Clinical Case Research Articles

Uncommon Neurosyphilis: Subacute Meningomyelitis with Distinctive “Candle Guttering Appearance”

AbstractIn this article, we presented an exceedingly rare clinical case of neurosyphilis, radiological revealed a distinctive “candle guttering appearance.” Posttreatment for syphilis, both clinical symptoms and radiological markers showed complete resolution.

Purple urine bag syndrome: a unique clinical case and management considerations

Purple urine bag syndrome (PUBS) is a rare and unusual event. It is related to symptomatic urinary infection and asymptomatic bacteriuria in patients with indwelling bladder catheters. The purple color of the urine is due to metabolic products of biochemical reactions formed by bacterial enzymes in the urine. Gastrointestinal tract flora breaks down the amino acid tryptophan into indole, which is subsequently absorbed into the portal circulation and converted into indoxyl sulfate. Indoxyl sulfate is then excreted into the urine, where it can be broken down into indoxyl if the appropriate alkaline environment and bacterial enzymes are present. The breakdown products, indigo, and indirubin appear blue and red. We reported on an elderly woman who was kept in a nursing home, had multiple comorbidities such as history of cerebrovascular accident (CVA), acute kidney injury (AKI) and she was hospitalized due to decreased consciousness, fever and kidney failure. On the third day of hospitalization, the patient developed PUBS while undergoing urinary catheterization in the hospital. She had no history of previous catheterization and chronic use of antibiotics, she was only using Tolterodine for a long time due to urinary urgency. Due to antibiotic resistance, the drugs were not changed and the purple color disappeared after changing the catheter and urinary bag.This was the first patient in this region to be reported with this manifestation.

Performance of Multimodal Artificial Intelligence Chatbots Evaluated on Clinical Oncology Cases

Multimodal artificial intelligence (AI) chatbots can process complex medical image and text-based information that may improve their accuracy as a clinical diagnostic and management tool compared with unimodal, text-only AI chatbots. However, the difference in medical accuracy of multimodal and text-only chatbots in addressing questions about clinical oncology cases remains to be tested. To evaluate the utility of prompt engineering (zero-shot chain-of-thought) and compare the competency of multimodal and unimodal AI chatbots to generate medically accurate responses to questions about clinical oncology cases. This cross-sectional study benchmarked the medical accuracy of multiple-choice and free-text responses generated by AI chatbots in response to 79 questions about clinical oncology cases with images. A unique set of 79 clinical oncology cases from JAMA Network Learning accessed on April 2, 2024, was posed to 10 AI chatbots. The primary outcome was medical accuracy evaluated by the number of correct responses by each AI chatbot. Multiple-choice responses were marked as correct based on the ground-truth, correct answer. Free-text responses were rated by a team of oncology specialists in duplicate and marked as correct based on consensus or resolved by a review of a third oncology specialist. This study evaluated 10 chatbots, including 3 multimodal and 7 unimodal chatbots. On the multiple-choice evaluation, the top-performing chatbot was chatbot 10 (57 of 79 [72.15%]), followed by the multimodal chatbot 2 (56 of 79 [70.89%]) and chatbot 5 (54 of 79 [68.35%]). On the free-text evaluation, the top-performing chatbots were chatbot 5, chatbot 7, and the multimodal chatbot 2 (30 of 79 [37.97%]), followed by chatbot 10 (29 of 79 [36.71%]) and chatbot 8 and the multimodal chatbot 3 (25 of 79 [31.65%]). The accuracy of multimodal chatbots decreased when tested on cases with multiple images compared with questions with single images. Nine out of 10 chatbots, including all 3 multimodal chatbots, demonstrated decreased accuracy of their free-text responses compared with multiple-choice responses to questions about cancer cases. In this cross-sectional study of chatbot accuracy tested on clinical oncology cases, multimodal chatbots were not consistently more accurate than unimodal chatbots. These results suggest that further research is required to optimize multimodal chatbots to make more use of information from images to improve oncology-specific medical accuracy and reliability.

MANEJO DO PACIENTE ONCOLÓGICO PRÉ E PÓS RADIOTERAPIA DE CABEÇA E PESCOÇO COM AUXÍLIO DA LASERTERAPIA NA CICATRIZAÇÃO E NO TRATAMENTO DAS MUCOSITES: RELATO DE CASO

Dental treatment for patients with head and neck cancer before and after treatment continues to be extremely important due to the impacts caused by the disease and the effects of its treatment, which in turn end up debilitating the health of these patients. In these cases, patients may present with oral and oropharyngeal mucositis and osteoradionecrosis, which are complications of head and neck radiotherapy. The aim of this paper is to report the clinical case of a 65-year-old male patient diagnosed with Non-Keratinizing Squamous Cell Carcinoma in the left parotid region. The patient sought dental care at the Dentistry Clinic of Faculdade São Lucas in Porto Velho – RO, referred for multiple extractions prior to chemotherapy and radiotherapy treatment. During intraoral inspection, it was possible to observe very poor oral hygiene, periodontal disease, fractured teeth, biofilm and dental caries. Surgical planning was therefore carried out for the extraction of 11 teeth in two sessions. In order to achieve this objective, the method used was the clinical case and a bibliographic review of scientific articles published in the last ten (10) years, without language restrictions, and indexed on the following search sites: PUBMED, ScientificElectronic Library (SciELO) and Google Scholar using the following keywords: “cancer patient”, “mucositis”, “laser therapy” and “head and neck radiotherapy”. Of all the articles found using the strategy described above, only twenty (20) met the inclusion and exclusion criteria.

A one-stage radical surgical treatment of hidradenitis suppurativa of stage III by the Hurley classification of axillary location with wound plastic surgery using a posterior shoulder flap (a clinical case)

A one-stage radical surgical treatment of hidradenitis suppurativa of stage III by the Hurley classification of axillary location with wound plastic surgery using a posterior shoulder flap (a clinical case)

Virulome and phylogenomic profiling of a novel Burkholderia pseudomallei strain from an Indian clinical isolate.

Highly pathogenic Burkholderia pseudomallei is the causative agent of melioidosis, a neglected tropical disease endemic in Southeast Asian tropical region. This bacterium encompasses diverse virulence factors which further undergo dynamic gene-expression flux as it transits through distinct environmental niches within the host which may lead to manifestation of differential clinical symptoms. B. pseudomallei, is classified as a Tier 1 select agent in the United States and regarded as a risk group 3 organism in India with the potential to be used as bioweapon. Considering these facts, it is vital to uncover both physiological and genetic heterogeneity of B. pseudomallei, particularly to identify any novel virulence factors that may contribute to pathogenicity. B. pseudomallei strain CM000113 was isolated from a clinical case in India, characterized it for its physiological, biochemical, and prominently genetic traits through WGS. It has a type 2 morphotype with faster doubling time and high biofilm producing capacity as compared to Pseudomonas aeruginosa. The genome size is 7.3 Mbp and it is phylogenetically close to B. pseudomallei strain Mahidol 1106a and Burkholderia mallei Turkey 2. We observed genetic heterogeneity, as key virulence factors that were identified shows sequence dissimilarity with reference strains. Additionally, presence of genomic islands, harbouring two virulence factors, GmhA and GmhB2, associated with pathogenesis indicates possibility of horizontal gene transfer. These results emphasize the need for an extensive study focusing the genome of B. pseudomallei and its associated heterogeneity, to identify molecular biomarkers aiding to develop point-of-care diagnostic kits for early diagnosis of melioidosis.

Animal neuropathic pain aroused by conglutinating oxidative regenerative cellulose on dorsal root ganglion.

Neuropathic pain arises as a consequence of injury or disease in the peripheral or central nervous system. Clinical cases have shown that spine postoperative chronic neuropathic pain remains a troublesome issue in medical treatment due to the presence of various degrees of peridural fibrosis and different inflammatory factors after spinal surgery. To address this issue, we developed a new neuropathic mice model that successfully simulates the real clinical situation by applying oxidative regenerative cellulose to L5 DRG (dorsal root ganglion). Behavior tests were done by von Fray and thermal stimuli. ELISA and real-time PCR were employed to detect the expression of genes involved in neuropathic pain. This model not only successfully induces chronic pain but also causes membrane thickening, non-neuronal cell recruitment, and a local increase of TNFα and interleukin-6. Additionally, this model did not cause neuron loss in the affected DRG, which mimics the characteristics of sticky tissue-induced neuropathic pain after clinic surgery. Based on this model, we administrated a TNF inhibitor to mice and successfully reduced mechanical allodynia after DRG surgery. In this study, the developed animal model may be a novel platform for delivering neuropathic pain treatments, such as target-based drug discovery or personalized diagnostic approaches.

Analysis of Powassan Virus Genome Sequences from Human Cases Reveals Substantial Genetic Diversity with Implications for Molecular Assay Development

Powassan virus (POWV) is an emerging tick-borne virus that causes severe meningoencephalitis in the United States, Canada, and Russia. Serology is generally the preferred diagnostic modality, but PCR on cerebrospinal fluid, blood, or urine has an important role, particularly in immunocompromised patients who are unable to mount a serologic response. Although the perceived poor sensitivity of PCR in the general population may be due to the biology of infection and health-seeking behavior (with short viremic periods that end before hospital presentation), limitations in assay design may also contribute. Genome sequences from clinical POWV cases are extremely scarce; PCR assay design has been informed by those available, but the numbers are limited. Larger numbers of genome sequences from tick-derived POWV are available, but it is not known if POWV genomes from human infections broadly mirror genomes from tick hosts, or if human infections are caused by a subset of more virulent strains. We obtained viral genomic data from 10 previously unpublished POWV human infections and showed that they broadly mirror the diversity of genome sequences seen in ticks, including all three major clades (lineage I, lineage II Northeast, and lineage II Midwest). These newly published clinical POWV genome sequences include the first confirmed lineage I infection in the United States, highlighting the relevance of all clades in human disease. An in silico analysis of published POWV PCR assays shows that many assays were optimized against a single clade and have mismatches that may affect their sensitivity when applied across clades. This analysis serves as a launching point for improved PCR design for clinical diagnostics and environmental surveillance.

Visual Snow Syndrome is unstable: A longitudinal investigation of VSS symptoms in a Naïve population.

This study aimed to investigate the nature of subclinical Visual Snow Syndrome (VSS). We sought to develop a means of recruiting naïve participants with subclinical VSS symptoms to participate in research; and to understand whether subclinical VSS symptoms are stable across time. VSS is a recently characterised neurological condition, whose primary symptom is visual snow (dynamic noise in the visual field). There is evidence that VSS may be common in the general population and that it is unnoticed by many who experience it. To fully characterise VSS, it is important to understand whether (and how) subclinical VSS progresses to a clinical form. Here, we present two related studies: Study 1 develops and validates the Melbourne Visual Snow Questionnaire (MVSQ), a tool for screening the general populationfor VSS symptoms; and Study 2 investigates the stability of subclinical VSS. We developed the MVSQ based on the results of other recent work investigating undiagnosed cases of VSS, and a validated questionnaire designed to identify people with tinnitus for research participation. We then tested the MVSQ in a population with clinical VSS, including assessing face validity (i.e., the extent to which people with clinical VSS believed the questionnaire accurately captured their symptoms). In Study 2, we deployed the MVSQ in a naïve sample of 155 participants, who completed the MVSQ twice, 6 weeks apart. The results of Study 1 indicated that the MVSQ was a viable method of recruiting people who experience VSS symptoms for research participation. It was deemed to have appropriate face validity and to pose little burden to those who completed it. In Study 2, VSS symptoms changed substantially across a 6-week period. Cohen's weighted kappa for diagnosis was 0.56, 95% CI [0.43, 0.69]. However, the impact of perceptual experiences was low and did not change over time, rank ICC = 0.71, 95% CI [0.59, 0.82]. The MVSQ is appropriate for assessing perceptual experiences in the general population. Determining the exact time scale across which symptoms fluctuate is important for understanding both clinical and subclinical cases of VSS.

Tratamento endodôntico em sessão única em dentes com lesão apical: relato de caso

Endodontics is a branch of dentistry responsible for treating the inside of the teeth through endodontic treatment. One of the main objectives of endodontic treatment is to guide the root canal system to a clean place, consequently eliminating microorganisms, providing the cure of the infection and later restoring the function of the tooth. Endodontic treatment performed correctly is successful in the long term regardless of the number of sessions, therefore, endodontic treatment in a single session is a great alternative due to the saving of operative time, lower risk of infiltrations, shorter time to resume function of the tooth in the stomatognathic system, reduced risk of cross-infection and reduced drug administration to patients who need antibiotic prophylaxis. The success of the root canal treatment will depend on the infection control through the correct cleaning and modeling of the canals, the filling of the same through the obturation and all the care to be executed and not the medication used between sessions. Thus, the objective of this work is to report the effectiveness of endodontic treatment in a single session through a clinical case report of a patient with a large periapical lesion in elements 21 and 22.

Neural networks pipeline for quality management in IVF laboratory

This study introduces a novel neural network-based pipeline for predicting clinical pregnancy rates in IVF treatments, integrating both clinical and laboratory data. We developed a metamodel combining deep neural networks and Kolmogorov-Arnold networks, leveraging their complementary strengths to enhance predictive accuracy and interpretability. The metamodel achieved robust performance metrics after training and fitting on 11500 clinical cases: accuracy = 0.72, AUC = 0.75, F1 score = 0.60, and Matthews Correlation Coefficient of 0.42. According to morpho-kinetical embryo evaluation, our model’s PRC of 0.66 significantly improves over existing time-lapse systems for pregnancy prediction, demonstrating better handling of imbalanced clinical data. The metamodel’s calibration metrics (Brier score = 0.20, expected calibration error = 0.06, maximum calibration error = 0.12, Hosmer-Lemeshow test p-value = 0.06) indicate robust reliability in predicting clinical pregnancy outcomes. We validated the model’s reproducibility using an independent dataset of 665 treatment cycles, showing close alignment between predicted and actual pregnancy rates (58.9% vs. 59.1%). With the Bayesian method, we proposed a robust framework for integrating historical data with real-time predictions from neural networks, enabling a transition from retrospective to prospective analysis. Our approach extends beyond conventional embryo selection, incorporating post-analytical phase evaluation in the IVF laboratory. This comprehensive framework enables detailed analysis across different patient subpopulations and time periods, facilitating the identification of systemic issues and IVF protocol optimization. The model’s ability to track pregnancy probabilities over time and staff members allows for both outcome prediction and retrospective and prospective assessment of IVF treatment efficacy, providing a data-driven strategy for continuous improvement in assisted reproductive technology.

Stem cell transplantation and allogeneic immunity: post treatment control or HIV cure?

Long-lasting HIV remission has been reported in a small group of people with HIV (PWH) following allogenic hematopoietic stem cell transplants (HSCT) for the treatment of hematologic malignancies. While the mechanisms of HIV remission following release from antiretroviral therapy (ART) were not initially known, subsequent findings from clinical cases and preclinical nonhuman primate studies have implicated mechanisms of clearance. Here, we review the six currently published human cases of long-term ART-free HIV remission. Since the first report of ART-free HIV remission following HSCT, five subsequent cases of HSCT-induced sustained HIV remission have been published. While the pre- and posttransplant treatment conditions vary greatly, all but one received cells from donors homozygous for a 32 bp deletion in the gene that encodes CCR5 (ccr5Δ32), the major HIV coreceptor. Studies in nonhuman primates and the newest published individual suggest that while CCR5 deficiency can protect donor cells from infection early posttransplant, it is not required for long term remission, as ablation of the viral reservoir is likely due to allogeneic immunity mediating a graft-versus-reservoir response. Studies of HSCT in PLWH and simian immunodeficiency virus (SIV)-infected monkeys show that those with durable remission are likely cured, demonstrated by complete ablation of the replication-competent HIV reservoir, gradual loss of anti-HIV immunity, and greater than 5 years of aviremia.

Syndromic obesity in children (using the example of clinical cases)

Obesity is a heterogeneous group of hereditary and acquired diseases associated with excessive accumulation of adipose tissue in the body. One example of syndromic obesity in children is Bardet-Biedl syndrome. This is a rare autosomal recessive disease from the group of ciliopathies, characterized by retinal dystrophy, obesity, polydactyly, mental retardation, hypogonadism, and renal dysfunction. The article presents two clinical cases of Bardet-Biedl syndrome. Diagnostic criteria for the disease are given, and the need for molecular genetic research methods in the early stages of the diagnostic search is shown. Promising directions in the treatment of the syndrome are considered.

Unusual onset and course of Crohn’s disease in children

The purpose of the article is to demonstrate a clinical case of Crohn’s disease in an 8-year-old child. Materials and methods: The given clinical example is a case of a non-classical variant of the course of Crohn’s disease in an 8-year-old child who debuted with an upper respiratory tract lesion in combination with abdominal pain against the background of long courses of antibacterial therapy. Conclusion: This clinical case demonstrates the complexity of the diagnostic search, the need for careful history collection and differential diagnosis.

Application of clinical case-guided, task-driven escape room teaching in nursing education: A quasi-experimental study

BackgroundIn the new era, the professional ability requirements for nursing personnel are no longer limited to traditional nursing knowledge and skills, but pay more attention to the cultivation and enhancement of their diversified abilities, such as humanistic caring ability, creative thinking, and so on. As a new type of education model that integrates gamification, flipped learning, and problem-based learning, escape room teaching plays an important role in effectively developing and stimulating students' humanistic care ability and creative thinking. PurposeTo investigate the effectiveness of an Escape Room teaching approach, clinical cases (C) as guide (G) and task (T) as driver (D) , within the CGTD model in the undergraduate Adult Nursing course. MethodUsing purposive sampling, 108 undergraduate nursing students in the class of 2020 were selected as the study subjects, and 11 innovative escape room teaching activities were conducted. Real clinical cases were selected, so that the student teams were immersed in clinical scenarios to complete the escape room game focusing on circulatory care, and the humanistic caring and creative thinking of the students in the two groups were compared before and after the intervention. ResultsNursing students' humanistic care and creative thinking scores at the end of the instruction were significantly better than those before the escape room instruction (P<0.05). ConclusionThe use of the CGTD-based escape room teaching method applied to adult nursing practice courses is an innovative teaching strategy that integrates theoretical knowledge into the game, which can significantly improve undergraduate nursing students' humanistic caring ability and creative thinking.

The Impact of Nusinersen Treatment on Respiratory Function in Patients with Spinal Muscular Atrophy: A Systematic Review.

Background/Objectives: This systematic review evaluated the impact of nusinersen therapy on respiratory health and function in individuals with spinal muscular atrophy (SMA) and determined whether nusinersen improves pulmonary function, focusing on differences based on patient age and the timing of treatment initiation. Methods: A systematic search of PubMed, Ovid Medline, ScienceDirect, and Web of Science databases was conducted up to January 2024 in accordance with the PRISMA guidelines. Thirteen studies were included, comprising clinical trials, observational studies, and case series that focused on respiratory outcomes in SMA patients treated with nusinersen. The data on study design, participant characteristics, nusinersen intervention, respiratory outcomes, and adverse events were extracted. The Joanna Briggs Institute Critical Appraisal Tool was used to assess study quality. A narrative synthesis was conducted to address the heterogeneity of the studies. Results: This review found a general trend of improvement in pulmonary function, specifically in forced vital capacity (FVC), although the extent and duration of improvement varied across the studies. Peak cough flow (PCF) and peak expiratory flow (PEF) showed positive trends in some studies, although the results were not consistently significant. Respiratory function improvements were frequently observed, particularly in younger patients and those treated earlier. Conclusions: Nusinersen appears to enhance respiratory function and improve motor outcomes in SMA patients, especially with early treatment. However, further research is needed to fully understand its mechanisms and long-term effects on respiratory health in SMA.

Nurses' adherence to ethical principles - A qualitative study.

Nursing is regulated by a set of professional standards. Whilst many forms of ethics apply to nursing, the biomedical ethical framework is common, involving autonomy, beneficence, non-maleficence and justice. In healthcare, nurses often encounter ethical dilemmas that require them to navigate conflicting ethical principles. However, how nurses adhere to these principles in such situations is unclear. To explore how registered nurses adhere to ethical principles when dealing with ethical dilemmas at work. A qualitative descriptive study design. Between August and December 2023, 21 registered nurses were recruited from a teaching hospital through purposive sampling. Data were collected through semi-structured in-person interviews or online video conferencing. Braun and Clarke's thematic analysis approach was employed to analyse the data. Interview participation was voluntary. Written consent was obtained before participation. Participants' real identities were replaced with pseudonyms. This study was approved by the SingHealth Centralised Institutional Review Board. The data analysis developed four major themes and 15 subthemes. The four major themes are "Addressing the dilemma," "Contemplating the principles and consequences," "Coordinating for well-informed, ethical decision," and "Self-reflecting and finding consolation." This study explains how nurses navigate and uphold ethical principles when caring for patients to the best of their ability. Fully adhering to ethical principles can be challenging for caring for actively dying patients. Further research can expound on nurses' experiences and adherence to ethical principles in complex clinical cases.

Comorbid conditions in pediatric practice

The comorbidity is an urgent scientific and practical problem of modern pediatrics. The practical significance of combined pathology in children is determined by its widespread occurrence and universal impact on all aspects of a child’s health and treatment options. In patients with congenital heart defects, outcomes are influenced by numerous non-cardiac and genetic factors. In childhood and adolescent bronchial asthma, concomitant diseases are a common cause of adverse outcomes, such as poor disease control, frequent seizures, decreased quality of life and increased healthcare costs. A stable interdependence between the state of the gastrointestinal tract and the development of allergic or autoimmune diseases has been proven. The article describes a clinical case of late diagnosis of concomitant pathology in a child with chronic gastritis with clinical symptoms, diagnostic criteria and drug treatment options. The understanding the etiology and pathogenesis of concomitant conditions in children will help identify risk groups for the formation of chronic noncommunicable diseases and develop a plan for their prevention.

Aneurism of the left portal vein branch in a teenager - a rare clinical case

The authors presented their own clinical observation of an aneurysm of the left portal vein branch in a teenager with a long-term asymptomatic course. Reduced serum concentrations of ceruloplasmin and α-1-antitrpsin made diagnostic search difficult, which could lead to incorrect therapeutic decisions. However, the results of imaging methods allowed us to establish the root cause of liver damage and its cirrhotic transformation. Vascular aneurysms of the portal vein system are a very rare pathology, and it should be taken into account in the differential diagnostic algorithm while excluding other, more obvious causes of liver pathology.

Unlocking the Potential of the Superficial Cervical Plexus Block in Chronic Pain Management: A Narrative Review and Single-Center, Retrospective Case Series.

Background/Objectives: The anesthetic block of the sensory branches of the superficial cervical plexus renders a specific area of the face, head, and anterior neck insensible and painless. Chronic pain in these areas can be difficult to diagnose and treat. In this report, we briefly review the existing evidence on the topic of the superficial cervical plexus block (SCPB) to set the context for our research. We then share our own clinical experience with the SCPB for managing chronic pain syndromes from both cancerous and non-cancerous etiologies. Methods: We first performed a comprehensive literature search and narrative review of clinical cases and studies that utilized the SCPB as an analgesic technique. We then conducted a retrospective case series of all patients who had received an SCPB at our pain clinic since 2020. Results: Our literature review found only a few cases reported, with most of them focusing on acute painful emergencies and perioperative pain syndromes and only very few addressing chronic pain. In our pain clinic, 14 patients received one or more SCPBs for chronic pain management. In 43% of these cases, the pain was related to cancer. The most common areas of pain corresponded to the regions supplied by the transverse cervical and great auricular nerves. The procedures were uneventful in all cases, and patients rated them as effective and worthwhile 71% of the time. Conclusions: Despite the lack of high-quality studies on SCPBs in pain management, the authors' experience suggests that it is a valid minimally invasive alternative for managing chronic face, head, and neck pain.