Rejected

Anterior cruciate ligament reconstruction (ACLR) results in persistent altered knee biomechanics, but contributing factors such as pain or patient function, leading to the altered loading, are unknown.

It remains unclear whether revascularization of moyamoya vasculopathy (MMV) has a positive effect on cognitive function. In this prospective, single-center study, we investigated the effect of revascularization on cognitive function in patients with MMV. We report clinical and radiological outcome parameters and the associations between clinical determinants and change in neurocognitive functioning.

Introduction Subdural hematoma without subarachnoid hemorrhage secondary to intracranial aneurysm rupture is rare and may complicate patient management due to delay in diagnosis and subsequent treatment. Herein, we describe a case presenting with pure SDH secondary to the rupture of a posterior communicating artery infundibular dilatation (PcoA-ID). To the best of our knowledge, this is the first case of rupture of a PcoA-ID with SDH in the convexity and tentorium, which also tracked into the upper cervical spine along the subdural space. Additionally, we briefly discuss the previously published cases of pure SDH secondary to intracranial aneurysm rupture. Case Report A 44-year-old female presented with headache, dizziness, nausea and left-sided diplopia to an outside institution. Initial diagnostic work-up showed no intracranial hemorrhage, however, magnetic resonance angiography and subsequent digital subtraction angiography revealed left posterior communicating artery infundibular dilatation. Two days later, the patient presented with a loss of consciousness. Computed tomography was positive for bilateral hemispheric subdural hematoma with no evidence of subarachnoid hemorrhage. Digital subtraction angiography showed left posterior communicating artery infundibular dilatation and pseudoaneurysm originating from the inferior area of the infundibular dilatation, concerning recent rupture. Balloon assisted coil embolization was performed and the patient had a good outcome without any neurological deficit. Conclusion Subdural hematoma in a young adult without a history of trauma or coagulopathy warrants additional vascular imaging to search for underlying vascular lesions. It should also be kept in mind that infundibular dilatation may rupture and cause a pure subdural hematoma.

Polymyalgia rheumatica (PMR) is an inflammatory rheumatism of the shoulder and pelvic girdles. In 16 to 21% of cases, PMR is associated with giant cell arteritis (GCA) that can lead to severe vascular complications. Ruling out GCA in patients with PMR is currently a critical challenge for clinicians. Two GCA phenotypes can be distinguished: cranial GCA (C-GCA) and large vessel GCA (LV-GCA). C-GCA is usually suspected when cranial manifestations (temporal headaches, jaw claudication, scalp tenderness, or visual disturbances) occur. Isolated LV-GCA is more difficult to diagnose, due to the lack of specificity of clinical features which can be limited to constitutional symptoms and/or unexplained fever. Furthermore, many studies have demonstrated the existence-in varying proportions-of subclinical GCA in patients with apparently isolated PMR features. In PMR patients, the occurrence of clinical features of C-GCA (new onset temporal headaches, jaw claudication, or abnormality of temporal arteries) are highly predictive of C-GCA. Additionally, glucocorticoids' resistance occurring during follow-up of PMR patients, the occurrence of constitutional symptoms, or acute phase reactants elevation are suggestive of associated GCA. Research into the predictive biomarkers of GCA in PMR patients is critical for selecting PMR patients for whom imaging and/or temporal artery biopsy is necessary. To date, Angiopoietin-2 and MMP-3 are powerful for predicting GCA in PMR patients, but these results need to be confirmed in further cohorts. In this review, we discuss the diagnostic challenges of subclinical GCA in PMR patients and will review the predictive factors of GCA in PMR patients.

In recent years, the use of topical morphine gel has increased in the palliative care setting to reduce pain in chronic wounds and fungating tumours. However, there is a paucity of evidence to support its effectiveness. Epidermolysis bullosa (EB) is a rare genetic skin fragility disorder characterised by painful chronic wounds. Adequate control of wound pain can be challenging in this patient group due to other complexities associated with the more severe sub-types of the disease. Topical morphine gel has been used as an adjunct therapy in a small number of EB patients in our tertiary centre in an attempt to improve pain control and quality of life. The purpose of this paper is to demonstrate the efficacy of topical morphine gel used in a variety of EB wounds as well as patient reported reduction in pain through a series of case studies. The case studies suggest a positive effect of topical morphine gel on painful wounds across a spectrum of EB subtypes.

COVID-19 is characterized by persistent symptoms beyond acute illness. In this prospective cohort study of patients with COVID-19, we sought to characterize the prevalence and persistence of symptoms up to 18 months after diagnosis. We followed 166 patients and assessed their symptoms during acute illness, and at 3 and 18 months after disease onset. The mean number of symptoms per patient during acute disease was 2.3 (SD:1.2), dropping to 1.8 (SD:1.1) at 3 months after recovery and to 0.6 (SD:0.9) at 18 months after recovery. However, this decrease was not unidirectional. Between acute illness and 3 months, the frequency of symptoms decreased for cough (64.5%→24.7%), ageusia (21.7% to6%), anosmia (17.5%→5.4%), and generalized pain (10.8% to 5.4%) but increased for dyspnea (53%→57.2%) weakness (47%→54.8%), and brain fog (3%→8.4%). Between 3 and 18 months, the frequency of symptoms decreased for all symptoms but remained relatively high for dyspnea (15.8%), weakness (21.2%), and brain fog (7.3%). Symptoms may persist for at least 18 months after acute COVID-19 infection. During the medium- to long-term recovery period, the prevalence of some symptoms may decrease or remain stable, and the prevalence of others may increase before slowly decreasing thereafter. These data should be considered when planning post-acute care for these patients.

Despite the number of people affected by chronic back pain, and the many available treatment options, even the best modalities provide limited pain reduction on a group level, often without simultaneous improvements in functioning or health-related quality of life. The objective was to provide an overview of the treatment of chronic back pain in clinical practice at a multidisciplinary pain centre, and to study patient and pain characteristics in different treatment groups.

Sleep disturbance is prevalent in patients with degenerative spinal disease, and recent studies have reported that surgical treatment is more effective for improving sleep quality than conservative treatment. We aimed to investigate the perioperative changes of sleep problems in patients who underwent surgical treatment for degenerative spinal disease with a concurrent sleep disorder, and presented them according to various clinical profiles possibly associated with sleep disturbance. In addition, we identified factors associated with poor sleep improvement after surgery. This study used data from the Korea Health Insurance Review and Assessment Service database from 2016 to 2018. We included 3183 patients aged ≥19 years who underwent surgery for degenerative spinal disease and had a concurrent sleep disorder. Perioperative changes in the two target outcomes, including the use of sleep medication and hospital visits owing to sleep disorders, were precisely investigated according to factors known to be associated with sleep disturbance, including demographics, comorbidities, and spinal regions. Logistic regression analysis was performed to identify factors associated with poor improvement in terms of sleep medication after surgery. All estimates were validated using bootstrap sampling. During the 1-year preoperative period, the use of sleep medications and hospital visits owing to sleep disorder increased continuously. However, they abruptly decreased shortly after surgical treatment, and throughout the 1-year postoperative period, they remained lower than those in the late preoperative period. At the 1-year follow-up, 75.6% (2407 of 3183) of our cohort showed improvement in sleep medication after surgery. Multivariable analysis identified only two variables as significant factors associated with non-improvement in sleep medication after surgery: depressive disorder (odds ratio (OR) = 1.25 [1.06-1.48]; = 0.008), and migraine (OR = 1.42 [1.04-1.94]; = 0.028). We could not investigate the actual sleep quality and resultant quality of life; however, our results justify the necessity for further high-quality studies that include such information and would arouse clinicians' attention to the importance of sleep disturbance in patients with degenerative spinal disease.

Chronic rhinosinusitis (CRS) is an inflammatory condition of the nose and paranasal sinuses defined by clinical symptoms, including two or more symptoms, one of which should be either nasal blockage or nasal discharge with or without facial pain/pressure or reduction in/loss of sense of smell […].

Monkeypox, a viral zoonosis caused by an Orthopoxvirus, is clinically characterized by fever, headache, lymphadenopathy, myalgia, rash and burdened by some complications that can be severe and life threatening. Monkeypox, endemic in some central and west African countries, in tropical areas near equator, rose to the headlines following its recent outbreak in non-endemic countries of Europe and the USA. Thus, the World Health Organization, worried about the growing dimension of the problem, declared monkeypox a global public health emergency. Now, after months of careful observation, the western scientific research is drawing conclusion that African endemic countries represent a reserve pool able to feed, through travelers and sexual networks, the outbreak in non-endemic countries in which high-risk communities such as gay and bisexual men are the most affected. Prevention through vaccination and early diagnosis are the core to breaking the chain of diffusion of this epidemic. Particular attention should be paid to avoid the spread from endemic countries, also implementing the economic investments in their public health system. Information campaigns and assistance to high-risk classes in non-endemic countries are important priorities, however, assuming that specific treatments for this disease are still tentative.