Persistent Pain Symptoms Research Articles

A fatal toxic shock-like syndrome post COVID-19 infection in a child

BackgroundChildren affected by Coronavirus disease 2019 (COVID-19) showed various manifestations. Some of them were severe cases presenting with multi-system inflammatory syndrome (MIS-C) causing multiple organ dysfunction.Case presentationWe report the case of a 12-year-old girl with recent COVID-19 infection who presented with persistent fever, abdominal pain and other symptoms that meet the definition of MIS-C. She had lymphopenia and a high level of inflammatory markers. She was admitted to pediatric intensive care unit since she rapidly developed refractory catecholamine-resistant shock with multiple organ failure. Echocardiography showed a small pericardial effusion with a normal ejection fraction (Ejection Fraction = 60%) and no valvular or coronary lesions. The child showed no signs of improvement even after receiving intravenous immunoglobulin, fresh frozen plasma, high doses of Vasopressors and corticosteroid. His outcome was fatal.ConclusionPediatric patients affected by the new COVID-19 related syndrome may show severe life-threatening conditions similar to Kawasaki disease shock syndrome. Hypotension in these patients results from heart failure and the decreased cardiac output. We report a new severe clinical feature of SARS-CoV-2 infection in children in whom hypotension was the result of refractory vasoplegia.

Factors Associated with the Development of Persistent Pain after mTBI

BackgroundPersistent pain after mild traumatic brain injury (mTBI) is widely experienced, yet little is known about who is at risk for experiencing persistent pain after their injury. AimsThe purpose of this study was to 1) determine if there are factors associated with later experiencing persistent pain after mTBI and 2) examine if there are symptom patterns associated with the experience of persistent pain. DesignSecondary analysis was conducted using de-identified data from an NIH-funded longitudinal study.SettingsParticipants were enrolled in the emergency department. ParticipantsParticipants were aged 21 to 92 and all had experienced mTBI. MethodsWe examined baseline characteristics, symptoms, and injury related variables associated with the endorsement of persistent pain among those with mTBI (N = 183) from baseline to 6 months post-injury. In order to identify a persistent pain phenotype, exploratory factor analysis was used to determine which symptoms co-occur with persistent pain. ResultsPersistent pain was found in 78% of those with mTBI. Those with lower overall health status at day 7 and at 1-month following injury had greater odds of developing persistent pain. Those with higher levels of general health status and physical function health status at day 7 and 1 month, and those with higher levels of overall health related status at 1 month had significantly lesser odds of persistent pain at 6 months. Factor analysis revealed that persistent pain and co-occurring symptoms (anxiety, depression, dizziness, nausea and vomiting, sleep disturbance, poor memory, poor concentration, longer to think and light sensitivity) loaded on one factor, indicating that these symptoms are associated. ConclusionsThose at increased risk for persistent pain should be screened beginning early in the recovery trajectory to reduce their risk of developing persistent pain. Identification of a phenotype offers potential for recognition of symptoms that cluster with persistent pain, improving the ability to treat patients more holistically, and develop interventions to support recovery from injury.

Validity and Diagnosis in Physical and Rehabilitation Medicine: Critical View and Future Perspectives.

Obtaining a diagnosis is an essential and integral part of physical and rehabilitation medicine in practice and research. Standardized psychometric properties are required of any classifications, diagnostic criteria, and diagnostic rules used. Physicians and researchers, in physical and rehabilitation medicine, need to understand these properties to determine the accuracy and consistency of their diagnosis. Although chronic musculoskeletal pain disorders are among the highly prevalent disorders seen in physical and rehabilitation medicine, limitations regarding existing diagnostic criteria for chronic musculoskeletal pain disorders still exist. Hence, the quest for developing diagnostic tools for chronic musculoskeletal pain that align with the standard properties remains open. These are discussed with an example for existing diagnostic criteria for fibromyalgia. This article primarily aimed to provide an overview of standard psychometric properties. A secondary aim was to critically appraise the tools currently used to diagnose chronic musculoskeletal pain disorders. The challenges and limitations of existing diagnostic tools are discussed. Potential approaches on how to improve the conceptualization of the construct of musculoskeletal pain disorders are also discussed. Adopting a network perspective, for example, can better constitute the disease instead of a single known underlying etiology for persistent or recurrent pain symptoms.

The controversial role of wellbeing assessment in juvenile idiopathic arthritis.

The use of the parent or patient global evaluation (PGE) of children's wellbeing as an outcome measure in patients with juvenile idiopathic arthritis (JIA) is controversial. It is widely agreed that integration of patient's and parent's perspective in clinical assessment could facilitate concordance with physician's choices and improve adherence to treatment.1 However, the PGE might be an imperfect indicator of disease activity in patients with JIA because it can be affected by persistent pain symptoms independent of joint inflammation and also by factors external to the disease such as mood, anxiety, pain coping, and family functioning.

Prevalence, diagnosis and antibiotic resistance pattern of H. pylori in the patients with heterogeneous gastroduodenal disorders

Background: Isolation of Helicobacter pylori (H. pylori) from gastric biopsies by Warren and Marshall has transformed our perception of gastro duodenal disorders. In India with miscellaneous environmental, dietary and lifestyle factors, it's common to acquire H. pylori infections. So screening becomes imperative for its early diagnosis and treatment. We intend to correlate the infection with diverse risk factors and also to appraise all microbiological diagnostic modalities with its local antibiogram. Methods and materials: Nine hundred and seventeen (n = 917) consecutive, symptomatic patients (562 males and 355 females) attending the endoscopy unit at a tertiary care center, Gujarat, India, were included. Four fragments of antral biopsies in a sterile Brain-heart infusion broth were processed for Rapid Urease Test (RUT), Gram's staining, Histopathology and Culture. Serum samples were tested for IgG antibody by ELISA. Susceptibility test was done by Kirby-Bauer disk diffusion method. Results: We found low Prevalence rate of H. pylori infection (15.2% 140/917). Symptoms of persistent gnawing abdominal pain (73%) was significantly associated with H. pylori infection (p < 0.01). Infection was mainly found in the patients with gastritis (44.2%), followed by reflux esophagitis (39%) and peptic ulcer disease (9.2%).The prevalence was higher in males (65%) probably due to their addictive habits to smoking/alcohol/tobacco. Amongst all the diagnostic techniques, serology was found 98.8% sensitive followed by Gram staining (96.8%) and histopathology (83%). Culture was 100% specific followed by RUT (99%). The combination of RUT with Gram's staining showed highest agreement of 95%. 83.8% of strains were resistant to metronidazole with a rising resistance to amoxicillin (72%) and clarithromycin (58%). Conclusion: Male gender, older age, chewing tobacco, Gastritis were individual risk factor associated to H. pylori infection. Combination of Gram staining and RUT was the Gold standard diagnostic test. Study recommends the need of sensitivity profile regionally and periodically before the general use of an eradication schedule.

Optimization of the quality of life of patients who need palliative care introduction

People suffering from chronic progressive diseases of non-infectious and infectious nature need palliative care. When a condition with an unfavorable prognosis occurs, an integrated approach is required, which involves patient care in the medical, psychological, social, and spiritual aspects. This assistance is aimed at improving the quality of life of such patients and implemented in Russia as part of the provision of palliative care, which aims to improve the quality of life of not only the patient himself but also his family members. This study aims to examine the impact of legal regulation of palliative care as well as the medical, psychological, social, and spiritual aspects of palliative care on the quality of life and needs of the patients and their families. Using content analysis and documentary observation, the results regarding the impact of legal, medical, psychological, social, and spiritual aspects combined in the provision of palliative care on the quality of life of patients in need were examined. The study revealed gaps in the legal regulation of the provision of palliative care for patients, particularly HIV-infected patients and those with chronic tuberculosis. As part of optimizing the provision of palliative care, creating a vertically integrated information system for palliative care (VIMIS Palliative) is necessary. To improve the professional stability of medical staff groups providing palliative care and preventing suicidal behavior among patients, health care organizers should improve the mechanisms of psychological interaction among all the participants in the palliative care system. Organizational and methodological approaches in administering anesthesia must be improved, and the knowledge of medical workers on the theoretical foundations of the formation of pain syndromes and the modern methodology for analgesic treatment is required. The organization of the state system of the artificial ventilation of the lungs at home is required with the aim of long-term respiratory support for patients in need. Additionally, further research is needed to determine the impact of nutritional support as a supportive therapy on the course of treatment and the results of palliative care, allowing to optimize the quality of life of patients in need. Optimization of the quality of life of incurable patients depends on the level of palliative care to achieve and maintain the maximum of their physical, psychological, social, and spiritual potential. Furthermore, palliative care should meet the following requirements: early-onset, continuity, succession, comprehensive, phased, and individual approach. Despite certain existing common problems in the implementation of palliative care and the difficulties caused by the restructuring of the health care system in the fight against coronavirus infection, the system is functioning and has the necessary resources to ensure the quality of life and alleviate persistent painful symptoms of patients.

The effects of a combined psychotherapy and physiotherapy group treatment program for survivors of torture incarcerated in an adult prison in Kurdistan, Iraq: A pilot study

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Survivors of torture have high rates of mental health problems and can experience a sequela of physical effects with the most common being persistent pain. Similar to survivors of torture, persons that are incarcerated have high rates of mental health problems, persistent pain and pain-related disability.The purpose of this study is to assess the effect of an interdisciplinary group treatment approach, involving psychotherapy and physiotherapy, with survivors of torture whom are incarcerated in a prison in Kurdistan, Iraq.&#x0D; &#x0D; &#x0D; Methods: A parallel group study design was used to compare a treatment group (n=11) and a wait-list control group (n=16). The treatment group participated in an interdisciplinary treatment service for a total of 10 weekly group sessions for each discipline.The primary outcome measures were symptoms of nociplastic pain, anxiety, depression, and PTSD. Secondary outcome measures evaluated physical functioning, sleep quality, and general self-efficacy.&#x0D; Results: A statistically significant reduction in outcome measure scores was seen in all symptoms measured immediately post-treatment.&#x0D; Discussion and Conclusion: These findings suggest that a culturally and contextually appropriate interdisciplinary group treatment intervention for survivors of torture in a prison could be effective for short-term reductions in symptoms of anxiety, depression, PTSD, persistent pain, and function. The study has limitations including a small sample size, lack of long-term outcome measures, and an inability to isolate effect of each component of care. The study does demonstrate the feasibility of implementing research that follows international research standards and practices within under-researched settings and post-conflict areas.&#x0D; &#x0D; &#x0D; &#x0D;

Embolisation des anévrysmes de l’artère splénique : traitement de choix. À propos d’un cas et revue de la littérature

Splenic artery aneurysms constitute 60% of digestive artery aneurysms. They are often discovered incidentally and by imaging. Currently, endovascular treatment is considered the first-line treatment, as it is less invasive with less morbidity and mortality than surgery. An aggressive approach in their management is certainly justified because the overall mortality of ruptured splenic aneurysms is 25%. False splenic aneurysms have a greater potential for rupture than true aneurysms because they grow faster. Endovascular treatment is generally indicated for aneurysms larger than 2cm or with an increase in size of more than 0.5cm/year. Embolization is rarely associated with an infarction of the spleen due to the good supply of short gastric vessels. Embolization is performed using different materials including coils, which can be used alone or with other embolic agents. Post-embolization syndrome can be seen with persistent pain, fever and other systemic symptoms. Endovascular treatment compared to open surgery is associated with better quality of life and appears to be the most cost-effective strategy. Endovascular treatment and especially coil embolization are starting to be the standard treatment. Surgical and laparoscopic treatment are reserved for ruptured aneurysms which are burdened with significant mortality, especially in pregnant women. We report the case of a 66-year-old female patient in whom a splenic artery aneurysm was discovered incidentally during an ultrasound for an ovarian cyst.

Axial spondyloarthritis 10 years on: still looking for the lost tribe.

Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.

Single loop allograft reconstruction for sternoclavicular joint instability

BackgroundVarious surgical strategies have been used for the treatment of sternoclavicular joint instability with variable results. The purpose of this study was to report the clinical results of patients who underwent single-loop allograft reconstruction for sternoclavicular joint instability.MethodsA total of 10 patients underwent single-loop allograft reconstruction for sternoclavicular joint instability from June 2012 to August 2014 by a single surgeon. All patients had a history of instability of the sternoclavicular joint with persistent chronic subluxation of the joint, magnetic resonance imaging disruption of the sternoclavicular ligaments, and persistent symptoms of pain and instability. Regarding the surgical technique, a single 5.5 mm drill hole was placed in the sternum and a second was placed in the medial aspect of the clavicle. A semitendinosus hamstring allograft was looped between the 2 holes and then tied in a square knot anteriorly. A #5 high-strength suture was used as cerclage as well. Nine of 10 patients (90% follow-up) were available at an average of 3.3 ± 0.84 years postoperatively. The average age of patients at the time of surgery was 42 years (range, 20-73 years). Patients were evaluated postoperatively with outcome scores (visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test), a question regarding tenderness at the sternoclavicular joint, and a question regarding residual instability and overall patient satisfaction (yes/no).ResultsThe average functional outcome scores for the Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons score were 11.8, 0.9, and 94.8, respectively. Three of 9 patients reported some residual tenderness located to the sternoclavicular joint. No patients reported any residual instability of the sternoclavicular joint. Eight of 9 patients reported that they were satisfied with the procedure. No patients required reoperation, and there were no complications.ConclusionSingle-loop allograft reconstruction of the sternoclavicular joint provides reliable pain relief, functional improvement, and joint stability for patients with chronic sternoclavicular joint instability. The simplicity of the procedure eliminates the need for small, multiple drill holes that may lead to fracture between tunnels or the use of a small, thin graft.

Effectiveness of a Guided Web-Based Self-help Intervention to Prevent Depression in Patients With Persistent Back Pain

Depression is a frequent comorbid condition in patients with persistent back pain and is associated with substantial adverse consequences, including the risk of developing opioid use disorders. Shifting the focus from depression treatment to preventing depression might be a viable way to reduce the disease burden. To evaluate the effectiveness of a web-based self-help intervention to reduce the incidence of major depressive episode (MDE) in patients with persistent back pain. Prevention of Depression in Back Pain Patients (PROD-BP) was a pragmatic, observer-blinded randomized clinical trial with a parallel design conducted in Germany. Eligible adults with a diagnosis of persistent back pain and subclinical depressive symptoms, but who were depression free, were recruited either on-site or after discharge from 82 orthopedic clinics between October 1, 2015, and July 31, 2017. All analyses were conducted according to the intention-to-treat principle from October 31, 2018, to April 30, 2019. The intervention group received an e-coach-guided, web-based self-help intervention that was based on cognitive behavioral therapy and tailored to the needs of patients with persistent back pain. The intervention included 6 obligatory modules and 3 optional modules to be completed by participants as well as feedback from e-coaches. Both the intervention and control groups had unrestricted access to treatment as usual. Primary outcome was time to onset of an MDE over a 12-month period as assessed by blinded diagnostic raters using the Structured Clinical Interview for DSM-5. Secondary outcomes included depression severity, quality of life, pain intensity, pain-related disability, pain self-efficacy, work capacity, and user satisfaction assessed with a variety of instruments. A total of 295 participants (mean [SD] age, 52.8 [7.7] years; 184 women [62.4%]) were recruited and randomized to either the intervention group (n = 149) or control group (n = 146). The intervention reduced the risk of MDE onset by 52% (hazard ratio, 0.48; 95% CI, 0.28-0.81; P < .001). Twenty-one participants (14.1%) in the intervention group and 41 participants (28.1%) in the control group experienced an MDE over the 12-month period. The number needed to treat to prevent 1 new case of MDE was 2.84 (95% CI, 1.79-9.44). Results of this trial showed that among patients with persistent back pain, depression can be prevented by a guided web-based self-help intervention in addition to treatment as usual. This finding suggests that using a scalable digital approach to integrate psychological treatment into routine pain management is feasible. German Clinical Trials Register Identifier: DRKS00007960.

Surgical treatment of atlantoaxial subluxation by intraoperative skull traction and C1-C2 fixation

BackgroundAtlantoaxial subluxation (AAS) is a not rare abnormality between the atlas (C1) and axis (C2). For AAS patients with persistent neck pain and neurologic symptoms, surgical intervention is a good choice. Nevertheless, there were still few reports about the use of intraoperative skull traction and different fixation methods in treatment of AAS.MethodsFrom January 2012 to December 2018, a total of 86 cases were admitted to our hospital and diagnosed as AAS. All the patients received atlantoaxial reduction with the help of intraoperative skull traction and C1-C2 fixation. Clinical and radiological parameters were collected through chart review.ResultsThere were 86 cases included in this study. The mean operative time was 153.9 ± 73.9 min, and the mean amount of intraoperative blood loss was 219.1 ± 195.6 ml. 81 patients underwent posterior reduction, internal fixation and fusion. 5 patients underwent anterior release, followed by posterior internal fixation and fusion. 82 patients got satisfactory postoperative outcomes while complications occurred in 4 patients. Significant neurologic improvement was observed in these patients. Bone fusion was achieved on the midline sagittal reconstructed CT images at the latest follow-up in all these patients except 1 case. All the patients were followed up for 34.84 ± 15.86 months at average (range 12–60 months). The mean ADI value was 7.55 ± 1.67 mm at average preoperatively, and improved to 4.03 ± 1.21 mm postoperatively, and to 4.21 ± 0.99 mm at the latest follow-up. The mean A-A angle was 15.48 ± 9.82 degrees at average preoperatively, and improved to 21.61 ± 10.43 degrees postoperatively, and to 19.73 ± 8.13 degrees at the latest follow-up. The mean A-A height was 35.61 ± 7.66 mm at average preoperatively, and improved to 40.08 ± 8.5 mm postoperatively, and to 38.83 ± 6.97 mm at the latest follow-up. There were complications in 4 patients, including pedicle misplacement, pedicle screw fracture, infection and one death.ConclusionIntraoperative skull traction can effectively facilitate the surgical procedures for ASS caused by different etiologies. Further research will be needed to investigate the safety and effectiveness of this method in the future.

Different kinds of acupuncture treatments for knee osteoarthritis: a multicentre, randomized controlled trial

IntroductionKnee osteoarthritis (KOA) is a chronic disease with symptoms of persistent pain or resting pain, joint stiffness, numbness, limitation of activity and even disability, with significant associated costs and effects on individuals’ life quality. The use of acupuncture for the management of chronic pain is receiving increasing recognition from both the public and professionals. The aim of this study is to identify the effects of three commonly used acupuncture treatments for KOA.Methods/analysisIn a prospective trial involving six hospitals in Zhejiang Province (China), 360 patients with KOA will be included. Eligible patients will be randomized into six groups: Acupuncture, Electro-acupuncture, Mild moxibustion, Warm-needling, Sham acupuncture and Celebrex treatment. Twelve treatment sessions will be performed over a 4-week period. The primary outcome will be the visual analogue scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function scores (the average of the past 3 days) at weeks 2 and 4 and at 3-month and 6-month follow-up. Secondary outcome measures will be as follows: the WOMAC pain score and WOMAC stiffness score (the average of the past 3 days); the Physical Activity Scale of the Elderly (PASE); knee joint swelling measurement; the WHO Quality Of Life-BREF (WHOQOL-BREF) life quality scale; and the incidence of adverse events.Trial registrationClinicalTrials.gov, NCT03563690. Registered on 2rd July 2018.

Properties of the Sickness Questionnaire in an Australian sample with chronic medically unexplained symptoms

Sickness behavior including malaise, fatigue and increased pain sensitivity is thought to be adaptive and facilitate recovery from disease. However, it may also reduce functioning and health if symptoms persists, which is why validated instruments for its assessment are needed. We evaluated the English translation of the Sickness Questionnaire (SicknessQ) in an Australian population of 156 participants with high level of persistent musculoskeletal pain and/or gastrointestinal symptoms without an organic explanation. The SicknessQ total score had an adequate model fit and no other models were found to fit data better. The SicknessQ correlated most strongly with fatigue, stress, anxiety and depression, which explained 62% of the variance in SicknessQ, but not with physical functioning. The mean score (8.9; 95 %CI: 8.0–9.8) was in between those previously reported in a general population sample and in primary care patients. In conclusion, the evaluation of the English version of the SicknessQ in an Australian sample with significant, chronic unexplained medical symptoms supports the use of the English version of the total SicknessQ score as an overall measure of sickness behavior.

In situ repair of partial-thickness rotator cuff tears: a critical analysis review.

After failed conservative management, operative intervention is typically indicated for patients with partial-thickness rotator cuff tears (PTRCTs) with persistent pain and disability symptoms.For PTRCTs involving < 50% of the tendon thickness, debridement with or without acromioplasty resulted in favourable outcomes in most studies.For PTRCTs involving > 50% of the tendon thickness, in situ repair has proven to significantly improve pain and functional outcomes for articular and bursal PTRCTs.The few available comparative studies in the literature showed similar functional and structural outcomes between in situ repair and repair after conversion to full-thickness tear for PTRCTs.Most non-overhead athletes return to sports at the same level as previous to the injury after in situ repair of PTRCTs. However, rates of return to preinjury level of competition for overhead athletes have been generally poor regardless of the utilized technique.During long-term follow-up, arthroscopic in situ repair of articular and bursal PTRCTs produced excellent functional outcomes in most patients, with a low rate of revision.Cite this article: EFORT Open Rev 2020;5:138-144. DOI: 10.1302/2058-5241.5.190010

Suicidal behaviour and clinical correlates in young adults in Rwanda: a population-based, cross-sectional study

# Background A significant proportion of persons who were contemplating suicide or completed suicide had met with a health care provider in the preceding months, however suicidal behaviour was not detected. To improve identification of persons with suicidal behaviour in need of care and support, this study aimed to investigate clinical symptoms that may identify young men and women (aged 20-35 years) with suicidal behaviour (ideation, plan and attempts) in Rwanda. # Methods This was a secondary analysis of data collected from a population based, cross-sectional study conducted in the Southern province of Rwanda in 2011/2012. After a response rate of 99.8%, the final sample was 917 people (477 women and 440 men). A validated Mini-International Neuropsychiatric Interview tool was used to measure suicidal behaviour. Bivariable and multivariable logistic regressions were performed to test the association between suicidal behaviour and clinical symptoms such as major depressive episode, physical pain symptoms and perceived overall health. # Results Approximately, 4.7% of the number of women (n=477) and 1.4% of the number of men (n=440) had attempted suicide in the preceding one month. For women, major depressive episode (Adjusted Odds Ratio, AOR=6.11; 95% confidence interval CI=4.03-10.84), physical pain symptoms experienced almost daily (AOR=1.80; 1.15-2.84) and poorly perceived overall health (AOR=3.08; 1.89-5.00) were statistically significant correlates of suicidal behaviour. For men, only major depressive episode was a statistically significant correlate of suicidal behaviour (AOR=4.75; 1.72-13.12). # Conclusion At health centre level, trained professionals should be made aware that young adults suffering from depression may also suffer from suicidal behaviour. It is therefore important to sensitively inquire about suicidal behaviour followed by appropriate support. For women in particular, suffering from persistent physical pain symptoms or poorly perceived overall health are warning signs that may indicate suicidal behaviour. At community level, community health workers can use the self-rated health form to identify people in poor health and escort them to the health centre for assessment.

Colorectal cancer in young adults: two case reports

Background: Colorectal cancer (CRC) in young adults is low, but for unclear reasons, a rise in CRC incidence has been reported in patients aged &lt;50 years. The incidence of CRC in young individuals has increased by 2% to 8% annually over the past two decades. CRC diagnosis in young people is always difficult, early detection of colorectal cancer is important for early diagnosis and improve clinical management.Case Description: Twenty four-year-old woman presented with symptoms of abdominal pain and vomiting for 5 months and weight loss. Thirty three-year-old man was hospitalized due to the symptoms of persistent abdominal pain for 5 months, fecal changes, bloody stools and weight loss. Both of them have no chronic disease or familial history of malignancy. The woman underwent an ileostomy and adhesiolysis through laparotomy due to a history of previous appendicitis. Intraoperative, colon was found dilated starting from the duodenum up to 10 cm proximal to the transverse colon so an extended right hemicolectomy is performed. The man underwent colostomy and Hartmann's procedure by laparotomy but the mass was failed to resected and followed by receiving adjuvant chemotherapy. Pathological finding post operative confirmed adenocarcinoma colorectal invasive for the woman and adenocarcinoma rectosigmoid for the man.Conclusion: Within a young group, CRC is usually diagnosed later and potentially associated with worst prognosis. Detecting CRC at an early, more treatable stage is important for cure and survival. This report suggest a greater suspicion rate and early screening that necessary when evaluating young patients with common symptoms.

Median Nerve Compression in the Forearm: A Clinical Diagnosis.

Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.

Post-mastectomy pain syndrome after mamma reduction plasty, an unusual case report

CRPS (complex regional pain syndrome) is well documented as a reflex sympathetic dystrophy. It mostly has been reported to occur in the extremities and has only been mentioned anecdotally in the breast after breast surgery or trauma of the chest wall. Recent literature describes a post-mastectomy pain syndrome (PMPS), which mimics CRPS symptoms and, despite the nomenclature, is not only limited to mastectomy procedures but also any other surgical procedure involving breast parenchyma. We report PMPS in a 39-year-old patient after revision operation of breast reduction surgery. Postoperatively, the patient showed symptoms of severe persistent pain, swelling, cutaneous temperature changes, and hyperhidrosis in the affected breast. Subcutaneous infiltration with triamcinolone acetonide and prilocaine only relieved the symptoms temporarily. Botox injections did not relieve her symptoms of sweating either. Two intercostal nerve branches were identified with ultrasonography and dissected in general anesthesia. This procedure relieved her symptoms. Surgeons should consider CRPS and PMPS as differential diagnosis of chronic disproportionate pain after breast surgery. Early identification and treatment will help alleviate persistent CRPS symptoms and avoid chronic soft tissue changes. Level of evidence: Level IV, diagnostic/therapeutic study.

(274) Novel Neurosteroid Intervention for Chronic Low Back Pain in Iraq/Afghanistan-Era Veterans

Chronic low back pain symptoms are extremely common among Iraq/Afghanistan-era Veterans. However, pharmacological management for pain is frequently suboptimal, and many Veterans experience persistent and unalleviated pain symptoms and/or intolerable side effects to pain medications. Current medications such as opioids that are frequently used to treat chronic pain symptoms have side effect risks such as respiratory depression, addiction, sedation, and potentially lethal interactions with other drugs. There is thus an acute and immediate need for the development of effective, safe, and non-habit-forming pharmacological treatments for chronic pain disorders. Neurosteroids are endogenous molecules that are enriched in human brain and hold promise for pain therapeutics. Data in rodent models demonstrate that neurosteroids exhibit pronounced analgesic actions, and our data in Iraq/Afghanistan-era Veterans suggest that neurosteroids are decreased in the setting of pain symptoms in clinical populations. Neurosteroids are hence logical candidates for pain alleviation and have not been tested yet for this indication. We thus conducted a 6-week randomized, double-blind, placebo-controlled trial of pregnenolone versus placebo to determine if adjunctive pregnenolone has therapeutic utility for the treatment of chronic low back pain in Iraq/Afghanistan-era Veterans. The primary outcome measure was average pain intensity ratings from a daily pain diary. Secondary outcomes included pain interference scores. Pregnenolone was extremely well-tolerated. Veterans randomized to pregnenolone reported significant reductions in low back pain relative to those randomized to placebo (pain diary p=0.024; pain recall p=0.010). Pain interference scores for “work” (p=0.040) and “activity” (p=0.031) were also improved in Veterans randomized to pregnenolone compared to placebo. Pregnenolone may thus represent a new intervention for pain conditions that is safe, well-tolerated, non-habit-forming, and potentially efficacious for the alleviation of pain symptoms in Iraq/Afghanistan-era Veterans.