Rejected

Multiple sclerosis (MS) is a chronic disease that may require decades of ongoing treatment. Therefore, the long-term safety and efficacy of disease-modifying therapies is an important consideration.

Ranolazine is a well-known antianginal drug, that was first licensed for use in the United States in 2006. It was objectively shown to improve exercise capacity and to lengthen the time to symptom onset in patients with coronary artery disease. The most commonly reported side effects of ranolazine include dizziness, headache, constipation, and nausea. Here, we describe a case of bradycardia, hyperkalemia, and acute renal injury in the setting of ranolazine use. Our patient is an 88-year-old female who presented with abdominal pain, nausea, and vomiting. Her medical comorbidities included hypertension, diabetes, CAD, heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, hypothyroidism, and a history of cerebrovascular accident without any residual deficits. Her prescription regimen included amlodipine, furosemide, isosorbide mononitrate, levothyroxine, metformin, omeprazole, and ranolazine. Physical examination was remarkable for bradycardia and decreased breath sounds in the left lower lung field. Laboratory studies were significant for a serum potassium level of 6.8 mEq/L and a serum creatinine level of 1.6 mg/dL. She was given insulin with dextrose, sodium polystyrene, and calcium gluconate in addition to fluids. Her bradycardia and renal function worsened over the next 24 hours. Ranolazine was discontinued. Metabolic derangements were treated appropriately. After 48 hours from presentation, potassium and renal function returned to baseline and her heart rate improved to a range of 60-100 bpm. She was discharged with an outpatient cardiology follow-up. Ranolazine treatment was not continued upon discharge. In summary, our case illustrates an association between ranolazine and renal failure induced hyperkalemia, leading to conduction delays in the myocardium. Though further studies are warranted, we suspect that this is a variant of the recently described BRASH syndrome. We propose that in cases such as ours, along with treatment of the hyperkalemia, medication review and removal of any offending agent should be considered.

Recent studies have shown that early diagnosis and intervention promote the patient's good prognosis. For patients who underwent cardiac surgery and require extracorporeal circulation support, the incidence of postoperative cognitive dysfunction (POCD) is higher than in other types of surgery due to greater changes in brain perfusion compared with normal physiological conditions. Recent studies have confirmed that the use of ulinastatin or dexmedetomidine in the perioperative period effectively reduces the incidence of POCD. In this study, ulinastatin was combined with dexmedetomidine to assess whether the combination of the two drugs could reduce the incidence of POCD. One hundred and eighty patients with heart valve replacement surgery undergoing cardiopulmonary bypass from August 2017 to December 2018 were enrolled, with age 60-80 years, American Society of Anesthesiologists (ASA) grades I-III, education level above elementary school, and either gender. According to the random number table method, patients were grouped into ulinastatin + dexmedetomidine (U+D) group, ulinastatin (U) group, dexmedetomidine (D) group, and normal saline (N) control group. Group U was pumped 20,000 UI/kg immediately after induction and the first day after surgery, group D continued to pump 0.4 μg/kg/h from induction to 2 h before extubation, group U+D dexmedetomidine 0.4 μg/kg/h + ulinastatin 20,000 UI/kg, and group N equal volume of physiological saline. The patients were enrolled with Mini-Mental State Examination (MMSE) before surgery. The cognitive function was assessed by Montreal Cognitive Assessment (MoCA) on the first day before surgery and on the seventh day after surgery. Inflammatory factors, such as S100β protein, interleukin (IL)-6, matrix metalloproteinase (MMP)-9, and tumor necrosis factor (TNF)-α, were detected in peripheral blood before anesthesia (T0), immediately after surgery (T1), and immediately after extubation (T2). One hundred and fifty-four patients enrolled in this study. Compared with group N, the incidence of POCD in group U+D was the lowest ( < 0.05), followed by group U and group D. Group U+D had the lowest concentration of inflammatory factors at the T1 and T2 time points, followed by group U and group D. Both ulinastatin and dexmedetomidine can reduce the perioperative inflammatory response and the incidence of POCD in patients with heart valve surgery, and their combination can better reduce the incidence of POCD.

Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors.

: Postoperative pain management (POPM) appeared to be weak in Rwanda. : The aim of this study was to compare POPM measures in a teaching hospital between 2013 and 2017. : A two-phase observational study in 2013 and 2017. was conducted. Participants were recruited prior to major surgery and followed for two postoperative days. A numerical rating scale (0-10) was administered to all participants in both years, and the International Pain Outcomes questionnaire was administered in 2017. Recruitment, consent, and data collection were performed in participants' preferred language. : One hundred adult participants undergoing major general, gynecologic, orthopedic, or urologic surgery were recruited in 2013 and 83 were recruited in 2017. Fourteen percent of participants in 2013 and 46% in 2017 scored their worst pain as severe (>6; < 0.001). This was despite improved preoperative recognition of patients at high risk for severe postoperative pain (those with chronic pain or preoperative pain); 27% and 0% of these patients were not documented in 2013 and 2017, respectively ( = 0.006). Other measures of improved planning included "any preoperative discussion of POPM" ( < 0.001) and "discussion of POPM options" ( = 0.002). Preemptive analgesia use increased (3% of participants in 2013 and 54% in 2017; < 0.001). Incidence of participants having no postoperative analgesic at all decreased from 25% in 2013 to 5% in 2017 ( < 0.001). : Though severe postoperative pain incidence did not improve from 2013 to 2017, POPM improved by a number of measures. These changes may be attributed to pain research conducted there having raised awareness.

Rising rates of caesarean section (CS) is an issue of particular concern. Recently, there has been research supporting Vaginal Births After Caesarean (VBAC), which is controversial. In Greece, over half of births in the country are by CS, placing Greece among countries with the highest CS rates. The aim of this study was to investigate the prevalence and the factors associated with VBACs and to compare the maternal/neonatal outcomes with a 'non-caesarean' control group.

The complex regional pain syndrome (CRPS) is an agonizing and disabling condition that can affect one or more extremities. Contrary to expectation, sporadic case reports about lower limb CRPS are present in literature. The usual sequence of events with respect to CRPS has always been prior trauma or inciting event, leading to manifestations. We hereby present a case of prolonged and undue immobilization without physical therapy, leading to CRPS in a susceptible phenotype. However, the unique feature of this case was severity of osteoporosis leading to bimalleolar fracture. To the best of our knowledge, there has been no case report of CRPS, leading to fracture.

Day surgery for inguinal hernia Hernia surgery has experienced a very positive development in the past 30 years: better meshes, better understanding of the anatomy and the nerves, improved skills-training, minimally invasive and more precise operations (e. g. also with the robot), just to name a few. This directly results in fewer recurrences, less chronic pain and better quality of life. In the current article, the growing importance day-care surgery of inguinal hernias is discussed – not least because of the statutory AVOS regulation that came into effect in Switzerland on 01.01.2019. This article reviews the indication and the most important surgical procedures for day-care groin hernia repair. There is no single standard procedure (no one-fits-all), since according to today's knowledge every patient is an individual case and must have access to an individually tailored procedure. For day-surgery inguinal hernia repair with mesh, both conventional and minimally invasive procedures are suitable. When planning outpatient hernia repairs, it must also be taken into account that acute postoperative pain is of negative prognostic significance, which is why optimal postoperative pain therapy should be well coordinated with the general practitioner in the first days after the operation. With all the positive aspects of AVOS, it is still not clear how the further training of the young generation will take place under the current conditions, as it is no longer provided for in the structural and reimbursement regulations. There is an urgent need for improvement here.

Pelvic venous insufficiency may cause pelvic congestion syndrome that is characterized by chronic pelvic pain exacerbated by prolonged standing, sexual activity or menstrual cycle. It may be treated by embolizing the dysfunctional pelvic venous drainage and sometimes resecting vulvar, perineal and thigh varices.

Replantation of a traumatic upper extremity amputation is a complex process accompanied by prolonged hospitalization, extended rehabilitation, and potential for graft failure secondary to poor perfusion to the distal extremity. The patient is faced with repeat visits to the operating room in addition to severe acute and chronic pain issues. We present the case of an 18-year-old male treated with prolonged continuous peripheral nerve blockade following traumatic left mid-humeral amputation and subsequent replantation. The patient maintained infraclavicular brachial plexus catheterization until hospital discharge, a course spanning 33 days and six follow-up surgical procedures. The patient was pain free and had been weaned off all opioids at a 4-week outpatient surgical debridement. Prolonged continuous infraclavicular brachial plexus blockade following replantation surgery has numerous potential benefits including augmentation of perfusion to the injured extremity, management of severe acute post-traumatic pain, and prevention of the chronic pain associated with transected nerves.