Somatic Awareness and Tender Points in a Community Sample

Somatic awareness (SA) refers to heightened sensitivity to a variety of physical sensations and symptoms. Few attempts have been made to dissociate the relationship of SA and affective symptoms with pain outcomes. We used a validated measure of mood and anxiety symptoms that includes questions related to SA to predict the number of tender points found on physical examination in a large cross-sectional community sample (the Midlife in the United States [MIDUS] Biomarker study). General distress, positive affect, and SA, which were all significantly associated with tender point number in bivariate analyses, were used as predictors of the number of tender points in a multivariate negative binomial regression model.

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Does Caregiver Behaviour Mediate the Relationship Between Cultural Individualism and Infant Pain at 12 Months of Age?

The study aimed to understand the relationship between caregiver culture and infant pain expression at the 12-month immunization and discern if a mechanism subsuming this relationship was the quality of caregiver behaviours (emotional availability). Infants (N = 393) with immunization data at 12 months of age were examined. Based on the Development of Infant Acute Pain Responding Model (DIAPR Model), a mediation model was developed to examine how caregiver behaviours mediate the relationship between caregiver heritage culture and infant pain.

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Is pain perception altered in people with depression? A systematic review and meta-analysis of experimental pain research

While clinical studies suggest depressed patients may be more vulnerable to pain, experimental research is equivocal. This meta-analysis aimed to clarify whether depression is associated with altered pain perception in response to noxious stimulation and to identify factors that might influence this association. A search of major electronic databases was conducted to identify experimental studies investigating pain response in depressed participants vs. healthy controls using established pain outcome measures.

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Table of Contents

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Editorial Board

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Masthead

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Overlapping Chronic Pain Conditions: Implications for Diagnosis and Classification

There is increasing recognition that many if not most common chronic pain conditions are heterogeneous with a high degree of overlap or coprevalence of other common pain conditions along with influences from biopsychosocial factors. At present, very little attention is given to the high degree of overlap of many common pain conditions when recruiting for clinical trials. As such, many if not most patients enrolled into clinical studies are not representative of most chronic pain patients. The failure to account for the heterogeneous and overlapping nature of most common pain conditions may result in treatment responses of small effect size when these treatments are administered to patients with chronic overlapping pain conditions (COPCs) represented in the general population.

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Toward a Mechanism-Based Approach to Pain Diagnosis

The past few decades have witnessed a huge leap forward in our understanding of the mechanistic underpinnings of pain, in normal states where it helps protect from injury, and also in pathological states where pain evolves from a symptom reflecting tissue injury to become the disease itself. However, despite these scientific advances, chronic pain remains extremely challenging to manage clinically. Although the number of potential treatment targets has grown substantially and a strong case has been made for a mechanism-based and individualized approach to pain therapy, arguably clinicians are not much more advanced now than 20 years ago, in their capacity to either diagnose or effectively treat their patients.

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Multidimensional Diagnostic Criteria for Chronic Pain: Introduction to the ACTTION–American Pain Society Pain Taxonomy (AAPT)

A variety of approaches have been used to develop diagnostic criteria for chronic pain. The published evidence of the reliability and validity of existing diagnostic criteria is limited, and these criteria have typically not been used in clinical practice. The availability of a widely accepted, consistently applied, and evidence-based taxonomy of diagnostic criteria would improve the quality of clinical research on chronic pain and would be of great value in clinical practice. To address the need for evidence-based diagnostic criteria for the major chronic pain conditions, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS) have collaborated on the development of the ACTTION-APS Pain Taxonomy (AAPT).

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Assessment of Psychosocial and Functional Impact of Chronic Pain

The psychosocial and functional consequences of chronic pain disorders have been well documented as having significant effects on the experience of pain, presentation to health care providers, responsiveness to and participation in treatment, disability, and health-related quality of life. Thus, psychosocial and functional consequences have been incorporated as 1 of the 5 dimensions within the integrated Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT): 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.

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The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes.

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Applying a Lifespan Developmental Perspective to Chronic Pain: Pediatrics to Geriatrics

An ideal taxonomy of chronic pain would be applicable to people of all ages. Developmental sciences focus on lifespan developmental approaches, and view the trajectory of processes in the life course from birth to death. In this article we provide a review of lifespan developmental models, describe normal developmental processes that affect pain processing, and identify deviations from those processes that lead to stable individual differences of clinical interest, specifically the development of chronic pain syndromes.

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Approaches to Demonstrating the Reliability and Validity of Core Diagnostic Criteria for Chronic Pain

The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society Pain Taxonomy (AAPT) is designed to be an evidence-based multidimensional chronic pain classification system that will facilitate more comprehensive and consistent chronic pain diagnoses, and thereby enhance research, clinical communication, and ultimately patient care. Core diagnostic criteria (dimension 1) for individual chronic pain conditions included in the initial version of AAPT will be the focus of subsequent empirical research to evaluate and provide evidence for their reliability and validity.

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Latent Trigger Points: What Are the Underlying Predictors?

Effectiveness of Ultrasound-Guided Versus Fluoroscopy or Computed Tomography Scanning Guidance in Lumbar Facet Joint Injections in Adults With Facet Joint Syndrome: A Meta-Analysis of Controlled Trials

Psychological Distress in Acute Low Back Pain: A Review of Measurement Scales and Levels of Distress Reported in the First 2 Months After Pain Onset

Electrical Stimulation for Hemiplegic Shoulder Function: A Systematic Review and Meta-Analysis of 15 Randomized Controlled Trials

Table of Contents

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Editorial Board

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The addition of a sagittal cervical posture corrective orthotic device to a multimodal rehabilitation program improves short and long term outcomes in patients with discogenic cervical radiculopathy

Long-term changes in musculoskeletal pain sites in the general population: The HUNT study

In a Norwegian prospective population-based cohort study, we examined whether the number of chronic musculoskeletal pain sites changed over an 11-year period, and if the number of pain sites at follow-up was associated with health-related and lifestyle factors at baseline. The study included data on 78,973 adults participating in the Nord-Trøndelag Health Study (HUNT) in 1995–1997 (HUNT2) and 2006–2008 (HUNT3). Based on three categories of baseline pain sites, associations between baseline health-related, lifestyle, and demographic factors and number of pain sites at follow-up were analysed with linear regression models adjusted for age, sex, marital status, physical activity, education, and other chronic diseases.

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Inter- and intra-rater reliability of clinical tests associated to functional lumbar segmental instability and motor control impairment in patients with LBP: a systematic review

Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review

Expectation influences the interruptive function of pain: Behavioural and neural findings

Abstract

Background

Expectations can dramatically influence the perception of pain, as has been shown in placebo analgesia or nocebo hyperalgesia. Here, we investigated the role of expectation on the interruptive function of pain – the negative consequences of pain on cognitive task performance – in 42 healthy human subjects.

Methods

Verbal and written instructions were used to manipulate the subjects’ expectation of how pain would influence their task performance in an established visual categorization task which was performed with or without concomitant painful thermal stimulation during 3T fMRI scanning. The categorization task was followed by a surprise recognition task.

Results

We observed a significant interaction between stimulation (pain/no pain) and expectancy (positive expectation/negative expectation): categorization accuracy decreased during painful stimulation in the negative expectancy group (N = 21), while no difference was observed in the positive expectancy group (N = 21). On the neural level, the positive expectancy group showed stronger activity in the anterior cingulate cortex (ACC) and hippocampus during painful stimulation compared to the negative group. Moreover, we detected a decrease in connectivity between ACC and fusiform gyrus during painful stimulation in the negative expectancy group, which was absent in the positive expectancy group.

Conclusion

Taken together, our data show that expectation can modulate the effect of pain on task performance and that these expectancy effects on the interruptive function of pain are mediated by activity and connectivity changes in brain areas involved in pain processing and task performance. The possibility of changing cognitive task performance by verbal information in clinical population warrants further investigation.

Significance

We show that the interruptive function of pain on concurrent visual task performance is influenced by expectation. Positive expectation can abolish the detrimental effects of pain on cognition. These expectancy effects on the interruptive function of pain are mediated by changes in functional connectivity between rostral ACC, posterior fusiform cortex and the hippocampus.

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Regular use of medication for musculoskeletal pain and risk of long-term sickness absence: A prospective cohort study among the general working population

Abstract

Background

The aim was to determine the prospective association between use of pain medication – due to musculoskeletal pain in the low back, neck/shoulder and hand/wrist – and long-term sickness absence.

Methods

Cox-regression analysis was performed to estimate the prospective association between regular use of pain medication and long-term sickness absence (LTSA; at least 6 consecutive weeks) among 9,544 employees from the general working population (Danish Work Environment Cohort Study 2010) and free from LTSA during 2009–2010. The fully adjusted model was controlled for age, gender, body mass index, smoking, leisure physical activity, job group, physical activity at work, psychosocial work environment, pain intensity, mental health and chronic disease.

Results

In 2010, the proportion of regular pain medication users due to musculoskeletal disorders was 20.8%: 13.4% as over-the-counter (i.e. non-prescription) and 7.4% as doctor prescribed. In the fully adjusted model, regular use of over-the-counter [HR 1.44 (95% CI 1.13–1.83)] and doctor prescribed (HR 2.18 (95% CI 1.67–2.86)) pain medication were prospectively associated with LTSA.

Conclusions

Regular use of pain medication due to musculoskeletal pain is prospectively associated with LTSA even when adjusted for pain intensity. This study suggests that use of pain medication can be an important factor to be aware of in the prevention of sickness absence. Thus, regular use of pain medication – and not solely the intensity of pain – can be an early indicator that musculoskeletal pain can lead to serious consequences such as long-term sickness absence.

Significance

Use of medication due to musculoskeletal pain is prospectively associated with long-term sickness absence even when adjusted for pain intensity. Use of pain medication can be a red flag to be aware of in the prevention of sickness absence.

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Losing a marble

A 44 year old woman with no medical history presented with abdominal pain, vomiting, and lack of bowel movement for four days. Apart from an increased bilirubin level (32 μmol/L, range: <21 μmol/L)...

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NICE recommends 3D heart imaging for diagnosing heart disease

Medical software that helps doctors visualise the blood vessels in the heart without invasive tests could help to diagnose heart conditions in patients with chest pain and suspected angina, the...

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Central sensitization as a determinant of patients’ benefit from total hip and knee replacement

Abstract

Background

Discrepancies exist between osteoarthritic joint changes and pain severity before and after total hip (THR) and knee (TKR) replacement. This study investigated whether the interaction between pre-operative widespread hyperalgesia and severity of radiographic osteoarthritis (OA) was associated with pain severity before and after joint replacement.

Methods

Data were analysed from 232 patients receiving THR and 241 receiving TKR. Pain was assessed pre-operatively and at 12 months post-operatively using the WOMAC Pain Scale. Widespread hyperalgesia was assessed through forearm pressure pain thresholds (PPTs). Radiographic OA was evaluated using the Kellgren and Lawrence scheme. Statistical analysis was conducted using multilevel models, and adjusted for confounding variables.

Results

Pre-operative: In knee patients, there was weak evidence that the effect of PPTs on pain severity was greater in patients with more severe OA (Grade 3 OA: ß = 0.96 vs. Grade 4: ß = 4.03), indicating that in these patients higher PPTs (less widespread hyperalgesia) was associated with less severe pain. In hip patients, the effect of PPTs on pain did not differ with radiographic OA (Grade 3 OA: ß = 3.95 vs. Grade 4: ß = 3.67).

Post-operative: There was weak evidence that knee patients with less severe OA who had greater widespread hyperalgesia benefitted less from surgery (Grade 3 OA: ß = 2.28; 95% CI −1.69 to 6.25). Conversely, there was weak evidence that hip patients with more severe OA who had greater widespread hyperalgesia benefitted more from surgery (Grade 4 OA: ß = −2.92; 95% CI −6.58 to 0.74).

Conclusions

Widespread sensitization may be a determinant of how much patients benefit from joint replacement, but the effect varies by joint and severity of structural joint changes.

Significance

Pre-operative widespread hyperalgesia and radiographic osteoarthritis (OA) severity may influence how much patients benefit from joint replacement. Patients undergoing knee replacement with less severe OA and greater widespread hyperalgesia benefitted less from surgery than patients with less hyperalgesia. Patients undergoing hip replacement with more severe OA and greater widespread hyperalgesia benefitted more than patients with less hyperalgesia.

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Exploring what factors mediate treatment effect: Example of the STarT Back study high-risk intervention

Interventions developed to improve disability outcomes for low back pain (LBP) often show only small effects. Mediation analysis was used to investigate what led to the effectiveness of the STarT Back trial, a large primary care-based trial which treated patients consulting with LBP according to their risk of a poor outcome. The high-risk subgroup, randomised to receive either psychologically-informed physiotherapy (n=93) or current best care (n=45), were investigated to explore pain-related distress and pain intensity as potential mediators of the relationship between treatment allocation and change in disability.

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What is the most effective treatment for frozen shoulder?

What you need to knowConsider the diagnosis in patients with pain and limitation of passive external rotation of the shoulderThere is insufficient evidence to reliably recommend a treatment approach....

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Does a combination of physical training, specific exercises and pain education improve health-related quality of life in patients with chronic neck pain? A randomised control trial with a 4-month follow up

To investigate the effect of combining pain education, specific exercises and graded physical activity training (exercise) compared with pain education alone (control) on physical health-related quality of life (HR-QoL) in chronic neck pain patients.

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Disease related, non-disease related, and situational catastrophizing in sickle cell disease and its relationship with pain

Catastrophizing is a potent psychological modulator of pain across several chronic pain populations; yet despite evidence that patients with sickle cell disease (SCD) catastrophize more than patients with other chronic pain conditions, prior research indicates that catastrophizing is not related to sickle cell pain after controlling for relevant covariates such as depression. Recent research suggests that pain-related catastrophizing should be assessed across pain contexts (e.g., dispositional and situational).

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Perceived injustice is associated with pain and functional outcomes in children and adolescents with chronic pain: a preliminary examination

Chronic pain is prevalent in children/adolescents and contributes to high healthcare utilization. Research suggests injustice perceptions about pain are important in adult patients and a possible treatment focus. We conducted a preliminary evaluation of the psychometric properties of the Injustice Experiences Questionnaire (IEQ) and the relationship between injustice perceptions, pain, and functioning in chronic pain patients (N=139, mean age=15 years, 72% female) presenting to a pediatric pain clinic.

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The impact of perceived injustice on appraisals of physical activity: An examination of the mediating role of attention bias to pain in a chronic low back pain sample

The current study examined the relationship between perceived injustice and attentional bias (AB) toward pain among individuals with chronic low back pain asked to perform and appraise the pain and difficulty of a standardized set of common physical activities. A pictorial dot-probe task assessed AB toward pain stimuli (i.e., pain faces cueing pain), after which participants performed the physical tasks. Participants also rated face stimuli in terms of pain, sadness, and anger expression. As hypothesized, perceived injustice was positively associated with AB toward pain stimuli; additionally, perceived injustice and AB were both positively associated with appraisals of pain and difficulty.

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Participant preferences for pharmacologic chronic pain treatment trial characteristics: an ACTTION adaptive choice-based conjoint study

Barriers to clinical trial recruitment can delay study completion, potentially resulting in increased costs and an unrepresentative sample. In the current study of 150 participants with chronic pain, we used a computerized adaptive choice-based conjoint (ACBC) survey that included 8 characteristics that may affect enrollment in pharmacologic pain treatment trials (i.e., treatment allocation; frequency of pain ratings; treatment administration method; current medications; number of study visits; availability of evening and weekend visits; invasiveness of laboratory procedures; payment).

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Reply to Letter to the Editor: 'Complex Regional pain Syndrome: measurement matters'

Reply from the authors

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A role for bradykinin signaling in chronic vulvar pain

Chronic vulvar pain is alarmingly common in women of reproductive age and is often accompanied by psychological distress, sexual dysfunction, and a significant reduction in quality of life. Localized provoked vulvodynia (LPV) is associated with intense vulvar pain concentrated in the vulvar vestibule (area surrounding vaginal opening). To date, the origins of vulvodynia are poorly understood, and treatment for LPV manages pain symptoms, but does not resolve the root causes of disease. Until recently, no definitive disease mechanisms had been identified; our work indicates LPV has inflammatory origins, although additional studies are needed to understand LPV pain.

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Single-stage Treatment of Osteomyelitis of the Cervical Spine Using Anterior Instrumentation and Titanium Mesh Cages

Study Design. A case series. Objective. The aim of this study was to evaluate the clinical outcomes of patients with osteomyelitis of the cervical spine who were treated with single-stage anterior debridement and fusion using titanium mesh cages along with anterior plates. Summary of Background Data. There have been few studies in single-stage surgical treatment of osteomyelitis of the cervical spine using titanium mesh cages along with anterior plates. Methods. Twenty-four patients treated for osteomyelitis of the cervical spine are presented. There were 11 male and 13 female with an average age of 53.3 years (42–63). Seventeen patients presented with a neurologic deficit at the time of diagnosis. Surgical treatment consisted of anterior debridement and fusion using titanium mesh cages along with anterior plates as a one-step procedure. The patients’ records and radiographs were retrospectively analyzed and follow-up clinical and radiographic data obtained. Results. The median follow-up period was 52 months. There were no implant failures. All patients showed a solid bony fusion without any recurrence of infection at latest follow-up. Changes in pain level, hematologic parameters, and neurologic status demonstrated a significant clinical improvement in all patients. Conclusion. This single-stage surgical treatment for osteomyelitis of the cervical spine provided satisfactory results. There is no increased risk of recurrence or persistence of infection related to the implantation of titanium mesh cages and instrumentation. Level of Evidence: 4

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Long-Term Course of Alternative and Integrative Therapy for Lumbar Disc Herniation and Risk Factors for Surgery: A Prospective Observational 5-Year Follow-Up Study

Study Design. Prospective observational 5-year study. Objective. To assess pain, functional disability, surgical status, and health care use of patients who actively selected complementary and alternative medicine treatment and risk factors for lumbar surgery. Summary of Background Data. Controversy continues regarding difference in long-term outcomes of conservative and surgical treatment. Methods. We recruited 150 consecutive lumbar disc herniation patients with radiating pain (numeric rating scale ≥5) from November, 2006 at a Korean medicine hospital outpatient department, of which 128 patients completed 6 months of complementary and alternative medicine treatment (herbal medicine, acupuncture, bee-venom pharmacopuncture, and Chuna manipulation). Follow-up data was collected every year for 5 years. Results. We assessed surgical status in 105 patients (82%), of which 8 replied that they had received surgery. Ninety-two patients (72%) attended the 5-year follow-up. Visual analog scale of back pain which was 4.19 ± 2.60 at baseline improved after treatment, decreasing to 0.94 ± 1.13 at 6 months, and was maintained at 1.25 ± 1.81 at 5 years. Visual analog scale of leg pain decreased from 7.50 ± 1.32 to 0.94 ± 1.29 and was sustained at 0.98 ± 1.73. Participants reported less disability with Oswestry Disability Index scores decreasing from 41.50 ± 15.07 at baseline to 11.24 ± 10.44 at 6 months, which then declined further to 7.61 ± 9.82 at 5 years. SF-36 quality-of-life health survey scores also improved, increasing from 33.41 ± 12.67 at baseline to 66.04 ± 15.77 at 6 months, and reaching 75.43 ± 15.79 at 5 years. In assessment of satisfaction with current state, 20% replied “highly satisfied,” 67% “satisfied,” 10% “fairly satisfied,” and 2% “dissatisfied.” Patients with younger age, previous treatment for current pain episode, and higher levels of sensory impairment and pain in the lower extremities were at higher risk of lumbar surgery. Conclusion. The long-term results of lumbar disc herniation patients receiving nonsurgical complementary and alternative medicine treatment were favorable and satisfaction rates were high. Level of Evidence: 2

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Motor Control Exercise for Nonspecific Low Back Pain: A Cochrane Review

Study Design. A systematic review. Objective. The aim of this review was to evaluate the effectiveness of motor control exercise (MCE) in patients with nonspecific low back pain (LBP). Summary of Background Data. MCE is a common form of exercise used for managing LBP. MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. Methods. We conducted electronic searches of CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers from their inception up to April 2015. Two independent review authors screened the search results, assessed risk of bias, and extracted the data. A third reviewer resolved any disagreement. We included randomized controlled trials comparing MCE with no treatment, another treatment, or as a supplement to other interventions in patients with nonspecific LBP. Primary outcomes were pain intensity and disability. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group 12-item criteria. We combined results in a meta-analysis expressed as mean difference and 95% confidence interval. We assessed the overall quality of the evidence using the GRADE approach. Results. We included 32 trials (n = 2628). Most included trials had a low risk of bias. For acute LBP, low to moderate quality evidence indicates no clinically important differences between MCE and spinal manipulative therapy or other forms of exercise. There is very low-quality evidence that the addition of MCE to medical management does not provide clinically important improvements. For recurrence at one year, there is very low-quality evidence that MCE and medical management decrease the risk of recurrence. For chronic LBP, there is low to moderate quality evidence that MCE is effective for reducing pain compared with minimal intervention. There is low to high-quality evidence that MCE is not clinically more effective than other exercises or manual therapy. There is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPAs) or telerehabilitation for pain and disability. Conclusion. MCE is probably more effective than a minimal intervention for reducing pain, but probably does not have an important effect on disability, in patients with chronic LBP. There was no clinically important difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. Level of Evidence: 1

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How Effective is Physical Therapy for Common Low Back Pain Diagnoses?: A Multivariate Analysis of 4597 Patients

Study Design. A retrospective review. Objective. The aim of this study is to evaluate whether the treatment of low back pain with physical therapy results in clinically significant improvements in patient-reported pain and functional outcomes. Summary of Background Data. Low back pain is a major cause of morbidity and disability in health care. Previous studies have found poor efficacy for surgery in the absence of specific indications. A variety of nonoperative treatments are available; however, there is scant evidence to guide the practitioner as to the efficacy of these treatments. Methods. Four thousand five hundred ninety-seven patients who underwent physical therapy for the nonoperative treatment of low back pain were included. The primary outcome measures were pre-and post-treatment scores on the Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS) during activity, and NPRS during rest. Previously published thresholds for minimal clinically important difference (MCID) were used to determine the proportion of patients meeting MCID for each of our outcomes. Patients with starting values below the MCID for each variable were excluded from analysis. Logistic regression analysis was used to determine patient risk factors predictive of treatment failure. Results. About 28.5% of patients met the MCID for improvement in ODI. Presence of night symptoms, obesity, and smoking were predictors of treatment failure for ODI. Fifty-nine percent of patients met the MCID for improvement in resting NPRS, with a history of venous thromboembolism, night symptoms, psychiatric disease, workers’ compensation status, smoking, and obesity predictive of treatment failure. Sixty percent of patients met the MCID for improvement in activity NPRS, with night symptoms, workers’ compensation status, and smoking predictive of treatment failure. Conclusion. We observed that a substantial percentage of the population did not meet MCID for pain and function following treatment of low back pain with physical therapy. Common risk factors for treatment failure included smoking and presence of night symptoms. Level of Evidence: 4

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Paracetamol is no more likely to exacerbate asthma in children than ibuprofen, shows study

Using paracetamol to treat fever or pain is no more likely than ibuprofen to exacerbate asthma in children with mild persistent asthma, a randomised trial has shown.1Observational data have...

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Intractable nausea and vomiting associated with poor glycaemic control in a patient with type 1 diabetes

A 54 year old woman with type 1 diabetes was referred to the diabetes clinic with a four year history of nausea, early satiety, abdominal pain, and intermittent vomiting. In recent months she had...

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