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Haemorrhage in patients with haemophilia is common after minor trauma but may occur spontaneously. Despite the diversity of bleeding sites, spontaneous haemothorax, on a non-traumatic basis, is an exceedingly rare event and only a few cases had been reported. We present a case of a 43-year-old man with a history of haemophilia A who had pleuritic chest pain for 1 day without significant history of trauma. Diagnostic thoracentesis showed bloody pleural fluid in which neither abnormal cell nor organism was found. He was treated by cryoprecipitate replacement and therapeutic thoracentesis for releasing haemothorax. After discharge, the patient returned for follow-up with complete radiological resolution. Regarding the consequences of retained haemothorax from conservative approach and the procedure-related bleeding of given therapeutic intervention in haemothorax making its management in patients with haemophilia to be more challenging. Our case illustrates a conservative treatment of spontaneous haemothorax in patient with haemophilia resulting in a good clinical outcome.

Behçet's disease (BD) is a multisystem inflammatory disease of unknown origin. It rarely but occasionally occurs together with myelodysplastic syndrome and primary myelofibrosis. Trisomy 8 is one of the most common cytogenetic abnormalities in myeloid neoplasms; however, the association of BD with polycythemia vera (PV) and trisomy 8 has not been reported. A 70-year-old woman, diagnosed with PV and treated with hydroxyurea, had bloody stool due to multiple ulcers in the ileocecal region. Considering the lack of a response to treatment and other features, we suspected complication with intestinal Behçet's-like disease. Our case suggests relationships among BD, trisomy 8, and PV.

Background: The outcome in infants and young children of intestinal obstruction due to intussusception is well documented in high-income countries. Our aim was to investigate the current pattern of presentation, management and outcome of childhood intussusception in a middle-income country using a multicentre approach. Methods: Records of children managed for intussusception in three centres in South West Nigeria were retrospectively reviewed and analysed. Results: One hundred and ninety children managed for intussusception were analysed. The male-to-female ratio was 1.8:1. The median age was 7 months with a peak age incidence of 3–6 months. Peak incidence was recorded during the dry season. Passage of bloody stool, vomiting, abdominal pain and fever were the most common presenting features. Seventy-three (38.4%) of the patients presented with the classic triad. The median duration of symptoms was three days and only 19 (10.1%) patients presented in less than 24 hours. Ileocolic intussusception was the most common anatomic type, occurring in 166 (87.4%) patients, and was significantly associated with age. Twenty-two (56.4%) had successful hydrostatic reduction, while 165 (88.2%) required surgery. Forty (21.1%) patients suffered postoperative complications. Eleven (5.8%) of the patients died. The median duration of hospital stay was six days, and this correlated with the duration of symptoms and the length of hospital stay. Conclusion: Delayed presentation is a persisting challenge in the management of childhood intussusception in Nigeria. Prompt referral to a paediatric surgeon may reduce the surgery rate, associated morbidity and the length of hospital stay.&nbsp

Rusty pipe syndrome is a benign clinical condition that causes a bloody nipple discharge that usually resolves spontaneously within a week. The first-line methods of treatment for rusty pipe syndrome are avoiding unnecessary research techniques and reducing the mother’s anxiety. However, in prolonged cases of rusty pipe syndrome, additional examinations should be performed to assess whether there is an underlying pathological disease, such as breast cancer or ductal papilloma. This case report presents a woman with rusty pipe syndrome and includes a literature review of databases for the period January 2001 through January 2021. A 27-year-old multiparous (gravida:3, para:3) mother gave birth at 37 weeks of gestation to a male infant. At the first breastfeeding, brownish, bloody milk was observed from both breasts. The mother had no history of surgery or trauma and had similar complaints after her previous two births. Pathological examination of a nipple blood sample and breast ultrasonography found no pathology. The bloody nipple discharge stopped spontaneously within 5 days. The mother was discharged on the seventh day after admission without complications.

Introduction: The triple burden of COVID-19, human immune virus (HIV), and TB co infection is one of the contemporary challenges to this globe. People living with chronic medical diseases such as HIV and TB are more likely to experience poor outcomes from COVID-19. This study aimed to report survival from triple co-infection with PTB, HIV, and COVID-19 in Wollega University referral hospital (WURH), western Ethiopia. Case Presentation: A 55-year-old male known HIV patient on HAART for the last 3 years presented to WURH on May 26, 2021, with chief complaints of shortness of breath of 5 days' duration associated with productive cough, history of high-grade fever, and severe headache. He had produced a lot of bloody sputum one month prior to the current complaints. On 1st day of his presentation, a Gene Expert test was done from sputum, and he was positive for pulmonary TB. On the same day, a nasopharyngeal sample for COVID-19 using polymerase chain reaction (PCR) was positive. On his 2nd day of admission, he was transferred to the COVID-19 treatment center with the diagnosis of severe COVID-19, PTB, and WHO stage-3 RVI. During his stay in the hospital, he was provided with oxygen via a nasal cannula. Intensive phase anti-TB treatment was initiated on the 3rd day of admission. HAART was continued with the same regimen he was taking prior to his presentation. On June 6, 2021, the patient was recovered and discharged from the hospital after 10 days of hospital stay. Conclusion: This case report suggests, after 10 days of admission with triple infections, there is a good clinical prognosis and survival from COVID-19. On admission, further diagnosis and investigations of TB co-infection should be performed for all patients admitted with COVID-19 due to their similar and non-specific clinical manifestations.

Background Isolated sphenoid sinus disease (ISSD) is a rare clinical entity with potentially serious complications. The etiological distribution of ISSD varies among different areas and ethnicities. We aimed to investigate the clinical features of patients with endoscopic treated ISSD. Methods We retrospectively reviewed all patients with ISSD who had undergone endoscopic surgery between April 2013 and May 2019. The patient records were reviewed for demographic data, clinical presentations, endoscopic and imaging study findings, surgical outcomes and complications. Results A total of 37 patients with ISSD who underwent surgery were recruited. We divided patients into three groups according to etiology, including inflammatory diseases (78.4%), neoplasms (13.5%) and spontaneous cerebrospinal fluid (CSF) leaks (8.1%); fungal ball (62.2%) constituted the major cause of ISSD. Overall, the most common presenting symptom was headache or facial pain (65.5%). The endoscopic findings of bloody discharge and tumor lesions were mainly from the neoplasm group. Bony defects were more obvious on computed tomography in the neoplasm and CSF leak groups. Magnetic resonance imaging revealed a higher rate of involvement of the cavernous sinus (40.0%) and intracranial extensions (40.0%) in the neoplasm group. To summarize the surgical outcomes, the success rate was 97.1%, and the major complication rate was 5.4%. Conclusion ISSD represents a variety of etiologies, mostly comprising fungal ball in our area, while there is still a considerable proportion of ISSDs attributed to neoplasm and CSF leak. Untreated ISSD can result in serious complications. We recommend early surgical intervention for all patients with ISSD.

The authors report a case of a 32-year-old Thai woman with a COVID-19 infection that presented with urticaria and angioedema with a pityriasis rosea (PR)-like rash at a private hospital in Thailand. She presented at the hospital with bloody nasal discharge and diarrhea but without fever, myalgia, or any respiratory symptoms. She complained of angioedema and PR-like lesions on the third day of the treatment. Urticarial rash appeared intermittently for four weeks after all medications were discontinued, during which the patient had no fever, no respiratory symptoms, or any other symptoms. However, the RT-PCR results for COVID-19 RNA were positive during the time that the urticarial symptoms persisted. The COVID-19 RNA became negative on the fourth day after the last urticarial episode. Urticarial rash may be a clue that the inflammatory process is activated by COVID-19 virus after the treatment is completed. Keywords: Cutaneous; Pityriasis rosea; Angioedema; Urticaria; COVID-19 DOI: doi.org/10.35755/jmedassocthai.2021.07.12420 Received 9 March 2021 | Revised 10 June 2021 | Accepted 15 June 2021

Background: According to World Health Organization statistics, the annual suicidal death rate is about one million people worldwide (mean mortality rate: 16/100.000). In some countries, suicide is the second leading cause of death in the 10-24-year age group. Wrist cutting is sometimes practiced with the goal of self-harm rather than being a suicidal attempt. However, if the bleeding is copious or allowed to continue unchecked, cardiac arrhythmia which is followed by severe hypovolemia, shock, circulatory collapse or cardiac arrest, and death may ensue. Another aim from self- cutting could be wound fabrication to mimic physical assault. In the current study, the updated knowledge concerning self-inflicted injuries including medicolegal, theoretical, and methodological approaches to assess such incidents, is discussed. Moreover, a rare case of unusual, ambiguous cut – wrist will be presented. It is a case of an Asian, female, domestic worker who was claimed to commit suicide at her sponsor’s house by deliberately cutting her left wrist. In a bloody scene, the deceased was found with a completely severed left wrist leading to a complete left- hand amputation. The right hand with a small bloody sharp knife was found behind the body. After a detailed examination of the death scene and full autopsy, the debate appeared. Both homicidal and suicidal scenarios were possible. However, no evidence was found to confirm the homicidal accusation.Consequently, the case was reported as a possible suicide with no previously reported similar cases in the literature.

Background. Endometriosis is defined as presence of endometrial glands outside the uterine cavity and it most commonly involves the structures within the pelvic cavity. Thoracic endometriosis syndrome usually presents as pneumothorax, hemoptysis, hemothorax or pulmonary nodules. Endometriosis presenting as hemorrhagic pleural effusion is rarely reported. Objectives. The aim of the study was to describe pleural endometriosis presenting as hemorrhagic pleural effusion and to insist on the role of medical thoracoscopy in making the diagnosis with the help of a case report. Methods. A case report of pleural endometriosis as a non-resolving hemorrhagic pleural effusion is presented. Results. A 28-years old female on treatment for her primary infertility presented with non-resolving bloody pleural effusion and she was on empirical anti-tubercular drugs for the last four months. Medical thoracoscopy revealed flat brownish grey plaques over the diaphragmatic pleura and the histology of pleural tissue revealed pleural endometriosis. She was initiated on gonadotropin releasing hormone-leuprolide and there was some clinico-radiological improvement. Conclusions. Thoracic endometriosis should be considered as one of the differentials for pleural effusion in female patient especially on treatment for infertility. Medical thoracoscopy should be the investigation of choice for evaluating pleural effusions before initiating empirical treatments.

Dysgerminoma is a rare malignant neoplasm, associated with hormonal dysfunctions, which occurs in canine and feline females from middle age to elderly, without racial predisposition. In the present report, we described a case of ovarian dysgerminoma in a dog, only abdominal distension, persistent vulvar bloody discharge and apathy. The animal in question underwent exploratory laparotomy, where general neoformations were detected in the ovaries, and a lymph node with abnormal characteristics was also found. Therefore, surgery for ovariosalpingoisterectomy and puncture of a fragment of the lymph node altered for incisional biopsy was performed. The diagnosis was made through histopathological examination of the ovaries of the fragment derived from the lymph node, the result of which indicated the presence of dysgerminoma in both ovaries and in the lymph node, characterizing a metastasis. In view of this result, the chemotherapy protocol with the association of carboplatin and vinblastine was instituted, which proved to be effective and not very toxic to the animal, with no clinical sign of metastasis being identified after its use.

We present a very rare case of rectal cancer in a patient with situs inversus totalis (SIT), which is a complete transposition of the thoracic and abdominal viscera. A woman in her 60s visited a local hospital reporting bloody stool and was diagnosed with upper rectal cancer and SIT. We made careful preoperative preparations for the congenital anomaly, and robotic-assisted high anterior resection with D3 lymph node dissection was performed. Although we adopted an unusual six-port placement, the operation was performed safely and efficiently without any adverse events. The patient recovered uneventfully. The pathological specimen was classified as pT3N2bM0 with negative resection margins. Robotic-assisted surgery is advantageous for rectal cancer treatment even when anatomical abnormalities make the surgical procedure more difficult.

ObjectivesCentral nervous system involvement is present in 70% of patients with hemophagocytic lymphohistiocytosis (CNS-HLH). CNS-HLH is defined by neurologic deficits, neuroimaging abnormalities, or positive cerebrospinal fluid (CSF) findings. The CSF cytomorphologic spectrum of CNS-HLH, however, has not been well investigated.MethodsA retrospective review was performed on 64 CSF specimens from pediatric and adult patients with HLH. Ten patients had clinicoradiologic evidence of CNS involvement.ResultsWe identified five CSF cytomorphologic patterns: (1) hemophagocytosis, (2) vacuolated macrophages without evidence of hemophagocytosis, (3) monocytes and/or nonvacuolated macrophages, (4) acellular specimens, and (5) bloody specimens. Patterns 1 and 2 were common in CNS-HLH and rare in patients without CNS involvement. The CSF cytomorphologic patterns did not correlate well with WBC counts or protein concentration.ConclusionsOur study offers a comprehensive view of the cytomorphologic features seen in CSF specimens from patients with HLH.

The aim of this study is to determine the factors that influence success of sonographically guided hydrostatic reduction of ileocolic intussusception in children. A retrospective study of patients with ileocolic intussusception who presented to our local university hospital between 2015 and 2020 was carried out. The demographic, clinical, radiological, and laboratory data of patients were reviewed. Data were collected from 106 patients, 7 of whom were excluded because they had contraindications for hydrostatic reduction of their intussusception. These 7 patients had primary surgery done for them. The success rate of Hydrostatic reduction was 60.6%. Univariate analysis was used to determine the effect of 14 variables on the success of the hydrostatic reduction of ileocolic intussusception. It was found that weight, age, duration of symptoms, and length of the intussusceptum were significantly greater in the group that failed hydrostatic reduction. An important correlation was found between failure of reduction of the intussusception and the position of the head of the intussusception, presence of free fluid within the peritoneum, presence of air-fluid levels, bloody defecation, vomiting, and abdominal distension. While no significant relationship was observed for sex, laboratory criteria, or mesenteric lymph node enlargement with the outcome of the reduction. Using multivariate analysis, 4 independent risk factors were identified for reduction failure: bloody defecation, duration of symptoms ≥ 24 h, length of the intussusceptum, and the presence of free fluid within the peritoneal cavity. These criteria could be used as predictive value to determine the patients with high risk of failure in regard of hydrostatic reduction of intussusceptions in children. It could be used as well in a later study to design a predictive mathematical model to predict the failure of a hydrostatic reduction of ileocolic intussusception.

Food protein-induced allergic proctocolitis (FPIAP) is a non-immunoglobulin E (IgE)-mediated food allergy, which presents with bloody mucoid stool in infants. Although IgE-mediated allergy and sensitizations to offending foods have been described in other non-IgE-mediated food allergies, it has not been investigated in FPIAP.To investigate IgE-mediated allergy and sensitization to offending foods in FPIAP.Patients (n = 204) were retrospectively recruited and grouped as FPIAP (n = 180; FPIAP with or without the symptoms of IgE-mediated food hypersensitivity to offending and nonoffending foods at initial consultation), FPIAP-IgE sensitization to offending foods (n = 17), and FPIAP-transition to IgE-mediated allergy to offending foods (n = 7). The study was performed in accordance with the protocol approved by the local ethical committee of the Hacettepe University.The median age of onset of symptoms and the development of tolerance was 2 months (interquartile range [IQR], 1.0-3.0) and 12 months (IQR, 10.0-14.0), respectively, and of the patients with skin prick test or serum specific IgE tests (n = 196), 38 (19.4%) had evidence of IgE sensitization to offending foods at the initial consultation or during follow-up; 17 (8.6%) had IgE sensitization, 7 (3.6%) indicated a transition to IgE-mediated allergy to FPIAP-induced foods. The median age of tolerance development of the FPIAP-transition group (19 months, IQR, 18.0-29.0) was significantly later than that of the FPIAP group (11 months, IQR, 10.0-14.0; P.001) and the FPIAP-IgE sensitization group (11.0 months, IQR, 9.5-12.0; P .001). Tolerance was observed within the study period in almost all the patients.Children with FPIAP may have sensitization or develop IgE-mediated allergy over time to offending foods. In addition, IgE sensitization in FPIAP does not have an unfavorable effect on tolerance development; however, the transition to an IgE-mediated phenotype may delay tolerance for a brief time.

A 32-year-old multiparous rural woman having 26 weeks of pregnancy with giant uterine fibroid extending up to the cervix had stillbirth 2 weeks back and left hospital against medical advice. She was readmitted in emergency with necrotic prolapsed uterine fibroid with offensive vaginal bleeding. On examination, the patient had necrotic prolapsed fibroid with very offensive bloody discharge and a large number of larvae of Dermatobia hominis (human botfly) were crawling in necrotic tissue. The location of this infestation at genital region is an extremely rare occurrence in postdelivery patients.

A 24-year-old man with a history of bloody sputum for 6 months was referred to our hospital with suspected alveolar hemorrhaging due to vasculitis. Chest computed tomography showed ground-glass opacities in both lungs, and an examination of his bronchoalveolar lavage fluid showed alveolar hemorrhaging. However, no evidence of vasculitis was found, and subsequent polysomnographic testing confirmed that he had severe obstructive sleep apnea (OSA). Since the alveolar hemorrhaging improved after the initiation of continuous positive airway pressure treatment, the diagnosis was negative-pressure alveolar hemorrhaging due to severe OSA.

Inflammatory bowel disease is rare in infants, and the early diagnosis is very important. We herein report an infant who received an early diagnosis of infantile Crohn’s disease (CD). A two-month-old boy presented with bloody stool. He developed a poor sucking tendency and a painful perianal lesion at three months of age. He was suspected of having infantile CD because of his atypical perianal lesion. Colonoscopy revealed that his perianal lesion had induced rectal longitudinal ulcers. Histology showed no granulomas but patchy inflammation reaching the submucosal layer. He was diagnosed with infantile CD based on the Japanese criteria. CD should be suspected in infants with atypical perianal lesions, irrespective of their age. Early colonoscopy with histology should be considered in these cases in order to prevent adverse outcomes in children.

An unneutered female cat of unknown age presented bloody lesions on the edematous face, and respiratory signs. Cytology and culture from the skin sample collected with fine-needle aspiration showed yeasts inside activated macrophages, and fungal growth characteristic of Histoplasma spp., which was molecularly confirmed that was Histoplasma capsulatum var. capsulatum. The cat was successfully treated with oral itraconazole (10 mg/kg/daily) for 120 days. This is the first case report of feline histoplasmosis confirmed molecularly in Brazil.

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, and it is still a major health problem in Nigeria especially among people with poor socio-economic status. This study was conducted with the aim of determining the prevalence of tuberculosis among two study subjects living in Hayin Dogo community of Samaru, Zaria, Kaduna state: “Al majirai” (Qur’anic school children) and children showing respiratory symptoms The major focus of this study is the al majirai, due to their unhygienic, overcrowded living environments and poor nutritional status. Two hundred sputum samples were collected from the al-majirai, and one hundred from the other children; convenience sampling method was employed. The samples were stained using the Ziehl Neelsen technique and observed microscopically for the presence of acid fast bacilli. The prevalence of acid fast bacilli (AFB) among the Al majirai was 0%, and 12% among the children attending the medical center. Symptoms such as night sweat and bloody sputum, as well as risk factors such as malnutrition and poor housing hygiene were found to be significantly associated with the infection in the children showing respiratory symptoms and attending the Ahmadu Bello University medical center (P

Background Pancreaticopleural fistula (PPF) is a rare disease, especially in children. Conservative treatment and surgery are traditional therapies, but surgery is invasive. The emergence of endoscopic retrograde cholangiopancreatography (ERCP) has provided a new noninvasive treatment for PPF and may become the first choice for children with PPF. Aim To explore the treatment response to ERCP for PPF in children. Methods Seven children with PPF were hospitalized in the Gastroenterology Department of Beijing Children's Hospital from December 2007 to May 2019. Data on these seven patients' clinical characteristics, diagnosis, treatments, and outcomes were analyzed, and their treatment responses following surgery and ERCP were compared. The correlation between the length of hospital stay and conservative treatment was analyzed. Peer-reviewed articles written in English and Chinese published from January 2009 to December 2019 were obtained from various open data sources and reviewed. Results The seven patients comprised three boys and four girls with a mean age of 6.57 ± 3.26 years. The main symptoms were chest tightness and pain (n = 4), intermittent fever (n = 3), dyspnea (n = 3), and abdominal pain (n = 1), and all patients had bloody pleural effusion. All seven patients were diagnosed with PPF by magnetic resonance cholangiopancreatography, and all were initially treated conservatively for a mean of 34.67 ± 22.03 d with a poor response. Among five patients who underwent ERCP, one required surgery because of intubation failure; thus, the success rate of ERCP was 80%. Two patients were successfully treated with surgery (100%). The postoperative hospital stay of the two patients treated by surgery was 20 and 30 d, respectively (mean of 25 d), and that of the four patients treated by ERCP ranged from 12 to 30 d (mean of 19.25 ± 8.85 d). The recovery time after ERCP was short [time to oral feeding, 4-6 d (mean, 5.33 ± 1.15 d); duration of closed thoracic drainage, 2-22 d (mean, 13.3 d)]. Analysis of previous cases of PPF published worldwide during the past decade showed that the treatment success rate of ERCP is not lower than that of surgery. There was no significant difference in the postoperative hospital stay between surgery (16 ± 10.95 d) and ERCP (18.7 ± 6.88 d, P > 0.05). A positive linear correlation was found between the overall hospital stay and ERCP intervention time (R 2 = 0.9992). Conclusion ERCP is recommended as the first-choice treatment for PPF in children. ERCP should be performed as early as possible if conditions permit.

A 41-year-old female patient was admitted to hospital with bloody stool and diarrhoea for 2 months, accompanied with fever, left earache, obvious saddle-nose deformity and red eyes for 2 weeks. She had history of repeated multiple sore joints for 6 months and hearing impairment in the left ear for 4 months. Laboratory tests showed elevated white cell count (WBC) of 15.57×10ˆ9/L, neutrophil of 76.8% and C reactive protein (CRP) of 95.4 mg/L. Haemoglobin was decreased at 94 g/L. Antineutrophil cytoplasmic antibody was negative. Colonoscopy showed diffuse inflammation and ulcers in the left-sided colon (figure 1). Histological findings from sigmoid colon showed chronic inflammation without vasculitis appearance. CT enterography revealed left-sided colon inflammation (figure 2). MRI of …

Highlights • In contrast with the usual idiopathic intussusception appearing in infants, neonatal intussusception in full-term newborns is a very rare entity. • It’s a challenging diagnosis since it has a misleading and variable presentation. • Early diagnosis may be enhanced with abdominal ultrasonography that showed the classic target and pseudo kidney signs. • An emergency laparotomy must be performed to confirm the ultrasound findings and to reduce the intussusception: Only way to save the patient. • The overall prognosis for neonates with intussusceptions depends on early diagnosis, because once a critical condition develops, as in this case, the mortality rate is likely to rise., Introduction In contrast with the usual idiopathic intussusception appearing in infants, neonatal intussusception in full-term newborns is a rare entity and usually due to an organic lead point lesion. It has a misleading and variable presentation. This manuscript reports a very rare case of neonatal idiopathic intussusception in a full-term male newborn in order to highlight the difficulties in establishing an early diagnosis. Presentation of case We present a full-term male newborn who was referred to our department at day 7 of life with fecaloid vomiting, distended abdomen and absence of intestinal transit. No bloody stool was identified. The newborn was in poor condition, dehydrated and hypothermic. He was promptly resuscitated and an abdominal ultrasound was quickly performed, it showed an ileocecal intussusception located in the right hypochondriac region. An emergency laparotomy was performed confirming the ultrasound findings. The pathological exam of the resected bowel confirmed the presence of an intussusception with areas of hemorrhagic rearrangements but no lead point was detected. The patient died from septicemia. Conclusion Intussusception occurring in the neonate is still difficult to assess, because of its rarity and its uncommon mode of presentation. This case report underlines the importance to make early diagnosis, because once a critical condition develops, the mortality rate is likely to rise.

Background Adult intussusception is less common than paediatric intussusception. The aim of this study was to explore the clinical presentation, aetiology, diagnosis and treatment of adult intussusception. Methods Adults (>18 years) with intussusception treated by surgical or conservative measures were included from January 2005 to January 2018, and the manifestation, types, diagnosis and treatment of adult intussusception in our centre were reviewed. Results A total of 150 patients with adult intussusception were included in this study. The clinical manifestations included 111 cases (74%) of abdominal pain, 38 cases (25.3%) of bloody stool, 37 cases (24.7%) of bowel obstructions, 33 cases (22%) of abdominal distension, 29 cases (19.3%) of nausea and vomiting, 19 cases (12.7%) of an abdominal mass, and 12 cases (8.0%) of diarrhoea. The types of intussusception were classified into 36 cases (24%) of enteric intussusception, 87 cases (58%) of intestine-colon intussusception and 27 cases (18%) of colonic intussusception. Surgical intervention was applied in 139 cases (92.7%), including 115 patients who underwent open surgery, and laparoscopy-assisted surgery was performed in 24 patients. The main pathogenesis of intussusception was malignant tumors in 51 cases (36.7%) and benign tumors and polyps in 49 cases (35.3%). Conclusion Malignant and benign tumors are the main causes of adult intussusception. Abdominal CT is the preferred evaluation method for the preoperative diagnosis of this condition. The choice of surgical procedure depends on the location and type of intussusception.

This study aimed to clarify the usefulness of the Ikari-curve left (IL) guiding catheter for balloon pulmonary angioplasty (BPA).The current BPA strategy for chronic thromboembolic pulmonary hypertension is dilation of as many branches as possible to normalize hemodynamics and oxygenation. The shape of the guiding catheter is a major factor in achieving this. However, conventional guiding catheters are difficult to introduce into particular branches. The IL guiding catheter may be suitable; however, its utility remains unclear.We retrospectively analyzed 202 consecutive BPA sessions of 40 patients from November 2016 to October 2019 and divided these sessions into two groups: the IL group where the IL guiding catheter was used and the non-IL group where other catheters were utilized. The occurrence of lung injury was determined by the presence of bloody sputum. We compared the rates of successful introduction into target vessels and assessed for the occurrence of lung injury.The average age of enrolled patients was 60.3 ± 14.4 years, with females comprising 65%. There were 99 sessions in the IL group. The median treated branches per session differed between the 2 groups (IL group: 15 versus non-IL group: 10, P < 0.05). The occurrence of lung injury was lower in the IL group (4.0% versus 11.7%, P = 0.07). The IL group had more successful vessel insertions than the non-IL group (78.8% versus 42.7%, P < 0.01).The IL guiding catheter may be introduced into branches that cannot be accessed by conventional guiding catheters.

Invasive breast cancer deriving from the milk duct and lobule that develops in the nipple is extremely rare, except in Paget’s disease and skin cancer. This is the second reported case of the development of invasive cancer confined to the nipple after breast-conserving surgery. A 69-year-old woman visited our department due to redness, swelling, and bloody discharge of the right nipple in the last month. A needle biopsy was suggestive of invasive ductal carcinoma; we performed a removal surgery of the right residual breast tissue and a second sentinel lymph node biopsy. She underwent these procedures 10 years previously as well. Thus, we diagnosed the present lesion as a local recurrence, but it was unknown whether the lesion was a true recurrence or second cancer, namely, metachronal ipsilateral breast cancer. The present case helps promote awareness that invasive cancer rarely develops in the nipple after conserving surgery. Patients should be encouraged to visit a medical facility if experiencing skin changes and swelling of the nipple. Additionally, breast cancer patients must be carefully selected for breast-conserving surgery; failure to do so may later result in nipple-specific local recurrence.

BACKGROUND Spinal anesthesia using a surface landmark-guided technique can be challenging in patients with anatomical alterations of the lumbar spine; however, it is unclear whether using ultrasonography can decrease the technical difficulties in these populations. We assessed whether an ultrasound-assisted technique could reduce the number of needle passes required for block success compared with the landmark-guided technique in patients with abnormal spinal anatomy. METHODS Forty-four patients with abnormal spinal anatomy including documented lumbar scoliosis and previous spinal surgery were randomized to receive either surface landmark-guided or preprocedural ultrasound-assisted spinal anesthesia. All spinal procedures were performed by 1 of 3 experienced anesthesiologists. The primary outcome was the number of needle passes required for successful dural puncture. Secondary outcomes included the success rate on the first pass, total procedure time, periprocedural pain scores, and the incidences of radicular pain, paresthesia, and bloody tap during the neuraxial procedure. Intergroup difference in the primary outcome was assessed for significance using Mann-Whitney U test. RESULTS The median (interquartile range [IQR; range]) number of needle passes was significantly lower in the ultrasound group than in the landmark group (ultrasound 1.5 [1-3 {1-5}]; landmark 6 [2-9.3 {1-15}]; P < .001). First-pass success was achieved in 11 (50.0%) and 2 (9.1%) patients in the ultrasound and landmark groups, respectively (P = .007). The total procedure time, defined as the sum of the time for identifying landmarks and performing spinal anesthesia, did not differ significantly between the 2 groups (ultrasound 141 seconds [115-181 seconds {101-336 seconds}]; landmark 146 seconds [90-295 seconds {53-404 seconds}]; P = .888). The ultrasound group showed lower periprocedural pain scores compared with the landmark group (ultrasound 3.5 [1-5 {0-7}]; landmark 5.5 [3-8 {0-9}]; P = .012). The incidences of complications during the procedure showed no significant differences between the 2 groups. CONCLUSIONS For anesthesiologists with experience in neuraxial ultrasonography, the use of ultrasound significantly reduces the technical difficulties of spinal anesthesia in patients with abnormal spinal anatomy compared with the landmark-guided technique. Our results can lead to practical suggestions that encourage the use of neuraxial ultrasonography for spinal anesthesia in such patients.

Background: Nipple discharge (ND) is defined as a fluid that flows or is expressed from the mammary ducts. Nipple discharge is classified as benign or pathologic on the basis of its clinical characteristics. Unilateral spontaneous bloody or clear nipple discharge from a single duct may be the first sign of breast carcinoma needing further evaluation. Aim of Study: The aim of this study is to assess manage-ment strategies for patients with nipple discharge (ND). Patients and Methods: This study was carried out on 50 female patients who presented with nipple discharge in the out patient clinics of Shebin El-Kom Teaching Hospital. Lactating females were excluded from the study. Patients were followed up for a minimum of 3 months and a maximum of 18 months on monthly basis. Results: The success rate of conservative management for benign ND was 88%. The discharge immediately stopped in patients managed by microdochectomy but hematoma developed in only one case that got resolved spontaneously. The discharge stopped in all patients managed by major duct excision, Discharge stopped immediately, but recurrence occured in two patients with purulent discharge. They need revision surgery for further debridement. In cases presented with a lump and FNAC showed malignant cells 16% (4 cases) they managed by modified radical mastectomy, the wound disrupted in one case, it occurs at the mammary fold and managed by secondary sutures later on. Conclusion: This study reveals the accuracy of clinical examination, sonomammography & FNAC in evaluating breast lump especially when applied together.

A 22-year-old male presented with spontaneous unilateral hemolacria and was found to have complete opacification of the ipsilateral nasolacrimal sac and duct. Endoscopic biopsy with histopathologic analysis revealed the diagnosis of nasolacrimal lymphangioma. Additional management included nasolacrimal stenting, and there was no hemolacria recurrence or epiphora. This is the first report of a nasolacrimal lymphangioma and describes the vascular malformation as a potential cause of bloody tearing.

What is known and objective Although the risk of major bleeding with non-vitamin K antagonist oral anticoagulant (NOAC) is low, life-threatening bleeding can occur. Case summary We report a case of an 81-year-old female with deep vein thrombosis who developed bilateral spontaneous haemothorax and haemopericardium after rivaroxaban therapy. Diagnostic thoracentesis revealed a grossly bloody pleural effusion. She was treated with factor eight inhibitor bypassing agent, but the result was not satisfactory. What is new and conclusion To our knowledge, this is the first case report of a concomitant presentation of spontaneous bilateral haemothorax and haemopericardium due to rivaroxaban use. This case highlights the potential risk of major haemorrhagic complication of NOAC, which could be life-threatening and require emergent reversal.

A 65-year-old man was followed up after undergoing Hartmann's operation for the treatment of obstructive colon cancer 1 year earlier. He presented with bloody stool and underwent examination, including lower gastrointestinal endoscopy, and he was diagnosed with rectal cancer. Since he had a history of multiple abdominal surgeries, including Hartmann's operation, severe pelvic adhesions were expected. Thus, in consideration of surgical safety and curability, transanal total mesorectal excision (Ta-TME) was performed. The duration of the surgery was 3 h, and there was minimal blood loss. Histopathological findings did not reveal remnants of cancer in the resected margin, and the patient was discharged on hospital day 7. Rectal cancer has a higher rate of local recurrence than colon cancer. To prevent local recurrence, ensuring a rectal circumferential resection margin (CRM) with TME is essential, which is, however, challenging in obese patients and in those with giant tumors, contracted pelvis, prostatic hypertrophy, etc., since these conditions complicate pelvic surgery. The same is true for patients with a history of multiple abdominal surgeries. It is expected that these problems can be resolved by Ta-TME. In the present case, Ta-TME was extremely useful in rectal cancer surgery for a patient with a history of multiple abdominal surgeries, including Hartmann's operation.

Background Necrotizing enterocolitis (NEC) has been associated with red blood cell (RBC) transfusions in preterm infants. Near-infrared spectroscopy (NIRS) can be used to noninvasively monitor regional oxygen saturations (rSO2). Clinical findings This former 28-week female premature infant, 29 days old, received an RBC transfusion due to increased apneic spells and a hematocrit of 27%. Within 24 hours she developed abdominal distension and passed a bloody stool (Bell's stage 2 NEC on abdominal x-ray). She completed 7 days of antibiotics and nothing-by-mouth status and was discharged home on room air and oral feedings on day of life 70. Primary diagnosis We describe the presentation of NEC following a RBC transfusion in a preterm infant monitored with cerebral and splanchnic NIRS. Interventions Mean rSO2 (cerebral and splanchnic) measurements were continuously recorded and calculated in 30-minute periods at baseline (prior to packed RBC transfusion), every hour during the RBC transfusion, and every 3 hours for the following 48 hours. Outcomes In this infant, average baseline splanchnic rSO2 was low at 46.5%, and increased during transfusion to 65%. However, following the RBC transfusion and an enteral feeding, splanchnic rSO2 dramatically decreased to 26%, and remained low until the time of NEC diagnosis. Practice recommendations To develop awareness of the increased risk for NEC in premature infants with significant anemia that receive packed RBC transfusions. With further studies and education, NIRS could be a valuable tool for the nurses and medical team to identify these at-risk neonates.

Highlights • Bronchial carcinoid tumor is exceedingly rare. • Diagnosis of bronchial carcinoid is often delayed or even missed. • Surgical excision is the main stay of treatment for bronchial carcinoid tumour. • Typical carcinoid tumour has excellent prognosis., Introduction Bronchial carcinoid tumors are rare, slow growing, malignant neuroendocrine tumors and account for less than 2% of all lung tumors. Early diagnosis is extremely important as the main stay of treatment is surgical excision. Presentation of case We present a rare case of bronchial typical carcinoid tumor in a 22-year-old female who presented with a complaint of intermittent productive cough with bloody sputum of 3 weeks’ duration associated with wheezing, low grade intermittent fever and loss of appetite. She was being treated as bronchial asthma for 10 years prior to her current presentation. Right lung bi-lobectomy with regional lymph node resection was done and she was discharged home in good condition. Discussion Majority of typical carcinoids are located in the central airways leading to bronchial obstruction with recurrent pneumonia, chest pain, wheezing and hemoptysis. Due to such nonspecific presentation most patients are misdiagnosed or diagnosed late. Both typical and atypical Carcinoids have similar radiologic features and definitive diagnosis relies on bronchoscopic tissue biopsy. Although hilar and mediastinal lymph nodes are the most common metastatic sites for typical carcinoids most lymphadenopathies are caused by a reactive inflammatory reaction. Conclusion Bronchial carcinoids are rare, malignant neuroendocrine tumors with complete surgical resection being the only curative management. Thus patients with recurrent respiratory symptoms despite optimum medical treatment should be thoroughly investigated for accurate and early diagnosis The outcome of typical carcinoids with lymph node metastasis is excellent with complete resection but close follow up is mandatory when dealing with larger tumors.

Highlights • Rectal duplication cyst is extremely rare. • Adult onset rectal duplication cyst usually contains malignant formation. • Complete tumor resection is needed for the disease to prevent malignant change. • Synchronous trans abdominal and anal approach was effective for complete tumor resection., Introduction Rectal duplication cyst is extremely rare. Most of the cases diagnosed before two years old. Adult onset rectal duplication cyst usually contains malignant formation. Then complete tumor resection is needed for the disease to prevent malignant change. Presentation of case A 52-year-old man was referred to our hospital due to bloody stool. Colonoscopy showed 20-mm of sub-mucosal tumor at low rectum. Biopsy revealed no specific findings. Abdominal computed tomography showed that a 20-mm low density mass at posterior of lower rectum. As the existence of malignant lesion was unassailable, we planned two team, trans abdominal and trans-anal, laparoscopic low anterior resection. Perioperative course was good. Macroscopically, rectum had a submucosal cystic mass fulfilled mucinous content. Histologically, cyst wall was covered with heterotopic ciliated epithelium and composed of smooth muscle. Discussion Trans-anal total mesorectal excision (ta-TME) was introduced as beneficial approach for rectal malignancies. Conclusion Complete resection was possible by TME was necessary for patients with adult rectal duplication cyst, and synchronous trans-abdominal and trans-anal approach is a promising option.

Background: The objective of the study was to evaluate a new medical treatment strategy for infertile patients with isthmocele. Methods: This was a retrospective evaluation of the records of infertile patients with symptomatic isthmocele who received non-invasive isthmocele treatment (NIIT) before in vitro fertilization (IVF) treatment cycles. Isthmocele volumes were measured before and after NIIT. The IVF results and isthmocele-related complaints were also analyzed. The patients were treated with a depot gonadotropin-releasing hormone agonist for 3 months before frozen-thawed embryo transfer cycles. Results: The mean isthmocele volume was 471.06 ± 182.81 mm 3 (range: 289.43 - 765.4 mm 3 ) in fresh cycles, but was reduced to 47.94 ± 29.48 mm 3 (range: 18.70 - 105.6 mm 3 ) in frozen-thawed cycles (P < 0.05). Intrauterine fluid was observed in two patients during fresh cycles, but was absent after NIIT during frozen-thawed cycles. There was no brown bloody discharge on the tip of the embryo transfer catheter in any case after NIIT. Two patients became pregnant and underwent term cesarean delivery (25%). Conclusions: NIIT can serve as an alternative pretreatment option for patients with isthmocele during IVF cycles. J Clin Med Res. 2020;12(5):307-314 doi: https://doi.org/10.14740/jocmr4140

Background: Hemorrhage is the most common during microvascular decompression (MVD) for hemifacial spasm (HFS), trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GN). However, remote supratentorial subdural hematoma is very rare, especially for those patients who reveal severe intraoperative venous bleeding without a definite bleeding source in the suboccipital surgical area, and immediate postoperative computed tomography (CT) reveals supratentorial subdural hematoma. The underlying mechanisms remain obscure. We report 10 cases to discuss the pathophysiology and develop appropriate therapeutic strategies for prevention and treatment. Patients and methods: We retrospectively analyzed clinical data of patients who underwent microvascular decompression in Nanjing Drum Tower Hospital between December 1, 2018 and December 31, 2020. Among 764 patients, bleeding events occurred in 10 cases, whose bleeding origin was not confirmed intraoperatively and immediate postoperative CT revealed supratentorial subdural hematoma. We reviewed characteristics, the intraoperative situations and the prognosis of the 10 cases. Results: The mean age of the patients was 55.4 years; 2 was male and 8 were female. All patients revealed draining large amounts of intraoperative cerebrospinal fluid (CSF) during the operation. Primary unknown cause of severe venous bleeding of 8 patients occurred in different time periods intraoperatively. However, hemorrhage all occurred in a very early stage before decompression. The operation was completed successfully in the 8 patients through the irrigation and drainage of the bloody cerebrospinal fluid. patient Postoperative CT indicated supratentorial acute subdural hematoma (ASDH) with hematoma volume

Intestinal metaplasia (IM) of the sinonasal mucosa is a putative precursor lesion of sinonasal intestinal type adenocarcinoma (sITAC), a carcinoma associated with wood-dust exposure(1-5). In this article, we compare genomic alterations in matched IM and sITAC to substantiate this connection. Case presentation: A 68-year-old man with a history of wood-dust exposure and one-month bloody nasal secretion was seen at his local hospital. A biopsy demonstrated poorly differentiated carcinoma with neuroendocrine features. Fine needle aspiration (FNA) from a slightly enlarged cervical lymph node was without metastatic tumor cells. On MRI, the tumor measured 38x33x37mm; no signs of lymph-node pathology were seen (T2N0M0). A tertiary center performed endoscopic surgery; perioperative frozen sections showed sITAC (margins were macroscopically free).

Spontaneous gallbladder hemorrhage (SGBH) is a rare diagnosis related to trauma, malignancy or vascular abnormalities, associated with significant morbidity and mortality. We present a case of SGBH in a 55-year-old patient with right upper quadrant (RUQ) pain following initiation of apixaban for deep vein thrombosis post recent kidney transplant. Multiple imaging studies revealed a distended gallbladder with heterogeneous hyperdense material in the lumen and cystic duct obstruction. Surgery revealed a gallbladder with chronic cholecystitis, hemorrhage and hematoma. This case highlights a rare adverse event of anticoagulation, and SGBH should be considered when acute RUQ pain occurs in this setting.

We present the case of a 66-year-old bisexual patient suffering from painful bloody defecation, linked to rectal thickening, rectovesical fistula and enlarged lymph nodes in the mesorectal area. The patient was misdiagnosed with rectal cancer (T3 N2) on MRI but the symptoms of the patient were due to lymphogranuloma venereum. After adequate treatment with doxycycline, symptoms faded within days; a control MRI showed complete regression of all pathologic alterations.

Comprehensive genomic profiling (CGP) is of increasing value for patients with metastatic castration-resistant prostate cancer (mCRPC). mCRPC tends to metastasize to bone, making tissue biopsies challenging to obtain. We hypothesized CGP of cell-free circulating tumor DNA (ctDNA) could offer a minimally invasive alternative to detect targetable genomic alterations (GA) that inform clinical care.Using plasma from 3,334 patients with mCRPC (including 1,674 screening samples from TRITON2/3), we evaluated the landscape of GAs detected in ctDNA and assessed concordance with tissue-based CGP.A total of 3,129 patients (94%) had detectable ctDNA with a median ctDNA fraction of 7.5%;Genomic analysis of ctDNA from patients with mCRPC recapitulates the genomic landscape detected in tissue biopsies, with a high level of agreement in detection of

1. Ashley R.B. Bjorklund, MD*,† 2. Tina M. Slusher, MD*,† 3. Abigail Faulman, MD‡ 4. Cynthia R. Howard, MD† 5. Beatrice Odongkara, MBChB§ 1. *Hennepin Healthcare, Minneapolis, MN 2. †University of Minnesota, Minneapolis, MN 3. ‡Children’s Minnesota, Minneapolis, MN 4. §Gulu University/Gulu Regional Referral Hospital, Gulu, Uganda A 12-year-old boy with a history of sickle cell disease (SCD) presents to a government regional referral hospital in Northern Uganda with complaints of feeling ill with fever and a painful lump on his forehead. He also notes pain and swelling of his left upper arm. The fever, forehead lump, and painful swelling of the left arm had been present for at least 2 months. He denies any trauma. On presentation to the hospital he is febrile, tachycardic, and ill appearing. Initial physical examination is remarkable for frontal bossing with multiple tender, fluctuant, round (2- to 3-cm-diameter) lesions over his forehead and scalp; respiratory distress; a prominent systolic murmur; thin limbs; a tender, indurated lesion (approximately 5 × 3 cm) draining purulent fluid on his left upper arm; and no noted focal neurologic deficits. In the emergency department, incision and drainage of the forehead lesion yields scant drainage despite what appears to be a visibly purulent and fluctuant swelling. The fluid obtained is serous and bloody, without overt purulence. There is concern that the lesions may involve more than the subcutaneous tissues, with possible extension to the bone. Laboratory tests show leukocytosis with a neutrophil predominance (white blood cell count, 23,360/μL [23.36×109/L]; neutrophils, 77.5%), thrombocytosis, and anemia (hemoglobin level, 7.7 g/dL [4.78 mmol/L]). Rapid diagnostic testing for malaria is negative. Urine is remarkable for dark coloration without red blood cells on microscopic examination. Cultures from the wound are sent to the laboratory. Radiographs of the cranium (Fig 1) and humerus (Fig 2) are obtained. Figures 1. Radiograph demonstrating lytic lesions of the frontal and parietal bones. Figure 2. Radiograph demonstrating …

The aim was to better understand the clinical characteristics of patients with mucormycosis in western China. We retrospectively investigated the clinical, laboratory, radiological and treatment profiles of mucormycosis patients during a 10-year period (2010–2019). As a result, 59 proven mucormycosis were enrolled in this study. It was found that 52.5% of patients had worse clinical outcomes. Pulmonary mucormycosis (PM) was the most common clinical manifestation. The most frequent risk factor was diabetes mellitus (38, 64.4%) for mucormycosis patients. Cough (43, 93.5%), fever (24, 52.2%) and hemoptysis/bloody phlegm (21, 45.7%) were the most common manifestations of PM. There were no differences in clinical manifestations, risk factors and laboratory tests between different clinical outcome groups (P>0.05). Lymph node enlargement (30, 65.2%), patchy shadows (28, 60.9%), cavitation (25, 53.3%) and bilateral lobe involvement (39, 84.8%) were the most common on chest CT. Nodule was more common in good outcome group (P

Background: Splenic fine needle aspiration cytology (FNAC) has been used as a diagnostic method since the turn of last century, with the first report being in 1916. It has the reputation of being dangerous & difficult to assess, but these prejudicial ideas are fundamentally wrong. FNAC remains the easy, cheap, safe and first mainstay diagnostic investigation. Objective: The objective of the present study was to evaluate and determining the diagnostic role of aspiration cytology in splenic lesions. Methods: Fine needle aspiration cytology (FNAC) of the spleen was performed in 34 cases in our retrospective analysis, with 28 cases aspirated under ultrasonological guidance and 6 cases aspirated blindly. There were 23 male and 11 female patients, ranging in age from 2 to 69 years, with 8 paediatric patients. All essential precautions and tests, including a coagulation profile, were carried out prior to the procedure. Results: Five of the 34 FNAC cases had bloody aspirates, while the other two had normal splenic aspirates. In 27 of the cases, a definitive diagnosis was possible. The most patients (8 cases) in the non-neoplastic group had extramedullary hematopoiesis, followed by 4 cases of tuberculosis, 3 cases each of kala azar and storage disease, and 2 cases with granulomas. We had two cases of non-Hodgkins lymphoma, one case of Hodgkin lymphoma, two cases of hairy cell leukaemia, and one case of histiocytosis in the neoplastic group. When aspiration was performed blindly or with ultrasound guidance, no significant differences in cellularity were observed. In our research, no procedural problems were discovered. Conclusion: As a result, when carried out with extreme caution, as a primary inquiry, FNAC spleen is a safe, low-cost, quick, and highly diagnostic treatment.

Background Intra-articular venous malformations (IAVM) are rare benign vascular anomalies that usually affect young patients and most common locate in the knee. The terminology of these lesions is still ill-defined, as they are often termed in the literature as synovial hemangiomas. Early diagnosis can be difficult, because they usually present with nonspecific clinical manifestations that are similar those of other rheumatic diseases, especially juvenile idiopathic arthritis (JIA). Case series We conducted a retrospective analysis of five pediatric patients admitted to our units for recurrent swelling of the knee, and compared their characteristics with those of literature reports. The average age at first symptom and time from onset to diagnosis was 3.9 years (range 18 months-7 years) and 3.5 years (range 1-7 years), respectively. In our patients, an initial misdiagnosis of JIA, bleeding disorder or traumatic arthropathy was made. On MRI imaging, the features of the lesion were similar in all patients, and were marked by isointense-to-hypointense signal in T1-weighted images, and hyperintense signal in T2-weighted images. When performed, arthrocentesis led to aspiration of bloody fluid. The diagnosis was confirmed with a biopsy and histopathologic assessment in all patients. Open surgery enabled complete excision of the mass and was followed by stable remission over time in all cases. Conclusions Our report highlights the challenges that may be posed by the detection of knee IAVM and the frequent long delay between onset of symptoms and diagnosis. The key elements for early recognition include careful assessment of patient history, demonstration of bloody fluid on arthrocentesis, and proper interpretation of MRI scanning.

Although direct-acting oral anticoagulants (DOACs) decrease the bleeding risk compared with vitamin K antagonists (VKAs), DOACs might cause spontaneous hemothorax in very elderly patients, even at a very low dose. Interactions between drugs might increase the risk of bleeding. In this article, we report a case of a 95-year-old man who developed spontaneous hemothorax while taking rivaroxaban 2.5 mg twice daily, 3 days after concomitant use of itraconazole. Rivaroxaban was discontinued, and thoracentesis was performed to drain grossly bloody pleural effusion. To our knowledge, this is the first case report of spontaneous hemothorax that might have been caused by concomitant low-dose rivaroxaban and azole anti-fungal agents. This case highlights the potential risk of spontaneous hemothorax in very elderly patients while taking rivaroxaban and azole anti-fungal agents simultaneously. Special attention should be paid to interactions between drugs that might increase the risk of bleeding. Drugs that have competing metabolic pathways should be avoided. Closer monitoring, including testing for anti-Xa and additional reassessment, should be considered in high-risk patients.

A 32-year-old chronic drug abuser was found dead at the entrance to his home, covered in blood. Pools of blood, bloody footprints and bloodstains were found across the apartment. A double-edged razor was recovered from the scene. Autopsy revealed multiple incised wounds: two on the palmar aspect of both forearms (37 cm and 33 cm long, oriented longitudinally). The cuts extended into the subcutaneous adipose tissue, muscles and blood vessels. There was an additional 30 cm cut extending across the middle of the torso anteriorly and two more cuts on the anteromedial aspect of the lower legs, set symmetrically (about 23 and 25 cm long). These three cuts were more shallow than the upper extremity wounds. No hesitation wounds were identified. Toxicological analysis identified MDMA (ecstasy). The cause of death was exsanguination. The deceased has been using ecstasy for the previous five years and had a history of inpatient psychiatric treatment due to psychosis with delusions and hallucinations. These self-inflicted incised wounds had many atypical features: location (torso, legs and arms), longitudinal orientation and symmetrical distribution, absence of hesitation injuries, use of both dominant and non-dominant hand. The absence of previous suicide attempts and suicide note suggest that these self-inflicted injuries were not planned beforehand, but were abrupt. We hypothesize that this injury pattern is associated with both acute and chronic effects of MDMA.

Person-to-person transmission of severe fever with thrombocytopenia syndrome virus (SFTSV) is a new threat to human health. Here we report an outbreak of nosocomial person-to-person transmission of SFTS. Among eight persons with face-to-face contact distance ≤50 centimeters and/or exposure time ≥30 minutes to the index patient, six became were infected. Only one of the 17 persons with exposure distance ≥ 50 centimeters and exposure time ≤ 30 minutes was infected (75% vs. 6.25%, p

The article describes the main achievements in the study of ulcerative colitis (UC) - a disease known since ancient times. «Bloody» non-epidemic diarrhea was described by Hippocrates. The first detailed description was made by K. Rokitansky in 1842. In 1875, S. Wilks and W. Mason first studied the pathomorphology of the colon in UC. The term «non-specific ulcerative colitis» was proposed by the Russian surgeon A. S. Kazachenko in 1913 at the 13th Congress of Russian surgeons. The historical excursion presents the main stages and achievements of surgical treatment of UC.