Rejected

Costal cartilage fractures are common in high-energy blunt chest trauma but are frequently missed on imaging evaluation and accordingly underreported in the literature. In this report, we describe a case of a 32-year-old male who sustained bilateral costal cartilage fractures following repeated blunt trauma in the gym sustained during bench press exercises. The patient presented with a painful "clicking" of a rib in and out of place while bending or turning sideways. Initial chest X-ray and computed tomography (CT) imaging were reported negative for fractures; however, a closer inspection of the CT image revealed bilateral costal cartilage fractures. As the patient's symptoms improved over time, a conservative approach to treatment with regular analgesia and advice to avoid external impact on the fracture sites was adopted. This unique case highlights an unusual mode of trauma and diagnostic complexity of costal cartilage fractures.

Although nickel allergy is a common cause of contact dermatitis, systemic reactions to nitinol stents are rare. A 61-year-old woman had presented with a nonhealing toe wound. Angiography revealed an external iliac artery stenosis, which was treated with a nitinol stent graft. However, she developed severe truncal pruritus, and within 3 months, her external iliac stent graft had thrombosed. Allergy testing revealed nickel sensitivity. After medical therapy had failed, stent graft removal was performed, resulting in complete resolution of her symptoms. The present case demonstrates a rare allergic reaction to the nitinol in commercially available stent grafts. Pruritus and rash are rare reactions to stenting; however, a nitinol allergy should be considered for patients with no other identifiable primary source.

The United States underwent massive expansion in opioid prescribing from 1990-2010, followed by opioid stewardship initiatives and reduced prescribing. Opioids are no longer considered first-line therapy for most chronic pain conditions and clinicians should first seek alternatives in most circumstances. Patients who have been treated with opioids long-term should be managed differently, sometimes even continued on opioids due to physiologic changes wrought by long-term opioid therapy and documented risks of discontinuation. When providing long-term opioid therapy, clinicians should document opioid stewardship measures, including assessments, consents, medication reconciliation, and offering naloxone, along with the rationale to continue opioid therapy. Clinicians should screen regularly for opioid use disorder and arrange for or directly provide treatment. In particular, buprenorphine can be highly useful for co-morbid pain and opioid use disorder. Addressing other substance use disorders, as well as preventive health related to substance use, should be a priority in patients with opioid use disorder. Patient-centered practices, such as shared decision-making and attending to related facets of a patient's life that influence health outcomes, should be implemented at all points of care.Key messagesAlthough opioids are no longer considered first-line therapy for most chronic pain, management of patients already taking long-term opioid therapy must be individualised.Documentation of opioid stewardship measures can help to organise opioid prescribing and protect clinicians from regulatory scrutiny.Management of resultant opioid use disorder should include provision of medications, most often buprenorphine, and several additional screening and preventive measures.

Pregnancy complicated with tuberculosis is increasingly common. The clinical characteristics of pregnancy complicated with miliary tuberculosis are summarized in this study.

An 83-year-old postmenopausal female P5L5 (all full-term normal deliveries) presented with complaints of foul-smelling purulent discharge per vagina for 15 days associated with pain in abdomen. A midline mass was palpable per abdomen in the suprapubic region corresponding to 16 weeks size gravid uterus, which was soft to firm in consistency. On examination per vaginum, the atrophied cervix was found flush with the vagina and purulent discharge was seen draining through the cervix. Blood reports showed raised total leucocyte count with granulocyte predominance. Abdominal ultrasonography revealed a uterine cavity filled with echogenic contents, with no abdominal cavity collection. The patient was started on IV antibiotics and planned for dilatation and curettage. On histopathology acute on chronic senile endometritis was found with no evidence of malignant cells. Tuberculosis gene testing was found to be negative. We conclude that the senile endometritis leading to cervical stenosis as seen during dilatation and curettage had led to the pyometra and no evidence of malignancy was found.

Background Acute appendicitis remains the most common cause of lower abdominal pain leading to emergency visits. Even though the standard treatment of acute appendicitis remains appendectomy, in recent times, multiple randomized control trials and meta-analyses have deduced conservative treatment as a successful alternative treatment. During the coronavirus disease (COVID) pandemic, with a shortage of staff and resources, treatment with conservative management of uncomplicated acute appendicitis became very beneficial under certain circumstances and conditions. This study aimed to assess whether it is effective to manage patients with uncomplicated acute appendicitis with antibiotic therapy. Methodology This was a single hospital based retrospective, cross-sectional study from Jan 2015 to May 2020. Patients with clinical and radiological features of uncomplicated acute appendicitis with Alvarado's score >6 were included in the study. Patients were kept on antibiotics, intravenous fluids, and analgesia as part of a conservative regime. Those who failed to respond to conservative therapy were managed surgically. The follow-up period was six months. Results One hundred eighty-two cases of uncomplicated acute appendicitis were included and managed conservatively, of which 52.2% were males while 47.8% were females. The median age of the patients was 26 years. Conservative treatment was successful in 26.2% of the patients, with a recurrence of 5.5% in the six-month follow-up period. The mean number of days of hospital stay was three days in patients treated with conservative or surgical treatment. Conclusion Conservative management is gaining popularity, and many centers are inclined towards non-operative management; however, appendectomy remains the gold standard treatment for appendicitis.

Aortic arch thrombus is a rare entity that can result in catastrophic sequelae. This is a case report of a 65-year-old female patient who presented with chest pain that started one day prior to arrival at the emergency department. Acute coronary syndrome (ACS) and pulmonary embolism (PE) were ruled out. A filling defect at the distal aortic arch evident on chest computed tomography angiography (CTA) was confirmed to be a floating distal aortic arch thrombus on transesophageal echocardiogram (TEE). There was no evidence of an underlying aneurysm, dissection, or significant atherosclerosis. The patient was considered to be at high risk for surgical intervention, hence, a decision was made to start the patient on chronic anticoagulation with direct oral anticoagulants (DOACs). A follow-up CTA three months later showed total resolution of the thrombus. The report highlights this treacherous pathology and provides an overview of the predisposing factors, radiologic findings, as well as management strategies for floating aortic arch thrombi.

To observe histological and inflammatory characteristics of epidural fat (EF) adjacent to the ossification area in patients with ossification of the thoracic ligament flavum (TOLF) and provide a preliminary research basis for investigating the impact of the EF on OLF.

COVID-19 toes represent the main dermatological COVID-19 cutaneous manifestation in pediatric patients. Its diagnosis exposes the whole family to social stigma and this aspect was not previously evaluated.

The long-tailed goral, Naemorhedus caudatus (Mammalia: Bovidae), is one of the endangered animals in the Republic of Korea (Korea). Sarcoptic mange mites infested in diverse species of mammals, including humans, but no case has been reported in long-tailed gorals. We report 2 cases of mange mite, Sarcoptes scabiei, infestation in long-tailed gorals. Mange mites were sampled in the skin legions of the 2 long-tailed gorals, which were rescued in 2 different regions, Uljin-gun, Gyeongsangbuk-do and Cheorwon-gun, Gangwon-do, Korea. Our results showed that the ectoparasite was the itch mite that burrowed into skin and caused scabies on the morphological inspection and placed within the phylogenetic relations of the species. The present study confirmed for the first time in Korea that mange mites are pathogenic scabies of long-tailed goral. Closer surveillance of this pathogenic ectoparasite in zoonotic and infectious ecosystems is warranted.