Rejected

Background Low back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period. Methodology We conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months. Results A total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028). Conclusions Patients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.

To improve pain relief for refractory pain condition, spinal cord stimulation (SCS) needs to target the dedicated neuronal fibers within the dorsal columns. Intraoperative feedback from the patient can optimize lead placement but requires "awake surgery", allowing interaction between patient and surgeon. This can produce negative effects like anxiety and stress. To better manage these aspects, we propose to combine intraoperative hypnosis with awake anesthesia. Seventy-four patients (35 females, 22-80 years) presenting with chronic refractory pain, were offered intraoperative hypnosis during awake SCS lead implantation. Interactive conversational hypnosis was used as well as interactive touch, which was enhanced during painful moments during the lead intraoperative programming. All patients participated actively during the intraoperative testing which helped to optimize the lead positioning. They kept an extremely positive memory of the surgery and of the hypnotic experience, despite some painful moments. Pain could be reduced in these patients by using interactions and touch, which works on Gate Control modulation. Positive memory was reinforced by congratulations to create self-confidence and to induce positive expectations, which could reinforce the Diffuse Noxious Inhibitory Controls at the spinal level. Cooperation was improved because the patient was actively participating and thus, much more alert when feedback was required. Combining intraoperative hypnosis with awake anesthesia appears helpful for SCS lead implantation. It enhances patient cooperation, allows optimization of lead positioning, and leads to better pain control, positive and resourceful memory.

Myocarditis is caused by inflammation affecting the heart muscle. The usual aetiological factor is viral, especially in immunocompetent hosts and developed countries. is a common cause of bacterial gastroenteritis but has rarely been associated with myocarditis.

Spinal anesthesia (SA) is the method of choice for surgery below umbilicus like elective cesarean section. However, Spinal anesthesia is associated with hypotension and limited analgesia duration. To minimize those complications adding opioids like fentanyl either sequentially with separate syringe or pre mixed with local anesthetics become common practice.

Enlargement of the major salivary glands (SGs) is a major risk factor for B-cell lymphoma among patients with primary Sjögren's syndrome (pSS). Ultrasound-guided core needle biopsy (US-guided CNB) could be a novel technique to manage SG enlargement among patients with pSS.

The metabolite itaconate has both anti-inflammatory and immunomodulatory effects. However, its influence on chronic pain is unclear. Here, we demonstrated that intraperitoneal injection of the itaconate derivative dimethyl itaconate (DI) alleviates chronic pain symptoms, such as allodynia and hyperalgesia, in spinal nerve ligation (SNL) and inflammatory pain models. Moreover, intraperitoneal DI reduced the secretion of inflammatory cytokines (i.e., interleukin-1β, tumour necrosis factor-alpha) in dorsal root ganglion (DRG), spinal cord and hind paw tissues, suppressed the activation of macrophages in DRG and glial cells in the spinal dorsal horn and decreased the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2) in the DRG and spinal cord. DI boosted nuclear factor-erythroid 2 p45-related factor 2 (Nrf2) levels in the DRG and spinal cord of SNL mice. Intraperitoneal administration of the Nrf2 inhibitor ML385 abolished the analgesic effect of DI and decreased the expression of Nrf2 in the DRG and spinal cord. Similarly, administration of DI potently reversed the lipopolysaccharide (LPS)-induced inflammatory effect in microglia. Reduction of endogenous itaconate levels by pretreatment with immune-responsive gene 1 (IRG1) siRNA blocked Nrf2 expression, which impaired the analgesic and anti-inflammatory effects of DI in vitro. Therefore, our findings reveal for the first time that intraperitoneal DI elicits anti-inflammatory effect and sustained chronic pain relief, which may be regarded as a promising therapeutic agent for chronic pain treatment.

This corrects the article on p. 225 in vol. 22, PMID: 32901462.

 Patients with tinnitus may have different severity levels of tinnitus distress. Visual analog scale (VAS) is a simple method to measure the extent of subjective distress caused by tinnitus. It includes ratings of tinnitus loudness, awareness, annoyance, and impact of tinnitus on life.

Increased susceptibility to opportunistic infections (OI) in multiple sclerosis (MS) patients is a real concern amongst neurologists when using disease-modifying therapies (DMTs). DMTs used in modulating or suppressing the immune system for MS management may risk the patient with lymphocytopenia, raising the possibility of OI; however, this lymphopenia may contemplate as a biomarker for drug response, degree of immunomodulation, and drug compliance. The OI could be reactivation of varicella-zoster, progressive multifocal leukoencephalopathy (PML) induced by John Cunningham virus (JC virus), infection, cryptococcal meningitis, atypical mycobacteria, and many more. We present a non-immunized case of varicella-zoster reactivation with dimethyl fumarate (DMF) therapy. Surprisingly, the patient's lymphocyte count trend during her previous follow-up visits remained in the range of normal to grade 1 lymphopenia but with her current flared-up rash presentation, she had a profoundly low CD8+ and CD4+ cell counts (CD8+ cell count << CD4+ cell counts) despite an absolute lymphocyte (ALC) level far above 500 cells/µl; in fact, it was 13.6% higher when compared to her last quarterly levels. Controlled trials with DMF claimed no serious infection even with a lymphopenia range of 500-800 cells/µl, which is untrue in real clinics and it would be wise and reasonable to follow the lymphocyte subsets along with ALC to prevent potential opportunistic infections. Recently, comprehensive strategies were evolved to mitigate OI risk for MS patients while on DMTs. These were not only limited to lymphocyte threshold monitoring but extended to address features in terms of screening recommendation, vaccination advice, the need for antibiotic prophylaxis, neuroimaging, laboratory checkups, medication dosing, and behavioral modifications. Our patient was not immunized with zoster vaccine and, unfortunately, DMF has no proper structured guidelines regarding vaccination against OI prevention as other few DMTs have. Our case could suggest that MS patients need proper vaccination guidelines from the Centers for Disease Control and Prevention (CDC) before starting DMF.

Atopic dermatitis (AD) is a heterogeneous inflammatory skin disease. A fresh look on the AD pathophysiology has focused on the skin barrier defect and immune dysfunctions. IL-17A and IL-19 seem to play role in AD pathogenesis.