Rejected

We present a case report of a 26-year-old female patient with acute visual impairment, who had been treated with 50 mg/day topiramate for 5 days for migraine prophylaxis. Ocular examination showed bilateral anterior chamber narrowing and macular striae. She had no previous ocular pathology, but her cycloplegic refraction showed a myopic shift of about 6 D. Topiramate was stopped and the patient's unaided visual level and macular stria returned to normal with topical steroid and cyclopentolate treatment. Recognition of this side effect and discontinuation of the causative drug may prevent angle closure and related vision loss.

Bunting (CSB) is a perennial herb belonging to genus (Papaveraceae), called "Yan-huang-lian" in the Chinese folk. Traditionally, it is used to treat acute conjunctivitis, corneal pannus, acute abdominal pain, hemorrhoidal bleeding, haematochezia, swelling, hepatitis, cirrhosis and liver cancer based on traditional Chinese medicine (TCM) concepts. This review aims to summarize and analyze the pharmacokinetics, pharmacological and toxicological properties of CSB and its extracts; to highlight the relevance of modern pharmacology to traditional pharmacology; also to assess its therapeutic potential. CSB related literatures were searched and screened from databases including PubMed, Web of Science and CNKI. The selected literatures provided reliable source identification evidences. In traditional medicine concepts, CSB has the effects of clearing away heat and detoxification, eliminating dampness, relieving pain, and stopping bleeding. Its modern pharmacology includes hepatoprotective, anticancer, anti-inflammatory, analgesic, antibacterial, anti-oxidative effects. Further, some pharmacological effects support its traditional uses. The CSB total alkaloids (CSBTA) are the main constituents isolated from this plant, and they exert the major of the pharmacological effects. Toxicological studies have shown that the toxicity of CSBTA is mild and reversible in rodents and beagle dogs. Although the present study summarizes the botany, phytochemistry, pharmacokinetics, pharmacology, toxicity, and applications of this plant, it is still necessary to systemically evaluate the chemistry, safety and parameters related to drug metabolism of the extracts or compounds from this plant before or in clinical trials in the future. Meanwhile, cancers and inflammatory-related diseases may be new research directions of this ethnomedicine.

Introduction Acute appendicitis happens to be increasingly common in school-going children and early part of adult life, peak incidence reaching in the teens and early twenties. Luminal obstruction of the vermiform appendix is thought to be essential for the development of appendicular ischemia, gangrene, and perforation. The treatment of choice in acute appendicitis is emergency appendectomy. Appendicitis particularly puts the surgeon in a dilemma whenever the patient presents late by around four to seven days. In case of delay in presentation, complications like appendicular lump formation occur. The factors that make the clinical presentation inconsistent which in turn makes the diagnosis challenging in the case of acute appendicitis are the variable position of the appendix, the degree/grade of inflammation, and the age of the patient. At present, the standard treatment is the Ochsner-Sherren regimen universalized by Oschner and has been mostly practised over many decades as the standard care for the appendicular lump. Conservative regimen does not work in a few cases where urgent surgical exploration is necessary. This study was conducted to compare early appendectomy versus conservative management followed by interval appendectomy in case of appendicular mass and to make a better strategy for effective management of patients with complicated appendicitis. Methods A total of 112 patients were diagnosed as having an appendicular lump as per the available records between June 2018 and June 2021. The total study population was divided into two comparative groups depending upon the treatment they received. The patients in group-1 received medical treatment and those in group-2 had undergone surgical management. The patients in group-1 were treated according to the Ochsner-Sherren regimen. The patients in group-2 were the patients in whom emergency appendectomy was done. If the general condition of the patient did not improve, pain and tenderness didn't subside, the size of phlegmon or abscess was increasing and other features of the acute abdomen were persistent, then it was regarded as a failure of medical treatment and the patient was prepared for surgery on an emergency basis. Results Out of 1192 cases of acute appendicitis admitted between June 2018 and June 2021, a total of 112 patients were diagnosed with an appendicular lump. As per the record, 64 patients were managed conventionally as per the Ochsner-Sherren regimen followed by elective interval appendectomy (group-1) and 48 cases were managed with an emergency surgical procedure (group-2). In group-1, out of 64 patients, non-operative treatment was successful in 58 patients (90.62%). Among the remaining patients, there was a failure of non-operative treatment in six patients and they were subjected to emergency surgical exploration (9.37%). So a total of 58 patients underwent interval appendectomy after six weeks. Out of 54 patients who had undergone emergency appendectomy in both groups, the per-operative finding was an appendicular lump in 55.5% of patients while a total of 44 patients in group-2, were discharged from the hospital within six days (91.66%). But in group-1, only 16 patients were discharged from the hospital within six days (25%), rest were discharged from the hospital after more than seven days of stay. Conclusion Early appendectomy in appendicular mass is safe due to the improvements in surgical techniques and better postoperative care.

Ustekinumab, a monoclonal antibody against interleukin (IL)-12 and IL-23 approved for the treatment of Crohn's disease, has shown to be an effective therapy with a favourable safety profile. Clinical trials and real-world studies have reported very few neurological adverse events, including posterior reversible encephalopathy syndrome, idiopathic intracranial hypertension and headache. We describe the case of a 48-year-old man with Crohn's disease who initiated treatment with ustekinumab on top of ongoing treatment with methotrexate 25 mg/week who presented with an acute-onset encephalopathy that rapidly evolved to severe tetraparesis and akinetic mutism, associated with extensive leukoencephalopathy and restricted diffusion on brain magnetic resonance imaging (MRI), 1 month after the second dose of ustekinumab. Comprehensive in-patient diagnostic testing ruled out vascular, demyelinating, metabolic, tumoral and infectious etiologies. Brain biopsy showed patchy infiltrates of foamy histiocytes with perivascular distribution, associated with edema, diffuse astrocytic gliosis and focal perivascular axonal destruction without demyelination, and ustekinumab-induced neurotoxicity was suspected. After drug discontinuation, the patient presented a complete clinical recovery despite the persistence of leukoencephalopathy. In conclusion, in an era in which biological therapies are continually evolving and expanding, knowledge about the potential neurotoxicity of these new therapies and their management becomes crucial. Although ustekinumab-induced encephalopathy is uncommon, the recognition of this potentially serious side effect is important because prompt withdrawal is associated with a favourable outcome. Whether methotrexate played an additional contributing role is currently unknown, but it is a factor that should be considered.

Primary biliary cholangitis (PBC), a chronic, autoimmune, cholestatic disease, typically occurs in elderly women and commonly presents with pruritus, fatigue, and cholestasis and its complications. Gastric antral vascular ectasia (GAVE), an uncommon cause of upper gastrointestinal bleeding, leading to transfusion-dependent chronic iron deficiency anemia, as the first presentation of PBC is unusual. We present the case of an elderly female with recurrent melena and transfusion-dependent anemia for a year without any history of jaundice, ascites, or hepatic encephalopathy. Investigations revealed iron-deficiency anemia, elevated transaminases, alkaline phosphatase (ALP), coarse liver, splenomegaly, and portal vein dilatation on ultrasound. An endoscopic evaluation revealed erythematous linear stripes in the antrum suggestive of GAVE, without esophageal or gastric varices. FibroScan (Echosens, Paris, France) revealed advanced F3 fibrosis. Further etiological workup showed positive antinuclear and antimitochondrial antibodies, elevated IgM levels, and negative viral markers (hepatitis B, C, A, and E). Clinically significant portal hypertension was revealed by the hepatic venous pressure gradient (HVPG), while transjugular liver biopsy (TJLB) revealed lymphocytic infiltration of bile duct epithelium with the destruction of small and medium-sized bile ductules. Iron supplementation, low-dose ursodeoxycholic acid, and argon plasma coagulation were used to treat the patient. At the three-month follow-up, no melena was reported and her hemoglobin and liver function tests remained normal. Patients with PBC presenting with GAVE and recurrent melena as a presenting symptom are rarely reported. An awareness of this presentation is important for its early diagnosis and effective treatment.

Dialysis disequilibrium syndrome is a severe complication associated with dialysis treatment. Manifestations may range from mild such as headache to severe such as seizures and coma. Risk factors for development include initial dialysis treatment, uraemia, metabolic acidosis, and extremes of age. We report a case of dialysis disequilibrium in a patient with a failing kidney transplant secondary to the recurrence of IgA nephropathy. Disturbance in cognition and neurologic functioning occurred six hours after the completion of initiation of intermittent haemodialysis. During two sessions of intermittent haemodialysis of 3 and 4 hours, urea was reduced by 21.9 and 17.2 mmol/L and measured serum osmolality was reduced by 25 and 14 mOsm/kg, respectively. Subsequent admission to the intensive care unit and initiation of continuous renal replacement therapy for 48 hours resulted in complete resolution of symptoms. In this case report, we discuss atypical clinical and radiologic features of dialysis disequilibrium occurring with modest reductions in urea and serum osmolality.

Chronic pain patients often develop mental disorders, and anxiety disorders are common. We hypothesize that the comorbid anxiety results from an imbalance between the reward and antireward system due to persistent pain, which leads to the dysfunction of the pain and anxiety regulatory system. In this review, we will focus on changes in neuroplasticity, especially in neural circuits, during chronic pain and anxiety as observed in animal studies. Several neural circuits within specific regions of the brain, including the nucleus accumbens, lateral habenular, parabrachial nucleus, medial septum, anterior cingulate cortex, amygdala, hippocampus, medial prefrontal cortex, and bed nucleus of the stria terminalis, will be discussed based on novel findings after chemogenetic or optogenetic manipulation. We believe that these animal studies provide novel insights into human conditions and can guide clinical practice.

Diabetes is a chronic disease caused by defective insulin secretion in the body, resulting in metabolic abnormalities with persistent blood glucose elevation. Osteoporosis is the most common diabetes complication. The aim of this study was to perform a meta-analysis of the effects of alendronate combined with atorvastatin compared with alendronate alone in the treatment of osteoporosis in diabetes mellitus.

Purpose Patients complain of moderate-intensity pain following thyroid surgery. Superficial cervical plexus block (SCPB) can be employed as a component of multimodal analgesia after thyroid surgery. This double-blind, randomized study aimed to compare the effects of bilateral SCPB (BSCPB) on postoperative analgesic requirements following thyroid surgery. Methods A total of 60 American Society of Anesthesiologists (ASA) I-II patients who underwent elective total thyroidectomy under general anesthesia were randomly assigned to Group 1 and Group 2. After inducing general anesthesia, BSCPB was not administered to Group 1, whereas BSCPB was administered using a three-point injection technique with 0.5% levobupivacaine in Group 2. Patient-controlled analgesia (PCA) was applied by using tramadol in both groups for postoperative analgesia. Tenoxicam was administered as rescue analgesic to patients in case of numeric rating scale (NRS) >4. The postoperative consumption of tramadol, rescue analgesic requirement, and hoarseness, hematoma, signs of local anesthetic toxicity were recorded. Results The consumption of tramadol for PCA at two, six, 12, and 24 hours postoperatively, NRS scores in the recovery room, and the number of patients who used tenoxicam as rescue analgesic were significantly lower in Group 2 than in Group 1. The hemodynamic values were similar between the groups. Conclusions Our study demonstrates that BSCPB, when applied as a component of multimodal analgesia, is an effective method for reducing the analgesic requirements following thyroid surgery.

Sarcoidosis is a granulomatous disease with multiple system involvement. It is characterized by the presence of non-caseating granulomas in the involved organs. The most commonly affected organ in sarcoidosis is the pulmonary interstitium. However, extra-pulmonary involvement can be manifested in almost any other organ system. Less commonly, sarcoidosis can manifest with massive splenomegaly. As extensive differential diagnoses, such as hematological malignancies, primary splenic or metastatic tumors, infiltrative disorders, and inflammatory disorders are considered, diagnosing sarcoidosis with the presentation of massive splenomegaly is clinically challenging. Here, we discuss the case of a 56-year-old female with splenic sarcoidosis and skin manifestation.