Early Recognition Research Articles

Infected Thrombosis Leading to Veno-Venous Extracorporeal Membrane Oxygenation Dysfunction in Chronic Thromboembolic Pulmonary Hypertension.

Nosocomial infections and thrombosis are frequent complications during extracorporeal membrane oxygenation (ECMO). Preventative measures and close monitoring for early recognition of these complications are imperative in patients supported with ECMO. We report the case of a 41 year old female on veno-venous ECMO awaiting surgical thrombectomy for chronic thromboembolic pulmonary hypertension that developed profound bacteremia leading to gross purulence and thrombosis of the membrane oxygenator. Recannulation in addition to targeted antibiotics, frequent cultures, imaging, and surgery were diagnostic and therapeutic interventions that led to ultimate resolution.

Type 2 T-Helper Cell Driven Manifestations of Inborn Errors of Immunity.

Monogenic lesions in pathways critical for effector functions responsible for immune surveillance, protection against autoinflammation and appropriate responses to allergens and microorganisms underlie the pathophysiology of inborn errors of immunity (IEI). Variants in cytokine production, cytokine signaling, epithelial barrier function, antigen presentation, receptor signaling, and cellular processes and metabolism can drive autoimmunity, immunodeficiency and/or allergic inflammation. Identification of these variants have improved our understanding of the role that many of these proteins play in skewing towards Th2 related allergic inflammation. Early onset or atypical atopic disease, often in conjunction with immunodeficiency and/or autoimmunity should raise suspicion for an IEI. This becomes a diagnostic dilemma if the initial clinical presentation is solely allergic inflammation, especially when the prevalence of allergic diseases is becoming more common. Genetic sequencing is necessary for IEI diagnosis and is helpful for early recognition and implementation of targeted treatment, if available. While genetic evaluation is not feasible for all patients with atopy, identifying atopic patients with molecular immune abnormalities may be helpful for diagnostic, therapeutic and prognostic purposes. In this review, we focus on IEI associated with Th2 driven allergic manifestations and classify them based on the affected molecular pathways and predominant clinical manifestations.

Diabetic acidosis with severe fetal hypoxia in pregnancy: Narrative review and case study.

Diabetic ketoacidosis (DKA) in pregnancy could be a disastrous event with increased maternal and perinatal morbidity and mortality. DKA can occur with a normal blood glucose level, known as euglycemic DKA. It particularly affects pregnant women with type I diabetes. Here, we report the case of a 28 year-old primigravid patient, with a diagnosis of type 1 diabetes for 8 years. This patient consulted our department at 29 weeks of gestation with a previous history of headaches, vomiting and diarrhea for 9 h. Blood glucose level was 8.8 mmol/L with a ketone test positive (>15 mg/dL). Blood test showed high anion gap (17.9 mmol/L) with low serum bicarbonate rate (21 mmol/L). Systemic examination and fetal heart rate (FHR) was reassuring. The patient was subsequently discharged. She returned to the clinic 19 h later with further symptoms of nausea, polyuria-polydipsia, asthenia and a weight loss of 4 kg since the day before. Blood sugar was 14.3 mmol/L and a ketone test was strongly positive. Cardiotocography showed fetal tachycardia and repeated late decelerations. A diagnosis of DKA was made and emergency cesarean was performed for fetal distress. At delivery, pH was acidosis (pH: 7.02, lactates: 6.2). The patient was successfully treated with intravenous hydration and insulin. Neonatal evolution was favorable. Pregnant women with type I diabetes can develop euglycemic DKA. Early recognition and prompt treatment could help prevent severe maternal and fetal adverse outcomes. DKA in pregnant women can induce fetal acidosis with abnormal FHR. In this situation, a cesarean can be performed to improve neonatal outcome even inducing a premature delivery. Prolonged pregnancy can lead to irreversible neonatal brain abnormalities.

What does the general population know about nonmelanoma skin cancer? Representative cross-sectional data from Germany

Abstract Aim Nonmelanoma skin cancer (NMSC) is the most common form of cancer in white-skinned populations. However, there is a lack of comprehensive research on the general population’s knowledge about NMSC. Subjects and methods As part of wave 8 of the German National Cancer Aid Monitoring (NCAM), 4000 participants aged 16–65 years (49.3% female) were interviewed by telephone about NMSC. Questions included awareness of (colloquial) terms for NMSC, its signs, consequences, risk factors, prevalence, and severity. Results Colloquial terms for skin cancer were heard of more often than medical terms (60.9–82.1% vs. 22.6–51.5%). In our sample, there was little familiarity with signs (15.8–36.4%), possible consequences (14.7–56.3%), prevalence (27.4%), and severity (29.0%) of NMSC. Most participants knew about UV-related risk factors for NMSC (73.0–78.7%). Women, those with higher education levels, full-time employment, lighter skin type, presence of more than 40 nevi, frequent childhood sunburns, or frequent intentional tanners achieved a higher knowledge score. Concern about NMSC was associated with more NMSC knowledge. Conclusion We found knowledge gaps regarding signs, consequences, and prevalence of NMSC. To ensure early recognition and treatment, the general population should be further educated, specifically targeting male, less educated, and unemployed individuals.

Motor polyradiculoneuropathy as an unusual presentation of neurobrucellosis: a case report and literature review

Brucellosis, a zoonotic disease caused by Brucella species, poses a significant global health concern. Among its diverse clinical manifestations, neurobrucellosis remains an infrequent yet debilitating complication. Here, we present a rare case of neurobrucellosis with unusual presentations in a 45-year-old woman. The patient’s clinical course included progressive lower extremity weakness, muscle wasting, and double vision, prompting a comprehensive diagnostic evaluation. Notable findings included polyneuropathy, elevated brucella agglutination titers in both cerebrospinal fluid and blood, abnormal EMG-NCV tests, and resolving symptoms with antibiotic therapy. The clinical presentation, diagnostic challenges, and differentiation from other neurological conditions are discussed. This case underscores the importance of considering neurobrucellosis in regions where brucellosis is prevalent and highlights this rare neurological complication’s distinctive clinical and radiological features. Early recognition and appropriate treatment are crucial to mitigate the significant morbidity associated with neurobrucellosis.

Case Report: A rare infection of multidrug-resistant Aeromonas caviae in a pediatric case with acute lymphoblastic leukemia and review of the literature

Aeromonas caviae infection of the bloodstream and intestine is a rare and severe opportunistic infection in immunocompromised people. In Southwest China, we first reported a case of bloodstream and intestinal infection with multidrug-resistant (MDR) Aeromonas caviae in a 4-year-old child with T-cell acute lymphoblastic leukemia. Blood and stool cultures were used to identify the infection. The selection of antibiotics was based on clinical expertise and medication sensitivity tests. We used linezolid, levofloxacin, and polymyxin B to treat the patient aggressively. Aeromonas caviae infection is uncommon in juvenile acute lymphoblastic leukemia. Doctors should be aware of the likelihood of opportunistic infection during the post-chemotherapy bone marrow suppression period. We further conducted a review of the literature and performed a detailed analysis of Aeromonas infection in pediatric leukemia. It is becoming increasingly apparent that antibiotic is abused domestically and abroad, resulting in the sharp increase of MDR bacteria. In general, most of the Aeromonas isolates are susceptible to third- or fourth-generation cephalosporins, aminoglycosides, quinolones, and carbapenem, but drug-resistant strains are being reported increasingly. We summarized the drug resistance rate of Aeromonas caviae and Aeromonas hydrophila in China in the last 10 years. Early recognition and effective treatment will improve prognosis and reduce mortality.

ECHO: Energy-Efficient Computation Harnessing Online Arithmetic—An MSDF-Based Accelerator for DNN Inference

Deep neural network (DNN) inference demands substantial computing power, resulting in significant energy consumption. A large number of negative output activations in convolution layers are rendered zero due to the invocation of the ReLU activation function. This results in a substantial number of unnecessary computations that consume significant amounts of energy. This paper presents ECHO, an accelerator for DNN inference designed for computation pruning, utilizing an unconventional arithmetic paradigm known as online/most significant digit first (MSDF) arithmetic, which performs computations in a digit-serial manner. The MSDF digit-serial computation of online arithmetic enables overlapped computation of successive operations, leading to substantial performance improvements. The online arithmetic, coupled with a negative output detection scheme, facilitates early and precise recognition of negative outputs. This, in turn, allows for the timely termination of unnecessary computations, resulting in a reduction in energy consumption. The implemented design has been realized on the Xilinx Virtex-7 VU3P FPGA and subjected to a comprehensive evaluation through a rigorous comparative analysis involving widely used performance metrics. The experimental results demonstrate promising power and performance improvements compared to contemporary methods. In particular, the proposed design achieved average improvements in power consumption of up to 81%, 82.9%, and 40.6% for VGG-16, ResNet-18, and ResNet-50 workloads compared to the conventional bit-serial design, respectively. Furthermore, significant average speedups of 2.39×, 2.6×, and 2.42× were observed when comparing the proposed design to conventional bit-serial designs for the VGG-16, ResNet-18, and ResNet-50 models, respectively.

Renal Hydatid Cyst

Renal hydatid cysts are a rare manifestation of echinococcosis, especially in pediatric cases. Diagnosis can be challenging, and delayed diagnosis may lead to larger cysts, increasing the risk of complications and the potential need for nephrectomy. Here, we present a case of a renal hydatid cyst in a pediatric patient, emphasizing the rarity of such cases in this age group. We discuss the diagnostic approach, highlighting the importance of early recognition and treatment to avoid the need for nephrectomy and to improve patient outcomes

The Approach to a Child with Dysmorphic Features: What the Pediatrician Should Know

The advancement of genetic knowledge and the discovery of an increasing number of genetic disorders has made the role of the geneticist progressively more complex and fundamental. However, most genetic disorders present during childhood; thus, their early recognition is a challenge for the pediatrician, who will be also involved in the follow-up of these children, often establishing a close relationship with them and their families and becoming a referral figure. In this review, we aim to provide the pediatrician with a general knowledge of the approach to treating a child with a genetic syndrome associated with dysmorphic features. We will discuss the red flags, the most common manifestations, the analytic collection of the family and personal medical history, and the signs that should alert the pediatrician during the physical examination. We will offer an overview of the physical malformations most commonly associated with genetic defects and the way to describe dysmorphic facial features. We will provide hints about some tools that can support the pediatrician in clinical practice and that also represent a useful educational resource, either online or through apps downloaded on a smartphone. Eventually, we will offer an overview of genetic testing, the ethical considerations, the consequences of incidental findings, and the main indications and limitations of the principal technologies.

Supraglottitis: An airway emergency

Supraglottitis is a life-threatening condition and refers to inflammation of the epiglottis and the surrounding supraglottic structures. Children usually present with only a swollen epiglottis, termed epiglottitis. Fortunately, the incidence of epiglottitis in children has declined following routine Haemophilus influenzae type B vaccination, but the incidence in adults has increased. Supraglottitis has a high morbidity and mortality from the associated risk of airway obstruction. Therefore, early recognition and urgent secondary care referral is paramount. However, the presentation of this condition can be subtle and differs between children and adults; this can lead to difficulties in diagnosis. This article will review the clinical presentation and management of supraglottitis, an important differential for acute sore throat and hoarse voice.

Anti-Hu antibody associated paraneoplastic neurological syndrome in a child with ganglioneuroblastoma: A rare case report and literature review.

Paraneoplastic neurological syndrome with anti-Hu antibody (Hu-PNS) is a neurological disorder that occur in patients with malignancy. The syndrome has a wide range of presentations and can present before diagnosis of primary malignancy. Familiarity with these paraneoplastic neurological syndromes can help early recognition and take appropriate regimens. Diagnosis and treatment of Hu-PNS. This is retrospective study that analyzed the clinical data of this case. Through retrospective analysis and targeted antibody screening, serum anti-Hu antibody was detected. Subsequent spinal imaging revealed a mass in the paraspinal region, which was confirmed as ganglioneuroblastoma by pathologic examination. The child was treated with a course of intravenous immunoglobulin and radical surgical operation without chemotherapy. The neurological symptoms were gradually improved and no signs indicate disease progression or tumor recurrence. Hu-PNS has rarely been reported in children with ganglioneuroblastomas. They can mimic non-neoplastic processes, making detection and diagnosis difficult. Serum and/or cerebrospinal fluid onconeural antibody can strongly indicate occult cancers. Early detection of paraneoplastic neurological syndromes can help take appropriate regimens and improve prognosis.

Beyond the Bony Fragment: A Review of Limbus Vertebra.

Vertebral limbus is a condition characterized by the intraspongious herniation of a portion of the nucleus pulposus. It is often asymptomatic, but it can sometimes cause nonspecific symptoms such as local pain and muscle spasm, or, in rare cases, radiculopathies, which is why it can be confused with vertebral fractures, spondyloarthropathies, infectious or tumoral processes. Early recognition of this pathology is preferable for a correct diagnosis and adequate treatment, the latter ranging from conservative approaches (such as personalized exercise programs and physical therapy) to surgical interventions reserved for severe cases with nerve compression.

Association of Age with Dual-Task Objective Cognitive Indicators and Gait Parameters in Older Adults.

Early recognition of dementia like Alzheimer's disease is crucial for disease diagnosis and treatment, and existing objective tools for early screening of cognitive impairment are limited. To investigate age-related behavioral indicators of dual-task cognitive performance and gait parameters and to explore potential objective markers of early cognitive decline. The community-based cognitive screening data was analyzed. Hierarchical cluster analysis and Pearson correlation analysis were performed on the 9-item subjective cognitive decline (SCD-9) scores, walking-cognitive dual-task performance, walking speed, and gait parameters of 152 participants. The significant differences of indicators that may related to cognitive decline were statistically analyzed across six age groups. A mathematical model with age as the independent variable and motor cognition composite score as the dependent variable was established to observe the trend of motor cognition dual-task performance with age. Strong correlation was found between motor cognitive scores and SCD and age. Gait parameters like the mean value of ankle angle, the left-right difference rate of ankle angle and knee angle and the coefficient of variation of gait cycle showed an excellent correlation with age. Motor cognition scores showed a decreasing trend with age. The slope of motor cognition scores with age after 50 years (k = -1.06) was six times higher than that before 50 years (k = -0.18). Cognitive performance and gait parameters in the walking-cognitive dual-task state are promising objective markers that could characterize age-related cognitive decline.

Psychometric properties of the positive mental health questionnaire: short form (PMHQ-SF18) in young adults

IntroductionPositive Mental Health (PMH) plays a pivotal role in the promoting of mental health. Assessing this phenomenon is essential for early recognition and intervention in mental health. To date, only one tool was validated with 39 items to assess PMH among Portuguese young adults.MethodThis study sought to examine the psychometric properties of the short version of the Positive Mental Health Questionnaire (PMHQ) among Portuguese university students. The PMHQ Short Form was administered to a sample of 3,647 university students via an online platform. Exploratory and confirmatory factor analyses were performed. The principal factor solution was employed because some items showed higher levels of kurtosis. Multivariate analysis was tested using the Mardia’s Test, Henze-Zirkler, and Royston. Findings of content, construct validity tests, and Cronbach’s alfa demonstrated the satisfactory validity and suitable reliability of the PMHQ-Short Form (PMHQ-SF).Results and discussionThe exploratory factor analysis produced six dimensions of the PMHQ-SF with three items in each factor demonstrating adequate internal reliability. The global internal consistency was 0.92, with factors ranging between 0.60 to 0.82. The results suggest that the PMHQ-SF is reliable, easier, and more practical to complete by university students due to the shortening of the number of items. The PMHQ-SF is useful for assessing positive mental health in young adults. The final version of the instrument contains from 32 to 18 items.

Implementation of a clinical breast exam and referral program in a rural district of Pakistan

BackgroundThe role of clinical breast examination (CBE) for early detection of breast cancer is extremely important in lower-middle-income countries (LMICs) where access to breast imaging is limited. Our study aimed to describe the outcomes of a community outreach breast education, home CBE and referral program for early recognition of breast abnormalities and improvement of breast cancer awareness in a rural district of Pakistan.MethodsEight health care workers (HCW) and a gynecologist were educated on basic breast cancer knowledge and trained to create breast cancer awareness and conduct CBE in the community. They were then deployed in the Dadu district of Pakistan where they carried out home visits to perform CBE in the community. Breast cancer awareness was assessed in the community using a standardized questionnaire and standard educational intervention was performed. Clinically detectable breast lesions were identified during home CBE and women were referred to the study gynecologist to confirm the presence of clinical abnormalities. Those confirmed to have clinical abnormalities were referred for imaging. Follow-up home visits were carried out to assess reasons for non-compliance in patients who did not follow-through with the gynecologist appointment or prescribed imaging and re-enforce the need for follow-up.ResultsBasic breast cancer knowledge of HCWs and study gynecologist improved post-intervention. HCWs conducted home CBE in 8757 women. Of these, 149 were warranted a CBE by a physician (to avoid missing an abnormality), while 20 were found to have a definitive lump by HCWs, all were referred to the study gynecologist (CBE checkpoint). Only 50% (10/20) of those with a suspected lump complied with the referral to the gynecologist, where 90% concordance was found between their CBEs. Follow-up home visits were conducted in 119/169 non-compliant patients. Major reasons for non-compliance were a lack of understanding of the risks and financial constraints. A significant improvement was observed in the community’s breast cancer knowledge at the follow-up visits using the standardized post-test.ConclusionsBasic and focused education of HCWs can increase their knowledge and dispel myths. Hand-on structured training can enable HCWs to perform CBE. Community awareness is essential for patient compliance and for early-detection, diagnosis, and treatment.

A puzzle unravelled: pancytopenia and hepatosplenomegaly in juvenile autoimmune hypothyroidism

Autoimmune thyroiditis is a common cause of hypothyroidism in adolescent females. While normocytic normochromic anemia is a recognized association with hypothyroidism, pancytopenia is seldom reported. This case report discusses a young adolescent girl with autoimmune hypothyroidism presenting with severe pancytopenia and hepatosplenomegaly. After extensive evaluation, hypoproliferative marrow with extramedullary hematopoiesis secondary to uncontrolled hypothyroidism was considered to be the most likely cause. Swift recovery following appropriate levothyroxine replacement further supports this hypothesis. Thus, hypothyroidism can be a potential cause of pancytopenia with hepatosplenomegaly. Early recognition and appropriate management can lead to prompt resolution and prevent unnecessary invasive procedures.

Effect of invasive species on forest composition in tropical dry forest: a case study of invasion by Gliricidia sepium

Ecological concerns caused by biological invasion have been considered an inevitable threat to global sustainability. The superior competitive ability of invasive plant species (IPS) has an impact on vegetation composition and loss of native flora. Recognising IPS at an early stage would significantly contribute to controlling invasive plants, protecting biodiversity and formulating appropriate strategies. Most of the studies available on invasive plants are descriptive and largely confined to non-woody species. The present study focused on the alien Gliricidia sepium, a tree species, to determine the invasive potential of its distribution in tropical dry deciduous forests of Central India. Forty square plots (25 × 25 m) were laid out at each uninvaded and invaded forest to enumerate phytosociological attributes to determine the impact of G. sepium on vegetation composition and community structure. Higher density (37.2 individuals ha−1), basal area (6.32 m2 ha−1) and importance value index (95.8) contributed by G. sepium clearly showed the suppression of seedlings, saplings and trees of native forest species at the invaded sites in terms of species richness, cover and other attributes as compared to at the uninvaded sites. Further, other invasive attributes such as higher seed production, dieback phenomenon, higher coppicing power and higher growth rate as observed during the study clearly affirmed the early speculation that the species might be invasive. The species has a strong potential to spread vigorously and may gradually become invasive throughout the country as already reported from various parts of India. In the present study area, G. sepium was introduced due to restoration and plantation programmes and our findings indicate its negative impact on the native vegetation. Thus, we strongly recommend the avoidance of this species for both plantation and restoration programmes, especially for Indian forests. The study helps in early recognition and rapid monitoring of G. sepium to control its spread throughout the country.

Dermatological Manifestations of COVID-19 Patients

Background: COVID-19 is a highly contagious respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was first identified in China, in December 2019. Almost 10% of the patients develop dermatological manifestations before the onset of respiratory illness, with cutaneous signs that can appear from before to several days after the diagnosis of COVID-19. We believe that the dermatologist can play an important role through early recognition of skin lesions suggestive of COVID-19, particularly in asymptomatic infections where this recognition could direct toward an early diagnosis of infection that certainly leads to a better prognosis. Objective: To explore the pattern of dermatological manifestations among COVID-19 Bangladeshi patients. Materials and Methods: A cross sectional study was carried out May 2020 to October 2021 with COVID 19 positive hospital admitted patients. Data were collected through a group of Dermatologists who were serving at COVID dedicated Hospitals. Dermatologists, who were working in different medical college hospital and health complexes, were attached with the study as research associate. Results: Among the muco-cutaneous findings, maculo-papular eruption 52(53.6%) was the most common, followed by chilblain like eruption 40(41.2%), petechiae or purpura 16 (16.5%), urticarial lesions 13(13.4%), vesicular lesion 10(10.3%), Bilateral conjunctivitis with clear/mucoid discharge 10 (10.3%), aphthous stomatitis 13 (13.4%), Alopecia 16(16.5%), Darkening of the face 13 (13.4%), Eczematoid reaction 13 (13.4%), livedo reticularis like eruption 5(5.2%) etc. Conclusion: The major dermatological patterns of COVID-19 can be classified as inflammatory reactions (maculopapular, urticarial and vesicular rashes), or lesions of vascular origin (chilblain like rashes, petechiae/purpura, and livedo reticularis like pattern).

Occupational nerve injuries.

Occupational nerve injuries span a broad array of pathologies and contribute toward functional limitation, disability, and economic impact. Early and accurate recognition, treatment, and management of workplace factors rely on a thorough understanding of the anatomic and biomechanical factors that drive nerve injury. This review explores the interplay between anatomy, biomechanics, and nerve pathology common to occupational nerve injury and provides the treating physician with a rational, evidence-based approach to diagnosis and to occupational aspects of management. Assessment of potential occupational nerve injury begins with a detailed understanding of the employee's work duties through a biomechanical lens. One must consider likelihood of occupational causation while accounting for predisposing conditions or preexisting symptoms. Beyond overt crush injury or laceration, potential mechanisms of nerve injury, with effects compounded over time, include compression, stretch, vibration, and repetitive or high-force movements of regional muscles and joints. Injury often occurs at nerve locations that experience higher pressures, changes in pressure over time, or abrupt changes in trajectory, often near a tethered point. This understanding, coupled with condition-specific knowledge presented in this review, equips managing physicians to diagnose occupational nerve injury and enhance treatment recommendations with rational activity modifications or equipment that can protect the nerve or decrease likelihood of continued injury. Long-term management often involves follow-up to assess effectiveness of interventions in the setting of the work environment, with gradual progression of the worker toward return to unrestricted duty or to a point of maximal medical improvement.

Differential diagnosis of contact dermatitis: A practical-approach review by the EADV Task Force on contact dermatitis.

The diagnosis of eczema ('dermatitis') is mostly clinical and depends on the clinical history and exploratory objective findings (primary lesions, patterns). Contact dermatitis remains as an important condition in the group of eczematous disorders, with important socioeconomic and occupational relevance. Although irritant and allergic contact dermatitis have a different pathogenesis, both are characterized by a rather typical morphology, are triggered by external factors and tend to occur primarily in the area of contact with the exogenous agent. In addition, allergic and irritant dermatitis may also co-exist. The importance of diagnosing contact dermatitis, especially when allergic in nature, is both due to the possibility of avoiding the trigger, and due to its role in aggravating other skin conditions. Nevertheless, the heterogeneity of clinical presentations in daily practice may pose an important challenge for the suspicion and correct diagnosis of contact dermatitis. Furthermore, other conditions, with different pathogenesis and treatment, may clinically simulate contact dermatitis. The Task Force aims to conduct a review of the unifying clinical features of contact dermatitis and characterize its main clinical phenotypes, and its simulators, in order to contribute to an early suspicion or recognition of contact dermatitis and enable a correct differential diagnosis.