Strong Pain Research Articles

Epithelioid sarcoma of femoral nerve: A case report

Introduction. Epithelioid sarcoma is a slow-growing malignant soft tissue tumor and occurs approximately in 1% of all soft tissue malignant tumors. This case report describes epithelioid sarcoma in femoral nerve and as we know it is the first described case of epithelioid sarcoma at this anatomical localisation. Case report. A 44-years-old female patient presented with strong pain in her left leg. On magnetic resonance imaging (MRI), tumor was presented as a node 8 cm in the diameter at left femoral nerve between ileopsoas and iliacus muscle, without infiltration of muscle fascia and tendons. Four enlarged lymph nodes described in left iliac fosa, were suspected on secondary tumor deposits. We preformed radical surgical excision of the tumor and femoral nerve transection with local lymp hnode disection. Histopathological analysis revealed epithelioid sarcoma, and tumor stained highly positive for anti-pan cytokeratin antibody (AE1/AE3), vimentin, cancer antigen 125 (CA125), anticytokeratin antibody (MNF116), hematopoietic progenitor cell antigen (CD34) and epithelial membrane antigen (EMA) markers. After the operation patient recived radiotherapy without chemotherapy. Six months postoperatively, there was no evidence of local relapses or distant metastases. Conclusion. Initial wide surgical resection and adjuvant radiotherapy is beneficial in treatment of epitheloid sarcoma.

Labor Pain through the Eyes of Brazilian Women and Delivery Nurses

Objective: Understanding the perception of women who have recently given birth in a Brazilian hospital regarding labor pain and nursing involvement in the labor process. Methodology: exploratory, descriptive and qualitative study carried out in a Maternity part of the supplementary health system in the Federal District (DF). Data were collected between May and July 2015 through interviews using a semi-structured questionnaire. The sample consisted of 16 mothers and data analysis followed Bardin methodology in three phases. Results: The pain experienced during labor is surrounded by feelings and expectations. Both positive and negative feelings experienced by mothers were identified in the interviews and unanimous opinion was the fact that the second stage is the most painful period as continuous pain is experienced. Some of the participants compared pain with strong menstrual cramps, renal colic and back pain; others, said labor pain was the strongest ever experienced. The immediate contact with the newborn was referred to as a reward for coping with breast pain and suffering. Other factors such as the importance of follow-up, support and coping with the pain and care provided by health staff were also highlighted. Conclusion: empowerment of the mother and family through knowledge is considered an important tool to fight pain and cope with the birth process in a positive and physiological way, which in the long run promotes a cultural change in the population regarding the importance of vaginal birth.

Nekritična primena nesteroidnih antinflamatornih lekova u terapiji hroničnog nemalignog bola - nekritična primena Nsail

Introduction: Pain is a subjective experience. Perception of the pain intensity is influenced by multiple factors including genetic, socio-economic and psychological factors. Chronic non-cancer pain represents the socioeconomic burden. In adolescent population, osteoid osteoma has an incidence of 10-12% in all symptomatic benign bone tumors. Nonsteroid anti-inflammatory drugs (NSAIDs) are the most frequently used medications for non-cancer pain treatment. Case report: Male, 17 years old, complained about moderate low back pain. Clinical examination was performed and subsequent diagnostic procedures (ultrasound examination of abdomen, nuclear magnetic resonance examination, and radiographic examination of lumbal spine) revealed discopathia and left leg sensory neuropathy. After examination by a pediatrician, physical medicine specialist and an orthopedic surgeon, he started using analgesic (ibuprofen 600 mg), vitamins and physical treatment. Diclofenac 75 mg was added for severe pain management. Haematuria, eosinophylia, decreased creatinine clearance were consequences of NSAIDs toxic nephritis. NSAIDs were stopped and patient reffered to pain specialist - different focuses of pain were suspected. Subspecialist verified pricking and heating sensation in upper leg, severe hip pain without functional deficit and dominating neuropathic pain originating from spinal nerve compression. New radiography reveiled presence of osteoid osteoma of the hip, and after orthopedic consultation, surgery (biopsy of tumor and tumor extirpation) was performed. In the postoperative period, strong pain disappeared, pregabalin was introduced and neuropathic pain was reduced by 20% and low back pain by 30%. Discussion: NSAIDs are the first line treatment of wide range of pain states. NSAIDs can cause numerous serious side effects including acute interstitial nephritis. Conclusion: Multiple causes and types of pain can exist simultaneously, therefore detailed physical examination, followed by other diagnostic Pre primene analgetika, neophodno je izvršiti detaljan klinički pregled i dijagnostičke pretrage, čime bi se smanjila nekritična primena NSAIL.

Complications with use of misoprostol for abortion in Madagascar: between ease of access and lack of information

ObjectiveThe objective was to learn what complications some women experienced in Madagascar following use of misoprostol for abortion and what treatment they received post misoprostol use. Study designThis was a qualitative study in 2015–2016 among women who had experienced complications after use of misoprostol, with or without additional methods, for abortion; what information they received before use; what dosage and regimens they used; what complications they experienced; and what treatment they received postuse. We initially conducted in-depth, semistructured interviews with 60 women who had undergone an abortion that resulted in complications. The results presented here are based on interviews with the subset of 19 women who had used misoprostol. ResultsThe 19 women were aged 16–40, with an average age of 21–26 at interview and average age of 18–21 at abortion. To obtain an abortion, they sought advice from partners, friends, family members, and/or traditional practitioners and health care providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens the women used on the advice of others were extremely variable, did not match WHO guidelines and were apparently ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/hemorrhage, strong pain and/or infection. ConclusionsThis study provides data on complications from the use of misoprostol as an abortifacient in Madagascar. Health care providers need training in correct misoprostol use and how to treat complications. Law and policy reforms are needed to support such training and to ensure the provision of safe abortion services in the public health system. ImplicationsHealth care providers who provide abortion care and treatment of abortion complications need training in correct misoprostol use and treatment of complications. Women and pharmacy workers also need this information. Law and policy reforms are needed to allow training and provision of safe services. Further research is needed on the extent and impact of incorrect misoprostol administration.

Reduction of post-surgical pain by Manual Medicine following tonsillectomy in adults

Objective Postoperative pain after tonsillectomy (TE) can usually be treated sufficiently by non-steroidal anti-inflammatory drugs (NSAIDs). In some patients, however, postoperative pain is more prominent on one side of the neck. Our clinical experience has demonstrated that these patients often show a segmental hypomobility of the upper cervical joints that can be successfully treated by manual medicine (MM). The analgetic effectiveness of this treatment was investigated in a prospective, randomized, placebocontrolled, single-blind study. Material and Methods 52 adults with exceptionally strong (visual analog scale VAS > 4) and/or unilateral pain after TE (between day 1 and 4) were included in this study. Postoperatively (TE) pain scores were immediately evaluated by VAS before (t0) and after (t1) the treatment (MM) as well as 4 hours (t2) and 1 day later (t3). Results Results show a significantly higher reduction in pain in the verum group compared to the placebo group (t1: p = 0.012, t3: p = 0.012, both Bonferroni-adjusted). The difference to t2 was not significant (p = 0.54 Conclusion This study has demonstrated effective pain reduction by manual medicine in adults with exceptionally strong and/or unilateral pain after TE and cervical hypomobolity.

Spinal miRNA-124 regulates synaptopodin and nociception in an animal model of bone cancer pain

Strong breakthrough pain is one of the most disabling symptoms of cancer since it affects up to 90% of cancer patients and is often refractory to treatments. Alteration in gene expression is a known mechanism of cancer pain in which microRNAs (miRNAs), a class of non-coding regulatory RNAs, play a crucial role. Here, in a mouse model of cancer pain, we show that miR-124 is down-regulated in the spinal cord, the first relay of the pain signal to the brain. Using in vitro and in vivo approaches, we demonstrate that miR-124 is an endogenous and specific inhibitor of synaptopodin (Synpo), a key protein for synaptic transmission. In addition, we demonstrate that Synpo is a key component of the nociceptive pathways. Interestingly, miR-124 was down-regulated in the spinal cord in cancer pain conditions, leading to an up-regulation of Synpo. Furthermore, intrathecal injections of miR-124 mimics in cancerous mice normalized Synpo expression and completely alleviated cancer pain in the early phase of the cancer. Finally, miR-124 was also down-regulated in the cerebrospinal fluid of cancer patients who developed pain, suggesting that miR-124 could be an efficient analgesic drug to treat cancer pain patients.

The effect of being imitated on empathy for pain in adults with high-functioning autism: Disturbed self-other distinction leads to altered empathic responding.

Autism spectrum disorder is a neurodevelopmental disorder that is associated with problems in empathy. Recent research suggests that impaired control over self-other overlap based on motor representations in individuals with autism spectrum disorder might underlie these difficulties. In order to investigate the relationship of self-other distinction and empathy for pain in high-functioning autism and matched controls, we manipulated self-other distinction by using a paradigm in which participants are either imitated or not by a hand on a computer screen. A strong pain stimulus is then inflicted on the observed hand. Behavioral and physiological results in this study showed that overall affective responses while watching pain movies were the same in adults with high-functioning autism as in controls. Furthermore, controls showed higher affective responding after being imitated during the whole experiment, replicating previous studies. Adults with high-functioning autism, however, showed increased empathic responses over time after being imitated. Further exploratory analyses suggested that while affective responding was initially lower after being imitated compared to not being imitated, affective responding in the latter part of the experiment was higher after being imitated. These results shed new light on empathic abilities in high-functioning autism and on the role of control over self-other representational sharing.

Dissatisfaction and persistent post-operative pain following total knee replacement – A 5 year follow-up of all patients from a whole region

Abstract Introduction Total knee replacement (TKR) is the treatment of choice for the millions of individuals whose osteoarthritis related pain can no longer be managed through non-invasive methods. Although most patients report improvement in pain and functioning following TKR, up to 30% report after 1–2 years persistent pain that interferes with their daily function. Further knowledge on long term results are highly demanded. The present study is the first 5 year follow-up of all patients from a whole region. Methods Patients were interviewed by letter concerning pain, overall satisfaction and forgotten joint score (FJS). In 2011, 607 patients in the region of North Denmark had a primary TKR, of which 20 was bilateral. Still alive are 546 patients. A total of 498 answered by letter (91%) of which 13 were not able to answer detailed due to psychological reasons. Results A total of 290 (59%) patients were very satisfied with their TKR, 140 (30%) were satisfied and 58 (12%) dissatisfied. Pain free were 269 (55%). 163 patients (33%) experienced moderate pain and 55 (11%) had strong pain. Dissatisfaction and pain were highly correlated, especially pain at walking: Among patients reporting strong pain, 35 (64%) scored higher than 6 on the VAS-average pain last 24 h versus 46 (84%) that scored higher than 6 on the VAS-pain after 30 min’s walk. Conclusions Among an unselected series of patients having TKR, 12% were dissatisfied and 11% still had strong pain 5 years later. Dissatisfaction was especially correlated with pain when walking. Thus, the association between dissatisfaction, pain at activity and the individual expectations should be further focused.

Fenomen Raynauda jako czynnik przepowiadający rzadką postać choroby wieńcowej — dławicę naczynioskurczową Prinzmetala

Opisany przypadek dotyczy mężczyzny skierowanego na szpitalny oddział ratunkowy z podstawowej opieki zdrowotnej z powodu silnych dolegliwości bólowych kręgosłupa występujących od 2 tygodni. Ze względu na niewyrównaną cukrzycę był on hospitalizowany w klinice endokrynologii. W trakcie tego pobytu kilkukrotnie wystąpił u niego napad zespołu Raynauda. Wkrótce po incydencie chory odczuwał bardzo silny i typowy ból w klatce piersiowej. W angiografi i naczyń wieńcowych wykonanej w momencie trwającego bólu stwierdzono skurcz w początkowym odcinku gałęzi międzykomorowej przedniej lewej tętnicy wieńcowej, który ustąpił po dowieńcowym podaniu nitrogliceryny. Markery martwicy mięśnia sercowego nie były podwyższone. Powyższy obraz kliniczny, w połączeniu z wynikami badań dodatkowych, przemawiał za dławicą Prinzmetala (naczynioskurczową). Interesujący jest fakt, że dolegliwości bólowe występujące w klatce piersiowej za każdym razem poprzedzał napadowy kurcz tętnic palców dłoni z ich zblednięciem i mrowieniem, a następnie zasinieniem i, kolejno, zaczerwienieniem oraz pieczeniem skóry. Zastosowana farmakoterapia, z wyboru w obu przypadkach taka sama, pozwoliła na ustąpienie dolegliwości zarówno ze strony klatki piersiowej, jak i palców dłoni chorego.

Focal necrosis mimicking breast cancer following coronary bypass grafting

BackgroundBreast cancer can be diagnosed easily in most cases. However, occasionally, we are faced with some conditions that can mimic it. These may include inflammations, benign tumors, cysts, hematomas, or, more rarely, focal necrosis.Case presentationThis report presents a case of focal breast necrosis following myocardial revascularization with the left internal mammary artery, which is a very rare condition, with only few cases described in the literature. The necrosis becomes usually apparent a few days or weeks after the surgery and is often coincidental with the dehiscence of sternotomy with necrosis of wound edges. As it mostly affects the skin, it can be easily recognized. Also, our patient developed a dehisced sternotomy shortly after the surgery but there were no obvious objective changes on the breast. The condition was first dominated only by non-specific subjective symptom—pain. Later, a lump in the breast occurred, when the sternotomy had already healed. Moreover, an enlarged lymph node was palpable in the axilla. Because of non-typical symptoms, the condition was suggestive of breast cancer for a relatively long time. The patient had suffered from a very strong pain until she was treated by mastectomy with a good clinical result.ConclusionsMammary necrosis following the coronary artery bypass is rare. In most cases, it manifests on the skin shortly after the surgery concurrently with dehisced sternotomy, so it can be easily diagnosed. However, in sporadic cases, the symptoms may occur later and may mimic breast cancer. Our objective is to raise awareness of this rare condition.

Five-Year Follow-Up After Laparoscopic Large Nerve Resection for Deep Infiltrating Sciatic Nerve Endometriosis

ObjectiveTo report neurologic follow-up of patients after laparoscopic large resection of deep infiltrating endometriosis of the sciatic nerve. DesignProspective clinical case series. SettingTertiary referral unit specializing in advanced gynecologic surgery and neuropelveology. PatientsAll data for patients who underwent laparoscopic surgery for endometriosis of the sciatic nerve between 2004 and 2016 (n = 259) were documented prospectively. In this study, patients who underwent a large resection of the sciatic nerve (>30% of the nerve) and were followed for at least 5 years were evaluated (n = 46). All patients presented preoperatively with incapacity for normal gait and foot drop. All were suffering from intractable and constant neuropathic sciatic pain (visual analog scale [VAS] score of 9 to 10 despite strong pain medicine), with sensorimotor disorders of the affected leg. InterventionsLaparoscopic large resection of endometriosis of the sciatic nerve. Measurements and Main ResultsAll procedures were performed by laparoscopy. Postoperative management included medical treatment with neuroleptic agents and intensive physiotherapy. At the 5-year follow-up, all patients reported significant pain reduction, with a median VAS score of 2.1 (range, 0 to 3) and recovery of normal gait, including the ability to climb stairs. ConclusionIn deep infiltrating intraneural endometriosis of the sciatic nerve, patients present with motor disorders before and after surgical resection. The average VAS score was reduced from 9.33 preoperatively to 1.25 at a 3-year follow-up. When full resection of endometriosis including nerve resection is completed, sciatic nerve function recover, but recovery of a normal gait may take at least 3 years and intensive physiotherapy.

Facial presentations of primary headache disorders.

Background Many patients with mid-face or lower face craniofacial pain are diagnosed, based on accompanying signs and symptoms and features other than location, as either atypical migraines or atypical TACs. Distinguishing features of headache disorders as a cause of facial pain include the temporal pattern of pain, associated symptoms including light and sound sensitivity and nausea, cranial autonomic symptoms, and the lack of local triggering among others. Results An intraoral neurovascular pain has been observed, and was termed neurovascular orofacial pain (NVOP). Due to its location, and signs imitating dental pulpitis, it has great diagnostic and therapeutic importance for differentiating NVOP from dental pathology. The hypothesized mechanism is neurogenic inflammatory activation within the space confined by dentine around the dental pulp, expressed in strong paroxysmal pain and typical allodynia to cold foods. Conclusion Facial manifestations of headache disorders and primary facial pain disorders share common trigeminal nerve input, yet they are highly distinct disorders. Somatotopic segregation may occur at the level of the trigeminal nucleus, thalamus, and somatosensory cortex, and distinct ionic or neurochemical signaling pathways may be involved. Further investigation of facial presentations of headache disorders has the potential to provide new insight into the interface between headache and facial pain.

Slow brushing reduces heat pain in humans.

C-tactile (CT) afferents are unmyelinated low-threshold mechanoreceptors optimized for signalling affective, gentle touch. In three separate psychophysical experiments, we examined the contribution of CT afferents to pain modulation. In total, 44 healthy volunteers experienced heat pain and CT optimal (slow brushing) and CT sub-optimal (fast brushing or vibration) stimuli. Three different experimental paradigms were used: Concurrent application of heat pain and tactile (slow brushing or vibration) stimulation; Slow brushing, applied for variable duration and intervals, preceding heat pain; Slow versus fast brushing preceding heat pain. Slow brushing was effective in reducing pain, whereas fast brushing or vibration was not. The reduction in pain was significant not only when the CT optimal touch was applied simultaneously with the painful stimulus but also when the two stimuli were separated in time. For subsequent stimulation, the pain reduction was more pronounced for a shorter time interval between brushing and pain. Likewise, the effect was more robust when pain was preceded by a longer duration of brush stimulation. Strong CT-related pain reduction was associated with low anxiety and high calmness scores obtained by a state anxiety questionnaire. Slow brushing - optimal for CT activation - is effective in reducing pain from cutaneous heating. The precise mechanisms for the pain relief are as yet unknown but possible mechanisms include inhibition of nociceptive projection neurons at the level of the dorsal horn as well as analgesia through cortical mechanisms. Slow brushing stimuli - optimal for activation of C-tactile fibres - can reduce pain from cutaneous heating. No such effect was seen with fast brushing or vibration. These observations indicate the role of C-tactile fibres in pain modulation.

A nontoxic pain killer designed by modeling of pathological receptor conformations.

Indiscriminate activation of opioid receptors provides pain relief but also severe central and intestinal side effects. We hypothesized that exploiting pathological (rather than physiological) conformation dynamics of opioid receptor-ligand interactions might yield ligands without adverse actions. By computer simulations at low pH, a hallmark of injured tissue, we designed an agonist that, because of its low acid dissociation constant, selectively activates peripheral μ-opioid receptors at the source of pain generation. Unlike the conventional opioid fentanyl, this agonist showed pH-sensitive binding, heterotrimeric guanine nucleotide-binding protein (G protein) subunit dissociation by fluorescence resonance energy transfer, and adenosine 3',5'-monophosphate inhibition in vitro. It produced injury-restricted analgesia in rats with different types of inflammatory pain without exhibiting respiratory depression, sedation, constipation, or addiction potential.

Assessment of physical properties of granules with paracetamol and caffeine

Caffeine increases the analgesic properties of acetaminophen and therefore it is reasonable to use both substances together in one drug form in stronger pain. Currently, there are no commercially available pharmaceutical combination products containing acetaminophen and caffeine, which is present as granules. The aim of the study was to obtain twelve different granules with these therapeutic substances and determine the effect of various excipients on the quality of the drug form. All the granules were made by wet granulation. Two types of binders were used: polyethylene glycol 6000 (PEG) and polyvinylpyrrolidone K30 (PVP) as well as different types of fillers. The physical properties of granules were assessed in accordance to the requirements of the European Pharmacopoeia 8th ed. The highest apparent density was found in preparations containing calcium hydrophosphate (0.609g/mL) and the lowest – containing mannitol (0.353g/mL) as a filler. The Hausner ratio of most prepared granules ranged from 1.05 to 1.11, while the compressibility index ranged from 4.59 to 10.48%. The evaluation of properties of individual granules helped to indicate formulation with good features, which perhaps will be a good alternative to currently available painkillers with caffeine and acetaminophen.

The impact of Reiki on side effects in patients with head-neck neoplasia undergoing radiotherapy: a pilot study

Cancer patients often report symptoms related to therapeutic treatment, whose management is based on traditional medicine. In recent years, however, there has been growing interest towards adopting some form of complementary medicine, among these, Reiki. The aim of this study is to evaluate how this type of discipline can contribute to managing radiotherapy-related symptoms in patients with head and neck cancer. The study was performed in the Radiotherapy Department at the Regina Elena National Cancer Institute in Rome. To assess QoL, the FACT-H N questionnaire was used, while the CTCAE Scale was adopted to evaluate mucositis, cutaneous toxicity and salivation. 10.5% of patients were reported to experience strong pain in the fifth week, compared to 21.1% of patients in the previous week; a degree of mucositis equal to G3 was also found in 15.5% of cases according to the clinical evaluation, as well as in 10.5% of patients according to the functional one. Only one case (5.3%) of grade 3 cutaneous toxicity was registered. The study shows how the Reiki treatment benefits patients in most cases, with both psychological support to help deal with the therapeutic process together with integrated support towards pain therapy.

The effectiveness of thyme honey for the management of treatment-induced xerostomia in head and neck cancer patients: Afeasibility randomized control trial.

Radiation-induced xerostomia is one of the most common side effects that head and neck cancer patients experience during and after treatment. Despite the various methods for the prevention and treatment of radiation-induced xerostomia, it remains highly prevalent among patients treated for head and neck cancers negatively influencing their lives. The purpose of this study was to evaluate the effectiveness of thyme honey as a means for managing radiation-induced xerostomia. This was a parallel randomised controlled trial with two equal arms, the experimental arm (thyme honey) and the control arm (saline). 72 head and neck cancer patients receiving radiotherapy or/and chemotherapy or/and surgery were recruited in a specialised cancer centre. Patients in both arms followed the same administration protocol with thyme honey and saline respectively. Identical assessments at baseline, 1 month and 6 months following completion of the intervention were performed in both arms including the National Cancer Institute (NCI) xerostomia scale and the Xerostomia Questionnaire (XQ) additionally to weekly oral clinical assessments. The ClinicalTrials.gov Identifier for this study is NCT01465308. Linear Mixed Models revealed the statistically significant effect of the intervention on xerostomia (F=8.474 p<0.001) and overall quality of life (F=13.158 p<0.001). Moreover, Generalised Estimating Equations revealed a statistically significant effect on strong and unbearable pain (F=10.524 p<0.001) and dysphagia (F=4.525 p=0.033). The study has demonstrated the safety and efficacy findings of Thyme honey in head and neck cancer patients for the management of treatment induced xerostomia.

股関節痛に対するボツリヌス治療が有効であった脳性麻痺症例

For the pain around the hip joint of patients with cerebral palsy, treatment with botulinum toxin type A (BTX) was provided. We report the case that a pain improved. There was five cases (one male, four female), and the age of the initial treatment was from 12 years old to 61years old. The state of the hip joint was three dislocation, subluxation one, osteoarthritis one case. The main symptoms were a strong pain when we moved a hip joint, sitting difficulty and sleep disorders due to the pain. We injected BTX 1–2 times into the muscles presented hyper tone with spasticity around the hip joint, and the strong pain was improved. They became able to sleep well in the night, or/and were able to reduce NSAIDs after BTX treatment, and the satisfaction of the patients and the caregiver was high. For the coxalgia of the patients with muscle tone abnormalities, there is the case that BTX treatment is effective.

Laser analgezija u toku ortodontske terapije

Introduction: Most of the patients feel pain 4 hours after the arch applying, gaining the highest level after 24 hours and its lowering in the next few days. Literature reports show that the fear of pain is a very important reason for discouraging the patient to agree for this kind of orthodontic treatment The aim of this study was to evaluate the effectiveness of the biostimulative laser treatment in pain reduction in patients with fixed orthodontic appliances. Materials and methods. Fifteen patients were treated with low energy level biostimulative diode laser, used 2 minutes per quadrant immediately after placement of fixed orthodontic appliances and in the following four days. The control group of 15 patients received analgesic therapy for period of five days. The pain was assessed subjectively as strong, medium or no pain. The pain disappeared in 20% of the subjects in the examined group after the first day, while in 60% and 26.6% of the subjects medium and isolated pain was still present at day 2 and 3, respectively. Results. The pain disappeared in all the patients treated with laser at day 5. In the control group, strong pain was present in all the subjects the first day, decreasing to 60% of strong pain and 20% medium pain the second day. After day three, the control group demonstrated medium localized pain in 40% of the cases, which dropped to 26.6% after the fourth day, suggesting delayed pain reduction, compared to the laser treated group. Conclusion. Our results suggest that the low energy laser treatment can successfully be used for pain reduction during the initial discomfort period after placing fixed orthodontic appliances.

Gas as a Sign of Critical Illness in Abdominal Diseases

Gas normally only occurs in the gastrointestinal system. Gas in the free abdominal compartment is a sign of perforation. But gas sometimes can also be seen in parenchymal organs (as abscess or covered perforation), also in the retroperitoneal room and very seldom in the wall of bowel or in vessels. Gas at wrong places (extragastral and extraintestinal) is an important sign in gastrointestinal diseases. Perforation of the GIT is occurring very rarely (1-2%). Most frequently it is caused by ulcers of the stomach and the duodenum. X-ray, sonography and endoscopy are most important in the diagnosis of this complication. X-ray is fairly reliable in detecting air but needs a greater emission of gas. Given optimal conditions during the examination ultrasound can detect small amounts of air (1-2 ml). In daily routine sensitivity of this method is low (approx. 50 %). The diagnosis of a covered perforation is very complicated as it is lacking the typical criteria of free air in X-ray and sonography. Patients with strong epigastric pain who were suspected to have a perforation were examined by ultrasound before and after undergoing endoscopy. We payed special attention to the presence of criteria of free air as well as any sonographical changes in the surrounding of the stomach. The detection of free air by sonography sometimes is better after endoscopy. A covered perforation can only be visualized by enhancement of air. Criteria of a covered perforation are: *Echogenuous enhancement of a strictly limited cavity of perforation. *Reverberations of air within the cavity. *Detection of the leakage. (Orifice of perforation) *Detection of air motion. *Change of sonographical image after second look sonography. The detection of a free or a covered perforation by endoscopy and other imaging methods is complicated. Second look sonography after insufflation of air by endoscopy can be useful and shows sometimes the perforation cavity. Under optimal conditions even the leakage can be visualized. The principle of a complementary sonography is little incriminatory. It provides the examiner with additional information, especially in a diagnostic procedure that is marked by a pressure of time. Gas in abdominal organs is a sign of abscess. Abscesses with gas can also occur between the bowel loops as interenteric abscesses. Gas in abdominal vessels can occur in situation of sepsis.