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Pilomatricomas are rare skin tumors related to hair follicles. They typically present in children, and the most common locations are head and neck. Pilomatricomas are usually painless; however, they can cause cosmetic problems. Treatment is decided on an individual basis and involves local excision. However, caution should be taken if the lesion is malignant, as resection with safe margins (0.5-1.0 cm) is determinant of the overall outcome. Radiotherapy is indicated in cases of residual tumor tissue or recurrence. The role of chemotherapy in pilomatricomas is still undetermined. We report a 55-year-old female with multiple lumps on her shoulder and back. The sonographic features of these lesions were typically consistent with pilomatricomas. The patient decided to opt for excision due to cosmetic reasons and the histopathology features were suggestive of pilomatricoma.

Systemic side effects of anti-cancer therapy remain a major limiting factor for patients, even with targeted therapy. Bevacizumab is an example of targeted cancer therapy which targets the vascular endothelial growth factor receptor (VEGFR) that has been approved for the treatment of various cancers and has been evaluated in metastatic urothelial carcinoma (MUC). We report a case of MUC on bevacizumab containing regimen who developed temporary asymptomatic sinus bradycardia with sinus pauses. That adverse event was thought to be related to the bevacizumab in her cancer regimen. Her Holter monitoring recording for a total duration of 28 days and 14 h after discharge did not show recurrence of sinus pauses. This case indicates the necessity for observation for the cardiac conduction defects as side effects in patients receiving bevacizumab, especially since they might be asymptomatic and transient.

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Fluorouracil (5-FU) is a chemotherapy medication often used alone or in combination with other agents (e.g., FOLFOX regimen) to treat gastrointestinal malignancies. Adverse effects of 5-FU include pancytopenia, alopecia, cardiotoxicity, and gastrointestinal symptoms. We describe a rare case of pulmonary toxicity associated with 5-FU. CASE PRESENTATION: The patient is a 78-year-old female with a history of unresectable metastatic cholangiocarcinoma on maintenance FOLFOX chemotherapy without Oxaliplatin (discontinued due to peripheral neuropathy and thrombocytopenia) presented with acute onset of dyspnea and pleuritic chest pain five days after a 5-FU and Leucovorin infusion. On initial evaluation, a chest radiograph showed pulmonary infiltrates for which she was treated with oral Levofloxacin as an outpatient. Despite this, she had progressive worsening of dyspnea, prompting further evaluation. Blood work revealed normal WBC and platelet counts, mild anemia with hemoglobin 9.4 g/dL, and normal BNP and troponin levels. ECHO showed normal systolic function. She was noted to be hypoxemic, requiring supplemental oxygen necessitating hospitalization. Repeat Chest radiograph showed worsening left upper lobe and lingular infiltrates. Her oxygen requirements rapidly increased from 3-4 L/min via nasal cannula to 12L/min via Oxymask. Despite treatment with broad-spectrum IV antibiotics, her dyspnea and hypoxia persisted. CTA chest was then performed, revealing extensive bilateral infiltrates and reactive enlarged mediastinal/hilar lymph nodes with no evidence of pulmonary embolism. She had a negative infectious workup, including a COVID-19 PCR. She underwent diagnostic bronchoscopy, which showed no endobronchial lesions or secretions. Bronchoalveolar lavage of the right middle lobe with three serial aliquots obtained progressively bloody returns diagnosing diffuse alveolar hemorrhage (DAH). The procedure was complicated by worsening hypoxia, and the patient required emergent intubation and transferred to the critical care unit, where she was treated with pulse dose steroids for three days. She was extubated to supplemental O2 via NC within 24 hours of treatment. Further lab evaluation showed negative ANA, ANCA, Anti GBM antibodies, Anti-dsDNA, and normal C3, C4 levels. Cytology of BAL was negative for malignancy. Given negative infectious and autoimmune workup, the diagnosis of DAH due to 5-FU was made. Steroid dose was reduced to Prednisone 1mg/kg with slow taper with improvement in clinical status and oxygen requirements. DISCUSSION: The diagnosis of 5-FU related pulmonary toxicity is based on clinical suspicion upon exclusion of infection, autoimmune disease, heart failure, and cancer progression. CONCLUSIONS: 5-FU induced pulmonary toxicity presenting as DAH is a rare entity. Prompt diagnosis can lead to early drug cessation and the use of high-dose steroids can improve patient outcomes. REFERENCE #1: Fernandez, L., Dominguez, A., Martinez, W., Sanabria, F., Leib, C. S., & Biomedical Research Group in Thorax. (2018). Pulmonary Toxicity Due to 5-Fluorouracil (5-FU) Manifested as Diffuse Alveolar Hemorrhage: Case Report. In D34. LUNG TRANSPLANT AND DRUG INDUCED LUNG DISEASE: CASE REPORTS (pp. A6577-A6577). American Thoracic Society. DISCLOSURES: No relevant relationships by Rajesh Kunadharaju, source=Web Response No relevant relationships by Puja Mehta, source=Web Response No relevant relationships by Ahmed Munir, source=Web Response No relevant relationships by Vandana Pai, source=Web Response No relevant relationships by Musa Saeed, source=Web Response

While malignant mesothelioma may initially present in a variety of ways, it is uncommon to present with systemic lupus erythematosus (SLE) seropositivity and thus obscuring its diagnosis. Our case involves a 75-year-old Caucasian male with a past medical history of essential hypertension, remote prostate cancer status post prostatectomy, and lifetime nontobacco use presenting with progressive shortness of breath over one month. After a negative cardiac assessment, a postcardiac catheterization chest X-ray (CXR) revealed a right-sided moderate-to-large pleural effusion that, on further workup, was found to be exudative. Effusion studies were negative for malignancy and bacterial growth. Recurrent accumulation of fluid after a thoracentesis one week prior prompted an autoimmune work up. Positive markers included antinuclear antibodies, anti-double stranded DNA antibodies, and anti-histone antibodies, while anti-Smith antibodies were negative. Although SLE was initially suspected based on serologies, no clinical signs or symptoms were present to fulfill the diagnosis criteria. A trial of oral prednisone resulted in decreased pleural effusion size with no further recurrence. Additional studies included a CT scan of the chest that showed pleural masses confirmed with biopsy to be epithelioid mesothelioma. Given the patient's age and new diagnosis of malignant mesothelioma, we hypothesized that the presence of autoantibodies was likely false positives due to acquired autoantibodies with age, hyperactivity of the immune system from malignancy, and possible prior asbestos exposure.

Hemosuccus pancreaticus is a rare but life-threatening cause of upper gastrointestinal bleeding through the main pancreatic duct. This clinical entity is a difficult diagnosis due to its rarity, intermittent nature of the hemorrhage, and peculiar clinical presentation. It is still considered a surgical problem but advances in medical therapy may enable clinically stable patients to undergo less-invasive angiographic embolization. We chronicle here a unique case of hemosuccus pancreaticus in a patient presenting with melena who could not be diagnosed on multiple standard forward-viewing esophagogastroduodenoscopies and computed tomography angiography. Eventually, side-viewing duodenoscope identified the intermittent bleeding through the ampulla of Vater. This paper illustrates that clinicians should be vigilant for this etiology, especially in patients with intermittent crescendo-decrescendo abdominal pain, acute gastrointestinal hemorrhage, and elevated serum lipase levels. A multidisciplinary team approach with the centralization of gastrointestinal bleed services and a well-established management protocol is of paramount importance to reduce the morbidity and mortality of this disorder. Additionally, this article serves to outline our current understanding of the epidemiology of and risk factors for hemosuccus pancreaticus, the pathophysiology of this disease, and currently available approaches to diagnosis and treatment.

Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.

Over the past decade, political framework in the energy sector all over the world has provoked a strong focus on the production of renewable energies. The study focuses on agent-based modelling approach to identify the suitable and economical distribution of biogas power plants over time in the area of interest. For sufficient supply of biomass (silage maize) on a regional basis to run biogas power plants economically and smoothly, different thematic layers with defined rules for Agent Analyst used to simulate the future installations of power plants. In conjunction with ArcGIS, the Agent Analyst software generates simulations that prove the robustness of the model in finding the suitable location of power plants. The resultant location from the model is analysed in different aspects. The designed methodology could be implemented in other areas with minor edits as per requirement of the area.

There is a global realization in all governmental setups of the need to provoke the efficient appraisal of crop water budgeting in order to manage water resources efficiently. This study aims to use the satellite remote sensing techniques to determine the water deficit in the crop rich Lower Bari Doab Canal (LBDC) command area. Crop classification was performed using multi-temporal NDVI profiles of Landsat-8 imagery by distinguishing the crop cycles based on reflectance curves. The reflectance-based crop coefficients (Kc) were derived by linear regression between normalized difference vegetation index (NDVI) cycles of the Moderate Resolution Imaging Spectroradiometer (MODIS) MOD13Q1 and MYD13Q1 products and Food and Agriculture Organization (FAO) defined crop coefficients. A MODIS 250 m NDVI product of the last 10 years (2004-2013) was used to identify the best performing crop cycle using Fourier filter method. The meteorological parameters including rainfall and temperature substantiated the reference evapotranspiration (ET0) calculated using the Hargreaves method. The difference of potential ET and actual ET, derived from the reflectance-based Kc calculated using reference NDVI and current NDVI, generates the water deficit. Results depict the strong correlation between ET, temperature and rainfall, as the regions having maximum temperature resulted in high ET and low rainfall and vice versa. The derived Kc values were observed to be accurate when compared with the crop calendar. Results revealed maximum water deficit at middle stage of the crops, which were observed to be particularly higher at the tail of the canal command. Moreover, results also depicted that kharif (summer) crops suffer higher deficit in comparison to rabi (winter) crops due to higher ET demand caused by higher temperature. Results of the research can be utilized for rational allocation of canal supplies and guiding farmers towards usage of alternate sources to avoid crop water stress.

Primary renal angiosarcoma is an exceedingly rare and aggressive neoplasm. Although it may occur in youth, this tumour is frequently reported in the sixth and seventh decades of life. The clinical presentation is frequently varied. Pathogenesis remains largely unknown and it has overlapping features with other tumours of the kidney. Current treatment options include variable combinations of surgery, chemotherapy and radiotherapy. Reports regarding the disease prognosis and natural history are limited. In this article, we chronicle the case of a patient with primary renal angiosarcoma presenting at an advanced stage as a widely metastasised tumour. Additionally, we undertake here a brief literature review highlighting the rarity and aggressiveness of this condition, its poor prognosis, and the lack of specific management guidelines.

Primary gastrointestinal lymphoma is a rare neoplasm that accounts for less than 5% of all gastrointestinal malignancies. We present a case of a 37-year-old woman positive for human immunodeficiency virus who presented with abdominal pain and vomiting for three months. She underwent endoscopic biopsy and was found to have high-grade diffuse large B-cell lymphoma in the jejunum. This report discusses her treatments and includes a brief literature review highlighting the rarity of this entity, the etiological agents implicated in its pathogenesis, and the lack of specific guidelines for treatment.

The objective of our study was to recognize hepatitis B reactivation as a complication of rituximab chemotherapy and to realize the importance of screening for prior Hepatitis B virus (HBV) exposure in all patients with hematologic malignancies who will receive rituximab as part of their therapy. Rituximab is a monoclonal antibody targeting CD 20 receptors on the membrane of B cells. In this case report, we described a 79-year-old man who presented to our department with nausea, fatigue, and jaundice. Two months ago, he had received the last dose of the chemotherapy regimen containing rituximab for follicular B cell lymphoma. Ultrasound and computed tomography (CT) scan of abdomen did not show any focal lesions. Liver function tests showed worsening hepatic failure and viral serology demonstrated active HBV infection. Antiviral therapy with entecavir and tenofovir disoproxil fumarate failed to improve his symptoms, and he died of fulminant hepatic failure. Rituximab targets CD 20 receptors positive B cells. It can destroy both cancerous and normal B cells. A decline in immune function can activate occult HBV infection. Prior to initiation of rituximab therapy, screening should be conducted in all cases for HBV associated serological markers. Patients with active or occult HBV infection must be started on appropriate antiviral therapy to prevent any severe outcomes with rituximab-containing regimens.

Seismic response of the multi-storey buildings is created by the interaction of both the structure and underlying soil medium. The seismic design philosophy is incorporated using response modification factor “R”. Current Code based values of “R” factor does not reflect the SSI problem as it is based on fixed base condition. In this study, the modified values of “R” factor for moment resisting frame (MRF) considering SSI are evaluated. The response of structure with and without SSI has been compared using equivalent linear static and nonlinear static pushover analyses for 10- storied moment resisting frame building. The building is located in seismic zone 2B situated on different soils with shear wave velocity (Vs) of 300m/sec (SD) and 1200m/s (SB). Code based “R” factor value for building frame system has been taken as 5.5. Soil medium is modelled using identical but mutually independent horizontal and vertical springs. It was found that the modified “R” factor values have been decreased by 47% and 43% for soil SD & SB respectively as compared to that of code based “R” factor.

A 52-year-old man was referred to our medical centre for the evaluation of persistent dyspepsia for several months. He denied nausea, vomiting, regurgitation, weight loss, haematemesis or melena. He had no history of pre-existing gastrointestinal disorders or non-steroidal anti-inflammatory drug use

Background Dengue is identified as serious vector born infectious disease by WHO, threating around 2.5 billion people around the globe. Pakistan is facing dengue epidemic since 1994 but 2010 and 2011 dengue outbreaks were worst. During 2011 dengue outbreak 22,562 cases were reported and 363 died due to this fatal infection in Pakistan. In this study, Lahore District was chosen as it was severely affected in 2011 dengue outbreak with 14,000 reported cases and 300 deaths. There is no vaccine developed yet for the disease control, so only effective early warning, prevention and control measures can reduce the potential disease risk. Methods This study proposes a method for detecting spatial autocorrelation of temporal dynamics of disease using Local Index of Spatial Autocorrelation (LISA) using three temporal indices: (a) how often the dengue cases occur, frequency index; (b) how long the epidemic wave prevails, duration index; (c) how significant dengue cases occur in successive periods, severity index. Overlay analysis of LISA value for each temporal index resulted in eight risk types. Results The mapping of spatio-temporal risk indices and their overlay analysis identified that 10.6% area of Lahore (184.3 km 2 and population density 119,110 persons/km 2 ) had high values for frequency, duration, and severity index ( p Conclusion Spatial risk identification by using local spatial-autocorrelation helps in identifying other possible causes of disease risk and further strategic planning for prevention and control measures.

Primary esophageal diffuse large B-cell lymphoma (DLBCL) is an extremely rare clinicopathologic entity. We report one case from our clinical experience and undertake a review of the previously published cases. A systematic literature search of the medical databases PubMed and Google Scholar was conducted. A total of 15 cases fulfilled the inclusion criteria. The data on patients’ characteristics, epidemiology, clinical features, HIV status, gross appearance of the lesion, esophageal location, treatment, and outcome were collected and analyzed. Primary esophageal DLBCL was more common among males, primarily in the fifth and sixth decades of life. Dysphagia was the most common initial clinical presentation. Tissue biopsy with immunohistochemistry was an indispensable diagnostic modality. The mainstay of treatment was chemotherapy with cyclophosphamide, vincristine, doxorubicin, and prednisone regimen, in addition to anti-CD20 antibody rituximab, with or without radiotherapy. This review serves to outline our current understanding of the epidemiology of and risk factors for primary esophageal DLBCL, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.

In recent years there has been an increase in the use of percutaneous Impella LVAD supported high risk coronary interventions. Currently this technique requires large diameter arteriotomy via Common Femoral Access (CFA) to allow equipement passage. Most commonly up to 14 French size sheaths are

World experience in last few decades has shown that aircraft usage varies from aircraft to aircraft, mission to mission and user to user. This paper describes the procedure to predict the remaining life of an in service aircraft based on the data from onboard flight data recorders. The proposed method uses 'rain flow cycle counting' and 'Palmgren-Miners' techniques to correlate flight parameters with usage frequency for structural life prediction and computes the impact of the actual loads resulting in 'strength degradation' and 'expected remaining life'. It identifies the most stressed areas along with fatigue life cycles thus estimating the remaining life cycles. The data acquired through the successful application of proposed methodology is also assistive in determining the maintenance cycle and its revision, which is a major cost driver during operations. The results attained through computations directly correspond to the severity of usage.

A mobile wireless sensor network owes its name to the presence of mobile sink or sensor nodes within the network. The advantages of mobile wireless sensor network over static wireless sensor network are better energy efficiency, improved coverage, enhanced target tracking and superior channel capacity. In this chapter we will present and discuss different classifications of mobile wireless sensor network as well as hierarchical multi-tiered architectures for such networks. This architecture makes basis for the future pervasive computing age. The importance of mobility in traditional wireless sensor network (WSN) is highlighted in this chapter along with the impact of mobility on different performance metrics in mobile WSN. A study of some of the possible application scenarios for pervasive computing involving mobile WSN is also presented. These application scenarios will be discussed in their implementation context. While discussing the possible applications, we will also study related technologies that appear promising to be integrated with mobile WSN in the ubiquitous computing. With an enormous growth in number of cellular subscribers, we therefore place the mobile phone as the key element in future ubiquitous wireless networks. With the powerful computing, communicating and storage capacities of these mobile devices, the network performance can benefit from the architecture in terms of scalability, energy efficiency and packet delay, etc. For mobile wireless sensor networks, there are basically two sensing modes, local sensing and remote sensing. By allowing and leveraging sink mobility and sink coordination, mobile WSN can achieve the goal of lower and balanced energy consumption with the following features:  Single-hop clustering. By allowing only single hop transmission between sensor and sink node, most previous multi hop relaying sensor nodes may become unnecessary. In fact, sensor nodes can enter sleep mode until the sink approaches. Therefore, the original energy budget for multi hop relaying can be saved.  Sink mobility and coordination. For a delay tolerant application, single mobile sink in fact equals virtually multiple static sinks at different positions. Multi-sink deployment can bring more uniform energy dissipation, therefore the possibility of energy hole will be reduced and network coverage will be improved. 1

This paper deals with the development and implementation of a framework of Intranet-SCADA using LabVIEW based Data Acquisition and Management. The system is robust, low on system requirements and easy to implement. This paper describes configuration of Remote Terminal Units to access and transmit real time data over the Intranet or Internet, receiving the IP data at the Master Terminal Unit and issuing responses to the Remote Terminal Units, logging all the data in a historian for future references at a centralized location, keeping the human operator updated via Human Machine Interface, and providing measures for any emergency and enabling control via e-mail over the internet giving true remote control capabilities.

This paper presents energy analysis of a new routing protocol CIDRSN (Cluster ID based Routing in static Sensor Networks) with closedform probability oferror and bit energy expression in Nakagami-m fading channel. CIDRSN takes the cluster ID as next hop address instead of cluster-head ID in routing table and eliminate the cluster formation phase and routing phase from being executed in each round, which reduces the energy consumption and increases the network life to about 16%. Robustness is increased by multi-path routing. Simulation results show that the proposed protocol outperforms the preceding hierarchical routing protocols.

Clustering approach is one of the most used routing methodologies for wireless sensor network. However, most of the clustering practices make use of greedy cluster head formation process, wherein each node broadcasts its interest in becoming cluster head which is both energy and network intensive. In this paper we present a mechanism for efficient clustering formation, wherein an optimal number of nodes are identified which can take part in clustering formation process. The gains achieved are both energy efficiency and reduced network traffic. In a uniformly placed sensor nodes network, our algorithm comes up with an energy efficient clustering scheme by reducing the number of nodes which take part in clustering process. We have made use of network density as a parameter for creating cluster in the network. A numerical analysis is presented for varying network topologies and simulations are conducted to verify that with increased area coverage, the number of edge nodes become increasingly large, thus contributing to energy gain and less network traffic size.