Neuropathic pain is a debilitating consequence of spinal cord injury (SCI) that correlates with sensory fiber sprouting. Recent data indicates that exercise initiated early after SCI prevents the development of allodynia and modulated nociceptive afferent plasticity. This study determined if delaying exercise intervention until pain is detected would similarly ameliorate established SCI-induced pain. Adult, female Sprague-Dawley rats with a C5 unilateral contusion were separated into SCI allodynic and SCI non-allodynic cohorts at 14 or 28 dpi when half of each group began exercising on automated running wheels. Allodynia, assessed by von Frey testing, was not ameliorated by exercise. Furthermore, rats that began exercise with no allodynia developed paw hypersensitivity within 2 weeks. At the initiation of exercise, the SCI Allodynia group displayed marked overlap of peptidergic and non-peptidergic nociceptive afferents in the C7 and L5 dorsal horn, while the SCI No Allodynia group had scant overlap. At the end of 5 weeks of exercise both the SCI Allodynia and SCI No Allodynia group had extensive overlap of the 2 c fiber types. Our findings show that exercise therapy initiated at early stages of allodynia is ineffective at attenuating neuropathic pain, but rather that it induces allodynia aberrant afferent plasticity in previously pain-free rats. These data, combined with our previous results suggest that there is a critical therapeutic window when exercise therapy may be effective at treating SCI-induced allodynia and that there are post-injury periods when exercise can be deleterious.

The United States' health care system is often compared with those of other industrialized countries, and consistently ranks poorly in terms of health care delivery, efficiency, and quality. However, there are several considerations unique to the United States that are often distorted in these analyses, and when considered in the context of the convoluted ethnic and social disparities that persist in the United States, the successes of the American health care system become more apparent.

Anti-NMDA receptor encephalitis is an autoimmune encephalitis precipitated by antibodies generated against NMDA receptors, resulting in abnormalities in behavior, cognition, memory, and movement. Anti-NMDA receptor encephalitis most commonly occurs as a paraneoplastic disorder associated with an ovarian teratoma. While the symptomatic presentation of NMDA receptor encephalitis can be severe, removal of an associated ovarian teratoma generally causes significant improvement and the resolution of symptoms. Thus, accurate detection and early treatment are crucial for superior outcomes in these rare cases. We present a case of a 19-year-old African American female with a strong family history of epilepsy who was brought to the ED after having two weeks of headaches, multiple seizures over the course of the previous two days, and behavioral changes. An MRI of the brain was normal, but she had an elevated opening pressure. The constellation of symptoms and elevated lumbar pressure raised the suspicion of a paraneoplastic syndrome, and a subsequent CT of the abdomen and pelvis revealed a 5 x 4.2 cm ovarian cyst. Further examination of the features of the cyst with ultrasound revealed areas of calcification. IVIG treatment was started for treatment of a suspected paraneoplastic related encephalitis. After a discussion with neuroradiology about the differential, repeat MRI brain and an MRI abdomen revealed minimal hyperintensities within the temporal lobes bilaterally in the former and evidence of previously unidentified bilateral dermoid cysts in the latter. The patient tested positive for NMDA CSF and underwent left salpingoophorectomy and right ovarian cystectomy. After treatment, she returned to her baseline but still experiences spontaneous jerking movements. This case report discusses the early use of IVIG, communication with radiology, and the importance of maintaining a broad differential. After a thorough review of the literature, there are very few cases in which NMDA receptor encephalitis has presented with bilateral ovarian teratomas.

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