Abstract Title
How Did It Get There? A Case of Thoracic discitis and paraspinal abscesses caused by a vaginal flora in a 73-year-old man.

Background
Gardnerella vaginalis (G. vaginalis) is a small, gram-variable rod typically part of the vaginal flora. The overgrowth of G. vaginalis is a well-known cause of bacterial vaginosis. Only a few cases document infection with G. vaginalis in men, the most common source being genitourinary. We present a case of a 73-year-old man with altered mental status and sepsis who was found to have multilevel thoracic discitis/osteomyelitis with paraspinal and mediastinal abscesses secondary to G. vaginalis.

Case Presentation
A 73-year-old man presented to Loyola University Medical Center (LUMC) as a transfer for escalated care for septic shock. He initially presented to an outside hospital after being found down for two days. He had altered mental status, chest discomfort, shortness of breath, and an inability to move his bilateral lower extremities (LE). He was afebrile, hypotensive, tachycardic, and tachypneic with cold LE bilaterally. Computed tomography of chest, abdomen and pelvis revealed T7-T10 discitis/osteomyelitis, a complex fluid collection along the left posterior mediastinum, and emphysematous cystitis. Magnetic resonance imaging of the thoracic spine confirmed the presence of discitis/osteomyelitis, mediastinal and paraspinal abscesses and revealed an epidural abscess (T1-T7-8) and canal stenosis (T9-10). He was empirically treated with vancomycin and piperacillin-tazobactam. He rapidly decompensated requiring intubation and was therefore transferred to LUMC.

At LUMC, neurosurgery was consulted for concerns of acute cord compression. He underwent T7-T10 laminectomy, T8-9 transpedicular decompression and T5-11 fusion for spinal infection with unstable T8 spine fracture. Frank purulence was noted upon fascial opening. Intraoperative cultures of thoracic epidural fluid, epidural swab and deep fascia wound cultures grew few colonies of G. vaginalis. Blood cultures were negative. After treatment of emphysematous cystitis, he was transitioned to ampicillin-sulbactam for 6 weeks. He remained afebrile with improved leukocytosis and negative blood cultures but was still unable to move his bilateral LE upon discharge (hospital day 27). Later, he was unfortunately readmitted to an outside hospital for unknown reasons and was lost to follow up. 

Discussion
This case demonstrates the pathogenic ability of G. vaginalis to cause extensive spinal abscesses and osteomyelitis. Although G. vaginalis can cause bacterial vaginosis and treatment for this is well-established, the management of this case is much more complex. This patient’s diagnosis is uncommon, so being aware of the pathogenicity of G. vaginalis to cause substantial infection and analyzing treatment outcomes for these cases is important for management of future cases. 


How Did It Get There? A Case of Thoracic Discitis and Paraspinal Abscesses Caused by a Vaginal Flora in a 73-year-old Man

Background
The International Mouse Phenotyping Consortium (IMPC) is a database that characterizes the function of over 20,000 protein-encoding genes in mice through knockout. Each knockout gene and its associated phenotype can be accessed through their website. For this project, we used the IMPC to explore the Atlastin GTPase 3 gene (Atl3), a gene related to Hereditary Sensory Neuropathy Type 1F (HSN1F). HSN1F is a rare neurological genetic disorder, characterized by the loss of sensation to the hands and feet due to a mutation in Atl3. When Atl3 is knocked out in mice, the IMPC revealed seven phenotypes: enlarged prostate gland, abnormal liver morphology, small adrenal glands, small kidney, enlarged lymph nodes, cataract, and enlarged urinary bladder.

Methods
The National Organization for Rare Disorders (NORD) was used to identify the disease of interest and its associated gene, Atl3. Using the IMPC database, seven phenotypes associated with the Atl3 knockout mice were identified and compiled into a well-known analytical tool, Microsoft Excel. The genes that showed that phenotype when knocked out in mice were compiled for each phenotype. Using variations of a common algorithm and conditional formatting in Microsoft Excel, the specific number of times a gene showed up and the number of phenotypes each gene was associated with were sorted visually with a specific color. Further analysis, totaling the number of times each specific gene appeared in multiple times was formatted graphically.

Results
The seven phenotypes associated with the Atl3 knockout mice were enlarged prostate gland, abnormal liver morphology, small adrenal glands, small kidney, enlarged lymph nodes, cataract, and enlarged urinary bladder. Our analysis revealed four genes, dynein cytoplasmic 1 light intermediate chain 1 (dync1li1), piggyBac transposable element derived 1 (Pgbd1), MAS-related GPR, member B2 (Mrgprb2), and ADNP homeobox 2 (Adnp2), that when knocked out in mice shared five of the seven phenotypes associated with the Atl3 knockout mouse.

Conclusion
Through the IMPC database, we identified dync1li1, Pgbd1, Mrgprb2, and Adnp2 as genes that potentially have an interaction or could be involved in pathways with Atl3 because they share five of the seven phenotypes. Based on our data, further research is recommended into these genes and how they relate to Atl3 as it shares these phenotypes. Utilizing currently existing tools such as the IMPC, genes and their interactions can be identified to further find genes that may have not been extensively studied yet that mimic the loss of Atl3.

Investigating Atl3-Related Genes Utilizing Data from the International Mouse Phenotyping Consortium

Background 
Prostate cancer (PCa) is the most diagnosed and second-leading cause of cancer-specific mortality among men in the United States. Prostate needle biopsy remains the standard diagnostic test, and MRI- ultrasound-guided fusion prostate biopsy (fBx) has improved the accuracy of Gleason score (GS) findings and thus PCa risk stratification. However, prostate biopsy only samples a small proportion of the prostate and is prone to error, with GS discordance between fBx and final pathology after radical prostatectomy affecting up to 35% of patients. Recent advances with mpMRI have altered diagnosis and staging strategies for PCa. The lesions at MRI are graded with Prostate Imaging Reporting & Data System (PI-RADS) 1 to 5, with PI-RADS 5 indicating the most concerning features of PCa. Exploring which subgroup of PI-RADS scores is more common to have discordance may be important in helping to determine conservative treatment options. This retrospective study aims to compare the rate of the discordance of GS between fBx and surgery as stratified by PI-RADS scores. 

Methods 
After obtaining IRB approval, we retrospectively reviewed records of patients who underwent RP from January 2016 through June 2024 with prior fBx. The rates of concordance and discordance of PCa GS in PI-RADS scores 3, 4 and 5 were compared between the fBx and surgery. Age, PSA, PSA density, and prostate volume were also noted for all patients. Chi-squared statistical analysis was utilized to assess the data.

Results 
Of the 341 patients, 63 were PI-RADS 3, 99 were PI-RADS 4, and 179 were PI-RADS 5. Overall discordance was 27% for PI-RADS 3, 29% for PI-RADS 4, and 40% for PI-RADS 5. Among them, PCa GS 8-9 at surgery in PI-RADS 5 patients (N=31) had a less aggressive PCa GS of 7 at fBx (11/31, 36%), indicating higher possibility of upgrading from fBx. There was a statistically significant difference in GS discordance between PI-RADS 3 and 4 vs. 5 (27% and 29% vs. 40%) (P<0.05).

Conclusion
Discordance in PCa GS between fBx and surgery is not uncommon, particularly for PI-RADS 5 lesions at MRI. In addition, PI-RADS 5 lesions with preoperative fBx GS 7 are prone to pathologic upgrade to GS 8-9 at surgery. This finding may have important implications for treatment options, particularly for patients who decide to pursue conservative management.

Discordance of Prostate Cancer Gleason Scores between Ultrasound-MRI Fusion Biopsy and Radical Prostatectomy as Stratified by PI-RADS Scores

Background: 
Infectious myositis, a rare but significant inflammatory muscle disease, involves infection of skeletal muscle tissue, typically caused by bacteria, viruses, fungi, and parasites. Staphylococcus aureus is the most common bacterial pathogen. Symptoms range from localized pain and swelling to systemic manifestations like fever and malaise. Early recognition and management are crucial to prevent complications like abscess formation, sepsis, and chronic disability 1. Here, we detail the case of a 21-year-old female with right lower extremity (RLE) pain and swelling who developed infectious myositis and an abscess in the anterior leg compartment despite having no skin defects.

Case Presentation:
A 21-year-old female with systemic lupus erythematosus (SLE) presented to the ED after a mechanical fall with RLE pain, swelling, and fevers for two days. Physical examination revealed RLE swelling and tenderness without overlying skin findings. Lab results showed creatine phosphokinase (CPK) 125, C-reactive protein (CRP) 12.3, erythrocyte sedimentation rate (ESR) 72, and D-dimer 4.19 FEU. Initial CT of the RLE indicated subcutaneous edema, muscle atrophy, and fascial plane blurring, suggesting myositis. A RLE Doppler ultrasound was negative for thromboembolic processes. Given symptom worsening despite a negative workup, repeat CT of the RLE with contrast was obtained five days later which revealed a complex, multiloculated fluid collection indicative of an abscess within the anterior compartment. She was treated with IV vancomycin and underwent incision and drainage of the RLE. Intraoperative cultures grew methicillin-resistant S. aureus. Despite persistent fevers, extensive workup was unrevealing, and blood cultures were negative. At discharge, she was afebrile with improved RLE symptoms and uneventful wound healing.

Discussion:
This case highlights an atypical presentation of infectious myositis in an immunosuppressed patient following a mechanical fall without any obvious historical or exam findings of skin lacerations. Differential diagnosis included myositis, pyomyositis, deep vein thrombosis, hematoma, and compartment syndrome. Despite high suspicion for myositis, normal CPK levels, lack of leukocytosis, and unrevealing CT imaging complicated diagnosis and management. Elevated ESR and CRP levels were ambiguous due to her SLE history. CT imaging, although useful, has limitations in detecting early or subtle inflammatory changes in soft tissue and persistence of symptoms necessitated further investigation. This case underscores the importance of maintaining a high index of clinical suspicion for infectious myositis and the need for repeat imaging or alternative diagnostic modalities 2 when initial tests are inconclusive, given the risk of serious complications like sepsis, osteomyelitis, and necrotizing fasciitis with delayed treatment.

Diagnostic Dilemma: Atypical Presentation of Infectious Myositis in a Young Immunocompromised Female Following a Mechanical Fall

Background
Compared to standard breast conserving surgery (BCS), oncoplastic breast conserving surgery (OBCS) has improved tumor exposure, resection of wider diameters and higher volumes, low rates of recurrence and re-resection, superior cosmetic outcomes, improved patient satisfaction, and decreased postoperative breast volume requiring lower doses of postoperative radiotherapy. OBCS has no difference in postoperative complications or overall survival compared to BCS. Racial disparities exist in both rates of reconstruction after mastectomy as well as complication rate after breast reconstruction, and though the use of OBCS has increased, there is little research investigating how race affects outcomes in OBCS. Our study compares outcomes between Hispanic and Non-Hispanic patients undergoing OBCS at a large community hospital.

Methods
A retrospective review was performed on patients who underwent oncoplastic surgery for breast cancer. Subjects were divided into Hispanic vs non-Hispanic groups. Primary outcomes included need for re-excision, hematoma formation, wound infection, areolar loss, skin necrosis, and delayed wound healing. 

Results
There were 30 patients (73%) in the Hispanic group and 11 patients (27%) in the non-Hispanic group. There was no significant difference in smoking status, hypertension, and diabetes mellitus (p=0.361, p=0.126, p=0.909) between the two groups. The average age in the Hispanic group was 55.8 +/- 9.1 whereas in the non-Hispanic group it was 58.4 +/-8.6 (p=0.416). The average BMI in the Hispanic group was 29.86 +/- 5.3 compared to 30.98 +/- 4.91 (p=0.549) in the non-Hispanic group. The average tumor size in the Hispanic group was 19.6mm +/- 11.1mm compared to 28.8mm +/- 26.4mm (p=0.148) in the non-Hispanic group. 

There were no significant differences in the need for margin re-excision (p=0.969) or post operative hematoma formation (p=0.478). There was no documented post operative wound infection, areolar loss, or skin necrosis in either group. The Hispanic group had significantly lower rates of delayed wound healing (3% in the Hispanic group vs 27% the non-Hispanic group, p=0.022). 

Conclusion
Oncoplastic breast conserving surgery is a valuable option when considering reconstruction for lumpectomy in the Hispanic population. There were no significant differences in demographics or outcomes amongst our two populations, except the Hispanic group had a lower rate of delayed wound healing. This study is limited by its small sample size and a future study with large samples is needed to corroborate these findings. Nonetheless, the benefits of oncoplastic breast conserving surgery cannot be understated and should always be considered for all patients who are appropriate candidates.


Oncoplastic Breast Conservation Surgery Outcomes are Similar Amongst Hispanic and Non-Hispanic Populations at a Large Community Hospital

Abstract Title
The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Background
Altered Mental Status (AMS) ranges from confusion to coma and is frequently encountered in patients admitted to the Intensive Care Unit (ICU). Etiologies include metabolic disturbances, neurological insults, and systemic illnesses. The precise impact of AMS on in-ICU mortality remains an area of ongoing research, necessitating comprehensive evaluation and elucidation. The objective of our study was to identify significant patterns and outcomes associated with the presence of AMS upon initial Emergency Department (ED) presentation to better inform ICU management and enhance patient care.

Methods
A retrospective cohort study was conducted using patient data from the Northwell Health network, focusing on adult ICU admissions between July 1, 2022, and July 1, 2023. The study included 21,900 unique patients. The primary variables were AMS presence and in-ICU mortality, both recorded as binary outcomes. Descriptive statistics were analyzed for patient demographics and clinical characteristics, including gender distribution and racial composition. The association between AMS and in-ICU mortality was tested using a Chi-square test of independence, with statistical significance set at p < 0.05. The impact of AMS on ICU and hospital stays, treatments (steroids and vasopressors), and acute renal failure incidence was further assessed using Chi-square tests with relative risks and 95% confidence intervals calculated.

Results
Patients with AMS experienced longer ICU and hospital stays, averaging 144.3 hours in the ICU and 13.6 days in the hospital compared to 111.3 hours and 10.1 days for those without AMS, respectively. Patients with AMS were more likely to receive steroids, χ2(1, N = 21,900) = 40.0, p < .001, RR = 1.13, 95% CI [1.08, 1.18]. They were also more likely to be on vasopressors, χ2(1, N = 21,900) = 98.2, p < .001, RR = 1.24, 95% CI [1.18, 1.31], and to develop acute renal failure, χ2(1, N = 21,900) = 53.1, p < .001, RR = 1.15, 95% CI [1.10, 1.20]. The Chi-square test demonstrated a significant association between AMS and in-ICU mortality, χ2(1, N = 21,900) = 111, p < .001, RR = 1.13, 95% CI [1.10, 1.17]. 

Conclusion 
AMS presence was significantly associated with longer ICU and hospital length of stay, more frequent need for vasopressors and steroids, a higher occurrence of acute renal failure, and increased in-ICU mortality rates. These findings underline the importance of AMS as a prognostic indicator in ICU settings and stress the need for increased awareness and proactive management of AMS to potentially improve patient outcomes in the ICU.

The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Background: Total hip and knee arthroplasty (THA and TKA) are two of the most common joint arthroplasties performed in the United States, with the prevalence of these procedures anticipated to continue increasing with the aging population. Therefore, medical education programs must expose students to the pathology, mechanisms of surgical intervention, and variance in implant materials for THA and TKA. One of the purposes of the WMed Skeletal Teaching and Research (STaR) Series is to target this educational goal, however, considering whether the collection is representative of the surrounding population is imperative when training medical providers to care for local communities. As few formal skeletal collections exist within the United States, research pertaining to representation of orthopedic surgeries is arguably nonexistent. The WMed STaR Series aims to target this gap in research, comparing representation of THA and TKA from the series to community statistics.

Methods: Donors from the WMed STaR Series were thoroughly evaluated for the presence of THAs and TKAs, as well as associated musculoskeletal pathology. The type and material of implant, laterality of intervention, donor medical history, and donor demographics were documented. Preliminary data collected from the series was evaluated in comparison to national statistics, and will plan to be compared to analogous data from orthopedic patients seen at the WMed Health clinic.

Results: The American College of Rheumatology cites about 1.2 million TKA and THA procedures in the U.S. annually with approximately 36.3% being THA and 63.7% being TKA. Upon evaluation of the STaR series, there were six THA (83% with a metal femoral head and a polymer socket, and the remaining 17% with a ceramic femoral head and a polymer socket) and seven TKA (all with metal tibial and femoral components and plastic spacers). This results in a relative frequency of 46.2% THA and 53.8% TKA in the WMed STaR Series, showing that while WMed has a similar proportion of THA and TKA to the national statistic, the STaR Series shows slightly higher prevalence of THA. 

Conclusion: The development of the WMed STaR Series will provide educators with a reference for orthopedic implants available for medical education, and will offer a unique perspective for further understanding of musculoskeletal pathology and mechanism for surgical intervention. Medical education resources that reflect the surrounding populations, such as the WMed STaR series, are imperative to prepare medical trainees to deliver comprehensive care to their communities. 


An Examination of Orthopedic Implants in the WMed Skeletal Teaching and Research Series: Presenting a Resource for Medical Education and Research

Authors: Ruth Agwaze, Grace Ro, Aspen Ainsworth, Bradley Van HeuKelum, Margaret Puelle

Title: Challenges Faced Treating Severe Postpartum Psychosis when Standard of Care is Contraindicated

Background: Thyroid dysfunction is a perinatal complication associated with mood disorders, particularly postpartum depression (Schmidt, 2022). However, there are few accounts of thyroid disorders leading to postpartum psychosis treated with antipsychotic and antithyroid agents (Fulton, 2024) We present a case of postpartum thyrotoxicosis and psychosis in which these medications were ineffective/contraindicated.

Case: A 36-year-old Black female G4P4004 with multiple sclerosis, migraines and anxiety presented to her primary care physician with persistent asymptomatic sinus tachycardia five months after a postpartum pulmonary embolism, despite treatment with propranolol. A few weeks later, she developed palpitations, weight loss, and tremors. Blood work showed free T4 > 4.4 ng/dL (reference range 0.9-1.7 ng/dL), antibodies to thyroglobulin and thyroid peroxidase, and undetectable TSH. She was diagnosed with Grave’s Disease and prescribed oral methimazole. Five months later, she presented to the hospital with diffuse abdominal pain and altered mental status. She had been self-treating with topical vitamin-infused oils instead of methimazole because she feared its side effects. For the next year, she had numerous hospitalizations due to paranoid and erratic behaviors, delusions of being married to a deceased rapper, and over 100-lb weight loss. In the hospital, she received IV methimazole which led to agranulocytosis. Higher antipsychotic and beta-blocker doses were ineffective. She had limited insight and made multiple attempts to leave against medical advice. Due to the need for consistent outpatient follow-up, social distancing, and concerns for future fertility, radioactive ablation was contraindicated. This left thyroidectomy as the only option, but she refused surgery when she was previously in a lucid state. Endocrinologists, psychiatrists, neurologists, and legal/ethical consultants concluded that treatment over objection was not acceptable because the patient was not in a life-threatening thyroid storm. Plasmapheresis was discussed, but this placed the patient at risk without guarantee that psychosis would resolve. One day, she spontaneously regained lucidity and consented to a thyroidectomy. She eventually returned to her baseline after weeks of levothyroxine treatment, and her tachycardia resolved. 

Discussion: This case demonstrates the diagnostic and therapeutic challenges of treating psychosis in the setting of postpartum thyroiditis, as well as ethical implications of treatment in patients with limited capacity. 

Conclusion/implications: This case provides further evidence that postpartum thyroid dysfunction can lead to postpartum psychosis. More research is necessary to understand the relationship between postpartum thyroiditis and psychosis, as well as guidelines for patients who may not respond to typical treatment regimens. 

References: 
1. Fulton, A., Mittal, N., & Deb, A. (2024). Postpartum Psychosis as a Consequence of Thyroiditis Versus Relapse: A Diagnostic Dilemma. Cureus, 16(1), e52357. https://doi.org/10.7759/cureus.52357
2. Schmidt, P. M. D. S., Longoni, A., Pinheiro, R. T., & Assis, A. M. (2022). Postpartum depression in maternal thyroidal changes. Thyroid research, 15(1), 6. https://doi.org/10.1186/s13044-022-00124-6

Challenges Faced Treating Severe Postpartum Psychosis when Standard of Care is Contraindicated

Background:

Lung adenocarcinoma is the most common lung cancer and has variable biology that affects outcomes and treatment. Numerous prognostic factors can be obtained from resected tumors, but a tool that could predict lung adenocarcinoma biology pre-operatively would help tailor decision-making. 

SILA is a radiomic tool that assigns scores to 9 groups of CT features which are collectively used to calculate a risk that a tumor recurs. While SILA recurrence risks have been validated, it is not yet known how the 9 groups of features themselves might relate to lung adenocarcinoma characteristics.

In this study, our aim was to elucidate novel associations between the 9 scores and known prognostic factors in lung adenocarcinoma. 

Methods:

We retrospectively reviewed resected lung adenocarcinoma cases with available preoperative CT images at our hospital between August 2016 and August 2022.

SILA analysis involved manual segmentation of lung lesions on CT scans. The software then generated scores for each of the 9 groups of features. The 9 features are referred to by color names, such as violet (V), indigo (I), etc. We reviewed the charts to record pertinent clinical-pathologic variables. 
Statistical tests used included chi square, Kruskal-Wallis to Dunn-Bonferroni-Tests post-hoc analysis, and Mann-Whitney U-Test.

Results:
Study cohort included 276 patients with a median age of 69. There were 176 (63.4%) female patients and 197 (71.4%) stage I. There were 54 (19.6%) recurrences.

Our results showed positive and negative associations between certain color scores and markers of tumor aggression, including standardized reuptake value (SUV) on T1 scans (p-values ranging from <0.001 to 0.009) and tumor size on CT (p-values from <0.001 to 0.009). In addition, color scores had associations with known prognostic factors that can only be determined after resection, including visceral pleural invasion (p-values from <0.001 to .045) and lymphovascular invasion (p values from <0.001 to .037).

Color scores were also significantly different between certain pathologic stages. For example, violet values were significantly different between stage IB and IA2 tumors (adjusted p=0.001) and between stage IA2 and IIB tumors (adjusted p<0.001). 

Conclusion:

The associations between SILA color scores and validated markers of tumor aggression point to the exciting possibility that color scores may provide information about lung adenocarcinoma biology pre-operatively. Future work will explore additional correlations between color scores and other pre- and post-operative clinicopathologic data.


Score Indicative of Lung Cancer Aggression (SILA) color scores are correlated with aggressive features in lung adenocarcinoma


Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic diagnosis that can be visualized as symmetric posterior white matter vasogenic edema in the occipital and parietal lobes that arises as a consequence of endothelial damage in vulnerable vasculature. PRES can present clinically as visual changes, headaches, seizures, and altered mental status. Although most cases of PRES have been described in the setting of hypertension, a rare subset has developed in the setting of blood transfusion in chronic anemia.

Here, we present the first case of an adult male who developed PRES following a blood transfusion. The patient is a 69-year-old caucasian male who had an acute exacerbation of chronic anemia and went on to develop PRES following the transfusion of three units of packed red blood cells. 

21 total cases of PRES following a blood-transfusion have been documented. 20 of these cases are reported in females and 1 in an adolescent male. In the setting of chronic anemia correction in patients with identifiable risk factors (i.e., hypoalbuminemia or metabolic acidosis), care should be taken to transfuse blood products over long periods of time with close monitoring of hemoglobin levels to mitigate the risk of developing PRES. In patients with PRES, early identification and discontinuation of inciting factors are critical to a favorable prognosis.

Posterior Reversible Encephalopathy Syndrome Related to Blood Transfusion in a Male Chronic Anemic: A Case Report

Background
Peutz-Jeghers syndrome (PJS), is an uncommon autosomal dominant disorder caused by a mutation at 19p13.3 that manifests as mucocutaneous pigmentation and hamartomatous polyps in the gastrointestinal system. We report a case of a 19-year-old young girl presented with intermittent episodes of abdominal pain and few occasions of fresh per rectal bleeding as well as features of anemia.
Case Presentation
A 19-year-old female patient with a urinary tract infection was brought into our internal medicine department. It was discovered that she had mucocutaneous pigmentation and iron deficiency anemia. She also reported having vague stomach ache and a couple instances of hematochezia since she was fifteen. Colonic polyps, colon cancer, or any other gastrointestinal condition were not present in the family history. Physical examination revealed no abnormalities, except for the presence of dark-brown pigmented maculae around the oral mucosa, lower lip and pulp of fingers. Numerous pedunculated polyps were seen dispersed throughout the colon during a colonoscopy. There were a lot of giant polyps. Polyps were seen in the large as well as small bowels during MR enterography.
Background
Peutz-Jeghers syndrome (PJS), is an uncommon autosomal dominant disorder caused by a mutation at 19p13.3 that manifests as mucocutaneous pigmentation and hamartomatous polyps in the gastrointestinal system. We report a case of a 19-year-old young girl presented with intermittent episodes of abdominal pain and few occasions of fresh per rectal bleeding as well as features of anemia.
Case Presentation
A 19-year-old female patient with a urinary tract infection was brought into our internal medicine department. It was discovered that she had mucocutaneous pigmentation and iron deficiency anemia. She also reported having vague stomach ache and a couple instances of hematochezia since she was fifteen. Colonic polyps, colon cancer, or any other gastrointestinal condition were not present in the family history. Physical examination revealed no abnormalities, except for the presence of dark-brown pigmented maculae around the oral mucosa, lower lip and pulp of fingers. Numerous pedunculated polyps were seen dispersed throughout the colon during a colonoscopy. There were a lot of giant polyps. Polyps were seen in the large as well as small bowels during MR enterography.
© 2018 American Medical Association. All rights reserved.
Discussion: PJS syndrome is incredibly rare; babies with an estimated incidence of 1:8,500 to 1:200,000 are affected. The young lady in our presentation met the inclusion criteria for the syndrome since she had mucocutaneous pigments on her hands and lips in addition to many Peutz-Jeghers polyps in the small the small and large intestine. Approximately 95% of PJS patients have mucocutaneous pigmentations, which may be the initial clinical clue prior to the onset of gastrointestinal symptoms. When a kid has iron deficiency anemia, which is common in youngsters, it is crucial to perform a complete physical examination and look into the family history. This enables the early detection of uncommon illnesses like Peutz-Jeghers syndrome. PJS patients have a cancer incidence that is almost fifteen times greater than the normal population. This case emphasizes the value of routine surveillance, patient education, and tertiary prevention strategies in preventing complications in individuals with post-diagnosed Puetz-Jeghers syndrome.

Iron Deficiency Anemia and Mucocutaneous Pigmentation: Diagnostic Clues for Peutz-Jeghers Syndrome

Background
Chronic Traumatic Encephalopathy (CTE) is a progressive neurodegenerative disease associated with repetitive head trauma, predominantly affecting contact sports athletes and military personnel. Given the high prevalence of traumatic brain injuries (TBI) managed by neurosurgeons, it is crucial to understand CTE's pathophysiology, clinical presentation, and management strategies to enhance patient outcomes.
Methods
A systematic review and meta-analysis were conducted following PRISMA guidelines.
Searches were performed in PubMed, Cochrane Library, Embase, and Google Scholar for studies published from January 2010 to May 2024. Inclusion criteria encompassed studies on CTE epidemiology, pathophysiology, clinical presentation, diagnostics, and therapeutics. Data extraction and quality assessment were conducted independently by two reviewers, with discrepancies resolved by a third reviewer.

Results
Fourteen studies met the inclusion criteria, totaling 2729 observations and 799 events of CTE. The pooled proportion of CTE cases was 72.82% (95% CI: 48.17% to 88.53%) using a random effects model, with substantial heterogeneity (I2 = 98.6%). Subgroup analysis indicated high pooled proportions among athletes (71.43%) and military personnel (74.29%). Sensitivity analysis confirmed the robustness of the findings.
The pathophysiology of CTE involves the accumulation of hyperphosphorylated tau
protein and chronic neuroinflammation, leading to significant neuronal damage.
Clinically, CTE presents with cognitive impairment, mood disorders, and behavioral
changes, complicating its diagnosis due to overlapping symptoms with other
neurodegenerative diseases. Current treatments focus on symptomatic management, with emerging therapies targeting tau pathology and neuroinflammation showing promise.

Conclusion
This meta-analysis underscores the significant prevalence of CTE among individuals
exposed to repetitive head trauma, highlighting the need for standardized diagnostic
criteria and personalized management approaches. Neurosurgeons are pivotal in
advancing diagnostic protocols and therapeutic strategies to improve outcomes for
patients with CTE. Further research is needed to enhance understanding and
management of CTE, ultimately benefiting the broader TBI patient population frequently
encountered in neurosurgical

Underline digital video library

How Did It Get There? A Case of Thoracic Discitis and Paraspinal Abscesses Caused by a Vaginal Flora in a 73-year-old Man

Investigating Atl3-Related Genes Utilizing Data from the International Mouse Phenotyping Consortium

Discordance of Prostate Cancer Gleason Scores between Ultrasound-MRI Fusion Biopsy and Radical Prostatectomy as Stratified by PI-RADS Scores

Diagnostic Dilemma: Atypical Presentation of Infectious Myositis in a Young Immunocompromised Female Following a Mechanical Fall

Oncoplastic Breast Conservation Surgery Outcomes are Similar Amongst Hispanic and Non-Hispanic Populations at a Large Community Hospital

The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

An Examination of Orthopedic Implants in the WMed Skeletal Teaching and Research Series: Presenting a Resource for Medical Education and Research

Challenges Faced Treating Severe Postpartum Psychosis when Standard of Care is Contraindicated

Score Indicative of Lung Cancer Aggression (SILA) color scores are correlated with aggressive features in lung adenocarcinoma

Posterior Reversible Encephalopathy Syndrome Related to Blood Transfusion in a Male Chronic Anemic: A Case Report

Iron Deficiency Anemia and Mucocutaneous Pigmentation: Diagnostic Clues for Peutz-Jeghers Syndrome

Chronic Traumatic Encephalopathy in Neurosurgical Practice: Insights from a Systematic Review and Meta-Analysis

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