Sharp Pain Research Articles

Eagles’ syndrome: is it the longest styloid process length to date? A case report and an overview of the literature

Eagle syndrome is a rare condition that occurs when the styloid process, a bony projection in the skull, becomes elongated and causes pain in the head, neck, and face. The causes of Eagle syndrome are not entirely clear, but it is believed to be related to a genetic predisposition or trauma to the head or neck. The most common symptoms of Eagle syndrome include a sharp pain in the throat or ear, difficulty swallowing, and a feeling of a foreign object in the throat. Other symptoms may include headaches, facial pain, and neck pain. Diagnosis of Eagle syndrome can be challenging as symptoms can be mistaken for other conditions such as myofascial pain syndromes, glossopharyngeal or trigeminal neuralgias, migraine and cervical arthritis. However, proper diagnosis can be established by performing adequate physical examination, taking clear medical history, and full workup including imaging tests such as X-rays, CT scans, or MRIs to confirm the diagnosis.

Immunohistochemical Glutamine Synthetase As a Surrogate Marker for Beta Catenin (Exon 3 Deletion) in a Rare Case of Hepatic Adenomatosis with Early Malignant Transformation to Well Differentiated Hepatocellular Carcinoma

Abstract Introduction/Objective Hepatic adenomatosis (HA) is a rare entity defined by ≥ 10 hepatocellular adenomas (HCAs). About half of HA cases are asymptomatic and incidentally found. Compared to individual HCAs, HA carries a higher risk of complications including: tumor rupture, bleeding, and an approximate 4.2% overall frequency of malignant transformation. Methods/Case Report A 29-year-old woman presented to the emergency department (ED) requesting a CT scan. She was seen by a gastroenterologist days prior to her ED visit for ongoing sharp rectal pain for 2-3 months. After a recent rectal exam, she was recommended to have a CT abdomen/pelvis to rule out a potential abscess. CT did not show a perianal or perirectal abscess but instead identified a 9.1 cm right hepatic lobe mass. A liver MRI showed a 6.4 x 8.5 cm mass with arterial enhancement. The patient had a prior history of OCP use. She underwent robotic wedge resection of liver segment 6 with cholecystectomy. Gross examination showed a 6 cm tumor with many smaller nodules ranging in size from 0.5-2.2 cm. Our case was submitted entirely for histologic examination. Microscopy demonstrated well differentiated hepatocellular carcinoma (WDHCC) confirmed with positive immunohistochemical (IHC) staining for HepPar1 and Arginase. Tumor cells showed mild patchy cytological atypia, occasional pseudoglands, and architectural atypia with “nodule in nodule growth.” There was reticulin loss in multiple areas and CD34 showed strong diffuse sinusoidal staining. Glypican 3, CRP, and HAA were negative. Low Ki-67, LFABP retention, and absent nuclear staining of beta catenin (BC) were noted. Glutamine synthetase (GS) was diffuse and homogeneous. The gallbladder was unremarkable. Results (if a Case Study enter NA) NA Conclusion This case emphasizes that, despite negative nuclear BC staining, diffuse homogenous staining of GS is a quality surrogate marker for BC mutations (ex. exon 3 deletions). Thorough gross, microscopic, and molecular examination in HA cases is essential for identifying transformation to WDHCC.

The pop-up pain: reconceptualizing the perception of short-lived pain among non-injured recreational marathoners

Multiple forms of short-lived pain are common experiences among non-injured recreational marathoners, yet there remains little in-depth qualitative research on the lived experience regarding the sociology of transient pain. This study seeks to fill the lacuna by exploring the relationship between transient pain and its multifaceted consequences within the running social world. Drawing on Leder’s notion of the dys-appearing body, the study investigates how non-injured runners interpret and attribute context-dependent significance to transient pain due to their runs. An ethnographic research design of two years was implemented in two running groups, using participant observation and semi-structured interviews. Three categories of transient pain were identified: (1) “Pre-flow pain” - discomfort at the start of a run before easing into a relaxed state, (2) “Impromptu pain” - unexpected, sharp pain that occurs during the run and (3) “Resurgent pain” - an ache that manifests after the end of a running session as a result of lingering effects from prior injuries. The data presented suggest that transient pain cannot be approached as a self-evident phenomenon occurring in a vacuum. Instead, it should be viewed as a nuanced pain epistemology that encompasses the lived experience of bodily pain within the subjective perception.

Sudden severe chest pain: an atypical presentation of an infective exacerbation of COPD

Presentation A 59-year-old female, recent ex smoker, with a history of COPD and anxiety, presents to her GP with acute onset sharp chest pain, associated with dyspnea, diaphoresis and palpitations. On examination tachycardia, tachypnea and rhonchi were noted in the absence of fever and crepitations. Differential Diagnosis Her presentation raises suspicion for several conditions that require urgent treatment, including AMI, PE and pneumothorax. Few indicators of infection were present initially. Investigations Given the risk of life-threatening conditions included in the differential diagnosis, hospital work-up was warranted. Investigations for AMI, PE, and pneumothorax were negative. Further investigations and development of the clinical course led to the conclusion of a diagnosis of IECOPD. Conclusion Presentations of IECOPD can be diagnostically difficult. Although painis not usual in IECOPD and pyrexia is common, this case illustrates the absence of such features in the presence of additional atypical features. Furthermore, acute chest pain often requires hospital investigation even if the ultimate diagnosis may be managed by the GP.

Remineralization Effect of Bioactive Glass With and Without Fluoride and Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) on Artificial Dentine Caries: An In Vitro Study.

Background/objectives Dentine hypersensitivity (DH) is a common dental condition marked by transient, sharp pain arising from dentinal exposure. Bioactive materials are capable of remineralization. This study aims to explore the remineralization effect of bioactive glass (BAG) with and without fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), using dentine discs as the test substrate. Materials and methods In this in vitro experimental study, 28 dentine discs were prepared from premolar teeth. Artificial caries were induced by subjecting the dentine discs to demineralization in acid for 72 hours. After demineralization, the discs were treated with various remineralizing dentifrices to evaluate their effects. The dentine discs (n=28) were divided into four groups: group 1 = BioMin (BioMin Technologies, London, United Kingdom), group 2 = NovaMin/Sensodyne Repair (GlaxoSmithKline plc, London, England, United Kingdom), group 3 = Recaldent (CPP-ACP; GC Orthodontics Inc., Alsip, Illinois, United States), and group 4 = deionized water (control group). All discs underwent a 28-day remineralization process using the respective dentifrices assigned to each group. The microhardness of the discs was measured using Vickers microhardness testing at three stages: baseline, post-demineralization, and post-remineralization. Results There was no significant difference in terms of microhardness between groups both at the baseline (F (3, 24) = 1.079, p = 0.995) and after the demineralization process (F (3, 24) = 1.310, p = 0.294). However, a significant difference was identified between the groups after the remineralization process (F (3, 24) = 34.008, p = 0.001). Additionally, the least significant difference (LSD) multiple comparison test was performed. There were significant differences identified in the remineralization condition, with group 1 having the highest values, followed by group 2, group 3, and group 4. Conclusion The results indicate that the remineralization effect on artificially induced dentine caries was more pronounced with bioactive glass containing fluoride compared to bioactive glass without fluoride and CPP-ACP.

Diagnostic Challenges and Management of Non-Odontogenic Toothache: A Case of Unilateral Pansinusitis Mimicking Dental Pain

This case report details the diagnostic challenge and subsequent management of a 38-year-old male patient who presented with severe, sharp, and non-localized pain in the right maxillary distal area. Initial¬ly unresponsive to non-steroidal anti-inflammatory drugs and antibiotics, the patient’s symptoms deviat¬ed from typical odontogenic pain characteristics. Comprehensive dental examinations revealed minimal pathologies, challenging initial assumptions of dental-origin pain. Advanced diagnostic imaging, including Orthopantomography and Cone Beam Computed Tomography (CBCT), was pivotal in identifying unilat¬eral pansinusitis, with notable obstruction in the maxillary, ethmoid, and frontal sinuses. Further microbi¬ological analysis confirmed a Staphylococcus aureus and anaerobic infection, refocusing the diagnosis to a non-odontogenic source. The patient underwent a targeted 14-day complex antibiotic regimen, supple¬mented with local treatments including Nasonex nasal spray and saline nasal irrigations. This integrative approach resulted in marked symptom improvement and was instrumental in the patient’s recovery. This case highlights the critical need for thorough evaluation in distinguishing between odontogenic and non-od¬ontogenic sources of orofacial pain, ensuring accurate diagnosis and effective treatment.

Marginal Excision as a Surgical Treatment for The Schwannoma of Posterior Aspect of Femur: A Case Report

Introduction: Schwannoma is a benign nerve sheath neoplasm attached to a peripheral nerve that often develops in the middle-aged population. It usually presents as an asymptomatic mass at first but can be transformed into a pain, swelling, neurologic, or mechanical symptom in several patients. In this study, we are reporting a case of a schwannoma of the posterior aspect of the thigh, in a young adult male. Case Presentation: We reported a 31-year-old male complained of sharp pain, tingling sensation, and mechanical block in the posterior aspect of the right thigh. Radiological imaging showed the tumor of the posterior aspect of the right thigh, with associated soft tissue edema, the cortex is not invaded. Surgical resection was performed on the patient and the tumor was excised with marginal excision surgery technique. Conclusions: The schwannomas of the femur can successfully be excised with no postoperative complications. There is no sign of a recurrent tumor in six months after the procedure.

Cannabinoids as a Natural Alternative for the Management of Neuropathic Pain: A Systematic Review of Randomized Placebo-Controlled Trials.

Dysfunction or damage to the nervous system may develop into and result in a chronic pain condition known as neuropathic pain. Neuropathic painis defined as the structural and functional alteration of the somatosensory component of the nervous system. The treatment of neuropathic pain is a complex endeavor, which often requires specialist care and intensive drug therapy. Recently, cannabinoids have emerged as an alternative and natural option for the treatment of chronic pain, with tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most extensively studied neuroactive components. The therapeutic potential of cannabis remains largely underexplored, primarily due to its social stigma and the restrictions that are in place on its cultivation. The primary aim of this systematic review was to explore the therapeutic value of cannabinoids in the management of chronic pain and thus achieve an improved quality of life for those patients. A systematic review of the literature published over the last two decades was performed usingthe following databases: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Turning research into practice (Trip), and Google Scholar. Studies that were completed and published between January 01, 2000 and August 31, 2024, in English language, were extracted and appraised. A combination of keywords and Boolean operators Cannabis OR Chronic Pain OR End of life OR Pain Management AND Drug therapywas employed for data extraction. The Cochrane risk-of-bias tool for randomized trials (RoB 2) was used for risk-of-bias assessment. The initial search resulted in 125282 articles; 86,781 of the articles were identified as duplicates and were removed from the primary analysis, and 38,501 abstracts were thus screened. Abstracts, case studies, reports, editorials, viewpoints, cross-sectional studies, cohort studies, case-control studies, case series, and letters to the editor/correspondence manuscripts (n =38,492) were furthermore excluded. Nine full-text articles were critically assessed and tested against the inclusion and exclusion criteria, and a further four articles were excluded with a total of five placebo-controlled randomized control studies being ultimately included in the final systematic review. Compared to placebo, cannabinoids provided significant relief from chronic pain(33% vs 15%) as measured by the visual analog scale. The transdermal application of CBD led to a more pronounced reduction in sharp pain, according to the neuropathic pain scale. Minimal to no side effects were recorded, further highlighting the potential benefits of cannabinoids.

Case Report: Emergency endovascular management of a ruptured giant abdominal aortic aneurysm with severely angulated and conical shaped neck using novel multiple stiff wire technique

Background Ruptured abdominal aortic aneurysm (rAAA) is commonly fatal, with an overall mortality rate of nearly 90%, and the risk of subsequent rupture remains high, especially in large aneurysm diameters or progressive disease. Unfavorable neck anatomy in EVAR is linked to early graft failure and long-term complications. Recently, a novel multiple stiff wire (MSW) technique has been developed to overcome the challenges of hostile neck anatomy without introducing additional devices and procedural complexity. It has also been feasible in a series of elective cases. In this case, we report the first-ever utilization of the MSW technique in an emergency case of an acute contained rAAA with a conical-shaped, severely angulated neck who underwent Endovascular Aortic Repair (EVAR). Case presentation A 61-year-old man came with intermittent sharp stomach pain radiating to his back since three weeks ago. Physical examination showed elevated blood pressure and anemic conjunctiva. Laboratory examinations showed anemia, leukocytosis, elevated D-dimer level, high creatinine level, and low eGFR. CT-Scan Angiography (CTA) revealed severely hostile anatomy, a conical-shaped abdominal aorta aneurysm with a length of 13.2 cm and a maximum diameter of 9.3 cm with angulation of 90.1°. The patient was diagnosed with Ruptured AAA with a conical-shaped, severely angulated neck. Endovascular Aortic Repair (EVAR) management with MSW technique was planned for him. After four days, The patient was discharged in a clinically stable condition with optimal medical treatment and education. Conclusion The endovascular approach could be performed in emergency settings and has been proven to reduce length of stay, mortality, and morbidity rates. In this case, the endovascular approach with the MSW technique showed promising results for the patient.

A bifunctional lactoferrin-derived amyloid coating prevents bacterial adhesion and occludes dentinal tubules via deep remineralization

Dentin hypersensitivity (DH) manifests as sharp and uncomfortable pain due to the exposure of dentinal tubules (DTs) following the erosion of tooth enamel. Desensitizing agents commonly used in clinical practice have limitations such as limited depth of penetration, slow remineralization and no antimicrobial properties. To alleviate these challenges, our study designed a lactoferrin-derived amyloid nanofilm (PTLF nanofilm) inspired by the saliva-acquired membrane (SAP). The nanofilm utilises Tris(2-carboxyethyl)phosphine (TCEP) to disrupt the disulfide bonds of lactoferrin (LF) under physiological conditions. The PTLF nanofilm modifies surfaces across various substrates and effectively prevents the early and stable adhesion of cariogenic bacteria, such as Streptococcus mutans and Lactobacillus acidophilus. Simultaneously, it adheres rapidly and securely to demineralized dentin surfaces, facilitating in-situ remineralization of HAP through a simple immersion process. This leads to the formation of a remineralized layer resembling natural dentin, with an occlusion depth of dentinal tubules exceeding 80 µm after three days. The in vivo and vitro results confirm that the PTLF nanofilm possesses good biocompatibility and its ability to exert simultaneous antimicrobial effects and dentin remineralization. Accordingly, this innovative bifunctional PTLF amyloid coating offers promising prospects for the management of DH-related conditions. Statement of significance1.We design a simple, fast, inexpensive, and easy-to-process PTLF nanofilm for nearly any material surface or shape.2.The PTLF nanofilm modifies surfaces across various substrates and effectively prevents the adhesion of cariogenic bacteria, such as Streptococcus mutans and Lactobacillus acidophilus.3.The abundant functional groups on the surface of PTLF nanofilm facilitate bioactive hydroxyapatite (HAP) formation and maintain stability at the HAP remineralization interface.

Osteopathic Approach to Proximal Hamstring Tendinopathy-related Sciatic Nerve Entrapment (PHTrSNE): Case Report

Abstract Proximal Hamstring Tendinopathy (PHT) provides a challenging diagnosis for clinicians due to limited evidence-based research. Presenting as chronic pain originating at the ischial tuberosity, PHT can progress to entrap the sciatic nerve, resulting in proximal hamstring tendinopathy-related sciatic nerve entrapment (PHTrSNE). This case expands the understanding of PHT by describing the osteopathic assessment and treatment of a runner with PHTrSNE. A 24-year-old female marathoner presented to the neurology clinic with a unique running gait: a left leg circumduction, or “leg whip,” that presented only when running. She also reported constantly dull hamstring pain, which occasionally elicited a sharp, shooting pain from her lower gluteal muscles to mid-hamstrings. Activities such as prolonged sitting and intense running exacerbated the sharp pain. On examination, the patient displayed ischial tuberosity tenderness and positive tests for hamstring tendinopathy. Evaluation with EMG/NCS showed mild chronic denervation of the left tibialis anterior muscle. A treatment plan for the patient’s PHTrSNE was created based on the principles of the neurological model of osteopathic medicine. Patients presenting with chronic hamstring discomfort accompanied by sharp, shooting pain may benefit from the diagnostic and therapeutic approach outlined in this study.

Awareness and management of slipping rib syndrome

Slipping Rib Syndrome (SRS) is a clinical condition caused by the instability of the costochondral junction, primarily affecting the lower ribs (8th, 9th, and 10th). This syndrome results in severe, often intermittent chest pain due to intercostal nerve entrapment. Diagnosing SRS can be challenging as symptoms often mimic other causes of chest pain. Key clinical features include sharp lower rib pain exacerbated by movement, tenderness on palpation, and pain provoked by the Hooking maneuver. Recent advances in diagnosis and treatment have been highlighted in the literature. Ultrasound has proven effective in confirming SRS diagnosis non-invasively, while surgical interventions offer excellent pain relief, with new diagnostic signs such as reduced rectus abdominis muscle thickness being proposed. Treatment ranges from intercostal nerve blocks and botulinum toxin injections for symptomatic relief to surgical excision of affected costal cartilage for more severe cases. Minimally invasive rib fixation and costal cartilage excision have shown success, providing less invasive options with faster recovery. Continued research and awareness are essential for improving SRS diagnosis and treatment, significantly enhancing patient quality of life.

Guide to extraluminal fish bone retrieval with serial computed tomography scans: a case series

BackgroundFish bone ingestion is commonly encountered in emergency department. It poses a diagnostic and therapeutic challenge particularly when it migrates extraluminally, necessitating a comprehensive and multidisciplinary approach for successful management.Case presentationHere we reported four cases of extraluminal fish bone. The first patient was a 68-year-old Chinese man who had odynophagia shortly after a meal involving fish. The second was a 50-year-old Iban man who reported a sharp throat pain after consuming fish 1 day prior. The third patient was a 55-year-old Malay woman who developed throat pain and odynophagia after consuming fish 1 day earlier. The fourth patient, a 70 year-old Iban man, presented late with odynophagia, neck pain, swelling, and fever 1 week after fish bone ingestion. These unintentional fish bone ingestions faced challenges and required repeat computed tomography scans using multiplanar reconstruction in guiding the surgical removal of the fish bone.ConclusionWe underscore the significance of multiplanar reconstruction in pinpointing the fish bone’s location, demonstrating the migratory route, and devising an accurate surgical plan.

The Causes of Intraoperative Pain among Elective Caesarean Section Patients under Sub-Arachnoid Block at the Tamale Teaching Hospital

Background: Intraoperative pain is a possible complication of neuraxial anaesthesia for caesarean delivery. Possible causes of intraoperative pain following caesarean section under spinal anaesthesia have been proposed. The potential consequences include inadequate anaesthesia, nerve injury during needle insertion, manipulation of internal organs during surgery, and psychological factors such as anxiety and fear. This study was conducted to assess the causes of intraoperative pain among patients undergoing elective caesarean section under sub-arachnoid block at the Tamale Teaching Hospital. Methods: A descriptive cross-sectional research design was employed in this study. A total of 55 women who have had elective caesarean section under sub-arachnoid block were selected for the study. Data was collected using a structured questionnaire and analysed with the SPSS. Results: Findings from the study showed a high incidence of intraoperative pain among women during elective caesarean section under sub-arachnoid block (96.4%). These were mainly sharp and aching pain. However, the levels of the pain experienced intraoperative were mild (52.7%) and moderate (43.6%). Increased length of time spent during surgery and ineffectiveness of medications/ injections given to prevent pain were the main factors contributing to intraoperative pain among patients during elective caesarean section under sub-arachnoid block. Conclusions: The study found a substantial incidence of intraoperative pain during caesarean delivery. To mitigate intraoperative discomfort and enhance the overall surgical experience for patients having elective CS, it is crucial to address these issues by employing optimised anaesthesia techniques, implementing effective pain management measures, and utilising preoperative psychological therapies.

The resisted torsional stress test in diagnosis of femoral stem loosening in uncemented total hip arthroplasty - first description and retrospective study.

Aseptic femoral stem loosening is among the most common causes for revision in total hip arthroplasty (THA). We describe a simple clinical test that triggers pain in the proximal femur in patients with a loose stem. A previously described passive rotation test was associated with a poor sensitivity. The resisted torsional stress test (RTST) was used for several years in our hospital, and this is the first description of its reliability. We retrospectively reviewed our database of uncemented stem revisions. Preoperative clinical reports were searched for data on the RTST. A positive RTST was defined as sharp pain felt at the stem level with active internal rotation against a passive external rotation impulse in 90° hip flexion. The definition of stem fixation (fixed vs. loose) was made by readout of the surgery reports. The RTST was reported in 83 cases and was positive in 32 of the 43 stems, which were found loose intraoperatively and in 9 of the 40 stems, which were well integrated. This leads to an accuracy of classification of 79.5%. The sensitivity was 80% and the specificity was 79.1%. PPV and NPV were 78% and 81%, respectively. The RTST provides a helpful tool in the clinical assessment of femoral stem fixation in THA with good accuracy and should be included in standard follow-up examinations and in the assessment of painful THAs.

Comparison of efficacy of commercially available desensitizing Toothpastes in reducing Dentin Hypersensitivity

Dentine hypersensitivity is characterized by a short sharp pain arising from exposed dentine in response to thermal, evaporative, tactile, osmotic or chemical stimuli that cannot be ascribed to any other form of dental defect. Today, multiple desensitizing toothpastes that claim superiority over each other in reducing dentin hypersensitivity are commercially available. The present study was undertaken to evaluate and compare the efficacy of three commercially available desensitizing toothpastes in reducing dentine hypersensitivity (herbal desensitizing toothpaste, desensitizing toothpaste and desensitizing toothpaste containing 8% arginine). After ethical clearance and informed consent, a total of 45 participants were recruited equally into 3 groups (Group 1: Herbal desensitizing toothpaste; Group 2: Desensitizing paste containing potassium salt; Group 3: Desensitizing toothpaste containing 8% Arginine) by a simple random sampling method. Dentine hypersensitivity was evaluated at the baseline, immediately, at 4th week and 8th week after using the assigned toothpaste. Dentine hypersensitivity was evaluated using the Schiff sensitivity score. In this study, the comparison of the efficacy of desensitizing toothpaste within group 1 at different time intervals was found to be statistically significant (p=0.004). Comparison of the efficacy of desensitizing toothpaste within group 2 and group 3 at different time intervals was found to be statistically highly significant (p=0.000). However, the comparison of the efficacy of desensitizing toothpaste between 3 groups at baseline (p=0.659), immediately (p=0.366), at the 4th week (p=0.388) and the 8th week (p=0.583) was found to be statistically nonsignificant. The present study can be useful, as it is important to assess the efficacy of various commercially available desensitizing toothpastes, since the use of desensitizing toothpastes is considered to be the primary strategy in the management of non-carious dentinal exposure causing dentinal hypersensitivity. Key Words - Dentine hypersensitivity, Herbal toothpaste, Sensitivity, Stimuli

Orthodontic pain with fixed appliances and clear aligners: A 6-month comparison

This prospective study compared pain perception, intensity, and analgesic use among patients treated with fixed appliances (FAs) and clear aligners (CAs) over 6 months. Digital surveys were collected from 87 adult patients treated with CA or FA from 2 orthodontic offices. The 7-item survey was sent at 3-time points (preappointment, 2-day postappointment, and 7-day postappointment) for each appointment. Wilcoxon, t test, and Fisher exact chi-square tests were performed with significance set at 0.05. The FA group had a higher rate and intensity of pain 2 days after the second, third, and fifth appointments (P<0.030). At 7 days postappointment, the FA group had a higher rate and intensity of pain for the first and fifth appointments. Dull pain was reported the most in both groups, with a proportion of FA patients reporting throbbing (31%) or sharp (20%) pain (P= 0.035) at 2 days postappointment. The CA group reported the most pain at rest, whereas the FA group reported chewing as the most painful (P= 0.002). The FA group had a higher rate of analgesic consumption after the first appointment (P= 0.037). Both the FA and CA groups experienced similar rates and intensities of pain 2 days after the delivery of appliances at the first appointment. Although CA pain intensity remained minimal, FA pain peaked 2 days postappointment whenever a new orthodontic stimulus was introduced and remained elevated 7 days postappointment when that stimulus was a new archwire material.

Protocol for neonatal pain assessment and management: Application of the ALPS Neo scale in routine care

Background and objectives. Neonatal pain research has advanced, disproving earlier beliefs that neonates cannot feel pain due to immature nervous systems. Incomplete myelination slows but does not prevent pain conduction. Pain responses start around 7.5 weeks post-conception, with pain receptors throughout the body by 20 weeks. Pain pathways are established by 22 weeks, but full modulation develops by 32 weeks, making preterm infants more sensitive. Nociceptors detect pain through A-delta (sharp pain) and C-fibers (dull pain). Tissue damage releases chemicals that lower the pain threshold. Pain is classified as nociceptive, somatic, or visceral and can be acute or chronic. Early pain exposure affects later responses. Validated pain scales for neonates include COVERS, PIPP, NIPS, NFCS, and ALPS Neo. Current practice emphasizes preventing and treating pain to minimize stress. Materials and methods. This study at Life Memorial Hospital will analyze patients over 1 month and over 6 months, with ethical approval obtained beforehand. Inclusion criteria: neonates with a gestational age over 35 weeks, birth weight over 2000 grams, needing routine care. Exclusion criteria: neonates needing respiratory support/sedation or with abnormal neurological exams. We will use the ALPS Neo pain assessment scale for its reliability and ease of integration into daily care, aiming to reduce pain or stress duration. Patients will be scored on facial expression, breathing, extremity tone, hand/foot activity, and activity level. Scores of 3-5 will prompt non-pharmacological interventions. Scores above 5 will require frequent reassessments and possible pharmacological intervention. The medical team will be trained on the ALPS Neo scale and non-pharmacological pain reduction methods. Pain from procedures like vaccinations will be assessed during the first two days of life. Initially, control patients will be evaluated without interventions. Over the next 6 months, patients will receive non-pharmacological interventions, including non-nutritive sucking, sucrose, Kangaroo Mother Care, swaddling, and maternal milk or formula. Our group aims to establish an evidence-based protocol for pain assessment and management and to use it in prospective research in which the objectives would be to use a pain scale for more accurate pain data from procedures, identify and reduce the most painful procedures, evaluate and improve the effectiveness of pain management strategies. Conclusions. This observational study at Life Memorial Hospital will use the ALPS Neo pain assessment scale to improve neonatal pain management within the Kangaroo Mother Care program. By comparing a 1-month control group with a 6-month group, we aim to identify and reduce procedural pain. The ALPS Neo scale will enable precise pain assessment and targeted non-pharmacological interventions, potentially guiding future pain management strategies. The choice of ALPS Neo, which is familiar to our team, will ease training and implementation. Success may lead to exploring scales with objective measures, though ALPS Neo will initially drive our improvements in pain management.

Adnexal Torsion of a 28 cm Paratubal Cyst: A Case Report

Objective: To report a rare case of a 28 cm left adnexal torsion requiring surgical intervention including detorsion and salpingectomy Methods: Case report. Results: An 18-year-old nulliparous female with morbid obesity presented to the emergency department complaining of one week of sharp right lower quadrant pain with nausea and vomiting that had acutely worsened. Vital signs were notable for tachycardia, but otherwise within normal ranges. She had a significant leukocytosis. Her pregnancy test was negative. A CT abdomen/pelvis was obtained that demonstrated a large multiloculated complex cystic mass measuring 28.5 x 19.8 x 13.3 cm with possible origin from the ovaries that could represent a serous cystadenoma. Additionally, the scan was remarkable for a heterogeneous and enlarged left ovary measuring 7.6 x 5.9 x 7.2 cm, surrounded by free fluid and mesenteric edema. On examination, she did not demonstrate any surgical abdomen findings. Her pain improved with pain medication. She was admitted, tumor markers obtained, and an ultrasound ordered. The ultrasound demonstrated normal appearing right ovary with present doppler flow and a simple cyst measuring 6.6 x 5.1 x 6.1 cm. The left adnexa was noted to have a complex versus solid mass with unclear boundaries of the ovary. Also noted on the ultrasound were two large simple midline cysts measuring 10.5 x 9.1 x 11.8 cm inferiorly and 18.2 x 15.5 x 17.2 cm superiorly. No free fluid was seen within the right upper quadrant on ultrasound. The view of the left upper quadrant was suboptimal. Due to these findings, Gynecologic Oncology service was also consulted and after discussion, decision made to proceed urgently to diagnostic laparoscopy with robotic assisted cystectomy versus oophorectomy. Upon laparoscopic entry into the abdomen, a large necrotic-appearing left adnexal mass was visualized coming from the left fallopian tube. Both the left fallopian tube and left ovary were necrotic, with the left ovary being torsed numerous times. After resection of the large left fallopian tube and cyst, the left ovary was detorsed, and the decision was made to leave the ovary in situ. It still appeared necrotic, but its blood supply was intact. There was a large simple paratubal cyst on the right fallopian tube that was also drained and excised. Postoperatively, her right lower quadrant pain resolved, and she was discharged on post-operative day 1. She prescribed a two-week course of doxycycline and metronidazole as pelvic inflammatory disease could not be ruled out. At outpatient follow-up, she was asymptomatic and ready to begin working again. Her pathology report confirmed a large left paratubal cyst with associated findings of ischemia due to torsion and a large right paratubal cyst. Conclusions: Adnexal torsion is a rare gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support, which can negatively impact fertility. Prompt diagnosis is key, but definitive diagnosis is only by direct visualization. The differential diagnosis for acute onset of severe pelvic pain with nausea and vomiting is broad and includes ectopic pregnancy, pelvic inflammatory disease, endometriosis, ruptured ovarian cyst, urologic issues and gastrointestinal issues. Commonly, ultrasound is used to help evaluate a possible torsion with several classic findings that were not noted in this case, other than a mass. The two best known risk factors for adnexal torsion are a mobile ovarian mass and a history of prior torsion. Although large ovarian masses greater than 5 cm are more likely to cause torsion, some experts hypothesize that very large masses are less likely to torse given the constraints of the pelvis. However, such was not the case here. Additionally, it has been observed that adnexal torsion typically affects the right adnexa due to theoretical protection from the descending colon on the left. Given that the case presented did not have any of the typical imaging findings for adnexal torsion and that her pain was on the right but the torsion on the left, it is important to maintain a high level of suspicion when evaluating patients with acute onset pelvic pain of any location with nausea and vomiting.

Treatment of Achilles tendon rupture in a patient with alkaptonuric ochronosis

The treatment result of a patient with spontaneous rupture of the Achilles tendon and features of diagnosing alkaptonuric ochronosis, a rare disease, are presented, providing doctors beneficial information for the prevention and/or delay of possible complications. On March 8, 2021, at about 20:50, while at his workplace, getting up from his chair from the table, patient K, 52 years old, felt a sharp pain in the lower third of his right shin and was urgently taken to the hospital. He was examined by a traumatologist and was initially diagnosed with rupture of the right Achilles tendon. His right lower limb was immobilized with a plaster splint. On March 11, 2021, he entered the military traumatology and orthopedics clinic of the Kirov Military Medical Academy for surgical treatment. Upon admission, the patient complained of pain in the right lower leg and impaired support function of the right lower limb. Based on complaints, medical history, laboratory results, and instrumental studies, subcutaneous rupture of the right Achilles tendon was diagnosed. On March 12, 2021, anchor suture of the right Achilles tendon was performed. Anesthesia — combined, access: two separate incisions on the posterior surface of the lower third of the right leg and in the area of the calcaneal tubercle, each 5 cm long, intraoperatively revealed a complete subcutaneous rupture of the right Achilles tendon. Notably, the tendon was black in color when cut. The postoperative period proceeded without complications, and postoperative wounds of linear shape in the right Achilles tendon healed by primary intention. No signs of disturbances were observed in peripheral circulation and innervation of the right lower limb. To confirm the diagnosis, a simple laboratory test was performed: a change in the color of urine during the day, after its additional alkalization. The color change is due to the polymerization of homogentisic acid, which is excreted in large quantities in the urine. To verify the diagnosis, a molecular genetic technique was performed: sequencing of the clinically significant HGD gene and encoding the enzyme homogentisate-1,2-dioxygenase, which are mutations that lead to alkaptonuria. The analysis results confirmed the presence of an amino acid substitution at the pGLy161Arg position, indicating pathogenicity. The use of simple methods of additional laboratory diagnostics and molecular genetic analysis enabled the diagnosis of alkaptonuric ochronosis. Thus, characteristic diagnostic signs were damage to the Achilles tendon in combination with the obtained anamnestic, clinical, and laboratory data of alkaptonuria.