Episodes Of Pain Research Articles

Interrater reliability of the modified prone instability test for lumbar segmental instability in individuals with mechanical low back pain.

The purpose of this study was to establish the interrater reliability of measures obtained with a novel Modified Prone Instability Test (mPIT), which, like the original Prone Instability Test (PIT), is proposed to identify lumbar segmental instability. The mPIT has clinical feasibility advantages to the PIT, but its psychometric properties are yet to be determined. Repeated measures (test-retest) design, methods study. The mPIT was administered by two blinded testers, an orthopedic physical therapy resident with < 1 year experience and board-certified orthopedic specialist physical therapist with >25 years' experience. Procedures were administered at an outpatient physical therapy clinic of a tertiary Medical Center. Participants included 50 adults (≥18 years old) with mechanical low back pain and no radicular (below the knee) symptoms (mean age 50.7 years, 66% female, 76% reported previous episodes of low back pain). Interrater reliability was measured via Fleiss' kappa coefficient. Assessments of the mPIT had moderate interrater agreement (κ = .579 [95% CI = .302 to .856], p < .001.). Measures obtained using the mPIT demonstrated moderate interrater reliability between a new graduate and an experienced clinician, which aligns with several studies examining interrater reliability of the original PIT. Further study examining comparative validation of the mPIT with other lumbar instability measures is warranted.

Predictive validity of the STarT Back screening tool among older adults with back pain.

The predictive validity of the STarT Back screening tool among older adults is uncertain. This study aimed to assess the predictive validity of the SBT among older adults in primary care. This prospective cohort study included 452 patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain. A poor outcome (persistent disabling back pain) was defined as a score of ≥7/24 on the Roland-Morris Disability Questionnaire (RMDQ) at 3, 6 or 12 months of follow-up. The ability of the SBT risk groups to identify persistent disabling back pain was assessed with multivariable logistic regression, area under receiver operating characteristics curve (AUC), and with the accuracy measures sensitivity, specificity, predictive values and likelihood ratios. The adjusted odds ratios (95% CI) for persistent disabling back pain were 2.40 (1.34-4.30) at 3 months, 3.42 (1.76-6.67) at 6 months and 2.81 (1.47-5.38) at 12 months for the medium-risk group (n = 118), and 8.90 (1.83-43.24), 2.66 (0.81-8.67) and 4.53 (1.24-16.46) for the high-risk group (n = 27), compared to the low-risk group (n = 282). There were no statistically significant differences in odds between the medium- and high-risk groups at any time point. AUC values (95% CI) were 0.65 (0.59-0.71), 0.67 (0.60-0.73) and 0.65 (0.58-0.71) at 3, 6 and 12 months. Accuracy measures were poor at all time points, with particularly poor sensitivity and negative likelihood ratio values. The predictive validity of the SBT risk groups in predicting persistent disabling back pain in older adults was poor. This study found that the STarT Back screening tool had poor predictive validity among older adults and that it may need recalibration or extension before widespread implementation among older adults. Having valid tools for this population may aid clinicians with allocating scarce healthcare resources, which is especially important considering the rapidly ageing population and its expected challenge to the healthcare systems.

Episodic Hyponatremia in Acute Intermittent Porphyria: A Case Report

Episodic Hyponatremia in Acute Intermittent Porphyria: A Case Report

Learning pains: system design, management, and lessons learned using electronic patient reported outcomes in the QUEST study of chronic post-amputation pain

BackgroundStudying pain clinically can be challenging. Typically, studies use paper diaries and measure pain from baseline and some pre-specified study endpoints. Both can lead to inaccuracies if studying on-demand device use. The QUEST study evaluating the safety and effectiveness of the investigational Altius device for treating chronic post-amputation pain (PAP) became, to our knowledge, the first longitudinal study to capture and validate repeated measurements using electronic patient-reported outcomes (ePRO).MethodsThe system was designed to capture pain episodes, device use, pain medication use and prosthetic use in “real-time.” Subjects received an electronic diary (eDiary) during screening and were required to demonstrate compliant reporting, and requisite pain levels to progress towards device implantation. Data were collected and merged with Altius session data and study visit data for 3 Month Primary Endpoint analysis. Compliance data across Device Treatment and End-of-Day Reports were also collected.ResultseDiary Eligibility pass rate during screening was 82% (410/497 subjects). Subjects generated 1,773,356 datapoints and 197,952 reports throughout QUEST. A total of 14,337 device uses were captured during Randomized Testing, with 77.0% and 82.7% compliant Device-use Reports and End-of-Day Reports captured, respectively. QUEST results are presented elsewhere (clinicaltrials.gov Identifier NCT 00221934).ConclusionsNeuros and partner vendors developed a unique system to capture accurate, “real-time” pain and treatment data from subjects with chronic PAP, despite health and technical-related challenges. This system provided a robust data set not yet seen in chronic pain literature and could provide a framework for better understanding chronic pain.Clinical Trial Information ClinicalTrials.gov ID NCT02221934, Registration Date: 2014–08-15.

Uso da Toxina Botulínica Tipo A em pacientes com Neuralgia Trigeminal

This article provides a systematic review of the efficacy of Botulinum Toxin Type A (TBA) in treating trigeminal neuralgia (TN), a painful disorder affecting the trigeminal nerve. TN is described in the literature as a facial pain of acute nature, often unilateral, characterized by episodes of intense and transient pain, comparable to electric shocks. The diagnosis is made through a detailed evaluation that includes anamnesis, characterization of symptoms, and imaging tests to exclude similar pathologies. Conventional therapy for TN involves the use of carbamazepine; however, in cases of pharmacological resistance or ineffectiveness of standard treatments, TBA emerges as a viable therapeutic alternative. The efficacy of TBA, as demonstrated in retrospective and prospective studies, is due to its ability to inhibit the release of neurotransmitters responsible for pain transmission and inflammatory processes. Various studies corroborate the efficacy of TBA, especially in patients over 50 years old, observing substantial improvement in symptoms with minimal adverse effects. The administration of TBA is carried out directly in the trigger zones, where it has proven to be well-tolerated, providing significant improvement in the quality of life of the affected patients. Despite promising results, the literature suggests the need for additional studies to optimize the dosage protocols and application of TBA, aiming to ensure its efficacy and safety in the long term. In conclusion, this article reiterates that TBA represents an effective and minimally invasive therapeutic alternative for the treatment of TN. However, it is essential to develop individualized therapeutic protocols and conduct more comprehensive studies to consolidate its use as the treatment of choice.

Sickle Cell Disease Complications and BMI Percentiles of Pediatric Patients

BMI percentile is a good index of nutritional status among pediatric patients. Yet there is a dearth of information about the relationship between this important anthropometric parameter and specific severity indices among pediatric patients. The study is designed to explore the possibility of such a relationship. Methods: Pediatric study participants were divided into test [HbSS, HbSC] and control [HbAA] groups. The questionnaire was administered to obtain information on age, gender, and clinical features of the disease [pain frequency, leg ulcer, priapism]. The anthropometry indices were determined. BMI as well as BMI percentiles were calculated. Data were summarized using relative frequency, mean, and standard deviation while analysis of variance, LSD post hoc tests and Chi‑squared tests were used for inferential statistics. Significant levels were set with P &lt; 0.05. Results: There were significant differences in the body weight, height and BMI of HbAA, HbSC and HbSS. The distribution of the BMI percentiles for the three genotypes showed that 5% of HbAA, 20% of HbSC, and 35.7% of HbSS were in unhealthy categories. The occurrence of leg ulcers and priapism among the two SCD genotypes was 0% and 3.57% respectively. The Chi-square tests showed a significant difference between BMI percentiles (X2=72.51; P=&lt;.001) or painful episodes (X2=15.992; P=.003) and hemoglobin genotypes [HbSS, HbSC]. Among SCD patients there was a relationship between BMI percentiles and pain frequency (X2=50.59; P=&lt;.001). Conclusion: The study suggests that SCD impacts BMI percentiles. Also, the frequency of occurrence of priapism and leg ulcers varied widely, indicating that priapism among the SCD patients may be a more common SCD complication than leg ulcer in the region. The fact that there was a higher frequency of pain among HbSS than HbSC suggests a bias in distribution of pain frequency in the 2 hemoglobinopathies.

Anti-CGRP monoclonal antibodies improve cognitive function in patients affected by chronic migraine complicated with medication overuse-headache

Background: Migraine represents one of the most disabling neurological diseases in the world. This burden is primarily due to recurrent pain episodes, alongside cognitive function impairments that patients may experience. This paper aims to explore the effect of three anti-calcitonin Gene-Related Peptide (CGRP) monoclonal antibodies (mAbs) – erenumab, fremanezumab, and galcanezumab – on the cognitive performance of a sample of patients suffering from migraine using the Montreal Cognitive Assessment (MoCA) questionnaire.Methods: A total of 215 patients suffering from migraine who visited the Modena Headache Center were enrolled. The MoCA questionnaire was filled in by the patients at the baseline and subsequent assessments were conducted at 6 and 12 months thereafter. Additionally, patients were requested to complete the 6-item Headache Impact Test, Migraine Disability Assessment Score, and Hospital Anxiety and Depression Scale every three months.Results: The sample was composed of 82% of female participants and 87% of the enrolled patients were diagnosed with chronic migraine. Following one year of treatment, there was a significant enhancement observed in MoCA scores compared to baseline measurements. Moreover, higher consumption of analgesics, elevated body mass index (BMI), and prolonged chronic migraine history exhibited an inverse correlation with MoCA score improvements after 12 months.Conclusions: Erenumab, fremanezumab, and galcanezumab have proven to be effective in relieving the cognitive impairment associated with migraine after 1 year of treatment. These findings underscore the reversibility of cognitive impairment among migraine sufferers, even among those suffering from chronic migraine, as delineated by the majority of the patients under study. This study revealed that prolonged chronic migraine history, higher baseline analgesic intake, and elevated BMI were all predictive of diminished cognitive enhancements following treatment.

Low back pain: justification of treatment standards (literature review)

Low back pain: justification of treatment standards (literature review)

Chest pain as an interdisciplinary problem – emphasis on somatoform disorders

Chest pain of a non-cardiac nature is one of the extremely significant problems of clinical medicine, which is associated with the widespread prevalence of this condition and the high healthcare costs for diagnosing and treating such patients. Along with neurological, gastroenterological and pulmonological diseases, mental disorders make a major contribution to the formation of chest pain. Moreover, the formation of pain in the chest area can be associated not only with such well-known psychopathological conditions as depression and anxiety disorders, but also with the pathology of the somatoform circle. This review presents data on the frequency of chest pain associated with mental disorders (pain as a symptom of a mental disorder, mental disorders as a consequence of a previous episode of chest pain, etc.), the nature of the relationship between pain symptoms and mental disorders, as well as the clinical picture somatoform disorders manifesting in the form of thoracalgia. Information is summarized on approaches to diagnosing mental disorders in patients with chest pain and the possibilities for their psychopharmacotherapy and psychotherapy. When discussing psychopharmacotherapy, emphasis is placed on the possibilities of using the atypical tranquilizer tofisopam in this category of patients, and a brief description of its effectiveness and safety is given. To illustrate the main points of the review, a clinical case of a patient with chest pain of non-cardiac origin, which manifested itself after a traumatic event, which in turn provoked a myocardial infarction, is also presented. Positive dynamics with subsequent recovery during therapy with tofisopam are described.

AN OVERVIEW OF LOW BACK PAIN: CLINICAL EVALUATION, DIAGNOSIS AND TREATMENT

Painful spine conditions are common among the general population, the incidence of this symptom being very high among all ages, but especially after forty years. Rehabilitation of patients with low back pain is very important because episodes of back pain constitute the second leading symptom prompting patients to seek evaluation by a physician. Consequently, the goals of the clinicians evaluating patients with an episode of low back pain are to have a differential diagnosis of the condition and its etiology, to rule out radiculopathy or other severe medical causes, to establish a rehabilitation plan that aims to prevent recurrence of this episode and to formulate a management plan if the condition does not improve promptly. Therefore, it is required to overview the spine pathophysiological changes that can cause low back pain in order to provide the best treatment options for the patients, according to their medical and social history, and thus, increasing their overall quality of life. Keywords: back pain, rehabilitation, physical modalities, exercise, disability.

THERAPEUTIC OPTIONS IN CALCIFIC ROTATOR CUFF TENDINOPATHY OF THE SHOULDER

Calcific tendinopathy in the tendons of the rotator cuff muscles of the shoulder is an increasingly common and disabling pathology. Calcific tendinopathy is a common disease that mainly affects people aged between 40 and 60. Women seem to be more affected than men. It has been suggested that various factors play a role in the condition, such as abnormal thyroid gland activity, metabolic diseases (e.g. gout, diabetes) and genetic predisposition. Various aetiological hypotheses have been put forward: the degenerative and multiphasic theories are the two most widely accepted. Clinically, calcific tendonitis is characterised by severe, disabling pain, often occurring spontaneously, usually in the morning or following exertion disproportionate to subsequent symptoms. There may be concomitant stiffness, giving rise to a clinical picture resembling frozen shoulder or hyperalgesic painful shoulder. Conventional radiography of the shoulder is the most appropriate imaging approach, but perfectly complemented by soft tissue ultrasound. Most acute painful episodes resolve spontaneously symptomatically. Numerous conservative treatments have been reported in the literature with varying levels of evidence of efficacy. In the present study we tried to evaluate which therapeutic option could give superior results both from a functional, lesional architectural and causal point of view in terms of reduction of callus size, but also from an imaging point of view. The use of various therapeutic protocols have shown a significant benefit of the association of ESWT with conventional FKT, and intra-articular infiltration, with a plus for the association of Corticosteroids and Sodium Hyaluronate regarding the speed of achieving the desired results. Similar results were obtained with the intra-articular shoulder PRP technique, but with slower achievement of the desired results. Arthroscopic surgery is the orthopaedic specialist's last option. Keywords: Calcific tendinopathy, rotator cuff muscles, shoulder, intra-articular infiltration.

Recurrent Orthodromic SVT AVRT with Multiple Accessory Pathway in WPW Syndrome: Ablate All or Not?

Background: Patients diagnosed with Wolff-Parkinson-White syndrome (WPW) have a relatively low, nevertheless persistent risk of unexpected mortality. However, this risk can be effectively mitigated by applying radiofrequency catheter ablation targeting the accessory pathway. It is difficult to accurately study predictors because only a minority of patients develop potentially malignant arrhythmias (MA) or passed away, despite essential risk variables being relatively well-known.1 This study aimed to describe ablation in WPW syndrome. Case presentation: A 16-year-old male presents with symptoms characterized by palpitations during intense physical exertion, followed by chest pain episodes. The physical examination, CXR, laboratorium, and echocardiography were all within the normal range; his ECG showed shortened PR interval and a delta wave with a positive delta wave at V1 and mostly positive at the inferior lead. He also has recorded ECG when the patient has a tachycardia event with SVT AVRT orthodromic pattern. He underwent EP Study and had several accessory pathways at the posteroseptal mitral annulus and anteroseptal tricuspid. The decision was made to perform ablation on the posteroseptal accessory pathway located at the mitral annulus. An electrophysiology (EP) investigation was conducted at the anteroseptal tricuspid annulus, which did not induce tachyarrhythmia. Conclusion: Wolff-Parkinson-White syndrome is a congenital cardiac pathway formation, with not all accessory pathways causing tachyarrhythmias. Ablation therapy is necessary for patients with multiple pathways, with pathways with an ERP less than 250 being the only option. Keyword: Ablation, Multiple Accessories Pathway, SVT AVRT Orthodromic, WPW Syndrome.

Site and duration of abdominal pain discriminate symptomatic uncomplicated diverticular disease from previous diverticulitis patients.

Abdominal pain in patients with diverticular disease (DD) can be challenging in clinical practice. Patients with symptomatic uncomplicated diverticular disease (SUDD) and patients with a previous acute diverticulitis (PD) may share a similar clinical pattern, difficult to differentiate from irritable bowel syndrome (IBS). We used standardized questionnaires for DD (short and long lasting abdominal pain) and IBS (following Rome III Criteria) to assess clinical features of abdominal pain, in terms of presence, severity and length, in SUDD and PD patients. One hundred and forty-eight SUDD and 118 PD patients completed all questionnaires. Short-lasting pain was more frequent in SUDD than PD patients (p = 0.007). Number of long-lasting pain episodes was higher in SUDD (6.6 ± 11.9) compared to PD patients (3.4 ± 6.9) (p < 0.001). PD patients reported long-lasting pain more frequently in the lower left abdomen (p < 0.001), while in SUDD it was more frequently diffuse (p = 0.002) or localized in the lower right quadrant (p = 0.009). Features associated with long-lasting pain (fever, confinement to bed, consultations, antibiotic therapy, hospitalization) were more often reported in PD patients. IBS criteria were reported in 28.2% of patients and were more frequent in SUDD than PD patients (37.2% vs 17.1%, p < 0.001). SUDD and PD patients presented different pattern of abdominal pain (length, number of long lasting episodes, site and associated features), with a third reporting overlap with IBS. Further observational studies are needed to better characterize abdominal symptoms in DD patients, especially in those not fulfilling IBS criteria.Trial registration: The REMAD Registry is registered as an observational study in ClinicalTrial.gov (ID: NCT03325829).

Multicenter, phase 1 study of etavopivat (FT-4202) treatment for up to 12 weeks in patients with sickle cell disease

AbstractEtavopivat is an investigational, once daily, oral, selective erythrocyte pyruvate kinase (PKR) activator. A multicenter, randomized, placebo-controlled, double-blind, 3-part, phase 1 study was conducted to characterize the safety and clinical activity of etavopivat. Thirty-six patients with sickle cell disease (SCD) were enrolled into 4 cohorts: 1 single-dose, 2 multiple ascending doses, and 1 open-label (OL). In the OL cohort, 15 patients (median age 33.0 years [range, 17-55]) received 400 mg etavopivat once daily for 12 weeks; 14 patients completed treatment. Consistent with the mechanism of PKR activation, increases in adenosine triphosphate and decreases in 2,3-diphosphoglycerate were observed and sustained over 12 weeks’ treatment. This translated clinically to an increase in hemoglobin (Hb; mean maximal increase 1.6 g/dL [range, 0.8-2.8]), with >1 g/dL increase in 11 (73%) patients during treatment. In addition, the oxygen tension at which Hb is 50% saturated was reduced (P = .0007) with a concomitant shift in point of sickling (P = .0034) to lower oxygen tension in oxygen-gradient ektacytometry. Hemolysis markers (absolute reticulocyte count, indirect bilirubin, and lactate dehydrogenase) decreased from baseline, along with matrix metalloproteinase-9 and erythropoietin. In the OL cohort, adverse events (AEs) were mostly grade 1/2, consistent with underlying SCD; 5 patients had serious AEs. Vaso-occlusive pain episode was the most common treatment-emergent AE (n = 7) in the OL cohort. In this, to our knowledge, the first study of etavopivat in SCD, 400 mg once daily for 12 weeks was well tolerated, resulting in rapid and sustained increases in Hb, improved red blood cell physiology, and decreased hemolysis. This trial was registered at www.ClinicalTrials.gov as #NCT03815695.

Noninvasive cardiac-specific biomarkers for the diagnosis and prevention of vascular stenosis in cardiovascular disorder.

The most frequent lesion in the blood vessels feeding the myocardium is vascular stenosis, a condition that develops slowly but can prove to be deadly in a long run. Non-invasive biomarkers could play a significant role in timely diagnosis, detection and management for vascular stenosis events associated with cardiovascular disorders. The study aimed to investigate high sensitivity troponin I (hs-TnI), cardiac troponin I (c-TnI) and high sensitivity C-reactive protein (hs-CRP) that may be used solely or in combination in detecting the extent of vascular stenosis in CVD patients. 274 patients with dyspnea/orthopnea complaints visiting the cardiologists were enrolled in this study. Angiographic study was conducted on the enrolled patients to examine the extent of stenosis in the five prominent vessels (LDA, LCX, PDA/PLV, RCA, and OM) connected to the myocardium. Samples from all the cases suspected to be having coronary artery stenosis were collected, and subjected to biochemical evaluation of certain cardiac inflammatory biomarkers (c-TnI, hsTn-I and hs-CRP) to check their sensitivity with the level of vascular stenosis. The extent of mild and culprit stenosis was detected during angiographic examination and the same was reported in the form significant (≥50% stenosis in the vessels) and non-significant (<50% stenosis in the vessels) Carotid Stenosis. Ethical Clearance for the study was provided by Dr. Ram Manohar Lohia Institute of Medical Sciences Institutional Ethical Committee. Informed consent was obtained from all the participants enrolled in the study. We observed that 85% of the total population enrolled in this study was suffering from hypertension followed by 62.40% detected with sporadic episodes of chest pain. Most of the subjects (42% of the total population) had stenosis in their LAD followed by 38% who had stenosis in their RCA. Almost 23% patients were reported to have stenosis in their LCX followed by OM (18% patients), PDA/PLV (13%) and only 10% patients had blockage problem in their diagonal. 24% of the subjects were found to have stenosis in a single vessel and hence were categorized in the Single Vessel Disease (SVD) group while 76% were having stenosis in two or more than two arteries (Multiple Vessel Disease). hs-TnI level was found to be correlated with the levels of stenosis and was higher in the MVD group as compared to the SVD group. hs-TnI could be used as a novel marker as it shows prominence in detecting the level of stenosis quite earlier as compared to c-TnI which gets detected only after a long duration in the CVD patients admitted for angiography. hs- CRP gets readily detected as inflammation marker in these patients and hence could be used in combination with hs-TnI to detect the risk of developing coronary artery disease.

P128 Predicting Persistent Inflammatory Arthritis in patients with Palindromic Rheumatism: Development of Scores for Risk Stratification

Abstract Background/Aims Palindromic rheumatism (PR) is a recognised precursor of rheumatoid arthritis (RA). Up to 50% of PR patients will progress to persistent inflammatory arthritis (PIA) but risk factors for progression remain unclear. Analysis of this large UK prospective PR cohort has been used to develop the first risk stratification tool to predict progression to PIA. Methods The Leeds PR cohort was recruited from regional primary and secondary care referrals. PR was defined as ‘a confirmed history/physical examination consistent with episodes of joint pain and swelling that returned to normal in the absence of an alternative diagnosis’. Clinical, serological and immunogenetic parameters were assessed at baseline and three monthly for the first year, then six monthly. Progression to PIA was defined as clinical synovitis persisting for &amp;gt;3 weeks as confirmed by a rheumatologist. Prediction models were developed by performing a Cox regression analysis, then applying LASSO to select the most important risk variables (using R). Results 161 PR patients were followed between July 2008 and January 2023. 33% (53/161) developed PIA and 91% of progressors met criteria for RA. 90% of patients were DMARD naive at baseline. Female gender, anti-cyclic citrullinated peptide (anti-CCP) positivity, rheumatoid factor (RF) positivity, age&amp;gt;40, smoking (ever) and a typical interval between attacks of &amp;lt; 1 month were all associated with progression (Table 1). Cox regression analysis showed female gender (HR 2.2CI1.1-4.7, p = 0.03) and anti-CCP&amp;gt;3x upper limit of normal (HR 5.9, CI 2.0-17.4, p = 0.002) were strongly associated with progression. 'Ever’ and 'Two-year’ prediction models were created to calculate risk of developing PIA (Table 1). Patients could be stratified into high, moderate and low risk groups, with progression rates of 53% (34/64), 25% (19/77) and 0% respectively in the ‘Ever’ model and 37% (27/ 73), 16% (11/69) and 0% respectively in the ‘Two-year’ model. Conclusion In patients with PR, female gender, positive anti-CCP, positive RF, age &amp;gt;40, smoking and a typical interval between attacks of &amp;lt; 1 month were predictive of progression to PIA. Combining these factors allows feasible risk stratification in clinical practice. High and moderate risk groups should be monitored in secondary care and considered for interventional trials. Disclosure R. Chowdhury: None. F. Shuweihdi: None. N. Sidhu: None. L. Duquenne: None. L. Garcia-Montoya: None. J. Nam: None. A. Di Matteo: None. K. Harnden: None. D. Sahin-Eroglu: None. P. Emery: Consultancies; BMS, AbbVie, MSD, Pfizer, Novartis, and Roche. Honoraria; Abbvie, Gilead, Lilly, Novartis. Grants/research support; AbbVie, BMS, Lilly, Samsung. K. Mankia: Honoraria; Abbvie, Lilly, UCB, Galapagos. Grants/research support; Gilead, Lilly.

Diagnostic evaluation and treatment of osteoarticular lesions in patients having sickle cell anemia: Literature review

Sickle cell anemia is a genetic disorder in which the structure of hemoglobin undergoes a significant alteration through a point mutation in the β-globin gene. When the gene is altered in sickle cell disease, hemoglobin S is expressed, causing the red blood cell to acquire the characteristic sickle shape. Thus, in the presence of this mutation, especially with changes in oxygen concentration and pH, hemoglobin S tends to polymerize, resulting in sickling of the red blood cells, leading to a shortened lifespan of red blood cells, vascular occlusion phenomena, and episodes of pain and organ damage. Among the complications caused by sickle cell disease, stroke, recurrent infections, osteoarticular disease, among others, can be mentioned. One of the complications that generates the greatest morbidity is osteoarticular lesions, which can present with symptoms such as pain, swelling, warmth, fever, reduced vascularization, and even necrosis. Therefore, this study aimed to evaluate the diagnostic methods used in osteoarticular lesions in patients with sickle cell anemia. Among the most commonly used diagnostic methods in patients with sickle cell disease suspected of osteoarticular lesions, we can emphasize imaging diagnostic methods such as X-rays, magnetic resonance imaging (MRI), scintigraphy, and PET-CT, which can be used to differentiate between different types of lesions and suspected infectious processes, such as osteomyelitis. Therefore, imaging diagnostic methods are essential in identifying the lesion and the best treatment, with total hip arthroplasty being the most invasive method, although it is often the initial choice due to the severity of the lesion, or it is used after unpromising results from other less invasive procedures, such as femoral head decompression, grafting, and subchondroplasty.

A rare variation of the infraorbital nerve, entrapping the infraorbital artery.

Anatomical variations are a common feature of the human anatomy. Variation can explain some pathological conditions and is important to keep them in mind during surgical procedures. The relations between nerves and their adjacent arteries have been proposed to play a role in the generation of peripheral trigger migraines. Close opposition between nerves and arteries can lead to vascular compression of the nerve that triggers episodes of pain. We did a routine dissection of the infratemporal fossa and orbital floor by opening the maxillary sinus. Here we report a case where the infraorbital nerves form a nervous loop entrapping the infraorbital artery in the infraorbital channel. Similar cases of close nervous and arterial apposition are described for the auriculotemporal and occipital nerves. We think that accumulating knowledge of these rare variations could expand our understanding of rare conditions such as primary infraorbital neuralgia.

Gout and its management.

Gout is a common and treatable chronic disease of monosodium urate crystal deposition. It is experienced as extremely painful episodes of joint inflammation that impact all aspects of the person's life. This Clinical Perspectives article provides an update on gout diagnosis, medications and strategies to improve the quality of gout care.

Treatment of Pelvic and Spinal Bone Metastases: Radiotherapy and Hyperthermia Alone vs. in Combination.

Painful pelvic and spinal bone metastases are a considerable challenge for doctors and patients. Conventional therapies include morphine-equivalent medication (MeM) and local radiotherapy (RT), but these interventions are not always successful. More recently, hyperthermia (HT) has been applied to complement RT and MeM, and this complex approach has shown promising synergistic results. The objective of our study was to present the results of RT combined with a special kind of HT (modulated electrohyperthermia, mEHT), in which some of the thermal effect is contributed by equivalent nonthermal components, drastically reducing the necessary power and energy. This retrospective study included 61 patients divided into three groups with pelvic and spinal bone metastases to compare the effects of RT and mEHT alone and in combination (RT + mEHT). A detailed evaluation of pain intensity, measured by the brief pain inventory score, MeM use, and breakthrough pain episodes, revealed no significant differences between RT and mEHT alone; thus, these individual methods were considered equivalent. However, RT + mEHT yielded significantly better results in terms of the above parameters. Clinically, mEHT has a lower risk of adverse thermal effects, and due to its efficacy, mEHT can be used to treat RT-resistant lesions.