Subacute Symptoms Research Articles

Metabolomics Approach to Identify Biomarkers of Acute and Subacute Mastitis in Milk Samples: A Pilot Case-Control Study.

Background and aims: Mastitis is one of the main complications during breastfeeding and contributes to the cessation of breastfeeding. However, the etiopathogenesis and diagnosis of mastitis are complex and not yet well defined. We aimed to identify metabolic and lipidic changes in human milk during acute and subacute mastitis in order to detect potential biomarkers of mastitis. Methods: We conducted a pilot case-control study including 14 breastfeeding women with acute mastitis, 32 with subacute mastitis symptoms, and 19 without any mastitis symptoms (control). Milk samples were collected and analyzed by proton nuclear magnetic resonance (H-NMR) for metabolomics analysis. To assess the association between the significant metabolites and lipids and the development of acute and subacute mastitis, multi-adjusted logistic regression models were developed. Results: The NMR-based metabolomics approach was able to identify and quantify a total of 40 metabolites in breast milk samples. After adjusting for confounding variables, acute mastitis was significantly associated with acetate (OR 3.9 IC 1.4-10.8), total cholesterol (OR 14 CI 3.2-62), esterified cholesterol (OR 3.3 CI 1.9-5.8), and sphingomyelin (OR 2.6 CI 1.2-5.8). The other metabolites presented weak association (OR < 2.5). Subacute mastitis was significantly associated with glutamine, lysophosphatidylcholine, phosphatidylcholine, plasmalogen, and total polyunsaturated fatty acids, but only cholesterol showed a strong association (OR > 2.5) with an OR of 2.6 (IC 1.1-6.6). Conclusions: Metabolic alteration in breast milk occurs during a process of both acute and subacute mastitis. Acetate, esterified cholesterol, lysophostidylcholine, and polyunsaturated fatty acids increased in both acute and subacute mastitis. However, according to the multi-adjusted regression logistic models, the candidate biomarkers for acute and subacute mastitis are cholesterol, lysophosphatidylcoholine, phosphatidylcholine, plasmalogen, and polyunsaturated fatty acids.

Robotic Sigmoidectomy for Diverticular Disease.

Introduction: Historically, colon resection was recommended after one episode of complicated diverticulitis. However, current trends favor a more individualized approach. This review examines elective sigmoidectomy for complicated diverticulitis as well as robotic approaches for diverticular disease. Methods: The literature was reviewed for timely (post 2000) and relevant articles regarding robotics and diverticulitis. The articles included large prospective series, retrospective analysis, meta-analyses and randomized controlled trials. Results: Primary anastomosis with or without protective ileostomy has emerged as an alternative to the Hartman's procedure in emergent or urgent surgery in patients without significant comorbidities. Elective sigmoidectomy after an episode of complicated diverticulitis should be decided on a case-by-case basis considering patient characteristics, continued subacute symptoms, complications from the disease, and chance of recurrence episodes. Conclusions: There are several variations techniques for robotic sigmoidectomy outlined in this article, and familiarity with all can help depending on the logistics of the case. Minimally invasive colectomy provides superior patient satisfaction and outcomes.

An unusual case of small-bowel obstruction: Broad ligament hernia.

Broad ligament hernias (BLHs) are rare internal hernias that can lead to serious complications if left untreated. In this case report, we present the case of a BLH in a female patient and discuss its clinical presentation, diagnosis and management. A 40-year-old woman presented with subacute intestinal obstruction symptoms, including the inability to pass flatus and faeces and recurrent bilious vomiting. A computed tomography (CT) scan confirmed small-bowel obstruction adjacent to the uterus within the left broad ligament. Diagnostic laparoscopy revealed a loop of obstructed small intestine within the broad ligament, which was released and found to be healthy. The defect between the broad and infundibulopelvic ligaments was closed with sutures. The patient had an uneventful recovery and was asymptomatic at a 6-month follow-up. BLHs can be congenital or acquired, with acquired defects often resulting from previous surgeries or pregnancy-related causes. The clinical presentation typically involves the symptoms of bowel obstruction, and a CT scan is the diagnostic modality of choice, showing characteristic findings such as closed-loop obstruction and bowel dilation. Laparoscopic management offers the advantages of faster recovery and less morbidity. Closure of the defect using nonabsorbable sutures is the standard surgical approach, although a wide opening of the defect has also been described. Recurrence is a possibility, particularly if absorbable sutures are used for closure. This case report highlights the importance of early diagnosis and intervention in BLHs to prevent the complications and emphasises the role of laparoscopy in their management.

Pre-injury psychiatric history, subacute symptoms and personality traits predict social reintegration at 3-month post-mild traumatic brain injury

ABSTRACT Background The purpose of the study was to identify whether the presence of a pre-injury psychiatric history, subacute post-concussive symptoms (PCS) and personality traits were predictive of less favorable social reintegration for 3 months following a mild traumatic brain injury (mTBI). Method A total of 76 patients with mTBI were included, and the presence of a pre-injury psychiatric history was identified from the medical chart. One-month post-accident, these patients completed the Millon Multiaxial Clinical Inventory, 3rd Edition assessing personality traits and the Rivermead Post-Concussion Symptoms Questionnaire to measure subacute PCS. Social reintegration was measured using the Mayo-Portland Adaptability Inventory, 4th Edition at 3-month post-accident. Results The presence of pre-injury psychiatric history, high levels of subacute PCS and Cluster B personality traits such as histrionic and borderline features were significant predictors of social reintegration quality at 3-month post injury. Conclusion This study provides new insights on cluster B personality traits and its influence on recovery and social reintegration at 3-month post mTBI.

589 Survivorship After Radical Gastrectomy with Adjuvant Chemoradiotherapy for Locally Advanced Gastric and Junctional Adenocarcinoma

Abstract Introduction In the US Intergroup-0116 trial adjuvant chemoradiotherapy (aCRT) significantly improved overall survival (OS) compared with surgery alone for locally advanced gastric adenocarcinoma. Subsequently, the CRITICS and ARTIST-2 trials demonstrated no additional benefit to aCRT compared with chemotherapy alone. The aim of this study was to evaluate long-term outcomes in survivorship among patients previously treated with radical D2 gastrectomy and aCRT (MacDonald Regimen). Method Consecutive patients who underwent aCRT following radical D2 gastrectomy between 2002-2018 were identified from a prospectively maintained database. Among patients without evidence of recurrence at 1 year postoperatively, long-term radiotherapy complications were coded using the framework of the Common Toxicity Criteria for Adverse Events (CTCAE) V5, and use of nutritional adjuncts and micronutrient supplementation recorded. Results Some 49 patients were included (pT3-4, 88%; pN2-3, 61%; diffuse type, 45%). Median, 1-, 3- and 5-year OS were 29.8 months, 90%, 45% and 41%. Late effects data were available for 18 patients. Gastrointestinal late effects were evident in 81% (most commonly dysphagia, subacute obstructive symptoms, food intolerance and diarrhoea). Small bowel obstruction occurred in 2 patients, small intestinal bacterial overgrowth in 2 patients and pancreatic exocrine insufficiency in 2 patients. 3 patients required long-term oral nutritional supplementation, and 2 required home enteral nutrition. Conclusions Despite adverse pathological features, long-term survival was achieved in a significant proportion of patients. However, these data highlight that adjuvant chemoradiotherapy following radical gastrectomy with D2 lymphadenectomy may be associated with considerable late effects in survivorship, and management within specialist multidisciplinary teams is advocated.

De novo variants in immune regulatory genes in Down syndrome regression disorder

BackgroundDown Syndrome Regression Disorder (DSRD) is a rare and poorly understood disorder of the central nervous system, characterized by acute or subacute neuropsychiatric symptoms in previously healthy individuals with Down syndrome (DS). Many patients exhibit immunotherapy-responsiveness, indicative of immune dysregulation as a potential underlying etiology. While hypotheses are emerging regarding the role of interferon signaling in DSRD and other autoimmune conditions associated with DS, it is unclear why a small subset of individuals with DS develop DSRD. The aim of this study was to investigate genes of immune regulation in persons with DSRD.MethodsThis study included individuals with DSRD aged 10–30 years with trio exome sequencing performed during the diagnostic work up. Descriptive statistics and univariate analysis (Chi-square and Fisher’s exact test) were used to describe and compare the characteristics of individuals with and without variants.ResultsForty-one individuals with DSRD had trio exome sequencing results. Eight (20%) had heterozygous de novo variants of immune regulatory genes, with four variants being pathogenic or likely pathogenic (UNC13D, XIAP, RNASEH2A, and DNASE1L3). All genes harboring pathogenic variants were associated with interferon type-1 inflammatory response. Individuals harboring variants were more likely to have a preceding trigger (p = 0.03, 95% CI 1.21–97.06), rapid clinical decline in less than 1 month (p = 0.01, 95% CI 1.67–52.06), and MRI abnormalities (p < 0.001, 95% CI 4.89–527.71).DiscussionA distinct subset of individuals with DSRD exhibited pathogenic variants in immune regulation genes associated with interferon-mediated inflammatory response, coinciding with previously established links between these genes and interferonopathies such as Aicardi-Goutieres syndrome. Our observations suggest that these variants might potentially contribute to the development of DSRD in individuals with DS.

Silent Danger: Uncovering Greater Omental Internal Herniation

Background: Internal hernias, though infrequent, are significant causes of intestinal obstruction, contributing to 0.2 to 4% of cases. Greater omental hernias, even rarer at 8%, predominantly affect older individuals, where senile atrophy often leads to omental defects. Objective: This study aims to highlight the importance of considering internal hernias in the differential diagnosis for intestinal obstruction, particularly in patients without prior abdominal interventions or trauma. Methods: We review a case of a 75-year-old female presenting with symptoms indicative of internal herniation, including the absence of significant historical abdominal insults. Diagnostic strategies involved physical examinations, imaging via X-ray and CT scans, and eventual surgical intervention. Results: The patient's initial presentation involved subacute obstruction symptoms, progressing to complete obstruction on the second day of admission. Imaging failed to reveal a definitive transition point, but suggested small bowel obstruction. Surgical findings confirmed an intact herniated bowel loop, successfully treated without complications. Conclusion: Internal hernias should be suspected in patients with intestinal obstruction symptoms, even in the absence of typical predisposing factors. Prompt recognition and treatment are crucial to prevent severe outcomes such as strangulation and necrosis.

The injection of Ghrelin (OXE-103) improves subacute concussion symptom burden and quality of life

The injection of Ghrelin (OXE-103) improves subacute concussion symptom burden and quality of life

Meant to Be

We describe an elderly patient who presented with progressively worsening weakness, significant subacute constitutional symptoms associated with pulmonary nodules and lymphadenopathy.

MRNA-LNP COVID-19 Vaccine Lipids Induce Complement Activation and Production of Proinflammatory Cytokines: Mechanisms, Effects of Complement Inhibitors, and Relevance to Adverse Reactions.

A small fraction of people vaccinated with mRNA-lipid nanoparticle (mRNA-LNP)-based COVID-19 vaccines display acute or subacute inflammatory symptoms whose mechanism has not been clarified to date. To better understand the molecular mechanism of these adverse events (AEs), here, we analyzed in vitro the vaccine-induced induction and interrelations of the following two major inflammatory processes: complement (C) activation and release of proinflammatory cytokines. Incubation of Pfizer-BioNTech's Comirnaty and Moderna's Spikevax with 75% human serum led to significant increases in C5a, sC5b-9, and Bb but not C4d, indicating C activation mainly via the alternative pathway. Control PEGylated liposomes (Doxebo) also induced C activation, but, on a weight basis, it was ~5 times less effective than that of Comirnaty. Viral or synthetic naked mRNAs had no C-activating effects. In peripheral blood mononuclear cell (PBMC) cultures supplemented with 20% autologous serum, besides C activation, Comirnaty induced the secretion of proinflammatory cytokines in the following order: IL-1α < IFN-γ < IL-1β < TNF-α < IL-6 < IL-8. Heat-inactivation of C in serum prevented a rise in IL-1α, IL-1β, and TNF-α, suggesting C-dependence of these cytokines' induction, although the C5 blocker Soliris and C1 inhibitor Berinert, which effectively inhibited C activation in both systems, did not suppress the release of any cytokines. These findings suggest that the inflammatory AEs of mRNA-LNP vaccines are due, at least in part, to stimulation of both arms of the innate immune system, whereupon C activation may be causally involved in the induction of some, but not all, inflammatory cytokines. Thus, the pharmacological attenuation of inflammatory AEs may not be achieved via monotherapy with the tested C inhibitors; efficacy may require combination therapy with different C inhibitors and/or other anti-inflammatory agents.

Corticosteroid treatment for acute hydrocephalus in neurosarcoidosis: a case report

BackgroundNeurosarcoidosis occurs symptomatically in 5–10% of patients with sarcoidosis, and hydrocephalus is a rare complication of neurosarcoidosis, with either acute or subacute onset and presenting symptoms related to increased intracranial pressure. It represents a potentially fatal manifestation with a mortality rate of 22% (increased to 75% in case of coexistence of seizures) that requires a prompt initiation of treatment. High-dose intravenous corticosteroid treatment and neurosurgical treatment must be considered in all cases of neurosarcoidosis hydrocephalus.Case presentationHere we present a case of hydrocephalus in neurosarcoidosis, complicated by generalized seizures, in a 29-year-old Caucasian male patient treated with medical treatment only, with optimal response.ConclusionSince neurosurgery treatment can lead to severe complications, this case report underlines the possibility to undergo only medical treatment in selected cases. Further studies are needed to stratify patients and better identify those eligible for only medical approach.

The Added Value of Bronchoalveolar Lavage for Pulmonary Tuberculosis Diagnosis in High-Risk Hospitalized Patients with Negative Sputum Samples.

Hospitalized patients with a high suspicion of pulmonary tuberculosis (HS-PTB) are isolated until a definite diagnosis can be determined. If doubt remains after negative sputum samples, bronchoscopy with bronchoalveolar lavage (BAL) is often sought. Still, evidence of the added value of BAL in this patient population is scarce. To address this issue, we included consecutive HS-PTB patients with negative sputum samples who underwent BAL between 2017 and 2018. Chest X-rays (CXR) and CT scans were evaluated by a chest radiologist blind to the final diagnosis. Independent predictors for PTB were assessed by multivariate regression, using all positive PTB patients between 2017 and 2019 (by sputum or BAL) as a control group (n = 41). Overall, 42 HS-PTB patients were included (mean age 51 ± 9, 36% female). BAL was a viable diagnostic for PTB in three (7%) cases and for other clinically relevant pathogens in six (14%). Independent predictors for PTB were ≥2 sub-acute symptoms (adjusted OR 3.18, 95% CI 1.04-9.8), CXR upper-lobe consolidation (AOR 8.70, 95% CI 2.5-29), and centrilobular nodules in chest CT (AOR 3.96, 95% CI 1.20-13.0, p = 0.02). In conclusion, bronchoscopy with BAL in hospitalized patients with HS-PTB had a 7% added diagnostic value after negative sputum samples. Our findings highlight specific predictors for PTB diagnosis that could be used in future controlled studies to personalize the diagnostic evaluation.

Network analysis and relationship of symptom factors to functional outcomes and quality of life following mild traumatic brain injury: a TRACK-TBI study.

Mild traumatic brain injury (mTBI) is a heterogenous injury which can be difficult to characterize and manage. Using cross-sectional network analysis (NA) to conceptualize mTBI symptoms offers an innovative solution to identify how mTBI symptoms relate to each other. The centrality hypothesis of network theory posits that certain symptoms in a network are more relevant (central) or have above average influence over the rest of the network. However, no studies have used NA to characterize the interrelationships between symptoms in a cohort of patients who presented with mTBI to a U.S. Level 1 trauma center emergency department and how subacute central symptoms relate to long-term outcomes. Patients with mTBI (Glasgow Coma Scale = 13-15) evaluated across 18 U.S. Level 1 trauma centers from 2013 to 2019 completed the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at 2 weeks (W2) post-injury (n = 1,593) and at 3 months (M3), 6 months (M6), and 12 months (M12) post-injury. Network maps were developed from RPQ subscale scores at each timepoint. RPQ scores at W2 were associated with M6 and M12 functional and quality of life outcomes. Network structure did not differ across timepoints, indicating no difference in symptoms/factors influence on the overall symptom network across time. The cognitive factor had the highest expected influence at W2 (1.761), M3 (1.245), and M6 (1.349). Fatigue had the highest expected influence at M12 (1.275). The emotional factor was the only other node with expected influence >1 at any timepoint, indicating disproportionate influence of emotional symptoms on overall symptom burden (M3 = 1.011; M6 = 1.076). Several symptom factors at 2-weeks post-injury were more strongly associated with incomplete recovery and/or poorer injury-related quality of life at 6 and 12 months post-injury than previously validated demographic and clinical covariates. The network analysis suggests that emotional, cognitive, and fatigue symptoms may be useful treatment targets in this population due to high centrality and activating potential of the overall symptom network.

Abstract 107: Endovascular Therapy for Tandem Vertebral and Basilar Artery Occlusion in a Patient with Low NIHSS

Introduction Basilar artery occlusion (BAO) is a devastating minority stroke subtype with variable clinical presentations and high mortality.1,2 The National Institute of Health Stroke Scale (NIHSS) cutoff for poor outcomes is lower in BAO compared to anterior circulation large vessel occlusions (LVO) due to the scale’s weighted scoring towards cortical signs.3,4 To bridge this gap, Alemseged et.al created the underutilized posterior circulation (PC) NIHSS as an improved stroke assessment tool in PC LVO to better identify endovascular therapy (EVT) candidates. 5 Current randomized trials point to mixed evidence regarding EVT for BAO; although recent studies such as Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION)6 and Basilar Artery Occlusion Chinese Endovascular Trial (BAOCHE)7 suggest positive results of EVT within 24hrs. Smaller retrospective subgroup analyses demonstrated EVT for BAO with low NIHSS has good clinical outcome of modified Rankin Scale (mRS) 0‐2 at 3 months in 60‐70% of patients4,8. We present a case of tandem vertebrobasilar artery occlusion in a patient with subacute symptoms and low NIHSS treated with mechanical thrombectomy. Methods '‐ Results 41‐year‐old male with past medical history of hypertension, insulin dependent diabetes and active smoking presented with worsening vertigo, nausea and vomiting for 3 weeks with progression to right sided headache and syncope. EMS noted right facial weakness prompting transport to nearest primary stroke center where CT head non‐contrast showed right cerebellar infarct and CT angiogram (CTA) head and neck showed right vertebral artery occlusion with basilar extension. Intravenous thrombolytic (IVT) was deferred due to unclear last known well. He was treated with aspirin 324mg and transferred to our tertiary stroke center. Arrival NIHSS was 1 for right upper extremity ataxia. Premorbid mRS was 0. Repeat CTA redemonstrated right vertebrobasilar artery tandem occlusion. CT perfusion was without mismatch. Patient underwent emergent mechanical thrombectomy with ADAPT to TICI3 revascularization with future plan for possible angioplasty and stenting of R vertebral stenosis. Subsequently admitted to neurocritical care unit and treated with dual antiplatelet therapy. Initially maintained on aspirin and Cangrelor infusion, then transitioned to aspirin and Plavix without hemorrhagic conversion. Diffusion weighted MRI brain showed right cerebellar and right pontine infarcts. Hospital course was complicated by severe intractable hiccups due to area postrema syndrome; ultimately resolved with baclofen and gabapentin after extensive unsuccessful medication trails. NIHSS remained 1 for ataxia throughout admission, although exam also revealed mild unsteady gait requiring home physical therapy and a walker on discharge. Post‐stroke mRS was 1 on discharge; 3‐month mRS is pending. Conclusion Evidence regarding EVT for low NIHSS BAO remains varied with some studies showing superior benefit with IVT alone9 while others suggest improved outcomes with EVT in mild to moderate deficits.4,8 One prospective study particularly revealed better outcomes in EVT for BAO due to tandem occlusions similar to this case.10 Given the potential devastating sequalae of BAO and limited overall treatment options, EVT should remain a strong contender for treatment of PC LVO, especially in patients with milder neurologic deficits or tandem occlusions. Additionally, heightened use of PC‐NIHSS may better prognosticate candidates for EVT.

Head Injury Due to Intimate Partner Violence: Injury Characteristics, Subacute Symptoms, and Receipt of Care.

Women survivors of intimate partner violence (IPV) have increased risk of repetitive neurotrauma in their lifetime but have received less research focus compared with populations of athletes, veterans, and emergency department patients. The current study examined the importance of IPV as a contextual mechanism of injury, by comparing women survivors of IPV based on whether they experienced a head injury due to IPV or a head injury not due to IPV. The analyses involved archival data from in-person interviews conducted with women who received a protective order against an intimate partner in Kentucky from 2001 to 2004 (n = 641). Women were excluded if they reported no head injury history (n = 268), resulting in two groups compared based on a retrospective cohort design: 255 women with at least one self-reported IPV-related head injury (M = 33.8 ± 9.0 years old, range: 19-65; 87.5% White) and 118 women with self-reported head injuries due to reasons other than IPV (M = 32.2 ± 9.1 years old, range: 18-62; 89.0% White). Participants were compared on injury characteristics, lifetime physical and sexual IPV severity, subacute symptoms of head injury, and receipt of care for head injury. Compared with women with head injuries unrelated to IPV, women with IPV-related head injuries reported a higher number of lifetime head injuries (Mdn[range]: IPV-related = 3[1-515] vs. non-IPV-related = 1[1-13], p < 0.001, r = 0.51) and a higher number of head injuries involving loss of consciousness (Mdn[range]: IPV-related = 1[1-35] vs. non-IPV-related = 1[1-4], p < 0.001, r = 0.27), but lower rates of hospitalization (IPV-related = 56.1% vs. non-IPV-related = 73.7%, p = 0.001, odds ratio [OR] = 2.20 [95% confidence interval (CI): 1.36, 3.55]) and formal rehabilitation (IPV-related = 3.2% vs. non-IPV-related = 9.4%, p = 0.011, OR = 3.18 [1.24, 8.13]) following head injury. Women with IPV-related head injuries had greater lifetime severity of physical IPV (p < 0.001, d = 0.64 [0.41, 0.86]) and sexual IPV (p < 0.001, d = 0.38 [0.16, 0.60]). Women with IPV-related head injuries endorsed all symptoms at greater rates than women with non-IPV-related head injuries (ps < 0.001), including physical (e.g., headaches: OR = 3.15 [1.81, 5.47]; dizziness: OR = 2.65 [1.68, 4.16]), cognitive (e.g., trouble problem solving: OR = 2.66 [1.53, 4.64]; inattention: OR = 2.39 [1.52, 3.78]), and emotional symptoms (e.g., depression: OR = 7.39 [4.48, 12.20]; anxiety: OR = 4.60 [2.82, 7.51]). The total count of symptoms endorsed was higher for women with IPV-related head injury than women with head injuries unrelated to IPV (p < 0.001, d = 0.71 [0.49, 0.94]). When controlling for lifetime physical and sexual IPV, IPV-related head injury was independently associated with symptom count (β = 0.261, p < 0.001) and accounted for additional variance in symptom count (ΔR2 = 0.06, p < 0.001). Among women survivors of IPV, those reporting IPV-related head injuries reported greater subacute symptoms, but a lower likelihood of being hospitalized or receiving rehabilitative care. Women with self-reported IPV-related head injuries represent an underserved population that is often unevaluated following injury and may have many unmet care needs. Future studies should examine persistent symptoms following IPV-related head injuries and interventions that would be most beneficial for this population.

“The chameleon among diseases” - an explorative view of sarcoidosis and identification of the consequences for affected patients and relatives using qualitative interviews

IntroductionSarcoidosis is a multisystemic disease, with the lungs being the main site of manifestation. Although the exact etiology remains unclear, both genetic and environmental factors are being discussed. Diagnostic evaluation is challenging, and the management of chronic patients and assessment of their needs proves difficult, especially in the absence of targeted therapy. Studies on sarcoidosis patients have shown that quality of life is limited even after clinically measurable parameters have resolved. The question remains how patients and their relatives perceive medical care and the diagnostic process and how these affect their well-being.MethodsQualitative, semi-structured interviews were conducted with patients and their relatives between September 2019 and February 2020. Interviews were recorded, transcribed verbatim, and analyzed using qualitative content analysis. Deductive hypotheses were then formed based on categories according to personal aspects, symptoms, diagnostic, daily life activity, therapy, psychological aspects and wishes.ResultsFourteen patients and five relatives were included. Most patients reported subacute symptoms before the first organ-related episode. A high degree of personal initiative was required from the majority of respondents in both the diagnostic and subsequent therapeutic processes. In addition, respondents reported so-called “doctor-hopping”, a lack of specialists or contacts, and a lack of medical support. The Internet and self-help groups played a fundamental role for patients and relatives in exchanging information with other affected persons and to compensate for an existing information deficit.ConclusionThe results provide new insights into patients’ and relatives’ perceptions of the sarcoidosis diagnosis and treatment process. Identification of barriers such as a lack of physicians and an information deficit highlights potential targets for strategies to optimize sarcoidosis management.

Tuberculosis glenohumeral: A propósito de un caso.

Glenohumeral monoarthritis due to tuberculosis is very rare, so its early diagnosis and treatment represents a challenge for the orthopedic surgeon. It should be suspected in those patients at risk, with subacute onset symptoms and who do not respond to conventional treatment. Although complementary imaging and analytical tests can help in the suspected diagnosis, the definitive diagnosis is microbiological. Anti-tuberculosis medical treatment is necessary to eradicate the pathology.

Diagnosing Atypical Flutter in the Post-atrial Fibrillation Ablation Patient: A Case Report.

Late atrial arrhythmias after catheter ablation for atrial fibrillation occur in up to 30% of post-ablation patients and are increasingly encountered by emergency physicians. However, diagnosing the exact mechanism of the arrhythmia on the surface electrocardiogram (ECG) remains challenging due to atrial scarring leading to heterogeneous P-wave morphology. A 74-year-old male with a history of prior catheter ablation for atrial fibrillation presented with palpitations and subacute symptoms of heart failure. The patient's ECG revealed narrow complex tachycardia with more P waves than QRS complexes. The differential diagnosis included typical flutter, atypical flutter, and focal atrial tachycardias with 2:1 conduction block. P waves were positive in V1 and across all precordial leads (absent precordial transition). This favors atypical flutter originating from the left atrium over typical cavotricuspid isthmus-dependent right atrial flutter. Transthoracic echocardiogram showed a reduced ejection fraction due to tachycardia-mediated cardiomyopathy. The patient underwent a repeat electrophysiology study and ablation, which confirmed the presence of an atypical flutter circuit using the mitral annulus, known as perimitral flutter. Repeat catheter ablation resulted in maintenance of sinus rhythm. At follow-up, his ejection fraction recovered. Recognizing ECG findings suggestive of atypical flutter impacts initial emergency department decisions and triage as atypical flutter post-atrial fibrillation ablation is frequently resistant to rate-controlling medications and often requires cardiology and/or electrophysiology consultation if available.

Neuroimaging in Cerebral Small Vessel Disease

Objective: To determine the role of neuroimaging in cerebral small vessel disease’s diagnosis and treatment. Study Design: Cross-sectional study. Place and Duration of Study: Department of Neurology, Khairpur Medical College, Khairpur Mir’s from 1st January 2022 to 30th September 2022. Methodology: Seventy five patients were enrolled. The patients were divided in to 5 groups depending on a 5 year interval in their age. The cases of CSVD were included suffering from transient ischemic attack (TIA), lacunar syndromes, stoke with subacute symptoms as cognitive as well as motor disturbances. The age of the patients was &gt;45 years. Clinical examination was conducted through standard procedure and each patient underwent brain magnetic resonance index (MRI) imaging. The neuroimaging features including white matter hyperintensities (WMH), lacunar infarcts (LI), enlarged perivascular spaces (EPVS), microbleeds, lacunae, brain atrophy, and subcortical infarcts. Binswanger’s disease, as well as leukoaraiosis, lacunar strokes and cerebral microbleeds (CMBs) were also observed. The MRI used 3.0 MRI system, using 32-channel head coils.The regions scoring was done through Kippss or Dacies score, as well as through MTA-scale, Koedam score, and GCA-scale, ranging within 0-3 points Results: There are more cases of females suffering from CSVD than males, however only in year 70 there was an equal incidence within gender. There was a significance association of CSVD markers with age wherein the WMH has a significant increase in trend with the ascending of year interval. Fazekas scale was applied quantify amount of the white matter T2-hyperintense-lesions which are accredited to CSVD. It was observed that presence of SVD markers in various age stratification showed highest incidence of MTA scale, Koedam score, Kippss/Dacies score and 3 markers numbers The WMH, CMBs, LI and EPVS were observed highest in the age group of 61-65 years while BA was observed highest in 66-70 years of age Conclusion: Neuroimaging techniques prove beneficial in exact and timely diagnosis of cerebral small vessel disease. Increasing age has higher risk of CSVD presented through increase incidence in CSVD markers. Keywords: White matter, Cognitive, Recurrence, Mortality, Etiology

Giant hiatal hernia: A review of the clinical presentation, surgical technique, and operative video

Introduction: Giant hiatal hernia represents 0.3–15% of all hiatal hernia. Its complication such as the strangulation of the stomach are life-threatening. Therefore, in most of the cases it must be surgically handled. Case Report: We report the case of a 74-year-old patient with giant hiatal hernia. He presented with sub-acute symptoms (e.g., vomiting, appetite loss, and hematemesis). Considering the symptomatology and complementary tests, we decided to perform a laparoscopic hernia repair using mesh reinforcement. We provided a commented operative video to describe the surgical procedure. We then discussed the surgical technique and decided how to conduct a safe and efficient repair. Conclusion: A surgical approach is the recommended treatment in most giant hiatal hernia due to its life-threatening complications. The technique should be tailored to the patient. Although there is no consensus whether to use a mesh reinforcement, we believed that a cautious mesh placement should be considered when the crura are of poor quality. Surgeons should also be cautious with the fundoplicature and the risk of stricture, therefore we propose the systematic use of a tube to test the passage in the esophago-gastric junction.