Clinical Case Research Articles

An arrhythmic variant of the manifestation of paraneoplastic Loeffler endomyocarditis. Clinical case

A clinical case of chronic undulating course of parneoplastic Loeffler endomyocarditis, the leading manifestations of which were ventricular arrhythmias, is presented. The paper demonstrates the complexity of early diagnosis of a rare pathology in a polymorbid patient and attempts to identify the "keys" to the correct diagnostic and therapeutic tactics for managing such patients.

Electrointestinography, ultrasonographic contractility, and borborygmi of the cecum and colon are not altered by a single episode of hand walking exercise in healthy horses.

To evaluate the effect of hand walking exercise on myoelectrical activity and contractility in normal, healthy horses. Prospective experimental design. A convenience sample of 8 horses were randomized to a control or hand walking treatment group; each horse underwent both treatments. After a 30-minute baseline electrointestinography (EIG), horses were stall rested or hand walked for 15 minutes. Electrointestinography was repeated immediately and at 2 hours. Ultrasonography and auscultation monitored cecal and left ventral colon (LVC) contractions during EIG. Electrointestinography spectral analysis obtained dominant frequency (DF), dominant power (DP), total power (TP) frequency distribution, and changes in slow-wave rhythmic activity. The median (IQR) DF in cycles per minute (cpm) was higher for the cecum (2.067 cpm; IQR, 0.633 cpm) compared to the LVC (2.0 cpm; IQR, 0.396 cpm) but was unchanged by either treatment. Cecal DP (0.0086 mV; IQR, 0.0070 mV) was higher than LVC DP (0.0068 mV; IQR, 0.0051 mV) in the hand walking group, but DP and TP were unaffected by either treatment over time. Borborygmi at all time points were unchanged in both treatment groups. Ultrasonographic contractions were similar across time in both treatment groups and correlated with borborygmi (ρ = 0.63). Dominant power did not correlate with contractions or borborygmi (P > .2081). Brief hand walking as a single strategy to increase gastrointestinal motility did not affect contractility or EIG in normal horses. Fasting and stall rest may not represent the spectrum of severity of gastrointestinal stasis observed in clinical cases. This model is directly applicable to horses fasted prior to surgical procedures.

Cannabinoids and General Anesthetics: Revisiting Molecular Mechanisms of Their Pharmacological Interactions.

Cannabis has been used for recreation and medical purposes for more than a millennium across the world; however, its use's consequences remain poorly understood. Although a growing number of surgical patients are regular cannabis consumers, little is known regarding the pharmacological interactions between cannabis and general anesthetics; consequently, there is not a solid consensus among anesthesiologists on the perioperative management of these patients. The existing evidence about the molecular mechanisms underlying pharmacological interactions between cannabinoids and anesthetic agents, both in animal models and in humans, shows divergent results. While some animal studies have demonstrated that phytocannabinoids (tetrahydrocannabinol [THC], cannabidiol [CBD], and cannabinol [CBN]) potentiate the anesthetic effects of inhalation and intravenous anesthetics, while others have found effects comparable with what has been described in humans so far. Clinical studies and case reports have consistently shown increased requirements of GABAergic anesthetic drugs (isoflurane, sevoflurane, propofol, midazolam) to achieve adequate levels of clinical anesthesia. Several potential molecular mechanisms have been proposed to explain the effects of these interactions. However, it is interesting to mention that in humans, it has been observed that the ingestion of THC enhances the hypnotic effect of ketamine. Animal studies have reported that cannabinoids enhance the analgesic effect of opioids due to a synergistic interaction of the endogenous cannabinoid system (ECS) with the endogenous opioid system (EOS) at the spinal cord level and in the central nervous system. However, human data reveals that cannabis users show higher scores of postoperative pain intensity as well as increased requirements of opioid medication for analgesia. This review aims to improve understanding of the molecular mechanisms and pharmacological interactions between cannabis and anesthetic drugs and the clinical outcomes that occur when these substances are used together.

Impact of biliary-pancreatic double stents on EUS-guided tissue acquisition among patients with solid pancreatic lesions: A multicenter study

ABSTRACT Background and Objective Although the impact of biliary stents on the accuracy of EUS-guided tissue acquisition (EUS-TA) is still controversial, the influence of biliary-pancreatic double stents on EUS-TA is even more inconclusive. The aim of the study was to determine whether the diagnostic yield of EUS-FNA in the diagnosis of solid pancreatic lesions will be affected after placement of biliary-pancreatic double stents. Methods A multicenter retrospective study including patients who underwent EUS-FNA with biliary duct obstruction was performed. Patients were divided into 2 groups according to whether there were biliary-pancreatic double stents before EUS-FNA. The patients' EUS-FNA report, histopathological results, and clinical case data were reviewed and compared. Results Ninety-two patients were included, 42 with biliary-pancreatic double stents and 50 without any stents. The puncture time taken by EUS-FNA was significantly longer in the stent group than the no-stent group (19 vs. 15 min, P < 0.001). No significant differences were observed in accuracy (90.5% vs. 94%), sensitivity (89.5% vs. 93.6%), specificity (100% vs. 100%), NPV (50% vs. 50%), PPV (100% vs. 100%), respectively, in both groups. Patients with larger lesions (OR = 1.600, 95% CI: 1.124–2.277) and those who required more passes had a higher diagnostic yield (OR = 9.376, 95% CI: 1.356–64.819) by multivariate analysis. Conclusions ERCP before EUS-FNA is feasible for the treatment of solid pancreatic lesions causing obstructive jaundice. It will not have a negative impact on the diagnostic accuracy and surgical complications, but the EUS-FNA operation time will be prolonged.

Spindle Cell Variant of Rhabdomyosarcoma: An Aggressive Clinical Case of the Oral Cavity

Rhabdomyosarcoma (RMS) is a malignant, soft tissue neoplasm consisting of cells derived from the primitive mesenchyme that exhibit a profound tendency to myogenesis. Historically, the spindle cell and sclerosing variants were subcategorized under embryonal type RMS. Spindle cell/sclerosing RMS (S-ScRMS) was recently recognized in 2013 by the World Health Organization as a stand-alone entity. Current data support that certain S-ScRMS cases have a more aggressive clinical course with a reduction of long-term survival, and those found in the head and neck region often exhibit extensive local recurrence. Here, we highlight an aggressive clinical course of S-ScRMS by presenting a case of a 7-year-old male child who presented with complaints of swelling in left cheek since 15 to 20 days. It was associated with pain. He was diagnosed as S-ScRMS and received chemotherapy but the disease was aggressive and progressed on chemotherapy. He received radiation but still the disease was inoperable, hence was kept on supportive care.

Clinical case of successful treatment of focal ventricular arrhythmia in a patient with arrhythmogenic mitral valve prolapse

The problem of managing of patients with mitral valve prolapse and ventricular arrhythmias — arrhythmogenic mitral valve prolapse — is quite relevant in routine clinical practice, which led to the creation in 2022 of an expert consensuses on the management of such patients. Based on the criteria, it is possible to identify a group of people at high risk of sudden cardiac death and implement measures to prevent death. How to manage patients at moderate risk of sudden cardiac death remains unclear. A clinical case of successful treatment of ventricular arrhythmias in a patient with arrhythmogenic mitral valve prolapse is presented.

High-altitude hypoxia exposure alters follicular metabolome and oocyte developmental potential in women.

To explore the effects of high-altitude hypoxia on the microenvironment of oocyte development and fertilization potential, we compared the metabolomic patterns of follicular fluid from women living in different altitude areas and traced their oocyte maturation and subsequent development. A total of 315 clinical cases were collected and divided into three groups according to their residence altitudes: 138 cases in low-altitude (< 2300m) group, 100 cases in middle-altitude (2300-2800m) group and 77 cases in high-altitude (> 2800m) group. The clinical outcomes were statistically estimated, including hormonal level, oocyte maturation, in vitro fertilization, and embryo development. Meanwhile, a metabolomic analysis was performed on the follicular fluid of women from different groups using ultra-high-performance liquid chromatography and high-resolution mass spectrometry and differential metabolites were analyzed through the KEGG pathway. The clinical data indicated that the physical condition and reproductive hormone secretion were similar among different groups. Although personalized gonadotropin-releasing hormone strategies were applied, the numbers of antral follicles and obtained oocytes were not impacted by the residence altitude change. In in vitro culture, the maturing rate, fertility rate and cleavage rate of high-altitude group were compared with the other groups. However, the rates of high-quality embryo, formative blastocyst, and available blastocyst were gradually decreased with the rise of residence altitude. Metabolome analysis identified 1193 metabolites in female follicular fluid. Differential analysis indicated that metabolic components in follicular fluid were remarkably changed with the elevation of residence altitude. These differential metabolites were closely related with amino acid metabolism, protein digestion and absorption, oocyte meiosis and steroid biosynthesis. The residence altitude alters the microenvironment of follicular fluid, which could damage the oocyte developmental potential. This study provides diagnostic basis and therapeutic targets for research on female oocyte and embryo development.

A safe, novel and ingenious method for autogenous bone graft storage in spine surgery with constrained resources - operative site as the bone bank.

The aim of our study is to establish whether the bone graft harvested and stored in the surgical wound by our novel technique is safe, reproducible and preserves the viability of the graft. In doing so, it promises successful bony fusion in spine and orthopaedic surgeries. A prospective clinical case series was conducted for autogenous bone graft storage in complex spine surgeries requiring staged procedures, in resource constrained settings. The bone graft harvested was morselized, wrapped in moist sterile gauze and stored in the paraspinal gutter within the operative site. Thereafter, the surgical wound was easily closed without tension. During the second stage surgery, the stored bone was retrieved and mixed with more autologous/allogenic bone (if necessary) and appropriately laid at fusion sites. Bacterial samples were sent before implantation. 16 complex spinal deformity patients who underwent surgery in a resource constrained hospital over a period of 5 years were included. Duration between both stages was within 2 weeks. All patients showed successful fusion, with mean follow-up of 2.6 years. There were no cases of deep or systemic infection in our series. Surgeons found harvesting, storing and retrieval of graft to be straightforward. The operative site provides an ideal, safe and reproducible location for bone graft storage for staged surgeries conducted in resource constrained situations. The osteogenic potential of the autogenous bone graft is retained. This technique can be extrapolated to other orthopaedic surgeries conducted under resource limited environments like in surgical camps or combat medical facilities.

Clinical Case of Acute Analgesic Nephropathy in a 14-Year-Old Child

Clinical Case of Acute Analgesic Nephropathy in a 14-Year-Old Child

Using case-based learning to teach evidence-based practice: A pilot study.

The American Speech-Language-Hearing Association (ASHA) promotes the use of evidence-based practice (EBP) in the provision of clinical services by speech-language pathologists (SLPs). Therefore, training in the EBP process is vital in the education of future SLPs. Case-based learning (CBL) has been found effective in facilitating transfer of knowledge and skills in various fields; however, its utilisation to teach EBP to SLP students is understudied. This phenomenological investigation explores the use of CBL, an active learning strategy that gives students the opportunity to practice application of knowledge to realistic scenarios, to teach EBP to graduate SLP students. Graduate SLP students worked in small groups to complete an article review activity centred around an assigned hypothetical clinical case. Students submitted article review papers and written reflections on their learning process. The written reflections and review papers were analysed using qualitative content analysis to understand students' approach to clinical cases and their perspectives on the CBL approach. Analysis of the papers and reflections indicated that students tended to rely heavily on scientific evidence for clinical decision making, often to the exclusion of clinical expertise or client perspectives. Students reported that the project was applicable to their future clinical practice. Further, they reported learning from multiple sources, including the instructor, class discussion and their peers. Results indicate that graduate SLP students found CBL activities beneficial for learning the principles of EBP. Students specifically indicated an appreciation for the realistic nature of the activities. Future applications are examined.

Textual Analysis of CT and MR images in bladder cancer: The promise and pitfalls in systematic review

Introduction: Textual analysis is a new stage in the development and improvement of radiology. Textual analysis (TA) or radiomics is a method of in-depth study of medical images using specialized computer programs. It`s based on the quantification of invisible features and provides tools for researchers to gain deep insights into tumor morphology.A number of mathematically extracted texture features (TF) can be correlate with morphological, molecular and genotypic characteristics of the studied field of interest. Aim: Analysis of the literature and comparative evaluation of publications to perform challenges and possibilities of texture analysis in bladder cancer. Materials and methods: We searched for scientific publications in the PubMed and Google Scholar information and analytical systems for 2016-2024 by keywords: «bladder cancer», «bladder cancer radiomics», «mri bladder cancer»». As a result, 40 articles were selected for analysis. Results: Our review demonstrates the methodology, challenges, opportunities and prospects of TA CT and MP imagesin bladder cancer.Numerous studies have demonstrated high accuracy of radiomics in local staging and estimation of tumor morphology, as well as in prediction of clinical outcomes. Conclusion: TA in controversial clinical cases is a useful way of increasing theinformationobtainable frommedical images. Further validation of these methodis required however.

From caustic soda ingestion to feeding jejunostomy

Abstract We present the case of a young woman who after ingestion of caustic soda for autolytic purposes presented diffuse stenosis in the middle and lower thirds of the esophagus and extensive and marked stenosis of the body, gastric antrum and duodenal bulb that required a feeding jejunostomy due to total intolerance to solids and liquids. Given the characteristic endoscopic and radiological findings, as well as its difficult subsequent management, it is a challenging clinical case.

Multiple morcelloma of the peritoneal cavity: a case report

Introduction. Uterine fibroids are benign monoclonal hormone-sensitive tumors arising from smooth muscle cells of the cervix or body uterus. Myomectomyhas become a treatment «golden standard» upon transition to the strategy of organ-preserving surgery. The introduction of morcellation into wide clinical practice allowed to expand the indications for laparoscopic myomectomy, which is usually much better tolerated by patients due to lower invasiveness, short period of rehabilitation and low blood loss. However, the use of morcellators along with the obvious advantages has also specific complications particularly emergence of iatrogenic parasitic fibroids of the abdominal cavity upon improper surgery technique.Aim: analysis of a clinical case of multiple morcelloma.Case presentation. Female patient I., 57 years old, underwent laparoscopic myomectomy in 2003. In 2023 during a routine examination at the Central Clinical Hospital «RZD-Medicine» multiple asymptomatic iatrogenic fibroids of the abdominal cavity were revealed. The patient underwent planned surgical intervention to remove all abnormal masses.Results. During the revision upon surgical intervention, a node of 1.5×1.5 cm was found on the parietal peritoneum along the left anterior wall, as well as a node of 1.5×1.5 cm on the parietal peritoneum along the right anterior wall. There was also observed a 2×3 cm node at the edge of the omentum. In the left and right side of peritoneum of the sacro-uterine ligament, there were found nodes of up to 1 cm in size. In the area of the small intestinal mesentery, a dense node of 4.5 cm was observed 70 cm away from the ileocecal valve. Due to small size, all the fibroids were extirpated and removed from the abdominal cavity without morcellation, complete hemostasis was performed. No complications were noted during postoperative period.Conclusion. Iatrogenic fibroids are quite rare but nevertheless a potential complication of laparoscopic myomectomy. Gynecologists should pay special attention to follow proper technique upon surgical intervention. Morcellation and subsequent extraction of fibroids should be performed strictly with use of airtight container to avoid ingress of myomatous tissue into the abdominal cavity followed by emergence of iatrogenic fibroids.

Adaptive questionnaires for facilitating patient data entry in clinical decision support systems: methods and application to STOPP/START v2

Clinical decision support systems are software tools that help clinicians to make medical decisions. However, their acceptance by clinicians is usually rather low. A known problem is that they often require clinicians to manually enter a lot of patient data, which is long and tedious. Existing solutions, such as the automatic data extraction from electronic health record, are not fully satisfying, because of low data quality and availability. In practice, many systems still include long questionnaire for data entry. In this paper, we propose an original solution to simplify patient data entry, using an adaptive questionnaire, i.e. a questionnaire that evolves during user interaction, showing or hiding questions dynamically. Considering a rule-based decision support systems, we designed methods for determining the relationships between rules and translating the system’s clinical rules into display rules that determine the items to show in the questionnaire, and methods for determining the optimal order of priority among the items in the questionnaire. We applied this approach to a decision support system implementing STOPP/START v2, a guideline for managing polypharmacy. We show that it permits reducing by about two thirds the number of clinical conditions displayed in the questionnaire, both on clinical cases and real patient data. Presented to clinicians during focus group sessions, the adaptive questionnaire was found “pretty easy to use”. In the future, this approach could be applied to other guidelines, and adapted for data entry by patients.

The Importance of the Skin Syndrome in the Primary Diagnosis of Connective Tissue Diseases in Children: Case Report

Background. Timely verification of the clinical diagnosis of connective tissue diseases in children based on the onset of the earliest symptoms, including skin manifestations, and timely initiation of treatment can prevent the development of irreversible complications, increase the life expectancy of patients and its quality. The aim of the study. To analyze the nature of skin manifestations as a marker of the onset connective tissue disorders, such as systemic lupus erythematosus (SLE), localized scleroderma (morphea), juvenile dermatomyositis (JDM), juvenile polyarteritis nodosa (PAN), systemic juvenile idiopathic arthritis (SJIA), and the timing of the main clinical diagnosis from the moment of manifestation of connective tissue disorders. To clearly demonstrate the importance of skin syndrome in the timeliness of clinical diagnosis, a clinical case is presented. Methods. Analysis of medical records and prospective observation of 47 patients aged up to 17 years 11 months with an established diagnosis of connective tissue diseases and the presence of skin syndrome at the onset of the disease. Results. Among patients with SLE, only 20.0% of children had skin syndrome only in the form of butterfly rash, and other skin manifestations were noted in 80.0% of patients. The period from the onset of skin syndrome to diagnosis was 8.0 ± 2.1 months. In 57.2% of patients with morphea, skin syndrome was detected exclusively in the form of single or multiple elements, and in 42.8% there was a combination of a pathognomonic morphological element with alopecia and scleroderma. The average time to make a clinical diagnosis of morphea from the onset of the skin syndrome was 11.0 ± 1.9 months. In all patients with JDM, skin manifestations were characterized by polymorphism (papules and Gottron’s sign, heliotrope rash, palmar capillaritis, livedo reticularis, cheilitis). The diagnosis was made 14.0 ± 3.2 months from the onset of skin syndrome. In patients with documented PAN, skin manifestations debuted in the form of erythema, areas of necrosis, palmar capillaritis, livedo reticularis, and cheilitis. The period from the onset of skin syndrome to clinical diagnosis was 6.0 ± 2.4 months. Among patients with SJIA, skin syndrome was represented by a maculopapular rash associated with fever and its regression when body temperature normalized. The period until clinical diagnosis was made from the onset of the skin syndrome was 2.0 ± 1.1 months. Conclusion. In most cases, the skin syndrome in patients at the onset of the disease was characterized by polymorphism and diversity of elements with the involvement of the vascular component. At the same time, the time from the debut of connective tissue disease in the form of the appearance of skin syndrome to the clinical diagnosis varied in the range from 2 to 14 months.

Botulinum toxin type A treatment for a parotid gland injury in two adult horses

SummaryThe most common disorder affecting the salivary glands in horses is trauma to the parotid gland or duct. Several management techniques have been described, each with their own set of complications. The objective of this case report was to describe the direct injection of botulinum toxin type A into the parotid gland and its outcome in two clinical cases involving damage to either the parotid salivary gland or its duct. Both cases involved iatrogenic damage to either the parotid salivary gland or its duct. Treatment for both cases involved the injection of 200 units of botulinum toxin type A into the parotid gland in order to reduce salivary production and to prevent the potential development of a chronic fistula. Follow‐up assessment after the treatment was conducted via telephone consultation and photographs from the owners. In both clinical cases, a marked reduction in saliva production from the parotid gland was noted within 2 days after toxin injection and the wounds healed without complication. In the first case, the treatment was repeated after 3 weeks. No short‐ or long‐term side effects after injection were reported by the owners. Limitations were the small number of cases and the lack of literature regarding the dose and treatment regime for botulinum toxin type A in horses. It was concluded that the administration of botulinum toxin type A appears to be a safe and effective therapeutic alternative or complementary procedure for the treatment and prevention of parotid gland or duct fistulas in horses.

Potential biomarkers of the effectiveness of pathogenetic therapy of spinal muscular atrophy in adults

The review summarizes and systematizes data on the prognostic significance of various biomarkers in determining the effectiveness of pathogenetic therapy for spinal muscular atrophy. The review includes a clinical case of a patient with type 3 spinal muscular atrophy. The case illustrates that a decrease in the level of heavy chains of neurofilaments in the cerebrospinal fluid of the patient during the use of pathogenetic therapy with nusinersen positively correlated with an improvement in motor function, assessed by standard functional scales.

Exploring the Role of Neutrophil Extracellular Traps in Systemic Lupus Erythematosus: A Clinical Case Study and Comprehensive Review.

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THE IMPACT OF PHOSPHORUS WEAPONS DURING A FULL-SCALE WAR

Due to military actions, there is destruction of Ukraine's ecosystems, deterioration of sanitary and hygienic indicators of drinking water, air, and soil. With the onset of full-scale war, the negative impact of harmful and dangerous substances (the use of chemical, phosphorus bombs, and other weapons) prohibited by the Geneva Convention leads to unforeseen consequences for the environment of Ukraine. The purpose of the study is to analyze injuries resulting from the action of white phosphorus of various types of phosphorus weapons, namely explosive weapons with a wide area of effect, mines, ammunition, long-range missiles; artillery, mortar shells, various types of grenades in the conditions of russian aggression against Ukraine. The following methods were used in the work: content analysis, comparative analysis, and systematization of the researched material. Research of scientific publications by domestic and foreign scientists using the PubMed and Google Scholar databases for the period 2001-2023 was conducted. Phosphorus munitions such as WP are known for their high effectiveness in combat operations, but also lead to serious injuries, both traumatic and post-traumatic psychological changes. White phosphorus (explosive bombs) causes burns of human body tissues upon contact with burning material, as well as burns of the upper respiratory tract due to inhalation of smoke or gases emitted during combustion. The article analyzes the regulatory framework prohibiting the use of phosphorus munitions in armed conflicts. Clinical cases of gunshot combined injuries of limbs with massive soft tissue defects, gunshot fractures, and the presence of multiple foreign bodies of metal density due to the use of phosphorus munitions are considered. An analysis of scientific research by foreign scientists on this issue was conducted. The article provides algorithms for providing first aid due to the action of phosphorus munitions, as well as methodological recommendations of the Ministry of Health of Ukraine (Order of the Ministry of Health of Ukraine No. 506 of March 20, 2022) for providing medical assistance at the prehospital stage in case of phosphorus munition injuries, burns, enteral poisoning, exposure to white phosphorus in the eyes.

Occupational Stress, Psychological Distress, and Psychoactive Substance Use: A Clinical Case Study

Occupational stress has become a major global issue, affecting workers' mental health and well-being. Increasing pressures in the professional environment have led to a significant rise in psychological distress among many individuals. To cope with this growing pressure, individuals resort to coping strategies and defense mechanisms, including the use of psychoactive substances. Objective: This study aims to highlight the complex interactions between occupational stress, psychological distress, and the use of psychoactive substances, with a focus on the underlying psychological processes of this comorbidity in a clinical case. Method: A clinical study was conducted on a Moroccan worker who presented both chronic occupational stress and cannabis dependence, with a thorough psychodynamic analysis. Results: The psychodynamic analysis of clinical cases revealed that personal factors, such as low self-esteem, lack of self-confidence, poor self-management, alexithymia, introversion, and narcissistic gaps, can be precipitating factors for stress. They can also lead to psychoactive substance use, which is used as a defensive and adjustment mechanism to restore psychological balance. Conclusion: Occupational stress weakens an individual's psychological resources, leading them to seek psychoactive substances as a means of defense, anesthesia, and avoidance of psychological suffering, in a form of self-medication.