Hybrid Transcatheter Approach to an Iatrogenic Left Ventricle-Coronary Sinus Fistula

This clinical case describes a subacute presentation of decompensated heart failure secondary to an iatrogenic left ventricle-to-coronary sinus fistula after sequential mitral valve surgical procedures. Computed tomography was used to select an unconventional hybrid transapical access approach and facilitate successful closure using a vascular plug.

Emicizumab for acquired hemophilia A: Report of two cases and dosing strategies

Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by autoantibodies against FVIII. Severe AHA is life-threatening. Currently, licensed hemostatic agents for the treatment of severe AHA have short half-lives and require intravenous administration, leading to a need for hospitalization, higher costs, and negative effects on quality of life. We present two cases of severe AHA with high inhibitor titers where emicizumab was safely and effectively used with intensive immunosuppression. These reports suggest in vivo efficacy even in high inhibitor environments. The optimal dosing regimen (accelerated vs. standard loading, maintenance frequency) is unknown and we discuss the current approaches.

Cocaine-associated Eustachian tube stenosis causing chronic 'glue ear': a rare cocaine-induced destructive lesion

BACKGROUND

Cocaine is one of the most used recreational drugs. Whilst medical uses exist, chronic recreational nasal use of cocaine is associated with progressive destruction of the osseocartilaginous structures of the nose, sinuses and palate - termed cocaine-induced midline destructive lesions.

CASE REPORT

A 43-year-old male with a history of chronic cocaine use, presented with conductive hearing loss and unilateral middle-ear effusion. Examination under anaesthesia revealed a completely stenosed left Eustachian tube orifice with intra-nasal adhesions. The adhesions were divided and the hearing loss was treated conservatively with hearing aids. Whilst intra-nasal cocaine-induced midline destructive lesions are a well-described condition, this is the first known report of Eustachian tube stenosis associated with cocaine use.

CONCLUSION

This unique report highlights the importance of thorough history-taking, rhinological and otological examination, and audiometric testing when assessing patients with a history of chronic cocaine use. This paper demonstrates the complexity of managing hearing loss in such cases, with multiple conservative and surgical options available.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

Untangling diagnostic confusion in internal abdominal hernias

BACKGROUND

Internal hernias involve the herniation of intestines through mesenteric or peritoneal defects in the gastrointestinal system. Etiologically, they are generally classified as congenital or acquired. Internal hernias often present with non-specific symptoms. Despite the increased use of computed tomography (CT), discrepancies between imaging findings and diagnostic accuracy continue to pose challenges for clinicians. This study aims to compare the outcomes of patients presenting to the emergency department with abdominal pain and receiving a preliminary internal hernia diagnosis through CT, followed by laparotomy.

METHODS

Our research is a retrospective, observational, and descriptive study. It includes patients presenting to the emergency department with abdominal pain, who were provisionally diagnosed with internal hernia based on CT. Patient data recorded age, gen-der, CT-identified internal hernia type, surgery, diagnoses, hospitalization status, duration of hospital stay, bowel resection, mortality, and blood parameters. The Welch classification was used to categorize internal hernia types, with eight types examined.

RESULTS

Among 112 patients with a preliminary internal hernia diagnosis based on abdominal CT, the median age was 52 years. Of these, 46 were female and 66 were male. Among all patients, 87 were admitted to the hospital for observation and surgery, while 25 were discharged after emergency department. Paraduodenal hernias were the most common provisional diagnosis (48 cases). Among these patients, 45 were discharged after symptom relief and were advised for elective re-evaluation. The exact diagnosis for these pa-tients remains unknown. Post-surgery, the diagnosis of internal hernia was confirmed in 32 cases. Among them, 15 were female and 17 were male, with a median age of 52. The median hospital stay for patients diagnosed with internal hernia was 5 days. Although acquired hernias exhibited higher resection and mortality rates, no statistically significant difference was found. Thirty-five cases received dif-ferent diagnoses: 19 had brid ileus, five had volvulus, six had acute appendicitis, one had duodenal perforation, three had gynecological malignancies, and one had renal malignancy.

CONCLUSION

Although internal hernias are rare, early diagnosis and treatment are very important due to the high risk of death. The study findings indicate that increased CT utilization leads to earlier diagnosis and treatment, resulting in improved prognosis for patients. This study holds one of the largest case series in the literature. It provides a novel perspective by evaluating radiologically-diagnosed cases, confirming diagnoses post-surgery, and comparing conditions that mimic internal hernias, thereby making a valuable contribution to the literature.

Acquired Focal Choroidal Excavation Secondary to Pachychoroid Choroidal Neovascular Membrane After Central Serous Chorioretinopathy

Purpose: To report a case of acquired conforming-type focal choroidal excavation (FCE) secondary to a pachychoroid choroidal neovascular membrane (CNVM) triggered by central serous chorioretinopathy (CSCR). Methods: A case and its findings were analyzed. Results: A 54-year-old Asian man who had spontaneous resolution of CSCR in the right eye presented with a pachychoroid CNVM and FCE 1 year after the initial CSCR diagnosis. Intravitreal antivascular endothelial growth factor injections were initiated, and the subretinal fluid and intraretinal hemorrhage resolved. The patient was followed for FCE progression for 3 years. Conclusions: Acquired FCE can occur secondary to CSCR and pachychoroid CNVM. The pathogenesis may be focal choroidal ischemia, choroidal vascular collapse, and fibrosis leading to choroidal excavation. This case highlights the progression of the spectrum of pachychoroid disorders from CSCR, pachychoroid CNVM, and subsequent acquired confirming-type FCE. Further research is needed to assess other diseases leading to acquired FCE and to determine the underlying mechanism.

Phenotypic Variability in Acquired and Idiopathic Dystonia

Background

To date, a few studies have systematically investigated differences in the clinical spectrum between acquired and idiopathic dystonias.

Objectives

To compare demographic data and clinical features in patients with adult-onset acquired and idiopathic dystonias.

Methods

Patients were identified from among those included in the Italian Dystonia Registry, a multicenter Italian dataset of patients with adult-onset dystonia. Study population included 116 patients with adult-onset acquired dystonia and 651 patients with isolated adult-onset idiopathic dystonia.

Results

Comparison of acquired and idiopathic dystonia revealed differences in the body distribution of dystonia, with oromandibular dystonia, limb and trunk dystonia being more frequent in patients with acquired dystonia. The acquired dystonia group was also characterized by lower age at dystonia onset, greater tendency to spread, lower frequency of head tremor, sensory trick and eye symptoms, and similar frequency of neck pain associated with CD and family history of dystonia/tremor.

Conclusions

The clinical phenomenology of dystonia may differ between acquired and idiopathic dystonia, particularly with regard to the body localization of dystonia and the tendency to spread. This dissimilarity raises the possibility of pathophysiological differences between etiologic categories.

Acquired Von Willebrand Factor Deficiency at Patient-Prosthesis Mismatch after AVR Procedure-A Narrative Review

Acquired von Willebrand factor deficiency has been described in patients with aortic valve stenosis due to high shear forces developed during passage through the narrowed valve orifice, which determines structural changes in this molecule. Similar flow conditions are present in patients with an aortic prosthesis that presents a patient-prosthesis mismatch. Patient-prosthesis mismatch is described by the smaller effective orifice area of the prosthesis than the native valve, which would probably determine similar changes in the molecules of the von Willebrand factor, leading to acquiring von Willebrand deficiency.

Vincristine-induced ptosis in a leukemia patient treated with pyridoxine and pyridostigmine

INTRODUCTION

Blepharoptosis, commonly referred to as ptosis or eyelid sagging, is a condition where the upper eyelid droops over the eye. It can be congenital or acquired and is caused by the weakening of the eyelid muscles.

CASE REPORT

We present a case of a 3-year-old boy with T-cell acute lymphoblastic leukemia who developed bilateral ptosis while on treatment with Berlin-Frankfurt Munster-98 protocol.

MANAGEMENT & OUTCOME

The patient was diagnosed with bilateral ptosis due to vincristine, the primary agent in the induction phase of the protocol. The addition of the neuroregenerative agents and supportive measures led to marked improvement, followed by complete resolution within 3 weeks.

DISCUSSION

Vincristine is an anticancer agent with known neurotoxicity, which has a significant role in treating hematological malignancies and sarcoma. In many studies, the addition of neuroregenerative agents such as pyridoxine and pyridostigmine has been noted to hasten recovery without any documented side effects. Similar findings were also drawn from our research due to India's higher incidence of vincristine-induced neurotoxicity. It is essential to promptly diagnose and manage symptoms at the earliest to prevent the risk of permanent nerve damage and inferior quality of life for the patient.

The Association of Nevus-Associated Melanoma with Common or Dysplastic Melanocytic Nevus: A Systematic Review and Meta-Analysis

Background: Cutaneous melanoma has an adjacent nevus remnant upon histological examination in 30% of cases (nevus-associated melanoma, NAM), while it appears de novo for 70% of tumors. Regarding NAM arising in acquired melanocytic nevus, currently there is no evidence on whether NAM more frequently develops in association with a dysplastic or common melanocytic nevus. Objectives: To conduct a systematic review and meta-analysis to investigate the proportion of dysplastic or common melanocytic nevus in NAM associated with acquired nevus. Methods: A systematic literature search is conducted using PubMed, Scopus, and the Cochrane Library. The PRISMA checklist is used. Studies reporting patients diagnosed with NAM arising in an acquired common or dysplastic melanocytic nevus are included. A meta-analysis of proportions is performed using the random-effects model. The magnitude of heterogeneity is assessed with the I² statistic. Results: A total of 22 studies with 2174 NAMs with an acquired nevus (dysplastic or common) are included. The proportion of dysplastic nevus in NAM varies considerably in the included studies, ranging from 0% to 100%. In the meta-analysis, the overall estimate of the proportion of having a dysplastic nevus in NAM is 51% (95% CI: 39-63%) with high heterogeneity at I²: 95.8% (p < 0.01). A sensitivity meta-analysis of 12 studies that included 30 or more acquired nevus-NAMs (2023 cases) shows that 65% of the NAMs developed in a dysplastic nevus (95% CI: 51-77%). In a meta-analysis of 4 studies reporting invasive-only acquired nevus-NAMs (764 cases), the proportion of dysplastic nevus is 56% (95% CI: 36-75%). Only 2 studies are found reporting in situ NAMs with an acquired nevus, and the pooled estimated proportion of dysplastic nevus is 71% (95% CI: 63-78%). Conclusions: The results of this meta-analysis suggest a higher proportion of dysplastic nevus in acquired nevus-NAM; however, there is considerable uncertainty and high heterogeneity, highlighting the need for future well-designed studies with uniform histopathological definitions for dysplastic nevus remnants which report the type of nevus in NAM separately for invasive melanomas, thin tumors, and by histological subtype.

Factor V Leiden-independent activated protein C resistance: Communication from the plasma coagulation inhibitors subcommittee of the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee

Activated protein C resistance (APC-R) due to the single-nucleotide polymorphism factor V Leiden (FVL) is the most common cause of hereditary thrombophilia. It is found predominantly in Caucasians and is uncommon or absent in other populations. Although FVL is responsible for >90% of cases of hereditary APC-R, a number of other F5 variants that also confer various degrees of APC-R and thrombotic risk have been described. Acquired APC-R due to increased levels of coagulation factors, reduced levels of inhibitors, or the presence of autoantibodies occurs in a variety of conditions and is an independent risk factor for thrombosis. It is common for thrombophilia screening protocols to restrict assessment for APC-R to demonstrating the presence or absence of FVL. The aim of this Scientific and Standardisation Committee communication is to detail the causes of FVL-independent APC-R to widen the diagnostic net, particularly in situations in which in vitro APC-R is encountered in the absence of FVL. Predilution clotting assays are not FVL specific and are used to detect clinically significant F5 variants conferring APC-R, whereas different forms of acquired APC-R are preferentially detected using the classical activated partial thromboplastin time-based APC-R assay without predilution and/or endogenous thrombin potential APC-R assays. Resource-specific recommendations are given to guide the detection of FVL-independent APC-R.

Risk Factors of Hospital-Acquired Pneumonia Among Hospitalized Patients With Cardiac Diseases

Background To our knowledge, no studies have been done in Saudi Arabia to determine the risk factors of hospital-acquired pneumonia (HAP) among hospitalized cardiac patients. This study aimed to assess these risk factors. Methods A retrospective study was done at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Five hundred hospitalized patients diagnosed with pre-existing cardiovascular disease (CVD) were included. A checklist was used to collect data about patients' demographic characteristics; BMI; smoking and alcohol abuse; type of cardiac disease; other chronic diseases; exposure to immunosuppressives; chemotherapy and radiotherapy in the last six months; glucocorticoid use; application of ventilator; initial, follow-up chest X-ray results; pneumonia vaccination status; nasogastric tube use; general anesthesia received; use of loop diuretics; presence of pulmonary diseases; levels of WBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); results of blood and respiratory cultures; number of hospitalizations and intensive care unit (ICU) admissions in the last six months; and Richmond Agitation and Sedation Scale (RASS) score. Results The prevalence of pneumonia was 7%. Females; patients with autoimmune diseases who were exposed to immunosuppressives or glucocorticoids; those with an initial or second abnormal chest X-ray; patients who used nasogastric tube, had pulmonary disease, and had high levels of WBC, ESR, or CRP; and patients hospitalized for more than two times had a significantly higher percentage of having pneumonia. Abnormal second chest X-ray, high ESR, and more than two times of hospitalization within the last six months were the risk factors of pneumonia on multivariate logistic regression analysis. Conclusion Better prevention and intervention programs are needed to assess the risk factors of pneumonia among admitted cardiac patients.

based population

Due to the low incidence of sixth cranial nerve palsies in children, there has been limited evidence published on this subject, especially from a population based within the UK. The incidence of etiologies has been found to vary significantly within the literature, especially with regard to neoplasms. The main aim of this study is to present the etiologies of newly diagnosed pediatric sixth nerve palsies in a UK-based population. We also take into consideration if the palsies were isolated or associated with other neurological signs or symptoms. Retrospective data collection was carried out on the medical records of 50 pediatric patients with a new-onset sixth nerve palsy. They all presented to a large tertiary referral hospital in the South of the UK between 1 January 2007 and 31 December 2017. Data collected for each patient included age, gender, ethnicity, unilateral versus bilateral, other signs and symptoms, etiology, where the patient first presented, and whether the palsy was the first presenting feature. Thirty-three (66%) patients had a new-onset sixth nerve palsy in conjunction with other neurological signs or symptoms and were considered non-isolated. Seventeen cases (34%) were found to be isolated. Etiologies included high intracranial pressure (18%), neoplasm (14%), surgery for neoplasm (14%), viral (14%), infection (12%), trauma (8%), idiopathic (6%), benign space-occupying lesion (4%), congenital (2%), inflammation (2%), Alexander's disease (2%), Kawasaki syndrome (2%), and diabetes (2%). Our study found non-isolated sixth nerve palsies to be the most common presentation. These patients had a high number of potentially sinister etiologies, the most common being high intracranial pressure followed by post-surgery for neoplasm and neoplasm. Isolated sixth nerve palsies were more commonly due to viral or idiopathic etiology; however, two cases of benign space-occupying lesion and one of neoplasm were identified.

Postnatal Posterior Fossa Arachnoid Cyst: A Developmental Etiology to Be Considered

Intracranial arachnoid cyst is the most common cystic congenital anomaly in the brain. In this study, we discuss a pregnancy that had serial fetal ultrasound scans throughout the pregnancy and a fetal anomaly scan at 24 weeks of gestation that was normal. The child was born healthy with normal development, but 12 months onward the head began to enlarge. The magnetic resonance imaging of the brain showed a large posterior fossa arachnoid cyst with hydrocephalus. We discuss the postulation to explain this pathogenesis of the cyst. This case highlights that not all symptomatic arachnoid cysts are congenital despite the manifestation being as early as infancy.

Garcin syndrome in a case of acquired immunodeficiency syndrome

In this study, we report a parapharyngeal diffuse large B-cell lymphoma in a human immunodeficiency virus (HIV) infected patient which had caused the patient to suffer from Garcin syndrome.

Prevalence and Clinical Significance of Heart Murmurs Detected on Cardiac Auscultation in 856 Cats

Simple Summary

Heart murmurs are a common finding in cats and, in many cases, the presence of an audible murmur on cardiac auscultation does not necessarily imply the presence of an underlying heart disease. Several studies have been published in the past to address the prevalence and clinical significance of heart murmurs in cats, but very few have looked into the exact origin of the blood flow turbulence responsible for this finding. We retrospectively reviewed clinical records and echocardiographic examinations of 856 cats with heart murmur and found that the majority of murmurs are caused by systolic anterior motion of the mitral valve (SAM) (39.2%) and dynamic right ventricular outflow tract obstruction (DRVOTO) (32%). These causes of murmur do not appear associated with a structural cardiac abnormality in 56.1% (SAM) and 85.0% (DRVOTO) of murmurs. This study also demonstrated that some heart murmur characteristics (timing, intensity and location) can occasionally discriminate between normal cats and cats with underlying heart disease, with the exception of loud and palpable murmurs, which are inevitably associated with significant cardiac abnormalities. However, since the majority of heart murmurs in cats appear to be systolic and mild–moderate in loudness, echocardiography should always be considered following identification of a heart murmur on physical examination in cats.

Abstract

Background: Cardiac auscultation is one of the most important clinical tools to identify patients with a potential heart disease. Although several publications have reported the prevalence of murmurs in cats, little information is available in relation to the exact origin of the blood flow turbulences responsible for these murmurs. The aim of this study was to determine the prevalence and clinical significance of murmurs detected during physical examination in cats. Methods: Retrospective evaluation of clinical records and echocardiographic examinations performed in cats for investigation of heart murmurs; Results: Records of 856 cats with full clinical information were available for review. The cause of murmur was identified in 93.1% of cases (72.3% with single blood flow turbulence, 26.4% with two, and 1.3% with three identifiable sources of murmur). Systolic anterior motion of the mitral valve (SAM) was the primary cause of murmur in this population (39.2%), followed by dynamic right ventricular outflow tract obstruction (DRVOTO) (32%) and flow murmurs (6.9%). Most cats with a murmur (56.7%) did not present any structural cardiac abnormality. Conclusions: This study indicates that some heart murmur characteristics (timing, loudness and point of maximal intensity) can potentially predict the presence of an underlying cardiac disease.

Treatment of hypothyroidism in infants, children and adolescents

In 2014, treatment guidelines from the American Thyroid Association reflected the general consensus that levothyroxine (LT4), adjusted to maintain a normal thyrotropin (TSH) level, is the preferred method for treatment of hypothyroidism. Although this is generally applicable to children, there are subsets of children for whom the diagnosis and treatment of hypothyroidism are problematic. These include children with congenital hypothyroidism (CH), low birth weight (LBW) and very low birth weight (VLBW), Down syndrome (DS), subclinical hypothyroidism, and obesity. In this Review, we focus on the progress and remaining pitfalls in diagnosis and treatment of hypothyroidism in these and other groups.

Obesity Subtyping: The Etiology, Prevention, and Management of Acquired versus Inherited Obese Phenotypes

The etiology of obesity is complex and idiosyncratic-with inherited, behavioral, and environmental factors determining the age and rate at which excessive adiposity develops. Moreover, the etiologic status of an obese phenotype (how and when it developed initially) strongly influences both the short-term response to intervention and long-term health trajectories. Nevertheless, current management strategies tend to be 'one-size-fits-all' protocols that fail to anticipate the heterogeneity of response generated by the etiologic status of each individual's phenotype. As a result, the efficacy of current lifestyle approaches varies from ineffective and potentially detrimental, to clinically successful; therefore, we posit that effective management strategies necessitate a personalized approach that incorporates the subtyping of obese phenotypes. Research shows that there are two broad etiologic subtypes: 'acquired' and 'inherited'. Acquired obesity denotes the development of excessive adiposity after puberty-and because the genesis of this subtype is behavioral, it is amenable to interventions based on diet and exercise. Conversely, inherited obesity subsumes all forms of excessive adiposity that are present at birth and develop prior to pubescence (pediatric and childhood). As the inherited phenotype is engendered in utero, this subtype has irreversible structural (anatomic) and physiologic (metabolic) perturbations that are not susceptible to intervention. As such, the most realizable outcome for many individuals with an inherited subtype will be a 'fit but fat' phenotype. Given that etiologic subtype strongly influences the effects of intervention and successful health management, the purpose of this 'perspective' article is to provide a concise overview of the differential development of acquired versus inherited obesity and offer insight into subtype-specific management.

Acquired Haemophilia A: A 15-Year Single-Centre Experience of Demography, Clinical Features and Outcome

Acquired haemophilia A (AHA) is a rare severe bleeding disorder resulting from the production of autoantibodies directed against coagulation factor VIII. At presentation, bleeding events can be severe, and an early diagnosis and treatment are of major importance. The current study aims to analyse the treated patients who have been diagnosed with AHA for a better understanding of our population and treatment outcome. We conducted a retrospective study with 26 patients who had been diagnosed with AHA and who were treated in our hospital between January 2006 and January 2021. The patients ranged in age from 30 to 85 years old: 46.10% were men, 46.10% had no known underlying condition, 27% had an underlying malignancy, 7.60% presented with other diseases: psoriatic arthritis and Paget's disease, and 19.30% presented with AHA during puerperium. All of the patients had bleeding events and were treated with bypass agents for this as well as with immunosuppressive therapy to eradicate the inhibitor. A total of 53.80% of the patients had major bleeding. Sixty-nine percent of the patients achieved complete remission, but 26.90% died during the follow-up, although bleeding was not the cause of death in any of these cases. Our observations underline the importance of clinical suspicion and early referral to centres with experience and laboratory facilities for managing AHA.

Case study: use of sentence completion with a person with aphasia and apraxia of speech

Several interventions for acquired apraxia of speech (AOS) involve models, imitation, or repetition to elicit production of words. Early researchers wrote about anecdotal experiences, in which sentence completion facilitated speech production for individuals with AOS. The use of sentence completion to elicit production of words during intervention has not been systematically researched. The purpose of this research was to evaluate the effectiveness of sentence completion to elicit correct productions of words, as part of an intervention for one individual with aphasia and AOS. Training occurred three times a week for six weeks. In each session, the participant answered 20 simple questions, for which the answer was one of 20 target words. Ten of these 20 words were used for training, while the other set of 10 words remained untrained. During training, the participant produced words, as the final word of a sentence. The participant improved production of the trained target words. By the end of training, the participant produced more words, as the final word in a sentence and as the answer to a simple question. For this case study, an individual with severe Broca's aphasia and severe AOS increased the number of personally-relevant words produced following training using sentence completion to elicit production.

Indications and outcomes of pediatric penetrating keratoplasty: A retrospective observational study

Background

Pediatric corneal transplantation can be indicated in congenital and acquired conditions. Challenges include preoperative evaluation, multiple intraoperative obstacles, and postoperative problems in follow-up and management. This study was aimed at identifying the indications and clinical outcomes of pediatric penetrating keratoplasty (PKP) in Jordan.

Methods

This retrospective cohort study was conducted in Amman, Jordan. Using the hospital's electronic database, all medical records of patients aged < 18 years who underwent PKP between January 2004 and October 2019 were reviewed. Preoperative evaluations included best-corrected distance visual acuity (BCDVA) and anterior and posterior segment examinations. Postoperative complications, BCDVA, and graft survival were examined 1 year postoperatively.

Results

A total of 149 cases of pediatric PKP were performed on 141 eyes of 118 patients with an age mean ± standard deviation (SD) of 11.44 ± 4.97 years at the time of surgery. Acquired non-traumatic corneal pathologies accounted for 65.8% of indications for PKP. The most frequent indication was advanced keratoconus (55.7%). Preoperative and 1-year postoperative BCDVAs significantly differed (P < 0.001), with 111 (74.5%) patients showing improved BCDVA, 12 (8.05%) patients showing worsened BCDVA, and 26 (17.45%) patients showing no change in BCDVA. The overall 1-year graft survival rate was 80.54%.

Conclusions

This was the largest study in Jordan involving pediatric patients who underwent PKP for various indications, showing a significant improvement in BCDVA, with a high survival rate at 1 year. Future studies with longer follow-up periods could provide stronger evidence for surgical outcomes and graft survival. Further, the option of lamellar keratoplasty in the pediatric age group should be assessed.

Acquired Iris Heterochromia After Pars Plana Vitrectomy

Describe a case of acquired heterochromia after intraocular surgery. A 63-year-old healthy female patient presented to the eye clinic with rhegmatogenous retinal detachment in her left eye. She underwent uncomplicated pars plana vitrectomy with implantation of posterior chamber intraocular lens. One week after the surgery the patient noticed a change in the color of her operated eye (green instead of blue), she came back to the clinic complaining about her eye color, weeks later her eye color returned back to blue. This case shows a unique presentation of transient acquired heterochromia after intraocular surgery in an adult patient and emphasizes the importance of counseling and reassuring patients regarding the possibility of this event.

Fetal and Neonatal Thyroid Dysfunction

Fetal and neonatal dysfunctions include rare serious disorders involving abnormal thyroid function during the second half of gestation, which may persist throughout life, as for most congenital thyroid disorders, or be transient, resolving in the first few weeks of life, as in autoimmune hyperthyroidism or hypothyroidism and some cases of congenital hypothyroidism (CH) with the thyroid gland in situ. Primary CH is diagnosed by neonatal screening, which has been implemented for 40 years in developed countries and should be introduced worldwide, as early treatment prevents irreversible neurodevelopmental delay. Central CH is a rarer entity occurring mostly in association with multiple pituitary hormone deficiencies. Other rare disorders impair the action of thyroid hormones. Neonatal Graves' disease (GD) results from the passage of thyrotropin receptor antibodies (TRAbs) across the placenta, from mother to fetus. It may affect the fetuses and neonates of mothers with a history of current or past GD, but hyperthyroidism develops only in those with high levels of stimulatory TRAb activity. The presence of antibodies predominantly blocking thyroid-stimulating hormone receptors may result in transient hypothyroidism, possibly followed by neonatal hyperthyroidism, depending on the balance between the antibodies present. Antithyroid drugs taken by the mother cross the placenta, treating potential fetal hyperthyroidism, but they may also cause transient fetal and neonatal hypothyroidism. Early diagnosis and treatment are key to optimizing the child's prognosis. This review focuses on the diagnosis and management of these patients during the fetal and neonatal periods. It includes the description of a case of fetal and neonatal autoimmune hyperthyroidism.

Development of a questionnaire for a patient-reported outcome after nasal reconstruction

INTRODUCTION

Our face plays an important role in communication and social life. Defects of the face have a big impact on socializing and psychics of patients with its deformities. A good esthetic outcome is an important task of each reconstructive surgery. With a modern concept of nose reconstruction, it is possible to achieve a better esthetic and functional outcome than it was possible with one phase reconstructions before. There was a specific tool missing to measure patients reported outcome and objectively evaluate benefits of nose reconstruction from a patients point of view and get reliable feedback about the whole procedure.  The goal of this paper is to develop such a questionnaire.

MATERIALS AND METHODS

A pilot questionnaire was developed with literature input. The questionnaire was tested on five patients. Based on patients feedback and a review from a psychologist, the second version of the questionnaire was made. It was sent to 39 patients, who underwent nose reconstruction in the years 2016-2020. After two appeals, 34 completed questionnaires were sent back (87,2%). The final version of the questionnaire was developed after a thorough mathematic and statistical analysis of collected data.

RESULTS

The group of patients who completed the questionnaire consisted of 16 females (47%) and 18 males (53%). On average, the patients were 69 years old (17-88 years). The final questionnaire is structured into six categories from A to F: A - general information defining the patient and purpose for reconstruction, B - satisfaction with esthetic outcome, C - satisfaction with function and stability, D - satisfaction with medical treatment, E - social and psychological impact, F - overall satisfaction. Most of the questions use a 5-point rating scale.

CONCLUSION

The questionnaire enables the patients to provide feedback on particular aspects of the treatment and their overall satisfaction with the whole procedure and its outcome. With statistical analysis, it is possible to discover specific treatment aspects that have crucial impact on overall satisfaction with the whole procedure. A patient-reported outcome helps to improve the quality of provided health care and the quality of patient life.

Non-medication Acquired Sticky Skin: Case Report of Idiopathic Acquired Cutaneous Adherence and Review of Medication-Induced Sticky Skin

Sticky skin is a dermatologic phenomenon in which the skin may cause objects to adhere to it on contact or adhere to itself or both. The entire skin can be affected in patients with sticky skin. Alternatively, just acral sites, such as the hand, can be involved. The acquisition of sticky skin has been described in patients treated with certain medications. These drugs include retinoids, proton pump inhibitors, and antifungals; they also include combination therapy utilizing an antineoplastic agent and an antifungal drug in patients with hormone-resistant prostate cancer.

The pathogenesis of acquired cutaneous adherence in patients with androgen-independent prostate cancer was postulated to be the result of therapy-induced elevation of endogenous retinoids. Retinoids have multiple biological effects on epidermal differentiation that may contribute to the pathogenesis of acquired cutaneous adherence. These include the induction of fine, granular, mucus-like deposits within and between the keratinocytes in the upper stratum spinosum and stratum corneum, modulation of lipid composition in keratinocytes, prevention of cross-linked, cornified envelope formation in keratinocytes by the inhibition of epidermal transglutaminase, and altered and decreased content of keratin within the epidermis. We describe an older man who developed non-medication acquired sticky skin (NoMasts). His acquired cutaneous adherence was considered to be idiopathic. We postulate that aging may be associated with elevated endogenous retinoid levels in older individuals and may have resulted in his sticky skin. Further investigation into these retinoid-induced effects and to what extent they promote acquired cutaneous adherence is still needed.

Variability in Oral Desmopressin Dose Requirements in Children with Central Diabetes Insipidus

There is inconsistency in the amount of oral desmopressin that children with central diabetes insipidus require. We investigated whether clinical characteristics influenced desmopressin dose requirements in 100 children with central diabetes insipidus. Extremely large doses were associated with acquired etiology (P = .04), greater body mass index z score, intact thirst, and additional pituitary hormone deficiencies (P < .001).

Bleeding Disorders in Primary Fibrinolysis

Fibrinolysis is a complex enzymatic process aimed at dissolving blood clots to prevent vascular occlusions. The fibrinolytic system is composed of a number of cofactors that, by regulating fibrin degradation, maintain the hemostatic balance. A dysregulation of fibrinolysis is associated with various pathological processes that result, depending on the type of abnormality, in prothrombotic or hemorrhagic states. This narrative review is focused on the congenital and acquired disorders of primary fibrinolysis in both adults and children characterized by a hyperfibrinolytic state with a bleeding phenotype.

Clinical characteristics and prognostic factors of acquired haemophilia A in Korea

INTRODUCTION

Acquired haemophilia A (AHA) treatment involves the haemostatic treatment for acute haemorrhage and immunosuppressive therapy (IST) to eradicate FVIII inhibitory antibodies.

AIM

We assessed the clinical features of AHA and analysed treatment outcomes in Korea. We further identified prognostic factors affecting treatment outcomes.

METHODS

Medical records of 55 patients with AHA from 18 institutions were reviewed retrospectively. Logistic and Cox regression analyses were performed to elucidate clinical factors affecting the achievement of complete remission (CR). The primary endpoint was time to CR after IST, and secondary endpoints were time to haemostasis, the achievement of CR, and overall survival (OS).

RESULTS

Among the 55 patients, 50 (91%) had bleeding symptoms. Bleeding was severe in 74% of patients. Thirty-six (72%) patients received haemostatic therapy. Of the 42 patients who received IST, 23 (52%) received steroid alone, with a 52% response rate, and 10 (25%) received a combination of steroid and cyclophosphamide, with an 83% response rate. Five (16%) patients relapsed after a median duration of 220 days. There were eight deaths. In the Cox regression analysis, the FVIII inhibitor titre ≥ 20 BU/mL was the only significant prognostic factor affecting time to CR and haemostasis. No significant difference was observed in OS based on the inhibitor titre.

CONCLUSION

The present study demonstrated the demographic data of AHA in Korea and showed that FVIII inhibitory antibody titre was a predictor of time to achieve CR after IST.

Reversal of Iris Heterochromia in Adult-Onset Acquired Horner Syndrome

ABSTRACT

Iris heterochromia is typically seen in association with congenital Horner syndrome. A man in his 40s with congenital iris heterochromia, blue in the right and brown in the left, presented with left-sided Horner syndrome. This was associated with recent change in color of his brown left iris to blue similar to the right iris. This case demonstrates a unique case of adult-onset Horner syndrome with reversal of iris heterochromia.

Acquired Gerbode Defect in a Patient With Infective Endocarditis of Bicuspid Aortic Valve

Aortic valve abscess is a fatal complication of infective endocarditis. Transthoracic echocardiography is the initial imaging obtained in suspected infective endocarditis. However, its accuracy in detecting cardiac complications remains low, thus should be followed by transesophageal echocardiography if the clinical situation permits. Here, we present a case of a bicuspid aortic valve infective endocarditis caused by Streptococcus agalactiae and complicated with aortic valve abscess and acquired Gerbode defect, which appeared as a tricuspid valve vegetation on transthoracic echocardiography.

furfur

Malassezia are emerging fungal pathogens causing opportunistic skin and severe systemic infection. Nosocomial outbreaks are associated with azole resistance and understanding of the underlying mechanisms are limited to knowledge from other fungal species. Herein, we identified distinct antifungal susceptibility patterns in 26 Malassezia furfur isolates derived from healthy and diseased individuals. A Y67F CYP51 mutation was identified in five isolates of M. furfur However, this mutation alone was insufficient to induce reduce azole susceptibility in the wild type strain. RNA-seq and differential gene analysis of healthy and disease derived strains exposed to clotrimazole in vitro identified several key metabolic pathways and transporter proteins which are involved in reduce azole susceptibility. The pleiotropic drug transporter PDR10 was the single most highly upregulated transporter gene in multiple strains of M. furfur after azole treatment and increased expression of PDR10 is associated with reduced azole susceptibility in some systemic disease isolates of M. furfur Deletion of PDR10 in a pathogenic M. furfur strain with reduced susceptibility reduced MIC values to the level of that in susceptible isolates. The current dearth of antifungal technologies, globally emerging multi-azole resistance, and broad agriculture and consumer care use of azoles means improved understanding of the mechanisms underlying intrinsic and acquired azole resistance in Malassezia is crucial for development of antibiotic stewardship and antifungal treatment strategies.

Prevalence of Multidrug-Resistant Tuberculosis in Dalian, China: A Retrospective Study

Purpose

Multidrug-resistant tuberculosis (MDR-TB) is the cause of serious health and economic burdens worldwide. The present study aimed to explore the initial and acquired drug-resistance rates among TB patients from 2012 to 2019 in Dalian, China. The effectiveness of MDR-TB prevention and control strategies were then evaluated.

Patients and Methods

Drug susceptibility testing (DST) was performed for 6429 diagnosed, culture-positive, Mycobacterium tuberculosis (MTB) strains, including 4661 new cases and 1768 previously treated cases. Descriptive statistics were employed to calculate the frequencies and percentages of TB strains, and the average annual growth rates (AAGRs) for each strain were calculated. The Chi-square test was applied to examine the significance of linear drug-resistance trends over time during the study period.

Results

Over the eight-year study period, the percentages of both initial (from 9.01% to 4.82%) and acquired (from 40.85% to 9.09%) MDR-TB cases decreased significantly, AAGRs of 8.55% and 19.32%, respectively. Among new and previously treated TB patients, significant downtrends were observed for the rates of both initial and acquired MDR-TB among young and middle-aged individuals (P < 0.05). Additionally, among both new and previously treated TB patients, the percentages of individuals with drug resistance against isoniazid (INH), rifampicin (RFP), ofloxacin (OFX), and amikacin (AMK) decreased significantly (P < 0.05) from 2012 to 2019 in Dalian, China.

Conclusion

The initial and acquired multidrug resistance rates exhibited significantly decreasing trends from 2012 to 2019, suggesting that MDR-TB prevalence has been controlled effectively in Dalian, China. The MDR-TB epidemic was reversed in the short term by establishing feasible strategies for detection, diagnosis, treatment, and infection control.

'De Novo' Brain AVMs-Hypotheses for Development and a Systematic Review of Reported Cases

Background and Objectives: Brain arteriovenous malformations AVMs have been consistently regarded as congenital malformations of the cerebral vasculature. However, recent case reports describing "de novo AVMs" have sparked a growing debate on the nature of these lesions. Materials and Methods: We have performed a systematic review of the literature concerning de novo AVMs utilizing the PubMed and Google Academic databases. Termes used in the search were "AVM," "arteriovenous," "de novo," and "acquired," in all possible combinations. Results: 53 articles including a total of 58 patients harboring allegedly acquired AVMs were identified by researching the literature. Of these, 32 were male (55.17%), and 25 were female (43.10%). Mean age at de novo AVM diagnosis was 27.833 years (standard deviation (SD) of 21.215 years and a 95% confidence interval (CI) of 22.3 to 33.3). Most de novo AVMs were managed via microsurgical resection (20 out of 58, 34.48%), followed by radiosurgery and conservative treatment for 11 patients (18.97%) each, endovascular embolization combined with resection for five patients (8.62%), and embolization alone for three (5.17%), the remaining eight cases (13.79%) having an unspecified therapy. Conclusions: Increasing evidence suggests that some of the AVMs discovered develop some time after birth. We are still a long way from finally elucidating their true nature, though there is reason to believe that they can also appear after birth. Thus, we reason that the de novo AVMs are the result of a 'second hit' of a variable type, such as a previous intracranial hemorrhage or vascular pathology. The congenital or acquired characteristic of AVMs may have a tremendous impact on prognosis, risk of hemorrhage, and short and long-term management.

Acquired haemophilia A in the postpartum and risk of relapse in subsequent pregnancies: A systematic literature review

BACKGROUND

About 1%-5% of acquired haemophilia A cases affect mothers in the postpartum setting.

AIMS

This study delineates the characteristics of this disease, specific to the postpartum setting, notably relapse in subsequent pregnancies.

METHODS

Report of two cases and literature study (1946-2019), yielding 73 articles describing 174 cases (total 176 cases).

RESULTS

Patients were aged 29.9 years (17-41) and 69% primigravidae. Diagnosis was made at a median of 60 days after delivery (range 0-308). Bleeding types were obstetrical (43.4%), cutaneous (41.3%), and muscular (36.7%). In >90% of the cases, FVIII at diagnosis was <1% (range 0%-8%). FVIII inhibitor was documented in 75.4% cases (median titre of 20 BU/ml, range 1-621). Haemostatic treatment was necessary in 57.1% using fresh frozen plasma (16%), factor concentrate (27.6%) and/or bypassing agents (37.4%). Immunosuppressive treatment was administered in 90.8%, mostly steroids (85.3%), alone or combined with immunosuppressants (27%). Rituximab was used mostly as a second line treatment. Only 24 patients (13.6%) had documented subsequent pregnancies and 6 (22.2%) suffered haemophilia recurrence during pregnancy.

CONCLUSION

This study allows better definition of: (1) clinical and laboratory characteristics of postpartum acquired haemophilia, (2) response to therapy, and (3) the risk of relapse for subsequent pregnancies.

Adult Acquired Buried Penis: A Hidden Problem in Obese Men

Buried penis is a condition where the penis is hidden by abdominal or suprapubic skin or fat. In adult men, buried penis occurs as an acquired condition most commonly caused by morbid obesity. The clinical characteristics of three obese men with adult acquired buried penis are described and the associated features of the buried penis are reviewed. In addition to morbid obesity, a buried penis can result from other etiologies, such as hidradenitis suppurativa, iatrogenic causes such as elective surgeries, infections, lichen sclerosus, penoscrotal lymphedema, and traumatic events. Lower urinary tract symptoms, such as voiding, and post-voiding problems are the most common presenting complaints; however, bacterial and fungal infections, phimosis, psychological issues, and sexual dysfunction, are also buried penis-related symptoms. The evaluation of a man with adult acquired buried penis begins with a detailed history for condition-related symptoms. Examination of the patient, both standing and supine with an attempt to demonstrate the penis using digital compression of the surrounding skin and fat, should be performed to determine the extent of the problem and whether comorbid conditions-such as infection and lichen sclerosus-are present. Both buried penis and lichen sclerosus can predispose to the development of penile squamous cell carcinoma; the diagnosis of this tumor can be delayed in men with adult acquired buried penis since an adequate penile examination is difficult or impossible. A multidisciplinary approach-including surgeons, primary care physician, registered dietitian nutritionist, and psychiatrist-should be considered for a patient with a buried penis. The surgical management is individualized and based on not only the extent of the problem but also whether an associated condition, such as urethral stricture, is present. Most patients are pleased with the functional and aesthetic outcome following surgery.

An Unusual Case of Pediatric Bilateral Congenital Optic Disc Pits With Unilateral High Myopia

Optic disc pits are rare congenital abnormalities. They are unilateral in 85% of the affected individuals. Optic disc pits occurring in the highly myopic eyes of the older adults are supposed to be acquired due to mechanical expansion of the disc from the axial elongation. High myopia is also a well described association of the optic disc pits of the congenital nature.  We present a rare case of bilateral congenital optic disc pits in a 15-year-old girl having anisometropic unilateral axial myopia and the emmetropia in the fellow eye. This unique combination of the findings of unilateral high myopia in a child with bilateral congenital optic disc pits, to the best of our knowledge has not been described in the literature earlier. Our case demonstrates a scenario where two different causative factors for the optic disc pits may be present concurrently in the same instance.

Late-onset myopathies: clinical features and diagnosis

Late-onset myopathies are not well-defined since there is no clear definition of 'late onset'. For practical reasons we decided to use the age of 40 years as a cut-off. There are diseases which only manifest as late onset myopathy (inclusion body myositis, oculopharyngeal muscular dystrophy and axial myopathy). In addition, there are diseases with a wide range of onset including 'late onset' muscle weakness. Well-known and rather frequently occurring examples are Becker muscular dystrophy, limb girdle muscular dystrophy, facioscapulohumeral dystrophy, Pompe disease, myotonic dystrophy type 2, and anoctamin-5-related distal myopathy. The above-mentioned diseases will be discussed in detail including clinical presentation - which can sometimes lead someone astray - and diagnostic tools based on real cases taken from the author's practice. Where appropriate a differential diagnosis is provided. Next generation sequencing (NGS) may speed up the diagnostic process in hereditary myopathies, but still there are diseases, e.g. with expansion repeats, deletions, etc, in which NGS is as yet not very helpful.

Relationship between atherogenic indices and acquired premature ejaculation

The aim of this study is to evaluate blood lipid parameters and level of atherogenic indices in acquired premature ejaculation (PE) patients. Between 2020 January and June 2020, 96 patients diagnosed with PE in our clinic and 84 control patients who applied to the urology outpatient clinic for other urological reasons were included in the study. Detailed medical and sexual histories of the patients were taken, and physical examination findings were recorded. In addition, 5-question premature ejaculation diagnostic tool (PEDT) was applied to patients and estimated intravaginal ejaculation latency times (IELT) were recorded. The mean values of lipid parameters; Risk Index of Castelli-1 (CRI-1 (Total cholesterol/ HDL)), CRI-2 (LDL/ HDL), Atherogenic Index of Plasma (AIP (log10 (triglyceride/ HDL)) and Atherogenic Coefficient (AC (HDL/ non-HDL)) were calculated. The average PEDT score was 7.68 + 5.05 (2-22), and the IELT arithmetic mean was 150.39 + 121.53 (5-900) seconds. In the APE group, triglyceride and AIP values were found to be higher than the control group (triglyceride: 188.75 + 76.39 versus 157.20 + 87.45; p = .049; AIP: 0.46 + 0.33 versus 0.35 + 0.35; p = .040). A fair positive correlation was found between PEDT scores and AIP values (r = .355, p < .001). AIP was found to be related to APE, and it was also found to be related to symptom severity.

Lipodystrophies-Disorders of the Fatty Tissue

Lipodystrophies are a heterogeneous group of physiological changes characterized by a selective loss of fatty tissue. Here, no fat cells are present, either through lack of differentiation, loss of function or premature apoptosis. As a consequence, lipids can only be stored ectopically in non-adipocytes with the major health consequences as fatty liver and insulin resistance. This is a crucial difference to being slim where the fat cells are present and store lipids if needed. A simple clinical classification of lipodystrophies is based on congenital vs. acquired and generalized vs. partial disturbance of fat distribution. Complications in patients with lipodystrophy depend on the clinical manifestations. For example, in diabetes mellitus microangiopathic complications such as nephropathy, retinopathy and neuropathy may develop. In addition, due to ectopic lipid accumulation in the liver, fatty liver hepatitis may also develop, possibly with cirrhosis. The consequences of extreme hypertriglyceridemia are typically acute pancreatitis or eruptive xanthomas. The combination of severe hyperglycemia with dyslipidemia and signs of insulin resistance can lead to premature atherosclerosis with its associated complications of coronary heart disease, peripheral vascular disease and cerebrovascular changes. Overall, lipodystrophy is rare with an estimated incidence for congenital (<1/1.000.000) and acquired (1-9/100.000) forms. Due to the rarity of the syndrome and the phenotypic range of metabolic complications, only studies with limited patient numbers can be considered. Experimental animal models are therefore useful to understand the molecular mechanisms in lipodystrophy and to identify possible therapeutic approaches.

Cross-reacting recombinant porcine FVIII inhibitors in patients with acquired haemophilia A

INTRODUCTION

Acquired haemophilia A (AHA) is a rare bleeding disorder caused by the development of autoantibodies to endogenous human factor VIII (hFVIII). If treatment of bleeding is required, one option is recombinant porcine FVIII (rpFVIII). Cross-reactivity between factor VIII inhibitors and rpFVIII has previously been described.

AIM

The aim of this study was to retrospectively assess the incidence of cross-reacting anti-porcine inhibitors in patients diagnosed with AHA in two UK centres.

METHODS

The plasma of fifty-one patients diagnosed with AHA via reduced FVIII:C and positive FVIII inhibitor titre as detected with a Nijmegen-Bethesda assay (NBA) was also tested by a porcine Bethesda assay (PBA). The NBA was modified by replacement of human FVIII with rpFVIII in the PBA, with determination of residual FVIII by one-stage clotting assay.

RESULTS

The median FVIII inhibitor titre by NBA was 22.8 BU/mL (range: 0.8-1000 BU/mL). 37% of samples exhibited linear, type 1 kinetics in the NBA. Negative PBA was observed in 26 patients, and 25 were positive (median PBA: 3.5 BU/mL; range: 0.8-120 BU/mL). Type 1 kinetics were observed in 40% of PBA-positive patients. At NBA tires of greater than 100 BU/mL, the positive predictive value for the presence of porcine cross-reactivity was 100%. At NBA below 5 BU/mL, the negative predictive value for the presence of porcine cross-reactivity was 71%.

CONCLUSION

Cross-reactivity between FVIII inhibitors and rpFVIII was observed in 49% of patients. The presence of inhibitors to rpFVIII may influence the treatment choice for patients with acquired haemophilia A.

Airway Abnormalities in Patients With Congenital Heart Disease: Incidence and Associated Factors

OBJECTIVES

Airway abnormalities complicate the perioperative course of patients with congenital heart disease (CHD), leading to significant morbidity and mortality. The literature describing airway abnormalities in those patients is scarce. This study aimed to determine the incidence of airway abnormalities in CHD patients and identify associated factors, genetic syndromes, and cardiac diagnoses.

DESIGN

Retrospective study conducted after institutional review board approval.

SETTING

Tertiary children's hospital.

PARTICIPANTS

Patients presenting for cardiac diagnostic, interventional, or surgical procedures from 2012 to 2018. A total of 9,495 encounters were reviewed.

EXCLUSION CRITERIA

age >18 years. Methods/Interventions: Age, weight, sex, intubation technique, number of intubation attempts, and difficult intubation (DI) were recorded. Using the International Classification of Diseases, Ninth and Tenth Revisions codes, genetic syndromes, acquired and congenital airway abnormalities, and cardiac diagnoses were identified. Multivariate generalized estimating equations modeling was used to identify independent predictors of airway abnormalities.

RESULTS

A total of 4,797 patients, with 8,657 encounters were included. The median age was 1.3 years (interquartile range [IQR]: 0.2-6.0) and weight was 9.2 kg (IQR: 4.3-19.2), and 55% were male. A total of 16.7% had at least 1 genetic syndrome; 8.5% had congenital airway abnormalities and 9.7% acquired. Incidence of DI was 1.1%. The most common syndromes were Down, 22q11.2 microdeletion, and CHARGE. The most frequent congenital airway abnormalities were laryngomalacia and bronchomalacia, and the most frequent acquired were partial and total vocal cord paralysis.

CONCLUSION

The likelihood of a coexistent airway abnormality should be considered in premature CHD patients, weight <10 kg, and in those with specific cardiac lesions and a concomitant genetic syndrome. Preoperative identification of patients at high risk of airway abnormalities is useful in planning their perioperative airway management.

A Rare Case of Acquired Transthoracic Littre's Hernia

Introduction  The Littre hernia is a rare complication of Meckel's diverticulum. Meckel's diverticulum is vestigial remnant of the omphalomesenteric duct occurring in approximately 2% of the general population with an estimated 4 to 16% risk of complications. Usual sites of the Littre hernia include inguinal (50%), umbilical (20%), and femoral (20%). We report a case of an acquired transthoracic Littre's hernia occurring through the left part of the diaphragm triggered by a history of traumatic rib fractures associated with alcohol abuse. Case Report  A 71-year-old man presented with 4-day history of worsening shortness of breath, colicky lower abdominal pain, and inability to open bowels despite passing flatus, without nausea or vomiting. His past medical history was remarkable for multiple traumatic rib fractures caused by falls which were associated with excessive alcohol consumption. A noncontrast computed tomography (CT) scan of the abdomen and pelvis showed distended jejunal loops containing air/fluid levels likely resulting from herniated jejunum between the left chest wall and left diaphragm. An urgent laparotomy was performed which revealed small bowel and omentum herniating through a small defect in the left posterior hemidiaphragm. The contents of the sac were reduced and a Meckel's diverticulum was found inside the sac, characteristic of Littre's hernia. The diaphragmatic defect was closed and the Meckel diverticulum stapled and excised. Discussion  Herniation of Meckel's diverticulum through the diaphragm most commonly occurs in the pediatric population. Acquired transthoracic Littre's hernia is rare and may arise following thoracobdominal trauma caused by surgery, motor vehicle accidents, and falls from height. Left-diaphragmatic tears are characteristically more clinically apparent and symptomatic than the right since the liver often has a protective effect on the right part of the diaphragm. Herniation of abdominal contents in the chest cavity causes respiratory distress and requires urgent surgical correction. Diagnosis is often delayed since diaphragmatic hernia tends to present very late after the initial trauma, subjecting the patient to possible life-threatening complications. While it is easier to reduce the herniated contents and repair the diaphragm via a thoracic approach, laparotomy is often preferred in cases of acute trauma associated with intra-abdominal injuries. Repair of Littre's hernia then consists of resection of the diverticulum and herniorraphy. Conclusion  Internal Littre's hernia is usually of congenital origin. This is the first case of a transthoracic Littre's hernia caused by traumatic rib fractures. Hence, it is of utter importance that a clinician is aware of such uncommon pathology.

Is Autism Inborn And Lifelong For Everyone?

Autism or autism spectrum disorder (ASD) is described as a lifelong condition with core behavioural symptoms appearing during infancy or early childhood. Genetic and other effects occurring during the earliest times of life are thought to play a significant contributory role to the presentation of autism, denoting that autism is typically seen as an innate or inborn condition. Such descriptions have, and continue to, define autism research and clinical practice. Inspection of the existing research literature, however, suggests that within the vast heterogeneity of autism, not everyone experiences autism in such a prescribed way. Various reports have observed the presentation of "acquired autism" following a period of typical development. Other findings have documented an abatement of clinically relevant autistic features and related comorbid pathology for some. Such reports offer important insights into the heterogeneity and complexity of autism.

Acquired erythropoietic protoporphyria: A systematic review of the literature

BACKGROUND

Erythropoietic protoporphyria (EPP) is a semi-dominantly inherited porphyria presenting with photosensitivity during early childhood. Acquired EPP has been reported; however, data regarding this rare disorder are scarce.

PURPOSE

To evaluate the characteristics of acquired EPP.

METHODS

A comprehensive search of PubMed, Google Scholar, ScienceDirect, and clinicaltrials.gov databases was performed by three reviewers. Studies describing patients with acquired EPP were included. Additionally, we present an index case of a 26-year-old patient who acquired clinically and biochemically typical EPP in association with myelodysplastic syndrome (MDS).

RESULTS

We included 20 case reports describing 20 patients. Most (80%) patients were male of mean age 58 ± 13 years. In all patients, acquired EPP was associated with hematological disease, most commonly MDS (85%) followed by myeloproliferative disease (10%). In 86% of cases, hematological disease led to abnormality or somatic mutation in chromosome 18q (the locus of the ferrochelatase gene). The mean erythrocyte protoporphyrin IX concentration was very high (4286 μg/dL). Most (90%) patients presented with photosensitivity, 20% experienced blistering, and 25% presented with hepatic insufficiency, both uncommon in EPP. In 55% of patients, hematological disease was diagnosed after occurrence of cutaneous symptoms. Beta-carotene led to partial control of symptoms in 5 patients and resolution in another patient. Azacitidine treatment of MDS led to resolution of cutaneous symptoms in three patients.

CONCLUSION

We present the distinct features of acquired EPP and highlight that any patient presenting with new-onset photosensitivity, irrespective of age should be evaluated for porphyria.