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Abstract Background Bone scintigraphy (BS) is established as an accurate, non-invasive method for the diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM). In a real-life setting, however, some patients with no cardiac uptake on BS turn out to have cardiac-biopsy-confirmed ATTR-CM. We retrospectively included all patients diagnosed at the French Referral Center for ATTR-CM and who had data for BS and a cardiac biopsy. Results Of 271 patients with positive cardiac biopsy, 14 (5%) had no cardiac uptake on 99mTc-hydroxymethylene diphosphonate BS. Cardiac uptake was found in four of the seven patients who had a second BS assessment with 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD). A retrospective review of the BS data found low cardiac uptake in four patients (two with HMDP and two with both radiotracers). Ultimately, six of the 14 patients with a biopsy-confirmed diagnosis of ATTR-CM did not show any cardiac radiotracer uptake. Conclusions An endomyocardial biopsy may be necessary for confirming the diagnosis of ATTR-CM in patients with clinical and imaging signs of cardiac amyloidosis but no cardiac radiotracer uptake in BS.

Androgen Insensitivity Syndrome (AIS) is a rare X-linked Disorder of Sexual Differentiation (DSD) caused by a mutation in the Androgen Receptor (AR) gene, which is located on the X chromosome (Xq11-q12). It can present with a wide spectrum of phenotypes depending on different mutations of the AR gene. It is classified into mild, partial, and complete AIS. In this series of cases, authors describe patients who presented to tertiary hospitals over several years. Case 1 presented with inguinal masses and primary amenorrhoea, which upon investigations revealed complete AIS. Case 2 was a young child who underwent surgery for an inguinal hernia, and later histopathology and karyotype revealed a diagnosis of complete AIS. Case 3 presented with large adnexal masses to oncology, where intraoperatively absent Mullerian structures, histopathology, and karyotype gave the diagnosis of Complete AIS. Case 4 presented with hirsutism, primary amenorrhoea, and clitoromegaly. Upon investigation, imaging and karyotype with virilising features led to the diagnosis of partial AIS. The absence of Mullerian structures on imaging, chromosomal analysis, and the finding of undescended testicular masses in inguinal regions clinch the diagnosis. These patients should undergo gonadectomy after puberty to decrease the chances of malignancy. Therefore, when investigating the cases of primary amenorrhoea, patients with absent pubic/axillary hair and absent uterus/ovaries should raise suspicion of AIS. Also, any young female child with an inguinal hernia should be investigated for AIS.

Dengue infection can take on many different forms, ranging from no symptoms to a mild fever, all the way to a severe condition known as dengue shock syndrome. Although the typical symptoms of dengue are well known, the virus can also cause rare neurological complications. Dengue encephalitis is a severe form of neuroinvasive dengue that can be fatal as the virus directly affects the central nervous system. This case series provides a comprehensive overview of dengue, its clinical spectrum, and the potential for severe neurological complications such as dengue encephalitis. It highlights the importance of considering dengue as a possible diagnosis in patients with encephalitis, particularly during a dengue epidemic.

Abstract Background Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population. Case presentation A total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 μg/kg was administered within 10 minutes, and a maintenance dose of 1.5 μg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients. Conclusion Dexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

Introduction Spontaneous tendon ruptures in end stage kidney disease patients have the potential to cause long- term morbidity, and timely intervention is required to prevent complications that can severely affect the functional status of the patient. Case presentation A series of six tendons (two triceps tendons and two bilateral patellar tendons) in three patients with ESKD undergoing hemodialysis is discussed in this case series. Patients were aged 61, 44 and 26 years, and on hemodialysis for 5, 10 and 5 years, respectively. Conclusion End -stage kidney disease is associated with a multitude of physiological changes, and the musculoskeletal system is no exception to this. Spontaneous tendon rupture is a multifactorial complication of ESKD, with serious implications for mobility and quality of life. As a result, these patients require a multifaceted approach to ensure optimum results and an early return to activity. We report a series of 6 spontaneous tendon ruptures in 3 patients with ESKD at our institution. We would like to outline the methods of repair for each case and further attempt to assess biochemical parameters that may have contributed to the disease process.

Key Clinical Message We report three cases of IMN from our center, where patients received a single dose of telitacicept after showing no response to conventional treatments. Although one case did not respond, the other two cases achieved complete or partial remission of proteinuria. These cases illustrates the telitacicept may offer new hope for the treatment of IMN. Abstract Despite the variety of treatment options available, effective therapies for refractory membranous nephropathy remain lacking. Recently, some reports have suggested that telitacicept is a new therapeutic option. However, only a few published studies have documented the use of telitacicept for treating idiopathic membranous nephropathy (IMN). We present three cases of IMN from our center, where patients received a single dose of telitacicept after showing no response to conventional treatments, including glucocorticoids, tacrolimus, mycophenolate mofetil, cyclophosphamide, cyclosporine, and rituximab. Although one case did not respond, the other two cases achieved complete or partial remission of proteinuria. Thus, telitacicept may offer new hope for the treatment of refractory membranous nephropathy.

Abstract Background Dravet syndrome is an infantile-onset developmental and epileptic encephalopathy (DEE) characterized by drug resistance, intractable seizures, and developmental comorbidities. This article focuses on manifestations in two Indonesian children with Javanese ethnicity who experienced Dravet syndrome with an SCN1A gene mutation, presenting genetic analysis findings using next-generation sequencing. Case presentation We present a case series involving two Indonesian children with Javanese ethnicity whom had their first febrile seizure at the age of 3 months, triggered after immunization. Both patients had global developmental delay and intractable seizures. We observed distinct genetic findings in both our cases. The first patient revealed heterozygous deletion mutation in three genes (TTC21B, SCN1A, and SCN9A). In our second patient, previously unreported mutation was discovered at canonical splice site upstream of exon 24 of the SCN1A gene. Our patient’s outcomes improved after therapeutic evaluation based on mutation findings When comparing clinical manifestations in our first and second patients, we found that the more severe the genetic mutation discovered, the more severe the patient’s clinical manifestations. Conclusion These findings emphasize the importance of comprehensive genetic testing beyond SCN1A, providing valuable insights for personalized management and tailored therapeutic interventions in patients with Dravet syndrome. Our study underscores the potential of next-generation sequencing in advancing genotype–phenotype correlations and enhancing diagnostic precision for effective disease management.

Abstract Background Complications such as forearm hematoma after coronary intervention through the radial artery are a common complication. Material and methods By observing, describing, and analyzing the pictures taken during clinical diagnosis and consultation, we summarize the prevention, treatment, and nursing of forearm hematoma after percutaneous coronary intervention, to provide reference for the nursing of patients with forearm hematoma. Results We have innovatively summarized the risk classification of forearm hematoma and the three key time points for preventing hematoma. Conclusion Complications such as forearm hematoma after coronary intervention through the radial artery are a common complication. We have innovatively summarized the risk classification of forearm hematoma and the three key time points for preventing hematoma, providing reference for the prevention and management of forearm hematoma in clinical practice. For patients undergoing transradial coronary intervention, the three key time points for preventing hematoma and symptomatic management based the risk classification of forearm hematoma are crucial.

Key Clinical Message Jejunalileal atresia is a cause of intestinal obstruction in the newborn, hence a surgical emergency. Prenatal diagnosis can be made by simple obstetric ultrasound and postnatal by plain abdominal x‐ray to plan a multidisciplinary approach to reduce morbidity and neonatal mortality. Abstract Atresia can occur anywhere along the intestines and is a common cause of intestinal obstruction in neonates. Jejunoileal atresia (JIA) is a rare disease occurring in 2.1 per 10,000 live births. Type 3b jejunoileal atresia occurs in 11% of all small bowel atresia. We present three cases of type 3b jejunoileal atresia. They were all missed by prenatal ultrasonography, and presented with features of intestinal obstruction. The diagnosis was confirmed by plain abdominal x‐rays and ultrasound, followed by laparotomy. Postoperative care was given in the neonatal unit according to local protocols. One recovered, however, two succumbed from neonatal infection. Jejunoileal atresia requires surgery and long postoperative care, with outcomes associated with numerous prognostic factors including multidisciplinary care and neonatal intensive care. Jejunoileal atresia is less commonly associated with other congenital anomalies, unlike duodenal atresia. Efforts are needed to scale up prenatal diagnosis of jejunoileal atresia, and therefore to plan for appropriate care after delivery. Also, further studies are needed to understand neonatal sepsis in the postoperative period and ways to improve outcomes.

Neuropsychiatric systemic lupus erythematosus (NPSLE) affects the brain, spinal cord, or other nerves and leads to neurological and psychiatric symptoms directly related to SLE. We report a series of four female patients with NPSLE as the first presentation for SLE. None of them were previously diagnosed with SLE. The first case involved a 50-yearold patient who presented with back pain and lower limb weakness for three weeks associated with numbness. A lumbar puncture was done, and CSF analysis showed high WBC and normal glucose levels with negative CSF cultures for bacteria. The patient was diagnosed with aseptic meningitis and treated with antibiotics and antiviral medication without improvement. So she was treated as a case of SLE aseptic meningitis with steroids. In the second case, a 20-yearold patient had a generalized tonic-clonic seizure with the acute manifestation of hypertensive urgency. Magnetic resonance imaging (MRI) was done and suggested posterior reversible encephalopathy syndrome (PRES). The third case was for a 38-year-old patient who complained of dizziness, general weakness, and convulsion. On review of the systems, the patients had positive symptoms of SLE. Anti-nuclear antibody (ANA) and double-stranded ds-DNA were positive. Computed tomography (CT) scans were done and showed a thymoma. The patient was diagnosed with SLE in association with focal seizures and thymoma. In the last case, a 44-year-old patient presented with tongue heaviness and right-side weakness. MRI revealed small acute lacunar infarction scattered at both cerebral hemispheres and the right side of the cerebellum, and chest CT showed pulmonary embolism (PE). The patient was diagnosed with an acute ischemic stroke and PE related to SLE. In conclusion, the neurological manifestations of SLE are a significant issue for both patients and clinicians. Here we report a unique case series and describe the prognosis and outcome of the treatment in these cases.

The Coronavirus disease of 2019 (COVID-19) pandemic had a public impact on various dimensions, including multisystemic complications. One such complication is subacute thyroiditis (SAT), also called subacute granulomatous or de Quervain thyroiditis, in which the severe acute respiratory syndrome-Coronavirus-2 virus affects thyroid tissue. Here we report seven patients with SAT and positive for COVID-19 and real-time quantitative-polymerase chain reaction. Neck pain was the most common symptom, followed by headache, fatigue, lethargy, and fever. Ultrasound revealed typical findings of the SAT. Corticosteroid treatment resulted in a complete improvement of inflammatory parameters and normalization of thyroid hormone levels. Our findings highlight the importance of considering rare cases of SAT as a potential complication of COVID-19. This report can also help physicians from various disciplines to identify such complications and provide better care for COVID-19 patients.

Abstract Background Inflammatory bowel diseases, consisting of Crohn’s disease and ulcerative colitis, are chronic bowel relapsing inflammatory disorders. Inflammatory bowel diseases begin rarely in infants. Approximately 25% of patients with inflammatory bowel diseases present before the age of 20 years. Very early-onset inflammatory bowel disease occurs before the age of 6 years; infantile inflammatory bowel diseases occurs before the age of 2 years, and is extremely rare in infants under 1 year of age. Case presentation Herein, we report a case series of 7-month-, 11-month-, and 12-month-old Syrian infants that presented with diarrhea, hematochezia, and pale appearance and were finally diagnosed with infantile inflammatory bowel disease and treated. Conclusions Early diagnosis and ruling out infantile inflammatory bowel diseases despite its rarity are recommended. Over and above that, new drugs such as vedolizumab, golimumab, and less invasive treatment methods should also be taken into consideration for better response and adequate remission with improved quality of life.

Abstract To evaluate the success of pulpotomy in treating immature permanent teeth with irreversible pulpitis. This case series included patients with irreversible pulpitis admitted to the Department of Oral Medicine at the author’s Hospital between 2015 and 2020. The pulpotomies were carried out by clinicians with > 5 years of working experience. The follow-up findings and radiographic images were reviewed by two attending dentists. This study included 49 teeth from 48 children (25 boys and 23 girls). The follow-up was 23.3 ± 6.8 months (from 12 to 40 months). The success rate of pulpotomy was 85.7% (42/49). Pulpotomy failed in seven teeth (14.3%). The treatment success rate for traumatic crown fracture was lower than for dental caries and dens evaginatus (P 0.05). Pulpotomy might be successfully used to treat immature permanent teeth with irreversible pulpitis in young patients mainly caused by caries and a fractured tubercle of dens evaginatus.

Abstract Background Pneumothorax (PTX) and pneumomediastinum (PM) have been reported as potential complications in patients with coronavirus disease 2019 (COVID-19); however, their risk factors and etiology remain unknown. Herein, we investigated the clinical characteristics of mechanically ventilated patients with COVID-19 with PTX or PM. Methods We examined patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit of a tertiary-level emergency medical center in Tokyo, Japan between April 1, 2020. and October 31, 2021. We collected and analyzed the clinical characteristics of the patients who presented with either PTX or PM during mechanical ventilation. Results During the study period, a total of 165 patients required mechanical ventilation, and 15 patients with PTX/PM during mechanical ventilation were selected. Three patients with obvious causes were excluded, and the remaining 12 patients were analyzed (7.3%). The mortality rate in these patients was as high as 50%, demonstrating the difficulty of treatment in the presence of PTX/PM. PTX/PM occurred 14.5 days after intubation. A peak pressure of > 30 cmH2O was only apparent in one patient, suggesting that high positive pressure ventilation may be less involved than mentioned in the literature. In addition, the inspiratory effort was not strong in our group of patients. (P0.1 was 2.1 cm H2O [1.0–3.8]). Conclusion Various factors are associated with the development of PTX/PM in patients on mechanical ventilation for COVID-19. We did not find a strong correlation between PTM/PM and barotrauma or strong inspiratory efforts, which have been identified as potential causes in previous studies.

Kikuchi–Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare, self-limiting disorder characterized by fever typically lasting for 1 week up to 1 month and painful necrotizing lymphadenopathy, primarily affecting young adults of Asian ancestry. Although the exact cause remains unclear, infectious and autoimmune mechanisms have been implicated in the pathogenesis of the disease. In this case series, we aim to describe the histopathological features of KFD over a ten-year period at Mount Sinai Medical Center of Florida, and review the current understanding of its pathogenesis, clinical presentation, diagnosis, and management. A retrospective review of our pathology database between January 2013 and May 2024 was performed to identify patients diagnosed with KFD at our institution. Eight cases of KFD were identified, with a mean age of 35 years (range 24–49) and slight male predilection (5:3). Three patients exhibited leukopenia, and two had concurrent HIV infection. One patient developed systemic lupus erythematosus (SLE), and another developed IgA nephropathy during follow-up. Histopathological examination revealed the characteristic features of KFD, including lymph node architectural effacement, histiocytic infiltration, and necrosis. In conclusion, KFD remains a diagnostic challenge due to its overlapping clinical features with other infectious and autoimmune diseases, particularly SLE. While most cases resolve spontaneously, long-term follow-up is warranted due to the potential for recurrence and autoimmune associations.

Key Clinical Message In young women presenting with atypical features of intracerebral hemorrhage, metastatic choriocarcinoma should be considered as a differential diagnosis. In resource‐poor settings, a high index of suspicion and serum β‐hCG are crucial for diagnosis. Abstract Intracerebral hemorrhage in the young is rarely caused by metastatic choriocarcinoma. Diagnosis of this condition may be particularly challenging in resource‐poor settings where access to diagnostic technologies may be limited. We present a case series of three young females diagnosed with metastatic choriocarcinoma after initially presenting with intracerebral hemorrhage, each demonstrating unique clinical manifestations. We aim to highlight the diagnostic considerations in the management of this infrequently encountered cause of intracerebral hemorrhage, especially in resource‐constrained settings. Case 1 involved a 21‐year‐old woman who was initially diagnosed with intracerebral hemorrhage likely of tumoral origin from an unknown primary source. Further evaluation revealed extremely high levels of β‐hCG and features suggestive of an intrauterine malignancy, which led to a diagnosis of metastatic choriocarcinoma. This further became complicated by pulmonary embolism. Unfortunately, she succumbed to respiratory failure during treatment. Case 2 is a young woman who presented to the emergency unit and was managed as a case of lobar intracerebral hemorrhage. Further checks revealed a previous history of hysterectomy done on account of placental site trophoblastic tumor, which promoted an evaluation for choriocarcinoma. Case 3 involved a 20‐year‐old patient who initially presented with headache and vomiting. An enhanced magnetic resonance imaging showed a large subacute right temporal occipital subependymal hemorrhage with mass effect. After probing further, we discovered that she underwent exploratory laparotomy for suspected ruptured ectopic gestation, which later turned out to be a gestational trophoblastic neoplasia. After further evaluation a diagnosis of choriocarcinoma with brain metastasis. Our case series emphasizes the importance of having a high index suspicion in young females who present with atypical features of ICH. The varied clinical scenarios highlight the challenges in diagnosing young females. It also underscores the critical role of serum β‐hCG, especially in resource‐limited settings where biopsies are not readily available. Building a repository of these diverse manifestations is essential for increasing the index of suspicion and ultimately improving patient outcomes.

Eosinophilic gastrointestinal diseases (EGIDs) are rare and heterogeneous diseases characterized by excessive eosinophilic infiltration of the digestive system. D-dimer levels and its possible association with disease course were not reported.

Abstract Background Bacterial and fungal superinfections are commonly reported in patients with coronavirus disease 2019. Case presentation We report the first case of brain and intramedullary abscesses caused by Pseudomonas aeruginosa and a rare case of brain abscesses caused by Aspergillus fumigatus in two post-coronavirus disease 2019 patients. The first patient—34-year-old Iranian woman—presented with weakness of the left upper limb, headaches, and lower limb paresthesia. She had a history of undiagnosed diabetes and had received corticosteroid therapy. The second patient—45-year-old Iranian man—presented with right-sided weakness and had a history of intensive care unit admission. Both patients passed away despite appropriate medical therapy. Conclusion The immune dysregulation induced by coronavirus disease 2019 and its’ treatments can predispose patients, especially immunosuppressed ones, to bacterial and fungal infections with unusual and opportunistic pathogens in the central nervous system. Pseudomonas aeruginosa and Aspergillus fumigatus should be considered as potential causes of brain infection in any coronavirus disease 2019 patient presenting with neurological symptoms and evidence of brain abscess in imaging, regardless of sinonasal involvement. These patients should get started on appropriate antimicrobial therapy as soon as possible, as any delay in diagnosis or treatment can be associated with adverse outcomes.

Here, we present a case series of four patients diagnosed with acute ischaemic stroke due to occlusion of the artery of Percheron (AOP), a rare stroke variant, observed in a single emergency centre within a three-month period. AOP occlusion is characterized by bilateral thalamic infarction with or without involvement of the mesencephalon. The presenting symptoms are diverse and not specific, but commonly include disturbance of consciousness, memory impairment, and vertical gaze palsy. In addition, due to the location of the infarction, imaging recognition is challenging and AOP occlusion often remains undiagnosed. This paper emphasizes the necessity of early recognition and appropriate management of AOP occlusion to significantly impact patient outcomes. Moreover, we argue that the condition might be more common than previously thought and that misdiagnosis or delay in diagnosis may lead to inappropriate treatment and potential failure to apply thrombolysis within the required timeframe.

Abstract Background Undifferentiated carcinomas of the pancreas with osteoclast-like giant cells (UCPOGC) are rare pancreatic neoplasms that account for less than 1% of all pancreatic malignancies. This case report of a 54-year-old male with metastatic UCPOGC adds to the existing literature and further ascertains the clinical and imaging features, treatment options, and prognosis of this rare entity. Case presentation We present the detailed clinical course of a 54-year-old Asian male patient with UCPOGC, with focus on the relevant clinical features and imaging findings that are characteristic of this disease entity. Conclusions UCPOGC is an extremely rare pancreatic tumor with a unique histopathology and clinical course. It is often difficult to distinguish UCPOGCs from other pancreatic tumors, such as traditional pancreatic ductal adenocarcinomas (PDAC), on imaging, and it therefore remains a pathological diagnosis. Surgery is generally regarded as the first-line treatment option, and the roles of chemotherapy and radiation are unclear. Due to the exceeding rarity of this tumor, large-scale clinical studies are not feasible. Therefore, it is important to share individual insights and experiences to improve our understanding and care for patients with this devastating disease.

Abstract Background Posttransplant lymphoproliferative disorder is one of the most severe complications after transplantation, caused by uncontrolled proliferation of Epstein–Barr virus-positive B-cells in the setting of chronic immunosuppression. As one of the biggest transplant centers worldwide, we observed a potential increase in the number of patients with posttransplant lymphoproliferative disorder presenting with gastrointestinal symptoms in 1 year, during the coronavirus disease 2019 pandemic. There is limited information about dysregulation of the immune system following coronavirus disease 2019 infection, which may lead to Epstein–Barr virus reactivation in Epstein–Barr virus-positive B-cells and development of posttransplant lymphoproliferative disorder. Furthermore, there is no consensus in literature on a modality that can help in early diagnosis of posttransplant lymphoproliferative disorder with nonspecific gastrointestinal presentations before late and fatal complications occur. Case presentation Our case series includes five Iranian (Persian) patients, three female (2, 2.5, and 5 years old) and two male (2 and 2.5 years old), who developed gastrointestinal posttransplant lymphoproliferative disorder after liver transplantation. All of our patients were on a similar immunosuppressant regimen and had similar Epstein–Barr virus serologic status (seronegative at time of transplantation but seropositive at time of posttransplant lymphoproliferative disorder diagnosis). Four patients had either a positive coronavirus disease 2019 polymerase chain reaction test or exposure within the family. Although all of our patients presented with nonspecific gastrointestinal symptoms, four patients developed late posttransplant lymphoproliferative disorder complications such as bowel perforation and obstruction. All five patients with gastrointestinal posttransplant lymphoproliferative disorder received chemotherapy, but only two survived and currently are continuing the therapy. In one of the surviving patients, prompt endoscopic investigation resulted in early diagnosis of posttransplant lymphoproliferative disorder and a better outcome. Conclusion Since 80% of our patients had exposure to coronavirus, a potential relationship might be suggested between the two. Furthermore, as we witnessed in one case, urgent endoscopic investigation in immunocompromised patients presenting with gastrointestinal symptoms can improve the clinical outcomes and therefore should be considered for early diagnosis of posttransplant lymphoproliferative disorder.

Abstract Background Chest X-ray offers high sensitivity and acceptable specificity as a tuberculosis screening tool, but in areas with a high burden of tuberculosis, there is often a lack of radiological expertise to interpret chest X-ray. Computer-aided detection systems based on artificial intelligence are therefore increasingly used to screen for tuberculosis-related abnormalities on digital chest radiographies. The CAD4TB software has previously been shown to demonstrate high sensitivity for chest X-ray tuberculosis-related abnormalities, but it is not yet calibrated for the detection of non-tuberculosis abnormalities. When screening for tuberculosis, users of computer-aided detection need to be aware that other chest pathologies are likely to be as prevalent as, or more prevalent than, active tuberculosis. However, non­-tuberculosis chest X-ray abnormalities detected during chest X-ray screening for tuberculosis remain poorly characterized in the sub-Saharan African setting, with only minimal literature. Case presentation In this case series, we report on four cases with non-tuberculosis abnormalities detected on CXR in TB TRIAGE + ACCURACY (ClinicalTrials.gov Identifier: NCT04666311), a study in adult presumptive tuberculosis cases at health facilities in Lesotho and South Africa to determine the diagnostic accuracy of two potential tuberculosis triage tests: computer-aided detection (CAD4TB v7, Delft, the Netherlands) and C-reactive protein (Alere Afinion, USA). The four Black African participants presented with the following chest X-ray abnormalities: a 59-year-old woman with pulmonary arteriovenous malformation, a 28-year-old man with pneumothorax, a 20-year-old man with massive bronchiectasis, and a 47-year-old woman with aspergilloma. Conclusions Solely using chest X-ray computer-aided detection systems based on artificial intelligence as a tuberculosis screening strategy in sub-Saharan Africa comes with benefits, but also risks. Due to the limitation of CAD4TB for non-tuberculosis-abnormality identification, the computer-aided detection software may miss significant chest X-ray abnormalities that require treatment, as exemplified in our four cases. Increased data collection, characterization of non-tuberculosis anomalies and research on the implications of these diseases for individuals and health systems in sub-Saharan Africa is needed to help improve existing artificial intelligence software programs and their use in countries with high tuberculosis burden.

Background: Non-specific neck pain is a common neuromusculoskeletal problem and affects about two thirds of people worldwide. Purpose: To find out the efficacy of the combination therapy in individuals with non-specific neck pain. Case: The intervention was given in 12 sessions (3 times per week for 4 weeks) with the total duration of therapy per session is 20 minutes. The sequence of interventions includes: ultrasound therapy, application of muscle energy techniques, and SNAGs mobilization. Evaluation of therapy in the form of pain was measured by a visual analogue scale and the range of motion of the cervical spine’s lateral flexion was measured by a goniometer. Result: The results of the case series showed a decrease in pain scores from an average of 5.67 to 2.73. In the range of motion of the cervical spine’s lateral flexion there was an increase from an average of 30 degrees to 36 degrees. Conclusion: The combination of ultrasound therapy, muscle energy technique, and sustained natural apophyseal glides provided benefits in reducing pain and increasing the range of motion of the cervical spine’s lateral flexion in individuals with non-specific neck pain. This case series can be used as a preliminary study to develop further research with experimental methods in proving the effectiveness of the combination therapy in treating non-specific neck pain.

Abstract Background The gold standard anesthesiologic procedure for urgent femur fracture surgery is Spinal Anesthesia. It is not always feasible because of patients' severe comorbidities and difficulties in optimizing drug therapy in the appropriate time frame such as discontinuation of anticoagulant drugs. The use of four peripheral nerve blocks (tetra-block) can be a winning weapon when all seems lost. Case presentation We present, in this case series, three Caucasian adult femur fractures (an 83-year-old woman, a 73-year-old man, and a 68-year-old woman) with different and major comorbidities (cardiac or circulatory disorders on anticoagulants therapy that were not discontinued on time; breast cancer and others) underwent the same anesthesiologic approach in the urgent setting. Ultrasound peripheral nerve blocks, that is femoral, lateral femoral cutaneous, obturator, and sciatic with parasacral approach were successfully performed in all patients who underwent intramedullary nailing for intertrochanteric fracture. We evaluated the adequacy of the anesthesia plane, postoperative pain control with the VAS scale, and the incidence of postoperative side effects. Conclusions Four peripheral nerve blocks (Tetra-block) can be alternative anesthesiologic management in urgent settings, in patients where drug therapy cannot be optimized, as in antiplatelet and anticoagulant therapy.

Background: Opioids are useful in the management of vaso-occlusive crisis among Sickle Cell Disease patients; however, there is a need to search for drugs that can ameliorate the withdrawal symptoms without causing further dependence. Case presentations: Three patients living with Sickle cell disease abusing Pentazocine were managed with Tab Chlorpromazine 100mg twice daily for three weeks and had a significant reduction in the level of craving and also experienced improved sleep. Chlorpromazine demonstrates a high affinity for dopamine (DA) receptors and acts as a receptor antagonist by inhibiting adenylate cyclase activity. Conclusion: Chlorpromazine was found to be useful in the management of cravings associated with Pentazocine addiction.

Key Clinical Message Impacted maxillary central incisors represent a relatively infrequent occurrence. This condition significantly impacts the patient's self‐esteem and aesthetic concerns. Effective resolution is achievable through a combined strategy involving surgical exposure, bracket attachment, and subsequent orthodontic extrusion. The Surgical orthodontic approach is the optimal strategy for addressing impacted maxillary central incisors. Abstract Central incisor is rarely impacted teeth often associated with supernumerary teeth. This case series includes three cases of central incisor impaction presented with complaints of missing teeth, unesthetic appearance, and unclear speech. All the cases were managed with surgical exposure followed by traction by orthodontic force, restoring smile aesthetics.

Background: The presence of sudden-onset fibromyalgia (FM) is poorly understood, characterized, and appreciated in both previous literature and the clinical setting. In this case series, we present 10 cases of sudden-onset FM seen in a community-based pain clinic, to characterize the presentation of this condition, stemming from both external trauma and idiopathic etiology. Methods: This retrospective case series identified 10 patients diagnosed with FM attending the pain clinic. These patients were referred to chronic pain management clinic in Thunder Bay, Ontario, Canada, from January 2019 until December 2021 and met the diagnostic criteria for FM. Information was collected on sex, gender, age, details of signs and symptoms, and FM severity score as well as clinical findings and outcomes. Results: The case series identified 10 community residents (9 women and 1 man, F/M: 9/1, age range: 34-64 years, mean age: 51.7 years), with symptoms attributed to FM. Majority of patients suffered from total body pain and mental disorders such as depression. 60% of patients were on opioids at the time of referral. Combination of pharmacological and non-pharmacological management improved their pain symptoms within 3-6 months on follow-up. Conclusion: Overall, effectively identifying sudden-onset FM can help clinicians improve patient-oriented outcomes and avoid the use of unnecessary narcotics in addition to better treating their patients.

Nonmetric characteristics, epigenetic traits, and cranial distinct traits are indicated by tubercles, ossicles, bony protuberances, foramina/notches, and other features on the human skull. For decades, they have piqued the interest of anatomists and anthropologists by supporting and providing evidence for human evolution. Torus occipitale is one such cranial nonmetric variation which is the projection/prominence of inion (midpoint of external occipital protuberance). According to studies, it is caused by the ossification of the ligamentum nuchae's connection to the external occipital protuberance. Yet another nonmetric trait, occipital bun is the posterior projection of the squamous part of the occipital bone below internal occipital protuberance. This case series reports how autapomorphic traits such as torus occipitale and occipital bun are helpful to determine race and the relationship between living taxa and paleontology. These tiny qualitative differences can be used as phenotypic connection markers between groups. We hereby report four types of torus occipitale and cases of occipital bun with their clinical and anthropological relevance.

Abstract Background This study aimed to explore the clinical values of the percutaneous spinal endoscopy “isolation zone” technique for discogenic low back pain (DLBP). Methods This retrospective case series study enrolled patients with intervertebral DLBP treated with the percutaneous spinal endoscopy “isolation zone” technique in the department of Orthopedics, Cangzhou central Hospital affiliated to TianJin Medical University between September 2017 and September 2020. Results Forty-five patients with DLBP were enrolled. The mean operation time was 94.7 ± 17.7 min. The visual analogue scale (VAS) score of lumbosacral pain was 6.95 ± 1.02 before operation, 2.64 ± 0.71, 1.80 ± 0.54, 1.42 ± 0.50, and 1.27 ± 0.45 at 1, 3, 6, and 12 months after operation, respectively. The Oswestry disability index (ODI) score of low back pain was 72.84 ± 5.95 before operation, 35.1 ± 5.30, 25.22 ± 4.85, 16.78 ± 4.63, and 10.91 ± 2.36 at 1, 3, 6, and 12 months after operation, respectively. At final follow-up, the treatment effect based on modified MacNab criteria was excellent in 24 cases, good in 13 cases, and fair in 8 cases. The excellent/good rate was 82.2%. Conclusion The percutaneous spinal endoscopic “isolation zone” technique seems to be a promising surgical alternative for DLBP.

Abstract Background Giant cell arteritis is a large vessel vasculitis of the arteries in the head and neck. The mainstay of management is with high-dose corticosteroids, and patients often face difficulties stopping or reducing steroids without recurrence of symptoms. Corticosteroids are well established to have numerous associated side effects, including osteoporosis, weight gain, and diabetes. Therefore, when tocilizumab was approved for up to 1 year for cases of relapsing or refractory giant cell arteritis by the National Institute of Health and Care Excellence (NICE) in April 2018, this offered an opportunity to benefit from new funding and to reduce steroid burden. Case presentation This case series describes the impact of the establishment of a new hub and spoke referral pathway for the use of tocilizumab in refractory or relapsing giant cell arteritis, with case examples from consecutive patients who accessed the funding between August 2018 and April 2021. A total of 16 patients were identified: 11 female and 5 male, with an average age of 72.4 (range 61–82) years, with a majority of 11 ethnically white. The central assessing hub is St George’s University Hospitals NHS Foundation Trust Hospital, serving a population of 1.3 million in the south of England. This is the first large case series looking into the impact of the establishment of a regional clinical pathway for the new tocilizumab funding. Conclusions The case series demonstrates that the use of tocilizumab has reduced both the duration and the dose of corticosteroids in these 16 cases (mean prednisolone reduction 20.4 mg: 95% CI 13.0–27.8 mg), with 50% of patients continuing on tocilizumab after the initial 12 month funding period. The disease course, patterns of response, and maintenance of remission are discussed, and we describe the benefits of replicating this hub and spoke tocilizumab pathway in other centers.

Abstract Hydatid cyst disease puts a significant burden on the health of humans every year. The lung is the second most common organ of implantation of Echinococcus larvae. Due to the importance of early diagnosis of tension pneumothorax, this paper provides four cases of hydatid disease that presented with tension pneumothorax.

Abstract Background During the COVID-19 pandemic, some studies describing different aspects of the infection included very similar participants, rising suspicion about double reporting. We aimed to evaluate the Gantt chart as a tool to highlight possible double reporting. The chart is routinely used in business applications to depict tasks of a project, by plotting horizontal bars against time, showing their time span and overlaps. Methods All case reports and case series of pregnant women with COVID-19, published by July 15, 2020, were included. Initial and final dates of participants’ enrollment, country, city, hospital, and number of pregnancies were plotted in the Gantt chart. Bars stand for enrollment dates of each study, according to hospital and city, thus allowing comparisons. Results We included 116 articles in the present analysis. The Gantt chart highlighted papers in which some participants were likely the same, thus allowing easier identification of double reporting of cases. Combining all information and pregnancy characteristics and outcomes helped to recognize duplications when the authors did not acknowledged the previous publication. Conclusions Unintended double reporting may occur, especially in exceptional times. The Gantt chart may help researchers to visually identify potential duplications, thus avoiding biased estimates in systematic reviews or meta-analysis.

Key Clinical Message Diagnosis of HAPE can be challenging when the presentation deviates from usual natural history. Point of care ultrasonography serves as a great diagnostic tool in such settings. An umbrella treatment could be beneficial during such scenarios.

Abstract Background Uterine anomalies occur because of Müllerian duct maldevelopment. Few of them are associated with adverse obstetric outcome (Reyes-Muñoz et al. in Diagnostics. 2019;9:4. https://doi.org/10.3390/diagnostics9040149 ). Genital outflow tract obstructive uterine anomalies invariably present in the adolescent age group. Case details We report a case series of uterine anomalies. Ten such cases presented like a “cluster” within a short span of just one month. Eight of these ten cases were diagnosed intraoperatively during cesarean section. One case was diagnosed during laparoscopic sterilization, and the other case was diagnosed before doing manual vacuum aspiration. There were four cases of bicornuate uterus, two cases each of unicornuate uterus and uterine didelphys, and one case each of septate uterus and arcuate uterus. All eight babies were healthy and without any obvious congenital anomalies. To the best of the authors’ knowledge, literature regarding these anomalies has been mentioned mostly as case reports (Bruand et al. in Cureus. 2020;12:3. https://doi.org/10.7759/cureus.7191 ) and a few case series (Ross et al. in BMJ Case Rep. 2018. https://doi.org/10.1136/bcr-2017-221815 ). All women were of Kannadiga ethnicity and in the age range of 19–35 years. They were from places nearby to our institute within a range of approximately 250 km. Conclusion We describe herein almost all types of uterine anomalies. These rare uterine anomalies presented in a short span of just four weeks like a “cluster”. This incidental finding is unusual. We need to design studies to understand the reasons for clustering of such cases in our clinical practice.

Extrapulmonary nontuberculous mycobacterial (NTM) disease remains largely enigmatic, yet these mycobacteria are increasingly acknowledged as important opportunistic pathogens in humans. Traditionally, NTM infections have been identified across various anatomical locations, with the respiratory system being the most affected and best understood. Historically, extrapulmonary NTM infection was predominantly associated with HIV/AIDS, with Mycobacterium avium lymphadenopathy being the most commonly reported. Today, however, because of the expanding utilization of immunosuppressive therapies and the demographic shift towards an aging population, an increasing number of NTM infections are expected and seen. Hence, a heightened index of suspicion is essential, necessitating a multifaceted approach to identification and drug sensitivity testing to improve treatment outcomes. In extrapulmonary NTM management, expert consultation is strongly recommended to determine the most efficacious treatment regimen, as individualized, patient-tailored therapies are often required. Furthermore, the economic burden of NTM disease is considerable, accompanied by high rates of hospitalization. To optimize the management of these intricate infections, there is an urgent need for comprehensive data on incidence, prevalence, and outcomes. This case-based series delves into the intricate nature of extrapulmonary NTM infections, focusing on both rapid and slow-growing NTM species, and explores therapeutic options, resistance mechanisms, and host-related immunological factors.

Background: Granular cell tumor (GCT) or Abrikossoff's tumor is an uncommon neuro-derived tumor in which Schwann cells are found and express S-100 protein. Often, it is a benign lesion. Histopathologically, there are granular cell infiltrations through the entire dermis without necrosis which are periodic acid Schiff (PAS) stain positive and reactive with S-100. The aim of this study is the clinicopathological evaluation of GCT. Material and Methods: In this paper, we described the experience of 6 patients with a GCT in different locations (4 cases in the skin and 2 cases in the mucosa), for example, a case with a tumor in the abdomen and a keloidal-like presentation with a highly sclerotic pattern (an uncommon pathological feature). Another case developed a lesion secondary to physical trauma. Result: In one case, the presence of a lesion in the lower lip associated with actinic damage secondary to chronic sun exposure resulted in misdiagnosis with actinic cheilitis and squamous cell carcinoma. Conclusion: Histopathologically, there were granular cell infiltrations through the entire dermis without necrosis which are PAS-positive and reactive with S-100.

Laparoscopic radical prostatectomy (LRP) is traditionally characterized as a technically difficult procedure with a long learning curve but it is successfully performed worldwide. The aim of this paper was to assess the initial learning curve and clinical outcomes for LRP in our center. We performed a retrospective study including 63 LRP cases, in the course of 22 months, performed by 2 urologists, with no previous LRP experience. All patients were previously assessed by a multidisciplinary team and were selected on the basis of low and intermediate risk disease attributes according to the classification of prostate cancer risk groups of the European Association of Urology. The main outcomes of follow-up are procedure duration, estimated blood loss, complications, positive surgical margins, biochemical relapse and urinary continence. The median follow-up was 19.6 months. The median procedure duration was 196.8 minutes and median blood loss 257.1 mL. Significant decrease in both outcomes was observed when comparing first and last cases in the series. There were 5 (7.9%) Clavien Dindo grade II complications. Undetectable prostate specific antigen (PSA) was observed in 59 (93.6%) patients, and fifty-five patients (87.3%) were continent. Following a methodical learning approach, LRP can be safely mastered with favorable outcomes.

Case reports are considered the smallest units of descriptive studies. They serve an important function in bringing out information regarding presentation, management, and/or outcomes of rare diseases. They can also be a starting point in understanding unique associations in clinical medicine and can introduce very effective treatment paradigms. Preparing the manuscript for a case report may be the first exposure to scientific writing for a budding clinician/researcher. This manuscript describes the steps of writing a case report and essential considerations when publishing these articles. Individual components of a case report and the “dos and don'ts” while preparing these components are detailed.

Introduction: Haemophagocytic lymphohistiocytosis (HLH) is an extremely rare condition characterised by excessive immune activation leading to haemophagocytic activity and has seldom been reported in pregnancy. HLH manifests as relapsing fevers with features of multi- organ failure and has a high mortality. Methods: A retrospective case series analysis using national data from MBRRACE-UK maternal death reports (n=5) and case notes from patients diagnosed with HLH during pregnancy at New Cross Hospital, Wolverhampton (n=2) between 2012 and 2021. Results: A total of seven cases were included. Cases uniformly presented with fever and experienced prodromal illnesses consisting of lymphadenopathy, fevers, and malaise. Gestation at presentation ranged from 9/40 to 11 months postpartum. All patients had multiple cytopaenias. Other common features included elevated liver enzymes (n=5), hyperferritinaemia (n=5), splenomegaly (n=4), hypofibrinogenemia (n=4) and elevated soluble interleukin-2 receptor α (CD25) levels (n=3). Underlying causes were identified in four cases. Median time from presentation to diagnosis was 35 days. Bone marrow biopsy was diagnostic in a majority of cases. Corticosteroids and ciclosporin were the most frequently used treatments. In some cases early delivery by caesarean section or termination of pregnancy was necessary to permit maternal treatment. Progression to multi-organ failure resulting in maternal death occurred in five cases: two cases survived. Pregnancy outcomes were: livebirth at term (n=2), preterm livebirth (n=3), termination of pregnancy (n=1), and miscarriage (n=1). Of the surviving infants, one had bone marrow suppression with anaemia at birth and sensorineural deafness. Conclusions: Due to the rarity of the condition, diagnosis is often delayed. In view of the high mortality, clinicians should consider HLH early when reviewing pregnant patients with unexplained pyrexia and multi-organ dysfunction. Early involvement of haematology should be sought, as prompt diagnosis is crucial for meaningful attempts at curative therapy. Important treatment considerations include fetal viability, maternal condition and treatment toxicity.

Abstract Background Severe acute respiratory syndrome coronavirus 2, the cause of coronavirus disease 2019, has become a global pandemic. Currently, there is no definitive treatment for coronavirus disease 2019. Convalescent plasma therapy has become a potential specific curative method, while vaccines as protection modalities require further work. Case presentation Eight non-intubated Indonesian patients, ages ranging from 40 to 74 years old, with coronavirus disease 2019 confirmed by viral Ribonucleid Acid (RNA) real-time polymerase chain reaction tests were included. Four patients were administered two doses of 200 mL convalescent plasma, and the other four patients were administered one dose of convalescent plasma with an antibody titer of 1:320, within the first 14 days since symptoms occurred. The median times from illness onset to convalescent plasma therapy and from the first day of hospital admission to convalescent plasma therapy were 13 and 6.5 days, respectively. All patients showed improvements in clinical symptoms, laboratory parameters, thorax imaging, negative conversion of polymerase chain reaction results, and decreased oxygen supplementation within 1 week after convalescent plasma therapy. Patients with two convalescent plasma doses tended to have faster recovery than those with one convalescent plasma dose. No severe adverse effects were observed in any patient. Conclusion This is the first case series in Indonesia showing that convalescent plasma therapy is safe and well tolerated and that early convalescent plasma therapy before the patient is intubated could potentially prevent disease progression, increase the recovery rate, and shorten the inpatient time of stay.

Abstract Background Cesarean scar pregnancy is a complicated and potentially life-threatening type of ectopic pregnancy. This study reports two women with cesarean scar pregnancy who were successfully treated with systemic methotrexate administration, and two other women who needed local re-administration of methotrexate after systemic injection. Case presentation Four Iranian pregnant women aged 29–34 years who were between 5 to 7 gestational weeks with cesarean scar pregnancy diagnosis are described. After a single dose of systemic methotrexate injection, the level of serum beta-human chorionic gonadotropin decreased in two of the women, while fetal activity was observed in the other two women. In the latter patients, methotrexate was injected under transvaginal ultrasound guidance into the gestational sac. As a result, the serum beta-human chorionic gonadotropin level first increased and then decreased in these patients. During the follow-up period, all the patients were stable and no complications were observed. Serum beta-human chorionic gonadotropin levels reached the non-pregnancy range from 4 to 9 weeks after treatment. Conclusion When diagnosed at early gestation, cesarean scar pregnancy can be treated successfully with methotrexate administration alone. The clinicians should be aware that the beta-human chorionic gonadotropin level may initially increase after methotrexate injection in some patients. However, the final outcome will be promising if the patients remain stable.

Abstract Background The objective of this study was to describe clinical manifestations and events of patients with mucopolysaccharidosis (MPS) VI in Turkey who are treated with galsulfase enzyme replacement therapy (ERT). Clinical data of 14 children with MPS VI who were followed up at the Department of Pediatrics of the Gazi University Faculty of Medicine in Ankara, Turkey were retrospectively collected from the patients’ medical records. Patients were selected based on availability of a pre-ERT baseline and follow-up clinical data for a similar period of time (1.9–3.2 years). Event data (occurrence of acute clinical events, onset of chronic events, surgeries) collected during hospital visits and telemedicine were available for up to 10 years after initiation of ERT (2.5–10 years). Results Age at initiation of ERT ranged from 2.8 to 15.8 years (mean age 7.5 years). All patients presented with reduced endurance and skeletal abnormalities (dysostosis multiplex) on radiography. Other common clinical manifestations were cardiac valve disease (N = 13), short stature (N = 11), cranial abnormalities on MRI (N = 10), spinal abnormalities on MRI (N = 7), and mild cognitive impairment (N = 6). School attendance was generally poor, and several patients had urinary incontinence. After 1.9 to 3.2 years of ERT, most patients showed improvements in endurance in the 6-min walk test and 3-min stair climb tests; the frequency of urinary incontinence decreased. ERT did not seem to prevent progression of cardiac valve disease, eye disorders, hearing loss, or bone disease. Long-term event-based data showed a high incidence of respiratory tract infections, adenotonsillectomy/adenoidectomy, reduced sleep quality, sleep apnea, and depression before initiation of ERT. The number of events tended to remain stable or decrease in all patients over 2.5–10 years follow-up. However, the nature of the events shifted over time, with a reduction in the frequency of respiratory tract infections and sleep problems and an increase in ophthalmologic events, ear tube insertions, and depression. Conclusions This case series shows the high disease burden of the MPS VI population in Turkey and provides a unique insight into their clinical journey based on real-life clinical and event-based data collected before and after initiation of ERT.

There are some reports about the neurological manifestations and complications of COVID-19. We present neurological manifestations in 6 hospitalized patients with COVID-19. The patients presented with common symptoms of COVID-19 along with common findings from high-resolution computed tomography (HRCT) scan such as ground-glass opacities (GGOs). Though, RT-PCR testing of SARS-CoV-2 was negative for all 6 cases. In the current report, acute cerebrovascular diseases affected older patients, while dementia, seizure and encephalopathy affected younger ones. Three of the 6 patients had proven strokes based on their neuroimaging. Four of the 6 patients had high d-dimer levels. Two of the cases experienced convulsion. The third patient presented with typical symptoms and signs of neuroleptic malignant syndrome. The sixth case was interesting for transient dementia. Unfortunately, four out of six patients died. The recent case series report the association between neurological involvements and COVID-19 infection. Clinicians should be alert of the neurologic symptoms in the setting of COVID-19, which might even be the first presentations of this infection.

Three patients with Achilles tendon partial injury were treated with local injection of peripheral blood mononuclear cells (PB-MNCs). All subjects were evaluated both clinically (American Orthopedic Foot & Ankle Society - AOFAS scale) and radiologically (MRI examination) at 2 months, and a clinical reassessment with the AOFAS scale was performed at 6 months. Functional and radiological signs of tendon healing processes were detected as early as 2 months after the procedure and the AOFAS scale rose from an initial average value of 37.0 to 82.7. Even though this study only involved a limited number of participants, our preliminary results indicate that regenerative therapies with PB-MNCs may be a valid alternative to surgical options for Achilles tendon partial injuries, especially in patients with contraindications to surgery, when other conservative approaches (exercises, physical therapies, sclerosing treatment) have failed. Further investigations on the subject seem rationally supported and advisable.

Abstract Severe traumatic brain injury (sTBI) is a major cause of death and disability worldwide, resulting in a significant individual and socioeconomic burden. Current treatment guidelines do not include any recommendations for neuroprotective or neuoregenerative drugs. Here, we present a combined treatment with Cerebrolysin and Citicoline in two cases. Both drugs are experimentally better than clinically proven in their own effectiveness, but there is almost no clinical data on the combination of the two. Our case study hints at a promising approach that may improve neurological outcome after sTBI. The first patient was a 29 years male motorcyclist suffered polytrauma in a high‐speed accident. He had severe bilateral chest trauma and fractures in both thighs and an sTBI. In addition to surgical and standard neurocritical care according to the evidence‐based guidelines, he was given neuroprotective therapy with Cerebrolysin (50 ml/day) and Citicoline (3 g/day), by continuous intravenous infusion (IV), for 21 days. The second patient was a 30 years male ski mountaineer who had suffered a fall over 300 m in open terrain. In addition to the sTBI, he had fractures in the cervical spine, ribs, pelvis, and lower extremities, as well as lung contusions and massive soft tissue trauma. After initial treatment in a local hospital, he was transferred to our department and received the same neuroprotective drugs, like all of our patients with sTBI. Considering the severity of the injuries (Injury Severity Score [ISS]: 43/50, Revised Trauma Score [RTS: 5.0304, 2.7794]) and the unfavorable outcome probability (Hukkelhoven Score) of 93.1% and 82.6%, the outcomes of both patients are surprisingly encouraging 1 year after the accident. They achieved a Glasgow Outcome Score of 6 and 5 and grades 2 and 4 on the modified Rankin Scale, respectively. Currently, both are able to take care of themselves in activities of daily life to a large extent. Neuroprotective drugs may improve the regeneration of cell membranes, improve blood brain barrier integrity, and reduce neuroinflammation leading to secondary damage to the injured brain. Our clinical experience and data suggest that the combined administration of Citicoline and Cerebrolysin may contribute to better recovery, without relevant side effects. However, it would be important to validate these results by means of a controlled, prospective study.

Abstract In persons bitten by a stray dog, prompt administration of post‐exposure rabies vaccination, anti‐rabies immunoglobulin, and wound care can save lives. However, rabies is often fatal once the patient develops signs and symptoms. Here, we describe two fatal cases of rabies following a long delay after dog bites.

Abstract To evaluate the effectiveness of targeted therapy on preventing or treating COVID‐19, in this study, we want to share our experience about 14 patients (nine women, five men; average age, 59 years) who were treated with targeted therapy due to their underlying malignant disorders in our center.

Opioid-based anesthesia is associated with unwanted adverse effects such as postoperative nausea and vomiting, respiratory depression, itching, and urinary retention. Opioid-free anesthesia is a combination of multimodal analgesia that aims to avoid perioperative opioids altogether. Various methods, such as regional blocks, and drugs, such as lignocaine, dexmedetomidine, and ketamine, can be used to evade the use of opioids. Here, in a series of five cases undergoing breast cancer surgery, we attempt to use a combination of analgesic techniques that result in complete avoidance of opioids during the intraoperative period.

Ganglioneuromas (GNs) are rare, benign tumors composed of ganglion cells, nerve fibers, and glial cells. Three types of colonic GN lesions exist: polypoid GNs, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. Less than 100 cases of GN are documented in the literature. A 10-year retrospective search of the pathology database at our institution identified eight cases of colonic GNs. All cases were incidental. Seven of the eight cases presented with colonoscopy findings of small sessile polyps (ranging between 0.1 and 0.7 cm) treated with polypectomy, whereas one case showed a 4 cm partially circumferential and partially obstructing mass in the ascending colon, treated with right hemicolectomy. Almost two-thirds of the cases (5/8) demonstrated associated diverticulosis. All cases were positive for S100 protein and Synaptophysin via immunohistochemistry (IHC). No syndromic association was identified in any of the cases. We also conducted a comprehensive review using PubMed to identify cases of colonic GN reported in the literature. In total, 173 studies were retrieved, among which 36 articles met our inclusion criteria (35 patients and 3 cases on animals). We conclude that while most GNs are incidental and solitary small sessile lesions, many can be diffuse and associated with syndromes. In these cases, the tumor can result in bowel obstruction simulating adenocarcinoma.

Median arcuate ligament syndrome (MALS), otherwise called celiac artery compression syndrome (CACS), is an uncommon disorder that results from an anatomical compression of the celiac axis and/or celiac ganglion by the MAL. Patients typically present with abdominal pain of unknown etiology exacerbated by eating along with nausea, vomiting, and weight loss. MALS is a diagnosis of exclusion that should be considered in patients with severe upper abdominal pain, which does not correlate with the objective findings. The cardinal feature which is elicited in the diagnosis of MALS relies on imaging studies of the celiac artery, demonstrating narrowing during expiration. The definitive treatment is the median arcuate ligament’s surgical release to achieve surgical decompression of the celiac plexus by division of the MAL. This article describes our experience with this entity, focusing on symptom presentation, diagnostic challenges, and management, including long-term follow-up in four cases.