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MultiCaRe_Reasoning0 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 53.0
Sex: Female
Title: Littoral cell angioma mimicking hepatic tumor
Keywords: vascular tumor; diagnostic imaging; liver; pathology; spleen;
Abstract:
Littoral cell angioma is a rare vascular tumor of the spleen that was described by Falk et al. in 1991. Because of the limited number, untypical imaging manifestations, and lack of knowledge on this tumor type, these tumors are often misdiagnosed. In most cases, the tumor presents with multiple small hypoattenuating nodules in the spleen with delayed enhancement. However, solitary littoral cell angiomas have not been well described. We present the CT features of an unusual littoral cell angioma mimicking hepatic tumor.
Image Caption and Description:
Image caption: (a) Axial unenhanced CT image demonstrates an ill-marginated solitary mass that fills the left abdominal quadrant. (b, c) The mass enhanced gradually and heterogeneously during the arterial and portal phase. (d) At delay phase the mass was still hypodense relative to the spleen. (e) On the coronal image of portal phase, the mass was located between the left lobe of the liver and the spleen, and it appeared closely related to both organs
Image description: Axial unenhanced CT scan (Fig. 1a) confirmed an ill-defined heterogeneous mass 9.1 cm in diameter that filled the left abdominal quadrant, located between the left lobe of the liver and the spleen.
After intravenous contrast medium injection the mass enhanced gradually and heterogeneously (Fig. 1b-e), but was still hypodense relative to the spleen.
Image caption: (a) Variably sized vascular channels lined with flat and tall endothelial cells (HE, x 100). The endothelial lining cells of these vessels were positive for CD31 (b) ( x 100) and CD68 (c) ( x 200)
Image description: Histologic examination (Fig. 2) revealed that the lesion was composed of variably sized vascular channels lined with flat and tall endothelial cells, with papillary fronds extending into the vascular channels.
Case Report:
A 53-year-old woman presented with a 10-year history of intermittent abdominal pain, swelling and continuous vomiting. The patient denied presence of fever, nausea, and weight loss. There were no significant findings at physical examination. An abdominal ultrasound exam revealed a 10.4 x 10.0 cm mass of heterogeneous echogenicity in the left upper abdomen. Axial unenhanced CT scan (Fig. 1a) confirmed an ill-defined heterogeneous mass 9.1 cm in diameter that filled the left abdominal quadrant, located between the left lobe of the liver and the spleen. The CT attenuation of the mass was around 26-53 HU on non-enhanced scan. After intravenous contrast medium injection the mass enhanced gradually and heterogeneously (Fig. 1b-e), but was still hypodense relative to the spleen. There was no accompanying lymphadenopathy or evidence of malignant process elsewhere in the abdomen. Because the origin of the mass was unknown and a primary malignancy could not be excluded, the patient underwent an explorative laparotomy. During the operation, a well-encapsulated mass was found under the left hepatic lobe and the pedicle arising from the spleen. Resection of the mass and the spleen was performed.
Gross examination of the spleen showed splenomegaly (580 g, 15 x 10 x 9 cm) with an ill-defined brownish nodule (5 x 8 x 8 cm). Histologic examination (Fig. 2) revealed that the lesion was composed of variably sized vascular channels lined with flat and tall endothelial cells, with papillary fronds extending into the vascular channels. No atypical cells or mitosis were present. The endothelial lining cells of the vascular channels were positive for CD31 and CD68, factor VIII and negative for CD34, CD21, and CD8. These findings were considered diagnostic of benign splenic littoral cell angioma.
OUTPUT:
| PMC3738355 |
MultiCaRe_Reasoning1 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 69.0
Sex: Female
Title: Central retinal artery occlusion following laser treatment for ocular ischemic aortic arch syndrome
Keywords: mri; aortic arch; carotid artery stenosis; carotid duplex ultrasound; ocular ischemic syndrome; panretinal laser; retrobulbar block;
Abstract:
Objective:
Ocular ischemic syndrome is a rare blinding condition generally caused by disease of the carotid artery. We describe a 69-year-old female with a 50 pack-year smoking history with aortic arch syndrome causing bilateral ocular ischemic syndrome.
Methods:
The patient presented with progressive visual loss and temple pain. Slit lamp biomicroscopy revealed bilateral iris neovascularization. This finding prompted a cardiovascular work up. Panretinal photocoagulation with retrobulbar block was performed in the right eye.
Results:
A temporal artery biopsy was negative. The carotid duplex ultrasound showed only a 1-39% stenosis. MRA revealed a more proximal occlusion of the aortic branch for which she underwent subclavian carotid bypass surgery. At the one month follow up, the right eye suffered profound vision loss secondary to a central retinal artery occlusion.
Conclusion:
Ocular neovascularization may be one of the clinical manifestations of aortic arch syndrome. This case also illustrates the limitations of relying solely on carotid duplex ultrasound testing. We caution against overly aggressive panretinal photocoagulation utilizing retrobulbar anesthesia.
Image Caption and Description:
Image caption: Slit lamp biomicroscopy of the anterior segment of the left eye shows marginal (arrow) and peripheral (arrowheads) circumferential neovascularization of the iris.
Image description: Slit lamp biomicroscopy showed iris neovascularization of both eyes (Figure 1 (Fig. 1)).
Image caption: Optical coherence tomography of the right eye (A) and the left eye (B) without evidence of macular edema
Image description: Optical coherence tomography showed no evidence of macular edema (Figure 2 (Fig. 2)).
Image caption: Fluorescein angiogram showing significantly delayed arterial filling with 60 seconds in the right eye (A) and 52 seconds in the left eye (B) and poor peripheral perfusion. Arteries are attenuated and veins are dilated and non-tortuous in both eyes. The late film (C) shows mild capillary leakage in the right eye at 6 minutes but no macular edema or neovascularization.
Image description: Fluorescein angiography exhibited delayed arterial filling and poor peripheral perfusion (Figure 3 (Fig. 3)).
Image caption: MRA extracranial showing severe narrowing of the origin of the right brachiocephalic artery (yellow arrow) and complete occlusion of the left common carotid artery with distal reconstitution of flow near the bifurcation (red arrow).
Image description: MRA Extracranial showed proximal occlusion of aortic arch branches (Figure 4 (Fig. 4)).
Case Report:
A 69-year-old Caucasian female with coronary artery disease, hyperlipidemia, bilateral cataract extraction three years prior, and a fifty pack-year smoking history presented to the clinic with chronic, progressive vision loss greater in the right eye, bilateral photophobia and flashes, and right eye and temple pain. Best corrected visual acuity was 20/50 in both eyes. Pupils were equal and without afferent pupillary defect (APD). Intraocular pressure was 12 mmHg and 10 mmHg in the right and left eyes, respectively. Confrontation visual fields revealed an inferonasal depression in the right eye. Slit lamp biomicroscopy showed iris neovascularization of both eyes (Figure 1 (Fig. 1)). Dilated fundus examination showed unremarkable optic nerves, attenuated arteries, and dilated, non-tortuous veins in both eyes with few drusen in the right macula and very few hemorrhages. Optical coherence tomography showed no evidence of macular edema (Figure 2 (Fig. 2)).
Fluorescein angiography exhibited delayed arterial filling and poor peripheral perfusion (Figure 3 (Fig. 3)). Right temporal artery biopsy was negative for giant cell arteritis. We ruled out hyperviscosity syndromes, blood dyscrasia, diabetes, Takayasu, collagen vascular disease, thyroid orbitopathy and various infectious causes of retinal ischemia and aortitis. CBC, SPEP, HbA1c, ESR, CRP, FTA-ABS, and hypercoagulation panel were unremarkable. Carotid duplex ultrasound indicated only mild carotid stenosis (1-39%) bilaterally. At the time of initial presentation, the patient was taking Lipitor, Aspirin 81 mg, Relafen, Klonopin, Zoloft, and Nexium.
The patient received pan-retinal photocoagulation (PRP) in the right eye. Due to low tolerance, a retrobulbar block without epinephrine was administered to the right eye prior to the second PRP ten days later at which time 3,625 spots with a duration of 20 milliseconds of 500 mW were delivered using the indirect laser ophthalmoscope. Eighteen days after this laser session visual acuity had dropped significantly in the right eye to count fingers at 3' with APD and attenuated posterior vasculature consistent with central retinal artery occlusion. MRA Extracranial showed proximal occlusion of aortic arch branches (Figure 4 (Fig. 4)). Due to concern for diminished blood supply from the aortic arch, the patient received a left subclavian artery to right common carotid artery bypass graft. One month after surgery, neovascular glaucoma developed in the right eye with intraocular pressure of 34 mmHg and 22 mmHg in the left eye. Pressures remained stable on Combigan twice daily. We treated the left eye with short sessions of laser for a total of 2,200 burns (0.05-0.07 sec, 300 micron) using the Laser indirect system for one session and the Varia multicolor slit-lamp system for the remaining 5 sessions. Six months after the bypass surgery, she maintained a visual acuity of 20/50 in the left eye and intraocular pressure was 18 mmHg.
OUTPUT:
| PMC5015624 |
MultiCaRe_Reasoning2 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 60.0
Sex: Male
Title: Promising Combination Therapy with Bevacizumab and Erlotinib in an EGFR-Mutated NSCLC Patient with MET Amplification Who Showed Intrinsic Resistance to Initial EGFR-TKI Therapy
Keywords: bevacizumab; egfr mutation; erlotinib; lung cancer; met amplification;
Abstract:
In lung cancer, several potential mechanisms of intrinsic and acquired resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have been explored, including mesenchymal-epithelial transition factor (MET) signaling pathway activation. On the other hand, vascular endothelial growth factor (VEGF) production of EGFR-mutated lung cancer cells is stimulated by predominantly activated MET signaling pathway. Therefore, the inhibition of VEGF axis as the downstream target of MET signaling pathway seems promising. Here, for the first time, we report the potential efficacy of combination therapy with bevacizumab and erlotinib in an EGFR-mutated NSCLC patient with MET amplification who showed intrinsic resistance to initial EGFR-TKI therapy. The patient was a 60-year-old male smoker, showing performance status (PS) 2, who presented with stage IV lung adenocarcinoma (cT4N2M1a) harboring the EGFR exon 19 deletion mutation. He was started on gefitinib at 250 mg/day. However, by 28 days, his symptoms further deteriorated along with the increased tumor size, resulting in PS 3. Then, repeat biopsy was performed, showing the positive MET amplification and the preserved EGFR exon 19 deletion mutation. Therefore, on the basis of the potential efficacy for activated MET signaling pathway as well as the confirmed safety by the known phase II trial for EGFR-mutated patients, the patient was started on combination therapy with bevacizumab at 15 mg/kg every 3 weeks plus erlotinib at 150 mg/day. By 21 days, his symptoms gradually improved along with the decreased tumor size, resulting in better PS with no severe toxicities.
Image Caption and Description:
Image caption: Chest X-ray and chest CT images before initial EGFR-TKI treatment. (a) Chest X-ray image showed a right hilar mass followed by lymphangitic carcinomatosis in the right lower lung field. (b) Chest CT image showed a large lung mass, extending to posterior chest wall and vertebral body, in the right lower lung as well as multiple lymphadenopathy and right pleural effusion.
Image description: In the imaging test of full body, chest X-ray and chest CT revealed a large lung mass, extending to posterior chest wall and vertebral body, surrounded by lymphangitic carcinomatosis in the right lower lung as well as multiple lymphadenopathy and right pleural effusion (Fig. 1a, b).
Image caption: Chest X-ray and chest CT images after 28 days of gefitinib therapy. (a) Chest X-ray image showed the increased right hilar mass and the worsened lymphangitic carcinomatosis. (b) Chest CT image showed interval progression of the lung mass and the lymphadenopathy.
Image description: However, by 28 days after the start of gefitinib therapy, his symptoms further deteriorated along with the increased tumor size, resulting in PS 3 (Fig. 2a, b).
Image caption: Chest X-ray and chest CT images after 21 days of combination therapy with bevacizumab and erlotinib. (a) Chest X-ray image showed the decreased right hilar mass and the improved lymphangitic carcinomatosis. (b) Chest CT image showed interval response of the lung mass and the lymphadenopathy. Especially, cavitation of the lung mass as bevacizumab-specific response was observed.
Image description: By 21 days after the start of this combination therapy, his symptoms gradually improved along with the decreased tumor size, resulting in better PS with no severe toxicities (Fig. 3a, b).
Case Report:
A 60-year-old male smoker presented with persistent cough and severe right-back pain. His performance status (PS) was 2 by the pain despite opioid use in palliative care. In the imaging test of full body, chest X-ray and chest CT revealed a large lung mass, extending to posterior chest wall and vertebral body, surrounded by lymphangitic carcinomatosis in the right lower lung as well as multiple lymphadenopathy and right pleural effusion (Fig. 1a, b). Bronchoscopic biopsy of the tumor lead to a diagnosis of primary lung adenocarcinoma (cT4N2M1a, stage IV) harboring the EGFR exon 19 deletion mutation. No other molecular analysis was performed. The patient was started on gefitinib at 250 mg/day for the treatment of lung adenocarcinoma. However, by 28 days after the start of gefitinib therapy, his symptoms further deteriorated along with the increased tumor size, resulting in PS 3 (Fig. 2a, b).
Then, repeat biopsy was performed from the lung tumor. First, in addition to the preserved EGFR exon 19 deletion mutation, EGFR T790M mutation was analyzed, resulting in negative status. Second, as a possible molecular alteration next to EGFR T790M mutation, fluorescence in situ hybridization (FISH) analysis for MET amplification was analyzed, resulting in positive status (mean MET per cell = 6.7, MET/CEP7 [centromeric enumeration probe for chromosome 7] ratio = 2.5). At this point, cytotoxic chemotherapy was not a candidate for treatment due to his poor PS. Furthermore, although crizotinib was known as potential MET inhibitor as well as anaplastic lymphoma kinase (ALK) inhibitor, combination therapy with crizotinib and EGFR-TKI was considered to lack the evidences about safety. Therefore, combination therapy with bevacizumab and erlotinib was selected on the basis of the potential efficacy for activated MET signaling pathway as well as the confirmed safety by the JO25567 phase II clinical trial.
The patient was started on erlotinib at 150 mg/day plus bevacizumab at 15 mg/kg every 3 weeks. By 21 days after the start of this combination therapy, his symptoms gradually improved along with the decreased tumor size, resulting in better PS with no severe toxicities (Fig. 3a, b). However, after 2 cycles of bevacizumab administration, he unfortunately fractured his face from falling down during the rehabilitation to improve the deteriorated activity of daily life (ADL). Then, he underwent open reduction and fixation of his face fracture under general anesthesia. Eventually, he was forced to quit this promising combination therapy.
OUTPUT:
| PMC6381877 |
MultiCaRe_Reasoning3 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 41.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 1. Right anterior oblique (RAO) cranial image of left coronary angiography showing spontaneous coronary artery dissection of left main (LM) and left anterior descending (LAD) artery (arrows).
Image description: SCAD of the left main (LM), left anterior descending (LAD), and left circumflex arteries (LCx; Figure 1). She was managed with emergent coronary artery bypass graft (CABG) of 2 vessels, including, left internal mammary artery to the LAD and saphenous vein graft (SVG) to the ramus intermedius artery.
Case Report:
A 41-year-old female with a past medical history of hypothyroidism and Prinzmetal's angina presented with worsening typical chest pain for 1 day. She was 10 weeks postpartum. Her pain was unresponsive to nitroglycerin and aspirin. Electrocardiogram showed T-wave inversions in anterolateral leads. She was taken to the cardiac catheterization laboratory and was found to have SCAD of the left main (LM), left anterior descending (LAD), and left circumflex arteries (LCx; Figure 1). She was managed with emergent coronary artery bypass graft (CABG) of 2 vessels, including, left internal mammary artery to the LAD and saphenous vein graft (SVG) to the ramus intermedius artery. Her subsequent recovery was uneventful and she was asymptomatic with normal echocardiogram at the 6-month follow-up.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning4 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 51.0
Sex: Male
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 2. Right anterior oblique (RAO) cranial view of right coronary angiography showing spontaneous coronary artery dissection of right coronary artery (RCA) (arrows).
Image description: He was taken to the cardiac catheterization laboratory where coronary angiography showed dissection of both the LAD and the right coronary artery (RCA; Figure 2).
Case Report:
A 51-year-old male with a history of SCAD presented to our medical Center with refractory angina and decreased exercise tolerance for 2 days. Electrocardiogram showed nonspecific ST-T wave changes with initial troponin level of 0.8 ng/mL (normal <0.01 ng/mL). He was taken to the cardiac catheterization laboratory where coronary angiography showed dissection of both the LAD and the right coronary artery (RCA; Figure 2). He was managed with the deployment of 2 overlapping drug-eluting stents with good angiographic results in the RCA. In his LAD, he had a residual dissection with an angiographically determined good flow. At the 3-month follow-up, he showed recovery of his exercise tolerance and no further episodes of angina.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning5 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 34.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 3. Right anterior oblique (RAO) cranial view of right coronary angiography showing spontaneous coronary artery dissection of proximal to mid right coronary artery (RCA) (arrows).
Image description: Repeat catheterization showed stable LAD dissection with new RCA dissection with TIMI grade 1 flow (incomplete filling of distal coronary artery; Figure 3).
Case Report:
A 34-year-old African American female with a recent Cesarean section presented with sudden-onset chest pain for 15 minutes. On admission, electrocardiogram showed ST-segment elevations in V4, V5, and V6. Cardiac catheterization was performed. It revealed a long dissection of the LAD, originating just distal to the ostium and extending up to the mid portion. Thrombolysis in myocardial infarction (TIMI) grade 3 flow (normal flow) was noted. She was initially managed with medical therapy. Two days later, she had recurrent chest pain. Electrocardiogram changes were consistent with ischemia. Repeat catheterization showed stable LAD dissection with new RCA dissection with TIMI grade 1 flow (incomplete filling of distal coronary artery; Figure 3). She underwent an emergent 2-vessel CABG (SVG to LAD and SVG to RCA). Her postoperative period was uneventful. She developed peripartum cardiomyopathy after 3 months but had recovered left ventricular systolic function at the 6-month follow-up.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning6 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 45.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 45-year-old female, professional marathon runner, with a history of Raynaud's phenomenon, migraines, gastroesophageal reflux disease, and serum-positive HLA-B27, developed a sudden-onset chest pain while riding her bicycle. The pain lasted 2 hours, throughout the duration of exercise, and was noted to radiate to her back and jaw. In the emergency room, the electrocardiogram showed anterior wall myocardial infarction (MI) with positive serum troponin of 0.15 ng/mL (normal <0.01 ng/mL). Cardiac catheterization ruled out coronary atherosclerotic disease. However, the LM had a long SCAD that was extending to the mid LAD. The blood supply distal to the lesion was compromised. It was successfully stented with 2 bare metal stents. At the 3-month follow-up, she had an uneventful recovery with partial recommencement of her strenuous physical activity.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning7 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 49.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 5. Right anterior oblique (RAO) cranial view of left coronary angiography showing spontaneous coronary artery dissection of mid-left anterior descending (LAD) artery (arrows).
Image description: Emergent catheterization revealed SCAD in the mid LAD with an unsuccessful wiring (Figure 4).
Case Report:
A 49-year-old female with stage IV sarcoidosis presented to our hospital with chest pain and shortness of breath. Electrocardiogram showed STEMI in the anterolateral leads. Emergent catheterization revealed SCAD in the mid LAD with an unsuccessful wiring (Figure 4). The patient was managed conservatively. Later, her hospital course was complicated by a left ventricular thrombus and an embolic stroke requiring anticoagulation. She was discharged to rehabilitation center where she stayed for a period of 6 weeks. At the follow-up in the outpatient clinic, the patient had no residual deficits of recent stroke and had no angina. Over the next year, she had worsening pulmonary hypertension secondary to her sarcoidosis and was deemed a suitable candidate for a heart and lung transplantation.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning8 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 56.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 6. Left anterior oblique (LAO) cranial view of left coronary angiography showing spontaneous coronary artery dissection of left circumflex artery (LCx) (arrows).
Image description: Left heart catheterization showed a SCAD involving the LCx with TIMI grade 3 distal flow (Figure 5).
Case Report:
A 56-year-old female developed sudden-onset, sharp chest pain that led to syncope. On admission, electrocardiogram showed NSTEMI with a troponin level of 4.5 ng/mL (normal <0.01 ng/mL). Left heart catheterization showed a SCAD involving the LCx with TIMI grade 3 distal flow (Figure 5). While receiving cardiac catheterization, she developed an acute stroke with left-sided visual field deficit and received intravenous tissue plasminogen activator with complete resolution. She was managed conservatively with medical therapy for NSTEMI. She remained compliant with her medications. Follow-up catheterization due to persistent chest pains showed healed LCx dissection with no atherosclerotic disease in the rest of her coronary arteries. She was started on nifedipine for possible diagnosis of Prinzmetal's angina (variant angina). Her symptoms improved drastically on subsequent follow-up visits.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning9 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 60.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 7. Right anterior oblique (RAO) cranial view of left coronary angiography showing spontaneous coronary artery dissection of first diagonal branch (D1) of left anterior descending (LAD) artery (arrows).
Image description: Coronary angiogram showed an abnormality in the diagonal branch of the LAD (mid D1 radiolucency) concerning for thrombus versus dissection (Figure 6).
Case Report:
A 60-year-old female presented to our medical institution with chest pain lasting 15 minutes. Electrocardiogram showed a new-onset right bundle branch block and she was found to have a troponin of 0.24 ng/mL (normal <0.01 ng/mL). Coronary angiogram showed an abnormality in the diagonal branch of the LAD (mid D1 radiolucency) concerning for thrombus versus dissection (Figure 6). Optical coherence tomography was performed to distinguish the lesion. Therein, a SCAD was noted, which was managed with drug-eluting stent placement. Final angiography displayed no evidence of thrombosis, distal embolization, or further dissection. She remained compliant with her dual antiplatelet therapy for 8 months. Subsequently, she experienced a major gastrointestinal bleeding after which clopidogrel (Plavix) was discontinued. She remained symptom-free on follow-up visits.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning10 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 34.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 8. Right anterior oblique (RAO) caudal view of left coronary angiogram showing spontaneous coronary artery dissection of mid left anterior descending (LAD) artery with intramural hematoma (arrows).
Image description: Coronary angiogram showed SCAD of the mid portion of the LAD with large intramural hematoma compromising the blood flow to the first and second diagonal branches of the LAD with TIMI grade 3 flow into distal vessel (Figure 7).
Case Report:
A 34-year-old female who was 38 weeks pregnant presented with atypical chest pain for 1 day. Electrocardiogram showed ST-segment elevations in the anterolateral leads with a negative first troponin level. Coronary angiogram showed SCAD of the mid portion of the LAD with large intramural hematoma compromising the blood flow to the first and second diagonal branches of the LAD with TIMI grade 3 flow into distal vessel (Figure 7). No intervention was done and she was admitted to the cardiac care unit where a conservative approach was adopted. After undergoing Cesarean section, repeat coronary catheterization was performed. It showed no evidence of intramural hematoma and a healed LAD dissection.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning11 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 36.0
Sex: Female
Title: Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review
Keywords: acute coronary syndrome; diagnosis; fibromuscular dysplasia; management; myocardial infarction; pregnancy-associated spontaneous coronary artery dissection; spontaneous coronary artery dissection;
Abstract:
Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.
Image Caption and Description:
Image caption: Case 9. Right anterior oblique (RAO) caudal view of left coronary angiography showing spontaneous coronary artery dissection of proximal left anterior descending (LAD) artery with compromised blood flow to diagonal branches (arrows).
Image description: Emergent catheterization showed a dissection of the proximal LAD after the first 2 septal perforators with evidence of luminal compromise by a hematoma (Figure 8).
Case Report:
A 36-year-old female who was 6-days postpartum presented with typical chest pain radiating to her left arm for 1 hour. Electrocardiogram showed ST-segment elevations in leads V2 and V3 and ST depressions in the inferior leads. Emergent catheterization showed a dissection of the proximal LAD after the first 2 septal perforators with evidence of luminal compromise by a hematoma (Figure 8). Conservative management was planned and she was started on dual antiplatelet therapy. Follow-up catheterization after 6 weeks showed no progression of the LAD dissection with resolution of the hematoma. She remained asymptomatic on follow-up visits.
OUTPUT:
| PMC5912312 |
MultiCaRe_Reasoning12 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 30.0
Sex: Male
Title: Malignant adenohypophysis spindle cell oncocytoma with repeating recurrences and a high Ki-67 index
Keywords: None
Abstract:
Adenohypophysis spindle cell oncocytoma (ASCO) is a rare tumor recently reported by Roncaroli et al in 2002. This tumor is considered a grade I tumor by the World Health Organization.We report a rare case of malignant ASCO with repeating recurrences and a high Ki-67 index-a challenging diagnosis guided by clinical presentations, radiological signs, and postoperative pathological tests.We represent a 30-year-old man who had suffered from headaches, diplopia, and impaired visual field and acuity. His magnetic resonance imaging revealed an abnormal sellar mass and was originally misdiagnosed as a pituitary macroadenoma. We present detailed analysis of the patient's disease course and review relevant literature.When surgically treated, the specimen revealed a typical histopathology pattern of ASCO. The tumor recurred for several times and the patient underwent 3 surgeries and 1 γ-knife treatment, which was accompanied by a continuously increasing Ki-67 index.This is the first reported case of malignant ASCO (WHO III-IV grade). Despite its rarity, ASCO should be considered in the differential diagnosis of sellar lesions that mimic pituitary adenomas.
Image Caption and Description:
Image caption: MRI for the abnormalities in the sellar region at different time points. A-C, Before the first surgery. A, Coronal-enhanced T1WI. B, Axial-enhanced T1WI. C, Sagittal-enhanced T1WI. D-E, Before gamma-knife treatment. D, Coronal-enhanced T1WI. E, Axial T1WI. F-H, Before the secondary surgery. F, Coronal-enhanced T1WI. G, Axial T1WI. H, Sagittal-enhanced T1WI. I-K, After the secondary surgery. I, Coronal-enhanced T1WI. J, Axial-enhanced T1WI. K, Sagittal-enhanced T1WI. L-P, Before the third surgery. L, Coronal T1WI. M, Coronal-enhanced T1WI. N, Coronal T2WI. O, Sagittal T1WI. P, Sagittal-enhanced T1WI. MRI = magnetic resonance imaging.
Image description: The magnetic resonance imaging (MRI) demonstrated an abnormal mixed signal mass with suprasellar, parasellar, and suprasellar invasiveness in the sellar area (Fig. 1A-C).
The sellar MRI revealed that the tumor recurred (Fig. 1D and E) and the patient underwent a gamma-knife treatment.
Necrosis, cyst degeneration, and hemorrhage within the tumor could be detected (Fig. 1F-H).
The sellar MRI after 1 week of the secondary surgery was shown as Fig. 1I to K.
The enhancement was inhomogeneous and the surrounding structures and tissues were further invaded (Fig. 1L-P).
Image caption: Histopathological and immunohistochemical examination images for the surgical specimen. A-K, Specimen after the first surgery. A, H & E, x10. B, H & E, x20. C, AE-1/AE-3, x10. D, AS-1, x10. E, CD34, x10. F, CD68, x10. G, Desmin, x10. H, S-100 protein, x10. I, SMA, x10. J, SMA, x20. K, Vimentin, x10. L, Specimen after the third surgery, Ki-67 proliferation index 45%, x10. H & E = hematoxylin and eosin, SMA = smooth muscle actin.
Image description: Ki-67 proliferation index was 6% (Fig. 2A-K).
ASCO. And the Ki-67 proliferation index increased to 45% (WHO III-IV grade, Fig. 2L), highly suggesting its malignancy.
Case Report:
A 30-year-old man came to Peking Union Medical College Hospital (PUMCH) with headaches, fatigue, diplopia, and impaired visual field and acuity for 6 months which had worsened since the previous 2 weeks. He denied polydipsia, polyuria, sexual hypoactivity, or any symptoms of unconsciousness, epilepsy, convulsion, and cognitive disorders. Physical examinations revealed that his right visual acuity was 0.5 and the left was 0.4. Goldmann perimetry revealed a bitemporal hemianopia. He was found to have ptosis of the right eyelid. The right pupillary reaction to light was absent. Other neurological examination results were normal. His past history was negative for head trauma. His social and family history and his system review were negative.
The magnetic resonance imaging (MRI) demonstrated an abnormal mixed signal mass with suprasellar, parasellar, and suprasellar invasiveness in the sellar area (Fig. 1A-C). The lesion was about 2.8 x 1.9 x 1.9 cm, inside which was some spotty necrosis. A dynamic contrast-enhanced scan showed heterogeneous enhancement. Relatively normal pituitary tissue with normal enhancement could be seen near the inferior lesion margin, but was squashed. The optic chiasma was mildly compressed but the basic shape was generally normal. The bilateral internal carotid arteries were also partly wrapped. Laboratory tests used to explore pituitary disorders showed normal levels of pituitary hormones, including prolactin (N < 20 mug/L), luteinizing hormone (LH) (N > 10 IU/L), follicle-stimulating hormone (FSH) (N > 20 IU/L), thyrotropin, and corticotropin. The diagnosis of nonfunctioning pituitary macroadenoma was suspected.
Via a trans-nasal-sphenoidal approach, a surgical exploration was performed. After drilling the sellar floor and opening the dura, a firm, tough, wheaten mass was found. As its consistency was too elastic and hypervascular to be easily cut by a surgical blade, and it adhered so tightly to the cavernous sinus and internal carotid artery, only subtotal resection was ultimately achieved. Repair of the sellar defect was done with autologous fat and fascia lata. The immediate postoperative sellar MRI was not performed. In a surprise twist, postsurgical hematoxylin and eosin (H & E) stained sections showed that the lesion contains epithelioid and spindled cells with eosinophilic cytoplasm arranged in sheets and nests. Mild-to-moderate nuclear atypia could also be observed. On immunohistochemical evaluation, the tumor cells were positive for Vimentin, CD68, CD34, Nestin, GFAP, Desmin, SMA, AE1/AE3, and S-100 protein, but were negative for NSE, Synuclein, NeuN, EMA, pituitary hormones (LH, FSH, ACTH, TSH, growth hormone, and prolactin), synaptophysin and chromogranin. Ki-67 proliferation index was 6% (Fig. 2A-K). The pathological test supported the diagnosis of adenohypophysis spindle-cell oncocytoma. The postsurgical course was uneventful and his clinical symptoms of headache and diplopia were markedly improved.
However, 1 month after the surgery, the patient's vision declined sharply and meanwhile he complained of severe ophthalmodynia of the right eye. The sellar MRI revealed that the tumor recurred (Fig. 1D and E) and the patient underwent a gamma-knife treatment. But the symptoms were not relieved significantly. Three months later, the sellar MRI showed the lesion was approximately 2.8 x 2.2 x 3.1 cm with equal T1 signal and inhomogeneous long T2 signal, which were enhanced with mass or nodosity after contrast administration. The suprasellar region, bilateral cavernous sinuses, and optic chiasma were further invaded. Necrosis, cyst degeneration, and hemorrhage within the tumor could be detected (Fig. 1F-H). A secondary surgery was performed through the left pterional approach. The tumor's texture was firm to elastic and the bleeding was heavy; therefore, we just performed a partial resection, decompressed the optic nerves and chiasm. The sellar MRI after 1 week of the secondary surgery was shown as Fig. 1I to K. Postsurgically, transient central diabetes-insipidus persisted for 2 weeks. Visual field and acuity remained unimproved. Histological evaluation revealed similar morphology and immunohistochemical profiles to the previous specimen. The Ki-67 index for this time increased to 19%. From the perspectives of pathologists, the pathological grade was considered WHO III.
One month after the secondary surgery, the patient came to PUMCH again complaining almost blindness and severe headache. A sellar MRI was arranged, demonstrating that the tumor recurred again to approximately 4.9 x 3.6 x 3.1 cm with necrosis, cyst degeneration, and hemorrhage. The enhancement was inhomogeneous and the surrounding structures and tissues were further invaded (Fig. 1L-P). The third surgery via a transsphenoidal approach was conducted for decompressing. Partial resection was achieved and the visual disturbance and headache were alleviated a lot. Pathological evaluation results were similar to previous, confirming the diagnosis of ASCO. And the Ki-67 proliferation index increased to 45% (WHO III-IV grade, Fig. 2L), highly suggesting its malignancy. The patient has already been followed up for nearly half a year and reported no recurrence of headache and visual deterioration. His right visual acuity was 0.4 and the left was 0.3, evaluated recently.
OUTPUT:
| PMC5287946 |
MultiCaRe_Reasoning13 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 40.0
Sex: Female
Title: A novel mucocele: Myxoglobulosis
Keywords: mucocele; mucus extravasation cyst; myxoglobulosis;
Abstract:
Oral extravasation mucoceles are among the most widely recognized submucosal lesions which are usually a result of trauma involving salivary glands and their ducts. This paper reports a case of a 40-year-old female patient with a chief complaint of a painless swelling on the lower lip since 6 months. Upon a provisional diagnosis of mucocele, surgical excision was carried out. Histopathological examination revealed a mucus extravasation cyst having lumen filled with unique mucinous globular structures similar to a rare variant of appendiceal mucocele, myxoglobulosis.
Image Caption and Description:
Image caption: Clinical image shows a well-defined, roughly oval swelling on the lower lip
Image description: Clinical examination revealed a well-defined, nontender, smooth-surfaced, roughly oval, fluctuant swelling [Figure 1].
Image caption: Histopathological image shows presence of large, eosinophilic globules having lamellated or whorled appearance (H&E stain, x4)
Image description: The lumen was filled with numerous mucinous globular structures which were oval or round in shape and of varying sizes [Figure 2].
Image caption: Histopathological image shows abundant mucin within the globules attached to the surrounding cystic capsule and few globules suspended freely within the lumen (PAS stain, x4)
Image description: Some of the globules were suspended freely within the lumen [Figure 3].
The mucinous globules showed positive results for PAS and Alcian blue [Figures 3 and 4].
Image caption: Histopathological image shows presence of mucin in the periphery with central cellular core (Alcian blue stain, x10)
Image description: Individual globules exhibited a mildly cellular core with peripheral laminations of dystrophic calcifications [Figure 4].
The mucinous globules showed positive results for PAS and Alcian blue [Figures 3 and 4].
Case Report:
A 40-year-old female patient was referred for evaluation of an asymptomatic swelling on the lower lip of 6 months duration with a history of local trauma. Clinical examination revealed a well-defined, nontender, smooth-surfaced, roughly oval, fluctuant swelling [Figure 1]. No relevant medical history was elicited. Oral hygiene was fair. A provisional diagnosis of mucocele was made; the lesion was excised under local anesthesia. Histopathological examination of the excised tissue revealed cystic lumen devoid of lining epithelium and surrounded by compressed granulation tissue and peripherally located mixed salivary glands. The lumen was filled with numerous mucinous globular structures which were oval or round in shape and of varying sizes [Figure 2]. Most of the globules present in the cystic lumen were attached to the surrounding cystic capsule and seemed dissociated from one another because of their globular organization. Some of the globules were suspended freely within the lumen [Figure 3]. Individual globules exhibited a mildly cellular core with peripheral laminations of dystrophic calcifications [Figure 4]. The granulation tissue forming the cystic wall was highly cellular, consisting of chronic inflammatory cells. The mucinous globules showed positive results for PAS and Alcian blue [Figures 3 and 4].
OUTPUT:
| PMC9106225 |
MultiCaRe_Reasoning14 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 29.0
Sex: Female
Title: Bochdalek hernia with retrocardiac spleen - Diagnostic dilemma for emergency care physicians-A case report
Keywords: bochdalek; diaphragm; emergency care; hernia; physician; retrocardiac; spleen;
Abstract:
Introduction:
Physicians working as first-level responders in emergency departments (ED) often encounter patients, of any age group with shortness of breath (SOB). Definitive diagnosis is quite challenging once the underlying pathology is rare and unusual and/or the ED physicians recommend and rely on non-specific investigations.
Presentation of case:
A 29-year-old female presented to the emergency department with sudden onset of shortness of breath and upper abdominal pain radiating to the left shoulder. Diagnosis of Bochdalek hernia was made clinically coupled with radiological findings of CXR and computed tomography (CT) by the surgeon on-call, while it was missed by an emergency care physician on her first visit.
Discussion:
Herniation of the abdominal contents into the thoracic cavity via the Bochdalek opening, commonly known as Bochdalek hernia is seen and diagnosed most commonly accidentally in early life. Adult cases of symptomatic Bochdalek hernia has been reported in the literature. These patients usually present with non-specific symptoms, thus pose a diagnostic challenge for an emergency care physician.
Conclusion:
The report of this case highlights the notion that such rare causes of acute onset dyspnea and upper abdominal pain pose a diagnostic challenge for novice emergency care physicians especially in situations where he/she does not ask for second-line help in general and recommend and rely on a non-specific investigation in specific.
Image Caption and Description:
Image caption: Pre-op x-ray chest with Chilaiditis Sign (a); Post-op x-ray chest (normal) (b).
Image description: Upon no improvement, the patient revisited the ED where chest x-ray (CXR) as primary imaging modality was requested by surgeon on-call that showed raised right hemidiaphragm with no well discernible outlines, air-filled bowel loops above the hepatic shadow, a chilaiditi's sign, with no mediastinal shift (Fig. 1a), thus a provisional diagnosis of the right-sided diagrammatic hernia was made.
Post-operative chest x-ray shows normal findings (Fig. 1b).
Image caption: Non-contrast CT-Intrathorasic Extrusion of Spleen, Stomach and Bowels (a); Non-contrast CT-retrocardiac spleen (b).
Image description:
Case Report:
A 29 years old female, physician by profession presented to the emergency department with a history of aggressive vomiting five weeks back followed by left upper abdominal, a single episode of loose motion, subcostal pain radiating to left shoulder associated with shortness of breath (SOB) and was unable to take full inspiration. The patient has a history of heartburn, early satiety, indigestion, and food regurgitation six years ago and diagnosed and managed as gastroesophageal reflux disease in her native country.
The primary evaluation shows a toxic looking afebrile patient with vitals as; respiratory rate-27/min, pulse 87/min. Along with first-level management, abdominal ultrasonography (US) and initial laboratory workup were done in ED with no abnormal findings and the patient discharged home after the primary management independently and not asking surgeon on-call help. Upon no improvement, the patient revisited the ED where chest x-ray (CXR) as primary imaging modality was requested by surgeon on-call that showed raised right hemidiaphragm with no well discernible outlines, air-filled bowel loops above the hepatic shadow, a chilaiditi's sign, with no mediastinal shift (Fig. 1a), thus a provisional diagnosis of the right-sided diagrammatic hernia was made.
Following CXR, a non-contrast CT requested showing stomach and parts of the colon in the right thoracic cavity (Fig. 2a) along with spleen located posterior to the heart - the retrocardiac spleen (Fig. 2b), thus a final diagnosis of Bochdalek hernia was made.
Severe vomiting, a few weeks earlier was the triggering event in the patient that led to the initiation of the clinical picture. After initial stabilization, the patient was transferred to a regional tertiary care facility for cardiothoracic surgeon evaluation and management where via open thoracotomy, contents reduced and fortunately there was no vascular compromise. Repair done. Post-operative chest x-ray shows normal findings (Fig. 1b). The patient had uneventful recovery and discharged home on 10th post-operative day. The patient did well in her follow-up period. To the best of our knowledge, it is the first reported case of Bochdalek hernia associated with the retrocardiac spleen in an adult female in the published literature.
OUTPUT:
| PMC7276389 |
MultiCaRe_Reasoning15 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 63.0
Sex: Female
Title: Carcinosarcoma of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma: a report of two cases
Keywords: alpha-fetoprotein; hepatoid adenocarcinoma; rhabdomyosarcoma; uterine carcinosarcoma;
Abstract:
We report two cases of uterine carcinosarcoma associated with alpha-fetoprotein (AFP)-producing hepatoid adenocarcinoma. Samples were obtained from two women aged 63 and 82 years. Serum AFP levels of the two samples were 10,131 and 401 ng/ml, respectively. Histologically, in both cases the tumor cells were composed of hepatoid adenocarcinoma component and sarcoma component including rhabdomyosarcoma. Immunohistochemical analyses revealed that AFP was expressed in the cytoplasm of the carcinomatous component. After surgery, the patients received six courses of carboplatin/paclitaxel chemotherapy, and the serum levels of AFP decreased to normal range. The first patient is alive and well at the 2-year follow-up, while the second patient died of disease 1 year after initial operative treatment. This is, to our knowledge, the second report of carcinosarcoma of the uterine corpus with AFP-producing hepatoid adenocarcinoma, as proven by immunohistochemical analyses.
Image Caption and Description:
Image caption: a Histological appearance of the carcinosarcoma. The carcinomatous component is composed of hepatoid adenocarcinoma and the sarcomatous component of spindle cells and large pleomorphic cells (HE, x400). b Tumor cells in the hepatoid areas show immunoreactivity for AFP (AFP, x400).
Image description: Microscopic examination showed that the polypoid tumor was a mixture of carcinomatous and sarcomatous components (fig. 1a).
Reactivity for AFP was cytoplasmic in the hepatoid carcinoma lesion (fig. 1b).
Case Report:
A 63-year-old multiparous woman, gravida 4, para 3, complained of abnormal vaginal bleeding of 2 months' duration. She went into menopause at age 54. The patient had no remarkable medical or family histories. On vaginal examination, the uterus was enlarged, non-tender, smooth and movable. Vaginal ultrasonogram and magnetic resonance imaging showed a polypoid mass of 14 x 10 cm in size in the uterus, possibly representing a carcinosarcoma or leiomyosarcoma. No free pelvic fluid was identified. Computed tomography (CT) showed the liver and bile ducts to be normal. The endometrial Pap smear was evaluated as positive. Biopsies of the endometrium were carried out and the histological diagnosis revealed carcinosarcoma. The serum AFP level was 10,131 ng/ml (normal <20). Other tumor markers and liver function test results were within normal limits. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy.
The resected enlarged uterus, weighing 560 g and measuring 14 x 12 x 7 cm, had a smooth glistening surface. The polypoid tumor originated from the uterine cavity when the anterior wall of the uterus was opened. The uterine adnexae were normal in shape and size. There was no evidence of a tumorous lesion. Microscopic examination showed that the polypoid tumor was a mixture of carcinomatous and sarcomatous components (fig. 1a). The tumor had invaded the uterine cervix, but no metastases were found in the dissected lymph nodes. The carcinomatous component showed adenocarcinoma arranged in sheets and cords with a hepatoid appearance. Reactivity for AFP was cytoplasmic in the hepatoid carcinoma lesion (fig. 1b). The sarcomatous component showed no reactivity for AFP. The large pleomorphic cells were positive for desmin, actin, CD10, MyoD1, and myoglobin and could be regarded as being rhabdomyosarcoma. There was no staining with S-100. In summary, the tumor was histopathologically diagnosed as heterologous uterine corpus carcinosarcoma associated with AFP-producing hepatoid adenocarcinoma.
Postoperatively, the patient received six courses of chemotherapy with paclitaxel (175 mg/m2) and carboplatin (AUC 5). This regimen was repeated every 3 weeks. After the third course of chemotherapy, the patient's serum AFP level decreased to 4.5 ng/ml. The patient is alive with no evidence of recurrence or increase in the serum AFP level in the 2 years since treatment.
OUTPUT:
| PMC3134036 |
MultiCaRe_Reasoning16 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 82.0
Sex: Female
Title: Carcinosarcoma of the uterine corpus with alpha-fetoprotein-producing hepatoid adenocarcinoma: a report of two cases
Keywords: alpha-fetoprotein; hepatoid adenocarcinoma; rhabdomyosarcoma; uterine carcinosarcoma;
Abstract:
We report two cases of uterine carcinosarcoma associated with alpha-fetoprotein (AFP)-producing hepatoid adenocarcinoma. Samples were obtained from two women aged 63 and 82 years. Serum AFP levels of the two samples were 10,131 and 401 ng/ml, respectively. Histologically, in both cases the tumor cells were composed of hepatoid adenocarcinoma component and sarcoma component including rhabdomyosarcoma. Immunohistochemical analyses revealed that AFP was expressed in the cytoplasm of the carcinomatous component. After surgery, the patients received six courses of carboplatin/paclitaxel chemotherapy, and the serum levels of AFP decreased to normal range. The first patient is alive and well at the 2-year follow-up, while the second patient died of disease 1 year after initial operative treatment. This is, to our knowledge, the second report of carcinosarcoma of the uterine corpus with AFP-producing hepatoid adenocarcinoma, as proven by immunohistochemical analyses.
Image Caption and Description:
Image caption: a Tumor showing a mixture of carcinomatous and sarcomatous components (HE, x100). b Tumor cells in the hepatoid areas immunoreactive for AFP (AFP, x400).
Image description: Histologically, the tumor was composed of carcinomatous and sarcomatous components (fig. 2a).
Immunohistochemistry also revealed AFP-positivity in many tumor cells (fig. 2b).
Case Report:
An 82-year-old woman, gravida 0, para 0, was referred to our hospital with vaginal bleeding of 2 months' duration. She had undergone surgery due to breast cancer at the age of 68. On pelvic examination, enlarged uterus without a palpable adnexal mass was detected. The vaginal wall showed no abnormalities. Portio vaginalis could not be detected, so the endometrial Pap smear could not be done. Magnetic resonance imaging revealed an enhanced mass, 8 cm in size, in the uterine corpus cavity, possibly representing malignant tumor. CT scan demonstrated ascites and no lymph nodes were detected. CT and ultrasonography revealed no abnormalities in the liver or bile duct. The serum AFP level was elevated (401 ng/ml), but no elevation of other markers, such as carcinoembryonic antigen or carbohydrate antigen 125, was observed. The blood count and serum biochemical data were unremarkable. From these results, malignant uterine tumor was highly suspected. A total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic washings was carried out. The resected uterus was enlarged and filled with a spongy material. There was no apparent extrauterine extension of the tumor. A partially necrotic polyp, 8 cm in size, was present within the endometrial cavity, which infiltrated into the myometrium for about two-thirds of its thickness but did not invade the cervix. Cytology of the pelvic washings was negative. Histologically, the tumor was composed of carcinomatous and sarcomatous components (fig. 2a). The carcinomatous component was an endometrioid adenocarcinoma with trabecular hepatoid cells, mostly showing hepatocellular carcinoma-like proliferation. Immunohistochemistry also revealed AFP-positivity in many tumor cells (fig. 2b).
The sarcomatous component showed rhabdoid features including spindle-shaped tumor cells. Occasional cells with eosinophilic cytoplasm and cytoplasmic cross-striations were identified. Immunohistochemistry showed focal positivity of tumor cells with desmin, MyoD1, and CD10. On pathologic examination, the tumor was interpreted as being a heterologous uterine corpus carcinosarcoma associated with AFP-producing hepatoid adenocarcinoma.
We did not carry out any adjuvant chemotherapy or irradiation because of the patient's advanced age, in addition, she and her family refused these therapies. Two months after the surgery, the patient's serum AFP level decreased to a normal level. However, multiple lung metastases with a high-serum AFP level reappeared and the patient died 1 year after the operation.
OUTPUT:
| PMC3134036 |
MultiCaRe_Reasoning17 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Female
Title: Daratumumab triplet therapies in patients with relapsed or refractory multiple myeloma: A "real world" experience
Keywords: daratumumab; multiple myeloma; real-word experience; relapsed refractory;
Abstract:
We report our retrospective analysis on 34 relapsed/refractory multiple myeloma (RRMM) patients treated with daratumumab based triplets. Twenty patients were females and 14 males. Median age was 73.2. Daratumumab was associated to lenalidomide in and dexamethasone (DRd) in 30 (88,3%) and to bortezomib and dexamethasone (DVd) in 4 cases (11,7%). The ORR was 88%. CR occurred in 12% of cases, VGPR in 44% and PR in 32%. The 12 months PFS and OS rates were 78% and 86,5%, respectively. Present data confirm those recently reported in the literature and further reinforce the early use of daratumumab-based triplets for RRMM patients.
Image Caption and Description:
Image caption: Kaplan-Meyer survival curves. (A) PFS in all patients, (B) OS in all patients, (C) PFS according to the best response, (D) PFS according to the previous lines of therapy, (E) PFS according to the sex, (F) OS according to the presence of anemia at relapse, G) OS according to the best response.
Image description: At a median follow-up of 16 months (range 35 - 1), the median PFS and OS have not been reached (NR); the 12-month PFS and OS rates were 78% and 86,5%, respectively (Fig. 1.
In the univariate analysis, the achievement of at least a VGPR, receiving just one line of previous therapy and the male gender resulted in a statistically significant better PFS (Fig. 1.
C, D, and E), whereas the absence of anemia at the start of the daratumumab-based triplets and the achievement of at least a VGPR predicted a better OS (Fig. 1.
Case Report:
The characteristics of patients are outlined in Table 1. Twenty of the 34 MM patients were females and 14 were males, the median age was 73,2 years (range 64.6-80.3) and the median time from diagnosis of MM to the first treatment with daratumumab was 37 months (range 235-3). Cytogenetic characteristics were obtained from only 7 patients, of these only one was unfavorable. Each patient received one line of therapy and 6 (14,7%) patients received two lines or more. All 34 RRMM patients received a previous bortezomib-based therapy in which bortezomib was given with dexamethasone alone (3 cases) or combined with melphalan (16 cases) or with thalidomide (15 cases). In addition, 4 patients received lenalidomide, 3 patients received pomalidomide and 1 patient received Carfilzomib. Before DRd, seven patients (20,6%) underwent to a prior autologous stem cell transplantation (ASCT), that it is consisted in a single ASCT in 5 patients and in a double ASCT in the other 2 cases.
Sixteen patients (47%) presented one or more comorbidities: cardiovascular diseases (11), solid tumors (4), metabolic disorders (3), other hematological disorders (2), rheumatological diseases (1), pulmonary diseases (1), neurological diseases (1) and gastrointestinal diseases (1).
Twelve patients (36%) were refractory to the previous therapy. Eight patients (23,5%) presented with anemia (Hb < 10 g/dl), 3 (8,8%) with chronic kidney disease (creatinine > 2 mg/dl), 19 (55,9%) with bone lesions, while none of the patients presented with hypercalcemia (Ca2+ > 11 mg/dl). Among the 34 patients, 18 (53%) had a monoclonal component (CM) > 2 g/dl and 18 patients (53%) had a Bence-Jones proteinuria.
All RRMM patients received daratumumab IV at the standard dose of 16 mg/kg whereas in 30 (88,3%) patients it was combined with lenalidomide and dexamethasone (DRd) and in the remaining 4 cases (11,7%) with bortezomib and dexamethasone (DVd). A median number of 8 cycles (range 1-32) was administered within a median follow-up of 16 months (range 1-35). Among DRd treated patients, the lenalidomide starting dose was reduced in 12 patients (35%) according to the renal function or due to neutropenia or thrombocytopenia. At the time of analysis, 25 (73,5%) patients were currently receiving treatment. Nine patients (26,5%) discontinued treatment for progressive disease (8 patients) and intolerance (1 case).
Patients who received at least two doses of daratumumab-based triplets were included in the statistical analysis. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier product-limit estimator.
The overall response rate (ORR) was 88%. A Complete Response (CR) occurred in 12% of cases, a Very Good Partial Response (VGPR) in 44%, and a Partial Response (PR) in 32%. The Median time to achieve at least a PR was 40 days (range 30-110 days). Progressive disease was observed in 8 patients (23,5%), in which 5 cases (14,7%) led to death. Twenty-six patients (76,4%) were responding to treatment at the time of analysis.
Moreover, 4 transplant-eligible patients, however refractory to the VTD scheme after a median of 6 cycles of daratumumab, deepened their response, allowed themselves to receive an ASCT, and then continued DRD therapy. One of these four patients progressed and died within 100 days after the transplant.
Adverse events are summarized in Table 2. The most common hematological toxicities of any grade were neutropenia (15 patients; 44%), managed with lenalidomide dose reduction, and thrombocytopenia (10 patients; 29%). Other common non-hematological toxicities of grade 1 involved 10 patients (29%), including asthenia, light-headedness and breathlessness, edema of lower extremities, intestinal intolerance with diarrheal episodes, and epigastralgia. Two patients (5,4%) presented pulmonary AEs, one case with pneumonia and the other case with a chronic obstructive pulmonary diseases (COPD) exacerbation. The only grade 4 AE case was observed at the beginning of the third cycle and consisted of intolerance with persistent gastrointestinal disorders that required patient hospitalization leading to a discontinuation of the therapy.
After an extensive oral premedication of our patients consisting of cetirizine dihydrochloride 10 mg, montelukast 10 mg, paracetamol 1000 mg and dexamethasone 20 mg that was administered once/daily from the day before to the day after the infusion, we observed a DARA infusion-related reactions (IRRs) in only 3 patients (8,8%). All IRRs were a grade 1 - 2 and occurred during the first infusion, with urticaria, tachycardia, and respiratory symptoms, such as bronchospasm and dyspnea.
At a median follow-up of 16 months (range 35 - 1), the median PFS and OS have not been reached (NR); the 12-month PFS and OS rates were 78% and 86,5%, respectively (Fig. 1. A and B). In the univariate analysis, the achievement of at least a VGPR, receiving just one line of previous therapy and the male gender resulted in a statistically significant better PFS (Fig. 1. C, D, and E), whereas the absence of anemia at the start of the daratumumab-based triplets and the achievement of at least a VGPR predicted a better OS (Fig. 1. F and G).
In the multivariate analysis, only the achievement of at least a VGPR resulted as an independent predictor of prolonged PFS, showing an HR of 0.037 (95% CI of 0.0001-0.988; p= .049). Interestingly, other potential predictors of unfavorable prognoses, such as the condition of early or late relapse, did not impact patients' clinical outcomes after DRd.
In the present series, 4 patients received DVd because they were previously exposed to lenalidomide. Compared to the DRd treated patients, they showed a worse PFS and a similar OS. Once again, the small number of cases did not allow conclusions to be drawn concerning this issue. Apart from the daratumumab triplet used, many other factors may have contributed to the worse outcome of these four patients, as for example, the fact that they all had received more than one line of previous therapies.
OUTPUT:
| PMC9184873 |
MultiCaRe_Reasoning18 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 71.0
Sex: Female
Title: Decitabine Induced Delayed Cardiomyopathy in Hematologic Malignancy
Keywords: None
Abstract:
Decitabine is a pyrimidine analogue of nucleoside cytidine, used for the treatment of myelodysplastic syndromes, chronic myelogenous leukemia, and acute myelogenous leukemia. We present a case of cardiomyopathy associated with decitabine used for secondary acute myelogenous leukemia. The patient presented with new heart failure symptoms and an ejection fraction decline.
Image Caption and Description:
Image caption: Transthoracic echocardiogram of the patient in parasternal long axis view (a) demonstrating an enlarged left ventricular cavity, in apical (four-chamber) view demonstrating a mildly abnormal end systolic (b) and normal end diastolic (c) left ventricular dimension (RV: right ventricle; LV: left ventricle; LA: left atrium; RA: right atrium).
Image description: Echocardiogram showed severe left ventricular systolic dysfunction (EF 28%), mildly abnormal end systolic dimension (Figure 1), and a mild reduction in right ventricular systolic function.
Image caption: Peak systolic strain pattern in cross-sectional view (a) and longitudinal view (b) demonstrates decrease in left ventricular strain pattern.
Image description: Global averaged left ventricular longitudinal peak systolic strain was abnormal at -12% (normal more negative than -18%) (Figure 2).
Case Report:
A 71-year-old female with a history significant for hypertension, hepatitis B, and hypothyroidism, underwent bone marrow biopsy which showed a hypercellular bone marrow with >90% cellularity and 81% myeloblasts expressing CD 34 and CD 117 markers, confirming a diagnosis of acute myeloid leukemia (AML). Molecular testing showed no evidence for FMS-like tyrosine kinase 3 internal tandem duplication, absence of nucleophosmin1 and KIT exon 8, and 17 mutations, suggesting a lower risk of relapse after chemotherapy. Based on cytogenetic studies, secondary AML was diagnosed. Given her advanced age, decitabine therapy was commenced. A baseline 2-D transthoracic echocardiogram (TTE) showed normal function with an ejection fraction (EF) of 55-60%. After completing 10 cycles of decitabine, she was noted to have a tachycardia and dyspnea by self-report. She was therefore referred to cardiology with these symptoms in preparation for allogeneic stem cell transplant.
The heart rate was 110/min, and a 2/6 ejection systolic murmur and a loud P2 with an S3 and S4 gallop were heard. Lungs were clear. No jugular venous distension or pedal edema was noted.
Laboratory data is significant for a serum creatinine level of 0.8 mg/dl, estimated glomerular filtration rate of 80 ml/min per 1.73 m2, and N-terminal pro-b-type natriuretic peptide level of 517 pg/ml. Her complete blood count showed a white blood cell count of 12.6 x 109/l with greater than 50% blasts, low hemoglobin at 7.8 g/dl, hematocrit value of 25%, large platelet count of 212 x 109/l, and lactate dehydrogenase level of 588 U/l. Serum troponin or creatinine phosphokinase levels were not performed due to a lack of discernibility in patients undergoing chemotherapy for cancer. Echocardiogram showed severe left ventricular systolic dysfunction (EF 28%), mildly abnormal end systolic dimension (Figure 1), and a mild reduction in right ventricular systolic function. Global averaged left ventricular longitudinal peak systolic strain was abnormal at -12% (normal more negative than -18%) (Figure 2). Nuclear stress test showed no evidence of coronary disease. Patient was euthyroid at the time of diagnosis.
The patient was diagnosed with New York Heart Association class II and American Heart Association stage B heart failure with reduced ejection fraction. In the absence of any viral illness, toxins, or coronary disease, or concomitant cardiotoxic medication use and known recent normal ejection fraction, the etiology was attributed to decitabine use. The patient was subsequently started on metoprolol succinate 50 mg twice a day and furosemide 20 mg daily. Follow-up echocardiogram 4 weeks later showed no change in the ejection fraction of 28%, but there was mild improvement in the global left ventricular longitudinal peak systolic strain at -15% (improved from -12%).
OUTPUT:
| PMC6186336 |
MultiCaRe_Reasoning19 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 24.0
Sex: Female
Title: Cysticercal Encephalitis in a Young Female: A Rare Presentation of Neurocysticercosis
Keywords: albendazole; dress syndrome; neurocysticercosis; taenia solium; tumour necrosis factor-alpha (tnfα);
Abstract:
One of the most frequent parasite infections of the central nervous system is neurocysticercosis. This neurologic condition is caused by Taenia solium (T. solium) larval infestation. Infected pork intake, poor hygiene practices, water tainted with T. solium, or asymptomatic carriers are the main ways of spread. We describe a case of neurocysticercosis in a young woman who presented with low-grade fever, headache, altered sensorium, and recurrent seizures. Computed tomography of the head revealed an inflammatory granuloma and a ring-increased attenuating lesion in the left temporal region. Additionally, a well-defined rounded discrete lesion was identified in the left parietal region on magnetic resonance imaging of the brain. Even if the symptoms do not initially suggest neurocysticercosis or if the patient lives in a region where the condition is uncommon, our case depicts adding neurocysticercosis to the differential diagnosis for encephalitis.
Image Caption and Description:
Image caption: An inflammatory granuloma on the right temporal side.
Image description: Further evaluation with a non-contrast computed tomography (CT) head shows a ring-enhancing lesion in the left temporal region with perifocal edema, an eccentric, and an inflammatory granuloma (Figure 1).
Image caption: MRI brain with contrast revealing a well-defined rounded discrete lesion seen in the left parietal region as shown in the sagittal (a), trans-axial (b), and coronal (c) sections.
Image description: In addition, magnetic resonance imaging (MRI) brain showed a well-defined rounded discrete hyperintense lesion in the left parietal region with mild to moderate vasogenic edema, leading to partial effacement of the adjoining sub-arachnoid space and moderate peripheral rim enhancement (Figure 2).
Image caption: MR venogram revealing that the left transverse sinus is hypoplastic.
Image description: On follow-up after two weeks, an MR venogram revealed that the left transverse sinus was hypoplastic, as shown in Figure 3.
Image caption: An urticarial, maculopapular eruption, and erythroderma as in arm.
Image description: However, on follow-up after two weeks, the patient developed skin rashes, remarkably elevated liver enzymes, and total bilirubin (Figure 4).
Case Report:
A 24-year-old female was brought to the emergency department with complaints of altered mental status and recurrent seizures associated with low-grade fever, headache, and altered sensorium for the last three days. The seizure was acute in onset, generalized tonic-clonic in nature, and associated with tongue biting, blood-tinged frothing, and urinary incontinence. It was her second episode of abnormal body movement and altered sensorium after being admitted to the hospital. Each episode lasted for 20-30 minutes. She returned from a hill station a few days ago, and her family and social history were insignificant.
On admission, the patient was afebrile, with a blood pressure of 110/70 mmHg, a Spo2 of 97%, and a heart rate of 86/min. Her physical examination revealed a Glasgow coma scale (GCS) score of 11 (eye: 4, verbal: 2, motor: 5). Her rest systemic examination was unremarkable. Her initial laboratory investigations were within normal range except for mild elevation of transaminases (Table 1). Further evaluation with a non-contrast computed tomography (CT) head shows a ring-enhancing lesion in the left temporal region with perifocal edema, an eccentric, and an inflammatory granuloma (Figure 1). In addition, magnetic resonance imaging (MRI) brain showed a well-defined rounded discrete hyperintense lesion in the left parietal region with mild to moderate vasogenic edema, leading to partial effacement of the adjoining sub-arachnoid space and moderate peripheral rim enhancement (Figure 2). On follow-up after two weeks, an MR venogram revealed that the left transverse sinus was hypoplastic, as shown in Figure 3.
Following confirmation of diagnosis, the patient was started on albendazole 400mg twice daily and carbamazepine. However, on follow-up after two weeks, the patient developed skin rashes, remarkably elevated liver enzymes, and total bilirubin (Figure 4).
After proper evaluation, immediately anti-epileptic drugs were discontinued, and for skin rashes, the patient was given oral fexofenadine and methylprednisolone, levetiracetam beside topical steroids. On subsequent follow-up, her rashes and deranged aminases resolved, and the patient was doing well.
OUTPUT:
| PMC9937515 |
MultiCaRe_Reasoning20 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Male
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 27-day-old boy presented to the emergency room with a 7-hour history of fever. After giving superficial skin cooling at home, the baby remained febrile. The peak temperature was 38.5 C. The baby had a poor appetite and symptoms of sneezing and a stuffy nose without vomiting and coughing. He was a term baby without extraordinary perinatal history. His parents had a history of sore throat and cough for several days during the Omicron epidemic, but they didn't test for SARS-CoV-2. After admission to our NICU, he was febrile at 38.3 C with a respiratory rate of 52 breaths/min and oxygen saturation of 95%-99% while breathing ambient air. His examination was remarkable for congested nares, clear rhinorrhea, and mild subcostal retractions. There were coarse breath sounds in all lung fields. No murmur of the heart could be heard. The liver was palpated at 1 cm-2 cm under the costal margin (consistent with age), and the spleen was not palpated. Laboratory data revealed that the total WBC count and the proportions of the major leukocyte subsets in peripheral blood were normal. Blood gas, C reactive protein (CRP), and transaminase levels were in the normal range. RNA test for SARS-CoV-2 from a throat swab was positive. Then, the baby was given physical cooling and nasal secretion removal to keep the airway clear (see Table 1).
The baby presented febrile once daily in the following four days, and the peak temperature decreased from 38.4 to 38 C. Meanwhile, he developed a cough and sputum, along with a dropping of SpO2 to 80% when feeding. His lung demonstrated scattered crackles (see Figure 1). Because of continuous fever and pneumonia, more investigations were performed. The total WBC count and the proportions of the major leukocyte subsets were still in the normal range. CRP was 4.3 mg/L (0-10 mg/L). Anemia was noticed: RBC was 2.73 x 1,012/L, hemoglobin was 91.0 g/L, and hematocrit was 27.4%. Alanine transaminase (ALT) was 88 U/L(<=41 U/L), aspartate transaminase (AST) was 180 IU/L(<=40 U/L), and glutamyltranspeptidase (gamma-GT) was 109 U/L(6-42 U/L). Further, pathogens tests identified that parainfluenza virus RNA was positive, but there was no evidence of infection for other pathogens such as RSV, EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), influenza A/B/H1N1/H3N2, adenovirus, mycoplasma, chlamydia, HIV, Human metapneumovirus, rhinovirus, and hepatitis B/C virus. Ultrasonography for the heart and abdomen was normal. Therefore, the baby was given the nebulization treatment of budesonide and ipratropium bromide solution and given Glutathione for hepatoprotection. In addition, he inhaled oxygen intermittently to avoid hypoxia when feeding.
On the 7th day after admission, the patient was no longer febrile but was still coughing and had nasal congestion. On the 10th day, respiratory symptoms improved greatly, and we re-tested the liver function after 5 days of hepatoprotective treatment. The transaminase level elevated markedly. ALT was up to 645 U/L(<=41 U/L), AST increased to 480 IU/L(<=40 U/L), and gamma-GT was 491 U/L(6-42 U/L). However, bilirubin, blood ammonia, blood glucose, lipids, lactate, coagulation function, and albumin levels were within the normal range. The patient's perinatal medical history and family history were tracked carefully, and the possibility of inherited metabolic liver disease was ruled out. Furthermore, the patient's history of drug exposure before/after admission was also reviewed, and there was no evidence of drug-induced liver injury. So, virus infection may contribute to liver injury and the elevation of transaminase levels. When the immune system clears the virus, the injury should be alleviated. Thus, we only administered glycyrrhizin and bicyclol to promote recovery.
On the 14th day, the baby looked well with the normal physical examination. Laboratory tests demonstrated that ALT decreased to 125 U/L(<=41 U/L), AST was 44 IU/L(<=40 U/L), and gamma-GT was 283 U/L(6-42 U/L). He continued to take glycyrrhizin and bicyclol after being discharged home. The liver transaminase level returned to normal on 8 and 15 days after discharge (see Table 2 and Figure 2).
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning21 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Female
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 7-day-old girl was admitted to our NICU because of a 30-hour intermittent fever with a peak temperature of 38.5 C. Her parents noted that she had a stuffy nose with clear rhinorrhea and choked when feeding over the past two days. She coughed occasionally but had sputum in her throat. Her appetite was unchanged without increasing work of breathing, vomiting, and diarrhea. Her caregivers had confirmed infection of SARS-CoV-2 several days ago. Her mother was healthy during pregnancy but detected fetal hydronephrosis with the right duplex kidney in the third trimester. The baby was born through an uneventful C-section delivery at a gestational age of 40w+6. The baby looked well after birth, and there was no evidence of early-onset sepsis. On physical examination, she had a temperature of 38.6 C and mild tachypnea of a respiratory rate of 50 breaths/min without retraction. Her lungs demonstrated coarse breath sounds without crackles and wheezes. The lab investigations showed that CRP was increased to 19.8 mg/L(0-10 mg/L) (see Table 1).
WBC, blood gas analysis, transaminase level, and bilirubin levels were all in the normal range. The blood culture for bacteria was negative. Chest x-rays suggested increased and blurred bilateral lung markings in both lung fields (see Figure 1). Cardiac ultrasound demonstrated a left-to-right shunt of 2.6 mm through a patent foramen ovale (PFO). Abdominal ultrasound showed mild bilateral hydronephrosis and calculus in the right kidney (3.1 mm x 2.7 mm), and there were no abnormalities in the liver, gallbladder, and spleen structures. PCR and quick antigen tests for SARS-CoV-2 from the throat swab were positive. There was no evidence of infection from other viruses [RSV, EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), influenza A/B, adenovirus, mycoplasma, chlamydia, HIV, Human metapneumovirus, rhinovirus, and hepatitis B/C virus]. Normal saline helped to clean the airway, and nasal drops were used to relieve nasal congestion. Moreover, superficial skin cooling was given when the baby was febrile, and piperacillin/tazobactam was administered for pneumonia.
The baby's body temperature declined to normal on the 2nd day after admission. The respiratory symptom alleviated over the following days. On the 6th day, the laboratory tests showed that the transaminase level increased significantly without abnormality of bilirubin and albumin (see Table 2 and Figure 2). Then, the hepatoprotective treatment of glycyrrhizin and bicyclol was administered.
ALT decreased by half on the 11th day. Given that the baby had recovered from fever and respiratory symptoms, she was discharged home with oral drugs of glycyrrhizin and bicyclol and was continued to be followed up in the outpatient department. Two weeks later, lab tests suggested that ALT and AST decreased to the normal range.
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning22 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Female
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 15-day-old girl was brought to the emergency center with a 2-day recurrent fever after contracting confirmed cases of COVID-19. The peak temperature was 38.1 C. Besides fever, she had a stuffy nose and a mild cough. She did not develop diarrhea and vomiting during the course. She had no complicated perinatal history. Her examination was febrile at 38.1 C with a respiratory rate of 48 breaths/min and oxygen saturation of 98%-100%. She had normal respiratory effort, and coarse breath sounds could be heard in all lung fields. Lab data of the WBC, CRP, blood gas, transaminase levels, and bilirubin levels were all in the normal range. The PCR test was positive for SARS-CoV-2 without other positive findings of other pathogens [RSV, EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), influenza A/B, adenovirus, mycoplasma, chlamydia, HIV, Human metapneumovirus, rhinovirus, and hepatitis B/C virus]. After admission, the baby was given the nebulization treatment of budesonide and ipratropium bromide, using normal saline and nasal drops to relieve nasal congestion and keep the nasal cavity clean (see Table 1).
The baby returned to normal temperature and developed frequent coughs over the days. Her lung examination demonstrated scattered crackles on the back side, and then, phlegm and wheezing sounds could be heard in the following days. Chest x-rays showed that bilateral lung markings increased and blurred, with patchy shadows on the right upper lung field (see Figure 1). The piperacillin/tazobactam for pneumonia was administered on the fourth day after admission. Since then, her symptoms and signs of respiratory improved gradually.
The baby got better on the 6th day after admission with wild nasal congestion. Laboratory tests showed that ALT and AST increased significantly (see Table 2 and Figure 2). She was also administered hepatoprotective treatment of glycyrrhizin and bicyclol. After a 2-week treatment, the liver function recovered totally.
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning23 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 0.0
Sex: Male
Title: Case report: Acute hepatitis in neonates with COVID-19 during the Omicron SARS-CoV-2 variant wave: a report of four cases
Keywords: covid-19; omicron variant; sars-cov-2; acute hepatitis; liver injury; neonate; transaminase;
Abstract:
Background:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), first emerging in December 2019 and continuously evolving, poses a considerable challenge worldwide. It was reported in the literature that neonates had mild upper respiratory symptoms and a better outcome after Omicron SARS-CoV-2 variant infection, but there was insufficient data about complications and prognosis.
Case presentation:
In this paper, we present the clinical and laboratory characteristics of four COVID-19 neonate patients with acute hepatitis during the Omicron SARS-CoV-2 variant wave. All patients had a clear history of Omicron exposure and were infected via contact with confirmed caregivers. Low to moderate fever and respiratory symptoms were the primary clinical manifestations, and all patients had a normal liver function at the initial stage of the course. Then, the fever lasted 2 to 4 days, and it was noted that hepatic dysfunction might have occurred 5 to 8 days after the first onset of fever, mainly characterized by moderate ALT and AST elevation (>3 to 10-fold of upper limit). There were no abnormalities in bilirubin levels, blood ammonia, protein synthesis, lipid metabolism, and coagulation. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks without other complications.
Conclusions:
This is the first case series about moderate to severe hepatitis in COVID-19 neonatal patients via horizontal transmission. Besides fever and respiratory symptoms, the clinical doctor should pay much attention to evaluating the risk of liver function injury after SARS-CoV-2 variants infection, which is usually asymptomatic and has a delayed onset.
Image Caption and Description:
Image caption: Chest x-ray images of the four patients. (1) CASE 1: increased and blurred bilateral lung markings. (2) CASE 2: increased and blurred bilateral lung markings. (3) CASE 3: increased and blurred bilateral lung markings and patchy shadows on the right upper lung field. (4) CASE 4: increased and blurred bilateral lung markings.
Image description: Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1).
Image caption: ALT level trend over time of the four patients. All patients had normal liver function at the initial stage of the course. ALT elevation (>41 U/L) occurred 5 to 8 days after the first onset of fever, then reached 3 to 10 folds of the upper range. All the patients received hepatoprotective therapy, and transaminase levels gradually decreased to the normal range after 2 to 3 weeks.
Image description: Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus.
Case Report:
A 24-day-old boy was admitted to the NICU for an 8-hour history of fever with a peak temperature of 38 C. The parents complained that the baby had a mild cough with sputum, and they noticed he seemed to have facial and lip cyanosis when feeding. The baby was lethargic and had a poor appetite, accompanied by watery diarrhea without emesis. He was born at a gestational age of 36w+4 via cesarean delivery. He had no remarkable perinatal history. His mother confirmed COVID-19 with fever and cough before he had symptoms. On physical examination, his temperature was 38 C with a respiratory rate of 46 breaths/min; blood pressure was in the normal range, and his SpO2 was 97% while feeding and breathing ambient air. Coarse breath without crackling sounds in all lung fields could be heard. No heart murmur was detected. Prominent reticulated mottling of the skin could be seen on the lower extremities, especially when he was febrile. Capillary refill time in the lower extremity was 2 s. The liver was palpated at 1 cm under the costal margin, and the spleen was not palpated. Laboratory data revealed that WBC, subsets proportion, CRP, procalcitonin (PCT), blood gas, electrolytes, transaminase, and bilirubin levels were all in the normal range. Blood culture was negative. No other apparent abnormalities were reported on the routine stool test. PCR test for the SARS-CoV-2 virus was positive. The common respiratory pathogens such as influenza A/B, RSV, parainfluenza, adenovirus, mycoplasma, and chlamydia were negative. Chest x-rays showed that bilateral lung markings increased and blurred (see Figure 1). The cardiac ultrasound was normal. The CRP tests were repeated, and sepsis was ruled out in the next few days. So, the baby was administered piperacillin/tazobactam for 36 h and nebulization treatment was given (see Table 1).
The fever lasted for 2 days, and the peak temperature was 38.6 C. The baby recovered with occasional cough and mild nasal congestion on the 5th day after admission. On the 6th day, the ALT and AST were significantly increased (see Table 2 and Figure 2). There was no evidence of infection for other pathogens related to liver injuries such as EBV, TORCH, ECHO virus, Coxsackie virus (CA16/CVB), and hepatitis B/C virus. He was also administered hepatoprotective treatment of glycyrrhizin and bicyclol.
The baby received hepatoprotective treatment for 5 days. On the 11th day after admission, repeated lab tests demonstrated that ALT and AST decreased to 97 U/L and 40 IU/L, respectively. Then he was discharged with hepatoprotective drugs. 4 days after discharge, the liver function went back to the normal range.
OUTPUT:
| PMC10196249 |
MultiCaRe_Reasoning24 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 5.0
Sex: Female
Title: Use of the adult attachment projective picture system in psychodynamic psychotherapy with a severely traumatized patient
Keywords: adult attachment projective picture system; adult attachment; psychoanalysis; psychotherapy; trauma;
Abstract:
The following case study is presented to facilitate an understanding of how the attachment information evident from Adult Attachment Projective Picture System (AAP) assessment can be integrated into a psychodynamic perspective in making therapeutic recommendations that integrate an attachment perspective. The Adult Attachment Projective Picture System (AAP) is a valid representational measure of internal representations of attachment based on the analysis of a set of free response picture stimuli designed to systematically activate the attachment system (George and West, 2012). The AAP provides a fruitful diagnostic tool for psychodynamic-oriented clinicians to identify attachment-based deficits and resources for an individual patient in therapy. This paper considers the use of the AAP with a traumatized patient in an inpatient setting and uses a case study to illustrate the components of the AAP that are particularly relevant to a psychodynamic conceptualization. The paper discusses also attachment-based recommendations for intervention.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
Gloria lived in an intact family with her parents and three younger siblings until her parents divorced at age 5, but she provided no details about her childhood before this time and would not speak at all about her biological father. Gloria and her siblings lived predominantly with their mother after the divorce. Her mother remarried 5 years later when Gloria was 10 years old and she viewed her stepfather as her "actual" father. She described him as being humorous, loved, and trusted, but she also described him impulsive, irascible, and argumentative. Gloria seemed insecure about her stepfather's acceptance, wondering how far she could push him before he would break. Would he accept her even if she acted like a wild child? Gloria stated that "once a week I pushed him until he burst," and she told how she tested him with "mischievousness" so as to push her stepfather into beating her. Gloria's deliberate misbehavior and her stepfather's beatings were central to their relationship.
Gloria's first major traumatic experience as a sadistic rape in late adolescence. The only details that she provided about her rape was that it occurred during daytime and that she did not know the rapist. After the rape, she began around 3 weeks later to have sudden headache and fainting attacks, fainting as much as three times a day. She also developed chronic dissociation experiences. Gloria's symptoms appeared to be associated with feeling of being exposed and to school or performance-related pressure. Although these problems persisted, she did not seek psychological treatment. Her symptoms, especially fainting, diminished when she studied abroad. Her symptoms reoccurred after returning home 2 years later, however, and she decided to go back abroad.
OUTPUT:
| PMC4122203 |
MultiCaRe_Reasoning25 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 30.0
Sex: Female
Title: Use of the adult attachment projective picture system in psychodynamic psychotherapy with a severely traumatized patient
Keywords: adult attachment projective picture system; adult attachment; psychoanalysis; psychotherapy; trauma;
Abstract:
The following case study is presented to facilitate an understanding of how the attachment information evident from Adult Attachment Projective Picture System (AAP) assessment can be integrated into a psychodynamic perspective in making therapeutic recommendations that integrate an attachment perspective. The Adult Attachment Projective Picture System (AAP) is a valid representational measure of internal representations of attachment based on the analysis of a set of free response picture stimuli designed to systematically activate the attachment system (George and West, 2012). The AAP provides a fruitful diagnostic tool for psychodynamic-oriented clinicians to identify attachment-based deficits and resources for an individual patient in therapy. This paper considers the use of the AAP with a traumatized patient in an inpatient setting and uses a case study to illustrate the components of the AAP that are particularly relevant to a psychodynamic conceptualization. The paper discusses also attachment-based recommendations for intervention.
Image Caption and Description:
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Case Report:
Gloria's second major traumatic experience was at 30 years old when her boyfriend of 2 years died in an accident. Gloria had separated from him shortly before his death, the reason being that she was no longer able to tolerate physical closeness. She felt severely guilty about his death and her guilt had masochistic qualities. As a result, she did not have another intimate relationship for many years.
Gloria had recently experienced a third trauma prior to her decision to seek treatment. She had been in a serious accident in which she had been thrown out of her car and into the air rendering her unconscious. She was thought at first to be dead. Her physical injuries included three spinal discs and a strain on the cervical spine and her fainting episodes increased to many episodes a day. Although Gloria reported in her initial interview, almost proudly, saying "I survived this," and she had since was unable to work.
Gloria felt that her symptoms had become debilitating, and she noticed that her fainting spells seemed related to stress. Her headaches had become so severe that she risked becoming unconscious. She was not able to recall what preceded the headaches and she could not remember any indicators associated with their onset, such as less debilitating headaches or other physical warning signs. Gloria described herself as being on autopilot. This "defensive mechanism" had saved her life more than 20 years ago, but now this automatic mechanism was out of her control.
Gloria had not allowed herself to think about this until she entered treatment and her treatment goal was "to get rid of it." She had a stiff commitment to being strong and carrying on. "I want to function. I will get through this. I want to be able to work. I have worked for many years to wipe out the traumatic event, to get rid of it, to repress it." This perspective had dominated her life and kept her moving forward. She was frightened of not being able to be in control of her symptoms and the prospect of becoming dependent on the pain medication prescribed to combat her severe headaches.
was a prominent psychoanalyst to use ethological concepts to describe the infant's biologically predisposed attachment to a primary caregiver. He viewed relatedness in early childhood as a primary and independent developmental goal that is not subservient to a physiological needs (e.g., hunger) or psychoanalytically defined primary processes. The infant is perceived from an interactional perspective, with a focus on the relationships with primary attachment figures. Attachment theory maintained some foundations of psychoanalytic theory (e.g., the developmental point of view) and there is a strong literature that discusses the divergences and convergences of psychoanalysis and attachment theory (e.g.,) and also developed some aspects further, particularly the delineation of the internal world.) overview of the intersection of these two approaches demonstrated that the relationship between attachment theory and psychoanalysis is more complex than adherents of either community have generally recognized. This paper addresses some of these complexities by integrating attachment assessment using the Adult Attachment Projective Picture System (AAP) in psychodynamic psychotherapy in an adult traumatized patient.
proposed that one major difference between psychoanalysis and attachment theory falls in the description of forms of defensive processes. Traditional psychoanalytic models provide a complex constellation of defenses to interpret a broad range of intrapsychic phenomenon, including phantasy, dream, wish, and impulse (e.g.,). Attachment theory delineates two basic processes that manifest in three forms. According to), Bowlby defined defense as forms exclusion directed to modulating difficult and anxious experiences with attachment figures, and the child's experiences with incomplete or failed bids for parental protection, care, and comfort. He defined defenses in terms of two qualitatively distinct processes: deactivation (retaining elements of intellectualization and denial) and cognitive disconnection (retaining elements of splitting).) pointed out that under normal circumstances these two exclusion processes are associated with goals to maintain physical and psychological proximity in the attachment-caregiving relationship under conditions when the child's experiences with the attachment figure are less than satisfying. George and Solomon refined model suggesting that deactivation and cognitive disconnection organized and supported at least minimal forms of representational, behavioral, and emotional regulation. proposed that these forms defensive exclusion functioned to segregate (akin to repression) memory, affect, and experience when the attachment figure was not available, conceiving of an extreme process he termed "segregated systems." Segregated systems were thought as associated with the painful and chronic distress experiences, such as those that accompany loss. Bowlby posited that segregated systems were the intrapsychic root of symptoms related pathological mourning and severe psychopathology. Attachment theorists have since demonstrated that segregated systems are associated with experiences of failed protection, attachment trauma, and disorganized/dysregulated attachment behavior and representation.
Consistent with a psychoanalytic approach, some attachment theorists have suggested that utilization of defensive process models is needed to provide a complete picture of the emotional and behavioral regulation processes individuals develop from their childhood relationships with attachment figures. Further, concluded, "In order to understand the relationship between adult attachment and mental health risk we need to examine the attachment concepts of defense and segregated systems, the mental processes that define disorganization" (p. 295). These theorists operationally defined basic defense scheme as a central element for evaluating representational patterns of attachment using the Adult Attachment Projective Picture System. Suggesting that these representational structures have developed under conditions of attachment trauma (abuse, loss, failed protection), the concept of segregated systems is fruitful to explain some forms of relationship-based psychopathology in adults.
The discussion that follows provides some ideas about using attachment concepts in clinical work by showing how the perspectives of a psychoanalyst and attachment assessment may improve the understanding of an individual case of a traumatized patient with the diagnosis of a PTSD with dissociative states (e.g., fainting in response to stressful situations).
The lifetime prevalence of PTSD in Germany has been found to be 1.3% with a female-to-male ratio of 3.25-1. Traumatized patients are frequently misdiagnosed and mistreated in the mental health system. The number and complexity of the symptoms lead to fragmented and incomplete treatment. PTSD patients are vulnerable to become re-victimized by caregivers because of their difficulties with close relationships. Severely traumatized PTSD patients (complex trauma) develop difficulties in modulating arousal and show signs of severe affect dysregulation (e.g., aggression against self and other, and problems with social attachment and dissociative states).
Dissociation, defined as a deficit of the integrative functions of memory, consciousness and identity, is often related to traumatic experiences and traumatic memories. During clinical interviews, dissociation is suggested either by such a degree of unwitting absorption in mental states that ordinary attention to the outside environment is seriously hampered. Dissociation can be accompanied by a sudden lack of continuity in discourse, thought or behavior of which the person is unaware (supposedly due to intrusion of dissociated mental contents in the flow of consciousness). Thus, for instance, a dissociative patient may suddenly interrupt her speech during a therapeutic session, stare into the void for minutes, and become unresponsive to the therapist's queries as to what is happening to her. Or a patient suffering from PTSD may suddenly utter fragmented and incoherent comments on intrusive mental images (usually related to traumatic memories) that surface in consciousness and hamper the continuity of the preceding dialog with the therapist. In the most extreme variety of dissociation (Dissociative Identity Disorder), an alternate ego state may appear during the clinical dialog, reporting (sometimes with an unusual tone of voice, e.g., like a child) memories of childhood abuse of which the patient has previously been totally unaware, or expressing attitudes and beliefs quite extraneous to the patients' personality.
Furthermore, shattered meaning propositions predominate. Trust, hope and sense of agency is accompanied by social avoidance, with loss of meaningful attachment and therefore lack of participation in preparing for future.
The founding premise of attachment theory is that stress, especially traumatic stress, produces a strong desire for proximity to and comfort by attachment figures; this desire is built into human biology as a survival safety mechanism and the mechanism is functions unchanged throughout the life span. Attachment experience shapes the ways in which individuals manage stress and are especially important when individuals experience a traumatic event. When attachment is secure, individuals know how and when to seek attachment figures and develop internal representations of self as deserving of care. Attachment security fosters confidence and trust that figures are available, empathic, and sensitive to their needs; security is a buffer or resilience factor that supports recovery from trauma. When attachment is insecure, emotional and behavioral reactions when distressed may be made even more painful by unconscious evaluations that wishes for comfort are illegitimate. Insecurity may result in additional painful interactions with the attachment figures rather than the functional comfort and protection for which attachment was intended. Insecurity fosters anxiety, anger, and fear, and increases the risk of developing trauma-related emotional disorders. Extreme forms of insecurity are associated with the breakdown of attachment and caregiving regulatory mechanisms risk emotional and homeostatic dysregulation, often termed disorganized attachment. The risk of dysregulation is heightened when attachment relationships are threatened or threatening, such as parental loss or psychiatric debilitation or maltreatment. defined events such as these as attachment traumas, events that involve terrifying threats to the integrity of self or attachment relationships. Attachment disorganization, conceived in terms of mechanisms of dysregulation and attachment trauma, has been shown to predict vulnerability to severe psychiatric symptomology, including dissociative symptoms.
found the metaphor of a "drama triangle" useful in thinking about the intersection between dissociation and disorganized attachment. The dissociation triangle addresses how disorganized attachment fosters dissociative mechanisms that create incompatible and separate representations of self as victim, rescuer, and persecutor. The child's representation of the attachment figure is represented in a conflicting manifold way. On the one side, the attachment figure is represented as source of the child's fear, the self as a victim of attachment figure as persecutor. On the other side, the attachment figure by virtue of being the child's biological protector is viewed as the child's source of safety and protection (rescuer). In the child's mind, representation of self and attachment figure shift among these three incompatible models that are too complex to be synthesized into an integrated model of self. Liotti's model provides us with an integrated psychodynamic and attachment approach to our first questions concerning Gloria's illness, questions regarding the childhood origins of her episodes of near unconsciousness and her inability to ask for help following traumatic assault.
examined cognitive perspectives on unresolved attachment in patients diagnosed with PTSD. They proposed that unresolved loss, as defined in attachment assessment during interview, involves intrusion avoidance phenomena similar to those of PTSD. Specifically, they develop a model based on unresolved loss that involves the failure to integrate representations of self and the world following a loss. The features of unresolved loss can be understood as emerging as a result of the activation of unintegrated representations of the loss experience and cognitive and behavioral avoidance processes. In this model, the sudden intrusion of memories, cognitions, and emotions associated with the loss automatically captures attention and initiates behavioral dispositions that are incompatible. With regard to attachment, the authors suggested that this was the mechanism that interfered with caregiving behavior. Lack of attentional resources and incompatible response tendencies can also result from safety behaviors directed at avoiding the perceived negative consequences of activating trauma memory. The authors proposed that these processes offer a novel way of understanding the disturbances in behavior and speech that are evident in mothers who are designated as unresolved with respect to loss.
This suggests that representational attachment measures, like the AAP, can provide a good understanding of the movement that the client might be making toward empowerment, integration, or understanding. Thus, even if a patient's overall attachment is unresolved (i.e., dysregulated), there may be indications in their responses to the AAP stimuli that suggest they are moving toward mental organization. Given the negative outcomes that are associated with abuse, focusing on resources and defensive strategies is arguably important for therapeutic recommendations.
OUTPUT:
| PMC4122203 |
MultiCaRe_Reasoning26 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 20.0
Sex: Male
Title: Characterization of Forearm Muscle Activation in Duchenne Muscular Dystrophy via High-Density Electromyography: A Case Study on the Implications for Myoelectric Control
Keywords: duchenne muscular dystrophy; forearm; hand; high-density surface electromyography; motor control; myocontrol; principal component analysis (pca); wrist;
Abstract:
Duchenne muscular dystrophy (DMD) is a genetic disorder that results in progressive muscular degeneration. Although medical advances increased their life expectancy, DMD individuals are still highly dependent on caregivers. Hand/wrist function is central for providing independence, and robotic exoskeletons are good candidates for effectively compensating for deteriorating functionality. Robotic hand exoskeletons require the accurate decoding of motor intention typically via surface electromyography (sEMG). Traditional low-density sEMG was used in the past to explore the muscular activations of individuals with DMD; however, it cannot provide high spatial resolution. This study characterized, for the first time, the forearm high-density (HD) electromyograms of three individuals with DMD while performing seven hand/wrist-related tasks and compared them to eight healthy individuals (all data available online). We looked into the spatial distribution of HD-sEMG patterns by using principal component analysis (PCA) and also assessed the repeatability and the amplitude distributions of muscle activity. Additionally, we used a machine learning approach to assess DMD individuals' potentials for myocontrol. Our analysis showed that although participants with DMD were able to repeat similar HD-sEMG patterns across gestures (similarly to healthy participants), a fewer number of electrodes was activated during their gestures compared to the healthy participants. Additionally, participants with DMD activated their muscles close to maximal contraction level (0.63 ± 0.23), whereas healthy participants had lower normalized activations (0.26 ± 0.2). Lastly, participants with DMD showed on average fewer PCs (3), explaining 90% of the complete gesture space than the healthy (5). However, the ability of the DMD participants to produce repeatable HD-sEMG patterns was unexpectedly comparable to that of healthy participants, and the same holds true for their offline myocontrol performance, disproving our hypothesis and suggesting a clear potential for the myocontrol of wearable exoskeletons. Our findings present evidence for the first time on how DMD leads to progressive alterations in hand/wrist motor control in DMD individuals compared to healthy. The better understanding of these alterations can lead to further developments for the intuitive and robust myoelectric control of active hand exoskeletons for individuals with DMD.
Image Caption and Description:
Image caption: The figure shows the process of the electrode placement. (A) The flexible custom-made sleeve that was used for marking the skin of the participant. The sleeve is flexible only around the circumferal direction and stiff along the longitudinal direction of the arm. (B) The marked skin of the participant. The longitudinal inter-electrode distance (LID) is fixed at 2 cm (L), while the circumferal inter-electrode distance (CID) depends on the forearm width of each participant. (C) The participant with all the 64 electrodes placed. The imaginary line (red line) that connects the lateral epicondyle and the styloid process of the ulna was used as the border between the dorsal and ventral side of the forearm. The placement of the electrodes starts right above this line, with electrode number one placed proximally (at 20% of forearm length from the elbow) and eight distally. The rest of the electrode rows are placed counterclockwise as someone is looking at his right arm. (D) This way, electrodes 1-32 were placed over the dorsal side (see sketch) and 33-64 over the ventral side of the forearm. The center of gravity (COG) is also shown for this gesture.
Image description: The experimental setup (Figure 1) included several components, and it was designed to record HD-sEMG signals from the forearm in a repeatable and systematic way.
Then, we measured the forearm length from the lateral epicondyle until the styloid process of the ulna and the forearm circumference at 20% of the forearm length from the elbow (Figure 1).
The participant had to wear a perforated sleeve (Figure 1) with equally placed holes and elastic only along the circumferal direction to ensure that the electrode placement was standardized for all participants.
We used a non-permanent marker to mark the skin of the participant (Figure 1) and then visually inspect the markings before applying the electrodes.
The first row of electrodes was placed above the imaginary line between the lateral epicondyle and the styloid process of the ulna and the last row below in such a way that the line lay in the middle between the two rows of electrodes (Figure 1).
Image caption: The 10 repetitions of third Duchenne muscular dystrophy (DMD) participant (DP3) for wrist extension that were used to acquire the average normalized map. The lower part shows an example of the protocol followed to record the data. In this example, the participant was instructed to extend his wrist for 3 s and then rest for 3 s. This was repeated 10 times. The same procedure was followed for all the seven gestures.
Image description: Participants performed seven different gestures involving hand and wrist motions (Figure 2).
For every gesture, 10 repetitions of 3 s contractions were performed, together with 10 repetitions of 3-s resting periods between the contractions (Figure 2).
For every electrode, the average of this 1-s contraction was calculated and used to construct 10 heatmaps per gesture (Figure 2).
Image caption: The heatmaps of two representative gestures for the three participants with Duchenne muscular dystrophy (DMD) and one healthy participant. (A-D) show wrist extension heatmaps for DP1 (A), DP2 (B), DP3 (C), and HP6 (D). (E-G) show wrist flexion heatmaps for DP1 (E), DP2 (F), DP3 (G), and HP6 (H). Regarding wrist extension, all participants exhibit similar activation patterns. However, for wrist flexion, there is higher variability in the activation patterns within participants. X marks show the center of gravity (COG) for each heatmap. Only the activations that are higher than 80% are used to calculate the COG.
Image description: For the visual inspection of the forearm activity per gesture, we constructed activity heatmaps by averaging the 10 repetition heatmaps (Figure 3).
The COG was calculated over electrodes presenting activations equal or larger than 80% of the maximal value of the heatmap (Figure 3).
The 10 heatmaps, one per gesture repetition, were used to construct one single average heatmap per gesture per participant (Figure 3) that was used for the motor control analysis.
Image caption: The histogram of squared Pearson correlation between the 10 repetitions for all gestures and for all participants. High correlation shows similarity between the repetitions and thus high repeatability. Both healthy and Duchenne muscular dystrophy (DMD) participants achieved similarly high repeatability on the tasks. The full vertical lines represent the mean and the dashed the standard deviation. The number of unique comparisons between 10 repetitions is 45 multiplied by the seven gestures makes 315 unique comparisons per participant. That explains the total of 2,520 events in the healthy histogram compared to the 945 in the DMD.
Image description: For every gesture, this resulted in 45 unique comparisons between the 10 repetitions and thus 45 coefficients per gesture (Figure 4).
Image caption: (A) The maximum normalized (left) and absolute (right) activation for each of the 10 repetitions of each gesture for all participants. Healthy participants generally performed the tasks with low levels of maximum normalized activation, while participants with Duchenne muscular dystrophy (DMD) showed higher levels of maximum normalized activation during the tasks. However, the maximum absolute activations were higher for the healthy participants. The full vertical lines represent the mean and the dashed the standard deviation. (B) The average center of gravity (COG) for the seven gestures for the healthy participants (black) and the participants with DMD (red). Healthy participants (gray shaded area) show on average a broader spatial distribution of the seven gestures than the participants with DMD (red shaded area). The red line represents the imaginary line that connects the lateral epicondyle and the styloid process of the ulna and was used as the border between the dorsal and ventral side of the forearm (see also Figure 1). The COG coordinates are normalized over the forearm circumference (COGx) and length (COGy).
Image description: The temporal distribution of activations between healthy and DMD was calculated via normalized and absolute activations per repetition of each gesture (Figure 5A).
Figure 5B shows the average spatial distribution of the healthy and DMD participants.
Image caption: (A) The percentage of variance explained as a function of the number of cumulative principal components (PCs). More than 90% of the variance (blue dashed line) of the data of the participants with Duchenne muscular dystrophy (DMD) is explained by three PCs, while for the healthy by five. The full lines represent the mean and the dashed the standard deviation. For clarity, we include only up to 10 of the 63 components, as those explain more than 99% of the variance explained. (B) The averaged squared Pearson correlation between the seven gestures of both groups of participants in the form of a similarity matrix. High correlation shows similarity between the gestures. Both healthy and DMD participants show correlated gestures; however, this phenomenon is more prominent in the DMD participants. A high value shows high correlation where one is the maximum (diagonal). The number of unique comparisons between the seven gestures is 21 per participant.
Image description: This number was used to explore the repertoire of orthogonal and uncorrelated sEMG patterns produced by the two groups of participants (Figure 6A).
We averaged the correlation values of the healthy participants and the participants with DMD separately to identify which gestures are mostly correlated per population, and we presented this in the form of a similarity matrix (Figure 6B).
Case Report:
The DMD participants had different levels of hand function. Participant one (DP1, 20 years old) was able to use his hands functionally, and no contractures relevant to hand/wrist movement were observed. Participant two (DP2, 22 years old) was able to functionally use his hand but experienced a decrease in strength and minimal contractures relevant to hand/wrist movement. Participant three (DP3, 25 years old) was not able to use his hands at all and was affected by immediate onset of fatigue during its use. Extensive contractures relevant to finger movement were observed, and only minimal movement of the fingers was possible (see Supplementary Video). All participants were able to perform the experimental protocol.
The Medical Ethics Committee of Twente approved the study design, the experimental protocol, and the procedures (Protocol number: NL59061.044.16). The study was conducted according to the ethical standards given in the Declaration of Helsinki in 1975, as revised in 2008.
The experimental setup (Figure 1) included several components, and it was designed to record HD-sEMG signals from the forearm in a repeatable and systematic way. Muscular activity was measured with a 128-channel amplification system (REFA 128 model, TMS International, Oldenzaal, The Netherlands). We used 64 monopolar electrodes around the forearm to acquire the raw sEMG signals. The signals were recorded with a decimal gain of 26.55 before the analog-to-digital converter (ADC); however, this gain factor is compensated by the acquisition software (Polybench, TMS International, Oldenzaal, The Netherlands), after the ADC. Additionally, REFA includes a first-order analog low-pass filter placed before the ADC with a -3 db point at 6.8 kHz. The 6.8-kHz low pass helps to make the REFA immune to high-frequency electromagnetic interference such as mobile phone networks. The analog signals were sampled with a frequency of 2,048 Hz and digitally converted with a 24-bit conversion (a resolution of 0.018 muV per bit, 300 mV dynamic range). The ADC of the device has an anti-aliasing digital low-pass filter with a cutoff frequency of 0.2 * sample frequency. This filter inside the ADC is used to convert the 1-bit signal with a high frequency into a 24-bit signal with a lower frequency. The acquisition software was executed in a host laptop (Lenovo Thinkpad T490, Lenovo, Beijing, China) with a Windows 10 operating system (Microsoft Corporation, Washington, USA). A computer screen was used to provide visual feedback of the task to the participants.
Electrode placement and configuration were based on previous work that normalized the electrode locations to each participant's arm circumference in order to account for different forearm thicknesses (Table 1). The inter-electrode distance in the longitudinal direction of the forearm was kept constant at 2 cm for covering the entire forearm.
First, we cleaned the skin of the dominant forearm of the participant with alcohol. Then, we measured the forearm length from the lateral epicondyle until the styloid process of the ulna and the forearm circumference at 20% of the forearm length from the elbow (Figure 1). The participant had to wear a perforated sleeve (Figure 1) with equally placed holes and elastic only along the circumferal direction to ensure that the electrode placement was standardized for all participants. We used a non-permanent marker to mark the skin of the participant (Figure 1) and then visually inspect the markings before applying the electrodes.
Conductive gel was applied to each of the 64 electrodes with a syringe, and they were subsequently attached to the forearm. The first row of electrodes was placed above the imaginary line between the lateral epicondyle and the styloid process of the ulna and the last row below in such a way that the line lay in the middle between the two rows of electrodes (Figure 1). The first electrode was attached proximally starting at the 20% of the forearm length from the elbow. Electrodes were placed from proximal to distal and in counterclockwise direction (from the perspective of a right-handed participant). This way, electrodes 1-32 were placed over the dorsal side (mostly extensor muscles) and 33-64 over the ventral side (mostly flexor muscles) of the forearm. The reference electrode was placed at the distal end of the forearm, over the head of the ulna.
Participants performed seven different gestures involving hand and wrist motions (Figure 2). The chosen gestures included: hand open/close, thumb flexion/extension, wrist flexion/extension, and index extension. These were chosen as they are involved in the most frequent ADL. First, each participant was instructed to perform all gestures without constraints (dynamic) with maximal voluntary effort in a single recording. This way, we recorded the maximum voluntary contraction (MVC) for every electrode across all gestures. For every gesture, 10 repetitions of 3 s contractions were performed, together with 10 repetitions of 3-s resting periods between the contractions (Figure 2). The participants were instructed to perform all movements in a comfortable fashion in order to avoid forceful contractions that may elicit co-contractions of agonist-antagonist muscle groups.
The timing of the gestures was dictated with the use of visual feedback. The visual feedback illustrated via photographs of human hands which gesture had to be performed. The sequence of images served to instruct the participant as a metronome when to perform the gesture (image of gesture appearing for 3 s) and when to relax (image of relaxed hand appearing for 3 s). Additionally, the measurements were performed in the morning in order to avoid effects of the end-of-the-day fatigue, especially for the participants with DMD. Furthermore, the participants had short breaks between gestures in order to rest.
All signal processing and data analyses were performed in Matlab 2018b software (The MathWorks Inc., USA). The raw sEMG signals were processed offline in order to compute the envelopes for each of the 64 electrodes per gesture and per participant. First, the raw data were filtered with a band-pass filter (fourth-order Butterworth, 20-450 Hz). Additionally, a second-order digital infinite impulse response notch filter (cutoff frequency of 50 Hz, Q factor of 50) was used to remove the power line noise (50 Hz for the EU). Despite its main limitation (signal distortion around the attenuated frequency), notch filtering is the mainstream technique for powerline signal removal, and a narrow bandwidth with a high Q factor can already address this. For highly powerline-contaminated signals, spectral interpolation may be more appropriate. The signals were subsequently rectified and filtered with a low-pass filter (third-order Butterworth, 2 Hz). Our choice for the cutoff frequency was motivated by the low-frequency dynamic tasks involved in this study and our previous study on real-time sEMG control of a hand exoskeleton. The resulting envelopes were visually inspected segmented, according to the acquisition protocol, to 10 contractions and periods (each lasting approximately 3 s) and normalized. A threshold was selected to define the onset of the activity, and the next 3 s after the onset were chosen as a contraction period. The threshold was defined as the time that the signal exceeded 10 standard deviations of the baseline (non-contraction) activity similar to Di Fabio, and the final segmentation was additionally assessed visually. The maximum value of the envelope of each electrode across the complete dataset was used as a normalization value for each electrode. This value was acquired using a moving average window of 1 s in order to account for signal artifacts. Signal quality was visually assessed both in the time and frequency domains, and faulty channels were replaced by linear interpolation of their surrounding neighboring channels (8-neighborhood). Different local conditions were applied to faulty electrodes placed in the longitudinal extremes (<8 neighboring channels).
Every 3-s contraction was further segmented in 1-s segments by keeping only the middle second of the contraction (steady-state phase) and discarding the transient phase. For every electrode, the average of this 1-s contraction was calculated and used to construct 10 heatmaps per gesture (Figure 2). For the visual inspection of the forearm activity per gesture, we constructed activity heatmaps by averaging the 10 repetition heatmaps (Figure 3).
We analyzed the data to assess HD-sEMG pattern repeatability, peaks, and dimensionality, as well as individuals' potential to generate activation patterns suitable for myocontrol applications for both healthy and DMD participants. The raw data used for this analysis are available online. All signal processing and data analyses were performed in Matlab 2018b software (The Mathworks Inc., USA). In the remainder of this section, we describe a set of analyses aimed at investigating differences between DMD and healthy participants at the level of motor control properties (Motor Control Properties section) and myocontrol performance (Myocontrol Performance section).
The degree of repeatability across repetitions per participant was calculated using squared Pearson correlation. Each heatmap (8 x 8) was reshaped into a vector (1 x 64) before the calculation of the squared Pearson correlation. The coefficient was extracted among the 10 repetitions per gesture and per participant. For every gesture, this resulted in 45 unique comparisons between the 10 repetitions and thus 45 coefficients per gesture (Figure 4).
The temporal distribution of activations between healthy and DMD was calculated via normalized and absolute activations per repetition of each gesture (Figure 5A). A normalization factor was calculated across all gestures and repetitions. For each gesture, the maximum absolute and normalized value of the 64-electrode heatmap were calculated for every participant and each repetition and plotted.
Figure 5B shows the average spatial distribution of the healthy and DMD participants. The spatial distribution of the sEMG potentials over the 8 x 8 normalized heatmap was calculated using the center of gravity (COG) by calculating the dorsal-ventral and the proximal-distal position of it as proposed by Elswijk et al.. The COG was calculated over electrodes presenting activations equal or larger than 80% of the maximal value of the heatmap (Figure 3). This way, only clusters of electrodes with a high peak amplitude were considered for the calculation of the COG in order to focus on the most relevant area of activation for each gesture.
The 10 heatmaps, one per gesture repetition, were used to construct one single average heatmap per gesture per participant (Figure 3) that was used for the motor control analysis. We quantified differences in dimensionality of orthogonal and uncorrelated sEMG patterns between the healthy and DMD participants via a PCA to the gesture-specific heatmaps per participant. For every participant, we performed a PCA to the concatenation (64 x 70) of the sEMG heatmaps of all gestures and repetitions per participant [64 electrodes x (7 gestures x 10 repetitions)]. The number of PCs needed to reconstruct the original seven gesture heatmaps was identified per participant by means of the variance explained (VE), and it was taken as the number of PCs that summed together explained more than 90% of the total variance. This number was used to explore the repertoire of orthogonal and uncorrelated sEMG patterns produced by the two groups of participants (Figure 6A).
Additionally, we calculated the squared Pearson correlation between all the gestures per participant (the same way as we did for the repeatability, Activation Pattern Repeatability Tests section). The coefficient was extracted from the average normalized heatmap of the 10 repetitions per gesture and per participant. For every participant, this resulted in 21 unique comparisons between the seven gestures and thus 21 coefficients per participant. We averaged the correlation values of the healthy participants and the participants with DMD separately to identify which gestures are mostly correlated per population, and we presented this in the form of a similarity matrix (Figure 6B).
We explored participants' gesture recognition performance via an offline pattern recognition algorithm applied to the band-pass filtered data (fourth-order Butterworth, 20-450 Hz) of each participant. We used a linear discriminant analysis (LDA) to recognize each of the gestures performed. LDA is a commonly used pattern recognition algorithm for prosthetic control and already commercialized by COAPT LLC (Chicago, USA). We chose it for the ease of implementation, classification speed, and high accuracy compared to other similar approaches. The 10 steady-state segments for every gesture were concatenated and created a 10-s vector. We trained the classifier by extracting four time-domain features from the raw segmented data including mean absolute value, zero crossing, slope sign change, and waveform length. We chose for a feature extraction window of 200 ms (with an overlap of 100 ms), which would be within acceptable range for real-time myoelectric applications. The classifier was validated with a three-split Monte Carlo cross-validation approach. Each time, a different part of the segmented data was used for training (always 70%) and testing (always 30%). The average off-line classification accuracy of these three trainings was used as performance metric per participant. Additionally, we tested how the offline classification accuracy per participant was affected by the number of gestures that had to be classified.
OUTPUT:
| PMC7174775 |
MultiCaRe_Reasoning27 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 58.0
Sex: Female
Title: Multimodal Imaging Characteristics of ADRP in a Family with p.Thr58Arg Substituted RHO Mutation
Keywords: None
Abstract:
Background:
Autosomal dominant retinitis pigmentosa (adRP) is a rare cause of progressive visual impairment in young patients and is frequently a result of RHO gene mutations. p.Thr58Arg rhodopsin mutation leads to misfolding of rhodopsin, subsequent accumulation in the endoplasmic reticulum, and leads to consecutive atrophy of photoreceptor cells through apoptosis.
Materials and methods:
We describe multimodal imaging findings in a 58-year-old female with adRP due to a c.173 C > G, p.Thr58Arg rhodopsin mutation (confirmed on genotyping), including ultra-wide-field fundus autofluorescence (UWF-FAF), color scanning laser ophthalmoscopy, structural optical coherence tomography (OCT), OCT-angiography (OCT-A), electroretinography (ERG), and visual field testing (HVF). Additionally, we compare the patient's phenotypic findings to those of her offspring, who was also affected by adRP.
Results:
The 58-year-old female and her son with symptoms of nyctalopia and decreased vision showed macular pigmentary changes in a bull's-eye pattern along with bone spicules in periphery with retinal atrophy. Genotyping confirmed p.Thr58Arg rhodopsin mutation. Wide area of dystrophic retina was noted on UWF-FAF, along with corresponding atrophy of photoreceptor layer on OCT. OCTA revealed complete nonperfusion of the superficial capillary plexus in areas of retinal dystrophy. ERG revealed increased latency and decreased amplitudes; HVF revealed constriction of visual fields consistent with retinal findings.
Conclusions:
Multimodal imaging is extremely helpful in delineating the extent of retinal dystrophy and comparable to ERG for monitoring of progress in retinitis pigmentosa. Photoreceptor layer thickness (measured with OCT) strongly correlated with ERG and can be used as a secondary surrogate for monitoring the disease progress.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
A 58-year-old female presented with complaints of progressive loss of vision and flashes of light in both eyes (OU). Her past ocular history was significant for progressive nyctalopia which was gradually worsening since her childhood. Her past medical history was significant for asthma, depression, musculoskeletal pain, well-controlled hypertension, and hyperlipidemia. Her systemic medications included hydrochlorothiazide, lisinopril, aspirin, albuterol, buspirone, duloxetine, lorazepam, gabapentin, hydrocodone-acetaminophen, tizanidine, and trazodone.
The patient's family history of adRP was further explored. Her paternal grandmother and the grandmother's two daughters were affected by RP. She has one son who is also affected with nyctalopia.
Her best-corrected visual acuity (BCVA) was 20/40 OD and 20/30 OS. Her intraocular pressure (IOP) was 20 OD and 19 OS. Anterior segment examination was unremarkable.
Fundoscopy of the right eye revealed normal optic nerve with a cup-to-disc ratio of 0.1 bilaterally. Examination of the posterior pole revealed perimacular pigmentary changes in a bull's-eye pattern. Large area of retinal atrophy in a doughnut shape was noted around vascular arcades. Attenuated vasculature was noted in the area of the dystrophic retina. Peripheral retinal examination revealed bone spicule pigmentation along the inferonasal quadrant.
Fundoscopy of OS showed similar findings. Bone spicules were noted in the inferotemporal quadrant.
OUTPUT:
| PMC7969344 |
MultiCaRe_Reasoning28 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 38.0
Sex: Male
Title: Multimodal Imaging Characteristics of ADRP in a Family with p.Thr58Arg Substituted RHO Mutation
Keywords: None
Abstract:
Background:
Autosomal dominant retinitis pigmentosa (adRP) is a rare cause of progressive visual impairment in young patients and is frequently a result of RHO gene mutations. p.Thr58Arg rhodopsin mutation leads to misfolding of rhodopsin, subsequent accumulation in the endoplasmic reticulum, and leads to consecutive atrophy of photoreceptor cells through apoptosis.
Materials and methods:
We describe multimodal imaging findings in a 58-year-old female with adRP due to a c.173 C > G, p.Thr58Arg rhodopsin mutation (confirmed on genotyping), including ultra-wide-field fundus autofluorescence (UWF-FAF), color scanning laser ophthalmoscopy, structural optical coherence tomography (OCT), OCT-angiography (OCT-A), electroretinography (ERG), and visual field testing (HVF). Additionally, we compare the patient's phenotypic findings to those of her offspring, who was also affected by adRP.
Results:
The 58-year-old female and her son with symptoms of nyctalopia and decreased vision showed macular pigmentary changes in a bull's-eye pattern along with bone spicules in periphery with retinal atrophy. Genotyping confirmed p.Thr58Arg rhodopsin mutation. Wide area of dystrophic retina was noted on UWF-FAF, along with corresponding atrophy of photoreceptor layer on OCT. OCTA revealed complete nonperfusion of the superficial capillary plexus in areas of retinal dystrophy. ERG revealed increased latency and decreased amplitudes; HVF revealed constriction of visual fields consistent with retinal findings.
Conclusions:
Multimodal imaging is extremely helpful in delineating the extent of retinal dystrophy and comparable to ERG for monitoring of progress in retinitis pigmentosa. Photoreceptor layer thickness (measured with OCT) strongly correlated with ERG and can be used as a secondary surrogate for monitoring the disease progress.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
The patient's 38- year-old son had similar symptoms of nyctalopia since he was a child. His past medical history was unremarkable. He denied distortions, floaters, and flashing lights OU. His past ophthalmic history was unremarkable.
His BCVA was 20/40-2 OD and 20/60-2 OS. Her intraocular pressure (IOP) was 20 OD and 19 OS. Anterior segment examination was unremarkable.
Fundoscopy of OD revealed normal optic nerve with a cup-to-disc ratio of 0.1 bilaterally. The fovea was normal. Large area of retinal atrophy was noted along the inferior arcade. An attenuated vasculature was noted in the area of the dystrophic retina. Peripheral retinal examination revealed bone spicule pigmentation along the inferonasal quadrant.
Fundoscopy of OS showed similar findings. Bone spicules were noted in the inferotemporal quadrant.
OUTPUT:
| PMC7969344 |
MultiCaRe_Reasoning29 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 8.0
Sex: Male
Title: Intraparenchymal Atypical Meningioma in Basal Ganglia Region in a Child: Case Report and Literature Review
Keywords: atypical meningioma; basal ganglia; intraparenchymal meningioma;
Abstract:
Intraparenchymal meningiomas without dural attachment are extremely rare, especially when they occur in basal ganglia region in child. An 8-year-old boy was admitted at our hospital, complaining of recurrent headache and vomiting for 3 months. Neurological examination showed impaired vision and mild paresis of the left extremities. Magnetic resonance imaging demonstrated a lesion located in the right basal ganglia region extending to superasellar cistern with solid, multiple cystic and necrotic components. Computed tomography revealed calcification within the mass. Due to the anterior cerebral artery involvement, a subtotal resection was achieved and postoperative radiotherapy was recommended. Histopathological examination indicated that the lesion was an atypical meningioma. The postoperative rehabilitation was uneventful. Mildly impaired vision and motor weakness of left extremities improved significantly and the patient returned to normal life after surgery. To our knowledge, intraparenchymal atypical meningioma in basal ganglia extending to superasellar cistern was never reported. The significance in differential diagnosis of lesions in basal ganglia should be emphasized.
Image Caption and Description:
Image caption: CT revealing calcification, necrosis, cystic formation of the mass lesion (A and B). No hyperostosis or bone absorbtion was observed (C).
Image description: CT (Fig. 1A, B) revealed an iso- to hyperdense lesion in the right basal ganglion extending to superasellar cistern, 4.0x4.4 cm in size with peripheral calcification.
No hyperostosis of sellaturcica was noticed (Fig. 1C).
Image caption: MRI showing a mass lesion in the right basal ganglia consisted of solid and cystic parts. The solid part manifesting isointense signal on T1-weighted (A), T2-weighted (B), and FLAIR (C) with heterogeneous enhancement (D and E); the cystic part showing hypointense signal on both T1-weighted (A) and FLAIR (C) and hyperintensity on T2-weighted images (B) without enhancement of the wall (D and E). Although the lower margin of the tumor touched the dorsum sellae dura, 'dura tail' sign was not noted (E). Postoperative MRI revealing that most of the tumor has been resected and the residual part detached from the dorsum sellae (F). Subdural fluid accumulation in the surgical region was also detected (F). FLAIR: fluid at tenuation inversion recovery, MRI: magetic resonance imaging.
Image description: Magnetic resonance imaging (MRI) demonstrated most of the mass lesion was iso-intense on T1-weighted, T2-weighted and fluid-attenuated inversion recovery images with inhomogeneous enhancement (Fig. 2A-E).
Postoperative MRI revealed that most of the tumor had been resected and the residual part has been detached from dorsumsellae (Fig. 2F).
Image caption: Hematoxylin-eosin staining exhibiting sheetlike growth, foci of spontaneous, increased cellularity, small cells with a high nucleus-to-cytoplasm ratio and prominent nucleoli (A: original magnification, x100; B: original magnification, x400). Immunohistochemical staining showing positive for epitheliod membrane antigen (D: original magnification, x400), but negative for glial fibrillary acidic protein (E: original magnification, x400) and S-100 protein (F: original magnification, x400). Ki-67 labeling index being approximately 10% (C: original magnification, x400).
Image description: Histopathological examination revealed features of atypical meningioma with Ki-67 labeling index been approximately 10% (Fig. 3A-C).
Immunohistochemistry showed the tumor positive for epithelial membrane antigen and negative for glial fibrillary acidic protein and S-100 protein (Fig. 3D-F).
Case Report:
An 8-year-old boy presented at our hospital complaining of recurrent headache and vomiting for 3 months. The patient saw a doctor in a clinic before admission to our hospital and took some medicine for cold. The symptoms got relief temporarily but became severe 1 week ago.
Neurological examination showed impaired vision and mild paresis (IV-grade of muscle strength) of the left extremities. CT (Fig. 1A, B) revealed an iso- to hyperdense lesion in the right basal ganglion extending to superasellar cistern, 4.0x4.4 cm in size with peripheral calcification. No hyperostosis of sellaturcica was noticed (Fig. 1C). Magnetic resonance imaging (MRI) demonstrated most of the mass lesion was iso-intense on T1-weighted, T2-weighted and fluid-attenuated inversion recovery images with inhomogeneous enhancement (Fig. 2A-E). No duraltail sign was noted. Diffusion tensor image revealed the right pyramidal tract was partially disrupted.
Under the guide of navigation, a transcortical (through the right middle frontal gyrus) approach was adopted to explore the lesion. There was no dural attachment, but the tumor was tightly adhered with the anterior cerebral artery (ACA). Small vessels supplied the anterior aspect of the tumor, subtotal resection (STR) was achieved.
Histopathological examination revealed features of atypical meningioma with Ki-67 labeling index been approximately 10% (Fig. 3A-C). Immunohistochemistry showed the tumor positive for epithelial membrane antigen and negative for glial fibrillary acidic protein and S-100 protein (Fig. 3D-F).
The patient suffered transient exacerbation of impaired vision and weakness of contralateral limbs after operation, which resolved significantly after 3 months follow-up. Postoperative MRI revealed that most of the tumor had been resected and the residual part has been detached from dorsumsellae (Fig. 2F).
OUTPUT:
| PMC5769854 |
MultiCaRe_Reasoning30 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 58.0
Sex: Female
Title: Engorged venous plexus mimicking adjacent segment disease: Case report and review of the literature
Keywords: adjacent segment disease; epidural venous plexus; lumbar radiculopathy;
Abstract:
Background:
An engorged venous plexus may mimic nerve compression from a herniated disk on the magnetic resonance (MR) studies as they both have similar signal intensities. During a laminectomy, if an engorged venous plexus is encountered instead of a disk herniation, there may be marked unanticipated bleeding.
Case description:
A 58-year-old female who had a prior anterior lumbar interbody fusion later returned with recurrent radiculopathy. Adjacent segment disease from a spinal disk herniation was suspected based on the surgical history, physical examination, and imaging (MRI) findings. Rather than a disk, an engorged venous plexuses (EVP) was encountered intraoperatively.
Conclusion:
Here, we discussed our findings regarding a lumbar EVP rather than a herniated disk and reviewed the current literature. Although rare, a higher index of suspicion for these vascular malformations based on combined historical information and MRI studies should allow one to better detect and/or anticipate an EVP rather than a routine disk.
Image Caption and Description:
Image caption: Preoperative T2-weighted magnetic resonance imaging in (a) sagittal and (b) axial views demonstrating the left-sided lateral recess epidural venous plexus at the adjacent level above a fusion mimicking a herniated disk associated with adjacent segment disease.
Image description: The MRI showed what appeared to be an L4-L5 left-sided disk herniation above the level of her prior fusion (i.e., adjacent L4-L5 segment disk disease) [Figure 1].
Image caption: Intraoperative view down the minimally invasive tubular retractor showing (a) the lateral edge of the dural and nerve root with cottonoids and Surgicel hemostatic material at both the nerve root shoulder and axilla after encountering copious venous bleeding. (b) View of the nerve root after exploration which demonstrated no herniated disk bulge or fragment.
Image description: Due to the fragility of the plexus and recurrent venous bleeding, multiple hemostatic agents were repeatedly employed to control the bleeding [Figure 2].
Image caption: (a) Preoperative and (b) postoperative T2-weighted magnetic resonance imaging showing resolution of the epidural venous plexus after surgical intervention, confirming its etiology as the source of radiculopathy.
Image description: She was discharged on postoperative day 1 after a follow-up MRI confirmed an EVP as the ultimate etiology of her radiculopathy [Figure 3].
Case Report:
A 58-year-old female presented with the left lower radiculopathy. Seven years ago, she had a prior L5-S1 ALIF. On examination she had decreased the left lower-extremity 1/5 motor function in the tibialis anterior and extensor hallucis longus distributions, plus a 3/5 in the gastrocnemius. The MRI showed what appeared to be an L4-L5 left-sided disk herniation above the level of her prior fusion (i.e., adjacent L4-L5 segment disk disease) [Figure 1].
She subsequently underwent an L4-L5 left-sided minimally invasive microdiscectomy. After the laminotomy was completed and nerve root identified, there was a large venous plexus in the nerve root axilla extending ventrally and laterally. This was successfully coagulated with bipolar cautery. Due to the fragility of the plexus and recurrent venous bleeding, multiple hemostatic agents were repeatedly employed to control the bleeding [Figure 2]. After successful cauterization, a thorough examination of the nerve root and disk showed no free fragments or accompanying disk herniations.
Postoperatively, she reported immediate improvement of her foot strength and resolution of her left lower extremity and buttock pain. She was discharged on postoperative day 1 after a follow-up MRI confirmed an EVP as the ultimate etiology of her radiculopathy [Figure 3]. Six months later, an examination showed improvement to 4-/5 motor strength in the left tibialis anterior and extensor hallucis longus distributions, plus 4+/5 in the gastrocnemius.
OUTPUT:
| PMC7265352 |
MultiCaRe_Reasoning31 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 80.0
Sex: Male
Title: Use of single photon metal artefact reduction in the detection of an impacted capsule endoscope
Keywords: None
Abstract:
Wireless capsule endoscopy was introduced over a decade ago and is now a widely used tool in the investigation of gastrointestinal pathologies. Despite its ubiquity, the full profile of indications, contraindications and complications is still being developed. Metal artefact reduction is a software technique which can significantly reduce the artefact produced by metallic objects on CT scans. This case exemplifies a rare but noteworthy complication of capsule endoscopy and highlights a novel application of metal artefact reduction.
Image Caption and Description:
Image caption: Plain chest radiograph displayed a metallic object (arrow) at the thoracic inlet to the left of midline at T2 level.
Image description: A chest radiograph demonstrated a metallic object at the level of the second thoracic vertebra to the left of the trachea (Figure 1).
Image caption: Non-contrast CT of neck in axial (a and c) and coronal (b and d) reformats showed the capsule endoscope at the left lower neck. The metal aliasing artefacts obscure the adjacent soft tissues (a and b). The endoscope in Zenker's diverticulum was better depicted after the artefacts were markedly reduced with metal artefact reduction.
Image description: To pinpoint the exact anatomical location of the foreign body a non-contrast CT scan of the neck (Figure 2) was performed.
Case Report:
An 80-year-old male was being investigated at a tertiary hospital for iron deficiency anaemia. His medical history, symptomology and physical examination did not indicate a cause. After gastroscopy and colonoscopy were also unremarkable he was referred for capsule endoscopy. The delivery of the capsule in the morning was routine; however, review of the images 8 hlater showed a static picture and no evidence the capsule had entered the stomach. The patient was clinically stable and contacted to present to the emergency department with a suspicion of capsule impaction.
A chest radiograph demonstrated a metallic object at the level of the second thoracic vertebra to the left of the trachea (Figure 1). The patient had no known oesophageal or tracheal diverticulum and expressed no symptoms of dysphagia. To pinpoint the exact anatomical location of the foreign body a non-contrast CT scan of the neck (Figure 2) was performed. The effective dose of CT was 0.81 mSv. This confirmed the object was the capsule endoscope lying to the left of the hypopharynx. The adjacent soft tissue was obscured by aliasing metal artefacts arising from the capsule. A single photon metal artefact reduction (MAR) software technique (O-MAR; Philips Healthcare, Cleveland, OH) was applied which successfully removed most of the metallic artefacts. It revealed the capsule was impacted in an oesophageal diverticulum.
The capsule was successfully endoscopically removed under a general anaesthetic and the patient's recovery was uncomplicated. A follow-up barium swallow study confirmed the presence of a Zenker's diverticulum which the patient opted not to surgically repair as he was asymptomatic. He was also offered endoscopic insertion of the capsule endoscope to bypass the diverticulum; however, the patient refused. His anaemia resolved with iron transfusions but no definitive cause was found. He was discharged from the clinic.
OUTPUT:
| PMC6159178 |
MultiCaRe_Reasoning32 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 15.0
Sex: Female
Title: Misclassification of pregnancy-related deaths in adult mortality surveys: case study in Senegal
Keywords: None
Abstract:
Objective:
In countries with limited vital registration data, maternal mortality levels are often estimated using siblings' survival histories (SSH) collected during retrospective adult mortality surveys. We explored how accurately adult deaths can be classified as pregnancy related using such data.
Method:
The study was conducted in a rural area of south-eastern Senegal with high maternal mortality, Bandafassi. We used data from a demographic surveillance system (DSS) in this area to identify deaths of women at reproductive ages between 2003 and 2009 and to locate the surviving adult sisters of the deceased and interview them. Siblings' survival histories were linked at the individual level to death records, and verbal autopsy data obtained by the demographic surveillance system. We compared the classification of adult female deaths as pregnancy related or not in interviews and DSS records.
Results:
There were 91 deaths at reproductive ages in the Bandafassi DSS between 2003 and 2009, but only 59 had known surviving sisters. Some deaths were omitted by respondents, or reported as alive or as having occurred during childhood (n = 8). Among deaths reported both in the SSH and DSS data, 94% of deaths classified as pregnancy related in the DSS data were also classified as such by siblings' survival histories. Only 70% of deaths classified as not pregnancy related in the DSS data were also classified as such by siblings' survival histories.
Conclusion:
Misclassifications of pregnancy-related deaths in retrospective adult mortality surveys may affect estimates of pregnancy-related mortality rates.
Image Caption and Description:
Image caption: []
Image description: []
Case Report:
For each death, the DSS has systematically recorded the age at death and the date of death (including day and month of death). A detailed VA questionnaire has been collected for deaths of children aged < 15 years old since 1985, and for all deaths since 2003. VA questionnaires are usually completed by close relatives of the deceased. For adults, they include an assessment of whether the deceased was pregnant at the time of death. After review of VA data by physicians, a likely cause of death is assigned to each recorded death using ICD-9 codes. According to this database, maternal mortality is high ( 915 per 100,000 live births for 2003-06,).
In August 2010, we conducted a pilot study aimed at determining the feasibility of linking retrospective survey data collected during SSH to DSS data, at the individual level. Prior studies comparing SSH and DSS data had been conducted at the aggregate level, and thus did not permit examining misclassification biases. In total, we interviewed 268 women aged 15-59 years who had at least one female sibling known to have died at reproductive ages according to the DSS datasets since the 1980s. Respondents were asked to complete the standard SSH questionnaire used during the 2005 DHS in Senegal. Interviewers were recruited among those who had participated in that DHS. Some survey respondents were members of the same sibship, and some deaths were thus potentially reported multiple times during the SSH survey.
We focus here on the subset of deaths having occurred in 2003-2009 because detailed VA questionnaires for adult deaths were systematically introduced in the Bandafassi DSS in 2003, and because this period matches the "reference period" usually used in producing estimates of adult and maternal mortality using SSH data (Timaeus and Jasseh 2004). We identify PR deaths in the DSS data as follows: 1) we use demographic surveillance data on dates of births and deaths to identify deaths having occurred at the time of delivery or within 2 months of a delivery regardless of the actual cause; 2) we use data from the VA questionnaires (i.e., a yes/no question asking VA respondent whether the deceased was pregnant at the time of the survey) to identify deaths having occurred during pregnancy. It is important to note that, in order to classify a death as PR or non-PR according to the DSS data, we do not use the ICD-9 codes assigned by physicians to each death. In SSH data, we define PR deaths as deaths reported to have occurred either during pregnancy, delivery or within 2 months of delivery according to the respondent.
We could not compare PR classifications obtained from SSH and DSS data for all deaths observed between 2003 and 2009 because, for some of the deceased, there were no eligible sisters in the DSS population or eligible sisters could not be located. In other cases, we could not ascertain whether the recorded death was PR because of missing data in the DSS dataset and/or the VA questionnaire. We thus begin by comparing the age at death, date of death, and PR classification obtained from the DSS of included vs. excluded deaths. We do so using chi2 tests of association. Among included deaths, we then examine the cross-classification of deaths as PR or non-PR, according to the SSH and DSS data. We calculate the proportion of deaths identified as PR (non-PR) in the DSS dataset, which were also classified as PR (non-PR) deaths in the SSH data. We do so for all reports collected during the SSH survey, and for a restricted sample in which we select at random one report of death per sibship (to avoid double-counting). In the case of discrepant classifications of PR deaths between SSH and DSS data, we report a) the cause of death as ascertained by physicians (using VA data), b) the time since the last recorded birth of the deceased, and c) the relationship between the deceased and the person who completed the VA questionnaire (e.g., sister-in-law). Finally, we use SSH data to investigate agreement between sisters about the reported timing of death in sibships where multiple sisters were interviewed.
OUTPUT:
| PMC3678730 |
MultiCaRe_Reasoning33 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: nan
Sex: Female
Title: Gender Differences in Patients With COVID-19: Focus on Severity and Mortality
Keywords: covid-19; sars; sars-cov-2; female; gender; male; morbidity; mortality;
Abstract:
Objective: The recent outbreak of Novel Coronavirus Disease (COVID-19) is reminiscent of the SARS outbreak in 2003. We aim to compare the severity and mortality between male and female patients with COVID-19 or SARS. Study Design and Setting: We extracted the data from: (1) a case series of 43 hospitalized patients we treated, (2) a public data set of the first 37 cases of patients who died of COVID-19 and 1,019 patients who survived in China, and (3) data of 524 patients with SARS, including 139 deaths, from Beijing in early 2003. Results: Older age and a high number of comorbidities were associated with higher severity and mortality in patients with both COVID-19 and SARS. Age was comparable between men and women in all data sets. In the case series, however, men's cases tended to be more serious than women's (P = 0.035). In the public data set, the number of men who died from COVID-19 is 2.4 times that of women (70.3 vs. 29.7%, P = 0.016). In SARS patients, the gender role in mortality was also observed. The percentage of males were higher in the deceased group than in the survived group (P = 0.015). Conclusion: While men and women have the same prevalence, men with COVID-19 are more at risk for worse outcomes and death, independent of age.
Image Caption and Description:
Image caption: Trend data of clinical classification of severity in a Case series of COVID-19. Numbers of cases of men or women in different clinical classes of severity. Chi-square (chi2) test for trend indicated that males tend to experience more serious cases of COVID-19 than females according to the clinical classification of severity including Mild+Moderate, Severe, and Critical.
Image description: Critical pneumonia, respectively. Chi-square (chi2) test for trend indicated that men's cases of COVID-19 tended to be more serious than women's (P = 0.035), according to the clinical classification of severity (Figure 1).
Image caption: Role of age and gender in morbidity and mortality in a Cases series of SARS, in 2003. (A) The whole spectrum of age in patients who died from and survived SARS. (B) Comparation of age between males and females in both patients who died from and survived SARS. (C) Gender distribution in both patients who died from and survived SARS. (D) Survival analysis comparing mortality rates between male and female patients with SARS.
Image description: While the deceased patients were significantly older than the patients who survived (Figure 3A), ages were comparable between men and women in both patients who deceased and survived with SARS (Figure 3B).
The proportion of men was higher in the deceased group (53.2%) than in the group who survived (42.3%) (chi2 test, P = 0.027) (Figure 3C).
Survival analysis showed that men had a significantly higher mortality rate than women (31.2 vs. 22.6%) in this hospital-based cohort (hazard ratio [95% CI] 1.47 [1.05-2.06], P = 0.026) (Figure 3D).
Case Report:
The demographic and clinical characteristics are shown in Table 1. The median age was 62 years (IQR, 51 to 70). Fever (95.3%) and cough (65.1%) were the most common symptoms, while diarrhea (16.3) was not common. 37.2% of patients had at least one underlying disorder (i.e., hypertension, diabetes, cardiovascular diseases, and chronic lung diseases). There is no significant difference in median age between male and female groups, but the maximum of the range of IQR is lower in male (66 years in men vs. 73 years in women). Symptoms and comorbidities were comparable between men and women. As expected, men had a higher level of hemoglobin. However, male patients also had elevated serum creatinine, white blood cells, and neutrophils. Among the 43-case series, 13 (30.2%) were diagnosed with Mild or Moderate pneumonia, while 14 (32.6%) and 16 (37.2%) were diagnosed with Severe and Critical pneumonia, respectively. Chi-square (chi2) test for trend indicated that men's cases of COVID-19 tended to be more serious than women's (P = 0.035), according to the clinical classification of severity (Figure 1).
Between March 25 and May 22, 2003, a total of 524 SARS patients, including 139 deaths, in the Beijing area were reported from 29 hospitals enrolled in our analysis. Fever (98.4%) and cough (76.9%) were the most common symptoms, while diarrhea (6.7%) was not common. 57.0% of the patients had at least one of the concomitant diseases including hypertension, diabetes, cardiovascular diseases, and chronic lung diseases. The mean duration from self-reported symptoms to death was 15 (IQR: 10-19) days. Table 2 summarizes the clinical and biochemical characteristics of all SARS patients. The median age of the deceased patients was much higher than that of the patients who survived (57 vs. 32, P < 0.001). The rate of the concomitant diseases in the deceased patients was also higher than that of the patients who survived (57.0% vs. 17.9%, P < 0.001). While the deceased patients were significantly older than the patients who survived (Figure 3A), ages were comparable between men and women in both patients who deceased and survived with SARS (Figure 3B). The proportion of men was higher in the deceased group (53.2%) than in the group who survived (42.3%) (chi2 test, P = 0.027) (Figure 3C). Survival analysis showed that men had a significantly higher mortality rate than women (31.2 vs. 22.6%) in this hospital-based cohort (hazard ratio [95% CI] 1.47 [1.05-2.06], P = 0.026) (Figure 3D).
OUTPUT:
| PMC7201103 |
MultiCaRe_Reasoning34 | As a physician engaged in clinical diagnostic reasoning, here is a case report from the pubmed, given the title, keywords, abstract and the case report, please analyze the input and accurately identify the diagnosis presented within it.
INPUT: Age: 54.0
Sex: Female
Title: A Novel Nonsense Mutation of ABCA8 in a Han-Chinese Family With ASCVD Leads to the Reduction of HDL-c Levels
Keywords: abca8; atherosclerosis; cholesterol efflux; nonsense mutation; reduced hdl-c levels;
Abstract:
Arteriosclerotic cardiovascular disease (ASCVD) is one of the major causes of death worldwide and most commonly develops as a result of atherosclerosis (AS). As we all know, dyslipidemia is a leading pathogenic risk factor for ASCVD, which leads to cardiac ischemic injury and myocardial infarction. Dyslipidemias include hypercholesterolemia, hypertriglyceridemia, increased low-density lipoprotein cholesterol (LDL-c) and decreased high density lipoproteins cholesterol (HDL-c). Mutations of dyslipidemia related genes have been proved to be the crucial contributor to the development of AS and ASCVD. In this study, a Han-Chinese family with ASCVD was enrolled and the lipid testing discovered an obvious reduced levels of HDL-c in the affected members. We then performed whole exome sequencing to detect the candidate genes of the family. After data filtering, a novel heterozygous nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 was detected and validated to be co-separated in the family members by Sanger sequencing. Previous studies have proved that deleterious heterozygous ABCA8 variants may disrupt cholesterol efflux and reduce HDL-c levels in humans and mice. This study may be the second report related to ABCA8 mutations in patients with reduced levels of HDL-c. Our study not only contributed to the genetic counseling and prenatal genetic diagnosis of patients with ASCVD caused by reduced HDL-c levels, but also provided a new sight among ABCA8, cholesterol efflux and HDL-c levels.
Image Caption and Description:
Image caption: The clinical and genetic information of the family. (A) Pedigree of the family with low levels of HDL-c. Family members are identified by generations and numbers. Squares indicate male family members; circles, female members; closed symbols, affected members; open symbols, unaffected members; arrow, proband. (B) The coronary angiography of the proband, the arrow shows the stenosis of the anterior descending coronary artery. The ECG testing of the proband before percutaneous coronary intervention (C) and after percutaneous coronary intervention (D). (E) Sequencing results of the ABCA8 mutation. Sequence chromatogram indicates a C to T transition of nucleotide 3460. (F) The structure of ABCA8 and the summary of reported mutations of ABCA8.
Image description: Coronary angiography indicated approximately 60-80% stenosis of the anterior descending coronary artery (Figure 1B), ECG testing also suggested the patient suffered from CHD (Figure 1C).
And breathing sound of the lungs was clearly, the heart rate was normal (Figure 1D), and the insertion site recovered well.
After data filtering, a novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 was identified and validated by Sanger sequencing in the proband (Figure 1E).
Sanger sequencing further confirmed that only the affected individuals (II-2, II-4, and III-1) carried the novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 (Figure 1F).
Case Report:
The proband (II-2), a 54-year-old lady, came to the hospital due to recurrent chest pain in last 2 years. Coronary angiography indicated approximately 60-80% stenosis of the anterior descending coronary artery (Figure 1B), ECG testing also suggested the patient suffered from CHD (Figure 1C). However, the lipid testing described the level of LDL-c (3.94 mmol/L; control: <3.12 mmol/L) and a distinctly reduced levels of HDL-c (0.41 mmol/L; control: 0.9-2.19 mmol/L) of the proband (Table 1). This discovery attracted our interest because most patients with ASCVD commonly presented high levels of LDL-c, TC, and TG. We then investigated the family history of the proband (II-2), which indicated that her young sister (II-4) has been diagnosed as the occlusion of left iliac artery and her father (I-1) was died from myocardial infarction at 60-year-old. Lipid testing further described that both her son (III-1) and her young sister (II-4) showed an overt reduced levels of HDL-c and normal levels of LDL-c, TC, and TG (Table 1). And his young sister (II-4) also suffered from arterial plaque in the left lower limb. The blood pressure of the proband was 80-120 mmHg and the fasting blood-glucose was 5.2 mmol/L. The proband (II-2) accepted the treatment of percutaneous coronary intervention, the proband did not complain any uncomfortable after treatment. And breathing sound of the lungs was clearly, the heart rate was normal (Figure 1D), and the insertion site recovered well. The II-4 is accepting recovery treatment by exercise and diet control.
We supposed that the low levels of HDL-c may be the leading cause of AS and ASCVD in this family. However, what's the genetic lesion underling the reduced levels of HDL-c in this family? We then isolated the genomic DNA of the proband and other family members (I-2, II-1, II-2, II-4, III-1, and III-2). Whole exome sequencing of the proband (II-2) was performed to detect the candidate gene of reduced levels of HDL-c.
In short, Exome capture and next-generation sequencing were conducted by Novogene Bioinformatics Institute (Beijing, China). One microgram of qualified genomic DNA from each person was captured by the Agilent's SureSelect Human All Exon kit V5 (Agilent Technologies, Inc., Santa Clara, CA, United States) and sequenced by Illumina Hiseq4000 (Illumina Inc., San Diego, CA, United States). Shortly, genomic DNA were randomly carved by Covaris S220 sonicator (Covaris, Inc., Woburn, MA, United States). Then the fragmented DNAs underwent three enzymatic steps: end repair, A-tailing and adapters ligation. The adapter-ligated DNA fragments were amplified with Herculase II fusion DNA polymerase (Agilent). Later, the exomes in the pre-capture libraries were captured by SureSelect capture library kit (Agilent). After DNA quality estimation, the captured DNA library was used for next-generation sequencing on Illumina Hiseq4000 platform. Downstream processing was carried out by Genome Analysis Toolkit (GATK), Varscan2 and Picard, and variant calls were performed by the GATK Haplotype Caller. Variant annotation referred to Ensemble release 82, and filtering was conducted by ANNOVAR Documentation.
The filtered non-synonymous SNPs or INDELs with an alternative allele frequency more than 1% in public databases were kicked before further analysis. The public databases contains the NHLBI Exome Sequencing Project Exome Variant Server (ESP6500), dbSNP1441, the 1000 Genomes project2, the ExAC database3 and in-house exome databases of Novogene (2500 exomes). Then the filtered SNVs and INDELs, predicted by SIFT4, Polyphen25, and MutationTaster6 to be damaging, were remained.
After data filtering, a novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 was identified and validated by Sanger sequencing in the proband (Figure 1E). Previous studies have revealed that deleterious heterozygous ABCA8 mutations may disrupt cholesterol efflux and reduce HDL-c levels in humans and mice. No other meaningful mutations related to lipid metabolism has been identified. Sanger sequencing further confirmed that only the affected individuals (II-2, II-4, and III-1) carried the novel nonsense mutation (NM_007168: c.3460C>T; p.R1154X) of ABCA8 (Figure 1F). The novel mutation, resulting a truncated protein, was absent in the healthy members (I-2, II-1, and III-2) and 200 local people who were used as an internal control to exclude the SNP in local people. Bioinformatics predicted that the newly identified mutation was deleterious and may disrupt the structure and function of ABCA8. On the basis of ACMG guidelines, the novel variant meetings the following criteria from the ACMG guidelines: PVS1, PS3, and PM2.
OUTPUT:
| PMC7373792 |
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