Rejected

Recent clinical studies showed that central nervous system (CNS) infection caused by varicella zoster virus (VZV) reactivation was more than previously reported. The clinical manifestations were often diverse and complex, and the outcome often varied among different patients. A systematic study is needed to provide clinical characteristics of the CNS VZV infection to help clinicians with clinical diagnosis and management. Toward that end, we retrospectively analyzed the clinical presentations, laboratory results, imaging findings, treatment and outcomes in74 patients with meningitis or meningoencephalitis caused by VZV reactivation in our center from August 2018 to December 2020. Fever, headache, cranial nerve involvement, cognitive changes, meningeal irritation, nausea, vomiting, and Ramsay-Hunt syndrome (RHS) were the most common clinical manifestations of VZV meningitis or meningoencephalitis. Brain MRI analysis showed no obvious abnormal manifestation. Compared to VZV meningoencephalitis, patients with VZV meningitis were younger (56.9±13.8 vs 66.1±8.5 years; P=0.01), and more likely to develope in winter (P=0.04), had lower cerebrospinal fluid (CSF) glucose content (3.68±0.79 vs 4.21±0.94 mmol/L, P=0.02), and a better outcome at discharge (P=0.00). The outcome at discharge was worse in male patients and when longer than 1.5 days passed between onset of the neurological symptoms to initiation of the antiviral treatment.Early intravenous antiviral treatment for VZV meningitis and meningoencephalitis is important and is expected for a good outcome.

Postoperative pain is a major adverse effect of surgery for mixed hemorrhoids. We evaluated whether spinal anesthesia with ropivacaine and hydromorphone provided safe and effective analgesia after surgery for mixed hemorrhoids.

The prognosis of patients with untreated pulmonary arterial hypertension (PAH) has historically been poor. Previous studies have recommended that sildenafil was beneficial, but the dose varies greatly. In this study, we aimed to evaluate the safety and effectiveness of sildenafil [dose: 20 mg/three times a day (TID)] for adult Asian PAH patients.

Pembrolizumab is one of the treatment options for treatment-refractory unresectable advanced or metastatic colorectal cancer with microsatellite instability-high (MSI-H) or deficiencies in DNA mismatch repair (dMMR). Herein, we report a case in which a recurrent cecal cancer lesion showed specific imaging findings and local inflammatory findings during treatment with pembrolizumab, followed by marked shrinkage. The patient was an 80-year-old woman. Postoperative peritoneal recurrence of cecal cancer of approximately 7 cm in size was observed. The patient had MSI-H and was treated with pembrolizumab. After five courses of treatment, the patient presented to our hospital with a chief complaint of abdominal pain. A blood test showed a strong inflammatory reaction, and computed tomography (CT) showed diffuse low-density area in the tumor. Under the suspicion of an abscess, conservative treatment was initiated and the patient quickly recovered. A CT at 1 month showed a marked reduction in size at the same site, and a CT at 3 months showed that the recurrent foci had almost disappeared. The inflammatory reaction before shrinkage in this case may have been caused by tumor immune response to pembrolizumab.

Migraine is a neurological disorder which impairs the patient's quality of life. Several association studies investigating the association between MTHFR gene C677T and A1298C polymorphisms and susceptibility to migraine were published. But the results were conflicting, so authors performed a meta-analysis of published case control studies to find out the exact association between MTHFR polymorphism and migraine susceptibility. Four databases were searched for suitable studies up to December, 2018. Odds ratios (OR) with 95% confidence intervals (CI) was calculated adopting additive, homozygote, co-dominant, dominant, and recessive genetic models. Results of MTHFR C677T polymorphism studies meta-analysis showed significant association with migraine risk using allele contrast, homozygote, dominant and recessive genetic models (T vs. C: OR = 1.18, 95% CI = 1.00-1.26,  = 0.05; TT vs. CC: OR = 1.24, 95% CI = 1.0-1.5,  = 0.04; CT vs. CC: OR = 1.08, 95% CI = 0.97-1.07,  = 0.25; TT + CT vs. CC: OR = 1.15, 95% CI = 1.0-1.29,  = 0.04; TT vs. CT + CC: OR = 1.97, 95% CI = 1.28-3.42,  = 0.002). However, results of MTHFR A1298 polymorphism studies meta-analysis did not show any association with migraine. Subgroup analysis based on ethnicity and migraine types i.e. migraine with aura (MA) and without aura (MO) were also performed. Results of present meta-analysis indicate overall association between MTHFR C677T polymorphism with migraine in total 24 studies, in Asian population and in MA cases but did not show any association with Caucasian population and MO cases.

Chronic stress can cause the gastrointestinal disorders characterized by an altered bowel movement and abdominal pain. Studies have shown that extract (HJE) has anti-inflammatory and antidiarrheal effects, and extract (PEP) has antioxidative and antistress effects. The present study aimed to investigate the possible effects of HJE and PEP in rat models with stress-induced gastrointestinal dysfunctions. The rats were exposed to water avoidance stress (WAS, 1 h/day) for 10 days to induce gastrointestinal disorders. We found that WAS significantly increased fecal pellet output during 1 h stress, gastric emptying, colonic contractility, and permeability compared to the normal rats. Pretreatment with HJE and PEP (0.25 and 0.5 mL/kg, both administered separately) improved the increased gastric emptying and colonic contractility induced by electrical field stimulation, acetylcholine, and serotonin and also alleviated the increased colonic permeability. HJE and PEP also increased the claudin-1 and occludin expressions, reduced by WAS. WAS increased the concentration of TNF- and TBARS and reduced FRAP. HJE and PEP recovered these effects. HJE and PEP improved the gastrointestinal disorders induced by WAS by upregulating the tight junction protein, possibly acting on cholinergic and serotonergic receptors to abolish the colonic hypercontractility and hyperpermeability and degradation of inflammatory cytokines via an antioxidant effect.

The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life.

The case is presented of a girl diagnosed with obstructive hydrocephalus due to pilomyxoid astrocytoma, which required a ventriculoperitoneal shunt (VPS) at the age of 5 years and 10 months. Two months later, magnetic resonance imaging of the brain did not show ventriculomegaly or other signs of increased intracranial pressure. At the age of 6 years and 2 months, a rapid onset of bilateral visual acuity loss developed and she was diagnosed with slit ventricle syndrome. Despite valve revisions of the VPS, she developed an abrupt decline of visual acuity to hand motion at 10 cm. Fundus examination revealed bilateral optic atrophy. She did not report any other systemic symptoms suggesting increased intracranial pressure, such as headache, nausea, vomiting, lethargy, irritability, or altered levels of consciousness.

Immune checkpoint inhibitors and their associated immune-related cutaneous adverse events are continuing to become a mainstay of cancer treatment regimens. While most rashes are mild and easily manageable, severe or persistent rashes like lichenoid dermatoses can significantly impact the quality of life and may require ICI cessation. Lichenoid dermatoses currently have no management guidelines beyond the use of topical or oral steroids. Our study is a single-institution retrospective chart review to characterize ICI-induced lichenoid eruptions, their treatments, and associated tumor response. We utilized natural language processing and our institutional medical record to identify patients with lichenoid eruptions on ICI therapy. One-hundred nineteen patients were identified, of which 108 rashes were characterized as lichenoid dermatitis and fifteen as lichenoid mucositis. Most patients presented with a diffuse distribution (86%, 101/117), with pruritus in lichenoid dermatoses (82%, 89/108) and pain in lichenoid mucositis (80%, 12/15). Successful treatments for lichenoid dermatitis included topical steroids (81%, 88/108), oral antihistamines (21%, 23/108), and oral steroids (15%, 16/108). Of lichenoid dermatitis patients, 21% (23/108) did not respond to treatment (7) or required oral steroids (16). Approximately 28% of patients who had lichenoid dermatitis had delay, reduction, or discontinuation of their ICI because of their irCAE. This descriptive study highlights the impact of lichenoid dermatitis on patients' ability to remain on ICI therapy and the need for more effective non-steroidal management strategies.

Coccygodynia is one of the chronic, refractory painful musculoskeletal disorders. Interventional procedures are applied to patients unresponsive to initial treatment in coccygodynia. This study aims to compare the treatment outcomes of ganglion impar block (GIB) and caudal epidural steroid injection (CESI) in patients with chronic coccygodynia.