Rejected

The current healthcare provision in Germany is established, in particular, for the diagnostics and treatment of chronic pain conditions; however, the current aim is to initiate the diagnostic and therapeutic approaches oriented towards the biopsychosocial pain model in the early stages of pain, i.e. before the onset of chronification, for patients with pain and a risk of chronification in order to actively avoid chronification processes. In this context, multiple risk factors play an important role for the diagnostic and therapeutic approaches as well as for the interdisciplinary multimodal pain therapy developed for this purpose. The Global Year of the International Association for the Study of Pain (IASP) 2020 addressed the prevention of (chronic) pain, a welcome opportunity to provide a short review of the evidence for and clinical experiences with timely diagnostic and therapeutic options and to summarize the current framework conditions and scientific recommendations for Germany. At the end of this article the implications for future research are summarized, particularly for the treatment of patients with pain and risk of chronification.

Low back pain (LBP) is an increasingly burdensome condition for patients and health professionals alike, with consistent demonstration of increasing persistent pain and disability. Previous decision support tools for LBP management have focused on a subset of factors owing to time constraints and ease of use for the clinician. With the explosion of interest in machine learning tools and the commitment from Western governments to introduce this technology, there are opportunities to develop intelligent decision support tools. We will do this for LBP using a Bayesian network, which will entail constructing a clinical reasoning model elicited from experts.

Nipple shields (shield) may reduce pain during breastfeeding, but the impact on infant sucking dynamics is not known. We examined the effects of shield use on sucking dynamics, milk removal and nipple pain in two groups of breastfeeding dyads: pain group (PG): shield used for nipple pain; comparison group (CG): no breastfeeding difficulties. Twenty PG (6 ± 4 weeks postnatal) and 28 CG dyads (8 ± 6 weeks postnatal) attended 2 monitored breastfeeding sessions with shield use randomised. Within-subject outcomes were compared. PG: shield use did not affect intra-oral vacuum (peak p = 0.17, baseline p = 0.59), sucking frequency (p = 0.20) or milk transfer (40 mL vs 48 mL, p = 0.80; percentage of available milk removed (PAMR) 55% vs 57%, p = 0.88), and reduced McGill pain scores (p = 0.012). CG: shield use increased non-nutritive sucking (10% more, p = 0.049), and reduced nutritive sucking (18% less, p = 0.017) and milk transfer (63 mL vs 31 mL p < 0.001, PAMR 65% vs 36% p < 0.001). For both groups, feeding duration increased by 2 min (p < 0.0001) and non-nutritive portions of the feed increased with shield use.Conclusion: Nipple shield use improved maternal comfort and did not impact milk removal or sucking strength in PG, but significantly reduced milk transfer and nutritive sucking in CG. What is Known: • Mothers report that nipple shields reduce nipple pain and enable continued breastfeeding. • Concerns that nipple shield use may reduce milk transfer and alter infant sucking patterns are based on limited published evidence. What is New: • Nipple shield use is associated with a 25% reduction in pain scores in breastfeeding mothers with chronic nipple pain. • Milk transfer is not reduced in dyads that regularly use a shield for chronic nipple pain. • Intra-oral vacuums are not impacted by nipple shield use in mothers experiencing pain.

Fibromyalgia (FM) is a syndrome of chronic widespread pain. While it has been studied in different populations and settings, the impact of FM and its associated psychological factors has not been previously studied among female war refugees.

To evaluate the safety and feasibility of ultrasound-guided intralesional injection of Talimogene laherparepvec (Imlygic, T-VEC) in patients with advanced non-palpable melanoma.

ANCA-associated vasculitis is a multiorgan autoimmune inflammatory disease that has a heterogeneous clinical presentation. Our case report provides additional evidence supporting the association between granulomatosis with polyangiitis and myositis. In our patient with proximal muscle weakness and pain, a normal creatine kinase and lack of antibodies to muscular fiber units ruled out primary myositis. Distinct magnetic resonance imaging of the brain within the deep gray matter in addition to positive serologies were consistent with a diagnosis of granulomatosis with polyangiitis. ANCA-associated vasculitis, specifically granulomatosis with polyangiitis, may be overlooked if musculoskeletal manifestations are the presenting symptoms. Prompt and aggressive treatment prevented this patient from experiencing multiorgan failure.

Radiofrequency denervation has been established for many years as an important minimally invasive procedure for the treatment of chronic pain conditions. Positive experiences of many users for various indications are contrasted by a nonuniform evidence. With meticulous patient selection and correct assessment of the indications a longer term reduction of pain, a reduced need for analgesics and an improvement in the quality of life can be achieved. The aim of this interdisciplinary position paper is to present the value of radiofrequency denervation in the treatment of chronic pain. The summarized recommendations of the expert group are based on the available evidence and on the clinical experiences of Austrian centers that frequently implement the procedure. The position paper contains recommendations on patient selection and proven indications. We discribe safety aspects, complications, side effects and contraindications.

The prevalence of internal iliac artery aneurysms (IIAA) is very low. Existing data on IIAA are scarce and mainly based on case reports and small retrospective series. We present the case of a 55-year-old African American man with a past medical history of HIV, hypertension, pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), coronary artery disease, polysubstance abuse, schizophrenia, depression, and bipolar disorder who presented to the emergency department with dyspnea on exertion. He was admitted for COPD exacerbation. He reported concerns of ambulatory chronic right hip pain, for which he underwent a CT, which revealed the presence of a partially visible right IIAA. A CT of his abdomen/pelvis revealed multiple aneurysms, including a partially thrombosed 8-cm fusiform right IIAA. Due to the presence of multiple aneurysms, the vascular surgery team was consulted, and elective repair was recommended. IIAA should be considered in the differential diagnosis of patients with significant smoking history and hip pain and acted upon immediately.

Migraine is a common neurovascular condition. This disorder has a complex genetic background. Several single-nucleotide polymorphisms (SNPs) or mutations within genes regulating glutamatergic neurotransmission, cortical excitability, ion channels, and solute carriers have been associated with polygenic and monogenic forms of migraine. SNPs within ACE, DBH, TRPM8, COMT, GABRQ, CALCA, TRPV1, and other genes have been reported to affect the risk of migraine or the associated clinical parameters. The distribution of some HLA alleles within the HLA-DRB1, HLA-DR2, HLA-B, and HLA-C regions have also been found to differ between migraineurs and healthy subjects. In addition, certain mitochondrial DNA changes and polymorphisms in this region have been shown to increase the risk of migraine. A few functional studies have investigated the molecular mechanisms contributing to these genetic factors in the development of migraine. Here we review studies evaluating the role of genetic polymorphisms and mRNA/miRNA dysregulation in migraine.

A 19-year-old woman with persistent anterior knee pain was diagnosed with a complex tibial and femoral torsional deformity (26° of femoral anteversion and 49° of tibial external rotation). To achieve the correct realignment of the lower limb, rotational double osteotomies were needed. After planning the correction on the computed tomography scan and three-dimensional (3D) model, a custom-made 3D-printed guiding system was produced to support the surgery.