Rejected

Revision thumb carpometacarpal (CMC) arthroplasty alleviates persistent pain and instability after nonimplant or implant CMC arthroplasty. Metacarpal subsidence onto the scaphoid causing impingement, missed diagnosis such as scaphotrapezoid arthritis, and metacarpophalangeal hyperextension are common causes of failed CMC arthroplasty. Literature shows that revision CMC arthroplasty has satisfactory outcomes. Currently, the mantra of revision is to restore the metacarpal height and treat concomitant pathology, but no single operation is a universal solution. Revision CMC arthroplasty has a relatively high complication rate, lower patient satisfaction than primary CMC arthroplasty, and may result in the need for further operative intervention.

Although an inverse relation between social support and psychological distress among chronic pain patients has been previously reported, little is known about what mediates this association. We examined mindfulness as a mediator of the relationship between social support and psychological distress. In this cross-sectional study, chronic pain patients (=94) completed assessments of social support, mindfulness, and psychological distress. Greater social support was associated with less psychological distress. Greater mindfulness was associated with greater social support and less psychological distress. Mediation analyses demonstrated that mindfulness partially mediated the relationship between social support and psychological distress. Findings support and extend prior research by demonstrating a potentially important mediating effect of mindfulness within chronic pain patients. This suggests an important link between social support and mindfulness, and that their integration in the pursuit of mental health should be considered in future behavioral interventions.

Trigeminal-mediated pain disorders can be devastating for patients refractory to medical therapy. Gasserian ganglion blocks and percutaneous trigeminal rhizotomy have been used with success to treat these patients, however, serious complication risks include facial hematoma, cranial nerve palsy, and stroke. Cone beam CT, combined with fluoroscopy and needle navigation has been shown to decrease needle pass rates, procedure time, radiation exposure, and complications in multiple interventional radiology procedures, but hitherto has not been utilized for Gasserian ganglion interventions. Here, we present two cases of trigeminal-mediated pain successfully treated via cone beam CT combined fluoroscopy and needle navigation.

A patient with a three-month history of persistent delusions of infestation presented to the emergency department with suicidal ideation secondary to complaints of worsening pruritus. Routine investigations failed to disclose any underlying organic cause for her pruritic sensations. The patient ascribed these to a parasitic infestation acquired following a brief stay at her maternal aunt's residence. Following a thorough psychiatric assessment and collateral history obtained from her aunt, it became clear that both the patient and her aunt held similar delusions of infestation. Her aunt was found to be the main inducer. The patient was admitted, successfully treated with low-dose quetiapine, and eventually deemed fit for discharge. Delusional parasitosis and folie à deux are both rare conditions that may sometimes co-occur.

Treatment for vertebral osteomyelitis varies depending on the extent of pathology and includes both medical and surgical approaches. Pathogen-directed antibiotic therapy is often the first-line treatment, however, refractory cases or those with sepsis, segmental instability, or epidural abscess may be candidates for surgical treatment. Patients with extensive bony destruction often require a corpectomy with the placement of a cage for anterior column reconstruction. In this case report, we describe a patient with a complex past medical history, including paraplegia secondary to a spinal cord infarct, chronic urinary tract infections (UTIs), acute myeloid leukemia (AML), and decubitus ulcers who presented with increasing back pain and imaging demonstrating vertebral osteomyelitis and diskitis with associated epidural abscess extending from L1-L4 vertebral bodies and significant osseous destruction of the L3 and L5 vertebral bodies. A multistage surgical approach was performed involving an initial laminectomy, wound wash-out, and bony debridement followed by an additional wound wash-out and then a posterior approach for corpectomy and graft placement accomplished by tying off the thecal sac. In rare cases where patients present with complete neurologic injury and extensive destructive osteomyelitis, a posterior approach for corpectomy and stabilization may be an option.

A 25-year-old Nepalese woman was referred to our hospital because of fever and intermittent abdominal pain with inguinal lymphadenopathy, which had lasted for several months. A liver biopsy of the positron emission tomography-positive lesion led to a diagnosis of hepatic tuberculosis. After the initiation of antituberculosis treatment, her symptoms resolved. However, 11 days after treatment initiation, chest and back pain, high-grade fever, and vomiting appeared and gradually worsened. She developed anemia and her serum ferritin level was elevated. Hemophagocytic syndrome due to the initial deterioration of tuberculosis was suspected and steroid therapy was initiated with the continuation of the antituberculosis drugs. Thereafter, the patient's condition improved remarkably.

Acute appendicitis is one of the leading causes of acute abdominal pain and surgical emergency. Stump appendicitis is a known complication of appendectomy whereby a retained appendiceal tip serves as a nidus for recurrent bouts of inflammation. Nevertheless, full-blown appendicitis of the vermiform appendix after a prior appendectomy remains a diagnostic conundrum.

Gastroduodenal intussusception is extremely rare and usually symptomatic in adults. Authors here report a case of a 99-year-old female with a gastroduodenal intussusception with no obstructive signs and symptoms or an obvious leading point showed on imaging modality. The index case presented with a three-day history of upper abdominal pain radiated to the back and right shoulder. Examination was unremarkable except for mild tenderness in the epigastric and right hypochondrial areas. A diagnosis of a small gastroduodenal intussusception was made by abdominal CT scan. The patient and family refused gastroscopy. Therefore, a conservative approach was followed, and the patient was discharged home on analgesia after two days of admission in the surgical ward.

Respiratory reflexes are tightly controlled by distinct types of vagal sensory afferent nerves. Afferent nerves can be categorized by their conduction velocity, axon diameter, myelination, responses to stimuli, ion channels/receptor expression, and embryological origin. Some airway vagal afferent nerves are sensitive to noxious stimuli (i.e. nociceptive). TRPV1, the capsaicin receptor, is selectively expressed on most vagal nociceptors. Vagal ganglia are comprised of jugular ganglia (neural crest origin) and nodose ganglia (placodal origin). Tac1 encodes Tachykinin1, the substance P precursor protein, and is mainly expressed in the jugular ganglia. P2X2, a purinergic receptor, is exclusively expressed in nodose ganglia. Previous data suggests that activation of jugular nociceptors and nodose nociceptors causes distinct reflexes. Here, we used intersectional genetics to simultaneously visualize nodose and jugular nociceptors. We generated a transgenic mouse model with dual recombinase responsive allele using Cre-Lox and Flp-FRT (Flippase-Flp recognition target) systems. With the ROSA26-RC::FLTG allele, cells with only Flp show tdTomato expression (by excising of FRT-flanked STOP cassette) while cells with both Flp and Cre have GFP expression (by excising of both FRT-flanked STOP cassette and loxP-flanked tdTomato). We generated TRPV1-FLP:Tac1-Cre:ROSA and TRPV1-FLP:P2X2-Cre:ROSA strains. Offspring (6 to 8 weeks old) were used for characterization. Vagal ganglia, lung and brainstem were collected and fixed with 4% paraformaldehyde. Tissue were cryosectioned for immunohistochemistry. In TRPV1-FLP:Tac1-Cre:ROSA, the majority of tdTomato expressing cells were in nodose ganglia and GFP expressing neurons were in jugular ganglia. In TRPV1-FLP:P2X2-Cre:ROSA, as expected, GFP expressing neurons were only observed in nodose ganglia while tdTomato expressing neurons were observed in both nodose and jugular ganglia. Reporter expressing neurons in both strains overlapped with anti-TRPV1 antibody staining indicating they were all nociceptive. In the brainstem, reporter expression was mainly in the nucleus of solitary tract (nTS) in both strains. In TRPV1-FLP:Tac1-Cre:ROSA strain, GFP expression (jugular nociceptors) was also observed in the paratrigeminal nucleus (Pa5). In the lung, most TRPV1+ fibers expressing Tac1 were found in close proximity to the epithelial layer of bronchi and bronchioles. Whereas TRPV1+ fibers expressing P2X2 often projected away from the conducting airways into the alveolar tissue. Taken together, we have developed cell type specific-dual reporter mouse models using a combinatorial/intersectional Cre and FLP strategy to successfully identify distinct nociceptive subtypes of afferent nerves in vagal ganglia, brainstem, and lung.