Rejected

A 27-year-old male presented to the outpatient clinic with a two-week history of daily episodes of palpitations, chest pain, and shortness of breath. He also complained of fatigue and nausea that continued after he recovered from an upper respiratory infection (URI) one month prior. Of note, he described the chest pain as increasing in intensity when sitting or standing upright. Auscultation revealed regular rate and rhythm with no audible rubs or murmurs. An electrocardiogram (ECG) was performed and showed diffuse ST-segment elevations that the machine interpreted as pericarditis. Based on the patient's symptoms and ECG findings, he was sent for an evaluation by cardiology. After he failed a trial of non-steroidal anti-inflammatory drugs (NSAIDs), the patient was started on colchicine and his symptoms ultimately resolved within a few weeks. Review of his records showed an ECG performed in the emergency department (ED) a year prior demonstrated morphology consistent with early repolarization (ER). The ECG morphology of ER, acute pericarditis (AP), and even acute myocardial infarction (AMI) can often be similar and difficult to differentiate. In this patient, confusing ER with AP may have led to unnecessary evaluation and treatment by a specialist.

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic condition in children. The treatment of JIA is mainly by drug therapy, which includes non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs (DMARDs). Sulfasalazine is a DMARD that is used as the second-line of therapy. Although believed to have an effective and safe profile, it has side effects ranging from mild gastrointestinal discomfort to hematopoietic alterations. In this study, we present a case of JIA with sulfasalazine-induced bone marrow suppression in a five-year-old child, which is rarely reported within the pediatric age group across the literature.

Pain is a major postoperative complication worldwide, which in turn impairs normal body performance and increases postoperative morbidity, hospitalisation, and the susceptibility to infections which also lead to chronic pain development.

Amyloidosis cutis dyschromica (ACD) is a rare form of primary cutaneous amyloidosis. ACD, first described by Morishima in 1970 is characterized by (i) macular, speckled, reticular hyperpigmentation with hypopigmented spots distributed extensively over the body; (ii) little or no pruritus; (iii) prepubertal onset; and (iv) focal subepidermal amyloid deposition. A 49-year-old woman presented with a 20-year history of progressive, asymptomatic, generalized mottled hyper- and hypopigmented macules all over the body. Histopathological examination of a punch biopsy specimen showed deposition of homogeneous, eosinophilic material in the papillary dermis. This amorphous, eosinophilic material was stained metachromatically with crystal violet stain and found to be compatible with amyloid. Based on the clinical and histopathological findings, the patient was diagnosed as having ACD. Amyloidosis cutis dyschromica must be considered in the differential diagnosis of patients with diffuse dyschromatosis including both hyperpigmented and hypopigmented lesions and histopathological confirmation is necessary in order to reach a correct diagnosis.

Symptoms of anxiety and depression are common in inflammatory bowel disease (IBD). Antidepressants are taken by approximately 30% of people with IBD. However, there are no current guidelines on treating co-morbid anxiety and depression in people with IBD with antidepressants, nor are there clear data on the role of antidepressants in managing physical symptoms of IBD.

Pneumomediastinum is defined as the presence of air in the mediastinum. Trauma to the nearby organs can cause air to escape into surrounding tissues that may manifest clinically as severe chest pain, voice change, or shortness of breath. However, pneumomediastinum can present spontaneously in healthy individuals with no inciting factors in which case the condition is termed spontaneous pneumomediastinum (SPM). Pneumomediastinum can be challenging to manage due to the absence of clear guidelines for the diagnosis and management. We present the case of a 21-year-old with no previous medical history who presented with chest pain that was aggravated by speech and breath. The pain was of sudden onset preceded by smoking at 2:00 am. The patient was tachycardic, tachypnoeic with crepitation on palpation and a crunch sound (Hamman's sign) on auscultation. The patient rated the pain as 5/10 on a 11-point numerical pain rating scale, which then evolved to 10/10. The patient did not have fever, loss of consciousness (LOC), diaphoresis, history of trauma, or previous similar presentation. There were no other associated symptoms. A chest X-ray (posteroanterior (PA) and lateral view) showed pneumomediastinum, but laboratory tests results were otherwise normal. The patient was observed in the emergency room overnight. He remained stable, his tachycardia settled, and there was no leukocytosis or desaturation; however, tachypnea was observed. His pain symptoms were treated with analgesia as needed and the patient was discharged home in a stable condition, to be followed on an outpatient basis. Spontaneous pneumomediastinum can be challenging to manage due to the lack of reliable incidence data as well as the absence of clear management guidelines. Further research will aid in understanding the true incidence of SPM in Saudi Arabia and help in establishing a consensual approach and treatment guidelines to deal with SPM in otherwise healthy individuals. To the best of our knowledge, this is the first case of SPM in a young male reported from a tertiary hospital in Riyadh, Saudi Arabia.

OBJECTIVEIntrathecal drug delivery devices (IDDDs) are a mainstay in the treatment of spasticity and refractory pain. While these devices have been shown to greatly improve the quality of life for patients, they also have a high perioperative complication and failure rate. A major complication of IDDD implantation is infection. The current standard of care in the treatment of IDDD infection necessitates that the pump be explanted and the infection treated prior to implantation of a new IDDD. This process leads to long hospital stays, interruptions in optimal medical management, and a high risk for dangerous drug withdrawals. The authors describe a technique that allows for the explantation of the infected pump and implantation of a new pump concurrently, which they have named the "Turner Switch" technique in honor of its inventor.METHODSThe authors conducted a retrospective analysis of cases of infected IDDDs in which patients underwent simultaneous explantation of the infected pump and implantation of a new pump. Demographics and clinical data were collected.RESULTSData from a total of 17 patients (11 male, 6 female) who underwent simultaneous IDDD explantation and implantation to treat infections were analyzed from a 3-year period. No patients experienced infection of the newly implanted pump or catheter. Of the 17 patients, 14 (82.4%) had baclofen pumps to treat spasticity and 3 (17.6%) had fentanyl pumps to treat chronic pain. The median hospital stay was 7 days, with 16 of 17 (94.1%) patients able to be discharged home or to a facility with a level of care similar to their preoperative care. All patients ultimately experienced complete resolution of their initial infections. Five patients (29.4%) required a return to the operating room within the next 5 months (for repair of a CSF leak in 2 cases, for treatment of infection at the old pump site in 2 cases, and for treatment of a CSF leak compounded with infection in 1 case). No patient experienced infection of the newly implanted pump or catheter.CONCLUSIONSIDDD infections represent a large portion of morbidity associated with these devices. The current standard of care for deep pump infections requires pump explantation and a course of antibiotics prior to reimplantation of the IDDD. The authors demonstrate the effectiveness of a procedure involving simultaneous explantation of an infected pump and implantation of a new pump on the contralateral side in the treatment of IDDD infections.

OBJECTIVEThe prevalence of trigeminal neuralgia (TN) in patients with multiple sclerosis (MS-TN) is higher than in the general population (idiopathic TN [ITN]). Glycerol rhizotomy (GR) is a percutaneous lesioning surgery commonly performed for the treatment of medically refractory TN. While treatment for acute pain relief is excellent, long-term pain relief is poorer. The object of this study was to assess the efficacy of percutaneous retrogasserian GR for the treatment of MS-TN versus ITN.METHODSA retrospective chart review was performed, identifying 219 patients who had undergone 401 GR procedures from 1983 to 2018 at a single academic institution. All patients were diagnosed with medically refractory MS-TN (182 procedures) or ITN (219 procedures). The primary outcome measures of interest were immediate pain relief and time to pain recurrence following initial and repeat GR procedures. Secondary outcomes included medication usage and presence of periprocedural hypesthesia.RESULTSThe initial pain-free response rate was similar between groups (p = 0.726): MS-TN initial GR 89.6%; MS-TN repeat GR 91.9%; ITN initial GR 89.6%; ITN repeat GR 87.0%. The median time to recurrence after initial GR was similar between MS-TN (2.7 ± 1.3 years) and ITN (2.1 ± 0.6 years) patients (p = 0.87). However, there was a statistically significant difference in the time to recurrence after repeat GR between MS-TN (2.3 ± 0.5 years) and ITN patients (1.2 ± 0.2 years; p < 0.05). The presence of periprocedural hypesthesia was highly predictive of pain-free survival (p < 0.01).CONCLUSIONSPatients with MS-TN achieve meaningful pain relief following GR, with an efficacy comparable to that following GR in patients with ITN. Initial and subsequent GR procedures are equally efficacious.

The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant.

Enhanced recovery pathways are a multimodal, multidisciplinary approach to patient care that aims to reduce the surgical stress response and maintain organ function resulting in faster recovery and improved outcomes.