Rejected

Human papillomavirus (HPV) vaccination has been associated with subsequent diffuse symptoms in girls, reducing public confidence in the vaccine. We examined if girls have nonspecific outcomes of HPV vaccination, using triangulation from a cohort, self-controlled case series (SCCS), and population time trend study in entire Denmark between 2000-2014. The study population consisted of 314,017 vaccinated girls and 314,017 age-matched unvaccinated girls (cohort analyses); 11,817 girls with hospital records (SCCS analyses); and 1,465,049 girls and boys (population time trend analyses). Main outcome measures were hospital records of pain, fatigue, or circulatory symptoms. The cohort study revealed no increased risk among HPV vaccine-exposed girls, with incidence rate ratios close to 1.0 for abdominal pain, nonspecific pain, headache, hypotension/syncope, tachycardia (including the postural orthostatic tachycardia syndrome), and malaise/fatigue (including the chronic fatigue syndrome). In the SCCS analyses, we observed no association between HPV vaccination and subsequent symptoms. In time trend analyses, we observed a steady increase in these hospital records in both girls and (HPV-unvaccinated) boys, with no relation to the 2009 HPV vaccine introduction in Denmark's vaccination program. This study with nationwide coverage showed no evidence of a causal link between HPV vaccination and diffuse autonomic symptoms leading to hospital contact.

Hirudotherapy (leech therapy) is one of the oldest practices in medical history, and nowadays it is used for several purposes in medicine. Salvage of flaps, wound healing, pain management, and treatment of varicose veins are among the common therapeutic applications of leeches. Complications associated with leech therapy include infections, bleeding, anemia, and allergic reaction. Cutaneous pseudolymphoma (benign proliferation of lymphoid cells in the skin) follows several underlying conditions. Although persistent arthropod bite reaction is one of the conditions associated with cutaneous pseudolymphoma, it has been rarely reported after medicinal leech therapy. Here we describe the case of a patient who presented with cutaneous pseudolymphoma after leech therapy as a rare cutaneous complication of hirudotherapy.

Lumbar puncture (LP) is done daily for both spinal anesthesia and emergency cases for cerebrospinal fluid (CSF) analysis. Subdural hemorrhage (SDH) is a rare but severe complication following diagnostic LP, which could be potentially fatal, and early diagnosis may be life-saving. We present a 28-year-old female patient who presented to our emergency department with a headache, fever, and vomiting, with normal initial laboratory and imaging. Diagnostic lumbar puncture was done to exclude central nervous system infection. After CSF results and cultures were negative, and nasal influenza B detected, medication was started and she was discharged home. Three days post-procedure, she was complaining of a severe, persistent headache and a head computed tomography (CT) was done, which revealed acute SDH. Extensive workup searching for the cause of SDH was negative, and with a stationary course of SDH, she has discharged home again with a diagnosis of SDH post LP complication. In conclusion, a headache post LP is common and usually benign and self-limited. Severe persistent headache that is not positional and doesn't respond to analgesics with caffeine should be considered a red flag after LP and should be investigated carefully for other possibilities such as SDH.

Patient-reported outcomes among survivors of pediatric hematopoietic stem cell transplant (HSCT) are understudied. We compared symptom prevalence, health-related quality of life (HRQOL), and risk factors in adult survivors of childhood hematologic malignancies treated with HSCT to those treated with conventional therapy and non-cancer controls. Survivors of childhood hematologic malignancies (HSCT N=112 [70% allogeneic, 30% autologous]; conventionally-treated N=1,106) and non-cancer controls (N=242) from the St. Jude Lifetime Cohort Study completed surveys assessing 10 symptom domains, and SF-36 HRQOL summary scores. Chronic health conditions (CHCs) were validated by clinical assessment. Multivariable logistic regression reveals that compared to non-cancer controls, HSCT survivors endorsed a significantly higher symptom prevalence in sensation (OR=4.7, 95% CI=2.6-8.4), motor/movement (OR=4.3, 95% CI=1.6-11.0), pulmonary (OR=4.6, 95% CI=1.8-11.8) and memory domains (OR=4.8, 95% CI=2.5-9.2), and poorer physical HRQOL (OR=6.9, 95% CI=2.8-17.0). HSCT and conventionally-treated survivors had a similar prevalence of all symptom domains and HRQOL (P's>0.05); however, HSCT survivors had a significantly higher cumulative prevalence for specific symptoms: double vision (P=0.04), very dry eyes (P<0.0001), and trouble seeing when wearing glasses (P<0.0001). Occurrence of organ-specific CHCs, instead of transplant receipt, was significantly associated with a higher prevalence of all symptom domains (P's<0.05) in adult survivors of childhood cancer, except for pain and anxiety domains. This study found that patient-reported outcomes were equally impaired between HSCT and conventionally-treated survivors, but poorer in both groups compared to non-cancer controls. Poor patient-reported outcomes in all survivors of childhood hematologic malignancies correlated with the presence of CHCs, whether treated with conventional therapy or HSCT.

Psoriasis (PsO) is a common, systemic, chronic, inflammatory disease characterized by key clinical symptoms, including itching, pain, and scaling. PsO is associated with a high prevalence of comorbidities, including other autoimmune diseases and malignancies. Furthermore, special populations, such as pregnant, pediatric, and elderly patients, and those with erythrodermic PsO, are challenging to treat and require tightly monitored disease and treatment management. Because certain populations have demographic or clinical characteristics that can affect the presentation of PsO and complicate treatment responses, these patient populations are largely excluded from clinical trials; therefore, most clinical evidence for the treatment of these patients is derived from case reports and series. Secukinumab, a fully human monoclonal interleukin-17A antibody, has been shown in several clinical trials to be effective and safe for the treatment of PsO; however, these studies offer only limited data on the use of secukinumab in patients with chronic illnesses or in special populations. This review explores the use of secukinumab for PsO in special populations, including pregnant women, children, elderly people, patients with erythrodermic PsO, and those with chronic illnesses, including latent tuberculosis, hepatitis B and C, HIV, multiple sclerosis, and malignancies.

The goal of this study was to assess differences in low back stabilization and underlying mechanisms between patients with low back pain (LBP) and healthy controls. It has been hypothesized that inadequate trunk stabilization could contribute to LBP through high tissue strains and/or impingement. Evidence to support this is inconsistent, and not all methods that have been used to study trunk stabilization are equally suitable. We have recently developed a method to assess intrinsic and reflexive contributions to trunk stabilization, which aims to circumvent the limitations of previous studies.

The patient was a 67-year-old man with advanced hepatocellular carcinoma (HCC) due to chronic hepatitis B. Due to refractoriness to radiofrequency ablation and transcatheter arterial chemoembolization, lenvatinib, a new oral mutikinase inhibitor, was started with a daily dose of 12 mg. However, on day 6 the patient developed acute-onset, right upper quadrant pain associated with fever; laboratory tests revealed leukocytosis and liver dysfunction. CT scan showed the swollen gallbladder with wall thickening with no evidence of gallstones, and the diagnosis of acute acalculous cholecystitis was made. After the resolution of cholecystitis by antibiotics and endoscopic nasogallbladder drainage placement, lenvatinib was resumed at a reduced daily dose of 4 mg. However, acute acalculous cholecystitis recurred, supporting lenvatinib as a cause of acute acalculous cholecystitis. Using the Naranjo adverse drug reaction probability scale, a score of 6 was derived, which indicates that this adverse event was probably caused by lenvatinib. In summary, we present a patient with advanced HCC who underwent repeated episodes of acute acalculous cholecystitis as a rare adverse event associated with lenvatinib.

Tolvaptan is approved to slow kidney function decline in adults with autosomal dominant polycystic kidney disease (ADPKD) at risk of rapid progression. Because studies indicated that the tolvaptan oxobutyric acid metabolite inhibits organic anion-transporting polypeptide (OATP)1B1 and OATP1B3, United States prescribing information advises avoiding concurrent use with OATP1B1/1B3 substrates, including hepatic hydroxymethyl glutaryl-CoA reductase inhibitors (statins). This analysis of the pivotal phase 3 tolvaptan trials (Tolvaptan Efficacy and Safety in Management of Autosomal Dominant Polycystic Kidney Disease and Its Outcomes [TEMPO] 3:4 trial [NCT00428948] and Replicating Evidence of Preserved Renal Function: an Investigation of Tolvaptan Safety and Efficacy in ADPKD [REPRISE] trial [NCT02160145]) examined the safety of concurrent tolvaptan/statin use.

Bladder-related pain symptoms in patients with bladder pain syndrome/interstitial cystitis (BPS/IC) are often accompanied by depression and memory deficits. Magnesium deficiency contributes to neuroinflammation and is associated with pain, depression, and memory deficits. Neuroinflammation is involved in the mechanical allodynia of cyclophosphamide (CYP)-induced cystitis. Magnesium-L-Threonate (L-TAMS) supplementation can attenuate neuroinflammation. This study aimed to determine whether and how L-TAMS influences mechanical allodynia and accompanying depressive symptoms and memory deficits in CYP-induced cystitis.

We report on a patient with a mild traumatic brain injury (TBI) who developed abdominal pain due to spinothalamic tract (STT) injuries revealed by diffusion tensor tractography (DTT).