IntroductionMultiple Sclerosis (MS) is a chronic autoimmune disorder causing nerve sheath demyelination and symptoms such as muscle weakness, mobility decline, and lack of coordination 1,2, generating unique health challenges and an economic burden 3-5. Patients experience reductions in bone and skeletal muscle mass6, muscle strength and function 7,8, and increased fracture risk 9, negatively impacting quality of life 10. Lower limb strength impairments8, poor balance 11 and spasticity12 also contribute to a lower quality of life10. Pharmacological treatments have been the primary option for patients with MS 13.Recent research has explored non-pharmacological treatments such as exercise, nutritional supplementation, and improved sleep quality14-21. Resistance exercise (RE) is particularly beneficial for MS rehabilitation, as it improves muscle strength and function, mobility, quality of life 22,23, and the immune system 24. High-dose vitamin D supplementation raises interleukin-10 (IL-10) levels in MS patients19, who tend to have lower levels of IL-10, which may contribute to the disease’s development 25. However, RE and vitamin D may not always improve physical fitness20,21. This could be due to unsatisfactory energy and protein intake, containing essential amino acids (EAA), which are necessary to stimulate muscle protein synthesis (MPS) and ultimately address sarcopenia 26, a condition prevalent in MS patients 27. EAA-based supplements enriched with L-leucine increase protein intake and optimise MPS in healthy older adults without compromising total energy intake during mealtimes28,29 and plasma EAA concentration is associated with muscle function in older women in the community 30. A higher protein intake, including specific amino acids, may positively impact bone health through mechanisms such as increasing insulin-like growth factor 1 (IGF-1) 31,32. Therefore, addressing dietary protein deficiencies alongside RE may optimise musculoskeletal health and function in female MS patients. This case study evaluated the effects of a 24-week home-based intervention, including EAAs and vitamin D3 supplementation, on muscle, bone, muscle strength, and function in a female patient with MS.

A hunting arrow traumatism to the head: a case report from NigerAssoumane Issa Ibrahim1,2, Roméo Bujiriri Murhega1,2,3 , Sanoussi Samuila1,21. Department of Neurosurgery, National Hospital of Niamey, Niamey, Niger 2. Faculty of Health Sciences of the Abdou Moumouni University of Niamey, Niger 3. Faculty of medicine, catholic university of Bukavu, Democratic Republic of Congo Corresponding author : Roméo Bujiriri Murhega, quartier Harobanda, ville de Niamey, Niger, +22782078866,[email protected], ORCID: 0000-0002- 0022-6355Key clinical message Arrow injuries have not disappeared in our environment despite the advances in the development of warfare tools in the world. All regions of the body can be the target of these arrows and in particular the cephalic region whose gravity will depend on the structures reached. Abstract With the development of modern weapons of war, arrow wounds have become rare in developed countries, but they are still common in developing countries, including Niger. These injuries are often serious and life-threatening when they are in the head and neck region, due to the presence of major vessels and vital organs in these areas of the body. Extraction of these arrows is usually difficult due to the proximity of major vital structures. Unskilled extraction can aggravate the injury or result in unintentional damage to vital structures with imminent risk of death. We present the case of a patient with a homemade arrow to the head in the left periorbital region that we successfully extracted at the National Hospital in Niamey. Our objective is to highlight the experience with this patient and review some reports in the literature.Keywords: Arrow wounds, head wounds, NiameyIntroduction Since ancient times, since prehistoric times, arrows have been used as weapons of war in many civilizations, including African civilizations.1 With advances in technology, arrows as weapons of war are now almost abandoned in developed countries. Nevertheless, in developing countries, arrow injuries are still a reality.1,2In developing countries, for example, penetrating head injuries occur most often after fights and conflicts between farmers, and these situations are much more frequent in practice than the rarity of reported cases would suggest.2,3Arrow injuries are very rare.4,5 All areas of the body can be targets, including the cephalic region, and the severity of which depends on several factors. Among these factors, we cite, the distance at which the arrow was shot, the degree of penetration of the arrow and the application or not of poison on the arrowhead, which is a common practice.1 These injuries can affect any part of the human body, including the head and neck and can be fatal.6 These head and neck injuries are often life-threatening due to the presence of major vessels and vital organs. Management of these injuries is not always easy due to the proximity of major vital structures. We report on a patient who received a left periorbital arrow and was successfully treated.Case Report A 42-year-old patient from a region far from Niamey (the Diffa region), located 1,318.8 kilometers from the city of Niamey, was referred to the surgical emergency room of the national hospital in Niamey five days after a fight between farmers over agricultural land. On admission, he presented with an impacted arrow in the left orbital rim 1 cm lateral to the medial canthus (Figure 1). The patient was conscious, without signs of intracranial hypertension or focal signs. His vision was normal. The CT scan performed showed the extracranial path of the arrow. It crossed the left orbital rim, the base of the nose to the right external canthus without penetrating the cranium (Figure 2 ). The patient had received antibiotics and tetanus prophylaxis. He underwent wound exploration with arrow removal under general anesthesia(Figure 3). The arrow was approached through a left eyebrow incision. Dissection was completed to the tip of the arrow, and the arrow was gently removed. The patient did well after surgery, no complications were recorded, and he was discharged 1 week after admission. Postoperative follow-up has not noted any particularities to date and the wound has healed well (Figure 4). Discussion Head injuries are a major global public health problem. These traumas encompass a wide range of etiologies.7 Among these etiologies we can mention, accidents on the public road, accidents at work, sports, trauma by bullets, trauma by arrows etc. Head injuries from arrows are too rare in developed countries, but in developing countries they have not disappeared despite advances in the field of tools of war. In developing countries, peasants still value their agricultural land, which is a source of wealth and economy.2 Nevertheless, conflicts between them are frequent and are the source of fights that most often involve bladed weapons, including arrows. In this work we report the case of a patient suffering from an arrow trauma to the head after agricultural conflicts in his village. In the literature, very few cases are reported on head injuries by arrow. The clinical manifestation of penetrating arrow injuries in the head area depends on the structure affected and the severity of the injury. The degree and severity of the injuries depend on the distance at which the arrow was fired, the trajectory it followed, the degree of penetration and the possible application of poisons to the tip of the arrow.8 Poisoned arrows cause paralysis or severe infection of the wound depending on the nature of the poison.2,9 Poisoned arrows cause paralysis or severe infection of the wound depending on the nature of the poison.2 Brain and spinal cord injuries can lead to paraplegia, quadriplegia, ventricular hemorrhage, or immediate death.1 The good news is that our patient the path of the arrow was exclusively extracranial and the large vessels were not affected. The emergency action to be taken will depend on the clinical condition of the patient at admission. Patients whose injuries are immediately life-threatening should be treated urgently, while those who are clinically stable and have optimal hemodynamic status are examined before the decision to explore is made.10,11 Our patient was clinically stable and had received a complete and unremarkable clinical examination. CT scan is an essential examination for the lesion assessment of patients with arrow trauma to the head.1It is usually indicated in patients who are hemodynamically stable, which was the case for our patient. The scanner is a non-invasive diagnostic tool that determines the trajectory of the arrow and its relationship with vital structures.12 An attempt at blind extraction can lead to a serious disaster, especially if major vessels have been hit. Our patient was able to perform the cranioencephalic CT scan which clearly showed us the extracranial trajectory of the arrow.Conclusion Arrow wounds to the head have never disappeared in developing countries despite advances in the manufacture of tools of war. Care is difficult when noble structures are affected. The prognosis is life-threatening when there is damage to the large vessels, especially in a context of limited resources. The urgency of the emergency always depends on the patient’s clinical condition at the time of admission to hospital.ACKNOWLEDGMENT NoneCONFLICTS OF INTEREST NoneAUTHOR CONTRIBUTIONS Assoumane Issa Ibrahim and Roméo Bujiriri Murhega have designed, conceptualized the study, and written the first draft under the supervision of Sanoussi Samuila .ETHICAL STATEMENT This case report received ethical clearance from the Ethical committee of the university of the first author.CONSENT Written informed consent was signed by the patient prior to the publication of this paperDATA AVAILABILITY STATEMENT All the materials used in this study are available on request.Bibliography 1. Abdullahi H, Adamu A, Hasheem MG. Penetrating Arrow Injuries of the Head and-Neck Region: Case Series and Review of Literature. Niger Med J J Niger Med Assoc. 2020;61(5):276-280. doi:10.4103/nmj.NMJ_17_20 2. Olasoji HO, Tahir AA, Ahidjo A, Madziga A. Penetrating arrow injuries of the maxillofacial region. Br J Oral Maxillofac Surg. 2005;43(4):329-332. doi:10.1016/j.bjoms.2004.10.026 3. Olasoji HO, Tahir A, Arotiba GT. Changing picture of facial fractures in northern Nigeria. Br J Oral Maxillofac Surg. 2002;40(2):140-143. doi:10.1054/bjom.2001.0716 4. Peloponissios N, Halkic N, Moeschler O, Schnyder P, Vuilleumier H. Penetrating thoracic trauma in arrow injuries. Ann Thorac Surg. 2001;71(3):1019-1021. doi:10.1016/S0003-4975(00)02179-2 5. Brywczynski JJ, Barrett TW, Lyon JA, Cotton BA. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J EMJ. 2008;25(11):711-715. doi:10.1136/emj.2008.058792 6. Hain JR. Fatal arrow wounds. J Forensic Sci. 1989;34(3):691-693. 7. Menezes JM, Batra K, Zhitny VP. A Nationwide Analysis of Gunshot Wounds of the Head and Neck: Morbidity, Mortality, and Cost. J Craniofac Surg .:10.1097/SCS.0000000000009268. doi:10.1097/SCS.00000000000092688. Madhok BM, Roy DDD, Yeluri S. Penetrating arrow injuries in Western India. Injury. 2005;36(9):1045-1050. doi:10.1016/j.injury.2005.05.032 9. Milner GR. Nineteenth-Century Arrow Wounds and Perceptions of Prehistoric Warfare. Am Antiq. 2005;70(1):144-156. doi:10.2307/40035273 10. Ngakane H, Muckart DJJ, Luvuno FM. Penetrating visceral injuries of the neck: Results of a conservative management policy. Br J Surg. 2005;77(8):908-910. doi:10.1002/bjs.1800770822 11. Biffl WL, Moore EE, Rehse DH, Offner PJ, Franciose RJ, Burch JM. Selective management of penetrating neck trauma based on cervical level of injury. Am J Surg. 1997;174(6):678-682. doi:10.1016/S0002-9610(97)00195-5 12. Gracias VH. Computed Tomography in the Evaluation of Penetrating Neck Trauma: A Preliminary Study. Arch Surg. 2001;136(11):1231. doi:10.1001/archsurg.136.11.1231

1. INTRODUCTIONIntramuscular myxoma (IMM) are benign soft tissue that account for 0.1 to 0.13 per 100,000 populations (1). Various theories have been described regarding the mechanism of IMM occurrence. Some researchers suggest that the reason is fibroblasts (unable to synthesize collagen fibers) that are not well differentiated from mesenchymal stem cells, which cause the synthesis of myxoid stroma without reticular fibers. Others consider the etiology of IMM to be caused by traumatic mechanisms or the growth of polysaccharide-producing cells in the neoplastic process (2). IMM is rare and can occur in the buttocks, thigh, upper extremities and shoulder muscles. Epidemiologically, its occurrence rate is higher in women (70%), increases with age (6th and 7th decade of life) and the most common sites of IMM is upper extremities muscles (50%-60%) (3). According to the location of the masses, soft-tissue myxomas are classified into superficial angiomyxoma, intramuscular myxoma, nerve sheath myxoma and aggressive angiomyxoma. From the clinical point of view, IMM is a palpable mass, painless, without inflammatory secretions and symptoms, which has no contractile properties and no stretch-contraction changes during flexion-extension of the adjacent muscles (4).From a diagnostic point of view, IMM is observed as a non-calcified mass in plain radiograph, which is seen in the supplementary findings with the help of ultrasonography as echogenic cystic lesions among the muscle tissue. The most important diagnostic method of IMM from other soft tissue lesions is magnetic resonance imaging (MRI), which can be seen as hypointense homogeneous mass in T1-weighted sections and hyperintense in T2-weighted sections (5). In case of edema with IMM in MRI sections (T1-weighted sections), it should be differentiated from other fluid-containing lesions (such as cystic teratoma, hematoma, myxoid sarcoma, cystic hygroma and even normal lymph nodes). Also, IMM should be differentiated from proliferative lesions, other myxoid neoplasms, myxochondroma, myxochondroma and myxoid liposarcoma (6). Cytology-histopathology findings with the help of intraoperative frozen section and needle biopsy help the information of MRI sections in the diagnosis of IMM. Density and ratio of cells/ collagen fibers, mucoid material secretion, nodular-vesicular pattern and fat density in histopathological sections contribute to IMM (7). In the present case, forearm intramuscular myxoma was observed inter-supinator muscle.

A document by Kritika Mishra. Click on the document to view its contents.

Myeloid sarcoma is a rare extramedullary tumoral infiltration of immature myeloid cells and can occur in different sites of the body, without leukemic infiltration A 38-year-old woman patient presented at emergency with a pleural effusion and bicytopenias. In the following days, she worsened with a chylothorax and pancytopenias. Pleural puncture cytologically

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Manuscript prepared for submission to Clinical Case Reports

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We present a 10-year follow-up and describe our experience in managing a case of neonatal severe primary hyperparathyroidism (NSHPT) for the first time in Iran. Microcephaly, mental retardation and epilepsy may be long time sequels of NSHPT and the brain MRI findings are compatible with old hypoxic-ischemic event.

A Case report of atypical preeclampsia with severity criteria for hydatidiform complete mole.

Lyme Neuroborreliosis: A case reportBabak Sayad1, Arefeh Babazadeh2, Mohammad Barary3, Rezvan Hosseinzadeh4, Soheil Ebrahimpour2, Zeinab Mohseni Afshar1, *Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, IranInfectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, IranStudent Research Committee, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, IranStudent Research Committee, Babol University of Medical Sciences, Babol, Iran

Rare Presentation of Papillary Thyroid CancerMahfujul Z. Haque, BS1Michael Burcescu, MD2Zirak Sajjad, BS11Michigan State University College of Human Medicine, Grand Rapids, MI, USA2Detroit Medical Center, Detroit, MI, USAWord Count: 444Table/Figure Count: 4Reference Count: 4Acknowledgements: N/AFunding Sources: NoneConflicts of Interest: NoneConsent Statement: N/ACorresponding author:Mahfujul Haque15 Michigan St NE,Grand Rapids, MI 49503Email: [email protected] informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.Key Words: papillary thyroid cancer, thyroid nodule, neoplasm, endocrine cancerArticle Type: Case ImageThe patient is a 51-year-old African American female with incidental thyroid nodules identified on MRI of the cervical spine. Patient describes a tender palpable right thyroid nodule but is otherwise asymptomatic. There is no history of tobacco use or toxic occupational exposure. There is no palpable neck mass. Thyroid panel was within normal limits. The majority of parathyroid adenomas are located adjacent and posterior or just inferior to the thyroid gland. Rarely, an intrathyroidal ectopic parathyroid gland may become adenomatous and mimic thyroid nodule. When it does, it is usually homogenously hypoechoic to thyroid tissue and may demonstrate a peripheral rim of hyper-vascularity. Here we describe the case of an incidental nodule with irregular margins and punctate echogenic foci consistent with a TI-RADS 5 nodule and suggestive of malignancy.Fine needle aspiration biopsy of right upper thyroid nodule showed moderately cellular with cohesive groups as sheets and singly scattered cells exhibiting nuclear grooves, powdery chromatin, irregular nuclear outlines. A few intranuclear pseudo-inclusions are seen with some colloids in the background. True papillae, psammoma bodies, and necrosis were not detectable despite sampling with 3 adequate passes.Figure 1A is an axial T1 that demonstrates an unexpected nodule of the right thyroid lobe after gadolinium administration.Figure 1B demonstrates the same nodule with a traditional T1 view. Figure 1C demonstrates a T2 hyper intensive nodularity of the right thyroid lobe. Figure 2A demonstrates a long-axis ultrasound image of the right thyroid lobe revealed a 1.5 x 1.0 x 1.3 cm hypoechoic solid nodule with irregular margins, punctate echogenic foci, and mildly increased vascularity on color Doppler investigation.Figure 2B demonstrates a transverse ultrasound image of the right thyroid lobe showed a 1.5 x 1.0 x 1.3 cm hypoechoic solid nodule with irregular margins and punctate echogenic foci. Figure 3Ademonstrates a longitudinal-axis ultrasound image of the right thyroid lobe with a slight enlargement of the nodule, measuring 1.5 x 1.2 x 1.3 cm, with hypoechoic wider than tall features, irregular margins, and punctate echogenic foci, which are consistent with the previous sonographic evaluation. Figure 3B demonstrates a longitudinal-axis color Doppler image of the right thyroid lobe reveals increased vascularity within the thyroid nodule, indicating heightened blood flow to the nodule. Figure 4A demonstrates a Longitudinal-axis ultrasound image of the right thyroid lobe with further nodule enlargement to 1.9 x 1.3 x 0.9 cm.Studies report that 5-15% of all detected thyroid nodules and up to 11% of incidental thyroid nodules, represent malignancy [2]. The SEER database reports the USA incidence of thyroid carcinoma to be 14.9 per 100,000 with a 1:2.8 male to female predilection [3]. Papillary thyroid cancer (PTC), a common endocrine tumor originating from thyroid follicular cells, represents 85% of thyroid malignancy [1]. PTC is invasive and known to metastasize to adjacent structures including: lungs, mediastinal lymph nodes, and bone. Well-established risk factors for thyroid cancer include radiation exposure, family history of thyroid cancer, occupational exposure, and obesity [1].PTC is associated with favorable mortality of 11-17% and a low recurrence rate of 5-15% [1][4]. Extra-thyroidal growth, larger tumor size, and older age at diagnosis detrimentally impact outcome [1]. The primary treatment for PTC is surgical. Preprocedural considerations include tumor size, metastases, extra-thyroidal extension, and airway compromise. Patients with unifocal PTC, measuring > 4 cm, are candidates for thyroid lobectomy [1][5]. For larger lesions, total or near-total thyroidectomy is often required [1][5]. Ablation with radioactive iodine (RAI) is recommended for patients with residual tumor or metastasis. Additional considerations include patient age, microvascular invasion, and histologic subtyping [1]. RAI is performed 4 - 6 weeks following excision and repeated until residual radiotracer uptake is eliminated [1]. Successful intervention results in decreased serum thyroglobulin within 4 - 6 weeks. Thyroid hormone supplementation reduces tumor stimulation by suppressing TSH production [1]. Sonographic and biochemical recurrence monitoring are typically performed at 6-12 month intervals for at least 5 years.

IntroductionVasculitis is an inflammatory disease with variable end-organ damage that is classified based on involvement of small, medium or large vessels.1 Leukocytoclastic vasculitis is a small-vessel vasculitis predominantly affecting dermal capillaries and venules, and often secondary to underlying systemic vasculitis, infection or drug exposure.1 Commonly implicated drugs include beta-lactam antibiotics and non-steroidal anti-inflammatory drugs,1 while calcium channel blockers and hydroxymethylglutaryl-coA reductase inhibitors (statins) have been rarely associated2-6 – with no previous formal case report for verapamil. We present a case of cutaneous leukocytoclastic vasculitis associated with recently initiated verapamil and atorvastatin.

Title: Outcome of PML-RARα Short Isoform and FLT3-ITD in a Patient with Several Adverse Prognostic Markers: a Case ReportMohammed A Bafail1, Rahaf AlTahan1Manar A Samman1, Suha A Tashkandi1, Ibraheem H Motabi2 , Abdul Ali Peer-Zada1*

Leukemic retinopathy is a severe complication of severe leukocytosis that results from untreated chronic myelogenous leukemia (CML). Immediate cytoreduction via leukapheresis may reverse ocular manifestations and prevent permanent vision damage. We present a case of a patient with acute unilateral vision loss found to have leukemic retinopathy in the setting of

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Newborn with amniotic band sequenceAbstract: Amniotic band sequence (ABS) is an uncommon congenital disorder where strands of amniotic tissue cause entrapment of the limbs, body wall, and viscera leading to an array of congenital malformations. We report a case of a newborn with prenatally undiagnosed amniotic band sequence.Keywords: amniotic band sequence, amniotic band syndrome