Rejected

To investigate the opioid requirements and prevalence of chronic postsurgical pain (CPSP) in liver transplant (LT) recipients and to evaluate the association of opioid use with postoperative survival.

Myopericarditis is inflammation of the pericardium with concurrent myocardial involvement. The clinical presentation of myopericarditis is often with varying degrees of cardiac symptomatology. Its etiology is often idiopathic, but it may also be related to infectious and inflammatory prodrome. Symptoms are proportional to the extent and pattern of myocardial involvement. Many are diagnosed sub-clinically during the management of other systemic illnesses. Echocardiography and cardiac magnetic resonance imaging are important tools in the evaluation of myopericarditis, as the diagnosis of left ventricular dysfunction greatly affects the management, follow-up, and prognosis of these patients. The acute management of myopericarditis remains without clear direction and focuses on symptom control. The use of NSAIDs is often cautioned, as it has been described to actually accelerate the myocarditic process in animal models, possibly increasing mortality. Colchicine, a well-established anti-inflammatory agent, may have a role in the management of acute myopericarditis. We present two cases, each involving a young male, without underlying medical conditions, who presented to the emergency room with acute onset chest pain. Both were found to have elevated cardiac biomarkers and electrocardiographic (EKG) changes, admitted as in-patients and eventually diagnosed with acute myopericarditis. They made full recoveries and were eventually discharged home. Both were started on colchicine during hospitalization, which were continued for several months upon discharge. Overall, there is limited published data regarding the medical management of myopericarditis. There need to be prospective studies and registries to further our knowledge in the management of this illness.

Hepatocellular adenoma (HCA) is a benign neoplasm of the hepatic parenchyma. The use of oral contraceptives (OCP) in women is the most well-established risk for the development of HCA. HCA commonly presents as an intracapsular mass of the liver but there are very few cases of extracapsular HCA. This is a case of a middle-aged female who presented to the emergency department with left shoulder pain and epigastric tenderness on physical exam. Subsequent imaging of the abdomen revealed a mass arising from the anterior wall of the stomach, with evidence of surrounding hemorrhage. The patient underwent exploratory laparotomy that revealed free blood in the peritoneum and a hemorrhagic mass arising from the stomach wall. The mass was successfully removed with no postoperative complications. Histopathological examination of the mass was consistent with an infarcted inflammatory HCA. This case illustrates this unusual presentation of a rare diagnosis.

The World Health Organization (WHO) declared COVID-19, a novel coronavirus infection, as a pandemic in March 2020. Since the origin of the disease in Wuhan, China, understanding the pathophysiology, clinical presentation, screening guidelines, and management of the disease has been ever-evolving. Though respiratory pathologies have been the major complications of a COVID-19 infection, other presentations like abdominal pain, deep venous thrombosis, cardiomyopathy, and even acute cerebrovascular ischemic attacks have been reported. We present a case of a young patient presenting with vertigo, possibly from COVID-19-induced acute vestibular neuritis. This is a 20-year-old Hispanic female patient presenting with intractable vertigo, nausea, and vomiting but without any typical symptoms like fever, cough, or shortness of breath. Initial examination and imaging ruled out an acute stroke. There was minimal improvement in her vestibular symptoms with the recommended COVID-19 treatment as of March 2020 (hydroxychloroquine and azithromycin) and symptomatic management. Her inflammatory markers were surprisingly normal all through the hospital course. She was then treated with oral prednisone and subsequently discharged home after a prolonged course of eight days. The pathophysiology of COVID-19-induced vestibular neuritis could be similar to any other viral infection. Clinicians should consider COVID-19 in the differential diagnosis for patients presenting with similar symptoms, especially in areas of a high prevalence of this disease. Early diagnosis of COVID-19 in such cases is important for proper isolation, to minimize exposure and avoid further unnecessary investigations. These symptoms will just resolve with symptomatic management like any other case of vestibular neuritis without any further management that is specific for a COVID-19 infection.

Fentanyl is a potent synthetic opioid used to alleviate severe and chronic pain, as well as an adjunct to general or local anesthesia. Although fentanyl has been used for decades, its full effects are still unknown. Its analgesic and anesthetic activity arises from stimulation of μ-opioid receptors, resulting in inhibition of adenyl cyclase and downregulation of cAMP, as well as decreased calcium channel activity and increased potassium channel activity. The μ-opioid receptors are abundantly distributed within the central nervous system, where they mediate analgesia, and in the nerve cells of the intestines, where they regulate gastrointestinal tract motility in the secretion or transport of fluids and electrolytes. They are also expressed in blood cells, blood vessel cells and skin. Given the widespread distribution of μ-opioid receptors, it is likely that fentanyl may also regulate the activity of many other cells, including platelets. Recent findings indicate that it may impair the action of ticagrelor: an oral P2Y12 receptor inhibitor acting as an antiplatelet drug. It could pose a risk of insufficient platelet inhibition and result in thrombotic complications in patients with coronary artery disease. This article tackles the issue of fentanyl interactions with antiplatelet drugs. The mechanism of this phenomenon is not fully understood. Similarly, the biological effects exerted by fentanyl on platelets and the presence of opioid receptors on the platelet surface remain an open question.

There have been studies suggesting the pain attenuating as well as pain inducing actions of hydrogen sulfide (HS). Exogenous administrated HS may be antinociceptive or pronociceptive, while the endogenous HS is pronociceptive. Experimental studies have shown that pharmacological inhibitors of HS biosynthetic enzymes may attenuate nociceptive as well as neuropathic pain. It suggests that nerve injury or inflammatory agents may induce the expression of HS biosynthetic enzymes to increase the endogenous production of HS, which acts as a pain neurotransmitter to produce pain. The endogenous HS may act through different mechanisms including opening of T-type calcium channels, activation of voltage-gated sodium channels, suppression of potassium channels, activation of TRPA1, TRPV1 and TRPC6 channels, upregulation of spinal NMDA receptors and sensitization of purinergic receptors. Exogenous administration of HS/precursors/donors attenuates or facilitates pain. It may be hypothesized that local administration of HS may cause pain; while it's systemic administration may attenuate pain. The doses of HS may also influence the pain response and HS in low doses may contribute in reducing pain, while HS in high doses may contribute in relieving pain. Accordingly, enzymatic inhibitors of HS synthesis or systemic administration of slow HS releasing agents/low dose HS donors may be useful in attenuating nociceptive and neuropathic pain. The present review describes the dual role of HS in pain attenuation and pain induction along with possible mechanisms.

Two types of Epstein Barr virus (EBV1/EBV2) have been shown to infect humans. Although their genomes are similar, the regions containing the EBNA genes differ. This study aimed to characterize the EBV genotypes of infectious mononucleosis (IM) cases in the metropolitan region of Belém, Brazil, from 2005 to 2016. A total of 8295 suspected cases with symptoms/signs of IM were investigated by infectious disease physicians at Evandro Chagas Institute, Health Care Service, from January 2005 to December 2016. Out of the total, 1645 (19.8%) samples had positive results for EBV by enzyme immunoassay and 251 (15.3%) were submitted to polymerase chain reaction (PCR) technique, using the EBNA3C region, in order to determine the type of EBV. Biochemical testing involving aspartate aminotransferase, alanine aminotransferase and gamma-glutamyl transferase were also performed. EBV type was identified by PCR in 30.3% (76/251) of individuals; of those, 71.1% (54/76) were classified as EBV1, 17.1% (13/76) as EBV2, and 11.8% (9/76) as EBV1 + EBV2. The main symptoms/signs observed with EBV1 infection were cervical lymphadenopathy (64.8%, 35/54), fever (63%, 34/54), headache (20.4%, 11/54), arthralgia (20.4%, 11/54), and exanthema (18.5%, 10/54). EBV2 infection was detected in all but two age groups, with an average age of 24 years. The most common signs/symptoms of EBV2 were fever (76.9%, 10/13), average duration of 18 days, and lymphadenopathy (69.2%, 9/13). In contrast, EBV1 + EBV2 coinfections were more frequent in those aged five years or less (20.0%, 2/10). The symptoms of EBV1 + EBV2 coinfection included fever (66.7%, 6/9), and cervical lymphadenopathy and headache (33.3%, 3/9) each. The mean values of hepatic enzymes according to type of EBV was significantly different (p < 0.05) in those EBV1 infected over 14 years of age. Thus, this pioneering study, using molecular methods, identified the EBV genotypes in 30.3% of the samples, with circulation of EBV1, EBV2, and EBV1 + EBV2 co-infection in cases of infectious mononucleosis in the northern region of Brazil.

Trigeminal neuralgia is a pain condition that is frequently misdiagnosed and challenging to manage. We present the case of a patient with trigeminal neuralgia with multiple misdiagnoses and poorly managed pain. Despite the presence of trigger zones both inside and outside her mouth, complete symptom resolution was ultimately achieved through onabotulinumtoxinA injections, delivered solely intraorally.

To observe the cell origin of N-methyl-D-aspartic acid(NMDA)receptor expression in skin after chronic ischemic pain modeling in rats and explore the role of NMDA receptor in type Ⅰ complex regional pain syndrome. Forty-two adult male Sprague-Dawley rats were randomly divided into five groups:sham operation group(=12),chronic post ischemia pain(CPIP)group(=12),CPIP+normal saline(NS)group(=6),CPIP+NMDA group(=6),and CPIP+MK801 group(=6).Six rats in the sham operation group and CPIP group were sacrificed under deep anesthesia one day after modeling.The plantar skin and L3-L5 spinal cord tissue were used for NR1(NMDA receptor)subunit immunofluorescence detection and for Western blotting of NR1,interleukin(IL)-1β,and tumor necrosis factor(TNF)-α.For the remaining rats,the mechanical withdrawal threshold(MWT)values on the 2nd,6th,10th and 14th day after ischemia were recorded,and the corresponding drugs were injected subcutaneously from the 6th day after ischemia.The skin and L3-L5 spinal cords were collected on the 14th day,and the same detection methods were applied. Compared with the sham operation group,the CPIP group had significantly higher expressions of NR1(1.708±0.064;=12.120, <0.001),IL-1β(2.575±0.305;=5.158, =0.003),and TNF-α(2.691±0.217;=7.786, <0.001)in the skin on the first day after modeling.After intervention with NMDA and MK801,the MWT value was [(20.37±0.95)g] in the CPIP+NS group,which was significantly higher than that in CPIP+NMDA group [(15.85±1.09)g;=10.920, <0.001] but significantly lower than that in CPIP+MK801 group[(22.95±0.96)g;=6.421, <0.001] 10 days after modeling.On the 14th day,compared with the MWT of the CPIP+NS group [(21.57±0.96)g],the CPIP+NMDA group had significantly decreased MWT value [(16.53±1.63)g;=12.190, <0.001],and the CPIP+MK801 group had significantly increased MWT value [(23.27±1.28)g;=4.094, =0.025].Compared with the sham operation group,the CPIP group had significantly increased NR1 expression(1.708±0.064;=10.910, <0.001)and the CPIP+NS group had significantly increased expressions of IL-1β(2.518±0.147;=11.010, <0.001)and TNF-α(1.949±0.184;=10.870, <0.001).Compared with the CPIP+NS group,the CPIP+NMDA group had significantly increased expressions of IL-1β(4.816±0.607;=16.670, =0.003)and TNF-α(2.629±0.349;=7.790, <0.001)and the CPIP+MK801 group had significantly decreased expressions of IL-1β(1.048±0.257;=10.660, =0.003)and TNF-α(0.790±0.165;=13.280, <0.001). NMDA receptor activation in skin keratinocytes after chronic ischemia in rats hinders the expression of inflammatory cytokines such as IL-1β and TNF-α,which may be involved in central sensitization and pain conduction of type Ⅰ complex regional pain syndrome.

Objective Reversible Splenial Lesion Syndrome (RESLES) is a clinical radiological syndrome characterized by a reversible lesion of the splenium of the corpus callosum with a decreased apparent diffusion coefficient (ADC) value. The clinical manifestations of RESLES are diverse. Methods Fifteen cases of adult RESLES patients (10 males and 5 females) were retrospectively selected from the radiology system using the key word "corpus callosum" at a university-affiliated tertiary care hospital between May 1, 2015 and Dec 31, 2019. The possible precipitating factors, clinicoradiological findings and modified Rankin Scale (mRS) on follow-up were then analyzed. Results The patient ages ranged from 22 to 53 years old. The mean age was 34 years old. The most common neurological symptoms included headache (3/15), dizziness (3/15), first onset of seizure (3/15), paroxysmal blurred vision (2/15), vertigo (2/15), amnesia (2/15), and confused consciousness without seizure (2/15), followed by drowsiness (1/15), paresthesia (1/15), dysmetria (1/15) and dysarthria (1/15). The precipitating factors included infection, seizure, anti-epileptic treatment with levetiracetam, carbamazepine, valproate, hyperglycemia, hypoglycemia, cerebral venous sinus thrombosis, and rabies vaccine injection prior to the onset of RESLES. All cases were carefully followed up and had excellent prognoses. Conclusion RESLES manifests as variety of symptoms with less specificity and precipitating factors. Paroxysmal blurred vision may be a relatively specific symptom of RESLES. Levetiracetam, carbamazepine or valproate could be the cause of RESLES, exposure to the rabies vaccine could be another predisposing factors for RESLES as well. RESLES type 1 was therefore found to be highly "reversible" with an excellent prognosis.