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As the navy began its first major offensive battles in late 1943, it went to great lengths to ensure a better press. Robert Sherrod of Time magazine was one of the biggest beneficiaries of this new policy, although at Tarawa he was lucky to survive the carnage of invasion day. Sherrod’s reporting on this battle, along with vivid visual images of the fighting, underlined the toughness of the fighting in the central Pacific. His experiences also made him a fierce partisan of the Marines, a fact that subsequently exacerbated the tension between the Marines and the army when Holland Smith relieved Ralph Smith during the Saipan invasion. Sherrod’s reporting on this controversy was extremely controversial, but he became convinced that the main takeaway from Saipan was the media’s continued neglect of the Pacific War.

Background Postpartum intrauterine device (PPIUD) use refers to intrauterine device (IUD) insertion after delivery but within 48 h of birth. In Uganda, the general use of modern methods of contraception is low with Objective We aimed to determine the proportion of TCu380A (copper) intrauterine devices expelled by 6 weeks postpartum, and identify risk factors for expulsion among women delivering at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. Methods We conducted a prospective cohort study from September 1, 2014 to January 31, 2015 at MRRH. We administered a structured questionnaire to all participants, to capture data on their baseline demographic, clinical and obstetric characteristics. We followed up women who accepted the PPIUD insertions at 6 weeks post insertion for any IUD expulsion. We fit multivariable log binomial regression models to identify risk factors for IUD expulsion. Results We enrolled 167 women who had PPIUDs inserted. Of the144 women who returned at 6 weeks for follow up, 13 (9%; 95%CI:4.9–15%) of them had the IUDs expelled. In the multivariable model, the significant risk factors for PPIUD expulsion were: IUD insertion more than 10 min post-delivery (aRR 8.1, 95%CI 1.26–51.98, p = 0.027) and bloody lochia flow of ≥15 days (aRR 8.5, 95%CI 1.47–48.47, p = 0.017). Conclusion The cumulative expulsion rate of postpartum IUDs among women delivering at MRRH was low and comparable to expulsion rates in interval insertions. Longer duration from delivery to IUD insertions and longer duration of bloody lochia flow were key risk factors for postpartum IUD expulsion. More emphasis should be put on prenatal counseling for postpartum family planning to allow for postplacental IUD insertions, which are associated with lower expulsion rates.

Background Cardiac synovial sarcoma (CSS) is an extremely rare malignant tumour with a poor prognosis. We report the case of a 31-year-old woman who presented with a CSS in the right atrium and was initially misdiagnosed with a tuberculoma. The aim of this article is to focus on the importance of having broad differential diagnoses including rare entities. Case summary A 31-year-old White woman, with a close contact with a relative having pulmonary tuberculosis, presented to the emergency unit with severe dyspnoea. Chest radiography and echocardiography showed a large pericardial effusion with a mass in the right atrium. Pericardiocentesis removed bloody exudative fluid with adenosine desaminase at 17 UI/L and no malignant cells in the cytological study. Cardiac magnetic resonance revealed a tuberculoma of the right atrium. Intraoperatively, the mass was only biopsied because of the local invasion. Histological study concluded to a CSS. The patient died 3 days later. Discussion This case highlights the importance of having broad differential diagnoses including rare entities. Histology was the key investigation for the diagnosis of CSS which has no clinical nor laboratory or imaging pathognomonic signs.

Background Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination. Methods From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow–Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement. Results Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8 %), coffee-ground in 227 patients (46.6 %), and clear in 193 patients (39.6 %). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS ≤ 11, whereas no additive value was found when the GBS was greater than 11. Conclusions Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.

Significance Hemolacria (bloody tears) is a rare clinical presentation with varied underlying etiologies. Thorough clinical evaluation is essential to diagnosis and management. Purpose This study aimed to report unilateral hemolacria in a known contact lens wearer with an occult, palpebral, conjunctival pyogenic granuloma and review the literature. Case report A 21-year-old female contact lens wearer presented to the clinic after three episodes of sudden painless bloody tears from the right eye. She was referred to the oculoplastic clinic for evaluation. On everting her right upper lid, a fleshy, nontender, ovoid, pedunculated mass was found attached to the palpebral conjunctiva of the right, nasal, upper tarsus. Surgical excision was performed in the office, and pathological examination of the lesion was consistent with pyogenic granuloma. Conclusions Unilateral hemolacria should raise clinical suspicion for a hidden conjunctival lesion such as pyogenic granuloma, although other more sinister causes of hemolacria must also be considered. Thorough evaluation including eyelid eversion is critical in identifying and managing occult conjunctival lesions.

Tuberculosis (TB) is an infectious disease which is one of the biggest health problems in the world, including Indonesia. The government, through the National Tuberculosis Control program, has made various efforts to control tuberculosis. However, this problem was exacerbated by the dramatic increase in the incidence of tuberculosis. This study aimed to determine the Cox proportional hazard regression model and the factors that affect the cure rate of TB patients. We used medical record data for inpatient TB patients for the period July-December 2017 at dr. Zainoel Abidin Hospital. The results showed that with α = 0.1, the factors that influenced the recovery of TB patients were the type of cough, the symptoms of bloody cough and symptoms of sweating at night. There were 33.93% of patients who did not work. This category included students, domestic helpers, and those who did not work until they suffered from tuberculosis and were treated at dr. Zainoel Abidin Hospital. The hazard ratio (failure ratio) showed that the tendency or cure rate for TB patients who did not experience cough symptoms was 70% greater than patients who experienced phlegm cough symptoms. The cure rate for TB patients who experienced coughing up blood symptoms was 53% greater than patients without these symptoms. The cure rate for TB patients who experienced symptoms of sweating at night was 54% greater than patients who did not sweat at night.

Periodic chest pain, with bloody pleural effusion, should raise the suspicion of pleural endometriosis as a well-known, but rare condition in clinical practice.

The oropharyngeal throat pack is commonly used in oral and maxillofacial surgery despite debated evidence regarding its barrier function. The study objectives were to investigate whether the oropharyngeal pack reduces blood ingestion and to evaluate its relationship with postoperative nausea and vomiting (PONV) and throat pain. This was a single-center, parallel group, single-blind randomized controlled trial. Participants undergoing orthognathic surgery, age ≥16 years, were included in the study. After intubation and prior to surgery start, the treatment group received oropharyngeal packing; the control group received no packing. Outcome variables were the quality of gastric contents aspirated by nasogastric tube (bloody or not bloody), PONV, and throat pain (visual analog scale). Thirty patients (treatment n = 15; control n = 15) were randomized and analyzed. There was no difference between the groups in quality of gastric contents (P = 1.00) or incidence of PONV at 2 hours and 24 hours (P = 1.00). Throat pain incidence and severity at 2 hours were both higher in the treatment group, but this was not statistically significant (P = 0.128, P = 0.223). The results indicate that the oropharyngeal pack is not an effective barrier against blood ingestion. Oropharyngeal packs do not improve or worsen PONV, but may increase throat pain.

Aim: Intussusception, the most common abdominal emergency in early childhood, is frequently misdiagnosed at initial presentation. The effect of using point-of-care ultrasonography (POCUS) by emergency medicine physicians on pediatric intussusception misdiagnosis rate remains unclear. Here, we summarize outcomes and misdiagnoses before and after training junior and senior physicians on using POCUS for diagnosing intussusception and compared their performance levels.Materials and Methods: This observational cohort analysis included patients with suspected intussusception who visited a pediatric emergency department (ED) between January 2017 and December 2019. All enrolled patients were evaluated by junior (Results: Of the 167 enrolled patients, 130 were confirmed to have intussusception by air reduction. Misdiagnosis rate was significantly lower in the post-training patient group after training than in the pre-training patient group (43.7 vs. 12.7%, P < 0.001). After training, fewer misdiagnoses were made by the junior (59.1 vs. 25.9%, P = 0.003) and senior (31.7 vs. 0%, P < 0.001) physicians. In the post-training patient group, the door-to-reduction time and rate of ultrasonography consultation with an expert also decreased significantly (118.2 ± 124.5 vs. 198 ± 250.2 min, P = 0.006). Abdominal pain (80.9%) was the most common symptom of intussusception, followed by vomiting (58.3%), fever (17.8%), bloody stool (15.4%), and diarrhea (14.2%). Even after training, the presenting symptoms of intussusception often leading junior physicians to misdiagnosis were diarrhea and fever.Conclusions: A brief POCUS training leads to decreased misdiagnosis rates in both the senior and junior physicians. Junior physicians should increase their awareness regarding diarrhea and fever being the presenting symptoms of intussusception, particularly in early childhood. Combining clinical judgment and POCUS results forms the core principle of the evaluation of children with intussusception.

Background Bacterial co-infection is infrequently observed with SARS-CoV-2/COVID-19 infection outside of critical care, however, antibiotics are commonly prescribed. Objectives To examine factors associated with antibiotic prescribing for suspected respiratory tract infection (RTI) and evaluate the nature and dynamics of prescribing in hospitalized patients with suspected and proven COVID-19 infection. Methods An antibiotic point prevalence survey in hospitalized adult patients was conducted in designated COVID-19 clinical areas (including critical care) in 15 Scottish hospitals. Antibiotics prescribed for RTI and factors associated with prescribing were investigated. Results Of 820 surveyed patients, 272 (prevalence 33.3%) received antibiotics for suspected RTI on the survey day and 58.8% were SARS-CoV-2 positive. Antibiotics were empirical in 91.9% and amoxicillin (24.6%), doxycycline (20.5%) and co-amoxiclav (15%) were most frequently prescribed. Oral antibiotics were prescribed in 54.5% and duration was recorded in 76.7% on wards for a median of 5 days. IV to oral switch occurred after a median of 2 days. Prescribing for RTI was independently and positively associated with COPD/chronic lung disease, purulent/bloody sputum, abnormal chest X-ray, and CRP ≥ 100 mg/L. Probable and definite hospital-acquired COVID-19 and diabetes were associated with a lower odds of receiving an antibiotic for RTI. Conclusions Antibiotic prescribing for suspected RTI was commonly observed and predominantly empirical in suspected or proven COVID-19. Initiatives to reinforce stewardship principles including clinical review, effective use of microbiological diagnostics and better understanding of the role of biomarkers are central to further limit unnecessary antibiotic therapy in COVID-19.

Thrombocytopenia is often seen as a laboratory finding during childhood. A supposed idiopathic thrombocytopenic purpura patient who was later diagnosed as Wiskott-Aldrich syndrome (WAS) and developed acquired thrombotic thrombocytopenic purpura (aTTP). Although autoimmune manifestations in WAS described, aTTP was reported just once. Five-year-old-boy was initially brought with cough, bloody stool (diarrhea), oral mucosal bleeding at 12th months of age. Following diagnosed with idiopathic thrombocytopenic purpura and receiving intravenous immunoglobulin, platelet count raised from 20,000 to 50,000/µL. One year after WAS diagnosis by mutation analysis, he presented with complaints of resistant fever, epistaxis, and melena. Hemoglobin decreased from 10 to 5.9 g/dL. Schistocytes in peripheral blood smear and high anti-ADAMTS-13 antibody level indicated development of aTTP.

Background Intussusception is the most common abdominal emergency in children. The first line treatment of uncomplicated pediatric intussusception is enema reduction. Until now, there have been no multi-center studies comparing the effectiveness and safety of UGHR and FGAR in the treatment of pediatric intussusception. The aim of this study was to compare the effectiveness and safety of the two most commonly used enema methods of pediatric intussusception: ultrasound-guided hydrostatic reduction (UGHR) and fluoroscopy-guided air reduction (FGAR). Methods From November 1, 2017 to October 31, 2018, we conducted a multi-center, prospective, cohort study. Children diagnosed with intussusception in four large Children’s Medical Centers in China were divided into UGHR and FGAR groups. Stratified analysis and subgroup analysis were used for further comparison. The success and recurrence rates were used to evaluate the effectiveness of enema reduction. The perforation rate was used to evaluate the safety of enema reduction. Results A total of 2124 cases met the inclusion criteria (UGHR group: 1119 cases; FGAR group: 1005 cases). The success and recurrence rates in the UGHR group were higher than in the FGAR group (95.80%, 9.28% vs. 93.13%, 10.65%) (P < 0.05, P > 0.05), respectively. The perforation rate in the UGHR group was 0.36% compared with 0.30% in the FGAR group (P > 0.05). Subgroup analysis showed the success rates in the UGHR group were higher than in the FGAR group of patients with onset time between 12 and 24 h (95.56% vs. 90.57%) (P < 0.05). Of patients aged 4 to 24 months, the success rates in the UGHR group were also higher than in the FGAR group (95.77% vs. 91.60%) (P < 0.05). Stratified analysis showed the success rates in the UGHR group were higher than in the FGAR group in patients with the symptom of bloody stool (91.91% vs 85.38%) (P < 0.05). Conclusions UGHR and FGAR are safe, nonsurgical treatment methods for acute pediatric intussusception. UGHR is superior to FGAR, no radiation risk, its success rate is higher, without a difference in perforation rate, especially for patients aged 4–24 months. Level of evidence Level II.

1. Daniela Titchiner, MD* 2. Priya Dukes, MD* 3. Rebecca Speier, MD* 4. Sharla Rent, MD* 1. *Duke University Hospital, Durham, NC 1. Address correspondence to Daniela Titchiner, MD, Department of Neonatology, Duke University Hospital, 2301 Erwin Rd, Durham, NC 27710. E-mail: daniela.titchiner{at}duke.edu A 3.8-kg male infant is born at 40 weeks’ gestation to a 30-year-old primigravida woman via normal spontaneous vaginal delivery. The pregnancy is uncomplicated, with appropriate prenatal care. Delivery is uneventful; the patient receives routine delivery care with Apgar scores of 7 at 1 minute and 9 at 5 minutes. The infant is transferred to newborn nursery with no complications. At 19 postnatal hours, he develops persistent tachypnea and stertor. The patient’s nares are suctioned bilaterally, followed by frank epistaxis and 2 episodes of bloody emesis. As a result, he is admitted to the NICU due to concern for respiratory distress and evaluation of bloody emesis. Initial examination in the NICU reveals an appropriate for gestational age term infant with mild tachypnea with RR 80, no increased work of breathing, saturating > 97% on room air. Chest radiograph demonstrates no abnormalities. The results of a complete blood cell count and coagulation studies are within normal limits. The examining NICU physician notes a soft-tissue mass in the left nasal meatus, without facial asymmetry or visible oropharynx abnormality noted. Pediatric otolaryngology (ENT) department is consulted and via flexible fiberoptic laryngoscopy visualizes a “soft, pink, mass in the …

Background Necrotizing enterocolitis (NEC), while classically discussed in preterm and low birth weight neonates, also occurs in the term infant and accounts for 10% of all NEC cases. Despite there being fewer reported cases of NEC in term infants, these presentations demonstrate differences in the onset, severity and risk factors from the classic presentation observed in premature infants. We present a novel case of term NEC that contravenes the reported literature making departures from clinical presentation, risk factors and location of perforation in an otherwise healthy term two-day old infant born after an uncomplicated pregnancy who presented with hematochezia. Case presentation A healthy term baby born after an uneventful pregnancy presented with bloody stool at 2 days of life who was otherwise well. Investigations revealed pneumoperitoneum from a large proximal transverse colonic perforation secondary to NEC. No typical risk factors for NEC were found. Conclusion Given the life-threatening potential of an unrecognized perforation we recommend the inclusion of NEC on the differential for neonatal hematochezia.

The patient was a 63-year-old male with mucus and bloody stool more than 20 times a day mixed with a lot of pseudomembrane. The symptoms lasted over three months. Thus, he underwent a colonoscopy in another hospital at disease onset, the polyp was found and resected during the procedure. The symptoms were reduced but recurred two weeks later. A recent colonoscopy showed a large number of erythematous inflammatory colonic polyps covered by fibrous purulent mucus. The polyps were sessile and erosive, dark red, accompanied by fibrous, purulent and mucous-like secretions, similar to those reported by Monsalve Alonso S et al.

Background: Canine visceral leishmaniasis (CVL) is a zoonosis of variable clinical presentation, either in systemic or cutaneous form. Clinical signs include anorexia, ophthalmopathies, and chronic kidney disease. In the state of Santa Catarina, the foci are concentrated in the capital and its adjacencies, in the east side of the state. The objective of this study is to outline the first three reported cases of CVL in the municipality of Curitibanos, since there are no reports to date in the region of the mountainous plateau, in the middle west of Santa Catarina. Cases: All dogs were treated at the Veterinary Clinic School of the Federal University of Santa Catarina, Campus Curitibanos. The animals, two males and one female, belonged to the same tutor, resided in Curitibanos, and were attended between 2016 and 2020. In the first case, attended in 2016, the complaint was of eye and skin changes about three months ago. The animal lived in an urban environment and came from Uruguaiana, Rio Grande do Sul. On physical examination, the animal presented skin peeling, wet and crusty lesions, bloody discharge in the ears and nasal hyperkeratosis, as well as signs suggestive of uveitis. In this case, euthanasia was carried out. The second case had complaints of respiratory, eye changes, hyporexia, and polydipsia. The dog was prostrate, dehydrated, with lymphadenomegaly and respiratory disorders, compatible with bacterial pneumonia. Bilateral corneal edema confirmed uveitis. Upon return, the animal remained dehydrated with enlarged lymph nodes. In the aspiration of the lymph nodes, suggestive forms of Leishmania sp. were observed . The recommended confirmatory tests were performed, leading to a definitive diagnosis of CVL. The patient was treated with miltefosine, but later died. The third case was attended for general evaluation after a positive diagnosis for CVL during an epidemiological survey of the second case. The animal was alert, tachycardic, and tachypneic with hyperemic mucous membranes. Miltefosine-based treatment and permanent use of deltamethrin-impregnated collar were prescribed and ovariohysterectomy was carried out. The patient is clinically well. In the search for vectors, in no place or moment of search, referring to the cases, vectors for CVL were found. Discussion : It is suggested that patients 2 and 3 are autochthonous cases, whose transmission form has not been fully elucidated, and vector transmission cannot be ruled out, as well as other less common forms of transmission. For case 1, it is suggested that it is an allochthone case, probably imported from the Uruguaiana region, where the disease is endemic. The conduct of a positive result for CVL is euthanasia, with the exception of dogs that have guardians who wish to perform treatment, but not always possible due to the high cost of miltefosine, the only drug approved for dog therapy in Brazil. In the first case, the owner opted for euthanasia, since in 2016 there was no possibility of treatment. For the last two cases, a treatment cycle was performed as recommended by the guidelines. Regarding the municipality of Curitibanos, in the first case diagnosed in 2016, the animal came from Uruguaiana. In conclusion, this study aimed to report the clinical and epidemiological characteristics related to the first three patients with CVL reported in Curitibanos.

Introduction: The laryngeal mask is used with the aim of increasing quality, safety, and care; however, despite having universal use and high efficacy for ventilation, this mask is not without complications. The objective of this research was to identify the frequency of complications associated with the use of a laryngeal mask in the Vicente Corral Moscoso and Jose Carrasco Public Hospitals in the City of Cuenca. Methods: This study was an observational, descriptive, prospective study involving 220 pediatric patients, classified as American Society of Anesthesiologists (ASA) I, II, or III from all medical specialties who underwent elective and emergency surgeries, required general anesthesia lasting for 30 to 240 minutes, and received different types of masks. The sample was obtained by applying the formula for an unknown population in which n = (Z2 x p x q)/e2), 95% confidence level (1.96), and a margin of error (e) of 5%. The probability of occurrence of the event (p) was 15%, and the probability of non-occurrence (q) was 85%. Results: Two-hundred twenty cases were enrolled in the study. The rate of laryngeal complications was 5.9%, and included frequent coughing with bloody discharge. Associated factors, such as classic mask, ages ranging from 2 to 5 years, time > 60 min, greater number of attempts, ASA > I, overweight nutritional status, and insert in formation were also evaluated. Conclusion: The laryngeal mask was validated as a device for pediatric anesthesia due to rapid learning, low failure rate, few complications, and usefulness in difficult airways. The evidence is insufficient to support the use of a cone particular device over another one.

Mesalazine is a key drug used for remission induction and maintenance therapy in inflammatory bowel disease (IBD). We sometimes encounter patients who develop allergic reactions to the drug and inevitably discontinue treatment. Of 692 patients who received mesalazine for IBD between 2014 and March 2020, 33 diagnosed with mesalazine allergy (43 episodes) were included, and their clinical manifestations were evaluated. For ten patients undergoing desensitization therapy, therapeutic outcomes were evaluated. The incidence of mesalazine allergy was 4.8%. The time from the start of oral medication to allergy onset was 10 ± 5 days for the first allergic attack and 2 ± 1 days for the second and subsequent allergic attacks. The observed clinical symptoms included fever (93%), diarrhea (26%), abdominal pain (23%), and bloody stool (12%). Drug-induced lymphocyte stimulation test was performed in 85% of the patients (28/33), and the sensitivity was 51%. Desensitization therapy with a time-dependent mesalazine granule formulation was successful in nine of the ten patients (90%), allowing them to receive 2000 mg or more of the drug. Fever was a common allergic symptom, and its presence appeared to be useful for distinguishing mesalazine allergy from exacerbation of the primary disease. Desensitization therapy was useful in patients with mesalazine allergy.

Background The synovial fluid test for alpha defensin has been reported to have an excellent performance in diagnosing periprosthetic joint infection (PJI). The purpose of this study was to evaluate the performance of the lateral flow test for synovial fluid alpha defensin by using the methods of a formal diagnostic accuracy study and to compare its performance with that of the laboratory-based alpha defensin test for PJI. Methods We conducted a diagnostic accuracy study of the index lateral flow immunoassay for synovial fluid alpha defensin relative to the reference 2013 Musculoskeletal Infection Society (MSIS) multicriteria definition of PJI. The study included a prospective multicenter cohort of outpatients with a failed hip or knee arthroplasty and a supplemental control cohort of fresh synovial fluid specimens submitted by physicians for diagnostic PJI testing. Results Among 57 patients with PJI and 248 patients without PJI in the overall prospective patient cohort, the sensitivity and specificity of the alpha defensin lateral flow test were 89.5% (95% confidence interval [CI]: 78.5% to 96.0%) and 94.8% (95% CI: 91.2% to 97.2%), respectively. The sensitivity increased to 94.3% (95% CI: 84.3% to 98.8%) after exclusion of 17 patients with grossly bloody aspirates (>1 million red blood cells/µL). Among the supplemental control cohort of fresh synovial fluid samples, including 65 samples from patients with PJI and 397 from patients without PJI, the sensitivity and specificity of the alpha defensin lateral flow test were 98.5% (95% CI: 91.7% to 100.0%) and 98.2% (95% CI: 96.4% to 99.3%), respectively. A comparison of the sensitivity and specificity of the alpha defensin lateral flow test with those of the alpha defensin enzyme-linked immunosorbent assay (ELISA) in the combined cohort did not demonstrate a significant difference in sensitivity (94.3% [95% CI: 88.5% to 97.7%] compared with 93.0% [95% CI: 87.1% to 96.7%]) or specificity (96.9% [95% CI: 95.3% to 98.1%] compared with 97.8% [95% CI: 96.4% to 98.8%]) (both p > 0.05). Conclusions The results of this study demonstrate the solid diagnostic performance of the alpha defensin test and have resulted in the U.S. Food and Drug Administration (FDA) authorization of the lateral-flow test with an intended use as an aid in the clinical diagnosis of PJI. Level of evidence Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Pythiosis is characterized most commonly by ulcerative dermatitis, mainly in the limbs of sheep and occasionally of goats. In sheep, Pythium insidiosum is also responsible for necrotizing rhinitis characterized by marked enlargement and deformity of the nasal region, severe respiratory difficulty, and bloody nasal discharge. A third form of pythiosis in sheep affects the digestive tract, involving ulceration of the esophagus, forestomachs, and abomasum. Pythiosis in sheep and goats has been reported only in Brazil where it occurs mainly in the semiarid region of the country, when animals congregate and stay for longer periods of time within or around water reservoirs. However, it has been reported as well in areas of humid environments, such as the Pantanal of Mato Grosso and in the Brazilian Cerrado. The diagnosis of the different presentations of pythiosis is based on gross and microscopic findings, coupled with detection of the agent by immunohistochemical, molecular, and/or culture-based methods.

Bin Wang,* Siyuan Jiang,* Lizhe Zhu, Wei Sheng, Yan Qiao, Huimin Zhang, Jian Zhang, Yang Liu, Na Hao, Xiaoxia Ma, Can Zhou, Yu Ren Department of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China*These authors contributed equally to this workCorrespondence: Can Zhou; Yu RenDepartment of Breast Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, 277 West Yanta Road, Xi’an, Shaanxi, People’s Republic of ChinaTel +86 13700222161Email zhoucanz2005@126.com ; renyyyyy@126.comIntroduction: Nipple discharge is a common symptom of breast disease. We aimed to perform a descriptive statistical analysis of the cases we evaluated and establish a model to predict intraductal tumors.Materials and Methods: We conducted a retrospective study of patients from 2007 to 2019. In total, 1333 patients who completed the fiberoptic ductoscopy (FDS) were evaluated. The variables were analyzed by χ2 test. Logistic regression was used to analyze the relationship between the patient’s clinical characteristics and intraductal tumors and establish a predictive model. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of the predictive ability of the model. Calibration curves and decision curve analysis (DCA) were used to evaluate the model.Results: Patients with spontaneous, single-duct, bloody discharge and a smooth ductal wall were more likely to be diagnosed with tumors by ductoscopy. A model was established based on five variables: age, side of discharge, spontaneous discharge status, duration of discharge, and color of discharge. The model was subsequently validated in 183 patients with complete data on the variables in the validation cohort. The area under the ROC curve (AUC) was calculated to be 0.716, indicating good predictive ability.Conclusion: Patients with the clinical characteristics of unilateral, bloody, single-duct, spontaneous discharge and a smooth ductal wall were more likely to have intraductal tumors by ductoscopy. Our nomogram can effectively predict intraductal tumors in patients with nipple discharge.Keywords: nipple discharge, ductoscopy, nomogram, breast tumor

Background Acute severe ulcerative colitis (UC) is a potentially life-threatening presentation and requires coordinated multi-disciplinary management. The aim of our prospective audit was to evaluate the inpatient management and outcome of patients with UC. Methods All consecutive patients admitted to Aberdeen Royal Infirmary for treatment of acute UC were prospectively recruited in the study over a 6 months period. All patients were followed up for a minimum of 3 months from the discharge date. Patient’s demographics, clinical data, endoscopic assessment, medical and surgical treatment details were collected. The clinically significant outcome was defined as steroid treatment failure requiring surgery or rescue therapies (ciclosporin or infliximab) despite intravenous steroid therapy. Statistical comparisons were made using Non-parametric Mann-Whitney test and Fishers Exact test. Results 27 patients (15 females; median age 41 years (IQR 31–63)) were admitted for treatment of UC during the 6 months period. 23 patients had severe UC as per Truelove and Witts Score. 19 patients had pre-existing diagnosis of UC prior admission. Faecal calprotectin was checked in 3 patients and were all >1000 ug/g. All patients received a minimum of 3 days of intravenous steroid. 10 patients were non-responsive to steroid therapy. 3 patients received rescue infliximab while 1 patient received ciclosporin. 7/27 (26%) required in-patient colectomy during the study period. Previous diagnosis of UC, previous admission or mesalazine use were not associated with steroid treatment failure. Only bloody stool frequency at Day 3 had a statistically significant association (p=0.03). The median (IQR) bloody stool frequency was 5 (1.8–10.3) for those who were in the steroid failure group compared to 3 (0–3) for those in the steroid responder group. Conclusions In our prospective study, the in-hospital colectomy rate was 7/27 (26%) for acute presentation of UC. Systemic oral steroid use prior to admission was associated with steroid treatment failure but was not statistically significant (p=0.05). Future study with a larger sample size could perhaps identify more clinical and laboratory variables that could be useful to stratify patients at risk of steroid failure.

Background Underwater endoscopic mucosal resection (UEMR) is a recently developed technique and is performed during water-aided colonoscopy for the treatment of colorectal polyps. The objective of this clinical trial was to evaluate the efficacy and safety of UEMR in comparison with conventional endoscopic mucosal resection (CEMR) of diminutive non-pedunculated colorectal polyps. Methods Patients with small size, non-pedunculated colorectal polyps (4–9 mm in size) who underwent colonoscopic polypectomy were enrolled in this multicenter randomized controlled clinical trial. The patients were randomly allocated to two groups, an UEMR group and a CEMR group. Efficacy and safety were compared between groups. Results In the intention-to-treat (ITT) analysis, the complete resection rate was 83.1% (59/71) in the UEMR group and 87.3% (62/71) in the CEMR group (P = 0.478). The en bloc resection rate was 94.4% (67/71) in the UEMR group and 91.5% (65/71) in the CEMR group (P = 0.512) (table 1). Immediate bleeding was observed in 1.4% of patients in the CEMR group (1/71) and 1.4% of patients in the UEMR group (1/71). None of the patients in the UEMR group complained of postprocedural bloody stool, whereas two patients in the CEMR group (2/71) reported this adverse event. Conclusions Our results indicate that UEMR is safer and just as effective as CEMR for the treatment of small colorectal polyps as such, UEMR is recommended as an alternative approach to excising small and non-pedunculated colorectal adenomatous polyps.

The conclusion returns to the poetics, aesthetics and politics of blood, showing that there are many different blood types in the poetics of horror made by women, but that each drop contains a world of pain, sorrow, and rage but also laughter and wonder, consolation and insight; each gush embodies a world of stories to convey, wisdom to impart and emotions to share. The overarching pattern is that female directed horror often addresses inner demons and extends the emotional spectrum of the genre beyond fear and disgust, and stretches the genre boundaries to introduce a poetics of horror in many different genres.

Fungating malignant lesions pose a huge deal of agony to the patients. Their management is also deemed as difficult by most physicians. This report describes a case of a 45-year-old paraplegic female with delayed presentation of a very aggressive fungating left breast mass, which was diagnosed as invasive ductal carcinoma. The uncontrollable hemorrhage had the surgeons succumb to the option of emergency mastectomy as a palliative treatment to save the life of the patient. Hence, we infer that the emergency mastectomy in a hemorrhagic fungating breast lesion can be life-saving and can be performed with little to no risk to the patient. Such a procedure, surprisingly, has never been documented in the surgical literature before.

1. Mohini Bollineni, MBBS* 2. Ruban Dhaliwal, MD, MPH* 3. Aditi Khokhar, MBBS† 1. *Division of Endocrinology, Department of Medicine, 2. †Division of Pediatric Endocrinology, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY A 3-year and 7-month-old girl presents to endocrine clinic with vaginal bleeding. She has had diffuse hyperpigmented flat lesions on the right half of her body since birth, breast enlargement for 2 weeks, and vaginal bleeding noted as bright red bloody discharge on urination for 3 days. Her birth length was at 75th percentile. She has been growing along 90th to 95th percentile since age 3 months. Her current height velocity is 9.3 cm per year. Her weight is at the 95th percentile. She does not have hearing or vision problems, bone pain, or headaches. There is no family history of early puberty. Mid-parental height is 67.4 in (89th percentile). On physical examination, her vital signs are normal for age. She has breast buds (Tanner 2 breast) bilaterally and Tanner 1 pubic hair. Large diffuse cafe-au-lait lesions are present on the right half of body including the right chest and trunk, extending inferiorly to the right upper leg and superiorly to the nape of neck. The lesions have irregular borders and are limited to the midline. There is no axillary freckling. She does not have any facial or skeletal deformities. The remainder of the physical examination is unremarkable. The laboratory values (listed in Table 1) reveal luteinizing hormone and follicle-stimulating hormone levels in prepubertal range with a low estradiol level. Growth hormone (GH) and insulin-like growth factor (IGF-1) levels are high for age. Serum prolactin …

Introduction Acute bloody diarrhoea is associated with E.Coli enterocolitis, progressing to haemolytic uraemic syndrome (STEC-HUS) in 10–15% of cases. Health Protection Scotland (HPS) guidelines recommend commencing pre-emptive IV fluids in children with acute bloody diarrhoea and high risk features until an E.Coli result is known to reduce progression and severity of STEC-HUS. The service impact of this change is unknown. Aims Establish baseline annual presentation rate of children with acute bloody diarrhoea to RHC, Glasgow Evaluate management of children eligible for pre–emptive IV fluids prior to guideline implementation Estimate service impact of guideline implementation Methods A microbiology search identified all stools sent from RHC (ED/CDU) between 1/3/18–1/3/19. Children with acute bloody diarrhoea and high risk features were identified by screening records of patients with bloody/diarrhoeal samples. Data regarding management/diagnosis was extracted. CMPI and IBD cases were excluded. Results 55 patients had acute bloody diarrhoea (9% of 577 stool samples). 8 CMPI and 7 IBD cases were excluded. Of the remaining 40, 29 had high risk features meeting criteria for pre-emptive IV fluids. 32 had blood tests and 24 had urinalysis. Of 29 high risk patients, 22 (76%) were admitted for an average of 2 days (excluding HUS) and 7 (24%) were not admitted. 14 (47%) received IV fluids >24 hours and 8 (28%) were discharged before 24 hours. 22 (76%) grew a bacterial pathogen (E.Coli (n=4), Campylobacter (n=15), Salmonella (n=3)) and 3 (10%) developed STEC-HUS. Mean time to stool culture result was 47.8 hours. Of 11 without high risk features, 1 grew a bacterial pathogen (Campylobacter). Conclusion In this cohort, implementing HPS guidelines would necessitate 22 additional inpatient hospital days for IV fluids, 8 additional blood tests and 16 additional urinalysis tests. High risk features appear sensitive for pathogenic bloody diarrhoea and captured all STEC-HUS/E.Coli cases.

Introduction Amoebiasis is a parasitic infection caused by a protozoan called Entamoeba Histolytica (EH). It is responsible for up to 100,000 deaths every year worldwide. Only a handful of cases of neonatal and infantile amoebiasis has been reported. Aims To highlight the incidence of this infection in the neonatal age group. To demonstrate the use of rapid antigen detection as a tool for diagnosis in areas with limited resources. Methods A total of six babies presented to the Neonatal Intensive Care Unit (NICU) over a period of 24 months. All of them but one shared a universal symptom of passing stool mixed with fresh blood. The first baby was born at 25 weeks of gestation. At the age of 2 weeks, he developed bloody stool associated with abdominal distension. He could not maintain adequate spontaneous breathing effort. Therefore, he had to be ventilated. Other two babies were preterm babies born at 26 and 25 weeks. However, they developed the infection at a corrected gestation of 38 and 44 weeks respectively. They remained well with no other associated symptoms. The other two babies were term well babies. They were reported to pass fresh blood mixed with their stool shortly after birth while on the postnatal ward. Interestingly, with one of these two babies, there was a history of confirmed neonatal amoebiasis with his older sibling. The sibling was born two years ago in a different country. The last baby was born at 23 weeks and 6 days of gestation. He developed small bowel perforation as a complication of Necrotising Enterocolitis. His infection has manifested by sudden increase in his ileostomy output associated with raised C-reactive protein. The diagnosis of amoebiasis was confirmed by the detection of EH antigens in stool (chromatographic immunoassay) in all babies. Conclusion Neonatal amoebiasis appears to be commoner than previously reported. In areas with high prevalence, It should be suspected in babies presenting with passing fresh blood in their stool. The diagnosis may be reliably made using rapid EH antigen detecting test.

Complete response of non–small cell lung cancer (NSCLC) with immune checkpoint inhibitor (ICI) monotherapy is rare. Here, we encountered an elderly patient who showed complete response of NSCLC following treatment with pembrolizumab. An 84‐year‐old man with a history of bloody sputum for several weeks visited a general physician. At that time, a chest X‐ray revealed a tumor shadow in the left middle lung field, and the patient was referred to our hospital. Following transbronchial biopsy, he was diagnosed with squamous cell carcinoma of the lung. Expression of programmed death ligand 1 (PD‐L1) in tumor cells was 80% or more by immunostaining. Based on the above, immunotherapy with pembrolizumab was performed as first‐line therapy. The cancer cells completely disappeared at the end of the fifth cycle. There were no side effects during the therapeutic course. Treatment with pembrolizumab continued for two years and was then discontinued at the patient's request. Since then, no tumor recurrence has been detected for about one and a half years without treatment. There have been few reports of lung cancer disappearing after treatment with pembrolizumab. In conclusion, in elderly NSCLC patients with PD‐L1 expression of 50% or more, pembrolizumab should be considered as first‐line treatment with the treatment period, and mechanism suggested in this report., Here, we present a case of an elderly patient who had a complete response of non–small cell lung cancer (NSCLC) following treatment with pembrolizumab. The complete response was maintained for one and a half years after discontinuation of two years of treatment. In elderly patients with NSCLC with PD‐L1 expression of more than 50%, pembrolizumab should be considered as first‐line treatment with the treatment period, and mechanism suggested in this report.

Introduction Published trials of intrapleural therapy for complex pleural effusions rely on fibrinolytics and deoxyribonuclease (DNase) with dwell times of less than six hours and frequent dosing. We reviewed our experience with fibrinolytics alone but with a longer dwell time (12 hours). Methods Tissue plasminogen activator (tPA, 1-6 mg per dose) was given through pigtail catheters placed using image guidance. Planned treatment was for a dwell time of 12 hours with repeat dosing daily for three days or until drainage was less than 100 cc or grossly bloody. Chest x-ray and/or computed tomography (CT) were used to determine completeness of pleural drainage. Results Forty-six patients presenting with 47 complex pleural effusions were given 131 doses of tPA. Doses of 4, 5, and 6 mg were most common (n=17, 70, and 33, respectively). Dwell time ranged from five to 14 hours with 12 hours being most common (n=115). Additional chest tubes were placed in 18 effusions. Ten effusions (21%) required decortication: seven for trapped lung and three for incomplete drainage. Drainage was considered complete in 33/40 (82.5%) effusions without trapped lung. Median chest tube duration was seven days (range three to 28 days). tPA therapy was discontinued in two patients for bleeding, but neither experienced hemodynamic instability. Conclusions tPA with a 12-hour dwell time is effective and safe for management of complex pleural effusions, although chest tube duration was prolonged. tPA alone is less expensive and easier than when combined with DNase, and this strategy warrants a prospective evaluation.

An 81-year-old male patient presented to the department of gastroenterology with increasing lower abdominal pain for 2 years, aggravated with bloody stool for 1 month. Computed tomographic examination revealed a huge cyst (207 × 93 × 208 mm3) in the abdominal cavity, absence of bladder, thickening and strengthening of the rectal wall, and benign prostatic hyperplasia. Colonoscopy showed colon cancer and surgery was planned. Interestingly, after magnetic resonance imaging and cystography, we found colon cancer and a large bladder diverticulum rather than tumor metastasis or others. Severe bacteremia occurred in the elderly chronic obstructive pulmonary disease patient before operation. After careful consideration, we decided to take a large risk and combined urology and gastrointestinal surgery professionals to carry out bladder diverticulectomy, cystostomy, radical resection of rectal carcinoma, and so on. Fortunately, the patient recovered well after the operation. In addition to the common tumor metastasis and cystadenoma, the abdominal mass should also be alert to the rare bladder diverticulum, which eventually leads to diagnostic confusion. Multidisciplinary diagnosis and treatment has become an important treatment for complex diseases.

Post-pancreaticoduodenectomy hemorrhage is a life-threatening complication that occurs in 2-10% of patients. The most common location for post-pancreaticoduodenectomy hemorrhage is the gastroduodenal artery stump. Nonetheless, unusual sources of hemorrhage, which are hard to locate, exist. Here, we report a rare postoperative hemorrhage after robotic-assisted pancreatoduodenectomy for pancreatic head cancer. A 67-year-old man presenting with appetite loss, general fatigue and painless jaundice was admitted to our ward. The patient had an elevated level of carbohydrate antigen 19-9 (50 U/mL). Computed tomography scan revealed a 17-mm wide low-density area in the uncinate process of the pancreas. Magnetic resonance cholangiopancreatography showed the dilation of bile and pancreatic ducts. Robotic-assisted pancreaticoduodenectomy was performed on the patient by using the da Vinci Model S Surgical System. On postoperative days 5 and 6, the patient vomited blood, and bloody fluid was observed in the drainage. Emergent gastroscopic examination was performed and revealed a large amount of hematocele in the stomach. On postoperative day 6, emergency operation was undertaken, and the output jejunal loop was found to have intussuscepted in the stomach. This is the first case report of output jejunal loop intussusception in the stomach that consequently caused hemorrhage after robotic-assisted pancreaticoduodenectomy for pancreatic head cancer.

Intestinal myiasis caused by fly larvae parasitic in gastrointestinal tract was rare reported in children. We reported an infant with bloody diarrhea caused by intestinal myiasis. A 1 year and 7 months old boy presented with the only symptom of bloody diarrhea of unknown origin. In the second week of onset, numerous moving worms were observed in the bloody stool after bowel preparation with polyethylene glycol for colonoscopy. The bloody diarrhea disappeared after 1 week of combined therapy with albendazole and metronidazole. On follow-up after 6 months, the patient remained well without bloody diarrhea. In conclusion, intestinal myiasis being a rare disease that is very challenging to diagnose, physicians should remember it when they receive cases of bloody diarrhea with non-specific symptoms without any apparent cause.

Key message Multiple patchy pulmonary consolidations that are unresponsive to antibiotics and/or exist at peri‐bronchial sites and bloody bronchoalveolar lavage may effectively help clinicians diagnose granulomatosis with polyangiitis., Multiple patchy pulmonary consolidations that are unresponsive to antibiotics and/or exist at peri‐bronchial sites and bloody bronchoalveolar lavage may effectively help clinicians diagnose granulomatosis with polyangiitis.

Background: To investigate the expressions of fibrinogen (Fib) and Interleukin-12 (IL-12) in serum of neonatal necrotizing enterocolitis (NEC), and to analyze the correlation between the two and their relationship with clinicopathological features. Methods: Forty two children with NEC treated in Xuzhou Children’s Hospital, Xuzhou Medical University Xuzhou, China from 2016-2019 were selected as an observation group and 40 children who underwent physical examination at the same period as a control group. The expression levels of Fib and IL-12 in the serum of two groups were detected by ELISA. The correlation between Fib and IL-12 in the observation group and the correlation among the expressions of Fib, IL-12, the clinicopathological features and common examination indexes of the children with NEC were investigated by Pearson correlation analysis. Results: The levels of Fib and IL-12 in the serum of the children in observation group were significantly higher than those in the control group were (P

Background Previous studies have provided initial data suggesting that small-bore (SB, ≤ 14Fr) chest tubes have the same efficacy as large-bore (LB, > 14 Fr) chest tubes for acute hemothorax (HTX), but data continue to be lacking in the setting of delayed HTX. This study compared complications of SB chest tubes to LB tubes in patients with delayed HTX. Methods This was a retrospective observational study across 7.5 yrs. at 6 Level 1 trauma centers. Patients were included if 1) diagnosed with a HTX or > 1 rib fracture with bloody effusion from chest tube; 2) initial chest tube placed ≥36 h of hospital admission. Patients were excluded for hemopneumothoraces. The primary endpoint was having at least one of the following chest tube complications: tube replacement, VATS, tube falling out, tube clogging, pneumonia, retained HTX, pleural empyema. Secondary outcomes included chest tube output volume and drainage rate. Dependent/independent and parametric/non-parametric analyses were used to assess primary and secondary outcomes. Results There were 160 SB patients (191 tubes) and 60 LB patients (72 tubes). Both comparison groups were similar in multiple demographic, injury, clinical features. The median (IQR) tube size for each group was as follows: SB [12 Fr (12–14)] and LB [32 Fr (28–32)]. The risk of having at least one chest tube complication was similar for LB and SB chest tubes (14% vs. 18%, p = 0.42). LB tubes had significantly larger risk of VATS, while SB tubes had significantly higher risk of pneumonia. SB tubes had significantly slower least squares (LS) mean initial output drainage rate compared to LB tubes (52.2 vs. 213.4 mL/hour, p p = 0.81. LB and SB groups had similar initial output volume (738.0 mL vs. 810.9, p = 0.59). Conclusions There was no clearly superior chest tube diameter size; both chest tube sizes demonstrated risks and benefits. Clinicians must be aware of these potential tradeoffs when deciding on the diameter of chest tube for the treatment of delayed HTXs.