Rejected

Fractures due to osteoporosis represent a serious burden on patients and healthcare systems. The objective of this review is to provide an overview of the anabolic agent abaloparatide (ABL) for the treatment of postmenopausal women with osteoporosis at high risk for fracture. A literature review was conducted using PubMed to identify articles focused on ABL published prior to February 10, 2020, using the search term 'abaloparatide'. ABL, a synthetic analog of human parathyroid hormone-related protein, increased bone mineral density (BMD), improved bone microarchitecture, and increased bone strength in preclinical and clinical studies. The pivotal phase 3 trial ACTIVE and its extension (ACTIVExtend) demonstrated the efficacy of initial treatment with ABL for 18 months followed by sequential treatment with alendronate (ALN) for an additional 24 months to reduce the risk of vertebral, nonvertebral, clinical, and major osteoporotic fractures and to increase BMD in postmenopausal women with osteoporosis. Discontinuations from ACTIVE were slightly more common in ABL-treated patients due to dizziness, palpitations, nausea, and headache. Post hoc analyses of ACTIVE and ACTIVExtend support the efficacy and safety of ABL in relevant subpopulations including postmenopausal women with various baseline risk factors, women ≥80 years, women with type 2 diabetes mellitus, and women with renal impairment. ABL is an effective and well-tolerated treatment for women with postmenopausal osteoporosis at high risk for fracture. Its therapeutic effects are sustained with subsequent ALN therapy.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a serious and complex physical illness that affects all body systems with a multiplicity of symptoms, but key hallmarks of the disease are pervasive fatigue and 'post-exertional malaise', exacerbation after physical and/or mental activity of the intrinsic fatigue and other symptoms that can be highly debilitating and last from days to months. Although the disease can vary widely between individuals, common symptoms also include pain, cognitive deficits, sleep dysfunction, as well as immune, neurological and autonomic symptoms. Typically, it is a very isolating illness socially, carrying a stigma because of the lack of understanding of the cause and pathophysiology.

Cryptococcosis is a serious and sometimes fatal fungal disease caused by Cryptococcus species. Worldwide, it is estimated to kill over 180,000 annually, with 75% of deaths occurring in sub-Saharan Africa. Though cryptococcal infections are rare in otherwise healthy individuals, there have been reported cases in immunocompetent persons. Most cases occur in individuals who have weakened immune systems, particularly those with advanced HIV/AIDS, thus making West Africa a potential hotspot of the disease. Despite this, there is no recent review article with a focus on published findings on cryptococcosis in Western Africa. Common clinical symptoms include chest pain, dry cough, headache, nausea, confusion, fever, fatigue and stiffness of the neck/neurological impairment. The CNS and the lung remains its preferred target even though rare cases of attack on other parts of the body were reported in this review. Cryptococcal antigen screening and India ink preparation were the most commonly used diagnostic methods. Repeated isolation from environmental samples was observed. Overall, data on the clinical prevalence of Cryptococcus is scarce and variable in the region. The environmental prevalence ranges from 2.3-22%. This review covers all published research findings on cryptococcosis in West Africa till date. The epidemiological data will likely be of interest to clinicians within and outside the continent. The nations covered in this review include; Benin Republic, Burkina Faso, Cote d'ivoire, Ghana, Guinea, Guinea- Bissau, Mali, Nigeria, Senegal and Sierra Leone. More studies are warranted to fill the observed gaps on the epidemiology of Cryptococcus in the region.

Chronic widespread pain (CWP), including fibromyalgia (FM), affects one in every ten adults and is one of the leading causes of sick leave and emotional distress. Due to an unclear etiology and a complex pathophysiology, FM is a condition with few, if any, effective and safe treatments. However, current research within the field of vagal nerve innervation suggests psychophysiological and electrical means by which FM may be treated. This study will investigate the efficacy of two different noninvasive vagal nerve stimulation techniques for the treatment of FM.

We report a case of statin-associated necrotising autoimmune myopathy successfully treated with subcutaneous immunoglobulin therapy (SCIG) monotherapy without corticosteroids. This is a 51-year old female with seronegative rheumatoid arthritis, who had been on statins for several years, who developed proximal muscle weakness and elevated creatine kinase after resuming her statin post sleeve gastrectomy for weight loss. Our patient had a history of severe side effects to prednisone. She did not respond to mycophenolate, cyclophosphamide, and rituximab treatment. She had responded to partial treatment with intravenous immunoglobulin (IVIG) but had a severe headache after IVIG infusion. IVIG treatment was discontinued. We tried SCIG treatment, and she was able to tolerate the SCIG treatment with intermittent headaches that were less intense. After treatment with SCIG, creatine kinase levels decreased significantly, with an improvement of muscle strength. She continues to do well on SCIG treatment. To our knowledge, no other cases of statin-associated necrotising autoimmune myopathy treated with SCIG have been reported in the literature. More studies and reports are needed to confirm the utility and efficacy of SCIG in statin-associated necrotising autoimmune myopathy, as well as to provide information about dosing, tolerability, and durability of SCIG in the treatment of statin-associated necrotising autoimmune myopathy.

A keloid scar is a benign skin tumor and we aimed to assess the Quality of Life (QoL) of black Africans with keloid scars based on the Dermatology Life Quality Index (DLQI). We conducted a cross-sectional descriptive study in the department of dermatology of the teaching hospital of Treichville in Ivory Coast. We recruited 132 patients with keloid and 3612 dermatoses without keloid: The prevalence was 3.50% (132/3753). We included 120 patients aged from 16 to 63 years old, the sex ratio was 0.46 (38/82) and the mean age was 34.20 years. Keloid scars were mostly secondary to skin trauma in 30.00 % and infection in 21.67%. The commonest site was the ear in 29.17 %. We reported Keloid with pain in 53.33% and pruritus in 95.00%. We observed psychological impact in 65.83%. The DLQI scores were moderate and high in 61.66 %. QoL was impacted significantly when keloid was associated with pain (p=0.046), pruritus (p=0.81) and functional disorders (p=0.29). The DLQI score could be a valuable tool to assess QoL in black African patients with keloid, for better treatment option.

Breast complaints in the emergency department (ED) include trauma, infection, pain, masses, and nipple discharge. Breast cancer mimics other inflammatory conditions such as mastitis and abscess. Differentiating infectious processes versus cancer can become problematic when no imaging is used. While mammogram is included in the initial imaging for outpatient breast evaluation, ultrasound is more available in the ED. We present a case of a patient seen in the ED for breast pain and mass. The patient had no imaging done, yet the ED physician attempted to drain the mass unsuccessfully and prescribed antibiotics. The patient followed up at a breast center where clinical Stage IIA right breast invasive ductal carcinoma (IDC) was diagnosed. This case highlights the importance of breast imaging before drainage for suspected abscess and the importance of follow-up for all breast complaints that present in the ED to rule out a malignancy.

The situation generated in the health system by the COVID-19 pandemic has provoked a crisis involving the necessity to cancel non-urgent and oncologic activity in the operating room and in day-to-day practice. As the situation continues, the need to reinstate attention for chronic pain patients grows. The restoration of this activity has to begin with on-site appointments and possible surgical procedures. On-site clinical activity has to guarantee the safety of patients and health workers. The objective of this review is to evaluate how to manage activity in pain units, considering the scenario generated by the pandemic and the implications of chronic pain on the immune system and proposed pharmacological and interventional therapies. Besides the established general recommendations (physical distance, surgical masks, gloves, etc.), we established specific recommendations that will allow patient treatment and relieve the disruption of the immune response. It is important to highlight the use of opioids with the least influence in the immune system. Further, individualised corticoid use, risk assessment, reduced immune suppression, and dose adjustment should take patient needs into account. In this scenario, we highlight the use of radiofrequency and neuromodulation therapies, techniques that do not interfere with the immune response. We describe procedures to implement these recommendations for individual clinical situations, the therapeutic possibilities and safety guidelines for each centre, and government recommendations during the COVID-19 pandemic.

To ascertain whether ear acupuncture (modified Battlefield technique) as an adjunct (Adj-BFA) to standard analgesia care (SAC) significantly reduces pain scores compared with sham acupuncture (Adj-Sham) or SAC alone, when delivered by medical and nursing practitioners in an ED.

A 78-year old male with longstanding type 2 diabetes presented with a 3-year history of left plantar ulcer. The patient reported occasional pain at the lesion. It had been treated as a neuropathic, diabetic ulcer with various topical agents. He did not report using offloading therapy. Examination revealed an ulcer on the sole of the left foot, over the area of the 3 and 4 metatarsal heads, with well-defined margins surrounded by callus. The base was pink with several islands suggestive of epithelialisation (Fig. 1). The wound margins did not appear undermined. There was no surrounding erythema or oedema. The patient's glycated haemoglobin was 7.12%. Working diagnosis was squamous cell carcinoma (possible Marjolin's ulcer).