Rejected

With increasing attention on the essential roles of the tumour microenvironment in recent years, the nervous system has emerged as a novel and crucial facilitator of cancer growth. In this Review, we describe the foundational, translational, and clinical advances illustrating how nerves contribute to tumour proliferation, stress adaptation, immunomodulation, metastasis, electrical hyperactivity and seizures, and neuropathic pain. Collectively, this expanding knowledge base reveals multiple therapeutic avenues for cancer neuroscience that warrant further exploration in clinical studies. We discuss the available clinical data, including ongoing trials investigating novel agents targeting the tumour-nerve axis, and the therapeutic potential for repurposing existing neuroactive drugs as an anti-cancer approach, particularly in combination with established treatment regimens. Lastly, we discuss the clinical challenges of these treatment strategies and highlight unanswered questions and future directions in the burgeoning field of cancer neuroscience.

A young male presented to a nearby hospital with a left shoulder dislocation after an alleged kickboxing injury. The patient reported worrying clinical findings including excruciating pain and absent sensation distally. Reduction was successful but his shoulder re-dislocated shortly after. His reported symptoms worsened and he was transferred to our institution. Imaging findings were not immediately concerning and he went to theatre the next day for an examination under anaesthetic. His shoulder was re-located easily and an immobiliser applied. Less than an hour later, the patient managed to re-dislocate his shoulder in recovery. He was subjected to another general anaesthetic and successful reduction. He absconded the following day after being declined multiple and increasing doses of opioid analgesia. He re-presented three weeks later with similar clinical findings but a different mechanism of injury. Further exploration of his collateral history revealed that he had been using a false identity. He had presented to all hospitals in our city within the previous 6 months. Once confronted, he did not return to these hospitals. He was also capable of self-relocating his shoulder. This case bore a striking resemblance to a case described by Warren in 2000 of a young lady with an apparently dislocated shoulder presenting to multiple city hospitals looking for analgesia and general anaesthetics. We wished to highlight the diagnostic and ethical challenges associated with these patients. They are vulnerable and so a high index of clinical suspicion is needed on the part of the surgeon to avoid unnecessary interventions. Effective communication between orthopaedic departments is a key recommendation from this case to mitigate risk of harm to these patients.

The purpose of this study was to assess the impact of the injectable opioid drug shortage on analgesia and sedation management in the medical intensive care unit (MICU). A single-center, retrospective cohort study was conducted of mechanically ventilated patients during the injectable opioid shortage. Outcomes were compared between a cohort of patients during the intravenous (IV) opioid shortage (01/01/18-03/31/18) and a control cohort (01/01/17-03/31/17). Total IV opioids and alternative sedative administration were assessed. Richmond Agitation Sedation Score (RASS) and Clinical Pain Observation Score (CPOT) assessments were also evaluated. The primary outcome was percentage of RASS within goal. Secondary outcomes included duration of mechanical ventilation, hospital/ICU length of stay, and mortality. One hundred patients were included (50 patients per cohort). In the shortage cohort, 23.2% fewer IV opioids were used (40 501.8 vs 52 713.8 oral morphine equivalents [OME]). No statistical differences were found in percentage of patients within goal RASS between the shortage and control (median 63.7% vs 74.8%;  = .094) or CPOT (median 49.7% vs 47.7%;  = .575). More patients received enteral opioids and propofol on day 1 in the shortage cohort when compared to the control (22% vs 4%;  = .007 and 76% vs 56%;  = .035) but there were no differences in benzodiazepine, dexmedetomidine, or antipsychotic use. No differences in mechanical ventilation, hospital/ICU length of stay, or mortality were found. Use of less IV opioids during the injectable opioid shortage did not affect achievement of goal RASS and CPOT scores or increase prescribing of sedative medications such as benzodiazepines in the MICU.

Celiac artery compression syndrome is a rare and poorly understood condition. Compression of the celiac artery by the median arcuate ligament causes intractable nausea, vomiting, and postprandial pain. We present a case of a 55-year-old male with a 50-pound unintentional weight loss and intractable vomiting, whose symptoms persisted despite robotic median arcuate ligament release. He later returned to the emergency department where he was found to have a low gallbladder ejection fraction on imaging indicative of biliary dyskinesia, for which he underwent a cholecystectomy. Eventually, his symptoms improved, and he was able to return to his baseline body weight.

A patient-centric approach to pain control represents a paradigm shift in analgesia and one that is both easy to endorse but challenging to execute. As pain mechanisms become increasingly elucidated, the understanding of pain has changed to encompass its complexities. Multiple types and mechanisms of pain have been described, and pain must be seen through the subjective experience of the patient. Earlier descriptions of pain based on intensity are one-dimensional and do not fully encompass the experience of pain. Thus, treating rheumatology patients or any patient in pain requires an understanding of the primary or secondary nature of the pain, underlying conditions, and patient factors such as anxiety, depression, fearfulness, and catastrophizing, all of which can shape and change the nature of the pain. Further, it is important to manage patient expectations concerning chronic pain as complete pain relief may not be possible, but a Patient Acceptable Symptomatic State (PASS) may serve. Functional goals are often more meaningful to patients than pain scores. Pharmacologic therapy for pain must consider side effects as well as analgesia. Patient-centered pain control requires a focus on wellness and disease prevention, personalized care plans, education, support for self-care, and may involve coordination across disciplines to help the patient meet personally meaningful objectives. While patient-centric care has become a buzzword in modern medicine, it is extremely relevant and may be very beneficial to pain patients.

We studied the outcome of cutting seton in the treatment of a high transsphincteric anal fistula in Sudan.

Brucellosis is a common zoonotic infection endemic to certain areas of the Mediterranean, Middle East, Central America, and Sub-Saharan Africa. We present a case of brucellosis in a patient who recently traveled to Grenada and returned to the United States with a wide degree of symptoms. This case explores the etiology, clinical presentation, investigation, and treatment of brucellosis. Though a patient's clinical presentation may be non-specific, the recognition of potential etiologies may aid in empirically treating the infection prior to laboratory confirmation.

The primary goal of spinal anesthesia in lower limb surgeries is to achieve a successful sensory and motor block. Adequate level of spinal block for lower limb orthopedic surgery is T10. Due to multiple factors affecting the level of spinal anesthesia, it is not always easy to control the level of spinal anesthesia.We proposed that maintaining patients in a 10° reverse Trendelenburg position after spinal anesthesia can significantly control the height of the sensory block, resulting in stable hemodynamics.

Narrative review.