Self-Shielding Gyroscopic Radiosurgery: A Prospective Experience and Analysis of the First 100 Patients

Background Stereotactic radiosurgery is a well-established treatment option for the management of various benign and malignant brain tumors. It can be delivered with several treatment platforms, usually requiring shielded radiation vaults to meet regulatory safety requirements. Recent technical advances have led to the first self-shielding platform enabling the delivery of gyroscopic radiosurgery (GRS). Given the limited number of GRS treatment platforms, the novelty of its characteristics, and the lack of available data, we report our prospective experience with the first 100 patients treated with GRS. Materials and methods Patients undergoing GRS for the treatment of intracranial tumors were enrolled in this prospective study. Patient and treatment characteristics, including patient satisfaction, were collected and analyzed. Results A total of 100 patients with 155 tumors were treated. The most commonly treated tumors comprised brain metastases (BM) (49%), vestibular schwannomas (31%), and meningiomas (14%). The median prescription dose for malignant and benign tumors was 20 and 13 Gy, respectively. The median prescription isodose line was 56%. Gross tumor volumes were small, with a median of 0.37 cc for BM and 0.92 cc for the other entities. The median total treatment time was 40 minutes. Dosimetric performance indices showed median values of 1.20 (conformity index), 1.24 (new conformity index), 1.74 (homogeneity index), and 3.13 (gradient index). Volumetric assessment of the treated tumors showed an overall decrease in size at the first available follow-up. Most patients were satisfied with the treatment experience. Conclusion Our first prospective experience of the use of GRS is favorable. Analyses of the dosimetric performance, treatment times, volumetric assessment, and patient satisfaction demonstrate its suitability for stereotactic treatments of intracranial tumors. Further prospective clinical and dosimetric analyses for GRS are pending.

The Radiosurgery Society Case-Based Discussion of the Management of Head and Neck or Skull Base Paragangliomas with Stereotactic Radiosurgery and Radiotherapy

Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) have been used for the treatment of head and neck or skull base paraganglioma for a considerable time, demonstrating promising local control rates and a favorable safety profile compared with surgical approaches. Nevertheless, the choice of treatment must be carefully tailored to each patient's preferences, tumor location, and size, as well as anticipated treatment-related morbidity. This case-based review serves as a practical and concise guide for the use of SRS and FSRT in the management of head and neck or skull base paragangliomas, providing information on the diagnosis, treatment, follow-up considerations, and potential pitfalls.

5-Year Renal Function Outcomes after SABR for Primary Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium of the Kidney (IROCK)

PURPOSE/OBJECTIVE(S)

Renal cell carcinoma (RCC) presents uncommonly in patients with a congenital solitary kidney or prior contralateral nephrectomy. The objective of this study was to compare renal function outcomes of stereotactic ablative body radiotherapy (SABR) in patients with solitary vs. bilateral kidneys.

MATERIALS/METHODS

Patients with primary RCC with ≥2 years of follow-up at 12 participating International Radiosurgery Consortium for Kidney (IROCK) institutions were included. Patients with upper tract urothelial carcinoma or metastatic disease were excluded. Renal function was measured by estimated glomerular filtration rate (eGFR). For patients where eGFR was not recorded, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to estimate eGFR based on known creatinine. Baseline characteristics and renal function outcomes were compared between solitary vs. bilateral kidneys. Multivariable logistic regression was used to identify factors predictive of eGFR decline ≥ 15 mL/min and any eGFR increase evaluated at 1-year post-SABR.

RESULTS

One hundred and ninety patients with solitary (n = 56) or bilateral kidneys (n = 134) underwent SABR and were followed for a median of 5.0 years (IQR: 3.4-6.8). Pre-SABR eGFR (mean ± SD) was similar in patients with solitary (61.1 ± 23.2 mL/min) vs. bilateral kidneys (58.0 ± 22.3 mL/min, p = 0.324). Mean tumor size was 3.70 ± 1.40 cm in solitary and 4.35 ± 2.50 cm in bilateral kidneys (p = 0.026). After SABR, an initial compensatory increase in eGFR was observed in both cohorts (22.7% solitary and 17.7% bilateral at 1 year). This compensatory increase persisted in patients with bilateral but not a solitary kidney (10.3% vs. 0% at 3-years and 21.1% vs. 0% at 5-years, respectively). At 5-years post-SABR, eGFR decreased by -14.5 ± 7.6 in solitary and -13.3 ± 15.9 mL/min in bilateral kidneys (p = 0.665). At all timepoints assessed, there were no significant differences in eGFR decline between solitary vs. bilateral cohorts (all p > 0.05). There were also no significant differences in post-SABR end-stage renal disease (7.1% vs. 6.7%) or dialysis (3.6% vs. 3.7%) in solitary vs. bilateral, respectively. Multivariable analysis demonstrated that increasing tumor size (OR per 1 cm: 1.57; 95% CI: 1.14-2.16, p = 0.006) and baseline eGFR (OR per 10 mL/min: 1.30; 95% CI: 1.02-1.66, p = 0.034) was more likely to be associated with eGFR decline ≥ 15 mL/min. There was no significant association between solitary vs. bilateral kidney and eGFR decline (OR: 1.22; 95% CI: 0.45-3.34, p = 0.693).

CONCLUSION

There was no observed difference between renal function outcomes in patients with a solitary vs. bilateral kidneys. While larger tumor size may increase the risk of eGFR decline post-SABR, treatment of a solitary kidney does not appear to increase the risk of renal dysfunction long-term.

Impact of Cochlear Dose on Hearing Preservation Following Stereotactic Radiosurgery in Treatment of Vestibular Schwannomas: A Multi-Center Study

OBJECTIVE

Stereotactic radiosurgery (SRS) is a well-established treatment for vestibular schwannomas (VS). Hearing loss remains a main morbidity of VS and its treatments, including SRS. The effects of radiation parameters of SRS on hearing remain unknown. The goal of this study is to determine the effect of tumor volume, patient demographics, pretreatment hearing status, cochlear radiation dose, total tumor radiation dose, fractionation, and other radiotherapy parameters on hearing deterioration.

METHODS

Multicenter retrospective analysis of 611 patients who underwent SRS for VS from 1990-2020 and had pre- and post-treatment audiograms.

RESULTS

Pure tone averages (PTAs) increased and word recognition scores (WRSs) decreased in treated ears at 12-60 months while remaining stable in untreated ears. Higher baseline PTA, higher tumor radiation dose, higher maximum cochlear dose, and usage of single fraction resulted in higher post radiation PTA; WRS was only predicted by baseline WRS and age. Higher baseline PTA, single fraction treatment, higher tumor radiation dose, and higher maximum cochlear dose resulted in a faster deterioration in PTA. Below a maximum cochlear dose of 3 Gy, there were no statistically significant changes in PTA or WRS.

CONCLUSIONS

Decline of hearing at one year in VS patients after SRS is directly related to maximum cochlear dose, single versus 3-fraction treatment, total tumor radiation dose, and baseline hearing level. The maximum safe cochlear dose for hearingtbrowd preservation at one year is 3 Gy, and the use of 3 fractions instead of one fraction was better at preserving hearing.

Meningioma involving the superior sagittal sinus: long-term outcome after robotic radiosurgery in primary and recurrent situation

Objective

Treatment for meningiomas involving the superior sagittal sinus (SSS) is challenging and proved to be associated with higher risks compared to other brain locations. Therapeutical strategies may be either microsurgical (sub-)total resection or adjuvant radiation, or a combination of both. Thrombosis or SSS occlusion following resection or radiosurgery needs to be further elucidated to assess whether single or combined treatment is superior. We here present tumor control and side effect data of robotic radiosurgery (RRS) in combination with or without microsurgery.

Methods

From our prospective database, we identified 137 patients with WHO grade I meningioma involving the SSS consecutively treated between 2005 and 2020. Treatment decisions were interdisciplinary. Patients underwent RRS as initial/solitary treatment (group 1), as adjuvant treatment after subtotal resection (group 2), or due to recurrent tumor growth after preceding microsurgery (group 3). Positive tumor response was assessed by MRI and defined as reduction of more than 50% of volume. Study endpoints were time to recurrence (TTR), time to RRS, risk factors for decreased survival, and side effects. Overall and specific recurrence rates for treatment groups were analyzed. Side effect data included therapy-related morbidity during follow-up (FU).

Results

A total of 137 patients (median age, 58.3 years) with SSS meningiomas WHO grade I were analyzed: 51 patients (37.2%) in group 1, 15 patients (11.0%) in group 2, and 71 patients (51.8%) in group 3. Positive MR (morphological response) to therapy was achieved in 50 patients (36.4%), no response was observed in 25 patients (18.2%), and radiological tumor progression was detected in 8 patients (5.8%). Overall 5-year probability of tumor recurrence was 15.8% (median TTR, 41.6 months). Five-year probabilities of recurrence were 0%, 8.3.%, and 21.5% for groups 1-3 (p = 0.06). In multivariate analysis, tumor volume was significantly associated with extent of SSS occlusion (p = 0.026) and sex (p = 0.011). Tumor volume significantly correlated with TTR (p = 0.0046). Acute sinus venous thrombosis or venous congestion-associated bleedings did not occur in any of the groups.

Conclusion

RRS for grade I meningiomas with SSS involvement represents a good option as first-line treatment, occasionally also in recurrent and adjuvant scenarios as part of a multimodal treatment strategy.

Robotic stereotactic body radiotherapy for the management of adrenal gland metastases: a bi-institutional analysis

PURPOSE

Adrenal gland metastases (AGMs) are a common manifestation of metastatic tumor spread, especially in non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). In patients with a limited systemic tumor burden, effective treatments for AGMs are needed. Due to varying fractionation schemes and limited reports, short-course treatment results for stereotactic body radiotherapy (SBRT) for AGMs are lacking. This work analyzes the outcomes of short-course SBRT for AGMs.

METHODS

Patients who underwent robotic SBRT for AGMs with one to five fractions were eligible for analysis.

RESULTS

In total, data from 55 patients with 72 AGMs from two institutions were analyzed. Most AGMs originated from renal cell carcinoma (38%) and NSCLC (35%). The median follow-up was 16.4 months. The median prescription dose and isodose line were 24 Gy and 70%, respectively. Most patients (85%) received SBRT with just one fraction. The median biologically effective dose assuming an α/β ratio of 10 (BED₁₀) was 80.4 Gy. The local control and progression-free survival after 1 and 2 years were 92.9%, 67.8%, and 46.2%, as well as 24.3%, respectively. Thirteen patients (24%) suffered from grade 1 or 2 toxicities. The BED₁₀ showed a significant impact on LC (p < 0.01). Treatments with a BED₁₀ equal to or above the median were associated with a better LC (p < 0.01).

CONCLUSION

Robotic SBRT is an efficient and safe treatment modality for AGM. Treatment-associated side effects are sporadic and manageable. Results suggest short-course SBRT to be a preferable and time-saving treatment option for the management of AGMs if an adequate BED₁₀ can be safely applied.

Robotic stereotactic body radiotherapy for localized prostate cancer: final analysis of the German HYPOSTAT trial

PURPOSE

We report results of the first German prospective multicenter single-arm phase II trial (ARO 2013-06; NCT02635256) of hypofractionated robotic stereotactic body radiotherapy (SBRT) for patients with localized prostate cancer (HYPOSTAT).

METHODS

Patients eligible for the HYPOSTAT study had localized prostate cancer (cT1‑3 cN0 cM0), Gleason score ≤ 7, prostate-specific antigen (PSA) ≤ 15 ng/ml, prostate volume ≤ 80 cm³, and an International Prostate Symptom Score (IPSS) ≤ 12. Initially, inclusion was limited to patients ≥ 75 years or patients 70-74 years with additional risk factors. The trial protocol was later amended to allow for enrolment of patients aged ≥ 60 years. The treatment consisted of 35 Gy delivered in 5 fractions to the prostate and for intermediate- or high-risk patients, also to the proximal seminal vesicles using the CyberKnife system (Accuray Inc., Sunnyvale, CA, USA). Primary endpoint was the rate of treatment-related gastrointestinal or genitourinary grade ≥ 2 toxicity based on the RTOG scale 12-15 months after treatment. Secondary endpoints were acute toxicity, late toxicity, urinary function, quality of life, and PSA response.

RESULTS

From July 2016 through December 2018, 85 eligible patients were enrolled and received treatment, of whom 83 could be evaluated regarding the primary endpoint. Patients mostly had intermediate-risk disease with a median PSA value of 7.97 ng/ml and Gleason score of 7a and 7b in 43.5% and 25.9% of patients, respectively. At the final follow-up 12-15 months after treatment, no patient suffered from treatment-related gastrointestinal or genitourinary grade ≥ 2 toxicity. Acute toxicity was mostly mild, with three grade 3 events, and the cumulative rate of grade ≥ 2 genitourinary toxicity was 8.4% (95% CI 4.1-16.4%). There were no major changes in urinary function or quality of life. The median PSA value dropped to 1.18 ng/ml 12-15 months after treatment. There was one patient who developed distant metastases.

CONCLUSION

Robotic SBRT with 35 Gy in 5 fractions was associated with a favorable short-term toxicity profile. Recruitment for the HYPOSTAT‑2 trial (ARO-2018‑4; NCT03795337), which further analyses the late toxicity of this regimen with a planned sample size of 500 patients, is ongoing.

A Central Slip Injury in a Professional Basketball Player

Hand injuries are extremely prevalent in sports such as ball sports. Delayed diagnosis or improperly managed injuries have the potential to prolong the athlete's return to the competition and permanently damage their abilities. We report the case of a 35-year-old male professional basketball player who presented to a chiropractor with pain and swelling of the right fifth finger two days after a basketball game. The injury occurred when a player passed the basketball and the ball hit his fifth finger "head-on". Examination revealed enlargement of the middle joint of the right fifth finger and a boutonniere deformity. He was diagnosed with a central slip injury using magnetic resonance imaging (MRI). Since there are no standard treatment guidelines for central slip injuries, multi-model chiropractic therapy was applied to the injury and adjacent sites. The patient returned to the game by the end of the third week and fully recovered within six weeks. Chiropractors must understand how to best guide athletes' clinical management of these injuries, given the inherent need for immediate and complete recovery.

Bilateral Cellulitis Presented As Lower-Extremity Pain Reported in a Chiropractic Clinic: A Case Report

Bilateral lower-extremity cellulitis is a rare but serious condition that can lead to long-term health complications if left untreated. Herein, we report a case of a 71-year-old obese male with a two-month history of lower-extremity pain and ankle swelling. Magnetic resonance imaging (MRI) revealed the presence of bilateral lower-extremity cellulitis, which was confirmed through blood culture by the patient's family doctor. The patient's initial presentation of musculoskeletal pain, limited mobility, and other features coupled with MRI findings served as indications for timely referral to the patient's family doctor for further evaluation and management. Chiropractors should be aware of the warning signs of infection and the importance of advanced imaging for diagnosing such cases. Early detection and prompt referral to a family doctor for care can help prevent long-term health complications associated with lower-extremity cellulitis.

Campylobacter fetus Cellulitis

Campylobacter fetus, a bacteria of the Campylobacter genus that are a group of bacteria known to cause intestinal infections, is a particular microbial agent due to its most common presentation being as a non-intestinal systemic infection and rarely as a focal infection, most frequently cellulitis. C. fetus's main reservoirs are cattle and sheep. Humans are usually infected by consuming raw milk and/or meat. Infection in humans is rare and generally related to immune deficiencies, malignancy, chronic liver disease, diabetes mellitus and elderly age, among other factors. Diagnosis is usually achieved by blood cultures due to the lack of focalized signs/symptoms and the pathogen's endovascular tropism. The authors present a case of cellulitis due to Campylobacter fetus, a microbial agent that affects susceptible patients with a mortality rate of up to 14%. We aim to emphasize the importance of potential bacterial seeding sites secondary to bacteremia given the agent tropism for vascular tissue. The medical diagnosis was performed by the identification of bacteria in blood cultures. Campylobacter spp. infections are more frequently related to undercooked poultry or meat, but in this case, the consumption of fresh cheese was considered the most likely source of infection. A literature review showed that, in patients with previous antibiotic cycles, a combination of carbapenem and gentamicin had better outcomes and lower relapse rates. Due to typical surface antigenic variation, immune control may not be attainable and may account for relapsing infections, even after appropriate therapy. The duration of treatment has yet to be well established. Based on other reported cases, we considered a four-week treatment to be sufficient, given clinical improvement and absence of recurrence in the follow-up time.

Peripheral Nerve Block Practice in Portugal: A National Survey

Regional anesthesia (RA) has several benefits and its use has increased with the advent of ultrasound-guided techniques. Opioid-sparing anesthesia and reduced use of general anesthesia are some of the mainstay advantages of RA. Although anesthetic practices differ deeply between countries, RA has assumed a crucial role in the daily practice of anesthesiologists, particularly during the COVID-19 pandemic period. This cross-sectional study provides an overview of peripheral nerve block (PNB) techniques performed in Portuguese hospitals. An online survey was reviewed by members of Clube de Anestesia Regional (CAR/ESRA Portugal) and then sent to a national mailing list of anesthesiologists. The survey focused on specific topics related to RA techniques such as the importance of training and experience, and the relevance of logistical limitations during the execution of RA. All data were collected anonymously and included in a Microsoft Excel (Microsoft Corp., Redmond, WA, USA) database, for further analysis. A total of 335 valid answers were obtained. All participants considered RA as a key competence in their daily practice. Half of those inquired performed PNB techniques once to twice per week. The main limitations identified for performing RA in Portuguese hospitals were the absence of block rooms and insufficiently trained personnel for the appropriate and safe execution of these techniques. This survey provides a comprehensive overview of RA in the Portuguese setting and could serve as a baseline for further studies.

Descriptive Study and Surgical Management Among Infiltrating Lobular Carcinoma Patients Admitted to King Abdulaziz Medical City From 2000 to 2017: A Retrospective Cross-Sectional Study

INTRODUCTION

Invasive lobular carcinoma (ILC) is the second most common histologic type of breast carcinoma. The etiology of ILC is unknown; however, many contributing risk factors have been suggested. Treatment of ILC can be divided into local and systemic. Our objectives were to assess the clinical presentations, risk factors, radiological findings, pathological types, and surgical options for patients with ILC treated at the national guard hospital. Identify the factors associated with metastasis and recurrence.

METHODS

Retrospective cross-sectional descriptive study at a tertiary care center in Riyadh. All adult patients aged 16 years and above, from different nationalities, and both genders, were diagnosed with ILC from 2000 to 2017 and followed up at KAMC. The sampling technique was a non-probability consecutive technique. Among 1066 patients identified, 91 patients were diagnosed with ILC over seventeen years study period.

RESULTS

The median age at the primary diagnosis was 50. On the clinical examination, 63 (71%) cases were found to have palpable masses which was the most suspicious finding. On radiology, the most encountered finding was speculated masses which were seen in 76 (84%). Regarding the pathology, unilateral breast cancer was seen in 82 while bilateral breast cancer was found only in eight. For the biopsy, a core needle biopsy was the most commonly used in 83 (91%) patients. The most documented surgery for ILC patients was a modified radical mastectomy. Metastasis in different organs was identified with the musculoskeletal system being the commonest site. Different significant variables were compared between patients with or without metastasis. Skin changes, post-operative invasion, estrogen, progesterone, and HER2 receptors were significantly associated with metastasis. Patients with metastasis were less likely to have conservative surgery. Regarding the Recurrence and five years survival, out of 62 cases, 10 had recurrence within five years, which was more prevalent in patients who had fine needle aspiration, excisional biopsy, and nulliparous patients.

CONCLUSION

To our knowledge, this is the first study to exclusively describe ILC in Saudi Arabia. The results of this current study are highly important, as these results provide baseline data of ILC in the capital city of Saudi Arabia.

Guillain-Barre Syndrome Secondary to the Use of Dabrafenib and Trametinib for the Treatment of Advanced Thyroid Carcinoma

BRAF V600E mutation in thyroid malignancies is associated with an aggressive phenotype with more rapid tumor growth and higher mortality. V600E is a driver mutation in the BRAF proto-oncogene, where valine (V) is substituted by glutamic acid (E) at amino acid 600. New chemotherapeutic agents targeting the mitogen-activated protein kinase (MAPK) pathway, including direct BRAF inhibitors, have become available and are increasingly used in various advanced thyroid malignancies. These agents are associated with various rare neurological adverse effects. We present a case of Guillain-Barre syndrome (GBS) secondary to dabrafenib and trametinib therapy for the management of anaplastic thyroid carcinoma. A few cases of GBS have been reported previously with the use of these agents in the treatment of melanoma. To our knowledge, this is the first case of GBS with the use of dabrafenib and trametinib for advanced thyroid malignancy. The knowledge of this rare, potentially life-threatening condition is important for clinicians to know, given the increased use of these agents in managing advanced thyroid malignancies.

A Potential Role of the Spike Protein in Neurodegenerative Diseases: A Narrative Review

Human prion protein and prion-like protein misfolding are widely recognized as playing a causal role in many neurodegenerative diseases. Based on in vitro and in vivo experimental evidence relating to prion and prion-like disease, we extrapolate from the compelling evidence that the spike glycoprotein of SARS-CoV-2 contains extended amino acid sequences characteristic of a prion-like protein to infer its potential to cause neurodegenerative disease. We propose that vaccine-induced spike protein synthesis can facilitate the accumulation of toxic prion-like fibrils in neurons. We outline various pathways through which these proteins could be expected to distribute throughout the body. We review both cellular pathologies and the expression of disease that could become more frequent in those who have undergone mRNA vaccination. Specifically, we describe the spike protein's contributions, via its prion-like properties, to neuroinflammation and neurodegenerative diseases; to clotting disorders within the vasculature; to further disease risk due to suppressed prion protein regulation in the context of widely prevalent insulin resistance; and to other health complications. We explain why these prion-like characteristics are more relevant to vaccine-related mRNA-induced spike proteins than natural infection with SARS-CoV-2. We note with an optimism an apparent loss of prion-like properties among the current Omicron variants. We acknowledge that the chain of pathological events described throughout this paper is only hypothetical and not yet verified. We also acknowledge that the evidence we usher in, while grounded in the research literature, is currently largely circumstantial, not direct. Finally, we describe the implications of our findings for the general public, and we briefly discuss public health recommendations we feel need urgent consideration. An earlier version of this article was previously posted to the Authorea preprint server on August 16, 2022.

Association of Left Atrial Deformation Analysis by Speckle Tracking Echocardiography With Left Atrial Appendage Thrombus in Patients With Primary Valvular Heart Disease

BACKGROUND

This study aimed to investigate the correlation between the functional parameters of the left atrium (LA) derived from deformation imaging, two-dimensional (2D) speckle tracking echocardiography (STE), and tissue Doppler imaging (TDI) strain and strain rate (SR) and the function of the left atrial appendage (LAA) as measured by transesophageal echocardiography (TEE) in patients with primary valvular heart disease.

METHODS

This cross-sectional research included 200 primary valvular heart disease cases, categorized into Group I (n = 74) with thrombus and Group II (n = 126) without thrombus. All patients were subjected to standard 12 lead electrocardiography, transthoracic echocardiography (TTE), strain and SR imaging of the LA by TDI and 2D speckle tracking, and TEE.

RESULTS

At a cut-off value of <10.50%, peak atrial longitudinal strain (PALS) is a predictor of thrombus with an area under the curve (AUC) of 0.975 (95% CI: 0.957-0.993), sensitivity of 94.6%, specificity of 93.7%, positive predictive value (PPV) of 89.7%, negative predictive value (NPV) of 96.7%, and accuracy of 94%. At a cut-off value of <0.295 m/s, LAA emptying velocity is a predictor of thrombus with an AUC of 0.967 (95% CI: 0.944-0.989), sensitivity of 94.6%, specificity of 90.5%, PPV of 85.4%, NPV of 96.6%, and accuracy of 92%. The PALS (<10.50%) and LAA velocity (<0.295 m/s) are significant predictors of thrombus (P = 0.001, β = 2.745, SE = 0.804, OR = 15.56, and 95% CI: 3.219-75.245; and P = 0.002, β = 2.499, SE = 0.799, OR = 12.17, and 95% CI: 2.543-58.201, respectively). Peak systolic strain < 12.55% and SR < 1.065/s are insignificant predictors of thrombus (β = 1.167, SE = 0.996, OR = 3.21, and 95% CI: 0.456-22.631; and β = 1.443, SE = 0.929, OR = 4.23, and 95% CI: 0.685-26.141, respectively).

CONCLUSIONS

Among LA deformation parameters derived from TTE, PALS is the best predictor of reduced LAA emptying velocity and LAA thrombus in primary valvular heart disease, regardless of the rhythm.

Multidrug-Resistant TB (MDR-TB) and Extensively Drug-Resistant TB (XDR-TB) Among Children: Where We Stand Now

Drug-resistant tuberculosis (DR-TB) has continued to be a global health cataclysm. It is an arduous condition to tackle but is curable with the proper choice of drug and adherence to the drug therapy. WHO has introduced newer drugs with all-oral shorter regimens, but the COVID-19 pandemic has disrupted the achievements and raised the severity. The COVID-19 controlling mechanism is based on social distancing, using face masks, personal protective equipment, medical glove, head shoe cover, face shield, goggles, hand hygiene, and many more. Around the globe, national and international health authorities impose lockdown and movement control orders to ensure social distancing and prevent transmission of COVID-19 infection. Therefore, WHO proposed a TB control program impaired during a pandemic. Children, the most vulnerable group, suffer more from the drug-resistant form and act as the storehouse of future fatal cases. It has dire effects on physical health and hampers their mental health and academic career. Treatment of drug-resistant cases has more success stories in children than adults, but enrollment for treatment has been persistently low in this age group. Despite that, drug-resistant childhood tuberculosis has been neglected, and proper surveillance has not yet been achieved. Insufficient reporting, lack of appropriate screening tools for children, less accessibility to the treatment facility, inadequate awareness, and reduced funding for TB have worsened the situation. All these have resulted in jeopardizing our dream to terminate this deadly condition. So, it is high time to focus on this issue to achieve our Sustainable Development Goals (SDGs), the goal of ending TB by 2030, as planned by WHO. This review explores childhood TB's current position and areas to improve. This review utilized electronic-based data searched through PubMed, Google Scholar, Google Search Engine, Science Direct, and Embase.

Correction: Austrian Syndrome: The Forgotten Triad of a Complex Condition in an Antibiotic Era

[This corrects the article DOI: 10.7759/cureus.32106.].

The Pseudo-Sign of Leser-Trélat: A Rare Presentation

The true sign of Leser-Trélat is a rare cutaneous marker suggestive of an underlying malignancy. Its hallmark finding is the abrupt onset of multiple seborrheic keratoses (SKs) that increase rapidly in number and/or size within weeks to months. When the ominous finding is present, the associated tumor is usually aggressive and portends a poor prognosis. The "pseudo-sign" of Leser-Trélat also presents with the rapid onset of multiple SKs, but without any underlying disease. It is less well-known, and there are only a few reports documenting the phenomenon. This paper reports the case of an 89-year-old male who presented with multiple SKs that rapidly progressed over his scalp, neck, arms, back, trunk, and legs within two to three weeks. A clinical workup revealed elevated pancreatic tumor markers. His cancer antigen (CA) 19-9 levels were 52 U/mL (normal range 0-37 U/mL). Computed tomography (CT) of his abdomen/pelvis without intravenous (IV) and oral contrast showed no evidence of cancer. Bothersome SKs, such as those where his clothes were rubbed against, were destroyed via cryotherapy or shave removal under local anesthesia depending on their size. The patient has remained without any symptoms or findings of an underlying malignancy, confirming that his presentation was consistent with the pseudo-sign of Leser-Trélat. Because it can be concerning when a patient suddenly develops multiple large SKs, recognition of the pseudo-sign is important to determine the appropriate course of action.

Acute Colonic Pseudo-Obstruction Secondary to Renal Calculus: A Case Report and Review of Pathophysiology

Acute colonic pseudo-obstruction (ACPO) is obstruction of the large bowel without a mechanical cause. The exact mechanism remains incompletely understood but is thought to result from disruption to the autonomic regulation of the colon, typically in the context of hospitalized patients with medical illness, precipitating medications, or recent surgical intervention. This paper presents an unusual case of ACPO in an ambulatory patient with a recently passed renal calculus, explores the anatomy and physiology underlying the autonomic dysfunction theory of ACPO pathogenesis in the context of the case, and provides a 3D reconstruction of the patient's CT to illustrate the abrupt caliber change at the splenic flexure characteristic of ACPO.

Mechanisms of Peripheral and Central Sensitization in Osteoarthritis Pain

Pain, the primary symptom of osteoarthritis (OA), reduces both the quality and quantity of life for patients. The pathophysiology of OA pain is complex and often difficult to explain solely by radiological structural changes. One reason for this discrepancy is pain sensitization (peripheral sensitization [PS] and central sensitization [CS]) in OA. Thus, an understanding of pain sensitization is important when considering treatment strategies and development for OA pain. In recent years, pro-inflammatory cytokines, nerve growth factors (NGFs), and serotonin have been identified as causative agents that induce peripheral and central sensitization and are becoming therapeutic targets for OA pain. However, the characteristics of the clinical manifestations of pain sensitization elicited by these molecules remain unclear, and it is not well understood who among OA patients should receive the therapeutic intervention. Thus, this review summarizes evidence on the pathophysiology of peripheral and central sensitization in OA pain and the clinical features and treatment options for this condition. While the majority of the literature supports the existence of pain sensitization in chronic OA pain, clinical identification and treatment of pain sensitization in OA are still in their infancy, and future studies with good methodological quality are needed.

The Relationship Between Cytokine Concentrations and Severity Scoring Index for Crimean-Congo Hemorrhagic Fever

Background This study aimed to investigate the effects of serum high mobility group box-1 (HMGB1), interleukin (IL)-6, IL-8, IL-1β, IL-10, and tumor necrosis factor alpha (TNF-α) levels on disease severity and mortality in Crimean-Congo hemorrhagic fever (CCHF) patients. Materials and methods This study was performed prospectively in the intensive care unit (ICU) and infection ward of a tertiary hospital in the Republic of Türkiye. Patients aged 18 years and older diagnosed with CCHF were included. Results Our study included 30 patients, of whom 83.3% were male, where the mean age was 51.6±14.35 years. The most common clinical findings in patients were malaise (90%) and myalgia (63.3%). In our study, IL-1β levels were found to be 1173.6 (783.0-1823.0) pg/mL, IL-6 69.9 (56.8-133.1) pg/mL, IL-8 191.2 (152.8-516.9) pg/mL, TNF-α 129.5 (104.9-270.8), HMGB1 37.01 (29.26-75.18), and IL-10 190.1 (IQR: 147.8-387.8) pg/mL. The patients' median Severity Scoring Index (SSI) score was found to be 2.5 (1.8-5.5). There was a moderate correlation between the patients' SSI score and serum IL-6 (r=0.464, p=0.010), TNF-α (r=0.420, p=0.021), and IL-10 levels (r=0.518, p=0.003), and a weak correlation between serum HMGB1 (r=0.392, p=0.032). The correlation between SSI and creatine phosphokinase (CPK) levels (r=0.499, p=0.036) was observed to be moderate. Conclusion It was seen that IL-10, IL-6, TNF-α, HMBG-1, and CPK levels evaluated at the CCHF patients' time of admission to the clinic and SSI clinical score were found to be significantly related. It is clear that more studies with patients and groups of healthy volunteers are needed on this subject.

Electrolyte Imbalance Among Bangladeshi Patients With COVID-19

Introduction Infection with SARS-CoV-2 begins in the lower respiratory tract, but COVID-19 often involves the renal system, resulting in serum electrolyte imbalance. Monitoring serum electrolyte levels and parameters of liver and kidney function is essential to understand disease prognosis. Objectives This study aimed to determine the effect of imbalances in serum electrolytes and other parameters on COVID-19 severity. Material and method This retrospective study comprised 241 patients, ages 14 years and older, including 186 patients who were moderately affected and 55 who were categorized as severely affected by COVID-19. Serum electrolytes (sodium (Na⁺), potassium (K⁺), and chloride (Cl^-)) and biomarkers of kidney and liver function (creatinine and alanine aminotransferase (ALT)) were measured and correlated with disease severity. This research was conducted among admitted patients of Holy Family Red Crescent Medical College Hospital designated into two groups based on retrospective hospital records. Individuals with moderate illness had evidence of lower respiratory tract infection (cough, cold, breathless, etc.) during clinical assessment or imaging (chest X-ray and computed tomography (CT) scan of the lungs) and have an oxygen saturation by pulse oximetry (SpO₂) ≥ 94% on room air at sea level. The severely ill group involved individuals with SpO₂ ≤94% on room air at sea level and respiratory rate ≥ 30 breaths/minute, and critically ill patients are those who needed mechanical ventilation or required intensive care unit (ICU) care. This categorization was based on the Coronavirus Disease 2019 (COVID-19) Treatment Guidelines (https://www.covid19treatmentguidelines.nih.gov/about-the-guidelines/whats-new/). Results Average Na⁺ and creatinine increased by 2.30 parts (95% confidence interval (CI) = 0.20, 4.81, P = 0.041) and 0.35 units (95% CI = 0.03, 0.68, P = 0.043) in severe cases compared with moderate cases. Older participants had relatively Na⁺ lowered to -0.06 parts (95% CI = -0.12, -0.001, P = 0.045), significant Cl^- reduction by 0.09 units (95% CI = -0.14, -0.04, P = 0.001), and ALT by 0.47 units (95% CI = -0.88, -0.06, P = 0.024), whereas serum creatinine was increased by 0.01 parts (95% CI = 0.001, 0.02, P = 0.024). The creatinine and ALT of COVID-19 participants were significantly higher in males by 0.34 units and 23.2 units, respectively, compared with females. In severe COVID-19 cases compared with moderate cases, the risks of hypernatremia, elevated chloride levels, and elevated serum creatinine levels were increased by 2.83-fold (95% CI = 1.26, 6.36, P = 0.012), 5.37-fold (95% CI = 1.90, 15.3, P = 0.002), and 2.00-fold (95% CI = 1.08, 4.31, P = 0.039), respectively. Conclusion Serum electrolyte and biomarker levels can serve as good indicators of the condition and disease prognosis of patients with COVID-19. Our purpose in this study was to determine the association between serum electrolyte imbalance and disease severity. We collected data from ex post facto hospital records and did not intend to assess the mortality rate. Consequently, this study expects that the prompt diagnosis of electrolyte disparity or disturbance possibly minimizes COVID-19-related morbidity and mortality.

A Case Report of Subacute Combined Degeneration Due to Nitrous Oxide-Induced Vitamin B12 Deficiency

Nitrous oxide, also known as "laughing gas," is a naturally occurring gas that is colorless, odorless, nonflammable, and nontoxic. It has been used as an inhalant anesthetic in the medical field for more than 150 years for dental and surgical procedures. Due to its wide availability and ability to cause euphoria, its recreational use is on the rise. We present a case of subacute combined degeneration (SCD) due to nitrous oxide-induced vitamin B12 deficiency. The patient presented with bilateral lower extremity paresthesia, weakness, and ataxic gait. The patient was found to have vitamin B12 deficiency. An MRI of the cervical spine revealed an abnormal T2 signal within the cervical spinal cord extending from the level of C2-C6 affecting only the posterior column. On the fifth day of hospitalization, the patient reported that he had been inhaling nitric oxide from whipped cream cans for recreational use. According to his clinical presentation and laboratory and imaging findings, we concluded that the patient had SCD. The patient slowly improved after receiving vitamin B12 supplementation therapy. Patients presenting with paresthesia, weakness, and laboratory studies indicating vitamin B12 deficiency should be questioned about nitrous oxide recreational use since the incidence is increasing.

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.

Evaluation of Local Application of Glucosamine Sulfate and Chondroitin Sulfate on Temporomandibular Joint Response and Alleviation of Pain and Tension During the Functional Treatment of Skeletal Class II Patients: A Randomized Control Clinical Trial

OBJECTIVE

 This study was conducted to assess the effects of applying a gel of combined glucosamine sulfate and chondroitin sulfate on the temporomandibular joint (TMJ) area in patients with skeletal Class II malocclusion treated by removable functional appliances in terms of TMJ internal proportions, levels of pain, and tension.

MATERIALS AND METHODS

The study included 36 patients aged 10-13 years with skeletal Class II malocclusion due to retrusion of the mandible characterized by: 4-8 degrees of the sagittal skeletal discrepancy (ANB) angle, 4-7 mm of overjet, 72-76 degrees of the sagittal mandibular positioning (SNB) angle, and a bone maturity stage located at pubertal growth spurt. Patients were distributed to the experimental group (Twin-Block appliance + Jointance® gel) or the control group (conventional treatment with the Twin-Block appliance). An allocation ratio of 1:1 was employed. Pre- and post-treatment digital lateral cephalometric radiograms were taken, and the TMJ joint spaces were measured using the Viewbox software (dHAL Software, Kifissia, Greece). The pain and discomfort levels were evaluated using a questionnaire with a four-point Likert scale at three assessment times.

RESULTS

 The anterior and posterior glenoid and anterior condylar distances to the pterygoid vertical (PTV) reference plane significantly decreased after treatment (p<.001), and the anterior joint space decreased significantly (p<.001). In contrast, the superior distance of the condyle to the Frankfort horizontal reference plane increased significantly after treatment, and the same results were found for the posterior and superior joint spaces (p<.05). There were no significant differences between the two groups in the evaluated linear variables. No significant differences were found when comparing pain and tension levels between the two groups at each assessment time. A gradual decrease in pain and tension levels was observed between the three evaluation times in both groups.

CONCLUSIONS

 A combination of glucosamine sulfate and chondroitin sulfate did not affect the temporomandibular joint spaces, pain, and tension levels in patients with skeletal Class II malocclusions treated by removable functional appliances.