Rejected

The current Dutch Pharmacogenetics Working Group (DPWG) guideline, describes the gene-drug interaction between CYP2D6 and the opioids codeine, tramadol and oxycodone. CYP2D6 genotype is translated into normal metaboliser (NM), intermediate metaboliser (IM), poor metaboliser (PM) or ultra-rapid metaboliser (UM). Codeine is contraindicated in UM adults if doses >20 mg every 6 h (q6h), in children ≥12 years if doses >10 mg q6h, or with additional risk factors. In PMs, an alternative analgesic should be given which is not or to a lesser extent metabolised by CYP2D6 (not tramadol). In IMs with insufficient analgesia, a higher dose or alternative analgesic should be given. For tramadol, the recommendations for IMs and PMs are the same as the recommendation for codeine and IMs. UMs should receive an alternative drug not or to a lesser extent metabolised by CYP2D6 or the dose should be decreased to 40% of the commonly prescribed dose. Due to the absence of effect on clinical outcomes of oxycodone in PMs, IMs and UMs no action is required. DPWG classifies CYP2D6 genotyping for codeine "beneficial" and recommends testing prior to, or shortly after initiation of treatment in case of higher doses or additional risk factors. CYP2D6 genotyping is classified as "potentially beneficial" for tramadol and can be considered on an individual patient basis.

The 2019 Coronavirus (SARS-CoV-2) is a novel respiratory virus which causes Coronavirus Disease19 (COVID-19). Although the predominant clinical picture of COVID-19 is represented by respiratory symptoms, neurological manifestations are being increasingly recognized. Headache, in particular migraine-like and tension types, has been largely reported in patients suffering from COVID-19 both in the acute and the healing phase of the infection. New daily persistent headache (NDPH) is a primary headache characterized by persistent and daily painful symptoms, with pain becoming continuous and non-remitting within 24 h, and lasting more than 3 months. Even though an increasing number of reports describe patients who develop a persistent headache, diagnosis of NPDH has been rarely explored in the context of COVID-19.

The objective of this study was to understand the experiences of nonpharmacologic therapy (NPT) providers implementing the Oregon Back Pain Policy (OBPP). The Medicaid OBPP expanded coverage of evidence-based NPTs for back pain and simultaneously restricted access to acute and chronic opioid therapy and some interventional approaches for chronic back pain. This study uses a cross-sectional, observational design. The authors conducted three online focus groups with 44 credentialed NPT providers in February 2020. Qualitative data analysis was conducted by a multidisciplinary team with an immersion/crystallization approach. Four themes emerged from the data. Participants reported: (1) a lack of direct communication about the policy and mixed levels of understanding of the policy, (2) belief that expanding access to NPT and restricting opioids was beneficial for patients, (3) implementation challenges that compromised access and the perceived effectiveness of care, and (4) financial challenges in accepting Medicaid referrals, due to reimbursement and administrative burden. The goal of the OBPP was to increase access to evidence-based back pain care, including new coverage of NPT services and decreased opioid prescribing for back pain. This study revealed that although many NPT providers support the goals of this policy, the policy was not communicated systematically to providers and was hampered by implementation challenges.

Despite the huge development of pain management in the past decades, pain remains elusive and many patients still remain in the middle of the ford struggling between low drug efficacy and their overuse. A reason for pain elusiveness is its nature of subjective phenomenon, escaping the meshes of the objectivist, mechanist-reductionist net prevailing in medicine. Actually, pain is not only a symptom but an essential aspect of life, consciousness and contact with the world and its noetic and autonoetic components play a key role in the development of the concepts of pleasure-unpleasure and good-evil. The intensity and tolerability of pain and suffering also depends on what the pain means to the patient. The outstanding effects of placebo and nocebo, behavioral and non-pharmacological techniques warrant the need for a shift from the traditional positivist idea of patient as passive carrier of disease to the patient as active player of recovery and move toward a patient's centered approach exploiting individual resources for recovery. Among the mentioned techniques, hypnosis has proved to increase pain threshold up to the level of surgical analgesia, improve acute and chronic pain as well as coping and resilience, helping to decrease both drug overuse and the costs of pharmacological therapy. The wealth of available data suggest the need for a holistic approach, aiming to take care of the individual as an inseparable mind-body unit in its interplay with the environment, where patient's inner world, his/her experience and cognition are taken into due account as powerful resources for recovery through a phenomenological-existential approach.

Pseudotumor cerebri syndrome (PTC) is characterized by increased intracranial pressure without a space-occupying lesion and a normal cerebrospinal fluid (CSF) composition without evidence of CSF infection. In this study, we aimed to compare the symptoms, signs, and clinical characteristics of patients presenting with a preliminary diagnosis of pseudotumor cerebri syndrome (PTC) who were diagnosed and not diagnosed with PTC.

We aimed to investigate changes in regional cerebral blood flow (rCBF) using arterial spin labelling (ASL) in patients with visual snow syndrome (VSS), in order to understand more about the underlying neurobiology of the condition, which remains mostly unknown.

As with past illnesses, an approach has been taken to vaccinate the population and halt the spread of COVID-19. On 13 April 2021, the US Food and Drug Administration called for a halt in the administration of the Johnson & Johnson (J&J) COVID-19 vaccine due to reports of thrombosis and thrombocytopenia being associated with vaccination. We present the case of a 43-year-old woman with a history of dyslipidaemia, depression, gastro-oesophageal reflux disease and obesity presenting with dyspnoea, headache and light headedness of 3 days' duration. Ten days prior, she had received the J&J COVID-19 vaccine. She was found to have thrombocytopenia, elevated D-dimers, pulmonary emboli and presented 1 day after discharge with an arterial clot despite being on apixaban. Six other US-based cases of venous thrombotic events are being reviewed at present. Patients should be informed of the possibility of such events to provide informed consent.

Type 2 immunity, illustrated by helper 2 lymphocytes (Th2) and downstream cytokines (IL-4, IL-13, IL-31) as well as group 2 innate lymphoid cells (ILC2), is important in host defense and wound healing. The hallmark of type 2 inflammation is eosinophilia and/or high IgE counts and is best recognized in atopic diathesis. Persistent eosinophilia, such as seen in hypereosinophilic syndromes, leads to fibrosis and hence therapeutic Type 2 inhibition in fibrotic diseases is of high interest. Furthermore, as demonstrated in cutaneous cell lymphoma, advanced disease is characterized by Th1 to Th2 switch allowing cancer progression and immunosuppression. Development of targeted monoclonal antibodies against IL-4Rα (eg, dupilumab) led to a paradigm shift for the treatment of atopic dermatitis (AD) and stimulated research to better understand the role of Type 2 inflammation in other skin conditions. In this review, we summarize up to date knowledge on the role of Type 2 inflammation in skin diseases other than AD and highlight whether the use of Type 2 targeted therapies has been documented or is being investigated in clinical trials. This manuscript reviews the role of Type 2 inflammation in dermatitis, neurodermatitis, IgE-mediated dermatoses (eg, bullous pemphigoid, chronic spontaneous urticaria), sclerodermoid conditions and skin neoplasms.

Shoulder complaints from glenohumeral subluxation are a common problem and limit patients during daily activities.