Annals of Medicine and Surgery最新文献

Background: Fulminant myocarditis (FM) is a potentially life-threatening disease that requires emergency care. The authors' study aims to explore clinical outcomes and predictors of survival when using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for the treatment of FM in adult and pediatric patients to analyze differences between both populations.

Methods: PubMed, Scopus, Web of Science, and Cochrane databases were searched for studies reporting the effect of VA-ECMO on patients diagnosed with fulminant myocarditis. Statistical analysis was performed using R version 4.2.2.

Results: Forty-three studies were included in our analysis with a total of 1268 patients. Survival rates were 65% and 71% among adult and pediatric patients, respectively. Patients who didn't suffer from cardiac arrest prior to VA-ECMO had better chances of survival in both populations; adults (OR 0.44; P<0.01) and pediatric (OR = 0.32; P= 0.006). Younger age was associated with higher survival among the adults (MD= -8.81; P<0.01). Additionally, pre-ECMO LVEF was higher among survivors in the pediatric group (MD= 8.23; P<0.01). Furthermore, no significant association was detected between sex, VA-ECMO duration, systolic blood pressure, lactate levels, and survival rates among both groups.

Conclusion: Using VA-ECMO in patients with fulminant myocarditis can significantly improve survival outcomes, with improved prognosis observed with younger age among adults and absence of prior history of cardiac arrest in both groups.

This case report documents a rare presentation of eyebrow bleeding occurring during migraine episodes in a 10-year-old girl, highlighting atypical signs associated with the disorder. Despite her normal neurological examinations and imaging studies, the patient experienced recurrent, severe headaches accompanied by localized bleeding and red spots on the forehead. This unusual symptomatology suggests potential underlying neurovascular and neuroinflammatory mechanisms, necessitating heightened awareness among healthcare providers. Following treatment with Coenzyme Q10, Vitamin B2, and Cyproheptadine, both headache frequency and symptom intensity significantly improved. This case underscores the importance of comprehensive evaluation and recognition of uncommon migraine manifestations in clinical practice.

Introduction and importance: Dyskeratosis congenita (DC) is a rare multisystem disorder primarily characterized by bone marrow failure due to telomere shortening. Typical clinical features include oral leukoplakia, skin hyperpigmentation, and nail dystrophy, along with an increased risk of malignancies. Hoyeraal-Hreidarsson syndrome (HH), a severe variant of DC, is associated with profound neurological and immunological complications, emphasizing the importance of early diagnosis and genetic evaluation to guide appropriate management.

Case presentation: The authors present a case of a 2-year-old girl diagnosed with Hoyeraal-Hreidarsson syndrome, linked to a newly discovered mutation in the poly (A)-specific ribonuclease (PARN) gene. The patient exhibited intrauterine growth retardation (IUGR), congenital cytomegalovirus (CMV) infection, immunodeficiency, microcephaly, and cerebellar hypoplasia. Whole-exome sequencing (WES) identified a novel mutation in the PARN gene.

Clinical discussion: Hoyeraal-Hreidarsson syndrome, a severe form of DC, manifests with multisystem involvement and is genetically heterogeneous. Early genetic testing through techniques such as WES can aid in diagnosing rare syndromes like HH and guide treatment strategies, including bone marrow transplantation.

Conclusion: This case underscores the importance of genetic evaluation in complex, rare syndromes like HH. Whole-exome sequencing plays a crucial role in identifying pathogenic mutations and tailoring management. The patient's prognosis is being closely monitored following bone marrow transplantation.

Introduction: Tuberculosis is a major public health issue in developing countries. Vasculitis, resulting from tubercular meningitis, can lead to stroke.

Case presentation: A 33-year-old male presented to the Emergency Department with relapsing-remitting fever with an evening rise in temperature for 1 month, personality changes (aggression and mutism) for 2 weeks, followed by difficulty in moving his lower limbs, and bowel and bladder incontinence. Neck rigidity, a positive Kernig's sign, bilateral mute plantar responses, and 0/5 power in bilateral lower limbs were noted on examinations. MRI of the brain was suggestive of tubercular meningitis and showed an infarct with hemorrhagic transformation in the relatively uncommon, right basifrontal lobe. Gene Xpert test done on cerebrospinal fluid confirmed the diagnosis.

Discussion: Tuberculous meningitis leading to infarct is a challenging diagnosis due to nonspecific symptoms and variable cerebrospinal fluid AFB staining results. Radiological imaging with MRI helps in suggesting the diagnosis and Gene Xpert confirms the diagnosis. Antitubercular therapy, steroids, physiotherapy, and supportive care are part of management.

Conclusion: This case highlights the importance of considering tubercular meningitis-related cerebral infarction despite initial negative CSF AFB stain. Radiological investigation may help in guiding the clinician towards a diagnosis of tuberculous meningitis with vasculitis.

Introduction: The first-line standard therapy for advanced HER2-positive gastric cancer is chemotherapy combined with trastuzumab and pembrolizumab, while pembrolizumab alone does not benefit as a monotherapy in patients with mismatch repair proficiency (pMMR). This case explores the therapeutic potential of adding pembrolizumab to patients who were resistant to trastuzumab, focusing on the synergistic effect of an immune checkmate inhibitor, combined with HER2 antibody.

Case presentation: An 87-year-old metastatic gastric cancer patient, whose medical history was significant for intolerance to chemotherapy and had a poor status of performance. Immunohistochemical staining was presented as HER2 (3+), pMMR, and PD-L1 was 4. Initially treated with trastuzumab monotherapy, the patient showed no response and experienced progressive disease. Subsequently, a combined regimen of trastuzumab and a half-dose of pembrolizumab was administered every 3 weeks. Remarkably, it led to a significant reduction in tumor size, achieving partial remission (PR) after two cycles. This response was sustained over 21 months, as evidenced by the latest CT scans.

Clinical discussion: The concurrent administration of trastuzumab and pembrolizumab has demonstrated synergistic antitumor activity, achieving clinical efficacy in cases where each agent alone proved ineffective. Preclinical studies illustrated that tumor regression induced by HER2 antibodies requires T cell involvement, and the combination of immune checkpoint inhibitors with trastuzumab augments HER2-specific T cell responses, promotes immune cell recruitment, and induces the expansion of peripheral memory T cells, which showed synergistic rationales for a combination of pembrolizumab and trastuzumab.

Conclusion: The observed synergy between pembrolizumab and trastuzumab highlights a promising treatment avenue that warrants further investigation.

Introduction: Digital panoramic radiographs (DPRs) are used in dental practice as the first diagnostic tool for the initial detection of head and neck regions soft-tissue calcifications. The aim of this study was to use a self-developed application (App) to evaluate the ability of dental students at different levels of training to examine known DPRs with different soft-tissue calcification.

Methods: A total of known 100 DPRs with (n=50) and without (n=50) calcification were independently evaluated by four groups: preclinical, first clinical and last clinical dental students, and dentists with less than or equal to 1 year of professional experience in the same time (15 min) and examination conditions. Unity software was used to develop the examination App, which allowed to mark areas with calcifications on the DPRs. The data were statistically analyzed between the groups (significance level: P<0.05) for every location, and the detection rate was calculated as a percentage of detected calcifications.

Results: Results revealed that the overall detection rate of calcifications in all groups was 29.17%. Dentists exhibited the highest detection rate (36.46%), followed by the last- (29.69%), first- (32.29%), and preclinical (15.10%) students.

Conclusion: These findings suggest that clinical experience plays a role in the correct detection of soft-tissue calcifications in DPRs. However, deficiencies in radiological training during dental education may contribute to diagnostic errors. As these can become life-threatening risks, the results highlight the need for early training in the dental curriculum to improve diagnostic performance and minimize possible diagnostic errors.

Introduction and importance: Achalasia, an uncommon esophageal motility disorder, presents therapeutic challenges, especially in refractory cases with a history of multiple surgeries. Here, we present a complex case illustrating the dilemmas and multidisciplinary approach required in managing such patients. This case underscores the relevance of newer techniques like robotic-assisted esophagectomy in refractory achalasia management.

Case presentation: A 53-year-old male with recurrent achalasia endured persistent dysphagia, reflux, and esophageal spasms despite undergoing Heller myotomies, fundoplications, and hiatal hernia repairs. Imaging revealed severe esophageal dilation and anatomical alterations post-surgeries. Opting for a robotic-assisted thoracoabdominal esophagectomy due to relentless symptoms, the patient faced technical hurdles due to adhesions and a dilated esophagus. Post-surgery, complications like thoracic duct injury, milky pleural effusion, atrial fibrillation, and limb ischemia arose, necessitating multidisciplinary intervention.

Clinical discussion: Managing refractory achalasia poses significant challenges, particularly in extensively operated patients. Despite aggressive surgeries, debilitating symptoms persisted, emphasizing the need for a multidisciplinary approach. Complications like thoracic duct injury and atrial fibrillation further complicate management, highlighting the intricacies of such cases. Careful consideration of surgical options and the potential of newer techniques like POEM are crucial in navigating such complexities.

Conclusion: Managing refractory achalasia, especially in patients with extensive surgical histories, requires a multidisciplinary approach and careful consideration of treatment options. This case underscores the evolving landscape of achalasia management and emphasizes the potential benefits of newer techniques like POEM in select cases.

Background: Hypertension is a prevalent non-communicable disease and unequivocally one of the most serious health threats of the twenty-first century. The prevention of both immediate and long-term consequences depends on ongoing therapeutic education.

Aims: To assess Tunisian hypertensive patients' knowledge of hypertension and then evaluate the impact of an educational program on knowledge among this population.

Methods: A randomized controlled trial was carried out among 639 hypertensive patients in Tunisia. The control group received only basic medical care, while the experimental group acquired additionally an educational program. The data collection tool was a questionnaire that included an information sheet and the Hypertension Knowledge Level Scale (HK-LS).

Results: Before to the implementation of the program, only 12.1% of the participants had a good level of knowledge about hypertension (12.8% for the experimental group, vs. 10.5% for the control group, P=0.57). Following the program's deployment, the rate of good level of knowledge became 63.6% for the experimental group vs. 11.4% for the control group, P<0.001). The results revealed that the experimental group showed a significant amelioration in the total score of the HK-LS: from 58.49 to 76.94%, P<0.0001. In contrast, no significant amelioration was noted in the control group. Concerning the six dimensions of the scale, the amelioration in the experimental group was observed in all dimensions, except the treatment dimension.

Conclusion: Overall, the findings indicated low levels of knowledge about hypertension. This kind of approach proved an effective improvement in disease-related knowledge and may be essential for hypertension management.