Medicine

Ouyang, Lecong; Zhang, Weidong; Wang, Zeqiang

doi: 10.1097/md.0000000000043003pmid: 40550040

Rationale: Giant emphysematous bullae (GEB) in chronic obstructive pulmonary disease cause severe respiratory compromise. While surgical resection is standard, bronchoscopic volume reduction is crucial for surgically ineligible patients. Accurate target bronchus identification remains challenging with conventional imaging. Patient concerns: A 67-year-old male with chronic obstructive pulmonary disease and right lung GEB presented with severe dyspnea (modified Medical Research Council score 4), hypercapnia (partial pressure of carbon dioxide: 45 mm Hg), and markedly limited exercise tolerance (6-minute walk distance: 62 m). He required home noninvasive ventilation and was deemed unfit for surgery due to critically impaired lung function (Forced expiratory volume in 1 second: 0.36 L, 12.2% predicted). Diagnoses: Preoperative high-resolution computed tomography (CT) and 3D reconstruction localized the target bronchus to the right middle lobe. However, percutaneous aspiration and drug injection via drainage tube revealed misalignment, prompting reidentification of the target bronchus in the posterior segment of the right upper lobe. Interventions: CT-guided percutaneous GEB volume reduction was performed, involving air extraction and intrabullous injection of erythromycin lactobionate. Subsequent selective bronchial occlusion of the posterior right upper lobe segment via bronchoscopic autologous blood and thrombin injection was conducted. Continuous negative-pressure drainage was maintained post-procedure. Outcomes: Follow-up CT at 6 months confirmed complete GEB closure. Dyspnea improved significantly (modified Medical Research Council score 3), exercise capacity increased (6-minute walk distance: 220 m), and ventilator use was discontinued. No complications or recurrence were observed during follow-up. Lessons: Percutaneous aspiration and drug injection refine target bronchus identification when imaging yields ambiguous results, enhancing precision for subsequent bronchoscopic interventions. This strategy minimizes reliance on endobronchial valves, reducing costs and procedural complexity. Larger studies are needed to validate long-term efficacy, but this approach offers a promising minimally invasive alternative for high-risk patients.

Ke, Caiping; Li, Manjie; Zhang, Chunning; Huang, Qiwen; Deng, Yongquan; Cheng, Junfen

doi: 10.1097/md.0000000000042724pmid: 40550073

Rationale: Advanced squamous cell carcinoma (SCC) of the lung remains a major clinical challenge due to limited therapeutic options, particularly in the post-immunotherapy setting. Combining immune checkpoint inhibitors with small-molecule multi-targeted tyrosine kinase inhibitors that include anti-angiogenic effects offers a promising approach to overcome treatment resistance and improve survival outcomes. Patient concerns: A 44-year-old female with a 2-year history of recurrent cough and sputum production presented with worsening symptoms over the past month, including increased cough frequency and sputum volume. No significant systemic symptoms, such as hemoptysis or dyspnea, were reported. Diagnoses: Chest computed tomography revealed a 35 mm × 31 mm mass in the right middle lung with enlarged supraclavicular and mediastinal lymph nodes. A biopsy confirmed the diagnosis of SCC. Staging was determined as cT3N3M1a (stage IVA), and genetic testing revealed no actionable driver mutations, while PD-L1 expression was 30% (tumor proportion score). Interventions: The patient initially received first-line treatment with pembrolizumab combined with docetaxel and nedaplatin, achieving partial response. After progression, second-line therapy included gemcitabine and cisplatin chemotherapy with synchronous radiotherapy, followed by camrelizumab and anlotinib. Regular imaging follow-ups guided therapy adjustments, including extended dosing intervals for camrelizumab during disease stabilization. Outcomes: Over 4 years of treatment, the patient achieved durable partial response, with significant reduction in tumor burden and no new metastases. As of the most recent follow-up, the patient exhibited an overall survival of 59 months and progression-free survival of 51 months for second-line therapy, with manageable adverse effects including secondary hypothyroidism and grade 2 hypertension. Lessons: This case underscores the potential efficacy of combining immune checkpoint inhibitors with small-molecule multi-targeted tyrosine kinase inhibitors in treating advanced SCC of the lung after progression on first-line therapy. The complementary mechanisms of immune modulation and tumor microenvironment normalization may offer an effective strategy for addressing immune resistance in SCC.

Jang, Yewon; Kim, Sungho; Chang, Min Cheol

doi: 10.1097/md.0000000000041876pmid: 40550024

Rationale: Because the diagnosis of complex regional pain syndrome (CRPS) majorly relies on patients’ subjective clinical complaints, CRPS can be overdiagnosed, underdiagnosed, or missed entirely in clinical practice. CRPS is related to dysfunction of the autonomic nervous system, which causes temperature changes in patients’ skin. This case report evaluates the effectiveness of the FLIR T560 portable thermal imaging camera in detecting hypothermia associated with CRPS type I, potentially enhancing diagnostic accuracy. Patient concerns: We present a 25-year-old female with pain and limited passive range of motion in all parts of her hands bilaterally for 7 months. The bilateral hand pain was aggravated by active and passive range of motion. Also, the patient had bilateral hyperesthesia and allodynia of her entire hands, and skin atrophy and hypohidrosis were observed on both hands. The skin color of both hands was relatively cyanotic. Stiffness was checked during the passive range of motion of her bilateral fingers. Additionally, mild motor weakness was checked on the finger flexor and extensor bilaterally. Diagnoses: The patient was diagnosed with CRPS type I. The FLIR T560 was used to record thermal images in an insulated room, revealing a lower surface temperature (approximately 1°C–2°C difference), shown as less bright, on her bilateral hands and forearms compared with a normal subject. Interventions: We administered Pregabalin 50 mg oral medication twice daily and the contrast bath. Outcomes: At 1-month-follow up, about 50% of her pain was reduced. Lessons: We demonstrate that the FLIR T560 thermal imaging camera can show hypothermia on the hands bilaterally in CRPS type I, which can be helpful for the accurate diagnosis of CRPS. The FLIR T560 camera is a portable and convenient tool that may support the diagnosis of CRPS.

Alrasheed, Marwan A.; Alamer, Khalid A.; Ghonem, Leen; Alsuhibani, Abdulrahman A.; Tawfik, Yahya M.; Alsultan, Mohammed M.; Aldhaeefi, Mohammed; Alshahrani, Hussam M.; Shaheen, Adnan A.; Almangour, Thamer A.

doi: 10.1097/md.0000000000042952pmid: 40550036

Therapeutic drug monitoring (TDM) is key to optimizing vancomycin therapy, as accurate sampling timing ensures valid drug levels and supports safe, effective clinical decisions. This study aimed to assess the timing accuracy of blood draws for vancomycin TDM, evaluate its clinical implications, and identify predictors of timing errors. A cross-sectional study was conducted at King Saud University Medical City, involving 103 patients from October 2023 to December 2023. The primary outcome was adherence to the blood sampling timing guidelines. Secondary outcomes included clinical cure rates, acute kidney injury incidence, and in-hospital mortality. Of the analyzed samples, 80.6% were improperly timed. Clinical cure rates were significantly higher among patients with correctly timed samples (75%) compared to those with incorrectly timed samples (57.83%). Timely sampling improved cure rates for pulmonary and skin infections (85.71%), while improper timing reduced them to 72.22% and 62.5%, respectively. Improper timing was linked to higher in-hospital mortality (30.12%) and acute kidney injury (15.66%). Multivariate analysis revealed that bacteremia significantly reduced the likelihood of clinical cure (odds ratio = 0.387, 95% confidence interval [0.160, 0.933], P = .035), while 3 times daily dosing significantly increased the odds of correctly timed samples (odds ratio = 5.1, 95% confidence interval [1.125, 23.11], P = .035). This study highlights the critical role of accurate timing in vancomycin TDM for achieving favorable patient outcomes and reducing adverse events. Strengthened institutional protocols and targeted training programs are essential to improve adherence to sampling guidelines and enhance patient safety.

Aydemir, Mustafa; Çakir, Mustafa; Oral, Okan; Yilmaz, Mesut

doi: 10.1097/md.0000000000042910pmid: 40550094

Background: Cushing syndrome (CS) is a rare endocrine disorder characterized by excessive secretion of glucocorticoids, leading to a variety of clinical manifestations, comorbidities, and increased mortality despite treatment. Despite advances in imaging modalities and biochemical testing, the diagnosis and management of CS remains challenging. Several tests are used to confirm the diagnosis of CS, including urinary free cortisol measurements, dexamethasone suppression tests (1 mg, 2 mg, and 8 mg), and nocturnal salivary cortisol measurements. However, each of these tests has some limitations, making the diagnosis of CS. Methods: In this paper, we explore the potential of state-of-the-art machine learning algorithms as a clinical decision support system for analyzing and classifying CS. Our aim is to use advanced machine learning methods to analyze the accuracy rates of diagnostic tests and identify the most sensitive tests for diagnosing CS. Results: In this study, we performed binary classification based on data from 278 patients with CS (CS+) and 220 healthy patients (CS-). We developed a linear mathematical model with high predictive ability, achieving a classification accuracy of 97.03% and a Kappa value of 94.05%. The correlation graph shows that CS has strong positive relationships with 2 mg (78.8%), 1 mg (76.9%), and mc (72.1%), and moderate positive correlations with 8 mg (45%) and saliva (45.4%). In contrast, gender has almost no correlation with CS, so it was removed from the dataset. As a result, the model achieves an overall classification accuracy of 97.03%. Finally, we converted the linear model into a mobile application for use by specialist doctors in the field of endocrinology. Conclusion: Traditional diagnostic methods can be time-consuming and require specialized medical expertise. Recently, advances in machine learning and mobile technology have opened new avenues for improving diagnostic accuracy and accessibility. This study explores the integration of machine learning algorithms into a mobile application designed to assist healthcare professionals and patients in the diagnosis of CS.

Tulaci, Kamil Gokce; Tulaci, Tugba

doi: 10.1097/md.0000000000042057pmid: 40550022

This study investigates the effect of the middle turbinate-septal suturing technique on postoperative synechiae formation and surgical success in endoscopic endonasal dacryocystorhinostomy. A total of 98 patients aged between 18 and 65 years who underwent endoscopic endonasal dacryocystorhinostomy and silicone tube intubation for nasolacrimal duct obstruction were included. The nonsuture group consisted of patients in whom the middle turbinate-septal suture procedure was not performed, and the suture group consisted of patients in whom the middle turbinate-septal suture procedure was performed. The rates of postoperative synechiae, granulation tissue formation, anatomical success, and functional success were compared between groups. The nonsuture group consisted of 45 patients and the suture group consisted of 53 patients. The comparison of postoperative synechiae and granulation tissue formation revealed that both synechiae and granulation tissue formation were significantly lower in suture group compared with nonsuture group (P = .046 and.04, respectively). In addition, both anatomical and functional success rates were significantly higher in the suture group than in the nonsuture group (P = .019 and .025, respectively). The results suggest that suturing the middle turbinate to the nasal septum at the conclusion of surgery diminishes the incidence of postoperative synechiae and positively affects surgical outcomes.

Ekpendu, Abuoma Cherry; Asghar, Muhammad Sohaib; May, Gregory; Jewell, Thomas; Patel, Pankajkumar

doi: 10.1097/md.0000000000042837pmid: 40550025

Rationale: Esophageal cancer accounts for about 1% of all cancer diagnoses in the United States. Patient concerns: An 82-year-old male presented to a dermatology clinic with a chief complaint of a skin lesion on the right lower lip. He denied any prior gastrointestinal symptoms or history. Diagnoses: A shave biopsy of the lip lesion revealed adenocarcinoma. Subsequent positron emission tomography–computed tomography demonstrated findings concerning for esophageal malignancy with metastatic disease. Interventions: Esophagogastroduodenoscopy identified a lesion in the distal esophagus, and biopsy confirmed invasive, moderately to poorly differentiated esophageal adenocarcinoma. Outcomes: The patient was referred to oncology, where he was diagnosed with stage IV metastatic esophageal adenocarcinoma. He was initiated on chemotherapy, which he tolerated well. Lessons: This case highlights the rare presentation of stage IV esophageal adenocarcinoma as a solitary lip lesion without typical gastrointestinal symptoms. Given the rarity of lip involvement, clinicians should maintain a high index of suspicion for systemic malignancy in atypical skin lesions. Early biopsy and diagnosis are crucial for timely intervention and improved outcomes. The purpose of the study is to highlight the importance of maintaining a high index of suspicion for gastrointestinal malignancy, even in the absence of traditional gastrointestinal symptoms, when evaluating unusual skin lesions.

Ning, Tao; Mei, Siwei; Ma, Mingming; Ruan, Xiaojun; Lan, Shi; Fu, Yongbin

doi: 10.1097/md.0000000000042906pmid: 40550049

Morel-Lavallée lesions (MLLs) are uncommon closed soft tissue injuries often arising from blunt trauma, characterized by a separation between the subcutaneous tissue and the underlying fascia, leading to fluid accumulation. This case report aims to enhance the understanding of ultrasonographic features associated with MLLs, supported by data from a patient with a confirmed MLL verified through surgical intervention or magnetic resonance imaging (MRI). A 45-year-old male presented with a history of lower leg trauma, sustained approximately 18 days prior to the initial ultrasonographic assessment. Comparative analysis was performed using a dataset of ultrasound imaging records from 37 patients with MLLs, confirmed through surgical or MRI evaluation between April 2019 and October 2023. Parameters examined included injury etiology, interval from trauma to ultrasound assessment, lesion location and dimensions, echotexture, presence or absence of a capsule, and color Doppler flow imaging (CDFI) findings for blood flow in and around the lesion. In this case, the patient exhibited a traumatic injury to the calf, a frequent site for MLLs, accounting for 18 of the 37 cases. The average lesion area was 15.9 cm², with the lesion appearing hypoechoic on ultrasound. Further assessment indicated heterogeneous echotexture within the lesion, presenting scattered and linear hyperechoic regions. A well-defined boundary encapsulated the lesion, consistent with findings in 34 of the 37 cases. CDFI showed an absence of internal blood flow within the lesion and minimal blood flow in the perilesional tissue, a pattern observed in 2 cases in the broader dataset. In conclusion, this report elucidates the typical ultrasonographic characteristics of MLLs, marked by hypoechoic presentation with a well-defined boundary and absence of internal or perilesional blood flow signals on CDFI. These findings contribute valuable insights into the sonographic diagnosis of MLLs, reinforcing ultrasound’s role as a primary imaging modality for evaluating complex soft tissue injuries.

Kim, Myung-Rho; Dugal, Jasmine; Wang, Shawn; Taylor, Spencer; Goel, Vidhani; Shafi, Amaan; Singh, Aditi; Batra, Kavita

doi: 10.1097/md.0000000000042885pmid: 40550079

Antithrombotic therapy following left atrial appendage occlusion (LAAO) is recommended to prevent device-induced thrombosis and stroke. Guidelines suggest oral anticoagulants and aspirin for the first 45 days and then dual antiplatelet therapy for 6 months. However, regimens for antithrombotic therapy varies widely. This study aimed to assess the characteristics of patients receiving minimal versus standard antithrombotic therapy post-LAAO, and to examine the association between treatment type and thrombotic/bleeding risk scores. We conducted a retrospective observational study of patients who underwent LAAO at a teaching hospital between April and December 2023. Patients were categorized into minimal (DOAC only) or standard (DOAC plus aspirin) therapy groups during the first 45 days, and into minimal (SAPT) or standard (DAPT) groups from 45 days to 6 months. Outcomes included CHA2DS2-VASc and HAS-BLED scores, comorbidities, and bleeding/thrombotic events. Statistical analyses included univariate and bivariate comparisons using Chi-square, Fisher exact test, and t-tests. Among 33 patients, 82% received minimal therapy and 18% for the standard therapy in the first 45 days. Standard therapy patients had higher rates of transient ischemic attack (50% vs 7.5%), stroke (100% vs 37%), coronary artery disease (100% vs 44.4%), and NSAID use (33.3% vs 3.7%, P < .05). The CHA2DS2-VASc scores were significantly higher in the standard group (6.5 ± 0.5 vs 4.6 ± 1.4, P = .002), with no difference in HAS-BLED scores. From 45 days to 6 months, 15.2% received minimal and 84.8% for the standard therapy, with no significant differences in scores. Patients with lower CHA2DS2-VASc scores were more likely to receive minimal therapy, indicating potential for risk-guided antithrombotic management post-LAAO. Further studies are needed to validate individualized treatment strategies.

Zhou, Hui; Luo, Yilin; Li, Shiguang; Zhang, Guoping; Zeng, Xianchun

doi: 10.1097/md.0000000000042862pmid: 40550035

Background: This study aims to explore research hotspots and development trends in molecular imaging of glioma from 2014 to 2024. Methods: A total of 2957 publications indexed in the web of science core collection (WoSCC) were analyzed using bibliometric techniques. To visualize the research landscape, co-citation clustering, keyword analysis, and technological trend mapping were performed using CiteSpace and Excel. Results: Publication output peaked in 2021. Emerging research trends included the integration of radiomics and artificial intelligence and the application of novel imaging modalities such as positron emission tomography and magnetic resonance spectroscopy. Significant progress was observed in blood–brain barrier disruption techniques and the development of molecular probes, especially those targeting IDH and MGMT mutations. Conclusion: Molecular imaging has been pivotal in advancing glioma research, contributing to improved diagnostic accuracy and personalized treatment strategies. However, challenges such as clinical translation and standardization remain. Future studies should focus on integrating advanced technologies into routine clinical practice to enhance patient care.