BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus ...BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.展开更多
BACKGROUND Total knee arthroplasty(TKA)is recognized as the most effective surgical intervention for relieving pain and improving joint mobility and deformity in patients with knee osteoarthritis and other synovial di...BACKGROUND Total knee arthroplasty(TKA)is recognized as the most effective surgical intervention for relieving pain and improving joint mobility and deformity in patients with knee osteoarthritis and other synovial diseases.The application of accelerated postoperative rehabilitation(enhanced recovery after surgery)has demonstrated its efficacy in improving patient outcomes,and early postoperative joint function exercise has become a key prognostic factor in knee replacement.The unexpected appearance of limb pain and swelling hindered the patient’s tendency for early mobilization,leading in prolonged hospitalization,delayed functional recovery and negative psychological responses.A retrospective analysis was conducted on a cohort of 116 patients who under-went TKA at our hospital between July 2019 and July 2021.The patients were divided into two groups:A control group(n=58)receiving programmatic nur-sing,and an observed group(n=58)receiving programmed nursing combined with a collaborative nursing model.A pain management team consisting of attending physicians,head nurses,and responsible nurses was established.Outcome measures included visual analogue scale(VAS)scores,activities of daily living(ADL)scale scores,and functional scores.The ADL scores of patients in both groups exhibited a continuous increase.However,there was no statistically significant difference in the ADL scores between the two groups at 48 h and the 7th d post-surgery(P>0.05).Upon reexamination at the 3rd mo,the observation group demonstrated higher ADL scores compared to the control group(67.48±14.69 vs 59.40±16.06,P<0.05).The VAS scores of both groups significantly decreased,with no significant difference observed between the groups at each time point(P>0.05).The functional status of patients in both groups exhibited a gradual increase prior to intervention and at the 1st,2nd,and 3rd month following discharge(P<0.05).There was no statistically significant difference in knee joint function scores between the two groups at the 1st month after discharge(47.52 vs 45.81,P>0.05).However,the knee joint function scores of patients in the observation group were significantly higher than those in the control group at the 2nd(59.38 vs 53.19,P<0.05)and 3rd month(71.92 vs 64.34,P<0.05)following discharge.CONCLUSION The utilization of programmed pain nursing in conjunction with collaborative nursing for out-of-hospital care of TKA patients has demonstrated favorable outcomes,encompassing pain reduction,enhanced prognosis,and improved nursing quality for patients.展开更多
Abdominal pain is a common symptom associated with irritable bowel syndrome and inflammatory bowel diseases(IBDs),affecting about 20%of the global population(Grundy et al.,2019).Current pain therapies are poorly effec...Abdominal pain is a common symptom associated with irritable bowel syndrome and inflammatory bowel diseases(IBDs),affecting about 20%of the global population(Grundy et al.,2019).Current pain therapies are poorly effective on visceral pain of intestinal origin and present several side effects,hence the need to identify novel molecular and cellular targets for drug development.展开更多
This editorial presents an analysis of an article recently published in the World Journal of Clinical Cases.Kawasaki disease(KD)is a well-known pediatric vasculitis characterized by fever,rash,conjunctivitis,oral muco...This editorial presents an analysis of an article recently published in the World Journal of Clinical Cases.Kawasaki disease(KD)is a well-known pediatric vasculitis characterized by fever,rash,conjunctivitis,oral mucosal changes,and swelling of the extremities.This editorial aims to delve into the intricate relationship between KD and abdominal pain,drawing insights from recent research findings to provide a comprehensive understanding and potential avenues for future investigation.展开更多
BACKGROUND Total knee arthroplasty(TKA)is a mature procedure recommended for correcting knee osteoarthritis deformity,relieving pain,and restoring normal biomechanics.Although TKA is a successful and cost-effective pr...BACKGROUND Total knee arthroplasty(TKA)is a mature procedure recommended for correcting knee osteoarthritis deformity,relieving pain,and restoring normal biomechanics.Although TKA is a successful and cost-effective procedure,patient dissatisfaction is as high as 50%.Knee pain after TKA is a significant cause of patient dissatisfaction;the most common location for residual pain is the anterior region.Between 4%and 40%of patients have anterior knee pain(AKP).AIM To investigate the effect of various TKA procedures on postoperative AKP.METHODS We searched PubMed,EMBASE,and Cochrane from January 2000 to September 2022.Randomized controlled trials with one intervention in the experimental group and no corresponding intervention(or other interventions)in the control group were collected.Two researchers independently read the title and abstract of the studies,preliminarily screened the articles,and read the full text in detail according to the selection criteria.Conflicts were resolved by consultation with a third researcher.And relevant data from the included studies were extracted and analyzed using Review Manager 5.4 software.RESULTS There were 25 randomized controlled trials;13 were comparative studies with or without patellar resurfacing.The meta-analysis showed no significant difference between the experimental and control groups(P=0.61).Six studies were comparative studies of circumpatellar denervation vs non-denervation,divided into three subgroups for meta-analysis.The two-subgroup meta-analysis showed no significant difference between the experimental and the control groups(P=0.31,P=0.50).One subgroup meta-analysis showed a significant difference between the experimental and control groups(P=0.001).Two studies compared fixed-bearing TKA and mobile-bearing TKA;the results meta-analysis showed no significant difference between the experimental and control groups(P=0.630).Two studies compared lateral retinacular release vs non-release;the meta-analysis showed a significant difference between the experimental and control groups(P=0.002);two other studies compared other factors.CONCLUSION Patellar resurfacing,mobile-bearing TKA,and fixed-bearing TKA do not reduce the incidence of AKP.Lateral retinacular release can reduce AKP;however,whether circumpatellar denervation can reduce AKP is controversial.展开更多
Neuropathic pain is a severe and chronic condition widely found in the general population.The reason for this is the extensive variety of damage or diseases that can spark this unpleasant constant feeling in patients....Neuropathic pain is a severe and chronic condition widely found in the general population.The reason for this is the extensive variety of damage or diseases that can spark this unpleasant constant feeling in patients.During the processing of pain,the dorsal root ganglia constitute an important region where dorsal root ganglion neurons play a crucial role in the transmission and propagation of sensory electrical stimulation.Furthermore,the dorsal root ganglia have recently exhibited a regenerative capacity that should not be neglected in the understanding of the development and resolution of neuropathic pain and in the elucidation of innovative therapies.Here,we will review the complex interplay between cells(satellite glial cells and inflammatory cells)and factors(cytokines,neurotrophic factors and genetic factors)that takes place within the dorsal root ganglia and accounts for the generation of the aberrant excitation of primary sensory neurons occurring in neuropathic pain.More importantly,we will summarize an updated view of the current pharmacologic and nonpharmacologic therapies targeting the dorsal root ganglia for the treatment of neuropathic pain.展开更多
BACKGROUND Hemorrhoids are among the most common and frequently encountered chronic anorectal diseases in anorectal surgery.They are venous clusters formed by con-gestion,expansion,and flexion of the venous plexus in ...BACKGROUND Hemorrhoids are among the most common and frequently encountered chronic anorectal diseases in anorectal surgery.They are venous clusters formed by con-gestion,expansion,and flexion of the venous plexus in the lower part of the rec-tum.Mixed hemorrhoids bleed easily and recurrently,and this can result in severe anemia.Hence,they may have a negative effect on the health of the patient and surgical treatment is required.Milligan-Morgan hemorrhoidectomy has been widely used since 1937 for the treatment of grade III and IV hemorrhoids.How-ever,most patients experience different degrees of postoperative pain that may cause anxiety.with mixed hemorrhoids post-surgery.METHODS The clinical data of patients with mixed hemorrhoids who underwent Milligan-Morgan hemorrhoidectomy were collected retrospectively.The basic character-istics of the enrolled patients with mixed hemorrhoids were recorded,and based on the Goligher clinical grading system,the hemorrhoids were classified as grades III or IV.The endpoint of this study was the disappearance of pain in all patients.Quantitative data were presented as mean±SD,such as age,pain score,and QoL score.Student’s t-test was used to compare the groups.RESULTS A total of 164 patients were enrolled.The distribution of the visual analog scale pain scores of all patients at 3,7,14 and 28 d after surgery showed that post-surgery pain was significantly reduced with the passage of time.Fourteen days after the operation,the pain had completely disappeared in some patients.Twenty-eight days after the surgery,none of the patients experienced any pain.Comparing the World Health Or-ganization Quality of Life-BREF self-reporting questionnaire scores of patients between 14 and 28 d after surgery,we observed that the quality-of-life scores of the patients post-surgery had significantly improved.There were six items that were compared at 14-and 28-d post-surgery.The mean QoL score 28 d after surgery(4.79±0.46)was higher than that at 14 d post-surgery(3.79±0.57).The mean health condition score 28 d after surgery(4.80±0.41)was also higher than that at 14 d post-surgery(4.01±0.62).The mean physical health score 28 d after surgery(32.10±2.96)was significantly higher than that at 14 d post-surgery(23.41±2.85).The mean psychological health score 28 d after surgery(27.22±1.62)was significantly higher than that at 14 d post-surgery(21.37±1.70).The mean social relations score 28 d after surgery(12.21±1.59)was significantly higher than that at 14 d post-surgery(6.32±1.66).The mean surrounding environment score 28 d after surgery(37.13±2.88)was significantly higher than that at 14 d post-surgery(28.42±2.86).The differences in quality-of-life scores at day 14 and day 28 post-surgery were ob-served to be statistically significant(P<0.001).CONCLUSION Milligan-Morgan hemorrhoidectomy can significantly improve the postoperative QoL of patients.Age,sex,and the number of surgical resections were important factors influencing Milligan-Morgan hemorrhoidectomy.展开更多
Objective The extent to which the association between hypertension and chronic pain in observational studies is either causally linked or influenced by other shared risk factors has not been substantially addressed.In...Objective The extent to which the association between hypertension and chronic pain in observational studies is either causally linked or influenced by other shared risk factors has not been substantially addressed.In the present study,Mendelian randomization(MR)was employed to examine the potential causal relationship between hypertension and risk of chronic pain.Methods The study data were derived from the pooled dataset of the genome-wide association study(GWAS),enabling the evaluation of the causal effects of hypertension on various types of chronic pain including chronic headache as well as chest,abdominal,joint,back,limb,and multisite chronic pain.We performed a bidirectional two-sample MR analysis using random effect inverse variance weighting(IVW),MR-Egger,weighted median,and weighted mode,quantified by odds ratio(OR).Results Genetically predicted essential hypertension was associated with an increased risk of chronic headache(OR=1.007,95%CI:1.003-1.011,P=0.002)and limb pain(OR=1.219,95%CI:1.033-1.439,P=0.019).No potential causal associations were identified between chronic pain and essential hypertension in the reverse direction MR(P>0.05).In addition,there was no potential causal association between secondary hypertension and chronic pain(P>0.05).Conclusion This study provided genetic evidence that a unidirectional causal relationship exists between essential hypertension and the increased risks of chronic headache and limb pain,and no causal relationship was found between secondary hypertension and chronic pain.These findings offer theoretical underpinnings for future research on managing hypertension and chronic pain.展开更多
In Quebec,Canada,the public healthcare system offers free medical services.However,patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage.In contras...In Quebec,Canada,the public healthcare system offers free medical services.However,patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage.In contrast,private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses.Once a patient with pain caused by a spinal disorder meets a pain medicine specialist,spinal intervention is quickly performed when indicated,and patients are provided lifestyle advice.Transforaminal epidural steroid injections are frequently administered to patients with radicular pain,and steroid injections are administered on a facet joint to control low back or neck pain.Additionally,medial branch blocks are performed prior to thermocoagulation.France’s universal healthcare system ensures accessibility at controlled costs.It emphasizes physical activity and provides free physical therapy services.However,certain interventions,such as transforaminal and interlaminar epidural injections,are not routinely used in France owing to limited therapeutic efficacy and safety concerns.This underutilization may be a potential cause of chronic pain for many patients.By examining the differences,strengths,and weaknesses of these two systems,valuable insights can be gained for the enhancement of global spinal pain management strategies,ultimately leading to improved patient outcomes and satisfaction.展开更多
In this editorial we comment on the article published in a recent issue of the World Journal of Clinical Cases.This article described a novel ultrasound-guided lateral recess block approach in treating a patient with ...In this editorial we comment on the article published in a recent issue of the World Journal of Clinical Cases.This article described a novel ultrasound-guided lateral recess block approach in treating a patient with lateral recess stenosis.The impact of spinal pain-related disability extends significantly,causing substantial human suffering and medical costs.Each county has its preferred treatment strategies for spinal pain.Here,we explore the lower back pain(LBP)treatment algorithm recommended in France.The treatment algorithm for LBP recommended by the French National Authority for Health emphasizes early patient activity and minimal medication use.It encourages the continuation of daily activities,limits excessive medication and spinal injections,and incorporates psychological assessments and non-pharmacological therapies for chronic cases.However,the algorithm may not aggressively address acute pain in the early stages,potentially delaying relief and increasing the risk of chronicity.Additionally,the recommended infiltrations primarily involve caudal epidural steroid injections,with limited consideration for other injection procedures,such as transforaminal or interlaminar epidural steroid injections.The fixed follow-up timeline may not accommodate patients who do not respond to initial treatment or experience intense pain,potentially delaying the exploration of alternative therapies.Despite these limitations,understanding the strengths and weaknesses of the French approach could inform adaptations in LBP treatment strategies globally,potentially enhancing patient outcomes and satisfaction across diverse healthcare systems.展开更多
In this article, we present our previous research, which highlighted adenosine triphosphate(ATP) as the cause of neuropathic pain during the acute phase of neuromyelitis optica spectrum disorder(NMOSD). In NMOSD patho...In this article, we present our previous research, which highlighted adenosine triphosphate(ATP) as the cause of neuropathic pain during the acute phase of neuromyelitis optica spectrum disorder(NMOSD). In NMOSD pathology, damageassociated molecular patterns(DAMPs), including ATP, are released from damaged astrocytes, triggering the activation of innate immune cells. ATP is a central mediator of acute pain in NMOSD.展开更多
Endometriosis is a common,estrogen-dependent,inflammatory,gynecologic disease process in which normal endometrial tissue is abnormally present outside the uterine cavity.[1]Endometriosis is a common cause of chronic p...Endometriosis is a common,estrogen-dependent,inflammatory,gynecologic disease process in which normal endometrial tissue is abnormally present outside the uterine cavity.[1]Endometriosis is a common cause of chronic pain,dyspareunia,dysmenorrhea,and infertility.Most commonly,endometriosis is found within the pelvis,specifically on the ovaries.Because of rupture,bleeding,infection,or torsion,ovarian endometriosis(OMA)may cause acute abdominal pain,which is similar to acute abdominal pain caused by other reasons and is not easy to diagnose.[2,3]Determining the clinical and pathological features of OMA is crucial for accurate assessment,diagnosis,and treatment.展开更多
Over the past two decades,the USA has witnessed a steep rise in the incidence of acute cholecystitis(AC),[1]even among children,[2]with over 200,000 cases annually.[3]Patients with AC often present to the emergency de...Over the past two decades,the USA has witnessed a steep rise in the incidence of acute cholecystitis(AC),[1]even among children,[2]with over 200,000 cases annually.[3]Patients with AC often present to the emergency department(ED)experiencing severe distress,with most describing their pain level as“intolerable.”[4]Furthermore,there is usually a considerable delay before surgery,with a median time from diagnosis of AC to surgery of 28.5 h,[5]and a substantial percentage of patients wait as long as 10 d.[6]Prolonged delays before surgery lead to increased opioid use,which is associated with extended hospital stays and higher rates of readmission after cholecystectomy.[7]Furthermore,opioids can lead to vomiting,respiratory depression,delirium,and ultimately addiction.[8]We propose a novel regional anesthesia technique for managing AC:right phrenic nerve blockade.This method could offer improved pain control and a more favorable risk profile in selected patients when compared to current ED practices.展开更多
In pat i e nt s,a s well as in animal mod e l s,hypersensitivity to external stimuli(hyperalgesia and allodynia)or spontaneous pain is often the first,and the most disabling,symptom of neuropathy(Davis et al.,2020).Th...In pat i e nt s,a s well as in animal mod e l s,hypersensitivity to external stimuli(hyperalgesia and allodynia)or spontaneous pain is often the first,and the most disabling,symptom of neuropathy(Davis et al.,2020).The increased activity of sensitive neurons drives pain development,making ion channel modulation a fundamental target for current pharmacotherapy as well as one of the most investigated by the R&D departments of pharmaceutical companies(Bennett et al.,2019).展开更多
BACKGROUND According to the World Health Organization analgesic ladder,cancer-related pain generally begins with pharmacotherapy in a stepwise approach.Nevertheless,some patients continue to experience poorly controll...BACKGROUND According to the World Health Organization analgesic ladder,cancer-related pain generally begins with pharmacotherapy in a stepwise approach.Nevertheless,some patients continue to experience poorly controlled pain despite medications,particularly when considering adverse effects and self-care quality.Percutaneous cervical cordotomy is an alternative interventional procedure for unremitting unilateral intractable cancer-related pain.CASE SUMMARY The patient was diagnosed with lung cancer with destruction of the brachial plexus and ribs.For 2 mo,the patient experienced progressive severe weakness and pain in the right upper extremity.Notably,the pain intensity reached an extreme level,particularly when lying supine,even under heavy sedation.This heightened pain response posed a significant challenge;as a result,the patient was unable to undergo further evaluation through magnetic resonance imaging.Ultimately,he underwent percutaneous cervical cordotomy for symptom relief,resulting in complete resolution of right arm pain.After a 3-mo follow-up,the pain did not recur,and only a flurbiprofen local patch was required for mild scapular tightness.CONCLUSION Cordotomy,under careful patient selection,appears to enhance the quality of life of patients with unilateral cancerrelated pain.展开更多
Bone is a mechanosensitive tissue and undergoes constant remodeling to adapt to the mechanical loading environment.However,it is unclear whether the signals of bone cells in response to mechanical stress are processed...Bone is a mechanosensitive tissue and undergoes constant remodeling to adapt to the mechanical loading environment.However,it is unclear whether the signals of bone cells in response to mechanical stress are processed and interpreted in the brain.In this study,we found that the hypothalamus of the brain regulates bone remodeling and structure by perceiving bone prostaglandin E2(PGE2)concentration in response to mechanical loading.Bone PGE2 levels are in proportion to their weight bearing.When weight bearing changes in the tail-suspension mice,the PGE2 concentrations in bones change in line with their weight bearing changes.Deletion of cyclooxygenase-2(COX2)in the osteoblast lineage cells or knockout of receptor 4(EP4)in sensory nerve blunts bone formation in response to mechanical loading.Moreover,knockout of TrkA in sensory nerve also significantly reduces mechanical load-induced bone formation.Moreover,mechanical loading induces cAMP-response element binding protein(CREB)phosphorylation in the hypothalamic arcuate nucleus(ARC)to inhibit sympathetic tyrosine hydroxylase(TH)expression in the paraventricular nucleus(PVN)for osteogenesis.Finally,we show that elevated PGE2 is associated with ankle osteoarthritis(AOA)and pain.Together,our data demonstrate that in response to mechanical loading,skeletal interoception occurs in the form of hypothalamic processing of PGE2-driven peripheral signaling to maintain physiologic bone homeostasis,while chronically elevated PGE2 can be sensed as pain during AOA and implication of potential treatment.展开更多
Objective: To explore the clinical effectiveness of combined use of intravenous pain pump with Parecoxib injection in alleviating pain in patients during the early postoperative period after thoracoscopic surgery. Met...Objective: To explore the clinical effectiveness of combined use of intravenous pain pump with Parecoxib injection in alleviating pain in patients during the early postoperative period after thoracoscopic surgery. Methods: Eighty patients who underwent thoracoscopic surgery in a tertiary hospital were selected as the study subjects and randomly divided into two groups, with 40 patients in each group. The control group received routine postoperative treatment with intravenous pain pump, while the experimental group received Parecoxib in addition to the standard postoperative pain pump treatment. Visual Analog Scale (VAS) pain scores were used to evaluate postoperative pain relief in both groups, along with adverse reactions, postoperative complications, and patient satisfaction with pain relief. Results: Patients who received Parecoxib injection in addition to the routine use of intravenous pain pump had VAS pain scores lower than 3 points at 6 h, 12 h, 24 h, and 36 h postoperatively compared to those in the control group. The incidence of postoperative lung collapse, pleural effusion, and pulmonary infections was also significantly lower in the experimental group. The differences between the two groups were statistically significant (P Conclusion: Early combined use of Parecoxib injection in the early postoperative period after thoracoscopic surgery has shown good clinical efficacy. It can reduce the level of pain in patients, promote effective coughing and expectoration, facilitate early mobilization of patients, improve patient compliance, reduce complications, shorten hospital stay, and expedite patient recovery. Therefore, it is worth promoting the widespread clinical application of Parecoxib injection in this setting.展开更多
BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gather...BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gathered from the National Hospital Ambulatory Medical Care Survey(NHAMCS) from 2007 to 2018.The study population included individuals of all ages presenting to USA EDs.The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain.The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.RESULTS:There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007(244,000 visits) to 2018(92,000 visits).The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older(from 43.8% to 57.6%),female patients(from 54.5% to 62.0%),black patients(from 22.5% to 30.4%),and Hispanic/Latino patients(from 9.4% to 19.6%).Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007,with a decrease to 68.5% in 2018.Pure oxycodone was the second most prescribed medication,accounting for 6.1% in 2007 and 31.5% in 2018.CONCLUSION:The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018.However,that number trended upward in 45-year-old and older,female,black,or Hispanic/Latino patients from 2007 to 2018.The total amount of pure oxycodone increased significantly from 2007 to 2008.展开更多
Traumatic amputations remain one of the most frequent and disturbing wounds of armed conflict.In this scenario,most amputees develop residual and phantom limb pain,impacting their quality of life.There are several ele...Traumatic amputations remain one of the most frequent and disturbing wounds of armed conflict.In this scenario,most amputees develop residual and phantom limb pain,impacting their quality of life.There are several elective surgical procedures available for both conditions,such as neuroma excision followed by nerve reconstruction,nerve relocation,e.g.,surgically implanting a transected nerve into a muscle,nerve transfers in cases of associated paralysis,and most recently,regenerative peripheral nerve interface surgery.Whenever possible in the post-conflict phase,a coordinated effort between traveling humanitarian surgeons specializing in reconstructive microsurgery and local healthcare providers is essential for successfully treating phantom and chronic residual limb pain in post-conflict amputees.While providing a detailed logistical framework for global humanitarian missions is beyond the scope of this article,we provide a brief perspective on a topic of utmost importance for reconstructive surgeons worldwide:the high-quality care and treatment of refugees and those whose lives have been impacted by conflict,disaster,or displacement.展开更多
文摘BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.
文摘BACKGROUND Total knee arthroplasty(TKA)is recognized as the most effective surgical intervention for relieving pain and improving joint mobility and deformity in patients with knee osteoarthritis and other synovial diseases.The application of accelerated postoperative rehabilitation(enhanced recovery after surgery)has demonstrated its efficacy in improving patient outcomes,and early postoperative joint function exercise has become a key prognostic factor in knee replacement.The unexpected appearance of limb pain and swelling hindered the patient’s tendency for early mobilization,leading in prolonged hospitalization,delayed functional recovery and negative psychological responses.A retrospective analysis was conducted on a cohort of 116 patients who under-went TKA at our hospital between July 2019 and July 2021.The patients were divided into two groups:A control group(n=58)receiving programmatic nur-sing,and an observed group(n=58)receiving programmed nursing combined with a collaborative nursing model.A pain management team consisting of attending physicians,head nurses,and responsible nurses was established.Outcome measures included visual analogue scale(VAS)scores,activities of daily living(ADL)scale scores,and functional scores.The ADL scores of patients in both groups exhibited a continuous increase.However,there was no statistically significant difference in the ADL scores between the two groups at 48 h and the 7th d post-surgery(P>0.05).Upon reexamination at the 3rd mo,the observation group demonstrated higher ADL scores compared to the control group(67.48±14.69 vs 59.40±16.06,P<0.05).The VAS scores of both groups significantly decreased,with no significant difference observed between the groups at each time point(P>0.05).The functional status of patients in both groups exhibited a gradual increase prior to intervention and at the 1st,2nd,and 3rd month following discharge(P<0.05).There was no statistically significant difference in knee joint function scores between the two groups at the 1st month after discharge(47.52 vs 45.81,P>0.05).However,the knee joint function scores of patients in the observation group were significantly higher than those in the control group at the 2nd(59.38 vs 53.19,P<0.05)and 3rd month(71.92 vs 64.34,P<0.05)following discharge.CONCLUSION The utilization of programmed pain nursing in conjunction with collaborative nursing for out-of-hospital care of TKA patients has demonstrated favorable outcomes,encompassing pain reduction,enhanced prognosis,and improved nursing quality for patients.
基金supported by the co-funding European Union-Next Generation EU,in the context of The National Recovery and Resilience Plan,Investment 1.5 Ecosystems of Innovation,Project Tuscany Health Ecosystem(THE),CUP:B83C22003920001Italian Ministry of University and Research(MIUR)-Dipartimenti di Eccellenza 2023-2027 to the Department NEUROFARBA(to CG)。
文摘Abdominal pain is a common symptom associated with irritable bowel syndrome and inflammatory bowel diseases(IBDs),affecting about 20%of the global population(Grundy et al.,2019).Current pain therapies are poorly effective on visceral pain of intestinal origin and present several side effects,hence the need to identify novel molecular and cellular targets for drug development.
基金Supported by The Hubei Pediatric Alliance Medical Research Project,No.HPAMRP202117。
文摘This editorial presents an analysis of an article recently published in the World Journal of Clinical Cases.Kawasaki disease(KD)is a well-known pediatric vasculitis characterized by fever,rash,conjunctivitis,oral mucosal changes,and swelling of the extremities.This editorial aims to delve into the intricate relationship between KD and abdominal pain,drawing insights from recent research findings to provide a comprehensive understanding and potential avenues for future investigation.
基金Supported by the Capital Fund Project for Clinical Diagnosis and Treatment Technology Research and Translational Application,No.Z201100005520091and Beijing Traditional Chinese Medicine Science and Technology Development Fund Project,No.JJ-2020-67.
文摘BACKGROUND Total knee arthroplasty(TKA)is a mature procedure recommended for correcting knee osteoarthritis deformity,relieving pain,and restoring normal biomechanics.Although TKA is a successful and cost-effective procedure,patient dissatisfaction is as high as 50%.Knee pain after TKA is a significant cause of patient dissatisfaction;the most common location for residual pain is the anterior region.Between 4%and 40%of patients have anterior knee pain(AKP).AIM To investigate the effect of various TKA procedures on postoperative AKP.METHODS We searched PubMed,EMBASE,and Cochrane from January 2000 to September 2022.Randomized controlled trials with one intervention in the experimental group and no corresponding intervention(or other interventions)in the control group were collected.Two researchers independently read the title and abstract of the studies,preliminarily screened the articles,and read the full text in detail according to the selection criteria.Conflicts were resolved by consultation with a third researcher.And relevant data from the included studies were extracted and analyzed using Review Manager 5.4 software.RESULTS There were 25 randomized controlled trials;13 were comparative studies with or without patellar resurfacing.The meta-analysis showed no significant difference between the experimental and control groups(P=0.61).Six studies were comparative studies of circumpatellar denervation vs non-denervation,divided into three subgroups for meta-analysis.The two-subgroup meta-analysis showed no significant difference between the experimental and the control groups(P=0.31,P=0.50).One subgroup meta-analysis showed a significant difference between the experimental and control groups(P=0.001).Two studies compared fixed-bearing TKA and mobile-bearing TKA;the results meta-analysis showed no significant difference between the experimental and control groups(P=0.630).Two studies compared lateral retinacular release vs non-release;the meta-analysis showed a significant difference between the experimental and control groups(P=0.002);two other studies compared other factors.CONCLUSION Patellar resurfacing,mobile-bearing TKA,and fixed-bearing TKA do not reduce the incidence of AKP.Lateral retinacular release can reduce AKP;however,whether circumpatellar denervation can reduce AKP is controversial.
基金under a contract of the“Nicolás Monardes”program(RC-0002-2021)from the Andalusian Health Service,Andalusian Regional Ministry of Health and Consumptionfunds from the Excellent Project from Andalusian Government(Proy Excel_00996)+8 种基金funded by the French Multiple Sclerosis Foundation(ARSEP,1259&1254)the National Multiple Sclerosis Society(NMSS,RG 5088-A-1)the program“Investissements d’Avenir”(ANR-10-IAIHU-06 and ANR-11-INBS-0011–Neur ATRIS)under a“Miguel Servet”contract(CP20-0049)from the Health Institute CarlosⅢ,Ministry of Science and Innovation,Spainreceived grants from Andalusian Government and the European Commission under the Seventh Framework Program of the European Union(agreement Num.291730,contract TAHUB-II-107)ARSEP 1254IBRO Return Home FellowshipAES2022 from Health Institute CarlosⅢ(PI22/01141)the Excellent Project from Andalusian Regional Ministry of University,Research and Innovation(Proy Excel_00996)。
文摘Neuropathic pain is a severe and chronic condition widely found in the general population.The reason for this is the extensive variety of damage or diseases that can spark this unpleasant constant feeling in patients.During the processing of pain,the dorsal root ganglia constitute an important region where dorsal root ganglion neurons play a crucial role in the transmission and propagation of sensory electrical stimulation.Furthermore,the dorsal root ganglia have recently exhibited a regenerative capacity that should not be neglected in the understanding of the development and resolution of neuropathic pain and in the elucidation of innovative therapies.Here,we will review the complex interplay between cells(satellite glial cells and inflammatory cells)and factors(cytokines,neurotrophic factors and genetic factors)that takes place within the dorsal root ganglia and accounts for the generation of the aberrant excitation of primary sensory neurons occurring in neuropathic pain.More importantly,we will summarize an updated view of the current pharmacologic and nonpharmacologic therapies targeting the dorsal root ganglia for the treatment of neuropathic pain.
文摘BACKGROUND Hemorrhoids are among the most common and frequently encountered chronic anorectal diseases in anorectal surgery.They are venous clusters formed by con-gestion,expansion,and flexion of the venous plexus in the lower part of the rec-tum.Mixed hemorrhoids bleed easily and recurrently,and this can result in severe anemia.Hence,they may have a negative effect on the health of the patient and surgical treatment is required.Milligan-Morgan hemorrhoidectomy has been widely used since 1937 for the treatment of grade III and IV hemorrhoids.How-ever,most patients experience different degrees of postoperative pain that may cause anxiety.with mixed hemorrhoids post-surgery.METHODS The clinical data of patients with mixed hemorrhoids who underwent Milligan-Morgan hemorrhoidectomy were collected retrospectively.The basic character-istics of the enrolled patients with mixed hemorrhoids were recorded,and based on the Goligher clinical grading system,the hemorrhoids were classified as grades III or IV.The endpoint of this study was the disappearance of pain in all patients.Quantitative data were presented as mean±SD,such as age,pain score,and QoL score.Student’s t-test was used to compare the groups.RESULTS A total of 164 patients were enrolled.The distribution of the visual analog scale pain scores of all patients at 3,7,14 and 28 d after surgery showed that post-surgery pain was significantly reduced with the passage of time.Fourteen days after the operation,the pain had completely disappeared in some patients.Twenty-eight days after the surgery,none of the patients experienced any pain.Comparing the World Health Or-ganization Quality of Life-BREF self-reporting questionnaire scores of patients between 14 and 28 d after surgery,we observed that the quality-of-life scores of the patients post-surgery had significantly improved.There were six items that were compared at 14-and 28-d post-surgery.The mean QoL score 28 d after surgery(4.79±0.46)was higher than that at 14 d post-surgery(3.79±0.57).The mean health condition score 28 d after surgery(4.80±0.41)was also higher than that at 14 d post-surgery(4.01±0.62).The mean physical health score 28 d after surgery(32.10±2.96)was significantly higher than that at 14 d post-surgery(23.41±2.85).The mean psychological health score 28 d after surgery(27.22±1.62)was significantly higher than that at 14 d post-surgery(21.37±1.70).The mean social relations score 28 d after surgery(12.21±1.59)was significantly higher than that at 14 d post-surgery(6.32±1.66).The mean surrounding environment score 28 d after surgery(37.13±2.88)was significantly higher than that at 14 d post-surgery(28.42±2.86).The differences in quality-of-life scores at day 14 and day 28 post-surgery were ob-served to be statistically significant(P<0.001).CONCLUSION Milligan-Morgan hemorrhoidectomy can significantly improve the postoperative QoL of patients.Age,sex,and the number of surgical resections were important factors influencing Milligan-Morgan hemorrhoidectomy.
文摘Objective The extent to which the association between hypertension and chronic pain in observational studies is either causally linked or influenced by other shared risk factors has not been substantially addressed.In the present study,Mendelian randomization(MR)was employed to examine the potential causal relationship between hypertension and risk of chronic pain.Methods The study data were derived from the pooled dataset of the genome-wide association study(GWAS),enabling the evaluation of the causal effects of hypertension on various types of chronic pain including chronic headache as well as chest,abdominal,joint,back,limb,and multisite chronic pain.We performed a bidirectional two-sample MR analysis using random effect inverse variance weighting(IVW),MR-Egger,weighted median,and weighted mode,quantified by odds ratio(OR).Results Genetically predicted essential hypertension was associated with an increased risk of chronic headache(OR=1.007,95%CI:1.003-1.011,P=0.002)and limb pain(OR=1.219,95%CI:1.033-1.439,P=0.019).No potential causal associations were identified between chronic pain and essential hypertension in the reverse direction MR(P>0.05).In addition,there was no potential causal association between secondary hypertension and chronic pain(P>0.05).Conclusion This study provided genetic evidence that a unidirectional causal relationship exists between essential hypertension and the increased risks of chronic headache and limb pain,and no causal relationship was found between secondary hypertension and chronic pain.These findings offer theoretical underpinnings for future research on managing hypertension and chronic pain.
基金Supported by National Research Foundation of Korea Grant,No.00219725.
文摘In Quebec,Canada,the public healthcare system offers free medical services.However,patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage.In contrast,private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses.Once a patient with pain caused by a spinal disorder meets a pain medicine specialist,spinal intervention is quickly performed when indicated,and patients are provided lifestyle advice.Transforaminal epidural steroid injections are frequently administered to patients with radicular pain,and steroid injections are administered on a facet joint to control low back or neck pain.Additionally,medial branch blocks are performed prior to thermocoagulation.France’s universal healthcare system ensures accessibility at controlled costs.It emphasizes physical activity and provides free physical therapy services.However,certain interventions,such as transforaminal and interlaminar epidural injections,are not routinely used in France owing to limited therapeutic efficacy and safety concerns.This underutilization may be a potential cause of chronic pain for many patients.By examining the differences,strengths,and weaknesses of these two systems,valuable insights can be gained for the enhancement of global spinal pain management strategies,ultimately leading to improved patient outcomes and satisfaction.
基金Supported by The National Research Foundation of Korea Grant funded by the Korea Government,No.00219725.
文摘In this editorial we comment on the article published in a recent issue of the World Journal of Clinical Cases.This article described a novel ultrasound-guided lateral recess block approach in treating a patient with lateral recess stenosis.The impact of spinal pain-related disability extends significantly,causing substantial human suffering and medical costs.Each county has its preferred treatment strategies for spinal pain.Here,we explore the lower back pain(LBP)treatment algorithm recommended in France.The treatment algorithm for LBP recommended by the French National Authority for Health emphasizes early patient activity and minimal medication use.It encourages the continuation of daily activities,limits excessive medication and spinal injections,and incorporates psychological assessments and non-pharmacological therapies for chronic cases.However,the algorithm may not aggressively address acute pain in the early stages,potentially delaying relief and increasing the risk of chronicity.Additionally,the recommended infiltrations primarily involve caudal epidural steroid injections,with limited consideration for other injection procedures,such as transforaminal or interlaminar epidural steroid injections.The fixed follow-up timeline may not accommodate patients who do not respond to initial treatment or experience intense pain,potentially delaying the exploration of alternative therapies.Despite these limitations,understanding the strengths and weaknesses of the French approach could inform adaptations in LBP treatment strategies globally,potentially enhancing patient outcomes and satisfaction across diverse healthcare systems.
文摘In this article, we present our previous research, which highlighted adenosine triphosphate(ATP) as the cause of neuropathic pain during the acute phase of neuromyelitis optica spectrum disorder(NMOSD). In NMOSD pathology, damageassociated molecular patterns(DAMPs), including ATP, are released from damaged astrocytes, triggering the activation of innate immune cells. ATP is a central mediator of acute pain in NMOSD.
基金supported by 4+X Clinical Research Project of Women's Hospital,School of Medicine,Zhejiang University(ZDFY2021-4X202).
文摘Endometriosis is a common,estrogen-dependent,inflammatory,gynecologic disease process in which normal endometrial tissue is abnormally present outside the uterine cavity.[1]Endometriosis is a common cause of chronic pain,dyspareunia,dysmenorrhea,and infertility.Most commonly,endometriosis is found within the pelvis,specifically on the ovaries.Because of rupture,bleeding,infection,or torsion,ovarian endometriosis(OMA)may cause acute abdominal pain,which is similar to acute abdominal pain caused by other reasons and is not easy to diagnose.[2,3]Determining the clinical and pathological features of OMA is crucial for accurate assessment,diagnosis,and treatment.
文摘Over the past two decades,the USA has witnessed a steep rise in the incidence of acute cholecystitis(AC),[1]even among children,[2]with over 200,000 cases annually.[3]Patients with AC often present to the emergency department(ED)experiencing severe distress,with most describing their pain level as“intolerable.”[4]Furthermore,there is usually a considerable delay before surgery,with a median time from diagnosis of AC to surgery of 28.5 h,[5]and a substantial percentage of patients wait as long as 10 d.[6]Prolonged delays before surgery lead to increased opioid use,which is associated with extended hospital stays and higher rates of readmission after cholecystectomy.[7]Furthermore,opioids can lead to vomiting,respiratory depression,delirium,and ultimately addiction.[8]We propose a novel regional anesthesia technique for managing AC:right phrenic nerve blockade.This method could offer improved pain control and a more favorable risk profile in selected patients when compared to current ED practices.
文摘In pat i e nt s,a s well as in animal mod e l s,hypersensitivity to external stimuli(hyperalgesia and allodynia)or spontaneous pain is often the first,and the most disabling,symptom of neuropathy(Davis et al.,2020).The increased activity of sensitive neurons drives pain development,making ion channel modulation a fundamental target for current pharmacotherapy as well as one of the most investigated by the R&D departments of pharmaceutical companies(Bennett et al.,2019).
文摘BACKGROUND According to the World Health Organization analgesic ladder,cancer-related pain generally begins with pharmacotherapy in a stepwise approach.Nevertheless,some patients continue to experience poorly controlled pain despite medications,particularly when considering adverse effects and self-care quality.Percutaneous cervical cordotomy is an alternative interventional procedure for unremitting unilateral intractable cancer-related pain.CASE SUMMARY The patient was diagnosed with lung cancer with destruction of the brachial plexus and ribs.For 2 mo,the patient experienced progressive severe weakness and pain in the right upper extremity.Notably,the pain intensity reached an extreme level,particularly when lying supine,even under heavy sedation.This heightened pain response posed a significant challenge;as a result,the patient was unable to undergo further evaluation through magnetic resonance imaging.Ultimately,he underwent percutaneous cervical cordotomy for symptom relief,resulting in complete resolution of right arm pain.After a 3-mo follow-up,the pain did not recur,and only a flurbiprofen local patch was required for mild scapular tightness.CONCLUSION Cordotomy,under careful patient selection,appears to enhance the quality of life of patients with unilateral cancerrelated pain.
基金This research was supported by NIH National Institute on Aging under Award Number R01 AG076783,R01 AG068997 and P01 AG066603(to X.C.).
文摘Bone is a mechanosensitive tissue and undergoes constant remodeling to adapt to the mechanical loading environment.However,it is unclear whether the signals of bone cells in response to mechanical stress are processed and interpreted in the brain.In this study,we found that the hypothalamus of the brain regulates bone remodeling and structure by perceiving bone prostaglandin E2(PGE2)concentration in response to mechanical loading.Bone PGE2 levels are in proportion to their weight bearing.When weight bearing changes in the tail-suspension mice,the PGE2 concentrations in bones change in line with their weight bearing changes.Deletion of cyclooxygenase-2(COX2)in the osteoblast lineage cells or knockout of receptor 4(EP4)in sensory nerve blunts bone formation in response to mechanical loading.Moreover,knockout of TrkA in sensory nerve also significantly reduces mechanical load-induced bone formation.Moreover,mechanical loading induces cAMP-response element binding protein(CREB)phosphorylation in the hypothalamic arcuate nucleus(ARC)to inhibit sympathetic tyrosine hydroxylase(TH)expression in the paraventricular nucleus(PVN)for osteogenesis.Finally,we show that elevated PGE2 is associated with ankle osteoarthritis(AOA)and pain.Together,our data demonstrate that in response to mechanical loading,skeletal interoception occurs in the form of hypothalamic processing of PGE2-driven peripheral signaling to maintain physiologic bone homeostasis,while chronically elevated PGE2 can be sensed as pain during AOA and implication of potential treatment.
文摘Objective: To explore the clinical effectiveness of combined use of intravenous pain pump with Parecoxib injection in alleviating pain in patients during the early postoperative period after thoracoscopic surgery. Methods: Eighty patients who underwent thoracoscopic surgery in a tertiary hospital were selected as the study subjects and randomly divided into two groups, with 40 patients in each group. The control group received routine postoperative treatment with intravenous pain pump, while the experimental group received Parecoxib in addition to the standard postoperative pain pump treatment. Visual Analog Scale (VAS) pain scores were used to evaluate postoperative pain relief in both groups, along with adverse reactions, postoperative complications, and patient satisfaction with pain relief. Results: Patients who received Parecoxib injection in addition to the routine use of intravenous pain pump had VAS pain scores lower than 3 points at 6 h, 12 h, 24 h, and 36 h postoperatively compared to those in the control group. The incidence of postoperative lung collapse, pleural effusion, and pulmonary infections was also significantly lower in the experimental group. The differences between the two groups were statistically significant (P Conclusion: Early combined use of Parecoxib injection in the early postoperative period after thoracoscopic surgery has shown good clinical efficacy. It can reduce the level of pain in patients, promote effective coughing and expectoration, facilitate early mobilization of patients, improve patient compliance, reduce complications, shorten hospital stay, and expedite patient recovery. Therefore, it is worth promoting the widespread clinical application of Parecoxib injection in this setting.
文摘BACKGROUND:To describe trends in oxycodone and oxycodone-containing analgesic prescribing for the treatment of back pain among adults in emergency departments(EDs) in the USA from 2007 to 2018.METHODS:Data were gathered from the National Hospital Ambulatory Medical Care Survey(NHAMCS) from 2007 to 2018.The study population included individuals of all ages presenting to USA EDs.The NHAMCS reasons for visit and oxycodone drug ID codes were used to isolate patients with back pain.The main outcome was the proportion of oxycodone and oxycodone-containing analgesics prescribed for back pain in the EDs over the specified time period.RESULTS:There was a relative decrease in the overall administration of oxycodone for back pain in the EDs by 62.3% from 2007(244,000 visits) to 2018(92,000 visits).The proportion of ED patients prescribed with oxycodone-containing analgesics for back pain increased among patients aged 45 years and older(from 43.8% to 57.6%),female patients(from 54.5% to 62.0%),black patients(from 22.5% to 30.4%),and Hispanic/Latino patients(from 9.4% to 19.6%).Oxycodone/acetaminophen was most prescribed and accounted for 90.2% of all oxycodone-containing analgesics in 2007,with a decrease to 68.5% in 2018.Pure oxycodone was the second most prescribed medication,accounting for 6.1% in 2007 and 31.5% in 2018.CONCLUSION:The overall number of oxycodone-containing analgesics decreased significantly from 2007 to 2018.However,that number trended upward in 45-year-old and older,female,black,or Hispanic/Latino patients from 2007 to 2018.The total amount of pure oxycodone increased significantly from 2007 to 2008.
文摘Traumatic amputations remain one of the most frequent and disturbing wounds of armed conflict.In this scenario,most amputees develop residual and phantom limb pain,impacting their quality of life.There are several elective surgical procedures available for both conditions,such as neuroma excision followed by nerve reconstruction,nerve relocation,e.g.,surgically implanting a transected nerve into a muscle,nerve transfers in cases of associated paralysis,and most recently,regenerative peripheral nerve interface surgery.Whenever possible in the post-conflict phase,a coordinated effort between traveling humanitarian surgeons specializing in reconstructive microsurgery and local healthcare providers is essential for successfully treating phantom and chronic residual limb pain in post-conflict amputees.While providing a detailed logistical framework for global humanitarian missions is beyond the scope of this article,we provide a brief perspective on a topic of utmost importance for reconstructive surgeons worldwide:the high-quality care and treatment of refugees and those whose lives have been impacted by conflict,disaster,or displacement.
