ARTICLES IN PRESS | YEAR-2023 | VOLUME-6

Rationale: Immune thrombocytopenic purpura may be associated with severe acute respiratory syndrome (SARS) or Coronaviruses. Probably fatal outcome for the disease has a remarkable effect on morbidity and mortality. T-wave is the positive deflection post-each QRS-complex. Physiologically, it represents ventricular repolarization.
Patient Concerns: A 66-year-old, teacher, married male, Egyptian patient was presented to the physician outpatient clinic with COVID-19 pneumonia with thrombocytopenia and abnormal T-wave.
Diagnosis: COVID pneumonia with immune thrombocytopenic purpura and novel T-wave graduation.
Interventions: Non-contrast chest CT, electrocardiography, oxygenation, and echocardiography.
Outcomes: Good response and better outcomes despite the presence of numerous remarkable risk factors were the results.
Lessons: The association of COVID pneumonia with immune thrombocytopenic purpura and novel T-wave graduation is highly interesting. An elder age, male sex, COVID-19 pneumonia, and immune thrombocytopenic purpura are constellation serious risk factors. Touching radiological variant pericardial injury with mild hypokalemia maybe interpret the novel T-wave graduation.

As a reliable psychological test, Tokyo University Egogram (TEG) 2^nd has been used widely. TEG was recently revised to TEG 3^rd. Authors continued TEG research on university students for long, in which results of 2018 by TEG 2^nd and results of 2019-2022 by TEG 3^rd were compared. For the 3^rd revision, FC dominant and AC dominant increased markedly, whereas CP dominant and NP dominant decreased. C dominant pattern showed remarkable increase, which is due to increase of AC dominant and FC dominant. This is a characteristic tendency for late teenagers. Further, mixed types of N-shaped and reverse N-shaped patterns were found.

Achalasia is an esophageal disorder characterized by loss of inhibitory neurons of the myenteric plexus in the lower esophageal sphincter, presenting with dysphagia, chest pain, and regurgitation. Although the etiology of achalasia is unknown, it has been associated with viral infections, and recent studies have noted concurrence of achalasia cases with COVID-19 infection. The case discussed in this report pertains to a 20-year-old female with a recent history of COVID-19 infection and subsequent SARS CoV-2 vaccine administration, presenting to the Emergency Department with a complaint of chest pain and shortness of breath. She was incidentally diagnosed with achalasia, after concern for pulmonary embolism prompted CT angiography of the chest. This case is unique due to the patient’s young age and lack of confounding ongoing medical issues to consider when analyzing disease presentation, as well as its potential link to COVID-19 infection. We hypothesize that SARS-CoV-2 might have caused a deviant immune response in this patient, leading to vagus nerve damage and the development of achalasia. With this case report, we hope to further explore the connection between COVID-19 and achalasia to help guide clinicians to potential viral etiologies of achalasia, allowing them for a prompt and efficient diagnosis and patient management.

Background: Recent diabetic focus includes imeglimin (Twymeeg).
Case Presentation: The case was an 83-year-old female with 19 years of type 2 diabetes (T2D) associated with recent treatment for dementia.
Result: HbA1c decreased from 10.0% to 6.6% for 4 months by Twymeeg 2000 mg/day. For neuropsychiatric symptoms in dementia, memantine and tiapride were provided and controlled. Furthermore, zinc acetate hydrate (Novelzin) was continued for T2D and dementia.
Discussion and Conclusion: Twymeeg administration was effective as the results of Trials of IMeglimin for Efficacy and Safety (TIMES) 2 and 3. Perspectives on the efficacy of zinc were discussed including Alzheimer’s-Plus with low zinc (APLZ).

Kommerell diverticulums are an uncommon congenital vascular disease involving an aberrant origin of the right or left subclavian artery and a dilation of its root. Here, we present the case of a 44-year-old woman with a relapse of a surgically repaired aberrant subclavian artery with a Kommerell diverticulum.

Clinical epidemiology focuses on issues relevant to clinical medicine, representing a distinctive field that converts clinical practice into a quantitative science. Public health epidemiology is the basis of knowledge about how to prevent and treat disease in populations. Clinicians are concerned with diagnosing disease, making a prognosis, and prescribing specific treatment for each patient. Epidemiologists seek to identify a specific source of infection, mode of transmission, or causative factors in order to identify future trends and specifically recommend control measures. Evidence-based medicine (EBM) is both a challenge and a consensus for clinicians and epidemiologists. Through this article, we review the challenges and consensus of epidemiologists and clinicians on evidence-based medicine towards a future consensus development for the goal of medical ethics (Medical ethics ME) with the spirit of “All for One, One for All”.

Ventricular septal rupture is an uncommon but serious complication of acute myocardial infarction that requires prompt and appropriate management. In this case, we present a typical example of a patient diagnosed with a ventricular septal rupture.

Background: Among oral hypoglycemic agents (OHAs), imeglimin (Twymeeg) would be in focus.
Case Presentation: The patient in this case is a 58-year-old female with a history of obesity and previous operations for posterior longitudinal ligament ossification. In early September 2022, she developed dizziness and a general feeling of unwellness, leading to a diagnosis of Type 2 Diabetes (T2D) with an HbA1c level of 11.1%.
Result: The patient was treated with a low carbohydrate diet (LCD) and Twymeeg, resulting in a significant decrease in HbA1c levels from 11.1% to 9.0%, 6.7%, and 5.9% over the course of three months. Pre-prandial and post-prandial blood glucose levels were measured with great accuracy.
Discussion and Conclusion: The administration of Twymeeg was found to be effective in reducing the patient’s HbA1c levels, and the relationship between HbA1c and glucose variability could be further investigated based on these results.

The incidence of moderate to severe pain after total knee arthroplasty (TKA) ranges from 30-60% [1]. In the context of enhanced recovery after surgery, multimodal analgesia with peripheral nerve block as the core has become the main method of postoperative analgesia after TKA, and good analgesia is conducive to the early recovery of patients. Genicular nerve block (GNB) provides good analgesia anterior to the knee, while infiltration between the popliteal artery and capsule of the knee (iPACK) block provides good analgesia posterior to the knee [2]. We report a case of genicular nerve block combined with iPACK block for postoperative analgesia after total knee arthroplasty.

This case report aims to introduce pneumoparotitis and the correct execution of CT examination to ensure a proper diagnosis. A 45-year-old male presented several times to the ER with Oedema of the left parotid region and neck, along with crackles on palpation. This symptomatology raised suspicion of an inflammatory pathology complicated with abscesses of the parotid gland or a pneumomediastinum due to a traumatic lesion of the airways or oesophagus. Several imaging examinations, such as ultrasound and neck-chest CT, were performed for this suspicion without a correct diagnosis. The use of endo-oral contrast with “puffing” was useful in diagnosing pneumo-parotitis. Therefore, we believe that this procedure could be helpful in the future.
Pneumoparotitis is a pathology caused by incontinence of the Stenone duct which determines the reflux of saliva and air into the gland predisposing to the onset of recurrent infections. This pathology is characterized by swelling and subcutaneous emphysema of the parotid region.
Adequate knowledge of pneumoparotitis and the correct execution of the CT examination is essential to demonstrate the incontinence of the Stenone duct to be able to exclude emergencies such as abscesses, air-gas infections, and traumatic lesions of the airways and oesophagus.

Compared to ordinary gastroscopy, painless gastroscopy has more advantages due to the application of anesthesia techniques such as sedation and analgesia, providing patients with comfort and a quick recovery. However, patients undergoing painless gastroscopy are often at risk of hypoxia, which can result in serious complications. Fortunately, more anesthesia providers have recognized this problem. Therefore, it is essential for anesthesia providers to identify risk factors to prevent hypoxemia. In conclusion, this review highlights the assessment of risk factors for hypoxemia in painless gastroscopy and common airway management methods to prevent and treat hypoxemia in high-risk populations during painless endoscopy.

What we are going to present is the case of a 65-year-old male patient affected by renal and hepatic disease without checking other cases in his family history. He had been submitted to maintenance hemodialysis for 4 months because of an autosomal recessive polycystic kidney disease. At the start of the hemodialysis session, he reported general malaise, abdominal pain, fever, and, during the last two days, even diarrhea. Laboratory workup showed neutrophilic leukocytosis and an increase in serum amylase and C-reactive protein. Abdominal contrast-enhanced CT scan and MRI cholangiography showed hepatic cysts with marked dilatation of the intra- and extrahepatic bile ducts. The patient underwent cholecystectomy with hepatic-jejunal anastomosis on the loop of Roux and was discharged with oral ciprofloxacin. Histology confirmed marked cystic dilatation of biliary ducts and choledochus. Similar episodes continued, and every time ciprofloxacin was prescribed. After 4 months, a retrograde-endoscopic-pancreatography was undertaken, which led to the diagnosis of Caroli’s syndrome associated with polycystic kidneys.
Given the rarity of the disease and the difficulty of diagnosis, it is our opinion that when patients with polycystic kidneys and liver cysts undergo recurrent episodes of septic fever of unknown origin, Caroli’s disease should be considered, and the appropriate tests should be carried out to confirm the diagnosis.

Background: Vildagliptin/Metformin (EquMet) and imeglimin (Twymeeg) are effective oral hypoglycemic agents (OHAs) for patients with type 2 diabetes (T2D).
Case Presentation: The patient was a 68-year-old male with T2D and fatty liver for several years. In November 2022, his HbA1c had increased to 8.2%, and he was started on Twymeeg, followed by EquMet.
Results: Over the course of four months, the patient’s HbA1c value successfully decreased from 8.2% to 6.7%, and he did not experience any gastrointestinal adverse effects (GIAEs).
Discussion and Conclusion: The combined treatment of EquMet and Twymeeg demonstrated clinical efficacy without any adverse effects. The Trials of IMeglimin for Efficacy and Safety (TIMES) provided various evidence of imeglimin’s effectiveness.

Vogt-Koyanagi-Harada disease (VKH) is a central nervous system condition that specifically affects vision and hearing. Descriptions of this disease date back to the 12th century, but the disease is named after three 20th-century physicians who described the collective manifestations of this disease. Alfred Vogt initially described bilateral iridocyclitis and eyebrow depigmentation in 1906, followed by Yoshizo Koyanagi’s 1926 description of bilateral serous detachments in association with cerebrospinal fluid (CSF) pleocytosis. Einosuke Harada identified the integumentary symptoms of the condition shortly thereafter. The disease presents with signs and symptoms of a loss of immune tolerance to melanocytes within the meninges, eyes, skin, hair, and ears [1]. The exact etiology of VKH is not firmly established, but current theories posit that patients develop T cell-mediated immunity against melanocytes following recovery from an inciting viral environmental factor [2]. Recent genetic studies have implicated the presence of human leukocyte antigen (HLA) cell surface markers HLA-DRB4, HLA-DRB1-04*05, and HLA-DRB-04*01, as well as non-HLA genes involving lymphocyte regulations in IL-12 production and IL-17 production [3,4]. Downregulation of microRNA in the production of interleukins and changes in non-coding RNA may also play a role in this condition [5].

Postoperative pain management after varicocele surgery poses a challenge for pediatric patients. The quadratus lumborum block (QLB) is a novel regional analgesia technique that entails injecting a local anesthetic around the quadratus lumborum muscle using ultrasound guidance. In this study, we present the utilization of a single transmuscular QLB in two children as an effective postoperative analgesic method for laparoscopic extraperitoneal high ligation of the spermatic vein (LEHLSV).

This article stipulates the airway management in a patient requiring cranial debridement and cranioplasty with a Montgomery T-tube (MTT) in situ. Anesthetic techniques that have been previously described for surgeries with MTT in situ which can be managed by applying a laryngeal mask or intubating a trachea tube easily. The airway management of patients with an MTT in situ, requiring a supine position with the head rightly tilted and flexed, has not yet been addressed. In this article, we explored some possible approaches to cope with this arising problem. We present how we managed to intubate a double-lumen endotracheal tube onto the superior tracheal limb of the T-tube since the 5.0 mm ID tracheal tube (equivalent to a 6.9 mm ED) could not pass through the tube readily. This technique could possibly be considered for patients in similar clinical scenarios.

With the arrival of an aging society and the progress of surgical procedures, total hip arthroplasty (THA) has been carried out more and more. However, postoperative pain severely affected the patient’s recovery, and there is currently no reliable analgesic method available. Evidence-based international expert consensus also recommends, compared to LIA, peripheral nerve block (PNB) as a central analgesic approach use in THA for improved outcomes [1]. In this case report, we described 4 cases of postoperative analgesia with pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve block (LFCNB) in patients undergoing THA.

Expiratory central airway collapse (ECAC) comprises tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). ECAC is a progressive disease that can be congenital or acquired, and it can be confirmed by inspiratory-dynamic expiratory chest CT or dynamic bronchoscopy. We present the case of a 65-year-old man who underwent radiofrequency ablation for hepatocellular carcinoma under general anesthesia. After tracheal intubation in the operating room, the respiratory sound in the left lung disappeared, and the respiratory sound in the right lung was clear during chest auscultation. Bronchoscopy revealed complete collapse of the left main bronchus. Intraoperative bronchoscopy confirmed that the patient had ECAC (both TBM and EDAC).

The case involves a 70-year-old female with Type 2 Diabetes (T2D) who had been prescribed EquMet (vildagliptin/metformin) and had a stable HbA1c. In August 2022, she tested positive for real-time polymerase chain reaction (RT-PCR) without showing any symptoms. By November 2022, her HbA1c had increased to 7.4%, and a chest CT scan revealed a consolidation lesion in her left lower lung, suggesting post-inflammatory pathology of COVID-19. Imeglimin (Twemeeg) was added to her treatment regimen, and it proved effective, resulting in a 0.9% reduction in HbA1c over 4 months without any gastrointestinal adverse effects (GIAEs). The combined treatment of EquMet and Twymeeg was effective, and the interrelationship between T2D and COVID-19 will be followed up.

The trichilemmal proliferating cyst is a member of the group of adnexal tumors arising from the hair follicle, more specifically from the isthmic trichilemmal segment of the external epithelial sheath of the hair follicle. It is most often located on the head and neck, but case reports of extracephalic localization are described in the literature. We report a case of a proliferating trichilemmal cyst on the back, where the diagnosis was made after the anatomopathological study of the excised specimen.

Azithromycin 1.5% ophthalmic solution is a viable and well-tolerated treatment option for bacterial conjunctivitis and blepharitis, offering the advantage of a shorter treatment duration compared to other topical antibiotics. While acute-type allergic reactions to topical azithromycin eye drops may be rare, it is important for ophthalmologists to be aware of this possibility and to inform patients about the potential occurrence of such reactions. We present three cases of unusual acute-type allergic reactions to topical azithromycin eye drops. These reactions manifested as epiphora, eyelid edema, pruritus, and hyperemia.

Background: Venous thrombosis is a common complication among critically ill patients with intracerebral hemorrhage, which may lead to pulmonary embolism.
Case Presentation: In this report, we present a case of a man who was diagnosed with left basal ganglia region hemorrhage, hypertension, and venous thromboembolism. Considering the risks, including rebleeding and the expansion of the hematoma, he did not receive any anticoagulation after onset. The thrombus located in the pulmonary artery was found by transesophageal echocardiography after he suffered cardiac arrest during the craniotomy. Additionally, a thrombus attached to the central venous catheter was observed by ultrasound. Unfortunately, he died of PE without receiving any effective treatment.
Conclusions: This case emphasizes the importance of prophylactic and therapeutic strategies for thromboembolic events among critically ill populations. It also underscores the critical role of perioperative ultrasound.

The patient is a 66-year-old female being treated for hypertension. She developed a cerebral vascular accident (CVA) in October 2019, and was subsequently diagnosed with type 2 diabetes (T2D) due to an HbA1c level of 9.8%. She began a low carbohydrate diet (LCD) and started taking oral hypoglycemic agents (OHAs) such as metformin and linagliptin. From July 2021, she occasionally experienced anxiety and palpitations, leading to a diagnosis of reactive depression (adjustment disorder). Despite treatment with etizolam as needed, these symptoms persisted. In December 2022, due to an increase in HbA1c levels to 7.7%, metformin was switched to imeglimin (Twymeeg). By April 2023, her HbA1c had decreased to 6.9%, and she reported a sustained sense of well-being without psychosomatic symptoms.

The perioperative management of pulmonary hypertension continues to be a great challenge for anesthesiologists. Among the various types of pulmonary hypertension, pulmonary hypertension associated with left heart disease is the most common, while pulmonary hypertensive crisis is one of the causes of perioperative mortality in these patients. We present the case of a 54-year-old female with severe valvular heart disease complicated by severe pulmonary hypertension and massive hemothorax, who underwent emergency exploratory thoracotomy, mitral valve replacement, and tricuspid valvuloplasty. The patient was in critical condition and suspected to have a pulmonary hypertension crisis. The rationale for this case report is to learn about the anesthetic management of patients with severe pulmonary hypertension.

The case involves a 74-year-old male with type 2 diabetes (T2D), hypertension, dyslipidemia, and diabetic kidney disease (DKD) at nephropathy stage G3b. He has been receiving treatment with insulin and anti-hypertensive agents (AHAs). In July 2021, his HbA1c was elevated to 7.9%. As a result, the extent of his low carbohydrate diet (LCD) was increased, and insulin doses were raised. The AHAs were changed from Olmesartan to Valsartan/Amlodipine, and Irbesartan/Amlodipine until 2023. By January 2023, his HbA1c had decreased to 6.8%, and his eGFR (CKD-EPI) had remained stable at 34-48 mL/min/1.73/m² for 4 years. A recent study demonstrated clinical improvement in renal function through continuous LCD in patients with DKD.

FMD is a rare systemic vascular disease characterized by abnormal cell proliferation in the artery walls, leading to artery narrowing, twisting, or bulging. It commonly affects the carotid and renal arteries and can result in renal diseases and stroke. This paper presents a case study of a 39-year-old unhoused female patient who experienced a stroke secondary to fibromuscular dysplasia (FMD) and left ventricular thrombus. The patient presented with asymmetric movement of the extremities and psychosis, so intoxication was initially suspected. However, further examination revealed facial asymmetry and motor weakness. CT scans showed a left anterior cerebral artery infarction and irregular contour of the cervical internal carotid arteries, consistent with FMD and carotid thrombus. Management involved stabilizing the patient, providing supportive treatment, and controlling blood pressure. Thrombolytic therapy was not administered due to the time elapsed since symptom onset. The patient was started on anticoagulation for the carotid plaque and left ventricular thrombus. A transthoracic echocardiogram revealed a large left ventricular thrombus and left atrial enlargement, and the patient was started on heart failure medications.
FMD and left ventricular thrombus are not directly related, but FMD can contribute to thrombus development through its impact on the cardiovascular system, including hypertension, arterial wall damage, aneurysm development, or dissection. Treatment for FMD may involve medication, observation, or surgical interventions like angioplasty and stenting. Anticoagulation therapy is essential for managing the left ventricular thrombus.
This case highlights the importance of early diagnosis and treatment of FMD to prevent complications such as stroke. It is important to consider FMD in the diagnosis of younger patients with a stroke, especially those with a history of hypertension, substance abuse, or other risk factors. Further research is needed to better understand the relationship between FMD and stroke and to optimize treatment strategies for these patients.

Background: The humanitarian situation in Somalia is characterized by unstable government, insecurity, fragility, and limited investments in funding essential public services and maternal newborn and health services are not spared. The health system in Somalia remained under-resourced to meet the urgent lifesaving, essential, and preventive health services. This study sought to assess the access and utilization of maternal and newborn child health services in Somalia.
Methodology: A cross-sectional design was used in this study. Descriptive and inferential statistical data analysis was conducted to establish the performance of indicators and relationships. The study targeted mothers of children 0-59 months.
Results: The results show a low (13.1%) attendance of focused (4^th visit) antenatal care among the mothers. 23.3% of the mothers from Somaliland attended at least three antenatal care visits, while the rest of the states only achieved less than 10%. At least 41.5% of the deliveries occurred at the health facility. Skilled attendants assisted 42.7% of the deliveries. No significant difference was observed in the number of women having an extra meal during pregnancy or delivery at the health facility or in predicting the number of ANC visits. Nonetheless, 43.2% of the infants in Somalia had not been exclusively breastfed for the first six months of life. The results equally demonstrated poor nutritional index with only 38.4% of the pregnant women having an extra meal during pregnancy. In Somalia, early health care seeking for common childhood illnesses is still low, with Respiratory Tract infections (RTIs) at 40%, malaria at 56.6%, and diarrhea at 63.4%.
Conclusion and Recommendations: There is a need for deliberate efforts to improve low-performing indicators and hence improve the survival of mothers and children.

Postoperative recurrence and metastasis of papillary thyroid carcinoma (PTC) to the superior vena cava (SVC) and right atrium (RA) are rare. The application of Extracorporeal Jugular-femoral Vein Bypass and anesthesia management for SVC reconstruction in this rare situation holds instructive significance. In this case, we describe the successful anesthesia management of a patient with multiple tumor thrombi due to postoperative recurrence of PTC. The diagnosis was based on computed tomography of the chest and blood vessels, revealing three-dimensional SVC, postoperative recurrence of PTC, and multiple tumor thrombi in the internal jugular vein (IJV), subclavian vein, brachiocephalic vein, SVC, and RA. An experienced multidisciplinary team was established, and a detailed plan was made for respiration and circulation support, with cardiopulmonary bypass on standby.

Objective: Direct radiologist to patient communication has been linked to higher levels of patient satisfaction, compliance, and overall treatment outcomes. Recent studies examining patient expectations in breast imaging indicate that 90% of women prefer result communication and review of imaging directly from their radiologist. Though the primary components of diagnostic breast imaging are patient centered, supplemental data suggests that screening mammography result consultation may represent an additional opportunity for engagement in the new era of patient-experience driven care. The primary aim of our study was to examine patient preferences for receiving real time screening mammography result communication (RTRC) and characteristics that may influence their willingness to participate.
Material and Methods: This quality-improvement based, IRB-approved, study was performed at three community-based academic breast radiology centers in a large metropolitan area between October 5, 2020, and January 2, 2021. Female patients presenting for screening mammography were invited to opt in for RTRC and/or participate in an electronic, HIPAA-compliant, simple survey that could be completed on the personal subject’s phone or tablet. Subjects opting in for RTRC were invited to wait in a consultation room during staff radiologist review. Once interpreted, the radiologist would discuss the results and next step recommendations with the patient. Self-reported patient demographic characteristics and RTRC preferences by age, race, ethnicity, level of education, household income, prior personal or family history of breast cancer, active (non-breast) cancer history and prior history of abnormal mammogram were assessed by categorical variable analysis using Chi-squared tests. A p-value <0.05 was determined to be statistically significant.
Results: 1714 screening mammograms were performed across our three community-based breast imaging centers and 11% (186/1714) of women completed the survey during the study timeframe. White women (92%) were statistically more likely to opt in for RTRC when compared with non-white (80%) counterparts (p=.026). Patients with a personal history (p=0.001) or family history (p=0.006) of breast cancer were statistically more likely to opt in for RTRC when compared with other cohorts. A positive correlation was observed between prior history of abnormal mammogram and preference for receiving RTRC (93%) but did not achieve statistical significance (p=.082). There was no correlation observed between RTRC preference and an active (non-breast) cancer diagnosis (p=0.415).
Conclusion: Our study confirms previous data suggesting that patients vastly prefer direct verbal communication ahead of written letter result notification. Our study also suggests that screening mammography RTRC may be of particular interest in patients with higher (personal or familial) risk for developing breast cancer. While this service may operationally add demand on radiologist-patient face time and cost to care delivery, an awareness of patient preferences and cohorts that may find value in this service option can be prioritized to optimize both patient experience and clinical workflow. Additional studies are warranted to further validate which practice models would achieve most benefit from this tailored service offering.

Serious anaphylactic reactions to anesthetics can be life-threatening events. Vecuronium is promoted as a neuromuscular blocking drug that is least likely to cause anaphylaxis due to its low histamine-releasing potential. Perioperative hypoxemia in patients with tetralogy of Fallot (TOF) due to anaphylactic reactions can be easily misdiagnosed as anoxic spells. We report a patient with TOF who suffered from symmetrical peripheral gangrene after undergoing catecholamine-refractory anaphylactic shock to vecuronium perioperatively. CPB (cardiopulmonary bypass) is the most effective support for severe anaphylactic shock during the perioperative period. Intradermal test screening for anaphylaxis to anesthetics is an effective method for prevention and diagnosis.

The incidence of bladder spasm in children with hypospadias treated with caudal block before surgery is uncommon. We presented a case of bladder spasm after urethroplasty surgery that was successfully treated with anisodamine without any sequelae. The caudal block plane may only reach the sacrum and does not reach the bladder wall. I suggest a local anesthetic drug dose of 1 ml/kg, totaling not more than 20 ml, to avoid the occurrence of postoperative bladder spasm and increase the comfort of children.

The case is a 51-year-old male with obesity, type 2 diabetes (T2D), dyslipidemia, and hypertension. His HbA1c value increased to 8.0%, accompanied by oral semaglutide administration. Glucose variability was exacerbated after that, and then novel imeglimin (Twymeeg) was initiated. HbA1c decreased from 7.4% to 6.7% over 4 months with a 3 kg weight reduction. The case also had low back pain (LBP) and lumbar spinal stenosis (LSS), probably resulting from Metabolic syndrome (Met-S), and had actual experience with a low carbohydrate diet (LCD) in the hospital meals. Four patterns of LCD meals had carbohydrates ranging from 17.8g to 28.0g, with 501-690kcal.

This case report presents a 67-year-old female with Parkinson’s disease who underwent deep brain stimulation (DBS) electrode replacement surgery. Following extubation, the patient developed persistent laryngospasm, requiring immediate intervention. Suspecting symptoms similar to levodopa withdrawal, the patient received intravenous propofol and enteral levodopa supplementation, leading to symptom improvement. The case underscores the importance of perioperative management, including timely medication supplementation and DBS functioning, in Parkinson’s patients to prevent neuroleptic malignant syndrome (NMS)-like complications. Anesthesiologists should be vigilant about potential airway issues and NMS in this population and maintain optimal fluid status during surgery. Prompt intervention can prevent irreversible damage and improve patient outcomes.

There is little information about right-to-left shunting with normal pulmonary artery pressure, which is produced as a consequence of right ventricle systolic dysfunction. We presented a case of unexpected transesophageal echocardiography findings of right-to-left shunting through an atrial septal defect despite normal pulmonary artery pressure, related to right ventricle systolic dysfunction in a 27-year-old young woman. Transesophageal echocardiography imaging revealed right ventricular systolic dysfunction and normal pulmonary artery pressure.

Complications of laparoscopic surgery include carbon dioxide (CO₂) embolism, primarily caused by the entry of CO₂ gas into blood vessels or solid organs. If significant clinical symptoms occur, timely intervention is crucial as it can be life-threatening. We report a case of CO₂ embolism during laparoscopic right hepatectomy. The patient was a 37-year-old male with no history of liver or kidney dysfunction. During the procedure, there were two episodes of oxygen desaturation (SpO₂), and the second episode was accompanied by a significant drop in blood pressure and an increase in heart rate. However, there was no sudden decrease in the end-tidal CO₂ partial pressure (ETCO₂). Simultaneously, a grinding murmur was auscultated in the precordial area, and foamy blood was aspirated from the right internal jugular vein catheter. This article describes a case of CO₂ embolism during laparoscopic surgery and provides a summary of its causes, clinical manifestations, diagnosis, and treatment. It is hoped that this article will contribute to the timely recognition and management of such cases, thereby preventing any potential adverse outcomes for patients.

The bacteria Actinomyces spp. a gram-positive bacteria responsible for the actinomycosis disease. Its 15–20% pulmonary presentation is generally chronic, progresses slowly, and might be misinterpreted as lung cancer or other long-term conditions. We describe a man in his 60s with weight loss and dyspnea. The presence of Actinomyces spp. was identified in a bronchial biopsy of the middle lobe, ruling out lung cancer as the initial diagnostic possibility. After a month of intravenously administered antibiotic treatment, the patient experienced bronchiectasis. Pulmonary actinomycosis should be considered since it is challenging to detect and sometimes mistaken for lung neoplasia or TB due to its comparable clinical and radiographic presentations. The prognosis of pulmonary actinomycosis (PA) is favorable, and it is feasible to avoid recurring complications with the correct antibiotic treatment.

Introduction: Splenic abscess is rare in children. This report discusses a case of splenic abscess complicating an infarction in a teenager at the Teaching Hospital of Borgou/Alibori in Benin Republic.
Patient and Observation: The patient was a 14-year-old teenager with hemoglobinopathy (SC), admitted to the pediatric department for generalized abdominal pain associated with fever and a dry cough. On physical examination, he presented with an infectious syndrome, generalized abdominal pain, highly sensitive splenomegaly, left lung consolidation, and severe malnutrition. Abdominal ultrasound and thoraco-abdominal CT-scan revealed a splenic infarction abscess. Following medical treatment, which included broad-spectrum antibiotic therapy and analgesia, a total splenectomy was performed. During surgery, the spleen appeared greyish and contained pus, which, upon cytobacteriological examination, isolated a Klebsiella pneumoniae strain sensitive to the combination of amoxicillin-clavulanic acid. The patient showed favorable evolution under this treatment.
Conclusion: Splenic abscess should be suspected in any subject with sickle cell disease presenting with painful and febrile splenomegaly.

Paragangliomas are rare neuroendocrine neoplasms, commonly located in the head and neck. They are sometimes first found in the bone, especially when there are contributing factors such as trauma, which can make clinical diagnosis more challenging. In this reported case, a patient presented with a painful mass in the right thigh caused by trauma. During the procedure for resecting the right femoral mass, the patient’s blood pressure significantly increased upon touching the tumor. Subsequently, a biopsy of the right thigh femur and a whole-body contrast-enhanced computed tomography (CT) examination confirmed the diagnosis of a right femoral paraganglioma with metastasis to the right neck.

The current case is a 102-year-old female centenarian with slight bronchopneumonia. She did not have any remarkable health or medical problems until 2022. In May 2023, she developed a cough and fever and underwent a lung CT scan, which revealed a consolidation shadow in the left posterior middle lung. This image was created with a 1mm width for each 1mm interval. Additionally, a further image was generated using maximum intensity projection (MIP) with a 3mm width for a slab thickness of 20mm. Based on this data, a diagnosis of slight bronchopneumonia in the left lung was made. She was treated with levofloxacin 500mg/day for 5 days, which led to clinical improvement.

Background: Carbon dioxide (CO₂) embolism is a rare but potentially life-threatening complication of endoscopic surgery. While endoscopic thyroidectomy is superior to traditional open thyroidectomy in terms of cosmetic results, it may lead to venous or fatal paradoxical CO₂ embolism. CO₂ embolism involves the inadvertent injection of carbon dioxide into a large vein, artery, or solid organ. The clinical manifestations of CO₂ embolism can vary from asymptomatic to neurological damage, cardiac failure, and even death, depending on the rate and volume of CO₂ entry and the patient’s general condition. This case can enhance our understanding of CO₂ embolization during endoscopic surgery.
Case Presentation: This case report describes an incident in which a gas embolism occurred during endoscopic right lobe and isthmus thyroidectomy, resulting in arrhythmia and dramatic fluctuations in circulation and oxygen levels. The operation was halted, and CO₂ injection was stopped. The surgical wound was covered with saline gauze, and the patient inhaled 100% pure oxygen while undergoing aggressive repeated manual pulmonary recruitment maneuvers. Additionally, vasoactive drugs such as m-hydroxyamine and ephedrine were administered to aid in treating the condition. The patient’s position was adjusted using the Durant maneuver (partial left lateral and Trendelenburg position). Following the aforementioned treatments, the patient’s ventricular arrhythmia transitioned back to a normal and regular sinus rhythm, and both circulation and oxygen levels stabilized.
Conclusions: Carbon dioxide embolism is an uncommon yet potentially severe complication of laparoscopic procedures. We anticipate that this particular case will enhance our comprehension of carbon dioxide embolism during endoscopic surgery.

This case involves a 76-year-old female patient with type 2 diabetes (T2D), diabetic gastroenteropathy, and slight arteriosclerosis. Her HbA1c levels have been unstable for years due to her typical carbohydrate intake. Her symptoms include constipation, nausea, and abdominal fullness. Despite being on magnesium oxide and picosulfate, she experiences difficulty achieving smooth bowel movements for an extended period.
In March 2023, her HbA1c levels increased to 8.5%. Subsequently, EquMet and Twymeeg were initiated, resulting in remarkable clinical effects, with her HbA1c dropping to 5.9% by August 2023. A Holter ECG recorded ventricular premature contractions (VPC) occurring 10 times (0.010%) over a 24-hour period. Additionally, plethysmography indicated a cardio-ankle vascular index (CAVI) of 9.5/9.3, suggesting slight arteriosclerosis.

This paper provides a detailed historical account of the Spanish Miliary Hospital in Cayey, Puerto Rico during the latter part of the 19th century, focusing on its role during the Spanish-American War and its impact on public health in Puerto Rico. The paper is divided into ten sections, each highlighting the development, growth, and function of the hospital during the Spanish American War and concludes with a look at the hospital today. Overall, this paper provides a comprehensive historical account of the Spanish Hospital in Cayey in Puerto Rican history, shedding light on its role in military medicine and public health during the Spanish-American War in the Central Mountain Region of Puerto Rico.

The presented case is a 68-year-old female with Type 1 diabetes (T1D). She was admitted for an emergency case with acute distress in January 2018 and was diagnosed with T1D with a blood glucose (BG) level of 459 mg/dL, HbA1c of 13.7%, glutamic acid decarboxylase autoantibody (GADA) level >2000 U/mL (<5 U/mL), and C-reactive protein (CRP) level of 1.10 ng/mL. She received Multiple Daily Injections (MDI) of insulin for 3 months, and then her HbA1c decreased to 7.3%. After that, she has been on a super-low carbohydrate diet (LCD) and received only Lantus XR and ipragliflozin. Serum CRP showed 0.2 ng/mL, suggesting a prolonged honeymoon period for years through continuous LCD.

For type 2 diabetes (T2D), the recommended meal has shifted from calorie restriction (CR) to a low carbohydrate diet (LCD). LCD gained worldwide prevalence through the efforts of Atkins and Bernstein, and we further developed LCD both medically and socially through the Japan LCD Promotion Association (JLCDPA). The beneficial and convenient methods of LCD include petite, standard, and super LCD, which have carbohydrate ratios of 40%, 26%, and 12%, respectively. For these three types, the approximate permitted carbohydrate amounts in each meal appear to be 20g, 30g, and 40g. Some foods with lower carbohydrate content include eggs (0.1g), a piece of cheese (0.2g), chicken meat (180g) (0.4g), and Japanese tofu (300g) (4g).

Spontaneous Pneumothorax is a potentially life-threatening condition that is brought on when air makes its way into the pleural spaces resulting in decreased negative pressure between the pleural membranes without trauma or injury occurring. Spontaneous pneumothorax was reported as an adverse complication of severe acute respiratory syndrome brought on by SARS-COV-2. It is thought spontaneous pneumothorax may be a consequence of the breakdown of elastic fibers within the lung tissue. This breakdown is believed to be caused by the body’s own immune response in particular by innate lymphoid cells (ILCs) which have been shown to be elevated in response to intracellular pathogens like viruses, but additional research is needed to clearly state a causal relationship between SARS-CoV-2 and the immune-mediated formation of pneumothorax. Limited studies look at the link between the pathophysiology of Pneumothorax and COVID-19, which is why the patient from this case is of interest. We present a unique case of a 27-year-old male presenting to the Emergency Department complaining of difficulty breathing, chest pain, and fatigue who had prior tested positive for COVID-19. A diagnosis of pneumothorax was made by chest x-ray. In this report, we discuss the pathophysiology, imaging, and management related to pneumothorax and its connection to COVID-19.

Sporadic or inherited deficiencies in the production or activity of the tumor suppressor P53 lead to Li-Fraumeni Syndrome (LFS), a multi-organ tumorigenic condition. Glioblastoma multiforme (GBM), a tumor that commonly presents with a median age of 64, has a higher chance of appearing in much younger patients who have LFS [9]. Since the implementation of the 2016 Toronto Protocol to increase cancer surveillance in LFS patients, three cases of LFS-GBM have been discussed [11-13]. Here, we report a case of LFS in an 18-year-old male who had a seizure due to a GBM that had evaded a full-body MRI six months prior. Furthermore, we discuss the potential quality of life (QOL) benefits of providing patients with a shorter brain MRI screening interval: better survival outcomes and peace of mind. Though there may be a rise in the financial cost with an increase in the number of MRI scans, the prevalence of aggressive tumors that must be treated early for a better prognosis warrants more frequent screening. Furthermore, we address the importance of expanding clinical knowledge on GBM in the LFS setting as well as addressing the benefits of the protocol through statistical studies.