Rejected

Introduction Rheumatoid arthritis (RA) is a chronic autoimmune disorder with variable disease course including periods of flares and remissions. High disease activity in terms of disease activity score-28 (DAS-28) results in significant morbidity. Hypothyroidism is found to be associated with higher DAS-28 scores in RA. This study is planned to determine overt and subclinical hypothyroidism and its correlation with the DAS-28 score in patients with RA. Methodology This study was conducted from June 2021 to March 2022 at the department of rheumatology and immunology at Shaikh Zayed Hospital, Lahore, Pakistan. Inclusion criteria were any male and female patients aged between 18 and 70 years. The blood samples of diagnosed patients with RA were sent for thyroid function tests (thyroxine [FT4], thyroid-stimulating hormone [TSH]), and erythrocyte sedimentation rate (ESR), and the patients were categorized as overt hypothyroidism, subclinical hypothyroidism, and non-hypothyroid. The collected data were analyzed on Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM Corp., Armonk, NY). Results The mean age of patients was 38.18 ± 9.78 years. The mean duration of symptoms was 14.65 ± 1.04 months. There were 182 (91%) females and 18 (9%) males. The mean number of swollen joints was 2.26 ± 2.8, and the mean number of tender joints was 4.16 ± 5.11. Sixty patients (30%) had high disease activity, i.e., DAS-28 score > 5.1. Fifty-seven patients (28.5%) with RA had subclinical hypothyroidism, and 19 patients (9.5%) had overt hypothyroidism. Pain visual analog scale (VAS) and DAS-28 were significantly higher in hypothyroid patients. Conclusion It was concluded that patients of RA with concomitant hypothyroidism had increased disease activity with increased tender joints. Thyroid function tests should be included in the clinical evaluation of RA patients. The evaluation of thyroid functional status must be done during screening in RA patients. This will detect thyroid disorders earlier, with early treatment initiation and possibly a better prognosis.

Acute postoperative pain control after lumbar surgery is imperative to minimizing long-term narcotic use and associated adverse sequela. The safety of intrathecal morphine for postoperative pain management in spine surgery has been investigated; however, to date, no studies have investigated the safety of intrathecal fentanyl with a myofascial plane (MP) block in lumbar procedures.

Ketamine is a dissociative anesthetic commonly used for the induction and maintenance of anesthesia and has a well-known role in analgesia. However, it also has the potential for addiction, which can lead to neurological, psychological, systemic, and biochemical consequences. In this case report, we are highlighting a rare case of a young Asian female with Ketamine addiction who presented with urinary complaints. The patient was found to have hyponatremia and laboratory tests were consistent with a syndrome of inappropriate antidiuretic hormone (SIADH) release in the absence of other causes.

Pregabalin, a prescription medication typically used for neuropathic pain, has increasingly been overused and abused. We present a unique case of a 51-year-old woman with a history of polysubstance use disorder and on methadone therapy who presented to the emergency department with altered mental status after consuming an unknown supratherapeutic amount of pregabalin. She was stabilized and discharged. Within 24 hours, she ingested another 1000mg of pregabalin, presenting again with altered mental status, along with tachycardia and hypertension. Computed tomography (CT) without contrast and fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR MRI) revealed subcortical white matter edema in the bilateral frontal and occipital lobes as well as the left parietal lobe, suggestive of posterior reversible encephalopathy syndrome (PRES). The patient recovered after four days of supportive treatment with an antihypertensive and an antiepileptic. PRES is a neurological phenomenon in which vasogenic edema, most commonly accumulating in the posterior parieto-occipital white matter, causes headaches, altered mental status, and seizures. To our knowledge, there has not been an established link between pregabalin toxicity and PRES, and the awareness of this potential complication can help in the early diagnosis and management of the disease to prevent further progression.

Migraine is prevalent, disabling, and peaks during people's peak productive years. The impact of migraine on people's professional lives, work productivity, and interpersonal relationships at work eventually affects everyone, has a significant detrimental effect on people with migraine, and a huge cost in terms of lost productivity. People with migraine want to work, so they do their best to work despite the varied migraine related and associated symptoms. Most of migraine-related productivity loss (89%) is due to presenteeism. People are less than half effective during a migraine attack due to the pain, migraine symptoms, attack unpredictability, migraine comorbidities, emotional impact, under-diagnosis and under-management, and the stigma. Migraine-related productivity loss may negatively affect people's career choice, job status and/or security, financial status, work relationships, mood, and confidence. Migraine is estimated to represent 16% of total US workforce presenteeism. Thankfully, there are ways to help support people with migraine in the workplace and increase their productivity such as: workplace migraine education programs, workplace migraine education and management programs, migraine-friendly work environment, migraine treatment optimization and advocacy. The example of the successful workplace migraine education and management program developed and run in collaboration between Fujitsu, the Japanase Headache Society, and the International Headache Society Global Patient Advocacy Coalition is discussed.

Patients with a suspected change in intracranial pressure or a trigeminal autonomic cephalgia require MRI. The need for investigation for other headache disorders is guided by the clinical evaluation of the patient. Particular care should be taken to identify any 'red flags'. Incidental findings on MRI occur in approximately 2% of patients. Patients with migraine have an increased rate of white matter lesions, but these are of uncertain clinical significance.

Mechanisms underlying persistent cardiopulmonary symptoms following SARS-CoV-2 infection (post-acute sequelae of COVID-19 "PASC" or "Long COVID") remain unclear. The purpose of this study was to elucidate the pathophysiology of cardiopulmonary PASC using multimodality cardiovascular imaging including cardiopulmonary exercise testing (CPET), cardiac magnetic resonance imaging (CMR) and ambulatory rhythm monitoring.

Ankylosing spondylitis (AS) impacts quality of life. We assessed patient-reported outcomes (PROs), pain, fatigue, health-related quality of life (HRQoL) and work productivity in a phase III trial of tofacitinib.

Chronic pelvic pain (CPP) is multifactorial in etiology and heterogeneous in presentation. Identification of all pain contributors is essential for successful management. Chronic overlapping pain conditions (COPCs) are a specified group of chronic pain conditions that commonly co-occur in patients. We briefly review individual COPCs and highlight risk factors and mechanisms that appear to be applicable across COPCs. We review evaluation and communication strategies that may help establish a productive therapeutic relationship between clinicians and patients. Management should include treatment of peripheral pain generators as well as co-occurring psychological conditions and central sensitization when present.