Clinical Difficulties Research Articles

Risk-Prediction Models for Clinical Decision-Making in Sarcoma Care: An International Survey Among Soft-Tissue Sarcoma Clinicians.

Risk prediction models (RPMs) are statistical tools that predict outcomes on the basis of clinical characteristics and can thereby support (shared) decision-making. With the shift toward personalized medicine, the number of RPMs has increased exponentially, including in multimodal sarcoma care. However, their integration into routine soft-tissue sarcoma (STS) care remains largely unknown. Therefore, we inventoried RPM use in sarcoma care during tumor board discussions and patient consultations as well as the attitudes toward the use of RPMs to support (shared) decision-making among STS clinicians. A 29-item survey was disseminated online to members of international sarcoma societies. This study enrolled 278 respondents. Respectively, 68% and 65% of the clinicians reported using RPMs during tumor board discussions and/or patient consultations. During tumor board discussions, RPMs were used primarily to assess the potential benefits of (neo)adjuvant chemotherapy. During patient consultations, RPMs were used to predict patient prognosis upon request and to assist in decision-making regarding (neo)adjuvant therapies. The reliability of patient risk predicted by RPMs and the absence of guidelines regarding the use of RPMs were identified as barriers. Additionally, some clinicians questioned the applicability of estimates from RPMs to individual patients and expressed concerns about causing unnecessary anxiety when discussing prognostic outcomes. Responding STS clinicians frequently use RPMs to support decision-making about (neo)adjuvant therapies. However, they expressed concerns about the applicability of RPM estimates to individual patients and reported challenges in communicating prognostic outcomes with patients. These findings highlight the difficulties clinicians face when integrating RPMs into patient consultations.

Outcome and survival of septic arthritis treated with 0.05% chlorhexidine solution: Description of 10 cases

SummaryBackgroundEstablished or ongoing septic arthritis requiring repeated joint flushing remains a treatment challenge with a poor survival outcome aggravated by the necessity of controlled antimicrobial usage.ObjectiveTo describe the outcomes and survival rates of patients with synovial sepsis treated by lavage with a 0.05% chlorhexidine solution.Study designClinical retrospective observational study.MethodsPatients with synovial sepsis underwent standing needle or arthroscopic lavage under general anaesthesia with a 0.05% chlorhexidine solution, followed by Lactate Ringer Solution (LRS). Complementary systemic and regional antibiotics were used. Short‐ (6 months) and long‐term (>1 year) outcomes were assessed.ResultsTen horses met the inclusion criteria. Affected joints included metacarpophalangeal joints (2), tarsocrural joint (1), radiocarpal and intercarpal joints (2), distal interphalangeal joints and navicular bursa (3), distal interphalangeal joints (2). Time from onset to referral ranged from 1 to 20 days, with a mean of 8.3 days. Eighty per cent of horses survived for more than 1 year. Four horses were retired to the field, three returned to a light level of work and one went back to full work.Main limitationsRetrospective study of a limited group of horses initially treated by different clinicians before referral, as such, first‐line treatment had differences between cases. Resolution was evaluated on based clinical signs rather than clinical pathology of synovial fluid due to clinical decisions or difficulty in obtaining samples.ConclusionWith this series of challenging synovial sepsis cases treated by lavage with a chlorhexidine solution, we provide a treatment protocol, proof of clinical concept and report patients' short‐ and long‐term clinical outcomes. Short‐ and long‐term postoperative lameness should be expected despite the resolution of the septic arthritis. This treatment poses a novel option for challenging cases but should be regarded as a salvage procedure due to the possibility of long‐term mild lameness.

Knowledge, Attitudes and Practices regarding dental vibe injection-comfort system amongst undergraduates and house officers at Liaquat college of medicine and dentistry; a KAP analysis

Objectives: To assess the Knowledge, attitudes and practices of final year dental students and house officers regarding the Dental Vibe Injection comfort system in reducing pain during local anesthesia administration Methods: A descriptive cross-sectional study was conducted involving House officers and final year dental students at LCMD, employing convenience sampling technique and sample size will be calculated via open-epi software that provide sample size of 137. However, data was collected via online Google forms comprising of a valid and reliable self-administered questionnaire with close ended questions. Results and conclusion More than half (56.4%) of the participants frequently encounter patient anxiety during LA, while a smaller group (35.0%) experienced it occasionally. Probably as a result of less clinical exposure, only 8.6% have not yet encountered this difficulty. Despite clinical limitations and difficulties, the majority (74.3%) acknowledge infection as a factor affecting LA efficacy. Only 22.1% of participants said that patient anxiety had no effect on their confidence, whereas the majority (77.9%) said that it did. The study shows how crucial it is to have a solid basis in dental education regarding patient communication, anxiety management, and the use of cutting-edge technologies.

Common Elements and Differences Among Treatment Approaches to Complex Post-Traumatic Stress Disorder: A Commentary on Five Case Studies.

Treating people who have experienced deep and prolonged developmental trauma, that is, complex post-traumatic stress disorder (cPTSD), can be challenging given the complexity and severity of their presentations. The main features of complex post-traumatic stress disorder, that is, affective and behavioral dysregulation, altered self-experience and identity disturbances, relational difficulties, negative self-concepts, and negative pathogenic beliefs, are, at the same time, therapeutic goals and obstacles to treatment. Therefore, clinicians must be aware of these difficulties in order to identify them and be ready to treat them when they arise during therapy with the same client. For this reason, the clinical cases presented in this issue of the Journal of Clinical Psychology: In Session provide a very useful overview of how to deal with these manifestations from the perspective of different models of psychotherapy. This commentary, after briefly reviewing the clinical features and therapeutic difficulties of these clients, offers a critical summary of the commonalities and differences between the various approaches presented by the clinical cases in this special issue. The purpose is to help the reader navigate the key aspects of treating the pathogenetic processes involved in cPTSD and to identify the different therapeutic tools that may be applicable to the different clinical presentations.

The association of infectious and parasitic pathogens in the etiology of chronic stomatitis and feline gingivostomatitis: a multifactorial approach

Feline chronic gingivostomatitis (FCGS) is a common pathology located in the oral cavity of felines. It has a chronic nature and generally presents as intense inflammation and ulcerative and ulcerative-proliferative lesions on the oral mucosa. It is a disease considered severe and rapidly progressing. It is considered a challenge for veterinarians, as its etiology is not defined, limiting its treatment and making the prognosis guarded. Chronic gingivostomatitis is considered a multifactorial disease and may be related to different etiological agents, nutritional management, environmental stress, bacteria, viruses and a relationship with the immune system of the affected animal. The association of these factors can lead to bacterial tartar plaques, mucosal hyperemia, halitosis, sialorrhea, among others. Felines aged 7 to 10 years are the most affected, but it can occur in younger or older cats. The Persian, Siamese, Abyssinian, Himalayan and Burmese breeds have a higher incidence, and are considered by some authors to be predisposing breeds. The patient's sex is not relevant, as both are affected. The complaint of recurrences is recurrent, because, due to the challenges encountered in finding a totally efficient protocol, the result of these has presented variable reactions to the treatments used by each veterinarian, however, the surgical intervention, carried out by extracting the molar and premolar teeth, has if considered more appropriate, with the aim of preventing the proliferation of bacteria, stopping the most intense inflammation and providing the patient with quality of life. It is important to highlight, in order to clarify, that, if partial or complete removal of the teeth is necessary, the animal will continue with its normal routine, as felines are not dependent on the extracted teeth for food. It is concluded, after exposing the challenges and clinical difficulties of FCGS that the present work aims to review the literature, discuss its clinical aspects, aiming to explain the clinical part, possible treatments, recommended surgical procedures and their prognosis.

Lynch Syndrome: Similarities and Differences of Recommendations in Published Guidelines.

In this review, we aimed to compare the recommendations for Lynch syndrome (LS). We compared the LS's guidelines of different medical societies, including recommendations for cancer surveillance, aspirin treatment, and universal screening. Most guidelines for LS patients recommend intervals of 1-2 years for performing colonoscopy, though there is disagreement regarding the age to begin CRC screening (dependent on status as a MLH1/MSH2 or MSH6/PMS2 carrier). There are inconsistencies between LS guidelines for gastric cancer surveillance. Most guidelines do not recommend routine surveillance of the pancreas and small bowel. Most but not all of the guidelines support endometrial and ovarian surveillance with transvaginal ultrasound and endometrial biopsy. Only two societies recommend urological surveillance, while others recommend surveillance among high-risk carriers with family history only. There is significant disagreement between the guidelines about the recommendation for limited or extended bowel resection among patients with CRC. Aspirin use is recommended by most societies, though some with reservations, and most of them recommend universal screening. There are significant disparities and disagreements in the guidelines and recommendations for patients with LS, causing confusion and difficulties for clinicians. Harmonization and cooperation are needed between the societies creating LS guidelines.

Clinical treatment difficulties and strategies for palatogingival groove

Palatogingival groove (PGG) is a common developmental deformity, which is prone to retain plaque, leading to local periodontal inflammation. Furthermore, the infection can spread to the dental pulp tissue through the PGG, eventually resulting in combined periodontal-endodontic lesions. The treatment methods include PGG treatment, periodontal treatment, endodontic treatment, etc. The abnormal anatomical structure of PGG will influence the treatment and prognosis of the affected tooth. Teeth with combined periodontal-endodontic lesions often have poor curative effect and prognosis. How to early intervene and improve its prognosis has become a hot and difficult issue for dentists in recent years. This article analyzes the challenges in the treatment of PGG and puts forward the corresponding strategies, so as to provide reference for the clinical diagnosis and treatment of PGG.

Electrical Stimulation Therapy - Dedicated to the Perfect Plastic Repair.

Tissue repair and reconstruction are a clinical difficulty. Bioelectricity has been identified as a critical factor in supporting tissue and cell viability during the repair process, presenting substantial potential for clinical application. This review delves into various sources of electrical stimulation and identifies appropriate electrode materials for clinical use. It also highlights the biological mechanisms of electrical stimulation at both the subcellular and cellular levels, elucidating how these interactions facilitate the repair and regeneration processes across different organs. Moreover, specific electrode materials and stimulation sources are outlined, detailing their impact on cellular activity. The future development trends are projected from two perspectives: the optimization of equipment performance and the fulfillment of clinical demands, focusing on the feasibility, safety, and cost-effectiveness of technologies.

Multidisciplinary clinical assessment and interventions for childhood listening difficulty and auditory processing disorder: Relation between research findings and clinical practice.

Listening difficulty (LiD), often classified as auditory processing disorder (APD), has been studied in both research and clinic settings. The aim of this study was to examine the predictive relation between these two settings. In our "SICLiD" research study, children with normal audiometry, but caregiver-reported LiD, performed poorly on both listening and cognitive tests. Here we examined results of clinical assessments and interventions for these children in relation to research performance. Study setting was a tertiary pediatric hospital. Electronic medical records were reviewed for 64 children aged 6-13 years recruited into a SICLiD LiD group based on a caregiver report (ECLiPS). The review focused on clinical assessments and interventions provided by Audiology, Occupational Therapy, Psychology (Developmental and Behavioral Pediatrics), and Speech-Language Pathology services, prior to study participation. Descriptive statistics on clinical encounters, identified conditions, and interventions were compared with quantitative, standardized performance on research tests. Z-scores were compared for participants with and without each clinical condition using univariate and logistic prediction analyses. Overall, 24 clinical categories related to LiD, including APD, were identified. Common conditions were attention (32%), language (28%), hearing (18%), anxiety (16%), and autism spectrum (6%) disorders. Performance on research tests varied significantly between providers, conditions, and interventions. Quantitative research data combined with caregiver reports provided reliable predictions of all clinical conditions except APD. Individual test significant correlations were scarce, but included the SCAN composite score, which predicted clinical language and attention difficulties, but not APD diagnoses. The variety of disciplines, assessments, conditions and interventions revealed here supports previous studies showing that LiD is a multifaceted problem of neurodevelopment. Comparisons between clinical- and research-based assessments suggest a path that prioritizes caregiver reports and selected psychometric tests for screening and diagnostic purposes.

Adolescent Girls With Anorexia Nervosa Clinical Profiles in Relation to Their Social Networks Use.

In recent years, social networks (SNs) have increasingly become a core activity adolescent's daily life. Their impact on mental health is an actual worldwide concern. This massive usage of social network has been suggested to increase the risk of depressive and anxiety disorders, as well as alterations in sleep quality and quantity. In particular, it has been suggested that it could increase concerns about body image and thereby encourage eating disorders. Aiming at further investigating these relations, this study examined, for the first time, the links between the clinical profile of adolescents with anorexia nervosa and SNs use patterns. The sample included 131 adolescent girls with anorexia nervosa who completed an online survey assessing their SNs practices in terms of duration, intensity and function of SNs use, misuse and addictive tendencies, as well as the number of online peers. Clinical characteristics such as eating behaviours, body image perception, depression, anxiety and sleep quality were also assessed. showed that adolescents with anorexia nervosa spend more than 3h per day on SNs. Those spending 5h per day or more preferred a passive use, with limited connection with peers and greater clinical difficulties. In addition, high problematic use of SNs significantly aggravated eating behaviour, dysmorphophobia, depressive symptoms and sleep impairment. The activities performed on SNs were not significantly associated with variations in clinical characteristics. Presents findings suggests that a profile of social networking marked by a problematic, prolonged and passive use, is associated with more severe symptomatology in adolescent girls with anorexia nervosa. These first data could inspire professionals to encourage a SNs use favouring care and recovery, thereby supporting adolescents with an eating disorder but also their relatives.

Prevention of early thrombosis in transplanted vein model by encapsulation with tirofiban microneedle drug delivery system

Early thrombosis following coronary artery bypass grafting (CABG) surgery leads to perioperative myocardial infarction, which causes difficulties for clinicians and patients. Moreover, once perioperative myocardial infarction occurs, the mortality rate is extremely high. In recent years, microneedle (MN) drug delivery systems have become a research hotspot with broad clinical application prospects. These systems are capable of achieving sustained, safe, and painless local drug release. In cardiovascular applications, MNs maximize local anticoagulant effects, inhibit endometrial hyperplasia, and reduce systemic side effects. We speculate that a MN drug delivery system can be used to target transplanted veins to inhibit their thrombosis and reduce the incidence of perioperative myocardial infarction after CABG surgery. Therefore, this study developed a hyaluronic acid MN patch loaded with tirofiban and conducted preliminary physicochemical tests. The safety, efficacy, biocompatibility, and targeting of the MN system were evaluated usingin vitroandin vivoexperiments using a jugular vein transplantation model. The results indicate that the MN system has excellent physical properties, safety, effectiveness, biocompatibility, and strong targeting, which can effectively inhibit early local thrombus formation. In addition, the observation of early postoperative endometrial hyperplasia activation provides a foundation for future research.

Challenges of patients with intrathecal baclofen pump therapy during COVID-19 pandemic in Saudi Arabia

Background: This study was carried out to analyze the effects of the coronavirus disease 2019 (COVID-19) pandemic on patients with intrathecal baclofen (ITB) therapy. Methods: Patients who came for ITB refill during the COVID-19 pandemic between March 2020 and August 2020 were contacted, and a survey was conducted regarding challenges faced during the COVID-19 pandemic. Data obtained from the chart review included demographics, diagnoses, pump information, baclofen dose, and COVID triage. Information was collected regarding travel arrangements, appointments, and problems related to ITB therapy or travel. The survey included 12 multiple-choice questions related to travel, appointment scheduling, and difficulties faced during the travel restrictions. Results: The study included 19 patients with ITB (mean age: 38.1±14.4) from outside Riyadh city who came for ITB refill during the COVID-19 pandemic. The majority of the patients were males. Spinal cord injury with paraplegia was the most common diagnosis (52.6%). In total, 7 patients had either clinical (31.6%) or travel-related difficulties (15.8%). No patient had ITB withdrawal at the time of the clinic visit. Nearly half (47.4%) of the patients had to change their appointment for refill. The percentage of patients who used a car as a mode of travel pre-COVID was 42.1%, which increased to 78.9% during the pandemic. They traveled 747.4±356.6 km (7.4±3.7 h) to reach the hospital for refill. Patients needed 1–4 accompanied persons for assistance during travel, with the majority (68.4%) requiring 2 accompanied persons. Statistical analysis did not reveal any significant associations between clinical or travel difficulties and appointment changes. Conclusions: A pandemic or similar disaster can pose challenges to patients on ITB therapy living in areas with limited access to specialized care. In this study, none of the patients had serious complications or adverse outcomes; however, the main difficulties were attributed to travel. It is crucial to establish strategies at institutional, regional, or national levels to formulate guidelines for managing patients with ITB therapy during a pandemic.

Customized lingual orthodontics: clinical features and difficulties

Lingual orthodontic technology has been in existence for over 50 years, undergoing various stages of emergence, development, decline, and maturity. In recent years, with the advancement of digital technology, customized lingual orthodontics has gradually become widely used in clinical practice, representing a significant achievement of digital technology in orthodontic clinical diagnosis and treatment. The integration of digital technology has made customized lingual orthodontics more convenient, precise, and efficient, enhancing patient comfort while significantly reducing the operational difficulty and technical barriers for orthodontists. This article focuses on analyzing the technical characteristics, operational challenges, and coping strategies of customized lingual orthodontics based on digital technology, aiming to provide a reference for clinical practice.

Evaluation of Third Molars According to the Operative Difficulty Score

Aim: Third molars (M3) are the most common type of impacted tooth, and the prevalence of impaction varies between 27% and 68.8%. The aim of this study was to evaluate M3 according to their operative difficulty score and angulation. Material and Method: A total of 1000 patients who returned to our clinic for M3 extraction were included in the study. Preoperative clinical and radiological operative difficulty scores (ODS) and angulations were evaluated from 0 to 6. Descriptive statistics were performed. Results: When M3 were evaluated according to ODS, 343 (34.3%) were ODS 1, 106 (10.6%) were ODS 3, 327 (32.7%) were ODS 4, 188 (18.8%) were ODS 5 and 36 (3.6%) were ODS 6. When evaluated according to their angulations, 621 (62.1%) M3 were found in the vertical position, 184 (18.4%) in the mesioangular position, 70 (7%) in the horizontal position, 104 (10.4%) in the distoangular position, and 21 (2.1%) in the buccolingual-palatal position. Conclusion: This study will allow the evaluation of the level of difficulty before the operation in the surgery of the M3 and the creation of a better treatment plan. Thus, perioperative and postoperative complications can be minimized.

Distinct role of Klotho in long bone and craniofacial bone: skeletal development, repair and regeneration.

Bone defects are highly prevalent diseases caused by trauma, tumors, inflammation, congenital malformations and endocrine abnormalities. Ideally effective and side effect free approach to dealing with bone defects remains a clinical conundrum. Klotho is an important protein, which plays an essential role in regulating aging and mineral ion homeostasis. More recently, research revealed the function of Klotho in regulating skeleton development and regeneration. Klotho has been identified in mesenchymal stem cells, osteoblasts, osteocytes and osteoclasts in different skeleton regions. The specific function and regulatory mechanisms of Klotho in long bone and craniofacial bone vary due to their different embryonic development, ossification and cell types, which remain unclear and without conclusion. Moreover, studies have confirmed that Klotho is a multifunctional protein that can inhibit inflammation, resist cancer and regulate the endocrine system, which may further accentuate the potential of Klotho to be the ideal molecule in inducing bone restoration clinically. Besides, as an endogenous protein, Klotho has a promising potential for clinical therapy without side effects. In the current review, we summarized the specific function of Klotho in long bone and craniofacial skeleton from phenotype to cellular alternation and signaling pathway. Moreover, we illustrated the possible future clinical application for Klotho. Further research on Klotho might help to solve the existing clinical difficulties in bone healing and increase the life quality of patients with bone injury and the elderly.

A prediction model for the walking and balance milestone in Parkinson's disease

BackgroundWalking and balance impairments, represented by freezing of gait and falls, are significant contributors to disability in advanced Parkinson's disease (PD) patients. However, the composite measure of the Walking and Balance Milestone (WBMS) has not been thoroughly investigated. MethodsThis study included 606 early-stage PD patients from the Parkinson's Progression Markers Initiative (PPMI) database, with a disease duration of less than 2 years and no WBMS at baseline. Patients were divided into a model development cohort (70 %) and a validation cohort (30 %) according to the enrollment site. Longitudinal follow-up data over a period of 12 years were analyzed. ResultsAmong all 606 patients, the estimated probability of being WBMS-free at the 5th and 10th year was 88 % and 60 %, respectively. Five clinical variables (Age, Symbol Digit Modalities Test (SDMT), postural instability and gait difficulty (PIGD) score, Movement Disorder Society-Unified Parkinson's Disease Rating Scale Part I (MDS-UPDRS-I) score, and REM Sleep Behavior Disorder (RBD) were used to construct the Cox predictive model. The C-index of the model was 0.75 in the development cohort and 0.76 in the validation cohort. By optimizing the PIGD and MDS-UPDRS-I variables, an easy-to-use model was achieved with comparable predictive performance. ConclusionA predictive model based on five baseline clinical measures (Age, SDMT, PIGD score, MDS-UPDRS-I score, RBD) could effectively estimate the risk of the WBMS in early PD patients. This model is valuable for prognostic counseling and clinical intervention trials for gait and balance impairment.

Constructing Mg-phytic acid enhanced hydrogel patch with janus structure for antibacterial and angiogenic urethral repair

Due to bacteria in urine and inadequate blood supply, urethral defect repair faces great clinical difficulties. Inspired by the natural structure of the urethra, in this study, we designed a multifunctional hydrogel urethral patch with a Janus structure. The inner layer was a double-network hydrogel of polyvinyl alcohol/carboxymethyl chitosan (PVA/CMCS) enhanced by natural phytic acid (PA) and Mg2+ (Mg2+-PA/PVA/CMCS). The outer layer was composed of poly (L-lactic acid) (PLLA) nanofibers to form a hydrophobic barrier, coupling via a micelle layer to ensure interfacial bonding. The patch exhibited mechanical properties matching soft tissues, with maximum tensile strength and toughness of 1.69±0.13 MPa and 24.7±0.9 MJ/m3, respectively, under the strengthening effect of Mg2+-PA chelation. Therein, the 4 % Mg2+-PA/PVA/CMCS composite patch could maintain unilateral hydrophobicity for at least 14 days and demonstrated an antibacterial rate of 99.0 %±0.1 % against E. coli. In PBS, the patch could deliver Mg2+ for at least 7 days and stabilize the surrounding pH environment for up to 28 days. In vitro cell experiments indicated that the 4 % Mg2+-PA/PVA/CMCS composite patch could promote the human umbilical vein endothelial cell (HUVEC) proliferation and migration, with the angiogenic protein expression enhanced more than 1.2 times compared with the Control group. In conclusion, the patch constructed in this study may provide a new approach to clinical urethral injury repair.

Uncommon Presentation Of A Giant Retroperitoneal Liposarcoma: A Peculiar Case Study

Introduction: Soft tissue sarcomas constitute less than 1% of all neoplasms, with approximately one-third of malignant tumors in the retroperitoneum being sarcomas. Among these, liposarcoma emerges as the most prevalent type. Retroperitoneal liposarcomas with intraperitoneal extension and extension into the inguinal canal are relatively uncommon, presenting a challenge for treatment due to their local aggressiveness and clinical nonspecificity. The clinical difficulty in managing these cases is exacerbated by patients often seeking medical attention late in the disease progression. The slow development and the scarcity of symptoms in the early stages contribute to delayed reporting. Consequently, these tumors are recognized for their capacity to reach enormous sizes before being diagnosed and addressed. Case Report: We present a case involving a 52-year-old man who underwent surgical resection for a massive, well-differentiated retroperitoneal liposarcoma. This tumor exhibited intraperitoneal extension and weighed a substantial 6.8 kilograms. Discussion: Retroperitoneal liposarcomas (RPS) frequently manifest as large, locally advanced lesions. The occurrence of RPS with intraperitoneal extension and extension into the inguinal canal is relatively uncommon. The clinical presentation is often delayed, attributed to the expansive nature of the retroperitoneal space. Evaluating these tumors necessitates a comprehensive, multimodal approach. Given that most RPS are characterized as low-grade, distant metastasis is infrequent, and the primary challenge lies in achieving effective local control and preventing recurrence. The preferred treatment involves radical resection of these tumors, incorporating en bloc resection of involved structures. In certain cases, the strategic use of neoadjuvant and adjuvant therapies, tailored to specific tumor histologies, may enhance local control and overall survival. Conclusion: Effectively managing retroperitoneal liposarcomas necessitates a multidisciplinary approach, ideally conducted at high-volume centers that specialize in the treatment of patients facing these intricate malignancies. Existing data indicate that radical resection stands as the primary opportunity for a cure. In select cases, chemotherapy and radiation therapy may offer a survival benefit, underlining the importance of individualized treatment strategies based on the specific characteristics of the tumor and the patient

Problems when diagnosing cutaneous leishmaniasis: a retrospective study analyzing clinical, histopathological and immunohistochemical features.

Cutaneous leishmaniasis (CL) incidence in Switzerland is rising due to factors like migration and globalization. The aim of this work was to investigate CL frequency in Switzerland and identify clinical and histopathological difficulties in diagnosing CL in a non-endemic country. This retrospective study evaluated the clinical and histopathological characteristics of all CL cases from two dermatopathology laboratories between 2000 and 2022. Skin biopsies were histopathologically reviewed using HE, Giemsa, and immunohistochemical stain for CD1a and a specific Leishmania antibody (LA). PCR to detect Leishmania DNA was performed if sufficient tissue was available. 42 cases (27m, 15f) were included. The correct clinical diagnosis of CL was only made in 15 (35.7%) cases. In seven (16.6%) cases, CL was missed in the initial histopathologic evaluation. Two main histopathological patterns were observed: granulomatous and pseudolymphomatous. Immunohistochemical staining with CD1a and Leishmania-specific antibody was positive in 91% and 80% of cases, respectively. Leishmania PCR was positive in 25 of 26 cases, mainly detecting Old World species. CL is rare in Switzerland and often misdiagnosed clinically and histopathologically. CD1a and specific Leishmania antibody stainings are useful. CL should be considered in non-healing ulcers, even without a history of travel to endemic areas.

Patients returning to the emergency department with symptoms of cauda equina syndrome: do the symptoms differ with radiological cauda equina compression?

Background The guidance for clinicians on who requires further investigation when suspecting cauda equina syndrome has become clearer in England following the publication of the national recommendations. This does not have specific advice for those patients who have had recent imaging with no compression, returning to a healthcare provider with a change in symptoms. These cases can cause difficulty for clinicians with limited access to imaging who can often be reassured by previous imaging. Method This study presents a retrospective review of the case notes of 45 patients presenting on two occasions to the same Emergency Department who underwent magnetic resonance imaging due to the clinical diagnosis of cauda equina syndrome. Those with compression of the cauda equina on the second visit were compared to those without a compressive cause for their symptoms. Results Patients presenting with an increased number of clinical symptoms associated with cauda equina syndrome on their return visit were more likely to have compression of the cauda equina on imaging. Conclusion The small numbers in this study would suggest caution, however, if patients present with an increasing number of symptoms further imaging should be considered, even with previous reassuring scans.