Left Ventricular Diastolic Dysfunction in Type 2 Diabetes Mellitus: A Single-Centre Observational Study From a Tertiary Care Hospital in South India

Background There is a high prevalence of left ventricular diastolic dysfunction (LVDD) in patients with type 2 diabetes mellitus (T2DM). The influencing factors of LVDD in T2DM are not fully understood.  Objective This study aimed at assessing the prevalence of LVDD in T2DM as well as looking at the association between various parameters related to T2DM with LVDD in patients with T2DM. Materials and methods This was a single-centre cross-sectional study in Kerala, India. The primary objective of the study was to assess the prevalence of LVDD in T2DM. The secondary objectives were to look for an association between higher glycated haemoglobin (HbA1c), complications of T2DM, age, and gender of the patient with the presence of LVDD. Results A total of 80 patients were included in the study. There were 40 patients with LVDD with a prevalence of 50%. There was a statistically significant positive association between increased age, longer duration of diabetes, higher HbA1C, the presence of diabetic neuropathy, diabetic retinopathy, and diabetic nephropathy with the prevalence of LVDD. A logistic regression analysis demonstrated that the presence of diabetic retinopathy is a risk factor for LVDD in the study subjects.

Adult-Onset Immunoglobulin A Vasculitis Following Hemodialysis Treatment: An Unusual Presentation

Immunoglobulin A (IgA) vasculitis, formerly known as Henoch-Schönlein purpura (HSP), is a small vessel vasculitis due to perivascular deposition of dominant IgA immune complexes. It classically presents with symptoms such as palpable purpura, abdominal pain, kidney dysfunction, and joint pain. It most commonly affects children less than 10 years old. We present the case of a 53-year-old male who developed purpuric rashes a few hours after receiving hemodialysis. Initially, the lesions were localized to his legs and buttocks. They continued to spread over his back, abdomen, and arms. He experienced joint pain in both of his wrists, as well as abdominal tenderness. Labs revealed elevated IgA levels: 422 mg/dL (normal: 61 - 356 mg/dL). C3, C4, and antinuclear antibody (ANA) levels were within normal limits. Oral prednisone and topical diphenhydramine resulted in significant improvement in his symptoms. To our knowledge, there are only five reports documenting the occurrence of HSP in adults undergoing hemodialysis. Although HSP is a rare finding in adults, recognition of the disease is important as it can cause significant morbidity and mortality if left untreated.

Epicardial Ablation as a Treatment of Recurrent Ventricular Tachycardia Originating From a Left Ventricular Aneurysm: A Case Report and Review of the Literature

Catheter ablation (CA) is an important therapeutic modality for the management of ventricular tachycardia (VT). In some patients, CA may be ineffective because of the inability to reach the effective target site from the endocardial surface. Partly, this is due to the effect of the transmural extent of the myocardial scars. The operator's ability to map and ablate the epicardial surface has enhanced our understanding of scar-related VT in various substrate states. A left ventricular aneurysm (LVA) that develops after myocardial infarction may increase the risk of VT. Endocardial ablation alone of LVA may be insufficient in preventing recurrent VT. Numerous studies have demonstrated greater freedom from recurrence with adjunctive epicardial mapping and ablation via a percutaneous subxiphoid technique. Currently, epicardial ablation is performed predominantly at high-volume tertiary referral centers via the percutaneous subxiphoid approach. In this review, we first report a case of a man in his 70s with ischemic cardiomyopathy, a large apical aneurysm, and recurrent VT status post-endocardial ablation who presented with incessant VT. The patient underwent successful epicardial ablation over the apical aneurysm. Second, our case showcases the percutaneous approach and underscores its clinical indications and potential complications.

Two-Hit Kidney Allograft Injury by SARS-CoV-2

Coronavirus disease 2019 (COVID-19) has been associated with acute kidney injury in kidney transplant recipients by several mechanisms. The authors report a case of acute kidney allograft dysfunction in a 48-year-old patient who presented in the emergency room with anasarca and nephrotic syndrome close after mild COVID-19 and no other clinical condition. Histopathology of the allograft biopsy revealed two distinct and simultaneous kidney lesions, collapsing glomerulopathy and thrombotic microangiopathy. Renal function persistently deteriorated, and definitive dialysis was initiated. After excluding other plausible causes for the findings, this case strengthens the hypothesis that the kidney allograft is also a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

An Audit of Inpatient Consultation-Liaison Psychiatry Services at an Inner New York City Safety Net Hospital

Background Our study's primary objective is to audit the resource utilization of a consultation-liaison (CL) psychiatry service in an inner New York City safety net hospital. This cross-sectional, observational study was conducted as a subset of a quality improvement project at the hospital to investigate the characteristics of the emergent nature of consults, types, and the specialty from which the referral was placed to the CL services. This study aims to improve the efficacy of our consult process by improving the appropriateness and precision of consult requests. Methodology This cross-sectional, observational study was reviewed and approved by the Institutional Review Board under a quality improvement exemption. The study investigated the EPIC electronic medical record data for characteristics of consult referrals in the third quarter of 2019 from July 1, 2019, to September 30, 2019. A total of 629 consults were recorded during this period. We excluded follow-up calls, duplicate data rows, and patients with missing data points; the final consults were 421. Patients who required more than one new consult (follow-up excluded) within 90 days were considered; thus, the total number of patients who were included in the study was 327. Results Of the 421 consults identified in the dataset for review, only 45.8% were valid consults, 32.8% were not valid, and 21.4% were uncertain. Further, the most common department from which consults were placed was Medicine (73.2%), followed by Surgery (12.8%), Obstetrics/Gynecology (9%), Critical Care (3.6%), and, finally, Pediatrics (1.4%). Conclusions The study overviews the quality of general consults for the CL psychiatry service and how the CL staff manages it. It also provides an idea about the number of consults that can be comprehensively addressed.

Conservative Management of Emphysematous Gastritis With Gastric Mucosal Ischaemia: A Case Report

Emphysematous gastritis is a rare condition historically associated with high mortality. It is characterised by gastric mural pneumatosis and portal venous gas, secondary to bacterial or fungal invasion. Given the rarity of the condition, there is little evidence to guide clinical decisions regarding whether a patient requires surgical resection. We describe the case of a 72-year-old male diagnosed with emphysematous gastritis, with endoscopic evidence of gastric fundus mucosal ischaemia. As there was no evidence of ischaemia extending to the serosa on exploratory laparotomy, gastrectomy was not performed, and the patient was managed conservatively. He subsequently made a full recovery, and was discharged without any further complications. This case demonstrates that in the absence of full-thickness gastric ischaemia, patients with emphysematous gastritis may be appropriate for conservative management without surgical resection.

A Sharp Rise in Autoimmune Encephalitis in the COVID-19 Era: A Case Series

BACKGROUND

Autoimmune encephalitis was very rare prior to the current pandemic. A sharp rise in cases has been observed from March to August of 2022 in Los Angeles. Such an increase, especially with certain types of antibodies, may point toward the possibility of post-infectious autoimmune encephalitis. While review articles on autoimmune encephalitis during this pandemic have been published, a sharp rise in one geographic area within a short period of time has not been documented yet.

AIMS

To report an alarming increase in autoimmune encephalitis with mostly positive glutamic acid decarboxylase (GAD) and/or voltage-gated potassium channel (VGKC) antibodies over six months during 2022 in Downtown Los Angeles.

MATERIAL AND METHODS

This is an observational case series from one neurocritical care practice in Downtown Los Angeles. Autoimmune encephalitis antibody panels were sent to patients with altered mental status or neurologic deficits of unclear etiology from March to August of 2022.

RESULTS

Of the 29 patients tested, 12 reports came back positive. Ten had positive GAD and/or VGKC antibodies, one had a positive myelin oligodendrocyte glycoprotein antibody, and one had a positive leucine-rich glioma-inactivated 1 protein antibody; a 41% positive rate.

CONCLUSIONS

This observation has important implications: (1) We may be entering an era of heightened autoimmune encephalitis. (2) These occurrences may be post-infectious in nature at this point of the pandemic. (3) Mostly GAD and VGKC antibodies have been identified (10 of them), which may point toward a new direction of research from a molecular mimicry standpoint. (4) To benefit patients, clinicians need to be aware of such disease manifestations and increase testing; resources must be increased to improve test availability and shorten turnaround time; and treatment, which is expansive, must be made widely available for these potentially reversible diseases.

Understanding the Demographic, Clinical, and Real-Time Polymerase Chain Reaction Profiles of COVID-19 Patients in a Tertiary Care Hospital in Northeast India

Introduction and aims The demographic and clinical profile and dynamics of real-time polymerase chain reaction (RT-PCR) in coronavirus disease 2019 (COVID-19) patients are not well understood. The study aimed to analyze the demographic, clinical, and RT-PCR profiles of COVID-19 patients. Methodology The study was a retrospective, observational study conducted at a COVID-19 care facility, and the study period was from April 2020 to March 2021. Patients with laboratory-confirmed COVID-19 by real-time polymerase chain reaction (RT-PCR) were enrolled in the study. Patients with incomplete details or with only single PCR tests were excluded. Demographic and clinical details and the results of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR collected at different time points were retrieved from the records. The statistical software Minitab version 17.1.0 package (Minitab, LLC, State College, PA, USA) and Rstudio version 1.3.959 (Rstudio, Boston, MA, USA) were used for the statistical analysis. Results The mean duration from symptom onset to the last positive RT-PCR was 14.2 ± 4.2 days. The proportions of positive RT-PCR tests were 100%, 40.6%, 7.5%, and 0% at the end of the first, second, third, and fourth weeks of illness. The median duration of days to first negative RT-PCR in the asymptomatic patients was 8 ± 4 days, and 88.2% of asymptomatic patients were RT-PCR-negative within 14 days. A total of 16 symptomatic patients had prolonged positive test results even after three weeks of symptom onset. Older patients were associated with prolonged RT-PCR positivity. Conclusion This study revealed that the average period of RT-PCR positivity from the onset of symptoms is >2 weeks in symptomatic COVID-19 patients. Prolonged observation in the elderly population and repeat RT-PCR before discharge or discontinuation of quarantine is required.

Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock and Hyperkalemia (BRASH) Syndrome: A Clinical Case Study

BRASH syndrome, which stands for Bradycardia, Renal failure, Atrioventricular (AV) Nodal blockade, and shock, is a relatively new clinical condition. Bradycardia develops because of the synergistic effect of AV-nodal blockers and hyperkalemia in a renal failure resulting in a vicious cycle of progressive bradycardia, renal hypoperfusion, and hyperkalemia. We present a case of an 88-year-old man with chronic systolic heart failure, atrial fibrillation, stage 3 chronic kidney disease, and dementia who presented to our emergency department with poor oral intake and weakness. He was found to have symptomatic bradycardia in the 30s secondary to hyperkalemia and beta-blockers in the setting of acute renal failure from dehydration, raising concern for BRASH syndrome. Treatment of each component conservatively resulted in complete resolution without the need for aggressive measures such as dialysis or pacing. This case report also discusses the pathophysiology, management, and the need for recognizing this underdiagnosed and novel clinical condition.

A Rare Geriatric Diagnosis of Eosinophilic Granulomatosis With Polyangiitis: A Case Report

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of systemic disease characterized by inflammation and necrotizing effects of the small and medium blood vessels. It is a vasculitis found in all age groups and both genders, although its etiology is unknown. The mean age at diagnosis is 40 years, consisting of an uncommon cause of vasculitis in people older than 65 years. It is the least common of the three antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (EGPA, granulomatosis with polyangiitis (GPA), and microscopic polyangiitis). The characteristic features of EGPA include extravascular eosinophilic granulomas, peripheral eosinophilia, and asthma, usually responsive to steroid treatment. In this article, we discuss a case of an 83-year-old male with a history of undetermined etiology of chronic kidney disease, chronic obstructive pulmonary disease (COPD), and severe chronic rhinosinusitis with nasal polyposis. First hospitalized with the suspicion of community-acquired pneumonia (CAP), based on worsening blood eosinophilia and unresolving respiratory symptoms, a suspicion for EGPA was raised. The development of an eosinophilic pleural effusion, later upon admission, was a predominant factor for its confirmation, as it constitutes a rare finding, only present in about 30% of patients. Laboratory tests showed elevated IgE, the presence of antineutrophil cytoplasmic antibodies directed against myeloperoxidase with a perinuclear staining pattern (ANCA-MPO), and the absence of antiproteinase 3 (anti-PR3) ANCA, which were consistent with the diagnosis. A pleural biopsy was then made, revealing fibrosis with the presence of eosinophils, although with no evidence of granulomas. According to the most recent and accepted classification criteria, the "2022 American College of Rheumatology and European Alliance of Associations for Rheumatology (ACR/EULAR) for EGPA," this patient presented with a score of 13 (a score greater than or equal to 6 is needed for the classification of EGPA). Hence, a diagnosis of EGPA was assumed, and the patient was initiated on corticosteroid therapy, with a favorable response. The aim of this article is to present a rare case of EGPA diagnosis made at the age of 83 years old, although there was evidence that could point to this disease years before the diagnosis was made. In the present case, it is important to point out the long diagnostic delay in a geriatric patient, much older than the median age of diagnosis for EGPA, culminating in a curious case of uncommon pleuroparenchymal involvement.

Colovesical Fistula Complicating the First Symptomatic Episode of Acute Diverticulitis in a Young Adult

Colovesical fistula is one of the known complications of acute diverticulitis. However, it is uncommon for a patient to present with a colovesical fistula without prior episodes of diverticulitis. In this case, we report a patient with acute diverticulitis presenting with a colovesical fistula with no antecedent history of any medical condition. The patient was treated with intravenous antibiotics and subsequently had a temporary laparoscopic colostomy. Although colovesical fistula caused by diverticular disease was once considered a relative contraindication to laparoscopic resection, this method is now being increasingly employed by experienced surgeons. Compared with laparoscopic colon resection surgery for uncomplicated diverticulitis, the minimally invasive treatment of colovesical fistula requires a longer operative time and advanced surgical skills.

Local Recurrence in Choroidal Melanomas following Robotic-Assisted Radiosurgery (CyberKnife)

Introduction

Tumor recurrence in choroidal melanoma has been associated with decreased overall survival due to metastatic spreading. To detect risk factors of local recurrence and side effects, we analyzed tumor planning and treatment parameters in patients with recurrence of choroidal melanoma after treatment with robotic-assisted radiosurgery (CyberKnife).

Methods

Six hundred ninety-four patients treated with CyberKnife between 2005 and 2019 were retrospectively reviewed. Age, gender, best-corrected visual acuity, tumor height, and diameter were recorded. Treatment planning and radiation doses were reviewed. Salvage therapy, overall survival, metastasis, and complications were recorded.

Results

Seventy-four patients showed local recurrence. Local recurrence occurred after 42.1 months post CyberKnife treatment (mean; range: 5-100 months). Fourteen out of 74 patients (18.9%) died during follow-up. Recurrence treatment included enucleation in 51 patients (68.9%) and radiosurgery in 19 patients (25.7%). Treatment planning without contrast medium MRI, radiation dose of less than 21 Gy, and insufficient margin delineation were identified as risk factors incrementing local control.

Discussion

Robotic-assisted radiosurgery (CyberKnife) is a suitable treatment option for large choroidal melanoma up to 12 mm. Patients with significantly better visual acuity received repeat CyberKnife treatment as salvage therapy and showed an eye retention rate of 81%.

Evaluation of Low-Molecular-Weight Heparin Treatment on First- and Second-Trimester Screening Test Results

Background The serum markers used in first- and second-trimester screening tests can be affected by different causes such as smoking, infertility treatment, and the presence of diabetes mellitus, which should be considered by obstetricians when giving information to patients. Low molecular weight heparin (LMWH) has a critical importance in the prophylaxis of deep vein thrombosis both in the antenatal and postnatal period. The aim of the current study is to investigate the effect of LMWH use on the first- and second-trimester screening results. Methods A retrospective analysis in our outpatient clinic between July 2018 and January 2021 of first- and second-trimester screening test results was conducted to assess the impact of LMWH treatment for patients with thrombophilia who started LMWH after pregnancy was detected were included. Test results were obtained as a multiple of median (MoM) combined with ultrasound measurements, maternal serum markers, and maternal age in addition to the nuchal translucency first-trimester test. Results The pregnancy-associated plasma protein-A (PAPP-A) MoM was lower and alpha-fetoprotein (AFP) and unconjugated estriol (uE3) MoMs were higher in patients treated with LMWH than in the control group (0.78 MoM vs 0.96 MoM; 1.00 MoM vs 0.97 MoM; and 0.89 MoM vs 0.76 MoM, respectively). Human chorionic gonadotropin (HCG) levels did not differ between groups at either time point. Conclusions Treatment of pregnant women with LMWH for thrombophilia may change the MoM values of serum markers for both first- and second-trimester screening tests. Obstetricians should be aware of this when advising screening tests to thrombophilia patients and should consider offering fetal DNA tests for this group instead.

Do Platelet-Rich Plasma Injections for Knee Osteoarthritis Work?

BACKGROUND

Recent evidence suggests a benefit in platelet-rich plasma injections (PRP) for the knee in the management of mild to moderate osteoarthritis (OA). There is a reported reduction in pain, stiffness, and improved function. However, there is very little level-one literature available that supports this practice and conclusively proves a benefit gained throughout the course. Three main randomized control trials (RCTs) conducted in North America are often referenced and cited to prove their efficacy. This study aimed to look at the outcomes of patients having undergone this treatment to determine if there was any benefit.

AIMS

This study aimed to determine if PRP injections administered in patients with knee OA over a six to eight-week time period demonstrated any benefit.

METHODS

The Western Ontario and McMaster Universities arthritis index (WOMAC) tool was used before each of the three PRP injections over the six to eight-week period, and six weeks after the final injection in 31 patients. Each injection was given spaced two to three weeks apart. The outcomes observed were pain, stiffness, and physical function, and the total WOMAC score was calculated.

RESULTS

The third injection showed a reduction in total WOMAC score, pain, stiffness, and physical function by 16.36%, 16.37%, 5.12%, and 18.03%, respectively. However, all scores returned close to baseline at the sixth-week follow-up post treatment.

CONCLUSION

Results showed a trend of reduction in the WOMAC score. However, they are overall indicative of a placebo effect from the injections. Further studies are needed to explore whether the grade of OA and patients' weight have a significant impact on the results.

A Retrospective Cohort Study on Maternal and Neonatal Clinical Characteristics and Outcomes of COVID-19: Does the Gestational Age Affect the Outcome?

Background To evaluate the maternal and neonatal clinical characteristics and outcomes of COVID-19 during pregnancy and to see whether infection with COVID-19 before or after the 20th gestational week affects these outcomes. Methods We conducted a retrospective study with data from pregnant women who were followed up and delivered at Acibadem Maslak Hospital between April 2020 and December 2021. Their demographics and clinical data were reviewed and compared. Results Among 1223 pregnant women, 42 (3.4%) were diagnosed with COVID-19 (SARS-CoV-2-positive). Approximately 52.4% of the 42 pregnant women with COVID-19 were diagnosed during or before the 20th gestational week, while 47.6% were positive after the 20th gestational week. The preterm birth rate was 11.9% and 5.9% in infected and uninfected pregnant women, respectively (p>0.05). In the infected pregnant women, the rate of preterm rupture of membranes (PROM) was 2.4%, small for gestational age (SGA) was 7.1%, cesarean delivery was 76.2%, and neonatal intensive care unit (NICU) admission was 9.5%. These rates among uninfected women were 0.9%, 9.1%, 61.7%, and 4.1%, respectively (p>0.05). Maternal ICU admission and intrapartum complications were higher in infected pregnant women (p>0.05). Postpartum hemorrhage (PPH), intrauterine growth retardation (IUGR), neonatal infection, and fetal demise were absent in SARS-CoV-2-positive pregnant women. Having a high school or lower education level significantly increased the risk of SARS-CoV-2 infection during pregnancy 10 times. Also, a one-week increase in gestational age significantly reduced the risk of SARS-CoV-2 infection during pregnancy. When SARS-CoV-2-positive pregnant women were compared according to whether or not they were positive before or after the 20th gestational week, there was no statistically significant difference between the two groups in terms of maternal outcomes, neonatal outcomes, and demographic characteristics. Conclusions COVID-19 during pregnancy did not adversely affect maternal and neonatal outcomes. Also, whether pregnant women were infected before or after the 20th gestational week did not have a negative impact on maternal and neonatal outcomes. However, infected pregnant women should be followed closely, and they should be informed in detail about the possible adverse outcomes and the importance of precautions for COVID-19.

Artificial Hallucinations in ChatGPT: Implications in Scientific Writing

While still in its infancy, ChatGPT (Generative Pretrained Transformer), introduced in November 2022, is bound to hugely impact many industries, including healthcare, medical education, biomedical research, and scientific writing. Implications of ChatGPT, that new chatbot introduced by OpenAI on academic writing, is largely unknown. In response to the Journal of Medical Science (Cureus) Turing Test - call for case reports written with the assistance of ChatGPT, we present two cases one of homocystinuria-associated osteoporosis, and the other is on late-onset Pompe disease (LOPD), a rare metabolic disorder. We tested ChatGPT to write about the pathogenesis of these conditions. We documented the positive, negative, and rather troubling aspects of our newly introduced chatbot's performance.

Should Preventive Antifungal Treatment Be Given to Patients With Abdominal Contamination in the Intensive Care Unit?

Background Intra-abdominal contamination is a critical risk factor for candidemia. Because of the high mortality of candidemia and delayed results of cultures, preventive antifungal (AF) treatment can be administered. Especially in the intensive care unit (ICU), it may be necessary to determine the preventive AF approach due to the poor clinical condition of the patients. However, this practice is not standard among clinicians, and it is controversial whether it is beneficial or not. This study aimed to evaluate the effects of different AF treatment approaches (prophylactic, empirical, and culture-directed) on mortality, development of candidemia, and length of hospital stay in these patients. The primary outcome of the study was mortality, and the secondary outcomes were the development of candidemia and length of hospital stay. Methodology This is a retrospective, single-center, cohort study. Adult patients who were hospitalized in the ICU with the diagnosis of intra-abdominal contamination between January 1, 2017, and December 31, 2020, were reviewed retrospectively from electronic hospital records and Infectious Diseases ICU patient follow-up forms. Age, gender, comorbid diseases, the reason for hospitalization, history of surgical operation, surgical procedure type, length of hospital stay, culture results of blood and intraoperative intra-abdominal samples (pus, peritoneal fluid, abscess), type of AF agents, and mortality status of the patients were recorded. Furthermore, white blood cell (WBC) count, platelet count, C-reactive protein (CRP) level, procalcitonin (PCT) level, and serum albumin levels in blood samples taken on three different days (the day of diagnosis, the day of operation, and the day of candidemia) were examined. The patients were grouped as without AF, receiving prophylactic AF, receiving empirical AF, and receiving culture-directed AF. Additionally, the study population was evaluated by dividing it into two groups, namely, those who developed candidemia and those who did not. The patients were evaluated regarding the development of candidemia, AF treatment approach, length of hospital stay, and mortality. Results A total of 196 patients were included in the study. Candidemia was determined in 31.6% of the patients. Candidemia was more common in patients with a history of previous surgery and presenting with acute abdominal pain than other causes. It was determined that 70% of the patients who developed candidemia had perforation, with the most common being colonic perforation. The hospital stay was longer in patients with candidemia than without candidemia (47.9 vs. 22.4 days; p < 0.001). When empirical and prophylactic AF recipients were compared, there was no difference in mortality and length of hospital stay. Prolongation of the time to empirical treatment after perforation/leak was associated with increased candidemia (p = 0.004). Furthermore, patients with a waiting time of ≥4.5 days until surgical operation were at a higher risk of developing candidemia. Conclusions Although the study did not demonstrate a difference in terms of reducing mortality, it was concluded that preventive AF therapy can be administered to reduce the risk of candidemia and hospitalization duration, especially in patients with a history of previous surgical operations and abdominal contamination with a prolonged waiting period until the surgical operation.

Correction: A Rare Case of Pontocerebellar Hypoplasia Type 1B With Literature Review

[This corrects the article DOI: 10.7759/cureus.27098.].

Atypical Dermatitis Herpetiform and Scalp Psoriasis in Ulcerative Colitis Patient Treated With Adalimumab

Adalimumab is a blocker of tumor necrosis factor (TNF)-alpha with established efficacy in the treatment of ulcerative colitis. However, literature indicated that adalimumab can, occasionally, induce paradoxical psoriasis reactions and, very rarely, dermatitis herpetiformis. We present a unique case of a 26-year-old female patient who developed a combination of dermatitis herpetiformis and scalp psoriasis paradoxically as a result of adalimumab treatment for ulcerative colitis. To the best of our knowledge, this is the first case of such a combination within the context of adalimumab therapy. The etiopathological underpinning of such a reaction remains elusive but is speculated to be complex and involves the interaction of several immunological and dermatological mechanisms. Adalimumab therapy is associated with a genuine risk for the development of paradoxical psoriasis and dermatitis herpetiformis. We, through this case report, added to the evidence confirming such an association. Clinicians should follow these potential adverse effects and make every effort to warn patients of their likelihood.

Correction: The Meaning of Lymphadenopathies During Adjuvant Durvalumab After Chemoradiotherapy for Lung Cancer: Thinking Beyond Disease Progression

[This corrects the article DOI: 10.7759/cureus.26729.].

Effect of a Motion Artifact Correction System on Cone-Beam Computed Tomography Image Characteristics

OBJECTIVES

Determine the effect of the motion correction system on cone-beam computed tomography (CBCT) image quality parameters, artifacts, and contrast-to-noise ratio (CNR) using different motion settings.

MATERIALS AND METHODS

A customized phantom insert array was prepared using SEDENTEX CT IQ Phantom (Leeds Test Objects, Yorkshire, England) stabilized over a rotating electric turntable. Thirty baseline CBCT scans were acquired with standardized technique factors on the ProMax 3D (Planmeca, Helsinki, Finland) machine using combinations of different motion settings, including no motion, three- and six-degree motion, and with and without the use of a motion correction system. The standardized images were exported to ImageJ software. Image quality parameters, artifacts, and CNR values were evaluated and compared among the different acquisition settings.

RESULTS

The use of the motion correction system algorithm compared with the different motion settings showed a statistically significant difference for all the parameters (p<0.05) except for artifact values for six-degree motion (p<0.07). The effect of different motion settings on the parameters was not statistically significant.

CONCLUSION

The use of a motion correction system, a proprietary algorithm-based system incorporated in the ProMax 3D CBCT unit, deteriorates the image quality characteristics evaluated in this in vitro study, namely artifact value and CNR. Its use in clinical settings might be limited to situations where patient motion is expected and appropriate head stabilization is not possible due to age or disease.

The Effect of the COVID-19 Pandemic on the Characteristics of Inpatients at the Orthopaedics and Traumatology Clinic in a Secondary Care Public Hospital in Turkey

Objective The aim of this study was to evaluate patients who were hospitalized at an orthopaedics and traumatology clinic in a secondary care public hospital in Turkey during the first two years of the COVID-19 pandemic. Methods This was a cross-sectional and retrospective study that included a total of 7439 patients - those who had been hospitalized between 11 March 2020, the date of the first confirmed case of COVID-19 in Turkey, and 10 March 2022 (2949 patients), and those hospitalized in the same clinic between 11 March 2018 and 10 March 2020, designated as the pre-pandemic group (control group; 4490 patients). Patients were divided into three groups: <18 years old, 18-65 years old and >65 years old and compared separately in terms of clinical, diagnostic and therapeutic characteristics as pandemic patients and control group. Results Despite the decline in both the number of admissions to the emergency service and visits to the outpatient clinic among inpatients during the pandemic period, the rate of admissions to the emergency department remained higher than that of the control group throughout the pandemic period (p<0.001). Surgical procedures were lower both numerically and proportionally in the patients who presented during the pandemic than in the pre-pandemic period (p<0.001). While the rate of traumatic surgery was higher in the pandemic group (29%) than in the pre-pandemic group (26.7%), the rate of elective surgery was higher in the pre-pandemic group (71.3%) than in the pandemic one (67.5%) (p=0.037 and p=0.001).The number of patients with fractures in all age groups decreased numerically in the pandemic cohort. While no significant difference was observed between pandemic and pre-pandemic cohorts in terms of the length of hospitalization in all age groups, Intensive Care Unit (ICU) hospitalization rate was found to have increased significantly in adult and elderly patient groups during the pandemic (p<0.001). Conclusion In our study, when the number of patients who underwent orthopaedic surgical treatment, in general, was examined, it appeared that the number of both traumatic and elective surgeries decreased during the pandemic significantly. It was found that the ICU stay rate increased significantly in adult and elderly patient groups during the pandemic. Although there were no confirmed cases of COVID-19 among the patients included in the study, it is known that the pandemic and especially the lockdown periods adversely affected the mental, physical and biological health of individuals. In this context our study will be able to serve as a guide for taking measures like: 1. increasing the ICU capacity of hospitals, 2. providing in-service training to improve the experience of nurses, doctors or other healthcare workers, especially in specialized units such as ICUs, operating rooms and emergency services, considering the number of personnel who may be affected by the pandemic, and 3. ensuring a balanced distribution of orthopaedic operations in private and public hospitals, to reduce the negative effects on orthopaedic health services of other pandemics that may arise in the future.

Rare Association Between Lichen Planus and Vogt-Koyanagi-Harada Syndrome: A Case Report

Vogt-Koyanagi-Harada syndrome (VKHS) is a rare inflammatory autoimmune condition that affects tissues with high melanocyte concentrations such as the skin, inner ears, eyes, and central nervous system. VKHS has previously been reported to be associated with various autoimmune diseases, but we have observed the first known co-occurrence of VKHS and lichen planus (LP). In this report, we examine the similarities between these two diseases and discuss how they relate to each other.

Our Experience in Tracking the Tract: Normal Biliary Anatomy and Variants on Magnetic Resonance Cholangiopancreatography in Living Donor Liver Transplantation

Objective Biliary anatomy is of paramount importance for hepatobiliary pancreatic surgeons for operative planning. Preoperative assessment with magnetic resonance cholangiopancreatography (MRCP) to evaluate the biliary anatomy plays a vital role, especially for prospective liver donors in living donor liver transplantation (LDLT). Our objective was to evaluate the diagnostic accuracy of MRCP in assessing the anatomical variations of the biliary system and the frequency of biliary variation in the donors of LDLT. Materials and Methods Sixty-five donors of living donor liver transplantation in the age range of 20 to 51 years were studied retrospectively to evaluate the anatomical variations of the biliary tree. As a part of the pre-transplantation donor workup, MRI with MRCP was performed in a 1.5T machine for all these candidates. MRCP source data sets were processed with maximum intensity projections, surface shading, and multi-planar reconstructions. Images were reviewed by two radiologists, and the classification system of Huang et al. was utilized to evaluate the biliary anatomy. The results were compared with the intraoperative cholangiogram, considered the gold standard. Results We identified standard biliary anatomy in 34 candidates (52.3%), and variant biliary anatomy was observed in 31 candidates (47.7%) on MRCP. An intraoperative cholangiogram showed standard anatomy in 36 candidates (55.4%) and biliary variation in 29 candidates (44.6%). Our study showed a sensitivity of 100% and a specificity of 94.5% for identifying biliary variant anatomy on MRCP in comparison with the gold standard intraoperative cholangiogram. The accuracy of MRCP in detecting the variant biliary anatomy in our study was 96.9%. The most common biliary variation was the right posterior sectoral duct draining into the left hepatic duct, Huang type A3. Conclusion The frequency of biliary variations is high in potential liver donors. MRCP is sensitive and highly accurate in identifying the biliary variations of surgical significance.

Acute Macular Neuroretinopathy Associated With COVID-19 Infection: Is Double Heterozygous Methylenetetrahydrofolate Reductase (MTHFR) Mutation an Underlying Risk Factor?

The goal of this report is to present a case of coronavirus disease 2019 (COVID-19)-associated acute macular neuroretinopathy (AMN) with an underlying MTHFR mutation. A 36-year-old male presented to the emergency department with a sudden-onset paracentral scotoma in his left eye. Although optical coherence tomography (OCT) was normal initially, four days later, it revealed a hyperreflective band in the outer plexiform layer with disruption of the ellipsoid zone/interdigitation zone. On infrared imaging and en-face OCT, wedge-shaped lesions were detected around the fovea with their tip oriented toward the fovea. OCT angiography, fundus autofluorescence, fundus fluorescein angiography, and visual fields were performed. The patient was positive for COVID-19 infection. The absence of medical history and the negative results of blood tests led to a diagnosis of AMN associated with COVID-19. Genetic testing for coagulation disorders was scheduled and revealed a heterozygous mutation for MTHFR C677T and A1298C. This is the first case of AMN in a patient with COVID-19 infection and a double heterozygous mutation of the MTHFR gene. Infection is the most commonly reported association of AMN, while MTHFR mutation may represent an additional underlying risk factor. Microthrombosis and small-vessel occlusion are thought to be involved in the pathophysiology of AMN, and patients should be tested for COVID-19 because it may be the first manifestation of the infection.