Rejected

Infants in neonatal intensive care units require painful and noxious stimuli as part of their care. Judicious use of analgesic medications, including opioids, is necessary. However, these medications have long- and short-term side effects, including potential neurotoxicity. This quality improvement project's primary aim was to decrease opioid exposure by 33% in the first 14 days of life for infants less than 1,250 g at birth within 12 months.

Determining the cause of wrist pain is a challenge for clinicians due to the complex biomechanical characteristics of the multiple articulations which comprise the wrist, and the intricacies of the soft tissue supporting them. Patients presenting with wrist pain can be diagnosed by obtaining a detailed history, physical examination and radiographic images. For some patients, a diagnosis remains elusive even after a complete appropriate work up, and the pain may persist following conservative management. The aim of this systematic review was to analyze the effect that psychosocial factors have on the development chronic idiopathic wrist pain in children and adolescents.

Few studies have compared the safety and efficacy of azilsartan medoxomil (AZL-M) and telmisartan in hypertensive patients, especially using ambulatory blood pressure monitoring (ABPM).

Opioids are frequently used to manage chronic non-cancer pain despite the lack of evidence of benefit and clear evidence of opioid-related harms. Patients undergoing high-dose opioid therapy are at risk of multiple complications, such as opioid toxicity, including fatal overdose and opioid dependence.

The use of regional anaesthesia in foot and ankle surgery is becoming well recognised, particularly in patients who prefer to stay awake during the procedure and for better post-operative analgesia. Its use is ideal for patients with multiple co-morbidities, in whom general anaesthesia (GA) otherwise would could be challenging. The procedures performed with landmark/anatomical guidance alone carry a relatively higher risk of complications, risk of inadvertant injection into the intarvascualr space leadinf to local anaesthetic toxicity, the majority of which complications are caused by incorrect placement of the needle. Hence, ultrasound guidance is frequently used to minimise those risks. Although various regional anaesthetic techniques for foot and ankle surgery have been described, their comprehensive review is lacking. This manuscript aims to fulfil this void. The focus will be on the peripheral methods of regional anaesthesia including the plexus and single nerve blocks. Various techniques with their benefits and potential complications will be discussed. In addition, the evidence on the efficacy of an ultrasound-guided approach as well as its cost implications will be explored. There are significant considerations in deciding whether to implement this technique in routine clinical practice and this review aims to summarise the available literature to establish the evidence base behind it.

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.

Nonbacterial thrombotic endocarditis (NBTE) is a rare entity most commonly diagnosed postmortem with rates in autopsy series ranging from 0.9 to 1.6%. A 63-year-old female with past medical history of hypertension and mitral valve prolapse presented to the hospital with shortness of breath, headache, and necrotic skin lesions on her hands and feet. Computed tomography (CT) scan of her chest demonstrated a pulmonary embolus in the right lower lung segmental artery and right upper lobe lobar to segmental pulmonary artery, a mass-like consolidation in the left upper lung field impeding the hilum. CT scan of the abdomen demonstrated metastatic disease in liver and bone and bilateral femoral deep vein thrombosis. Transesophageal echocardiography revealed severe mitral regurgitation with two small mobile plaques on the mitral valve and two immobile plaques on the descending aorta. Magnetic resonance imaging of the brain was consistent with subacute infarcts and metastatic disease. Bronchoscopy was performed and pathology revealed primary adenocarcinoma of the lung. She was treated with anticoagulation and systemic chemotherapy. The patient and family elected to proceed with hospice due to her clinical decline, poor performance status, and poor prognosis after a prolonged hospital stay. Underlying malignancy is detected in approximately 40-85% of patients with NBTE. Lung cancer is the most frequently associated malignancy followed by pancreatic, stomach, breast, and ovarian cancer. Widespread necrotic skin lesions as presenting symptoms of primary lung adenocarcinoma are rare. In the present case, the diagnosis of necrotic skin lesions and NBTE preceded that of the neoplastic disease. Necrotic skin lesions and NBTE can be the first manifestations of an occult malignancy causing extensive multi-organ infarcts. NBTE can present with such extensive skin lesions as a first presenting sign of malignancy. To the best of our knowledge, this is the first case to present with such extensive skin lesions as the first presenting symptom of lung adenocarcinoma.

Despite established exposure limits and safety standards as well as the availability of carbon monoxide (CO) alarms, each year 50,000 people in the United States visit emergency departments for CO poisoning. Carbon monoxide poisoning can occur from brief exposures to high levels of CO or from longer exposures to lower levels. Common symptoms can include headaches, nausea and vomiting, dizziness, general malaise, and altered mental status. Some patients may have chest pain, shortness of breath, and myocardial ischemia, and may require mechanical ventilation and treatment of shock. Individuals poisoned by CO often develop brain injury manifested by neurological problems, including cognitive sequelae, anxiety and depression, persistent headaches, dizziness, sleep problems, motor weakness, vestibular and balance problems, gaze abnormalities, peripheral neuropathies, hearing loss, tinnitus, Parkinsonian-like syndrome, and other problems. In addition, some will have cardiac issues or other ailments. While breathing oxygen hastens the removal of carboxyhemoglobin (COHb), hyperbaric oxygen (HBO2) hastens COHb elimination and favorably modulates inflammatory processes instigated by CO poisoning, an effect not observed with breathing normobaric oxygen. Hyperbaric oxygen improves mitochondrial function, inhibits lipid peroxidation transiently, impairs leukocyte adhesion to injured microvasculature, and reduces brain inflammation caused by the CO-induced adduct formation of myelin basic protein. Based upon three supportive randomized clinical trials in humans and considerable evidence from animal studies, HBO2 should be considered for all cases of acute symptomatic CO poisoning. Hyperbaric oxygen is indicated for CO poisoning complicated by cyanide poisoning, often concomitantly with smoke inhalation.

Choriocarcinoma is a highly aggressive germ cell tumor and can metastasize to the brain. Although brain metastasis has a poor prognosis, the optimal treatment strategy remains unclear due to its low incidence. A 33-year-old man presenting with multiple lung nodules on chest radiography was referred to our hospital. Computed tomography revealed bilateral lung nodules and a large pelvic mass, and brain magnetic resonance imaging (MRI) demonstrated multiple brain lesions. He developed progressive headache and nausea and underwent two craniotomies because of rapid tumor growth and intratumoral hemorrhage. Metastasis of choriocarcinoma was strongly suspected because of histological findings and detection of urine human chorionic gonadotropin (hCG). He immediately received chemotherapy with bleomycin, etoposide, and cisplatin (BEP). Although the pelvic mass and pulmonary lesions reduced in size and the β-hCG level decreased after one cycle of BEP, brain MRI displayed an increase in the size and number of brain metastases. He underwent whole-brain radiotherapy (WBRT) concurrently with 2 cycles of BEP, leading to successful reduction of brain metastases. After 4 cycles of BEP, the β-hCG level was still higher than the normal range, and the pelvic and pulmonary lesions remained. He continued chemotherapy with paclitaxel, ifosfamide, and cisplatin (TIP) and etoposide, ifosfamide, and cisplatin (VIP). The β-hCG level normalized, and the residual pelvic mass was resected, revealing no viable cancer cells. Multimodal treatment, including two craniotomies and chemotherapy concurrent with WBRT, can achieve good control of lesions of the brain and other sites.

To evaluate the predictive validity of the Assessment of SpondyloArthritis international Society (ASAS) axial spondyloarthritis (axSpA), Amor, European Spondylarthropathy Study Group (ESSG) and modified New York (mNY) classification criteria.