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 Introduction: The aim of this study is to compare the efficacy of epidural versus entonox methods for labor analgesia in nulliparous women. 

Methods: This randomized controlled trial was performed on 84 nulliparous women with - pregnancy admitted to Imam Reza Hospital in 10 May 2010- 10 May 2011. 

They were randomly divided into two groups 42 women inhaled entonox in active phase at the beginning of each contraction, and for 42 cases, epidural catheter was inserted and analgesic substance was injected and it was increased adjusted with contraction progressing by bupivacaine combined with fentanyl. The rate of pain was measured with pain scores (minimum pain 0 and maximum pain 10).

 Results: In epidural analgesia, pain score was lower in all stages of labor than entonox analgesia 42% of cases had no pain, while as in entonox group, pain has been decreased 4 scores in 7% of cases and there was no complete analgesia. Duration of different stages of labor was not statistically different between two groups (P=0.89). Cesarean rate was similar in two groups. First and five minute Apgar were not statistically different between two groups (P=0.87, P=0.75, respectively). 

Conclusions: Epidural analgesia with more relief in labor pain is the desired method. This method doesn’t cause more cesarean rate or prolonged labor duration. Although Entonox decreases labor pain in first stage, but doesn’t affect on second stage and fetus Apgar.  

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 Introduction: Several mehods have been proposed to alleviate pain after hysterectomy. Pre-emptive analgesia has been used to relieve pain following abdominal hysterectomy with conflicting results. This study was performed to evaluate the efficacy of pre-incision skin infiltration of Lidocaine in relieving postoperative pain in patients undergoing abdominal hysterectomy. 

Methods: 60 patients with ASA class of I or II scheduled for abdominal hysterectomy were recruited for the study. The patients were randomly assigned to receive pre-incision skin infiltration of either lidocaine or normal saline. The patients were evaluated with respect to postoperative pain scores and analgesic requirements in the first two postoperative days. They were also asked for satisfaction regarding the pain relief intervention.

Results: The patients were similar with respect to demographic characteristics. Patients in the saline group complained of more pain than the lidocaine group in the recovery room(p<0.001). However, the patients were similar with respect to postoperative pain scores and analgesic requirements. They were also similar regarding satisfaction rates during the first 24 hours postoperatively.

 Conclusions: We conclude that pre-incision skin infiltration of lidocaine is not effective in reducing postoperative pain following abdominal hysterectomy and does not affect the patients’ satisfaction. 

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Introduction: Although patients do not experience sever pain after laparoscopic surgery, most of them experience acute or chronic pain afterward. While conventional pain killers including NSAID and narcotics in laparoscopic surgery have specific side effects, their application is inevitable. This study compares the efficacy of local anesthetic drugs and conventional pain killers in post-operative pain control.

Methods: This prospective clinical trial was conducted in two groups of patients (n=93). Group 1, as control group, was given conventional pain killers such as narcotics and NSAIDs. In another group as treatment group, at the end of laparoscopic surgeries, prior to port withdrawal, a local anesthetic mixture, a short acting (Lidocaine 2%) plus a long acting (Bupivacaine 0.5%) is instilled through the port lumen between the abdominal wall layers. The efficacy of both types of medications was compared with regards to their effectiveness and side effects.

Results: 85% of the control group, received 5 to 20ml Morphine for pain control while the others were controlled with trans-rectal NSAIDs. In the treatment group, the pain of 65% of the patients was controlled only by local anesthetic drugs, 30% required NSAIDs and the other 5% required narcotics administration for pain control.

Conclusions: The administration of local anesthetic drugs after laparoscopic surgery is an effective method for pain control with a low complication rate and side effects of narcotics.

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 Introduction: shorter hospital stay and less pain in comparison to open surgery considered to be major benefits for laparoscopic cholecystectomy. We compared the effect of intraperitoneal hydrocortisone plus bupivacaine with bupivacaine alone on pain relief following laparoscopic cholecystectomy. 

Methods: Sixty two patients participated in this double-blind, randomized clinical trial. Patients randomly received intraperitoneal instillation of either 100 mg bupivacaine in 250 ml normal saline (n=32) or 100 mg hydrocortisone plus 100 mg bupivacaine in 250 ml normal saline (n=30) before insufflation of CO₂ into the peritoneum. Abdominal and shoulder pain were evaluated using VAS postoperatively. The patients were also followed for postoperative analgesic requirements, nausea and vomiting, and return of bowel function. 

We used independent Student t-test and Chi-square test and Mann-Whitney U tests with SPSS software to compare quantitative and qualitative variables, respectively. P value less than 0.05 was considered significant. 

 Results: Sixty patients completed the study. Patients in the hydrocortisone plus bupivacaine group had significantly lower abdominal and shoulder pain scores (11.72 vs 8.92 in the bupivacaine and bupivacaine plus hydrocortisone group, respectively P<0.01). The patients were similar regarding analgesic requirements .The patients were similar with respect to return of bowel function, nausea and vomiting. No adverse reaction was observed in either group. 

Conclusions: Intraperitoneal administrations of hydrocortisone plus bupivacaine can alleviate pain after laparoscopic cholecystectomy better than intraperitoneal bupivacaine alone.  

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Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder that manifests with hemolytic anemia, thrombosis, and peripheral blood cytopenias.Acute abdominal pain is one of the PNH clinical manifestations due to venous thrombosis of intra-abdominal sites including hepatic, portal, mesenteric, and splenic veins.Eculizumaband allogeneic bone marrow transplantation (BMT) arethe only widely effective therapies for these patients.

We report a case of PNH disorder which presented with abdominal pain and mild tenderness. Abdominal X ray and sonography revealed intra-peritonealfree fluid and air. At laparotomy, an ischemic segment of jejunum with stricture and perforationwith mesenteric venous thrombosis were found. The patient also had a history of hepatic vein thrombosis two years before.

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Introduction: Propofol is a popular intravenous anesthetic and a quick inducer of anesthesia with quick recovery. However, its downside lies with pain and discomfort during intravenous injections when injected in small blood vessels in the back of the hand, which prevails in 85% of children. This study investigates the effect of Dexamethasone in reducing propofol injection pain in children.
Methods: In this double-blind clinical trial, 50 children aged from 6 to 13 years undergoing elective Adenotonsillectomy in Birjand-based Valiasr Hospital were randomly assigned into case and control groups. Intravenouscannulation was performed with intravenous cannula No. 22 on hands of all participants. Under similar conditions, 0.2 mg (oral) Midazolam as premedication and 20 ml of juice were administered for all the patients two hours before surgery. The same volume of Dexamethasone and normal saline (0.15 mg/Kg) was injected in the case and control groups, respectively. Immediately after, 20% of anesthesia induction dose of propofol (1%) was injected on all patients following which injection pain severity was measured using the Face Pain Scale (FPS) on a scale from 0 to 10. The remaining doses of propofol, Atracurium, and Fentanyl were subsequently injected whereby the anesthesia process was completed. The collected data were analyzed in SPSS-17 using t-test, Mann-Whitney, Fisher, and McNemar’s tests. The significance level was set at P<0.05.
Results: Half of the participants were female. Pain severity rates were 4.32±4.89 and 6.48±1.76 in case and control groups, respectively. The results showed that pain severity was significantly greater in the controls than the cases. Heart rate increased in both groups after intervention (p <0.001). In terms of drug injection complication, three cases were reported in the control group, while there was only one patient in the cases with a significant difference between the groups according to Fisher and McNemar tests.
Conclusions: Dexamethasone can be used as an effective and routine drug in the operating room to reduce propofol injection pain in children before the induction dose of propofol, hence increased satisfaction of children from anesthesia.

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• Introduction: Pain management is one of the most essential components of postoperative care. Nowadays, the common treatment methods for pain include the use of two large groups of analgesics, namely opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Therefore, the present study aimed to compare the effects of ketorolac (i.e., a non-inflammatory drug) and pethidine (i.e., a synthetic opioid pain medication) on pain and complications due to hemorrhoidectomy.
• Methods: This randomized controlled trial included 90 patients with hemorrhoids who underwent hemorrhoidectomy at Imam Reza Hospital in Birjand, Iran, from May 2017 to 2018. The participants were assigned into two groups, namely the ketorolac group who received ketorolac therapy and the pethidine group who received pethidine. The severity of pain and complications were measured immediately, as well as at 6, and 12 hours after surgery in both study groups. The quantitative data were expressed as mean and percentage. Data analysis was performed using SPSS software (version 22.0) through Mann-Whitney, Friedman, and Chi-square tests. A p-value less than 0.05 was considered statistically significant.
• Results: According to the obtained results, out of 90 patients with hemorrhoid, 70.3% were males. The mean age of the participants was 48.29±8.8 years, and there was no significant difference between the two study groups regarding age (47.2±8.7 years in the pethidine group, and 49.4±9 years in the ketorolac group, P=0.196). In the ketorolac group, the mean pain scores were 2.33±1.36, 2.28±1.00, and 1.57±0.75, immediately, as well as at 6, and 12 hours after surgery, respectively. In addition, in the pethidine group, the mean pain scores were obtained at 3.15±1.61, 2.64±1.00, and 1.97±0.69, immediately as well as at 6, and 12 hours after surgery, respectively. Accordingly, the pain level was significantly lower in the ketorolac group, compared to that in the pethidine group (P<0.05). However, the pain level was higher at 24 hours after surgery in the ketorolac group than that in the pethidine group; nevertheless, the difference was not statistically significant (P=0.996).
• Conclusions: The findings of the present study suggest more significant therapeutic effects of nonsteroidal NSAIDs, compared to opioid drugs on pain after hemorrhoidectomy.

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• ​Introduction: Cholecystitis is one of the most common diagnoses among patients referred to surgical emergencies with acute or recurrent abdominal pain. The mainstay of treatment for this disease is cholecystectomy, and the gold standard procedure is laparoscopic cholecystectomy. Pain which is the most common complication after laparoscopic cholecystectomy gives priority to the administration of the best pain relief medicine. This study aimed to compare the efficacy of diclofenac suppository with intravenous Meperidine for pain relief in opioid-dependent and independent patients undergoing laparoscopic cholecystectomy.
• Methods: A total of 120 opioid-dependent and independent patients (60 each) participated in this single-blinded study. Each group was randomly divided into two equal subgroups and 100 mg diclofenac suppository and 25 mg Meperidine via intravenous injection were administered to the participants in each group. Pain intensity was measured by the Verbal Rating Scale (VRS) pain scale 24 hours after recovery. The data were analyzed in SPSS software (version16.0). A P-value of less than 0.05 was considered statistically significant.
• Results: Based on the results of the study, Meperidine for pain relief after laparoscopic cholecystectomy was reported to be more effective in opioid-dependent patients and diclofenac in opioid-independent patients. Moreover, the use of diclofenac in 90% of opioid-independent patients resulted in favorable responses and ease of pain (Fisher=61.01; P=0.001), and the rate of opioid-dependent patients treated with Meperidine with excellent responses was measured at 83.3% (Fisher=56.98, P=0.001).
• Conclusions: Meperidine can be the mainstay of treatment for pain relief after laparoscopic cholecystectomy used in opioid-dependent patients; however, the selected drug for pain relief after laparoscopic cholecystectomy in opioid-independent patients is diclofenac.

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• Measuring patella height has been a hot topic for decades. Multiple radiological indices exist for native knees and arthroplasty. A concise concept of patella height analysis is needed for daily practice and scientific research.

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• Throughout the coronavirus disease 2019 pandemic, patients using oral anticoagulants for mechanical valve replacement and/or another clinical-pathological condition might have faced various clinical scenarios. Rectus sheath hematoma is one of the acute abdominal pain syndromes. This study presented a patient with developed anticoagulation-induced rectus sheath hematoma after mitral valve replacement.

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• Introduction: Dental surgeries are always associated with pain and swelling for several consecutive days. Recent articles have shown conflicting results in the use of new techniques such as low-power lasers to treat postoperative pain and swelling. This study aimed to evaluate the reduction of pain, swelling, and trismus after surgery of the third molar-impacted tooth after the use of a low-power laser.
• Method: This study was a randomized, single-blind, split-mouth clinical trial involving patients who were referred to the special clinic of Birjand Dental School from December 2021 to June 2021 and required bilateral removal of the occluded third molars. Immediately after surgery, the patient was given a radiation laser with a wavelength of 780 nm and a power of 70 MW for 30 seconds at a dose or power density of 52.5 j/cm2. The extent of swelling and trismus was assessed by measuring the dimensions of the face and the amount of mouth opening as well as the amount of pain on the second and seventh days after surgery. Statistical analysis was performed using the Wilcoxon and Mann–Whitney U test by SPSS (Version 21) at the significant level of (5 %).
• Results: The intensity of pain and swelling decreased significantly over time and the amount of trismus increased significantly during the seventh day compared to the second day (p.value<0.05). The amount of pain on the 7th day after surgery in the group without laser was 1.98±0.26 and the amount of pain in the group with laser was 0.85 ± 0.92 which was not statistically significant between the two groups (value>0.05). The amount of trismus on 7-day was 38.79 ±9.94 and on the side, with laser, it was no significant difference. The distance between the tragus and the corner of the lip on day 7 after surgery was 110.03 ± 5.77 mm and in the laser group was 109.66 ±5.67 mm, no significant difference was observed between the two groups. The distance between the gonium and the outer corner on day 7 after surgery was 98.84 ±7.24 mm in the laser group and 98.21± 6.93 mm in the non-laser group and no significant difference was observed.
• Conclusion: The use of low-power laser reduced the pain, reduce postoperative swelling, and trismus caused by surgery but this reduction was not significant. Therefore, it is suggested that the study method should be changed and the sample size must be increased in further studies.

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• The limbus vertebra is formed due to anterior herniation of the nucleus pulposus between the ring apophysis and the adjacent vertebral body, resulting in the formation of a triangular, smooth bony fragment that ossifies separately. It is commonly located in the mid-lumbar spine, usually at the antero-superior margin of a single vertebral body. We present the case of a 31-year-old male who presented to the Emergency Department with complaints of sciatica after bending forwards. The plain radiograph of the lumbosacral spine was suspicious for a L5 chip fracture but was diagnosed to have limbus vertebra and discharged. Limbus vertebra is generally identified incidentally, and most patients with anterior limbus vertebra are asymptomatic. Some patients with posterior limbus vertebra can present with symptoms of nerve compression. It can be mistaken for vertebral fracture, infection, degenerative disease of the spine or tumour, resulting in further diagnostic evaluation. Most patients are management conservatively, while those patients with symptoms of nerve compression requiring total laminectomy. Emergency physicians should consider the limbus vertebra as a differential diagnosis in patients presenting with lumbar pain, particular in young patients.

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• The novel coronavirus (SARS‑CoV‑2) has caused widespread pneumonia in the world, with typical signs and symptoms of viral pneumonia such as cough, sore throat, fever, fatigue, and myalgia. Atypical signs and symptoms such as cardiac, gastrointestinal, neurological, and genital manifestations also have been reported. These atypical symptoms may initially be misdiagnosed and patients may not treat them properly; thus, it is important to consider these atypical symptoms in such cases. In this article, we report a patient with testicular pain, an atypical and rare sign and symptom of Covid-19.