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Objective This study aimed to analyze right-to-left shunt-related dizziness in three patients without hypoxemia. Methods Case 1 was a 47-year-old man with a history of cerebral infarction 8 years previously and recurrent dizziness for > 6 months. Patent foramen ovale (PFO) was found with a severe right-to-left shunt. Case 2 was a 50-year-old man with acute stroke. He had a history of repeated dizziness for > 4 years. He was diagnosed with PFO with a severe right-to-left shunt after admission. Case 3 was a 73-year-old woman with recurrent dizziness for > 10 months. Pulmonary arteriovenous fistula was diagnosed upon admission. No patients had hypoxemia. Results After percutaneous PFO occlusion in Cases 1 and 2, the patients were followed up for 6 months and 1 year, respectively. Two patients had relief of dizziness without recurrence. In Case 3, the pallor improved and the dizziness was relieved after pulmonary arteriovenous fistula embolization and did not recur over a 6-month follow-up. Conclusions There was a possible association between a severe right-to-left shunt and dizziness, although hypoxemia was absent in the cases. Intervention to eliminate a left-to-right shunt can improve dizziness in patients without hypoxemia with a severe right-to-left shunt.

Currently, there is relatively limited research regarding the relationship between the red blood cell distribution width to platelet ratio (RPR) and the prognosis of patients with acute ischemic stroke (AIS). Therefore, this study aims to investigate the association between RPR and the incidence of unfavorable functional outcomes in AIS patients. This study utilized a prospective cohort design and included 1,682 patients who had been diagnosed with AIS and were treated at Shenzhen Second People’s Hospital from January 2022 to June 2024. To evaluate the relationship between RPR and the incidence of 90-day unfavorable outcomes, a binary logistic regression model was employed. Furthermore, an additional logistic regression model that included cubic spline functions was utilized to investigate possible nonlinear associations between them. A range of sensitivity analyses and subgroup analyses were conducted to strengthen the reliability of the results. After adjusting for confounding variables, the binary logistic regression analysis demonstrated that for each 0.1 unit increase in RPR, the incidence of unfavorable outcomes at 90 days for AIS patients increased by 45.5% (OR = 1.455, 95% CI: 1.268–1.669). Additionally, the study found a nonlinear relationship between RPR and 90-day unfavorable outcomes, with an inflection point occurring at RPR = 0.33. On the left side of the inflection point, the OR for the relationship between RPR (per 0.1 unit) and 90-day unfavorable outcomes was 1.708 (95% CI: 1.403–2.080). On the right side of the inflection point, the OR for their relationship was 0.942 (95% CI: 0.630–1.410). Sensitivity analysis further confirmed the reliability of these results. This study identifies a distinct positive link between RPR and 90-day unfavorable outcomes in patients with AIS. Additionally, a non-linear relationship was observed in the relationship between them. Specifically, when the RPR value falls below 0.33, a significant positive association is noted. These findings offer valuable insights for improving rehabilitation strategies and enhancing clinical management for AIS patients.

Background Hepatocellular carcinoma (HCC) is the third most common malignant tumor after gastric cancer and esophageal cancer, which is a serious threat to human health. Methyltransferase-like protein 16 (METTL16) regulates the occurrence and development of various cancers, but its molecular mechanism in HCC has not been fully investigated. Methods A series of databases were used to predict gene expression, methylation sites, correlation analysis, and protein interaction analysis. Gene expression levels were detected by quantitative real-time polymerase chain reaction (qRT-PCR), western blot, and immunohistochemistry (IHC). What’s more, drug-resistant cell lines were established for drug resistance analysis. Cell proliferation was measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and 5-ethynyl-2’-deoxyuridine (EdU) staining. Flow cytometry, transwell and wound healing assays were used for apoptosis, invasion and migration, respectively. In addition, the regulatory mechanism of METTL16 in HCC was investigated by methylated RNA immunoprecipitation (MeRIP), RNA immunoprecipitation (RIP) and co-immunoprecipitation (Co-IP). Finally, constructing subcutaneous transplanted tumor in nude mice confirmed the effect of METTL16 in vivo. Results METTL16 was up-regulated in HCC drug-resistant tissues and cells. Knockdown of METTL16 inhibited Cisplatin (DDP) resistance, proliferation, invasion and migration of HCC cells, but promoted apoptosis. Besides, laminin subunit alpha 4 (LAMA4), which was overexpressed in HCC drug-resistant tissues and cells, was selected as the target of METTL16. Mechanistically, METTL16 and m6A reader insulin like growth factor 2 mRNA binding protein 2 (IGF2BP2) co-regulated the m6A modification and mRNA stability of LAMA4, and LAMA4 weakened the effects of METTL16 knockdown on HCC drug-resistance. Meanwhile, LAMA4 bound to collagen type IV alpha 1 chain (COL4A1) and facilitated DDP resistance and HCC progression via COL4A1. Similarly, in vivo, METTL16 induced tumor growth, as well as LAMA4 and COL4A1 expression, and increased DDP resistance. Conclusion METTL16 and IGF2BP2 jointly mediated the m6A methylation modification of LAMA4, thereby promoting DDP resistance and malignant progression of HCC through regulation of COL4A1.

Background Talaromycosis is an aggressive and life-threatening disease, caused by the pathogen Talaromyces marneffei ( T. marneffei ) which was first isolated from the bamboo rats ( Rhizomys sinensis ). T. marneffei was traditionally known for its high incidence and mortality rates in human immunodeficiency virus (HIV) patients. Epidemiological data reveal a concerning upward trend of infections among HIV-negative individuals, including immunocompetent hosts. At the meantime, although the bamboo rats have been reported to be associated with T. marneffei infection, there is a noticeable rising trend of the bamboo rats hunting and farming industry. Public awareness regarding the zoonotic transmission risks associated with these rodents remains limited. Case presentation We report five cases of T. marneffei infection occurring within a single year, all involving individuals with a history of hunting wild bamboo rats ( Rhizomys spp., likely Rhizomys sinensis ). All five patients underwent HIV testing upon admission, with uniformly negative results. Notably, other immunodeficiency diseases, chronic comorbidities or prior immunosuppressive therapy were not found in these patients. The clustered emergence of these cases—affecting immunocompetent individuals within neighboring geographic areas over a brief timeframe, all sharing exposure through bamboo rat hunting—warrants detailed characterization. We herein present clinical profiles of these five cases. Conclusions These cases demonstrate epidemiological associations between contact with wild bamboo rats and T. marneffei infections in immunocompetent individuals. The atypical clinical symptoms and variable imaging manifestations of T. marneffei infection may lead to increased underdiagnosis and misdiagnosis. Systematic implementation of exposure history, particularly documenting contact with wild animals for patients with pulmonary infection to make a timely diagnosis. This study also underscores the urgent need for public awareness regarding the potential risks of T. marneffei infections associated with hunting wild bamboo rats and the bamboo rat farming industry.

In the modern medical education system, teaching of clinical neurology in outpatient settings is crucial for training future neurologists. The neurology outpatient clinic is a pivotal setting for both initial consultations and follow-up visits. It plays a significant role in the prevention, diagnosis, treatment, and ongoing monitoring of neurological disorders, and is a critical platform for clinical education. Under the guidance of experienced physicians during their clinical rotations, medical students enhance their clinical reasoning ability and skills by learning about the diagnosis and treatment of neurological diseases, thereby laying a solid foundation for becoming competent doctors. Despite the advancements in this field, there is a lack of comprehensive reports on the current status and challenges of teaching neurology in outpatient settings. This gap significantly impedes the development of scientific policies to improve teaching standards. We need to clarify the existing issues to develop effective strategies, such as actively embracing advanced educational achievements and experiences, continuously refining teaching models and methods, and enhancing the quality of education, to cultivate more outstanding medical professionals. This article summarizes the current state and issues of teaching clinical neurology in outpatient settings, and analyzes countermeasures to provide a foundation for future practice and study.

Abstract IntroductionAs acquired immunodeficiency syndrome (AIDS) becomes more widespread, there will be an increasing need for diagnostic AIDS-related neurological syndromes. AIDS-related myelitis is easy to be ignored, and AIDS-related longitudinal myelitis has not yet been reported.Case presentationA 45-year-old male patient was admitted to our hospital after 3 days of progressive slurred speech and limb weakness. Neurologic examination revealed near-complete four-limb paralysis with dyspnea, dysarthria, and neck rigidity. Contrast-enhanced T2-weighted magnetic resonance imaging showed hyperintensities within the entire spinal cord. Cerebrospinal fluid analysis showed elevated white blood cell count and protein level. He was administered high-dose immunoglobulin and methylprednisolone. There was rapid regression in his symptoms after a month of therapy.ConclusionsThis unique presentation of AIDS with longitudinal myelitis involving the entire spinal cord enriches our understanding of the clinical spectrum of this condition. Our case provides essential information for the diagnosis and treatment of longitudinal myelitis in AIDS patients.

Background Patients with severe thalassemia may experience adverse effects from transfusion such as fever, rash, and iron overload after long-term transfusion therapy. Severe headaches as a side effect of blood transfusion in patients with thalassemia are not commonly observed, especially when combined with superficial siderosis of the central nervous system, which is easily misdiagnosed and requires excessive examination and treatment. Case Presentation A 31-year-old woman was admitted with severe headache and vomiting over 3 days following blood transfusion. She was diagnosed with intermediate α-thalassemia at 2 years of age and had a history of irregular blood transfusions. Physical examination revealed horizontal nystagmus with no other abnormal neurological signs. Magnetic resonance (MR) imaging, MR venography, MR arteriography, and cerebrospinal fluid analysis were normal. However, susceptibility-weighted imaging showed abnormal signals in the bilateral and fourth ventricles. Initial antibiotics, antivirals, decompression of intracranial pressure, iron chelation, and symptomatic treatments were administered; subsequently, small intermittent blood transfusions were cautiously administered for severe anemia. The patient’s headache was gradually relieved, and she was discharged on day 9. At the 5-month follow-up, the patient’s headache recurred following another transfusion. Conclusions Severe post-transfusion headache in patients with thalassemia has not been fully recognized and is easily misdiagnosed, leading to excessive examination and treatment. Understanding the clinical features of transfusion-related headaches can help identify this complication, but the exact pathophysiological mechanism requires further research.

ObjectiveTo analyze the clinical profile and long-term prognosis of relapsing anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis.MethodThis is a retrospective, multicenter, self-controlled study of 10 patients with relapsing anti-NMDAR encephalitis. Relapse was defined as new psychiatric or neurologic syndrome unexplainable by other causes that improved after immunotherapy.ResultsThe main symptoms at first onset and relapse included psychiatric symptoms, cognitive impairment, speech dysfunction, seizures, consciousness disturbance, movement disorders, central hypoventilation, and autonomic dysfunction. There were significantly fewer seizures and consciousness disturbances at relapse. At the first onset, the antibody positivity rate was significantly higher in the cerebrospinal fluid (CSF) than in the serum, and abnormal electroencephalograms results were noted in all patients. The relapse rate was 12.2%. After first-onset discharge, the duration of medication intake was 3.10 ± 2.69 months; the relapse time was 18.3 ± 16.5 months. The Modified Rankin Scale (MRS) score at relapse was significantly lower than that at the first onset. The MRS scores at relapse and first onset after immunotherapy were significantly lower than those before immunotherapy. At follow-up, the average duration of antiepileptic drug (AED) intake was < 1 year; the relapse rate was low.ConclusionsPatients have fewer symptoms and better quality of life at relapse than at the first onset. Active immunotherapy can significantly improve the quality of life during first onset and relapse. Encephalitis antibody testing in the CSF is preferred at first onset and relapse. Increasing antibody titers suggest clinical relapse. Prematurely stopping immunotherapy may lead to relapse, but prolonged AED intake is unnecessary.

Myasthenia gravis (MG) and premature ovarian failure (POF) are rare. MF and POF greatly affect patients’ health. Combined occurrence of MF and POF in young women can have serious consequences. We report two cases of MG with POF. Case 1 was a 20-year-old woman who presented with myasthenic crisis and menopause in September 2015 and November 2015, respectively. The patient’s estradiol and follicle-stimulating hormone levels were abnormal. She was administered plasmapheresis and methylprednisolone pulse therapy. She improved and was discharged with normal restoration of menstruation after 3 months. Case 2 was a 21-year-old woman who had right eyelid droop and double vision in June 2014. She presented with menstrual disorder and menopause in August 2014 and September 2014, respectively. Estradiol and follicle-stimulating hormone levels were abnormal. She underwent progesterone therapy. She was admitted to hospital again in March 2016 with a myasthenic crisis. She received methylprednisolone pulse therapy and underwent thymectomy, but menstruation was not restored. In conclusion, there is comorbidity of POF in MG, and there is a close relationship between these two diseases. MG may subsequently lead to development of POF, and timely immunotherapy for MG may normalize POF.

Patients with essential thrombocythemia (ET) can experience hemorrhagic or ischemic vascular events. The prevention of these complications is challenging, and the overall risk of vascular events caused by ET is often overlooked. A 34-year-old man was admitted for a 10-day history of weakness and numbness in his right limbs. He had been diagnosed with ET in 2008 but had stopped receiving treatment half a year before admission. Physical examination showed a superficial sense of disturbance in the right limbs and decreased muscle strength in the right upper and lower limbs (4/5). His platelet count (459 × 109/L) was elevated. Magnetic resonance imaging showed acute watershed infarction, and he was treated successfully. However, he was readmitted for headache and left limb weakness 14 months later. A head computed tomography scan revealed spontaneous subdural hemorrhage. He underwent subdural hematoma removal and decompressive craniectomy. Surgery and pathological investigation revealed no venous sinus thrombosis or vascular malformation. His condition improved, and he exhibited a stable condition 1 year after discharge. Successive development of ischemic stroke and spontaneous subdural hemorrhage is rare in a patient with ET. This case suggests that ET is not only a risk factor for stroke but can also cause highly heterogeneous strokes.