Managing valproic acid toxicity-related hyperammonaemia: an unpredicted course

A 20-year-old woman presented following an intentional overdose of valproic acid. Use of valproic acid, either acute or chronic, can result in hyperammonaemia. Mild hyperammonaemia with chronic use is mostly asymptomatic but can also present with concern for encephalopathy. Acute valproic acid toxicity results in significant hyperammonaemia, which can contribute to encephalopathy. Levocarnitine is the treatment of choice in valproic acid toxicity-related hyperammonaemia. For severe cases of encephalopathy, intermittent haemodialysis can also be considered. To our knowledge, this is the first case report to clearly show symptom relapse and hyperammonaemia after discontinuing levocarnitine. We recommend levocarnitine therapy for at least 72 hours, followed by an additional 24 hours of monitoring for symptom relapse and hyperammonaemia after levocarnitine discontinuation.

Relapsed Symptoms in a Patient Treated for Pubic Symphysis Septic Arthritis/Adjacent Osteomyelitis: Diagnostic Challenges

We describe the case of a 14-year-old girl with relapsed pain following adequate treatment of pubic symphysis septic arthritis with adjacent osteomyelitis. Evaluation of her symptoms was challenging, because magnetic resonance imaging (MRI) was not helpful and repeat surgical exploration was not favored. She was treated with a combination of prolonged antimicrobial therapy and local steroid injection. This case highlights the limitations of MRI as a follow-up study for evaluating symptom relapse of acute osteomyelitis.

Impact of a New Parent Behavioral-Schema Training on Children with ADHD: A Pragmatic Control Trial

Objectives: To examine whether adding schema therapy strategies to the conventional parent behavioral program prevents symptom relapse in children with attention deficit hyperactivity disorder (ADHD). Method: The intervention was designed as an adaptive pragmatic control trial. The parent behavioral training and schema-enhanced parent behavior therapy (SPBT) protocols were delivered to the control group (40 parents of 23 children) and experimental group (97 parents of 54 children), respectively. Participants were assessed at baseline, mid-treatment, and termination. Parents and teachers indicated the severity of ADHD and comorbid symptoms through their responses to standardized questionnaires designed for this purpose. Results: A nested growth curve analysis demonstrated that participants in the schema-enhanced intervention group had a lower risk of symptom relapse than the control group. Conclusion: Participation in the SPBT program significantly reduced relapse rates by the end of the intervention. Future research may determine the long-term effects of the treatment.

COVID-19 in Iran, a comprehensive investigation from exposure to treatment outcomes

Background There is a growing need for information regarding the recent coronavirus disease of 2019 (Covid-19). We present a comprehensive report of Covid-19 patients in Iran.Methods One hundred hospitalized patients with Covid-19 were studied. Data on potential source of exposure, demographic, clinical, and paraclinical features, therapy outcome, and post-discharge follow-up were analyzed.Results The median age of the patients was 58 years, and the majority of the patients (72.7%) were above 50 years of age. Fever was present in 45.2% of the patients on admission. The most common clinical symptoms were shortness of breath (74%) and cough (68%). Most patients had elevated C-reactive protein (92.3%), elevated erythrocyte sedimentation rate (82.9%), lymphocytopenia (74.2 %) on admission. Lower lobes of the lung were most commonly involved, and ground-glass opacity (81.8%) was the most frequent finding in CT scans. The administration of hydroxychloroquine improved the clinical outcome of the patients. Lopinavir/ritonavir was efficacious at younger ages. Of the 70 discharged patients, 40% had symptom relapse, (8.6%) were readmitted to the hospital, and 3 patients (4.3%) died.Conclusions This report demonstrates a heterogeneous nature of clinical manifestations in patients affected with Covid-19. The most common presenting symptoms are non-specific, so attention should be made on broader testing, especially in age groups with the greatest risk and younger individuals who can serve as carriers of the disease. Hydroxychloroquine and lopinavir/ritonavir (in younger age group) can be potential treatment options. Finally, patients discharged from the hospital should be followed up because of potential symptom relapse.

COVID-19 in Iran, a comprehensive investigation from exposure to treatment outcomes

PurposeThere is a growing need for information regarding the recent coronavirus disease of 2019 (Covid-19). We present a comprehensive report of Covid-19 patients in Iran.MethodsOne hundred hospitalized patients with Covid-19 were studied. Data on potential source of exposure, demographic, clinical, and paraclinical features, therapy outcome, and post-discharge follow-up were analyzed.ResultsThe median age of the patients was 58 years, and the majority of the patients (72.7%) were above 50 years of age. Fever was present in 45.2% of the patients on admission. The most common clinical symptoms were shortness of breath (74%) and cough (68%). Most patients had elevated C-reactive protein (92.3%), elevated erythrocyte sedimentation rate (82.9%), lymphocytopenia (74.2 %) on admission. Lower lobes of the lung were most commonly involved, and ground-glass opacity (81.8%) was the most frequent finding in CT scans. The administration of hydroxychloroquine improved the clinical outcome of the patients. Lopinavir/ritonavir was efficacious at younger ages. Of the 70 discharged patients, 40% had symptom relapse, (8.6%) were readmitted to the hospital, and 3 patients (4.3%) died.ConclusionThis report demonstrates a heterogeneous nature of clinical manifestations in patients affected with Covid-19. The most common presenting symptoms are non-specific, so attention should be made on broader testing, especially in age groups with the greatest risk and younger individuals who can serve as carriers of the disease. Hydroxychloroquine and lopinavir/ritonavir (in younger age group) can be potential treatment options. Finally, patients discharged from the hospital should be followed up because of potential symptom relapse.

Effectiveness of Tocilizumab in the Treatment of Fasciitis with Eosinophilia: Two Case Reports

Fasciitis with eosinophilia (FE) is a rare connective tissue disease. Due to its rarity, large-scale studies are lacking, which makes its treatment challenging. Systemic corticosteroids (SCSs) are the cornerstone of treatment; however, additional immunosuppressive drugs (ISDs) are frequently necessary (usually methotrexate). We report 2 patients, for whom an SCS and methotrexate were not a viable long-term option. In the first case, we were unable to taper the SCS dose without symptom relapse, the patient showed only a partial response to methotrexate and presented side effects. The second case never fully responded to the SCS and methotrexate and demonstrated serious SCS adverse effects. Both patients were started on tocilizumab with extremely favourable results, making this drug a potential therapeutic weapon for these patients.

Subungal Squamous Cell Carcinoma: A Case Report

Malignant tumors of the hand are rare. Squamous cell carcinoma (SCC) is the most common tumor that can develop at the nail bed. However, its prevalence is extremely rare. We report a male patient with SCC in the middle finger and provide a review of related literature. A 70-year-old male patient presented with subungal exudate of the right middle finger for 2 years. The lesion was treated by the patient himself without any relief. He visited the other hospital and underwent removal of the affected fingernail followed by histopathological examination. An extended excision was performed to remove the lesion located in close proximity with the distal phalanx along with a portion of the phalangeal soft tissues. The tumor shows malignant squamous sheets and nests with invasive growth pattern and pleomorphism. At the 6-month postoperative follow-up, neither symptom relapse nor other complications were observed. Various types of skin cancers, such as SCCs and malignant melanomas, can develop in the hand. However, their incidence is extremely rare. In particular, subungal lesions, which may be mistaken as fungal nail infections, require histopathological examination if they respond only slowly to treatment.

Posterior Percutaneous Endoscopic Cervical Diskectomy as a treatment for cervical radiculopathy

Anterior cervical diskectomy and fusion (ACDF) is the gold standard treatment for patients with cervical radiculopathy. However, the use of ACDF for patients with cervical radiculopathy can result in several disadvantages, such as limitation of motion and accelerating degeneration of adjacent segment. An alternative, less invasive endoscopic technique, posterior percutaneous endoscopic cervical diskectomy (PPECD), was applied to address the above problems associated with ACDF. The patient presented with pain and weakness of the left arm for 2 years. P-PECD was applied and complete decompression of the nerve root was achieved. The symptoms were relieved after surgery. Postoperative MR showed the ruptured disk fragment was successful removed. No spinal instability or symptom relapse was observed in follow-up. PPECD may be an option for patients with cervical radiculopathy.