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Background Catatonia is a presenting sign for many primary psychiatric disorders but it can also herald medical and neurological conditions. Increasing research has highlighted co-occurrence catatonia and delirium and how this combination warrants a thorough medical workup. Case presentation We present a case of a middle-aged woman with catatonia and delirium secondary to neurosarcoidosis only involving the brain; we document her 30-day hospitalization and intensive medical work-up that eventually revealed isolated neurosarcoidosis. This is the first reported case to our knowledge in the literature of catatonia occurring due to isolated neurosarcoidosis. Conclusion For this patient, albeit with a history of schizophrenia, the presence of delirium pushed the medical team to pursue a comprehensive work up instead of relying on a psychiatric diagnosis as the explanation for her puzzling clinical presentation. This case report supports a paradigm shift for physicians to think of catatonia similar to delirium: A syndrome that results from an underlying condition that must be treated in order to resolve the catatonia.

Background: Inflammatory breast disorders include a wide array of underlying causes, ranging from common benign infection, noninfectious inflammation and inflammation resulting from underlying breast malignancy. Mastitis refers to inflammation of the breast parenchyma, often presenting with pain, heat and redness that may be a debilitating illness with prolonged morbidity. It may also present with a wide array of other nonspecific symptoms, which may lead to delayed diagnosis and inappropriate treatment. Aim of Study: To discuss imaging findings in inflammatory breast disease by ultrasound. Patients and Methods: This was a prospective study which was carried out at Ain Shams University Hospitals; the study was conducted on 100 women with inflammatory breast diseases referred to the Radiology Department and Surgical Outpatient's Clinics. Results: Echogenic edematous fat lobules of the studied group show that; 30 (30.0%) were negative and 70 (70%) were positive, interstitial edema; 24 (24.0%) were negative and 76 (76%) were positive, defined collections; 68 (68.0%) were negative and 32 (32%) were positive. Lymph node enlargement; 54 (54.0%) were negative and 46 (46.0%) were positive. There was lymph node enlargement for only 45 (31 cases show reactive lymph nodes oval in shape with preserved shape and hilum and 14 cases show suspicious lymph nodes with cortical thickening and eccentric hilum). Follow-up by u/s and histopathology of the studied group show that 93 (93.0%) were resolved and 7 (7.0%) were IDC by histopathology. Conclusion: Ultrasound plays a fundamental role in the diagnostic work up of mastitis patients. An ideal ultrasound should ensure an accurate diagnosis, guide for interventional procedures whenever necessary and should be used to monitor adequate management by short term follow-up studies along the course of therapy.

Lymphoid infiltrates, benign and malignant, are encountered routinely in bone marrow trephine biopsies and require a systematic approach to reach a final diagnosis. Like any other histopathological finding, evaluation of lymphoid infiltrates requires interpretation in light of the clinical context to direct investigations appropriately and ensure a timely and accurate diagnosis. Work-up should be undertaken within a specialist integrated haematological malignancy diagnostic service (SIHMDS) to ensure appropriate investigations are available and used where required. Malignant lymphoid infiltrates may be overt and easily identified on routine stains and confirmed using an appropriate immunohistochemical panel or they may be subtle requiring further work up and correlation with other diagnostic modalities, as will be highlighted using illustrative cases. Clinical context remains paramount.

Funding Information: We kindly thank Business Finland and UPM-Kymmene Oyj (Finland) for their financial support. We also thank Lisa Ruetz for her help in sample preparation and data collection. The BOKU doctoral school ABC&M and the Austrian Biorefinery Center Tulln (ABCT) are gratefully acknowledged for their support. Publisher Copyright: © 2023 The Authors Periodate oxidation of cellulose to produce “dialdehyde cellulose” (DAC) has lately received increasing attention in sustainable materials development. Despite the longstanding research interest and numerous reported studies, there is still an enormous variation in the proposed preparation and work-up protocols. This apparently reduces comparability and causes reproducibility problems in DAC research. Two simple but prevalent work-up protocols, namely glycol quenching and filtration/washing, were critically examined and compared, resulting in this cautionary note. Various analytical techniques were applied to quantify residual iodine species and organic contaminations from quenching side reactions. The commonly practiced glycol addition cannot remove all oxidising iodine compounds. Both glycol and the formed formaldehyde are incorporated into DAC's polymeric structure. Quenching of excess periodate with glycol can thus clearly be discouraged. Instead, simple washing protocols are recommended which do not bearthe risk of side reactions with organic contaminants. While simple washing was sufficient for mildly oxidised celluloses, higher oxidised samples were more likely to trap residual (per)iodate, as determined by thiosulfate titration. For work-up, simple washing with water is proposed while determining potential iodine contaminations after washing with a simple colorimetric test and, if needed, removal of residual periodate by washing with an aqueous sodium thiosulfate solution.

Objective: Macrolide allergy is rarely reported, and there is limited knowledge of hypersensitivity reactions (HRs) in children. The negative predictive value (NPV) of drug provocation tests (DPTs) for macrolides is unresolved. We aim to evaluate the clinical features of macrolide allergy in children, and determine the NPV of macrolide DPTs. Materials and Methods: Pediatric patients who were referred to our allergy department with a suspicion of macrolide allergy were evaluated by DPTs with or without prior skin tests between 2011 and 2020. Characteristics of the HRs and patients, the results of skin and DPTs were recorded. At least three months after evaluation of the patients with allergy work up, telephone interviews were performed. Patients were asked whether they had reused the suspected macrolide or not. Patients who reported HR during subsequent drug intake were invited for reevaluation. Results: A total of 160 children (161 reactions) (55.6% male) with a suspicion of macrolide allergy were enrolled for the study, and all children had a mild index reaction. The median age was 48 (18-102) months, and the median time between the suspected allergic reaction and allergy work-up was 3 (2-8) months. The most frequently reported suspected agent was clarithromycin, in 151 patients (94.4%). Macrolide allergy was confirmed in 8 (5%) patients. Only one patient reported skin eruptions upon reuse despite a negative DPT and he was invited to be reevaluated. A second DPT was performed resulting in urticarial lesions. The NPV was found to be 97.4% for negative DPT with macrolides. Conclusion: Confirmed macrolide allergy is rare in children, and DPTs are the gold standard to assess suspected macrolide allergy. The NPV of macrolide provocation tests seems to be high in children. Keywords: Children, drug hypersensitivity, drug provocation test, macrolide, negative predictive value

INTRODUCTION Unintentional weight loss is an important clinical problem. The role of CT is not firmly established in the workup of these patients. The aim of this study is to determine the diagnostic yield of CT Thorax, Abdomen and Pelvis (CT TAP) in patients with unexplained weight loss and to determine whether clinical or laboratory variables are associated with positive CT findings. METHODS A retrospective review was performed of CT TAP examinations over 12 months with weight loss as an indication. Patients' electronic records and radiology reports were reviewed. Clinical and laboratory variables were assessed for correlation with positive findings on CT. RESULTS 461 CT TAP studies with weight loss as the primary indication were identified. 124 were excluded; 82 due to a recent history of malignancy, 41 because CT TAP was used for staging of a new malignancy and one study was incomplete. This left 337 eligible examinations. 217 studies had findings of no clinical relevance, 50 studies were normal, 40 studies identified a possible cause of weight loss and 30 studies identified a definite cause. Of the 40 where a possible cause was identified, further work up led to a diagnosis which explained the weight loss in 13 patients. The diagnostic yield of CT TAP was 12.8%. Age, abdominal symptoms, degree of weight loss, anaemia, tumour markers and LDH did not significantly correlate with positive findings on CT. CONCLUSION CT TAP is a helpful investigation in patients with unexplained weight loss with a diagnostic yield of 12.8%.

Cardiovascular imaging has experienced and is still experiencing tremendous advancements as far as hardware as well as software technology is concerned. In every day clinical routine, crucial decisions are daily being taken based on imaging findings. These decisions include changes to treatment strategies, performing further testing, recommending or adhering to preventive measures, and ultimately affect patient outcomes. Appropriate use of different imaging modalities which includes choosing the right modality, adequate performance of the imaging test as well as professional reporting is crucial for providing high quality medical care. Furthermore, a growing body of scientific evidence is currently available that show the clinical relevance of different imaging methods in the clarification of different disease constellations. This article describes various imaging modalities that are used in the work-up of CAD in everyday cardiac routine.

The skin often provides initial clues of hypercoagulability with features such as livedo reticularis, livedo racemosa, retiform purpura, necrosis, and ulcerations. Because these cutaneous manifestations are nonspecific, laboratory testing is often needed to evaluate for underlying causes of hypercoagulability. Importantly, these disorders are reported to be the most common mimicker, resulting in an erroneous diagnosis of pyoderma gangrenosum. Understanding inherent properties of, and indications for, available tests is necessary for appropriate ordering and interpretation of results. Additionally, ordering of these tests in an indiscriminate manner may lead to inaccurate results, complicating the interpretation and approach to management. This second article in this continuing medical education series summarizes information on methodology, test characteristics, and limitations of several in vitro laboratory tests used for the work up of hypercoagulability and vasculopathic disease as it pertains to dermatologic disease.

Background: Infertility is a major problem throughout the world. In a country like India, it is associated with a social stigma. The cause can be multifactorial and many couples are seeking medical help for infertility nowadays. As part of the female infertility workup, hysterosalpingography plays an important role. Methods And Material: A retrospective study was done in the department of Radiodiagnosis of a rural tertiary care hospital, India. All patients who were referred for hysterosalpingography study as part of infertility workup between January 2018 and December 2020 to the department of Radiodiagnosis were included in the study. Results: A total of 173 patients are included in the study. Out of these 173 patients, 3 women had repeat Hysterosalpingography studies. 43.2% of these studies are abnormal. 56.8% cases showed normal ndings. Tubal abnormalities were the most common accounting for 34.6% of the total studies. Uterine abnormalities were seen in 6.8% of the total studies. Both fallopian tube and uterine abnormalities were seen in 1.7%. Post-operative follow-up imaging was available for 3 patients. All three patients had a bilateral tubal block in the rst study and showed tubal patency in post recanalization HSG study. Conclusion: Hysterosalpingography is a lesser invasive procedure, cost-effective, and does not require anesthesia compared to laparoscopy. This is a huge advantage, especially in a rural setup. It can be considered as a screening investigation along with an ultrasound examination. Tubal blockage is the most common abnormality accounting for nearly one-third of the causes of infertility in our study. Tuberculosis should always be ruled out as a cause of tubal blockage in India where it is more prevalent.

Purpose Genetic diagnostics of neurodevelopmental disorders with epilepsy (NDDE) are predominantly applied in children, thus limited information is available regarding adults or elderly. Methods We investigated 150 adult/elderly individuals with NDDE by conventional karyotyping, FMR1 testing, chromosomal microarray, panel sequencing, and for unresolved cases, also by exome sequencing (nsingle = 71, ntrios = 24). Results We identified (likely) pathogenic variants in 71 cases (47.3%) comprising fragile X syndrome (n = 1), disease-causing copy number (n = 23), and single-nucleotide variants (n = 49). Seven individuals displayed multiple independent genetic diagnoses. The diagnostic yield correlated with the severity of intellectual disability. Individuals with anecdotal evidence of exogenic early-life events (e.g., nuchal cord, complications at delivery) with alleged/unproven association to the disorder had a particularly high yield of 58.3%. Screening for disease-specific comorbidities was indicated in 45.1% and direct treatment consequences arose in 11.8% of diagnosed individuals. Conclusion Panel/exome sequencing displayed the highest yield and should be considered as first-tier diagnostics in NDDE. This high yield and the numerous indications for additional screening or treatment modifications arising from genetic diagnoses indicate a current medical undersupply of genetically undiagnosed adult/elderly individuals with NDDE. Moreover, knowledge of the course of elderly individuals will ultimately help in counseling newly diagnosed individuals with NDDE.

To explore the spectrum of presentation, underlying monogenetic defects and outcome in very early onset inflammatory bowel disease (VEO-IBD).The prospective, observational study was conducted at the Children's Hospital, Lahore, Pakistan, from January 2017 to December 2018, and comprised children developing features of inflammatory bowel disease aged6 years. Data included demography, clinical presentation, diagnostic tools and outcome. Data was analysed using SPSS 21.Of the 60 children with relevant symptoms, 26(43.3%) were diagnosed as having very early onset inflammatory bowel disease. Of them, 13(50%) had underlying monogenic defect, and 16(61.5%) had ulcerative colitis. There were 22(84.6%) males with median age of 1.5(11) months in monogenic inflammatory bowel disease versus 24(43) months for non-monogenic inflammatory bowel disease (p0.05). In the monogenic group, isolated rectal bleeding was the major presentation 13(100%) versus non-monogenic who presented mainly with failure to thrive 13(100%). Upper and lower endoscopies with histopathology had good diagnostic yield and inflammatory infiltrates on the biopsied tissues were the major findings. Mutations detected among the subjects were XIAP, PRKDC, PIK3CD, RAG-1, LRBA, DOCK8, TTC7, MEFV and EPCAM. Mortality was significantly higher in the monogenic group 7(54%) than in the non-monogenic group 2(15%) (p0.05).Very early onset inflammatory bowel disease should be suspected when conventional management fails to rectify common disease mimickers. Testing for underlying immunological defect and genetic mutation would be helpful for managing these rare disorders.

Adrenal tumors are commonly discovered incidentally on cross-sectional abdominal imaging performed for reasons other than adrenal mass. Incidence of adrenal tumors increased 10-fold in the past 2 decades, with most diagnosed in older adults. In any patient with a newly discovered adrenal mass, determining whether the adrenal mass is malignant and whether it is hormonally active is equally important to guide the best management. Malignancy is diagnosed in 5% to 8% of patients with adrenal tumors, with a higher risk in young patients, if history of extra-adrenal malignancy, in those with large adrenal tumors with indeterminate imaging characteristics, and in bilateral adrenal tumors. Although overt hormone excess is uncommon in adrenal incidentalomas, mild autonomous cortisol secretion can be diagnosed in up to 30% to 50% of patients. Because autonomous cortisol secretion is associated with increased cardiovascular morbidity and metabolic abnormalities, all patients with adrenal incidentalomas require work up with dexamethasone suppression test. Management of adrenal tumors varies based on etiology, associated comorbidities, and patient’s preference. This article reviews the current evidence on the diagnosis and evaluation of patients with adrenal mass and focuses on management of the most common etiologies of adrenal incidentalomas.

Background: Leukocyte esterase (LE) and α-defensin (AD) are two synovial biomarkers that are used for the diagnosis of periprosthetic joint infection (PJI), however, the superiority of one over the other remains unknown. We aimed to compare their diagnostic value.Methods: In this retrospective study, we evaluated patients who underwent revision total hip and knee arthroplasty at a single institution between 2013 and 2019 for whom both LE and AD were available. PJI was defined by the 2018 International Consensus Meeting criteria. The diagnostic performance of AD and LE was compared.Results: Overall, 122 patients (28 PJI and 94 aseptic revisions) were included. The area under the curve was 0.905 (95% confidence interval[CI]:0.820-0.991) and 0.913 [95%CI:0.834-0.992] for LE and AD, respectively. Positive and negative predictive values were 95.8% (95%CI:76.5%-99.4%) and 94.9% (95%CI:89.4%-97.6%) for LE and 89.0% (95%CI:72.2%-96.1%) and 96.0% (95%CI:90.5%-98.3%) for AD. While both tests were useful in 18 cases that were inconclusive based on preoperative findings, AD had no benefit over LE.Conclusion: Both LE and AD are valuable markers in patients with suspected PJI. Since LE is very inexpensive and readily available point-of-care test, we believe it offers more value in the work up of suspected PJI.

Background & Objective: Liver lesions are difficult to diagnose and to differentiate primary from metastatic carcinoma, while Biopsy has its limitations. Cell block technology is easily accessible with high diagnostic accuracy. Our aim is 1) To find the role of cell block technology as an alternative to biopsy in identifying liver lesions; 2) To find the efficacy of cell block along with immunohistochemistry (IHC) and ancillary studies in differentiating primary from metastatic lesions; 3) To identify the site of origin of metastatic lesions. This is a descriptive study undertaken in two tertiary care hospitals over a period of three years. Methods: Retrospective review of adequate samples from fine needle aspirations from liver lesions under radiological coverage, converted into cell block was done. IHC was applied as needed. Usefulness of cell block preparation was evaluated, and the final diagnosis correlated with the biopsy results. Results: Analysis of 323 cases found sensitivity of 98.75% and positive predictive value of 99% for all lesions. Sensitivity for metastatic carcinomas was slightly more than hepatocellular carcinoma. However, accuracy of cell block results for individual metastatic lesions and site of origin was less. IHC and morphological pattern worked as an important adjunct in the final diagnosis. On the other hand, contribution of viral markers as a supplement in the final work up was ambiguous. Conclusion: High precision of validity results of cell block technology in comparison with biopsy highlights its pivotal role in conjunction with supportive tests for diagnosing and differentiating liver lesions as well as identifying primary sites in liver metastasis.

BACKGROUND & AIMS: Little is known about cholestasis, including its most severe variant secondary sclerosing cholangitis (SSC), in critically ill patients with coronavirus disease 19 (COVID-19). In this study, we analysed the occurrence of cholestatic liver injury and SSC, including clinical, serological, radiological and histopathological findings. METHODS: We conducted a retrospective single-centre analysis of all consecutive patients admitted to the intensive care unit (ICU) as a result of severe COVID-19 at the University Hospital Zurich to describe cholestatic injury in these patients. The findings were compared to a retrospective cohort of patients with severe influenza A. RESULTS: A total of 34 patients with severe COVID-19 admitted to the ICU were included. Of these, 14 patients (41%) had no cholestasis (group 0), 11 patients (32%, group 1) developed mild and 9 patients (27%, group 2) severe cholestasis. Patients in group 2 had a more complicated disease course indicated by significantly longer ICU stay (median 51 days, IQR 25-86.5) than the other groups (group 0: median 9.5 days, IQR 3.8-18.3, P = .001; and group 1: median 16 days, IQR 8-30, P

Screening for hypo- or hyperthyroidism in adults is generally done by measuring the serum thyrotropin (thyroid-stimulating hormone, TSH) concentration. This is an efficient approach in case of suspected acquired thyroid disease. However, in infants and children, congenital hypothalamus-pituitary-thyroid (HPT) axis disorders also need to be considered, including primary and central congenital hypothyroidism, and even rarer thyroid hormone receptor and transporter defects. In primary congenital hypothyroidism, TSH will be elevated, but in the other congenital HPT axis disorders, TSH is usually within the normal range. Free thyroxine (FT4) assessment is essential for the diagnosis in these conditions.Conclusion: Here we discuss a number of rare congenital HPT axis disorders in which TSH is normal, but FT4 is low, and provide a clinical algorithm to distinguish between these disorders. What is Known:• A single thyroid-stimulating hormone (TSH) measurement is an appropriate screening method for primary hypothyroidism.• For central hypothyroidism and rare thyroid hormone receptor and transporter defects a free thyroxine (FT4) measurement is essential for the diagnosis because TSH is usually normal. What is New:• Here we present a new problem-oriented clinical algorithm including a diagnostic flow-chart for low FT4 and normal TSH in infants and children.

Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.

Immune thrombocytopenic purpura (ITP) is a rare hematologic condition through to affect 3.3 in 100,000 adults per year in the United States. Many cases of immune thrombocytopenia are diagnosed incidentally with laboratory tests that reveal low platelet count, without a clear cause. However, when platelet counts are very low, patients may show signs of bleeding. Here we present the case of a 24-year-old female with mucocutaneous bleeding ten days after receiving her first dose of SARS-CoV-2 vaccine, who was subsequently found to have severe thrombocytopenia. Extensive work up for new thrombocytopenia was unremarkable suggesting a diagnosis of ITP, potentially secondary to vaccination. Empiric treatment with glucocorticoids was initiated without response prompting the use of intravenous immunoglobulin G. The patient was discharged on hospital day five with a platelet count over 20,000 platelets per microliter. In summary, ITP is a potential sequela of the SARS-CoV-2 vaccine, and otherwise healthy young individuals may be at risk for hematologic side effects.

The aim of this study is to discuss the role of the chiropractor in triage of a patient presenting with acute onset of worsening dizziness of unknown etiology. We present a 66-year-old-female who presented to a hospital-based chiropractic clinic with acute onset worsening dizziness with multiple comorbid conditions. Patient presented to the chiropractic clinic for routine management of low back pain; however, upon review of systems, the patient indicated symptoms as described above. The patient was immediately transported to the ED for further evaluation and work up by the appropriate medical professionals. Patient was admitted for observation with suspected intracranial hemorrhage. The role of the chiropractor in a multidisciplinary setting includes not only evaluation and management of musculoskeletal conditions, but also the identification of red flag signs and initiation of triage in efforts of providing complete and comprehensive, patient-centered care. This case report highlights the importance of detailed history, review of systems, and physical examination in an outpatient clinical setting, regardless of the specialty of the practitioner.

Case Presentation A 44-year-old woman with a history of renal cell carcinoma and thyroid cancer was referred to our institution for evaluation of cystic lung disease. She was an active smoker with a 15-pack-year of tobacco use. Two years before her presentation, she underwent a left nephrectomy for renal cell carcinoma, clear cell type. Four months before, she had a total thyroidectomy that showed nodules consistent with noninvasive follicular thyroid neoplasm with papillary like nuclear features. She had no previous pulmonary complaints. Her family history was positive for breast cancer in her grandmother. There was no family history of pneumothorax. She complained of mild shortness of breath with exertion and occasional nonproductive cough. As part of her oncologic work up, she underwent a chest CT scan of the lungs ( Fig 1 ).

Summary Background : Computed Tomography Angiography (CTA) is utilised in pre-operative work up in adults undergoing microsurgical reconstruction. The evidence for the use of CTA pre-operatively in the paediatric population prior to reconstruction remains unclear so far as there are limited studies. Arguably the use of CTA in place of conventional angiography avoids vessel damage, which can be amplified in the paediatric population due to smaller vessel calibre. Materials and Methods : Four papers satisfying inclusion criteria were identified through PubMed, EMBASE, Cochrane database, Google Scholar and citation searching. Results : There is low grade evidence from multiple case series describing the use of CTA pre-operatively in paediatric extremity trauma prior to microsurgical reconstruction. Literature suggests that CTA may be utilised effectively in such cases. Conclusion : Evidence suggests CTA can be useful in pre-operative work-up for paediatric patients undergoing extremity reconstructive microsurgery. However, the evidence is obtained from several small case series in which selection bias is suspected thus making generalisation to larger populations difficult. Although evidence for the use of pre-operative CTA exists in the adult population which can be sensibly extrapolated into the paediatric population, higher level studies looking further at the application in paediatrics are required.

Introduction: Extra-skeletal Tc-99m MDP uptake is not uncommon. It could be a problematic when it mimics a metastatic osseous lesion. Due to lack of proper anatomical localization, Planar bone scintigraphy (PBS) alone can't resolve this problem. Adding single photon emission tomography / computed tomography (SPECT/CT) images increases the diagnostic accuracy of planar bone scintigraphy. SPECT/CT has great impact on patients' management by preventing misinterpretation through precise localization and proper characterization of these uncertain lesions. In this study, we compared the diagnostic accuracy of SPECT/CT versus PBS in characterization of extra-skeletal lesions detected on conventional PBS in known cancer patients. Materials and Methods: This is a retrospective study including 50patients with known cancer referred for conventional (PBS) for metastatic work up. PBS was acquired followed by SPECT/CT images for the concerned area. Diagnostic performance indices from both modalities (PBS& SPECT/CT) were compared against the reference standard (clinical/imaging follow-up). Results: A total of 50 known cancer patients were included in this study (37 females, 13 males) with median age 64 years (range: 15-79). The sensitivity, specificity, and accuracy for SPECT/CT in identification of extra-osseous lesions all were 100% compared to 28%, 72% and 44% respectively for PBS. Uncertain lesions decreased from 38% to 0% by adding SPECT/CT.Only 10% of lesions showed calcium deposition, while the rest had other causes for extra-skeletal uptake. Conclusion: SPECT/CT enhances the diagnostic accuracy of planar bone scan for characterizations of extra-skeletal lesions that mimic osseous metastasis thus significantly impact patient’s management.

Biliary malformations in children are rare, but important to recognize. Diagnostic delay compromises outcomes. Some may be diagnosed prenatally, others in the newborn period, usually with clinical presentation of jaundice, with or without abdominal pain and fever. A strong level of suspicion is needed with any patient. Abdominal ultrasound, which is widely available, is an excellent initial imaging tool. Further work up may include magnetic resonance cholangiopancreatography (MRCP) to completely define the biliary tree. Surgical management is the primary treatment for many biliary disorders.

All cases undergoing FNAC for thyroid swelling during study period were included in the study. The data was collected as per the pre-designed proforma including the general profile, clinical examination, laboratory investigations, USG findings and FNAC observations.In our study we found, correlation between antithyroglobulin antibody levels, 100-500 IU/ml (53), 501-1000 IU/ml (87) & >1000 IU/ml (10). Chi square = 8.2068; p-value= 0.7120 (insignificant). Correlation between T3 levels, Normal (18), Low (24) and High (108). Chi square = 12.3129; p-value= 0.3580 (insignificant). Correlation between T4 levels, Normal (00), Low (24) and High (108). Chi square = 19.9758; p-value= 0.00012 (significant). Correlation between T4 levels, Normal (00), Low (24) and High (108). Chi square = 79.0167; p-value Prospective Observational Study. Antithyroglobulin antibodies may be insignificant statistically, yet they should always be tested for, in order to establish a better understanding of the cases. The ATG levels should be kept in mind before prescribing a treatment regime for such cases. This not only leads the pathologists to continuously seek for better than the present investigations but also leads clinicians to decide a dynamic management regime. Though there is a defined protocol for thyroid work up of clinically diagnosed patients, newer and more sensitive test need to be devised.

The aim of the present study was to assess the outcomes of an allergy work up of patients with a penicillin allergy label by primary care. Patients and methods An allergy work up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests (ST) were challenged with amoxicillin. Patients who were delabeled were subsequently contacted by phone in six months to determine outcomes after any therapeutic penicillin-class antibiotic intake. Results A total of 39 patients were evaluated and 33 (84.6%) were delabeled. Five patients were penicillin skin test positive and one was oral challenge positive. We succeeded in contacting 33 delabeled patients at six months. Twenty two patients had tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retook a penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. Conclusion We highlights the importance of allergy work up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labeled as beta-lactam allergic and this mislabeling could increase the health care costs and leads to the development of drug resistance by the use of wide spectrum antibiotics.

A Caucasian male infant born full term via normal spontaneous vaginal delivery was given vitamin K after birth, circumcised on day of life (DOL) 1, and discharged from the nursery on DOL 2. At the time of circumcision, oozing from the surgical site was noted and initially resolved with silver nitrate. Over the next two days, he presented to local emergency rooms multiple times for recurrent bleeding, eventually developing hemorrhagic shock resulting in admission to the neonatal intensive care unit. After extensive work up, he was ultimately diagnosed with severe congenital factor XIII deficiency. Congenital factor XIII deficiency is a rare bleeding disorder characterized by normal prothrombin time (PT) and activated partial thromboplastin time (aPTT) coagulation labs on routine screening, and has a high risk of complications, such as spontaneous intracranial hemorrhage. Although uncommon, when caring for a child with bleeding, physicians must have a high index of suspicion to make this diagnosis in order to initiate proper treatment and start prophylaxis given the risk of morbidity and mortality in untreated patients.

Peripheral neuropathies have many nonspecific features that are shared by various neurologic disorders. These disorders include atypical peripheral neuropathies along with neurologic disorders outside of the peripheral nervous system. An understanding of clinical fundamentals and a measured approach to laboratory work-up can assist the provider in achieving diagnostic confidence.

Discriminating thyroid and parathyroid lesions may sometimes pose a diagnostic difficulty. Medullary thyroid carcinomas (MTCs) display various cytologic and architectural features that resemble other thyroid and even rarely some parathyroid neoplasms. Moreover, some MTCs may have negative serum calcitonin, rendering them difficult to diagnose. Hence, to reach an appropriate diagnosis in problematic cases of these three categories – thyroid lesions, MTC and parathyroid lesions – the use of several immunohistochemical panels has been suggested and applied. However, conventional markers are not always conclusive in problematic cases. Thus, in the current study we aim to evaluate the diagnostic utility of using GATA3 and INSM1 (insulinoma-associated protein 1) as novel nuclear markers to be applied as an adjunct in case of histopathologic suspicion. A retrospective study was carried out on samples of lesions from three groups: group 1: thyroid lesions (27), group 2: medullary thyroid carcinoma (25); 1/25 had negative serum levels of calcitonin, and group 3: parathyroid lesions (36). Biopsies were received at the Pathology Laboratory of Ain Shams University Hospitals. INSM1 showed 98% diagnostic accuracy in diagnosing MTC and differentiating it from other thyroid lesions. The case of MTC with negative serum calcitonin showed positive INSM1 staining. GATA3 showed 96.8% diagnostic accuracy in diagnosing parathyroid lesions and differentiating them from thyroid lesions. Using immunohistochemical staining by GATA3 and INSM1, in the appropriate histopathological setting, significantly aids in the differentiation between thyroid lesions, parathyroid lesions and MTCs. INSM1 could serve as a potential diagnostic marker in the rare cases of non-secretory MTC and in metastatic work up.

Marjan Alidoost, Gabriella A Conte, Varsha Gupta, Swapnil Patel, Ishan Patel, Mohammed Shariff, Shreya Gor, Michael J Levitt, Arif Asif, Mohammad A Hossain Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, New Jersey, 07753, USACorrespondence: Gabriella A ConteChief Resident, Internal Medicine Residency Program, Department of Medicine, Jersey Shore University Medical Center, Hackensack-Meridian Health, Neptune, NJ, 07753, USATel +1 201-446-4611Email gabriella.conte@hackensackmeridian.orgBackground: Venous thromboembolism is a significant clinical event, with an annual incidence of 1– 2 per 1000 population. Risk factors include recent surgery, prolonged immobility, oral contraceptive use, and active cancer. Inherited risks include protein C and S deficiencies, antithrombin deficiency, factor V Leiden mutation and prothrombin. These factors can be tested to guide therapy, but current evidence suggests that testing for inherited thrombophilia is not recommended in most inpatient settings. In the era of high value care, hypercoagulable testing for VTE creates a financial burden for the hospital and patients. We performed a retrospective chart review of hypercoagulable orders on VTE patients at our institution.Methods: Institutional Review Board approval was obtained. A total of 287 adult patients admitted over a 3-month period with the diagnosis of VTE were included. Patients were identified via ICD-10 codes and data were collected from electronic medical records. Patient characteristics, provoked versus unprovoked VTE, and relative contraindications for hypercoagulability work-up were analyzed. Our primary outcome was to assess the appropriateness of thrombophilia testing in VTE patients based on screening guidelines. Our secondary outcome was to analyze the cost burden of ordering these tests.Results: A total of 287 patients were included in our data analysis. Patient risk factors for VTE were malignancy, previous DVT, immobilization, surgery 3 months prior, and central line placement. Fifty-seven of 287 patients had at least one hypercoagulable test ordered during hospitalization which did not adhere to guidelines. Misuse of testing occurred during active thrombosis, active anticoagulation, presence of risk factors, first episode of VTE, and malignancy. The cost of ordering these 5 thrombophilia tests totaled over $40,000.Conclusion: In our study, numerous patients were tested without compliance to standard recommendations, which created financial and value-based burdens on our health care system. Increased awareness among clinicians is thus warranted to ensure high value care.Keywords: venous thromboembolism, VTE, hypercoagulability, thrombophilia

Aim To assess the changes induced by the COVID-19 lockdown on cardiac biometric variables recorded using an implantable cardiac monitor (ICM) in a patient population monitored for syncope work-up, as well to assess whether there has been an effect on arrhythmic events among the patients. Methods Longitudinal cohort study. We included 245 adult patients monitored with an ICM indicated for the investigation of syncope. The records from days 1 to 12 March 2020 (prior to the institution of lockdown by the state government) with days 16 to 28 March 2020 were compared. Results Daily physical exercise reduced markedly after the imposition of lockdown (132 [55–233] minutes vs. 78 [21–154] minutes). The mean daytime HR prior to lockdown was 77 [69–85] bpm, whereas during lockdown it was 74 [66–81] bpm. During the lockdown period, a drop in the variability in heart rate (114 [94–136] ms vs. 111 [92–133] ms) was observed. Although the incidence of AF was similar over both periods, the daily AF burden was significantly higher post-lockdown (405 [391–425] minutes vs. 423 [423–537] minutes). No differences in the number of other arrhythmias were found. Conclusions The establishment of mandatory lockdown has led to a marked drop in daily physical activity in this population which probably explains changes observed in other cardiac biometric variables. Although, in the short term, we have not documented an increased risk of arrhythmia, we cannot rule out an effect in the medium to long term or in other populations of at-risk patients.

Objectives The PIRADS Steering Committee has called for “higher quality data before making evidence-based recommendations on MRI without contrast enhancement as an initial diagnostic work up,” however, recognizing biparametric (bp) MRI as a reasonable option in a low-risk setting such as screening. With bpMRI, more men can undergo MRI at a lower cost and they can be spared the invasiveness of intravenous access. The aim of this study was to assess cancer detection in bpMRI vs mpMRI in sequential screening for prostate cancer (PCa). Methods Within the ongoing Göteborg PCa screening 2 trial, we assessed cancer detection in 551 consecutive participants undergoing prostate MRI. In the same session, readers first assessed bpMRI and then mpMRI. Four targeted biopsies were performed for lesions scored PIRADS 3–5 with bpMRI and/or mpMRI. Results Cancer was detected in 84/551 cases (15.2%; 95% CI: 12.4–18.4) with mpMRI and in 83/551 cases (15.1%; 95% CI: 12.3–18.2%) with bpMRI. The relative risk (RR) for cancer detection with bpMRI compared to mpMRI was 0.99 (95% one-sided CI: > 94.8); bpMRI was non-inferior to mpMRI (10% non-inferiority margin). bpMRI resulted in fewer false positives, 45/128 (35.2%), compared to mpMRI, 52/136 (38.2%), RR = 0.92; 95% CI: 0.84–0.98. Of 8 lesions scored positive only with mpMRI, 7 were false positives. The PPV for MRI and targeted biopsy was 83/128 (64.8%) for bpMRI and 84/136 (61.8%) for mpMRI, RR = 1.05, 95% CI: 1.01–1.10. Conclusions In a PSA-screened population, bpMRI was non-inferior to mpMRI for cancer detection and resulted in fewer false positives. Key Points • In screening for prostate cancer with PSA followed by MRI, biparametric MRI allows radiologists to detect an almost similar number of prostate cancers and score fewer false positive lesions compared to multiparametric MRI. • In a screening program, high sensitivity should be weighed against cost and risks for healthy men; a large number of men can be saved the exposure of gadolinium contrast medium by adopting biparametric MRI and at the same time allowing for a higher turnover in the MRI room.

Aim: To study the clinical profile and outcome of diabetic foot ulcer in a Tertiary Care Centre. Theclinical profile of 200 patients with diabetic foot ulcer was studied. Methods: Patients with diabeticfoot ulcer of both genders with age above 18 years willing to participate were included in the study.All patients were subjected to routine diabetic work up with Doppler study and X-ray foot to rule outbone involvement. Results & discussion: The majority of patients with diabetic foot ulcers were ofage group 51 to 60 years, male predominant, mostly with a duration of diabetes mellitus more than6 years had intermittent claudication and most population with a single ulcer. Conclusion: Ourstudy gives important information that diabetic foot ulcer is more common among middle-agedpeople with male predominance which gives the importance of screening diabetic patients forneuropathy and peripheral vascular disease.

Background: The diagnosis of acute appendicitis is purely based on history, clinical examination and some laboratory investigations (e.g. WBC count). Certain diagnosis can only be obtained at surgery and after pathological examination of surgical specimen. The Atema scoring system can distinguish complicated from non-complicated appendicitis preoperatively. Objective: To evaluate the validity and diagnostic accuracy of the Atema scoring system in differentiating complicated from non- complicated appendicitis before surgery. Patients and Methods: A prospective study was carried out on 60 patients complaining of acute abdominal pain, diagnosed as acute appendicitis using the Alvarado score and undergoing open appendectomy operation in the Emergency Department, Faculty of Medicine, Al-Azhar University from December 2019 to July 2020. Routine clinical and laboratory work up were done, the Atema Score was calculated to every patient in the study preoperatively. The decision to operate was made by a senior surgeon (consultant). The intraoperative finding whether the acute appendicitis was complicated or not was recorded. Post operatively, the histo-pathological examination results were recorded for each patient. The ROC curve was done, the cut-off point of the Atema scoring system was detected based on the ROC curve. The area under the ROC curve and the p-value were calculated. The sensitivity, specificity, positive predictive value and negative predictive value of the Atema scoring system above the level of the cut-off point were calculated. Results: In total of 60 patients, 37 patients (61.7%) had complicated appendicitis and 23 patients (38.3%) had non-complicated appendicitis. The sensitivity of the Atema score has a diagnostic accuracy of 0.944 (Area under the curve) with sensitivity 86.96% and specificity 89.19% with positive predictive value 83.3% and negative predictive value 91.7%. Conclusion: The Atema score can significantly differentiate between complicated and non-complicated acute appendicitis. A higher score denotes increased probability of the presence of complications as perforation and gangrene.

Background: Evaluation of the diagnostic value of computed tomography (CT) cholangiography with minimum intensity projection (MinIP) in the work up of patients with obstructive biliary disease through correlation with percutaneous trans hepatic cholangiography (PTC) results. Objective: In this study, we aimed to evaluate the diagnostic value of CT cholangiography with MinIP in the work up of patients with obstructive biliary disease through correlation with PTC results. Patients and Method: The study included 36 patients (26 males and 10 females), with biliary obstruction. CT cholangiography was done to reach a definite diagnosis for the cause of obstruction and PTC was done during their management plan. Analysis of the image data with (MinIP) images was created on a separate workstation and compared to that of PTC. Results: The CT cholangiography using MinIP technique correctly diagnosed the cause of obstruction among all included cases. No significant difference was found between measurements of obstructing lesion size. We had a novel observation about that axial images are significantly better to reveal the obstructing biliary lesion if the cause of obstruction is intrahepatic; while coronal images are significantly better to reveal the obstructing biliary lesion if the cause of obstruction is extrahepatic. Conclusion: CT cholangiography with MinIP is a complete noninvasive technique that provides projectional images similar to that of PTC without administration of oral specific contrast agents, requires no medications, less operator dependent and no complications were encountered in adequately screened patients.

Bow Hunter's syndrome, also referred to as rotational occlusion of the vertebral artery, is caused by dynamic compression of a patient's dominant vertebral artery. We reported a case of successful clinical and imaging work up of Bow Hunter's Syndrome that occurred in a 79-year-old female patient. We discussed the clinical presentation, imaging findings, and subsequent management options of this rare syndrome. The gold standard for diagnosis is dynamic cerebral angiography, which allows the reproduction of symptoms with head turn greater than 30-45 degrees. Subsequent management is based on the underlying etiology causing rotational compression.

Background: Many shortcomings associated with haemodialysis for instance, intradialysis blood pressure changes, often lead to inadequate dialysis dose. Measures are needed to improve on this.Objectives: To determine the risk factors and clinical correlates of intradialysis blood pressure variations.Methods: Maintenance haemodialysis sessions for 232 consented patients with end stage kidney disease who had 1248 sessions were studied. Data collected was from history, examination findings, serum electrolytes and hematocrit. Blood pressure reading was taken manually at rest. Statistical analysis was with SPSS 22. Chi square and t-test were used to compare proportions and means respectively while regression analysis was used to determine predictors of blood pressure changes.Results: The mean age of participants was 49.9 + 4.6. More participants (38.8%) had hypertension associated CKD, than chronic glomerulonephritis, (37.9%). Majority (60.7%) had internal jugular catheter. Intradialysis hypertension was commoner than intradialysis hypotension (24.4% versus 19.4%). Intradialysis hypotension was commoner in females, diabetics and with less frequent dialysis while intradialysis hypertension was commoner in males, frequent erythropoietin use. The mean dialysis dose (Kt/V) was 1.02 + 0.4, with 0.68 + 0.1for intradialysis hypotension and 0.84 + 0.2 for intradialysis hypertension.Conclusion: Risk factors for intradialysis hypertension were males, frequent erythropoietin use while for intradialysis hypotension, were female gender and less frequent dialysis. Effective intra and inter-dialytic blood pressure control with adequate pre dialysis work up should be carried out to lessen the degree, burden and outcome of these variations.

The differential diagnosis in cellular effusions with cytological atypia often includes malignant mesothelioma (MM), reactive mesothelial proliferation, and malignancies of metastatic origin, particularly carcinomas. The International Reporting System for Serous Fluid recently established guidelines for reporting MM. In conjunction with the cytomorphologic evaluation, the role of immunochemistry (IC) was emphasized as a very useful tool in the workup of serous fluids, especially with the availability of novel markers. Utilizing a panel of markers, IC allows the characterization of the cells, whether mesothelial or not, and when mesothelial origin is established, IC can frequently assist in delineating its benign or malignant nature. IC can also confirm metastatic disease, allowing the identification of the primary origin in most cases. This review summarizes the current status of IC and its role in the diagnosis of MM and its differential diagnosis in serous fluids.

Background: Overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life lost, and 3.8% of disability-adjusted life-years (DALYs) worldwide. Bariatric surgery is the most effective modality for long-term weight loss and for resolving the associated comorbidities. However, controversies exist regarding the ideal weight loss metabolic procedure. This allowed continuous search for new techniques.Aim of the work: to evaluate short-term outcomes and associated complications of laparoscopic sleeve gastrectomy with loop bipartition.Patients and Methods: The present study was conducted on fifteen patients who met the National Institute of Health criteria for bariatric surgery. These patients were enrolled in a prospective study at Ain-Shams University Hospitals from December 2015 to May 2017) and they underwent laparoscopic sleeve gastrectomy with loop bipartition. Preoperative work up included full history, full clinical examination, abdominal ultrasonography, biochemical labs. Procedure was performed by laparoscopic approach.Results: excess weight loss percentage at 6 months, 12 months respectively was 67%, 92%. This results were very comparable to mahdy et al. and santoro et al. Sleeve gastrectomy with loop bipartition comorbidities related outcomes were complete remission of 66% in T2DM, 71% in HTN, 100% others comorbidities and another studies for bipartition reached more than 90% in T2DM, 80% in HTN, 85% others comorbidities. In our study we recorded that Sleeve gastrectomy with loop bipartition has strong impact on resolution of comorbidities in comparison with BPD, DS, RYGB.Conclusion: Sleeve gastrectomy with loop bipartition is a new promising procedure that based on a new paradigm of helping GI facing and adapting to the modern diet without adding new morbidities with precise adsjusting of the neurohormonal aspects. Preliminary results points to potent simple safe procedure in treating obesity and metabolic syndrome.

Aim to evaluate the role of preoperative magnetic resonance imaging (MRI) in assessing patients with a history of quiescent hip septic arthritis undergoing total hip arthroplasty. Materials and methods retrospective consecutive study of patients with previous history of septic arthritis who underwent MRI scans of their hips prior to primary hip arthroplasty surgery and who also had minimum 2 years follow up postoperatively. Detailed radiographic examinations were obtained, demographic and microbiological data collected. The primary outcome measure was whether a preoperative MRI scan had influenced the surgical decision-making and planning. Rate of recurrence of infection and complications was also collected at final follow up. Results sixteen patients with quiescent hip septic arthritis were included. There were 4 males and 12 females with average age at time of primary hip arthroplasty 51.7 years (range 22–75). Five patients had childhood septic arthritis with no documented microbiology data. Eleven patients had adult onset septic arthritis. In patients with childhood septic arthritis the MRI findings were similar to those with degenerative joint disease and had no added value to the routine surgical work up. MRIs of patients with adult onset septic arthritis showed persistent findings of effusion, marrow oedema and soft tissue oedema and had no added value to the surgical planning. All but one underwent single stage total hip arthroplasty. At final follow up, with average 4.6 years (range 2–8), none had a recurrence of infection. Conclusion In our experience, preoperative MRI scans did not influence the surgical decision making and are not recommended for routine practice in the surgical work up of quiescent septic arthritis prior to total hip arthroplasty.

Thirty per cent of cases of erectile dysfunction (ED)/male impotence are resistant to oral treatment. Half of these cases are due to blood drainage from the corpora cavernosa occurring too soon, due to cavernovenous leakage (CVL). The aim of this study was to report on an innovative treatment scheme combining pre- and post-operative haemodynamic assessment, venous embolisation, and open surgery for drug resistant ED caused by CVL.An analysis of prospectively collected data, with clinical and haemodynamic pre- and post-operative assessment, was carried out. Forty-five consecutive patients operated on for drug resistant ED caused by CVL were evaluated pre-operatively and three months post-operatively by pharmacologically challenged penile duplex sonography (PC-PDS), pharmacologically challenged Erection Hardness Score (PC-EHS), and pharmacologically challenged computed caverno tomography (PC-CCT). Follow up consisted of patient interview, PC-PDS, PC-EHS and if needed PC-CCT.Mean patient age was 43.9 ± 12.0 years (range 20-67). Forty-nine per cent of patients had primary ED. Patients with diabetes, a smoking habit, hypercholesterolaemia, and hypertension were 18%, 11%, 9%, and 4%, respectively. Three months post-operatively, PC-EHS increased from 2.0 ± 0.7 to 3.1 ± 0.74 (p .001), with an EHS of 3 being the threshold allowing for penetration. Deep dorsal vein velocity, a haemodynamic marker of CVL, decreased from 14.2 ± 13.0 to 0.9 ± 3.5 cm/s (p .001). After a 14.0 ± 10.7 month follow up, the primary success rate (clinical EHS ≥ 3, possible sexual intercourse with penetration, no vascular re-operation, no penile prosthesis implant) was 73.3%. Four patients (9%) underwent successful re-operation for persistent ED and CVL. Accordingly, compared with a possible penetration rate of 8.9% before surgery, 37 patients (secondary success rate: 82.2%) were able to achieve sexual intercourse with penetration. Type of ED (primary vs. secondary) and diabetes had no influence on the results. Thirty-two per cent of patients with secondary success achieved penetration with no medication.After a 14 month follow up, pre-operative work up, embolisation, and open surgery during the same procedure allowed patients with ED resistant to oral medical to achieve intercourse with penetration.

COVID-19 is a viral respiratory disease associated with neurologic complications such as encephalitis or stroke in a minority of patients. The wide variety of neurologic manifestations with often unclear etiology may confound diagnosis and management. We present a young man admitted following an 8-day onset of self-resolving episodes of left hemiplegia and hemifacial droop. Diagnostic work up for seizures and stroke was largely negative. “Intra-ictal” ECD-single-photon emission computerized tomography/computerized tomography was consistent with right middle cerebral artery ischemia. Subsequent diagnostic work up revealed positive COVID-19 screening and newly-elevated antiphospholipid antibodies. Antiepileptic medications were discontinued, and the patient was successfully treated as an outpatient with corticosteroids leading to resolution of symptoms.

A 50-year-old woman with a history of controlled Graves’ disease without clinical ophthalmopathy presents with 2 months of left more than right periorbital swelling and proptosis. Her eye symptoms and signs began 3 days following her second vaccination against the COVID-19 virus. Orbital imaging, elevated thyroid stimulating immunoglobulin, and negative systemic work up for other diseases were consistent with a diagnosis of active thyroid eye disease. The temporal relationship to her vaccination was likely consistent with autoimmune/inflammatory syndrome associated with adjuvants. Clinicians should remind patients of the symptoms and signs of thyroid eye disease and to seek appropriate medical and ophthalmic advice if they occur after the COVID-19 vaccine., Patient with history of Graves’ disease activates with thyroid eye disease after COVID-19 vaccination.