Presence Of Night Pain Research Articles

Investigation of Vitamin D Levels and the Effects of Being an Agricultural Worker on Etiology and Night Pain in Children and Adolescents With Chronic Low Back Pain.

Chronic low back pain in children is a condition that should be investigated. In this study, we examined the effects of agricultural work on imaging results, risk factors, night pain, and vitamin D levels in children and adolescents with chronic low back pain. The study included 133 patients who presented to the Physical Medicine and Rehabilitation and Neurosurgery outpatient clinics with low back pain that had lasted more than three months. The patients were evaluated based on the duration of their low back pain, the presence of night pain, a family history of low back pain, their employment status, local or radicular pain, and their body mass index (BMI). A physical examination was carried out to look into the etiologies of low back pain. Appropriate imaging, such as x-ray radiography, magnetic resonance imaging (MRI), and computed tomography (CT), was performed for the patients. Blood samples were collected from patients to assess inflammatory pathologies and vitamin D levels. The 133 patients in the study ranged in age from seven to 16 years, with a mean age of 14.3 + 1.9 years. Further, 60.2% (n = 80) of the cases were male, while 39.8% (n = 53) were female. Imaging revealed findings in 59.4% of the patients. In 97.7% of the participants, D hypovitaminosis was detected. There was no significant relationship between the patients' imaging findings and vitamin D deficiency, family history, BMI, and employment status (p = 0.441, 0.147, 0.082, 0.605). The relationship between family history, employment status, and night pain was statistically significant (p < 0.001). There was no statistically significant relationship between night pain and vitamin D deficiency (p = 0.667). Mechanical strain due to agricultural work and family history was found to be associated with night pain in patients with chronic low back pain in our study. The most important finding of this study is that night pain, which is considered a red flag, can occur in both inflammatory pathologies and situations causing mechanical low back pain, and risk factors should be thoroughly investigated. Studies with patients who have sufficient vitamin D will help to clarify the relationship between chronic low back pain and vitamin D.

Presence of Night Pain, Neuropathic Pain, or Depressive Disorder Does Not Adversely Affect Outcomes After Total Knee Arthroplasty: A Prospective Cohort Study.

A considerable proportion of patients warranting total knee arthroplasty (TKA) have night pain, neuropathic pain, and/or depressive disorder, which may not be resolved by TKA. This prospective, longitudinal cohort study aimed to document the prevalence of night pain, neuropathic pain, and depressive disorder in patients with advanced knee osteoarthritis undergoing TKA and to determine whether the specific coexisting pain and/or disorder at the time of TKA adversely affected postoperative outcomes. In this study, 148 patients undergoing TKA were longitudinally evaluated. The presence of night pain, neuropathic pain (determined using Douleur Neuropathique 4 [DN4]) and depressive disorder (determined using the Patient Health Questionnaire-9 [PHQ-9]) was determined before and 6 weeks, 3 months and 1 year after TKA. In addition, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol-5 Dimension (EQ-5D) scores were assessed before and 1 year after TKA. Potential associations of night pain, neuropathic pain, and/or depressive disorder with pre- and postoperative WOMAC and EQ-5D scores were examined in subgroup analyses. Preoperatively, 72% (n = 106) of patients reported night pain, and the prevalences of neuropathic pain and depressive disorder were 15% and 17%, respectively. Preoperatively, compared with patients without night pain, those with night pain had significantly poorer preoperative WOMAC scores, but no significant difference was seen between groups 1 year after TKA. Preoperatively, the WOMAC, EQ-5D, and EQ-5D health scores of patients with neuropathic pain were not significantly different from those of patients without neuropathic pain, and there was no difference in clinical outcome scores 1 year after TKA between these groups. Preoperatively, the patients with depressive disorder showed significantly poorer preoperative WOMAC, EQ-5D, and EQ-5D health scores than those without depressive disorder, but no significant differences in scores were observed 1 year after TKA between these groups. This study revealed a considerable prevalence of night pain, neuropathic pain, and depressive disorder in patients undergoing TKA and that patients with these specific conditions reported poorer functional and quality of life scores preoperatively. However, such adverse effects disappeared after TKA. Our study findings suggest that TKA can provide satisfactory outcomes for patients with these specific conditions.

Selected Clinical Features Fail to Predict Inflammatory Gene Expressions for TNF-\u03b1, TNFR1, NSMAF, Casp3 and IL-8 in Tendons of Patients with Rotator Cuff Tendinopathy

The pathophysiology of rotator cuff tendinopathy is not fully understood, particularly in terms of the local inflammatory process. This study aimed to investigate the expression of selected molecules in the tumour necrosis factor (TNF)-α transduction pathway, including TNF-α, TNF receptor 1 (TNFR1), neutral sphingomyelinase activation associated factor (NSMAF), caspase 3 (Casp3), and interleukin (IL)-8, in patients with rotator cuff tendinopathy that had undergone surgical treatment. We included 44 participants that underwent arthroscopy, due to rotator cuff tendinopathy. Samples from the injured tendon were collected during arthroscopy, and RT-PCR was performed to determine gene expression. Pearson correlation analyses or U-Mann–Whitney test were performed to identify associations with the following parameters: sex, age at admission, body mass index, the presence of night pain, previous treatment (nonsteroidal anti-inflammatory drugs and/or steroids), medical history of the shoulder injury, upper subluxation of the humeral head, and the number of tendons injured. RT-PCR showed that the selected pro-inflammatory factors involved in the TNF-α signalling pathway expression levels were expressed in the tendon tissues. However, the levels of expression varied from patient to patient. Variations were over 250-fold for TNF-α, about 130-fold for TNFR1, NSMAF, and Casp3, and 1000-fold for IL-8. We could not confirm that any of the clinical parameters investigated were associated with the level of gene expression in the TNF-α pathway and IL-8.

Preoperative Osteopathic Manipulative Therapy Improves Postoperative Pain and Reduces Opioid Consumption After Total Knee Arthroplasty: A Prospective Comparative Study.

Pain is a therapeutic challenge after total knee arthroplasty (TKA), and it could lead to the overuse of opioids. Few methodologically robust clinical studies have been performed to assess the effectiveness of osteopathic manipulative therapy (OMTh; manipulative care performed by non-US-trained osteopaths) for postsurgical pain. To evaluate the effectiveness of standardized preoperative OMTh on early postoperative pain and opioid consumption after TKA. This comparative, nonrandomized study took place from 2013 to 2015 and included patients who had primary unilateral TKA for osteoarthritis in a knee that had not undergone any previous surgery. Patients were divided into 2 consecutive groups: 1 group received traditional preoperative management, and the other group received associated preoperative OMTh (general OMTh [rhythmic mobilization of all the body joints, from the ankles to the skull, using long-lever manipulation] and myofascial relaxation). The primary evaluation criterion was knee pain at rest 1 month after surgery: 0 (no pain) to 100 (the worst imaginable pain). The secondary evaluation criteria were: (1) knee pain while walking 1 month after surgery, (2) average weekly knee pain during the first month after surgery, (3) the presence of night pain and the consumption of sleeping pills and opioids or morphine at least once per week, (4) the International Knee Society scores and the Western Ontario and McMaster University Osteoarthritis index at postoperative 6 months and 1 year. The number of patients needed for a superiority trial was determined. No eligible patient refused OMTh when proposed. Seventy patients were evaluated (mean [SD] age, 75 [8] years; 47 women and 23 men). The 2 treatment groups contained 35 patients each. At postoperative month 1, the OMTh group had significantly less pain at rest (mean [SD], 6.8 [6] vs 20.9 [17.3]; P=.00001) and while walking (7.9 [9.4] vs 23.5 [20.6]; P=.0001) compared with the group that received traditional preoperative management. The consumption of opioids during the first postoperative week was significantly lower in the OMTh group (P=.0001). No statistically significant difference was found in the International Knee Society or Western Ontario and McMaster University Osteoarthritis scores between the 2 groups at 6 months and 1 year of follow-up. Standardized preoperative OMTh was found to be effective in reducing pain in the first month after TKA for osteoarthritis and significantly reduced opioid consumption during the first postoperative week.

Association between inflammatory back pain features, acute and structural sacroiliitis on MRI, and the diagnosis of spondyloarthritis.

To evaluate the association between inflammatory back pain (IBP) features, acute and structural MRI findings suggestive of sacroiliitis, and diagnosis of spondyloarthritis (SpA). Data from 224 patients who underwent MRI for suspected sacroiliitis (2005-2015) was retrospectively reviewed by an expert rheumatologist for the presence of IBP features and for clinical standard of reference diagnosis. A telephone questionnaire was performed in cases of missing data. Acute and structural MRI parameters were scored by an experienced radiologist for the presence of sacroiliitis using the Assessment of Spondyloarthritis International Society (ASAS) criteria, Berlin score, and observer's global impression (GI) scores. Association between IBP features and MRI scores, and odds ratio for SpA diagnosis, were calculated. One hundred ninety-three subjects were included (119 F:74 M, mean age 39.7 ± 15.6, mean follow-up 49 ± 18months). Fifty-two (26.9%) subjects were diagnosed with SpA. IBP scores were significantly higher in SpA patients (p < 0.001). IBP, ASAS, and GI MRI scores were significantly associated with the SpA diagnosis (p < 0.001 for all). The presence of night pain and morning stiffness was significantly associated with sacroiliac-joints' bone marrow edema (BME, p < 0.05). Sensitivity for diagnosis of SpA was high for IBP (96%) and low for the MRI parameters (26.9-57.4%), and specificity was low for IBP (32%) and high for the MRI parameters (88.3-94.3%). The presence of IBP features is highly associated with diagnosis of SpA and correlates with MRI BME, all probably reflect inflammation. The combination of IBP and MRI should be the cornerstone in the clinician's final diagnosis of SpA.

Red Flags for Low Back Pain Are Not Always Really Red: A Prospective Evaluation of the Clinical Utility of Commonly Used Screening Questions for Low Back Pain.

Low back pain has a high prevalence and morbidity, and is a source of substantial health-care spending. Numerous published guidelines support the use of so-called red flag questions to screen for serious pathology in patients with low back pain. This paper examines the effectiveness of red flag questions as a screening tool for patients presenting with low back pain to a multidisciplinary academic spine center. We conducted a retrospective review of the cases of 9,940 patients with a chief complaint of low back pain. The patients completed a questionnaire that included several red flag questions during their first physician visit. Diagnostic data for the same clinical episode were collected from medical records and were corroborated with imaging reports. Patients who were diagnosed as having a vertebral fracture, malignancy, infection, or cauda equina syndrome were classified as having a red flag diagnosis. Specific individual red flags and combinations of red flags were associated with an increased probability of underlying serious spinal pathology, e.g., recent trauma and an age of >50 years were associated with vertebral fracture. The presence or absence of other red flags, such as night pain, was unrelated to any particular diagnosis. For instance, for patients with no recent history of infection and no fever, chills, or sweating, the presence of night pain was a false-positive finding for infection >96% of the time. In general, the absence of red flag responses did not meaningfully decrease the likelihood of a red flag diagnosis; 64% of patients with spinal malignancy had no associated red flags. While a positive response to a red flag question may indicate the presence of serious disease, a negative response to 1 or 2 red flag questions does not meaningfully decrease the likelihood of a red flag diagnosis. Clinicians should use caution when utilizing red flag questions as screening tools.

CORR Insights®: What Factors are Predictive of Patient-reported Outcomes? A Prospective Study of 337 Shoulder Arthroplasties.

Where Are We Now? In an age where an impending burden will be placed on physicians to show benefits of treatment, studies that elucidate factors impacting the results of treatment of disease will undoubtedly grow in importance. Orthopaedic surgeons understand that patient-reported outcomes and patient satisfaction can differ substantially from surgeon-perceived outcomes. But while a surgeon may consider successful restoration of functional mobility as a good result, a patient may not place the same level of importance on an objective parameter like that, instead perceiving subjective factors such as absence or presence of night pain as more important. The development of, and extensive experience with, the Simple Shoulder Test has validated the usefulness of patient-reported outcomes scores. The Simple Shoulder Test allows the collection of outcomes data even when the patient is unable to physically return to the evaluator for followup. Of course, there are limitations to data interpretation due to the absence of radiographic and physical examination followup. For example, whether a patient's responses to the questions included in the Simple Shoulder Test correlate to a radiographic finding or clinical examination finding go unanswered. Still, the current study by Matsen and colleagues represents a great start to answering many questions regarding factors associated with outcome following shoulder arthroplasty. Where Do We Need To Go? But questions do remain. Although, a relatively large number of patients are included in this study, the patient population and specific procedure type are quite heterogeneous. More narrowly focused outcome studies are needed to better understand factors influencing the outcomes in specific diagnoses. More narrowly focused outcome studies are also needed to better understand factors influencing the outcomes in specific arthroplasty procedures (anatomic total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty, for example). Additionally, studies exploring the relationship between radiographic and clinical examination findings and subjective outcome measurement tools such as the Simple Shoulder Test are needed because this investigation is representative of patients at a relatively short followup period. Middle- and long-term followup periods are necessary, as they could certainly impact the relationship between radiographic and clinical examination findings. How Do We Get There? Clearly, future studies using the same basic study design employed by Matsen and colleagues in this study should try to strengthen the conclusions of this study and yield new information more specific to certain diagnoses and certain procedures. Additionally, longer followup could strengthen or possibly change the conclusions in a study such as this. Finally, although it is certainly difficult, if not impossible, to get all patients to return for radiographic and clinical examination followup, a study including a correlation of these findings with the Simple Shoulder Test in perhaps a more limited number of patients is warranted.

Evaluation of Factors Associated with Night Pain in Women Undergoing Carpal Tunnel Release

Night pain has important diagnostic and prognostic values in patients with carpal tunnel syndrome (CTS). We aimed to determine whether night pain is associated with certain patient characteristics in female patients undergoing carpal tunnel release. We recruited 75 women with the mean age of 54 years who were scheduled for carpal tunnel release. Diagnosis of CTS was made based on both the clinical symptoms and the results of electrophysiologic studies. Patient characteristics investigated as factors potentially associated with night pain were: age, body mass index (BMI), symptom duration, comorbidities such as diabetes mellitus (DM) and thyroid disease, electrophysiologic severity of CTS, and sleep position. We conducted a logistic regression analysis to examine the relationships between the presence of night pain and the different patients' demographic and clinical variables. Absence of night pain was associated with increased age (odds ratio (OR), 0.918, 95% confidence interval (CI), 0.851 to 0.99) and presence of DM (OR, 0.196; 95% CI, 0.046 to 0.835). The other variables assessed were not found to be associated with presence or absence of night pain. This study found that in women undergoing carpal tunnel release, older patients or those having DM are slightly less likely to have night pain. As night pain is an important prognostic factor for CTS, further studies are warranted to determine whether the absence of night pain could affect outcome assessment of CTS in the elderly or patients with DM.

Inflammatory Spinal Disease in Psoriatic Arthritis: A Report from the GRAPPA 2010 Annual Meeting

Diagnosing axial disease in patients with psoriatic arthritis (PsA) has been largely dependent on identifying inflammatory back pain (IBP), which itself has been difficult to define. We review the criteria used to identify IBP in patients with ankylosing spondylitis (AS) and other forms of spondyloarthritis. Recently, the Ankylosing SpondyloArthritis International Society (ASAS) developed a list of clinical and radiographic criteria for identifying IBP in patients with AS. However, it is more difficult to identify IBP in patients with PsA because generally they have less pain than patients with rheumatoid arthritis or AS. Further, PsA patients may have clinical symptoms of pain but negative radiographs. It may be more useful to identify sacroiliitis or syndesmophytes by magnetic resonance imaging (MRI), since MRI identifies lesions in the sacroiliac joints and the spine much earlier than can be detected on radiographs. In summary, all patients with PsA should be assessed for axial involvement with history, physical examination, and imaging. Patients with psoriasis whose history includes onset of back pain before age 40 years, the presence of night pain, and improvement with exercise but not with rest, or who have limited neck or back mobility, should be referred to a rheumatologist.

Clinical reasoning for a patient with neck and upper extremity symptoms: A case requiring referral

The purpose of this case report is to describe a 56-year old female patient with a bizarre pattern of cervicobrachial symptoms. The patient was managed according to the McKenzie "Mechanical Diagnosis and Therapy" principles and the physical examination alongside the movement testing showed inconsistent findings. Due to the patient's cancer-related medical history, presence of night pain, general weakness and the non-response to treatment, a referral to a medical specialist was immediately made. Imaging studies revealed metastases to the axial skeleton in multiple sites and a metastatic lesion was established as a medical diagnosis. With many physical therapists becoming first-entry providers it is likely that encounters with cases other than the purely musculoskeletal will increase. Serious pathologies can mimic musculoskeletal disorders, confusing even the most experienced therapist and as a result, pernicious and possibly life-threatening disease might easily be missed. This would be crucial especially in cases when the patient should immediately be referred to a medical specialist. Physical therapists should hone their clinical skills not only in treatment aspects but also in screening procedures in order to prompt a referral when it is required.

O1-4.5 Prognostic value of a novel classification scheme of clinical symptoms and signs of heart failure adjusted for major confounders

<b>Background and Purpose:</b> Mechanical hip pain and disease-based hip pain can have similar signs and symptoms, thereby presenting a differential diagnostic challenge for clinicians. Hip pain is a common complaint addressed by physical therapists; therefore, it would be advantageous for them to be knowledgeable about differential diagnosis for hip pain, so that they can screen for possible serious conditions outside the realm of physical therapist practice and make the appropriate referral. <b>Case Description:</b> A 77-year-old man was referred for physical therapy by his primary care physician (PCP) with diagnoses of lumbar spine and left hip osteoarthritis and possible trochanteric bursitis. After the examination, the physical therapist determined that the patient should return to his PCP for further testing. Findings leading to this conclusion were pain severity out of proportion to the reported injury, the presence of night pain, a positive “sign of the buttock,” and empty end feels of all hip joint motions, which represented a noncapsular pattern of joint restriction. <b>Outcomes:</b> The patient was diagnosed later with primary lung adenocarcinoma with widespread metastases. A computerized tomography scan of the left hip revealed a metastatic lesion at the left proximal femur. <b>Discussion:</b> Physical therapists’ ability to adequately screen for conditions requiring examination by a physician can lead to a more timely diagnosis of serious medical conditions. Investigators have found published descriptions of end feels, capsular versus noncapsular patterns of restriction, and the sign of the buttock to be beneficial screening tools for use in people with hip, pelvis, or lumbar spine pain.

Patient Screening by a Physical Therapist for Nonmusculoskeletal Hip Pain

Mechanical hip pain and disease-based hip pain can have similar signs and symptoms, thereby presenting a differential diagnostic challenge for clinicians. Hip pain is a common complaint addressed by physical therapists; therefore, it would be advantageous for them to be knowledgeable about differential diagnosis for hip pain, so that they can screen for possible serious conditions outside the realm of physical therapist practice and make the appropriate referral. A 77-year-old man was referred for physical therapy by his primary care physician (PCP) with diagnoses of lumbar spine and left hip osteoarthritis and possible trochanteric bursitis. After the examination, the physical therapist determined that the patient should return to his PCP for further testing. Findings leading to this conclusion were pain severity out of proportion to the reported injury, the presence of night pain, a positive "sign of the buttock," and empty end feels of all hip joint motions, which represented a noncapsular pattern of joint restriction. The patient was diagnosed later with primary lung adenocarcinoma with widespread metastases. A computerized tomography scan of the left hip revealed a metastatic lesion at the left proximal femur. Physical therapists' ability to adequately screen for conditions requiring examination by a physician can lead to a more timely diagnosis of serious medical conditions. Investigators have found published descriptions of end feels, capsular versus noncapsular patterns of restriction, and the sign of the buttock to be beneficial screening tools for use in people with hip, pelvis, or lumbar spine pain.

Assessment of subacromial impingement syndrome in the primary care setting: development of an evidence based clinical framework

Shoulder pain is the third most common musculoskeletal condition presenting to primary care. The term subacromial impingement syndrome (SIS) describes a number of pathologies of the rotator cuff, from bursitis to tendinopathy. The aim of this review is to present an evidence based approach to assessing the shoulder complex in order to assist the primary care clinician in diagnosing SIS. In addition a clinical framework that outlines an examination structure to guide therapists’ assessment of patients with possible SIS is also presented. Approximately 34 clinical tests exist for testing the structures of the shoulder complex for SIS, but the evidence-base on the validity, reliability and the diagnostic accuracy is either absent or reveals data that suggests that no test alone is perfect for diagnosis. The patient’s age and the presence of night pain are the two most useful features of the clinical history in establishing a pre-test probability, especially for a

Bone Scan as a Screening Tool in Children and Adolescents With Back Pain

Retrospective review of 142 patients from 2 teaching hospitals, investigated for persistent backache. The inclusion criteria were to be up to 18 years, to have no known associated diseases, and to have had a bone scan as a part of their work up. Other tests were also used to reach the final diagnosis. The utility of the bone scan to detect underlying pathology was assessed. On the whole, 75 patients were found to have pathology while only 52 children had a positive bone scan. We also looked for associated findings that could indicate the presence of pathology. The age of the patients, the duration of symptoms, and the presence of night pain seemed to be irrelevant on predicting underlying pathology. The sensitivity of the bone scan was low, 0.613 (95% CI: 0.549-0.654), although it proved to be highly specific, 0.91 (95% CI: 0.83-0.95). A careful analysis of the data and the different diagnosis suggests that Technetium bone scan still holds a place in the study of these patients; however, there is a big concern by the fact that some primary malignancies went undetected on the scan.

Epidemiology of spine tumors presenting to musculoskeletal physiatrists

Slipman CW, Patel RK, Botwin K, Huston C, Zhang L, Lenrow D, Garvan C. Epidemiology of spine tumors presenting to musculoskeletal physiatrists. Arch Phys Med Rehabil 2003;84:492-5. Objective: To report the incidence and epidemiologic formation of previously undetected primary and secondary spine tumors presenting as spinal and/or extremity pain to a physiatrist practicing in an academic or private practice multidisciplinary spine center. Design: Multicenter retrospective chart review. Setting: Three multidisciplinary spine settings (1 academic, 2 private). Participants: Charts of patients from 33 academic and 18 private practice settings. Interventions: Not applicable. Main Outcome Measures: Epidemiologic data collected included incidence, age, gender, race, and duration of symptoms before initial presentation. Symptom presentation data collected included intensity of pain when supine, sitting, standing, or walking; character of the pain; pain intensity as measured on the visual analog scale (VAS); spontaneous versus traumatic etiology; unexplained weight loss; presence of night pain; and fever. In addition, the results of radiographic studies including plain films, imaging, bone scan, and magnetic resonance imaging were recorded. The type of neoplastic disease was also assessed, primary versus metastatic, as well as the metastatic source. Results: The incidence of spine tumors was .69% in academic multidisciplinary spine centers and .12% in private practice multidisciplinary spine centers. Patients with spinal pain because of neoplastic disease who presented to musculoskeletal physiatrists were an average age of 65.3 years and reported a relatively high likelihood of night pain, aching character of symptom manifestation, spontaneous onset of symptoms, history of cancer, standing and walking provoking symptoms, and unexplained weight loss. In addition, the pain intensity level ranged widely, with an average VAS score of 6.8. Conclusions: There are many similarities and differences in the clinical presentation of patients with spinal pain from spine tumors who present to musculoskeletal physiatrists practicing in multidisciplinary spine centers when compared with those presenting to a primary care setting.

Pain and analgesia requirement after day case exodontia in children

Introduction Children undergoing day case dental extractions are not routinely given systemic analgesia and it is sometimes debated if such patients should receive i.v. opioids or NSAIDs intraoperatively. Infiltration with local anaesthesia during GA has been shown to reduce early postoperative distress after exodontia in children, and the severity of distress is related to the number of teeth extracted (1). We have conducted an audit to assess the severity of pain and the analgesic requirements of children undergoing dental extraction under the care of the community dental service in a day ward setting of a teaching hospital.Methods After preoperative assessment, children were accompanied to theatre by a parent, and anaesthesia was induced either with intravenous propofol or by inhalation of sevoflurane in nitrous oxide and oxygen, followed by maintenance with the same. Children breathed spontaneously via a Humphrey ADE system with a FGF of 3 l·min−1 delivered by a facemask +/– a nasal airway or a LMA. Apical infiltration of prilocaine 3% with felypressin 0.03 unit·ml−1 was used for extraction of most deciduous ‘D’, ‘E’ teeth or for permanent ‘6’ teeth. After surgery, the patient was transferred to a recovery area adjacent to the operating room.Age, weight, ASA score, number and type of teeth extracted and use of local anaesthetic were noted in the operating room. Recovery nurses recorded pain severity on awakening and on discharge. Analgesia given in recovery (if any) was also noted. On discharge, parents were given a questionnaire to complete and return by post. Details requested in the questionnaire were the amount and frequency of analgesia required on the day of the dental extraction, pain severity, presence of night pain and the severity of pain the next morning.Results Eighty‐seven children between the age of 2 and 11 participated in the audit. Except for one child who was ASA 3, all the others were either ASA 1 or 2. The average weight of the children was 22 kg and average number of teeth extracted per child was 6 (range 1–14). Local infiltration was given to 56 out of 87 children.The majority of the children had no pain or only mild pain (88%) and required or received no analgesia in recovery. Eleven children (12%) who needed paracetamol in recovery had either ‘D’, ‘E’ or ‘6’ removed and had pain scores recorded as moderate or severe. Eight of these 11 children did not have local anaesthetic infiltration. (Fig. 1).Pain scores of children on waking up from anaesthetic and before discharge from the hospital.imageReturn rate of questionnaires was 57%. The majority of the children (72%) required paracetamol on the day of the extraction at home irrespective of the number and type of teeth extracted and had mild or no pain. Extraction of ‘D’, ‘E’ or ‘6’ was associated with higher pain scores up to 24 hrs post‐extraction.Conclusions Pain is very subjective and can be difficult to assess in children. Our audit showed that after simple extruction of deciduous teeth, children do not routinely need analgesia in the hospital. However, if ‘D’, ‘E’ or ‘6’ is extracted, it is important to ensure that proper analgesia is given and this may pretrentially be infiltration with prilocaine.

Lumbar spinal stenosis and diabetes. Outcome of surgical decompression

We reviewed 25 diabetic (mean age 68 years) and 25 non-diabetic patients (mean age 71 years) who had undergone decompression for lumbar spinal stenosis at a mean of 3.4 years after operation to determine whether diabetes affected the outcome of surgery. The preoperative symptoms were similar in the two groups except that an abrupt onset of symptoms, the presence of night pain and the absence of any posture-related pain relief were recorded only by diabetic patients. Nerve-conduction velocity was slowed in 80% of the diabetic and in 25% of the non-diabetic patients. Peripheral vascular deficiency was diagnosed in 20% of patients with diabetes and in 4% of non-diabetics. The outcome of surgery was similarly successful in the two groups. Mistaken preoperative diagnosis was the cause of failure in three diabetic patients, two with diabetic neuropathy and one with diabetic angiopathy.

Endoscopic findings in patients with ulcer-like dyspepsia.

One hundred and sixty-seven patients in a single general practice who presented with ulcer-like dyspepsia were offered an upper gastrointestinal fibre endoscopy. Twenty-two patients had a peptic ulcer while only three had a gastric ulcer. One patient had a carcinoma of the cardia, one an adenocarcinoma in the body of the stomach and one a carcinoma at the ampulla of Vater. In another 55 patients the main findings at endoscopy were edema/reddening or erosions in the antral or duodenal mucosa. Endoscopic findings were normal in 46 patients. Malignancies were found only in patients over 50 years of age and only 4 ulcers were seen in patients under 40. The clinical findings of presence of night pain, pain relief after food intake and history of peptic ulcer were more common in patients with an existing peptic ulcer than in those with a normal endoscopy.