Rejected

Pneumatosis Intestinalis and hepato-portal venous gas are rare but ominous radiological findings that are synonymous with mesenteric ischaemia and bowel infarction in the majority of cases. Very uncommonly benign pathology have been implicated, including respiratory and inflammatory bowel disease. We provide a case of a 69-year-old gentleman with extensive peripheral vascular disease, who presented with generalized abdominal pain and findings of both pneumatosis intestinalis and hepato-portal venous gas. Laboratory investigations were unequivocal, with only mild lactatemia. Emergency laparotomy was performed, which revealed no obvious cause and only some turbid pelvic free fluid. The patient had an uncomplicated recovery. This case illustrates the importance of guiding decisions based on the patient's clinical state, and of keeping an open mind to benign pathology. It also highlights the importance of early surgical intervention in cases of high clinical suspicion.

There is evidence that 15 % of gastric cancer patients in Zambia survive more than one-year after diagnosis. The major contributing factor to these poor outcomes is late case detection. We set out to investigate the time course of gastric cancer diagnosis in Zambia. The study was conducted at the University Teaching Hospital, in Lusaka. Consenting patients presenting to the endoscopy unit were enrolled and their endoscopic findings recorded. An interviewer-administered questionnaire was used to collect information on basic characteristics, presenting symptoms and duration. We enrolled 388 patients, 92 (24%) of whom had gastric cancer. About two-thirds of the gastric cancers were located in the distal part of the stomach. The median time to endoscopic gastric cancer diagnosis was 12 weeks, IQR 4-32 weeks after the first health care consultation. This was despite gastric cancer patients seeking healthcare attention within a median of 2 weeks, IQR 0-4 weeks of noticing the symptoms. Patients presenting with persistent vomiting or evidence of blood loss had significantly shorter delays than those with abdominal pain (p<0.05 and p<0.001 respectively). Delayed referral for diagnostic endoscopy is a contributing factor to late gastric cancer diagnosis in Zambia. The delay is highest in patients presenting with abdominal pain.

We report a rare complication following a routine elective tonsillectomy. A 32-year-old woman woke up from general anaesthesia with left sided hemiparesis. She underwent extensive investigations, which were normal. At follow-up neurology clinic she was given a new diagnosis of hemiplegic migraine and commenced on treatment. This case draws attention to a rare cause of postoperative hemiparesis. Hemiplegic migraine is a differential diagnosis for postoperative motor deficit after exclusion of an acute neurological or metabolic event.

To investigate whether T786C, 4VNTR and G894 T gene polymorphisms could mediate in andrological treatment response in Spaniards.

Aim Potentially inappropriate medications (PIMs) in older people are associated with the increased use of health care services. The aim of this study was to investigate the prevalence of PIMs among the elderly being referred to pharmacies in Tehran using the Beers criteria of 2012, and identify factors related to PIMs. Methods This cross-sectional study was conducted on elderly patients (60 years and above) referred to pharmacies in Tehran, in 2017. The Beers' criteria 2012 were used to evaluate PIMs. The logistic regression analysis was used to find sociodemographic predictors of PIMs. Results The mean age of 1591 patients was 70.51 years. The overall prevalence of PIMs was 26.0%. The most frequent PIMs, in order of frequency, included diclofenac (13.5%), alprazolam (9.3%), and chlordiazepoxide (9.1%) and clonazepam (8.4%). The pain medications were found to be most common PIMs (37.6%). Polypharmacy (OR=3.64, CI 95%: .81-4.70; p<0.001), number of chronic disease (OR=2.371, CI 95%:1.71-3.28; p<0.001) insomnia (OR=1.45, CI 95%: 1.13-1.87; p<0.01) and type of specialists were found as PIMs risk factors. Internal medicine specialists prescribed PIMs significantly fewer times than other specialists(OR=0.59, CI 95%: 0.40-0.88; p<0.01, and the orthopedic specialists prescribed PIMs significantly more times than other physicians (OR=3.23, CI 95%: 5.76-1.81; p<0.001). Conclusion High prevalence of PIMs among Iranian elderly patients implies a need for the development and operationalization of scientific guidelines for the use of medicines. It is also necessary to hold training courses for physicians to be educated in such cases.

Using anesthetic gel may not sufficiently exclude pain perception during and after cystoscopy in male patients. To evaluate the analgesic efficacy and safety of intramuscular parecoxib (40 mg) for outpatient-based rigid cystoscopy, we performed a prospective, randomized and controlled study. Consecutive male patients requiring diagnostic cystoscopy in our hospital were divided into group A (1% tetracaine gel, n=50) and group B (parecoxib, n=51) at random. Patients received intramuscular injections of either 2 mL sterile saline in group A or 40 mg parecoxib in group B 30 min before the procedure. Tetracaine gel was injected into the urethra 3 min before the procedure in group A, with patients receiving plain lubricant gel in group B at the same time. Cystoscopy-associated pain levels were evaluated using the Visual Analog Score (VAS) during the procedure. Post-procedure urethral pain and complications were recorded and analyzed. The results showed that male patients experienced significantly less pain in group B than in group A (2.70±1.36 vs. 3.56±1.74, P=0.008). The percentage of patients with dysuria pain was not significantly different between the two groups. In addition, 24 h after cystoscopy, the patients with no previous experience of cystoscopy were more likely to declare urethral pain (59.2% vs. 33.3%, P=0.012, relative risk=1.78). No difference was observed in analgesic-related complications between the two groups. We conclude that intramuscular injection of 40 mg parecoxib may improve comfort for male patients undergoing rigid cystoscopy.

This study aimed to evaluate the effect of clinical factors on the outcome of arthrocentesis in the treatment of temporomandibular joint (TMJ) internal derangement.

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches –migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition.

The study aims to investigate signs and symptoms of temporomandibular disorders (TMD) among physicians in a tertiary health-care center. It has estimated the level of symptomatology, determined the association with demographic data, and identified the related occupational risk factors. A cross-sectional survey was used, and physicians of genders, all age groups, and nationalities from King Abdulaziz Medical City in Riyadh, Saudi Arabia, were recruited. Subjects who had rheumatic arthritis, osteoarthritis, trigeminal neuralgia, or temporomandibular joint (TMJ) trauma were excluded. The data were collected through a self-administered questionnaire that measured TMD severity and oral parafunctional behaviors. Fonseca's anamnestic index (FAI) and an oral validated behavior checklist were used to assess the signs and symptoms of TMD. A total of 282 physicians participated in the study, and the prevalence of TMD signs among physicians was 37% (106); among them, 88 (83%) were within the light dysfunction category. Female physicians reported significantly higher FAI than males for side-to-side mandibular movement (12% vs. 5%,  = 0.04), reporting ear pain (18% vs. 10%,  = 0.04), and noticing clicking when chewing or opening the mouth (35% vs. 20%,  = 0.006). Younger practitioners (28-31 years old) who reported clicking while chewing or opening the mouth tended to have reported higher TMD dysfunction (35%) than those aged 40 and above (13%;  = 0.007). Self-reported signs of TMD were 37% among our population. Information collected from FAI is useful in early diagnosis and prevention of TMD.