Dyspnea Research Articles

A case of late presentation of recurrent primary choledocholithiasis 30 years post-cholecystectomy: Presentation and management

Acute cholangitis typically occurs secondary to biliary obstruction and bile stasis. While the most common cause is secondary choledocholithiasis (i.e., stones form in the gallbladder and are expelled into the common bile duct), there is little information on primary choledocholithiasis as the principal source of this obstruction. Furthermore, it is particularly rare to see symptomatic choledocholithiasis years to decades later in patients who previously underwent cholecystectomy. We report a complex case of a 75-year-old woman who presented to the emergency department with a 3 to 4-day history of abdominal pain, nausea, generalized weakness, fever, and shortness of breath. She had septic cholangitis due to primary choledocholithiasis 30 years post-cholecystectomy and numerous other comorbidities that increased the complexity of her case. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted to remove the stone but was unsuccessful due to duodenal diverticula. Eventually, this patient underwent common bile duct exploration using a robot-assisted approach. A 2 cm stone at the distal common bile duct was removed, and her clinical status dramatically improved. The efficiency and increased fine control of a robot-assisted approach introduces our idea that this approach should be an alternative management option for minimally invasive common bile duct exploration in patients who have high-risk comorbidities and failed ERCP. Keywords: Acute cholangitis, primary choledocholithiasis, recurrent choledocholithiasis, post-cholecystectomy, robotic-assisted common bile duct exploration

Pulmonary aortic endocarditis in patient with patent ductus arteriosus

Introduction: Right-sided heart endocarditis is uncommon, comprising only 5-10% of all infective endocarditis cases. The infective process may be isolated to pulmonary valve or concomitantly involve other valves. Prompt diagnosis by transthoracic echocardiography, aggressive antibiotics from the beginning, and surgical removal of the vegetation for infective endocarditis help prevent the risk of multiorgan failure and fatal pulmonary embolism. Case summary: A 38-year-old female, the medical history was normal, gave birth naturally at a district hospital 3 months ago. She admitted to the hospital because of fever and continuous shortness of breath 1 month before admission. Echocardiography detected: vegetations (10x23mm) on left pulmonary aortic and patent ductus arteriosus. A CT scan showed a mixed-echo mass in the left pulmonary artery. The patient had surgery to remove the vegetation and close the patent ductus arteriosus. The patient was stable after surgery and discharged 2 weeks after surgery. Conclusion: Pulmonary aortic vegetations and patent ductus arteriosus are rare lesions and high risk of death. The diagnosis should be considered in any febrile, septic patient with congenital heart disease. Surgery removal of vegetations and aggressive antibiotic treatment should be performed together to improve the outcome.

Assesment of factors for late diagnosis of idiopathic pulmonary arterial hypertension in real clinical practice

Idiopathic (primary) pulmonary arterial hypertension – a rare progressive disease that shortens life, usually diagnosed at a late stage. Therefore, it is critical to have a low threshold for suspicion of pulmonary hypertension (PH) and to refer patients to specialized centers for diagnostic evaluation and treatment as early as possible. Echocardiography is the method of choice for pulmonary hypertension assessing. Aim of the study. To determine the reason for the late diagnosis of idiopathic pulmonary arterial hypertension.Material and methods. Using the developed questionnaire, 41 patients, men and women aged 18 years and older, who were reliably diagnosed with idiopathic pulmonary arterial hypertension, were interviewed.Results and discussion. The diagnosis of idiopathic pulmonary arterial hypertension in clinical practice is made on average 7.1±6.0 years from the onset of the first symptoms of the disease. In 95% of cases, the onset of idiopathic pulmonary arterial hypertension begins with shortness of breath on exertion. Most often, the development of the disease was preceded by an acute respiratory viral infection. All patients underwent diagnostic echocardiography at the time of their first visit, but the diagnosis was established in only 56% of patients.Conclusions. Reasons for late diagnosis of idiopathic pulmonary arterial hypertension: the nature of the disease at its onset and errors in diagnosis.

A co-created citizen science project on the short term effects of outdoor residential woodsmoke on the respiratory health of adults in the Netherlands

Background and aimWoodsmoke from household fireplaces contributes significantly to outdoor air pollution in the Netherlands. The current understanding of the respiratory health effects of exposure to smoke from residential wood burning is limited. This study investigated the association between short-term changes in outdoor woodsmoke exposure and lung function, respiratory symptoms, and medication use in adults in the Netherlands.MethodsThis study was co-created with citizen scientists and other relevant stakeholders. A panel study was conducted with repeated observations in 46 adults between February and May 2021 in four Dutch towns. Participants recorded their symptoms and medication use in daily diaries, and conducted morning and evening home spirometry measurements. Woodsmoke exposure was characterized by measuring levoglucosan (most specific marker for woodsmoke exposure), black/brown carbon, fine and ultrafine particulate matter at central monitoring sites. Individual woodsmoke perception (smell) was recorded in daily diaries. Linear and logistic regression models were used to investigate the association between respiratory health and woodsmoke exposure. Models were adjusted for time-varying confounders and accounted for repeated observations within participants.ResultsConsistent positive associations were found between levoglucosan and shortness of breath (SOB) during rest and extra respiratory medication use. Odds ratios for current day exposure to levoglucosan were 1.12 (95% CI: 0.97, 1.30) for SOB during rest and 1.19 (95% CI: 1.07, 1.33) for extra medication use, expressed per interquartile range of levoglucosan concentrations (69.16 ng/m3). Positive non-significant associations were found between levoglucosan and nasal symptoms, cough and waking up with SOB. No consistent association was found between levoglucosan and lung function. Associations found between woodsmoke markers, SOB during rest and extra medication use remained after the inclusion of PM2.5 and UFP in two-pollutant models.ConclusionsAdults experienced more SOB during rest, nasal symptoms and used more medication to treat respiratory symptoms on days with higher levels of outdoor woodsmoke concentrations.

Exploring the effect of peppermint oil massage on pulmonary function in patients with bronchial asthma: insights from a case series

Bronchial asthma (BA) is a chronic inflammatory disorder characterized by airway hyperresponsiveness and obstruction, leading to symptoms such as coughing, wheezing, and shortness of breath. Management typically involves inhaled corticosteroids, but their adverse effects necessitate exploring alternative therapies. Aromatherapy massage, particularly using peppermint oil, may offer therapeutic benefits due to its anti-inflammatory and broncho dilatory properties. This study investigates the impact of upper back massage with peppermint oil on pulmonary function in BA patients. Three female patients with a history of poorly controlled BA participated in this case series. Each patient received a 20-minute upper back massage with peppermint oil daily for 10 days. Pulmonary function tests (PFTs) were conducted before and after the intervention, measuring forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), the FEV1/FVC ratio, peak expiratory flow rate (PEFR), and forced expiratory flow (FEF 25-75%). All patients showed improvement in pulmonary function post-intervention. Case 1: FVC increased from 80% to 97%, FEV1 from 67% to 82%, and PEFR from 72% to 93%. Case 2: FVC improved from 69% to 81%, FEV1 from 64% to 76%, and FEF 25-75% from 40% to 50%. Case 3: FVC rose from 74% to 78%, FEV1 from 55% to 60%, and PEFR from 56% to 63%. Upper back massage using peppermint oil appears to enhance pulmonary function in individuals with bronchial asthma.

The housing environment and its effect on Hispanic children with asthma

IntroductionSubstandard housing in Hispanic minority communities has been associated with detrimental effects on children with asthma that is affected by diverse indoor triggers. Identifying those triggers and offering adequate medical treatment and ways to prevent exposure to triggers will help reduce the number of asthma attacks among children who reside in Hispanic minority communities.ObjectiveOur study aimed to identify the influence of substandard housing quality and its effect on asthma symptoms. Our objectives included assessing the impact of building, flooring types, heating sources, window shading, parental smoking behaviors, moisture and mold in the home, ventilation, and owning a pet on asthma symptom occurrence.Materials and methodsOur study was based on a cross-sectional analytical study involving 353 individuals, their parents, and their homes. Logistic regression modeling was conducted to explain the dependence of each asthma symptom on the investigated independent variables, with child age and sex being investigated as covariables. A post hoc test was employed to ensure goodness of fit, and a pseudo-R square was calculated for each regression model. The Hosmer-Lemenshow test was performed post hoc to ensure goodness of fit, and models were preserved if p > 0.05.ResultsThe overall prevalence of asthma-related symptoms in our study sample was 19.37%, and sleeping quality was affected due to asthma in 23% of participating children. We also found that children living with asthma near agricultural fields were more prone to asthma-related symptoms, as well as those children living in homes with excessive moisture and those who kept stuffed toys or pets inside their rooms.ConclusionsOur study highlights how a variety of environmental factors, such as living near an agricultural area and having curtains, increases shortness of breath. Having leaks and excessive moisture in houses increases shortness of breath, wheezing, coughing, and rates of colds. Another important exposure is having a pet inside the house which increases chest tightness. A comprehensive understanding of these factors and how they impacted targeted participants, especially those who are Hispanic minorities and living in substandard housing, is essential for informing the design of effective interventions and improving respiratory health in the home environment.

Challenges in the diagnostics of mantle cell lymphoma in an elderly comorbid patient

We present a case of a rare lymphoproliferative disease diagnosed while differentiating between the causes of exudative-constrictive pericarditis. An 83-year old man was hospitalized with shortness of breath, edema and newly diagnosed atrial fibrillation (AF). Initially, the signs and symptoms were interpreted as manifestations of heart failure due to old myocardial infarction, arterial hypertension and AF. However, no significant systolic or diastolic dysfunction of the left ventricle and valve disease were identified and natriuretic peptide level was normal. Despite treatment, dyspnea and edema persisted, and pleural effusion (requiring drainage) and pericardial effusion increased. Repeated echocardiography showed signs of exudative-constrictive pericarditis. We consequently excluded the infectious (tuberculosis) and non-infectious (electrolyte disorders, hypothyroidism, solid tumors) etiologies of effusion. Taking into account the long-standing mediastinal lymphadenopathy (the patient had been previously examined, but the cause not identified), anemia, episodes of low-grade fever, weight loss, and polyneuropathy, a lymphoproliferative disease was suspected. Serum protein electrophoresis identified an M spike in the gamma globulin region. Immunophenotyping of peripheral blood lymphocytes and immunohistochemical examination of bone marrow confirmed the diagnosis of mantle cell lymphoma. The patient was referred for specialized treatment. At 5 months of the follow-up, the therapy was successful, the patient was stable with no cardiac complaints, no edema, and no new AF episodes. The case demonstrates the need to strictly follow differential diagnostic algorithms to identify the causes of nonspecific symptoms beyond one medical specialty.

Clinical features and surgical outcomes of membranous subaortic stenosis in three siblings: a case series and literature review

Introduction: Subvalvular aortic stenosis (SAS) is a rare heart condition that can cause LVOT obstruction and lead to serious complications. While surgery is the main treatment, recurrence is a concern. This case series highlights the challenges in managing SAS in young patients. Case Series: Three young brothers presented with symptoms of shortness of breath and chest tightness. All were diagnosed with membranous SAS through echocardiography and Doppler ultrasound. Surgical intervention was performed to remove the obstruction, but all three patients experienced recurrence within two years. Discussion: This case series of three brothers suggests a genetic predisposition. Symptoms included exertional dyspnea and chest tightness, diagnosed via echocardiography. Surgical intervention is the primary treatment, but its timing is debated due to recurrence risks and complications. Conclusions: This case series suggests a possible genetic predisposition to SAS. Despite successful initial surgery, the high recurrence rate highlights the need for improved management strategies and long-term follow-up. Further research is crucial to understand the causes of recurrence and optimize treatment for children with SAS.

Occult Pneumomediastinum - An Atypical Presentation of Chest Discomfort in a Patient with Depression

Pneumomediastinum (mediastinal emphysema) is an uncommon condition characterized by the accumulation of air or gas in the mediastinum. Here is a case of a 16-year-old female known to have depression who presented to the emergency department with complaints of shortness of breath, restlessness, chest discomfort, and hoarseness of voice for 2 days. She was initially diagnosed with panic attack, and later on clinical examination, surgical emphysema over the right supraclavicular area was noticed. Chest X-ray was found to be normal, and further imaging with high-resolution computed tomography (HRCT) of the thorax showed pneumomediastinum. In this report, the clinical presentations, radiological features, and management of pneumomediastinum will be discussed.

Hubungan Kepatuhan Minum Obat dengan Kualitas Hidup Pasien TB Paru di Puskesmas Mustika Jaya Tahun 2023

Pulmonary tuberculosis is caused by a Mycobacterium tuberculosis infection, which attacks the lungs and causes respiratory issues such as chronic cough and shortness of breath. This study aims to analyze the relationship between medication adherence and the quality of life of pulmonary TB patients at Mustika Jaya Public Health Center in 2023. The research design is observational analytic with a cross-sectional approach, using a sample of 78 TB patients selected through purposive sampling. The instruments used include the Morisky Medication Adherence Scale (MMAS-8) for medication adherence and the WHOQOL-BREF questionnaire for quality of life assessment. Chi-square test results showed a significant relationship between medication adherence and quality of life, with a p-value of 0.00. A total of 51.7% of patients who adhered to their medication had a good quality of life. In conclusion, there is a significant positive relationship between medication adherence and quality of life in pulmonary TB patients at Mustika Jaya Health Center in 2023.

Transcatheter aortic valve replacement and the value of increasing treatment for severe symptomatic aortic stenosis: a plain language summary

Plain Language Summary What is this summary about? This article summarizes an economic evaluation of transcatheter aortic valve replacement (TAVR), a treatment for severe symptomatic aortic stenosis (SSAS). SSAS occurs when the aortic valve, which allows blood to leave the heart, becomes very narrow. This reduces blood flow to the body, causing symptoms like tiredness, chest pain, dizziness, or fainting. Treating SSAS requires replacing the valve. Untreated SSAS results in heart failure and death. Before TAVR, SSAS patients had two options, medical management and surgical aortic valve replacement (SAVR). Medical management helps with symptoms but does not replace the valve, leading patients to eventually die from SSAS. SAVR replaces the valve through open-heart surgery, which is invasive, involving making a large cut through the chest bone. Concerns about this invasiveness led many patients to avoid SAVR, leaving their SSAS untreated. TAVR was introduced in 2010. It is less invasive than SAVR, involving inserting a new valve through a small cut in the leg. TAVR has become popular and twice as many patients now undergo TAVR compared to SAVR. We measure TAVR’s net benefits as the value of its health benefits minus its healthcare costs. We measure these net benefits in three patient groups aged 65 and above in the United States. Group 1 patients are ineligible for SAVR, so TAVR is their only treatment option. Group 2 patients would have received SAVR if TAVR were not available. Group 3 patients are eligible for SAVR but concerned about its invasiveness, and so would have stayed untreated without TAVR. Economic evaluation: A type of study that measures the benefits and costs of a treatment like TAVR and judges whether the benefits are sufficiently large to justify the costs (or put another way, whether the technology represents good value-for-money). Transcatheter aortic valve replacement (TAVR): Replacement of the aortic valve in SSAS patients using a thin tube called a catheter that enters the body through a small cut near the leg and delivers and installs a valve replacement. New treatment option for SSAS from 2010 onwards. A minimally invasive treatment. Aortic stenosis (AS): A heart condition where a heart valve called the aortic valve becomes very narrow, forcing the heart to work harder and limiting blood flow to the rest of the body. Severe Symptomatic Aortic Stenosis (SSAS): Severe form of AS when the narrowing of the aortic valve is significant and accompanied by symptoms like fatigue, chest pain, shortness of breath, dizziness, or fainting. What were the key takeaways? Net benefits per patient are significant in all groups, roughly equal in groups 1 and 2, and over six times larger in group 3. When net benefits are added up across patients, group 3’s total net benefit is 30 times larger than that of groups 1 and 2 combined. What are the main conclusions? Past studies ignored TAVR’s value in helping treat patients who might go untreated because of concerns over SAVR’s invasiveness. But this is TAVR’s largest value to SSAS patients. Our findings support continuing and increasing access to TAVR among SSAS patients, especially those who may go untreated because of concerns about invasive treatment. Aortic valve: One of the four heart valves. It connects the left side of the heart with the aorta, which is the large artery carrying oxygen-rich blood to the body. The aortic valve controls blood flow into the aorta, ensuring it moves in one direction. Medical management (MM): Involves medication and monitoring of SSAS patients but no treatment in the form of valve replacement. Associated with high risk of death. Surgical aortic valve replacement (SAVR): Replacement of the aortic valve in SSAS patients through open heart surgery. The sole treatment option for SSAS before 2010. A highly invasive treatment given its use of open-heart surgery. This is an abstract of the Plain Language Summary of Publication article. View the full Plain Language Summary PDF of this article to read the full-text Link to original article here

Validation of 11 added items of the outpatient version of the Utrecht Symptom Diary in patients receiving chemotherapy or targeted therapy

IntroductionThe Utrecht Symptom Diary (USD) is a validated Dutch patient-reported outcome measurement (PROM) tool - based on the Edmonton Symptom Assessment System - to assess and monitor symptoms in cancer patients. The USD contains 11 items concerning frequently occurring symptoms in cancer patients (pain, sleeping problems, dry mouth, dysphagia, lack of appetite, abnormal stool, nausea, shortness of breath, fatigue, anxiety and depressed mood) and an item on overall well-being. For the outpatient USD 11 items concerning frequently occurring signs and symptoms in patients receiving chemotherapy and/or targeted therapy were added to the USD: taste alteration, oral pain, weight loss, diarrhoea, hair changes, skin problems, nail problems, eye problems, tingling, concentration problems and problems with sexuality. This current study aimed to evaluate the 11 added items on this treatment specific outpatient USD in cancer patients receiving intravenous chemotherapy and/or targeted therapy.MethodsObservational longitudinal retrospective cohort study including all adult outpatients with cancer receiving intravenous chemotherapy and/or targeted therapy in an academic hospital in the Netherlands who completed at least one outpatient USD as part of routine care (2012–2021). Relevance, comprehensiveness as well as criterion and construct validity were assessed.Results1733 patients who completed ≥ 1 outpatient USD during intravenous chemotherapy and/or targeted therapy were included for analysis. Relevance as well as comprehensiveness of the items on the outpatient USD in this patient population was shown. Criterion validation was demonstrated for all added items of the outpatient USD – except for the item on oral pain. An additional analysis showed that mouth problems were detected with both outpatient USD items oral pain and dry mouth. Construct validity was demonstrated for the items hair changes and skin and nail problems. Construct validity on eye problems was not tested due to the low number of paired outpatient USDs.ConclusionsThe treatment specific outpatient USD is a validated PROM in outpatients with cancer receiving intravenous chemotherapy and/or targeted therapy. Considering its validity in this broad group of patients, we think the treatment-specific outpatient USD is widely applicable. In addition to providing tailored supportive symptom care, the USD-data can be used to increase knowledge about symptom burden in daily practice in this population.

An Agent-Based "Virtual Clinical Trial" for the Analysis and Evaluation of COPD Patients Cohorts Behavior

Chronic Obstructive Pulmonary Disease (COPD) is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to symptoms such as shortness of breath, coughing, and chest tightness. Treatment typically involves lifestyle adjustments, medication, and pulmonary rehabilitation to improve lung function and quality of life. This study presents a model examining COPD patient behavior within cohort-based strategies, focusing on how environmental factors impact vital signs across the entire cohort. We developed a comprehensive virtual clinical trial model that encompasses study protocol design, participant recruitment, virtual data collection, outcome analysis, and conclusions. This includes remote symptom monitoring, virtual healthcare consultations, treatment adherence assessments, and research data collection. Additionally, we explore the influence of external variables such as environmental conditions, comorbidities, and lifestyle factors on chronic disease symptoms and disease stability. We used an Agent-Based Model(ABM) to incorporate these factors to assess COPD progression and treatment efficacy. Individual agents represent COPD patients, each characterized by attributes such as age, smoking history, lung function, comorbidities, and treatment plans.

Efficacy of High Flow Nasal Cannula in the Treatment of Patients with COVID-19 with Acute Respiratory Distress Syndrome: Results of Single Centre Study in Vietnam.

Most hospitalized patients required invasive or non-invasive ventilation and High Flow Nasal Cannula (HFNC). Therefore, this study was conducted to describe the characteristics of patients with severe Coronavirus Disease-2019 (COVID-19) treated by HFNC and its effectiveness for reducing the rate of intubated-mechanical ventilation in the Intensive Care Unit (ICU) of Phu Chanh COVID-19 Department-Binh Duong General Hospital. It was a cross-sectional and descriptive study. All severe patients with COVID-19 with acute respiratory failure eligible for the study were included. Patient characteristics, clinical symptoms, laboratory results, and treatment methods were collected for analysis; parameters and data related to HFNC treatment and follow-up were analysed. 80 patients, aged of 49.7 ± 16.6years, were treated with HFNC at admission in ICU. 14 patients had type 2 diabetes (17.5%), 3 patients had chronic respiratory disease (3.8%), 19 patients had high blood pressure (23.8%), and 5 patients with other comorbidities (7.4%). The majority of patients with severe COVID-19 had typical symptoms of COVID-19 such as shortness of breath (97.5%), intensive tired (81.3%), cough (73.7%), anosmia (48.3%), ageusia (41.3%), and fever (26.3%). The results of arterial blood gases demonstrated severe hypoxia under optimal conventional oxygen therapy (PaO2 = 52.5 ± 17.4mmHg). Respiratory rate, SpO2, PaO2 were significantly improved after using HFNC at 1st day, 3rd day and 7th day (P < 0.05; P < 0.05; P < 0.01; respectively). Receiver operating characteristics (ROC) index was significantly increased after treating with HFNC vs before HFNC treatment (4.79 ± 1.86, 5.53 ± 2.39, and 7.41 ± 4.24 vs 2.97 ± 0.39; P < 0.05, P < 0.05 and P < 0.01, respectively). 54 (67.5%) patients were success with HFNC treatment and 26 (32.5%) patients with HFNC failure needed to treat with Continuous Positive Airway Pressure (CPAP) (13 patients; 50%) or intubated ventilation (13 patients; 50%). HFNC therapy could be considered as a useful and effective alternative treatment for patients with acute respiratory failure. HFNC might help to delay the intubated ventilation for patients with respiratory failure and to minimise the risk of invasive ventilation complications and mortality. However, it is crucial to closely monitor the evolution of patient's respiratory status and responsiveness of HFNC treatment to avoid unintended delay of intubation-mechanical ventilation. An independent ethics committee approved the study (The Ethics Committee of Binh Duong General Hospital; No. HDDD-BVDK BINH DUONG 9.2021), which was performed in accordance with the Declaration of Helsinki, Guidelines for Good Clinical Practice.

Using a Patient-Reported Outcome Measure to Assess Physical, Psychosocial, and Existential Issues in COPD.

Background: Chronic obstructive pulmonary disease (COPD) is marked by severe physical symptoms, impaired quality of life, and high psychological distress. Despite its impact, the identification of not only physical but also psychosocial and existential issues in the clinic lags behind that of other patient groups. Methods: This study aimed to assess physical, psychosocial, and existential issues among patients with COPD using a patient-reported outcome measure for general palliative care (the 'PRO-Pall') in a Danish outpatient clinic. We included 115 adults with COPD who completed the PRO-Pall either electronically or in the clinic. Sociodemographic and illness-related data were retrieved from their electronic health records. Results: We found that shortness of breath, tiredness, and difficulty walking were predominant physical issues. Worry about change in social roles was the most frequently reported psychosocial issue, while existential issues were reported by approximately one in ten patients. Most patients (44.5%) felt able to share their feelings with family or friends, and a majority (62.2%) felt their illness-related issues were addressed satisfactorily. Females expressed a greater need for rest and males more frequently reported intimacy issues. Higher COPD-impact on life measured by the COPD Assessment Test was associated with lower ratings on the quality-of-life item of the PRO-Pall independent of age, gender, lung function, and smoking status. Conclusions: Patients reported issues in physical, psychosocial, and existential dimensions of the PRO-Pall. The PRO-Pall shows potential as a broader alternative to measures that focus mainly on physical issues.

Dynamics of the functional state of the cardiovascular system in individuals after cholecystectomy under the influence of a rehabilitation program in sanatorium-resort conditions.

The article discusses the dynamics of the functional state of the cardiovascular system (CVS) in individuals after laparoscopic cholecystectomy (LCС) under the influence of a rehabilitation program in SANATORIUM-RESORT CONDITIONS. The study involved 79 individuals after LCC aged 45 to 59 years. The individuals were divided into 2 groups: group A (n=39) and group B (n=40). Individuals in group A received rehabilitation services according to the clinical protocol (diet, hydrotherapy, mineral or coniferous baths, and physical therapy, etc.) In group B, individual rehabilitation programs were formed depending on the existing dysfunctions and the tolerance of the CVS to physical activity. In group B, the rehabilitation intervention to increase the function of endurance and physical performance was applied Nordic walking (NW). The initial examination in both groups revealed an increase in resting heart rate (RHR), diastolic (DBP) and systolic (SBP) blood pressure, a decrease in the performance of a 6- minute walk test and the presence of a feeling of shortness of breath during the test. The implementation of a physical rehabilitation (physical therapy) program in group B, which used Nordic walking to increase physical activity, tolerance to physical activity, and improve cardiovascular function, was effective. The use of NW in sanatorium-resort conditions of rehabilitation (lasting at least 18 days) has a positive effect and leads to a statistically significant decrease in RHR, SBP, DBP, an increase in walking distance in 6 minutes and a decrease in the feeling of shortness of breath when walking, compared to the control group. It was established that diet therapy, hydrotherapy, mineral or coniferous baths, and other water procedures, classical abdominal and back massage, group daily therapeutic gymnastics in group A did not have a positive effect on increasing the level of physical activity tolerance, CVS functioning in patients after LCC.

A-9-Years-Old Female with Diabetes Mellitus Type 1 with Hyperthyroidism

Diabetes Mellitus Type 1 (DMT1) and thyroid disease can occur together, which is defined as a variant of autoimmune polyglandular syndrome type 3. It is known that the action of insulin and thyroid hormones affect cellular metabolism, thyroid hormones contribute to carbohydrate metabolism and pancreatic function. Since the thyroid gland plays a central role in the regulation of metabolism, abnormal thyroid function can have a major impact on the control of diabetes and poor glycemic control can cause alterations in thyroid hormone. A female, 9 years old, with decreased consciousness. Previous medical history, polyuria, increased appetite, and drastic weight loss. She also complained of sweating even in a cold room and was often emotional. On physical examination, there was fever, shortness of breath, tachycardia, and a soft and diffused slightly enlarged thyroid gland, with no bruit on auscultation. Laboratory tests showed blood glucose levels at 739 mg/dL, HbA1c 9.2%, C-peptide 0.2 ng/mL, TSH levels 0.01 µIU/mL, FT4 levels 2.77 ng/dL, the presence of metabolic acidosis, proteinuria, glucosuria, and ketonuria. Thyroid dysfunction will have a negative effect on DM control while poor glucose control will harm the work of thyroid hormones. Improvement in glycemic control and routine insulin injection with the right dose will reduce the risk of diabetic vascular and metabolic complications onset and progression.

Unusual Presentation of Tuberculosis in the Lungs and Lymph Nodes

Abstract Introduction/Objective Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis mainly affecting the lungs. Despite treatment advancements, TB remains a major cause of morbidity. This report presents a patient with active pulmonary and lymph node TB. Methods/Case Report The patient is a 41-year-old male from Bangladesh admitted for worsening cough and shortness of breath. Earlier, he had a cough and right cervical lymphadenopathy with lymph node biopsy demonstrating noncaseating granuloma and a positive Quantiferon-Gold. Outpatient workup included negative sputum TB PCR with negative cultures. The patient was febrile, tachycardic, and oxygenating normally. D-dimer was 1484. CT angiography was negative for emboli and showed mediastinal and right hilar lymphadenopathy. Imaging was otherwise non-indicative of active TB. We started rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy with bronchoalveolar lavage for additional sputum sampling and excisional lymph node biopsy to rule out malignancy. Workup for autoimmune disease and sarcoidosis was negative. An acid-fast bacilli stain of the biopsy was positive, indicating active TB. The patient was discharged on RIPE with outpatient follow-up. Results (if a Case Study enter NA) NA Conclusion Histological findings of TB demonstrate caseating granulomatous lesions. Sarcoidosis can be considered in patients with hilar or mediastinal lymphadenopathy with noncaseating granulomatous lesions. However, both active and inactive TB should be considered in the differential diagnosis with biopsy results indicating noncaseating granuloma, as infected tissues can lack the central necrosis to produce caseation. Common chest radiographic findings in TB include pulmonary consolidation, hilar and mediastinal lymphadenopathy, disseminated miliary disease, and a normal chest radiograph. Our patient had just hilar and mediastinal lymphadenopathy. While a common finding in tuberculosis, this is also present in other inflammatory pathologies, emphasizing the importance of keeping a broad differential even in settings where initial biopsy and imaging results may indicate latent infection or other diagnoses. We utilized the expertise of pathologists to identify lymph nodes with active TB infection in a patient who previously had inconsistent pathological and radiological findings. Without the help of the pathologists in this case, diagnosing and treating this patient would not have been possible, showing the necessity of histopathological correlation with clinical and radiologic findings.

Disseminated Toxoplasma Gondii Infection in a Deceased Donor Kidney Transplant Recipient: A Fatal Case Report

Abstract Introduction/Objective Post-transplant immunosuppression predisposes patients to severe complications from opportunistic infections, including Toxoplasma gondii. Typically asymptomatic and self-limited in immunocompetent individuals, Toxoplasma gondii can cause life-threatening disseminated disease in immunocompromised patients like solid organ transplant recipients. The challenge in diagnosing Toxoplasmosis is further exacerbated in patients receiving prophylactic therapy with agents such as Atovaquone, which may mask clinical suspicion. This case report describes a fatal presentation of disseminated Toxoplasmosis in a kidney transplant recipient. Methods/Case Report A 44-year-old male with a history of deceased donor kidney transplant presented to the emergency department two months post-transplant with symptoms of malaise, shortness of breath, hypoxemia, and hypotension. Despite medical interventions, the patient deteriorated rapidly, developing acute hypoxemic respiratory failure and septic shock requiring intubation. Subsequently, he succumbed to multisystem organ failure five days after admission. The autopsy revealed disseminated Toxoplasma gondii infection, with tachyzoites/bradyzoites identified in multiple organs, including the brain, bone marrow, and lymph nodes. Positive Toxoplasma immunohistochemical staining and PCR confirmed the diagnosis. Results (if a Case Study enter NA) NA Conclusion Toxoplasma infection in post-transplant patients can manifest as a severe and potentially fatal complication. Dissemination can arise from the reactivation of latent infection, donor transmission, or new acquisition. In this case, the infection likely resulted from the reactivation of latent infection in the donor, compounded by immunosuppression in the recipient. Notably, the patient received Atovaquone prophylaxis due to a sulfa allergy. Nonetheless, the case highlights the potential for delayed diagnosis due to atypical presentations in immunocompromised patients. Clinicians should maintain a high index of suspicion for Toxoplasma infection in post- transplant patients, particularly in those with unexplained clinical deterioration. This case emphasizes the importance of maintaining a high index of suspicion for T. gondii infection in post-transplant patients, even in those receiving prophylaxis.

Mediastinal Teratoma with Angiosarcomatous Overgrowth in a Background of Vasculogenic Mesenchymal Tumor

Abstract Introduction/Objective Vasculogenic mesenchymal tumor refers to neoplastic reiteration of embryonic vasculogenesis. It is most commonly associated with nonseminomatous germ cell tumors of the mediastinum, in particular yolk sac tumor. In rare instances these lesions progress to angiosarcoma. Herein, we describe a case of angiosarcoma in a background of vasculogenic mesenchymal tumor in the setting of a mediastinal teratoma. Methods/Case Report A 33-year-old male, with a past medical history of anxiety, and right orchiectomy for testicular torsion, presented with shortness of breath, chest pain, and left arm swelling. Imaging studies demonstrated a mediastinal mass. Biopsy of the mass showed a germ cell tumor most compatible with a teratoma in the limited specimen. The patient received two rounds of chemotherapy and additional treatments were discontinued due to poor tolerance. Subsequent imaging showed continued increase in the size along with mass effect causing moderate to severe compression of the superior vena cava. Subsequently, the patient underwent resection of the mass. Grossly the mass was predominantly encapsulated with areas of capsular disruption. Sectioning revealed heterogeneous cut surfaces with fleshy, cystic, and necrotic areas. Morphologically the tumor was composed predominantly of teratomatous elements with areas of anastomosing atypical vascular channels within a hypocellular stroma suggestive of vascular genic mesenchymal as well as areas reminiscent of Masson lesion. Focally within these areas were malignant spindle cell proliferations compatible with angiosarcoma. The patient had an elevated AFP; however, no yolk sac tumor component was identified after thorough sampling. Final diagnosis of teratoma with angiosarcoma in a background of vasculogenic mesenchymal tumor was rendered after expert consultation. Results (if a Case Study enter NA) NA Conclusion Somatic-type malignancy and sarcomatous overgrowth are known to occur in mediastinal germ cell tumors; however, classification of the sarcomatous overgrowth can be challenging. Vasculogenic mesenchymal tumor is an exceedingly rare sarcomatous overgrowth that can rarely progress to angiosarcoma.