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ImportanceTherapy for advanced melanoma has transformed during the past decade, but early detection and prognostic assessment of cutaneous melanoma (CM) remain paramount goals. Best practices for screening and use of pigmented lesion evaluation tools and gene expression profile (GEP) testing in CM remain to be defined.ObjectiveTo provide consensus recommendations on optimal screening practices and prebiopsy diagnostic, postbiopsy diagnostic, and prognostic assessment of CM.Evidence reviewCase scenarios were interrogated using a modified Delphi consensus method. Melanoma panelists (n = 60) were invited to vote on hypothetical scenarios via an emailed survey (n = 42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45).FindingsThe panelists reached consensus (≥70% agreement) in supporting a risk-stratified approach to melanoma screening in clinical settings and public screening events, screening personnel recommendations (self/partner, primary care provider, general dermatologist, and pigmented lesion expert), screening intervals, and acceptable appointment wait times. Participants also reached consensus that visual and dermoscopic examination are sufficient for evaluation and follow-up of melanocytic skin lesions deemed innocuous. The panelists reached consensus on interpreting reflectance confocal microscopy and some but not all results from epidermal tape stripping, but they did not reach consensus on use of certain pigmented lesion evaluation tools, such as electrical impedance spectroscopy. Regarding GEP scores, the panelists reached consensus that a low-risk prognostic GEP score should not outweigh concerning histologic features when selecting patients to undergo sentinel lymph node biopsy but did not reach consensus on imaging recommendations in the setting of a high-risk prognostic GEP score and low-risk histology and/or negative nodal status.Conclusions and relevanceFor this consensus statement, panelists reached consensus on aspects of a risk-stratified approach to melanoma screening and follow-up as well as use of visual examination and dermoscopy. These findings support a practical approach to diagnosing and evaluating CM. Panelists did not reach consensus on a clearly defined role for GEP testing in clinical decision-making, citing the need for additional studies to establish the clinical use of existing GEP assays.

Abstract Introduction Subacute adult‐acquired hemichorea is a striking presentation with a broad differential, including ischemic, metabolic, and inflammatory causes. Case We encountered a 74‐year‐old woman with rapid onset of hemichorea and associated encephalopathy. Following a thorough workup without identification of clear imaging or laboratory abnormalities, we empirically treated with IVIg. Her hemichorea dramatically improved. Due to relapses of hemichorea, she required repeat immunotherapy with IVIg or high dose steroids followed by maintenance mycophenolate. Discussion This case of seronegative autoimmune hemichorea highlights the importance of a high index of suspicion for an inflammatory etiology of chorea when other causes are ruled out and performing an immunotherapy trial.

Objective: The best approach to minimize the observed higher mortality of newborn infants with low birth weight who require congenital heart surgery is unclear. This retrospective study was designed to review outcomes of newborn infants weighing 3500 g at surgery were excluded. Results: Median age was 24 days and weight at the time of surgery was 1920 g. Twenty-six (25%) operative mortalities were recorded. Median follow-up period was 2.7 years. The 1- and 3-year overall Kaplan-Meier survival estimate was 72.4% ± 4.5% and 69.1% ± 4.6%. The 1-year survival of patients who had a weight increase >300 g from birth to surgery was far superior to the survival of those who did not achieve such a weight gain (81.4% ± 5.6% vs 64.0% ± 6.7%; log-rank P = .04). By multivariable Cox-hazard regression analysis, the independent predictor of 1-year mortality was genetic syndrome (hazard ratio, 3.54; 95% CI, 1.67-7.82; P

Professor Moises A [...]

This case study discusses the factors that led to the speech delay of Kendrick Veriel Surbakti, a six-year-old child, and his spoken language. This case study uses a qualitative method with the type of intrinsic case studies by understanding individual problems. This case study observes in depth by means of direct observation and interviews of the informants concerned. The results showed that the factors of Kendrick's speech and oral language delay included the condition of the family environment, social and cultural environment, lack of verbal stimulation in the surrounding environment as well as shyness to talk to others and the use of gadgets. And from the results of the case study that has been conducted, Kendrick is only able to pronounce 2 to 4 words consecutively and the pronunciation of consonant letters is less precise when speaking.

Introduction: Gram-negative bacteria have developed a broad spectrum of resistance due to antibiotic degradation enzymes, including Extended-spectrum Beta-lactamases (ESBL), AmpC β-lactamases, and carbapenemases. Carbapenemase-producing organisms, such as Escherichia coli, Klebsiella species, Acinetobacter species, and Pseudomonas species, have become one of the most important causes of nosocomial and community-acquired infections. Aim: To identify carbapenemase-producing organisms among Multidrug-resistant (MDR) clinical isolates and detect Metallo β-Lactam Carbapenemases (MBL). Materials and Methods: The present study is a cross-sectional study that included 1266 clinical samples from patients visiting the Department of Microbiology, Ranagaraya Medical College, Kakinada, Andhra Pradesh, India. from July 2022 to December 2022. The samples were processed using the standard culture and antimicrobial susceptibility test, employing the Kirby-Bauer Disk Diffusion method. The present study included organisms that were resistant to either imipenem or meropenem. Carbapenemases were detected using the Modified Hodge test (MHT), and MBL carbapenemases were detected using the Imipenem Ethylene Diamine Tetraacetic acid (EDTA) Double Disk Test (DDT) following the guidelines of the Clinical and Laboratory Standards Institute (CLSI). Descriptive statistics were performed on the collected data. Results: The study samples comprised 842 (66.5%) Gram-negative isolates and 424 (33.5%) Gram-positive isolates. Among the Gram-negative isolates, 80 (9.5%) were carbapenem-resistant, of which MHT showed 56 (70%) positive isolates (carbapenemase-producing) and 24 (30%) negative isolates. Imipenem-EDTA DDT showed 50 (62.5%) positive isolates (MBL-producing) and 30 (37.5%) negative isolates. Conclusion: Carbapenemase production in Gram-negative organisms has reduced the clinical utility of the carbapenem group of drugs, posing a major challenge in the treatment of severe infections. In summary, the majority of carbapenem-resistant isolates in the present study were from the Enterobacteriaceae family. These isolates were subjected carbapenem-resistant isolates to MHT and DDT tests to identify carbapenemase and metallo-beta-lactamase-producing strains that were resistant to a wide spectrum of antibiotics. The present study enables the early detection of these MDR strains, ensuring appropriate management.

Groundwater dependency has increased due to several factors like population increase, industrialization, and climate change impact. Analysis of groundwater is important to know the present status and also for better management of natural resources. Groundwater samples from 41 locations were collected along the study area during the pre and post-monsoon seasons, and samples were analysed for pH, EC, total dissolved solids (TDS), major cations, and anions like Ca2+, Mg2+, Na+, K+, Cl−, HCO3− and SO42−. From the chemical analysis results, seawater intrusion is identified through qualitative approaches, i.e., Simson ratio (Cl/(HCO3 + CO3) and Na/Cl ratio. Simson ratio ranges between 0.316 to 2.119 during pre-monsoon and 0.124 to 3.947 during post-monsoon, and from Na/Cl ratio, 30 samples fell under seawater intrusion during pre-monsoon and 38 samples during post-monsoon. The Simpson ratio results also show that seawater intrusion is reducing during the post-monsoon due to increasing groundwater levels caused by rains. From the water quality index classification, 4.88% of the water samples fell under excellent in both seasons, and the rest of the samples were all in the remaining four classes. The spatial analysis was also done to understand the changes in groundwater quality and seawater intrusion over space. HIGHLIGHTS Assessment and status of groundwater quality in the coastal area.; Factors controlling groundwater quality in the study area.; Analysis of seawater intrusion risk assessment.; Identification of water suitability for drinking purposes.; Spatial analysis for identification of areas under threat.;

Key Clinical Message This case demonstrates an atypical presentation of choledochal cysts (CDCs) and elaborates on the diagnostic challenges encountered when presented with CDCs in adulthood, as it principally presents in children. Abstract A choledochal cyst is a rare congenital anomaly characterized by cystic dilations in the extrahepatic and intrahepatic biliary trees. These cysts are classified according to their location and characteristics. This case study aims to demonstrate how nonspecific clinical features can pose a diagnostic dilemma when presented in adults. Additionally, the case report provides an overview of diagnostic methods and treatment options. In this case, we discuss a 50‐year‐old female who presented with a 2‐ to 3‐day history of severe colicky pain in the right upper quadrant of her abdomen without any other symptoms or abnormal laboratory tests. In addition to ultrasonography evidence of CBD dilation and cholelithiasis, MRCP results confirmed the diagnosis. She underwent surgical intervention involving cyst excision, a Roux‐en‐Y hepatojejunostomy, and a cholecystectomy. The postoperative period was without significant complications. The case presented here illustrates the potential outcomes for individuals who present with choledochal cysts during adulthood. Often, these cases present with vague symptoms or as the underlying cause of a more severe condition. This case contributes to the existing knowledge of choledochal cysts by providing insight into the clinical presentation, diagnostic methods, and treatment options.

OBJECTIVES/GOALS: Artificial Intelligence (AI) is gaining popularity in a variety of disciplines. While clinical applications for AI have increased in recent years, the use of AI in pediatric congenital heart disease (CHD) is limited. The goal of this systematic review was to assess how AI is currently used in this patient population and to describe knowledge gaps. METHODS/STUDY POPULATION: A systematic search was performed up to July 2023 using PubMed and Scopus databases and revealed 814 articles. Upon initial screening, 161 duplicates, 76 non-AI articles, and an additional 318 irrelevant articles were removed. A total of 259 full-text articles were reviewed for relevance. Articles that did not include a retrospective or prospective review of human subject data were excluded. Articles that had only results in the adult, prenatal, or non-CHD population were excluded. The remaining 68 articles were included in this review. RESULTS/ANTICIPATED RESULTS: Of the 68 articles in this review, 19 were performed within cardiac surgery, 41 were within cardiology, and the remaining 8 included articles were combined cardiac surgery and cardiology. Upon initial review, 24 used AI for diagnostic purposes, 40 for predicting survival or adverse outcomes, 2 for developing training tools, and 2 for surveillance of CHD trends. We anticipate that upon further review of these 68 articles, there will be a wide variety in the types of AI models that were used. The results will reveal a multitude of challenges and limitations that future studies will need to further address. DISCUSSION/SIGNIFICANCE: While technical innovations in pediatric CHD have dramatically improved survival rates, we have hit a plateau in improving the complications of these patients. AI has created an opportunity to build new diagnostic, predictive, teaching, and surveillance tools for advancing CHD care, but it seems we still have a long way to go.

ABSTRACTThe gut is a major source of bacteria and antigens that contribute to neuroinflammation after brain injury. Colonic epithelial cells (ECs) are responsible for secreting major cellular components of the innate defense system, including antimicrobial proteins (AMP) and mucins. These cells serve as a critical regulator of gut barrier function and maintain host-microbe homeostasis. In this study, we determined post-stroke host defense responses at the colonic epithelial surface in mice. We then tested if the enhancement of these epithelial protective mechanisms is beneficial in young and aged mice after stroke. AMPs were significantly increased in the colonic ECs of young males, but not in young females after experimental stroke. In contrast, mucin-related genes were enhanced in young females and contributed to mucus formation that maintains the distance between the host and gut bacteria. Bacterial community profiling was done using universal amplification of 16S rRNA gene sequences. The sex-specific colonic epithelial defense responses after stroke in young females were reversed with ovariectomy and led to a shift from a predominately mucin response to the enhanced AMP expression seen in males after stroke. Estradiol (E2) replacement prior to stroke in aged females increased mucin gene expression in the colonic ECs. Interestingly, we found that E2 treatment reduced stroke-associated neuronal hyperactivity in the insular cortex, a brain region that interacts with visceral organs such as the gut, in parallel to an increase in the composition of Lactobacillus and Bifidobacterium in the gut microbiota. This is the first study demonstrating sex differences in host defense mechanisms in the gut after brain injury.

ImportanceUse of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care.ObjectiveTo develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies.Evidence reviewThe MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed.FindingsThe MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility.Conclusions and relevanceMore evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.

Turmeric, known as “The golden spice” in India, is prized for its curcumin pigment, offering various uses as a food preservative, spice, and coloring agent. Its medicinal potential is gaining global recognition. A total of 24 turmeric genotypes were evaluated at Medicinal and Aromatic Plants Research Station, Anand Agricultural University, Anand, Gujarat. Significant genetic diversity among the genotypes was revealed through multivariate analysis of variance (MANOVA). Discriminant function analysis and selection indices were employed to improve grain yield and other important traits in turmeric. The results showed that selecting multiple traits simultaneously through a selection index yields higher genetic gain compared to selecting single traits. The comparison of selection efficiency for different trait combinations demonstrated an increase in selection efficiency with an increasing number of traits. The highest selection efficiency was observed when all six attributes were considered. The study identified the most effective four trait combination, comprising curing percentage, leaf oil percentage, rhizome oil percentage and fresh rhizome yield per plant, for enhancing grain yield in turmeric. The best-performing genotype, ATG-17, showed promise for future breeding activities.

IgG4-related disease-associated hypertrophic pachymeningitis (IgG4RD-HP) is a fibroinflammatory autoimmune disorder in which diagnosis is difficult without biopsy. Guidance on management of disease refractory to glucocorticoids and intravenous rituximab is limited. We present the case of a 68-year-old woman with IgG4RD-HP who developed sensorineural hearing loss with associated bulky basilar pachymeningeal enhancement. Her cerebrospinal fluid was inflammatory and had an elevated IgG4 concentration, strongly suggestive of IgG4RD-HP. Biopsy of involved meninges was not possible due to surgical risk. Over years she developed bilateral optic neuropathies and hydrocephalus, requiring intravenous rituximab and ventriculoperitoneal shunt. Her disease was refractory to glucocorticoids. Despite maintenance intravenous rituximab, she developed slowly progressive symptoms of intracranial hypertension and hydrocephalus with persistently inflammatory spinal fluid. Switching to intrathecal rituximab therapy led to dramatic improvement in gait and headache and reduced pachymeningeal bulk and metabolic activity. In patients with IgG4RD-HP refractory to glucocorticoids and intravenous rituximab, intrathecal rituximab may be an efficacious therapy.