Specific Clinical Presentations Research Articles

A rare case of hemophagocytic lymphohistiocytosis (HLH) secondary to Salmonella infection

HLH (Hemophagocytic lymphohistiocytosis) is a severe hyperinflammatory disease which could be caused by a range of pathogenic organisms, involving Salmonella. This unique case of bacterial-induced HLH tells the story of a 24y/o male who has been admitted to the hospital and is experiencing the severe symptoms of HLH that developed after an enteric fever caused by Salmonella. Despite earlier hospitalization and intravenous antibiotic treatment, he presented with a high temperature, excessive sweating, yellowish staining of urine and eyes, shortness of breath, and significant systemic inflammation. Laboratory studies revealed severe anemia, bicytopenia, and increased markers such as hyperferritinemia and hypertriglyceridemia, resulting in the diagnosis of HLH. The treatment method includes intensive care with intravenous immunoglobulins (IVIG), corticosteroids, and broad-spectrum antibiotics to address both the underlying infection and the inflammatory condition. Despite intense care, his condition was complex and created substantial complications. This instance emphasizes the significance of early detection as well as treatment of HLH, especially when accompanied by bacterial infections, which are not generally thought to produce this strong immunological response. The example emphasizes the requirement to include HLH in the individuals differential diagnosis with severe illness and systemic inflammatory reactions that do not respond to standard treatment. It also emphasizes the necessity of a comprehensive therapeutic approach, customized to the underlying cause and specific clinical presentations of the disease, in improving outcomes in critically sick patients.

Long COVID and lung thromboembolism in young adults

Long-term COVID-19 (Long COVID) and pulmonary thromboembolism (PTE) significantly challenge healthcare, especially in young adults who are typically at lower risk for such severe outcomes. This review explores the complex relationship between long-term COVID and PTE, focusing on the pathophysiological mechanisms, diagnostic challenges, and therapeutic approaches. Persistent inflammation and immune dysregulation associated with long-term COVID-19 contribute to this demographic's increased thrombotic risk. The symptom overlaps between long-term COVID and PTE complicate the accuracy and timeliness of diagnoses, highlighting the necessity for improved diagnostic strategies. Findings emphasize the need for anticoagulation protocols tailored to the specific clinical presentations of Long COVID patients and suggest that extended treatment durations may be beneficial. The potential of genetic and biomarker research to identify individuals at heightened risk of thrombotic complications is discussed. The review calls for a multidisciplinary approach that integrates medical and psychosocial interventions to manage the long-term effects of COVID-19 effectively. As the pandemic evolves, advancing our understanding and adapting healthcare strategies to these insights are crucial for developing effective clinical practices. This is essential for addressing the immediate health impacts and reducing the broader socioeconomic burdens associated with long-term COVID and PTE in young adults.

Data-driven identification of distinct pain drawing patterns and their association with clinical and psychological factors: a study of 21,123 patients with spinal pain.

The variability in pain drawing styles and analysis methods has raised concerns about the reliability of pain drawings as a screening tool for nonpain symptoms. In this study, a data-driven approach to pain drawing analysis has been used to enhance the reliability. The aim was to identify distinct clusters of pain patterns by using latent class analysis (LCA) on 46 predefined anatomical areas of a freehand digital pain drawing. Clusters were described in the clinical domains of activity limitation, pain intensity, and psychological factors. A total of 21,123 individuals were included from 2 subgroups by primary pain complaint (low back pain (LBP) [n = 15,465]) or midback/neck pain (MBPNP) [n = 5658]). Five clusters were identified for the LBP subgroup: LBP and radiating pain (19.9%), radiating pain (25.8%), local LBP (24.8%), LBP and whole leg pain (18.7%), and widespread pain (10.8%). Four clusters were identified for the MBPNP subgroup: MBPNP bilateral posterior (19.9%), MBPNP unilateral posterior + anterior (23.6%), MBPNP unilateral posterior (45.4%), and widespread pain (11.1%). The clusters derived by LCA corresponded to common, specific, and recognizable clinical presentations. Statistically significant differences were found between these clusters in every self-reported health domain. Similarly, for both LBP and MBPNP, pain drawings involving more extensive pain areas were associated with higher activity limitation, more intense pain, and more psychological distress. This study presents a versatile data-driven approach for analyzing pain drawings to assist in managing spinal pain.

Improving outcomes in atherosclerotic renovascular disease: importance of clinical presentation and multi-disciplinary review

Background and objectivesAtherosclerotic renal artery stenosis may cause hypertension, chronic kidney disease and heart failure, but large randomized control trials to date have shown no major additional benefit of renal revascularization over optimal medical management. However, these trials did not consider outcomes specifically in relation to clinical presentations. Given that atherosclerotic renal artery stenosis is a heterogenous condition, measures of success likely differ according to the clinical presentation. Our retrospective study objectives were to determine the effects of revascularization when applied to specific clinical presentations and after careful multi-disciplinary team review.MethodsAll patients presenting to our centre and its referring hospitals with radiological findings of at least one renal artery stenosis > 50% between January 2015 and January 2020 were reviewed at the renovascular multi-disciplinary team meeting with revascularization considered in accordance with international guidelines, notably for patients with anatomically significant renal artery stenosis, adequately sized kidney and presentations with any of; deteriorating kidney function, heart failure syndrome, or uncontrollable hypertension. Optimal medical management was recommended for all patients which included lipid lowering agents, anti-platelets and anti-hypertensives targeting blood pressure ≤ 130/80 mmHg. The effect of revascularization was assessed according to the clinical presentation; blood pressure and number of agents in those with renovascular hypertension, delta glomerular filtration rate in those with ischaemic nephropathy and heart failure re-admissions in those with heart failure syndromes.ResultsDuring this 5-year period, 127 patients with stenosis ≥ 50% were considered by the multidisciplinary team, with 57 undergoing revascularization (17 primarily for severe hypertension, 25 deteriorating kidney function, 6 heart failure syndrome and 9 for very severe anatomical stenosis). Seventy-nine percent of all revascularized patients had a positive outcome specific to their clinical presentation, with 82% of those with severe hypertension improving blood pressure control, 72% with progressive ischaemic nephropathy having attenuated GFR decline, and no further heart failure admissions in those with heart failure. Seventy-eight percent of patients revascularized for high grade stenosis alone had better blood pressure control with 55% also manifesting renal functional benefits.ConclusionsMulti-disciplinary team discussion successfully identified a group of patients more likely to benefit from revascularization based on 3 key factors: clinical presentation, severity of the renal artery lesion and the state of the kidney beyond the stenotic lesion. In this way, a large proportion of patients can clinically improve after revascularization if their outcomes are considered according to the nature of their clinical presentation.Graphical

Current understanding of acute zonal occult outer retinopathy (AZOOR).

Acute Zonal Occult Outer Retinopathy (AZOOR) is characterized by sudden visual impairment, often presenting with scotoma and photopsia in young to middle-aged adults, showing a female predominance. This condition, distinct from genetic disorders like retinitis pigmentosa, lacks a hereditary basis and exhibits unique fundus changes and imaging features indicative of outer retinal dysfunction. Recent advancements have broadened our understanding, identifying variants like Acute Annular Outer Retinopathy (AAOR) and Multizonal outer retinopathy and retinal pigment epitheliopathy (MORR), each with specific clinical presentations and imaging characteristics. The diagnosis of AZOOR and its variants primarily relies on excluding other conditions through comprehensive evaluation, including imaging and serological testing. Treatment approaches, including the use of corticosteroids and immunosuppressives, remain debated, with some evidence suggesting benefits in the early stages. The prognosis of AZOOR varies, with most patients experiencing stabilization, although complications like choroidal neovascularization may occur, requiring targeted therapy. This manuscript elucidates the complexity of AZOOR, emphasizing the necessity of high clinical suspicion and the role of advanced imaging in diagnosis and management.

Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review.

Cytomegalovirus (CMV) is a potential pathogen that causes gastrointestinal (GI) tract diseases regardless of host immunity. In contrast to immunocompromised individuals, immunocompetent patients lack a comprehensive overview of the gastrointestinal manifestations. This study aims to provide a comprehensive summary of the current evidence regarding presentations, diagnostics, management, risk assessment, and outcomes in immunocompetent patients with CMV GI disease. A thorough literature search of English publications up to April 2022 was conducted across electronic databases to identify relevant articles, with eligible case series selected for detailed analysis. The majority of immunocompetent patients affected by CMV GI disease are typically elderly, critically ill, or burdened with comorbidities that compromise immunity. Clinical presentations range from subtle symptoms to severe surgical conditions, including instances of mortality. Specific clinical presentations, blood test results, or endoscopic features are lacking, necessitating reliance on histopathological tests such as immunohistochemistry staining for diagnosis. While antiviral therapy may offer benefits in improving outcomes, careful individual assessment is warranted due to diverse comorbidities and potential side effects. Mortality rates vary considerably based on underlying medical conditions and therapeutic approaches. It is imperative for clinicians to maintain vigilance for CMV GI disease among high-risk groups, despite their baseline immunocompetence, in order to enhance clinical outcomes.

Identification of Novel and Recurrent Variants in BTD, GBE1, AGL and ASL Genes in Families with Metabolic Disorders in Saudi Arabia.

Background and Objectives: Inherited metabolic disorders (IMDs) are a group of genetic disorders characterized by defects in enzymes or transport proteins involved in metabolic processes. These defects result in an abnormal accumulation of metabolites and thus interfere with the body's metabolism. A variety of IMDs exist and differential diagnosis is often challenging. Our objective was to gain insight into the genetic basis of IMDs and the correlations between specific genetic mutations and clinical presentations in patients admitted at various hospitals in the Madinah region of the Kingdom of Saudi Arabia. Material and Methods: Whole exome sequencing (WES) has emerged as a powerful tool for diagnosing IMDs and allows for the identification of disease-causing genetic mutations in individuals suspected of IMDs. This ensures accurate diagnosis and appropriate management. WES was performed in four families with multiple individuals showing clinical presentation of IMDs. Validation of the variants identified through WES was conducted using Sanger sequencing. Furthermore, various computational analyses were employed to uncover the disease gene co-expression and metabolic pathways. Results: Exome variant data analysis revealed missense variants in the BTD (c.1270G > C), ASL (c.1300G > T), GBE1 (c.985T > G) and AGL (c.113C > G) genes. Mutations in these genes are known to cause IMDs. Conclusions: Thus, our data showed that exome sequencing, in conjunction with clinical and biochemical characteristics and pathological hallmarks, could deliver an accurate and high-throughput outcome for the diagnosis and sub-typing of IMDs. Overall, our findings emphasize that the integration of WES with clinical and pathological information has the potential to improve the diagnosis and understanding of IMDs and related disorders, ultimately benefiting patients and the medical community.

Clinical Approach to Myelopathy Diagnosis.

This article describes an integrative strategy to evaluate patients with suspected myelopathy, provides advice on diagnostic approach, and outlines the framework for the etiologic diagnosis of myelopathies. Advances in diagnostic neuroimaging techniques of the spinal cord and improved understanding of the immune pathogenic mechanisms associated with spinal cord disorders have expanded the knowledge of inflammatory and noninflammatory myelopathies. The discovery of biomarkers of disease, such as anti-aquaporin 4 and anti-myelin oligodendrocyte glycoprotein antibodies involved in myelitis and other immune-related mechanisms, the emergence and identification of infectious disorders that target the spinal cord, and better recognition of myelopathies associated with vascular pathologies have expanded our knowledge about the broad clinical spectrum of myelopathies. Myelopathies include a group of inflammatory and noninflammatory disorders of the spinal cord that exhibit a wide variety of motor, sensory, gait, and sensory disturbances and produce major neurologic disability. Both inflammatory and noninflammatory myelopathies comprise a broad spectrum of pathophysiologic mechanisms and etiologic factors that lead to specific clinical features and presentations. Knowledge of the clinical variety of myelopathies and understanding of strategies for the precise diagnosis, identification of etiologic factors, and implementation of therapies can help improve outcomes.

The Application of Large Language Models for Radiologic Decision Making

Background and purposeLarge language models (LLMs) have seen explosive growth, but their potential role in medical applications remains underexplored. Our study investigates the capability of LLMs to predict the most appropriate imaging study for specific clinical presentations in various subspecialty areas in radiology. Methods and materialsChat Generative Pretrained Transformer (ChatGPT), by OpenAI and Glass AI by Glass Health were tested on 1,075 clinical scenarios from 11 ACR expert panels to determine the most appropriate imaging study, benchmarked against the ACR Appropriateness Criteria. Two responses per clinical presentation were generated and averaged for the final clinical presentation score. Clinical presentation scores for each topic area were averaged as its final score. The average of the topic scores within a panel determined the final score of each panel. LLM responses were on a scale of 0 to 3. Partial scores were given for nonspecific answers. Pearson correlation coefficient (R-value) was calculated for each panel to determine a context-specific performance. ResultsGlass AI scored significantly higher than ChatGPT (2.32 ± 0.67 versus 2.08 ± 0.74, P = .002). Both LLMs performed the best in the Polytrauma, Breast, and Vascular panels, and performed the worst in the Neurologic, Musculoskeletal, and Cardiac panels. Glass AI outperformed ChatGPT in 10 of 11 panels, except Obstetrics and Gynecology. Maximum agreement was in the Pediatrics, Neurologic, and Thoracic panels, and the most disagreement occurred in the Vascular, Breast, and Urologic panels. ConclusionLLMs can be used to predict imaging studies, with Glass AI’s superior performance indicating the benefits of extra medical-text training. This supports the potential of LLMs in radiologic decision making.

Early Cholecystectomy in Patients with Sickle Cell Disease with Uncomplicated Cholelithiasis Is Associated with Better Outcomes.

Up to 85% of patients with sickle cell disease (SCD) will develop gallstones by their third decade. Cholecystectomy is the most commonly performed procedure in these patients. Cholecystectomy is recommended for patients with SCD with symptomatic cholelithiasis and leads to lower morbidity. No contemporary large studies have evaluated this recommendation or associated clinical outcomes. This study evaluates clinical outcomes after cholecystectomy in patients with SCD and cholelithiasis with specific advanced clinical presentations. The Nationwide Inpatient Sample was queried for patients with SCD and gallbladder disease between 2006 and 2015. Patients were divided into groups based on their disease presentation, including uncomplicated cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. Clinical outcomes associated with disease presentation were analyzed. Statistical analysis was performed using the Student's t -test, chi-square test, ANOVA, and logistic regression. There were 6,662 patients with SCD who presented with cholelithiasis. Median age was 20 (interquartile range 16 to 34) years and 54% were female patients. Cholecystectomy was performed in 1,779 patients with SCD with the most common indication being chronic cholecystitis (44%), followed by uncomplicated cholelithiasis (27%), acute cholecystitis (21%), and choledocholithiasis or gallstone pancreatitis (8%). On multivariable regression, advanced clinical presentation was the strongest predictor of perioperative vaso-occlusive crisis, which was the most common complication. Patients undergoing cholecystectomy for uncomplicated cholelithiasis were at lower risk than those with acute cholecystitis (odds ratio [OR] 2.37; 95% CI 1.64 to 3.41), chronic cholecystitis (OR 1.74; 95% CI 1.26 to 2.4), and choledocholithiasis or gallstone pancreatitis (OR 2.24; 95% CI 1.41 to 3.57). Seventy-three percent of patients with SCD have advanced clinical presentation at the time of their cholecystectomy. After cholecystectomy, perioperative vaso-occlusive events were significantly increased in patients with advanced clinical presentation. These data support screening abdominal ultrasounds and early cholecystectomy for cholelithiasis in patients with SCD.

Concussion-Related Disruptions to Hub Connectivity in the Default Mode Network Are Related to Symptoms and Cognition.

Concussions present with a myriad of symptomatic and cognitive concerns; however, the relationship between these functional disruptions and the underlying changes in the brain are not yet well understood. Hubs, or brain regions that are connected to many different functional networks, may be specifically disrupted after concussion. Given the implications in concussion research, we quantified hub disruption within the default mode network (DMN) and between the DMN and other brain networks. We collected resting-state functional magnetic resonance imaging data from collegiate student-athletes (n = 44) at three time points: baseline (before beginning their athletic season), acute post-injury (approximately 48h after a diagnosed concussion), and recovery (after starting return-to-play progression, but before returning to contact). We used self-reported symptoms and computerized cognitive assessments collected across similar time points to link these functional connectivity changes to clinical outcomes. Concussion resulted in increased connectivity between regions within the DMN compared with baseline and recovery, and this post-injury connectivity was more positively related to symptoms and more negatively related to visual memory performance compared with baseline and recovery. Further, concussion led to decreased connectivity between DMN hubs and visual network non-hubs relative to baseline and recovery, and this post-injury connectivity was more negatively related to somatic symptoms and more positively related to visual memory performance compared with baseline and recovery. Relationships between functional connectivity, symptoms, and cognition were not significantly different at baseline versus recovery. These results highlight a unique relationship between self-reported symptoms, visual memory performance, and acute functional connectivity changes involving DMN hubs after concussion in athletes. This may provide evidence for a disrupted balance of within- and between-network communication highlighting possible network inefficiencies after concussion. These results aid in our understanding of the pathophysiological disruptions after concussion and inform our understanding of the associations between disruptions in brain connectivity and specific clinical presentations acutely post-injury.

Clinical presentation and diagnosis of pediatric urinary tract infections: A comprehensive study

Background: Urinary tract infections (UTIs) pose a significant health concern for children worldwide, with a prevalence ranging from 2% to 20%. If not promptly diagnosed and treated, these infections can lead to severe complications such as renal scarring, hypertension, and chronic renal failure. Aims and Objectives: This study aims to evaluate the clinical presentation, diagnostic methods, and common bacterial pathogens associated with pediatric UTIs. The focus is on identifying age-specific symptoms and improving diagnostic accuracy to mitigate long-term complications. Materials and Methods: Over 1 year, we conducted a cross-sectional study at MES Medical College in Perinthalmanna, Kerala. Fifty-four children with culture-positive UTIs were included. Clinical data were collected using a semi-structured pro forma, and laboratory tests were performed to identify the causative organisms and their antibiotic susceptibility patterns. Results: Among neonates, fever (100%), jaundice (100%), and vomiting (83.3%) were the most common symptoms. Older children predominantly presented with fever (93.3%), pain or burning during urination (79.63%), and lethargy (53.7%). Escherichia coli was the most frequently identified pathogen, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa. High sensitivity was noted for piperacillin-tazobactam (100%) and amikacin (88.89%). Conclusion: Early and precise diagnosis of pediatric UTIs, based on specific clinical presentations and laboratory tests, is crucial for preventing severe complications. Recognizing common pathogens and their antibiotic sensitivities helps in developing effective treatment guidelines.

Monogenic Hypertension Linked to the Renin-Angiotensin-Aldosterone System.

Mendelian forms of renin-angiotensin-aldosterone system (RAAS)-related hypertension, commonly referred to as monogenic hypertension, represent a rare but significant subset of hypertensive disorders characterized by genetic mutations that disrupt the normal physiological mechanisms of blood pressure regulation. This review focuses on elucidating the germline mutations affecting RAAS pathways that lead to distinct forms of heritable hypertension. By understanding the pathophysiological basis of conditions such as Gordon's syndrome, Liddle syndrome, congenital adrenal hyperplasia, and familial hyperaldosteronism types, this review aims to highlight the unique clinical features, diagnostic challenges, and therapeutic implications associated with these disorders. Recognizing specific clinical presentations and family histories indicative of monogenic hypertension is crucial for diagnosis, particularly as it often manifests as early-onset hypertension, abnormalities in potassium and blood pH, and occasionally, abnormal sexual development or related syndromes. Therefore, employing a targeted diagnostic approach through next-generation sequencing is essential to pinpoint the responsible genetic mutations, enabling accurate and individualized treatment plans. The critical importance of certain readily available specific channel blockers, such as thiazides or low-dose corticosteroids, in managing these disorders must be emphasized, as they play a key role in preventing serious complications, including cerebrovascular events. As advancements in genetic and molecular sciences continue to evolve, a deeper comprehension of the mechanisms underlying RAAS-related monogenic hypertension promises to revolutionize the management of this complex disorder, offering hope for more effective and individualized treatment options.

Ethnogenetic-specific mutations in Alzheimer’s disease: A marker of clinical outcomes

Alzheimer’s disease (AD) presents a substantial global health challenge, with its pathogenesis influenced by a complex interplay of genetic and molecular factors. Approximately 1% of AD cases are attributed to early onset autosomal dominant familial AD (fAD), with genetics contributing to about 70% of overall AD risk. Understanding the genetic basis and molecular mechanisms is paramount for early diagnosis and prognosis improvement. This study explores a previously underexplored area of fAD, examining how different mutations within the same gene, encoding a single protein, may influence the clinical features and progression of fAD subtypes. Our investigation focuses on distinct fAD subtypes — Iranian (T714A), Swedish (KM670/671NL), and Australian (L723P) — and their associated mutations within the C-terminus domain of amyloid precursor protein (APP). Through an extensive analysis of existing literature encompassing clinical severity, pathogenicity, neuropathology, and biological processes, we reveal critical insights into these fAD subtypes. Leveraging bioinformatics tools, we correlate the physicochemical properties of translated mutant proteins with clinical and neuropathological features. Notably, our findings demonstrate that mutations occurring between codons 714 and 717 of the APP gene share a higher similarity, resulting in lower root mean squared deviation scores. These mutations are associated with a broader spectrum of clinical symptoms, including myoclonus and seizures, and an earlier age of onset. Moreover, we observe a direct correlation between the location of genetic mutations on the protein sequence and specific physicochemical properties, clinical presentations, and neuropathological features among fAD subtypes. Mutations with higher structural similarity tend to manifest similar clinical and physical characteristics. While certain neuropathological findings correlate with an increasing epitope toxicity burden, our analysis indicates that epitope toxicity does not significantly impact clinical outcomes. In summary, our study provides novel insights into the heterogeneous nature of fAD subtypes, illuminating the intricate relationship between genetic mutations, physicochemical properties, and clinical manifestations. These findings offer a foundation for further research into tailored therapeutic approaches and personalized medicine for fAD.

Multifaceted analysis of cross-tissue transcriptomes reveals phenotype–endotype associations in atopic dermatitis

Atopic dermatitis (AD) is a skin disease that is heterogeneous both in terms of clinical manifestations and molecular profiles. It is increasingly recognized that AD is a systemic rather than a local disease and should be assessed in the context of whole-body pathophysiology. Here we show, via integrated RNA-sequencing of skin tissue and peripheral blood mononuclear cell (PBMC) samples along with clinical data from 115 AD patients and 14 matched healthy controls, that specific clinical presentations associate with matching differential molecular signatures. We establish a regression model based on transcriptome modules identified in weighted gene co-expression network analysis to extract molecular features associated with detailed clinical phenotypes of AD. The two main, qualitatively differential skin manifestations of AD, erythema and papulation are distinguished by differential immunological signatures. We further apply the regression model to a longitudinal dataset of 30 AD patients for personalized monitoring, highlighting patient heterogeneity in disease trajectories. The longitudinal features of blood tests and PBMC transcriptome modules identify three patient clusters which are aligned with clinical severity and reflect treatment history. Our approach thus serves as a framework for effective clinical investigation to gain a holistic view on the pathophysiology of complex human diseases.

A case presentation on rare case of retroperitoneal liposarcoma

Retroperitoneal liposarcoma is a rare biologically heterogeneous tumor that present considerable challenges due to its size and deep location.as consequences, the majority of the patients with high grade rpls will develop locally recurrent disease following surgery, and this constitutes the cause of death in most patients. Symptoms are usually nonspecific and they do not appear until the tumor becomes very large. Early diagnosis is difficult as there is an absence of specific clinical presentations. A painless abdominal lump that enlarges in a long period of time in an adult is the most common history of patient. Metastasis at initial presentation is uncommon. Surgical exploration is needed for the final pathological diagnosis. Case presentation: we report a case of 56 year old male patient who underwent a complete surgical excision of pleomorphic retroperitoneal liposarcoma. Retroperitoneal liposarcomas are rare soft tissue sarcoma. They often cause minimal or no symptoms and can reach a significant size, growing undetected in retroperitoneal space before invading or compressing surrounding organs, eventually leading to clinical symptoms. Complete surgical excision is the mainstay of treatment. Whenever possible, macroscopically complete resection should be aimed at, often requiring en bloc removal of adjacent structures such as the abdominal wall, psoas, or paravertebral muscles.

Antegrade Crossing Techniques for Hard Proximal Occlusion Caps Without the Use of Dedicated Chronic Total Occlusion Devices: A Pictorial Review.

Infra-inguinal Chronic Total Occlusions recanalisation is considered technically challenging. The conventional manipulation of standard guidewires and catheters has proven to be successful in a considerable percentage of cases but success rate could dramatically drop in presence of challenging lesions. The additional use of retrograde access and re-entry devices could increase technical success but could negatively affect procedural time and overall costs. Twenty different techniques of Chronic Total Occlusions antegrade crossing are hereby described with appropriate schematic representations. The aim is to help operators to apply them in specific anatomy subsets and clinical presentations and ultimately to increase procedural success rate.

Diagnosis and treatment of biliary mucinous cystic neoplasms: A single-center experience

BackgroundBiliary mucinous cystic neoplasms (BMCNs) are rare hepatobiliary cystic tumors, which can be divided into noninvasive and invasive types. This study aimed to investigate the diagnosis, treatment, and prognosis of BMCNs in a large single center. MethodsWe analyzed 49 patients with BMCNs confirmed by postoperative pathology at the First Affiliated Hospital, Zhejiang University School of Medicine between January 2007 and December 2021. ResultsAmong the 49 patients, 37 were female (75.5%), and the average age was 57.04 years. Common symptoms included abdominal discomfort, jaundice and fever, while 22 patients (44.9%) had no symptoms. Serum carbohydrate antigen (CA) 19-9 and CA125 concentrations were elevated in 34.8% and 19.6% of patients, respectively. Forty-eight patients had tumors in the intrahepatic bile ducts and only one had a tumor in the extrahepatic bile duct. Forty-eight patients with noninvasive intrahepatic BMCNs were further analyzed in terms of pathological features: 34 (70.8%) had low-grade intraepithelial neoplasms (LGINs), and 14 (29.2%) had high-grade intraepithelial neoplasms (HGINs). The potential immunohistochemical markers of BMCNs were cytokeratin (CK) 19, CK7, estrogen receptor and progesterone receptor. Follow-up data for 37 patients with intrahepatic BMCNs were obtained. The median overall survival (OS) of BMCNs was not reached. The longest survival time was 137 months.The 5- and 10-year OS rates were 100% and 85.4%, respectively. The 5- and 10-year recurrence-free survival (RFS) rates were 93.9% and 80.2%, respectively. ConclusionsBMCNs are rare cystic neoplasms that commonly occur in middle-aged females. BMCNs can only be diagnosed and classified by postoperative pathology, as there are no specific clinical presentations, serological indicators or imaging modalities for preoperative diagnosis. Complete surgical resection is necessary for BMCNs, and the postoperative prognosis is favorable.

An Updated Review on Atrophic Rhinitis and Empty Nose Syndrome.

Objective: Atrophic rhinitis (AR) is a rare clinical condition affecting the nasal mucosa. It is characterized by progressive nasal congestion and thick, bothersome nasal secretions. In this narrative review, pathogenesis, differences between the 2 types of AR, new management modalities, and the impact of management on lifestyle have been highlighted. Materials and Methods: An extensive literature search was conducted using PubMed, Web of Science, Google Scholar, and Saudi Digital Library databases. The articles were investigated to extract information on the pathogenesis, types, new treatment modalities, and the impact of management on lifestyle. Results: AR has primary and secondary types that affect different populations and have specific clinical presentations. Primary AR is common in women and countries with long, warm seasons. Secondary AR is the most common disease in the industrialized world. It is more common among adults who have systemic disease, have undergone extensive nasal surgery, and have experienced nasal trauma. Certain infections, autoimmune disorders, chronic sinusitis, hormonal imbalance, poor nutritional condition, and iron deficiency anemia have been suggested as etiological factors. Conservative treatment is safe, inexpensive, and effective. Hygiene, a well-balanced diet, smoking cessation, and early detection and treatment of nasal pathology can help prevent AR. Some interventions shown to improve quality of life was explained in detail. Conclusions: This paper reviewed published relevant literature on AR related to pathogenesis, types, new treatment modalities, and the impact of treatment on lifestyle, thus, providing a comprehensive view of the management and prevention of AR.

Use of Large Language Models to Predict Neuroimaging

PurposeLarge language models (LLMs) have demonstrated a level of competency within the medical field. The aim of this study was to explore the ability of LLMs to predict the best neuroradiologic imaging modality given specific clinical presentations. In addition, the authors seek to determine if LLMs can outperform an experienced neuroradiologist in this regard. MethodsChatGPT and Glass AI, a health care–based LLM by Glass Health, were used. ChatGPT was prompted to rank the three best neuroimaging modalities while taking the best responses from Glass AI and the neuroradiologist. The responses were compared with the ACR Appropriateness Criteria for 147 conditions. Clinical scenarios were passed into each LLM twice to account for stochasticity. Each output was scored out of 3 on the basis of the criteria. Partial scores were given for nonspecific answers. ResultsChatGPT and Glass AI scored 1.75 and 1.83, respectively, with no statistically significant difference. The neuroradiologist scored 2.20, significantly outperforming both LLMs. ChatGPT was also found to be the more inconsistent of the two LLMs, with the score difference between both outputs being statistically significant. Additionally, scores between different ranks output by ChatGPT were statistically significant. ConclusionsLLMs perform well in selecting appropriate neuroradiologic imaging procedures when prompted with specific clinical scenarios. ChatGPT performed the same as Glass AI, suggesting that with medical text training, ChatGPT could significantly improve its function in this application. LLMs did not outperform an experienced neuroradiologist, indicating the need for continued improvement in the medical context.