Rejected

Dengue fever (DF) is the most common arthropod-borne viral illness with significant public health implications that can cause severe clinical symptoms and possibly death. We sought to determine the epidemiological and clinical characteristics of patients presented with DF to the Royal Hospital in a recent outbreak in Oman.

Psychological stress in a chronic course is implicated in various diseases, such as coronary artery disease, diabetes, ulcerative colitis, and psychosomatic pain disorders. Commensal microbiota in the host tissues interact with each other and maintain overall health. Oral and gut microbiomes are considered as the most ecologically rich and taxonomically diverse microbiota communities in humans. The effects of psychological stress on the gut microbiome have been well documented, and the interaction is commonly referred as the microbiota-gut-brain axis. Like the gut microbiome, the oral microbiome contributes to maintaining both local and systemic health. Although the effects of psychological stress on the oral microbiome have been studied, comprehensive knowledge about the oral-brain axis is lacking. The oral cavity and gut can communicate with each other through the microbiota. Three-way interactions within the oral-gut-brain microbiota might exist in patients with psychological stress and disorders. The effect of psychological stress on the gut and oral microbiomes, and the potential interactions within the oral-gut-brain axis are discussed in this review.

Almost all children with burns experience pain as a result of a complex pathophysiologic process that is usually untreated, and up to 38% of all pediatric burn victims develop anxiety disorders due to pain after hospital admission. Hence, it is important to manage pain and anxiety in the care of burn victim children. The goal of this review was to develop an evidence-based guideline for procedural pain management and sedation for burned children undergoing wound care procedures.

A 74-year-old woman was taken to our hospital with a chief complaint of chest and back pain. She was diagnosed with Stanford type A acute aortic dissection and underwent ascending aortic replacement. Fifteen months after surgery, a giant anastomotic aneurysm was found at the proximal and distal anastomoses on chest computed tomography (CT), and reoperation was indicated. Following sternal re-entry, anastomotic dehiscence was found where BioGlue, albumin/glutaraldehyde sealant, had been applied during the previous surgery, and caused aneurysm. Severe postoperative adhesion precluded extensive surgery, and redo replacement of the ascending aorta was carried out. Histopathological examination revealed extensive necrosis of smooth muscle cells in the aortic wall at the anastomotic site and a marked inflammatory cell infiltration around the aortic wall and the artificial graft, and association of BioGlue use was suggested. The use of appropriate tissue adhesives to reinforce the dissected aortic wall is important, as well as careful long-term follow-up.

The Food and Drug Administration has approved crizotinib (Xalkori) to treat adult and pediatric patients ages one year and older who have recurrent or refractory inflammatory anaplastic lymphoma kinase (ALK)-positive myofibroblastic tumors.The most common adverse effects in adults are vision disorders, nausea, and edema. The most common adverse effects in pediatric patients are vomiting, nausea, diarrhea, abdominal pain, rash, vision disorder, upper respiratory tract infection, cough, pyrexia, musculoskeletal pain, fatigue, edema, constipation, and headache.

Urachal cancer is a rare but aggressive malignancy. A urachal mass concerning for adenocarcinoma was identified in a 32-year-old G2P1 female on 12-week ultrasound and confirmed on pelvic MRI. Due to progressive growth of the mass and refractory abdominal pain, a multi-disciplinary meeting was held, after which the patient chose to undergo an exploratory laparotomy. A tubo-ovarian abscess was identified involving the intestine, right ovary, fallopian tube, and communicating with a patent, necrotic urachus. This is the first reported case of a tubo-ovarian abscess masquerading as a urachal malignancy, which can present similarly with abdominal pain and irritative urinary symptoms.

Pyometra is an easily overlooked disease with nonspecific symptoms; however, a delayed diagnosis can lead to severe complications. An 80-year-old frail woman presented to our hospital with a chief complaint of persistent fever for 10 days. Her blood tests showed an elevated inflammatory response, and computed tomography showed a 10-cm cystic lesion in the pelvic floor compressing the bladder. A catheter was inserted from the vagina into the uterine cavity, resulting in pus drainage and pyometra diagnosis. A pus culture was subsequently performed, which detected , a common cause of respiratory tract infections in cystic fibrosis and bloodstream infections, and. To the best of our knowledge, this is the first report of pyometra caused by . The patient was treated with drainage and piperacillin-tazobactam administration. Pyometra is especially prevalent in older women with impaired activities of daily living and dementia. Although fever, lower abdominal pain, and increased discharge may occur, symptoms are often nonspecific, and half of such cases are asymptomatic. Furthermore, delayed diagnosis can lead to perforation of the uterus and consequent pan-peritonitis. Thus, the diagnosis of pyometra should be considered in older women presenting with unknown fever, and imaging studies and gynecological consultation should be requested promptly.

In older individuals, minor trauma may cause potentially fatal intracranial subdural hematoma (SDH). Rarely, these patients present with only low back and radicular pain as gravity redistributes the SDH to the lumbar spine. A 69-year-old male presented to a chiropractor with a 10-day history of acute on chronic low back pain, which radiated into his lower extremities bilaterally, involving weakness and difficulty walking, and a ground-level fall onto his elbows 16 days prior. He had visited his primary care provider, orthopedist, and traditional Chinese medicine practitioner, received oral analgesics and three ketorolac injections, and had lumbar radiographs, followed by acupuncture, cupping, and spinal manipulation without lasting relief. Considering the patient's concerning presentation, the chiropractor ordered lumbar magnetic resonance imaging (MRI) on the first visit, revealing findings suggestive of late subacute lumbar SDH, and recommended urgent brain MRI and neurosurgical referral. The patient went to an orthopedic surgeon at a nearby hospital, becoming disoriented upon presentation, prompting admission. Brain MRI confirmed bilateral chronic intracranial SDH, prompting emergency hematoma evacuation via burr hole craniostomy. The patient's gait rapidly improved, and the pain subsided over the following two weeks. This case highlights an older male identified as having spinal SDH by a chiropractor, leading to referral and surgery for concurrent life-threatening intracranial SDH. Clinicians should be aware that spinal SDH may stem from asymptomatic intracranial SDH and should be suspicious of SDH in older individuals after a fall, signs of which warrant emergency referral for MRI and surgical evaluation.

Contrast-induced encephalopathy (CIE) is a rare but well-known complication of mostly intra-arterial contrast administration and presents with a variety of neurological deficits due to disruption of the blood-brain barrier. We present a case of CIE after administration of intravenous contrast for computed tomography pulmonary angiogram (CTPE). A woman in her mid-70s with history of chronic obstructive pulmonary disease (COPD) presented with progressively worsening shortness of breath. She was diagnosed with multifocal pneumonia and started on IV antibiotics, IV steroids, and bilevel positive airway pressure (BiPAP) ventilation. A CTPE was done to rule out a pulmonary embolism during which she received 100 cc of Isovue 370 (iopamidol 76%), a low-osmolar, non-ionic, monomeric, iodine-based contrast agent. Within minutes of the contrast administration, the patient developed confusion and agitation with elevated blood pressure. Neurological evaluation revealed no gross focal motor or cranial nerve deficits and bilateral 2+ reflexes with mute plantar reflexes. Laboratory investigations were unchanged. She was shifted to the ICU but continued to remain drowsy and disoriented. CT brain done within two hours of onset revealed no intracranial abnormality. She was managed conservatively with IV fluids, neuro-checks, and blood pressure control. Her sensorium improved within 48 hours with supportive treatment. Repeat neuroimaging was not performed. She was discharged after four days with the resolution of her respiratory symptoms. CIE is a known but uncommon complication associated with the use of intraarterial contrast media but has been found to occur even after intravenous administration, which has been reported only once in literature. The presentation is highly variable, ranging from headache to coma, with transient cortical blindness being the most commonly identified. The diagnosis requires a high index of suspicion, and brain imaging is usually pathognomonic; however, cases in the absence of radiological signs have also been diagnosed. Typically, symptoms resolve within 48-72 hours and the disease runs a benign course, but cases of persistent neurological deficit and even cases of fatal cerebral edema have been reported.Treatment is usually supportive with intravenous hydra-tion and anticonvulsants and the occasional use of IV steroids and mannitol with favorable outcomes.