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Background: Frozen Shoulder is a painful shoulder condition with insidious onset that was associated with stiffness and loss of motion in the shoulder joint. Mulligan Mobilization with Movement for shoulder joint combines sustained manual application of ‘gliding’ force to a joint, with the aim of repositioning the positional faults with concurrent physiological motion of the joint. Kinesiotaping improves glenohumeral motions and reduces microtrauma and mechanical irritation of soft tissue structures and reorient shoulder movements through arc of improved glenohumeral motion. Objective: To compare effect of Mulligan Mobilization with Movement and Kinesiotaping on pain and active shoulder range of motion using VAS and universal goniometer. Method: 30 subjects were selected as per inclusion and exclusion criteria and were randomly allocated into 2 groups of 15 each. Group A received Mulligan Mobilization with Movement and Group B received Kinesiotaping for shoulder joint. Pre and Post intervention shoulder external rotation, abduction and internal rotation range of motion and VAS scores were analysed. Result: The statistical analysis showed that there is a significant increase in range of motion and significant reduction in pain scores post intervention in both the groups (p

Purpose To determine classification criteria for juvenile idiopathic arthritis (JIA)-associated chronic anterior uveitis (CAU). Design Machine learning of cases with JIA CAU and 8 other anterior uveitides. Methods Cases of anterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the anterior uveitides. The resulting criteria were evaluated on the validation set. Results One thousand eighty-three cases of anterior uveitides, including 202 cases of JIA CAU, were evaluated by machine learning. The overall accuracy for anterior uveitides was 97.5% in the training set and 96.7% in the validation set (95% confidence interval 92.4, 98.6). Key criteria for JIA CAU included 1) chronic anterior uveitis (or if newly diagnosed insidious onset) and 2) JIA, except for the systemic, rheumatoid factor-positive polyarthritis, and enthesitis related arthritis variants. The misclassification rates for JIA CAU were 2.4% in the training set and 0% in the validation set, respectively. Conclusions The criteria for JIA CAU had a low misclassification rate and appeared to perform well enough for use in clinical and translational research.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary surfactant homeostasis disorder resulting in buildup of lipo-proteinaceous material within the alveoli. PAP is classified as primary (autoimmune and hereditary), secondary, congenital and unclassifiable type based on the underlying pathogenesis. PAP has an insidious onset and can, in some cases, progress to severe respiratory failure. Diagnosis is often secured with bronchoalveolar lavage in the setting of classic imaging findings. Recent insights into genetic alterations and autoimmune mechanisms have provided newer diagnostics and treatment options. In this review, we discuss the etiopathogenesis, diagnosis and treatment options available and emerging for PAP.

Paro cardiaco en salas de recuperacion posanestesica, entidad poco frecuente en esterilizacion tubaria. Factores descencadenantes como sobresedación, bloqueo espinal alto,uso de opiodes, toxicidad sistemica por anestesicos locales. La ligadura de trompas como metodo anticonceptivo definitivo que se realiza de preferencia bajo anestesia raquidea. Paciente de 35 años en su puerperio de 12 horas, se somete a salpingoclasia bilateral bajo anestesia raquidea, con dosis de fentanil de 20 mcg y bupivacaina pesada de 12 mg.Nivel de dermatoma alcanzado de T6 (ideal para el procedimiento quirurgico), sin ninguna otra administracion medicamentosa. En la unidad de recuperacion postanestesica presenta paro cardiaco con inicio de manera inmediata de soporte vital avanzado con buenos resultados posteriores. Se le pracrican los examenes complementarios e interconsultas correspondiente. Paciente es dada de alta hospitalaria sin secuelas neurologicas a los 4 dias posteriores al evento. Prevenir y tratar la causa correspondiente del paro cardiaco.

Sepsis can develop during the body's response to a critical illness leading to multiple organ failure, irreversible shock, and death. Sepsis has been vexing health care providers for centuries due to its insidious onset, generalized metabolic dysfunction, and lack of specific therapy. A common factor underlying sepsis is the characteristic hypermetabolic response as the body ramps up every physiological system in its fight against the underlying critical illness. A hypermetabolic response requires supraphysiological amounts of energy, which is mostly supplied via oxidative phosphorylation generated ATP. A by-product of oxidative phosphorylation is hydrogen peroxide (H2O2), a toxic, membrane-permeable oxidizing agent that is produced in far greater amounts during a hypermetabolic state. Continued production of mitochondrial H2O2 can overwhelm cellular reductive (antioxidant) capacity leading to a build-up within cells and eventual diffusion into the bloodstream. H2O2 is a metabolic poison that can inhibit enzyme systems leading to organ failure, microangiopathic dysfunction, and irreversible septic shock. The toxic effects of H2O2 mirror the clinical and laboratory abnormalities observed in sepsis, and toxic levels of blood H2O2 have been reported in patients with septic shock. This review provides evidence to support a causal role for H2O2 in the pathogenesis of sepsis, and an evidence-based therapeutic intervention to reduce H2O2 levels in the body and restore redox homeostasis, which is necessary for normal organ function and vascular responsiveness.

Primary liver cancer (PLC) is one of the most common malignant tumors in China. PLC is characterized by insidious onset, rapid progress, poor quality of life, and short survival time. Notably, current treatment strategies remain unsatisfactory. Traditional Chinese medicines (TCM) have been used to treat a variety of diseases, including liver diseases, for more than 2000 years. In this study, we performed a review of the use frequency and clinical efficacy of TCM in treating PLC. Relevant literature from January 1, 2009, to January 1, 2021 was retrieved from network databases of China National Knowledge Infrastructure (CNKI), Chongqing VIP, Wanfang, PubMed, and SinoMed. The most frequently used TCM and their efficacy in PLC treatment were summarized. Based on the inclusion and exclusion criteria, 33 articles were selected. Overall, the efficacy of the combination of TCM and Western medicines in the treatment of PLC was higher than that in the control groups (i.e. treatment with Western medicines alone) (65.11% vs. 44.31%, P

A 64-year old male presented with a several-year history of an insidious-onset tender, itchy and xerotic rash on his lower legs. Past medical history was significant for Graves’ disease and Graves’ ophthalmopathy. The examination revealed peau d’orange-appearing plaques on his shins clinically consistent with pretibial myxedema. A punch biopsy showed separation of collagen bundles with extensive dermal mucin deposition, confirming the diagnosis of pretibial myxedema. After initially failing treatment with a topical clobetasol 0.05% ointment, the patient switched to regular pentoxifylline and triamcinolone 0.1% ointment under occlusion. He remains under follow-up.

Introdução: A esclerose lateral primária (ELP) é uma doença rara caracterizada por uma degeneração do neurônio motor superior ocorrendo geralmente na sexta década de vida com um início insidioso de uma paresia espástica simétrica, lentamente progressiva, frequentemente começando em membros superiores e inferiores. A prática de exercícios pode trazer benefícios a estes sujeitos levando a uma aprendizagem motora (AM) e melhorando o repertório motor insuficiente. Objetivo: Determinar o efeito de um protocolo de intervenção baseado na AM para melhorar a marcha e equilíbrio em jovem com ELP. Metodologia: É um estudo de caso composto por uma mulher, 29 anos, solteira, colombiana, branca, submetida à avaliação pré-teste (1 sessão), intervenção de protocolo (18 sessões) e pós teste (1 sessão). Para coleta de dados foram utilizados a Escala de Tinetti, Teste de Romberg, Timed Get Up And Go, Teste de alcance funcional, Baropodometria e Estabilometria. Resultados: A Escala de Tinetti (reação postural) mostrou melhora para balaço em um pé; na Escala de Tinetti (marcha) os resultados positivos foram encontrados em largura, simetria, continuidade e direção do passo; Testes de Romberg mostraram evolução para estabilidade sobre superfície plana com olhos fechados e sobre espuma de Fomy com olhos abertos; no teste Timed Get Up & Go o tempo de percurso foi reduzido de 13,64 segundos para 12,5 segundos. Conclusão: Após a aplicação do protocolo de intervenção baseado na AM houve avanços funcionais em marcha e equilíbrio de jovem com ELP.

Background Primary appendiceal tumors are histologically diverse and have an insidious onset and few specific clinical manifestations. In the majority of cases, these tumors are discovered after appendectomy during pathological exam of the resected tissue. Treatment may include appendectomy (simple or radical) and right hemicolectomy depending on factors such as histological type, tumor size and lymph node/organ involvement. The aim of this case study is to describe a rare case of a giant appendicular mucocele and raise awareness of this condition and its management options and follow-up protocol. Case summary We present the case of a 43-year-old patient who presented to our emergency department with mild right lower quadrant pain. After the initial check-up and imaging exams, he underwent surgery, where a giant 20 cm × 13 cm appendicular tumor was found and resected. Appendicular mucocele was suspected due to the macroscopic appearance and was later confirmed by the pathological exam. The patient's postoperative evolution was uneventful, and after discharge, he was included in our follow-up program. Conclusion In conclusion, mucinous appendiceal neoplasms embody a rare pathology; they are asymptomatic or have few, unspecific clinical signs and in many cases are discovered after appendectomy.

Psoas abscess is a rare condition that can present with vague clinical features. Its insidious onset can lead to a delay in diagnosis, resulting in high rates of complications and mortality. Here we describe a unique case of a patient presenting with enterocutaneous fistula and pneumoretroperitoneum due to ruptured psoas abscess.

Guillain Barre Syndrome (GBS) is an autoimmune disorder which affects the peripheral nervous system. It is a rare disorder affects in 1 per million people in year. It is characterized by symmetrical, progressive limb weakness and tingling. Case Report: A 53 year old male patient was presented with insidious onset of difficulty in moving right upper and lower limbs as well as gradual weakness of left limbs, and breathing difficulty, known case of diabetics’ mellitus and hypertension. Nerve conduction study shows suggest axonopathy; Acute Inflammatory Demyelinating Polyneuropathy (AIDP) is identified, which is a subtype of Guillain Barre Syndrome. Patient gradually develops areflexia, bifacial weakness, and quadriparesis. Patient was treated with IV immunoglobulin and intranasal oxygen therapy. Patient shows slight improvement in his medical condition, shows improvement in the power of lower limbs after one week of therapy. Physiotherapy was suggested. Keywords: Guillain Barre Syndrome, GBS, Acute Inflammatory Demyelinating Polyneuropathy, AIDP.

Alzheimer's disease (AD) is a neuronal disorder with insidious onset and slow progression, leading to growing global concern with huge implications for individuals and society. The occurrence of AD has been increased and has become an important health issue throughout the world. In recent years, the care of more than 35 million patients with AD costs over $ 600 billion per year, it is approximately 1 percent of the global Gross Domestic Product. Currently, the therapeutic approach is not effective for neurological deficits especially after the development of these major neurological disorders. The discovery of the technique called cell-based therapy has shown promising results and made important conclusions beyond AD using the stem cells approach. Here we review recent progress on stem cell-based therapy in the context of AD.

Purpose Glutaric aciduria type 1 (GA1), a rare inherited neurometabolic disorder, results in a complex movement disorder (MD) with predominant dystonia if untreated. Implementation into newborn screening (NBS) programs and adherence to recommended therapy are thought to improve the neurological outcome. Methods Systematic literature search for articles published from 2000 to 2019 was performed using the PRISMA protocol. Studies reporting on more than one individual identified by NBS were included. We investigated effects of interventional and noninterventional variables on neurological outcome. Results Fifteen publications reporting on 647 GA1 patients were included. In the NBS group (n = 261 patients), 195 patients remained asymptomatic (74.7%), while 66 patients (25.3%) developed a MD. Compared with the NBS group, a much higher proportion of patients (349/386; 90.4%; p

Occupational bronchiolitis is characterized by inflammation of the small airways, and represents a heterogeneous set of lung conditions that can occur following a range of inhalation exposures related to work. The most common clinical presentation includes insidious onset of exertional dyspnea and cough. Multiple reports in recent years have drawn attention to previously unrecognized risk factors for occupational bronchiolitis following exposures in several settings. Both current and past occupational exposures, including prior military deployment-related exposures, should be considered in patients undergoing evaluation for unexplained dyspnea. Diagnostic testing for potential bronchiolitis should include a thorough assessment of the small airways.

Purpose To report the rate of return to sport after surgical treatment for posterior shoulder instability among athletes. Methods A systematic review of the literature regarding rate of return to sport after surgical treatment for posterior shoulder instability was undertaken. The primary outcome measure was return to sport. The secondary outcome measures included rate of return to sport to preinjury level, time to return to sport, injury type, reoperations after primary surgery, and objective patient-reported outcome data. Data is summarized with ranges and tables. Results A total of 23 studies met inclusion criteria. The rate of return to sport ranged from 57.9%-100%. The rate of return to sport to the preinjury level ranged from 47.4%-100%. Time to return to sport ranged from 4.3-7.7 months. Furthermore, 66% of subjects had an acute traumatic injury and 34% were of insidious onset. The most commonly reported outcome measures were American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores and visual analog scale (VAS) pain scores. At a minimum of 1-year follow-up, ASES and VAS pain scores improved. Revision rates ranged from 0%-36.8%. Conclusion The systematic review demonstrated high rates of return to sport and relatively high rates of return to preinjury level of sport among all athletes who underwent surgical treatment for posterior shoulder instability. Objective patient-reported outcome metrics improved postoperatively whereas revision rates remained low.

In this report, we aim to present a sporadic case of a 17-year old female patient who presented to the Radiodiagnosis department in JSS Hospital, Mysuru, India with complaints of insidious onset of difficulty in walking, motor & sensory impairment, slurring of speech, difficulty in food ingestion, and hearing impairment. Magnetic resonance imaging revealed bilateral vestibular & non vestibular Schwannomas with extensive cranial nerve involvement, multiple spinal & falcine meningiomas, and cervicodorsal intramedullary ependymoma amongst other findings. These core features give rise to the acronym MISME, which describes Multiple Inherited Schwannomas, Meningiomas and Ependymomas. This case is being reported to highlight the rare constellation of multiple cranial nerve Schwannomas, meningiomas, ependymomas and other peripheral nerve sheath tumors in a single patient and will add to the evidence of MISME in world literature.

Medial discoid meniscus is a rare entity with a reported incidence of 0.12 to 0.3%, although the real incidence may be greater because not all the patients are symptomatic. Like lateral discoid menisci, medial discoid menisci are prone to degeneration that may prompt the presence of mechanical symptoms at early age. We present the case of a 14 year old male patient with bilateral knee symptoms of insidious onset without a traumatic event. Magnetic resonance revealed bilateral medial discoid menisci. Arthroscopic medial meniscus remodelling was performed in the right knee and, three months later, in the left knee, due to limitating mechanical symptoms. At the latest follow up -6 months for the right knee, 3 months for the left knee-, the patient resumed his sports activities.

Cholangiocarcinoma (CCA) is a rare tumor that arises from cholangiocytes, the epithelial cells of the bile duct. The tumor is characterized by insidious onset, high degree of malignancy, poor prognosis and high recurrence rate. Due to the lack of specific biomarkers, it is difficult to diagnose CCA early and evaluate prognosis. Extracellular vesicles (EVs), which include apoptotic bodies, microvesicles and exosomes, have emerged as having important roles in cell-to-cell communication in both normal physiology and pathological conditions. Some research has found that EVs play a crucial role in the occurrence and development of CCA. EVs can carry specific molecular substances such as nucleic acids and proteins, which have potential for the diagnosis and therapy of CCA. This article reviews the current knowledge on the role of EVs in CCA. We highlight EVs and their functions in the physiology and pathophysiology of CCA, and discuss their therapeutic potential and their role as biomarkers.

The global burden of diabetes is rapidly increasing, from 451 million people in 2019 to 693 million by 20451. The insidious onset of type 2 diabetes delays diagnosis and increases morbidity2. Given the multifactorial vascular effects of diabetes, we hypothesized that smartphone-based photoplethysmography could provide a widely accessible digital biomarker for diabetes. Here we developed a deep neural network (DNN) to detect prevalent diabetes using smartphone-based photoplethysmography from an initial cohort of 53,870 individuals (the ‘primary cohort’), which we then validated in a separate cohort of 7,806 individuals (the ‘contemporary cohort’) and a cohort of 181 prospectively enrolled individuals from three clinics (the ‘clinic cohort’). The DNN achieved an area under the curve for prevalent diabetes of 0.766 in the primary cohort (95% confidence interval: 0.750–0.782; sensitivity 75%, specificity 65%) and 0.740 in the contemporary cohort (95% confidence interval: 0.723–0.758; sensitivity 81%, specificity 54%). When the output of the DNN, called the DNN score, was included in a regression analysis alongside age, gender, race/ethnicity and body mass index, the area under the curve was 0.830 and the DNN score remained independently predictive of diabetes. The performance of the DNN in the clinic cohort was similar to that in other validation datasets. There was a significant and positive association between the continuous DNN score and hemoglobin A1c (P ≤ 0.001) among those with hemoglobin A1c data. These findings demonstrate that smartphone-based photoplethysmography provides a readily attainable, non-invasive digital biomarker of prevalent diabetes. A deep neural network applied to smartphone-based vascular imaging can detect diabetes, opening new possibilities for non-invasive diagnosis.

Introduction: Adhesive capsulitis, also called frozen shoulder, affects about 3-5% of the population, especially in the age group 40 to 60 years, affecting more women and having an insidious onset. Objective: Analyze the isolated effect of joint manipulation by Maitland method in treating patients with adhesive capsulitis of the shoulder, the level of pain, range of motions of the shoulder and functional capacity. Method: It is about a cases studies in which four volunteers underwent protocol Maitland to shoulder for 15 sessions. The evaluation instruments used were the Visual Analog Scale, Goniometer and Shoulder Pain and Disability Index to measure the level of disability of the shoulder. Results: There was decreased pain from 55.5 to 80.0%, increased all range of motions, especially flexion of the shoulder, with more than 100% gains in the four cases investigated and improved functional capacity between 27.9 – 91.9%. Conclusion: These results suggest that the therapy had improved outcomes assessed, as clinically relevant contribution, but indicate the need to develop more studies to prove the effectiveness of the method isolated.

KEY POINTS A 61-year-old woman presented to her family physician’s office with long-standing bilateral leg swelling. She voiced that her legs had become “heavy” and that the skin was “thick” and “burning.” She had started using a cane for gait instability. An insidious onset of

Background: Caseous lymphadenitis (CLA), caused by the gram-positive bacteria Corynebacterium pseudotuberculosis, has been present in Great Britain since the 1980s and is now considered endemic. CLA is considered to be an iceberg disease; that is, it is a production-limiting disease, characterised by slow insidious onset, that has production-limiting effects in a larger proportion of the flock than is exhibiting clinical signs at any given point in time. Aim of the article: The disease has been previously reviewed in In Practice (Baird 2003). In this article we consider updates in our understanding of the pathology, risk factors for flocks and the challenges of initiating control where the cost of the disease is still relatively unquantified.

La tuberculosis abdominal comprende alrededor del 5% de todos los casos de tuberculosis, esta patología es considerada una enfermedad de inicio insidioso y presentación crónica, misma que rara vez es catalogada como una urgencia; sus complicaciones, sin un adecuado enfoque clínico, pueden desorientar al médico, en muchos casos de tuberculosis en niños, la confirmación de laboratorio nunca se establece, como sucede con este caso en particular y es allí donde se determina que un diagnóstico presuntivo de tuberculosis abdominal basado en la respuesta clínica o imagenológica que presente el paciente al tratamiento empírico, especialmente para situaciones en las que existe un alto índice de sospecha de esta patología. Palabras clave: tuberculosis abdominal, tuberculosis en niños, tratamiento.

As a common gastrointestinal tumor, the incidence of pancreatic cancer has been increasing in recent years. The disease shows multi-gene, multi-step complex evolution from occurrence to dissemination. Furthermore, pancreatic cancer has an insidious onset and an extremely poor prognosis, so it is difficult to obtain cinical specimens at different stages of the disease, and it is, therefore, difficult to observe tumorigenesis and tumor development in patients with pancreatic cancer. At present, no standard protocols stipulate clinical treatment of pancreatic cancer, and the benefit rate of new targeted therapies is low. For this reason, a well-established preclinical model of pancreatic cancer must be established to allow further exploration of the occurrence, development, invasion, and metastasis mechanism of pancreatic cancer, as well as to facilitate research into new therapeutic targets. A large number of animal models of pancreatic cancer are currently available, including a cancer cell line-based xenograft, a patient-derived xenograft, several mouse models (including transgenic mice), and organoid models. These models have their own characteristics, but they still cannot perfectly predict the clinical outcome of the new treatment. In this paper, we present the distinctive features of the currently popular pancreatic cancer models, and discuss their preparation methods, clinical relations, scientific purposes and limitations.

Background and objectives: Frozen shoulder is a common musculoskeletal condition. Telerehabilitation has seen emerging use in a variety of conditions. This case report aims to investigate the feasibility of adopting telerehabilitation in treating frozen shoulder. Case presentation: A 43-year old female presented with frozen shoulder of insidious onset. She underwent four sessions of physiotherapy. Sessions two and three were telerehabilitation sessions; the initial and final sessions were conducted in-person. Results: The subject was compliant with all exercises prescribed during her rehabilitation and achieved all rehabilitation goals in four sessions. She was then discharged from physiotherapy. Conclusion: Telerehabilitation is feasible in treating frozen shoulder. One barrier to implementation of telerehabilitation includes the lack of technical skills and knowledge despite the high prevalence of technology in today’s society. Telerehabilitation increases accessibility and ease of rehabilitation. Telerehabilitation can be considered for segments of the population that are most inclined to use technology.

Background Foot and ankle are some of the most frequently injured places in football players' bodies. Overuse injuries have an insidious onset and can restrain athletes from sports temporary or even permanently. This study aimed to investigate the relationship between the clinical evaluation of the foot and ankle and findings obtained from foot plantar pressure measurements with the development of overuse injury, during the one-year follow-up. Methods One hundred licensed football players were included in the study. Presence of joint hypermobility, foot posture assessment, ankle and first metatarsophalangeal joint range of motion measurements, pedobarographic plantar pressure assessment of foot was carried out. Then, the footballers were followed for 12 months for the development of new foot and ankle overuse injuries, and the clinical and pedobarographic data of the footballers with at least one injury were compared with the group without injury. Results We found asymmetric pressure distribution between the preferred and non-preferred foot in the group who had an injury in the pedobarographic static foot plantar pressure measurements (P=0.040). A statistically significant limitation was found in the ankle eversion, first metatarsophalangeal joint dorsiflexion and ankle plantar flexion degrees in the injured group compared to the uninjured group (P=0.029, P=0.023, P=0.044, respectively). Conclusions These findings suggest that impairments in foot plantar pressure distribution and limitations in ankle and foot joint range of motion may be risk factors for the development of foot and ankle overuse injury.

In patients with acute epidermal necrolysis, the most frequent diagnosis is Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and less frequently Toxic Epidermal Necrolysis-like Lupus Erythematosus (TEN-LE). Both groups of conditions present with erythema, papules and/or bullae, and sheet-like detachment of skin.1 Proposed features to support TEN-LE include the absence of 'high-risk' drug use, UV-exposure, an insidious onset of symptoms, a photo-distributed cutaneous eruption, minimal mucosal involvement, and autoimmune serology consistent with systemic lupus erythematosus (SLE).

Although tuberculosis is a widespread disease in Morocco, musculoskeletal form is relatively rare and even rarer when affects the sacroiliac joint. Tuberculous sacroiliitis remains a challenge for orthopedists owing to its insidious onset and non-specific clinical presentation. Herein, we report the case of a 23-year-old male with a growing mass in his left gluteal area, diagnosed with tuberculous sacroiliitis, based on bacteriological and histological findings. The aim of our work is to draw attention to the importance of continued awareness for early detection and adequate treatment of this very rare entity.

Melioidosis, a disease with protean clinical manifestations, is prevalent in many parts of India, with established endemic hotspots on the southern coast of the country. However, it is still underdiagnosed in many resource-poor regions of the country. We report what is, to the best of our knowledge, the first case of melioidosis diagnosed and treated in Bihar, an economically underdeveloped state in East India. The patient, a 52-year-old diabetic male, presented to the outpatient department with a fever of insidious onset along with pain and restriction of movement in the right shoulder joint and right knee joint, and swelling and tenderness of bilateral ankle joints. Radiological features were suggestive of multiple joint and organ abscesses. A diagnosis of disseminated septicaemic melioidosis was confirmed microbiologically. The patient improved clinically following aggressive treatment with meropenem and cotrimoxazole. The case highlights the need for increased clinical suspicion of melioidosis and adequate diagnostic facilities, as well as the need for early institution of appropriate empirical antibiotics in suspected cases of melioidosis in this region of the world.

Actinomycosis is a rare bacterial condition that is seen infrequently and no studies have examined its prevalence or incidence globally. The author, a stoma care clinical nurse specialist (CNS), found herself caring for two such patients 3 weeks apart, both of whom were diagnosed with pelvic actinomycosis. Both patients had been fitted with copper intrauterine devices (IUDs) 10 years previously and were not aware that leaving IUDs in situ for a prolonged period increased their risk of infection. This article gives an overview of the condition, with discussion around the two patients the author cared for within her own specialty; not all aspects of the condition are included as the she has no clinical experience in microbiology and is not a gynaecological CNS. The case studies show how both women presented and were treated, with interventions including emergency surgery, long-term antibiotic therapy and stoma formation. Pelvic actinomycosis is often associated with the use of an IUD, and greater awareness about the risk of leaving IUDs in situ for prolonged periods is needed among gastrointestinal, colorectal and gynaecological practitioners.

Essential hypertension (EH) is a clinically frequent cardiovascular disease, with insidious onset, causing increased pressure load and neuroregulation disorders in patients. Long-term EH can cause left ventricular hypertrophy (LVH), which can lead to arrhythmia and even death. The soluble suppression of tumorigenicity 2 (sST2), matrix metalloproteinase-3 (MMP-3), and galectin-3 (Gal-3) in serum plays an important role in the occurrence, development, and prognosis of cardiovascular diseases. In our study, we divided EH patients into 3 levels and groups with or without LVH, according to their condition. The levels of sST2, MMP-3, and Gal-3 in the serum were measured in different groups of patients. Our results showed that the levels of sST2, MMP-3, and Gal-3 in the serum increased progressively with the level in different EH groups. The levels of sST2, MMP-3, and Gal-3 in the serum of the LVH group were higher than those of the NLVH group, and it is positively correlated with LVH-related indexes. The risk of developing and progressing to LVH in patients with EH can be determined by the method of measuring three indicators.

A 19-year-old Division-1 collegiate soccer player presents to the training room with insidious onset right anterior knee pain. The pain started while she was doing rehabilitation following a right anterior cruciate ligament (ACL) reconstruction using a contralateral patellar tendon autograft. She

Primary empty sella syndrome (PESS) on background idiopathic intracranial hypertension (IIH) presenting with profound bilateral visual loss is a rare clinical occurrence. We report the case of PESS on background IIH in a 37‑year‑old obese Nigerian female. At presentation, she had a history of an insidious onset of loss of vision in both eyes with an associated history of headaches and tinnitus. Clinical examination and imaging studies revealed papilloedema and empty sella with a completely flattened pituitary gland. This report highlights that PESS could initially present to an ophthalmologist as a case of profound bilateral visual loss. Keywords: Bilateral visual loss, diaphragma sellae, empty sella, idiopathic intracranial hypertension, primary empty sella syndrome

Pulmonary alveolar proteinosis is an uncommon cause of insidious onset shortness of breath and hypoxemia. It is caused by an accumulation of surfactant within the alveoli. Left untreated, it can be fatal. Standard-of-care treatment is whole-lung lavage; however, in severe cases, the associated hypoxemia can be profound and single-lung ventilation would not be tolerated, potentially preventing a lifesaving treatment. Single cases using veno-venous extracorporeal membrane oxygenation to perform whole-lung lavage have been reported. Here we describe three patients with severe pulmonary alveolar proteinosis who were successfully treated with whole-lung lavage using veno-venous extracorporeal membrane oxygenation for oxygenation support.

Sinonasal malignancies rare and pathologically diverse and make up

With the global population ageing rapidly, Alzheimer's disease (AD) is particularly prominent in older adults, which has an insidious onset followed by gradual, irreversible deterioration in cognitive domains (memory, communication, etc). Thus the detection of Alzheimer's disease is crucial for timely intervention to slow down disease progression. This paper presents a comparative study of different acoustic and linguistic features for the AD detection using various classifiers. Experimental results on ADReSS dataset reflect that the proposed models using ComParE, X-vector, Linguistics, TFIDF and BERT features are able to detect AD with high accuracy and sensitivity, and are comparable with the state-of-the-art results reported. While most previous work used manual transcripts, our results also indicate that similar or even better performance could be obtained using automatically recognized transcripts over manually collected ones. This work achieves accuracy scores at 0.67 for acoustic features and 0.88 for linguistic features on either manual or ASR transcripts on the ADReSS Challenge1 test set.

Introduction and importance Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy. Case presentation We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA). Clinical discussion The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis. Conclusion Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available., Highlights • Intra-ampullary papillary tubular neoplasms (IAPNs) are unusual neoplasms capable of potential malignant progression. • We report a rare case of IAPN which was treated through transduonal ampullectomy (TDA). • TDA can be adopted as an alternative treatment approach to manage IAPNs with great efficacy and fair long-term results.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated polyneuropathy. It usually has an insidious onset, progressive course and heterogeneous clinical features. As far as we know, there is no epidemiological information on CIDP in South America and the Caribbean. Our aim was to estimate the frequency of CIDP in the South-Eastern region of Santiago, where our hospital is based and the population number assigned is officially reported every year by the health authorities. Records of 581 patients registered with the diagnosis of neuropathy were found and all patients meeting the diagnostic criteria of the EFNS/PNS for definitive and possible CIDP were included. Data were collected using a data extraction protocol designed by the authors and which included demographic, clinical, laboratory and electrophysiological information. The estimated prevalence and incidence of CIDP were 2.95/100,000 and 0.46/100,000 respectively. Fifteen patients (8 men, 7 women) were classified as definitive or possible CIDP. Nine patients had typical CIDP and three also had diabetes mellitus. The prevalence and incidence rates were similar to those reported in other regions of the world.

Introduction: Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease wich variable symptoms affecting numerous organs and insidious onset of an unpredictable course, with episodes of activity and remission. The development of the disease is evaluated by a combination of clinical history, physical and laboratory tests to identify risk factors related to the stage or complications of the disease. The American College of Rheumatology (ACR 97) was the first to establish criteria for SLE classification. In 2012, The Systemic Lupus International Collaborating Clinics (SLICC 12) published a new set of criteria aimed at optimizing the classification of SLE. Objectives: Compare the criteria proposed by ACR 97 and SLICC 12 for the diagnosis of SLE and to gather information on clinical characteristics, diagnosis, and treatment. Methodology: Literature review, using the PubMed-NCBI database. The inclusion criteria were: articles published in the last five years; study in humans and selection by the direct relation with the selected theme. Results: SLICC 12 demonstrated a higher sensitivity diagnosed in reports compared with as ACR 97. Conclusion: We found that SLICC 12 is the classification criterion for SLE presenting the most excellent variety of laboratory, cutaneous, immunological and neuropsychiatric findings, allowing a better performance of the classification of patients with SLE and thus the early diagnosis of the disease.

Juvenile idiopathic arthritis (JIA) is a group of disorders occurring in children with arthritis of more than 6 weeks' duration. JIA may have varied systemic and ocular presentations, which can pose a diagnostic challenge. Chronic uveitis with insidious onset is the most common type of ocular presentation. This report highlights a case of enthesitis-related arthritis, a type of JIA, in a 12-year-old boy who presented with severe intermediate uveitis that mimicked endophthalmitis.