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Experience gained in performing 3615 laparoscopic sterilizations in India over a 10-year period is reported. A simplified technique was developed for performing sterilization under local anesthesia without neuroleptanalgesia, avoiding uterine manipulators, performing direct trocar insertion without prior pneumoperitoneum, and using air for pneumoperitoneum. Beginning in 1973 laparoscopic sterilizations were performed using monopolar electrocoagulation and Hulka clips. The first 100 cases were done under local anesthesia with neuroleptanalgesia (75 mg meperidine, .6 mg atropine intravenously), using uterine manipulators and creating pneumoperitoneum with a Cerres needle and CO2. In 1974, neuroleptanalgesia was no longer used and air was used instead of CO2 for penumoperitoneum (3515 cases). The patients did not fast but were allowed to have liquids and given a glucose drink just prior to survery. The air was insufflated with a sigmoidoscopy bulb or a fish tank minicompressor. Since 1977 the trocar cannula has been inserted directly, without creating a pneumoperitoneum (1035 cases). Since 1980 the semilithotomy position and uterine manipulators are no longer used. A simple supine position with knees bent at right angles and a 30 degree Trendelenburg position was used in the last 435 cases. Of the 3515 cases performed under local anesthesia without neuroleptanalgesia, only 12 (.34%) needed medication during surgery. 20 patients developed vasovagal attacks and required atropine. None needed general anesthesia. Of the 3515 cases in which air was used for pneumoperitoneum, none developed air embolism. When preperitoneal (8 cases), omental (3 cases), and mediastinal (1 case) emphysema developed, it took 3-4 days to subside because the air was absorbed slowly. Postoperative shoulder pain persisted in 1038 cases (29.5%), but it was more of an annoyance than a complication. Of the 1035 cases of direct trocar insertion, there was no injury to the bowel or a blood vessel. In 14 cases (1.3%) the trocar was found to be extraperitoneal and reinserted for correct placement. Pneumoperitoneum with a Verres or spinal needle was created in 21 technically difficult cases (2%), which included obesity, previous scars, and a bulky postpartum uterus. A uterine manipulator wwas used in 9 technically difficult cases (2.07%).
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PMID:Development of a simplified laparoscopic sterilization technique. 623 98

We report 16 adult men (age, 41 to 75 yr) with neuralgic amyotrophy (NA) who presented with dyspnea due to involvement of the diaphragm. All patients developed breathlessness after a prodrome of acute severe neck and shoulder pain. Bilateral diaphragm paralysis (BDP) was confirmed in 12 patients and unilateral diaphragm paralysis (UDP) in four by the absence of electrical and mechanical responses to percutaneous phrenic nerve stimulation. Global expiratory muscle strength was well preserved in all patients, but inspiratory muscle strength was reduced in proportion to the extent of diaphragmatic involvement. Lung function showed low lung volumes with preservation of carbon monoxide transfer coefficient in all patients. Two BDP patients were hypoxic (PaO2 = 67 and 54 mm Hg, respectively) on daytime arterial blood gas analysis; the latter patient with pre-existing chronic obstructive pulmonary disease and marked obesity also had borderline hypercapnia (PaO2 = 49 mm Hg). Overnight sleep studies in three BDP and two UDP patients showed frequent intermittent arterial oxygen desaturations apparently caused by obstructive sleep apneas, but there was no evidence of alveolar hypoventilation. Follow-up muscle studies in five BDP and four UDP patients between 2 and 4 yr after initial referral showed complete recovery of diaphragmatic function in only two UDP patients, one of whom relapsed a year later. We postulate that NA may be an important but underrecognized cause of diaphragmatic paralysis in otherwise normal patients. Diaphragmatic strength returns very slowly, if at all.
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PMID:Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic evaluation of 16 patients presenting with dyspnea. 842 Apr 34

The objective of this work was to address the relationship between physical activity in the workplace and subsequent musculoskeletal pain syndromes. We performed a survey of 5,042 men and women aged 70-75 years, selected from the retirement population of a large national employer (the post office). Subjects were sent a short postal questionnaire enquiring about all occupations held for at least 1 year, the physical activities performed in those jobs, and about recent rheumatic symptoms. The 1-month period prevalence of rheumatic symptoms ranged from 19.9% for hip pain or stiffness in men to 50% for knee pain or stiffness in women. Symptoms were more common in women than men at all sites and there were significant (P < 0.001) associations between symptoms at different sites. Obesity was significantly (P < 0.001) associated with the risk of pain or stiffness at the knee and hip. Prolonged occupational exposure (20+ years) to heavy lifting was associated with hip pain (RR = 1.5; 95% CI = 1.2-1.8); and prolonged exposure to working with arms elevated was associated with an increased risk of shoulder pain (RR = 1.4; 95% CI = 1.2-1.6). Tall stature (P = 0.003) and heavy lifting (P < 0.001) were both associated with increased risks of low back pain among men. This survey confirms the high prevalence of musculoskeletal symptoms observed in previous population-based studies. Associations between occupational activities and musculoskeletal symptoms were specific for activity type and skeletal site involved. Our results imply that the adverse effects of these occupational activities can be found many years after cessation of exposure.
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PMID:Occupational physical activity and long-term risk of musculoskeletal symptoms: a national survey of post office pensioners. 913 Dec 14

Experience with 1000 minilaparotomy sterilizations performed over 6 years in a community hospital in Melrose, Massachusetts are reported. The method used was the Tural (tubouterine resection and ligation) technique. The Tural procedure was developed as a modification of previous surgical techniques. A loop of fallopian tube is grasped with a Babcock clamp and doubly tied with a double 0 chromic catgut. The tied loop is then excised and both free ends are doubly tied separately with double 0 surgilon suture. At the end of the procedure both severed ends of the tubes diverge from each other. In the 1000 case studies, 578 were primary interval sterilizations and 145 were sterilizations performed at the time of cesarean sections. The primary interval patients were done via a minilaparotomy Pfannenstiel incision, and the postpartum patients via a semicircular periumbilical incision. In 1980, the average postpartum hospital stay was 3.4 days. The average postpartum hospital stay with tubal sterilization added was 3.7 days. There was never a need to stop in midprocedure with minilaparotomy or extend the operation because of poor visibility. There was no unusual bleeding, cancelling of the procedure because of adhesions, adherent retroversion, or other pelvic disease. There were no pregnancies, no complications, and no hospital readmissions. Minilaparotomy for tubal sterilization emerged as a safe, economical alternative to conventional laparoscopy. It offers greater operative simplicity and avoids the rare major complications of visceral, vascular, and thermal injuries associated with laparoscopy. Because of disastrous consequences in a small but significant number of cases with laparoscopic electrocautery of the fallopian tubes, a method of nonelectric laparoscopic sterilization was sought by several investigators. A comparative study of female sterilization conducted by the International Research Program revealed the tubal ring was associated with a higher failure rate than electrocoagulation, the Racket clip, or modified Pomeroy technique. An unrecognized bowel injury is 1 of the most serious complications in laparoscopic sterilization. Uchida reported no failures and minimal complications in more than 20,000 minilaparotomies over a 28-year period. The argument that there is more postoperative pain with a minilaparotomy than a laparoscopic procedure was not found in this experience. Some of the positive aspects of minilaparotomy for sterilization are: no shoulder pain secondary to peritoneal insufflation; no contraindication for conditions such as obesity and previous surgery; and thermal injuries to bowel and pelvic organs are prevented.
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PMID:A report of 1000 cases of minilaparotomy sterilizations in a community hospital. 1226 15

Having a better understanding of the intersection between chronic pain and obesity in the Mexican American community can be valuable for pain management specialists in determining treatment, service, and prevention strategies. The objectives of this study were (1) to describe the type and severity of chronic pain among overweight/obese Hispanic adults aged 40 years and older, and (2) to determine the association between chronic pain indices and key demographic variables, including excessive weight. Hispanic adults (N=101) were interviewed using validated questionnaires and measured for BMI and waist circumference. Data analyses revealed that most participants had widespread pain; 60% were suffering severe pain (including back, knee, and shoulder pain); the most common pain location was head (headache, 80%), followed by knee and upper back (75-76%), shoulder (73%) and lower back (73%). Greater obesity was associated with some negative pain outcomes. Results are relevant for pain management with this at-risk population.
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PMID:Typology of chronic pain among overweight Mexican Americans. 2184 Dec 94

Obesity is a risk factor for fibromyalgia in adults, but whether a similar relationship exists in children is uncertain. This study examined whether obesity is associated with reporting of musculoskeletal pain, including chronic regional pain (CRP) and chronic widespread pain (CWP), in adolescents, in a population-based setting. A pain questionnaire was administered to offspring of the Avon Longitudinal Study of Parents and Children at age 17, asking about site, duration, and pain intensity, from which participants with different types of musculoskeletal pain were identified. Relationships between obesity and pain were examined by calculating odds ratios stratified by gender and adjusted for socioeconomic status as reflected by level of maternal education. A total of 3376 participants (1424 boys) with complete data were identified, mean age 17.8; 44.7% of participants reported any pain within the last month lasting 1day or longer; 16.3% reported lower back pain, 9.6% shoulder pain, 9.4% upper back pain, 8.9% neck pain, 8.7% knee pain, 6.8% ankle/foot pain, 4.7% CRP, and 4.3% CWP; 7.0% of participants were obese. Obesity was associated with increased odds of any pain (odds ratio [OR] 1.33, P=.04), CRP (OR 2.04, P=.005), and knee pain (OR 1.87, P=.001), but not CWP (OR 1.10, P=.5). Compared with non obese participants, those with any pain, knee pain, and CRP reported more severe average pain (P<.01). Obese adolescents were more likely to report musculoskeletal pain, including knee pain and CRP. Moreover, obese adolescents with knee pain and CRP had relatively high pain scores, suggesting a more severe phenotype with worse prognosis.
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PMID:Obesity is a risk factor for musculoskeletal pain in adolescents: findings from a population-based cohort. 2280 79

Shoulder pain and loss of shoulder function are common complaints reported by a variety of patients. This article suggests that shoulder pain and loss of function are directly proportional to lifestyle choices, including smoking and obesity. To investigate possible relationships between lifestyle choices and shoulder health, the authors conducted an online survey combining the Oxford Shoulder Questionnaire, the Shoulder Rating Questionnaire, and the Subjective Shoulder Rating System. Data were collected from 166 respondents. Statistical significance was set at P < .05. The data show a statistically significant correlation between decreased shoulder function and cigarette smoking and a similar correlation between decreased shoulder function, elevated cholesterol, and obesity.
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PMID:A shoulder health survey: correlating behaviors and comorbidities with shoulder problems. 2301 30

An 85-year-old man was admitted to our hospital for swollen and painful bilateral lower legs and a high fever. He was initially diagnosed with acute cellulitis and treated with antibiotics. Several days after the improvement of his swollen legs, he complained of both shoulder and arm pain. The laboratory data at this time were as follow: C-reactive protein 10.7 mg/dL, uric acid 8.7 mg/dL, and creatinine 1.07 mg/dL. Both rheumatoid factor and anti-CCP antibody were negative. Whole-body gallium scintigraphy showed a high pathological accumulation in both the shoulders and left wrist. As polymyalgia rheumatica was suspected, oral prednisolone (PSL) of 10 mg/day was started. The patient's shoulder pain improved and he was discharged. However, he was hospitalized twice in the next month because of left shoulder, left knee, right arm, and right wrist pain. During the third hospitalization, we found a subcutaneous nodule on right toe. Aspiration material from the nodule was a white paste, showing acicular crystals under the microscope. According to these findings, the nodule was diagnosed as a tophaceous nodule, and recurrent episodes of polyarthritis were diagnosed as chronic tophaceous gout. Low-dose PSL was continued and febuxostat was added. This patient had multiple risk factors for chronic tophaceous gout: obesity, a habit of drinking, diabetes mellitus, hyperlipidemia, congestive heart failure, and interruption of allopurinol treatment. We herein discuss the clinical course of the patient, the interruption of allopurinol treatment and polypharmacy in elderly patients.
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PMID:[An elderly man presenting polyarthritis diagnosed as chronic tophaceous gout]. 2670 Jul 82

Background: Playing-related musculoskeletal disorders are the most frequent complaints among instrumental musicians. The aims of this study were: to assess the prevalence of musculoskeletal pain; to evaluate neck, shoulder, and lower back disability; and to determine the associated factors with the presence of musculoskeletal pain among musicians. Methods: A population-based, cross-sectional descriptive study was conducted. We selected Spaniard musicians over 16 years old who played a musical instrument for at least five hours per week. They answered the Spanish versions of the Standardised Nordic Questionnaire, the Oswestry Disability Index, Neck Disability Index and Shoulder Pain and Disability Index. Results: We found 94.8% of musicians presented at least one symptomatic region in the last 12 months, and 72.3% in the last seven days. Female musicians (OR 4.38, CI 2.11-9.12), musicians with overweight or obesity (OR 5.32, CI 2.18-12.97), and musicians who play more than 14 h per week (OR 3.86, CI 1.80-8.29)were shown to be a higher risk of suffering musculoskeletal pain. Conclusions: Musculoskeletal disorders symptoms are highly prevalent in musicians. The main risk factors related to musculoskeletal disorders symptoms were gender (being female), overweight, obesity, and spending playing more than 14 h a week practicing. This study highlights the need to provide strategies to prevent occupational disabilities among musicians. Further studies are needed to analyse the prevalence of pain in the musician using other sampling methods.
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PMID:Prevalence, Disability and Associated Factors of Playing-Related Musculoskeletal Pain among Musicians: A Population-Based Cross-Sectional Descriptive Study. 3251 98

The effect of preoperative opioid use in orthopedic patients has been highlighted. Numerous studies have identified worse patient outcomes with pre-operative opioid use; however, there is currently no information identifying risk factors for preoperative opioid use in the total shoulder arthroplasty (TSA) population. The purpose of this study was to determine risk factors for preoperative opioid use in patients undergoing primary anatomic TSA for primary osteoarthritis (OA) and to determine baseline preoperative patient-reported outcomes (PROs) in preoperative opioid users compared with nonopioid users. The authors studied 982 TSAs performed for primary glenohumeral joint OA in a prospective TSA registry. Patient demographic and clinical characteristics were prospectively assessed and included age; sex; socioeconomic status (SES); smoking status; body mass index (BMI); and history of chronic back pain, depression, diabetes mellitus, and heart disease. Preoperative PROs, range of motion measurements, and preoperative opioid use for shoulder pain were assessed. Overall, 254 (25.9%) of 982 total patients were taking preoperative opioids for shoulder pain in the setting of primary OA. Female sex (P=.023), younger age (P=.019), obesity (BMI >30 kg/m2) (P=.043), chronic back pain (P<.001), and lower SES (P=.002) were associated with increased preoperative opioid use following multivariate logistic regression. Patients with opioid use had significantly worse preoperative pain scores (P<.001), American Shoulder and Elbow Surgeons scores (P<.001), and total Constant scores (P<.002) compared with the non-opioid group. [Orthopedics. 2020;43(6):356-360.].
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PMID:Risk Factors for Preoperative Opioid Use in Patients Undergoing Primary Anatomic Total Shoulder Arthroplasty. 3274 15


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