Direct analysis in real time mass spectrometry (DART-MS/MS) for rapid urine opioid detection in a clinical setting.

BACKGROUND AND AIMS: Current laboratory methods for opioid detection involve an initial screening with immunoassays which offers efficient but non-specific results and a subsequent liquid chromatography-tandem mass spectrometry (LC-MS/MS) confirmation which offers accurate results but requires extensive sample preparation and turnaround time. Direct Analysis in Real Time (DART) tandem mass spectrometry is evaluated as an alternative approach for accurate opioid detection with efficient sample preparation and turnaround time. MATERIALS AND METHODS: DART-MS/MS was optimized by testing the method with varying temperatures, operation modes, extraction methods, hydrolysis times, and vortex times. The method was evaluated for 12 opioids by testing the analytical measurement range, percent carryover, precision studies, stability, and method-to-method comparison with LC-MS/MS. RESULTS: DART-MS/MS shows high sensitivity and specificity for the detection of 6-acetylmorphine, codeine, hydromorphone, oxymorphone, hydrocodone, naloxone, buprenorphine, norfentanyl, and fentanyl in urine samples. However, its performance was suboptimal for norbuprenorphine, morphine and oxycodone. CONCLUSION: In this proof-of-concept study, DART-MS/MS is evaluated for its rapid quantitative definitive testing of opioids drugs in urine. Further research is needed to expand its application to other areas of drug testing.

Rare presentations of small bowel endometriosis.

Despite endometriosis being a relatively common chronic gynecological condition in women of childbearing age, small bowel endometriosis is rare. Presentations can vary from completely asymptomatic to reported symptoms of abdominal pain, bloating, and diarrhea. The following two cases depict very atypical manifestations of ileal endometriosis that presented as obscure intermittent gastrointestinal bleeding and bowel obstruction requiring surgical intervention. The first case describes a previously healthy 40-year-old woman with severe symptomatic iron deficiency anemia and intermittent melena. A small bowel enteroscopy diagnosed multiple ulcerated strictures in the distal small bowel as the likely culprit. Despite nonsteroidal anti-inflammatory drug-induced enteropathy being initially considered as the likely etiology, histopathological examination of the resected distal ileal segment revealed evidence of endometriosis. The second case describes a 66-year-old with a presumptive diagnosis of Crohn's disease who reported a 10-year history of intermittent perimenstrual abdominal pain, diarrhea, and nausea with vomiting. Following two subsequent episodes of acute bowel obstruction and surgical resection of the patient's stricturing terminal ileal disease, histopathological examination demonstrated active chronic inflammation with endometriosis. Small bowel endometriosis should be considered as an unusual differential diagnosis in women who may present with obscure gastrointestinal bleeding from the small bowel or recurrent bowel obstruction.

Relato de caso de lombalgia inflamatória com extenso comprometimento anatômico-funcional: a importância de uma adequada abordagem da dor lombar na Atenção Primária à Saúde / Case report of inflammatory low back pain with extensive anatomical-functional impairment: The importance of an adequate approach to low back pain in Primary Care / Presentación de un caso de lumbalgia inflamatoria con afectación anatómico-funcional extensa: La importancia de un abordaje adecuado de la lumbalgia en Atención Primaria de Salud

Introdução: A lombalgia é uma condição prevalente e que apresenta importante impacto na capacidade funcional e na qualidade de vida, sendo a sua correta abordagem na Atenção Primária à Saúde fundamental para a identificação e o estabelecimento de um diagnóstico etiológico precoce de possíveis patologias que possam estar relacionadas a desfechos mórbidos e a graves limitações funcionais. Apresentação do caso: Paciente de 56 anos, sexo masculino, hipertenso, foi encaminhado para serviço especializado de reumatologia com histórico de lombalgia havia mais de 20 anos. Ao exame físico foi constatada presença de deformidades da coluna vertebral e extensa limitação de movimentos. Exames radiográficos mostravam esclerose de articulações sacroilíacas, osteopenia difusa e coluna vertebral em aspecto de "bambu". Conclusões: Constata-se a importância de que na abordagem das lombalgias na atenção primária se busque o reconhecimento de possíveis etiologias graves e potencialmente incapacitantes que possam estar subjacentes à queixa de dor lombar. Com esse objetivo, é fundamental o reconhecimento das chamadas red flags relacionadas às lombalgias, além de sua caracterização como mecânica ou inflamatória. Perante a atuação da atenção primária no oferecimento de um cuidado pautado na integralidade e na prevenção de agravos, reafirma-se a importância de uma avaliação clínica pormenorizada das lombalgias nesse nível de atenção à saúde.

Introduction: Low back pain is a prevalent condition that has an important impact on functional capacity and quality of life, and its correct approach in Primary Care is fundamental to the identification and establishment of an early etiological diagnosis of possible pathologies that may be related to outcomes morbid conditions and serious functional limitations. Case presentation: 56-year-old male patient, hypertensive, referred to a specialized rheumatology service with a history of low back pain for over 20 years. Physical examination revealed the presence of spinal deformities and extensive movement limitations. Radiographic examinations showing sclerosis of the sacro-iliac joints, diffuse osteopenia and a "bamboo" appearance of the spine. Conclusions: It is important that in the approach of low back pain in Primary Care, we seek to recognize possible serious and potentially disabling etiologies that may underlie the complaint of low back pain. For that, it is essential to recognize the so-called "red flags" related to low back pain, in addition to its characterization as mechanical or inflammatory. Given the role of Primary Care in offering care based on integrality and in the prevention of injuries, the importance of a detailed clinical assessment of low back pain at this level of health care is reaffirmed.

Introducción: La lumbalgia es una patología prevalente que tiene un impacto importante en la capacidad funcional y la calidad de vida, y su correcto abordaje en Atención Primaria de Salud es fundamental para la identificación y establecimiento de un diagnóstico etiológico precoz de posibles patologías que puedan estar relacionadas con los resultados, condiciones morbosas y limitaciones funcionales graves. Presentación del caso: Paciente masculino de 56 años, hipertenso, remitido a servicio especializado de reumatología con antecedentes de dolor lumbar de más de 20 años. El examen físico reveló la presencia de deformidades de la columna y amplias limitaciones de movimiento. Los exámenes radiológicos muestran esclerosis de las articulaciones sacroilíacas, osteopenia difusa y una apariencia de "bambú" de la columna. Conclusiones: Es importante que al abordar la lumbalgia en Atención Primaria de Salud busquemos reconocer las posibles etiologías graves y potencialmente incapacitantes que pueden subyacer a la queja de lumbalgia. Con este objetivo, es fundamental reconocer las llamadas "banderas rojas" relacionadas con la lumbalgia, además de su caracterización como mecánica o inflamatoria. Dado el papel de Atención Primaria de Salud a la hora de ofrecer una atención basada en la integralidad y prevención de enfermedades, se reafirma la importancia de una evaluación clínica detallada de la lumbalgia en este nivel de atención sanitaria.

MFG-E8 Ameliorates Nerve Injury-Induced Neuropathic Pain by Regulating Microglial Polarization and Neuroinflammation via Integrin ß3/SOCS3/STAT3 Pathway in Mice.

Spinal microglial polarization plays a crucial role in the pathological processes of neuropathic pain following peripheral nerve injury. Accumulating evidence suggests that milk fat globule epidermal growth factor-8 (MFG-E8) exhibits anti-inflammatory effect and regulates microglial polarization through the integrin ß3 receptor. However, the impact of MFG-E8 on microglial polarization in the context of neuropathic pain has not yet been investigated. In this study, we evaluated the effect of MFG-E8 on pain hypersensitivity and spinal microglial polarization following spared nerve injury (SNI) of the sciatic nerve in mice. We determined the molecular mechanisms underlying the effects of MFG-E8 on pain hypersensitivity and spinal microglial polarization using pain behavior assessment, western blot (WB) analysis, immunofluorescence (IF) staining, quantitative polymerase chain reaction (qPCR), enzyme-linked immunosorbent assay (ELISA), and small interfering RNA (siRNA) transfection. Our findings indicate that SNI significantly increased the levels of MFG-E8 and integrin ß3 expressed in microglia within the spinal cord of mice. Additionally, we observed that intrathecal injection of recombinant human MFG-E8 (rhMFG-E8) alleviated SNI induced-mechanical allodynia and thermal hyperalgesia. Furthermore, the results suggested that rhMFG-E8 facilitated M2 microglial polarization and ameliorated neuroinflammation via integrin ß3/SOCS3/STAT3 pathway in the spinal cord of mice with SNI. Importantly, these effects were negated by integrin ß3 siRNA, or SOCS3 siRNA. These results demonstrate that MFG-E8 ameliorates peripheral nerve injury induced-mechanical allodynia and thermal hyperalgesia by driving M2 microglial polarization and mitigating neuroinflammation mediated by integrin ß3/SOCS3/STAT3 pathway in the spinal cord of mice. MFG-E8 may serve as a promising target for the treatment of neuropathic pain.

Potentiation of Imipramine-Induced Anti-hyperalgesic and Anti-Nociceptive Effects by Citicoline in the Sciatic Nerve Ligated Mice.

BACKGROUND: Peripheral neuropathic pain is a result of damage/illness of the peripheral nerves. The mechanisms caused by its pathophysiology are not completely understood. METHODS: Imipramine is a tricyclic antidepressant that is sometimes used to treat neuropathic pain. Moreover, citicoline is considered a novel adjuvant for painful disorders such as neuropathic pain. So, a possible interaction between imipramine and citicoline on pain behavior was examined in nerve-ligated mice using tail-flick and hot plate tests. RESULTS: The results indicated that induction of neuropathic pain by sciatic nerve ligation caused hyperalgesia in nerve-ligated mice. On the other hand, intraperitoneal (i.p.) administration of citicoline (50, 75, and 100 mg/kg), and imipramine (2.5 and 5 mg/kg) induced anti-hyperalgesic and anti-nociceptive effects in nerve-ligated mice. Furthermore, citicoline potentiated the anti-hyperalgesic and anti-nociceptive effects of imipramine when they were co-administrated in nerve-ligated mice. Interestingly, there was an additive effect between imipramine and citicoline upon induction of anti-hyperalgesic and anti-nociceptive effects in nerve-ligated mice. CONCLUSION: Therefore, it can be concluded that citicoline (as an adjuvant substance) enhanced the efficacy of imipramine for the modulation of pain behavior in nerve-ligated mice.

Validation of a computerized model for a new biomechanical concept- the fossa-foveolar mismatch- the answer to lesions of the ligamentous fossa-foveolar complex in the hip?

BACKGROUND: Hip-preserving surgery in young patients frequently reveals lesions of the ligamentum teres (LT). Histological and clinical evidence supports that those lesions could be source of intraarticular hip pain. It has been hypothesized that LT degeneration could be linked to the abnormal positioning of the fovea outside the lunate surface during various daily motions. We introduce the "fossa-foveolar mismatch" (FFM) by determining the trajectory of the fovea in the fossa during hip motions, enabling a comparison across diverse hip-pathomorphologies. AIMS: to determine (1) intraobserver reliability and (2) interobserver reproducibility of our computer-assisted 3-dimensional (3D) model of the FFM. MATERIALS AND METHODS: All patients with joint preserving surgery for femoroacetabular impingement syndrome (FAIS) or developmental dysplasia of the hip (DDH) at our institution (11. 2015-08.2019)were initially eligible. We employed a simple random sampling technique to select 15 patients for analysis. Three-dimensional surface models based on preoperative computed tomography (CT) scans were built, the fossa virtually excised, the fovea capitis marked. Models were subjected to physiological range of motion with validated 3D collision detection software. Using a standardized medial view on the resected fossa and the transparent lunate surface, the FFM-index was calculated for 17 motions. It was obtained by dividing the surface occupied by the fovea outside of the fossa by the total foveolar tracking surface. Three observers independently performed all analyses twice. (1) Intraobserver reliability and (2) interobserver reproducibility were calculated using intraclass correlation coefficients (ICCs). RESULTS: (1) We obtained excellent intraobserver ICCs for the FFM-index averaging 0.92 with 95% CI 0.77-0.9 among the three raters for all motions. (2) Interobserver reproducibility between raters was good to excellent, ranging from 0.76 to 0.98. CONCLUSIONS: The FFM-index showed excellent intraobserver reliability and interobserver reproducibility for all motions. This innovative approach deepens our understanding of biomechanical implications, providing valuable insights for identifying patient populations at risk.

Comparison of postoperative pain in robotic and laparoscopic myomectomy: a retrospective cohort study.

Gynecologic surgery with minimally invasive method using robotic or laparoscopic techniques has gained popularity for reducing perioperative discomfort and length of hospital stay. However, the debate over postoperative pain superiority between traditional laparoscopy and robotic surgery persist. This study compared the postoperative pain of patients within 24 h of robotic (RM) and laparoscopic myomectomy (LM). This retrospective cohort study included 24 and 53 patients who underwent RM and LM, respectively, between January 2019 and July 2023. The primary outcomes were the postoperative pain levels of patients within 24 h and the use and dosage of postoperative analgesia. Additional perioperative analgesia, including long-acting non-steroidal anti-inflammatory drugs (Dynastat) and abdominal nerve block, was also recorded. The secondary outcomes were blood loss and hospitalization duration. The patient characteristics were similar between the groups. Factors that could potentially increase pain, such as the number of ports (p < 0.0001), additional procedures (p = 0.0195), operative time (p < 0.0001), number of myomas (p = 0.0057), and the largest myoma size (p = 0.0086), were significantly higher in the RM group than in the LM group. However, there were no significantly different in the postoperative visual analog scale pain scores, use and dosage of ketorolac and opioid, and use of Dynastat and nerve block between the groups. Hospitalization duration and intraoperative blood loss were similar between the groups. RM and LM offer comparable postoperative pain outcomes, emphasizing the importance of patient-specific factors in decision-making regarding myomectomy techniques.

Effect of aerobic exercise program on neuropathic pain and quality of life in person with paraplegia: study protocol for a randomized controlled trial.

BACKGROUND: Individuals with spinal cord injury (SCI) often suffer from neuropathic pain which is often disabling and negatively affects function, participation, and quality of life (QoL). Pharmacological treatments lack efficacy in neuropathic pain reduction hence studying alternatives to drug treatment is necessary. Preclinical evidence of various aerobic exercises has shown positive effects on neuropathic pain but scientific studies investigating its effect in the SCI human population are limited. METHODOLOGY: This study is a double-blind, parallel, two-group, randomized controlled trial with an interventional study design that aims to evaluate the effectiveness of aerobic exercise program on neuropathic pain and quality of life (QoL) in individuals with chronic paraplegia. Thirty individuals with chronic paraplegia with the neurological level of injury from T2 to L2 will be recruited from the rehabilitation department at a super specialty hospital based on the inclusion criteria. Using a 1:1 allocation ratio, the participants will be randomly assigned to one of the two groups. The intervention group will perform high-intensity interval training (HIIT) aerobic exercise using an arm ergometer based on their peak heart rate, and the control group will perform free-hand arm aerobic exercise. In both groups, the intervention will be delivered as 30-min sessions, four times a week for 6 weeks. OUTCOME MEASURES: International Spinal Cord Injury Pain Basic Data Set Version 3.0 will be used for diagnosing and assessing neuropathic pain and its interference with day-to-day activities, mood, and sleep. The International Spinal Cord Society (ISCoS) QoL basic data set will be used to assess QoL, and 6-min push test distance will be used to assess peak heart rate and aerobic capacity. DISCUSSION: The effectiveness of the aerobic exercise program will be assessed based on the changes in neuropathic pain score and its interference with day-to-day activities, mood, sleep, QoL, and aerobic capacity after 3 weeks mid-intervention and after 6 weeks post-intervention. The trial will provide new knowledge about the effectiveness of the aerobic exercise program in improving neuropathic pain and QoL in individuals with chronic paraplegia. TRIAL REGISTRATION: Clinical Trials Registry-India CTRI/2023/08/056257. Registered on 8 August 2023.

Pain to cold food ingestion following root canal therapy: where is the source?

Two cases of pain evoked by cold food ingestion, following root canal therapy (RCT), are presented. The source of pain was detected when cold application to the vestibular, periapical area corresponding to the teeth involved evoked strong pain of about 30 sec durations. In the first case, the patient suffered from strong pain in the right mandibular area over the last 4 months. After successive RCT of 3 right mandibular teeth the spontaneous pain eased significantly, but strong pain evoked by cold food ingestion persisted. Cold application to the vestibular periapical area of teeth involved identified the source of pain, which was abolished by 80 mg/day of slow-release propranolol. In the second case, cold allodynia developed after RCT. The RCT was performed for prosthetic reasons with no prior pain. Pain could be duplicated by cold application to the vestibular area of the treated tooth. The patient preferred no treatment when the source of pain was explained. In both cases cold application did not produce any pain in other intra oral locations, including the contralateral vestibular area or the mid soft or hard palate. Pain mechanisms, neurovascular and neuropathic, which differ for each case are discussed.

Relationships between stenosis severity, functional limitation, pain, and quality of life in patients with cervical spondylotic radiculopathy.

Background/aim: This study aimed to examine the relationships between severity of stenosis, pain, functional limitation, disability, and quality of life in patients with cervical spondylotic radiculopathy. Materials and methods: Patients (45 female, 19 male) with radiculopathy due to spondylotic changes in the cervical spine were included in this study. Stenosis severity (thecal sac cross-sectional area (CSA)), numbness, neck and arm pain severity, functional limitation (Cervical Radiculopathy Impact Scale), disability, and quality of life (EQ-5D-3L General Quality of Life Scale) were evaluated. The study was registered at ClinicalTrials.gov as NCT06001359. Results: According to CSA values, 28 (43.75%) patients had severe stenosis and 36 (56.25%) had moderate stenosis, and the average CSA was 81.65 ± 10.08 mm2. Positive correlations were found between both neck and arm pain and neck disability (r = 0.597, r = 0.359), and negative correlations were found for the General Quality of Life Scale index score and EQ-5D-3L visual analog scale (r = -0.787, r = -0.518). There were significant positive correlations between Cervical Radiculopathy Impact Scale subscales and severity of stenosis, neck and arm pain, numbness, and disability (p < 0.05 for all). A significant negative correlation was observed between Cervical Radiculopathy Impact Scale subscales and quality of life (p < 0.01). Stenosis severity was correlated with pain, neck disability, and quality of life (p < 0.01 for all). Conclusion: There are direct relationships between cervical spondylotic radiculopathy and neck and arm pain, numbness, disability, and quality of life. Additionally, an increase in the severity of cervical stenosis is associated with an increase in pain and disability.

Spinal stabilization exercises for transversus abdominis and lumbar multifidus thickness via telerehabilitation and face-to-face approaches in patients with nonspecific chronic neck pain: a randomized controlled trial.

Background/aim: Strengthening the muscles of the lumbar region in individuals with neck pain may be protective against future back problems. In addition, telerehabilitation applications, which gained momentum in the literature and clinical practice during the COVID-19 pandemic, are among the applications preferred by patients thanks to their various advantages. This study aimed to compare the effects of telerehabilitation and spinal stabilization exercises applied with face-to-face approaches on the thickness of the transversus abdominis (M.TrA) and lumbar multifidus (M.LM) muscles in patients with nonspecific neck pain. Materials and methods: The primary outcomes were the thickness of the M.TrA and M.LM. Neck pain intensity and neck disability were secondary outcomes. Muscle thickness was evaluated with an ultrasound device, neck pain intensity was assessed with a visual analog scale, and disability was assessed with the Neck Disability Index. Patients were randomly assigned to the telerehabilitation group (TRG) (n = 13) or the control group (CG) (n = 13). While the TRG did the exercises with live videos and video recordings, the CG did exercises face-to-face in the clinic. Both groups performed the same exercises for 45 minutes per session 3 days a week for 8 weeks. Results: At the end of the treatment, the thicknesses of the M.TrA and M.LM were increased and neck pain intensity and neck disability were decreased in both groups (p < 0.05). The groups were similar in terms of these variables (p > 0.05). Conclusion: Telerehabilitation and face-to-face spinal stabilization exercises are both beneficial for spinal muscle architecture and clinical variables as a preventive measure against future lower back problems in individuals with neck pain.

Comparing the Efficacy of Landmark-Based Fascia Iliaca Compartment Block and Pericapsular Nerve Group Block for Preoperative Positioning and Postoperative Analgesia in Patients Undergoing Surgery for Hip Fractures: A Randomized Controlled Trial.

BACKGROUND: Subarachnoid block is the most common anesthetic technique for patients having corrective hip surgeries. However, adequate positioning for a successful subarachnoid block is a major challenge in this particular population of patients, owing to the site of fracture. Regional anesthesia, in the form of nerve blocks, is an effective means of alleviating such constraints and gives an added benefit of prolonged postoperative analgesia. The pericapsular nerve group (PENG) block and the fascia iliaca compartment block (FICB), under ultrasonography guidance, are a few examples of the commonly performed peripheral nerve blocks in such settings. However, the landmark-based techniques of nerve blockade still hold good in many resource poor settings, given the lack of ultrasonography facilities. AIM: To compare the ease of spinal positioning using the patient sitting satisfaction score between the landmark-guided FICB and PENG block. MATERIALS AND METHODS: This study was done on 80 patients of the American Society of Anesthesiology (ASA) grade I or II with intertrochanteric fractures of the hip joint scheduled for proximal femoral nailing. Patients were allocated into two groups of 40 each through computer generated random numbers, to receive 30 ml of 0.5% ropivacaine via the landmark-guided technique of FICB in Group F and peripheral nerve stimulator assisted landmark-guided PENG block in Group P, 30 minutes prior to spinal positioning. Time to passive leg raise (PLR) to 15 degrees and time to PLR to 30 degrees with a standard goniometer guidance at visual analogue scale (VAS) score < 4 and ease of spinal positioning through the sitting satisfaction score at the 30th minute were assessed. Any adverse effects and events of failure were noted. The duration of postoperative analgesia was measured through the time to the first dose of paracetamol on arrival at the post-anesthesia care unit. RESULTS: Statistical analysis was done using JASP version (0.18.3.0) using the independent samples t-test and significance was taken when p value was < 0.001. The time to PLR to 15 degrees and 30 degrees were achieved faster in the patients who received the PENG block in comparison to the patients who received the FICB, and the average patient sitting satisfaction score was significantly higher in Group P as compared to Group F (p < 0.001). While the overall amount of analgesics used in both groups was similar, the overall period of postoperative analgesia was prolonged in Group F compared to Group P (p < 0.001). CONCLUSION: The landmark guided PENG block is feasible and superior to the landmark-guided FICB for preoperative positioning and analgesia. The FICB provides a longer duration of postoperative analgesia for patients with intertrochanteric fractures.

Knowledge, Awareness, and Prevalence of Irritable Bowel Syndrome in the Saudi Community: A Cross-Sectional Study.

Background The common chronic condition known as irritable bowel syndrome (IBS) lacks any visible anatomical, biochemical, or pathogenic cause. IBS significantly strains healthcare systems by sending a considerable number of patients to gastrointestinal clinics. Objective The present study investigated the knowledge, awareness, and prevalence of IBS among a sample of the Saudi community. Methods The current cross-sectional investigation was carried out from January 2, 2024, to March 15, 2024, using an electronically distributed questionnaire. IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States) was employed for statistical analysis. Results The study included 1,008 participants (655, 65% females and 353, 35% males). Most individuals (421, 42%) were from the age group of 18-30 years. Among participants, the prevalence of IBS was 31.8% (n=320). Regarding IBS knowledge, 42.2% (n=425) had low knowledge scores, 38.6% (n=389) had moderate knowledge scores, and only 19.2% (n=194) had high knowledge scores. The majority of respondents (886, 87.9%) believe that IBS affects QoL. Most participants (885, 87.8%) had good knowledge of the common symptoms of IBS. Additionally, 85.1% (n=858) of respondents recognized the psychological and emotional effects associated with IBS. Younger participants (under 20 years old) and single participants had significantly lower knowledge scores than their comparable groups (p<.001). Female participants had a higher percentage of high knowledge scores (13.4%) than males (5.9%) (p=.002). Conclusion The current study's findings showed that participants' knowledge of IBS was inadequate. Around one-third of the participants suffered from IBS. Younger, unmarried individuals and females had different knowledge scores than their counterparts. The study's findings imply that further education and awareness campaigns are needed to improve understanding of IBS.

Cannabidiol for the Treatment of Cervical Spondyloarthritis-Related Pain: A Case Report.

Spondyloarthritis (SA) is a chronic inflammatory disease that predominantly affects the spinal column. SA-related pain can be intense, persistent, and disabling. Studies with cannabis have been conducted involving patients with refractory epilepsy, multiple sclerosis, Parkinson's disease, sleep disorders, and chronic pain. Cannabidiol is the major non-psychotropic component of cannabis, has anti-inflammatory and analgesic properties, and exerts anxiolytic and mood-stabilizing effects. This paper reports a case of a 72-year-old male with SA, with mild stenoses of the spinal canal at C4-C5 and C5-C6 and stenoses of the left neural foramina at C3-C4, C4-C5, C5-C6, and C6-C7. The use of cannabidiol in our patient achieved satisfactory results in the control of pain related to cervical spondyloarthritis.

Stereotactic Ablative Radiation Therapy for Sacral Bone Metastasis in Recurrent Type A Thymoma: A Two-Year Follow-Up Demonstrating Pain Reduction and Local Control.

A 74-year-old Asian man presented with sacral bone metastasis-related pain caused by a metastatic thymoma. Computed tomography revealed an approximately 6-cm sacral mass, which was confirmed as a metastatic thymoma. The patient was referred to our department and underwent stereotactic ablative radiation therapy (SABR) using volumetric modulated arc therapy and received a total dose of 35 Gy in five fractions. One year after SABR, the sacral lesion had decreased in size, and the pain medication was reduced. After two years, the patient no longer required pain medication, indicating successful management of bone metastases in recurrent Type A Thymoma.

Left Infrapatellar Branch of the Saphenous Peripheral Nerve Stimulation Relieves Refractory Pain Following Total Knee Replacement.

Osteoarthritis, the most common joint disease of adults worldwide, is increasing in prevalence due to an increase in aging and rates of obesity in developed countries. Treatment options include physical therapy, pharmacologic management, non-pharmacologic management, and total knee replacement surgery. When conservative measures fail, total knee replacement surgery is pursued. The patient is a 61-year-old woman with a history of severe chronic osteoarthritic knee pain following total left and right knee arthroplasty in 2016 and 2019, respectively, who presents with refractory post-total knee replacement pain. Following her surgeries, the patient was in excruciating 10/10 pain on the numerical rating scale (NRS) and was unable to walk or stand. She underwent revisions which, unfortunately, did not ameliorate her pain. She was later referred to chronic pain management in which a peripheral nerve stimulator (PNS) was offered and implanted. Following her PNS trial, the patient achieved >80% pain relief in her left knee. After the permanent PNS implant, the patient noted she had 100% pain relief (0/10 on the NRS) in her left knee and was able to regain mobility. Here, we discuss a case demonstrating rapid pain relief following the minimally invasive PNS implantation for refractory pain following total knee arthroplasty. Refractory pain following total knee arthroplasty can increase morbidity and mortality as a consequence. Thus, proper management is needed to reduce these adverse outcomes. In patients who have failed conservative medical management, PNS may be an alternative, efficacious treatment option for refractory knee pain. Despite the efficacy in our case, further research is needed to define the optimal patient group that would benefit from PNS for refractory knee pain following total knee arthroplasty.

A Clinical Study of Anterior Abdominal Wall Hernias and Its Management: A Medical College Experience.

Objective We aim to evaluate the various risk factors contributing to the occurrence of anterior abdominal wall hernias and assess the various surgical modalities. Materials and methods This prospective observational research was conducted between 2022 and 2024 at a tertiary care health center, involving 100 participants with an anterior abdominal wall hernia diagnosis aged over 14 years. The study excluded patients under 14 years with bleeding diathesis, inherited coagulopathies, inguinal or femoral hernias, or recurrent ventral hernias. Participants underwent detailed clinical examinations and biochemical evaluations and underwent a primary ultrasonography (USG)/contrast-enhanced computed tomography (CECT) to determine defect size. Risk factors were documented, including age, gender, occupation, body mass index (BMI), comorbidities, previous surgery history, multiparity, smoking, chronic straining due to constipation or benign prostatic hyperplasia (BPH), malnutrition, chronic steroid use, chronic renal failure, and chronic liver disease. The surgical procedure was determined by the same surgical team for all cases. Standard antibiotic prophylaxis and preoperative painting/draping protocols were followed in all cases. Intraoperatively, intraoperative time (in hours) was documented. Postoperative parameters included pain, hematoma formation, seroma formation, surgical site infections (SSIs), and early recurrence. These intra- and postoperative findings constituted the primary outcome parameters. Secondary outcome parameters included hospital stay duration and time taken to return to work. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 16 (IBM SPSS Statistics, Armonk, NY) software. Results The study analyzed the occurrence of ventral hernias in 100 patients, with the fourth decade having the highest occurrence (n=42 (42%)). The majority of the participants were male (female: n=47 (47%), male: n=53 (53%)). The majority of the participants were laborers, and 24% (n=24) were office workers. The study found that hypertension, diabetes mellitus, and chronic obstructive pulmonary disease were risk factors for hernias. Other risk factors included obesity, previous history of surgery, multiparity, smoking, chronic straining, malnutrition, and chronic steroid use. The most common type of ventral hernia was umbilical hernia (n=33 (33%)), followed by paraumbilical hernias (n=30 (30%)), and incisional hernias (n=20 (20%)). Of the 100 patients, 74% underwent open hernia repair, with the mean operation time being minimal in cases managed with laparoscopic repair (2.5±0.67 hours). Postoperative pain was highest with the Rives-Stoppa (RS) repair with component separation group. The incidence of surgical site infection was the maximum among cases of open anatomical repair (41.7%), followed by RS repair (31.3%), while it was the minimum in laparoscopic repair (3.7%). Early recurrence was lower in the laparoscopic group (n=1 (3.7%)). Conclusion The study highlights risk factors for abdominal wall hernia and management approaches. Understanding these is crucial for identifying and preventing recurrence. Surgeons must choose the right surgical approach based on patient health and symptoms to achieve desired outcomes and minimize complications. In addition, surgical expertise, availability of resources, and knowledge of what works best for the surgeon constitute important determinants of surgical outcomes.

Age-dependent flexion relaxation phenomenon in chronic low back pain patients.

Background: The flexion relaxation phenomenon (FRP) is characterized by suddenly reduced paraspinal muscle activity during full flexion. Previous studies showed significant differences in FRP and flexion angles in chronic low back pain (cLBP) patients compared to individuals without back pain (no-BP). However, the relationship between FRP and flexion angles remains insufficiently understood in older populations. Thus, this study investigated the relationship between FRP and flexion angles concerning to the age and presence of cLBP. Methods: Forty no-BP subjects (20m/20f; mean age 41.5 years) and thirty-eight cLBP patients (19m/19f; mean age 43.52 years) performed maximum full upper body flexion task. Electromyographic (EMG) measurements were conducted to assess the activity of lumbar erector spinae (ESL), thoracic erector spinae (EST), and multifidus (MF). Lumbar, thoracic, and pelvic angles at the onset (OnsetL/T/P) and offset of the FRP (OffsetL/T/P) and maximum trunk inclination (MaxL/T/P) were calculated. The FRP was evaluated using a flexion relaxation ratio (FRR). Results: cLBP patients showed smaller FRR in MF and right ESL compared to no-BP individuals (p < 0.05), while no differences were found in flexion angles between two groups. Subjects over 40 showed smaller FRR in MF and ESL, and smaller flexion angles on OffsetL and MaxL (p < 0.05). Age-related analysis in the cLBP group revealed that patients over 40, compared to younger ones, had smaller FRR in MF and ESL, and smaller values in all thoracic and lumbar flexion angles (p < 0.05). While in no-BP group, significant larger flexion angles in OnsetL and OffsetT (p < 0.05) were observed in participants over 40. Pain-related analysis in the older group revealed that the cLBP patients, compared to no-BP individuals, had smaller FRR in right MF and right ESL, and smaller values in all lumbar and thoracic flexion angles (p < 0.05), while in younger group, there were no significant pain-related differences in FRR, with larger values in all lumbar flexion angles (p < 0.05). Conclusion: Our findings indicate a reduction or absence of FRP in cLBP patients compared to no-BP individuals, with age being a significant factor as those over 40 showed smaller FRP and flexion angles compared to younger individuals.

A comprehensive review of traditional Chinese medicine in treating neuropathic pain.

Neuropathic pain (NP) is a common, intractable chronic pain caused by nerve dysfunction and primary lesion of the nervous system. The etiology and pathogenesis of NP have not yet been clarified, so there is a lack of precise and effective clinical treatments. In recent years, traditional Chinese medicine (TCM) has shown increasing advantages in alleviating NP. Our review aimed to define the therapeutic effect of TCM (including TCM prescriptions, TCM extracts and natural products from TCM) on NP and reveal the underlying mechanisms. Literature from 2018 to 2024 was collected from databases including Web of Science, PubMed, ScienceDirect, Google academic and CNKI databases. Herbal medicine, Traditional Chinese medicines (TCM), neuropathic pain, neuralgia and peripheral neuropathy were used as the search terms. The anti-NP activity of TCM is clarified to propose strategies for discovering active compounds against NP, and provide reference to screen anti-NP drugs from TCM. We concluded that TCM has the characteristics of multi-level, multi-component, multi-target and multi-pathway, which can alleviate NP through various pathways such as anti-inflammation, anti-oxidant, anti-apoptotic pathway, regulating autophagy, regulating intestinal flora, and influencing ion channels. Based on the experimental study and anti-NP mechanism of TCM, this paper can offer analytical evidence to support the effectiveness in treating NP. These references will be helpful to the research and development of innovative TCM with multiple levels and multiple targets. TCM can be an effective treatment for NP and can serve as a treasure house for new drug development.

Quantitative assessment of rotator cuff injuries using synthetic MRI and IDEAL-IQ imaging techniques.

Purpose: To evaluate synthetic magnetic resonance imaging (SyMRI) and iterative decomposition of water and fat with echo asymmetry and least squares estimation (IDEAL-IQ) imaging for a comprehensive evaluation of rotator cuff injuries (RCI). Methods: Ninety-seven patients with RCI were classified into four groups based on the arthroscopic results: (grade II), partial tear (grade III), complete tear (grade IV), and controls (grade I). T1 (Transverse Relaxation Time 1), T2 (Transverse Relaxation Time 2), proton density (PD), and fat fraction (FF) were evaluated using SyMRI and IDEAL-IQ. Measurement reliability was assessed using intraclass correlation coefficients (ICC). The diagnostic potential for grading RCI was evaluated using ordinal regression and ROC analyses. Results: A high measurement reliability (ICC > 0.7) was observed across subregions. T1 and T2 significantly varied across grades, particularly T2 in the lateral subregion between grades III and IV (P < 0.001) and the central subregion between grades II and III (P < 0.001). ROC analyses yielded valuable diagnostic accuracy, including T2 in the lateral subregion with an AUC of 0.891, distinguishing grade I from grade IV. Positive correlations were found between T2 values in specific shoulder subregions and injury grade (r = 0.615 for lateral, r = 0.542 for medial, both P < 0.001). In grade IV, FF was notably increased in the supraspinatus, infraspinatus, and subscapularis muscles compared with grades I-III. There were no significant FF variations in the teres minor muscle among grades. Conclusions: Quantitative MRI parameters from SyMRI and IDEAL-IQ, especially T2 and FF, may classify and assess RCI severity. The results could help improve the accuracy of diagnosing different grades of RCI, offering clinicians additional tools for improving patient outcomes through personalized medicine.