Cross-modal similar clinical case retrieval using a modular model based on contrastive learning and k-nearest neighbor search.

OBJECTIVE: Electronic health record systems have made it possible for clinicians to use previously encountered similar cases to support clinical decision-making. However, most studies for similar case retrieval were based on single-modal data. The existing studies on cross-modal clinical case retrieval were limited. We aimed to develop a CRoss-Modal Retrieval (CRMR) model to retrieve similar clinical cases recorded in different data modalities. MATERIALS AND METHODS: The publically available Medical Information Mart for Intensive Care-Chest X-ray (MIMIC-CXR) dataset was used for model development and testing. The CRMR model was designed as a modular model containing two feature extraction models, two feature transformation models, one feature transformation optimization model, and one case retrieval model. The ability to retrieve similar clinical cases recorded in different data modalities was facilitated by the use of contrastive deep learning and k-nearest neighbor search. RESULTS: The average retrieval precision, denoted as AP@k, of the developed CRMR model, were 76.9 %@5, 76.7 %@10, 76.5 %@20, 76.3 %@50, and 77.9 %@100, respectively. Here k is the number of similar cases returned after retrieval. The average retrieval time varied from 0.013 ms to 0.016 ms with k varying from 5 to 100. Moreover, the model can retrieve similar cases with the same multiple radiographic manifestations as the query case. DISCUSSION: The CRMR model has shown promising cross-modal retrieval performance in clinical case analysis, with the potential for future scalability and improvement in handling diverse disease types and data modalities. The CRMR model has promising potential to aid clinicians in making optimal and explainable clinical decisions.

Conservative Management of a Forearm Refracture With the Titanium Elastic Nailing System (TENS) In Situ in a 14-Year-Old Male: A Case Report.

This case report presents a 14-year-old male patient with a medical history of left nephrectomy for cystic nephroma and resolved hypertension, who sustained a right both-bone middle shaft forearm fracture while playing football. The injury was managed initially with manipulation under anesthesia, the insertion of the Titanium Elastic Nailing System (TENS), and the application of an above-elbow cast. Clinical and radiographic reviews confirmed fracture healing after seven weeks, allowing for cast removal and advising the patient to avoid contact sports. However, 10 weeks post-initial treatment, the patient experienced a refracture following another traumatic incident. The refracture was treated conservatively with a combination of above-elbow and below-elbow casts over six weeks. Regular follow-ups every two weeks indicated satisfactory progress, leading to the removal of the TENS approximately four and a half months post-refracture. Subsequent clinical and radiographic evaluations showed complete fracture healing, with the patient regaining a full range of motion and intact neurovascular status at the final follow-up. This case highlights the potential for successful conservative management of pediatric forearm refractures with intramedullary nails in situ.

Cutaneous Manifestations of Langerhans Cell Histiocytosis in Pediatric Age: A Case Report.

Langerhans cell histiocytosis (LCH) is a rare histiocytic neoplastic disorder that mainly affects the skin and bones, with dermatological manifestations that can be easily confused with other dermatological conditions, such as seborrheic eczema, psoriasis, lesions of herpes simplex virus infection, fungal infection, lichen planus, and cutaneous lymphomas. This case report describes an eight-month-old infant who, at a child health appointment, presented with progressive erythematous papulovesicular lesions, initially treated with hygiene measures (skin hydration and hygiene) and mupirocin ointment, but which persisted and worsened, leading to a skin biopsy. The diagnosis of self-limiting congenital histiocytosis was confirmed, and the child was referred to the Portuguese Oncology Institute. The case highlights the importance of early recognition of LCH, the multidisciplinary approach, and the crucial role of the family doctor in the diagnosis and appropriate management of this rare condition.

Multisystem Inflammatory Syndrome in Children: A Case Report.

This case report delves into the case of a patient in the Dominican Republic with multisystem inflammatory syndrome in children (MIS-C). MIS-C is a rare, hyper-inflammatory condition that develops in children as a delayed response to a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, typically appearing with general markers of inflammation such as erythema and, in severe cases, cardiorespiratory symptoms. The three-year-old patient discussed in this report presented with signs of inflammation, such as erythema, rashes, and chapped skin, and reported experiencing diarrhea, vomiting, and fever for multiple days. Notably, a concurrent parasitic presence was found in the patient's fecal sample, and antibiotics were heavily used throughout the course of treatment. We explain the merits and drawbacks behind using antibiotic therapy for MIS-C and suggest steps that clinicians and researchers can take in order to minimize the potential misuse of antibiotics. Specifically, we identify that prioritizing tests for concurrent infections or illnesses is imperative in treating MIS-C patients, and we conclude by stating that using blood cultures and coprological examinations in tandem is an effective strategy for this purpose.

Fluorodeoxyglucose Positron Emission Tomography Evaluation of Chronic Recurrent Multifocal Osteomyelitis.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease that predominantly affects children and adolescents. Currently, CRMO diagnoses are based on a combination of clinical, radiological, pathological, and longitudinal findings. However, distinguishing CRMO from malignant bone tumors using imaging is occasionally challenging. Fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging characteristics in CRMO (specifically, the maximum standardized uptake value (SUVmax)) have been described previously. The lesions exhibited increased FDG uptake despite the benign nature of the disease; the SUVmax was notably high (4.90). These findings suggest that FDG/PET plays a limited role in the differential diagnosis of CRMO.

Calcium Hydroxyapatite as a Co-adjuvant Treatment Option in a Patient With Morphea: A Report of a Case With a One-Year Follow-Up.

Morphea, or localized scleroderma, is a chronic inflammatory condition that unequivocally affects the dermis and subcutaneous connective tissue. It undeniably causes significant disfigurement in approximately half of patients, profoundly impacting their self-esteem. The available treatment options include corticosteroids (taken orally or administered subcutaneously), phototherapy, CO2 fractional laser treatment, and biologically mediated medications. It is crucial to note that using fillers as adjuvant therapy for inflammatory diseases indisputably raises concerns due to the potential to trigger inflammation and lead to disease reactivation. In one case, a 24-year-old patient with morphea on her face underwent a combined approach involving plastic surgery, dermatology, and regenerative aesthetics treatment with lipo-filling initially by an expert plastic surgeon. Then, after reviewing the literature and consensus from the dermatologist, aesthetics physician, and alternative medicine expert, it was decided to use calcium hydroxylapatite-carboxymethylcellulose (Radiesse, Merz Pharmaceuticals GmbH, Frankfurt, Germany) in the affected area. After a year of follow-up, there was a significant improvement in the appearance of her face and skin, as confirmed by a 10-point improvement on an activity measuring scale. Additional research will solidify whether calcium hydroxylapatite (CaHA) is the optimal injectable for treating dermal autoimmune diseases. Our initial approach demonstrates significant promise for regenerative biostimulation. Through collaboration, we have effectively integrated plastic surgery techniques, fillers, dermatologists, and alternative medicine perspectives to treat inflammatory diseases, providing a comprehensive and robust exploration of morphea treatment.

Regional nerve blocks for peripheral neuropathy: a rare clinical case report.

Peripheral neuropathy is a common complication in patients with diabetes. However, the appropriateness of administering nerve block anesthesia to these patients remains uncertain. Key concerns include the potential for prolonged block duration, an increased risk of local anesthetic toxicity, and the possibility of further damaging already compromised peripheral nerves. We herein report a case involving a patient with diabetic peripheral neuropathy who underwent finger amputation under ultrasound-guided nerve block anesthesia and subsequently lost pain and temperature sensation in both hands 1 month later. For critically ill patients undergoing surgery, regional anesthesia, such as a nerve block, may be a more suitable option than general anesthesia. When performing nerve block procedures in patients with diabetes, using ultrasound guidance is recommended to ensure precise targeting and reduce the risk of complications. However, it remains unclear whether nerve block anesthesia exacerbates peripheral neuropathy.

Clinical Reasoning Skills Among Second-Phase Medical Students in West Bengal, India: An Exploratory Study.

Introduction Proper application of clinical reasoning skills is essential to reduce diagnostic and management errors. Explicit inclusion of training and assessment of clinical reasoning skills is the demand of time. The study intended to measure the clinical reasoning skills of second-phase undergraduate students in a medical college in West Bengal, India, and its distribution across several individual variables. Methods The clinical reasoning skills of 105 undergraduate medical students were assessed in a cross-sectional exploratory study using key feature questions (KFQs) with the partial credit scoring system. Six case vignettes aligned to the core competencies in the subject of pharmacology, pathology, and microbiology were designed and validated by the subject material experts for this purpose. The responses of the participants were collected through Google Forms (Google, Mountain View, CA) after obtaining written informed consent. The scores obtained in all KFQs were added and expressed in percentage of the maximum attainable score. Results The mean (±SD) clinical reasoning score of the participants was 42.5 (±12.6). Only 29.6% of respondents scored ≥ 50. Students with higher subjective economic status (p-value = 0.01) and perceived autonomy (p-value < 0.001) were more likely to have higher clinical reasoning scores. The marks obtained in previous summative examinations were significantly correlated with clinical reasoning scores. Conclusion Average score < 50.0 and inability to score ≥ 50.0 by more than two-thirds of the participants reflected the deficit in the clinical reasoning skills of second-phase MBBS students. The association of clinical reasoning skills with economic status, autonomy, and previous academic performances needs further exploration.

Hemoptysis as the Initial Presentation of a Ruptured Aortic Aneurysm: A Case Report and Literature Review.

Hemoptysis has a broad differential diagnosis, with common causes including bronchiectasis, bronchitis, pulmonary tuberculosis, and lung neoplasms. While often benign, it can sometimes indicate more severe, life-threatening conditions. Herein we report the case of an 86-year-old woman who presented to the emergency department with a 30-day history of hemoptysis ultimately leading to hemodynamic instability. She was initially admitted to the emergency department for resuscitation and diagnostic workup. During the hospitalization, we identified a large, ruptured aneurysm of the descending and diaphragmatic aorta contained by a hematoma communicating the tracheobronchial tree. This case highlights the importance of considering a broad differential diagnosis in patients presenting with hemoptysis as it can signal severe underlying conditions such as a ruptured aortic aneurysm. Early recognition and appropriate management of these cases are crucial to improving patient outcomes.

Association between hallucinations and sensory processing difficulties in children and adolescents.

Introduction: Hallucinations are serious symptoms that can lead to high levels of distress, functional impairment, and increased risk of suicide in both adults and children. However, their etiology and treatment remain unclear. Hallucinations and sensory processing difficulties (SPDs) are associated with various psychiatric disorders, including mood, anxiety, and post-traumatic stress disorder. This study aimed to investigate the potential association between hallucinations and SPDs in a pediatric population. Methods: We conducted a cross-sectional study with 335 children aged 6-18 years who visited the child psychiatry outpatient clinic at Osaka Metropolitan University Hospital between April 2020 and March 2023 and continued treatment for at least three months. After excluding those with intellectual disabilities or uncontrolled epilepsy, 304 participants were included in the analyses. The presence of hallucinations was assessed through interviews with the children and their parents. SPDs were evaluated using the Short Sensory Profile. Binomial logistic regression analysis was conducted to assess the association between hallucinations and SPDs, adjusting for age, sex, autism spectrum disorder, socioeconomic difficulties (low-income, single-parent households), and the presence of mood and anxiety disorders. Results: Hallucinations were present in 64 children (21%). Logistic regression analysis showed a significant positive association between SPDs and hallucinations, even after adjusting for age, sex, autism spectrum disorder, socioeconomic difficulties, and the presence of mood and anxiety disorders (odds ratio, 1.02; 95% CI, 1.008-1.036; p = 0.002). Conclusion: The results of this study suggest a potential association between hallucinations and SPDs in pediatric patients. Further prospective studies are needed to explore the causal relationship between these factors and determine whether interventions for SPDs can alleviate hallucinations in children.

Osler-Weber-Rendu Syndrome as a Rare Cause of Liver Cirrhosis.

It is essential to comprehend the clinical manifestations of hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. This autosomal dominant vascular disorder presents with distinct symptoms, including mucocutaneous telangiectasia, epistaxis, gastrointestinal bleeding, and iron deficiency anemia. Furthermore, arteriovenous malformations (AVMs) commonly occur in the pulmonary, hepatic, and cerebral circulations. Hepatic involvement may be uncommon, depending on the subtype of HHT. HHT is a rare cause of liver cirrhosis. We present the case of a 59-year-old female patient referred to a hepatology consultation for the etiological study of liver disease that progressed to liver cirrhosis. From the study carried out, the presence of hepatic arteriovenous shunt was detected, which raised the suspicion of HHT, with the genetic study confirming the diagnosis. In this case, we intend to demonstrate the diagnostic difficulty of this entity, which led to a long time between the initial manifestation and the diagnostic conclusion. We would also like to highlight the importance of imaging and genetic studies in determining the etiology of the disease.

Acute Laceration in the Transverse Mesocolon After a Colonoscopy: A Case Report.

Colonoscopy is a widely used examination for colonic diseases with low risk. Hemoperitoneum due to injury of transverse mesocolon is an extremely rare but potentially lethal complication. We present a case of an elderly woman who complained of continuous abdominal pain after a colonoscopy, with progressive anemia. An emergency exploratory laparoscopy revealed a laceration of the transverse mesocolon. The underlying mechanism is unclear due to its rarity. Old age, atherosclerotic disease, the long operating time of colonoscopy, and manual compression on the abdomen during the procedure may be risk factors for transverse mesenteric laceration during colonoscopy.

Spontaneous Air Embolism Following Contrast Injection: A Diagnostic Challenge in a Post-COVID-19 Patient.

A 72-year-old male with a complex medical history, including chronic obstructive pulmonary disease (COPD), hypertension, atrial fibrillation, and a recent COVID-19 infection, presented to the emergency department with shortness of breath and chest pain. Physical examination revealed stable vital signs but notable bilateral decreased air entry and diffuse wheezing. A computed tomography angiogram (CTA) of the chest confirmed a small to moderate volume of air embolism within the main pulmonary artery and right ventricle, with no evidence of pulmonary embolism. The air embolism was suspected to have been introduced during a contrast injection for the CT scan, as no other iatrogenic factors, recent invasive procedures, or history of lung trauma were present. Initial management included repositioning the patient to a supine position and administering 100% oxygen, which was critical in stabilizing his condition. Despite the ongoing symptoms of shortness of breath, the patient's condition improved with supportive care focused on managing COPD exacerbation. Spontaneous air embolism without decompression sickness or prior instrumentation is exceptionally rare, particularly in a post-COVID-19 patient, making this case notable. It highlights the critical need for prompt recognition, thorough evaluation, and appropriate management of air embolism in complex medical scenarios to prevent life-threatening complications. This case also underscores the importance of considering iatrogenic causes, such as contrast injection, in the differential diagnosis, especially following recent imaging studies.

Breaking the taboo of using the nursing process: lived experiences of nursing students and faculty members.

BACKGROUND: Despite the numerous advantages of the nursing process, nursing students often struggle with utilizing this model. Therefore, studies suggest innovative teaching methods to address this issue. Teaching based on real clinical cases is considered a collaborative learning method that enhances students' active learning for the development of critical thinking and problem-solving skills. In this method, students can acquire sufficient knowledge about patient care by accessing authentic information. OBJECTIVE: The aim of the present study was to investigate the experiences of nursing students and faculty members regarding the implementation of nursing process educational workshops, based on real case studies. DESIGN: A qualitative descriptive study. PARTICIPANTS: 9 Nursing students and 7 faculty members from the Isfahan School of Nursing and Midwifery who attended the workshops. METHODS: This qualitative descriptive study was conducted from 2021 to 2023. Data was collected through semi-structured individual and focus group interviews using a qualitative content analysis approach for data analysis. RESULTS: After analyzing the data, a theme titled "Breaking Taboos in the Nursing Process" was identified. This theme consists of four categories: "Strengthening the Cognitive Infrastructure for Accepting the Nursing Process," "Enhancing the Applicability of the Nursing Process," "Assisting in Positive Professional Identity," and "Facilitating a Self-Directed Learning Platform." Additionally, thirteen subcategories were obtained. CONCLUSION: The data obtained from the present study showed that conducting nursing process educational workshops, where real clinical cases are discussed, analyzed, and criticized, increases critical thinking, learning motivation, and understanding of the necessity and importance of implementing the nursing process. Therefore, it is recommended that instructors utilize this innovative and effective teaching method for instructing the nursing process.

Multimodality Radiologic and Pathologic Findings in Large B-cell Lymphoma With Hepatic Presentation in an Unusually Young Male.

Diffuse large B-cell lymphoma (DLBCL) is the most prevalent type of non-Hodgkin lymphoma (NHL), and typically presents in patients who are at least 60 years old with gastrointestinal (GI) tract involvement. We report a case of a young patient with DLBCL. A 27-year-old African American male presented to the emergency room with complaints of abdominal distention. Imaging showed hepatosplenomegaly with multiple nodular lesions in both the liver and spleen. The biopsy confirmed a diagnosis of DLBCL. This case report highlights a rare clinical presentation of DLBCL due to the uncommon hepatic initial presentation of the disease paired with the patient's age and race varying significantly from the demographic norm. Clinicians should maintain a high index of suspicion for DLBCL in patients with atypical extranodal involvement, such as in this patient, to optimize patient outcomes.

Takotsubo Cardiomyopathy in the Absence of an Identifiable Emotional Stressor.

This is a case presentation of a 61-year-old female with a history of long-term asymptomatic left bundle branch block and recurrent nephrolithiasis who presented to the emergency department with chest pain that radiated to the left shoulder and jaw, nausea, vomiting, and generalized weakness. On admission, the electrocardiogram showed prolonged QRS complex, significant T-wave inversions in leads V2-V4, and left bundle branch block. Troponin I serum levels were found to be markedly elevated. The echocardiogram demonstrated left ventricular hypokinesis. The patient was admitted for treatment of non-ST-elevation myocardial infarction and was placed on a heparin drip with daily aspirin and high-intensity statin. Cardiac catheterization showed angiographically normal coronary arteries with no signs of obstruction or stenosis. Upon questioning, the patient did not endorse any recent emotionally or physically triggering incidents. Despite the lack of an identifiable emotional stressor, the patient met the diagnostic criteria for takotsubo cardiomyopathy (TTC) and was subsequently placed on evidence-based medical therapy. While most individuals with TTC will fully recover their cardiac function with proper treatment, a subset of patients may continue to have symptoms of persistent heart failure following their initial diagnosis. The pathophysiology of TTC is still not well understood. While the leading theory describes a catecholamine surge secondary to an emotionally or physically triggering event causing myocardial injury and subsequent temporary cardiac dysfunction, further research must be done to understand the underlying pathophysiology of this condition fully.

Effectiveness and safety of tildrakizumab in individuals with HIV and psoriasis: A case series.

Psoriasis, a chronic inflammatory skin disease, presents unique challenges when co-occurring with HIV. Tildrakizumab, an IL-23p19 inhibitor, has demonstrated efficacy in treating moderate-to-severe psoriasis. This retrospective case series reports three individuals living with HIV and psoriasis treated with tildrakizumab. Clinical outcomes, including Psoriasis Area and Severity Index (PASI) and HIV viral load, were recorded over a year. All three patients achieved significant clinical improvements with tildrakizumab, with PASI scores improving by over 95%. No adverse effects were reported, and HIV viral loads remained undetectable. Tildrakizumab appears to be a safe and effective treatment option for psoriasis in individuals living with HIV, providing significant benefits without compromising HIV control.

Certolizumab-Induced Liver Injury in Ankylosing Spondylitis: A Case Report and Causality Assessment.

Certolizumab-induced liver injury is exceptionally rare, with only a few cases reported in the literature. We present the case of a 34-year-old man with axial ankylosing spondylitis (AS) who developed a drug-induced liver injury following treatment with certolizumab. Despite the initial ineffectiveness of non-steroidal anti-inflammatory drugs and an inadequate response to infliximab, the patient achieved remission of AS symptoms with certolizumab. However, he subsequently developed elevated liver enzymes indicative of hepatocellular injury. Investigations excluded viral hepatitis and autoimmune liver diseases, pointing to certolizumab as the likely cause. The updated Roussel Uclaf Causality Assessment Method confirmed a probable causal relationship between certolizumab and hepatotoxicity. Discontinuation of certolizumab led to normalization of liver enzymes without recurrence of liver injury. This case highlights the need for vigilant monitoring for hepatotoxicity in patients receiving tumor necrosis factor inhibitors.

An Unlikely Case of Blastomycosis in an Elderly Female: A Diagnostic Challenge in a Non-endemic Region.

Blastomyces dermatitidis is a fungus typically found in the soil of endemic regions such as the Midwest, concentrating in areas like Ohio, Mississippi, and the Great Lakes area. The systemic infection caused by inhaling Blastomyces dermatitidis is known as blastomycosis. The frequency of blastomycosis in non-endemic regions is increasing for a variety of speculated reasons, such as higher rates of immunosuppressed individuals and possible climate. Due to clinician unfamiliarity, misdiagnosis of blastomycosis is common, which potentiates worsening systemic infections. This study shows the clinical course of a patient with blastomycosis in a non-endemic region, highlighting the need for education for clinicians in non-endemic areas. A 72-year-old female with a history of chronic obstructive pulmonary disease (COPD), coronary artery disease, a 47-year smoking history, and hypertension presented for outpatient management of COPD. CT three months prior to presentation showed nodular opacities in the lungs. A bronchoscopy was performed and revealed negative findings for malignancy or infection; the patient developed worsening symptoms leading to hospitalization. Subsequent testing revealed Blastomyces dermatitidis. She was promptly treated with a six to 12-month course of itraconazole with close follow-up. The study highlights the need not to rule out causes of infection based on location. Blastomycosis can resemble community-acquired pneumonia. Making the correct diagnosis is paramount, as delays can result in morbidity. Fungal cultures may be the gold standard, but due to the long culture time, there need to be other diagnostic tests like urine antigen testing. This study highlights the need to increase awareness of clinicians who experience blastomycosis patients in a non-endemic region.

Challenges in Diagnosing Varicella-Zoster Virus Encephalitis in an Immunocompromised Patient.

Varicella-zoster virus (VZV) is a virus of the alphaherpesvirus family that is one of the common causes of infectious encephalitis worldwide, especially among those who are immunocompromised. In this case report, we discuss a case of a 55-year-old female with end-stage renal disease presenting with altered mental status and weakness. She was recently diagnosed with herpes zoster on oral acyclovir and multiple scattered dermatomal rashes on presentation. Cerebral spinal fluid analysis showed neutrophilic pleocytosis, high glucose and protein, and anti-VZV Immunoglobulin G (IgG) antibodies. She was started on treatment early with acyclovir and demonstrated good clinical improvement afterward two weeks. This case highlights to importance of performing lumbar puncture and looking for anti-VZV antibodies to rule out encephalitis in patients with altered mental status and starting acyclovir treatment early.