RB-DEM Modeling and Simulation of Non-Persisting Rough Open Joints Based on the IFS-Enhanced Method

When the geological environment of rock masses is disturbed,numerous non-persisting open joints can appear within it.It is crucial to investigate the effect of open joints on the mechanical properties of rock mass.However,it has been challenging to generate realistic open joints in traditional experimental tests and numerical simulations.This paper presents a novel solution to solve the problem.By utilizing the stochastic distribution of joints and an enhanced-fractal interpolation system(IFS)method,rough curves with any orientation can be generated.The Douglas-Peucker algorithm is then applied to simplify these curves by removing unnecessary points while preserving their fundamental shape.Subsequently,open joints are created by connecting points that move to both sides of rough curves based on the aperture distribution.Mesh modeling is performed to construct the final mesh model.Finally,the RB-DEM method is applied to transform the mesh model into a discrete element model containing geometric information about these open joints.Furthermore,this study explores the impacts of rough open joint orientation,aperture,and number on rock fracture mechanics.This method provides a realistic and effective approach for modeling and simulating these non-persisting open joints.

Subxyphoid Pericardial Drainage for Tuberculous Pericardial Effusion in Antananarivo

Introduction: Tuberculosis is the leading cause of pericardial effusion in sub-Saharan African countries. The aim of this study was to describe the diagnosis and the surgical management of tuberculous pericardial effusion in low-income country. Methods: This was a retrospective and descriptive study performed at Vascular Surgery Unit for 10 years-period (from January 2012 to December 2021), including all cases of drainage of pericardial effusion due to tuberculosis. Results: Sixty-seven cases were recorded, including 38 males (56.71%) and 29 women (43.28%). The average age was 35.47 years old. Patients lived in urban areas in 67.16% of cases. Thirteen patients (13.43%) had a previous history of pulmonary tuberculosis. The most common risk factors for tuberculosis infection were malnourishment (80.59%), indoor air pollution (77.61%) and close contact with tuberculosis patient (40.29%). The commonest symptom were dyspnea, (95.52%), chest pain (89.55%), fever (67.16%), tachycardia (95.52%) and cough (80.59%). Twenty-seven patients (39.02%) presented clinical signs of cardiac tamponade. Electrocardiogram showed sinus tachycardia (97.53%) with microvoltage (39.02%). Chest-X-ray showed cardiomegaly (100%) and pleural effusion (56.71%). Echocardiography showed moderate (43.28%) and large (56.71%) pericardial effusion. All patients underwent subxiphoid pericardial drainage. Mycobacterium tuberculosis detection via GeneXpert test of pericardial effusion were positive in 38.80% of patients. Pericardial biopsies confirmed the diagnosis of tuberculosis in 41.79%. The mortality rate was 8.95%. Conclusion: Subxiphoid pericardial drainage reduced thr risk of cardiac tamponade in patients with massive pericardial effusion. Histopathology of pericardial biopsies made a definitive diagnosis for tuberculosis.

Bacteriological Profile of Effusion Fluids Infections at Charles De Gaulle University Pediatric Hospital from 2017 to 2020

Introduction: Microbiology of effusion fluids in children in Burkina Faso is characterized by the scarcity of data. This work aimed to study the bacteriological and antibiotics susceptibility profile of bacteria involved in effusion fluid infections in paediatrics in order to improve the choice of probabilistic antibiotics therapy. Methods: A cross-sectional, descriptive study was used in children aged 0 to 15 years from 2017 to 2020 at the Charles De Gaulle Pediatric University Hospital Center (CHUP-CDG) in Ouagadougou. Classical bacteriology methods such as macroscopy, Gram staining, identification galleries and antibiotics susceptibility testing were used. Results: Of 231 samples, 64 bacteria were isolated. The most common bacterial strains of pleural fluid were Staphylococcus aureus (25%) and 40% for Enterobacteriaceae. Of the peritoneal fluid, 77% were Enterobacteriaceae with 57% Escherichia coli;and from joint fluid, 33% were S. aureus and 22% for P. aeruginosa. The overall susceptibility profile showed 29% extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL), 10% methicillin-resistant S. aureus (MRSA), and 8% carbapenemases. Conclusion: Bacteriological profile is characterized by ESBL-producing Enterobacteriaceae and MRSA. The most active antibiotics were macrolides, aminoglycosides, and cefoxitin (methicillin) for Gram-positive cocci, carbapenems, and aminoglycosides for Gram-negative bacilli. Then, the monitoring of antibiotics resistance must be permanent.

Comparison of efficacy of lung ultrasound and chest X-ray in diagnosing pulmonary edema and pleural effusion in ICU patients: A single centre, prospective, observational study

Background and Aims While chest X-ray (CXR) has been a conventional tool in intensive care units (ICUs) to identify lung pathologies, computed tomography (CT) scan remains the gold standard. Use of lung ultrasound (LUS) in resource-rich ICUs is still under investigation. The present study compares the utility of LUS to that of CXR in identifying pulmonary edema and pleural effusion in ICU patients. In addition, consolidation and pneumothorax were analyzed as secondary outcome measures. Material and Methods This is a prospective, single centric, observational study. Patients admitted in ICU were examined for lung pathologies, using LUS by a trained intensivist;and CXR done within 4 hours of each other. The final diagnosis was ascertained by an independent senior radiologist, based on the complete medical chart including clinical findings and the results of thoracic CT, if available. The results were compared and analyzed. Results Sensitivity, specificity and diagnostic accuracy of LUS was 95%, 94.4%, 94.67% for pleural effusion;and 98.33%, 97.78%, 98.00% for pulmonary edema respectively. Corresponding values with CXR were 48.33%, 76.67%, 65.33% for pleural effusion;and 36.67%, 82.22% and 64.00% for pulmonary edema respectively. Sensitivity, specificity and diagnostic accuracy of LUS was 91.30%, 96.85%, 96.00% for consolidation;and 100.00%, 79.02%, 80.00% for pneumothorax respectively. Corresponding values with CXR were 60.87%, 81.10%, 78.00% for consolidation;and 71.3%, 97.20%, 96.00% for pneumothorax respectively. Conclusion LUS has better diagnostic accuracy in diagnosis of pleural effusion and pulmonary edema when compared with CXR and is thus recommended as an effective alternative for diagnosis of these conditions in acute care settings. Our study recommends that a thoracic CT scan can be avoided in most of such cases.

Pulmonary Edema and Pleural Effusion Detection Using Efficient Net-V1-B4 Architecture and AdamW Optimizer from Chest X-Rays Images

This paper presents a novelmulticlass systemdesigned to detect pleural effusion and pulmonary edema on chest Xray images,addressing the critical need for early detection in healthcare.A new comprehensive dataset was formed by combining 28,309 samples from the ChestX-ray14,PadChest,and CheXpert databases,with 10,287,6022,and 12,000 samples representing Pleural Effusion,Pulmonary Edema,and Normal cases,respectively.Consequently,the preprocessing step involves applying the Contrast Limited Adaptive Histogram Equalization(CLAHE)method to boost the local contrast of the X-ray samples,then resizing the images to 380×380 dimensions,followed by using the data augmentation technique.The classification task employs a deep learning model based on the EfficientNet-V1-B4 architecture and is trained using the AdamW optimizer.The proposed multiclass system achieved an accuracy(ACC)of 98.3%,recall of 98.3%,precision of 98.7%,and F1-score of 98.7%.Moreover,the robustness of the model was revealed by the Receiver Operating Characteristic(ROC)analysis,which demonstrated an Area Under the Curve(AUC)of 1.00 for edema and normal cases and 0.99 for effusion.The experimental results demonstrate the superiority of the proposedmulti-class system,which has the potential to assist clinicians in timely and accurate diagnosis,leading to improved patient outcomes.Notably,ablation-CAM visualization at the last convolutional layer portrayed further enhanced diagnostic capabilities with heat maps on X-ray images,which will aid clinicians in interpreting and localizing abnormalities more effectively.

Pleural effusion,ascites,colon ulcers and hematochezia:What we can learn from the diagnostic process of a patient with plasma cell myeloma:A case report

BACKGROUND Plasma cell myeloma(PCM)is characterized by hypercalcemia,renal impairment,anemia,and bone destruction.While pleural effusion,ascites,abdominal pain,and bloody stool are common manifestations of lung disease or gastrointestinal disorders,they are rarely observed in patients with PCM.CASE SUMMARY A 66-year-old woman presented with complaints of recurrent chest tightness,wheezing,and abdominal bloating accompanied by bloody stools.Computed tomography revealed pleural effusion and ascites.Pleural effusion tests showed inflammation,but the T-cell spot test and carcinoembryonic antigen were negative.Endoscopy showed colonic mucosal edema with ulcer formation and local intestinal lumen stenosis.Echocardiography revealed enlarged atria and reduced left ventricular systolic function.The diagnosis remained unclear.Further testing revealed elevated blood light chain lambda and urine immunoglobulin levels.Blood immunofixation electrophoresis was positive for immunoglobulin G lambda type.Smear cytology of the bone marrow showed a high proportion of plasma cells,accounting for about 4.5%.Histopathological examination of the bone marrow suggested PCM.Flow cytometry showed abnormal plasma cells with strong expression of CD38,CD138,cLambda,CD28,CD200,and CD117.Fluorescence in situ hybridization gene testing of the bone marrow suggested 1q21 gene amplification,but cytogenetic testing showed no clonal abnormalities.Colonic mucosa and bone marrow biopsy tissues were negative for Highman Congo red staining.The patient was finally diagnosed with PCM.CONCLUSION A diagnosis of PCM should be considered in older patients with pleural effusion,ascites,and multi-organ injury.

Subdural effusion associated with COVID-19 encephalopathy: A case report

BACKGROUND The precise mechanism by which severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)impacts the central nervous system remains unclear,with manifestations spanning from mild symptoms(e.g.,olfactory and gustatory deficits,hallucinations,and headache)to severe complications(e.g.,stroke,seizures,encephalitis,and neurally demyelinating lesions).The occurrence of single-pass subdural effusion,as described below,is extremely rare.CASE SUMMARY A 56-year-old male patient presented with left-sided limb weakness and slurred speech as predominant clinical symptoms.Through comprehensive imaging and diagnostic assessments,he was diagnosed with cerebral infarction complicated by hemorrhagic transformation affecting the right frontal,temporal,and parietal regions.In addition,an intracranial infection with SARS-CoV-2 was identified during the rehabilitation process;consequently,an idiopathic subdural effusion developed.Remarkably,the subdural effusion underwent absorption within 6 d,with no recurrence observed during the 3-month follow-up.CONCLUSION Subdural effusion is a potentially rare intracranial complication associated with SARS-CoV-2 infection.

Numerical simulation of formation mechanism of unloading joints in granitic pluton

The Beishan pluton in Gansu of China was selected as the simulated model.The simulation results indicate that the formation of unloading joints in granite is mainly influenced by the unloading rate of confin-ing pressure.Among the rates tested,the slowest unloading rate 0.025 MPa/s is found to be most conducive to the development of unloading joints.Therefore,a slower unloading rate is favourable for the occurrence of unloading joints.A series of simulations with varying initial depths of uplift ranging from 900 m to 200 m were conducted.The results confirm that when the specimen rises to a depth of 550-500 m,the unloading joints begin to form.The uplift from a depth of 700-500 m,with variations in both vertical and lateral un-loading rates,was simulated.The generation of unloading joints exhibits a negative correlation with vertical unloading and no correlation with lateral unloading,indicating that the unloading joints are mainly controlled by the unloading of vertical pressure.Throughout the simulation process,the vertical joints exhibit irregular and unrealistic regularity,suggesting a more complex formation mechanism than that of the unloading joints.

Shear behavior and off-fault damage of saw-cut smooth and tension-induced rough joints in granite

The damage of rock joints or fractures upon shear includes the surface damage occurring at the contact asperities and the damage beneath the shear surface within the host rock.The latter is commonly known as off-fault damage and has been much less investigated than the surface damage.The main contribution of this study is to compare the results of direct shear tests conducted on saw-cut planar joints and tension-induced rough granite joints under normal stresses ranging from 1 MPa to 50 MPa.The shear-induced off-fault damages are quantified and compared with the optical microscope observation.Our results clearly show that the planar joints slip stably under all the normal stresses except under 50 MPa,where some local fractures and regular stick-slip occur towards the end of the test.Both post-peak stress drop and stick-slip occur for all the rough joints.The residual shear strength envelopes for the rough joints and the peak shear strength envelope for the planar joints almost overlap.The root mean square(RMS)of asperity height for the rough joints decreases while it increases for the planar joint after shear,and a larger normal stress usually leads to a more significant decrease or increase in RMS.Besides,the extent of off-fault damage(or damage zone)increases with normal stress for both planar and rough joints,and it is restricted to a very thin layer with limited micro-cracks beneath the planar joint surface.In comparison,the thickness of the damage zone for the rough joints is about an order of magnitude larger than that of the planar joints,and the coalesced micro-cracks are generally inclined to the shear direction with acute angles.The findings obtained in this study contribute to a better understanding on the frictional behavior and damage characteristics of rock joints or fractures with different roughness.

On the calibration of a shear stress criterion for rock joints to represent the full stress-strain profile

Conventional numerical solutions developed to describe the geomechanical behavior of rock interfaces subjected to differential load emphasize peak and residual shear strengths.The detailed analysis of preand post-peak shear stress-displacement behavior is central to various time-dependent and dynamic rock mechanic problems such as rockbursts and structural instabilities in highly stressed conditions.The complete stress-displacement surface(CSDS)model was developed to describe analytically the pre-and post-peak behavior of rock interfaces under differential loads.Original formulations of the CSDS model required extensive curve-fitting iterations which limited its practical applicability and transparent integration into engineering tools.The present work proposes modifications to the CSDS model aimed at developing a comprehensive and modern calibration protocol to describe the complete shear stressdisplacement behavior of rock interfaces under differential loads.The proposed update to the CSDS model incorporates the concept of mobilized shear strength to enhance the post-peak formulations.Barton’s concepts of joint roughness coefficient(JRC)and joint compressive strength(JCS)are incorporated to facilitate empirical estimations for peak shear stress and normal closure relations.Triaxial/uniaxial compression test and direct shear test results are used to validate the updated model and exemplify the proposed calibration method.The results illustrate that the revised model successfully predicts the post-peak and complete axial stressestrain and shear stressedisplacement curves for rock joints.

Effect of cold-working on corrosion induced damage in lug joints

Lug joints are preferred joineries for transferring heavy loads to parent components in aerospace vehicles.They experience corrosion due to environmental conditions,improper surface finishes and rubbing displacement between the pin and lug-hole.This causes damage of different sizes and shapes near the lug-hole.Stiffness degradation due to corrosion-induced damage is modelled as a through-pit at one of the identified critical locations through stress analysis.The effect of this pit on fatigue crack initiation life is estimated.Lug-hole is pre-stressed by cold-working and the benefits of inducing plastic wake on the intended performance of the lug joint during the damages due to corrosion are brought out and compared with non-cold-worked lug-hole.Numerical analysis is performed on this lug joint with pressfit.The results obtained highlight the benefits of cold-working and the methodology can be extended to damage growth and analyse the effect of surface treatments for better structural integrity of components of aerospace vehicles.

Microstructure,Corrosion and Mechanical Properties of Medium-Thick 6061-T6 Alloy/T2 Pure Cu Dissimilar Joints Produced by Double Side Friction Stir Z Shape Lap-Butt Welding

A novel double side friction stir Z shape lap-butt welding(DS-FSZW)process was proposed to achieve excellent mechanical properties of Al/Cu medium-thick dissimilar joints.The influence of welding parameters on weld microstructure and properties of DS-FSZW joint were systematically investigated.It indicated that defect-free medium-thick Al/Cu DS-FSZW joint could be achieved under an optimal welding parameter.DS-FSZW joint was prone to form void defects in the bottom of the second-pass weld.The recrystallization mechanisms at the top and middle of the weld nugget zone(WNZ)were continuous dynamic recrystallization(CDRX)and geometric dynamic recrystallization(GDRX).While the major recrystallization mechanism at the bottom of the WNZ was GDRX.DS-FSZW joint of the optimal welding condition with 850 r/min-400 mm/min was produced with a continuous thin and crack-free IMCs layer at the Al/Cu interface,and the maximum tensile strength of this joint is 160.57 MPa,which is equivalent to 65.54%of pure Cu base material.Moreover,the corrosion resistance of Al/Cu DS-FSZW joints also achieved its maximum value at the optimal welding parameter of 850 r/min-400 mm/min.It demonstrates that the DS-FSZW process can simultaneously produce medium-thick Al/Cu joints with excellent mechanical performance and corrosion resistance.

Superconducting joints using reacted multifilament MgB_(2)wires:A technology toward cryogen-free MRI magnets

The development of superconducting joining technology for reacted magnesium diboride(MgB_(2))conductors remains a critical challenge for the advancement of cryogen-free MgB_(2)-based magnets for magnetic resonance imaging(MRI).Herein,the fabrication of superconducting joints using reacted carbon-doped multifilament MgB_(2)wires for MRI magnets is reported.To achieve successful superconducting joints,the powder-in-mold method was employed,which involved tuning the filament protection mechanism,the powder compaction pressure,and the heat treatment condition.The fabricated joints demonstrated clear superconducting-to-normal transitions in self-field,with effective magnetic field screening up to 0.5 T at 20 K.To evaluate the interface between one of the MgB_(2)filaments and the MgB_(2)bulk within the joint,serial sectioning was conducted for the first time in this type of superconducting joint.The serial sectioning revealed space formation at the interface,potentially caused by the volume shrinkage associated with the MgB_(2)formation or the combined effect of the volume shrinkage and the different thermal expansion coefficients of the MgB_(2)bulk,the filament,the mold,and the sealing material.These findings are expected to be pivotal in developing MgB_(2)superconducting joining technology for MRI magnet applications through interface engineering.

Evaluation of microstructure and mechanical properties of squeeze overcast Al7075-Cu composite joints

Al7075-Cu composite joints were prepared by the squeeze overcast process.The effects of melt temperature,die temperature,and squeeze pressure on hardness and ultimate tensile strength(UTS)of squeeze overcast Al7075-Cu composite joints were studied.The experimental results depict that squeeze pressure is the most significant process parameter affecting the hardness and UTS.The optimal values of UTS(48 MPa)and hardness(76 HRB)are achieved at a melt temperature of 800℃,a die temperature of 250℃,and a squeeze pressure of 90 MPa.Scanning electron microscopy(SEM)shows that fractured surfaces show flatfaced morphology at the optimal experimental condition.Energy-dispersive spectroscopy(EDS)analysis depicts that the atomic weight percentage of Zn decreases with an increase in melt temperature and squeeze pressure.The optimal mechanical properties of the Al7075-Cu overcast joint were achieved at the Al2Cu eutectic phase due to the large number of copper atoms that dispersed into the aluminum melt during the solidification process and the formation of strong intermetallic bonds.Gray relational analysis integrated with the Taguchi method was used to develop an optimal set of control variables for multi-response parametric optimization.Confirmatory tests were performed to validate the effectiveness of the employed technique.The manufacturing of squeeze overcast Al7075-Cu composite joints at optimal process parameters delivers a great indication to acknowledge a new method for foundry practitioners to manufacture materials with superior mechanical properties.

Progressive Failure Analysis of Composite/Aluminum Riveted Joints Subjected to Pull-Through Loading

Out-of-plane mechanical properties of the riveted joints restrict the performance of the wing box assembly of airplane.It is necessary to investigate the pull-through performance of the composite/metal riveted joints in order to guide the riveting design and ensure the safety of the wing box assembly.The progressive failure mechanism of composite/aluminum riveted joint subjected to pull-through loading was investigated by experiments and finite element method.A progressive damage model based on the Hashin-type criteria and zero-thickness cohesive zone method was developed by VUMAT subroutine,which was validated by both open-hole tensile test and three-point bending test.Predicted load-displacement response,failure modes and damage propagation were analysed and compared with the results of the pull-through tests.There are 4 obvious characteristic stages on the load-displacement curve of the pull-through test and that of the finite element model:first load take-up stage,damage stage,second load take-up stage and failure stage.Relative error of stiffness,first load peak and second load peak between finite element method and experiments were 8.1%,-3.3%and 10.6%,respectively.It was found that the specimen was mainly broken by rivet-penetration fracture and delamination of plies of the composite laminate.And the material within the scope of the rivet head is more dangerous with more serious tensile damages than other regions,especially for 90°plies.This study proposes a numerical method for damage prediction and reveals the progressive failure mechanism of the hybrid material riveted joints subjected to the pull-through loading.

Pleural effusion in critically ill patients and intensive care setting

Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses.Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients,with a wide range of variable prevalence rates of up to 50%-60%in some studies.This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit(ICU).The original disease that caused pleural effusion can be the exact cause of ICU admission.There is an impairment in the pleural fluid turnover and cycling in critically ill and mechanically ventilated patients.There are also many difficulties in diagnosing pleural effusion in the ICU,including clinical,radiological,and even laboratory difficulties.These difficulties are due to unusual presentation,inability to undergo some diagnostic procedures,and heterogenous results of some of the performed tests.Pleural effusion can affect the patient’s outcome and prognosis due to the hemodynamics and lung mechanics changes in these patients,who usually have frequent comorbidities.Similarly,pleural effusion drainage can modify the ICUadmitted patient’s outcome.Finally,pleural effusion analysis can change the original diagnosis in some cases and redirect the management toward a different way.

Experimental study on the shear performance of quasi-NPR steel bolted rock joints

Quasi-NPR(negative Poisson’s ratio)steel is a new type of super bolt material with high strength,high ductility,and a micro-negative Poisson’s effect.This material overcomes the contrasting characteristics of the high strength and high ductility of steel and it has significant energy-absorbing characteristics,which is of high value in deep rock and soil support engineering.However,research on the shear resistance of quasi-NPR steel has not been carried out.To study the shear performance of quasi-NPR steel bolted rock joints,indoor shear tests of bolted rock joints under different normal stress conditions were carried out.Q235 steel and#45 steel,two representative ordinary bolt steels,were set up as a control group for comparative tests to compare and analyze the shear strength,deformation and instability mode,shear energy absorption characteristics,and bolting contribution of different types of bolts.The results show that the jointed rock masses without bolt reinforcement undergo brittle failure under shear load,while the bolted jointed rock masses show obvious ductile failure characteristics.The shear deformation ca-pacity of quasi-NPR steel is more than 3.5 times that of Q235 steel and#45 steel.No fracture occurs in the quasi-NPR steel during large shear deformation and it can provide stable shear resistance.However,the other two types of control bolts become fractured under the same conditions.Quasi-NPR steel has significant energy-absorbing characteristics under shear load and has obvious advantages in terms of absorbing the energy released by shear deformation of jointed rock masses as compared with ordinary steel.In particular,the shear force plays a major role in resisting the shear deformation of Q235 steel and#45 steel,therefore,fracture failure occurs under small bolt deformation.However,the axial force of quasi-NPR steel can be fully exerted when resisting joint shear deformation;the steel itself does not break when large shear deformation occurs,and the supporting effect of the jointed rock mass is effectively guaranteed.

Combined aqueous misdirection and persistent choroidal effusions following implantation of a Preserflo Micro Shunt

AIM:To describe a case of aqueous misdirection complicated by subsequent persistent choroidal effusions following implantation of a Preserflo Micro Shunt(PMS)device to treat advanced closed angle glaucoma.METHODS:A 67-year-old caucasian female with advanced primar y angle-closure glaucoma on four medications with an intraocular pressure(IOP)of 26 mm Hg was listed for a PMS insertion with mitomycin C(MMC).RESULTS:Past ocular history was significant for pseudophakia and previous yttrium aluminum garnet(YAG)peripheral iridotomy.Surgery was uneventful but on the first postoperative day,she developed aqueous misdirection complicated by subsequent development of persistent uveal effusions.Conventional treatment strategies including atropine drops,YAG hyaloidotomy and choroidal effusion drainage proved ineffective.A combination of oral steroids and pars plana vitrectomy(PPV)along with an irido-zonulohyloidectomy(IZH)proved efficacious.CONCLUSION:To the best of the author’s knowledge,this is the first published case of aqueous misdirection complicated with the presence of significant,unresolving choroidal effusions,highlighting the possibility and sequelae of comorbid pathology in nanophthalmic eyes.

Pleuro-Pericardial Inflammation and Effusion: A Rare Acute Initial Presentation of Rheumatoid Arthritis

Background: Rheumatoid arthritis is a systemic inflammatory arthritis characterized by joint pain and morning stiffness. The affected joints are typically symmetrically affected, and given the inflammatory nature of this condition, patients often present with warmth and erythema around affected joints as well as fatigue. Extra-articular manifestations, especially pleuro-pericardial inflammation, are rare initial presentations, although may be seen in advanced or undertreated disease. Case Presentation: We describe a case of a rheumatoid arthritis presenting atypically in a middle-aged male who came to the emergency department complaining of diffuse muscle pain and swelling in the distal extremities. Cardiac ultrasound revealed pleuro-pericardial inflammation and effusions. Myositis and infectious causes were ruled out and bilateral hand x-rays did not show erosions or any evidence of arthritic changes. All rheumatological auto-antibodies were negative except for rheumatoid factor and anti-cyclic citrullinated peptide (CCP) and a diagnosis of rheumatoid arthritis was made. The patient was started on prednisone with excellent response. Conclusions: This case highlights that rheumatoid arthritis can uncommonly present initially with extra-articular manifestations that are often manifested in advanced disease. Typically, extra-articular manifestations, especially those as severe as this patient’s, occur with untreated, advanced disease and could accompany extensive arthritic joint changes. Thus, it is important to have an understanding of rare, atypical presentations of rheumatoid arthritis so that a high index of suspicion can be maintained to make the diagnosis and initiate treatment in a timely manner.

Development of subdural empyema from subdural effusion after suppurative encephalitis:A case report

BACKGROUND Chronic subdural effusion is very common in the cranial imaging of middle-aged and older people.Herein,we report a patient misdiagnosed with subdural effusion,who was eventually diagnosed with chronic subdural empyema(SDE)caused by Streptococcus pneumoniae.CASE SUMMARY A 63-year-old man was brought to our emergency room with a headache,vomiting,and disturbed consciousness.Computed tomography(CT)revealed a bilateral subdural effusion at the top left side of the frontal lobe.Cerebrospinal fluid examination after lumbar puncture indicated suppurative meningitis,which improved after anti-infective therapy.However,the patient then presented with acute cognitive dysfunction and right limb paralysis.Repeat CT showed an increase in left frontoparietal subdural effusion,disappearance of the left lateral ventricle,and a shift of the midline to the right.Urgent burr hole drainage showed SDE that was culture-positive for Streptococcus pneumoniae.His condition improved after adequate drainage and antibiotic treatment.CONCLUSION Patients with unexplained subdural effusion,especially asymmetric subdural effusion with intracranial infection,should be assessed for chronic SDE.Early surgical treatment may be beneficial.