Rejected

The main purpose of this study was to investigate the prevalence, characteristics, and intensity of children's pain in emergency departments. The secondary purpose was to evaluate the interobserver agreement regarding the level of pain perceived by professionals, parents, and children.

Thorough physical examination is a must for proper diagnosis of medical diseases and to elucidate all physical findings. Abdominal pain is a very common presentation to Emergency Department, compromising 5%-10% of all visits, and around a quarter are discharged with no particular diagnosis. Pyocolpos is one of those presentations that requires a thorough physical examination, including that of the external genitalia. A 3-year-old girl presented with recurrent history of abdominal pain and a recent history of fever with acute abdomen picture-like presentation, with difficulty voiding over the past few days. She was previously assessed for recurrent abdominal pain, without any identifiable etiology. Upon inspection for indwelling catheter insertion, absence of the vaginal introitus was noted with a bulging mass and an imperforate hymen. Pyocolpos was diagnosed and drained following hymenotomy. Pyocolpos is a rare complication of hydrocolpos. Enlarged vagina causes extrinsic compression to nearby structures, such as the bladder trigone and ureters, causing hydronephrosis, hydroureter, and other sequel including acute kidney injury and urosepsis. An imperforate hymen must be considered in the differential for chronic and recurrent abdominal pain, and can be easily identified by a thorough physical examination, including that of the external genitalia, which is a must in today's every medical practice.

Burkitt lymphoma (BL) is one of the highly aggressive non-Hodgkin B-cell lymphomas. The optic nerve can be affected in case of isolated lymphoma or together with the central nervous system (CNS) and systemic lymphoma. We report a rare case of involvement of bilateral optic nerves in BL. A 31-year-old lady who was diagnosed with BL presented with severe intermittent headache and vomiting with blurring of vision in both eyes for one week. Visual acuity on presentation was 6/9 in the right eye and 6/24 in the left eye, with a reduction of the left eye optic nerve functions. Fundoscopy showed swollen optic disc in the right eye and temporal pallor disc in the left. Magnetic resonance imaging of the brain and orbit showed increased leptomeningeal enhancement in the right frontal and temporal lobes and the right optic nerve. Lumbar puncture revealed high opening pressure (50 cmHO). Pleocytosis and the presence of lymphomatous infiltration were noted in cerebrospinal fluid analysis. After the completion of four cycles of chemotherapy, her condition unfortunately deteriorated, and she was subsequently planned for palliative therapy. CNS-directed therapies should be considered given the high risk of CNS relapse.

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease characterized by severe pain and morning stiffness, mainly affecting the shoulder girdle. A 75-year-old woman, previously healthy, received the first dose of ChAdOx1 vaccine and two weeks later started with pain in the shoulder and pelvic girdles and knees of inflammatory characteristics, accompanied by morning stiffness (about one hour), anorexia, asthenia, and activities of daily living (ADL) dependence. She started analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) with no improvement. The symptoms aggravated three days after the second vaccine dose, and she was referred to our center. At observation, she presented shoulder, hip, and knee active range of motion limitation. Blood analysis revealed an Erythrocyte Sedimentation Rate (ESR) of 120mm/h (reference value < 20mm/h) and C-Reactive Protein (CRP) of 80mg/L (reference value < 5mg/L). Ultrasound showed effusion on both shoulders, hips, and knees. The paraneoplastic syndrome was ruled out. She started oral corticosteroids and a rehabilitation program, and a month later, she presented controlled pain, normal analysis, and ADL independence. This case shows symptomatic and analytic features of PRM after the first vaccine dose and aggravation soon after the second. As such, we consider establishing a potential relationship between the inoculation and the development of PRM. A few cases were published reporting a PRM-like syndrome following a COVID-19 vaccine; however, the underlying mechanism and prognosis are still unknown.

Laparoscopic adjustable gastric banding (LAGB) over laparoscopic sleeve gastrectomy (LSG) is a rare bariatric surgery. The objective of this case report is to add to the limited literature regarding this procedure. LAGB plus LSG is an effective bariatric procedure for patients that desire additional weight loss who do not qualify for or want gastric bypass. A 39-year-old African American Female with a pertinent past medical history of morbid obesity, gastroesophageal reflux disease (GERD), sleep apnea, and chronic back pain presents for gastric bypass consultation in 2020. The patient had a prior bariatric surgical history of gastric band placement (2014), removal (2016), and LSG (2018). The patient was unsatisfied with her weight loss and pursued a consultation for gastric bypass. Upon further investigation, gastric bypass was not indicated for the patient due to low BMI. The patient was presented with the option of LAGB over LSG for increased weight loss and improvement or resolution of comorbid conditions. The patient appreciated the physicians' recommendation, and on June 3, 2021, a LAGB was placed over the prior sleeve gastrectomy. No complications occurred preoperatively or postoperatively. The patient continues to adhere to diet and exercise instructions, and at her most recent follow-up, she reported resolution of GERD symptoms and had a reduced BMI of 33.2. It is important to note that the long-term outcomes of this procedure are yet to be fully discovered due to the rarity of the surgery and some literature deficiencies. Overall, LAGB, in combination with LSG, is a safe and effective procedure for increasing weight loss, improving quality of life, and decreasing mortality for patients for whom the surgery is indicated.

Atypical presentations of occipital neuralgia might have an anatomical cause. Therefore, a better understanding of variant anatomy in this region can help physicians who treat such patients. During the dissection of the suboccipital region in an 83-year-old at-death male cadaver, an unusual finding was noted between the suboccipital and greater occipital nerves. No branches from this segment of the suboccipital nerve were identified. Therefore, initially, the suboccipital muscles were thought to be innervated not by the suboccipital nerve but rather by branches of the medial (greater occipital nerve) and lateral branches of the C2 dorsal ramus. However, with microdissection, these fibers were found to ascend with the medial branch of the C2 ramus (greater occipital nerve) and to distribute fibers to the rectus capitis minor and major and then continue with the greater occipital nerve to the skin over the occiput. No fibers from the suboccipital nerve traveled to the C2 spinal nerve or its lateral branch. The lateral part of the dorsal ramus of C2 innervated the obliquus capitis superior and obliquus capitis inferior. Additionally, a long slender branch from the lateral branch of the C2 dorsal ramus traveled medially to innervate the skin over the C2 spinous process. This case demonstrates that some fibers in the greater occipital nerve (C2), both cutaneous and motor, can be derived from the suboccipital nerve (C1). This information can help in diagnosing some patients with atypical presentations and can help better target all involved occipital nerves.

Acute respiratory distress syndrome (ARDS) is still associated with significant mortality, especially the elderly and those with comorbidities are at highest risk of death. Neuromuscular blocking agents (NMBAs) are used in a large but highly variable proportion of patients with ARDS.

Patients suffering from chronic pain (CP) with overactivity frequently experience sleep disturbance. We presented a 35-year-old woman suffering from CP. To improve the sleep disturbance of individuals suffering from CP with overactivity, it is important to combine cognitive behavioral therapy for insomnia and activity pacing.

Dorsal root ganglion stimulation (DRG-S) is widely accepted for treating focal pain syndromes. We present the case of a 46-year-old woman with severe lumbar radiculopathy with an implanted spinal cord stimulator (SCS) that had lost efficacy. She developed an incisional hernia after undergoing a minimally invasive, extreme lateral interbody fusion and SCS explant. After herniorrhaphy, she presented with severe pain at the T10-T11 dermatomes, which we treated with DRG-S. One-year after lumbar fusion, her refractory lumbar and radicular pain returned, which we ultimately treated with bilateral T12+S1 DRG-S. DRG-S was thus used to successfully treat focal postsurgical and diffuse chronic pain.

Insulin centrally activates the sympathetic nervous system. However, little is known about the effects of insulin on peripheral primary sensory neurons. Transient receptor potential vanilloid 1 (TRPV1), of which capsaicin (CAP) is an agonist, is widely expressed in small dorsal root ganglia (DRG) neurons subserving skeletal muscle thin-fiber afferents expressing sensory nociceptors and/or metabolically sensitive skeletal muscle receptors. Evidence suggests that insulin increases the sensitivity of these sensory receptors as well as translocation of TRPV1 from cytosol to plasma membrane in DRG neurons. We therefore hypothesized that insulin potentiates the responsiveness of thin fiber muscle afferents to TRPV1 activation.