Notes

Warthin-Like Different associated with Papillary Thyroid gland Carcinoma: An infrequent Variant.
Most of the patients who presented were older than five years of age. A majority of the patients presented after 24 hours of the commencement of their symptoms. Of the included participants, 36 patients (47.47%) were found to have an underlying torsion of appendix testes that was appropriately managed. Testicular torsion was observed in 15 patients, out of which eight viable testes were salvaged with a subsequent orchidopexy while seven torsions required orchiectomy owing to their non-viability. Other findings included epididymo-orchitis and infected hydrocele. A total of 19 testes appeared completely normal upon scrotal exploration. Conclusion Scrotal exploration should be considered as part of the medical and surgical workup and in the management of acute scrotum, as it divulges the specific underlying testicular pathology. Prompt scrotal exploration can aid in ascertaining the underlying etiology and is, therefore, pivotal in the apt management of the underlying pathology.Auto-brewery syndrome (ABS), also known as gut fermentation syndrome, is a very rare disorder. It is characterized by the endogenous production of alcohol. It typically presents with the signs of alcohol intoxication, such as staggering gait, slurred speech, gastrointestinal distress, and state of confusion. Due to the nonspecific symptoms, it is necessary to rule out other etiologies before reaching a diagnosis of ABS. The confirmatory test for this syndrome is the raised levels of blood or breath ethanol after a glucose challenge test. The management includes the use of antifungal drugs and avoidance of a carbohydrate-rich diet. In this review, we summarize the etiology, clinical presentation, diagnostic tests, management, and medicolegal aspects of ABS.Brooke-Spiegler syndrome (BSS) is a rare hereditary autosomal dominant disorder with variable phenotypic expressivity that results in a variety of benign cutaneous face, scalp, and neck tumors with a histology profile of cylindroma, spiradenoma and trichoepithelioma. Reports of lymph node and distant metastasis are scarce. We present the first case of Brooke-Spiegler syndrome with metastasis to the cervical spine. An 86-year-old female with Brooke-Spiegler syndrome presented to the clinic with a finding of cervical spine lesion involving vertebral body, prevertebral, paraspinal, foraminal, and epidural spaces. The histopathology of the lesion showed benign cylindroma. Considering the location of the lesion and local invasion of neural structures, the malignant transformation of existing tumors could not be excluded. Brooke-Spiegler syndrome rarely presents with malignant transformation and distant metastatic spread. It is important to be aware of these rare cases while monitoring the disease and addressing clinical symptoms. This is to our knowledge the first case of metastatic spread of the cylindroma to the cervical spine resulting in local bone destruction and neural elements compromise. Physicians should be aware of this rare possibility.
External ventricular drains (EVD) are used for emergent management of acute hydrocephalus and for monitoring of intracranial pressure.Common complications of EVDs include malposition, infection, and hemorrhage.Here, the authors present a novel case of EVD migration causing Parinaud's syndrome.

A thirty-three-year-old female presented with witnessed seizure secondary to a left supraclinoid internal carotid artery aneurysm and trace subarachnoid hemorrhage. Two days after radiographic confirmation of an accurately placed EVD, she was found to have vertical gaze palsy (Parinaud's syndrome).Repeat CT head demonstrated inward migration of the EVD with left midbrain compression.After readjustment of the EVD, her Parinaud's syndrome improved each day until discharge home.

This is a novel clinical presentation of an EVD causing Parinaud's syndrome.There is only one other case report in the literature of this phenomenon.Although a practical solution to prevent this incident from occurring is unclear, vigilance for changes in neurological exam allowed for quick assessment and revision of the EVD and subsequent recovery in this patient.
This is a novel clinical presentation of an EVD causing Parinaud's syndrome. There is only one other case report in the literature of this phenomenon. Although a practical solution to prevent this incident from occurring is unclear, vigilance for changes in neurological exam allowed for quick assessment and revision of the EVD and subsequent recovery in this patient.Objectives To investigate the epidemiology, management, and predictors of mortality in severe sepsis and septic shock in the intensive care units (ICUs) of Trinidad, Trinidad & Tobago. Methods A prospective observational study in four ICUs over a one-year period (August 2017-August 2018) was conducted. Physiologic variables, treatment data, and outcomes were collected on admission to ICU and daily until 28 days. The 28-day mortality and ICU mortality were recorded. Subgroup analysis was performed based on survival, and predictors of mortality were determined through logistic regression. Results Outcome data were available for 163 patients. The 28-day mortality rates for sepsis and septic shock were 42% and 47%, respectively. ICU mortality rate for sepsis was 34%. The most common suspected source of infection was pneumonia (33%). Acute kidney injury (AKI) was common and present in 71% of patients, with renal replacement therapy only being used in 30% of cases. Mechanical ventilation was required in 84% of cases. Moderate-to-severe acute respiratory distress syndrome (ARDS) (OR 4; 95% CI 1.9-8.8; p 60 mmHg within the first 24 hours of admission were higher in patients who did not survive (p less then 0.05). Conclusions Sepsis and septic shock are associated with a high 28-day mortality. Organ dysfunction with renal and pulmonary involvement was an important factor in predicting a higher mortality.Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has spread globally, resulting in an ongoing pandemic. Real-time reverse transcription-polymerase chain reaction (rRT-PCR) from a viral swab is diagnostic. The most common site to take this swab is from the nasopharyngeal area; however, patients with tracheostomies represent a major challenge as they have two sources for colonization and possible infection including the nose and the trachea. We present the case of a patient who had a COVID-19 diagnostic swab through his tracheostomy, when unfortunately the swab broke, resulting in a bronchial foreign body.Scapular spine stress fractures are a rare but well-recognised complication following reverse total shoulder arthroplasty (RTSA). They present a challenge with no consensus on management. Both operative fixation and conservative measures are associated with high rates of mal- or non-union and decreased functional outcomes. We present the case of a 60-year-old female, who presented with a scapular spine fracture one year following RTSA. Treatment consisted of initial immobilisation, physiotherapy and the application of a portable low-intensity pulsed ultrasound (LIPUS) system (EXOGENÒ Ultrasound Bone Healing System, Bioventus, Durham NC, Netherlands). Following a three-month treatment course, there was a significant improvement in patient-reported pain and functional scores (Oxford Shoulder Score from 5/48 to 38/48). Sequential radiographic imaging confirmed fracture union. Clinicians may consider the use of LIPUS therapy as a potential adjunctive treatment modality to promote the union of scapular spine stress fractures following RTSA.Background Migraine is amongst the top 10 most disabling conditions, and the disease burden is highest in young and middle-aged women. Another variant of the migraine headache, menstrual migraine (MM) is experienced by this cohort of patients. Former studies have done comparisons between various demographic and clinical features of MM versus menstrual-unrelated migraine (MUM) in patients presenting to various clinics with the primary complaint of headaches. We aimed to compare symptoms of migraine in women attending gynecology outpatient clinics, regardless of their presenting complaint. This would help lessen the selection bias and produce more generalizable results. Methods and materials A cross-sectional study was conducted in the outpatient gynecology clinics at a tertiary care hospital over six months. The clinic attendees were screened for sufferers of a primary headache of the migraine type. The migraineurs were then stratified into groups A, MM patients, and group B, MUM patients, using the International Headache Society (HIS) criteria. They were then questioned for the presence of various symptoms associated with their migraine attacks for comparison. Results One-hundred eighty-one women (between 12 years to 55 years) were found to have primary headaches; amongst these, 126 patients met the inclusion criteria and consented to participate; from these, 62 (49.2%) patients had MM and 64 (50.8%) patients had MUM. The symptoms of nausea (p=0.00269), photophobia (p=0.000088), and phonophobia (p=0.0281) were statistically higher in MM patients while vomiting was not a significant feature. Both groups had a predominantly unilateral headache. The average days of the attack had a significant difference between the two groups (p=0.000019), where the duration was longer for MM patients. Conclusions It was observed that patients with MM tend to experience more features associated with migraine headaches, including a longer duration of attacks, and have a worse experience overall.Objective This study aimed to estimate and investigate the prevalence and the risk factors implicated in contact dermatitis among healthcare workers in the Al'Qassim region, Saudi Arabia, during the COVID-19 pandemic. Methodology We conducted a cross-sectional survey among healthcare workers at hospitals in the Al'Qassim region. Data was collected using a standardized and validated Nordic Occupational Skin Questionnaire version 2002. We included 408 participants in the analysis. Results The majority of the respondents (66.7%) were females. The mean age of participants was 34 (SD ±9) years. Most of the participants who reported contact dermatitis were nurses (58.6%). Direct patient care roles represent 78% of participants. Respondents who work 40-50 hours per week represent 61.5% of the sample. The most commonly recorded symptoms were dryness (92.9%), itchiness (50%), and redness (46.4%) of the skin. The most affected site was hand 93.5%. Hand cleanser was the commonest substance implicated in the worsening ofveloping contact dermatitis include female gender, history of eye allergies, and young age group.Castleman's disease is a rare clinicopathological condition characterized by hyperplasia of lymph nodes. We report the case of a 12-year-old boy who presented with painful oral and genital ulcers, who was assumed to have Behçet's disease. However, the patient did not show any clinical improvement on colchicine and systemic corticosteroids. Later, the patient developed severe abdominal pain and vomiting. Abdominal CT revealed a mass lesion superior to the right kidney. After a thorough investigation, he was diagnosed with unicentric Castleman's disease. Despite the complete resection of the mass, the patient continued to have the symptoms of abdominal pain and orogenital ulcers. Immunomodulatory therapy resulted in remarkable clinical improvement. This case report demonstrates how unicentric Castleman's disease can share similar clinical behavior to the multicentric disease.
We aim to create and validate an electronic search algorithm for accurate detection of disseminated intravascular coagulopathy (DIC) from medical records.

Patients with DIC in Mayo Clinic's intensive care units (ICUs) from Jan 1, 2007,to May 4, 2018, were included in the study. An algorithm was developed based on clinical notes and ICD diagnosis codes. A cohort of 50 patients was included with DIC diagnosis, its variations, and no diagnosis of DIC. Then, the next set of 50 patients was used to refine the algorithm. Results were compared with a manual reviewer and the disagreements were resolved by the third reviewer. The same process was repeated with 'revised clinical note search' for the first and second derivation cohort with additional exclusion terms. The obtained sensitivity and specificity were reported. The generated algorithm was applied to another set of 50 patients for validation.

In the first derivation cohort- DIC search by clinical notes and diagnosis codes had 92% sensitivity and 100% specificity. Sensitivity dropped to 71% in the second cohort although specificity remains the same. Therefore, the algorithm was refined to clinical notes search only. The revised search was reapplied to first and second derivation cohorts and results obtained for the first derivation were the same but 91.3% sensitive and 100% specific for the second derivation. The search was locked and applied in the validation cohort with 95.8% sensitivity and 100% specificity, respectively.

The revised clinical note based electronic search algorithm was found to be highly sensitive and specific for DIC during the corresponding ICU duration.
The revised clinical note based electronic search algorithm was found to be highly sensitive and specific for DIC during the corresponding ICU duration.Pyogenic liver abscesses are uncommon entities with potentially devastating consequences requiring immediate diagnosis and treatment. Fusobacterium nucleatum is an anaerobic, gram-negative oral commensal that has been seldom reported as a cause of liver abscess, particularly in immunocompetent hosts. We describe a case of an 80-year-old female patient presenting with a fusobacterium liver abscess associated with thrombosis of the left cephalic vein.After approval, initial biologics etanercept, infliximab, and adalimumab became useful in the therapeutic armamentarium to treat rheumatoid arthritis (RA) patients who had an inadequate response to disease-modifying anti-rheumatic drugs (DMARDs). However, all phase-III clinical trials submitted to the FDA, by design, excluded patients who were human immunodeficiency virus (HIV) positive. They are another subset of patients with low immunity due to their HIV-positive status. Very little information is available about the use of biologics in this new group of patients if they fail to respond to DMARDS. The available literature is limited to case reports about HIV-positive RA patients with reported side effects. These side effects range from no opportunistic infections (OIs) in some to acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulopathy (DIC) reported in others. Some HIV cases may initially present with rheumatological manifestations. With growing epidemiologic evidence of frequent joint manifestations in HIV-positive patients, HIV testing should be done more frequently in patients with RA, even those who deny risk factors for HIV. This review may help develop future guidelines on how to manage HIV-positive RA patients.Percutaneous endoscopic gastrostomy (PEG) is a well-established and successful method of nutritional delivery. Complications, although rare, are divided into early or late. Buried bumper syndrome (BBS) is usually a late complication of PEG tube insertion and can cause many issues such as pressure necrosis, peritonitis, and septic shock. Endoscopic evaluation is the definitive diagnosis, and treatment depends on each patient and the degree of depth of disc migration. We present to you a case of buried bumper syndrome in a 66-year-old female that was initially thought to be complicated with peritonitis, and surprisingly occurring only one week after initial PEG tube placement.Purpose We investigate the effect that variation in the anatomy of the greater trochanter (GT), in particular the medial overhang, can have on femoral stem alignment in total hip arthroplasty (THA). Methods Pre- and post-operative anteroposterior pelvic radiographs of 576 consecutive patients undergoing THA were retrospectively analysed. Medial overhang of the GT relative to the lateral femur diaphysis was measured. The femoral morphology was classified according to Dorr classification. The alignment of the femoral stem axes on post-operative radiographs was recorded. Results Following exclusions, 500 THAs performed by six surgeons all using the same cemented polish tapered stems were analysed 320 THAs were performed via the posterior-lateral approach and 180 via the direct-lateral approach. Mean stem varus was 0.53° (range -7 to 7°). Mean medial overhang was 21 mm (range 8-43 mm). An overhang of 30 mm of overhang). Conclusions Scrutiny of pre-operative radiographs to determine high-risk patients is important, and we propose a classification system of GT anatomy to aid assessment.Nonbacterial thromboembolic endocarditis (NBTE), or marantic endocarditis, is a rare complication associated with advanced cancer. Enoxaparin or unfractionated heparin is considered the standard treatment for NBTE. In this case report, we describe a 59-year-old female with metastatic pancreatic cancer who presented with embolic stroke and was found to have new NBTE of the mitral valve while she was receiving the therapeutic dose of enoxaparin. Of note, her recent echocardiogram one week ago was negative for mitral valve vegetations. Our case emphasized that for patients with advanced cancer presenting with stroke, the diagnosis of NBTE should be entertained even for those on systemic anticoagulation.Coronary artery disease (CAD) is a significant contributor to mortality in America. A common risk factor of CAD is hyperlipidemia. Treatment guidelines of hyperlipidemia are well established. Statins are the cornerstone of treating hyperlipidemia. New medications such as proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9 inhibitors) have also illustrated significant results in treating hyperlipidemia. While multiple studies exemplify the disparities in statin and PCSK9 inhibitors utilization to reduce CAD mortality and risk factors, there are no systematic reviews to validate these disparities. We conducted a search on PubMed, including Medline and PubMed Central, and Google Scholar. For this analysis, we selected articles published between 2000 and 2020 and those that fit the inclusion and exclusion criteria. Based on the type of study, we performed appropriate quality assessments and deleted studies with a score of less than seven or with a high risk of biases. The search strategy resulted in 322 studies. After inclusion and exclusion criteria were applied, we included 20 articles in the analysis of this review. This systematic review demonstrates that non-white races and women were less likely to receive the correct, clinically indicated, therapy for hyperlipidemia. A multi-faceted approach is required to solve this inequality in healthcare.Tumor-associated macrophages (TAMs) have recently emerged as potentially crucial therapeutic targets for cancer. Thus, the development of macrophage-mediated phagocytosis assays is vital for preclinical drug screening of different tumor cells. This assay can be used to evaluate the effect of anti-cancer therapy, such as immunotherapy, radiotherapy, and chemotherapy, on different tumor cells. Here, we describe the in-vitro phagocytosis assay in detail. As an example of immunotherapy treatment, we used a monoclonal antibody to block an anti-phagocytic signal (CD47) to evaluate the assay using human brain tumor cells and monocyte-derived macrophages. We also demonstrated that this assay can be used to evaluate the effect of different irradiation doses on the phagocytosis of brain tumor cells. This functional assay is fast, accurate, and highly reproducible. Furthermore, the results successfully demonstrate that anti-CD47 antibodies and irradiation can enhance the macrophage-mediated phagocytosis of brain tumors.Pancreatic cancer patients experience debilitating pain, which makes pain management an integral part of the treatment plan. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-guided CPN) is an alternative palliative therapy for patients with pain due to pancreatic cancer. We report a patient who developed paralytic ileus after undergoing EUS-guided CPN. A 77-year-old male patient presented with nausea, vomiting, and abdominal pain of one-day duration. He was diagnosed with stage IV pancreatic adenocarcinoma three weeks prior to presentation for which he underwent EUS-guided CPN. He had a 30-pack-year smoking history and quit 31 years ago. He reported moderate alcohol use and denied illicit drug use. In the emergency department, vital signs demonstrated normal blood pressure, heart rate, respiratory rate, and temperature. Abdominal exam was significant for minimal epigastric tenderness without guarding or rebound. Complete blood count (CBC), basic metabolic panel (BMP), and liver function tests were ucapture the occurrence of the rare side effects of EUS-guided CPN.This case report presents the case of a 28-year-old man who developed scurvy during the coronavirus disease 2019 (COVID-19) pandemic. Scurvy is a disease resulting from a nutritional deficiency of vitamin C (ascorbic acid). It is a rare condition, whose signs and symptoms can vary from patient to patient. The treatment is vitamin C supplementation, which is often followed by a swift recovery. To our knowledge, this is the first reported case of scurvy during the COVID-19 pandemic. This article highlights a rare acquired bleeding disorder, which may manifest more commonly during a pandemic due to food scarcity or stay-at-home mandates in those already at risk.In this technical report, we describe a method for teaching the Neonatal Resuscitation Program (NRP) courses while also maintaining social distancing during the COVID-19 pandemic a method we call 'Socially Distanced NRP.' The unique aspects of Socially Distanced NRP courses include small class sizes, keeping one group of students and their instructors together throughout the course, and creating socially distanced stations where students complete the performance skills, integrated skills, and simulation and debriefing parts of the NRP course. The four socially distanced stations include airway, chest compressions, umbilical venous catheter placement, and team leader. Feedback from 79 NRP students showed no difference in overall course rating between Socially Distanced NRP and standard NRP courses. No cases of COVID-19 transmission were identified in the Socially Distanced NRP courses. We believe that Socially Distanced NRP is a safe and effective way to provide mandatory NRP training during the COVID-19 pandemic.Platypnea-orthodeoxia syndrome (POS) is an extraordinary medical condition characterized by positional dyspnea (platypnea) and arterial desaturation or hypoxemia (orthodeoxia) in the setting of an upright position. The difficulty breathing is alleviated upon lying down. It is the opposite of orthopnea and is manifested by a decrease in oxygen saturation when changing from supine to an orthostatic position. POS can have an intracardiac or an extracardiac etiology. Herein we report a case of an 87-year-old man presenting with acute on chronic dyspnea who showed promising improvement in oxygen saturation after patent foramen ovale (PFO) closure.Bertolotti's syndrome is a congenital condition characterized by the sacralization of the lower lumbar vertebrae or the lumbarization of the sacral vertebrae. The cause of pain in Bertolotti's syndrome is multifactorial. This lumbosacral transitional vertebra has a prevalence of 4% to 30%. Rarely, it is considered in the differential diagnosis of low back pain in young people. Therefore, every aspect of Bertolotti's syndrome needs to be meticulously addressed, and it should be included in the differential diagnosis of chronic back pain. Herein, we present a case of Bertolotti's syndrome presented with chronic lower back pain, confirmed on X-ray and magnetic resonance imaging (MRI). He was managed with analgesics and steroids injection with regular follow-up.Protamine sulfate is a common reversal agent of systemic heparinization used during procedures. While the exact epidemiology of adverse events is unknown, prior allergic response to protamine-containing compounds or concomitant use of neutral protamine Hagedorn (NPH) insulin is associated with an increased risk of tachyarrhythmias and bradyarrhythmias. We present a case of a 68-year-old woman with no prior history of protamine sulfate intolerance that suffered bradycardic arrest following protamine infusion. Healthcare providers should recognize the potential for life-threatening tachyarrhythmias and bradyarrhythmias following protamine reversal, especially in diabetic patients at risk for autonomic dysfunction; medication and allergy review are encouraged prior to heparin reversal, especially in diabetic patients.Background Laparoscopic surgery is becoming the gold standard for most abdominal surgeries in recent times. Laparoscopic repair of perforated duodenal ulcer (PDU), however, is still an area of debate. The purpose of this study was to evaluate the safety and efficacy of laparoscopic repair of PDU versus open repair. Methods In this cross-sectional study, patients were consecutively sampled. Out of 101 patients with clinically diagnosed PDU, 36 patients underwent laparoscopic Graham patch repair and 65 underwent open Graham patch repair in a tertiary care academic hospital. Open repair was via upper midline incision, and laparoscopic repair by the three-port technique. The following stages were calculated operative time, duration of postoperative analgesia, time taken to mobilize, and patient length of stay after the operation. Results The mean operative time was somewhat longer in the laparoscopy group compared to the open repair group (74.01 vs 56.17 minutes, respectively). Mean postoperative analgesia requirement, time taken to mobilize, and hospital stay were significantly shorter after laparoscopy than after open repair (1.21 days, 9.32 hours, and 3.12 days vs 3.83 days, 16.20 hours, and 4.85 days, respectively). Three patients (8%) in the laparoscopy group and 35 (54%) in the open repair group had postoperative complications. Conclusions Laparoscopic repair of PDU is a safe approach and better than open repair in terms of operative time with the right level of expertise only, postoperative analgesia requirement, mobilization, duration of hospital stay, and incidence of postoperative respiratory and wound complications.Fungating malignant lesions pose a huge deal of agony to the patients. Their management is also deemed as difficult by most physicians. This report describes a case of a 45-year-old paraplegic female with delayed presentation of a very aggressive fungating left breast mass, which was diagnosed as invasive ductal carcinoma. The uncontrollable hemorrhage had the surgeons succumb to the option of emergency mastectomy as a palliative treatment to save the life of the patient. Hence, we infer that the emergency mastectomy in a hemorrhagic fungating breast lesion can be life-saving and can be performed with little to no risk to the patient. Such a procedure, surprisingly, has never been documented in the surgical literature before.Antidepressant discontinuation syndrome (ADDS) is reported to occur in almost 30-50% of the patients who take antidepressants for a duration of at least four to six weeks and then suddenly discontinue the drug. Since there is an increase in the use of antidepressants for various reasons by general practitioners, patient education about when and how to discontinue a drug is not acknowledged enough. It is reported to occur with the use of different classes of antidepressants - selective serotonin reuptake inhibitor (SSRI), monoamineoxidase inhibitor (MAOI), tricyclic antidepressants (TCAs), and atypical antipsychotics like risperidone, trazodone, clozapine, and venlafaxine. Slow tapering off the drugs has also caused ADDS. Symptoms start within two to four days of quitting the drug and are usually mild lasting for two to four weeks (can persist for six to 12 months) but could be severe enough leaving the patient nonambulatory. Here, we represent a case of a 55-year-old female who presented to the outpatient clinic with complaints of headache, vomiting, and diarrhea. The patient had 10 to 12 episodes of watery diarrhea every day and bilateral, continuous, pressing headache associated with multiple episodes of non-projectile vomiting. She was investigated for ultrasound sonography (USG) abdomen, CT head, and lab investigations which turned around to be normal. A follow-up visit with detailed history revealed she suddenly stopped taking escitalopram after six months by herself without tapering off the dose, two days before the onset of symptoms. Escitalopram was reinstated and the symptoms started to resolve in two to three days. All the unnecessary investigations and treatment could have been prevented if the proper history was taken and revealed at the initial visit.Objectives To evaluate the sociodemographic and clinical characteristics of patients presented with acute self-poisoning at a tertiary care hospital in Pakistan. Methods and Patients A comparative study was conducted at Lady Reading Hospital MTI between May 2018 to May 2019 for a duration of 12 months. All patients diagnosed with acute self-poisoning were included in the study. Patients with inconclusive diagnosis, who were dead prior to the arrival to the hospital, or had an incomplete history of poison exposure were excluded from the study. At the time of arrival to the emergency department, the patient was first stabilized. Patients were grouped into two according to the type of exposure, i.e., accidental self-poisoning and deliberate self-poisoning (DSP). Sociodemographic and clinical characteristics of patients were recorded in a preformed proforma. The data were analyzed using Statistical Package for the Social Sciences (SPSS) Version 26 (IBM Corp., Armonk, NY, USA). Results The mortality rate in patients with accidental poisoning was 9.62%, whereas it was 26.28% in DSP patients. Data were stratified according to the mode of poisoning, i.e., accidental vs DSP, and variables were assessed in patients who did not survive. It was found that 60% of patients who died in the accidental group were aged 0-15 years. In contrast, only one patient between aged 0-15 years died in the DSP group and the majority of the deaths occurred in those aged 25.1-35 years (31 [75.6%]). Conclusions In conclusion, women more often attempted suicide, whereas males suffered accidental poisoning more frequently. Firstly, we found a female predominance in the DSP group, whereas males were more prevalent in with young children experiencing accidental poisoning. Longer time from ingestion of poison to the arrival is associated with poor patient prognosis.One challenge in medical education is the inability to compare and aggregate outcomes data across continuing educational activities due to variations in evaluation tools, data collection approaches and reporting. To address this challenge, Gilead collaborated with CE Outcomes to develop, pilot, and implement a standardized outcomes evaluation across Gilead directed medical education activities around the world. Development of the standardized tool occurred during late 2018, with Gilead stakeholders invited to provide input on the questions and structure of the evaluation form. Once input was captured, a draft evaluation tool was developed and circulated for feedback. Questions were created to collect 1) participant demographic characteristics 2)data on planned changes to practice, key learnings and anticipated barriers, and 3) learner satisfaction with content and perceived achievement of learning objectives. The evaluation tool was piloted in H1 2019 across 7 medical education activities. Revisions based on pilot feedback were incorporated. The evaluation tool was broadly released during H2 2019 and data were collected from over 30 educational activities. By the end of 2019, it was possible to compare outcomes results from individual activities and aggregate data to demonstrate overall educational reach and impact. Continuing education activities provide valuable up-to-date information to clinicians with the goal of improving patient care. While often challenging to highlight the impact of education due to variations in outcomes, this standardized approach establishes a method to collect meaningful outcomes data that demonstrates the collective impact of continuing education and allows for comparison across individual activities.
Previous investigations suggest the use of extract from the roots of
(EPs 7630) for improvement of the symptoms of uncomplicated upper airway inflammations, due to its antimicrobial and immunomodulatory actions. The aim of this investigation was to evaluate the effects of EPs 7630 on chemokine production in nasal mucosa and clinical parameters of patients with acute postviral rhinosinusitis (APRS).

Twenty-six (
 = 26) APRS patients and 25 (
 = 25) control subjects were included in this prospective study. We measured the concentrations of thirteen chemokines in nasal secretions of APRS patients and controls by flow cytometry. The patients with APRS were treated by EPs 7630 20 mg oral tablets, three times daily for 10 days. We compared the chemokine levels in nasal secretions, nasal symptoms and endoscopic findings in patients, before and after therapy.

We found higher Total Symptom Score (TSS) and higher concentrations of MCP-1, MIP-1α, MIP-1β, MIP-3α, ENA-78 and IL-8 in nasal secretions of APRS patients than in controls. After therapy by EPs 7630, we found significant improvement in all symptoms and endoscopic findings of APRS. The concentrations of MCP-1, IP-10 and MIP-1β were significantly increased and levels of MIP-1α, ENA-78, GROα and IL-8 significantly decreased in nasal fluid samples after therapy. No adverse effects were reported during the treatment.

Our results suggest the presence of modulatory effects of EPs 7630 on production of chemokines regulating the function of neutrophils and monocytes in the site of inflammation of the nasal mucosa in patients with APRS.
Our results suggest the presence of modulatory effects of EPs 7630 on production of chemokines regulating the function of neutrophils and monocytes in the site of inflammation of the nasal mucosa in patients with APRS.Hearing loss is the most common neurosensory deficit. It results from a variety of heritable and acquired causes and is linked to multiple deleterious effects on a child's development that can be ameliorated by prompt identification and individualized therapies. Diagnosing hearing loss in newborns is challenging, especially in mild or progressive cases, and its management requires a multidisciplinary team of healthcare providers comprising audiologists, pediatricians, otolaryngologists, and genetic counselors. While physiologic newborn hearing screening has resulted in earlier diagnosis of hearing loss than ever before, a growing body of knowledge supports the concurrent implementation of genetic and cytomegalovirus testing to offset the limitations inherent to a singular screening modality. In this review, we discuss the contemporary role of screening for hearing loss in newborns as well as future directions in its diagnosis and treatment.The terrorist attacks that occurred in France in 2015 and 2016, which had many victims, proved that it is essential to identify victims following the methodology developed by International Criminal Police Organization (INTERPOL) for such events. Initially designed for natural disasters, this approach must be strictly respected should a terrorist attack occur. This includes the specific collection of bodies and body parts, as well as the setup of an antemortem unit, postmortem unit, and Identification Commission. This commission is made up of specialists and will make decisions on the basis of primary identifying elements (fingerprints, DNA, dental records) and/or secondary identifying elements (other distinctive and particularly discriminating signs). A multidisciplinary team, combining specifically trained police officers and scientists, must provide a reliable and consolidated list of deceased people based on biometric elements cross checked with elements from the investigations. Any list of names generatedof the experience of the November 2015 attacks in Paris, this innovative method proved its effectiveness during the Nice attack in July 2016. It can only be successful in a context where all the individuals involved in the crisis, up to the highest authorities, understand it, support it, and relay it in the best interest of the victims' families.KEY POINTSThe INTERPOL protocol must be used in order to identify victims after a terrorist attack.Some adaptations to the abovementioned protocol can be put in place in order to speed up the identification process in such circumstances.The lessons learned from the 2015 Paris terrorist attack can be useful to other disaster victim identification (DVI) units.The main aims of a medico-judicial unit are to ensure the examination of assault victims or persons in custody and to perform sampling necessary for investigations. Forensic examination is essential to describe the wounds and to evaluate the consequences of an assault by determining days of total incapacity for work (ITT). After the Paris attack on November 13, 2015, 121 victims were examined at the medico-judicial units of Paris. An initial forensic certificate was issued by forensic physicians with an assessment of physical ITT. A consultation with a forensic psychiatrist was systematically scheduled on the same day to obtain a forensic certificate for the psychological ITT. The average age of the victims was (33 ± 7) years and the sex ratio was 1.26. Most victims were in the Bataclan concert hall (78/121 or 64.5%). Of the 121 victims, 73 (60.3%) had projectile lesions (bullets, bolts and nuts, metal fragments, etc.) and 48 (39.7%) had non-projectile lesions (bruises, hematomas, etc.). The average physical ITT was 27 days (0; 190). The evaluation of the number of days of physical ITT was often complicated as some patients were still in medical care at the time of the initial examination. This experience enabled the Paris medico-judicial unit to anticipate the management required should any future event of this magnitude occur. It also reinforced cooperation between the medico-judicial unit and other departments, mostly emergency services and the forensic psychiatric unit. The Paris medico-judicial unit was thus able to offer a unique place of care by providing both physical and psychological examinations.The Belgian disaster victim identification (DVI) team is involved in many investigations in our country. Indeed, this specialized team of the federal police oversees searching for and investigating criminally buried dead bodies, identification of unknown putrefied corpses, and more. The Belgian DVI team also assists with the identification of victims of mass disasters (natural, accidental, and mass murders). In this article, we consider the contributions of different teams (forensic pathology, anthropology, and odontology, federal police, and crime scene investigation) both on the scene of the attack at the Brussels National Airport (Zaventem) and in the laboratory work (autopsies, sample studies).The terrorist attacks of November 2015 led to the immediate death of 129 victims admitted to the Legal and Forensic Medicine Institute of Paris, including 41 unidentified. During the Disaster Victim Identification (DVI) operations, 22 bodies were examined by the postmortem (PM) dental team with the aim of establishing PM odontograms. At the same time, the dental expert in the antemortem (AM) unit collected a large number of dental files, progressively filtered as the list of missing persons became reduced. Feedback from these events has highlighted the difficulties of implementing the DVI chain principles in a legal framework, published the day before the attacks, and also the technical complexity of collecting dental data on a week end of terror. The return on experience after this event has represented a paradigm shift on previous methods of DVI in Paris and even more in France. Indeed, the victim identification procedure was redesigned, integrating new technical means such as a CT scan directly on spot, allowing the extraction of maxillofacial data as soon as possible in order to support the PM dental examination team. Moreover, the National Dental Council proceeded to the overall remodeling of the dental identification unit, which is composed of trained members, from local, regional and national aspects. These forensic experts are dedicated, at the request of the legal authorities, to DVI operations and deployed throughout the country capable of managing AM and PM data. This unit aims also to share experiences and awareness-raising among health professionals and investigators in order to optimize a better submission of AM elements and also to enhance the major interest of odontology as a primary identifier in disaster.Terrorist attacks have been on the rise. During the recent terrorist attacks in France, terrorists perpetrated their acts using weapons of war, as well as explosive charges. These two modes of action, when combined, can create skin lesions with similar macroscopic appearances, which can sometimes go unnoticed because of body fragmentation. A total of 68 autopsies, 83 external examinations, 140 standard radiographic examinations, and 49 computed tomography (CT) scans were performed over 7 days during the 2015 terrorist attacks in France. Bodies were injured by firearms and shrapnel-like projectiles. We analysed the clinical findings for the secondary blast cutaneous lesions from the explosive devices and compared these lesions with ballistic-related lesions to highlight that patterns can be macroscopically similar on external examination. Secondary blast injuries are characterised by penetrating trauma associated with materials added to explosive systems that are propelled by explosive air movement. These injuen anatomopathological analyses of the orifices also help determine the cause of the wounds.On the evening of November 13, 2015, the city of Paris and its surroundings was hit by a series of attacks committed by terrorist groups, using firearms and explosives. The final toll was 140 people deceased (130 victims and 10 terrorists or their relatives) and more than 413 injured, making these attacks the worst mass killings ever recorded in Paris in peacetime. This article presents the forensic operations carried out at the Medicolegal Institute of Paris (MLIP) following these attacks. A total of 68 autopsies of bodies or body fragments and 83 external examinations were performed within 7 days, and the overall forensic operations (including formal identification of the latest victims) were completed 10 days after the attacks. Over this period, 156 body presentations (some bodies were presented several times) were provided to families or relatives. Regarding the 130 civilian casualties, 129 died from firearm wounds and one died from blast injuries after an explosion. Of the 10 terrorists or their relativeolve a very large number of victims in a constrained time.Solid pseudopapillary neoplasms (SPN) of the pancreas are rare neoplasms accounting for 1-2% of all pancreatic tumors and have a general female predominance. We report a case and intraoperative videos of SPN involving the whole pancreatic tail. A 19-year-old female patient initially presented to another healthcare facility complaining of abdominal pain, which was started 6 years ago. A contrast-enhanced Computed Tomography (CT) scan of the abdomen showed a large mass measuring 15.6 cm × 11.6 cm × 11 cm, arising from the pancreas with an enhancing cystic component. The patient underwent exploratory laparotomy, which revealed a huge mass occupying most of the abdominal cavity. Thus, we proceeded with a distal pancreatectomy and splenectomy. Intraoperatively, the frozen section showed that the mass had features of a solid pseudopapillary tumor of the pancreas with negative resection margins. The SPN diagnosis was confirmed by histopathology and immunohistochemistry. The pathophysiology behind the development of SPN and its cellular origin is still a matter of debate with multiple proposed hypotheses. SPNs are asymptomatic in almost 70% of all cases and usually discovered incidentally. The pre-operative diagnosis of SPNs remains a clinical challenge despite all the current advances in the diagnostic modalities. Surgical management with negative resection margins is the mainstay of treatment, even with metastasis and vascular invasion, surgical excision should be performed whenever feasible. The recurrence rate after surgical resection has been reported to be 3-9%. The prognosis of SPN limited to the pancreas is generally excellent with over 95% cure rate following complete surgical resection. SPN is a rare entity of a controversial origin but is considered as a low-grade malignancy. Surgical resection to achieve complete excision constitutes the mainstay of treatment, which mostly results in an excellent prognosis.
Contrast-enhanced ultrasonography (CE-US) brings a higher signal-to-noise ratio and a higher sensitivity for slow flow than traditional B-mode ultrasonography (US). However, it remains unclear whether CE-US is also superior to B-mode US in detecting early-stage pancreatic cancer (PC).

This was a retrospective study enrolling patients suspected of pancreatic insufficiency between June 2015 and December 2019. Enrolled patients successively received B-mode US and CE-US examinations, and some their demographic and clinical data were collected. The diagnostic capacity of the two examinations was calculated and receiver operating characteristic (ROC) curves was used to compare the area under the curve (AUC). A subgroup analysis was performed to explore the effects of tumor size on the diagnostic accuracy of B-mode US and CE-US.

There were 128 patients enrolled in this study; 74 patients were diagnosed as early-stage PC patients and the remaining 54 were diagnosed with benign pancreatic lesions. The mean size of the PC was 17.8±4.9 mm. The results revealed that 68 of the 74 PC patients were correctly diagnosed by CE-US, and all 54 patients with benign pancreatic lesions were also correctly diagnosed. Meanwhile, only 55 of the 74 PC patients and 50 of the 54 patients with benign pancreatic lesions were diagnosed correctly using B-mode US. The ROC curve showed that the AUCs of CE-US and B-mode US were 0.959 and 0.835, respectively. According to the subgroup analysis, CE-US exhibited better accuracy than B-mode US for smaller tumors (size <20 mm, P=0.002; size <10 mm, P=0.043; size <5 mm, P=0.025).

CE-US was clearly superior to the conventional B-mode US in detecting early-stage PC, especially smaller sized PC.
CE-US was clearly superior to the conventional B-mode US in detecting early-stage PC, especially smaller sized PC.
We sought to examine the impact of neoadjuvant chemotherapy (NCT), single agent (SA) or multi-agent (MA) chemotherapy, and chemoradiation (NCRT) on response and survival in pancreatic cancer.

Utilizing the National Cancer Database, we identified patients who underwent resection of the pancreatic head for adenocarcinoma [2006-2013]. Overall survival (OS) analysis was performed using the Kaplan-Meier method. Multivariable cox proportional hazard models (MVA) and propensity score matching (PSM) were developed to identify predictors of survival. For upfront surgery (UFS), OS was limited to receipt of adjuvant treatment.

We identified 26,563 patients who underwent pancreatic head resection UFS =23,877, NCRT =1,482, and NCT =1,204. MA-NCT was utilized in 77% and after PSM, 52%. There was improved R0 resections and 30-day mortality associated with neoadjuvant therapy compared to UFS. Overall response rate to neoadjuvant therapy was 24%. The highest response rate seen with MA-NCRT. Response rates for SA-NCT, MA-NCT, SA-NCRT, and MA-NCRT were 11.5%, 18.1%, 27.5%, and 33.1% (P=0.01). However, OS was improved with neoadjuvant therapy regardless of response compared to UFS (P=0.03). After PSM, the median OS for UFS, SA-NCT, MA-NCT, SA-NCRT, and MA-NCRT was 21.9, 21.5, 29.8, 25.3, and 25.8 months in all patients (P=0.001). MVA after PSM demonstrated that only MA-NCT was associated with decreased mortality while increasing age, higher Charlson-Deyo index, N1, higher grade, tumor size, and positive margins were associated with higher mortality.

There was improved OS associated with MA-NCT in pancreatic cancer patients compared to UFS with adjuvant therapy. OS was improved regardless of response to therapy.
There was improved OS associated with MA-NCT in pancreatic cancer patients compared to UFS with adjuvant therapy. OS was improved regardless of response to therapy.
Imaging and alpha fetoprotein (AFP) measurement are used as surveillance methods during interventional therapy in patients with unresectable liver cancer, but their accuracy has been challenged in patients receiving drug perfusion therapy. Circulating tumor DNA (ctDNA) can reflect tumor load and treatment efficacy. Studies of the prognostic value of ctDNA in unresectable liver cancer are needed.

Forty-two patients with unresectable liver cancer were prospective enrolled in this study. Pre-treatment, in-treatment plasma samples and available matched tissue samples were collected. Targeted-capture sequencing of 1,021 genes that are frequently mutated in solid tumors.

Targeted-capture sequencing of 1,021 genes that are frequently mutated in solid tumors revealed that the most frequently mutated genes in ctDNA were TP53 (52.4%) and TERT (35.7%). The ctDNA abundance was more closely correlated with tumor size than the AFP level and was also related to BCLC stage (P<0.001). Gene mutations profile in ctDNA rden prior to immunotherapy.
Alternative splicing (AS) is a transcriptional regulation mechanism, which can expand the coding ability of genome and contribute to the occurrence and development of cancer. A systematic analysis of AS in hepatocellular carcinoma (HCC) is lacking and urgently needed.

Univariate and multivariate Cox regression analyses were used to distinguish survival-related AS events and to calculate the risk score. Kaplan-Meier analysis and receiver operating characteristic (ROC) curves were used to evaluate the AS events' clinical significance to build a risk model in HCC.

Data of AS events was obtained from the Splice-Seq database. The corresponding clinical information of HCC was downloaded from The Cancer Genome Atlas (TCGA) data portal. We analyzed 78,878 AS events from 13,045 genes in HCC patients. A total of 2,440 and 2,888 AS events were significantly related to HCC patients' disease-free survival (DFS) and overall survival (OS). The two prognostic models (DFS and OS) were constructed based on a total of seven AS types from survival-related AS events above.
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