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Introduction Increased levels of homocysteine (Hcy) may lead to endothelial damage and increase the risk of cardiovascular and renal malfunction. The current study aimed to evaluate the association of serum Hcy levels with gender, body mass index (BMI), duration of diabetes mellitus type 2 (DMT2), hemoglobin A1c (HbA1c), and blood pressure (BP). Methodology A prospective observational study was conducted at Hayatabad Medical Complex in Peshawar, Pakistan in the department of endocrinology from June 2020 to June 2021. All patients with diagnosed DMT2 above the age of 18 years were included in the study. Individuals with unconfirmed diagnoses with ages over 75 years were excluded from the study. All data including the patient's age, gender, and medical history were recorded. Height and weight were used to calculate the BMI. BP was examined thrice and a mean value was recorded for each patient. For laboratory investigation, a vial of 3 ml blood was extracted keeping sterile and aseptic conditions by a trained nurse. The sample was sent for the determination of HbA1c and serum Hcy levels. Measurement of serum Hcy was done by chemiluminescent microparticle immunoassay. All data were documented by the researchers on a predefined pro forma. Results A total of 188 patients with DMT2 were included in the study with a mean age ± SD of 54.65 ± 8.42 years. Normal (7%), BP, and duration of DMT2. However, the study failed to find an association between serum Hcy and BMI. It is recommended that patients with poor glycemic control or those with the duration of DMT2 of more than five years must be regularly checked for hyperhomocysteinemia and renal function tests. Large-scale and multi-center studies are required in order to determine the validity of these findings. The current study suggests that patients with diabetes mellitus and hypertension are likely to have increased levels of Hcy and, therefore, must be regularly screened for hyperhomocysteinemia.A four-year-old girl presented with a three-day history of squint and irritability. Examination showed reduced visual acuity in both eyes, the presence of a false localizing sign, and bilateral optic disc swelling. On investigation, her blood laboratory workup was within the normal range. Imaging of the brain showed no evidence of a space-occupying lesion or cerebral venous sinus thrombosis. The lumbar puncture opening pressure was 27cmH20 and the cerebrospinal fluid workup was normal. The diagnosis of idiopathic intracranial hypertension (IIH) was made based on the diagnostic criteria for pseudotumor cerebri syndrome. She was successfully treated with acetazolamide with resolved symptoms and signs. This highlights the possibility of IIH presenting with inconspicuous symptoms in preschool children, which needs a high index suspicion by clinicians. Hence, solving the challenges in the workup, especially in children, is very crucial.Objective The need for clinicians to access Infectious Diseases (ID) consultants for clinical decision-making support increased during the Coronavirus Disease 2019 (COVID-19) pandemic. Traditional ID consultations with face-to-face (FTF) patient assessments are not always possible or practical during a pandemic and involve added exposure risk and personal protective equipment (PPE) use. Electronic consultations (e-consults) may provide an alternative and improve access to ID specialists during the pandemic. Methods We implemented ID e-consult platforms designed to answer clinical questions related to COVID-19 at three academic clinical institutions in Dallas, Texas. We conducted a retrospective review of all COVID-19 ID e-consults between March 16, 2020 and May 15, 2020 evaluating characteristics and outcomes of e-consults among the clinical sites. Results We completed 198 COVID-19 ID e-consults at participating institutions. The most common e-consult indications were for 63 (32%) repeat testing, 61 (31%) initial testing, 65 (33%) treatment options, and 61 (31%) Infection Prevention (IP). Based on the e-consult recommendation, 53 (27%) of patients were initially tested for COVID-19, 45 (23%) were re-tested, 44 (22%) of patients had PPE precautions initiated, and 37 (19%) had PPE precautions removed. The median time to consult completion was four hours and 8 (4%) consults were converted to standard FTF consults. Conclusion E-consult services can provide safe and timely access to ID specialists during the COVID-19 pandemic, minimizing the risk of infection to the patient and health care workers, while preserving PPE and testing supplies.Erythema multiforme is a self-limited condition that is characterized by the rapid onset of symmetric targetoid lesions. This hypersensitivity reaction is commonly triggered by herpes simplex virus and Mycoplasma pneumoniae infections. Pembrolizumab is an anti-programmed cell death protein 1 (PD-1) inhibitor that is associated with drug-induced erythema multiforme. Radiotherapy is a rarely reported trigger of erythema multiforme. We report a case of recurrent pembrolizumab and radiotherapy-induced erythema multiforme in a patient with stage IV non-small cell lung cancer. This study aimed to highlight a unique cause of erythema multiforme and to review the common radiation-induced cutaneous reactions.During the COVID-19 pandemic, stroke remains a leading cause of death and disability. Since the approach towards patients, treatments, and follow-up regimens has changed, tele-rehabilitation became a pillar for patients with ongoing recovery processes and rehabilitation strategies, especially for post-stroke patients. We describe the case of a 50-year-old male, suffering from right spastic hemiplegia and patellar clonus, for whom rehabilitation services were delivered both in-person (conventional physical therapy and radial extracorporeal shock wave therapy) as well as with the aid of a tele-rehabilitation program. Assessments were conducted remotely via a self-adapted treadmill and stabilometric equipment, both connected to the Internet. At discharge and at 20 weeks follow-up, the patient showed decreased spasticity grade, improvement in sensorimotor function, balance, functional mobility, clonus score, ambulation distance, and decreased pain intensity. The case highlights the utility of tele-rehabilitation strategies in complementing and enhancing the effects of conventional physical therapy and radial extracorporeal shock wave therapy (rESWT) in post-stroke spasticity.Granular cell tumors are rare benign soft-tissue lesions that most commonly occur in the head and neck. They usually present in adulthood and are rarely seen in children. Here we present a 13-year-old girl who experienced symptoms of hoarseness of voice for most of her childhood and was unsuccessfully treated for asthma, acid reflux, allergies, and bronchitis before direct visualization revealed what was initially thought to be a vocal cord cyst. Surgical excision and pathology revealed the unexpected diagnosis of a vocal cord granular cell tumor. The patient has had resolution of dysphonia and is undergoing voice therapy.A 96-year-old female with severe dementia complained of subacute onset of right arm swelling after sleep using her right arm as a pillow. Computed tomography and ultrasonography could not detect any significant findings. Nevertheless, her unilateral edema was similar to that of a venous disorder; therefore, we performed angiography of the brachial vein with the right arm in a normal position and in an abduction position; significant stenosis was seen in the latter position. We diagnosed her with venous thoracic outlet syndrome. This case was unique from the typical cases of venous thoracic outlet syndrome because of the subacute onset of symptoms, high age at onset, and discrepancies between ultrasonography and angiography findings. Dementia is the key factor explaining these features. The diagnosis of thoracic outlet syndrome is generally difficult. Although provocative physical examination maneuvers and ultrasonography are essential, dynamic testing with provocative maneuvers allows physicians to detect venous compression, even if it is difficult to capture with static imaging tests. Once the diagnosis and its etiology were confirmed, corresponding intervention, including physical therapy, is warranted.Introduction To date, the proper choice of graft for anterior cruciate ligament (ACL) reconstruction remains a matter of conflict. We aimed to compare the clinical and functional outcomes of the two most commonly utilized autografts, bone-patella tendon-bone (BPTB) and four-strand hamstring tendon (HT) graft, at 6 and 12 months after surgery. Methods In a prospective randomized study, we included a total of 60 patients undergoing ACL reconstruction, thirty in BPTB and thirty in HT group. All patients were amateur athletes and were evaluated at 6 and12 months after surgery for (a)postoperativefunctionality of the operated knee by the Tegner, the Lysholm and the International Knee Documentation Committee (IKDC) scoring scales, (b) anterior cruciate ligament (ACL) instability of the operated knee compared to the healthy contralateral knee by the KT-1000 arthrometer and (c) theextension and flexion muscle strength of the operated knee by a CYBEXisokinetic dynamometer. Results Patients in the two groups did not di). Conclusion Both BPTB and HT grafts present with benefits and drawbacks and remain viable autograft options for primary ACL reconstruction as each has, although HT grafts seem to be more susceptible to re-rupture. https://www.selleckchem.com/mTOR.html The graft selection should be based on the needs and activities of each patient.While colonic leiomyomas are common, leiomyosarcomas of the GI tract are rare. Increased mitotic rate, as well as lymph node involvement, portend a worse prognosis in leiomyosarcomas. They can arise anywhere along the GI tract, but anal canal occurrence is extremely rare. We present the case of a 75-year-old male diagnosed eight years prior with leiomyoma of the anorectal junction. There was a recurrence after endoscopic resection. He was referred to colorectal surgery due to symptoms of bleeding, skin irritation, anal pruritus, and rectal pain. On exam, he had a palpable mass at the dentate line. Workup revealed a 3.5 cm mass at the anorectal junction with pathology showing a leiomyosarcoma with moderate atypia and a high mitotic rate. MRI revealed invasion into the prostate. Robotic pelvic exenteration, including cystoprostatectomy, abdominoperineal resection, and ileal conduit, was performed. Final pathology results showed a grade 2 leiomyosarcoma invading the prostate and skeletal muscle and incidentally found Gleason 3+4 prostate cancer, pT2. A very small percentage of anorectal leiomyosarcoma cases were located in the anal canal. Surgery remains the best curative option, as chemotherapy and radiation data are limited. This rare tumor, which previously has not been documented to have degenerated from a benign rectal leiomyoma, was diagnosed as a result of close monitoring after previous local resections and cured by local resection and radiation.Background This study aimed to understand the attitudes, beliefs, and concerns of physicians across India regarding the economic burden of diabetes and subsequently the cost-effectiveness of low-cost dapagliflozin for the management of patients with uncontrolled type 2 diabetes mellitus (T2DM) on background metformin therapy in Indian clinical settings. Method A cross-sectional questionnaire survey was conducted among physicians treating people with T2DM with or without complications. The questions covered the general aspects of affordability and adherence to diabetes medications as well as specific details of low-cost dapagliflozin and its cost-effectiveness. Results In total, 844 physicians provided a response to the survey questionnaire. The physicians who participated in the study included diabetologists, endocrinologists, cardiologists, consulting physicians, and family physicians. A majority of the physicians (53%) opined that only 10%-30% of their patients can afford the cost of newer antidiabetic medicines, while 25% of the physicians mentioned that less then 10% of their patients had issues related to affordability.
