Rejected

To compare the efficacy and safety of sub-tenon block to peribulbar block with respect to analgesia, akinesia, and complications.

Postoperative pain, the most common complication of dentoalveolar surgery, is routinely controlled by non-steroidal anti-inflammatory drugs (NSAIDs). However, despite its proven efficacy, the long-term consumption of NSAIDs is associated with several serious and adverse effects. As a result, photobiomodulation (PBM) or low-level laser therapy (LLLT) is used in many treatment modalities to reduce pain, inflammation, and promote healing.

Falciform ligament appendagitis is an extremely rare disorder, which is characterized by hematogenous or nonhematogenous inflammatory changes in the fat appendage that is contiguous with the falciform ligament. The imaging and clinical features of this condition are similar to those of epiploic appendagitis, especially when caused by torsion of the fatty appendage (ie, falciform ligament appendage torsion). We report 2 cases of falciform ligament appendagitis with localized epigastric pain. The ultrasound imaging features of the 2 cases presented here were an oval hyperechoic mass contiguous with the falciform ligament and increased echogenicity of the surrounding inflammatory fat. Both patients were managed conservatively with symptomatic treatment alone. Understanding the imaging features of this falciform ligament appendagitis is important, because ultrasound is often the first choice for noninvasive imaging of acute abdomen. As there is limited detailed literature on falciform ligament appendagitis comparing high-frequency linear probes with CT and MRI, we consider this case report to add valuable information on this poorly reported condition.

A 81-year-old female had chronic renal failure and was undergoing hemodialysis, visited orthopaedic clinic after striking her head on the ceiling of a car while driving on a rough road. An odontoid fracture went unidentified on the initial radiograph. One month later, she came to our hospital with persistent neck pain. A radiography and computed tomography revealed a C1-two subluxation secondary to the fracture. Posterior occipito-C1-C2-C3 fixation was performed, and the patient wore a halo-vest for two-month post-surgery. After two months, the halo-vest was removed, and the patient was not experiencing any pain or neurological deficits. In older patients, even minor head trauma can result in cervical vertebral fractures. Therefore, potential fractures should be considered during initial evaluations to avoid the serious consequences of an incorrect initial diagnosis. Care should be taken when choosing between conservative or surgical treatments, considering all potential risks and complications.

Intrahepatic cholestasis of pregnancy (ICP) is characterized by pruritus and an elevation in serum bile acid concentrations, typically developing in the late second and/or the third trimester and rapidly resolving after delivery. ICP is a rare condition that most often presents in the late second or early third trimesters of pregnancy. Physicians should be aware of this unusual presentation of ICP and screen their patients appropriately during prenatal consultations by monitoring symptom severity and laboratory tests, including bile acids and liver enzyme levels, in addition to monitoring the fetal condition to start treatment modality including maternal treatment and determine the time of delivery to avoid fetal complications. This is a case of severe ICP diagnosed in the late second trimester and went into labor at 33 weeks of gestational age.

Sacroiliac joint pain (SIJP) has been difficult to properly manage in the medical field. Patients are initially managed with medications and physical therapy but may require further interventions including intra-articular corticosteroid injections, radiofrequency ablation, and sacroiliac joint fusion. Although peripheral nerve stimulation (PNS) and peripheral field nerve stimulation (PFNS) have been used with varying success, subcutaneous spinal cord stimulation (SCS) has not yet been utilized. We present the case of a patient with bilateral SIJP who had successful resolution with the use of subcutaneously-implanted SCS electrode leads. A 74-year-old female patient with a history of lumbar stenosis status post epidural steroid injection and minimally invasive lumbar decompression presented with year-long chronic low back pain (LBP) with unsuccessful pain relief from medical management and physical therapy. On physical exam, pain elicited with tenderness over both sacroiliac joints with positive Patrick's and Gaenslen's test bilaterally. After successful pain relief from a diagnostic SI joint injection, the patient underwent an SCS trial. Trial SCS leads were placed epidurally at T7 and subcutaneously next to bilateral SI joints. Epidural stimulation provided no pain relief after three days. Stimulation was then changed to the subcutaneous leads, with subsequent 90% pain relief. The patient then underwent a permanent implant with subcutaneous lead placement without complications. She reported pain relief ongoing for two years. SIJP is a difficult condition to treat despite various modalities. Recent advances in neuromodulation have shown anecdotal success with PNS. SCS involves electrode leads placed in the epidural space to provide axial back and radicular pain coverage. In this case, however, SCS leads were placed subcutaneously with excellent pain relief. Our case showcases the successful use of subcutaneous-implanted SCS which can provide another viable minimally invasive treatment option in the management of this pain source.

Hemorrhagic pericardial effusion is a rare presenting sign of undiagnosed rheumatoid arthritis (RA). We present a case of a 58-year-old female with a history of mucinous cystadenoma with subsequent omental caking status-post small bowel resection, chronic intermittent bilateral knee pain, carpal tunnel syndrome of the left hand, and drainage of a peritoneal inclusion cyst two days prior to admission. The patient had pleuritic chest pain and acute-onset shortness of breath but was hemodynamically stable on presentation. Transthoracic echocardiogram and CT scan demonstrated a large pericardial effusion measuring 1.5 cm anteriorly, 2.21 cm posteriorly, and 2.5 cm laterally. Diagnostic pericardiocentesis revealed a hemorrhagic pericardial fluid with a glucose level of 133 mg/dL, pH of 7.34, albumin of 2.6 g/dL, red blood cell count of 401,000 cells per cubic millimeters (CUMM), white blood cell count of 1,400 CUMM, lactate dehydrogenase (LDH) of 930 U/L, and protein of 5 g/dL. Infectious and malignancy workups were negative. Rheumatologic workup was positive for elevated rheumatoid factor and anti-cyclic citrullinated peptide. The patient was diagnosed with RA; she was started on methotrexate with folic acid, and a pericardial drain was kept in place for three days. We present a brief review of the workup, etiologies, and therapeutic approach for patients who present with hemorrhagic pericardial effusion secondary to undiagnosed RA.

Retropharyngeal emphysema (RPE) is a condition that occurs when air is trapped in the retropharyngeal space. It is a rare condition that is either spontaneous or secondary to various etiologies. A case of a three-year-old patient with retropharyngeal emphysema secondary to local palate trauma was presented to King Fahd Hospital of the University. The patient was further investigated by flexible nasopharyngoscopy; however, it showed no additional complications. The patient was admitted to the hospital and managed conservatively with analgesia and antibiotics. Lateral neck X-ray showed complete resolution of retropharyngeal emphysema a few days after admission. The patient was discharged on oral antibiotics and a follow-up after one week was arranged. Upon follow-up, the patient's condition improved with no further complications.

Childhood ataxia may be due to multifactorial causes of impairment in the coordination of movement and balance. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, and progressive childhood ataxia indicates inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. CT and MRI of the central nervous system are the usual modalities used in imaging children presenting with ataxia, based on the clinical presentation. This document provides initial imaging guidelines for a child presenting with acute ataxia with or without a history of recent trauma, recurrent ataxia with interval normal neurological examination, chronic progressive ataxia, and chronic nonprogressive ataxia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

We present the cases of two otherwise healthy adults, one with meningitis and another with a subdural abscess, with both conditions attributable to . A 31-year-old man was admitted with a 3-day history of fever, headache, and vomiting. Physical examination revealed intermittent confusion, irritability, and neck stiffness. Cerebrospinal fluid (CSF) culture was positive for . Contrast-enhanced magnetic resonance imaging (C-MRI) revealed multiple small lesions on the bilateral frontal lobes. Intravenous ceftriaxone and vancomycin were administered, followed by intravenous moxifloxacin. His symptoms resolved within 3 months. Additionally, a 66-year-old man was admitted for acute fever with confusion, abnormal behavior, and a recent history of acute respiratory infection. Physical examination revealed confusion, neck stiffness, and a positive right Babinski sign. CSF metagenomic analysis detected . C-MRI disclosed left occipitotemporal meningoencephalitis with subdural abscesses. Intravenous ceftriaxone was administered for 3 weeks. His condition gradually improved, with resorbed lesions detected on repeat MRI. This study expanded the clinical and imaging spectra of meningitis. In healthy adults, can invade the brain, but subdural abscess is a rare neuroimaging manifestation. Early diagnosis of meningitis by high-throughput sequencing and flexible treatment strategies are necessary for satisfactory outcomes.