Cureus最新文献

Kostmann syndrome, also known as severe congenital neutropenia, is a congenital disorder characterized by genetic mutations that prevent the progression of myeloid differentiation in the bone marrow. Most cases are associated with specific genetic mutations, including those in HAX1 and ELANE. Treatment with antibiotics and granulocyte colony-stimulating factor (G-CSF) is primarily prophylactic. We report a pediatric case of severe congenital neutropenia present since birth, with negative whole-exome sequencing (WES), complicated by multiple hospital admissions for recurrent infections and subsequent progression to myelodysplastic syndrome with excess blasts associated with monosomy 7, for which the patient ultimately underwent hematopoietic stem cell transplantation (HSCT). This case highlights that many patients with Kostmann syndrome can present with negative genetic testing and draws attention to the importance of surveillance for malignant transformation.

Penetrating foot injuries are associated with a significant risk of retained foreign bodies, infection, and damage to osseous or soft tissue structures. Imaging is routinely recommended to assess the depth of penetration and exclude bone involvement. We report a case of a penetrating foot injury caused by a metallic wood screw that penetrated the sole of the shoe and the plantar aspect of the foot. Clinical assessment by an orthopedic specialist and radiographic imaging revealed no evidence of osseous injury. The foreign body was removed under local anesthesia with intravenous analgesia using a controlled rotational technique, followed by empirical antibiotic therapy and tetanus prophylaxis. Post-procedural imaging confirmed complete removal of the foreign body. No immediate complications were observed in the emergency department, and the patient was discharged with an urgent referral for outpatient orthopedic follow-up. This case highlights the importance of combining careful clinical examination with appropriate imaging in the emergency department management of penetrating foot injuries to guide safe foreign body removal and reduce the risk of complications.

[This retracts the article on p. e49461 in vol. 15, PMID: 38152804.].

Von Willebrand disease (VWD) is the most common inherited bleeding disorder and predisposes patients to hemorrhagic complications following trauma or invasive procedures. Chiropractic spinal manipulation is widely used for musculoskeletal pain; however, serious complications have been reported, particularly in patients with underlying coagulopathies. Iliopsoas hematoma with secondary femoral neuropathy is an uncommon but potentially disabling condition. We present a clinical case highlighting this rare complication following chiropractic manipulation in a patient with VWD and review the relevant literature. We describe the clinical course and follow-up of a 32-year-old female patient with known VWD who developed acute neurological deficits after chiropractic manipulation. Imaging findings were analyzed using radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Hematoma volume was calculated using the ABC/2 formula, which has been well validated and shows a high correlation with volumes calculated using planimetric techniques. An extensive review of the literature regarding iliopsoas hematomas, chiropractic complications, and management strategies in coagulopathic patients was performed. After chiropractic manipulation, the patient developed severe lumbar and inguinal pain, followed by progressive weakness and sensory impairment of the left lower limb. Imaging revealed a large left iliopsoas hematoma measuring approximately 896 cc, causing femoral nerve compression. Management included coagulation factor replacement, pain control, and interventional radiology-guided drainage, resulting in significant hematoma reduction and neurological improvement. At the six-month follow-up, residual neuropathy and muscle atrophy persisted, although functional recovery was evident. Patients with VWD are at high risk for severe hemorrhagic complications even after seemingly minor manipulative therapies. Chiropractic spinal manipulation may precipitate life-threatening or disabling bleeding events in this population. Early recognition, appropriate imaging, correction of the coagulopathy, and multidisciplinary management are crucial to optimize outcomes. This case highlights the importance of patient counseling, risk stratification, and caution when considering alternative therapies in individuals with inherited bleeding disorders.

Acute mesenteric ischemia is a highly lethal vascular emergency most often caused by arterial embolism. Paradoxical embolism through a patent foramen ovale (PFO) is a well-recognized cause of cryptogenic stroke, but it is a rare and underrecognized cause of mesenteric arterial occlusion. A 68-year-old woman with a history of paradoxical embolism, chronic deep vein thrombosis, and a patent foramen ovale presented with sudden, severe abdominal pain and vomiting. She had previously undergone brachial artery embolectomy and had been maintained on long-term apixaban, which she later discontinued after being lost to follow-up. Computed tomography angiography revealed abrupt occlusion of the superior mesenteric artery and a newly identified left renal mass suspicious for malignancy. Telemetry showed no atrial fibrillation, blood cultures were negative, and no intracardiac thrombus was identified. Lower extremity Doppler ultrasound demonstrated chronic but not acute deep vein thrombosis. In the absence of alternative arterial embolic sources and given the temporal relationship to anticoagulation interruption, presumed paradoxical embolism was considered the most plausible mechanism. Despite emergent surgery, the patient developed extensive bowel necrosis and died after transition to comfort-focused care. This case adds to the limited literature on extracerebral paradoxical embolism and highlights the importance of sustained anticoagulation and longitudinal follow-up in patients with PFO and venous thromboembolism, particularly when additional hypercoagulable conditions are suspected.

Medical billing and coding remain among the least understood aspects of daily practice for many physicians, including radiation oncologists. Legacy linear accelerator (LINAC)-based radiation treatment delivery codes have remained largely unchanged over the past decade, despite substantial advances in image guidance, intensity-modulated techniques, and motion management. This has drawn the attention of those empowered to insist upon updates to the coding and the amount of time involved in individual therapy administrations. In 2023, the American Medical Association's (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) Relativity Assessment Workgroup (RAW) mandated re-evaluation of these codes and requested that radiation oncology (RO) specialty societies provide contemporary definitions, times, and resource information for treatment delivery services. The American College of Radiation Oncology (ACRO) and the American Society for Radiation Oncology (ASTRO) jointly developed a new complexity-based code set for megavoltage external beam radiation therapy (EBRT). The RUC subsequently surveyed physicians and recommended relative value units (RVUs). In October 2025, CMS finalized the use of this new code set, effective January 1, 2026. Written by ACRO members involved in the code development and valuation processes, this report places the 2026 code set in historical context and provides practical, physician-focused guidance on applying the new delivery Current Procedural Terminology® (CPT®) codes 77402, 77407, and 77412 (as well as 77387 for professional components of image guidance) in everyday practice. We also summarize the AMA and CMS process, define the complexity framework, and provide concrete clinical examples for appropriate code selection with an emphasis on image guidance, motion management, multiple isocenters, and mixed photon-electron techniques.

Background: Adequate public awareness of anesthesia practices and the role of anesthesiologists is essential for informed consent, patient confidence, and perioperative safety. Despite advances in anesthetic care, gaps in patient knowledge and misconceptions remain common.

Methodology: This cross-sectional study was conducted among adults aged 18 years or older with a prior history of elective anesthesia. Data were collected using a structured, self-administered online questionnaire distributed via Google Forms. The survey assessed demographic characteristics, prior anesthesia exposure, knowledge of anesthesia types, perceptions of anesthesiologists' roles, fears, communication quality, trust, and satisfaction.

Results: A total of 298 participants were included, of whom 155 (52.0%) were female. General anesthesia was the most frequently reported type (190, 63.8%). Awareness of general anesthesia (272, 91.3%) and local anesthesia (263, 88.3%) was high, but knowledge of regional techniques was limited, including spinal anesthesia (47, 15.8%), epidural anesthesia (39, 13.1%), and peripheral nerve blocks (45, 15.1%). Familiarity with the anesthesiologist's role was reported by 239 participants (80.2%), and 212 (71.1%) correctly identified that the anesthesiologist remains in the operating room throughout surgery. The most common anesthesia-related fear was experiencing pain during the procedure (138, 46.3%). Communication outcomes were favorable, with 106 participants (35.6%) receiving complete explanations and 268 (89.9%) reporting either being satisfied or very satisfied. Female participants demonstrated significantly higher awareness scores than males (P < 0.001). Being informed about anesthesia consent (208, 69.8%) and preferring to meet the anesthesiologist preoperatively (208, 69.8%) were associated with significantly higher awareness and perception scores (both P < 0.001). Regression analysis identified preference to meet the anesthesiologist as the strongest positive predictor of both awareness and perception while receiving regional anesthesia negatively predicted perception scores.

Conclusions: Although patient trust and satisfaction with anesthesiologists were high, significant gaps remained in knowledge of regional anesthesia. Preoperative education regarding anesthesia can enhance public awareness and perceptions of anesthesia care.

Acute pulmonary embolism remains a major cause of cardiovascular morbidity and mortality, with presentations ranging from stable exertional breathlessness to rapidly fatal hemodynamic collapse. In patients who fall in the intermediate high-risk and high-risk categories, prompt restoration of pulmonary perfusion is crucial to reduce right ventricular dysfunction and prevent clinical deterioration. Systemic thrombolysis can achieve rapid reperfusion but carries a substantial risk of major bleeding and intracranial hemorrhage, particularly in older adults or those with comorbidities. This therapeutic limitation has driven increasing interest in mechanical thrombectomy, a catheter-based intervention that offers rapid clot debulking while minimizing hemorrhagic risk. We report a case of high-risk acute pulmonary embolism, which led to hemodynamic compromise and cardiopulmonary collapse, in which systemic thrombolysis failed to achieve adequate reperfusion and correction of acute hypoxia. The patient was successfully treated with catheter-directed aspiration thrombectomy. This highlights the need for consideration of mechanical thrombectomy as a fast and efficient treatment for selected patients who fall into intermediate and high-risk categories, especially as the technology and experience develop.

Fluoride varnish (FV) and conventional glass ionomer cement (GIC) sealants are widely used strategies for the prevention of occlusal caries in newly erupted permanent molars. However, their comparative effectiveness remains unclear. We aimed to evaluate the preventive efficacy of FV versus GIC sealants in pediatric populations. PubMed, Web of Science (WoS), Scopus, and Cochrane CENTRAL were systematically searched through January 2026 to identify randomized controlled trials (RCTs) comparing FV and GIC sealants. The primary outcome was the incidence of occlusal caries involving dentin ( International Caries Detection and Assessment System (ICDAS) ≥4). Secondary outcomes included caries development on adjacent second molars, plaque accumulation measured by the Visible Plaque Index (VPI), and patient-reported levels of anxiety and pain during application. Standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were computed using random-effects models. Five RCTs including 1,626 patients and 5,060 teeth met the inclusion criteria. The incidence of occlusal caries and second molar caries, as well as anxiety and pain levels, was comparable between the FV and GIC groups. Patients receiving FV had modestly higher plaque scores compared to those receiving GIC (SMD = 0.11, 95% CI: 0.01 to 0.21, p = 0.03). Both FV and GIC sealants provide effective protection against occlusal caries in newly erupted permanent molars, with FV demonstrating a slight disadvantage in plaque accumulation. These findings suggest that clinicians can select either modality based on logistical considerations, patient preference, and resource availability, without compromising clinical effectiveness.

Intramuscular hematomas have varied etiologies, and accurate diagnosis requires a detailed medical history in combination with laboratory and imaging evaluations. We report a case of a giant thigh hematoma that enlarged over a chronic course and was ultimately attributed to a post-traumatic arteriovenous fistula (AVF). An 18-year-old man was diagnosed with an intramuscular hematoma after blunt trauma to the thigh, which gradually enlarged. He later presented with sudden worsening of thigh swelling and pain and was transported to the emergency department. Contrast-enhanced CT showed extravasation in the proximal thigh together with dilation of the internal iliac and inferior gluteal arteries, raising suspicion of a vascular malformation. Angiography performed the same day confirmed active bleeding from an AVF at the level of the inferior gluteal artery. Because surgical hemostasis was deemed difficult, transcatheter arterial embolization (TAE) was performed, and achieved hemostasis. Three months later, with no recurrence of abnormal vessels, the giant hematoma was excised. The patient has remained free of recurrence for five years. When encountering a large intramuscular hematoma, clinicians should consider a high-flow vascular malformation. Identification of signal voids on MRI and extravasation on contrast-enhanced CT is critical for early diagnosis. For active bleeding due to high-flow lesions, arterial embolization is an effective therapeutic option.