Case report: How I do it? Laparoscopic hepatectomy with transcatheter arterial ICG staining for hepatolithiasis review

Background

Hepatolithiasis is regarded as the presence of stones in the intrahepatic bile ducts. Recurrent inflammation of bile ducts can bring many bad effects. How to completely remove stones is still a challenge.

Presentation

A 66-year-old male went to our hospital because of hepatolithiasis and choledocholithiasis. Selective hepatic arteriography and transcatheter arterial embolization followed by laparoscopic watershed hepatectomy under fluorescent navigation and laparoscopic common bile duct exploration on mass removal are performed.

Clinical discussion

For patients who suffer from hepatolithiasis, the main treatment principles of the operation are to remove the stones, correct the stenosis, and prevent recurrence. The laparoscopic watershed hepatectomy under fluorescent navigation can provide important support for precision liver surgery, which can give some suggestions for future hepatectomy.

Conclusion

Based on the three-dimensional (3D) visual watershed analysis, trans-arterial DSA positive fluorescence navigation has some advantages, which successfully overcome the shortcomings of the reverse staining method and the positive staining method.

Evaluation the level of vitamin D and its relationship with clinical symptoms in patients with COVID-19 referred to the medical center in Bam city

Background

Vitamin D is a steroid hormone that protects against viral infections by influencing innate and adaptive immune responses. The effectiveness of vitamin D3 supplementation in COVID-19 is unknown. The study's goal was to elucidate the relationship between blood vitamin D levels and COVID-19 clinical outcomes by examining the effect of a single high dose of vitamin D3 on the length of hospital stay in COVID-19 patients.

Methods

The descriptive, retrospective study was performed from March to May 2021 at a referral center for patients with COVID-19, in Bam, Iran. A checklist consisting of demographic variables was used to gather data, and laboratory assessments of serum 25(OH) D were evaluated and documented. The connection between serum vitamin D and patient clinical outcomes was investigated after patients were given a single oral dose of 200,000 IU of vitamin D3.

Results

71 COVID-19 patients were treated. Radiological results did not change substantially amongst individuals with various levels of 25(OH)D. After a single dosage of vitamin D3, mean blood levels of 25-hydroxyvitamin D increased considerably and the need for intubation and SpO2 decreased, and as did the respiratory rate in patients requiring hospitalization due to COVID-19.

Conclusion

A single administration of 200,000 IU of vitamin D3 significantly reduced the severity of COVID-19.

Validation of the German version of the Asthma Impairment and Risk Questionnaire (AIRQ)

BACKGROUND

The Asthma Impairment and Risk Questionnaire (AIRQ), a 10-item, equally weighted, yes/no tool assessing symptom impairment and risk of exacerbations in patients with asthma aged ≥12 years, was developed and validated in a US patient population to evaluate varying levels of asthma control. This study aimed to validate the German language version of the AIRQ in patients aged ≥12 years with different levels of asthma control.

METHODS

A cross-sectional, observational, multi-centre study comprising a single visit was conducted in multiple specialised asthma centres and general practices in Germany. A total of 300 patients completed the following measures: 1) Patient Sociodemographic and Clinical Questionnaire, 2) AIRQ, 3) Asthma Control Test (ACT), and 4) Asthma Control Questionnaire (ACQ-6). Logistic regression analyses were conducted to assess the AIRQ score cut points with the greatest predictive validity in discriminating between different control levels relative to a standard of ACT plus prior-year exacerbations or ACQ-6 plus prior-year exacerbations.

RESULTS

The German version of the AIRQ demonstrated a robust capability to correctly identify well-controlled versus not well- or very poorly controlled (AUC values of 0.90 or higher) and well- or not well-controlled versus very poorly controlled asthma (AUC values of 0.89 or higher).

CONCLUSIONS

The German version of the AIRQ is a suitable tool to identify adults with varying levels of asthma control, which in turn can help to accurately identify patients with uncontrolled asthma in clinical practice.

Non-cholera Vibrio infections in Southeast Asia: A systematic review and meta-analysis

We reviewed and analyzed the existing data on vibriosis in Southeast Asia to better understand its burden and prevalent causal agents. We searched PubMed, Web of Science, and EMBASE for studies published between January 2000 and April 2024. A random-effects meta-analysis was used to estimate the pooled isolation rate of non-cholera Vibrio species. Among the 1385 retrieved studies, 22 met the inclusion criteria for the systematic review and 11 were included in the meta-analysis. The pooled isolation rate of non-cholera Vibrio species among diarrheal patients was 5.0 %. Most species that caused vibriosis included V. parahaemolyticus, V. mimicus, V. vulnificus, non-O1/non-O139 V. cholerae, V. fluvialis, and V. alginolyticus. Pooled isolation rate of V. parahaemolyticus and non-O1 V. cholerae were 7.0, and 4.0, respectively. The prevalence of vibriosis in Southeast Asia is non-negligible. Public health strategies should prioritize enhanced surveillance, and clinicians should consider vibriosis in diarrheal patients with seafood consumption history.

A young female's battle with toxic epidermal necrolysis induced by NSAIDs: a case report

Introduction

Stevens-Johnson Syndrome (SJS) is a rare but severe mucocutaneous reaction often triggered by medications or infections, characterized by extensive epidermal detachment and mucosal involvement. This condition poses a high risk of morbidity and mortality, requiring prompt recognition and treatment.

Case presentation

An 18-year-old Asian female from eastern Nepal presented with nonitchy red spots, high fever, and significant discomfort following the administration of ibuprofen for minor sores. She developed extensive skin involvement covering 25% of her body surface area and severe mucosal lesions. Laboratory investigations revealed anemia, leukocytosis, and coagulopathy. She was admitted to the ICU, where she received broad-spectrum antibiotics, corticosteroids, and supportive care. The patient also developed acute kidney injury during treatment but eventually recovered and was discharged after a week.

Clinical discussion

The rapid onset of SJS in this patient reveals the unpredictable nature of drug-induced reactions. Early intervention with a multidisciplinary approach involving dermatology, intensive care, and infectious disease specialists was crucial in managing her condition. Despite the controversy surrounding corticosteroid use in SJS, their administration likely contributed to the rapid improvement in inflammation and skin healing. The case highlights the importance of early recognition, prompt management, and careful monitoring for adverse drug reactions, especially when prescribing medications known to cause SJS.

Conclusion

The successful outcome achieved through a multidisciplinary approach provides valuable insights into the effective strategies for handling severe drug reactions, emphasizing that early diagnosis and comprehensive management in patients with SJS is critical.

Leveraging Artificial Neural Networks and Support Vector Machines for Accurate Classification of Breast Tumors in Ultrasound Images

Background and Aim Breast cancer is a leading cause of cancer-related deaths among women, and ultrasound imaging is crucial for early detection. However, variability in interpretation can affect diagnosis. Therefore, this study compared the performance of artificial neural networks (ANNs) and support vector machines (SVMs) in classifying breast tumors using ultrasound images. Method This comparative study was conducted from June 1, 2023, to June 1, 2024, using a convenience sampling method. Data were gathered from the Center for Breast Diseases at Nanakali Hospital in Erbil, Kurdistan Region of Iraq, and a publicly available dataset from Kaggle. ANN and SVM models were then applied to classify the tumors. Statistical analysis was performed using R (R Foundation for Statistical Computing, Vienna, Austria) and IBM SPSS Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, New York, United States), with performance metrics such as accuracy, sensitivity, specificity, and Kappa coefficient calculated for both models. Results The ANN model achieved an accuracy of 87.78%, with a sensitivity of 86.67% and a specificity of 88.89%. The SVM model demonstrated an accuracy of 86.67%, with a higher specificity of 95.56% but a lower sensitivity of 77.78%. Both models showed substantial agreement between predicted and actual classifications, with Kappa coefficients of 75.56% for ANN and 73.33% for SVM. The mean, skewness, and area were identified as the most important variables for the ANN model, while solidity, circularity, and perimeter were the most critical features of the SVM model. Conclusions The results indicated that ANN had a marginally higher accuracy than SVM in classifying breast tumors. It is recommended to further optimize these models for clinical use, improve the integration of machine learning in medical imaging, and expand the dataset to enhance model generalizability and robustness.

Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

BACKGROUND AND OBJECTIVES

Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era.

METHODS

This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis.

RESULTS

Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction.

CONCLUSION

These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

Idiopathic intracranial hypertension following childbirth: a case report and management strategies

Introduction

A postpartum headache, also known as pseudotumor cerebri, is defined as a headache and shoulder or neck pain that occur in the first 6 weeks following childbirth. Common causes of headaches during puerperium include pre-eclampsia, subarachnoid hemorrhage, cerebral venous thrombosis, meningitis, brain tumors, cerebrovascular diseases, and posterior reversible encephalopathy syndrome. Pseudotumor cerebri is an extremely rare cause of postpartum severe headache with visual disturbance with or without papilledema.

Case presentation

Here, the authors present a 32-year-old postpartum female patient who presented with a severe headache and visual disturbance for 10 days. Neurological examination did not show any focal or lateralizing deficit. However, a fundus examination showed severe bilateral papilledema. A contrast-enhanced brain MRI did not reveal a space-occupying mass lesion. MRV excluded venous occlusion. A lumbar puncture demonstrated a high opening pressure of 75 cmH2O with a normal cell count and protein and glucose levels. The patient was diagnosed with idiopathic intracranial hypertension. After 8 weeks of treatment with diazomid and topiramate, the patient improved clinically, and her papilledema regressed.

Clinical discussion

The occurrence of IIH is very rare among postpartum females. To our knowledge, very few cases of postpartum IIH have been reported in the medical literature. Although rare, patients with postpartum headache with visual disturbances should have a fundoscopic examination. The patient was diagnosed and managed in time, which led to significant clinical improvement and salvage of her vision.

Conclusion

As described in this case, idiopathic intracranial hypertension can cause severe headaches with and without visual disturbance during the postpartum period (despite being rare in this period), so it should be considered in the differential diagnosis.

Generative Artificial Intelligence: Applications in Scientific Writing and Data Analysis in Wound Healing Research

ABSTRACT

Generative artificial intelligence (AI) models are a new technological development with vast research use cases among medical subspecialties. These powerful large language models offer a wide range of possibilities in wound care, from personalized patient support to optimized treatment plans and improved scientific writing. They can also assist in efficiently navigating the literature and selecting and summarizing articles, enabling researchers to focus on impactful studies relevant to wound care management and enhancing response quality through prompt-learning iterations. For nonnative English-speaking medical practitioners and authors, generative AI may aid in grammar and vocabulary selection. Although reports have suggested limitations of the conversational agent on medical translation pertaining to the precise interpretation of medical context, when used with verified resources, this language model can breach language barriers and promote practice-changing advancements in global wound care. Further, AI-powered chatbots can enable continuous monitoring of wound healing progress and real-time insights into treatment responses through frequent, readily available remote patient follow-ups.However, implementing AI in wound care research requires careful consideration of potential limitations, especially in accurately translating complex medical terms and workflows. Ethical considerations are vital to ensure reliable and credible wound care research when using AI technologies. Although ChatGPT shows promise for transforming wound care management, the authors warn against overreliance on the technology. Considering the potential limitations and risks, proper validation and oversight are essential to unlock its true potential while ensuring patient safety and the effectiveness of wound care treatments.

Use of N-Acetylcysteine in the Management of Isoniazid-Induced Liver Injury in a Tuberculosis Patient: A Case Report

Drug-induced liver injury (DILI) is a rare but significant cause of acute liver failure, often challenging to diagnose due to its clinical similarity to other liver conditions. Since most drugs are metabolized by liver enzymes, the liver is at risk for hepatotoxicity. Although DILI has a low incidence in clinical practice, it remains a critical consideration for patients on potentially hepatotoxic medications. Acetaminophen is the most commonly implicated drug in DILI cases and is prioritized in toxicology screenings. Effective management of DILI requires the prompt discontinuation of the offending drug and supportive care. This case report discusses a 65-year-old male patient who developed elevated liver enzymes three weeks after starting tuberculosis treatment, raising suspicion of DILI. This report explores the diagnostic process, management strategies, and therapeutic role of N-acetylcysteine (NAC), emphasizing its mechanism of action, current clinical applications, and potential future uses in treating DILI.

Phlegmonous Gastritis With Streptococcal Toxic Shock Syndrome: A Rare Complication After Endoscopy

Phlegmonous gastritis is a rare, suppurative bacterial infection of the gastric wall and one of the rarest complications after upper gastrointestinal endoscopy. The pathogenesis is not fully clear, but multiple risk factors have been described in literature as mucosal injury and achlorhydria. We report a case of a 76-year-old male with vomiting and epigastric pain, two days after an upper endoscopy, who presented in septic shock. The diagnostics with computed tomography showed diffuse thickening of the gastric wall, and the differential diagnosis of phlegmonous gastritis was made. Subsequently, he developed abdominal compartment syndrome and clinically deteriorated, necessitating open partial gastric resection. This case of a rare complication after upper gastrointestinal endoscopy with a potentially fatal outcome illustrates septic shock and abdominal compartment syndrome as severe complications. In this case, a combination of early antibiotic treatment and calculated surgical interventions showed a favorable outcome. Only a limited number of cases of phlegmonous gastritis after endoscopy have been published, and to the best of our knowledge, this is the second case of phlegmonous gastritis with subsequent abdominal compartment syndrome as a complication.

The primary cause of markedly elevated aminotransferases in hospitalized patients with cirrhosis in ischemic hepatitis

BACKGROUND

Marked elevation in aminotransferases (≥1000 IU/l) is typically associated with acute liver injury. Here, we hypothesized that the cause of elevation in aminotransferases ≥1000 in patients with cirrhosis is likely due to a limited number of disorders and may be associated with poor outcomes.

AIM

We aimed to investigate the most common etiologies of acute elevations in aminotransferases in patients with cirrhosis, and to examine their associated outcomes.

METHODS

From May 2012 to December 2022, all hospitalized patients with cirrhosis and an aspartate aminotransferase or alanine aminotransferase ≥ 1000 IU/l were identified through Medical University of South Carolina's Clinical Data Warehouse. Complete clinical data were abstracted for each patient, and in-hospital mortality was examined.

RESULTS

The cohort was made up of 152 patients, who were 57 ± 12 years old, with 51 (34%) women. Underlying liver disease included mainly hepatitis C cirrhosis, alcohol-related cirrhosis, metabolic dysfunction-associated steatohepatitis cirrhosis, autoimmune cirrhosis, primary sclerosing cholangitis cirrhosis, and cryptogenic cirrhosis. The most common cause of marked elevation in aminotransferases in cirrhotic patients was ischemic hepatitis (71%), followed by chemoembolization (7%), autoimmune hepatitis (6%), drug-induced liver injury (3%), post-transjugular intrahepatic portosystemic shunt placement (3%), rhabdomyolysis (3%), and hepatitis C (2%). During hospitalization and over a 1-month follow-up period, the mortality rate in patients with ischemic hepatitis was 73% (79/108), while that for other causes of liver injury was 20% (9/44).

CONCLUSION

Ischemic hepatitis is the leading cause of marked elevation of aminotransferases in patients with cirrhosis, with distinctive clinical characteristics than other etiologies, and significantly poorer outcomes.

A case of invasive Aspergillus niger spondylodiscitis with epidural abscess following COVID-19 infection in an immunocompromised host with literature review

Introduction and Importance

Aspergillosis is defined as an opportunistic infection that may spread hematogenously. COVID-19 infection has not been reported as a direct cause or risk factor. Its treatment (e.g. corticosteroids) significantly increases the risk for invasive infections. The respiratory system remains the main target, and the Aspergillus fumigatus is the most responsible subtype. Other species like Aspergillus (A) flavus, A. niger, and A. nidulans follow in frequency. Other included sites are the skeletal muscular system and the entire spine leading to spondylodiscitis. Only a total of 118 cases of Aspergillus spondylodiscitis have been reported in the literature, and only 21 cases reporting spinal epidural abscess were identified.

Case Presentation

The authors report a new rare case of invasive A. Niger spondylodiscitis with epidural and iliopsoas abscesses in a 63-year-old North African female patient with a history of coronavirus infection (COVID-19) treated with high doses of corticosteroids. The patient had favorable medical and radiological outcomes after 6 months of antibiotic and antifungal therapy.

Clinical Discussion

Fungal spondylodiscitis is a rare pathology that may be lethal. Immunosuppression plays a determining role. Discovertebral contamination results from hematogenous dissemination, found in the majority of cases in adults. The main symptom is segmental spinal pain, with an inflammatory pattern most often predominating in the thoracolumbar spine. Clinical signs of spinal cord compression, such as paresthesias, radiculalgia, and paraplegia, can sometimes be associated. Diagnosis of such spondylodiscitis is based on cultures and/or histology, whereas in most cases, it was made by MRI. Epidural abscess remains a rare entity. The authors will explore the current literature in more detail to dissect and explain this rare entity.

Conclusion

Aspergillus spondylodiscitis remains a rare and very demanding clinical entity. Early diagnosis and well-targeted medical treatment seem the ideal solution given that this type of infection has a poor prognosis.

Assessing the Pathophysiology, Morbidity, and Mortality of Obstructive Sleep Apnea

The basic definitions of obstructive sleep apnea (OSA), its epidemiology, its clinical features and complications, and the morbidity and mortality of OSA are discussed. Included in this treatise is a discussion of the various symptomatic and polysomnographic phenotypes of COPD that may enable better treatment and impact mortality in persons with OSA. The goal of this article is to serve as a reference for life and disability insurance company medical directors and underwriters when underwriting an applicant with probable or diagnosed sleep apnea. It is well-referenced (133 ref.) allowing for more in-depth investigation of any aspect of sleep apnea being queried.

Rare presentation of huge ectopic ureterocele in an adult female: a case report

Introduction and importance

Ectopic ureteroceles are primarily found in children, often detected incidentally during antenatal ultrasonography or due to urinary tract infection (UTI) symptoms. However, they are rare in adults, with limited published cases.

Case presentation

This report details a case of a 24-year-old woman who experienced recurrent UTIs and sudden urinary retention, ultimately needing manual compression to urinate due to poor urine flow. Intravenous urography revealed a large right ectopic ureterocele that protruded through the urethra during urination. Cystoscopy confirmed extensive right-sided ureteroceles affecting the bladder and causing her urinary difficulties.

Clinical discussion

Although ectopic ureteroceles in adults can present with a range of symptoms, including obstruction and recurrent infections, the management approach is often individualized based on the clinical presentation and imaging findings. In this case, endoscopic incision was chosen for its minimally invasive nature, leading to full recovery without complications. Despite the risks of recurrence and potential scarring, the patient showed no recurrence at follow-up and remains symptom-free.

Conclusion

This case underscores the rarity of symptomatic giant ectopic ureteroceles in adult females and highlights the importance of considering this condition in women with recurrent UTIs.

Laparoscopic-Assisted Enterolithotomy for Recurrent Gallstone Ileus: A Case Report

Gallstone ileus is the mechanical obstruction of the bowel due to gallstone impaction. It forms when a fistula is created between the gallbladder and the gastrointestinal tract, which can result in small bowel obstruction. Its surgical management ranges from enterolithotomy, cholecystectomy, and fistula closure performed together (one-stage) or performed separately (two-stage), while some patients undergo simple enterolithotomy. Emergency surgery with open enterolithotomy, with or without biliary tract surgery, has been replaced by laparoscopic-assisted enterolithotomy as a safer and more rapid procedure. This report is of a 68-year-old woman treated with laparoscopic-assisted enterolithotomy for gallstone ileus which recurred. A 68-year-old woman with type 2 diabetes mellitus, hypertension, breast cancer, and end-stage renal disease on hemodialysis presented with a gallstone ileus and was surgically managed with successful laparoscopic-assisted enterolithotomy. Seven days after the initial surgery, she again presented with gallstone ileus requiring reoperation. A repeat laparoscopic-assisted enterolithotomy was performed with no complications and full resolution of her symptoms. Operative management of gallstone ileus and subsequent recurrence continues to be highly debated. With no randomized studies and limited data, there is no current gold standard surgical procedure for either setting. Simple laparoscopic-assisted enterolithotomy is the favored surgical technique as it is associated with decreased morbidity, mortality, operative time, and complications. This report demonstrates that a CT scan is crucial in differentiating recurrent gallstone ileus from postoperative ileus, with a repeat laparoscopic-assisted enterolithotomy providing a safe and effective treatment option. Moreover, patient follow up is essential for monitoring symptom resolution.

Biliary atresia with rare associations: a case report and literature review

Introduction and importance

Biliary atresia is a rare, progressive cholangiopathy that affects newborns, causing jaundice and other manifestations of hyperbilirubinemia. The incidence is higher in Asia than in Europe. The only available treatment is a surgical operation called Kasai portoenterostomy. In this case, the authors highlighted rare congenital anomalies that came with biliary atresia.

Case presentation

A 10-day-old male infant was admitted to the hospital due to recurrent vomiting, yellowish skin, and scleral icterus. Laboratory investigations revealed elevated total serum and direct bilirubin levels. An atrophic gallbladder was observed on ultrasound. Intrahepatic cholangiography confirmed the diagnosis of biliary atresia, leading to the performance of a Kasai procedure. Additionally, the patient had intestinal malrotation and volvulus, which were managed with a Ladd's procedure. Following surgery, there was notable improvement in liver enzymes and bilirubin levels, and the patient was discharged after 7 days. The infant has been initiated on oral vitamins, ursodeoxycholic acid, and antibiotics.

Clinical discussion

Biliary atresia is a challenging condition characterized by progressive narrowing and fibrosis of the biliary tree. It is rarely associated with rare congenital anomalies like situs inversus totalis, intestinal malrotation, and volvulus. Diagnosis involves abdominal ultrasound and MRCG. The biliary atresia was managed by the Kasai procedure and the intestinal malrotation, and volvulus were managed by Ladd's procedure.

Conclusion

This case report highlights the importance of considering rare associations such as situs inversus, intestinal malrotation and volvulus in the diagnosis of biliary atresia in newborn. Early diagnosis and prompt intervention are crucial for optimal outcomes.

Evaluating laminar and lateral mass screw techniques in cervical injury management: A case series

INTRODUCTION AND IMPORTANCE

The cervical spine is a dynamic structure that protects adjacent nervous innervation and maintains the range of motion (ROM) of the head and neck. Fractures in this area can lead to high mortality and morbidity, with bone fractures accounting for 56 % of cervical spinal cord injuries. This case series presents a series of cervical pathologies treated with posterior decompression and stabilization using laminar and lateral mass screw fixation.

METHODS

This research is a case series of four patients treated with laminar and lateral mass screw technique. All patients received a surgical procedure, including posterior compression and stabilization, which included the use of a laminar and lateral mass screw. We followed the patient for 12 months. During follow up, outcome measures consisting of VAS, range of motion, neurological status, ODI Score, SF-12 Score and any complications related to the surgical procedure was recorded and calculated every 3 months.

OUTCOMES

This series examines four distinct cases. The initial case pertained to a female patient, aged 72, who exhibited tetraparesis resulting from a burst fracture occurring in the C3-C5 vertebrae. The underlying etiology of this pathology is considered to be mineral bone disease associated with thyroid hormone imbalance due to thyroid cancer. The second instance was a 14-year-old child experiencing neck pain due to spondylitis tuberculosis in the C1-C2 region, accompanied by a retropharyngeal abscess and occipitocervical dissociation (OCD) with basilar invagination. The third example pertained to a patient who is 9 years old and presented with weakness in all extremities due to C1 fracture-dislocation. The fourth case was a 14-year-old patient who experienced a fall from a bunk bed. This patient was diagnosed with Traumatic Atlantoaxial dislocation with odontoid fracture Type II. All patients showed improved cervical curvature and range of motion with the advantages of reduction of intraoperative haemorrhage, as well as a decrease in postoperative rehabilitation duration. Overall, the data shows a general trend of improvement in VAS and ODI scores over time, with SF-12 scores stabilizing or slightly decreasing by 12 months post-operation.

CONCLUSION

The use of a lateral mass screw for subaxial cervical injuries can be employed to manage cervical spine pathologies like fractures and infections, including spondylitis TB. However, more research is required to evaluate the long-term complications and success rates of this technique.

Microsurgical clipping of large MCA aneurysm in a 2-month-old child

BACKGROUND

Cerebral aneurysms in children have a low incidence and accounts for less than 4% of all cerebral aneurysms. These aneurysms have been linked to various factors. Severe headache, seizures, and motor-sensory deficits are common presentations.

CASE REPORT

We describe the case of a 2-month-old male patient who presented with generalized tonic-clonic seizures for 4 days. At the hospital, he was stabilized with ventilatory support, sedation, and antiepileptic drugs. A NCCT (Head) showed intraparenchymal hemorrhage in the left fronto-parieto-temporal lobe and subarachnoid hemorrhage. Subsequently a CT angiogram revealed an aneurysm of the left M3 segment of MCA. Successfully, the patient underwent microsurgical clipping of aneurysm and evacuation of hematoma.

CONCLUSIONS

Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. As per literature, aneurysmal clipping and neurological endovascular therapy have shown similar results.

Jejunal Perforation Due to Histoplasmosis Regarding a Case

Histoplasmosis is an increasing infection that mainly affects immunocompromised individuals such as patients with HIV/AIDS, with the disseminated form, especially gastrointestinal, being common in this population. The clinical presentation ranges from asymptomatic to symptoms that mimic other abdominal diseases. Jejunal perforation due to histoplasmosis, although rare, has been reported in a few cases, typically in men living with HIV in their fourth decade of life. We present the case of a 34-year-old male, with a history of HIV and colonic histoplasmosis who presented with acute abdominal pain requiring exploratory laparotomy and intestinal resection due to jejunal perforation, with histological confirmation of histoplasmosis in the resected intestinal segment.

Successful Rescue of Ventricular Fibrillation Electrical Storm Secondary to Acute Myocardial Infarction in a Patient Presenting to a District General Hospital: A Case Report

Ventricular arrhythmia is a critical and challenging cardiovascular complication of myocardial infarction (MI). An electrical storm (ES), characterised by three or more episodes of sustained ventricular arrhythmia within 24 hours, poses a significant life-threatening risk. Standard management includes advanced life support (ALS) protocols and specialised pharmacological interventions. We present the case of a 43-year-old female who presented to the emergency department (ED) following an out-of-hospital ventricular fibrillation (OOHVF) arrest, with the return of spontaneous circulation (ROSC) achieved after multiple defibrillation shocks. Electrocardiography (ECG) revealed anterior ST-segment elevation MI (STEMI) involving the left anterior descending (LAD) artery. During her ED stay, she experienced recurrent ventricular fibrillation (VF) arrests requiring repeated defibrillation, adrenaline, amiodarone, and thrombolysis with alteplase. She was subsequently intubated and transferred to a primary percutaneous coronary intervention (PPCI) centre with intensive care support. Angiography confirmed a 100% occlusion of the LAD, which was successfully treated with stenting. The patient was admitted to the intensive care unit (ICU) and later discharged with full neurological recovery, on secondary prevention and heart failure therapy, with follow-up planned. This case underscores the complexity of managing electrical storms in MI, particularly in non-PPCI centres. It emphasises the importance of thrombolysis as an early reperfusion strategy in STEMI, especially when PPCI is not immediately available.

Ogilvie's Syndrome Following Herpes Zoster Infection: A Comprehensive Review of the Literature

This systematic review explores the association between herpes zoster (HZ) infection and Ogilvie's syndrome (acute colonic pseudo-obstruction), evaluating how varicella-zoster virus (VZV) reactivation may contribute to autonomic dysfunction leading to intestinal obstruction. A comprehensive search was conducted in PubMed, Scopus, and Cochrane Library databases up to October 2024, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included case reports, clinical images, and letters reporting Ogilvie's syndrome secondary to HZ or VZV infection. After screening 219 publications and additional grey literature, 27 studies describing 28 cases met the inclusion criteria. Data were extracted on patient demographics, clinical manifestations, diagnostic methods, and outcomes. The quality of studies was assessed using the Joanna Briggs Institute critical appraisal checklist. The results from 27 studies encompassing 28 patients with intestinal pseudo-obstruction secondary to VZV or HZ infection indicated a mean age of 60 years, predominantly affecting males (71.5%). Notably, 47.6% had underlying immunosuppressive conditions. The primary clinical manifestations included abdominal distention and severe constipation. Most patients (93%) exhibited a herpetiform rash, primarily in thoracic dermatomes. Symptoms of pseudo-obstruction often preceded the rash (58%), and imaging in the vast majority revealed colonic distension with no intra-abdominal pathology. Treatment focused on conservative management of both pseudo-obstruction and HZ symptoms, with 93% of patients achieving full recovery, while the mortality rate was identified at 7%. The findings suggest that HZ-induced Ogilvie's syndrome may be an underdiagnosed condition, requiring a high index of suspicion, particularly in immunocompromised patients. Early recognition and conservative treatment can prevent unnecessary surgical interventions. Further studies are needed to clarify the pathophysiological mechanisms linking VZV reactivation to colonic pseudo-obstruction.

Ten-year evaluation on efficacy, safety, and predictability of femtosecond laser corneal small incision lenticule extraction for correction of myopia and myopic astigmatism: a case series

Objective

The objective was to evaluate the 10-year long-term outcomes of patients undergoing small incision lenticule extraction (SMILE).

Methods

In this continuous case series, the authors enrolled a total of 113 patients (208 eyes) who underwent SMILE 10 years prior. Measured parameters included uncorrected visual acuity (UCVA), corrected distance visual acuity (CDVA), and cycloplegia spherical equivalent error (SER).

Results

One hundred thirteen patients were enrolled in this study. Patients' age ranged from 18 to 44 years (mean: 30.2 years). One hundred ninety-three eyes (92.8%) and 176 eyes (84.6%) had an UCVA≥20/20 at 3 months and 10 years postoperatively. The mean efficacy index, measured at 3 months and 10 years postoperatively, were 1.041 and 1.023, respectively; the difference was not statistically significant. Three months after the operation, best-corrected visual acuity (BCVA) decreased by 1 line in 19 eyes (9.1%), remained unchanged in 158 eyes (76.0%), and increased by ≥1 line in 31 eyes (14.9%). Ten years after operation, BCVA decreased by 2 lines in 15 eyes (7.2%) and by 1 line in 35 eyes (16.8%); remained unchanged in 142 eyes (68.3%); increased ≥1 line in 16 eyes (7.7%). The mean safety index, measured at 3 months and 10 years postoperatively, were 1.147 and 1.331, respectively; the difference was not statistically significant. The mean SER at 3 months and 10 years postoperatively was -0.112 and -0.276, respectively; the difference was statistically significant.

Conclusion

There was a decrease in SER 10 years after SMILE surgery compared with 3 months postoperatively, there was no significant decrease in the efficacy index or safety index.

Peri anal region is an overlooked location for pilonidal recurrence after surgical excision and closure - A case series

INTRODUCTION AND IMPORTANCE

Patients with pilonidal disease (PD) often undergo wide excision of pilonidal sinuses and flap-based closures. Patients who failed these procedures can have recurrent perianal wounds obscured by hair and unrecognized even by the treating physicians. In this report, we describe a series of pilonidal patients with recurrent disease and perianal wounds.

CASE PRESENTATION

Five pilonidal patients with recurrent disease after surgical excision and flap closure were referred to our Pilonidal Care Clinic. All five were found to have perianal wounds. Each patient was treated with regular manual and laser epilation and only one patient required a Gips procedure. All wounds were successfully healed.

CLINICAL DISCUSSION

After removal of hair at the perianal region, patients with recurrent pilonidal disease can expose a pilonidal sinus that was previously unrecognized. Peri-anal wounds can have poor wound healing due to the close proximity of the wound to the anal verge, risk of contamination, difficulty of consistent observation of the wound, and moist environment of the anus that retains bacteria. Careful consideration of proper wound care post-excision of perianal pilonidal sinuses should be prioritized.

CONCLUSIONS

Pilonidal perianal wounds after previous surgical excision and flap closure can be obscured by hair, resulting in recurrent pain and drainage. The perianal wounds can be successfully healed with regular manual and laser epilation and selectively excised using Gips procedure.

Use of indocyanine green-human serum albumin complexes in fluorescence image-guided laparoscopic anatomical liver resection: a case series study (with video)

BACKGROUND

This study aimed to investigate the feasibility and efficacy of near-infrared fluorescence-guided laparoscopic anatomical hepatectomy (LAH) using a novel indocyanine green (ICG)-human serum albumin complex (HSA) in patients with hepatocellular carcinoma.

METHODS

Clinical data of hepatocellular carcinoma patients who underwent ICG-HSA fluorescence-guided LAH at our center from January 2024 to April 2024 were prospectively collected and analyzed. Ultraviolet absorption spectroscopy was used to test the absorption and stability of ICG-HSA complex solutions under different conditions. After determining the optimal ratio, the complex was administered intravenously during surgery to perform negative staining via Glissonean pedicle isolation. LAH was performed along the fluorescence-demarcated boundaries.

RESULTS

Thirty-one patients were included (24 men; mean age, 54.61 ± 13.54 years). The median maximum tumor diameter was 2.80 (interquartile range [IQR], 2.00-4.00) cm. S8 segmentectomy (22.6%) and right posterior segmentectomy (19.4%) were the most common resections performed. Successful fluorescence negative staining was achieved in all patients using ICG and HSA at a 1:6 molar ratio at room temperature. Mean operation time was 297.58 ± 85.53 min, Median intraoperative blood loss was 100.0 mL (IQR, 50.0-200.0). The median surgical margin distance was 0.90 cm (IQR, 0.40-1.50). The postoperative complication rate was 45.2% (35.5% Clavien-Dindo grade I and 9.7% grade II). The median length of hospital stay was 5.0 days (IQR, 4.0-5.0).

CONCLUSION

ICG-HSA-assisted LAH is safe and feasible. Compared with free ICG, the novel ICG-HSA complex exhibits better optical properties and in vivo stability, which can improve the accuracy of intraoperative liver segment localization and optimize the anatomical dissection plane. It has the potential to become an ideal fluorescent imaging agent for anatomical hepatectomy.

Safety of risdiplam in spinal muscular atrophy patients after short-term treatment with nusinersen

INTRODUCTION/AIMS

Following the approval of risdiplam, there are more possibilities for disease-modifying therapy (DMT) in children with spinal muscular atrophy (SMA). Non-treatment-naïve subjects with SMA involved in the JEWELFISH study, designed to evaluate the safety and tolerability of risdiplam, were required to undergo a washout period before receiving risdiplam. This study aims to investigate the safety of administering risdiplam in patients within 90 days of receiving treatment with nusinersen.

METHODS

Data were collected on SMA patients who had undergone treatment with nusinersen, and who then received risdiplam within 90 days of their last dose of nusinersen, including demographic characteristics, information on treatment with nusinersen and risdiplam, adverse events, and laboratory assessments in a follow-up period of 90 days, presented as median (range).

RESULTS

A total of 15 children with SMA were reported, including 8 males and 7 females. The median number of doses of previous nusinersen treatment received was 8 (6-17) doses, and the median age at first risdiplam treatment was 4.3 (1.9-11.2) years. Specifically, 8 children received risdiplam 30 days or less after their most recent nusinersen treatment, 2 at 31-60 days after nusinersen, and 5 at 61-89 days post-nusinersen. Adverse events of pyrexia, pneumonia, vomiting and rash were reported in 4 patients.

DISCUSSION

Our study showed good safety data on patients who received risdiplam following nusinersen within the washout period of 90 days. This supplements the JEWELFISH study in the era of DMT, providing additional guidance for clinicians, but additional data from other centers is needed.

Management of cloacal exstrophy: Experience from tertiary hospital, Tanzania. Case series

INTRODUCTION AND IMPORTANCE

Cloacal exstrophy (CE) is defined as a complex anomaly that affects the urogenital and intestinal tracts. It is the most serious form of anomaly that is described within the so-called exstrophy-epispadias complex. These malformations usually present a challenge in the management of particular conditions, as most of these forms require multiple surgeries, resulting in the use of multidisciplinary approaches, including reconstructive urologists, pediatric surgeons, orthopedic surgeons, endocrinologists, pediatricians, psychologists and nutritionists. Additionally, these patients present with ambiguous genitalia, which is another aspect that needs to be taken into consideration during the management of this condition.

CASE PRESENTATION

The first patient, a baby who was 8 days of life and referred from a peripheral hospital, presented with classic features of cloaca exstrophy. He underwent first-stage cloacal exstrophy repair. The intraoperative findings included a bi-halved bladder and phallus, and the ureters were not appreciated, but there was continuous urine leakage from the bi-halved bladder and no uterus or ovaries. Poorly formed cecum, cecal-cutaneous fistula with an everted part of the terminal ileum protruding outside (mucosa-out), no transverse, no descending colon, collapsing small bowel, left undescended testis in the inguinal region, and right abdominal undescended testis. He first underwent surgery, which involved ileostomy, omphalocele closure and proper bladder exstrophy construction. The second patient, a 6-day-old female, had a similar presentation and physical findings as the first patient did, except that she had elephantoid trunk deformity with a cecal fistula, bifid clitoris, two cervical orifices, and two uteri completely separated with ovaries. Mobilization of the hindgut, closure of the cecal fistula, and proper bladder exstrophy after repair of the posterior wall were performed. The third patient was a 10-day-old female, similar to the second patient, but this patient presented with a left leg deformity with wide diastasis. In this case, the urinary bladder was not bivalved, and the cecal fistula had perforated just below the posterior wall of the urinary bladder. A mild omphalocele, bifid clitoris and vagina, one cervical orifice, and two uteri completely separated, with ovaries observed. Mobilization of the hindgut, closure of the cecal fistula, and proper bladder exstrophy after repair of the posterior wall were performed. The postoperative period was uneventful.

CLINICAL DISCUSSION

Surgical management of cloacal exstrophy is typically undertaken in the newborn period (48-72 h) as a combined effort between pediatric surgery and urology. In the setting of associated spinal dysraphism, neurosurgical consultation and closure should be undertaken as soon as the infant becomes medically stable. Early operation minimizes bacterial colonization of exposed viscera and may decrease the need for pelvic osteotomy. The goals of treatment include securing the abdominal wall and bladder closure, preserving renal function, preventing short bowel syndrome, creating functional and cosmetically acceptable genitalia, and attaining acceptable urinary and fecal continence.

CONCLUSION

Cloacal exstrophy remains a rare and complex congenital anomaly characterized by an array of anatomical defects affecting multiple organ systems. With respect to the approach of this congenital malformation, it is therefore important that these individuals and their families remain under the care of a multidisciplinary team of providers who can offer medical care, counseling and life-long follow-up.

Fumarate hydratase-deficient renal cell carcinoma complicated with liver metastasis: case report

Background

Fumarate hydratase-deficient renal cell carcinoma (FH-RCC) is a rare subtype of kidney tumor. Most of them are solitary lesions, making preoperative diagnosis difficult, aggressive, and with poor prognosis. They may metastasize even at an early stage, however, there is currently no optimal diagnostic and therapeutic approach for metastatic FH-RCC.

Methods

We report the case of a 34-year-old male patient with renal tumor and liver metastasis, who underwent open tumor resection of the right kidney combined with resection of liver metastases. Postoperative pathology was confirmed, followed by targeted therapy.

Results

Postoperative pathological results confirmed FH-RCC, targeted therapy was performed after surgery. No tumor recurrence was observed during the follow-up of almost 16 months.

Conclusion

FH-RCC patients with liver metastasis can achieve a good prognosis through early resection of primary tumor and metastatic lesions combined with targeted therapy.

A survival case of high-dose amlodipine intoxication with non-cardiogenic pulmonary edema: a case report

Introduction

Dihydropyridines calcium channel blockers at high dose can have conduction abnormalities, reduced inotropism, and non-cardiogenic pulmonary oedema (NCPE) which otherwise, at standard dosage have only vascular selectivity. They remain one of the commonly used anti-hypertensive exhibiting very lethal outcomes (50% mortality rates) in its overdose.

Case presentation

The authors present a case of a 21-year-old male with amlodipine intoxication with 43 tabs of 10 mg (total of 430 mg) ingestion manifested by loss of consciousness, hypotension, tachycardia, and respiratory distress.

Discussion

An amlodipine overdose causes refractory hypotension due to vasodilation and impaired cardiac metabolism and contractility. Further amlodipine toxicity can result in NCPE that manifests clinically as respiratory distress and low oxygen levels due to lung injury caused by inflammation and increased vascular permeability.

Conclusion

This case report emphasizes the significance of early recognition and prompt treatment of amlodipine intoxication, which can result in serious complications like fluid overload and respiratory distress.

Deep Learning Features and Metabolic Tumor Volume Based on PET/CT to Construct Risk Stratification in Non-small Cell Lung Cancer

RATIONALE AND OBJECTIVES

To build a risk stratification by incorporating PET/CT-based deep learning features and whole-body metabolic tumor volume (MTVwb), which was to make predictions about overall survival (OS) and progression-free survival (PFS) for those with non-small cell lung cancer (NSCLC) as a complement to the TNM staging.

MATERIALS AND METHODS

The study enrolled 590 patients with NSCLC (413 for training and 177 for testing). Features were extracted by employing a convolutional neural network. The combined risk stratification (CRS) was constructed by the selected features and MTVwb, which were contrasted and integrated with TNM staging. In the testing set, those were verified.

RESULTS

Multivariate analysis revealed that CRS was an independent predictor of OS and PFS. C-indexes of the CRS demonstrated statistically significant increases in comparison to TNM staging, excepting predicting OS in the testing set (for OS, C-index=0.71 vs. 0.691 in the training set and 0.73 vs. 0.736 in the testing set; for PFS, C-index=0.702 vs. 0.686 in the training set and 0.732 vs. 0.71 in the testing set). The nomogram that combined CRS with TNM staging demonstrated the most superior model performance in the training and testing sets (C-index=0.741 and 0.771).

CONCLUSION

The addition of CRS improves TNM staging's predictive power and shows potential as a useful tool to support physicians in making treatment decisions.

Spontaneous transomental hernia: a case report of a rare internal hernia with a challenging diagnosis

Introduction and Importance

Transomental hernia (TOH) is an extremely rare clinical condition that represents 1-4% of all internal hernias. Spontaneous TOH occurs in patients with no history of surgery or previous abdominal trauma. It happens after protrusion of the abdominal viscera, commonly the small bowel loops through a defect on the great omentum.

Presentation of the case

We present a case of occlusion due to TOH in a 66-year-old man who underwent a laparotomy, and operative exploration showed 10 cm of small bowel incarcerated through a defect in the right side of the greater omentum of 4 cm in diameter.

Discussion

The diagnosis is usually delayed because symptoms are nonspecific. Postoperative morbidity and mortality are important because patients present most frequently with gangrenous bowel, making morbidity and mortality higher. Therefore, it constitutes a critical surgical emergency and must be quickly recognized and managed. Computed tomography (CT) scan plays a prominent role in diagnosis. Midline laparotomy is the main emergency approach for patients with unknown bowel obstruction. Some authors suggest a laparoscopic approach, but it requires a surgeon's experience and propitious patient's conditions.

Conclusion

TOH is the rarest type of internal hernia with extremely difficult preoperative diagnosis due to nonspecific semiology. This type of hernia has the highest morbidity and mortality rates of all internal hernias. Thus, it must be suspected whenever there is bowel obstruction of unknown origin and quickly managed.

A prediction nomogram for mortality in patients following wasp stings: a retrospective study

Numerous studies have shown that wasp stings can lead to serious, sometimes fatal, health outcomes. Predicting deaths associated with wasp stings remains challenging yet is of critical importance. This study was conducted to identify predictors and develop a visual model for predicting mortality following wasp stings. Clinical data from 486 patients were analyzed, dividing them into two groups: survival group (N = 435) and death group (N = 51). Various statistical methods were used to create a prognostic model, including one-way analysis, the least absolute shrinkage and selection operator (LASSO) regression, and binary logistic regression. The model's accuracy was evaluated through ROC curves, calibration plots, and decision curve analysis (DCA). The study identified four key predictors of mortality: receiving more than 50 stings, having serum lactate dehydrogenase (LDH) levels of ≥ 2200 U/L, activated partial thromboplastin time (APTT) of ≥ 90 s, and the requirement for invasive mechanical ventilation within 24 h. These factors contributed to a model with an area under the ROC curve of 0.980 (95% CI: [0.968-0.992]), indicating high calibration and applicability. The decision curve analysis confirmed the model's substantial net clinical benefit. Thus, the number of stings, serum LDH, APTT, and the need for early invasive mechanical ventilation are reliable, independent predictors of death among patients experiencing wasp stings. The developed predictive model exhibits high levels of accuracy, sensitivity, consistency, and practical use.

CPAP vs HFNC in treatment of patients with COVID-19 ARDS: A retrospective propensity-matched study

Background

Previous studies exploring the application of noninvasive ventilation or high-flow nasal cannula in patients with COVID-19-related acute respiratory distress syndrome (ARDS) have yielded conflicting results on whether any method of respiratory support is superior. Our aim is to compare the efficacy and safety of respiratory therapy with high-flow nasal cannula and noninvasive ventilation with continuous positive airway pressure in treatment of COVID-19-related ARDS.

Methods

This is a retrospective cohort study based on data from patients who received respiratory support as part of their treatment in the COVID intensive care unit at the University Hospital Centre Zagreb between February 2021 and February 2023. Using propensity score analysis, 42 patients treated with high-flow nasal cannula (HFNC group) were compared to 42 patients treated with noninvasive ventilation with continuous positive airway pressure (CPAP group). Primary outcome was intubation rate.

Results

Intubation rate was 71.4% (30/42) in the HFNC group and 40.5% (17/42) in the CPAP group (p = 0.004). Hazard ratio for intubation was 3.676 (95% confidence interval [CI] 1.480 to 9.232) with the HFNC versus CPAP group. Marginally significant difference in survival between the two groups was observed at 30 days (p = 0.050) but was statistically significant at 60 days (p = 0.043).

Conclusions

Respiratory support with high-flow nasal cannula and noninvasive ventilation with continuous positive airway pressure yielded significantly different intubation rates in favour of continuous positive airway pressure. The same patients also had better 30-day and 60-day survival post-admission.

Impact of an In-Hospital postoperative imaging after uncomplicated elective posterior lumbar fixation: A case series

PURPOSE

Following spinal fixation, postoperative imaging is routinely performed. The value of routine postoperative imaging and its impact on the surgical decision remains uncertain, especially in degenerative cases. Moreover, routine postoperative imaging is not free and is an ionizing radiation. This study investigated the value of postoperative imaging after uneventful uncomplicated elective posterior lumbar fixation.

METHODS

This case series retrospectively reviewed the medical records of patients who underwent elective posterior lumbar fixation surgeries at our institution within two years. A series of 98 cases met our selection criteria. Their mean age was 51.2 years. We reviewed the decisions taken after performing the routine postoperative images. We searched for further diagnostic or imaging studies, revision surgery, or an extended hospital stay.

RESULTS

We found no particular decision was made after performing the postoperative imaging after uneventful uncomplicated elective posterior lumbar fixation surgeries. Moreover, there was no change in the hospital stay or the regular postoperative clinical management for all the included patients. No revision surgery was required based on the postoperative routine images.

CONCLUSIONS

We found that routine postoperative imaging after posterior fixation of a degenerative lumbar spine is of limited value. A randomized, controlled study is helpful to confirm this finding.

Intracellularly Gelated Macrophages Loaded with Probiotics for Therapy of Colitis

Probiotics therapy has garnered significant attention in the treatment of inflammatory bowel disease (IBD). However, a large number of oral administrated probiotics are inactivated after passing through the gastric acid environment, and their ability to colonize in the intestine is also weak. Herein, this study develops a novel probiotics formulation (GM-EcN) by incorporating Escherichia coli Nissle 1917 (EcN) into intracellularly gelated macrophages (GM). Intracellular hydrogel is designed to load and prevent EcN from digestion in gastric juice, and GM acts as a macrophage-like carrier to carry the attached probiotics to colonize in the inflammatory intestine. In addition, hydrogel serves as an ideal cytoskeletal structure to maintain the intact cell morphology and membrane structure of GM, comparable to source macrophages. Due to the receptor-ligand interaction, inflammation-related membrane proteins enable GM as a cell sponge to sequestrate and neutralize multiple inflammatory cytokines. In vivo treatment demonstrates that GM-EcN efficiently alleviates IBD symptoms and enhances gut microbiota recovery.

Trans-Oral Protrusion of the Distal End of a Ventriculoperitoneal Shunt: A Case Report of an Unusual Complication

Ventriculoperitoneal shunting (VPS) is the surgical technique of choice to manage pediatric hydrocephalus. Despite having good results, it is prone to complications, some of which are rare. This is the case report of a 2-year-old male, with an uncomplicated VPS done at 6 months of age, presenting with vomiting, irritability, anorexia, and drooling. There was an oral protrusion of a tube dripping clear fluid. Imaging studies demonstrated evidence of gastric perforation with a cephalic migration and transoral protrusion of the distal end of the shunt tubing. A gastroplasty, and immediate revision of the distal shunt were done free of any complications. This case report underlines the importance of recognizing and managing trans-oral protrusion of the distal end of VPS system in a timely manner, and raises awareness of this uncommon complication and its potential influence on patient health and survival, given ventriculitis' high lethality.

Exploring the Potential Use of Virtual Reality with a Supraorbital Keyhole Craniotomy for Anterior Skull Base Meningiomas: Two Case Reports

INTRODUCTION

A supraorbital keyhole craniotomy (SOKC) is a novel alternative to frontal craniotomies for accessing the anterior fossa for resecting tumors and clipping aneurysms; however, its implementation is limited in patients at a high risk of complications. We present two cases involving the use of augmented reality (AR) and virtual reality (VR) for patient selection and preoperative planning for a supraorbital tumor resection of anterior fossa meningiomas.

METHODS

This is a prospective, single-center case series at a research institute. We identified patients with an anterior or middle fossa meningioma regardless of age, gender, and tumor characteristics who could undergo an SOKC and MRI. The preoperative planning was performed with the BrainLab Magic Leap AR/VR platform. The meningiomas were resected through the SOKC under neuronavigation.

RESULTS

We identified two cases: a 37-year-old male with a meningioma in the sellar region and an 84-year-old male with a right anterior fossa meningioma, both confirmed by MRI. Both patients had a complete tumor resection by a minimally invasive SOKC after preoperative planning with the AR/VR platform. Postoperatively, hyponatremia complicated the first case, while the second case developed an intracranial hemorrhage. They both recovered after the appropriate interventions.

CONCLUSIONS

The use of an SOKC for anterior skull base meningiomas should be individualized after considering the lesion characteristics, vascular control needs, and the surgeon's expertise. VR/AR-assisted preoperative evaluation and planning will optimize the patient selection and surgical outcomes. We can utilize VR/AR technologies to identify patients that will benefit from an SOKC and expand the implementation of the approach beyond its current limitations.

T-Cell Phenotypes and Systemic Cytokine Profiles of People Living with HIV Admitted to Hospital with COVID-19

Whether SARS-CoV-2 infection leads to a higher mortality and morbidity in people living with HIV (PLWH) in Africa remains inconclusive. In this study, we explored the differences in the T-cell phenotypes between people with and without HIV on the day of admission (V1) and ±7 days later (V2), as well as their cytokine/chemokine profiles on V1. Patients admitted with COVID-19 were recruited between May 2020 and December 2021 from the Steve Biko Academic and Tshwane District Hospitals in Pretoria, South Africa. Of 174 patients, 37 (21%) were PLWH. T-cell profiles were determined by flow cytometry, and cytokine levels were determined using a multiplex suspension bead array. PLWH were significantly younger than those without HIV, and were more likely to be female. In an adjusted analysis, PLWH had higher percentages of CD4+ central memory (CM) programmed cell death protein 1 (PD-1)+, CD8+ effector memory (EM)2, and CD8+ EM4 CD57+ cells, as well as higher concentrations of interleukin (IL)-35 at admission. PLWH with CD4+ T-cell counts of >200 cells/mm3 had altered CD4+ and CD8+ T-cell profiles, lower levels of systemic inflammation measured by plasma ferritin and PCT levels, and less severe disease. PLWH with CD4+ T-cell counts of <200 cells/mm3 on admission had higher concentrations of IL-6 and lower levels of IL-29. At V2, the percentages of CD4+ CM PD-1+ T-cells and CD8+ EM4 T-cells co-expressing CD57 and PD-1 remained higher in PLWH, while all other CD8+ EM populations were lower. Fewer CD8+ EM T-cells after ±7 days of admission may be indicative of mechanisms inhibiting EM T-cell survival, as indicated by the higher expression of IL-35 and the T-cell maturation arrest observed in PLWH. This profile was not observed in PLWH with severe immunodeficiency, highlighting the need for differentiated care in the broader PLWH population.

Laparoscopic extraperitoneal approach for lateral lymph node dissection for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer: a case series and short-term outcomes

BACKGROUND

There have been few reports of a totally extraperitoneal approach for laparoscopic lateral lymph node dissection (LLND) for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer. Therefore, this study reports the short-term outcomes of LLND via an extraperitoneal approach.

METHODS

A total of 10 patients underwent LLND through a laparoscopic extraperitoneal approach in our hospital since October 2018. Patients with suspected resectable lateral lymph node recurrence after surgery for rectal cancer on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography CT (PET-CT) were selected for this procedure.

RESULTS

Nine of the 10 cases were completed using this procedure, but one case was converted to an intraperitoneal approach. The median operative time was 231 min, and the median estimated blood loss was 10 ml. There was one case of wound infection, but no other postoperative complications were seen. In one patient, no metastases were found in the retrieved lymph nodes.

CONCLUSION

The short-term outcomes of LLND through a laparoscopic extraperitoneal approach were acceptable. Because this procedure can be performed without violating the peritoneum, it is less invasive than the conventional intraperitoneal approach and is useful for metachronous lateral pelvic lymph node metastases.

Emerging Vibrio vulnificus-Associated Infections After Seawater Exposure-Cases from the Bulgarian Black Sea Coast

Objectives: The aim of the current report is to present three cases of necrotizing fasciitis and sepsis caused by Vibrio vulnificus on the Bulgarian Black Sea coast. Materials and Methods: Two of the patients are males, 70 and 86 years of age, respectively, and one is an 86-year-old female. Data were collected from the patients' examination records. V. vulnificus was isolated on 5% sheep blood agar from wound and blood samples and identified by the automated system Phoenix M50 (BD, Franklin Lakes, NJ, USA). Antimicrobial susceptibility was tested with two well-known methods (disk diffusion and broth microdilution). Results: All of the patients were admitted to our hospital due to pain, swelling, ulceration, and bullae on the legs and were febrile. They underwent surgery and received intensive care support. One of the patients developed septicemia and septic shock; one of his legs was amputated, but the outcome was fatal. The other patient received immediate approptiate antibiotic and surgical treatment, and the outcome was favorable. The third patient underwent emergency fasciotomy but died a few hours after admission. Conclusions: Global climate change is affecting the distribution of Vibrio spp., and their incidence is expected to increase. It is important to highlight the need for awareness among immunocompromised and elderly patients of the potential threat posed by V. vulnificus infections.

Copaiba Oleoresin Improves Weight Gain and IL-10 Concentration, with No Impact on Hepatic Histology, in Liver Cirrhosis

Copaifera sp. is a native tree in the Amazon region. Copaiba oleoresin has components such as sesquiterpenes, which have anti-inflammatory and antioxidant potential. Liver cirrhosis is the end stage of liver disease with limited therapeutic options. We aimed to evaluate the effect of copaiba oleoresin supplementation on the liver of animals with thioacetamide (TAA)-induced cirrhosis. For the induction of liver cirrhosis, 100 mg/kg of TAA was administered intraperitoneally twice a week for 8 weeks. A total of 200 mg/kg/day of copaiba oleoresin was administered via gavage for the same period. Copaiba oleoresin supplementation improved cirrhosis-associated cachexia by increasing weight gain and body fat. In addition, copaiba oleoresin attenuated systemic inflammation, as shown by the decrease in the circulating C-reactive protein. In the liver, the copaiba oleoresin decreased carbonyl proteins and increased IL-10 compared with TAA-treated rats. TAA groups demonstrated increased SOD, catalase, GST, and GSH activity in the liver. In conclusion, the supplementation of copaiba oleoresin demonstrated a beneficial systemic effect in alleviating cirrhotic cachexia and antioxidant and anti-inflammatory action in the liver. However, it failed to improve the serological and histological markers of liver damage, which could be associated with the advanced stage of the disease.

From COVID-19 to monkeypox: a novel predictive model for emerging infectious diseases

The outbreak of emerging infectious diseases poses significant challenges to global public health. Accurate early forecasting is crucial for effective resource allocation and emergency response planning. This study aims to develop a comprehensive predictive model for emerging infectious diseases, integrating the blending framework, transfer learning, incremental learning, and the biological feature Rt to increase prediction accuracy and practicality. By transferring features from a COVID-19 dataset to a monkeypox dataset and introducing dynamically updated incremental learning techniques, the model's predictive capability in data-scarce scenarios was significantly improved. The research findings demonstrate that the blending framework performs exceptionally well in short-term (7-day) predictions. Furthermore, the combination of transfer learning and incremental learning techniques significantly enhanced the adaptability and precision, with a 91.41% improvement in the RMSE and an 89.13% improvement in the MAE. In particular, the inclusion of the Rt feature enabled the model to more accurately reflect the dynamics of disease spread, further improving the RMSE by 1.91% and the MAE by 2.17%. This study underscores the significant application potential of multimodel fusion and real-time data updates in infectious disease prediction, offering new theoretical perspectives and technical support. This research not only enriches the theoretical foundation of infectious disease prediction models but also provides reliable technical support for public health emergency responses. Future research should continue to explore integrating data from multiple sources and enhancing model generalization capabilities to further enhance the practicality and reliability of predictive tools.

Hepatopulmonary syndrome secondary to metabolic associated fatty liver disease in childhood - novel treatment with growth hormone replacement therapy: a case report and systematic review of literature

Objective

Hepatopulmonary syndrome (HPS) is a rare complication of metabolic associated fatty liver disease (MAFLD) occurring subsequent to hypopituitarism, often developing after resection of hypothalamic or pituitary tumors. The aim of this study is to report an illustrative case of an HPS patient who was successfully treated with growth hormone replacement therapy, without liver transplantation which is conventionally regarded as the only treatment option. Additionally, we conducted a comprehensive review of published case reports of HPS in the pediatric population.

Methods

We systematically searched literature databases to identify case reports and case series of HPS associated with hypopituitarism diagnosed in childhood. The search included MEDLINE/PubMed, Scopus, Embase, and Google Scholar from 1990 to 2023. The review process adhered to the PRISMA checklist for comprehensive reporting and methodological transparency.

Results

An 18-year-old female, who had been followed up for MAFLD after craniopharyngioma resection, presented with cyanosis and progressive dyspnea. She was diagnosed with severe degree of HPS. The patient began treatment with recombinant human growth hormone, leading to a significant improvement in respiratory symptoms within 3 months, and normalization of lung shunt ratio after 6 months of therapy. In our systematic review, nine patients from nine studies across six countries were identified. The median age at diagnosis of hypopituitarism was 10.5 years (range 1-16 years), and HPS was diagnosed at a median interval of 7 years later (range 0-26 years). Half of the patients had not received growth hormone therapy after being diagnosed with hypopituitarism, which subsequently led to the diagnosis of HPS. Three patients underwent liver transplantation, but non-alcoholic steatohepatitis recurred in all cases. Six patients were successfully treated with growth hormone replacement therapy without undergoing liver transplantation.

Conclusions

HPS can occur in pediatric patients with MAFLD who have undergone resection of the tumor in the hypothalamus or pituitary gland. Our findings suggest that growth hormone replacement therapy can be a possible alternative to liver transplantation for HPS patients. However, further investigations need to be performed to validate the efficacy of growth hormone treatment in different causes of HPS cases.

The show must go on: fostering residents' sustainable employability in medical education - a qualitative exploration of the Resident Leadership Program

BACKGROUND

Residents' sustainable employability (SE) is threatened by high burn-out rates, sleep deficits, and career dissatisfaction. Medical education may contribute to residents' SE by providing them with opportunities to influence their employment contexts and to develop conscious self-regulation. This paper explores how residents, participating in the Resident Leadership Program (RLP), are enabled to work on, and learn about, their SE.

METHODS

The RLP took place between February and July 2021 and consisted of lectures on, and practice in, quality improvement (QI) work. SE was the theme that governed residents' QI projects. In this study, residents were interviewed individually before the program (n = 8), were observed while participating in the program (45 h) and were interviewed in three groups after the program (n = 8). The data were analysed in accordance with the 'flexible-coding' method.

RESULTS

The findings are presented in four 'acts' mirroring an unfolding play as a metaphor to show how residents' understanding of context, self-regulations, and quality improvement work-relevant to their SE-changed in the RLP. The acts include 'setting the stage', describing how residents experienced the context of medicine; 'acting the part', depicting how residents managed their employment contexts using self-regulation; 'changing the décor', elaborating on residents' QI projects; and 'growing one's role', presenting residents' take-aways from participating in the RLP that may benefit their SE. These take-aways encompassed awareness of the importance of SE, a reconsideration and/or adjustment of self-regulation, feeling better equipped to navigate employment contexts, and increased joy in work because of contributing to peers' SE through QI work.

CONCLUSIONS

Our results indicate that medical education is a fruitful environment for providing important lessons and tools for residents to work on and learn about their SE, likely benefiting their SE throughout their careers.

A case report on renal metastasis as an unusual presentation of choriocarcinoma

BACKGROUND

Choriocarcinoma is an aggressively invasive neoplasm, characterized by its rapid proliferation and propensity for metastasis to distant organs via hematogenous dissemination. Lungs (80%), vagina (30%), pelvis (20%), liver (10%), and brain (10%) are the most frequently metastasized organs. Renal metastases are very rare. The clinical manifestations of choriocarcinoma varies depending on the site of disease, making diagnosis challenging. In this report, we provide a clinical case of choriocarcinoma with metastases to the renal and pulmonary systems, displaying symptoms akin to those observed in ectopic pregnancy.

CASE PRESENTATION

A 27-year-old female, G2P1, with a previous history of full-term pregnancy in 2018, presented to the hospital with the onset of vaginal bleeding and accompanying abdominal aches. Investigations uncovered a left adnexal mass with a human chorionic gonadotropin (hCG) level of 77,4 mIU/mL and a left pulmonary nodule measuring 31 mm x 21 mm. Laparoscopy was performed due to the high suspicion of an ectopic pregnancy. However, no visible villi were identified during the surgery, and postoperative blood hCG levels continued to rise. A diagnostic curettage also failed to reveal any villi, maintaining the suspicion of a persistent ectopic pregnancy. Following two ineffective courses of methotrexate therapy, the patient was referred to our facility. Prior to her referral, an ultrasound had indicated a mass in the right kidney. However, upon arrival at our hospital, subsequent ultrasonography failed to detect any renal masses. Despite two months of outpatient monitoring, there was a sudden and significant increase in her serum hCG levels. An emergency laparoscopy was performed, revealing no pregnancy-related lesion. After surgery, the patient's hCG levels dropped dramatically to less than one-tenth of the original amount. Multisite enhanced computed tomography(CT)revealed suspicious lesions in both the renal and pulmonary regions. Upon thorough multidisciplinary consultation, a diagnosis of choriocarcinoma was entertained. Consequently, the patient successfully underwent eight cycles of chemotherapy and has remained recurrence-free for the past year.

CONCLUSIONS

This case underscores the potential for choriocarcinoma in women of reproductive age who exhibit radiological signs of renal masses. Early and accurate diagnosis, followed by prompt intervention, is essential to prevent needless surgery procedures.

Disseminated Ureaplasma infection: A case report of septic polyarthritis in a patient on Rituximab therapy

Introduction

Immunocompromised individuals, such as those undergoing Rituximab therapy, are susceptible to severe infections by these organisms. We present a rare case of polyarticular septic arthritis caused by disseminated Ureaplasma urealyticum in a Rituximab-treated patient.

Presentation of case

A 38-year-old male with a history of schizophrenia and multiple sclerosis presented with intense pain, swelling, and fever, along with limited joint mobility. Despite initial treatment with antibiotics and surgical intervention, the patient's condition deteriorated. PCR assays confirmed the presence of Ureaplasma urealyticum, prompting a change in antibiotic therapy. With focused antimicrobial treatment and supportive care, the patient exhibited gradual improvement, although reinfection occurred one month after discharge, necessitating additional surgical interventions and antibiotic therapy.

Discussion

Septic arthritis due to Ureaplasma urealyticum is exceedingly rare but can occur in immunocompromised patients undergoing Rituximab therapy. Accurate pathogen identification using PCR assays is crucial for optimizing therapeutic outcomes in such cases. Treatment typically involves a combination of surgical debridement and tailored antimicrobial therapy with agents effective against Ureaplasma species. Close monitoring for disease recurrence and joint function is essential for long-term management.

Conclusion

This case highlights the diagnostic challenges and therapeutic complexities of septic arthritis caused by Ureaplasma urealyticum in immunocompromised patients undergoing Rituximab treatment. Interdisciplinary collaboration and the use of PCR assays for accurate pathogen identification are crucial for successful outcomes in such cases. Clinicians should consider the unique susceptibility of immunocompromised individuals to rare pathogens and tailor antimicrobial therapy accordingly.

Down Syndrome in Children: A Primary Immunodeficiency with Immune Dysregulation

Background: The multisystemic features of Down syndrome (DS) in children are accompanied by immunodeficiency, making them susceptible to infections and immune dysregulation with autoimmune, allergic, inflammatory, and hematological complications. This study was aimed at a better understanding of the abnormalities within the B and T cell compartments and their correlations with clinical immunophenotypes. Methods: Medical records of 35 DS children were retrospectively reviewed, referring to clinical symptomatology including history of infections, immune dysregulation disorders, and humoral and cellular immune response. Results: While the etiology of respiratory tract infections included typical viral and bacterial pathogens, SARS-CoV2-induced inflammatory disease and syndromic immunodeficiency contributed significantly to the deterioration of the clinical course. Allergic diseases in the form of asthma, allergic rhinitis, and alimentary allergy were the most frequent manifestations of immune dysregulation and were followed by autoimmune disorders, such as Crohn's disease, celiac disease, autoimmune thyroiditis, and alopecia, as well as inflammatory disorders, balanitis xerotica obliterans and lymphadenopathy, and a hematological disorder of myelopoiesis. Deficiency of serum immunoglobulin levels, reduced numbers of naïve B cells, and non-switched memory B cells along with low naïve T helper cells and significantly reduced regulatory T helper cells were the most prominent immune abnormalities. Conclusions: The loss of naïveté in B and T lymphocyte compartments with a deficiency of regulatory T cells may be underpinning pathomechanisms for the skewed immune response. The clinical immunophenotype in DS is complex and represents syndromic primary immunodeficiency with immune dysregulation.

Central nervous system solitary fibrous tumors: Case series in accordance with the WHO 2021 reclassification. Framework for patient surveillance

PURPOSE

Solitary fibrous tumors (SFTs) are a rare type of mesenchymal tumors. The World Health Organization reclassified SFTs in 2021. Currently, guidelines concerning treatment and follow-up are lacking. We performed a retrospective case series with reclassification of SFTs, according to the most recent WHO classification, to explore tumor-behavior. The purpose is to build a framework for long-term patient surveillance.

METHODOLOGY

A retrospective case study was performed according to the PROCESS guidelines. Inclusion criteria were: patients operated on between 2013 and 2023 in two neurosurgical centers with the diagnosis of 'hemangiopericytoma' or SFT on histopathological stains. Patients were excluded if the original stains of the primary tumor were unavailable. The following demographic, radiologic and therapeutic parameters were included in the review: age, sex, original and reclassified anatomopathological diagnosis, location, extent of resection, use of postoperative radiotherapy, location of and time to recurrence, location of-and time to metastasis, and survival. Histological material was re-examined by experienced neuropathologists.

RESULTS

Ten patients were identified with a solitary fibrous tumor of the central nervous system (CNS) (three females) between 2013 and 2023. Age at diagnosis ranged from 38 up to 81. Eight patients were treated by gross total resection (GTR) and postoperative radiotherapy (RT) was applied in five cases. Initial WHO grading consisted of three grade I, two grade II, and six grade III lesions. Reclassification according to the WHO 2021 classification of CNS tumors resulted in seven reclassifications, all towards a lower grade. Four patients showed local recurrence, six to eight years after diagnosis, and five patients developed systemic metastases, nine to 13 years after diagnosis.

DISCUSSION

Although rare, SFT should be included in the differential diagnosis of intracranial tumors with extra-axial growth patterns. The current histological grade according to the WHO 2021 does not seem to account for local recurrence rate or systemic metastasis. When a solitary fibrous tumor is presumed, gross total resection is the recommended treatment. Lifelong patient follow-up is necessary due to the risk of delayed recurrence and distant metastasis, even after gross-total resection. We would advocate for the use of CT thorax-abdomen or full body PET in the detection of systemic metastases at diagnosis and during follow-up, however optimal intervals remain unclear.