Clinical Findings Research Articles

Assessing the need for coronary angiography in high-risk acute coronary syndrome patients using artificial intelligence and computed tomography

Abstract Background/Introduction The use of coronary computed tomography angiography (CCTA) in managing high-risk acute coronary syndrome (ACS) patients is increasingly common. Yet, its role remains unvalidated in this context, posing challenges to traditional clinical decision-making algorithms. Physicians, accustomed to a hierarchical and structured approach involving symptom assessment, electrocardiograms, and biomarkers for deciding on the necessity of invasive coronary angiography (ICA), now face dilemmas when CCTA results challenge established diagnostic pathways and contradict clinical decisions based on usual criteria. Meanwhile, the potential of artificial intelligence (AI) which processes information in a way fundamentally different from human clinical reasoning, has been shown to aid decision-making in cardiovascular medicine. Yet, it has not been tested in this acute setting. Purpose This study aimed to evaluate the efficacy of the Chat Generative Pre-trained Transformer (ChatGPT) in guiding the need for ICA in high-risk ACS patients based on both standard clinical data and CCTA findings. Methods This investigation is a sub-study of a larger research project where high-risk ACS patients (all having a theoretical guideline-based indication for ICA) underwent CCTA prior to ICA. ChatGPT analyzed clinical vignettes containing patient data, electrocardiograms, troponin levels, and CCTA results to determine the necessity of ICA. The AI's recommendations were then compared to actual ICA findings to assess its decision-making accuracy. Results Among 86 patients with a clear indication for ICA, ChatGPT recommended against it for 19 patients, 16 of whom indeed had no significant findings at ICA (Figure). For 67 patients, ChatGPT advised proceeding with ICA, and a significant lesion was confirmed in 58 of them. Consequently, ChatGPT's overall accuracy stood at 86%, with a sensitivity of 95% and a specificity of 64%. The model's negative predictive value was 84%, and its positive predictive value was 87%. Conclusion These preliminary data suggest that ChatGPT can effectively assist in guiding the need for ICA among high-risk ACS patients, potentially reducing unnecessary procedures but further clinical studies to refine AI's role in clinical decision-making are required.ChatGPT's decision as per ICA's results

Impact of dapagliflozin on supraventricular and ventricular arrhythmias, assessed by Holter ECG, in patients with heart failure with reduced ejection fraction

Abstract Background & Introduction Dapagliflozin has significantly reduced morbidity & mortality in patients with heart failure with reduced ejection fraction (HFrEF) (1). Some studies reported supraventricular & ventricular arrhythmia suppression, but Holter ECG was underused, hindering precise assessment of arrhythmia burden. Purpose We aim to assess the impact of dapagliflozin on reduction of arrhythmia in HFrEF at 1 year follow-up (FU) by Holter ECG. Methods This is a single center, prospective study. We have screened 219 HFrEF patients, but only 156 patients were enrolled with LVEF <40% in sinus rhythm from December 2021 to July 2023. All patients had dapagliflozin 10 mg once/day tablet with the standard HF therapy. Clinical evaluation, NYHA evaluation, 6-minute walking test (6MWT), echocardiogram, 24-hours Holter ECG and laboratory work-up were done at baseline, and FU at 6 months and 12 months. Results Males constituted 61.5% of study population; mean± SD participants’ age was 56.8 ± 8.6 years. The most common comorbidities were: ischemic etiology (63.3%), dilated cardiomyopathy (28.1%), hypertension (27.3%), smokers (14.7%), and type II diabetes (31.4%). LVEF was ≤ 35% in 85.9% of patients. We have reported (7.69%) deaths during 1-year FU, and 4 patients (2.56%) didn't complete 1-year FU. Main clinical and echocardiographic findings (baseline vs. 1-year FU): NYHA FC III& ambulant IV dropped from (42.9 to 32.9%), P value<0.05. Distance walked in 6MWT improved from 191.52 ± 75.37 to 219.35 ± 71.51 mean± SD meters, P value<0.05. E/e improved (9.4 to 8.3 cm/s, P value <0.01), LVEF improved (31.3 to 36.4%, P value<0.05). HF emergency: [HF visits dropped (23.7 to 19.2%) and HF hospitalization dropped (11.1 to 7.8%)], P value<0.05. Holter ECG (baseline vs. 1-year FU): Supraventricular Arrhythmia: [Paroxysmal AF reduced (56.2 to 47.6%), frequent PACs (≥ 10%) dropped (3.8 to 1.4%) & Intermittent 1st degree heart block dropped (12.5 to 7.3%)] P value <0.01. Ventricular Arrhythmia: [PVCs >5%-<10% dropped (16% to 9.3%), Frequent PVCs >10% dropped (3.2 to 1.4%), and NSVT dropped (7.8 to 3.1%)], P value <0.01. Stepwise logistic regression multivariable model aiming to predict the occurrence of ventricular and supraventricular arrhythmias has indicated a direct linear correlation with male gender, smoking, body mass index, left atrial volume, and a history of myocardial infarction. Conversely, there is an inverse relationship with systolic blood pressure, 6MWT distance, LVEF, and the administration of dapagliflozin (OR 0.72 [0.61 - 1.07], P value <0.01) concerning the likelihood of supraventricular and ventricular arrhythmias. Conclusions Dapagliflozin has demonstrated significant improvement in functional and echocardiographic parameters in HFrEF patients. Furthermore, it has effectively decreased the incidence of supraventricular and ventricular arrhythmias, identified through 24-hour Holter ECG monitoring during 1-year follow-up.

Exploring heart failure prevalence and overlooked dimensions: a comprehensive NT Pro-BNP study in high-risk primary care patients

Abstract Background Heart failure (HF) is a prevalent syndrome linked to significant morbidity and mortality, especially in those with comorbid conditions like diabetes, hypertension, and atherosclerotic cardiovascular disease. Early detection and intervention are crucial. Natriuretic peptides, particularly NT-proBNP, are promising biomarkers for identifying at-risk individuals, but their use in primary care settings is not fully understood. Methods This prospective cohort study enrolled 874 participants aged 40 and above with documented risk factors for HF, such as diabetes mellitus, hypertension, metabolic syndrome, obesity, atherosclerotic cardiovascular disease, genetic variants for cardiomyopathy, or exposure to cardiotoxic agents. NT-proBNP levels were measured in blood samples collected at primary care clinics, and participants underwent comprehensive cardiac evaluations at a referral hospital. Clinical characteristics, laboratory findings, electrocardiography, and echocardiography results were recorded. Results The study included 874 patients with at least one risk factor for HF, with a mean age of 62.5 ± 9.1 years and 51.9% female. According to the 2022 AHA/ACC/HFSA HF Guideline, 69.1% were Stage A HF, 21.9% Stage B HF, and 9% Stage C HF. Clinical characteristics, laboratory and echocardiographic findings are shown in Picture 1. The majority had hypertension (71.1%), while other prevalent comorbidities included diabetes mellitus (43.4%), dyslipidemia (35.2%), obesity (27.1%), and atherosclerotic cardiovascular disease (26.2%). Laboratory findings showed a significant decrease in HbA1C, eGFR, LDL, triglycerides, and hemoglobin from Stage A to C HF. Median NT-proBNP levels rose from Stage A to C HF (46.4 pg/mL in Stage A, 219 pg/mL in Stage B, and 268.5 pg/mL in stage C), with 84.8% of Stage B HF patients exhibiting elevated levels. NT-proBNP levels were correlated positively with left atrial volume index, left ventricular mass index, age, E/e’, and estimated systolic pulmonary artery pressure levels. Conversely, NT-proBNP levels showed a negative correlation with estimated glomerular filtration rate and left ventricular ejection fraction. Among Stage C patients, 92.4% had HFpEF. The Picture 2 depicted the study's design and outcomes, providing a comprehensive visual representation. Conclusion NT-proBNP screening in primary care settings identified a substantial proportion of individuals with undiagnosed HF, particularly those in Stage B and Stage C. The high prevalence of HFpEF underscores the need for comprehensive evaluation and management strategies targeting this population. Early detection facilitated by NT-proBNP screening may lead to timely interventions and improved outcomes in individuals at risk for HF.

Associations of different definitions of iron deficiency with cardiac structure and function, congestion, exercise capacity and prognosis in heart failure

Abstract Background It is uncertain how best to diagnose iron deficiency (ID) in patients with heart failure (HF) as different ID definitions have been proposed with discordant results. Objectives To assess the relationship of different ID definitions with cardiac structure and function, congestion, exercise capacity, and prognosis in outpatients with HF. Methods ID was defined according to guidelines (G-ID: ferritin <100 ng/mL or ferritin 100-299 ng/mL with transferrin saturation [TSAT] <20%) or as TSAT <20%. Alternative definitions (iron <13 ¼mol/L, ferritin <100 and <300 ng/mL) were explored. Relationship with rest and exercise ultrasound findings, cardiopulmonary exercise testing and a composite endpoint of cardiovascular hospitalisations or all-cause mortality were assessed. Results Of 1502 patients (72% with left ventricular ejection fraction [LVEF] ≥50%), 471 (31%) had TSAT <20%, while 728 (48%) had G-ID. Compared to those without ID, patients with TSAT <20% or G-ID showed impaired cardiac structure and function at rest and peak exercise and lower peak oxygen consumption; they were also more likely to display a discontinuous renal venous flow pattern and more lung B-lines. Only TSAT <20% was associated with significant inferior vena cava dilatation. Lower TSAT, iron and haemoglobin were associated with more severe effort intolerance and ultrasound signs of congestion, while ferritin and LVEF were not (Picture 1). During a median follow-up of 16 months, 62 (4%) patients died, and 244 (16%) were hospitalised for cardiovascular reasons. No patients were hospitalised immediately after the enrolment visit because of clinical findings. At Kaplan-Meier analyses, TSAT <20% was associated with a greater risk of adverse events, as were iron ≤13 ¼mol/L, ferritin ≥300 ng/mL and <100 ng/mL (p <0.01 vs ferritin 100-299 ng/mL) and G-ID (Picture 2). After adjusting for age, sex, diabetes, haemoglobin, estimated glomerular filtration rate (eGFR), NT-proBNP, rest LVEF and peak VO2 <16 mL/kg/min, TSAT <20% and iron ≤13 ¼mol/L were associated with worse outcomes (hazard ratio 2.41, 95% confidence interval 1.85-3.14 and 1.90, 1.46-2.47), while G-ID or ferritin <100 or <300 ng/mL were not (Picture 1). Conclusions In outpatients with HF, TSAT <20% is more consistently associated with echocardiographic signs of poorer functional capacity and multi-organ congestion than other ID definitions. TSAT <20% and iron ≤13 ¼mol/L, but not G-ID or ferritin-based ID, seem to predict a worse prognosis.Picture 1Picture 2

Metabolic profile of acute ischemic stroke patients in a tertiary care hospital

Background: When the blood supply to a portion of the brain is blocked or diminished, brain tissue cannot get oxygen and nutrients, resulting in an ischemic stroke. This study aimed to investigate the prevalence of hyperglycemia and dyslipidemia among patients with acute stroke in a tertiary healthcare setting in Bangladesh. Methods: This cross-sectional study was conducted from January 2022 to December 2022 at a tertiary healthcare facility in Bangladesh, focusing on patients with acute ischemic stroke. Data was collected through a face-to-face interview, and medical records were reviewed. The study included 40 patients with acute stroke, evidenced by clinical findings and a CT scan of the Brain. Written informed consent was obtained after proper explanation, and participants were free to refuse or withdraw at any point. Confidentiality and privacy were maintained. Results: The majority of participants (37.5%) were aged 60-69, with more males (57.5%) than females (42.5%). Most (70%) lived in urban areas. Among the participants, 82.5% had hypertension, and 52.5% had diabetes mellitus. The mean of HbA1c was 7.6% and of triglyceride was 205.0 mg/dl. Of the participants with acute stroke, 47.5% had extracranial carotid stenosis. Conclusions: Nearly half of those who had an acute stroke also had diabetes, and four out of five had a history of hypertension. Among the patient hyperglycemia and dyslipidemia was common. Nearly half of those who suffered an acute stroke also experienced carotid stenosis. Consideration should be given to managing hypertension, DM, dyslipidemia, and carotid stenosis among patients with acute stroke. J Shaheed Suhrawardy Med Coll 2023; 15(1): 50-54

Clinical Profile And Aetiology of Acute Kidney Injury Developing In Patients Hospitalized Due To Non-Renal Cause With Pre-Existing Normal Renal Function

Background: Acute kidney injury (AKI) is a common complication in patients hospitalized for non-kidney disease and having normal renal function. Early detection of development of deteriorating renal function and assessment of its cause can help to manage the cases effectively and can prevent further kidney damage or progression to end stage renal failure. Methods: This observational study was done on 50 patients selected from the departments of Medicine and Nephrology of Dhaka Medical College (DMCH) and BSMMU, from June 2012 to November 2012. Patients were included in the study who developed clinical features and biochemical findings of acute kidney injury, while being admitted with various non-renal diseases and had previous normal renal function. Results: In this study the cause of deterioration of renal function was Sepsis in 44.0% of the patients, 42.0% had fluid loss, 6.0% had used nephrotoxic drugs, 4.0% had hepatitis, 2.0% patients each had pancreatitis and insect bite respectively. 40% of the patients were above 40 years of age, 54% were male. Vomiting was present in 42% of the patients and diarrhoea in 20% of the patients. 26% patients had DM and 22% had hypertension. Conclusion: Sepsis and hypovolemia were the common causes of developing acute kidney injury in the hospital. In-hospital mortality was 18.0% and 22.0% patients developed CKD after three months follow-up. J Dhaka Med Coll. 2023; 32(1) : 85-91

Outcome of Endometriosis Treatment In Infertile Patients In A Tertiary Level Hospital

Introduction: Prevalence of endometriosis is 6-10% in reproductive-age females. Around 25-35% of infertile women may be affected by endometriosis. Modalities of treatment for infertile patients depends on the stage of the disease. It starts from ovulation inducing drug to advanced ART. The objective of this study was to assess the outcome of surgical treatment in infertile, endometriosis patients. Materials and Methods: It was an observational study, which was conducted at Reproductive Endocrinology and infertility Unit, Dhaka Medical College. Total 144 patients were included during July 2018 to July 2021, aged 20-40 yrs. All the demographic variables, clinical and sonographic findings, and hormonal assessment were done. Then, staging was done by clinical pelvic assessment, and ultrasonographic findings. Patients who had ovarian endometrioma, more than 4 cm, were selected for laparoscopic surgery. In patients whose endometrioma was less than 4 cm, or had no ovarian endometrioma, were selected for ovulation induction with or without prior GnRH agonist therapy. Further infertility management were planned according to ovarian reserve, tubal patency, and male factor. Result: Mean age of the patients were 28.30±4.95 yrs. 75.0% patients had primary infertility. Dysmenorrhea was the most common symptom (86.96%), followed by chronic pelvic pain (81.16%). Bilaterality of endometrioma was associated with decreased serum AMH. Laparoscopic surgery was the mainstay of treatment, Cystectomy was done in 58% patients. Conservative treatment was done in remaining patients. Fertility enhancing treatment was done by ovulation inducing drug -letrozole, GnRH agonist, followed by controlled ovarian stimulation and followed by IUI. IVF was advised for fertility management in 26patients (18.06%). Conclusion: Endometriosis is not only associated with decreased ovarian reserve but also responsible for diminished response to ovarian stimulation. So, it is a great challenge to obtain successful fertility treatment for this group of patients. J Dhaka Med Coll. 2023; 32(1) : 9-15

Recognisable Neuroradiological Findings in Five Neurogenetic Disorders.

The rate of discovery and increased understanding of genetic causes for neurodevelopmental disorders has peaked over the past decade. It is well recognised that some genes show marked variability in neuroradiological phenotypes, and inversely, some radiological phenotypes are associated with several different genetic conditions. However, some readily recognisable brain magnetic resonance imaging (MRI) patterns, especially in the context of corresponding associated clinical findings, should prompt consideration of a pathogenic variant in a specific gene or gene pathway. As these conditions can often prove challenging to diagnose, a clinical suspicion of a specific disorder may be invaluable to guide and interpret genetic testing. This review focuses on five neurogenetic syndromes with recognisable brain findings that radiologists, paediatric neurologists, geneticists, and other specialists involved in neurodevelopmental disorders should be able to recognise in order to pinpoint the gene or gene groups involved and delve into their molecular mechanisms. The comprehensively reviewed conditions include DDX3X-related neurodevelopmental disorder, Van Maldergem syndrome, NMDAR-related disorders, EML1-associated disorder and ARFGEF2-related periventricular nodular heterotopia with microcephaly.

Riedel’s thyroiditis: A case report and review of the ultrasound findings of this rare disease entity

Introduction: Riedel’s thyroiditis is a rare inflammatory disease of the thyroid with non-specific and varied presentations. A typical presentation and ultrasound findings are reported in this case. Case Report: A 68-year-old male is referred to Ear, Nose and Throat for a neck lump that varied in size over 2 years. An ultrasound scan identified a suspicious nodule on the left thyroid that was biopsied confirming the diagnosis of Riedel’s thyroiditis. Discussion: The aetiology, presentation and management of Riedel’s thyroiditis are explored. The use of ultrasound and the utility of other imaging and biochemical tests are discussed. Conclusion: Riedel’s thyroiditis is a difficult condition to diagnose due to rarity, varied presentation, with non-specific clinical, biochemical and radiographic findings which often mimic thyroid cancers. Definitive diagnosis of Riedel’s thyroiditis requires histological analysis, and while fine-needle aspirations are typically insufficient, diagnostic samples can be taken with ultrasound-guided core biopsies.

Pott’s Puffy Tumor in Young Age: A Systematic Review and Our Experience

Background: Pott’s Puffy Tumor (PPT) in young-age patients is a rare clinical entity characterized by osteomyelitis of the frontal bone with a subperiosteal abscess collection. Previous reviews primarily consist of small, retrospective case series and anecdotal reports. This study aims to present the largest, most up-to-date systematic review of essential clinical findings, diagnostic modalities, microbiologic considerations, and treatment approaches for managing PPT in pediatric and adolescent populations. Methods: PubMed, Scopus, and Web of Science databases were systematically screened until 3 January 2024. The protocol of this investigation was registered on PROSPERO in January 2024, and the systematic review was performed according to the PRISMA statement. The study included 184 patients from 109 articles and an additional case from the authors’ institution. Results: PPT commonly stems from untreated rhinosinusitis, respectively, acute pansinusitis, frontal acute rhinosinusitis and chronic rhinosinusitis, and direct head trauma. Infections typically involve a polymicrobial anaerobe-predominant microbiome. Computed tomography and magnetic resonance imaging are routinely used for presurgical assessment and posttreatment surveillance. Intracranial complications were significantly associated with the type of surgical treatment (p value < 0.0001). Conclusions: PPT is a significant and relatively morbid disease often under-recognized and misdiagnosed due to its variable clinical presentation. Management includes both antimicrobial therapy and surgical intervention, emphasizing the importance of an interdisciplinary approach.

Prognostic value of isolated tumor cells and micrometastasis of lymph nodes in invasive urinary bladder cancer.

The prognostic significance of nodal micrometastasis and isolated tumor cells (ITC) in urinary bladder cancer (UBC) is unknown. We aimed to evaluate the prevalence, clinical impact, and clinicopathological characteristics of nodal micrometastasis and ITC in UBC. A total of 124 patients with UBC undergoing surgery were investigated. Detection of micrometastasis and ITC was performed using pancytokeratin immunohistochemistry (IHC). Histopathologic and clinical findings were correlated with patients' outcome. IHC detected nodal micrometastasis and ITC (pNmi group) in 12.9% (13/101) of originally node-negative patients and in 26.1% (6/23) of originally node-positive patients (pN+ group). The remaining 88 were truly node-negative patients (pN0 group). After IHC, all 13 patients in the pNmi group were upstaged from pN0 to pN1-2 and one patient in the pN+ group was changed from pN1 to pN2. Nodal micrometastasis and ITC were significantly associated with mixed urothelial carcinoma (UC) (p = 0.002), UC with discohesive pattern (p = 0.006), glandular differentiation (p = 0.043), lymphovascular invasion (p = 0.009), and budding-like tumor cell clusters (p = 0.002). The pNmi group had significantly worse cancer-specific survival than the pN0 group in univariate (p = 0.004) and multivariate (p = 0.040) analysis. IHC frequently identified nodal micrometastasis and ITC in originally node-negative UBC patients on routine pathological examination. Nodal micrometastasis and ITC were independently associated with cancer-related mortality in UBC. IHC might be selectively used to detect micrometastasis and ITC in UBC having specific pathological features.

Dual-energy CT angiography in detecting underlying causes of intracerebral hemorrhage: an observational cohort study.

CT angiography (CTA) is often used to detect underlying causes of acute intracerebral hemorrhage (ICH). Dual-energy CT (DECT) is able to distinguish materials with similar attenuation but different compositions, such as hemorrhage and contrast. We aimed to evaluate the diagnostic yield of DECT angiography (DECTA), compared to conventional CTA in detecting underlying ICH causes. All non-traumatic ICH patients who underwent DECTA (both arterial as well as delayed venous phase) at our center between January 2014 and February 2020 were analyzed. Conventional CTA acquisitions were reconstructed ('merged') from DECTA data. Structural ICH causes were assessed on both reconstructed conventional CTA and DECTA. The final diagnosis was based on all available diagnostic and clinical findings during one-year follow up. Of 206 included ICH patients, 30 (14.6%) had an underlying cause as final diagnosis. Conventional CTA showed a cause in 24 patients (11.7%), DECTA in 32 (15.5%). Both false positive and false negative findings occurred more frequently on conventional CTA. DECTA detected neoplastic ICH in all seven patients with a definite neoplastic ICH diagnosis, whereas conventional CTA only detected four of these cases. Both developmental venous anomalies (DVA) and cerebral venous sinus thrombosis (CVST) were more frequently seen on DECTA. Arteriovenous malformations and aneurysms were detected equally on both imaging modalities. Performing DECTA at clinical presentation of ICH may be of additional diagnostic value in the early detection of underlying causes, especially neoplasms, CVST and DVAs.

Kikuchi lymphadenitis, a rare case: an overview of its clinical presentation, diagnostic challenges, and therapeutic approaches

Kikuchi-Fujimoto Disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, self-limiting condition typically presenting with lymphadenopathy and fever. The etiology remains unclear, but it is thought to be associated with viral infections and autoimmune processes. We report a case of a female who presented with cervical lymphadenopathy. An excisional biopsy of the lymph node was performed, showing characteristic histopathological features of KFD. Based on the clinical presentation and histopathological findings, a diagnosis of Kikuchi-Fujimoto disease was made. The patient was managed with supportive care, including antipyretics and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). No antibiotics or corticosteroids were administered. The patient's symptoms gradually resolved over a period. Follow-up at three months revealed the resolution of symptoms with no recurrence. The patient remained asymptomatic at subsequent visits. KFD should be considered in young patients presenting with fever and lymphadenopathy. Diagnosis is confirmed through lymph node biopsy demonstrating characteristic histopathological features. The disease typically follows a benign course with spontaneous resolution, and management is primarily supportive.

Case report: Orbital myeloid sarcoma: a report of two rare cases and review of the literature

Myeloid sarcoma (MS) occurs when primitive or naive myeloid cells form outside the bone marrow. It occurs mainly in soft/connective tissue and skin; orbital involvement is rare. We report the cases of two female adults, analyze the clinicopathologic characteristics, and review the literature. The average age of both patients was 28 years and they presented unilateral proptosis combined with varying degrees of impaired visual acuity and restricted ocular motility in the affected eye. Despite this, they maintained good overall health and no notable family history. However, the patients had no systemic clinical manifestations of acute myeloid leukemia (AML). Both patients underwent surgical resection of the orbital tumor. Immunohistochemistry showed positive staining for CD43, Leukocyte Common Antigen (LCA), and myeloperoxidase (MPO) and a high level of positive staining for Ki67, which were diagnostic for MS. Bone marrow cytology examination showed no apparent abnormalities. Postoperative chemotherapy, local radiotherapy, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) were performed in Case 1, while the second patient underwent adjuvant chemotherapy and radiotherapy. No recurrence or metastasis was found in either patient during follow-up (one more than 5 years, the other more than 10 years). The occurrence of orbital MS is infrequent, with atypical clinical and imaging findings. The diagnosis depends on pathomorphology and immunohistochemical staining, and the prognosis is good with postoperative adjuvant chemotherapy, local radiotherapy, and allo-HSCT.

Tuberculous Pleurisy in a Patient with a History of Breast Cancer: Diagnostic Challenges and Management Options

Background: Tuberculosis (TB) and cancer are increasingly prevalent diseases that can be challenging to diagnose due to similarities in clinical and radiological findings. This case report describes a 46-year-old woman with a history of breast cancer who developed tuberculous pleurisy (TP). Case presentation: A 46-year-old woman who underwent mastectomy and chemotherapy for BC in 2023 had hypertension, but no history of TB. The patient presented with dry cough, fever, and stomach discomfort, with an oxygen saturation level of 60%, but no respiratory distress before their appointment. Microscopy and culture tests were negative for Mycobacterium TB, A positive result was observed with an IFN-γ level of 0.35 IU/ml and 26% of the negative control after TB antigen stimulation. Histological analysis using hematoxylin and eosin staining showed Langhans giant cells, epithelioid cell granulomas, caseous necrosis, and necrotic foci. These findings indicate granulomatous inflammation with no signs of malignancy. Following the diagnosis, the patient received a daily dose of 300 mg isoniazid, 600 mg rifampin, 1500 mg pyrazinamide, and 10 mg pyridoxine for six months without any adverse effects. Conclusion: Physicians must employ a combination of diagnostic techniques, including morphological and microbiological confirmation, to accurately diagnose pleural effusion in this patient population.

Variants of the PTPN11 Gene in Mexican Patients with Noonan Syndrome

Background/Objectives: Noonan syndrome (NS) is a genetic multisystem disease characterized by distinctive facial features, short stature, chest deformity, and congenital heart defects. NS is caused by gene variants of the RAS/MAPK pathway, with PTPN11 accounting for about 50% of cases. This study aimed to identify PTPN11 pathogenic variants in Mexican patients with NS to enhance our understanding of the disease in this population. Methods: This study included 91 probands and 60 relatives, all of which were clinically evaluated by a geneticist. Sanger sequencing was used to screen the entire PTPN11 gene. Results: Twenty-one previously reported pathogenic variants were identified in 47.3% of the probands. The most frequently occurring were p.Asn308Asp (16.3%) and p.Met504Val (16.3%). Variants p.Tyr279Cys and p.Thr468Met were found exclusively in patients with lentiginosis. Eighty-three percent of patients carried a variant in one of the three exons (3, 8, or 13) where the greatest genetic diversity was observed. Common clinical findings identified in probands included short stature (82%), cardiac anomalies (70.7%), short neck (68.4%), and pectus excavatum (63.2%), although features represented by only one patient each were also detected. Conclusions: This study confirmed the clinical diagnosis of NS in 43 probands and 11 relatives, and further genetic analysis of the remaining 48 probands is required to identify the causal variant. The genetic and clinical variability observed in our cohort was consistent with reports from other populations, underscoring the importance of comprehensive care for all patients. This research provides the most extensive clinical and molecular characterization of NS in Mexican patients, identifying pathogenic variants of PTPN11.

Early Childhood Cholestasis, Causes & Associated Factors in Children

Background: Newborn cholestasis is explained as a persisted rise of the serum conjugated bilirubin outside the first two weeks of life. There are many etiologies of newborn cholestasis that must be differentiated since immediate interference may give a better outcome. Objective: Newborn cholestasis is explained as a persisted rise of the serum conjugated bilirubin outside the first two weeks of life. There are many etiologies of newborn cholestasis that must be differentiated since immediate interference may give a better outcome. Patients and Methods: A cross-sectional research of forty-eight children consulting the Childhood Wellbeing Teaching Hospital in Baghdad/Medical City from 1st of November 2018 to the 30th of November 2021, complete evaluation by full history, physical checkup and laboratory studies. Cholestasis was demarcated as an extended raise of the levels of conjugated bilirubin outside the 1st 2 weeks of age above 1.0mg/dl(17.1µmol/l) if the whole serum bilirubin(TSB) is <5.0 mg/dL or above 20% of the TSB if the TSB is >5.0 mg/dl. Results: Out of 48 children involved in the study ,62.5% resided in Baghdad, and the remainder was belonged to other districts. The mean age of children was 11.1 months. The males constituted 58.3% of them. Eleven cases (22.9%) were caused by congenital infection, nine 18.8% had no cause detected, while 16.7% caused by biliary atresia and 16.7% had unidentified etiology, however 10.4% was related to sepsis. Biliary atresia was more frequent in boys in 62.5% compared to 37.5% in females. Family history was positive only in11.1% of idiopathic neonatal hepatitis. It was found that 81% of cholestatic jaundice were caused by congenital infection. In comparison, 62.5% caused by biliary atresia and 60% caused by sepsis appeared on the second week of the child's age, and this difference was significant statistically P-value 0.01. Conclusion: Innate infections are the most frequent source, where CMV contagion is the most commonly detected. Clinical findings included clay colored stool & elevated alkaline phosphatase concentrations observed primarily on biliary atresia. There are no specific test to identify the etiology of newborn cholestasis.

Postanesthetic rhabdomyolysis in 7 warmblood horses.

To describe the clinical findings, outcomes, and muscle histopathology in warmblood horses that developed severe rhabdomyolysis in the perianesthetic period despite remaining stable while under general anesthesia. 7 warmblood horses, 6 geldings and 1 mare, with a median age of 9 years (range, 4 to 18 years) and median weight of 615 kg (range, 550 to 703 kg). Records from the Valberg Neuromuscular Diagnostic Laboratory and Michigan State University were reviewed (2016 to 2023) to identify warmbloods with postanesthetic myopathy (PAM). Warmblood horses with no history of myopathy developed PAM after remaining stable while under general anesthesia. Five of 7 horses were in regular work prior to anesthesia, and activity level was unknown in 2 horses. Time to standing in recovery was prolonged, 3 horses were euthanized due to persistent recumbency, and rhabdomyolysis recurred in 4 horses 5 to 11 days after anesthesia, with 1 surviving. Horses had muscle stiffness, pain, and sweating and struggled to remain standing. As PAM developed, serum creatine kinase activity and lactate concentrations (12 ± 7 mmol/L; n = 5) were markedly increased. At necropsy, histopathology revealed complete glycogen depletion (5 of 7), acute myodegeneration (6 of 7), and chronic active myodegeneration of representative skeletal muscle samples. A semimembranosus biopsy obtained 14 days after anesthesia from the survivor had rare glycogen-depleted fibers. Warmblood horses are susceptible to fatal PAM characterized by acute myodegeneration, lactic acidosis, and muscle glycogen depletion that occurs up to 11 days after anesthesia. In horses with delayed recovery after anesthesia, monitoring for 2 weeks after anesthesia, including assessment of serum creatine kinase activity and blood lactate, could potentially improve outcomes.

The diagnostic challenge of differentiating Tumefactive Multiple Sclerosis (TMS) from other brain lesions: a case report and literature review on a rare subtype of MS

Introduction and Importance: This case report is a clinical diagnosis walk through of a rare subtype of Multiple sclerosis (MS). It gives an overview of how Tumefactive multiple sclerosis (TMS) is systematically narrowed down as the definitive diagnosis. Case Presentation: Our 29 year old male patient presented to the emergency department. He collapsed after experiencing pain over his right frontotemporal region followed by a seizure witnessed by his family. Magnetic Resonance Imaging of the brain displayed a diffuse enlargement and abnormal T2 weighted and FLAIR hyperintense signals in the diagnostic impressions described by the radiologist of the right temporoparietal region. Clinical Discussion: Liquefactive Multiple Sclerosis, also known as tumefactive multiple sclerosis or Marburg-type multiple sclerosis, is a rare subtype of the neurological disorder that can be difficult to diagnose. Unlike the traditional form of Multiple sclerosis (MS), Tumefactive multiple sclerosis (TMS) can present as a brain tumor and must be diagnosed with a biopsy rather than via magnetic resonance imaging (MRI) and clinical findings alone. Patients can typically present with headache, cognitive abnormalities, mental confusion, aphasia, apraxia, seizures, and weakness. Here, we discuss the presentation, disease diagnosis process and patient management. Conclusion: The patient was stabilized and discharged with a referral to the neurosurgery and neurology departments for outpatient consultation for future clinical management and treatment of their condition.

Efficacy and tolerability of subcutaneous repository corticotropin injection in refractory ocular inflammatory diseases

Abstract Background Repository corticotropin injection (RCI) has been suggested to exert immunomodulatory and anti-inflammatory effects in ocular inflammation. The index retrospective study aimed to evaluate the efficacy and tolerability of subcutaneous RCI in patients with active scleritis or uveitis. Main body Medical records of patients who were diagnosed with different types of active scleritis or uveitis and received RCI for more than six months at a tertiary eye center were reviewed. Patient characteristics including age, sex, comorbidities, clinical findings, treatment details, and adverse events were recorded. A total of 17 eyes of 17 patients were included. Median age was 43 years old and 53% of patients were male. Mean treatment duration was 25.4 ± 15.5 months. Indications for RCI therapy were scleritis (7 anterior and 1 posterior) (47.8%), panuveitis (17.4%), retinal vasculitis (17.4%), chronic/recurrent anterior uveitis (13%), and posterior uveitis (4.35%). RCI was initiated at a dose of 40 to 80 units 3 times weekly. Given the adequate control of inflammation, RCI was successfully discontinued in four patients (23.5%). Prior to RCI therapy, 14 (82.3%) patients were on oral prednisone at an average of 10 mg daily (range 2.5–40 mg), and two (11.7%) patients discontinued prednisone immediately before initiating RCI due to side effects. After six months of therapy, the prednisone dose was reduced in four (23.5%) patients to an average of 3 mg daily (range 1–5 mg) and was stopped in eight (53%) patients. Concomitant immunomodulatory therapies (IMTs) included mycophenolate mofetil (23.5%) and methotrexate (23.5%), and adalimumab (23.5%). Ten patients were on IMTs prior to using RCI, and during the course of treatment, IMT was stopped in two patients and reduced in one. Side effects included insomnia (23%), hypertension (11.7%), lower extremity edema (11.7%), hyperglycemia (11.7%), weight gain (11.7%), and infection (5.8%). Conclusion RCI may be considered as a potential therapy with acceptable tolerability for patients with non-infectious scleritis or uveitis.