To evaluate the impact of abdominal binder (AB) use on postoperative shoulder pain in patients recovering from laparoscopic gynecologic surgery.This was a prospective randomized study conducted in a tertiary teaching hospital. Overall, 144 patients underwent laparoscopic gynecologic surgery. The postoperative use of an AB for 24 hours was added to the pulmonary recruitment maneuver.P = 1.000). The severity of the worst shoulder pain, measured using a numerical rating scale, did not differ between the 2 groups . The severity of surgical site pain, pain and nausea medications, and the ambulation time were not different in the 2 groups.Of 144 consenting patients, 72 patients each were allocated to the AB and control groups, respectively, and 14 patients were excluded. Finally, 130 patients were analyzed, with 68 in the AB group and 62 in the control group. There was no difference in the incidence of postoperative shoulder pain between the 2 groups (55.9% vs 56.5%, The use of an AB was not beneficial for postoperative shoulder pain following laparoscopic gynecologic surgery. Surgical site pain, ambulation time, and postoperative nausea and vomiting were not improved with the use of an AB. In laparoscopic gynecologic surgeries, the frequency of postoperative shoulder pain ranges from 35 to 83%.,4 Shoulder pain after laparoscopic surgery is frequently positional and can be triggered by deep breathing; thus, shoulder pain could slow down recovery.Laparoscopic techniques are widely used in gynecological surgeries worldwide. Compared with laparotomy, laparoscopic techniques reduce blood loss, postoperative pain, and hospital stay2) in the abdominal cavity stimulates the phrenic nerves thus causing shoulder pain.,7The exact mechanism of shoulder pain after laparoscopic surgery remains unclear; however, the main hypothesis is that residual carbon dioxide  could facilitate the absorption of residual CO2 into the peritoneum and pelvis through physical pressure. According to Henry law, the amount of gas dissolved in a liquid is proportional to its partial pressure above the liquid.A previous study reported that the pulmonary recruitment maneuver in the Trendelenburg position significantly reduced the intensity and frequency of shoulder pain in patients who underwent laparoscopic gynecological surgery.This study aimed to evaluate the impact of AB use on postoperative shoulder pain in patients recovering from laparoscopic gynecologic surgery. We assessed the impact of AB use on surgical site pain, ambulation time, and postoperative nausea and vomiting as a secondary aim.The Institutional Review Board of the Seoul National University College of Medicine approved this study . The study was registered at ClinicalTrials.gov before patient recruitment . Only patients who provided written informed consent were enrolled to participate in this study. We conducted this study in compliance with the Good Clinical Practice guidelines and the Helsinki Declaration, and the report was written based on the applicable Consolidated Standards of Reporting Trials guidelines.This study was conducted at the Seoul National University Hospital. We included adult patients aged 20 to 79 years with American Society of Anesthesiologists Physical Status classification I to III who underwent elective laparoscopic gynecological surgery under general anesthesia.The exclusion criteria were patients who had conversion to open surgery from laparoscopic surgery, changes in intraabdominal pressure due to surgical difficulties, a previous shoulder disease or history of shoulder surgery, difficulty wearing an AB due to skin disease or wounds in the abdomen, and development of postoperative subcutaneous emphysema. Moreover, we excluded cases, in which we could not evaluate the occurrence of shoulder pain because of early discharge or patient refusal to participate in the survey.Before patient recruitment, a clinical research coordinator who was not involved in this study generated and kept a random allocation sequence table with a one-to-one ratio using the R software . Patients were allocated to 2 groups: the control (C) and AB groups. Owing to the nature of the AB, concealing the intervention from patients and the anesthetist performing the intervention applying the AB was not possible. However, researchers who collected the data or analyzed the records were separated and blinded.2 concentration was maintained between 30 and 40 cmH2O. Intraperitoneal CO2 insufflation was maintained at a flow rate of 12 L/min and intraperitoneal pressure at 12 mm Hg. The laparoscopic procedures were performed in the full Trendelenburg position. At 30 minutes before the end of surgery, 30 mg ketorolac and 1 g acetaminophen were administered intravenously for postoperative pain control. When the laparoscopic procedure ended, CO2 was passively drained. At the end of surgery, the attending anesthesiologist placed the operating table in the Trendelenburg position at 30° and performed a pulmonary alveolar recruitment maneuver (continuous positive airway pressure 45 cmH2O administered 5 times for 7 seconds). The pulmonary recruitment maneuver was performed by one anesthesiologist in charge of this research (Y.J.K.).The anesthetic and surgical management of the patients were performed in the same manner, except that an AB was worn after surgery in the AB group. To prevent postoperative nausea and vomiting, 5 mg of dexamethasone and 0.075 mg of palonosetron were injected intravenously before inducing anesthesia. Total intravenous anesthesia was used for the induction and maintenance of anesthesia . After loss of consciousness, 0.6 mg/kg rocuronium was administered intravenously to facilitate endotracheal intubation. After the anesthetist confirmed a train-of-four count of 0, endotracheal intubation was performed. The ventilation mode was volume-controlled with the tidal volume set at 8 mL/kg for the ideal body weight. During the maintenance of anesthesia, the end-respiratory COIn the AB group, an elastic AB was worn by another researcher (S.Y.H.) in the Trendelenburg position . Sugammadex was used to reverse muscle relaxation before placing the patient in a supine position. The AB was worn for 24 hours.Sugammadex was also used to reverse muscle relaxation in the control group, and extubation was performed. The patient was placed in the supine position. The patients were transferred to the post-anesthesia care unit. To control postoperative pain, a multimodal analgesia approach was employed. This included intravenous patient-controlled analgesia, with zaltoprofen administered 3 times a day. Additionally, acetaminophen or fentanyl was administered when the patient experienced pain rated at 4 or above on the numerical rating scale, or when requested by the patient.The incidence of postoperative shoulder pain was the primary outcome measure. The follow-up duration was 36 hours postoperatively. At 12, 24, and 36 hours postoperatively. After transfer to general ward, a trained research nurse visited patients and explained how and when to fill out the pain diary and interviewed pain characteristics during follow-up period. The patients recorded shoulder pain and surgical site pain at the pain diary using numerical rating scale. In addition, it was recorded whether shoulder pain occurred at any time during the follow-up period. If shoulder pain was present, the worst pain score was recorded. Patients were also asked whether the shoulder pain was related to the position. We assessed the frequency and the scores of surgical site pain at 12, 24, and 36 hours postoperatively. Rescue pain and nausea medications, and ambulation time after surgery were recorded.t test and Mann–Whitney U test to compare continuous variables with normal and skewed distributions, respectively. Statistical significance was set at P value < .05. To compare pain scores measured 3 times, 2-way repeated measure analysis of variance was conducted, and statistical significance set at P value < .0167 after Bonferroni correction. Statistical analyses were performed using the R software.Data are presented as numbers (proportions) for categorical variables, while data for continuous variables are presented as means (standard deviations) or medians (interquartile ranges) depending on the normality of the data distribution evaluated using the Shapiro–Wilk test. We used the chi-square test or Fisher exact test to compare categorical variables and Student  The sample size was calculated by assuming a 40% reduction in the incidence of postoperative shoulder pain in the experimental group compared to that in the control group. The sample size was 61 patients in each group, using an α error of 0.05 and power (1 − β) of 0.8. Considering a 15% dropout rate of participants, we recruited 72 patients for each group. The total sample size was 144.A previous study reported the incidence of postoperative shoulder pain as 63% in patients who underwent laparoscopic gynecologic surgery with pulmonary recruitment maneuver.We enrolled 144 patients from September 2021 to May 2022 . The severity of shoulder pain did not differ between the 2 groups . Figure Patient characteristics and intraoperative findings are summarized in Table The severity of surgical site pain, pain and nausea medications, and ambulation time did not differ between the 2 groups Table . This study was the first to compare the AB status by frequency of shoulder pain as a primary outcome measure after laparoscopic gynecologic surgery. We expected that the AB would reduce postoperative shoulder pain; however, our study showed that using an AB did not reduce postoperative shoulder or surgical site pain following laparoscopic gynecologic surgery.In this study, AB use did not provide any additional benefit compared to the use of the pulmonary alveolar recruitment maneuver alone following laparoscopic gynecologic surgeries. A previous study on the efficacy of AB on postoperative pain control showed that the association between time and postoperative shoulder pain differed according to AB status.2 is commonly used for laparoscopic surgery because of its high solubility in blood and low reactivity. However, CO2 could remain after pneumoperitoneum desufflation. The residual CO2 adjacent to the diaphragm can irritate the end of the phrenic nerve. Excessive stretching of the diaphragm due to pneumoperitoneum pressure is another explanation for postoperative shoulder pain. Pressure on the phrenic nerve, which originates from the C3 to C8 roots and ends on the diaphragm, may cause shoulder pain.,9CO2, a pulmonary alveolar recruitment maneuver filling the abdominal cavity with normal saline and active evacuation of CO2 have been introduced to decrease postoperative shoulder pain. To prevent excessive stretching of the diaphragm, which causes postoperative shoulder pain, the following strategies were proposed: low CO2 flow rate, low intraabdominal pressure, and deep muscular block. Nevertheless, the best technique for resolving shoulder pain has not been identified.Various interventions have been proposed to ameliorate postoperative shoulder pain. To reduce the remaining CO The Trendelenburg position aided residual CO2 migration to the pelvis, which has an ampule vasculature and promoted residual CO2 resorption. However, forcing patients to maintain the Trendelenburg position for 24 hours could be challenging. Hence, we attempted to induce CO2 movement in this study by performing the pulmonary recruitment maneuver in the Trendelenburg position and increasing abdominal pressure using an AB to facilitate CO2 absorption. We expected an increase in intraabdominal pressure when the AB was worn. In addition, wearing the AB is easy and inexpensive.Recently, a study reported that the postoperative Trendelenburg position decreased the frequency and severity of postoperative shoulder pain after gynecologic laparoscopic surgery.2 absorption. In a healthy adult, the normal intraabdominal pressure ranges from 5 to 7 mm Hg. It is reported that the abdominal pressure increases by 1.1 ± 0.7 mm Hg when using an elastic binder. The CO2 solubility coefficient was 0.0308 mmol/L/mm Hg. When wearing an AB, the intraabdominal pressure increases by approximately 1 mm Hg, resulting in a further dissolved amount of CO2 of 0.0308 mmol/L. This may not be sufficient to prevent postoperative shoulder pain. Second, the AB may form a compartment, preventing CO2 adjacent to the diaphragm from reaching the pelvis. Free air in radiologic images is used to identify the location of perforation in the acute abdomen. This might indicate that free air does not move easily. To prevent trapping CO2 near the diaphragm, we conducted sequential procedures for the patients after surgery. First, the pulmonary recruitment maneuver in the Trendelenburg position facilitates the caudal movement of CO2. Following this, we applied an AB while maintaining the same position. After these procedures, the patient’s position was changed to supine. Our intention was to minimize the accumulation of CO2 adjacent to the diaphragm. However, removal of CO2 may not have been insufficient, and the AB might aggravate isolation of remaining CO2. This result indirectly suggests that CO2-induced phrenic nerve irritation is a contributing factor to shoulder pain after laparoscopy.Despite the use of ABs, the frequency and severity of postoperative shoulder pain did not decrease in this study. There are possible explanations for this ineffectiveness. First, the increase in abdominal pressure from the AB was insufficient to promote residual CO; however, another study showed reduced postoperative pain with an AB in the first week. In a study of patients undergoing incisional hernia repair surgery, AB use reduced postoperative pain, but similar findings were not observed in patients undergoing umbilical or epigastric hernia repair surgery. In our study, AB use did not reduce postoperative surgical site pain or ambulation time. However, because our protocol did not use the enhanced recovery after surgery system, early ambulation was not enforced. Overall, the advantages of using an AB may be insignificant, and further studies are required.The impact of using an AB after laparoscopic surgery on pain and recovery remains controversial. A previous study in gynecologic surgery showed that using an AB did not improve postoperative pain or respiratory function Although the insufflation flow rate is unified in 2 groups, it should be interpreted with caution, as it can lead to different results at lower flows.There were several limitations in this study. First, the follow-up period was 36 hours. This time frame was chosen because most patients undergoing laparoscopic gynecologic surgery at this institute were discharged on the morning of the second day after surgery. However, 7 patients first complained of shoulder pain at postoperative 36 hours. A longer follow-up period may be required for understanding the characteristics of shoulder pain. Second, owing to the nature of ABs, double blinding was impossible. The patients knew if they would or would not be wearing an AB while signing the consent form. This could influence the investigation of pain. Third, it was difficult to guarantee that the patient would continue to wear an AB, although the patient was asked to wear it continuously. The AB could be removed for some time such as to check dressings or the drainage bag. Third, 12L/min is a relatively high insufflation flow which was reported to associate with postoperative shoulder pain.The use of an AB was not beneficial in terms of postoperative shoulder pain in laparoscopic gynecologic surgery. Moreover, surgical site pain, ambulation time, and postoperative nausea and vomiting did not improve with the use of an AB. Based on our results, AB use is not recommended in patients undergoing laparoscopic gynecologic surgery.Conceptualization: Hee-Soo Kim.Data curation: Yoon Jung Kim, So Yeong Hwang.Formal analysis: Yoon Jung Kim.Investigation: Yoon Jung Kim.Supervision: Hee-Soo Kim.Writing – original draft: Yoon Jung Kim.Writing – review & editing: Yoon Jung Kim, Hee-Soo Kim, So Yeong Hwang.


To better understand the sensation of bladder “pressure” and “discomfort”, and how they are similar or distinct from the “pain” and “urgency” symptoms in IC/BPS and OAB.IC/BPS and OAB patients rated their bladder pain, pressure, discomfort, and urinary urgency on separate 0–10 numeric rating scales (NRS). Their NRS ratings were compared between IC/BPS and OAB, and Pearson correlations were performed.p < 0.001). The correlations between urgency and pain, and between urgency and pressure were weak in OAB (0.21 and 0.26). The correlation between urgency and discomfort was moderate in OAB (0.45). The most bothersome symptom of IC/BPS was bladder/pubic pain, while the most bothersome symptom of OAB was urinary urgency and daytime frequency.Among IC/BPS patients (n = 27), their mean numeric ratings of pain, pressure, discomfort, and urinary urgency were almost identical . The three-way correlations between pain, pressure, or discomfort were very strong . Among OAB patients (n = 51), their mean numeric ratings of pain, pressure, and discomfort  were significantly lower than urgency (6.1 ± 2.6, IC/BPS patients interpreted bladder pain, pressure, or discomfort as the similar concepts and rated their intensity similarly. It is unclear whether pressure or discomfort provide additional information beyond pain in IC/BPS. Discomfort may also be confused with urgency in OAB. We should re-examine the descriptors pressure or discomfort in the IC/BPS case definition.The online version contains supplementary material available at 10.1186/s12894-022-01164-8. The descriptors “pain, pressure or discomfort” are used collectively to describe the abnormal bladder or pelvic sensations associated with interstitial cystitis/bladder pain syndrome (IC/BPS). For example, the AUA/SUFU Guideline defines IC/BPS as “an unpleasant sensation  perceived to be related to the urinary bladder, associated with lower urinary tract symptoms […]” . The ESSPresumably “pressure” or “discomfort” were included along with “pain” because not all IC/BPS patients complained of pain. Humphrey et al. noted that some IC/BPS patients mentioned bladder discomfort and pressure in addition to bladder pain during qualitative interviews . Bogart pressure is the urgency. When I get the pressure I’ve gotta make a dash for the bathroom because it is very uncomfortable.” [Overactive bladder (OAB) syndrome is defined by the cardinal symptom of urinary urgency . Howeverrtable.”  About 30rtable.” . This cartable.” , 2. In oIn this study, we asked IC/BPS and OAB patients to rate their bladder “pain”, “pressure”, “discomfort”, and urinary “urgency” sensation on separate numeric rating scales. We then compared their mean ratings and correlations, to discover group differences between IC/BPS and OAB patients. Our objective is to better understand the sensation of bladder “pressure” and “discomfort”, and how they are similar or distinct from “pain”  and “urgency”  in the two clinical populations. This study may provide further clarity on the distinguishing factors between bladder pain, pressure, discomfort and urgency symptoms.Patients who presented to urology clinic and were diagnosed clinically with IC/BPS or OAB by one urologist (HHL) consented to participate in this questionnaire study between late 2012 and early 2014 (the timing of the enrollment was related to funding). The clinical diagnosis of IC/BPS and OAB was consistent with the AUA IC/BPS Guideline  respectiThink about the pain associated with your bladder. On average, how would you rate these symptoms in the past 4 weeks? Think about the pressure associated with your bladder. On average, how would you rate these symptoms in the past 4 weeks? Think about the discomfort associated with your bladder. On average, how would you rate these symptoms in the past 4 weeks? Think about the urgency to urinate associated with your bladder. On average, how would you rate these symptoms in the past 4 weeks? Patients completed the following questions to rate their bladder pain, pressure, discomfort, and urinary urgency on separate 0–10 numeric rating scales (NRS):We intentionally chose not to define these descriptors for the patients because we wanted the patients to interpret their bladder sensations for themselves when rating them.In addition, patients were also asked to identify their single most bothersome symptom over the past 4 weeks among the followings: (1) pain, pressure, discomfort in the pubic or bladder area, (2) pain, pressure, discomfort in the area between your perineum  or vaginal area , (3) pain, discomfort during or after sexual activity, (4) strong need to urinate with little or no warning, (5) frequent urination during the day, (6) frequent urination at night, (7) sense of not emptying your bladder completely, (8) other. For the most bothersome symptom question, we did not separate out pain from pressure or discomfort. The exact wordings of these questions were identical to the SYM-Q questionnaire administrated in the MAPP Study.As mentioned earlier, the clinical diagnosis of IC/BPS and OAB was based on patient chief complaint, history, physical examination findings, and laboratory and diagnostic workup as indicated in accordance to the AUA Guidelines on IC/BPS and OAB , 5. The Additional questionnaires used to characterize the cohorts included: (1) genitourinary pain index (GUPI) , (2) intp < 0.05. Since formal comparison of pain, pressure, and discomfort ratings have never been done in these two populations, a priori power calculation was not performed.For comparisons between IC/BPS and OAB cohorts, Wilcoxon sum-rank tests and chi-square tests were used to compare continuous and categorical data respectively. Paired t-tests were used to compare within group variables of interest. Spearman’s rank coefficient was used to assess correlation between quantitative variables. All analyses were performed using R version 4.1.0 with statistical significance set at p = 0.003, < 0.001, 0.002, respectively), while OAB participants had significantly higher scores on OAB-q, ICIQ-UI, and ICIQ-OAB .There were no statistical differences in age, sex, and race between the IC/BPS and OAB cohorts. Both men and women were represented, and the cohorts were predominantly white , see Table Among IC/BPS patients (n = 27), their mean numeric ratings of pain, pressure, discomfort, and urinary urgency were almost identical . There was a significantly bigger difference in ratings between bladder pain and urgency (urgency minus pain = 4.1 ± 3.2) than between bladder pressure and urgency  and between bladder discomfort and urgency  among OAB patients.Among OAB patients (n = 51), their mean numeric ratings of pain, pressure, and discomfort  were significantly lower than urgency , see Table Among OAB patients, the correlations between pain and urgency , and between pressure and urgency were weak 0.21 and 0.26). The correlation between discomfort and urgency was moderate in OAB (r = 0.45). The scatterplots are shown in Fig.  and 0.26p < 0.001). Frequency during the day was identified as the most bothersome symptom in 41.2% of OAB patients and 18.5% in IC/BPS patients (p < 0.05). In addition, 25.5% of OAB patients reported urinary frequency at night as the most bothersome symptom.The most bothersome symptom for over half of IC/BPS patients (51.9%) was pain, pressure or discomfort localized in the bladder and pubic region rather than the perineal area in men or vaginal area in women (7.4%). While a small percentage of OAB patients (9.8%) did complain of pain in the bladder and pubic area , the most bothersome symptoms were urinary urgency and daytime frequency (41.2% for both). Approximately 41.2% of OAB patients reported urgency as their most bothersome symptom in contrast to ~ 4% in IC/BPS patients  IC/BPS patients also reported non-zero urinary urgency or frequency along with pain.Among OAB patients, 50 of 51 (98%) reported non-zero urinary urgency, 24 (47.1%) reported non-zero bladder pain, 36 (70.6%) reported non-zero pressure, and 39 (76.5%) reported non-zero discomfort.In this study, we compared the bladder pain, pressure, discomfort, and urgency sensation between IC/BPS and OAB patients, in order to better understand how bladder “pressure” and “discomfort” are similar or distinct from “pain”  and “urgency”  in the two clinical populations.In our cohort of IC/BPS patients, there was no patient who reported any pressure or discomfort without pain. Every single patient reported pain, pressure, AND discomfort. Thus we were unable to compare IC/BPS patients with pressure or discomfort alone versus those with pain. Their mean numeric ratings of pain, pressure, or discomfort were nearly identical. In addition, the three-way correlations between pain, pressure, or discomfort were very strong . In fact, the correlation between pain and discomfort ratings was extremely high (r = 0.95), almost approaching a straight line Fig. c. This sAmong OAB patients, the correlations between urgency and pain, and between urgency and pressure were very weak (0.21 and 0.26 respectively). The correlation between urgency and discomfort was moderate in OAB (r = 0.45). This suggest that OAB patients can distinguish urinary urgency from pain and pressure, but this distinction is less clear cut between urgency and discomfort symptoms. It is conceivable that “urgency” may be confused with “discomfort” by some OAB patients, or at least the distinction between these terms may vary among patients. This observation is consistent with a qualitative study which showed that OAB patients described their urgency as “pressure” or “discomfort [Pain, on the other hand, is a much better descriptor distinguishing IC/BPS from OAB. Even though a subset of OAB patients reported non-zero bladder pain, their NRS of pain was mild (2.0 ± 2.6 out of 10) and was significantly lower than those reported by IC/BPS. More importantly, it was their most bothersome symptom that distinguished OAB from IC/BPS. The most bothersome symptom of IC/BPS patients is pain in the bladder/pubic area. The most bothersome symptoms of OAB patients are urinary urgency and frequency. These findings clearly confirmed “pain” and “urgency” as cardinal and most bothersome symptom of IC/BPS and OAB, respectively.The report of non-zero  bladder pain in OAB might raise the questions whether we could have misdiagnosed IC/BPS for OAB, and vice versa. However, this possibility was low since 100% of our IC/BPS patients reported pain while 98% of OAB our patients reported urgency. The distribution of their single most bothersome symptoms also aligned well with the accepted case definitions of IC/BPS and OAB. Based on the current evidence, it is possible that the subgroup of OAB patients with pain may have different underlying pathophysiology  from OAB patients without pain –16. ThisPotential limitations of the study included the small sample size, and that our cohort was predominantly white in the United States. It is possible that patients in other ethnic groups, cultures, or in other countries might interpret these bladder sensations differently from our cohort. Future studies with larger sample size and a more diverse demographics or ethnic makeup should be conducted to further examine our findings.In future studies, it would also be beneficial to examine whether the discomfort was related to “fear of pain” (which will point to IC/BPS) versus “fear of leakage” (which will point to OAB).IC/BPS patients interpreted bladder pain, pressure, or discomfort as the similar concepts and rated their intensity similarly. It is unclear whether the descriptors pressure or discomfort provide additional information beyond the pain descriptor in IC/BPS. Bladder discomfort may also be confused with urgency in OAB. We should re-examine the descriptors pressure or discomfort in the IC/BPS case definition.Additional file 1. Supplemental Table 1. Characteristics and demographics.


Madelung deformity is a rare congenital hand difference with little known regarding the patient perspective. In this cross-sectional survey study, we harnessed the global reach of social media to understand the clinical spectrum of Madelung deformity and its impact on physical, mental, and social health.T-scores were calculated, interpreted, and compared between patients who underwent surgery and those who did not. Correlations between scores were calculated using the Spearman rank correlation coefficient.A survey was developed based on a previously published protocol and multiple Patient-Reported Outcomes Measurement Information System (PROMIS) short forms. The survey was distributed on several Madelung deformity communities on Facebook and Instagram. Mean PROMIS scores for adults were as follows: pain intensity, 4.9 ± 2.8; pain interference, 57.6 ± 10.0; upper extremity, 35.2 ± 8.1; depression, 53.8 ± 11.1; anxiety, 55.4 ± 11.4; and ability to participate in social roles and activities, 42.5 ± 7.7. Mean scores for children were as follows: pain intensity, 5.0 ± 2.8; pain interference, 55.7 ± 11.3; upper extremity function, 24.6 ± 10.4; depressive symptoms, 57.7 ± 11.3; anxiety, 57.3 ± 11.9; and peer relationships, 42.2 ± 10.3.Madelung deformity has significant effects on patients’ physical, mental, and social well-being, even after surgical treatment. Using social media, we were able to compensate for Madelung deformity’s rarity by engaging an international audience, demonstrating the feasibility to conduct research through it, and providing a global perspective of the disease entity. This congenital hand difference is caused by a premature growth arrest of the distal radius, leading to a shortened radius with a volar and ulnar angulation, relative overgrowth of the ulna, and pyramidization of the proximal carpal row. The deformity is often caused by mutations in the short stature homeobox (SHOX) gene, which is associated with both Leri-Weill dyschondrosteosis and Turner syndrome.4 Madelung deformity is extremely rare, and its incidence and prevalence are relatively unknown, with hand surgeons seeing very few, if any, cases during their surgical career. This is evident by the sparse literature, with the largest recently published case series study including 19 patients, raising several unanswered questions regarding etiology, diagnostics, classifications, treatment options, and surgical outcomes. Furthermore, small-powered studies often inadequately describe functional status, and only a handful of studies have even considered the patient perspective.In April 1878, after a lecture in Berlin by a German surgeon, the condition “Madelung deformity” was introduced to the surgical community. To increase our understanding of these deformities, it is therefore paramount to perform studies using validated patient-reported outcome measures (PROMs) in a large sample size of patients. Although the investigation of PROMs through combining data from multiple centers has provided us insights into other congenital hand differences, this has not translated to an increased understanding of Madelung deformity due to the low numbers of patients captured. To date, a potentially useful tool to study these rare patient populations that may otherwise be extremely difficult to reach is social media.This is remarkable, given that it is well established that congenital hand differences have a profound and lifelong impact on the physical, mental, and social aspects of patients’ lives. advised for use in rare diseases,16 we collaborated with several social media communities to conduct a cross-sectional survey. The PROMIS allows for an assessment of multiple physical, mental, and social health domains and has been proven to be efficient and reliable for different upper extremity conditions. To the best of our knowledge, this is the first and largest-to-date study of PROMs for Madelung deformity.This study’s primary aim is to understand the clinical spectrum of Madelung deformity and its impact on physical, mental, and social health by harnessing the global reach of social media. Using the universal Patient-Reported Outcomes Measurement Information System (PROMIS),@madelungdeformity”). The survey was kept online for a total of 9 days from the initial launch date . Ethical approval for this cross-sectional survey study was waived by our hospital Medical Ethics Committee. Data were collected through an online survey created with Google Forms. The survey was distributed through a post  on exist The following variables were collected: age, assigned sex at birth, height, weight, affected arm(s), previously diagnosed genetic conditions, previously diagnosed medical conditions, medication use (including painkillers), family history of Madelung deformity, and any (corrective) surgeries of the hand, wrist, or arm. Based on the selected age range (18+ or 8-17 years), participants were presented with either adult or pediatric versions of the PROMIS forms. The complete question list is available in Supplementary File 1.Questions regarding demographic characteristics were based on a previously published protocol that proposed various changes in the methodology of future Madelung deformity studies. covering physical, mental and social health. For adults, the following forms and versions were used: (1) Pain Intensity 1a Version 1.0; (2) Pain Interference 8a Version 1.0; (3) Upper Extremity 7a Version 2.0; (4) Depression 8a Version 1.0; (5) Anxiety 8a Version 1.0; and (6) Ability to Participate in Social Roles and Activities 8a Version 2.0. For children, we used the short forms: (1) Pediatric Pain Intensity 1a Version 1.0; (2) Pediatric Pain Interference 8a Version 2.0; (3) Pediatric Upper Extremity 8a Version 2.0; (4) Pediatric Depressive Symptoms 8a Version 2.0; (5) Pediatric Anxiety 8a Version 2.0, and (6) Pediatric Peer Relationships 8a Version 2.0; Regarding pain, “Pain Intensity” assesses how much a person hurts, whereas “Pain Interference” considers self-reported consequences of pain on relevant aspects of one’s life.The PROMIS short forms consisted of fixed sets of questions for 6 health domains,T-score metric, in which 50 is the mean and 10 is the standard deviation of a relevant reference population.T-scores were calculated based on scoring tables of each domain’s published manuals, using self-developed software in Python (Python Version 3.7.4). Higher scores represent a higher level of the measured domain, and their interpretation in different domains is shown in Supplementary Figure 1.After exporting raw survey data from Google Forms, each entry was manually inspected to remove errors , perform metric unit conversions , and determine analgesic use by reviewing all listed medications. The PROMIS short forms were scored using a t test  or Welch t test  was performed. Equality of variances was assessed using the Levene test. For nonnormally distributed scores, the Mann-Whitney U test was performed. All analyses were performed separately for adult and pediatric patients. Correlations between the different PROMIS short form scores were calculated using the Spearman rank correlation coefficient (ρ), with correlation strength interpreted as low (<0.3), moderate (0.3-0.5), or high (>0.5).Means were compared between patients who underwent surgery and those who did not. For normally distributed scores, an independent-samples An overview of the patient characteristics is shown in P = .045).Descriptive data of the PROMIS short forms are presented for adults and children in Correlations between the PROMIS short form scores are shown in This cross-sectional survey highlights Madelung deformity’s impact from the patient perspective, showing significant effects of the disease on one’s physical, mental, and social health. Even after surgical treatment, the health burden of this congenital hand difference remains. Despite Madelung deformity’s rarity, we were able to engage a relatively broad international audience through the use of social media, allowing us to assess patient outcomes and determine demographic characteristics.; however, no population-based data or epidemiological studies are available. Therefore, our knowledge regarding demographic characteristics has been derived from small-powered studies. Mean reported adult patient height in our study was 157 cm (5′2″), which is at the 27th percentile for women in the United States. Previous studies reported average heights of 159 cm or below standard heights at the 19th percentile,21 not surprising given that a substantial proportion of patients with Madelung deformity have confirmed SHOX gene mutations, which is strongly associated with short stature and dyschondrosteosis.4 Of our participants, 28% reported having this genetic mutation, and 47% reported on Madelung deformity occurring in family members. Interestingly, it has been hypothesized that a substantial amount of patients have underlying diagnoses of dyschondrosteosis.23 The collection of genetic material in future prospective studies, as recommended in a previously published protocol, will hopefully provide a definite answer.The overwhelmingly female patient composition and bilateral occurrence of Madelung deformity have been extensively described25 One study using a “Pain Score”  reported scores of 14.5 and 25.0 before and after surgery, respectively. Another study only reported preoperative measurements of 3.3/4 . This widely heterogeneous registration of pain is suboptimal, and studies should quantify pain in an analogous manner using a VAS or NRS, both before and after surgery, without merging the variable in a “wrist score.” In this study, we not only recorded pain intensity but also highlighted the consequences of pain on a person’s life, showing mild interference in adults, moderate interference in children who did not undergo surgery, and mild interference in children who underwent surgery; notably, 49% of participants reported the use of analgesics. The presence of pain in surgical patients postoperatively seems in stark contrast to the literature. On the one hand, there is potential for bias in this cross-sectional survey study as symptomatic persons might be more vocal about their symptoms and engage in social media communities. On the other hand, it may be that a short follow-up period or loss of follow-up results in underreporting of this outcome in the literature, as most studies have not quantified pain or have only reported preoperative measurements.8 Nevertheless, in future studies we would be most interested in the difference between preoperative and postoperative pain instead of single cross-sectional measurements.While the often-reported pain is the primary indication for surgical treatment, its quantification in a preoperative or postoperative setting has not been consistent. Some studies measured pain using a Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), reporting preoperative scores of 9/10 and 50/100, and postoperative scores of 0/10 and 22.5/100, respectively.28 most recently reclassified Madelung deformity as an entire upper limb malformation of the radioulnar (anteroposterior) axis (OMT type IA2.vii). A previous study applying PROMIS to congenital hand anomalies reports median upper extremity scores of 37 (<11 years) and 45 (11-17 years) in children with entire limb malformations (OMT type IA) and worse upper extremity function in children with bilateral compared with unilateral deformities. In contrast, another study reported scores within the normal range in 41 children (5-17 years) with a similar OMT type. Our results show moderately impaired functioning in adults (35.2 ± 8.1) and severely impaired functioning in children (24.6 ± 10.4). A noteworthy point is the slightly lower postoperative score in adults and a slightly higher score in children, albeit not significant. The results of our study, which mainly involves data entries from adults with Madelung deformity , can unfortunately not be compared with these aforementioned studies. However, the bilateral occurrence (92%), the lack of consensus regarding optimal treatment, and the relatively late age of onset, diagnosis, and corrective surgery might all play a role in decreased upper extremity function.The Oberg-Manske-Tonkin (OMT) classification, a proven and adopted classification framework for congenital hand and upper limb anomalies,11 It could be argued that Madelung deformity is associated with higher levels of pain compared with other congenital upper limb differences, in turn resulting in poorer mental and social health.Our findings suggest that Madelung deformity has a significant impact on one’s mental and social health. We found that both adults and children experience higher levels of depression and anxiety in comparison with population norms. For adult patients, we found slightly increased depression levels still within normal limits and a mild level of anxiety. For children, depression and anxiety levels were both moderate. Scores varied widely, and both groups included patients with severe levels of depression and anxiety. Regarding social health, adults reported a mildly decreased ability to participate in social roles and activities compared with the general population. Children reported good peer relationships; however, scores again ranged widely, with 53% reporting fair to poor peer relationships. To our knowledge, no other studies on mental or social health in patients with Madelung deformity exist. Previous studies of other congenital upper extremity differences have reported varying results regarding mental and social health outcomes, ranging from no effect to significant impairments.33 It is plausible that pain and impaired function lead to a vicious circle with decreased levels of physical, mental, and social health, emphasizing the need for treatments improving pain and functioning. Moreover, it also highlights the need for psychological screening and support in both initial work-up and postsurgical follow-up.For both adults and children, decreased physical health appears to be associated with decreased mental and social health levels. Pain and impaired physical functioning have bidirectional associations with depression, anxiety, and social participation.16 As demonstrated by Timberlake et al, social media appears to be a potentially useful tool to study these specific populations; however, an implementation to investigate patient outcomes has not been described. We were able to engage a considerable international audience, compensating the low patient numbers as seen in single-center and even multicenter study designs, by harnessing social media to assess patient outcomes in a rare population. We believe that selecting an appropriate survey or questionnaire is paramount; PROMIS offers a suitable solution, given that its measurement properties have been thoroughly examined, and it is intended for use in every patient population, including the variety of congenital hand differences. The possibility of distributing PROMIS with short forms or computer-adaptive tests allows for the measurement of multiple health domains with relatively few questions, enabling a full assessment of a patient’s health status without being too much of a burden while taking into consideration the importance of material readability. Moving forward, the relatively low presence of surgeons and academic institutions on social media platforms has been demonstrated, and there is substantial room for improvement both for research and for education. As clinicians need to gain a full understanding of the burden their patients carry, the combination of our and previous study designs using social media surveys could serve as a blueprint for assessing the health status of other rare conditions.The patient perspective is crucial in the treatment of rare congenital anomalies. For most rare diseases, it is unfeasible to develop disease-specific measures or conduct methodologically sound validation studies due to insufficient patient numbers. In addition, although we limited the survey to participants with “diagnosed” Madelung deformity after a medical assessment, the possibility remained that an undiagnosed or wrongly diagnosed  person would participate. That being said, we considered the probability of obtaining incorrect data to be relatively limited as each entry was checked manually, and questions were added for screening purposes. Finally, we did not distribute our survey on the social media platform Twitter. However, as it has the fewest patient users and minimal engagement, we believe the effect on inclusions to be negligible. Despite these limitations, to the best of our knowledge, this is the largest study on Madelung deformity outcomes and the first to assess the patient outcomes regarding physical, mental, and social health. We used PROMIS as a self-assessment tool, which has been extensively validated in large populations and proven to be more feasible than other known instruments for patients with congenital hand differences.The main limitation was that our survey data were obtained from social media communities on Facebook and Instagram, making the methodology prone to self-reporting bias.In conclusion, Madelung deformity has significant effects on patients’ physical, mental, and social well-being. Even after surgical treatment, the health burden of this congenital hand difference is observed. Using social media, we were able to compensate for Madelung deformity’s rarity by engaging an international audience, demonstrating the feasibility to conduct research through it, and providing a global perspective of the disease entity.Click here for additional data file.Supplemental material, sj-jpg-1-han-10.1177_15589447211054133 for #MadelungDeformity: Insights Into a Rare Congenital Difference Using Social Media by Abbas Peymani, Max M. Lokhorst, Austin D. Chen, Chantal M.A.M. van der Horst, Bernard T. Lee, Samuel J. Lin and Simon D. Strackee in HANDClick here for additional data file.Supplemental material, sj-pdf-2-han-10.1177_15589447211054133 for #MadelungDeformity: Insights Into a Rare Congenital Difference Using Social Media by Abbas Peymani, Max M. Lokhorst, Austin D. Chen, Chantal M.A.M. van der Horst, Bernard T. Lee, Samuel J. Lin and Simon D. Strackee in HAND


Pain control after operations is essential in decreasing the patient recovery period and potential morbidity. Prescribing opiates is very effective, but significant side effects accompany them. This study aims to examine the effect of local ketamine infiltration in decreasing pain intensity in patients undergoing transabdominal hysterectomy.  In this double-blind, randomized, controlled clinical trial, a total of 92 patients undergoing transabdominal hysterectomy aged 30–60 years were selected and divided into two intervention and control groups randomly. For the intervention group, ketamine was injected subcutaneously into the incision site at a dose of 0.5 mg/kg after the operation. In the control group, 5 mg normal saline was used in the same method. Postoperative pain intensity was measured using the visual analog scale (VAS: 0–10). The pain score and dose of administered opioids were documented at 1, 2, 4, 6, 12, and 24 hours and compared between the two groups.  Postoperative pain intensity was significantly lower in the intervention group than in the control group, except for hour 24. The mean amounts of administered opioids were significantly lower in the intervention group at hours 6 and 12, as well as the total amount of used opioids, and no significant side effects were documented.  Local ketamine subcutaneous injection in the incisional site is effective and is a safe procedure for reducing pain scores in patients who underwent a transabdominal hysterectomy. The incidence of postoperative pain (PP) after abdominal surgery has been reported between 0% and 34% , 2. PostOverusing narcotic analgesics in such patients could bring a lot of significant side effects, a condition that has persuaded scientists to use safer alternative pain-control methods and medications –9. Also,Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is a potentially effective and safe medication associated widely pre- and postoperatively to decrease pain intensity and has been reported to be associated with a significant decrease in narcotics use for this purpose . There iThis double-blind, placebo-controlled, clinical trial was conducted to examine the analgesic effect of ketamine infiltrated locally in the incisional site in transabdominal hysterectomy. After the approval of the study protocol by the Ethics Committee of the Tehran University of Medical Sciences and obtaining written consent from the participants, a total of 100 patients undergoing abdominal hysterectomy  referred to Valiasr Teaching Center from 2014 to 2015 were selected to participate in this study. The age range of patients was considered between 30 and 60 years.Exclusion criteria were patient refusal, patients with cardiac problems, schizophrenia, seizure, hypertension, history of drug/alcohol addiction, brain space-occupying lesion, and intracerebral pressure elevation.α = 0, β = 0.01, and power = 80%, the sample size was estimated at 46 patients in each group, which was augmented to 50 patients to consider possible losses.To detect one level decrease in the pain score according to the visual analog scale (VAS) and to assume https://Randomization.org). Accordingly, patients were randomized into either case or control groups. Induction and maintenance of anesthesia were performed similarly in both groups, including intravenous midazolam (0.01 mg/kg) and fentanyl (3 mic/kg) as premedication agents and intravenous sodium thiopental (5 mg/kg) followed by atracurium (0.01 mg/kg) as induction agents. Then, the patients underwent laryngoscopic tracheal intubation and mechanical ventilation after that. Anesthesia was continued using continuous infusion of propofol (100–150 mic/kg), fentanyl, and atracurium when needed.Patients were classified into two case and control groups according to the type of analgesia they received. First, each patient received a random computer-generated code  was infiltrated subcutaneously (0.5 mg/kg in 5 ccs) in the incisional site of patients in the case group. Instead of ketamine, normal saline  was used similarly in the control group. Patients were then transferred to the recovery after extubation and antagonizing relaxing effects of neuromuscular blockers. Pain intensity was recorded at hours 1, 2, 4, 6, 12, and 24 after surgery in patients who were instructed about how to refer to pain using the visual analog scale (VAS), which allows identification and qualification of neuropathic symptoms reflecting spontaneous or paroxysmal pain and evoked pain, which was considered positive with scores higher than zero. Accordingly, 0 indicated no pain and 10 showed the most severe pain experienced by the patient . In patit-test were used for comparisons. A normal distribution of the numerical data was assured using the Kolmogorov–Smirnov test. A P value <0.05 was considered statistically significant.SPSS software  was used for statistical analysis. The quantitative variables were expressed as the mean ± standard deviation, and the qualitative variables were defined as frequency (%). Repeated measures analysis (RMA) and the independent samples P=0.80). The two groups were also comparable in the mean weight .All the initially recruited 92 patients completed the study protocol. The mean age of patients was 49.41 ± 7.10 years in the case group and 49.25 ± 6.98 years in the control group . So, it could be concluded that younger patients requested narcotics more frequently than their older counterparts.Although the number of narcotics requested by patients decreased by age, this correlation was not statistically significant  for more invasive and routinely painful procedures. In that case, patients can have a decreased risk of developing persistent postoperative pain in the months that follow.To the best of the authors' knowledge, no other study has ever examined the effect of local infiltration of ketamine at the site of incision on postoperative pain after hysterectomy. Therefore, this study was performed to determine the impact of a low dose ketamine infiltration in the wound on postoperative analgesia.


Diagnosing the precise etiology of low back pain (LBP) is crucial for facilitating speedy recovery in patients. Maigne's syndrome (MS), commonly referred to as thoracolumbar junction syndrome, is a condition characterized by pain resulting from nerve entrapment, yet its underlying mechanisms remain poorly understood. This study presents a series of six case reports wherein patients diagnosed with MS received acupuncture treatment.Six individuals with LBP were included in the study, and all were diagnosed with MS.The diagnosis was confirmed in all six patients through pinch-roll and thoracic vertebrae compression tests, indicating the presence of thoracolumbar junction syndrome.Acupuncture treatment was administered to all patients, primarily targeting the T11–L2 facet joints, with additional acupoints selected based on the specific nerve entrapment of MS including the superior cluneal, subcostal, and iliohypogastric nerves.Following acupuncture therapy, all patients reported improvements in their LBP symptoms, while four patients also exhibited amelioration in their thoracic vertebrae compression test results.These findings underscore the significance of promptly diagnosing the underlying cause of LBP and suggest that acupuncture may be an effective approach in alleviating MS-related pain. LBP is also ranked highest in terms of lived-with disabilities and ranked sixth in overall burden in terms of disability-adjusted life years, thus representing a real public health challenge. There is a wide variety of potential etiologies for LBP and one potential cause is Maigne’s syndrome (MS). Kuniya et al, in a prospective study of 834 consecutive patients in a surgical spine center clinic, reported the incidence of MS to be 14%.Low back pain (LBP) is one of the most prevalent types of pain affecting the human population. An initial episode of LBP occurs in 6.3% to 15.4% of the population, and the chance of recurrence within 1 year can be up to 90%.,5 MS is poorly understood, and there are no specific clinical prediction rules or clear diagnostic criteria. This is because nerve-related pain is caused by soft tissue damage outside the spinal canal. Radiological findings are usually negative. A skin rolling test can also be performed to compare heaviness on either side. The superior cluneal nerve (SCN), subcostal nerve (SN), and iliohypogastric nerve (IN) have a direct connection with the thoracolumbar junction and the entrapment of those nerves are related to MS, commonly causing lumbosacral pain. If a patient responds sensitively while performing the pinch-roll test along the main distribution areas of the SCN, SN, and IN, the facet joint at the thoracic-lumbar junction should be palpated. The tenderness in the facet joint indicates a diagnosis of MS.MS, also known as the thoracolumbar junction syndrome, is defined as pain caused by cluneal nerve entrapment, and pseudosciatica caused by the thoracolumbar lateral nerve branch.–12 Conservative management approaches include a selective exercise regimen, corticosteroid or analgesic or anti-inflammatory medication, and spinal manipulative therapy.–16 However, most of these treatments produce limited pain relief and are accompanied by serious side effects, such as drowsiness, dizziness, addiction, allergic responses, reversible reduction of liver function, and negative impacts on gastrointestinal functions.–22 According to a Cochrane review, acupuncture is better than no treatment in terms of quick pain relief and functional improvement. Herein, we present 6 case reports with the aim of suggesting alternative treatments and provide insight into the effectiveness and safety of acupuncture for MS. This study was prepared in accordance with the CARE guidelines.Invasive treatments for MS include percutaneous rhizotomy, electrocoagulation, surgical denervation of the involved facet joint, superior and middle cluneal nerve release, and ultrasound-guided neural blocks.,26 The TVCT was applied to the facet joint areas of both T12 and L1, using combined modules: the Human Body Scale Sensor  and HX711 Weighing Pressure Sensor . We pressed up to 83.36 N (8.5 kg kg•f) and measured the N that the patient feels tenderness  with MS who provided consent for publication, from January 1 to April 30, 2021. Patients with MS were diagnosed using the pinch-roll and thoracic vertebrae compression test (TVCT). The pinch-roll test was performed from the iliac crest on the back of the human body to the outside, which are the main distribution areas of the SCN, SN, and IN.All patients with MS received acupuncture without variation. During the treatment period, 2 different acupuncture treatments were applied selectively, which were acupuncture or acupotomy. Overall, 8 to 10 acupoints were selected. The T11–L2 facet joint  were used identically in all patients, with 3 to 4 needles inserted at each pain side. We used 0.30 × 40 mm disposable stainless-steel needles  with a depth of 3.0 to 4.0 mm, and the acupuncture time was 15 minutes.In case of entrapment of the SCN, where the SCN exits under the skin of the buttocks in the direction of travel of the SCN, 6 to 7 Ashi points were added, which were the tender points at the area of the nerve pathways Fig. A. In casAcupotomy was applied when the patient’s disease period was over 3 months or other treatment like orthopedic manipulation did not work. We used 0.5 × 40 mm disposable stainless steel WOOJEON DOCHIM needles  at the same acupoints as manual acupuncture.Cupping was applied for 3 minutes. In cases of entrapment of the SCN, Huatuo jiaji of T12 and the tender points at the upper part of the iliac crest were used. In cases of entrapment of the SN, Huatuo jiaji of T12 and the tender points at the lateral iliac crest were targeted. In cases of entrapment of the IN, Huatuo jiaji of T12 and the tender points at the gluteus medius muscle were targeted.Interference current therapy (ICT) was applied in all cases. In cases of bilateral pain , ICT was applied crossing the levator inferior and quadratus lumborum region. In the single case of unilateral pain (case 4), ICT was applied by crossing the levator inferior and quadratus lumborum upward and the gluteus medius downward.A hot pack was applied from the lower part of the thoracic vertebrae to the lumbar sacrum.Chuna was applied using a Leander Table . For the lumbar region and pelvis, the collateral lumbar distraction (lumbar roll), iliac posterior downward displacement correction, and anterior superior displacement correction techniques were used. For the thoracic region, the supine head flexion correction technique was used. After acupuncture, Chuna was performed once daily. Table Hyeolbuchukeo-tang gami, which is most frequently used for cases of blood stasis in Korean medicine, shows anti-inflammatory and antinociceptive effects, and improves blood circulation, was used for cases when the period of disease was long. The EQ-VAS is a scale ranging from 0 to 100 , allowing the comprehensive judgment of one’s own health status. In addition, the RDQ is a patient-reported outcome (PRO) designed to assess physical disability due to LBP. The RDQ contains 24 items related specifically to physical functions likely to be affected by LBP derived from the Sickness Impact Profile, which is a 136-item health status measure covering all aspects of physical and mental function. Each question is limited to the phrase “because of my back pain.” The scores range from 0 (no disability) to 24 (maximum disability). The RDQ is better suited to patients for mild to moderate disability, and the Oswestry Disability Index to patients for persistent severe disability. Therefore, we used RDQ in association with outpatient treatment. Adverse reactions or side effects were confirmed through medical records. The TVCT was checked every time before acupuncture at both sides of the thoracic 12 (T12) and lumbar 1 (L1) vertebrae. In the TVCT, 83.36 N was used as a negative criterion. This is because, in our experience, when the patient did not feel pain even when the patient was compressed up to 83.36 N at entrapment of the SCN or SN or IN, pinch-roll tests, NRS, and lumbar flexion tests also showed negative results.The Numerical Rating Scale (NRS), EuroQol-visual analogue scale (EQ-VAS), Roland-Morris Disability Questionnaire (RDQ), and TVCT were used. The NRS is used to measure pain, which rates pain intensity as an integer from 0 to 10.The characteristics of the cases are summarized and presented in Table  to rule out lumbar spinal canal stenosis and a pinch-roll test on the lower extremities were both negative, sciatic nerve entrapment and lateral femoral nerve syndrome were excluded. The pinch-roll test was positive in regions 1 and 2 (Fig. A 45-year-old male patient had a traffic accident on December 03, 2020. He was treated at another clinic and diagnosed with sprain in the lower back, but did not show any improvement after treatment. The first visit to our clinic was on January 25, 2021. At the first visit, the patient complained of bilateral LBP when standing, and the pain seemed to spread from the back to both hips and inguinal area. When he got up from a chair or the floor, his lower back did not straighten, and he experienced severe pain while turning when he layed down. The pain occurred during lumbar extension. He had a history of stage 3 ureteral cancer and a history of left kidney organ donation. As the tibial nerve compression testA 74-year-old female patient developed acute back pain while lifting a flower pot on April 25, 2021. She arrived at the clinic on April 26 without visiting other clinics. She complained of pain in the form of a belt wrapped around the waist. Pain occurred during both lumbar flexion and extension. She had no radiating pain or abnormal sensations in the lower extremities. She was diagnosed with MS of SCN through the TVCT and pinch-roll test, and the acupoints were selected based on the diagnosis of MS with entrapment of SCN Table . After tA 55-year-old slightly obese female patient with a history of facial paralysis and cervical radiculopathy, who not currently taking any medications, suddenly experienced LBP at work on February 10, 2021. She worked as an shop assistant. In particular, she suffered from back pain on both sides while standing at work, faced difficulty while standing for a long time, and had to rest. She did not have any radiating pain or any abnormal sensations in the lower extremities. She complained of severe pain during lumbar extension. She was diagnosed with MS syndrome of SCN and IN through the pinch-roll test and TVCT. She was treated with acupuncture on 10 acupoints based on the diagnosis of MS with the entrapment of SCN and IN on February 10 and February 15, 2021 (Table With no past medical history, a 52-year-old male patient developed severe back pain while working at a farm on February 24, 2021. He mainly complained of pain in his left lower back and side, and the pain was severe enough to cause sleep disturbance. He visited this clinic on February 27, 2021 without visiting another clinic beforehand. MS with entrapment of SCN and IN was diagnosed through the pinch-roll and TVCT (Table His NRS score was 7, RDQ score was 11, EQ-VAS was 40, and his TVCT result was 79.34 N for the left T12, negative for the right T12, 78.65 N for the left L1, and negative for the right L1. The severe pain was slightly improved by the second visit on March 2, 2021, but he complained of a pulling symptom in his left flank. His NRS score was 5, RDQ score was 7, EQ-VAS was 50, and his TVCT result was 73.26 N for the left T12, negative for the right T12, 75.02 N for the left L1, and negative for the right L1. At the third visit on March 6, 2021, his NRS was 3 and his TVCT result was 69.33 N for the left T12, negative for the right T12, 72.28 N for the left L1, and negative for the right L1 (Table A slightly obese 54-year-old female patient without previous diseases sprained her back on January 23, 2021 and visited the clinic on January 25, 2021 without visiting other clinics. On January 25, she complained of severe pain that made it difficult to move and to turn around. She was diagnosed with MS with the entrapment of SCN through the pinch-roll and TVCT (Table A 48-year-old male patient got LBP during his weekend rest on March 13, 2021. He received manual treatment from an orthopedic before March 19, 2021, but the pain did not improve. He described bilateral back pain. MS with the entrapment of the SCN and IN was diagnosed through the pinch-roll and TVCT. Twenty acupoints were selected based on the entrapment of both side of SCN and IN (Table On March 26, his pain improved markedly and he had almost no discomfort in his daily life; his NRS score at this point was 1, RDQ score was 6, EQ-VAS was 35, and his TVCT result was negative for the left and right T12 as well as the left L1, and 74.73 N for the right L1 (Table This patient was treated with acupotomy, as the pain was stubborn even when receiving orthopedic manipulation. Figure This case series identified improvements in LBP due to MS through the use of acupuncture. The NRS, indicating pain, dropped to a value of 3 or less in all cases; scores in the EQ-VAS and RDQ, which measure the physical disability of patients with LBP, also improved. Interestingly, intractable LBP not responding to orthopedic manipulation was improved with acupuncture, with the understanding of the trigger points at the entrapment site of MS. Misdiagnosis of LBP due to MS leads to delayed appropriate treatments, and extends the treatment period. The main difference in LBP due to MS with that of herniated disc is the region of pain. Pain in patients with MS appears in the lower back and gluteal region, and radiating pain does not appear below the knee. We speculate that this is owing to the etiology of entrapment of the SCN, SN and IN in MS. This study was performed at a primary clinic, thus the skin rolling test and thoracic vertebrae compression test are most reliable tests to discern LBP due to MS from others like simple strain or sprain.MS can be misdiagnosed as pain is rarely felt at the thoracolumbar region, but rather presents in a similar fashion to LBP of the lumbosacral origin. reported on the surgical outcomes of SCN entrapment over 20 articles. However, only few studies on acupuncture for MS have been reported. Nevertheless, acupuncture has been used to stimulate myofasia. Here, in this study, we used acupuncture to stimulate myofasia, which caused the entrapment of nerves in MS. Acupotomy is a thicker acupuncture that make strong effect, and the treatment time is relatively short due to no need for retention. In addition, it recreates the original physiological state by facilitating the blood circulation of the tissue by exfoliating the adherent tissue. In Kim’s study, patients with acute LBP with NRS over 5 showed statistically significant NRS score reductions, improvements in the range of movement and RMDQ, improvements in EQ-5D and EQ-VAS scores, and satisfaction after acupotomy.Isu et al Following what Maigne claimed, we clinically identified the nerve entrapment points, which are the tender points as the “Ashi-point” – in which areas SCN, SN, and IN well captured. These Ashi-points are the specific treatment points, and the effect confirmed it as a target.Our study had strengths in that pain due to entrapment of nerves was improved easily with acupunture. Maigne claimed that articular facet syndrome with thoracolumbar junction syndrome and entrapment of the nerve at the iliac crest can be associated, requiring treatment of the spine and of the iliac crest. This will also require a follow-up study to prove the correlation with the frequency of MS through structural evaluation of the spine. And due to the nature of the Korean primary medical clinic, treatments such as cupping, herbal medicine, and chuna were performed in parallel with acupuncture treatment. Thus, lack of control over multiple interventions is a limitation in confirming the effectiveness of acupuncture treatment through this study.This study had the following limitations. Clinically, chronic MS is considered to recur frequently when there is a structural displacement of the spine, such as a compression fracture.This study was considered to be a case series in which the characteristics of MS were effectively discriminated against patients with LBP in a primary clinic, and the treatment effect was quick. It is also significant in that this study is the first case series report of patients with MS who improved through a combination of Korean medicine treatments.We extend our sincere thanks to Hongmin Chu, Joohyun Lee for their contributions to this paper, including the figures.Conceptualization: Hyocheong Chae, Myungseok Ryu.Funding acquisition: Changsop Yang.Investigation: Hyocheong Chae, Myungseok Ryu.Project administration: Changsop Yang.Supervision: Sungha Kim.Writing – original draft: Hyocheong Chae, Hesol Lee.Writing – review & editing: Hesol Lee, Sungha Kim.


ObjectiveWe aimed to describe epidemiologic trends in outcomes of colonic diverticular disease (CDD) hospitalizations in morbidly obese patients.MethodsWe searched the United States National Inpatient Sample databases from 2010 through 2019, obtained the incidence rate of morbid obesity (MO) among CDD hospitalizations, and used Joinpoint analysis to obtain trends in these rates adjusted for age and sex. Hospitalizations involving patients less than 18 years of age were excluded. Trends in mortality rate, mean length of hospital stay (LOS), and mean total hospital charge were analyzed. Multivariate regression analysis was used to obtain trends in adjusted mortality, mean LOS, and mean total hospital charge.ResultsWe found an average annual percent change of 7.5%  in the adjusted incidence of MO among hospitalizations for CDD over the study period. We noted a 7.2% decline in mortality (p = 0.011) and a 0.1 days reduction in adjusted LOS (p < 0.001) over the study period. Hospitalizations among the middle-aged and elderly had adjusted odds ratios of 7.18  and 24.8 , respectively, for mortality compared to those in young adults. The mean LOS was 0.29 days higher in females compared to males (p < 0.001).ConclusionThe incidence of MO increased among CDD hospitalizations while mortality and mean LOS reduced over the study period. Outcomes were worse in older patients, with an increased mean LOS in females compared to males. Colonic diverticulosis refers to the presence of diverticula that result from herniation of colonic mucosa and muscularis mucosa through the muscularis propria at sites of vascular penetration . DivertiDiverticular disease can range in severity from symptomatic uncomplicated diverticular disease manifesting as bloating, mild abdominal pain, and changes in bowel habit to symptomatic disease with complications such as acute diverticulitis or diverticular hemorrhage, which often prompt hospitalization and may necessitate endoscopic procedures or surgical intervention . DivertiDiverticular disease impacts markedly on patients' well-being and is one of the most economically significant diseases in gastroenterology. It accounts for almost two million ambulatory visits, over 370,000 emergency department visits, and over 200,000 hospital admissions, and contributes to over 4,600 deaths every year ,7. HealtThe incidence of obesity has risen in the US over the past half-century . ObesityStudy design and data sourceWe carried out a retrospective longitudinal trends study involving CDD hospitalizations in morbidly obese patients in the United States. Data were sourced from the Nationwide Inpatient Sample (NIS) databases from 2010 to 2019. The NIS is a database of inpatient hospital stays derived from billing data submitted by hospitals to statewide data organizations across the US, covering more than 97% of the US population . The datStudy population and variablesWe searched the databases for hospitalizations for CDD and isolated those with MO using ICD codes. Hospitalizations involving patients less than 18 years were excluded. The NIS includes variables on patient demographics, including age, sex, race, and median household income (MHOI) for the patient’s zip code , and primary payer. It also contains hospital-specific variables, including bed size, teaching status, and location. We assessed the comorbidity burden using Sundararajan’s adaptation of the modified Deyo’s Charlson Comorbidity Index (CCI). This modification groups CCI into four groups in increasing risk for mortality. It has been adapted to population-based research. A score of >3 has about a 25% 10-year mortality, while a score of 2 or 1 has a 10% and 4% 10-year mortality, respectively. This cutoff point was chosen as a means of assessment of the increased risk of mortality . Total hOutcome measuresBiodemographic trends of hospitalizations for CDD in patients with MO were highlighted. Specifically, we obtained the incidence of MO among CDD hospitalizations and expressed the rate as a percentage. We adjusted this rate for age and gender and used Joinpoint regression analysis to obtain trends in these adjusted rates.We analyzed trends in inpatient mortality rate, mean length of hospital stay (LOS), and mean THC of both cohorts. We also highlighted disparities in outcomes of these hospitalizations stratified by sex , race , and MHOI quartile (low-income quartile (LIQ) and high-income quartile (HIQ)).Statistical analysisWe used Stata® version 16 software  and Joinpoint Regression Program version 4.9.1.0  for data analysis. We analyzed the weighted sample following HCUP regulations for utilizing the NIS database. Age was grouped as young adults (18-44 years), middle-aged adults (45-64 years), and elderly (65 years and above). The incidence of MO among CDD hospitalizations was calculated with the HCUP methodology for disease incidence . We usedEthical considerationsThis study did not require Cook County Health Institutional Review Board approval as the NIS database lacks patient and hospital-level identifiers.Data availability statementThe NIS is a publicly available inpatient care database that contains data on more than seven million hospitalizations annually. Its large sample size makes it ideal for developing regional and national estimates and enables analyses of special populations, uncommon conditions, and rare treatments.IncidenceOf the 305 million hospitalizations included in our study, more than 2.7 million were for CDD, with 142,110 of these patients being morbidly obese. The incidence rate of MO among hospitalizations with CDD increased from 3.4% in 2010 to 7.2% in 2019  of 7.5%  in the incidence of MO among CDD hospitalizations from 2010 to 2019. Between 2010 and 2013, the annual percentage change (APC) was 12.4% . There was no significant trend in APC between 2013 and 2017 . An APC of 11.3%  was noted between 2017 and 2019.Biodemographic dataThe biodemographic data of hospitalizations with CDD and MO are shown in Table OutcomesTable There was a 7.2% decline in mortality over the study period when adjusted for age, sex, and race (p = 0.011). Compared to young adults, the middle-aged and elderly had adjusted odds ratios (aOR) of 7.18  and 24.8 , respectively, for mortality. There was no significant difference in adjusted mortality between males and females (p = 0.223). There was no significant difference in adjusted mortality among Blacks (p = 0.754) or Hispanics (p = 0.369) when compared to Whites. Among White hospitalizations, there was a 10% decline in mortality when adjusted for age and sex (p = 0.02). When Black hospitalizations were adjusted for age and sex, there was no significant trend in adjusted mortality (p = 0.737).There was a 0.1 days reduction in adjusted overall LOS over the study period (p < 0.001). Middle-aged and elderly patients had increases in adjusted LOS of 0.36  and 0.76  when compared to young adults. LOS was 0.29 days higher in females compared to males (p < 0.001). There was a 0.11 days reduction in adjusted LOS among Whites and a 0.1 days reduction in adjusted LOS among Blacks over the study period (both p < 0.001).There was a $668 increase in THC over the study period (p < 0.001). Middle-aged and elderly patients had increases in adjusted THC of $6,815 (p < 0.001) and $11,695 (p < 0.001) when compared to young adults. There was no significant difference in adjusted THC between males and females (p = 0.825).We demonstrated that the incidence of MO in our cohort of patients increased over the study period. This is in keeping with concerns over the global obesity epidemic. From 1999 to 2020, the prevalence of obesity in the US increased from 30.5% to 41.9%. During the same time, the prevalence of MO rose from 4.7% to 9.2% [Obesity has previously been shown to increase the likelihood of developing CDD. Positive associations were also found between weight gain and increased waist circumference/waist-to-hip ratio and the development of diverticular complications -15,25. TWe found increased mean age and an increasing proportion of elderly patients in our study population. Similar findings have been demonstrated in other studies. In the US and many other developed nations, the prevalence of obesity in the elderly is increasingly in parallel to the general population-wide increase in obesity prevalence. This is likely due to lower physical activity and intrinsic age-related metabolic changes in the elderly . ObesityOur study also showed that more of the admissions were catered for at small and medium-sized hospitals compared to large hospitals over the study period, but there was an increased proportion of patients managed at urban teaching hospitals. This could be explained by the increasing proportion of elderly patients and comorbidities leading to the need for care at a teaching hospital level. However, this may also reflect an increase in the complexity of CDD cases in relation to MO itself. Increased visceral fat and obesity have been associated with increased severity of the presentation of diverticulitis and an increase in complicated disease .Despite this notable increase in MO prevalence and the probable increase in the severity and complications of CDD, we noted a decline in mortality and LOS over the study period. These improvements in overall outcomes are contrary to the findings of other retrospective reviews ,31 that Our study highlighted increased mortality, LOS, and THC in older patients compared to young adults. Old age has previously been shown to be an independent predictor of more severe CDD with worse outcomes, likely due to poorer functional status and the increased prevalence of coexisting comorbidities and frailty ,36. Our Our study has some notable limitations. The NIS is an administrative database and is prone to the limitations associated with administrative databases. Firstly, ICD-9 and ICD-10 codes were utilized to document diagnoses that may not correspond completely to clinical and laboratory parameters. Thus, reported findings relied on an appropriate representation of administrative codes and accurate data collection. Secondly, the NIS contains data on admissions rather than individual patients. Patients with recurrent CDD may be documented as multiple admissions. Thirdly, the NIS lacks laboratory/radiologic data or data used to grade clinical disease severity; therefore, we could not stratify outcomes based on CDD severity. Lastly, we could not determine the effect of treatment modalities and medication adherence on outcomes. Nonetheless, this database provided a unique opportunity to study this cohort at a population level. Multiple centers are accounted for to ensure national representation.The incidence of MO increased among CDD hospitalizations over the study period. Mortality rate and LOS trended down from 2010 to 2019. These are likely due to improved care for patients hospitalized with complications of CDD. Outcomes were however worse in older patients compared to young adults, with increased LOS in females compared to males. These findings highlight the need for improved care in these subgroups. Further research on lifestyle and medical care for morbidly obese patients as well as amelioration of CDD complications in these patients is needed.


The OsteoCool Tumor Ablation Post-Market Study (OPuS One) was a prospective, multi-national, single-arm study to investigate safety and effectiveness of radiofrequency ablation (RFA) for palliation of painful lytic bone metastases with 12 months of follow-up. RFA has demonstrated effective palliation of osseous metastases in small clinical studies with short-term follow-up; however, a long-term assessment with robust subject numbers is lacking.Prospective assessments were conducted at Baseline, 3 days, 1 week, and 1, 3, 6, and 12-months. Pain and quality of life were measured prior to RFA and postoperatively using the Brief Pain Inventory, European Quality of Life—5 Dimension, and European Organization for Research and Treatment of Cancer Care Quality of Life Questionnaire for palliative care. Radiation, chemotherapy and opioid usage, and related adverse events were collected.P < 0.0001). Post hoc analysis found neither systemic chemotherapy nor local radiation therapy at the index site of RFA influenced worst pain, average pain, or pain interference. Six subjects had device/procedure-related adverse events.206 subjects were treated with RFA at 15 institutions in OPuS One. Worst pain, average pain, pain interference and quality of life significantly improved at all visits starting 3 days post-RFA and sustained to 12 months (RFA for lytic metastases provides rapid (within 3 days) and statistically significant pain and quality of life improvements with sustained long-term relief through 12 months and a high degree of safety, independent of radiation.www.springer.com/00266.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors The online version contains supplementary material available at 10.1007/s00270-023-03417-x. Two-thirds of patients with osseous metastatic cancer report pain that alters quality of life , 2. AddiTreatment is focused on pain relief, reduction of SREs, and improvement in quality of life. External beam radiation therapy (EBRT) is considered the standard of care for symptomatic patients. Lytic metastases provide challenges for EBRT as they are more likely to cause radiation-induced fractures , 6.Small prospective studies on percutaneous RFA have demonstrated pain relief –10 and dOPuS One is a prospective multicenter study designed to evaluate the effectiveness and safety of RFA for painful metastatic lytic lesions. Results from the first 100 patients followed up to 6 months after RFA treatment have been published . This maTwo hundred eighteen 218) patients at 15 international centers were enrolled in a prospective, post-market, open label study—OsteoCool Tumor Ablation Post-Market Study (OPuS One)—between September 2017 through February 2020. The full study protocol is available online (NCT03249584).8 patientPer the Helsinki Declaration, the Clinical Investigation Plan (CIP), Informed Consent Forms, and associated materials were each approved by the local Institutional Review Board (IRB) or Ethics Committee (EC). All patients provided informed written consent before participating in this study.Ablation of the targeted tumor(s) was performed using the OsteoCool™ RFA System . Target tumors were accessed using an 8, 10, or 13-gauge introducer cannula. At the completion of RFA, polymethylmethacrylate (PMMA) augmentation, if utilized, was injected through the same bone access cannula.Follow-up assessments occurred post-procedure at 3 days, 1 week, and 1, 3, 6 and 12-months. Subjects completed validated questionnaires to measure their pain, quality of life, and function. The Brief Pain Inventory (BPI) short form  is self-Quality of life measures included The European Quality of Life – Five Dimensions (EQ-5D)  and The P value was ≤ 0.05 from SW test, Wilcoxon signed-rank test was used; otherwise, paired t test was used. Also, post hoc was the decision to use the same test across all time points within an assessment. If the data at any of the timepoints are non-normal, a Wilcoxon signed-rank was applied; otherwise, a t test was used.Change in outcomes from baseline was tested for statistical significance. Statistical testing outside the primary and secondary objective (reported previously ) is consTo evaluate the potential relevance of chemotherapy or radiation therapy at the site of RFA treatment on patient outcome measures , post hoc linear mixed modeling analysis was performed after adjusting for the following covariates: follow-up visit, baseline outcome measure, age, gender and days between baseline visit and RFA procedure. SAS software  was used for all analyses.Although not required per protocol, PMMA augmentation was performed in 257 (97%) of procedures. Table Following RFA, patients experienced significant improvement in worst pain and average pain at 3 days sustained up to twelve months Fig. a, c. OveP < 0.05) except 3 days for quality of life and emotional functioning and 12 months for physical and emotional functioning  .More subjects decreased their OMED than increased their OMED at all visits, with the percentage of subjects with decreased OMED ranging from 34 to 51% (P < 0.02). A post hoc sub-group analysis was also performed on radiation-naïve subjects through end of follow-up (166/206) and found significant improvements in BPI worst pain, BPI average pain, BPI interference, and EQ-5D index at each follow-up visit through 12-months .From Baseline through the end of follow-up, 166/206 (81%) of subjects never received radiation therapy at the index site of RFA and 81/206 (39%) were off systemic chemotherapy Table . After aDevice, therapy, and/or procedure-related adverse events, in 6/206 patients (2.9%), were reported including, drug hypersensitivity, folliculitis, intramuscular hematoma, intra-abdominal fluid collection, pneumonia, and respiratory failure. The latter three adverse events were considered serious. A total of 82 deaths (40%) were reported during the study. All deaths were classified by the Clinical Events Committee and none were related to the device, therapy, or procedure but instead attributed to the natural course of disease. No post-procedure vertebral fractures at the treated site(s) were observed for the duration of the study.The results of this large prospective study of percutaneous ablation treatment for osseous metastases add to evidence that percutaneous ablation is safe and effective –10, 18. Other studies have shown durable pain palliation from percutaneous ablation, but their clinical impact is limited by smaller numbers or shorter follow-up duration. Tanigawa et al. showed a 70% pain overall response rate in 33 patients, but only six patients were followed up to 12 months post-RFA . Goetz eComplication rates reported for osseous RFA are low with multiple prospective and retrospective series reporting no SREs , 18, 24.Other musculoskeletal ablation studies had higher rates of previous radiation use or did not report the numbers –9, 32. GOne limitation of our study is the dropout rate. The most common cause of dropout was death from the underlying disease. This could be addressed with future studies moving RFA earlier in the care continuum. An additional limitation is the concurrent use of other therapies. Prior to the procedure the patients had chemotherapy (34%) or steroids (25%). While these agents may have provided some effect, the typical referral pattern for RFA is made when the pain is recalcitrant suggesting these agents failed to palliate . FinallyIn conclusion, the study demonstrated safe, rapid and durable palliation with no SREs. Given that many of the advantages noted in this study address the more commonly seen disadvantages of radiation including time to pain relief and post-radiation fractures, future investigation to evaluate the benefits of pairing RFA-assisted PMMA augmentation with radiation in the palliative setting is warranted.Supplementary file1 (DOCX 80 KB)Below is the link to the electronic supplementary material.