Rejected

It has been reported that the incidence of spilled gallstones during laparoscopic cholecystectomy can be from 6-40%. Treatment of these sequelae are often reactive to symptoms produced from the presence of the spilled stones. Herein is presented a case of a 57 year old male with a history of left lower quadrant abdominal pain that had been present for several years and was thought to be due to diverticulitis. On diagnostic laparoscopy he was found to have multiple stones causing an inflammatory response in his left lower quadrant. These stones were removed and the left lower quadrant was washed out. The patient recovered well and had abatement of symptoms at his two months postoperative visit. This case is an example of a spilled gallstones being confused as diverticulitis. Recognition of the spilled stones on diagnostic laparoscopy spared the patient a larger operation and resulted in his symptoms resolving.

It is estimated that there are 3.8 million breast cancer survivors in the United States. Addressing survivors' post-treatment needs is critical to providing quality healthcare.

BACKGROUND Prolonged fever in pediatric patients is often a diagnostic challenge. Clinicians tend to associate prolonged fever with COVID-19-related diseases in patients with a history of SARS-CoV-2 infection. Here we present a patient who was admitted with a clinical suspicion of multi-inflammatory syndrome in children (MIS-C) and was finally diagnosed with a renal abscess. CASE REPORT A 16-year-old girl with prolonged fever, bilateral non-purulent conjunctivitis, weight loss, muscle pain, general malaise, cough, and yellow sputum was admitted to Heim Pál National Pediatric Institute, Budapest, Hungary. She had proven SARS-CoV-2 infection 3 weeks prior to admission. Although inflammatory markers were elevated, repeated urine analyses, aerobic and anaerobic urine cultures, hemoculture, chest X-ray, and otorhinolaryngology examinations were negative. Based on clinical and laboratory criteria, the diagnosis of MIS-C was eventually ruled out. Abdominal ultrasound revealed a 17×20×15 mm simplex cyst at the edge of the parenchyma in the upper third of the left kidney. Magnetic resonance imaging was performed, showing a multi-compartment, septated, thick-walled parenchymal lesion of 50×40×52 mm in the upper pole of the right kidney, which showed signal characteristics of an abscess, and 20×16 mm and 8 mm lesions in the upper pole of the left kidney, which appeared to be cysts. After being unresponsive to intravenous wide-spectrum antibiotic therapy (meropenem 2 g tid for 5 days), surgical intervention was needed to remove the abscess. CONCLUSIONS This case demonstrates that during the COVID-19 pandemic, besides the obvious post-COVID etiology, other life-threatening conditions should be investigated in the first line.

Adequate pain control is essential for patients undergoing liver transplantation (LT). Mutiple analgesic strategies have been implemented during the perioperative period. There is no consensus on the optimal perioperative analgesia management.

Pseudotumor cerebri is a manifestation of intracranial hypertension in an otherwise normal individual. We hereby report phenytoin induced pseudotumor cerebri in a nine-year-old boy who received the same as a prophylactic anticonvulsant following surgical removal of unifocal Langerhans cell histiocytosis involving the right frontal bone. The child was evaluated for headache and diplopia after starting phenytoin and on evaluation was found to have bilateral sixth nerve palsy. The only abnormality detected was an elevated cerebrospinal fluid pressure. Withdrawal of phenytoin resulted in complete resolution of symptoms. Despite meticulous literature search, we came across only one other report of phenytoin induced pseudotumor cerebri. We report this case to highlight the need to consider this entity whenever a patient presents with new onset or persistent headache and visual symptoms soon after starting a medication since a high degree of suspicion is needed to arrive at the diagnosis and to take appropriate steps before it progresses to very harmful complications like vision loss.

Giant pituitary adenomas are benign intracranial tumours with a diameter ≥4 cm. Even if hormonally non-functional, they may still cause local extension, leading to symptoms that include mostly gland dysfunction, mass effects, and, much less frequently, apoplexy due to haemorrhage or infarction. Neurological presentation of giant pituitary tumour apoplexy is even more rare and has not been systematically reviewed.

The optimal treatment strategy of Lisfranc injury is still in debate. This study aimed to compare the functional outcome and complications of dorsal bridge plating (BP) and transarticular screws (TAS). A systematic review and meta-analysis of the present literature was performed. PubMed, EMBASE, and Cochrane databases were searched using set search criteria and date range January 2000 to July 26, 2021. Randomized controlled trials (RCTs) and observational comparative studies concerning the outcome of dorsal BP and TAS for the fixation of Lisfranc injuries were eligible for inclusion. Random effect models were used to analyze pooled data. Forest plots using 95% confidence intervals (CI) were created to illustrate mean differences and odds ratios. Four observational studies were eligible for inclusion, including 111 patients in the BP group and 87 patients in the TAS group. American Orthopaedic Foot & Ankle Society (AOFAS) score was significantly higher in the BP group (mean difference 7.08, 95% CI 1.50-12.66, p = .01). Osteoarthritis was significantly less common in the BP group compared to the TAS group (odds ratio 0.45, 95% CI 0.22-0.94, p = .03). No significant difference was found between the groups in terms of postoperative infection, hardware removal, chronic pain, and secondary arthrodesis. Dorsal bridge plating of fractures in the Lisfranc joint may lead to better functional outcome and a lower incidence of post-traumatic arthritis when compared to transarticular screws. A larger body of high-quality evidence is required to independently analyze the severity of fractures in the different columns involved and subsequent outcomes of operative management.

The aim of the study was to compare the safety profiles (prevalence of both local and systemic side effects) of COVID-19 vaccines (Pfizer-BioNTech, Moderna, Oxford-AstraZeneca) among healthcare workers (doctors, nurses, and pharmacists) administered with a first and a second dose of the vaccines. Another goal of the research was to evaluate potential demographic and clinical risk factors for the frequency and intensity of side effects. A post-marketing, cross-sectional survey-based study was carried out on a sample of 971 respondents (323 doctors, 324 nurses, and 324 pharmacists), all more than 18 years old, who have taken two doses of the following SARS-CoV-2 vaccines: BNT162b2 (Pfizer-BioNTech) (group 1), mRNA-1273 (Moderna) (group 2), and ChAdOx1 nCoV-19 (Oxford-AstraZeneca) (group 3). A validated, self-administered questionnaire was developed and delivered online to the target population group of healthcare workers. The survey was conducted during the third wave of the COVID-19 (1 February 2021-1 July 2021) pandemic. It was based on the CAWI (computer-assisted web interview) method. Questionnaires were disseminated using selected social media. The BNT162b2 (Pfizer-BioNTech) vaccine was the most commonly administered COVID-19 vaccine among healthcare professionals in Poland (69.61%). Side effects following a SARS-CoV-2 vaccine were reported by 53.11% of respondents in group 1, 72% in group 2, and 67.59% in group 3. The following were the most common side effects regardless of the type of vaccine administered: pain at the injection site, headache, muscle pain, fever, chills, and fatigue. The number and intensity of reported side effects following administration of a BNT162b2 (Pfizer-BioNTech) vaccine were significantly lower than in the other two study groups ( < 0.00001). Risk factors for side effects following administration of one of the SARS-CoV-2 vaccines subject to the analysis included being female, young, and suffering from a diagnosed allergy. Our results clearly show that the short-term safety profiles of the eligible COVID-19 vaccines (Pfizer-BioNTech, Moderna, Oxford-AstraZeneca) are acceptable. Nevertheless, the two-dose COVID-19 vaccines available in Poland differ significantly in the frequency of both local and systemic side effects and their intensity. Women, young people, and patients diagnosed with allergies are particularly exposed to the risk of side effects. Further studies are needed to determine the long-term safety profile of COVID-19 vaccines.

Dyspnea, shortness of breath, and chest pain are frequent symptoms of post-COVID syndrome (PCS). These symptoms are unrelated to organ damage in most patients after mild acute COVID infection. Hyperventilation has been identified as a cause of exercise-induced dyspnea in PCS. Since there is a broad overlap in symptomatology with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), causes for dyspnea and potential consequences can be deduced by a stringent application of assumptions made for ME/CFS in our recent review papers. One of the first stimuli of respiration in exercise is caused by metabolic feedback via skeletal muscle afferents. Hyperventilation in PCS, which occurs early on during exercise, can arise from a combined disturbance of a poor skeletal muscle energetic situation and autonomic dysfunction (overshooting respiratory response), both found in ME/CFS. The exaggerated respiratory response aggravating dyspnea does not only limit the ability to exercise but further impairs the muscular energetic situation: one of the buffering mechanisms to respiratory alkalosis is a proton shift from intracellular to extracellular space via the sodium-proton-exchanger subtype 1 (NHE1), thereby loading cells with sodium. This adds to two other sodium loading mechanisms already operative, namely glycolytic metabolism (intracellular acidosis) and impaired Na/KATPase activity. High intracellular sodium has unfavorable effects on mitochondrial calcium and metabolism via sodium-calcium-exchangers (NCX). Mitochondrial calcium overload by high intracellular sodium reversing the transport mode of NCX to import calcium is a key driver for fatigue and chronification. Prevention of hyperventilation has a therapeutic potential by keeping intracellular sodium below the threshold where calcium overload occurs.

Pulmonary hypertension (PH), as a consequence of lung disease or hypoxia, has been classified as Group 3 PH by the World Symposium on Pulmonary Hypertension. The most common lung diseases associated with Group 3 PH are chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). PH in ILD (PH-ILD) is associated with reduced exercise capacity, greater supplemental oxygen needs, decreased quality of life, and earlier death compared to ILD alone. Several agents have been evaluated in clinical trials for the treatment of Group 3 PH, but only one treatment has been recently approved by the FDA as conclusively demonstrating efficacy for the treatment of pulmonary hypertension in this group. In the INCREASE study, treprostinil inhalation solution (Tyvaso) demonstrated significant clinical benefit for patients with PH-ILD. The inhaled route of administration may be associated with cough, throat irritation, pharyngolaryngeal pain and risk of bronchospasm and are important considerations upon initiation of therapy. Here we provide a practical review of inhaled prostacyclin therapy and suggestions for healthcare professionals to optimize the management and outcomes for the treatment of WHO Group 3, PH-ILD patients. Recommendations include up-to-date practical considerations pertaining to the entire care team and encompass patient education and communication, monitoring, titration methods and mitigation of side effects.