Rejected

A 10-year-old boy with no past medical history presented with complaints of nausea and vomiting associated with morning headache for the last month. Ophthalmic nerve and eye exam showed diplopia and strabismus with no other significant findings on physical and neurological examination. Magnetic resonance imaging (MRI) of the brain revealed a homogenous hyperdense and enhancing mass in the pineal region. The endoscopic biopsy of the pineal region demonstrated the cells with highly pleomorphic and hyperchromatic nuclei with an increase in mitotic activity. There were many vessels but no area of vascular proliferation and necrosis. Granular bodies with eosinophilia were identified. Immunohistochemistry was positive for class III b-tubulin with epidermal growth factor receptor (EGFR) staining and glial fibrillary acidic protein (GFAP). Immunostaining was positive for p53, Phosphatase and Tensin homolog (PTEN), and oligodendrocyte transcription factor (OLIG2), while staining for cluster of differentiation (CD)34, cytokeratin (CK), human melanoma black (HMB)45, and isocitrate dehydrogenase (IDH)-R132H mutation was negative, consistent with atypical pleomorphic neoplasm of the pineal region. The patient underwent tumor resection via a sub-occipital trans-tentorial approach, followed by one dose of chemotherapy. The patient experienced a resolution of the symptom and was doing well on his bi-monthly follow up.

To evaluate the long-term adverse reactions of paracetamol in children who required intensive care shortly after birth. Paracetamol is a widely used analgesic in neonates, but the long-term studies are lacking. Previous epidemiological studies have reported associations between early paracetamol intake and diseases in childhood.

Since the 1990s, the emergency department (ED) unscheduled return visit (URV), or "bounce-back," has been used as a quality of care measurement. During that time, resident training was also scrutinized and uncovered a need for closer resident supervision, especially of second-year residents. Over the years, bounce-backs have continued to be analyzed with vigor, but research on residency training and supervision has lagged with few studies concurrently investigating residency supervision and bounce-backs. Other literature on resident supervision suggests that with adequate attending supervision, resident performance is equivalent to attending performance. With that in mind, it was hypothesized that resident bounce-back rates will be equivalent to attending bounce-back rates, and there will be no change among residency years. The primary objective of this study was to determine the rate at which patients are seen as a bounce-back visit within 72 hours of their initial visit to a community hospital ED during the study time frame. The secondary aims were to evaluate if the ED bounce-back rate is impacted by training level (residents or attending) and to describe bounce-back patient characteristics, including primary complaint/disease, age, comorbidities and issues with compliance.

A 36-year-old woman presented with a 3-month history of recurrent substernal chest pain, which acutely worsened 2 days prior to presentation. Her initial troponin I was mildly elevated and ECG showed subtle changes initially concerning for ischaemia; however, these were present on her prior ECG and were not considered an acute change. Because of her age and lack of significant risk factors, she was considered low risk for cardiac disease and initially treated conservatively for a non-ST elevation myocardial infarction. Due to persistent symptoms and dynamic changes on ECG concerning for ischaemia, she was immediately taken for a cardiac catheterisation and was found to have critical left main coronary artery dissection with a focal stenotic lesion. She had an extensive workup to identify the underlying cause of her coronary artery dissection which was unrevealing. She underwent an uncomplicated coronary artery bypass graft surgery and was discharged home in stable condition.

The definition of traumatic brain injury (TBI) has expanded to include mild TBI and postconcussive syndrome. This evolution has resulted in difficulty disentangling the physical trauma of mild TBI from the emotional trauma of posttraumatic stress disorder (PTSD). Advances in stress neurobiology and knowledge of brain injury at the macroscopic, microscopic, biochemical, and molecular levels call for a redefinition of TBI that encompasses both physical and emotional TBI. Conceptualizing a spectrum of TBI with both physical and emotional causation resolves the irreconcilable tangle between diagnostic categories and acknowledges overlapping forms of brain injury and shared systemic effects due to hormonal and inflammatory mediators. Recognizing emotional TBI shifts the interpretation of emotional trauma from a confound to a comorbid, related cause of brain injury. The mechanism of emotional TBI includes the intricate actions of stress hormones on diverse brain functions due to changes in synaptic plasticity, where chronically elevated hormone levels reduce neurogenesis, resulting in dendritic atrophy and impaired cognition. The overlapping effects of physical and emotional trauma are seen in neuropathology (ie, reduction of hippocampal volume in TBI and PTSD); fMRI (similar regional activations in physical and emotional pain); and systemic sequelae, including changes in proinflammatory cytokine levels and immune cell function. Accumulating evidence favors a change in the definition of TBI to encompass emotional TBI. The definition of TBI will be strengthened by the inclusion of both physical and emotional trauma that result in diverse and overlapping forms of brain injury with sequelae for physical and mental health.

To report on comparative effectiveness of minimally invasive versus traditional open kidney transplantation.

Somatic symptom disorder is excessive anxiety towards persistent symptoms that do not have an identifiable physical origin. Fibromyalgia is a stress-related illness. The overwhelming majority of fibromyalgia patients seeking medical care are women. Most fibromyalgia sufferers fulfil the somatic symptom disorder diagnostic criteria. The objectives of this article are the following: 1) to examine fibromyalgia and somatic symptom disorder analogy. 2) to discuss stress-evoked neuropathic pain sexual dimorphism, and 3) to propose a neuropathic pathogenesis that may explain how stressed women could develop fibromyalgia. Recent research demonstrates a clear link between fibromyalgia and small fibre neuropathy. Dorsal root ganglia contain the small nerve fibre nuclei. In rodents, physical, chemical, or environmental stressors lead to dorsal root ganglia phenotypic changes and to hyperalgesia. This phenomenon is much more frequent in females. Prolactin, oestrogens, and progesterone alter dorsal root ganglia physiology, establishing abnormal connections between the stress response system and pain pathways. Rather than a mental somatic symptom disorder, fibromyalgia patients may have a stress-induced neuropathic pain syndrome. Sexually dimorphic dorsal root ganglia physiology may explain why it is women who more often develop fibromyalgia. Understanding fibromyalgia as a real stress-evoked neuropathic pain syndrome may lead to more compassionate patient care and may open new avenues for gender-related neuropathic pain investigation.

A focused library of new 3-(3-methyl-2,5-dioxo-3-phenylpyrrolidin-1-yl)propanamides and their nonimide analogs were synthesized and tested for anticonvulsant activity. These compounds were obtained through the coupling reaction of the starting carboxylic acids with appropriate amines. The initial anticonvulsant screening was performed in mice (intraperitoneal administration) using the maximal electroshock seizure (MES) and the subcutaneous pentylenetetrazole (scPTZ) seizure models. The most promising compound 6 showed more potent protection in the MES and scPTZ tests than valproic acid, which is still recognized as one of the most relevant first-line anticonvulsants. The structure-activity relationship analysis revealed that the presence of the pyrrolidine-2,5-dione ring is important but not indispensable to retain anticonvulsant activity. Additionally, compound 6 showed potent antinociceptive properties in the oxaliplatin-induced neuropathic pain model in mice. The most plausible mechanism of action for compound 6 may result from its influence on the neuronal sodium channel (Site 2) and the high-voltage-activated L-type calcium channel.

Oral mucositis caused by radiation therapy is a common problem in cancer patients, especially those with head and neck cancer. Numerous experimental and clinical studies have attempted to find a drug to alleviate oral mucositis. Sumatriptan, is conventionally used to treat migraine attack and cluster headache. Recently, low doses have been shown to have anti-inflammatory properties. In this study we aimed to measure the effect of sumatriptan on experimental radiotherapy-induced oral mucositis.

We read with interest the article by Nielson et al. describing the iliopsoas plane block (IPB), targeting the sensory hip articular branches of the femoral nerve without causing motor blockade. We applaud this group on the development of this clinically relevant technique. The authors also discuss the pericapsular nerve group (PENG) block as a reasonable alternative. In our clinical practice we have utilized PENG blocks extensively and have observed excellent analgesia for various hip surgeries. We have previously reported several cases of inadvertent motor blockade using the PENG block in patients undergoing total hip arthroplasty. Possible explanations of inadvertent motor blockade include technical issues, specifically injecting local anesthetic superficial to the iliopsoas plane or medial to the psoas tendon and performing the block postoperatively within disrupted tissue planes. Subsequent to this publication we have had additional cases of quadriceps motor weakness despite the PENG block being performed by experienced staff and taking precautions outlined by Girón-Arango et al. This has led to reduced usage of the PENG block in our institution. We suggest that randomized controlled clinical trials be performed to further assess the effectiveness and adverse effects of the PENG block.