Cureus最新文献

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.

Objective: The objective of this study was to compare the efficacy and safety of conventional Dresden, transepithelial (epithelium-on), and accelerated corneal collagen cross-linking (CXL) protocols for the treatment of progressive keratoconus.

Methods: A systematic review of 84 studies was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. Study screening and data extraction were supported by AI-assisted tools with full manual verification. Extracted outcomes included keratometric stabilization, visual acuity, endothelial cell density (ECD), complications, corneal thickness changes, and biomechanical or surrogate markers.

Results: Conventional epithelium-off (epi-off) CXL demonstrated the most consistent long-term keratometric stabilization and visual acuity preservation, with mean Kmax flattening of approximately 1.0-2.3 D at 12-36 months and durability extending up to five years in long-term datasets, alongside corrected distance visual acuity improvements of approximately 0.10-0.23 logMAR. Accelerated CXL protocols achieved comparable short-term outcomes (approximately 0.8-1.5 D Kmax flattening at 6-12 months) but exhibited greater variability in durability at longer follow-up. Standard transepithelial approaches generally produced smaller effects, although enhanced epi-on protocols incorporating oxygen supplementation or modified riboflavin delivery achieved keratometric stabilization approaching epi-off outcomes in selected studies (approximately 1.5-1.7 D flattening). Across all protocols, endothelial cell density was preserved, with changes typically within physiologic variability (<5%). Transient corneal haze occurred more frequently following conventional epi-off CXL (approximately 40-70%) than accelerated protocols (approximately 20-47%), while serious complications, including infectious keratitis, remained rare (approximately 0.001-0.5%).

Conclusion: Conventional epi-off CXL has the strongest evidence for durable keratometric stabilization and visual acuity preservation in progressive keratoconus. Accelerated protocols offer similar short-term efficacy with improved treatment efficiency, while enhanced transepithelial approaches may be appropriate for selected patients prioritizing reduced invasiveness and postoperative discomfort, with potential trade-offs in long-term durability.

Septoplasty is a commonly performed procedure with known complications including infection, bleeding, ocular injury, septal abscess, septal perforation, and long-term sequelae; however, middle turbinate involvement is rare and sparsely described in the literature. We report the case of a 20-year-old woman with no significant medical history who underwent septoplasty with submucosal diathermy of the inferior turbinates at a private facility and subsequently presented with persistent nasal obstruction. Computed tomography demonstrated bilaterally hanging middle turbinates. The patient was managed with revision septoplasty, bilateral excision of the hanging middle turbinates with hemostasis, and repeat submucosal diathermy of the inferior turbinates, resulting in an uncomplicated postoperative course and complete symptomatic improvement. This case underscores the importance of preoperative computed tomography in revision septoplasty to delineate nasal anatomy and guide appropriate surgical management.

Facial hyperpigmentation is a common clinical manifestation of various dermatologic conditions and may arise from multiple endogenous and exogenous factors. Its therapeutic management remains a clinical challenge due to its persistent nature and the limited long-term effectiveness of conventional treatment strategies. In recent years, emerging regenerative approaches, such as the use of exosomes and the combination of non-cross-linked hyaluronic acid with succinic acid, have been described in the international literature based on their biological, anti-inflammatory, and tissue microenvironment modulatory properties. In this case report, we present two patients with facial hyperpigmentation of similar etiology who were treated using a combined protocol based on plant-derived exosomes and non-cross-linked hyaluronic acid plus succinic acid. We describe the treatment protocol, follow-up, and the final clinical outcomes observed.

[This corrects the article DOI: 10.7759/cureus.93323.].

A gossypiboma (GPB), also referred to as a textiloma (TXT), is a mass formed as a result of the body's inflammatory and granulomatous response to retained surgical textile material (RSTM), most commonly gauze or mesh fibers. Its reported incidence ranges from 1 in 1,000 to 1 in 10,000 surgical procedures, although the true frequency is believed to be significantly higher due to underreporting related to medicolegal concerns. This entity is clinically important because it may mimic more common postoperative complications such as abscess (ABS), seroma (SER), or mesh infection (MI), frequently leading to diagnostic delay and unnecessary morbidity. The purpose of this report is to present an uncommon instance of mesh-associated textiloma (MAT) following ventral hernia repair with polypropylene mesh (PPM) and to highlight its radiologic, histopathologic, and clinical features that allow differentiation from other postoperative collections. A 39-year-old female patient with a history of ventral hernia underwent surgical repair with mesh implantation. Postoperatively, she developed persistent umbilical discharge and, three months later, progressive abdominal fluid leakage. Contrast-enhanced computed tomography (CECT) revealed a well-defined hypodense intraperitoneal collection measuring 80 × 64 × 40 mm with a fistulous tract (FT) extending to the abdominal wall, without evidence of systemic inflammatory dissemination. These features, particularly the encapsulated nature of the collection and the organized fistulization pattern, were highly suggestive of a chronic foreign-body reaction (FBR) rather than an acute ABS, which typically presents with diffuse inflammatory infiltration, or MI, which is associated with diffuse mesh thickening and surrounding cellulitis. A second surgical exploration was performed, and the resected specimen underwent histopathological examination (HPE), which demonstrated foreign-body granulomatous inflammation (FBGI) with multinucleated giant cells (MGC) surrounding textile fibers embedded in fibrous tissue, consistent with MAT, and without evidence of dysplasia or malignancy. Following complete excision and aponeurotic closure, the patient recovered uneventfully, with no recurrence during follow-up. This case reinforces that MAT should be included in the differential diagnosis of persistent postoperative collections after mesh-based hernia repair and demonstrates that characteristic CECT findings combined with timely surgical management are essential to reduce morbidity and prevent long-term complications.