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Here, we report the use of a methylene blue oral rinse for the treatment of oral mucositis–associated pain. A child receiving chemotherapy for acute lymphoblastic leukemia had progressive decline in clinical condition from uncontrolled oral pain associated with mucositis. Conventional therapy was shown to be ineffective and eventually discontinued. The patient received a methylene oral rinse treatment, which provided good pain control and allowed him to recover successfully completing his chemotherapy. The use of the methylene blue oral rinse can be a safe, inexpensive, and effective treatment for mucositis-related oral pain in the pediatric cancer patient population.

The present research aims to analyze and evaluate a didactic and technological tool and see the impact to encourage study in the students of the Systems Engineering School at the National University of Trujillo, during the 2020-II semester. It was possible to implement the Stormboard application for the development of Brainstorming as a didactic strategy through which it is intended to encourage the creative and innovative aspect of students when addressing topics and case studies. Analyzing the results obtained, we can point out that impacts were determined on the level of motivation for the study of students with a value of 8%, as well as the impact on the level of perception of educational services of students was determined in the order of 24% and finally, results of the impact on the level of student satisfaction were obtained in the order of 17%. Finally, it is proposed that these didactic initiatives be taken into account in the academic and institutional policies of the Systems Engineering School of in order to extrapolate the practice to other academic units at the National University of Trujillo.

Background Oral mucositis (OM) in patients receiving cancer therapy is thus far not well managed with standard approaches. We aimed to assess the safety and effectiveness of methylene blue (MB) oral rinse for OM pain in patients receiving cancer therapy. Methods In this randomized, single-blind phase 2 clinical trial, patients were randomized to one of four arms: MB 0.025%+conventional therapy (CTx) (n = 15), MB 0.05%+CTx (n = 14), MB 0.1%+CTx (n = 15), or CTx alone (n = 16). Intervention groups received MB oral rinse every 6 h for 2 days with outcomes measured at days 1–2; safety was evaluated up to 30 days. The primary outcome measured change in the pain numeric rating scale (0–10) from baseline to day 2. Secondary outcome measured change in oral function burden scores from baseline to day 2, World Health Organization OM grades, morphine equivalent daily doses, and adverse events. The trial was registered with ClinicalTrials.gov ID: NCT03469284. Results Sixty patients (mean age 43, range 22–62 years) completed the study. Compared with those who received CTx alone, those who received MB had a significant reduction of pain scores at day 2 of treatment (mean ± SD); 0.025%: 5.2 ± 2.9, 0.05%: 4.5 ± 2.9, 0.1%: 5.15 ± 2.6) and reduction of oral function burden scores (0.025%: 2.5 ± 1.55, 0.05%: 2.8 ± 1.7, 0.1%: 2.9 ± 1.60). No serious adverse events were noted, but eight patients reported burning sensation of the oral cavity with the first dose, and this caused one patient to discontinue therapy. Conclusions MB oral rinse showed significant pain reduction and improved oral functioning with minimal adverse effects. Trial registration ClinicalTrials.gov ID: NCT03469284.

Pelvic floor dysfunction and its associated symptoms are a common clinical challenge in the cancer population. Despite the noninvasive nature of pelvic floor rehabilitation (PFR) for this condition and the promising clinical results observed with its use, PFR appears to be an underused therapy.The purpose of this study was to quantify the association between physical therapy of the pelvic floor and its effect on pain relief and the associated symptoms in cancer patients with pelvic floor dysfunction.Retrospective cohort study.With the use of an electronic database in our pain medicine department, we retrospectively quantified the pain relief and symptom improvement in patients diagnosed as having chronic pelvic floor dysfunction who had undergone PFR.Of the 68 patients available for analysis, 49 met the inclusion criteria. Baseline characteristics of included patients were generally similar. The duration of pelvic pain before PFR was 53.7 months (mean) (SD, 182.5 months; median, 12 months). Of the 49 study patients, 23 (47%) had bladder dysfunction, 24 (49%) had dyspareunia, 2 (4%) had erectile dysfunction, and one (2%) had rectal dysfunction. Most symptoms associated with pelvic floor dysfunction resolved after PFR.Single-center, small data, retrospective study.PFR is an effective tool for treating the pain associated with pelvic floor dysfunction and its related symptoms. This conservative approach can contribute to lowering the use of opiate analgesics.

Pain is common in advanced cancer is often refractory to standard treatment. Ketamine has shown promise as an effective adjuvant despite conflicting reports. The aim of this retrospective was to analyze the efficacy of subanesthetic ketamine infusion in the ambulatory setting over an extended follow-up period of 3 months for symptoms related to refractory cancer pain. Forty seven patients treated with intravenous ketamine infusion for refractory cancer pain at a tertiary referral cancer center. Patients demonstrated improvement from baseline in worst, mean, current and least pain immediately after treatment (p

We present a simulation of the orbits of Galactic Centre stars, also known as ‘S-stars’, with the purpose of describing the motion of those bodies for which complete orbits are known with greater accuracy. The aim is to have a better understanding of the inner parts of the Galactic potential. The simulation assumes that the spacetime around the central black hole of the Galaxy may be modelled by the Schwarzschild metric, while stellar interactions are approximated classically. We model the central object as a black hole with mass 4.31 × 106 M⊙, fix the Galactic Centre distance at R = 8.33 kpc and include 37 orbiting stars, all of which have masses of 10 M⊙, except for S2, which has a mass of 20 M⊙. Our method allows us to predict the semimajor axis, a; eccentricity, ϵ; and period, T for these stars and predict their periastron shift, δΘ. In particular for S2, the most scrutinized star, we find δΘ = 11.9342 arcmin, in strong agreement with the observed value.

Scope of the investigation: No standard protocol has been established for the treatment of myofascial pain syndrome (MPS). Invasive therapies such as dry needling and trigger point injection (TPI) with active pharmacological agents are commonly used. Growing evidence suggests the efficacy of TPI is independent of the injectate selected. Normal saline (NS) solution has been described as an efficient injectate used in TPI for the treatment of MPS. Methods: A broad literature search was performed to compare the use of NS and other pharmacological agents as the injectate in TPI for the treatment of MPS. Results: We identified 13 reports comparing the safety and efficacy of NS with that of botulinum toxin A or local anesthetic with or without steroid in TPI. Conclusion: Pain of myofascial origin can be adequately treated with TPI independent of the injectate used. The use of NS in TPI offers lower cost, safety, and a more favorable side effect profile than other TPI injectates.

There is limited human imaging data on the association of adventitial thickness (AT) with arterial disease. Systemic lupus erythematosus (SLE) is a prototypical disease model for studying markers of premature arterial disease. To determine if increased aortic AT is associated with aortic atherosclerosis [increased intima media thickness (IMT) or plaques], stiffness [increased pressure-strain elastic modulus (PSEM)], and vessel remodeling. In total, 70 SLE patients and 26 age- and sex-matched controls underwent transesophageal echocardiography (TEE). Two-dimensional guided M-mode images were obtained to assess AT, IMT, and plaques, and PSEM at the proximal, mid, and distal thoracic aorta. Images were interpreted by 3 observers unaware of the subjects’ clinical data and each other’s measurements. Abnormal aortic AT, IMT, and PSEM were defined as > 2SD above the overall mean values in controls and corresponded to > 1 mm, > 1 mm, and > 10.6 Pascal units, respectively. Plaques were defined as focal-protruding IMT > 50% of the surrounding vessel wall. Abnormal aortic AT, atherosclerosis, and abnormal stiffness were more frequent in SLE patients than in controls (all p ≤ 0.02). In SLE patients, abnormal AT combined with atherosclerosis was associated with larger aortic end-diastolic diameters than in controls (p ≤ 0.05). In SLE patients, aortic AT was greater in patients with atherosclerosis and in those with abnormal stiffness than in patients without these abnormalities (all p ≤ 0.02). In patients with abnormal AT, the degree of aortic stiffness was similar to those with atherosclerosis (p = 0.22). In patients with SLE, increased aortic AT is associated with aortic atherosclerosis, abnormal stiffness, and eccentric vessel remodeling.

Background: Transesophageal echocardiography (TEE) has not been compared to transthoracic echocardiography (TTE) for assessment of left ventricular diastolic function (LVDF). Left ventricular diastolic dysfunction is common in systemic lupus erythematosus (SLE), a disease model of premature myocardial disease. Methods: 66 patients with SLE (mean age 36±12 years, 91% women) and 26 age-and-sex matched healthy volunteers (mean age 34±11 years, 85% women) underwent TEE immediately followed by TTE. From basal four-chamber views, mitral inflow E and A velocities, E/A ratio, E deceleration time, isovolumic relaxation time, septal and lateral mitral E’ and A’ velocities, septal E’/A’ ratio, mitral E to septal and lateral E’ ratios, and pulmonary veins systolic to diastolic peak velocities ratio were measured. Measurements were averaged over 3 cardiac cycles and performed by 2 independent observers. Results: LVDF parameters were worse in patients than in controls by TEE and TTE (all p?0.03). Most LVDF parameters were similar within each group by TEE and TTE (all p?0.17). By both techniques, mitral E and A, mitral and septal E/A ratios, septal and lateral E’, septal and lateral E/E’ ratios, and average E/E’ ratio were highly correlated (r=0.64-0.96, all p?0.003); E deceleration time, isovolumic relaxation time, and septal A’ velocities were moderately correlated (r=0.43-0.54, all p?0.03); and pulmonary veins systolic to diastolic ratio showed the lowest correlation (r=0.27, p=0.04). Conclusion: By TEE and TTE, LVDF parameters were worse in SLE patients than in controls; and in both groups, LVDF parameters assessed by TEE and TTE were similar and significantly correlated.

El rabdomiosarcoma (RMS) es considerado globalmente como una única enfermedad. Existen diferencias importantes de comportamiento entre un RMS y otro, dependiendo de su lugar de origen, su aspecto histológico al microscopio, su tamaño y su posible diseminación a otras localizaciones, así como de la cantidad de tumor residual que queda tras la cirugía inicial y de la edad del paciente en elmomento del diagnóstico.

The recent success of the dark matter model has proven to be an invaluable tool for describing the formation, evolution and stability of galaxies. In this work we study the enhancement function, F , of the gravitational lensing of gravitational waves by galactic dark matter halos and show how this function may be used to distinguish between halo models. In particular we compare an isothermal sphere with an NFW type density distribution, both of which are assumed to be spherically symmetric, and find that our technique clearly distinguishes between the models.

Background: Sacroiliac joint (SIJ) pain is a common source of lower back pain; the factors associated have not been studied in cancer patients. Observing patients with bone marrow aspiration and biopsy (BMAB) who subsequently developed SIJ-pain led to this investigation. Aim: To investigate this possible relationship. Methods: A cohort study of cancer patients diagnosed with SIJ pain. The association of BMAB with SIJ pain was evaluated, as were variables that differed between the groups. Results: The prevalence of SIJ pain was 4.95% (231/4669). Among 231 patients with SIJ pain, 34% (78/231) did not have prior history of lower back pain and had undergone BMAB prior to their diagnosis of SIJ pain. A statistically significant association between BMAB–SIJ-pain was found (p

Background: The effects of adenosine in acute chronic pain are not clear. Literature supports both a pronociceptive/inflammatory role of the A2aR/A2bR and antihyperalgesia/allodynia with A1Rs/A3Rs. Adenosine could participate in the reactivation of chronic regional pain syndrome (CRPS) through inflammatory pathways and via A2Rs. Plastic changes in the brain CRPS-related overlap with those seen in systemic inflammation and persist even after symptoms of CRPS resolve. Aim: To illustrate the hypothesis that intravenous adenosine can reactivate dormant CRPS. Case report: An individual with successfully treated CRPS developed supraventricular tachycardia, he was treated with intravenous adenosine. Shortly after a second dose, he developed severe pain at a lower limb from relapsed CRPS. Treatment included lumbar sympathetic block, physical therapy and pharmacological agents. Conclusion: Intravenous adenosine can reactivate dormant CRPS. Its potential pronociceptive role in CRPS calls for further studies to better elucidate the underlying mechanisms.

The progression of atherosclerosis versus arterial stiffness with age within and between arteries has not been defined. Systemic lupus erythematosus (SLE) is a human model of accelerated arterial disease that may permit this determination. 76 SLE patients (69 women, age 37 ± 12 years) and 26 age-and-sex-matched controls (22 women, age 34 ± 11 years) underwent transesophageal echocardiography and carotid ultrasonography for assessment of atherosclerosis [plaques and intima-media thickening (IMT)] and arterial stiffness [increased pressure-strain elastic modulus (PSEM)] of the descending thoracic aorta and carotid arteries. Since IMT is highly associated with plaques, IMT was used as a marker of atherosclerosis to assess its progression in relation with age and PSEM. Aortic and carotid plaques, IMT, and PSEM were greater in patients than in controls (all p ≤ 0.05). Within the aorta and within the carotid arteries, the average percent increases per decade of age for IMT versus PSEM were similar in patients (8.55% versus 9.33% and 3.39% versus 2.46%, respectively) and controls (5.53% versus 6.60% and 4.75% versus 3.49%, respectively) (all p ≥ 0.58). However, in SLE patients, the average percent increases per decade of age for IMT and PSEM were higher in the aorta than in the carotid arteries (8.55% and 9.33% versus 3.39% and 2.46%, respectively, both p ≤ 0.03). In patients with SLE, atherosclerosis and arterial stiffness progress with age parallel to each other within arteries, but divergently between arteries with different anatomy and hemodynamics.

A 66-year-old gentleman with no prior cardiac history presented with dyspnea on exertion and chest pain for 1 month. His workup included a transthoracic echocardiogram, which demonstrated findings suggestive of cor triatriatum (C-TAT) with uncertain degree of hemodynamic obstruction. In addition, mild left ventricular systolic dysfunction and segmental wall motion abnormalities suggestive of coronary artery disease were noted. The patient then underwent transesophageal echocardiography (TEE) to define better the structural characteristics and hemodynamic significance of the C-TAT, left and right heart catheterization to assess pressure gradients between the upper and lower left atrial chambers by simultaneous measurement of pulmonary capillary wedge and left ventricular end-diastolic pressures, and coronary angiography. Multiplane 2-dimensional TEE demonstrated an atrial membrane extending from the inferior portion of the interatrial septum to the superior aspect of the lateral atrial wall. This membrane exhibited a medial large oval opening with bidirectional flow and a ≤2 mm Hg gradient. Three-dimensional TEE imaging re-demonstrated this obliquely oriented membrane; however, of most importance, it revealed that the membrane divided the atria into a medial funnel and C-shaped cavity with a large distal oval shape opening and an even larger lateral atrial cavity. These findings were inconsistent with a true C-TAT and rather demonstrated what we defined as a pseudo-C-TAT membrane. Simultaneous right and left heart catheterization confirmed a minimal gradient of 3 to 5 mm Hg and coronary angiography demonstrated severe 3-vessel coronary disease as the primary cause of the patient’s clinical syndrome.

Objective Post dural puncture headache (PDPH) is a common complication in patients following diagnostic or therapeutic lumbar puncture, procedures requiring epidural access, and spinal surgery. Epidural blood patch (EBP), the gold standard for the treatment of this pathology requires training not provided to emergency physicians. In addition, the presence of concomitant pathology and abnormal laboratory values are contraindications to perform EBP. In presence of these limitations, we sought for a non-interventional management of PDPH utilizing high-flow oxygen and pro-serotonin agents. We reviewed the mechanism of action of this therapy Methods To illustrate our proposal, we report a series of twelve consecutive patients with PDPH treated with high-flow oxygen therapy at 12 L/min via a non-rebreathing mask and intravenous metoclopramide. Results All patients were treated with this conservative therapy, no adverse reactions were observed. After the intervention, the headache resolved without further indications for PDPH. Conclusion Our series suggests that combining high-flow oxygen and pro-serotonin agents such metoclopramide in the ED might be a feasible option as effective as the invasive methods used in treating PDPH. This therapy appears to be efficient and to minimize risk, cost and side effects. It presents an easily accessible alternative that should be considered when PDPH is not a viable option.

BackgroundThere is a growing body of literature implicating angiotensin II in the modulation of tumor associated inflammation and pain. However, the impact of angiotensin converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) on this pathway has not yet been studied in oral cancers. Our objective is to investigate the role of ACEi and ARB pharmacotherapy on preoperative pain and inflammatory biomarkers, neutrophil to lymphocyte ratio (NLR) and monocyte to lymphocyte ratio (MLR), in patients with oral cancer.MethodsWe performed a retrospective study on patients who underwent oral cancer surgery. Wilcoxon rank sum test or Kruskal-Wallis analysis were used to evaluate differences in demographic, tumor-related, and preoperative characteristics and among patients using ARBs, ACEis, and no treatment. Multivariable analysis was fitted to estimate the effects of important covariates on severe preoperative pain.Results162 patients with oral malignancies were included in the study. After adjusting for significant covariates, patients with perineural invasion were found to have higher levels of pain (p = 0.0278). Likewise, patients taking ARBs were found to have lower levels of perineural invasion (p = 0.035). Our analysis did not demonstrate a significant difference in pain levels when comparing ARBs or ACEis to the no treatment group (p= 0.250). Furthermore, ARB or ACEi use did not significantly alter preoperative NLR (p = 0.701) or MLR (p = 0.869).ConclusionsWhen compared to no treatment, ARBs and ACEis are not associated with significant analgesic effect or decreased inflammatory scores (NLR, MLR).

Background There is a growing body of literature implicating angiotensin II in the modulation of tumour-associated inflammation and pain. However, the impact of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) on pain and inflammation has not yet been studied in oral cancers. The objective is to investigate the role of ACEi and ARB pharmacotherapy on preoperative pain and inflammatory biomarkers, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR), in patients with oral cancer. Methods We performed a retrospective study on patients who underwent oral cancer surgery. The Wilcoxon rank-sum test or Kruskal-Wallis analysis was used to evaluate differences in demographic, tumour-related and preoperative characteristics and amongst patients using ARBs, ACEis and no treatment. Multivariable analysis was fitted to estimate the effects of important covariates on severe preoperative pain. Results A total of 162 patients with oral malignancies were included in the study. After adjusting for significant covariates, patients with perineural invasion were found to have higher levels of pain (p = 0.0278). Similarly, patients taking ARBs were found to have lower levels of perineural invasion (p = 0.035). The analysis did not demonstrate a significant difference in pain levels when comparing ARBs or ACEis to the no treatment group (p = 0.250). Furthermore, the use of ARB or ACEi did not significantly alter preoperative NLR (p = 0.701) or MLR (p = 0.869). Conclusions When compared to no treatment, ARBs and ACEis are not associated with significant analgesic effect or decreased inflammatory scores (NLR, PLR and MLR).

The sacroiliac (SI) joint can be directly jeopardized by malignancy and indirectly by ergonomic changes of pelvic obliquity that introduces uneven weight distribution. Cancer treatment can exacerbate preexisting arthritis and cause diffuse arthropathies, but these are unlikely to be isolated to the SI joint. The cancer population is exposed to unique stressors that might facilitate development of SI joint pain that includes cancer itself and therapy-related complications. Like the general population, cancer patients are subject to aging and BMI and musculoskeletal structural changes that affect symmetric body functioning and posturing. No frank association between sacroiliitis and cancer has been identified. Therefore, we believe there is a need to characterize any relationship between cancer and SI joint dysfunction and pain.

Objective Gastroparesis is a debilitating condition that causes nausea, vomiting, and abdominal pain. Management includes analgesics and antiemetics, but symptoms are often refractory. Haloperidol has been utilized in the palliative care setting for similar symptoms. The study objective was to determine whether haloperidol as an adjunct to conventional therapy would improve symptoms in gastroparesis patients presenting to the emergency department (ED). Study Design and Methods This was a randomized, double-blind, placebo-controlled trial of adult ED patients with acute exacerbation of previously diagnosed gastroparesis. The treatment group received 5 mg of haloperidol plus conventional therapy (determined by the treating physician). The control group received a placebo plus conventional therapy. The severity of each subject's abdominal pain and nausea were assessed before intervention and every 15 minutes thereafter for 1 hour using a 10-point scale for pain and a 5-point scale for nausea. Primary outcomes were decreased pain and nausea 1 hour after treatment. Results Of the 33 study patients, 15 were randomized to receive haloperidol. Before treatment, the mean intensity of pain was 8.5 in the haloperidol group and 8.28 in the placebo group; mean pretreatment nausea scores were 4.53 and 4.11, respectively. One hour after therapy, the mean pain and nausea scores in the haloperidol group were 3.13 and 1.83 compared to 7.17 and 3.39 in the placebo group. The reduction in mean pain intensity therapy was 5.37 in the haloperidol group (p ≤ 0.001) compared to 1.11 in the placebo group (p = 0.11). The reduction in mean nausea score was 2.70 in the haloperidol group (p ≤ 0.001) and 0.72 in the placebo group (p = 0.05). Therefore, the reductions in symptom scores were statistically significant in the haloperidol group but not in the placebo group. No adverse events were reported. Conclusions Haloperidol as an adjunctive therapy is superior to placebo for acute gastroparesis symptoms.

Background: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) have sufficient scientific support for their use as tissue protectors. Preliminary studies suggest that their angiotensin-II type 2 receptor (AT2R)-blocking properties have a beneficial profile in the treatment of neuropathic pain. Objectives: The purpose of the current study was to quantify the extent of the somatosensory effects of ACEI and ARB in cancer patients with chemotherapy-induced peripheral neuropathy. Study Design: We performed a retrospective review of cancer patients with peripheral neuropathy of the upper limbs induced by known neurotoxic anti-cancer agents. Setting: Pain Medicine department at academic tertiary care cancer center. Methods: Using our quantitative sensory testing (QST) data bank, we retrospectively compared the tactile function and the touch, sharp, and thermal thresholds of patients who were previously receiving ACEI or ARB for high blood pressure with these variables in controls who were not receiving ACEI or ARB. Results: Of the 209 patients available for analysis, 145 met inclusion criteria. Baseline characteristics of patients included were generally similar. We identified 29 patients who were receiving AT2R inhibitors prior to starting chemotherapy. Touch thresholds were statistically lower in the thenar aspect of hand in the study group (patients who received AT2R inhibitors) than in the control group [mean (± SD), median 3.03 g (± 11.05), median 0.56 g and 6.75 g (± 18.28), 0.56 g, respectively (P = 0.0441)]. Similarly, the cold pain threshold was statistically higher at the thenar area for the study group [mean (± SD), median 13.23°C (± 8.02), 11.73°C] than for controls [9.89°C (± 6.62), 10.05°C (P = 0.0369)]. Limitations: Inadequacies in the original data acquisition and documentation of the QST and the medical records could not be addressed due to the retrospective nature of the study. Similarly, a discrepancy on the size of the comparison groups could not be reconciled. In addition, based on the available information and the lack of documented concomitant pain levels, we did not find an objective parameter able to correlate the QST findings with pain levels. Conclusions: AT2R inhibitors might offer partial and selective neuroprotective qualities of the myelinated fibers A-β and A-δ in cancer patients who receive neurotoxic chemotherapy. Key words: Quantitative sensory testing, chemotherapy-induced peripheral neuropathy, angiotensin-II type 2 receptor (AT2R)

Study Objective: Our hypothesis is that systemic lidocaine can signifi cantly reduce chronic pain associated with fi bromyalgia. A secondary goal of the study is to determine if other patient demographics can affect the response to IV lidocaine.

Oral mucositis is a common and often debilitating complication among cancer patients receiving radiation therapy to the head and neck or chemotherapy agents, or undergoing hematopoietic stem cell transplantation. Pain and decreased oral function associated with oral mucositis may persist long after the conclusion of therapy. Although most patients respond to conservative management, a subset of patients develops intractable pain with severe consequences. For some, the use of total parenteral nutrition with insertion of percutaneous endoscopic gastrostomy feeding tubes is the only alternative. Current recommendations to treat mucositis and its related pain include basic oral care, bland oral rinses, topical anesthetics, and systemic analgesics. We believe that chemical neurolysis of the affected areas with methylene blue used as an oral rinse is a noninvasive, efficient, safe, and cost-effective alternative that can provide prolonged analgesia in patients with intractable pain of oral mucositis. The benefits of this therapy are reflected in its improvement of patients' quality of life by enabling oral feeding and controlling pain. We report a series of 5 consecutive patients with intractable oral mucositis-related pain despite conventional treatment with systemic opiates. All 5 patients responded well to the use of 0.05% methylene blue as mouth rinse, demonstrating sustained analgesia over 3 weeks. The treatment was tolerated well, and overall patient satisfaction was very high. We also observed that methylene blue rinse significantly reduced the total opioid requirement, as demonstrated by reductions in the patients' morphine equivalent daily dose scores after its use. Our case series suggests that 0.5% methylene blue oral rinse therapy is an effective and inexpensive modality that can be used safely to palliate intractable oral pain in patients with mucositis associated with cancer treatment. To our knowledge, this is the first report using this therapy to treat pain from oral mucositis.

Background: Pain of myofascial origin is a well-recognized pathology characterized by the presence of two components: referred pain; which is often distant from its source and specific to each muscle, and the trigger point, a localized hyperirritable band present in the affected muscle and able to reproduce the referred pain when stimulated. Myofascial pain (MP) commonly coexists in patients with acute or chronic pain of other etiologies. The uniqueness of the clinical presentation of some MPs and the lack of training of most specialties represent a clinical challenge. Thus, many patients with MPS receive less than optimal management of this condition. Objective: Pain at the anterior torso, originating at the posterior torso, can mimic common pathologies that correlate with the same anatomical area such as cardiac and intra-abdominal conditions. These clinical characteristics could be caused by MP of the iliocostalis thoracis-lumborum (ITL) muscle. However, this entity has not been well addressed in the medical literature. In this report we characterize the manifestations, diagnosis, and clinical implications of ITL MP. Study Design: Observational assessment. Setting: Two university-based academic emergency medicine departments (ED) in an urban setting in the United States. Methods: A convenience sample of 43 patients who presented to the ED with pain at the anterior aspect of the torso (chest, abdomen, or pelvis) and clinical evidence of MP originated in the ITL muscle. Of a clinical trial of patients with MP, we describe a subgroup of patients with MP of the ITL which was clinically evident by the presence of a trigger point (TP) in its ability to reproduce the referred pain present at the anterior aspect of the torso. Patients received a TP injection. In this trial we intend to demonstrate that TP injections using particulate steroids mixed with a local are no more effective than saline alone to treat MP. The primary outcome was pain control (decrease in intensity of 50% or more below baseline numeric pain rating). A follow-up telephone interview was performed by third-party abstractors. Results: Forty-three patients presented with pain of the anterior torso and ipsilateral back, both correlating with the level of the TP of the ITL muscle. The pain had been present from 2 days to 7 years. The most common locations of pain were the right-lower quadrant and the left side of the chest. In many of them a pattern of missed diagnosis was evident despite extensive workups and consultations. Only 17 patients were able to identify the precipitating event; the most common was coughing. Two weeks after TP injection, all patients still had satisfactory pain control. After treatment, no missed pathology or returns to the ED were reported. Limitations: This descriptive portion of the ongoing study does not affect the integrity of the trial itself but could be subject to the introduction of subject selection and selective reporting bias. Similarly, this convenience sample does not establish the incidence of this pathology and challenges the external validity to other clinical settings. Conclusions: Anterior torso pain often resulted in extensive workups before ITL myofascial pain was diagnosed. TP injections were diagnostic and therapeutic of ITL myofascial pain. Key words: Iliocostalis thoracis-lumborum muscle, myofascial pain, referred pain, trigger point injection

Cerebrovascular disease (CVD) manifested as focal brain injury on MRI or cognitive dysfunctionis common in patients with systemic lupus erythematosus (SLE). However, the association of LA dysfunction and CVD in SLE patients in sinus rhythm has not been established. 66patients with SLE (96% women

Cancer therapy-induced oral mucositis (CTIOM) can cause intolerable oral pain resulting in difficulty in chewing, swallowing and speaking. Thus, leading to patients requiring aggressive measures, such as parenteral feeding, the placement of gastric feeding tubes and discontinuation of oncologic treatments. Although, pain is the debilitating symptom, current efforts seem to focus independently in the histological damage, not in pain and symptom care. Current strategies for managing pain from CTIOM entail maintaining oral hygiene and the use of oral rinses, topical anesthetics, prophylactic antimicrobials and systemic analgesics such as opioids. Novel therapies, such as methylene blue oral rinse, are being investigated, with positive outcomes. Therefore, there is a need to identify treatment modalities for pain of CTIOM. Ideally, this should be noninvasive, safe and cost-effective, while providing sustained analgesia.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and chronic complication associated with cancer treatment. Prior investigations have demonstrated the presence of subclinical peripheral neuropathy in patients with colorectal cancer even before the patients had received chemotherapy. OBJECTIVE: To investigate subclinical peripheral neuropathy of the upper limbs in patients with squamous cell carcinoma (SCC) of the head and neck which developed before their exposure to neurotoxic anticancer agents. STUDY DESIGN: Retrospective analysis. METHODS: With the use of our quantitative sensory testing (QST) data bank, we retrospectively assessed the afferent fiber function of 25 patients with SCC of the head and neck before they had received chemotherapy (the patient group) and compared our findings with those from 23 healthy control patients. Skin temperature, sensorimotor function, sharpness detection, thermal detection, and touch detection (using both von Frey monofilaments and the Bumps detection test) were measured. RESULTS: Touch thresholds were statistically higher in the patient group than in the healthy volunteer group at the palm (mean [± SD], 0.54 g [± 0.07 g] and 0.27 g [± 0.05 g], respectively [P < 0.01]) and at the forearm (0.74 g [± 0.12 g] and 0.41 g [± 0.08 g] [P < 0.05]). There was also a clear deficit in touch sensation as indicated by a Bumps detection threshold in patients of 6.5 μm ± 0.8 μm and in controls of 3.7 μm ± 0.5 μm. This yields an elevation in threshold to 165% in the patients relative to that of the control volunteers. The grooved pegboard test showed delayed completion times for patients compared with controls, with differences of 18.65 seconds in the dominant hand and of 23.36 seconds in the nondominant hand. The sharpness detection thresholds did not differ between patients and volunteers. LIMITATIONS: Inadequacies in the original data acquisition and documentation of the QST and the medical records could not be addressed due to the retrospective nature of the study. In addition, based on available information, we did not find an objective parameter able to correlate the QST findings with pre-pain levels. CONCLUSION: Patients with SCC were found to have deficits in sensory function before undergoing treatment, suggesting that cancer itself alters peripheral nerve function and may contribute to the development of CIPN. These results confirm the sensitivity of the Bumps detection test and highlight its potential role in early detection of peripheral neuropathy, especially in cancer patients for whom chemotherapies associated with CIPN have been prescribed.

Neurocognitive dysfunction and brain injury on magnetic resonance imaging (MRI) are common in patients with systemic lupus erythematosus (SLE) and are associated with increased morbidity and mortality. However, brain MRI is expensive, is restricted by payers, and requires high expertise. Neurocognitive assessment is an easily available, safe, and inexpensive clinical tool that may select patients needing brain MRI. In this cross-sectional and controlled study, 76 SLE patients (69 women, age 37 ± 12 years) and 26 age and gender-matched healthy subjects (22 women, age 34 ± 11 years) underwent assessment of attention, memory, processing speed, executive function, motor function, and global neurocognitive function. All subjects underwent brain MRI with T1-weighted, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging. Hemispheric and whole brain lesion load in cm3 were determined using semi-automated methods. Neurocognitive z-scores in all clinical domains were significantly lower and whole brain and right and left hemispheres brain lesion load were significantly greater in patients than in controls (all p ≤ 0.02). There was significant correlation between neurocognitive z-scores in all domains and whole brain lesion load: processing speed (r = − 0.46; p

Cancer pain management is comprehensive, and it generally begins with pharmacotherapy in a step-wise approach per analgesic guidelines established decades ago by the World Health Organization. This analgesic ladder involves the prescribing of co-analgesics, adjuvants, and opioids, with each step depending on pain severity. Although the majority of cancer pain responds to this strategy, there exist patients who do not respond adequately or experience significant side effects or intolerance to pain medications. It is in these patients whom clinicians consider interventional approaches. One approach to manage unremitting unilateral malignant pain includes evaluation for cordotomy, which is an approach that has been effective in such cases. We present a patient with breast cancer metastatic to the pelvis, with associated severe pelvic and right lower limb pain. Due to progressive disease, her pain worsened despite aggressive opioid dose escalations. She ultimately underwent percutaneous left anterolateral cervical cordotomy for malignant right leg pain, resulting in complete resolution of leg pain. We propose that, in select patients with neoplasm-related pain, cordotomy may prove very effective. Level of Evidence V

Background: Aortic (Ao) atherosclerosis is common in systemic lupus erythematosus (SLE), is best assessed by transesophageal echocardiography (TEE), and is characterized by increased intima-media thickness (IMT) and plaques. Although TEE may also allow characterization of Ao adventitial thickness (AT), there is limited data on the pathogenic role of adventitial thickening in Ao atherosclerosis. Methods: 68 SLE patients (62 women, age 36 ± 12 years) and 25 age-and-gender matched healthy controls (22 women, age 34 ± 11 years) underwent multiplane TEE. At a depth of 3-4 cm using narrow sector scan, 2-dimensional guided M-mode images were obtained to assess the presence of plaques, IMT outside of plaques, AT outside of plaques, and AT in plaques at three different levels of the thoracic Ao (proximal, mid, distal). At each aortic level, 3 IMT and 3 AT measurements were taken during end diastole using electronic calipers. These measurements were then averaged. Unaware of subjects’ clinical data, one observer assessed for IMT and plaques while a second observer assessed AT. For purpose of analysis, intima-media thickening was defined as >1 mm which is >2SD above the corresponding overall mean IMT in controls (0.66 ± 0.17 mm), and adventitial thickening as >1.07 mm which is >2SD above the corresponding overall mean AT in controls (0.81 ± 0.13 mm). Plaques were defined as focal-protruding IMT >50% of the surrounding vessel wall at any aortic level. Results: As shown in Table 1A, intima-media thickening and plaques were greater in patients than in controls. Similarly, adventitial thickening was more common in patients than in controls. In addition, AT was greater in patients with intima media thickening, plaques, and intima-media thickening or plaques ( Table 1B) . Furthermore, AT was greater in plaques than AT outside of plaques ( Table 1C ). Conclusion: Adventitial thickening is a pathogenic factor of Ao atherosclerosis in SLE.

Introduction: Aortic (Ao) and carotid (Ca) atherosclerosis (Athero) and cerebrovascular disease (CVD) are common and associated with high morbidity and mortality in systemic lupus erythematosus (SLE). However, it is unknown whether Ao and Ca Athero are parallel or divergently associated with CVD. Methods: 77 SLE patients (age 37±12 years, 70 women) and 26 age-and-sex matched healthy controls (age 34±11 years, 22 women) underwent 1) transesophageal echocardiography and carotid ultrasonography for detection of Athero defined as intima-media thickening (≥2SD of the mean intima-media thickness in controls) or plaques (focal and protruding intima-media thickening that exceeds 50% of the surrounding vessel wall); 2) assessment of prevalent CVD defined as acute stroke/TIA, neurocognitive dysfunction, or focal brain injury on MRI; and 3) assessment of incident stroke/TIA, cognitive disability, or death during a median follow-up of 52 months. Results: Ao but not Ca Athero was more frequent in patients than in controls (42% versus 8%, p=0.006, and 17% versus 12%, p=0.75). Acute stroke/TIA occurred in 31% of patients, focal brain injury in 54%, neurocognitive dysfunction in 44%, or any CVD in 70% of patients. During follow-up, 26% of patients developed stroke/TIA, cognitive disability, or died. Ao but not Ca Athero was associated with prevalent focal brain injury (p=0.06), cognitive dysfunction (p=0.04), or any CVD (p=0.03) ( Table 1 ). Ca Athero was associated with acute stroke/TIA (p=0.02), but Ao Athero detected more patients with these conditions (50% versus 33%). Although Ao and Ca Athero were associated with incident stroke/TIA, cognitive disability, or death (both p≤0.01), Ao Athero identified more patients with these events (65% versus 45%). Conclusion: In patients with SLE Ao as compared to Ca Athero is associated with higher prevalence and incidence of CVD and mortality. Therefore, Ao Athero may be a stronger pathogenic factor or marker for CVD in SLE than Ca Athero.