The patient is treated with therapeutic apixaban.

The patient had a TAVR with a 29 mm self-expanding Medtronic core-valve placed 7 years prior.

The patient presented to the clinic for the evaluation of acute onset chest pain.

The patient had elevated blood pressure on home monitoring of 190/90 mmHg.

The patient described the chest pain as substernal, severe, radiating posteriorly, and lasting for 45 min before resolving spontaneously.

A routine echocardiogram performed 2 months prior showed a properly functioning bioprosthetic aortic valve with normal haemodynamic performance.

The Doppler measured peak transaortic gradient was 4 mmHg.

The mean transaortic gradient was 2 mmHg.

Vital signs in the clinic were noted as unremarkable.

The patient was referred to the emergency department for assessment of the coronary anatomy and to rule out aortic dissection.

During imaging, the patient developed acute respiratory failure with severe pruritis and urticaria.

The patient was admitted for inpatient management.

Evaluation in the emergency department was notable for the absence of hives, stridor, or other associated signs or symptoms of anaphylaxis.

Lab evaluation demonstrated a troponin-I value of 0.22 ng/mL.

The troponin-I reference value is <0.04 ng/mL.

The patient’s baseline BNP was 22–71 pg/mL.

The patient had a positive COVID-19 polymerase chain reaction rapid test.

Chest x-ray was notable for diffuse interstitial pulmonary oedema.

Electrocardiogram demonstrated sinus tachycardia with the left bundle branch block unchanged from prior.

CT angiography of the chest ruled out acute aortic dissection.

CT angiography ruled out pulmonary embolism.

The patient was hospitalized for acute decompensated heart failure.

The patient was treated with non-invasive positive pressure ventilation.

The patient was treated with nitroglycerine infusion.

The patient was treated with intravenous furosemide 40 mg twice daily.

The patient’s respiratory status improved by Day 1 of the hospital admission.

POCUS performed on hospital Day 2 was suggestive of a significant diastolic flow across the TAVR valve.

POCUS directed further investigation for the diagnosis of prosthetic valve failure.

TTE on hospital Day 3 revealed severe aortic regurgitation with an eccentric and anteriorly directed jet.

TTE showed holodiastolic flow reversal in the descending thoracic aorta.

The peak measured transaortic gradient was 9 mmHg.

The mean transaortic gradient was 5 mmHg.

The hospital system was experiencing staffing shortages and resource limitations related to an ongoing community COVID-19 surge.

The hospital policy at the time was to delay routine TEE until patients were designated as COVID-19 recovered.

The patient was treated for 2 days with continuous heparin infusion for presumptive treatment of acute coronary syndrome.

The patient was restarted on therapeutic apixaban 5 mg twice daily.

The patient was discharged after 7 days.

The patient was transitioned from intravenous furosemide to oral torsemide 20 mg twice daily.

Three days after hospital discharge, TEE confirmed proper positioning of the bioprosthetic stent-valve.

TEE showed restriction of the non-coronary cusp prosthetic leaflet.

TEE showed an eccentric regurgitant jet consistent with severe aortic regurgitation.

The acute TAVR valve regurgitation was treated with a valve-in-valve TAVR 17 days post-discharge.

The patient was seen in the clinic 30 days after valve-in-valve TAVR.

A TTE demonstrated bioprosthetic stent-valve in the aortic position.

The TTE showed no paravalvular aortic regurgitation.

She had a transcatheter aortic valve replacement (TAVR).

She presented with a COVID-19 infection.

She was found to have severe bioprosthetic valvular regurgitation.

Features were suggestive of valve thrombosis.

The patient is treated with therapeutic apixaban.

The Doppler measured peak transaortic gradient was 4 mmHg.

The mean transaortic gradient was 2 mmHg.

Vital signs in the clinic were noted as unremarkable.

The patient was admitted for inpatient management.

Lab evaluation demonstrated a troponin-I value of 0.22 ng/mL.

The troponin-I reference value is <0.04 ng/mL.

The patient’s baseline BNP was 22–71 pg/mL.

CT angiography ruled out pulmonary embolism.

The patient was treated with nitroglycerine infusion.

The peak measured transaortic gradient was 9 mmHg.

The mean transaortic gradient was 5 mmHg.

The patient was discharged after 7 days.

The TTE showed no paravalvular aortic regurgitation.


Your body needs to keep your blood clean and your organs working well. If your kidneys aren’t doing their job, it’s like having a leaky faucet — waste builds up, and you might feel tired or sick. You should talk to a doctor if you notice these signs so they can check your kidneys and help you feel better.

Kidney function is essential for filtering waste and excess fluids from the blood. When kidney function declines, toxins accumulate, leading to symptoms like fatigue, swelling, and high blood pressure. Early detection through regular screening is key to managing the condition and preventing complications. Lifestyle changes and medical monitoring are often recommended to support kidney health.

The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., hyperkalemia, metabolic acidosis), and fluid overload, which can manifest clinically as fatigue, hypertension, and edema. Declining glomerular filtration rate (GFR) is a key biomarker for chronic kidney disease progression, and early intervention through pharmacological management, dietary modification, and monitoring of biomarkers such as serum creatinine and proteinuria is critical to slow disease progression and reduce cardiovascular risk.

On 24 November 2012, a 31-year-old woman was diagnosed as a suspected rabies case by the First Affiliated Hospital of Zhengzhou University.

The hospital reported the case to the Henan Center for Disease Control and Prevention (CDC).

A detailed epidemiological investigation of the suspected rabies case was performed.

The woman was a farmer living in a rural area of Xuchang, Henan Province, China.

She lived with her husband and two sons.

She said she had not travelled anywhere recently.

At about 17:00 on 25 August 2012, the woman and her 7-year-old son were attacked by a stray dog while walking nearby to their village.

The woman sustained bites on her right thigh.

The dog was buried on the village outskirts without laboratory investigation for RV.

The mother washed the son’s bites with municipal tap water shortly after the incident.

On 26 August, the son received a rabies vaccine at the healthcare unit in their village.

He completed a full course of standard vaccines.

The vaccine used was freeze-dried rabies vaccine for human use [Vero cells], produced by Liaoning Chengda Biotechnology Co., Ltd.

The vaccination regimen was five doses on days 0, 3, 7, 14, and 28.

The mother did not recognize the risk posed to her by the dog bite.

She only washed her own wounds the following day, following the doctor’s advice.

She declined the rabies vaccine for economic reasons.

Both the mother’s and son’s wounds were determined by the doctor to constitute category III exposure bites.

Category III exposure bites are defined by the World Health Organization (WHO) as single or multiple transdermal bites or scratches; contamination of mucous membrane with saliva.

Neither the mother nor her son were treated as recommended by the WHO for category III rabies exposure.

WHO-recommended treatment for category III rabies exposure includes wound cleaning, rabies vaccination, and direct wound infiltration with rabies immunoglobulin (RIG).

The rabies vaccine is not in the Chinese National Immunization Scheme.

Rabies vaccine and RIG are currently provided for a fee in China.

On 20 November 2012, the woman presented with a persistent fever (39 °C), nausea, vomiting, chest tightness, and agitation to the Xiangcheng County People’s Hospital.

She received a diagnosis of encephalitis.

She was treated for 2 days with cefoperazone, sulbactam, levofloxacin, and supportive treatment.

On 22 November, her symptoms worsened and she developed a mild coma, drooling, and melena.

She was then transferred to the Xuchang City Central Hospital.

On 24 November, she was transferred to the First Affiliated Hospital of Zhengzhou University.

She received a diagnosis of suspected rabies.

She was treated with symptomatic and supportive therapies.

On 4 December 2012, saliva, serum, and cerebrospinal fluid (CSF) from the patient were collected.

On 15 December 2012, a serum sample was collected from her son, who was in good health when sampled.

Both sets of specimens were transported under refrigeration to the Henan CDC for testing.

Total ribonucleic acid (RNA) was extracted from the CSF and saliva.

RV N and G genes were amplified using nested polymerase chain reaction (PCR).

Negative controls (RNAse-free water) and positive controls were included in each set of reactions.

Amplification products were detected after electrophoresis using 2% agarose gel.

The N and G genes were amplified from the woman patient’s saliva.

The N and G genes were not amplified from her CSF.

Amplification products were purified and sequenced using an automated ABI 3730 DNA Sequencer.

Molecular phylogenetic analysis was conducted using the maximum likelihood method based on the Kimura’s two parameter model with MEGA 5 software.

The nucleotide sequence from the female (Henan) patient (Henan JSS, GenBank accession number KP221203) G protein was compared against nucleotide sequences of G protein genes from RV identified in GenBank.

Henan JSS, along with previous Henan RV strains, the Chinese vaccine strain, and 8743THA, were grouped into GT1.

Rabies virus neutralizing antibody (RVNA) titers in the sera were assayed by a standard rapid fluorescent focus inhibition test with some modifications.

A serum specimen from the patient was collected on day 12 of her illness.

Her son’s serum was collected 3 months after the bites.

The mother’s serum RVNA titer was 0.68 IU/ml.

The son’s serum RVNA titer was 2.29 IU/ml.

The mother and son were considered positive according to the diagnosis criteria for RVNA reactions.

The diagnosis criteria for RVNA reactions define RVNA titers ≥0.05 IU/ml as the WHO recommended protective level.

Because the son did not receive immediate RIG treatment, he remained at possible risk for RV infection.

RVNA of the son has been actively monitored.

His health condition has been assessed every 6 months post his initial result.

The son is alive and healthy after 2 years of follow-up.

In August 2012, a woman and her son were attacked by a stray dog in Henan, China.

The son received rabies postexposure prophylaxis.

The son's postexposure prophylaxis included wound treatment followed by vaccine.

The son's postexposure prophylaxis did not include immunoglobulin.

The mother did not receive rabies postexposure prophylaxis.

Rabies infection was laboratory confirmed in the mother.

The son is alive and healthy after 2 years of follow-up.

The woman was a farmer living in a rural area of Xuchang, Henan Province, China.

She lived with her husband and two sons.

She said she had not travelled anywhere recently.

The woman sustained bites on her right thigh.

He completed a full course of standard vaccines.

The vaccination regimen was five doses on days 0, 3, 7, 14, and 28.

The mother did not recognize the risk posed to her by the dog bite.

She only washed her own wounds the following day, following the doctor’s advice.

She declined the rabies vaccine for economic reasons.

The rabies vaccine is not in the Chinese National Immunization Scheme.

Rabies vaccine and RIG are currently provided for a fee in China.

She received a diagnosis of encephalitis.

She was then transferred to the Xuchang City Central Hospital.

She received a diagnosis of suspected rabies.

She was treated with symptomatic and supportive therapies.

Total ribonucleic acid (RNA) was extracted from the CSF and saliva.

RV N and G genes were amplified using nested polymerase chain reaction (PCR).

Amplification products were detected after electrophoresis using 2% agarose gel.

The N and G genes were amplified from the woman patient’s saliva.

The N and G genes were not amplified from her CSF.

A serum specimen from the patient was collected on day 12 of her illness.

Her son’s serum was collected 3 months after the bites.

The mother’s serum RVNA titer was 0.68 IU/ml.

The son’s serum RVNA titer was 2.29 IU/ml.

RVNA of the son has been actively monitored.

His health condition has been assessed every 6 months post his initial result.

The son is alive and healthy after 2 years of follow-up.

**System Role:**

You are an expert medical editor and Health Literacy specialist. Your task is to transform complex medical text into three distinct versions based on the reader's health literacy level. You must maintain the source language of the input while adjusting the linguistic complexity. Use the provided Gold Summary as the factual anchor to ensure the simplified versions remain accurate and focused on the most important information.

**User Prompt:**

Please process the following medical Source Text and its corresponding Gold Summary to generate three versions tailored to different health literacy levels.
### Instructions for Each Level:

1. Level: Low Health Literacy (High Readability)

Target: Individuals needing the simplest terms for immediate action.

Linguistic Goal: Use "living room" language. Replace all medical jargon with functional descriptions (e.g., "renal" becomes "kidney").

Information Density: Focus strictly on the "need-to-know" info found in the Gold Summary.

Strategy: High paraphrasing using analogies. One idea per sentence.

Faithfulness: Must align perfectly with the Gold Summary.

2. Level: Intermediate Health Literacy (Medium Readability)

Target: The general public (news-reading level).

Linguistic Goal: Standard vocabulary. Common medical terms are okay, but technical "doctor-speak" must be simplified.

Information Density: Balanced. Use the Gold Summary as the lead, supplemented by necessary context from the Source Text.

Strategy: Moderate paraphrasing. Remove minor technical details to avoid information overload.

Faithfulness: Maintains the main narrative of the Gold Summary.

3. Level: Proficient Health Literacy (Low Readability)

Target: Researchers, clinicians, or highly informed patients.

Linguistic Goal: Technical and academic language. Prioritize clinical nuance and medical accuracy.

Information Density: High. Use the Full Source Text to include data, physiological mechanisms, and statistics.

Strategy: Minimal paraphrasing. Retain all original technical terminology.

Faithfulness: Adhere to the Source Text; you may add related subclaims that provide deeper scientific context.

I will provide the following information:

- Input Language: <<<SOURCE_LANGUAGE>>>
- Gold Summary (the anchor reference summary): <<<GOLD_SUMMARY>>>
- Source Text (detailed content): <<<FULL_TEXT>>>

**Output Format (JSON only):**
    {
    "low_health_literacy": "...",
    "intermediate_health_literacy": "...",
    "proficient_health_literacy": "..."
    }


He presented with right limb weakness and unclear speech for the past 10 h.

He was diagnosed with diabetes one month before admission.

His right limb muscle strength was Grade IV.

Brain MRI revealed left basal ganglia and right parietal lobe cerebral infarction.

The infarction was consistent with embolic stroke.

The normal range for white cell count is 3.5–9.5 × 10^9/L.

Highly sensitive Troponin I was 0.08 ng/ml.

The normal range for highly sensitive Troponin I is 0-0.0268 ng/ml.

Chest CT showed bilateral lung markings were heavier.

Transthoracic echocardiography showed the aortic valve was bicuspid combined with calcification.

Transthoracic echocardiography showed moderate regurgitation.

A 16.4 mm*7.8 mm vegetation was seen on the right posterior aortic valve.

The patient was diagnosed with infective endocarditis.

According to the AHA/ACC guideline, delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke if hemodynamically stable.

The patient was prescribed vancomycin 0.5 g every 6 h.

Transesophageal echocardiography 10 days later showed the vegetation was smaller than before.

Transesophageal echocardiography one month later revealed a large periaortic abscess.

The abscess led to formation of an aortic sinus pseudoaneurysm.

Flows were in from the pseudoaneurysm and out to the left ventricular.

Moderate mitral valve regurgitation was present.

Cardiopulmonary bypass and aortic valve replacement surgery via median sternotomy were performed.

During the operation, bicuspid deformity combined with vegetation was confirmed.

An aortic annular abscess eroded into the base of the anterior mitral leaflet.

Aortic valve vegetations and perivalvular abscesses were completely removed.

5/0 Prolene suture was used to continuously suture bovine pericardium.

The tissue culture of the diseased aortic valve showed no bacterial growth.

No pathogenic microorganism was identified.

The patient was discharged two weeks later.

During one-month follow-up, the patient felt well.

Laboratory testing revealed that blood white cell count and percentage were normal.

A 44-year-old man was admitted due to weakness of his right limbs and unclear speech for 10 h.

He had recurrent fevers for 1 month before admission.

Transthoracic echocardiography showed a mix-echoic vegetation attached to the bicuspid aortic valve.

Transthoracic echocardiography showed moderate aortic regurgitation.

Transthoracic echocardiography showed a possible aortic annular abscess.

The patient seem to be clinically improved.

Follow-up transesophageal echocardiography revealed a large periaortic abscess led to aortic sinus pseudoaneurysm.

The patient underwent mechanical prosthetic valve replacement.

The patient underwent annulus reconstruction.

Perivalvular abscess may be insidious deterioration in patients who seem to be clinically improved.

Highly sensitive Troponin I was 0.08 ng/ml.

No pathogenic microorganism was identified.

The patient was discharged two weeks later.


Kidney function is essential for filtering waste and excess fluids from the blood. When kidney function declines, toxins accumulate, leading to symptoms like fatigue, swelling, and high blood pressure. Early detection through regular screening is key to managing the condition and preventing complications. Lifestyle changes and medical monitoring can help maintain kidney health.

The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by underlying pathophysiological mechanisms including glomerular injury, tubular atrophy, and vascular remodeling, with clinical outcomes dependent on stage, comorbidities, and biomarker profiles such as estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR).

The patient is a 34-year-old Caucasian woman.

The patient was referred to the department of dermatology.

The patient had recurrent and diffuse tinea corporis.

The patient had recalcitrant crusted scabies.

All studies of human subjects were approved by the Institutional Review Board of University Hospitals Case Medical Center.

The patient provided written informed consent.

Earlier treatments included topical ketoconazole 2% cream.

Earlier treatments included oxiconazole nitrate 1% cream.

Earlier treatments included permethrin 5% cream.

The patient reported that her skin problems had been intermittent over the preceding 3 years.

The medical history of this patient revealed end-stage renal disease requiring hemodialysis.

The medical history of this patient revealed obesity.

The medical history of this patient revealed non-insulin-dependent diabetes.

The medical history of this patient revealed hypertension.

The medical history of this patient revealed recurrent cellulitis.

The medical history of this patient revealed methicillin-resistant Staphylococcus aureus bacteremia.

The patient was diagnosed with bilateral cataracts.

The patient was diagnosed with mild sensorineural hearing loss in one ear.

Diabetes and hypertension were diagnosed with nephrotic syndrome at age 29.

The patient had frequent admissions for dialysis catheter site cellulitis.

The patient had methicillin-resistant S. aureus bacteremia secondary to catheter line infections.

The patient has lived with her maternal grandmother since birth.

The mother reportedly died from a prescription narcotic overdose at age 29.

There was no evidence of birth defects or immunodeficiency in the maternal family.

The patient exhibited coarse facial features with a prominent brow ridge.

The patient exhibited midface hypoplasia.

The patient exhibited slight down slanting of palpebral fissures.

The skin examination was significant for thick, hyperkeratotic, white, and flaking plaques on the palms.

The skin examination was significant for thick, hyperkeratotic, white, and flaking plaques on the soles.

The skin examination was significant for thick, hyperkeratotic, white, and flaking plaques on the digits.

The skin examination was significant for thick, hyperkeratotic, white, and flaking plaques under the distal nails.

Moist erosions and bright erythema along many of the proximal nail folds were noted.

The nail plates appeared normal except distal onycholysis overlying the plaques.

There were crusted papules and erosions diffusely scattered on the face, ears, trunk, and extremities.

Earlier mineral oil scrapings had revealed multiple live mites.

The exam was consistent with crusted scabies.

A fungal culture from the nail fold grew unidentified, non-Candida yeast.

It was recommended to the referring dermatologist that the patient continues topical antifungal treatment as needed.

It was recommended to the referring dermatologist to begin oral ivermectin 0.2 mg/kg daily on days 1, 2, 8, 9, 15, 22, and 29.

An undiagnosed immune syndrome with cutaneous-specific immunodeficiency was suspected.

The patient was referred to medical genetics for evaluation.

The patient had a normal serum protein electrophoresis interpretation.

The patient was negative for antinuclear antibodies.

Electrolyte panels were consistent with renal failure and routine dialysis.

The white blood cell count would fluctuate between admissions.

The patient’s lymphocyte count was consistently within normal limits.

The scabies infection resolved after 3 months using routine maintenance doses of ivermectin.

The tinea corporis infection resolved using the daily application of topical antifungal creams.

The patient had a cutaneous immunodeficiency.

The patient had recurrent crusted scabies infestation.

The patient had recurrent staphylococcal cellulitis.

The patient was suspected to have an undiagnosed syndrome.

A cytogenetic fluorescence in situ hybridization analysis was performed.

A 9.34 Mb duplication was found within the short (p) arm of chromosome 1.

The duplication was from 1p36.11 to 1p36.21.

An adjacent 193 kb copy gain was entirely within 1p36.11.

Chromosome 4 had a 906 kb gain in 4p16.1.

Chromosome 9 had an 81 kb copy gain in 9p24.3.

Over 100 genes were localized within these duplicated regions.

82 genes had expression changed >1.5-fold compared to a healthy age-matched skin control.

The lipolytic enzyme arylacetamide deacetylase-like 3 was found within the duplicated 1p36 region of chromosome 1.

The patient is a 34-year-old Caucasian woman.

The patient was referred to the department of dermatology.

The patient had recurrent and diffuse tinea corporis.

The patient had recalcitrant crusted scabies.

The patient provided written informed consent.

Earlier treatments included topical ketoconazole 2% cream.

Earlier treatments included oxiconazole nitrate 1% cream.

Earlier treatments included permethrin 5% cream.

The medical history of this patient revealed obesity.

The medical history of this patient revealed hypertension.

The patient was diagnosed with bilateral cataracts.

The patient has lived with her maternal grandmother since birth.

The patient exhibited midface hypoplasia.

The patient exhibited slight down slanting of palpebral fissures.

Earlier mineral oil scrapings had revealed multiple live mites.

The exam was consistent with crusted scabies.

The patient was referred to medical genetics for evaluation.

The patient was negative for antinuclear antibodies.

The white blood cell count would fluctuate between admissions.


The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by underlying pathophysiological mechanisms including tubular atrophy, interstitial fibrosis, and vascular remodeling, with clinical outcomes dependent on stage, comorbidities, and biomarker profiles such as estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR).

He presented with acute onset of abdominal pain.

The pain started 2 days before presentation.

The pain was diffuse across his mid-to-lower abdomen.

His medical history was significant for end-stage renal disease from congenital renal hypoplasia.

He received a kidney transplant 7 years ago.

He had been requiring intermittent hemodialysis for the past 2 years.

He was on immunosuppression with oral prednisone (5 mg/day).

He was on immunosuppression with mycophenolate mofetil (250 mg/day).

On physical examination, his blood pressure was 105/60.

His abdominal examination demonstrated generalized tenderness.

There was remarkable lower abdomen rebound tenderness.

Computed tomography of the abdomen and pelvis with intravenous contrast was performed.

Abdominal CT demonstrated ruptured jejunal diverticulum.

There was associated free intraperitoneal air.

Numerous small bowel diverticuli were noted.

Marked jejunal diverticulosis was noted.

The patient underwent a segmental jejunal resection and anastomosis.

His postoperative course was uneventful.

The patient was dismissed from the hospital.

He continued his immunosuppression, including prednisone.

He continued his immunosuppression, including mycophenolate mofetil.

One month later, the patient presented with the same symptoms.

He was found to have recurrent jejunal diverticulum perforation.

He again underwent a segmental jejunal resection and anastomosis.

Information on the risks and benefits of mycophenolate mofetil was provided.

Information on alternative options such as azathioprine was provided.

Three months after hospitalization, the patient continued to do well.

He had no further episode of abdominal pain.

The patient has end-stage renal disease.

The patient had a failed kidney transplant.

The patient was on low-dose mycophenolate mofetil.

The patient presented with acute onset of abdominal pain.

The patient was given the diagnosis of perforated jejunal diverticulum.

The patient developed a recurrent jejunal perforation a month later.

The patient had a second segmental jejunal resection operation.

His postoperative course was uneventful.


The patient is a 43-year-old Malay female.

She was referred to the low vision clinic by an ophthalmologist.

She was diagnosed with tractional retinal detachment secondary to diabetic retinopathy.

She was diagnosed with diabetes mellitus 5 years ago.

She is currently on treatment for diabetes mellitus at a government hospital.

Her treatment includes metformin 500 mg twice daily.

Her treatment includes glicazide 60 mg daily.

Her treatment includes insulin 18 unit/day (nocte).

Her glycosylated hemoglobin (HbAIc) was 7 mmol/L at her last visit.

She is on treatment for hypertension with hydrochlorothiazide 12.5 mg daily.

She is on treatment for cholesterol with atorvastatin 20 mg daily.

There was no evidence of diabetic nephropathy.

There was no evidence of diabetic neuropathy.

There was no family history of diabetes mellitus.

There was no family history of retinal detachment.

Her main complaint at presentation was blurred vision at both distance and near.

She had never used nor was ever prescribed contact lens or glasses.

She reported difficulty in recognizing faces.

She reported difficulty with orientation and mobility.

She had been told that 'nothing more can be done' to alleviate her condition.

She agreed to be referred to the low vision clinic as a last attempt.

Her distance vision for right eye was 6/48.

Her distance vision for left eye was 6/48.

Subjective refraction improved her distance vision to 6/48 using -1.75Ds in the right eye.

Subjective refraction improved her distance vision to 6/38 with a +3.50 Ds in the left eye.

Addition of +2.50 Ds enabled her to read N24 for the right eye.

Addition of +2.50 Ds enabled her to read N16 for the left eye.

Visual field assessment testing at near using an Amsler’s chart revealed no abnormality.

Examination of her fundi showed diabetic retinopathy changes.

Examination of her fundi showed tractional retinal detachment.

The DASS score showed she was in a state of severe stress (score = 34).

The DASS score showed she was severely anxious (score = 16).

The DASS score showed she was depressed (score = 38).

The LVQoL questionnaire assessment score was 43.

Using a +6.00 Ds spectacle magnifier, she improved her near vision to N10 at 20 cm.

A 3× monocular telescope improved her left eye distance vision to 6/12.

She was introduced to eccentric viewing techniques.

A pair of distance spectacles with prescription RE-1.75 Ds, LE +3.50 Ds was prescribed.

A 3x monocular telescope was prescribed.

She was referred to an orientation & mobility clinic.

She agreed to a referral to the Social Welfare Department.

She was referred to a clinical psychology clinic.

She was referred to an occupational therapy clinic.

She was advised to return for a review in 3 months.

After 3 months, the patient returned for a follow-up.

Her visual acuity for both eyes remained the same at 6/48.

Subjective refraction and visual field status were unchanged.

The DASS score for stress decreased from 34 to 14.

The DASS score for depression decreased from 38 to 18.

A further three months review was given.

She was advised to continue with sessions at the psychology clinic.

She was advised to continue with sessions at the occupational therapy clinic.

She was advised to continue with sessions at the orientation & mobility clinic.

The patient is a 43-year-old Asian female.

The patient has tractional retinal detachment.

The tractional retinal detachment is secondary to diabetic retinopathy.

Mental health screening was performed during low vision rehabilitation.

Quality of life screening was performed during low vision rehabilitation.

Mental health screening and quality of life screening can improve the management of this patient.

The patient is a 43-year-old Malay female.

She was diagnosed with diabetes mellitus 5 years ago.

Her treatment includes metformin 500 mg twice daily.

Her treatment includes glicazide 60 mg daily.

Her treatment includes insulin 18 unit/day (nocte).

There was no evidence of diabetic nephropathy.

There was no evidence of diabetic neuropathy.

There was no family history of diabetes mellitus.

There was no family history of retinal detachment.

She reported difficulty in recognizing faces.

Her distance vision for right eye was 6/48.

Her distance vision for left eye was 6/48.

The DASS score showed she was depressed (score = 38).

The LVQoL questionnaire assessment score was 43.

She was introduced to eccentric viewing techniques.

A 3x monocular telescope was prescribed.

She was referred to an orientation & mobility clinic.

She was referred to a clinical psychology clinic.

She was referred to an occupational therapy clinic.

She was advised to return for a review in 3 months.

After 3 months, the patient returned for a follow-up.

The DASS score for stress decreased from 34 to 14.

A further three months review was given.


The patient had a left lower lobe nodule in the lung.

The patient was scheduled for thoracoscopic wedge resection of the left lower lobe.

Anesthesia was induced with 0.04 mg/kg of midazolam.

Anesthesia was induced with 0.6 μg/kg of sufentanil.

Anesthesia was induced with 2 mg/kg of propofol.

Anesthesia was induced with 0.6 mg/kg of rocuronium.

A left 35 Fr endobronchial tube was successfully intubated at a depth of 28 cm to incisors.

Fiberoptic bronchoscopy was used to confirm the location of the tube after the patient was placed in the right lateral decubitus position.

Anesthesia was maintained with sevoflurane 1.5 vol%.

Anesthesia was maintained with oxygen 2 L/min.

Anesthesia was maintained with remifentanil 250 mcg/hr.

Anesthesia was maintained with 4 mg/kg/h of propofol.

The intraoperative pathological diagnosis of the excised mass was invasive adenocarcinoma.

The patient underwent VATS combined with left lower lobectomy.

The patient was transferred to the post-anesthesia care unit for decannulation.

The patient recovered consciousness from anesthesia after 30 min.

The patient exhibited effective spontaneous ventilation.

The tracheal tube seemed to be mechanically constrained.

The endotracheal tube could not be withdrawn.

Propofol and remifentanil were administered intravenously for sedation.

A fiberoptic bronchoscope revealed that the surgical suture of the bronchial membrane was inserted into the distal end of the left branch of the tracheal tube.

Detailed consultations were held with respiratory physicians and thoracic surgeons.

The thoracic surgeon assured that breaking the suture will not cause adverse effects on the patient.

The respiratory doctor burned the sutures using an argon electrode (ERBE 20132–177) with the aid of fiberoptic bronchoscope.

The mode of the argon electrode was strong electrocoagulation.

The power of the argon electrode was 35 W.

The bronchial tube was pulled out smoothly.

The patient was safely sent back to the ward after CT review.

The patient was followed-up on the 1, 3, and 7 days after the operation.

There were no related complications such as bronchial leak or bronchial rupture.

The patient underwent video-assisted thoracoscopic surgery.

The surgery was combined with left lower lobectomy.

The distal end of the left branch of the tracheal tube was lodged by surgical sutures.

The respiratory physician burned the sutures using an argon electrode.

The physician discussed the procedure with thoracic surgery experts.

The power of the argon electrode was 35 W.


She was admitted for evaluation of intermittent abdominal tenderness, dry eye, and dry mouth.

The dry eye and dry mouth had been present for several years.

She had not sought medical treatment for the dry eye and dry mouth.

She had a history of dilated cardiomyopathy.

She had a history of glaucoma of the left eye.

She was being treated with loop diuretics.

She was being treated with proton pump inhibitors.

She was being treated with anthocyanosides for glaucoma.

In the physical examination, her lower extremities were in an edematous state.

The white blood cell count was 8,600/mm3.

Urinalysis showed proteinuria of 6.3 g/day.

Urinalysis showed 30–49 red blood cells per high-power field.

Serologic investigation revealed the presence of anti-nuclear antibody (ANA; 1:80, homogeneous plus speckled pattern).

Serologic investigation revealed the presence of rheumatoid factor (390 IU/mL).

Serologic investigation was positive for autoantibody to the Ro (SS-A) antigen (>200 U/mL).

Serology was negative for antibodies against double-stranded DNA.

Serology was negative for antibodies against La (SS-B).

Serology was negative for antibodies against Sm.

Serology was negative for antibodies against ribonucleoproteins.

Serology was negative for antineutrophil cytoplasmic antibodies.

Serology was negative for lupus anticoagulant.

Serology was negative for IgG/IgM anti-cardiolipin.

Serology was negative for IgG β2-glycoprotein-1.

C4 levels were within normal ranges at 16 mg/dL.

Total hemolytic complement 50 levels were within normal ranges at 33.1 U/mL.

Tests for hepatitis B surface antigen were negative.

Tests for hepatitis C antibodies were negative.

Tests for human immunodeficiency virus antibodies were negative.

Minor salivary gland biopsy showed diffuse lymphocytic infiltrations with a focus score of 3.

Salivary scintigraphy showed non-visualization in both salivary glands.

The findings were consistent with the class 4 Schall grading system.

She was diagnosed with Sjögren’s syndrome.

The diagnosis fulfilled the 2002 American-European consensus classification criteria.

She underwent a percutaneous renal biopsy due to nephrotic syndrome.

Glomerular basement membrane thickening was observed by light microscopy.

Mesangial matrix widening was observed by light microscopy.

Moderate interstitial fibrosis was noted.

Weakly positive staining for IgG, IgA, IgM, and C3 on the outer surface of capillary walls was revealed by immunofluorescent staining.

Diffuse subepithelial electron-dense deposit was observed by electron microscopy.

The histopathological findings were consistent with membranous glomerulonephritis.

Abdominal computed tomography (CT) and colonoscopy were performed due to intermittent abdominal tenderness.

No malignancy was observed at admission.

No bowel perforation was observed at admission.

She had sudden onset of severe abdominal pain 3 months later.

Abdominal CT showed newly developed pneumoperitoneum with peritonitis.

Abdominal CT showed small bowel perforation.

An emergency operation and small bowel biopsy were performed.

The specimen had a necrotic and ulcerous lesion measuring 4.5 × 5 cm.

Immunohistochemical examination showed expression of CD20.

Immunohistochemical examination showed expression of CD79a.

Immunohistochemical examination showed expression of BCL-2.

Immunohistochemical examination did not show expression of CD3.

Immunohistochemical examination did not show expression of CD10.

Immunohistochemical examination did not show expression of BCL-6.

The proliferation fraction as determined by Ki-67 was 50%–60%.

The majority of tumor cells were positive for EBV by in situ hybridization.

The patient declined treatment with chemotherapy.

She had been receiving intermittent low-dose oral corticosteroid.

She had been receiving hydroxychloroquine.

There was improvement in proteinuria (1.79 g/day) after 1 year of follow-up.

There was improvement in sicca symptoms after 1 year of follow-up.

One year of follow-up positron emission tomography-CT scan showed a stable disease state for the malignant lymphoma.

She developed membranous glomerulonephritis.

She developed Epstein-Barr virus-positive diffuse large B-cell lymphoma.

The diagnosis of Sjögren's syndrome was based on dry eyes.

The diagnosis of Sjögren's syndrome was based on dry mouth.

The diagnosis of Sjögren's syndrome was based on a positive anti-nuclear antibody test.

The diagnosis of Sjögren's syndrome was based on anti-Ro (SS-A) antibody.

The diagnosis of Sjögren's syndrome was based on a salivary gland biopsy.

The diagnosis of Sjögren's syndrome was based on salivary scintigraphy.

Renal biopsy confirmed the diagnosis of membranous glomerulonephritis.

Three months later, her small bowel was perforated with pneumoperitoneum.

The biopsy revealed Epstein-Barr virus-positive diffuse large B-cell lymphoma.

The dry eye and dry mouth had been present for several years.

She had a history of dilated cardiomyopathy.

She had a history of glaucoma of the left eye.

She was being treated with loop diuretics.

She was being treated with proton pump inhibitors.

She was being treated with anthocyanosides for glaucoma.

The white blood cell count was 8,600/mm3.

Urinalysis showed proteinuria of 6.3 g/day.

Urinalysis showed 30–49 red blood cells per high-power field.

Serology was negative for antibodies against La (SS-B).

Serology was negative for antibodies against Sm.

Serology was negative for antibodies against ribonucleoproteins.

Serology was negative for antineutrophil cytoplasmic antibodies.

Serology was negative for lupus anticoagulant.

Serology was negative for IgG/IgM anti-cardiolipin.

Serology was negative for IgG β2-glycoprotein-1.

C4 levels were within normal ranges at 16 mg/dL.

Tests for hepatitis B surface antigen were negative.

Tests for hepatitis C antibodies were negative.

Tests for human immunodeficiency virus antibodies were negative.

She was diagnosed with Sjögren’s syndrome.

Mesangial matrix widening was observed by light microscopy.

Moderate interstitial fibrosis was noted.

No malignancy was observed at admission.

No bowel perforation was observed at admission.

She had sudden onset of severe abdominal pain 3 months later.

Abdominal CT showed small bowel perforation.

An emergency operation and small bowel biopsy were performed.

Immunohistochemical examination showed expression of CD20.

Immunohistochemical examination showed expression of CD79a.

Immunohistochemical examination showed expression of BCL-2.

Immunohistochemical examination did not show expression of CD3.

Immunohistochemical examination did not show expression of CD10.

The proliferation fraction as determined by Ki-67 was 50%–60%.

The patient declined treatment with chemotherapy.

She had been receiving hydroxychloroquine.


The patient has a history of hypertension.

The patient was admitted from another institution.

The patient was diagnosed with acute abdomen.

The patient reported approximately 48 hours of pain in the lower abdominal area.

The pain did not subside with common analgesics.

On admission, the patient had a positive Blumberg sign.

A blood count showed a leukocytosis of 18,320 mm³.

A blood count showed a neutrophilia of 85%.

A computed tomography (CT) of the abdomen with intravenous contrast was performed.

The CT showed a saccular image of 52 x 41 mm dependent on the loop of the terminal ileum.

The CT showed a pattern of bread crumbs.

The CT showed rarefaction of adjacent fat.

The CT showed findings related to Meckel's diverticulitis.

The CT showed free liquid in the abdominal cavity.

Signs of associated peritonitis were considered.

The surgery showed a prominent diverticulum dependent on the small intestine.

The diverticulum was located 25 cm from the ileocecal valve.

An enterotomy of approximately 5 cm of the small intestine was performed.

A lateral-lateral anastomosis with mechanical suture was performed.

The pathological anatomy described a segment of the small intestine with a lesion of saccular appearance.

Histological cuts showed ulceration of the mucosa and submucosa.

Histological cuts showed acute inflammation in the serosa.

There was no significant alteration of the enteric wall away from the lesion.

The description confirmed the diagnosis of perforated Meckel's diverticulitis.

The patient was referred from another institution.

On physical examination, the patient presented signs of peritoneal irritation.

The admission blood count showed leukocytosis.

The admission blood count showed neutrophilia.

Computed tomography of the abdomen with intravenous contrast was performed.

The computed tomography was interpreted as Meckel's diverticulitis complicated.

The diagnosis was corroborated during the surgical act.

The diagnosis was confirmed by pathological anatomy.


The patient was a 64-year-old Indian man.

He had complaints of abdominal pain, vomiting, and not passing flatus or feces for four days.

The patient's general condition was poor.

X-rays of the abdomen showed multiple air fluid levels.

The X-rays were suggestive of acute intestinal obstruction.

The provisional diagnosis was acute abdomen (acute intestinal obstruction).

The patient was sent for an urgent laparotomy.

On exploration, the patient had severely dilated small gut loops.

The terminal ileal loop was twisted around the omental band.

The ileal loop was adherent to the left pelvic wall.

On releasing the omental band, the ileal loop was dissected free from the left pelvic wall.

A large, white, oval shaped, extra-luminal body was found in the region of the sigmoid colon.

The body was soft to firm in consistency.

Part of the appendices epiploicae attached to the sigmoid colon were calcified.

The stalks of the calcified appendices epiploicae were constricted.

The peritoneal loose body was largely parasitized to the omentum.

The body had a separate feeding vessel supplying it from the omentum.

The body measured 7 cm in length and 5 cm in width.

On the cut surface, it had a classic appearance like a boiled egg.

The white peripheral part was smooth and soft in consistency.

The central yellow part was slightly firm in the periphery.

The central yellow part was hard (calcified) at the central point.

Histological examination showed laminated strands of a fibrinoid substance.

The peripheral white part contained a large amount of proteinaceous material.

The peripheral white part resembled boiled albumin with high collagen deposition.

The central yellow part contained saponified fat with calcification.

He resumed his oral diet on the third post-operative day.

He was discharged from the hospital five days after the operation.

A giant loose peritoneal body measuring 7 × 5 cm was found incidentally in a 64-year-old Indian man.

The patient presented with acute intestinal obstruction.

The current hypothesis and opinion on the genesis of such large bodies are presented.

The problems in diagnosis are discussed.


She presented with recurrent attacks of hypoglycemia.

Diagnostic tests repeatedly documented glucose levels below 40 mg/dl.

A CT scan of the abdomen revealed a large lesion of around 5 to 6 cm in relation to the pancreatic body and tail.

There were also large masses of about 3–5 cm in the retroperitoneum and in the area of the celiac trunk and around the mesenteric artery.

In the pancreatic body there was a hypervascularized area suspicious for an insulinoma.

The patient reported a weight loss of 12 kilograms over the previous 4 months.

A somatostatin receptor scintigraphy showed an enhanced uptake in the region of the pancreatic body/tail.

A somatostatin receptor scintigraphy showed an enhanced uptake in the right axilla.

A palpable mass was noted in the right axilla.

The scintigraphy excluded the possibility of other involved areas.

The patient had a past history of an operation on the right eyebrow 2 years prior.

The eyebrow lesion was reported as a Merkel cell carcinoma.

Histopathology showed rather uniform tumor cells in a trabecular growth pattern.

The tumor cells had monomorphous pale-stained nuclei.

There was invasion of dermal lymphatics and blood vessels.

Immunohistochemistry revealed strong positivity for cytokeratin 20.

Immunohistochemistry revealed a dot-like pattern of cytokeratin 20.

There was a weak expression of chromogranin A.

After excision, radiation therapy was administered at the site of the primary lesion.

Radiation therapy was also administered at the draining lymphatic vessels.

Radiation therapy was also administered at the first lymph node station.

A year later, a large abdominal mass was noted of uncertain origin.

An ultrasound guided biopsy showed an unspecified small cell cancer.

Palliative radiotherapy of 30 Gray over 2 months was administered.

No definitive diagnosis of metastasis in the spleen, left adrenal gland, and axilla was established.

The working clinical diagnosis was symptomatic insulinoma not responding to medical measures.

A decision for surgical resection of the large lesion was made.

Surgical exploration revealed a large mass of about 5 cm in the tail of the pancreas.

The mass was in close proximity to the spleen and the splenic flexure of the transverse colon.

There was no evidence of any metastatic disease to the liver, peritoneum, and the adnexae.

A distal pancreatectomy, splenectomy, adrenalectomy, and resection of the splenic flexure of the colon were performed.

Pathological examination revealed a tumor in the pancreatic tail.

The tumor was also present in the adrenal gland.

The tumor was also present in the peripancreatic tissue.

The tumor was also present in the surrounding soft tissue.

Grossly, the mass displayed a whitish and glassy cut surface.

The mass contained extended areas of haemorrhage and necrosis.

Histologically, the tumor displayed endocrine architecture with mostly solid formations of rather monomorphic cells.

The tumor was mitotically highly active (mitotic count >10 per high power field).

The tumor contained abundant areas of necrosis.

Immunohistochemically, the tumor cells were strongly positive for synaptophysin.

Immunohistochemically, the tumor cells were strongly positive for cytokeratin 20.

The proliferative activity (MIB-1) reached approximately 80%.

Gross examination of the resected specimen revealed a well demarcated, brownish tumor of the pancreatic body.

Microscopically, the tumor displayed endocrine architecture with trabecular arrangements of uniform tumor cells.

Immunohistochemistry revealed strong positivity for synaptophysin.

Immunohistochemistry revealed focal positivity for insulin.

The proliferative activity (MIB-1) was approximately 1%.

The diagnosis of a poorly differentiated endocrine carcinoma (Merkel cell carcinoma) was made.

The diagnosis of a benign pancreatic insulinoma was made.

The patient had a smooth postoperative recovery.

The bouts of hypoglycaemia completely disappeared.

She was discharged home within 3 weeks of surgery.

We report an unusual occurrence of pancreatic metastases from a previously diagnosed Merkel cell carcinoma with the discovery of a concomitant insulinoma.

An 82-year old lady suffered from recurrent attacks of hypoglycemia.

Two years prior she had an excision done on her eyebrow that was reported as Merkel cell carcinoma.

An extended distal pancreatectomy and splenectomy along with resection of the left flexure of the colon for her abdominal mass was carried out.

Final histopathology of the mass was a poorly differentiated endocrine carcinoma in the pancreatic tail.

Final histopathology showed the tumor in the peripancreatic tissue.

Final histopathology showed the tumor in the surrounding soft tissue.

The histopathology was consistent with metastatic Merkel cell carcinoma.

An insulinoma of the pancreatic body was also found.

She presented with recurrent attacks of hypoglycemia.

A palpable mass was noted in the right axilla.

The scintigraphy excluded the possibility of other involved areas.

The eyebrow lesion was reported as a Merkel cell carcinoma.

The tumor cells had monomorphous pale-stained nuclei.

There was invasion of dermal lymphatics and blood vessels.

Immunohistochemistry revealed a dot-like pattern of cytokeratin 20.

There was a weak expression of chromogranin A.

A year later, a large abdominal mass was noted of uncertain origin.

Palliative radiotherapy of 30 Gray over 2 months was administered.

A decision for surgical resection of the large lesion was made.

Pathological examination revealed a tumor in the pancreatic tail.

The tumor was also present in the adrenal gland.

The tumor was also present in the peripancreatic tissue.

The tumor was also present in the surrounding soft tissue.

Grossly, the mass displayed a whitish and glassy cut surface.

The mass contained extended areas of haemorrhage and necrosis.

The tumor contained abundant areas of necrosis.

The proliferative activity (MIB-1) reached approximately 80%.

Immunohistochemistry revealed strong positivity for synaptophysin.

Immunohistochemistry revealed focal positivity for insulin.

The proliferative activity (MIB-1) was approximately 1%.

The diagnosis of a benign pancreatic insulinoma was made.

The patient had a smooth postoperative recovery.

The bouts of hypoglycaemia completely disappeared.

She was discharged home within 3 weeks of surgery.


The patient had chest tightness and chest pain for more than 2 months.

The patient had a weight loss of 10 kilogram in the past 2 months.

The patient had a history of afternoon low fever before 1 week.

The patient had enlarged superficial lymph nodes.

The patient had swollen skin on the right side of the chest.

The patient had solid percussion sounds on the right side of the chest.

The patient had enlarged liver on the right side.

The patient had a history of mitral valvuloplasty and aortic valve replacement at the Second Affiliated Hospital of Nanchang University on 2021-08-11.

The patient had long-term oral treatment with warfarin anticoagulation.

The patient had long-term oral treatment with metoprolol.

The patient was a smoker for 40 years, 10 cigarettes per day.

The patient had no history of contact with a chronically coughing person suspected of or treated for TB.

The CT examination showed multiple wall nodules in the right pleura.

The CT examination showed right pleural encapsulated effusion.

The CT examination showed bone destruction in the 2nd thoracic vertebra.

The CT examination showed multiple slightly hypodense nodules in the liver.

The possibility of multiple metastases of right lung cancer with malignant pleural fluid was considered.

The histopathology showed coagulative necrosis combining with granulomatous inflammation.

Acid-fast bacilli staining was positive.

The diagnosis of TB infection was definite.

The patient was hospitalized for chest disease.

The patient's main symptoms included chest tightness.

The patient's main symptoms included chest pain.

The patient's main symptoms included fatigue.

The patient's main symptoms included anorexia.

The patient's main symptoms included weight loss.

The patient's heart rate was 109 times/min.

CT scans of the neck, chest, and abdomen revealed multiple nodules in the right pleura.

CT scans revealed right pleural encapsulated effusion.

CT scans showed limited, incomplete expansion of the middle and lower lobes of the right lung.

CT scans showed enlarged lymph nodes in the right hilar and mediastinal and diaphragm groups.

CT scans showed multiple slightly low-density nodules in the liver.

CT scans showed bone destruction in the 2nd thoracic vertebra.

The findings raised the possibility of multiple liver metastases of right lung cancer.

The findings raised the possibility of malignant pleural fluid.

The lymph nodes in the neck, mediastinum, abdomen, and pelvis were enlarged bilaterally.

The patient was diagnosed with atypical systemic HDTB.

The patient received three months of conventional anti-TB treatment.

The patient refused follow-up at our hospital.

The patient's symptoms improved significantly during telephone follow-up.

Acid-fast bacilli staining was positive.

The diagnosis of TB infection was definite.

The patient was hospitalized for chest disease.

The patient's main symptoms included chest pain.

The patient's main symptoms included fatigue.

The patient's main symptoms included anorexia.

The patient's heart rate was 109 times/min.

The patient refused follow-up at our hospital.


The patient was a 51-year-old Caucasian left-handed housewife.

The patient had a weight of 61 kg and height of 159 cm.

The patient was admitted due to severe sudden onset headache.

The patient had transient loss of consciousness.

On examination, the patient was fully conscious and oriented.

The patient complained of severe headache.

No focal neurological deficit was found.

CT scan of the head revealed acute subarachnoid hemorrhage.

The cerebral vasculature harbored three saccular aneurysms.

The right MCA aneurysm was presumed to be the ruptured aneurysm.

A right pterional craniotomy was performed.

The sphenoid ridge was drilled flush with the orbital roof.

Gentle frontal lobe retraction allowed CSF drainage.

The Sylvian fissure was opened from medial to lateral.

A saccular aneurysm was found in the MCA trifurcation.

The distal basilar artery aneurysm was located between the right PCA and right SCA.

The aneurysm dome projected laterally to the right.

The left ICA bifurcation aneurysm was identified.

The patient experienced an uneventful post-operative period.

The patient was discharged within 5 days of surgery.

A follow-up CT angiography confirmed successful obliteration of all lesions.

The patient is a 51 year-old Caucasian right handed housewife lady.

The patient presented with a headache of acute onset.

The headache was caused by acute subarachnoid hemorrhage.

Cerebral computed tomographic angiography revealed multiple aneurysms.

The patient underwent a right pterional craniotomy.

The right pterional craniotomy was performed to obliterate right middle cerebral, distal basilar and left carotid bifurcation aneurysms.

The post-operative course was uneventful.


The patient is a 21-year-old male Japanese student.

He is an active member of an equestrian club.

He sustained a right toe injury during an accident in a club-related activity.

The injury resulted in the severance of his right toe above the interphalangeal joint.

He was directed to the rehabilitation department 2 weeks post-injury.

He had no remarkable medical or family history.

The patient agreed to provide the case report and consented to its publication, including any accompanying images.

The ethics committee of our institution waived the need for ethical review, as the patient provided written consent for the case report.

Initial assessments indicated pain localized to the injury site, primarily during walking.

One month post-injury, the patient also reported pain in the right knee joint while engaging in riding or walking.

The pain in the area of the hallux deficit hindered his ability to apply pressure on the thenars.

Diagnostic tests, including walking cycle analysis, temporospatial gait parameters, foot pressure distribution, ground reaction force measurements, toe grip force, and one-leg standing tests, were conducted.

The foot pressure during a comfortable walk were recorded using a Zebris plantar pressure platform.

The center of pressure (COP) during a comfortable walking pace was captured using force plates.

A diminished foot pressure was observed not just in the hallux but also in the metatarsal head of toes two to five on the injured side.

The left-foot COP shifted toward the left toe in the late stance phase.

The right-foot COP transitioned toward the second toe, exhibiting greater spatial variability.

Assessing the walking cycle using a Zebris plantar pressure platform, the load response and single-support durations were reduced.

Vertical ground reaction force during the second peak of walking was diminished on the right side.

The patient was unable to maintain a one-leg stand for 10 seconds on the right foot.

Pain levels for the toe and knee were rated 5 out of 10 on a numerical rating scale (NRS).

A rehabilitation protocol was designed to enhance medial foot loading and improve foot pressure during walking and standing.

The regimen included balance and trunk strength training.

Starting from the fifth week, the focus shifted to lower limb strength training.

From the ninth week, dynamic joint stability exercises were introduced to enhance neuromuscular coordination for movement stabilization.

After 3 months, foot pressure and COP movement during walking improved.

Pressure distribution across toes two to five and the metatarsal head improved.

There were negligible discrepancies between the left and right sides in both the vertical and anterior–posterior directions.

The pressure was consistently distributed from the second toe of the right foot.

Notable enhancements were also observed in the pre-leg phase.

The second peak of the vertical component of the ground reaction force increased.

One-leg standing on the right foot became stable for 10 seconds, even on a balance mat.

NRS scores for the toe and knee pain reduced to 0, indicating a return to pre-injury levels of activity.

The patient is a 21-year-old Japanese individual.

The patient had a traumatic hallux deficit.

Only a portion of the basal phalanx was intact.

The instability led to impaired balance.

The instability led to walking difficulties.

Biomechanical assessment revealed the need for a rehabilitation strategy for the foot.

Biomechanical assessment revealed the need for a rehabilitation strategy for the knee.

Biomechanical assessment revealed the need for a rehabilitation strategy for the hip.

Biomechanical assessment revealed the need for a rehabilitation strategy for the trunk.

A rehabilitation protocol was designed to enhance medial foot loading during walking.

A rehabilitation protocol was designed to enhance medial foot loading during standing.

The rehabilitation protocol included balance training.

The rehabilitation protocol included trunk strength training.

The rehabilitation period lasted 12 weeks.

The load response and single-support phases of the gait cycle on the affected side increased from 46.9% to 49.3%.

The pre-swing phase of the gait cycle on the affected side decreased from 14.6% to 11.6%.

The vertical component of the ground reaction force rose from 599.8 to 647.5 N.

Enhanced stability from balance training contributed to the patient's improved walking.

Enhanced stability from balance training contributed to the patient's improved balance.

Increased muscle strength contributed to the patient's improved walking.

Increased muscle strength contributed to the patient's improved balance.

The patient is a 21-year-old male Japanese student.

He is an active member of an equestrian club.

He sustained a right toe injury during an accident in a club-related activity.

He was directed to the rehabilitation department 2 weeks post-injury.

He had no remarkable medical or family history.

The left-foot COP shifted toward the left toe in the late stance phase.

The regimen included balance and trunk strength training.

Starting from the fifth week, the focus shifted to lower limb strength training.

After 3 months, foot pressure and COP movement during walking improved.

Pressure distribution across toes two to five and the metatarsal head improved.

The pressure was consistently distributed from the second toe of the right foot.

Notable enhancements were also observed in the pre-leg phase.

The patient is a 21-year-old Japanese individual.

The patient had a traumatic hallux deficit.

Only a portion of the basal phalanx was intact.

The instability led to impaired balance.

The instability led to walking difficulties.

The rehabilitation protocol included balance training.

The rehabilitation protocol included trunk strength training.

The rehabilitation period lasted 12 weeks.

The vertical component of the ground reaction force rose from 599.8 to 647.5 N.

Increased muscle strength contributed to the patient's improved walking.

Increased muscle strength contributed to the patient's improved balance.


The patient was admitted to the hospital on November 10, 2021.

The patient was admitted due to complaining of fever for 7 days.

On November 2019, he was diagnosed with B-cell acute lymphoblastic leukemia.

He received multiple chemotherapy sessions.

His bone marrow was retested as minimal residual disease-negative complete remission.

On November 26, 2020, the patient underwent allogeneic HSCT.

He received treatment such as leukocytosis.

On December 29, 2020, he developed thrombocytopenia.

He was treated with platelet transfusion.

Bone marrow CR and MDR were repeatedly rechecked.

The results showed complete implantation of FISH donor.

Fever occurred repeatedly in February, March, and May 2021.

After anti-infection, anti-fungal, and anti-viral treatment, the patient improved.

7 days before admission, the patient developed a fever.

The patient was hospitalized in a tertiary hospital in Guangzhou.

The chest CT showed multiple inflammations in both lungs.

The bronchial fluid was found positive for MTB complex nucleic acid.

The patient was considered to be post-HSCT TB.

He was admitted to our hospital after consultation.

The patient had acute lymphoblastic leukemia.

The patient suffered from pulmonary TB infection after HSCT.

The patient had a poor response to linezolid-containing regimen.

The patient developed side effects such as gingival bleeding and thrombocytopenia.

The administration was switched to contezolid.

After 15 days of continuous treatment, the patient's platelet increased to 58×109/L.

The patient was discharged in stable condition.

During subsequent anti-TB treatment with contezolid for more than 7 months, the platelets remained stable.

No hematological adverse reactions were observed.

No symptoms of peripheral neuropathy were observed.

Repeat imaging showed that the bilateral lung lesions were significantly reduced.


A four-year-old girl presented to the emergency service with painful left hip and fever.

There was no previous relevant medical history.

There were no other local or systemic symptoms, except for a cervical adenopathy.

On physical examination, she walked with a limp.

Movements of the left hip were painful (mainly external rotation), but not restricted.

Blood exam revealed anemia (Hb 8.7 gr/dL).

An initial X-ray to the pelvis revealed no changes.

An ultrasound of the left hip was performed.

The ultrasound revealed small infusion and synovitis.

The puncture was macroscopically compatible with reactive arthritis.

General and bacteriological tests were demanded.

A CT scan to the abdomen and pelvis was performed.

The CT scan revealed a left adrenal mass.

The CT scan revealed retroperitoneal adenopathies in the celiac trunk and superior mesenteric artery.

No bone or articular involvement was found in the CT scan.

No further alterations were reported in the thoracic CT scan.

No alterations were reported in peripheral blood smears.

Bacteriological examination of the hip effusion was negative.

The direct myelogram was compatible with infiltration from neuroblastoma.

Bone marrow biopsy and cervical adenopathy specimens were collected to perform histological diagnosis.

Skeletal scintigraphy demonstrated numerous points of osteoblastic activity compatible with metastatic activity.

The 12 iodine-123 metaiodobenzylguanidine scintigraphy concluded: 'Abdominal mass with low expression of noradrenergic transporters.'

The 12 iodine-123 metaiodobenzylguanidine scintigraphy concluded: 'Diffuse bone metastasization with high expression of noradrenergic transporters.'

The 12 iodine-123 metaiodobenzylguanidine scintigraphy concluded: 'No other soft tissue involvement was detected.'

In the histological report of the cervical adenopathy, the diagnosis of neuroblastoma NOS was performed.

Immunohistochemistry revealed extensive expression for synaptophysin.

Immunohistochemistry revealed extensive expression for CD56 (NCAM).

Immunohistochemistry revealed absence of expression of myogenin.

Bone marrow biopsy revealed extensive metastatic involvement.

The patient started chemotherapy two weeks after admission.

The patient received 8 cycles of rapid COJEC protocol.

After six months of follow-up, the primary tumor was still without criteria for resection.

Despite a decrease in the metastatic involvement, the primary tumor was still without criteria for resection.

Given the chemotherapy-related renal toxicity, it was decided to proceed with irinotecan in combination with temozolomide (TEMIRI).

After thirteen months of follow-up, no significant regression of the primary tumor occurred.

The patient was proposed for stem cell treatment.

A four-year-old girl presented with fever and a painful limp in the left hip.

Pain characteristics and anemia detected in the blood analyses were the first warning signs that the hip process was not standard.

The primary suspicion was of septic arthritis.

A CT scan of the abdomen revealed an adrenal neuroblastoma.

There was no previous relevant medical history.

On physical examination, she walked with a limp.

Blood exam revealed anemia (Hb 8.7 gr/dL).

An ultrasound of the left hip was performed.

General and bacteriological tests were demanded.

The CT scan revealed a left adrenal mass.


The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by factors including glomerular filtration rate (GFR), proteinuria, and comorbidities such as diabetes and hypertension. Early intervention with pharmacological agents, dietary modifications, and blood pressure control is critical to slow disease progression and reduce cardiovascular risk.

She was admitted with acute myocardial infarction due to a spontaneous right coronary artery dissection.

Her medical history included a conservatively managed left posterolateral branch myocardial infarction at the age of 39.

At 51, she was treated for breast cancer with a curative intent.

An emergency percutaneous coronary intervention of the right coronary artery was performed.

The post-procedural course was complicated by ventricular tachycardia and fibrillation.

She developed cardiogenic shock due to failure of the right ventricle.

The cardiogenic shock was refractory to fluid resuscitation and inotropes.

She was stabilized using peripheral veno-arterial extracorporeal membrane oxygenation.

Echocardiography showed a dilated right ventricle with severely impaired function.

Echocardiography showed paradoxical septal motion with signs of right ventricular volume overload.

Echocardiography showed severe tricuspid regurgitation with elevated filling pressures.

The left ventricular function was slightly impaired.

She developed heparin-induced thrombocytopaenia.

She was rejected for an urgent heart transplant listing due to the recent oncological history.

The veno-arterial extracorporeal membrane oxygenation was exchanged for percutaneous veno-pulmonary extracorporeal membrane oxygenation.

Weaning from extracorporeal membrane oxygenation was initially successful.

Within days after discontinuation of the extracorporeal membrane oxygenation, she developed fast recurrent ventricular tachycardias.

The ventricular tachycardias were haemodynamically poorly tolerated.

Intravenous administration of amiodarone resulted in further progression of right ventricular failure.

Amiodarone caused a slow junctional rhythm that was poorly tolerated haemodynamically.

Escalation in the inotropic regimen in the days after extracorporeal membrane oxygenation weaning further contributed to the incessant ventricular tachycardias.

A decision was made to perform a bidirectional cavopulmonary anastomosis with a concomitant tricuspid valve annuloplasty.

In a bidirectional cavopulmonary anastomosis, the superior vena cava is disconnected from the right atrium and anastomosed end-to-side to the right pulmonary artery.

The bidirectional cavopulmonary anastomosis redirects a substantial proportion of the venous return directly to the lungs, bypassing the right ventricle.

The patient underwent bidirectional cavopulmonary anastomosis and restrictive tricuspid valve annuloplasty.

She had an arterial oxygen saturation of 95% in ambient air.

She could be weaned off veno-arterial extracorporeal membrane oxygenation and inotropes within 3 weeks after the operation.

Echocardiography showed normalization of right ventricular dimensions.

Echocardiography showed moderate to severely impaired right ventricular function.

Echocardiography showed trivial tricuspid valve regurgitation.

A subcutaneous implantable cardioverter-defibrillator seemed most appropriate.

Implanting the subcutaneous implantable cardioverter-defibrillator was postponed due to a sternal wound infection.

She was discharged home with a LifeVest Wearable Defibrillator.

The peripheral oxygen saturation at discharge was 99%.

She completed a cardiac rehabilitation program.

Her New York Heart Association functional class IV improved to III at the 6-month follow-up examination.

There have not been any heart failure-related admissions.

She had refractory right ventricular failure.

The cause was spontaneous dissection of the right coronary artery.

She remained dependent on mechanical support for several weeks.

A right ventricular assist device implant was explored as a long-term support option.

A bidirectional cavopulmonary anastomosis was explored as a long-term support option.

Possible right ventricular functional recovery was considered.

A decision in favour of the bidirectional cavopulmonary anastomosis was made.

A concomitant tricuspid valve annuloplasty was performed.

Postoperatively, her clinical condition improved significantly.

Echocardiography showed slight improvement of right ventricular function.

At 51, she was treated for breast cancer with a curative intent.

The left ventricular function was slightly impaired.

She developed heparin-induced thrombocytopaenia.

She had an arterial oxygen saturation of 95% in ambient air.

Echocardiography showed trivial tricuspid valve regurgitation.

She was discharged home with a LifeVest Wearable Defibrillator.

The peripheral oxygen saturation at discharge was 99%.

She completed a cardiac rehabilitation program.

There have not been any heart failure-related admissions.


The patient was transported to the hospital 4 h after being injured in a motor vehicle accident.

The patient's body temperature was 36.6°C.

The patient's blood pressure was 186/115 mmHg.

The patient's oxygen saturation was 96% on nasal cannula at 1 L.

Electrocardiography revealed premature ventricular contraction.

Electrocardiography revealed an incomplete right bundle branch block.

Contrast-enhanced computed tomography showed serial fractures from the left fourth to seventh ribs.

The sixth rib was protruding into the thoracic cavity toward the heart.

The fifth rib was fractured near the heart.

The seventh rib was fractured near the diaphragm.

A small pleural effusion, suspected to be a hemothorax, was observed in the left thorax.

The pleural effusion was not increasing in size.

Extravasation into a liver cyst was identified.

The bleeding needed to be stopped by interventional radiology prior to surgery.

Nine hours after the injury, the CK-MB level decreased to 15.7 U/L.

Nine hours after the injury, the troponin I level increased to 1.009 ng/mL.

Exploratory VATS was immediately performed.

The left ventricular wall was crushed below the injured pericardium on the anterior side of the phrenic nerve.

No penetrating injury to the abdominal cavity was observed.

There was no bleeding in the damaged area.

A fragment of the sixth rib was protruding into the thoracic cavity.

The injury to the left ventricular wall did not penetrate deep into the lumen.

The injury was closed horizontally using a U-shaped suture with 4-0 non-resorbable polypropylene with felt.

The injury was covered with collagen-fibrin patch (TachoSil®).

The lacerated pericardium was sparsely sutured.

The scattered bone fragments were removed.

The fifth and sixth ribs were repaired using bioresorbable plates (SUPER FIXSORB-MX®) as braces.

A 20-Fr. double lumen chest tube was placed to the anterior side.

A 28-Fr. single lumen chest tube was placed to the posterior side.

The patient was extubated on postoperative day 2.

The chest tubes were removed on postoperative day 4.

Paroxysmal atrial fibrillation appeared transiently.

The atrial fibrillation improved after the administration of beta-blockers.

The patient's myocardial enzyme levels gradually decreased.

The patient was discharged from the hospital on postoperative day 16.

No major abnormalities were noted 3 months postoperatively.

The patient was injured in a motor vehicle accident.

The patient suffered from left hemothorax.

The patient had multiple rib fractures near the heart.

A comprehensive assessment raised suspicions of lacerated pericardium.

A comprehensive assessment raised suspicions of myocardial injury.

A thoracoscopy was performed 9 h after injury.

A penetrating cardiac injury was detected.

The injury was surgically treated via video-assisted thoracoscopic surgery.

The patient was discharged on postoperative day 16.

The patient's body temperature was 36.6°C.

The patient's blood pressure was 186/115 mmHg.

The fifth rib was fractured near the heart.

Extravasation into a liver cyst was identified.

Exploratory VATS was immediately performed.

There was no bleeding in the damaged area.

The lacerated pericardium was sparsely sutured.

The scattered bone fragments were removed.


He had no personal or family history of interest.

He presented to the paediatric emergency department with abnormal ocular movements of a year's duration.

The family reported about 5-6 episodes a day of about 5-10 seconds duration.

The episodes consisted of horizontal conjugate ocular movements with rapid jerks.

There were no associated head or limb movements.

The episodes did not associate with fixation of the gaze.

The episodes did not associate with position or movements of the head.

The patient could not self-provoke the episodes.

The patient could identify the onset of the episodes.

The episodes were of sudden onset and cessation.

Some episodes gave the impression of disconnection from the environment or loss of consciousness.

The episodes always occurred in the waking state.

The episodes never occurred during sleep.

The parents observed a higher frequency of episodes on days of greater stress.

The parents observed a higher frequency of episodes on days of greater physical fatigue.

There were no other triggers identified.

There was no consumption of other toxic substances.

The symptoms had not changed or progressed since their onset.

The neurological examination between episodes was normal.

Ophthalmologic evaluation ruled out visual pathology.

Otolaryngologic evaluation ruled out pathology in that area.

Otolaryngologic evaluation described a high intensity, low amplitude jerk nystagmus episode.

The patient was hospitalized for further evaluation.

General laboratory tests showed no pathological findings.

Videotaping of the episodes by the family was of great help in the diagnostic orientation.

The video-electroencephalogram demonstrated an electro-clinical correlate of the episodes.

The VEEG was performed in the waking state.

The VEEG recorded two separate events of about 8-10 seconds duration.

The background tracing was normal for his age.

Epileptiform activity was recorded in the left temporal and occipital region.

The epileptiform activity later generalized.

Treatment with carbamazepine was initiated orally at an ascending dose.

A brain magnetic resonance study with contrast was completed.

The MRI showed no evidence of structural alterations.

The MRI showed no evidence of cortical development anomalies.

The final diagnosis was ictal nystagmus.

He was discharged to home with a dose of carbamazepine of 13 mg/kg/day.

In outpatient follow-up in Neuropediatric consultations, 2 years after the start of treatment, good adherence was noted.

In outpatient follow-up in Neuropediatric consultations, 2 years after the start of treatment, absence of side effects to treatment was noted.

In outpatient follow-up in Neuropediatric consultations, 2 years after the start of treatment, there were no new episodes.

The patient is an 8-year-old male school-age child.

The patient has no relevant medical history.

He presented with a 1-year history of conjugate horizontal rapid eye movement jerking.

The eye movement jerking was associated with mild miosis.

Some episodes had a questionable disconnection from the environment.

Some episodes had questionable impairment of consciousness.

There were no other accompanying signs or symptoms.

The video-electroencephalogram demonstrated an electro-clinical correlate.

Epileptiform activity was noted in the left temporal and occipital region.

The epileptiform activity later generalized during episodes.

Treatment with carbamazepine was initiated.

The patient had a good evolution after treatment.

There was no recurrence of episodes at 2 years of follow-up.

He had no personal or family history of interest.

There were no associated head or limb movements.

The patient could not self-provoke the episodes.

The episodes were of sudden onset and cessation.

The episodes always occurred in the waking state.

The episodes never occurred during sleep.

There were no other triggers identified.

There was no consumption of other toxic substances.

The patient was hospitalized for further evaluation.

The VEEG was performed in the waking state.

The background tracing was normal for his age.

The epileptiform activity later generalized.

The final diagnosis was ictal nystagmus.


He had a history of an enlarged left testicle for 10 weeks.

Clinical examination revealed nontender swelling of the left testicle.

His alpha-fetoprotein (AFP) levels were within normal limits.

His beta-human chorionic gonadotropin (BHCG) levels were within normal limits.

His lactate dehydrogenase (LDH) concentration was 267 U/L.

Ultrasonography showed an enlarged left testicle measuring 7 × 5.5 × 4.3 cm.

The estimated volume of the left testicle was 87 ml.

A large, heterogeneous mass involved the entire testicle.

The right testicle measured 3.7 × 2.5 × 1.8 cm.

The estimated volume of the right testicle was 8.8 ml.

The macroscopic specimen had well-circumscribed nodular lesions of varying sizes.

The largest lesion contained solid and gelatinous components.

Sections showed tumor composed of sheets of small, blue, round cells.

The tumor was divided into nodules by fibrous septae.

Immunostaining showed the tumor to be cytokeratin 20 (CK20)-positive.

The CK20 staining pattern was typical paranuclear dotlike.

The tumor was positive for CK (paranuclear dots).

The tumor was negative for placental alkaline phosphatase (PLAP).

The tumor was negative for prostate-specific antigen (PSA).

The tumor was negative for chromogranin.

The tumor was negative for thyroid transcription factor 1 (TTF-1).

The immunostaining pattern raised the possibility of metastatic Merkel cell carcinoma (MCC).

The patient presented again 3 months later with a right testicular mass.

Tumor markers, including LDH, AFP, and BHCG, were within normal limits.

Ultrasonographic imaging showed a new lesion in the right testis measuring 3 × 2.6 × 2.3 cm.

The patient underwent right orchiectomy.

Sections showed diffuse infiltration of small, blue, round cells.

Immunostains were positive for synaptophysin.

Immunostains were positive for CK20 (dotlike).

Immunostains were positive for cytokeratin AE1/AE3 (dotlike).

The tumor cells were negative for inhibin.

The tumor cells were negative for TTF-1.

The tumor cells were negative for napsin A.

The pattern was consistent with a poorly differentiated neuroendocrine tumor.

The pattern was in keeping with metastatic MCC.

A staging computed tomographic scan did not show evidence of other metastases.

The patient received six cycles of adjuvant carboplatin and etoposide chemotherapy.

He remained disease-free 18 months following completion of chemotherapy.

A 66-year-old Maori man presented to our hospital with left testicular swelling.

His alpha-fetoprotein and beta-human chorionic gonadotrophin levels were within normal limits.

His lactate dehydrogenase concentration was elevated to 267 U/L.

Ultrasound imaging confirmed a large testicular mass.

His histological examination revealed a neuroendocrine tumor with an immunostaining pattern suggesting Merkel cell carcinoma.

He presented to our hospital again 3 months later with right testicular swelling.

Right testicular swelling was confirmed on ultrasound sonography to be a tumor.

His histological examination revealed metastatic Merkel cell carcinoma.

Computed tomographic imaging did not reveal spread to other organs.

He received six cycles of adjuvant carboplatin and etoposide chemotherapy.

He remained disease-free 18 months after completion of chemotherapy.

The estimated volume of the left testicle was 87 ml.

The right testicle measured 3.7 × 2.5 × 1.8 cm.

The tumor was divided into nodules by fibrous septae.

The tumor was positive for CK (paranuclear dots).

The tumor was negative for chromogranin.

The patient underwent right orchiectomy.

Immunostains were positive for synaptophysin.

Immunostains were positive for CK20 (dotlike).

The tumor cells were negative for inhibin.

The tumor cells were negative for TTF-1.

The tumor cells were negative for napsin A.

The pattern was in keeping with metastatic MCC.


She had a 1 year history of intermittent pain in the right side of the waist without obvious inducement.

She did not notice other symptoms such as nausea and vomiting, chills, high fever, chest tightness, frequent urination, urgency of urination, and painful urination.

The symptoms gradually worsened in the recent 2 mo.

She had no previous history of viral hepatitis B or cirrhosis.

Clinical examination showed no obvious abnormality.

All laboratory blood tests were within normal limits.

Indocyanine green 15 min retention was rated 2.9%.

Abdominal CT showed multiple nodules and abnormal lumpy low-density shadows in the liver parenchyma.

The larger lesions were located in the left lobe and caudate lobe of the liver.

The larger lesions measured about 9.5 cm × 6.3 cm and 8.1 cm × 6.5 cm.

Abdominal MRI revealed multiple space-occupying lesions in the liver.

Combined with enhanced CT scan, hemangioma was considered.

Compression of the main portal vein and right portal vein was noted.

The total liver volume was about 1739 cm3.

The lesion liver volume was about 571 cm3.

The residual liver volume was about 1168 cm3.

She had a 1 year history of intermittent pain in the right side of the waist.

Computed tomography and magnetic resonance imaging diagnosed giant hemangioma of the caudate lobe.

Computed tomography and magnetic resonance imaging diagnosed hemangioma of the left lobe of the liver.

Surgical treatment was performed after discussion.

Intraoperative bleeding was about 600 mL.

Postoperative pathological findings were cavernous hemangioma.

There were no obvious postoperative complications.

The patient was discharged 10 d after surgery.


A 66-year-old man was admitted to the clinic of a primary care doctor.

He complained of a sudden deterioration in right hypochondrial pain persisting for 2 weeks.

A computed tomography (CT) scan revealed a right adrenal hemorrhage.

A computed tomography (CT) scan revealed an abnormal tumor in the upper lobe of his left lung.

He was referred to our hospital for further examination and treatment.

His past medical history and family history were unremarkable.

He was a current smoker with a history of 46 pack-years.

An enhanced CT scan showed a massive shadow in the left lung S1 + 2 progressing to S6 beyond the lung lobe.

The maximum diameter of the left lung lesion was about 42 mm.

The right adrenal lesion showed no active bleeding.

The carcinoembryonic antigen (CEA) was 5.6 ng/mL.

The neuron-specific enolase (NSE) was 18.52 ng/mL.

The patient had mild anemia with a hemoglobin of 10.3 g/dL.

A bronchoscopic trans-bronchial lung biopsy showed no evidence of malignancy.

A CT-guided percutaneous needle biopsy was performed.

The pathological examination showed a non-small cell lung cancer.

The adrenal lesion was diagnosed as a nonfunctional tumor based on endocrine examinations and adrenal medulla scintigraphy.

18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG accumulation in the left lung nodule with an SUVmax of 17.0.

18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG accumulation in the right adrenal lesion with an SUVmax of 4.1.

The clinical stage was classified as cT2bN0M1b, stage IV (TNM classification 7th edition).

A complete resection of the primary lung cancer was considered possible.

The lung tumor showed areas of atypical cells with eosinophilic cytoplasms.

The lung tumor showed a sarcomatous component with extensive necrosis.

The tumor cells were positive for cytokeratin AE1/3, CAM5.2, CK7, and p63 (partial).

The tumor cells were negative for 34βE12, CK20, TTF-1, calretinin, and D2-40.

The adrenal tumor was similar in pathologic and immunohistochemical analyses.

The final diagnosis was pleomorphic carcinoma of the lung with an adrenal metastasis, pT2bN0M1b, stage IV (TNM classification 7th edition).

The patient received chemotherapy as stage IV NSCLC.

The chemotherapy regimen included 60 mg/m2 of cisplatin on day 1.

The chemotherapy regimen included 40 mg/m2 of TS-1 twice a day on days 1 to 14.

The chemotherapy regimen was repeated every 4 weeks.

After two courses, he decided to quit the intravenous chemotherapy.

He refused to take TS-1 because he feared adverse events.

He has survived without any recurrences for 6 years since the surgery.

The patient was referred to the hospital because of a right adrenal hemorrhage.

The patient was referred to the hospital because of a lung tumor.

The lung tumor was a primary lung cancer.

The adrenal hemorrhage was due to a metastatic cancer.

Resection of the lung tumor was performed.

The diagnosis was pleomorphic carcinoma with adrenal metastasis.

The patient has remained recurrence-free for 6 years since the surgery.

The right adrenal lesion showed no active bleeding.

The carcinoembryonic antigen (CEA) was 5.6 ng/mL.

The neuron-specific enolase (NSE) was 18.52 ng/mL.

The patient received chemotherapy as stage IV NSCLC.

The chemotherapy regimen was repeated every 4 weeks.


The patient has a history of hypertension.

The patient has decompensated diabetes mellitus.

The patient was referred to the hospital with critical limb ischemia.

The patient had rest pain on the left leg.

The patient had an ulcer on the left leg.

The patient's blood pressure was 160/90 mmHg.

The patient's heart rate was 130 beats per minute.

A mesogastrium systolic bruit was heard on abdominal auscultation.

Electrocardiogram showed signs of ST segment depression.

Coronary angiography showed severe coronary artery disease.

Duplex ultrasound showed widespread irregularities of the aortic wall.

Duplex ultrasound showed monophasic wave on the right common femoral artery.

Duplex ultrasound showed direct flow on the left femoral axis.

Duplex ultrasound showed diffuse disease of both superficial femoral arteries.

Duplex ultrasound showed distal occlusion in the left superficial femoral artery.

CT-scan showed atherosclerotic disease on the infrarenal abdominal aorta.

CT-scan showed focal dissection of the infrarenal abdominal aorta.

CT-scan showed occlusion of the right common iliac artery origin.

CT-scan showed short dissection of the left common iliac artery origin.

The presence of ulcers in the left leg was the indication to address the left superficial femoral artery.

The intervention was carried out through an antegrade percutaneous homolateral access.

A drug eluting balloon (6.0 × 60 mm Luminor®) was used in the proximal left superficial femoral artery.

A stent (5.0x80mm iVolution) was placed in the distal left superficial femoral artery.

The final result was complete lesion healing in the left foot at three weeks.

After two months, the patient was readmitted due to gangrene of the right foot.

The patient had asymptomatic COVID-19 infection.

Control CT showed a similar vascular pattern on the right side.

The rapid and aggressive right foot lesions evolution was the indication to address vascular lesions in the right axis.

The intervention was carried under general anesthesia.

Surgical exposure of both common femoral arteries was performed.

Aorto-iliac repair was performed using an AFX aortic endograft.

Stenting of the right common iliac artery was performed with a balloon expandable stent (Isthmus 10 × 39).

A drug eluting balloon (Luminor 5 × 200) was used in the right superficial femoral artery.

The multiple intervention determined the increase of the distal flow.

The reappearance of dorsalis pedis pulse was noted.

The patient was asymptomatic for right foot pain after two days.

The patient underwent right foot minor amputation.

The patient was discharged after a week with double antiplatelet therapy.

CT angiography performed after two months confirmed the proper positioning of the aortic stent-graft.

CT angiography confirmed good patency of the iliac-femoral axis.

CT angiography confirmed right foot ulcers healing.

We report a case of complex revascularization in a diabetic patient with aggressive right foot lesions evolution after COVID-19 infection.

The patient presenting a Peripheral arterial ischemic involving the infrarenal aorta, iliac, femoral.

The simultaneous intervention consisted of an endovascular aortic stent-graft placement and angioplasty of femoral artery.

The patient has a history of hypertension.

The patient has decompensated diabetes mellitus.

The patient had rest pain on the left leg.

The patient had an ulcer on the left leg.

The patient's blood pressure was 160/90 mmHg.

The patient's heart rate was 130 beats per minute.

The patient had asymptomatic COVID-19 infection.

The intervention was carried under general anesthesia.

The reappearance of dorsalis pedis pulse was noted.

The patient underwent right foot minor amputation.

CT angiography confirmed right foot ulcers healing.


A 58-year-old Japanese man was presented to our out-patient unit complaining of posterior cervical pain.

The pain firstly appeared 3 months before the first contact to us without any particular triggers such as trauma.

He was relieved from the pain when lying flat.

He kept working as a plumber and the pain got worse over the time period.

A brain computed tomography (CT) was performed 1.5 months after the onset in another clinic.

The brain CT revealed bilateral subdural effusion.

Later on, when he was presented to our hospital, numbness and weakness of extremities also appeared.

A hand-held dynamometer revealed his weakened grip strength of both of his hands by 30–40 kg.

He was presented with bilateral muscle weakness in his lower extremities which was 4 of 5 in the Manual Muscle Test (MMT) score.

His Japanese Orthopedic Association (JOA) score was 13.5.

A fat suppression T2-weighted MRI without gadolinium enhancement of the cervical spine illustrated a fluid collection in the soft tissue spaces of the retrospinal region at C1-C2 level.

The MRI demonstrated spinal canal stenosis at C3/4 level.

A cisternoscintigram and a CT myelogram were performed with intradural injection of 111In-DTPA.

The 111In-DTPA cisternoscintigram clearly revealed CSF leakage into the retrospinal region at C1-C2 level.

The CT myelogram also suggested blockage at lower level of the cervical spinal canal.

72 h of conservative therapy, including bed rest, intravenous fluid hydration, muscle relaxants and non-steroidal anti-inflammatory drugs, was ineffective at improving his symptoms.

The re-examination of brain CT showed progression of the bilateral subdural effusions to bilateral subdural hematomas.

We gave a diagnosis of intracranial hypotension due to the CSF leakage from C1-C2 level.

We performed burr-hole drainage of the subdural hematoma.

We performed blood-patch therapy at C1/2 level.

In the laminoplasty, CSF flew out from the epidural space subsequently to the opening of lamina.

After sufficient decompression, the CSF flow was reduced in the operation field, without detection and restoration of dural tear.

In the blood-patch therapy, an epidural catheter was inserted from the surgical field at C3–4 level to C1-C2 level under x-ray fluoroscopy observation.

Approximately 5 ml of autologous blood sampled from patient’s peripheral vein was injected to the epidural site at C1-C2 level.

Postoperative response was significantly favorable.

The imaging features that suggested CSF leak and intracranial hypotension disappeared.

He discharged on postoperative day 10 with satisfaction.

No signs of recurrence were observed for 5 months postoperatively up to this point.

The patient returned to his daily life as well as his occupation.

The patient had posterior cervical pain persisting for 3 months.

The patient had numbness and muscle weakness of extremities.

A fat suppression T2-weighted image of MRI illustrated fluid collection in the retrospinal region at C1-C2 level.

An 111In-DTPA cisternoscintigram revealed the presence of CSF leakage into the same region.

The MRI showed stenosis in spinal canal at C3/4 level.

A CT myelogram suggested a blockage at the C3/4 level.

The diagnosis was intracranial hypotension due to the CSF leakage.

The CSF leakage might be caused by the spinal canal stenosis at C3/4 level.

Despite 72 h of conservative therapy, a brain CT showed the development of bilateral subdural hematomas.

Burr-hole drainage of the subdural hematoma was performed.

Blood-patch therapy at C1/2 level was performed.

Improvement of symptoms was obtained post-operatively.

Imaging features suggesting the CSF leak and subdural hematoma were obtained post-operatively.

He was relieved from the pain when lying flat.

The brain CT revealed bilateral subdural effusion.

We performed blood-patch therapy at C1/2 level.