Distressing cancer pain remains a serious symptom management issue for patients and family caregivers, particularly within home settings. Technology can support home-based cancer symptom management but must consider the experience of patients and family caregivers, as well as the broader environmental context.This study aimed to test the feasibility and acceptability of a smart health sensing system—Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C)—that was designed to support the monitoring and management of cancer pain in the home setting.Dyads of patients with cancer and their primary family caregivers were recruited from an outpatient palliative care clinic at an academic medical center. BESI-C was deployed in each dyad home for approximately 2 weeks. Data were collected via environmental sensors to assess the home context ; Bluetooth beacons to help localize dyad positions; and smart watches worn by both patients and caregivers, equipped with heart rate monitors, accelerometers, and a custom app to deliver ecological momentary assessments (EMAs). EMAs enabled dyads to record and characterize pain events from both their own and their partners’ perspectives. Sensor data streams were integrated to describe and explore the context of cancer pain events. Feasibility was assessed both technically and procedurally. Acceptability was assessed using postdeployment surveys and structured interviews with participants.Overall, 5 deployments  were completed, and 283 unique pain events were recorded. Using our “BESI-C Performance Scoring Instrument,” the overall technical feasibility score for deployments was 86.4 out of 100. Procedural feasibility challenges included the rurality of dyads, smart watch battery life and EMA reliability, and the length of time required for deployment installation. Postdeployment acceptability Likert surveys  found that dyads disagreed that BESI-C was a burden (1.7 out of 5) or compromised their privacy (1.9 out of 5) and agreed that the system collected helpful information to better manage cancer pain (4.6 out of 5). Participants also expressed an interest in seeing their own individual data (4.4 out of 5) and strongly agreed that it is important that data collected by BESI-C are shared with their respective partners (4.8 out of 5) and health care providers (4.8 out of 5). Qualitative feedback from participants suggested that BESI-C positively improved patient-caregiver communication regarding pain management. Importantly, we demonstrated proof of concept that seriously ill patients with cancer and their caregivers will mark pain events in real time using a smart watch.It is feasible to deploy BESI-C, and dyads find the system acceptable. By leveraging human-centered design and the integration of heterogenous environmental, physiological, and behavioral data, the BESI-C system offers an innovative approach to monitor cancer pain, mitigate the escalation of pain and distress, and improve symptom management self-efficacy.RR2-10.2196/16178 Pain is a pervasive problem in advanced-stage cancer, occurring in almost 100% of patients ). CompliThis study aimed to address the need for improved cancer pain management and represents a multiphase, interdisciplinary effort to design and test an in-home smart health remote monitoring system known as the Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C). Our research has a particular focus on supporting the pain management needs of patients with advanced cancer and their family caregivers in rural settings, a population with well-documented disparities and challenges related to symptom management -27. The procedurally as (1) logistic barriers related to in-home deployment  and (2) participant recruitment and attrition rates and technically as (3) the fidelity of data capture, recorded as a composite score after each deployment. Acceptability was operationalized as dyad perceptions and receptivity to BESI-C and assessed at the time of removal of BESI-C from a dyad’s home by (1) a Likert-style survey and (2) structured interview questions asking about general experiences with the system.This descriptive study assessed the feasibility and acceptability of the BESI-C system. Feasibility was operationalized Ethics approval was granted by the University of Virginia Health Sciences Institutional Review Board (HSR IRB 21017), and all participants provided informed consent before data collection. The participants were shown prototypes or pictures of the BESI-C system during the informed consent process to better understand the project.Patients and family caregivers were recruited from an outpatient palliative care clinic at an academic medical center in the southeastern United States. BESI-C was deployed in patient and caregiver homes living in Central Virginia between April 2019 and December 2019 (before the COVID-19 pandemic).Our goal was to recruit patients and family caregivers coping with difficult cancer-related pain in a home setting. Therefore, we used a purposive sampling technique , and patAfter patients and caregivers provided informed consent, basic clinical and demographic data were collected, and a time was scheduled to deploy BESI-C in their homes. A team consisting of clinicians (1 nurse faculty and 1 nursing student) and technicians (1-2 engineering students) traveled to participant homes to set up the BESI-C system and provide education regarding system use. The first author (VL) maintained a detailed audit log to record procedural and technical challenges related to each deployment.Participants were asked to maintain and use the BESI-C system in their homes for 10 to 14 days. During deployment, remote system monitoring was performed by our technical team (using the software platform TeamViewer), and participants had a study phone number to call if they had problems or questions. All data streams were deidentified and labeled only by the study ID number. Our team also provided brief, periodic check-ins every 3 to 4 days via telephone calls or text (depending on dyad preference) or as needed, if technical issues arose. Both patients and caregivers were asked to keep a ground truth daily log during deployment to record key events that may influence pain or functionality of the system .During deployment, streaming data were passively collected from the smart watches worn by both patients and caregivers (heart rate and motion), environmental sensors , and Bluetooth beacons . Active data  were collected from ecological momentary assessments (EMAs) delivered via smart watches, including on-demand EMAs that allowed patients and caregivers to record and describe patient pain events from their own perspective when they occurred, as well as 30-minute follow-up pain reassessment EMAs (7 items). The smart watches also generated a daily scheduled EMA survey (12 items) to assess other factors over the past 24 hours that can influence pain, such as self-reported sleep quality and mood. EMAs were purposely designed to be fast and easy to complete and used simple Likert scale (0-10) or categorical response options . Details of EMA data collection are the focus of a subsequent publication.At the conclusion of the deployment, our team returned to the participants’ home, removed the equipment, and assessed the patient and caregiver experience with BESI-C by a structured interview and a Likert-style survey administered to both the patient and the family caregiver. Responses were captured verbally and recorded by pen-and-paper by study team members for deployments 1 to 4 and via an iPad (Apple Inc) for deployment 5. All participants were asked 13 Likert-style survey questions designed to assess their opinions regarding perceptions of system helpfulness (n=1), burden and privacy concerns (n=3), data sharing preferences (n=3), ease of using smart watches to mark and describe pain events (n=3), concerns regarding environmental sensors (n=1), and perceived impact of the system on cancer pain management and communication with their partner (n=2). Optional free-text responses within the survey allowed participants to expand on their answers or provide suggestions regarding system components. Structured interview questions  provided additional opportunities for participants to discuss their experiences with the system. As the goal of this study was to understand the feasibility and acceptability of very specific features of our system architecture to guide future work, we opted to create a customized survey and interview guide , informet tests (2-tailed) were performed across all individual and category variables to assess statistically significant differences (Cronbach α=.05) between patient and caregiver mean scores. Likert scale survey items in which the respondent selected the option “don’t know” were omitted from analysis. Textual data (open-text survey and structured interview responses) were exported into Microsoft Word and organized into clusters using a basic descriptive content analysis approach that mapped to the questions asked . Our goal with the analysis of open-ended responses was not to conduct a qualitative analysis with a high level of abstraction, but instead, consistent with a descriptive approach, to stay close to our data and concretely understand participant responses [Postdeployment survey and structured interview data collected from patients and caregivers were verified and entered into Qualtrics for data management and storage. Quantitative responses were exported to SPSS , and basic descriptive statistics were run, including frequency counts and percentages for demographic data and individual and category means for Likert scale items. Independent sample esponses .We created a BESI-C Performance Scoring Instrument  to quantA total of 10 individuals (5 dyads of patients and their primary family caregivers) completed BESI-C feasibility and acceptability deployments . OverallLogistic deployment barriers included the rural location of dyads, which involved challenges coordinating time-intensive trips to dyad homes along with internet stability issues and the length of time it took to set up the system, which varied according to the size of the home and other unanticipated factors. For example, in some homes, limited or poorly situated electrical outlets to plug in environmental sensors created challenges and added time to system installation. Participant recruitment was significantly disrupted by the COVID-19 pandemic . Screening for eligibility was complicated by inherent limitations within the electronic health record, which made it difficult to verify key eligibility criteria such as caregiver status. A total of 2 dyads signed consent but withdrew before deployment; one due to being too busy; the other dyad was lost to follow-up and unable to be contacted. In all, 80% (4/5) of dyads who signed the consent form and had the system installed completed the minimum (10 days) target length of data collection. One dyad  only completed 9 days of data collection, but this was due to technical failures that truncated data input versus voluntary attrition.Postdeployment Likert surveys demonstrated that, overall, patients and caregivers perceived the BESI-C system to be helpful and low burden . SpecifiWithin Write-in or free-text survey items revealed that participants found the BESI-C system beneficial, particularly in relation to dyadic communication. Questions inquiring about specific hardware components of the system architecture  yielded minimal or no comments or suggestions. Most of the feedback from the participants involved the smart watch interface and its functionality. A caregiver expressed concern regarding how environmental sensors may be perceived by visitors to the home (“is the government spying on us?”) Both caregivers and patients acknowledged some frustration with the technical challenges with the smart watches, including battery life, occasional lag in the touch-to-wake screen tap feature, and inconsistency with EMA delivery. A caregiver expressed the desire for greater flexibility in describing unusual events that may influence pain.Structured interviews allowed participants to more fully contextualize or expand upon their survey responses, and dyads largely reiterated perceptions documented in the free-text survey items, particularly related to technical inconsistencies with smart watch functioning. Despite technical glitches with the smart watch app interface, when asked, “about what percentage of the time did you wear the smart watch in a 24-hr period?” 40% (4/10) of the participants said 100% of the time, 30% (3/10) said 75% of the time, and 10% (1/10) said 85% of the time; this question was added after deployment 3, and so only answered by participants of deployments 4 and 5. A participant was particularly averse to wearing the smart watch as he explained, “he doesn’t wear a watch in general” and expressed a dislike for jewelry. Participants also expressed a desire for clearer instructions about wearing the smart watch and an interest in having the smart watch capture distress from symptoms other than pain, such as nausea. Because of the high degree of similarity in responses to free-text survey items and structured interview questions, qualitative feedback was integrated and is summarized in both the patient and the family caregiver via smart watches programmed with a custom app to collect participant-reported EMA data, as well as passive physiological data. This is critically important, as a holistic understanding of the family caregiver experience in the context of the patient experience is essential for designing effective cancer interventions [In this study, we demonstrated the acceptability and feasibility of deploying a smart health system, BESI-C, in the homes of adults with advanced cancer, to collect holistic and heterogenous sensing data from patients, caregivers, and the home environment. Importantly, our findings suggest an innovative approach to supporting home-based symptom self-management for cancer pain, promoting patient and caregiver self-efficacy, and strengthening the relationship between caregivers and care recipients—all critical and persistent gaps in oncology care ,42. Moreventions ,52. Intewill mark pain events in real time using a smart watch and that they find this activity meaningful and not overly burdensome. This is a noteworthy finding given the severity of illness experienced by palliative care patient populations, which can make data collection extremely difficult or impossible [We found that patients and caregivers coping with serious, advanced cancer possible -55. We bpossible ,56,57 anpossible . We alsopossible -60.We also learned that once participants became accustomed to the smart watch interface , they were able to answer the EMAs very quickly, generally in <30 seconds. Postdeployment assessments also revealed that the participants were willing to answer additional EMAs. This was helpful information, as we purposely designed the EMAs for this study to be as streamlined and brief as possible to enhance adherence and reduce participant burden; this required making difficult choices about questions to include and ones to omit. Confirmation that we had latitude to add questions increased our confidence to add EMAs to the next iteration of our smart watch app, such as important questions about the use of nonpharmacological measures taken to reduce pain and other co-occurring symptoms, such as fatigue. Importantly, we also confirmed that patients and caregivers not only want to share collected data with their health care providers but that they wish to see their own data and for their partners to see their data. This is an important finding, as prior work has demonstrated challenges in ensuring health care providers understand and act upon patient-reported outcome data . Given tAnother interesting finding is that BESI-C may influence dyadic communication related to cancer pain management and medication use. Unfortunately, we were unable to interpret the direction of these Likert scale survey items . Qualitative responses, however, were able to shed light on these ambiguous quantitative results. In the postdeployment interviews, both patients and caregivers discussed that BESI-C made them more attuned to their partner’s experience and created more awareness of pain in a way that facilitated earlier, more proactive symptom management and enhanced communication. Navigating challenging cancer symptoms is an immensely stressful experience for patients and caregivers, and the potential for BESI-C to lessen distress by improving interpersonal communication is exciting..” Recognizing the BESI-C’s role in addressing breakthrough pain, and being more explicit about it, was an important realization for our team, as controlling breakthrough pain is considered a key element of comprehensive cancer pain management [then take pain medication, and if so, how much later? Or did they take pain medication and then mark a pain event afterward? We ultimately dealt with this thorny problem by revising our reassessment pain EMAs to retrospectively ask participants what was done to manage the pain and approximately what time the patient took their medication, if applicable.Importantly, we also learned to provide clearer instructions regarding marking pain events on smart watches. With our first deployments, we purposely did not provide overly specific instructions regarding how and when participants should mark pain events. This created confusion for some participants, who were unsure when exactly they were supposed to mark pain events and what exactly constituted a “cancer-related pain event,” particularly if the patient experienced some level of constant, baseline pain (which is normative for many patients with cancer). In response to this, we became clearer that our on-demand EMAs were best designed to capture “breakthrough pain”—pain that increases or “breaks through” a patient’s baseline level of pain, which is notoriously difficult to assess and manage owing to its short duration, intensity, and unpredictable nature ,48,62,63nagement . In addiWe also found that participants, overall, accepted passive environmental monitoring and did not feel this compromised their privacy. However, it remains critical for researchers working in this field to be aware of, and sensitive to, concerns regarding environmental monitoring that may be particularly relevant for participant groups where long-standing systemic and structural factors have resulted in negative and discriminatory experiences related to such types of surveillance. Transparent informed consent, easy ways for participants to opt out (such as simply unplugging devices), and flexible monitoring protocols  are essential to ensure that systems such as BESI-C are culturally sensitive.Our “BESI-C Performance Scoring Instrument” proved to be a helpful tool to assess holistic system functioning, while being able to identify trends regarding individual system components. To our knowledge, this is the first document created to monitor technology health modeled after clinical assessment tools.We suggest that this type of scoring sheet be adapted for other complex sensing systems or remote health monitoring systems to provide team members with a concise, clear, and quantifiable snapshot of system performance and a way to compare functioning and ensure a positive trajectory over time.It is encouraging that the BESI-C overall composite performance scores increased over time, with a clear increase after our first deployment. Our scoring instrument confirmed that our environmental sensors had the most stable data-capture fidelity. This was not surprising, as this technology evolved from a previous, well-established project designed to monitor agitation in home-based patients with dementia and had more prior testing -67. The In contrast, the BESI-C smart watch app (the newest aspect of the system) proved to be less reliable, with inconsistent delivery of EMAs and challenges with battery life  and losing synchronization with the correct date and time. Unreliability of the smart watch app likely resulted in underreporting of pain events and contributed to other missing data. A key reason for these challenges with the smart watch app was automatic Android operating system updates, which affected system stability, a known challenge when using off-the-shelf commercial products . On the A key technical lesson learned during these initial deployments was related to the importance of periodic code reviews and putting best practices in place regarding the software coding procedures. With each deployment, we learned new information regarding data capture that required iterative changes. However, the clinical team often underestimated the complexity or length of time needed to make, implement, and test these changes. Technical challenges reinforced the importance of clear, frequent, and transparent interdisciplinary communication as well as the importance of streamlining deployment procedures with this particularly sick and fragile patient population.Despite the known challenges of participant recruitment for palliative care–related research ,55,69, wOur study was complicated by the need for informed consent from both the patient and family caregiver. At times, this presented logistic challenges. For example, the patient’s family caregiver was not always physically present in the clinic when the study was discussed and the patient signed consent . This resulted in one instance where the (consented) patient repeatedly assured the study team that he had discussed the study with his caregiver, who agreed to participate and would sign the informed consent form at home. However, when we arrived at the dyad home, our team quickly ascertained that the patient had not discussed the study with his wife. After careful discussion and emphasizing voluntary participation, the caregiver agreed, consented, and the deployment proceeded smoothly. After this experience, we made significant changes to our consenting procedures to ensure that if the caregiver is not with the patient at the time of the clinic visit, the caregiver is contacted before deployment, and interest in participating is directly confirmed by a study team member. We also learned the importance of deploying BESI-C as soon as possible after obtaining informed consent. Reducing time delays between consent and deployment proved essential to mitigate attrition and accommodate the dynamic clinical status of patients who are seriously ill.Another primary recruitment challenge included screening potentially eligible clinic patients, as some key study criteria were not easily verifiable within the electronic health records. For example, it was difficult to determine whether the patient had a full-time family caregiver. We found that the most accurate (but not necessarily most efficient) way to identify potentially eligible patients was to discuss the daily clinic list face-to-face with the patient’s primary palliative care provider, who was more familiar with the nuances of the patient’s social context and clinical trajectory. Ultimately, we met our prestudy identified goal of 80% of enrolled dyads completing the full deployment (4 out of 5 completed the full deployment). We also set a prestudy goal of 50% of eligible dyads to enroll, but this proved difficult to accurately assess and reinforce the importance of having a stronger infrastructure in place for tracking participant screening, eligibility, enrollment, and reasons for not enrolling, such as with a REDCap  database and a dedicated clinical research coordinator who could be physically present in clinic full-time to discuss the study with all eligible and interested participants.Recruitment was also severely disrupted by the COVID-19 pandemic, which put a temporary halt on all human subject research and had a particularly negative impact on our research, which involved small research teams entering participant homes. We initially intended to recruit 15 dyads but were only able to complete 5 deployments before the COVID-19 restrictions were enacted. During this hiatus, we pivoted and completely redesigned our system to be contactless and allow for self-installation. This was a significant undertaking, from both the clinical and engineering sides of the project, but has resulted in a more scalable, streamlined system architecture (the “BESI Box” ) for futWith each deployment, our team became better and faster at setting up and removing the BESI-C system in participant homes. We also learned important lessons regarding the inherent challenges of in-home research. Specifically, we recognized the importance of explicit protocols for identifying and promptly responding to unexpected safety issues at home. For example, during a deployment, it was discovered that the participant home had multiple unsecured firearms whose locations interfered with sensor placement. This was detected by the engineering team members during the installation of environmental sensors in bedrooms and other living spaces but not by the nurse team members who remained in the living room teaching the caregiver about the smart watch app. Consequently, this critical information was not shared with the entire team until the return car ride. On the basis of this experience the team decided on an illogical but nonthreatening “safety phrase”  that would alert team members a huddle was immediately needed to reassess safety in the home..The primary limitation of this study is the sample size, which reduces generalizability and the ability to detect statistical significance in our analysis of survey responses. However, our sample size is consistent with the scope of feasibility and acceptability studies that deploy complex remote health monitoring technology with actual patients ,67,73 anThe BESI-C smart health remote monitoring system offers a holistic and innovative approach for monitoring and managing cancer pain in the home context. In this study, we successfully demonstrated the feasibility and acceptability of BESI-C using a sample of primarily rural patients with advanced cancer and their family caregivers. We also demonstrated the exciting possibilities of using heterogenous environmental, physiological, and behavioral sensing data to increase awareness and understanding of the cancer pain experience and promote enhanced communication among patients, caregivers, and health care providers. Future work will test the BESI-C in a larger and more diverse sample; continue to streamline system architecture; deploy a no-contact, self-installation system in response to the COVID-19 pandemic and to enhance scalability; explore how to best share data visualizations of collected data with key stakeholders; and design and deliver just-in-time personalized pain management interventions to patients and caregivers.


Background: Healthcare providers encounter varying languages every day in patient care. The goal of this study was to examine whether a difference exists in pain scoring and treatment amongst pediatric patients whose families’ primary language was not English. We hypothesized that patients of both Arabic-speaking (AS) and Spanish-speaking (SS) backgrounds received higher pain scores and higher daily opioid equivalents (OEs) postoperatively compared to English-speaking (ES) patients. Methods: This was a retrospective cohort study of patients undergoing surgery for treatment of various esophageal and airway disorders from 2014 to 2019. Records were queried for patients undergoing thoracotomies for treatment of esophageal and airway disorders. Analysis was focused on the three most common languages in this selected population: English, Arabic, and Spanish. Propensity score matching was utilized for comparisons of pain scores between AS, SS, and ES patient groups. Primary outcomes were opioid equivalents (OEs) and pain scores postoperatively. Multivariable median regression analysis was used to perform an adjusted comparison of pain scores as well as OEs. Results: A total of 610 patient encounters were included in our analysis. In propensity matched analysis, there were no significant differences in OEs between all groups postoperatively. However, statistically significant higher pain scores were reported in the ES group matched AS groups. Conclusions: Language differences did not lead to difference in pain assessment and treatment. The United States has become a destination for international patients needing world class medical care. With the arrival of different nationalities, cultures, and races, differences in languages spoken by patients and their families is expected. A large quaternary children’s hospital in New England received 2700 international patients from over 110 countries in 2019 ,4. With While racial and ethnic disparities in pain management have been well-documented ,16,17,18Many families with different primary languages travel to have a wide array of surgical procedures performed on their children at our quaternary children’s hospital. Arabic-speaking (AS) and Spanish-speaking (SS) patients come for treatment of esophageal and airway disorders, ranging from primary tracheoesophageal fistula (TEF) ligations and esophageal atresia repairs, to more complex, multi-staged procedures for management of long gap esophageal atresia. However, language may be a barrier in communication and hence, pain management.While previously published studies show racial or ethnic disparity in pain recognition and treatment ,20, raceRecognizing cultural differences and potential language barriers when providing patient care, we sought to observe whether there were differences in the way pain is recognized and treated for non-English-speaking patients and their families compared to their English-speaking (ES) counterparts. We hypothesized that patients of both AS and SS families received higher pain scores and higher daily opioid equivalents (OEs) over the course of the first 48 h postoperatively, following TEF repair.Following Institutional Review Board approval, this retrospective cohort study was a review of all patients who underwent surgery for open repair of TEF and/or open repair of esophageal atresia between 2014–2019. The institutional surgical approach to TEF and esophageal atresia is consistent, via open thoracotomy, and therefore, a consistent pain profile is expected. In addition to a consistent surgical technique, a select team of surgeons and anesthesiologists performed these operations during this time period, providing consistent surgical skills and anesthetic management among all patients. Regional anesthesia adjuncts used were either an epidural or paravertebral catheters, at the discretion of the anesthesiologist of record, with continuous local anesthetic infusion for at least 48 h. The electronic medical record was queried for patient encounters of those who underwent open thoracotomy for the following procedures  codes in parenthesis): cervical tracheopexy (31750), thoracic tracheopexy (31760), aortopexy (33800), repair esophageal atresia and TEF, congenital (43314), repair esophageal atresia without TEF (43313), TEF repair, cervical approach (43305), and TEF repair, thoracic approach, not congenital (43312). Patients of all age groups and all primary spoken languages were included in data collection. Subsequently, analysis was then focused on the three most common languages in this selected population: English, Arabic, and Spanish. The primary variable of interest was parental primary language. As these patients tend to have multiple procedures over different encounters, only the initial and secondary encounters were included. Patient encounters were excluded from data analysis if they involved simultaneous cardiac surgery or if the surgical approach was a sternotomy. Data collection included age, weight, sex, primary language spoken, and concomitant regional anesthesia at time of surgery, surgical duration, postoperative ventilation method, and postoperative destination (intensive care unit versus inpatient floor). Additionally, the presence or absence of regional anesthesia at the time of surgery, as well as any diagnosis of chronic pain and developmental delay diagnosed after 1 month of age, were queried using International Classification of Disease (ICD) 9 and 10 codes . PrimaryContinuous data within each group were presented as medians and interquartile ranges, and categorical data were presented as frequencies and percentages. Univariate comparisons were done using the Wilcoxon rank sum test, Fisher’s exact test, or the Chi-square test, as appropriate. Propensity score matching was utilized for comparisons of pain scores between AS, SS, and ES patient groups. Propensity score matching (PSM) was performed using 1:5 between the AS and ES patient groups, and between the SS and ES patient groups with nearest neighbor matching and using the following matching variables: age, weight, sex, procedure type, encounter number, developmental delay, and history of chronic pain. Standardized mean differences (SMD) were calculated before and after propensity score matching, with values less than 0.2 considered as a reflection of good balance between the matched groups. Multivariable median regression analysis was used to perform an adjusted comparison of pain scores as well as OEs between AS, SS, and ES patient groups while accounting for clustering of multiple encounters per patient. A sensitivity analysis was performed using traditional multivariable median regression modeling, each adjusting for the following confounding variables: age, weight, sex, procedure, encounter number, developmental delay, history of chronic pain, regional use, opioid infusions, surgical duration, ventilation, and ICU admission.p values. A two-tailed p < 0.05 was considered statistically significant. Stata  was implemented for all statistical analyses.Results from median regression analyses were presented as adjusted difference in medians between comparison groups with corresponding 95% confidence intervals and A total of 985 patient encounters were queried during data collection. After exclusion criteria were applied, a total of 610 total patient encounters  were utilized during data analysis . Of the Median OEs per kilogram of body weight and median pain scores for each language group are reported in Baseline variables of the patients before and after propensity score matching (PSM) are presented in Regional anesthesia was utilized as an adjunct in 68% of ES patients (369/537), 57% of AS patients (26/45), and 75% of SS patients (21/28). When the groups with regional anesthesia were compared, OEs between AS and ES patients were similar amongst the two groups. AS patients had statistically significant lower pain scores than ES patients for the first 24 h postoperatively . SS patiOEs and pain scores between AS and ES patients, without regional anesthesia, were also compared. AS patients received similar OEs when compared to ES patients. AS patients received statistically significant lower scores for the first pain score and at 12 h postoperatively . SS patiTo further address variables that may affect pain scores and OEs, a sensitivity test using multivariable regression analysis was performed, adjusting for age, weight, sex, developmental delay diagnosis, chronic pain diagnosis, surgical duration, procedure type, first or second encounter, regional anesthesia utilization, ICU admission, postoperative ventilator status, and postoperative continuous opioid infusion . OEs andp = 0.029 and 0–2, p = 0.016, respectively). After multivariate analysis, there was no statistical difference in pain scores between the two groups, which supported that this difference, again, may not be clinically significant.AS and SS patients had comparable pain scores and similar OEs per kilogram as their ES counterparts after surgical repair for conditions including and related to esophageal atresia (EA)/tracheoesophageal fistula (TEF). While unmatched data showed overall higher reported pain scores among ES patients compared to AS patients, there was no difference in pain scores or OEs between these two groups after propensity score matching. Although the additional multivariate analysis showed statistically significant higher pain scores for ES patients at 12 and 24 h postoperatively, there was no clinical significance in such differences. The interquartile range of pain scores between AS–ES and SS–ES compared groups ranged from 0 to 4 and 0 to 5, respectively. Considering a pain score of 0–4 is considered mild, large doses of opioids would not be administered within this range, and our results reflected this. Although a pain score of 5 is considered moderate pain, the few SS patients did not contribute to a significant increase to overall requirement of opioids. Only four SS patients had a first pain score of 5: one had a 6 h postoperative pain score of 5 and one had a pain score of 5 at both first pain score and 6 h postoperatively. Similarly, unmatched data showed SS patients had higher OEs, and initial analysis revealed no difference in pain scores or OEs between SS and ES patients, except for higher pain scores among ES patients at 6 and 36 h postoperatively  being FLACC scores. While verbal cues were not readily used in most patients, it was possible that parental language could have played a part in observer scoring. Finally, an additional unobtainable piece of information was the primary language of the healthcare providers, including the post anesthesia care unit, intensive care unit, and floor nurses, who were interacting with these patients and their families. The potential benefit for enhanced patient–provider interactions between those with concordant primary language could alter the results.Parental primary language did not impact pain recognition and pain management in our EA and TEF patient population. Standardization of surgical technique, anesthetic management, pain assessment, and postoperative management may have played a role in our results. Future prospective studies that assess language discordant parent–provider relationships and its impact on perioperative pediatric pain management, and patient or parent satisfaction, are needed.


This retrospective study of prospectively collected data aimed to identify unique pain and disability trajectories in patients following lumbar discectomy surgery. Patients of this study population presented chiefly with lumbar radiculopathy and underwent discectomy surgery from thirteen sites enrolled in the CSORN registry. Outcome variables of interest included numeric rating scales for leg/back pain and modified Oswestry disability index scores at baseline, 3, 12, and 24 months post-operatively. Latent class growth analysis was used to identify distinct courses in each outcome. Data from 524 patients revealed three unique trajectories for leg pain , disability  and back pain . Construct validity was supported by statistically significant differences in the proportions of patients attaining the criteria for minimal important change  or clinical success in disability (50% or Oswestry score ≤ 22) (p < 0.001). The variable proportions of patients belonging to poor outcome trajectories shows a disconnect between improved disability and persistence of pain. It will be beneficial to incorporate this information into the realm of patient expectation setting in concert with future findings of potential factors predictive of subgroup membership. In most cases, lumbar radiculopathy is caused by compression of nerve roots from disease in the intervertebral disc or associated structures1. The point prevalence of lumbosacral radiculopathy ranges from 1.6 to 13.4% in men and women between 45 and 64 years of age2.Commonly referred to as sciatica, lumbosacral radiculopathy is a symptom of spine pathology characterized by pain from the back/buttock radiating into the lower extremity and may also include motor weakness and sensory disturbances3. Current evidence shows that lumbar discectomy is superior to non-surgical treatment for pain relief and improvement in function in the short-term, but not at mid-term and long-term follow-up5. Whether approached using a minimally invasive or open technique, lumbar discectomy surgery is supported as a highly effective procedure for the majority of patients, though with variability in outcome11. For instance, studies have reported that between 30 and 70% of patients indicate pain as a continuing problem following surgery, suggesting that many patients do not experience a favorable postoperative outcome trajectory13. Research in other surgical spine interventions such as decompression with or without fusion for spinal stenosis supports that different pain and disability trajectories may exist within a broader patient population undergoing lumbosacral surgery14.Lumbar discectomy is a common surgical procedure to treat lumbosacral radiculopathy due to disc pathologyTherefore, we aim to explore the distinct courses of pain and disability following discectomy surgery in patients affected by lower extremity radiculopathy. Specifically, the objectives of this study are to: (1) identify the postoperative trajectories of pain and disability in patients who underwent lumbar discectomy surgery, and (2) investigate the construct validity of the trajectory subgroups based on clinically meaningful changes in pain and disability. These results may be useful in understanding prognosis and postoperative course of symptoms experienced by patients.This was a retrospective longitudinal analysis of prospective data collected from patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) from January 2015 to June 2020. The CSORN is a national collaboration of orthopaedic and neurological spine surgeons that maintains a registry of spine surgery outcomes. Patient-reported data were collected at pre-operative baseline, and 3, 12, and 24 months after surgery.Inclusion criteria were as follows: (1) age ≥ 18 years , (2) lumbar radiculopathy as diagnosed by the attending surgeon, and (3) received open or minimally invasive lumbar discectomy surgery with a posterior midline or paracentral approach for degenerative pathology. We excluded patients who underwent surgery other than discectomy  and those with non-degenerative pathology . Ethical approval for this study was provided by the Horizon Health Network Research Ethics Boards . Patients were provided study information and written informed consent was obtained before study enrolment by signing forms approved by the Horizon Health Network Research Ethics Boards (file no. 10269). All methods were performed in accordance with the principles of the ICH Harmonized Tripartite Guidelines: Good Clinical Practice and the Tri-Council Policy Statement.Prior to surgery, baseline demographic and clinical data were collected from the patient and treating surgeon Table . These v15. Scores provided a measure of average pain intensity over the previous 24 h period where scores could range from 0 (no pain) to 10 (worst pain imaginable) and were categorized as: 0 ‘no pain’, 1–3 ‘mild pain’, 4–6 ‘moderate pain’, and 7–10 ‘severe pain’17. The NRS has good test–retest reliability and responsiveness19. The level of minimal important change (MIC) in pain intensity is estimated to be 30%20.The 11-point numeric pain rating scale (NRS) was used to separately quantify leg and back pain intensity21. The questionnaire evaluated difficulty performing 10 functional activities with an overall score that ranged from 0 to 100 (higher scores represented greater disability). The categorization of total scores was: 0–20 ‘minimal disability’, 21–40 ‘moderate disability’, 41–60 ‘severe disability’, 61–80 ‘crippled’, and 81–100 ‘bedbound or exaggerating’22. The questionnaire has excellent test–retest reliability and responsiveness23. The MIC is estimated to be 30%20. We categorized patients as meeting criteria for MIC, as well as, criteria for relative (50% improvement)14 and absolute (ODI score ≤ 22)24 estimates of clinical success.The modified Oswestry Disability Index (ODI) was used to measure pain-related disability25. In this way, person-centred models can identify meaningful patient subgroups based on the development of their symptoms over time, and not just at a particular time point, which better aligns with the perspectives of patients and clinicians26.All analyses were conducted using Stata 16.1 software . To identify the trajectories of pain and disability in patients who underwent lumbar discectomy (aim one), we constructed separate latent class growth analysis models for each study outcome. Compared to variable-centred models that investigate associations between variables , person-centred approaches such as latent class growth analysis seek to identify subgroups of individuals who share particular attributes 26.Patients who undergo lumbar discectomy for radiculopathy may primarily experience axial or peripheral symptoms with varying levels of disability. For example, some patients report high levels of leg pain intensity with minimal back pain, while others report predominant back pain. Moreover, some patients have minimal pain but are identified as surgical candidates because of neurological impairment. Given these heterogeneous presentations and the nature of the study outcomes, we excluded patients with low baseline scores on the model outcome: NRS scores < 3 for the leg pain and back pain models, and ODI score < 21 for the disability model. These classifications were specific to the model outcome, and therefore, patients could have contributed data to one, two, or all three trajectory models. We also excluded patients with missing outcome data at the preoperative baseline and those with outcome data at less than two time points. Latent class growth analysis handles missing data with maximum likelihood estimation, resulting in asymptotically unbiased parameter estimates when data are missing at random27. The subgroups identified by the model were assigned descriptive labels based on clinical judgement and the proportion of patients meeting benchmarks for clinically important improvement and clinical success.Starting with single class models and a censored normal distribution, we increased the number of classes and complexity of polynomial distributions until optimal models were identified. Initial decisions regarding optimal model specification were made using the Bayesian information criteria. Final model selection was based on additional statistical and clinical judgments. We tested the models using four a priori diagnostic criteria: (1) a minimum average posterior probability of group membership of 0.7; (2) close correspondence between the estimated group membership probability and the proportion of participants assigned to each group based on the posterior probability; (3) minimum odds of correct classification greater than five; and (4) precise confidence intervals around estimations of group membership probabilities20. Differences between trajectory classes were examined with Fisher’s exact test. Alpha was 5% for all inferential analyses.To investigate the construct validity of the trajectory subgroups (aim two), we generated descriptive statistics for leg pain, back pain, and pain-related disability, stratified by trajectory class and calculated the proportion of patients within each trajectory who met clinical benchmarks for minimal improvement and clinical success at the 12-month follow-up. The measurement of MIC as a 30% change from baseline was selected over other available approaches to allow for the application of a consistent, simplified standard for both pain and disability outcomesOf 562 patients with lumbar radiculopathy who underwent discectomy surgery, 36 patients (6.4%) were excluded for having data at less than two time points and two (0.4%) were excluded for missing baseline data. In total, 524 patients treated by one of 57 surgeons from 13 institutions contributed data to one or more trajectory models. Data from 7 patients in the leg pain model, 55 patients in the back pain model, and 22 patients in the disability model were excluded owing to low baseline scores representing minimal pain (NRS < 3) or disability  experienced an excellent-fair pattern of recovery. Other investigations have also found substantial reductions in mean disability when averaging the population as a whole29.Where the existing literature generally explores the outcomes of patients following discectomy surgery by describing average changes for the population as a whole, the aim in this investigation was to delve deeper into the different classes of recovery patterns that may exist for the outcome measures of pain and disability across time. A recent systematic review and meta-analysis reported the leg pain experienced by patients following discectomy surgery to undergo a sharp decrease that is ultimately preserved in the long-termInterestingly, leg pain improvement appeared to be independent of baseline leg pain as the three distinct subgroups reported very similar preoperative pain levels. For the back pain outcome, however, the mean baseline pain level for the poor subgroup fell within the severe range which was not the case for the other two subgroups. The 4.7% of patients who did not achieve disability improvement also belonged to the severe disability category at baseline unlike the remainder of the population.14. This comparison supports the notion that distinct groupings of recovery patterns exist which vary according to the clinical features of the overall population of interest. The subgroups identified in this study, particularly the disparity in belonging to the poor outcome group seen between pain and disability, provide valuable knowledge of relevance to the shared-decision making process. To contribute further insight to the selection and decision-making steps, a research project is presently underway with the objective of isolating preoperative factors predictive of membership to one subgroup over another.It is important to note that the novel subgroups identified for patients experiencing radiculopathy who underwent discectomy differ greatly from those described in a recent study similarly centered on the trajectory subgroups for patients receiving decompression to treat lumbar spinal stenosisThis study established different trajectories for pain and disability while identifying evidence for construct validity using a large set of patient data collected on a national scale. The three follow-up time points available allowed for subgroups of recovery patterns to be modelled both in the short- and long-term. Utilizing a trajectory technique enabled an understanding of unique subgroups of patient outcomes that would be otherwise unexplored when referring to average scores for the population as a whole.A recognized limitation of this investigation is the retrospective nature in which it was conducted which leaves the potential for uncontrolled confounding factors to influence the results. Though the vast majority of patients included in the study had data at preoperative baseline and at least 2 of 3 follow-up time points, non-randomly missing data may introduce bias as latent class growth analysis assumes data to be missing at random. However, complete data were available for approximately three-quarters of the patient population, thus missing data is unlikely to have a significant impact on the study results.Patients with lumbar radiculopathy experience unique pain and disability trajectories after discectomy. These findings suggest that few patients with these clinical features demonstrate poor outcomes at the level of disability which is not similarly seen in the proportion of patients reporting poor outcomes for postoperative pain. This information is of importance to the realm of patient expectation setting while taking into consideration the principal goals expressed for recovery.Supplementary Tables.


Correct and prompt diagnosis is essential for the appropriate management of patients. Often, children and their caretakers cannot provide a reliable history to allow clinicians to determine the cause of the pain. This study's objective was to find out the prevalence of abnormal ultrasonographic findings among referred patients with pain abdomen in the radiology department of a tertiary care center of Nepal.A descriptive cross-sectional study was conducted among patients in the out-patient and emergency department with complaints of abdominal pain from 2021 April 5 to August 30 in a tertiary care hospital. Ethical clearance was taken from IRC (registration no: 423/2021). The convenience sampling method was used. Written informed consent was taken from each study participant. Collected data were entered and analyzed on Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage for binary data.Among 250 patients with pain abdomen referred to the department of radiology, 169 (67.6%)  had abnormal ultrasonographic findings. Mean age of the patients was 39.4±17.9 years. Initial clinical diagnosis was in agreement with the abdominal ultrasound diagnosis in 57 (22.8%) patients. For the remaining 193 patients, the diagnosis obtained from abdominal ultrasound differed from the initial clinical diagnosis.Most of the cases of pain abdomen showed abnormalities in ultrasound. Clinical evaluation should be used together with ultrasound abdomen in order to arrive at a correct diagnosis. Ethical approval was obtained from the Institutional Review Committee (IRC) of Nobel Medical College (IRC registration no: 423/2021). Those patients who were willing to give consent were included in this study. Convenience sampling technique was used and the sample size was calculated by the formula,A descriptive cross-sectional study was conducted from April 5The sample size was calculated using the given formula:2 × p × q / e2n = Z2 × 0.50 × (1-0.50) / (0.07)2  = (1.96)  = 196Where,n= minimum required sample sizeZ= 1.96 at 95% Confidence Interval (CI)p= 50%, for maximum sample size calculationq= 1-pe= margin of error, 7%The minimum required sample size was 196. But, we included 250 referred patients with pain in the abdomen from OPD and the emergency department to the radiology department of our center.All USG reports were kept in record separately. Day to day Performa was filled up and checked.Data was entered in the Statistical Package for the Social Sciences version 20. The collected data was analyzed using the same. Descriptive statistics were used and variables were represented in terms of frequency and percentages. Point estimate at 95% CI was calculated.Among 250 patients with pain abdomen referred to the department of radiology, 169 (67.6%)  had abnormal ultrasonographic finding. Based on the ultrasound diagnosis, 20 (8%) were diagnosed as fatty liver, 20 (8%) as ureteric calculi, 15 (6%) as renal cyst, 12 (4.8%) cases each as fibroid and hydronephrosis, 11 (4.4%) each case as nephrolithiasis and cystitis, 8 (3.2%) as bulky uterus, 7 (2.8%) as Acute appendicitis and prostatomegaly, 6 (2.4%) cholelithiasis and mesenteric lymphadenopathy .Most of the patients in this study were females 161 (64.4%) and 89 (35.6%) were males. Age of the patient ranged from 3 years to 87 years. Most of the patients 70 (28%) in our study were in the age group 21-30 years. Mean age of the patients was 39.4±17.9 years. Among these patients, 64 (25.6%) of the patients were from the Brahmin ethnic group followed by the Madeshi group 60 (24%). Most of them believed in Hinduism 234 (93.6%) .Most of the cases were referred from Opd 178 (71.20%) whereas 72 (28.80%) were from the Emergency department .The self-reported chief abdominal complaints by the patients were non-specific abdominal pain in 93 (37.2%), epigastric pain 35 (14%), lower abdominal pain 29 (11.6%), and loin pain 25 (10%) .Based on clinical examination, 104 (41.6%) cases were diagnosed as acute peptic ulcer disease, 29 (11.6%) as renal calculus, 16 (6.4%) as appendicitis, 12 (4.8%) as acute calculus cholecystitis, 12 (4.8%) as cholelithiasis, 10 (4.0%) as ureteric calculus, 8 (3.2%) as Ovarian cyst, 8 (3.2%) Urinary tract obstruction and others.Initial clinical diagnosis was in agreement with the abdominal ultrasound diagnosis in 57 (22.8%) patients. For the remaining 193 (77.2%) patients, the diagnosis obtained from abdominal ultrasound differed from the Initial clinical diagnosis. Cases of abdominal ultrasound diagnosis agreed with the Initial clinical diagnosis were renal calculi 18 (7.2 %), Fibroid 11 (4.4%), Acute appendicitis 6 (2.4%), mesenteric lymphadenopathy 5 (2%), Cholelithiasis 4 (1.6%), cystitis 4 (1.6%), Pancreatitis 4 (1.6%), Nephrolithiasis 2 (0.8%), PCOD 1 (0.4%), Urachal sinus 1 (0.4%) and Umbilical hernia 1 (0.4%).9 The cases referred for Ultrasound were mainly from OPD (71.2%) whereas 70% and 97.3% of the cases were from ER in a study done by Lameris W, et al. and by Nural MS, et al.9 Out of 250 patients in our study 37.2% complained pain abdomen, 14% epigastric pain, 11.6%, lower abdominal pain and 10% loin pain whereas it was described differently in study done by Speets.8In this study, the mean age of the patients was 39.4 ±17.9 years which was different from the previous study.8 The initial clinical diagnosis made before Ultrasound diagnosis were appendicitis, cholecystitis, pancreatitis, umbilical hernia and others. A similar initial diagnosis was presented by Nural MS, et al.9In our study, 32.1% cases were normal scans whereas 41% normal scans in Speets.9 So the cases should be diagnosed in accordance with the ACR appropriateness of imaging modality. It is considered that Ultrasonography is the initial imaging study of choice for evaluating patients with acute right upper quadrant pain with high ACR appropriate rating.This study revealed that 77.2% of initial diagnosis did not match with ultrasound diagnosis. This ratio is only 23% in study by Nural MS, et al.The present study had a relatively small number of patients examined. The number of patients was limited as the study was restricted to patients subjected to abdominal US as the first diagnostic imaging method.Most of the cases of pain abdomen will show abnormalities in ultrasound. So, it should be used together with ultrasound abdomen in order to arrive at a correct diagnosis. Abdominal ultrasound was suitable for the diagnosis of patients with abdominal symptoms. It is recommended that Ultrasound diagnostic imaging be performed as first line diagnosing modality for patients and further referral to respective departments can treat patients in less time.


Background: In this study, we examined the length of stay (LoS)-predictive comorbidities, hospital costs-predictive comorbidities, and mortality‐predictive comorbidities in immobile ischemic stroke (IS) patients; second, we used the Charlson Comorbidity Index (CCI) to assess the association between comorbidity and the LoS and hospitalization costs of stroke; third, we assessed the magnitude of excess IS mortality related to comorbidities.Methods: Between November 2015 and July 2017, 5114 patients hospitalized for IS in 25 general hospitals from six provinces in eastern, western, and central China were evaluated. LoS was the period from the date of admission to the date of discharge or date of death. Costs were collected from the hospital information system (HIS) after the enrolled patients were discharged or died in hospital. The HIS belongs to the hospital’s financial system, which records all the expenses of the patient during the hospital stay. Cause of death was recorded in the HIS for 90 days after admission regardless of whether death occurred before or after discharge. Using the CCI, a comorbidity index was categorized as zero, one, two, and three or more CCI diseases. A generalized linear model with a gamma distribution and a log link was used to assess the association of LoS and hospital costs with the comorbidity index. Kaplan–Meier survival curves was used to examine overall survival rates.Results: We found that 55.2% of IS patients had a comorbidity. Prevalence of peripheral vascular disease (21.7%) and diabetes without end-organ damage (18.8%) were the major comorbidities. A high CCI=3+ score was an effective predictor of a high risk of longer LoS and death compared with a low CCI score; and CCI=2 score and CCI=3+ score were efficient predictors of a high risk of elevated hospital costs. Specifically, the most notable LoS-specific comorbidities, and cost-specific comorbidities was dementia, while the most notable mortality-specific comorbidities was moderate or severe renal disease.Conclusion: CCI has significant predictive value for clinical outcomes in IS. Due to population aging, the CCI should be used to identify, monitor and manage chronic comorbidities among immobile IS populations. Implications for policy makersThe Charlson Comorbidity Index (CCI) has significant predictive value for clinical outcomes in immobile patients with ischemic stroke (IS). Health insurance plans should use the CCI to assess and identifies the complexity of stroke-related diseases and the current disease status  of the insured member. For clinical staff, CCI should be used to assess IS patients most likely to experience the worse clinical outcomes and assess, monitor and treat comorbidities during hospitalization. Due to population aging, the CCI should be used to identify, monitor and manage chronic comorbidities among the immobile IS population. We also recommend establishing a geriatric care system, where the CCI can be optimized in patient treatment.  Implications for the public Stroke sufferers commonly have comorbidities, such as hypertension or diabetes, that directly or indirectly present barriers to optimal stroke recovery. The results indicate that comorbidities were central drivers of length of stay (LoS), hospital cost, and mortality in Chinese immobile ischemic stroke (IS) patients. Assessing the association between comorbidity and the LoS and hospitalization costs of stroke, and understanding the magnitude of excess IS mortality related to comorbidities, promises both to save the lives of stroke sufferers through integrating medical interventions according to their comorbidities and to better manage hospital costs of IS stroke patients with comorbidities.3 Globally, there were 80.1 million prevalent cases of stroke, with 84.4% ischemic stroke (IS).4 In 2016, 5.5 million died of stroke, and IS accounted for 49.1% of all stroke deaths.4 Stroke has been the leading cause of death in China in recent years,5 with 1.8 million annual deaths, accounting for roughly 30% of worldwide stroke mortality.7 Stroke also imposes a significant economic burden on society, families and individuals.8 In 2015, the annual cost for stroke care was estimated to RMB37.5 billion,9 and 2017 hospitalization cost per IS patient was RMB10 131, while China’s per capita disposable income was only RMB25 974.10 With increasing life expectancy and population aging, the stroke burden will pose an even more serious healthcare and economic challenge to China.11 Stroke is the second most common cause of death and disability worldwide.14 that directly or indirectly present barriers to optimal stroke recovery.16 China has 7.5 million stroke survivors who suffered from comorbidities.17 These stroke survivors usually spend a significant period immobilized in bed,19 leading to personal functional limitations, loss of muscle mass, and medical complications.21 Comorbidity and immobility have a substantial effect on the final outcome of stroke patients, and often impede recovery, impacting directly or indirectly length of stay (LoS) in hospital, hospital costs, and death.16 Stroke sufferers commonly have comorbidities, such as hypertension, cardiovascular disease, diabetes, or other ailments, including bleeding, medical complications, or stroke recurrence,22 Yang et al examined the mortality-specific comorbidity among inpatients with IS in Sichuan province from 2012 to 2017.23 However, in China, there has been no nation-wide research on the LoS-specific comorbidities, hospital costs-specific comorbidities, and mortality‐specific comorbidities of immobile patients with IS. Assessing the association between comorbidity and the LoS and hospitalization costs of stroke, and understanding the magnitude of excess IS mortality related to comorbidities, promises both to save the lives of stroke sufferers through integrating medical interventions according to their comorbidities and to better manage hospital costs of IS stroke patients with comorbidities.24 This study examines the LoS-predictive comorbidities, hospital costs-predictive comorbidities, and mortality‐predictive comorbidities in immobile IS patients; second, we used the Charlson Comorbidity Index (CCI) to assess the association between comorbidity and the LoS and hospitalization costs of stroke; third, we assessed the magnitude of excess IS mortality related to comorbidities. We use a unique, large scale hospital-based multicenter dataset with an exhaustive discharge diagnosis to measure the stroke burden nationally of immobility IS patients with comorbidities. The impact of comorbidity on survival after hemorrhagic stroke among dialysis patients has been studied in Taiwan province.19 comprising six tertiary hospitals, 11 secondary hospitals, and eight community hospitals. Study subjects met the following inclusion criteria: (i) aged 18 years or older; (ii) immobile, where the patient’s basic physiological needs were carried out in bed, except for active or passive bedside sitting/standing/wheelchair use for examination; (iii) ability to understand the study’s aims and to sign the consent form; (iv) diagnosed with IS as the major illness in their medical records. IS was defined according to the World Health Organization (WHO) definition as focal neurological deficit lasting for 24 hours with no apparent other than vascular cause,25 which was coded I63.x in the International Classification of Disease, 10th revision (ICD-10) based on pathological subtypes.27 All eligible inpatients of the selected hospitals were continuously enrolled. A total of 5114 participants enrolled in the study, with follow-ups continuing 90 days after enrollment unless they died in hospital or relinquished medical treatment. Survival time was measured by the duration from the date of hospital admission to the date of death and LoS was defined as the period from the date of admission to the date of hospital discharge or date of death, which is an important performance indicator of hospital management.30 Hospital costs were derived from the hospital information system (HIS) in each hospital after the enrolled patients died or were discharged from hospital. The HIS belongs to the hospital’s financial system, which records all the expenses of the patient during the hospital stay. The listed cause of death of the IS patient was recorded in the HIS for 90 days after the date of admission regardless of whether death occurred before or after discharge. Dates of death were collected from standardized HIS case report forms. Supported by National Health and Family Planning Commission’s agenda to improve the outcomes among immobile patients with stroke, the target population is all immobile stroke inpatients in 25 general hospitals in China. In order to ensure the representativeness of the study sample, between November 2015 and July 2017, we collected stroke patient data in 25 general hospitals in eastern China , western China (Sichuan province), and central China (Henan province and Hubei province),33 the CCI accounts for multiple comorbidities by creating a sum score, weighted according to the presence of 19 comorbid conditions.34 We used the actual weighted score derived from the CCI. Different comorbid conditions had different weights in CCI. For example, 35 CCI was designed to enable researchers to control for the prognostic impact of other chronic diseases on the outcomes of patients with a specific disease, and it is commonly used in outcome and mortality studies.36 The CCI data in our study were derived from the discharge ICD-10 codes and patient histories obtained from the HIS standardized case report forms. Following previous studies, the total CCI score for each patient was categorized into four levels of comorbidity, 0 (none), 1 (moderate), 2 (severe), and 3+ (very severe). Comorbidity was assessed using the CCI, which identifies multiple comorbidities. Adjusted specifically for stroke evaluation,37 except for cerebrovascular disease. Control variables included gender , age , education level , and type of insurance.38 The type of insurance comprised no insurance, New Cooperative Medical System (NCMS) for rural residents,39 Urban Resident Basic Medical Insurance (URBMI) for urban unemployed, elderly, children and students,40 and Urban Employee Basic Medical Insurance (UEBMI) for urban employed and retired.41 NCMS, UEBMI and URBMI were China’s three basic social health insurance schemes, but differed in reimbursement ratios, coverage and contributions.38 Previous research indicated that medical insurance was associated with the cost and adverse clinical outcomes of stroke,44 therefore, we included the type of insurance in the analysis. We identified all 19 comorbidities included in the CCI,2 test. Generalized linear model with a gamma distribution and a log link was used to assess the association of LoS and hospital costs with the CCI score. The results were reported as percentage changes (= exp^coefficient-1) and 95% confidence intervals (CIs) in LoS and hospital costs for IS, in association with the presence of comorbidities. Kaplan–Meier survival curves was used to examine overall survival. Using multivariable Cox regression models, adjusted for gender, age, education level, and type of insurance, the relative risk of death of all mortality causes was expressed as hazard ratios (HRs) with 95% CIs. In order to further analyze the specific types of comorbidity, we identified the nine most prevalent types of comorbidities as binary variables: peripheral vascular disease, diabetes without end-organ damage, congestive heart failure, chronic pulmonary disease, mild liver disease, moderate or severe renal disease, dementia, tumor without metastasis, and diabetes with end-organ damage. A P value of less than.05 was considered statistically significant. Statistical analysis was performed with Stata version 14 for Windows . We employed descriptive statistics to summarize patients’ characteristics. In the univariate analysis, LoS and hospital costs were compared between different subgroups using the rank-sum test, and death proportions were compared between different subgroup using the χP = .069) and death , while there is a significance difference between the average hospital costs of males and females. Three quarters of the participants were older than 60 years, and 22.4% older than 80 years. Participants younger than 59 years had higher average hospital costs than the elderly, while increasing age increased the risk of mortality. More than one third of participants had a primary school background and 20.9% had a high school and above education level. With regard to insurance type, 2070 (40.5%) participants were covered by NCMS, 24.4% by UEBMI and 19.2% by URBMI, and 15.9% had no insurance. The proportion of participants with no comorbidities was 44.8%, with 31.3% with one, 13.8% with two and 10.1% with three or more comorbidities. The most frequent comorbid conditions in P < .001). The data for hospitalizations, analyzed according to CCI scores, are presented in  Descriptive statistics are shown in P = .712) and CCI = 2 , whereas a high CCI = 3+ score was associated with a significantly 16.4% higher likelihood of increased LoS compared with a CCI = 0 score .P < .001), chronic pulmonary disease , congestive heart failure , and diabetes without end-organ damage . Compared with the no comorbid condition, the percentage change in LoS was significant among IS patients with dementia  was not significant, but the CCI = 2 group  was associated with a 10.8%, and CCI = 3+ group  a 21.6%, higher likelihood of increased hospital costs compared with a CCI = 0 scores. Compared with no comorbidity, the percentage change was most notable among IS patients with dementia , moderate or severe renal disease , congestive heart failure , and chronic pulmonary disease .P = .110) and CCI = 2 group  in the Cox regression model after adjusting for confounders. However, as shown in P < .001). The overall death rate was 7.06%, with the CCI = 0 group accounting for 5.7% of deaths, the CCI = 1 group accounting for 4.9% of deaths, CCI = 2 group accounting for 9.5% of deaths and CCI = 3+ accounting for 16.4% of deaths. P < .001), followed by patients with tumor without metastasis , congestive heart failure , diabetes with end-organ damage , and peripheral vascular disease . As shown in  Our study systematically examined the associations between comorbidity and LoS, hospital costs, and mortality among immobile IS patients. Overall, 55.2% of our sample’s IS patients had a comorbid condition, with a high CCI score associated with increased average LoS, higher hospital costs, and a greater likelihood of death.23 Previous research indicated that 94.2% of stroke sufferers have one or more comorbid conditions in Scotland,45 and the prevalence of comorbidity ranged from 44% in Denmark34 to 99% in Ontario, Canada.46 These differences are likely due to a variety of factors, including the study design,23 study periods,34 study subjects,46 local factors ,33 and the use of different classifications or ICD codes for determining comorbidities.16 The prevalence estimates of comorbidities among immobile IS patients in China was 55.2%, which is lower than a retrospective analysis extracted from the Sichuan Provincial People’s Hospital database reporting that 79% of inpatients with IS had at least one comorbidity.47 Second, there are some common potential risk factors for both peripheral vascular disease and IS, including hypertension, alcohol assumption and atherosclerosis.51 We cannot, however, infer the sequence and the causality of IS and peripheral vascular disease. Since vascular examinations were routinely conducted for immobile patients , tests such as Doppler ultrasound, computed tomography angiography, magnetic resonance angiography, may contribute to the higher prevalence of peripheral vascular disease in our study.23 This result suggests that early tests, such as Doppler ultrasound, may improve the detection rate of peripheral vascular disease in immobile IS patients, and prospective clinical study is required to justify this issue. We found the most frequent comorbid condition was peripheral vascular disease (21%). There are a number of possible explanations for this situation. Participants enrolled in our study were immobile, and the literature indicates that peripheral vascular disease are closely related to immobilization.33 Since CCI = 3+ group had a higher likelihood of increased LoS and hospital costs compared with a CCI = 0 score, with similar results for the CCI = 1 group and CCI = 2 group, CCI = 3+ patients need more attention during hospitalization. Dementia, chronic pulmonary disease, and congestive heart failure were LoS and hospital cost‐specific comorbidities. One explanation is that approximately three in four participants enrolled in our study were the elderly, and these chronic diseases tend to cluster in cohorts with increasing age. Our results suggested that a CCI = 2 score was related to higher hospital costs, and a high CCI = 3+ score was positively correlated with both longer LoS and higher hospital costs, which supports CCI as a measure for the disease burden of IS.52 We also found that high comorbidity as measured by the CCI = 3+ was associated with an approximately 2.5-fold higher risk of death than a low CCI = 0 score. This confirms the use of CCI to predict short-term death in the Chinese IS population is meaningful. Our results also indicate that moderate or severe renal disease and tumor without metastasis increased the death rate. This can be explained by stroke rates for end-stage renal disease patients and cancer are substantially higher than for the general population, and those renal and cancer patients have a poor prognosis and high mortality rate, despite advances in diagnosis and treatment.36 which identify patients with multiple chronic diseases in a universally applicable, transparent, and auditable method, through a weighted measure of the burden of chronic disease that predicts long term prognosis, outcomes and costs.54 In addition, the CCI was designed to enable researchers to control for the prognostic impact of other chronic diseases on the health outcomes of patients with a specific chronic disease. Without CCI, researchers often excluded patients with other chronic diseases from their studies to eliminate the potential of ‘confounding’ factors. For instance, studies of patients with diabetes might exclude patients with dementia or cancer to make certain that they did not confound the clinical outcomes. Such exclusions limited the number of participants to whom the study results applied.34 Further, reference to a CCI indicator is both a simple and more direct method than a nonstandard list of a variety of different chronic disease conditions, which facilitates doctors’ decision-making. Therefore, knowing a patient has a CCI score of 3+ provides more useful information than just knowing if the patient has hypertension or dementia. In the future, health insurance plans should require and use the CCI to identify the complexity of stroke-related diseases and the current chronic disease status  of the insured member. Based on the stratification of zero, one, two, and three or more CCI diseases, and the patients’ comorbid conditions, the government should increase the financial investment, raise reimbursement rates and set up differential reimbursements to meet the health needs of patients with multiple diseases. For clinical staff, CCI should be used to assess, monitor, and treat comorbidities during hospitalization.55 The early use of the CCI plays a critical role in the identification of IS patients most likely to experience the worse clinical outcomes and may help target interventions according to the resulting risk information, which can tackle such conditions and reduce their pernicious effects. The association between the scores of CCI and multiple clinical outcomes, including LoS, hospital costs, and mortality, supports the notion that the CCI should be used to identify and manage chronic comorbidities,56 Comorbidities associated with the aging population will pose a significant challenge to China’s health system. Combined with tailored stroke interventions according to patient comorbidity, we recommend the establishment of a geriatric care system to improve the health of the stroke-prone population and reduce the stroke burden on the health system. China is encountering formidable healthcare challenges related to population aging, with 12% of the population over 65 years old in 2020, which is forecast to rise to 26% by 2050. Our study has some limitations. Common to health research, a retrospective post-hoc analysis study design was used in the current study, where existing data was analyzed to answer new questions. For example, some clinical data, such as the details of the cause of death, laboratory data, clinical severity of stroke and premorbid Rankin scale data were not recorded in the HIS, which is an inherent drawback in retrospective analysis of a prospectively collected database. Second, no data on the severity of comorbidities was available. Third, we cannot infer the sequence and the causality of IS and peripheral vascular disease. Fourth, diagnostic validity of comorbidity might be influenced by heterogeneity of physician documentation and code assignment accuracy from different sites. Prospective studies with more sophisticated evaluations are required to address these limitations. Comorbidities were central drivers of LoS, hospital cost, and mortality in Chinese immobile IS patients. We found CCI had a significant predictive value for clinical and economic outcomes in IS patients. Due to population aging, the CCI should be used to identify, monitor and manage chronic comorbidities among the immobile IS population. We also recommend establishing a geriatric care system, where the CCI can be optimized in patient treatment. The authors thank research participants and nursing staff for their kind and efficient contribution to the study. We acknowledge the helpful comments by three anonymous reviewers. The Ethics Committee of Peking Union Medical College Hospital (S-700) approved the project. All patients provided written informed consent before enrollment in the study, and all IS patients coded I63.x according to the ICD-10 enrolled in the current study (N = 5114). Patients’ records and information were anonymized and de-identified prior to the analysis. Authors declare that they have no competing interests. Study concept and design: XW. Analysis and interpretation of data: HL and DZ. Editing of the manuscript and drafting of tables: HL and DZ. Critical review of the manuscript for important intellectual content: XW, HL, and DZ. Patient recruitment, data collection, and manuscript editing: BS, JJ, YL, XW, SC, EM and SN. All authors critically reviewed and approved the manuscript before it was submitted.Supplementary file 1 contains Table S1.Click here for additional data file.


Sportsman’s hernia is a painful syndrome in the inguinal area occurring in patients who play sports at an amatorial or professional level. Pain arises during sport, and sometimes persists after activity, representing an obstacle to sport resumption. A laparoscopic/endoscopic approach is proposed by many authors for treatment of the inguinal wall defect. Aim of this study is to assess the open technique in terms of safety and effectiveness, in order to obtain the benefit of an open treatment in an outpatient management. From October 2017 to July 2019, 34 patients underwent surgery for groin pain syndrome. All cases exhibited a bulging of the inguinal posterior wall. 14 patients were treated with Lichtenstein technique with transversalis fascia plication and placement of a polypropylene mesh fixed with fibrin glue. In 20 cases, a polypropylene mesh was placed in the preperitoneal space. The procedure was performed in day surgery facilities. Early or late postoperative complications did not occur in both groups. All patients returned to sport, in 32 cases with complete pain relief, whereas 2 patients experienced mild residual pain. The average value of return to sport was 34.11 ± 8.44 days. The average value of return to play was 53.82 ± 11.69 days. With regard to postoperative pain, no substantial differences between the two techniques were detected, and good results in terms of the resumption of sport were ensured in both groups. Surgical treatment for sportsman’s hernia should be considered only after the failure of conservative treatment. The open technique is safe and allows a rapid postoperative recovery. Sportsman’s hernia is defined as a bulge at the posterior wall of the inguinal canal, sometimes associated with chronic pain in the inguinal and pelvic areas. The bulge is not a real hernia, but it is linked to a posterior wall weakness. Pain arises with a subtle, or less commonly, acute onset, and the symptoms include complaints by athletes who enjoy activities requiring rapid changes in direction and extreme overload, such as soccer, rugby, steeplechase, skiing, ice hockey, and cricket –3. OccasTherefore, the sportsman’s hernia is considered within the definition of the groin pain syndrome (GPS). At present, a consensus for a more suitable terminology has not been achieved, and in a systematic review, Serner et al.  stressedIn February 2016, the first Italian Consensus Conference  identifiThe true incidence of sportsman’s hernias is unknown, due to disagreements of terminology and diagnosis.In most studies a prevalence of GPS in amateur athletes can be found; in fact, amateur athletes do not have the same access to suitable care, including conservative and surgical care , 10. By Lovell  showed tThe treatment for sportsman’s hernia is a complex question and requires different professional figures for a multidisciplinary approach. But not more than 40% of athletes treated only with conservative techniques resumed normal sports activities . TherefoThe aim of this study is the evaluation of a surgical anterior approach for the treatment of the sportsman’s hernia.A retrospective study was carried out by the Department of Surgical Sciences, Sapienza University of Rome, Italy, and the Department of General Surgery at the University of Udine, Italy. From October 2017 to July 2019, 53 patients with suspected clinical diagnosis of sportsman’s hernia were considered. The inclusion criteria were the professional or amateur level sport activity, age ranging between 18 and 70 years, a BMI <30, an American Society of Anesthesiologists (ASA) score I e II, the presence of long-standing groin pain syndrome (LSGPS) without other pathologies, and the presence of inguinal bulging at the clinical examination. Patients with other inguinal or pelvic diseases, such as pelvic or hip trauma (3 patients), overt inguinal or inguinoscrotal hernia (11 patients), and prior surgery in the inguinal region (3 patients) were excluded from our study and underwent different surgery or conservative treatment. Thirty-six cases were considered eligible to our analysis.The diagnostic work up was carried out using dynamic ultrasonography of the abdominal wall, searching for the presence of a posterior wall bulging under Valsalva’s maneuver, confirming our clinical suspect, and detecting any possible contralateral defects. In the case of posterior inguinal wall bulging, patients underwent plan pelvic radiograph, “Flamingo stress view” and oblique radiograph of Dunn.A pelvic MRI was performed as well. Two patients were excluded from surgery due to a pelvic imbalance and bone marrow edema. The main MRI findings were represented by rectus abdominis and adductor aponeurosis tears , dehiscence of adductor tendons , rectus abdominis edema , pubic ligament insertion atrophy . However, in all cases a bulging during Valsalva’s maneuver was present and identifiable during MRI.A total of 34 patients were selected for surgery and sent to preoperative physiotherapy for eight weeks to focus on muscle stretching. No patients experienced lasting pain relief, and therefore, were sent to surgery. A comprehensive, informed consent was obtained. Patients were treated by open procedures with local anesthesia, and they were divided into two groups, based on the anterior or preperitoneal mesh placement; the surgical technique chosen depended on the team preferences and expertise. In 14 patients (41.2%) the chosen technique was a Lichtenstein hernioplasty with transversalis fascia plication and placement of a polypropylene light mesh fixed with fibrin glue . In the other 20 cases (58.8%), a polypropylene light mesh was placed in the preperitoneal space, not using fixation devices. In both cases, therefore, no sutures were used. Both procedures were performed with an open access, as outpatient, with the aim of discharging the patients 4 h after surgery. A modified Post Anesthesia Discharge Scoring System (PADSS)  was admiPatients were requested to undergo physiotherapy sessions beginning 2 weeks after surgery to strengthen the hips and thigh muscles, and in particular, the adductors, quadriceps, rotators, and iliopsoas muscle. At the same time, patients were invited to carefully start again sports activities. Sudden movements were prohibited; the only sport allowed was the brisk walk, progressing to jogging and running over 3–4 weeks. Special activities, such as running on a track and performing sprints could be resumed from the twentieth postoperative day onward.After discharge, all patients were followed up at 48 h, at one week, and after one month, to rule out the presence of early complications. The postoperative pain was assessed with a 0–10 Numerical Rating Scale test (NRS) administered at 48 h and a week after the surgical procedure. Moreover, all patients underwent a postoperative rehabilitation program from the next 48 h after surgery.The rehabilitation program is divided into progressive modules and tailored depending on the needs of the patient. It lasted about 3 months after surgery and was aimed to reduce pre-existing risk factors and whenever not possible, to learn compensatory strategies, improve the core stabilization and strength around the pelvis particularly in single-leg stance.In our rehabilitation program core exercises represented the first step, starting with static activation of the core muscles and gradually progressing by adding limb movements in stable positions and more unstable positions, until reaching more functional and dynamic positions.Physiotherapists paid particular attention to the development of a strong single-leg position and to the adductor strengthening, progressively adding external load.Moreover, muscle stretching was routinely performed.The physiotherapists were also present in the first phases of the return to sport, to directly supervise all the progress and any issues or change in the personal rehabilitation program. Particularly, each patient was asked to report any adverse response within 3 days of rest after the training in order to tailor its program, sometimes returning to the previous level of activity. To progress in their sports, the training should be pain-free.The Return to Sport (RTS), indicating the time to onset of training in their respective sports activities, and Return to Play (RTP), meant as the time to acquire the ability to play obtaining the best results, were evaluated.The total follow up was extended for three months after surgery.p-value = 0.451 and W = 0.877607The statistical analysis has been conducted using the Student t-test. The Normality test (Shapiro-Wilk test), has been conducted due to the small sample size, with a 2. Thirty patients played football, four played football and dance, one played football and judo, and one boxing.Thirty-six patients were included in the study, whose main characteristics are presented in These symptoms and diagnosis are unusual in a boxer, but in this case, he used to train also by racing, so that it’s more likely that the principal aethiology of the groin pain syndrome was not the sport practiced but rather the way he trained.All patients complained of pelvic pain that increased during physical stress. Symptoms lasted a median of 14 weeks and in the meantime, 52.7% of the patients continued to play their respective sports. Only in one case (2.8%) daily activities were partially hindered.Pain occurred mainly at the insertion of the rectum on the pelvis (79.4%) and/or at the superficial ring (55.8%), particularly while under strain or when coughing. None of the patients had relevant comorbidities.p = 0.79). All patients were discharged 4 h after surgery, without immediate complications. The PADSS was administered before discharge to ensure their safe return home. Postoperative pain was treated with 1 g of Paracetamol, two times per day.Dynamic ultrasonography showed a bulge of the posterior inguinal wall in 100% of cases. In one case, a retraction of the long adductor insertion was revealed. After the imaging study, 34 patients were considered eligible to surgical treatment. In the group treated with anterior inguinal hernioplasty, one patient underwent a partial tenotomy of the proximal insertion of the long adductor. None of the patients underwent bilateral hernia repair. The mean time of the surgical interventions was 56.42 ± 8.32 min for the anterior approach and 44.5 ± 12.5 min for the posterior one , in which a superficial seroma was observed without requiring treatment.p = 0.99). The average value of NRS a week later was 1.71 for the anterior technique, and 1.35 for the posterior one (p = 0.58)The NRS values were comparable in both techniques. The average value of NRS at 48 h was 2.71 for the anterior approach, and 2.50 for the posterior one  of patients followed the rehabilitative protocol and all patients returned to their respective sport. In two cases , the final outcome was satisfactory in terms of resumption of sport, but the remission of pain was incomplete.p = 0.92).The median value of RTS was 35 days. The RTS following the anterior approach was 34.28 ± 5.62 days, while that following the posterior approach was 34.0 ± 9.94 days (p = 0.16). Results are reported in The median value of RTP was 56 days. The average RTP after anterior treatment was 57.14 ± 13.85 days, while after the posterior approach it was 51.50 ± 9.23 days , Legg-Calve-Perthes Disease), visceral causes , bones , muscle-tendons , neurological causes (nervous entrapment syndrome), genitourinary diseases , cancers, infections, rheumatic diseases, and lymphatic causes .Symptoms can be bilateral in up to 12% of cases. Pain involves, typically, the pubic area with irradiation to the adductor region in 40% of cases and to the inguinal, and the perineal and genital area in 6% of cases only, with an insidiously onset in 2/3 of patients . ConsequThe symptoms at onset of sportsman’s hernia are variable and can arise during warmup and attenuate during gameplay or can occur only during gameplay and regress with rest . Pain isα angle >55°).Diagnostic imaging of GPS is of fundamental importance. According to the first Italian Consensus Conference , the diaBasal and dynamic ultrasound allows for the assessment of abdominal and adductor muscle tendons, and the evaluation of the inguinal canal posterior wall and structures, the urinary tract, and external genitalia.MRI can provide detailed information concerning bones, tendons, and muscles and is useful to identify the presence of bone marrow edemas (BME) at the pubic branch.The sportsman’s hernia treatment requires a multidisciplinary approach and all therapies supporting surgical procedures, including active or passive physiotherapy, shock waves, and injections of platelet enriched plasma (PEP) performed before and after surgery are essential for the optimal functional recovery of the patient.Such treatments must be tailored on the patients’ clinical history, its sport level and on the results of diagnostic tests and should be aimed at the functional recovery and rapid RTS for the patient, with the purpose to minimize the absence of the athlete from sport, as well as improving performances , 27.Physiotherapy and rehabilitation with exercises to reinforce the abdominal wall, lumbar region, and coxo-femoral joint are recommended.A systematic review published by Jørgensen et al.  in 2019 p < 0.001) and 90% of patients returned to sport after three months from surgery compared 27% of the athletes in the conservative-treatment group (p < 0.0001).In a study conducted by Paajanen et al.  comparinEkstrand et al.  comparedAccording to several authors, surgery should be reserved only in case of evident bulging, enforcing the transversalis fascia, similar to conventional groin hernioplasty , 15, 30,Open hernioplasty without the use of prosthetic devices was proposed by Litwin et al. , and patThe Minimal Repair Technique (MRT) does not require the use of mesh as well as the Shouldice one, and it is based on the assumption that GPS is caused by a limited weakness of the posterior wall of the inguinal canal, resulting in the entrapment of the genital branch of the genitofemoral nerve. However, the suture may determine a power imbalance on the pubic symphysis (rectus abdominis versus adductor) and leads to a chronic inflammatory condition that acts directly on the sensitive branches of the nerves , 32, 33.In this study, the results after the open anterior and posterior surgical techniques were compared, analyzing how a different approach to the inguinal nerves can lead to a possible appearance of postoperative pain or chronic neuralgia, invalidating the results of surgery. A careful identification of the nerves allowed to limit any damage in both cases, although the mesh placed back to the transversalis fascia potentially should avoid direct contact with the nerves . HoweverThe defect on the abdominal wall can be also treated using a laparoscopic approach, with TAPP  o endoscCurrently, based on data in the literature, there is not an approach for repairing sportsman’s hernia that is better than another. The studies and reviews available rarely report comparisons between techniques, suggesting that GPS treatment—whether open or laparoscopic—is often based on the surgical team experience. Thus, additional studies are required to compare the main surgical approaches and their outcomes.p < 0.001). Moreover, the TEP approach proved to be less painful than the minimal repair technique during the first month, whereas both procedures are similarly effective in treating chronic pain.According to Caudill et al.  the resuJørgensen et al.  comparedst postoperative day and athletes usually return to full activity within 2–4 months after operation , and allow the surgeon to view both the rectus abdominis and conjoint tendon insertion on the pubic tubercle, so that a long adductor tenotomy might be performed, when appropriate. No differences have been detected comparing the anterior and the posterior open approach, mainly in terms of postoperative pain and persistent neuralgia.