Rejected

Calcinosis cutis refers to the deposition of calcium salts in the cutaneous and subcutaneous tissue and is frequently associated with inflammation. Gastric calcinosis can be classified into metastatic, dystrophic, and idiopathic; metastatic calcinosis is the most common type. In metastatic calcification, calcium salts are deposited in normal soft tissues in the setting of altered metabolism of serum calcium and phosphorus and is a rare and serious complication of chronic renal failure. The important factors contributing to the development of metastatic calcinosis are hypercalcemia, hyperphosphatemia, and an elevated calcium-phosphate product. The most striking feature of this diagnosis is the calcification around the large joints. While it mostly involves dermis of small and medium-sized vessels, it can rarely affect the mucosal layers of the gastrointestinal (GI) tract. Calcinosis presents as a marker for the presence of calcifications in other organs, such as heart or lung, which can be life-threatening. Patients rarely present with clinical symptoms of GI upset, dyspepsia, or epigastric pain that are attributed to calcinosis. If patients present with GI symptoms, infectious causes remain to be higher on the differential. We present a case of incidental finding of gastric mucosal calcinosis during the workup and treatment of dysphagia.

Pituitary apoplexy (PA) is a rare, usually vision-threatening and occasionally life-threatening entity. The exact incidence of PA in large series of pituitary adenomas is variable; however, it is more common in macroadenomas and nonfunctioning adenomas though it has been reported rarely in microadenomas. There are several well-known precipitating factors for PA including the use of anticoagulants, surgery, head trauma, pregnancy, etc. The typical clinical presentation is characterized by the near universal presence of headache with or without the following: visual disturbances, extraocular palsies, altered sensorium. MRI is the imaging modality of choice. Most patients have hormonal and/or electrolyte disturbances at the time of presentation which needs to be quickly corrected. Both conservative and surgical treatment modalities have been advised for the management of this condition. However, on the basis of the evidence available in the literature, the treatment should be individualized for each patient with PA. If conservative management is chosen, close clinical monitoring is necessary for early identification of deterioration. Surgery generally is through the trans-sphenoidal route. Most patients have a good recovery in visual function and extraocular palsy. There is some evidence in the literature that surgical intervention, when necessary, should be undertaken early as it is associated with better visual outcome. The majority of the patients will have residual hormonal deficits which will require prolonged hormone replacement therapy. There is a small but significant risk of recurrent PA in patients with residual tumors, especially, in those with large tumor residues. There is also a small risk of tumor recurrence following PA and hence all patients should undergo surveillance imaging periodically to detect the possible recurrence of tumor. In recent years, the mortality from PA has decreased significantly. A high index of suspicion and prompt multidisciplinary management will often lead to an overall good outcome.

If one is searching for a perfect example of why the Pure Food and Drug Act of 1906 was needed, this 1901 SWANSON'S RHEUMATIC CURE CO. foldover brochure would fit the bill (Figures 1A, 1B, and 1C). The SWANSON "FIVE DROP" REMEDIES were heralded as "the faithful guardian and sentinel of the human system" that "stands at the door and challenges every germ that knocks for admittance." FIVE DROPS had an "unfailing effect in the following diseases Rheumatism in all its forms, Sciatica, Backache, Neuralgia, Nervousness, Sleeplessness, Nervous and Neuralgic Headaches, Nervous Dyspepsia, and Nervous affections of every description, Asthma, Hay Fever, Croup and Bronchitis, Catarrh, Heart Weakness, (), Earache, La Grippe, Malaria, Creeping Numbness and kindred diseases." What couldn't these drops cure? A bottle of Swanson's Five Drops is pictured in Figures 2A and 2B.

Two patient case reports are presented describing the use of cannabidiol (CBD) for the symptomatic relief of a lumbar compression fracture and in the mitigation of thoracic discomfort and dysesthesia secondary to a surgically resected meningioma.

Ketamine is utilized often in the emergency department (ED) for rapid sequence intubation, procedural sedation, and acute pain management. The treatment of migraine headache in the ED varies widely and is dependent on several factors including migraine cause, previous successful abortive methods, and provider preference. Several medications are currently employed to treat acute migraine including nonsteroidal anti-inflammatory drugs, triptans, antihistamines, prochlorperazine, and corticosteroids, among others. Interest in ketamine as an abortive agent to treat migraine has increased as evidenced by recent studies evaluating its use in the ED. This review examines the data regarding the use of ketamine to treat migraine headache. The concept of treating migraine headache with ketamine has been studied for more than 20 years. Early studies conducted primarily in the outpatient setting evaluated ketamine through multiple routes of administration and differing migraine causes with varying results. These early data seem to suggest that ketamine provides relief from headache severity but provides little information regarding the optimal dose and route of administration. Recent active comparator and placebo-controlled trials in the ED utilizing subdissociative doses of ketamine (0.2-0.3 mg/kg intravenously) show conflicting results. To confound the decision regarding its use further, ED providers encounter differing recommendations regarding its place in therapy. Current data suggest that ketamine may provide pain relief to patients with migraine headache. Although there may be a role for ketamine in certain cases after more robust evidence becomes available, currently it is premature to incorporate ketamine into routine use. Several questions remain to be answered including its overall efficacy, place in therapy, dosage, and risk of undesirable side effects.

The objective of the study is to compare the efficacy of Thoracic epidural with Intercostal block plus intravenous morphine infusion for postoperative analgesia in patients undergoing elective thoracotomy.