Rejected

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by myocardial necrosis and fibrofatty substitution of the myocardium, predominantly of the right ventricle. The evaluation of risk associated with gestation and delivery in patients with ARVC is difficult due to the small number of already reported cases. We present our experience of patients with ARVC who completed a pregnancy and delivery. A case series of nine women in Calgary, Canada, from 2013 to 2018, who were diagnosed with ARVC before or during pregnancy. Patients were identified using our Cardiac-Obstetrics database, and information was collected through electronic charts and patient recollection. All pregnancies reported were singleton with an average maternal age of 31 years. Six patients had a related genetic mutation. Beta blockers were being used by eight, and five had an implantable cardioverter-defibrillator (ICD) prior to the pregnancy. None of the patients developed heart failure during pregnancy, but one had a complicated antepartum and postpartum course. All pregnancies delivered at term with eight receiving neuroaxial analgesia. Five patients delivered vaginally. Those without an ICD had continuous cardiac monitoring intrapartum. The incidence of small for gestational age (33%) was higher than the general population. All of the patients breastfed the newborns. Pregnancies in these patients with ARVC were generally well tolerated. Given the rarity of the disease and absence of any clinical guidelines, multidisciplinary care is essential in the management of these patients.

We hereby report a puzzling case of multiple sclerosis (MS) relapse presenting as Takotsubo syndrome (TTS). Female, 42-years old, who presented herself to the Emergency Room of University Hospital "ASST Spedali Civili" of Brescia, Italy, for a severe headache and a non-ST-segment elevation acute coronary syndrome. Coronary angiogram showed no signs of coronary atherosclerosis. Upon further neurological evaluation, a diagnosis of MS relapse, related to TTS, was made, and treatment was started accordingly. The patient was discharged after 12 days after the admission, free of symptoms, and without signs of neurological and cardiological active disease. A hallmark of TTS is its association with a preceding stressful event. It may also be connected to a wide variety of diseases, including neurological ones, such as stroke, intracranial bleeding, head trauma, migraine, and seizures. However, up to our knowledge, only few cases of MS-induced TTS were previously described. Whether it is plausible to consider TTS as an uncommon extra-neurological manifestation of MS is still debated, however all the evidence points in that direction, considering the central role of catecholamines in TTS pathogenesis. With this case report the authors hope to encourage research on this field and on the intricate topic of brain-heart connections.

The purpose of this study was to compare patients with osteochondral lesions of the talus (OCLT) with and without concomitant chronic ankle instability (CAI).

Dry, itchy skin can lower quality of life (QoL) and aggravate skin diseases. Moisturizing skin care products can have beneficial effects on dry skin. However, the role of a daily skin care routine is understudied. To understand how daily skin care with a mild cleanser and moisturizer impacts skin health and patients' QoL, in dry skin population. A randomized, investigator-blinded study of 52 participants with moderate to severe dry skin. The treatment group (n = 39) used mild cleanser and moisturizer twice daily for two weeks whereas the control group (n = 13) used mild cleanser without moisturizer. Total Clinical Score (TCS; erythema, scale and fissures), Visual Dryness Score (VDS) and subjective itch-related quality of life (ItchyQoL) were collected. The treatment group showed significantly more improvement in TCS and VDS compared to the control group after two weeks. Among the three components of the ItchyQoL (symptoms, functioning, and emotions), symptom showed significantly greater improvement in the treatment compared to the control group. Over 80% of participants in the treatment group agreed that the regimen led to decrease in dryness/pruritus and improved skin texture. A consistent skin care regimen should be an integral component of management of dry skin.

To investigate the sedation weaning strategies in critically ill patients with mechanical ventilation in pediatric intensive care unit (PICU) and to explore the effect of different sedative weaning patterns on withdrawal syndrome. A single-center prospective cohort study was conducted from April 1, 2016 to April 30, 2017. One hundred and twelve patients who required mechanical ventilation and benzodiazepines and (or) opioids for at least 5 consecutive days in PICU of Shanghai Children's Medical Center were enrolled. Twenty patients (17.9%) had an intermittent weaning pattern, defined as a 50% or greater increase in daily benzodiazepine and (or) opioid dose after the start of weaning, and the remaining 92 cases (82.1%) had a steady weaning pattern. The demographic and clinical features, duration and dose of sedative and analgesics, and the incidence of withdrawal syndrome were evaluated. Mann-Whitney test was used for comparison about clinical features between different weaning pattern groups and children with withdrawal syndrome or not. Logistic regression was used to explore the risk factors of withdrawal syndrome. Among the 112 patients, 46 (41.1%) had withdrawal syndrome. The patients with the intermittent weaning pattern had a high score of pediatric risk of mortality Ⅲ (PRISM-Ⅲ) (10.0 (3.5, 12.0) 6.0 (2.0, 10.0), 654.50, 0.043) and were prone to re-intubation (35.0% (7/20) 7.6% (7/92), 0.003). The patients with withdrawal syndrome had longer duration of sedation (19.5 (16.8, 24.3) 10.0 (7.0, 17.3) days, 743.50, 0.01), higher incidence of intermittent weaning pattern (32.6% (15/46) 7.6% (5/66),χ(2)=11.58, 0.001), longer PICU hospitalization (19.0 (15.8, 25.3) 12.0 (8.8, 17.0) days, 755.00, 0.01) and higher cost (89 (57,109) 53 (32, 79) thousand yuan, 804.00, 0.01). Logistic regression showed that intermittent weaning pattern (odds ratio ()4.85, 95 confidence interval () 1.39-16.91, 0.013), perioperative period of liver transplantation (6.97, 95 1.25-39.04, 0.027) and a cumulative dose of midazolam ≥ 34.7 mg/kg (8.12, 95 3.09-21.37, 0.01) were risk factors of withdrawal syndrome. Withdrawal syndrome is more likely to occur in children who are intermittently weaned from sedation. Steady weaning strategy may help prevent iatrogenic withdrawal syndrome.

We evaluated whether parental clinical conditions were associated with fever after a first dose of MCV in the child in a cohort study including 244125 children born in Kaiser Permanente Northern California between 2009 – 2016 who received MCV between ages 1 – 2 years. Each child was linked with his/her mother and father when possible. Parental clinical conditions present before and after their child's birth were identified. We defined fever in the children as clinic and emergency department visits with a fever code 7-10 days after a first dose of MCV ("MCV- associated fever"). We evaluated parental clinical conditions associated with MCV-associated fever using multivariate logistic regression analyses. After adjusting for multiple factors, including healthcare utilization, maternal fever (OR = 1.19, 95% CI 1.06 – 1.32), fever after MCV (OR = 5.90, 95% CI 1.35 – 25.78), respiratory infections (OR = 1.20, 95% CI 1.10 – 1.31), migraine (OR = 1.14, 95% CI 1.05 – 1.24), syncope (OR 1.14, 95% CI 1.01 – 1.27), and essential thrombocythemia (OR = 1.93, 95% CI 1.15 – 3.25) were significantly associated with MCV- associated fever. Paternal respiratory infections (OR = 1.15, 95% CI 1.05 – 1.27), fever associated with respiratory infections (OR = 1.47, 95% CI 1.23 – 1.76) and vitiligo (OR = 1.63, 95% CI 1.06 – 2.53) were significantly associated with MCV- associated fever. Parental clinical conditions, specifically fever alone and fever associated with respiratory infection, are associated with fever in their child 7-10 days after MCV.

Patient descriptions of pain shape the pain experience, yet there is insufficient understanding of how patient communication can help providers lessen pain's psychological and physical impact.

Chronic flight-related neck pain is a common, well-recognized problem in military aircrew. The reasons for flight-related neck pain are multifactorial; however, there are currently no evidence-based guidelines for its prevention or clinical management. This case study describes the novel use of a synthetic training device in the rehabilitation of a Chinook crewman with chronic neck pain. The patient is a 34-yr-old rear crewman with 10 yr flying experience in the Chinook helicopter. He has a history of intermittent neck and shoulder pain since 2009 following a rugby injury. Over the years he has self-managed recurrent episodes of neck pain. However, in November 2017 his pain was so severe that he could no longer continue flying. This pain made him unfit for flying duties for 18 mo and he received intensive rehabilitation and injection therapy. RAF Odiham's new flying simulator was used in his return to flying program, so enabling him to become fully fit and return to all flying duties. Management and treatment of chronic flight-related neck pain is challenging. This case study highlights the importance of a multifactorial management approach and how a synthetic training device can be used in the rehabilitation of rotary rear crew.

COVID-19 pandemic is an emerging, rapidly evolving situation. Migraine is one of the commonest and highly disabling chronic neurological diseases in the world. During the pandemic and lockdown, migraine patients are facing an enormous problem in getting optimum care because of difficulty in access, forced social isolation, and encountering a health system that is getting rapidly overwhelmed. It is important that they must be protected by minimizing their visits to the clinics and emergency departments. Paradoxically multiple triggers are in operation which is likely to increase their headache frequency. Hence physicians should be made aware of the new rules of the game in treating migraines during this time of the pandemic so that these patients get optimum treatment and care and don't feel left out. This review tries to answer a series of questions related to managing migraines in the times of COVID-19 pandemic.

Chronic bacterial prostatitis (CBP) and chronic prostatitis/chronic pelvic pain syndrome IIIa (CP/CPPS IIIa) are separate nosologies defined diagnostic verification criteria according to the NIH-NIDDK classification (1995). The identification of enterobacteria in the prostatic secretion (PS) has long been a criterion for the diagnosis of CBP, while PS in patients suffering CP/CPPS IIIa was considered as "sterile". However, the introduction of various methods of PS`s in-depth analysis and UPOINTS classification (2010) development with the allocation of site I (infection) allows us to consider the infectious factor as an etiological predictor of the initiation of inflammation in the prostate with CP/CPPS IIIa. Thus, the determination of the features of the taxonomic composition of microbiota in BP and CP/CPPS IIIa can act as a differentiating factor of these conditions.