Diagnosis Of Chronic Pain Research Articles

Risk of Suicidal Self-directed Violence Among US Veteran Survivors of Head and Neck Cancer

Head and neck cancer (HNC) survivors are about twice as likely to die by suicide compared with other cancer survivors. To examine the associations between precancer mental health and pain and postcancer receipt of mental health, substance use disorder (SUD), or palliative care services with risk of suicidal self-directed violence (SSDV). This retrospective cohort study used the Veterans Health Administration data of 7803 veterans with a diagnosis of HNC (stage I-IVB) who received cancer treatment between January 1, 2012, and January 1, 2018. Data were analyzed between May 2020 and July 2021. Presence of precancer chronic pain and SUD diagnoses, and postcancer SUD, mental health, or palliative care treatment. Exposures were defined using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes in Veterans Health Administration administrative data. Documented SSDV event, including suicide attempt or death by suicide, after HNC diagnosis. Among the cohort of 7803 veterans (7685 [98.4%] male; mean [SD] age, 65 [10.7] years), 72 (0.9%) had at least 1 documented SSDV event following their cancer diagnosis, and 51 (0.7%) died by suicide. Four adjusted modified Poisson regression analyses identified that precancer chronic pain (incidence rate ratio [IRR], 2.58; 95% CI 1.54-4.32) or mood disorder diagnoses (IRR, 1.95; 95% CI, 1.17-3.24) were associated with higher risk of postcancer SSDV. Those who had at least 1 documented mental health (IRR, 2.73; 95% CI, 1.24-6.03) or SUD (IRR, 3.92; 95% CI, 2.46-6.24) treatment encounter in the 90 days following HNC diagnosis were at higher risk for SSDV. A palliative care encounter within 90 days of postcancer diagnosis was associated with decreased risk of SSVD (IRR, 0.49; 95% CI, 0.31-0.78). In this cohort study, a high proportion of HNC survivors with an SSVD event died from their injuries. Identification of risk factors for SSDV among HNC survivors may help direct additional resources to those who are at high risk. Referral to palliative care appears to be an important component of supportive oncologic care to reduce the risk of SSDV.

Association of 3 CDC opioid prescription guidelines for chronic pain and 2 payer pharmacy coverage changes on opioid initiation practices.

BACKGROUND: Due to the US opioid epidemic, in March of 2016, the Centers for Disease Control and Prevention (CDC) published new guidelines for primary care providers on opioid prescribing for chronic pain. Payer coverage changes were also implemented to help modify opioid prescribing behavior. Whether these initiatives were associated with changes in opioid initiation patterns is unknown. OBJECTIVE: To assess the association between 3 of the 2016 CDC guidelines and 2 subsequent payer pharmacy coverage changes with changes in opioid initiation behavior across different provider specialties. METHODS: We conducted a real-world evidence study using claims data from OptumLabs Data Warehouse between January of 2014 and December of 2018. Subjects were continuously enrolled opioid naive patients, aged at least 18 years, who had at least 1 chronic pain diagnosis within 2 weeks before their first (first-time) opioid prescription. The study used multiple treatment period segmented regression analysis to evaluate the association, across different provider specialties, between the CDC guideline release and the payer pharmacy coverage changes with immediate change in level and overall change in the rate of first-time extended-release opioid prescriptions, firsttime opioid prescriptions at doses of at least 50 MME (morphine milligram equivalent) per day, and first-time opioid prescriptions with overlapping benzodiazepine prescription. RESULTS: The CDC guidelines were not associated with any change in the rate of first-time prescriptions of extended-release opioids. However, a January 2017 payer pharmacy coverage change was associated with a reduction over time in first-time extended-release opioid prescription rates by 22.15 in every 100,000 prescriptions (CI = -40.04 to -2.92, P = 0.013). The CDC guidelines were associated with an immediate decline in level of first-time opioid prescription at doses of at least 50 MME per day by 74.00 in every 10,000 prescriptions (CI = -124.86 to -23.13, P = 0.004) and an increased rate of decline over time by 13.64 in every 10,000 prescriptions (CI = -17.07 to -10.21, P < 0.001). These associations varied across provider types and specialties. The March 2018, payer coverage change was associated with an immediate reduction in level of first-time opioid prescriptions at doses of at least 50 MME per day across all specialties and an increased reduction over time among surgeons. The CDC guidelines were associated, respectively, with a reduction in the rate of overlapping first-time opioid prescriptions with benzodiazepines among family medicine, internal medicine, surgeons, emergency medicine providers, and providers with unknown specialty by 6.11, 5.10, 2.89, 11.43, and 9.11 in every 10,000 prescriptions monthly (CI = -9.48 to -2.73, -9.86 to -0.35, -5.40 to -0.38, -17.26 to -5.61 and -11.96 to -6.25, respectively, P < 0.001, P = 0.035, P = 0.024, P < 0.001 and P < 0.001). CONCLUSIONS: Some specialist providers also adopted the CDC guidelines, and the response to the guidelines differed across various provider specialties. Some CDC guidelines were associated with a reduction in high-risk first-time opioid prescriptions. Payer pharmacy coverage changes reinforced the guidelines both in situations where the CDC guidelines did and did not show any association. DISCLOSURE: This research was funded by Agency for Healthcare Research and Quality (R01 HS025164; PI: Karaca-Mandic). Karaca-Mandic reports grants from the American Cancer Society and Sempre Health, along with fees from Tactile Medical and Precision Health Economics, unrelated to this study. The other authors have nothing to disclose.

Chronic tenosynovitis of the hand – an unusual presentation of tuberculosis in children

Tuberculosis remains the most common cause of death from infectious diseases worldwide. Extrapulmonary tuberculosis with musculoskeletal involvement occurs in about 10-15% of cases, mainly affecting joints and bones. Of these, only 1-5% are reported as synovitis of the hand. However, prompt diagnosis and treatment are often delayed and, if left untreated, bone and tendon destruction soon ensue and may lead to chronic synovitis. A 15-year-old girl presented with recurrent pain of the hand following trauma. Imaging showed tenosynovitis and tendon rupture. Surgical treatment was performed. Pathological assessment revealed necrotic caseous granulomas. Chest radiography showed no abnormal findings, but both Tuberculin Skin Test and Interferon Gamma-Release Assay were positive. Tuberculous tenosynovitis was diagnosed, and 12-month anti-tuberculous chemotherapy was instated. Five years after surgery, the patient maintained chronic pain and functional hand limitation.Tuberculous tenosynovitis of the hand is a rare and insidious condition that should be considered in the differential diagnosis of chronic hand pain. Delayed diagnosis and treatment can lead to residual functional limitation, making disease recognition critical.

The Effectiveness of TranscranialDirect Current Stimulation (TDCS) on Anxiety, Depression, and Physical Symptoms of People with Chronic Pain

Introduction: Chronic pain and the experience of living with it are unique. Individual perception of pain is affected by physical, psychological, and social variables. This study aimed to determine the effectiveness of transcranial direct current stimulation (tDCS) on anxiety and depression and physical symptoms of patients with chronic pain.Method: This study was a semi-experimental study with pre-test, post-test, and follow-up with the control group. The statistical population of the study included all outpatients of men and women referred to all medical centers in Tehran in 2019 who had received a definitive diagnosis of chronic pain by neurologists, rheumatologists and psychiatrists, and other relevant specialists. The sampling method in this study had two stages: first, through available sampling, selected from several women with a definite diagnosis of chronic pain, and then, based on inclusion criteria and conducting a pre-test session with interviews. A clinical trial conducted by a researcher under the supervision of a psychiatrist based on DSM-5 diagnostic criteria, 30 women (15 for each group) of women who had the highest scores (as baseline) after completion The questionnaires were selected by simple random sampling method and after random allocation, they were replaced in two groups of intervention and control. Data were obtained using the Beck depression questionnaire and the Beck anxiety questionnaire. Repeated variance analysis was used to analyze the data. The above analysis was carried out using SPSS.22 software.Results: The results showed that the effectiveness of transcranial direct current stimulation (tDCS) was effective on anxiety and depression and physical symptoms of people with chronic pain.Conclusion: It can be concluded that transcranial direct current stimulation (tDCS) is effective in reducing anxiety, depression, and physical symptoms of people with chronic pain and can be used to improve psychological problems in people with chronic pain.

Chronic Pain Increases the Risk of Dementia: A Nationwide Population-Based Cohort Study

Chronic pain (CP) may increase the risk of cognitive impairment; however, the association between CP and dementia is still unclear. Therefore, we conducted this study to clarify the association between CP and dementia. Retrospective cohort study. Nationwide population based. This study recruited 27,792 patients (>= 50 years) with CP from the Taiwan National Health Insurance Research Database between January 1, 2000, and December 31, 2015, as the study cohort. The comparison cohort consists of patients without CP who were matched 1:1 for age, gender, and index date with the study cohort. A comparison of the risk of dementia between the two cohorts was performed by following up until 2015. The prevalence of CP was 13.4% in the population aged >= 50 years. Patients with CP had a higher risk of dementia than those without CP (adjusted hazard ratio [AHR]: 1.21; 95% confidence interval [CI]: 1.15-1.26). Compared with the other age subgroups, the 50-64 years age group with CP had the highest risk of dementia (AHR: 1.28; 95% CI: 1.14-1.43). The impact of CP on the increased risk of dementia was more prominent in the younger age subgroup and decreased with aging. The increased risk of dementia in patients with CP was persistent, even following up for more than 5 years (AHR: 1.19; 95% CI: 1.12-1.26). Using "analgesics use at least 3 months" as the surrogate criteria of CP may underestimate the diagnosis of CP. CP was associated with a higher risk of dementia, especially in the 50-64 years age group. Early treatment of CP for the prevention of dementia is suggested.

A Prospective Single-Center Study of the Effects of Repetitive Transcranial Magnetic Stimulation at 2-Week Follow-Up in 17 Patients with Chronic Orofacial Pain Diagnosed by Infrared Thermography.

BackgroundInfrared thermography is a diagnostic method used to monitor acute and chronic orofacial pain syndrome. Repetitive transcranial magnetic stimulation (rTMS) is a form of non-invasive brain stimulation. This prospective study from a single center aimed to investigate the effects of rTMS and used infrared thermography as a confirmatory test of orofacial pain.Material/MethodsWe used infrared thermography to examine the incidence of inflammatory changes as orofacial pain triggers. During the analysis of rTMS effects on patients with orofacial pain, we compared the decrease in pain and the thermal difference in the study group (n=17) and in the research group (n=13).ResultsIn the control group (n=13), there were no statistically significant changes. Both groups showed a significant decrease in self-reported pain. Numerical pain rating scores were significantly lower after S2 stimulation than after S1/M1 (P=0.0071) or sham (P=0.0187) stimulation. The Brief Pain Inventory scores were also lower 3 to 5 days after S2 stimulation than at the pretreatment baseline (P=0.0127 for the intensity of pain and p=0.0074 for the interference of pain), and after S1/M1 (P=0.001 and P=0.0001) and sham (P=0.0491 and P=0.0359) stimulations.ConclusionsThe findings from this study support the role of infrared thermography for the diagnosis of chronic orofacial pain, and showed that on the first and fifth days of rTMS therapy in the study group there was a significant reduction of the thermography findings when compared with the control group without rTMS therapy.

Pain in an Internal Medicine Ward: An Undervalued Reality?

IntroductionPain is prevalent in most pathologic situations that require healthcare and is very common in hospitalised patients. However, there is limited evidence about the prevalence and the actual management of pain in medical wards. The aim of this work was to evaluate and characterise pain management in an internal medicine ward.MethodsRetrospective analysis of clinical data of patients consecutively discharged from the internal medicine ward of a central tertiary hospital over a period of five months in 2018.Results199 patients evaluated, the median age was 78 years and 63% were female. Of these, 14% had a previous diagnosis of chronic pain, 24% were on chronic pain medication, and in 29% medication was interrupted. Pain was noted in medical records of 118 patients, with moderate to severe intensity in 67%. Among those, 71% had pain occurrence registered in the medical notes but not characterised in duration in 61%. The most common attributed etiologies of pain were musculoskeletal (16%), visceral (9%), and headache (8%); no identifiable cause was specified in 57%. In the group of patients reporting pain, 63% received analgesics. Opioids were used in 35% and 47% of patients with moderate and severe pain, respectively. At discharge, 12 patients were still referred pain, 16 had pain listed as a diagnosis, 45 were medicated for pain, and eight were referred for pain consultation.ConclusionsDespite being highly prevalent in the internal medicine ward, pain is still under-recognised, undervalued, and under-treated. Education of healthcare staff and adoption of treatment protocols is essential to improve care for these patients.

Diagnostic Effect of Consultation Referral from Gastroenterologists to Generalists in Patients with Undiagnosed Chronic Abdominal Pain: A Retrospective Study.

This study aimed to investigate consultation outcomes from gastroenterologists to generalist physicians for the diagnostic workup of undiagnosed chronic abdominal pain. This was a single-center, retrospective, descriptive study. Patients were included who were ≥15 years old and consulted from the Department of Gastroenterology to the Department of Diagnostic Medicine, to establish a diagnosis for chronic abdominal pain, at the Dokkyo University Hospital from 1 April 2016 to 31 August 2020. We retrospectively reviewed the patients’ medical charts and extracted data. A total of 12 cases were included. Eight patients (66.7%) were diagnosed with and treated for functional gastrointestinal disorders (FGID) at the Department of Gastroenterology; their lack of improvement under treatment for FGID was the reason for their referral to the Department of Diagnostic Medicine for further examination. After this consultation, new possible diagnoses were generated for eight patients (66.7%). Six of the eight patients (75.0%) were diagnosed with abdominal wall pain (anterior cutaneous nerve entrapment syndrome, n = 3; myofascial pain, n = 1; falciform pain, n = 1; and herpes zoster non-herpeticus; n = 1). Consultation referral from gastroenterologists to generalists could generate new possible diagnoses in approximately 70% of patients with undiagnosed chronic abdominal pain.

Interests and concerns regarding medical marijuana among chronic pain patients in Ohio: an online survey

BackgroundSince the legalization of medical marijuana (MMJ) in Ohio in 2018, many chronic pain (CP) patients have become interested in it as an alternative or adjunct to prescription opioids. This has not only created a need for pain management specialists to learn about this potential indication for MMJ but also for them to have more detailed knowledge of patient attitudes and willingness to comply with providers’ recommendations regarding its safe use with other pain medications. For this purpose, we surveyed CP patients in a region severely affected by the opioid crisis in order to provide better education, formulate treatment plans, and develop clinical policies.MethodsWe designed and administered the Medical Marijuana Interest Questionnaire (MMIQ) online to patients of the Western Reserve Hospital Center for Pain Medicine (CPM) with a diagnosis of CP who were not yet using MMJ. Questions addressed demographic and clinical characteristics, willingness to consider MMJ, and compliance with treatment plans and concerns. We then carried out a statistical analysis including Pearson chi-square, Spearman’s rho and Kendall’s tau tests to measure associations between variables to identify factors that may influence willingness to use MMJ.ResultsAfter sending 1047 email invitations to complete the MMIQ, 242 (23.1%) completed questionnaires were returned. The average age range of all respondents was 51-60 years, 171 (70.7%) were female and 147 (60.7%) were current opioid users. The 204 (84.3%) respondents who were willing to consider using MMJ were given access to the entire questionnaire. Of these, 138 (67.6%) reported wanting to use less opioids after starting MMJ and 191 (93.6%) were amenable to following their pain specialists’ recommendations about using MMJ concurrently with opioids. Their greatest concern on a 0-5 scale was affordability (2.98) and there was a statistically significant negative correlation between older age and preference for inhaled forms (p = 0.023).ConclusionThe MMIQ was successful in eliciting important data regarding patients’ attitudes about MMJ for opioid titration and potential compliance. Our study was limited by being administered online rather than in-person, which skewed the demographic makeup of the sample. The MMIQ can be used to study similar populations or adapted to patients already using MMJ. Similar surveys of MMJ-experienced patients could be combined with chart reviews to study the success of these products for pain control and opioid substitution.

Factors associated with persistent high health care utilization in managed Medicaid.

Prior studies have had difficulty predicting which patients will have persistent high utilization past 1year within the Medicaid population. The objective of this study was to examine the medical diagnoses at the time of enrollment of patients with persistent high health care utilization over 24 months following enrollment in Medicaid managed care in a large integrated care setting. Retrospective cohort study in a large integrated managed health care system. We identified a cohort of high utilizers (top 5% of health care costs in 2014) and extracted their electronic health record data (2014-2016). Differences in baseline characteristics of high utilizers and the general Medicaid population were determined using bivariate analysis. We used multivariable regression to determine the independent association between medical comorbidities and demographics with persistent high health care utilization over the 2 years following enrollment. Compared with the general Medicaid managed care enrollee population, schizophrenia was the only mental health diagnosis at the time of enrollment associated with persistent high health care utilization (risk ratio [RR], 1.50; 95% CI, 1.20-1.86). Additional characteristics associated with persistent high utilization included age between 31and 50 years (RR, 1.20; 95% CI, 1.02-1.41), dual enrollment in Medicaid and Medicare (RR, 1.26; 95% CI, 1.09-1.45), chronic pain diagnoses (RR, 1.26; 95% CI, 1.04-1.53), and multimorbidity (RR, 1.43; 95% CI, 1.25-1.63). Among adults newly enrolled in Medicaid managed care, certain diagnoses noted at the time of enrollment into the plan are associated with persistent high health care utilization over the first 2 years, suggesting that targeting early supportive case management to these individuals could optimize care and reduce health care costs.

Medical and social aspects in women of reproductive age with chronic pelvic pain

The objective: a study of the medical and social characteristics of women in reproductive age with chronic pelvic pain on the basis of retrospective analysis.Materials and methods. The analysis of medical documentation of 314 patients in reproductive age with a verified diagnosis of chronic pelvic pain (CPP) was performed on the basis of studying of case histories and outpatient cards. Data were analyzed: anthropometric data, age, body mass index, place of residence, gynecological pathology, duration and nature of the menstrual cycle, comorbidities, previous treatment, disease duration, pain intensity, bad habits, number of pregnancies and births, reproductive plans and other methods examination.Results. It was found that more than a third of women, who were treated for pathologies that cause CPP, need medical help again. 58 % of patients sought help for CPP for the first time, 42 % had already received treatment for CPP. Concomitant non-gynecological pathology is more often observed in such patients (48.7 %).The most commonly diagnosed were interstitial cystitis (42 %) and irritable bowel syndrome (34 %). The combination of gynecological, urological and surgical pathology was found in 22 % of patients. Patients with CPP had deficiency in vitamin D (68 % of the 162 patients tested for vitamin D) and had subjectively more severe pain. At the same time, the lack of routine examination of thyroid function and vitamin D status attracted attention. Simultaneously, women with CPP are much more likely than the general population to have infertility (56.4 %), and the incidence of miscarriage is twice as high as the population, with a tendency to recurrent pregnancy loss.Conclusions. Concomitant non-gynecological pathology, infertility, miscarriage, vitamin D deficiency and subjectively more severe pain are more common in women with chronic pelvic pain. However, the level of diagnosing thyroid pathology and determining the concentration of vitamin D in such patients is insufficient.

Predictors of Self-Reported Neglect-like Symptoms and Involuntary Movements in Complex Regional Pain Syndrome Compared to Other Chronic Limb Pain Conditions

ObjectiveIn addition to pain, people with complex regional pain syndrome (CRPS) often report inattention to and disengagement from their affected limb (i.e., “neglect-like symptoms”). Understanding how these symptoms relate to other characteristics of CRPS, and chronic pain generally, could provide insights for preventing and treating CRPS.MethodsWe administered an online survey to people who received a diagnosis of CRPS (n = 335) and other chronic limb pain (n = 407). Neglect-like symptoms were assessed using the Neurobehavioral questionnaire.ResultsA principal component analysis identified two components: motor and cognitive neglect-like symptoms, and involuntary movements. Internal consistency of the components was acceptable. We conducted regression analyses with these as outcomes. Having CRPS, a painful lower limb, higher pain intensity, and somatic symptoms were associated with more motor and cognitive neglect-like symptoms. Having CRPS, higher pain intensity, depression, and somatic symptoms were associated with more involuntary movements. Age, gender, anxiety, disease duration, hours of pain per day, affected side, whether the limb was the most painful body part, and number of pain-related medical diagnoses were no predictors. Finally, motor and cognitive neglect-like symptoms were related to tremor; and involuntary movements to changes in skin color, swelling, sweating, toenails, weakness, and tremor.ConclusionsThis study confirms the specificity of inattention to and disengagement from the affected limb in CRPS, independent of other factors. Furthermore, two components of the Neurobehavioral questionnaire were disentangled: motor and cognitive neglect-like symptoms, and involuntary movements. Results could potentially help clinicians to better assess neglect-like symptoms in chronic pain .

Chronic pain syndromes in ICD 11. Complex therapy concept

In the International Classification of Diseases (ICD‑10), the diagnosis of chronic pain is not presented, which makes it difficult to conduct accurate epidemiological studies and prevents the development of an adequate diagnosis and multimodal therapy strategy. ICD‑11 will be the first version to include chronic pain as a diagnosis. According to the new concept, chronic pain is a real disease associated with multiple changes in the nervous, endocrine and immune systems. Developing a comprehensive treatment plan is of paramount importance and requires a multimodal plan that includes non‑drug and pharmacotherapeutic strategies for pain management. One of the promising areas of pharmacotherapy is the use of complex therapy regimens: meloxicam (Amelotex) – tolperisone (Calmirex) – B vitamins (compliments B).

The Tasks for Diagnosis and Treatment of Chronic Pain

The Tasks for Diagnosis and Treatment of Chronic Pain

Reliability and clinical utility of the chronic pain classification in the 11th Revision of the International Classification of Diseases from a global perspective: results from India, Cuba, and New Zealand.

Chronic pain affects 1 in 5 persons and contributes substantially to the global burden of disease. The 11th Revision of the International Classification of Diseases (ICD-11) includes a comprehensive classification of chronic pain. The aim of this ecological implementation field study was to evaluate the classification's interrater reliability and clinical utility in countries with different income levels. The study was conducted in 4 pain clinics in Cuba, India, and New Zealand. Twenty-one clinicians used the ICD-11 to diagnose and code n = 353 patients with chronic pain. Of these, 111 were assessed by 2 clinicians, and Fleiss' kappa was calculated to establish interrater reliability for any diagnosis assigned to ≥15 patients. The clinicians rated the clinical utility of all diagnoses. The interrater reliability could be calculated for 11 diagnoses. It was substantial for 10 diagnoses and moderate for 1 (kappa: 0.596-0.783). The mean clinical utility of the ICD-11 chronic pain diagnoses was rated as 8.45 ± 1.69/10. Clinical utility was rated higher for ICD-11 than for the commonly used classification systems (P < 0.001, η2 = 0.25) and differed between all centers (P < 0.001, η2 = 0.60). The utility of the ICD-11 diagnoses was rated higher than the commonly used diagnoses in Dunedin and Havana, and no difference was found in Kolkata and Hyderabad. The study showed the high interrater reliability of the new chronic pain diagnoses. The perceived clinical utility of the diagnoses indicates their superiority or equality compared with the classification systems currently used in pain clinics. These results suggest the global applicability of the classification in specialized pain treatment settings.

Incidence, prevalence, and trends in endometriosis diagnosis: a United States population-based study from 2006 to 2015

Accurate estimates of incidence and prevalence of endometriosis among nonselected cohorts are lacking in the United States, and earlier reports have produced varying results. This study aimed to define endometriosis incidence and prevalence in a US population and evaluate factors influencing these estimates over time. A 10-year retrospective cohort study using Kaiser Permanente Washington electronic health records database was completed. The primary analysis included women enrollees aged 16 to 60 years, from January 2006 to December 2015, who had a uterus, were continuously enrolled for at least 2 years before cohort entry and had at least 1 healthcare utilization. Secondary analysis included all women enrollees aged 16 to 60 years during this time. Incident endometriosis was identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, diagnosis codes. Annual incidence rates were age-adjusted by direct standardization to the 2015 study population. Secular trends in incidence overall and by 5-year age group, race and ethnicity, diagnosis modality, and practitioner type were assessed using Poisson regression analyses. Prevalent cases were defined as women enrolled in 2015 and had an endometriosis diagnosis before the end of 2015. The prevalence rates of chronic pelvic pain and dysmenorrhea defined by the International Classification of Diseases, Ninth Revision and Tenth Revision, diagnosis codes in 2006-2015 were estimated. Among 332,056 eligible women who contributed 1,176,329 person-years during the 10-year study period, 2863 incident endometriosis cases were identified for an average incidence of 24.3 cases per 10,000 person-years. In our primary analysis, incidence rates declined over the study interval from a high of 30.2 per 10,000 person-years in 2006 to 17.4 per 10,000 person-years in 2015 and were highest among women aged 36 to 45 years in most years. Incidence rates were similar across race and ethnicity groups. The distribution of the 2863 incident cases by the diagnosis modality was as follows: 45.5% surgical, 5.7% imaging, and 48.8% clinical. Endometriosis incidence rates per 10,000 person-years were similar in women who were surgically and clinically diagnosed and decreased significantly from 2006 to 2015 (surgically diagnosed endometriosis dropped from 13.4 to 7.4 and clinically diagnosed endometriosis dropped from 16.1 to 8.9; P value of <.001 for linear trend over time for each). Incident case distribution by diagnosing provider was as follows: 73.6% obstetrician and gynecologist, 15.7% primary care provider, and 10.7% "other." Incidence of endometriosis diagnosed by an obstetrician and gynecologist and primary care provider decreased over the study interval (P<.001 for linear trend over time for each). Method of diagnosis and provider type did not differ by race and ethnicity. Among 135,162 women who contributed person-time in 2015, 2521 women were diagnosed with endometriosis, a prevalence rate of 1.9%. In our secondary analysis, the frequency of chronic pelvic pain diagnosis increased over the study interval from 3.0% in 2006 to 5.6% in2015. The incidence rates of endometriosis declined over the 10-year study interval and did so uniformly across age groups, races and ethnicities, and the main diagnosing modalities and providers. Declining rates may reflect a shift in practice patterns in the United States away from the diagnosis of endometriosis both clinically and surgically, rather than favoring more general diagnoses of chronic pelvic pain. The prevalence of endometriosis in 2015 in the United States is in keeping with data from recent studies outside the United States using health record data.

Healthcare utilization following minimally invasive apical prolapse repair in a large integrated healthcare system.

We sought to describe healthcare utilization (HU) following minimally invasive apical prolapse repair (MIAR) and its association with duration of hospital stay, patient characteristics, and perioperative factors. This retrospective study included women undergoing MIAR within a large managed care organization between January 1, 2011, and June 30, 2018, and aimed to quantify HU within 30days of surgery. HU was dichotomized into two groups: normal and high, based on typical postoperative utilization of healthcare resources. The primary outcome was the rate of normal versus high HU overall and by duration of hospital stay [discharge home on day of surgery versus postoperative day (POD) 1-2]. Multivariable logistic regression was performed to identify factors predictive of high HU. A p value of < 0.05 was considered statistically significant. Of the 4208 patients in our final cohort, 17% had high HU, while 83% were normal utilizers. High utilizers were more likely to have multiple comorbidities (p < 0.01) and a diagnosis of chronic pelvic pain (p = 0.02) and were less likely to be discharged on day of surgery (p < 0.01). A higher burden of disease, a concurrent mid-urethral sling or posterior colporrhaphy, and discharge on POD 1-2 were independently predictive of high HU. Within the high HU cohort, the most common type of unanticipated healthcare encounter was emergency department visit for urinary retention or pain. Same-day discharge after MIAR does not result in increased HU, even after adjusting for relevant demographic and clinical characteristics. Pre-existing chronic pain diagnoses, multiple comorbidities, and concurrent mid-urethral sling are associated with high HU in this population.

A rare case of low backache (Bertolotti’s syndrome)

Lumbosacral transition of L5 vertebra is an anatomical variation. Enlarged transverse process of L5 vertebra may form a pseudo joint with ilium or sacrum. This may lead to low back pain, especially in young adults due to change in biomechanical properties of the lumber spine. This condition is referred to as Bertolotti’s syndrome. We present a case of 40 years old male surgeon with low backache not responding to oral and intravenous pain killers which prevented him from carrying out his daily routine activities. The pain was severe, excruciating and radiating to right buttock with Visual Analogue Scale (VAS) score ranging from 8/10. There was tenderness over right sacroiliac area provoked by deep palpation. Provisional diagnosis of right sacroilitis was made. Fluoroscopy revealed anomalous articulation between right enlarged L5 transverse process with ipsilateral ala of sacrum forming a pseudo arthrosis with maximum tenderness over it. Periarticular injection at pseudo joint with 0.1 % bupivacaine and of triamcinolone 40 mg was given under fluoroscope and confirmed with dye. There was immediate relief from pain. In young individuals with chronic low back pain diagnosis of Bertolotti’s syndrome should also be kept in mind. Key words: Low back pain; Bertolotti’s syndrome; Visual Analogue Scale Citation: Ali L, Ahmad K, Ali U. A rare case of low backache (Bertolotti’s syndrome). Anaesth pain intensive care 2021;25(2):402-405. DOI: doi.org/10.35975/apic.v25i3.1508 Received: May 6, 2021, Reviewed: May 11, 2021, Accepted: May 20, 2021

Chronic pain severity, impact, and opioid use among patients with cancer: An analysis of biopsychosocial factors using the CHOIR learning health care system.

Despite the biopsychosocial underpinnings of chronic noncancer pain, relatively little is known about the contribution of psychosocial factors to chronic cancer pain. The authors aimed to characterize associations between biopsychosocial factors and pain and opioid use among individuals with chronic pain and cancer. The authors conducted a retrospective, cross-sectional study of 700 patients with chronic pain and cancer seeking treatment at an academic tertiary pain clinic. Patients completed demographic questionnaires and validated psychosocial and pain measures. Multivariable, hierarchical linear and logistic regressions assessed the relative contributions of biopsychosocial factors to the primary dependent variables of pain severity, pain interference, and opioid use. Participants were 62% female and 66% White with a mean age of 59 ± 15 years, and 55% held a college degree or higher. Older age, African American or "other" race, sleep disturbance, and pain catastrophizing were significantly associated with higher pain severity (F(5,657) = 22.45; P ≤ .001; R2 = 0.22). Depression, sleep disturbance, pain catastrophizing, lower emotional support, and higher pain severity were significantly associated with pain interference (F(5,653) = 9.47; P ≤ .001; R2 = 0.44). Lastly, a poor cancer prognosis (Exp(B) = 1.62) and sleep disturbance (Exp(B) = 1.02) were associated with taking opioids, whereas identifying as Asian (Exp(B) = 0.48) or Hispanic (Exp(B) = 0.47) was associated with lower odds of using opioids. Modifiable psychological factors-specifically sleep disturbance, depression, and pain catastrophizing-were uniquely associated with pain and opioid use in patients with chronic pain and diverse cancer diagnoses. Future behavioral pain interventions that concurrently target sleep may improve pain among patients with cancer. Feeling depressed, worrying about pain, and bad sleep are related to higher pain symptoms in individuals with chronic pain and cancer. Specifically, those who struggle to sleep have worse pain and use more opioids. Also, individuals who have a bad prognosis for their cancer are more likely to be using opioid pain medications. Although race and cancer are related to chronic pain in patients, psychological well-being is also strongly related to this same pain.

Acute and Chronic Pain from Facial Skin and Oral Mucosa: Unique Neurobiology and Challenging Treatment.

The oral cavity is a portal into the digestive system, which exhibits unique sensory properties. Like facial skin, the oral mucosa needs to be exquisitely sensitive and selective, in order to detect harmful toxins versus edible food. Chemosensation and somatosensation by multiple receptors, including transient receptor potential channels, are well-developed to meet these needs. In contrast to facial skin, however, the oral mucosa rarely exhibits itch responses. Like the gut, the oral cavity performs mechanical and chemical digestion. Therefore, the oral mucosa needs to be insensitive, to some degree, in order to endure noxious irritation. Persistent pain from the oral mucosa is often due to ulcers, involving both tissue injury and infection. Trigeminal nerve injury and trigeminal neuralgia produce intractable pain in the orofacial skin and the oral mucosa, through mechanisms distinct from those seen in the spinal area, which is particularly difficult to predict or treat. The diagnosis and treatment of idiopathic chronic pain, such as atypical odontalgia (idiopathic painful trigeminal neuropathy or post-traumatic trigeminal neuropathy) and burning mouth syndrome, remain especially challenging. The central integration of gustatory inputs might modulate chronic oral and facial pain. A lack of pain in chronic inflammation inside the oral cavity, such as chronic periodontitis, involves the specialized functioning of oral bacteria. A more detailed understanding of the unique neurobiology of pain from the orofacial skin and the oral mucosa should help us develop novel methods for better treating persistent orofacial pain.