He had a severe trauma of the left hemithorax, left hypochondrium, and left flank three years before the current presentation.

He was admitted to the Department of Gastroenterology.

He had nausea, repeated vomiting, epigastric pain, and intermittent constipation for over a month.

He had loss of appetite and significant weight loss in the past six months.

Physical examination revealed a firm, palpable abdominal mass in the left hypochondrium and left flank.

Laboratory tests showed a low iron serum level of 46 μg/dL.

Upper endoscopy described a deformed stomach with an extrinsic compression especially on the antrum.

The extrinsic compression made difficult the passage through the pylorus.

There was no significant distention of the gastric body on insufflation.

An abdominal ultrasound highlighted a heterogeneous mass with tissular and cystic components.

The mass extended from the left hepatic lobe to the spleen’s hilum.

Contrast-enhanced ultrasonography pointed out that the tissular component of the tumor was enhanced in the arterial phase.

The tissular component presented a wash-out phenomenon in the late phase.

The cystic and necrotic components were unenhanced.

A contrast-enhanced abdominal computed tomography was scheduled.

The CT scan described a heterogeneous tumor of 17×15×14 cm containing numerous necrosis and cystic areas.

The tumor originated in the fundus and greater curvature of the stomach.

The tumor was causing a mass effect on the stomach, spleen, splenic vein, and enveloping the body and pancreatic tail.

We suspected it was a GIST with necrotic areas.

We proposed the patient for surgery due to tumor size and gastric outlet obstruction symptoms.

The giant tumor occupied most of the upper abdominal cavity with adherence to the gastric wall.

After the gastro-colic ligament was sectioned, tumor appurtenance of the great gastric wall was confirmed.

Infiltration of the tail of the pancreas and splenic pedicle was confirmed.

No hepatic or peritoneal metastases were found.

The rest of the abdominal organs seemed macroscopically normal.

En bloc surgical removal of the tumor was decided, including adjacent lymph nodes, spleen, and pancreas tail.

The pancreas tail was sectioned 5 cm proximal from the splenic pedicle.

The tumor block included the greater curvature of the stomach.

The greater curvature of the stomach was sealed with a linear stapler.

The resected piece measured 23×17×10 cm.

The tumor had 22×10 cm with many cystic and necrotic areas.

Tumor fragments were embedded in 10% formalin for 24 hours.

Classical staining with Hematoxylin–Eosin described similar characteristics of a mesenchymal tumor.

The tumor was composed of spindle-shaped cells with a high mitotic rate, over 5 mitoses/50 high-power fields.

The tumor had an 86% risk of progression (PT4Nx).

A partially encapsulated tumor proliferation was noted in the thickness of the muscular tunic of the gastric wall.

The tumor proliferation had a pseudonodular appearance composed of fusiform cells.

The cells had hypertrophic nuclei with unevenly arranged chromatin and karyorrhexes.

The cells were arranged in a fasciculate pattern.

The tumor had myxoid, hemorrhage, and necrosis areas.

Neoplastic proliferation invaded only the submucosa.

The neoplastic proliferation did not affect the gastric mucosa.

The neoplastic proliferation did not invade adjacent splenic or pancreatic parenchyma.

The mitotic rate was high, >5 mitoses/50 HPFs.

No evidence of perineural invasion was noted.

IHC staining revealed that tumor cells were strongly diffuse positive for CD117/c-kit.

IHC staining revealed that tumor cells were strongly diffuse positive for CD34.

IHC staining revealed that tumor cells were strongly diffuse positive for DOG1.

SMA and neuron-specific enolase (NSE) were variable focal positives in tumor proliferation.

The Ki67 proliferation rate was positive in more than 5% of the tumor cells in 50 HPFs.

The patient was successfully discharged.

The patient underwent oncology follow-up with Imatinib.

There was no relapse a year after surgical resection.

The patient was diagnosed with a giant gastric GIST.

The tumor presented for intermittent gastric outlet obstruction symptoms.

There are only several cases of gastric exophytic gastric GIST provoking intermittent gastric outlet obstruction.

Tumor resection should be adapted to every patient's status.

The surgical approach should be focused on en bloc extraction.

The surgical approach should aim for preservation of invaded organs as much as possible.

He was admitted to the Department of Gastroenterology.

Laboratory tests showed a low iron serum level of 46 μg/dL.

The mass extended from the left hepatic lobe to the spleen’s hilum.

The cystic and necrotic components were unenhanced.

A contrast-enhanced abdominal computed tomography was scheduled.

We suspected it was a GIST with necrotic areas.

No hepatic or peritoneal metastases were found.

The rest of the abdominal organs seemed macroscopically normal.

The tumor block included the greater curvature of the stomach.

The greater curvature of the stomach was sealed with a linear stapler.

The resected piece measured 23×17×10 cm.

The tumor had 22×10 cm with many cystic and necrotic areas.

Tumor fragments were embedded in 10% formalin for 24 hours.

The tumor had an 86% risk of progression (PT4Nx).

The cells were arranged in a fasciculate pattern.

The tumor had myxoid, hemorrhage, and necrosis areas.

Neoplastic proliferation invaded only the submucosa.

The neoplastic proliferation did not affect the gastric mucosa.

The mitotic rate was high, >5 mitoses/50 HPFs.

No evidence of perineural invasion was noted.

The patient was successfully discharged.

The patient underwent oncology follow-up with Imatinib.

There was no relapse a year after surgical resection.


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 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 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.

The patient is a 51-year-old Caucasian woman.

She presented with spinal, pelvic, and sternal inflammatory pain lasting for many years.

The symptoms had a strong negative impact on her quality of life.

She did not present palmoplantar pustulosis.

She had been diagnosed with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome at the age of 40 years.

She had received sulfasalazine and nonsteroidal anti-inflammatory drugs (NSAIDs) for many years with incomplete pain relief.

She also had a history of cervical and lumbar arthrodesis.

Total spine and pelvis magnetic resonance imaging (MRI) showed a short tau inversion recovery (STIR) hypersignal on several thoracic vertebrae (T6, T7, T8, and T9).

Total spine and pelvis MRI showed a short tau inversion recovery (STIR) hypersignal on the sternal part of the right clavicle.

Bone marrow oedema was also found on the right iliac bone.

Bone scintigraphy showed anterior chest wall involvement.

Right sternoclavicular hyperostosis was found on computed tomography.

The C-reactive protein (CRP) was found to be 89.2 mg/L.

The reference range for CRP is 0–5 mg/L.

Several blood tests performed earlier had already shown elevation of inflammation parameters.

The diagnosis of active SAPHO syndrome was confirmed.

Conventional synthetic disease-modifying antirheumatic drug (csDMARD) as methotrexate was not considered.

Methotrexate is more effective on peripheral arthritis.

Methotrexate has not shown comparable activity in axial disease in patients with axial spondyloarthritis.

Anti-tumour necrosis factor (TNF) drugs could not be prescribed because the criteria for reimbursement of these drugs in Belgium were not met.

The criteria for reimbursement were not met in the absence of sacroiliitis.

Tofacitinib 5 mg twice daily was initiated.

The patient reported rapid and significant reduction of pain within weeks of starting the treatment.

Blood tests performed one month after the onset of treatment showed a clear regression of inflammatory parameters.

The CRP was 25.5 mg/L one month after the onset of treatment.

The CRP was 14 mg/L after 4 months of treatment.

The CRP was 9.9 mg/L after 10 months of treatment.

Total spine and pelvis MRI performed after 3 months of treatment showed regression of the STIR hypersignal on the body of the thoracic vertebrae.

The hypersignal of the right iliac bone disappeared after 3 months of treatment.

The rheumatic evolution was favourable from a clinical, biological, and radiological point of view since the introduction of a JAK-inhibitor.

The treatment had to be discontinued due to pulmonary embolism occurring after 8 months on tofacitinib.

Spinal, pelvic, and chest (sternal and costal) pain reappeared after discontinuation of tofacitinib.

Elevation of inflammatory parameters occurred after discontinuation of tofacitinib.

Written informed consent was obtained from the patient for the publication of this report and its accompanying images.

The patient was a 51-year-old Caucasian woman.

She had SAPHO syndrome with mainly axial involvement.

She had been treated with sulfasalazine and anti-inflammatory drugs for many years.

The treatment with sulfasalazine and anti-inflammatory drugs was without any success.

A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved.

Imaging showed considerable regression of the vertebral and pelvic lesions.

Tofacitinib had to be discontinued due to the occurrence of pulmonary embolism.

Recurrence of bone pain and biologic inflammation was rapidly observed.

The patient is a 51-year-old Caucasian woman.

She did not present palmoplantar pustulosis.

The reference range for CRP is 0–5 mg/L.

The diagnosis of active SAPHO syndrome was confirmed.

Tofacitinib 5 mg twice daily was initiated.

The CRP was 14 mg/L after 4 months of treatment.

The CRP was 9.9 mg/L after 10 months of treatment.

**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": "..."
    }


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 manifestations often emerging in the later stages of disease. Early intervention through biomarker monitoring, blood pressure control, and pharmacological management (e.g., RAS inhibitors) is critical to slow disease progression and preserve renal function.

A 65-year-old man was admitted in the emergency department for seizures.

His medical history included diabetes mellitus.

His medical history included arterial hypertension.

Four months before admission, a chest X-Ray performed because of a persistent cough revealed a lung mass.

The lung biopsy yielded a squamous non-small-cell lung cancer.

The lung biopsy showed 80% expression of PD-L1.

Extended evaluation showed a unique hepatic metastasis.

Following consultation with the institutional multidisciplinary team in charge of lung cancer, the patient was treated with intravenous pembrolizumab.

Pembrolizumab was started 3 months before admission.

Pembrolizumab was given as a single-drug regimen.

Pembrolizumab was given at 200 mg every three weeks.

The patient had no tolerability issues with pembrolizumab.

The patient had no adherence issues with pembrolizumab.

Routine biochemical and hematology tests were normal.

The electroencephalogram performed 12 h after seizures was normal.

Brain CT scan found a focal hypodense lesion in the right frontal lobe.

Brain MRI showed an intracranial round-shaped lesion with a maximal diameter of 18 mm.

The lesion had low signal intensity on T1-weighted images.

The lesion had intermediate signal intensity on T2-weighted images.

The lesion was associated with perilesional edema.

The lesion showed wall enhancement on T1-weighted gadolinium-enhanced images.

The lesion was suggestive of brain abscess.

Brain metastasis could not be ruled out.

The patient was transferred to the neurosurgical department for a total removal of the lesion.

The excision was performed with craniotomy.

Per-operative macroscopic findings were also suggestive of brain abscess.

Empirical antimicrobial therapy was started after surgery.

Antimicrobial therapy included intravenous ceftriaxone.

Antimicrobial therapy included metronidazole.

Microscopic examination revealed numerous filamentous-branching Gram-positive rods.

Nocardia farcinica was identified by MALDI-TOF mass spectrometry.

Antibiotic treatment was modified to meropenem 1 g every 8 h.

Antibiotic treatment was modified to cotrimoxazole 1600 mg/400 mg every 8 h.

Antibiotic treatment included folinic acid.

Body-CT did not show any other localization of nocardiosis.

The mass tumor had decreased by 80% after the sixth cycle of pembrolizumab.

Drug susceptibility testing found a meropenem MIC of 32 mg/L.

Drug susceptibility testing found a linezolid MIC of 4 mg/L.

Drug susceptibility testing found a cotrimoxazole MIC of 0.5 mg/L.

Meropenem was replaced by linezolid 600 mg every 12 h.

Linezolid was given in combination with cotrimoxazole.

Following the diagnosis, additional risk factors for cerebral nocardiosis were ruled out.

After 2 months, the patient was asymptomatic, except for asthenia.

The patient did not receive additional dose of pembrolizumab.

At 10 weeks of treatment, he developed thrombocytopenia due to linezolid.

He died 3 months after the diagnosis of cerebral nocardiosis.

His death was probably related to a major upper-gastrointestinal bleeding.

The upper-gastrointestinal bleeding was probably related to a peptic ulcer disease.

The upper-gastrointestinal bleeding was probably related to thrombocytopenia.

This is the first clinical case of a cerebral nocardiosis revealed after seizure in a patient treated by pembrolizumab for a metastatic lung cancer.

The patient was not receiving any additional immunosuppressive therapy.

The patient had no risk factors for cerebral nocardiosis.

A brain CT-scan did not reveal any lesion before pembrolizumab.

The 3-month delay between the start of pembrolizumab and the diagnosis of cerebral nocardiosis suggests that the infection occurred prior to the CPI.

The patient died during treatment for cerebral nocardiosis.

The lung cancer tumor mass had decreased by 80% after the sixth cycle of pembrolizumab.

His medical history included diabetes mellitus.

His medical history included arterial hypertension.

The lung biopsy showed 80% expression of PD-L1.

Extended evaluation showed a unique hepatic metastasis.

Pembrolizumab was started 3 months before admission.

Pembrolizumab was given as a single-drug regimen.

Pembrolizumab was given at 200 mg every three weeks.

The patient had no tolerability issues with pembrolizumab.

The patient had no adherence issues with pembrolizumab.

Routine biochemical and hematology tests were normal.

The lesion had low signal intensity on T1-weighted images.

The lesion was associated with perilesional edema.

The lesion was suggestive of brain abscess.

Brain metastasis could not be ruled out.

The excision was performed with craniotomy.

Empirical antimicrobial therapy was started after surgery.

Antimicrobial therapy included intravenous ceftriaxone.

Antimicrobial therapy included metronidazole.

Antibiotic treatment included folinic acid.

Meropenem was replaced by linezolid 600 mg every 12 h.

Linezolid was given in combination with cotrimoxazole.


The disease evolution has lasted two years.

The patient has localized pain on the distal phalanx of the left thumb.

The pain is rated as 9 on the visual analogue scale.

The pain increases with changes in temperature.

Physical examination showed subungual pain.

Physical examination showed mild volume increase.

Physical examination showed palpation of a radial-sided tumour.

Ultrasound reported a highly vascularised nodular lesion.

The lesion is circumscribed, hypoechoic, and homogeneous.

The lesion is located on the medial edge of the distal phalanx of the first finger.

There is thickening of the synovial sheath.

These findings are characteristic of glomus tumours.

The surgery required glasses with two-fold magnification.

The surgery used regional block anaesthesia and ischaemia.

The surgical approach was to the distal phalanx and transverse subungual.

A white-yellowish tumour, well encapsulated, was visualised.

Cauterisation of the vascular bed was performed.

The wound was sutured with monofilament nylon 4/0.

A piece was sent for histopathological study.

The patient attended a two-week follow-up appointment.

The surgical wound showed adequate healing.

The patient could mobilise the distal interphalangeal joint.

The pain was rated as 1 point on the visual analogue scale.

The histopathological study reported a glomus tumour.

The patient reported chronic, burning pain radiating to the distal phalanx of the thumb.

The pain had been present for two years.

Interphalangeal Doppler ultrasound was performed.

Interphalangeal Doppler ultrasound is an excellent alternative due to its easy accessibility.

A glomus tumor in the interphalangeal phalanx of the thumb was diagnosed.

A H-approach was performed on the interphalangeal fold.

Subungual dissection and resection of the tumoral piece were performed.

The surgical wound was found to be healing adequately.

The patient was able to mobilize the interphalangeal distal joint.

The visual analogue scale (VAS) was 1 point.

The anatomopathological evaluation reported the existence of a glomus tumor.


A 63-year-old man was referred to Modarres Hospital, Tehran.

He had gradual onset of obscure generalized abdominal pain six hours before admission.

His pain was located in the epigastric and periumbilical region.

There was no radiation of pain to anywhere else.

There was moderate abdominal distension.

There was periumbilical abdominal tenderness.

Initial blood tests showed white cell count (WBC) of 21.7 × 109/L.

Initial blood tests showed neutrophils 84.2%.

Initial blood tests showed hemoglobin (Hb) 15.2 g/dL.

About five hours after resuscitation and appropriate fluid therapy, he has not felt better.

Abdominopelvic CT-scan showed evidence of hematoma near the head of pancreas.

Abdominopelvic CT-scan showed perihepatic and perisplenic fluid.

He was transferred to operating room emergently.

Massive intraperitoneal hematoma was evacuated.

Right medial visceral rotation, the Cattell-Braasch maneuver, was performed.

Active bleeding in the base of IPDA was detected.

IPDA was suture ligated at the base with 4/0 nonabsorbable stitch.

The post-operative period was uneventful.

Oral fluids were started the day after the surgery.

The patient was discharged from the hospital two days after the surgery.

One week after discharge, he had a normal follow-up.

There were no concerning problems one week after discharge.

The patient had idiopathic spontaneous intraperitoneal hemorrhage.

The hemorrhage was caused by spontaneous rupture of non-aneurysmal inferior pancreaticoduodenal artery.


He had a previous history of hypertension.

He had a previous history of coronary artery disease.

He was admitted to the hospital due to heart failure.

He had undergone percutaneous coronary interventions in the circumflex artery in 2019.

He had undergone percutaneous coronary interventions in the left anterior descending artery in 2020.

The interventions were performed at another hospital.

The patient was asymptomatic before admission.

A systolic murmur was heard on auscultation.

Electrocardiogram was within normal range.

Brain natriuretic peptide was 150.4 pg/mL.

The normal range for brain natriuretic peptide is <100 pg/mL.

Trans-thoracic echocardiogram revealed a left ventricular ejection fraction of 66%.

Trans-thoracic echocardiogram revealed a left ventricular diastolic diameter of 41 mm.

The peak velocity of the aortic valve was 3.5 m/s.

The mean aortic valve pressure gradient was 33 mmHg.

The aortic valve area using the Doppler method was 0.78 cm2.

The presence of a VSD can affect TTE-derived peak velocity and mean PG.

Membranous VSD was observed in cardiac computed tomography.

Double-chambered right ventricle was observed in cardiac computed tomography.

Trans-oesophageal echocardiogram, CT, and catheter-based AVA were 0.6–0.7 cm2.

Based on these findings, the patient was diagnosed with severe aortic stenosis.

Cardiac CT showed the cardiac anatomy was suitable for TAV implantation.

The VSD orifice was located 3.5–7.3 mm from the aortic valve annulus.

A thin sub-aortic band was attached to the LV outflow tract.

Coronary angiogram showed no significant stenosis.

The catheter-based pressure gradient between LV apex and aorta was 27 mmHg.

No pressure gradient was observed between LV apex and LVOT.

Right heart catheterization showed normal wedge pressure of 17 mmHg.

Right heart catheterization showed a slightly decreased cardiac index of 2.1 L/min/m2.

Pulmonary hypertension with a mean pressure of 38 mmHg was observed.

A pressure gradient of 50 mmHg between high-pressure and low-pressure chambers of the right ventricle was observed.

Severe aortic stenosis in combination with left-to-right shunt due to VSD was diagnosed as the leading cause of heart failure.

These findings fulfilled the indication for invasive treatment for aortic stenosis and VSD.

Surgical aortic valve replacement, VSD closure, myectomy of the right ventricle, and sub-aortic band resection were discussed.

The surgical team deemed the patient not a surgical candidate.

The surgical team cited the patient’s age as a reason not to perform surgery.

The surgical team cited high risk of surgery as a reason not to perform surgery.

The surgical team cited frailty as a reason not to perform surgery.

A TAVI procedure with VSD orifice coverage using a valve skirt was planned.

A 26-mm Evolut Pro Plus™ valve was selected.

The valve has a long skirt at the bottom, which could cover the VSD orifice completely.

The valve was deployed 9 mm from the annulus level.

The valve was deployed to cover the entire orifice of VSD with the valve skirt.

The valve was deployed by watching TOE to confirm no structural damage.

The valve did not interfere with mitral valve movement.

No leak across the valve was observed by TOE.

Complete coverage of the VSD orifice with the valve skirt was observed by TOE.

The amount of left-to-right shunt decreased.

The catheter-based Qp/Qs ratio decreased from 1.9 to 1.2.

Trans-thoracic echocardiogram–based aortic valve pressure gradient decreased from 33 to 2 mmHg.

Post-procedural TOE revealed no leakage.

Post-procedural TOE revealed a decrease in left-to-right shunt.

Post-procedural ECG finding was unchanged.

Post-procedural ECG showed sinus rhythm.

Post-procedural ECG showed a PR interval of 194 ms.

Post-procedural ECG showed a QRS duration of 70 ms.

The patient was discharged from hospital 7 days after the procedure.

The patient had not been admitted to hospital since discharge.

The patient was admitted to the hospital with congestive heart failure.

The patient had low-flow low-gradient severe AS.

The patient had a double-chambered right ventricle.

The patient was not deemed to be a surgical candidate.

Surgical aortic valve replacement, VSD closure, sub-aortic band resection, and myectomy of RV would be considered as definitive treatment.

TAVI was performed using a 26 mm Evolut Pro Plus™ self-expanding valve.

VSD orifice closure was performed using the skirt part of the self-expanding valve.

A VSD occluder is not approved and thus not available in our country.

The mean aortic valve pressure gradient improved from 33 to 2 mmHg.

The shunt flow (Qp/Qs) decreased from 1.9 to 1.2.

The patient was discharged to home 7 days after the procedure.

The patient remained well and had not been admitted to hospital since discharge.

He had a previous history of hypertension.

He had a previous history of coronary artery disease.

He was admitted to the hospital due to heart failure.

The interventions were performed at another hospital.

The patient was asymptomatic before admission.

A systolic murmur was heard on auscultation.

Electrocardiogram was within normal range.

Brain natriuretic peptide was 150.4 pg/mL.

The normal range for brain natriuretic peptide is <100 pg/mL.

The peak velocity of the aortic valve was 3.5 m/s.

The mean aortic valve pressure gradient was 33 mmHg.

The aortic valve area using the Doppler method was 0.78 cm2.

Membranous VSD was observed in cardiac computed tomography.

A thin sub-aortic band was attached to the LV outflow tract.

Coronary angiogram showed no significant stenosis.

No pressure gradient was observed between LV apex and LVOT.

The surgical team deemed the patient not a surgical candidate.

A 26-mm Evolut Pro Plus™ valve was selected.

The valve was deployed 9 mm from the annulus level.

The valve did not interfere with mitral valve movement.

No leak across the valve was observed by TOE.

The amount of left-to-right shunt decreased.

The catheter-based Qp/Qs ratio decreased from 1.9 to 1.2.

Post-procedural TOE revealed no leakage.

Post-procedural TOE revealed a decrease in left-to-right shunt.

Post-procedural ECG finding was unchanged.

Post-procedural ECG showed sinus rhythm.

Post-procedural ECG showed a PR interval of 194 ms.

Post-procedural ECG showed a QRS duration of 70 ms.

The patient had not been admitted to hospital since discharge.


It is a case report of a 13-year-old girl.

She had swelling over her right hand for 5 months.

The swelling was situated over the dorsum and medial aspect of the hand.

There was no lesion elsewhere in the body.

There were no associated features such as pain, fever, or signs influencing general health.

On examination, the swelling was firm in consistency.

The swelling occupied the dorsal and inner side of the fifth metacarpal.

There was no feature suggestive of inflammatory pathology.

On deep palpation, the swelling was tender.

Routine hematological examination was within normal limits.

Radiology revealed an osteolytic fusiform expansible lesion involving the distal 2/3rd of the fifth metacarpal.

The lesion involved the articular surface.

The cortical was paper thin, breached, inflated, and without periosteal reaction.

The tumor radiograph had a 'soap bubble' appearance.

The provisional diagnosis was aneurysmal bone cyst and GCT.

The chest X-ray was within normal limits.

The biopsy conferred the diagnosis of GCT.

The technique used was free osteoarticular metatarsal transfer, described by Maini et al.

A dorsal approach was used for the enbloc resection.

The incision included the previous biopsy track.

The fifth metatarsal was removed except the base.

Partial resection of surrounding muscles was performed.

The capsule and collateral ligament of the fifth metacarpophalangeal joint were left.

The fourth metatarsal was harvested from the foot.

The capsuloligamentous of the metatarsal was sutured to the counter capsuloligamentous structure at the recipient site.

The metatarsal was fixed with the leftover base of the metacarpal by K-wires.

At the 14th post-operative day, the sutures were removed.

Union at the junction occurred in 6 weeks.

No obvious changes were noticed at the transferred metatarsal.

Initially, the movements had both extension and flexion lag.

At the end of 6 months of follow-up, the movements were painless and almost up to normal.

Flexion was restricted terminally at the metacarpophalangeal joint.

The patient was able to grasp any object.

The patient had pretty good grip strength.

After 2 years of follow-up, the procedure was fulfilling expectations.

The procedure corroborates the reliability of this method.

During the initial follow-up, the patient had mild-to-moderate pain over the foot while walking.

The patient was unable to dorsiflex the fourth toe.

She is now free from pain or any complaint such as deformity or difficulty in walking.

There is still slight weakness of the fourth toe’s dorsiflexor.

It is a case report of a 13-year-old girl.

She had a history of swelling over her right hand for 5 months.

X-ray revealed an osteolytic fusiform expansible lesion.

The biopsy conferred the diagnosis of GCT.

A dorsal approach was used for the enbloc resection of the fifth metacarpals (except at the base).

Partial excision of the surrounding muscles was done.

The fourth metatarsal was harvested from the foot along with its capsule and collateral ligament of the metatarsophalangeal joint.

The harvested fourth metatarsal was sutured to the counter capsuloligamentous structure at the recipient site.

It is a case report of a 13-year-old girl.

There was no lesion elsewhere in the body.

On deep palpation, the swelling was tender.

The lesion involved the articular surface.

The chest X-ray was within normal limits.

The biopsy conferred the diagnosis of GCT.

The incision included the previous biopsy track.

The fifth metatarsal was removed except the base.

The fourth metatarsal was harvested from the foot.

Union at the junction occurred in 6 weeks.

The patient was able to grasp any object.

The patient had pretty good grip strength.


The patient was a 72-year-old Caucasian woman.

She had a history of childhood encephalitis with motor sequelae.

She had a 10-year history of full-thickness rectal prolapse.

The rectal prolapse had progressively worsened despite two surgical procedures.

The first surgical procedure was anal encirclement 13 years before presentation.

The second surgical procedure was an encirclement associated with stapler mucous prolapsectomy 6 years before presentation.

She had severe fecal incontinence associated with repeated rectal bleeding for 2 years.

The patient's Wexner incontinence score was 19.

Anorectal manometry showed marked hypotonia of the anal canal at rest (20 mmHg).

Anorectal manometry showed marked hypotonia of the anal canal during contraction (40 mmHg).

Endorectal ultrasonographic examination revealed no documentable sphincter lesions.

The muscle fibers appeared markedly thinned on endorectal ultrasonographic examination.

Electromyographic recordings disclosed severe neurogenic damage to her external anal sphincter.

The patient declined to undergo construction of a definitive colostomy.

The full-thickness rectal wall was incised circumferentially at 2 cm from the pectinate line.

A coloanal anastomosis was constructed with a 29 circular stapler.

The operation proceeded with dynamic graciloplasty.

The gracile muscle was mobilized down to its insertion on the tibial tuberosity.

Electrical stimuli were delivered to identify the neurovascular peduncle.

This step is crucial to identify the site for definitive intramuscular electrode implantation.

The gracile muscle was tunnelled and wrapped around the sigmoid colon anastomosed to the residual rectum.

The muscle tendon was fixed on the perineal skin.

A subcutaneous pouch was created in the right iliac fossa to house the neurostimulator.

The leads connecting the neurostimulator to the gracile muscle were tunnelled subcutaneously.

A temporary transverse colostomy was constructed.

The patient had an uneventful postoperative course.

On day 7, the patient began regular leg gymnastics with a soft balloon placed between her knees.

Neurostimulation delivered at low frequency began on day 20.

Neurostimulation continued for about 2 months before the frequency was increased.

In the sixth month, clinical examination showed a slight improvement in sphincter tone.

In the sixth month, manometric evaluation showed pressure at 30 mmHg without electrical stimulation.

In the sixth month, manometric evaluation showed pressure at 55 mmHg with electrical stimulation.

One year after the operation, the colostomy was closed under manometric evaluation.

One year after the operation, manometric evaluation showed pressure at 40 mmHg without electrical stimulation.

One year after the operation, manometric evaluation showed pressure at 65 mmHg with electrical stimulation.

Two years after the combined operation, no further recurrent rectal prolapse was visible.

The patient was continent for solids (Wexner incontinence score 9).

The patient could switch the pacemaker device on and off without help.

The patient is a 72-year-old Caucasian woman.

The patient had full-thickness rectal prolapse.

The fecal incontinence was associated with full-thickness rectal prolapse.

The fecal incontinence was from severe neuromuscular damage.

The patient was a 72-year-old Caucasian woman.

She had a 10-year history of full-thickness rectal prolapse.

The patient's Wexner incontinence score was 19.

The operation proceeded with dynamic graciloplasty.

The muscle tendon was fixed on the perineal skin.

A temporary transverse colostomy was constructed.

The patient had an uneventful postoperative course.

Neurostimulation delivered at low frequency began on day 20.


The patient is a 44-year-old pediatrician working in Faryab Province, Afghanistan.

The patient presented with compressing chest pain and dizziness.

The chest pain and dizziness occurred during a common cold or exertion.

The patient had previously experienced the same symptoms during an upper respiratory infection and exertions.

The patient had no history of heart disease.

The patient's blood pressure was 120/80 mm Hg.

The patient's heart rate was 86 beats/minute.

The patient's oxygen saturation was 97%.

The physical examination was unremarkable.

The patient tested negative for COVID-19.

The abdominal ultrasonography showed no abnormalities.

Echocardiography revealed grade 1 left ventricular diastolic dysfunction.

Echocardiography showed normal structural and valves of the heart.

Blood examinations did not indicate any abnormalities.

Coronary angiography showed a mid-LAD myocardial bridge with systolic compression.

The coronary angiography showed significant stenosis.

A calcium channel blocker, Diltiazem 60mg per day, was prescribed.

The patient tolerated the medication well.

The patient remained asymptomatic during two years of follow-up.

The patient is a 44-year-old man from Faryab Province in Afghanistan.

The patient presented with chest pain and dizziness.

The patient was suffering a common cold at the time of presentation.

The patient underwent coronary angiography.

The coronary angiography showed a myocardial bridge at the middle portion of the left anterior descending artery.

The myocardial bridge was associated with significant stenosis causing ischemia.

The patient was treated with a calcium channel blocker as initial treatment.


She had no medical history of pneumonia.

She had no familial history of immunodeficiency.

She was admitted to the hospital due to 3 days of fever.

She had 15 min of respiratory and cardiac arrest.

The body temperature decreased for 4 to 5 h.

The body temperature climbed to 40.3 °C.

Shortness of breath accompanied the fever.

The body temperature did not decrease obviously after oral administration of ibuprofen.

Wheezing caused by the retention of phlegm in the throat occurred.

She occasionally coughed up a small amount of yellow phlegm.

On 11 November, the patient still had a high fever.

Her body temperature fluctuated around approximately 40 °C.

The patient’s body temperature did not obviously decrease after oral ibuprofen and acetaminophen alternately.

Acute infection was considered from then on.

The patient received an intravenous infusion of 0.14 g Zithromax.

The patient received an intravenous infusion of 120 mg rographolide.

The patient received aerosol inhalation of 2 mg budesonide.

Her body temperature rose to a peak of 40 °C.

On 12 November, the patient still had a persistent fever.

She had wheezing due to the retention of phlegm in her throat.

On 13 November, the patient had sudden respiratory and cardiac arrest 3 h before admission.

She was immediately and continuously treated with cardiopulmonary resuscitation by physicians.

She received intravenous injection of adrenaline (4 times).

She was treated with trachea cannula and mechanical ventilation.

Her heart beat recovered approximately 15 min later.

The patient remained in a deep comatose state with no spontaneous breathing.

The patient was transferred to our hospital.

She immediately underwent electrocardiogram (ECG) monitoring.

Bloody fluid was visible in the indwelling gastrointestinal decompression tube.

The blood-gas analysis showed metabolic acidosis.

The patient was treated with sodium bicarbonate to correct the acidosis.

She was diagnosed with an acute CNS infection.

After cardiopulmonary resuscitation, she was admitted to the pediatric intensive care unit (PICU).

The head CT scan showed extensive brain swelling.

The head CT scan showed decreased brain parenchymal density.

The head CT scan showed narrowed cerebral ventricles and cisterns.

These findings prompted a diagnosis of extensive brain edema and hernia.

The chest posteroanterior radiograph showed fuzzy, coarse bilateral lung markings.

The chest posteroanterior radiograph showed visible small patchy shadows in the right inferior lung.

The chest posteroanterior radiograph showed a clear pulmonary hilus.

These findings were diagnosed as pneumonia.

Routine blood examination results suggested the presence of a bacterial infection.

The patient was treated with vancomycin to control an infection.

The patient was treated with meropenem to control an infection.

After that, immunoglobulin (1 g/kg) was administered for immune support.

The patient was still in a deep coma state.

Light reflexes of both pupils were absent.

The patient’s spontaneous breathing was weak and irregular.

She had no response to painful stimulation.

Compared with earlier, her rash was reduced.

The pulmonary lesions shown on the chest posteroanterior radiograph were slightly absorbed.

Immunoglobulin (1 g/kg) was continuously administered to neutralize pathogens.

On 15 November, transcranial Doppler ultrasound assessment showed that the patient’s anterior and posterior cerebral circulation corresponded to the diagnostic criteria for brain death.

On 17 November, various organ functions failed.

The patient could not tolerate a spontaneous breathing test.

Viral antigen detection based on both an immunofluorescence assay and the Luminex xTAG respiratory viral panel assay was positive for RSV in the patient’s nasopharyngeal aspirates.

The nasopharyngeal aspirates were collected on 14 Nov.

The viral antigen detection was negative for adenovirus.

The viral antigen detection was negative for influenza A and B viruses.

The viral antigen detection was negative for parainfluenza virus 1–4.

The viral antigen detection was negative for human metapneumovirus.

The viral antigen detection was negative for enteroviruses and rhinoviruses.

The viral antigen detection was negative for human coronavirus HKU1, 229E, NL63 and OC43.

The viral antigen detection was negative for human bocavirus.

The patient’s guardian refused to consent to lumbar puncture.

Cerebrospinal fluid (CSF) was not available for the detection of CNS infection.

The amounts of red blood cells (RBCs) continuously decreased after the onset of symptoms.

The amounts of hemoglobin continuously decreased after the onset of symptoms.

The amounts of platelets continuously decreased after the onset of symptoms.

Extremely high levels of C-reactive protein from the third day suggested viral or bacterial infection.

Bacterial cultures of blood specimens yielded negative results.

The percentage of T lymphocytes was 46.6%.

The proportions of B lymphocytes were 45.6%.

All these immunological indexes indicated dysfunction of the patient’s immune system.

Oral swab, nasopharyngeal aspirate, and serum specimens were collected on 14 Nov.

The specimens were subjected to multiplex metagenomic analyses using an NGS platform.

The nucleic acid library was constructed as previously described.

The amplified nucleic acid libraries were analyzed using an Illumina HiSeq 4000 sequencer.

The raw sequence reads were filtered using previously described criteria to obtain valid sequences.

When bacteriophages, plant-origin sequences, and contamination from reagents were excluded, only human RSV was identified.

At least one specific sequence from the oral swab was identified.

At least one specific sequence from the nasopharyngeal aspirate was identified.

No virus-related sequences were detected in the serum specimen.

Large numbers of sequence reads related to bacteria were detected in the oral swab, nasopharyngeal aspirate, or/and serum specimens.

Bacterial culture of the blood specimens yielded negative results.

The complete length of the RSV genome was obtained using NGS methods and gap amplification.

It was found to cluster in the BA genotype.

It had the signature 60-bp duplication in the G gene.

The newly identified virus was named RSVB/BCH-Y/2016.

The full genome sequence was deposited in GenBank under accession number KY924878.

The phylogenetic analysis was conducted with representative sequences from nearly all RSVB subgroups.

RSVB/BCH-Y/2016 belonged to BA9 subgroup.

The G gene of this strain was most closely related to strain RSVB/GZ/13–730.

The G gene shared 98.82% homology with strain RSVB/GZ/13–730.

Strain RSVB/GZ/13–730 was isolated from a child in Guangzhou, China, in 2013.

For the six most important antigenic sites in the fusion protein, no mutation was found in RSVB/BCH-Y/2016.

The child developed normally up to the age of 2 years old.

Cardiopulmonary arrest occurred within 3 days after the onset of symptoms.

The symptoms included cough and high fever.

Viral antigen detection verified an RSV infection.

Microbiome analyses of oral swab and nasopharyngeal aspirate specimens verified an RSV infection.

Bacterial culture of blood specimens yielded negative results.

The RSV strain detected in this patient was subtyped as RSVB9.

No mutation was found in the six antigenic sites for targeted drugs or vaccines.

She had no medical history of pneumonia.

She had no familial history of immunodeficiency.

She was admitted to the hospital due to 3 days of fever.

She had 15 min of respiratory and cardiac arrest.

The body temperature decreased for 4 to 5 h.

The body temperature climbed to 40.3 °C.

Shortness of breath accompanied the fever.

Wheezing caused by the retention of phlegm in the throat occurred.

She occasionally coughed up a small amount of yellow phlegm.

On 11 November, the patient still had a high fever.

Her body temperature fluctuated around approximately 40 °C.

Acute infection was considered from then on.

The patient received an intravenous infusion of 0.14 g Zithromax.

The patient received an intravenous infusion of 120 mg rographolide.

The patient received aerosol inhalation of 2 mg budesonide.

Her body temperature rose to a peak of 40 °C.

On 12 November, the patient still had a persistent fever.

She had wheezing due to the retention of phlegm in her throat.

She received intravenous injection of adrenaline (4 times).

She was treated with trachea cannula and mechanical ventilation.

Her heart beat recovered approximately 15 min later.

The patient remained in a deep comatose state with no spontaneous breathing.

The patient was transferred to our hospital.

She immediately underwent electrocardiogram (ECG) monitoring.

The blood-gas analysis showed metabolic acidosis.

The patient was treated with sodium bicarbonate to correct the acidosis.

She was diagnosed with an acute CNS infection.

The head CT scan showed extensive brain swelling.

The head CT scan showed decreased brain parenchymal density.

The head CT scan showed narrowed cerebral ventricles and cisterns.

These findings prompted a diagnosis of extensive brain edema and hernia.

The chest posteroanterior radiograph showed a clear pulmonary hilus.

These findings were diagnosed as pneumonia.

The patient was treated with vancomycin to control an infection.

The patient was treated with meropenem to control an infection.

After that, immunoglobulin (1 g/kg) was administered for immune support.

The patient was still in a deep coma state.

Light reflexes of both pupils were absent.

The patient’s spontaneous breathing was weak and irregular.

She had no response to painful stimulation.

Compared with earlier, her rash was reduced.

On 17 November, various organ functions failed.

The patient could not tolerate a spontaneous breathing test.

The nasopharyngeal aspirates were collected on 14 Nov.

The viral antigen detection was negative for adenovirus.

The viral antigen detection was negative for influenza A and B viruses.

The viral antigen detection was negative for parainfluenza virus 1–4.

The viral antigen detection was negative for human metapneumovirus.

The viral antigen detection was negative for enteroviruses and rhinoviruses.

The viral antigen detection was negative for human bocavirus.

The patient’s guardian refused to consent to lumbar puncture.

The amounts of platelets continuously decreased after the onset of symptoms.

Bacterial cultures of blood specimens yielded negative results.

The percentage of T lymphocytes was 46.6%.

The proportions of B lymphocytes were 45.6%.

The nucleic acid library was constructed as previously described.

At least one specific sequence from the oral swab was identified.

No virus-related sequences were detected in the serum specimen.

Bacterial culture of the blood specimens yielded negative results.

It was found to cluster in the BA genotype.

It had the signature 60-bp duplication in the G gene.

The newly identified virus was named RSVB/BCH-Y/2016.

RSVB/BCH-Y/2016 belonged to BA9 subgroup.

The G gene of this strain was most closely related to strain RSVB/GZ/13–730.

The G gene shared 98.82% homology with strain RSVB/GZ/13–730.


The patient presented with 7 days of dizziness.

The patient presented with 7 days of fatigue.

The patient presented with 7 days of nausea.

The patient presented with 7 days of vomiting.

The patient was transported to the emergency department.

The patient was discharged home after initial evaluation.

Approximately 4 days after discharge, emergency medical services were called after the patient experienced syncope.

An ECG obtained en route reported anterior ST-segment elevations.

Before arrival at the hospital, the patient developed ventricular fibrillation.

Upon arrival at the emergency department, ventricular fibrillation recurred.

Resuscitative efforts restored sinus rhythm and spontaneous circulation.

On arrival, the patient's heart rate was 77 b.p.m.

On arrival, the patient had a regular rhythm.

On arrival, the patient had hypotension (86 mmHg/48 mmHg).

The patient required mechanical ventilation with a rate of 28.

The patient required mechanical ventilation with a tidal volume of 500 mL.

The patient required mechanical ventilation with FiO2 100%.

The patient required mechanical ventilation with positive end-expiratory pressure of 8 cmH2O.

The subsequent ECG showed wide complex rhythm consistent with slow ventricular tachycardia.

The subsequent ECG showed right bundle branch block morphology.

The subsequent ECG showed left axis deviation.

There was high suspicion for acute coronary syndrome.

The patient was presumed to have an ST-segment elevation myocardial infarction.

Epinephrine infusion was started due to bradycardia with hypotension.

The patient was emergently taken to the catheterization lab.

Coronary angiography did not reveal coronary stenosis.

Right heart catheterization revealed elevated right-sided filling pressures.

Pulmonary artery pressure was 61/28 (39) mmHg.

Pulmonary capillary wedge pressure was 15 mmHg.

A point-of-care echocardiogram was performed.

The point-of-care echocardiogram demonstrated a dilated right ventricle.

The point-of-care echocardiogram demonstrated severely reduced right ventricular function.

There was concern for pulmonary embolism.

Immediate pulmonary angiography was performed.

Pulmonary angiography revealed large, bilateral pulmonary emboli.

EkoSonic™ endovascular thrombolysis catheters were advanced into both main pulmonary arteries.

5 mg of tissue plasminogen activator was delivered through each catheter.

2 mg/catheter/h of tissue plasminogen activator was delivered for 2 h.

1 mg/catheter/h of tissue plasminogen activator was delivered for 16 h.

Infusion was guided by fibrinogen monitoring.

Upper and lower extremity Doppler ultrasounds showed no evidence of venous thrombosis.

Formal transthoracic echocardiogram confirmed depressed right ventricular function.

Computed tomography of the chest showed bilateral peripheral ground-glass opacities.

Computed tomography of the chest showed wedge-shaped opacities in the right lung.

The wedge-shaped opacities were thought to represent pulmonary infarctions.

The patient was started on broad-spectrum antibiotics for pneumonia.

Tracheal aspirate culture was positive for methicillin-resistant Staphylococcus aureus.

Repeat ECG showed first-degree atrioventricular (AV) block.

Repeat ECG showed incomplete right bundle branch block.

Repeat ECG showed a prolonged QTc interval (498 ms).

Over the following 4 days, the patient developed anaemia.

CT of the chest, abdomen, and pelvis showed a mediastinal haematoma.

CT of the chest, abdomen, and pelvis showed persistent ground-glass opacities.

The patient was found to be positive for SARS-CoV-2.

The patient was transferred to a COVID-19-dedicated intensive care unit.

The patient was placed under enhanced contact precautions.

Following extubation, the patient did well.

The patient was admitted to an inpatient rehabilitation facility.

The patient was prescribed lifelong apixaban 5 mg twice daily.

At 1 month follow-up, the patient described mild exertional dyspnoea.

Transthoracic echocardiogram at 1 month follow-up noted improvement of right ventricular dilation.

Transthoracic echocardiogram at 1 month follow-up noted improvement of right ventricular systolic function.

He presented after experiencing syncope and cardiac arrest.

There was concern for acute coronary syndrome.

Coronary angiogram did not reveal significant coronary obstruction.

A bedside echocardiogram was rapidly performed.

The bedside echocardiogram was indicative of right ventricular strain.

The pulmonary angiogram revealed massive pulmonary embolism.

He successfully underwent catheter-directed thrombolysis.

He was discharged home on lifelong anticoagulation.

The patient presented with 7 days of dizziness.

The patient presented with 7 days of fatigue.

The patient presented with 7 days of nausea.

The patient presented with 7 days of vomiting.

The patient was transported to the emergency department.

The patient was discharged home after initial evaluation.

On arrival, the patient's heart rate was 77 b.p.m.

On arrival, the patient had a regular rhythm.

On arrival, the patient had hypotension (86 mmHg/48 mmHg).

The patient required mechanical ventilation with a rate of 28.

The patient required mechanical ventilation with FiO2 100%.

The subsequent ECG showed right bundle branch block morphology.

The subsequent ECG showed left axis deviation.

There was high suspicion for acute coronary syndrome.

The patient was emergently taken to the catheterization lab.

Coronary angiography did not reveal coronary stenosis.

Pulmonary artery pressure was 61/28 (39) mmHg.

Pulmonary capillary wedge pressure was 15 mmHg.

A point-of-care echocardiogram was performed.

There was concern for pulmonary embolism.

Immediate pulmonary angiography was performed.

Pulmonary angiography revealed large, bilateral pulmonary emboli.

Infusion was guided by fibrinogen monitoring.

Repeat ECG showed first-degree atrioventricular (AV) block.

Repeat ECG showed incomplete right bundle branch block.

Repeat ECG showed a prolonged QTc interval (498 ms).

Over the following 4 days, the patient developed anaemia.

The patient was found to be positive for SARS-CoV-2.

The patient was placed under enhanced contact precautions.

Following extubation, the patient did well.

The patient was admitted to an inpatient rehabilitation facility.

The patient was prescribed lifelong apixaban 5 mg twice daily.


The patient is a 29-year-old Asian female.

She presented with recurrent episodes of severe headache, nausea, and vomiting.

She described the headache as 'pulling' downward.

She reported axial tension and rotatory manipulation of her neck one week prior to the onset of her symptoms.

She denied immediate symptoms after the chiropractic manipulation.

She experienced increasingly painful headaches over the 2 weeks following her chiropractic manipulation.

She had no known prior history of trauma.

She had no known prior history of dural structural pathology.

She had no known prior history of connective tissue disease.

Physical exam was normal with no neurological deficits.

Previous cervical MRI with and without contrast had been unremarkable.

Cervical MRI at presentation revealed a CSF-isodense ventral extradural fluid collection in the lower cervical spine and upper thoracic spine.

There was no mass effect on the thecal sac.

There was no abnormal venous engorgement.

The patient was managed conservatively with bed rest for 2 weeks.

She made a complete spontaneous recovery.

Follow-up cervical MRI at 6 months demonstrated decreased size of ventral extradural fluid collection.

We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine.

The patient received manipulation one week prior to developing symptoms.

The patient developed symptoms of severe orthostatic headache, nausea, and vomiting.

Magnetic resonance imaging (MRI) revealed a new C5-C6 ventral CSF collection.

Symptomatic onset corresponded with the recent cervical chiropractic adjustment.

We present serial imaging correlating with her symptomatology.

We review the pertinent literature on complications of chiropractic manipulation.


The patient was diagnosed with high-risk CD20+ common-type B-cell precursor acute lymphoblastic leukemia.

The patient received two cycles of HyperCVAD.

The patient consulted the National Cancer Institute for a relapse and five-day polyarthralgia.

The patient was initiated into the protocol established in 2003 by the Adult Acute Lymphoblastic Leukemia Research Group (GRAALL-2003).

The patient developed febrile neutropenia.

The patient had cellulitis of the left hand without abscess.

The patient had methicillin-sensitive Staphylococcus aureus bacteremia.

Cefapime and oxacillin were administered.

On day 21 of hospitalization, the patient presented lesions on the back of the left hand.

The lesions on the back of the left hand were of the type erythematoedematosa plaque.

The lesions on the back of the left hand had mild and fine desquamation on the surface.

The lesions on the back of the left hand had central blood crust.

The patient had lesions in the right scapular and infra-scapular region.

The lesions in the right scapular and infra-scapular region were 3 mm non-follicular papules.

The lesions in the right scapular and infra-scapular region were grouped.

The lesions in the right scapular and infra-scapular region were some erythematous and others erythemoparous.

The lesions were assessed by the Dermatology Service.

A skin biopsy was taken for histopathological study.

The results were inconclusive for the diagnosis of mycosis.

No culture was done for fungi of the biopsy.

An invasive fungal infection was suspected.

The chest and sinus computed tomography (CT) scans were negative for invasive aspergillosis.

The serum galactomannan detection was negative for invasive aspergillosis.

Despite antimicrobial and antifungal treatment, the patient did not show significant improvement.

The patient persisted with a fever of up to 40 °C.

The patient had 1 cm nodules, soft, depressible, painless and in the previous sites of venipuncture.

The blood count showed a profound neutropenia (20 white blood cells per µl).

The control CT scan of the paranasal sinuses showed incipient chronic inflammatory changes in the right maxillary sinus.

The abdomen scan documented hepatosplenomegaly.

The three blood cultures and the urine culture from day 28 of hospitalization showed yeast-like structures.

The yeast-like structures were not identified in the automated panel Yeast ID (BD Phoenix™ 100).

Arthroconidia were observed by microscopy.

Colonies compatible with Geotrichum spp. were documented.

The diagnosis was confirmed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry.

Treatment with amphotericin B deoxycholate was given at a daily dose of 1 mg/kg for 14 days.

400 mg/day of voriconazole was given for four weeks.

The patient recovered from neutropenia on day 24 of the combined antifungal treatment.

The patient was discharged on day 101 of hospitalisation due to clinical improvement.

The patient has relapsed acute lymphoblastic leukemia.

The patient had five-day-old polyarthralgia.

The patient had cellulitis without abscesses.

The patient had methicillin-resistant Staphylococcus aureus bacteremia.

The patient received therapy with oxacillin and cefepime.

An invasive fungal infection was suspected.

Arthroconidia were identified in the blood cultures.

Matrix-assisted laser desorption ionization-mass spectrometry confirmed the presence of Geotrichum spp.

Antifungal treatment was adjusted to 14 days of deoxycholate amphotericin B.

Antifungal treatment was adjusted to four weeks of voriconazole.

The patient was discharged after a prolonged stay.

The patient received two cycles of HyperCVAD.

The patient developed febrile neutropenia.

Cefapime and oxacillin were administered.

A skin biopsy was taken for histopathological study.

No culture was done for fungi of the biopsy.

An invasive fungal infection was suspected.

The patient persisted with a fever of up to 40 °C.

The abdomen scan documented hepatosplenomegaly.

Arthroconidia were observed by microscopy.

400 mg/day of voriconazole was given for four weeks.


The patient is a 24-year-old Caucasian man.

He had fever and upper quadrant abdominal pain over the previous 20 days.

Before admission, ciprofloxacin and metronidazole, followed by cefixime had been prescribed.

Six years prior, the patient had been diagnosed with PSC.

Six years prior, the patient had been diagnosed with UC.

Six years prior, the patient had been diagnosed with suspected retroperitoneal fibrosis.

Six years prior, the patient had been diagnosed with bile sludge.

Six years prior, the patient had been diagnosed with splenomegaly.

At that time, ursodiol 300mg BID was prescribed.

At that time, mesalamine 4g per day was prescribed.

At that time, exploratory laparotomy and a biopsy of the perihepatic, retroperitoneal tissue were performed.

Over this six-year period, the patient presented with recurrent episodes of cholangitis.

The serum level of aminotransferases remained substantially normal.

There was a progressive worsening of cholestatic test results.

There was a progressive liver enlargement along with fibrosis.

Gamma glutamyl transpeptidase (GGT) increased from 141UI/L to 344UI/L.

Alkaline phosphatase (ALP) increased from 847UI/L to 2534UI/L.

Hepatic tissue stiffness, measured by FibroScan®, progressed from 12.6 to 17.3kPa.

The patient was never treated with immunosuppressive therapy.

The patient was never treated with corticosteroids.

One month before admission, an upper endoscopy was performed.

The upper endoscopy excluded esophageal varices.

One week before admission, a magnetic resonance of his abdomen and bile ducts was performed.

The magnetic resonance revealed further enlargement of the liver.

The magnetic resonance revealed further enlargement of the spleen.

The magnetic resonance revealed further enlargement of the tissue surrounding his hepatic hilum.

The tissue surrounding his hepatic hilum caused a compression of his second duodenal tract.

The tissue surrounding his hepatic hilum caused a wrapping of the splenic and hepatic arteries.

Beading and narrowing of the intra-hepatic and common bile ducts were reported.

A narrowing of the pancreatic duct was also reported.

At admission, the patient had a fever of 38.8°C.

Physical examination revealed tenderness of his epigastrium.

Physical examination revealed tenderness of his right upper hypochondrium.

Microbiological blood and urine investigations were negative for bacteria.

An abdominal sonography revealed an enlarged liver.

An abdominal sonography revealed thickened choledocus.

An abdominal sonography revealed dilatation of the intra-hepatic biliary tree.

An abdominal sonography revealed splenomegaly.

An abdominal sonography revealed lymphadenopathy of the hepatic hilus.

A colonoscopy showed erythema of the colonic mucosa from the rectum to the cecum.

Random biopsy showed focal atrophy of the colonic mucosa with edema.

Random biopsy showed chronic inflammatory infiltrates.

Specific investigations for CMV were not carried out.

Imipenem 500mg IV four times daily was administered.

Three days later, imipenem was substituted with tigecycline 50mg IV BID.

Further blood and urine cultures for bacteria were negative.

The erythrocyte sedimentation rate (ESR) remained high.

The C-reactive protein level (C-RP) remained high.

The white blood cell (WBC) count decreased.

The upper abdominal pain subsided slightly.

Investigations for Toxoplasma gondii were negative.

Investigations for measles were negative.

Investigations for parotitis were negative.

Investigations for hepatitis C virus (HCV) were negative.

Results for varicella zoster virus indicated previous infection.

Results for human herpes virus indicated previous infection.

Results for Epstein Barr indicated previous infection.

Results for rubella indicated previous infection.

Results for parvo virus B19 indicated previous infection.

CD4?+?T lymphocytes were 1055mm3 (20.3%).

Mycobacterium tuberculosis interferon gamma release assay showed negative results.

Twelve days after admission, teicoplanin 400mg die was prescribed.

Twelve days after admission, gentamicin 80mg TID was prescribed.

Twelve days after admission, metronidazole 500mg TID was prescribed.

Two days later, DNA Cytomegalovirus was detected in the blood with ≤253 copies/mL.

Three days later, this value increased to 6189 copies/mL.

Three days later, 1431 copies/mL were evidenced from a urine sample.

CMV serology indicated acute CMV infection.

The patient’s abdominal pain extended to the right lower abdominal quadrant.

The patient’s abdominal pain radiated to the right groin.

The patient’s abdominal pain radiated to the right testicle.

Ultrasound suggested acute appendicitis.

Histology showed inflammatory infiltrates, including lymphocytes and neutrophils.

Histochemistry was positive for CMV early antigens.

Real time reaction of the appendix tissue was positive.

Shell vial culture of the appendix tissue was positive.

Microbiological investigations for bacteria showed Peptococcus spp.

Microbiological investigations for fungi showed Candida albicans.

Teicoplanin, gentamicin and metronidazole were administered for a total of 12 days.

Intravenous ganciclovir 5mg/kg twice was administered for 15 days.

After discharge, oral valganciclovir 900mg BID was prescribed for 10 days.

After this, the CMV nucleic acid in the blood and urine was negative.

After this, ESR remained abnormally high.

After this, cholestatic liver test results remained abnormally high.

The authors report on a case of acute primary Cytomegalovirus infection complicated with acute appendicitis due to Cytomegalovirus in an apparently immunocompetent 24-year-old Caucasian man.

The patient also suffered from primary sclerosing cholangitis and ulcerative colitis.

Diagnosis was based on clinical manifestations.

Diagnosis was based on serology results.

Diagnosis was based on microbiological findings.

Diagnosis was based on histological findings.

Treatment consisted of anti-Cytomegalovirus therapy.

The patient is a 24-year-old Caucasian man.

Six years prior, the patient had been diagnosed with PSC.

Six years prior, the patient had been diagnosed with UC.

Six years prior, the patient had been diagnosed with bile sludge.

Six years prior, the patient had been diagnosed with splenomegaly.

At that time, ursodiol 300mg BID was prescribed.

At that time, mesalamine 4g per day was prescribed.

There was a progressive worsening of cholestatic test results.

There was a progressive liver enlargement along with fibrosis.

Alkaline phosphatase (ALP) increased from 847UI/L to 2534UI/L.

The patient was never treated with immunosuppressive therapy.

The patient was never treated with corticosteroids.

One month before admission, an upper endoscopy was performed.

The upper endoscopy excluded esophageal varices.

The magnetic resonance revealed further enlargement of the liver.

The magnetic resonance revealed further enlargement of the spleen.

A narrowing of the pancreatic duct was also reported.

At admission, the patient had a fever of 38.8°C.

Physical examination revealed tenderness of his epigastrium.

An abdominal sonography revealed an enlarged liver.

An abdominal sonography revealed thickened choledocus.

An abdominal sonography revealed splenomegaly.

Random biopsy showed chronic inflammatory infiltrates.

Specific investigations for CMV were not carried out.

Imipenem 500mg IV four times daily was administered.

Further blood and urine cultures for bacteria were negative.

The erythrocyte sedimentation rate (ESR) remained high.

The C-reactive protein level (C-RP) remained high.

The white blood cell (WBC) count decreased.

The upper abdominal pain subsided slightly.

Investigations for Toxoplasma gondii were negative.

Investigations for measles were negative.

Investigations for parotitis were negative.

Investigations for hepatitis C virus (HCV) were negative.

Results for varicella zoster virus indicated previous infection.

Results for human herpes virus indicated previous infection.

Results for Epstein Barr indicated previous infection.

Results for rubella indicated previous infection.

Results for parvo virus B19 indicated previous infection.

CD4?+?T lymphocytes were 1055mm3 (20.3%).

Twelve days after admission, teicoplanin 400mg die was prescribed.

Twelve days after admission, gentamicin 80mg TID was prescribed.

Three days later, this value increased to 6189 copies/mL.

CMV serology indicated acute CMV infection.

The patient’s abdominal pain radiated to the right groin.

The patient’s abdominal pain radiated to the right testicle.

Ultrasound suggested acute appendicitis.

Histochemistry was positive for CMV early antigens.

Real time reaction of the appendix tissue was positive.

Shell vial culture of the appendix tissue was positive.

Microbiological investigations for fungi showed Candida albicans.

Intravenous ganciclovir 5mg/kg twice was administered for 15 days.

After this, ESR remained abnormally high.


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 preserve renal function.

The patient is a 34-year-old Han female.

The patient had a slight limp without obvious inducement 7 or 8 years previously.

Approximately 1 year prior to the presentation, she had given birth to a boy.

She developed progressive walking instability approximately 1 year prior to the presentation.

Five months prior to the evaluation, she started experiencing static tremors in her hands and head.

She had occasional numbness in the limbs.

The tremor was significantly aggravated during movement.

She had a history of cephalosporin allergy.

She had undergone an appendectomy 20 years prior.

She had a history of tobacco and alcohol use for 10 years.

She had no relatives with similar symptoms.

At the time of presentation, she had dysarthria.

Her bilateral finger-nose test was unstable.

She demonstrated instability on her calcaneus tibial test.

She had bilateral Babinski and Chaddock's signs.

The total score of the scale for the assessment and rating of ataxia was 24.

The fast alternating hand movement sub-score was 3.

The Mini-Mental State Examination score was within the normal range.

She failed to complete the Montreal Cognitive Scale due to tremors of the hands and head.

The results for tumor markers were not significantly abnormal.

The results for ceruloplasmin were not significantly abnormal.

The results for immune-related autoantibodies were not significantly abnormal.

The results for the five items of thyroid function were not significantly abnormal.

The results for the three items of rheumatism were not significantly abnormal.

The results for the five items of immunity were not significantly abnormal.

The results for antinuclear antibody were not significantly abnormal.

The results for anticardiolipin antibody were not significantly abnormal.

The results for screening and confirmation of anti-neutrophil cytoplasmic antibody were not significantly abnormal.

Lumbar puncture results showed no abnormalities.

Brain MRI revealed speckled and small patchy abnormal signals bilaterally in the corona radiata.

The lesions were hypointense on T1 images.

The lesions were hyperintense on T2 and FLAIR images.

There were no obvious abnormal signals on diffusion-weighted images.

The radiological diagnosis was multiple white matter demyelinating lesions.

Color Doppler ultrasonography of the gynecological, abdominal, cardiac, carotid, and intracranial arteries revealed no obvious abnormalities.

The detection of hereditary disease genes revealed mutations in POLR3A.

The genetic variant c.4044C > G is classified as PM2.

The clinical significance of c.4044C > G remains unclear.

The genetic variant c.1186-2A > G is classified as PVS1 and PM2.

The genetic variant c.1186-2A > G has the potential to influence RNA splicing.

The patient did not undergo genetic testing for her parents or son.

Her condition was diagnosed as POLR3A-related leukodystrophy (HLD7).

She was administered injectable acetylglutamine.

No other drugs were used during the hospital stay.

The symptoms did not show significant improvement during the 1 month of follow-up.

The symptoms appeared aggravated during the 1 month of follow-up.

The patient required assistance to walk.

The patient was unable to hold objects in her hands.

After discharge, she was treated with vitamin B12.

After discharge, she was treated with vitamin E.

After discharge, she was treated with coenzyme Q.

After discharge, she was treated with traditional Chinese medicine.

The traditional Chinese medicine included Ganoderma lucidum.

The traditional Chinese medicine included ginseng.

The traditional Chinese medicine included Poria Cocos.

As of recent follow-up (1 year after discharge), she is able to walk slowly alone.

As of recent follow-up, she is able to climb stairs.

As of recent follow-up, the degree of head and hand tremors has reduced significantly.

As of recent follow-up, she is able to hold objects.

As of recent follow-up, she is able to cook independently.

As of recent follow-up, her speech is slower and more indistinct than before.

MRI of the brain revealed demyelinating lesions in the white matter.

Genetic testing identified the c.4044C > G variant in the POLR3A gene.

Genetic testing identified the c.1186-2A > G variant in the POLR3A gene.

The patient was diagnosed with hypomyelinating leukodystrophy type 7.

The patient received neurotrophic and symptomatic supportive therapy.

After 1 month of follow-up, there was no improvement in her symptoms.

The patient is a 34-year-old Han female.

She had occasional numbness in the limbs.

The tremor was significantly aggravated during movement.

She had a history of cephalosporin allergy.

She had undergone an appendectomy 20 years prior.

She had a history of tobacco and alcohol use for 10 years.

She had no relatives with similar symptoms.

At the time of presentation, she had dysarthria.

Her bilateral finger-nose test was unstable.

She demonstrated instability on her calcaneus tibial test.

She had bilateral Babinski and Chaddock's signs.

The fast alternating hand movement sub-score was 3.

The results for tumor markers were not significantly abnormal.

The results for ceruloplasmin were not significantly abnormal.

Lumbar puncture results showed no abnormalities.

The lesions were hypointense on T1 images.

The lesions were hyperintense on T2 and FLAIR images.

The genetic variant c.4044C > G is classified as PM2.

The clinical significance of c.4044C > G remains unclear.

The genetic variant c.1186-2A > G is classified as PVS1 and PM2.

She was administered injectable acetylglutamine.

No other drugs were used during the hospital stay.

The patient required assistance to walk.

The patient was unable to hold objects in her hands.

After discharge, she was treated with vitamin B12.

After discharge, she was treated with vitamin E.

After discharge, she was treated with coenzyme Q.

The traditional Chinese medicine included Ganoderma lucidum.

The traditional Chinese medicine included ginseng.

The traditional Chinese medicine included Poria Cocos.

As of recent follow-up, she is able to climb stairs.

As of recent follow-up, she is able to hold objects.

As of recent follow-up, she is able to cook independently.


A 14-year-old boy attended a local hospital for ankylosing spondylitis.

Chest radiography showed an enhanced circular-density shadow near the left mediastinum.

The shadow intersected with the mediastinum at an obtuse angle.

Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment.

The patient had no major illness before.

Mandatory spondylitis was discovered this time because of his left hip pain.

The results of the physical examination were normal.

Blood analysis and the blood biochemistries, as well as urine analysis, were all normal.

Electrocardiogram and arterial blood gas were also normal.

Enhanced chest CT suggested irregular soft tissue density above the left aortic arch.

The mass was about 5.5 cm × 3.2 cm × 2.8 cm in size.

During surgery, a left pericardial defect was observed.

The bronchogenic cyst was removed by thoracoscopic surgery.

The pericardial defect remained untreated.

A satisfactory outcome was achieved after the operation.

The patient was diagnosed with a mediastinal tumor.

The pathological diagnosis of the tumor was a bronchogenic cyst.


She presented with progressive left groin pain.

The left groin pain is due to degenerative hip osteoarthritis.

She had a previous knee arthrodesis on the left leg.

The knee arthrodesis was a result of a traffic accident during childhood.

There was a leg length discrepancy of 8.5 cm at the expense of the left leg.

The leg length discrepancy was corrected by an orthopedic shoe.

Log roll and rotation with the hip in flexion (and knee in extension) were painful.

Radiographs showed left hip osteoarthritis.

Previous conservative treatment had become insufficient.

A total hip arthroplasty (THA) was proposed.

Radiographically, there was a normal anatomy of the hip joint.

A direct anterior approach (DAA) THA was planned.

A literature search on PubMed was performed.

Search terms included: Knee arthrodesis; femoral anteversion; and arthroplasty hip.

A case of a THA after knee arthrodesis using a posterolateral approach was found.

A case series by Bourne et al. of 16 patients was found.

No literature was found about the anterior approach in this specific case.

This case report presents the case of a 77 year old female patient.

The patient has degenerative hip disease.

The patient has an ipsilateral arthrodesis of the knee.

The patient had a forgotten joint score of 93.75 at 1 year.

The difficulty in this case consists in finding the correct stem anteversion with the altered knee anatomy.

Pre-operative templating on X-rays was used.


The patient has a body mass index of 22.5 kg/m2.

The patient has a previous clinical history of diffuse scleroderma.

The patient has mild pulmonary hypertension.

The patient has secondary gastroesophageal reflux.

The patient has severe esophageal motility disease.

The patient is receiving immunosuppression, antihypertensive, proton pump inhibitor, and prokinetic management.

The patient has a weak response to medical therapy.

The patient is admitted for surgical management after a 1-year follow-up with cardiology, pneumology, and gastroenterology.

The patient has a previous diagnosis of esophageal aperistalsis.

The patient has poor response to medical therapy.

Physical examination revealed no significant findings.

The lung transplant surgical team determined the patient was not a candidate given the severity of the GERD.

The medical committee decided an open total gastrectomy with roux-en-Y anastomosis prior to lung transplant.

Follow-up one week later with esophagogram revealed normal esophageal morphology.

Follow-up one week later with esophagogram revealed no stenosis.

Follow-up one week later with esophagogram revealed adequate esophago-jejunal anastomosis diameter.

Follow-up one week later with esophagogram revealed no extravasation of the contrast medium.

Follow-up one week later with esophagogram revealed adequate transit of the medium to the small intestine.

Follow-up one week later with esophagogram revealed no evidence of reflux of the medium.

An upper gastrointestinal endoscopy is performed within a 3-month period.

The upper gastrointestinal endoscopy revealed mild esophago-jejunal anastomosis stricture.

The stricture resolved after three balloon dilations of 11 mm, 15 mm, and 18 mm, respectively.

The patient continues follow-up consults.

The patient is asymptomatic according to the Gastroesophageal Reflux Disease Health Related Quality of Life (GERD-HRQL) instrument.

The patient currently awaits lung transplant.

The patient has a previous history of intestinal pneumonitis.

The patient has gastroesophageal reflux secondary to systemic scleroderma.

A lung transplant was initially not a viable option due to persistent gastroesophageal reflux.

An open gastrectomy with roux-en-Y anastomosis was performed.

Follow-up one week later revealed normal anatomy.

Follow-up one week later showed an adequate esophageal-jejunal anastomosis.

Follow-up one week later showed adequate contrast medium transit via esophagogram.

There was no evidence of contrast medium reflux.

This led to the patient becoming a candidate for lung transplant.


He had a five-month history of bilateral radiating pain through the hips, legs and ankles.

He reported numbness, paresthesia and mild weakness in one lateral lower extremity.

A pin-prick sensation test showed bilateral patchy loss of sensation and vibration in the legs and feet.

The patient did not report bowel or bladder problems.

MRI revealed a lesion extending from L3 to L5.

T1-weighted MRI showed an intradural, extra-medullary, isointense mass behind the vertebral bodies of L3 to L5.

The mass was eccentric to the left and showed homogenous enhancement with contrast.

The vertebral body of L4 exhibited a compressed deformation.

Gastroscopy, colonoscopy and computed tomography scans of the abdomen and the thorax identified no additional masses.

A lumbar laminectomy of L3 to L5 was performed.

The tumor was soft with a rich blood supply.

The tumor closely adhered to the medulla spinalis.

Lower extremity pain resolved immediately following surgery.

Lower limb strength began to improve within a few days.

The patient reported symptoms of postoperative dysuria.

Dysuria symptoms showed improvement after one week.

During the two-year postoperative follow-up, the patient exhibited no clinical signs of tumor recurrence.

During the two-year postoperative follow-up, the patient exhibited no MRI radiological signs of tumor recurrence or metastasis.

Postoperative histopathology confirmed a completely resected solid tumor.

The specimen was a fully encapsulated smooth soft-tissue mass.

Standard hematoxylin and eosin staining revealed sheet-like proliferation of NET cells in a trabecular pattern.

There were no visible mitoses or necrosis.

The tumor was positive for synaptophysin.

The tumor was positive for chromogranin (CgA).

These findings are consistent with the known cellular characteristics of a typical CT.

He had a five-month history of bilateral lower extremity pain.

He had mild weakness in one lateral lower extremity.

An en bloc resection of the tumor was performed.

Postoperative histopathology and immunohistochemical analysis of the tumor were consistent with that of a carcinoid tumor.

There were no clinical signs of tumor recurrence at the patient's two year postoperative follow-up.

There were no radiological signs of tumor recurrence at the patient's two year postoperative follow-up.

There were no clinical or radiological signs of metastasis at the patient's two year postoperative follow-up.


The patient recently arrived in Burhakaba town of Somalia from Sa’ada in northwest of Yemen.

The patient was referred to the hospital with a complaint of left upper hypochondrium mass.

The patient had high grade fever, headache, abdominal pain, nausea, vomiting, and weight loss for two months.

The patient claimed he had experienced a similar clinical condition three months ago.

Before reporting to the hospital, he had visited a local hospital in the region.

At the local hospital, he was administered local symptomatic treatment of antipyretics, antibiotics, and transfused with 2 units of whole blood.

After the treatment at the local hospital, he felt mild improvement.

Two months later, his clinical signs recurred with loss of appetite, weight loss, and generalized weakness.

On presentation at the hospital, the patient appeared ill, thin, febrile, and pale.

Abdominal examination revealed splenomegaly.

The other system examinations were normal.

The initial laboratory investigation showed white blood cell count 1.03 x10^9/L.

The initial laboratory investigation showed hemoglobin 6.6 g/dl.

The initial laboratory investigation showed platelet 70x10^9/L.

The initial laboratory investigation showed C-reactive protein 45.73 mg/L.

The initial laboratory investigation showed aspartate transaminase 104.5 U/I.

The initial laboratory investigation showed alanine transaminase 112.5 U/I.

The initial laboratory investigation showed serum creatinine 1.4 mg/dl.

The initial laboratory investigation showed serum urea 54.3 mg/dl.

A rapid diagnostic test for plasmodium parasite antigen was conducted and was found to be positive.

Abdominal ultrasound revealed enlargement of the liver (20cm).

Abdominal ultrasound revealed enlargement of the spleen (30cm).

The patient was admitted initially for treatment of malaria.

The patient was given four doses of intravenous artesunate 120mg.

The patient was transfused one unit of whole blood.

On the third day of admission, no significant improvement was observed.

Infectious disease tests such as human immunodeficiency virus, viral hepatitis, and Brucella serological tests were conducted and found to be negative.

An anti-Leishmania antibody with ELISA was not detected.

A peripheral blood smear showed only pancytopenia and no evidence of malaria parasite.

A tru-cut biopsy of the spleen was performed.

The histopathology examinations of the tru-cut biopsy revealed consistent features with visceral leishmaniasis.

An urgent combination therapy of sodium stibogluconate 800mg/day with paromomycin 600mg/day for 17 days was given.

After the fourth week of treatment, significant improvement was observed.

At the end of the fifth week, the patient was fully recovered.

The patient was discharged following normal results of another tru-cut biopsy of the spleen.

The patient is a 24-year-old from an endemic region of Somalia.

The patient had fever, headache, abdominal pain, nausea, vomiting, and weight loss for two months.

The patient received symptomatic treatment and a blood transfusion.

The patient showed no improvement after initial treatment.

Physical examination revealed fever, pallor, and hepatosplenomegaly.

The rapid diagnostic test was positive for plasmodium parasite antigen.

The patient received three days of anti-malarial treatment.

The symptoms persisted despite anti-malarial treatment.

Hepatosplenomegaly worsened after three days of anti-malarial treatment.

Infectious disease tests ruled out HIV, viral hepatitis, Brucella, and Leishmania antibodies.

Peripheral blood smear showed pancytopenia.

Bone marrow aspiration revealed no evidence of infection or malignancy.

A tru-cut biopsy of the spleen was performed.

The spleen biopsy confirmed the diagnosis of visceral leishmaniasis.

The patient received a combination therapy of sodium stibogluconate and paromomycin.

The patient showed significant improvement after treatment.

The patient was discharged after completing treatment.

The spleen biopsy results were normal after treatment.

Abdominal examination revealed splenomegaly.

The other system examinations were normal.

The initial laboratory investigation showed hemoglobin 6.6 g/dl.

The initial laboratory investigation showed platelet 70x10^9/L.

Abdominal ultrasound revealed enlargement of the liver (20cm).

Abdominal ultrasound revealed enlargement of the spleen (30cm).

The patient was admitted initially for treatment of malaria.

The patient was given four doses of intravenous artesunate 120mg.

The patient was transfused one unit of whole blood.

An anti-Leishmania antibody with ELISA was not detected.

A tru-cut biopsy of the spleen was performed.

At the end of the fifth week, the patient was fully recovered.

The patient is a 24-year-old from an endemic region of Somalia.

The patient showed no improvement after initial treatment.

The patient received three days of anti-malarial treatment.

The symptoms persisted despite anti-malarial treatment.

Peripheral blood smear showed pancytopenia.

A tru-cut biopsy of the spleen was performed.

The patient showed significant improvement after treatment.

The patient was discharged after completing treatment.

The spleen biopsy results were normal after treatment.


The patient is a 65-year-old woman with persistent atrial fibrillation.

She underwent mechanical aortic and mitral valve replacement in 1995 for rheumatic valvular disease.

She required a redo surgery due to an extensive pannus with two biological prostheses in January 2020.

She also required a single-chamber pacemaker.

Her current medical therapy included oral anticoagulation (apixaban 5 mg twice daily).

She developed chronic anaemia due to active intestinal angiodysplasia.

Investigations ruled out other causes of anaemia, including haemolytic anaemia.

The patient presented with two biological prostheses (VHD) without active rheumatic valve disease.

The patient may be a candidate for LAAc.

Transesophageal echocardiography (TEE) revealed spontaneous contrast in the LAA without formation of a thrombus.

One centimetre inside the LAA, the maximum landing zone diameter was 22 mm.

The shape of the LAA was tortuous and difficult to assess.

Pre-operative computed tomography (CT) revealed an unusual LAA morphology that was horn-like in shape.

The LAA had an inferior implantation and a superior axis.

The ostium was close to the mitral prosthesis ring.

A first procedure was performed using a standard left femoral venous approach.

The transseptal puncture was performed postero-inferiorly as recommended under TEE guidance.

Despite multiple attempts, it was not possible to advance the sheath beyond the first centimetre of the ostium.

The deployment of a 31 mm Watchman FLX was attempted but was unsuccessful given the unsuitable sheath position.

A 3D printing model was prepared using SLS laser sintering technology.

Simulation was performed from inferior and superior access points.

Excessive sheath kinking was demonstrated with an inferior approach.

Successful deployment was feasible using a superior approach.

Transseptal puncture (second procedure) was performed using a right jugular venous approach under TEE guidance.

Apixaban was discontinued 72 h before the procedure.

2000 IU unfractionated heparin was administered after jugular puncture.

A Swartz SL0 sheath and a BRK-1 XS Series transseptal needle were used.

Safe access to the left atrium was achieved by advancing a 0.014 stiff coronary wire Iron Man through the BRK-1 XS needle.

The sheath was advanced in the left atrium over the needle and Iron Man wire.

The SL0 was exchanged for the single-curve 14Fr delivery sheath over an Amplatz Super Stiff guidewire.

Deep and safe advancement of the delivery sheath was performed over a pigtail catheter and the Amplatz Super Stiff guidewire.

Proper sheath alignment without kinking was obtained.

Successful implantation of a Watchman FLX 31 device in stable position without residual leakage was achieved.

The position was as predicted during the simulation on the 3D-printed model.

No complications occurred during the first or second procedures.

Following the successful second procedure, the patient continued to receive apixaban (2.5 mg twice daily) until the control CT scan at month 2.

At the patient’s 3-month follow-up visit, and after cessation of oral anticoagulation, an improvement in symptoms was seen with no need for additional transfusions.

Imaging demonstrated complete LAA occlusion and correct placement of the device along the LAA superior axis as predicted by the simulation procedure.

TEE follow-up confirmed there was no leakage around the device.

After 9 months’ follow-up, there was no need for further transfusions.

The patient’s pulmonary pressure and functional class had improved.

The patient has persistent atrial fibrillation.

The patient was referred for left atrial appendage closure (LAAc).

Transesophageal echocardiography (TEE) revealed spontaneous contrast in the left atrial appendage (LAA).

Transesophageal echocardiography (TEE) did not reveal formation of a thrombus.

The left atrial appendage shape was tortuous.

The left atrial appendage was difficult to assess.

A first LAAc procedure was unsuccessful.

The first LAAc procedure was unsuccessful given the unsuitable sheath position.

A soft three-dimensional (3D) model printing was performed by laser sintering.

The 3D model revealed excessive sheath kinking with an inferior approach.

The 3D model suggested successful deployment would be feasible using a superior approach.

A successful trans-jugular implantation of a Watchman FLX 31 device was achieved.

The Watchman FLX 31 device was in stable position.

There was no residual leakage after the device implantation.

At 3-month follow-up, the patient's symptoms improved.

Oral anticoagulation was ceased after the procedure.

Imaging demonstrated complete LAA occlusion.

Imaging demonstrated correct placement of the device along the LAA superior axis.

She also required a single-chamber pacemaker.

She developed chronic anaemia due to active intestinal angiodysplasia.

The patient may be a candidate for LAAc.

The shape of the LAA was tortuous and difficult to assess.

The LAA had an inferior implantation and a superior axis.

The ostium was close to the mitral prosthesis ring.

A 3D printing model was prepared using SLS laser sintering technology.

Simulation was performed from inferior and superior access points.

Excessive sheath kinking was demonstrated with an inferior approach.

Successful deployment was feasible using a superior approach.

Apixaban was discontinued 72 h before the procedure.

2000 IU unfractionated heparin was administered after jugular puncture.

A Swartz SL0 sheath and a BRK-1 XS Series transseptal needle were used.

Proper sheath alignment without kinking was obtained.

No complications occurred during the first or second procedures.

TEE follow-up confirmed there was no leakage around the device.

After 9 months’ follow-up, there was no need for further transfusions.

The patient’s pulmonary pressure and functional class had improved.

The patient has persistent atrial fibrillation.

The patient was referred for left atrial appendage closure (LAAc).

The left atrial appendage shape was tortuous.

The left atrial appendage was difficult to assess.

A first LAAc procedure was unsuccessful.

The Watchman FLX 31 device was in stable position.

There was no residual leakage after the device implantation.

At 3-month follow-up, the patient's symptoms improved.

Oral anticoagulation was ceased after the procedure.

Imaging demonstrated complete LAA occlusion.