Rejected

Introduction Fever is the most common presenting symptom in children and causes distress in patients and parents. Although nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as antipyretics, they should be reserved for pain or chronic inflammatory conditions due to safety concerns. If we can safely achieve the same antipyretic effect using a higher dose (20 mg/kg) of paracetamol, NSAIDs may be avoided for treating fever. There is a paucity of literature comparing the antipyretic effect of mefenamic acid and high-dose paracetamol. We hypothesized that there would be no difference in the antipyretic effect of high-dose paracetamol and mefenamic acid. Methods In this randomized control trial, 165 febrile children were randomly allocated to one of the following three groups: standard-dose (15 mg/kg) paracetamol (SDPCM) as the control group and high-dose (20 mg/kg) paracetamol (HDPCM) and mefenamic acid (6 mg/kg) (MFN) as the intervention groups. The temperature was measured using a digital thermometer at the start of drug dosage and every 15 minutes until it reached normal. One-way between-group analysis of variance (ANOVA) was used to compare outcome measures such as time for temperature to reach normal, fall of temperature in 60 minutes, and time for the next fever. Post hoc analysis was performed to compare mean differences. Patients were monitored for adverse effects. Results Out of 165 enrolled patients, 159 were analyzed. The baseline demographic data were comparable among the groups. There was a statistically significant difference in the mean time taken for the temperature to reach normal (F-value (F) (2,156)=3.184, p<0.05) and the mean reduction in temperature at 60 minutes (F (2,156)=23.40, p<0.001) among the groups. The mean time for temperature to reach normal in the SDPCM group (97.50±26.60 minutes) was longer than that in the HDPCM (85.09±31.43 minutes) and MFN (84.90±30.42 minutes) groups. The decrease in temperature over 60 minutes was greater in the HDPCM (0.46°C±0.19°C) and MFN (0.45°C±0.11°C) groups than in the SDPCM (0.33°C±0.10°C) group. The time to the next fever spike was shorter for the SDPCM group (5.07±2.66 hours) than for the HDPCM (7.20±3.08 hours) and MFN (8.82±3.83 hours) groups. Post hoc analysis demonstrated that high-dose paracetamol and mefenamic acid had similar and faster antipyretic effects than standard-dose paracetamol. Although the duration of action was found to be longer in the mefenamic acid group, the difference was not statistically significant. There were negligible adverse effects in the groups. Conclusion  Standard-dose paracetamol (15 mg/kg/dose) had a slower and shorter antipyretic effect than high-dose paracetamol (20 mg/kg/dose) and mefenamic acid (6 mg/kg/dose). A single dose of high-dose paracetamol was safe and had a similar antipyretic effect as mefenamic acid. Mefenamic acid may be avoided as an antipyretic and spared for pain and anti-inflammatory indications. Multicentered double-blind clinical trials with larger sample sizes and comparisons of other NSAIDs will be required to confirm these findings.

Renal cell carcinoma (RCC) constitutes about 2% of all adult malignancies and is the most common malignant renal neoplasm with bony metastases occurring in up to 50% of patients with RCC. In this case, we report a 42-year-old male who presented with chronic back pain and had a sudden episode of paraplegia. The patient was initially referred to the orthopedics service. He had a lumbar X-ray done followed by a CT of the spine that showed a burst fracture of the L1 vertebra with incidental finding of a right renal mass suspicious of RCC. Upon further investigations, the patient was found to have a large heterogeneous renal cortical mass with multiple cystic changes and necrosis invading the Gerota's fascia as well as a tumor thrombus extending into the right renal vein and inferior vena cava. Although it has been well established that RCC metastasizes to bones and it is not uncommon for vertebral column involvement, sudden paraplegia and incontinence resulting from lumbar fracture due to metastatic RCC has not been widely published. Conclusively, RCC is a common malignancy in which a significant number of patients have metastatic disease upon presentation and this can lead to initial confusion and delay in diagnosis, hence it should be part of the differential diagnosis when investigating chronic bony pain and pathological fractures.

Data on the prevalence of nontraumatic headaches with red flag symptoms in Asia are sparse. Therefore, the objectives of this study were to determine the final diagnosis and prevalence of abnormal CT scans in patients who presented to the emergency department (ED) with red flag symptoms.

An intertransverse process block (ITPB) is a paraspinal thoracic nerve block technique, where the local anesthetic (LA) is injected into the thoracic intertransverse tissue complex posterior to the superior costotransverse ligament (SCTL). Although an ITPB can be ultrasound-guided, it is performed using surrogate bony landmarks without even identifying the SCTL. This report describes a transverse ultrasound imaging technique to identify the retro-SCTL space and perform an ITPB with a retro-SCTL space injection, in 2 patients undergoing video-assisted thoracoscopic surgery. The resultant bilateral, symmetrical, thoracolumbar anesthesia was consistent with epidural spread of the LA and effective for perioperative analgesia.

Primary Angiitis of the Central Nervous System (PACNS) is a rare form of vasculitis that solely affects the Central Nervous System (CNS). Its presentation varies widely from a simple headache to a stroke-like presentation. PACNS management is divided into an induction phase, which includes corticosteroids, cyclophosphamide and rituximab, and a maintenance phase which includes: methotrexate, mycophenolate mofetil, rituximab and azathioprine.

Physical activity has many health-related benefits, including prevention and management of chronic disease, weight management, and improved mental health. Active girls and women of all ages and abilities are at risk of relative energy deficiency in sport, a syndrome encompassing low energy availability, menstrual irregularities, and disordered bone metabolism. Presence of amenorrhea or oligomenorrhea may suggest reduced energy availability. Active females are at risk of overuse injuries, including patellofemoral pain syndrome, iliotibial band syndrome, and stress fractures; treatment usually includes activity modification, a period of rest, and physical therapy. Active females are also at risk of acute injuries, including concussion and anterior cruciate ligament injuries. Pregnant patients without contraindications who were physically active before pregnancy can continue these activities, and those who were not previously active may gradually increase their activity level to a goal of 150 minutes per week. Moderate exercise during pregnancy reduces the risk of gestational diabetes mellitus, preeclampsia, and cesarean delivery. Postpartum exercise focused on core and pelvic floor strengthening can improve pelvic floor dysfunction. Supervised exercise programs focused on strength and balance have been consistently shown to reduce the risk of falls and injurious falls in older women.

Alagille syndrome (AGS) is a disorder that leads to increased serum cholesterol and bile acids, which can result in debilitating xanthomas and pruritus. External biliary drainage and transplantation are effective treatments for AGS. Internal biliary diversion with Roux-en-Y cholecystocolostomy has been described for other biliary conditions, but not AGS. Three patients with severe pruritus due to AGS underwent Roux-en-Y cholecystocolostomy for internal biliary drainage. Retrospective analysis compared preoperative and post-operative lab values and symptom scores (0, none-4, severe). Three patients underwent cholecystocolostomy. All patients had at least three diagnostic criteria for AGS. Mean preoperative pruritus score was 3.33 (range, 2-4) and mean post-operative score was 1. Mean preoperative xanthoma score was 1.33 (range, 0-4) and post-operative score was 1 at 2-month follow-up. Roux-en-Y cholecystocolostomy can be considered for AGS, which is refractory to medical management. This procedure accomplishes internal biliary diversion without significant physiologic derangements.

Scalp pruritus is a common skin problem that remains therapeutic challenge. The relationships between the dysbiosis of microbiota and skin diseases have caught attention recently. However, there are few reports about microbiota on itchy scalp. This study investigated scalp microbial characteristics of subjects with mild scalp pruritus of undetermined origin and preliminarily screened physiological factors and bacteria potentially related to pruritus. The pruritus severity of 17 qualified females was evaluated by Visual Analogue Scale (VAS). Microbiota collection was done at both itchy (n = 20) and non-itchy sites (n = 27) at occiput and crown of the same subject and Illumina sequencing was performed at the V3-V4 hypervariable regions of 16S rRNA. The corresponding sebum content, hydration, pH, trans-epidermal water loss, erythema index and porphyrin numbers were also measured by skin tester. We identified 3044 amplicon sequence variants from 821 genera. The itchy and non-itchy sites had different microbiota structures (p = 0.045, by multivariate analysis of variance), while there were large inter- and intra-individual variations. Both sites had Staphylococcus, Cutibacterium and Lawsonella as predominant genera, which were not significantly related to pruritus. The use of three genera Lactobacillus, Morganella and Pseudomonas, could well distinguish non-itchy from itchy groups, whereas different composition patterns existed inside each group. Our investigation indicated that though the bacterial community structure on itchy scalp was individual specific, there was difference between itchy and non-itchy sites. The study provides new insights into microbiota profiling on itchy scalp, which will help microbiota-targeted therapeutic experiment or products design for scalp pruritus.

Chronic diseases contribute to high rates of disability and mortality. Patient engagement in chronic disease self-management is an essential component of chronic disease models of health care. Wearables provide patient-centered health data in real time, which can help inform self-management decision-making. Despite the perceived benefits of wearables in improving chronic disease self-management, their influence on health care outcomes remains poorly understood.