Persistent Localized Pain Research Articles

Angiogenesis of Avascular Necrosis of the Femoral Head: A Classic Treatment Strategy.

Avascular necrosis of the femoral head (ANFH) is a type of osteonecrosis due to the cessation of blood supply, characterized by persistent local pain and collapse of the joint. The etiology of ANFH is multifaceted, and while its precise pathogenesis remains elusive, it is currently widely believed that the femoral head is highly dependent on the vascular system. A large number of studies have shown that vascular injury is the initial factor in the onset of ANFH. In this review, we briefly introduced the process of angiogenesis and the blood supply to the femoral head, with a focus on summarizing the existing research on promoting angiogenesis for the treatment of ANFH. We conclude that providing alternative pathways through angiogenesis to resolve the problem of the obstructed free flow of the blood is an important means of treating ANFH. Moreover, we also looked forward to the mechanism of endothelial metabolism, which has not yet been studied in femoral head necrosis models, providing potential strategies for more effective use of angiogenesis for the treatment of femoral head necrosis.

A 26 years old primigravida woman presented with abdominal cutaneous entrapment syndrome: a case report

BackgroundAbdominal cutaneous nerve entrapment syndrome (ACNES) is characterized by severe, mostly refractory, chronic pain due to the entrapment of the cutaneous branches of the lower torso intercostal nerves at the lateral edge of the rectus abdominis muscle. ACNES is rare compared to other pregnancy-related peripheral neuropathies and is often overlooked as a differential diagnosis for abdominal pain, despite the diagnosis relying primarily on patient history and physical examination. Emergency physicians and other medical personnel’s lack of exposure to such cases results in unnecessary laboratory requests, repeated visits, and increased fear and tension for the patient.Case presentationA 26-year-old primigravida on her second trimester of pregnancy presented to our Emergency department with persistent localized right upper quadrant abdominal pain. Despite repeated visit to the nearby hospital, no diagnosis was settled and the pain persisted. At our ED after a thorough history, physical examination and diagnostic test no abnormality was found. Finally Abdominal cutaneous nerve entrapment syndrome (ACNES) was considered and a mixture of 1 ml 2% lidocaine with adrenaline and 1 ml dexamethasone (4 mg) was infiltrated into the fascial plane in a fanning fashion into the most tender area using a modified technique and the patient reported significant improvement in pain.ConclusionAbdominal cutaneous nerve entrapment syndrome (ACNES) is a cause of abdominal pain in pregnancy that is often overlooked. The objective of this study is to describe a rare case of ACNES in a 26-year-old primigravida woman who presented to a low-resource emergency department to assist patient management.

Management of isolated anterior talofibular ligament lesion in patients suffering from chronic ankle instability: comparison of two minimally invasive surgical techniques.

The aim of the present study was to retrospectively compare the outcomes of two minimally invasive surgical techniques in patients with isolated anterior talofibular ligament (ATFL) lesion suffering from chronic ankle instability (CAI). Thirty-six patients with ATFL lesion suffering from CAI were treated at our department from 2010 to 2017 and retrospectively reviewed after an average time of 4 years (2 to 9 years). Eighteen patients underwent a four-step operative protocol, including: synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and non-weightbearing. Eighteen patients underwent arthroscopic Broström procedure. Patients were assessed pre-operatively and at follow-up with American Orthopedic Foot & Ankle Society Score (AOFAS) scale, Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion, anterior drawer test, and talar tilt test. Wilcoxon test was utilized to compare the pre-operative and follow-up status. The Mann-Whitney U test was used to make comparisons between the two surgical techniques. Statistical significance was established at p < 0.05. Mean overall AOFAS, Karlsson-Peterson and Tegner scores significantly increased at follow-up compared to pre-operatory status (p < 0.05). However, no statistically significant differences concerning mean AOFAS score (90.2 in the four-step group vs. 89.2 in the Broström arthroscopic group), mean Karlsson-Peterson score (88.1 and 85.9 respectively), and median Tegner activity level (6.0 vs. 5.5) were reported between the two groups (p = n.s.). The complications in the arthroscopic four-step treatment group included damage to the superficial branch of the peroneal nerve in one case. The complications in the arthroscopic Broström included nerve injury in one case and persistent local pain nearby suture knot in one case. Both arthroscopic Broström and a four-step operative procedure including synovectomy, debridement of ATFL lesion borders, capsular shrinkage and immobilization, improved functional outcomes in patients with ATFL lesion suffering from CAI.

Clinical and imaging outcomes of cerebrospinal fluid-venous fistula embolization

BackgroundWe report outcomes of spontaneous intracranial hypotension (SIH) patients who underwent transvenous embolization of cerebrospinal fluid-venous fistulas (CSFVFs) confirmed on digital subtraction myelography (DSM) performed at our institution.MethodsThis is a...

New approaches for prevention of complications after Lichtenstein surgery

To describe the new approaches for prevention of complications after hernia repair. We have proposed the method of combined hernia repair including 2 new techniques to prevent complications after Lichtenstein surgery. The results of 100 surgeries over 5 years (2017-2021) for oblique inguinal hernias were analyzed. Patients were divided into 2 groups by 50 patients depending on surgical technique. We assessed the incidence and severity of postoperative complications, as well as duration of inpatient treatment. According to visual-analogue scale of pain syndrome, local pain intensity in the main group was 1.3 times less than in the control group in 1 hour after surgery, after 1 day - almost 2 times less, after 5 days - 1.7 times less. After 3 months, 1 (2%) patient in the control group had persistent local pain. In the main group, no patient had chronic pain (p<0.05). In the control group, ultrasound of postoperative wound area revealed serous fluid in the mesh area in 36 (60%) patients by the 6th day after surgery. In the main group, there were no ultrasound signs of seroma in any case. Incidence of complications was significantly lower in the main group (p<0.05). Mean length of hospital-stay was significantly less in the main group (6.2±1.1 and 7.1±1.2 days, respectively), p<0.05. The proposed new modification of Lichtenstein procedure is an effective method for prevention of the most common postoperative complications.

Head and Neck Langerhans Cell Histiocytosis in Children

Langerhans Cell Histiocytosis (LCH) is a sporadic myeloid neoplasm with proliferation of dendritic cells.1 In the United States, LCH has an estimated annual incidence of approximately 1 per million children.2 Controversy exists regarding management of LCH in head and neck: debridement, chemotherapy, or both. Few reports describe LCH in the OMS literature. The purpose of this study was to present experience with LCH of head and neck in children.This was a retrospective review of children with LCH at Children's Healthcare of Atlanta from 2009 to 2020. A patient was included when he or she: 1) was 18 years old or younger, 2) had LCH in the head and neck, and 3) had complete medical records. Medical records were reviewed for demographic information, lesion characteristics, and clinical presentations. Radiographic images were reviewed for specific findings characteristic of LCH (e.g., osteolytic changes, lymphadenopathy). Treatment regimen (debridement, debridement with chemotherapy, or chemotherapy only) and length of follow-up were recorded. The outcome variable was disease reactivation defined as: 1) a new LCH lesion or 2) an increase in size/recurrence of a lesion after treatment. Data were collected using a standardized collection form. Descriptive statistics were calculated.Overall, 67 patients (42 males) with a mean age of 6.5 years old met inclusion criteria. According to clinical, radiographic, and histological features, there were 3 presentations of LCH in the head and neck: 1) lesions in 1 system without CNS risk (i.e., single system without CNS risk, SS-), 2) lesions in 1 system with CNS risk (i.e., single system with CNS risk, SS+), or 3) multisystem (> 2 systems, MS) presentations. As a group, length of follow-up was on average 3 years (3 months-10.5 years).There were 24 patients (17 males) with an average age of 10 years old (19 months to 18 years) with SS- LCH. Lesions appeared as persistent local swelling (n = 18, 75%) and/or pain (n = 8, 33.3%). Lesions were predominately located in calvaria (n = 15, 62.5%) and mandible (n = 7, 29.2%). Radiographically, most patients had osteolytic changes (n = 18, 78.3%). Patients were treated via debridement (n = 16, 72.7%), chemotherapy (n = 5, 22.7%), or debridement with chemotherapy (n = 2, 9.1%). Three patients (12.5%) experienced reactivation.There were 30 patients (18 males) with an average age of 6 years old (9 month to 15 years) with SS+ LCH. Patients presented with persistent local swelling (n = 21, 70%), recurrent ear infection (n = 5, 16.7%), localized pain (n = 4, 13.3%), or systemic symptoms (n = 2, 6.5%). Radiographic findings were osteolytic changes (n = 24, 77.4%) and/or soft-tissue mass (15, 48.4%). All except 2 patients completed treatment consist of debridement (n = 1, 3.3%), chemotherapy (n = 17, 56.7%), or debridement with chemotherapy (n = 11, 36.7%). One patient (3.3%) who was treated with chemotherapy had disease reactivation.Thirteen patients (9 males) with an average age of 2 years old (1 day to 7 years) had MS LCH. LCH was found in skin (n = 9, 69.2%), lymphatic system (n = 6, 46.2%), and at least 1 bone (range 1-5). In this group, patients presented with extracranial visceral organ involvement on imaging (e.g., hepatosplenomegaly, pulmonary nodules). Patients were treated with chemotherapy (n = 12, 92.3%) or debridement with chemotherapy (n = 1, 7.7%). Six patients (40%) experienced reactivation, and 1 patient passed away during treatment.There are 3 separate categories of LCH in the head and neck. Oral and maxillofacial surgeons who provide care to children would benefit from approaching head and neck LCH based on these categories. A referral to hematology/oncology is necessary for appropriate diagnosis and management.

Low Donor Site Morbidity Associated With Tricortical Calcaneal Bone Graft.

Autologous grafting is widely used in orthopaedic surgery because of its high osteogenic capacity, immunologic compatibility, for the absence of risk of disease transmission, and for not requiring a bone bank. The posterior-superior calcaneal tuberosity is an option for obtaining a cortical and cancellous structural bone. This study aims to describe the operative technique and complications observed at the donor site of the posterior-superior calcaneal tuberosity. Patients who underwent graft harvesting from the posterior-superior calcaneal tuberosity were retrospectively evaluated by pain outcomes, imaging tests, and intra- and postoperative complications. Twenty patients with a median age of 69 years (range 48-77) and follow-up of 16 months (12-26) were assessed. Median postoperative pain at the donor site was 0 (0-6), with 2 patients reporting persistent local pain. No case of Achilles tendon rupture or intra- or postoperative calcaneal fracture were identified. One patient developed a superficial infection that was quickly resolved using oral antibiotic therapy. The posterior-superior calcaneal tuberosity is an alternative source of autologous graft with low donor site morbidity. Level IV, case series.

Quality of Life After Elective Laparoscopic Sigmoidectomy for Symptomatic Uncomplicated Diverticular Disease.

Symptomatic uncomplicated diverticular disease (SUDD) is characterized by abdominal pain and altered bowel function and may affect quality of life. When symptoms are severe and conservative therapy is ineffective, surgical intervention becomes an option. This study aims to investigate quality of life after elective sigmoidectomy for patients affected by SUDD. Retrospective multicenter review of consecutive patients affected by SUDD that underwent elective laparoscopic sigmoidectomy from January 2015 to March 2018. SUDD was defined as the presence of diverticula with persistent localized pain and diarrhea or constipation without macroscopic inflammation. Quality of life was investigated using the Gastrointestinal Quality of Life Index questionnaire at baseline, and at 6 and 12 months after surgery. Readmissions, unplanned clinical examination, mesalazine resumption, and emergency department visit for abdominal symptoms were recorded. Fifty-two patients were included in the analysis. Gastrointestinal Quality of Life Index score at 6 months from surgery did not statistically differ from baseline (96±10.2 vs. 89±11.2; P>0.05), while patients reported a better quality of life at 12 months after surgery (109±8.6; P<0.05). Within the first year of follow-up, 3 patients (5.8%) were readmitted for acute enteritis, 8 patients (15.4%) had emergency room access for abdominal pain, and 8 patients had unplanned outpatients' medical examinations for referred lower abdominal pain and bowel changes. Mesalazine was resumed in 17.3% of patients. Elective laparoscopic sigmoidectomy for SUDD is safe and effective in improving quality of life, although in some cases symptoms may persist.

Surgical treatment of rib fracture nonunion: A single center experience

IntroductionIn contrast to the emerging evidence on the operative treatment of flail chest, there is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe our standardized approach and report the outcome (e.g. patient satisfaction, pain and complications) after surgical treatment of a rib fracture nonunion. MethodsA single centre retrospective cohort study was performed at a level 1 trauma centre. Symptomatic rib nonunion was defined as a severe persistent localized pain associated with the nonunion of one or more rib fractures on a chest CT scan at least 3 months after the initial trauma. Patients after initial operative treatment of rib fractures were excluded. ResultsNineteen patients (11 men, 8 women), with symptomatic nonunions were included. Fourteen patients were referred from other hospitals and 8 patients received treatment from a pain medicine specialist. The mean follow-up was 36 months. No in-hospital complications were observed. In 2 patients, new fractures adjacent to the implant, without new trauma were observed. Furthermore 3 patients requested implant removal with a persistent nonunion in one patient. There was a mean follow-up of 36 months, the majority of patients (n = 13) were satisfied with the results of their surgical treatment and all patients experienced a reduction in the number of complaints. Persisting pain was a common complaint. Three patients reporting severe pain used opioid analgesics on a daily or weekly basis. Only 1 patient needed ongoing treatment by a pain medicine specialist. ConclusionSurgical fixation of symptomatic rib nonunion is a safe and feasible procedure, with a low perioperative complication rate, and might be beneficial in selected symptomatic patients in the future. In our study, although the majority of patients were satisfied and the pain level subjectively decreases, complaints of persistent pain were common.

Risk Factors for the Failure of Spinal Burst Fractures Treated Conservatively According to the Thoracolumbar Injury Classification and Severity Score (TLICS): A Retrospective Cohort Trial.

BackgroundThe management of thoracolumbar (TL) burst fractures is still controversial. The thoracolumbar injury classification and severity score (TLICS) algorithm is now widely used to guide clinical decision making, however, in clinical practice, we come to realize that TLICS also has its limitations for treating patients with total scores less than 4, for which conservative treatment may not be optimal in all cases.PurposeThe aim of this study is to identify several risk factors for the failure of conservative treatment of TL burst fractures according to TLICS algorithm.MethodsFrom June 2008 to December 2013, a cohort of 129 patients with T10-l2 TL burst fractures with a TLISC score ≤3 treated non-operatively were identified and included into this retrospective study. Age, sex, pain intensity, interpedicular distance (IPD), canal compromise, loss of vertebral body height and kyphotic angle (KA) were selected as potential risk factors and compared between the non-operative success group and the non-operative failure group.ResultsOne hundred and four patients successfully completed non-operative treatment, the other 25 patients were converted to surgical treatment because of persistent local back pain or progressive neurological deficits during follow-up. Our results showed that age, visual analogue scale (VAS) score and IPD, KA were significantly different between the two groups. Furthermore, regression analysis indicated that VAS score and IPD could be considered as significant predictors for the failure of conservative treatment.ConclusionThe recommendation of non-operative treatment for TLICS score ≤3 has limitations in some patients, and VAS score and IPD could be considered as risk factors for the failure of conservative treatment. Thus, conservative treatment should be decided with caution in patients with greater VAS scores or IPD. If non-operative management is decided, a close follow-up is necessary.

Analysis of the results of implantation of total hip endoprothesis in severe dysplastic coxarthrosis.

The aim of this study is to affirm the importance of operative treatment of severe dysplastic coxarthrosis through analysis of the results of implantation of total cementless endoprothesis in patients with DDH Crowe types III and IV. This retrospective study involved 28 patients (30 hips) with dysplastic coxarthrosis, in whom an implantation of cementless total hip endoprothesis was performed at the University Clinic for Orthopaedic Surgery in Skopje. In 26 of the patients the involvement was unilateral and in two patients it was bilateral. The inclusion criterion was radiographically proved severe hip dysplasia Crowe types III and IV. Twenty-one of the patients were female and 7 male, and age distribution was in an interval from 30 to 65 years. The ingrowth of the implant was evaluated using the clinical method, native radiographs and radioisotopic examination with Tc99m. The follow-up period lasted 5 years, and the results were evaluated using the Harris hip score system. 19 of the patients presented an excellent result of the operative treatment, there were 8 good results with persistent local pain 6 months postoperatively, in one case a surgical revision and reimplantation of the acetabular cup was performed, while one patient underwent a surgical revision and reimplantation of the femoral stem and in another patient there was nonunion at the place of the subtrochanteric osteotomy. Full weight-bearing without the use of crutches was achieved 3 months postoperatively, and no serious early postoperative complications were registered in our patients. In the majority of cases in whom a total hip replacement with cementless endoprothesis is performed because of dysplastic coxarthrosis, a sufficient primary fixation both of the acetabular and the femoral component is achieved, unless one-third of the acetabular cup is left uncovered with bone stock. The problems of decreased muscle strength and limping are usually solved by means of physical therapy in a time period of 45 months.

Spinal and paraspinal pneumococcal infections—a review

Spinal and paraspinal infections caused by Streptococcus pneumoniae remain a rare event. We present two cases from our institution, discuss the pathophysiology, and present a literature review of an additional 50 cases of spinal pneumococcal infections. Spinal epidural abscess and vertebral osteomyelitis as well as paraspinal abscesses caused by pneumococcus were included in the analysis. As has been reported for spinal infections due to other bacteria, persistent localized back pain with an elevation in inflammatory markers was almost universal. The lumbar spine was the most commonly involved. Pneumococcus was most frequently isolated from material obtained at the site of the infection; blood cultures were a less common source. The majority of patients with neurologic deficits had spinal epidural abscess or phlegmon, and had a higher mortality. Most patients were treated with 6 weeks of parenteral antimicrobials, and surgical intervention was not associated with a mortality benefit.

English

Foreign bodies have always posed a challenge to the surgeons. Foreign bodies seen in urological practice are either self-inserted (1), iatrogenic, traumatic or migrated from other sites. They usually present late with complications and a vague history .It is mostly seen in young adults. Radiological studies aid in the diagnosis. Here we present two such cases .First is a case of a large foreign body, inserted in vagina presented as a large bladder stone, protruding into the vagina with vesico-vaginal fistula. Second is the case of traumatic insertion of a metallic clip on the shaft of the penis, presenting with urethral stricture and persistent local pain. Both were managed successfully.

The Use of Mitek Bone Anchors for Synthetic Mesh Fixation to Repair Recalcitrant Abdominal Hernias

Repair of recurrent abdominal hernias is a surgical challenge. These patients usually present to the plastic surgeon as a last resort for treatment. Such recalcitrant hernias cause enormous morbidity and constitute a financial burden to any health service. It is important to explore novel and potentially effective repair methods. We report on a technique using overlay prolene mesh fixed to bone by Mitek anchors. All patients who had Mitek bone anchor fixation of synthetic mesh, to repair recurrent iatrogenic abdominal hernias between 2003 and 2010 by one surgeon (C.M.M.), were retrospectively reviewed. The indications, operative details, and clinical outcomes were documented. A total of 7 patients (6 females, 1 male) aged 35 to 60 (average 53) years were included in the study. The causes of herniation were previous surgical incisions (3) and abdominal flap harvests (4). They had had a median of 3 hernia repairs before referral to plastic surgery. The operations lasted for a mean of 6 hours (range, 3-10½ hr). There were no major intra- and postoperative problems although 1 patient requested removal of 2 of his 8 Mitek anchors because of persistent localized pain and tenderness. After a mean follow-up of 24 months (range, 4-34), only 1 patient developed a recurrent lower abdominal bulge. Our single operator series demonstrated that Mitek bone anchor fixation of prosthetic mesh reinforcement of abdominal wall hernia repair is an effective treatment technique associated with a low morbidity. This method of recalcitrant hernia repair may be a useful addition to the armamentarium of the plastic surgeon.

Obstetric and gynecological outcome in a patient with traumatic pelvic fracture and perineal injuries

A 19-year-old woman presented with pelvic trauma following a road accident. She was hemodynamically stable. Examination revealed perineal injuries and type C pelvic fracture, which was stabilized with an external fixator. The broken ends of the pubic bone were brought together by an orthopedic wire. The detached vaginal wall and torn anal sphincter were surgically repaired after making a diverting colostomy. The postoperative period was uneventful. Colostomy was reversed after 3 months. Postoperatively the patient developed a cystocele, dyspareunia and vaginal pain. She conceived spontaneously and was planned for an elective cesarean at 37 weeks gestation; however, she presented in labor at 36 weeks and had a normal vaginal delivery. Pelvic fractures may be associated with genitourinary and anal sphincter injuries, which require management by a multidisciplinary team. On recovery the patient may develop prolapse, dyspareunia and persistent local pain. Spontaneous conception and normal vaginal delivery are nevertheless possible.

Neuromodulators for pain management in rheumatoid arthritis

Pain management is a high priority for patients with rheumatoid arthritis (RA). Despite deficiencies in research data, neuromodulators have gained widespread clinical acceptance as adjuvants in the management of patients with chronic musculoskeletal pain. The aim of this review was to determine the efficacy and safety of neuromodulators in pain management in patients with RA. Neuromodulators included in this review were anticonvulsants (gabapentin, pregabalin, phenytoin, sodium valproate, lamotrigine, carbamazepine, levetiracetam, oxcarbazepine, tiagabine and topiramate), ketamine, bupropion, methylphenidate, nefopam, capsaicin and the cannabinoids. We performed a computer-assisted search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, 4th quarter), MEDLINE (1950 to week 1 November 2010), EMBASE (Week 44, 2010) and PsycINFO (1806 to week 2 November 2010). We also searched the 2008 and 2009 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) conference abstracts and performed a handsearch of reference lists of articles. We included randomised controlled trials which compared any neuromodulator to another therapy (active or placebo, including non-pharmacological therapies) in adult patients with RA that had at least one clinically relevant outcome measure. Two blinded review authors independently extracted data and assessed the risk of bias in the trials. Meta-analyses were used to examine the efficacy of a neuromodulator on pain, depression and function as well as their safety. Four trials with high risk of bias were included in this review. Two trials evaluated oral nefopam (52 participants) and one trial each evaluated topical capsaicin (31 participants) and oromucosal cannabis (58 participants).The pooled analyses identified a significant reduction in pain levels favouring nefopam over placebo (weighted mean difference (WMD) -21.16, 95% CI -35.61 to -6.71; number needed to treat (NNT) 2, 95% CI 1.4 to 9.5) after two weeks. There were insufficient data to assess withdrawals due to adverse events. Nefopam was associated with significantly more adverse events (RR 4.11, 95% CI 1.58 to 10.69; NNTH 9, 95% CI 2 to 367), which were predominantly nausea and sweating.In a mixed population trial, qualitative analysis of patients with RA showed a significantly greater reduction in pain favouring topical capsaicin over placebo at one and two weeks (MD -23.80, 95% CI -44.81 to -2.79; NNT 3, 95% CI 2 to 47; MD -34.40, 95% CI -54.66 to -14.14; NNT 2, 95% CI 1.4 to 6 respectively). No separate safety data were available for patients with RA, however 44% of patients developed burning at the site of application and 2% withdrew because of this.One small, low quality trial assessed oromucosal cannabis against placebo and found a small, significant difference favouring cannabis in the verbal rating score 'pain at present' (MD -0.72, 95% CI -1.31 to -0.13) after five weeks. Patients receiving cannabis were significantly more likely to suffer an adverse event (risk ratio (RR) 1.82, 95% CI 1.10 to 3.00; NNTH 3, 95% CI 3 to 13). These were most commonly dizziness (26%), dry mouth (13%) and light headedness (10%). There is currently weak evidence that oral nefopam, topical capsaicin and oromucosal cannabis are all superior to placebo in reducing pain in patients with RA. However, each agent is associated with a significant side effect profile. The confidence in our estimates is not strong given the difficulties with blinding, the small numbers of participants evaluated and the lack of adverse event data. In some patients, however, even a small degree of pain relief may be considered worthwhile. Until further research is available, given the relatively mild nature of the adverse events, capsaicin could be considered as an add-on therapy for patients with persistent local pain and inadequate response or intolerance to other treatments. Oral nefopam and oromucosal cannabis have more significant side effect profiles however and the potential harms seem to outweigh any modest benefit achieved.

Management of the common European viper’s bite

The common European viper is widespread throughout Europe. In Hungary it can be found mainly in the Zemplén Mountains, on the upper course of the Tisza River, and Zala and Somogy counties. Viper's bite is one of the rarest injuries that requires emergency medical care. The venom contains polypeptides and hydrolytic enzymes which have neurotoxic, cytotoxic, hemolytic and hemorrhagic effects. Local symptoms may include double points, pain, swelling, and suffusion at the site of the bite. Very occasionally, particularly in case of small children and elderly people, viper bite can cause life threatening angioedema, as well as shock and, therefore, professional medical help should always be sought preferably in a hospital that has a toxicology and poison control centre. Authors present the history of a 64-year-old nature enthusiast, who, after having been bitten by a viper, lost consciousness and experienced persistent local redness and pain. Soon after the viper bite, the patient suffered another potentially fatal accident, a stroke of lightning that he also survived. In connection with the case, authors provide an overview of the clinical symptoms caused by viper venom, and current issues of professional care.

Trauma and work-related pain syndromes: Risk factors, clinical picture, insurance and law interventions

In the past decade, major progress has been made in our understanding of fibromyalgia syndrome (FMS). Various triggers have been implicated as contributing to symptom development in FMS when genetically susceptible individuals are challenged. A substantial amount of data points towards the association between trauma and chronic widespread pain/fibromyalgia syndrome (CWP/FMS). There is abundant data suggesting that the pathogenesis of CWP/FMS might be related to cervical spine injury. Furthermore, several persistent local pain conditions may progress to CWP/FMS. These conditions may share a common pathogenic mechanism namely, central sensitisation. Physical trauma and emotional trauma co-exist in many traumatic events and may interact in the pathogenesis of CWP/FMS.

Sacroiliac Joint Fusion With Fibular Bone Graft in Patients With Failed Percutaneous Iliosacral Screw Fixation

Numerous studies have described screw fixation of sacroiliac (SI) joint, but there have been very few reports in the literature regarding long-term pain levels after SI joint fixation and their management. The objective of this study was to analyze the results of SI joint fusion with fibular bone graft in patients with persistent late pain after iliosacral screw fixation. Eleven consecutive patients with persistent late pain following iliosacral screw fixation with failed conservative methods were managed with fibular bone grafting of the SI joint. The patients were followed up at 2, 6, 12, 24 weeks and every 3 months thereafter. They were clinically assessed for pain, infection, and ambulation. The average duration of follow-up was 18 months. There were neither intraoperative complications nor postoperative wound infection. Eight patients were pain free and returned to their work. The remaining three patients were having persistent-localized pain, but they were able to manage their daily activities. Fibular graft is feasible and apparently effective choice for SI joint fusion. This procedure avoids further metal work, which results in successful fusion and pain relief as well as stabilizing the SI joint.

Efficacy and Safety of Ketoprofen Patch in Patients With Rheumatoid Arthritis: A Randomized, Double‐Blind, Placebo‐Controlled Study

This study assessed the efficacy and safety of ketoprofen patch compared with placebo in patients who had rheumatoid arthritis and persistent wrist pain. Patients (N = 676)who had achieved systemic disease control with a disease-modifying antirheumatic drug and/or systemic corticosteroid, but still had persistent wrist pain, were randomized to a 2-week course of once-daily treatment with application of a 20-mg ketoprofen patch or a placebo patch to the wrist. The primary efficacy end point was the percent change from baseline to the end of treatment in the intensity of wrist pain scored by each patient on a 100-mm visual analog scale. The mean ± SD percent change on the pain intensity scale was significantly larger in patients treated with ketoprofen than in those receiving placebo (31.2% ± 30.3% [95% confidence interval: 28.0-34.4] vs 25.5% ± 31.2% [95% confidence interval: 22.1-28.8]; P = .020). However, the actual difference of the mean pain intensity scale between the 2 groups was small at the end of treatment. The frequency of adverse events was similar in both groups. The ketoprofen patch was more effective than placebo for relieving persistent local joint pain in patients with rheumatoid arthritis. The patch was also safe and well tolerated during the 2-week treatment period.