Notes

Multimodal sex-related variants toddler and in infant-directed maternal dna habits in the course of a few months 3 by means of 14 involving development.
He responded to a course of steroids and direct oral anticoagulation and is in complete remission for the past 18 months. Conclusion It is always imperative to investigate the cause of anaemia and consider hemolysis in a patient presenting with multiple unexplained thromboses.
Vitamin B12 (VitB12) deficiency rarely manifests with visual symptoms. Optic nerve damage in VitB12 deficiency is thought to be via degeneration. However, optic neuritis, though infrequent, has been reported secondary to VitB12 deficiency.

We conducted a systematic review of all the reported cases of VitB12 deficiency with optic nerve involvement in Pubmed, Cochrane, and Google Scholar any date up to September 6, 2020. We have discussed the findings and compiled the available information on ophthalmological manifestations of VitB12 deficiency. We aim to provide a unified knowledge about the evidence related to types of optic neuropathies reported to date secondary to VitB12 deficiency. We also present a case of bilateral optic neuritis secondary to VitB12 deficiency.

We present a 29-year-old previously healthy male with progressive, painful, bilateral, but asymmetric visual deterioration for forty-five days. A detailed history, examination, and laboratory workup were carried out. He was diagnosed as having optic neuritis secondary to VitB12 deficiency. He showed partial improvement with the replacement of VitB12.

We suggest promptly identifying and replacing VitB12 in patients with optic neuritis with proven VitB12 deficiency to prevent permanent damage to the optic nerve. Patients with VitB12 deficiency should have a baseline fundoscopic exam to rule out subclinical optic nerve damage. Moreover, patients who present with visual disturbances should be screened for VitB12 deficiency, especially the vegan population.
We suggest promptly identifying and replacing VitB12 in patients with optic neuritis with proven VitB12 deficiency to prevent permanent damage to the optic nerve. Patients with VitB12 deficiency should have a baseline fundoscopic exam to rule out subclinical optic nerve damage. Moreover, patients who present with visual disturbances should be screened for VitB12 deficiency, especially the vegan population.•These two cases highlight the limitations in current grading systems, particularly in the context of gallbladder size.•We propose modifications to the PGS to include not only abnormal anatomy but instances of distorted gallbladder anatomy due to inflammation and/or the large to giant size in order to account for the increased risk of complications.•Both distorted gallbladder anatomy and giant gallbladder size can make laparoscopic cholecystectomy a challenge, and thus warrant contribution to overall clinical grade.•While the PGS, Tokyo Guidelines, and AAST grading scales are validated grading scales for acute cholecystitis, additional modifications can further characterize different types of acute cholecystitis to better guide patient management.
Stroke data from Sierra Leone is limited, despite the increase in global burden of the disease. The aim of this study was to assess the risk factors, clinical outcomes and predictors of stroke mortality at a tertiary hospital in Freetown, Sierra Leone.

This retrospective cohort study was conducted on stroke patients admitted at the Connaught Teaching Hospital between 1st January to December 31, 2018. Clinical data related to stroke, with variables including patients' demographics, stroke subtype, vascular risk factors, modified Rankin Scale (mRS), and outcomes were documented. In-hospital mortality, associated risk factors and predictors of stroke were determined. The study was approved by the Sierra Leone Ethics and Scientific Review Committee. It was registered under Research Registry https//www.researchregistry.com/browse-the-registry#home/with the unique identifying number researchregistry6009.

We studied 178 (95 male and 83 female) patients. The mean age was 59.8±14.0 years, median was 58.1years (rhighlights a high stroke mortality in a resource limited hospital, with some stroke patients having difficulties in accessing Computer Tomogram (CT) scan services. It illustrates the need to establish a stroke care setting to improve the quality of stroke care.
The clinical impacts of bilateralism on prognosis and clinical decision-making remain contradictory particularly in areas with low incidence and delayed diagnosis of primary breast cancer. Identification of women at risk of bilateral breast cancer is required to improve patient management and to design the appropriate surveillance.

A total of 1083 women were enrolled and analyzed for the presence of synchronous and metachronous bilateral breast cancer as cases and unilateral breast cancer as controls during the median follow-up of 4.8 years.

The incidence of bilateral breast cancer was 7.5% (81 of 1083). In comparison with unilateral breast cancers, bilateral cases were significantly diagnosed in younger women (
=0.037, mean age was 35.6 years) who had a larger tumor size (
=0.012, mean tumor size was 8cm in diameter). Histological type of lobular cancer was identified as one of the risk factors for the development of contralateral breast cancer (OR 5.564, 95% CI 3.219-9.620) and synchronous bilateral breast cancer (OR 2.561, 95% CI 1.182-5.550). Bilateral breast cancer had significantly shorter progression-free survival (Mean survival was 26.6 vs 52.5 months for bilateral and unilateral breast cancers, respectively;
=0.001) and shorter time to develop distant metastasis (Mean survival was 41.7 vs 104 months for bilateral and unilateral breast cancers, respectively;
=0.001).

Patients with first primary breast tumors with lobular histological type and advanced stages were observed to have higher risks for the development of contralateral breast cancers.
Patients with first primary breast tumors with lobular histological type and advanced stages were observed to have higher risks for the development of contralateral breast cancers.
Rheumatoid arthritis (RA) is a common rheumatological disease which can involve a variety of different renal manifestations. This may be explained by disease effect itself or by medications used for treatment that may lead to renal dysfunction and its complications.We aimed to identify the prevalence and factors that played a role in renal dysfunction among RA Jordanian patients.

285 patients with RA visiting outpatient clinic between March 2016 and March 2017 were included in a retrospective study design. Age, gender, comorbidities, duration of the disease, medications and laboratory results were gathered and scoring of RA activity was done.

Data gathered from the 285 patients showed a female predominance with 88.4% female and 11.6% male. The average disease duration was 6.7 years. Age, DM, HTN, and serum CRP were associated with worse renal function on univariate analysis. 44 patients (18.8%) presented with microscopic hematuria, 16 (6.9%) with proteinuria and only 5 (2.1%) patients presented with both microscopic hematuria and proteinuria. Patients with eGFR <60ml/min had longer disease duration with a mean of 11 years (±7.7) in comparison to 6.4 years (±6.1) for those with eGFR>90ml/min (P=0.001).

Renal dysfunction is not common in RA Jordanian population and has variable presentations. Age and the duration of illness play a major role in the progression of CKD if present. Future prospective studies evaluating renal biopsies in RA patients are needed.
Renal dysfunction is not common in RA Jordanian population and has variable presentations. Age and the duration of illness play a major role in the progression of CKD if present. Future prospective studies evaluating renal biopsies in RA patients are needed.
Numerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically.

This prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique.

Most patient were middle aged females having multiple gallstones, the mean operation time was 35min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty.There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, idder and the presence of bile or pus outside the gall bladder.Strangulation or amputation of the penis is the preserve of psychotic patients in the majority of cases. This situation can be the cause of major complications both urinary and sexual. The management is multidisciplinary between urologist and psychiatrist. We report two observations of strangulation and amputation in schizophrenic patients.
Sclerosing angiomatoid vascular transformation (SANT) is a rare vascular disease of the spleen, which is difficult to diagnose due to its pre-intervention appearance of malignancy. Case Report An 85-year-old male was transferred to our clinic for thrombocytopenia and splenic mass. A contrast enhanced abdominal CT and MRI showed nodular lesions, the largest 50mm in diameter, and several areas of heterogeneous contrast field involvement in the spleen parenchyma. Laparoscopic splenectomy was performed with normal range of platelet level. The patient's postoperative course was uneventful and he was discharged on the 6th postoperative day. Histopathology revealed SANT. The patient is now in the 18 th month of remission with platelet levels within normal range and with no recurrence.

Between 2004 and April 2020, a total of 230 SANT patients who underwent laparoscopic or open splenectomy or biopsy were reported in the literature. Most patients were female (52.1%), and the median age was 46 years (9 weeks-85 years). Most patients were asymptomatic (56%). Open splenectomy was performed on 166 patients (72.1%),laparoscopic splenectomy on 35 patients (15.2%) and laparoscopic partial splenectomy on 15 patients (6.5%). The median operation time and spleen weight were 143 minutes (88-213) and 260gr (68-2,720), respectively. Median follow-up time was 12 months (0-166). No recurrence was seen in patients undergoing total splenectomy.

SANT is an unusual disease of the spleen. In the light of this systematic review, a minimally invasive method for total or partial splenectomy,specifically laparoscopy, can be preferred as the treatment of choice.
SANT is an unusual disease of the spleen. In the light of this systematic review, a minimally invasive method for total or partial splenectomy,specifically laparoscopy, can be preferred as the treatment of choice.Liposarcoma is the most common soft tissue tumor which is commonly found in the retroperitoneal region. This kind of tumor is usually well-differentiated with low to no potential to metastasize. Thymoliposarcomas are extremely rare tumors that are difficult to diagnose and differentiate from thymomas and other benign conditions. Presentation of a caseThis report presents a case of a 46-year-old male patient with dyspnea, generalized fatigue and non-specific chest pain caused by a giant anterior mediastinal mass. Computed tomography scan revealed a large mass in the anterior mediastinum. CT guided biopsy was consistent with thymolipoma. The tumor was surgically resected. 4-Chloro-DL-phenylalanine nmr The histological analysis of the tumor revealed thymoliposarcoma. DiscussionThymoliposarcoma usually presents with non-specific symptoms. The mean age of the diagnosis is 55.8 years old with a slight predominance in males. The corner stone of the treatment remains surgical excision of the tumor while the role of adjuvant therapy is not well documented.
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