Measuring the Intensity of Chronic Pain: Are the Visual Analogue Scale and the Verbal Rating Scale Interchangeable?

OBJECTIVES: The 0 to 100 mm visual analogue scale (VAS) and the five-category verbal rating scale (VRS) are commonly used for measuring pain intensity. An open question remains as to whether these scales can be used interchangeably to allow comparisons between intensities of pain in the clinical setting or increased statistical power in pain research. METHODS: Seven hundred and ninety-six patients were requested to rate the present intensity of their chronic pain on the two scales. Spearman's rank correlation coefficients between VAS and VRS were calculated. For testing interchangeability, VAS was transformed into a discrete ordinal scale by dividing the entire VAS into five categories, either equidistantly (biased) or using frequency distributions of VAS (unbiased). We used Goodman-Kruskal's gamma and Wilson's e measures of ordinal association quantified the relationships between the transformed VAS and VRS scores and Svensson method to evaluate agreement between biased and unbiased discrete VAS and VRS scales. RESULTS: Average VAS and VRS scores were 76 ± 18 mm and "severe," respectively. Spearman's rank correlation coefficient values between continuous VAS and VRS were 0.77 to 0.85. Goodman-Kruskal's gamma ordinal associations between discrete VAS and VRS were 0.82 to 0.92 and 0.90 to 0.98 for the biased and unbiased VAS, respectively. Wilson's e measures were 0.51 to 0.61 and 0.54 to 0.65, accordingly. Svensson analysis showed low probability of agreement between both biased (0.66 to 0.76) and unbiased (0.75 to 0.82) VAS and VRS. DISCUSSION: Regardless of the relatively high Spearman correlations between original VAS and VRS, the low ordinal association and low probability of agreement between discrete VAS and VRS suggest that they are not interchangeable. Therefore, VAS and VRS should not be used interchangeably in the clinical setting or for increased statistical power in pain research.

Examining disaster planning models for large scale burn incidents--a theoretical plane crash into a high rise building.

BACKGROUND: The escalation of global terrorist attacks has resulted in a rise of traumatic injuries. Planning for mass casualty incidents (MCIs) is critical to decrease the morbidity and mortality that ensues after large-scale terrorist attacks. This study provides criteria for the management of burn victims following large-scale disasters. METHODS: Mass casualty outcomes from three disasters involving commercial aircraft crashes were analyzed. The three events included the El-Al cargo Aircraft crash near the Amsterdam Schiphol Airport in 1992, the World Trade Center attacks in New York and the attack against the Pentagon in Washington, DC on 9/11/01. RESULTS: Using the data obtained from these events, the severity of injuries in patients were determined. The result is a general template that may be customized with locally or regionally specific data, in order to evaluate the preparedness of a specific burn alignment for such a scenario. CONCLUSION: Recommendations based on the analysis of previous MCI's were put forth. Based on the needs recognized during these past events, suggestions were made to enhance the preparedness of burn units, hospitals and national agencies as well as municipal authorities.

Is prophylactic acyclovir treatment warranted for prevention of herpes simplex virus infections in facial burns? A review of the literature.

Both cosmetic facial resurfacing and facial burns cause an injury to the dermal layer of the skin. This injury renders the patient susceptible to primary herpes simplex virus (HSV) infection or, more commonly, to HSV reactivation. This in turn can lead to bacterial superinfection, possibly resulting in scarring and systemic dissemination in the immunosuppressed burn patient. HSV reactivation rates have been reported to be up to 50% in cosmetic procedures without acyclovir prophylaxis and up to 25% in patients with burn injury. Currently, acyclovir prophylaxis is a common practice in facial resurfacing, but no such recommendations have been issued for patients with burn injury. HSV usually presents in a febrile burn patient between the first and third postburn weeks as a cluster of small, umbilicated vesicles or vesicopustules on an erythematous base found within or around the margins of healing partial-thickness wounds. Diagnosis is confirmed through viral culture from the base of an unroofed vesicle, and treatment is begun with intravenous acyclovir. Antiviral prophylaxis should be strongly considered for HSV infection prevention in patients with major burn injury, particularly with burns involving the face. Acyclovir is the primary drug of choice, and contact precautions should be practiced. High suspicion levels and alertness to this entity can help prompt diagnosis and timely treatment while alleviating late complications.

Latent pisotriquetral arthrosis unmasked following carpal tunnel release.

The causes of persistent wrist pain following carpal tunnel release include scar tenderness and pillar pain. The goal of this study was to evaluate latent pisotriquetral arthrosis as a source of ulnar-sided wrist pain following open carpal tunnel release. Seven hundred consecutive carpal tunnel releases were reviewed, looking for postoperative presentation of pisotriquetral arthrosis, as well as management and outcome. Fourteen patients with long-standing postoperative pain at the base of the hypothenar eminence had clinical and radiographic signs of pisotriquetral degenerative arthrosis, which conceivably had existed preoperatively and been unmasked thereafter. In 6 patients with persistent symptoms despite conservative measures, excision of pisiform was curative. Altered isometric stresses over the pisotriquetral articulation as a result of releasing the transverse ligament, which constitutes a major radial static stabilizer of this joint, seems to cause articular maltracking, and consequently aggravates a preexisting asymptomatic pisotriquetral arthrosis. Long-standing discomfort is characteristically associated with loss of grip strength and dexterity. Pisotriquetral dysfunction and arthrosis should always be considered in the differential diagnosis of persistent wrist pain following either open or endoscopic carpal tunnel release that does not respond to nonoperative measures. Clinical scrutiny, adequate clinical inspection, and radiographic evaluation readily establish the diagnosis. Conservative treatment includes immobilization, nonsteroidal anti-inflammatory drugs, and intra-articular injection of corticosteroids under fluoroscopic control. The corticosteroid injection combined with a local anesthetic also serves as a diagnostic test. Excision of the pisiform is indicated where conservative treatment has failed.

Treatment of earlobe keloids by extralesional excision combined with preoperative and postoperative "sandwich" radiotherapy.

BACKGROUND: Earlobe keloids can form after cosmetic ear piercing, trauma, infection, or burns, or spontaneously. These keloids are highly resistant for treatment and are followed by severe cosmetic implications. There are various surgical and nonsurgical treatment modalities for earlobe keloids, with no universally accepted treatment policy and a wide range of reported recurrence rates. The authors present their experience of treating earlobe keloids using the "sandwich" technique protocol; extralesional excision and external-beam radiotherapy are given a day before and a day after the operation. METHODS: The authors retrospectively reviewed all patients with earlobe keloids treated by the "sandwich" technique between the years 1996 and 2005. Patients were categorized into two groups: a high-risk group for previously treated patients and patients with a tendency for hypertrophic scars and keloids, and a low-risk group for the others. All patients underwent extralesional excision of the keloid and local radiotherapy before the excision and following it. Follow-up was a minimum of half a year and included a patient satisfaction questionnaire and documentation of keloid recurrence or cure. RESULTS: A total of 23 patients were treated by this protocol; 57 percent were male. Patients had an average age of 24 years. The most common keloid etiology was earlobe piercing. Recurrence rates for the low-risk and high-risk groups were 25 and 27 percent [percent of the patients], respectively. Overall patient satisfaction was high. CONCLUSION: The combined excision and "sandwich" radiotherapy technique is a simple and effective method for treating earlobe keloids, with high patient satisfaction and low recurrence and complication rates.

Comprehensive approach in surgical reconstruction of facial nerve paralysis: a 10-year perspective.

Facial paralysis presents diverse functional and aesthetic abnormalities. Reconstruction may be achieved by several methods. We reviewed the management and outcome of facial paralysis patients to establish principles on which a comprehensive reconstructive approach may be based. Records were reviewed of all patients operated for facial paralysis at our institution between 1998 and 2007. Ninety-five patients were included, of which 15 patients had static reconstruction alone, and 80 patients had dynamic reconstruction. Presented is our experience in reconstruction of facial paralysis over the past decade, delineating a comprehensive approach to this condition. Various surgical techniques are described.

Simple wrist ganglia in children: a follow-up study.

Our study aimed at characterizing the natural history and defining the indications for surgical intervention for pediatric ganglia. Thirty-four cases of children under the age of 17 years were reviewed. Twenty-nine children were treated conservatively, with spontaneous resolution in 27 within an average of 9 months; four were treated by aspiration; recurrence was observed in one, and one underwent surgical excision without recurrence. We recommend a conservative management coupled with reassurance for the child and parents. Surgery should be considered for ganglions with atypical appearance or complaints, and large cysts that do not show signs of resolution within a year.

Failure of flexor pollicis longus repair caused by anomalous flexor pollicis longus to index flexor digitorum profundus interconnections: a case report.

We describe a case of an early rupture of a repaired flexor pollicis longus tendon in a young woman. The cause of failure was an anomalous tendinous band that connected the tendon of the flexor pollicis longus to the tendon of the flexor digitorum profundus of the index finger. Forceful flexion of the unrestricted index finger applied a tensile force that was transmitted through the anomalous band to the repaired site and resulted in repair failure.

Genetics in melanoma.

Melanoma is the leading cause of death from skin tumors worldwide, with an annual increase in incidence over the past decade. The molecular mechanisms involved in melanoma pathogenesis are beginning to be unraveled. While a family history of melanoma and exposure to ultraviolet irradiation have been known for years as risk factors in melanoma development, the precise genes involved in inherited predisposition were defined only in the past decade. Germline mutations in two genes that play a pivotal role in controlling cell cycle and division--CDKN2A and cyclin-dependent kinase 4 (CDK4)--have been detected in autosomal, dominant, high penetrance familial melanoma cases. In addition to these two highly penetrant genes, germline mutations and polymorphisms in a few low penetrance genes have been reported in familial melanoma cases: melanocortin-1 receptor, epidermal growth factor, glutathione s-transferase M1, cytochrome p450 debrisoquine hydroxylase locus (CYP2D6) and vitamin D receptor.