Cureus最新文献

Perioperative management of immune thrombocytopenic purpura (ITP) in cardiac surgery represents a rare yet formidable clinical challenge driven by immune-mediated platelet dysfunction, obligatory systemic anticoagulation, and the profound hemostatic derangements induced by cardiopulmonary bypass. We systematically synthesized the available evidence on perioperative strategies and outcomes in adults with ITP undergoing cardiac surgery in elective and urgent or emergent settings by reviewing PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane CENTRAL, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform from inception through August 26, 2025. Nineteen studies comprising approximately 74 patients, predominantly with severe thrombocytopenia, were identified, including three observational cohorts and sixteen case reports or series. Reported management approaches centered on rapid immunomodulation with intravenous immunoglobulin and/or corticosteroids, selective adjunctive platelet transfusion, antifibrinolytic therapy, thrombopoietin receptor agonists in selected cases, and carefully monitored cardiopulmonary bypass anticoagulation, most commonly using unfractionated heparin with activated clotting time guidance; bivalirudin was described in isolated reports. Across studies, perioperative bleeding occurred in approximately 32% of patients, platelet transfusion in 45%, reoperation for bleeding in 8%, thrombotic complications in 6%, and perioperative mortality in 7%, with consistently inferior outcomes observed in urgent and emergent procedures. Although the evidence base remains largely case-derived and heterogeneous, these data support a coherent multimodal perioperative strategy integrating rapid platelet-directed immunotherapy, patient blood management-guided hemostasis, antifibrinolytic use, and vigilant anticoagulation, while underscoring the urgent need for prospective, multicenter registries with harmonized outcome definitions to inform standardized, evidence-based perioperative pathways for this high-risk population.

Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common cause of paroxysmal supraventricular tachycardia in adults and frequently presents with sudden-onset palpitations and regular narrow-complex tachycardia. Although generally considered benign, recurrent symptomatic episodes often lead to repeated emergency department visits and reduced quality of life, warranting definitive therapy. We report the case of a 42-year-old woman who presented with several hours of palpitations and was found to have a regular narrow-complex tachycardia at approximately 200 beats per minute without visible P waves. Subtle pseudo r' deflections in lead V1 and pseudo S waves in the inferior leads were noted, consistent with typical slow-fast AVNRT. Vagal maneuvers were ineffective, and intravenous adenosine at a dose of 12 mg resulted in transient atrioventricular block followed by the prompt restoration of sinus rhythm. Post-conversion electrocardiography demonstrated normal atrioventricular conduction without evidence of ventricular preexcitation, and transthoracic echocardiography confirmed the absence of structural heart disease. The patient reported multiple similar episodes over the preceding months, frequently occurring around the onset of menstruation, suggesting a potential influence of hormonal fluctuations on arrhythmia susceptibility. Given the recurrent and symptomatic nature of the episodes, she was referred for electrophysiological study and catheter ablation, which is recommended as first-line definitive therapy for AVNRT. This case highlights the classic electrocardiographic features and adenosine sensitivity of AVNRT, supports early referral for curative ablation in recurrent cases, and draws attention to possible hormonal modulation as a trigger for supraventricular tachycardia in susceptible patients.

Nasolabial cysts are rare, nonodontogenic cysts of the anterior nasal floor and nasolabial fold. Bilateral presentation is uncommon and may mimic inferior turbinate hypertrophy, leading to misdiagnosis. A 41-year-old Qatari man presented with a five-year history of persistent nasal obstruction, headache, and nasal discharge. He had chronic sinonasal polyposis and a prolonged history of topical nasal decongestant use, with poor response to intranasal steroids. Two CT scans performed three years apart were initially reported as showing sinonasal polyposis; however, retrospective review revealed subtle, bilateral, well-circumscribed anterior cystic lesions inferior to the inferior turbinates that had been overlooked. During functional endoscopic sinus surgery, symmetric bilateral nasolabial cysts measuring 1.5-2.5 cm were identified and excised endoscopically. Histopathology confirmed respiratory epithelium-lined cysts. Postoperative recovery was favorable, with no recurrence at 4.5 months. Bilateral nasolabial cysts are rare and can clinically and radiologically mimic inferior turbinate hypertrophy, especially in patients with rhinitis or sinonasal polyposis. Careful review of the anterior nasal cavity on imaging can prevent misdiagnosis. Endoscopic excision is both diagnostic and curative.

Food safety is a key public health function, as the catering sector is a frequently cited source of outbreaks. This study evaluated the knowledge and attitudes of food business operators (FBOs) in Attica, Greece, regarding food hygiene. A cross-sectional study was carried out in 522 mass catering establishments located in Attica. Knowledge and attitudes were assessed using a 25-item questionnaire. Statistical analysis included the chi-square test and multiple logistic regression to identify factors associated with adequate knowledge and positive attitudes in the study population. Questions related to hand hygiene (98.9%, n=516) and pathogen identification (Salmonella: 98.1%, n=512) received high scores. However, significant gaps in knowledge were identified regarding the transmission of typhoid fever through food (27.6%, n=144) and the risks associated with raw beef (31%, n=162). Overall, 47.9% (n=250) of participants demonstrated "good knowledge" (score ≥ 18/25), while 52.1% (n=272) had insufficient knowledge. In terms of attitudes, 59.8% (n=312) showed a satisfactory level. Multivariate analysis revealed that good knowledge was significantly associated with larger company size (≥51 employees: OR=2.68, p=0.020), high educational level (Master's/Doctorate: OR=5.04, p=0.006), and familiarity with Hazard Analysis and Critical Control Points (HACCP)-based systems (OR=0.15 for those who were not familiar, p=0.002). In contrast, participants with the role of owner within the company (OR=0.38, p=0.018) and managers (OR=0.36, p=0.021) were less likely to have good knowledge compared to head chefs. Positive attitudes were strongly associated with previous experience in the food industry (OR=12.96, p=0.018) and official inspections in the last five years (OR=1.75, p=0.022). Although basic awareness of food hygiene issues is widespread, specific technical knowledge remains inadequate among half of all FBOs. Specific training programs, especially for personnel performing the roles of owner and manager, as well as consistent official controls, are important factors in strengthening food safety culture and protecting public health.

Delayed diagnosis in outpatient care is a major source of preventable patient harm. Unlike inpatient settings, outpatient diagnosis unfolds longitudinally across multiple encounters, increasing reliance on effective documentation and information continuity. Emerging evidence suggests that fragmented documentation may represent a hidden system-level driver of diagnostic error and delayed diagnosis. A PRISMA-compliant systematic review was conducted. PubMed, Scopus, and Google Scholar were searched for studies published within the last 10 years that examined documentation-related contributors to delayed diagnosis in outpatient care. Predefined inclusion and exclusion criteria were applied, and 13 eligible studies were qualitatively synthesized. Across diverse outpatient clinical settings, documentation fragmentation, incomplete longitudinal information synthesis, and failures in diagnostic follow-up were consistently associated with delayed diagnosis. These system-level factors frequently obscured evolving clinical patterns despite appropriate evaluation during individual encounters. Delayed diagnosis in outpatient care is commonly driven by documentation and information continuity failures rather than isolated clinician error. Recognizing documentation fragmentation as a hidden driver of diagnostic error highlights the need for interventions that support longitudinal synthesis and diagnostic follow-up to improve diagnostic timeliness and patient safety.

De Winter's T-wave pattern is a high-risk ST-elevation myocardial infarction (STEMI) equivalent signifying acute proximal left anterior descending (LAD) occlusion, characterized by precordial upsloping ST-depression and tall, peaked T-waves. We present a 69-year-old man with chest pain whose electrocardiogram (ECG) showed a classic De Winter's pattern. He rapidly developed acute respiratory failure, and his high-sensitivity troponin I peaked at >27,027 pg/mL. Urgent angiography identified severe in-stent restenosis (ISR) in the proximal-mid LAD as the culprit lesion. This was successfully treated with a drug-coating balloon. This case highlights that De Winter's pattern is a critical finding that must be immediately recognized to prevent delays in emergent reperfusion therapy.

Musculoskeletal disorders (MSDs) continue to be problematic globally. Numerous guideline-based management approaches have been advocated for MSDs, but long-term recovery is elusive. Thus, innovations should be explored to help mitigate the adverse consequences of these disorders. The objective of this paper was to provide a narrative literature review and critical reflection of MSDs and healthy buildings in the hotel industry. Searches of the peer-reviewed medical literature (via PubMed) and hospitality literature (via SCImago) were conducted for MSDs, healthy buildings, and hotels. The available evidence from the searches was synthesized and critically examined, and research and implementation recommendations were proposed. Key findings include the available evidence displays a substantial risk of bias, and numerous gaps in knowledge and research exist at the aggregate interface of MSDs, healthy buildings, and hotels; hotel workers appear to be particularly vulnerable to MSDs, yet interventions are needed to address MSDs in this occupational setting; and interventions delivered in luxury resort hotels may be useful for guests with MSDs. This paper is the first known attempt to critically examine the new field intersecting MSDs, healthy buildings, and the hotel industry. In consideration of the limited available evidence, it offers recommendations for medical and hotel stakeholders to advance the field through scientifically sound research and implementation efforts. If positive findings are observed in future initiatives, a new healthcare value proposition is created, with the desired outcome of mitigating MSDs and improving the health, wellness, quality of life, and experiential takeaway of hotel employees and guests.

Whipple's disease, associated with chronic infection by Tropheryma whipplei, is an uncommon multisystem condition. It is frequently underdiagnosed because of its nonspecific and variable symptoms. Early recognition is important, as delays in diagnosis can result in multisystem involvement and potentially serious outcomes. A 74-year-old man experienced chronic diarrhea, weight loss, and fatigue over three months. Initial investigations, including imaging and endoscopy, did not reveal any abnormalities. As symptoms persisted, a repeat endoscopy was performed after one month, showing multiple whitish elevated plaques in the duodenum. Histology identified periodic acid-Schiff and CD68-positive foamy macrophages with negative Ziehl-Neelsen staining, confirming Whipple's disease. The patient was treated with ceftriaxone for two weeks, followed by a year of doxycycline and hydroxychloroquine, leading to rapid clinical remission. Due to ongoing histological changes, antibiotic therapy was continued for another year with trimethoprim-sulfamethoxazole and an additional six months of doxycycline. The patient remains asymptomatic on follow-up. Whipple's disease has clinical features that overlap with other chronic gastrointestinal and rheumatologic disorders, often leading to diagnostic challenges. This case demonstrates the importance of maintaining a high index of suspicion and performing repeat endoscopic evaluation if symptoms continue despite unremarkable initial findings. Timely administration of suitable antibiotic therapy is associated with favorable clinical outcomes, even in cases with prolonged or atypical presentations.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency, the most common erythrocyte enzymatic disorder, predisposes patients to oxidative stress-induced acute hemolysis. Affected patients are at risk of developing hemolysis in the setting of triggers such as certain drugs, infections, or foods (fava beans). Although some drugs like antimalarials (primaquine, tafenoquine), sulfonamides, and dapsone are well-known triggers of hemolysis, reports of this adverse effect are rare with standard bismuth-based quadruple therapy for Helicobacter pylori. In this report, we present a 65-year-old male who developed profound anemia (hemoglobin 5.8 g/dL, drop of 4.4 points from baseline) within hours of initiating metronidazole- and tetracycline-containing quadruple therapy. Laboratory evaluation revealed reduced G6PD enzyme activity (3.8 U/g; normal 9.9-16.6 U/g), confirming acute hemolytic anemia secondary to G6PD deficiency. Notably, the patient was a Jehovah's Witness and declined all blood products, requiring atypical management. Quadruple therapy was discontinued, and the patient was managed with intravenous fluids, iron supplementation, and erythropoietin (EPO) therapy, resulting in gradual hematologic recovery. Regarding H. pylori treatment, the patient was initiated on triple therapy (clarithromycin, amoxicillin, proton pump inhibitor), without recurrence of hemolysis. This case highlights the rarity of G6PD deficiency as an etiology of unexplained hemolysis during initiation of H. pylori eradication therapy and underscores the importance of unique management strategies in the setting of blood transfusion refusal. Clinicians should maintain a high suspicion for G6PD deficiency in high-risk populations and exercise caution when prescribing oxidative regimens for H. pylori in these patients.