Hidden Cause Research Articles

Unnoticed freshwater leech as a hidden cause for recurring epistaxis: a case series and review of literature conducted at Tertiary Care Hospital Sikkim, North East India

BackgroundWhile leeches as intranasal foreign bodies are not frequently encountered, they can be one of the causes of epistaxis. The aim of the study is to raise awareness among healthcare professionals about the possibility of patients from leech endemic regions presenting with epistaxis.Case presentationWe present a series of epistaxis cases due to intranasal leech infestation. In our series of 10 cases, there were 7 male and 3 female patients, aged between 2 and 53 years old. The duration of the complaint ranged from 1 to 5 weeks. All patients experienced with blood-stain nasal discharge or frank nasal bleeding at some point and most of them have a history of leech infestation from spring water as a local source. This article presents our approach to managing nasal leech infestation as epistaxis and outlines the precautionary measures taken for the retrieval of this living foreign body.ConclusionDetails of the history must be taken before concluding the diagnosis. Maintain a high index of suspicion of leech infestation as a hidden cause of epistaxis especially in patients coming from endemic areas.

The most likely common cause

The common cause principle for two random variables A and B is examined in the case of causal insufficiency, when their common cause C is known to exist, but only the joint probability of A and B is observed. As a result, C cannot be uniquely identified (the latent confounder problem). We show that the generalized maximum likelihood method can be applied to this situation and allows identification of C that is consistent with the common cause principle. It closely relates to the maximum entropy principle. Investigation of the two binary symmetric variables reveals a non-analytic behavior of conditional probabilities reminiscent of a second-order phase transition. This occurs during the transition from correlation to anti-correlation in the observed probability distribution. The relation between the generalized likelihood approach and alternative methods, such as predictive likelihood and minimum common entropy, is discussed. The consideration of the common cause for three observed variables (and one hidden cause) uncovers causal structures that defy representation through directed acyclic graphs with the Markov condition.

Is Partial ACL Tear a Cause of Painful Swollen Knees?

Abstract Study Design: Retrospective case series. Objective: In this study, we will identify if partial ACL tear is a common hidden cause of chronic pain and swelling of the knee in adults. And we will evaluate the effectiveness of arthroscopic selective bundle reconstruction in the management of this condition. Background: The Anterior Cruciate Ligament (ACL) has two anatomical bundles, the anteromedial (AM) and the posterolateral (PL), each bundle was named according to the site of its tibial insertion.[1] Partial ACL tear is evident and symptomatic when the percentage of the torn fibers is more than 50% of ligament fibers. AM bundle is more liable to injury than PL.[2] Symptomps of partial ACL tear may be giving way and instability but persistent knee pain and swelling is often present as the main presenting symptom of the patient due to micro-instability of the knee, The primary complication of longstanding partial ACL tears is early knee degeneration.[3] Patients and Methods: 37 patients with chronic knee pain and swelling, related to activity and resistant to non-operative treatment, underwent diagnostic knee arthroscopy. In 3 cases diagnostic arthroscopy revealed osteochondral ulcers of the medial compartment of the knee managed by drilling and 4 cases showed non-specific synovitis managed by arthroscopic synovectomy. 30 of these patients, who were included in this study, were found to suffer from partial ACL tear and underwent single bundle reconstruction, 18 of them underwent selective AM bundle reconstruction while preserving PL bundle. Twelve patients underwent selective PL bundle reconstruction with AM bundle preservation. Semitendinosus tendon graft was utilized for all reconstructions. The femoral side was always fixed with an adjustable loop (Zimmer), and the tibial side with a biodegradable interference screw. Lysholm score[4] was used to assess the outcomes. Patients with severe degenerative disorders, lower limb mal-alignment and multiple ligamentous injuries of the knee were excluded from our study. Results: Marked decrease in the knee pain and swelling postoperatively. The preoperative score had a mean value of 66.17±10.39. At 2 years, the postoperative score was 96.1±6.71, indicating a highly statistically significant improvement (P value 0.001). Hypothesis: Partial ACL tears are the commonest hidden cause of pain and swelling of the knee among young adults. Conclusion: Arthroscopic selective bundle reconstruction diminishes knee pain and swelling with a very satisfactory postoperative clinical outcomes.

Chip-Level Defect Analysis with Virtual Bad Wafers Based on Huge Big Data Handling for Semiconductor Production

Semiconductors continue to shrink in die size because of benefits like cost savings, lower power consumption, and improved performance. However, this reduction leads to more defects due to increased inter-cell interference. Among the various defect types, customer-found defects are the most costly. Thus, finding the root cause of customer-found defects has become crucial to the quality of semiconductors. Traditional methods involve analyzing the pathways of many low-yield wafers. Yet, because of the extremely limited number of customer-found defects, obtaining significant results is difficult. After the products are provided to customers, they undergo rigorous testing and selection, leading to a very low defect rate. However, since the timing of defect occurrence varies depending on the environment in which the product is used, the quantity of defective samples is often quite small. Unfortunately, with such a low number of samples, typically 10 or fewer, it becomes impossible to investigate the root cause of wafer-level defects using conventional methods. This paper introduces a novel approach to finding the root cause of these rare defective chips for the first time in the semiconductor industry. Defective wafers are identified using rare customer-found chips and chip-level EDS (Electrical Die Sorting) data, and these newly identified defective wafers are termed vBADs (virtual bad wafers). The performance of root cause analysis is dramatically improved with vBADs. However, the chip-level analysis presented here demands substantial computing power. Therefore, MPP (Massive Parallel Processing) architecture is implemented and optimized to handle large volumes of chip-level data within a large architecture infrastructure that can manage big data. This allows for a chip-level defect analysis system that can recommend the relevant EDS test and identify the root cause in real time even with a single defective chip. The experimental results demonstrate that the proposed root cause search can reveal the hidden cause of a single defective chip by amplifying it with 90 vBADs, and system performance improves by a factor of 61.

A hidden cause of middle-aged onset heart failure with preserved ejection fraction: a GTPBP3 variant.

A hidden cause of middle-aged onset heart failure with preserved ejection fraction: a GTPBP3 variant.

P-36 Hidden cause of decreased fertility rate during Grave's disease

Abstract Introduction Thyroid autoimmune disorders interfere with the physiology of reproduction, cause premature ovarianfailure, and mimic the early stage of menopause. Recently, no specific research was made to measure Grave's disease and infertility rates in young patients. Clinical Case Due to an inability to conceive for two years, a 24-year-old Caucasian female was referred to the clinic with typical symptoms and complaints of Grave's disease. She has a family history of Grave's disease and Diabetes mellitus. Ultrasound confirmed the presence of a highly vascularized non-homogeneous hyperplastic thyroid gland. A thyroid scan with Tc99m revealed generalized increased uptake. Laboratory investigations showed a decrease in TSH-!0.005mIU/ml (n.0.4mIU/ml - 4.0mIU/ml), elevated FT4-31.8 pmol/l (n.8.0pmol/l-22.0pmol/l), FT3- 9.69pmol/l (n3.4 pmol/l-6.76pmol/l) and positive Anti-TG -190.05 AU/ml (n>150), Anti-TPO - 75.7 IU/ml (n>75) Anti-TSHR-27.3 IU/l (n>1,5). Prolactin and gonadal hormones were within normal limits AMH - 1.8 ng/ml(n1.52ng/ml-9.95ng/ml), Fsh- 6mIU/ml(n3.9mIU/ml-12.4mIU/ml). The patient was started on Methimazole and Beta-blocker. While decreasing the Methimazole dosage for further discontinuation, disease recurrence developed, and a total thyroidectomy was performed. Post- operatively, the patient was maintained on Levothyroxine. After 6 months of follow-up due to irregular Levothyroxine intake, the patient reached a hypothyroid status, during which, the patient had 2 consecutive spontaneous pregnancies, from which, one ended with spontaneous miscarriage in the early weeks of pregnancy and another, ectopic pregnancy treated with right salpingectomy. HSG confirmed weak left fallopian tube patency. After several months of keeping TSH below 2.5 mIU/ml, IVF treatment was scheduled. The results of the infertility workup showed a decrease in ovarian reserve AMH - 0.163ng/ml (n1.52ng/ml-9.95ng/ml), Fsh-16.23 mIU/ml(n3.9mIU/ml- 12.4mIU/ml), due to it, modified natural cycle IVF was performed. She received 2 oocytes and 2 embryos. One high-grade blastocyst was transferred in a fresh cycle that ended with pregnancy and delivery. The child was born without a genetic disorder but with natal teeth. Conclusion This is a rare case of infertility with diminished ovarian reserve due to Grave's disease. A pregnancy was reached by proper correction of thyroid hormonal parameters and modified natural cycle IVF. It indicates a possible need for close monitoring of the functional ovarian reserve in patients planning pregnancy even at the young age group.

WARNING TO DELAY IN DIAGNOSING MICROSCOPIC COLITIS IN OLDER ADULTS. A SERIES OF CASES.

Microscopic colitis (MC) is a chronic inflammatory bowel disease causing non-bloody diarrhea, and several cases are undiagnosed as a hidden cause of chronic diarrhea. We aimed to report the symptoms, delay diagnosis and the treatment of MC in a case series. All patients were treated at a Gastroenterology reference office from May 2022 to June 2023. Personal history including preexisting disorders, use of medications and smoking habits were collected. The delay between the onset of symptoms and the correct diagnosis was informed. All patients consented to use budesonide MMX (Corament®) off label. During the study period, six Caucasoid patients were diagnosed with MC, five females and one male, between the ages of 65 and 74. All patients had comorbities and were taking multiple prescription drugs. Laboratory findings showed negative serology for celiac disease for all patients, normal levels of albumin and vitamin B12. The delay between the symptoms and the MC diagnosis varied from 2 months to 6 years. All patients had a previous diagnosis of irritable bowel syndrome. All patients were in complete clinical remission during the treatment and referred no side effects of the drug. Older females using high-risk medications are suggestive of MC. Preventing delay in the diagnosis of MC is crucial to improvement in patients´ quality of life. Budesonide MMX appears to be effective, safe and well-tolerated. • Microscopic Colitis is a chronic inflammatory bowel disease causing non-bloody diarrhea. • Several cases are undiagnosed and can be a hidden cause of chronic diarrhea. • Treatment with budesonide MMX (Corament®, off label) was effective and safe.

Adult pulmonary sequestration: a hidden cause of recurrent hemoptysis (case report)

Adult pulmonary sequestration: a hidden cause of recurrent hemoptysis (case report)

Obstructive sleep apnoea: A hidden cause of refractory hypertension?

Obstructive sleep apnoea: A hidden cause of refractory hypertension?

Unsafe abortion; the hidden cause of maternal death

Despite the advancements in medical technology, unsafe abortion is common worldwide and it is estimated that about 13% of maternal deaths occur each year due to unsafe abortion predominantly in developing countries. However, since 1990, substantial global progress has been made to address various causes of maternal death including severe bleeding, hypertensive disorders of pregnancy and obstructed labor. On the contrary there has been minimal efforts in addressing the risks associated with unsafe abortion though highly preventable. The high prevalence is owed to a lack of awareness on safe abortion practices, desire for educational pursuit and poor use of contraceptives that lead to unplanned pregnancy. In attempting unsafe abortion, early health complications such as infection, hemorrhage, injury to internal organs, infertility and post abortion stress disorders are seen as long-term complications. Thus, mass education on contraceptives is highly needed to protect mothers from death due to unsafe abortion.

A Rare Case of Infantile Otalgia and Otorrhagia due to Alive Leech Bite

Abstract Pediatric ear infestation with leeches is a rare event; however, it can lead to serious complications. Leeches usually make their way into the human body through bathing with or drinking of contaminated water from nonhygienic sources and swimming in infested water. To our knowledge, this is the first report of leech removal from the external auditory canal in an infant. We described the case of a 3-month-old infant who presented to our institution with sudden left otalgia, otorrhagia, poor oral intake, and prolonged crying for 4 days, culminating in a single epileptic attack, drowsiness, and electrolyte disturbances. Microscopic visualization of the left ear revealed minimal oozing of blood with clots obscuring the ear canal and a live motile 3 cm leech deeply seated near the tympanic membrane. Extraction was performed. The bloody discharge ceased completely and all symptoms were relieved. Leech infestation is typically considered after other potential etiologies in infants with sudden otorrhagia and otalgia living in an endemic region. It should be considered a hidden cause of pediatric discomfort. Detailed history taking and meticulous ear examinations are vital for the prompt management to avoid unnecessary computed tomography imaging and radiation, unhelpful interventions, and delayed treatment. A diagnosis was reached and treatment performed by careful inspection and leech removal, respectively.

A One Health approach revealed the long-term role of Mycobacterium caprae as the hidden cause of human tuberculosis in a region of Spain, 2003 to 2022.

IntroductionMycobacterium caprae is a member of the Mycobacterium tuberculosis complex (MTBC) not routinely identified to species level. It lacks specific clinical features of presentation and may therefore not be identified as the causative agent of tuberculosis. Use of whole genome sequencing (WGS) in the investigation of a family microepidemic of tuberculosis in Almería, Spain, unexpectedly identified the involvement of M. caprae.AimWe aimed to evaluate the presence of additional unidentified M. caprae cases and to determine the magnitude of this occurrence.MethodsFirst-line characterisation of the MTBC isolates was done by MIRU-VNTR, followed by WGS. Human and animal M. caprae isolates were integrated in the analysis.ResultsA comprehensive One Health strategy allowed us to (i) detect other 11 M. caprae infections in humans in a period of 18 years, (ii) systematically analyse M. caprae infections on an epidemiologically related goat farm and (iii) geographically expand the study by including 16 M. caprae isolates from other provinces. Integrative genomic analysis of 41 human and animal M. caprae isolates showed a high diversity of strains. The animal isolates' diversity was compatible with long-term infection, and close genomic relationships existed between isolates from goats on the farm and recent cases of M. caprae infection in humans.DiscussionZoonotic circulation of M. caprae strains had gone unnoticed for 18 years. Systematic characterisation of MTBC at species level and/or extended investigation of the possible sources of exposure in all tuberculosis cases would minimise the risk of overlooking similar zoonotic events.

Levothyroxine absorption test followed by directly observed treatment on an outpatient basis to address long-term high thyrotropin levels in a hypothyroid patient: a case report

BackgroundFor the treatment of hypothyroidism, patients are usually placed on lifelong levothyroxine replacement therapy. Achieving clinical and biochemical euthyroid status is sometimes difficult because of several factors, including poor compliance or poor absorption of levothyroxine in the gut mucosa.Case presentationWe present the case of a 45-year-old South Asian female with hypothyroidism on lifelong levothyroxine replacement. However, on her multiple follow-up visits over the past 2 years, it was noted that her thyrotropin level was never controlled and was not in range. A thorough history was unyielding in terms of compliance regarding levothyroxine medication and use of over-the-counter pills or mineral supplements that may interfere with the absorption of levothyroxine. Hence, we performed levothyroxine absorption test to rule out any malabsorption as well as document pseudo-malabsorption favoring drug nonadherence. Levothyroxine absorption test resulted in more than 56% absorption of levothyroxine; therefore, the patient was put on weekly directly observed treatment strategy resulting in normalization of thyrotropin levels on successive follow-ups.ConclusionDirectly observed treatment to replace levothyroxine once a week can be used as an alternative by health care professionals in patients in whom compliance to daily levothyroxine is the hidden cause of persistently raised thyrotropin. This strategy can reduce undue health burden on the patient and improve adherence to self-medication under confident supervision of the treating physician.

Non-severe allergic transfusion reaction: A hidden cause of wastage of blood product and laboratory resources.

Blood transfusions are often needlessly aborted following a non-severe allergic reaction despite responding well to medication resulting into partial transfusion of the implicated blood product. This results in the wastage of untransfused blood component and resources spent on unnecessary laboratory work-up of these reactions. We aimed to review the amount of blood product and laboratory resource wastage associated with non-severe allergic transfusion reaction (ATR) in a tertiary care hospital. A total of 174,632 blood products were released and transfused during the study period (2019-2021). There were 336 adverse transfusion reactions with an estimated rate of 1.9 per 1000 blood products administered. Of 336, 145 (43%) were ATR, of which 141 (97%) were non-severe and 4 (3%) were severe. The most commonly associated symptom was found to be urticaria in 31 (22%). All non-severe ATR completely resolved with medication. Seventy-nine percent of the transfusions associated with non-severe ATRs were aborted, of which 37% were followed by additional transfusions. The estimated loss of blood product volume and the cost of non-severe ATR (including transfusion reaction work-up, discarded blood product and additional transfusion) was 11,185 ml (11 L) and Pakistani rupees 1,831,546 ($11,592.06 or €8598.78), respectively. Non-severe ATR was found to be associated with a significant proportion of laboratory resource wastage and that of blood product in our institution. Revision of institutional guidelines for management and lab work-up of transfusion reactions would be helpful in alleviating this unnecessary loss in a resource-constraint transfusion-setting.

Quantum causal inference in the presence of hidden common causes: An entropic approach

Quantum causality is an emerging field of study which has the potential to greatly advance our understanding of quantum systems. In this paper, we put forth a theoretical framework for merging quantum information science and causal inference by exploiting entropic principles. For this purpose, we leverage the tradeoff between the entropy of hidden cause and the conditional mutual information of observed variables to develop a scalable algorithmic approach for inferring causality in the presence of latent confounders (common causes) in quantum systems. As an application, we consider a system of three entangled qubits and transmit the second and third qubits over separate noisy quantum channels. In this model, we validate that the first qubit is a latent confounder and the common cause of the second and third qubits. In contrast, when two entangled qubits are prepared and one of them is sent over a noisy channel, there is no common confounder. We also demonstrate that the proposed approach outperforms the results of classical causal inference for the Tubingen database when the variables are classical by exploiting quantum dependence between variables through density matrices rather than joint probability distributions. Thus, the proposed approach unifies classical and quantum causal inference in a principled way.

Frequency of Urinary Tract Infection in Febrile Children without Any Focus on Infection

Background: In newborns and young children, a urinary tract infection is a frequent hidden cause of fever. Children younger than a year old who appear with fever and symptoms of UTI are usually given treatment for something else. Objectives: The objective of this study was to assess the prevalence of UTI in children presenting to a tertiary care hospital between the ages of 1 month and 36 months with nonspecific fever. Duration and study settings: The Children's Hospital Pakistan Institute of Medical Science, SZABMU, Islamabad, was the site of this trial, which ran from Jan 2018 to June 2018. Study design: Descriptive cross sectional Methodology: After a complete medical history and physical examination, a urine sample was taken for testing and culture using a soft tube in younger children and a clean catch approach in older children or those who are cooperative. Urisys 2400 was used to analyse the urine samples. Larger children's urine samples were grown on CLED agar plates (cysteine lactose, electrolyte deficient). Clinitek Siemens, a haematology analyser, was used to determine the number of white blood cells in the blood. The Pakistan Institute of Medical Sciences in Islamabad is home to a state-of-the-art laboratory where tests including leucocyte count, urine DR, and culture were conducted. A pre-designed proforma was used to record the patient's demographic information, medical history, diagnosis, and laboratory results. Results: In this study, 6.47 percent (n=18) of 278 children aged 1 to 36 who presented to a tertiary care hospital with a fever and no other obvious signs of infection were found to have a urinary tract infection. Conclusion: Children arriving to a tertiary care hospital with a fever and no other signs of infection are not likely to have a urinary tract infection. Keywords: UTI in children with diffuse fever and no obvious source of infection.

Regional metal pollution risk assessment based on a long short-term memory model: A case study of the South Altai Mountain mining area, China

The discharge of wastewater and waste rock in mining production activities is a significant hidden cause of soil heavy metal pollution. The accumulation of heavy metals in soil occurs through a variety of processes, and exposure to these metals can permanently damage the human body. Due to multiple factors, such as the formation causes, sources, and distribution trends of heavy metals in mineral resources, reasonably applying different machine learning methods to monitor and evaluate heavy metal pollution remains challenging. In this paper, we choose the copper mining area in the southern Altai Mountains of China as the study area, and 19 different types of spatial data are uniformly managed in a distributed database to improve monitoring efficiency. Furthermore, we propose a heavy metal pollution evaluation framework based on a stacked long short-term memory (LSTM) model, which considers spatial data correlations and extracts spatial clustering features. Information is screened through state updating in the framework, the short-term memory features of long sequences are extracted, and an effective prediction model is established. The results show that 26 of the 31 mining occurrences in the study area are in moderate- and high-pollution-risk grids, suggesting that the spatial distribution of copper mines is consistent with the predicted spatial distribution of pollution risk. Overall, these results show that using the optimized stacked LSTM model to integrate multisource geological features and mine the internal rules of feature information has a positive effect on improving the risk assessment of heavy metal pollution.

Understanding Knowledge Level of The Thermal Implication and Its Effects Towards Physiological State in Construction Sector

Heat stress normally known as a hidden cause of accidents in construction sectors. To ensure the productivity and health of workers in the construction site, it is necessary to evaluate the effects of temperature and relative humidity on the workers’ physiology under hot conditions. Hence, the aims of this paper are: (i) to investigate the knowledge of heat stress and workers perceptions on workers performance in construction site, (ii) to identify the environment factor of heat stress in the construction site and (iii) explore the measurement physiology parameters for heat stress. Heat stress questionnaires and experiment test were combined to extract useful information. An online survey was undertaken with a representative sample (N=292) from Malaysia construction sector. While, the experiment was carried out in a well-controlled climate chamber to obtain datasets with four conditions combining air temperature and relative humidity (32 °C/70 %, 34 °C/92, 34 °C/74% and 38 °C/83%). At a climate chamber, the subjects doing a job such as lifting and carry the 10 kg workload were exposed to different combinations of air temperatures and relative humidity. The subject’s physiological responses to the environment were then investigated. The survey’s finding showed 71.9% of the workers understand about heat stress. 22.6% of the workers perceive that the temperature is hot and quite hot and relative humidity result showed that 50.9 % of the workers perceived that part of their mouth and throat are dry while working. Besides, the experiment study showed that workers physical demands varies according to their work task with a combination of the influences from individual and environmental factors.

Rendering Magnetism Visible: Diagrams and Experiments Between 1300 and 1700

Human beings can neither see nor feel magnetism, although its effects can be made manifest to sense experience through experiments. Since antiquity, philosophers have therefore often viewed magnetism as an “occult” force, for whose manifest effects a hidden cause had to be sought. Around 1300, scholars began to address the seemingly occult nature of magnetism not only through experimental investigation but also visually, attempting to represent experimental results in diagrams. Historical research on diagrams has been fairly negligent about the relation between diagrams and scientific practices, including experiments. This paper will try to redress the balance, by focusing on diagrams in manuscripts and printed texts between 1300 and 1700 that were produced in response to magnetic experiments. It will be argued that naturalistic and geometrizing forms of representation were combined in order to render experiments with magnetism understandable, replicable, and meaningful. This resulted in a visual style of diagram that oscillated between the abstract representation of invisible entities or powers and the concrete and performative depiction of actual objects or operations.

Neuroimaging features of antiphospholipid antibody-related stroke compared with atrial fibrillation-related stroke

Recognizing the lesion pattern of antiphospholipid antibody-related stroke (aPL-stroke) may contribute to establishing the cause in patients with cryptogenic stroke. We aimed to describe the neuroimaging features of aPL-stroke compared with atrial fibrillation-related stroke (AF-stroke), a major hidden cause of cryptogenic stroke. Using a prospective stroke registry, we identified consecutive aPL- and AF-stroke patients without other potential causes of stroke. Neuroimaging features based on diffusion-weighted imaging and angiographic findings at admission were compared. A total of 56 and 333 patients were included in the aPL- and AF-stroke groups, respectively. aPL-stroke patients more often presented with single small lesions (aPL-stroke, 30.4% vs. AF-stroke, 7.5%, p < 0.001), while the predominant pattern in AF-stroke patients was large territorial lesions (26.8% vs. 56.5%, p < 0.001). aPL-stroke patients had smaller infarct volume (1.58 mL [0.45; 9.41] vs. 11.32 mL [2.82; 33.08], p < 0.001) and less experience of relevant artery occlusion (17.9% vs. 54.7%, p < 0.001). The proportion of multi-territory lesions, an embolic pattern, was similar between the two groups (28.6% vs. 22.8%, p = 0.44). In comparison only including patients with multi-territory lesions as well, aPL-stroke patients showed small lesion dominance and smaller infarct volume. Multivariate analyses showed independent associations between mild neuroimaging features (small lesion prevalence, smaller infarct volume, and absence of relevant artery occlusion) and aPL-stroke. Patterns of small lesion prevalence, small infarct volume, and absence of relevant artery occlusion were suggestive of aPL-stroke rather than AF-stroke. Cryptogenic stroke patients with such neuroimaging features may benefit from aPL testing for a precise diagnosis.