Search

Purpose Real-world evidence (RWE) with regard to allergen-specific immunotherapy (AIT) adherence is increasingly available. Economic modelling has already shown AIT to be cost-effective in the treatment of allergic rhinitis compared with symptomatic treatment. However, analyzing sublingual (SLIT) and subcutaneous (SCIT) immunotherapeutic approaches based on RWE adherence data are not available for Germany. This analysis outlines the cost-effectiveness of SCIT compared with SLIT as well as a symptomatic treatment modality on the basis of recent RWE adherence data. Methods A Markov model, with predefined disease stages and a time period of 9 years, was adapted for this analysis. A 6-grass subcutaneous allergoid SCIT preparation and a 5-grass pollen SLIT tablet was employed as AIT administrations. Quality-adjusted life years (QALYs) were calculated based on symptom scores and used as the effectiveness variable. Total costs and cost effectiveness of SCIT, SLIT and symptomatic treatment (ST) were calculated. Model uncertainties were estimated by means of additional sensitivity analyses. Applied discount rate was 3%. Results Both SCIT and SLIT preparations proved superior compared to symptomatic treatment with regard to effectiveness. Although more expensive, AIT also proved to be cost-effective. A direct comparison of SCIT (Allergovit®) and SLIT (Oralair®) showed lower total costs for SCIT treatment over the study period of 9 years (SCIT 1779 € versus SLIT 2438 €) and improved effectiveness (SCIT 7.17 QALYs versus SLIT 7.11 QALYs). Conclusion AIT represents a cost-effective treatment option for patients with allergic rhinitis compared with symptomatic treatment. SCIT appeared to be dominant and cost-effective, due in particular to higher patient adherence and lower drug costs.

Purpose Painful osteoarthritis is common in elderly patients, and low-dose radiotherapy has been demonstrated to provide effective symptomatic treatment. We examined the analgesic effects of low-dose radiotherapy for osteoarthritis in the elderly aiming to reveal potential differences in the response rates relating to increasing age. Methods A retrospective analysis was performed at two university hospitals including elderly patients (≥ 65 years) undergoing radiotherapy for osteoarthritis between 2008 and 2020. Pain intensity and response were quantified using the numerical rating scale (NRS) and the Pannewitz score. Age groups were defined for young old (65–74 years), older old (75–84 years), and oldest old patients (≥ 85 years). Results In all, 970 patients with 1185 treated sites and a median age of 76 years were analyzed. Mean NRS was 66 at baseline (t0), 53 after radiotherapy (t1), and 44 at first follow-up (t2) (p p = 0.172) or t2 (p = 0.684). In addition, pain response after re-irradiation (n = 384 sites) was 61.0% and was comparable between age groups (p = 0.535). Conclusion Low-dose radiotherapy results in pain reduction in about two-thirds of treated sites with no difference relating to increasing age, showing that radiotherapy is an effective analgesic treatment for osteoarthritis even at advanced ages.

Despite the active introduction of surgical treatments for cardiac pathology and new synthetic cardiotonic drugs, cardiac glycosides (CG) remain an important component of the pharmacological treatment of heart diseases. Moreover, interest in this group of drugs is only increasing with the discovery of new pharmacological effects, such as antitumor and antiviral. However, despite many years of experience, the issue of managing patients with symptoms of both acute and chronic poisoning with cardiac glycosides remains one of the leading ones. The literature review provides a brief historical outline of cardiac glycoside poisoning and comprehensively describes the pharmacokinetics and pharmacodynamics of this group of drugs. The clinical picture of intoxication is described. We analyzed modern ideas and limitations of using antidote therapy such as digoxin immune Fab-antibody fragments, as well as the features of pathogenetic and symptomatic treatment of patients with acute glycoside poisoning.

The new KIMO guidelines ‘Oral Health Care for Children’ approach caries as a behavioural related disease and unequivocally assign priority to causal caries treatment, emphasising lifestyle and behavioural changes. The 5-step concept of non-restorative caries treatment (NRCT) is recommended as treatment of choice for cavitated dentine lesions in primary dentition. Communicative aspects of NRCT are supported by limited technical interventions, for the purpose of effective oral care. A balance between aetiological and symptomatic treatment is sought for each child individually, in close cooperation with the parents. Technical aspects per tooth range from limited interventions like making cavities accessible for brushing, applying fluoride varnish or SDF, covering the cavity with a layer of glass ionomer cement to treatment like ART restoration or the Hall technique, in cases of necessity. Lifestyle changes lead to sustainable treatment results and enhance the quality of life of the child or young person.De nieuwe KIMO-richtlijn ‘Mondzorg voor Jeugdigen’ beschouwt cariës als een gedragsgerelateerde ziekte en verleent ondubbel­zinnig prioriteit aan causale cariëstherapie met een accent op leefstijl- en gedragsverandering. Het 5-puntenconcept van niet-restauratieve caviteits­behandeling wordt aanbevolen als eerste keuze bij behandeling van gecaviteerde dentinelaesies in melkelementen. Hierbij worden communicatieve aspecten van de zorg ondersteund door beperkte technische interventie ten behoeve van doelmatige mondzorg. Bij ieder kind wordt in goed overleg met de ouders gezocht naar balans tussen causale behandeling en symptoom­bestrijding. De technische middelen per gebitselement variëren van beperkte interventies als het bereikbaar maken van laesies om effectief te poetsen, het aanbrengen van fluoride of zilverdiaminefluoride, de caviteitsbodem bedekken met glasionomeercement tot noodgrepen in de vorm van ART-restauraties of Hall-kronen. Leefstijlverandering zorgt voor een duurzaam resultaat van behandeling en draagt bij aan de kwaliteit van leven van het kind.

Mitochondrial diseases are some of the most common inherited neurometabolic disorders, and major progress has been made in our understanding, diagnosis, and treatment of these conditions in the past 5 years. Development of national mitochondrial disease cohorts and international collaborations has changed our knowledge of the spectrum of clinical phenotypes and natural history of mitochondrial diseases. Advances in high-throughput sequencing technologies have altered the diagnostic algorithm for mitochondrial diseases by increasingly using a genetics-first approach, with more than 350 disease-causing genes identified to date. While the current management strategy for mitochondrial disease focuses on surveillance for multisystem involvement and effective symptomatic treatment, new endeavours are underway to find better treatments, including repurposing current drugs, use of novel small molecules, and gene therapies. Developments made in reproductive technology offer women the opportunity to prevent transmission of DNA-related mitochondrial disease to their children.

Introduction Distinguishing intraarticular lesion from extraarticular lesion need a thorough clinical evaluation in case of atraumatic knee pain. The main objective of this case report was to describe about the clinical course of a patient with unrelenting symptoms with suspected lateral meniscus lesion. Case description A 48-year old man was diagnosed with suspected lesion in the anterior horn of lateral meniscus for 9 months had received pharmacological and physiotherapy interventions. Yet the patient did not respond favourably to former symptomatic treatment. As the history and objective evaluation consistently matched with abnormal neurodynamics, in the similar line, the patient was treated with neural mobilization in a modified slump position, 15 repetitions per session for three consecutive days combined with postural correction exercises. Result The outcomes were measured with numeric pain rating scale (NPRS) and knee society scale (KSS). The patient responded very well to neural mobilization combined with postural correction exercises. The NPRS (4 at rest; 7 on activity) before our intervention reduced to (0 at rest, 1 on activity) at the end of 3 rd consecutive day intervention and the KSS improved to 75 from 55 in pain score & 90 from 80 on function score. At 2-months follow-up, the patient completely recovered from pain and knee dysfunction. Conclusion This case report signifies that abnormal neurodynamics can be a factor for lateral knee pain. Neural mobilization with postural correction exercises may be recommended as an appropriate treatment for patient with lateral-knee-pain due to abnormal neurodynamics.

This manuscript aimed to describe and analyze acute trimethyltin poisoning caused by exposure to polyvinyl chloride production and review the literature. Combined with an analysis of occupational hygiene survey data, the clinical data of 8 cases of acute trimethyltin poisoning were analyzed retrospectively. The clinical manifestations of acute trimethyltin poisoning are mainly related to central nervous system damage, hypokalemia and metabolic acidosis in patients with severe poisoning. Early positive potassium supplementation and symptomatic treatment are beneficial to the improvement of the condition. The early recognition of central nervous system manifestations and hypokalemia is beneficial for early diagnosis and correct treatment.

The first reinfection in the world in Hong Kong, later in Europe (Holland, Belgium) and USA, was documented. In Mexico until November 2020 there are no medical articles that tell us about reinfection; in Celaya Guanajuato the case of a female patient presented with symptoms of COVID-19, 2 polymerase chain reaction in real time tests are performed, in the Laboratory of Public Health from Guanajuato State in an interval of time, less than 5 months; the first in June 2020, with a positive result, received symptomatic treatment and isolation at home for 14 days, negative IgG antibodies test 38 days later; the second time, she presented clinical data on COVID-19 in November From 2020. It was not find references about re-infections by SARS-CoV-2 in Mexico; in Celaya Guanajuato was presented the case of female patient who has symptoms of COVID-19, with new positive PCR, required hospitalization and high-flow oxygen therapy when presenting with pneumonia, was performed simple chest Computing tomography, IgG and IgM antibodies.The evolution was good with discharge from hospitalization 72 hours after admission, continuing his outpatient management until discharge.

Alveolar echinococcosis (AE) is considered as a fatal zoonosis caused by the larvae of Echinococcus multilocularis. The lungs and brain are the most common metastatic organs. We report a human case of hepatic alveolar echinococcosis accompanied by lung and brain metastasis. In particular, the patient had a history of tuberculosis and the lung lesions were easily misdiagnosed as lung abscesses. The lesions of liver and lung underwent radical resection and confirmed as alveolar echinococcosis by pathological examination. The patient had no surgical complications after operation and was discharged after symptomatic treatment. Unfortunately, the patient later developed multiple intracerebral AE metastases. We required the patient to take albendazole orally for life and follow up.

Background Current guidelines recommend empiric antibiotics as first-line treatment for uncomplicated UTI. Despite proven benefits in treatment, antibiotic resistance rates remain on the rise. This meta-analysis aims to determine whether non-steroidal anti-inflammatory drugs can serve as an effective and safe option in the treatment of uncomplicated lower UTI among non-pregnant women compared to antibiotics. Methods A systematic literature search in PUBMED, CENTRAL, and ACP databases from inception to April 2021 was conducted to identify randomized controlled trials that compare the use of non-steroidal anti-inflammatory drugs versus antibiotics in non-pregnant women ≥18 years old with uncomplicated lower urinary tract infection. Primary outcomes were symptom resolution of UTI by Day 3 or 4 of intervention, and upper UTI complications. Secondary outcomes include persistence of positive urine culture despite treatment and need for another rescue antibiotic. Random and fixed-effects model for dichotomous data using Mantel-Haenszel and Peto odds method were reported at 95% CI followed by sensitivity analysis for substantial heterogeneity. Results Four RCTs involving 1165 patients were analyzed. The probability of having a symptom resolution by Day 3 or 4 with NSAID use is only less than three-fourths of that with antibiotic treatment (RR: 0.69, 95% CIs [0.55, 0.86], p = 0.0008, I2 = 73%, moderate certainty of evidence). The odds of developing upper UTI complications with use of NSAIDs are 6.49 to 1 for antibiotics (Peto OR: 6.49, 95% CIs [3.02, 13.92], p 2 = 0%, moderate certainty of evidence). Secondary analysis showed that the NSAID group is 2.77x more likely to have persistence of a positive microbiologic urine culture than the antibiotic group (RR: 2.77, 95% CIs [1.95, 3.94], p 2 = 36%, moderate certainty of evidence). Treatment with NSAIDs are three times more likely to use a secondary or rescue antibiotic due to persistent or worsening symptoms as compared to antibiotics (RR: 3.16, 95% CIs [2.24, 4.44], p 2 = 47%, low certainty of evidence). Conclusion Antibiotic treatment was more effective than use of non-steroidal anti-inflammatory drugs for acute uncomplicated lower urinary tract infection with an overall moderate certainty of evidence.

Our study aims to assess improvement with symptomatic treatment of pain-related functional gastrointestinal disorders (FGIDs) in a biopsychosocial construct and evaluate validity of Rome III criteria. Children with chronic abdominal pain diagnosed with an FGID or organic disease were followed for 1 year: 256/334 were diagnosed with an FGID and 78/334 were diagnosed with a possible organic disease due to alarm signs or not meeting Rome III criteria. After 1 year, 251 had true FGID and 46 had organic diseases. Ninety percent of FGID patients improved with symptomatic treatment over an average of 5.4 months. With a 95% confidence interval, Rome criteria predicted FGIDs with sensitivity 0.89, specificity 0.90, positive predictive value 0.98, and negative predictive value 0.59. We conclude that symptomatic treatment of pain-related FGIDs results in clinical improvement and could reduce invasive/expensive testing. Rome III criteria’s high specificity and positive predictive value suggest they can rule in a diagnosis of FGID.

The SARS-CoV-2 virus was first detected in Wuhan, China in December 2019 and was known to produce acute severe respiratory illness in humans which rapidly spread almost throughout the world within a few months. This human coronavirus has seven strains and they commonly produce illness in the nervous system, respiratory system and hepato- intestinal systems. This present review is an attempt to illustrate recent reports pertaining to the management of SARS-CoV-2. Further, it also highlights the diagnosis and clinical management of COVID-19. Various search engines like Scopus, Pubmed and WHO databases were accessed and literature on current advances about COVID-19 including structural features, replication, possible pathogenic, symptoms, diagnosis, prognosis, methods of prevention and possible therapeutic agents used for treatment of patients was reviewed. Current studies indicate that COVID-19 is very infectious with droplet transmission potential. The key modalities to prevent the infection is by keeping social distancing, respiratory/hand hygiene, detection of infection and subsequent quarantine of the infected persons. Presently, either no vaccine for prevention or specific treatments available, however, COVID-19 patients may be managed by using some repositioned drugs and symptomatic treatment. © 2021 Pharma Book Syndicate. All rights reserved.

Genital herpes is a recurrent, lifelong sexual transmitted infection caused by HSV, especially type 2. Genital herpes is the most common infection in HIV patient. HSV-2 can increase the risk of HIV acquisition 2 to 3 times. Clinical manifestations of genital herpes can be different between HIV- infected and non-HIV patients. HIV-infected patients have a high risk of developing chronic and severe genital ulcers with atypical manifestation, prolonged healing, and resistant to treatment, depends on CD4 count. Genital herpes can be diagnosed based on history, clinical manifestation, laboratory and histopathologic examination. Management of genital herpes includes education and counseling patients and sexual partners, systemic antiviral, and symptomatic treatment.

Pancreatic cancer is one of the most common malignancies with poor prognosis and high mortality. Advanced-stage disease at diagnosis and the dominant clinical symptoms significantly deteriorate the quality of life. The paper presents an analysis of the results of quality of life studies in patients with locally advanced and metastatic pancreatic cancer, as well as the relationship between therapeutic decisions and quality of life indicators. It has been shown that the initial assessment of life quality can have prognostic value. Appropriate symptomatic treatment of patients with advanced pancreatic cancer improves the quality of life, increases the compliance and prolongs survival. The assessment of the quality of life in patients with advanced pancreatic cancer has multivariable significance, which is not limited only to improving the quality of life.

In this research, I have tried to overview the diagnosis and treatment of smallpox performed by Heo Joon, a representative physician of Joseon dynasty. In order to accomplish this, I analyzed the smallpox related contents shown in the Essentials of Smallpox translated in Korean and a comprehensive medical book Treasured Mirror of Eastern Medicine, both written by Heo Joon. In examining these sources, I found out that Heo Joon used a medical method called ‘Syndrome differentiation’ in treating smallpox. Next, I compared the medical cases of smallpox left behind by physicians before and after Heo Joon, so as to shed light on the meaning Heo Joon’s smallpox medicine has in the history of medicine. Heo Joon read the Compendium of Smallpox published by the Joseon government and medical books newly imported from Ming (明) China, in order to write the Essentials of Smallpox. His goal was to concentrate all the knowledge related to smallpox in just one book. One aspect that was considered was that this book’s target reader did not know anything about smallpox and could not read the Chinese letters. Heo Joon, to solve this problem, collected and organized the essentials of previous medical information and at the same time provided Korean translations. For Heo Joon, the main point of smallpox medicine was to discriminate the good or bad state of prognosis through the looks and colors of the smallpox, and to distinguish the lightness or heaviness of the symptoms through the concomitant symptoms. And such thoughts materialized into judging deficiency and excess, distinguishing concomitant symptoms, and discriminating similar symptoms. Not long after the Essentials of Smallpox was published, Treasured Mirror was published. As a comprehensive medical book that covered many diseases, Treasured Mirror had to have a coherent theoretical system on diagnosing diseases and treating them. What Heo Joon regarded as the most important content, namely discrimination and distinguishment of the looks and symptoms of smallpox, was included in Treasured Mirror in the name of ‘Syndrome differentiation’. There are not any specific Heo Joon’s medical case left today, so we do not know how much his smallpox medicine contributed to uplifting the cure rate of smallpox in reality. However, comparing the case in the Compendium of Smallpox to case recorded by later physicians such as Park Jinhee, Ryu Sang, syndrome differentiation proposed by Heo Joon was not only succeeded by physicians of later generations but also contributed greatly to the success in treating smallpox. Heo Joon did not know about the pathology, causes of the smallpox, discovered by biomedicine. Even considering this, his medical contribution is clear. Based on the visible symptoms of smallpox and medical accomplishments of the previous eras, he organized and compactly proposed the causes, progression, distinguishing concomitant symptoms, treatments for symptoms development, etc. of the smallpox. In addition, in order to overcome the limit of simple symptomatic treatment, he entitled the chapter of medical thought of analysis symptoms ‘syndrome differentiation’ present in the previous medical books. It was the advent of Joseon’s edition of smallpox medicine based on syndrome differentiation.

ZusammenfassungStörungen des Gehens, der Mobilität und Stürze sind häufige Gesundheitsprobleme von Patienten mit chronischen, neurologischen Erkrankungen. Daher ist es wichtig, neben der Behandlung der neurologischen Grunderkrankung auch symptomatische Therapieoptionen mit dem Ziel der Verbesserung des Gehens einzusetzen.Mittels einer selektiven Literaturrecherche von Studien mit expliziter Untersuchung der Gehfähigkeit wurden symptomatische Therapiemöglichkeiten in den folgenden klinischen Entscheidungsfeldern identifiziert und diskutiert: (1) hypokinetische Gangstörung (z.B. bei M. Parkinson, Normaldruckhydrocephalus und vaskulärer Enzephalopathie), (2) Gangunsicherheit mit Ataxie (sensorisch und zerebellär) und (3) spastisch-paretische Gangstörung (bei Multipler Sklerose). Es werden medikamentöse und nicht-medikamentöse Therapieoptionen analysiert, speziell zu den Funktionsbereichen „Lokomotion“, „posturale Kontrolle“, „Modulation“ und „Adaptionsfähigkeit“. Die medikamentösen Behandlungskonzepte orientieren sich vorwiegend an den pathophysiologischen Veränderungen der Grunderkrankungen. Physikalisch-medizinische Basistherapien sowie Gang- und Bewegungstherapien erweitern das therapeutische Spektrum. Zudem können geh-relevante Einzelsymptome effizient mittels physikalisch-medizinischer oder pharmakologischer Therapien verbessert werden.Die Behandlungsoptionen neurologischer Gangstörungen sind gut und systematisch untersucht und ermöglichen eine individuelle Anpassung an die zugrundeliegende neurologische Erkrankung, an die Funktionsdefizite der individuellen Gangstörung sowie an relevante Einzelsymptome, welche das Gehen nochmals verschlechtern.

Risperidone is a potent psychotropic agent has been approved for symptomatic treatment of irritability in children and adolescents with autism spectrum disorders. However, its bitter taste and dose adjustment of liquid dosage forms are a main hurdle for patient acceptance.Thus, this recent study investigate the formulation of taste masked risperidone orally disintegration minitablets (ODMT) as a way of enhancing patient acceptance.Taste masked risperidone hydrogenated castor oil or Cetyl alcohol based granules were prepared using a simple melt granulation technique in different drug to lipid ratios; drug release, bitterness score of the prepared granular formulations were evaluated. DSC was also performed to detect the possible drug lipid interaction. The selected lipid-based granules were further compressed into ODMT formulations. Bitterness score was assessed by gustatory sensation test and results were compared to marketed liquid formulations of risperidone.All the prepared ODMT formulations showed high content uniformity, with minimum dose fluctuation compared to marketed oral liquid preparations.In conclusion, risperidone lipid-based granules could be formulated in different ratios by simple techniques and commonly used excipients into taste masked risperidone ODMT with accurate and flexible doses suitable for pediatric use with high taste preference and acceptability.

Fibroadenoma is the most common benign tumor occurring in young to middle aged women which disappear after the menopause. Though few cases remain asymptomatic throughout, but the tumor may progress to carcinoma. The conventional treatment includes surgical excision and cryoblation [1]. Symptomatic treatment through homoeopathy can be effective as seen in previous studies [2, 3]. In this case report, a female aged 33 years of age suffering from fibroadenoma breast, diagnosed in 2015 is given constitutional homoeopathic treatment. After three months of treatment the sonographic report shows normal findings.

Background: SARS-CoV-2 (Covid-19) pandemic which was firstly identified in Wuhan/China in December 2019.There still exists no precise treatment for this pandemic yet despite many agents are tried in prophylaxis and treatment for Covid-19. In this study, we aimed to investigate the efficacy of 2-aticyto complex in clinical course in these patients. Materials and Methods: 150 patients who applied to the Infection Diseases Polyclinics between dates September 2020-November 2020 having diagnosed with Covid-19 were included in our study. The patients were randomized into 2 groups (75 in each group) of which the first group only had the treatment of National Guideline and the second group had Viruthol® including 2-aticyto complex (at the dose of 27000 mcg/day) in addition to the treatment of the National Guideline. The laboratory parameters, clinical outcomes and the first day on which PCR result turned into negative of the patients were compared. Results: In Viruthol® group, LDH, CRP, D-Dimer and ferritin levels were significantly decreased compared to the control group, while lymphocyte levels were higher. (p=0.02, p=0.001, p=0.01, p=0.02, p=0,001 respectively). In addition to that, clinical symptoms such as fever, headache, weakness, loss of taste and smell and muscle-joint pain recovered more rapidly in contrast with the control group (p=0.001, p=0.05, p=0.001, p=0.001, p=0.001, respectively). PCR results of the Viruthol® group turned negative in a statistically significant shorter period of time with respect to the control group (p=0.001). Conclusion: Viruthol® containing 2-aticyto complex may be an agent that can be used both symptomatic treatment and improving the clinical situation and recovery of the patients followed up for Covid-19.

Veltischev Researchand Clinical Institutefor Pediatricsofthe Pirogov Russian National Research Medical University, Moscow, Russia The article presents modern data on the most common monogenic connective tissue disease – Ehlers–Danlos syndrome. The authors describe two previous classifications of the syndrome: Berlin (1988) classification, which distinguishes 11 types of the disease, and Beyton (1998) classification, which includes 6 types of the syndrome and takes into account the results of molecular genetic studies. Particular attention is paid to a new classification, proposed by the International Consortium in 2017. This classification is based on the clinical and molecular genetic data and unites 13 types of Ehlers–Danlos syndrome, divided in 7 groups (A–G), depending on the main molecular defect. This defect determines the violation of various collagen structures (primary, spatial, cross-linking) and others constituents of the connective tissue (myomatrix, glycosaminoglycans, complement component, etc.). The classification provides general clinical symptoms for all types of the disease and comprehensive information on the specific signs of each of the 13 types of the syndrome.The authors discuss approaches to the pathogenetic therapy of the syndrome, the possibilities of symptomatic treatment, including both medications of different spectrum of action, and physiotherapeutic measures, exercise therapy. The complex of the listed therapeutic measures is aimed at stabilizing the main pathological process, preventing complications, improving the patient’s quality of life and social adaptation. The authors emphasize that correct patient management, targeted medical supervision and medical genetic counseling requires molecular genetic verification of the diagnosis.

Introduction. Cough accompanies an acute infectious process in the respiratory tract. The article focuses on the symptomatic treatment of cough using a modern herbal preparation with complex action and standard therapy.Goal. To study the effects of a herbal preparation with complex action in the treatment of cough in children.Materials and methods. The study included 72 patients of both sexes (mean age 14.6 ± 2.3 years) with a symptom of unproductive/unproductive cough, against the background of acute bronchitis or community-acquired pneumonia.Results and discussion. When using a herbal preparation with complex action was used in ¾ of the children, cough decreased by the 3rd day and in most patients it stopped by the 10 th day. The severity of daytime and nighttime coughs decreased by 3.0–3.5 points, the number of seizures decreased to 2–4 per day, the duration of seizures also decreased significantly, the median of this indicator in the main group reached 0 points. In both groups, the proportion of patients with seizure frequency of no more than 4 per day increased. While taking a herbal preparation, a more pronounced decrease in all indicators of cough by 3.5 times was noted throughout the treatment, and the corresponding effects developed 3 days ahead of time against the background of a full course of therapy. The average value of the efficacy and safety assessment given by the medical researchers to the action of the herbal preparation with complex action was 3.6 points. Analysis of objective and subjective data based on the results of evaluating case histories and individually developed questionnaires for patients on drug tolerance showed equivalence in terms of excellent and good results. Against the background of the full course of treatment with the herbal preparation, a 1.8 times more pronounced decrease in the characteristics of the cough syndrome was noted.Conclusion. The drug has shown high efficacy and safety, which makes it possible to recommend it as a symptomatic therapy for cough in school-age children as part of a combination or monotherapy.

This is the pre-registration of the protocol for a scoping review on economic evaluations of cannabis-based products in treating multiple sclerosis symptoms.

Treball Final de Grau en Medicina. Codi: MD1158. Curs acadèmic: 2021/2022 Antecedentes: El cáncer es la principal causa de mortalidad en el mundo. Los avances científicos lo han convertido con frecuencia en enfermedad crónica, lo que implica la necesidad de recursos para garantizar un adecuado manejo de los pacientes. Las propiedades atribuidas a los cannabinoides los sitúan como posible opción terapéutica en aquellos pacientes con síntomas refractarios. Objetivos: Realizar una revisión sistemática para describir si el cannabis medicinal puede tener un efecto beneficioso sobre el dolor, las alteraciones del sueño, la falta de apetito y las alteraciones del estado de ánimo en pacientes oncológicos avanzados. Métodos: Se recurrió a las bases de datos PubMed, Cochrane Library, ClinicalTrials, Tripdatabase, LILACS y Medline para la búsqueda de estudios en inglés o español con diseño tipo ensayo clínico u observacional prospectivo publicados entre 2011 y 2021 y que incluyeran a pacientes oncológicos avanzados con clínica refractaria que recurrían a los cannabinoides. Se extrajeron los datos principales de los estudios incluidos y se valoró el riesgo de sesgo con las herramientas Cochrane y la calidad de la evidencia con el manual GRADE. Resultados: Se incluyeron ocho estudios y en la mayoría se observó un efecto numéricamente beneficioso de los cannabinoides, encontrándose superioridad significativa solo en algunos de ellos para las variables dolor, alteraciones del sueño, falta de apetito y alteraciones del estado de ánimo. El riesgo de sesgo fue valorado de moderado a alto y la certeza de la evidencia de moderada a muy baja. Conclusiones: El uso de cannabinoides con fines medicinales no puede considerarse beneficioso a partir de los estudios revisados por su falta de homogeneidad, el riesgo de sesgo y la calidad de su evidencia. Se requieren más investigaciones de alta calidad para apoyar la evidencia disponible. Background: Cancer is the main cause of death worldwide. Scientific progress has made this pathology a frequently chronic disease, generating the need of resources that may help a correct management of these patients. The properties attributed to cannabinoids make them a possible therapeutic option in those patients with refractory symptoms. Objectives: To conduct a systematic review to describe if medical cannabis may have any benefit in pain, sleep disruption, lack of appetite and mood disorders in advanced oncologic patients. Methods: The following database were reviewed: PubMed, Cochrane Library, ClinicalTrials, Tripdatabase, LILACS and Medline. Clinical trials and prospective observational studies published between 2011 and 2021 (both in English or Spanish) that included advanced oncologic patients with refractory symptoms that resorted to medical cannabis were selected. The main information contained in the included studies was evaluated and the risk of bias and the quality of evidence was assessed with Cochrane tools and the GRADE manual respectively. Results: Eight studies were included and in most of them a numerically beneficial effect of cannabinoids was observed, finding statistical superiority of the outcomes of pain, sleep disruptions, lack of appetite and mood disorders in some of the analysed studies. The risk of bias was moderate to high, and the quality of evidence was moderate to very low. Conclusions: Use of cannabinoids with medicinal purposes cannot be considered a beneficial approach on the basis of the reviewed studies because of the lack of homogeneity, the risk of bias and the quality of evidence. More high quality investigations are needed to support the existing evidence.

Összefoglaló. A methaemoglobinaemia az oxigén szállítására képtelen methemoglobin szintjének kóros emelkedését jelenti a vérben, ami jelentős szöveti oxigénhiányt okozhat, súlyos, akár életveszélyes tünetekhez vezethet. Methaemoglobinaemiát számos, oxidáló hatású exogén anyag idézhet elő, ezek közé tartoznak a partidrogként használt alkil-nitritek, az ún. „popperek” is. A „poppereket” korábban „alacsony rizikójú” drogként tartották számon, azonban számos esetet közöltek, amikor súlyos, időnként fatális kimenetelű methaemoglobinaemiát okoztak. A folyadékok gőzének belélegzése euforizáló, szexuálisvágy-fokozó és simaizom-lazító hatású, ezért a „popperek” igen népszerűek a homo- és biszexuális férfiak körében, de fiatal felnőttek és tinédzserek is használják. A folyadékok szájon át való fogyasztása különösen veszélyes. A szerzők két esetet ismertetnek, amelyekben a „popperek” használatát követően methaemoglobinaemia alakult ki. Mindkét betegnél, a jó általános állapot mellett, centrális és perifériás cyanosis tüneteit észlelték. Az alkalmazás módja (inhaláció/lenyelés), a methaemoglobinaemia súlyossága (16,4% és 57%) és a terápia eltérő volt a két betegnél. Az első beteg oxigén adása és tüneti kezelés mellett gyógyult, a másodiknál antidotum (metilénkék) adására is szükség volt. Mindketten panaszmentesen távoztak a kórházból. A szerzők célja az volt, hogy felhívják a figyelmet az illékony alkil-nitrit-származékok által okozott methaemoglobinaemiára, annak felismerésére, kezelésére, és bemutassák azok kevésbé ismert szövődményeit is. Orv Hetil. 2021; 162(8): 306–313. Summary. Methemoglobinemia means the abnormally elevated level of methemoglobin in the blood, which is incapable of oxygen transport, accordingly it can cause significant tissue hypoxia, leading to severe or even life-threatening clinical symptoms. Several exogen oxidative agents can induce methemoglobinemia, including alkyl-nitrites which are also used as party drugs, the so-called ‘poppers’. The ‘poppers’ were previously considered ‘low-risk’ drugs, however, several cases have been published when they caused severe, sometimes fatal methemoglobinemia. Inhaling vapours from liquids has euphoric, smooth-muscle relaxing and aphrodisiac effects, therefore ‘poppers’ are extremely popular among gay and bisexual men but also used by young adults and teenagers. Oral consumption of the fluids is particularly dangerous. The authors present two cases when methemoglobinemia developed after ‘poppers’ usage. Both patients were in good general condition and symptoms of central and peripheral cyanosis were detected. The method of application (inhalation/ ingestion), the severity of methemoglobinemia (16,4% and 57%) and the treatment were different in the two patients. The first patient recovered with inhalation of oxygen and symptomatic treatment; the second patient required administration of antidote (methylene blue). Both patients left the hospital without complaints. The authors’ aim was to attract attention to methemoglobinemia caused by volatile alkyl-nitrites, its recognition, treatment and to present their lesser-known complications. Orv Hetil. 2021; 12(8): 306–313.

Objetive. Hospital resources are insufficient given the demand for seriously ill patients with COVID-19. Proper resource management is essential to provide the best possible care. Criteria to help make appropriate and timely decisions were reviewed, following ethical principles. The prioritization of invasive ventilatory support must be done in a transparent and objective manner, comprehensively evaluating the patient and based on objective criteria such as prognostic scales, life cycle or clinical commitment. Symptomatic treatment (including palliative care) is essential in this pandemic and communication with the patient or family makes it possible to humanize the care of health personnel. Objetivo. Los recursos hospitalarios resultan insuficientes ante la demanda de pacientes graves con COVID-19. La adecuada gestión de recursos es esencial para brindar la mejor atención posible. Se revisaron criterios que ayuden a tomar decisiones adecuadas y oportunas, siguiendo principios éticos. La priorización del soporte ventilatorio invasivo debe hacerse de manera transparente y objetiva, evaluando integralmente al paciente y basado en criterios objetivos como escalas de pronóstico, ciclo de vida o compromiso clínico. El tratamiento sintomático (incluyendo cuidados paliativos) es indispensable en esta pandemia y la comunicación con el paciente o la familia permiten humanizar la atención del personal de salud.

Bo-Wen Sun,1,* Min Zhang,1,* Ping-Chao Wang,2 Jiang-Tao Song3 1Department of Respiratory Medicine, Heilongjiang Provincial Hospital, Harbin Institute of Technology, Harbin, 150036, People’s Republic of China; 2Department of Critical Care Medicine, People’s Hospital of Hanchuan, Hanchuan, 431600, People’s Republic of China; 3Department of Orthopedics, People’s Hospital of Hanchuan, Hanchuan, 431600, People’s Republic of China*These authors contributed equally to this workCorrespondence: Ping-Chao WangDepartment of Critical Care Medicine, People’s Hospital of Hanchuan, No. 1 Of Peoples Avenue, Hanchuan, 431600, People’s Republic of ChinaTel +8613508692696Email wamgpimgchao@21cn.comJiang-Tao SongDepartment of Orthopedics, People’s Hospital of Hanchuan, No. 1 Of Peoples Avenue, Hanchuan, 431600, People’s Republic of ChinaTel +8613429921750Email somgjiamgtao@163.comObjective: This study aimed to investigate the clinical manifestation and treatment effects of extrapulmonary complications in cases of novel coronavirus pneumonia.Methods: The clinical data of patients with novel coronavirus pneumonia who were admitted to Hanchuan People’s Hospital between January and March 2020 were retrospectively analyzed, and the clinical characteristics, laboratory test results, and treatment pathways of patients with extrapulmonary complications were analyzed and summarized.Results: Of the 500 patients in this study, 97 patients with a history of chronic diseases were excluded, and 152 patients had extrapulmonary complications. Common extrapulmonary syndromes: 98 patients (64.47%) suffered from digestive system involvement; 43 patients (28.29%) suffered from cardiovascular system damage; 32 patients (21.05%) had urinary system damage; 25 patients (16.45%) had nervous system damage; and 30 patients (19.74%) had more than two kinds of system damage. In all cases, these patients were treated with comprehensive measures, and effective outcomes were achieved.Conclusion: According to the clinical characteristics and laboratory test results of this sample group, early evaluation of patients with extrapulmonary complications and timely symptomatic treatment can effectively improve outcomes of pneumonia treatment, accelerate the alleviation of symptoms, and improve patients’ condition.Keywords: novel coronavirus pneumonia, clinical characteristics, laboratory test, extrapulmonary complications, curative effect

Background Cases of obturator nerve impingement (ONI) caused by osteophytes resulting from bone hyperplasia on the sacroiliac articular surface have never been reported. This paper presents such a case in a patient in whom severe lower limb pain was caused by osteophyte compression of the sacroiliac joint on the obturator nerve. Case summary A 65-year-old Asian man presented with severe pain and numbness in his left lower limb, which became aggravated during walking and showed intermittent claudication. The physical examination revealed that the muscle strength of the left lower limb had decreased and that the passive knee flexion test result was positive. Computed tomography (CT) and 3D reconstruction showed a large osteophyte located in the anterior lower part of the left sacroiliac joint. The results of electrophysiological examination showed peripheral neuropathy. A CT-guided obturator nerve block significantly reduced the severity of pain in this patient. According to the above findings, ONI caused by the osteophyte in the sacroiliac joint was diagnosed. This patient underwent an operation to remove the bone spur and symptomatic treatment. After therapy, the patient's pain and numbness were significantly relieved. The last follow-up was performed 6 mo after the operation, and the patient recovered well without other complications, returned to work, and resumed his normal lifestyle. Conclusion Osteophytes of the sacroiliac joint can cause ONI, which leads to symptoms including severe radiative pain in the lower limb in patients. The diagnosis and differentiation of this disease should attract the attention of clinicians. Surgical excision of osteophytes should be considered when conservative treatment is not effective.

Background Trichomonas vaginalis (TV) is a sexually transmitted parasite associated with multiple adverse outcomes in women. Estimating TV incidence is challenging because of its largely asymptomatic presentation. Methods Per-capita prevalence was estimated using the National Health and Nutrition Examination Survey, 2013 to 2018. Incidence was estimated using ordinary differential equations assuming static incidence at steady state and fit using Bayesian techniques. Model inputs included estimates of proportion of asymptomatic cases, natural clearance, and time to symptomatic treatment seeking. Posterior distributions were drawn, and uncertainty was reported, from 25th (Q1) to 75th (Q3) percentiles. Aggregated measures were estimated by combining component distributions. Results Among 15- to 59-year-olds in 2018, the number of prevalent TV infections was 2.6 (Q1, 2.4; Q3, 2.7) million overall, 470,000 (Q1, 414,000; Q3, 530,000) among men, and 2.1 (Q1, 2.0; Q3, 2.2) million among women; the numbers of incident infections were 6.9 (Q1, 6.2; Q3, 7.6) million, 3.3 (Q1, 2.8; Q3, 3.8) million, and 3.5 (Q1, 3.1; Q3, 4.0) million among all persons, men, and women, respectively. Persons aged 15 to 24 years comprised 15.6% and 16.3% of all prevalent and incident infections, respectively; prevalence and incidence in both sexes increased with age. Incidences in both sexes were highly dependent on estimates of natural clearance, which were based on few data. Conclusions Prevalence and incidence of TV are substantial in the United States, particularly among those 25 years or older. Although estimated prevalence is higher in women, estimated incidence is similar in men and women. Data on key parameters of TV infection are limited; future research should focus on clarifying the natural history of TV.

BACKGROUND Intrahepatic portosystemic venous shunt (IPSVS) is a rare hepatic disease with different clinical manifestations. Most IPSVS patients with mild shunts are asymptomatic, while the patients with severe shunts present complications such as hepatic encephalopathy. For patients with portal hypertension accompanied by intrahepatic shunt, portal hypertension may lead to hemodynamic changes that may result in exacerbated portal shunt and increased shunt flow. CASE SUMMARY A 57-year-old man, with the medical history of chronic hepatitis B and liver cirrhosis, was admitted to our hospital with abnormal behavior for 10 mo. He had received the esophageal varices ligation and entecavir therapy 1 year ago. Comparing with former examination results, the degree of esophageal varices was significantly reduced, while the right branch of the portal vein was significantly expanded and tortuous. Meanwhile, abdominal ultrasound presented the right posterior branch of portal vein connected with the retrohepatic inferior vena cava. The imaging findings indicated the diagnosis of IPSVS and hepatic encephalopathy. Instead of radiologic interventions or surgical therapies, this patient had only accepted symptomatic treatment. No recurrence of hepatic encephalopathy was observed during 1-year follow-up. CONCLUSION Hemodynamic changes may exacerbate intrahepatic portosystemic shunt. The intervention or surgery should be carefully applied to patients with severe portal hypertension due to the risk of hemorrhage.

Rheumatoid arthritis is most significant and devastating to the human body. It is an autoimmune disorder that affects almost 2-4% of the population of the world. Rheumatoid arthritis usually occurs when the immune system works against one’s own body and attacks it. Rheumatoid arthritis generally affects the joints like wrists, elbows, knees and ankles. Even though the reason for causing RA is unknown, the contributing factors for the development of the RA are of various types. Usually women are more affected by RA then men due to the prevalence of hormonal changes. Age is also an important factor that contributes for the development of RA. The general treatment approach for rheumatoid arthritis is to prevent further damage of joints and lower the inflammation and pain. Symptomatic treatment is also the base for RA treatment in many patients. Considering these side effects and limited use of the synthetic drugs, a deep focus has been put into herbal drugs as useful remedies to treat RA successfully. So there has been as growing trend towards development of polyherbal formulation employing potent herbs to treat the disease. Scientific investigations had been carried out to prove the potency of the herbs to treat RA in various animal and invitro models. Many polyherbal formulations had been marketed successfully and were prescribed by the physician. In this view the standardization stands as utmost important parameter for proving the quality of the formulation. Considering the marketed formulations attempts are to be made to determine the quality and effect of the herbal formulations. Investigations are also to be made to determine the interaction between the herbs employed in the formulation.

Objective: This study is to analyze correlation between traditional Chinese medicine (TCM) syndrome distribution characteristics and prognosis of hypertensive intracerebral hemorrhage (HICH) operation. Methods: In this study, a total of 150 patients who had received HICH operation from April, 2017 to December, 2020 in our hospital and conformed to inclusion standards were selected. According to classification of TCM syndromes, amount of bleeding of patients was recorded through multiple radiological technologies, baseline information was collected, and prognosis was investigated. The final event was long-term follow-up visit of all-cause mortalities. Moreover, correlation between prognosis and TCM syndromes was analyzed. Results: It found through investigations that there are no statistically significant differences in composition ratio of TCM syndromes among patients with different genders and different age ranges (P > 0.05). Among so many TCM syndromes, bleeding amount of patients with declining vitality and distraction is the highest, while bleeding amount of patients with stirring wind due to yin deficiency is the lowest. With respect NIHSS scores, the patients with declining vitality and distraction show the highest NIHSS scores at admission and 10 d of the course of the disease, followed by patients with upward disturbance of wind-fire. There are statistically significant differences among these two groups (P < 0.05). In this study, follow-up visits are performed to all 150 patients and the average follow-up visit time ranges within 2 - 15 months. A total of 13 deaths are reported. Number of all-cause deaths has statistically significant differences among different syndromes (P < 0.05). Conclusions: Evolutionary characteristics of TCM syndromes of HICH are manifested by development from evidence-based symptoms to deficiency syndromes. Different syndromes are correlated with prognosis of patients. On the one hand, this can be used as an objective index for TCM syndrome classification. On the other hand, this is conducive to judge prognosis recovery of patients and to apply the corresponding symptomatic treatment.

Background: The role of salivary-specific IgG4 and IgA in subcutaneous immunotherapy (SCIT) is not well defined. We aimed to investigate the change of IgG4 and IgA in both serum and saliva and their correlations with IgE-blocking-factor (IgE-BF) during SCIT. Method: 307 Dermatophagoides pteronyssinus (DP) allergic rhinitis and/or asthma patients were recruited for this study. 286 patients received DP-SCIT for 1 year. Twenty-one patients received only symptomatic treatment. DP-, Der p 1-, and Der p 2-specific IgE in serum, specific-IgG4 and Der p 2-specific IgA1 and IgA2 in both serum and saliva were measured at timepoints 0, 4, and 12 months during DP-SCIT. Correlation between salivary and serological IgG4, IgA, and their correlation with DP-specific IgE-BF measured in serum was evaluated. Results: During DP-SCIT, the allergen-specific IgG4 in both saliva and serum increased and correlated significantly, the correlation becomes stronger over the treatment time. DP-specific IgE-BF significantly correlated with DP-specific IgG4 in serum (p < 0.0001) at different timepoints and in saliva at 12 months of SCIT (p < 0.01). No change in Der p 2-specific IgA during DP-SCIT was observed, and the IgA in serum did not correlate with IgA in saliva. There was no correlation between DP IgE-BF and Der p 2-specific IgA in serum or saliva. The control group did not exhibit significant changes in any antibody level measured. Conclusion: The IgE blocking activity induced by DP-SCIT treatment correlated with specific IgG4 and not IgA. The IgG4 in saliva correlates with serum IgG4 and can be an alternative immunological marker beyond 1 year of SCIT treatment.

Myoclonus is a hyperkinetic movement disorder characterized by a sudden, brief, involuntary jerk. Positive myoclonus is caused by abrupt muscle contractions, while negative myoclonus by sudden cessation of ongoing muscular contractions. Myoclonus can be classified in various ways according to body distribution, relation to activity, neurophysiology, and etiology. The neurophysiological classification of myoclonus by means of electrophysiological tests is helpful in guiding the best therapeutic strategy. Given the diverse etiologies of myoclonus, a thorough history and detailed physical examination are key to the evaluation of myoclonus. These along with basic laboratory testing and neurophysiological studies help in narrowing down the clinical possibilities. Though symptomatic treatment is required in the majority of cases, treatment of the underlying etiology should be the primary aim whenever possible. Symptomatic treatment is often not satisfactory, and a combination of different drugs is often required to control the myoclonus. This review addresses the etiology, classification, clinical approach, and management of myoclonus.

Sleep disorders are common among persons with dementia: 50.8% of them have insomnia. 1 The behavioural and psychological symptoms of dementia (BPSD), including day‐night reversal and wandering during the night, increase the care burden of patients' family members and care staff. In general, pharmacological therapy is prescribed to treat sleep disorders; however, as its effectiveness is limited, non‐pharmacological therapy (NPT) has also been proposed. 2 Weighted blankets (WBs) have been used as an NPT in the USA and the Nordic countries, and their effectiveness has started to attract the attention of Japanese medical professionals. Phototherapy is the most common and effective form of NPT, and other forms of this intervention such as lifestyle therapy, electrical stimulation, and cognitive behavioural therapy are also widely employed. 3 To facilitate better sleep quality in persons with dementia afflicted with symptoms of day‐night reversal, the Alzheimer's Association of America recommends various types of lifestyle changes: reducing naps, increasing daytime activity, and regulating sleep rhythms with adequate exposure to sunlight. 4 WBs have demonstrated positive psychological effects in adults with depression and in children with developmental disabilities. They have also been used for persons with dementia in Nordic countries. Field et al. reported that pressure stimulation of the body releases oxytocin, a happy hormone, which has a calming effect and activates the secretion of serotonin. 5 This study was the first clinical trial of WBs for persons with dementia in Japan. CASE PRESENTATION Our case study demonstrates the effectiveness of a WB for a person with severe dementia. The participant was a woman in her 80s living in a nursing home who agreed to participate in the study. At the time of the case study, she was 138 cm tall and weighed 42 kg. She was diagnosed with Alzheimer's disease in 1991. Her symptoms progressed over time, and she began to exhibit symptoms such as wandering, collecting things, and odd eating behaviours. There were complaints from the neighbours about these symptoms, and she was moved to a nursing home in June 2016. At that time, her Clinical Dementia Rating was 3 (severe dementia) and ranked at care level 5 (extreme need of care) on the Long‐term Care Insurance system. She had a sleep disorder, with BPSD including day‐night reversal, wandering during the night, and hallucinations. Because she had difficulty answering questions, using the Mini‐Mental State Examination was not feasible. She had never received pharmacological therapy for her sleep disorder, and her only daily medication was a laxative. She needed mild care support with daily activities. For example, when she fell asleep while sitting up and eating, the care staff would help her eat. She frequently left her room and wandered around the floor throughout the night. The care staff would catch her wandering and lead her back to bed to lie down. The care staff attempted lifestyle therapies from the time of her admission, such as promoting participation in activities during the day and sleep induction at night. The results of the lifestyle therapies showed a slight increase in sleep time, but her nocturnal auditory hallucinations, hallucinations, and wandering did not decrease; thus, the burden on the care staff increased.

Erythema nodosum (EN) is a delayed hypersensitivity response that may be triggered by a range of conditions, including infections and vaccines. Rare cases of EN caused by COVID-19 were recently reported but none due to COVID-19 vaccines were documented. We report here a case of EN occurring after COVID-19 vaccination. Patient presented with painful nodular lesions of all 4 limbs, evolving for one month. These lesions appeared 48 h after the second dose of COVID-19 vaccination. The patient reported no recent infectious episodes. The physical examination found numerous, erythematous dermohypodermatitis knots with no palpable adenopathy. Some were regressive according to biligenesis shades. Biology and radiology findings eliminated other common causes of this dermatosis. The skin biopsy was done and suggested EN. The final diagnosis was post COVID-19 vaccine EN. Patient received a symptomatic treatment and had a slight improvement of the lesions 10 days after diagnosis. Physicians should be aware of the side effects of the vaccine including skin manifestations, especially since more people are bound to be vaccinated.

Biliary injuries during cholecystectomy represent serious adverse events that can have a profound impact on the patient’s quality of life and on the surgeon’s well-being and career. Sometimes, they can have an unexpectedly disastrous effect on the whole community, as demonstrated by the case of Anthony Eden, former foreign secretary and prime minister of Britain in the 1950s. Mr. Eden, later Lord Avon, had been suffering from biliary symptoms for a while when he had his cholecystectomy performed on April 12, 1953. On post-op day 1, a bile leak was evident, possibly due to a complete transection of the common bile duct. After a first reoperation to drain a bile collection, the definitive repair was performed in Boston by Dr. Cattell on June 10, 1953, with a loop hepatico-jejunostomy. Unfortunately, the bilioenteric anastomosis became gradually narrow, causing recurrent cholangitis, and Mr. Eden started a symptomatic treatment with pethidine, barbiturate, and amphetamine. These could have affected his perception of reality and his political judgement during the Suez Canal Crisis and, other than being the ultimate reason for 3,000+ war casualties, might have caused a Third World War. The historical and clinical implications of this case are thoroughly discussed.