Oligosymptomatic Patients Research Articles

Assessment of mild cognitive dysfunction in patients with atrial fibrillation utilizing the R4Alz assessment test

Abstract Background/Introduction The association between atrial fibrillation and cognitive dysfunction has accumulated a growing body of evidence in recent years. However, establishing such a diagnosis remains challenging, especially in mild oligosymptomatic patients. REMEDES for Alzheimer (R4Alz) is a novel test, designed to assess cognitive control decline at an early stage. Purpose We sought to evaluate the prevalence of early, mild cognitive dysfunction in patients with paroxysmal atrial fibrillation with the use of established and novel diagnostic tools. Methods This is a prospective cross-sectional study that enrolled consecutive patients with history of paroxysmal atrial fibrillation and matched healthy controls, from a tertiary cardiology department. Patients with history of stroke or known cognitive dysfunction of any type were excluded from the study. Demographic and clinical data were collected. All study participants were subjected to Montreal Cognitive Assessment (MoCA) and to R4Alz within the same day. Cognitive function and attention ability is assessed at three stages with R4Alz: working memory updating (R1), supervisory attention system (R2) and task/rule switching and control of inhibition (R3). The primary endpoint was the difference in cognitive function between patients with atrial fibrillation and controls. Secondary endpoints included the correlation between the two assessment tests in both groups. Statistical analysis was performed with R version 4.1.0 and a p-value<0.05 was considered statistically significant. Results Fifty-five patients with atrial fibrillation and thirty-four controls were enrolled in the study (Mean age: 62.6 y, Female gender: 62.9%). MoCA scores (25.4 ± 4.11 for patients with atrial fibrillation vs 22.3 ± 3.72 for healthy controls, p-value <0.001) (Figure 1) as well as scores of all stages of R4ALz {working memory (R1a, R1b, R1c), supervisory attention system (R2) and task/rule switching – inhibition control (R3a1, R3a2, R3b)} were indicative of mild cognitive dysfunction in patients with atrial fibrillation. The control group exhibited significantly better cognitive performance on all assessment tools (Table 1).Figure 1Table 1

Evidence of brain metabolism redistribution from neocortex to primitive brain structures in early acute COVID-19 respiratory syndrome

BackgroundNeuropsychiatric sequelae of COVID-19 have been widely documented in patients with severe neurological symptoms during the chronic or subacute phase of the disease. However, it remains unclear whether subclinical changes in brain metabolism can occur early in the acute phase of the disease. The aim of this study was to identify and quantify changes in brain metabolism in patients hospitalized for acute respiratory syndrome due to COVID-19 with no or mild neurological symptoms.ResultsTwenty-three non-intubated patients (13 women; mean age 55.5 ± 12.1 years) hospitalized with positive nasopharyngeal swab test (RT-PCR) for COVID-19, requiring supplemental oxygen and no or mild neurological symptoms were studied. Serum C-reactive protein measured at admission ranged from 6.43 to 189.0 mg/L (mean: 96.9 ± 54.2 mg/L). The mean supplemental oxygen demand was 2.9 ± 1.4 L/min. [18F]FDG PET/CT images were acquired with a median of 12 (4–20) days of symptoms. After visual interpretation of the images, semiquantitative analysis of [18F]FDG uptake in multiple brain regions was evaluated using dedicated software and the standard deviation (SD) of brain uptake in each region was automatically calculated in comparison with reference values of a normal database. Evolutionarily ancient structures showed positive SD mean values of [18F]FDG uptake. Lenticular nuclei were bilaterally hypermetabolic (> 2 SD) in 21/23 (91.3%) patients, and thalamus in 16/23 (69.6%), bilaterally in 11/23 (47.8%). About half of patients showed hypermetabolism in brainstems, 40% in hippocampi, and 30% in cerebellums. In contrast, neocortical regions (frontal, parietal, temporal and occipital lobes) presented negative SD mean values of [18F]FDG uptake and hypometabolism (< 2 SD) was observed in up to a third of patients. Associations were found between hypoxia, inflammation, coagulation markers, and [18F]FDG uptake in various brain structures.ConclusionsBrain metabolism is clearly affected during the acute phase of COVID-19 respiratory syndrome in neurologically asymptomatic or oligosymptomatic patients. The most frequent finding is marked hypermetabolism in evolutionary ancient structures such as lenticular nucleus and thalami. Neocortical metabolism was reduced in up to one third of patients, suggesting a redistribution of brain metabolism from the neocortex to evolutionary ancient brain structures in these patients.

Renal manifestations in adults with mitochondrial disease from the mtDNA m.3243A>G pathogenic variant

Mitochondrial diseases are a phenotype and genotype heterogeneous group of disorders that typically have a multisystemic involvement. The m.3243A>G pathogenic variant is the most frequent mitochondrial DNA defect, and it causes several different clinical syndromes, such as mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS), and the maternally inherited diabetes and deafness (MIDD) syndromes.Not frequently reported, renal involvement in these diseases is probably underestimated, yet it increases morbidity. It generally manifests as subnephrotic proteinuria and progressive deterioration of kidney function. Adult presentation of mitochondrial diseases is hard to recognize, especially in oligosymptomatic patients or those with exclusive kidney involvement. However, suspicion should always arise when family history, particularly on the maternal side, and multisystemic symptoms, most often of the central nervous system and skeletal muscles, are present.In this review we discuss the clinical diagnosis and approach of patients with renal manifestations in the context of the mtDNA m.3243A>G pathogenic variant.

Sclerotic Bone Lesions as a Clue in the Diagnosis of Three Generations of Tuberous Sclerosis Complex: Case Report and Review of Literature

Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder that can involve multiple organ systems. Diagnosis is based on independent clinical diagnostic criteria and genetic diagnostic criteria (pathogenic variants on TSC1 and TSC2 genes). To make a definitive diagnosis can be especially difficult in oligosymptomatic or asymptomatic patients and in those patients with genetic variants of uncertain significance (VUS). Early diagnosis and lifelong surveillance are paramount to avoid morbidity and potentially life-threatening complications. To increase diagnostic sensibility, less known manifestations of TSC can be helpful. Herein we show a case in which SBLs were used as a diagnostic clue to help diagnose three generations of oligosymptomatic TSC carrying a VUS in TSC1. SBLs are commonly detected in imaging studies of patients with TSC and have been recently included as a minor clinical diagnostic criterion. Clinicians and radiologists should be aware of their significance as they can be mistaken with osteoblastic metastases.

Features of the course of Covid-19 infection in children

The COVID-19 infection has become an unexpected challenge for global health in recent years. The SARS-CoV-2 virus, which causes severe illness in adults, was most often asymptomatic in the pediatric population. However, since the appearance of the new virus, the estimated share of infected children has risen from less than 2% to 8.5% of all infected patients. Taking into account the fact that asymptomatic and oligosymptomatic pediatric patients most often do not complain, it can be assumed that the exact occurrence rate of the SARS-CoV-2 virus among children is higher than officially published data. Similarly to adults, the presence of comorbidities in children was associated with severe forms of the coronavirus infection and the need for intensive care. The clinical pattern of COVID-19 in children is not fundamentally different from that in adult patients, but however, gastrointestinal symptoms are found much more often. In addition, complications characteristic of the pediatric population are observed. The aim hereof was to analyze the features of the manifestation of the COVID-19 infection in pediatric patients.

Renal manifestations in adults with mitochondrial disease from the mtDNA m.3243A>G pathogenic variant

Mitochondrial diseases are a phenotype and genotype heterogeneous group of disorders that typically have a multisystemic involvement. The m.3243A>G pathogenic variant is the most frequent mitochondrial DNA defect, and it causes several different clinical syndromes, such as mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS), and the maternally inherited diabetes and deafness (MIDD) syndromes.Not frequently reported, renal involvement in these diseases is probably underestimated, yet it increases morbidity. It generally manifests as subnephrotic proteinuria and progressive deterioration of kidney function. Adult presentation of mitochondrial diseases is hard to recognize, especially in oligosymptomatic patients or those with exclusive kidney involvement. However, suspicion should always arise when family history, particularly on the maternal side, and multisystemic symptoms, most often of the central nervous system and skeletal muscles, are present.In this review we discuss the clinical diagnosis and approach of patients with renal manifestations in the context of the mtDNA m.3243A>G pathogenic variant.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT.

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

Androgen receptor polyQ alleles and COVID-19 severity in men: A replication study.

Ample evidence indicates a sex-related difference in severity of COVID-19, with less favorable outcomes observed in men. Genetic factors have been proposed as candidates to explain this difference. The polyglutamine (polyQ) polymorphism in the androgen receptor gene has been recently described as a genetic biomarker of COVID-19 severity. To test the association between the androgen receptor polyQ polymorphism and COVID-19 severity in a large cohort of COVID-19 male patients. This study included 1136 male patients infected with SARS-CoV-2 as confirmed by positive PCR. Patients were retrospectively and prospectively enrolled from March to November 2020. Patients were classified according to their severity into three categories: oligosymptomatic, hospitalized and severe patients requiring ventilatory support. The number of CAG repeats (polyQ polymorphism) at the androgen receptor was obtained by PCR and patients were classified as either short (<23 repeats) or long (≥23 repeats) allele carriers. The association between polyQ alleles (short or long) and COVID-19 severity was assessed by Chi-squared (Chi2 ) and logistic regression analysis. The mean number of polyQ CAG repeats was 22 (±3). Patients were classified as oligosymptomatic (15.5%), hospitalized (63.2%), and severe patients (21.3%) requiring substantial respiratory support. PolyQ alleles distribution did not show significant differences between severity classes in our cohort (Chi2 test p>0.05). Similar results were observed after adjusting by known risk factors such as age, comorbidities, and ethnicity (multivariate logistic regression analysis). Androgen sensitivity may be a critical factor in COVID-19 disease severity. However, we did not find an association between the polyQ polymorphism and the COVID-19 severity. Additional studies are needed to clarify the mechanism underlying the association between androgens and COVID-19 outcome. The results obtained in our study do not support the role of this polymorphism as biomarker of COVID-19 severity.

Sleep-disordered breathing-Update 2021

HintergrundSchlafbezogene Atmungsstörungen (SBAS) und andere Schlafstörungen sind sehr häufige Erkrankungen, die zu erheblichen Einbußen hinsichtlich der Lebensqualität, Arbeitsfähigkeit und Prognose beitragen können.FragestellungWelche neuen Erkenntnisse gab es in der Schlaf- und Beatmungsmedizin zwischen November 2019 und Oktober 2021, die die Versorgung von Patienten mit SBAS maßgeblich beeinflussen?Material und MethodenEs wurde eine systematische Literaturrecherche im Zeitraum November 2019 bis Oktober 2021 und eine Auswahl der relevantesten Artikel durchgeführt.ErgebnisseDie für die Versorgung von Patienten mit SBAS relevantesten Ergebnisse waren: 1) Eine Therapie mit Continuous Positive Airway Pressure (CPAP) kann zwar bei Patienten mit SBAS den arteriellen Blutdruck senken, führt aber bei a‑ oder oligosymptomatischen Patienten und SBAS zu keiner Reduktion des Risikos für Myokardinfarkt oder Schlaganfall. 2) Nachdem in den letzten Jahren die Wirksamkeit der Unterkieferprotrusionsschienen (UKPS) bei ausgewählten Patienten mit obstruktiver Schlafapnoe (OSA) gezeigt wurde, sind UKPS seit 2021 als Secondline-Therapie nach CPAP auch erstattungsfähig. 3) Solriamfetol und Pitolisant wurden durch die Europäische Arzneimittelbehörde (EMA) für die Indikation der residualen Tagesschläfrigkeit bei Patienten mit OSA zugelassen. 4) Telemedizinische Verfahren können in der Langzeitbetreuung von Patienten mit SBAS hilfreich sein.SchlussfolgerungenDie diskutierten Studien liefern für die Versorgung von Patienten mit SBAS relevante Ergebnisse.

Detection of health deterioration in a COVID-19 patient at home: the potential of ambient sensor systems

The COVID-19 pandemic created increased interest in monitoring patients at home to allow timely recognition of health deteriorations. Hospital care is particularly demanding in these patients because of the necessity for isolation to avoid further spread of the disease. Therefore, home care is a preferred treatment setting for these patients. This is, to our knowledge, the first report indicating the potential of an affordable, contactless, and unobtrusive ambient sensor system for the detection of signs of health deterioration in a patient with COVID-19 by a caregiver from a distance. Prospective data acquisition and correlation of the data with clinical events were obtained from an 81-year-old senior with COVID-19 before and, in particular, over a period of 10 days prior to hospitalization. Clinical signs included weakness, increased respiration rate, sleep disturbances, and confusion. The visualization of a combination of this information on a dedicated dashboard allowed the caregiver to recognize a serious health deterioration that required a lifesaving hospitalization. The potential of such ambient sensor systems to detect signs of serious health deterioration in patients with COVID-19 opens new opportunities for use in asymptomatic or oligosymptomatic patients who live alone and are sent back to their homes for isolation in quarantine after diagnosis.

GERD-A Burning Problem after Sleeve Gastrectomy?

Background: Surgical treatment is the most effective method of treatment for obesity; and laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric surgery. Objective: The aim of the study was evaluation of the frequency of occurrence and the degree of progression of changes characteristic of GERD in patients who had undergone LSG in clinical; endoscopic; and microscopic images in the obtained bioptats; and an attempt to correlate the results obtained with the effectiveness of bariatric treatment. Materials and Method: The anonymized clinical data concerning 214 patients who had undergone LSG were collected from the database. Invitations for check-up examinations were distributed, to which 37 patients responded. Two patients were excluded from the study. In 35 patients after LSG check-up clinical examination, bariatric endoscopy (BE) and bariatric microscopy (BM) were performed on bioptats collected from the site of the gastro-esophageal junction; and 3 specimens collected at 2 cm intervals from the Z-line. The study was performed according to the standard protocol. Results: In the analyzed group, clinical symptoms of GERD occurred in 12 patients (34.5%), including 10 females and 2 males. The symptom reported by all patients was retrosternal pain/burning (heartburn). In BE, foci of ectopic mucosa in the epicardial part of the esophagus were found in 16 patients (14 F and 2 M). No correlation was observed between the analyzed parameters and the occurrence of the above-mentioned changes. In BM, only in three patients were the changes described as normal esophageal mucosa; while in another three, as foci of intestinal metaplasia, Barrett’s esophagus. In this group no foci of dysplasia were found. In eight patients, the changes were described as inflammatory. In ten patients from this group, microscopic changes occurred without clinical symptoms of the disease. Conclusions: GERD is an important clinical problem in patients after LSG; therefore; the problem of occurrence or exacerbation of symptoms of the disease should be discussed with the patient during qualification for bariatric surgery. The bariatric effectiveness of LSG does not correlate with the occurrence of the symptoms of GERD after the procedure. However; the lack of clinical symptoms of the disease does not mean the lack of its occurrence. Therefore; the endoscopic check-up after LSG should be routinely performed. During the qualification for LSG screening, histopathologic examinations of the esophagus may be useful for the assessment of the microscopic symptoms of GERD in oligosymptomatic patients; and exclusion of rare pathologies of the esophagus (e.g., eosinophilic esophagitis), which may complicate post-operative course.

Exploring Inflammatory Status in Febrile Seizures Associated with Urinary Tract Infections: A Two-Step Cluster Approach.

Background: Urinary tract infections (UTIs) are considered common facilitating factors, along with other infections, in triggering febrile seizures (FS). The main purpose of our study was to identify specific inflammatory patterns of UTI cases from other infections in a specific cluster, using a combination of inflammatory biomarkers to differentiate UTIs from other bacterial diseases triggering FS. Method: This prospective study included a number of 136 patients with 197 distinct FS events, from patients hospitalized in the Pediatric Clinical Hospital Sibiu, among which 10.2% were diagnosed with UTIs. Results: In one-third of the patients with UTIs (20 cases), the symptoms were limited to fever and FS. Using two-step cluster analysis, a distinct UTI inflammatory pattern has emerged: highest platelet values (PLT), median value 331 × 103/mm3 and intermediate C-reactive protein (CRP), median value 15 mg/dL, platelet distribution width (PDW), median value 9.65%, platelet-large cell ratio (P-LCR), median value 14.45%, mean platelet volume (MPV), median value 8.60 fL and neutrophil-to-lymphocyte values (NLR), median value 3.64. Furthermore, higher PDW (median value 12.25%), P-LCR (median value 28.55%), MPV (median value 10.40 fL), CRP (median value 74.00 mg/dL) and NLR values (median value 4.11) were associated mainly (85.7%) with bacterial lower respiratory infections. UTIs were highly unlikely in these patients with significantly increased CRP values and normal values of platelet indices. Conclusions: Considering the nonspecific clinical picture of UTIs at an early age, to optimize the management of FS, a fast diagnosis of UTI is mandatory. The analysis of the inflammatory biomarker clusters (rather than individual parameters) correlated with urine leukocyte and nitrite stick evaluation for specific age groups could help in identifying even oligosymptomatic UTIs patients. The study limitation (20 UTI cases) recommends future multicentric trials on larger datasets to validate the model.

Sacral fracture associated with a Tarlov cyst causing an anterior sacral CSF fistula and intraventricular fat emboli – a case report and review of the literature

Background Sacral fractures are rare and either associated with high-energy trauma or osteoporosis in most cases. A search of the current literature on sacral fractures and cerebrospinal fluid fistula identified only few cases. Pathological fractures are uncommon and exceedingly rare in case of Tarlov cysts. Sacral fractures can be missed in oligosymptomatic patients. However, severe complications may emerge as shown by this case report. Methods We present the case of a pathological sacral fracture at the level S2/3 following a low-impact trauma, associated with a Tarlov cyst, which was complicated by an anterior CSF fistula and intraventricular fat emboli. Results The patient was treated conservatively with strict bedrest and a CT-guided blood patch. Postponed mobilization was successful with decreasing orthostatic symptoms. Follow-up MRI and CT imaging showed a complete resolution of the ventral CSF fistula and ossification of the fracture. The intraventricular fat did not resolve, however, there was no radiological sign of hydrocephalus with excellent clinical outcome at 6-months follow-up. Conclusion Although exceedingly rare, sacral Tarlov cysts may be associated with pathological fractures of the sacrum. Relevant complications can emerge and need to be properly addressed.

Correlation of Intraoperative Neurophysiological Parameters and Outcomes in Patients with Intramedullary Tumors.

Introduction:Intramedullary spinal cord tumors (IMSCT) account for about 2%–4% of all central nervous system tumors. Surgical resection is the main treatment step, but might cause damage to functional tissues. Intraoperative neuromonitoring (IONM) is an adopted measure to decrease surgical complications. Below, we describe the results of IMSCT submitted to surgery under IONM at a tertiary institution.Methods:The sample consisted of consecutive patients with IMSCT admitted to the Neurological Institute of Curitiba from January 2007 to November 2016. A total of 47 patients were surgically treated. Twenty-three were male (48.9%) and 24 were female (51.1%). The mean age was 42.77 years. The mean follow-up time was 42.7 months.Results:Neurological status improved in 29 patients (62%), stable in 6 (13%), and worse in 12 (25%). Patients who presented with motor symptoms at initial diagnosis had a worse outcome compared to patients with sensory impairment and pain (P = 0.026). Patients with a change in electromyography had worse neurological outcomes compared to patients who did not show changes in monitoring (P = 0.017).Discussion and Conclusion:No prospective randomized high evidence study has been performed to date to compare clinical evolution after surgery with or without monitoring. In our sample, surgical resection was well succeeded mainly in oligosymptomatic patients with low preoperative McCormick classification and no worsening of IONM during surgery. We believe that microsurgical resection of IMSCT with simultaneous IONM is the gold standard treatment and achieved with good results.

Perilesional edema in brain metastases as predictive factor of response to systemic therapy in non-small cell lung cancer patients: a preliminary study.

BackgroundThe significance of upfront systemic therapies as an alternative to whole brain radiotherapy (WBRT) for multiple brain metastases (BM) is debatable. Our purpose is to investigate if peritumoral edema could predict the intracranial response to systemic chemotherapy (chemo) in patients with advanced non-squamous non-small cell lung cancer (non-SQ-NSCLC) and synchronous multiple BM.MethodsIn this observational cohort study, we evaluated the outcome of 28 patients with multiple BM (≥3) treated with chemo based on cisplatin/carboplatin plus pemetrexed (chemo, group A, n=17) or WBRT plus subsequent chemo (group B, n=11). The intracranial response, assessed by the response assessment neuro-oncology (RANO) BM criteria, was correlated with the degree of BM-associated edema estimated by the maximum diameter ratio among fluid attenuated inversion recovery (FLAIR) and gadolinium-enhanced T1WI (T1Gd) per each BM at the baseline brain magnetic resonance imaging (MRI).ResultsNo differences were observed in baseline characteristics between both groups, except for the number of patients under steroid treatment that was clearly superior in group B (P=0.007). Median OS was similar between groups. Regarding FLAIR/T1Gd ratio (F/Gd), patients treated with chemo alone exhibited significantly higher values (P=0.001) in those who developed intracranial progression disease (PD) (2.80±0.32 mm), compared with those who achieved partial response (PR) (1.30±0.11 mm) or stable disease (SD) (1.35±0.09 mm). In patients treated with WBRT, F/Gd ratio was not predictive of response.ConclusionsPeritumoral edema estimated by F/Gd ratio appears a promising predictive tool to identify oligosymptomatic patients with multiple BM in whom WBRT can be postponed.

Abdominal complications in patients with a ventriculoperitoneal shunt: proposal for management recommendations from a single pediatric tertiary center.

The aim of this study was to describe our experience in the management of patients with ventriculoperitoneal shunt-related complications (abdominal pseudocyst, bowel-related complications, and ascites) and to propose treatment recommendations. A retrospective descriptive study was conducted in patients with ventriculoperitoneal shunt-related abdominal complications seen between 2009 and 2019 at a tertiary-care pediatric center. Patients were classified according to their diagnosis into the following: group A (abdominal pseudocyst), group B (bowel-related complications), and group C (ascites). The following variables were studied in all three groups: age, sex, etiology of hydrocephalus, history of pyogenic ventriculitis, history of abdominal surgery, clinical presentation, presence of ventricular enlargement on computed tomography scan, abdominal ultrasonography, shunt series X-ray, cerebrospinal fluid cultures, urgent as well as elective surgical interventions, antibiotic treatment, length of hospital stay, follow-up, and outcome. Overall, 48 patients were analyzed: group A, n=29; group B, n=15; and group C, n=4. In all cases, surgical decision-making was based on symptom severity at the time of diagnosis, presence of ventricular enlargement on computed tomography scan, and cerebrospinal fluid culture results. In patients with positive cultures, the shunt system was removed, and an external ventricular drain was placed. In oligosymptomatic patients, cerebrospinal fluid culture results were awaited to define long-term treatment and in patients with ventricular enlargement or clinically difficult-to-treat symptoms, the distal catheter was exteriorized at the thoracic level. In patients with shunt-related abdominal complications, surgical management depends on symptom severity and/or whether infection is present at the time of diagnosis.

A rare complication of cholecystolithiasis: perforation of the gallbladder

Common complications of cholelithiasis include gallbladder inflammation, cholangitis, and acute pancreatitis. On the other hand, rare complications include gallbladder carcinoma, gallstone ileus, Mirizzi syndrome and gallbladder perforation. Some patients with cholecystitis do not require hospitalization. It is of key importance for proper further diagnosis and treatment to remember about the possible complications of cholecystitis, especially in oligosymptomatic patients. Therefore, ultrasound examinations in patients with a history of gallbladder stones should be performed with appropriate care. Ultrasound should be performed carefully in patients with a history of cholecystolithiasis, especially those oligosymptomatic, bearing in mind that there are some rare complications of this highly common clinical entity.

Zinc monotherapy for young patients with oligosymptomatic Wilson disease: A single center, retrospective study

Background and aimsFew studies have focused on the treatment failure of zinc monotherapy for oligosymptomatic Wilson disease (WD) patients. Therefore, we aimed to evaluate the long-term efficacy of zinc monotherapy in oligosymptomatic patients and to analyze the possible factors that may influence the outcome of this treatment. MethodsWe retrospectively reviewed the medical records of oligosymptomatic WD patients who received zinc monotherapy from the time of diagnosis. Then, the characteristics of patients who were treated with zinc monotherapy successfully and those who experienced treatment failure were investigated. ResultsForty oligosymptomatic WD patients were identified that have received zinc monotherapy as initial treatment, with a median age of 3.83 years at the time of diagnosis. 36 (90%) patients had abnormal alanine transaminase/aspartate transaminase levels at baseline. None of the patients became symptomatic during zinc monotherapy. 28 (70%, Group 1) patients were treated with zinc monotherapy successfully for a median period of 2.4 years. In Group 1, serum aminotransferase levels significantly decreased 6 and 12 months after zinc therapy compared to the baseline levels (P < 0.05). 12 (30%, Group 2) patients experienced treatment failure with zinc monotherapy due to uncontrolled serum liver enzyme levels, and d-penicillamine was combined. The baseline 24-hour urine copper levels before treatment were significantly higher in Group 2 compared to that in Group 1 (182.5 vs 90.92 μg /day, P = 0.018). Comparing the age at onset; ceruloplasmin, serum copper, ALT, and AST levels; and proportions of abdominal ultrasonography abnormality at baseline between Group 1 and 2 revealed no statistically significant differences. ConclusionsWe found that high initial 24 -h urinary copper levels may lead to treatment failure of zinc monotherapy in oligosymptomatic WD patients. It might be reasonable to follow up liver function tests more closely during zinc monotherapy and to begin combination treatment with chelators early in patients with high level of 24 -h urinary copper.

Cutaneous Manifestations Associated with COVID-19: A Narrative Review

COVID-19 is an infectious disease caused by the new coronavirus, SARS-CoV-2, that has spread rapidly throughout the world. This has resulted in an urgent need to obtain information regarding its pathogenesis, diagnosis and clinical manifestations. More specifically, skin manifestations, seldom reported initially, have been increasingly described. We performed a literature search in the PubMed database, regarding cutaneous manifestations associated with COVID-19. This article describes the clinical and histological findings of the main skin lesions observed in the context of SARS-CoV-2 infection. Cutaneous manifestations associated with COVID-19 have been described in multiple retrospective and prospective studies, case series and case reports. The reported incidence reached 20.4%. Although there was substantial heterogeneity in terms of clinical patterns, the main ones include: erythematous/maculopapular, urticarial, papulovesicular, and purpuric/petechial eruptions, chilblain-like lesions and livedoid/acro-ischemic lesions. In the vast majority, the underlying pathophysiologic mechanisms are not fully understood, although histopathological findings and biomolecular studies can add relevant data. The recognition of cutaneous manifestations associated with COVID-19 is of utmost importance. They may help establishing an early diagnosis, namely in oligosymptomatic patients or when confirmatory tests are impossible to perform. Moreover, chilblain-like lesions and acro-ischemia, also seem to play an important role in terms of prognosis.

SARS-CoV-2 docet.

One year has passed since the Sars-CoV-2 infection diagnosis was made in a patient hospitalized in Codogno unveiling the outbreak of coronavirus in Italy and the start of one of the worst pandemics in history. Today, we know a lot more about Covid-19 infection than we did a year ago. We know that the fight against the spread of the virus, when not correctly done, favours the development of variants of the original covid-19 strain and, we also know that these variants especially the one defined as the "English" variant, has the ability to spread much more and more quickly than the original strain. We know that people, even at lethal risk of complications, are especially old aged, but we also know that those who are oligosymptomatic or asymptomatic patients can spread the infection. Grossi E. et al. report in the following pages the results of a research conducted on pregnant women which shows how the risk of contracting the infection is higher in pregnancy although in an asymptomatic form and that the risk is also transmitted to the unborn child. This data makes the report here provided by Intraccolo U. et al. even more interesting according to which the Italian female population tends to excessively medicalise low-risk pregnancies. [...].