Non-immune Intravascular Hemolytic Anemia, an Unusual Presentation of Severe Vitamin B-12 Deficiency.

Vitamin B12 deficiency is a multifactorial condition, with a wide range of clinical presentations from mild to severe anemia and anemia-related neurological deficits. Hemolysis is a unique cause but has increasingly been recognized lately as a possible B12 deficiency presentation. Our patient presented with hemolytic anemia, for which extensive workup has excluded the common hemolysis etiologies. Therefore, it was attributed to B12 deficiency and improved significantly after treatment. Our case highlights the significance of this unusual presentation and its clinical implementation.

Coronary Arteriovenous Fistula Originating From the Left Main Coronary Artery.

We report a case of coronary artery fistula arising from the left main coronary artery in a 62-year-old patient presenting with atrial fibrillation. He underwent a transthoracic echocardiogram which suggested a possible coronary artery fistula. Cardiac computed tomographic angiography and cardiac catheterization confirmed the diagnosis. Coronary artery fistula originated from the left main coronary artery, which is rare and terminated in the coronary sinus. Multi-modality imaging helps to delineate anatomy and decide treatment options. Small asymptomatic fistulas do not require treatment, and large or symptomatic fistulas need closure. Our patient was asymptomatic, and we opted for conservative management with close outpatient echocardiographic monitoring.

Superior Vena Cava Syndrome Due to Thrombosis: A Case Report.

Superior vena cava (SVC) syndrome is a clinical entity with signs and symptoms resulting from obstruction of blood flow through the SVC. The resulting obstruction leads to edema in the upper body, including the head, neck, and upper extremities. Clinical signs and symptoms can include plethora, cyanosis, dyspnea, stridor, cough, and hoarseness, as well as more serious complications such as cerebral edema leading to headache, confusion, and coma. Here, we present an interesting case of a 66-year-old female, with a medical history of esophageal cancer in remission and thyroid cancer currently undergoing radiation therapy, who was admitted for facial and upper extremity swelling. The initial impression was of angioedema or an allergic reaction. Imaging studies showed thrombus in the SVC resulting in SVC syndrome. The patient was treated with heparin initially, with a plan for an interventional radiologist to perform catheter-guided thrombolysis. However, the patient became unstable and ended up requiring mechanical ventilation. The patient was eventually discharged on oral anticoagulants. This case was rare as the patient developed SVC syndrome from venous thrombosis in the absence of any external tumor compression or as a result of an intravascular catheter.

Carotidynia Versus Transient Perivascular Inflammation of the Carotid Artery (TIPIC) Syndrome: Finding Common Ground.

Carotidynia remains mired in controversy. Whether to identify this self-limiting unilateral neck pain as a distinct clinical entity or a diagnostic sign associated with a variety of conditions remains a topic of ongoing debate. Adding to the discussion is the occasional finding on imaging studies of a transient inflammatory process surrounding the carotid artery in a number of individuals who present with unilateral neck pain. Although some use carotidynia as the designation of choice by which to identify this inflammatory process, the acronym TIPIC (transient perivascular inflammation of the carotid artery) syndrome is being touted as a far more descriptive and less contentious alternative. Having TIPIC syndrome replace carotidynia, however, need not necessarily signal the latter's outright elimination as some have advocated. When used as a diagnostic sign, carotidynia provides an appreciation of the many conditions that may be associated with idiopathic unilateral neck pain.

A Hybrid Model for Family History Information Identification and Relation Extraction: Development and Evaluation of an End-to-End Information Extraction System.

BACKGROUND: Family history information is important to assess the risk of inherited medical conditions. Natural language processing has the potential to extract this information from unstructured free-text notes to improve patient care and decision making. We describe the end-to-end information extraction system the Medical University of South Carolina team developed when participating in the 2019 National Natural Language Processing Clinical Challenge (n2c2)/Open Health Natural Language Processing (OHNLP) shared task. OBJECTIVE: This task involves identifying mentions of family members and observations in electronic health record text notes and recognizing the 2 types of relations (family member-living status relations and family member-observation relations). Our system aims to achieve a high level of performance by integrating heuristics and advanced information extraction methods. Our efforts also include improving the performance of 2 subtasks by exploiting additional labeled data and clinical text-based embedding models. METHODS: We present a hybrid method that combines machine learning and rule-based approaches. We implemented an end-to-end system with multiple information extraction and attribute classification components. For entity identification, we trained bidirectional long short-term memory deep learning models. These models incorporated static word embeddings and context-dependent embeddings. We created a voting ensemble that combined the predictions of all individual models. For relation extraction, we trained 2 relation extraction models. The first model determined the living status of each family member. The second model identified observations associated with each family member. We implemented online gradient descent models to extract related entity pairs. As part of postchallenge efforts, we used the BioCreative/OHNLP 2018 corpus and trained new models with the union of these 2 datasets. We also pretrained language models using clinical notes from the Medical Information Mart for Intensive Care (MIMIC-III) clinical database. RESULTS: The voting ensemble achieved better performance than individual classifiers. In the entity identification task, our top-performing system reached a precision of 78.90% and a recall of 83.84%. Our natural language processing system for entity identification took 3rd place out of 17 teams in the challenge. We ranked 4th out of 9 teams in the relation extraction task. Our system substantially benefited from the combination of the 2 datasets. Compared to our official submission with F1 scores of 81.30% and 64.94% for entity identification and relation extraction, respectively, the revised system yielded significantly better performance (P<.05) with F1 scores of 86.02% and 72.48%, respectively. CONCLUSIONS: We demonstrated that a hybrid model could be used to successfully extract family history information recorded in unstructured free-text notes. In this study, our approach to entity identification as a sequence labeling problem produced satisfactory results. Our postchallenge efforts significantly improved performance by leveraging additional labeled data and using word vector representations learned from large collections of clinical notes.

A Rare Presentation of a Rare Case: Acute Respiratory Failure in Swyer-James-Macleod Syndrome.

Swyer-James-Macleod syndrome (SJMS) is a rare clinical entity acquired during childhood due to a respiratory infection leading to bronchiolitis obliterans. This inciting event is hypothesized to cause structural and functional changes of the developing alveoli, terminal bronchioles, and the corresponding pulmonary vasculature, resulting in emphysematous changes and a matched ventilation-perfusion defect. We present a 67-year-old male patient with hypercapnic respiratory failure requiring invasive mechanical ventilation, who had typical features of SJMS undiagnosed before this admission. He was extubated successfully, discharged home, and continues to be stable at a 90-day follow-up period. This marks one of the rare accounts where a patient with SJMS was given ventilatory support emergently, and one of the oldest patients reported. SJMS is under-reported due to its indolent clinical course and misdiagnosed as some other pulmonary abnormality. The clinical course progression and prognosis are unclear and variable in many affected patients due to this condition's rarity.

Korean clinical entity recognition from diagnosis text using BERT.

BACKGROUND: While clinical entity recognition mostly aims at electronic health records (EHRs), there are also the demands of dealing with the other type of text data. Automatic medical diagnosis is an example of new applications using a different data source. In this work, we are interested in extracting Korean clinical entities from a new medical dataset, which is completely different from EHRs. The dataset is collected from an online QA site for medical diagnosis. Bidirectional Encoder Representations from Transformers (BERT), which is one of the best language representation models, is used to extract the entities. RESULTS: A slightly modified version of BERT labeling strategy replaces the original labeling to enhance the separation of postpositions in Korean. A new clinical entity recognition dataset that we construct, as well as a standard NER dataset, have been used for the experiments. A pre-trained multilingual BERT model is used for the initialization of the entity recognition model. BERT significantly outperforms a character-level bidirectional LSTM-CRF, a benchmark model, in terms of all metrics. The micro-averaged precision, recall, and f1 of BERT are 0.83, 0.85 and 0.84, whereas that of bi-LSTM-CRF are 0.82, 0.79 and 0.81 respectively. The recall values of BERT are especially better than that of the other model. It can be interpreted that the trained BERT model could detect out of vocabulary (OOV) words better than bi-LSTM-CRF. CONCLUSIONS: The recently developed BERT and its WordPiece tokenization are effective for the Korean clinical entity recognition. The experiments using a new dataset constructed for the purpose and a standard NER dataset show the superiority of BERT compared to a state-of-the-art method. To the best of our knowledge, this work is one of the first studies dealing with clinical entity extraction from non-EHR data.

Extracting entities with attributes in clinical text via joint deep learning.

OBJECTIVE: Extracting clinical entities and their attributes is a fundamental task of natural language processing (NLP) in the medical domain. This task is typically recognized as 2 sequential subtasks in a pipeline, clinical entity or attribute recognition followed by entity-attribute relation extraction. One problem of pipeline methods is that errors from entity recognition are unavoidably passed to relation extraction. We propose a novel joint deep learning method to recognize clinical entities or attributes and extract entity-attribute relations simultaneously. MATERIALS AND METHODS: The proposed method integrates 2 state-of-the-art methods for named entity recognition and relation extraction, namely bidirectional long short-term memory with conditional random field and bidirectional long short-term memory, into a unified framework. In this method, relation constraints between clinical entities and attributes and weights of the 2 subtasks are also considered simultaneously. We compare the method with other related methods (ie, pipeline methods and other joint deep learning methods) on an existing English corpus from SemEval-2015 and a newly developed Chinese corpus. RESULTS: Our proposed method achieves the best F1 of 74.46% on entity recognition and the best F1 of 50.21% on relation extraction on the English corpus, and 89.32% and 88.13% on the Chinese corpora, respectively, which outperform the other methods on both tasks. CONCLUSIONS: The joint deep learning-based method could improve both entity recognition and relation extraction from clinical text in both English and Chinese, indicating that the approach is promising.

Entity recognition in Chinese clinical text using attention-based CNN-LSTM-CRF.

BACKGROUND: Clinical entity recognition as a fundamental task of clinical text processing has been attracted a great deal of attention during the last decade. However, most studies focus on clinical text in English rather than other languages. Recently, a few researchers have began to study entity recognition in Chinese clinical text. METHODS: In this paper, a novel deep neural network, called attention-based CNN-LSTM-CRF, is proposed to recognize entities in Chinese clinical text. Attention-based CNN-LSTM-CRF is an extension of LSTM-CRF by introducing a CNN (convolutional neural network) layer after the input layer to capture local context information of words of interest and an attention layer before the CRF layer to select relevant words in the same sentence. RESULTS: In order to evaluate the proposed method, we compare it with other two currently popular methods, CRF (conditional random field) and LSTM-CRF, on two benchmark datasets. One of the datasets is publically available and only contains contiguous clinical entities, and the other one is constructed by us and contains contiguous and discontiguous clinical entities. Experimental results show that attention-based CNN-LSTM-CRF outperforms CRF and LSTM-CRF. CONCLUSIONS: CNN and attention mechanism are individually beneficial to LSTM-CRF-based Chinese clinical entity recognition system, no matter whether contiguous clinical entities are considered. The conribution of attention mechanism is greater than CNN.

Mitral Stenosis in Pregnancy: A Comprehensive Review of a Challenging Cardio-Obstetric Clinical Entity.

BACKGROUND: Mitral stenosis is one of the most commonly encountered valvular heart diseases during pregnancy, the majority are rheumatic in origin and poorly tolerated due to cardiocirculatory changes that occur during pregnancy, labor and postpartum. OBJECTIVE: The distinctive physiological events that arise during pregnancy and labor and the influence of mitral stenosis are tackled in this article. METHODS: Through PUBMED and MEDLINE searches, we reviewed the literature of the last decade as well as the recommendations from guidelines of high-impact worldwide. RESULTS: Cardiac decompensation usually takes place late in pregnancy as the hemodynamic burden of pregnancy become more pronounced as well as after delivery due to an abrupt increase of preload secondary to autotransfusion and aorto-caval decompression. The maternal and fetal complications correlate with the New York Heart Association (NYHA) functional classification and the grade of mitral stenosis. Medical therapy should be tried first. If symptoms continue in spite of optimal medical therapy, invasive procedures are recommended. Several studies revealed that vaginal delivery under epidural anesthesia is endurable and of low-risk unless obstetrically contraindicated. CONCLUSION: Pregnancy and mitral stenosis remain a complex entity and a well-known trigger of maternal mortality during pregnancy and peri-partum period if not managed adequately. A good appreciation and recognition of the physiology of pregnancy and its impact on the pre-existing mitral stenosis and the presence of a specialized multidisciplinary team to handle such cases significantly decrease maternal and fetal mortality and morbidity.

"Medô medo": investigação sobre a fobia em Freud, Lacan e autores contemporâneos a partir de um caso clínico / "Medô medo": investigation on the phobia in Freud, Lacan and contemporary authors from a clinical case

A partir de um caso clínico emerge a seguinte questão: a fobia deve ser considerada uma entidade clínica ou uma figura clínica a se presentificar em contextos diversos? O presente artigo investiga o item nas obras de Freud, Lacan e de dois autores da atua­lidade: Ricardo Diaz Romero e Charles Melman, que reacendem o debate em torno do tema. A psicanálise, como constructo teórico que surge a partir da escuta clínica de Freud, somente mantém seu sentido no que continua a nos possibilitar tratar o real da clínica pelo simbólico. Neste sentido é que, efetuado um percurso teórico, retornamos, ao final do artigo, à experiência clínica.

Fear fear: an investigation about phobia in Freud, Lacan and other contemporary authors (Diaz Romero and Charles Melman) based on a clinical case. A question emerges based on a clinical case: should phobia be considered a clinical entity or a clinical figure to make itself present in various contexts? The present article investigates this matter in the works of Freud, Lacan and two current authors that reignite the debate around the theme. Psychoanalysis, as a theoretical body to emerge from Freud's clinical listening, only maintains its reason of being in which it still makes possible for us to handle the real in clinical experience through the symbolic. It is in this sense that, trailing a theoretical path, we return to the clinical experience at the end of the article.

"Medô medo": investigação sobre a fobia em Freud, Lacan e autores contemporâneos a partir de um caso clínico

A partir de um caso clínico emerge a seguinte questão: a fobia deve ser considerada uma entidade clínica ou uma figura clínica a se presentificar em contextos diversos? O presente artigo investiga o item nas obras de Freud, Lacan e de dois autores da atua­lidade: Ricardo Diaz Romero e Charles Melman, que reacendem o debate em torno do tema. A psicanálise, como constructo teórico que surge a partir da escuta clínica de Freud, somente mantém seu sentido no que continua a nos possibilitar tratar o real da clínica pelo simbólico. Neste sentido é que, efetuado um percurso teórico, retornamos, ao final do artigo, à experiência clínica.(AU)

Fear fear: an investigation about phobia in Freud, Lacan and other contemporary authors (Diaz Romero and Charles Melman) based on a clinical case. A question emerges based on a clinical case: should phobia be considered a clinical entity or a clinical figure to make itself present in various contexts? The present article investigates this matter in the works of Freud, Lacan and two current authors that reignite the debate around the theme. Psychoanalysis, as a theoretical body to emerge from Freud's clinical listening, only maintains its reason of being in which it still makes possible for us to handle the real in clinical experience through the symbolic. It is in this sense that, trailing a theoretical path, we return to the clinical experience at the end of the article.(AU)

Cutaneous polyarteritis nodosa: an update.

Cutaneous symptoms are observed in 25%-60% of polyarteritis nodosa (PN) patients. On the other hand, cutaneous polyarteritis nodosa (CPN) is designated for the cutaneous limited form of PN and demonstrates benign prognosis. However, there has been much debate on whether or not CPN can progress to PN. Although CPN lesions are fundamentally limited to skin, some CPN cases show extracutaneous symptoms such as peripheral neuropathy and myalgia. According to PN diagnostic criteria, a disease with both cutaneous and at least one extracutaneous symptom with appropriate histopathological findings can be diagnosed as PN. The same is true according to diagnostic criteria established by American College of Rheumatology (ACR). In addition, there are no specific diagnostic criteria for CPN. In this study, CPN cases were retrospectively collected from multiple Japanese clinics, and analyzed for detailed clinical and histopathological manifestations, in order to redefine the clinical entity of CPN and to propose appropriate diagnostic criteria for CPN and PN. According to the CPN description in Rook's Textbook of Dermatology, one of global standard textbooks, we collected 22 cases with appropriate histopathological findings. Of the 22 cases, none progressed to PN or death during the follow-up period, 32% had peripheral neuropathy, and 27% had myalgia. Regarding extracutaneous symptoms with CPN, 17 dermatological specialists in vasculitis sustained the opinion that CPN can be accompanied by peripheral neuropathy and myalgia, but these symptoms are limited to the same area as skin lesions. Based on these results, we devised new drafts for CPN and PN diagnostic criteria. Our study shows the efficacy of these criteria, and most dermatologists recognized that our new diagnostic criteria for CPN and PN are appropriate at the present time. In conclusion, this study suggests that CPN does not progress to PN, and introduces new drafts for CPN and PN diagnostic criteria. (*English Translation of J Jpn Coll Angiol 2009; 49: 87-91.).