Search

Computed tomography (CTA)-derived fractional flow reserve (FFR CT ) guides the need for invasive coronary angiography (ICA). Late outcomes after FFR CT are reported in stable ischemic heart disease but not in acute chest pain in the emergency department (ACP-ED). The objectives are to assess the risk of death, myocardial infarction (MI), revascularization, and ICA after FFR CT . From 2015 to 2018, 389 low-risk patients with ACP-ED (negative biomarkers, no electrocardiographic ischemia) underwent CTA and FFR CT and were entered into a prospective institutional registry; patients were followed up for 41 ± 10 months. CTA stenosis ≥50% was present in 81% of the patients. Positive (FFR CT ≤0.80) and negative FFR CT were observed in 124 (32%) and 265 patients (68%), respectively. ICA was performed in 108 of 124 patients (87%) with positive FFR CT and 89 of 265 patients (34%) with negative FFR CT (p <0.00001). Revascularization was performed in 87 of 124 (70%) patients with positive FFR CT and in 22 of 265 (8%) with negative FFR CT (p <0.00001). Appropriateness of revascularization was established by blinded adjudication of ICA and invasive FFR using practice guidelines; revascularization was appropriate in 81 of 124 (65%) and 6 of 265 (2%) of FFR CT -positive and -negative patients, respectively (p <0.00001). At follow-up, for patients with positive versus negative FFR CT , the rates were 0.8% versus 0% for death (p = 0.32) and 1.6% versus 0.4% for MI (p = 0.24). In conclusion, in low-risk patients with ACP-ED who underwent CTA and FFR CT , the risk of late death (0.2%) and MI (0.7%) are low. Negative FFR CT is associated with excellent long-term prognosis, and positive FFR CT predicts obstructive disease requiring revascularization. FFR CT can safely triage patients with ACP-ED and reduce unnecessary ICA and revascularization., Competing Interests: Declaration of competing interest Dr. Fonte is an employee of HeartFlow, Inc. and owns equity or stocks. The remaining authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To investigate the risk factors of acute pain after laparoscopic radical resection of colorectal cancer (CRC) in elderly patients., Methods: Totally, 143 elderly patients (≥ 60 y old) who received laparoscopic radical resection of CRC in the People's Hospital of Xinjiang Uygur Autonomous Region from March 2021 to August 2022 were retrospectively analyzed. The patients were divided into 2 groups according to visual analog scale (VAS) scores 24 h after surgery: mild pain group (VAS score ≤ 3, n=108) and moderate to severe pain group (VAS score >3, n=35). The data of the patients, including sex, age, height, body mass, intraoperative blood loss, intraoperative urine volume, intraoperative opioid dosage, operation duration, preoperative Hospital Anxiety and Depression Scale (HADS) scores, preoperative Mini-Mental State Examination scores, VAS scores, postoperative nausea and vomiting scores were recorded. Multivariate logistic regression analysis was used to screen the risk factors of postoperative acute pain in elderly patients undergoing laparoscopic radical resection of CRC., Results: The preoperative HADS score of the moderate to severe pain group was significantly increased compared with that of the mild pain group (10.8±2.4 vs. 6.2±1.9), as well as the operation duration (226.4±18.3 vs. 186.1±12.7), the intraoperative dosage of remifentanil (3.7±0.2 vs. 3.2±0.4), the preoperative VAS score [4(2, 7) vs. 2 (0, 4)] and postoperative VAS score [5 (4, 6) vs. 3 (2, 3)] ( P <0.05). Multivariate logistic regression analysis showed that high preoperative HADS score, long operation duration, and high preoperative VAS score ( P <0.05) were independent risk factors for acute pain after laparoscopic radical resection of CRC in elderly patients., Conclusion: Preoperative anxiety and depression, preoperative pain, and long operation duration are risk factors for acute pain in elderly patients after laparoscopic radical resection of CRC., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Comparison of acute pain syndrome after septoplasty, rhinoplasty, and rhinoseptoplasty was carried out. It is shown that the intensity of acute pain is higher in patients after rhinoseptoplasty in the first 3-6 h after surgery., (© 2023. Pleiades Publishing, Ltd.)

Background: Inguinal hernia is a common condition; however, irreducible inguinal hernias are rare. In this retrospective study, two laparoscopic procedures for irreducible inguinal hernia were compared., Materials and Methods: The study cohort comprised 88 patients who had undergone laparoscopic repair of primary irreducible inguinal hernias between 1 June 2011 and 31 December 2019. The patients were retrospectively divided into Hybrid (Group H) and Standard Transabdominal Preperitoneal (TAPP) Groups (Group S). Patient characteristics, hernia details, and intraoperative and postoperative complications were compared between study groups., Results: There were no significant differences between the two groups in baseline characteristics, including age, sex, body mass index, hernia type, operation time, hospital stay, cost, and duration of follow-up. No recurrence or surgical site infection occurred in either group. There were no significant differences between the two groups in incidence of spermatic vessel injury (0% vs. 2.04%, P = 0.370), vas deferens injury (0% vs. 6.12%, P = 0.116), epigastric vessels injury (0% vs. 4.08%, P = 0.202), scrotal hematoma (7.69% vs. 2.04%, P = 0.206), dysuria (5.13% vs. 8.16%, P = 0.575), fever (17.95% vs. 16.32%, P = 0.841), seroma (25.64% vs. 32.65%, P = 0.474), chronic pain (0% vs. 2.04%, P = 0.370), sensation of a foreign body (2.56% vs. 2.04%, P = 0.870), or pain on ejaculation (0% vs. 2.04%, P = 0.370). The incidence of acute pain was higher in Group H than in Group S (43.59% vs. 8.16%, P = 0.000)., Conclusion: The hybrid TAPP procedure is a safe and feasible means of treating irreducible inguinal hernias. Though it is associated with a higher incidence of postoperative acute pain than the standard TAPP procedure, it may have advantages in avoiding injuries to the vas deferens and spermatic vessels., Competing Interests: Declaration of competing interest Drs. Yuchen Liu,Hongming Zhang, Jinxin Cao, Yilin Zhu, Shuo Yang, Zhenyu Zou, Jie Chen, Minggang Wang have no conflicts of interest or financial ties to disclose., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Purpose: We conducted this study to investigate the efficacy, safety, and clinical value of postoperative compression in preventing seroma formation, relieving acute pain, and improving QoL after groin hernia repair., Methods: This multi-center, prospective, observational real-world study was conducted from March 1, 2022, to August 31, 2022. The study was completed in 53 hospitals in 25 provinces in China. A total of 497 patients who underwent groin hernia repair were enrolled. All patients used a compression device to compress the operative region after surgery. The primary outcome was seroma incidence 1 month after surgery. Secondary outcomes included postoperative acute pain and QoL., Results: A total of 497 patients [median (IQR) age 55 (41-67) years, 456 (91.8%) male] were enrolled, of whom 454 underwent laparoscopic groin hernia repair and 43 open hernia repair. The follow-up rate was 98.4% 1 month after surgery. Seroma incidence was 7.2% (35 of 489 patients) overall, lower than reported by previous research. No significant differences were found between the two groups (P > 0.05). VAS scores after compression were significantly lower than before compression overall and in both groups (P < 0.001). The laparoscopic group showed a high level of QoL compared with the open group, but there was no significant difference between the two groups (P > 0.05). CCS score correlated positively with VAS score., Conclusion: Postoperative compression, to a certain extent, can reduce seroma incidence, relieve postoperative acute pain, and improve QoL after groin hernia repair. Further large-scale randomized controlled studies are warranted to determine long-term outcomes., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: Laparoscopic inguinal hernia repair has significantly reduced the incidence of postoperative acute and chronic pain compared to open repair, but it remains problematic. This study's purpose was to retrospectively identify predictive factors of acute pain after laparoscopic inguinal hernia repair., Methods: We reviewed the medical records of 193 patients. After excluding atypical cases and female patients, 156 patients were analysed. Factors affecting rescue analgesic requirements were investigated via multivariable logistic regression analysis. Independent variables included age, body mass index, analgesics used during surgery and surgical factors (unilateral/bilateral, primary/recurrent). The degree of postoperative pain and the hospital stay duration after surgery were also investigated., Results: Of the 156 patients, 40 (25.6%) required rescue analgesics. Patients under 60 years of age were about seven times more likely to need rescue analgesics than patients over 80 years of age. Primary surgery patients were about 5.5 times more likely to need rescue analgesics than recurrent surgery patients. The maximum verbal rating scale score was less than 3 in 89% of patients. All patients were discharged by two days postoperatively., Conclusion: Laparoscopic inguinal hernia repair results in less postoperative acute pain. However, analgesia management should be considered prudently for younger patients and primary surgery patients.

Photorefractive keratectomy (PRK) is an alternative to LASIK and can cause intense acute pain that is often not relieved by standard treatments. To assess potential therapeutics for this type of acute pain, appropriate preclinical models are needed. We describe a preclinical corneal abrasion rat model that simulates the initial stages of PRK surgery and demonstrates similar pain and tear dysfunction as seen clinically. We used both behavioral and homeostatic assays to determine the therapeutic potential of resveratrol on pain and tear production. Studies were conducted in male and female Sprague-Dawley rats. Heptanol was applied to one eye and the superficial corneal epithelium was removed, mimicking the abrasion used in PRK. Spontaneous pain was assessed with orbital tightening (OT) scores for 7 days. Topical resveratrol increased OT scores sex-specifically in abraded males, but not females, at 72 h and 1 week after abrasion. Resveratrol increased tear production in abraded males, with no effect in abraded females. There was no correlation between OT score at 1 week and tear production measurements, demonstrating no relationship between spontaneous ocular pain and tear dysfunction in this model. These findings demonstrate the usefulness of our corneal abrasion preclinical PRK model for the assessment of ocular pain therapeutics and indicate that topical resveratrol may not be useful for managing PRK-induced pain., Competing Interests: Declaration of competing interest D.M. Hegarty, None; J.R. Carroll, None; D. Nguyen, None; V.S. Halls, None; D.I. Robbins, Ted's Brain Science (O); T.J. Price, Ted's Brain Science (O); G. Dussor, Ted's Brain Science (O); S.A. Aicher, None. Ted's Brain Science is a company developing resveratrol-based therapeutics for pain., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy., Methods: A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints., Results: A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001)., Conclusions: This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results., (© 2022. The Author(s).)

Purpose: The aim of this study was to identify preoperative predictors for the occurrence of early severe postoperative pain in patients undergoing photorefractive keratectomy (PRK). The implementation of preoperative screening methods may facilitate more specific or aggressive pain therapies specifically targeted to individuals at a high risk of experiencing severe postoperative pain., Methods: This was exploratory research that included patients who underwent PRK. Before PRK, patients were administered a sociodemographic questionnaire, the Pain Catastrophizing Scale, and the State-Trait Anxiety Inventory and underwent corneal sensitivity and conditioned pain modulation (CPM) tests. Post-PRK pain was assessed using a pain intensity visual analog scale (VAS), and the short-form McGill Pain Questionnaire (SF-MPQ) was completed 21 days before PRK and 1, 24, 48, and 72 hours after PRK. Spearman correlations were calculated for pain scores and preoperative predictors., Results: This research included 34 eyes of 34 patients. Preoperative corneal sensitivity was positively correlated with post-PRK pain scores as assessed by VAS and SF-MPQ (rho = 0.39 and rho = 0.41, respectively, P < 0.05). No correlations were found between Pain Catastrophizing Scale, State-Trait Anxiety Inventory, and CPM scores and post-PRK pain scores ( P > 0.05)., Conclusions: Abnormal presurgical corneal sensitivity was a protective marker for severe pain after PRK, while scores as assessed by VAS and SF-MPQ and CPM were not related to postoperative pain., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Severe acute pain after total knee arthroplasty (TKA) may cause delay in muscle strength and functional recovery, and it is a risk factor for chronic postoperative pain. Although pharmacological approaches are the typical firstline to treat acute pain; recently, nonpharmacological approaches such as exercise have been increasingly applied. The purpose of this investigation was to evaluate the effects of a rehabilitation program involving isometric quadriceps exercise with auditory and visual feedback to improve the short-term outcome after TKA. Sixty-two patients, planning a primary unilateral TKA, were randomly assigned to either an intervention group ( n  = 31) involving isometric quadriceps exercise with auditory and visual feedback in usual rehabilitation after TKA or a control group ( n  = 31) involving a standardized program for TKA. Patients in the intervention group performed the isometric quadriceps muscle exercise using the Quadriceps Training Machine from 2 to 14 days after TKA instead of the traditional quadriceps sets. Pain intensity, isometric knee extension strength, range of motion, timed up and go test (TUG), 10-m gait speed, 6-minute walking distance, the Western Ontario and McMaster University Osteoarthritis index (WOMAC), the hospital anxiety and depression scale, and the pain catastrophizing scale were assessed before TKA (baseline) and 1 to 3 weeks after TKA. Pain intensity significantly decreased in the intervention group than in the control group at 1 ( p  = 0.005), 2 ( p  = 0.002), and 3 ( p  = 0.010) weeks after TKA. Greater improvements in TUG ( p  = 0.036), 10-m gait speed ( p  = 0.047), WOMAC total score ( p  = 0.017), pain ( p  = 0.010), and function ( p  = 0.028) 3 weeks after TKA were observed in the intervention group. These results suggest that isometric quadriceps exercises with auditory and visual feedback provided early knee pain relief, possibly leading to better improvements in physical performance, and patient's perception of physical function in the early stages of postoperative TKA. Further studies should investigate whether this short-term effect is sustainable., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Pain has become an important factor in evaluating patients' quality of life and clinical treatment. For gastric cancer (GC) patients, open radical gastrectomy (OG) causes significant trauma to the body, increases patients' pain after operation, and delays early recovery. The aim of this study was to investigate the predictive factors of acute pain after OG within postoperative 72 h., Methods: From March 2020 to September 2021, 307 patients who underwent OG were included in the study in Nanjing Drum Tower Hospital. The predictors included demographic predictors, pathological data, surgical predictors, and intraoperative predictors. The pain scores at 12, 24, 48, and 72 h after operation were evaluated by numeric rating scale (NRS). The predictors of acute pain were determined by univariate and multivariate analysis., Results: The average pain score (NRS) of patients showed a downward trend over time within 72 h after OG. Multivariate analysis indicated that total gastrectomy (OR 1.823, 95% CI 1.094-3.040, P < 0.05), AJCC TNM stage (II) (OR.232, 95% CI 0.062-0.872, P < 0.05), AJCC TNM stage(III) (OR.185, 95% CI 0.049-0.698, P < 0.05), BMI (kg/m 2 ) (OR 1.75, 95% CI 1.029-2.976, P < 0.05), distant metastasis (OR 3.054, 95% CI 1.019-9.155, P < 0.05), intraoperative transfusion (OR 2.246, 95% CI 1.267-3.982, P < 0.01) were significant predictive factors for acute pain after OG., Conclusion: Reasonable postoperative acute pain control was the prerequisite for accelerating the postoperative rehabilitation of patients. In order to reduce the occurrence of excessive or insufficient analgesia, it was necessary for patients who underwent OG to formulate appropriate analgesics according to risk factors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Xie, Wei, Ma and Ge.)

Background: Although percutaneous vertebroplasty (PVP) can effectively relieve the pain for patients with acute osteoporotic vertebral compression fractures (OVCFs), many patients still complain of mild back pain in the early postoperative period., Objectives: The aim of this study was to assess the effect of early limited activity (LA) on prognosis after bipedicular small-cement-volume (i.e., PVP) to treat single-segment acute OVCFs., Study Design: A prospective study and retrospective observations were performed on 125 patients with a minimum of 1 year of follow-up., Setting: A university hospital orthopedics and pathology departments., Methods: All patients were allocated into an LA group (n = 64) and an unlimited activity group (ULA group, n = 61). Patients in the LA group were suggested to keep time of off-bed activity < 4 hours per day in the first 3 weeks postoperatively. Patients in the ULA group did not limit activity. The demographic, clinical, and radiologic outcomes were assessed, such as pain intensity Numeric Rating Scale (NRS-11) and vertebral height ratio (i.e., fractured vertebral height/adjacent nonfractured vertebral height). Based on outcomes following surgery, all patients were classified as responders (NRS-11 score 1-day postoperation < 50% of preoperative NRS-11 score) or low responders (NRS-11 score 1-day postoperation >= 50% of preoperative NRS-11 score)., Results: The demographic results and complications were similar. In the LA group, NRS-11 scores at 1 and 3 months postoperation respectively were 2.23 ± 0.42 and 1.46 ± 0.40, and corresponding scores respectively were 2.85 ± 0.80 and 1.73 ± 0.77 in the ULA group, and there was a difference in the 2 groups in both time points (P < 0.05). At 12 months postoperation, anterior and middle vertebral height ratio respectively were 78.42% ± 3.52% and 82.37% ± 3.49% in the LA group, which were higher than 76.87% ± 3.68% and 81.10% ± 3.31% in the ULA group (P < 0.05). Thirty-two cases were low responders. Among those, NRS-11 scores at 1 and 3 months postoperation respectively were 2.29 ± 0.45 and 1.53 ± 0.46 in the LA group, which were lower than 3.67 ± 0.80 and 2.56 ± 0.79 in the ULA group (P < 0.05), and at 12 months postoperation, anterior vertebral height ratio was 79.81% ± 3.25% in the LA group and 75.60% ± 3.50% in the ULA group (P < 0.05)., Limitations: First, some patients lacked the results of bone mineral density during follow-up; second, the limited time in our study was chosen from our previous working experience, which may lack an objective basis; third, NRS-11 is solely used as an indicator of clinical outcomes in our study; finally, our next studies can increase the sample size to improve the clinically difference., Conclusions: LA in the early period after PVP can help patients achieve more pain relief postoperatively and maintain better vertebral shape, especially for low responders., Key Words: Osteoporotic vertebral compression fractures, percutaneous vertebroplasty, Numeric Rating Scale, vertebral height, responders, low responders, limited activity, complications.

A 55-year-old woman presented at the Emergency Department with flank pain. She was pale, hemodynamically unstable, and had a palpable mass in her right flank. CTA of the abdomen revealed a bleeding from an angiomyolipoma of the right kidney, which was successfully treated by selective coiling of the supplying renal artery.

Background: We conducted a cohort study of adult patients presenting for orthopaedic trauma surgery at a statewide trauma centre, with the aims of determining (i) the incidence and risk factors for severe acute pain in the PACU, and (ii) the incidence and risk factors for persistent post-surgical pain at 3 months., Methods: Data were collected before operation, in the PACU, 72 h after surgery and 3 months after surgery, and included numerical rating scale (NRS) scores for pain, and modified Brief Pain Inventory-Short Form, Kessler Psychological Distress Scale, World Health Organization Disability Assessment Schedule, and Pain Catastrophizing Scale scores., Results: Severe acute pain in the PACU was reported by 171 (56%; 95% confidence interval [CI]: 51%, 62%) of the 303 included patients. Female sex (odds ratio [OR]: 1.86; 95% CI: 1.06, 3.26) and prior post-injury surgery (OR: 2.21; 95% CI: 1.11, 4.41) remained associated with severe acute pain after multivariable adjustment. Persistent post-surgical pain at 3 months was reported by 149 (65%; 95% CI: 59%, 71%) of the 229 included patients. The preoperative NRS score (OR: 1.17; 95% CI: 1.03, 1.32) remained associated with persistent pain after multivariable adjustment., Conclusions: We identified three easy-to-measure risk factors: female sex, prior post-injury surgery for severe acute pain, and preoperative NRS scores for persistent pain. Further research is required to identify pain management strategies and psychosocial interventions to reduce the burden of pain, disability, and distress in these patients., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: When a woman with an endometrioma presents with acute abdominal pain, it is unclear whether ovarian torsion should be suspected., Objectives: To compare patient characteristics, imaging results, and surgical management of endometriomas in elective versus emergent surgeries., Methods: This retrospective cohort study included women treated at our institution during the period 1990-2015 who presented with histologically verified endometrioma and who underwent either planned surgery or emergent surgery due to suspected adnexal torsion., Results: Of 225 surgeries performed, 174 were elective and 51 emergent. Patients in the emergent group were significantly younger (33.9 ± 11.1 vs. 39.01 ± 10.9 years, P = 0.004). Abdominal pain was the main complaint of all the emergent surgery patients and the leading complaint in 21% of the elective surgery patients (P < 0.001), with right-sided predominance in both groups. Sonographic parameters were similar in both groups. Bilateral ovarian cysts were noted in 11.7% and 11.0% of emergent and elective patients, respectively (P = 0.87). Laboratory evaluation was notable for a higher white blood cell count and CA125 levels among emergent patients. All patients in the emergent group and 93% of patients in the elective group were managed laparoscopically. No cases of torsion were noted. The rate of intra-pelvic adhesions was similar in both groups (56.8% vs. 66.6%, P = 0.19)., Conclusions: Endometrioma may present with acute abdominal pain. However, adnexal torsion in these patients is rare. These cases can be managed using a minimally invasive approach, assuming an optimal surgical setting.

Background: Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia., Methods: This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy., Results: A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P < 0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P < 0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P < 0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P < 0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P < 0.001). There was a decline in policy adherence in the later cohort., Conclusion: Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement., (© 2018 Royal Australasian College of Surgeons.)

Introduction: Methods to improve clinical systems safety suffer from significant difficulties in implementation and scaling up. We used an upscaling implementation strategy entitled Supported Champions in a quality and safety improvement programme for emergency surgery at regional level, focusing on patients with right iliac fossa pain., Methods: A before-after study was conducted across four acute NHS Trusts: A 6 month intervention phase was preceded and followed by 3 months of data collection. An established Human Factors intervention was led at each Trust by a small group of staff selected as Champions. Champions received training in teamwork and systems improvement and were supported by Human Factors experts. The primary improvement aim was to expedite surgery for patients with sepsis, using Royal College of Surgeons emergency surgery guidelines as the measure. Additional outcomes studied included length of inpatient stay and 30-day readmission rates., Results: Breaches of RCS urgency guidelines decreased markedly from 13.7% of operated patients pre-intervention to 3.5% post-intervention (p = 0.000). Mean time from booking to incision decreased in three of the four sites, whilst median length of stay increased in 3 of 4. Overall 30-day readmission rate remained stable (7.84% pre-intervention versus 7.31% post-intervention, p = 0.959)., Discussion: The Supported Champions model allowed all surgical teams to reduce delay for septic patients by more than 50%, using distinct Quality Improvement strategies to address local issues. Improvement was implemented in 4 diverse settings with a quarter of the level of expert input previously used in a single hospital., (Copyright © 2018. Published by Elsevier Ltd.)

Background: Acute scrotal pain has various causes. Testicular torsion, torsion of appendages and Epididymo-orchitis are common causes, while varicocele thromboses are a rare cause. Varicocele thromboses can occur post operatively or spontaneously. Five cases of post-operative and five cases of spontaneous thromboses have been described till date. The traditional advice in the management of thrombosed varicocele has been to manage it conservatively in all patients by drugs and scrotal support with little description of the surgical treatment. Herein, we present an unusual sixth case of spontaneous thromboses of varicocele and discuss its presentation and surgical management. We would also like to highlight the differentiating points between spontaneous thrombosis and post operative in vitro clot formation in the varicoceles, as these two entities can often be confused for each other., Case Presentation: A 68 year-old man presented with excruciating scrotal pain of one week duration. Doppler study of scrotum revealed left varicocele with no evidence of Epididymo-orchitis. He was treated with intravenous antibiotics, analgesics and scrotal elevation. He had no relief and continued to have severe pain. Clinical examination was normal. Patient underwent exploratory surgery on a semi- emergent basis. Exploration revealed normal testis with thrombosed varicoceles. Patient underwent Varicocelectomy. Postoperatively patient had immediate pain relief. Histopathology revealed prominent thrombosed varicocele. A varicocelectomy specimen (done for primary infertility) was used for comparison. The differentiating points between the two entities were noted., Conclusion: Spontaneous thrombosis of varicocele is a rare cause of acute scrotal pain. Pain out of proportion to clinical features is characteristic. Patients not responding to medical therapy may need varicocelectomy. Varicocelectomy may give immediate relief. Histopathology is useful in this disorder.

Objective: To compare the effectiveness, adverse effects, and cost-effectiveness of percutaneous neurolytic celiac plexus block (NCPB) versus traditional medication strategies for the treatment of patients with advanced cancer having severe upper abdominal cancer pain., Methods: This retrospective study included 81 patients with advanced upper abdominal cancer admitted to The Sixth People's Hospital Affiliated to Shanghai Jiaotong University between January 2013 and July 2014. The patients were divided into percutaneous NCPB (treatment) and medication for pain (control) groups. The outcomes were measured in terms of Numeric Rating Scale (NRS) score and Karnofsky Performance Status (KPS) score before treatment and on the 3rd, 7th, 14th, and 28th days posttreatment. The effectiveness and cost-effectiveness of the therapy were assessed using analysis of the health economics., Results: The improvements in NRS score (1.42 ± 1.09 vs 4.03 ± 0.96, P < .01) and KPS score (65.55 ± 9.09 vs 63.03 ± 8.961, P < .01) in the treatment group were significantly superior compared to the control group on the 7th day of treatment, followed by no significant difference between the 2 groups on the 14th and the 28th day of treatment. Health economics evaluation revealed that the medicine-specific costs and total health care costs were significantly reduced in the treatment group compared to the control group ( P < .05), but no significant differences between the 2 groups ( P > .05) were seen in the costs of hospitalization, examinations, and treatment., Conclusion: The percutaneous NCPB method shows promising results and better cost-effectiveness for treating patients with advanced cancer having severe upper abdominal pain.

Purpose of Review: The purpose of this review is to summarize the latest advances in pediatric regional anesthesia with special emphasis on its role in the ambulatory surgical setting., Recent Findings: Undertreated pain in children following ambulatory surgery is not a rare occurrence and it is associated with increased morbidity and significant psychosocial harm. Use of regional anesthesia as part of the anesthetic approach in the ambulatory setting is safe when performed on children under general anesthesia and inclusion of certain adjuncts improves block outcomes. Ultrasonographic visualization during blockade improves safety and prolongs duration. Ambulatory continuous nerve blocks in older children are safe, efficacious, and associated with high patient and caregiver satisfaction rates. In the ever-growing field of pediatric same-day surgery, safe and efficient flow through the perioperative period necessitates use of a multimodal approach, of which regional anesthesia is but one important component. Perioperative complications are minimized with less opioid use, and yet appropriate pain management must be ensured. Pediatric regional anesthesia has been shown to be exceedingly safe under general anesthesia. Findings demonstrate that advances in ultrasound technology have contributed to safer and longer-lasting analgesia. It facilitates the development of new methods by which regional anesthesia can improve postoperative analgesia in children upon discharge and beyond.

Aim: To describe our experience of all patients presenting to a tertiary referral centre over a 5-year time period with acute scrotum and to investigate the role of Doppler ultrasonography (DUS) for investigating this group of patients., Method: A retrospective analysis was performed on all patients presenting to the emergency department (ED) of a level 1 trauma centre with acute scrotum from 2009 to 2014 inclusive. Inclusion criteria included all patients who underwent an investigatory DUS and/or emergency scrotal exploration. Recorded patient demographics included age, presenting symptoms, duration of symptoms and relevant examination findings., Result: Three-hundred and twelve patients were included with a mean age of 15 years (range 1 day-40 years). In total, 106 patients underwent immediate scrotal exploration, and testicular torsion (TT) was found in 30 % (n = 32/106). Two-hundred and twenty-two patients were initially investigated with DUS and 16 (7.2 %) proceeded to scrotal exploration. Of this sub-group, 2/16 presented with a history <24 h and exploration was negative for TT. In comparison, 14/16 presented with a history >24 h, and DUS findings were consistent with TT. No patients with a normal DUS represented to the ED after discharge., Conclusion: DUS may prevent unnecessary scrotal exploration in patients presenting with acute scrotal pain and is useful for diagnosing TT in patients presenting with symptoms >24 h.

Objectives: The aim was to review the pediatric cohort undergoing surgical exploration for acute scrotal pain at our institution and assess the entity of chronic orchalgia post exploration in this cohort., Materials and Methods: A retrospective review of all pediatric patients who underwent surgery for acute scrotal pain at a single institution between 1 January 2001 and 1 January 2012 was conducted., Results: A total of 1084 patients underwent scrotal exploration for acute scrotal pain where the underlying cause could not be clinically ascertained. Causes found at exploratory surgery are shown in the table. Forty-four children (4.1%) re-presented with another episode of acute scrotal pain and underwent re-exploration. A hundred of the 772 children with testicular appendage torsion at initial exploration had unilateral exploration only. Seven (7%) of these re-presented with contralateral appendage torsion. The complication rate of initial scrotal exploration was 5.6% and that of re-exploration was 6.8%. All complications were managed conservatively except for a painful reactive hydrocele that underwent the Jaboulay procedure. Fifteen (1.4%) children in this cohort developed chronic orchalgia. Thirteen (87%) of these had definite pathology found at initial exploration. One of 61 (2%) with postoperative complications (a reactive hydrocele) developed chronic orchalgia. Pediatric chronic pain specialists were consulted for all patients. In 10 of the 15 (67%), significant comorbidities included constipation, anxiety, somatization, hydrocele, dysfunctional voiding, and multiple joint pain. The Jaboulay procedure for reactive hydrocele and re-exploration to pex the testes due to suspected intermittent testicular torsion resolved chronic orchalgia in one patient each., Discussion: Pediatric chronic orchalgia post exploration is uncommon. It has a multifactorial etiology. Comorbidities are common. It is possible that some unexplored patients labeled as chronic orchalgia in the literature may have underlying correctable pathology. Surgically correctable pathology such as intermittent testicular torsion, metachronous testicular appendage torsion, and symptomatic hydrocele or varicocele should be excluded in children with chronic orchalgia. Chronic pain specialists should be consulted and associated comorbidities managed. Prior surgical exploration and testicular fixation in children with chronic orchalgia helped reassure patients and families that there was no underlying surgical cause for the pain and facilitated compliance with chronic pain management., Conclusions: Pediatric chronic orchalgia has a multifactorial etiology and is uncommon after scrotal exploration surgery. Comorbidities are common and must be managed. Surgical exploration helps reassure patients that there is no correctable cause for the pain and facilitates engagement with chronic pain management., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Increased incidence of upper cervical metastases and higher life expectancy resulted in higher operative rates in patients. The purpose of this study was to explore the methods and the clinical outcomes of palliative surgery for cervical spinal metastases.A systematic review of a 15-case series of upper cervical metastases treated with palliative surgery was performed. All cases underwent palliative surgery, including anterior tumor resection and internal fixation in 3 cases, posterior tumor resection and internal fixation in 10 cases, and combined anterior and posterior tumor resection and internal fixation in 2 cases. Patients were followed-up clinically and radiologically after the operation, and visual analog scale (VAS) and activities of daily living scores were calculated. In addition, a literature review was performed and patients with upper cervical spine metastases were analyzed.The mean follow-up period was 12.5 months (range, 3-26 months) in this consecutive case series. The pain was substantially relieved in 93.3% (14/15) of the patients after the operation. The VAS and Japanese Orthopedic Association scores showed improved clinical outcomes, from 7.86 ± 1.72 and 11.13 ± 2.19 preoperatively to 2.13 ± 1.40 and 14.26 ± 3.03 postoperatively, respectively. The mean survival time was 9.5 months (range, 5-26 months). Dural tear occurred in 1 patient. Wound infections, instrumentation failure, and postoperative death were not observed. Among our cases and other cases reported in the literature, 72% of the patients were treated with simple anterior or posterior operation, and only 12% of the patients (3/25) underwent complex combined anterior and posterior operation.Metastatic upper cervical spine disease is not a rare occurrence. Balancing the perspective of patients on palliative surgery concerning the clinical benefits of operation versus its operative risks can assist the decision for surgery.

Objective: There is a limited information about the role of Substance P (SP) in acute pain nociception following surgical stimulation in patients with a chronic inflammatory state not to mention the link between this neuropeptide level changes and intensity of pain. The goal of the research was to find the correlation between SP level changes and acute pain intensity in patients with rheumatoid arthritis undergoing elective orthopedic surgery., Material and Methods: Patients with rheumatoid arthritis (RA) were enrolled in the study. The correlation between acute pain intensity and concentration of SP in serum as well as in drainage fluid from postoperative wound was assessed in patients with RA who underwent Total Knee Replacement (TKA) under spinal anesthesia., Results: In patients with RA a correlation between intensity of acute pain and serum SP was found postoperatively, whereas there was no correlation between intensity of acute pain and concentration of SP in drainage fluid., Conclusions: 1. The correlation between acute pain intensity and SP serum concentration was found postoperatively in patients with RA. 2. The correlation between acute pain intensity and SP concentration in drainage fluid was not found postoperatively in patients with RA.

Acute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four-limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four-limb amputation., (© 2015 World Institute of Pain.)

Background: With increasing human longevity there is increasing prevalence of osteoporosis and of osteoporotic vertebral fractures. Most vertebral fractures do not require medical therapy for pain, but a minority are associated with severe pain and disability. Vertebroplasty has been used increasingly for painful acute osteoporotic fractures. The best available evidence for vertebroplasty is provided by two placebo controlled trials which showed no significant clinical benefit of vertebroplasty over placebo. These were not acute fracture trials with the majority of fractures in both trials being well beyond the acute time frame of 6 weeks. There is evidence from an open label randomized controlled trial of vertebroplasty versus conservative therapy in acute fractures suggesting clinical efficacy in acute vertebral fractures., Methods: This is a blinded trial of Vertebroplasty for Acute Painful Osteoporotic fractURes - the VAPOUR trial. Patients greater than 60 years in age with new severe onset of back pain and osteoporotic vertebral fractures of less than 6 weeks duration will be enrolled. They will be randomized to receive either vertebroplasty or a placebo procedure. Data regarding pain, disability, and quality of life will be collected over a 6-month period. The enrolled patients and the outcome assessors will remain blinded for the duration of the trial., Discussion: The VAPOUR trial will apply similar methodology to the previous blinded trials but in a patient group with exclusively acute fractures and the most severe pain., Trial Registration: ClinicalTrials.gov trial identifier: NCT01482793 registered on 28 November 2011.

The use of opioids for both benign and cancer-related chronic pain has increased exponentially over the last few years. For this reason, increasing numbers of such patients are presenting for surgery. It is known that continuous use of opioids is associated with an increase in postoperative analgesic requirements. This is believed to be mediated by the development of tolerance and opioid-induced hyperalgesia. Patients treated with opioids have special needs in the perioperative setting and it is the anesthesiologist's responsibility to manage these needs optimally. The aim of the present paper is to briefly orient the reader in the management of postoperative pain in patients chronically treated with licit opioids.

We present a rare case of a patient presenting with acute onset knee pain, which was subsequently diagnosed and treated as acute calcific deposition in the lateral collateral ligament. A 51-year-old gentleman presented to the emergency department with acute onset, excruciating, and left knee pain. There was no preceding history of trauma or systemic upset. Examination revealed exquisite tenderness over the lateral aspect of the knee with leg edema and an associated knee effusion. Blood tests showed a raised C-reactive protein. Plain radiographs of the knee showed a poorly defined calcific deposition with a "cloud-like" configuration. Following exclusion of all more threatening causes of symptoms, the patient was diagnosed with acute calcific tendinitis. The patient's pain was unremitting despite intravenous opiates, and he was taken to the operation theater for exploration and removal of the irritant crystal deposition from the lateral fibular collateral ligament resulting in complete resolution of symptoms. Acute calcific deposition in the lateral collateral ligament is a rare condition. There have been very few reports of this in the literature to date, and no reported cases of surgical excision. Calcific deposition can be treated successfully using conservative measures with symptoms settling after 4 to 6 weeks, however operative excision has been shown to be appropriate in specific cases. Acute calcific deposition should be considered in patients with unexplained acute knee pain and swelling, following the exclusion of other more common conditions. We present the first operatively treated case with accompanying radiology images, intraoperative medical photography, and histological slides., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Management and outcomes of pediatric patients with testicular torsion initially presenting as acute abdominal pain were evaluated., Patients and Methods: The case records of 84 children operated on for testicular torsion from January 1999 through May 2012 were retrospectively reviewed. Of the total number of operated patients, 9 presented with abdominal pain but without initial scrotal pain, and only they were included in the study. The diagnosis of testicular torsion was made clinically and confirmed by Doppler ultrasound and scrotal exploration., Results: The most common presenting symptoms were abdominal pain and vomiting. The patient's scrotum and testicles were not examined during the first evaluation in 6 cases, while in 3 cases the testicles were examined during the first physical examination. At surgery, 4 testes were salvaged, while 5 have been lost because of testicular necrosis. The mean duration of symptoms was 4 h in the group of salvaged testes and 39 h in the orchidectomy group. There were no major complications., Conclusion: Testicular torsion should always be included in differential diagnosis when evaluating lower abdominal pain in young males. The external genital organs should be examined in every child or adolescent with acute abdominal pain., (Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Testicular torsion is a well known emergency situation in clinical urology. Usually cases with torsion of the testis, epididimis or Morgagni's hydatid present for operative emergency procedures due to an "acute scrotum". Also Amyand's hernia, anterior wall abscess, tumours of the testis or cholesterol granulomas have been described as mimicking a testicular torsion. We present the first case of thrombosis of an extraspermatic blood vessel as an unusual cause of an acute scrotum in 15-year-old boy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Context: The first publication of the European Association of Urology (EAU) guidelines on Pain Management in Urology dates back to 2003. Since then, these guidelines have been revised several times with the most recent update achieved in 2010., Objective: Given the scope of the full text guidelines, condensing the entire document was no option in this context. This paper presents a summary of the section of pain management in prostate cancer, a topic considered of direct relevance for the practicing urologist., Evidence Acquisition: A multidisciplinary expert panel (urologists, anaesthesiologists, radio-oncologists) compiled this document based on a comprehensive consultation of the literature. Data were identified through a structured search, covering the time frame 2000 through 2010, using Medline and Embase as well as the Cochrane Library of systematic reviews. The scientific papers were weighed by the expert panel and a level of evidence (LE) assigned. Recommendations have been graded as a means to provide transparency between the underlying evidence and the guidance provided. Pain can occur in each stage of prostate cancer. It could be caused by the cancer itself (77%), be related to the cancer treatment (19%) or be unrelated to either (3%). The incidence of pain rises to 90% as patients enter the terminal phase of their illness. The physician's task is to discover and treat the cause of pain and the pain itself, to determine whether or not the underlying cause is treatable, to provide pain relief and palliative care. These tasks more often than not require a multidisciplinary team. Pain management involves mainly pharmacotherapy, including direct anticancer therapy such as androgen deprivation and chemotherapy, as well as analgetics, for instance non-steroidal anti-inflammatory drugs (NSAIDs) or opioids. In case of local impairment due to the cancer or its metastases, primary treatments like surgery, radiotherapy or radionuclides can provide adequate pain relief. In addition, in palliative care, functional, psychosocial and spiritual support are essential components. The EAU guidelines on Pain Management in Urology are available in a number of different formats through the EAU Central Office and the EAU website ( http://www.uroweb.org/guidelines/online-guidelines/ )., Conclusion: The mainstay of pain management in prostate cancer is involvement of and collaboration between experts from a number of disciplines to be able to achieve a complete pain evaluation and to offer the full range of treatment options. Prostate cancer-related pain can, in most cases, be managed effectively, but it requires careful monitoring where a balance should be found between pain relief and potential side effects of treatment and quality of life (QoL).

A 50-year-old male presented with a rare case of hemangioblastoma of cauda equina origin, without clinical signs of von Hippel-Lindau syndrome, manifesting as pain radiating from the back to the left thigh. Magnetic resonance imaging before surgery revealed an intradural spinal tumor at the L3-L4 levels with serpentine flow voids of tortuous and convoluted vessels, which appeared to be continuous with the left L5 nerve root. Surgical removal of the tumor was successfully accomplished via the posterior unilateral approach, and the histological diagnosis was hemangioblastoma. Clinical symptoms resolved dramatically after surgery, although the patient developed mild dysesthesia of the left L5 area early after surgery which was gradually improved late after surgery.