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Myasthenia gravis (MG) is an autoimmune condition affecting the neuromuscular junction characterised by weakness and fatiguability, carrying a high morbidity if treatment is delayed. A clear association with thymoma has led to management with thymectomy as a common practice, but MG presenting post-thymectomy has rarely been reported. We present a case of an 82- year-old woman developing fatigue, ptosis and dysarthria 3 months after thymectomy. After a clinical diagnosis of MG was made, she responded well to prompt treatment with prednisolone and pyridostigmine. Her anti-acetylcholine receptor antibody (anti-AChR) subsequently came back positive. Our systematic review reveals that post-thymectomy MG can be categorised as early-onset or late-onset form with differing aetiology, and demonstrated correlation between preoperative anti-AChR titres and post-thymectomy MG. The postulated mechanisms for post-thymectomy MG centre around long-lasting peripheral autoantibodies. Clinicians should actively look for MG symptoms in thymoma patients and measure anti-AChR preoperatively to aid prognostication.

Objective: The purpose of this study was to determine the usefulness of active decompression and distraction sugosteogenesis (ADDS) for the management of non-syndromic odontogenic keratocysts (OKC). Materials and Methods: A retrospective case series study was designed and implemented. The study observed the Declaration of Helsinki on medical protocol and ethics and it was approved by the university’s Institutional Review Board (IRB). The medical files of all patients who underwent ADDS for OKCs of the jaws at the Department of Oral and Maxillofacial Surgery of a tertiary university-affiliated medical center were reviewed. Data were collected on patient’s age, gender, presenting signs and symptoms, lesion location, locularity, pre-ADDS, size of the lesion, post-ADDS, pain, days with bloody discharge and/or proteinaceous fluid inside the system’s external unit, days to achieve hermetic seal, size of the lesion 2 weeks after ADDS, percentage of reduction, patient’s complaints/complications, and follow-up period. Pre- and post-ADDS panoramic radiographs were reviewed for reduction parameters. Results: Six patients, 5 males and 1 female, with an average age of 45.16 years (range 16-74 years) were studied. ADDS was performed during 4 weeks in all patients. During the therapy, the extraoral unit collected blood during 2.83 days in average. In average, after the third day, the cystic cavity started to drain a proteinaceous fluid for about 9.33 days (range 6-15 days). The average pre-ADDS Standard Lesional Area Index (SLAI) was 18.17 cm2 (range 4.40 cm2-34.58 m2) and, after 2 weeks of ADDS, the average SLAI was 5.47 cm2 (range 0.49 cm2-15.39 cm2). The average percentage of reduction, after 2 weeks, was 73.93% (range 55.49%-97.51%), which yielded an overall good reaction of OKCs to ADDS. No significant reduction of the lesions was observed from week 2 to week 4, when ADDS ceased. All lesions were enucleated after 3 months. After an average of 14 months of follow-up (12 to 17 months), no signs of recurrence have been observed.

Objectives: Consistent with biopsychosocial models, shared pathophysiological conditions underlying both physical pain and depressive symptoms can result in the clustering of pain and depressive symptoms. However, previous studies have not investigated a higher-order construct capturing both pain and depressive symptoms over time. Furthermore, research has not identified trajectory antecedents (e.g. perceived family financial stress) and their consequences for later-life health and well-being. The present study sought to address these gaps in the research.Method: Using prospective data over 23 years from 244 long-term married women, the present study estimated latent growth curves in a structural equation model (more specifically a parallel trajectory model was estimated).Results: Family financial strain in midlife was, on average, associated with a higher initial level (β = .37, p < .001) and rate of change (β = .20, p = .045) of pain-depressive symptoms trajectories, which, in turn, contributed to health and well-being challenges, including the level and rate of change in physical limitations (β = .50, p < .001 and 0.43, p < .001, respectively), memory impairment (β = .47 and .47, p < .001, respectively), and loneliness (β = .63, p = < .001 and .28, p = .022, respectively) in later years. The adverse influence of family financial strain on pain-depressive symptoms trajectories weakened under high levels of marital closeness (β = -.10, p = .032). Conclusion: These findings emphasize the necessity of policies and interventions that focus on reducing adults' stressful life circumstances and further developing protective factors that can aid in the redirection of adverse pain-depressive symptoms trajectories.Supplemental data for this article are available online at https://doi.org/10.1080/13607863.2021.1993129.

Uterine rupture can be associated with severe maternal and neonatal morbidity and mortality. It should be considered as a differential diagnosis in all pregnant women who present with acute abdomen, haemoperitoneum and have specific risk factors, even during the first trimester. This is a case report of a 25-year-old woman who presented to emergency department with abdominal pain and vaginal bleeding at approximately 6–8 weeks gestation. She developed an acute surgical abdomen and required urgent surgical management. Despite intervention, she had massive haemorrhage, disseminate intravascular coagulation, admission to intensive care unit and prolonged hospital stay as complications. Posterior uterine wall rupture while rare, must be considered as a differential diagnosis as early intervention is crucial to prevent bad outcomes.

This study sought to validate a combined assessment for major depression and generalized anxiety, administered by health providers in a primary care setting in Mozambique. Patients attending a primary care visit ( N = 502) were enrolled in the study and completed the Patient Health Questionniare–9, the Generalized Anxiety Disorder–7, and six items identified in a global systematic qualitative review of depression that were not captured in existing measures (e.g., social isolation, “thinking too much,” and “heart problems”). A separate trained mental health provider conducted the Mini International Neuropsychiatric Interview 5.0, adapted for Mozambique, to establish clinical diagnoses. Item response theory, factor analysis, and receiver operating characteristics were all used to identify the best screening items. Eight items were identified for the final screener: four items from the Patient Health Questionniare–9, two from the Generalized Anxiety Disorder–7, and two from the global depression literature. A cut-score of 7 was found to consistently increase the diagnostic likelihood of having a particular disorder. Overall, findings indicate good clinical utility of the screener in primary care in Mozambique.

A girl born by normal vaginal delivery at 34 weeks’ gestation was noted to have a discrete midline scalp swelling from birth. This parieto-occipital lesion was non-tender, non-pulsatile and measured 10 mm in diameter. At 4 weeks of age, the lesion remained similar in size and had developed a

A 74-year-old woman presents with a 7-day history of increasing lower abdominal pains and reduced bowel movements; resulting in absolute constipation.Twenty-four hours prior to admission she also had symptoms of nauseous and significant abdominal distention. Her past medical history included; diverticulitis, type 2 diabetes, hypercholesterolemia, an ultrasound scan in 2005 confirming gallstones, but no previous abdominal surgery.She was initially treated for bowel obstruction and a CT arranged. CT showed a 4.5 cm gallstone in mid-sigmoid colon and a cholecystocolonic fistula. She was booked for colonoscopy±laparotomy, but on the morning of her planned procedure she repeatedly opened her bowels. Subsequent colonoscopy was negative and repeat CT confirmed the stone was no longer within the gastrointestinal tract.

Adrenoleukodystrophy (ALD) is an X linked recessive genetic disorder caused by an abnormality in the ABCD1 gene on the X chromosome, that affects 1 in 20 000 people. In X linked adrenoleukodystrophy (X-ALD), a defect in lignoceroyl-coenzyme A ligase causes pathognomonic tissue accumulation of very long chain fatty acids (VLCFA) in the adrenal cortex and nervous system. The phenotypic variability ranges from cerebral inflammatory demyelination of childhood onset, leading to death within 5 years, to adults remaining presymptomatic through more than five decades. Our case is that of a man who was previously diagnosed with bipolar affective disorder presented with dystonic posturing. During transit, he had an episode of generalised convulsive status epilepticus. He presented with spasticity and exaggerated reflexes. Three important signs of adrenal insufficiency were observed: hypotension, hyperpigmentation and comatose state. The diagnosis of X-ALD should be considered in young men presenting with gradually progressive unexplained cognitive and behavioural problems, a strong family history, adrenal insufficiency, bilateral upper motor signs with absent ankle reflexes.

Most patients with cystic fibrosis (CF) develop multisystemic clinical manifestations, the minority having mild or atypical symptoms. We describe an adolescent with chronic cough and purulent rhinorrhoea since the first year of life, with diagnoses of asthma, allergic rhinitis and chronic rhinosinusitis. Under therapy with long-acting bronchodilators, antihistamines, inhaled corticosteroids, antileukotrienes and several courses of empirical oral antibiotic therapy, there was no clinical improvement. There was no reference to gastrointestinal symptoms. Due to clinical worsening, extended investigations were initiated, which revealed Pseudomonas aeruginosa in sputum culture, sweat test with a positive result and heterozygosity for F508del and R334W mutations in genetic study which allowed to confirm the diagnosis of CF. In this case, heterozygosity with a class IV mutation can explain the atypical clinical presentation. It is very important to consider this diagnosis when chronic symptoms persist, despite optimised therapy for other respiratory pathologies and in case of isolation of atypical bacterial agents.

Primary amyloidosis is a rare systemic disorder often associated with multiple organ dysfunction. The most common form, light chain amyloidosis, has an estimated age-adjusted incidence of 5.1–12.8 cases per million person-years. Spine involvement is extremely uncommon. We present the case of a young Asian man with newly diagnosed amyloidosis involving the lumbar spine among multiple organs with a pathological vertebral fracture that required urgent spine surgery. We believe this is the first reported case to discuss the perianaesthetic challenges in the management of lumbar spine amyloidosis.

Functional metastatic pheochromocytoma (PCC) is a very rare tumour and cytoreductive adrenalectomy with oligo metastatectomy is recommended in cases of low tumour burden. We report a rare case of metastatic PCC with an incidentally detected suspicious nodule seen on the anterior surface of the right lobe of the liver. The adrenal and the lesion were excised and sent for histopathology which was reported as a metastasis from PCC. This lesion was not visualised preoperatively on DOTA-PET-CT, highlighting the importance of keeping a low threshold for suspicion of metastasis in abnormal lesions and taking a biopsy during surgery. Inspection of the liver and rest of the abdomen for any abnormality should be done even when operating for any apparently benign lesions.

A 60-year-old man presented with severe abdominal pain, two episodes of massive haematemesis and chest discomfort. CT angiography showed a saccular aneurysm of the juxtaphrenic aorta with possible oesophageal erosion. Upper GI endoscopy revealed external compression of the lower oesophagus—near total luminal obstruction with impending rupture of the aortic aneurysm. Emergency aneurysmal repair by interposition grafting using 20 mm Dacron graft with oesophageal–gastric reconstruction done. Postoperative period was uneventful

Mycotic aneurysms are rare and if left untreated, can have devastating outcomes. In this case, a 72-year-old man presented to hospital with fevers, night sweats and abdominal pain. A CT scan revealed the development an infrarenal pseudoaneurysm over the course of 8 weeks, increasing from 2.8 cm to a 3.1 cm. The aneurysm was not present on a CT scan performed 6 months earlier. The patient underwent an emergency endovascular repair of the aortic aneurysm (EVAR) and was placed on broad-spectrum antibiotics. Intra-aortic blood cultures aspirated adjacent to the aneurysm and tissue biopsy confirmed tuberculosis bovis as the cause of the mycotic aneurysm. The patient had been treated with intravesical BCG for transitional cell carcinoma of the bladder several months prior. The patient was treated with an extended course of antituberculosis medication. He recovered well and was back to his baseline function within weeks.

We report a case of a 60-year-old man who struggled with frequent migraines for 12.5 years, which were refractory to all conventional therapies. Six months before initial consultation, these migraines become chronic. The patient was then advised to follow the Low Inflammatory Foods Everyday (LIFE) diet, a nutrient-dense, dark green leafy vegetable-rich, whole food plant-based diet. Within 2 months, his headache frequency declined from 18 to 24 headache days per month to 1, and he discontinued his preventive and abortive migraine medications. After 3 months, the patient had no headaches. These results far exceed the goal of migraine treatment with medication, which is to reduce migraine frequency by >50% per month. In addition, the results were durable; this patient has been migraine-free for 7.5 years. Serum beta-carotene more than tripled after the patient started the LIFE diet, consistent with its high content of dark green leafy vegetables. Weight, high-sensitivity C-reactive protein (hsCRP), complete blood count (CBC), hydration status, sodium and other electrolytes remained constant throughout the study.

A 4-week-old boy presented to the hospital with symptoms of diarrhoea and vomiting initially thought to be due to cow’s milk allergy. He was discharged with extensively hydrolysed formula. The patient represented with worsening of symptoms with metabolic acidosis and was screened and treated for sepsis. However, his condition deteriorated further and he developed methaemoglobinaemia. He was transferred to the high dependency unit and was given two doses of methylene blue. Further investigations were carried out, including rapid trio exome sequencing, which identified a homozygous pathogenic Peptidase D (PEPD) variant (c.978G>A, p.(Trp326*)). This was consistent with a diagnosis of prolidase deficiency.

An asymptomatic woman aged 24 years was informed about the presence of a heart murmur by her attending obstetrician while she was hospitalised for a spontaneous abortion 6 months ago and was subsequently referred to us to rule out underlying heart disease. After clinical examination and relevant laboratory evaluation, a diagnosis of severe valvular pulmonary stenosis (PS) was established. Interestingly, our patient had undergone an open thoracotomy for surgical closure of a patent ductus arteriosus (PDA) under general anaesthesia 12 years ago in the absence of any appreciable shunt across the ligated ductus at present. Considering the severe gradient across her pulmonary valve, she underwent a successful percutaneous balloon pulmonary valvuloplasty (PBPV) procedure with excellent haemodynamic outcome. The pertinent literature concerning the rare combination of PDA in association with PS as well as the technicalities of PBPV procedure in an adult are discussed.

A young woman presented to neurology with a 1 month history of progressive diplopia on lateral gaze and a 1 week history of headaches. On examination she was found to have complex ophthalmoparesis with binocular horizontal diplopia, failure of abduction bilaterally and limited upgaze with convergence-retraction nystagmus. The rest of the neurological examination was normal. She was admitted for investigations: blood, CT brain, MR brain and lumbar puncture results were normal. Anti-GD1a antibodies were strongly positive; anti-GM1, anti-GM2 and anti-GD1b were also positive. On follow-up 3 weeks later, the complex ophthalmoplegia persisted. It was decided to treat with intravenous immunoglobulins (IVIgs) with good response but recurrence at 2 weeks post infusion. She was treated with 4 weekly IVIg courses and remains responsive and controlled over 1 year since presentation but becomes symptomatic in the week running up to each dose; thus, disease modifying treatment is currently being considered.

We present the case of a young male patient who presented with paralysing muscle weakness due to severe hypokalaemia and hypophosphataemia. The initial patient history evaluations could not establish the aetiology. Only after we reviewed the patient’s history did he reveal that he had been following a severe calorie-restricted regime, the human chorionic gonadotropin diet, which had ended 2 days prior to developing symptoms. This information then allowed us to diagnose severe refeeding syndrome. As a further complication, the patient developed rhabdomyolysis. After correction of serum electrolytes, symptoms resolved completely. This case emphasises the potential harm of severely calorie-restricted diets, often recommended by online ‘experts’. Furthermore, we underline the importance of thorough history taking.

The most common cause of congenital heart block (CHB) is neonatal lupus, an acquired autoimmune disease caused by transplacental transfer of maternal antibodies to the fetus. A full-term female neonate was admitted to neonatal intensive care unit for severe bradycardia with stable haemodynamics. The mother, showing no clinical symptoms or any particular history, was transferred to our tertiary centre for profound fetal bradycardia. At birth, the infant’s ECG showed a third-degree atrioventricular block and echocardiography was normal. Cardiac neonatal lupus was confirmed with positive maternal anti-Ro antibodies. Under close monitoring, the infant tolerated the bradycardia well (median 67 beats per minute (bpm)) and was discharged on day 6 of life. There was no indication for pacemaker, but she would be on regular follow-up with a paediatric cardiologist. This article holds an important insight as it is the first confirmed case of autoimmune CHB in Cambodia in which the mother’s antibody was found only after diagnosis on the neonate.

In India, bee stings are very common, seen mainly in farmers and honey collectors. Usually, it presents with local reactions and anaphylaxis. It rarely requires urgent hospitalisation. Other major complications seen are acute renal failure, intravascular coagulation, rhabdomyolysis and acute pulmonary oedema. Stroke as a presentation is uncommon. We report a case of a 45-year-old man presenting with right-sided hemiplegia and aphasia due to multiple bee stings. Diffusion MRI showed left middle cerebral artery territory hyperacute infarct.

We describe the case of a 32-year-old man from Cape Verde having headache and increasing visual loss. Clinical and radiological investigations disclosed a massive destructive lesion involving the anterior and central skull base, orbit and nasoethmoid region initially interpreted as a malignant small round cell tumour. Surgical biopsies were negative for neoplasm, showing an intense inflammatory infiltrate together with fungus, later characterised as Aspergillus flavus spp. The patient was immunocompetent with no evidence of congenital or acquired immunodeficiencies. Invasive fungal infections in immunocompetent patients are rare and can be a diagnostic challenge. The best diagnostic clues include the patient’s origin from tropical climates, imaging features and the identification of fungal hyphae on pathology specimens. Although a devastating disease in immunocompromised patients, craniocerebral aspergillosis in immunocompetent patients carries a better prognosis. Available literature supports the combined used of ‘conservative’ surgical resection and antifungal therapy as the best treatment option.

A 4-year-old boy presented with acute febrile illness with altered sensorium, decreased responsiveness to command, excessive sleepiness, headache and generalised-onset motor seizures for the past 2 days with intact bladder and bowel control. There was no history of jaundice, change in the colour of

An 8-year-old girl presented with precocious puberty and an otherwise normal examination. MRI of the pituitary was normal; however, an incidental oval, non-enhancing T2 hyperintense lesion in the right temporal subcortical white matter was identified ([figure 1][1]). The neuro-radiographic

A 78-year-old woman with hypertension, diabetes mellitus type 2 and bilateral sensorineural hearing loss was referenced to geriatric psychiatry consultation. She presented cognitive dysfunction, erotomanic delusion and complex musical hallucinations (MH), described as hearing her neighbour singing a familiar church song along with bells in the background, making comments and talking to her. A computed tomography (CT) of the brain detected small right nucleocapsular and bilateral external capsules hypodensities of presumed vascular aetiology during hospitalisation. MH are a rare phenomenon with heterogeneous aetiology. Most frequently, the cause is hearing impairment; other causes include social isolation, cognitive dysfunction, vascular risk factors and medication. Studies suggest that some brain areas related to musical memory circuitry might be related and not fully mapped. Auditory verbal hallucinations with a voice that either comments, talks or sings to the patient have never been described in the literature, making this clinical case attractive. info:eu-repo/semantics/publishedVersion

A 28-year-old woman presented with complaints of breathlessness on exertion NYHA class II and palpitations for the past 2 years. On examination she had irregularly irregular pulse and mid-diastolic murmur at the apex. An ECG revealed atrial fibrillation with controlled ventricular rate. Her

A 58-year-old man presented with a 3-month history of painless blurred vision in the right eye. There was no antecedent history of trauma, flashes and floaters. Best-corrected visual acuity was 20/200 in the right eye and 20/30 in the left eye. Right eye intraocular pressure (IOP) was 9 mm Hg

Recurrent painful ophthalmoplegic neuropathy (RPON), previously called ophthalmoplegic migraine, is a rare condition characterised by recurrent episodes of headache and ophthalmoplegia. We report a case of 11-year-old girl with recurrent painful ophthalmoplegia due to isolated right oculomotor nerve involvement. MR brain imaging showed enhancing lesion of cisternal segment of right oculomotor nerve. A possibility of Tolosa Hunt syndrome was considered and she was treated with glucocorticoids, followed by azathioprine due to recurrence. In the fourth episode, she developed migraine headache followed by right third nerve palsy, after which the diagnosis was revised to RPON. She was started on flunarizine along with short-term glucocorticoids. At 1-year follow-up, she remained asymptomatic. RPON should be considered in patients with recurrent third nerve palsy to avoid inadvertent long-term exposure to immunosuppressive agents.

We present a 65-year-old female smoker who presented with acute bilateral blurred vision. Investigations led to an endobronchial ultrasound-guided fine-needle aspiration resulting in an early diagnosis of limited stage small cell lung cancer. Positive recoverin antibodies supported the diagnosis of cancer-associated retinopathy (CAR). CAR was the first manifestation of systemic malignancy in our patient and early diagnosis enabled curative intent systemic treatment with chemotherapy and radiotherapy. Ocular-specific treatment is required in CAR, although no standardised treatment exists. Current treatment options include steroids and immunosuppressive agents. Our patient was administered bilateral intravitreal dexamethasone implants, resulting in significant visual field and electroretinogram improvement at 8 weeks post-intervention. To our knowledge, this represents the first reported successful use of intravitreal dexamethasone implants as first-line therapy, in conjunction with chemoradiotherapy. Intravitreal dexamethasone implants therefore may provide an effective and safe treatment for CAR by reducing intraocular inflammation without systemic effects.

A 53-year-old woman without medical problems presented with 5-month history of dizziness, difficulty speaking, severe ataxia, which worsened a day before admission to inability to stand unsupported. An extensive workup was initiated to find the cause of ataxia. The laboratory investigations and imaging of the brain and whole spine revealed no lesions. She was found to have autoimmune thyroiditis, positive coeliac disease antibodies without clinical features and vitamin D deficiency. No intravenous steroids or immunosuppressive therapy was given. Cerebrospinal fluid showed lymphocytic pleocytosis. The workup for the cause of severe ataxia revealed an oropharyngeal lesion with cervical lymph nodes, and the biopsy showed classical Hodgkin’s lymphoma of mixed cellularity. She was treated with chemotherapy followed by radiation therapy and made a remarkable recovery, and currently, she is in remission without distant metastases, 5 years after the initial diagnosis. Her neurological status improved, and she remained with mild ataxia.

Primary neuroendocrine tumours of the kidney are rare, and their pathophysiology is uncertain; since their discovery in 1966, they have been described only a few times in the literature. We present a case of a well-differentiated neuroendocrine tumour of the kidney in an asymptomatic patient, which required a multidisciplinary approach by the hospital’s team, including precise surgical treatment and an effective radiopathological diagnosis. The patient underwent right radical nephrectomy. During follow-up, he remained asymptomatic, and no metastases or complications were identified.

Renal cell carcinoma (RCC) frequently presents with osseous metastasis, predominantly lytic and prone to pathological fracture. The metastatic lesion in the extremity presents with local swelling, pain and immobility due to pathological fracture. The solitary or oligometastatic lesions should be treated with curative intent, which can help the patient to lead a more prolonged and disability-free life. The RCCs and their metastases are hypervascular with an exuberant arterial supply. Surgery can lead to uncontrolled life-threatening haemorrhage. Preoperative transarterial embolisation reduces tumour vascularity significantly and reduces intraoperative blood loss. We present a 46-year-old male patient with solitary hypervascular metastatic recurrence of RCC with a pathological femoral fracture with an infeasible initial surgery due to profuse haemorrhage. He was successfully treated by preoperative transarterial embolisation, followed by surgical resection and implantation of a megaprosthesis. Multidisciplinary management reduces patient morbidity and mortality with successful treatment in solitary hypervascular metastasis from RCC.

We report the case of a 10-year-old boy that presented with a palpable, painless, frontal lesion. Laboratory assessments were unremarkable and the patient was asymptomatic. Initial investigation, with a skull radiograph and unenhanced CT scan, showed a lytic midline frontal lesion involving the inner and outer tables of the skull and a large subgaleal hypodense component. MRI further depicted communication with the epidural space and contact with the superior sagittal sinus (SSS). Subsequent evaluation by Doppler ultrasound and MR angiography excluded a sinus pericranii and showed normal patency of the SSS. Surgical biopsy revealed chronic granulomatous inflammation; PCR was positive for Mycobacterium sp. One year after surgical resection and antitubercular therapy, there are no signs of recurrence. Primary calvarial involvement by tuberculosis is rare, even in developing countries. Familiarity with the expected clinical and imaging features is required to avoid diagnostic delay.

A 30-year-old man was referred by a general ophthalmologist for retina examination owing to his high myopia status. His presenting visual acuity in the right eye was 6/6 with a refraction of −2.75 dioptre sphere (DS), −2.75 dioptre cylinder (DC) at 170° and that in the left eye was 6/9 with a

A 49-year-old woman was referred to the retina clinic with incidentally noted retinal pigmentation. She had long-standing poor left visual acuity (VA) due to a compressive optic neuropathy treated by surgery in childhood. She also had chronic angle closure glaucoma, treated with bilateral laser

OBJECTIVE African American women are exposed to multiple adverse psychosocial factors, including racism, discrimination, poverty, neighborhood stress, anxiety, and depression. The impact of these psychosocial factors on cardiovascular disease (CVD) risk in women during early adulthood is limited. This review aims to summarize and synthesize the recent literature on psychosocial factors related to CVD risk in young African American women. METHODS We conducted a comprehensive search of the literature in PubMed, APA PsycINFO, and CINAHL. We systematically reviewed the literature for studies examining associations between psychosocial factors (e.g. racism, discrimination, neighborhood stress, anxiety) and CVD risk factors (e.g. body mass index [BMI], blood pressure, diabetes) in African American women age 19-24 years. Eligible studies measured at least one psychosocial factor, a CVD risk factor, and included young adult African American women (age 19-24) or reported sex-stratified analyses. RESULTS We identified nine studies that met our inclusion criteria: six cross-sectional and three longitudinal studies. Of these, eight studies reported that psychosocial factors (i.e. perceived stress, racial discrimination, internalized racism, depression) are related to higher BMI and blood pressure. The majority of studies were conducted among college students or had a small sample size (

Aneurysmal bone cysts are locally aggressive benign bone tumours with a high risk of recurrence. We describe a case in a 4-year-old girl, involving the right acetabulum. A direct posterior approach was used and the lesion ablated with curettage and local adjuvants with bone grafting. The cyst resolved swiftly with an uncomplicated recovery.

Background: Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries. Methods: A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups. Results: For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups. Conclusions: The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.

OBJECTIVE Somatic complaints are known to complicate recovery after mild traumatic brain injury (mTBI), but the construct is poorly understood due to evolving definitions of associated disorders and uncertainty related to its position within the broader construct network of psychopathology. Methods: To better understand measures of somatic symptom reporting widely used with mTBI patients, we examined relationships between the Brief Symptom Inventory-18 Somatization (SOM) scale, the Minnesota Multiple Personality Inventory-2-Restructured Form Somatic Complaints (RC1) scale, other measures of psychological and personality functioning, and mTBI in both athlete concussion (n = 100) and civilian trauma (n = 75 mTBI, n = 79 orthopedic injury) samples. Results: The association between post-injury SOM and RC1 was moderate (r=.37-.46) and similar to associations between these inventories and depression and anxiety symptoms. In civilians with mTBI, RC1 was more strongly associated with diverse personality dimensions than SOM. mTBI athletes reported increases in somatic symptoms from pre- to post-injury, with larger group effect sizes on SOM (ηp2 = 0.34, p < .001) than RC1 (ηp2 = 0.09, p = .003). Civilian mTBI patients showed a trend for somewhat higher post-injury RC1 scores than orthopedic trauma controls (ηp2 = 0.02, p = .068). Conclusions: Findings add to the current knowledge of the influence of somatic complaints in mTBI. BSI-18 SOM and MMPI-2-RF RC1 are not interchangeable, as they are only modestly correlated and demonstrate differing associations with other clinical outcomes and mTBI.

Purpose: The current study aims to quantify the effect of brief behavioral treatment for insomnia (BBTI) studies through meta-analysis. Method: Searches were performed from inception to February 2020, reporting on the effects of BBTI using randomized controlled trials (RCT) (adults aged 32 to 84). The main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE%), and total sleep time (TST). Results: BBTI showed improved SOL compared with control group in mean difference at early (-15.42 [95% CI: -33.05 to -12.01; I2 =49%]) and late follow-up (-10.52 [95% CI: -1.12 to 0.54; I2=93%]). This was statistically significant at early follow-up, but not at late follow-up. The improvement of WASO by BBTI over the control group was shown at early follow-up (-17.47 [95% CI: -2.67 to 0.45; I2=90%]), and was statistically significant. For WASO, a non-statistically significant improvement of BBTI over the control group was shown at late follow-up (-12.77 [95% CI: -22.47 to -3.08; I2=0%]). SE% was shown improved statistically significant by BBTI over control group at early (4.47 [95% CI: -0.35 to 9.29; I2=98%]) and at late follow-up (6.52 [95% CI: -4.00 to 17.05; I2=89%]). The TST was shown no improvement by BBTI at early follow-up in mean difference (-2.97 [95% CI -38.83 to 32.90; I2=96%]). At late follow-up, TST was shown improvement in BBTI with mean difference (14.52 [95% CI: -31.64 to 60.68; I2=94%]) compared with the control group.Conclusion: Current evidence suggests that BBTI can be considered preliminarily efficacious and can be used for samples of middle-aged and older adults.

An elderly patient presented with acute-onset right-sided weakness and aphasia. A large penumbra was noted in the left middle cerebral artery (MCA) territory without any infarct core. The patient was noted to have a carotid–carotid bypass. This posed certain technical challenge in accessing the intracranial circulation across the carotid bypass; however, the guiding catheter with soft distal segment was successfully navigated coaxially over the aspiration catheter across the bypass and intracranial circulation was accessed for mechanical thrombectomy. Complete recanalisation and reperfusion were achieved with significant neurological recovery of the patient post-thrombectomy. The aim of this report is to emphasise on this rarely encountered situation in thrombectomy and its successful management. The procedure should not be delayed or deferred due to lack of operator experience.

Interpretation bias is a transdiagnostic mechanism underlying anxiety. Theoretical models highlight the role of parental interpretation bias in predicting and maintaining child anxiety. However, very few studies have examined parent interpretation bias as a treatment target. The current pilot study tested the feasibility and acceptability of an interpretation bias intervention delivered by a smartphone app, called HabitWorks, in parents of anxious children who self-reported at least mild symptoms of anxiety and negative interpretation bias. Parents of anxious youth (ages 8 to 16) were recruited from the waitlists of three child anxiety clinics. They were asked to complete interpretation modification exercises via the HabitWorks app 3 times per week for 1 month. Participants completed assessments at pre- and post-intervention and 1-month follow-up to assess changes in interpretation bias, anxiety symptoms, and overall perceptions of HabitWorks. Participants (N = 14) (Mage = 44.36; 14.29% men, 85.71% women) completed an average of 13.29 exercises out of the 12 prescribed. Acceptability ratings were high. Interpretation bias, as measured by an assessment version of the intervention exercise, significantly improved from pre- to posttreatment, and these improvements were maintained at the 1-month follow-up. Anxiety symptoms significantly improved from the “mild” severity range to the “none to minimal” range. In this pilot feasibility study in parents of anxious youth, HabitWorks was a feasible and acceptable low-intensity intervention. These preliminary results support a future controlled trial of HabitWorks for parents. Future studies are also needed to test whether targeting interpretation bias in parents has downstream effects on maladaptive parent behaviors and ultimately, child interpretation bias and anxiety.

Establishing the cause of unilateral leg pain is difficult in the settings of tibial diaphyseal sclerosis. This patient, a 36-year-old woman presented with unilateral pretibial leg pain for past 7 months without history of trauma, infections, systemic or metabolic disease. Besides local deep tenderness, other clinical findings and blood investigations were normal. Radiograph and CT scan showed both periosteal and endosteal cortical thickening with obliteration of medulla of the tibial midshaft. MRI scan detected marrow oedema and bone scan revealed increased tracer uptake at the affected site of tibia. She was treated by saucerisation and re-establishment of the medullary canal. Biopsy of the harvested tissue had trabecular bone without any sign of inflammation. Patient was pain free after 3 months of operation and was able to perform her activity of daily living without any difficulties. Ribbing disease is a disease of exclusion and need high degree of suspicion for its diagnosis.

A 36-year-old man with schizophrenia, on two times per day clozapine, presented with a 2-year history of diffuse intermittent body pain.Per chart review—and on presentation—his physical examination had been consistently unremarkable, without point-tenderness elicited at any major muscle groups or focal neurological deficits. Workup for myopathy, neuropathy and supratherapeutic clozapine levels had similarly been unrevealing.Given that prior interventions had been unsuccessful in alleviating these symptoms, we queried whether clozapine might have been contributory. As a result, we adopted a previously described strategy of scheduling the bulk of patients’ medication during non-waking hours.At 1-month follow-up, the patient reported about a 50% improvement in his symptoms. At 6-month follow-up, this improvement in symptoms had been sustained.Our findings add to the limited anecdotal reports of this side effect whose true prevalence remains unknown. Timely recognition has the potential to promote adherence to therapy among patients in the maintenance phase.

Granulomatosis with polyangiitis (GPA) is a rare disorder characterised by inflammation of small-sized and medium-sized blood vessels that result in damage to various organ systems, but it most commonly affects the respiratory tract and kidneys. It is one of the few entities that can present with ocular inflammation as well as renal impairment at the same time. We describe a case of a 38-year-old man with conjunctivitis, episcleritis, anterior uveitis as a first manifestation of GPA. His presentation with red eye and anterior uveitis prompted further workup, which revealed acute renal failure (creatinine 442 mmol/L), elevated inflammatory markers (erythrocyte sedimentation rate of 85 mmol/hour and C reactive protein of 72 mg/L), and a c-antineutrophil cytoplasmic antibody titre >8. An urgent renal biopsy was performed demonstrating necrotising crescentic glomerulonephritis, which led to the final diagnosis of GPA. Treatment induction with intravenous methylprednisolone and plasmapheresis followed by an oral prednisone taper and intravenous rituximab infusions leading to resolution of all symptoms and normalisation of kidney function. This report highlights conditions that can present with both ocular inflammation and renal dysfunction with a focus on GPA and its ocular manifestations.

Lymphoepithelial carcinoma (LEC) of the larynx is an extremely rare tumour which, unlike its nasopharyngeal counterpart, has shown a propensity to affect elderly Caucasian men and is not commonly associated with Epstein-Barr virus. We present a 70-year-old Chinese man who complained of hoarseness and dysphagia. Nasoendoscopy revealed a left supraglottic tumour. Preoperative MRI (in particular Diffusion Weighted Imaging) showed the possibility of two distinct components within a tumour. The patient underwent total pharyngolaryngectomy and bilateral selective neck dissection. The final histology report confirmed the presence of a tumour with two distinct components: predominant LEC with a smaller conventional (keratinising) squamous cell carcinoma component. The patient recovered well after surgery and subsequently underwent adjuvant radiotherapy. Final staging was pT3 N2c M0 (AJCC stage IVA). Follow-up over 2 years revealed no tumour recurrence.

Inherited thrombophilic disorders are well‐established predisposing factors for venous thromboembolism, but their role in arterial ischaemic stroke is uncertain. The exact mechanism of arterial thrombosis in thrombophilias remains elusive. Herein, we report a case of a 30-year-old woman who was admitted to our facility with sudden-onset right-sided ptosis and ophthalmoplegia. Detailed clinical features, neuroimaging and laboratory evaluation clinched the diagnosis of ischaemic stroke in midbrain due to microvascular obstruction associated with isolated protein S deficiency. She was treated with oral anticoagulant (warfarin) and physiotherapy; without any improvement of her symptoms at 2 months of follow-up. A high index of clinical suspicion is needed in any case of young ischaemic stroke in absence of common cardiac and vascular risk factors, to recognise the presence of inherited thrombophilia.

Porphyria cutanea tarda is the most common type of porphyria. It is associated with a deficiency of uroporphyrinogen decarboxylase enzyme responsible for heme synthesis. Clinical manifestations are predominantly dermatological and very rarely present with ocular involvement. Although scleral thinning in the interpalpebral area is a well-documented entity, sight-threatening corneal involvement is rarely described. We, herein report a case of a 58-year-old man who presented with ocular surface dryness, photophobia and mild redness. Slit-lamp biomicroscopy revealed corneo-scleral thinning in both eyes. The diagnosis was confirmed with a urine porphyrin test, serum iron and serum ferritin levels. We started him on conservative management after which he was lost to follow-up. He presented again after 6 years with total corneal opacification and progressive loss of vision in the right eye.

A 49-year-old man presented to our emergency department with dyspnoea and fluid overload. He denied any chest pain. Comorbidities included non-dilated ischaemic cardiomyopathy and bipolar affective disorder. An admission ECG demonstrated sinus rhythm with left bundle branch block (QRS duration=126

A 70-year-old woman who had been taking oral steroids with tapering after an acute exacerbation of idiopathic pulmonary fibrosis (IPF) was diagnosed with stage IIIB squamous cell lung cancer by transbronchial lung biopsy from left hilum 6 months before admission. At the time, she had anorexia due to