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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.

Tamoxifen exposure is a recognised risk for primary endometrial cancer. This case serves as a reminder to meticulously check the past medical history and inform patients of the risk-benefit of treatment as part of a shared-decision making process.

A 16‐year‐old boy with negative past medical history presented to an outside hospital with a first time right‐sided focal seizure. Neurologic examination at presentation was normal. CT performed in the emergency room revealed a large left intra‐axial cerebral mass without haemorrhage ([

A 72-year-old woman with past medical history of rectal cancer resection (adenocarcinoma, pT3N1aM0) presented with a 2-month history of dysphagia. Imaging studies found a thoracic esophageal cancer, for which subtotal esophagectomy with gastric conduit reconstruction via retrosternal route followed by chemoradiotherapy were performed (squamous cell carcinoma, pT4N1M0, RM1). Seven months after the esophagectomy, a contrast-enhanced computed tomography (CT) demonstrated a new asymptomatic mass inside the right atrium. A thrombus or a tumorous lesion was suspected. Positron emission tomography (PET)/CT showed abnormal uptake in the mass. After a thorough discussion by a multidisciplinary oncology group, we performed 1-week anticoagulant therapy first, resulting in mass enlargement. Then tumorectomy was carried out. The final pathological findings revealed that the mass was squamous cell carcinoma, yielding the diagnosis of cardiac metastasis from esophageal cancer. The patient's postoperative course was unremarkable. PET/CT may help to estimate malignancy and to omit invasive heart surgery.

Purpose To report a novel case of dark without pressure in a patient with a choroidal osteoma. To our knowledge this association has not been previously reported. Methods Observational case report. Review of clinical examination and multi-modal imaging findings in a patient with a choroidal osteoma and dark without pressure. Results A 21-year-old African American female with no significant past medical history presented with a large, unilateral, juxtapapillary, subretinal, orange-colored, ovoid shaped lesion with macular involvement. An overlying area of mottled pigmentary changes, fibrosis, and atrophy were present. Adjacent to and surrounding the osteoma was an annular band of hyperpigmented mid-peripheral retina with a sharply demarcated scalloped border that abruptly changed to normal-appearing peripheral retina. Multi-modal imaging including wide-field fluorescein angiography, optical coherence tomography, and ophthalmic B-scan were performed. The funduscopic and imaging findings were consistent with a diagnosis of choroidal osteoma and dark without pressure. Conclusion The examination and imaging findings in this patient suggest a unique association between two relatively uncommon lesions, choroidal osteoma and dark without pressure. Though these two lesions may simply be coinciding in the same eye, there may be an association with space- occupying lesions causing a change in photoreceptor structure.

The differential diagnosis of bilateral lower extremity weakness is broad. We present a very rare case of a 48-year old male patient, with walking difficulties due to Bing-Neel syndrome. On clinical examination, there was a significant loss of muscle power in all his lower extremities key-muscle groups. The lumbar spine magnetic resonance imaging (MRI) showed only mild degenerative changes, whereas the MRI of the head indicated a diffuse meningeal thickening at the right temporal region, characterized by significant enhancement after contrast administration. Serum protein electrophoresis detected an IgM-kappa monoclonal protein. The patient received intrathecal chemotherapy with methotrexate and cytarabine, and was started on oral ibrutinib 420mg daily. In conclusion, a past medical history of Waldenstrom macroglobulinemia in conjunction with neurological manifestations should alert the treating physician for Bing-Neel syndrome. A complete diagnostic imaging and serologic protocol helps in setting the final diagnosis. Steroids are part of the treatment, but should be given after the diagnosis is set. Neurosurgical intervention is indicated for histologic confirmation in the case of diagnostic uncertainty.

BackgroundThere is an urgent need to develop a simplified risk tool that enables rapid triaging of SARS CoV-2 positive patients during hospital admission, which complements current practice. Many predictive tools developed to date are complex, rely on multiple blood results and past medical history, do not include chest X ray results and rely on Artificial Intelligence rather than simplified algorithms. Our aim was to develop a simplified risk-tool based on five parameters and CXR image data that predicts the 60-day survival of adult SARS CoV-2 positive patients at hospital admission.MethodsWe analysed the NCCID database of patient blood variables and CXR images from 19 hospitals across the UK contributed clinical data on SARS CoV-2 positive patients using multivariable logistic regression. The initial dataset was non-randomly split between development and internal validation dataset with 1434 and 310 SARS CoV-2 positive patients, respectively. External validation of final model conducted on 741 Accident and Emergency admissions with suspected SARS CoV-2 infection from a separate NHS Trust which was not part of the initial NCCID data set.FindingsThe LUCAS mortality score included five strongest predictors (lymphocyte count, urea, CRP, age, sex), which are available at any point of care with rapid turnaround of results. Our simple multivariable logistic model showed high discrimination for fatal outcome with the AUC-ROC in development cohort 0.765 (95% confidence interval (CI): 0.738 - 0.790), in internal validation cohort 0.744 (CI: 0.673 - 0.808), and in external validation cohort 0.752 (CI: 0.713 - 0.787). The discriminatory power of LUCAS mortality score was increased slightly when including the CXR image data (for normal versus abnormal): internal validation AUC-ROC 0.770 (CI: 0.695 - 0.836) and external validation AUC-ROC 0.791 (CI: 0.746 - 0.833). The discriminatory power of LUCAS and LUCAS + CXR performed in the upper quartile of pre-existing risk stratification scores with the added advantage of using only 5 predictors.InterpretationThis simplified prognostic tool derived from objective parameters can be used to obtain valid predictions of mortality in patients within 60 days SARS CoV-2 RT-PCR results. This free-to-use simplified tool can be used to assist the triage of patients into low, moderate, high or very high risk of fatality and is available athttps://mdscore.net/.Summary boxWhat is already known on this topic?Clinical prediction models such as NEWS2 is currently used in practice as mortality risk assessment. In a rapid response to support COVID-19 patient assessment and resource management, published risk tools and models have been found to have a high risk of bias and therefore cannot be translated into clinical practice.What this study adds?A newly developed and validated risk tool (LUCAS) based on rapid and routine blood tests predicts the mortality of patients infected with SARS-CoV-2 virus. This prediction model has both high and robust predictive power and has been tested on an external set of patients and therefore can be used to effectively triage patients when resources are limited. In addition, LUCAS can be used with chest imaging information and NEWS2 score.

Background: There is an urgent need to develop a simplified risk tool that enables rapid triaging of SARS CoV-2 positive patients during hospital admission, which complements current practice. Many predictive tools developed to date are complex, rely on multiple blood results and past medical history, do not include chest X ray results and rely on Artificial Intelligence rather than simplified algorithms. Our aim was to develop a simplified risk-tool based on five parameters and CXR image data that predicts the 60-day survival of adult SARS CoV-2 positive patients at hospital admission. Methods: We analysed the NCCID database of patient blood variables and CXR images from 19 hospitals across the UK contributed clinical data on SARS CoV-2 positive patients using multivariable logistic regression. The initial dataset was non-randomly split between development and internal validation dataset with 1434 and 310 SARS CoV-2 positive patients, respectively. External validation of final model conducted on 741 Accident and Emergency admissions with suspected SARS CoV-2 infection from a separate NHS Trust which was not part of the initial NCCID data set. Findings: The LUCAS mortality score included five strongest predictors (lymphocyte count, urea, CRP, age, sex), which are available at any point of care with rapid turnaround of results. Our simple multivariable logistic model showed high discrimination for fatal outcome with the AUC-ROC in development cohort 0.765 (95% confidence interval (CI): 0.738 - 0.790), in internal validation cohort 0.744 (CI: 0.673 - 0.808), and in external validation cohort 0.752 (CI: 0.713 - 0.787). The discriminatory power of LUCAS mortality score was increased slightly when including the CXR image data (for normal versus abnormal): internal validation AUC-ROC 0.770 (CI: 0.695 - 0.836) and external validation AUC-ROC 0.791 (CI: 0.746 - 0.833). The discriminatory power of LUCAS and LUCAS + CXR performed in the upper quartile of pre-existing risk stratification scores with the added advantage of using only 5 predictors. Interpretation: This simplified prognostic tool derived from objective parameters can be used to obtain valid predictions of mortality in patients within 60 days SARS CoV-2 RT-PCR results. This free-to-use simplified tool can be used to assist the triage of patients into low, moderate, high or very high risk of fatality and is available at https://mdscore.net/. Funding Statement: EPSRC Impact Acceleration account fund EP/R511705/1; AS is funded by a Wellcome Trust fellowship 205188/Z/16/Z; University of Brighton COVID-19 Research Urgency Fund. Declaration of Interests: All researchers declare no competing interests. Ethics Approval Statement: De-identified and pseudo-anonymised patient data were obtained from data sets which were approved by the ethics committee as part of the existing Cardiac MRI Database NHS REC IRAS Ref: 222349 and University of Brighton REC (8011).

A 14-year-old male patient presented to the emergency room with fever, loose stools, shortness of breath and swelling over the right popliteal fossa for 5 days. He had no significant past medical history and received all the vaccinations according to the immunisation schedule. He had an oxygen

Segmental Arterial Mediolysis (SAM) is a rare, poorly understood vasculopathy that involves vacuolization of the arterial wall, most commonly of the visceral arteries. There are no established therapeutic or monitoring guidelines for SAM, and intervention typically depends on patient presentation. The purpose of this study is to review the management and outcomes of patients with this rare vascular disease METHODS: Single center retrospective review of patients diagnosed with SAM between 2011 and 2019. Included were patients with radiological diagnosis of SAM. Demographic factors, past medical history, presenting symptoms, affected vessels, management, and lesion characteristics over time were collected. Demographic and periprocedural factors, and medical management strategies were compared for those who required operative intervention versus those managed non-operatively.Thirty patients were included, 21 (70%) were male, mean age was 53.5 years (range: 35.7-72.2). Twenty-seven patients were managed non-operatively, 3 patients required surgical intervention. Patients who underwent operative intervention were more likely to present with pain30 days (P0.05), and hemorrhage (P0.01). Abdominal pain was the most common presenting symptom (n = 24, 80%). Arterial dissection was the most common radiological finding at time of presentation (n = 20, 67%). The celiac artery and its branches were most often involved (n=22, 73%) followed by the superior mesenteric artery and its branches (n = 15, 50%). Non-operative management most often consisted of anti-hypertensive therapy (n = 13, 43%), antiplatelet agents (n = 17, 57%%), and lipid-lowering agents (n = 13, 43%), with 7 patients receiving all three. Six patients demonstrated confirmed resolution of lesions during surveillance imaging, with average time to resolution of 325.5 days.Patients who underwent intervention for SAM presented with either mesenteric ischemia or pseudoaneurysm rupture. In patients that present without those conditions, medical management consisting of anti-hypertensives, antiplatelet agents, and lipid-lowering therapy was effective. Non operative management resulted in symptom resolution in all patients and surveillance imaging showed resolution of radiographic abnormalities in 6 patients out of 27 at less than one year.

Background: Trauma patients undergoing damage control surgery (DCS) have a propensity for complicated abdominal closures and intra-abdominal complications. Studies show that management of open abdomens with direct peritoneal resuscitation (DPR) reduces intra-abdominal complications and accelerates abdominal closure. This novel study compares intra-abdominal complication rates and the effect of DPR initiation in patients who received DPR and those who did not. Patients and Methods: A retrospective chart review was performed on 120 patients who underwent DCS. Fifty patients were identified as DCS with DPR, and matched to 70 controls by gender, race, age, body mass index (BMI), past medical history, mechanism of trauma, and injury severity score. Results: The two groups of patients, those without DPR (-DPR) and those with DPR (+DPR), were similar in their characteristics. The +DPR group was more likely to have a mesh closure than the -DPR (14% and 3%; p = 0.022). The +DPR group took longer to have a final closure (3.5 ± 2.6 days vs. 2.5 ± 1.8; p = 0.020). Infection complications and mechanical failure of the closure technique were similar among the two groups. Timing of DPR initiation had no effect on closure type but did statistically increase the number of days to closure (initiation at first operation 2.8 ± 1.8 days vs. initiation at subsequent operations 6.0 ± 3.3 days; p ≤ 0.001). Conclusions: The use of DPR did not result in different outcomes in trauma patients. Therefore, traditional resuscitative measures for DCS may not be inferior to DCS with DPR. When choosing to use DPR, initiating it at the first operation could reduce the number of days to closure.

Effective use of noninvasive ventilation in patients with chronic obstructive pulmonary disease is well-known. However, noninvasive ventilation in patients presenting with altered sensorium and severe acidosis (pH

BACKGROUND: Interleukin (IL)-17 plays a central role in orchestrating the cytokine cascade and accelerates atherosclerosis and plaque vulnerability in animal models. However, epidemiological data evaluating the role of IL-17 levels in unstable angina are lacking. The aim of our study is to evaluate and compare the IL-17 levels in unstable angina (UA) cases before and after treatment. METHODS: This cross-sectional study was performed from July to October 2018 in Ali Iben-abitaleb heart center, Zahedan, Iran. 48 patients with UA in the age range of below 50 years entered the study. All demographic, past medical history, physical examination, electrocardiogram (EKG or ECG), and transthoracic echocardiogram (TTE) data were collected. Serum level of IL-17 was measured using enzyme-linked immunosorbent assay (ELISA) method. In all the tests, P< 0.05 was considered as statistically significant. All data analyses were performed using the SPSS 13.0 software (SPSS Inc., Chicago, Illinois, USA). RESULTS: In this study, 48 UA patients, including 34 women and 16 men with a mean age of 56.60 years were included in the study. The mean serum level of interleukin 17 after treatment (65.13 ± 53.29 pg/dl) was significantly lower than Its level before treatment (94.89 ± 51.25 pg/dL) (P< 0/05). CONCLUSION: Our findings point towards a role of inflammation in the form of increased activity of IL-17 in UA patients and thus suggest that IL-17-driven inflammation may play a role in the promotion of clinical instability in patients with coronary artery disease.

Частота посттравматических абсцессов среди всех абсцессов печени составляет 14,5 ± 2,2 %. Посттравматические абсцессы характеризуются тяжелым и длительным течением. Целью работы явилось изучение возможностей ультразвуковой визуализации в диагностике и лечении посттравматических абсцессов печени. Изучены результаты обследования и лечения 36 пациентов с посттравматическими абсцессами печени. Установлено, что такие абсцессы развиваются у пациентов с травмами, контузиями, ранениями печени, в т.ч. в сочетании с повреждениями органов брюшной полости, грудной клетки, скелета, и в связи со стертостью клинической картины, тяжелым состоянием больного, преобладанием симптомов повреждения других внутренних органов и костей могут быть своевременно не диагностированы. Установлено, что при подозрении на травму печени в анамнезе и наличии клинико-лабораторных признаков гнойно-воспалительного процесса пациенту необходимо выполнение УЗИ печени для выявления возможного абсцедирования. Определено, что характерными эхопризнаками посттравматического абсцесса печени являются неправильная форма, слабовыраженная демаркационная зона, наличие в просвете полиморфных гиперизоэхогенных, изогиперэхогенных или гиперэхогенных включений. Сделано заключение, что методом выбора в лечении посттравматических абсцессов печени является чрескожное эхоконтролируемое дренирование, которое при необходимости может быть выполнено симультанно с аспирацией плеврального выпота и дренированием абсцессов другой локализации.

Objective : Chronic subdural hematoma (CSDH) is one of the most common pathology in daily neurosurgical practice and incidence increases with age. The aim of this study was to evaluate the prognostic factors and surgical outcome of CSDH in patients aging over 90 years compared with a control group of patients aging under 90 years.Methods : This study reviewed 25 patients with CSDH aged over 90 years of age treated in our department. This group was compared with a younger group of 25 patients aged below their eighties. At admission past medical history was recorded concerning comorbidities (hypertension, dementia, ictus cerebri, diabetes, and heart failure or attack). History of alcohol abuse, anticoagulant and antiplatelet therapy, head trauma and seizures were analyzed. Standard neurological examination and Markwalder score at admission, 48 hours after surgery and 1–6 months follow-up, radiologic data including location and CSDH maximum thickness were also evaluated.Results : Their mean age was 92.8 years and the median was 92.4 years (range, 90–100 years). In older group, the Markwalder evaluation at one month documented the complete recovery of 24 patients out of 25 without statistical difference with the younger group. This data was confirmed at 6-month follow-up. One patient died from cardiovascular failure 20 days after surgery. The presence of comorbidities, risk factors (antiplatelet therapy, anticoagulant therapy, history of alcohol abuse, and head trauma), preoperative symptoms, mono or bilateral CSDH, maximum thickness of hematoma, surgical time and recurrence were similar and statistically not significant in both groups.Conclusion : In this study, we demonstrate that surgery for very old patients above 90 years of age affected by CSDH is safe and allows complete recovery. Comparing two groups of patients above and under 90 years old we found that complication rate and recovery were similar in both groups.

A 68-year-old woman with a past medical history of chronic obstructive pulmonary disease and squamous cell carcinoma of the lung with recent right upper and middle lobectomy was admitted for dyspnea and volume overload. She was diagnosed with right-sided heart failure (RHF) through clinical, laboratory, and echocardiographic means. In the setting of chronic respiratory failure, the recent right lung lobectomy was deemed to be the inciting factor of the RHF. The mechanism by which RHF occurs in this situation is multifactorial, and it is essential to undergo pre-operative risk stratification and post-operative monitoring to avoid emergent events.

BACKGROUND International Statistical Classification of Disease and Related Health Problems, 10th Revision codes (ICD-10) are used to characterize cohort comorbidities. Recent literature does not demonstrate standardized extraction methods. OBJECTIVE Compare COVID-19 cohort manual-chart-review and ICD-10-based comorbidity data; characterize the accuracy of different methods of extracting ICD-10-code-based comorbidity, including the temporal accuracy with respect to critical time points such as day of admission. METHODS Design: Retrospective cross-sectional study. MEASUREMENTS ICD-10-based-data performance characteristics relative to manual-chart-review. RESULTS Discharge billing diagnoses had a sensitivity of 0.82 (95% Confidence Interval [CI]: 0.79-0.85; comorbidity range 0.35-0.96). The past medical history table had a sensitivity of 0.72 (95% CI: 0.69-0.76; range 0.44-0.87). The active problem list had a sensitivity of 0.67 (95% CI: 0.63-0.71; range 0.47-0.71). On day of admission, the active problem list had a sensitivity of 0.58 (95% CI: 0.54-0.63; range 0.30-0.68) and past medical history table had a sensitivity of 0.48 (95% CI: 0.43-0.53; range 0.30-0.56). CONCLUSIONS AND RELEVANCE ICD-10-based comorbidity data performance varies depending on comorbidity, data source, and time of retrieval; there are notable opportunities for improvement. Future researchers should clearly outline comorbidity data source and validate against manual-chart-review. This article is protected by copyright. All rights reserved.

У роботі визначено модифіковані фактори ризику, що впливають на розвиток і перебіг виразкових дефектів стоп у хворих на цукровий діабет (ЦД) із синдромом діабетичної стопи (СДС). У більшості хворих на ЦД при надходженні до стаціонару з приводу СДС відзначаються: тривала декомпенсація ЦД, порушення ліпідного обміну, супутня серцево-судинна патологія (ішемічна хвороба серця), артеріальна гіпертензія). Встановлено, що формування сенсомоторної нейропатії у пацієнтів із ЦД є основним фактором ризику утворення виразкових дефектів стоп. На момент виявлення виразки у більшості пацієнтів спостерігається поєднання сенсомоторної нейропатії з іншими факторами ризику — деформацією стоп, наявністю виразок і/або ампутацій в анамнезі, макроангіопатією. Наявність інфекції у виразковому дефекті є значущим фактором ризику несприятливого перебігу СДС. Досягнення стабільної компенсації ЦД, цільових значень ліпідного спектра крові та артеріального тиску дозволяє у коротші терміни забезпечити загоєння виразкових дефектів.

Summary Background/Purpose Pediatric urology procedures are amongst the most commonly performed in children. The need for proactive treatment of pain is essential for optimal patient care. Current guidelines recommend the routine use of regional anesthesia in children as appropriate unless contraindicated. Given the commonality of urologic procedures in children, it is essential to understand the indications for and the utility of regional anesthesia. Methods The current literature was searched using PubMed as the primary platform. Search words included ‘dorsal penile nerve block,’ ‘pudendal nerve block,’ ‘ring block,’ ‘spinal anesthesia,’ and ‘caudal,’ along with ‘pediatric’, ‘circumcision,’ ‘hypospadias,’ ‘urology’, and ‘urological surgery’ as part of the keywords of the search. Results The articles resulting from the literature search were reviewed for content, clarity and study design by two co-authors, and agreement determined the incorporation into the review. Additionally, a detailed description of study design, regional anesthetic technique, local anesthetic(s) used, and outcomes of each study referenced was incorporated into the supplemental table. Conclusion Given the variance in block technique and local anesthetic choice amongst the current reported studies in the literature, it is difficult to truly compare and infer superiority of the regional anesthetic choices for ambulatory penoscrotal procedures. When choosing a regional anesthetic technique, careful consideration must be placed on block coverage, severity of expected pain and surgical duration of the procedure, type and dose of local anesthetic, as well as the patient’s past medical history and anatomy. Moreover, the regional block chosen should result from a thorough preoperative discussion between the surgeon and the anesthesiologist.

We present a case of indolent neurolymphomatosis in a 55-year-old male patient with worsening pain and weakness in his right leg over the past few months. The patient has a past medical history of type II diabetes mellitus, four-year history of worsening left foot drop, left lower limb pain and weakness attributed to diabetic amyotrophy, and back pain. The new right-sided symptoms prompted further imaging which revealed a left sciatic nerve mass which was biopsied. Initial biopsy results were inconclusive. 18F-FDG PET/CT revealed the full extent of this patient's disease and helped plan for a more representative biopsy site, which finally established a diagnosis of diffuse large B-cell lymphoma involving the lumbosacral nerve roots. The patient underwent a course of chemotherapy. 18F-FDG PET/CT was ordered again at the end of treatment showing partial response to therapy. He underwent radiation therapy to the site of residual disease, with complete metabolic response of lesions on follow up PET CT.

Objective Intermittent photic stimulation (IPS) is an activation procedure performed during electroencephalography (EEG) to detect photosensitive patients. This procedure is recommended in routine EEGs but the benefit of IPS in the general population is not clearly ascertained. Methods We retrospectively analyzed 7683 EEGs of patients referred for a routine EEG to the Clinical Physiology Department of Lariboisiere hospital, mainly from the emergency ward and the department of neurology, not specifically involved in epilepsy. All EEGs were performed with a standardized protocol. Photic driving response, photomyoclonic response and photoparoxysmal response (PPR) were specifically collected. A correlation analysis was performed between the response induced by IPS, demographical and clinical data, and current treatment or recreational drug use. Results Median age was 56.4 years (41.7-71.2); 3,042 (39.6%) of patients were female; 1,208 patients (15.7%) had a past medical history of epilepsy. Photic driving response occurred in 67 EEGs (0.9%), and PPR in 6 EEGs (0.1%), all with a known history of epilepsy. Thus 0.5% (6/1,208) of epilepsy patients had a PPR. Photomyoclonic responses were not observed. Juvenile myoclonic epilepsy was the only factor associated with the presence of PPR (RR=75.26 [11.82-479.21]). PPR was not associated with clinical symptoms or seizures. There was no correlation with the type of treatment or recreational drug use. Conclusions Our results confirm that responses to IPS are rare in adult patients and especially PPR. Moreover, all patients with a PPR had a known previous history of epilepsy. These results question the benefit of IPS in adult patients with no history of epilepsy.

INTRODUCTION Coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with hypercoagulability which can predispose infected patients to both arterial and venous thromboembolic complications. Despite therapeutic anticoagulation, there remains a risk of ischemic strokes, which may lead to adverse patient outcomes. Only a few cases are described in the literature regarding SARS-CoV-2 positive patients developing thrombotic ischemic strokes despite therapeutic anticoagulation. CASE REPORT The following is a case discussion regarding a 71-year-old female with past medical history of hypertension, diabetes mellitus type 2, hyperlipidemia, and hypothyroidism who was admitted with severe SARS-CoV-2 infection to the intensive care unit and later developed acute left upper extremity weakness on the 5th day of her admission. Initial National Institutes of Health stroke scale (NIHSS) was 15. Subsequent brain imaging was significant for right middle cerebral artery ischemic stroke. The patient was therapeutically anticoagulated with 1.5 mg/kg subcutaneous dose of Enoxaparin since day 1 of her admission. D-dimer upon admission was 1.84 mg/L (

Background. An estimated 25% of primary and secondary syphilis, a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum, occurs in patients coinfected with human immunodeficiency virus (HIV) (Chesson et al., 2005). This association is especially evident in men who have sex with men (MSM). In HIV-positive patients, primary syphilis infection may progress more rapidly to the tertiary, and most destructive, stage and reinfection can start with the latent or tertiary stage; in such patients, advanced syphilis may arise without clinical warning signs (Kenyan et al., 2018). It is important to note that neurosyphilis can occur during any stage of infection in all patients, regardless of immunocompetence status (CDC, 2021). Case Presentation. A 56-year-old male with a past medical history of well-controlled HIV with a CD4 count of 700 cells/mm3 and an undetectable viral load, psoriasis, and a remote episode of treated syphilis, presented with a two-week history of a diffuse desquamating rash, alopecia, sinusitis, unilateral conjunctivitis, and blurred vision. His last sexual encounter was over ten months ago. The diagnosis of syphilis was confirmed by microhemagglutination assay, and he was treated for presumed neuro-ocular infection with a two-week course of intravenous Penicillin G. Conclusion. Syphilis has acquired a reputation as “the great masquerader” due to its protean manifestations. It may follow an unpredictable course, especially in HIV-positive patients, including those whose treatment has achieved undetectable serology. For example, ocular syphilis may present in an otherwise asymptomatic individual (Rein, 2020) and alopecia may arise as the sole indication of acute syphilitic infection (Doche et al., 2017). Therefore, a high index of suspicion is warranted in order to prevent severe and irreversible complications.

Purpose The purpose of this study was to report a case of infective necrotizing scleritis following XEN Gel Stent with mitomycin-C. Methods Case report. This is a case report of a 68-year-old woman. Results XEN Gel Stent glaucoma surgery enhanced with mitomycin-C 0.04% and combined with cataract surgery was performed at a regional center to manage the patient's primary open-angle glaucoma. Past medical history was significant for rheumatoid arthritis requiring treatment with methotrexate and adalimumab. Periocular pain and swelling developed 14 months after the initial operation, followed by a rapid deterioration of visual acuity to 20/60, intraocular pressure of 4 mm Hg, and worsening pain 5 months later. On initial presentation to Sydney Eye Hospital, 180 degrees of scleral necrosis was evident with a moderate anterior segment inflammatory reaction and a large temporal choroidal effusion due to hypotony. Empirical hourly topical ofloxacin and cephalothin 5% drops, with oral moxifloxacin, were initiated. Conjunctival swab grew Staphylococcus aureus and Staphylococcus lugdunensis. Significant clinical improvement occurred, but the XEN Gel Stent became exposed after 9 days of treatment with worsening hypotony. Urgent surgical revision was performed to remove the XEN Gel Stent and apply a tutoplast plug with overlying amniotic membrane graft. Intraocular pressure gradually improved over 6 weeks to 15 mm Hg with reversal of hypotonous changes, and visual acuity stabilized at 20/40. Conclusions To our knowledge, this is the first reported case of necrotizing scleritis following XEN Gel Stent insertion. It is a reminder that infection should always be the primary differential diagnosis in patients with surgical-induced necrotizing scleritis.

Congenital agenesis of major salivary glands is considered a very infrequent condition and typically appears to be a coincidental finding. It can be present as sporadic case or may be combined with aplasia or hypoplasia of other salivary glands or the lacrimal glands, or as a part of syndromes. Only 23 cases documented in the literature to date, while the youngest patient was 50 days old. Plenty of radiographic useful techniques and treatment is closely related to the clinical manifestations; therefore. We present a case of 52 year old female who was referred to our radiology department for recurrent numbness of the left upper limb, experienced over the previous three months. Complete absence of the left parotid gland was incidentally demonstrated at the brain MRI scan. Based on the patient's past medical history, physical examination and demonstrated radiographic techniques it was an asymptomatic, no-syndromic and no-familious unilateral aplasia of the parotid gland. In the present report, we aimed to underline that this rare condition may be asymptomatic and co-exist with other medical conditions and syndromes.

Background Constrictive pericarditis (CP) is characterized by scarring and loss of elasticity of the pericardium. This case demonstrates that mixed martial arts (MMA) is a previously unrecognized risk factor for CP, diagnosis of which is supported by cardiac imaging, right and left heart catheterization, and histological findings of dense fibrous tissue without chronic inflammation. Case presentation A 47-year-old Caucasian male former mixed martial arts (MMA) fighter from the Western United States presented to liver clinic for elevated liver injury tests (LIT) and a 35-pound weight loss with associated diarrhea, lower extremity edema, dyspnea on exertion, and worsening fatigue over a period of 6 months. Past medical history includes concussion, right bundle branch block, migraine headache, hypertension, chronic pain related to musculoskeletal injuries and fractures secondary to MMA competition. Involvement in MMA was extensive with an 8-year history of professional MMA competition and 13-year history of MMA fighting with recurrent trauma to the chest wall. The patient also reported a 20-year history of performance enhancing drugs including testosterone. Physical exam was notable for elevated jugular venous pressure, hepatomegaly, and trace peripheral edema. An extensive workup was performed including laboratory studies, abdominal computerized tomography, liver biopsy, echocardiogram, and cardiac magnetic resonance imaging. Finally, right and left heart catheterization—the gold standard—confirmed discordance of the right ventricle-left ventricle, consistent with constrictive physiology. Pericardiectomy was performed with histologic evidence of chronic pericarditis. The patient’s hospital course was uncomplicated and he returned to NYHA functional class I. Conclusions CP can be a sequela of recurrent pericarditis or hemorrhagic effusions and may have a delayed presentation. In cases of recurrent trauma, CP may be managed with pericardiectomy with apparent good outcome. Further studies are warranted to analyze the occurrence of CP in MMA so as to better define the risk in such adults.

Background: Tuberculosis (TB) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) infections are leading causes of morbidity and mortality worldwide. People living with HIV/AIDS (PLWHA) are highly susceptible to TB infection and progression to active TB disease. This study aims to determine the proportion and risk factors of TB among PLWHA in Jazan Region, southwestern Saudi Arabia. Methods: A cross-sectional study was conducted among HIV-infected individuals attending the main referral hospital in Jazan Region during the period 2017–2019. The participants’ TB status, CD4+ lymphocyte count, and viral load were assessed. In addition, their demographic and clinical information was collected using a structured questionnaire. Results: A total of 316 HIV-positive individuals aged between 13 and 81 years (75% male and 25% female) were enrolled in this study. Of them, 30 (9.5%; 95% confidence interval [CI]: 5.2, 10.6%) were diagnosed with TB: 46.7% (14/30) had pulmonary TB and 53.3% (16/30) had extrapulmonary TB. The highest proportion of TB-positive PLWHA was found among participants aged 18–30 years (11.6%) and among non-Saudis (14.0%) when compared to other age groups and Saudi participants (7.4%). Multivariate analysis showed that male gender (adjusted odds ratio [AOR] = 4.79; 95% CI = 1.22, 18.74), past medical history (PMH) of TB (AOR = 29.67; 95% CI = 5.31, 164.32), PMH of other RTIs (AOR = 5.86; 95 % CI = 2.14, 16.06), CD4+ lymphocyte count of

Background To evaluate the value of Glasgow Aneurysm Score (GAS) in predicting long-term mortality and survival in patients who have undergone endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Methods A retrospective single-center study of 257 patients with non-ruptured AAA undergoing EVAR between January 2013 and 2021. GAS scores were compared between the survivors (group 1) and the long-term mortality (group 2) groups. Cox regression analysis was used to determine independent predictors of late mortality. Receiver operating characteristic curve (ROC) analysis was used to determine the optimum cut-off values of GAS values to determine the effect on late-mortality. Survival analysis was conducted using Kaplan-Meier. Results The study included 257 patients with a mean age of 69.75 ± 7.75 (46–92), who underwent EVAR due to AAA. Average follow up period was 18.98 ± 22.84 months (0–88). Fourty-five (17.8%) mortalities occured during long-term follow-up. A past medical history of cancer resulted in a 2.5 fold increase in risk of long-term mortality (OR: 2.52, 95% CI 1.10–5.76; p = 0.029). GAS values were higher in group 2 compared to group 1 (81.02 ± 10.33 vs. 73.73 ± 10.46; p 77.5 were: 12.8% and 24.8% respectively (p = 0.014). Every 10 point increase in GAS resulted in approximately a 2 fold increase in risk of long-term mortality (OR: 1.8, 95% CI 1.3–2.5; p 77.5 were 75.7% and 61.7%, respectively (p = 0.013). Conclusions The findings of our study suggests that an increase in GAS score may predict long-term mortality. In addition, the mortality rates in patients above the GAS cut-off value almost doubled compared to those below. Furthermore, the presence of a past history of cancer resulted in a 2.5 fold increase in long-term mortality risk. Addition of cancer to the GAS scoring system may be considered in future studies. Further studies are necessary to consolidate these findings.

A 33-year-old Japanese man with no significant past medical history was admitted to our hospital for evaluation of weight gain and pitting edema. A laboratory test confirmed nephrotic-range proteinuria. Renal biopsy showed subepithelial deposits, and membranous nephropathy (MN) was diagnosed. Closer examination clarified an active syphilis infection. After renal biopsy, we prescribed amoxicillin for 8 weeks to treat the syphilis infection. Three weeks later, the patient's proteinuria dramatically decreased. This case is of interest because syphilis can become a cause of acute-onset MN in younger adults, and the incidence of syphilis is increasing in Japan. .

Background This report describes the case of a patient whose pituitary microadenoma resolved after he contracted coronavirus disease 2019. To our knowledge, this is one of the first reported cases of pituitary tumor resolution due to viral illness. We present this case to further investigate the relationship between inflammatory response and tumor remission. Case presentation A 32-year-old man in Yemen presented to the hospital with fever, low blood oxygen saturation, and shortness of breath. The patient was diagnosed with coronavirus disease 2019. Past medical history included pituitary microadenoma that was diagnosed using magnetic resonance imaging and secondary adrenal insufficiency, which was treated with steroids. Due to the severity of coronavirus disease 2019, he was treated with steroids and supportive care. Three months after his initial presentation to the hospital, brain magnetic resonance imaging was performed and compared with past scans. Magnetic resonance imaging revealed changes in the microadenoma, including the disappearance of the hypointense lesion and hyperintense enhancement observed on the previous scan. Conclusions Pituitary adenomas rarely undergo spontaneous resolution. Therefore, we hypothesized that tumor resolution was secondary to an immune response to coronavirus disease 2019.

Advances in the care of burn-injured pediatric patients have improved mortality over the last 20 years. However, massive burn injuries (50% TBSA or greater) in pediatric patients, while overall rare, have a significant morbidity and mortality. The primary aim for this study is to analyze treatment and outcomes in massive pediatric burn injuries. A retrospective study of children with burn injuries 50% TBSA or greater who were admitted to Shriners Hospital for Children Northern California, from May 1, 2009 to May 22, 2020, was conducted. Data were collected from the electronic health records through a comprehensive chart review that included: patient demographics, past medical history, treatment interventions, and outcomes. This study included 69 patients (59.4% male) with a mean age of 8.7 ± 6 years. The median time from injury to admission was 2 (1–4) days. In this study, 63.8% of patients were from Mexico, 34.8% were from the United States, and 1% patient was from American Samoa. The median time from injury to admission was 2 (1−4) days. Mean TBSA was 66% ± 12%. The median TBSA of second-degree burns was 0 (0–6) %, and the mean TBSA of third-degree burns was 60% ± 16%. Forty percent of patients suffered an inhalation injury and 83% of patients received a tracheostomy. The median number of days requiring ventilator assistance was 26 (12–58) days. Mean length of hospitalization was 90 ± 60 days, with 61 ± 41 days spent in the intensive care unit. The mean number of surgical procedures was 6 ± 4. The time between surgical procedures was 12 ± 6 days. The median time from admission to the first surgical procedure was 1 (0–2) day. At the first procedure, a mean of 42% ± 15% TBSA of the burn injury was excised. Sixty-two percent of patients received autografting (22% ± 11% TBSA) and 52% of patients received allografting (27% ± 17% TBSA) during the first procedure. For survivors, the median number of inpatient occupational therapy encounters was 143.5 (83–215) and inpatient physical therapy encounters was 139.5 (81–215). Twenty-five percent of the patients included in this study died as a result of their burn injury. Multivariate regression revealed that sustaining an inhalation injury was a significant and independent predictor of death (odds ratio: 3.4, 95% confidence interval: 1.05 to 11, P = .04). Massive burn injuries in children required a very high number of surgical procedures and hospital resources. Most children who died as a result of their massive burn injury died within the first month of admission. Inhalation independently increases the risk of dying in pediatric patients with a massive burn injury.

Background Stevens-Johnson syndrome is a rare medical condition with severe mucocutaneous lesions due to adverse drug reactions characterized by exudative multiform erythema, stomatitis, and conjunctivitis. Long-term oral consequences of such cases include xerostomia, caries, impactions, and multiple dental developmental aberrations as short root anomalies. Aim and objective To highlight the role of pedodontist in early diagnosis and treatment planning of dental abnormalities due to Stevens-Johnson syndrome (SJS) using a cone-beam computed tomography (CBCT). Case description A 16-year-old male reported a chief complaint of decayed posterior teeth. Past medical history revealed adverse reactions to an unknown drug at the age of 4 to 5 years. In addition to carious teeth, clinical examination revealed that all canines were missing along with mandibular incisors. On CBCT examination, abnormal short, plump roots with normal crown were seen in all permanent first molars and incisors along with impacted canines and mandibular incisors. This condition was diagnosed as a "Short root anomaly" (SRA) due to SJS. He was found positive to allergy tests for NSAIDs such as ibuprofen and paracetamol. Conclusion NSAIDs can cause a severe adverse reaction resulting in SJS. If this hypersensitivity reaction occurs early during the development of a permanent tooth it may cause dental anomalies such as short roots, root dysmorphia, agenesis, and multiple impacted teeth. Clinical significance This report highlights a unique case of multiple dental aberrations due to SJS and the role of a pedodontist in the early diagnosis and treatment planning of such cases with the help of CBCT. Short root anomalies can be misdiagnosed as root resorption or immature apex. Medical history, clinical and CBCT findings are essential for diagnosis and treatment in SJS patients. Careful orthodontic treatment planning is required in cases of short root anomalies. How to cite this article Katyal S, Yadav V. Diagnostic and Treatment Approach in the Management of Dental Anomalies Associated with Stevens-Johnson Syndrome: A Case Report. Int J Clin Pediatr Dent 2021;14(4):569-574.

Background. Mucormycosis is a rare and invasive fungal infection, affecting almost exclusively immunocompromised individuals. Immunosuppressive effects of corticosteroids which are widely prescribed in COVID-19 patients might be a predisposing factor for opportunistic infections even though the other factors should also be considered. Case Presentation. A middle-aged man without any significant past medical history was admitted to the hospital due to a severe COVID-19 infection. He received a high dose of corticosteroids as a part of the treatment. Five days after discharge, he presents with a headache and fever. Eventually, orbital mucormycosis was diagnosed for him and he was treated with antifungal medications. Conclusion. Opportunistic infections should be considered during the current pandemic of COVID-19, during which corticosteroids are widely prescribed.

Összefoglaló. Az emlőtumor miatt kezelt, majd gondozott beteget – több tünetmentes év után – fejfájás, szédülés, ataxia, megváltozott, furcsa viselkedés, emlékezetzavar és dezorientáció miatt neurológiai, majd belgyógyászati osztályokon vizsgálták. Az alapos kivizsgálás ellenére a tüneteit magyarázó organikus eltérést nem igazoltak, ugyanakkor már a kezdetektől felmerült a szomatizációs tünetképzés lehetősége, ezért pszichiátriai osztályos felvételére került sor. Az elvégzett vizsgálatok, illetve a klinikai kép regresszív állapotot valószínűsítettek. Terápiás próbálkozásaink ellenére a páciens állapota romlott, végül a megismételt neurológiai vizsgálatok meningitis carcinomatosát igazoltak. Az esettel szemléltetni kívánjuk, hogy a beteg premorbid működési nívója, személyiségstruktúrája hogyan képes befolyásolni az ellátószemélyzetet, milyen külső és belső konfliktusokat válthat ki. A diagnózishoz vezető folyamat bemutatásával fel kívánjuk hívni a figyelmet az interdiszciplináris együttműködés fontosságára. Orv Hetil. 2021; 162(43): 1744–1748. Summary. Our patient with known breast cancer in her past medical history was hospitalized – after several asymptomatic years – for headache, dizziness, ataxia, changed behaviour and disorientation. Thorough internal and neurologic investigations did not find any disease underlying her symptoms, therefore the possibility of somatization disorder was raised. Despite lege artis therapeutic interventions carried out on the psychiatry ward, the patient’s condition deteriorated and repeated neurological examinations eventually revealed carcinomatous meningitis. With this case, we would like to illustrate how the patient’s premorbid function level and personality features might influence the attitude and opinion of the health care personnel, and what kind of external and internal conflicts might be triggered. By presenting the complexity of the diagnostic work-up, we would like to emphasize the importance of interdisciplinary cooperation in the interest of our patients. Orv Hetil. 2021; 162(43): 1744–1748.

Author(s): Correa, Kelly; Craver, Scott; Sandhu, Amar | Abstract: Introduction: Meningitis is a serious and potentially life-threatening infection of the central nervous system. Cryptococcus neoformans is a rare fungal cause of meningitis that commonly presents with atypical symptoms. Although this infection is most common in immunocompromised patients, it also occurs in immunocompetent patients. This case report describes an atypical presentation of cryptococcal meningitis in a seemingly immunocompetent patient.Case Report: A 40-year-old immunocompetent patient with no significant past medical history had visited the emergency department (ED) five times within a span of 30 days reporting dental pain and headache. Throughout each of the visits, no clear symptoms signaling the need for a meningitis workup were observed, as the patient had been afebrile, displayed no nuchal rigidity, and his presenting symptoms subsided within the ED after treatment. A lumbar puncture was performed after emergency medical services brought the patient in for his sixth ED visit, initially for stroke-like symptoms and altered mental status. Spinal fluid was indicative of cryptococcal meningitis.Conclusion: This case highlights the challenge of identifying cryptococcal meningitis in the ED, particularly in immunocompetent patients who do not display classic meningitis symptoms. It also highlights the importance of keeping a broad differential and carefully ruling out diagnoses when patients return to the ED multiple times for the same complaint.

Objective Identifying the morphological features of thymus in patients with myasthenia gravis (MG) with anti-acetylcholine receptor (AChR) antibodies and concomitant Hashimoto's thyroiditis (HT), which were recruited from a single surgical unit of a tertiary referral hospital located in the North-Eastern region of Romania, over a period of 11 years. Patients, materials and methods We retrospectively reviewed clinical, imaging, laboratory, thymic pathology, and outcome data that were obtained from medical records of patients with MG and concomitant HT, to whom a thymectomy was performed for a suspected thymic lesion. All the surgical interventions were done in the Third Clinic of Surgery, St. Spiridon Emergency County Hospital, Iasi, Romania, for an 11 years' period, i.e., from January 1, 2000 and December 31, 2010. Results Four patients (three females and one male) were included. The mean age of the patients at the time of their thymectomy was 40.25 years. Of all patients, 75% had moderate or severe MG, 100% had anti-AChR antibodies, and an electromyographic decrement greater than 25%. All patients have been diagnosed with HT in their past medical history by a full thyroid panel [high thyroid-stimulating hormone (TSH) values, low free thyroxine (fT4) values, and the presence of the anti-thyroid antibodies] and all of them have been treated with Euthyrox. Our four patients expressed different MG subtypes, each of them being associated with different thymus pathology. Thoracic computed tomography (CT) scan revealed heterogeneous mediastinal masses and established the correct diagnosis only in 25% of cases. The pathological exams also revealed a heterogeneous pattern of thymic lesions. In contrast with other studies, our patients with MG with anti-AChR antibodies and concomitant HT presented atrophic thymus more frequently (50%), but with particular morphological changes of Hassall's corpuscles. Also, 25% of cases were diagnosed with thymic lympho-follicular hyperplasia (TLFH) associated with thymic epithelial hyperplasia. In B2 thymoma, neoplastic epithelial cells expressed cytokeratin 19 (CK19) immunoreactivity, high Ki67 labeling index and strong p63 immunopositivity. Conclusions In our series, MG and HT occurred simultaneously, or one of them was diagnosed before the other, raising some new questions regarding the immune mechanism of these two autoimmune diseases. Due to the heterogeneous morphological changes of the thymus that we found in this study, we can hypothesize that thymus is involved in the pathogenic mechanism of MG with anti-AChR-antibodies and concomitant HT development.

Objectives Chronic rhinosinusitis (CRS) affects approximately 12% of the population and leads to increased health care utilization and indirect costs exceeding $20 billion annually in the United States. The Lund‐Mackay score (LMS) measures radiographic disease severity for CRS but poorly correlates with symptom scores. The association between LMS and health care utilization in CRS patients has not yet been investigated. The study aimed to assess the association between health care utilization and CRS radiographic severity using LMS. Methods CRS patients enrolled in a clinical registry were evaluated. Nasal endoscopy findings and LMS were recorded for patients with sinus CT imaging. Patient symptom scores, demographic characteristics, and health care utilization measures were collected. The relationship between these factors and LMS was examined. Results A total of 556 patients met inclusion criteria. Mean age was 45.3 years, 53.4% were male, and 41.7% had nasal polyps. There was no difference in sex, smoking history, 22‐item Sino‐nasal Outcome Test scores, or past medical history factors between patients with high (≥8, n = 410) and low (

Background Since COVID-19 global pandemic, “early awake proning in non-intubated patients with COVID-19” has been suggested as anecdotal evidence. Hereby, we report an awake and non-intubated patient with COVID-19 pneumonia who was successfully managed with early self-proning. Case presentation A 68-year-old male presented to the emergency department with a respiratory distress. He was non-smoker and denied any significant past medical history. His chest computed tomography scan showed “ground glass opacities” and “consolidation areas” located especially in the peripheral sites of both lungs which were consistent with a coronavirus pneumonia and reverse transcription polymerase chain reaction amplification by a nasopharyngeal swab sample for SARS-Cov-2 was also positive. His initial therapy with hdroxychloroquine and favipiravir was started. Due to deterioration of the patient’s oxygenation, he was transferred to the intensive care unit for further treatment with non-invasive mechanical ventilation on supine position and intermittent “awake early self-proning positioning” was applied. Additionally, antibiotherapy, anticoagulant therapy, and convalescent plasma therapy were also administered to the patient. On the 17th day of the ICU admission, he was transferred back to the ward. And the patient was discharged from the hospital on the 19th day of his initial admission. Conclusions Although some case reports and small case series initially noted potential improvement in oxygenation by awake proning, further research is required to evaluate the exact benefits and proper applications of prone positioning in awake patients with COVID-19 pneumonia.

A 27-year-old G1P1 patient diagnosed with a moderately differentiated squamous cell carcinoma of the cervix after cervical biopsy presented for counseling regarding fertility-sparing treatment immediately after diagnosis. The patient had no significant past medical history nor abdominal surgeries.