Search Results (51)

Background and Clinical Significance: The most common cause of liver toxicity with the use of immune checkpoint inhibitors (ICIs) is autoimmune hepatitis. As most patients with prior viral infections such as hepatitis B and hepatitis C were excluded in trials for the use of ICIs, the safety of ICIs in these patients with active or prior treated hepatitis is unknown. With expanded use of these medications in many malignancies, it is important to understand the risk of viral reactivation with these medications. There are only few case series and reports documenting hepatitis B reactivations with the use of ICIs. Case Presentation: We present a middle-aged woman with a history of treated hepatitis B who presented with metastatic gastric cancer. She was treated with two cycles of 5-FU, oxaliplatin and nivolumab followed by maintenance nivolumab. After 14 months of nivolumab, she developed marked transaminitis and was found to have reactivation of hepatitis B. As autoimmune hepatitis was the initial suspicion, the patient was initiated on prednisone 1 mg/kg with no improvement in transaminases. Due to the significant elevation of HBV DNA, she was diagnosed with hepatitis B reactivation. She was initiated on entecavir with normalization of transaminases and improvement in HBV DNA levels. She was successfully rechallenged with nivolumab with no evidence of recurrent transaminitis or worsening HBV DNA levels. Conclusions: There are case series of HBV reactivation with the use of ICIs. We believe that any patients with known history of HBV should get baseline viral titers prior to initiation of ICIs with serial monitoring of DNA levels. Prospective studies to evaluate risk of reactivation may need to be performed for us to get a better understanding of risks of viral reactivation and potential effects it may have on safety and efficacy of ICIs. Full article

Malignant melanoma demonstrates strikingly varied clinical presentations, on account of which it is often challenging to diagnose. We describe herein a rare case of amelanotic malignant melanoma (AMM) in the buccinator muscle presenting as a solitary mass. A middle-aged woman presented with a non-pigmented swelling under the right buccal mucosa. Magnetic resonance imaging (MRI) revealed a well-circumscribed lesion without local invasion. A needle biopsy did not establish the diagnosis and was instead interpreted as suggestive of a salivary gland tumor, reinforcing an initial impression of myoepithelioma. Histopathological analysis of an excised specimen revealed poorly defined, pleomorphic tumor cells and a scattering of melanin-containing cells. The diagnosis of AMM was established by integrating these histopathological features with the clinico-radiological findings and the immunohistochemical results, which were positive for HMB-45, S-100, and SOX10 and negative for cytokeratin. Whole-body positron-emission tomography-computed tomography found no primary lesion. Because tumor nests suggesting possible residual disease were observed near the resection margin, a wider, secondary excision including the affected portion of the buccal mucosa and overlying skin was performed together with neck dissection. Histopathological examination of the re-resection specimen showed no residual tumor, indicating that no malignant cells were identified in the adjacent oral mucosa or facial skin. The patient has remained disease-free for three years. Full article

Cutaneous co-infection with Mycobacterium tuberculosis (MTB) and Mycobacterium avium complex (MAC) is extremely rare and easily missed due to overlapping histopathological features. We report a previously healthy, HIV-negative middle-aged woman who presented with a progressive destructive mass in the left inguinal-perineal region. Imaging revealed sinus tract formation, osteolytic bone lesions, and chronic inflammation in the right middle lobe of the lung. Initial metagenomic next-generation sequencing (mNGS) detected 3756 reads of the Mycobacterium tuberculosis complex (MTBC) and 111 reads of Mycobacterium intracellulare (M. intracellulare); the latter was interpreted as possible colonization or contamination because of its low abundance. Empirical anti-tuberculosis therapy produced only transient partial improvement, followed by paradoxical worsening, local recurrence, and new bone destruction. After a high suspicion of mixed infection, a MAC-directed combination regimen (including azithromycin and a short course of amikacin) was added, leading to complete clinical cure; subsequent repeat cultures confirmed the presence of MAC. This is the first report of cutaneous MTB-MAC co-infection in the inguinal-perineal region of an adult without overt immune abnormalities, accompanied by disseminated bone lesions. This case highlights that in regions where nontuberculous mycobacteria (NTM) are co-endemic, atypical destructive skin lesions with paradoxical worsening despite initial response to anti-tuberculosis therapy should raise suspicion of MAC co-infection. The combination of mNGS and conventional culture facilitates identification of mixed infections and guides precision therapy, but mNGS results must be interpreted cautiously in the clinical context. Full article

The Book of Margery Kempe is an extraordinary work of female visionary writing, in which Margery Kempe narrates her intimate and direct communications with Jesus Christ. The aim of this paper is to investigate how Kempe fashions herself into an authoritative religious figure and the impact of her self-fashioning. The study reveals that Kempe builds up her image as a chosen woman through a designed narrative discourse, which features disorder, imbalance, and homogeneity. To be specific, Kempe intentionally foregrounds her spiritual life endorsed by Christ and downplays her secular life in order to establish her authority. Moreover, Kempe’s work replicates the essential ingredients of hagiography, namely trials, divine intervention, and redemption, which naturally elevates Kempe to sainthood and therefore justifies her position of spiritual authority. Following on from this, Kempe, like other holy women, is well-qualified to instruct her fellow Christians to emulate her form of life, that is, to live a devout life. The establishment of Kempe’s spiritual authority is the epitome of women’s pursuit of spiritual leadership in the later Middle Ages, when they struggled with social conventions and ecclesiastical regulations. Full article

Pregnancy (HP), defined as the coexistence of intrauterine and ectopic gestations, is a rare condition, especially in spontaneous conception, but it is a life-threatening obstetric emergency when rupture occurs, with a reported maternal mortality rate of 0.03%. Diagnosis is often delayed because confirmation of an intrauterine pregnancy can mask clinical signs of a concurrent ectopic gestation. Early recognition and prompt surgical intervention are therefore critical to maternal safety and preservation of intrauterine viability. This case highlights the diagnostic challenges and successful management of a spontaneous ruptured heterotopic pregnancy. Case presentation: A 34-year-old Middle Eastern woman, gravida 4, with a spontaneous conception, presented with sudden severe lower abdominal pain and signs of acute hemoperitoneum (hypotension, tachycardia, and marked peritoneal signs). Transvaginal ultrasound demonstrated a viable intrauterine pregnancy at 9 weeks 4 days gestation, together with a ruptured left tubal ectopic pregnancy of similar gestational age. The patient underwent urgent laparoscopic left salpingectomy with evacuation of approximately 1200 mL of intraperitoneal blood and clots. Postoperatively, she developed significant anemia (hemoglobin drop from 11.2 g/dL on admission to 6.5 g/dL) requiring transfusion of four units of packed red blood cells. Serial ultrasonographic follow-up confirmed ongoing viability of the intrauterine pregnancy, which ultimately resulted in a live birth at term. Progressive resolution of the postoperative pelvic hematoma was also noted. Conclusions: Ruptured heterotopic pregnancy remains a diagnostic and therapeutic challenge. This case, along with a synthesis of the contemporary literature, demonstrates that a high clinical index of suspicion, timely ultrasound diagnosis, and immediate minimally invasive surgical management are paramount. Furthermore, rigorous postoperative monitoring and resuscitation, including targeted transfusion, are essential to achieve maternal stabilization while allowing continuation of a viable intrauterine pregnancy, with reported live birth rates exceeding 70% following timely intervention. Full article

Background and Clinical Significance: Parkinson’s disease (PD) is a neurodegenerative condition characterized by motor and non-motor symptoms, which significantly impact patients’ autonomy and quality of life levels. Basically, the PD diagnosis is clinical and, in some cases, can be challenging to diagnose due to the heterogeneity of the symptoms. Case Presentation: A 58-year-old woman who, during the COVID-19 lockdown, referred to experiences of slight tremor and stiffness in her left hand at rest, but without any other associated symptoms. Firstly, after consulting a general practitioner (GP), the patient was diagnosed with cervical radiculopathy (CR), presented as essential tremor and stiffness to the hand. Nevertheless, during the initial physiotherapy evaluation, the motor symptoms did not fully align with the diagnosis of CR. For this reason, the presence of non-motor symptoms was thoroughly investigated. Notably, hyperhidrosis was identified as a significant non-motor symptom, leading to the patient’s subsequent referral to a neurologist, who finally diagnosed PD. Conclusions: This case report highlights the essential role of physiotherapists in conducting independent assessments and comprehensive investigations of all patients’ symptoms, even when a medical diagnosis has already been established. This is particularly crucial when there is suspicion that musculoskeletal symptoms may be indicative of neurodegenerative diseases such as PD, which is well-known for its extensive array of non-motor symptoms. Especially in women with PD, non-motor symptoms tend to emerge earlier and in a more subtle manner than motor symptoms, making diagnosis challenging. Therefore, meticulous anamnestic data collection is essential, especially by physiotherapists working in direct-access settings. Full article

The study aims to reconstruct the life history of an individual whose skeleton was recovered during the excavation of the late medieval Pauline monastery of the Blessed Virgin Mary on Moslavina Mountain, Croatia. The monastery was one of the most important ecclesiastical centres in continental Croatia during the 14th/15th centuries CE and was abandoned between 1520 and 1544 due to fear of imminent Ottoman attacks. The inscription and coat of arms on the tombstone of a tomb located in the chancel, next to the main altar, indicate that the skeleton belongs to Sofia Kaštelančić née di Prata (di Pordenone), a member of Croatian late medieval high-ranking nobility. We conducted a conventional bioarchaeological study, carbon and nitrogen stable isotopes analysis, paleoradiological imaging (CT/CBCT scanning), and three-dimensional facial reconstruction. The skeleton belongs to a middle-aged woman between 40 and 50 years old with an estimated stature of about 161 cm. Numerous pathological changes, such as ante mortem tooth loss, caries, abscess, linear enamel hypoplasia, dysodontiasis, and osteophytosis were observed, with the most notable pathology being the fracture of the right ankle, a fact also confirmed by CT scanning. Carbon and nitrogen isotopic values are consistent with a terrestrial diet based on C₃ plants with no marine input, and the consumption of large quantities of animal-based proteins. Three-dimensional facial reconstruction made it possible for the first time in over 500 years to obtain the approximate physical appearance of the individual. The presented results are consistent with the hypothesis that the skeleton probably belongs to Sofia Kaštelančić. Nevertheless, none of the observed osteological traits are individually or collectively diagnostic of Sofia, so, in the absence of individualising evidence, the identification remains hypothetical rather than demonstrative. Full article

Background/Objectives: The extension of euthanasia and physician-assisted suicide to individuals with mental disorders presents a profound ethical, clinical, and legal challenge. While increasingly accepted in some jurisdictions, their application in psychiatric contexts—particularly in cases of depression—raises concerns about diagnostic precision, therapeutic adequacy, and the validity of informed consent. This study examines two controversial Belgian cases to explore the complexities of euthanasia for psychological suffering. Methods: A qualitative case analysis was conducted through a qualitative analysis of publicly available media sources. The cases were examined through clinical, psychoanalytic, and medico-legal lenses to assess diagnostic clarity, treatment history, and ethical considerations. No access to official medical records was available. Case Presentation: The first case involved a young woman whose depressive symptoms were reportedly linked to trauma from a terrorist attack. The second concerned a middle-aged woman convicted of infanticide and later diagnosed with Major Depression. Discussion: In both cases, euthanasia was granted on the grounds of “irreversible psychological suffering.” However, the absence of detailed clinical documentation, potential unresolved trauma, and lack of psychodynamic assessment raised doubts about the robustness of the evaluations and the validity of informed consent. Conclusions: These findings highlight the need for a more rigorous, multidisciplinary, and ethically grounded approach to psychiatric euthanasia. This study underscores the importance of precise diagnostic criteria, comprehensive treatment histories, and deeper exploration of unconscious and existential motivations. Safeguarding clinical integrity and ethical standards is essential in end-of-life decisions involving mental illness. Full article

Background: Skeletal metastases from carcinoid tumours are extremely rare. Their correct diagnosis is a challenging problem for clinicians and pathologists, with important clinical implications for patients. In most cases, examination for the possible presence of skeletal metastases is initiated only when patients present symptoms suggestive of skeletal metastases. Case presentation: In this paper, the authors present the case of a middle-aged woman suffering from back pain due to a bronchial carcinoid that metastasised to the spine. We managed skeletal metastases with vertebroplasty and achieved excellent results and the complete remission of symptoms six months after the procedure. Conclusions: The relevance of this case report is that it highlights the importance of correctly diagnosing and treating these rare lesions to improve the quality of life of metastatic oncologic patients. Full article

Understanding the determinants of the occupational health of specific populations and their work-related vulnerabilities is important for developing more effective psychosocial interventions. The aims of this study were (1) to explore differences in occupational health between groups of men versus women and heterosexual versus LGBTQIA+ individuals living in Portugal; (2) to assess whether belonging to LGBTQIA+ groups or being a woman predicts worse occupational health; and (3) to evaluate differences in absenteeism frequency and possible predictors based on sexual orientation and gender. This cross-sectional quantitative study involved 577 participants living and working in Portugal (mean age: 41.62 years, SD = 11.41). To assess occupational health, we used the Copenhagen Psychosocial Questionnaire (COPSOQ III—Middle Version). Women and LGBTQIA+ individuals reported poorer occupational health compared to men and heterosexual individuals, although greater discrepancies were observed in LGBTQIA+ individuals, especially in mental health indicators. Gender and sexual orientation were found to have modest but statistically significant effects on occupational health. The absenteeism frequency was higher among women. Our data suggest improvements in terms of women’s occupational health in Portugal, but not gender equality, which indicates that there are still points to be improved. These findings also suggest the persistence of stigma related to sexual diversity and its effects on the occupational health of LGBTQIA+ and underscore the need for more inclusive workplace policies in Portugal. Full article

Background and Clinical Significance: Spiradenoma is a rare benign skin adnexal tumor with unknown incidence and prevalence, typically affecting young to middle-aged adults without a sexual predilection. Case Presentation: A 59-year-old woman presented with a palpable lesion in the suprapubic region that had been there for 20 years and had become enlarged over the past 2 months. Physical examination revealed a firm, non-tender, subcutaneous mass, approximately 2 cm in size, in the right pubic region. Ultrasound revealed a hypoechoic, heterogeneous lesion with a well-defined border, measuring 2.37 × 0.94 × 1.67 cm, without hypervascularity. Therefore, the patient underwent excision of the subcutaneous tumor. The pathology report confirmed the diagnosis of spiradenoma of the pubis. Histochemistry showed that the inner luminal cells were positive for CK7, and the outer basaloid cells were positive for p63. CD56 and CD117 were focally positive. Conclusions: With an accurate diagnosis and appropriate surgical excision, the prognosis for spiradenoma is generally excellent. However, a long-term follow-up is advisable. Full article

Introduction: Cervical mesonephric ductal adenocarcinoma (MA) is an HPV-independent adenocarcinoma that occurs in middle-aged women. MA originates from remnants of the Wolffian duct that usually regress in females once the induction of sex differentiation is activated. MA is a rare disease that accounts for less than 1% of all cervical adenocarcinomas. Clinical Case: We report a case of MA in which abdominal radical hysterectomy (ARH) was performed after neoadjuvant chemotherapy (NAC). The patient was a 66-year-old woman with abnormal genital bleeding. A colposcopy examination revealed macroscopic invasive cancer. A pelvic MRI scan revealed a 53 × 26 mm tumor in the cervix, and the histological diagnosis of the cervix was endometrioid carcinoma, with the diagnosis being cervical adenocarcinoma cT1b3N0M0. One course of NAC with paclitaxel-carboplatin (PC) was administered to shrink the tumor and stop the bleeding, and ARH was performed. Postoperative histopathological diagnosis was MA. The surgical margins of the resected specimen were negative, and NAC had been effective, so the patient underwent five courses of PC therapy after surgery. There has been no recurrence 12 months after surgery. Conclusions: There is no established standard treatment, but there are reports that PC therapy is effective. It is necessary to search for effective treatments by following up and accumulating further cases. Full article

This study aimed to investigate the effects of prolonged inhalation of nature-derived odors indoors on humans. Twenty-six women participated in this study. Heart rate variability, heart rate, blood pressure, pulse rate, estradiol, testosterone, and cortisol were used as indicators of autonomic nervous system and endocrine system activities. Profile of mood state, state–trait anxiety inventory, menopause rating scale and general sleep disturbance scale were used as psychological indicators. The order was as follows: After the participants relaxed in a chair for 5 min, their heart rate variability and heart rate were measured for 3 min with their eyes closed. Subsequently, blood pressure and pulse rate were measured, salivary samples were collected for estradiol, testosterone, and cortisol analyses, and a subjective assessment was conducted. The participants received a diffuser containing fir essential oil and were instructed on its usage and precautions. Subsequently, they returned home and inhaled the fir oil for a week. After 7 days, participants revisited the laboratory for posttest measurements, conducted at the same time as the pretest. Prolonged inhalation of the fir essential oil resulted in increased estradiol concentration, decreased systolic and diastolic blood pressure, relief of menopausal symptoms, reduced anxiety levels, improved sleep quality and mood states. Prolonged inhalation of the fir essential oil induced physiological and psychological relaxation on menopausal women. Full article

Thoracic outlet syndrome (TOS) is recognised in approximately 8% of the population. Vascular presentation is rare and diagnosis is often elusive due to its rarity. As episodes of TOS in the upper extremities are rare, proven protocols for rehabilitation management are lacking. The purpose of our article is to present a clinical examination protocol and a treatment protocol for patients after an episode of venous thrombosis in the upper limb (VTOS). We report the case of a middle-aged woman with right venous TOS with pain in the right upper extremity, accompanied by oedema and mild violet discolouration. The results after 10 sessions of physiotherapy were as follows: a reduction in symptoms of approximately 40%, an improvement of approximately 15% in sports performance, and an improvement of approximately 25% in work. There was also an improvement in the results of TOS provocation tests, i.e., a 50–100% improvement in pulse rate and about 30% less discolouration in the extremity. Additionally, there was a significant improvement in posture between the two sides of the upper quadrant. The results after 10 physiotherapy sessions are surprising due to chronic disease after the thrombosis episode. It appears that even after a long period of time since diagnosis, improvement is possible. Full article

The Count de Rethel: An Historical Novel (1779) can be ascribed to Georgiana Spencer Cavendish, Duchess of Devonshire (1757–1806) as a translation of Anecdotes de la cour de Philippe-Auguste (1733) by Marguerite de Lussan. The action is set at the court of Philip II of France, known as Philip Augustus, at the time of the war with King Henry II and the Crusade with Richard I, known as the Lionheart. This inspired revival of fictionalised medieval history heralding romanticism in the age of sensibility refashions the codes of chivalry according to the aesthetics of the second half of the eighteenth century. This essay focuses on the interplay between fiction and history, between the present of writing and the rewriting of history through Cavendish’s translational prism, featuring the Middle Ages as a golden age of heroism and the Count de Rethel as a paragon of ancient virtue set against contemporary men of fashion. Full article