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Vaginal cuff dehiscence is a rare but potentially life-threatening post-hysterectomy complication. Here we report two cases of vaginal cuff dehiscence with distinct imaging features and describe the CT findings of vaginal cuff dehiscence. Both patients underwent repair surgery, and the diagnoses were confirmed. Radiologic features of vaginal cuff dehiscence are uncommonly described in the literature. Vaginal cuff mural discontinuity and omental fat tissue or bowel herniation into the vaginal canal are the most common appearances of vaginal cuff dehiscence. Pelvic hematoma, bowel obstruction, and pneumoperitoneum can accompany. These two cases highlight the CT appearances, potential presentations, and management of vaginal cuff dehiscence in the emergency setting.

Highlights • The spleen is normally located in the left hypochondriac region just underneath the 9th to 11th intercostal spaces. • Splenoptosis, wandering spleen or floating spleen, is a rare entity in which the spleen migrates from its normal position. • The diagnosis is confirmed by imaging modalities. • The only definitive treatment is surgical intervention., Background Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. Case presentation In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

Background Low-pressure hydrocephalus (LPH) is a relatively rare condition, and its presentation is similar to the classically seen high-pressure hydrocephalus, with headaches, cranial nerve dysfunction, ataxia, and disturbances of consciousness. Cerebral cerebrospinal fluid loss in the presence of altered brain viscoelastic properties has previously been suggested as the pathophysiologic process leading to ventriculomegaly, despite low or negative intracranial pressures and patent shunts. More recently, cerebral venous overdrainage has been proposed as a possible explanation in the pathogenesis of LPH, although its connection to lumbar punctures in patients with shunts has not been contemplated yet. The effectiveness of epidural blood patch in the management of post-lumbar puncture LPH has been shown in children but has not been reported in adults. Case Description Herein we detail 2 episodes of shunt malfunction in a 30-year-old female patient with a history of hydrocephalus related to a posterior fossa tumor diagnosed during childhood. In both instances, imaging studies demonstrated ventricular dilation along with perimedullary cistern enlargement and brainstem distortion, which occurred following a lumbar puncture despite a patent shunt. A lumbar blood patch was effective in both episodes, enabling resolution of the ventriculomegaly and a good outcome. Conclusions A blood patch can be efficient in adults with post-lumbar puncture LPH. Some symptoms may be explained by brainstem compression caused by enlarged cerebrospinal fluid spaces at the skull base. The role of cerebral venous overdrainage in the setting of post-lumbar puncture LPH is further supported.

Highlights • The small intestine is an essential constituent of the digestive system and plays a major role in the absorption of nutrients. • Acute mesenteric ischemia remains an emergency case. • Failure to adapt and the inadequate nutritional supply result in Short bowel syndrome. • A minimal indispensable length is required for nutritional autonomy. • Parenteral Nutrition still presents a pertinent problem of complications, charges and impairment in quality of life., Introduction The small bowel is an essential organ for maintaining adequate nutrition. Decrease in length could be associated with malnutrition and may require that the patient receives parenteral nutritional support. We report a case of a 59-year-old man who survived32 years with a short bowel of 35 cm length without any parenteral nutrition. Case presentation A 59-year-old gentleman, with a history of hypercoagulable state, presented for severe abdominal pain and obstipation of one day's duration. Upon presentation, the patient was hemodynamically unstable, with abdominal guarding and tenderness upon physical examination. Laboratory studies showed metabolic acidosis with leukocytosis and electrolyte disturbances, and an abdominal CT scan showed thickening of the sigmoid and multiple air-fluid levels. The patient was operated urgently for suspicion of mesenteric ischemia, however, he was found intraoperatively to have a very short dilated small bowel with jejunotransverse anastomosis. Discussion The necessity for surgical resection of the small bowel can arise for a sum of reasons. However, the removal of a big amount of small bowel may not be adaptive and appropriate digestion will no more be possible. In the aftermath of the resection, patients require parenteral nutrition for a certain period after which they may switch to enteral and oral nutrition, and subsequently intestinal adaptation by thickening and growth of the remaining intestinal villi. Conclusion Patients with a short bowel, particularly those surgically removed, can survive even with a very short remaining bowel length, as a result of intestinal adaptation, nutrition enhancement, and elimination of parenteral nutrition.

On March 11, 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic, and in the weeks following, public health organizations, medical associations, and governing bodies throughout the world recommended limiting contact with others to "flatten the curve" of COVID-19. Although both ischemic and hemorrhagic strokes have been reported with COVID-19, there has been anecdotal suggestion of an overall decrease in stroke admissions. To date, the effects of any pandemic on telestroke service lines have not been described. The purpose of this cross-sectional analysis of telestroke activations in the 30 days before and after the declaration of the COVID-19 pandemic is to describe the difference in case volumes of telestroke activations, the characteristics of patients, and treatment recommendations between the 2 time frames. We found a 50.0% reduction in total telestroke activations between the predeclaration group (142 patients) and the postdeclaration group (71 patients). There were no statistically significant differences in age (P=.95), sex (P=.10), diagnosis (P=.26), or regional variations (P=.08) in activation volumes. The percentage of patients for whom we recommended urgent stroke treatment with intravenous alteplase, mechanical thrombectomy, or both decreased from 44.4% (28 of 63) to 33.3% (11 of 33). The reasons for the sunstantial decrease in telestroke activations and urgent stroke treatment recommendations are likely multifactorial but nevertheless underscore the importance of continued public health measures to encourage patients and families to seek emergency medical care at the time of symptom onset.

Background: Frontal QRS-T angle (FQRST) has previously been correlated with mortality in patients with stable coronary artery disease, but its role as survival predictor after ST-elevation myocardial infarction (STEMI) remains unknown. Methods: We evaluated 267 consecutive patients with STEMI undergoing reperfusion or coronary artery bypass grafting. Data assessed included demographics, clinical presentation, electrocardiograms, medical therapy, and one-year mortality. Results: Of 267 patients, 187 (70%) were males and most (49.4%) patients were Caucasian. All-cause mortality was significantly higher among patients with the highest (101–180°) FQRST [28% vs. 15%, p = 0.02]. Patients with FQRST 1–50° had higher survival (85.6%) compared with FQRST = 51–100° (72.3%) and FQRST = 101–180° (67.9%), [log rank, p = 0.01]. Adjusting for significant variables identified during univariate analysis, FQRST (OR = 2.04 [95% CI: 1.31–13.50]) remained an independent predictor of one-year mortality. FQRST-based risk score (1–50° = 0 points, 51–100° = 2 points, 101–180° = 5 points) had excellent discriminatory ability for one-year mortality when combined with Mayo Clinic Risk Score (C statistic = 0.875 [95%CI: 0.813–0.937]. A high (>4 points) FQRST risk score was associated with greater mortality (32% vs. 19%, p = 0.02) and longer length of stay (6 vs. 2 days, p

Introduction Clavicle fractures and acromioclavicular joint dislocations are very common injuries. However, the combination of both, known as “floating clavicle” is extremely rare, with approximately 40 cases reported. Presentation of case We report a case of a healthy 51-year-old male who suffered a high-velocity biking accident, with a bipolar clavicle injury (type IV acromioclavicular joint dislocation and proximal clavicle fracture), with concomitant rib fractures and pulmonary contusion. He received early surgical treatment by open reduction and osteosynthesis of the proximal clavicle (distal ulna plate, Protean®) and open reduction and stabilization with a MINAR® implant for the acromioclavicular joint. After an initial one-month immobilization, he started physical therapy. In the 10-month follow-up he presented with a pain-free full range of motion, a good cosmetic result, and radiological consolidation. Discussion Bipolar clavicle injury is a rare clinical entity that encompasses a spectrum of combined clavicle fractures, acromioclavicular or sternoclavicular joint dislocations. They are sustained in a high-energy context, and accompanying injuries must be sought. Diagnosis is made through X-Ray and CT. Despite the lack of clinical guidelines, most authors agree on surgical management of at least one of the injuries, with multiple surgical techniques available. There is an emphasis in surgical treatment of the young and active patient. Conservative treatment is associated with poorer results. Conclusion It is advisable to have a high index of suspicion for floating clavicle in a high-energy trauma patient, given possible life-threatening injuries, and long-term shoulder sequelae. Surgery should be considered in a young and active patient., Highlights • “Floating clavicle” is a rare injury that should be suspected in a high energy accident. • Other life-threatening injuries must be ruled out. • There are no guidelines regarding best treatment. • Surgical treatment is usually advocated for young and active patients. • ORIF of sternoclavicular fracture and acromioclavicular joint dislocation yields good results.

Background Spontaneous pneumomediastinum (SPM) is a rare condition defined by the presence of air in the mediastinum in the absence of traumatic or iatrogenic injury. Although the imaging findings and complications of SARS-CoV-2 infection have been reported many times, there are few reports of the prevalence and outcomes of patients with SPM. Purpose In this paper, we aimed to illustrate the different manifestations, management, and outcome of three cases of SPM in COVID-19 patients and provide an extensive review available literature. Materials and Methods Detailed report of patients' demographics, clinical presentation, management, and outcome of three cases of COVID-19 induced SPM seen in our institution was provided. Additionally, literature search was employed through March 2021 using Pubmed and Google scholar databases where a total of 22 articles consisting of 35 patients were included. Results Statistical analysis of the reviewed articles showed that SPM in COVID-19 occurs in patients with a mean age of 55.6 ± 16.7 years. Furthermore, 80% of the 35 patients are males and almost 60% have comorbidities. Intriguingly, SPM in COVID-19 is associated with a 28.5% mortality rate. These findings are consistent with our case series and are different from previous reports of SPM in non-COVID-19 cases where it most commonly occurs in younger individuals and has a self-limiting course with a good outcome. Conclusion Therefore, SPM in COVID-19 patients occurs in older patients and is potentially associated with a higher mortality rate. Further studies are necessary to assess its role as a prognostic marker of poor outcome.

Background Coronavirus disease 2019 (COVID-19) is a highly variable condition. Validated tools to assist in the early detection of patients at high risk of mortality can help guide medical decisions. Objective To validate externally, as well as in patients from the second pandemic wave in Europe, our previously developed mortality prediction model for hospitalized COVID-19 patients. Methods Three validation cohorts were generated: two external with 185 and 730 patients from the first wave and one internal with 119 patients from the second wave. The probability of death was calculated for all subjects using our prediction model, which includes SpO2/FiO2 ratio, neutrophil-to-lymphocyte ratio, LDH, interleukin-6 and age. Discrimination and calibration were evaluated in the validation cohorts. The prediction model was updated by re-estimating individual risk factor effects in the overall cohort (N=1477). Results The mortality prediction model showed good performance in the external validation cohorts 1 and 2, and in the second wave validation cohort 3 (AUC 0.94, 0.86 and 0.86, respectively), with excellent calibration (calibration slope 0.86, 0.94 and 0.79; intercept 0.05, 0.03 and 0.10, respectively). The updated model accurately predicted mortality in the overall cohort (AUC 0.91), which included patients from both the first and second COVID-19 waves. The updated model was also useful to predict fatal outcome in patients without respiratory distress at the time of evaluation. Conclusions This is the first COVID-19 mortality prediction model validated in patients from the first and second pandemic waves. The COR+12 online calculator is freely available to facilitate its implementation (https://utrero-rico.shinyapps.io/COR12_Score/), We externally validated a mortality prediction model for hospitalized COVID-19 patients, which included early one-time measurements of SpO2/FiO2, N/L ratio, LDH, IL-6 and age. The model has been updated with 1477 patients from the first and second waves.

Background For the past few months, HMOs have faced crowded emergency rooms and insufficient hospital and intensive-care-unit beds, all from the worst pandemic of this century, COVID-19. Methods In a large HMO in Brazil, our approach was to allow treating physicians to prescribe antiviral medications immediately at presentation, and prednisone starting on day-6 of symptoms to treat pulmonary inflammation. We implemented this COVID-19 protocol for outpatients and studied 717 consecutive SARS-CoV-2-positive patients age 40 years or older presenting at our emergency rooms. Results Use of hydroxychloroquine (HCQ), prednisone or both significantly reduced hospitalization risk by 50–60%. Ivermectin, azithromycin and oseltamivir did not substantially reduce risk further. Hospitalization risk was doubled for people with type-2 diabetes or obesity, increased by two-thirds for people with heart disease, and by 75% for each decade of age over age 40. Similar magnitudes of reduced risk with HCQ and prednisone use were seen for mortality risk, though were not significant because of only 11 deaths among the 717 patients. No cardiac arrhythmias requiring medication termination were observed for any of the medications. Conclusions This work adds to the growing literature of studies that have found substantial benefit for use of HCQ combined with other agents in the early outpatient treatment of COVID-19, and adds the possibility of steroid use to enhance treatment efficacy.

Highlights • COVID-19 is an adjunctive risk factor for burn injured patients. • Isolation of suspected cases and development of management procedures are essential preventive measures to reduce viral spread. • We developed an admission protocol to our Burn Unit which proved itself effective in minimizing the contagion between patients and healthcare workers., Background The actual pandemic outbreak is the third time in the last two decades in which a coronavirus results in a major global spread with serious consequences in terms of vastity of affected patients, life losses, health system organization efforts and socio-economic implications. Lacking effective therapies and vaccinations, during viral outbreak the major and most incisive mean for viral spread control is spread prevention, especially for the fragile burn-injured patients we are called to care for in Burn Units. Methods We developed an admission and inpatient management protocol to preserve burn patients from SARS-CoV-2 contagion, in order to avoid additional morbidity and mortality in patients with already compromised health conditions. Data from burn-injured patients admitted to our Unit following this new protocol were retrospectively analyzed in order to verify its effectiveness in prevention of viral spread. Results From the 8th of March to the 8th of June, we admitted 18 patients in the Burn Unit ICU and semi-ICU and 17 patients in the Burn Ward. Two of them resulted positive to COVID-19 nasopharyngeal swab and bronchoalveolar lavage collected immediately on admission, for both the extension of burns and their general clinical conditions implied ICU admission. Moreover, a caregiver of an admitted child resulted positive to the nasopharyngeal swab. No other cases of SARS-CoV-2 positivity have been reported neither between hospitalized patients nor between healthcare workers. Conclusion The evidence of high ICU admission rate and high mortality in patients affected by SARS-CoV-2 combined with the fragile clinical conditions of burn patients required the development of an admission and hospitalization management protocol which proved itself effective in minimizing viral spread among patients and healthcare workers.

Highlights • N95 respirators are equivalent to type 3 face masks in preventing infection transmission. • Proper donning and doffing is critical for safe use of PPE. • Face shields should be used only in combination with lower face protection. • High volume evacuation helps to limit the production of aerosolized particles at the source., With the 2019 emergence of coronavirus disease 19 (colloquially called COVID-19) came renewed public concern about airborne and aerosolized virus transmission. Accompanying this concern were many conflicting dialogues about which forms of personal protective equipment best protect dental health care practitioners and their patients from viral exposure. In this comprehensive review we provide a thorough and critical assessment of face masks and face shields, some of the most frequently recommended personal safeguards against viral infection. We begin by describing the function and practicality of the most common mask types used in dentistry: procedural masks, surgical masks, and filtering respirator facemasks (also called N95s). This is followed by a critical assessment of mask use based on a review of published evidence in three key domains: the degree to which each mask type is shown to protect against airborne and aerosolized disease, the reported likelihood for non-compliance among mask users, and risk factors associated with both proper and improper mask use. We use this information to conclude our review with several practical, evidence-based recommendations for mask use in dental and dental educational clinics.

Highlights • Anorectal malignant melanoma, is a rare and aggressive form of melanoma. • Very different from its cutaneous counterpart. • There is no optimal treatment. Surgery is the mainstay of treatment, but the extent is controversial. • Patient’s quality of life deserves attention when choosing the adequate surgical technic., Introduction Anorectal malignant melanoma (AMM), is a rare and aggressive form of melanoma. Accounts for

Highlights • Most of beaches tend to have a lot of shells and other sharp objects that might hurt you while you’re walking on the beach. • A 9-year-old female patient was presented to the ER with a left knee injury because of a penetrating Scapharca inaequivalis. • The patient underwent a local surgical procedure to remove the foreign body. Interestingly, the seashell (Scapharca inaequivalis) pinned her left knee in water. • Through this article we want to draw attention to the puncture wounds and cuts caused by sea shells. • The particuliarity lies in the fact that the sea shells injuries can be made both in water and on the sand., Introduction Most of beaches tend to have a lot of shells and other sharp objects that might hurt you while you’re walking on the beach. Cuts, particularly on the bottom of feet, are common at the beach. In this article we want to present a rare case of a little girl with a knee wound made by a seashell, while playing in the water. Case presentation A 9-year-old female patient was presented to the ER with a left knee injury because of a penetrating Scapharca inaequivalis. Since this type of trauma is considered a surgical emergency, taking a thorough history along with careful examination to find out the mechanism and cause of the trauma is crucial towards correct diagnosis and management of the disease. The patient underwent a local surgical procedure to remove the foreign body. Interestingly, the seashell (Scapharca inaequivalis) pinned her left knee in water. Conclusions Through this article we want to draw attention to the puncture wounds and cuts caused by sea shells. The particuliarity lies in the fact that the sea shells injuries can be made both in water and on the sand. One main concern with cuts on the feet is risk of infection, especially with diabetic patients.

Highlights • Radiographic score can play a pivotal role for patients with MERS pneumonia. • The cutoff radiographic (RG) score is 10 on 10th day from MERS-CoV exposure. • Patients with RG score above the cutoff are prone to show respiratory distress. • Patients with RG score above 10 on 10th day from viral exposure need aggressive care., The aim of this study is to determine the earliest cutoff of radiographic score as a potential prognostic indicator of fatal outcomes in patients with acute Middle East respiratory syndrome coronavirus (MERS-CoV) pneumonia. The institutional review board approved this retrospective study. Serial chest radiographies (CXRs) were obtained from viral exposure until death or discharge in 35 patients with laboratory confirmed MERS-CoV infection. Radiographic scores were calculated by multiplying a four-point scale of involved lung area and three-point scale of abnormal opacification, in each of the six lung zones. Receiver operating characteristics (ROC) analyses were performed to identify optimal day and radiographic score for the prediction of respiratory distress, and univariate and multivariate logistic regression analyses were performed to assess significant predictive factors for intubation or tracheostomy. Among 35 patients (22 men, 13 women; median age: 48 years), 25 demonstrated abnormal opacity on CXR (MERS pneumonia), whereas no abnormality was detected in 10 patients (MERS upper respiratory tract infection). Seven patients required ventilator support (intubation group) and three of them eventually expired. The average incubation period was 5.4 days (standard deviation, ±2.8; range, 2–11). Patients in the intubation group had a higher incidence of diffuse lung involvement, higher radiographic scores, and fibrosing sequela on follow up study compared with those in the non-intubation group. However, patients’ age and comorbidity did not differ significantly between the two groups. The ROC analysis revealed an area under curve of 0.726 for the radiographic score on day 10 with an optimal cutoff score of 10 for prediction of intubation, with a sensitivity of 71% and specificity of 67%. Our study suggest that MERS patients with radiographic score > 10 on day 10 from viral exposure require aggressive therapy with careful surveillance and follow-up evaluation.

Highlights • Although Axillary Schwannoma is a rare condition, physicians should recognize it as a part of their differential diagnosis of an axillary swelling. • Preoperative utilization of Tru-cut biopsy in diagnosing this condition will further help surgeons to plan proper surgical treatment. • The author recommends utilizing an intraoperative nerve stimulator to facilitate nerve preservation during excision; aiming to provide optimal management and better outcome., Introduction Schwannoma is a benign encapsulated tumor of the peripheral nervous system which is mainly located in the head and neck. However, axillary Schwannoma is rare. In this article, the author presents an interesting case of a right axillary Schwannoma, where the diagnosis was preoperatively made on a Tru-cut biopsy. Case presentation We report a case of an enlarged right axillary swelling in a sixty-year-old male. Proper radiologic workup was performed. Furthermore, a Tru-cut biopsy was taken which revealed evidence of schwannoma. Having such symptomatic lesion, operative excision was done with the use of a nerve stimulator, which aided in preserving nerve function. Conclusion With such non-specific presentation, axillary Schwannoma may be easily missed and mismanaged. A Tru-cut biopsy may provide great help in expert hands, aiding operative planning; likewise in the case we are presenting. Furthermore, utilizing an intraoperative nerve stimulator will facilitate nerve preservation.

Background: The clinical epidemiology of hospitalized COVID-19 patients has never been described before in Lebanon. Moreover, the hospital admission and PCR positivity rates have not been assessed and compared yet. Objectives: To describe the characteristics and outcomes of hospitalized patients with coronavirus induced disease 2019 (COVID-19) in Lebanon and identify risk factors for severe disease or death. Study design: This is a retrospective mono-center cohort study in which we used patients’ files to extract and analyse data on demographic and clinical characteristics, as well as mortality. Moreover, we tracked the pandemic by recording the daily total and ICU inpatient census and the PCR positivity rate for admitted and outpatients. Results: Although the total admission rate increased from September to April, the ICU census switched this trend in December to stabilize at an average of around 10 patients/day until April. The case fatality rate was 19% for the 902 hospitalized patients, of which the majority (80%) had severe COVID-19. The severity odds ratio is significantly decreased in immunosuppressed cases (OR, 0.18; CI, 0.05-0.67; p=0.011). Additionally, the odds of COVID-19 related death are significantly greater if consolidations are found in the chest computed tomography (CT) scan (OR, 12; CI, 2.63-55.08; p=0.0013). Conclusion: Consolidations in the lungs significantly increase the COVID-19 death risk. Risk factors identification is important to improve patients’ management and vaccination strategies. In addition, hospital statistics are good indicators of a pandemic's track.

Background Cardiovascular disease is the leading cause of death in India. Previously it was thought to be a disease of the elderly but now an epidemiological transition is being seen with increasing incidence in the very young adults as well. Such patterns are not well studied in the South East Asian population. Objective To study the epidemiological profile of very young (≤35 years) adults presenting with an acute myocardial infarction (AMI) in comparison with an older cohort. Methodology The present study included all patients presenting with AMI to the emergency or to the out-patient department of the G B Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi between January 2014 and October 2015. A total of 102 subjects ≤35 years with AMI comprised the study subjects (cases) and were compared with 104 subjects >35 years old with AMI (Controls). Results & conclusion Most of the very young AMI patients presented with an anterior wall ST segment elevation myocardial infarction, a stable hemodynamic profile, single vessel disease and better left ventricular ejection fraction as compared with controls. Most of the patients were from urban and semi-urban areas, middle and lower middle socioeconomic status and were smokers but lacked other traditional risk factors.

Background: Asthma still represents a cause of death and hospital admissions worldwide. Our study aimed at analyzing the trend of Emergency Room (ER) asthma admissions in Northeast Italy in order to investigate the relevance of specific patient-related determinants and environmental triggers (pollens, mold spores, and pollutants). Methods: Retrospective data from admissions for asthma exacerbations registered between the years 2013 and 2015 in two main ERs in Northeast Italy were collected. Data about patients' age, sex and nationality were recorded. Classification of disease severity followed the current Italian ER triage scoring system (white: no need for emergency treatment; green: need for fast treatment; yellow: severe condition; red: life-threatening condition). Data on pollen/mold spore counts and pollutants were analyzed. Results: Overall, 1745 ​ER admissions for asthma were registered, with a persistent and significant increase year by year. A slight prevalence of females and patients over 50 years old was observed. Immigrants accounted for 32%, 36% and 26% of admissions respectively in 2013, 2014 and 2015. The prevalence of immigrants' admissions was significantly higher when comparing the relative ratio of immigrant populations/Italian nationals (p ​

Introduction Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. Presentation of case A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein. Discussion There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely. Conclusion Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis., Highlights • Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment because of high postoperative morbidity and mortality. • No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. • Hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with liver cirrhosis. • Hybrid surgery using laparoscopy and Lichtenstein’s technique is effective for patients with incarcerated inguinal hernia with severe abdominal varicosis.

OBJECTIVES: The SARS-CoV-2 pandemic greatly influenced the overall quality of healthcare. The purpose of this study was to compare the time variables for acute stroke treatment and evaluate differences in the pre-hospital and in-hospital care before and during the SARS-CoV-2 pandemic, as well as between the first and second waves. MATERIALS AND METHODS: Observational and retrospective study from an Italian hospital, including patients who underwent thrombectomy between January 1st 2019 and December 31st 2020. RESULTS: Out of a total of 594 patients, 301 were treated in 2019 and 293 in 2020. The majority observed in 2019 came from spoke centers (67,1%), while in 2020 more than half (52%, p < 0.01) were evaluated at the hospital's emergency room directly (ER-NCGH). When compared to 2019, time metrics were globally increased in 2020, particularly in the ER-NCGH groups during the period of the first wave (N = 24 and N = 56, respectively): "Onset-to-door":50,5 vs 88,5, p

Purpose Pulmonary embolism (PE) in COVID-19 patients can play a key role in precipitating clinical conditions. We aimed to evaluate PE distribution on CTA and to investigate any possible association with D-dimer (DD), pulmonary stage of disease and prognosis. Method COVID-19 patients of two affiliated Hospitals, undergone a CTA examination for PE suspicion, were retrospectively enrolled. Comorbidities, laboratory tests and clinical outcomes (hospitalization, discharge, death) were assessed. A parenchymal stage (early, progressive, peak, absorption) for lung involvement was assigned. Results A cohort of 114 patients (mean age 61 years; 26.3 % females) with severe COVID-19 pneumonia were evaluated. At last follow-up 25 (21.9 %) were hospitalized, 72 (63.2 %) discharged, 17 (14.9 %) dead. Eighty-eight patients (77.2 %) had at least one comorbidity, being cardiovascular ones the most frequent (44.7 %). CTA revealed PE in 65 patients (57 %), with concomitant pulmonary trunk and/or main arteries involvement in 16.9 %. PE defects were ubiquitous in 18.5 % of cases. The predominant parenchymal stages were the progressive (24.6 %) and peak (67.7 %). DD levels showed a significant correlation with PE occurrence and extent in pulmonary branches, despite anticoagulant therapies; trend of correlation with pulmonary stages was also noted. Conclusions PE is a frequent complication in severe COVID-19 patients, particularly during central parenchymal stages and despite ongoing anticoagulant therapy. CTA and DD levels play a crucial role in the assessment of suspected PE, despite anticoagulant therapies, along with proper information about lung involvement extent.

Highlights • Foreign body ingestion is a relatively common and benign condition; some serious complications, however, can arise. • Approximately 1% of all ingested FB will cause perforation requiring surgical treatment. • Sharp FB, such as fish bones, chicken bones and needles, are more prone to migrate outside the gastrointestinal lumen if they are not removed early. • The patient reported here is the first one in the literature to present a splenic rupture due to extra-luminal migration of an ingested fish bone through the splenic flexure of the colon., Introduction The ingestion of foreign bodies (FB) is a common problem worldwide and affects all ages; it is, however, particularly important in the pediatric population and in mentally impaired adults. The typical outcome of FB ingestion is good, since the majority of ingested material is passed spontaneously through the gastrointestinal tract. Serious complications can occur, however, including bowel perforation or obstruction and gastrointestinal bleeding, amongst others. Extraluminal migration of ingested foreign bodies is very rare and reported cases so far have shown, more commonly, migration to neck structures, with very few reported cases of migration to the abdomen. To date, there is no reported case of extraluminal migration of ingested FB to the spleen. Case presentation A 59-year-old man presented with acute abdominal pain and dyspnea. A CT scan revealed a FB within the spleen, with a ruptured capsule and perisplenic collection. Surgery was performed and a 3cm-long fishbone was extracted, with hemoperitoneum secondary to spleen rupture. The patient was discharged on the third postoperative day with good recovery and without any complications; pneumococcal polysaccharide vaccination was provided. Conclusion FB ingestion is a relatively benign condition; however, some serious complications can arise infrequently. The patient reported herein is the first in the literature to present a splenic rupture due to extra luminal migration of an ingested fish bone.

Background Dengue has been an important health issue in southern Thailand. However, this area has only a surveillance-prevention system, without step-by-step guidelines on dengue treatment for patients admitted from households to primary care units (PCUs) and district hospitals. Therefore, this study were to develop and use a dengue patient care guideline (DPCG), and to evaluate knowledge, attitude, practice (KAP) of dengue patient care. Methods 26 health care providers (13 nurses, and 13 public health officials) from eight PCUs and the district hospital developed the DPCG. The study design was based on the community participatory action research that integrated the Iowa model involving the following steps: preparation, guideline development, use and monitoring, evaluation and conclusion, and referring technology. We assessed the improvement between before and after using the DPCG regarding the participants' KAP on patient care and preparedness of equipment. McNamara's test was used to compare the changing results before and after using the DPCG. Qualitative data collection was performed in two meeting discussions with six open-end items. Using a thematic analysis technique, we extracted conclusions and suggested solutions. Results The guideline included four steps for patients' care provision at households, PCUs, outpatient departments, emergency rooms, and inpatient departments. After using the DPCG in 39 dengue patients of which 30 patients were admitted to the inpatient department1 and two patients were referred to the tertiary care hospital without mortality. The overall participants' knowledge and attitude, two of six aspects of patients' care, and three of eight types of equipment management were significantly improved (p, Highlights • We developed a dengue patient care guideline (DPCG). • DPCG was used for patients from household to PCU and district hospital. • The participants improved their performance in knowledge, attitude, and practice. • DPCG needs all stakeholders to participate, integrate, and coordinate.

This article describes the study protocol for an evaluation of an innovative model of care that supports home health nurses (HHN) who serve children with medical complexity ( CMC). CMC constitute a small proportion of children, but have very high need for health services, are hospitalized frequently, and account for significant proportion of pediatric healthcare expenditures. High-quality home health nursing services are important for CMC, but models of care of home healthcare, after discharge of CMC from the hospital, have not been tested. Our project aims are to develop, implement, and test a model of care, called ICollab, to improve home healthcare delivery for CMC. The ICollab model consists of collaboration between HHN, primary-care physicians and clinicians of the complex care program of a tertiary-care children's hospital in the care of CMC. In this randomized clinical trial, we will recruit 110 CMC discharged home on home health nursing services. The intervention group (n = 55) will receive the ICollab intervention for 6 months post-discharge from the hospital, in addition to usual care. Children in the control group (n = 55) will receive only usual care. Outcome measures will include healthcare utilization metrics (hospitalization rates, emergency room visit rates, and days to readmission), caregiver burden and caregiver satisfaction with home healthcare, HHN retention, and HHN collaboration with other healthcare providers. We hypothesize that ICollab will reduce healthcare utilization and caregiver burden, and improve caregiver satisfaction with home healthcare, increase HHN retention, and increase HHN collaboration with other healthcare providers. Results of this study have the potential to provide a critically needed evidence-base for interventions to improve the quality of healthcare delivery for CMC. This study is registered on clinicaltrials.gov (NCT03978468) and is ongoing., Highlights • Although an increasing number of children with medical complexity in the U.S. receive home health nursing services, the quality of these services is not optimal. • Models of care that optimize communication and collaboration between home health nurses and other providers as children transition from hospital to home, have not been previously tested. • This RCT will evaluate the effect of an innovative care model on reducing hospital re-admissions, emergency room visits, improving caregiver satisfaction, reducing caregiver burden and improving home health nurse retention.

A 38-year-old male who sustained blunt abdominal trauma at work presented to the emergency department with complaints of abdominal pain localized primarily in the peri-umbilical region. The patient was discharged home after a brief uneventful hospitalization only to return 13 days later with signs and symptoms of acute bowel obstruction. Following clinical and radiological workup, a computed tomography (CT) scan was obtained which revealed markedly dilated and thickened bowel, induration and vascular congestion seen along the adjacent mesentery with fat stranding. The patient was taken emergently to the operating room (OR) where a small mesenteric defect was found, secondary to trauma, facilitating an internal hernia precipitating a small bowel obstruction. We urge the surgeon to maintain a low index of suspicion for acute bowel obstruction in the blunt trauma population. A CT scan is essential in evaluating this patient population and we cannot underscore enough the importance and value of this modality in radiologic imaging. We further recommend resection of the compromised bowel and associated mesentery.

Background A seasonal peak in asthma exacerbations in the fall has previously been reported. The association between fall exacerbations and viral respiratory tract infections (RTI) remains uncertain. Objective To investigate the number of fall exacerbations and the incidence of RTIs in a pediatric asthmatic population using an at-home mucus collection methodology. Methods This was a 16-week, multicenter, randomized, double-blind, parallel-group exploratory study. Children, 4–11 years of age with a clinical diagnosis of asthma requiring use of an inhaled corticosteroid, a morning peak expiratory flow ≥70% predicted and a history of ≥1 asthma exacerbation during the previous respiratory viral season were eligible for enrollment. Subjects were randomized (1:1) to receive fluticasone propionate/salmeterol (FP/SAL) 100/50 mcg or FP 100 mcg prior to starting school. Subjects collected mucus samples using an at-home kit when they experienced respiratory symptoms. Mucus samples obtained during symptomatic periods were analyzed for common respiratory viruses by multiplex polymerase chain reaction. The number of exacerbations requiring systemic corticosteroids was recorded. Results In total, 339 (FP/SAL, n = 171; FP, n = 168) subjects were randomized and included in the intent-to-treat population; 292 (86%) completed the study. Of the 537 mucus samples collected, 64% tested positive for viruses, but only 6% of positive samples were associated with an asthma exacerbation. Exacerbations were infrequent, with only 41 subjects reporting 49 exacerbations in total. Adverse events were reported in 66% of subjects. Conclusions In a susceptible population, the fall asthma exacerbation rates in children were low despite frequent detection of viral RTIs. NCT01192178; GSK ID: ADA113872., Highlights • Upper respiratory viral infections determined by at-home mucus collection at the time of symptoms. • The majority of subjects reported ≥1 period of upper respiratory symptoms. • Asthma exacerbations were infrequent, despite treatment and it being the fall season. • The majority of upper respiratory viral infections were not associated with exacerbations. • Additional virus, environment or host factors may influence exacerbation risk.

Our aim was to study the clinical profile, immediate outcome and risk factors associated with poor outcome in critically ill children presenting with seizures requiring PICU admission. As seizures lasting 10 min or more can potentially cause brain damage, we included all children regardless of seizure duration. The records of 157 children aged 1 month to 16 years admitted in the PICU at a tertiary hospital in India with seizures as the presenting symptom during a three-year period were studied retrospectively. Median age of patients was 4 years. 34 (21%) had pre-existing epilepsy and 33 (21%) had previous developmental delay/neuro-deficit. Seizure duration was > 30 min in 75 (47.7%) and 56 (35.6%) required the use of more than 2 antiseizure drugs. 101 (64%) had acute symptomatic seizures, 28 (17%) remote symptomatic and 27 (17.1%) had unknown cause. New onset neurological deficit was seen in 18 (15.6%) and 14 (8.9%) died. Young age, high PEWS score at presentation, prolonged/recurrent seizures, CNS infection, need for multiple antiseizure drugs and ventilation/pressor use were risk factors for poor outcome. Neurological outcome and survival of children in our study were good. Further all-inclusive studies irrespective of seizure duration are needed to obtain a complete picture of critical children presenting with seizures., Highlights • All critical children presenting with seizures were included irrespective of seizure duration • 52.2% patients had seizures lasting for less than 30 min • 28.6% patients had CNS infection as the underlying etiology • Short-term neurological outcome was comparable to previous reports • Mortality associated with status epilepticus was lower than that reported by other Indian studies

It was December 2019 that china reported series of patients with respiratory symptoms, a disease that later named COVID-19; and from there spread to other countries around the world; and in February 2020, the world health organization declared COVID-19 as a pandemic. From the beginning, it was assumed that COVID-19 occurrence in pediatric patients is less and has less severity but nowadays; there are a reports that shows severe cases with multiple organ involvement. The most manifestation symptom is fever but convulsion is rare as the first manifestation symptom. Here we describe a 3 years old; previously healthy boy that presented with repeated fever induced seizure and status epilepticus and positive RT-PCR for COVID-19 that in the first day; brain CT scan revealed brain edema and 5 days later, there was intracerebral hemorrhage in brain MRI.

Objectives To examine the safety and effectiveness of percutaneous nephrolithotomy (PCNL) as an outpatient procedure, as in most centres PCNL is performed as an inpatient procedure that necessitates postoperative hospital admission. Patients and methods Our study included 186 patients undergoing PCNL for renal calculi. Only those who met strict inclusion criteria were discharged home on the same day. Preoperative eligibility criteria for outpatient management included no complex medical problem, normal renal function, and easy access to an emergency room. Patients were divided into two groups. The outpatient group (Group 1) included those patients discharged on the same day as the PCNL and the hospitalised group (Group 2) included those who were considered appropriate for outpatient management but needed to be hospitalised. Results In all, 162 patients (87%) fulfilled the inclusion criteria for outpatient management and 146 of these patients (90.1%) planned for outpatient management were discharged on the same operative day (Group 1). The mean time to discharge home was 8.97 h. In all, 16 patients who opted for the outpatient approach subsequently required hospitalisation (Group 2). In the hospitalised group the mean operative time was longer, which was probably related to its higher stone burden. Conclusion PCNL can be safely performed with excellent outcomes as an outpatient procedure. Outpatient PCNL offers several advantages including a more rapid patient convalescence, reduced healthcare expenditure, decreased postoperative nosocomial infections with no additional morbidity for the patient, and with no compromising of the stone-free rate.

Highlights • Complete coronary artery transection after a stab wound is survivable. • At even slight suspicion, surgical exploration of pericardial sac and heart is always strongly justified. • Off-pump coronary artery by-pass is a safe alternative for transected artery treatment. • Examination and treatment of cardiac injuries in facility with “heart team” and cardiac surgical expertise is always strongly recommended., Introduction Penetrating heart injury as a consequence of a stab wound is usually considered fatal. Nevertheless, there are rare lucky cases with mild symptoms which deserve clinical suspicion and proper management. Presentation of case We report a penetrating cardiac trauma with left anterior descending coronary artery transection after a stab wound. Successful revascularization without cardiopulmonary bypass support was performed. Discussion Coronary artery injuries after penetrating cardiac trauma are mostly fatal. The standard approach has traditionally been coronary artery ligation with serious morbidity. We report a case of complete coronary artery transection with delayed revascularization validating the safety of off-pump approach. We add a short literature review of the management of traumatic coronary artery injury. Conclusion This adds to the world literature on coronary artery trauma with successful off-pump revascularization. Coronary artery transection stab-wound victims can have only mild symptoms. Slightest intimation of heart injury should provoke proper clinical examination and management.

Ketogenic diet has been shown to be efficacious in some epileptic encephalopathies but rarely reported as being useful in children with Ohtahara syndrome. This could possibly be attributed to the rarity of the disease and associated short survival period. We report on a 5-year-old child with Ohtahara syndrome, whose seizures failed to improve with all known medications, continued to show persistent suppression-burst pattern on the electroencephalography (EEG) and had substantial reduction in seizure frequency for one year post-initiation of ketogenic diet. He has not had a single visit to the emergency room because of seizures in the last one year, and more importantly, there has been a clear improvement noted in his level of interaction and temperament. Patients with Ohtahara syndrome invariably have medically intractable seizures and catastrophic neurodevelopmental outcome. Ketogenic diet is a treatment modality that might be worth considering even in this group of patients.