Replacement of the metacarpo-phalangeal joints (MCPJ) with silastic Swanson’s implants can help decrease pain, stiffness and allow for improved function in rheumatoid arthritis (RA). There is a lack of patient reported outcome measure (PROM) studies assessing the efficacy of this procedure in RA. The aim of this study was to report any change in function, pain, stiffness and satisfaction following the Swanson MCPJ replacement using patient reported outcomes in a rheumatoid population.The combined results of 64 RA patients (71 hands) with 284 Swanson MCPJ arthroplasties (mean follow-up: 75.85 months) were assessed using the validated M-SACRAH questionnaire and a separate satisfaction questionnaire. Radiographic evaluation was performed to insure correct alignment of the hinged prosthesis postoperatively. No attempt was made to identify other predictors, radiologically or clinically. Data analysed in the study was interpreted in the context of the number of hands and survivorship was defined as implant fracture, loosening or revision.The mean total functional outcome score improved by 46.2% and the total pain outcome improved by 60.2%. The total stiffness outcome improved by 56.9% postoperatively and the results obtained from the satisfaction questions revealed that 73.2% of patients would retrospectively elect to have the procedure again. We report two postoperative complications in this group of superficial wound infections. Radiographically, all MCPJs showed improved alignment, however five patients reported worsening pain, four patients reported increased stiffness and four reported reduced function postoperatively. There was one re-operation of a 5th MCPJ Swanson’s, which did not require implant exchange and one implant was revised. Implant survivorship was 98.6%.Patient satisfaction and functional surrogate markers were overall favourable. Our results support the continued use of Swanson silastic arthoplasty in advanced RA. It is estimated that approximately 600,000 people in the United Kingdom are affected by rheumatoid arthritis. A prevalence study reports that the disease effects 1% of men and 3% of women worldwide . AlthougSilicone implants have been used since the late 1960s to replace destroyed MCPJs in the rheumatoid hand. Swanson first described MCPJ replacement using a hinged, double stemmed silicone implants in 1969. This has emerged as the preferred, most commonly used implant because of its durability and flexibility . The mosAlthough radiological and physical outcomes are clearly important in assessing biomechanical changes  they havFrom our local arthroplasty database of two senior surgeons over an 18 year period, 64 patients (71 hands) with long standing RA who had undergone the Swanson 2–5 MCPJ arthroplasty (284 implants) were identified. The mean follow-up period was 75.85 months (range 3–207) months. One patient died from unrelated causes to the procedure and was lost to follow-up. All arthroplasties were performed in the same hospital by one of two senior consultant surgeons  and routinely on the end stage rheumatoid hand (Larsen grade 4 or 5) using the same surgical technique (though slightly modified) and postoperative management as described by Swanson [After gaining verbal consent, patients were asked to complete the M-SACRAH questionnaire assessing preoperative and postoperative level of pain, stiffness and function. This study was largely prospective in its data collection, but some data had to be collected retrospectively. Patients operated on or after 2010 had their preoperative questionnaires collected prospectively at preassessment clinic using the M-SACRAH. Prior to 2010 the author’s own prospective data recording in patient medical notes provided the data for the preoperative M-SACRAH questions. Any outstanding  questions hence had to be obtained in a retrospective manner to allow comparative M-SACRAH scoring.t test examining outcomes before and after surgery. Differences were deemed statistically significant if the p-value was <0.05.In addition, patients were asked to answer three individual satisfaction related questions: (1) overall how pleased have you been with the results of your surgery so far? , (2) in hindsight, would you still elect to have the procedure done? (Yes/Maybe/No), (3) would you recommend this procedure? (Yes/Maybe/No). Radiographic evaluation was performed to insure correct alignment of the hinged prosthesis postoperatively. No attempt was made to identify other predictors, radiologically or clinically and data analysed in the study was interpreted in the context of the number of hands. The aim of this study was to assess the success and overall satisfaction following the Swanson MCP arthroplasty using patient reported outcomes. Postoperative complications including infection, re-operation, stiffness as well as implant survival rate were determined. Survivorship was defined as implant fracture, loosening or revision. Statistical comparisons were performed in Excel using two-sided paired Student’s All procedures were performed by the senior surgeons (CRH or SJB) in accordance  with the technique described by Swanson . GeneralOne patient had died at the time of follow-up from causes unrelated to the surgery. The baseline characteristics are outlined in Table Highly significant improvements in all domains of function, pain and stiffness scores were reported following the Swanson MCPJ arthroplasty. The majority of patients reported improvement in all areas, however individual variation in response to surgery was observed with five patients reporting moderately worsening of pain, four patients reporting a deteriorating function due to stiffness and four patients reported worsening stiffness postoperatively. One patient reporting no change in stiffness, however this did not correlate with deteriorating function. Overall there is a remarkable uniformity in the observed reported outcomes. Summary of the results for all interventions is reported in Table We report two postoperative complications in this group of superficial wound infections in patients on Methotrexate, which resolved with a course of oral antibiotics. There was one re-operation of a 5th MCP Swanson’s due to delicate soft tissue coverage and worry of skin breakdown. At re-operation the Swanson was not exchanged but the Silicon ridge laterally was trimmed with a knife. One implant was revised at 9 years due to clinically evident silicon synovitis. Radiographically, all MCPJs showed good anatomical alignment at the scheduled 1 year follow-up with no significant recurrent ulnar deviation (>10°). Thirty-three patients did not have up to date radiographs for assessment. There was radiographic evidence confirming three implant fractures (4.22%), however these did not require revision as there was no clinical evidence of silicone synovitis.The Swanson’s arthoplasty technique offers excellent immediate results with reduction in pain, improvement of arc of motion and correction of the deformity . DespiteAlthough patient-reported outcome measure (PROM) studies are becoming more fashionable in assessing the effectiveness of surgical procedures, we are aware of only one other study in the published literature that reports on the effectiveness of this procedure using PROM’s. Our results compare well with other studies reporting favourable results in the short term , 16–18. An additional important factor in hand biomechanics that makes silicon MCPJ challenging is that it is difficult to evaluate each joint in isolation because there is substantial interplay between adjacent joints in the hand with some advocating evaluation of surrounding joints before planning silicon MCPJ arthroplasty . Two of In the cohort analysed in this study, patients reported an overall decrease in pain with the majority (58%) very pleased and most (84.5%) would retrospectively have the procedure performed again. These favourable satisfaction outcomes have been echoed by other studies in the published literature , 24. PatDespite the limitations in observational studies of this kind we still feel that overall there is a remarkable uniformity in the observed reported outcomes suggesting the Swanson MCPJ replacement to be an effective procedure in this patient population with mainly favourable results in terms of reduction in stiffness, pain, improvements in function and good satisfaction results. In our opinion therefore this procedure should still be considered as a viable option in management of rheumatoid patients with intractable pain and progressive loss of hand function.


This study aimed to compare the effectiveness and safety of coblation annuloplasty and radiofrequency thermocoagulation for lumbar discogenic pain.Patients who suffered from lumbar discogenic pain and underwent coblation annuloplasty and radiofrequency thermocoagulation surgery were included. A questionnaire, including the visual analo scale (VAS), MacNab criteria, pain relief rate, and any complications due to surgery, was completed by the patients with the help of a trained volunteer who was blinded to the study. Data were collected at 1 week, and 1, 3, 6, and 12 months after surgery. Significant pain relief was defined as postoperative pain relief ≥50% compared with the preoperative state. Any complications during or after surgery were also recorded.A total of 122 patients were included; 37 patients were lost in the follow-up and 85 were evaluated. Among these, 45 patients underwent coblation annuloplasty  and 40 underwent radiofrequency thermocoagulation procedures .P < .05). The CA group had significantly lower VAS scores at 6 and 12 months of follow-up than did the RF group (P < .05). According to the modified MacNab criteria, the proportions of patients with excellent and/or good results at 3, 6, and 12 months of follow-up were significantly higher in the CA group compared with the RF group (P < .05).VAS pain scores were decreased at 1 week and 1, 3, 6, and 12 months postoperatively compared with preoperation in both groups (Only 2 patients reported soreness at the needle insertion site in the CA group. However, 3 patients had soreness at the needle insertion site, 3 had increased intensity of low back pain, 1 had intracranial hypotension, and 2 had new numbness in the leg and foot in the RF group. At the 1-year follow-up, this numbness was present all of the time. No major complications occurred in the CA group.Our study suggests that CA is a more effective and safe minimally invasive procedure than RF for treating lumbar discogenic pain. If untreated, chronic pain can be debilitating, unrelenting, and severely affects quality of life. Socioeconomic consequences of low back pain are massive and a burden. Degenerative discs are responsible for lumbar discogenic pain,which is defined as a disorder of the nucleus pulposus, rupture of the annulus fibrosus, and injury of the cartilage endplate.Lumbar discogenic pain accounts for more than 60% of patients who suffer from chronic low back pain and lower extremity pain. Over the past few years, a variety of minimally invasive percutaneous intradiscal techniques have been developed to minimize trauma, avoid injury of normal tissues, and improve recovery and clinical outcomes of patients.There are some treatments for lumbar discogenic pain due to degenerative discs. Conservative noninvasive therapies include medication, physical therapy, never block, behavior management, and psychotherapy. However, recrudescence easily occurs and conservative treatment is sometimes ineffective in severe cases. Surgery is mainly used for severe cases, but complications, such as nerve root injury, epidural fibrosis, trauma to the cauda equina, vascular complications, and discitis, can occur.,7 However, the surrounding tissue might be damaged by radiofrequency thermocoagulation at 70 to 90°C. Injury of the cartilage endplate by heat radiation and a change in spinal stability by contraction of the nucleus pulposus may accelerate degeneration of the intervertebral discs.As a minimally invasive procedure, radiofrequency thermocoagulation technology is used to treat degenerative disc diseases by shrinkage of the prominent parts of the nucleus, denervation of the annulus, and thermocoagulation of inflammatory tissue. Many clinical studies have been performed to prove the efficacy of coblation nucleoplasty for low back pain with or without lower extremity pain secondary to contained lumbar disc herniation, and only a few complications have been reported.–12 Coblation nucleoplasty technology overcomes the shortcomings of radiofrequency thermocoagulation technology.Since 1999, coblation nucleoplasty technology was approved for the spine by the US Food and Drug Administration. Coblation nucleoplasty not only has the above-mentioned 3 functions of radiofrequency thermocoagulation, but also has other characteristics, including ablation and a low temperature. The whole procedure works at relatively low temperatures (40–70°C), which decrease the risk of injury in the surrounding tissues.However, the superiority of coblation annulopasty is not conclusive compared with radiofrequency thermocoagulation. Therefore, this study aimed to compare the effectiveness and safety of coblationan annulopasty and radiofrequency thermocoagulation in the treatment of lumbar discogenic low back pain and/or lower extremity pain.22.1This retrospective study was approved by the Ethics Examining Committee of Human Research of Xuanwu Hospital, Capital Medical University, Beijing, China. A total of 122 patients with low back pain and/or lower extremity pain secondary to contained lumbar disc herniation underwent minimally invasive surgery during January 2013 to Octobor 2015 at Xuanwu Hospital.The inclusion criteria were as follows: patients with low back pain and/or lower extremity pain for ≥3 months; age between18 and 70 years; Visual analog scale (VAS) score ≥4; failure of conservative therapy for longer than 6 weeks, including medication, physical therapy, and injection therapies ; contained disc herniation ≤6 mm and ≤1/3 of the sagittal diameter of the spinal canal and a disc height ≥50% compared with normal adjacent discs confirmed by lumbar magnetic resonance imaging; and positive provocation discography confirming concordant pain at the suspected disc.The exclusion criteria were as follows: patients with major neurological deficits, such as sensory or motor deficits or asymmetrical reflexes; previous spinal surgery at the level to be treated; disc herniation with sequestration or disc space collapse; spinal fractures or tumors; spinal instability, spinal stenosis, or spinal deformity; infection; uncontrolled psychological disorders; and allergies to contrast media or drugs used in the procedure.2.2The procedure was performed in an operating room with the patient in the prone position or in the lateral decubitus position. A 10-cm cushion was placed under the lumbar region. Cefazoline (1.5 g) was administered intravenously as a prophylactic antibiotic before the procedure. The patient was kept in the same position and received monitoring of vital signs. The puncture point was determined through the posterolateral approach toward the treat-disc level, which was approximately 8 to 10 cm lateral to the midline of the spine. After sterilization, the skin and soft tissues were infiltrated with local anesthetic. Under fluoroscopic guidance, a 17-guage cannula needle was slowly inserted into the outer annulus. The position of the cannula needle at the outer part of the annulus fibrosus was tested by loss of resistance with a glass syringe. Anteroposterior and lateral fluoroscopic views were also taken to confirm the position of the cannula needle at the outer part of the annulus fibrosus. Discography was performed with contrast material to evaluate annular integrity and concordant pain. The whole procedure was performed by a senior experienced pain physician.2.3The coblation wand  was inserted into the cannula. The ablation function was approximately 5 mm beyond the tip of the cannula. This position was marked by a depth stop marker on the shaft of the wand. Movement or paresthesia in the patient's lower extremity was then tested with a coagulation radiofrequency controller set at 2 for half a second. Annuloplasty was achieved through 6 standard channels in the annulus. These channels were created by advancement of the wand in the ablation mode and retraction of the wand in the coagulation mode. After withdrawal of the wand, 2 mL of 0.5% lidocaine and 10 mg of triamcinolone acetonide were injected into the annuloplasty tract.2.4An electrode was inserted into a 20-gauge 15-cm radiofrequency cannula  with a 10-mm active tip instead of a stylet. To avoid injury of nerves, electrical stimulation was carried out by motor stimulation at 2 Hz and sensory stimulation at 50 Hz. After 2 mL of 0.5% lidocaine was injected, radiofrequency thermocoagulation was performed at 70 to 90°C for 90 to 360 s. After withdrawal of the electrode, 2 mL of 0.5% lidocaine and 10 mg of triamcinolone acetonide were injected.All of the patients were required to stay in bed for 48 hours following the procedure. After being discharged, patients were advised to perform limited walking, standing, and sitting. They were also advised to avoid lifting, bending, or stooping for 2 weeks. No strenuous activity was allowed for 3 months after the procedure.2.5All of the patients were required to complete a questionnaire. Data were collected by a trained volunteer who was blinded to the study at 1 week and 1, 3, 6, and 12 months postoperatively.Assessment of the VAS was performed by the patients themselves. A VAS score of 0 indicates no pain and a score of 10 indicates severe pain. were used to assess the patient's functional status with outcomes of excellent, good, fair, and poor. Excellent results included disappearance of symptoms and complete recovery in working and life activities. Good results included occasional episodes of low back pain or leg pain, and no limitations in working and life activities. Fair results included symptom relief, but with limitations in certain working and life activities. Poor results included insufficient improvement of symptoms and requirement of periodic administration of drugs after surgical treatment. Excellent and/or good results were considered to be effective treatment, and fair and/or poor results were considered to be ineffective treatment.The modified MacNab criteriaSignificant pain relief was defined as postoperative pain relief ≥50% compared with the preoperative state and was used to assess the patient's degree of pain relief. Complications, such as hemorrhages, discitis, worsening of pain, paresthesia, intracranial hypotension, numbness, and infection were recorded.2.6t-test. The Wilcoxon signed-rank test was used to evaluate the functional status of patients after 12 months of follow-up. A value of P < .05 was considered statistically significant in all analyses.Data analysis was performed with SPSS 22.0 statistical package . For descriptive statistics, we used mean ± SD when the distribution of data was normal and used median (minimum − maximum) when the data were not normally distributed. Repeated measures analysis of variance (ANOVA) was used to compare the improvement in pain VAS scores between the preoperative and postoperative time points. Significant differences in changes in time between groups in terms of mean values were assessed with the independent 3A total of 122 patients underwent radiofrequency thermocoagulation or coblation annulopasty surgery. After excluding patients who were lost in follow-up and those with incomplete data, a final total of 85 patients were evaluated. Coblation annuloplasty  and radiofrequency thermocoagulation  procedures were compared.P > .05).Demographic characteristics regarding sex distribution, age, duration of pain, preoperative VAS score, and the treated level are shown in Table P < .05, Table The VAS score was decreased at 1 week and 1, 3, 6, and 12 months postoperatively in both groups compared with preoperatively , 33 (73.30%), 27 (60%),26 (57.80%), and 23 (51.1%) patients reported significant pain relief at 1 week and 1, 3, 6, and 12 months postoperatively in the CA group, with 33 (82.5%), 29 (72.5%), 25 (62.5%), 18 (45%), and 15 (37.5%) patients in the RF group, respectively. There were no significant differences in pain relief between the 2 groups.  score from 51.08% to 19.84% in 1 year. A total of 84% of patients who underwent radiofrequency achieved a significant level of satisfaction. However, a prospective, double-blind, randomized trial of 28 patients reported that percutaneous intradiscal radiofrequency thermocoagulation  was not effective in reducing chronic discogenic low back pain. This study showed that the VAS score in the RF group decreased from 6.50 to 4.20, which is similar to Manuel et al's study. Therefore, RF is effective in the treatment of lumbar discogenic pain.Few studies have focused on radiofrequency thermocoagulation, but its clinical application is wide. Radiofrequency thermocoagulation technology is used to treat degenerative disc diseases by shrinkage of the prominent parts of the nucleus, denervation of the annulus, and thermocoagulation of inflammatory tissue.–12 In 2003, Singh et al reported that 75% of patients had a significant reduction in numeric pain scores at 12 months postoperatively compared with baseline, and 54% of patients showed pain relief of 50% or more at 12 months postoperatively. Additionally, significant improvement was reported in 54%, 44%, and 49% of patients in sitting, standing, and walking abilities at 12 months postoperatively, respectively. A retrospective study was conducted in 50 patients who underwent intradiscal coblation therapy for symptomatic contained lumbar degenerative disc disease. This retrospective study showed that analgesic consumption was reduced or stopped in 90% of patients after 1 year. Additionally, the VAS score was 4 points and the ODI was 7.2 compared with baseline at 24 months of follow-up.Clinical studies have shown the effectiveness of coblation nucleoplasty in treating low back pain with or without lower extremity pain secondary to contained lumbar disc herniation. reported the outcomes of coblation annuloplasty in 17 consecutive patients with discogenic low back pain. The preoperative pain VAS score was 6.5 ± 0.8. The pain VAS score decreased to 2.9 ± 1.6, 2.9 ± 1.7, 3.2 ± 1.6, and 3.2 ± 1.7 at 1 week and 1, 3, and 6 months postoperatively, respectively. According to the modified MacNab criteria, the proportions of patients with excellent and/or good ratings were 13 (76.5%), 11 (64.7%), and 10 (58.8%) at 1, 3, and 6 months of follow-up, respectively. No serious complications were observed. In this study, the preoperative and postoperative pain VAS scores, and the percentage of patients with excellent and/or good results were similar to those by He et al.To date, only a few studies on annuloplasty for lumbar discogenic pain have been performed. In 2015, He et al,19 This procedure relieves pressure on the nerve roots by removing the nucleus pulposus, decreasing volume of the nucleus, and immediately reducing intradiscal pressure.,21 Low back pain with or without lower extremity pain can be induced by pressure on nerve roots and ingrown nerve fibers in tears of the annulus fibrosus. Therefore, the effectiveness of coblation nucleoplasty in treating discogenic low back pain with or without lower extremity pain is uncertain. This is because the nerve fibers on the outer side of the fiber ring are not inactivated, and the fiber ring is considered as the major origin of discogenic pain. The target of our experimental treatment is more meaningful in the annulus fibrosus.Nucleoplasty technology can be used for radicular pain.This study showed that CA had better results compared with RF. Improvement in the VAS score was greater in patients in the CA group than in the RF group. Additionally, the patient's functional status as determined by the modified MacNab criteria in the CA group was better than that in the RF group. The reason for this finding might be that RF action on the target, depending on the radiofrequency heat to contracture tissue, the electrode cannot be moved during the operation when the position of the cannula is confirmed. In CA, the wand can be advanced and retracted through 6 standard channels in the annulus, and the scope of work involved is greater than in RF. Other specific mechanisms need to be further studied. The surrounding tissue might be damaged by heat radiation at 70–90°C. A temperature above the range of 42–50°C is cytotoxic to nerve fibers. Low intracranial pressure may also be due to dural injury caused by thermal radiation, resulting in cerebrospinal fluid extravasation. Nutrients in the intervertebral disc are transferred by the cartilage endplate. Injury of the cartilage endplate by heat radiation and a change in spinal stability by contraction of the nucleus pulposus may accelerate degeneration of intervertebral discs.In this study, 2 patients in the CA group reported soreness at the needle insertion site after the operation, but the symptoms completely disappeared within 2 weeks. No hemorrhage, paresthesia, or infection was observed. Three patients in the RF group reported soreness at the needle insertion site, 3 showed increased intensity of back pain, and 2 reported new numbness in the leg and foot. At the 1-year follow-up, this numbness was present all of the time. One patient suffered from intracranial hypotension. In 2011, Erdinc reported a burning-like sensation in the region on the lesion and an increase in severity of low back pain in 2 patients who were treated by RF. Radiofrequency lesioning of the medial branch interrupts the afferent and efferent neurons. This may be the reason and this may also be due to insufficient or partial denervation leading to neuropathic pain.Some limitations of our study should be mentioned. Because of reasons involved in radiofrequency thermocoagulation technology, this technology has been eliminated in our department. Therefore, this study was not a prospective control study, which is a limitation. We found that bias was inevitable in the follow-up data. The study sample size was small. Further controlled studies with a larger sample size are necessary to better determine the efficacy of these treatments.5This study shows that coblation annuloplasty is a more effective and safe minimally invasive procedure than radiofrequency thermocoagulation. Coblation annuloplasty can be used as an alternative treatment for radiofrequency thermocoagulation for discogenic low back pain and/or lower extremity pain secondary to contained lumbar disc herniation.


Chest pain accounts for approximately 6% of all emergency department (ED) visits and is the most common reason for emergency hospital admission. One of the most serious diagnoses emergency physicians must consider is acute coronary syndrome (ACS). This is both common and serious, as ischemic heart disease remains the single biggest cause of death in the western world. The history and physical examination are cornerstones of our diagnostic approach in this patient group. Their importance is emphasized in guidelines, but there is little evidence to support their supposed association. The purpose of this article was to summarize the findings of recent investigations regarding the ability of various components of the history and physical examination to identify which patients presenting to the ED with chest pain require further investigation for possible ACS.Previous studies have consistently identified a number of factors that increase the probability of ACS. These include radiation of the pain, aggravation of the pain by exertion, vomiting, and diaphoresis. Traditional cardiac risk factors identified by the Framingham Heart Study are of limited diagnostic utility in the ED. Clinician gestalt has very low predictive ability, even in patients with a non-diagnostic electrocardiogram (ECG), and gestalt does not seem to be enhanced appreciably by clinical experience. The history and physical alone are unable to reduce a patient’s risk of ACS to a generally acceptable level (<1%).Ultimately, our review of the evidence clearly demonstrates that “atypical” symptoms cannot rule out ACS, while “typical” symptoms cannot rule it in. Therefore, if a patient has symptoms that are compatible with ACS and an alternative cause cannot be identified, clinicians must strongly consider the need for further investigation with ECG and troponin measurement. A 50-year-old man presented to the emergency department (ED) because he was experiencing chest pain after eating a large meal. He had discomfort in his central chest, which he described as “like indigestion.” The pain did not radiate, was not associated with other symptoms, and resolved spontaneously after 30 minutes. The patient had no relevant medical history and no risk factors for ischemic heart disease. An electrocardiogram (ECG) obtained soon after his arrival in the ED was normal.Is acute coronary syndrome (ACS) likely to be the cause of this man’s chest pain? Can we use any features of his history and physical examination to determine the likelihood of ACS?Ischemic heart disease remains the leading cause of death in the United States, accounting for a quarter of all deaths.6Chest pain is the second most common reason for ED visits, accounting for 5.4% of all presentations, and many of these patients are admitted for evaluation for ACS.Electrocardiography and troponin testing are considered the cornerstones of the diagnosis of AMI and ACS, but they are both insensitive at the time of ED evaluation.Milner and associates prospectively recorded the symptomatology and medical history of 531 patients presenting to an ED with chest pain. Their primary focus was on age-related differences in the presentation of ACS. Of the patients diagnosed with ACS, those older than 70 had a higher burden of comorbidities than did those younger than 70. The comorbidities included a history of MI , coronary heart disease , hypercholesterolemia , and heart failure . Further analysis showed that chest pain , radiation to the arm , and fatigue  were all positively associated with ACS in younger subjects, yet none of these factors was significant in older subjects. An increasing number of typical symptoms was associated with ACS in those under 70 years of age. However, the “typicality” of presentation had no association with ACS in older patients. These findings suggest that older patients with ACS have a higher burden of traditional cardiac risk factors but present with few of the traditional symptoms.In 2004, two internists conducted a systematic review of the literature to assess bedside findings useful in diagnosing AMI in patients with chest pain.Bruyninckx and associates conducted a meta-analysis of patients with chest pain, looking for features that predicted AMI or ACS.Body and colleagues examined 804 patients who sought treatment in a university-affiliated ED in the United Kingdom for complaints suggestive of cardiac chest painAs an extension of that study, Greenslade and colleagues in Australia and New Zealand sought to determine whether the HPI and physical examination features associated with ACS and AMI were consistent across multiple patient populations.The Framingham Heart Study is a landmark longitudinal experiment in population health. Designed by Dr. Thomas Dawber and funded through the National Heart, Lung, and Blood Institute, the purpose of the study was to identify the risk factors associated with cardiovascular disease.Jayes and associates prospectively collected data from 5,773 patients evaluated in the EDs of six hospitals, who had the typical symptoms suggestive of ischemic disease.This question was revisited by Han and co-workers through a post-hoc analysis of the Internet Tracking Registry of Acute Coronary Syndromes (i*trACS).In 2008, Body and associates enrolled a study population of 796 patients over the age of 25 who presented to their university-affiliated ED with suspected cardiac chest pain.Hess and his research team described the presentations of 2,718 patients assessed in three academic EDs between 2007 and 2010, looking at in-hospital and cardiac events 30 days after discharge.One question arises out of these investigations: why have atypical symptoms become more important than in previous studies? Part of the answer is that the definition of cardiac disease has changed as the technology used to detect it has improved. For example, CK/CK-MB testing is no longer part of the ED workup because it is insensitive compared with troponin testing,Assuming no significant change in the underlying prevalence of cardiac disease, these results suggest that enhanced technologies allow clinicians to detect larger and larger proportions of patients with the disease, beyond the “textbook” cases to the atypical and protean presentations. As the definition of disease widens and a resulting increase in number of patients with cardiovascular disease occurs, the spectrum of clinical presentations must also change. Recent studies of ED patients with chest pain, with a newer emphasis on the predictive power of atypical symptoms, likely reflect this wider range of detectable disease and presentations.One response to the poor ability of the HPI and physical exam to identify ACS is to argue that clinician gestalt—a physician’s accumulation of experience combined with data gathered during a patient encounter—is still reliable for this assessment. To assess the accuracy of clinicians’ sense of the diagnosis and outcome, Kline and colleagues retrospectively examined a cohort of adults who came to an ED with complaints of shortness of breath or chest pain.Another investigation by Body and associates prospectively enrolled 458 ED patients presenting with suspected cardiac chest pain, 81 (17.7%) of whom had AMI.Carlton and colleagues focused on clinician gestalt where it might help the most—in the assessment of patients with a non-diagnostic ECG.tot = 1.43. Using 0.16 as our pre-test probability of disease ,38The patient had no prior medical problems and had experienced central, indigestion-like pain that was acute in onset. From the To be considered a “strong” test with the ability to rule in or rule out diagnoses, a test should have LRs greater than 10, or smaller than 0.1. LRs of this size will generally alter the post-test probability of disease by 45%.A few factors are consistently associated with an increased likelihood of ACS: pain accompanied by diaphoresis or vomiting, radiation of the pain , and pain aggravated by exertion. Similarly, the features that decreased the risk of ACS were reproducible chest wall tenderness, or pain that was pleuritic, sharp, or positional. These features are useful in identifying a low- or no-risk subgroup of ED patients with chest pain as a part of a rational rule-out strategy that includes troponin measurement and ECG testing. Acute care providers should strongly consider these factors when risk stratifying patients with chest pain.


Control of persistent pain following spinal surgery is an unmet clinical need. This study compared the efficacy and safety of buprenorphine transdermal system (BTDS) to oral tramadol/acetaminophen (TA) in Korean patients with persistent, moderate pain following spinal surgery.n = 47; 5 μg/h titrated to 20 μg/h) or twice-daily TA  for 6 weeks. The study compared pain reduction with BTDS versus TA at week 6. Quality of life (QoL), treatment satisfaction, medication compliance, and adverse events (AEs) were assessed. Open-label, interventional, randomized multicenter study. Adults with persistent postoperative pain  were enrolled. Patients received once-weekly BTDS (P < 0.0001) and improved QoL . The BTDS group achieved better medication compliance (97.8% versus 91.0%). Incidence of AEs (26.1% versus 20.0%) and adverse drug reactions (20.3% versus 16.9%) were comparable between groups. At week 6, both groups reported significant pain reduction (mean NRS change: BTDS −2.02; TA −2.76, both NCT01983111. For patients with persistent pain following spinal surgery, BTDS is an alternative to TA for reducing pain and supports medication compliance. This trial is registered with Clinicaltrials.gov:  Spinal stenosis is a common cause of pain affecting the back and legs due to narrowing of the spinal canal or neural foramen. Decompression surgery is often performed to treat this condition by removing excess bone, thickened ligaments, degenerate disc material, and other fibrous tissue causing the stenosis. Sometimes, a fusion procedure is performed to fuse two adjoining vertebrae together to make the spine more stable in the case of severe spinal stenosis or unstable spondylolisthesis . The incμ-receptor, tramadol may be prescribed for patients with complicated pain etiology owing to its dual mechanism of action: binding to μ-receptors as well as inhibiting serotonin and norepinephrine reuptake in the central nervous system  and administration site erythema [1 event]), while 3 subjects receiving TA had elevated liver enzymes . Two serious AEs were reported in the BTDS group: “postprocedural infection” at 2.90%  and “arthralgia” at 1.45% ; no SAEs were reported in the TA group. No serious adverse drug reactions were reported. All adverse events were of grade 1 (mild) or 2 (moderate) in severity. There were no adverse events of grade 3 (severe) or above.In both groups, the most commonly reported AE was gastrointestinal disorders, mainly nausea and constipation  or pruritus  at the patch application site . We also note that the possibility of dose increases could make it more difficult to interpret comparisons between the groups. Nevertheless, the observed proportion of subjects with a dose increase was very similar in the 2 groups . Moreover, the actual dose increases in both groups were modest, from 5 μg/h to 10 μg/h for BTDS and from 1 tablet twice daily to 2 tablets twice daily for TA. Only 8 subjects in the BTDS group and 7 in the TA group had their prescribed pain medication up-titrated even though there were many subjects with moderate pain in the second week . This implies that active up-titration of the medication dose may not have taken place for some subjects. For BTDS, it is possible that the longer dosing interval and slower titration (no more than once every 7 days) could have led to fewer subjects having their medication up-titrated. These characteristics should be taken into account when designing future studies involving BTDS therapy. Despite the small number of up-titration cases, the mean NRS scores recorded at week 6 were below 3 for both treatments , which is considered a meaningful level of pain control [Some limitations of our study should be considered when interpreting the results. Increase in pain medication dose was permitted during the study, similar to normal clinical practice, in which doses would be adjusted for individual patients to achieve an acceptable level of pain control. However, the equivalent efficacy of initial doses for the study and control treatments could not be determined at the outset. We therefore selected the lowest available doses  may have implications for patient preference and compliance and would need to be taken into consideration by physicians when individualizing treatment for patients. As transdermal buprenorphine is not recommended for patients with rapidly changing analgesic requirements, subjects with severe or unstable pain would have been underrepresented in this study. Thus, our conclusions may not be generalizable to patients with more severe pain.While both groups of subjects showed statistically significant improvement in most of the parameters evaluated, the compliance rate was higher among subjects using the buprenorphine patch than among those receiving tramadol/acetaminophen tablets. Similar observations were made by Lovborg et al. in their review of transdermal opioid patches . All subThe buprenorphine transdermal system was comparable to oral tramadol/acetaminophen in reducing pain intensity after 6 weeks of treatment in patients with persistent moderate postoperative pain at 1–3 months after spinal surgery. Patients treated with BTDS also had better compliance to the prescribed treatment.Supplementary Table S1. Details of adverse events listed by System Organ Class for the Safety Set.


Background. Various postoperative pain relief modalities, including continuous femoral nerve block (CFNB), local infiltration analgesia (LIA), and combination therapy, have been reported for total knee arthroplasty. However, no studies have compared CFNB with LIA for total hip arthroplasty (THA). The aim of this study was to compare the efficacy of CFNB versus LIA after THA. Methods. We retrospectively reviewed the postoperative outcomes of 93 THA patients . Patients were divided into three groups according to postoperative analgesic technique: CFNB, LIA, or combined CFNB+LIA. We measured the following postoperative outcome parameters: visual analog scale (VAS) for pain at rest, supplemental analgesia, side effects, mobilization, length of hospital stay, and Harris Hip Score (HHS). Results. The CFNB+LIA group had significantly lower VAS pain scores than the CFNB and LIA groups on postoperative day 1. There were no significant differences among the three groups in use of supplemental analgesia, side effects, mobilization, length of hospital stay, or HHS at 3 months after THA. Conclusions. Although there were no clinically significant differences in outcomes among the three groups, combination therapy with CFNB and LIA provided better pain relief after THA than CFNB or LIA alone, with few side effects. Acute postoperative pain is a distinct risk factor for prolonged pain . PostopeLocal infiltration analgesia (LIA) offers better pain control, reduced narcotic consumption, and earlier mobilization, without increased risks . MoreoveAll patients included in this study gave their written, informed consent. Ethical approval was obtained from the Institutional Review Board of our institution. We retrospectively reviewed and analyzed the clinical outcomes of patients who received one of three postoperative analgesia protocols after THA. Inclusion criteria included patients who underwent THA at our hospital from January 2014 to March 2015 and who were able to provide informed consent and cooperate with the study. We excluded patients with local infection, cemented THA, revision THA, bleeding tendency due to anticoagulant therapy, renal insufficiency, or allergy to local anesthetics or other medications. This study included 93 patients (20 men and 73 women). The mean age at surgery was 69 years (range 37–92). The preoperative diagnoses were osteoarthritis in 81 hips, avascular necrosis of the femoral head in eight hips, rheumatoid arthritis in two hips, and femoral neck fracture in two hips. Three experienced surgeons performed all operations in this study. All THA surgeries were performed via the direct lateral (Hardinge) approach and used cementless implants .n = 30), LIA , or combined CFNB and LIA   . In the On the first postoperative day, all patients started anticoagulation therapy with fondaparinux (2.5 mg/day), which was continued for 14 days. On the first postoperative day, all patients began a regimen of movement and strengthening exercises; they were encouraged to achieve full weight-bearing exercises on postoperative day 2.The primary outcome was patient pain intensity at rest on postoperative day 1. Early (postoperative days 1 to 7) walking capacity was assessed with straight-leg raising and T-cane ambulation. Middle-term walking capacity was measured 2 weeks after surgery with the 10-meter walking test and timed up and go test. Late-term physical activity was assessed 3 months after surgery with the Harris Hip Score (HHS) . Food coThe patient's pain intensity at rest was self-assessed using a visual analog scale (VAS) 24 h postoperatively. The VAS for pain self-assessment is a widely used, valid, and reliable tool to measure pain intensity . PatientThe 10-meter walking test has been used in gait studies of patients with neurologic movement disorders in general  and to eGlobal muscle performance was assessed with the timed up and go test. First described by Podsiadlo and Richardson , this isp < 0.05; power: 0.8) suggested that 29 patients would be needed in each group. Values are shown as mean ± standard deviation; values of p < 0.05 were considered significant. Statistical analysis was conducted with SPSS version 22  for Windows .Differences in data among groups were tested with one-way or two-way repeated-measures analysis of variance (ANOVA) with Tukey's post hoc test. The Pearson Chi-squared test was used to compare differences in sex ratio and diagnosis. A pilot study was performed with ten patients in each group. In the pilot study, the mean VAS was 30.5 mm in the CFNB group, 20.5 mm in the LIA group, and 13 mm in the CFNB+LIA group, with a standard deviation of 10. Based on the effect size in this pilot study, a power calculation for a trial . The use of diclofenac sodium suppositories within 24 hours after surgery was similar among the three groups . The incidence of nausea/vomiting was not affected by the treatment modality (p = 0.88). None of the patients experienced systemic toxicity from ropivacaine. There were no cases of delayed wound healing, wound infection, or prosthesis infection. None of the patients required repeat surgery during the study period.No significant differences in patient background were identified among groups. These data are summarized in p = 0.69 and 0.51, resp.). Walking capacity was measured 2 weeks after surgery with the 10-meter walking test and timed up and go test. No significant differences were seen among groups in either test on postoperative day 14. The mean hospital stay after surgery, including postoperative physical therapy, was 19.2 ± 2.5 days. No significant differences in length of hospital stay were observed among the three groups (p = 0.48). The HHS was similar in the three groups 3 months after surgery (p = 0.90). HHS improved significantly in all three groups postoperatively .To evaluate early walking capacity, we assessed quadriceps strength and T-cane ambulation. Patients achieved straight-leg raise 5.6 ± 2.9 days after surgery and assisted ambulation with a walking cane 6.8 ± 2.6 days postoperatively. No significant differences were found among groups regarding either the straight-leg raise or T-cane ambulation (This study compared the acute postoperative pain levels in patients receiving CFNB, LIA, or combined CFNB and LIA after THA. Our results indicate that combined CFNB and LIA provided significantly better pain relief on the first postoperative day than either modality alone. PONV and other perioperative complications were comparable among the three study groups. No significant differences were seen in patient mobilization among the three postoperative analgesia groups at 2 weeks or 3 months after surgery.CFNB has been widely used in TKA patients , 21. ComIn TKA, peri- and intra-articular infiltration of analgesics can improve early analgesia and mobilization more effectively than CFNB . HoweverBecause we found only slight differences among interventions, clinicians should focus on other factors such as cost and intervention-related complications when choosing analgesic treatments after THA . A potenThis study has some limitations. First, this is a retrospective study rather than a randomized-control trial. A prospective, randomized, controlled study should be conducted to eliminate selection bias and obtain more consolidated results. However, the present study had little selection bias because all surgeries were performed by experienced hip surgeons and there were no significant differences in patient backgrounds among groups. Second, we performed all THA under general anesthesia. Several clinical studies support the use of spinal anesthesia in orthopedic surgery –37. SpinThree-in-one CFNB blocks the femoral nerve, obturator nerve, and lateral femoral cutaneous nerve without sciatic nerve blockade. LIA enables pain relief in accordance with the surgeon's demands, including the sciatic nerve region directly. In this study, we analyzed the additive effects of CFNB and LIA after THA. Although combination therapy with CFNB and LIA did not accelerate functional recovery in patients after THA, excellent pain relief with few side effects was achieved in patients following THA. Further studies with a larger sample size are needed to assess whether combination therapy with CFNB and LIA can prevent long-term pain.


Intra-articular temporomandibular disorders are often related to pain in the area of the temporomandibular joint, ear, and temple. The aim of the study was to investigate the efficiency of anterior repositioning splints in decreasing pain related to temporomandibular joint disc displacement with reduction. U test (p ≤ 0.005).  The research material consisted of 112 patients, aged 24 to 45 years, of both genders, who reported for treatment at the Consulting Room of Temporomandibular Joint Dysfunctions at the Jagiellonian University in Cracow between 2014 and 2016 due to pain in the area of the temporomandibular joint(s) and noise(s) of temporomandibular joint(s) present during jaw movements with comorbid contracture of masticatory muscles. Subjects were examined according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocol and, after diagnosis of painful disc displacement with reduction and masticatory muscle contracture, they were assigned randomly to either the study or control groups (56 patients in each). In the study group, we used an anterior repositioning splint on the full lower arch for about 20 hours usage over a 4-month period. In the control group, a noninvasive therapy was applied using a biostimulation laser over 12 sessions performed every second day on the area of both temporomandibular joints with mouth open and while performing muscle self-exercises with a dominant protrusive position of the mandible. Pain intensity was evaluated using the Verbal Numerical Rating Scale (VNRS) immediately before the treatment and then after 4 and 16 weeks. The obtained data were analyzed using the Mann–Whitney p=0.0004).  The VNRS values reported during the final examination for the study group were significantly lower than for the control group (NCT03057262. The anterior repositioning splint is an efficient tool in decreasing pain related to disc displacement with reduction. This trial is registered with Clinicaltrials.gov  Intra-articular temporomandibular disorders present as various pathological conditions, often concerning derangements of the condyle-disc complex , 2. TheyMany studies confirm that disc displacement with reduction (DDwR) is the most prevalent derangement of the condyle-disc complex –6. The DTherefore, the aim of the study was to investigate the efficiency of anterior repositioning splints in the alleviation of pain related to temporomandibular joint disc displacement with reduction.This is a prospective outcome study which consisted of 112 subjects of both genders with unilateral or bilateral disc displacement(s) with reduction and pain in the area of TMJ. Patients were recruited from the Consulting Room of Temporomandibular Joint Dysfunction at the Jagiellonian University in Cracow during the years 2014–2016 and were included in the study if they met the following criteria: (1) unilateral or bilateral presence of clicking, popping, and/or snapping noise(s) detected with palpation during opening or closing or lateral or protrusive movements in TMJ(s); (2) in the previous 30 days, any TMJ noise(s) present with jaw movement or function; (3) unilateral or bilateral pain in the area of TMJ(s); (4) presence of masticatory muscle contracture during palpation; (5) full dentition or single tooth loss; (6) good general health; (7) positive mandible protrusion test; (8) no contraindications for laser therapy; and (9) patient consent to be involved in the study. Other patients representing TMJ intra-articular disorders who had undergone treatment during the years 2014–2016 were excluded because of partial tooth loss or edentulism, contraindications for laser therapy as well as absence of appropriate symptoms and/or consent to be involved in the study.Clinical assessment of temporomandibular joints and masticatory muscles was performed by one experienced, self-trained examiner according to DC/TMD recommendations . TMJ noiPain level was evaluated using the Verbal Numerical Rating Scale (VNRS). VNRS comprises assessment that is based on an 11-point numerical scale (0–10) in combination with a color-coded scale, in which an increase in the score is accompanied by an increase in color intensity indicated on the scale. Clinical examinations of TMJ noise(s) and pain level evaluations were performed immediately before the treatment (examination I) and then during follow-up visits after 4 weeks (examination II) and 16 weeks (examination III). At the beginning of the treatment, each ARS was adjusted, and upon follow-up visits, occlusion was checked using clinical observations and marking paper to prevent occlusal changes.The study protocol was conducted in accordance with the Declaration of Helsinki and approved by the Local Bioethical Committee (no. 122.6120.43.2016). All patients provided written informed consent prior to participating in the study.U test because of noncompliance with the normal distribution in the tested groups (p ≤ 0.005).The obtained data were compared using the Mann–Whitney p=0.5015), which indicates that groups are similar in terms of reported pain levels. The VNRS values collected during examination II are lower across the two groups in comparison to examination I , and they differ significantly (p=0.00048). The values collected during examination III are much lower across the two groups in comparison to examination I; namely, the mean value of reported VNRS for SG was 0.411, and for CG was 1.303. These mean values differ significantly (p=0.0004). The statistical analysis is presented in A total of 112 subjects were included in the study: 83 women and 29 men, aged 24–45 years (mean age: 31). The study group (SG) included 40 women and 16 men, and the control group (CG) contained 43 women and 13 men. The clinical findings collected during follow-up visits in SG and CG and their specification are presented in Tables Disc displacement with reduction is the most common derangements of the condyle-disc complex . There aA serious limitation of this study was the use of only clinical findings without magnetic resonance imaging (MRI) for ruling in a diagnosis of DDwR, because the sensitivity of this method without imaging is 0.34 [The use of ARS in the treatment of disc displacement plays an important role, due to TMJ tissue unloading including retrodiscal tissues and insertions of selected masticatory muscles to articular discs , 19, 20.On the other hand, randomized clinical trials performed by Schiffman et al. and Haketa et al. showed that occlusal splint therapy could be an efficient method in displaced disc recapture and also pain level alleviation , 24. In The assumption behind the control group design was to use noninvasive intervention with low risk of side effects to reduce TMJ(s) pain. Therefore, laser biostimulation combined with TMJ and masticatory muscle self-exercises was a suitable solution. The setup of 12 laser sessions, performed every other day on the area of both temporomandibular joints, is a standard and valid procedure in the Consulting Room of Temporomandibular Joint Dysfunction at the Jagiellonian University for TMJ(s) pain alleviation. Furthermore, regular performance of exercises by the patient provides long-term biomechanical stability to impaired TMJ(s) and masticatory muscle function. The combination of noninvasive techniques could be a sufficient solution to reduce pain among patients with temporomandibular disorders .Invasive treatment such as arthroscopies, arthrocentesis, and other surgical techniques are still considered after failure of conservative management , 25. InvConsidering the limitation of the study, we can state that the anterior repositioning splint is an efficient tool in decreasing pain related to disc displacement with reduction.


O-methyltransferase gene were selected for analysis.Use of opioids for pain management has increased over the past decade; however, inadequate analgesic response is common. Genetic variability may be related to opioid efficacy, but due to the many possible combinations and variables, statistical computations may be difficult. This study investigated whether data processing with support vector machine learning could predict required opioid dose in cancer pain patients, using genetic profiling. Eighteen single nucleotide polymorphisms (SNPs) within the µ and δ opioid receptor genes and the catechol-Data from 1237 cancer pain patients were included in the analysis. Support vector machine learning did not find any associations between the assessed SNPs and opioid dose in cancer pain patients, and hence, did not provide additional information regarding prediction of required opioid dose using genetic profiling. Opioids are the basis in treatment of severe pain of both benign and malignant origin. Unfortunately, the clinical use is limited by large inter-individual differences in analgesic responses, and insufficient treatment is often seen. Unacceptable side effects may also appear, potentially reducing quality of life. Thus, identification of biomarkers that can predict the appropriate opioid type and dose for the individual patient is highly warranted. Currently, there is no well-validated objective means of identifying patients likely to experience adequate opioid analgesia, and quantitative sensory testing as well as clinical biomarkers have been applied with low success –3.Various factors such as gender, age, and genetic variation may influence the analgesic response to opioids. Several single nucleotide polymorphisms (SNPs) in different candidate genes have been demonstrated to be associated with altered pain sensitivity and analgesic response . The genThe objective of the present study was to use SVM analysis of various SNPs to predict the required opioid dose in cancer pain patients.Data from the EPOS study was used for analysis . In brieThe median oral morphine equivalent dose in the full population of 2294 patients was 180 mg/24 h. Therefore, patients were divided into two groups: Group 1 requiring less or equal to 180 mg/24 h; group 2 requiring more than 180 mg/24 h.OPRM1 gene, one in OPRK1, three in OPRD1 and six in COMT, were selected as relevant. The SNPs were selected according to previous studies, in which genetic associations to opioid analgesic effects were found [OPRK1 was discarded. SNPs were coded to be binary variables for inclusion in the SVM, hence, they were coded so that carriage of the minor allele equals 1 and homozygous for the major allele equals 0 in the model.In the present study, nineteen SNPs; nine SNPs in the re found , 8, 9. TSVM is a binary classifier, previously used in other prediction studies in pain medicine , 11. In P values below 0.05 were considered statistically significant.The null hypothesis was that SVM analysis of various SNPs could not predict the required opioid dose in cancer pain patients. All data are reported as mean ± standard deviation. Results from SVM classification were analyzed using Chi square tests. Out of 2294 EPOS participants, 1057 were excluded due to missing one or several of the selected SNPs. The included 1237 patients  had an age of 62.6 ± 12.3 years and BMI of 23.4 ± 4.6). Of these, 662 (53%) required less or equal to 180 mg/24 h oral morphine equivalents, and 575 (47%) required more than 180 mg/24 h.P = 0.08), 2 features; 52.9% (P = 0.08), 3 features; 52.9% (P = 0.08), 4 features; 52.9% (P = 0.08), 5 features; 52.9% (P = 0.08), 6 features; 53.0% (P = 0.07), 7 features; 53.0% (P = 0.07), 8 features; 53.0% (P = 0.07), 9 features; 53.0% (P = 0.07) and 10 features; 52.8% (P = 0.08).Machine learning was unable to distinguish between patients requiring less or equal to 180 mg/24 h oral morphine equivalents and those requiring more, using any number of SNP features from 1 to 10. Classification accuracies were: 1 feature; 52.9%  to predict and assess data relationship exist, but here, a SVM approach was selected, according to two reviews , 16. MacAlthough the method of SVM presents itself with several limitations, methodological limitations of the study design itself may also have had an influence on the result. First, as opioid dose was the primary outcome in the EPOS study, it was used as outcome in the present study as well. Here it was anticipated that opioid dose is related to opioid response, i.e. high dose = less responsiveness to opioid analgesia, and low dose = high responsiveness to opioid analgesia, however this is only a rough estimation and many other factors may be important. Hence, a composite score taking pain intensity, opioid dose and side-effects into consideration might be a better outcome for association analyses of opioid efficacy . HoweverMoreover, as human genetic factors only account for part of the inter-individual difference in pain sensitivity, several cofactors may also influence opioid consumption during the post-operative period. These include age, gender, mood, anxiety, drug–drug interactions and epigenetic factors. Thus, human experimental pain studies, conducted in a controlled setting, have shown to be of value to explore the genetic contribution to both pain sensitivity and analgesic responses .


Neoadjuvant chemoradiotherapy (nCRT) followed by surgery for patients with esophageal or junctional cancer has become a standard of care. The comprehensive complication index (CCI) has recently been developed and accounts for all postoperative complications. Hence, CCI better reflects the burden of all combined postoperative complications in surgical patients than the Clavien–Dindo score alone, which incorporates only the most severe complication. This study was designed to evaluate the severity of complications in patients treated with nCRT followed by esophagectomy versus in patients who underwent esophagectomy alone using the comprehensive complication index.www.assessurgery.com). CCI of patients who underwent nCRT followed by surgery was compared with the CCI of patients who underwent surgery alone.All patients included in the CROSS trial—a randomized, clinical trial on the value of nCRT followed by esophagectomy—were included. Complications were assessed and graded using the Clavien–Dindo classification. CCI was derived from these scores, using the CCI calculator available online (p = 0.58). There also was no difference in CCI between subgroups of patients with anastomotic leakage, pulmonary complications, cardiac complications, thromboembolic events, chyle leakage, and wound infections.In both groups 161 patients were included. The median (and interquartile range) CCI of patients with nCRT and surgery was 26.22 (17.28–42.43) versus 25.74 (8.66–43.01) in patients who underwent surgery alone (Neoadjuvant chemoradiotherapy according to CROSS did not have a negative impact on postoperative complication severity expressed by CCI compared with patients who underwent surgery alone for potentially curable esophageal or junctional cancer. Esophageal cancer remains one of the most common cancers worldwide.17The largest, published, randomized clinical trial on the value of neoadjuvant chemoradiotherapy  also showed a survival benefit.In the past decades, not only the frequency but also the severity of postoperative complications has become an important quality measure in surgical studies. Also, patients’ reported grading of complications gives a better insight into the burden of a complicated postoperative course. Therefore, several severity-scoring systems have been developed.Patients with esophageal cancer or cancer of the esophagogastric junction (cT1-4aN0-3M0) who underwent a curative surgical resection of the esophagus and who participated in the CROSS trial were selected from the study database. The CROSS trial is a multicenter, randomized, controlled trial that compared overall survival for patients who were treated with neoadjuvant chemoradiotherapy followed by esophagectomy and the patients who underwent esophagectomy alone. The inclusion and exclusion criteria as well as staging procedures have been described previously.Complications were defined using the complete and commonly applicable National Cancer Institute’s Common Terminology Criteria for Adverse Events, 4.0.www.assessurgery.com. The final index yields a score from 0 (no complication) to 100 (death).27The CCI is a complication index introduced by Slankamenac et al.To investigate whether postoperative complication severity is influenced by neoadjuvant treatment, the severity of all combined complications was measured using the CCI. Based on results in earlier studies of patients who underwent esophageal cancer surgery in which specific complications have shown an increase in incidence, six subgroups were formed in this study. For example, some studies show influence of neoadjuvant treatment on pulmonary complications, due to the radiation field. In subgroup 2, patients with pulmonary complications are compared. Only patients with the specific complication were used to calculate the specific complication CCI.We used the original database of the CROSS study in which postoperative complications were scored by data managers in each participating center. Cross checking of these complications and grading every complication according to the Clavien–Dindo classification was done by one of the authors (NN). The CCI was calculated afterwards. In addition, for each patient the traditional endpoints, the total number of complications, the presence of any complication (yes/no) and the most severe complications (≥IIIb according to the Clavien–Dindo classification) were assessed.As previously described,U test. For cross-tabulations, Pearson’s chi-square test with continuity correction was used. All statistical analyses were performed on the statistical package SPSS 22.0 . p < 0.05 two-sided was considered statistically significant.Adjustment for possible confounders was not necessary, because the data were controlled for confounding by randomization. Baseline continuous data were described as means with standard deviation or, in case of a not-normally distributed variable, with the median and interquartile range. Normal distribution was calculated using the Kolmogorov–Smirnov test. Groups were compared using the nonparametric Mann–Whitney p < 0.001). In patients who were analyzed in the current study (n = 322), the combined treatment group 136 (85 %) patients developed at least one complication versus 125 (78 %) the surgery alone group . There also was no statistically significant difference for grade II-grade V complications , followed by anastomotic leakage  and cardiac arrhythmias . Significantly more infections of the chest wound were found in patients with neoadjuvant treatment who underwent a transthoracic esophagectomy . The incidence of all other complications was not significantly different between the two groups.Analyses in six subgroups showed that respiratory complications, i.e., pneumonia were the most common  compared with 25.74 (IQR 8.66–43.01) in the surgery alone group (p = 0.78). The same was true for the other subgroups with patients who developed pulmonary or cardiac complications, thromboembolic event, chyle leakage, or wound infection (Table In subgroup analyses of the specific complications, CCI for patients who underwent neoadjuvant chemoradiotherapy and developed an anastomotic leak was not statistically different from patients who underwent surgery alone: 8.66 8.66–33.73] vs. 8.66 [8.66–33.73] (3.73 vs. The Dutch CROSS study showed an absolute 5-years survival benefit of 13 % for patients who underwent neoadjuvant chemoradiotherapy followed by an esophagectomy for esophageal or esophagogastric cancer. Hence, neoadjuvant chemoradiotherapy is nowadays widely used in clinical practice. However, it is important to consider the possible harm of neoadjuvant chemoradiotherapy, because trials frequently focus on the benefit of a treatment.The benefit of neoadjuvant treatment has been a topic of many studies but the harm has been described less extensively. The Cochrane review, published in 2010, demonstrates that postoperative complications often are ill described or missing at all.5With the recently developed sensitive comprehensive complication index, it is possible to take the severity of all complications into consideration, thus improving the accuracy of reporting the impact of all side effects combined.There are several limitations to the current study. Because our study included patients from seven participating hospitals, it may be possible that there is some difference in reporting and treatment of complications. All complications were reviewed by one of the authors to preserve uniformity in application of the Clavien–Dindo classification. In the Netherlands, the transference to the Medium or Intensive Care Unit for more intensive monitoring of the patients is relatively low, which in the Clavien–Dindo system directly results in a grade IV complication but is not always accompanied by organ failure. The difference in complications scored in the CROSS trial differ because of the difference between the Clavien–Dindo classification and the CCI. In the CROSS study, only the most severe complication counted. This study only reports early complications, within 30 days and/or within hospital admission. Later complications, e.g., stenosis or complications due to recurrence, were not included. Another possible limitation of this study is that postoperative complications were not the primary endpoint of the CROSS trial. The study was powered to show a difference in overall survival; therefore, the sample size of this study might be too small to show differences in rare complications. However, as described by Slankamenac et al., when using the CCI as opposed to the original Clavien–Dindo classification as an endpoint, meaningful comparison can be obtained with smaller sample sizes.20The CCI can be used as a tool to monitor postoperative recovery in a detailed and structured way. Because all data in the present study were prospectively registered, this study shows a realistic view of postoperative complications in patients with cancer of the esophageal and esophagogastric junction. This study shows that the frequency of complications described in patients extracted from CROSS trial is similar in the two groups; and the outcome of specific complications in the two groups is similar. Neoadjuvant chemoradiotherapy does not show a negative impact on the overall postoperative morbidity as expressed by the CCI compared with patients who underwent surgery alone for potentially curable esophageal or esophagogastric junctional cancer.


Chronic leg ulcers (CLUs) pose serious public health concerns worldwide. They mainly affect the elderly population. Pinch grafting (PG) could be used to treat a variety of CLUs. However, in Cameroon, there is scarce data on the outcome of PG of CLUs in elderly patients in rural hospitals where most of these patients seek for medical attention and where clinicians rely on unconventional wound dressing methods to treat CLUs. Our objective was to describe the outcome of PG of CLUs in elderly patients in rural Cameroon.This was a prospective study conducted in a rural hospital of North West Cameroon. From February 2015 to January 2016, comprehensive historical and clinical data were collected per elderly patient who presented with a chronic leg ulcer necessitating PG. PG was done using a simple procedure and each patient followed up for 8 months. Outcome was described in terms of ulcer healing and pain and donor site complications.2 (mean: 17.66 ± 8.35 cm 2). We registered one  graft rejection. Concerning the other ulcers, ten  had healed after 12 postoperative weeks while 2  had healed after 14 postoperative weeks and the mean healing time was 12.33 ± 0.78 weeks. Patients with healed ulcers had reduced ulcer site pain from the immediate postoperative period but there was no significant difference in the mean pain scores before and after graft . These ulcers remained healed after 8 postoperative months. Each donor site had healed 2 weeks after PG. Donor site problems were minimal and included hypopigmentation.Our series included 13 patients: 8 males  and 5 females  aged from 69 to 88 years (mean: 77.54 ± 5.70 years). Three patients  had associated co-morbidities. All the ulcers were unilateral with durations ranging from 7 to 41 months (mean: 19.46 ± 11.03 months). The ulcers ranged in size from 9.0 to 38.1 cmThe outcome of PG of CLUs in our series of older patients was satisfactory. This finding does not discount the role of conservative therapy, but we encourage clinicians in rural Cameroon to consider PG over long-term unconventional conservative therapy in the elderly. Chronic leg ulcers (CLUs) pose serious public health concerns worldwide –4. The gPrevious reports suggest that pinch grafting (PG) could be used to treat a variety of CLUs –16. Somethe ulcer itself: onset, duration, position, multiplicity, tenderness, temperature, size (length X width X π/4) , edge, bsurrounding tissues: state of adjacent tissue, local circulation and innervationThis was a prospective study carried out in a Level 1 hospital which is located in a remote village in the North West region of Cameroon. A level 1 hospital is a rural hospital or health center  with a small number of beds; it has a sparsely equipped operating room for ‘minor’ procedures; it provides emergency measures in management of 90–95% of trauma and obstetrics cases; and it conducts referral of other patients for further management at a higher level. A chronic leg ulcer was considered as a wound of the leg that persisted for ≥ 3 months . CLUs reUlcer pain was graded using a validated 10 echelon visual analogue scale (VAS).Ethics approval for this study was obtained from the Institutional Review Board of the Faculty of Health Sciences, University of Buea, Cameroon. All the participants signed an informed consent form prior to data collection for the study.Conservative therapy (mainly by ulcer debridement and dressing) was done until enough granulation tissue was generated on the ulcer surfaces. Antibiotics were not systematically used but in 2 of the 13 patients, antibiotics were administered for cellulitis.PG in our series was done by the same (2) general practitioners. The anterior aspect of the ipsilateral thigh was used in all cases as the donor site. The site was prepared with Cetrimide solution and Povidone iodine and an area of skin roughly equivalent to the ulcer was demarcated for obtainment of the grafts. The demarcated zone was locally anaesthetized by superficial infiltration with 2% Lidocaine combined with epinephrine. Using a syringe needle inclined to about 30 degrees, tents of skin were raised and cut using a scalpel to harvest multiple small split-thickness grafts whose depths were limited to the dermal layer. These varied from 15 to 35 pinches in our series. The grafts were then put inside a petri dish containing 0.9% saline. Lidocaine combined with epinephrine was applied on the surface of the donor site to achieve faster haemostasis. Vaseline gauze imbibed in 0.9% saline and compressive dressings were then applied on the donor site. The dermal surfaces of the grafts were placed on the ulcer a few mm apart . Local circulation in tissues surrounding the ulcers was intact in all the patients except in case 8. Local innervation was conserved in all the affected limbs: neurological examination revealed that muscle tone and power as well as sensation to touch, pain, and vibrations were normal in all the affected limbs.One patient died at the sixth postoperative month and was excluded from the study. Table The pregraft ulcer pain scores ranged from 4 to 9 (mean: 6.77) with 92.31% (95% CI: 63.97%-99.81%) having ulcer pain scores ≥ 5. Nine of the 13 ulcers were traumatic while 4 were probably ischaemic (and ischaemic) ulcers. Nine of the ulcers were due to trauma, and 4 probably due to ischaemia.th case, there was partial graft rejection by the fifth postoperative day which progressed to complete graft rejection by the second postoperative week. Concerning the other ulcers, ten  had healed after 12 postoperative weeks while 2  had healed after 14 postoperative weeks. The mean healing time was 12.33 weeks ± 0.78 weeks. The healed ulcers remained healed throughout the follow up period. Post graft, the pain scores ranged from 2-9 (mean: 4.23) and although only 7.69% (95% CI: 0.19–36.03%) of the patients had pain scores ≥ 5, this was not significantly different from the 92.31% of patients with pre-graft pain scores ≥ 5 (p = 0.92 from Fischer’s exact test). There was no significant difference in the mean pain scores before and after graft . None of the patients developed new ulcers during the follow-up period. Donor sites were all healed by the end of the second postoperative week. Donor site problems remained minimal and included mild hypopigmentation  in a low-income setting was technically feasible and the outcome was satisfactory. These findings do not discount the role of conservative therapy. However, prolonged unconventional conservative management as definitive treatment for all CLUs in elderly patients may not be worthwhile. More reports on the experience of clinicians on the subject matter could possibly create a platform for progressive refinements in PG procedures and help address the dismal burden of CLUs in elderly patients in rural Cameroon.


To prospectively evaluate the incidence of post-ablation syndrome (fever and flu-like symptoms) and impact on the quality of life in the first 10 days following percutaneous image-guided cryoablation for renal cell carcinoma (RCC).A prospective study of all cryoablation procedures with biopsy proven RCC was conducted with institutional review board approval between 08/2012 and 04/2016. Sixty-four patients  underwent cryoablation. Mean age was 68 (range 24–86). A telephone questionnaire survey was conducted on days 1, 3, 5, 7 and 10 following cryoablation, and complications were recorded. Data collected included temperature, degree of flu-like symptoms, severity of pain, percentage of pain relief with analgesics, interference with general activity and with work .Following cryoablation, six patients (9%) out of 64 developed post-ablation syndrome. Thirty-three patients (52%) developed flu-like symptoms only, which completely resolved by day 10 in 25 patients (39%). One patient had pyrexia only, which was self- limiting by day 10. Twenty-four patients (38%) were asymptomatic. Pain (mean score = 2.1) and interference on general activities (mean score = 1.8) and work (mean score = 2) following cryoablation peaked on day 3 and improved subsequently. Forty-six patients (72%) had 90–100% pain relief by day 10. No major complications were observed.The full spectrum of post-ablation syndrome following cryoablation occurs in approximately 9% of patients; however, 61% of patients experience flu-like symptoms in the first 10 days, which are self-limiting. Over the last decade, percutaneous image-guided thermal ablation has emerged as a useful minimally invasive nephron-sparing therapeutic intervention to treat small cancers in a variety of organs, in particular the liver and kidney, where ablative techniques are now established –4.The two principal methods of thermal ablation are using heat-based energy, e.g., radiofrequency ablation (RFA) or microwave ablation (MWA) and cryoablation, which is an ice-based energy to induce tissue necrosis and cancer cell death , 5. ImagFor liver and kidney tumours, cryoablation has been shown to be safe and efficacious through data generated from cohort studies –14. An iInitial clinical experience of the technique shows, however, that some patients develop flu-like symptoms similar to the post-ablation syndrome described following RFA , 17 and This consists of low-grade fever, malaise, myalgia and nausea or vomiting, which occurs typically in the first 24–48 h after the procedure. The mechanism for this reaction has been speculated to stem from the production of cytokines as part of an inflammatory response to the necrotic tissues , 23, 24.To our knowledge, there has not been any published data evaluating post-cryoablation syndrome in a large cohort of patients following cryoablation of renal cell cancer (RCC).The primary aim of this study was to evaluate prospectively the incidence of post-cryoablation syndrome and to determine its impact on the quality of life in the first 10 days after cryoablation.This prospective study of all image-guided renal cryoablations in a single specialist oncology centre in the United Kingdom was conducted with institutional review board approval between August 2012 and April 2016. No ethics approval was required as the study was not classified as research under the United Kingdom National Health Service Health Research Authority. All patients were followed up with a standardised questionnaire to assess clinical response.Only patients treated with cryoablation for biopsy proved RCC were included in the study cohort. Lesions that were not biopsied or benign histological findings were excluded from the study. Other exclusion criteria included previous locoregional therapy to the kidney. All procedures performed accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained for this survey in all cases by the interventional oncology programme coordinator and nurse.All patients were recommended for cryoablation following multidisciplinary team (MDT) assessment and consensus agreement. The procedure was performed using a dedicated computed tomography (CT)-equipped interventional suite under general anaesthesia by a consultant interventional radiologist (TMW or JTS). Contrast-enhanced CT guidance allowed perioperative visualisation of the tumour and its margin through sequential scanning. All patients were scanned on a 64 slice MDCT scanner . For all scans, the tube kilovoltage (kVp) was fixed at 120 kV and was not adjusted according to patient size. Prior to insertion of the cryoprobes, three helical acquisitions were performed. The first was a non-contrast-enhanced scan, followed by arterial and portal venous phase acquisitions which were performed at 30 and 65 s, respectively, after injection of 100 mls of Niopam 300 intra-venous contrast agent . This was to confirm the tumour volume based on the pre-procedural planning CT and determine the number of cryoprobes required for treatment. Adjunctive protective measures, including hydrodissection, pneumo-dissection or retrograde pyeloperfusion, were taken to prevent injury to surrounding structures. The technique for these has been described in a previous paper by Wah et al. .A combination of 17G Ice Sphere and Ice Seed cryoprobes  were inserted percutaneously into the tumour under CT guidance, typically at the periphery, simulating a clock-face approach to sculpt the required ice ball to ensure an adequate zone of ablation and effective coverage of the tumour during treatment. Two complete cycles of freezing and thawing were performed . One or several needle biopsies were obtained for histological confirmation immediate prior to cryoablation treatment.After cryoablation, all patients were monitored in the post-general anaesthesia (GA) recovery area and vital observations such as blood pressure, heart rate, oxygen saturations and respiratory rate were monitored. Patients were discharged home the next day if they were haemodynamically stable and had recovered from GA to the point of tolerating oral intake and were passing adequate volumes of urine with stable renal function. Simple analgesia, such as orally taken paracetamol and codeine, was provided if required in the post-operative period.Post-cryoablation complications were classified based on the Society of Interventional Radiology Classification System into minor and major complications . Minor cA survey was conducted with a standardised questionnaire on days 1, 3, 5, 7 and 10 following their cryoablation procedure. Please see appendix section for the questionnaire. All inpatients and outpatients were surveyed with the same questionnaire. This survey was conducted by one of two interventional nurse/coordinators and carried out by telephone if the patient had been discharged or in person if the patient was still in hospital.All patients were asked to monitor their temperatures in the morning when they first woke up and as needed, for the initial 10 days following their cryoablation. The patients were instructed to use a forehead thermometer for temperature measurements, which was given to them at discharge.Clinical symptoms including temperature, flu-like symptoms, severity of pain, percentage pain relief with oral analgesics, type of oral analgesic, and any interference with general activity or work were recorded. All symptoms and interferences with lifestyle were graded 0–10 with a numeric intensity scale. Fever was defined as temperature > 37 °C.A full complete spectrum of post-ablation syndrome is defined as a combination of fever and flu-like symptoms, which includes myalgia, malaise and pain at the site of ablation. This is similar to the recognised post-embolisation syndrome and post-ablation syndrome following RFA, which has been defined in the literature , 19, 21.t test to assess whether the presence of fever influenced the severity/grade of the flu-like symptoms.Statistical analysis was performed with software . Patients with post-ablation syndrome, the presence of either fever or flu-like symptoms or both were compared using a two-sample Simple linear regression analysis was used to see if there was any correlation between cryoablation time and severity of flu-like symptoms and pain. Analysis of variance was used to compare the number of cryoprobes with the severity of flu-like symptoms and post-procedure pain experienced to see if there was any correlation.n = 50); papillary type RCC (n = 8) and chromophobe type RCC (n = 7). The average size of the ablated renal lesion was 3.0 cm (range 0.9–6.8 cm). Mean CRYO time was 34.5 min (range 31–51 min), and mean number of cryoprobes used was 6 (range 2–12).A total of 64 patients underwent cryoablation for biopsy proven RCC and met the inclusion criteria. Of these, 43 patients were male and 21 were female, with a mean age of 68 (range 24–86). One patient had two renal tumours cryoablated; therefore, a total of 65 renal lesions histologically confirmed as renal cell carcinoma (RCC) were ablated. The pathology of the specimens was clear cell RCC  in total developed a fever (temperature > 37 °C) in the first 10 days following cryoablation. The mean temperature in the first 10 days following cryoablation was 36.3 °C (range 35–38.5). The mean temperature of all patients who did not have fever compared with those who had fever is shown in Fig. 1% in totThe mean temperature in the group with fever peaked on day 3. A total of 39 patients (61%) experienced flu-like symptoms following cryoablation, with the peak in severity of symptoms on day 3. The mean score for flu-like symptoms (out of 10) in the first 10 days following cryoablation was 1.6 (range 0–8).Six patients (9%) out of 64 developed complete post-ablation syndrome and experienced both fever and flu-like symptoms. These flu-like symptoms peaked on day 3 and resolved spontaneously in 5 out of the 6 cases. In the case where the flu-like symptoms did not resolve, the patient had remained an inpatient following cryoablation and developed their first pyrexial episode (temperature of 39 °C) on day 10, which was attributed to a chest infection and right foot cellulitis, which subsequently resolved with antibiotics.Thirty-three patients (52%) developed flu-like symptoms only, without fever during the first 10 days following cryoablation. These flu-like symptoms had completely resolved by day 10 in 25 of the 33 patients. Of the eight patients who had residual flu-like symptoms on day 10, six rated the severity as only 1 or 2.One patient developed fever without any flu-like symptoms. This resolved without any treatment by day 10.Twenty-four patients (37.5%) did not have any flu-like symptoms or fever following cryoablation.n = 6) (fever and flu-like symptoms) compared with the flu-like symptoms in patients who did not have fever (n = 33) shows that the patients who had fever also experienced more severe flu-like symptoms as demonstrated by a higher mean score .The mean scores for flu-like symptoms in the first 10 days following cryoablation in patients who had complete spectrum of post-ablation syndrome  over the 10 days. Eight patients (13%) had no pain in the 10 days following cryoablation and 56 patients (87%) experienced some pain during the first 10 days, with the peak at day 3 where patients had a mean score of 2.8 out of 10. Thirty-eight patients (59%) did not require any analgesia for pain relief. Forty-six patients (72%) had 90–100% relief of their pain by day 10 with or without simple analgesics. Seventeen patients required only simple orally taken paracetamol for pain relief, and nine patients required orally taken ibuprofen or codeine in addition to paracetamol. The overall percentage of pain relief by day 10 with or without analgesics ranged from 0 to 100% (Mean = 8%).Figure Between day 1 and day 10, the mean interference on general activities was 1.8 (range 0–10) and mean interference on work was 2.0 (range 0–10).The interference on general activities and work activities following cryoablation peaked on day 3 for both categories. The mean score for interference on general activities at day 3 was 3.4, and the mean score for interference on work activities at day 3 was 3.2. Figure P > 0.05).No statistical correlation was found between the total cryoablation time or number of cryoprobes used with the severity of the flu-like symptoms or pain experienced  or fever (n = 1). In a previous RFA study [However, the results for patients experiencing at least one of the components of post-ablation syndrome are similar for our cryoablation cohort compared to other published data on RFA, which found 56% experienced either fever or flu-like symptoms. In this study, 63% developed either flu-like symptoms  where more than 6 cryoprobes were used, of which six patients (9%) required more than 10 cryoprobes.It is vital to distinguish the clinical course of post-ablation syndrome after cryoablation with post-procedural complications such as concurrent infection. Overall, post-cryoablation syndrome symptoms tend to be mild, with a low-grade fever, and self-limiting and resolve spontaneously with conservative management compared to concurrent infection which should be considered in the event of unresolving or delayed onset fever as seen in the patient from our cohort who developed a concurrent chest infection and cellulitis.The mean pain experienced in the first 10 days following cryoablation is similar to published post-RFA results and the cooling effect of cryoablation does not appear to have a therapeutic effect on overall pain although overall scores remain low (mean score 2.1) with 72% having 90–100% pain relief by day 10 with simple analgesics and 26 patients (41%) having no pain by day 10, without the use of any analgesics. Quantification of pain and evaluation of interference with lifestyle through effect on general activities and work remains subjective. Our survey highlights a trend in the pain experienced following cryoablation that peaks on day 3, slightly later than the pain following RFA, which peaked on day 1. The overall mean scores are, however, comparable. There was also no statistically significant difference in the pain experienced with or without concurrent fever.The mean scores for interference on general activities (mean score 1.8 out of 10) and work (mean score 2.0) which both peaked on day 3 in our cryoablation group were similar to the published RFA data, with fever having no apparent influence on the severity of lifestyle interference. In Wah et al. , the oveThis study is limited by its small sample size and subjectivity from the patient’s own measurement of their temperature and using a telephone survey to assess clinical symptoms and lifestyle interference. It does form the basis for a larger formal study to review such findings.The full spectrum of post-ablation syndrome following cryoablation occurs in approximately 9% of patients; however, 61% of patients experience flu-like symptoms in the first 10 days, which are self-limiting.Patients should be reassured that such symptoms are often self-limiting and further investigation is only required when there is persistent or late onset fever indicating possible concurrent infection.


The voluntary withdrawal of artificial nutrition and hydration (ANH) in patients with severe disorders of consciousness  constitutes a fundamental ethical issue extending beyond the boundaries of end-of-life decisions. The term “Vegetative State” was originally adopted to define “an organic body capable of growth and development but devoid of sensation and thought” . In thisRecently it was proposed the alternative name “unresponsive wakefulness syndrome” (VS/UWS) , to defiIn this manuscript, we will briefly review the recent literature indicating that some patients with DoC reveal a form of residual awareness  and thatwhatever the experiencing person says it is, existing whenever the experiencing person says it does.” Such subjectivity implies that pain may only be detected when a patient reports its manifestation. Therefore, the presence of consciousness would seem to constitute a fundamental prerequisite in the individual appraisal and experience of pain. Analogous considerations may be applied to the concept of suffering, defined as “the state of severe distress associated with events that threaten the intactness of the person” , the dehydration and starvation may have benefits  and to refuse food and fluids and to have relief of distress through provision of medicine may be a right . HoweverNeurophysiological and fMRI studies are finding ways to assess awareness in VS/UWS patients , 58. Theper se constitute a source of pain in healthy subjects .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.