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Background Patients suffering from progressive symptoms of benign prostatic hyperplasia (BPH) increasingly turn to the internet for information on invasive and minimally invasive surgical therapies (MIST). This study aimed to identify online articles accessed by patients seeking guidance on said options and to evaluate the quality and readability of their content. Methods Social media analytics tool Buzzumo was used to identify the most shared articles on Facebook, Twitter, Reddit, and Pinterest related to BPH surgical treatments from 2016 to 2021. The content quality was graded using the DISCERN tool; a questionnaire that assesses the quality of written information on treatment choices for a health problem. An online Automatic Readability Checker was used to evaluate the readability of the written transcripts. Google Trends data was used to evaluate search term popularity for BPH procedures from 2016 to 2021. Google trends data and DISCERN ratings were analyzed with ANOVA and paired t-test, respectively. Results Thirty-nine percent of identified articles were rated as low quality, 39% as moderate quality, and 22% as high quality using the DISCERN tool, with no significant difference among reviewer ratings (p = 0.0561). The median reading level of all articles was 12th grade. Google Trends data illustrated a rising popularity of MIST such as Rezūm and Urolift, exceeding interest in more invasive procedures like Holmium laser enucleation of the prostate (HoLEP) and laser surgery. Transurethral resection of the prostate (TURP) remained popular with no significant difference between MIST and TURP on Google Trends (p = 3.46). Conclusions The most accessed articles on BPH treatments have important shortcomings including risks of treatment and other available options for treatment. Article transcripts exceed the reading level of the average adult patient. TURP has remained a popular procedure online, but there is a notable rising interest in MIST, especially Urolift.

BACKGROUND In parallel with the increase in the number of children with life-limiting or life-threatening diseases, the need for and right to pediatric palliative care is also increasing. This study aimed to examine the metabolic diseases, evaluate the symptoms, and review the needs of children who were admitted to the pediatric palliative care service. METHODS Following the approval of the local ethics committee (18/7/2019-107), the computer records of patients hospitalized in the pediatric palliative care service between December 1, 2018 and January 6, 2019 were reviewed retrospectively. Dr Behcet Uz Children's Hospital, Pediatric Palliative Care Center is third center in Turkey. Our pediatric palliative care center has one year of experience. RESULTS In the study period, there were 101 patients who were hospitalized in the pediatric palliative care service. Eighteen patients (19.7%) diagnosed with inborn errors of metabolism were included in the study. The mean age was 3.2 ± 2.1 (0-8) years. Although it could not be shown statistically, the duration of hospitalization of patients with congenital malformation was long. CONCLUSION Pediatric palliative care provides the best care with the control of various symptoms in neurodegenerative congenital metabolic diseases that do not have treatment or treatment, but progressive symptoms cannot be prevented.

Peripheral nerve injuries (PNIs) continue to present both diagnostic and treatment challenges. While nerve transections are typically a straightforward diagnosis, other types of PNIs, such as chronic or traumatic nerve compression, may be more difficult to evaluate due to their varied presentation and limitations of current diagnostic tools. As a result, diagnosis may be delayed, and these patients may go on to develop progressive symptoms, impeding normal activity. In the past, PNIs were diagnosed by history and clinical examination alone or techniques that raised concerns regarding accuracy, invasiveness, or operator dependency. Magnetic resonance neurography (MRN) has been increasingly utilized in clinical settings due to its ability to visualize complex nerve structures along their entire pathway and distinguish nerves from surrounding vasculature and tissue in a noninvasive manner. In this review, we discuss the clinical applications of MRN in the diagnosis, as well as pre- and postsurgical assessments of patients with peripheral neuropathies.

In broad terms, "advanced" heart failure describes a clinical syndrome characterized by persistent or progressive symptoms and ventricular dysfunction despite guideline-directed medical therapy. Clinically the definition is often dependent upon iterative and integrated clinical assessments to identify patients with worsening status and reliance on specific therapies. This review examines current consensus definitions, highlights strategies for risk stratification and prognostication, and examines short- and long-term treatment strategies. Lastly, this paper explores future directions of research and development for the field.

We describe an adolescent with long-standing atresia of the head/neck arteries and severe aortic coarctation. Because of progressive symptoms, a series of interventions was undertaken to provide direct aorta–to–carotid artery flow and coarctation treatment. This case highlights the unusual physiological features associated with atresia of all head and neck arteries. (Level of Difficulty: Advanced.), Graphical abstract, We describe an adolescent with long-standing atresia of the head/neck arteries and severe aortic coarctation. Because of progressive symptoms…

Diabetic peripheral neuropathy is a diabetes-related complication with vague and progressive symptoms with few available treatments. The aim of this study was to describe the experiences of diabetic peripheral neuropathy among adults living with type 1 diabetes. Twelve interviews were performed and qualitative content analysis was used. The overarching theme ‘living with challenges in the shadow of diabetes’ substantiated by the categories ‘pay attention to changes over time’, ‘frequent needs to facilitate living’ and ‘burdens to manage’ represents a daily awareness of the complication where autodidactic strategies were implemented. The conclusion indicates that it might be beneficial if nurses in diabetes care initiate an open-minded dialogue with adults with diabetic peripheral neuropathy to highlight their experiences and to discuss further strategies to facilitate living.

At various times in history, technology has led to abrupt and far-reaching changes in how societies communicate: printing with moveable type in the 15th century; broadcasting in the 19th century and early 20th century; electronic transfer of information in the late 20th century; and machine learning with robotic systems in the 21st century. In that context, it is timely to reflect on the past, present and future trajectory of knowledge relating to medicine and what might be lost and gained as science and society increasingly enter the digital age. Here, the topic of interest is multiple sclerosis. Broad consensus on the pathogenesis of multiple sclerosis was reached in the late 1980s, the application of which has since yielded significant advances in therapy. In 2020, a reasonable formulation would consider multiple sclerosis to involve a distinct geographical distribution resulting from the interplay of environmental and genetic aetiological factors; inflammatory and degenerative disease mechanisms working in sequence or in parallel expressed as an evolving phenotype characterised by intermittent and then progressive symptoms and signs leading to gradual accumulation of disability; clinical features and their pathological substrate represented by various surrogate laboratory biomarkers; the availability of therapies that modify the course of the illness but varying in their risks and benefits making for complex prescribing algorithms; and, underpinning the whole scientific endeavour, the wish to settle the hopes and fears for their future of affected individuals. Digital technology uses binary rather than continuous analogue variables to detect patterns in large datasets, far outstripping the capacity of human agency for memory and analysis. Artificial intelligence develops systems that function according to preset rules but, primed by training datasets, generate their own information, learn from experience and adapt in order to achieve goals through deep learning. The boundaries of artificial intelligence are provisionally mapped in …

Introduction: CrossFit is a physical fitness program characterized by high-intensity workouts that can be associated with serious injury. Acute compartment syndrome in the upper limbs is a rare occurrence. It may occur after intense physical exercise, and its usual treatment is surgical. Hyperbaric oxygen therapy is a treatment described as adjunctive in cases of compartmental syndrome. Presentation: We describe the case of a CrossFit practitioner who, after intense training, developed progressive symptoms of rhabdomyolysis and acute bilateral arm compartment syndrome, who was successfully treated with hyperbaric oxygen therapy and required no fasciotomy as surgical treatment. Conclusion: Acute compartment syndrome in the arms after intense physical exercise is a rare occurrence that should be suspected by practitioners of physical activity experiencing intense, disproportionate and progressive pain. In the case presented, hyperbaric oxygen therapy was successfully used in the treatment of the disorder, with satisfactory progress, and without the need for a surgical fasciotomy as therapy.

Palliative care (PC) focuses on improving the quality of life and minimizing suffering in patients with chronic, symptomatic, and life-threatening disease. Because of severe and progressive symptoms, coexisting lung disease, anxiety, and depression, lung cancer (LC) patients derive robust benefit fr

Cavernous malformations (CM), also known as cavernous angiomas or cavernomas, are benign vascular hamartomas having a sinusoidal type of wall structure.CM occurs in the brain stem with a frequency of 9–35 % of cases. They are most often localized in the brain stem, have a higher risk of hemorrhage compared to supratentorial. After the primary hemorrhage, the risks of recurrent hemorrhages are very high. CM located in the brain stem has not always been subjected to surgical treatment. Conservative treatment was recommended for most patients. At the same time, according to the literature data, mortality reached 20 %, and during radiosurgery up to 8.3 % with recurrence of hemorrhage up to 59 %. The aim of the study was to evaluate the results of surgical treatment of patients with cavernomas of the brain stem. Materials and methods. the study included 16 patients who had hemorrhages in different parts of the brain stem. There were 12 males (75 %) and 4 females (25 %). Indications for surgical treatment were: presence of subacute hematoma, recurrent hemorrhage and progressive symptoms of brain stem damage. All patients were operated using modern methods of microsurgery. Neurophysiological monitoring was performed intraoperatively. Statistical processing was carried out with the program Statistica (version 10). Results. There was no operational mortality. At discharge, patients were assessed on the Rankin scale. Good functional outcomes were achieved in 87.8 % of cases (Rankin 1 – 43.8 %, Rankin 2 – 31.5 %, Rankin 3 – 12.5 %). Summary . Symptomatic malformations of the brain stem are subject to surgical removal when they are anatomically accessible. The use of modern methods of neuroimaging, adequate, sparing surgical approaches, microsurgical techniques for removing the cavernous brain stem, allows us to achieve good functional results in the operated patients, in the absence of postoperative mortality.

Introduction Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) was recently described in 2010, therefore the long-term prognosis is uncertain and there is no consensus on which steroid-sparing treatment is the most indicated. We present a case of CLIPPERS successfully treated with leflunomide. Case report A 43-year-old man with progressive symptoms of pontocerebellar dysfunction and radiological findings consistent with CLIPPERS was admitted to our clinic and treated with steroids in the acute phase, then he continue leflunomide for one year, showing sustained clinical and radiological remission. The treatment was changed to azathioprine and continued two more years in remission. Conclusion As far as we have documented, this is the first case of CLIPPERS kept under control with leflunomide in the medium-term with a good relative prognosis.

Purpose To characterize the management, outcomes, and emergency department (ED) length of stay (LOS) following iodinated contrast media extravasation events in the ED. Methods All ED patients who developed iodinated contrast media extravasation following contrast-enhanced CT (CECT) from October 2007–December 2016 were retrospectively identified. Medical records were reviewed and management, complications, frequency of surgical consultation, and ED LOS were quantified using descriptive statistics. The Wilcoxon rank sum test was used to compare ED LOS in patients who did and did not receive surgical consultation. Results A total of 199 contrast extravasation episodes occurred in ED patients during the 9-year study period. Of these, 42 patients underwent surgical consultation to evaluate the contrast extravasation event. No patient developed progressive symptoms, compartment syndrome, or tissue necrosis, and none received treatment beyond supportive care (warm/cold packs, elevation, compression). Median ED LOS for patients who did and did not receive surgical consultation was 11.3 h versus 9.0 h, respectively (p Conclusion Close observation and supportive care are sufficient for contrast extravasation events in the ED without concerning symptoms (progressive pain/swelling, altered tissue perfusion, sensory changes, or blistering/ulceration). Routine surgical consultation is likely unnecessary in the absence of these symptoms – concordant with the current American College of Radiology guidelines – and may be associated with longer ED LOS without impacting management.

Osteochondritis dissecans of the capitellum is an overuse injury that occurs primarily in adolescent athletes that causes pain and motion loss and can lead to chronic dysfunction. When diagnosed in its early stages, most lesions can be treated conservatively and without long-term consequences. Many osteochondritis dissecans lesions, however, continue to cause progressive symptoms despite nonoperative measures or are too advanced at the time of initial clinical presentation to be effectively treated without surgical intervention. The authors describe a safe and reproducible technique for the arthroscopic treatment of unstable, contained capitellar lesions.

Objective The progression rate for clinical manifestations in hemifacial spasm (HFS) varies; however, little is known about the factors contributing to this. The purpose of this study was to identify independent factors affecting the rate of symptom progression and to evaluate clinical outcomes according to progression rates. Methods The study enrolled 1335 patients who underwent microvascular decompression for HFS between July 2004 and January 2015. We assessed detailed history, clinical manifestations, and outcomes. Based on the duration and severity of symptoms, patients were classified into rapidly progressive and slowly progressive groups. We identified predisposing factors affecting the differences between the 2 groups and evaluated the clinical outcome in each group. Results Of 1335 patients with HFS, 825 (61.8%) were classified as rapidly progressive, and 510 (38.2%) were classified as slowly progressive. In univariable and multivariable analyses, younger age at surgery, older age at symptom onset, and absence of intraoperative facial nerve indentation were significant predisposing factors for rapid progression. The rapidly progressive group had worse outcomes than the slowly progressive group following microvascular decompression. Conclusions In this study, patients with rapidly progressive HFS had worse clinical outcomes. Therefore, patients with rapidly progressive symptoms should be warned in advance that the prognosis may be worse after microvascular decompression. This study is also useful to understand the differences in symptom progression rates in HFS in order to inform patients about symptom progression.

Heart failure is a progressive and fatal disease impacting millions of American each year. Divided into stages, heart failure presents with progressive symptoms requiring a wide range of medical treatments. Treatments include diet and lifestyle changes, medications, electrical therapies (defibrillator and/or cardiac resynchronization therapy), as well as mechanical circulatory support. Cardiac transplant is the gold standard treatment of heart failure, although the availability of donors limits the utility of a cardiac transplant. This article outlines heart failure treatments and the indications, contraindications, and pretransplant evaluation for a cardiac transplant. Information on the allocation of donor hearts and donor characteristics is also included for the reader.

Post-polio syndrome (PPS) is a constellation of new and progressive symptoms developing several years following infection with the acute viral illness poliomyelitis caused by the poliovirus. PPS is characterized by the onset of fatigue, weakness in one or more extremities, including the potential to involve the muscles of the respiratory system, and pain.

Anterior cervical procedures have become the gold standard since the description of Smith, Robinson and Cloward in the 1960s. Surgical treatment is indicated when prior conservative therapy has failed or progressive symptoms are present. Preoperative CT and MRI images are accomplished to determine bony or discoligamentous neural compressions. The patient is placed in a supine position: a right-sided approach prior to fluoroscopic control is recommended. The skin is incised at the median border of the sternocleidomastoid muscle ending across the midline. The subcutaneous tissue is undermined with longitudinal platysma split, and the subplatysmal space and the neck fasciae are accessed bluntly. After identifying the longus colli muscles, the retractors are placed.

BACKGROUND Cranial nerve schwannomas are radiologically characterized by nodular cranial nerve enhancement on magnetic resonance imaging (MRI). Schwannomas typically present with gradually progressive symptoms, but isolated reports have suggested that schwannomas may cause fluctuating symptoms as well. METHODS This is a report of ten cases of presumed cranial nerve schwannoma that presented with transient or recurring ocular motor nerve deficits. RESULTS Schwannomas of the third, fourth, and fifth nerves resulted in fluctuating deficits of all 3 ocular motor nerves. Persistent nodular cranial nerve enhancement was present on sequential MRI studies. Several episodes of transient oculomotor (III) deficts were associated with headaches, mimicking ophthalmoplegic migraine. CONCLUSIONS Cranial nerve schwannomas may result in relapsing and remitting cranial nerve symptoms.

Background and Objective: The optimal management of intracranial arterial stenosis is unclear, particularly in patients who have failed medical management. We report a multicenter real-world experience of endovascular recanalization of intracranial atherosclerotic stenosis refractory to aggressive medical therapy. Methods: Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (TIA or stroke) who had failed medical therapy were identified. All of the patients were considered to be at high risk with unstable symptomatic intracranial stenosis and progression or recurrence of symptoms despite the best medical management and underwent endovascular intervention either with stenting and/or balloon angioplasty. Results: 98 patients presented with recurrent TIAs (n= 40) or recurrent or progressive strokes (n= 58) and were treated in 8 stroke centers from 2009 to 2017. All patients were treated either with dual antiplatelet therapy (84%) or anticoagulation and all had statin therapy prior to recurrence or progression of their symptoms. There was one periprocedural perforation resulting in patient death. There were 3 patients who had periprocedural strokes and 2 patients had symptomatic intraparenchymal hemorrhage with a total of four (4%) periprocedural mortality. The all-cause mortality rate at discharge was 6%. At 90-day follow-up, 7 (10%) patients had TIAs and 2 (3%) patients had ipsilateral strokes, and 78% of patients had mRS of 2 or less. Conclusion: Endovascular recanalization of unstable intracranial atherosclerotic stenosis who have failed medical therapy is feasible and safe.

Background Since the 1950s cerebrospinal fluid (CSF) shunt dependency has no longer been a contradiction to normal life, including sexuality and pregnancy in women, because of advances in the understanding of hydrocephalus and shunt technology. Although pregnancy in shunt-dependent women is rare, it causes uncertainty among treating physicians. Case Description We report the case of a 34-year-old pregnant woman with a ventriculoperitoneal shunt. Throughout her pregnancy she experienced progressive symptoms of CSF underdrainage without any signs of other pregnancy-related complications. After the delivery of a healthy infant, shunt resistance had to be readjusted to prepregnancy levels. A comprehensive review of the literature reports in English, listed in PubMed, is provided. Conclusions Conservative treatment of pregnancy-related functional underdrainage by consecutive valve pressure adjustment is possible, easy, and safe.

Though Sandhigata Vata is described under the broad heading of Vatavyadhi in most of the Samhita and Sangraha Granthas, it is not included under 80 types of “Nanatmaja Vatavyadhi”, Charaka was first, who described separately Sandhigata Vata as - “Sandhigata Anila” in Vatavyadhi chapter. The clinical presentation of Sandhigata Vata resembles to Osteoarthritis, which is the most common form of arthritis. It begins asymptomatically in middle age with progressive symptoms in advancing age. It increases in prevalence with age especially in weight bearing joints. Female are prone with 25% prevalence were 16% in male. In present study 21 patients fulfilling diagnostic criteria of Sandhigata Vata were selected. Patients were treated with Nirgundi Taila locally 8ml on affected joints, with Dashmoola Ghrita 12g. with meal internally twice a day with luke warm water. After a course of therapy of 2 month symptomatic improvement was observed at various levels with better results in the patients treated with Nirgundi Taila and Dashmoola Ghrita.

Small-bowel obstruction is a frequent disorder in emergency medicine and represents a major burden for patients and health care systems worldwide. Within the past years, progress has been made regarding the management of small-bowel obstructions, including the use of contrast agent swallow as a tool in the decision-making process. This is a prospective controlled study investigating the central role of contrast agent swallow in the diagnostic and treatment algorithm for small-bowel obstruction at a university department of surgery. Endpoints were the correct identification of patients who needed operative treatment and the accuracy of a conservative treatment decision including the analysis of dropout from this routine algorithm. We performed a single-center analysis of 181 consecutive patients diagnosed with a small-bowel obstruction based on clinical, radiologic, and sonographic findings. Patients with clinical signs of strangulation or peritonitis underwent immediate surgery (group 1). Patients without signs of peritonitis and incomplete stop in the initial abdominal plain film were considered eligible for Gastrografin® challenge (group 2). Seventy-six of the 181 patients (42.0%) underwent immediate surgery. A Gastrografin® challenge was initialized in 105 of the 181 patients (58.0%). Twenty of these 105 patients (19.1%) with persisting or progressive symptoms and absence of contrast agent in the colon after 12 and 24 h subsequently underwent surgery. Here, a segmental bowel resection was necessary in 6 of these 20 patients (30.0%). In 16 out of 20 patients (80.0%) who failed the Gastrografin® challenge, a corresponding correlate in terms of a strangulation was detected intraoperatively. The Gastrografin® challenge had a specificity of 96% and a sensitivity of 100%; accuracy to predict the need for exploration was 96%. A straightforward algorithm based mainly on contrast agent swallow for patients with small-bowel obstructions enabled a timely and very accurate differentiation between patients qualifying for conservative and operative treatment.

Upper airway manifestations of Crohn's disease are rare with the most common being tracheobronchitis. We present a case report of a 12-year-old male with suspected Crohn's disease who presented with progressive symptoms of upper airway obstruction. Biopsies of thickened, pale, fibrotic supraglottic tissues were consistent with supraglottic involvement of Crohn's disease. He was treated with intralesional steroid injection with resolution of symptoms, obviating the need for systemic steroid treatment, which has been described in cases of Crohn's disease involving the airway.

Parkinson′s disease and its plus syndromes are an important cause of morbidity in the geriatric age group. Its plus syndromes show a myriad of clinical features characterized by progressive symptoms. Here we present a 65-year-old woman with progressive "Parkinsonian-like features," i.e., mask-like face, slowness of all movements and tendency to fall, and difficulty in eye movements, leading to the diagnosis of Steele Richardson Olszewski Syndrome or progressive supranuclear palsy.

Accessory mitral valve tissue (AMVT) causing left ventricular outflow tract obstruction (LVOTO) is rare. We report a case of AMVT causing severe LVOTO resulting in acutely progressive symptoms of near-collapse. Urgent surgical resection eliminated the patient’s life-threatening symptoms. AMVT should be considered among potential LVOTO diagnoses, and early surgical intervention may be required.

Obstructive prosthetic valve thrombosis (PVT) is a rare but severe complication that usually occurs in the presence of suboptimal anticoagulation. Although fluoroscopy is commonly used to detect abnormal leaflet motion as a surrogate marker for PVT, its inability to directly visualize adjacent tissue and valve physiology leaves it susceptible to miss clinically important PVT. In this manuscript, we report the case of a 54-year-old woman with a mechanical mitral valve who was admitted to our institute with exertional dyspnea. Although valve fluoroscopy was normal, subsequent 3D echocardiography and ECG-gated multiphase computed tomography confirmed the presence of PVT that was subsequently treated successfully with surgical replacement. Our case demonstrates the utility of multimodality imaging in establishing PVT in patients with abnormal prosthetic valve physiology and progressive symptoms.

Our goal was to validate the hypothesis that the lumbosacral angle (LSA) increases in children with spinal dysraphism who present with progressive symptoms and signs of tethered cord syndrome (TCS), and if so, to determine for which different types and/or levels the LSA would be a valid indicator of progressive TCS. Moreover, we studied the influence of surgical untethering and eventual retethering on the LSA.We retrospectively analyzed the data of 33 children with spinal dysraphism and 33 controls with medulloblastoma. We measured the LSA at different moments during follow-up and correlated this with progression in symptomatology.LSA measurements had an acceptable intra- and interobserver variability, however, some children with severe deformity of the caudal part of the spinal column, and for obvious reasons those with caudal regression syndrome were excluded. LSA measurements in children with spinal dysraphism were significantly different from the control group (mean LSA change, 21.0A degrees and 3.1A degrees respectively). However, both groups were not age-matched, and when dividing both groups into comparable age categories, we no longer observed a significant difference. Moreover, we did not observe a significant difference between 26 children with progressive TCS as opposed to seven children with stable TCS (mean LSA change, 20.6A degrees and 22.4A degrees respectively).We did not observe significant differences in LSA measurements for children with clinically progressive TCS as opposed to clinically stable TCS. Therefore, the LSA does not help the clinician to determine if there is significant spinal cord tethering, nor if surgical untethering is needed.

SUMMARY: Very large and giant (≥15 mm) cerebral aneurysms have a poor natural history, with high risk of subarachnoid hemorrhage or progressive symptoms of mass effect. Several endovascular techniques may be applied for treatment, depending on location, size, anatomy and presence of collateral circulation. The authors reviewed their clinical experience in endovascular treatment of 232 very large and giant aneurysms and present their perspective on the present state of the art in endovascular therapy for these aneurysms.

Introduction: Acute bacterial supraglotittis in adults is a distinct although rare condition that differs aetiologically and clinically from the classic paediatric form of the disease. Only a handful of cases of supraglotittis produced by Neisseria meningitidis have been described in the literature. Case presentation: Here, we present the first description, to the best of our knowledge, of meningococcal supraglotittis in an immunosuppressed patient, with unique features of rapidly progressive symptoms, septic shock and multiorgan compromise. Conclusion: In view of the recent reports describing a growing incidence of this condition in adults, increasing awareness about its clinical features, natural history and potential complications is needed to enable early recognition and optimal management of emerging cases.

Progeria is a rare genetic disease that manifests with progressive symptoms eventually leading to death. The only current treatment protocol of such patients is symptom based. However, recent trials are testing potential and promising drugs to treat the underlying genetic mutation and increase life expectancy of such patients.

Treatments for mitochondrial disease, while developing, remain limited. Therapies complementary to traditional medical and surgical approaches may benefit the patient with mitochondrial disease. The goals of the 'allied health professions' of physical, occupational, speech and respiratory therapies are to maintain and if possible, improve patients' existing strength, functioning and mobility. These therapists also play an important role in helping patients to compensate for disabilities and adapt to progressive symptoms. Novel forms of physical and occupational therapies, equine or "hippotherapy" and pet therapy, use the human to animal relationship to improve physical and emotional health. To enhance quality of life, an integrated team of experts, under the guidance and supervision of the physician, should be available to the patient with mitochondrial disease.

We describe the largest reported epineural ganglion of the ulnar nerve arising in the cubital tunnel. A 54-year-old male, driver presented with progressive symptoms of left sided cubital tunnel syndrome. Surgery demonstrated a 11 × 3 cm ganglion which was successfully removed. Post-operatively the patient demonstrated partial recovery with no recurrence of the ganglion.

We are reporting about a 48-year-old female patient with progressive symptoms of dopa-responsive dystonia since the age of 14. She has received levodopa with moderate success throughout almost the entire course of her illness. Over the last few years her symptoms have worsened significantly, with an increase especially in the Parkinson-like symptoms. A high oral dose of levodopa was not tolerated, prompting us to decide in favour of intrajejunal dopa administration. Placement of a Jet-PEG and administration of 80 mg L-dopa/h produced a good symptomatic response, without relevant side effects and especially without dyskinesias. This is the first published case of treatment of dopa-responsive dystonia with a Duodopa pump and high dose levodopa (>1800 mg/day).

Purpose: To report a case of bilateral ulnar neuropathy as an extraocular complication following retinal detachment surgery and face-down positioning. Methods: Case report. Results: Bilateral hypoesthesia and numbness of the 4th and 5th finger started 2 weeks after vitrectomy for retinal detachment and face-down positioning. Due to progressive symptoms 6 months later, unilateral ulnar nerve decompression at the elbow was performed. Conclusions: This case report demonstrates that strict face-down positioning bears the risk of ulnar neuropathy.

We present a 58-year-old man with neurological manifestations indicating increased intracranial pressure in association with hyperthyroidism. Hyperthyroidism due to a hyperfunctioning solitary thyroid nodule was the underlying cause, since all the symptoms disappeared after the treatment of hyperthyroidism. Our aim is to emphasize that hyperthyroidism should be suspected in a patient with progressive symptoms of increased intracranial pressure.

SUMMARY We describe a 65-year-old male who presented with unilateral sacroiliitis as the first manifestation of metastatic prostatic carcinoma. When progressive symptoms are unresponsive to conventional therapy, a reconsideration of the diagnosis is necessary with appropriate further imaging studies. We discuss the differential diagnosis of sacroiliitis including, mechanisms of joint involvement in malignancy, and present a review of the literature.

Gout can be defined as the presence of monosodium urate crystals (MSUCs) in tissues. These MSUCs may induce acute inflammation when shed into the synovial fluid or cause aggregate-inducing chronic tissue inflammation. The nucleation and formation of MSUCs is related to the presence of longstanding hyperuricemia, which is an essential factor in the development of gout. Other factors, such as level of hyperuricemia, time exposed to hyperuricemia, and genetic or acquired tissue predisposition for the nucleation of MSUCs, may explain why not all patients with hyperuricemia develop gout, or why some patients develop early or rapidly progressive symptoms associated with gout.

This study examined how a sample of family practitioners, general internists, and osteopathic physicians practicing in the state of Maine (N=353) diagnose symptoms of cognitive dysfunction. Physicians' reported diagnostic approaches were compared to American and Canadian expert panel recommendations, and were associated with their sociodemographic and office practice characteristics. Sample members responded to a self-administered questionnaire, which was completed in response to a clinical vignette describing a patient with either mild symptoms or more progressive symptoms of cognitive dysfunction. Results showed that 59 percent of respondents would perform a formal cognitive status test and 32 percent would perform a depression screening test; both types of tests are recommended by American and Canadian expert panels. Adjusting for other factors, female physicians were twice as likely as males to perform a depression screening test (OR=2.04; 95 percent C1=1.13-3.67). Most respondents (87 percent) would order at least three of four recommended laboratory tests, and 59 percent would order a computerized tomography (CT) scan, even though expert guidelines are ambiguous about the value of CT scans in diagnostic workups. Diagnostic approaches were not significantly affected by plans to refer patients to other physicians for additional testing. Practicing physicians should be encouraged to perform recommended nueropsychological and mental status tests when patients present with symptoms of cognitive dysfunction.

Inborn errors of metabolism may present with acute neurological symptoms at any age. However, especially in neonates and infants, these conditions may be acute and if untreated may lead to permanent cerebral lesions or to death. Knowledge of the main signs and symptoms of these conditions may be lifesaving, especially for conditions that are treatable. From the pathophysiological perspective, errors of metabolism can be divided into disorders causing “intoxication,” disorders impairing energy production, and disorders involving complex molecules. From the clinical perspective, errors of metabolism may present with acute symptoms in the neonatal period and early infancy; late-onset acute and recurrent attacks; chronic and progressive symptoms. Nonspecific readily available biochemical markers may suggest the underlying condition but in most cases the choice of appropriate biochemical and molecular tests is required to establish the diagnosis. Progress in the treatment of inborn errors of metabolism has been slower than progress in diagnostic methods and in understanding of the pathophysiology of these disorders. Nevertheless, outcomes are improving with the use of dialysis and drugs to promote the removal of toxic metabolites and measures to keep catabolism to a minimum. Early intervention is crucial when neurological sequelae could be avoided, which requires constant vigilance and routine measurement of diagnostic biochemical markers in suspected cases.

Clomiphene citrate is widely used by the female population for the management of a wide array of medical conditions especially those related to ovulation, but its use in male population remains controversial. Efficacy of clomiphene is not well established in male hypogonadism and infertility. Its side effects and complications are also poorly studied or reported. We present a case of a man with infertility issues for which he started receiving clomiphene citrate 3 weeks before presenting with progressive symptoms of headache, vomiting, transient blurred vision and diplopia, which eventually turned out to be the symptoms of intracranial venous thrombosis. After excluding the common causes of intracranial venous thrombosis and hypercoagulable state, clomiphene citrate seems the most likely culprit.

ultiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS). Presence of plaques is the main pathological feature of MS, occurring in myelinated axons within the CNS (brain and spi-nal cord). MS is classified as relapsing-remitting MS (RRMS) characterized by attacks, whose symptoms occur so suddenly with subsequent partial or complete recovery; primary-progressive MS (PPMS) with progressive symptoms accumulated over time; and sec-ondary-progressive MS (SPMS), after the initial form of RRMS. The most common type of MS is the relapsing-remitting (when attacks may sequelae or not)

Diabetic myelopathy is a common pathological finding in patients with diabetes mellitus, but its manifestations can be masked by advanced diabetic neuropathy. This case illustrates that it should be suspected in all diabetic patients with subacute progressive symptoms affecting all extremities even in the absence of dysfunction of bowel/bladder sphincters.

We report a 70-year-old woman with Isaacs' syndrome (acquired neuromyotonia) who showed a marked improvement after immunoadsorption plasmapheresis (IAP). She developed hyperhidrosis in her teens, and slowly progressive symptoms of neuromyotonia for over 50 years. An in vitro investigation of her serum with patch-clamp technique suggested the presence of antibodies against potassium channels. She was treated with IAP, which brought disappearance of her symptoms. Though the symptoms started to recur in 3 weeks, moderate improvement has been maintained by immunosuppressive drug treatment.

Although they are delayed, progressive symptoms occurring after polio have recently received considerable attention, dysphagia in patients who have had polio has not been well-studied. The findings of historical, neurologic, and cineradiographic examinations in 13 patients with dysphagia who had had polio are presented. Historical evidence indicates that progressive dysphagia is among the worsening problems encountered by some patients several decades after their acute polio illness. Thorough evaluation of dysphagia symptoms in patients who have had polio is indicated to determine optimal feeding management and to search for treatable contributing factors.

Reconstructive surgery was performed in a 57-year old woman in whom initially the left coronary artery had originated from the pulmonary trunk, producing progressive symptoms of congestive heart failure. Recurrence of shunting was documented by Doppler echocardiography and contrast angiography, necessitating a second surgical intervention 17 months after the first procedure.

Huntington's disease (HD) is an autosomal dominant inherited disorder of the central nervous system. Consequently, a child of an affected parent has a 50% risk of developing the disease. This article provides an overview of HD by providing a brief history of the disease and describing progressive symptoms of chorea, dystonia, incoordination and decreased mental acuity. Steps in diagnosis, treatment and prognosis are outlined. Because persons at risk for HD have usually witnessed the deterioration of an HD parent, they are often dominated by fears of developing HD themselves. Life's choices, such as whether or not to have children, then become dilemmas. The importance of maintaining a positive life perspective, while making practical choices about employment, marriage, children and other concerns needs to be addressed.

Evaluation of feed materials, culture environments, and tolerance of salinity and dissolved oxygen confirmed that the moi, a polynemid (threadfin), is amenable to further aquaculture development. Wild-caught juvenile moi grew faster on a diet of cut fish and squid than on prepared commercial feed, and they grew faster in a 23-m3 net-pen than in 0.7-m3 cylindrical tanks. Juveniles survived dilution of culture water from 34‰ salinity seawater to 1‰ in 1 h, and showed no ill effects from being held at 5–15‰ for 40 d. They survived depletion of dissolved oxygen to levels below 4 mg/L, but showed progressive symptoms of hypoxic stress indicating lethal levels near 3 mg/L. Moi are protandrous hermaphrodites; fish matured spontaneously as males at fork lengths greater than 20 cm (in both net-pens and tanks) 6–7 months after capture at 6 cm. Growth rates indicated the potential for maturation as females within a year in captivity.