Initial Clinical Examination Research Articles

Deciphering acute shoulder trauma with normal initial X-ray: Contributions of ultrasonography and MRI

IntroductionShoulder trauma with normal radiographs is a frequent emergency presentation. The predominance of pain makes clinical examination unreliable, and complementary imaging is often needed for diagnosis. The aim of the present study was to assess the contribution of ultrasonography (US) and magnetic resonance imaging (MRI) in deciphering such trauma. The study hypothesis was that MRI can confirm most diagnoses and reveal occult lesions. Methods48 patients with a median age of 33 years (IQR, 22-48.75), admitted to the Emergency Department between February and September 2016, were prospectively included. All had normal X-ray and underwent emergency and deferred emergency (D+7-10) clinical examination, and US and MRI at D+7-14. The same examinations were repeated to establish diagnosis and initiate treatment. MRI was considered as gold-standard for definite diagnosis. ResultsDiagnoses comprised: 14 shoulder contusions; 13 rotator cuff tears; 8 acromioclavicular sprains; 6 fractures: 3 greater tuberosity, 2 humeral head, 1 lateral quarter of the clavicle; 3 subluxations or anterior dislocations with spontaneous reduction; 1 posterior dislocation with spontaneous reduction; 1 case of resorption of calcification in the pectoralis major tendon; 1 case of coracobrachialis strain; and 1 partial pectoralis major detachment. Concordance with final diagnosis was 42% (20/48) on initial clinical examination and 52% (25/48) on reassessment. On US, concordance was 71% (34/48), with 82% positive predictive value for cuff tear and 0% for instability. MRI was contributive in all cases, revealing 48 abnormal signals in 41 patients, thus establishing 48 diagnoses. ConclusionExcept in precise diagnostic situations such as rotator cuff tear, US is not a contributive examination, completely overlooking shoulder instability and bone contusion. MRI should play an increasing role in deciphering these traumas. Level of evidenceII; prospective cohort study.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial

ABSTRACTObjectivesDeep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia.MethodsThis was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three‐dimensional/four‐dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow‐up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated.ResultsThirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs –0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ‐NRS), 0 (interquartile range (IQR), 0–0)) while a marked reduction was observed in the study group (median Δ‐NRS, –3 (IQR, –4 to –2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ‐NRS, 0 (IQR, –2 to 0) vs 0 (IQR, 0–1); P = 0.01).ConclusionsIn women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Grave thoraco-intestinal complication secondary to an undetected traumatic rupture of the diaphragm: a case report

BackgroundDiaphragmatic lesions as a result of blunt or penetrating trauma are challenging to detect in the initial trauma setting. This is especially true when diaphragmatic trauma is part of a polytrauma. Complications of undetected diaphragmatic defects with incarcerating bowel are rare, but as in our patient can be serious.Case presentationA 57-year-old female presented to the Emergency Room of our Hospital in a critical condition with 3 days of increasing abdominal pain. The initial clinical examination showed peritonism with tinkling peristaltic bowel sounds of mechanical obstruction. A thoraco-abdominal CT scan demonstrated colon prolapsed through the left diaphragmatic center with a large sero-pneumothorax under tension. As the patient was hemodynamically increasingly unstable with developing septic shock, an emergency laparotomy was performed. After retraction of the left colon, which had herniated through a defect of the tendinous center of the left diaphragm and was perforated due to transmural ischemia, large amounts of feces and gas discharged from the left thorax. A left hemicolectomy resulting in a Hartmann-type procedure was performed. A fully established pleural empyema required meticulous debridement and lavage conducted via the 7–10 cm in diameter phrenic opening followed by a diaphragmatic defect reconstruction. Due to pneumonia and recurring pleural empyema redo-debridement of the left pleural space via thoracotomy were required. The patient was discharged on day 56. A thorough history of possible trauma revealed a bicycle-fall trauma 7 months prior to this hospitalization with a surgically stabilized fracture of the left femur and conservatively treated fractures of ribs 3–9 on the left side.ConclusionThis is the first report on a primarily established empyema at the time of first surgical intervention for feco-pneumothorax secondary to delayed diagnosed diaphragmatic rupture following abdomino-thoracic blunt trauma with colic perforation into the pleural space, requiring repetitive surgical debridement in order to control local and systemic sepsis. Thorough investigation should always be undertaken in cases of blunt abdominal and thoracic trauma to exclude diaphragmatic injury in order to avoid post-traumatic complications.

A comparative study to evaluate the efficacy of losartan versus atenolol in essential hypertensive patients on cardiovascular morbidity and lipid profile

Background: Hypertension as a vascular disease entity is the common health problem occurring in the general population, characterized by sustained elevation of blood pressure (BP). Hypertension is one of the leading causes of the global burden of disease. Aim and Objective: The objective of the study was: (1) To study the efficacy of losartan and atenolol in patients with hypertension and (2) To study the changes in lipid profile on treatment. Materials and Methods: It was a prospective, open-label, parallel group, comparative study after obtaining informed consent in medicine outpatient department; 100 adult patients aged 40–60 years of either sex with newly diagnosed mild and moderate hypertensive patients were included. Patients were screened in two steps, initial clinical examination by a physician followed by required biochemical investigations includes echocardiogram (ECG), 2D ECHO, and lipid profile. Fifty patients each on LOSARTAN and ATENOLOL were randomly chosen and grouped as follows: (a) Group A – 50 patients who were prescribed Tab. losartan (50 mg/day) and (b) Group B – 50 patients who were prescribed Tab. atenolol (50 mg/day). Patients were recruited for a period of 6 months and were called for follow-up visit at the 3rd and 6th month. The collected data were entered into a specially designed pro forma (case recording form) for study. Results: Mean age of the patients was 52.72 years with a range from 42 years to 64 years. In this study, only 3% of patients were the elderly (>60 years). About 30% of the patients had smoking and 40% of patients had alcohol history. Mean body mass index of the patients was 24.42 kg/m2 with a range from 18.9 kg/m2 to 34.6 kg/m2. Our study observed that baseline systolic (P = 0.704) as well as diastolic BP (P = 0.324) were comparable between both groups. We observed that systolic BP at 3 months was significantly lower in Group A in comparison to Group B (P = 0.007); however, diastolic BP at 3 months was comparable between both groups (P = 0.143). Both systolic (P = 0.125) and diastolic BP (P = 0.108) at 6 months were comparable between both groups. On presentation, 44% of patients in Group A and 46% in Group B had mild left ventricular hypertrophy (LVH) (P = 0.841). At 3 months, there were a significantly lesser number of patients with LVH on ECG examination in Group A in comparison to Group B (16% vs. 36%; P = 0.022). At 6 months, 12% of patients in Group A and 18% in Group B had mild LVH (P = 0.400). Our study observed that mean total cholesterol levels were comparable between both groups at baseline (P = 0.665). However, total cholesterol levels were significantly lower in Group A in comparison to Group B at 3 months (P < 0.0001) and 6 months (P = 0.027). Conclusion: Our study observed that both losartan and atenolol are equally effective in long-term reduction of BP. However, losartan was more effective in reducing LVH in both short term and long term. In addition, losartan also significantly improved lipid profile in terms of decreasing total cholesterol, triglycerides, and low-density lipoprotein, and increasing high-density lipoprotein.

Cerebral Venous Sinus Thrombosis as an Uncommon Presentation of Polycythemia Vera

Cerebral venous sinus thrombosis (CVST) accounts for &lt;1% of all cerebrovascular accidents which were attributed to increased viscosity of blood and activation of platelet in blood vessels. Polycythemia vera (PV) increases the risk of vaso-occlusive events including CVST which may be initial unusual presentation of disease. We present a 28-year-old male patient with headache associated with nausea, vomiting, and blurring of vision. Initial clinical examination was unremarkable, and blood investigations revealed erythrocytosis and neutrophilic leukocytosis with prominent granules. Brain imaging studies were consistent of cerebral venous thrombosis with hemorrhagic transformation and perilesional edema with midline shift. He was managed by decompressive hemicraniectomy, low molecular weight heparin, central nervous system decongestants, antiepileptics, and supportive care with close monitoring. PV is a hypercoagulable state which may precipitate vascular thrombosis. CVST is rare presentation of PV. Early screening for occult prothrombotic entities with prompt management increases the patient outcome and prognosis.

Clinical-Dermoscopic-Histopathological Correlations in Collision Skin Tumours.

Objectives:Collision tumours are rare situations characterised by the coincidence of two different skin neoplasms in the same lesion.Methods:We have analyzed 41 collision skin tumours from one department in the clinical-dermoscopic-histopathologic correlations.Results:We present 41 collisions tumours. The mean age of our patients was 67.9 years, the mean diameter of the lesion was 11.6 mm. The most frequent locations were trunk (27 lesions) and head/neck (11 lesions). The collisions were classified as benign/benign (13 cases), benign/malignant (25 cases) and malignant/malignant (3 cases). The most frequent participants were seborrheic keratosis (24 cases), malignant melanoma (17 cases), melanocytic nevus (14 cases), basal cell carcinoma (12 cases) and heamangioma (10 cases). Thirty cases were of “dominant/minor” type and 11 cases of “half to half” type. Malignant tumours were a part of 28 collisions; these lesions were larger, patients were older and the malignant part was dominant in most cases. More than half of the collisions were unexpected by the initial clinical examination. Six collisions were missed by the initial histopathological examination.Conclusions:Collision tumours can be missed by clinical or even histopathological examination. Dermoscopy is very helpful in the recognizing of difficult cases and cooperating with the histopathologist.

Isolated jejunal perforation - hidden danger in blunt abdominal trauma

Introduction. Isolated jejunal perforation (IJP) without any associated injuries is rare in blunt abdominal trauma (BAT). It most commonly occurs in decelerating trauma. Diagnosis of traumatic intestinal perforation may be difficult in the first hours after injury so unrecognized ?missing? intestinal injuries incidences are as high as 24%. Unrecognized traumatic bowel perforation without adequate treatment leads to the intestinal leakage into the peritoneal cavity, leading to secondary peritonitis and potentially lethal complications. Case outline. We presented the case of a 43-year-old woman injured in a road traffic accident. She was admitted to emergency surgery after diagnostic procedures according to the protocol for trauma. Initial examination, and body computed tomography (CT) revealed orthopedic injuries. Daily monitoring and follow-up examinations were done, she did not complain of any discomfort nor pain in the abdomen, and there were no signs of abdominal injury. Two days after trauma, follow-up abdominal CT revealed highly suspected jejunum perforation, still without signs of pneumoperitoneum. Laparotomy was performed and diagnosis of IJP was confirmed. Bowel perforation was surgically closed in two layers, followed by drainage of septic collections, abdominal saline lavage and primary abdominal closure. The patient was discharged on the seventh postoperative day without complications. Conclusion. In the case of BAT due to severe traumatic force in patient with nonspecific clinical signs of abdominal trauma on initial clinical and radiological examination, follow-up in a short period is necessary, to detect hidden jejunal perforation. Surgery is a life-saving for those patients and treatment of these injuries usually require simple operative procedures.

Apathetic hyperthyroidism presenting as conversion disorder: a case report

Background: Thyroid storm is a life-threatening health condition associated with hyperthyroidism. Apathetic hyperthyroidism is an atypical presentation of the thyrotoxicosis spectrum; this atypical presentation of apathetic thyroid storm makes the diagnosis of thyroid storm more challenging. Case Presentation: A previously healthy 23-year-old female presented to the emergency department with a 3-hour history of inability to talk or move limbs. Initial clinical examination showed that patient was conscious, alert, and febrile, with no external rashes or neck stiffness but was unable to move all limbs. Increased reflexes in all four limbs with no clonus and no rigidity was found. There was no sign of stroke in computed tomography scan, and other neurological assessments were normal. Cardiac examination showed persistent sinus tachycardia reaching 160 heartbeats per minute, despite antipyretic and fluid treatment. This finding raised the suspicion of hyperthyroidism and thyrotoxicosis. Thyroid function test revealed thyroid stimulating hormone level of 0.005 μlU/ml, free thyroxine >100, and free triiodothyronine of 41. Patient was admitted and treatment of anti-thyroid medication, steroid, and beta-blocker was initiated. The condition improved and patient was discharged home. Conclusion: The diagnosis of apathetic hyperthyroidism is difficult and sometimes delayed owing to its atypical presentation. The patient could potentially quietly sink into coma, if high index of suspicion is not maintained.

Lacrimal Gland Orbital Lobe Cystic Mucosa-Associated Lymphoid Tissue Lymphoma: Case Report and Literature Review

This report describes a case of cystic, extranodal, marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue of the orbital lobe of the lacrimal gland in a 70-year-old female. Case of cystic MALT lymphoma isolated to the orbital lobe of the lacrimal gland are rare, with six case reported in the literature. Initial clinical examination revealed bilateral dermatochalasis and a medial left upper lid contour deformity thought to be involutional ptosis. There was no suspicion for a mass lesion. Imaging and subsequent specialist clinical, pathologic, an immunochemical evaluation showed diagnostic features of cystic lacrimal gland orbital lobe MALT lymphoma. Clinical, radiographic, and immunohistopathologic and immunohistochemical findings are detailed. A review of literature was performed and discussed.

Investigating the Diagnostic Value of Ultrasound in Determining the Opposite Inguinal Hernia in Children with Unilateral Inguinal Hernia Diagnosis

Objective: This study was conducted to evaluate and compare the results of ultrasound and clinical examination in the diagnosis of inguinal hernia in children and also to evaluate the benefits and complications of ultrasound in these children. Study Design: This study, was performed by a cross-sectional method in Children's Medical Center Hospital during 2013-2014 years and follow up was done until July 2020 with the help of a questionnaire from 70 children who had been referred due to unilateral inguinal hernia symptoms. All 70 children underwent Ultrasonographic evaluation and the results of the ultrasound were compared with the initial clinical examination and then with surgery and follow up. Results: In 95.7% of cases, uni or bilateral inguinal hernia was correctly diagnosed by ultrasound. Ultrasound revealed 13.4% of cases were bilateral and 86.6% were unilateral, all of which were confirmed by surgery. In 17.1% of cases, although they were referred with the chief complaint and clinical examination of unilateral inguinal hernia, Bilateral diagnosis was made for them during the ultrasound, and during the surgery, 75% of them were confirmed to have bilateral inguinal hernia. Conclusion: Ultrasound is effective in diagnosing the opposite side of the hernia in cases with unilateral hernia.

Clinical Experience with Calcitonin Gene-Related Peptide (CGRP) in Patients with Post-Concussion Headaches

To evaluate the role of CGRP Antagonists in the management of Post-Concussion Headaches. Headaches are one of the most common, debilitating symptoms experienced in post-concussion patients. Previous studies show these symptoms are mediated through a CGRP dependent mechanism. Injectable monoclonal antibodies directed against CGRP have seen widespread use for the management of migraines since their approval in 2018, however there has been minimal evaluation of their effectiveness in managing post-concussion headaches. A retrospective review of post-concussion patients who were administered intramuscular CGRP Antagonists once monthly in a fixed dose. This study examined reported severity of headaches evaluated at the initial clinical examinations compared to subsequent examinations post-administration of medication. Of 3 subjects evaluated and receiving erenumab (n = 2) or fremanezumab (n = 1), all showed some form of improvement in their symptoms. Mean (SD) age was 51.7 (6.23). Of these subjects, one patient reported = 1 adverse event (AE). No subjects had serious AE that required discontinuation of treatment. CGRP Antagonists show potential to be a useful approach for the management of post-concussion headaches.

Molecular identification of Actinomadura madurae isolated from a patient originally from Algeria; observations from a case report

BackgroundMycetoma is a chronic granulomatous subcutaneous infection caused by anaerobic pseudofilamentous bacteria or fungi. It is commonly prevalent in tropical and subtropical countries. Men are more susceptible to the disease due to greater participation in agricultural works. Mycetoma commonly involves lower extremities, wherein untreated cases lead to aggressive therapeutic choices, such as amputation of the affected body organs and consequently lifelong disability.Case presentationIn this report, we present the rare case of a 58-year-old man, originally from Algeria with a left foot chronic tumefaction of 5 years. In the initial clinical examination, mycetoma was diagnosed based on tumefaction and the presence of multiple sinuses with the emission of white grains. The latter was observed via direct examination. The histopathological analysis demonstrated an actinomycetoma caused by bacteria, as the etiological agent. Imaging showed a bone involvement with osteolysis at the levels of 2nd to 4th metatarsal diaphysis. The mycological and bacterial cultures were both negative. For an accurate diagnosis, the obtained grains were subjected to molecular analysis, targeting the 16S-rDNA gene. Molecular identification yielded Actinomadura madurae as the causal agent, and 800/160 mg of trimethoprim/sulfamethoxazole was prescribed twice a day for 1 year, as a treatment.ConclusionConsidering low information about this disease, especially in non-endemic areas, it is of high importance to enhance the knowledge and awareness of clinicians and healthcare providers, in particular in the countries with immigration issues.

Assessment of the effect of stretching the muscles posterior thigh and shin onthe intensity of cervicalgia and patient′s posture

Introduction. The human body is a single system of interconnected organs that are connected not only anatomically, but also functionally. The most extensive fascial-muscular associations are called «anatomical trains» (the concept of Thomas Myers), the impact on which can cause changes at a significant distance from the point of application of force. The available literature describes the effect of stretching hamstrings (an important component of the «surface posterior muscle band») on changes in the function of the temporomandibular joint, lumbodynia, mobility of the lumbosacral spine and hip joints. However, the values of stretching hamstings on human posture and reducing cervicalgia were not evaluated.The goal of research — investigate the effect of active isolated stretching of the muscles posterior thigh and shin on the intensity of cervicalgia and patient posture.Materials and methods. The material for this work is the results of observation of 17 patients aged 15–17 years with cervicalgia of various genesis, who are under inpatient treatment for spinal deformities with a distinct increase in the severity of thoracic physiological kyphosis (juvenile osteochondrosis, dysplastic kyphoscoliosis, cervical spine dysplasia, etc.). Patients performed daily physical exercises for 12 days with active isolated stretching of the muscles of the posterior surface of the thigh and lower leg (according to the concept of Thomas Myers — «surface posterior muscle band»). The orthopedic status and clinical condition of patients were evaluated. Instrumental diagnostics was performed by the method of topography of optical deformities of the spine (TODS) (Novosibirsk, «Medical topographic systems» — LLC «METOS»), as well as using a standard tablet computer with a software application (patent RU 2638644) «Smart-Ortho 2D» for Android. The intensity of pain in the cervical spine was assessed by the doctor using a dynamometer-algometer, as well as by the patients themselves on the VAS scale.Results. During the initial clinical examination, 14 out of 17 (or 82 % of cases) observed patients with complaints of cervicalgia registered femoral-lumbar rigidity. It was most pronounced in the limitations of the Tomayer test (the forward tilt of the torso). In 15 patients (88 %), the value of thoracic physiological kyphosis exceeded the norm (20–23 mm according to TODS data) by 6–43 mm. Active isolated stretching of the posterior thigh and lower leg muscles resulted in complete elimination of pain syndrome in all patients in the study group. With regard to kyphotic posture, we note that these therapeutic measures did not cause significant changes in the parameters of the sagittal profile of the vertebral column, but there was a clear trend to reduce the severity of thoracic kyphosis with simultaneous deepening of lumbar lordosis. The angle of the anterior pelvic tilt changed (increased) according to the TODS data. The Tomayer test began to approach the norm in 12 people (70,5 %).Conclusion. The use of active isolated exercises aimed at stretching the «surface posterior muscle band» in the observed group of patients contributed to the complete relief of pain in 100 % of cases. At the same time, these therapeutic measures did not have a significant effect on the severity of physiological sagittal bends and pelvic tilt. The results of clinical observation of patients with cervicalgia of various genesis, being treated and using a set of exercises with active isolated stretching of muscles posterior thigh and shin, make it possible to recommend this complex for using. The simplicity of the exercises does not cause any difficulties in performing, which makes it understandable and accessible for general prophylaxis.

Reabilitação estética e funcional com laminados cerâmicos reforçados por dissilicato de lítio: relato de caso clínico

Objetivo: Apresentar um relato de caso clínico de reabilitação estética e funcional do sorriso com laminados cerâmicos minimamente invasivos, descrevendo o protocolo clínico por meio de facetas cerâmicas reforçadas por dissilicato de lítio. Detalhamento do caso: Paciente do gênero feminino, procurou atendimento odontológico queixando-se da aparência estética do seu sorriso. O exame clínico inicial identificou restaurações de resina composta insatisfatórias quanto à forma, textura e cor nos elementos 11, 12, 13, 21, 22 e 23, e ausência de características, como: simetria entre os dentes homólogos, curva incisiva convexa acompanhando a concavidade do lábio inferior e falta de preenchimento do corredor bucal. No planejamento, optou-se por realizar laminados cerâmicos em dissilicato de lítio. O tratamento foi iniciado com a confecção de facetas fresadas em resina acrílica (PMMA) para o ensaio restaurador. Posteriormente, as facetas de cerâmica reforçadas por dissilicato de lítio (IPS e.max) foram cimentadas com resina composta Z-100 (3M ESPE) aquecida a 68°C. Considerações finais: O sucesso do tratamento depende do correto diagnóstico, planejamento do caso, e execução correta da técnica de preparo dos elementos dentários e que a utilização de cerâmica reforçada por Dissilicato de Lítio é uma excelente opção para a reabilitação estética e funcional de dentes anteriores.

Persistent idiopathic unilateral isolated hypoglossal nerve palsy \u2013 a report of two cases

IntroductionIsolated unilateral hypoglossal nerve palsy is an infrequent condition that usually appears in connection to an underlying disease. Rarely, the cause cannot be determined, and there is no symptom remission.Case descriptionWe report two cases of male patients who developed persistent idiopathic isolated unilateral hypoglossal nerve palsy. The younger patient complained of involuntary movements of the tongue, while the older patient developed dysarthria. In both cases, the symptoms lasted for several weeks before the initial clinical examination, and after comprehensive clinical, laboratory, and imaging investigations, no underlying cause was detected. Both patients did not show remission of symptoms on the follow-up examinations done after several months.DiscussionIdiopathic isolated unilateral hypoglossal nerve palsy is an underreported condition, most likely due to the expected reversible nature of the disease. In the case of persistence of symptoms, extensive medical assessment is needed before postulating a diagnosis of persistent idiopathic isolated unilateral hypoglossal nerve palsy. There are no treatment guidelines for this condition, but oral steroids were reported as a treatment option. Therefore, physicians should use a systematic approach to exclude serious underlying pathology or identify a treatable condition.

083 Linear morphea with evidence of hair regrowth

A 32-year-old male presented for initial evaluation of alopecia on the frontal scalp of eight months duration. On initial clinical examination, he was found to have a 7.0cm x 1.2cm sclerotic plaque on the paramedian forehead extending to the scalp with associated alopecia. No ocular, neurological, or odontostomatologic complications were identified. A 4mm punch biopsy from the frontal scalp demonstrated marked follicular dropout with absent sebaceous glands and presence of perifollicular and perivascular lymphocytic inflammation.

An unusual case of recurrent episodes of muscle weakness: Co-occurrence of Andersen-Tawil syndrome and glycogen storage disease type IXd

A 25-year-old male patient presented with periodic paralysis that increased in severity and frequency with age, accompanied with muscle pain and significantly elevated creatine kinase (CK) levels. Initial clinical and genetic examination confirmed Andersen-Tawil syndrome. Although his father carried the same genetic mutation (p.G300A), he experienced minor and infrequent attacks of paralysis. A change in the patient's symptoms, such as accompanying pain, contracture, and significant CK elevation, lead to a reconsideration of the diagnosis. A muscle biopsy of the biceps brachii in the patient revealed glycogen storage, but no tubular aggregates. Analysis of the phosphorylase kinase regulatory subunit alpha 1 (PHKA1) gene revealed a pathogenic mutation (p.C1082X), indicating glycogen storage disease type Ⅸd. The case demonstrates that co-occurrence of glycogen storage disease type Ⅸd may prolong attacks of muscle weakness, and cause serious muscle pain in patients with Andersen-Tawil syndrome.

Application value of 18F-FDG PETCT imaging in the clinical initial diagnosis and follow-up of primary lesions of cervical cancer.

BackgroundCervical cancer is a common malignant tumor in gynecology with a high death rate. his study aims to analyze the application value of 18F-fluorodeoxyglucose imaging examination (18F-FDG PETCT) imaging in the initial clinical diagnosis and follow-up examination of cervical cancer.MethodsThe clinical data of 71 patients with cervical lesions who were admitted to our hospital from March 2017 to March 2019 were retrospectively collected all patients underwent 18F-FDG PETCT examination. The results of the pathological examination were a benchmark to calculate the sensitivity, specificity, and accuracy of 18F-FDG PETCT imaging in the diagnosis of primary lesions of cervical cancer and the diagnosis of postoperative recurrence, residual, and metastasis.ResultsThere were 39 patients initially suspected, and 30 cases were diagnosed as cervical cancer by pathological examination, including 22 cases with squamous cell carcinoma, 4 cases with adenocarcinoma, 3 cases with carcinoma in situ, and 1 case with adenosquamous carcinoma. The maximum standard uptake (SUVmax) value was (10.36±5.22), and the patient’s lesions showed different degrees of increase of 18F-FDG metabolism. The necrotic area in the patient's lesion showed reduced/defect metabolism. The sensitivity of 18F-FDG PETCT imaging in the diagnosis of primary lesions of cervical cancer was 86.66%, specificity was 44.44%, and accuracy was 76.92%. In the 32 cases followed up for monitoring after the operation, 16 cases showed recurrence, metastasis, residual and other conditions, and 7 cases showed local recurrence/metastasis. 18F-FDG PETCT images showed: abnormal widening of the cervix, stump nodules/mass in the vagina, and rectal and bladder infiltration. All patients with local recurrence were treated with local tissue biopsy or surgical resection under 18F-FDG PETCT image localization. The diagnostic sensitivity, specificity and diagnostic coincidence rate of 18F-FDG PETCT imaging for postoperative follow-up of cervical cancer patients were 100%, 75.00% and 87.50%, respectively.ConclusionsFor patients with cervical cancer who are initially diagnosed or followed up, they can all be tested by 18F-FDG PETCT imaging, which can provide a reference for the formulation of diagnosis and treatment plan and the evaluation of prognosis.

Associations Between Initial Clinical Examination and Imaging Findings and Return-to-Sport in Male Athletes With Acute Adductor Injuries: A Prospective Cohort Study

Background: Time to return-to-sport (RTS) after acute adductor injuries varies among athletes, yet we know little about which factors determine this variance. Purpose: To investigate the association between initial clinical and imaging examination findings and time to RTS in male athletes with acute adductor injuries. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: Male adult athletes with an acute adductor injury were included within 7 days of injury. Standardized patient history and clinical and magnetic resonance imaging (MRI) examinations were conducted for all athletes. Athletes performed a supervised standardized criteria-based exercise treatment program. Three RTS milestones were defined: (1) clinically pain-free, (2) completed controlled sports training, and (3) first full team training. Univariate and multiple regression analyses were performed to determine the association between the specific candidate variables of the initial examinations and the RTS milestones. Results: We included 81 male adult athletes. The median duration for the 3 RTS milestones were 15 days (interquartile range, 12-28 days), 24 days (16-32 days), and 22 days (15-31 days), respectively. Clinical examination including patient history was able to explain 63%, 74%, and 68% of the variance in time to RTS. The strongest predictors for longer time to RTS were pain on palpation of the proximal adductor longus insertion or a palpable defect. The addition of MRI increased the explained variance with 7%, 0%, and 7%. The strongest MRI predictor was injury at the bone-tendon junction. Post hoc multiple regression analyses of players without the 2 most important clinical findings were able to explain 24% to 31% of the variance, with no added value of the MRI findings. Conclusion: The strongest predictors of a longer time to RTS after acute adductor injury were palpation pain at the proximal adductor longus insertion, a palpable defect, and/or an injury at the bone-tendon junction on MRI. For athletes without any of these findings, even extensive clinical and MRI examination does not assist considerably in providing a more precise estimate of time to RTS.

Role of emergency physician–performed ultrasound in the differential diagnosis of abdominal pain

Objectives:This prospective study was performed to evaluate the diagnostic accuracy of bedside point‐of‐care abdominal ultrasonography performed by emergency physician in patients with non‐traumatic acute abdominal pain.Methods:The patients, who were admitted to emergency department due to abdominal pain, were included in this study. The emergency physician obtained a routine history, physical examination, blood draws, and ordered diagnostic imaging. After the initial clinical examinations, all the patients underwent ultrasonography for abdominal pathologies by emergency physician and radiologist, respectively. Point‐of‐care abdominal ultrasonography compared with abdominal ultrasonography performed by radiologist as the gold standard.Results:The study included 122 patients. Gallbladder and appendix pathologies were the most commonly detected in the abdominal ultrasonography. Compared with abdominal ultrasonography, point‐of‐care abdominal ultrasonography was found to have 89% sensitivity and 94% specificity in gallbladder pathologies; 91% sensitivity and 91% specificity in acute appendicitis; 79% sensitivity and 97% specificity in abdominal free fluid; 83% sensitivity and 96% specificity in ovarian pathologies. Compared to final diagnosis, preliminary diagnoses of emergency physicians were correct in 92 (75.4%) patients.Conclusion:This study showed that emergency physicians were successful in identifying abdominal organ pathologies with point‐of‐care abdominal ultrasonography after training.