Revisiting BPPV: Incidence and Behavior of Atypical Variants

The patients with sudden sensorineural hearing loss (SSNHL) may complain of vertigo. Although there have been many reports on SSNHL with vertigo (SSNHL_V), changes in the pattern of nystagmus have not been studied as yet. This study is a retrospective study and aims to investigate the characteristic changes in type of nystagmus and clinical features in patients with SSNHL_V who experienced a change in their nystagmus pattern during follow-up. Among 50 patients with SSNHL_V between January 2012 and December 2015, we identified 15 patients with SSNHL_V whose pattern of nystagmus changed. Initial nystagmus was classified into 5 subgroups: paretic type, irritative type, persistent geotropic direction-changing positional nystagmus (PG-DCPN), persistent apogeotropic direction-changing positional nystagmus (PA-DCPN), and posterior semicircular canal benign paroxysmal positional vertigo. The most common pattern of initial nystagmus was PG-DCPN (n = 7). The change of initial nystagmus pattern occurred on day 2 to 75 from symptom onset, and 2 (of 15) patients showed further conversion. The most common pattern of final nystagmus was PA-DCPN (n = 9). Hearing improvement after treatment was not significantly different (P = .59) between SSNHL_V patients with nystagmus change (25 ± 17 dB, n = 15) and those without nystagmus change (28 ± 18 dB, n = 35). In conclusion, clinician's attention is required in evaluating the vertigo symptom in patients with SSNHL_V because the initial patterns of nystagmus can be converted to another type of nystagmus. The presence of nystagmus change during follow-up may not be a prognosticator for hearing recovery in patients with SSNHL_V.

Predictors of Crohn’s Disease

Covering the Cover

This retrospective study evaluated the use of the Automated Neuropsychological Assessment Metrics (ANAM4) Expanded battery in a clinical setting to determine if the resolution of physiological symptoms, in the absence of neurocognitive assessment, was sufficient data in the return-to-duty (RTD) determination. In this study, 508 U.S. Naval Academy midshipmen were diagnosed with concussion and prescribed a standard treatment protocol. As directed by the protocol, they were evaluated and tracked by medical providers until determined to have normal balance and to be asymptomatic at rest and with exertion. Upon the resolution of these physiological symptoms, the midshipmen were referred for neurocognitive (ANAM4) testing. When results indicated a return to neurocognitive baseline, a RTD determination was made. The analysis of data in this study indicated that RTD determinations based solely on the resolution of physiological symptoms would have resulted in 25.1% of the sample being returned to duty before neurocognitive recovery. Additional analysis of the ANAM4 reliable change index (RCI) data for each of the concussed patients revealed a pattern of scores that correlated with an expected length of recovery. Individuals with at least one RCI greater than or equal to -1.64 returned to neurocognitive baseline in 8.92 days, whereas individuals with 2 or more RCIs greater than or equal to -1.25 (but less than -1.64) returned to baseline in 5.78 days, and those with a difference in measured reaction times that were greater or equal to -1.25 returned to baseline in 3.20 days. Furthermore, findings indicated that female service members required additional time for the resolution of physical symptoms as compared to their male counterparts. The mean number of days from injury to being deemed symptoms free in males was approximately 14, as compared to females who were deemed symptom free in 21 days. This difference is statistically significant. Findings of this investigation revealed three specific outcomes. First, a computerized neurocognitive assessment instrument should be used as an adjunct measure in evaluating the resolution of physiological symptoms following a concussive injury. Second, results revealed that based on the RCIs of postinjury ANAM4 assessments, it is possible to estimate the remaining recovery time needed for a return to neurocognitive baseline. Third, results of this analysis revealed that gender appears to be a factor in time between concussive injury and resolution of symptoms.

Primary cutaneous lymphomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Hypnotherapy for Children With Functional Abdominal Pain or Irritable Bowel Syndrome: A Randomized Controlled Trial

The aim of the study was to present the clinical characteristics, treatment, and outcomes of pediatric collagenous gastritis (CG). This is a retrospective cohort study. Patients were identified via query of the institutional pathology database. Clinical data was obtained by review of medical records. Forty patients (57.5% female) were identified, mean age 11.3 ± 3.7 years (2-16years). Isolated CG was present in 66.7%, coexisting collagenous duodenitis (CD) in 17.5%, collagenous colitis (CC) in 7.5%, and collagenous ileitis in 2.5%. Atopic comorbidities were found in 25%, autoimmune comorbidities in 12.5%. Abdominal pain (77.5%), vomiting (65%), anemia (57.5%), nausea (55.5%), diarrhea (32.5%), anorexia (25.0%), weight loss (25%), gastrointestinal bleed (22.5%), poor growth (20%), poor weight gain (12.5%). All had abnormal endoscopic findings on esophago-gastro-duodenoscopy (EGD), most commonly gastric nodularity (77.5%), visible blood (20%), erosions/superficial ulcerations (10%), ulcers (7.5%). Histologically, all patients had increased subepithelial collagen deposition. A variety of medications aimed towards inflammation and symptomatic treatment were used. Patients with anemia received iron supplementation and responded. Otherwise, there was no significant association of clinical or histologic improvement with specific treatments. 87.5% reported improvement or resolution of symptoms at the last follow-up (34.8 ± 27.0 months). Persistent sub-epithelial collagen was noted in 73.1% on the last EGD. Despite persistent findings of increased sub-epithelial collagen deposition during the follow-up period, most patients with CG show remission or resolution of clinical symptoms. Anemia responds to iron supplementation in all patients.

Purpose: Sparse data exists comparing the presentation of celiac disease in a GI private practice to that of a celiac population at a large tertiary center. Our goal was to understand better how celiac disease presents in the community versus at referral centers and facilitate its future prompt diagnosis to improve health outcomes. Methods: Two databases were reviewed retrospectively and than compared. The first consisted of patients seen in a community based, private GI practice, while the second database, comprised patients evaluated at a large tertiary care center. Patients were identified as having celiac disease via pathological determination. Charts were reviewed for demographic information, tissue transglutaminase antibody (TTG) level, and presenting signs/symptoms. Continuous variables were compared using Student's T test, categorical variables were compared using Fisher's Exact test. Both databases were IRB approved by the respective institutions. Results: The community population consisted of 117 patients with biopsy-confirmed celiac disease while the tertiary population had 770 patients. The mean age at diagnosis was 48.6 (range 18-88) in the community compared to 43.6 in the tertiary setting (p=0.002). The most common reasons for referral to the community practice and tertiary center, respectively, were: diarrhea (58.1% and 40.0%; p=0.01), dyspepsia/abdominal pain (46.2% and 33.2%; p=nss), and anemia (42.7% and 19.4%; p<0.001). Weight loss (25.6% and 16.5%; p=0.05), malaise/fatigue (24.8% and 7.2%, p<0.0001), anxiety/depression (10.3% and 21.0%, p=0.003), and elevated liver enzymes (6.0% and 3.4%, p=nss) were also common at initial assessment. 40.9% of patients at the tertiary care center had no GI symptoms at presentation vs. 18.8% in the community population (p<0.0001). 13.4% of the community patients tested did not meet the lab diagnostic criteria (TTG≥20) for diagnosis of celiac disease while that number was 15.5% in the tertiary care center(p=nss). 89.9% of the community patients that did follow up noted success of therapy either as decrease in symptoms, TTG levels, or both while 91.5% of tertiary care patients noted improvement (p=nss). Conclusion: In comparison to a community GI practice, patients with celiac disease seen at a tertiary referral center were younger with fewer classic symptoms. However, the proportion of TTG negative patients is similar. Both groups had comparable high rates of symptom resolution. Our data are valuable when interpreting celiac disease studies conducted at urban tertiary care centers and then applying findings to community-based GI practices.

Background: The association between interstitial lung disease (ILD), anti-neutrophil cytoplasmic autoantibodies (ANCA) and vasculitis has been described in case reports and small series. Treatment approaches have been diverse and include the use of various immunosuppressive agents. To date, little is known about the clinical phenotype and outcomes of ANCA associated ILD. Objectives: The objectives of this study were to ascertain the prevalence of ANCA in ILD patients at a tertiary respiratory centre; describe the clinical phenotype; describe lung function outcome and examine the progression of computed tomography (CT) patterns in patients with ANCA-associated ILD. Methods: This retrospective observational study was conducted at a tertiary ILD centre. Patients with ILD and coexistent ANCA were identified from review of a clinical database. All patients had a multidisciplinary team diagnosis of ILD confirmed on CT scan and had no other underlying cause of ILD identified. Data regarding clinical characteristics, CT scan pattern of ILD, pulmonary function tests (PFTs) and treatment were collected retrospectively. Results: Sixty-nine patients that fulfilled the criteria of coexistent ILD and ANCA were identified. Thirty-one patients were cANCA positive and 38 patients pANCA positive with a median age of 67 years (interquartile range 15 years). Sixteen patients were positive for MPO–ANCA and eight for PR3-ANCA. Only 26% of the cANCA and 24% of the pANCA population had coexistent ANCA-associated vasculitis diagnosed by a MDT clinic comprising of rheumatology, respiratory and renal physicians. Figures 1 and 2 show the treatment distribution in c and pANCA populations respectively. Approximately 23% of the entire study population did not require treatment. Of the patients that required treatment, steroids were used in 81% of cANCA and 61% of pANCA patients. The most commonly used disease modifying anti-rheumatic drug was mycophenolate mofetil followed by azathioprine and/or methotrexate. Only a small proportion of patients required cyclophosphamide or rituximab. At 24-months follow-up, 68% were alive, 22% deceased and data unavailable for 10% of the cANCA group compared to 61% alive, 2% end-of-life, 16% deceased and 21% unavailable data in the pANCA group. Diffusing capacity of the lungs for carbon monoxide (DLCO) declined in both p and cANCA groups over the first 12 months before improving. This improvement in PFTs is likely due to treatment escalation over time. Overall the pANCA group showed a mixture of progressive fibrotic and inflammatory CT features while the cANCA and MPO-ANCA groups showed predominantly progressive fibrotic CT findings. Kruskal-Wallis test was used to determine whether there was an association between the PFTs of the p and cANCA population at three to six months, 12 months and 24 months. This test was then repeated for comparison of the MPO-ANCA and PR3-ANCA study population. There was no significant difference in lung function over time between the pANCA and cANCA group or MPO-ANCA and PR3-ANCA group. Conclusion: Although pANCA is thought to be associated with ILD or pulmonary fibrosis, we detected equal numbers of c and pANCA in a well characterised population of ILD patients. Approximately one quarter of patients with p or cANCA had an MDT diagnosis of ANCA-associated vasculitis. The clinical and CT characteristics did not differ between c and pANCA ILD patients. The two-year mortality of patients with ANCA and ILD was significant (22% in cANCA-ILD and 16% in pANCA). In surviving patients, the FVC and DLCO improved over a 24-month period. Disclosure of Interests: None declared

Candida urinary tract infections (UTIs) are common nosocomial infections among critically ill patients hospitalized in pediatric intensive care Units (PICU). We aimed to report outcomes of critically ill pediatric patients who received micafungin for hospital acquired Candida UTIs. We analyzed treatment success rates and success rates among different Candida species. This retrospective cohort study included patients who received micafungin for Candida UTI as first choice in our PICU between January 2017 and July 2018. Data, including demographic and clinical features, were retrospectively collected from medical files of the patients. Treatment efficacy was defined as resolution of clinical symptoms and a negative culture for Candida at day 14 after initiation of micafungin treatment. Twenty-four pediatric patients (median age 5.72 years, range, 2 months-16 years) were included in the present study. Fourteen (58.3%) patients had urinary catheters at the time of Candida isolation. Resolution of symptoms and a negative culture at day 3 of micafungin treatment were achieved in 17 (70.8%) and 14 (58.3%) patients, respectively. Moreover, 19 (79.2%) patients had a normal urine analysis and negative culture 14 days after initiation of micafungin treatment. Treatment responses did not statistically differ between Candida species. Micafungin is safe and efficacious in critically ill pediatric patients with Candida UTIs. Its efficacy in our pediatric population was as comparable to that observed in adult studies, therefore, it should be considered as an effective therapeutic option in Candida UTIs of critically ill pediatric patients.

Using Pharmacy Data on Partial Adherence to Inform Clinical Care of Patients With Serious Mental Illness

Non-cystic fibrosis bronchiectasis (NCFB) remains underdiagnosed in pediatric populations, particularly in the Middle East. To characterize the high-resolution computed tomography (HRCT) features of NCFB in pediatric patients, including extent, morphological subtype, and lobar distribution, and to evaluate their associations with underlying clinical diagnoses at a tertiary care center in Oman. We conducted a retrospective cross-sectional study at Sultan Qaboos University Hospital (SQUH), a tertiary center in Oman, reviewing pediatric patients ≤18 years diagnosed with NCFB between January 2000 and December 2022. High-resolution computed tomography (HRCT) reports prepared by pediatric radiologists were reviewed. Data on clinical features, radiological patterns, lobar involvement, and etiologies were analyzed descriptively usingIBM SPSS Statistics for Macintosh, Version 19.0 (IBM Corp.,Armonk, NY). Of the 150 patients reviewed, 61 met the inclusion criteria. The mean age at diagnosis was 7.3 years, with 35 (57.4%) being male. Diffuse bronchiectasis was predominant, observed in 48 patients (78.7%), and involved more than two lobes in 40 cases (65.6%). The left lower lobe was the most frequently affected, seen in 13 patients (21.6%). Cylindrical bronchiectasis was present in all patients, while cystic in 25 patients (41.0%) and varicose in 19 patients (31.1%) forms were more common in those with systemic disorders, such as primary immunodeficiency (PID, 18 patients; 37.5%) and primary ciliary dyskinesia (PCD, 8 patients; 16.7%). Patients diagnosed at age ≥5 years had a significantly higher prevalence of diffuse disease. HRCT is a crucial diagnostic tool for pediatric NCFB, particularly in children with recurrent infections or systemic comorbidities, such as PID or PCD. Early imaging may prevent irreversible damage and guide targeted treatment. Establishing national guidelines for pediatric chest CT utilization and incorporating multidisciplinary assessments may improve diagnostic timeliness and outcomes.

Background Upper gastrointestinal bleeding (UGIB) is one of the most common major medical emergencies. This study sought to determine the epidemiology, clinical characteristics, and outcomes of UGIB in the largest major tertiary care center in Bahrain, compared to regional and international cohorts. Methods We conducted a retrospective cohort study of all patients diagnosed with UGIB between April 2021 and April 2022 in Salmaniya Medical Complex, Bahrain's largest tertiary-level public hospital. The primary outcomes measured included 30-day mortality rates and one-year readmission rates. Other variables collected included demographic factors, baseline characteristics, comorbidities, symptomatology, endoscopic findings, and etiologies of the bleeding. Results A total of 212 patients with UGIB were included. The mean age of the patients was 56.7 ± 19.1 years. More than 50% of patients with UGIB presented with melena and symptoms of anemia. The most common cause of UGIB in Bahrain was duodenal ulcers, which were found in 75 patients (37.7%). One in two patients with UGIB required packed red blood cells, while fresh-frozen plasma and platelet transfusions were reserved for severe cases. The readmission rate within one year of discharge (14.2%) was associated with smoking, cardiac history, melena, gastric malignancy, and rescope during admission. The 30-day mortality (15.6%) was associated with comorbidities of chronic kidney disease, cerebrovascular disease, and hematochezia on presentation. Conclusion Overall, the mortality rate of UGIB in Bahrain is higher than in countries in the region, the UK, and the US, signaling potential gaps in management and a reflection of a more complex patient population.

A 55-year-old man presented to a neuro-otology clinic with a 9-month history of episodic spinning vertigo lasting seconds, triggered by bending forward, lying flat, laughing, or exercising with weights. He noticed fullness in the right ear and unpleasant loudness of his own voice (autophony), without hearing loss or tinnitus. Examination while asymptomatic showed no spontaneous, gaze-evoked or positional nystagmus. Benign paroxysmal positional vertigo (BPPV) was first considered, and he was offered a pair of home video goggles to self-record episodes.1 Three months later, he returned, reporting frequent positional vertigo. Home videos showed paroxysmal rightward torsional down-beating nystagmus on lying supine from the sitting position (latency: 7.2 seconds, duration: 9.4 seconds, peak slow-phase velocity: 10.3°/s; video 1, figure 1, A and B). Sitting up did not produce nystagmus reversal. We hypothesized that this pattern of nystagmus could be provoked by right superior canal (SC) BPPV or unplugging of an SC dehiscence. However, multiple repositioning maneuvers for right SC BPPV/left posterior canal BPPV were conducted without symptom resolution.

IntroductionDescending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM.MethodsIn this retrospective study, patients’ hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002–2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22.ResultsOut of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up.ConclusionWe report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.