Undiagnosed Pathology Research Articles

Hysteroscopic Identification of Intrauterine Pathology in Oocyte Donation Cycles: A Retrospective Study.

Hysteroscopy remains the gold standard for the diagnosis and treatment of intracavitary uterine anomalies. As for recipients where oocyte donation is mandatory, accurate evaluation of previously missed intrauterine pathology may be an important step to optimize implantation process. The aim of this study was to hysteroscopically assess the incidence of unidentified intrauterine pathology prior to embryo transfer in an oocyte recipient population. A retrospective descriptive study was conducted between 2013 and 2022 at Assisting Nature In Vitro Fertilization (IVF) Centre in Thessaloniki, Greece. The study population consisted of oocyte recipient women who underwent hysteroscopy one-three months before embryo transfer. Furthermore, oocyte recipients after repeated implantation failure were investigated as a subgroup. Any identified pathology was treated accordingly. In total, 180 women underwent diagnostic hysteroscopy prior to embryo transfer with donor oocytes. The mean maternal age at the time of intervention was 38.9 (+5.2) years, while the mean duration of infertility was 6.03 (+1.23) years. Additionally, 21.7% (n=39) of the study population had abnormal hysteroscopic findings. In particular, congenital uterine anomalies (U1a: 1.1% {n=2}, U2a: 5.6% {n=10}, U2b: 2.2% {n=4}) and polyps (n=16) were the main findings in the sample population. Furthermore, 2.8% (n=5) had submucous fibroids and 1.1% (n=2) were diagnosed with intrauterine adhesions. Notably, in recipients after repeated implantation failure intrauterine pathology rates were even higher (39.5%). Oocyte recipients and especially those with repeated implantation failures probably have high rates of previously undiagnosed intrauterine pathologyso, hysteroscopy would be justified in these subfertile populations.

Mansonic neuroschistosomiasis in the childhood: an undiagnosed pathology?

Schistosomiasis is an endemic parasitic disease in several tropical countries. In Brazil, the only prevalent species of parasite responsible for schistosomiasis is Schistosoma mansoni. Neuroschistosomiasis is the second most frequent form of infection and the primary ectopic manifestation, with predominant involvement of the lower thoracic spinal cord and lumbar and lumbosacral regions. The frequent contact of children with contaminated ponds and the immaturity of their immune systems make this age group especially susceptible to infection by this parasite. Therefore, neuroschistosomiasis mansoni should always be considered in cases of transverse myelitis in children from endemic regions. The treatment for this condition is quite simple and effective, resulting in total recovery of neurological deficits if the diagnosis is made early.

Prevalence of Serious Pathology Among Adults with Low Back Pain Presenting for Chiropractic Care: A Retrospective Chart Review of Integrated Clinics in Hong Kong

BackgroundThere is a limited understanding of the frequency at which chiropractors encounter patients with serious pathology such as malignancy, fracture, and infection. This retrospective study aimed to estimate the prevalence and types of serious pathology among adults with new low back pain presenting to chiropractors in an integrated healthcare organization in Hong Kong, with the hypothesis that such pathology would be found in less than 5% of patients.Material/MethodsWe identified adults presenting to a chiropractor with new low back pain across 30 clinics with 38 chiropractors, and a subset with previously undiagnosed serious pathology from January 2020 through July 2022. Data were extracted from the electronic medical records, including messaging alerts for serious pathology, notes, radiology reports, and specialist follow-up. Descriptive statistics were utilized to analyze results.ResultsAmong the 7221 identified patients with new-onset low back pain (mean age 61.6±14.3), 35 presented with serious pathology. After excluding 54 cases not meeting inclusion criteria, the prevalence of serious pathology (95% CI) was 35/7221 (0.48%; 0.35–0.67%). Individual condition prevalence included metastasis (0.25%; 0.16–0.39%), fracture (0.12%; 0.07–0.24%), infection (0.04%; 0.01–0.12%), vascular pathology (0.03%; 0.01–0.10%), primary tumor (0.03%; 0.01–0.10%), and gastrointestinal emergency (0.01%; 0.00–0.08%).ConclusionsThis study found that serious pathology was uncommon among adults with new low back pain presenting for chiropractic care in Hong Kong, findings which are most consistent with previous research describing the prevalence of serious pathology among low back pain patients in primary care settings.

60-year-old Female with Edema.

IntroductionMany patients present to the emergency department (ED) with nonspecific, acute-on-chronic complaints. It requires a thorough diagnostic approach and broad differential diagnosis to determine whether there is serious, undiagnosed pathology.Case PresentationA 60-year-old female presented to the ED for gradually worsening bilateral lower extremity swelling with associated abdominal distension, ascites, diarrhea, vomiting, and weight loss.DiscussionThis case takes the reader through the evaluation of a patient with acute-on-chronic complaints who presented in a decompensated state.

Increasing the uptake in a general practice prostate cancer screening programme

BackgroundProstate cancer (PC) is the second most common cause of cancer deaths among males worldwide. Prostate-specific antigen (PSA) is a predictive indicator of prostate pathology. Men with elevated PSA levels...

The Role of Physical Deconditioning in Cardiological and Pulmonological Medical Practice

Abstract The examination of the patient with a recent episode of C19 and residual cardiorespiratory symptoms requires a complete two-line assessment of previously undiagnosed chronic pathology. As conventional investigations were insufficient in clarifying the remaining symptomatology, it was necessary to broaden the range of investigations and to take a different approach to this category of patients. Depending on the symptoms and the patient’s general condition at the beginning of the examination, the attending physician should not disregard the period of restrictions involving significant limitations regarding exercise imposed during the pandemic. Physical exertion minimization and isolation at home have led to a series of functional disorders throughout the body, particularly cardio-respiratory, musculo-articular and neuro-psychiatric disorders. The effects of a sedentary lifestyle or the lack of physical exertion are not limited to elderly individuals, nor to a single system or apparatus, but have undesirable consequences for the whole body. In this context, the pulmonologist was obliged to answer the question “does the patient have a previously undiagnosed chronic respiratory disease before COVID19 or is the patient physically deconditioned?”. This is how the cardio-respiratory exercise test - the stair-climbing exercise test - came into play in assessing this category of patients. As the medical rehabilitation units could not cope with all the patients, it was necessary to create a home-based rehabilitation programme that was cheap, fast, and allowing telephone monitoring and quantifiable results.

Reactivation of Q fever: case report of osteoarticular infection developing at the site of a soft tissue injury

Coxiella burnetii , the causative agent of Q fever, is known to cause acute and persistent infection, but reactivation of infection is rarely reported. This case demonstrates reactivation of a distant, untreated Q fever infection after a relatively innocuous soft tissue injury in an adjacent joint without pre-existing pathology. A 52-year-old male abbatoir worker sustained an adductor muscle tear in a workplace injury. He was unable to walk thereafter, and developed a chronic, progressive, destructive septic arthritis of the adjacent hip with surrounding osteomyelitis of the femur and acetabulum. He had evidence of prior Q fever infection, with a positive skin test and serology 15 years beforehand. He was diagnosed with chronic osteoarticular Q fever on the basis of markedly elevated phase I antibodies, and symptomatic and serological response to prolonged antibiotic treatment with doxycycline and hydroxychloroquine. He required a two-stage hip arthroplasty. This case illustrates reactivation of latent C. burnetii infection at the site of a soft tissue injury. Clinicians need to be aware of this possibility in patients with previous Q fever infection, and in the setting of undiagnosed osteoarticular pathology following soft tissue injury.

Endovascular approach in the management of idiopathic myointimal hyperplasia of the inferior mesenteric vein

BackgroundIdiopathic myointimal hyperplasia of the mesenteric vein (IMHMV) is a rare, often undiagnosed pathology affecting the colon. Patients typically present with severe abdominal pain and inflammation caused by smooth muscle proliferation of the veins, leading to arterialization, stenosis, and potential occlusion. The etiology remains unclear, but it has been hypothesized that an arteriovenous connection may be associated with the pathology. This is the first reported case indicating such an association. This case additionally highlights the potential utility of endovascular treatment, as endovascular embolization is generally a less invasive alternative to surgical resection in the treatment of such vascular disorders.Case PresentationThis report describes a 24-year-old female patient with findings of colitis and an abnormal arteriovenous connection of the inferior mesenteric arterial and venous systems. Partial embolization of this arteriovenous connection temporarily improved the patient’s condition, but her symptoms ultimately returned due to the presence of multiple smaller feeder vessels not amenable to embolization, necessitating colonic resection for definitive treatment. Although prior reports have hypothesized that arterial pressurization of the veins may precipitate myointimal hyperplasia, to the authors’ knowledge, this is the first report of IMHMV with an associated abnormal arteriovenous connection.ConclusionsThis case illustrates the possibility of an association between an arteriovenous connection and IMHMV. This rare diagnosis should be considered in patients with a similar presentation of abdominal pain after common etiologies like IBD have been excluded.

Charles Bonnet Syndrome in Patients with Open-Angle Glaucoma: Prevalence and Correlation to Visual Field Loss

To determine the prevalence and characteristics of Charles Bonnet Syndrome (CBS) and its relation to visual field loss (VFL) in patients with open-angle glaucoma (OAG). Prospective, cross-sectional study. Adult patients (n= 337) with manifest OAG with verified VFL and without significant macular disease or extraocular conditions known to cause visual hallucinations. Patients attending the glaucoma outpatient department of the Skåne University hospital, Malmö, Sweden, between April 1, 2018, and December 31, 2018, were consecutively evaluated for inclusion. Potentially eligible patients admitting to having complex visual hallucinations were interviewed to explore the characteristics of their hallucinatory experiences. Recent automated visual field examinations were available for all participants, and swept-source OCT was performed in participants with CBS to rule out previously undiagnosed macular pathology. The correlation between potential risk factors and CBS was evaluated with logistic regression analysis. Prevalence of CBS in patients with OAG. Charles Bonnet Syndrome was found in 7.1% (95% confidence interval [CI], 4.7-10.6) of patients with OAG. Participants with CBS were more likely to have at least 1 eye with a visual field index (VFI) of ≤30% compared with those without CBS (71% vs. 34.2%; P= 0.001). Although the best-corrected visual acuity (BCVA) in the worse eye was significantly lower in participants with CBS (decimal equivalent of Snellen BCVA: 0.25 vs. 0.6, P= 0.003), 33% of these participants had a BCVA of ≥0.5 in the worse eye. In multivariable analysis, CBS was correlated to the VFI of the better eye (odds ratio, 0.984; 95% CI, 0.969-0.998, P= 0.030) and the BCVA of the worse-seeing eye (odds ratio, 0.210; 95% CI, 0.046-0.952, P= 0.043). Charles Bonnet Syndrome was not a rare condition in patients with glaucoma. Patients with a combination of advanced VFL and low BCVA had the highest risk of CBS; however, 1 of 3 patients with CBS hada BCVA of ≥0.5 in both eyes. These findings emphasize the importance of being attentive to symptoms ofCBS in patients with glaucomatous VFL even when visual acuity is preserved.

P13 Finding an answer for an adolescent with back pain

Case report - IntroductionThis is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety.Case report - Case descriptionB was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region.Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system.Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - DiscussionThis was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren’s with lymphocytic interstitial nephritis and positive Sjogren’s autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease.Minor pelvi-calyceal distension can occur as a normal finding in well-hydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management.In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution.Case report - Key learning pointsNon-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable causeHydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations Assessment of renal function (including MAG 3 renogram) is important to guide further managementSurgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered tooLeft undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being

A holistic approach to predicting diabetes risk via biomarkers.

Leo Tolstoy's novel Anna Karenina starts with the famous line, “All happy families are alike; each unhappy family is unhappy in its own way.” This “Anna Karenina Principle” has been applied in numerous contexts, including ecological risk assessment, microbiomes, economics, and many others. In physiology and health, we might rephrase it as a hypothesis; “All healthy physiologies are healthy in relatively standard ways, but there are limitless ways in which physiology can go awry.” This hypothesis raises interesting corollaries: to what extent is there a general, unique profile of physiological “health,” which might be perturbed in a multiplicity of ways? Can we understand health as the body's ability to maintain such a homeostatic state, or more broadly its dynamic equilibrium? Might having an overall profile that is far from average be an indicator either of a specific but undiagnosed pathology, or of a general lack of resiliency predisposing the individual to higher risks of a host of adverse outcomes?

O-024 Endoscopic management of the unexplained infertility, what does it add?

Abstract text Endoscopic management of the unexplained infertility, what does it add? Stephan Gordts stephan.gordts@lifeexpertcentre.be Unexplained infertility “strictu sensu” is not a diagnosis, but a description of a status where no causal factor is identified in a couple trying to conceive for at least one year. The more parameters are assessed, the more likely to identify an etiology, the less likely becomes “unexplained” infertility. Limiting the fertility exploration to indirect visualization techniques like ultrasound, HSG or HycoSy involves the risk of missing existing pathologies. Uterus Uterine volumetric abnormalities can be detected by indirect techniques, but information is lacking on the visualization of the endometrium in case of chronic endometritis and the presence of endometrial defects and hypervascularization areas as seen in patients with adenomyosis. Tubo-ovarian Even with the increased accuracy of indirect visualization techniques, lesions of minimal endometriosis and tubo-ovarian adhesions are not detected (Table). Tubal normality constitutes not only normal tubal patency but also normal tubal function. The importance of subtle tubal lesions is underestimated. Hydatid of Morgagni are detected in 38.1% in patients with infertility versus only in 16,7% in fertile women (Gupta et al. JMIG 2017).Removal of these lesions resulted in a spontaneous pregnancy rate of 58.7% versus 20.6 in the non-treated group (Rasheed et al. EJOG Repr. 2011). Endometriosis In a series of 107 patients with unexplained infertility and 3 failed IVF cycles (Agni Pantou et al. J. Clin. Med. 2019)laparoscopy revealed the presence of endometriosis in 57.97%, peri-adnexal adhesions in 23.3% and was normal in 18.69%. Also, in a group of patients with 3 failed IVF cycles and unexplained infertility (Xiaoming Yu et al.Medicine 2019) laparoscopy showed endometriosis in 57.7%, tubal abnormalities in 31.1% and adhesions in 33.3%. Laparoscopic correction of these pathologies did not only result in a spontaneous pregnancy rate of 35% but resulted also in a higher pregnancy rate after IVF compared to the non-treated control group. Unexplained infertility hides frequently undiagnosed endometriosis. Endometrial BCL6 levels, a proto-oncogene where overexpression is associated with increased cellular proliferation and progesterone resistance, are increased in patients with endometriosis. In case of elevated BCL6 in patients with unexplained infertility, laparoscopy confirmed the presence of endometriosis in 93.8% (Evans-Hoeker et al. 2016). Abnormal BCL6 expression in a population with unexplained infertility reduced the chance of having a successful IVF treatment in 74% of the population (Almquist et al. Fertil Steril 2017). Transvaginal Hydro Laparoscopy Direct endoscopic visualization remains important but due to the invasiveness, diagnostic standard laparoscopy is frequently postponed or omitted in the exploration of the infertile patient. The technique of transvaginal hydro-laparoscopy allows in a minimal invasive way the inspection of the pelvis. In a consecutive series of 2288 patients without obvious pelvic pathology, findings were normal in 49.3%, endometriosis was diagnosed in 15.9% and tubal pathology in 14.5% of the patients (Gordts et al. FVV 2021). The rate of failed access was 1% and the complication rate 0.74%. Causing a minimal ovarian trauma, treatment of these early endometriotic lesions resulted in a spontaneous pregnancy rate of 73.2%. Conclusion The inappropriate use of “unexplained infertility” by omitting the diagnostic endoscopy in the exploration of the infertile patient, can hide undiagnosed and treatable pathology, jeopardizing possibilities for patients for a spontaneous conception and can be responsible for reduced pregnancy rates after IVF.

Histological analysis of the products of conception in first trimester spontaneous abortions

Aims: To evaluate the histopathological findings of products of conception in the first trimester spontaneous abortions.
 Methods: A hospital based descriptive cross sectional study conducted from March 2018 to March 2019, among the women admitted with diagnosis of first trimester spontaneous abortion at Paropakar Maternity and Women’s Hospital.
 Results: Among 80 cases of spontaneous abortions, incomplete abortion was the commonest type constituting 42.5% of the studied group. The majority of participants belonged to age group of 21-30 years (61.2%) with a mean age of 26.8±6.1 years. Histopathologic examination confirmed products of conception in 60 (75%) patients, partial molar pregnancy in 9 (11.25%) patients, decidual reaction in 9 (11.25%) patients and hydropic abortus in only 2 (2.5%) patients. The molar pregnancy was more prevalent among women of Tibeto-Nepalese ethnic group 26.5% (n=9). Partial hydatidiform mole was more common in primiparous (19.3%) than in multiparous (14.2%).
 Conclusions: The histopathological examination of the products of conception proved to be an important tool in detecting undiagnosed pathology like molar pregnancy and hydropic changes that necessitate special follow-up protocol and further management.

Pharmacologic Differences in Children

Children are physiologically different from adults. Their anesthetic care requires ample consideration of the pharmacologic effects of medications on their minds and bodies to provide an overall pleasant and safe experience. There are many available pharmacologic agents that can be used in the course of a child’s anesthetic. It is essential to be aware of the potential uses and risks of each. Pediatric anesthesia providers must consider physiologic differences in children versus adults that affect pharmacodynamics. They should also consider various medication routes that are available to initiate sedation or anesthesia, dosing changes that need to be made due to metabolism immaturity and increased risk of medication toxicity, concern for possible neurotoxic effects of medications on the developing brain, and adverse effects of medication due to congenital issues or undiagnosed pathology. Medications we use in pediatric anesthesia have always been off label due to limited studies in this population of patients and ongoing studies will help enhance our practice. This review contains 4 figures, 7 tables, and 64 references. Key Words: anesthetic neurotoxicity, anesthesia uptake, apnea risk, benzodiazepine effects, neonates, midazolam bioavailability, opioids, opioid-sparing medications, premedication routes, propofol infusion syndrome, succinylcholine complications, sugammadex, uptake and distribution in infants.

Biological and Socio-Cultural Factors Have the Potential to Influence the Health and Performance of Elite Female Athletes: A Cross Sectional Survey of 219 Elite Female Athletes in Aotearoa New Zealand.

Health is a pre-requisite for optimal performance yet the parameters which govern health and performance of elite female athletes are little understood. The aim of this study was to quantify the health status of elite female athletes, and understand sociocultural factors influencing that status. The survey addressed demographic, health and athletic performance history, training load, contraceptive use, sport-specific appearance and performance pressures, and communication barriers. Three hundred and fifty-seven elite New Zealand female athletes were recruited to complete an on-line survey. Two hundred and nineteen athletes completed the survey. Oligomenorrhea/amenorrhea had been diagnosed in only 12% of athletes compared with 50% of athletes not on hormonal contraception who reported symptoms consistent with this diagnosis. Stress fractures and iron deficiency were common and associated with oligomenorrhoea/amenorrhea (P = 0.002), disordered eating (P = 0.009) or menorrhagia (P = 0.026). Athletes involved in individual sports (P = 0.047) and with higher training volumes (P < 0.001) were more likely to report a medical illness. Seventy-three percent of athletes felt pressured by their sport to alter their physical appearance to conform to gender ideals with 15% engaging in disordered eating practices. Barriers to communicating female health issues included male coaches and support staff, and lack of quality information pertaining to health. Elite female athletes may fail to reach peak performance due to specific health issues and undiagnosed pathology. Sociocultural factors influence the effectiveness of support of female's health and performance. Organizational and cultural change is required if elite female athletes are to combine optimal health with best performance.

Cardiovascular magnetic resonance imaging reveals asymptomatic cardiomyopathy in newly diagnosed, HIV-infected South African adults

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): University of Stellenbosch Cardiology Research Fund and United States National Institutes of Health/Fogarty International Center Background Cardiovascular disease (CVD) is a leading cause of death and disability in people living with HIV (PLWH). The coronary disease burden in high income countries contrast what is experienced in low- and middle-income countries where cardiomyopathy remains prevalent. Cardiovascular magnetic resonance imaging (CMR) has the unique ability to characterise tissues to obtain "virtual histology". Our data support a high burden of myocardial disease, already present at the time of HIV diagnosis in a young South African cohort. Purpose Early, undiagnosed myocardial pathology in some antiretroviral therapy (ART) naïve persons appear to precede the development of poorly prognostic HIV associated cardiomyopathy. The burden and mechanisms underlying the progression to more advanced disease in treatment naïve PLWH remain largely unknown, as does the modifying effect of ART on these abnormalities. Studying early myocardial disease and its progression with serial CMR evaluation will improve our understanding of disease evolution. Methods 24 newly diagnosed, ART naïve adults without known CVD underwent a contrasted, 1.5T CMR study. Assessments included: Left ventricular (LV) volumes, mass, ejection fraction (EF), native and post-contrast T1 mapping, T2 mapping, extracellular volume (ECV) mapping, and late gadolinium enhancement (LGE) imaging. Quantitative measurements were obtained using a semi-automated software. Qualitative LGE findings were reviewed by an EACVI level III accredited cardiologist. Results The median age of the cohort was 33, interquartile range (IQR) 30-43 years. Median CD4 count was 250, IQR 152-520 cells/uL. All patients had non-dilated LV"s according to indexed end diastolic volumes (Mean: 85 ± 15ml/m²). No patient had overt systolic dysfunction (Mean EF: 62 ± 6%). Non-trivial pericardial effusions were present in 71% of cases. Indexed LV mass measured normal (Mean: 65 ± 12g/m²). Mean global native T1 and T2 values were 1043 ± 46 and 49 ± 4ms respectively. Native T1 values were highest in the septum and inferior wall (Mean: 1054 ± 50 and 1047 ± 51ms respectively). Mean global ECV was 28 ± 4%. Non-ischaemic LGE was present in 71% of participants. In those with LGE, midmyocardial enhancement of the inferior septum represented 71% of abnormalities (Figure). Conclusion In this young cohort of newly diagnosed HIV-infected persons, the prevalence of myocardial abnormalities were high. The midmyocardial LGE and abnormal mapping parameters (high for our scanner and high normal for published data) suggest myocardial inflammation and fibrosis already present at HIV-diagnosis. This was most appreciable in the septum and inferior walls, and likely represents a diffuse process that may progress to symptomatic cardiomyopathy over time. Serial evaluation on ART and comparison with a matched HIV-negative control group is planned. This will allow quantitative comparison of tissue characterisation and explore the nature and evolution of these abnormalities. Abstract Figure. Late gadolinium enhancement (Arrows)

Ophthalmic Presentation of Undiagnosed Sinonasal Masses.

To evaluate clinical features of patients who first present with orbital symptoms and signs due to undiagnosed sinonasal pathology. Retrospective chart review for patients seen at Moorfields Eye Hospital between 1969 and 2020. Patient demographics and clinical features were reviewed. Four hundred and forty-eight patients (250 males; 56%) presented to ophthalmologists with undiagnosed sinonasal pathologies, the patients attending at an average age of 47 years and having first symptoms at an average age of 46 years. The commonest presenting symptoms were proptosis (153 patients; 34%), orbital ache or pain (133; 31%), periorbital swelling (130; 29%), and diplopia (98; 22%). Eighty-seven patients (20%) had a corrected acuity of 6/18 or worse, and 66 (16%) had an ipsilateral relative afferent pupillary defect. There was 2.3 mm relative exophthalmos (median 2 mm; range 0-17 mm) in patients with unilateral disease, an orbital mass was palpable in 218 patients (49%), ocular movements were reduced in 252/448 (56%), and nonaxial displacement of the globe was recorded in 296/424 (74%). The commonest pathologies were sinus mucoceles (38%), sinus carcinoma (11%), and granulomatous polyangiitis (10%). Multivariate regression analysis of mass lesions identified periorbital pain (odds ratio, 6.0; 95% confidence interval, 1.7-21.5; P = 0.005) and reduced motility (odds ratio, 3.2; 95% confidence interval, 1.1-9.0; P = 0.03) as features most predictive for undiagnosed sinonasal malignancy. This study describes a large group of patients in whom unknown midfacial masses presented initially to the ophthalmologist: Mucoceles and sinonasal malignancy were the commonest lesions, and nonaxial globe displacement-particularly inferolateral, lateral, or upward-is commonly associated with sinonasal pathology. Pain and reduced ocular movements significantly favor a malignant, rather than benign, tumor.

Discrepant histological diagnoses affects the near term FJS-12 and could be one of the causes of unhappy TKR patient

Introduction:TKR is one of the most successful operations in orthopedics. Still a sizable percentage of patients (20%) remain dissatisfied after a well executed TKR. The aim of the study is to examine the excised synovium from the suprapatellar region in osteoarthritic knees during TKR operation and evaluate the HP report to know whether discrepant diagnoses affects the Forgotten Joint Score-12 at various time intervals and in few cases the unrelenting pain and discomfort post TKR surgery could be due to some undiagnosed pathology within the joint.Hypotheses:The study was started with null hypothesis. The statistical significance was measured with Chi-square test and two sample t test.Methods:This is a prospective cohort study. Two hundred(160 Female 40 Male) end stage osteoarthritis patients who underwent primary TKR were studied. Inclusion criteria was patient with end stage osteoarthritis. Patients with clinically and serologically proven rheumatoid arthritis were excluded. The synovium excised during the TKR procedure was sent for HP examination. Statistics: The study was started with null hypothesis. The statistical significance was measured with Chi-square test and two sample t test.Results:184 of the 200 patients (92%) knee synovium showed HP features of osteoarthritis. The discordant diagnoses and discrepant diagnosis rate was 8 % and 7 % respectively which is statistically significant by ChiConclusion:8% of our patients exhibited results which were totally unexpected. Our study showed a 7 % rate of discrepant diagnosis, which if missed would have affected the function and long term survival of the implanted TKR.

The FOCCUS study: a prospective evaluation of the frequency, severity and treatable causes of gastrointestinal symptoms during and after chemotherapy

BackgroundThe underlying mechanisms of chemotherapy-induced gastrointestinal (GI) symptoms are poorly researched. This study characterised the nature, frequency, severity and treatable causes for GI symptoms prospectively in patients undergoing chemotherapy for GI malignancy.MethodsPatients receiving chemotherapy for a GI malignancy were assessed pre-chemotherapy, then monthly for 1 year using the Gastrointestinal Symptom Rating Scale, a validated patient-reported outcome measure. Patients with new, troublesome GI symptoms were offered investigations to diagnose the cause(s). Their oncologist was alerted when investigations were abnormal.ResultsA total of 241 patients, 60% male, median age 63 years (range 30–88), were enrolled; 122 patients were withdrawn, 93%, because of progressive disease or death. During the study, > 20% patients reported chronic faecal incontinence and > 10% reported moderate or severe problems with taste, dysphagia, belching, heartburn, early satiety, appetite, nausea, abdominal cramps, peri-rectal pain, rectal flatulence, borborygmi, urgency of defecation or tenesmus. Thirty percent reported continuing passage of hard stools and 30% on-going diarrhoea. Moderate or severe fatigue affected 40% participants at its peak and persisted in 15% at 1 year. Toxicity dictated change in chemotherapy for 13–29% patients/month. Common Terminology Criteria for Adverse Events underestimated gastrointestinal morbidity. Pre-chemotherapy screening identified previously undiagnosed pathology: exocrine pancreatic insufficiency (9%), vitamin B12 deficiency (12%) and thyroid dysfunction (20%). Patients often refused investigations to diagnose their chemotherapy-induced symptoms; however, for every three investigations performed, one treatable cause was diagnosed: particularly small intestinal bacterial overgrowth (54%), bile acid malabsorption (43%), previously not described after chemotherapy, and unsuspected urinary tract infection (17%).ConclusionsPatients undergoing chemotherapy for GI malignancy commonly have difficult GI symptoms requiring active management which does not occur routinely. The underlying causes for these symptoms are often treatable or curable. Randomised trials are urgently needed to show whether timely investigation and treatment of symptoms improve quality of life and survival.Trial registrationClinicalTrials.gov Identifier: NCT02121626

Distribution of Ventilation in Pneumoperitoneum: Comment.

We read with great interest a very informative and well-conducted study by Shono et al. titled “Positive End-expiratory Pressure and Distribution of Ventilation in Pneumoperitoneum Combined with Steep Trendelenburg Position” published in the Journal.1 The study has objectively shown that application of positive end-expiratory pressure (PEEP) of 15 cm H2O resulted in more homogeneous ventilation and favorable pulmonary physiologic effects during robot-assisted laparoscopic prostatectomy, but did not improve postoperative lung function. Whereas that authors have focused on the beneficial pulmonary effects of high PEEP values, the article would benefit readers considerably if the authors could address its potential ill effects on some other organ systems.In this regard we wish to highlight our concern regarding application of high PEEP on intracranial pressure (ICP) in patients given a steep Trendelenberg position. It is known that ICP rises rapidly with pneumoperitoneum and this increase is more pronounced due to the effects of gravity in patients assuming the head-down Trendelenburg position.2,3 Increased intraabdominal pressure displaces the diaphragm cranially, narrowing the inferior vena cava and decreasing venous return which, in turn, increases the ICP.3 The high intrathoracic pressures due to positive pressure ventilation and high intraabdominal pressure due to pneumoperitoneum cause a triple compartment syndrome because of an increase in ICP. In susceptible populations such as patients with head injuries or patients who have undiagnosed intracranial pathology, neurologic deterioration could be a concern. Clinically, even minor adverse effects of raised ICP may present in different ways.4 In a study by Cooke et al., headache and nausea were found to be significantly higher after laparoscopic abdominal surgery, possibly due to raised ICP.4Shono et al. have reported that phenylephrine requirement in the high PEEP group was significantly greater than in the normal PEEP group. For maintenance of cerebral perfusion pressure, a higher mean arterial pressure should have been targeted in view of the raised ICP. The authors have reported a raised arterial carbon dioxide of 49 ± 5 mm Hg which may also have detrimental effect on the ICP. Adjusting the respiratory rate to normalize the end tidal carbon dioxide could have been considered in the study design. In susceptible individuals, surgeries lasting 484 ± 81 min with a persistently high ICP resulting from a high PEEP of 15 cm H2O could result in a greater incidence of complications. These complications should be investigated before we can recommend universal application of a high PEEP in all patients. Prospective authors planning similar studies could consider adding incidence of adverse effects on ICP or intraocular pressure as one of their secondary objectives; otherwise, they could include these concerns as limitations of their study.The authors declare no competing interests.