BACKGROUND: Tandem spinal stenosis (TSS) is a condition characterized by the narrowing of the spinal canal in multiple segments of the spine. Predominantly observed in the cervical and lumbar regions, TSS also manifests in the conjunction of the cervical and thoracic spine. The simultaneous occurrence of cervical and thoracic spinal stenosis engenders intricate symptoms, potentially leading to missed and delayed diagnosis. Furthermore, the presence of tandem cervical and thoracic stenosis (TCTS) introduces a notable impact on the decision-making calculus of surgeons when contemplating either one-staged or two-staged surgery. Currently, there is no agreed-upon strategy for surgical intervention of TCTS in the literature.
METHODS: Medical databases in English (Pubmed, Web of Science, Embase, the Cochrane Database of Systematic Reviews) and Chinese (CNKI, Wanfang Data, VIP CMJD) were searched using Medical Subject Heading queries for the terms \"tandem cervical and thoracic stenosis\", \"cervical stenosis AND thoracic stenosis\", \"tandem spinal stenosis\" and \"concomitant spinal stenosis\" from January 1980 to March 2023. We included studies involving adult individuals with TCTS. Articles exclusively focused on disorders within a single spine region or devoid of any mention of spinal disorders were excluded.
RESULTS: Initially, a total of 1625 literatures underwent consideration for inclusion in the study. Following the elimination of the duplicates through the utilization of EndNote, and a meticulous screening process involving scrutiny of abstracts and full-texts, 23 clinical studies met the predefined inclusion criteria. Of these, 2 studies solely focused on missed diagnosis, 19 studies exclusively discussed surgical strategy for TCTS, and 2 articles evaluated both surgical strategy and missed diagnosis.
CONCLUSIONS: Our study revealed a missed diagnosis rate of 7.2% in TCTS, with the thoracic stenosis emerging as the predominant area susceptible to oversight. Therefore, the meticulous identification of TCTS assumes paramount significance as the inaugural step in its effective management. While both one-staged and two-staged surgeries have exhibited efficacy in addressing TCTS, the selection of the optimal surgical plan should be contingent upon the individualized circumstances of the patients.

Joint hypermobility syndromes, particularly chronic pain associated with this condition, including Hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD), present diagnostic challenges due to their multifactorial origins and remain poorly understood from biomechanical and genomic-molecular perspectives. Recent diagnostic guidelines have differentiated hEDS, HSD, and benign joint hypermobility, providing a more objective diagnostic framework. However, incorrect diagnoses and underdiagnoses persist, leading to prolonged journeys for affected individuals. Musculoskeletal manifestations, chronic pain, dysautonomia, and gastrointestinal symptoms illustrate the multifactorial impact of these conditions, affecting both the physical and emotional well-being of affected individuals. Infrared thermography (IRT) emerges as a promising tool for joint assessment, especially in detecting inflammatory processes. Thermal distribution patterns offer valuable insights into joint dysfunctions, although the direct correlation between pain and inflammation remains challenging. The prevalence of neuropathies among hypermobile individuals accentuates the discordance between pain perception and thermographic findings, further complicating diagnosis and management. Despite its potential, the clinical integration of IRT faces challenges, with conflicting evidence hindering its adoption. However, studies demonstrate objective temperature disparities between healthy and diseased joints, especially under dynamic thermography, suggesting its potential utility in clinical practice. Future research focused on refining diagnostic criteria and elucidating the underlying mechanisms of hypermobility syndromes will be essential to improve diagnostic accuracy and enhance patient care in this complex and multidimensional context.

Tuberculosis (TB) is the leading infectious cause of mortality in sub-Saharan Africa (SSA); the high prevalence of TB in this region is due to human immunodeficiency virus (HIV)-coinfection. Despite the advent of modalities to diagnose TB, undiagnosed TB-related deaths among HIV-infected patients remain significantly high. This systematic review aims at characterizing missed TB cases from postmortem studies. This review informs on the burden of TB missed diagnosis and highlights the need of improving TB case-finding strategies, especially among the high-risk groups and early TB therapy initiation to keeping in with the World Health Organization\'s end TB strategy. We searched PubMed, Cochrane, Web of Science, and African journals online for studies that looked into missed TB cases following postmortem using the following key terms: postmortem, TB diagnosis, and HIV; we included cross-sectional and cohorts from 1980 in the English language that were carried out in SSA among adults\' population. Authors used the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for reporting, the quality of the included studies was assessed using the Newcastle-Ottawa Scale for observational studies, and STATA 17.0 software was used for analysis. This study was registered in the International Prospective Register of Systematic Reviews with registration number CRD42024507515. The combined prevalence of postmortem missed TB diagnosis among the 6025 participants was 27.13% (95% confidence interval [CI] =14.52-41.89), with a high level of heterogeneity at 98.65% (P < 0.001). The prevalence varied significantly across the included studies, ranging from 1.21% (95% CI = 0.93-1.59) in the general population to 66.67% (95% CI = 50.98-79.37) in people living with HIV (PLWHIV). This current literature suggests that SSA is a region with a high prevalence of missed TB cases but with significant variations between countries. In addition, this study confirms a high number of missed TB infections within the PLWHIV. These results highlight the immediate need for targeted screening and diagnosis strategies and relevant policies.

Granulomatous lobular mastitis (GLM) is a benign and infrequent chronic breast ailment. Although this lesion can be clinically and radiographically mistaken for early-onset breast cancer, it is a rare occurrence for the two to coexist. This report describes three such cases. In all three patients, the primary signs and symptoms were related to the formation of diffuse breast masses or abscesses. Breast ultrasound and MRI revealed glandular edema and dilated breast ducts. The biopsies of all lesions exhibited both granulomatous inflammation confined to the lobules of the breast, abundant interstitial inflammatory cell infiltrates, and apparently cancerous cells located in dilated ducts with intact basement membranes. The surgically excised specimens confirmed the diagnosis of GLM and ductal carcinoma in situ (DCIS) in all three patients who underwent breast mass resection. By clinical imaging and clinical manifestations, GLM may obscure a concurrent DCIS, as highlighted by the cases reported herein.

Thyrotoxic periodic paralysis (TPP) is a rare condition that presents with episodic periodic paralysis due to hypokalemia that develops from hyperthyroidism. Timely diagnosis is still an ongoing challenge due to lack of awareness, self-resolving episodes, and the fact that it clinically mimics familial hypokalemic periodic paralysis (FHPP), which is more common in the West. TPP is more commonly seen among Asians but has been emerging in Western countries due to globalization. We present a case of a 24-year-old Hispanic male who presented with bilateral lower extremity weakness. He had five such episodes in the past year, which resolved on their own. The current episode of weakness was worse, and he required a wheelchair to ambulate. Despite extensive work, it took over four months to make a definitive diagnosis and treat his hyperthyroidism. A literature review reported that most cases of TPP are usually diagnosed after multiple episodes, and the causes of diagnostic error were studied. Through this review, we present a case of TPP with diagnostic delay, a literature review discussing the etiology, pathogenesis, clinical manifestations, and management, with an emphasis on the diagnostic challenge of TPP. Awareness of this condition, timely evaluation for hyperthyroidism as a cause for hypokalemic periodic paralysis, and understanding the factors that contribute to its diagnostic challenge will aid in timely recognition and treatment.

BACKGROUND: The purpose of this study was to qualitatively explore patient-reported barriers to surgery for primary hyperparathyroidism (PHPT) and identify actionable interventions to improve access to surgical care.
METHODS: We recruited forty-nine patients in an endocrine surgery clinic at a large, academic medical to participate in an 11- question phone interview. All interviewees underwent parathyroidectomy for primary hyperparathyroidism. Responses were recorded and a codebook of qualitative themes, blinded to patient race and sex, was created by 3 independent reviewers. Comments were subsequently sorted into the codebook with patient demographic information.
RESULTS: Patients that experienced delays in parathyroidectomy most commonly cited \"issues with the referral process\" and \"missed diagnosis\" as the cause. Patients were asked to identify the most challenging part about the surgery process. Commonly evoked themes among patients of both races and sexes included \"transportation\" and \"financial\" with subthemes of \"no ride,\" \"distance from surgeon,\" \"insurance,\" and \"difficulty taking time off work.\" Patients were asked to name actionable interventions to improve access to surgical care. The most commonly evoked theme involved \"support systems,\" with subthemes of \"transportation assistance,\" \"financial,\" and \"patient advocacy.\" Physician factors were also commonly evoked among patients of both races with subthemes of \"knowledge\", \"communication,\" and \"listening.\"
CONCLUSIONS: PHPT patients cited multiple barriers to undergoing surgery. Future work can focus on examining these questions with a larger patient cohort and examining delays at the referral and diagnosis stage, which was most commonly cited by our respondents.

Urinary ascites represents a scarcely observed pseudo-acute kidney injury in clinical settings. Protracted or missed diagnosis may hold grave ramifications for patient outcomes.
We reported a case involving an elderly female patient experiencing pseudo-acute kidney injury accompanied by ascites, wherein her renal dysfunction persisted despite medical intervention and hemodialysis. Urinary ascites was identified via a methylene blue test and by contrasting creatinine levels in serum and ascites. This patient\'s kidney function was multiple typified by a marked elevation in serum creatinine/Cystatin C ratio (> 2 L/dL), potentially serving as a clue for the clinical diagnosis of pseudo-acute kidney injury engendered by urinary ascites.
This case suggested the potential diagnostic value of an asynchronous increase in serum creatinine and serum CysC (or an increased ratio of blood creatinine to blood CysC) in patients with pseudo-acute kidney injury.

BACKGROUND: Stroke presenting with a reduced level of consciousness (RLOC) may result in diagnostic error and/or delay. Missed or delayed diagnosis of acute ischaemic stroke may preclude otherwise applicable hyperacute stroke interventions. The frequency, reasons for, and consequences of diagnostic error and delay due to RLOC are uncertain.
METHODS: The databases PubMed, EMBASE, and Cochrane library were searched in adherence with the PRISMA guidelines. The systematic review was prospectively registered on PROSPERO.
RESULTS: Initial searches returned 1162 results, of which 6 fulfilled inclusion criteria. The majority of identified studies show that ischaemic stroke presenting with RLOC is at increased risk of missed or delayed diagnosis. Hyperacute stroke interventions may also be delayed. There is limited evidence regarding the reason for these delays; however, the delays may result from neuroimaging delay associated with diagnostic uncertainty. There is also limited evidence regarding the outcomes of patients with stroke and RLOC who experience diagnostic delay; however, the available literature suggests that outcomes may be poor, including motor and cognitive impairment, as well as long-term impaired consciousness. The included studies did not evaluate, but have suggested urgent MRI access, educational interventions, and protocolisation of the evaluation of RLOC as means to reduce poor outcomes.
CONCLUSIONS: Ischaemic stroke patients with RLOC are at risk of diagnostic delay and error. These patients may have poor outcomes. Additional research is required to identify the contributing factors more clearly and to provide amelioration strategies.

Lipoma is a common soft tissue tumour in the human body, but at the same time is very rare in the palm and rarer still in the thenar region. These lipomas in the hand can give rise to various problems such as cosmetic, functional, and neurological compromise among others and removing them becomes important when symptomatic. Diagnosing a hand pathology becomes important as a missed diagnosis can have long-term functional consequences for a patient. In the case report, we discuss a hand palmar prominence which presented as an effusion and later turned out to be a large lipoma. Further, we also present a literature review of published thenar lipoma cases to throw light on the nuances of this rare pathology location, which, to our knowledge, has not been done comprehensively.

BACKGROUND Still\'s disease is a rare multisystemic autoinflammatory disorder. The diagnosis of adult-onset Still\'s disease (AoSD) can be challenging due to the rarity and overlapping features with many other systemic disorders. Complications of the illness can involve many systems in the human body. One of the least documented hematological complications of AoSD is thromboembolic phenomena. CASE REPORT This text outlines the presentation of a 43-year-old woman with a known diagnosis of AoSD, whose disease-modifying anti-rheumatic drugs (DMARDs) had been tapered and stopped due to remission. She presented with respiratory symptoms and features of an AoSD flare. Lack of complete improvement on antibiotic therapy and reinitiating of DMARDs prompted seeking an alternative/concurrent diagnosis. The work-up yielded a pulmonary embolism (PE) on the background of having no other risk factors for thrombosis. CONCLUSIONS In the reviewed literature, there is a close association between hyperferritinemia and AoSD complicated with venous thromboemboli (VTEs). A rigorous search for alternative diagnoses as well as other potential uncommon complications of AoSD is needed when working-up patients with AoSD, especially those that are not getting better on therapy. Given the rarity of AoSD, meticulous data collection may be useful in understanding the pathophysiology and features of presentation of the illness, including complications such as VTEs.