Rejected

Low back pain (LBP) is currently a major reason for disability worldwide. Therapeutic massage is one of the most popular non-pharmacological methods for managing chronic LBP (CLBP), and the Fateh method is a massage technique based on Iranian Traditional Medicine.

Thromboangitis obliteransis (TAO) is a nonatherosclerotic, inflammatory, occlusive arteritis that affects small and medium-sized arteries, veins and nerves. A large proportion of patients with TAO suffer from claudication, and the ultimate condition is gangrene and limb loss if there is no treatment or the cessation of smoking. Endovascular revascularisations are performed frequently and provide acceptable results in patients who are not suitable for surgery. In this study, we aimed to show our clinical experience in patients with TAO who were treated with endovascular revascularisation.

To report the presentation and management of a 65-year-old female who presented with chronic angle closure glaucoma and an atypical iris membrane.

Autoinflammatory diseases related to RIPK1 mutations have been recently described. Two distinct clinical phenotypes have been reported and depend on the type and location of the mutation. When the mutation is recessive with loss of function, patients develop a combined phenotype of immune deficiency with recurrent bacterial and fungal infections and signs of early inflammatory bowel disease, non-erosive polyarthritis and growth retardation. On the other hand, when the mutation is dominant, gain of function, the manifestations are only auto-inflammatory with extensive lymphoproliferation, oral lesions such as aphthosis or ulcers, abdominal pain and hepatosplenomegaly. The mutations described for the dominant form affect only the cleavage site of caspase 8 and the clinical phenotype is called CRIA for Cleavage-Resistant RIPK1-Induced Autoinflammatory syndrome. The recessive form is severe and life-threatening requiring hematopoietic stem cell transplantation while the dominant form responds well to interleukin-6 receptor antagonists. Thus, RIPK1 mutations can induce various clinical manifestations with two distinct phenotypes. Although still rare, because of their recent description, these diseases can be suspected by an internist, in front of recurrent digestive features and will be increasingly diagnosed in the future through the integration of this gene in the diagnostic chips dedicated to autoinflammatory diseases and early inflammatory bowel diseases, using next generation sequencing.

We present a case of Brown-Séquard syndrome (BSS) after thoracic endovascular aortic repair (TEVAR) to treat Stanford type B aortic dissection. A 49-year-old male presented to the emergency department with acute tearing pain between the scapulae, connected to respiratory movements. Computed tomography showed Stanford type B aortic dissection from the left subclavian artery to the level of the 11th thoracic vertebra. Conservative treatment was initiated with intravenous antihypertensives. However, due to persistent pain and an increase in the aortic diameter with an intramural hematoma, TEVAR was performed. The patient developed symptoms suspicious of spinal cord ischemia postoperatively. A lesion limited to the left-sided spinal cord was observed on magnetic resonance imaging at the level of the 4th to 5th thoracic vertebra. BSS after TEVAR is a rare phenomenon with a fairly good prognosis, depending on the initial injury severity.

Scarpa triangle defects with exposure of femoral bypass are challenging to treat. The authors present the case of a 46 years-old male with a groin defect of 10×18cm with an exposure on 5cm of an allograft of the deep femoral artery. Bypass was performed in emergency because of a limb ischemia with deep femoral artery thrombosis and aneurysm of the superficial femoral artery. The reconstructive surgery may propose a large musculo-cutaneous flap to fill the dead spaces surrounding the infected bypass, the flap should be vascularized by the deep femoral arteria, could not be the rectus abdominals flap because of the precedent abdominal incision. The homolateral pediculated ALT-flap with vastus lateral component appeared to be a good solution because of its versatility and the low morbidity of the donor site.

Factors associated with the optimal physician resident learning are yet to be fully understood. We aimed to correlate the characteristics of residency programs with the learning perception of residents. This was a cross-sectional study using an online structured questionnaire published on social networks, enrolling physician residents from almost all specialties in Brazil. The collection tool was settled considering the current national standards of medical residency programs in Brazil and it was internally validated. The response rate was 71.4% (n = 1,419). The median age was 28 years (IQR = 27-30), 51.9% were from clinical areas and 69.9% from the first or second postgraduation year. Adequate quality of faculty supervision was reported by 50.9%; frequent supervision of assistance activities in 22.1%; proper structure for carrying out healthcare in 82.1%, formal appraisals in 81.8%, classroom activities more than three times a week in 12.3%. Learning was rated as satisfactory by 70.8%. We found an 'inverted-U' shape correlation between duty hours and learning – briefer and longer workloads were associated with unsatisfactory learning. The factors independently associated with learning satisfaction were quantity (OR = 10.79, 95%CI = 7.38-15.77) and quality (1.68, 1.19-2.37) of preceptorship, structure for healthcare (2.10, 1.44-3.08), formal evaluations (1.83, 1.26-2.67), and briefer workload (0.18, 0.04-0.90) and age (0.94, 0.89-0.99) (AUROC = 0.838, 95%CI = 0.816-0.860). We conclude that the perception of satisfactory learning was influenced by higher frequency and quality of faculty supervision, adequate structure for healthcare, formal assessments, and reduced duty hours and age. Regulatory institutions should reinforce strategies to guarantee the fulfillment of residency standards and faculties should receive continued formal training to maximize their teaching skills.

Genito-pelvic pain (GPP) affects a sizable minority of women and results of existing treatments can be variable. A method of general pain treatment that has not yet been extended to penetration-related GPP is Explicit Motor Imagery (EMI), which uses pain-related images to help individuals with pain alter their responses to pain, resulting in reduced pain, less pain-related anxiety, and improved function.

To describe the clinical, endoscopic, and histologic features in patients with acute esophageal necrosis (AEN).

Hypophysitis is considered a rare inflammatory disease of the pituitary. For a long time, primary autoimmune hypophysitis (PAH) stood out as the most relevant type of hypophysitis. However, with the advent on immunotherapy for the treatment of malignancy and identification of hypophysitis as an immune related adverse event, hypophysitis has garnered increasing interest and recognition. Therefore awareness, early recognition, and appropriate management is important as the indication for immunomodulatory therapies broaden. Regardless of cause, symptoms and signs may be related to mass effect (headache, visual disturbance) and hormonal disruption which warrant prompt evaluation. In the vast majority, a diagnosis of hypophysitis can be made presumptively in the appropriate clinical context with radiological findings consistent with hypophysitis and following the exclusion of other causes. Although subtle differences currently exist in management and outcomes expectations between primary and secondary causes of hypophysitis, universally, treatment is aimed at symptom management and hormonal replacement. In this review we discuss the epidemiology, diagnosis, and treatment of hypophysitis with a focus on recent data and highlight subtypes of particular interest while recognizing the gaps in knowledge that remain.