SN Comprehensive Clinical Medicine最新文献

We present a patient with systemic sclerosis–systemic lupus eritematosus (SSc-SLE) overlap syndrome who was initially diagnosed as SLE. The patient underwent kidney biopsy and was diagnosed as SSc renal crisis as a result of the biopsy. With this case, we aimed to raise awareness about renal crisis in limited scleroderma cases. We present a rare case of renal crisis in a 49-year-old male patient with limited SSc-SLE overlap syndrome. The patient, who applied to the rheumatology clinic with complaints of bruising on the fingers and toes, weight loss, and swelling in the legs, was diagnosed with SLE in April 2022. Renal function tests were normal at that time. About 2 months after this diagnosis, he applied to the emergency department of our hospital with complaints of shortness of breath and chest pain. He was admitted to our clinic because his blood pressure was 160/100 mmHg and his creatinine (cre) value was 3.8 mg/dl. We detected SSc renal crisis as a result of kidney biopsy performed in our patient with marked sclerodactyly. The patient was diagnosed with a rare coexistence of limited SSc and SLE. Renal crisis in limited SSc is a rare condition. Our patient is still dialysis dependent. In SSc-SLE overlapping patients presenting with renal failure, the picture may be associated with SSc kidney crisis, lupus nephritis, or a coexistence of kidney crisis and lupus nephritis. The differential diagnosis of renal involvement of SSc-SLE overlap syndrome is a challenging clinical management. Renal crisis is rare, especially in limited SSc. However, renal crisis must be kept in mind in the differential diagnosis who has resistant hypertension and SSc skin findings even though other signs of SSc are subtle.

Diplopia is a common complaint with two subtypes: monocular and binocular in the emergency department (ED) and outpatient clinic. Monocular diplopia is typically associated with ocular abnormalities and refractive errors, whereas binocular diplopia may indicate the presence of an underlying life-threatening cause. To emphasize the importance of identifying underlying neurologic disease in individuals experiencing diplopia. Over a 3-year period, patients admitted to the ED and neurology outpatient clinic with diplopia were retrospectively analyzed. ‘Secondary diplopia’ was defined when an organic cause was found. ‘Isolated diplopia’ was identified as the absence of additional signs and symptoms other than diplopia. All patients were examined for risk factors and investigated for an etiology. Out of the 222 (male: 138) patients, 213 (96%) had binocular diplopia. Secondary diplopia was observed in 113 (53%) patients and 82 (38.4%) had isolated diplopia. One hundred twenty-five (58.6%) patients had at least one sign or symptom associated with diplopia. The incidence of diabetes was significantly higher in secondary diplopia. Ninety-three (43.6%) patients had ocular cranial nerve palsy, most commonly in the 6th cranial nerve. Diplopia with at least one associated sign or symptom and ocular cranial nerve involvement was statistically significant for secondary diplopia. In cases of acute diplopia the presence of at least one additional associated sign or symptom was significantly higher. It is very important to investigate an underlying neurologic etiology that may be life-threatening because secondary diplopia was detected in half of the patients with diplopia in the present study.

Acute appendicitis is one of the most common surgical emergencies. The role of the neutrophils to lymphocytes ratio in diagnosing appendicitis is debatable. For this, this study aimed to investigate the diagnostic value of neutrophils to lymphocytes ratio to diagnose acute appendicitis. In the case–control method designed for this study, a total of 505 candidates for appendicitis surgery from July 2020 to July 2021 in Bojnurd City (eastern north of Iran) were investigated. Inclusion criteria were age 15–75, and the patients should have pathology results for their diagnosis. The exclusion criteria were acute infection in the last week, history of blood transfusion, and history of chronic autoimmune disease. The clinical history and symptoms, laboratory tests, sonography evidence, and CT scans of participants before surgery were gathered. The appendix pathology was evaluated by a pathologist after surgery, and two groups of pathology results were approved appendicitis and no approved appendicitis. Collected variables were analyzed through a t-test or Mann–Whitney test, and logistic regression was used to remove possible confounders; diagnostic accuracy was performed using receiver operating curve analysis. The result of the study showed that 273 (54.3%) of the participants were male and 260 (67.3%) were residents of the city. Sixty-seven point three percent (67.3%) of the patients had nausea and vomiting; the tenderness and shift of pain to the right were reported in 481 (94.4%) and 359 (71.2%) of them, respectively. The mean ± standard deviation age of patients was 31.1 ± 12.6. The mean and standard deviation of neutrophils to lymphocytes ratio in non-appendicitis were 7.5 ± 6.1 and in acute appendicitis were 3.5 ± 3.3, and there was a significant difference between the two groups (p-value < 0.0001). In the cut point of 3.76 for the neutrophil to lymphocyte ratio, the receiver operating curve area was 0.78 (95% CI 0.75, 0.82), and for this criteria, the sensitivity was 0.74.3 (95% CI 69.4, 78.7), and specificity was 0.74.65 (95% CI 66.5, 81.7). In the final model of logistic regression, the odds ratio of male gender was 1.7 (95% CI 1.05, 2.65), leukocyte counts 1.00023 (95% CI 1.0005, 1.00003), abdominal pain shift to the right 1.82 (95% CI 1.15, 2.98), and neutrophils to lymphocytes ratio 1.72 (95% CI 1.05, 2.65), and there were as predictors of acute appendicitis. It is evident that the neutrophil to lymphocyte ratio (NLR) is a valuable marker for diagnosing acute appendicitis. Furthermore, when combined with male gender, high leukocyte count, and right-sided abdominal pain, the NLR becomes an effective set of predictors for this condition.

Abstract

The duration of cardiopulmonary resuscitation (CPR) affects neurological outcomes. Conclusive data on its decremental effect on neurological outcomes have not been explored before in a quantitative review. PubMed and Google Scholar were searched for relevant studies from 2015 up to May 2023 using relevant keywords. The odds of good neurological outcomes were studied. Binary random effects were used to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). A leave-one-out sensitivity analysis was performed. Heterogeneity was assessed using I² statistics. For outcomes showing moderate to high heterogeneity, subgroup analysis was performed for follow-up duration or type of study. A p value of < 0.05 was considered statistically significant. A total of 349,027 cardiac arrest patients (mean age, 70.2 years; males, 56.6%) from four studies were included in the meta-analysis. Of them, the initial rhythm was shockable in 11% (38,465/349,027) and non-shockable in 88.97% (310,562/349,027) of the population. Odds of having favorable neurological outcomes were 0.32 (95% CI 0.10–1.01, p = 0.05) for 6–10 min (n = 14,118), 0.10 (95% CI 0.02–0.64, p = 0.02) for 11–15 min (n = 43,885), 0.05 (95% CI 0.01–0.36, p 0.01) for 16–20 min (n = 66,174), 0.04 (95% CI 0.01–0.21, p < 0.01) for > 20 min (n = 181,262), and 0.03 (95% CI 0.00–1.55, p = 0.08) for > 30 min (n = 66,461) when compared to patients receiving CPR for < 5 min (n = 6420). Steady decremental odds of favorable neurological outcomes were seen with every 5 min of increased CPR duration, with a statistically significant decline seen in CPR duration from 11 to 15 min onwards.

Abstract

The recommended post-operative radiotherapy dose of approximately 60 Gy may be reduced during treatment planning, and the optimal irradiation method and dose remain unclear. We aimed to clarify the usefulness and safety of post-operative radiotherapy for soft tissue sarcomas. Forty-five patients with soft-tissue sarcomas who underwent adjuvant radiotherapy at two institutions from June 2014 to August 2020 were included. Patients with a high risk of recurrence underwent post-operative irradiation, with doses of 60–70 Gy and 50 Gy used in patients with positive and negative resection margins, respectively. The median patient age was 72 (21–88) years. The most common histological types of sarcomas were myxofibrosarcoma (n = 12) and dedifferentiated liposarcoma (n = 11), followed by other sarcomas. Thirty patients were newly diagnosed, and 15 underwent surgery for localized recurrent disease. Thirty-two and 13 patients underwent wide and marginal resection, respectively. Surgical margins were negative in 12 patients and positive in 33 patients. Chemotherapy was administered before or after radiotherapy in 16 patients. The 2-year local control, progression-free survival, and overall survival rates after post-operative radiotherapy were 88%, 78%, and 93%, respectively. In patients with positive resection margins, doses of ≥ 60 Gy contributed to local control (p = 0.0002, log-rank test) and progression-free survival (p = 0.0033). Late grade 3 adverse events were observed in 7% of the patients. Post-operative radiotherapy for soft tissue sarcomas is safe and effective, with high doses (≥ 60 Gy) contributing to reduced recurrence among patients with positive resection margins.

Abstract

Although cesarean section is an essential maternal healthcare service, it has both maternal and neonatal adverse outcomes as compared to spontaneous vaginal delivery. Physical activities enhance the strength of the abdominal, diaphragm, and pelvic floor muscles, stretching the thigh and back leg adductors; all these help the women more easily turn to and keep their natural relaxant pelvic adequacy. This might facilitate spontaneous vaginal delivery with a short duration of labor. The objective of this study is to assess the effect of degree of physical activity during pregnancy on mode of delivery and duration of labor. A cross-sectional study was conducted in 150 women who gave birth from November 2021 to February 2022 at MTUTH, Ethiopia. Data was collected through face-to-face interviews using a structured questionnaire. Descriptive analysis, chi-square, and t test were conducted to check the presence of any association between the dependent and independent variables. A p value of < 0.05 will be considered statistically significant. Our study found that 87% of women who engaged in vigorous physical activities had spontaneous vaginal deliveries. Of those women who have light physical activities, only 16.5% have spontaneous vaginal delivery. The duration of labor for women with vigorous and light physical activity was 5.2 ± 2.07 and 8.9 ± 2.8 h, respectively. Engaging in the recommended amount of aerobic exercise while pregnant under a doctor’s supervision is crucial for reducing the duration of labor and the need for an operational delivery.

Multiple sclerosis (MS), an autoimmune central nervous system disease responsible for significant morbidity and mortality worldwide, remains imperfectly understood and treated clinically. Recent advances in treating MS have come in the form of new immunomodulatory agents. Of these, anti-CD20 monoclonal antibodies (mAbs) have exhibited particular promise in treating relapsing–remitting multiple sclerosis (RRMS), the early stage of the disease where the adaptive immune system facilitates an autoimmune attack against myelin. The depletion of CD20 positive B cells in patients with RRMS has been associated with decreased symptoms, disease progression, and lesions on MRI, as well as a more favorable side effect profile relative to other immunomodulatory therapies for MS. Of the anti-CD20 mAbs available for use in MS, one of the newest is ofatumumab, a fully human anti-CD20 IgG1κ, sold under the trade name Kesimpta. The present investigation reviews the efficacy and safety of ofatumumab for MS, highlighting the role that B cells play in the initial inflammatory stage of MS and their depletion in decreasing clinical symptoms, T2-enhancing MRI lesions, and progression to the immune-independent phase of MS.

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract. The anatomy of Meckel’s diverticulum varies, and when it is attached to the abdominal wall or mesentery by means of fibrous cords, it can cause obstruction including massive bowel gangrene which has not yet been reported in the literature. A middle-aged man presented to the emergency wing with a history of obstipation and vomiting for 2 days. A CECT (Contrast Enhanced Computed Tomography) abdomen revealed dilated ileal bowel loops with multiple strictures, mesenteric lymph nodes, and mild ascites. With a provisional diagnosis of tuberculosis of the abdomen, he was taken for emergency laparotomy. Around 200 cm of distal ileum was found gangrenous due to the herniation of it beneath a mesodiverticular band which was connected to the apex of Meckel’s diverticulum found 50 cm from the ileocolic junction. The gangrenous bowel along with the gangrenous Meckel’s diverticulum was resected, and an end ileostomy and distal mucosal fistula were made. Meckel’s diverticulum must be kept as a differential in any young patients presenting with acute intestinal obstruction with no previous history of abdominal surgery, TB abdomen, or inflammatory bowel disease. While recommendations suggest resection of symptomatic Meckel’s diverticulum with a narrow base and wide body due to its propensity to rotate along its axis and cause gangrene of Meckel’s diverticulum, we believe Meckel’s diverticulum with a band attaching it to umbilicus or with ileal mesentery must be considered for resection to prevent grave complications.

Nowadays, changes of lifestyle have been associated with a dramatic increase in the prevalence of obesity. Metabolic-associated fatty liver disease (MAFLD) is a growing global health problem. To determine prevalence of MAFLD among general population, attending the out patients clinics of Beni-Suef University hospital, without history of alcohol intake, chronic liver disease, viral hepatitis infection, DM or HTN, and the efficacy of other hepatic steatosis indices in its detection. The studied subjects were classified according to MAFLD criteria. CBC, AST, ALT, creatinine, fasting blood glucose (HbA1c), lipid profile (cholesterol triglyceride), HOMA-IR, high-sensitive CRP, imaging with abdominal ultrasound, ARFI, and TE (FibroScan and CAP) were done to all subjects. Also, HS index and FAST Score were done. Efficacy of these data was assessed as predictors of MAFLD. From 588 participant, 165 patients (28.1%) had positive MAFLD criteria. FibroScan, CAP, ARFI, and FAST score were higher among the MAFLD group but without statistical significance, while HBA1c, hepatic ultrasound finding, and (HS Index) showed a statistically significant difference between groups. HSI could predict steatosis at a cutoff 39.1405 with 61% sensitivity and 71% specificity. MAFLD is common in general population. HS index is simple to calculate and can help physicians to screen patients who need follow-up for early detection of liver steatosis and lifestyle counseling.

Abstract

Aortic dissection with concurrent ST-elevation myocardial infarction (STEMI) is rarely reported. As the proportion of myocardial infarction is higher in the emergency setting compared to aortic dissection, the diagnosis of aortic dissection may be overlooked, and it can be potentially fatal. By using bedside available information, detailed history taking, and multimodality imaging in the emergency setting, it is possible to avoid a mistaken diagnosis. Here, we present a case of aortic aneurysm presenting with anterior STEMI. A 79-year-old woman was admitted to our emergency department with decreased consciousness. Shortly before the patient went unconscious, she had a short episode of dyspnea. Her ECG showed marked ST elevation in the anterior leads. However, her chest radiograph revealed mediastinal widening and a prominent aortic knob. Due to suspicion of aortic dissection from the chest radiograph and loss of consciousness, which may be a sign of malperfusion syndrome of aortic dissection, bedside handheld echocardiography was then performed. It revealed hypokinesis of anterior and anteroseptal walls, pericardial effusion, and dilated aortic root to ascending aorta with severe aortic regurgitation. The presence intimal flap can not be clearly excluded. Based on her imaging and clinical findings, aortic dissection was suspected and thrombolysis was postponed. The patient proceeded to undergo triple-rule-out computed tomography, from which the finding of ascending aortic aneurysm was noted, along with multiple stenosis of LAD (moderate-to-severe) and LCx (moderate), and there was no presence of false lumen. Acute aortic dissection should be considered a differential diagnosis in patients presenting with symptoms suggesting acute coronary syndrome. A suspected case of acute aortic dissection should necessitate further imaging studies. Therefore, multimodality imaging plays a vital role in the emergency setting, as it may avoid fatal consequences of misdiagnosis and mistreatment.