Rejected

Non-steroidal anti-inflammatory drugs (NSAIDs) are often used as analgesic and antipyretic drugs. Nephrotoxicity is a common side effect and leads in 1-5% of pediatric cases to acute kidney injury (AKI). The nephrotoxic effects of NSAIDs arise mainly from two pathological mechanisms: (1) acute tubulo-interstitial nephritis (ATIN) following immune reaction and (2) prerenal failure because of reduced renal plasma flow. Histological examinations are required to confirm the pathomechanism of AKI after NSAID exposure. The aim of this study was to illustrate the risk of ATIN in children with AKI after NSAID exposure. The medical records of all 100 pediatric patients with biopsy-proven AKI treated between January 2006 and 2016 at La Timone Hospital, Marseille, France, were analyzed retrospectively. Twenty-five of these patients had ATIN, four of which were healthy children who had been treated with NSAIDs. In other words, NSAID side effects accounted for 4% of all cases of biopsy-proven AKI and 16% of all cases of ATIN. None of the patients had hypovolemia when they received NSAIDs. Clinical symptoms were non-specific. All patients had abdominal pain and vomiting but normal urine volume output. Maximum serum creatinine levels ranged from 300 to 512 μmol/l, with estimated minimum creatinine clearances of 12-26 ml/min/1.73 m. None of the patients had significant proteinuria. One child had hyperechogenic enlarged kidneys. Three patients were treated with steroids, one of whom also received intravenous methylprednisolone. Renal function improved gradually in all patients, but the patient who received methylprednisolone developed moderate chronic kidney disease (CKD). Biopsy proven-AKI secondary to NSAID use can be severe and be associated with ATIN. Since NSAID-induced ATIN can lead to CKD, clinicians using NSAIDs should focus on preventing AKI.

Sağ E, Sönmez HE, Demir S, Bilginer Y, Ergen FB, Aydıngöz Ü, Özen S. Chronic recurrent multifocal osteomyelitis in children: a single center experience over five years. Turk J Pediatr 2019; 61: 386-391. Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease characterized by sterile bone inflammation. It is an orphan disease with many unclear aspects in terms of diagnosis, treatment and follow-up. The aim of this study was to report our experience of pediatric CRMO patients. Children who were diagnosed with CRMO, and were followed-up between January 2008 and January 2017, were included in this study. There were 15 CRMO patients (8M/7F) with a median age at diagnosis of 9.0 years (range: 0.6-15.0). Bone pain was the most common presenting symptom. All of the patients had multifocal bone lesions. Vertebrae (66.7%) and femur (66.7%) were the most commonly affected bones. Eight of the patients also had sacroiliitis; however, only one of them was HLA-B27 positive. Whole-body magnetic resonance imaging (MRI) was used as a diagnostic tool in 13 patients revealing bone marrow edema (84.6%), osteitis (69.2%), and periosteal reaction (61.5%). All patients were initially treated with non-steroidal anti-inflammatory drugs (NSAIDs), however, disease-modifying anti-rheumatic drugs, anti-TNF agents or pamidronate were added to therapy due to inadequate treatment response. Clinical remission was achieved in 12 patients (1 with NSAIDs, 3 with methotrexate, 1 with pamidronate and 7 with an anti-TNF agent). During the follow-up period, relapses were observed in four patients who presented with pain and/or a newly formed bone lesion on MRI. Eventually, however, all of these patients also reached remission. CRMO is a chronic disease which may have a progressive or relapsing-remitting course. Improvement of the knowledge about this rare disease may help to enlighten the unknowns of the disease.

: Chronic pain has a significant impact on the physical and psychological functioning of those living with this condition. It is now recognized that acceptance and commitment therapy (ACT) is an effective intervention in managing chronic pain; however, several barriers limit its accessibility. : The current study aimed to evaluate the effectiveness of an 8-week bibliotherapy-type self-administered psychological intervention with minimal therapeutic contact, based on ACT, in the management of chronic pain. : This was a randomized controlled trial with three measurement periods (pretest, posttest, and 3 months after the intervention; ClinicalTrials.gov Identifier: NCT03924687). A total of 140 adults with chronic pain were randomly assigned to an ACT self-help condition or a wait-list control condition. : Two-way repeated measures analysis of variance (ANOVA) models showed statistically significant differences between pretest and posttest in terms of pain-related disability (main variable), depression (secondary variable), pain-related acceptance, and psychological inflexibility ( = 0.46-0.88) in favor of the ACT self-help condition. At the 3-month follow-up, these differences were maintained and nearly 54% of participants reported an overall improvement of their physical and mental health. : These results suggest that a psychological intervention self-administered through ACT bibliotherapy with minimal therapeutic support can improve the physical and emotional functioning of adults from the community who live with chronic pain.

Painful diabetic neuropathy is associated with low quality of life, depression and anxiety. Patients are limited in their performance of activities of daily living due to fears related to their condition. Treatment modalities are needed to help patients cope with their pain and pain-related disability. Exposure is an effective treatment in other chronic pain syndromes, increasing patients' functional ability and quality of life. This paper presents an Exposure treatment protocol for patients with painful diabetic neuropathy.

Primary intraosseous arteriovenous malformations (AVMs) are rare and have only been occasionally reported. We herein report a histologically proven case of primary intraosseous AVM in the distal humerus which mimicked an osteomyelitis on radiography.

Blaise Pascal (1623-1662) was a French philosopher, who wrote the Pensées, a collection of "thoughts" about the apparent insignificance of human existence. In the last three centuries, it was claimed that his disease was mental. Hysteria, melancholia, and post-traumatic neurosis were taken into consideration, but none of the proposed diagnoses seems to be satisfactory. The aim of our work is to identify Pascal's mysterious illness. We correlated the symptoms of the indirect anamnesis (Pascal's letters to friends, letters and biographies made by his sisters and granddaughter) and autopsy data. Based on these data, we consider that Pascal's illness, which has affected him all his life and caused his death, was celiac disease, the diagnosis being supported by: childhood abdominal pain with gradual progression to neurological manifestations in his middle-age, which were expressed by migraine-type headaches, peripheral neuropathy, epilepsy, neuropsychiatric disorders (depression). The hypothesis of a celiac disease is also argued by autopsy data: lack of closure of the fontanelle due to type D hypovitaminosis, intestinal gangrene because celiac disease accelerates the post-mortem autolysis, gliosis and calcification of the nervous tissue. The second cause of his death was a chronic traumatic subdural hematoma, probably located in the superior temporal region, which was the reason for his left-sided hemianopsia that occurred immediately after a carriage accident. Conclusions: Pascal's philosophy reflects his own inner life, which was deeply influenced by the organic affections he suffered.

The purpose of this study was to investigate muscle activity variability within and between the right and left side of lumbar muscles in patients with chronic low back pain (cLBP) compared to healthy controls (HCs) during sustained quiet sitting. Surface electromyographic (EMG) signals were collected bilaterally from the lumbar muscles with 2 high density surface EMG grids of 9×14 electrodes. Root mean square values (RMS) over 1-sec epochs of all bipolar EMG leadings were obtained. Between-sides alternating activation was computed, as well as temporal- and spatial variability within the electrode grids through the coefficient of variation and correlations between RMS distributions. The subjective influence of sitting was evaluated by the rating of perceived exertion and the amount of LBP on a numeric pain rating scale. Compared to HCs, the patients with cLBP had lower temporal (p = 0.03) and similar spatial muscle activity variability during sitting, despite a more variable sitting position. This did not result in increased muscle fatigue indicated by EMG, but the patients with cLBP reported higher levels of RPE during- and more LBP after the sitting and as a consequence ended the sitting earlier than HCs (p < 0.01). Present findings lend support to the presence of less tolerance for low-level static muscle load in patients with cLBP.

Cross-sectional study.

Building on the recent finding that chronic pain patients with impaired functioning of the descending nociceptive inhibitory system (DNIS) present lower resting heart rate variability (HRV), this study aims to investigate the impact of Spinal Cord Stimulation (SCS) on HRV in patients with Failed Back Surgery Syndrome (FBSS). More precisely, we hypothesize that SCS influences the DNIS, with increased parasympathetic tone as a consequence, as measurable by HRV analysis.

Dermatitis herpetiformis (DH) is an inflammatory disease of the skin, considered the specific cutaneous manifestation of celiac disease (CD). Both DH and CD occur in gluten-sensitive individuals, share the same Human Leukocyte Antigen (HLA) haplotypes (DQ2 and DQ8), and improve following the administration of a gluten-free diet. Moreover, almost all DH patients show typical CD alterations at the small bowel biopsy, ranging from villous atrophy to augmented presence of intraepithelial lymphocytes, as well as the generation of circulating autoantibodies against tissue transglutaminase (tTG). Clinically, DH presents with polymorphic lesions, including papules, vesicles, and small blisters, symmetrically distributed in typical anatomical sites including the extensor aspects of the limbs, the elbows, the sacral regions, and the buttocks. Intense pruritus is almost the rule. However, many atypical presentations of DH have also been reported. Moreover, recent evidence suggested that DH is changing. Firstly, some studies reported a reduced incidence of DH, probably due to early recognition of CD, so that there is not enough time for DH to develop. Moreover, data from Japanese literature highlighted the absence of intestinal involvement as well as of the typical serological markers of CD (i.e., anti-tTG antibodies) in Japanese patients with DH. Similar cases may also occur in Caucasian patients, complicating DH diagnosis. The latter relies on the combination of clinical, histopathologic, and immunopathologic findings. Detecting granular IgA deposits at the dermal-epidermal junction by direct immunofluorescence (DIF) from perilesional skin represents the most specific diagnostic tool. Further, assessing serum titers of autoantibodies against epidermal transglutaminase (eTG), the supposed autoantigen of DH, may also serve as a clue for the diagnosis. However, a study from our group has recently demonstrated that granular IgA deposits may also occur in celiac patients with non-DH inflammatory skin diseases, raising questions about the effective role of eTG IgA autoantibodies in DH and suggesting the need of revising diagnostic criteria, conceivably emphasizing clinical aspects of the disease along with DIF. DH usually responds to the gluten-free diet. Topical clobetasol ointment or dapsone may be also applied to favor rapid disease control. Our review will focus on novel pathogenic insights, controversies, and management aspects of DH.