%) and vomiting (84%) were the most frequent side effects related with methylergonovine administration, followed by fatigue (34.4%), diaphoresis (12%), and dizziness (11.2%). Seventy two (57.6%) patients reported perceptive alterations, mainly sensation to be floating, sensation of peacefulness, and feelings of pleasant relaxation.Intravenous methylergonovine originated a quick and strong relief of pain in our patients. The degree of improvement, either considering the mean VAS score 60 minutes after dosing or the percentage of patients experiencing total pain relief, was similar to the improvement described with the use of intravenous prochlorperazine, a conventional antipsychotic, in several randomized clinical trials -12.It is difficult to compare our data with those published for dihydoergotamine because, with only one exception in which it was found to be less effective than chlopromazine , this drThe fact that only one of the seven patients who received an additional dose of methylergonovine achieved complete pain relief, suggests that little or no drug benefit can be expected in initially nonresponder patients.Most frequent methylergonovine side effect is hypertension, hypotension having been described less frequently . HoweverNausea and vomiting have been reported to occur occasionally following methylergonovine administration . In our In our study men with migraine were excluded because methylergonovine, as an uterotonic drug, is basically used in women, and data concerning its pharmacological activity in men are lacking. Methylergonovine pharmacokinetics has been studied in women and in men: no differences between them were found when the drug was administered intravenously and, after oral administration, the wide interindividual variation in pharmacokinetic parameters did not allowed to compare adequately both groups . AdditioThe main limitation of our study is its non-controlled design due to the difficulties to carry out a controlled randomized clinical trial in Colombia, where this kind of studies are not easily performed if they are not sponsored by a international pharmaceutical company, mainly due to financial reasons. However, we think that the sample size of our study, the pronounced effect over pain, and the low interindividual variability of the data support the consistency of our results.An additional limitation is the fact that patients were dismissed from the hospital 30 minutes after the last evaluation, and were not followed later to assess headache recurrence. Methylergonovine half-life is short - 1.94 ± 0.34 hours after i.v. administration in women  and recuThere is a need for effective and low cost drugs for the acute treatment of severe migraine and status migrainosus. Sumatriptan is a very effective but expensive drug. Opioids are scarcely effective and most headache specialists advise against their use . AlthougDespite the above mentioned limitations, we think that our results suggest that intravenous methylergonovine, at least in the medium dose used in this study, can be an effective and safe drug in the emergency management of severe refractory migraine, and in an environment with limited access to health resources could be an alternative to triptans.The authors declare that they have no competing interests.AINM, GCG and WMB diagnosed and treated patients. EPC and FR participated in the design of the study and drafted the manuscript. All authors read and approved the manuscript's final version.


Current analgesics have drawbacks such as delays in acquisition, lag-times for effect, and side effects. We recently presented a preliminary report of a new analgesic method involving a two-minute sciatic nerve press, which resulted in immediate short-term relief of pain associated with dental and renal diseases. The present study investigated whether this technique was effective for pain associated with other disease types, and whether the relief was effective for up to one hour.This randomized, placebo-controlled, parallel-group trial was conducted in four hospitals in Anhui Province, China. Patients with pain were sequentially recruited by participating physicians during clinic visits, and 135 patients aged 15 – 80 years were enrolled. Dental disease patients included those with acute pulpitis and periapical abscesses. Renal disease patients included those with kidney infections and/or stones. Tumor patients included those with nose, breast, stomach and liver cancers, while Emergency Room patients had various pathologies. Patients were randomly assigned to receive a "sciatic nerve press" in which pressure was applied simultaneously to the sciatic nerves at the back of both thighs, or a "placebo press" in which pressure was applied to a parallel region on the front of the thighs. Each fist applied a pressure of 11 – 20 kg for 2 minutes. Patients rated their level of pain before and after the procedure.th minutes, and the relief decreased 47% by the 60th minutes.The "sciatic nerve press" produced immediate relief of pain in all patient groups. Emergency patients reported a 43.5% reduction in pain (p < 0.001). Significant pain relief for dental, renal and tumor patients lasted for 60 minutes (p < 0.001). The peak pain relief occurred at the 10 – 20Two minutes of pressure on both sciatic nerves produced immediate significant short-term conduction analgesia. This technique is a convenient, safe and powerful method for the short-term treatment of clinical pain associated with a diverse range of pathologies.Current Controlled Trials ACTRN012606000439549 Human beings have long suffered from pain caused by diseases. In medicine, pain is one of the most common reasons for patients to seek care. Analgesics used in current practice have drawbacks such as delays in acquisition and lag-times for effect after administration. In addition, many commonly used analgesics have considerable side-effects -4.Many non-drug analgesic interventions have been used to help manage pain, including acupuncture, cryoanalgesia, transcutaneous electrical nerve stimulation (TENS), exercise, and music therapy, etc. -7. ThougWe recently published a preliminary report on a new analgesic method, a 2-min sciatic nerve press, which immediately relieved pain brought on by various dental and renal diseases . The tecThe present study examined whether the technique worked on more pathologies, and whether pain relief extended to up to one hour.The study was a randomized, single-blinded, placebo-controlled, parallel-group trial consisting of 135 patients treated between October 2005 and May 2006 at four hospitals in China. The study was separately approved by each participating hospital – Anhui Province Hospital, Hefei, 230001, China ; Maanshan People Hospital, Maanshan, 243000, China ; Tongling Count Hospital, Tongling Count, 244100, China , and Chuzou Zhongxiyi Hospital, Chuzou, 239000, China . Written informed consent was obtained from each participating patient.Patients were divided into "sciatic press" and "placebo press" groups. Instructions and explanations were equally provided to all patients. Patients were informed that the experiments were designed to test whether the methods were effective for pain relief. Patients were advised that they could discontinue participation in the study at any time without penalty, and that their healthcare treatment would not otherwise be affected.After informed consent was obtained, the participating doctor(s) or assistants taught the patients how to evaluate pain using a visual analogue scale (VAS), where pain scored from "0" for no pain, to "10" for most pain. Thereafter, randomization of patients to the "sciatic press" or "placebo press" group was performed using the method of Random Permuted Blocks. The three stages of the test were then described to each patient: baseline pain rating, 2 min of leg pressure while lying down, and post-pressure pain rating at the specified times.Two test designs were used. For Emergency patients, pain was rated once after pressure application. In contrast, renal, dental and tumor patients underwent the 60 min test in which pain was rated at 10-min intervals for a period of one hour after pressure application. In this context, the '0 min' point indicated the time at which the 2-min leg pressure stopped and the post-pressure pain rating stage commenced. The baseline pain rating and leg pressure stages were identical for the two types of tests.The positions of sciatic nerve pressure and the fist gesture used for pressure application are shown in Figure The inclusion criterion was any patient who was feeling pain during a clinic visit to the Emergency room, Renal, Dental, or Oncology Clinics. Exclusion criteria were age less than 15 years, emotional instability, or administration of another analgesic within 12 hours of the test. For enrolled patients, the dental diseases included acute pulpitis and periapical abscesses. The renal diseases included infections and/or stones, and the tumors included those of the nose, breast, stomach, and liver. While Emergency Room enrollees had various pathologies. No patients had previously been treated with the sciatic press method. For tumor patients, analgesics were discontinued 11–13 hours prior to the test, and the study began when patients reported they had moderate-to-severe pain.The patient groups and characteristics are shown in Table t-tests for both groups. Comparisons with the "placebo press" groups were performed using an analysis of covariance procedure, with adjustment for baseline VAS score, gender and age. All tests were two-sided, and a p-value of < 0.05 was considered to indicate significance. All statistical analyses were performed using SPSS statistical software (release 13.0).Renal, dental and oncology patients were analyzed as one group in terms of relief of pain. Emergency room patients were analyzed separately, and without pathology categorization. The baseline VAS scores and age of the participants were compared between the "sciatic press" and "placebo press" groups using t-tests. Categorical data were analyzed using chi-square, or Fisher Exact tests. In terms of pain relief, changes from baseline were assessed using paired The study included 95 Emergency Department patients with various pain-related conditions Figure . Followith minute, and by 35.3% at the 60th minute.To test the longer-term effectiveness of the "sciatic press" method, 40 patients with pain from tumors, dental and renal diseases were tested for a period of one hour Figure . Pain dath and 60th minutes. Data were also expressed by subtracting "placebo press" values from "sciatic press" values and plotting the resultant value against time  compared to the first 10 min (11–15% reduction). In this group, 25% of patients had pain at the early time points but not at later times. For this study setting, we cannot rule out the total or partial contribution of a placebo effect, or some anterior nerve stimulation to the late drop. Pain discontinuity could also be contributing partially.Stimulation of peripheral nerves elevates the pain threshold -32. AccoPinch press of the rat sciatic nerve with a vascular clip (pinch force 120 g) caused attenuation of WDR neuron responses to various innocuous and noxious stimuli . While tTwo minutes of pressure on both sciatic nerves can produce immediate and significant conduction analgesia. This procedure provides a convenient, safe and powerful method for the short-term treatment of clinical pain induced by diverse disease types.The author(s) declare that they have no competing interests.JH was the primary investigator, had full access to all data, and takes responsibility for the integrity of the data and the decision to submit the work for publication. BW participated in renal clinical tests and data analysis. XJ collaborated in the pilot study and the mechanism study. FZ collaborated in the technical aspects and in administrative support for tumor patient testing. TZ participated in Emergency room tests. WZ collaborated in clinical tests on dental patients and in data interpretation. All authors read and approved the manuscript.The pre-publication history for this paper can be accessed here:


In recent years, general surgeons who perform inguinal hernia repair have paid attention to successful reduction in the recurrence rate. The Lichtenstein technique is widely used because it is easy to learn and is associated with a low rate of complication and recurrences. Today, the new objective in primary hernia surgery should be to reduce complications such as chronic pain. Chronic pain after hernia repair can be disabling, with considerable impact on quality of life and there is evidence to suggest increased use of health services by patients who have chronic pain. We have proposed an international randomized controlled trial with seven referenced European centers: The TI.ME.LI. trial. The aim of this study is to evaluate pain and further disabling complications in patients undergoing Lichtenstein technique for primary inguinal hernia repair by fixing the mesh with fibrin sealant versus sutures (control group). In recent years, general surgeons performing inguinal hernia repair have paid attention to successful reduction of recurrence rates. The Lichtenstein technique is widely used because it is easy to learn and it is associated with a low rate of complications and recurrences. Meshoma Inguinal hernia repair is a common surgical procedure performed worldwide, with an annual procedural rate of 2,800 per million people in U.S. alone. In U.K. Inguinal herniorrhaphy is often performed as a day-case procedure with minimal postoperative morbidity. After inguinal hernia repair, patients can return to work early and enjoy a good quality of life. Despite 69Chronic pain or persistent neuralgia has been recognized as a complication after inguinal hernia repair but was reported in the 1980s as a rare and infrequent condition. Studies 5The ‘pain complex syndrome’ after hernia repair includes three different aspects: 1) numbness and burning sensation  - the incidence was observed in 10 to 23% in open inguinal hernia repair in Cochrane review; 2) groin1815Etiology of this problem includes non-neuropathic and neuropathic causes or a combination of both. Non-neuropathic causes include mechanical pressure of folded or wadded mesh, periosteal reaction and scar-tissue formation. Neuropathic pain can be caused by compression of one or more nerves by ‘perineural fibrosis,’ suture material, staples and tacks or by nerves injuries. So if it is possible to limit the use of suture and fixation devices, chronic groin pain could be reduced.22 FollowBased on this study, we have planned an international randomized controlled trial with seven referenced European centers: the TI.ME.LI. trial.Our observational study design focuses on the absence of complications like pain complex syndrome in the patients undergoing hernia repair with a totally sutureless technique and a mesh fixation with fibrin sealant.This study took place from June 2004 to March 2006. A total of 113 consecutive patients  were operated with this technique for primary unilateral inguinal hernia. The age range varied from 45 to 65 years for females (mean age 55) and from 26 to 90 years for males (mean age 58). Exclusion criteria were recurrent hernia, femoral hernia, complicated hernia, obesity. All surgeries were performed by the same most experienced surgeon under local anesthesia. All patients were fully briefed about the surgical procedure and an informed consent was obtained.The median operating time (skin-to-skin) was 40 min and no immediate postoperative complications were observed. All patients were operated as day cases, with a maximum hospital stay of 20 h; none required readmission.The inguinal region was prepared and the hernia sac managed according to the Lichtenstein technique. The ilioProf. Giampiero CAMPANELLI, Milan, Italy Prof. Gérard CHAMPAULT, Bondy, FranceProf. Manuel HIDALGO, Madrid, SpainDr. Andreas HOEFERLIN, Mainz, GermanyProf. Marc MISEREZ, Leuven, BelgiumProf. Andrew KINGSNORTH, Plymouth, UKProf. Jacob ROSENBERG, Copenhagen, DenmarkBased on our hypothesis and on this observational study, we have proposed a randomized controlled trial, according with the nations involved and our own investigators:The TI.ME.LI. trial is a prospective randomized controlled trial - a patient- and evaluator-blinded study. The aim of this study is to evaluate pain and further disabling complications in patients undergoing Lichtenstein technique for primary inguinal hernia repair by fixing the mesh with fibrin sealant versus sutures (control group).Based on review of literature1516 and 15In the fibrin sealant group, the two tails of the mesh will be fixed together by overlapping their edges and by surrounding the cord. The tails will be joined up to by one suture. No other sutures will be used. First, the mesh will be put correctly in place. A small spot (1 ml) of glue will be applied on the pubis under the mesh without spray and then the remaining part (3 ml) over the mesh on the entire surface in a thin uniform layer by spray. Four milliliters of fibrin sealant will be used per mesh. In the control group, the mesh will be fixed in a conventional manner. Nerve resection (if occurred) will be recorded; it should be avoided.A close follow-up will be performed  after surgery, with a final evaluation 12 months after surgery, which will end the participation to the study. Visual analog pain scores and quality of life (S.F.12) scores will be used to evaluate the results from the patients. The following parameters will be evaluated as secondary endpoints: recurrence; overall wound-healing complication rate ; early postoperative pain at 1 week and 1 month after surgery; mid-term postoperative pain at 6 months after surgery; incidence of patients without pain at 1, 6, 12 months after surgery; use of analgesic drugs; patient's satisfaction; incidence of adverse events; quality of life assessed by a questionnaire preoperatively, at 1, 6 and 12 months; hospital stay; and time to return to normal activities.Active males over the age of 18 years and up to 70 years.Presence of an uncomplicated unilateral primary inguinal hernia.Subjects eligible for elective inguinal hernia repair using Lichtenstein technique.Written signed informed consent.Inclusion criteria for the study are:Recurrent, bilateral, scrotal, incarcerated or femoral hernias.Hernia types L3 and M3 according the European Hernia Society classification assessed preoperatively or intra-operatively.BMI equal to or more than 35.Concomitant abdominal surgery.Ongoing long-term analgesic or steroid treatmentPatients receiving antiplatelet agents or anticoagulants.Known history of alcohol or drug abuseLiver cirrhosis (child C).Hypersensitivity to bovine aprotinin or known immunodeficiency.Severely compromised physical or psychological health, concurrently participating in another clinical trial and having received another investigational drug or device within the last 30 days.Subjects fulfilling the following exclusion criteria will not be recruited into the study:At the moment, the trial is underway in all the seven countries and the final report is expected in the 2008 spring.The analysis of the primary endpoint will be performed on two analysis sets - ‘Intent to Treat’ population and ‘per protocol’ population. The percentage of patients with at least one of the complications defined and its 95% confidence interval will be described per group and in total. It will be compared between the two groups using the Chi-square test.Prof. Volker Schumpelick, Germany.Prof. Jean-Bernard Flament, France.Prof. Franco Corcione, Italy.An Independent Data Monitoring Committee has been established:We have a good evaluation of our observational study in the patients operated, 18 months after surgery. No complications like hematoma or seroma were observed in follow-up at 1 week, 1 month, 6 months and 18 months. At 18 months, none of the patients had developed a recurrence. In our observational study, postoperative pain was evaluated by a phone call from 1 week to 18 months after surgery, using a score going from 1 to 5, where 1 corresponded to a pain-free status and 5 to the worst conceivable pain.Of the total 113 patients, 92 patients (81.5%) - 82 male and 10 female - reported complete absence of pain. Eighteen patients (15.8%) - 16 male and 2 female - reported a pain score of 2 and only 3 male (2.7%) patients reported a pain score of 3. In no patients was a score of more than 3 registered .The objective of the study was to evaluate the mid- and long-term postoperative pain, numbness and groin discomfort in open inguinal hernia repair by Lichtenstein technique after mesh fixation with fibrin sealant compared with mesh fixation with sutures.For a common pathology such as inguinal hernia, the goal is to have ‘no defects.’ Thus for primary inguinal hernia by Lichtenstein's operation, we should aim for the following: a) local anesthesia; b) mesh (and plug?); c) tension-free sutureless; d) patients are able to anbulate early and get discharged the same day; e) rapid return to work; f) a rcurrence rate of < 1%; and g) absence of patient discomfort, numbness or neuralgia.Our preliminary observational study has shown that the use of fibrin sealant in inguinal hernia repair protects the patients from groin discomfort for as long as 18 months. So mesh fixation with fibrin sealant appears to be suitable for use in open tension-free repair. At 18 months, we have not observed any complications related to the technique.