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Thyroid storm is a rare, fatal complication of thyrotoxicosis that necessitates aggressive medical treatment. We present a case of a patient who developed duodenal ulcer perforation as a result of a thyroid storm caused by Graves’ thyrotoxicosis. In addition to life-threatening intra-abdominal sepsis complicated by high anion-gap metabolic acidosis, he was found to have severely deranged thyroid hormone levels and clinical features compatible with thyroid storm based on the Burch-Wartofsky Score. Diagnosis and management of such patients with compromised gastrointestinal (GI) tract present a remarkable clinical challenge to the anaesthetist and the intensivists. Multidisciplinary care with rapid preoperative optimisation, careful intraoperative anaesthetic techniques and postoperative care resulted in excellent outcomes. This case report sheds light on how to tailor general anaesthesia to minimise physiological derangement associated with thyroid storm and re-establish homeostasis in patients presenting for emergent surgery, particularly those with GI dysfunction.

Nodular lymphangitis is an infectious disease characterised by the development of inflammatory skin nodules that follow the direction of lymphatic drainage. We present a woman in her 70s with nodular lymphangitis that developed after mild trauma with a cactus. Surgical intervention was performed on a finger abscess with isolation ofNocardia brasiliensisin the microbiological samples. Initial antibiotherapy was modified, treating with cotrimoxazole, firstly intravenous and finally oral, therapy during 3 months with a complete resolution of the infection.

Although uncommon, vaginal fibroepithelial polyps can present as prolapsing vaginal tissue, causing discomfort and anxiety. Surgical excision of the polyps can provide a minimally invasive solution. In this case, we describe a nulliparous female in late adolescence who presented for evaluation of tissue protruding through the vagina. On exam, a 5×4 cm fibroepithelial polyp was extending from the distal posterior vagina on a broad stalk. Successful transperineal surgical excision was performed. Fibroepithelial polyps, although uncommon, can be a cause for prolapsing vaginal tissue and should be part of the differential diagnosis, especially in patients who have no risk factors for pelvic organ prolapse. They can be excised vaginally, alleviating symptoms and distress. Because they sometimes recur, continued surveillance with gynaecological exams is recommended.

A man in his 20s attended the emergency department with three days of fever, headache, reduced appetite and a sore throat. COVID-19 point-of-care test was negative. Blood cultures grew a gram-negative coccobacillus,Neisseria elongata. Following an episode of confusion, MRI head revealed septic emboli. Prolapse of the mitral valve with regurgitation was noted on echocardiography. Infection was found to have originated from multiple dental caries and treatment required a combination of dental extraction, prolonged antibiotic therapy and surgery for mitral valve repair.N. elongatais part of the normal oropharyngeal flora but is also a rare cause of endocarditis. There are no established treatment guidelines for endocarditis of this aetiology.N. elongataendocarditis may present atypically, with a murmur only developing several days later. ‘Classical’ stigmata should not be relied on to make a diagnosis.N. elongatapredominantly affects the left side of the heart and predisposes to embolic events.

Costello syndrome (CS) is a rare genetic syndrome affecting multiple organs, generally caused by mutations of theHRASgene, belonging to theRAS/MAPKgenes family.A male patient with CS developed a painful pulsatile mass on the lateral side of the wrist. An initial ultrasonographic investigation confirmed the presence of a radial artery lesion, possibly an arterial aneurysm. On surgical resection, histological evaluation showed a tangle of vascular structures with variable calibre and abnormal wall histology. Immunohistochemical stainings revealed a very poor endothelial contribution to the central vascular wall structure. These histological observations led us to conclude we had managed an acute vascular malformation (VM) rupture, rather than a common arterial aneurysmal condition. Considering the molecular mechanisms regulated byRAS/MAPKgenes, CS patients might have a higher risk of developing VMs and, in the presence of a pulsatile mass with acute onset, VM rupture should be considered.

We highlight the role of contrast-enhanced ultrasound (CEUS) as a supplementary modality to ultrasound (USG) examination in ovarian torsion in this case report. The reported patient had clinical history suspicious of ovarian torsion; however, USG and Doppler flow study findings were equivocal. CEUS was performed to solve the diagnostic dilemma and to know the status of ovarian parenchymal viability which revealed non-enhancement of the ovarian cyst wall and pedicle throughout the USG examination thus establishing the diagnosis of non-viable or infarcted ovarian parenchyma. The per operative and histopathology findings were consistent with our CEUS findings. CEUS is an emerging promising modality which provides information regarding parenchymal perfusion, resulting in a reliable diagnosis of ovarian torsion along with information on ovarian parenchymal viability. This ability makes CEUS equivalent to contrast-enhanced CT or MRI.

We report a case of a patient presenting with subacute neurological symptoms 10 years postkidney transplant. Cognitive deficits included acalculia and left upper limb dysesthesia, progressing to hemiplegic upper motor neuron weakness. Investigations included an MRI with multiple FLAIR hyperintensities, while a lumbar puncture was sterile with negative flow cytometry. Ultimately, PCR testing for John Cunningham virus was positive on cerebrospinal fluid. The diagnosis of progressive multifocal leukoencephalopathy (PML) was confirmed on the basis of the above.Initially, the patient was managed with withdrawal of immunosuppressants and close observation. Mirtazapine was commenced based on case reports of successful use in non-transplant patients; the patient’s recovery was temporally related to withdrawal of immunosuppression and increasing mirtazapine dosage. The patient is currently maintained on prednisolone and mirtazapine with stable graft function and improved mobility and cognitive function.

Fat embolism syndrome (FES) is a rare complication of long bone fractures with an incidence of 0.3%–1.3%. FES most commonly presents within 72 hours of injury but may develop as late as 10 days following a fracture. FES is rarely associated with elective orthopaedic procedures. In this case report, we describe a patient who developed FES 9 days after an elective left total hip arthroplasty. Presentation far outside of the typical 72-hour window for FES, the diagnosis was initially missed. The patient initially presented to our emergency room on postoperative day 14 with 5 days of dyspnoea and was diagnosed with pneumonia and sent home on antibiotics. Sixteen days following this ED admission and on postoperative day 30, she remained dyspneic and was found to be hypoxic to 74% on room air. CT angiography at this time found bilateral diffuse ground glass opacities. Bronchoalveolar lavage was notable for lipid-laden macrophages, and FES was subsequently diagnosed.

Gestational diabetes mellitus (GDM) is defined as the first onset of glucose intolerance in pregnancy without prior known diabetes. While it is commonly associated with metabolic risk factors such as obesity and hypertension, a small percentage of women with GDM have underlying autoimmune causes, with presence of islet-cell antibodies resulting in autoimmune-mediated destruction of the pancreas. We present a case of idiopathic postpartum pancreatitis precipitating fulminant diabetic ketoacidosis in a patient with otherwise well-controlled GDM during pregnancy, and subsequent findings of positive anti-glutamic acid decarboxylase antibody. This is the first presentation of autoimmune diabetes diagnosed postnatally in a woman who has no previous medical or family history.

Endogenous endophthalmitis (EE) is a rare infectious disease of the intraocular tissues with a major risk of significant visual loss. We describe a case of a female patient who presented with altered mental status and vision loss. The patient was found to have bacteraemia, meningitis and bilateral EE caused by

Spinal epidural abscess (SEA) usually extends over three to four vertebrae. We present a case of holospinal epidural abscess (HEA) caused by the

We conducted a two-year (2019–2020) longitudinal study in Jiangsu Province, China to analyze risk factors of pinworm infection and evaluate the effect of behavior change communication–based (BCC-based) interventions in preschool children. The positive rate of pinworm infection was higher in private preschool (2%) than in public preschool (0.24%). Poor sanitation behaviors were risk factors among private preschool children. BCC-based intervention could improve knowledge and practice and reduce pinworm infection. This study may help fill in gaps in pinworm control. (Am J Public Health. 2022;112(12):1716–1720. https://doi.org/10.2105/AJPH.2022.307067 )

Aortitis and aortic dissection are very rare in children. The clinical presentation of aortitis varies across a spectrum, ranging from incidental findings to fatal aortic dissection and rupture. A high index of suspicion is needed to establish an accurate and timely diagnosis. Here, we present an unfortunate case of fatal infective aortitis with aortic rupture and cardiac tamponade in a healthy toddler. Postmortem report implicatedKingella kingaeas the causative organism of aortic pseudoaneurysm and rupture, leading to the instantaneous death of the child.

A man in his mid-20s presented with a painless swelling over his right thigh, which had been progressively increasing over 3 years. He underwent an excisional biopsy for the same, which showed reactive lymphadenopathy. Since the last year and a half, he developed a lower abdominal wall swelling with mild redness over it. In addition, over the last few months before presentation to haematology outpatient clinic, he experienced bouts of fever, night sweats, anorexia, weight loss and right inguinal lymphadenopathy. On examination, splenomegaly was identified. In view of the patients’ symptoms, he underwent a positron emission tomography scan, which showed hypermetabolic activity in the subcutaneous tissue sparing the lymph nodes and spleen. A deep skin punch biopsy taken from his right thigh was consistent with the diagnosis of subcutaneous panniculitis-like T-cell lymphoma αβ T-cell phenotype. The patient was treated successfully with oral steroids and on routine follow-up, he is in remission for 5 years.

A woman in her 40s presented with a 3-month-long history of fever and tender erythematous bullous skin lesions not responsive to antibiotics. There had been no previous gastrointestinal, respiratory or urinary infection, nor did she have any history of autoimmune disease, drug reaction or vasculitis.Histological evaluation of skin biopsy showed diffuse dense neutrophilic infiltrates located in dermis diagnostic of Sweet syndrome. Haematological investigations showed leucocytosis with circulating immature cells, which on further investigations with bone marrow biopsy, were evident of chronic myelogenous leukaemia in the accelerated phase. Sweet syndrome was the presenting characteristic of chronic myelogenous leukaemia in this case, which is a rare association. Investigating unusual skin lesions can aid in the suspicion of underlying cancer, allowing for prompt action.

Objectives. To systematically identify and analyze US state-level legislation concerning people who were undocumented during the COVID-19 pandemic, from January 2020 through August 2021. Methods. Using standard public health law research methods, we searched Westlaw’s online database between November 2021 and January 2022 to identify legislation addressing COVID-19 and people who were undocumented. We abstracted relevant information, analyzed the data, and identified primary themes for each bill and resolution. Results. Sixty-six bills and resolutions, from 13 states, met the inclusion criteria. Legislation addressed 5 primary themes: eligibility and access to health-related services (n = 16), health and personal information (n = 10), housing assistance (n = 13), job security and employment benefits (n = 14), and monetary assistance (n = 13). Conclusions. Approximately one quarter of state legislatures introduced bills or resolutions regarding people who were undocumented and COVID-19. State-level laws are an important tool to mitigate the disproportionate impact of public health emergencies on vulnerable groups. Public Health Implications. As states shift attention away from the exigencies of COVID-19, this research provides insight into how law might be used to protect those who are undocumented throughout the full cycle of future public health emergencies. (Am J Public Health. 2022;112(12):1757–1764. https://doi.org/10.2105/AJPH.2022.307090 )

Objectives. To estimate excess mortality from non–COVID-19 causes during the COVID-19 pandemic in Philadelphia, Pennsylvania, and understand disparities by race/ethnicity, age, and sex. Methods. We used Poisson regression models of weekly deaths using data from Pennsylvania’s vital registration system (2018–2021). Results. There was significant excess mortality as a result of heart disease, homicide, diabetes, drug overdoses, traffic crashes, and falls in 2020–2021; the burden of this excess non–COVID-19 mortality fell on non-Hispanic Black Philadelphians. Among younger non-Hispanic Black men, homicide and drug overdoses were responsible for 54% and 18% of excess deaths—more than COVID-19 (17%). For younger non-Hispanic Black women, drug overdoses accounted for 51% of excess deaths, whereas COVID-19 accounted for 40%. Conclusions. Excess mortality was not solely caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; the causative agent of COVID-19), particularly at younger ages. Indirect pandemic mortality exacerbated prepandemic disparities by race/ethnicity. Public Health Implications. Excess mortality as a result of non–COVID-19 causes may reflect indirect pandemic mortality. National cause-of-death data lag behind local cause-of-death data; local data should be examined as an early indication of trends and disparities. Public health practitioners must center health equity in pandemic response and planning. (Am J Public Health. 2022;112(12):1800–1803. https://doi.org/10.2105/AJPH.2022.307096 )

Spontaneous haemoperitoneum is a rare condition with a variety of aetiologies. Regardless of the cause, it is invariably a life-threatening condition that requires urgent diagnosis and management. The most common causes of spontaneous haemoperitoneum include gynaecological, hepatic, splenic and vascular causes. However, here, we present a rare case of spontaneous haemoperitoneum secondary to idiopathic omental venous malformation.Our patient presented with acute onset of right iliac fossa pain, and a CT scan revealed a massive haemoperitoneum. A laparoscopic converted to open laparotomy was performed to diagnose and treat the patient. We discuss the management approach for such patients with spontaneous haemoperitoneum.

A woman presented two weeks after uncomplicated cataract surgery with decreased visual acuity from endophthalmitis. One week after initial management with intravitreal antibiotics, her visual acuity decreased further, undergoing pars plana vitrectomy with intravitreal and intravenous antimicrobial coverage with preliminary improvement. Three days after vitrectomy, her vision decreased with recurrent inflammation. Initial cultures grew

Objectives. To examine the effect of the January 2017 leak of the federal government’s intent to broaden the public charge rule (making participation in some public programs a barrier to citizenship) on immigrant mothers and newborns in New York State. Methods. We used New York State Medicaid data (2014–2019) to measure the effects of the rule leak (January 2017) on Medicaid enrollment, health care utilization, and severe maternal morbidity among women who joined Medicaid during their pregnancies and on the birth weight of their newborns. We repeated our analyses using simulated measures of citizenship status. Results. We observed an immediate statewide delay in prenatal Medicaid enrollment by immigrant mothers (odds ratio = 1.49). Using predicted citizenship, we observed significantly larger declines in birth weight (−56 grams) among infants of immigrant mothers. Conclusions. Leak of the public charge rule was associated with a significant delay in prenatal Medicaid enrollment among immigrant women and a significant decrease in birth weight among their newborns. Local public health officials should consider expanding health access and outreach programs to immigrant communities during times of pervasive antiimmigrant sentiment. (Am J Public Health. 2022; 112(12):1747–1756. https://doi.org/10.2105/AJPH.2022.307066 )

Vaccination remains key to reducing the risk of COVID-19–related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021–April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721–1725. https://doi.org/10.2105/AJPH.2022.307030 )

Objectives. To investigate whether the 2016 US presidential election and the subsequent leak of a proposed change to the public charge rule reduced immigrant families’ participation in food and nutrition assistance programs. Methods. We used nationally representative data on n = 57 808 households in the United States from the 2015–2018 Current Population Survey–Food Security Supplement. We implemented difference-in-difference-in-difference analyses to investigate whether the election and proposed rule change produced decreases in immigrant families’ participation in food and nutrition assistance programs and whether such decreases varied according to state policy generosity toward immigrants. Results. Findings indicate significant and large decreases in Supplemental Nutrition Assistance Program, School Breakfast Program, and National School Lunch Program participation among immigrants in moderately generous states but no changes to receipt of food assistance from nongovernmental sources or to household food insecurity. Conclusions. Both anti-immigrant rhetoric and the perceived threat of policy enactment can be enough to produce chilling effects that have potentially serious implications for the health of immigrant households and thus the health of the nation. (Am J Public Health. 2022;112(12):1738–1746. https://doi.org/10.2105/AJPH.2022.307011 )

Superficial temporal artery (STA) pseudoaneurysms are rare vascular lesions that typically present after traumatic head injury. Currently, surgery is the recommended treatment as spontaneous resolution has not been previously reported. Our study aims to present a review of the literature on STA pseudoaneurysms and report a case of spontaneous resolution of a traumatic STA pseudoaneurysm without the need for direct intervention.

Uterine carcinosarcomas are aggressive gynaecological cancers comprising less than 5% of uterine malignancies. We present the case of a woman in her 70s with a complicated history of advanced anal carcinoma treated with pelvic radiotherapy and multiple laparotomies, who was referred to gynae-oncology following MRI surveillance imaging showing evidence of endometrial carcinoma and para-aortic lymphadenopathy. Successful surgical excision required multidisciplinary teamwork between gynae-oncology, colorectal and urology surgeons. The patient underwent midline laparotomy, with adhesiolysis, ileum resection and side to side anastomosis, posterior exenteration, left kidney mobilisation and suspension, para-aortic lymph node debulking and left ureteric stent insertion. Significant challenge was posed by the extensive adhesions from previous laparotomies and the debulking of the para-aortic lymph nodes around the renal vessels. This case demonstrates the importance of a multidisciplinary approach in complex pelvic surgery and the vitality of good communication between colleagues in achieving effective patient care.

Cotard’s delusion is a delusion where one believes they are dead or deny aspects of their existence. Cotard’s syndrome includes expansive variation in presentations as well as inciting factors. Cotard’s syndrome is relatively rare and may include nihilistic delusions that one is missing organs, cannot die or that one does not truly exist. Cotard’s syndrome is often associated with other mental illnesses such as depression and schizophrenia but has not been widely associated with methamphetamine use. The following is a report of a patient with no previous signs of mental illness developing a schizophrenia-spectrum disorder with Cotard’s delusion after years of using methamphetamine.

This paper presents the case of a male dialysis patient, with generalised epilepsy, who experienced complications after starting medium cut-off (MCO) dialysis. While receiving haemodiafiltration, the patient’s epilepsy had been relatively well controlled using two antiseizure medications (brivaracetam and sodium valproate). However, the patient’s seizure frequency increased when he was changed to MCO dialysis. MCO is a new dialysis method that has been developed to allow for better clearance of uraemic toxins through its larger pore size. We hypothesise that using the highly permeable MCO membrane changed the seizure threshold by an unknown mechanism. This is the first reported case to observe increased seizure frequency in a patient receiving MCO dialysis. The case highlights the need for caution when prescribing dialysis methods to patients with epilepsy.

Neonicotinoid is a new class of systemic insecticides that are selectively toxic to insects. However, cases of human toxicity have been reported. A man in his 60s, who worked as a pest control operator (which required the use of thiamethoxam), presented with fever and headache. We investigated the levels of thiamethoxam and clothianidin in the blood and urine. Our results suggested that chronic thiamethoxam intoxication was caused by occupational inhalation exposure and environmental pollution. After cessation of insecticide use, the patient remained asymptomatic but had persistent oral dysesthesia and postural finger tremor, even at undetectable levels of thiamethoxam and clothianidin. This case report is the first to describe human thiamethoxam intoxication after occupational inhalation exposure. When similar symptoms are encountered and a history of insecticide use is confirmed, clinicians should consider the diagnosis of neonicotinoid intoxication.

A man in his 60s presented with a subacute paracentral scotoma and preserved visual acuity in the left eye. He was found to have a very subtle area of deep retinal whitening at the macula and multiple retinal cholesterol emboli. Optical coherence tomography (OCT) with En face imaging revealed globular paracentral acute middle maculopathy (PAMM). A diagnosis of PAMM associated with branch artery occlusion was made and the patient was immediately transferred to the nearest stroke centre. Investigations revealed severe carotid occlusive disease for which the patient underwent carotid endarterectomy. Paracentral scotomas in patients with little clinical findings on fundus examination should raise the suspicion for PAMM, which is easily identifiable on OCT. Eye care professionals must recognise PAMM as a possible sign of acute retinal arterial ischaemia—an ocular and systemic emergency that requires immediate referral to specialised stroke centres.

First described by Fischer in 1962, the limb shaking syndrome is a haemodynamic transient ischaemic attack (TIA) clinically characterised by brief, dysrhythmic, flailing or jerking movements, involving limbs contralateral to an occlusion of the internal carotid artery (ICA), which occur with a change in posture such as standing from sitting. We present the case of a woman in her 60s who presented with left-sided weakness suggestive of right hemispheric stroke, with previous episodes of limb shaking TIAs, which were caused by significant cerebral hypo-perfusion due to a combination of postural hypotension and a significant stenosis of the left ICA.

A woman aged mid 70s with mild learning difficulty presented with eye symptoms, headache and shoulder pains. She was found to have bilateral posterior scleritis secondary to giant cell arteritis. Posterior scleritis is a potentially blinding condition, with ambiguous symptoms and signs, therefore diagnosis is commonly delayed. This patient was seen in General Practice as well as in Accident and Emergency, where diagnoses of acute angle closure glaucoma as well as iritis were rightfully considered. Her symptoms persisted for 11 days before ophthalmic opinion was sought. Thorough assessment of a painful red eye as well as knowledge of these red-flag signs may allow early treatment and a better outcome for patients. The Royal College of Ophthalmologists has published guidance on how to assess and manage visual loss in people with learning difficulties, including recognising ‘symptoms’ such as hesitancy on steps, eye rubbing and loss of interest in activities.