Rejected

Amphetamine toxicity typically presents with hypertension and tachycardia. Conversely, clonidine acts as an agonist at central α2 and imidazoline receptors, which may cause brief initial hypertension followed by hypotension and bradycardia in overdose. We report a case of mixed ingestion resulting in posterior reversible encephalopathy syndrome (PRES) successfully treated with phentolamine.A 17-year-old male adolescent presented to the emergency department 2 hours after ingesting up to 25 each of clonidine 0.1-mg tablets and dextroamphetamine 10 mg extended-release capsules. He reported nausea and fatigue with initial blood pressure (BP) 145/95 mm Hg and heart rate (HR) 52 beats per minute (bpm). Nine hours postingestion (HPI), the patient developed headache, photophobia, and confusion with BP 182/111 mm Hg and HR 48 bpm. A computed tomography scan of the head revealed generalized fullness of the cerebellum, upward bulging of the tentorial leaflets, effacement of the fourth ventricle, and crowding of the foramen magnum, suspicious for an atypical presentation of PRES. The patient's systolic BP rose over 200 mm Hg and treated with 2 mg of intravenous phentolamine at 14 HPI. Blood pressure decreased to 133/82 mm Hg, and HR increased to 56 bpm with improvements in headache. Following repeat doses of phentolamine, nicardipine was initiated and increased to 2.5 mg/h for 12 hours. The patient was stable with normal vital signs at 36 HPI.The delayed presentation of hypertensive emergency with PRES may have been due to the actions of extended-release dextroamphetamine and the α2-agonistic effects of clonidine. Phentolamine was chosen for its α1-antagonism and was effective in managing symptoms.

The aim of this study was to translate the Central Sensitization Inventory (CSI) into the Turkish language, to perform a psychometric validation, and to investigate its reliability in patients with chronic spinal pain with an organic origin, patients with fibromyalgia, and pain-free control individuals.

Studies have proved that the enhanced recovery after surgery (ERAS) protocol can significantly improve the recovery course of patients during the perioperative period. The application of minimally invasive surgery is a critical component of ERAS protocol. Single-incision plus one port laparoscopic surgery (SILS plus one) could achieve further minimally invasive surgical results than conventional laparoscopic surgery (CLS). The objective of this trial is to evaluate the safety and feasibility of SILS plus one with ERAS protocol in colorectal cancer.

Inflammatory Bowel Disease (IBD) is becoming more common in an increasingly diverse population. Exposure history is important, especially when prescribing immunosuppressive therapy. We present a case of suspected disseminated histoplasmosis in a gentleman with longstanding Ulcerative Colitis (UC) on anti-TNF with an atypical, large, non-healing duodenal ulcer. We aim to highlight risks, presentation, and management of histoplasmosis in IBD patients on immunosuppression with anti-TNFs. A 49-year-old-male with a 21-year history of left sided UC in remission on Infliximab (10 years) presented to our ED with orthostatic symptoms and melena. He reported two months of heartburn and epigastric pain refractory to acid suppression. In the ED, vitals were unremarkable. Labs showed BUN 38 mg/dL, hemoglobin 13.3 g/dL, and abnormal AST/ALT. Evaluation of mild chest discomfort revealed normal EKG and calcified nodule in the left lower lobe on chest X-ray. Tuberculosis testing was negative. EGD found a massive, 3-4cm, cratered, medial wall, hemi-circumferential ulcer from duodenal apex into the second duodenal segment (D2). Biopsies revealed acute inflammation, without CMV, dysplasia, malignancy or helicobacter pylori. CT identified a large mass 5×3.1×3.2cm in the pancreaticoduodenal groove from D2 without pancreatic duct dilation. There were prominent right axillary and sub-pectoral lymph nodes and the calcified granuloma seen on X-ray. He denied NSAID use. Symptomatic improvement occurred on aggressive acid suppression. EGD a month later showed persistent ulcer with unchanged pathology. EUS showed significant peri-duodenal thickening without malignant findings. IgG/IgG4 immunostains were negative. CEA and CA 19-9 were normal. Subsequent EGDs and imaging showed no changes. He developed duodenal stenosis requiring dilation. Hematology/Oncology evaluation was unrevealing and hyper-secretory disorder was ruled out. Lack of healing over seven months prompted referral to Infectious Disease. They identified bird dropping exposure with repeated deck pressure washing. Positive Histoplasma immunodiffusion M band indicated prior infection. Given exposure, lab, chest imaging and endoscopic findings, treatment for disseminated histoplasmosis (DH) with Itraconazole was initiated. Infliximab was held and mesalamines were restarted. Histoplasmosis is endemic to the Ohio/Mississippi River Valley and other countries. Disseminated histoplasmosis, typically found in the immunocompromised, presents in many ways with GI involvement in 70%. Diagnosis can be difficult as histoplasmosis mimics other diseases, including IBD. Prognosis is poor if left untreated. Endoscopically, ulcerations, mass-like lesions, or strictures are seen. Aside from identifying yeast, pathology is nonspecific. Severity guides treatment, classically involving Itraconazole. In IBD and diseases managed with immunosuppression (e.g. anti-TNFs), stopping therapy during infections is standard of care. Therapy may resume after treatment response. Treatment may be a year for DH. Prophylaxis for histoplasmosis, the most common fungal infection with anti-TNF use, is controversial. Literature exists where anti-TNF was continued during treatment of histoplasmosis with good outcomes. There were no recurrences with continuation or re-initiation of anti-TNF after treatment. However, many patients switched therapies. Though histoplasmosis rarely causes infection in IBD patients, outcomes can be poor. We must be aware of possible exposures, atypical or presentations mimicking IBD to identify infection early, stop immunosuppression and provide timely treatment.

Smegma pearls can cause diagnostic dilemmas for pediatricians who are unfamiliar with this condition leading to unnecessary investigations and referrals. Despite the common occurrence of smegma pearls in uncircumcised young boys, it is not often reported in the literature. Smegma is a normal secretion consisting of desquamated epithelial cells, fat, and protein. It has mixed bacterial flora with smegma bacillus in 50% of cases. Smegma itself is neither damaging nor irritating substance and as Howe has stated, it is not carcinogenic also. Smegma production and keratinization of cells facilitate the separation of the fused foreskin from the glans epithelium. we are presenting a case of a penile nodule in the shaft of the penis without any pain, bleeding, or discharge. The smegma content gives a yellowish color to the lump. Smegma pearls do not have any covering sac. When the smegma is covered in a well-formed epithelial wall, it is called a smegma cyst. Long-standing smegma collection can turn into a hard stone-like structure called Smegmolith due to chronic irritation and mineral accumulation. Treatment should include monitoring for resolution with parental reassurance. Smegma pearls are benign, and they spontaneously resolve over time. This case report intends to help pediatricians correctly identify this benign, yet not widely published in the literature condition and reassure the parents and patients to improve the patient care and avoid unnecessary tests and referrals.

Cavernous sinus metastasis is a rare clinical finding, presenting most commonly with complaints of headache, diplopia, visual field defects, facial pain, and progressive neurological deficits. Many patients present with features of III, IV, and VI nerve palsies. We hereby report an unusual case of cavernous sinus metastasis from primary breast cancer in a 40-year-old female, who presented with binocular diplopia due to left VI nerve palsy as the first presenting complaint. The patient had a history of surgery for left breast cancer which was performed at another center. Contrast-enhanced computed tomography (CECT) scan of thorax and abdomen revealed a residual neoplastic left breast mass with satellite nodules, left axillary lymphadenopathy, and hepatic, splenic, and skeletal metastasis. Contrast-enhanced magnetic resonance imaging (CE-MRI) of brain and orbit showed enhancing lesion of 20 mm x 10 mm along the lateral wall of left cavernous sinus and left petrous apex. She was referred to radiation oncology department for further management. This case report highlights the importance of ophthalmologists in such life-threatening conditions, who may first present to them.

Knowledge of the clinical course and consequences of COVID-19 initially evolved in the context of severe presentations and among those with comorbidities. However, understanding the outcomes of milder infections in healthy individuals is important for safe return-to-duty in extreme environments or to occupations requiring significant fitness. We reviewed the literature to characterize the nature and timing of persistent and emergent clinical sequelae in milder COVID-19 cases to facilitate development of post-COVID-19 screening and surveillance protocols. We searched databases including EMBASE, MEDLINE, Cochrane COVID-19 study register, gray literature, clinical trial registries, and relevant health and disease prevention sources for publications from 2019 to February 18, 2021, documenting COVID-19 sequelae. Articles were included if the COVID-19 severity was mild and there were no, or only minor, pre-existing comorbidities. Persistent and emergent sequelae were then stratified based on time since diagnosis. Among those with mild COVID-19, sequelae were shown to emerge or persist for months following presumed recovery. Among those with no comorbidities, cardiac, hematological, and respiratory sequelae emerged after 1-2 mo, and primarily cardiac abnormalities persisted at ≥ 3 mo. Among those with minor comorbidities, persistent respiratory abnormalities, fatigue, dyspnea, and headache were common, and mental health symptoms emerged by 1-2 mo postinfection. After presumed recovery from mild COVID-19, a range of symptoms can persist and later emerge. Whether these are new or previously unrecognized is unclear. Under-recognized COVID-19 sequelae may increase the risk of subtle or sudden incapacitation and have implications for return-to-work (RTW) screening and surveillance for safety-critical roles.

Low-value services have limited or no benefit to patients. Rates of low-value service in public hospitals may vary by patient insurance status, given that there may be different financial incentives for treatment of privately insured patients.

Although pain services have been established in many hospitals, there is considerable heterogeneity among them with respect to organization of service, staff and qualifications of staff, and treatment approaches.With this recommendation, the German Society for Anesthesiology and Intensive Care Medicine defines requirements for pain services in hospitals with respect to organizational standards and staff qualifications. The therapy offered by pain services supplements the treatment provided by the other departments involved, ensuring the high quality of specialized pain management in all areas of the hospital. Pain services shall oversee treatment with specialized analgesia techniques as well as the involvement of consultants, bringing together in-hospital pain medicine expertise in one service with availability 24 h and 7 days per week via a single contact. The medical head of the pain service shall be a qualified provider of pain medicine as defined by the German Medical Association and as a minimum should also have undergone additional training in basic psychosomatic medicine. Further members of the medical staff should possess the credentials of a medical specialist: non-medical staff should have completed continuing education in the treatment of pain. Minimal guidelines for personnel resources were defined: these included a specific time frame for first contacts (20 min) and follow-up (10 min) for specific analgesic techniques and for the involvement of consultants (first contact 45 min, follow-up 20 min), with additional time for travel, set-up, training and quality management. In addition to definition of the space and equipment needed, each service should draft its own budget, and this should be adequate and plannable. Written agreements between the disciplines and transparent documentation, including patient-reported outcomes, are recommended to ensure quality. The provision of specialized pain therapy should have high priority over all disciplines or departments.

Corona virus disease 2019 (COVID-19) remains an incurable, progressive pneumonia-like illness characterized by fever, dry cough, fatigue, and headache during its early stages. COVID-19 has ultimately resulted in mortality in at least 2 million people worldwide. Millions of people globally have already been affected by this disease, and the numbers are expected to increase, perhaps until an effective cure or vaccine is identified. Although Africa was initially purported by the World Health Organization (WHO) to be severely hit by the pandemic, Africa recorded the least number of cases during the first wave, with lowest rates of infections, compared to Asia, Europe, and the Americas. This statistic might be attributed to the low testing capacity, existing public health awareness and lessons learnt during Ebola epidemic. Nonetheless, the relatively low rate of infection should be an opportunity for Africa to be better prepared to overcome this and future epidemics. In this paper, the authors provide insights into the dynamics and transmission of the severe acute respiratory syndrome corona virus (SARS-CoV-2) during the first wave of the pandemic; possible explanations into the relatively low rates of infection recorded in Africa; with recommendations for Africa to continue to fight Covid-19; and position itself to effectively manage future pandemics.