Search

The concept of atopy was initially developed in the first quarter of the 20th century on the basis of clinical observations without any knowledge of pathogenic mechanisms. Atopy involves a collection of comorbidities that share pathogenic features, and atopic comorbidities affect outcomes of concomitant conditions rather than existing synchronously. The clinical importance of understanding the relationship of these conditions is necessary because the treatment of one condition influences the others, and the development of one leads to or precedes the development of another. Environmental influences and multigenetic predispositions result in complex relationships among the atopic conditions sharing a type 2 pathogenesis. The specialty of Allergy and Immunology is devoted to managing the comorbidities of atopy, and better understanding of their connections can improve patient care.

Chickenpox is a common disease leading to a large number of clinical manifestations, ranging from mild spontaneously resolving forms to severe complicated cases requiring hospitalization and parenteral therapy. Despite the fact that this infection is benign in the majority of cases, it can lead to disseminated life-threatening processes in pregnant women and unimmunized newborns infected during the perinatal period, as well as it can cause intrauterine death and fetal abnormalities.Currently, there are no unified therapeutic approaches in the management of pregnant women with chickenpox. The nature and severity of infection in children depends on the moment of infection (before or after birth, intrapartum), the immune status of the mother against the human herpesvirus type 3 (HHV-3), the gestational age of the fetus and the presence of concomitant conditions.

Atrial fibrillation (AF) contributes to morbidity and mortality of millions of individuals. Its molecular, cellular, neurohumoral, and hemodynamic pathophysiological mechanisms are complex, and there is increasing awareness that a wide range of comorbidities can contribute to AF-promoting atrial remodeling. Moreover, recent research has highlighted that AF risk is not constant and that the temporal variation in concomitant conditions contributes to the complexity of AF dynamics. In this review, we provide an overview of fundamental AF mechanisms related to established and emerging comorbidities or risk factors and their role in the AF-promoting effects. We focus on the accumulating evidence for the relevance of temporally dynamic changes in these risk factors and the consequence for AF initiation and maintenance. Finally, we highlight the important implications for future research and clinical practice resulting from the dynamic interaction between AF risk factors and mechanisms.

Background Epicardial placement of the left ventricular (LV) lead via a video‐assisted thoracoscopic (VAT) approach is an alternative to the standard transvenous technique. Hypothesis Long‐term safety and efficacy of VAT and transvenous LV lead implantation are comparable. To test it, we reviewed our experience and we compared the outcomes of patients who underwent implantation with the two techniques. Methods The VAT procedure is performed under general anesthesia, with oro‐tracheal intubation and right‐sided ventilation, and requires two 5 mm and one 15 mm thoracoscopic ports. After pericardiotomy at the spot of the epicardial target area, pacing measurements are taken and a spiral screw electrode is anchored at the final pacing site. The electrode is then tunneled to the pectoral pocket and connected to the device. Results 105 patients were referred to our center for epicardial LV lead implantation. After pre‐operative assessment, 5 patients were excluded because of concomitant conditions precluding surgery. The remaining 100 underwent the procedure. LV lead implantation was successful in all patients (median pacing threshold 0.8 ± 0.5 V, no phrenic nerve stimulation) and cardiac resynchronization therapy was established in all but one patient. The median procedure time was 75 min. During a median follow‐up of 24 months, there were no differences in terms of death, cardiovascular hospitalizations or device‐related complications vs the group of 100 patients who had undergone transvenous implantation. Patients of both groups displayed similar improvements in terms of ventricular reverse remodeling and functional status. Conclusions Our VAT approach proved safe and effective, and is a viable alternative in the case of failed transvenous LV implantation.

Patients with vertebral artery injury from penetrating neck trauma may not present with signs of vascular injury because of anatomical characteristics and concomitant conditions, such as hypothermia and shock. If patients are hemodynamically stable, imaging tests should be performed to examine the posterior components, including the vertebral artery., Although the “zone” approach may be useful for the surgical treatment of injuries to the anterior components of the neck, the “no zone” approach using imaging techniques should be applied when searching for posterior components, including the vertebral artery.

BACKGROUND A growing amount of evidence has suggested that 1,25-dihydroxyvitamin D [1,25(OH)2D]-mediated hypercalcemia can be found not only in lymphoma and granulomatous disorders, but also in solid organ malignancies. Using systematic review technique, we aimed to summarize all available evidence of possible 1,25(OH)2D-mediated hypercalcemia in patients with solid organ malignancies. METHODS Potentially eligible articles were identified from MEDLINE and EMBASE databases from inception to December 2020 using search strategy consisting of terms related to "Vitamin D", "Hypercalcemia" and "Malignancy". Eligible article must be either case report or case series that reports individual level data of a patient or patients with hypercalcemia associated with solid organ malignancy and elevated 1,25(OH)2D without concomitant conditions that may otherwise explain 1,25(OH)2D-mediated hypercalcemia. Characteristics of the patients were extracted from each study. Eligible cases were categorized into three groups, including "definite", "probable" and "possible" cases, using the criteria to assess the strength of evidence that hypercalcemia observed in the eligible cases was caused by the presence of tumor that resulted in the increased production of 1,25(OH)2D. RESULTS A total of 1,673 articles were identified. After systematic review, 17 articles reporting 17 patients with 11 different types of solid organ malignancies associated with hypercalcemia secondary to elevated 1,25(OH)2D were identified. Based on the criteria to assess the strength of evidence of hypercalcemia mediated by tumor-associated increased production of 1,25(OH)2D, there were 4 definite cases and 13 probable cases. CONCLUSIONS This systematic review of case reports and case series revealed 17 patients with 11 different types of solid organ malignancies associated with hypercalcemia and elevated 1,25(OH)2D.

Aims Treatment patterns were compared between randomized groups in EAST-AFNET 4 to assess whether differences in anticoagulation, therapy of concomitant diseases, or intensity of care can explain the clinical benefit achieved with early rhythm control in EAST-AFNET 4. Methods and results Cardiovascular treatment patterns and number of visits were compared between randomized groups in EAST-AFNET 4. Oral anticoagulation was used in >90% of patients during follow-up without differences between randomized groups. There were no differences in treatment of concomitant conditions between groups. The type of rhythm control varied by country and centre. Over time, antiarrhythmic drugs were given to 1171/1395 (84%) patients in early therapy, and to 202/1394 (14%) in usual care. Atrial fibrillation (AF) ablation was performed in 340/1395 (24%) patients randomized to early therapy, and in 168/1394 (12%) patients randomized to usual care. 97% of rhythm control therapies were within class I and class III recommendations of AF guidelines. Patients randomized to early therapy transmitted 297 166 telemetric electrocardiograms (ECGs) to a core lab. In total, 97 978 abnormal ECGs were sent to study sites. The resulting difference between study visits was low (0.06 visits/patient/year), with slightly more visits in early therapy (usual care 0.39 visits/patient/year; early rhythm control 0.45 visits/patient/year, P Conclusion The clinical benefit of early, systematic rhythm control therapy was achieved using variable treatment patterns of antiarrhythmic drugs and AF ablation, applied within guideline recommendations.

Significance: Chronic venous disease (CVD) is prevalent in the aging population and leads to venous leg ulcers (VLUs). These wounds can last and recur for years, significantly impacting quality of life. A large body of literature exists on CVD and VLU diagnosis and treatment. Multiple algorithms, guidelines, and consensus documents have been published on this topic, highlighting the importance of this issue in clinical practice. However, these documents are not fully aligned with each other. Recent Advances: The latest update of the internationally used classification system for CVD was recently published. Our review aims to summarize the existing information to provide an educational tool for clinicians new to this topic, and to highlight the commonalities between the published recommendations. Critical issues: VLUs need to be treated with consideration for the extent of venous disease present in the patient. This requires a good understanding of the various components involved and the possible additional concomitant conditions by the first-line clinician who encounters the patient. A multidisciplinary team is necessary for a successful overall treatment plan, and this plan should be tailored to each patient's specific needs and lifestyle. Future Directions: Compression is still the mainstay of treatment for CVD and VLUs. Compression is needed long term, but it does not suffice by itself to prevent recurrences without interventional correction. Venous intervention should be offered early to prevent or slow disease progression and reduce recurrence.

The development of perianal ulcers related to the use of a hemorrhoidal ointment has not been reported in the literature. We describe a series of 11 patients who were treated for perianal ulcers in 10 Spanish hospitals after they used the same ointment containing the active ingredients triamcinolone acetonide, lidocaine, and pentosan polysulfate sodium. No prior or concomitant conditions suggesting an alternative cause for the condition could be identified, and after the patients stopped using the ointment, their ulcers cleared completely in 8 weeks on average. This case series shows the damage that can be caused by an over-the-counter pharmaceutical product used without medical follow-up. It also illustrates the need to ask patients with perianal ulcers about any topical agents used before the lesions appeared.

У статті наведено актуальні алгоритми ведення пацієнтів із йододефіцитом, у тому числі оптимальний комплекс лабораторної оцінки тиреоїдного статусу перед призначенням терапії — визначення рівнів ТТГ, вільн. Т4 (та вільн. Т3), АТПО (та АТТГ), при підозрі на гіпертиреоз — визначення антитіл до рецептора ТТГ стимулюючих, за наявності додаткового утворення в ділянці щитоподібної залози — визначення рівнів паратгормону, кальцію іонізованого, 25-гідроксивітаміну D, кальцитоніну. Обґрунтовано необхідність ураховування інтерферуючих факторів, які впливають на результати досліджень (супутні стани у пацієнта, приймання препаратів, дотримання пацієнтом умов преаналітичного етапу), у тому числі можливість отримання хибних результатів, якщо пацієнт приймає препарати біотину та лабораторне до- слідження проводилося за біотин-залежною методикою імуноаналізу.

Background Hidradenitis suppurativa is a chronic recurrent systemic inflammatory disease that mainly involves large skin folds. It develops when pilosebaceous units become blocked, leading to the formation of painful nodules, abscesses, fistulas, and scarring. The impact of this disease on quality of life is great. Objectives To describe the prevalence and clinical features of hidradenitis suppurativa in patients treated at Hospital Italiano de Buenos Aires and determine the frequency of comorbidities and time to diagnosis in this population. Material and methods Retrospective descriptive cross-sectional study. Information was extracted from the computerized clinical records of all patients with a diagnosis of hidradenitis suppurativa managed in Hospital Italiano de Buenos Aires between July 2012 and October 2017. Results Our initial search of the records yielded 180 cases; the diagnosis was confirmed in 66 cases. Sixty-five percent of the patients were women, and the mean age was 37 years. The prevalence of this diagnosis was 0.02%. The armpits, vulva, and groin were the locations most frequently affected. Smoking, overweight, and obesity were the most commonly recorded concomitant conditions. Male sex and perianal and gluteal locations were associated with severity. Time until diagnosis varied widely, ranging from diagnosis at the first visit in some cases to as long as 142 months and 21 visits. Conclusions Our findings are consistent with the literature on hidradenitis suppurativa. This is the first Argentinian study to describe the prevalence of this disease as well as the concomitant conditions found and the rate of diagnostic error.

Recent studies show that perennial allergic rhinitis is prevalent among older people, but the management of this disease is underestimated and not determined. This article describes the persistent allergic rhinitis in patients of the older age group and identifies the primary goals of treatment based on the age-related physiological factors, concomitant conditions and the use of other drugs. Special attention is paid to the various options for the drug therapy in elderly patients over the age of 60 years. The second-generation antihistamines and intranasal glucocorticosteroids also have primacy over other drugs, when supervising older patients. A randomized open multicenter clinical study showed that Momate Rhino Advance (a combination of intranasal antihistamines (azelastine) and intranasal glucocorticosteroids (mometasone) for the treatment of allergic rhinitis) made by Indian Glenmark Pharmaceuticals Ltd. is effective and safe in patients aged 60 years and older, who are diagnosed with the above disease.

Mild cognitive impairment (MCI) associated with physical frailty gave rise to the new concept of cognitive frailty. Previous studies have suggested that MCI may represent a condition that precedes Alzheimer's disease (AD), in view of its higher conversion rate to dementia, when compared with the conversion rate of cognitively healthy older adults. Therefore, and considering that MCI represents a reversible condition, the identification of biomarkers for this condition is imperative to early diagnosis. Accordingly, this study aimed to assess whether the platelet and plasma levels of ADAM10 could be related with the concomitant conditions of MCI and physical frailty, in order to support a new blood-based biomarker for the construct of cognitive frailty. Sixty-one adults aged 60 years or older participated in this study. The results showed that ADAM10 levels are reduced in platelets (p < 0.05) and increased in plasma (p < 0.05) of older adults with MCI compared to healthy controls, regardless of the physical frailty condition. The analysis of the ROC curve of ADAM10 in platelets showed sensitivity and specificity of 72.7 and 73.9%, respectively, to correct differentiate between participants with preserved cognition from those with MCI. For plasma samples, ADAM10 presented 62.5 and 90.0%, sensitivity and specificity respectively, to differentiate the aforementioned conditions. Together with other clinical criteria blood ADAM10 could be a relevant, low-invasive, low-cost and fast processing biomarker tool to help in the early and accurate diagnosis of MCI, however this marker was not able to identify cognitive frailty.

Comorbidity is a noun that describes the simultaneous presence of two chronic diseases or conditions in a patient. It is a given that medical illness is common in psychiatric patients and that psychiatric pathology is common in medical conditions. In the following pages, we will attempt to provide a clinical approach to concomitant conditions, rather than a laundry list of diagnoses.

Objetivo: identificar el nivel de conocimiento de los criterios diagnósticos de fibromialgia en los médicos reumatólogos del Perú. Materiales y métodos: estudio descriptivo transversal. Al XX Congreso Peruano de Reumatología realizado del 22 al 24 de noviembre de 2018 en Lima, Perú, asistieron 150 médicos reumatólogos peruanos de los cuales se encuestaron a 96 médicos. Se aplicó un cuestionario previamente elaborado y validado teniendo en cuenta los criterios de fibromialgia del Colegio Americano de Reumatología de 2010. El análisis estadístico descriptivo se realizó con el paquete estadístico SPSS. Resultados: la mayoría de reumatólogos fueron varones (58,3%) de 25 a 40 años de edad (47,9%). El 33,3% tenía más de 20 años de egresado, el 43,8% refirió que asiste una vez por año a congresos de reumatología, el 27,1% ejerce la docencia en algún centro de estudios superiores y el 40,6% identifica de uno a dos casos nuevos de fibromialgia por año. El 57,3% presentó un nivel de conocimiento regular sobre fibromialgia; más de la mitad sabía que el diagnóstico es clínico, conocía el grupo etario característico, sabía de las entidades que coexisten frecuentemente con fibromialgia y de las comorbilidades de salud mental, además, de los exámenes auxiliares para el diagnóstico diferencial. Sin embargo, más del 90% desconocía las enfermedades con síntomas parecidos. No se encontraron diferencias significativas del nivel de conocimiento sobre fibromialgia según edad (p=0,762), sexo (p=0,732) ni años de egresado (p=0,615). Conclusiones: el nivel de conocimiento de los criterios diagnósticos de fibromialgia en los médicos reumatólogos del Perú es regular.

© The Authors 2020., Both malnutrition (which here refers to undernutrition) and obesity are prevalent in older adults, but they are frequently seen as mutually exclusive. In fact, a low body mass index (BMI) is one of the aetiological diagnostic criteria for malnutrition. On the contrary, the concomitant presence of malnutrition and obesity has been less studied. The aim of this study was to characterise the nutritional status of community-dwelling older adults (≥ 65 years old) living in Portugal. The study included a nationally representative sample of randomly selected community-dwelling older adults. Trained nutritionists collected data through face-to-face structured interviews regarding sociodemographic characteristics, nutritional status and anthropometric measures (namely, weight and height), among other variables of the PEN-3S study. Nutritional status was assessed by the 18-item Mini Nutritional Assessment (full MNA®), in which a lower score indicates worse nutritional status. The World Health Organisation’s (WHO) BMI cut-offs for adults were followed (obesity: BMI ≥ 30Kg/m2 ). MNA and BMI categories estimates (95% CI) were obtained using Complex Samples analysis (SPSS® 24.0). Non-difference between sexes was analysed with Chi-square tests. Complete information was available for 1110 community-dwelling participants (mean age: 75.9 ± 8.1 years; 48.9% women; 71.4% attended school for < 5 years). According to the MNA, 0.5% (95%CI: 0.2–1.7) were classified as malnourished and 16.0% (12.9–19.7) were at risk of malnutrition. Following WHO’s BMI criteria, 0.6% (0.2–1.5) had a BMI ≤ 18.5Kg/m2 , 41.9% (37.9–46.0) had a BMI between 25–30Kg/m2 , and 36.7% (32.8–40.9) presented a BMI ≥ 30Kg/m2 . The prevalence of risk of malnutrition was significantly higher for women (20.1%, 95% CI: 15.4–25.9) than men (10.4%, 7.6–14.1; p < 0.001). The prevalence of obesity was also significantly higher for women (42.2%, 35.9–48.7 versus 29.3%, 24.8–34.2; p = 0.007). Moreover, 13.9% (9.2–20.4) were simultaneously at risk of malnutrition and had a BMI ≥ 30Kg/m2 , while no one in this BMI category was classified as malnourished. Although appropriate BMI cut-offs for older adults are still uncertain, these results highlight that a high BMI does not exclude the risk of malnutrition, particularly in women. Therefore, health professionals should routinely screen for malnutrition using multi-component, validated screening tools, irrespective of the BMI. In fact, malnutrition is preventable if detected on time and effective interventions exist. The concomitant presence of malnutrition and obesity may pose additional challenges to the treatment.

Situs inversus totalis is a rare recessive autosomal congenital abnormality in which the mediastinal and abdominal organs are in a mirrored position when compared to the usual topography. The literature reports some cases of situs inversus totalis and concomitant conditions: spinal abnormalities, cardiac malformations and hematological diseases, such as idiopathic thrombocytopenic purpura, which is an autoimmune disease that causes thrombocytopenia due to platelet destruction or suppression of its production. This article aimed to report the coexistence of situs inversus totalis and idiopathic thrombocytopenic purpura.

Chronic rhinosinusitis (CRS) is a common comorbidity in patients with asthma, and they share similar pathophysiologic mechanisms. The concomitant conditions of CRS and asthma can significantly exacerbate each other. The medical and/or surgical treatment of CRS may significantly improve asthma control.

Drug-induces and other iatrogenic lesions of kidney in HIV patients are inevitable upon ART and a therapy for the main opportunistic and concomitant conditions. Besides the direct effects of HIV, the side effects of drugs, such as acute renal lesions, crystal nephropathy, glomerulonephritis, acute and chronic renal failure, and functional renal impairments, are associated with poor ART efficacy and unfavorable prognosis and outcome. In the present paper, the morphological and clinical manifestations of ART-induced renal lesions are described. The main approaches to the early diagnostics of and screening for kidney lesions are suggested. The significance of the most prevalent functional and clinical renal disorders routinely encountered by physicians is evaluated.

Testosterone (T) is deeply involved in every step of the male sexual response. However, the occurrence of sexual disorders cannot be automatically related to a decline in T levels. In fact, this relationship is complicated by organic, relational and psychological factors, which can independently impair sexual function. For example, it is recognized that erectile dysfunction (ED) can result from vascular damage as well as from low levels of T. T therapy (TTh) can improve sexual function but meta-analyses show that it improves erectile function only in men with ED and overt hypogonadism. Similarly, impaired sexual desire can result from a wide range of organic, relational and psychological factors, although it is recognized as one of the most specific symptoms of hypogonadism. Accordingly, low desire is improved by TTh in men with overt hypogonadism. The association between low T levels and delayed ejaculation has not been well studied and needs further confirmation, as does the role of TTh in such cases. Meta-analyses have found that TTh can improve orgasmic function in hypogonadal men. Clinicians should bear in mind that sexual dysfunctions have multifactorial causes and hypogonadism represents only one of these. Only hypogonadal men are likely to improve their sexual symptoms when treated with TTh. The assessment of serum T levels is mandatory before patients are prescribed TTh, as are the assessment and possible treatment of other concomitant conditions.

Injections about the shoulder serve diagnostic as well as therapeutic purposes. Diagnosis of shoulder conditions, such as rotator cuff tears, acromioclavicular joint pathology, subacromial impingement or anterolateral pain syndrome, glenohumeral joint pathology, suprascapular nerve entrapment, and biceps tendon pathologies, is often complicated by concomitant conditions with overlapping symptoms and by inconclusive physical examination and imaging results. Injections of anesthetic agents can often help clinicians locate the source of pain. However, technique and accuracy of needle placement can vary by route. Accuracy is often improved with the use of ultrasonography guidance, although studies differ on the benefits of guided versus unguided injection.

This paper explores the multiple ways experiences of pregnancy and early motherhood come to 'rework' the biographies of women living with epilepsy. Pregnancy is explored as a temporarily concurrent status alongside the long-term condition of epilepsy. Narrative interviews were conducted with 32 women from across the UK. Analysis of these narratives suggests that biographical disruption and continuity are both useful in the conceptualisation of women's diverse experiences of pregnancy and epilepsy. Such findings challenge the notion that the presence of a condition over a long period of time leads to the normalisation of illness. Participants' narratives demonstrate that, for some, pregnancy and early motherhood may be disruptive and can raise concerns regarding an ever present condition that may previously have been taken for granted. Findings also indicate the need for a greater consideration of gender and care responsibilities, as well explorations of concomitant conditions, in the theorising of biographies and chronic illness.

Surgical and hybrid lead extraction has developed considerably over the past several decades. Although transvenous lead extraction is the standard approach to remove infected or malfunctioning cardiac implantable electronic device leads, surgical approaches may be necessary in complex cases not amenable to transvenous lead extraction or in cases that involve concomitant pathologies, such as tricuspid valve regurgitation. We describe our experience with 4 minimally invasive surgical approaches to lead extraction as well as our experience with hybrid open heart surgery and transvenous lead extraction as an option for patients who present with concomitant conditions.

Cardiac implantable electronic devices (CIEDs) have been in use for over 50 years and their therapeutic value is undisputable. With the rapidly aging population, it is estimated that the number of CIEDs will grow dramatically over the next 2 decades. Given these predictions, the topic of management of concomitant conditions associated with older age becomes more relevant than ever. In particular, the number of patients with an implanted CIED diagnosed with cancer is expected to rise by about 70%, from 14 million in 2012 to 22 million within the next 2 decades. Treatment of most of these tumors and tumor metastases requires radiation therapy. However, the necessary high doses of radiation can potentially interact with the function, longevity, and integrity of the CIEDs and/or cause harm to the patient. The impact of an absence of clear therapeutic guidelines for oncology patients with CIEDs who should undergo radiation therapy is vast; and due to the fear of possible complications related to device failure, many of these patients may not be treated adequately to their needs, which can strongly affect their prognosis. This article summarizes the available data on the management of patients with CIEDs undergoing radiotherapy. It systematically presents possible causes and consequences of direct and scattered radiation on CIEDs, highlights possible complications that may occur during this kind of treatment, and provides practical guidance for this challenging real life clinical setting.

Treatment-resistant hypertension, or resistant hypertension, is defined as blood pressure that remains above target despite concurrent use of at least three antihypertensive agents from different classes at optimal doses, one of which should be a diuretic. Important considerations in the diagnosis of treatment-resistant hypertension include the exclusion of pseudoresistance and the evaluation of potential secondary causes of hypertension and of concomitant conditions that maintain high blood pressure. The ability to diagnose true treatment-resistant hypertension is important for selection of patients who may be appropriately treated with an invasive therapy. Currently, there are three interventional approaches to treat resistant hypertension, namely: (1) reduction of the activity of the sympathetic nervous system by renal nerve ablation, (2) stimulation of baroreceptors and (3) creation of a peripheral arterial venous anastomosis. This review focuses on the rationale behind these invasive approaches and the clinical results.

Objectives To determine whether long-term treatment with dopaminergic agents (DAs) might dampen the response to a non-dopaminergic agent, such as gabapentin enacarbil. Methods We performed a two-week randomized, double-blind, crossover, and placebo-controlled study in a single, referral center in dopamine treatment-naive patients and non-augmented patients continuously treated with dopaminergics for the last five consecutive years. Following washout from any previous CNS-active drugs, patients were randomized into one of two groups for two consecutive two-week treatment periods with gabapentin enacarbil (GBPen) and placebo. Treatment was administered at 7 PM at a fixed dose of 600 mg/day. RLS severity was measured weekly using the International RLS Scale (IRLS) and Clinical Global Improvement (CGI). An M-SIT was also performed between 6 pm and midnight at the end of each treatment condition. Results There were no significant differences between groups in age, sex, duration of disease, ferritin levels, RLS severity at baseline, or existing concomitant conditions. Both groups improved more during treatment with GBPen than during placebo on the IRLS scale, CGI and mSIT. However, improvements were greater in the DA-naive group than in long-term treatment with DAs group on the IRLS (p Conclusions Previous long-term treatment with DAs reduces future response to GBPen in RLS patients. Potential pathiophysiological explanations are discussed. Our finding has strong implications for the initial choice of treatment in RLS and supports the notion that initial treatment should not be started with DAs. Classification of evidence The study provides class II evidence supporting reduced effects of gabapentin enacarbil in RLS patients previously exposed to long-term treatment with dopamine agonists.

Purpose of review: The current review focuses on the neonatal presentation of disorders of sex development, summarize the current approach to the evaluation of newborns and describes recent advances in understanding of underlying genetic aetiology of these conditions.\ud \ud Recent findings: Several possible candidate genes as well as other adverse environmental factors have been described as contributing to several clinical subgroups of 46,XY DSDs. Moreover, registry-based studies showed that infants with suspected DSD may have extragenital anomalies and in 46,XY cases, being small for gestational age (SGA), cardiac and neurological malformations are the commonest concomitant conditions.\ud \ud Summary: Considering that children and adults with DSD may be at risk of several comorbidities a clear aetiological diagnosis will guide further management. To date, a firm diagnosis is not reached in over half of the cases of 46,XY DSD. Whilst it is likely that improved diagnostic resources will bridge this gap in the future, the next challenge to the clinical community will be to show that such advances will result in an improvement in clinical care.

Background: Epicardial placement of the left ventricular (LV) lead is an alternative approach to the standard cardiac resynchronization therapy (CRT) procedure. In our center we developed a minimally invasive thoracoscopic technique. We reviewed our experience to evaluate the long-term safety and effectiveness of the technique. Methods: The procedure is performed under general anesthesia with oro-tracheal intubation and right-sided ventilation, and requires 3 thoracoscopic ports (two 5-mm and one 15-mm). We analyzed 94 consecutive patients referred to our center for epicardial LV lead implantation. Results: Five patients were excluded because of concomitant conditions precluding surgery or lack of indication for CRT. The remaining 89 patients underwent the procedure. Of these, 57 had undergone previous unsuccessful LV lead implantation (Group 1). In the remaining 32 patients, effective CRT was discontinued owing to LV lead dislodgment (Group 2). LV lead implantation was successful in all patients (median pacing threshold 0.8V, IQR: 0.6-1.2, at 0.5 ms, no phrenic nerve stimulation) and CRT was successfully established in all but one patient. No complications were reported, except for 2 cases of transitory peri-electrode bleeding and 3 cases of ventricular fibrillation induced during the procedure (no sequelae). The median procedure time was 75 min (IQR: 55-95). During a median follow-up of 24 [IQR: 13-39] months, 21 patients died and 4 additional device-related complications were reported (comparable rates between groups). Conclusions: Our thoracoscopic approach proved to be safe and effective. It is a viable alternative to the standard transvenous approach in the case of failed de novo implantation and in those patients who positively respond to CRT but experience LV lead dislodgment.

Actinomycosis is a chronic, opportunistic infection caused by Actinomyces species, such as Actinomyces bacillus. Actinomycosis in long bones is very rare. To the best of our knowledge, isolated primary actinomycosis of the humerus is rarely reported in literature. We present a rare case of a refractory primary actinomycosis of the humerus. A 66-year-old man with no history of concomitant conditions was admitted to our hospital with a history of a tumour on the distal third of the left arm as a result of a closed trauma without fracture 20 years before. Pathological anatomy samples showed the presence of Actinomyces. Cultures were subjected to a prolonged incubation of 21 days under aerobic and anaerobic conditions and were always negative. He underwent several surgical procedures and received long-term antibiotic therapy with poor outcome. Primary actinomycosis in long bones is uncommon. Diagnosis may be challenging: considering the small number of case studies reported in the literature, symptoms are not specific, and the organism is difficult to isolate. Antibiotic treatment may not be sufficient to improve the clinical condition, and surgical alternatives should be considered

In Roux-en-Y reconstructions, choledocholithiasis could represent a really challenging condition to treat which can be treated by a surgical-assisted ERCP. Only six cases of transjejunal laparoscopic-assisted ERCP (LAERCP) can be found in literature to date and no large series are present. A young woman who had undergone a laparoscopic Roux-en-Y gastric bypass 2 years earlier came complaining recurrent abdominal pain. Radiologic exams found stones in the common bile duct and no signs of internal hernia. We therefore decided to perform a transjejunal LAERCP finding a concomitant internal hernia in the Petersen’s space which was repaired at the same time. The post-operative course was uneventful. Transjejunal LAERCP is a feasible technique to deal with choledocholithiasis, and it allows at the same time to identify and treat concomitant conditions like internal hernias.

Management of patients with severe immune-mediated uveitis requires the use of immunosuppressive drugs in selected cases. This may be especially challenging in certain patients with concomitant conditions, which could increase the risk of side effects or modify guidelines for the use of such drugs. Therapeutic decision-making and management may be of particular difficulty in pregnancy as well as in patients with associated malignancies unrelated to a specific ophthalmic inflammatory condition.The main aim of this review is to provide an updated comprehensive practical guide for practitioners regarding the therapeutic decision-making and management of patients with severe immune-mediated uveitis in the context of pregnancy and malignancies.Management of patients with immune-mediated uveitis requiring immunosuppressive/immunomodulatory drugs might be particularly complicated by other conditions affecting their health and immune status. Clinicians should take into account such conditions, which might influence treatment response and the clinical outcome of these patients.

Several observational studies have clearly shown a significant relationship between low testosterone (T) and a higher cardiovascular (CV) risk profile [1]. However, it is not completely known whether reduced T levels in elderly males might play a direct pathogenetic role in the stratification of CV risk, or if CV diseases (CVD) and low T are concomitant conditions, both associated with the aging process. Much evidence supports both of these possibilities. In their work, Walsh and Kitchens [2] elegantly reviewed the available evidence. After a short overview on physiology of T production and regulation, Walsh and Kitchens [2] faced the complicated issue of the relationship between hypogonadism and CVD, based on epidemiological studies. One of their first conclusions is that low T is more a marker of poor health than a cause of symptoms and clinical outcomes. Accordingly, three distinct meta-analyses [1,4,5] have reported an association between low T and an increased CV mortality, but they failed to demonstrate a relationship with CV morbidity. We previously hypothesized that the reduction of T in unfavorable situations represents a resilient, protective mechanism, turning off T-dependent functions (such as physical and sexual activity) that are not desirable when the physical condition, including CV function, is ailing. CVD-associated hypogonadism might also represent a restraint to male fertility, thus limiting fatherhood in unhealthy conditions such as malnutrition, obesity, or CVD. In fact, in these unfavorable conditions, it was found that an increased testis volume was a positive predictor of incident CV events [6,7], in particular, in those having had a previous CV event [7]. Subjects that are less healthy and frailer, because they are affected by overt or

The stricturing and fistulizing forms of Crohn’s disease (CD) exhibit many different results to clinical treatment and good response to surgical therapy. The prevalence of strictures in CD ranges from 12 to 54% and they are more frequently in patients with longer disease duration, and the terminal ileum is the most commonly affected location. The pharmacobezoars can be formed in any part of the gastro-intestinal tract and are often associated with factors predisposing anatomic, functional or other concomitant conditions. The pharmacological properties of drugs may contribute to the pathophysiology of bezoars. The objective of this case report is to alert for the importance of the qual-ity of prescribed medications that are used by patients with CD, through the finding of more than 350 tablets of mesalazine during the surgical treatment of a patient with the fibrostenotic pattern. Keywords: Crohn’s disease; intestinal obstruction; constriction, pathologic; mesalazine; surgery.

The problems that a patient experiences after the creation of a temporary or permanent stoma can result from many factors, but a carefully constructed stoma located in an ideal location is typically associated with appropriate function and an acceptable quality of life. The construction of the stoma can be confounded by many concomitant conditions that increase the distance that the bowel must traverse or shorten the bowel's capacity to reach. Stomas can be further troubled by a variety of problems that potentially arise early in the recovery period or months later. Surgeons must be familiar with these obstacles and complications to avoid their occurrence and minimize their impact.

The prompt and accurate diagnosis of pulmonary embolism (PE) greatly influences patient outcomes. However, diagnosing PE is one of the most difficult challenges confronting physicians, even more so when the clinical suspicion is addressed in children, during pregnancy, or in elderly patients. In these patient groups, symptoms and signs from concomitant conditions or diseases may mimic PE and make difficult defining clinical probability categories for PE as usually applied to general adult patients. Moreover, the diagnostic techniques show wider, specific limitations in these settings. PE is considered rare in children. The diagnostic management of a child with suspected PE is largely extrapolated from the knowledge achieved in adult patients. An increased risk of venous thromboembolism is reported in all trimesters of pregnancy and in the puerperium. An accurate diagnosis of PE in pregnancy has important implications, including the need for prolonged anticoagulation, delivery planning, and prophylaxis during future pregnancies, as well as concerns about future oral contraceptive use and estrogen therapy. Although incidence, morbidity, and mortality increase steadily with age, PE remains an underdiagnosed disease in elderly patients. About 40% of PE found at necropsy were not suspected antemortem. In the present article, challenges in diagnosing PE in children, during pregnancy, and in the elderly will be discussed, reviewing the available clinical, laboratory, and instrumental diagnostic strategies.

The reported efficacy of various treatments for alopecia is difficult to compare based on a general lack of consideration in case reports/series and clinical trials of the spontaneous regrowth or baseline prognostic factors seen in alopecia areata and a general lack of quantification of hair growth. This report will give both the investigator and clinician guidelines for clinical trial design that will take into account variables known to effect efficacy results such as baseline severity, pattern, and duration of hair loss, age of the subject, and concomitant conditions that may impact on potential regrowth. Reliable methods of assessment of efficacy and response criteria that will enable direct comparison of results between agents will also be discussed.

Patients with rosacea frequently present with coexisting skin conditions, such as seborrheic dermatitis, acne, perioral dermatitis, and melasma, which may complicate diagnosis and treatment. This article discusses the presentation, pathophysiology, and management of rosacea with common concomitant skin disorders.

Aim. Тo study the oral health among the poor citizens and the implementation of the program of preferential prosthetic dentistry in the Republic of Bashkortostan. Methods. The study involved 80 patients with prosthetic dentistry in the past who were asked to complete a survey questionnaire and underwent clinical examination. Statistical processing was performed using Microsoft Excel and Statistica 6.0 software. Results. Secondary partial adentia prevailed in poor, reaching 83.75%, with secondary complete adentia reaching 16.25%. The average age of patients was 63.4 years: female patients - 64.66 years, male patients - 67.25 years. 100% of patients had concomitant somatic diseases, with most of the patients having 2-3 comorbidities. Among concomitant conditions, musculoskeletal diseases were observed in 71% of cases, cardiovascular diseases - in 50% of cases, endocrine diseases - in 35% of cases. 86.25% of patients named financial strait as the main cause of a late visit to a dentist, the remaining 13.75% indicated a lack of time, poor health and unwillingness to care for themselves as the reason. Conclusion. Low-income patients need further support in preferential dentistry and oral health examination.

This article reports on 45 cases in which extra-articular ossifications were removed following cranial-cerebral traumata. Radiologically detectable relapses occurred in 6% of the patients only; however, in none of these cases did the relapses lead to reankylosis of the joint. In the sagittal plane, the average gain in mobility was an increase of 84 degrees in the hip joint and of 100 degrees in the elbow joint. Considerable complications were caused by four fractures in extremely osteoporotic bones. To reduce the fracture rate, surgery should be performed as soon as possible after bone maturation. In addition, treatment of patients with craniocerebral traumata and serious concomitant conditions requires an experienced rehabilitation team.

On Swedish women's distressing sexual dysfunctions: : Some concomitant conditions and life satisfaction

SUMMARYObjectives: The goals of this presentation are to review the American College of Rheumatology [ACR] research classification criteria for the fibromyalgia syndrome [FMS] and to show how they facilitate the differential diagnosis of pain in a variety of clinical presentations.Findings: The ACR criteria were developed directly from a research validation study and apply best to that setting. In lieu of a better resource, these criteria have been applied to community clinical practice as well. The design of the ACR Criteria study is outlined. The results show how the ACR Criteria directly follow the study findings. In patients with chronic widespread pain, the presence of 11 of 18 anatomically defined tender points [TePs] sufficiently sensitized to be painful when stimulated by four kilograms of digital pressure identified FMS irrespective of concomitant conditions, including conditions with the potential to cause pain. The ACR criteria depend only on pain, so they do not take into consideration other c...

Glucocorticoids are the mainstay of treatment for patients with polymyalgia rheumatica (PMR) and often produce substantial clinical improvements, but treatment can be complicated by relapse, adverse effects of therapies, and concomitant conditions. New recommendations aim to guide clinicians and improve the management of this disorder.