Local Pain Research Articles

A 26 years old primigravida woman presented with abdominal cutaneous entrapment syndrome: a case report

BackgroundAbdominal cutaneous nerve entrapment syndrome (ACNES) is characterized by severe, mostly refractory, chronic pain due to the entrapment of the cutaneous branches of the lower torso intercostal nerves at the lateral edge of the rectus abdominis muscle. ACNES is rare compared to other pregnancy-related peripheral neuropathies and is often overlooked as a differential diagnosis for abdominal pain, despite the diagnosis relying primarily on patient history and physical examination. Emergency physicians and other medical personnel’s lack of exposure to such cases results in unnecessary laboratory requests, repeated visits, and increased fear and tension for the patient.Case presentationA 26-year-old primigravida on her second trimester of pregnancy presented to our Emergency department with persistent localized right upper quadrant abdominal pain. Despite repeated visit to the nearby hospital, no diagnosis was settled and the pain persisted. At our ED after a thorough history, physical examination and diagnostic test no abnormality was found. Finally Abdominal cutaneous nerve entrapment syndrome (ACNES) was considered and a mixture of 1 ml 2% lidocaine with adrenaline and 1 ml dexamethasone (4 mg) was infiltrated into the fascial plane in a fanning fashion into the most tender area using a modified technique and the patient reported significant improvement in pain.ConclusionAbdominal cutaneous nerve entrapment syndrome (ACNES) is a cause of abdominal pain in pregnancy that is often overlooked. The objective of this study is to describe a rare case of ACNES in a 26-year-old primigravida woman who presented to a low-resource emergency department to assist patient management.

Sinding-Larsen-Johansson disease. Clinical features, imaging findings, conservative treatments and research perspectives: a scoping review.

This review aims to consolidate existing research on the pathogenesis, clinical diagnosis, imaging outcomes, and conservative treatments of Sinding-Larsen-Johansson disease (SLJD), identifying literature gaps. Scoping Review. A comprehensive literature search was conducted across databases including PubMed, Scopus, Medline OVID, Embase, Web of Science, and Grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) checklist. The body of evidence on SLJD, primarily derived from case studies, reveals limited and often conflicting data. Key findings include: (1) SLJD commonly presents as localized knee pain in physically active adolescents, particularly males, (2) ultrasound and MRI are the most effective diagnostic tools, (3) conservative treatment, which mainly focuses on activity limitation, yields positive outcomes within two to eight months. Our review shows that SLJD mainly affects physically active adolescents aged 9-17 years. The authors recommend conservative treatment, rest and/or cryotherapy, passive mobilization, muscle restraint, isometric exercise, and NSAIDs. Further cohort studies are necessary to refine the management and application of the SLJD treatment database.

Lidocaine-Loaded Iontophoresis-Driven Fiber-Based Microneedle Patch for Controllable and Long-Lasting Transdermal Local Analgesia

AbstractThe acute pain induced by clinical procedures, such as venipuncture, dental operations, and dermatological treatments, as well as postoperative pain, drives the advancement of anesthetic techniques aimed at alleviating discomfort. This situation underscores the ongoing significance of effective pain management strategies within the field of anesthesia. This paper presents an integrated iontophoresis (ITP)-driven fiber-based microneedle patch (IFMP) regulated by a smartphone for controllable, long-lasting lidocaine transdermal delivery. The IFMP integrates pure cotton fiber canvas-based dissolving microneedles (MNs) with ITP into a patch, with the MNs tips and gel layers significantly increasing the drug-loading capacity, achieving a one-step drug administration strategy of “dissolution, diffusion, and ITP.” Lidocaine is released via the microchannels of MNs by passive diffusion. Additionally, an electric current initiates active ITP for lidocaine delivery, creating synergy. User-requirement-based drug release by precisely modulating electrical signals in rat pain models is described herein. A smartphone application enables precise dosage control. It offers three different delivery modes: single-dose, pulse delivery, and sustained-release, ensuring rapid onset, and long-lasting pain relief. This versatility makes the system suitable for various pain conditions. The IFMP represents a promising system for patient-controlled local analgesia treatment, enabling active and long-term local self-controlled pain management in a safe and regulated manner. Graphical Abstract The iontophoresis-driven fiber-based microneedle patch combines fiber-based dissolving microneedles with iontophoresis, facilitating controlled lidocaine release through diffusion and electrical activation for enhanced effect. Precise modulation of electrical signals allows user-requirement-based drug release in rat pain models. A smart application supports precise dosing in single-dose, pulse, or sustained-release modes, ensuring efficient and prolonged pain management.

Clinical Characteristics and Diagnostic Imaging of Low Back Pain: A Systematic Review

Low back pain (LBP) is a prevalent and debilitating condition with diverse clinical presentations and etiologies. This systematic review aimed to synthesize the current literature on the clinical characteristics and diagnostic imaging findings associated with LBP, providing a comprehensive overview of this multifaceted condition. A systematic search of electronic databases was conducted, encompassing studies published between 2018 and 2023. Studies reporting on clinical characteristics (pain location, duration, severity, radiation, associated symptoms) and diagnostic imaging findings (X-ray, CT, MRI) in LBP patients were included. Data extraction and quality assessment were performed independently by two reviewers. Twenty studies, with a total of 9,232 patients, were included. The most common clinical presentation was localized LBP (85%), followed by pain duration of less than 3 months (60%) and moderate pain severity (55%). Radicular pain and neurological deficits were reported in a significant minority of patients (20% and 15%, respectively). The most frequent imaging finding was degenerative changes (40-70%), followed by disc herniation (20-35%) and spondylolisthesis (5-12%). Other less frequent findings included spinal stenosis, compression fractures, and tumors. This review highlights the heterogeneity of clinical presentations and imaging findings in LBP. While localized LBP is predominant, a substantial proportion of patients experience radicular pain and neurological deficits. Degenerative changes are the most frequent imaging finding, followed by disc herniation. The choice of imaging modality should be guided by clinical presentation and suspected etiology.

Tratamento de urgência de abcesso periapical agudo em evolução: Relato de um caso clínico

During emergency care, when the patient has pain, it is one of the main duties of the dental surgeon to promote pain relief to the patient. Acute apical abscess (AGA) is one of the most common causes found in urgent care. They are odontogenic infections, consisting mainly of anaerobic microorganisms, which lead to pain and/or edema, and have the potential to diffuse through the cortical bone, with eventual lethal consequences. The present study aims to describe the case report of drainage of an evolved acute periapical abscess and its respective treatment at the Primary Care Clinic II (CAB II) of the Faculty of Dentistry of Pernambuco - University of Pernambuco (FOP/UPE). Where the patient complained of spontaneous, pulsatile, localized pain and edema. Endodontic intervention is essential for immediate symptom relief, and there is no consensus in the literature that establishes a care protocol in these cases. Even though there is no requirement for standardization of the protocol for emergency care, we conclude that it is of great importance to conduct a procedure that performs the drainage of the abscess to avoid systemic compromise.

Low back pain characteristics in adolescent patients with early-stage spondylolysis: a prospective study.

Early-stage spondylolysis (ESS) is a common cause of acute low back pain (LBP) in adolescents. When treating patients with ESS, early diagnosis is essential, yet difficult without magnetic resonance imaging. This study evaluates a self-reported questionnaire for detecting ESS. We evaluated a total of 69 adolescents (≤ 18years old) with acute LBP (≤ 1month) with plain radiography, magnetic resonance imaging and a questionnaire including the following parameters: exercise frequency per week, daily training time, the necessity for stopping sports activity, pain-producing situations, pain quality, pain response to hyperextension or hyperflexion, pain location, and pain extent. Patients with obvious pathological findings other than ESS (e.g., disk herniation or infection) were excluded. The correlation of each question and gender, regarding ESS was determined, to evaluate the value of the originally developed questionnaire. 24 out of 69 patients were diagnosed with ESS (ESS group), with a mean age of 13.9years old and 21 males and 3 females in the group. 45 patients had NS-LBP, with a mean age of 14.6years old, and 28 males and 17 females in the group. Correlation analyses showed weak associations between ESS and higher frequency of exercise per week, longer training time per day, and pain-producing situations. There was also a moderate association between ESS and male gender. Exercise frequency, training time, pain-provoking situations, and gender could be important factors to detect ESS within this questionnaire.

Study to determine the efficacy and onset of Bonipar, a topical analgesic for the management of acute and chronic musculoskeletal pain

BackgroundOpioid abuse and mortality are ravaging American society, highlighting the need to find alternative effective analgesics with fewer side effects. FDA-approved topical analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), are commonly used to treat musculoskeletal pain but can cause adverse effects. Natural compounds, including essential oils, are potential therapeutic alternatives for managing musculoskeletal pain. If these compounds can provide comparable analgesia to FDA-approved products, it will increase the available options for people with pain, improving quality of life with minimal morbidity and mortality. ObjectiveThis study assesses the effectiveness and onset of action of Bonipar, a topical analgesic formulated with camphor, methyl salicylate, and oils of coconut, eucalyptus, nutmeg, and rosemary, in managing musculoskeletal pain compared to 1.5 % diclofenac solution, an FDA-approved topical non-steroidal anti-inflammatory drug. MethodsOne hundred sixty-four adult patients with localized musculoskeletal pain were randomly assigned to twice-daily applications of either Bonipar or Diclofenac for one week. The primary outcome measure was a 50 % reduction in pain after one week. Secondary outcomes included the change in pain from baseline and onset of action, defined as the first reduction in pain by 20 %. ResultsAll patients completed the initial pain assessment to determine the onset of action. One-week data was available for 74 patients treated with diclofenac and 72 patients treated with Bonipar. Data for 18 patients were incomplete. The proportion of patients achieving a 50 % reduction in pain was statistically similar between the two groups. The success rates of achieving a 50 % pain reduction with Bonipar were found to be non-inferior to those treated with diclofenac. All follow-up time points showed roughly similar results between the groups. Regression models adjusted for age and sex revealed no significant effects on pain changes. Secondary analyses demonstrated no significant differences between the groups. DiscussionThe topical analgesic Bonipar demonstrates a comparable onset of action, with efficacy non-inferior to diclofenac in the management of musculoskeletal pain, while showing fewer adverse effects compared to diclofenac. These findings highlight the potential of Bonipar as a valuable alternative for the treatment of localized pain.

Pain and Discomfort Among Mohs Surgeons: An Ergonomic Model of Procedural Dermatologists

Background: Dermatologic surgeons are at risk for work-related injuries and chronic pain. Objectives: To investigate the prevalence and characteristics of pain and discomfort among fellowship trained Mohs surgeons across the United States Methods: A cross-sectional survey study was conducted of members of the American College of Mohs Surgery (ACMS).Participants reported the continuous variables of hours spent working, standing versus sitting while operating, typing to the electronic medical record, and exercising per week. Results: 107 male and female respondents participated. 88.7% of respondents reported chronic pain; the most common anatomic locations for pain were the neck (54.2%), upper back (38.2%), and lower back (33.6%). At these anatomic locations, male respondents less frequently complained of upper back pain (odds ratio (OR) 0.349, 95% confidence interval (CI) 0.155 to 0.787; P = 0.010) but more frequently complained of lower back pain (OR 2.462, 95% CI 1.606 to 13.320; P = 0.044), than female respondents. Respondents were significantly more likely to report regular pain-relieving medication use when suffering from pain at the neck (OR 4.665, 95% CI 1.450 to 15.007; P = 0.006) or upper back (OR 3.366, 95% CI 1.251 to 9.054; P = 0.013). Respondents regularly using sit-stand stools were less likely to report neck pain (OR 0.326, 95% CI 0.105 to 1.015; P = 0.046). Conclusions: Pain is prevalent among Mohs surgeons. Adopting and training in an ergonomically-friendly environment and incorporating an ergonomically aware mindset early in a surgeon’s career may decrease one’s risk for job-related injury and pain.

Enhanced diclofenac sodium delivery through advanced self-microemulsifying pectin-based transdermal patches

Diclofenac sodium (DCFNa) presents significant challenges in local pain relief due to its poor solubility and limited skin permeability. This study aimed to enhance the solubility and skin permeation of DCFNa by developing DCFNa-loaded self-microemulsifying drug delivery system (SMEDDS) embedded pressure-sensitive adhesive (PSA) patch. The solubility of DCFNa in various solvents was evaluated, and a ternary phase diagram was constructed to optimize the SMEDDS formulation. The transdermal patch, composed of pectin and polyacrylate, was optimized using a simplex lattice experimental design to achieve the desired adhesion strength and to select the most suitable patch for skin drug accumulation study. Clove oil, Tween® 80, and propylene glycol were identified as the appropriate oil, surfactant, and co-surfactant, respectively, for achieving highest DCFNa solubility. The SMEDDS was formed with a ratio of 5:35:60 (oil: Smix [1:1 surfactant: co-surfactant]: water), yielding nano-sized droplets (22.64 ± 0.74 nm) and significantly enhancing DCFNa solubility (329.62 ± 10.16 mg/mL) compared to phosphate buffer (5.03 ± 1.01 mg/mL). The DCFNa-loaded SMEDDS demonstrated a 9-fold increase in skin permeability compared to the DCFNa solution. The optimized PSA patch, containing 20 % pectin and 40 % polyacrylate, exhibited superior tacking and peel strength. Additionally, a 1 % DCFNa-loaded SMEDDS patch delivered twice greater drug accumulation in the skin and showed no skin irritation, maintaining better adhesion for up to 24 h compared to commercial patches.

271 Does social buffering amongst familiar weaned beef calves mitigate castration stressors?

Abstract Co-mingling of beef feeder calves from multiple sources results in biological and behavioral stressors. This study is part of a project exploring social relationships between individual beef cattle and potential benefits of social buffering during stress events. Here, the specific objective was to explore whether feeder calves form preferential relationships which buffer them from surgical castration pain. Within the experiment, two treatment groups were established: Familiar calves were defined as calves who shared a source farm with two other calves in the pen, and Unfamiliar calves were defined as calves who did not share a source with any other pen-mates. It was hypothesized that Familiar calves would exhibit more lying, fewer pain-related behaviors, and fewer agonistic interactions following surgical castration than Unfamiliar pen-mates. Weaned beef bull calves [n = 102, body weight (BW) range ± SD = 112.95 to 370.10 ± 67.8 kg] from 23 source farms were randomly assigned to home pens, each comprised of three Familiar calves and three Unfamiliar calves. Cameras placed above the pens recorded video from which postural (standing and lying), social (agonistic and bunk displacements) and pain-related behaviors (wound checking and hind leg stamping) were quantified. Cattle were handled through a hydraulic squeeze chute once weekly over four consecutive weeks for data collection and standard processing procedures. On d 14 relative to arrival, calves were surgically castrated with multimodal pain mitigation. During all processing events, calves were marked with livestock paint for behavioral observations. Behavior was observed continuously for 15 min at five different time points (0 h, 1 h, 4 h, 24 h, 48 h) relative to when the last calf returned to the home pen after processing, and researchers were blind to treatment allocation. These time periods corresponded to expected periods when pain was absent and present based on duration of local anesthesia and systemic pain relief. Calf was the experimental unit. For the purpose of this abstract, data from the 48 h periods following d 7 and 14 were analyzed using the PROC GLIMMIX procedure of SAS; the model included treatment (Familiar, Unfamiliar) by week interaction. A P-value of ≤ 0.05 was considered significantly different. Regardless of treatment, preliminary analyses identified decreased lying (P < 0.02) and increased wound checking (P < 0.01) 48h following castration (d 14) when compared with the previous week (d 7). There were no observed differences for hindleg stamping (P = 0.2), agonistic behaviors (P > 0.06) or bunk displacement (P = 0.09). Based on preliminary analyses, we did not observe evidence of social buffering effects on castration stress during the immediate post-surgical period.

Postpartum thromboprophylaxis with enoxaparin: a prospective cohort study on patients' adherence, injection experience, and information retention after counselling by pharmacists.

This research aimed to determine postpartum females' self-reported adherence to and experience with short-term thromboprophylaxis using enoxaparin injection, after counselling by pharmacists. It also sought to assess their knowledge of thromboprophylaxis, injection techniques, and confidence in self-injecting. This prospective cohort study was conducted at a public tertiary hospital in Malaysia from March to June 2023. Self-injection-naïve postpartum females who were initiated on thromboprophylaxis and counselled by a pharmacist were conveniently sampled. Knowledge regarding thromboprophylaxis, injection readiness, and technique were assessed one day after the counselling session. A telephonic interview was conducted at the end of the 10-day therapy to determine adherence and adverse effects experienced. A total of 259 subjects were successfully followed up, with 87.6% (n = 227) adherent to the therapy. Nonadherence was predominantly due to forgetfulness; four had their treatment withheld due to bleeding. One-third of subjects experienced localised pain and bruising. Subjects answered a median of 5/7 knowledge questions and recalled a median of 8/10 injection steps correctly, with those who read the information leaflet provided after counselling scoring significantly higher (P = .02). The majority declared moderate confidence in their ability to self-inject. Subjects who intended to self-inject (P < .01) and were more confident (P = .02) demonstrated better injection technique. Postpartum females counselled by pharmacists largely adhered to short-term enoxaparin for thromboprophylaxis. The impact of the counselling session may be enhanced by addressing their psychological readiness to self-inject, awareness of adverse effects identification, mitigation, and management, as well as setting reminders to prevent forgetfulness to inject.

A summary of pain and pain-related variables in the Avon Longitudinal Study of Parents and Children.

To study pain, data on pain characteristics, possible triggers and consequences - such as the impact of pain on people's lives - need to be available. When not collated, described and/or organised in a systematic manner, it can be difficult to assess how useful an existing dataset may be for one's project. This data note describes and categorises the complex and multi-modal indices of pain available in the Avon Longitudinal Study of Parents and Children (ALSPAC). Data from two generations of the ALSPAC cohort; index child participants (Generation 1, G1), their mothers and fathers/mothers' partners (Generation 0, G0) were used. Search terms such as 'pain', 'ache', 'hurt', 'sore', specific pain conditions, labour pain and methods of pain relief were used to identify pain and pain-related variables. These data were extracted from all waves of data collection. We developed pain categories and subsequently categorised variables in an iterative process. Repeated measurements of the same variables over waves of data collection were also identified. We identified 21 categories of pain variables, which were subsequently grouped into themes: pain characteristics, extended pain characteristics and causes, treatment for pain, pain interference and pain-related to specific events. Pain and pain-related data have been collected from G1 participants, G0 mothers, and G0 partners, although there are fewer data for the partners. There were some repeated measurements, most commonly, of pain location. As is typical with longitudinal birth cohort studies, maternal proxy-reports were used during participants' younger years and self-reports were utilised from adolescence onwards. Researchers interested in studying pain can feasibly do so in two generations of a regional UK population who have been followed up over 30 years. ALSPAC can be used to study pain from the early years through to young adulthood and in mothers from the perinatal period onwards.

Anxiety and Depression in Youth With Chronic Pain

For youth with chronic pain, anxiety and depression are reported as consequences of experiencing pain and maintaining factors of ongoing pain and disability. However, prevalence estimates of anxiety and depression remain unclear. To report the prevalence of clinical anxiety and depression for youth with chronic pain and compare symptoms of anxiety and depression between youth with and without chronic pain. MEDLINE, PsycINFO, CENTRAL, and Embase from inception to April 30, 2023. Included studies that reported prevalence data or symptom scores for anxiety and/or depression in individuals younger than 25 years (mean, ≤18 years) with chronic pain and were published in English. From 9648 nonduplicate records, 801 full-text articles were screened. Screening and data extraction occurred in duplicate. Prevalence was determined using event rate calculations. Between-group symptom differences were calculated using Hedges g. Analyses were conducted using the random-effects model. Reporting bias and Grading of Recommendation, Assessment, Development, and Evaluation assessments were conducted. Prevalence of anxiety and depression (based on diagnosis and clinical cutoff scores) and differences in anxiety and depression symptoms. Moderators of prevalence and symptom differences were analyzed when data allowed. A total of 79 studies were included with a total sample of 22 956 youth (n = 12 614 with chronic pain). Most youth were female (mean, 74%), with an age range of 4 to 24 (mean [SD], 13.7 [2.10]) years. The prevalence estimate of anxiety diagnoses was 34.6% (95% CI, 24.0%-47.0%) and the portion that exceeded clinical cutoff scores was 23.9% (95% CI, 18.3%-30.6%). The prevalence of depression diagnoses was 12.2% (95% CI, 7.8%-18.7%) and the portion that exceeded clinical cutoff scores was 23.5% (95% CI, 18.7%-29.2%). Youth with chronic pain had greater symptoms of anxiety (g = 0.61; 95% CI, 0.46-0.77) and depression (g = 0.74; 95% CI, 0.63-0.85) compared with controls. Sex, age, pain location, and recruitment sample may moderate anxiety and depression. Considerable heterogeneity was reported for all outcomes. Studies had a low reporting bias, and outcomes were moderate to high quality. The findings of this meta-analysis suggest that 1 in 3 youth with chronic pain meet criteria for anxiety disorder, and 1 in 8 meet criteria for a depressive disorder. This represents a major clinical comorbidity. Moving forward, screening, prevention, and treatment of mental health should be important health care priorities for youth with chronic pain.

SARS-CoV-2 infection and vaccination in patients with pituitary diseases: the experience of a Brazilian reference center.

To evaluate the prevalence and characteristics of SARS-CoV-2 infection, and the prevalence, efficacy, and safety of anti-SARS-CoV-2 vaccination in patients with pituitary diseases. Observational, cross-sectional study of adult patients with pituitary diseases followed in a reference center. Clinical data were collected and a questionnaire about SARS-CoV-2 infection, vaccination and its possible adverse effects was applied. COVID-19 disease severity was defined as mild, moderate, and severe according to the WHO classification. 145 patients were studied (79 women; age 50 ± 15.8 years; duration of pituitary disease 16.8 ± 11.5 years), the cause of pituitary disease was tumoral in 74.5%, and 45.9% were on glucocorticoid replacement due to ACTH deficiency. SARS-CoV-2 infection was confirmed in 51 patients (35.2%; 32 women; age 53.8 ± 14.8 years, 22 before vaccination), with 28 (54.9%), 17 (33.3%) and 6 (11.8%) cases of mild, moderate, and severe disease, respectively, and hospitalization was indicated in 7 (14%) cases. One mild case presented pituitary apoplexy after SARS-CoV-2 infection. Advanced age was a risk factor for COVID-19. Patients with moderate and severe forms of COVID-19 had higher prevalence of dyslipidemia and duration of pituitary disease. All but one of the participants were vaccinated against COVID-19, and 60.4% had adverse events, the most common local pain (54.0%), fever (33.3%), and headache (18.4%), with one case of alopecia and two of persistent fatigue. The prevalence of SARS-CoV-2 infection in our cohort was 35.2%, including 14% of moderate and severe cases requiring hospitalization. The vaccination was universal and safe.

EP264 - Dermatofibrosarcoma protuberance of the perianal region

Abstract Introduction Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade sarcoma affecting dermis and subcutaneous fat. Typically presents as slow-growing lump on the trunk, extremities or head and neck.(1) It can be locally aggressive with a high recurrence rate.(2) Only 6 reported cases of DFSP in peri-anal region. Case Description A 26-year-old male presented with slow-growing peri-anal lump for over a year with intermittent localised pain and episodes of bleeding. No other symptoms or trauma to peri-anal area noted. No relevant medical or surgical history. Examination revealed an irreducible two-by-five by one-centimetre semi-pedunculated perianal lump extending from the seven o’clock to eleven o’clock position. It was firm and tethered to the skin. Case Description Flexible sigmoidoscopy was normal. Excision biopsy histology reported diffuse infiltration of spindle cells with storiform pattern of growth without clear margins. Immunohistochemistry analysis expressed CD34 with minimal focal expression of SMA and variable Ki-67 proliferation indexed up to 15-20% in most active areas. SOX10, S100, desmin, factor XIIIA, MNF116 and CD31 were negative. Diagnosis was DFSP. Local lower gastrointestinal multi-disciplinary arranged urgent imaging and referral to tertiary centre. Magnetic resonance imaging of the pelvis identified no definite underlying localised restricted diffusion or solid enhancing nodule. Wide local excision at tertiary centre with histopathology confirmed clear margins. Conclusion Patient is under follow-up locally and at the tertiary. Urgency and a singular episode of stool incontinence was reported at two-weeks follow-up which subsequently normalised. He is currently under 3-6 monthly reviews with repeat MRI prior to next appointment. Patient has returned to normal activities.

Classification Criteria for Axial Disease in Youth with Juvenile Spondyloarthritis.

To develop and validate classification criteria for axial disease in youth with juvenile spondyloarthritis (SpA; AxJSpA). This international initiative consisted of four phases: 1) Item generation; 2) Item reduction; 3) Criteria development; and 4) Validation of the AxJSpA criteria by an independent team of experts in an internationally representative Validation cohort. These criteria are intended to be used on youth with a physician diagnosis of juvenile SpA and for whom axial disease is suspected. Item generation consisted of a systematic literature review and a free-listing exercise using input from international physicians and collectively resulted in 108 items. After the item reduction exercise and expert panel input, 37 items remained for further consideration. The final AxJSpA criteria domains included: imaging: active inflammation, imaging: structural lesions, pain chronicity, pain pattern, pain location, stiffness, and genetics. The most heavily weighted domains were active inflammation and structural lesions on imaging. Imaging typical of sacroiliitis was deemed necessary, but not sufficient, to classify a youth with AxJSpA. The threshold for classification of AxJSpA was a score of ≥55 (out of 100). When tested in the validation data set, the final criteria had a specificity of 97.5% (95% CI: 91.4-99.7), sensitivity of 64.3% (95% CI: 54.9-73.1) and Area Under the Receiver Operating Characteristic (AUROC) curve of 0.81 (95% CI: 0.76-0.86). The new AxJSpA classification criteria require an entry criterion, physician diagnosis of juvenile SpA, and include seven weighted domains. The AxJSpA classification criteria are validated and designed to identify participants for research studies.

11th revision of the International Classification of Diseases chronic primary pain diagnoses in children and adolescents: representation of pediatric patients in the new classification system.

Chronic pain is common among children and adolescents; however, the diagnoses in the newly developed 11th revision of the International Classification of Diseases (ICD-11) chronic pain chapter are based on adult criteria, overlooking pediatric neurodevelopmental differences. The chronic pain diagnoses have demonstrated good clinical applicability in adults, but to date, no field study has examined these diagnoses to the most specific diagnostic level in a pediatric sample. The current study aimed to explore pediatric representation within the ICD-11, with focus on chronic primary pain. Healthcare professionals (HCPs) at a specialized pediatric pain center documented the symptoms of and assigned both ICD-10 and ICD-11 diagnoses to N = 402 patients. Using criteria-based computer algorithms, specific ICD-11 pain diagnoses were allocated for each documented pain location, with residual diagnoses (ie, "unspecified") assigned if criteria were not (fully) met. Within the ICD-11, the algorithms assigned specific pain diagnoses to most patients (73.6%). In ICD-10, HCPs could not specify a diagnosis for 5.2% of patients; the ICD-11 algorithm allocated a residual chronic primary pain diagnosis in 51.2%. Residual categories were especially prevalent among younger children, boys, patients with headaches, and those with lower pain severity. Overall, clinical utility of the ICD-11 was high, although less effective for chronic back pain and headache diagnoses. The latter also exhibited the lowest agreement between HCPs and algorithm. The current study underscores the need for evidence-based improvements to the ICD-11 diagnostic criteria in pediatrics. Developing pediatric coding notes could improve the visibility of patients internationally and improve the likelihood of receiving reimbursement for necessary treatments through accurate coding.

Sacrococcygeal Chordoma: A Clinical and Imaging Review

Sacrococcygeal chordoma is a rare, locally aggressive malignant tumor originating from remnants of the notochord, and it represents the most common primary malignancy of the sacrum. This review provides an in-depth discussion of the clinical presentation, pathological features, imaging characteristics, and management of sacrococcygeal chordomas. These tumors typically present with local pain, neurological deficits, and a palpable mass, and they are known for their high recurrence rate and challenging surgical management. Imaging, especially MRI, is crucial for accurate diagnosis and surgical planning, given its ability to delineate the extent of the tumor and its relationship with surrounding structures. Complete surgical excision remains the cornerstone of treatment, with prognosis largely depending on the ability to achieve negative surgical margins. We present a case of a 45-year-old male who presented with bowel and bladder dysfunction and a painful, progressively enlarging mass over the sacrum. MRI revealed a large, well-defined soft tissue mass involving the distal sacrum and coccyx, extending into the retrorectal space. The patient underwent successful en bloc surgical resection, and histopathological examination confirmed the diagnosis of chondroid chordoma.

Local anaesthetic to reduce injection pain in patients who are prescribed intramuscular benzathine penicillin G: a systematic review and meta-analysis

Three to 4-weekly intramuscular injections of benzathine penicillin G (BPG) for a prolonged period (e.g., 10 years, until age 40 years, or lifelong) are recommended for preventing group A streptococcal infections that cause recurrent acute rheumatic fever (ARF) and potential progression to rheumatic heart disease (RHD). The duration of treatment, frequency and local pain associated with BPG injections may lead to reduced compliance. Shorter courses of BPG are recommended for the treatment of syphilis and Streptococcal infections. We aimed to assess the effects of local anaesthesia in reducing injection pain in patients who are being treated with BPG. In this systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Conference Proceedings Citation Index-Science and LILACS from database inception up to May 4, 2024, and performed additional searches for grey literature. Randomised controlled trials comparing BPG vs. BPG administered alongside local anaesthetics were included. Randomized controlled trials using BPG, irrespectively of indication, and testing any local anaesthetic agent for pain alleviation were considered eligible. We applied GRADE to assess the quality of evidence. Summary data were extracted from included trials. The primary outcome was injection pain, assessed through mean differences. A random-effects model was utilized to account for study heterogeneity. This study is registered with PROSPERO, CRD42022342437. Database searches identified a total of 3958 records, and 3 additional records were retrieved from grey literature searches. After removal of duplicates, screening of abstracts and full-text review, eight trials were included, combining a total of 489 patients (151 patients with RHD). Immediate pain level, as reported by patients, was of high intensity in most studies. Low intensity pain was still reported at 24h. Administration of lidocaine mixed with BPG was associated with a significant reduction in immediate post-injection pain (mean difference-3.84, 95% confidence interval-6.19 to-1.48, P=0.0001; 4 studies; I2=98%; GRADE: moderate quality), pain at 5 min (mean difference-2.85, 95% CI confidence interval-3.78 to-1.92, P<0.0001; 1 study; GRADE: moderate quality), and pain at 20 min (mean difference-1.85, 95% confidence interval-2.61 to-1.09, P<0.0001; 1 study; GRADE: moderate quality) on a 1 to 10 scale. One study assessed lidocaine cream applied to the skin prior to BPG injection and showed no significant reduction in injection pain (mean difference=-0.54, 95% CI confidence interval-1.17 to 0.09, P=0.13; 1 study; GRADE: low quality). Mepivacaine mixed with BPG in patients with syphilis showed a significant reduction of immediate post-injection pain (mean difference-2.19, 95% CI confidence interval-2.49 to-1.89, P<0.0001; 1 study; GRADE: moderate quality). Two studies assessed procaine mixed with BPG and reported: lower immediate pain levels or pain assessed at 1h (mean difference and 95% CI confidence intervals not provided, P=0.001 and P=0.008, respectively; 1 study; GRADE: low quality), or less immediate pain and pain at 24h on the buttock injected with procaine mixed with BPG (mean difference and 95% CI confidence intervals not provided, P<0.001 for both; 1 study; Grade: low quality). No severe adverse reactions were reported. In patients receiving intramuscular BPG injections, moderate quality quantitative evidence suggests that BPG injections diluted with lidocaine or mepivacaine may improve post-injection pain scores compared to BPG injections diluted with sterile water. Procaine may also have a benefit, but quality of evidence was lower. Most studies included small patient samples and assessed pain levels at different timepoints. Due to insufficient data we were not able to assess the impact of injection volume, and local anaesthetics' dose on pain intensity and duration of pain relief. WHO.

Prevalence of Myofascial Trigger Points in Isolated Idiopathic Cervical Dystonia: A Possible Contributor to Pain, Movement and Disability.

Myofascial trigger points (TrPs) are hypersensitive points located in a tight band of muscle that, when palpated, produce not only local pain but also referred (distant) pain. The role of TrPs in patients with cervical dystonia (CD) has not been investigated. To identify the presence of TrPs in patients with isolated idiopathic CD and their association with pain. Thirty-one patients (74.2% women; age: 61.2 years, SD: 10.1 years) participated. TrPs were explored in the sternocleidomastoid, upper trapezius, splenius capitis, levator scapulae, anterior scalene, suboccipital, and infraspinatus muscles. Clinical features of CD were documented as well as the presence of pain. The severity of dystonia and its consequences were assessed using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). The mean number of TrPs for each patient was 12 (SD:3), with no differences between patients with pain (n = 20) and those without pain (n = 11). Active TrPs were only found in patients with pain (mean: 7.5, SD:4). Latent TrPs were found in both groups but were more prevalent (P < 0.001) in patients without pain (mean: 11, SD:3.5) than in those with pain (mean: 5, SD:3.5). The number of active TrPs or latent TrPs was positively associated with the TWSTRS disability subscale and the TWSTRS total score. The number of active, but not latent, TrPs was associated with worse scores on the TWSTRS pain subscale. Active TrPs were present in patients with CD reporting pain, while latent TrPs were present in all CD patients, irrespective of their pain status. The numbers of active/latent TrPs were associated with disability. TrPs could act as pain generators in CD and also contribute to the involuntary muscle contractions characteristic of dystonia.