Episodes Of Pain Research Articles

A 5-day course of repetitive transcranial magnetic stimulation before pain onset ameliorates future pain and increases sensorimotor peak alpha frequency

Abstract Repetitive transcranial magnetic stimulation (rTMS) has shown promise as an intervention for pain. An unexplored research question is whether the delivery of rTMS prior to pain onset might protect against a future episode of prolonged pain. The present study aimed to determine whether (1) 5 consecutive days of rTMS delivered prior to experimentally induced prolonged jaw pain has a prophylactic effect on future pain intensity and (2) whether these effects were accompanied by increases in corticomotor excitability (CME) and/or sensorimotor peak alpha frequency (PAF). On each day from day 0 to 4, 40 healthy individuals received a single session of active (n = 21) or sham (n = 19) rTMS over the left primary motor cortex. Peak alpha frequency and CME were assessed on day 0 (before rTMS) and day 4 (after rTMS). Prolonged pain was induced via intramuscular injection of nerve growth factor in the right masseter muscle after the final rTMS session. From days 5 to 25, participants completed twice-daily electronic diaries including pain on chewing and yawning (primary outcomes), as well as pain during other activities (eg, talking), functional limitation in jaw function and muscle soreness (secondary outcomes). Compared to sham, individuals who received active rTMS subsequently experienced lower pain on chewing and yawning. Furthermore, active rTMS led to an increase in PAF. This is the first study to show that rTMS delivered prior to prolonged pain onset can protect against future pain. Our findings suggest that rTMS may hold promise as a prophylactic intervention for pain.

A seventeen-year, population-based study to identify dynamic patterns of interfering neck pain and its burden in South Korea

AimThe aim of this study were to introduce a profile of a nationwide cohort for patients with neck pain and to identify the patterns of recurrent neck pain over time. MethodsHealth insurance data for 1,127,323 patients (43.5 ± 11.5 years, 60.8% females) with neck pain in 2010 were extracted from the National Health Information Database of South Korea. Data on the duration and frequency of neck pain and the number of healthcare visits recorded between 2002 and 2018 were screened and used for descriptive analysis. ResultsDuring the study period, patients experienced 4.1 episodes of neck pain, and 74% of patients experienced multiple episodes. The duration of one episode was 12.1 ± 35.7 days. Following each episode, more than 73% of patients experienced a subsequent episode of neck pain. As patients experienced more episodes, the recurrence rate increased gradually from 73% to 80%, and subsequent episodes occurred in a shorter time and lasted longer with a higher number of healthcare visits, compared to a preceding episode. ConclusionThe study highlighted the dynamic pattern of interfering neck pain, with episodes occurring more frequently and lasting longer over time. Early intensive management with a long-term follow-up is recommended to prevent a dynamic pattern of interfering neck pain.

Minimal clinically important difference in the Japanese Orthopedic Association Score and shoulder 36 after arthroscopic rotator cuff repair in a Japanese population: A retrospective cohort study

BackgroundIn Japan, the Japanese Orthopedic Association (JOA) score is widely used as a clinician-reported outcome after shoulder surgery. However, Shoulder36 is positioned as a general patient-reported outcome measure. This study aimed to determine the correlations between the JOA score and scores in the domains of the Shoulder36 and their minimal clinically important differences (MCIDs) and cutoff values for the patient-acceptable symptom state (PASS) after unilateral arthroscopic rotator cuff repair (ARCR). MethodsWe evaluated 145 patients using the JOA score and Shoulder36 before and 1 year after surgery. The MCID and PASS cutoff values were determined by patients’ responses to the following anchor item: A, none (“no good at all”); B, poor (“some effect but unsatisfactory”); C, good (“satisfactory effect with occasional episodes of pain or stiffness”); D, excellent (“ideal response, virtually pain-free”). The correlations between the JOA score and the domains of the Shoulder36 were statistically calculated. The border between B and C was defined as the threshold for PASS. ResultsThere were significant correlations between the JOA score and the Shoulder36 domains. The responses to the anchor item were as follows: A (n = 0), B (n = 21), C (n = 76), and D (n = 48). The MCID for the JOA score was 19.5 points and the MCIDs for Shoulder36 were 0.5 points for pain, 0.667 for range of motion, 0.67 for muscle strength, 0.3 for general health, 0.571 for activities of daily living, and 1.0 for sports ability. The PASS cutoff value was 89.0 points for the JOA score and 3.8 points for pain, 3.667 for range of motion, 3.0 for muscle strength, 3.7 for general health, 3.7 for activities of daily living, and 3.0 for sports ability in the Shoulder36. ConclusionsThe MCID and cutoff PASS values for the JOA score and Shoulder36 identified in this study will help to determine the effectiveness of multidisciplinary management after ARCR.

Infections in sickle cell disease.

Sickle cell disease (SCD) is one of the commonest severe inherited disorders in the world. Infection accounts for a significant amount of the morbidity and mortality, particularly in sub- Saharan Africa, but is relatively poorly studied and characterized. Patients with SCD have significant immunodeficiency and are more likely to suffer severe and life-threatening complications of infection, and additionally infections can trigger complications of SCD itself. Those with more severe forms of SCD have functional asplenia from a very early age, which accounts for much of the morbidity in young children, particularly invasive infections from encapsulated bacteria including Streptococcus Pneumoniae, Haemophilus Influenzae, Salmonella Typhi and meningococcal disease. Additionally, there are other defects in immune function in SCD, associated with anemia, tissue infarction and impaired adaptive immunity. Complications of infections in SCD include acute chest syndrome (ACS), acute painful episodes, osteomyelitis, meningitis, urinary tract infections, overwhelming sepsis and death. Viral infections cause significant morbidity, particularly severe anemia associated with Parvovirus, and to a lesser extent other infections such as influenza and COVID19. The relationship between malaria and SCD is complicated and discussed in this review. Unlike many of the genetic risk factors for poor outcomes in SCD, it is theoretically possible to modify the risks associated with infections with established public health measures. These include the provision of vaccinations, prophylactic antibiotics and access to clean water and mosquito avoidance, although current financial restraints and political priorities have made this difficult.

Proper counseling for diagnosis and management of cannabinoid hyperemesis syndrome: a case report.

Cannabinoid hyperemesis syndrome (CHS) is an increasingly recognized condition linked to chronic cannabis use, yet it remains frequently overlooked in clinical practice. The syndrome is characterized by cyclic episodes of severe nausea, vomiting, and abdominal pain, often relieved temporarily by hot showers or baths. With the rising prevalence of cannabis use following its legalization, the incidence of CHS has surged, presenting a significant challenge in both diagnosis and management within primary healthcare settings. Understanding the epidemiology, risk factors, and potential long-term sequelae of CHS is crucial for timely identification and intervention. This case report highlights the challenge of diagnosis and management of CHS in primary healthcare. To emphasize the importance of proper counseling and the use of Rome IV criteria in diagnosing CHS. To illustrate how this may reduce patient suffering and unnecessary investigation. A 22-year-old female with chronic, daily cannabis use presented with recurrent episodes of intense nausea, vomiting, and abdominal pain over a 2-year period. Extensive diagnostic evaluations were inconclusive. A tentative diagnosis of CHS was made by a medical student and family doctor based on published criteria. The Rome IV criteria were then applied for confirmation of diagnosis and management. In so doing, the patient was advised to cease cannabis use for a minimum of 3 months. Initially, symptom improvement was reported with cannabis cessation. However, symptoms recurred following a relapse in cannabis use. To confirm the diagnosis of CHS, counseling should specify the need for a minimum of 3 months of cannabis cessation to achieve symptom relief. Increased physician and patient awareness of this minimal time period for drug cessation can help to avoid unnecessary investigations, and prolonged patient suffering. This case emphasizes the need for vigilance in recognizing CHS and consideration of cannabis as a potential cause of cyclic vomiting.

CORRELATION BETWEEN MUSCULOSKELETAL PAIN AND COGNITION AMONG UNIVERSITY LEVEL STUDENTS USING THE RUFF FIGURAL FLUENCY TEST.

BACKGROUND: Hand grip strength and function are important for day- to-day tasks. Although chronic pain has long been known to affect cognitive outcomes, new research published in the last decade has focused on the multi-dimensional impacts of pain on multiple cognitive areas; OBJECTIVE: To study cognitive impairment and musculoskeletal pain in university level students and to evaluate the relationship between musculoskeletal pain and cognition in university level students; METHODOLOGY: Study design is cross sectional and observational with sample size87 at MGM SCHOOL OF PHYSIOTHERAPY With age 18 to 27 years having any musculoskeletal pain; RESULTS: The statistical significance of the participants' pain in days with the p value is 0.001 (p<0.001). The amount of errors made by participants with a p value of 0.001 (i.e., p<0.001), the correlation coefficient r-value between the length of the pain episode and the length of the rough figural fluency test was recorded as -0.068, which is statistically insignificant at the 5% level with a non-linear link with a non-linear link, the correlation coefficient r-value for pain duration and ruff figural fluency test errors was observed as -0.11, which is statistically insignificant at the 5% level.CONCLUSION: This study concluded that there is a significant relation between pain and cognition and has a positive correlation between pain and cognition.

Minimally invasive treatment with radiofrequency ablation and kyphoplasty for avascular necrosis of the spine in sickle cell disease: illustrative case.

Avascular necrosis (AVN) of the spine is a rare sequela of chronic sickle cell disease (SCD) in which the shape of the sickled red blood cells interfere with the normal vascular supply of vertebral bodies. In this report, the authors describe a case of progressive spinal AVN treated with radiofrequency ablation (RFA) and kyphoplasty for the patient's persistent lower back pain. A 38-year-old male with long-standing spinal AVN due to SCD had been managed conservatively with hydroxyurea and oral opioid analgesics for several years until breakthrough episodes of low-back pain began to occur with an inability to perform activities of daily life. The patient's condition progressed to involve multiple vertebral bodies, leading to a refractory response. Bipedicular RFA directed at L3 and L4 with kyphoplasty was proposed as a novel, minimally invasive approach. The patient was found to have lasting postoperative relief. Patients with pain attributed to a sickle cell crisis can benefit from RFA and kyphoplasty to potentially eliminate or minimize symptoms from spinal AVN due to chronic SCD not responding to conservative management. https://thejns.org/doi/10.3171/CASE24343.

Analysis of the role of PANoptosis in intervertebral disk degeneration via integrated bioinformatics analysis and experimental validation

Intervertebral disc degeneration (IVDD) is an age-related orthopedic degenerative disease characterized by recurrent episodes of lower back pain, and death of nucleus pulposus cells (NPCs) has been identified as a key factor in the pathophysiological process of IVDD episodes. Recent studies have shown that “ PANapoptosis ”, a newly characterized form of cell death, has emerged as an important factor contributing to the development of several diseases. However, studies on the specific mechanisms of its role in the development of IVDD are lacking. The aim of this study was to explore the characterization of PANoptosis in IVDD and to identify potential biomarkers and therapeutic targets as well as therapeutic agents. We constructed a PANoptosis gene set, based on the GEO database, and used weighted gene co-expression network analysis (WGCNA) and differential expression analysis to identify PANoptosis genes associated with the pathophysiological process of IVDD episodes by Gene Set Enrichment Analysis (GSEA), immune infiltration, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) to explore the underlying biological mechanisms of PANoptosis and its role in IVDD. Comprehensive bioinformatics analysis showed that seven key genes (APAF1, MEFV, NLRP3, TNF, GSDMD, AIM2, and IRF1) of PANoptosis have good diagnostic value. In addition, we predicted potential therapeutic agents, among which Andrographolide (AG) had the highest correlation and binding affinity to the target. Finally, we performed Western blotting and quantitative real-time polymerase chain reaction (qRT-PCR) assays, molecular docking, and cell flow to validate the expression of PANoptosis-related genes and the therapeutic effect of AG. We further divided SD rats into sham-operated, IVDD model, and Andrographolide-treated groups, administered AG at 50 mg/kg via gavage for one month, and observed significant therapeutic effects through HE staining. This study identifies key PANoptosis genes and demonstrates the potential of AG as a therapeutic agent for IVDD.

BN SO16 - Gastro-gastric intussusception without any lead point – a case report and review of literature

Abstract Background Gastrogastric intussusception in a rare condition in adults. The underlying aetiologies include pathological lead points, anatomical abnormalities, previous foregut surgery or foreign body. The management of symptomatic gastrogastric intussusception in the absence of these aetiologies remains poorly defined and is highlighted by the paucity of evidence available for guidance. We present a case of idiopathic gastrogastric intussusception and a review of the literature. Method A 34-year-old male patient with a background of thrombocytopenia-absent radius (TAR) syndrome presented with recurrent episodes of upper abdominal pain and vomiting. Investigations with a CT abdomen revealed proximal gastrogastric intussusception. Subsequent endoscopy showed oedematous mucosa along the lesser curve and no pathological lead points or anatomical abnormalities. Histological findings were normal. Results The patient remained symptomatic despite a normal subsequent CT abdomen. A consensus decision was reached, and the patient was counselled for a laparoscopic gastropexy. Laparoscopic findings showed a central area of scar tissue circumferentially along the mid-body of the stomach highlighting the chronicity of the condition. No hiatal abnormalities were identified. A gastropexy was performed in two layers along the greater curvature of the stomach with non-absorbable interrupted sutures. The postoperative course was unremarkable. The patient remained asymptomatic on 6-week clinic follow up. Conclusion No previous case reports of idiopathic gastrogastric intussusception were identified on our literature search. It is our impression that this is the first such case-report to illustrate the diagnostic challenges of this rare, intermittently symptomatic condition and the successful management of it.

Managing emotional and physical stress in sickle cell anemia: a review of effective strategies and approaches

Sickle cell anemia (SCA) is a genetic blood disorder characterized by recurrent pain episodes, chronic complications, and significant emotional and physical stress. This review article explores effective strategies for managing both the emotional and physical aspects of stress in SCA patients. A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, and Google Scholar, using keywords such as “sickle cell anemia,” “stress management,” “psychological support,” and “pain management.” Emotional stress in SCA arises from chronic pain, frequent hospitalizations, and disease uncertainty, leading to conditions such as anxiety and depression. Effective management of emotional stress involves a combination of psychological counseling, cognitive-behavioral therapy (CBT), and support groups, which help patients develop coping strategies and address the mental health challenges of living with a chronic illness. This review evaluates various psychological interventions and their impact on patient outcomes, emphasizing the need for integrated mental health support in the management of SCA. Physical stress in SCA is primarily due to acute vaso-occlusive crises and chronic pain, which require effective pain management and preventive measures. The review explores pharmacological treatments, such as opioids and hydroxyurea, as well as non-pharmacological approaches, including physical therapy and lifestyle modifications. Additionally, the article discusses innovative therapies like gene therapy and stem cell transplantation, which hold promise for long-term disease management.

German Real-World Experience of Patients with Diverse Features of Acute Intermittent Porphyria Treated with Givosiran.

Background/Objectives: Acute intermittent porphyria (AIP) is a metabolic disease characterised by neurovisceral crises with episodes of acute abdominal pain alongside life-altering, and often hidden, chronic symptoms. The elimination of precipitating factors, hemin therapy, and pain relief are strategies used to treat porphyria symptoms, but are often reserved for patients suffering recurrent, acute attacks. Givosiran (siRNA) is an emerging AIP therapy capable of silencing delta-aminolevulinic acid synthase-1 (ALAS1) and, in turn, reducing the accumulation of delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) that precede porphyria symptoms. The aim of this study was to investigate the efficacy and safety of givosiran administration in patients with both acute and chronic AIP burden, who were poorly responsive to current therapies, using a personalised medicine approach. Methods: Real-world data were collected in consecutive patients treated with givosiran at an accredited German Porphyria Clinical Center. Biochemical, clinical, and HR-QoL outcomes were monitored alongside adverse events (AEs). Results: Twenty-eight patients treated between 2018 and 2024 were sub-categorised into groups corresponding to Ipnet terms 13 'Sporadic Attacks, 5 'Symptomatic High Excretors', 5 'Prophylactic Heme', and 5 "Recurrent Attacks'. The mean time from diagnosis to treatment was 9.2 years (range in months 1-324), and the mean duration of treatment was 30 months (range 3-68). After 6 months of monthly givosiran injection (2.5 mg/kg), all patients' ALA levels reached <2ULN, and 60% of patients attained PBG levels < 2ULN (p < 0.001). These biochemical responses were not different between sub-groups (p > 0.05). Clinically, 75% of patients' chronic and acute porphyria symptoms improved. The total patient populations' annualised attack ratio (AAR) improved; Historical AAR: 2.9 (0-12.0) vs. Givo AAR: 0.45 (0-3.0) (p < 0.01). During follow-up, nine patients experienced minor breakthrough episodes. Of these, three patients required hemin infusion. An association between clinical success and a shorter interim period between diagnosis and treatment was evident (r = -0.522, p = 0.0061). All patients' indices of HR-QoL improved under givosiran, including mental health (38%, p < 0.0001) and pain (38%, p < 0.0001). Patient-reported health (givosiran 77.9% vs. baseline 37.1%, p < 0.0001) and clinical outcome scores (86.9%: good-very good) were also positive. Two patients withdrew from treatment <6 months, citing fatigue, which was a common side effect. A mild elevation in liver enzymes (AST and/or ALT < 1.5ULN, 15.4%) and reduced glomerular filtration rates (GFR, 11.5%) were also evident, but no life-threatening adverse events (AEs) were attributed to givosiran treatment. Conclusions: Givosiran is effective in preventing severe acute attacks and reducing the chronic health burden in patients with acute intermittent porphyria. Importantly, HR-QoL improved in patients suffering chronic AIP burden with few incidences of historical attacks. All patients experienced substantially improved mental health, ease of living, and self-perceived health.

Marfan's Syndrome with Acute Inferior Wall ST-segment Elevation Myocardial Infarction in A Combined Family of 13 Cases

Marfan's syndrome (MFS) is a rare autosomal dominant connective tissue disorder, often associated with genetic mutations and most patients have a family history of the disease. Its clinical manifestations are mainly skeletal, ocular and cardiovascular pathologies. We report a case of a 34-year-old male diagnosed with Marfan's syndrome at the age of 22 and presenting with ocular symptoms. Following an episode of sudden chest pain, he was admitted to the hospital with an acute inferior wall ST-segment elevation myocardial infarction, and was diagnosed with a mid-right coronary artery occlusion by coronary angiography. He underwent coronary artery balloon dilatation to restore grade 3 flow, and a stent was implantated 4 months later. In a subsequent epidemiologic survey of 26 family members from 4 generations, 13 members were diagnosed with Marfan's syndrome, all of them presented with ocular signs. After more than 3 years of follow-up of the entire family, there is currently no one with coarctation of the aorta and no sudden death. Since some patients with Marfan's syndrome can present with acute chest pain complicated by aortic coarctation, if the coarctation involves the aortic root it can lead to severe stenosis or occlusion of the coronary arteries, resulting in electrocardiograms showing typical changes for a ST-segment elevation myocardial infarction. Considering the complexity and life-threatening nature of Marfan's syndrome, it is important consider the various etiologies of chest pain in patients with Marfan's syndrome.

Profiles of Nonpharmacologic Treatment Receipt in the First 10 Weeks Following a New Back Pain Diagnosis Among Active Duty Soldiers: A Latent Class Analysis.

US service members experience high rates of back pain. Guidelines prioritize nonpharmacologic treatment (NPT) as first-line pain treatments; however, NPT utilization patterns research is limited. This study examined NPT patterns of care within the first 10 weeks following an index back pain diagnosis. Data were from the Substance Use and Psychological Injury Combat Study and included 222,427 active duty soldiers with an index back pain diagnosis following return from Afghanistan/Iraq deployment in 2008-2014. We fit a series of latent class analysis models to identify homogenous subgroups of soldiers with NPT utilization during the 10-week period and measured associations with soldier characteristics and clinical characteristics within 90 days before the back pain diagnosis, with the distinct NPT utilization classes. Approval for this study was granted by the Brandeis University Committee for Protection of Human Subjects (Institutional Review Board #14153) and the Uniformed Services University Institutional Review Board. Only half of the soldiers received any NPT within their 10-week early treatment window. Latent class analysis identified 4 classes over the 10-week early treatment window: Class 1 (None/Low NPT, 65%); Class 2 (High and Decreasing NPT, 15%); Class 3 (Low and Increasing NPT, 13%), and Class 4 (Sustained NPT, 7%). Soldier clinical characteristics from the 90-day preperiod window were most important in distinguishing class membership in relation to Class 1, particularly comorbid pain conditions, diagnosis of traumatic brain injury, receipt of prescription opioids, and receipt of invasive surgery. Patterns of weekly NPT utilization during an early treatment window following a new back pain diagnosis varied temporally, with approximately half of soldiers using NPT. Half of the soldiers did not receive any NPT within their 10-week early treatment window, which highlights opportunities for increasing use of NPT utilization among military members with a new back pain episode. Future research is needed in the Military Health System to examine the extent to which NPT patterns are associated with pain management outcomes.

Management of iatrogenic atrial perforation caused by pacemaker electrodes: a case report

BackgroundThe complications associated with cardiac device implants ranges between 5.3% and 14.3%. Cardiac perforation due to “leads” represent a very rare complication of cardiac device implantation, ranging between 0.3% and 0.7%. Clinically, they can manifest different, nonspecific symptoms; hence, the diagnosis may not be immediate.Case presentationOur clinical case describes the successful treatment of cardiac tamponade occurring in a Caucasian 79-year-old man following a pacemaker implantation. Two days after the procedure, the patient reported an episode of nonspecific chest pain associated with syncope. The echocardiogram performed revealed a pericardial effusion in the apical area, along the right chambers, with a thickness of 7 mm, not hemodynamically significant. A chest computed tomography scan with contrast showed hemopericardium (maximum thickness of 11 mm), caused by an atrial perforation. A few hours later, the patient experienced hemodynamic instability. For this reason, an urgent sternotomy was performed with drainage of a significant hemopericardial effusion, revealing a perforation of the upper free wall of the right atrium with pericardial injury caused by the retractable screw lead. The perforation site was sutured and the sternal wound was closed. The patient was discharged after 4 days without further complications. At the control visit, scheduled 30 days after the hospital discharge, the patient was in good conditions.ConclusionsAlthough the atrial perforations from leads are very rare complications of pacemaker implantation procedures, they are potentially lethal. In conclusion, this clinical case highlights the need, before hospital discharge, of an accurate screening for evaluation the pericardial effusion in patients that undergo to the cardiac implantable electronic devices.

Societal costs of older adults with low back pain seeking chiropractic care: findings from the BACE-C cohort study

BackgroundTo describe the societal costs during one year of follow-up among older adults seeking chiropractic care due to a new episode of low back pain (LBP), and to determine what factors predict high societal costs in this population.MethodsProspective cohort study, within chiropractic private practices (n = 38) in the Netherlands. 223 people ≥ 55 years of age with a new episode of LBP seeking chiropractic care participated. The primary outcome was total societal costs. High societal costs were defined as patients with costs in the top 20th percentile. The final prediction models were obtained using forward selection. Results were presented for the total population and stratified for retirement status. The model’s prognostic accuracy (Hosmer–Lemeshow X2, Nagelkerke’s R2) and discriminative ability [area under the receiver operating curve (AUC)] were assessed, and the models were internally validated using bootstrapping.ResultsThe mean total annual societal cost per patient was €5297 [95% confidence interval (CI): 4191–6403]. The biggest cost driver was presenteeism (65% of total costs), and costs were higher among non-retired participants (€7759; 95% CI 6047–9470) than retired participants (€1892; 95% CI 1088–2695). In the total population, younger age [odds ratio (OR): 0.87 for each additional year; 95% CI 0.80–0.95], being male instead of female (OR 2.96; 95% CI 1.19–7.44), less alcohol intake (OR 0.49; 95% CI 0.20–1.19), working instead of retirement (OR 9.37; 95% CI 1.83–48.04), and more disability at baseline (OR 1.08; 95% CI 1.00–1.16) were found to be predictive of high societal costs. Working was found to be the strongest predictor for high societal costs. After internal validation, the model’s fit was good, it’s explained variance was moderate (28%) and their AUCs could be interpreted as moderate (0.85). For non-pensioners, the same predictive factors were identified as for the entire population. The costs for the retired participants showed too little variation to be able to predict high costs.ConclusionsThis study estimated the mean total annual societal cost of older adults seeking chiropractic care due to a new episode of LBP at €5297 (95% CI 4191–6403).These costs were mainly due to high levels of presenteeism, and extensively differed based upon work status.

Osteopathic Manipulative Treatment: A Safe and Feasible Adjunct in Sickle Cell Disease Pain Management.

Children and adolescents and young adults (CAYAs) with sickle cell disease (SCD) suffer from recurrent acute pain episodes that result in hospitalization and confer substantial morbidity. Pharmacologic pain control is often inadequate, thus non-pharmacologic modalities are needed. Osteopathic manipulative treatment (OMT) is a potentially valuable non-pharmacologic addition to pain management. We describe eight patients hospitalized with SCD pain who received OMT. OMT was safe, feasible, and a promising adjunctive option for management of SCD pain.

Elevated Posterior Insula Glutamate in Patients with Sickle Cell Disease

Sickle cell disease (SCD) is an inherited hemolytic disorder accompanied by chronic pain and recurrent acute painful episodes known as vaso-occlusive crises (VOCs). Increased Glx (glutamate+glutamine) and lowered insula GABA concentration has been reported in the insula of patients with fibromyalgia, a nociplastic chronic pain condition, and may affect the pathophysiology of pain-related syndromes. Therefore, proton magnetic resonance spectroscopy (1H-MRS) was conducted to measure levels of Glx and other brain metabolites using a single voxel (size: 2×3×3 cm3) in the right posterior insula cortex (PIC) in 17 individuals with SCD and 17 ethnicity-, age- and sex-matched healthy controls (HCs). The frequency of VOCs in the preceding 12 months was recorded. The concentration of Glx (p=0.019) and the ratio of Glx to tCr (total creatine, p=0.035) in the PIC were significantly higher in patients with SCD as compared to matched HCs (n=17). Secondary analyses with the unpaired full sample of 24 SCD also showed a significantly higher level of Glx/tCr than HCs (n=19), with a positive correlation between the level of Glx/tCr and the number of VOCs (p=0.034, r=0.476), as well as a negative correlation between Glx and sensory sensitivity assessed by tonic pressure pain in gastrocnemius area of the non-dominant leg (p=0.040, r=-0.462). The unpaired full sample additionally revealed a significant difference in sensory sensitivity (p=0.050). Altered metabolites such as GABA and myoinositol were also observed between SCD and HCs. These results suggest that elevated excitatory neurotransmission in the insula might contribute to nociplastic pain in SCD. PerspectiveOur work highlighted the innovative finding of elevated levels of the excitatory neurotransmitter glutamate with glutamine in patients with SCD compared to healthy controls. The trend of positive relationship between Glx/tCr and the frequency of VOCs suggests that an excitatory brain neurotransmitter imbalance may be involved in VOCs.

Treatment of trigeminal neuralgia by acupuncture combined with Chinese medicine from the perspective of modern medicine: A review.

Trigeminal neuralgia (TN) is characterized by recurrent episodes of transient severe pain in its distribution area, with abrupt onset and termination. With the progression of the disease, patients are prone to concurrent psychiatric disorders, such as anxiety and depression, which seriously affect patients' quality of life. Currently, anticonvulsant drugs are commonly used in clinical practice as the primary treatment, but long-term use of drugs is prone to drug resistance, limiting clinical application. Acupuncture and traditional Chinese medicine (TCM), as alternative and complementary therapies, can make up for the deficiencies in modern medicine and are accepted by patients with the advantages of safety and effectiveness. TCM therapy works by promoting the release of endogenous opioid peptides, adjusting the level of inflammatory factors, and improving negative emotions to exert analgesic effects. This paper discusses the clinical efficacy and safety of acupuncture combined with Chinese medicine in the treatment of TN from the perspective of modern medicine and provides a theoretical basis for seeking better therapeutic targets.

When thinking about pain contributes to suffering: the example of pain catastrophizing.

The extensive literature on the potent role negative thoughts about pain have on the experience of pain and pain-related suffering has documented associations with important neurobiological processes involved in amplifying nociceptive signals. We focus this review on pain catastrophizing (pCAT)- appraisals of pain as threatening, overwhelming, and unmanageable- and review the evidence that these thoughts are learned in childhood through experience and observation of others, particularly caretakers and parents. For children who have learned pCAT, repeated exposures to pain over time activate pCAT and likely contribute to further amplification of pain through changes in the neurobiological pain regulatory systems, which overlap with those regulating the stress response. We propose that repeated pain and stress exposures throughout childhood, adolescence, and into adulthood alter the neurobiology of pain via a repetitive positive feedback loop that increases risk for heightened pain sensitivity over time with repeated exposures. At some point, often precipitated by an acute episode of pain and possibly influenced by allostatic load, pCAT contributes to persistence of episodic or acute pain and exacerbates pain-related suffering. This developmental trajectory is not inevitable, as the impact of pCAT on pain and pain-related suffering can be influenced by various factors. We also present future directions for work in this area.

P38 Lupus enteritis as a first presentation of systemic lupus erythematosus in a previously well patient: a very rare occurrence

Abstract Introduction Lupus enteritis is an anecdotally rare condition (with no formal estimates of incidence) which can pose a diagnostic challenge, especially when presenting without other lupus-related symptoms and signs. Here, we present an unusual case where lupus enteritis was the first manifestation of systemic lupus erythematosus (SLE). Case description A 65-year-old South Asian female presented with a 6-month history of intermittent nausea, vomiting and abdominal pain, with the only systemic feature being worsening fatigue. She had no connective tissue disease features, previous miscarriage or venous thromboembolism (VTE). Over six months, she had multiple hospitalisations in different hospitals with recurrent attacks of episodic abdominal pain and vomiting, associated with migratory and reversible intestinal inflammation on serial imaging. Initial investigations revealed lymphopenia (0.99x109/L) and hypoalbuminaemia (25 g/L). During a two-month admission at our centre, she underwent detailed gastrointestinal investigations, including four abdomino-pelvic CT scans during transient episodes of pain and vomiting, showing diffuse wall thickening affecting different parts of the gastrointestinal tract at different times. Following discussion at specialist radiology and inflammatory bowel disease multidisciplinary meetings, these CT scans and an MRI small bowel study were confirmed to demonstrate a transient, migratory, reversible pattern of bowel inflammation affecting the ileum, jejunum and colon at different time points; there were no clinical, endoscopic, histological or imaging features of inflammatory bowel disease. Gastro-duodenal biopsies were normal and negative for amyloidosis and tuberculosis. Colonic biopsies excluded inflammation. C1 esterase inhibitory deficiency was excluded. A vasculitis screen was negative, but immunology was positive for anti-nuclear and anti-chromatin antibodies, with positive crithidia, but normal dsDNA. C3 was normal, but C4 was low at 0.04 g/L. Urinalysis showed significant albuminuria (413.8 mg/mmol). Following multidisciplinary discussion between gastroenterology, clinical immunology and rheumatology, a diagnosis of SLE was made, with an initial presentation of lupus enteritis. She received a tapering dose of corticosteroids and hydroxychloroquine. The patient suffered from a right-sided multi-segmental pulmonary embolus with infarction, but this was felt to be due to her nephrotic syndrome (negative anti-cardiolipin and β2-glycoprotein antibodies). Renal biopsy revealed class I lupus nephritis with podocytopathy. The patient was duly commenced on tacrolimus as a steroid-sparing agent. Discussion Lupus enteritis is a rare, poorly-defined condition, with only small amounts evidence regarding treatment and management in the literature, although a narrative review of 58 papers has recently been published. However, the average time between diagnosis of SLE and presentation with lupus enteritis is around 44 months, meaning that isolated enteritis as a first presentation of SLE is extremely rare. Only two out of 150 patients reviewed by Janssens et al (from a single tertiary lupus centre) presented with enteritis prior to a diagnosis of SLE. Lupus enteritis is potentially serious if left untreated, and can lead to life-threatening complications such as intestinal necrosis and/or perforation. This rare presentation highlights the importance of considering lupus enteritis in the differential in any patient presenting with non-specific gastrointestinal symptoms and a migratory pattern of intestinal inflammation on radiological investigations. This can enable prompt diagnosis and timely management. Key learning points • Lupus enteritis can be a first presentation of SLE without any other classical manifestations. • Lupus enteritis is extremely rare, but can be life-threatening if not identified and rapidly treated. • Radiology can demonstrate transient, migratory bowel inflammation on serial imaging.