Rejected

The objective of this study was to describe the anatomy of the spinal nerves, specifically the last thoracic nerve (T13) and the first to third lumbar nerves (L1 to L3), in order to safely carry out an accurate proximal paravertebral block (PPVB) in sheep. This study consisted of 2 phases. In Phase 1, 7 sheep cadavers were dissected to identify the path and relevant anatomical landmarks of spinal nerves T13 and L1 to L3. In Phase 2, 2 healthy sheep received bilateral injections of 0.35 mL/kg body weight (BW) for each hemithoracolumbar area (0.088 mL/kg BW per nerve) of a dye-lidocaine solution (50:50) using a PPVB approach and then assessed for 15 min for signs of systemic and local effects of lidocaine. After euthanasia, the infiltrated area was dissected to assess the spread of the dye. Successful nerve staining (> 2 cm in length), macroscopic evidence of intraneural/intravascular injection, and spread to the epidural space and the abdominal cavity were recorded. In Phase 1, each branch of all nerves was easily identified and located using the caudal aspect of the spinous apophysis and the lateral edge of the transverse process of the respective vertebrae. An overlap was observed between the costoabdominal (T13), the iliohypogastric (L1), and ilioinguinal (L2) nerves. In Phase 2, all nerves were stained at least 2 cm from the injection site. There was no diffusion of the dye into the epidural space or abdominal cavity. In conclusion, using the anatomical landmarks described specifically for sheep, the PPVB provided accurate perineural distribution of the injected dye-lidocaine solution, which could result in clinical analgesia of the flank.

Chronic hemorrhoidal disease is a common anorectal condition that leads to hemorrhoidal hyperplasia, which affects millions of people worldwide and is a significant medical and socioeconomic issue. Rectal bleeding is one of the main chronic symptoms. Recurrent rectal bleeding can alter an individual's quality of life and, more rarely, cause anemia. Pain is less common, occurring only in the event of complications such as congestive exacerbation, external hemorrhoidal thrombosis, or fissures. The most standard treatment involves dietary and hygiene measures, use of phlebotonic drugs, and nonsurgical treatment such as infrared photocoagulation or elastic band ligation. Excisional treatments such as hemorrhoidectomy and hemorrhoidopexy are the reference standards for treatment of hemorrhoidal disease. Embolization of the rectal arteries (ie, emborrhoid) has recently emerged as an effective treatment option, with few reported adverse effects, minimal blood loss, and a same-day hospital procedure. Hemorrhoid embolization is performed by using femoral or radial access. The inferior mesenteric artery and then the superior rectal arteries are catheterized with a microcatheter. Embolization can be performed by using different agents. Studies have shown improvement in symptoms and high technical success rates after treatment. The basic principles of hemorrhoid embolization that must be understood to achieve effective treatment, including those related to patient evaluation, the arterial anatomy, basic embolization, and published results, are reviewed. RSNA, 2022.

Polytrauma victims are usually in severe pain with difficulty in breathing. There are limited regional analgesia options that cover the shoulder region as well as the rib and other associated fractures. The erector spinae plane block (ESPB) is a versatile block which has established a role in the management of rib fracture pain and has emerging indications for managing pain in the shoulder and upper humerus regions. We examined the efficacy of ultrasound guided ESPB at the T2 level in two polytrauma patients with unilateral scapular, humerus, and rib fractures undergoing surgery in the shoulder region. It provided excellent postoperative analgesia and helped to alleviate pain of associated rib and other fractures, thereby facilitating early postoperative recovery and rehabilitation.

Coronavirus disease 2019 (COVID-19) pandemic is increasingly recognized as a serious, worldwide public health concern. Most of the patients with COVID-19 are asymptomatic or show mild symptoms. It is important to identify the unusual manifestations and their long-term complication.

Vasculitis is a heterogeneous group of disorders characterized by multifocal segmental inflammation of the small and medium vessels of the central nervous system. The predominant symptoms of cerebral vasculitis are stroke, headache, and encephalopathy. Additional symptoms include seizures, cranial nerve palsies, and myelopathy. Imaging techniques play a crucial role in identifying the diagnosis of vasculitis and demonstrating brain involvement. An 89-year-old woman with permanent atrial fibrillation developed an embolic stroke. In treatment, intravenous thrombolysis and thrombectomy with complete antegrade reperfusion of the left middle cerebral artery was used, without the clinical effectiveness. Brain MRI revealed bilateral oval lesions in medial parts of the orbits, which were initially misinterpreted as orbital tumors. Final diagnosis confirmed thickened arterial walls as orbital changes due to inflammatory arteritis. Ten days later, follow-up MRI was performed and showed complete regression of the orbital masses. Primary central nervous system vasculitis, manifesting as acute ischemic stroke, may be reversible with early systemic thrombolytic treatment.

Methemoglobinemia is a rare condition characterised by hypoxic state manifesting as headache, nausea, fatigue, and confusion. We report a 2-year-old boy presenting with fever and cough for 7 days with an episode of hypoxia as the saturation declined and did not improve on face mask oxygenation. On further evaluation, acute intravascular hemolysis was established following decreased haemoglobin level, increased levels of lactate dehydrogenase, and unconjugated bilirubin in the setting of documented infection. Assessment of arterial blood gas showed a significantly raised saturation gap and detection of methemoglobin confirmed the diagnosis. He was managed conservatively with packed red blood cells transfusion following which hypoxia was corrected. Methemoglobinemia as a result of hemolysis can be a non-cardio-respiratory cause of hypoxia and inciting aetiology needs to be addressed.

Lower extremity deep vein thrombosis (DVT) is frequently encountered in clinical practice. Postthrombotic syndrome (PTS) is a common sequela of DVT and encompasses a wide variety of symptoms, including severe pain, edema, and ulceration, all of which may contribute to a negative impact on quality of life. Studies have demonstrated that acute thrombosis of the iliofemoral venous segment is correlated with high rates of PTS, increased severity of symptoms, and high rates of thrombus recurrence, despite patients receiving treatment with standard-of-care anticoagulation therapy. Endovascular interventions, including catheter-directed thrombolysis, pharmacomechanical thrombectomy, and mechanical thrombectomy, have generated significant interest as a method for reduction of short-term symptom severity and potential reduction of downstream PTS severity. While there is high-quality evidence evaluating the role of catheter-directed and pharmacomechanical thrombectomy for acute iliofemoral DVT, newer mechanical-only devices that utilize thrombectomy without fibrinolytic medication are less studied. Currently, there are limited data evaluating the efficacy and safety of these treatment modalities, although investigations are ongoing.

Long COVID is defined as symptoms related to various organs following COVID-19. There is currently very little information available about the prevalence of these symptoms and their long-term recovery time. The aim of this study was to describe the symptoms that persisted nine months after COVID-19. This cross-sectional study was conducted in Antalya, Türkiye, between November 1 and 30, 2020 on COVID-19 patients. Patients were contacted approximately nine months later by two infectious diseases physicians, and the questionnaire which included 27 symptoms was completed. Of the 390 patients who met the criteria, 329 agreed to participate in the study. Patients' average age was 48.9 ± 14.4 years, and 51.7% were male. 79.3% of the people still had at least one symptom at the end of the ninth month. The most common symptoms were weakness-fatigue (54.7%), forgetfulness (45.3%), effort loss (35.0%), sleep disturbance (34.3%), joint pain (27.4%), and hair loss (23.4%). According to analysis performed in terms of sex; hair loss, diarrhea, nausea, dizziness, sore throat, loss of taste and smell were more common in women than in men (p= 0.042, p= 0.047, p= 0.050, p= 0.026, p= 0.016, p= 0.036, p= 0.027, respectively). Individuals aged 65 years and over had a significantly lower number of symptoms (p= 0.029) than all other age groups. Furthermore, the number of symptoms was higher in patients who used steroids (p= 0.049). This study is an important source of information on the long-term symptoms of COVID-19. Our results have shown that the symptoms associated with COVID-19 do not completely resolve even after nine months, which explains why long COVID requires continuous monitoring.

Various approach strategies have been followed for management of temporomandibular joint (TMJ) dislocation. In this study, a total of 12 patients (21 TM joints) with chronic recurrent TMJ dislocations were managed surgically by articular eminectomy due to unsatisfactory outcomes of conservative management methods. An improvement in pain, range of jaw movements and maximal mouth opening was achieved in 10 patients (83.3%).

Diabetes mellitus (DM) is a major independent risk factor for cardiovascular disease. Patients who present with the metabolic emergency of diabetic ketoacidosis (DKA) have similar symptoms of diaphoresis, nausea, emesis, and abdominal pain, which can conceal acute coronary syndrome (ACS). We present a unique case where computed tomography (CT) of the abdomen and pelvis with IV contrast played an integral role in diagnosing an acute myocardial infarction in a patient with no typical ischemic symptoms. A 56-year-old female presented to the emergency department with abdominal pain, nausea, and vomiting. She was suspected of having DKA. Aggressive management was started, including weight-based appropriate IV regular insulin. A CT abdomen and pelvis with IV contrast was performed due to persistent abdomen pain. This demonstrated severe hypoattenuation of the posteroinferior aspect of the left ventricular wall. An EKG was immediately performed and was consistent with an inferior STEMI. The patient was taken to the interventional cardiology suite where they found the culprit lesion to be mid-circumflex with 100% stenosis. This case highlights many important lessons in approaching diabetic patients who are presenting with DKA. DM is associated with cardiac autonomic neuropathy (CAN), a condition that greatly influences perceived chest pain. While little is known about this condition, some manifestations include resting tachycardia, exercise intolerance, orthostatic hypotension, and an increased risk of silent myocardial infarction. Critically, providers must maintain a low threshold to assess for cardiac ischemia in diabetic patients and more readily obtain EKGs in triage as well as during the patient's course in the ED to prevent complications from delayed ACS care.