In order to implement more effective policies for cancer pain management, a better understanding of current practices is needed. Physicians managing cancer pain and patients experiencing cancer pain were randomly surveyed across 10 Asian countries to assess attitudes and perceptions toward cancer pain management. A total of 463 physicians (77.3% oncologists) with a median experience of 13 years were included. Medical school training on opioid use was considered inadequate by 30.5% of physicians and 55.9% indicated ≤10 h of continuing medical education (CME). Of the 1190 patients included, 1026 reported moderate-to-severe pain . Discordance was observed between physician and patient outcomes on pain assessment with 88.3% of physicians reporting pain quantification, while 49.5% of patients claimed that no scale was used. Inadequate assessment of pain was recognized as a barrier to therapy optimization by 49.7% of physicians. Additional barriers identified were patients’ reluctance owing to fear of addiction (67.2%) and adverse events (65.0%), patients’ reluctance to report pain (52.5%), excessive regulations (48.0%) and reluctance to prescribe opioids (42.8%). Opioid use was confirmed only in 53.2% (286/538) of patients remembering their medication. Pain affected the activities of daily living for 81.3% of patients. These findings highlight the need for better training and CME opportunities for cancer pain management in Asia. Collaborative efforts between physicians, patients, policy makers, and related parties may assist in overcoming the barriers identified. Addressing the opioid stigma and enhancing awareness is vital to improving current standards of patient care. The incidence of cancer in Asia is expected to reach 10.6 million by the year 2030 The consequences of inadequate pain management are exacerbated in developing Asian countries due to the socioeconomic burden associated with life-threatening disease conditions. Inadequate assessment of pain, opioid access and regulations, and stigmas associated with opioid use are significant barriers to optimal pain management The ability to undertake informed policy decisions will require relevant data regarding cancer pain management practices in Asia. This cross-sectional ACHEON survey was designed to evaluate the current status of cancer pain management and includes data from 460 physicians in cancer practice and 1180 cancer patients from 10 countries/regions in Asia. To the best of our knowledge, this is the largest survey of its kind to evaluate the attitudes and perceptions of physicians treating cancer pain, as well as pain severity and quality of life (QoL) in cancer patients.Physicians and patients were recruited from 10 countries/regions across Asia, including China (CN), Hong Kong (HK), Indonesia (INDO), the Republic of Korea (SK), Malaysia (MY), Philippines (PH), Singapore (SG), Taiwan (TW), Thailand (TH), and Vietnam (VN), and surveyed anonymously over a period of 4 months (September–December 2013). ACHEON was a questionnaire-based survey and required no other intervention involving the participants. In some cases, respondents included noninstitutionally affiliated patients experiencing cancer pain, as well as physicians operating private practices. An ethical review fulfilling the function of an IRB  was therefore conducted, and the study design and conduct was reviewed by a group of 16 external experts from various countries in Asia. The survey was additionally conducted in accordance with the European Society for Opinion and Market Research (ESOMAR) code of conduct for market research studies The primary objective of the present study was to assess the extent and impact of cancer pain on patients’ lives,  their levels of satisfaction with treatment, and the perceived efficacy of their prescribed pain medication. We also sought to assess the attitudes and perceptions of physicians and patients toward cancer pain management in Asia and identify potential barriers to opioid prescription.Physicians were selected according to eligibility criteria and included those involved in managing cancer pain, those involved in the direct care of patients with cancer pain and those willing to participate in all aspects of the study. They were randomly selected from databases of medical associations, national registries, official societies, and other organizations. Physicians who were employed by or affiliated with a pharmaceutical company were excluded from the survey.Patients aged ≥18 years with a documented history of cancer pain in the preceding month were randomly contacted through patients’ associations, doctor referrals, hospital intercepts, online panels, patient referrals, door-to-door recruitment, or phone book recruitment. Patients who were employees or related to employees of any health-care, pharmaceutical, advertising or market research companies, or those involved in any other pain management studies were excluded.The questionnaires for the physician and patient surveys were developed by a steering committee of 16 pain management specialists, representing most of the participating countries. A consensus questionnaire was created, which was then translated into the local languages of the participating countries.The questions for physicians were grouped into broad categories which included demographic data , education and training, screening and assessment of pain, and pain management practices. Accordingly, the questions for patients were focused on demographic data, screening for pain and pain assessment, perceived doctors’ attitudes toward pain, effect of pain on QoL and activities of daily living (including employment), and treatment of pain.Informed consent from the physicians was obtained following initial contact via telephone or face-to-face meetings in which a description of the study was provided. Subsequently, interviews were scheduled via telephone or face-to-face meetings. Patients meeting the inclusion criteria were administered a paper- or a web-based secure link questionnaire for self-completion, which also included a patient disclosure and informed consent section.Physician profiling was conducted on the basis of questions related to age, sex, years in practice, specialization, adequacy of training in medical school, and residency. Numeric rating scales (NRS) from 0 to 10 were used to evaluate attitudes and clinical practice patterns including screening, assessment, and optimization of cancer pain management with an emphasis on opioid analgesics. Participants had the option of selecting more than one response in some categories. Depending on the nature of the statement, an NRS score >5 (high) represented adequacy or agreement, an NRS score of 5 was considered neutral and NRS scores <5 (low) indicated inadequacy or disagreement. These categorized scores were reported as a percentage of all respondents and median  scores were calculated where applicable. The questionnaire for patients was designed to assess the severity of pain experienced using the verbal 11-point Box Scale (BS-11) pain scale, perceived attitudes toward pain, satisfaction with treatment and QoL. It included statements with “yes” or “no” responses, or a 5-point Likert rating scale from “completely agree” to “completely disagree.”n = 1026) reported suffering from moderate-to-severe pain (BS-11 median [IQR] score 6.0 [3.0]) for a median duration of 12  months.Responses from 463 physicians managing cancer pain and 1190 patients experiencing cancer pain were analyzed (demographic characteristics are presented in Tablesn = 141/463) of physicians. Notably, 55.9% (n = 259) of physicians reported ≤10 h of continuing medical education (CME) training on cancer pain management in the preceding year.Medical school training on cancer pain management and opioid use was considered inadequate by 30.5%  and quantify  pain. A NRS such as the visual analog scale (VAS), BS-11 pain scale, the FACES or verbal questionnaire (0–10) rating scale were used for pain quantification by 86.8% (n = 402) of physicians. The proportional usage of these pain assessment tools is presented in FigureThe majority of physicians stated that they assess patients routinely to characterize  were asked about pain by their doctors. However, when patients were asked if pain was assessed quantitatively, only 50.5% (n = 601) confirmed that it was conducted  of physicians as “inadequate assessment of pain”  of patients reported that pain specialists were primarily involved in managing their pain, while the majority of patients had never been referred to a pain clinic or pain specialist  of physicians followed by country-specific  and hospital/practice-specific  guidelines. The majority of physicians  agreed that opioid therapy should be first-line therapy in cancer patients with moderate-to-severe pain. A total of 1056 of 1190 patients were currently being treated for pain. However, opioid use was confirmed only in 53.2% of patients (286/538), for those who could remember the type of medication prescribed.Overall, physicians expressed unanimity on the effectiveness of opioid use in the management of cancer pain and exhibited a good understanding of dosing regimens. International guidelines were considered important by 56.4% (n = 311), fear of adverse events , and reluctance to report pain  were important barriers. Excessive regulatory barriers to the use of opioids were identified as a problem by 48.0% (n = 222) of physicians  of physicians, however, 78.8% (n = 365) of physicians noted discordance between the pain levels they assessed versus the pain experienced by their patients.The effects of pain intensity on QoL were assessed by 93.1% (n = 703) of patients reported that they were satisfied with their treatment and 71.9% (n = 759) perceived their medication to be efficacious. However, 81.3% (n = 967) of patients cited that chronic cancer pain affected their activities of daily living  of patients were unemployed. Of these, 41.8% had discontinued work due to chronic cancer pain. Additionally, among the patients that were employed, 69.7% (186 of 267) claimed that pain impacted their performance at work.In a striking observation, it was noted that 77.6%  Medical opioid usage in Asia is lagging behind rates seen in North America and some European nations In this analysis, a profound impact of pain was apparent on the physical, social, and economic well-being of patients and their overall QoL. Importantly, chronic pain was identified as a major cause of unemployment and impacted work performance for many patients. This has significant negative implications for the entire region, which includes several developing economies.For the responses from the patients surveyed, we identified some contrasts between the countries and regions . While most patients reported being satisfied with the way their physicians treat their pain, three-quarters still felt that their doctors would rather treat the cancer rather than the pain and this was most evident in PH, followed by CN, TW and VN. There was also a notably large IQR score of 6.0 regarding the type of pain scale used (with the biggest discrepancies coming from SG and Thailand). When queried as to the reason why patients thought they were not being referred to pain specialists, only 5% of Chinese respondents answered “because they are not available” compared to 66% in the Philippines, indicating a wide discrepancy between these two countries in terms of the availability of these specialists.Overall, more than four in five patients saw the doctor managing their cancer pain at least once a month. This differed significantly in HK & MY, where only half of all patients reported seeing their doctor as frequently. Half of all patients said their doctor used a pain scale to assess their pain, with HK, CN & SK patients reporting the highest incidence & INDO & TH reporting the lowest. Three-quarters of doctors explained that cancer pain can be controlled, although this was considerably lower in Thailand.Aside from the mindset of only taking pain medication when absolutely necessary, key reasons for not being treated for pain were cost concerns  and concerns over side effects of pain medication . Over three-quarters of patients interviewed were not currently employed, with the highest employment seen in HK, INDO, MY, and SG. However, whether this was solely due to their cancer pain is difficult to determine.Global health advocacy groups have reached the consensus that cancer pain relief should be recognized as a human right As with all questionnaire-based surveys of this kind, our findings were subject to certain limitations due to the qualitative design. Country-dependent discrepancies in recruitment methods cannot be ruled out, and the survey was designed to encompass various scenarios of clinical practice, leading to some restriction in choice of responses. Furthermore, comorbidities were not accounted for, which may have impacted negative perceptions. Nevertheless, we believe these results to be of significant value in that they provide a snapshot of real-life scenarios in clinical practice, and may assist in delineating theoretical assumptions about cancer pain.The ACHEON survey results highlight a number of barriers that hinder effective opioid use, as well as the need for better training and CME opportunities for pain management. Inadequate pain assessment practices associated with suboptimal pain management are likely to be reducing QoL for a large number of cancer patients. Addressing the stigmas surrounding opioid use and enhancing awareness is also essential to improve current standards of patient care.


The mechanisms causing cognitive problems in chronic pain patients are not well understood. We used the Stroop color word task (SCWT) to investigate distraction-induced analgesia, cognitive performance, and cerebral activation patterns in 29 fibromyalgia (FM) patients  and 31 healthy controls (HC) . In the first study, SCWT was used to investigate distraction-induced analgesia in FM patients. Two versions of the task were applied, one with only congruent color-word images and one with incongruent images. Pressure pain thresholds were assessed using a pressure algometer before, during, and following SCWT. In the second study, reaction times (RTs) were assessed and functional magnetic resonance imaging (fMRI) was used to investigate cerebral activation patterns in FM patients and HC during the SCWT. An event-related task mixing incongruent and congruent images was used. In study one, we found reduced pressure pain sensitivity during SCWT in both groups alike and no statistically significant differences were seen between the incongruent and congruent conditions. The study two revealed longer RTs during the incongruent compared to the congruent condition in both groups. FM patients had longer RTs than HC in both conditions. Furthermore, we found a significant interaction between group and congruency; that is, the group differences in RTs were more pronounced during the incongruent condition. This was reflected in a reduced activation of the caudate nucleus, lingual gyrus, temporal areas, and the hippocampus in FM patients compared to HC. In conclusion, we found normal pain inhibition during SWTC in FM patients. The cognitive difficulties seen in FM patients, reflected in longer RTs, were related to reduced activation of the caudate nucleus and hippocampus during incongruent SCWT, which most likely affected the mechanisms of cognitive learning in FM patients. Fibromyalgia (FM) is a chronic pain syndrome, however, many FM patients also suffer from disturbed sleep, fatigue, mood disorders and cognitive impairment. The cognitive dysfunctions reported by FM patients In accordance with this, pain intensity has been shown to influence cognitive task performance in chronic pain patients using a Stroop paradigm Attentional resources are limited and therefore different stimuli compete with each other for attentional space. Based on this, a bi-directional interference between the perception of pain and the performance of cognitive tasks would be expected, i.e., not only would pain interfere with cognition but focusing on a cognitive task would also decrease pain perception. This is in line with previous findings showing that focusing on the pain can enhance pain perception and that pain perception can be decreased by distraction or cognitive tasks However, using a more tonic pain stimulus it has been reported that the cognitive modulation of pain-related brain responses was not uniform but depended on behavioral strategy and that none of the brain areas showing attention-related responses, including dorsolateral prefrontal cortex (dlPFC) and posterior parietal cortex, were modulated by pain The authors concluded that pain stimuli in healthy subjects did not interfere with brain activities evoked by cognitively demanding tasks. Further, mild or moderate pain was not found to affect performance on a cognitive task, nor did the pain alter brain activity related to this task To our knowledge, no previous studies have investigated the effects of chronic pain on attention-related cerebral responses during the SCWT, or the effects of Stroop on pain sensitivity in chronic pain patients. The aims of this study were two-fold. The first aim was to investigate the effect of cognitive load on distraction induced analgesia in FM patients and HC using the SCWT. In the SCWT the subjects are required to respond to the font color of color words, either congruent (“yellow” written in yellow) or incongruent (“yellow” written in green) Secondly, we wanted to use SCWT to investigate the effects of chronic ongoing pain on cerebral correlates of cognition in FM patients. As mentioned earlier, structures in the brain that are involved in cognition and pain perception are highly overlapping so mapping the neural correlates of this interference test would provide valuable knowledge as to which cerebral structures are impaired during cognition in FM. We chose the SCWT since it is a purely cognitive task known to activate the dorsal ACC (dACC) Subjects were recruited by newspaper advertisement to participate in a multi-center experimental study  where FM patients were randomized to physical exercise or relaxation therapy. The current study was performed in the Stockholm cohort only and relies on baseline data before start of treatment, therefore no outcome of the clinical trial is reported in this manuscript.FM patients: 31 women with FM were initially included in the study. However 2 patients had to be excluded (one due to not meeting MRI safety criteria and one due to inability to participate). The final cohort consisted of 29 FM patients average age 49.8 years (range 25–64 years). In study one, one participant was excluded due to inability to participate, leaving 28 participants. Four participants were unwilling or unable to participate in the fMRI part of the study; one participant reported falling asleep during the scan and one participant was not scanned due to technical failure of the equipment, leaving 23 participants.Inclusion criteria for women with FM were to be of working age, 20–65 years, and meeting the ACR-1990 classification criteria for FM Healthy controls: 32 healthy female controls were recruited, one had to be excluded due to MR scan showing signs of neuroinflammatory changes, resulting in the final cohort consisting of 31 women, average age 46.3 years (range 20–63 years). All healthy subjects were interviewed regarding their health and completed relevant questionnaires. In study two one participant was unwilling to participate in the fMRI part of the study, one participant was not able to use the response box and one participant’s data was missing due to technical failure, this leaving 28 participants in study 2.The subject characteristics are presented in The regional ethics committee in Stockholm approved the study and written informed consent was obtained from all participants.2, circular, flat rubber tip on the end. It had a display that informed the experimenter how forcefully they were pressing and at which rate. The chosen rate was approximately 50 kPa/s. A response button was attached to the algometer and the subjects were instructed to push the button at the instant the pressure become painful. When this button was pressed, the current pressure froze on the screen. The algometer was calibrated for accuracy before each participant.Pressure pain thresholds (PPTs) were assessed using a pressure algometer . The pressure algometer had a gun shaped handle with a 1 cmImages were presented on a 17″ LCD screen with a resolution of 1024×768 pixels. Participants were given a response button box (Current designs) with four response buttons in the colors red, green, yellow and blue. The colors red, green and yellow together with the Swedish translation of these words made up the stimuli.FMRI data was collected using a 3.0 tesla scanner  and a 32-channel head-coil (MR instruments Inc). Foam wedges and headphones were used to minimize head motion and reduce perceived scanner noise.Subjects were familiarized with the SCWT and assessed regarding pressure pain modulation during SCWT. They returned on the following day for the SCWT fMRI scan. The patients had to refrain from analgesics, NSAIDS and hypnotics 48 hours before the assessment of pain modulation during SCWT and 72 hours before the fMRI scan. Prior to fMRI a 3-plane localizer was performed followed by ASSET-calibration for parallel imaging.Two paradigms were used in the SCWT test, one paradigm using only classic Stroop images: color words written in incongruent colors (for instance the word “green” in red color), and one control task with color words written in congruent colors (the word “red” in red color). Both paradigms lasted 10 minutes, each stimulus was presented on the screen for 2 seconds and the interstimulus interval (ISI) was three seconds. During the ISI a fixation cross appeared after a second and stayed on the screen for one second. The experimenter orally instructed the participants to respond based on the color of the text and not the word that they were reading. Participants were explicitly instructed to only use the red, green and yellow buttons as blue stimuli was not used. A test run was performed using congruent images and the experimenter ended the run when confident that the participant had familiarized themselves with the speed of the experiment and the location of the buttons. Participants pressed the response buttons with the index, middle and ring finger on the right hand.To acquaint the participants with the algometer it was demonstrated at the upper arm before testing at the thigh. PPTs were assessed eight times during the congruent and incongruent condition respectively. Twice before the beginning of the paradigm, then at 60, 180, 300, 420 and 540 seconds into the task, and finally once 10 minutes after the task had ended. Blood pressure and heart rate was measured using an automated blood pressure monitor once before the beginning of the task, then 90, 210, 330 and 450 seconds into the task, and finally 10 minutes following task conclusion. The last measurement taken 10 minutes following the conclusion of the first task was also used as the initial measurement prior to the second task.Half of the FM patients as well as healthy controls started with the incongruent condition followed by the congruent condition, and vice versa. In order to avoid sensitization, PPTs were initially assessed at the right thigh following the left thigh in half of the participants and vice versa in a counterbalanced order.Imaging parameters were as following: single shot EPI with a flip angle of 90°, TE 30 and TR 2500. Field of view (FOV) 28.8, 48 axial slices with a slice thickness of 3 mm, no slice spacing, which were acquired interleaved. There were two runs lasting 10 minutes. There were 84 images in each run with an even distribution of congruent and incongruent trials; the order of presentation of congruent and incongruent images was randomized. Interstimulus asynchrony was jittered between six and ten seconds, averaging at eight seconds. The stimulus was presented on a screen (24×32 cm) behind the participants, which was made visible via a mirror placed on the coil. A fixation-cross preceded each stimulus 500 ms followed by a blank screen for 1500 ms. The stimulus was on for 3000 ms. The word “Ready” appeared on the screen prior to the first fMRI run, the experimenter asked the participant to read the word on the screen out loud to ensure that they were positioned in such a way that they could see the words on the screen, as well as to confirm their ability to read the words used as stimuli. The paradigm was run using Neurobehavioural Systems Presentation software and is illustrated in In order to assess the effect of SCWT on pressure pain sensitivity the relative change in PPTs at m. quadriceps during SCWT was analyzed. In analogy with our previous studies of pain inhibitory mechanisms the PPTs were normalized  Greenhouse-Geisser corrections were used in case of significant test of sphericity.Group differences in absolute PPTs at baseline and reaction times were assessed by Students’ independent t-test. Post hoc analysis of intraindividual differences in PPTs over time and reaction times were assessed by Students’ paired t-test. Group differences in the number of errors during the SCWT, were analyzed by Independent Samples Mann-Whitney U-test.Data was analyzed using SPM8 . EPI images were realigned and then normalized to the canonical EPI-template in standard Montreal Neurological Insititute (MNI) space. Finally the images were smoothed using an 8 mm full-width-at-half-maximum (FWHM)-kernel. For each individual subject, first-level analysis was performed using a fixed effects analysis compounding both scans into the same general linear model (GLM). Stimulus onset times of congruent and incongruent stimuli were entered as regressors of interest, and movement parameters were entered as covariates of no interest. All regressors were convolved with the canonical hemodynamic response function  as implemented in SPM8 before they were entered into the general first level linear model The subject characteristics are presented in The average absolute PPT at m. quadriceps was 161 kPa in FM patients and 292 kPa in healthy controls (p<0.0001) at baseline and the absolute PPT was lower in FM patients compared to controls at all times during incongruent as well as congruent SCWT (p<0.0001). The effect of SCWT on normalized PPTs is shown in PPTs were significantly higher in FM patients during congruent SCWT at all times compared to baseline (p<0.05) with the exception at 7 min, but no statistically significant difference was seen 10 min following SCWT compared to baseline. In HC PPTs were higher at all times during congruent SCWT compared to baseline (p<0.01) and remained elevated 10 min following Stroop (p = 0.016).There were no statistically significant group differences in BP or HR at baseline. Regarding systolic BP, there was a statistically significant effect of TIME , CONGRUENCY  but not GROUP and no statistically significant interactions were seen. During incongruent SCWT systolic BP increased at 90 s compared to baseline  and then returned to baseline. No statistically significant differences from baseline were seen during congruent SCWT.Regarding diastolic BP there was a statistically significant effect of TIME , but not CONGRUENCY or GROUP and no statistically significant interactions were seen. During incongruent SCWT diastolic blood pressure increased at 90 s , 210 s  and 330 s  and then returned to baseline values (81 mm Hg), whereas it increased at 90 s  during congruent SCWT and then returned to baseline.Regarding HR there was a statistically significant effect of TIME  but not CONGRUENCY or GROUP and no statistically significant interactions were seen. During incongruent SCWT there was a statistically significant HR increase from baseline (69 bmp) at 210 s  and at 330 s , no other significant increases from baseline were seen during incongruent or congruent SCWT.Average RTs for HC were 870.57 ms (standard deviation (SD)  = 165.42 ms) for incongruent stimuli, and 758.20 ms (SD = 121.47 ms) for congruent stimuli. The average RTs for FM patients were 1017.81 ms, (SD = 207.10 ms) for incongruent stimuli and 836.53 ms (SD = 149.25 ms) for congruent stimuli . There wCompared to HC, FM patients had longer RTs during incongruent (p = 0.005) as well as congruent (p = 0.027) SCWT, but the group difference was more pronounced during the incongruent than the congruent task. This is illustrated in There were no significant group differences regarding the number of errors made during congruent  or incongruent  SCWT.The main effect of the contrast incongruent – congruent when both groups were analyzed together revealed an expected activation network including the parietal lobe, dorsal ACC (dACC), posterior cingulate cortex (PCC), precuneus, insula and dlPFC, , Table 2FM patients showed no regions with more activity than HC for incongruent >congruent images. When contrasting HC>FM we found greater activation in the caudate nucleus , temporal areas encompassing the hippocampus and the lingual gyrus , Table 3We found a normal inhibition of pressure pain sensitivity in FM patients compared to healthy controls when engaging in the cognitive task. This was independent of the cognitive demand/load thus suggesting that distraction of attention away from painful stimuli, rather than engaging in the cognitive task per see was mediating the decreased pain sensitivity. To our knowledge, this is the first evidence that FM patients have a normal ability to regulate pain sensitivity during distraction. As expected, FM patients had slower RTs during the cognitive task, but did not make more mistakes. Several brain regions showed more profound activation in both groups alike during the cognitively more demanding (incongruent) task compared to the congruent task, mainly cerebellum, inferior parietal lobe, dACC, PCC and right insula. FM patients did not show increased task related activation of ACC. Instead reduced task related cerebral activations were seen when FM patients were compared to healthy controls in brain regions implicated in cognitive processing and memory such as the caudate nucleus, and hippocampus.We found the same relative reduction in pressure pain sensitivity in both groups when engaging in the SCWT task. Furthermore, the cognitive load did not influence pain sensitivity. To our knowledge, this is the first evidence of normal activation of top-down pain inhibitory mechanisms in FM patients and our results indicate that distraction from pain stimuli can reduce, although not normalize, pain sensitivity in FM patients.The effect of distraction on heat pain sensitivity has been studied previously in healthy individuals, and it was found that the PAG is activated during distraction away from the painful stimuli. The authors also reported a correlation between the degree of PAG activation and reduced pain sensitivity The current findings are in accordance with a pilot study conducted in our group showing normal ability of FM patients to inhibit pressure pain sensitivity during a stressful variant of the incongruent SCWT accompanied by profound BP and HR increases (unpublished data). The paradigm of the present study was chosen to ensure that the increase in BP and HR would be very modest, in fact, it was only seen during the first part of the SCWT, offsetting baroreceptor analgesia as an likely explanation FM patients had longer RTs during SCWT compared to controls and the group difference was even more pronounced during the incongruent trials, however they did not make more mistakes. This is in accordance with previous studies The ability to learn new action schemas is required in order to perform well on the SCWT. Caudate nucleus and hippocampus are areas that are connected to each other and involved in learning as well as pain modulation, making them highly clinically relevant in FM syndrome. Normal functioning of the caudate nucleus depends on dopamine (DA), and DA modulates reciprocally with serotonin Contrary to our hypothesis and to previous findings We did not assess the cerebral correlates of pain modulation during SCWT with fMRI, which would have provided additional important information. Also, contrary to previous studies, we did not assess the effects of evoked painful stimuli on cognitive function. Combining these two approaches during fMRI in future studies could improve our understanding of the cerebral interactions during pain processing and cognition. Finally, we did not want to exclude patients on antidepressants/anticonvulsants since this would risk bias our FM cohort towards less affected individuals.To our knowledge, this is the first evidence that FM patients have a normal ability to regulate pain sensitivity when focusing on a cognitive task. We found evidence of slower cognitive processing in FM patients related to task difficulty. Contrary to our hypothesis, no evidence of ACC dysfunction during SCWT was seen. Instead FM patients had reduced activation of caudate nucleus and hippocampus during SCWT in line with problems learning new actions schemas.


Evolution of healthcare assistance in the ICU, due to its technological apparatus, has increased survival of critically ill patients substantially. In this ballast, patients who require prolonged length of stay, as well as demand continued intensive care support ), are increasingly identified. These patients suffer from chronic critical illness (CCI), a rapidly growing syndrome which has immune, neuroendocrine and metabolic particularities-today, they represent 5-15% of all patients admitted to the ICU.To describe the epidemiological characteristics of CCI in an adult ICU and to analyze possible predicting factors of evolution to CCI at admission to the ICU.t test for evaluation of continuous variables and chi-square test for categorical variables.Retrospective analysis of patients admitted to the General Hospital of Fortaleza-SESA from November 2014 to February 2015. The CCI was defined as prolonged MV . Descriptive statistical analysis was utilized for demographic characters, p = 0.048 and p = 0.033, respectively). The mean MV time, ICU and hospital length of stay were significantly increased in the CCI population, with 34 ± 12 days (p < 0.001).From 86 patients admitted in that period, 13 (15%) were identified as chronically critical. The mean age of these patients was 57 ± 22 years, and 61% of them were female, mean SOFA score (at admission) was 6.5 ± 3.3 points and mean APACHE II score was 18 ± 5.5 points, statistically similar to the other patients. At admission, 61.3% had hypertension, 46.1% were diabetics; chronic kidney disease (CKD) and chronic cardiovascular disease were identified in 23% each. The presence of diabetes mellitus (DM) and CKD were significantly higher in the CCI population (The prevalence of CCI in this study follows the current literature. High SOFA and APACHE II scores do not seem able to identify the patients who will evolve from severely ill to CCI. The present study suggests that comorbidities, at admission, may indicate which patients will survive acute critical illness to become CCI-as well as CKD and DM. The significant post-ICU mortality highlights the need for more suitable follow-up for the CCI population after discharge.


Patients frequently experience postoperative pain after a total knee arthroplasty; such pain is always challenging to treat and may delay the patient's recovery. It is unclear whether local infiltration or a femoral nerve block offers a better analgesic effect after total knee arthroplasty.We performed a systematic review and meta-analysis of randomized controlled trials to compare local infiltration with a femoral nerve block in patients who underwent a primary unilateral total knee arthroplasty. We searched Pubmed, EMBASE, and the Cochrane Library through December 2014. Two reviewers scanned abstracts and extracted data. The data collected included numeric rating scale values for pain at rest and pain upon movement and opioid consumption in the first 24 hours. Mean differences with 95% confidence intervals were calculated for each end point. A sensitivity analysis was conducted to evaluate potential sources of heterogeneity.p=0.02) in the first 24 hours differed significantly between the patients who received local infiltration and those who received a femoral nerve block, there were no differences in the numeric rating scale results for pain at rest  or opioid consumption  in the first 24 hours.While the numeric rating scale values for pain upon movement (MD-0.62; 95%CI: -1.13 to -0.12; Local infiltration and femoral nerve block showed no significant differences in pain intensity at rest or opioid consumption after total knee arthroplasty, but the femoral nerve block was associated with reduced pain upon movement. Every year, approximately 130,000 patients receive knee replacements in the United States Pain management after total knee arthroplasty is a multipart strategy. It often includes intravenous opioids, epidural analgesia, or peripheral nerve blocks in combination with oral analgesics and cryotherapy Using systematic review methods and meta-analysis, our objective is to synthesize evidence from randomized controlled trials to compare the effectiveness of local infiltration with that of a femoral nerve block for pain control in patients undergoing total knee arthroplasty.We searched articles in three electronic databases, Pubmed, EMBASE, and the Cochrane Library, for reports published between January 1, 2000, and January 26, 2015. The search terms included femoral nerve block, local infiltration, total knee arthroplasty, pain, analgesia, and randomized controlled trial. We removed duplicate articles that were located in more than one database. We included randomized controlled trials that compared the use of local infiltration with the use of a femoral nerve block for patients who underwent primary unilateral total knee arthroplasty. We excluded trials about bilateral total knee arthroplasty.Two reviewers  screened the relevant titles, abstracts, and full papers according to the previously mentioned criteria. If these two reviewers did not agree on a selection, a third reviewer (Quan Li) was consulted.Information was extracted regarding study characteristics, participant characteristics, the anesthesia procedures common to randomized groups, intervention , and analgesia assessment .Three aspects were assessed to compare the effectiveness of local infiltration and femoral nerve block for pain management in patients after total knee arthroplasty: 1. The NRS value for pain at rest in the first 24 hours; 2. The NRS value for pain upon movement in the first 24 hours; and 3. opioid consumption in the first 24 hours.Possible biases were recorded in a Cochrane risk of bias table 2 statistic and chi-squared tests. A fixed-effects model was used when the heterogeneity test did not reveal statistical significance . Otherwise, the random effects model was used. Three continuous variables were included in this meta-analysis  and the mean difference (MD) and 95% confidence interval (95% CI) were determined. All tests of statistical significance were two-sided Review Manager Software  was used for the meta-analysis. The heterogeneity of the studies was tested using the IOriginally, 23 records were identified through the PubMed, EMBASE, and Cochrane Library databases. The full text of all articles except one p=0.35; p=0.02; The results of the NRS for pain at rest in the first 24 hours showed no differences between local infiltration and femoral nerve block  was conducted. No individual study significantly affected the heterogeneity results  A-C.We selected articles from various databases to obtain relatively fair and objective results. Ultimately, 6 out of 23 articles were included for analysis, most of which were randomized, controlled and double-blind experiments, except for two In comparing local infiltration and femoral nerve block for pain control after total knee arthroplasty, different studies drew different conclusions. Toftdahl K et al. Our systematic review and meta-analysis provide a substantial evaluation of the effectiveness of local infiltration and femoral nerve block for pain control after total knee arthroplasty. Our data indicate that the two analgesic regimens offer a similar quality of pain relief at rest and are associated with similar levels of opioid consumption during the first 24 hours after total knee arthroplasty. The NRS value for pain upon movement was significantly lower in the femoral nerve block group.Meftah M et al. Patients in the study of Ng FY et al. Moghtadaei M et al. Although these three studies Our study has the following limitations: 1. Because of language and database limitations, only published full-text articles in English were included, and this resulted in small number of included studies; 2. No data about postoperative movement functions were extracted for analysis, so the assessment of analgesia for total knee arthroplasty was not comprehensive.In summary, local infiltration provides analgesia comparable to that of a femoral nerve block for patients receiving total knee arthroplasty based on pain at rest and opioid consumption, but a femoral nerve block reduces pain upon movement.


The concept of attachment is relevant for the onset and development of chronic pain. Insecure attachment styles negatively affect therapeutic outcome. Insecurely attached patients seem to be less able to sustain positive effects of a multimodal treatment program. However, it has never been tested before if an attachment-oriented approach can improve treatment results of insecurely attached patients in a multimodal outpatient setting. To test this assumption, we compare the short- and long-term outcomes for pain patients who will receive multidisciplinary, attachment-oriented treatment with the outcomes for patients in a control group, who will receive the multidisciplinary state-of-the-art treatment.Two patient groups  are assessed before treatment, after treatment, and at a 6 month follow-up. The study is conducted in a block design: After data collection of the first block (controls) and before as well as during data collection for the second block (treatment group), the health care personnel of the outpatient pain clinic receives training on attachment theory and its use in the therapeutic context. Pain intensity as measured with visual analogue scales and physical functioning will serve as the primary outcome measures.The design of our study allows for a continuous exchange of experienced team members, which may help bring about concrete attachment related guidelines for the enhancement of therapeutic outcome. This would be the first attempt at an attachment-oriented improvement of multimodal pain programs.An attachment-based approach may be a promising way to enhance long-term treatment outcomes for insecurely attached pain patients.DRKS00008715 (registered on the 3rd of June 2015). Today, it is widely acknowledged that the onset and development of chronic pain syndromes is a result of complex interactions between biological, psychological and social influences, including patients’ beliefs about their self-efficacy, hypervigilant monitoring of bodily sensations, familial conflict or social support , 22, 32.secure style, and the three insecure styles dismissing, preoccupied, and fearful [Attachment theory provides a useful framework to classify patients’ relatively stable cognitive, emotional and behavioral response styles to stressors (such as pain), which have been successfully linked to disease processes in general , 35 and  fearful , 38. Bar fearful .Fig. 1AtThese attachment styles relate to patients’ stress responsiveness, their beliefs about their ability to cope with the experience of pain, or specific interaction patterns with spouses or health care personnel , 39. PatThese findings are especially relevant given that insecure attachment styles are overrepresented in patients suffering from chronic pain , 46. AttPatients in the intervention group, who receive an attachment-based multidisciplinary treatment, will report a larger mean reduction of the pain intensity between pre-treatment and post-treatment assessments than patients in the control group, who receive the state-of-the-art multidisciplinary treatment. It is expected that this larger reduction of the pain intensity in the intervention group compared to controls can be specifically attributed to better outcomes for the intervention group patients than control group patients who have been assessed with insecure attachment styles. Moreover, patients with an insecure attachment style and patients with more attachment anxiety are expected to report higher levels of pain intensity as well as physical functioning.The intervention is specifically designed to improve the therapeutic relationship and to hereby improve treatment outcomes. Therefore, we expect to find improved ratings of the relationship  between patients and therapists in the intervention group which will mediate the treatment outcomes pain intensity and physical functioning.There will be a greater decline in help-seeking behavior and use of medication in the intervention group compared to the control group from pre-treatment to after the 6-month follow-up. This will be especially hypothesized for insecurely attached patients in the intervention group.Subjective self-awareness of the patients particularly with regard to self-esteem will be expected to change to a greater extent in the intervention group compared to the control group.To date, the knowledge about attachment concepts has not been used to improve pain treatment outcomes with the help of a differential approach based on individual attachment styles. Therefore, we will compare the short- and long-term treatment outcomes for pain patients who will receive multidisciplinary, attachment-specific treatment with the outcomes for patients in a control group who will receive the multidisciplinary state-of-the-art treatment  and 3 assessments T1, T2, and T3 . We decided against a randomized controlled trial because (a) we had ethical concerns with a design that would put patients on a waiting list for several months, and (b) a block design ensures that the intervention’s effects only influence the outcomes of the treatment group: After collection of data for the control group, the health care personnel of the outpatient pain clinic receives training sessions on attachment theory and its use in the therapeutic context. These training sessions will not be carried out until data collection for the control group will be complete. More attachment-related training sessions alternating with supervision meetings will be held on a monthly basis to assist the therapeutic team in the practical application during data collection for the second sample, the treatment group. During our weekly team meetings, the case reviews will be complemented with a discussion on the individual attachment style of each patient. Also these meetings will be used to collect situations, which are perceived to be critical for the forming of a working alliance by the therapeutic team . These critical situations will be subsequently used to structure the discussions of individual cases in the bi-monthly training sessions.have experienced chronic pain for at least six monthsare between 18 and 80 years of agehave previously received standard treatment consisting of at least one rehabilitation program or two inpatient treatments, which did not yield lasting effects.Our participants are enrolled as outpatients in the orthopedic clinic of the Heidelberg University Hospital and participate in a four-week outpatient multidisciplinary pain treatment including physiotherapy, ergotherapy, music and dance therapy, individual and group psychotherapy. As such, theyhigh C-reactive protein (CRP) levels as an indicator of rheumatoid arthritisacute inflammations of the spinea tumora diagnosed psychosisa diagnosis of a bipolar or neurological disorderan insufficient ability to communicate in GermanExclusion criteria includeThe study procedures were approved by the Institutional Review Board of the Medical Faculty, University of Heidelberg (S-305/2013). As such, they comply with the ethical standards established in the Declaration of Helsinki and with the guidelines of ICH-GCP. Upon arrival at the department, the principal investigator verbally states the study purpose and procedures to eligible patients and informs them about their right of withdrawal at all times. Additionally, all participants obtain an information sheet on the study objectives and modalities, data preparation and pseudonymized data storage. All participating patients provide written informed consent.We calculated the necessary sample size for each of our two subsamples (intervention and control) with the G*Power Analysis software program for two-sample t-tests , and by Descriptive statistics will be used to describe the characteristics of the study sample. Analysis of variance will be used for the evaluation of the changes of the continuous outcomes pain intensity and physical functioning . Research condition (attachment style and study group), will be used as independent variable. Demographic variables such as sex, age, education and clinical variables such as opioid intake and comorbidity will be entered as covariates. Partial regression coefficients will be used to determine if the “working alliance” mediates the effect of attachment on the continuous outcomes .Missing data on the questionnaires will be handled according to the questionnaire protocol.By drawing on attachment theoretical ideas, we do not mean to change any of the overall aims of multimodal pain treatment. Also, it would be unrealistic to aim at a complete reversal of underlying insecure attachment patterns to a secure pattern in such a setting.Rather, we aim at an improvement of the therapeutic alliance (a) in terms of the therapists’ general ability to provide a secure base for his patients, and (b) in the therapists’ ability to understand and deal with their patients’ individual attachment-based motivations and needs. Thus, the intervention’s guidelines should help facilitate the attainment of the program’s aims by enhancing the patient’s sense of having a secure base. Therefore, our intervention training includes both general directions for building a meaningful therapeutic relationship, and guidelines, which are specifically tailored to the needs of individual attachment styles.To develop general guidelines for an improvement of the working alliance, we identified as useful starting point the therapeutic approach of the complementary therapeutic relationship. This approach emphasizes the underlying motives (such as the attachment motive) of patients , 48.We also developed more specific guidelines for each attachment style based on a further development of existing literature on the application of attachment ideas to specific therapeutic settings. For example, attachment theoretical ideas have been incorporated in therapeutic programs for the treatment of borderline personality disorder, depression, medically unexplained symptoms, family and couple therapy , 28, 29.For example, patients with preoccupied attachment styles might benefit more from an initially concordant approach which puts emphasis on the therapist’s role as a secure base. Patients with preoccupied or fearful attachment styles might feel overwhelmed by a program which is too fast in emphasizing autonomy, and possibly reinforce existing fears of rejection and abandonment. On the other hand, dismissively attached patients might feel uncomfortable with high levels of proximity, and the amount of guidance and care preoccupied patients favor to feel safe.The multimodal setting requires an attachment-based concept, which can be employed by medical personnel with diverse professional backgrounds such as doctors, physiotherapists, occupational therapists, music and dance therapists. Additionally, therapists may avail themselves of diverse methodological approaches such as psychoanalytical or cognitive behavioral therapy.Each team member is provided with a manual of the general guidelines and the attachment style-specific guidelines. In the course of data collection for the intervention group, these guidelines will also be constantly extended.The Structured Clinical Interview for DSM-IV Axis I Disorders  is a seItems are adapted from the German Pain Questionnaire. The German pain questionnaire  has beeavoidance and anxiety (a) specifically with regard to partners or spouses and (b) more globally with regard to friends and relatives. The original version of the ECR-R [Assessments of both intervention group and baseline group are identical. For an overview of all measures at T1, T2, and T3, see Table he ECR-R  was baseThe ECR-RD has shown high levels of test-retest stability and discriminant validity . We deciFrom these four prototype ratings, the ‘model of self’ and the ‘model of other’ scales were calculated as proposed by the authors. Patients with positive models of both self and other were classified as ‘secure’, patients with negative/neutral models for both as ‘fearful’, and individuals with mixed results as ‘preoccupied’ or ‘dismissing’. The RQ-2 has been shown to have an acceptable level of psychometric soundness as a brief screening instrument, and it is relatively independent from self-deceptive biases. The RQ-2 implemented has been used in multiple international studies and proved to be an efficient screening instrument with good construct validity across cultures.With two Visual Analogue Scales, we assess the pain intensity at present and within the previous week. Patients are also asked to indicate the number of days they experienced pain, and the number of days they experienced strong pain, both within the previous month. Physical functioning will be assessed with the Oswestry Disability Index by Mannion et al. , which hSubjective pain intensity over the preceding week was measured on a visual analogue scale  rangingThe validated Oswestry Disability Index  is currThe Depression Anxiety Stress Scales  is madeThe SF-12 Health Survey  is a shoThe inventory of Interpersonal Problems  is The Rosenberg Self-Esteem Scale , a widelCoping strategies in the context of chronic pain refer to the way individuals who experience pain develop ways to tolerate, minimize or reduce their pain. The Coping Strategies Questionnaire  is inteThe Working Alliance Inventory-Short Revised  is a reThe German Stations-Erfahrungs-Bogen  is an inContinuous exchange of experienced team members might help bring about concrete attachment related guidelines for the enhancement of therapeutic outcome for pain patients and allow us to develop a standardized training manual for pain patients. To our knowledge, such concrete guidelines are rare in applications of attachment concepts to therapy of chronic pain patients in a multimodal setting. Also, as patients with preoccupied and fearful attachment styles are less able to maintain the positive results of multimodal pain treatment over a period of time, an attachment-based approach is a promising way to enhance the prospects especially for these patients.We do not believe that two training sessions for the therapeutic team will suffice to yield large effects on therapeutic outcome. However, we expect that the constant exchange within the team during weekly team meetings and monthly supervision sessions will facilitate the development of a clear understanding of attachment styles as well as a repertoire of methods to deal with incidents, which are critical for the working alliance. Therefore, therapists are likely to become more seasoned in recognizing and dealing with the attachment behavior of their patients in the course of the study. As a result, effects might only become apparent in an advanced phase of data collection for the intervention group.Patients with a preoccupied attachment style and, even more pronounced, the ones with a fearful attachment style, gain the least from the state-of-the art multidisciplinary pain treatment. These patients are known to have difficulty with the regulation of distance and proximity to other people. Our program in the outpatient clinic offers many opportunities to express distancing or proximity-seeking behavior in dealing with doctors, physiotherapists, psychologists and the group of other patients and therefore provides many chances for difficulty. Even if the therapeutic team is trained in attachment concepts, the time frame might not be enough to use this new knowledge to their advantage. It is very likely that in such a setting, patients with insecure attachment patterns will at some point elicit (negative) reactions either from staff or from other patients similar to the ones they continuously experience in their every-day lives. This would confirm their general expectations of themselves and others in relationships, hereby reinforcing these expectations.The short time frame of this setting, which is already packed with activity, might simply not be enough to adequately absorb these experiences and to tap into them in a therapeutic sense. Therefore, the setting in itself could be unsuited to a treatment concept which is individually tailored to specific attachment styles. It might even be unsuited altogether for patients who are known to have difficulty to become self-dependent once the intense support they receive throughout the program discontinues. On the other hand, as such an individually tailored attachment concept has never been applied to multimodal pain treatment and attachment styles clearly are very relevant in this setting, there is also the chance that treatment can be largely improved. Moreover, we do not aim at altering the individual attachment patterns of the patients themselves. Rather, we use the knowledge about these patterns to form an adequate basis from which we can start working with the patients on their pain related goals without overstraining them.Recruitment of patients for the control group started in March 2012. Pre- and post-treatment assessments were complete by Oct. 2013 with a total of 184 patients who received a questionnaire at T1 (for an overview of the recruitment process including dropout numbers, see Fig.


To evaluate the epidemiological evolution of patients with HIV (PtHIV), between 2002 and 2012, in a day-hospital that became an HIV reference centre for south-west Burkina Faso.This was a retrospective study of PtHIV followed in the Bobo Dioulasso university hospital since 2002. The study was based on clinical data recorded using ESOPE software and analysed using Excel and SAS.st line drugs). However, there was also a slight increase in the rate of therapeutic failures and the percentage of patients who progressed to 2nd or 3rd line-ARVs.A total of 7320 patients have been treated at the centre since 2002; the active file of patients increased from 147 in 2002 to 3684 patients in 2012. Mean age was stable at 38.4 years and the majority were female (71%). The delay to initiation of antiretroviral (ARV) treatment after HIV diagnosis decreased from 12.9 months in 2002 to 7.2 months in 2012. The percentage of PtHIV lost to follow-up, untreated for HIV and deaths all decreased after 2005. Voluntary anonymous screening and/or an evocative clinical picture were the main reasons for HIV diagnosis, usually at a late stage (41.1% at WHO stage 3). Virological success increased due to a decrease in time to initiation of ARV treatment and an increase in percentage of patients treated . In 2012, the UNAIDS report estimated that 35.3 million individuals worldwide were living with the human immunodeficiency virus (PtHIV), representing a prevalence of 0.8% [3 irrespective of clinical symptoms [Burkina Faso is one of the countries in sub-Saharan Africa that has the lowest prevalence of HIV. The number of PtVIH was 120 000 [IQR: 100 000–150 000] in 2013, representing a prevalence of 1% in the general adult population 15–49 years)  and the number of news patients diagnosed yearly is reported in the In terms of education, 47.6% of patients were illiterate, 26.9% had attended primary school, 23.7% had attended secondary school and only 1.8% had received further education.In terms of marital status, 20.8% patients were single, 1.8% were living with a partner, 42.1% were in a monogamous marriage, 7.5% were in a polygamous marriage, 21.2% were widowed and 6.6% were divorced. There was an average of 2.2 children/female.There was no significant change in the socio-demographic data over time.–4)in 2012 (The median time between HIV detection and the first consultation decreased from 8.7 months [IQR: 4.4–14.4 months] in 2002 to 0.2 months [IQR: 0.1–0.7 months] (p<10)in 2012 .The percentage of patients lost to follow-up increased from 2002 to 2005 (45.7%) and then decreased constantly to 6.3% in 2012 . The majThe annual mortality rate evolved in the same way between 2002 and 2012, with an increase until 2004 (9.1%) and then a decrease to 2.1% in 2012 .In the day-hospital of Bobo Dioulasso, there were three main contexts for the detection of HIV seropositivity: voluntary and anonymous screening (52.7%), a suggestive clinical picture (44.4%) and the prevention of mother-child transmission (3.0%), with a similar distribution over time. Nevertheless, diagnosis remained late, with a similar distribution of the different WHO stages each year . In 2012The majority of patients were infected with HIV-1 (93.4%), 2.6% with HIV-2 and 4.0% were coinfected with HIV-1 and HIV-2.3 (196.9/mm3 in 2002 and 267.7/mm3 in 2012 (p<10–4) (Mean CD4 count at HIV diagnosis since 2002 was 241.8/mm(p<10–4) .Therapeutic cover with ARVs increased significantly from 121 patients (19.7%) in 2002 to 3335 patients (90.5%) in 2012 .–4)  and 16% of patients had CD4 <50/mm3 [The median delay to initiation of ARV treatment from diagnosis decreased from 12.8 months [IQR: 6.0–19.5 months] in 2002 to 0.6 months [IQR: 0.3–0.9 months] in 2012 p = 10–4) . This de . This dOver three-quarters (84%) of treated patients had virological success  and 16.0% had virological failure, with 2.5% having a viral load between 300 and 1000 cp/ml, 2.7% between 1000 and 10 000 cp/ml, 4.8% between 10 000 and 100 000 and 6% >100 000 cp/ml.In 2012, most of the treated patients were receiving first-line ARV treatment (94.9%), 5.1% were receiving second-line and 0.04% third-line treatment.The most widely used combination of ARVs used in 2012 was the association of two nucleoside reverse transcriptase inhibitors (NRTIs) with a non-nucleoside reverse transcriptase inhibitor (NNRTI) in 80.4% of cases. In 19.5% of treated patients, the ARV combination was the association of two NRTIs with a norvir-boosted protease inhibitor. Finally, 0.08% received two NRTIs plus an integrase inhibitor.The most widely used combination of NRTIs was 3TC + AZT (lamivudine/zidovudine) in 62.1% of cases. The most widely used NNRTI was efavirenz (EVF) in 54.5% of cases, followed by nevirapine (NVP) in 45.5% of cases. The most widely used protease inhibitor was lopinavir boosted by norvir (79.8%) and then indinavir (10.4%). Finally, the most widely used integrase inhibitor was raltegravir.The distribution of the different therapeutic lines of ARVs used in 2012 had changed since 2002 with the availability of new molecules. The most widely prescribed ARV combinations were 3TC/AZT/EFV (26.3%) and 3TC/AZT/NVP (26.3%) .In terms of second-line treatment, the molecules used since 2006 were those recommended by WHO (i.e. ABC+DDI+LPV/r or TDF+FTC+LPV/r). Since 2010, the combination TDF+FTC+DRVr has also been available via the LADY 2 research protocol.The proportion of untreated patients decreased between 2002 and 2012, from 80.9% in 2002, to 51.8% in 2005, 30% in 2007 and 9.5% in 2012.3 in 2002 [IQR: 72-441/mm3] to 386/mm3 [IQR: 252-573/mm3] in 2005, 488/mm3 [IQR: 356–639] in 2007 and 544/mm3 [IQR: 458-594/mm3] in 2012 (p = 10–4) [3 decreased from 51.6% in 2002 to 37.7% in 2005, 29.4% in 2007 and 16% in 2002 [Conversely, median CD4 counts in these patients at diagnosis increased from 104/mm in 2002 .Before 2006, there was not enough treatment available to treat all eligible patients. However, from 2006 all patients responding to WHO criteria received ART if they wanted it.The day-hospital in Bobo Dioulasso, with an active file of 3684 patients followed in 2012, represents a successful model for the management of PtHIV in sub-Saharan Africa. The latest socio-demographic data to be described in this part of Africa are similar to those observed in our study , with a The management of PtHIV in this centre is characterized by a net decrease in time (between the date of HIV diagnosis and the first consultation) to the initiation of ARV treatment since 2002, which can be explained by an increase in number of medical and paramedical personnel in the Bobo Dioulasso centre, improved access to training on HIV management and a better structural organization for the reception of PtHIV. Late consultations with a view to obtaining ARV treatment remain an important factor in morbidity and mortality , 21.According to our study, the number of patients lost to follow-up has decreased since 2005. In addition to a decrease in time to treatment of these PtHIV, this decrease in patients lost to follow-up can be explained by the use, since 2007, of software for the administration of ARV dispensing, which makes it easier to identify patients on ARV who do not present at the pharmacy to renew their treatment. The number of patients lost to follow-up in the day-hospital of Bobo Dioulasso is very low in comparison to the figure reported in countries in southern Africa in a recent literature review (60%) , these pst out of 187 in the latest classification of the human development index) [Intensification of follow-up also enables the rapid initiation of ARV treatment, which can impact on the HIV epidemic in many regards, notably on mortality due to AIDS , 26. In t index) .Most of our patients received first-line treatment, but the rate of therapeutic failure is increasing in Africa with some patients already being treated with second- or even third-line ARV protocols , 33. TheThe majority of our treated patients were immuno-virological successes and were still receiving first-line treatment. This therapeutic success is explained by the basic but crucial therapeutic education of patients (TEP) introduced in our centre via multiple groups. According to data from 18 countries, the rate of compliance decreases over time: it is 86% and 72% at 12 and 60 months, respectively . For thiThis study has several limitations and biases. First, because it is a non-comparative retrospective study, and secondly, because we used data that were collected routinely and missing date are inevitable. Thirdly, in including all patients who were in care at any time over the course of a given year to calculate LTF for that year , we introduce a survivor bias. Finally no analysis could be conducted to estimate the effect of change in care over time or of the impact of specific aspects of care in improving patient outcomesIn conclusion, this study illustrates the excellent performance, over 10 years (2002–2012), of a hospital centre that has become a reference centre for the management of PtHIV in Bobo Dioulasso and a good example for sub-Saharan Africa. It demonstrates how to improve the reception, medical follow-up, psycho-social follow-up and quality of management of HIV and opportunistic infections in these patients.


To investigate the improvement of dysmenorrhea and menorrhagia after wedge-shaped resection of uterus. The clinical data of 15 patients who experienced wedge-shaped resection of uterus for adenomyosis were retrospectively analyzed from September 2012 to October 2013. We use the amount of the completed soaked napkins to measure the menstrual blood volume, and the visual analog scale to evaluate the degree of dysmenorrhea. We used the 2 index to evaluate the improvement of dysmenorrhea and menorrhagia after operation. All operations were successful, no serious complication occurred. Before the operation, all 15 patients used more than 25 pieces of completed soaked napkins, after the operation, 13 patients had significantly decreased menstrual flow, the average amount of completed soaked napkins was 3.6. Meanwhile, 2 patients had no menstrual after surgery. Before the operation, among the 10 patients with severe dysmenorrhea, 9 patients had significant relief on pain, they only experienced slight pain after surgery, only 1 patient still experienced moderate pain. Two patients with slight pain had no pain after operation. Among the 3 patients with moderate pain, 2 patients experienced slight pain and 1 patient felt no pain after operation. The wedge-shaped resection of uterus is a safe and effective procedure to significantly reduce menorrhagia and alleviate the extent of dysmenorrhea, which is a promising alternative for patient who suffered from dysmenorrhea and menorrhagia for adenomyosis. The signs and symptoms include progressive dysmenorrhea, menorrhagia, abnormal uterine bleeding, enlarged uterus, dyspareunia, and infertility, which can seriously affect the patient's quality of life. Currently, the treatments mainly include pharmacotherapy, such as oral contraceptives, nonsteroidal antiinflammatory painkillers, progesterone, gonadotropin-releasing hormone analog (GnRHa) and surgery. So how to clear away eutopic endometrium which caused dysmenorrhea and menorrhagia but preserve uterus and ovary function become the focus of many gynecologist, especially for those patients who refused to take medicine, but had severe dysmenorrhea and heavy menstruation. Wedge-shaped resection of uterus is the procedure in which the uterus body and most endometrium are deleted, and the remnant uterus muscle is sutured. The advantage of this procedure is significant relieve patients’ discomfort and reserving uterine artery ascending branch, which can delay the occurrence of menopause symptoms.Drug treatment can relieve the symptom in short-term, but drug withdrawal usually results in the recurrence. Although adenomyosis mainly occurs in multiparous women, those women still want to preserve uterine. What's more, the newly recognized theory about endometriosis is eutopic endometrium determinism.The aim of the present study is to analyze the improvement of symptoms after the wedge-shaped resection of uterus, and to explore whether wedge-shaped resection of uterus is a promising treatment for adenomyosis inducing dysmenorrhea and menorrhagia.22.1Fifteen patients were admitted in our study during September 2012 to October 2013. This study was approved by the institutional ethics committee, and informed consent was taken from all subjects. The including criteria were: the patients were multiparous and had no desire for giving birth to another child, there were no other reasons leading to dysmenorrhea and menorrhagia and none of the patients had any history of serious health conditions. All of them underwent wedge-shaped resection of uterus, and pathological examination verified adenomyosis. The age of patients ranged from 32 to 42 years old, the mean age was 33.2 ± 3.2 years old. All the patients were multiparous women, 10 patients gave birth to 2 children. Six patients had minor uterus myoma protruding serosal layer, the diameter of which was 2 cm. Two patients had ovary endometriosis which was discovered during the operation. After surgery, all the patients were followed up for 7 to 12 months. No patient had recurrent lesion.2.2The uterus was pulled outside of the abdominal incision. This technique involves determining the location and border of lesions by inspection and/or palpation. For those ill-defined borders, we resected the most uterus body as much as possible, so the width of left uterus in each side was 2 cm. Longitudinal incision of the uterus wall along the borders of adenomyoma. Sharp and blunt separation of the lesion with scissors to remove the whole adenomyoma and part of normal myometrium. Thus, we resected the main body and most endometrium from anterior and posterior wall of the uterus Fig. , which a2.3The degree of dysmenorrheal (pain) was assessed using the visual analog scale. The left end of the scale was set at 0 (no pain) and the right end of scale at 100 (intolerable pain). The scale of 10 to 30 was slight pain, 40 to 60 was moderate pain, 70 to 100 was severe pain. The degree of pain was self-reported by patients. For menstrual flow, the number of sanitary napkins used 1 day, which was completed soaked was counted. When the amount of used napkin was more than 25 pieces, we determined menorrhagia.2.4We called the patients to ask for the situation of dysmenorrheal relief and menstrual flow every month after operation, also, we advised the patient to take B ultrasonic examination every 3 months after operation to find the recurrence.2.5P < 0.05 was considered statistically significant.The SPSS 13.0 software package was used for statistical analysis. 33.1All the operations were successful, no serious complication occurred. The lesion of adenomyosis ranged from 3 cm × 2 cm to 10 cm × 8 cm. At the same time, pelvic adhesion lysis was taken in 6 patients, ovary chocolate cyst was stripped in 2 patients, and minor myoma was excised in 6 patients.3.2According to the visual analog scale, when the score was <30, we considered the pain was slight, when the score ranged from 40 to 60, the pain was moderate, when the score was above 70, the pain was sever. In our study, before the operation, 10 patients had severe dysmenorrheal, 3 patients had moderate dysmenorrhea, and 2 patients had slight dysmenorrhea. After operation, 3 patients undergoing moderate pain had mild pain, the remission rate was as high as 100%, especially, 1 patient felt no pain after operation. In the 10 patients who suffered from severe dysmenorrheal, only 1 patient still experienced moderate pain. All patients suffered from menorrhagia. The used napkins was counted, as shown in Table 3.3The adenomyosis showed low density mass in the enlarged uterus with or without blood flow signal. In our study, B ultrasonic taken 3 months later after operation showed shrunk uterus with little or no blood flow signal as shown in Fig. 4 The symptoms of adenomyosis include dysmenorrhea, menorrhagia, abnormal uterine bleeding, and diffuse uterine enlargement, sometimes leading to pelvic pressure and frequent urination. Hysterectomy, which eliminate the underlying source of symptoms, is the most common treatment for adenomyosis. For women who wish to preserve their uterus, the alternative options include hormonal therapy,,6 endometrial ablation therapy, and uterine artery embolization.,9 Hormonal treatment offer only temporary alleviation of symptoms and is associated with some severe side effects, endometrial ablation is an alternative when the depth of myometrial penetration is limited, uterine artery embolization has elicited severe complication.,9Adenomyosis is a common benign gynecological disorder affecting premenopausal women. It is characterized by the presence of ectopic endometrial glands and stroma in myometrium and hyperplasia of adjacent smooth muscle.Wedge-shaped resection of uterus removed uterus body and most endometrium, which disposed lesions but preserved the ascending uterus artery, so the function of ovary was not affected. This was the advantage of the procedure for it delayed the occurrence of menopausal syndrome, but the weakness of this procedure was the loss of the productive function, so it was only suitable for multiparous women who had no desire for another child.Wedge-shaped resection of uterus could significantly relieve the symptom of dysmenorrhea and menorrhagia. As shown in the period of follow up, 2 patients had no menstruation and menstruation flow was significantly decreased for the deletion of endometrium. Also, patients who had high menstrual pain score before treatment were free of menstrual pain after surgery. They reported a significant improvement in their quality of life. All the patients had no adverse effect or complication; recurrences were not recorded during the treatment or follow-up period.Our study suggests that clinical improvement in symptomatic adenomyosis is achievable with the wedge-shaped resection of uterus, which may be a promising alternative for patients who suffered from dysmenorrhea and menorrhagia for adenomyosis but still want to preserve the uterus.


In degenerative disc, the innervated outer annulus is confirmed to the major origin resulted in discogenic pain. To alleviate the discogenic pain, annuloplasty with electrothermal technology was proved to be effective, which mainly involves the thermal heating of the annulus to denature collagen fibers and denervate posterior annular nerve fibers. However, little is known that efficacy of annuloplasty with coblation technology in treating discogenic pain through directly interrupting nerves in outer annulus.The purpose of this study was to evaluate the clinical outcomes of coblation annuloplasty for the treatment of discogenic low back pain.In a clinical prospective observational study, 17 consecutive patients with discogenic low back pain underwent coblation annuloplasty under local anesthesia. Pain visual analogue scale (VAS) scores, patient responses stating significant (≥50%) pain relief, and modified MacNab criteria were adopted to evaluate the pain intensity, degree of pain relief, and functional status after 6 months of follow-up.The preoperative pain VAS score was 6.5 ± 0.8 and the pain VAS score decreased to 2.9 ± 1.6 (95% CI 2.1–3.8), 2.9 ± 1.7 (95% CI 2.1–3.8), 3.2 ± 1.6 (95% CI 2.4–4.1), 3.2 ± 1.7 (95% CI 2.4–4.2) at 1 week and 1, 3 and 6 month postoperatively, respectively. 12 (70.6%), 11 (64.7%), 10 (58.8%) and 10 (58.8%) of patients reported significant pain relief at 1 week and 1, 3 and 6 months postoperatively. At 1, 3, and 6 months postoperatively, the numbers of patients with “excellent” or “good” ratings were 13 (76.5%), 11 (64.7%), and 10 (58.8%) according to the modified MacNab criteria. No serious complications were observed.The finds show that coblation annuloplasty is an effective, safe, and less uncomfortable procedure in managing discogenic low back pain. Although discogenic pain may be generated from irritated nerves in annulus or nucleus, the outer annulus was confirmed as the major origin through discography.8In a normal lumbar disc, nerve fibers mainly innervate the periphery of the outer annulus13 The concept of annuloplasty originated from the technique of intradiscal electrothermal therapy (IDET) reported by Saal and Saal in the 2000s, which mainly involves the thermal heating of the annulus to denature collagen fibers and denervate posterior annular nerve fibers.14 And then, in the 2012's review of “effectiveness of thermal annular procedures in treating discogenic low back pain”, the results showed fair evidence for IDET in treating discogenic low back pain.15 However, the technical difficulties and time involved in threading a curved wire around the annulus were the major drawbacks, which limited the application of this procedure.To alleviate discogenic pain, annuloplasty was proved to be effective.18 However, the benefit in treating discogenic pain from nucleoplasty was limited, due to the scope of interruption of nerves maybe hardly reach to the outer annulus. Whereas, rare literatures reported that coblation annuloplasty was performed to manage discogenic pain. Based on its advantages of easer in technical operation, more security in therapeutic temperature and directly interrupting nerves in outer annulus, we hypothesized that coblation annuloplasty can relieve discogenic low back pain secondary to contained disc herniation.Present, coblation nucleoplasty as a minimally invasive procedure using radiofrequency energy to ablate nucleus was performed to alleviate discogenic pain through lowering intradiscal pressure and interrupting ingrown nerve endings along pathologic annular tears.After obtaining the approval of the institution's Ethics Examining Committee of Human Research  and written informed patient consent, 17 patients mainly complained of discogenic low back pain secondary to contained disc herniation scheduled to receive coblation annuloplasty between October 2013 and June 2014 at Xuanwu Hospital.Inclusion criteria for the coblation annuloplasty were as follows: unilateral discogenic low back pain without radicular pain and no neurological deficits, such as sensory or motor deficits or loss of reflexes; the pain VAS ≥ 4; the duration of pain ≥ 3 months; short-term or no treatment response to conservative management, including medication, physical therapy, and fluoroscopically directed injection therapies ; contained disc herniation ≤ 6 mm and not compromising ≥1/3 of the central spinal canal according to magnetic resonance imaging (MRI)—the MRI scans must show an abnormal nucleogram with annular disruption in L4/5, L5/S1, or both and disc height ≥ 50%; a positive one-level provocation discography and fulfillment of criteria for a positive disc with provocation of concordant pain with an intensity of at least 7 of 10.Patients affected by coagulopathy, uncontrolled psychological disorders, disc herniation with sequestration, infection, spinal instability, spinal fractures, tumor, advanced spondylosis resulting in osseous foraminal stenosis, or disc space collapse, as well as those with previous spinal surgery on the same level, were excluded from the study.The procedure was performed in an operating room using sterile technique. The patient was placed in lateral position on the operation table; a 10-cm cushion was placed under the lumbar. The patient received the vital sign monitoring and oxygen supply at 3 L per minute via nasal prong throughout the procedure. Before the procedure, an intravenous injection of etimicin (1.0 g) was administered as a prophylactic antibiotic. Patients received intravenous injection of fentanil (50 μg) and were able to respond if a nerve root was irritated by thermal or mechanical stimulation. All procedures were performed under local anesthesia.Under fluoroscopic guidance with anterior-posterior (AP) and lateral views and the assisted orientation of another metal needle, a 12-gauge, 15-cm cannula was advanced via a left or right posterolatral approach to the posterior margin of outer annulus. Cannula was advanced slowly and the advancement was stopped immediately when there was an increase of resistance signaling entry into the annulus. The resistance was check using loss of resistance with glass syringe. When cannula was advanced to only contact the posterior margin of outer annulus but not into annulus, the resistance was loss. Then, cannula was advanced into annulus slightly until the resistance occurred. A paresthesia may be elicited if the exiting nerve root was contacted. The cannula position was adjusted until the parethesia disappeared. During the process of cannula advancement, the cannula position should be check under the AP and lateral views, and the final position should be in the posterior outer layer of annulus, as shown in Figure The coblation wand  Co. Ltd, China) was inserted into the cannula and advanced slightly into the annulus. The position of the tip of wand was check again under AP and lateral views Figure . The maxClinical improvement of pain after coblation annuloplasty was qualified with a pain VAS score recorded preoperatively and at 1 week and 1, 3, and 6 months postoperatively. Significant pain relief (postoperative pain relief ≥50% compared with the preoperative state) was recorded at 1 week and 1, 3, and 6 months postoperatively. Patient's functional status was assessed with “excellent,” “good,” “fair,” and “poor” according to the modified MacNab criteria and recorded at 1, 3, and 6 months postoperatively. Complications, such as hemorrhages, paresthesia, and infection, were recorded.P < 0.05 was considered statistically significant in all analyses. Statistical analyses were performed using GraphPad Prism version 5.0 .The patients’ demographic and baseline clinical data were analyzed descriptively. Repeated measures analysis of variance (ANOVA: a parametric test) was used to compare the improvement in pain VAS scores between the preoperative and postoperative time points. The Wilcoxon signed-rank test was used to evaluate the amount of significant pain relief and the functional status of patients after 6 months of follow-up. A value of A total of 17 patients with discogenic low back pain undergone coblation annuloplasty, 11 males and 6 females. The mean pain VAS score was 6.5 ± 0.8 (range 5–8), mean age was 52 ± 7 year-old (range 36–63 year-old), and average duration of pain was 5 ± 3 years (range 0.5–12 years) , and the L5/S1 disc level in 6 cases (35.3%)  and the pain VAS score decreased to 2.9 ± 1.6 (95% CI 2.1–3.8), 2.9 ± 1.7 (95% CI 2.1–3.8), 3.2 ± 1.6 (95% CI 2.4–4.1), 3.2 ± 1.7 (95% CI 2.4–4.2) at 1 week and 1, 3, and 6 month postoperatively, respectively , 11 64.7%) and 10 (58.8%); the numbers of patients with “fair” ratings were 2 (11.8%), 3 (17.6%) and 3 (17.6%); and the numbers of patients with “poor” ratings were 2 (11.8%), 3 (17.6%), and 4 (23.5%) ; 4 patients were observed to 7 months postoperatively: significant pain relief was reported in 2 patients (1 patient with low back pain only and 1 patient with low back and buttock pain preoperatively), 20–30% of pain relief was reported in 1 patient with low back, buttock and thigh pain preoperatively and 30–40% of pain relief was reported in 1 patient with low back and buttock pain preoperatively; 4 patients were observed to 6 months postoperatively: significant pain relief was found in 2 patients , and 30% to 40% of pain relief was reported in 1 patient with low back pain only preoperatively and 20% to 30% of pain relief was found in 1 patient with low back, buttock and thigh pain preoperatively.Among 17 patients, 2 patients experienced ecchymoma and 5 patients reported soreness at the needle insertion site, but the symptoms completely disappeared within two weeks after operation. No hemorrhages, paresthesia, or infection were observed.In this study, >50% of patients expressed significant pain relief and “excellent” or “good” according to the modified MacNab criteria after 6 months follow-up. Remarkable reduction in discogenic low back pain and significant improvement in functional status were demonstrated after coblation annuloplasty.18Coblation technology is applied through a PERC-D wand, which has 1 mm diameter and is a bipolar instrument design. Through the wand, coblation technology can provide a therapeutic effect with two modes: coblation and coagulation. During coblation process, the tissue molecular bonds are breakup into various elementary molecular and low molecular weight gases with a highly focused plasma field, which is generated around the tip of wand in conductive medium with radiofrequency energy and creates small channel in tissues. During coagulation process, the adjacent tissue are thermally sealed, including shrinkage of collages. The advantage of ablation technology is replacing the thermally damaging vaporization with molecular dissociation at a low temperature ablative process (40–70°C).23 However, the efficacy data of nucleoplasty for lumbar discogenic pain was rare.25In 1999, the coblation technology was approved for use in spine by US Food and Drug Administration, and the coblation nucleoplasty was first performed in 2000. Later, the efficacy data of cobation nucleopalsty in treating contained disc herniation with associated symptoms were reported by a series of clinical studies.24 published the clinical outcomes of coblation nucleoplasty in treating 47 patients with discogenic low back pain. The proportion of patients who reported ≥ 50% pain relief was 80%, 74% 63% and 53% at the 1, 3, 6 and 12 months follow-up, respectively. And the functional improvements were reported by 46% of patients for sitting ability, 41% for standing ability, and 49% for walking ability at postoperative 12 month. To 2013, Kumar et al25 again published the therapeutic role of nucleoplasty in the management of discogenic axial back pain on 30 patients. The clinical outcomes showed that significant pain relief (VAS decrease ≥ 30%) was 53.30% and 60%, significant reduction in the functional disability (Oswestry Disability Index (ODI) decrease ≥ 12.8%) was 93.30% and 80%, significant improvement in quality of life (ShortForm-36 [SF-36] increase ≥ 5%) was 96.7% and 83.30% at 6 and 12 month postoperatively.In 2004, Singh et al27 because of decompression of nerve root through removing nucleus material, decreasing nucleus volume and lowering intradiscal pressure.29 In contrast, the benefit of coblation nucleoplasty in treating discogenic low back pain is uncertain, because the scope of interruption of nerves hardly reached to the outer annulus, which was considered as the major origin of discogenic pain.8However, more proponents and clinical evidence supported nucleoplasty for individual with lumbar radicular pain,14 In previous studies of IDET, the pain VAS score obviously decreased from mean 6.1–7.4 preoperatively to 1.7–3 at 6 month postoperatively,13 which consistent with the results of our study, the pain VAS score significantly decreased from pre-operative 6.5 to 3.2 at 6 month postoperatively. In this study, the functional status was evaluated with the modified MacNab criteria, which was different from other study of IDET with ODI and SF-36 questionnaires,11 but similar clinical outcomes were proved. Although rare efficacy data of coblation annuloplasty was published, the initial clinical evidence supported that coblation annuloplasty appeared to be an alternative to IDET for treatment of discogenic low back pain was provided in our study.In this study, the therapeutic purpose of coblation annuloplasty is similar with IDET, which is to denature collagen fibers and denervate posterior annular nerve fibers.17, which is technical deficiency compared with IDET. However, interesting, among 5 patients with no concordant reproduced pain, 20% to 30% of pain relief was observed in 1 patient and over 50% of pain relief in 2 patients. The possible explanation is that lowering the tension in the outer annulus is benefit for decompression of nerves innervated the outer annulus.29 Additionally, the modification of biochemical state to inhibit inflammatory stimulation to nerves innervated the outer annulus maybe play one therapeutic role in treating discogenic pain.30During coblation annuloplasty process of this study, complete, part and no concordant pain was reproduced in 5, 7 and 5 patients, respectively. For the phenomenon of part concordant reproduced pain, the possible explanation is that the scope of interruption of nerves maybe only locate along access path of the tip of wand31 No complications, such as hemorrhages, paresthesias, or infections, were observed in this study.In our study, 2 patients experienced ecchymoma and 5 patients reported soreness at the needle insertion site, which has been reported as the most common side effect in coblation technology; however, the symptoms completely disappeared in two weeks after operation.18 A thermal mapping study in the porcine model confirms a steep temperature drop off from the tip of wand. When the distance from the tip of wand is 1 mm and 5 mm, the temperature decreased to ≤20°C and 0°C, respectively.32 Additionally, the radius of the thermal zone of coagulation is approximately 1 mm when the wand is moved 0.5 cm/sec.33 Therefore, the security in temperature is the most important advantages in coblation technology. During the whole annuloplasty process, the patients were under light sedation and maintain protective reflexes in order to report immediately possibly nerve injury in our study.The limitation of this study is lack of control group, historic or placebo. Conducting a blind, randomized, placebo-control study may be prohibitively expensive and logistically difficult in a practice setting. The technique of coblation annuloplasty is maybe criticized in our study, because of the potential nerve injury due to the tip of wand placed on periphery of outer annulus, which is closed to traversing or exiting nerve root. However, different from other thermal annular therapies, coblation technology is a nonheat driven process.Although the annulus as the target tissue to be treated with coblation technique in our study, the nucleus was irrelevantly be dealt in some cases during surgical process. But, we adopted the phrase “cobaltion annuluplasty” as being more accurately descriptive of the procedure.Coblation annuloplasty is an effective, safe, minimally invasive and less uncomfortable procedure for treatment of discogenic low back pain.