Causes and Management of Acute Abdominal Pain in Children: A Review Article

Acute abdominal pain is one of the commonest prevalent grievances in children, and it frequently requires emergency room diagnosis and management. Abdominal pain in children differs with age, concomitant symptoms, and pain site. While most cases of acute abdominal embarrassment are self-limiting and benevolent, there are certain diseases that can be life-threatening and necessitate instant care, such as appendicitis, intussusception, or intestinal obstruction. To decide the cause of acute abdominal pain and recognize children with surgical conditions, scrupulous history taking and numerous physical checkups are mandatory.The most important and realistic first goal in the evaluation of acute AP is to distinguish between surgical and nonsurgical situations, which are further divided into urgent and non-urgent categories. A thorough history and physical examination, laboratory investigations to evaluate comorbidity, and imaging scans are usually used for these purposes. Management decisions should necessitate teamwork between the emergency room physician, a surgeon, and a radiologist. Consecutivereassessment and symptomatic treatment with hardworking follow-up are necessary for management as soon aspossible in urgent disorder.

Site, frequency, and duration of pain in young children with spina bifida

PURPOSE: To investigate the: (1) percent of children with spina bifida (SB) complaining of pain, (2) frequency, duration, and cause of pain by sex, level of lesion type of SB, and ambulation status, (3) body sites reported to hurt, by variables in objective 2, and (4) associations between physical and mental/emotional health between caregiver and child. METHODS: Cross-sectional study of 101 caregivers of children (3 to 6 years old) with SB. Survey data and information from medical records were included. Pearson chi-square, one-way ANOVA, Fisher’s exact test, logistic regressions, and bivariate correlations were used. RESULTS: Seventy percent reported that their child complained of pain, which did not significantly differ by sex, level of lesion, type of SB, or ambulation status. Most (86%) were reported to have experienced pain for less than 24 hours. The most frequently reported pain site was the head, followed by the abdomen and the lower body. Number of pain sites was moderately correlated with frequency of pain complaints. Correlations between how caregivers reported their own physical/mental/emotional health and how they rated that of their children ranged from weak (r = 0.22) to moderate (r = 0.55). CONCLUSION: Almost seven of ten children reportedly complained of pain ranging from at least once a month to everyday. Pain needs to be routinely assessed and treated in this population.

Dorsal root ganglion stimulation combined with spinal cord stimulation for effective treatment of postherpetic neuralgia - A case report -

Background: Although spinal cord stimulation (SCS) can be a treatment option for intractable postherpetic neuralgia (PHN), obtaining proper stimulation at the thoracic dermatome is difficult. Dorsal root ganglion (DRG) stimulation may be an effective treatment for patients with insufficient efficacy in SCS only.Case: A 54-year-old man with intractable PHN was referred to our clinic. Pain was localized to the distribution of the T1–3 dermatomes. SCS trial was conducted, and lead was placed within the epidural space over the C6–T1 level; however, the stimulation was inadequate for his pain site. Therefore, another lead was placed within the left T1 and T2 DRG for trial, and T1 DRG stimulation provided adequate stimulation. T1 DRG stimulation and SCS could cover the entire pain site with paresthesia, and his pain was decreased by over 50%.Conclusions: DRG stimulation combined with SCS may be a good treatment option for intractable thoracic PHN.

Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs – a Danish population-based cohort study

Background People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship. Methods We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0–7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization. Results For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03–1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03–1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09–1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01–1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes. Conclusions We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

Assessing neuropathic pain in sickle cell disease: How useful is quantitative sensory testing?

Quantitative sensory testing (QST) is a psychophysical test of sensory function which may assist in assessing neuropathic pain (NP). This study compares QST findings with a standardized NP questionnaire to assess their agreement among Jamaicans with sickle cell disease (SCD). A cross sectional study consecutively recruited SCD patients 14 years and older, not pregnant, and without history of clinical stroke or acute illness in Kingston, Jamaica. QST identified thresholds for cold detection, heat detection, heat pain and pressure pain at the dominant thenar eminence, opposite dorsolateral foot and the subject's most frequent pain site. The Douleur Neuropathique 4 (DN4) was interviewer-administered to diagnose NP. Subjects were divided into low and high sensitization groups if below the 5th and above the 95th percentiles, respectively on QST measures. Kappa agreement coefficients, and receiver operator characteristic (ROC) curves were performed to compare QST with the DN4. Two hundred and fifty-seven SCD subjects were recruited (mean age 31.7±12.2 years, 55.7% female, 75% SS genotype). Kappa agreements were fair (0.2-0.4) to good (0.6-0.8) between DN4 individual items of itching, hypoesthesia to touch, hypoesthesia to pinprick and brush allodynia with various QST sensitization groups. However, kappa agreements between the NP overall diagnosis on the DN4 with sensitization groups were poor (<0.2). Only heat detection (0.75) and heat pain (0.75) at the leg as a pain site showed satisfactory area under the curve (>0.7). QST may assist in assessing individual components of NP but its use should be limited as a tool to augment clinical assessments.

Prognosis and transition of multi-site pain during the course of 5 years: Results of knee pain and function from a prospective cohort study among 756 adolescents

Introduction Multi-site pain has not been investigated among adolescents suffering from knee pain. This study aimed to examine the trajectory of pain in adolescents with knee-pain, to determine if multi-site pain in adolescents together with other established prognostic factors (frequency of pain, sex, sports participation, Health Related Quality of Life (HRQoL)) was associated with five-year prognosis of knee-pain and function. Methods This prospective cohort study included 504 adolescents with knee pain and 252 controls. At five-year follow-up, participants responded to an questionnaire which documented prescence and severity of knee pain and co-occurring pain. Results At follow-up, 358 (71.0%) of those with knee-pain at baseline, and 182 (72.2%) controls responded. Female sex, low HRQoL, daily pain, and multi-site pain were associated with an increased odds of knee pain after 5 years (odds ratio: 1.41–3.37). Baseline multi-site pain was not associated with problems running at follow-up, whereas higher sports participation at baseline was associated with less problems running at follow-up (odd ratio 0.49). Among those with knee-pain at inclusion, the number of pain sites increased from a median of 2 (IQR 1–3) to 4 (IQR 2–6) at follow-up (P<0.05). Those with multi-site pain at follow-up score significantly worse in self-reported knee function, compared to those with one pain site only. Conclusion This study identified a set of factors that appeared to be associated with an increased risk of knee pain at five years follow up. Research is needed to understand and help direct treatment of adolescents with multi-site pain.

POS0982 DIAGNOSTIC VALUE OF SPECT/CT IN AXIAL SPONDYLOARTHRITIS AND OTHER LOW BACK PAIN

Background:Spondyloarthropathies (SpA) including ankylosing spondylitis are characterized by inflammatory arthritis involving the spine and peripheral joints. Bone SPECT/CT is in the spotlight as it can reflect the current level of inflammation.Objectives:We aimed to investigate the diagnostic performance of bone SPECT/CT for axial SpA (axSpA) at the level of sacroiliac joints.Methods:Patients with low back pain who had undergone SPECT/CT of the SI joints were selected for inclusion in this study through a retrospective review of medical records from August 2016 and July 2018. We used semi-quantitative scoring methods for SPECT/CT. For visual scoring, a score of 0 was assigned when tracer uptake in the sacroiliac joint was less than that in the sacrum; a score of 1, when equal to that in the sacrum; and a score of 2, when greater than that in the sacrum. A score of 2 was considered positive for the diagnosis of sacroiliitis on SPECT/CT (Figure 1). The diagnosis of axSpA was retained when patients fulfilled the Assessment of SpA International Society criteria.Results:A total of 164 patients were enrolled (34 patients with axSpA). The remaining 130 patients had non-axSpA rheumatic inflammatory disease (n=24), vertebral disk herniation (n=13), avascular necrosis (n=11), and others such as bursitis, and fracture (n=85). The mean age of aSpA (37.8±15.6 years) was lower than controls (49.8±16.4 years) (p<0.001), and axSpA (64.5 %) had more male than others (42.1 %) (p=0.024). The sensitivity, specificity, positive and negative predictive values of bone SPECT/CT for axSpA were 83.9%, 63.2%, 34.7%, and 94.4%, respectively. The bone SPECT/CT maximal score and BASDAI score has positive correlation (r=0.481, p=0.007). The bone SPECT/CT compared with MRI is marginal correlation (k=0.369, p<0.001).Conclusion:In patients with low back pain, the bone SPECT/CT has a high negative predictive value that can exclude AS. In addition, when contraindication in MRI the bone SPECT/CT can be an alternative test.References:[1]Rahul V. Parghane, Baljinder Singh, Aman Sharma, Harmandeep Singh, Paramjeet Singh, and Anish Bhattacharya. Role of 99mTc-Methylene Diphosphonate SPECT/CT in the Detection of Sacroiliitis in Patients with Spondyloarthropathy: Comparison with Clinical Markers and MRI. J Nucl Med Technol 2017; 45:280–28[2]Anuj Jain, Suruchi Jain, w A n i l A g a r w a l, Sanjay Gambhir, Chetna Shamshery, and Amita Agarwal(2015). Evaluation of Efficacy of Bone Scan With SPECT/CT in the Management of Low Back Pain. A Study Supported by Differential Diagnostic Local Anesthetic Blocks. Clin J Pain 2015;31:1054–1059[3]Yong-il Kim, Minseok Suh, Yu Kyeong Kim, Ho-Young Lee and Kichul Shin. The usefulness of bone SPECT/CT imaging with volume of interest analysis in early axial spondyloarthritis. BMC Musculoskeletal Disorders (2015) 16:9[4]Jennifer Saunders, Mel Cusi, and Hans Van der Wall. What’s Old Is New Again: The Sacroiliac Joint as a Cause of Lateralizing Low Back Pain. Tomography (2018) VOLUME 4 NUMBER 2[5]Satoshi Kato, Satoru Demura, Hidenori Matsubara, Anri Inak2, Kazuya Shinmura, Noriaki Yokogawa, Hideki Murakam1, Seigo Kinuya and Hiroyuki Tsuchiya. Utility of bone SPECT/CT to identify the primary cause of pain in elderly patients with degenerative lumbar spine disease. Journal of Orthopaedic Surgery and Research (2019) 14:185[6]Romain De Laroche, Erwan Simon, Nicolas Suignard, Thomas Williams, Marc-Pierre Henry, Philippe Robin, Ronan Abgral, David Bourhis Pierre-Yves Salaun, Frédéric Dubrana, Solène Querellou. Clinical interest of quantitative bone SPECT-CT in the preoperative assessment of knee osteoarthritis. De Laroche et al. Medicine (2018) 97:35[7]Inki Lee, Hendra Budiawan, Jee Youn Moon, Gi Jeong Cheon, Yong Chul Kim, Jin Chul Paeng, Keon Wook Kang, June-Key Chung, and Dong Soo Lee. The Value of SPECT/CT in Localizing Pain Site and Prediction of Treatment Response in Patients with Chronic Low Back Pain. J Korean Med Sci 2014; 29: 1711-1716Disclosure of Interests:None declared.

Assessment and Management of Pain in Palliative Care

Palliative care is an essential component in any disease management. Pain assessment acts as the connecting link between the nerves, brain and spinal cord. Classification and assessment of the pain have great significance in controlling the pain-related symptoms. Pain is broadly divided into three types nociceptive, neuropathic and mixed depending upon the damage caused. Nociceptive pain is caused due to the stimulation of the pain receptors in the tissues and is further divided into visceral and somatic depending on the pain site. Neuropathic pain arises when the nervous system gets damaged or start dysfunctioning. Cancer pain assessment includes several factors like the site, intensity, syndrome, timing and temporal variation of pain. Edmonton staging system for cancer pain prognostic is widely used for pain management includes emotional/psychological distress cognitive impairment caused by pain. A comprehensive understanding of pain assessment will help in enhancing the quality of life of the patients.

Sensory Function and Psychological Factors in Children With Complex Regional Pain Syndrome Type 1

Objective: To assess thermal-sensory thresholds and psychosocial factors in children with Complex Regional Pain Syndrome Type 1 (CRPS-I) compared to healthy children. Methods: We conducted quantitative sensory testing on 34 children with CRPS-I and 56 pain-free children. Warm, cool, heat, and cold stimuli were applied to the forearm. Children with CRPS-I had the protocol administered to the pain site and the contralateral-pain site. Participants completed the self-report Behavior Assessment System for Children. Results: Longer pain durations (>5.1 months) were associated with decreased sensitivity to cold pain on the pain site ( P = .04). Higher pain-intensity ratings were associated with elevated anxiety scores ( P = .03). Anxiety and social stress were associated with warmth sensitivity (both P < .05) on the contralateral-pain site. Conclusions: Pain duration is an important factor in assessing pediatric CRPS-I. Hyposensitivity in the affected limb may emerge due to degeneration of nociceptive nerves. Anxiety may contribute to thermal-sensory perception in childhood CRPS-I.