A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurologic Impairment

The term “severe neurologic impairment” (SNI) is used to describe a group of disorders of the central nervous system which arise in childhood, resulting in motor impairment, cognitive impairment and medical complexity. As a result, much assistance is required with activities of daily living. Since these patients are often unable to self-report pain, or they may exhibit uncommon behaviors when suffering, pain manifestations may go unrecognized. In this article, the basic principles of how to approach pain in children with SNI are discussed.

The Clinicopathological Features And Surgical Procedure of Adnexal Mass With Abdominal Pain In Pediatric And Adolescent Patients

Objective: To investigate the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients.Methods: A total of 212 pediatric and adolescent adnexal masses with abdominal pain who underwent surgery were retrospectively reviewed. The patients were divided into two groups, namely, the emergency surgery (EMS, n=96) group and the elective surgery (ELS, n=116) group, according to whether they had been surgically diagnosed with emergency conditions. EMS group refers to patients who had been surgically diagnosed with emergency conditions including adnexal masses torsion，corpus luteum rupture，and rupture of ectopic pregnancy. ELS group refers to patients with adnexal mass without emergency condition. The differences between the two groups were compared using the chi- squared test.Results: At the surgery evaluation, the median age was 14.5±3.6 years. A total of 175 patients (82.5%, 175/212) had menstruation, and 37 patients (17.5%, 37/212) had not yet begun menstruating. A total of 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. Pelvic abdominal ultrasound was the first imaging modality used in all the patients (n = 212/212; 100%). Tumor markers were abnormally elevated in 26 patients.Compared with the ELS group, the proportion of patients with emergency onset of pain, pain duration less than 3 months, persistent and intense of pain were significantly higher than those in ELS group (P < 0.05). There were significantly more patients without menarche in the EMS group than in the ELS group (p<0.05). The average tumor size in the ELS group was larger than that in the EMS group (p<0.05). In the EMS group, 78 cases（ 81.3%,78/96）had adnexal mass torsion, 16 cases (16.7%，16/96) had mass rupture, and 2 cases (2.1%, 2/96）had ectopic pregnancy. Of the 78 patients with adnexal mass torsion, 49 cases (62.8%, 49/78）underwent ovary-preserving surgery, and 24 cases (30.8%，24/78）underwent adnexectomy. The most common pathologic types of adnexal torsion were mature teratoma cysts and simple cysts, accounting for 29% and 26%, respectively.Conclusions: Adnexal masses combined with abdominal pain in pediatric and adolescent patients, especially for patients presented as acute pain which characterized by emergency pain onset, persistent pain that cannot be relieved or recurrent pain，should be considered due to the possibility of adnexal mass combined with acute complications, and emergency surgery should be performed immediately. For patients with suspected malignant lesions, a comprehensive evaluation of the lesions should be conducted preoperatively to select the appropriate surgical method and strategy. After the discovery of an adnexal mass, evaluation should be performed quickly, and long-term management should be implemented.

Complete Dental Management of an Autism and Intellectual Disability Patient under General Anaesthesia: A Case Report

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and the presence of restricted interests and repetitive behaviours. Comorbidities following ASD, such as seizure, intellectual disability, and sensory impairment worsen patients’ ability to care for themselves. We present the case of a 22-year-old man with autism, intellectual disability and visual impairment who had recurrent pain in his upper and lower left posterior teeth that had cavities. On the first visit, the patient was observed and had panoramic x-ray. Clinical examination could not be done properly due to lack of patient cooperation. Restoration, pulp capping, tooth extraction, and odontectomy were planned under general anaesthesia.

Rare Case of Lumbosacral Conjoint Root Diagnosed as Sequestered Disc by MRI: A Case Report

Introduction: Conjoint nerve root is embryological nerve root abnormality mainly affecting lumbosacral region. The atypical roots present primarily as a bifid, conjoined structure originating from a wide area of the dura. The conjoint roots are highly liable to trauma due to their size and attachment to surrounding structures. The effects of compression and entrapment are augmented in the case of having stenosis of the lateral recesses where developmental changes and disc herniations deplete the available reserve space. Conjoined nerve roots are a relatively uncommon finding but are frequently left undiagnosed on preoperative imaging studies. Misinterpretation as sequestered disc can lead to devastating results especially during limited spine approach. Case Report: A 43-year-old male patient presented with low back pain gradually progressing over the last three years. Pain was radiating to his left leg associated with tingling sensation and a mild weakness in his left foot. Clinical examination revealed normal muscle bulk and tone. Strength was full bilaterally except the mild weakness 3/5 on toe dorsiflexion of the left foot. Deep tendon reflexes were 3+ at the left knee and ankle. Plantar responses were flexor. Sensation was intact, and there was no loss of sphincters control or bladder dysfunction. A standard plain lumbosacral MRI was performed. The patient was admitted for L5/S1 discectomy. Surgical intervention was recommended, during the surgery we recognized the huge conjoint root. Adhesiolysis and discectomy was done carefully without causing any serious neural injury to the conjoint root. Clinical surgical outcome was good. Pain and tingling sensation disappeared only paresthesia over the S1 dermatome. Postoperative course was uneventful, and the patient was discharged after his neurological improvement on day 7, post operation. However, the patient complained of recurrent pain on follow-up visit and continues being followed-up. Conclusion: The conjoined nerve root anomaly diagnosis is not easy and has several points of significance. If misdiagnosed, it could be incorrectly treated as a case for a herniated disc. Neurosurgeons should consider these anomalies in their differential diagnosis. Cases of conjoined nerve root anomaly may be wrongly managed and result in wrong level of surgery with a poor outcome. Researchers conclude that the correct diagnosis of root anomalies is vital for the patient, any misinterpretation could lead to catastrophic consequences.

Disseminated Mycobacterium avium infection in a young woman with sickle cell disease and iatrogenic iron overload

A 29-year-old woman with known sickle cell disease (SCD) and iatrogenic iron overload presented to the emergency department with a recurrent pain crisis and fever. Blood cultures obtained at a recent prior admission for the same complaints grew M avium. Bone marrow biopsy revealed non-caseating granulomas, but stains for mycobacteria and fungi were negative. Disseminated non-tuberculous mycobacterial infections (NTMIs) occur almost exclusively in immunosuppressed patients. SCD is not considered a risk factor for the development of disseminated NTMIs, making diagnosis challenging in this population. However, a number of case reports describing disseminated NTMIs in patients with SCD have been published. This case adds to the current literature, suggesting SCD with iatrogenic iron overload is a possible risk factor for disseminated NTMIs. Potential mechanisms for this increased risk include 1) functional asplenia, 2) iatrogenic iron overload, 3) chronic indwelling central venous catheters, and 4) hydroxyurea use. Further investigation is required to describe the strength and mechanism of the relationship between SCD and disseminated NTMIs.

Complex Regional Pain Syndrome with Aortic Distress after Thoracic Endovascular Aortic Repair and False Lumen Exclusion with “Candy Plug” Technique

A 41-year-old male presented for pain treated with oxycodone. A zone-2 thoracic endovascular aortic repair with distal PETTICOAT (provisional extension to induce complete attachment) for complicated Type-IIIb aortic dissection was performed 18 months before. Repeated hospitalizations did not show any issues to justify the recurrent pain. The aortic nature of the pain was suspected considering the plug as a pain trigger. Through a left thoracoabdominal incision in the eighth intercostal space, the candy plug was removed. Pain diminished after thoracoabdominal surgery steadily.

Pain Abdomen as a Presentation of Congenital Malrotation of Gut: A Case Series

Malrotation of the gut can present at any age but the majority of patients present in neonatal period or early infancy. Most children present with a history of recurrent colicky abdominal pain, vomiting which can be bilious and failure to thrive. Delay in diagnosis leads to increase in mortality and morbidity. Here we present a series of three patients, one girl aged 6 years, one 10 months old boy and one 10 years old boy, who got admitted at our Pediatric Department in a one month period. Patients had a history of recurrent abdominal pain and occasional vomiting, seen and managed by multiple paediatricians and GP doctors with extensive diagnostic workup but never the accurate diagnosis was made. Thorough history was taken and examination done, planned work up done for diagnosis. High index of suspicion is needed in children presenting with recurrent pain in the abdomen. Targeted work-up should be done and patients be kept on follow-up for diagnosis of late presentation of congenital malrotation of the gut.

Using Technology to Assess Bidirectionality between Daily Pain and Physical Activity: The Role of Marginalization during Emerging Adulthood

Emerging adulthood is often overlooked as a developmental time period critical to shaping future health outcomes. Recurrent pain is a commonly experienced health concern within this age group, particularly headaches and low back pain, and early experiences of recurrent pain are related to subsequent chronic pain and disability. Furthermore, adults from marginalized populations report more frequent and severe recurrent pain. Many studies have demonstrated the therapeutic effect of physical activity on pain relief; however, others have demonstrated that physical activity can also exacerbate pain symptoms. Therefore, the current study aimed to (1) assess a bidirectional relationship between reported pain and engagement in physical activity among an emerging adult sample (N = 265) and (2) determine whether sociodemographic factors moderate this relationship. Using longitudinal daily reported pain and ActiGraph monitor data collected over two weeks, a novel dynamic structural equation modeling approach was employed. Results indicated no significant cross-lagged relationships between pain and physical activity, and no significant moderation effects. These findings suggest that a bidirectional relationship does not exist among a diverse college sample of emerging adults even after considering sociodemographic moderators. Excellent retention and few missing data suggest that using accelerometers and daily diaries are feasible methods to collect data in this population. Sample considerations and future analytical approaches are discussed.