Rejected

Acromegaly is a rare disease with an annual incidence of 3 to 4 cases in a million. Diagnosis is often delayed due to the slow progression of the disease. Persistent elevation of growth hormone (GH) in acromegaly causes a reduction in life expectancy by 10 years. Aside from multiple cardiovascular, respiratory and metabolic co-morbidities, it has also been proven to cause an increased incidence of cancer. The main treatment of acromegaly is surgical excision of the functioning pituitary adenoma. Multiple comorbidities, including obstructive sleep apnea (OSA), left ventricular hypertrophy (LVH) and soft tissue swelling, make surgery complicated, if not impossible. Medical therapy to reduce comorbidities may be indicated in certain situations. Somatostatin receptor ligands (SRL) are able to reduce, and possibly normalize, IGF-1 levels. Reduction of insulin-like growth factor-1 (IGF-1), the main mediator of GH, is able to resolve headache, sweating, fatigue and soft tissue swelling, and also reduce ventricular hypertrophy. This case report illustrates the successful use of the SRL octreotide LAR in treating acromegaly. It also confirms the observation from several case series that thyroid cancer is the most common malignancy in acromegaly.

: Sibling relationships are longstanding across an individual's life and are influential in children's development. The study of siblings in pediatric pain is, although in early stages, a growing field. : This scoping review sought to summarize and map the type of research available examining siblings and pediatric pain to identify gaps and directions for future research. : Studies were identified based on a search of PubMed, CINAHL, PsycInfo, Embase, and Web of Science (up to November 2016). We extracted data about study methods, the sample, outcome assessment, and the influence/relationships investigated. : Thirty-five studies were included. Most studies used quantitative methods (= 28), and participants typically included children (i.e., aged 6-12; = 24) and adolescents (i.e., aged 13-18; = 18). The majority of studies examined siblings in the context of chronic and disease-related pain (= 30). Though quantitative studies primarily focused on the genetic influence of pain conditions (= 18), qualitative and mixed-methods studies typically focused on exploring the impact of siblings with and without pain on one another (= 2) and the impact of pain on the broader dyadic relationship/functioning (= 4). : Sibling research in pediatric pain has been primarily focused on the biological/physical components of pain, using quantitative approaches. Conducting more studies using qualitative or mixed-methods designs, incorporating multiple assessment measures (e.g., observational, self-report) and multiple perspectives (e.g., siblings, health professionals), may provide an opportunity to gain richer and more comprehensive information regarding the experience of siblings.

Pain is a highly prevalent experience in pediatric medical populations, both in an acute form (e.g., iatrogenic pain from needle procedures) as well as in more chronic forms (e.g., as a result of arthritis, inflammatory bowel disease, or as a disease/disorder in and of itself). Guided by the biopsychosocial model, the overarching objective of this work is to examine cognitive behavioral treatment of anxiety in pain contexts. Specific aims are to (a) provide a brief overview of anxiety in youth with a high fear of needles and those experiencing chronic pain, (b) review the evidence base for cognitive behavioral therapy (CBT) for these populations, (c) outline considerations for implementing CBT-based approaches, and (d) provide two case examples which illustrate the application of CBT in these contexts. Brief concluding remarks include suggestions for future research such as improved screening and treatment of comorbid anxiety in the context of pain.

: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI. : A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI. : In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action. : A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame. : A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.

Prognosis research studies (e.g. those deriving prognostic models or examining potential predictors of outcome) often collect information on time-varying predictors their intended moment of use, sometimes using a measurement method different to that which would be used. We aimed to illustrate how estimates of predictor-outcome associations and prognostic model performance obtained from such studies may differ to those at the earlier, intended moment of use.

Atopic dermatitis (AD) is the most common chronic skin disorder among infants and young children. It is characterized by chronic relapsing eczema with itch and is caused by skin barrier dysfunction and immunological dysregulation. Scratching of the lesion site can damage the skin and increase epithelial permeability, thereby allowing large molecular weight antigens to be absorbed transcutaneously. However, a recent study demonstrated that Langerhans cells are localized close below the skin surface and extend dendrites vertically to penetrate the tight junctions (TJs) in erythematous lesions, even though the TJs were functionally intact. Therefore, epidermal barrier disruption is not critical for antigen uptake by Langerhans cells. In contrast, 2 critical damage-associated patterns-IL-33 and IL-1alpha-are reportedly released from damaged epithelial cells. Dendritic cells activated by IL-33 and thymic stromal lymphopoietin (TSLP) (induced by IL-1 alpha) express MHC class II and costimulatory molecules and facilitate naive T cell differentiation into IL-5- and IL-13-secreting Th2 cells. IL-33 and TSLP also activate type 2 innate lymphoid cells, induce large amounts of IL-5 and IL-13, and participate in the pathogenesis of AD. Primary prevention and proactive treatment of AD are critically important for preventing epicutaneous sensitization in AD patients. However, future studies are required to elucidate the most beneficial primary prevention strategies, including the indicated patient cohort and the timing and method of their application.

Atopic dermatitis (AD) is a chronic inflammatory skin disease with hallmark characteristics in terms of pruritus, psychological stress, and sleep disturbance, all possibly associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD). Epidemiological data indicate that AD and ADHD exhibit a parallel rise in global prevalence, and several cross-sectional studies have indicated co-occurrence of the 2 conditions. Furthermore, recent cohort studies have reported a temporal association between AD and later development of ADHD. However, underlying pathophysiological mechanisms of this association are insufficiently explored. The aim of the present review was to provide any clinician encountering AD an update on the most recent studies examining the possible AD-ADHD association. In turn, this could aid counseling of patients and parents. This review may encourage healthcare providers to refer AD patients and families to psychiatric specialists when ADHD is suspected.

has been infrequently reported as a cause of infection in humans. It has been associated with a variety of clinical syndromes but -related endocarditis is extremely rare. We present the case of a 76-year-old diabetic patient who was admitted to our hospital due to severe lumbar pain resistant to nonsteroidal anti-inflammatory drugs accompanied by fever (up to 38.5°C). The vital signs were normal and the physical examination was unremarkable except for tenderness over right flank. Laboratory investigation showed a mild leukocytosis (white blood cell count of 11,360×10/L) with elevation of inflammatory markers. Cardiac ultrasound showed a large vegetation on the mitral valve. Abdominal computed tomogrpahy revealed a ruptured aneurysm of the right renal artery. Multiple sets of blood culture grew

Aortic dissections (AD) are a frequent cause of sudden death and are typically associated with chest, back, and/or abdominal pain. Several cases of AD with neurologic presenting symptoms, such as paresthesia, headache, and seizures were noted at the Pima County Office of the Medical Examiner (PCOME) in Tucson, Arizona. Our aim was to compare the location of AD with central nervous system (CNS) versus classic symptoms. Retrospective data were collected from the archives at the PCOME from 2001-2014. There were 61 natural death cases involving the aorta with known antemortem symptoms; 43 cases of AD with classic (non-CNS) symptoms and 18 cases with CNS symptoms. The cases were classified based on Debakey and Stanford classification systems. Patients with CNS symptoms had a greater proportion of Debakey type II dissections (44%) than without CNS symptoms (16%). This association was statistically significant ( = 0.0337, chi-square test). Seventeen percent of cases with CNS symptoms had AD involving the carotid arteries, and involvement of the carotid arteries was significantly associated with CNS symptoms ( = 0.0227, Fisher's exact test). There were a higher percentage of females with CNS symptoms (44%), than without CNS symptoms (23%). Our findings suggest a need for a higher index of suspicion and further investigation of cases with neurologic symptoms, focusing particularly on the aortic arch and its branches.

Osteoarthritis is a chronic degenerative joint disease causing pain and disability. Glucosamine sulphate is a well known oral supplement for its treatment. The present pioneering study provides an overview of the accentuated transdermal delivery of glucosamine sulphate through the optimized gel formulation with guar gum and sodium carboxymethyl cellulose (Na-CMC). Response surface methodology based on the three-level three-factor central composite design provided the optimum concentration of guar gum, Na-CMC and glycerol for a maximum flux. The transdermal characterization, ex vivo permeation study and in vivo study were performed with optimized gel formulation. The factorial design predicted the optimum values of guar gum, Na-CMC and glycerol which were 418.53 mg, 444.97 mg and 2322.4 mg respectively for 25 g of the gel. This optimized gel demonstrated the maximum flux, i.e., 1047.46 μg cm h. The optimized gel showed satisfactory results with respect to drug uniformity, pH, stability, rheological properties, zeta potential, drug-excipient compatibility and skin irritation. The release of the drug from the optimized transdermal gel followed the controlled first order Fickian (non-steady) release pattern. The in vivo study was carried out in a rat model of osteoarthritis induced by monosodium iodoacetate damaging the tibial plateau. In this study the optimized formulation effectively reduced the symptoms like reduction in swelling of the knee joint, gross changes in digitized radio images and morphological and histopathological alterations. Additionally the changes in the release pattern of the proinflammatory cytokine tumor necrosis factor-α illustrated the efficacy of the transdermal gel for the treatment of experimental osteoarthritis. Thus the optimized gel was found to be a unique potential vehicle for transdermal application of glucosamine sulphate which effectively attenuates the experimental osteoarthritis.