Intensity and, to a lesser degree, frequency of visual symptoms previously associated with neck pain or focal vision disorders (computer vision syndrome) showed better classification accuracy using gain at neck torsion position, indicating cervical driven visual disturbances. Moreover, SPNTdiff presented with slightly lower classification accuracy as compared to gain at neck torsion position. Our study confirmed the relationship between cervical driven oculomotor deficits and some visual complaints .Subjective visual complaints are commonly reported in patients with neck pain, but their relation to objectively measured oculomotor functions during smooth pursuit neck torsion tests (SPNTs) has not yet been investigated. The aim of the study was to analyse classification accuracy of visual symptom intensity and frequency based on SPNT results. Forty-three patients with neck pain were referred by orthopaedic outpatient clinics where they were required to fill out 16-item proformas of visual complaints. Infrared video-oculography was used to measure smooth pursuit eye movements during neutral and neck torsion positions. Parameters of gain and SPNT difference (SPNT The cervical spine has undergone scientific scrutiny for many years. From university professors to highly skilled clinicians, many attempts have been made to concur about interconnected signs and symptoms, but the overall understanding remains based on the assumptions that “In the cervical spine, everything is possible”. Many unfortunate people, therefore, suffer from a variety of different symptoms attributed to neck pain disorders ,2. WhileVisual disturbances have been reported over the years in those with neck pain disorders ,6,7. WhiWhile visual symptoms associated with neck pain have received some attention in the literature , focal vdiff) [Oculomotor control of which the ability to smoothly follow a moving target with one’s eyes has been frequently investigated in clinical and research practice  and is adiff) .As to date, no well-established link has been identified between visual symptoms and oculomotor deficits in neck pain patients; it would be of clinical importance to assess such relationship. Visual disturbances remain subjective visual complaints that are often dismissed in clinical practice due to the lack of ability to identify concurrent gaze-related cervicogenic driven functional signs. Therefore, the aim of this study was to investigate whether oculomotor control during the SPNT is related to different visual symptoms commonly described by patients with neck pain disorders.Patients with chronic neck pain were referred from orthopaedic outpatient clinics and were assessed for suitability via telephone interviews prior to participating in the study. All patients had to present with a minimum of 50° of cervical rotation to each side and be free from previous traumatic injury to the neck or head, shoulder or upper extremities pain, and any neurological or vestibular disorders, and were required to have not taken any medication or alcohol for the last 30 h prior to participating in the study. Prior to participation, they read and signed a consent form. The study was approved by the national medical ethics committee (number: 0120-47/2020/6) and was performed in accordance with the Declaration of Helsinki.Patients were required to mark pain intensity on a visual analogue scale (VAS). Each patient underwent a magnetic resonance imaging assessment prior to the initial screening at the orthopaedic outpatient clinic. This information was used to describe the extent and variability of cervical spine structural impairments. The SPNT protocol consisted of three different neck positions: (i) facing forward position , (ii) right neck torsion position at 45° (rotation of the trunk underneath the stationary head to 45° to the left), and (iii) left neck torsion position at 45° (rotation of the trunk underneath the stationary head to 45° to the right). Hip angle during sitting on a chair was 80° of flexion while feet were placed flat on the floor. All measurements were conducted by the same examiner in an isolated room with dimmed lights.−1 and 30° of target movement amplitude with velocity of 30°s−1) at all three different neck positions. Different target movement velocities and amplitudes during all neck positions were performed in random order. After completing the SPNT at each neck position, recalibration of the eye-tracking device was performed during a 5-min rest.Before the test, all patients performed five familiarization warm-up cycles. For each condition patients were required to track 10 cycles of cyclic sinusoidal target movements with their eyes, followed by 1-min rest interval. Patients were tested at two different target movement profiles  was used to measure smooth pursuit eye movements at a sampling rate of 100 Hz ,19,20. Adiff) was calculated, as presented in Equation (1). The calculation was adapted and is similar to that described by Tjell et al. [The eye movement data were filtered for blinks and fixations using Tobii Pro Lab software . The square waves  and saccades were removed from the eye movement data using custom-written software in Matlab . The eye movement data were fitted with a corresponding reference sinusoid with synchronized signal acquisition starting points. Each fitted reference sinusoid consisted of 10 cycles with correspondingly fixed amplitude (converted from angular degrees to pixels) and frequency that matched the profile for each individual condition. The first and last 10% of the amplitude in each eye movement cycle were removed from further analysis. The horizontal eye movements were analysed using gain, calculated as the ratio between eye velocity amplitude and visual target velocity amplitude, as described by Tjell et al. . Gain tol et al. :SPNTdiffEquation (1): gain neutral represents the average gain in the neutral position, gain torsion L represents the average gain during the left neck torsion position, and gain torsion R represents the average gain during the right neck torsion position.For the 16-item proforma, the intensity of the visual symptoms was scaled as 1—mild, 2—moderate, 3—severe and for frequency as 1—rare, 2—occasional, 3—frequent, 4—always. If no visual symptoms were present, patients were instructed to leave the specific item blank (treated as zero score).diff, the Naïve Bayes machine-learning approach was used [diff at the most reliable and specific target movement profiles were used as predictor variables [Median and interquartile range were calculated for intensity and frequency score for each visual symptom as well as the percentage of patients reporting presence of individual visual complaints. Classification analysis was performed in Orange data-mining software . To analyse the accuracy of the classifying intensity or frequency of visual disturbances using gain or SPNTwas used ,23. Gainariables ,25 and tTo develop the machine-learning classifier, data from 43 patients were randomly split into four folds. Three folds were used for model training and cross-validated with the remaining fold, repeating the procedure for all folds. Performance of the machine-learning classifier for each target movement profile was described by the area under the curve (AUC), sensitivity, and specificity.The mean age of 43 patients  enrolled in this study was 41.3 ± 6.7 years (age range 25–51 years) with average pain duration of 13.4 ± 9.1 months and average VAS score 4.9 ± 1.7. The cervical spine magnetic-imaging assessment presented disc protrusions or herniations at the levels from C4 to Th1 in 27 patients, 9 patients presented with facet joints osteoarthritis at the levels from C5 to Th1, 12 patients presented with low-grade spondylolisthesis, and 9 patients presented with cervical spinal stenosis. Thirty-four patients presented with a combination of at least two types of structural deformities; however, in nine patients only one type of structural impairment was present.Percentage of patients as well as median score with interquartile range for intensity and frequency of each visual symptom are presented in diff proved to be slightly lower as compared to gain at neck torsion position for both intensity and frequency of visual symptoms. In general, classification accuracy was medium to low or non-present.Results of the classification analysis are presented in diff but for a smaller number of visual symptoms for both intensity and frequency.The highest classification accuracy of symptom intensity was observed for need to concentrate to read, followed by sore eyes, words moving on page, eye strain, heavy eyes, difficulty judging distance, blurred vision, and red eyes. A similar trend was observed for classifications using SPNTdiff, with both presenting with either moderate or low classification accuracy. Moreover, gain during neck torsion manoeuvre seems to have a more pronounced relation as compared to gain during neutral position, indicating that functional deficits of the cervical spine are related to some subjective visual complaints. SPNTdiff presented with slightly lower classification accuracy as compared to gain during neck torsion position. The highest classification accuracy based on gain was observed for the following visual symptoms: need to concentrate to read, sore eyes, words moving on page, eye strain, heavy eyes, difficulty judging distance, blurred vision, and red eyes. Similar trends were observed for SPNTdiff, but fewer symptoms presented with at least low classification accuracy.The aim of this study was to investigate the relation between oculomotor control during the SPNT and different visual symptoms described by patients with neck pain disorders. Based on the results from our study, it can be concluded that intensity as opposed to frequency of visual symptoms is more related to the parameters of gain and SPNTThe results of our study confirm a stronger relationship between intensity of visual symptoms and SPNT performance than between frequency of visual symptoms and SPNT performance. This is in line with other studies reporting that intensity of subjective symptoms correlates to objective measures of neuromuscular functions of the neck in patients with neck pain disorders . On the diff and certain visual complaints. These deficits might be related to errors in proprioceptive information derived from the neck, transmitted by the cervico-collic and cervico-ocular reflexes [Functional connections between cervical spine deficits at neck torsion position and sensory mismatch commonly observed in neck pain patients could explain the relationship between gain at neck torsion position as well as SPNTreflexes , which creflexes . Neck mureflexes . In addireflexes , where ereflexes ,31. The diff. This information adds to findings reported by Gimse et al. [diff. The presence of pain in the neck region would generally lead to stiffening of the neck muscles [Symptoms that have previously been associated with neck pain disorders, concentrating to read, words moving on page, difficulty judging distance, and blurred vision ,33 showee et al.  where mo muscles , which i muscles . Increas muscles  that can muscles . Difficu muscles .Prolonged time spent in the position where focal vision has to be frequently maintained could lead to focal vision disorders that are suggested to worsen with prolonged use of computers and mobile devices ; therefoNone of the patients from our study reported double vision or diplopia, sensitivity to light, and spots in eyes; therefore, these symptoms were not further analysed. Although Treleaven and Takasaki  reportedImportant limitations of the study were that a heterogenous group of neck pain patients were included in the analysis, altogether possibly influencing the results of our study. Future studies should subgroup patients based on the level and region of pain  and trauOur study confirmed the relationship between cervical driven oculomotor deficits measured during the SPNT and some of the commonly reported visual complaints in patients with neck pain disorders. Intensity of visual symptoms should be considered in clinical practice as it might show a more pronounced relationship to oculomotor control deficits measured during neck torsion positions. Although some relationship was found between visual complaints and oculomotor deficits related to cervical spine, other potential causes not investigated in our study should be considered.


Fibromyalgia is a widespread condition which is currently underdiagnosed; therefore we conceived this study in order to assess whether a diagnostic suspicion may be assumed during widespread screening procedures, so that patients for which a reasonable diagnostic suspicion exist may be redirected towards rheumatologic evaluation. We analyzed a sample of 1060 patients, all of whom were female and undergoing standard breast cancer screening procedures, and proceeded to evaluate the level of pain they endured during mammographic exam. We also acquired a range of other information which we related to the level of pain endured; we suggested a rheumatologic examination for those patients who endured the highest level of pain and then we evaluated how many patients in this subgroup were actually diagnosed with fibromyalgia. Out of the 1060 patients who participated to our study, 139 presented level 4 pain intensity; One patient did not go for rheumatologic examination; the remaining 138 underwent rheumatologic evaluation, and 50  were diagnosed with fibromyalgia. Our study shows that assessing the level of pain endured by patients during standard widespread screening procedures may be an effective asset in deciding whether or not to suggest specialist rheumatologic evaluation for fibromyalgia. Fibromyalgia (FM) is a complex systemic pathology characterized by generalized musculoskeletal pain, sleep disturbance, stiffness, fatigue, and psychological problems ,2. FM isDiagnostic criteria were modified by the ACR in 2010 and 2011, firstly shifting the diagnostic focus away from tender points and towards a clearer and more specific variety of symptoms, then allowing for the possibility of self-reported diagnosis in a research setting, as well as adding a fibromyalgia severity score .Cognitive difficulties, while not commonly assessed at diagnosis, are also common in FM. These include so called “Fibro Fog,” or dyscognition, defined as cognitive dysfunction characterized by memory lapses, confusion, as well as impairing concentration, planning, and organization . Fibro FThe etiology of FM is unknown, and it is likely multifactorial. First-degree relatives of patients with FM are 8.5 times more likely to have this disorder than the general population . HoweverThe strongest evidence points to dysregulation of pain modulation, based upon the results of experimentally induced pain testing yielding heightened processing and attenuated inhibitory process of noxious stimuli ,10, as wPatients with FM have a three-times-higher concentration of substance P in the cerebrospinal fluid . ActivatResearch has demonstrated that FM patients have a lower level of dopamine, which plays a central role in painful conditions modulating pain perception and natural analgesia within supraspinal regions and the spine ,19. It wSome studies have shown a relationship between smoking habit and FM .Prevalence rates of FM have been found to vary between 0.2–4.7% . Among wThere is currently no mass screening program for the detection of fibromyalgia; we decided to evaluate the possibility of assuming the diagnostic suspicion of pain using well-established mass screening procedures .In the literature, there are a series of reference scales validated for diagnosing pain , includiNumerical rating scales have shown high correlations with other pain assessment tools in several studies ,30. The More complex scales ) help to better frame not only the presence/absence of pain but also the impact on the amount of life and daily activities; there are also dedicated scales to detect the possible presence of neuropathic pain , or the risk of addiction in patients undergoing opioid therapy  .It has been shown that pain intensity can be reported quite easily by most patients and that several methods of pain intensity measurement have shown a high intercorrelation ,34. HoweThe aim of this study is, therefore, to investigate whether a link can exist between the level of pain experienced by female patients while undergoing standard mammographic cancer screening procedures and an eventual diagnosis of FM; a subordinate aim was to assess the association between the level of pain endured by the patients and a range of other factors gathered with a questionnaire filled by the patients.This prospective study was performed between June 2017 and July 2020.We analyzed a sample of 1060 patients, all females and all Caucasian, to be subjected to standard breast cancer screening procedures, including mammography and 3D prone ecography with the Sofia system ; we excluded from our study those patients who had previously received breast surgical interventions, those whose breasts were affected by benign pathologies, those who were breastfeeding and those who were affected by other rheumatologic pathologies.Our study proceeded in two distinct phases: during the first phase (round 1) our patients, after having undergone their mammographic exam, were interviewed in order to acquire the following information: age, level of pain on a semiquantitative basis , smoking habit and number of cigarettes/day, coffee drinking habit and number of coffee cups/day, number of children, previous breastfeeding, level of perceived psychological stress, educational qualification, annual income, breast density along with ACR BIRADS classification. We did not consider breast size as a factor as there is no significant evidence of a relation between size and breast pain; in fact, looking at the medical literature, there isnot enough research on the subject in order to demonstrate the contrary .According to the American College of Rheumatology preliminary diagnostic criteria for fibromyalgia , muscle We applied the same level of compression (13 daN) for all the exams we performed, so as to eliminate a possible bias in the onset of pain arousing from a different level compression. After having collected the said information, we proceeded to perform a statistical analysis to investigate the association between the above-mentioned factors and the level of pain. Our patients were informed in writing about the study’s objectives and methods and all agreed to be interviewed; the data were collected prospectively as part of a data collection for subsequent ultrasound evaluation directed at patients whose mammography were negative for malignant tumors .Those patients who experienced the highest level of pain (level 4) were invited to receive a rheumatological examination in order to assess a possible diagnosis of fibromyalgia along with the ACR criteria. The reason why we selected only these patients for rheumatologic examination is that they were the ones who experienced a level of pain far higher than what is reasonably expected from a standard mammography. When, one year later, these patients came back for a new roundof routine breast cancer screening (round 2), we interviewed them in order to assess how many, within this selected cluster, had received an actual diagnosis of fibromyalgia after the rheumatologic exam which we suggested.p-values to measure the association between each of the considered variables and pain scores were computed with a simple ordinal logistic regression model. Variables that resulted to significant to the univariate regression analysis were included in a multivariate ordinal logistic regression model. A p-value < 0.05 was considered statistically significant. All analyses were performed using the statistical software R, version 4.0.2.Data are presented as mean and standard deviation for continuous variables and as frequency and percentages for categorical variables. Pain scores are reported as frequency (percentages) with 95% C.I. The demographic characteristics of the sample are reported in Out of the 1060 patients who participated inour study, 470 presented level 1 pain intensity , 266 presented level 2 pain intensity , 185 presented with level 3 pain intensity (17.45% 15.17–19.74 CI 95%), 139 presented level 4 pain intensity (13.11% 11.08–15.15 CI 95%) ; one of Within the income groups we have divided our patients into percentiles: group 1 goes from the 1st to the 33rd percentile; group 2 goes from the 34th to the 66th percentile; and group 3 goes from the 67th to the 100th percentile. Stress level was assessed by asking our patients about their perceived stress level, similar to our pain level assessment: we felt that a more thorough assessment exceeded the goals of our study. Regarding the pain levels, we divided them into four groups based on the perceived stress level. Breast density, on the other hand, was evaluated in four classes with increasing density according to the guidelines of the ACR.p < 0.01) was found between the levels pain scores and the following factors: age, coffee cups per day, number of children, stress level, breastfeeding, higher income level, breast density, benign pathology and Previous breast surgeries; there was no significant statistical association between other factors we considered and pain level  have consulted a rheumatologist and 50  were diagnosed with fibromyalgia. At ordinal logistic regression a statistically significant association  appears to be associated with a lower average age, number of cigarettes greater than 15, three or more children, a medium-high stress level, three or more coffees per day, having breastfed, low income, medium-high breast density and previous benign disease.p-value Pearson Chi-square coefficient < 0.01).Compared to the multivariate ordinal regression model, the variables that lose significance in the multivariate model are breastfeeding, benign pathology, and previous surgery, while the level of education becomes a significant factor read in relation to the other factors. The multivariate model shows a significant goodness of fit to the data -based clinical diagnosis and criteria-based diagnosis for fibromyalgia, which further contributes to complicate the diagnostic algorithm for this condition .Due to such difficulties, elaborating preliminary procedures in the context of widespread and consolidated diagnostic screening paradigms can help to select those clusters of patients with an increased likelihood of being affected by such conditions and which can afterwards be redirected towards dedicated professionals for diagnosis and care.A significant association between age, stress level, and especially breast density on one side, and pain level on the other was expected, as it is consistent with most scientific literature on the subject ,39,40,41In some studies, drinking coffee has been shown to mitigate pain perception, owing to a direct action consisting ofcentral blocking of adenosine receptors that influence pain signaling and by interaction with peripherical adenosine receptors distributed on sensory afferent fibers .Our resuWhile a larger number of pregnancies appeared to be related to a higher pain level, previous breastfeeding did not show such a significant correlation; further studies will be needed to investigate the subject. We may postulate that having a larger number of children could be correlated with a higher stress level which is related to a higher pain level, or that hormonal changes happening during pregnancy may, somehow, be related to a lower pain feeling threshold.Moreover, patients with a higher income and those who were more educatedexperienced a higher level of pain, although our statistical analyses offered results that were not particularly consistent regarding this subject;education to auniversity degree level, for instance, appeared to be correlated to a higher pain level in univariate analyses, but such result was not confirmed in multivariate analyses.The most notable limit of our study is that our sample was an all-female one, which limits the applicability of our findings for both mixed gender and general population samples; also, our patients were all Caucasian.Another limitation could be the great variability of the subjects subjected to screening: it has been shown that many factors such as the social situation, the situation and the work environment and the history of a previous injury can nevertheless influence the perception of pain and show great differences between individuals .Finally, as previously said, the patients we selected for rheumatologic examination were only those who experienced the highest level of pain, as we were reasonably sure that such an intense pain was not sensibly compatible with a standard mammography. This posits an inherent limit to our study which should be taken onto account when interpreting its results.Moreover, our study is a monocentric one and further multicentric studies may provide deeper insights on the topic.Our study showed a significant association between a high level of pain while undergoing routine mammographic exam and the diagnosis of fibromyalgia; the insidious nature of such disease, on one side, and the large and widespread use of mammographic screening, on the other, suggest that the latter might be used to at least obtain a FM’s diagnosticsuspicion, until more extensive screening routines for fibromyalgia become available such as the use of advanced imaging or artificial intelligence methods already applied or being studied in the breast sector ,44,45,46


Evidence suggests that diagnostic imaging for low back pain does not improve care in the absence of suspicion of serious pathology. However, the effect of imaging use on clinical outcomes has not been investigated in patients presenting to chiropractors. The aim of this study was to determine if diagnostic imaging affects clinical outcomes in patients with low back pain presenting for chiropractic care.A matched observational study using prospective longitudinal observational data with one year follow up was performed in primary care chiropractic clinics in Denmark. Data was collected from November 2016 to December 2019. Participants included low back pain patients presenting for chiropractic care, who were either referred or not referred for diagnostic imaging during their initial visit. Patients were excluded if they were less than 18 years old, had a diagnosis of underlying pathology, or had previous imaging relevant to their current clinical presentation. Coarsened exact matching was used to match participants referred for diagnostic imaging with participants not referred for diagnostic imaging on baseline variables including participant demographics, pain characteristics, and clinical history. Mixed linear and logistic regression models were used to assess the effect of imaging on back pain intensity and disability at two-weeks, three-months, and one-year, and on global perceived effect and satisfaction with care at two-weeks.2162 patients were included, with 24.1% referred for imaging. Near perfect balance between matched groups was achieved for baseline variables except age and leg pain. Participants referred for imaging had slightly higher back pain intensity at two-weeks  and one-year , and disability at two-weeks , but the changes are unlikely to be clinically meaningful. No difference between groups was found for the other outcome measures. Similar results were found when sensitivity analysis, adjusted for age and leg pain intensity, was performed.Diagnostic imaging did not result in better clinical outcomes in patients with low back pain presenting for chiropractic care. These results support that current guideline recommendations against routine imaging apply equally to chiropractic practice. International back pain guidelines recommend against diagnostic imaging for the management of low back pain in the absence of clinical suspicion of underlying serious pathology  or fracture –3. ThereStudies assessing the impact of diagnostic imaging on patient management and outcomes have typically been performed in general medical care settings and do not show evidence that routine imaging improves clinical management . It may Low back pain is the most common reason for patients to present for chiropractic care , 21, 22.A matched cohort study design was performed using the Danish Chiropractic low back pain cohort (ChiCo) study, a prospective longitudinal observational study with one year follow-up performed between November 2016 and December 2019 . As the The ChiCo cohort includes 2818 patients who presented to Danish chiropractors with a new or recurrent episode of low back pain, with or without leg pain, for which they were not in an ongoing course of treatment or long-term management. To be included, patients needed to be 18 years old or over and able to complete electronic questionnaires in Danish. Patients with a confirmed diagnosis of fracture, infection, cancer or other serious pathology were excluded from the ChiCo study. Baseline questionnaires were completed by both participants and chiropractors, and participants underwent a baseline clinical assessment with the treating chiropractor. Follow-up questionnaires were completed by participants at two weeks, three months, and one year. Treatment was provided as needed and not impacted by participation in the study. No limitation was placed on access to other healthcare services. For the current study, participants identified by the chiropractor at baseline to have previous imaging relevant to their current clinical presentation were excluded (N = 656). All other participants in the ChiCo study were eligible for inclusion (N = 2162).Baseline assessment for each participant included two patient questionnaires and a clinical assessment questionnaire completed by the treating chiropractor. The first patient baseline questionnaire was performed at the clinic prior to assessment with the chiropractor. This baseline questionnaire included: age; sex; low back and leg pain intensity, measured on a 0–10 numerical rating scale; low back disability, measured using the Roland Morris Disability Questionnaire (RMDQ), with results proportionally recalculated to a score from 0 to 100; duration of current episode of low back pain ; risk of poor prognosis, measured using the STarT back tool; previous imaging for back pain (yes/no); and expectations about the use of imaging within the initial assessment (yes/no). The second patient baseline questionnaire was performed immediately after the initial assessment, and included: previous treatment for back pain ; and existing co-morbidities. The clinical assessment questionnaire completed by the chiropractor at the first visit included: suspicion of serious pathology as the cause of low back pain (yes/no); low back pain diagnosis ; pre-existing and relevant imaging for the presenting low back pain (yes/no); intention to treat the patient with high velocity, low amplitude manipulation (yes/no); and whether they referred the participant for imaging .Follow-up questionnaires were completed online via REDCap by participants at two weeks, three months, and one year. All follow-up questionnaires included the low back pain numerical rating scale and RMDQ. In addition, the two-week questionnaire included items on satisfaction with care and global perceived effect on low back pain.Participants who were referred for diagnostic imaging  by the chiropractor at the first visit were defined as the exposure group. Participants who were not referred for imaging at the first visit were defined as the non-exposure group.Matching was performed using baseline variables which were considered by the research team to potentially affect the decision to refer for imaging and were also associated with outcome measures on regression analysis. Baseline variable selection was informed by the literature on reasons chiropractors refer for imaging , 29–31, The primary outcomes were participant reported low back pain intensity and disability at three months.Secondary outcomes were participant reported low back pain intensity and disability at two weeks and one year, and global perceived effect on low back pain and satisfaction with care at two weeks. Global perceived effect was measured on a seven-point Likert scale from ‘much better’ (response 1) to ‘much worse’ (response 7). Responses were dichotomised for analysis to ‘improved’  or ‘not improved’ . Satisfaction with care was measured on a five-point Likert scale from ‘to a very high degree’ (response 1) to ‘not at all’ (response 5). Responses were dichotomised for analysis to ‘satisfied’  or ‘not satisfied’ .Missing baseline data were imputed using multiple imputation in SPSS , depending on the type and reason for the missing data. Twenty-seven percent of ChiCo participants did not receive the second baseline questionnaire to complete. Therefore, data related to previous treatment and co-morbidities were imputed for these participants. Missing data were also imputed for baseline leg pain intensity (2.3% missing), low back pain intensity (2.0% missing), and duration of back pain (0.7% missing). Participants with missing outcome data were removed from the analyses.To account for potential differences between the groups that may have impacted on outcomes, the exposure and non-exposure groups were matched on baseline variables using coarsened exact matching (CEM) , 33. In Baseline variables in the exposure and non-exposure groups were presented descriptively. Observed and CEM-weighted standardised differences in means between the exposed and non-exposed groups were calculated for baseline variables used in the matching process.The effect of imaging was estimated using mixed models with random effects of chiropractors and CEM-weightings. The primary model was adjusted for the outcome measure at baseline (low back pain intensity or disability) as well as for duration of pain. Sensitivity analyses were performed with additional adjustment for covariates that did not achieve almost perfect balance with CEM matching (standardised difference in means of zero). Mixed linear models were used for continuous outcomes (back pain intensity and disability), and mixed effect logistic regression was performed for dichotomous outcomes . Separate models were conducted for each time point . All data analyses were performed using STATA .Of the 2,162 participants included in this study, 874 (40.4%) were female, the mean age was 43.3 years (SD: 13.4), and 522 (24.1%) were referred for imaging at the first visit. Of those referred for imaging, 505 (96.7%) were referred for X-ray alone, 8 (1.5%) for X-ray and MRI, 7 (1.3%) for MRI alone, and 2 (0.4%) for X-ray, CT, and MRI. The baseline characteristics of participants referred and not referred for imaging are presented in Table Table The results from the mixed models with CEM weightings are presented in Table To our knowledge, this is the first study that has assessed the effect of diagnostic imaging for low back pain patients who present to chiropractic care. This study found that patients with low back pain presenting for chiropractic care who received diagnostic imaging had similar clinical outcomes when compared to matched patients who did not receive diagnostic imaging. For secondary outcomes, there was a trend towards poorer outcomes among the patients who received imaging; however, differences were small and unlikely to be clinically important.Strengths of this study include the use of prospective longitudinal observational data from a large sample of care-seeking patients with back pain. Statistical methods were used in this study to use observational data to investigate causal effects by matching exposed and unexposed participants on multiple observed baseline variables , thus apA limitation of this study is that unmeasured variables cannot be accounted for. Randomisation ideally results in groups that are similar for both known and unknown variables , whereasThe results of this study suggest that the effectiveness of imaging in patients who seek care from chiropractors for low back pain is similar to results observed in those who seek medical care. Meta-analyses of six randomised controlled trials assessing the effectiveness of imaging for low back pain in patients seeking care from medical doctors  found a Previous randomised controlled trials have found that patients receiving diagnostic imaging have a higher satisfaction with care , 10. In The results of this study support that recommendations from current clinical guidelines for the use of imaging for low back pain are equally relevant for patients presenting for chiropractic care as for those patients presenting to other health professionals –3. The cIn this observational study, diagnostic imaging did not result in better clinical outcomes in patients with low back pain presenting for chiropractic care. Conversely, there was a trend towards slightly poorer outcomes in the imaging group; however, differences were of unlikely clinical importance. These results suggest that current guideline recommendations against routine imaging apply equally to chiropractic practice.


Endometriosis is a disease that is becoming more and more challenging for the medical community. The current therapeutic concepts  often do not lead to sufficient pain control, and late diagnosis and high recurrence rates mean that women affected by the disease can suffer for decades before receiving proper treatment. Although the introduction of certified endometriosis centers has created contact points for surgical therapies performed by endometriosis experts, these centers are not sufficient to offer the affected patients the all-encompassing long-term support they need. In recent years, new findings regarding the pathogenesis and correlations of the pain phenomena caused by endometriosis have shown that conventional therapy strategies are not adequate and individual long-term concepts must be developed. Not only can endometriosis cause nociceptive pain, but it can also lead to a nociplastic reaction with central sensitization. Hence, aside from the classic cyclic complaints, patients increasingly suffer from atypical pain. Due to the high number of affected patients who are treated inadequately, it is necessary for gynecologists in private practices to become familiar with multimodal treatment concepts since they are the central point of contact of their patients. The following article will provide an overview of treatment strategies for chronic symptomatic endometriosis. Endometriosis (EM) is a widely unrecognized gynecological disease. When affected women talk about their pain, their social environment (family and school), but also their pediatricians, family doctors and, above all, gynecologists tend to simply accept it—even though this disease often lasts throughout the entire reproductive phase of their lives and in most cases causes complaints well before their 20th birthday . EndometIt is becoming more and more apparent that the results of conventional  therapies are not satisfactory in the long run . While sAs a first step, we wanted to understand the pain profile of patients diagnosed with and treated for endometriosis. When we analyzed the patients, we found that pain was the main reason they had come to the clinic (about 90%). Half of the women were already on hormonal therapy. Of these, 41.6% reported that their pain continued to occur “cyclically”. Further analysis revealed that these patients also bled during hormonal therapy, and that they perceived the associated pain to be cyclic. In contrast, 55.5% of the patients reported their pain to be acyclic. In patients not receiving hormonal therapy, cyclic pain was predominant (58.4%), yet even in this group, 44.4% reported suffering from acyclic pain. The median pain score on the VAS was 6. Half of all women reported other types of pain, such as dyspareunia, dysuria and dysuria . This inIn this kind of situation, the pain problem should be assessed via an in-depth medical history. It is important to determine whether the pain could be caused by other factors or whether it might be related to surgical problems. Then, a thorough gynecologic and ultrasound examination should follow. Once organ destruction is ruled out, the working hypothesis is that the chronic pain is related to endometriosis. Since endometriosis is essentially a hormonal disease, hormonal drug therapy is a basic therapy. Thus, it is important to check whether the patient is on hormonal therapy and, if so, whether it is sufficient. If not, hormonal therapy should be initiated.No hormonal therapy: It is important to know why this is the case. If the patient wants to have children, for example, hormonal therapy is not appropriate, since it will only waste time. In this case, other conservative multimodal strategies should be offered. However, the desire to have children should then be pursued and hastened accordingly, and if necessary, the patient should be referred to a fertility center. There are times, however, when a “respite from pain” may be beneficial to the patient. This option should be discussed if the patient is in great distress. If the patient is in severe pain, hormonal therapy may be prescribed for 3–6 months. This relieves the patient so that she can recover. However, these days, it is not uncommon for patients to deliberately turn down hormonal therapies A current trend shows that patients are reluctant to accept hormonal therapies. More and more women are rejecting synthetic hormones because they believe that they are unnatural and thus bad for the body. However, since endometriosis is a hormone-dependent disease, which can develop progressively, but can also lead to increasingly severe pain if left untreated due to central sensitization, the patient should receive objective counseling and advice. This might change the patient’s attitude towards hormonal therapy. The benefit of bioidentical progesterone is also often discussed in this context: these can be taken concomitantly and are often perceived as helpful, but there are currently no studies available, and this recommendation is based on patients’ reports. However, if hormones are not well-tolerated and have adverse side effects, one needs to think about alternatives. Although international guidelines recommend COC as a first-line therapy, I agree with Casper that progestin mono-preparations (POP) should be the better first-line option ,14. HoweHormonal therapy, but bleeding: As described by Brandes et al., even light bleeding is often painful when a patient is on hormonal therapy . Thus, tHormonal therapy/no bleeding/persistent pain, in most cases acyclic: In this case, switching from COCs to POPs (Dng) should be attempted. When taking COCs, the cumulative estrogen level exceeds 50 pg/nl, which means that the value is in the active range of proliferation. With POPs, the estrogen level usually remains within the therapeutic window. Although both Dng and Gonadotropin analogues (GnRha) achieve comparable levels of pain reduction during first-line therapy , in the Reminder: In order to evaluate the success of hormonal therapy, the patient MUST be free of bleeding, otherwise it CANNOT work!Another important pillar of therapy is, of course, surgery. It is necessary to thoroughly evaluate whether surgery makes sense for the patient at this point or not. Especially during initial diagnosis, persisting pain under adequate therapy is an important indication for surgery. In this case, surgery often proves to be very effective in reducing pain as well as central sensitization ,20. In cIn case of persistent pain or intense discomfort, the principles of pain therapy should be discussed together with hormonal therapy. Painkillers cannot directly influence endometriosis lesions, but they inhibit the release of pain neurotransmitters and thus also have an anti-inflammatory effect. They intervene in cases of acute nociceptive pain. It is interesting that many patients are also reluctant to take painkillers. They are concerned/afraid that painkillers are dangerous and not healthy for the body. Many patients consciously try to endure the pain or only take painkillers “if there is no other way”. We recommend assessing the pain level according to the visual analogue scale (VAS) and asking patients whether they are bedridden and unable to work. Assessing the intensity of pain is very important. The patient should be encouraged to keep a pain diary so that all ups and downs can be recorded and evaluated. If patients do take painkillers, the product and dosage should be registered, as many patients make mistakes when taking them. Over-the-counter analgesics, for example, are sometimes extremely overdosed. When specifically asked about this, many women state that they have to take more and more painkillers because they frequently suffer from therapy-resistant pain . This is why basic information and advice concerning the purpose of pain therapy and the application regimen is obligatory. According to WHO recommendations, non-steroidal analgesics are part of first-line pain therapy. It is recommended that these be taken early on during the days of pain—in low doses, but regularly and following a fixed schedule. Waiting until the pain is no longer bearable is not advisable here, since it only means that very high doses must then be taken before the pain subsides. Ibuprofen, naproxen or metamizole are suitable analgesics. When taking them, it is advisable to also think about gastroprotection. One could start with an intake of ibuprofen 400 mg 1-1-1, which can then be increased to 3 × 800 mg. If necessary, one could add metamizole, i.e., in the form of drops. Unfortunately, there are very few studies investigating analgesics as pain medication for endometriosis. Only naproxen and ibuprofen have been the subject of some studies for the treatment of dysmenorrhea ,23. The https://www.youtube.com/watch?v=Auca88tmUu8; https://www.pelvicexercises.com.au/pelvic-floor-muscle-tension-article/; https://www.pelvicpain.org.au/our-mission/ (accessed on 10 January 2022). Endometriosis patients can also be prescribed physiotherapy or manual therapy under the indication of lumbar spine syndrome. Regarding the pelvic floor, it must be emphasized that dyspareunia plays a significant role in the patient’s suffering. It is therefore important to discuss this topic with the patient, and if necessary with her partner, and to point out the possibility of seeking sexual medical counseling. In this case, pelvic floor relaxation exercises, TENS applications as well as yoga [https://cucabylinda.com/product/ohnut-set/, accessed on 10 January 2022).It is perfectly understandable and has been well-documented that pain can lead to poor posture and can affect the entire musculoskeletal system. There is extensive data on changes that occurred in patients with chronic pelvic floor pain. Significant changes are especially apparent in the patients’ tone, strength, stamina and their ability to coordinate and relax muscles ,27. If p as yoga  and osteIt is interesting to note that an ever-increasing role is attributed to the patients’ diet when it comes to the development and progression of endometriosis. More and more patients observe that their unspecific intestinal complaints, which they themselves have never considered to be a “gynecological problem”, follow a cyclical pattern. This phenomenon is known as “endo belly”, which means that the patients’ belly is severely bloated . This caAnother important factor in the development and experience of the disease is, of course, the psyche. Various studies have shown that the health-related quality of life of women with endometriosis is significantly lower compared to women who do not suffer from endometriosis . This isAll of these steps are components of a multimodal therapy. If it is not possible to establish an outpatient network for the multimodal therapy of an endometriosis patient, or if the measures are not effective, inpatient multimodal pain therapies offered by some pain centers are also an option. In this case, it is important to ensure that the gynecological aspects of the organically caused disease are also taken into account and that the main component of the multimodal pain therapy is not primarily a psychosomatic approach—a joint  concept would be ideal. Our own experience has shown that this group of patients is highly motivated and that their “efforts” are rewarded by positive results. Endometriosis patients often have such a high level of suffering that they are open to all options that promise to reduce their pain.Endometriosis-associated pain is caused by peripheral (activity of lesions and pain nerve fibers) and central sensitization. Our step-by-step approach was designed to help consider the various aspects of therapy. Central sensitization and its effects are often underestimated, but ultimately lead to patients slipping into a chronic pain syndrome that can gradually worsen. Secondary myofascial pain in the pelvis, in particular, significantly reduces the patients’ quality of life. When the pain becomes chronic, it can also overlap with other chronic pain syndromes such as irritable bowel syndrome (IBS) and painful bladder syndrome or vulvodynia. This is easily recognizable by the lowered pain threshold. In this case, multimodal therapy is even more important.


To compare the effectiveness and complications of intraligamentary anesthesia (ILA) with conventional inferior alveolar nerve block (IANB) during injection and dental treatment of mandibular posterior teeth.n = 35) received ILA injection or IANB group (n = 37) received the conventional IANB. Our primary outcome was to assess pain and stress (discomfort) during the injection and dental treatment, using the numeric rating scale (NRS) from 0 to 10 , whereas recording 24-h postoperative complications was our secondary outcomes.In this randomized, prospective clinical trial, 72 patients , scheduled for dental treatment of mandibular posterior teeth, were randomly allocated to ILA group (p = 0.03), while pain during dental treatment was similar in both groups (p = 0.2). Patients in both groups also reported similar law values of discomfort during treatment (p = 0.7). Although no signs of nerve contact or any other postoperative complications were observed, five patients in IANB group (none in ILA group) reported temporary irritations.Patients in ILA group reported significantly less pain during injection when compared with IANB group (This study showed equivalent effectiveness of both intraligamentary anesthesia and conventional inferior alveolar nerve block, for pain control during routine dental treatment of mandibular posterior teeth. Nevertheless, ILA showed significantly less pain during injection. No major postoperative complications in both groups were observed.ILA could be considered as an effective alternative for routine dental treatment.NCT04563351The online version contains supplementary material available at 10.1007/s00784-021-03787-x. Pain is a relevant problem in dental treatment , making The evidence suggests that IANB is relatively painful and has a comparatively higher failure rate . It alsoA considerable number of literatures on ILA as alternative technique for IANB were generated over the last years , 11. ILAClinicalTrails.gov (ID: NCT04563351). The sample size calculation using “G*power version 3.1” (Heinrich-Heine-University/Germany) was based on the following estimates: T test for means (difference between two independent means), effect size 0.7, α error 0.05, and power (1-ß error) 0.9. It resulted in a samples size of 36 patients in each of the two groups (IANB and ILA).This prospective randomized comparative clinical trial was conducted in the integrated clinical course in the dental school of the University of Greifswald, Germany, after the approval of the local ethics committee of the medical faculty in Greifswald (No. BB 174/18) in a period from December 2018 to June 2019. It was also registered in The patients requiring regular dental treatment in permanent mandibular posterior teeth under local anesthesia were recruited with an age range of 18 to 50 years. Patients were not included if they had a clinical or radiographic sign of acute abscess, pus, or peri-radicular pathology. Also, patients with a systemic disease requiring special considerations during their dental treatment or patients with contra-indications for any of the components of the anesthetic solution  were excluded.Only one tooth per patient was included in the study. A computer-generated random number list with allocation concealment was used to assign patients to one of the two groups , Citojet syringe , and Ultrajet syringe . The patients were also placed in a supine position and the dentist administered the ILA injection without using topical anesthesia with cannulas of 12 mm in length and a gauge of 0.30 mm . Also, Ultracain DS Forte 1:100.000  was used from 1.7-ml ampules. The needle was navigated through the gingival sulcus with the bevel towards the alveolar bone and away from the root surface, at an angle of 30°–40° to the long axis of the tooth and 2–3 mm into the periodontal ligament space between root and alveolar bone. For each root, 0.2 ml of local anesthetic was injected over at least 20 s according to Endo et al. (2008) as well as Bender and Taubenheim (2014) .The intensity of pain during the injection of the LA and during the dental treatment was the primary outcome, assessed by the patient using the numeric rating scale (NRS) 0–10 .The secondary outcomes were postoperative complications, temporary irritation, and the duration of the anesthesia (when the feeling of numbness had disappeared) being assessed after 24 h by calling the patient.p values < 0.05, Mann-Whitney U test and Kruskal-Wallis H, and in cases of p values > 0.05, Student’s t test and one-way ANOVA for independent samples were employed for the main analysis between ILA and IANB. In addition, the data for the different ILA syringe systems were compared in a sub analysis. The influence of categorical variables was shown with chi-square tests and cross tables. A significance level was set at 0.05. All analyses were carried out using SPSS Statistics version 22 .Skewedness, quartiles, and standard deviations were checked for the distribution of the data. For the descriptive analysis of categorical data, absolute and relative frequencies were calculated. For continuous data, minimum, maximum, median, and mean values. Categorical data were visualized via bar charts and consistent data via boxplots. For further explorative data analysis, Kolmogorov-Smirnov test was employed to test for a difference among ILA and IANB. In cases of p = 0.00, Fig. Seventy-two adult patients  were enrolled and participated in this study. They were randomizer located in two groups, IANB group (37 teeth were treated in 37 patients) and ILA group (35 teeth were treated in 35 patients). Both groups showed similar distributions of patients’ age, body mass, gender, treated teeth, and experience level of clinical instructors Table . The perp = 0.03), while both techniques were similarly effective in pain control during the dental treatment (p = 0.2). In cases of ILA, 6 (17%) patients reported high scores of pain (> 5) during treatment and 2 (5.7%) patients during the injection; for IANB, 2 (5.4%) patients reported high scores of pain (> 5) during the injection  showed lower pain scores during the injection and treatment reported by the patients in ILA and IANB groups Table . Howeverp = 0.7), but the distribution showed considerable variation within patients of both groups. One patient in each group rated the experience as unpleasant  and Ultrajet (18.1%), high scores of pains > 5) during following dental treatment were reported. For Citojet syringes, two patients (18%) reported high score of pain (> 5) during the injection and the subsequent treatment were reported. Still, the comparison of the pain parameters for the three different ILA syringes showed a very similar outcome Table , Fig. 5. during fp = 0.005). Three years later, the same authors in another study confirmed the superiority of ILA and found a mean injection pain score of 2.19 ± 1.8 (mean ± SD) for ILA vs. 3.65 ± 1.9 (mean ± SD) for IANB (p < 0.00) [The results of this study indicate that ILA is at least as efficient as IANB in terms of effective pain control and the degree of unpleasantness for routine dental treatment as proposed by other studies and meta-analysis , 10, 11.Although our study as well as other previously mentioned studies had reported a clear superiority of ILA over IANB for injection pain control, “regardless of the type of syringe systems used”, both anesthetic techniques showed no statistically significant differences concerning the success rate, the depth of the block, and pain scores during the subsequent dental treatment.As the pain recognized by the patient is the most important reason for anxiety or phobia of dental treatment and the main aspect in the evaluation of the effectiveness of local anesthetic techniques , 11, thuOn contrast to our result, Dumbrigue et al. reported that the injections of ILA were associated with more pain and discomfort to the patient compared with IANB; however, the authors did not consider each extracted tooth as an independent sample . SeveralIn addition, our study is in agreement with Kämmerer et al.’s  study whOur study confirmed ILA as a reliable alternative technique to IANB with the superiority of the following: the amount of local anesthesia for ILA was small and carries no risk of systemic toxicity with accidental intravascular injection , 15. As ILA has shown to be a safe and reliable method of local anesthesia for treatment of lower premolars and molars, with a success rate comparable to IANB without complications and temporary irritations. Thus, ILA can be considered as an effective alternative to IANB for routine dental treatment to reduce known side effects of IANB.ESM 1 (DOC 33 kb)ESM 2(DOC 217 kb)


Male circumcision is recognized as the most effective method of phimosis treatment. Analyzing the literature, the information about the influence of male circumcision due to phimosis for patients' subjective symptoms such as itching, burning, penile pain, pain during intercourse, and quality of sexual life is insufficient.To investigate the effect of male circumcision due to phimosis to patients' subjective symptoms, including erectile function and satisfaction with their genitals.The single-center prospective study began in January 2018 and ended in January 2020. Sixty-nine male, adult patients, who were qualified for circumcision due to phimosis, were included in the study.The study outcomes were obtained using questionnaires such as visual analog scale 0-10 for itching, burning, penile pain, and penile pain during intercourse; International Index of Erectile Function (IIEF-5) and Male Genital Self Image Scale 7 (MGSIS-7) to assess the changes in patients sexual functioning.Before the circumcision of the 69 patients included in the study, 59 patients (86%) reported some subjective symptoms of phimosis. The most frequent and most severe complaint was pain during intercourse, then itching and burning of the penis. Penile pain at rest was the least frequent. After 3 months from circumcision, subjective symptoms almost completely disappeared. All of 69 patients declared to have a sexual partner. 3 months after circumcision, all patients achieved significant improvement in both obtaining and maintaining an erection based on IIEF-5 score. Their sexual intercourse was more satisfying for them.All patients suffering from phimosis were embarrassed about their genitals before surgery. 3 months after circumcision, satisfaction with genital self-image increased significantly.Male circumcision due to phimosis is not only relieving the clinical symptoms of phimosis, but it also improves the quality of sexual life.Czajkowski M, Czajkowska K, Zarańska K, et al. Male Circumcision Due to Phimosis as the Procedure That Is Not Only Relieving Clinical Symptoms of Phimosis But Also Improves the Quality of Sexual Life. Sex Med 2021;9:100315. Formerly, it was practiced for hygienic and religious reasons. In Judaism and Islam, it is a holy commandment.Phimosis is referred to be a condition when the foreskin becomes unretractable . It can ,In addition, phimosis is a strong risk factor for penile cancer.Subjective symptoms in patients suffering from phimosis could be itching, burning, penile pain, and dyspareunia. However, despite its high incidence, in the literature, there is a lack of conclusive data about the real incidence of subjective symptoms in patients suffering from phimosis.There are no clear guidelines on when circumcision is necessary. Noteworthy, many urologists believe that uncomplicated phimosis is not an indication for male circumcision. Moreover, patients suffering from phimosis are often afraid to undergo circumcision.Analyzing the literature, the information about the influence of male circumcision due to phimosis for patients' subjective symptoms such as itching, burning, penile pain, pain during intercourse, and quality of sexual life is insufficient.The main question that was attempted to answer was how male circumcision due to phimosis affects erectile function (EF), patient self-satisfaction with genitals and whether the MC resolved the subjective symptoms in a group of patients with phimosis.The single-center prospective study was conducted from January 2018 to January 2020. An independent Ethics Committee has approved it.69 Caucasian male, adult patients suffering from phimosis were included in the study. Informed consent for circumcision was obtained from every patient participating in the study. The patients were operated on the same urologist under local anesthesia and using sleeve circumcision technique. There were no complications such as bleeding, infection, or wound dehiscence during the study. The characteristic of the study group is presented in The median age of patients was 45.1 , and the median BMI was 28.4 . To determine clinical symptoms of phimosis, EF, and patient's satisfaction with genitals we used visual analog scale 0-10 (VAS 0-10) for itching, burning, penile pain, and penile pain during intercourse; International Index of Erectile Function (IIEF-5) and Male Genital Self Image Scale 7 (MGSIS-7) questionnaires. All patients completed questionnaires before and 3 months after the surgery.P-value < .05. Data were visualized with boxplots and line plots using ggplot2 package.The statistical analysis was performed using R version 3.4.3 statistical program.All results were presented as mean and standard deviation. Before circumcision of the 69 patients included in the study, 59 patients (86%) reported any subjective symptoms of phimosis. The most frequent and most severe complaint was pain during intercourse , then itching  and burning  of the penis. Penile pain at rest  was less frequent than others. After 3 months from circumcision, subjective symptoms almost completely disappeared or were minimized . The data from the VAS 0-10 for itching, burning, penile pain, and penile pain during intercourse are presented in All of 69 patients declare to have a sexual partner, but before surgery, only 45 patients (65%) found sexual satisfaction. The patients were divided into 4 groups in accordance with the severity of erectile dysfunction (ED) based on the IIEF-5 score . As per this scale, before circumcision, a particular number of patients belonged to the mentioned groups: 23 (33.3%) severe; 4 (5.8%) moderate; 8 (11.6%) mild to moderate; 14 (20.3%) mild; 20 (29.0%) no ED. 3 months after circumcision, all patients achieved significant improvement in both obtaining and maintaining an erection based on IIEF-5 score. Their sexual intercourse was more satisfying for them. The declared level of satisfaction with sexual life was 87% (n = 60). The distribution of patients into groups depending to the severity of ED was as follows: 21 (30.4%) severe; 2 (2.9%) moderate; 4 (5.8%) mild to moderate; 8 (11.6%) mild; and 34 (49.3%) no ED. The results from the IIEF-5 questionnaire are presented in All patients suffering from phimosis were embarrassed about their genitals before surgery. Most answers in the questionnaire (MGSIS-7) related to satisfaction with genitals and the comfort of showing them to others were negative. 3 months after circumcision, satisfaction with genital self-image increased significantly, and patients answered positively to the same questions from MGSIS-7. Results from MGSIS-7 questionnaire are presented in ,MC is considered the most effective treatment for phimosis with efficacy estimated at nearly 100%.To our best knowledge, there is a lack of research using VAS to investigate the impact of male circumcision due to phimosis to alleviate typical symptoms of phimosis such as itching, burning, penile pain at rest, and during sexual intercourse. This kind of test seems to be valuable as a tool for urological consultation because some of the male patients suffering from phimosis are afraid of circumcision harmful effects. In our study, the most frequent complaints before circumcision were pain during intercourse (VAS 3.5 ± 3.2), itching (VAS 2.6 ± 2.7), and burning (VAS 2.1 ± 2.6). Only a few patients reported penile pain without any stimulation (VAS 0.6 ± 1.4). After surgery, all clinical symptoms of phimosis disappear or were minimized .,The role of the prepuce, which is removed during circumcision in sexuality is not clear. It is an integral part of the external genitalia, and it is covering the glans of the penis. Somatosensory innervation becomes from the dorsal nerve of the penis.The meta-analysis by Yang et al assessed the influence of MC on premature ejaculation, intravaginal ejaculation latency time, the difficulty of orgasm, ED, and pain during intercourse. There were no significant differences in premature ejaculation and difficulty of orgasm. However, in the group of circumcised men were significant lower ED, pain during intercourse and intravaginal ejaculation latency time.P = .141). It is worth noting that the confidence in obtaining and maintaining an erection increased significantly in patients after circumcision.P = .4) and Xia et al in the research with the group of 81 patients . In both studies, differences between mean IIEF-5 score were not significant.,P < .005).Yang et al compared EFs in the large group of 442 young adults before and 90 days after circumcision did not achieve significant differences between the mean total IIEF-5 . Moreover, patients enrolled in the study achieved improvement in all aspect of EFs presented in Following Yang et al study, the range of age was 19-35 years,The good self-image of the genital area is an essential part of psychological well-being. In the group of patients with penile abnormalities, genital self-image has been decreased. To investigate the relation between the appearance of phimosis and genital perception, we used Male Genital Self-Image Scale-7 (MGSIS-7).Male circumcision in patient suffering from phimosis relieved all clinical symptoms of phimosis. Moreover, it was able to improve sexual life by better EF and positive genital self-image. This knowledge, important for the patient, will certainly become beneficial for urologists during the explanation process before the patient signs the consent to the circumcision due to phimosis.Mateusz Czajkowski, Conceptualization, Investigation, Formal Analysis, Acquisition of Data, Writing - Original Draft, Writing - Review & Editing; Katarzyna Czajkowska, Methodology, Investigation, Project Administration, Writing - Review & Editing; Karolina Zarańska, Acquisition of Data, Writing - Review & Editing; Alicja Giemza, Acquisition of Data, Writing - Review & Editing; Jakub Kłącz, Acquisition of Data, Writing - Review & Editing; Małgorzata Sokołowska-Wojdyło, Conceptualization, Writing - Review & Editing; Marcin Matuszewski, Conceptualization, Writing - Review & Editing.


Purpose: Evidence of the impact of nutritional risk on health outcomes and hospital costs among Chinese older inpatients is limited. Relatively few studies have investigated the association between clinical and cost outcomes and nutritional risk in immobile older inpatients, particularly those with neoplasms, injury, digestive, cardiac, and respiratory conditions.Methods: This China-wide prospective observational cohort study comprised 5,386 immobile older inpatients hospitalized at 25 hospitals. All patients were screened for nutritional risk using the Nutrition Risk Screening (NRS 2002). A descriptive analysis of baseline variables was followed by multivariate analysis  to compare the health and economic outcomes, namely, mortality, length of hospital stay (LoS), and hospital costs associated with a positive NRS 2002 result.Results: The prevalence of a positive NRS 2002 result was 65.3% . The prevalence of “at-risk” patients (NRS 2002 scores of 3+) was highest in patients with cardiac conditions (31.5%) and lowest in patients with diseases of the respiratory system (6.9%). Controlling for sex, age, education, type of insurance, smoking status, the main diagnosed disease, and Charlson comorbidity index (CCI), the multivariate analysis showed that the NRS 2002 score = 3  were associated with approximately a 1.5-fold higher likelihood of death. NRS 2002 scores = 4  and NRS scores ≥ 5  were associated with a 2-fold higher likelihood of death, compared with NRS 2002 scores <3. An NRS 2002 score of 3 , score of 4 , and scores of ≥ 5  were associated with a significantly  higher likelihood of increased LoS compared with an NRS 2002 scores <3. The NRS 2002 score = 3 group  was associated with a 17.8%, the NRS 2002 score = 4 group  a 31.1%, and the NRS 2002 score ≥ 5 group  a 44.3%, higher likelihood of increased hospital costs compared with a NRS 2002 scores <3 group. Specifically, the most notable mortality-specific comorbidity and LoS-specific comorbidity was injury, while the most notable cost-specific comorbidity was diseases of the digestive system.Conclusions: This study demonstrated the high burden of undernutrition at the time of hospital admission on the health and hospital cost outcomes for older immobile inpatients. These findings underscore the need for nutritional risk screening in all Chinese hospitalized patients, and improved diagnosis, treatment, and nutritional support to improve immobile patient outcomes and to reduce healthcare costs. Many older adults suffer from undernutrition that signals a generally poor nutritional status –6. The nThe worldwide prevalence of undernutrition among older hospital patients ranges from 30 to 50% of all admissions , 13–16, With the largest population in the world, China has a numerically large number of adults aged 65 years and older, with the ratio of non-working old age to working-age adults growing . The undIn China, there is a lack of studies addressing the impact of nutritional risk on health outcomes and health costs, especially in older inpatients with immobility. Our national prospective observational cohort study assesses the association between nutritional risk and clinical outcomes and hospital costs among hospitalized immobile older inpatients, and whether the associations differed by sex, age group , disease diagnosis, and Charlson comorbidity index (CCI) score.Supported by the agenda of the National Health and Family Planning Commission to improve the outcomes among older inpatients, the target population is all older adults hospitalized in 25 general hospitals in China. To ensure the representativeness of the study sample, between November 2015 and July 2017, we used a two-stage stratified random sampling design to create a nationally representative sample of patients in China. In the first stage, a simple random sampling procedure was used to select five provinces and Beijing municipality in eastern China , western China (Sichuan province), and central China (Henan province and Hubei province), a total of six tertiary hospitals enrolled in this stage. In the second stage, 11 secondary hospitals and eight community hospitals were randomly selected from the hospitals attached to these tertiary hospitals.We collected data on immobile inpatients aged ≥ 65 years old; with basic physiological needs carried out in bed, except for active or passive bedside sitting/standing/wheelchair use for examination; and willingness to provide informed consent. A total of 5,386 participants were enrolled in the study, with follow-ups continuing 90 days after enrolment unless they died in the hospital or relinquished medical treatment.The study was approved by the Ethics Committee of Peking Union Medical College Hospital (S-700), and all participants, or their proxies, provided written informed consent before enrolment in the study. Records and information of patients were anonymized and de-identified before the analysis.The data were collected by trained and certified registered nurses. To ensure data quality, the research group developed the project survey manual and operation manual. To ensure accurate data collection, all the nurses received systematic training and testing before they recorded information of patients and applied the NRS 2002. They are all proficient in the process of investigation. All questionnaire results were reviewed by the attentive head nurse in each ward to ensure the completeness and correctness of the raw data. Also, the research group established a quality control team, a communication platform based on the WeChat App to guarantee timely feedback. Proxy respondents, usually a spouse or other legal guardian, were interviewed when the patients were incapable of responding to the questions themselves.According to the European Society for Parenteral and Enteral Nutrition (ESPEN) recommendations , Nutriti2). The NRS 2002 score was calculated by adding the “nutritional score” of 0–3 to the “disease severity score” of 0–3, plus one extra point for “older” patients, who were aged 70 years and older as a subset of all over 65-year-old participants. A total NRS 2002 score ≥ 3 was considered as nutritionally “at-risk,” and the “disease severity score” was categorized as moderate = 3, high = 4, and very high = 5+ , duration of hospitalization measured by the length of hospital stay (LoS), and hospital treatment costs. Treatment costs were derived from the Hospital Information System (HIS) in each hospital after the enrolled patients died or were discharged from the hospital. The HIS belongs to the financial system of the hospital, which records all the expenses incurred by the patient during their hospital stay.We collected sociodemographic variables and health-related variables, with the covariates selected based on previous research –16, 28. 2 test or Fisher's exact test for qualitative variables and Kruskal–Wallis test for quantitative variables. Cox proportional hazards models were constructed to determine the association of nutritional risk with mortality and a generalized linear model with a gamma distribution and a log link was used to assess the association of LoS and hospital costs with the NRS 2002 score. The NRS 2002 score was modeled as both a continuous variable and a categorical variable . The results were reported as hazard ratios (HRs) in mortality and reported as percentage changes (=exp∧coefficient-1) and 95% CIs in LoS and hospital costs. We adjusted for covariate factors in three stages: (1) we adjusted for age and sex; (2) we added education, insurance, and smoking status; and (3) we additionally adjusted for disease diagnosis and CCI score (the fully adjusted model). To examine the shape of the association between NRS 2002 scores and mortality, LoS, and hospital costs, we conducted a restricted cubic spline analysis. We analyzed whether the association of mortality, LoS, and hospital costs with the NRS 2002 score differed by sex, age group , disease diagnosis, and CCI score by separately adding an interaction term to the fully adjusted model. A P value of < 0.05 was considered statistically significant.Statistical analysis was conducted using Stata version 14 for Windows . Descriptive results are expressed as mean and SD or as number and percentage. Bivariate analyses were performed using the χAs shown in the baseline sample characteristics in To assess nutritional status, NRS 2002 scores were calculated . Of the P < 0.001). P < 0.001).Death occurred in 8.4% of patients , the numThe average LoS in the group with NRS scores <3 was 15.0 ± 10.7 days; NRS score 3 was 17.4 ± 15.2 days; NRS score 4 was 20.2 ± 21.6 days; and NRS scores ≥ 5 was 20.8 ± 17.5 . SimilarP < 0.001).In P = 0.001), but did not differ by sex (P = 0.410), age (P = 0.853), and CCI score (P = 0.357). In addition, the relative risk of death from all causes was most notable among immobile older patients with injury . Also, in For the analysis of overall mortality, P < 0.05). In Concerning LoS , the assP > 0.05). In As can be seen in This national study is among the first to examine the burden of undernutrition in Chinese older immobile inpatients with diseases. After adjustment for covariates, nutritional risk, measured by NRS 2002, negatively impacted mortality and hospital LoS and increased the cost of hospitalization.The prevalence of undernutrition risk, based on a positive NRS 2002 result score ≥ 3), was 65.3% in this study. Our NRS result was the same as in Switzerland (64.6 and 62.7%) , but sig, was 65.P < 0.001). A Swiss study of 2028 patients hospitalized in medical wards reported that nutritional risk assessed by NRS 2002 at the time of hospital admission was a good predictor of short-term (30 and 180 days) mortality, with an increased risk in mortality comparing patients scoring NRS 2002 scores of 3 with those with ≥ 5 points  might increase the risk of medical complications, longer LoS, and death , 47. FurThe average LoS in patients with NRS 2002 scores <3 was shorter than the other groups, and a statistically significant association between LoS and a positive NRS 2002 result was demonstrated in our multivariate analysis. Similar LoS findings have been reported in the United States , SwitzerThe association between nutritional risk and LoS was significantly different for patients with cardiovascular and digestive system diseases, neoplasms, and injury, a finding also in accordance with previous studies , 8, 28. Besides the clinical outcomes, international studies have revealed the increased hospital costs and overall economic burden associated with undernutrition in hospitals. In China, there is limited up-to-date information regarding the hospitalization costs associated with hospital undernutrition. After covariate adjustment, “at-risk” (NRS 2002 scores of 3+) older patients had higher hospital costs compared with “not-at-risk” patients (NRS 2002 scores <3). This is consistent with previous studies that reported that undernutrition could raise by 30.13% the average cost associated with hospitalization . SimilarSeveral studies found that early nutrition intervention for “at-risk” patients is highly cost-effective compared to delayed nutrition therapy –56. We rOne limitation of our study was a follow-up for 90 days, with future investigations recommended undertaking observations over a longer duration to better clarify the present findings. In addition, our use of a limited number of nutritional assessment tools restricted the comparison of our results with other studies. Since our study was the first of its kind focusing on immobile older inpatients in China, few comparisons could be made to other Chinese studies. As discussed above, the participants were immobile, but the mandatory NRS 2002 tool does not include this component. We also do not have data on whether the nutritional status might worsen during the hospital stay, which might impact the evaluated health outcomes. Future Chinese studies should employ a wider range of evaluations and further assess the clinical and economic impact of nutritional interventions  in preventing undernutrition across the different Chinese health settings. Also, future studies should develop a more detailed classification of hospital costs specifically associated with being nutritionally “at-risk.” It will be of interest to further assess the different types of health expenditures, namely, the parenteral nutrition, enteral nutrition, medical treatments, nursing care, and X-rays, among nutritionally “at-risk” patients in China.Early assessment, identification, and adequate management of “at-risk” undernutrition patients are warranted. Considering nutritional support can improve health outcomes and reduce healthcare costs. Greater attention to nutrition during the hospital stay and post-discharge among the older population is necessary to provide enhanced quality interventions and care for this vulnerable subpopulation.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Peking Union Medical College Hospital (S-700). The patients/participants provided their written informed consent to participate in this study.Study concept and design by XWu. Analysis, interpretation of data, editing of the manuscript, and drafting of tables by HL and DZ. A critical review of the manuscript for important intellectual content by XWu, HL, DZ, SN, and EM. Patient recruitment, data collection, and manuscript editing by BS, JJ, YL, XWe, SC, WC, SN, and EM. All authors critically reviewed and approved the manuscript before it was submitted.This work was supported by the National Health and Family Planning Commission  (Grant Number: 201502017). The funding bodies had no specific role in study design or data collection, analysis, and interpretation, or manuscript conception and writing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background and Objectives: Burning mouth syndrome (BMS) is an enigmatic, idiopathic, chronic, often painful clinical entity, where patients experience oral burning without clear clinical changes on the oral mucosa. There are yet to be well established standardized and validated definitions, diagnostic criteria or classifications for burning mouth syndrome. The aim of this study is to determine whether vitamin B complex and zinc supplements or 0.02% topical capsaicin rinse, can help alleviate BMS pain/burning levels. The objectives: (1) Gather data before and after treatment with vitamin B complex and zinc supplements (2) After the vitamin B complex and zinc protocol gather data before and after treatment with 0.02% topical capsaicin rinse (3) Data analysis and assessment for both treatment methods. Materials and Methods: 89 patients took part in the vitamin B and zinc supplement treatment regimen, out of those 20 patients took part in the capsaicin rinse treatment regimen. Before and after each treatment pain/burning levels were determined using the Visual analogue scale, salivary flow was also determined. Results: Both treatment methods showed statistically significant data in reducing pain/burning levels. There were no statistically significant changes in the salivary flow after any treatment. Conclusion: vitamin B and zinc supplement therapy and topical capsaicin rinse therapy can be an effective way to decrease pain/burning sensation levels in patients with BMS. More research should be conducted to determine the benefit of either vitamin B and zinc supplement therapy or topical capsaicin rinse therapy, so that BMS patients have treatment options, that have as few side-effects as possible. Burning mouth syndrome (BMS) is an enigmatic, idiopathic, chronic, often painful clinical entity, where patients experience oral burning without clear clinical changes on the oral mucosa. There are yet to be well established standardized and validated definitions, diagnostic criteria or classifications for burning mouth syndrome ,2. BurniAt present there are 3 approaches for the treatment of BMS: behavioral strategies, topical therapies , systemic therapies . Despite having randomized clinical trials reviewing management approaches and providing evidence-based treatment algorithms, the results to treat BMS remain inconclusive .Research has reported that patients with BMS may have decreased levels of vitamins B1 (thiamine), B2 (riboflavin), B6 (pyridoxine), B12  ,10,11. ARecent research has reported that topical capsaicin was used as an analgesic for the treatment of BMS with positive results ,17,18. BThe aim of this study is to determine, whether vitamin B complex and zinc supplements or 0.02% topical capsaicin rinse, can help alleviate BMS pain/burning levels.The research data was acquired between 31 July 2018 and 22 September 2020. The clinical trial was conducted at the Institute of Stomatology (Stomatoloģijas institūts), Riga, Latvia. This controlled clinical trial is part of the doctoral thesis, which has been approved by the Research Ethics Committee of Rīga Stradiņš University (RSU). The research article has been made in accordance with the Helsinki declaration. All subjects gave their informed consent for inclusion before participation in the study. Overall 89 patients  took part in the vitamin B and zinc supplement treatment regimen, out of those 20 patients took part in the capsaicin rinse treatment regimen.Any type of oropharyngeal symptom that can be persistent or intermittent with possible phases of remission/exacerbation during the dayAbsence of any clinically and instrumentally detectable oropharyngeal lesionAbsence of any type of local and/or systemic factor, such as oral diseases, drugs, trauma, hypersensitivity reactions, physical/chemical agentsIn addition (but not mandatory): symptoms are persistent  .To determine the pain/burning sensation intensity, the visual analogue scale (VAS)  was used . During Salivary flow was determined during the appointments with a doctor before and after treatment procedures. Patients were required to collect saliva into 2 tubes  for 5 min each. The flow of the unstimulated saliva was observed when the patient was at rest. The stimulated saliva flow was collected after the patient was chewing a piece of paraffin to stimulate salivation. The norm was set at 0.2 mL/min for unstimulated saliva flow and 0.5–2 mL/min for stimulated saliva flow. If patients had an unstimulated salivary flow of <0.2 mL/min and stimulated flow < 0.5 mL/min, then it was confirmed that the patient had hyposalivation .Additionally, these parameters were also determined—the median age and sex of the patients, the most affected area, median duration of the disease, number of patients with a 50% recovery and full recovery.(a)Zinc supplement pill ). 1 pill—500 mg. Patients ingested 1 pill a day for 1 month in the morning.(b)Vitamin B complex supplement pill (35 mg thiamine (vitamin B1), 35 mg riboflavin (vitamin B2), 35 mg niacin (vitamin B3), 35 mg Pantothenic acid (vitamin B5), 25 mg pyridoxine (vitamin B6), 10 μg vitamin B12, 600 μg Folic acid (vitamin B9), 150 μg Biotin (vitamin B7). 1 pill—370 mg. Patients ingested 2 pills a day for 1 month in the morning and in the evening.During the study patients received two supplements at the same time:In this study the dosages of said supplements did not exceed the recommended dosages as presented in the text “Tolerable Upper Intake Levels for Vitamins and Minerals” done by the European food and safety authority (EFSA). A combined treatment was chosen, so that patients did not have to wait even longer to receive Capsaicin treatment, in the case if the treatment with either zinc or Vitamin B supplements would not be sufficient. Patients only receiving only one treatment option would lead to a higher patient dissatisfaction and a risk of leaving the study, without receiving any other possible treatment options. Pain/burning levels were determined before and after treatment in all three-time frames . Salivary flow levels were determined before and after treatment during the appointment.If the patients’ treatment was not effective after the Vitamin B and Zinc Supplement Therapy Protocol, patients received a treatment regimen with a 0.02% capsaicin rinse . The patp < 0.05). Overall patient data and data frequencies were also checked. To check correlation, the Spearman correlation test was used.Data was analyzed using the Statistical Package for Social Sciences . For nonparametric data, the Wilcoxon test was used for variable comparison before and after each treatment method. The adopted significance level was 5% (Median age for 89 of the patients in the study was 59 years (interquartile range (IQR) 19).The most affected area by the burning sensation was the tip of the tongue, affecting 77 patients  77.6–92.8%), followed by the sides of the tongue, affecting 56 patients , ventral surface of the tongue, affecting 30 patients , lips, affecting 24 patients , palate, affecting 19 patients  and cheeks, affecting 7 patients .The median duration of disease was 6 months (IQR 9).p < 0.000.Median pain/burning sensation levels in the morning before the treatment had a score of 2 (IQR 3). After the treatment the score lowered to 1 (IQR 2). 52 patients  noted improvement, 6  noted worsening, 31  had no change in pain/burning sensation levels, Z = −5.503, p < 0.000.Median pain/burning sensation levels in the afternoon before the treatment had a score of 4 (IQR 2). After the treatment the score lowered to 2 (IQR 2.5). 61 patient  noted improvement, 5  noted worsening, 23  noted no change, Z = −6.156, p < 0.000.Median pain/burning sensation levels in the evening before the treatment had a score of 5.5 (IQR 3). The level score lowered to 3 (IQR 3) after the treatment. 60 patients  noted improvement, 6  noted worsening, 23  noted no change, Z = −6.259, Data shows an increase of pain/burning sensation throughout the day, from morning till evening with a score rising from 2 to 5.5 before the treatment and 1 to 3 after the treatment, but overall data shows lowered pain/burning sensation levels for 58.43% of the patients in all 3 time periods after receiving the treatment. p = 0.046.The median pain/burning sensation score in the morning period for the 20 patients after the vitamin B and zinc supplement therapy protocol was 2 (IQR 1). After the treatment with topical capsaicin the median lowered to 0 (IQR 2). 9 patients  noted improvement, 1  noted worsening, 10  had no change in pain/burning sensation levels, Z = −1.996, p = 0.009In the afternoon period the median pain/burning sensation score for the 20 patients after vitamin B and zinc supplement therapy protocol was 3 (IQR 1). After the treatment with capsaicin the median was 1.5 (IQR 3). 10 patients (50% CI 27.2–72.8%) noted improvement, 2  noted worsening, 8  had no change in pain/burning sensation levels, Z = −2.613, p = 0.005.In the evening period the median pain/burning sensation score for the 20 patients after vitamin B and zinc supplement therapy protocol was 4 (IQR 3). After the treatment with capsaicin the median was 2 (IQR 6). 10 patients (50% CI 27.2–72.8%) noted improvement, 2  noted worsening, 8  had no change in pain/burning sensation levels, Z = −2.789, Data shows an increase in pain/burning sensation throughout the day, from morning till evening with a score rising from 2 to 4 before the treatment and 0 to 2 after the treatment, but overall data shows lowered pain/burning sensation levels for 9  patients in all three time periods of the day after receiving the treatment. p = 0.04) showed an improvement of unstimulated salivary flow and 31 patient  showed an improvement of stimulated salivary flow, the rest of the patients noted either no changes or worsening.Before the treatment procedures we assessed salivary flow rates for 48  of our patients, that complained of reduced salivary flow. Their salivary flow rate for unstimulated saliva was 0.2 mL/min (IQR 0.19) and for stimulated saliva—0.8 mL/min (IQR 0.64), showing that patients had a normal within range unstimulated and stimulated salivary flow rate. The salivary flow was determined a second time after vitamin B and zinc treatment regimen, where the unstimulated salivary flow rate stayed at 0.21 mL/min (IQR 0.28) and stimulated salivary flow rate increased to 1 mL/min (IQR 0.53). 28 patients . The stimulated salivary flow median levels went from 0.94 (IQR 0.85) to 0.91 mL/min (IQR 0.61), with 7 patients (70%) noting improvement z = −1.486, p = 0.137).In the capsaicin rinse treatment regimen group the salivary flow levels were checked for 10 patients, where the lowered unstimulated salivary flow increased from 0.14 (IQR 0.21) ml/min (before the treatment) to 0.225 mL/min (IQR 0.41) (after treatment), with 7 patients (70%) noting improvement , followed by the mucosal surface of the lower lip and anterior hard palate ,4, or thIn this study the median age of patients was 59 (IQR 19) years (mean 57.66 ± Standard deviation (SD) 13.161), the female/male ratio was 10:1. Similarly another study showed, that the mean age of patients with BMS was 61.17 (SD ± 11.75) and the female/male ratio = 3:1 . CompariIn literature the mean severity of BMS pain has been assessed at about 5–8 cm (or 50–80 mm) on a 10 cm (100 mm) Visual Analogue Scale (VAS), with mean VAS pain levels of 7.5 in women and 6.11 in men [Before the treatments, the median levels of pain/burning sensation increased throughout the day. After the vitamin B and zinc supplement therapy there was a decrease in burning sensation in all three-time frames of the day, but still showing that the pain/burning sensation increased throughout the day, with it being the lowest in the morning and highest in the evening. For those patients without or inadequate improvement after the Vitamin B and Zinc Supplement therapy, oral capsaicin therapy was implemented.After oral capsaicin rinse therapy there was a decrease of pain/burning sensation, but still presented an increase of pain/burning sensation from the morning period till the evening.The vitamin B and zinc supplement therapy showed a decrease by 1 point, 2 points, 2.5 points of pain/burning levels for the morning, afternoon, evening respectively, but the oral capsaicin rinse therapy showed decrease by 2 points, 1.5 points, 2 points of pain/burning levels for the morning, afternoon, evening respectively, overall showing, that both treatment regimens had differences in their ability to change the scores of VAS for pain/burning sensation.A larger percent of patients fully recovered using the topical capsaicin protocol (20%) compared to vitamin B and zinc treatment regimen (7.8%), although there were less patients in that specific group. Both treatment options showed results in alleviating pain for patients.Those patients, that did not take part in the oral Capsaicin rinse therapy after receiving Vitamin B and zinc supplements, showed a decrease of pain/burning levels by 1 point for the morning period, by 2 points during the afternoon, by 2 points during the evening. Those patients that after vitamin B and zinc treatment regimen did take part in the oral Capsaicin rinse therapy, after the Vitamin B and zinc treatment regimen showed no changes of pain/burning levels for the morning period, decrease by 1 point during the afternoon, by 2 during the evening .The benefits of vitamin supplements in neuropathic pain treatment can be divided in two aspects: those decreasing damage effects on the nervous fiber vitamin B12) and those that are antinociceptive and antihyperalgesic   and thos. Lamey  reportedThe essential trace element zinc (Zn) has many physiologic roles, being required for growth and functioning of the immune system . It can Capsaicin is known to act on the transient receptor potential cation channel vanilloid subfamily member 1 (TRPV1), which is involved in somatic and visceral peripheral inflammation, in the modulation of nociceptive inputs to spinal cord and brain stem centers, as well as the integration of diverse painful stimuli. Topical capsaicin medications are used for the treatment of painful states derived from neuralgia, diabetic neuropathy, osteoarthritis and rheumatoid arthritis providing analgesic and anti-inflamatory effects on sensory neurons. It has also been reported, that capsaicin can result in an increase of salivary flow by affecting TRPV1 receptors ,29. ReseIn two studies, where a capsaicin oral rinse and an oral capsaicin gel was used, patients experienced pain relief ,17. AlthIn this study it was observed that patients with BMS have a normal non-stimulated salivary flow and stimulated salivary flow and it was also observed that there was a small improvement of non-stimulated and stimulated salivary flow after vitamin B and zinc supplement therapy. Patients who took part in the oral capsaicin rinse therapy had a small increase from lowered to normal levels of non-stimulated salivary flow and a decrease of stimulated salivary flow . A study reported that patients with BMS had a resting salivary flow of 0.40 SD ± 0.27) mL/min and a stimulated salivary flow of 0.87 (SD ± 0.47) mL/min . Overall7 mL/min Overall there are not many studies that describe either using treatment options as vitamin B replacement therapy and zinc replacement therapy or topical capsaicin rinse therapy. This is the only study, that has looked into both.By using a combined vitamin B and zinc treatment and the following treatment with capsaicin, it is possible to greatly reduce the number of patients with BMS and reduce the number of patients that might need a more serious drug treatment. Many parameters were checked before and after treatment. The limitation of the study is that there is no placebo group to compare the existing results and that not all the study participants consented on having all of their clinical data collected. Another limitation of the study is the fact, that the number of subjects is relatively small and that the administration of a combined treatment makes a direct interpretation of the results at the moment difficult.In this study using a Vitamin B and zinc combined supplement therapy we were able to reduce pain/burning levels  for patients with BMS. For patients, that felt that the level of improvement was not satisfactory for their health, by receiving a topical capsaicin rinse were able to reduce their pain/ burning levels further. Vitamin B and zinc supplement therapy and topical capsaicin rinse therapy can be an effective way to decrease pain/burning sensation levels in patients with BMS. More research should be conducted to determine the benefit of either vitamin B and zinc supplement therapy or topical capsaicin rinse therapy, so that BMS patients have treatment options that have as few side-effects as possible.