Severe Pain Research Articles

Optimizing analgesia for endometrial biopsy: A prospective, randomized comparative study

AbstractAimThis prospective, randomized, observational study aimed to compare the efficacy of intrauterine lidocaine, oral dexketoprofen, cervical lidocaine spray, and paracervical block with prilocaine for pain management during outpatient endometrial biopsy (EMB).MethodsOne hundred ninety‐seven women aged 18–75 undergoing EMB were randomly assigned to one of four groups: intrauterine lidocaine (n = 49), oral dexketoprofen (n = 48), cervical lidocaine spray (n = 50), or paracervical block with prilocaine (n = 50). Pain intensity was assessed using a visual analog scale (VAS) immediately post‐procedure and at 30 min, with additional analgesia needs recorded at 60 min. Statistical analyses included Kruskal–Wallis, chi‐square tests, and post hoc analysis.ResultsThe intrauterine lidocaine group had the lowest pain scores, while oral dexketoprofen had the highest (p < 0.001). Intrauterine lidocaine and paracervical block scores were significantly lower than those in the lidocaine spray and dexketoprofen groups (p < 0.001). Additional analgesia was needed in 30% of the lidocaine spray group, with none required in other groups. Severe pain (VAS ≥5.8) was more frequent in the dexketoprofen group compared to others (p < 0.001).ConclusionIntrauterine lidocaine and paracervical block are more effective than lidocaine spray and oral dexketoprofen in reducing procedural pain during EMB, highlighting the importance of appropriate analgesic selection to enhance patient comfort in office‐based gynecological procedures.

Misdiagnosis of type A acute aortic dissection in the emergency department: 10 Year retrospective cohort study

AbstractBackgroundType A acute aortic dissection (TAAAD) is a serious cardiovascular disease with a high mortality rate and prompt diagnosis is the key to survival. However, misdiagnosis is common in the Emergency Department (ED). The aim of this study is to evaluate the rate of misdiagnosis, factors associated with misdiagnosis and patient outcomes.MethodsThis retrospective cohort study recruited 91 patients with TAAAD at the ED of a tertiary university hospital in Hong Kong from 2013 to 2022. Patients were divided into the following two groups: correct diagnosis (60 patients) and misdiagnosis (31 patients) of TAAAD. Clinical symptoms, signs, and investigations were analyzed as factors associated with misdiagnosis by multivariate analysis. In‐patient mortality, 30‐day mortality, 1‐year mortality, and hospital length of stay (LOS) were compared between the two groups.ResultsThe misdiagnosis rate of TAAAD was 34.1% (31/91). Absence of severe intensity pain (OR = 6.01, 95% confidence interval [CI] = 1.41–25.63, p = 0.015), less urgent triage category (OR = 4.46, 95% CI = 1.77–11.22, p = 0.002), and absence of point‐of‐care ultrasound exam (POCUS) (OR = 13.00, 95% CI = 3.05–55.40, p = 0.001) were associated with misdiagnosis. There were no statistically significant differences between correct diagnosis and misdiagnosis groups in patient outcomes including in‐hospital mortality (28.3% vs. 38.7%), 30‐day mortality (28.3% vs. 38.7%), 1‐year mortality (30.0% vs. 41.9%), or hospital LOS (15.5 ± 15.6 days vs. 14.7 ± 15.5 days).ConclusionsOne‐third of cases in our study were misdiagnosed. The absence of severe intensity pain, less urgent triage category, and absence of POCUS ultrasound exam were independent factors associated with misdiagnosis. More widespread use of POCUS of the aorta and heart may help to improve the diagnosis of TAAAD in the ED.

UK medical cannabis registry: A clinical outcome analysis of medical cannabis therapy in chronic pain patients with and without co-morbid sleep impairment.

Chronic pain (CP) affects 35.0%-51.3% of the UK population, with 67%-88% reporting sleep disturbances. Cannabis-based medicinal products (CBMPs) have shown therapeutic potential in managing CP. Evidence suggests poor sleep worsens pain perception; therefore, this study aimed to assess patient-reported outcome measures (PROMs) following CBMP treatment in CP patients with and without co-morbid sleep impairment. A prospective cohort study of CP patients from the UK Medical Cannabis Registry was conducted. Participants were separated by baseline single-item sleep quality scale (SQS) score into sleep impaired (SQS ≤3) and unimpaired (SQS ≥4) cohorts. The primary outcome assessed changes in PROMs from baseline to 1-, 3-, 6-, and 12-months. Participants completed the following: SQS, General Anxiety Disorder-7, EQ-5D-5L, Brief Pain Inventory (BPI), and Short-Form McGill Pain Questionnaire-2. Significance was defined as p < 0.050. 1139 participants met the inclusion criteria (sleep impaired: n = 517, 45.4%; sleep unimpaired: n = 622, 54.61%). The sleep impaired cohort showed improvements in all PROMs at each follow-up (p < 0.010). The sleep unimpaired cohort showed similar results (p < 0.050), except in SQS and ED-5Q-5L: self-care and anxiety/depression scores (p > 0.050). However, the sleep impaired cohort observed greater improvements in BPI pain severity (p < 0.050) and SQS (p < 0.001) than the sleep unimpaired cohort at all follow-ups. 2817 adverse events were self-reported between both cohorts (p = 0.197). These findings align with literature that shows associated improvements in pain outcomes following CBMP administration. Sleep impaired individuals were more likely to experience greater pain severity improvements. However, this was not confirmed on multivariate logistic regression analysis and instead may be confounded by baseline pain severity. Whilst these results show promise for the effects of CBMPs on CP, they must be examined within the limitations of the study design. These findings provide further evidence to support the design of subsequent randomized controlled trials to verify causality between CBMPs and pain outcomes.

Predicting persistent back pain causing severe interference with daily activities among community-dwelling older adults: the OPAL cohort study.

Many older adults experience disabling back and leg pain. This study aimed to identify factors associated with back pain causing severe interference with daily activities over 2 years. Participants were 2,109 community-dwelling adults (aged 65-100 years; mean age 74.2 (SD 6.3)) enrolled in a prospective cohort study who reported back pain at baseline and provided back pain data at 2 years follow-up. Baseline data included demographics, socio-economic factors, back pain presentation and age-associated adverse health states (e.g. frailty, falls, walking confidence). At 2 years follow-up, we asked if they were currently experiencing back pain and if so, asked participants to rate how much their back pain interfered with their daily activities on a scale of 0-10. Severe back pain interference was defined by a rating of 7 or more. The association between baseline factors and severe back pain interference at two years was assessed using logistic regression models. At two years, 77% of participants (1,611/2,109) still reported back pain, 25% (544/2,083) also reported leg pain and 14% (227/1,611) reported severe back pain interference with activities. Improvements in symptoms were observed over the two years follow-up in 880/2,109 participants (41.7%), 41.2% (869/2,109) of participants report no change and worsening symptoms was reported by 17.1% (360/2109) of participants. After adjusting for back pain troublesomeness at baseline, factors associated with reporting severe interference were adequacy of income (careful with money [OR 1.91; 95% CI 1.19-3.06]; prefer not to say [OR 2.22; 95% CI 1.11-4.43]), low endorsement of exercise in later life (OR 1.18; 95% CI 1.02-1.37), neurogenic claudication symptoms (OR 1.68 (95% CI 1.15-2.46)], multisite pain (OR 1.13; 95% CI 1.02-1.24) and low walking confidence (OR 1.15; 95% CI 1.08-1.22). After adjusting for baseline pain severity, we identified five factors that were associated with severe pain limitation at two years follow-up among a cohort of community dwelling older people reporting back and leg pain. These included other pain characteristics, walking confidence and attitude to activity in later life. We also identified a socioeconomic factor (perceived adequacy of income). Future research should focus on whether identifying individuals using these risk factors in order to intervene improves back pain outcomes for older people.

Associations between menstrual pain and sexual function: the role of visceral hypersensitivity on developing sexual pain.

Dyspareunia, defined as pain before, during or after intercourse, is a subset of female sexual dysfunction with overlapping gynecologic, urologic and psychosocial etiologies. This study aimed to evaluate the impact of menstrual pain and visceral hypersensitivity on sexual function and to identify risk factors for sexual pain in healthy reproductive-age females. In this prospective cohort study, we evaluated gynecologic and psychologic self-reported histories, validated sexual function questionnaires, and conducted a standardized gynecologic examination enhanced by quantitative sensory testing in reproductive-aged females with menstrual pain versus pain-free controls. Correlation analysis was conducted between the Female Sexual Function Index (FSFI) pain subdomain score and a priori hypothesized risk factors for dyspareunia: menstrual pain severity, experimentally provoked bladder sensitivity, anxiety, depression, pain catastrophizing, and vaginal pressure-pain sensitivity. The primary outcome was severity of sexual pain as measured by the FSFI, comparing participants with moderate-to-severe dysmenorrhea (n = 99), dysmenorrhea with bladder hypersensitivity (n = 49) identified on non-invasive oral water challenge, and pain-free controls (n = 37). In our young (median age 22 [IQR 19, 29]), nulliparous, predominantly heterosexual cohort (78.3%, 144/185), 64.3% (119/185) engaged in sexual intercourse within the four-week recall period. The median total FSFI score was 27.2 (22.0, 30.2). Across groups, only the dysmenorrhea with bladder hypersensitivity phenotype met the threshold for sexual dysfunction as measured by total FSFI score (24.6 [20.0, 28.1], p= 0.008). Dysfunction was driven by difficulties with lubrication and higher pain levels during and after intercourse. On physical examination, those with and without dyspareunia were largely indistinguishable, with little to no tenderness of the pelvic floor, bladder, uterus and uterosacral ligaments. Amongst the six hypothesized risk factors for sexual pain, only experimentally provoked bladder pain was significantly associated with the severity of dyspareunia (r = 0.41, corrected p< 0.001). Young, otherwise healthy individuals with dysmenorrhea and occult visceral hypersensitivity exhibit signs of sexual dysfunction and significantly higher rates of dyspareunia in the absence of reliable clinical examination findings. Strengths include the use of a nonclinical sample of almost exclusively nulliparous females with no co-morbid pelvic pain diagnoses and prospective diary confirmation of dysmenorrhea severity. The study is limited by the narrow heteronormative, cisnormative sexual experience of penile-vaginal intercourse captured by the FSFI. Sexual pain is more prevalent in those with dysmenorrhea with bladder hypersensitivity than isolated dysmenorrhea, suggesting visceral hypersensitivity may be a non-structural mechanistic driver for dyspareunia.

Djenkolism: Acute Kidney Injury Unresponsive to Conservative Therapy - A Case Report

Djenkol beans (Archidendron jiringa), a popular food in Southeast Asia, can cause djenkolism—a condition leading to acute kidney injury due to the presence of djenkol acid. This case report details a 26-year-old male who presented with three days of anuria following the consumption of half a kilogram of djenkol beans. Upon admission, he exhibited severe abdominal pain, costovertebral tenderness, and elevated renal markers, leading to a diagnosis of obstructive uropathy caused by djenkolic acid crystals. Initial conservative treatment was ineffective, prompting the need for emergency ureteroscopy and placement of bilateral JJ stents to relieve the obstruction. Post-procedure, the patient experienced significant improvement, with a marked increase in urine output; post-obstructive diuresis in the first 24 hours, and resolution of abdominal pain, alongside improved renal function. This case underscores the importance of recognizing djenkolism as a potential cause of acute kidney injury, and advocating for timely diagnosis and intervention to mitigate kidney damage. Public awareness regarding the risks associated with djenkol consumption is also essential. Keywords: Djenkolism, Obstructive Uropathy, Post-Obstructive Diuresis, Acute Kidney Injury

Protein-losing enteropathy as the first presentation of systemic lupus erythematosus as the first case reported in Palestine, case report with systematic review

Introduction: Systemic lupus erythematosus is a chronic inflammatory disease affecting women, causing gastrointestinal issues like acute pancreatitis, esophagitis, and protein-losing enteropathy. Protein loss is uncommon, but a case study shows protein losing enteropathy as a first sign. Importance: Protein-losing enteropathy (PLE) is a rare gastrointestinal manifestation of SLE, often seen years before diagnosis. Suspecting hypoalbuminemia without protein loss is crucial, but diagnosis is challenging due to imaging and histological findings. Case presentation: A 22-year-old woman with epigastric pain experienced sudden abdominal pain, vomiting, and arthralgia. An abdominal CT scan revealed moderate bilateral hydronephrosis, pelvic free fluid, a kidney stone, and a cyst. Laboratory tests showed normal hemoglobin levels, platelets, white blood cells, C-reactive protein, and ESR. Diagnosis of SLE was confirmed, and pulse steroid therapy and hydroxychloroquine were initiated. Severe ascites required pigtail insertion, and Ceftazidime was added. The patient’s condition improved, and she was discharged with regular follow-ups. Clinical discussion: A 22-year-old female was diagnosed with protein-losing enteropathy, a rare gastrointestinal manifestation of Systemic Lupus erythematosus (SLE). The disease is divided into mesenteric vasculitis, pseudo obstruction, and protein loss enteropathy. The patient also had severe enteritis, abdominal pain, nausea, and diarrhea. The study found that the main complaint was abdominal pain with dysphagia, mainly due to active SLE inflammation. The patient responded well to treatment, with a 62.5% rapid improvement in pulse steroids and a cure for underlying causes through DMARDS or immunosuppressant drugs. Conclusions: The case presents a rare SLE diagnosis with gastrointestinal involvement, pleural effusion, and progressive swelling. Despite correct diagnosis and aggressive treatment, clinical improvement occurred, requiring high clinical suspicion.

National Institute of Health and Care Excellence Clinical Criteria for the Diagnosis of Knee Osteoarthritis: A Prospective Diagnostic Accuracy Study in Individuals with Type 2 Diabetes.

The National Institute of Health and Care Excellence (NICE) criteria for osteoarthritis (OA) obviate the need for physical exam or imaging, and their use may improve timely diagnosis of OA. However, they have not been validated. Within a larger study of individuals with type 2 diabetes, participants with and without self-reported knee pain underwent assessment of the NICE criteria for knee OA by questionnaire (index test), and clinical evaluation for established or possible knee OA by a rheumatologist (reference standard). We calculated the sensitivity, specificity, likelihood ratio positive (LR+) and likelihood ratio negative (LR-) of the NICE criteria and modified NICE criteria without the stiffness criterion. Our study included 96 participants: mean age 65.4 (SD 8.3) years and 52% were women. Individuals who fulfilled NICE criteria for knee OA (55.2%) included a spectrum of pain severity on a 11-point pain numeric rating scale with a median score of 5 (range: 1-9). Rheumatologist assessment identified 56 (58.3%) participants with symptomatic knee OA. The sensitivity, specificity, LR+, and LR- of NICE criteria for symptomatic knee OA were 0.84 (95% CI 0.74, 0.94), 0.85 (95% CI 0.74, 0.96), 5.6 and 0.19, respectively. For modified NICE criteria, these were 0.89 (95% CI 0.82, 0.97), 0.85 (95% CI 0.74, 0.96), 5.93 and 0.13. The NICE criteria have high sensitivity and specificity for detecting symptomatic knee OA in a population with type 2 diabetes. We found that a modified version, omitting the stiffness criterion, performed similarly. These criteria should be validated in other settings and populations.

Innovative Complementary Cooling Intervention for Women's Multiple Sclerosis Symptoms: A Mixed-Methods Study.

Purpose: This mixed-methods study examined the relationship between multiple sclerosis symptoms to perceived severity, frequency of Uhthoff's phenomenon, the effectiveness of complementary cooling therapy on women's symptom clusters, and quality of life. This study explored the experiences of women with multiple sclerosis when using the Opal Cool Wrap related to heat intolerance, a complementary alternative therapy. Methods: Quantitative analysis of results from surveys from 62 women and seven qualitative semi-structured interviews with a subset of women who completed the surveys validated and illustrated the quantitative findings. Findings: Significant improvement in perceived severity for health transition, physical functioning, role-physical, bodily pain, and social functioning based on pre-/post-cooling therapy use. Three themes emerged from seven interviews: (1) being overheated impacts the quality of life; (2) cool wrap, a helpful tool for managing heat symptoms; and (3) strategies to remain cool. Conclusion: This study provides a comprehensive mixed-methods lens on the unique challenges women with multiple sclerosis face and information for disease management. Heat-related multiple sclerosis symptom clusters and Uhthoff's phenomenon women experience are common and impact safety, independence, health, and quality of life. Identifying complementary strategies such as cool showers and a cooling device to prevent and manage heat-related symptoms is a priority.

Clinical Effectiveness of Viddha Karma in PCOS: A Case Report

ABSTRACT Polycystic ovary syndrome (PCOS) is a common hormonal disorder affecting women of reproductive age. Ayurveda, an ancient Indian medical system, offers a comprehensive approach to addressing PCOS, including treatments like Viddha Karma. In the case of PCOS, Viddha Karma aims to relieve symptoms and enhance overall well-being. A 27 -year-old unmarried female patient came with complaints of irregular and scanty menses for the past 3-4 years, along with severe abdominal pain during the first 1-3 days of menstruation. She was treated with Shaman Chikitsa and Viddha Karma for 8 months. The patient’s menstrual cycle become regular, the volume of bleeding increased to a normal level, and she experienced a weight reduction of 5 kg. The examination of Viddha Karma principles in the management of PCOS emphasizes its potential as a supplementary treatment that tackles the underlying causes and promotes overall well-being. However, further research and clinical trials are necessary to gain a comprehensive understanding of its effectiveness.

EGS SO04 - Gastrodoudenal Artery Pseudoaneurysm Secondary to blunt abdominal trauma: A rare case report

Abstract Background Visceral artery pseudoaneurysms (VAPAs) are rare, potentially life-threatning aneurysms found in the celiac, superior, or inferior mesenteric arteries. They are most common in the splenic artery (60-70%), followed by hepatic arteries (20%) and celiac or mesenteric arteries (10%). Usually asymptomatic, VAPAs are often discovered incidentally during abdominal imaging. They pose a high risk of rupture and haemorrhage. Risk factors include iatrogenic injury and abdominal trauma. Traumatic VAPAs are extremely rare with unclear management guidelines. Treatment options vary from observation to endovascular therapy or surgical repair. This report presents a case of a gastoduodenal artery psuedoaneurysm due to blunt abdominal trauma. Method A case report: a 68-year-old male with a high BMI and atrial fibrillation managed with edoxaban, presented with severe upper abdominal pain following a fall. Initial examination and laboratory results suggested acute pancreatitis or cholecystitis, but a CT angiography revealed a GDA pseudoaneurysm with active extravasation. The patient was referred for urgent therapeutic embolization; however, the pseudoaneurysm had spontaneously thrombosed, precluding the need for embolization. The patient was managed conservatively, with close monitoring in the high dependency unit (HDU), analgesics, proton pump inhibitors, and mechanical venous thromboembolism prophylaxis. He remained hemodynamically stable and was discharged with instructions for follow-up care. Results GDA pseudoaneurysms are rare, accounting for 0.01-1% of all visceral artery aneurysms, with trauma being an exceptionally infrequent cause. The management of VAPAs, particularly in hemodynamically stable patients, can range from conservative observation to endovascular interventions. This case underscores the importance of a multidisciplinary approach involving surgery, interventional radiology, and vascular teams for optimal management. Conclusion Gastroduodenal artery pseudoaneurysms secondary to blunt abdominal trauma can be effectively managed conservatively in stable patients. Comprehensive history-taking, appropriate imaging, and multidisciplinary discussions are crucial for successful outcomes. Continued monitoring is essential to ensure patient safety and address potential complications.

HPB SO14 - Surprise Inside: Gallbladder Herniation in a Parastomal Hernia - A Rare Case Report and Management Insight

Abstract Background Parastomal hernias are a common complication of stoma formation, affecting approximately 40% of patients within two years. Gallbladder herniation within a parastomal hernia is a rare phenomenon, with only 18 cases previously reported. Patients are typically elderly females, with the condition attributed to ageing factors such as loss of visceral fat and elastic tissue, liver shrinkage, and the increased length and loss of elasticity of the gallbladder mesentery. These factors contribute to visceroptosis of the gallbladder, increasing its mobility and the risk of herniation. Method We present the case of a 68-year-old female with a four-day history of severe parastomal hernia pain and swelling. She had an emergency left hemicolectomy and transverse colostomy in the right upper quadrant 10 years prior for ischaemic colitis and perforation. Her stoma was functioning well. Vital signs and biochemistry results were normal. On examination her hernia was severely tender but partially reducible. CT revealed a right upper abdominal parastomal hernia containing loops of colon and surprisingly the gallbladder with a long stretched cystic duct. There was no evidence of cholecystitis, bowel obstruction, or compromise within the hernial sac. Results With analgesia, the patient's pain improved, though her hernia remained irreducible. She was discharged after two days of conservative management and referred back to the hospital where she had the initial operation. On enquiry with that hospital it was reported that an elective parastomal hernia repair with completion right colectomy and end ileostomy was performed. The gallbladder was mobilised and reduced back into the peritoneal cavity, and the hernial defect was closed. The patient made an excellent recovery and was discharged home three days after surgery. Conclusion Cholecystic parastomal herniation is a very rare phenomenon and should be considered as a differential in similar cases. Management should be based on clinical presentation, radiological diagnosis, and a multidisciplinary team approach. No standardised classification or approach exists. We propose classifying gallbladder herniations as either being simple (without inflammatory sequelae) or complicated (with cholecystitis, gallbladder torsion, incarceration or perforation). Simple herniations, such as the case presented, can be managed electively with intra-operative reduction of the gallbladder sufficing. Complicated herniations during acute admissions indicate the need for emergency surgical intervention with combined cholecystectomy and parastomal hernia repair.

An ayurvedic approach to the management of Fissure-in-ano: A case Study

Background: In today's sedentary lifestyle, coupled with unhealthy dietary habits and stress, digestive disorders such as Fissure-in-ano have become prevalent. Fissure-in-ano is a longitudinal tear in the anal canal, most commonly occurring in the posterior midline, characterized by severe pain, burning sensation, and occasional bleeding. In Ayurveda, this condition aligns with Parikartika, often caused by improper administration of therapies like Basti (enema) or Virechana (purgative). Case Study: It explores the efficacy of per rectal Administration of Kaseesadi Taila for the management of Parikartika in a 35-year-old female patient presenting with anal pain, burning, and rectal bleeding post-defecation. Materials &amp; Methods: It involved daily rectal Administration of Kaseesadi Taila (10ml) for 7 days. Results: It showed significant improvement by day 3, with complete relief of symptoms and healing of the fissure by day 7. The therapeutic benefits of Kaseesadi Taila are attributed to its Lekhana (scraping), Shodhana (cleansing), and Ropana (healing) properties, which promote wound healing, reduce inflammation, and facilitate easier bowel movements. Conclusion: Kaseesadi Taila is an effective, cost-efficient treatment for fissure-in-ano, providing significant symptom relief without the drawbacks of conventional surgical interventions.

Clinical effect of indirect moxibustion with Taiyi moxa stick in treatment of back myofascitis: a randomized controlled trial

To observe the impact of indirect moxibustion with Taiyi moxa stick on pain severity and the quality of life in the patients with back myofascitis, and evaluate its clinical effect and safety. Seventy-two patients with back myofascitis were randomly divided into an observation group (36 cases, 1 cases dropped out) and a control group (36 cases, 3 cases dropped out). Three to six ashi points were selected using acupoint diagnosis methods. In the observation group, the indirect moxibustion with Taiyi moxa stick was operated at the ashi points, once every other day, three times a week. In the control group, the topical treatment with diclofenac sodium gel was given at ashi points, three times daily. The treatment was delivered consecutively for 2 weeks in the two groups. The scores of visual analogue scale (VAS) and the short-form McGill pain questionnaire (SF-MPQ) were recorded before treatment, after 1 and 2 weeks of treatment, and after 4 weeks of treatment completion (follow-up visit) in the two groups separately. The difference value between VAS score after 2 weeks of treatment and that before treatment was taken as the primary outcome. The SF-36 score was observed before treatment, after 2 weeks of treatment and during the follow-up visit, and the safety was evaluated in the two groups. The difference value of VAS scores was (-4.57±1.50) points and (-2.40±1.31) points in the observation group and the control group, respectively, the reduction of the score in the observation treatment was larger than that of the control group (P<0.001). After 1 and 2 weeks of treatment and during the follow-up visit, VAS and SF-MPQ scores were reduced when compared with those before treatment (P<0.05) in the two groups, and VAS and SF-MPQ scores in the observation group were lower than those in the control group (P<0.05). In the follow-up visit, VAS and SF-MPQ scores in the observation group were dropped in comparison with those after 1 week of treatment (P<0.05), and these scores in the control group were elevated compared with those after 2 weeks of treatment (P < 0.05). After 2 weeks of treatment and during the follow-up visit, the score of each dimension and total score of SF-36 scale were increased in comparison with those before treatment in the observation group (P<0.05); and the scores of the dimensions except that of mental health of SF-36 scale were elevated in the control group (P<0.05). During the follow-up visit, in the control group, the scores of physical functioning, bodily pain, general health and role emotional were elevated when compared with those before treatment (P<0.05). After 2 weeks of treatment and during the follow-up visit, the score of every dimension and total score of SF-36 scale in the observation group were higher than those in the control group (P<0.05). During the follow-up visit, the score of bodily pain was increased when compared with that after 2 weeks of treatment in the observation group (P<0.05), while the scores of bodily pain and vitality were dropped in the control group (P<0.05). No adverse event happened in the two groups. The indirect moxibustion with Taiyi moxa stick effectively reduces pain severity and improves the quality of life in the patients with back myofascitis. This therapy presents the superior and persistent effect compared with topical application of diclofenac sodium gel.

Mental and physical health characteristics of older and younger adults receiving medication for opioid use disorder

BackgroundMethadone is an effective and widely used medication for opioid use disorder (MOUD). Within in the United States (US), older adults represent an increasing proportion of those receiving MOUD, yet little is known about characteristics of older individuals in these programs.ObjectivesTo evaluate mental and physical health characteristics of younger and older adults receiving MOUD and test whether age moderates the relation between physical and mental health variables.MethodsData for this secondary analysis are drawn from a cross-sectional survey of a convenience sample of individuals seeking methadone dosing as part of MOUD at four opioid treatment programs in two regions of the US. Descriptive statistics and correlational and moderation analyses examined outcomes of pain severity, pain interference, self-rated health, physical activity, depression, and anxiety across younger (18-49) and older (50+ years) participants.ResultsAnalyses included 469 participants (mean [range] age, 41.01 [20–70] years). Older participants reported higher pain severity and interference, less physical activity, and worse self-rated health than those in the younger age group (ps &amp;lt; 0.05). Associations between mental and physical health variables were generally weak-to-moderate in the older age group (r = 0.26 to r = 0.44, p &amp;lt; 0.01), and weak in the younger age group, although age did not moderate associations.ConclusionClinically significant mental and physical health variables are associated among individuals receiving methadone for MOUD, with older adults facing unique challenges.Clinical implicationsOpioid use treatment should include not only pain management but also assessment and treatment of depression and anxiety and optimization of other health behaviors (e.g., physical activity) across age groups. Pain management and health promotion are particularly relevant targets for aging individuals receiving MOUD.

Abstract 4145822: The Enigma of Chest Pain: Rare Presentation of ALCAPA Syndrome in a Young Adult

Introduction: Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare congenital anomaly(incidence:1 in 300,000 live births) typically presenting during infancy. Adult presentations are even rarer due to a high mortality rate of nearly 90% in the first year of life without surgical intervention. This report examines an adult patient with exercise-induced chest pain who received a delayed diagnosis of ALCAPA via multimodal imaging. Case Summary: A 21-year-old male presented to the emergency department(ED) with severe retrosternal chest pain radiating to both shoulders and arms, which began during exercise 30 minutes prior. He had a history of similar, milder episodes during exercise, previously treated as musculoskeletal pain and gastroesophageal reflux disease in the ED. His medical, social, and family histories were unremarkable. Physical examination revealed a soft, continuous murmur along the left sternal border. During this visit, An EKG done showed sinus tachycardia at 110 bpm and deep T-wave inversions in the anterolateral leads, a dynamic ST-T changes from his baseline.Serial Cardiac biomarkers and a lipid profile were within normal ranges. Initially managed for acute coronary syndrome-unstable angina with antithrombotic therapy, beta-blockers, and nitrates, he underwent urgent coronary angiography. This revealed a dilated right coronary artery (RCA) with retrograde flow to the left coronary artery (LCA) into the main pulmonary artery (PA) via collaterals, with no evidence of atherosclerosis (Figure 1).Echocardiography (Figure 2) and coronary CT angiography (Figure 3) confirmed the diagnosis of ALCAPA. The patient underwent successful surgical repair with aortic reimplantation of the LCA and was discharged in good health. Discussion: In adult ALCAPA patients, good collateral circulation may develop; however, myocardial ischemia can occur due to the "coronary steal phenomenon" and poor collateral flow regulation, leading to angina, arrhythmias, and sudden cardiac death. ALCAPA should be considered a differential diagnosis in adults presenting with exercise intolerance, as most sudden cardiac death cases occur by the fourth decade. A high index of clinical suspicion and a multimodality imaging approach is essential for the early diagnosis of this rare coronary anomaly, underscoring the critical role of early surgical intervention in preventing catastrophic, life-threatening events.

Abstract 4119169: Navigating Complexity: The Carlino Technique in Multivessel Percutaneous Coronary Intervention for Chronic Total Occlusion

Introduction: Since the advent of percutaneous coronary intervention (PCI), the scope of this therapeutic intervention has broadened to include cases of life-threatening multivessel coronary artery disease that previously may have only been corrected surgically. PCI has become a common treatment of chronic total occlusion, and techniques continue to be developed to tackle more challenging cases. We present a complex case of NSTEMI with multi-vessel coronary artery disease treated with PCI via the Carlino technique. Case Description: A 60-year-old female with a history of hypertension, diabetes mellitus, and ischemic heart disease presented with severe chest pain that radiated to the neck and was associated with nausea and vomiting. Her EKG showed marked left-axis deviation, ST depressions in V2-V4, and RBBB. She was diagnosed with NSTEMI with a thrombolysis in myocardial infarction (TIMI) score of 5. She was loaded with aspirin and clopidogrel and was taken for left heart catheterization (LHC), which demonstrated three-vessel coronary artery disease with chronic 100% occlusion of the proximal left anterior descending artery, ostial 60-70% stenosis, and proximal 90-95% diseased left circumflex artery, while her right coronary artery had proximal 20-30% obstruction and mid 50-60% with right to left filling. The patient was advised CABG by the heart team, but the patient refused, and PCI was attempted on a shared decision basis. PCI was successful with the use of the Carlino technique: 0.5 ml of contrast dye was injected through a microcatheter to hydraulically recanalise the occlusion. The patient showed dramatic improvement and was discharged home on oral medications. Discussion: Treating multi-vessel coronary artery disease and CTO is challenging. PCI, particularly with the Carlino technique, offers a reliable approach. This technique, a modification of contrast-guided STAR, involves gentle contrast injection via microcatheter to modify plaque compliance and provide topographic information with regards to equipment location within vasculature, enhancing procedural success, especially in cases with impenetrable caps or calcified areas. Conclusion: This case is an example of how adaptive PCI techniques, such as the Carlino technique, can be employed to tackle complex instances of MvCAD that previously may have only been surgically corrected.

Abstract 4123480: Navigating Aspirin Allergy With Rapid Desensitization In A Patient Requiring Urgent Coronary Intervention

Introduction: Aspirin (ASA) hypersensitivity is a challenge in determining the appropriate, cost-effective therapy in patients after percutaneous coronary intervention (PCI). Various ASA desensitization protocols were studied and showed favorable outcomes. In this case, we highlight the use of rapid ASA desensitization protocols for patients requiring dual antiplatelet therapy (DAPT) post urgent PCI. Case: A 52-year-old male presented with severe left-sided chest pain associated with diaphoresis. He had a history of allergic reaction to ASA at the age of 18 years with swelling of the face and throat without shortness of breath or hypotension. Physical examination was unremarkable except for tachycardia. Workup showed no ECG abnormalities but significantly elevated, uptrending high sensitivity troponin. Medical management included clopidogrel load, heparin drip, and nitropaste for persistent pain. Urgent coronary angiography showed a severe bifurcating lesion in the LCx and OM1 arteries, successfully treated with the T stent technique using a drug-eluting stent. He received cilostazol and prasugrel, overlapped with a tirofiban drip post PCI. ASA desensitization was performed with oral ASA every 90 minutes for four doses (Figure). Vital signs were monitored every 30, 60, and 90 minutes after each dose. He was discharged home with no reported symptoms on follow up. Discussion: DAPT with ASA and oral P2Y12 inhibitors is recommended for patients with PCI. ASA desensitization could be considered for patients who are intolerant to ASA. Major clinical ASA desensitization protocols, like in ADAPTED and SCRIPPS studies, showed good outcomes in major adverse cardiovascular events. However, one limitation of these widely used protocols is the prolonged time required to achieve desensitization. The rapid protocol used in our patient who did not have ASA exacerbated respiratory disease showed effectiveness with shorter hospital stay. Conclusion: ASA desensitization is an appropriate option for patients with a history of ASA allergy requiring DAPT. Rapid desensitization protocols are associated with shorter hospitalization courses, and future efforts should evaluate their effectiveness in randomized controlled trials.

A Randomized Controlled Trial on the Effect of Zucchini Seed Oil on Nipple Pain Among Lactating Women

Objective:Nipple pain is one of the most common reasons for early termination of breastfeeding; thus, effective treatment of this condition is very important. Previous studies have proposed the anti-inflammatory and analgesic properties of theCucurbita pepoplant. The present study was conducted to determine the effects ofC. peposeed oil on the severity of nipple pain in lactating women.Methods:In this randomized clinical trial study, 60 lactating women with nipple pain were randomly assigned to either the intervention group (zucchini seed oil) or the control group (breast milk). In the intervention group, 0.5 mL of zucchini seed oil was applied to the nipples and areola three times a day after each breastfeeding session to ensure the absence of an allergy to zucchini compounds. In the control group, three to four drops of breast milk were applied to the nipples and areola after each breastfeeding session. Pain score was recorded using a visual analog scale before the intervention and on the third and eighth day after the intervention. Data analysis was done using the Statistical Software for Social Sciences software (version 24). Apvalue of less than .05 was considered statistically significant.Results:Before the intervention, there was no significant difference between the intervention and control groups with regard to mean pain severity (p= .330). On the third day, the mean pain intensity in the intervention group significantly decreased compared with the control group (p= .023). On the eighth day, the mean pain severity was significantly lower in the intervention group compared with the control group (p= .016).Conclusions:The findings of this study indicate that zucchini seed oil extract was effective in reducing the severity of nipple pain in lactating women. Therefore, use of this oil extract is suggested for treatment of nipple pain in lactating women.

Persistent postsurgical pain in hip fracture patients. A prospective longitudinal study with multifaceted assessment.

Some patients with postoperative hip fractures (HF) experience persistent severe pain. In this longitudinal study, we examined the characteristics of patients with persistent pain after HF surgery, and the factors influencing pain intensity. We conducted an 8-week prospective study in patients with postsurgical HF. Verbal rating scale (VRS), and multifaceted outcomes, including pressure pain threshold (PPT) (affected site and biceps), were evaluated at 2, 4, and 8 weeks postoperatively. Patients were divided into mild (VRS ≤1) and severe (VRS ≥2) groups according to pain intensity at 8 weeks postoperatively. Statistical analyses were performed using two-way ANOVA and decision-tree analysis. VRS, PPT at the affected site and biceps, and physical activity (PA) time were significantly lower in the severe group than in the mild group 2 weeks postoperatively. VRS, PPT at the affected site, pain catastrophizing (PCS)-13, and the Tampa Scale for Kineshiophobia (TSK)-11 did not show significant improvements in the severe group. Decision tree analysis revealed that the VRS and PCS-13 at 4 weeks, PA time at 2 weeks, and TSK-11 change between 4 weeks and 2 weeks were factors influencing severe pain intensity at 8 weeks after HF surgery. Persistent severe pain after HF surgery was characterised by high peripheral and central sensitisation, pain catastrophizing, and reduced PA at 2 weeks after HF surgery. In addition, early pain intensity, pain catastrophizing, and PA may be hierarchically influential factors for persistent pain 8 weeks after HF surgery.