Rejected

Sphenoid sinus metastasis is extremely rare. Herein, we report a case of occult hepatocellular carcinoma with initial symptoms of decreased vision and headache, which were caused by sphenoid sinus metastasis. A 44-year-old man recently complained of bilateral decreased vision and headache. Head MRI showed a soft tissue mass in the sphenoid sinus. Pathological examination of the resected sphenoid sinus mass indicated metastatic carcinoma. Subsequently, F-FDG PET/CT and immunohistochemical analysis of the sphenoid sinus mass confirmed the hepatic origin of the primary lesion.

We describe the case of a 75-year-old female with chronic low back pain (CLBP), on opioids for more than 15 years. She presented with an acute episode of nausea, vomiting, abdominal pain, and shortness of breath. After a complete work-up, it was concluded that her presenting symptoms were likely due to her high levels of CLBP and high dose opioids. At the time of intervention, her opioid dosage was between 50-90 MME (Morphine milligram equivalent) (Norco 8 × 7.5 mg/day + Fentanyl 12 mcg patch). She was subsequently seen by the physician for seven outpatient internal medicine appointments over nine months and received Pain Neuroscience Education (PNE) in conjunction with monitored tapering of opioids and other medication associated with her CLBP. This case report demonstrates how a physician might deliver PNE as a viable nonpharmacological treatment option for the tapering of long-term opioids for chronic pain.

COVID-19 mortality disproportionally affects nursing homes, creating enormous pressures to deliver high-quality end-of-life care. Comprehensive palliative care should be an explicit part of both national and global COVID-19 response plans. Therefore, we aimed to identify, review and compare national and international COVID-19 guidance for nursing homes concerning palliative care, issued by government bodies and professional associations. We performed a directed documentary and content analysis of newly developed or adapted COVID-19 guidance documents from across the world. Documents were collected via expert consultation and independently screened against pre-specified eligibility criteria. We applied thematic analysis and narrative synthesis techniques. We identified 21 eligible documents covering both nursing homes and palliative care; from the World Health Organization (n=3), and eight individual countries: USA (n=7), the Netherlands (n=2), Ireland (n=1), United Kingdom (n=3), Switzerland (n=3), New Zealand (n=1), Belgium (n=1). International documents focused primarily on infection prevention and control, including only a few sentences on palliative care related topics. Palliative care themes most frequently mentioned across documents were end-of-life visits, advance care planning documentation, and clinical decision-making towards the end of life (focusing on hospital transfers). There is a dearth of comprehensive international COVID-19 guidance on palliative care for nursing homes. Most have a limited focus both regarding breadth of topics and recommendations made. Key aspects of palliative care, i.e. symptom management, staff education and support, referral to specialist services or hospice, and family support, need greater attention in future guidelines.

To compare the outcomes of intravesical injection of botulinum toxin A (BoNTA) with intravesical electromotive drug administration (EMDA) of BoNTA on urinary incontinence secondary to neuropathic detrusor overactivity (NDO) in children with myelomeningocele (MMC).

Indigofera is the third-largest genus in the family of Fabaceae, with approximately 750 species. It is distributed across all tropical regions. Indigofera species are widely employed in traditional medicine all around the world, against many ailments. Thus, based on these medicinal properties, various investigations have been undertaken in order to appraise the pharmacological activities and the chemical composition of these species. A recent paper provides a summary of the phytochemistry and pharmacology of the genus Indigofera. Consequently, this review is a continuation of this previous study by updating some data and adding information about the phylogeny and traditional uses of the genus.

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare monogenic primary immunodeficiency due to mutations of FOXP3, a master transcription factor of regulatory T cells (Treg). IPEX syndrome leads to fatal course in most cases during early childhood or severe multi-organ immune-mediated disorders in patients who survive. Currently hematopoietic stem cell transplantation represents the only known effective cure for IPEX syndrome. However, older patients with a mild disease not severe enough to justify transplantation, raise concerns regarding the appropriate therapeutic management, which is therefore based on supportive and replacement therapies combined with pharmacological immunosuppression. Herein, we report the case of a 22-year-old man with an incomplete IPEX syndrome without endocrine disorders having suffered from severe enteropathy since his birth treated with a combination of various immunosuppressant agents. He developed severe exacerbation of inflammatory low back pain in relation to sacroiliitis. Eventually, infliximab was initiated to control his back pain with rapid resolution as well as digestive improvement and also reduced biological inflammatory markers. In parallel, flow cytometry analysis revealed an increase in the frequency of circulating FOXP3+ CD4+ Treg cells. Altogether these data highlight that anti-TNF may represent a promising therapeutic option in patients with IPEX syndrome.

Premamillary artery (PMA) usually arises from the posterior communicating artery. So, the internal carotid artery (ICA) origin for PMA is rare. We report a rare case of a patient who presented with subarachnoid hemorrhage due to kissing aneurysms arising from the origin of anterior choroidal artery (AchoA) and the aberrant origin of PMA and was successfully treated with coil embolization.

Cerebral aneurysm and aneurysm rupture have rarely been reported in the literature during pregnancy. Aneurysm might rupture and may cause intracranial hemorrhage during or after pregnancy. Aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy presents a challenge regarding treatment and management. There is no institution which has a large patient population or experience in managing this condition during pregnancy in the literature. Due to the limited number of cases, there are no available treatment guidelines. Thus, treatment is usually based on a case-by-case approach.

We present a rare case of multiple intracranial arteriovenous fistulas (AVFs). A young female presented with headache and a left eyelid pulsatile swelling. Magnetic resonance imaging demonstrated numerous dilated cortical veins, along with a prominent left superior ophthalmic vein. A diagnostic cerebral angiogram revealed 5 distinct AVFs including 4 dural AVFs (dAVFs) and a pial AVF (pAVF). The largest dAVF was at the superior sagittal sinus (SSS). The others included bilateral ethmoidal, torcular, and a pAVF arising of the right pericallosal artery. She was treated by endovascular transarterial Onyx embolization. Only the SSS fistula was treated via middle meningeal artery feeders with complete occlusion. Immediate follow-up angiogram also showed complete spontaneous occlusion of the untreated dAVFs and the pial AVF. This case is exceedingly unique considering the multiplicity of AVFs, concurrent presence of pial and dural AVF, and spontaneous occlusion of all untreated AVFs after embolizing the largest shunting fistula.