Clinical Situations Research Articles

Quel est le seuil de détection clinique d’une inégalité de longueur des membres inférieurs ? Étude in silico de la reproductibilité et optimisation par un support gradué centimétrique

Introduction: The threshold of a Leg Length Discrepancy (LLD) by clinical examination on a sheet or centimeter paper (CP) is not known precisely whether or not it concerns limbs equipped with a hip prosthesis. We therefore conducted a prospective in silico study in order to: 1) determine the reproducibility and sensitivity of the clinical measurement of the LLD in different ideal and "degraded" clinical situations, 2) determine the threshold from which the human eye is capable of detecting a length inequality in clinic, 3) to determine whether the use of a graduated support (centimeter paper) improves the clinical measurement threshold.Hypothesis: Our hypothesis was that clinical measurement on a centimeter support would improve clinical measurement accuracy.Material and methods: This was an in silico study, the experiment was conducted on a mannequin. Different inequalities were created on a mannequin and photographed with a total of 30 inequalities from -22 to +22mm on sheet or centimeter paper (CP). This was a multicenter study, with 40 different readers. We asked the readers to make a second measurement one month later. We evaluated the inter- and intra-observer reproducibility. The error rate at the threshold of 3mm and 5mm were calculated versus the gold standard. Finally, we determined at which thresholds respectively 75% and 95% of the measurements were correct.Results: A total of 4140 measurements were performed and compared to the gold standard. With a threshold of 75% accurate measurement, the LLD detection threshold was 2.8 mm on centimeter paper and 4.5 mm on sheet. With a threshold of 95% accurate measurement, the LLD detection threshold was 3.4 mm on centimeter paper and 5.2 mm on sheet. Interobserver agreement (assessed overall on the 40 observers by Krippendorff's generalized Kappa) was 0.86 (95% confidence interval (CI95%) = 0.79 to 0.92) on CP and 0.71 (CI95% = 0.63 to 0.79) on sheet. Intra-observer agreement assessed by the intraclass correlation coefficient among observers who made 2 measurements had a median value (IQR) of 0.96 (0.94 to 0.99) on CP and 0.90 (0.83 to 0.94) on sheet.Discussion: The clinical detection threshold on sheet at the patient's bed appears close to 5mm. A more precise measurement is possible with graduated centimeter paper. A study in daily practice on patients in real situations would confirm our results.Level of evidence: III; prospective diagnostic comparative in Silico study

Development of modified laser Doppler flowmetry device for real-time monitoring of esophageal mucosal blood flow: a preclinical assessment with an animal model.

This study aimed to modify a laser Doppler flowmeter designed and assembled at our institute. After measuring sensitivity evaluation in ex vivo experiments, we confirmed the efficacy of this new device for monitoring real-time esophageal mucosal blood flow changes after thoracic stent graft implantation by simulating various clinical situations in an animal model. Thoracic stent graft implantation was performed in a swine model (n = 8). Esophageal mucosal blood flow decreased significantly from baseline (34.1 ± 18.8ml/min/100g vs. 16.7 ± 6.6ml/min/100g, P < 0.05) in the lower esophagus (Th6-Th8) where the stent graft covered the aorta. In the hemorrhagic shock model (shock index ≥ 1.0), esophageal mucosal blood flow showed a remarkable change from baseline in the upper esophagus (Th1-Th3), where the stent graft did not cover the aorta (20.8 ± 9.8ml/min/100g vs. 12.9 ± 8.6ml/min/100g, P < 0.01); however, it returned to the baseline value within a 30-min period. Mucosal blood flow remained stable in the esophagus, where the stent graft did not cover the aorta. After elevating the mean blood pressure to > 70mmHg with continuous intravenous noradrenaline infusion, esophageal mucosal blood flow increased significantly in both regions; however, the reaction was different between the two regions. Our newly developed laser Doppler flowmeter could measure real-time esophageal mucosal blood flow changes in various clinical situations during thoracic stent graft implantation in a swine model. Hence, this device can be applied in many medical fields by downsizing it.

Quantitative and qualitative analysis of contrast-enhanced ultrasound for differentiating benign and malignant superficial enlarged lymph nodes.

In many clinical situations, it is critical to exclude or identify abnormally lymph nodes (LNs). The nature of superficial abnormally LNs is closely related to the stage, treatment, and prognosis of the disease. Ultrasound (US) is an important method for examining superficial LNs due to its cheap and safe characteristics. However, it is still difficult to determine the nature of some LNs with overlapping benign and malignant features in images. Contrast-enhanced ultrasound (CEUS) can be used to evaluate the microperfusion status of tissues in real time, and it can improve diagnostic accuracy to a certain extent. Therefore, in this study, we will analyze the correlation between CEUS quantitative parameters and benign and malignant superficial abnormally LNs, to evaluate the efficacy and value of CEUS in distinguishing benign and malignant superficial LNs. This study retrospectively analyzed 120 patients of abnormal LNs who underwent US and CEUS at the China-Japan Union Hospital of Jilin University from December 2020 to August 2023. All 120 cases of abnormal LNs underwent US-guided coarse needle biopsy, and accurate pathological results were obtained, along with complete US and CEUS images. According to the pathological results, LNs were divided into benign and malignant groups, and the qualitative and quantitative parameters of US and CEUS between the two groups were analyzed. The cutoff value is determined by the receiver operating characteristic (ROC) curve of the subjects, and sensitivity, specificity, and accuracy are applied to evaluate the ability of the cutoff value to distinguish between the two groups. There were a total of 120 LNs, including 36 in the benign group and 84 in the malignant group. The results showed that malignant LNs were usually characterized by the disappearance of lymphatic hilum, round ness index (L/T) <2, irregular morphology, and the manifestation of uneven perfusion (P<0.05). The differences in the quantitative parameters peak enhancement (PE), rise time (RT), time to peak (TTP), wash-in rate (WIR), and wash-out rate (WOR) were statistically significant (P<0.05). The result showed that RT and TTP in the malignant LNs were higher than those in the benign LNs, while the PE, WIR, and WOR were lower. A comparison of the ∆ values showed that the differences in ∆PE, ∆WIR, and ∆fall time (FT) were statistically significant (P<0.05), Among them, the ∆PE and ∆WIR of malignant LNs were higher than those of benign LNs, while the ∆FT was lower than that of benign LNs. Quantitative analysis of CEUS features is valuable in the diagnosis of benign and malignant LNs, and US combined with CEUS helps to improve the accuracy of identifying the nature of LNs.

TDAH : quels sont les effets cardiovasculaires du méthylphénidate et quelles sont les conséquences éventuelles pour la pratique clinique ?

ContextMethylphenidate is the first-line pharmacological treatment for ADHD, and its prevalence continues to grow, with an increase of 116% over the last ten years in France. Its use in hospitals has been extended to neurologists, psychiatrists and pediatricians, and its prescription can be renewed by a general practitioner. Cardiovascular complications are rare, but life-threatening. Management practices currently vary widely from one medical center or doctor to another. ObjectivesReviewing the cardiovascular effects of methylphenidate in adults and children with ADHD, aiming to propose a practical management plan without intending to replace existing recommendations. MethodsThe subject under study aimed to answer the following PICO question “What are the cardiovascular consequences (outcomes) when using MPH (intervention) for an ADHD population (population) regardless of age”. We carried out systematic review of international reviews and meta-analyses, selected using the PRISMA methodology via the PubMed, Cochrane Library and Google Scholar databases. Their methodological quality was assessed using the AMSTAR-2 scale. Cardiovascular events considered were the adrenergic effects of MPH on the cardiovascular system, looking for changes in blood pressure and heart rate, and the serious cardiovascular effects represented by sudden death/arrhythmia, myocardial infarction and stroke. A total of 17 systematic reviews and meta-analyses met the eligibility criteria. ResultsOf the 734 articles found, twelve were finally selected. Four concerned a population of children, five a mixed population of adults and children and three a population of adults only. They included two systematic reviews and ten meta-analyses. Three reviews included cohort studies and nine included randomized controlled trials. Three clinical situations can be distinguished depending on the age of the patient and the length of exposure to methylphenidate. The first, on initiation of treatment, there was a marked by a short-term increase in blood pressure and heart rate. The second involves a patient under the age of 35 with short- to medium-term exposure to MPH. A persistent adrenergic effect tends to increase the risk of sudden death by 12% (if the resting heart rate increases by ten beats per minute). This risk is further increased if the patient has psychiatric comorbidities and their associated treatments, congenital heart disease and uses recreational substances. Finally, the last situation involves a patient exposed to MPH for several years and aged over 35, whose main risk is the onset of atheromatous disease with myocardial infarction and ventricular arrhythmia. In this case, a comprehensive approach is required, identifying risk factors and behavioral factors likely to exacerbate the risk of CV disease. ConclusionsThe short-term cardiovascular effects of MPH are well documented and statistically significant, with a moderate but significant increase in blood pressure (+2mmHg) and heart rate (+5bpm). Longer-term cardiovascular safety data are often lacking, leading to conflicting conclusions. Meta-analyses of cohort studies conclude that there is an increase in cardiovascular risk, while meta-analyses of randomized trials find no significant statistical association. This means that patients and their families need to be made aware of this lack of data. Personalized management based on age, duration of exposure to MPH and the clinical profile of patients as defined by cohort studies seems to us to be the most appropriate approach. In people under 35, the main risk is sudden death. In this population, it is important to identify any congenital heart disease and to look for psychiatric comorbidities, and by assessing the substance abuse. For people over 35, the main risk is coronary heart disease. In this case, a comprehensive approach is required, identifying risk factors and behavioral factors likely to exacerbate the risk of CV disease. Our daily practice is more in line with cohort studies including patients with co-morbidities associated with their ADHD, as well as a significant risk of having risky behaviors, depressive episodes, heart disease and prolonged exposure to MPH and other drugs. Prescribing MPH in this context is tricky, with a higher risk of cardiovascular events. Close clinical monitoring is therefore necessary, and specialist advice may be required.

A Retrospective Analysis of Four STI Pathogens in Obstetrics and Gynecological Patients in Hangzhou, China.

Among sexually transmitted infection (STI) pathogens, UU, CT, NG, and MG are very commonly detected. A retrospective study was conducted to analyze the clinical situations and laboratory data of patients in-fected with the four pathogens in Hangzhou city, Zhejiang Province, China. For this study, 4,716 female outpatients and inpatients of the Department of Obstetrics and Gynecology of Hangzhou Third People´s Hospital were randomly selected from January 2019 to December 2023. Multiple types of specimens were collected and four STI pathogens were detected. Data collection was taken from the hospital's electronic medical records and statistical analysis was processed with SPSS 25.0 software. In the past five years, year by year, the positive rate presented an increasing trend. Out of 4,716 patients, 2,931 were positive, and the positive rate was 62.15%. The positive rate of single infection was significantly higher than of co-infection (p < 0.05). The highest positive rate of all STI patients was found in the  20 age group, and the rate was significantly different between each age group (p < 0.05). Single infection with UU occurred significantly more often than with the other three pathogens (p < 0.05), and co-infection with UU and CT and UU, CT, and MG were significantly dominating (p < 0.05). Only three patients had an infection with all four pathogens, and it was extremely rare. The 21 - 30 and 31 - 40 age groups had high incidences of infection, with a significant difference compared with other age groups (p < 0.05). The positive rate shows an increasing trend in Hangzhou in the past five years. More single infection than co-infection and more younger patients were detected. Single infection with UU was dominant in all positive patients. The publicity and more screening testing items of STI for younger people should be strengthened in Hangzhou, and the people of Hangzhou should be made more aware that information technology is helpful in aiding the control of STI diseases.

The mediating role of positive psychological capital in the relationship between metacognition and self-directed learning ability: A cross-sectional study

BackgroundSelf-directed learning is a fundamental skill and requirement for lifelong learning. It enables nursing students to enhance their learning ability, academic achievement, clinical performance, and adaptability to clinical situations. Metacognition (i.e., the process of reflecting on one's own cognitive activities) helps internalize learning strategies, construct self-concept, and solve problems. Positive psychological capital is a positive psychological state that stimulates the pursuit of individual development; it helps nursing students to cope effectively with various problems. However, it remains unclear if metacognition impacts self-directed learning ability (SDLA) through positive psychological capital; if confirmed, this would provide basic data for the development of effective teaching and learning methods. ObjectivesTo examine the mediating effect of positive psychological capital in the relationship between metacognition and SDLA in nursing students. DesignA cross-sectional, descriptive survey study. ParticipantsThe participants were 172 nursing students from four nursing colleges. MethodsWe measured metacognition, positive psychological capital, and SDLA using an online questionnaire; data were collected from September 7 to 23, 2023. We used Pearson's correlation coefficient to analyze correlations. To test the mediating effect of positive psychological capital, we used three-step regression analysis, Sobel's test, and Hayes's Process Macro - Model 4. ResultsSDLA was correlated with metacognition (r = 0.689, p < .001) and positive psychological capital (r = 0.605, p < .001). Metacognition influenced positive psychological capital (B = 0.324, p < .001) and SDLA (B = 0.614, p < .001). Positive psychological capital mediated the relationship between metacognition and SDLA (B = 0.297, p < .001; z = 3.214, p = .001 [Sobel test]). ConclusionLearning strategies aiming to enhance nursing students' SDLA require successful metacognition to boost positive psychological capital. This study's empirical evidence on the potential benefits of linking metacognition with positive psychological capital has practical implications in relation to helping nursing students attain core academic goals.

The Role of Behavioral Management in Enhancing Clinical Care and Efficiency, Minimizing Social Disruption, and Promoting Welfare in Captive Primates.

Medical procedures necessary for routine care can induce stress in both the veterinary and human clinical situations. In the research environment, nonhuman primates undergo procedures like physical examination, blood sampling, and intravenous drug or fluid administration either as a part of routine veterinary care or during the modeling of clinical disease and interventions under study. Behavioral management techniques, such as training for cooperation, allow caregivers to train primates to voluntarily engage in various medical procedures. This approach reduces stress and anxiety associated with necessary procedures, thereby enhancing efficiency and minimizing the invasiveness of medical care. Consequently, veterinary evaluation and care can be provided without compromise, resulting in enhanced clinical outcomes and overall better health. In this study, we explored the impact of the behavioral management program implemented at our center on a subset of animals undergoing routine veterinary care, focusing on the overall experience, including animal welfare, scientific rigor, and efficiency in terms of economics and time. We investigated its impact on key factors, such as the total procedure and recovery time, incidence of side effects, and welfare indicators, revealing a significant positive influence on animal care. Furthermore, through case studies, we illustrate how behavioral management facilitates timely medical care and monitoring, effectively mitigating stressors that could otherwise impair health and welfare, enabling the provision of care that would have otherwise been unachievable. A thoughtfully designed primate behavioral management program, integrating cooperation and participation with veterinary care, forms the cornerstone of superior animal welfare, enhanced clinical care, and more accurate scientific outcomes.

In-hospital initiation of angiotensin receptor-neprilysin inhibition in acute heart failure: the PREMIER trial.

The efficacy and safety of early sacubitril/valsartan (Sac/Val) initiation after acute heart failure (AHF) has not been demonstrated outside North America. The present study aimed to evaluate the effect of in-hospital Sac/Val therapy initiation after an AHF episode on N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in Japanese patients. This was an investigator-initiated, multicentre, prospective, randomized, open-label, blinded-endpoint pragmatic trial. After haemodynamic stabilization within 7 days after hospitalization, eligible inpatients were allocated to switch from angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to Sac/Val (Sac/Val group) or to continue angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (control group). The primary efficacy endpoint was the 8-week proportional change in geometric means of NT-proBNP levels. A total of 400 patients were equally randomized, and 376 (median age 75 years, 31.9% women, de novo heart failure rate 55.6%, and median left ventricular ejection fraction 37%) were analysed. The per cent changes in NT-proBNP level geometric means at Weeks 4/8 were -35%/-45% (Sac/Val group) and -18%/-32% (control group), and their group ratio (Sac/Val vs. control) was 0.80 (95% confidence interval 0.68-0.94; P = .008) at Week 4 and 0.81 (95% confidence interval 0.68-0.95; P = .012) at Week 8, respectively. In the pre-specified subgroup analyses, the effects of Sac/Val were confined to patients with a left ventricular ejection fraction < 40% and were more evident in those in sinus rhythm and taking mineralocorticoid receptor antagonists. No adverse safety signal was evident. In-hospital Sac/Val therapy initiation in addition to contemporary recommended therapy triggered a greater NT-proBNP level reduction in Japanese patients hospitalized for AHF. These findings may expand the evidence on Sac/Val therapy in this clinical situation outside North America. ClinicalTrial.gov (NCT05164653) and Japan Registry of Clinical Trials (jRCTs021210046).

Monitoring of adverse effects of antituberculosis drugs: case study of hepatic cytolysis and skin reactions

Introduction. Tuberculosis remains a major public health issue worldwide. Progress in treatment, particularly with the emergence of anti-tuberculosis drugs, has been significant. However, identifying the drugs responsible for adverse effects is crucial to establish a practical approach in clinical situations, including the assessment and monitoring of these effects. Methods. This case study describes the monitoring and management of adverse effects of anti-tuberculosis drugs in patients at the Tuberculosis and Respiratory Diseases Control Department (SCTMR) in Sidi Bel Abbes (Algeria). Results. The observed effects include nine cases of hepatic cytolysis and two cases of skin reactions. This work revealed a predominantly high intrinsic imputability of anti-tuberculosis drugs, with a rating of I3 (C2S2) for six cases and I5 (C2S3) for five cases. The therapeutic interventions implemented and their compliance with international recommendations are discussed. Discussion. SCTMR specialists generally follow international recommendations to manage adverse effects of antituberculosis drugs. However, the high imputability of anti-tuberculosis drugs indicates that they are strongly incriminated in the occurrence of these adverse effects. Conclusion. Adverse effects of anti-tuberculosis treatment are not rare, requiring rigorous clinical, biological and pharmacovigilance monitoring. These surveillances can reduce mortality and morbidity associated with tuberculosis treatment. A government commitment is essential to revitalize the national pharmacovigilance center and improve the detection of serious adverse effects.

Artificial urinary sphincter and stricture disease: surgical principles in management.

Iatrogenic stress urinary incontinence (SUI) is the most common complication of surgical treatment of prostate cancer, regardless of operative approach, and has a major impact on patients' quality of life. Although SUI can occur after surgical treatment of benign prostatic hyperplasia, specifically transurethral prostate resection, laser enucleation of the prostate, and simple open prostatectomy, these therapeutic modalities play a much less significant role in the etiology of SUI. Artificial urethral sphincter (AUS) implantation is considered the standard treatment modality providing high success rates, including durable efficacy, and optimal patient satisfaction for moderate to severe urinary incontinence resulting mainly from radical prostatectomy. However, although complication rates are generally acceptably low, revision and/or explantation may be required due to mechanical failure and non-mechanical problems, specifically urethral atrophy/cuff deficient occlusion, infection, and cuff erosion. Several risk factors for AUS failure associated with a fragile, compromised urethra have been identified and these play a critical role in device cuff erosion and subsequent removal of the device. Among others, apparently the most impacting factors are irradiation, urethral stent placement, a previous AUS placement, and importantly presence of urethral stricture or prior urethroplasty. Generally, any clinical situation leading to a diseased urethra or lack of urethral integrity is associated with impaired local blood perfusion, and consequently lower success rates. The present review aims to evaluate the impact of the presence of prior urethral strictures and urethroplasty on the outcomes of AUS implantation on one hand, and vice-versa, the influence of AUS placement on later urethral stricture surgery, particularly following cuff erosion.

Mutant P53 modulation by cryptolepine through cell cycle arrest and apoptosis in triple negative breast cancer

BackgroundTriple Negative Breast cancer is an aggressive breast cancer subtype. It has a more aggressive clinical course, an earlier age of onset, a larger propensity for metastasis, and worse clinical outcomes as evidenced by a higher risk of recurrence and a shorter survival rate. Currently, the primary options for TNBC treatment are surgery, radiation, and chemotherapy. These treatments however remain ineffective due to recurrence. However, given that p53 mutations have been identified in more than 60–88 % of TNBC, translating p53 into the clinical situation is particularly important in TNBC. In this study, we screened and evaluated the therapeutic potential of cryptolepine (CRP) in TNBC in-vitro models being an anti-malarial drug it could be repurposed as an anti-cancer therapeutic targeting TNBC. Moreover, the cytotoxicity activity of cryptolepine to TNBC cells and a detailed anti-tumor mechanism in mutant P53 has not been reported before. MethodsMTT assays were used to examine the cytotoxicity and cell viability activity of Cryptolepine in TNBC, non-TNBC T47D and MCF-7 and non-malignant MCF10A cells. Scratch wound and clonogenic assay was used to evaluate the cryptolepine’s effect on migration and colony forming ability of TNBC cells. Flow cytometry, MMP and DAPI was used to assess cell cycle arrest and cell apoptosis mechanism. The expression of proteins was detected by western blots. The differential expression of RNAs was evaluated by RT-PCR and the interaction between P53 and drug was evaluated computationally using in-silico approach and in-vitro using ChIP assay. ResultsIn this study, we found that cryptolepine has more preferential cytotoxicity in TNBC than non-TNBC cells. Notably, our studies revealed the mechanism by which cryptolepine induces intrinsic apoptosis and inhibit migration, colony formation ability, induce cell cycle arrest by inducing conformational change in the mutant P53 thereby increasing its DNA binding ability, hence activating its tumor suppressing potential significantly. ConclusionOur study revealed that CRP significantly reduced the proliferation, migration and colony forming ability of TNBC cells lines. Moreover, it was revealed that CRP induces cell cycle arrest and apoptosis by activating mutant P53 and enhancing its DNA binding ability to induce its tumor suppressing ability.

Predictors of Clinical Hematological Toxicities under Radiotherapy in Patients with Cervical Cancer-A Risk Analysis.

Cervical cancer ranks third in frequency among female cancers globally and causes high mortality worldwide. Concurrent chemoradiotherapy improves the overall survival in cervical cancer patients by 6% but it can cause significant acute and late toxicities affecting patient quality of life. Whole pelvis radiotherapy doses of 10-20 Gy can lead to myelosuppression and to subsequent hematological toxicities since pelvic bones contain half of bone marrow tissue. A total of 69 patients with IB-IVB-staged cervical cancer have been included in this retrospective cohort study. We analyzed clinical adverse events and changes in blood cell counts (hemoglobin, neutrophils, leukocytes, and platelets) during radiation or chemoradiotherapy received at the Oncological Institute of Bucharest from 2018 to 2021. Decreases in hemoglobin levels of over 2.30 g/dL during treatment were associated with BMI > 23.2 kg/m2 (OR = 8.68, 95%CI = [1.01, 75.01]), age over 53 years (OR = 4.60 95%CI = [1.10, 19.22]), with conformational 3D irradiation (OR = 4.78, 95%CI = [1.31, 17.40]) and with total EQD2 of over 66.1 Gy (OR = 3.67, 95%CI = [1.02, 13.14]). The hemoglobin decrease rate of 0.07 g/dL/day was related to 95% isodose volume (OR = 18.00). Neutropenia is associated frequently with gastrointestinal side effects and with the bowel and rectal V45 isodoses (OR = 16.5 and OR = 18.0, respectively). Associations of total external and internal radiation dose with the time durations calculated from the initiation of treatment to the onset of hematological adverse reactions were also obtained. The maximum drop in leukocytes was observed before day 35 from the RT initiation in patients who underwent treatment with 3D conformal radiotherapy (OR = 4.44, 95%CI = [1.25, 15.82]). Neutrophil levels under 2.2 × 103/μL and thrombocyte levels under 131 × 103/μL during the follow-up period were associated with a total planned dose of 54 Gy to the pelvic region volume (OR = 6.82 and OR = 6.67, respectively). This study shows the existence of clinical and blood predictors of hematological adverse reactions in cervical cancer patients. Thus, patients who are in a precarious clinical situation, with low hematological values (but not yet abnormal), should be monitored during days 29-35 after the initiation of RT, especially if they are obese or over 53 years of age.

Urgent MRI: when, what, and why—a single Italian center experience

PurposeThe aim of our study is to provide a list of clinical situations that might justify the performance of an urgent MRI (uMRI) based on clinical relevance, correlating the MRI findings with the clinical indications and the urgent management of patients.MethodsWe reviewed all uMRI scans of brain (buMRI) and spine (suMRI) performed in our Department from August 2020 to February 2024. We analyzed the main clinical indications, the neuroradiological findings, and the relevance of these results in the therapeutic decisions.ResultsThe main indication for buMRI was the evaluation of ischemic stroke detected at preliminary CT scan followed by coma, status epilepticus, suspected acute inflammatory diseases, trauma, suspicious of infective diseases, and pre-surgical evaluation of cerebral tumors. The main findings were: ischemia, acute inflammatory conditions, post-traumatic and post-ictal alterations, venous thrombosis, infective diseases, and cerebral tumors. 65% of patients underwent an urgent therapeutic intervention. The main indications for suMRI were clinical suspicion of myelopathy and radiculopathy including cauda equina syndrome secondary to trauma, neoplasms, inflammatory and infective diseases, degenerative changes, surgery, and vascular diseases. The main findings were: post-traumatic, degenerative and neoplastic myelopathy or radiculopathy, inflammatory and infective changes of the spinal cord, post-surgical fluid collections, and vascular diseases. About 77% of suMRI was followed by an urgent surgery.ConclusionsOur study showed an overall good correlation between buMRI-suMRI findings and the clinical indications for the examinations. Also, uMRI affected the urgent management in a good percentage of patients, proving the significance of uMRI findings.

Clinical case of colchicum poisoning

Introduction. Autumn colchicum or crocus is a popular plant among gardeners, characterized by early beautiful flowering, but few people know that it is poisonous. Acute colchicum poisoning is a dangerous urgent clinical situation with high mortality rates. By disrupting cell division, colchicum venom leads to multiple organ failure and death in just a few days. However, colchicum extract in small doses is often used in modern medicine to treat various diseases, due to its high antimitotic and moderate anti-inflammatory activity. The article describes the clinical observation of a patient admitted to the toxicology department after a suicide attempt using a crocus flower, containing the alkaloid colchicine. The results of laboratory and pathological studies are presented. Clinical observation. A clinical case of acute crocus poisoning with the development of hemodynamic disorders, dyspeptic syndrome, respiratory failure, cytolysis syndrome, and oliguria is presented. Treatment was aimed at restoring organ functions and consisted of infusion, detoxification, and hemostatic therapy. Limitations. To carry out this scientific work, a study was conducted within the framework of only one clinical case committed on the territory of the Udmurt Republic. In this case report, there was no comparison group or observation group. The described documents were provided by the Budgetary Health Institution of the Udmurt Republic "City Clinical Hospital no. 6" of the Ministry of Health of the Udmurt Republic and the Budgetary Health Institution of the Udmurt Republic “Bureau of Forensic Medical Examination of the Ministry of Health of the Udmurt Republic” by prior agreement. Conclusion. Colchicum poisoning is a rare and extremely severe pathology, leading to multiple organ failure, agranulocytosis and death. Considering the rapid absorption in the gastrointestinal tract and the initial symptoms in the form of gastrointestinal lesion syndrome, early diagnosis in the absence of anamnesis is difficult, therefore, it is necessary to highlight the issues of diagnosing this poisoning, as well as the study and implementation of modern methods of treating colchicine poisoni

Exploring Ethical Theories Among Medical Residents in Clinical Situations: A Cross-Sectional Study

Human beings are faced with numerous behavioral options in different situations, but they can only choose a limited number of them. Ethical beliefs, values, and principles guide individuals in decision-makings. This study focuses on medical residents' perspectives towards four ethical principles (Deontology, Utilitarianism, Virtue, and Principlism) in various clinical situations. This descriptive-analytical study was performed cross-sectional basis among a population of medical residents of Shiraz University of Medical Sciences. Data were gathered by multi-stage cluster sampling method using a researcher-made questionnaire including demographic information and five different clinical scenarios. The data were analyzed using the Chi-square test and descriptive and inferential statistics in SPSS22. The results of this study showed that there was no significant relationship between gender, specialty, year of study, and the four ethical principles mentioned in the participants. However, a significant correlation was observed between the types of scenarios and their alignment with a particular type of decision or ethical theory. The ethical philosophy of medical residents has been evolving gradually over time, even before entering the residency period. Therefore, focusing on practical ethics training and the commitment of residents to implementing the principles and values of professional ethics can shape the ethical philosophy of residents towards professional ethics and humanity.

Artificial Intelligence Recognition Model Using Liquid-Based Cytology Images to Discriminate Malignancy and Histological Types of Non-Small-Cell Lung Cancer

Introduction: Artificial intelligence image recognition has applications in clinical practice. The purpose of this study was to develop an automated image classification model for lung cancer cytology using a deep learning convolutional neural network (DCNN). Methods: Liquid-based cytology samples from 8 normal parenchymal (N), 22 adenocarcinoma (ADC), and 15 squamous cell carcinoma (SQCC) surgical specimens were prepared, and 45 Papanicolaou-stained slides were scanned using whole-slide imaging. The final dataset of 9,141 patches consisted of 2,737 N, 4,756 ADC, and 1,648 SQCC samples. Densenet-121 was used as the DCNN to classify N versus malignant (ADC+SQCC) and ADC versus SQCC images. AdamW optimizer and 5-fold cross-validation were used in the training. Results: For malignancy prediction, the sensitivity, specificity, and accuracy were 0.97, 0.85, and 0.94, respectively, in the patch-level classification, and 0.92, 0.88, and 0.91, respectively, in the case-level classification. For SQCC prediction, the sensitivity, specificity, and accuracy were 0.86, 0.91, and 0.90, respectively, in the patch-level classification and 0.73, 0.82, and 0.78, respectively, in the case-level classification. Conclusion: The DCNN model performed excellently in predicting malignancy and histological types of lung cancer. This model may be useful for predicting cytopathological diagnosis in clinical situations by reinforcing training.

The choice of a method for restoring coronary blood flow in myocardial infarction with ST segment elevation (literature review)

In the structure of total mortality, cardiovascular diseases are in the first place in the world. The main and most common reason for this is the incidence of myocardial infarction (MI). The basis of the pathogenesis of MI with ST elevation is persistent and complete thrombotic occlusion of the large epicardial branch of the coronary artery, leading to extensive necrosis of the heart muscle with the development of life-threatening complications, including death, the frequency of which is 8–10 %. The prognosis for MI is influenced by the presence of risk factors, complications, hemodynamic status, polymorbidity, as well as tactics for restoring coronary blood flow. To eliminate acute coronary artery occlusion, conservative treatment is used – thrombolytic therapy, surgical – primary percutaneous intervention, thromboextraction, coronary bypass surgery, as well as their combination. Today, there are scattered and isolated studies characterizing the approach to treatment in patients with MI with ST elevation in various diseases and with polymorbid pathology, the relationship with risk factors and laboratory and instrumental data has not been established, among which predictors of rapid response and death in patients with polymorbid pathology for emergency physicians have not been determined. It can be assumed that the chosen optimal patient management tactics in a specific clinical situation, taking into account the above-mentioned factors, will reduce the development of complications and increase the survival rate of patients with MI.

Role of Hysteroscopy in the Management of Uterine Vascular Malformations with a Focus on Enhanced Myometrial Vascularity – A Review of Diagnosis and Treatment with the Suggested Algorithm

Abstract Postpregnancy bleeding is common after failed pregnancy, termination of pregnancy, and postnatally after both vaginal and cesarean delivery. Pelvic ultrasound (US) is usually the initial imaging modality of choice to ascertain the cause when the bleeding is heavy or prolonged. When used in combination with Doppler studies, US can help differentiate retained products of conception (RPOC) from rarer uterine vascular malformations (UVM), including true arterial vascular malformations and areas of enhanced endometrial vascularity (EMV), which may themselves be associated with any RPOC present. While the management of RPOC is well established and has evolved from an almost universal surgical approach to increasingly more medical or expectant alternatives, clinical decisions over the management of a concurrent UVM are less clear and treatment options need to be individualized depending on features of the lesion and the clinical situation with hysteroscopy featured as an important modality, especially when dealing with EMV’s. In this review, we discuss the role of hysteroscopy in the treatment of enhanced myometrial vascularity with and without associated RPOC and propose a management algorithm.

Review and adaptation of European Federation of Internal Medicine clinical guidelines on acute heart failure

The article discusses the adaptation of European Federation of Internal Medicine clinical guidelines for the management of patients with acute heart failure (AHF). An algorithm has been proposed for the differential diagnostic examination of patients with AHF and acute shortness of breath, signs of congestion, hypoxemia, including the determination of natriuretic peptides (NUPs) and/or cardiac troponin, assessment of the congestion severity using echocardiography, as well as the potential of chest radiography and lung ultrasound in certain clinical situations. Special attention is paid to methods for assessing and treating signs of fluid congestion, which have the most accurate prognostic value in patients hospitalized due to AHF. Assessment of the prognosis and the need for hospitalization of AHF patients in the intensive care unit are highlighted. Treatment strategies for patients with hypotension and low cardiac output are discussed. The latest guidelines for the treatment of patients with AHF, taking into account concomitant diseases, are presented. Indications for hospital discharge of patients with AHF, optimization of the further treatment plan, effective strategies for reducing the risk of rehospitalization and mortality, both at the hospital discharge and outpatient stage, are discussed.

Periapical surgery and different root obturation protocols for upper central incisor: A finite elements analysis

BackgroundThe aim of this study was to determine the effect of root canal filling using different obturation materials combined with apicoectomy in upper central incisors under loading with 1 N and 100 N. The effect of incomplete root formation was also investigated. MethodsBased on a CBCT-scan, a model of an upper central incisor was created. The model was altered to simulate different clinical situations: root canal treatment, apicoectomy at two different lengths and with different obturation protocols, and immature root formation after trauma. In each model the tooth was loaded with 1 and 100 N, and peak Von Mises stress of bone and tooth, elastic strain of the periodontal ligament, as well as rotation and displacement of the tooth were measured. ResultsPeriapical surgery increases stress in dentin and the surrounding bone. Different obturation materials only produce minor differences in a coronally intact tooth. ConclusionsInterincisal angle or loading direction strongly affects all measured values and needs to be considered when planning periapical surgery or comparing finite element analysis. Immature roots show the highest stress values in this study, reaching half the yield strength of dentine.