Rejected

Pain, swelling and joint stiffness are the major problems following arthroscopic ACL reconstruction (ACLR) surgery that restrict early return to sports and athletic activities. The patients often receive prolonged analgesic medications to control the inflammatory response and resume the pre-injury activities. This systematic review aims to evaluate the safety and efficacy of intraarticular (IA) hyaluronic acid (HA) injection following ACLR.

Aqualyx (Marllor International Ltd, Rimini, Italy) was originally developed in Italy by Professor Pasquale Motolese and has been commercially available since 2009. It is a deoxycholate, aqueous gelatinous solution mixed with saline and buffering compounds. It is the only drug approved by the European Union for the reduction in localized fat. Aqualyx is sold exclusively to doctors and nurses trained in intralipotherapy. In the case of our patient, the product administered was advertised as Aqualyx, but was not administered by a trained health professional and was administered too superficially. The patient developed severe pain following the injection and was unable to sit for several weeks. There was localized skin necrosis, and palpable collections where the injection was administered. Our initial suspicion was development of an abscess or hematoma. To characterize further, we arranged an ultrasound scan that showed a "superficial hypoechoic lesion" but no deeper infection or spread. The numerous painful nodules ruptured onto the skin surface, resulting in purulent and bleeding lesions. This case demonstrates the importance of appropriate training and competence in performing cosmetic procedures including injections and fat dissolving treatments.

Introduction In the present study, the combination of two tablets, one with Aspirin and Promethazine and the other with vitamin D3, C, and B3 along with zinc and selenium supplementation was proposed as an intervention (APMV2020). The ingredients in the formulation represent a precise, tailored therapy for the symptoms of COVID-19, combined with natural constituents to help the body itself build immunity to recover from infection. The present study was conducted to clinically validate the safety and efficacy of the APMV2020 tablets. Trial design The present trial is a randomized, multicentric, controlled clinical trial involving 260 mild to moderate COVID-19 patients. The treatment duration was of 10 days. Methodology The subjects were randomized to receive either the control intervention (clinical management protocol for COVID-19 advocated by the Indian Council of Medical Research (ICMR) or the test intervention (treatment with APMV2020 tablets along with the standard control treatment. The assessment days were baseline, days five and 10. Results APMV2020 significantly (<0.05) improved symptoms of COVID-19 like cough, myalgia, headache, and anosmia as compared to the control group. APMV2020 treatment also reduced inflammatory markers like lactate dehydrogenase (LDH), ferritin, and C-reactive protein (CRP). Conclusion APMV2020 can prove as a good candidate to be integrated into the COVID-19 management protocol. As it can offer speedy clinical recovery to reduce the burden on healthcare infrastructure, second, the combination shows significant anti-inflammatory potential to improve prognosis, and lastly, the immunomodulatory properties offer long-term protection that can help in combating long COVID symptoms and complications.

Primary non-Hodgkin lymphoma of the bone is quite rare, accounting for less than 2% of all lymphomas in adults. We present a unique case of chronic left heel pain in a 34-year-old pregnant woman with a remote history of lower extremity trauma. Unresponsive to conservative treatment, advanced imaging showed an infiltrative soft tissue mass involving the calcaneus and surrounding soft tissues. Biopsy of the area confirmed the diagnosis of Stage I-AE diffuse large B-cell lymphoma. The patient underwent 20 localized radiation treatments to the left heel. Nine years after the diagnosis, the patient remains in remission without signs of disease recurrence. This case report demonstrates that atypical and less common causes of chronic heel pain should be considered in certain clinical scenarios, especially in those unresponsive to conservative treatment.

Syphilis is a rare cause of vision loss that mostly occurs after an infection of the meninges, brain tissue, and parenchyma. Syphilis can mimic auto-immune disease like giant cell arteritis which also manifest as sudden vision loss. Spirochete can spread through sexual contact and cause painless ulcers. Spirochetes can disseminate systemically and lead to secondary syphilis. Ocular syphilis can affect all parts of the eye in secondary and tertiary stages. It can present as scleritis, inflammation of the optic nerve, and uveitis. We present the case of a 59- year-old male suffering from severe vision loss in the left eye and headache initially misdiagnosed with giant cell arteritis. He was correctly diagnosed with ocular syphilis after seeing a red macular rash on palms and soles, and was given penicillin G and probenecid. His visual acuity and field of vision improved soon. Ocular syphilis is usually diagnosed late or misdiagnosed and leads to irreversible vision loss. Physicians should keep in mind the possibility of ocular syphilis in patients presenting with a sudden loss of vision and severe headaches.

Pemphigus is an autoimmune blistering disease affecting the skin and mucus membranes. It is a debilitating skin condition with painful bullae and erosions, which may limit the patient's daily activities. Therefore, measuring the quality of life (QoL) from the perspective of physical, functional, social, and emotional well-being is important to address the disease burden. This study aims to review the demography and assess the impact of disease on QoL in pemphigus patients at the Department of Dermatology, Hospital Melaka.

Coracoid transfer is a reliable method for managing anterior shoulder instability in athletes who play contact sports; however, differences between the Bristow and Latarjet procedures are unclear.

Cryptococcal meningoencephalitis is mainly caused by Cryptococcus neoformans and accounts for 90% of fungal meningitis cases in Japan. Cryptococcal meningoencephalitis is a rare disease, and similar to tuberculosis meningitis. It often exhibits subacute or chronic progression symptoms such as headache, fever, coma, personality changes, and memory disturbance. Cryptococcal meningoencephalitis often develops in immunosuppressed hosts, but can sometimes occur in healthy individuals, and the mortality rate is 10-25%, indicating a poor prognosis. For the treatment of cryptococcal meningoencephalitis, introduction therapy using a combination of liposomal amphotericin B and flucytosine is recommended. However, in practice, cryptococcal meningoencephalitis is refractory and often requires prolonged treatment; therefore, it is the most difficult to treat among the central nervous system infections. We discuss the following 11 issues: I. Sustainability of first-line treatments, II. Treatment options in case of decreased renal function, III. Association with increased intracranial pressure IV. Causes of visual impairment, V. Necessary steps when symptoms/laboratory findings worsen during antifungal treatment, VI. Cerebral infarction, VII. Difficulty in controlling underlying and comorbid diseases, VIII. Indications for lumbar and ventricular drainage (Ommaya reservoir placement), IX. Pros and cons of concomitant use of corticosteroids, X. Treatment evaluation index: usefulness of head MRI, and XI. Determining the end of treatment and the need for preventive medication.

Gulf War Illness (GWI) afflicts ~30% of the US military personnel who served in the 1990-91 Persian Gulf War. Symptoms include cognitive deficits, muscle pain, weakness, exercise intolerance and fatigue which are still present after 30 years in war Veterans. Suspect causal agents include exposure to the compounds pyridostigmine (PB), permetrim (PM) and N,N-diethyl-m-toluamide (DEET) which were used as protectants against nerve gases (PB) and insects. We previously reported a study to model GWI in which young male rats were provided PB, PM and DEET at equivalent human doses and physical restraint (to induce stress) for 3 weeks. In GWI animals, skeletal muscle weight was 35% lower vs. controls, which correlated with decreases in myofiber area, limb strength and treadmill time/distance. In a follow up study, we reported on the beneficial effects of the cacao flavanol (-)-epicatechin (epi) provided for 2 weeks by oral gavage on skeletal muscle atrophy and loss of function. In the current study, we wished to explore the potential of Epi to beneficially impact neurological measures of memory including multiple markers of hippocampus structure and function. Male Wistar rats underwent 3 weeks of exposure to either vehicles or DEET, PM, PB and stress. Subgroups of GWI rats (n=7/subgroup) received 15 days of either water (vehicle) or 1 mg/kg/day of Epi treatment by oral gavage and were compared to normal control (n=7). Object recognition tasks were performed to assess effects on memory and hippocampus samples were collected for histological and biochemical analysis. Results demonstrate that Epi treatment yields significant improvements in short and long-term memory vs. GWI rats yielding values similar to those of controls. The assessment of hippocampus oxidative stress (protein carbonylation) and pro-inflammatory cytokines levels (ELISA) of IL-1β, TNF-α and IFN-γ (figure) yielded significant increases with GWI that were fully normalized with Epi to become comparable to controls. Significant increases in markers of hippocampus neuroinflammation (Iba1 and GFAP) and cell death (caspase activity) were noted with GWI and were significantly reduced with Epi. The neuronal survival signaling pathways (TREM2, PI3K and AKT) were adversely impacted by GWI and were partially or fully restored by Epi. Multiple markers of mitochondrial function (citrate synthase activity and ATP levels) adversely impacted by GWI and were fully restored by Epi. Thus, in an animal model of GWI, Epi beneficially impacted markers of hippocampus neuroinflammation, oxidative stress, cell survival, neurotoxicity and mitochondrial function. Such effects translated into improvements in functional endpoints associated with memory centers. As per the recognized safety profile of Epi clinical studies are warranted to explore the effects of treatment in Gulf War Veterans.

The fibularis (peroneus) quartus is a variant muscle found within the lateral leg compartment in ~11.5% of cadaveric specimens, though recent studies have shown a higher prevalence of ~20.9 – 21.9%. The proximal muscular attachments can originate from the fibula, fibularis brevis, fibularis longus, and/or the intermuscular septi that form the boundaries of the lateral leg compartment, but it then descends to reside posterior to the lateral malleolus of the fibula. The distal attachment of the fibularis quartus varies greatly, and fibularis quartus muscular variants are often named according to location of its distal attachment. The most common distal insertion site of a fibularis quartus muscle is the lateral surface of the calcaneus into either the fibular trochlea or the retrotrochlear eminence. Therefore, this variant of the fibularis quartus inserting into the lateral surface of the calcaneus is called the fibulocalcaneus externum. During routine cadaveric dissection of a 79-year-old Caucasian male, a rare and novel variation of the fibularis quartus muscle was discovered. Although this variant is seen arising from the fibula, fibularis brevis, and the posterior intermuscular septum, descending posterior to the lateral malleolus, and attaching distally to the lateral surface of the calcaneus, it is unique in that the muscle is inverted, with the tendonous part being more proximal and the muscular portion arising distally. This novel muscle was found unilaterally in the left leg via dissection initially with its distal head inserting on the fibular trochlea of the calcaneus, but ultrasonographic imaging verified its bilateral presence. The subsequent dissection of the right leg revealed a similar inverted muscle, but this variation split into two distal muscle bellies inserting into the retrotrochlear eminence posteriorly and the fibular trochlear anteriorly. Given its anatomy, we have named this rare fibularis quartus variant the fibulocalcaneus externum invertus muscle. Like most fibularis quartus variants, the fibulocalcaneus externum invertus muscle can cause ankle instability, ankle locking, chronic lateral ankle pain, and peroneal compartment syndrome, especially due to acting as a space-occupying lesion within the superior peroneal tunnel due to its distal muscle belly/bellies. While it is unknown if this person had any clinical signs and/or symptoms, clinicians, surgeons, and/or radiologists should be aware of the fibulocalcaneus externum invertus when assessing radiological imaging or preparing for ankle surgeries in and around the lateral leg compartment.