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Introduction: Cardiac disorders are common in patients with chronic obstructive pulmonary disease (COPD). They worsen shortness of breath and physical capacity and reduce the quality of life. Ultrasound assessment of cardiac function could contribute to assessing the severity of the disease. This study aimed to assess the prognostic significance of echocardiographic parameters on the rate of exacerbations and mortality. Materials and methods: This was a prospective study of patients with COPD without exacerbation in the previous 1 month. Patients over 40 years of age, current or former smokers with more than 10 pack-years of smoking, and postbronchodilator FEV1/FVC < 0.7 were included. All patients underwent two-dimensional transthoracic Doppler echocardiography at rest by an experienced cardiologist. Echocardiographic parameters were evaluated for prognostic significance on a composite endpoint of moderate and severe exacerbations and death for 1 year. Data from postbronchodilator spirometry, symptoms, quality of life, and demographic and clinical information were also collected. Results: A total of 96 patients were analyzed with a mean FEV1 of 55.8%. A total of 64 patients (67%) reached the composite endpoint. A significantly higher proportion of patients with deceleration time deviations (86.2 vs. 58.2%, p = 0.0055) and increased septal thickness (55.6 vs. 24.6%, p = 0.0099) reached the primary endpoint at one-year follow-up. Echocardiographic disorders showed a correlation with the quality of life, but not with lung function. Conclusion: Non-invasive assessment of cardiac function by echocardiography could be included in the complex assessment of disease severity in COPD patients.

Background Different methods are available to assess the healing status of repaired root for medial meniscus posterior root tears (MMPRT) using second-look arthroscopy. However, few studies are comparing them or validating their usefulness. Therefore, it was hypothesized that the semi-quantitative arthroscopic score might correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. Methods Data of 61 patients who underwent MMPRT pullout repair and second-look arthroscopy were retrospectively evaluated. The semi-quantitative arthroscopic scoring system was divided into three evaluation criteria: scores from 0 to 10 points include the width of the bridging tissue, stability of the repaired root, and synovial coverage. The qualitative evaluation was classified into 4 status; complete healing, lax healing, scar tissue healing, and failed healing according to the stability and mobility of the repaired root. Multivariate linear regression analyses were used to identify predictors of 1-year postoperative clinical outcomes, including Knee Injury and Osteoarthritis Outcome, Lysholm, or International Knee Documentation Committee scores. Spearman's correlation analysis was used to analyze the correlation between second-look arthroscopic score/qualitative evaluation and 1-year postoperative clinical outcomes. In addition, the optimal cutoff point of semi-quantitative arthroscopic score was determined by receiver operating characteristic (ROC) curve. The Mann–Whitney U test was used to compare clinical outcomes between patients with semi-quantitative arthroscopic scores ≥8 and scores Results All clinical scores significantly improved at 1 year postoperatively. A good correlation was observed between the semi-quantitative score and clinical scores, but none between qualitative evaluation and clinical scores. The optimal cutoff point of semi-quantitative second-look arthroscopic score was 8 points. Significantly, better clinical outcomes were observed in patients with semi-quantitative scores ≥8 points. Conclusions All 1-year postoperative clinical scores were significantly improved. The semi-quantitative arthroscopic scores correlate more with 1-year clinical outcomes in patients with MMPRT than the qualitative evaluation. Level of evidence IV case series study.

Rhino-orbital-cerebral mucormycosis is an invasive fungal infection associated with mortality of 25–62%. There has been a surge in the number of cases during this second wave of coronavirus disease-2019 (COVID-19) in India. We report 10 cases of mucormycosis admitted to our adult intensive care unit. After reviewing the patient's information, we found that 60% of patients had received steroids, and most had uncontrolled blood sugar levels. Most patients received treatment with surgical debridement and antifungal, although the mortality rate was as high as 40%. We report two unique cases of renal and gastrointestinal mucormycosis as well. We concluded that poor glycemic control was the primary etiology behind the rise in the number of cases. Our report also stresses the importance of early surgical intervention and suggests further research comparing the efficacy of combination antifungal therapy versus single antifungal (amphotericin B) to help resource-limited settings in these times of drug crisis. How to cite this article: Yadav S, Sharma A, Kothari N, Bhatia PK, Goyal S, Goyal A. Mucormycosis: A Case Series of Patients Admitted in Non-COVID-19 Intensive Care Unit of a Tertiary Care Center during the Second Wave. Indian J Crit Care Med 2021;25(10):1193–1196.

Background: In COVID-19, EGFR production is upregulated in the alveolar epithelial cells. EGFR overexpression further activates STAT-3 and increases lung pathology. The EGFR pathway is also one of the major nodes in pulmonary fibrosis. Methods: Nimotuzumab, a humanized anti-EGFR antibody, was used to treat three patients with severe or moderate COVID-19. The antibody was administered in combination with other drugs included in the national COVID-19 protocol. Results: Nimotuzumab was well tolerated. IL-6 decreased from the first antibody infusion. Clinical symptoms significantly improved after nimotuzumab administration, and the CT scans at discharge showed major resolution of the lung lesions and no signs of fibrosis. Conclusion: Safe anti-EGFR antibodies like nimotuzumab may modulate COVID-19-associated hyperinflammation and prevent fibrosis. Clinical Trial Registration: RPCEC00000369 (RPCEC rpcec.sld.cu)., Lay abstract Background: In COVID-19, the protein EGFR is overactive in the infected lung cells. Methods: Nimotuzumab, an anti-EGFR antibody, was used to treat three patients with severe or moderate COVID-19. The antibody was administered in combination with other drugs included in the national COVID-19 protocol. Results: Nimotuzumab was safe. The most important inflammatory markers decreased from the first administration. The patients’ clinical symptoms and imaging results improved significantly. Conclusion: Anti-EGFR antibodies like nimotuzumab may contribute to the recovery of COVID-19 patients without long-term consequences.

Combining single-joint hybrid assistive limb (HAL-SJ) with botulinum toxin A (BTX-A) therapy is novel and has great therapeutic potential for the rehabilitation of stroke patients with upper limb paralysis. The purpose of this observational case series study was to evaluate the effect of BTX-A and HAL-SJ combination therapy on different exoskeleton robots used for treating upper limb paralysis. The HAL-SJ combination received a BTX-A injection followed by HAL-SJ-assisted rehabilitation for 60 min per session, 10 times per week, during 2 weeks of hospitalization. Clinical evaluations to assess motor function, limb functions used during daily activities, and spasticity were performed prior to injection, at 2-week post-treatment intervention, and at the 4-month follow-up visit. The total Fugl-Meyer assessment-upper limb (FMA-UE), proximal FMA-UE, action research arm test (ARAT), Motor Activity Log (MAL), and Disability Assessment Scale (DAS) showed a statistically significant difference, and a large effect size. However, the FMA distal assessment at 2-week post-treatment intervention showed no significant difference and a moderate effect size. The FMA-UE scores of the extracted systematic review articles showed that our design improved upper limb function. The change in the total FMA-UE score in this study showed that, compared to previous reports in the exoskeletal robotic therapy group, our combination therapy had a higher score than five of the seven references. Our results suggest that BTX-A therapy and HAL-SJ combination therapy may improve upper limb function, similar to other treatment methods in the literature.

Background Conventional topical antimicrobial therapy cannot maintain a constant local concentration, resulting in uncontrolled infection and complications. We propose continuous local antibiotic perfusion (CLAP), which can maintain a constant appropriate local antibiotic concentration for a long time with less invasiveness and complications. CLAP is clearly different from traditional treatment because it uses negative pressure to direct the continuously infused antibiotic solution to the center of infection and excrete it outside the body. This study aimed to demonstrate the effectiveness of CLAP by presenting cases in which even refractory bone and soft-tissue infections caused by the hypervirulent Klebsiella pneumoniae (hvKp) could be cured without significant tissue loss and dysfunction. Methods This study is a case series in which four patients with limb infection due to hvKp were treated by CLAP. hvKp was defined by a positive string test. The therapy included intra-soft-tissue antibiotic perfusion and intramedullary antibiotic perfusion. Gentamicin (60 mg/50 cc) was infused continuously through dual-lumen tubes and bone marrow needles at low-flow rates (2 mL/h). Negative pressure was used to collect the antimicrobial solution and eliminate the dead space. Results The infection was controlled in all four patients after a mean period of 44.3 days. The mean maximum blood concentration of gentamicin was 1.6 μg/dL, and no cases of renal dysfunction or ototoxicity occurred. After CLAP, wound closure was required in two patients and iliac bone grafting was required in one patient. As sequelae, there were one case of osteoarthritis and one case of higher brain dysfunction due to hypoxia. Conclusions Our results suggest that intractable hvKp infections can be controlled by CLAP. CLAP may give us the option to directly control local infections with less systemic complications. Therefore, it is considered a valuable treatment for further basic and clinical research, and this research report may be a first step.

Segmental overgrowth has been widely described in patients with congenital vascular anomalies. However, segmental undergrowth has been poorly characterized, and no large series of patients have been published. We present the clinical and molecular characteristics a cohort of 37 patients with vascular malformations and segmental undergrowth. True undergrowth was only considered when the musculoskeletal system was involved to avoid confusion with other causes of segmental reduction, as in lipodystrophy or the long-term osteopenia seen in patients with Servelle-Martorell syndrome. Deep high-throughput sequencing was performed in tissue samples from 20 patients using a custom panel. We identified three groups: undergrowth associated with (1) venous, (2) capillary-venous, and (3) lymphatic-capillary-venous malformations. Congenital or early childhood onset undergrowth can occur with or without associated overgrowth. Different likely pathogenic or pathogenic variants were detected in 13 of 20 (65%) tissue samples in the PIK3CA, TEK, GNAQ, or GNA11 genes. In conclusion, the eponymous Servelle-Martorell syndrome should not be used as a synonym for undergrowth. Segmental undergrowth should be considered a characteristic associated with vascular malformations. Patients with PIK3CA variants show all different combinations of overgrowth and undergrowth. Thus, the term PROS (PIK3CA-related overgrowth spectrum) does not cover the entire spectrum.

Angina is a significant contributor to disability and impairment in quality of life in patients with chronic coronary syndromes (CCS). An elevated heart rate (HR) may trigger myocardial ischemia by increasing oxygen consumption and decreasing the diastolic time, compromising the coronary flow. HR-lowering strategies offer symptom control and prevent cardiovascular events in subgroups of patients with CCS. However, the best therapeutic approach to achieve the desired HR in patients with CCS can be challenging based on efficacy and tolerability. Guidelines usually propose β-blockers and/or non-dihydropyridine calcium channel blockers (CCB) for angina patients with elevated HR. Nonetheless, there is no clear evidence of greater antianginal efficacy of this strategy versus an alternative HR-lowering agent. Ivabradine reduces the HR by blocking the If current in the sinoatrial node without affecting myocardial contractility or vascular tone. The magnitude of the HR reduction by ivabradine is proportional to the initial HR, which decreases the risk of significant bradycardia. Ivabradine increases the diastolic time and the coronary flow reserve to a greater extent than β-blockers and favors collateralization, improving the regional blood flow. We present two clinical cases of patients with symptomatic CCS in whom HR control with ivabradine was fundamental for symptom control and improvement in left ventricular (LV) function. An earlier combination of ivabradine plus β-blockers would have provided more rapid symptom control and improved LV function in the first case. In the second case, the primary mechanism responsible for angina was most likely a coronary vasomotor abnormality, in which the use of β-blockers aggravated the discomfort. The combination of a dihydropyridine CCB plus ivabradine was highly influential in symptom control. Due to its effects beyond HR reduction and good tolerability, ivabradine should be considered an essential ally in managing patients with angina and high HR with or without LV dysfunction.

Background To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. Methods Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query ‘Pineal Cyst’ AND ‘Surgery’ as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. Results All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4–63) with 77% females. Mean cyst size was 15 mm (5–35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0–228). Presentation: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), ‘psychiatric’ (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0–9). Outcomes: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74–19.02) and resection over fenestration (OR = 12.64; 3.07–52.01). Age predicted worse outcomes (OR = 0.95; 0.91–0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). Conclusions Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Study Objective To describe the surgical techniques and short-term outcomes for 33 cases of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (RvNOTES) to treat endometriosis. Design Retrospective case series study. Setting Academic tertiary care university hospital in Houston, TX. Patients Patients who underwent RvNOTES resection of endometriosis between March 2020 and March 2021. Interventions RvNOTES. Measurements and Main Results A total of 33 cases of patients, with pathology-confirmed endometriosis, who underwent RvNOTES total hysterectomy with resection of endometriosis were included in the study. Thirty-two cases were completed successfully by RvNOTES, and 1 case was converted to robotic transumbilical single-incision laparoscopic surgery plus 1 additional port owing to an obliterated posterior cul-de-sac and upper abdominal wall endometriosis. The average operative time was 141.93 ± 40.22 (85–264) minutes, and the mean estimated blood loss was 52.25 ± 33.82 (25–150) mL. The mean preoperative pain score using the visual analog scale (VAS) score was 8.08 ± 2.39 (2–10). The mean VAS pain score 1 week after surgery was 6.73 ± 2.62 (0–10), which was significantly lower than the preoperative scores (p = .059). The mean VAS pain score in the second and third week after surgery was 4.81 ± 2.42 (0–9) and 2.63 ± 2.36 (0–7) respectively, which were both significantly lower than those before surgery (p = .001). There were 4 postoperative complications: urinary tract infection, pneumonia, headache requiring admission, and conversion disorder. Conclusion RvNOTES is a safe and feasible approach for the treatment of endometriosis, with promising short-term improvements in pain.

Didik Librianto,1 Ismail Hadisoebroto Dilogo,2 Achmad Fauzi Kamal,2 Ifran Saleh,2 Fachrisal Ipang,1 Dina Aprilya2 1Orthopedic Spine Surgeon, Fatmawati General Hospital, Jakarta, Indonesia; 2Department of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Jakarta, IndonesiaCorrespondence: Dina AprilyaDepartment of Orthopedic and Traumatology, Faculty of Medicine Universitas Indonesia, Prof. Soelarto building, 1st floor, RS Fatmawati Street, Jakarta, 12430, IndonesiaTel +6289655106136Fax +6221-7660616Email dina.cia.aprilya@gmail.comBackground: Kyphosis in spondylitis tuberculosis (STb) is more than just a cosmetic issue. It has a potentially detrimental effect on both spine-associated structures and cardiopulmonary function. It can be corrected in any stage of STb; however, the corrective surgery is challenging, especially in the late case, in which the additional stiffness of the spine can come into consideration. To date, the cantilever technique is still a gold standard for sagittal plane deformity correction. However, no study to date has explored its effectiveness for thoracolumbar kyphotic deformity, especially that caused by spondylitis tuberculosis.Methods: This is a retrospective study of 16 consecutive cases of spondylitis tuberculosis with thoracolumbar kyphosis that underwent corrective surgery in our center in the period of 2020– 2021. We aim to evaluate the effectiveness of the cantilever technique that we use for kyphotic correction in thoracolumbar STb patients.Results: At the 3-months follow-up, the mean Cobb angle was 14.6°± 10.27°, with the mean gain of 20.90°± 12.00° and positively correlate with the thoracolumbar kyphosis (TLK) correction (68.69%, r = 0.654, p = 0.001). The mean thoracic kyphosis, lumbar lordosis, and sagittal vertebral axis were 30.6°± 13.08°, 39.4°± 16.02°, and 1.4± 4.09 cm, respectively, with sagittal Cobb difference of 12.70± 9.85.Conclusion: The kyphotic Cobb angle reduction by cantilever technique in the thoracolumbar area significantly improved the thoracolumbar kyphosis and realign the spinal sagittal axis. Thus, the cantilever technique remains the gold standard for sagittal plane deformity correction which can be applied for kyphotic deformity correction in thoracolumbar STb cases.Keywords: thoracolumbar spine, kyphotic deformity, spondylitis tuberculosis, deformity correction, cantilever technique

Introduction Neratinib and neratinib-based combinations have demonstrated efficacy for treatment of human epidermal growth factor receptor 2–positive (HER2+) early-stage and metastatic breast cancers. However, diarrhea has been reported as a common adverse event leading to neratinib discontinuation. Results from the CONTROL trial suggest that proactive diarrhea management with antidiarrheal prophylaxis or dose escalation of neratinib from a lower starting dose to the full FDA-approved dose of 240 mg/day can reduce the incidence, duration, and severity of neratinib-associated diarrhea in patients with early-stage breast cancer. Dose escalation has been included in the FDA-approved label for both early-stage and metastatic HER2+ breast cancer since June 2021. Case series This series of five cases details real-world clinical implementation of strategies for management of neratinib-induced diarrhea in patients with early-stage and metastatic HER2+ breast cancer, including a patient with a pre-existing gastrointestinal disorder. Management and outcome In four of five cases, diarrhea was managed with neratinib dose escalation, and antidiarrheal prophylaxis with loperamide plus colestipol was used in the remaining case. Management of diarrhea allowed all patients to remain on therapy. Discussion This case series shows that neratinib-associated diarrhea can be managed effectively with neratinib dose escalation from a lower initial starting dose and/or prophylactic antidiarrheal medications in a real-world clinical setting. The findings highlight the importance of patient-provider communication in proactive management of adverse events. Widespread implementation of the strategies described here may improve adherence and thereby clinical outcomes for patients with HER2+ breast cancer treated with neratinib.

Background Cutaneous leishmaniasis (CL) is a tropical infection with a relatively high incidence rate in Iran. The present study aimed to explore the time trend and associated factors of CL in Dezful, in southwest Iran. Methods This case series study was conducted on all CL patients registered from 2014 to 2019. The descriptive analysis of the data was done using SPSS 20 software and the time series model on the number of cases was run through Interactive Time Series Modeling software. Results A total of 5349 leishmaniasis cases were identified in the study area during 2014–2019. The highest incidence rate was 35 840 per 100 000 in 2014. The fitted time series model revealed a decreasing trend with an annual periodic pattern. The mean age of infection was 19.82 y (standard deviation 21.87). The infection was most frequent in the 1–10 y age group (41.7%). Also, females were more prone to leishmaniasis (54.7%). Most lesions were located on the hand (23.1%), face (19.7%), and forearm (17.75%) and 48.5% of patients had only one lesion. Conclusions The results revealed a decreasing trend of leishmaniasis in Dezful. It has been predicted that this infection will reach a minimum rate (300 per 100 000) in the winter of 2021.

Aim To assess the effect of combined periodontal and orthodontic treatment (OT) in stage-IV periodontitis patients. Materials and methods Three focused questions were addressed using the Population, Intervention, Comparison, Outcome, and Study Design criteria. Randomized controlled trials (RCTs), controlled clinical trials, follow-up studies, case series, and controlled/uncontrolled before/after studies were assessed for inclusion. Primary outcomes included mean changes in pocket probing depth (PPD) and clinical attachment level (CAL). Qualitative synthesis of results was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Out of 916 records, 1 retrospective case series study reported the effect of OT of tilted molars, 2 RCTs and 10 prospective and 2 retrospective case series studies reported the effect of OT of treated intra-bony defects and 0 articles reported the effect of OT of treated furcation defects. Mean PPD changes were reported in 14 articles, and mean CAL changes were reported in 8 articles. Risk of bias was high in both included RCTs, critical in nine articles, and serious in four articles. No articles included patient-reported outcomes, and three articles reported harms/adverse effects. Conclusions Evidence is limited by (i) the lack or low number of included studies, (ii) the apparent methodological and clinical heterogeneity, and (iii) the high risk of bias of the retrieved studies. No solid conclusions could be drawn concerning OT in stage-IV periodontitis patients with respect to tilted molars, teeth with treated intra-bony defects, and teeth with treated furcation defects.

Sternoclavicular joint pathology can be an uncommon cause of pain and discomfort around the neck and shoulder region. Typically, patients localize their pain deep to the joint and experience referred pain to the ipsilateral neck and shoulder; however, it often presents as a diffuse nonspecific pain. Given the paucity of this pathology and atypical presentation, the use of injections can be helpful to confirm the diagnosis of sternoclavicular arthropathy. Currently, most injections are done via computed tomography. Although this method is accurate, it exposes patients to radiation and burdens the patient with the requirement of multiple appointments. This case series outlines the use of ultrasound-guided sternoclavicular joint injections conducted in the clinic. The patients in this series underwent an ultrasound-guided injection in the affected sternoclavicular joint, which confirmed the diagnosis, and they were subsequently treated with resection arthroplasty. The use of ultrasound-guided injections of the sternoclavicular joint is a safe and accurate alternative diagnostic method, which saves the patient from harmful radiation and additional appointments. Limitations and efficacy may vary depending on skill and comfort level of the operator.

Changfang Fu,1 Gang Wang,1 Wulin Yang2 1The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, People’s Republic of China; 2Anhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, 230031, People’s Republic of ChinaCorrespondence: Wulin YangAnhui Province Key Laboratory of Medical Physics and Technology, Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, 350 Shushanhu Road, Hefei, 230031, Anhui, People’s Republic of ChinaEmail yangw@cmpt.ac.cnGang WangOncology Department, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Luyang District, Hefei, 230001, Anhui, People’s Republic of ChinaEmail wanggang829@126.comAbstract: Immune checkpoint inhibitors may cause unique immune-related adverse events. Vascular thrombosis, especially arterial thrombosis, is rare but life-threatening, and little is known about its relevance to immunotherapy. Here, we reported two cases of vascular thrombosis, including venous and arterial thrombosis in cancer patients receiving anti-PD-1 antibody in combination with chemotherapy. Systemic corticosteroids and anticoagulant treatment were administered immediately in two cases. In case 1, anti-PD-1 antibody was permanently discontinued, and recurrence of vascular thrombosis was not observed during the follow-up. In case 2, the patient continued anti-PD-1 immunotherapy and unfortunately died of cerebral infarction 2 months later. This case report provides a strong evidence for the association between PD-1 blockade and vascular thrombosis and offers some general guidelines on the management of the immune-related vascular thrombosis events induced by anti-PD-1 therapy.Keywords: immune checkpoint inhibitors, immune-related adverse events, pembrolizumab, tislelizumab, pulmonary embolism, deep vein thrombosis

Ya Bin Zhou,&ast; Yuan Yuan Xiao,&ast; Jin Jing Chao, Lin Ma Department of Dermatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, 100045, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Yuan Yuan XiaoDepartment of Dermatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, 100045, People’s Republic of ChinaTel +86 10 59616884Fax +86 10 59718700Email xyy81924@126.comAbstract: Tinea capitis is a common dermatophytosis predominantly occurring in children, which needs oral antifungal drug therapy. Itraconazole pulse therapy has been widely applicated in the treatment of adult onychomycosis. However, only a few studies are available for the treatment of pediatric tinea capitis with itraconazole pulse therapy. The therapy schedules vary with respect to dose and intermission. Here, we report four cases of tinea capitis that were treated with a novel high-dose itraconazole pulse therapy (6– 10 mg/kg/d with 3 weeks off between consecutive pulses). After 2– 3 pulses therapy, all the patients were cured and no adverse reactions were observed. We demonstrate the efficacy and safety of this novel itraconazole pulse therapy schedule. It may be a promising therapy in the treatment of tinea capitis in children.Keywords: tinea capitis, itraconazole pulse therapy, children, Microsporum canis, Nannizzia gypsea

Background We performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia. Results This was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure Conclusion By adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.

Purpose: To examine the incidence and initial presentation of sports-related ocular injury in youth. Methods: This retrospective case series study was performed at Massachusetts Eye and Ear, Boston, Massachusetts. Inclusion criteria were visit dates between January 1, 2010 and December 31, 2015, age 5 to 25 years, an ocular injury International Classifcation of Disease code, and a sports-related mechanism of injury. Results: The final sample was 223 patients, representing approximately 20% of all youth eye injuries (mean age: 16.2 years (range: 6 to 24 years); 78.9% boys, 21.2% girls). The most common diagnosis was hyphema (72.2%). Most injuries occurred with soccer (23.3%), baseball (17.0%), and basketball (11.7%), with a mean visual acuity of 20/40, 20/50, and 20/50, respectively. The injuries with the lowest mean visual acuity resulted from paintball (20/500) and airsoft gun shooting (20/200). Thirty-three patients (14.7%) required surgical intervention. The average number of follow-up visits within 1 year was five. Conclusions: Approximately 20% of youth ocular injury visits were sports related, with male teenagers affected most. Hyphema was the most common type of sports-related eye injury posing a lifelong risk of ocular complications. Popular youth sports such as soccer, baseball, and basketball caused the most eye injuries. Shooting sports with paintball and airsoft guns were associated with the greatest loss of vision. Patients infrequently reported the use of protective eyewear at the time of injury. Protective eye equipment should be worn by youth participating in sports to prevent ocular trauma and the potential for surgical intervention. [ J Pediatr Ophthalmol Strabismus . 2021;58(6):377–384.]

Fanhai Lin,1,2,&ast; Zhenming Yang,1,3,&ast; Ye Qiu,4 Wen Zeng,3 Guangnan Liu,5 Jianquan Zhang1 1Department of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, Guangdong, 518000, People’s Republic of China; 2Department of Pulmonary and Critical Care Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530016,People’s Republic of China; 3Department of Respiratory Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 4Department of Comprehensive Internal Medicine, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People’s Republic of China; 5Department of Respiratory Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530005,People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Jianquan ZhangDepartment of Respiratory and Critical Medicine, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Middle Road, Shenzhen, 518000, Guangdong, People’s Republic of ChinaTel +8613978123845Fax +86755-23482484Email jqzhang2002@126.comBackground: Talaromyces marneffei is considered to commonly cause infection in individuals with human immunodeficiency virus (HIV) infection. However, the epidemiology of T. marneffei has changed, and an increasing number of HIV-negative but immunodeficient patients are infected with T. marneffei. The mechanisms of T. marneffei infection of HIV-negative hosts are complex and diverse. We report 2 cases of HIV-negative lung cancer with T. marneffei infection and positive anti-interferon-gamma autoantibodies (AIGAs) to provide clinical experience.Case Presentation: We report lung adenocarcinoma combined with T. marneffei infection in HIV-negative patients, and their AIGAs were measured. Both patients were male with a family history of cancer and presented with recurrent fever and cough. The patients were negative for HIV antibodies but positive for AIGAs. Chest computed tomography (CT) showed pulmonary nodules, exudative lesions and solid changes. The patients were diagnosed with lung adenocarcinoma and Talaromycosis marneffei (TSM) by pathological examination and tissue culture. Patient 1 received only antifungal treatment, refused antitumor treatment and died in February 2019, and Patient 2 unfortunately died in April 2019 after antifungal and antitumor treatments.Conclusion: An increasing number of HIV-negative but immunodeficient patients are infected with T. marneffei. The 2 patients in this report had lung cancer and positive AIGAs, causing immunodeficiencies, but the mechanism of T. marneffei infection in such patients is complex. Clinically, we should consider a comprehensive immunological examination to avoid the omission of other immunodeficiencies. We recommend routine testing for AIGA levels in HIV-negative marneffei patients. It is difficult to distinguish between lung cancer and disseminated TSM due to similar clinical characteristics and imaging, and multiple biopsies and cultures of diseased tissue are necessary. Early antifungal treatment and standard antitumor treatment can achieve satisfactory curative effects when a patient has both diseases.Keywords: Talaromyces marneffei, lung adenocarcinoma, adult immunodeficiency, anti-interferon-γ antibodies

To review and represent three different mandibular reconstruction modalities following surgical treatment of massive mandibular fibrous Dysplasia (MMFD). The present retrospective case series study was conducted on 24 patients who had MMFD and treated via resection and immediate reconstruction at Al-Azhar University Hospitals, Egypt. Patients were divided into three groups according to the grafting procedure. Group I patients were grafted with iliac bone graft (IBG), group II patients were grafted with IBG and bone marrow aspirate concentrate (BMAC), while group III patients were grafted with free vascularized fibula graft (FVFG). Postoperative clinical and radiographic assessments were performed immediately, at 6 months, 12 months and 2 years to evaluate lesion recurrence and bone graft resorption. Other study variables included assessment of postoperative wound dehiscence, infection rate, amount of edema, and facial bone contour. The parameters of the clinical analysis showed non-statistically significant differences among all groups. Postoperative wound healing was clinically uneventful in all groups, except for two cases of wound dehiscence in group I (8.3%) and one case in group III (4.2%). Most patients had appropriate postoperative facial contour, and adequate facial symmetry. The radiographic measurements revealed a highly statistically significant difference between group I and II at 12 months, and two years, without any statistically significant difference between group II and III. MMFD surgical defect should be repaired for function and cosmetics aims especially in young adult patients. The findings of the present study have shown that when compared to traditional IBG alone or FVFG, the use of autogenous IBG with BMAC injection produces a favorable outcome with few difficulties.

Breast cancer is the leading cause of death in females worldwide. Radiotherapy plays an important role for locoregional control in the comprehensive management of breast cancer. Chronic radiation-induced ulcer of the axilla can occur, and it is complicated to treat for these lesions. The application of a thoracodorsal artery perforator flap offers many advantages to be one of the most efficient treatments for radiation-induced ulcers of the axillary region. We introduce a series of 5 patients with radiation-induced ulcers of the axilla treated by using a thoracodorsal artery perforator flap. The mean operative time was 190 minutes. During at least a two-year follow-up, no complication has been found, and the patient has achieved good cosmetic result without movement limitation of the upper limb.

BACKGROUND: Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings. AIMS: This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long-term outcomes. MATERIALS AND METHODS: A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14-year period by one operative group. RESULTS: A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n = 32). Obstetric cause was implicated in 26.8% (n = 11) and other causes include 26.8% (n = 11) from vaginal and abdominal surgery, 14.6% (n = 6) from perianal abscess, 7.32% (n = 3) as complications of Crohn's disease and 2.44% (n = 1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n = 33). Post-operative symptoms were limited to flatal incontinence in 4.88% (n = 2), faecal incontinence in 2.44% (n = 1), and persistent perineal pain in 7.32% (n = 3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique. CONCLUSIONS: This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post-operative symptoms.

Background Acute pancreatitis after liver resection is a rare but serious complication, and few cases have been described in the literature. Extended lymphadenectomy, and long ischemia due to the Pringle maneuver could be responsible of post-liver resection acute pancreatitis, but the exact causes of AP after hepatectomy remain unclear. Cases presentation We report here three cases of AP after hepatectomy and we strongly hypothesize that this is due to the bile leakage white test. 502 hepatectomy were performed at our center and 3 patients (0.6%) experienced acute pancreatitis after LR and all of these three patients underwent the white test at the end of the liver resection. None underwent additionally lymphadenectomy to the liver resection. All patient had a white-test during the liver surgery. We identified distal implantation of the cystic duct in these three patients as a potential cause for acute pancreatitis. Conclusion The white test is useful for detection of bile leakage after liver resection, but we do not recommend a systematic use after LR, because severe acute pancreatitis can be lethal for the patient, especially in case of distal cystic implantation which may facilitate reflux in the main pancreatic duct.

SUMMARY OBJECTIVE: Pulmonary metastasectomy for the treatment of metastatic colorectal cancer is essential, but high ranked evidence of survival benefit is lacking. Here, we aimed to examine the prognostic factors after pulmonary metastasectomy in patients with colorectal cancer. METHODS: This is a single-center, retrospective hospital-based observational case series study. We reviewed data for 607 patients with metastatic colorectal cancer (mCRC) who were treated and observed from 2012 to 2019. Of the 607 patients with mCRC, 87 were with solitary lung metastases. Of the 87 patients, 39 were not appropriate for metastasectomy, while 15 patients recognized as suitable candidates by the multidisciplinary thoracic tumor board rejected metastasectomy. Consequently, only 33 patients were included in the final analysis. RESULTS: Rectum was detected as the primary site in 16 (48.5%) patients. Over 80% of patients had metachronous lung metastases, with a median of 29.0 months from initial diagnosis. Video-assisted thoracic surgery with wedge resection was performed in 20 (60.6%) patients. Over 90% of patients had solitary metastasis resected, with 97% of R0 resection. Median tumor size was 23.0 mm (min: 10; max: 90). Adjuvant treatment was given to 31 (93.9%) patients, while neoadjuvant treatment was given only to 8 (25%) patients. Of the 33 patients, there were 25 (75.7%) relapses. The most frequent site of relapse was lung in 15 (45.5%) patients. Interestingly, there were only 4 (12.2%) patients who had a relapse in the liver after lung metastasectomy. We found that median disease-free survival (DFS) and overall survival (OS) were 43.0 (13.0–73.0) and 55.0 (31.6–78.4) months, respectively. CONCLUSIONS: Pulmonary metastasectomy was associated with significantly long-time survival rates in mCRC (43 months of DFS and 55 months of OS). The second relapse occurred in 25 (75.7%) patients, with isolated lung metastases in nearly half of the patients (45.5%). Therefore, lung metastases in mCRC were unique and a multidisciplinary team including a thoracic surgeon should manage these patients.

Xin-Yue Zhang,1,2,&ast; Hai-Ping Dai,1,2,&ast; Ling Zhang,1,2 Si-Ning Liu,1,2 Yin Dai,1,2 De-Pei Wu,1,2 Xiao-Wen Tang1,2 1National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People’s Republic of China; 2Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, 215123, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: De-Pei Wu; Xiao-Wen TangDepartment of Hematology, The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, People’s Republic of ChinaTel +8651267781856Fax +8651265113556Email drwudepei@163.com; xwtang1020@163.comAbstract: EP300-ZNF384-positive B cell acute lymphoblastic leukemia (B-ALL) patients are reported to have a unique immunophenotype with high expression of CD19 and CD22, weak expression of CD20 and aberrant expression of CD13 and/or CD33, sensitivity to chemotherapy and a favorable outcome. To date, the cases of only 53 patients have been reported, albeit few reports on salvage therapy when conventional chemotherapies failed. Here, we describe two relapsed and refractory adult B-ALL patients with EP300-ZNF384 who achieved second remission through tandem CD19/CD22 CAR T-cell therapy. Grade 3 and 2 cytokine release syndrome were observed in cases 1 and 2, respectively. No immune effector cell-associated neurotoxicity syndrome was detected. Both patients underwent consolidate haploidentical hematopoietic stem cell transplantation (HSCT), and each maintained measurable residual disease-negative remission for 14 and 13 months, respectively. Our study suggests that CD19/CD22 CAR T-cell therapy bridging to allogeneic HSCT may be a viable option for EP300-ZNF384-positive B-ALL.Keywords: chimeric antigen receptor T-cells, CD19/CD22, EP300-ZNF384, acute lymphoblastic leukemia, relapsed/refractory

Granuloma annulare (GA) is a common, benign, often self-limiting granulomatous disease. The condition classically presents clinically with asymptomatic, flesh-colored to erythematous, nonscaling papules, often arranged in a ring or annular pattern. Histologically, GA is characterized by a perivascular lymphocytic infiltrate, the accumulation of macrophages in the dermis, and palisading of the macrophages around degenerated areas with altered collagen. A delayed-type cell-mediated hypersensitivity reaction is the favored hypothesis; however, the etiology and pathogenesis of GA is not fully understood. It has been associated with various systemic diseases, including diabetes mellitus and dyslipidemia, and has also been reported to develop after exposure to assorted triggers, often cutaneous trauma.1 Although uncommon, familial occurrences of GA have also been reported. Friedman and Winkelmann2 last reviewed familial GA in 1987, describing 11 families and 21 cases of GA with at least 2 immediate family members affected. These authors also suggested that the incidence of specific human leukocyte antigens (HLAs) (eg, HLA-B35) within some of these family members might indicate that genetically predisposed individuals could develop a cell-mediated immune reaction in response to an unknown antigen. In this report, we describe the cases of 2 patients, a father and his daughter, who presented with clinical and histologically confirmed GA. We also review all familial occurrences of GA since 1987.

Author(s): Moschella, Phillip; Shull, Hannah; Pittman, Mark; Gleason, Alex; Roth, Prerana | Abstract: Introduction: The increasing incidence of Neisseria gonorrhoeae infections and emergence of cephalosporin-resistant strains means the threat of disseminated gonococcal infection and endocarditis needs to be reimagined into the differential diagnosis for patients treated in the emergency department (ED) for sexually transmitted infections and for endocarditis itself. Only 70 cases of disseminated gonococcal infection (DGI) with endocarditis had been reported through 2014.1-4 In 2019, however, an outbreak of DGI with one case of endocarditis was reported.5 This case series of three patients with DGI and endocarditis, in addition to the recent outbreak, may represent a warning sign for reemergence of this threat.Case Report: We describe three cases within a recent three-year period of gonococcal endocarditis as seen and treated at our institution. These cases show divergent presentations of this insidious disease with both classical and atypical features. One case displayed a classic migratory rash with positive urine testing and a remote history of sexually transmitted infections, while another patient developed isolated culture-confirmed endocarditis with negative cervical testing and imaging, and the final case was a male patient who presented to the ED with fulminant endocarditis as the first ED presentation of infection.Conclusion: Secondary to an overall rise in incidence and possibly due to increasing antibiotic- resistance patterns, gonococcal endocarditis should be included in the differential diagnosis of any case of endocarditis. Reciprocally, increased vigilance should surround the evaluation of any patient for sexually transmitted diseases while in the ED for both the development of DGI and endocarditis.

We often come across differences in the severity of androgenetic alopecia (AGA) as assessed subjectively by the patients themselves and objectively by the attending physicians. For the purpose of examining the differences in the assessment of AGA between patients and physicians, we presented the Norwood classification to male patients and the Shiseido classification to female patients and asked them to assess the degree of hair loss by themselves. We compared the results with the severity as assessed by 2 specified dermatologists. The results show that the assessments of the severity of AGA were consistent between the patients and physicians in 42% (15/36) of cases, the physicians reported a higher grade of severity than the patients themselves in 30% (11/36) of cases, and the patients reported a higher grade of severity than the physicians in 28% (10/36) of cases; however, the Wilcoxon signed rank statistical analysis showed no significant difference between the patients and physicians assessments. AGA should be treated in accordance with individual symptoms and wishes and not a standardized treatment protocol.

Study design Retrospective comparative review. Objective The aim of this study was to determine the short-term impact of the COVID-19 pandemic on the demographic and clinical profile of new idiopathic scoliosis (IS) patients, with a particular focus on treatment and late referral. Summary of background data The COVID-19 pandemic has limited health-care services and public access and, as a result, the diagnosis and management of non-COVID-19 health conditions have been compromised. Delayed diagnosis of IS may limit conservative treatment options and subsequently, increase a patient’s risk of requiring surgical intervention. Methods The volume of spine referrals received and new IS clinic visits were compared between March 15–October 15, 2019 and the same period in 2020. A chart and radiographic review detailed the patient profile at initial presentation. Descriptive statistics and comparative analyses examined the referral source, curve magnitude, skeletal maturity, and prescribed treatment. Late referrals were those with a curve magnitude ≥ 50°, or > 40° and Risser 2 or less. Results During the 2020 study period, the referral volume decreased 76% and clinic visits 55%. The 2019 cohort was similar in age (13.7 ± 2.1 years vs 13.3 ± 2.3 years, p = 0.08), Risser score distribution (p = 0.32), menarchal status (0.07), and curve magnitude (37.1° ± 3.8° vs 39.0° ± 16.0°, p = 0.22). During the pandemic, there was an increased proportion of referrals made by pediatricians (41 to 54%, p = 0.01). The proportion of brace prescriptions increased from 30 to 42% (p = 0.01). The proportion of surgical bookings and late referrals were increased but did not reach significance. Conclusion Despite no significant increase in the magnitude of the curve at initial presentation or the proportion of late referrals, there was a marked decrease in referral volume, over the first 7 months of the COVID-19 pandemic. This suggests that the majority of expected new IS patients remain undiagnosed. A future increase in late referrals should be anticipated. Level of evidence III.

Dermatomyositis is a multisystem autoimmune connective tissue disease that can manifest with proximal muscle weakness, interstitial lung disease, and characteristic skin findings such as erythema and papules over the dorsal joints of the hand, periungual changes, heliotrope rash, and pruritic erythematous inflammation of the chest, back, arms, legs, and scalp. Erythromelalgia is a clinical diagnosis characterized by swelling, erythema, and burning pain, typically of the extremities and often triggered by heat or exertion. It can be classified as primary, due to genetic mutations, or secondary, associated with myeloproliferative, vascular, musculoskeletal, or neurologic disease.1 There have been reports of biopsies of erythromelalgia having some features of connective tissue disease.2,3 There are also reports of erythromelalgia associated with systemic lupus erythematosus and rheumatoid arthritis, two autoimmune connective tissue diseases.4 Here, we present two cases of erythromelalgia associated with dermatomyositis, which, to our knowledge, has not been reported in the literature to date. Case 1 An 81-year-old woman with a history of treated breast cancer presented to the dermatology clinic for evaluation of swelling and discoloration of her bilateral hands and feet of approximately 10 years' duration associated with heat intolerance. She had been seen by numerous vascular and lymphedema specialists over the years with the ultimate conclusion that her swelling was not associated with a vascular etiology. The patient noticed improvement of her symptoms when she was exposed to air conditioning or cold water. At presentation, she also reported shortness of breath, a burning sensation on her feet and scalp, subjective proximal muscle weakness, dysphagia, and weight gain. Her physical examination was notable for periungual telangiectasias, scale, and erythema on the V of her neck area, her extensor arms, and around her eyes (Fig 1). She believed that the erythema on the V of her neck area started 30 years ago, indicating the possibility that she had had potentially undiagnosed amyopathic dermatomyositis (DM) for years before her diagnosis of erythromelalgia. The patient's basic laboratory workup and immunologic studies were unrevealing, and a myositis panel was negative. Muscle magnetic resonance imaging and electromyography were not performed because of the absence of muscle pain or objective weakness on physical examination. Two skin biopsy specimens from the upper portion of the arm and the dorsal surface of the hand showed interface dermatitis (Fig 2), consistent with a diagnosis of DM based on clinicopathologic correlation with typical features of DM (as opposed to lupus, drug reaction, viral exanthem, lichen planus, or graft versus host disease). Pulmonary function testing showed an obstructive pattern with decreased carbon monoxide diffusion in the lung (62%), and chest computed tomography (CT) showed stable interstitial lung changes. The malignancy workup (including age-appropriate screening and CT of the chest, abdomen, and pelvis) was negative. The patient has had some relief from the burning sensation on her feet from topical 5% lidocaine and petroleum jelly. Because of shared decision-making and risk-benefit analysis, the patient has not started immunosuppressive therapy for her DM, but she is being followed closely. Open in a separate window Fig 1 Patient 1. Swelling and erythema on bilateral hands and feet.

This study aimed to explore changes in gambling behaviours and gambling disorder (GD) treatment uptake during the COVID-19 pandemic among those with a heightened vulnerability to gambling-related harm. This was a single-center, cross-sectional, retrospective case series study assessing gambling behaviours and GD counselling participation among a vulnerable population sector following the COVID-19 shutdown. The clinical records of clients at a community substance use disorder (SUD) treatment center were explored (N = 67). Eight clients (n = 8) had satisfied the objective criteria, and were qualified for data exploration and analysis of gambling activities and GD treatment participation following the COVID-19 shutdown. All clients in the study belonged to subgroups at an elevated risk for gambling-related harm, with a mean duration of gambling problems of 9.5 years. Following the COVID-19 shutdown, an increase in gambling activities was noted in five cases. Migration to online gambling was noted in three cases. In two cases, no change in gambling activities was noted, and a reduction of gambling activities was noted in one case. In seven cases, no screening for gambling problems prior to current SUD program was noted. None had a history of, nor were currently engaged in counselling for gambling problems. The COVID-19 crisis and associated increase in gambling participation, coupled with a diminutive gambling counselling uptake during the pandemic, present an opportunity to rethink current behavioural addictions service delivery model for those with an increased vulnerability to gambling-related harm. Further investigation of the changes in gambling participation, and a closer look at optimizing GD service delivery among vulnerable population sectors during the COVID-19 crisis is warranted.

Objective To describe a stepwise surgical approach for conservative management of placenta previa accreta to preserve the uterus and to evaluate the efficacy and safety of this approach in controlling postpartum hemorrhage including intrapartum hemorrhage. Methods A prospective case series study conducted on 62 pregnant women with one or more cesarean deliveries diagnosed with placenta previa accreta between January 2018 and June 2019 at Ain Shams University Maternity Hospital. All participants underwent a conservative stepwise surgical approach through Pfannenstiel skin incision with fetal delivery through a uterine incision just above the upper border of the placenta, followed by bilateral uterine artery ligation with myometrial excision of the remaining adherent placenta and cervico-isthmic sutures by MMG (the main surgeon) and MS. Results Among 62 women, the surgical approach was successful in controlling postpartum hemorrhage and preserving the uterus in 50 (80.64%) participants. Three women (4.83%) had urinary bladder injuries, all were managed intraoperatively during the cesarean section. Five women (8%) had postpartum pyrexia and five women (8%) had postpartum endometritis, all were managed conservatively with broad-spectrum antibiotics. Conclusion The stepwise surgical approach can be applied to the conservative management of placenta previa accreta to avoid unnecessary cesarean hysterectomy.

We encountered 4 patients with acute pancreatitis (AP) of various etiologies and coexisting acute cholangitis who underwent endoscopic biliary stenting (EBS) and nasopancreatic drainage (NPD) via endoscopic retrograde cholangiopancreatography (ERCP) during the early phase of AP. ERCP is performed to treat acute cholangitis even in the context of AP. However, in difficult cases, accidental contrast media injection or guidewire insertion into the pancreatic duct can happen during ERCP for the purpose of EBS. It is concerned that cannulation injury and increased pancreatic duct pressure can exacerbate existing AP. Because pancreatic guidewire-associated techniques were required for all of them due to difficult biliary cannulation, we performed a NPD catheter placement using the pancreatic guidewire to decompress the pancreatic duct to prevent further exacerbating AP. Surprisingly, all patients dramatically improved without systemic or local complications. NPD could be performed without any adverse events and did not worsen the course of AP. Early decompression of a pancreatic duct using NPD may rather improve AP that had already developed. Further prospective research is needed to confirm our observations.

Background Our laboratory published the first evidence that nutritional ketosis, induced by a ketogenic diet (KD) or time-restricted diet (TRD), ameliorates disease progression in polycystic kidney disease (PKD) animal models. We reasoned that, due to their frequent use for numerous health benefits, some autosomal dominant PKD (ADPKD) patients may already have had experience with ketogenic dietary interventions (KDIs). This retrospective case series study is designed to collect the first real-life observations of ADPKD patients about safety, feasibility and possible benefits of KDIs in ADPKD as part of a translational project pipeline. Methods Patients with ADPKD who had already used KDIs were recruited to retrospectively collect observational and medical data about beneficial or adverse effects and the feasibility and safety of KDIs in questionnaire-based interviews. Results A total of 131 ADPKD patients took part in this study. About 74 executed a KD and 52 a TRD for 6 months on average. A total of 86% of participants reported that KDIs had improved their overall health, 67% described improvements in ADPKD-associated health issues, 90% observed significant weight loss, 64% of participants with hypertension reported improvements in blood pressure, 66% noticed adverse effects that are frequently observed with KDIs, 22 participants reported safety concerns like hyperlipidemia, 45 participants reported slight improvements in estimated glomerular filtration rate and 92% experienced KDIs as feasible while 53% reported breaks during their diet. Conclusions Our preliminary data indicate that KDIs may be safe, feasible and potentially beneficial for ADPKD patients, highlighting that prospective clinical trials are warranted to confirm these results in a controlled setting and elucidate the impact of KDIs specifically on kidney function and cyst progression.

Endoscopy for revealing the orifice of congenital H-type tracheoesophageal fistula (cTEF) is important for diagnostics and therapeutics. To facilitate the identification and catheterization of cTEF, we developed a new modified flexible endoscopy technique using a laryngeal mask with intermittent airflow. A retrospective case series study was conducted from April 2016 to July 2019 at a national regional children's medical center. Twelve infants with cTEF underwent this flexible endoscopy technique. The intermittent positive pressure airflow through laryngeal mask was able to reveal the orifice of cTEF easily in tracheal lumen. Under the visual flexible endoscope, cannulation with a 3-French ureteral catheter in fistula was successfully used in all cases. There were no immediate or delayed complications. This case series shows that the flexible endoscopy technique is a safe, easy, and technically efficient approach for diagnosis and cannulation of cTEF.

Vestibular migraine (VM) and Menière’s disease (MD) are common neurotological disorders causing episodic vertigo. Sometimes, VM is accompanied by cochlear symptoms suggestive for MD. Therefore, in those cases, the differential diagnosis between the two disorders can be difficult. Moreover, a comorbidity with migraine in MD patients is widely reported, up to the hypothesis of a possible MD-VM overlapping syndrome. In this brief case report, we consider the clinical history of a family presenting high incidence of subjects fulfilling the diagnostic criteria of VM and single case fulfilling criteria for definite MD. The relationship between VM and MD is still under debate; anyway, it can be speculated that commonly shared genetic mutations could play a role as predisposing factors in both disorders. A congenital nystagmus in the family was present too, but its correlation with the other conditions is still not clear. Future goal of our work will be to assess genetics in this family.

Keywords: CTCL classifications; CTCL, cutaneous T-cell lymphoma; LDH, lactate dehydrogenase; MF, mycosis fungoides; SS, Sezary syndrome; Sezary syndrome; T cell; WBC, white blood cell; clinical cases; leukemic progression; lymphoma; medical dermatology; mycosis fungoides. Conflict of interest statement Dr Dummer reports intermittent, project-focused consulting and/or advisory relationships with Novartis, Merck Sharp and Dhome, Bristol-Myers Squibb, Roche, Amgen, Takeda, Pierre Fabre, Sun Pharma, Sanofi, Catalym, Second Genome, Regeneron, and Alligator outside the submitted work. Dr Ramelyte reports intermittent, project-focused consulting and/or advisory relationships with Amgen, Novartis, Sanofi, Pierre Fabre, and Sun Pharma outside the submitted work. Dr Kim reports grants and personal fees from Actelion and 10.13039/501100009754Galderma; personal fees from Helsinn and Almirall; and grants from 10.13039/501100004628MedImmune, Kyowa Kirin, and Soligenix outside the submitted work. Drs Maredia, Cozzio, and Rozati have no conflicts of interest to declare.

Lichen planus is a benign, chronic, mucocutaneous disorder that affects the skin, mucosae, and nails. The occurrence of nail lichen planus has been reported to be about 10% to 15%.1,2 Nail lichen planus is more common in adults than in children, and it mostly affects the fingernails rather than the toenails.3 The many nail abnormalities found in nail lichen planus depend on its pathologic location: the nail matrix or the nail bed. Dorsal pterygium is an irreversible and classic finding in nail lichen planus. The disease may lead to permanent disfigurement, which has both functional and psychological consequences. Early diagnosis and prompt treatment are also important to prevent the development of pterygium. Nail lichen planus can sometimes be difficult to diagnose and differentiate from other nail disorders. This is especially the case in patients without other mucocutaneous findings. Systemic corticosteroids are the first-line treatment, but they have inconsistent outcomes. There are few published reports on the clinical characteristics and treatment outcomes of nail lichen planus in Asians. The aims of our study were to review the clinical characteristics of, treatment approaches to, and treatment outcomes of nail lichen planus.

Background Minimally invasive adrenalectomy represents the treatment of choice of pheochromocytoma (PCC). For large or invasive PCCs, an open approach is currently recommended, in order to ensure complete tumor resection, prevent tumor rupture, avoid local recurrence, and limit perioperative hemodynamic instability. The aim of this study is to analyze perioperative outcomes of laparoscopic adrenalectomies (LAs) for large adrenal PCCs. Methods All consecutive LAs for PCC performed at a single institution between 1998 and 2020 were included. Two groups were defined: lesions larger (group 1) and smaller (group 2) than 5 cm. Short-term outcomes were compared in order to find any significant difference between the two groups. Outcomes One hundred fourteen patients underwent LA during the study period: 46 for lesions larger and 68 for lesions smaller than 5 cm. No significant differences were found in patients’ characteristics, median operative time, conversion rate, intraoperative hemodynamic and metabolic parameters, postoperative intensive care unit (ICU) admission rate, complications rate, and length of hospital stay. Long-term oncologic outcomes were similar, with a recurrence rate of 5.1% in group 1 vs 3.6% in group 2 (p = 1). Conclusion Minimally invasive adrenalectomy seems to be safe and effective even in large PCC. The recommendation to prefer an open approach for large PCCs should probably be reconsidered.

Aleksandra Bolewska,1 Monika S&lstrok;owi&nacute;ska,1 Agata B&lstrok;o&nacute;ska,1 Justyna Ceryn,2 Bart&lstrok;omiej Grala,3 Joanna Narbutt,2 Magdalena Ci&aogon;&zdot;y&nacute;ska,4 Wojciech Ma&lstrok;ecki,5 Ma&lstrok;gorzata Skibi&nacute;ska,2 Aleksandra Lesiak,2 Elwira Paluchowska,1 Witold Owczarek1 1Department of Dermatology, Military Institute of Medicine, Warsaw, Poland; 2Department of Dermatology, Pediatric Dermatology and Oncology, Medical University of Lodz, &Lstrok;ód&zacute;, Poland; 3Department of Pathology, Military Institute of Medicine, Warsaw, Poland; 4Department of Proliferative Diseases, Nicolaus Copernicus Multidisciplinary Centre for Oncology and Traumatology, &Lstrok;ód&zacute;, Poland; 5Department of Clinical Oncology and Chemotherapy, Podd&eogon;bice Health Centre, Podd&eogon;bice, PolandCorrespondence: Aleksandra Bolewska Tel +48 261 816 241; +48 604 783 340Email aleksandra.bolewska@wp.plAbstract: Lung cancer most often metastasizes to the central nervous system, bone and liver. Although metastases to the skin are quite rare, it is estimated that they may be the first clinical manifestation of this disease in 0.7%– 12% of cases. Metastases to the skin are caused by adenocarcinoma (about 30%), squamous cell carcinoma (30%) and undifferentiated carcinoma (40%). Nasal tip metastases are extremely rare. They can be confused with more common skin problems, including non-melanoma skin cancers, rhinophyma, inflammatory tumors or infectious diseases. We report two patients with a tumor on the nose, which proved to be the first sign of the metastatic lung cancer.Keywords: lung cancer, skin metastasis, ulceration, tumor

Wei Ji,1 Yunlong Xing,2 Jinshu Ma,3 Zhuo Zhao,4 Hongqin Xu,5 Shuang Zheng,6 Wei Li,1 Xu Li5 1Cancer Center, The First Hospital of Jilin University, Changchun, People’s Republic of China; 2Plastic Surgery, China-Japan Union Hospital, Jilin University, Changchun, People’s Republic of China; 3Department of Pathology, China-Japan Union Hospital, Jilin University, Changchun, People’s Republic of China; 4Cardiology Department, The Second Hospital of Jilin University, Changchun, People’s Republic of China; 5Department of Hepatology, The First Hospital of Jilin University, Changchun, People’s Republic of China; 6Department of Radiology, The First Hospital of Jilin University, Changchun, People’s Republic of ChinaCorrespondence: Xu LiDepartment of Hepatology, The First Hospital of Jilin University, No. 71, Xinmin Street, Changchun, 130021, People’s Republic of ChinaTel +86 158 0430 1765Email jdyylx@jlu.edu.cnBackground: Primary liver sarcomatoid carcinoma (PLSC) is rare. To improve the understanding of PLSC, cases were described and reviewing the literature.Methods: A retrospective analysis was performed on 14 cases of PLSC diagnosed by pathology in Northeastern China from 2010 to 2020. An individual participant data analysis based on reported cases was conducted to determine epidemiological characteristics, clinical characteristics, and prognoses of PLSC.Results: A total of 136 cases involved our 14 cases and 122 cases from previous reports. The percentages of sarcomatoid hepatocellular carcinoma, sarcomatoid cholangiolocellular carcinoma, and mixed and unclassified types were 36.8%, 41.9%, 5.9%, and 15.4%, respectively. A total of 95.6% PLSC was found in Asia. There was a lower percentage of hepatitis-infected patients in Japan, when compared with the Republic of Korea (38.5% vs 70.0%, P< 0.05). Five cases were initially misdiagnosed as a hepatic abscess by imaging. A total of 36.7% cases had metastases when being diagnosed, and 68.9% cases relapsed during the follow-up. The median disease-free survival and overall survival (OS) were 3 months and 5 months, respectively. Only radical surgery (hazard ratio = 0.308, 95% confidence interval 0.186– 0.512, P< 0.001) indicated a better OS.Conclusion: PLSC was more prevalent in Asia and there were possibilities of misdiagnoses. Surgery is still an effective treatment and can significantly prolong the OS. Only limited strategies for recurrent or advanced PLSC, immunotherapy may be possible treatment.Keywords: liver, sarcomatoid carcinoma, pathology, immunotherapy