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When resecting the internal jugular veins bilaterally in surgery for head and neck cancer, it is necessary to perform neck dissection in two stages or to reconstruct the internal jugular veins in one stage. Reconstruction of the internal jugular vein using grafting or direct anastomosis to the external jugular vein have both been reported. We report the case of a 53-year-old man with accidental injury to the left internal jugular vein after resection of the right internal jugular vein for supraglottic cancer. The left internal jugular vein was damaged near the inflow of the subclavian vein, making vein grafting difficult. Therefore, internal jugular venous return was reestablished by end-to-side anastomosis of the left internal jugular vein to the left external jugular vein system. In this surgical procedure, by incising the internal jugular vein obliquely, it was not necessary to match the calibers of the internal jugular vein and the external jugular vein system, and a smooth hemodynamic body was reconstructed. In addition, we were able to reconstruct the internal jugular vein while preserving blood flow in the external jugular vein system. End-to-side anastomosis of the internal jugular vein to the external jugular system is an option for internal jugular vein reconstruction.

Congenital nephrogenic diabetes insipidus (CNDI) is a rare disease that results in polyuria due to decreased responsiveness to the antidiuretic hormone in the collecting ducts of the kidney. Without compensation by drinking large amounts of water, dehydration and hypernatremia can rapidly develop. We present a case of a patient originally diagnosed with CNDI who required surgery and a fasting period due to adhesive bowel obstruction. The patient was a 46-year-old man who was originally diagnosed with CNDI. He was prescribed trichlormethiazide but self-discontinued treatment in the process. His normal urine output was about 7,000–8,000 mL/day. He underwent robot-assisted radical cystectomy and uretero-cutaneostomy for bladder cancer. Two years later, he was hospitalized due to adhesive bowel obstruction. A 5% glucose solution was infused, and the dose was adjusted according to the urine volume and electrolytes. An adhesiotomy was performed due to recurrent bowel obstruction in a short period of time. A 5% glucose solution was used as the main infusion during the perioperative period. Once drinking water was resumed after surgery, urinary output and electrolytes were easily controlled. In conclusion, patients with CNDI should be given a 5% glucose solution as the primary infusion, and the infusion volume should be adjusted by monitoring daily urine output, electrolytes, and blood glucose levels. Infusion management is easier if oral intake is initiated as early as possible.

Cesarean section can lead to residual myometrial thickness thinning and cesarean scar syndrome. We report a novel trimming technique for residual myometrial thickness recovery in women with cesarean scar syndrome. Case 1: A 33-year-old woman who developed cesarean scar syndrome (CSS) and abnormal uterine bleeding post-cesarean scar became pregnant following hysteroscopic treatment. The myometrium at previous scar was dehiscent; therefore, a transverse incision was made above the scar. Post-operative uterine recovery failed owing to lochia retention, and developed cesarean scar syndrome again. Case 2: A 29-year-old woman who developed cesarean scar syndrome post-cesarean section became pregnant spontaneously. The myometrium at the previous scar was dehiscent like case 1. Scar repair was performed using a trimming technique during cesarean section; there were no subsequent complications and she conceived again spontaneously. Performing this novel surgical procedure during cesarean section may contribute to residual myometrial thickness recovery in women with cesarean scar syndrome.

Garré’s osteomyelitis, first described by Carl Garré in 1893, is a type of chronic osteomyelitis accompanied by hyperplastic periostitis. This condition affects relatively young patients and occurs in the fibula, femur, and other long bones as chronic non-purulent sclerosing osteomyelitis. Further, reactive periosteal bone formation develops due to chronic irritation or infection. In the maxillofacial region, it often occurs in the first molar region of the mandible due to caries and other similar causes, and it is rarely associated with impacted teeth. Herein, we present a 12-year-old female patient who primarily complained of swelling on the right side of the mandible. Despite taking antibiotics prescribed at local otolaryngologist, the swelling did not completely resolve. Thus, the patient was referred to the Department of Otorhinolaryngology at our hospital, where a dental-related disease was suspected. On a computed tomography scan, radiolucent findings were observed around the germ of the impacted wisdom tooth as well as hyperostosis in the lower jaw. Thus, Garré’s osteomyelitis was suspected. The patient received oral anti-inflammatory treatment by the incision prior to surgery. Thereafter, the tooth germ was enucleated and newly-formed bone, which was laterally located to the cortical bone of the mandible, was removed under the effect of general anesthesia. On computed tomography scan 9 months after the surgery, hyperostosis in the angle of the mandible disappeared. Thereafter, pain and swelling did not recur, and the patient was doing well.

Posterior reversible encephalopathy syndrome (PRES) is characterized by transient vasogenic edema predominantly in supratentorial areas within the posterior circulation regions. Although PRES with only brainstem involvement is quite rare, accurate diagnosis is important because prompt antihypertensive therapy contributes to a favorable outcome. Herein, we report a case with isolated brainstem PRES showing dramatical improvement in an apparent diffusion coefficient (ADC) value of the lesion in magnetic resonance imaging (MRI) after clinical remission. The present case suggests the association between favorable clinical course and complete amelioration on MRI.

Positive thinking is one of the psychological skills that mental training programs aim to help athletes cultivate in order to enhance performance. It has been noted, however, that some athletes do not find positive thinking effective for that purpose. This case report describes a fencing athlete who used positive thinking to cope with negative ruminations prior to a competition and then stopped using positive thinking and engaged in mindfulness. As a result of applying mindfulness, the patient developed the ability to take part in competitions without obsessing and without negative ruminations. These findings show the importance of assessing, in detail, how the psychological skills training used with athletes is affecting their cognition, behavior, and performance and of implementing appropriate interventions based on these assessments.

Chronic active Epstein–Barr virus (CAEBV) infection is a rare disease, mainly affecting children, typically characterized by persistent infectious mononucleosis (IM)-like symptoms. We describe an adult case of CAEBV without IM-like symptoms, which was indistinguishable from autoimmune hepatitis (AIH). A 60-year-old woman with liver damage was diagnosed with AIH (International Diagnostic Score: 16 points). She had been treated with prednisolone for three years; however, her transaminases had never normalized. She was admitted for another liver biopsy due to repeated high fevers and worsening of her liver damage over two months. Her EBV-DNA copy number was 2.9 × 10(4) copies/μg DNA, and EBV-encoded small RNA1-positive lymphocytic infiltration was observed in both the present and previously collected (three years ago) liver tissue samples. This case implies that hepatic involvement in a CAEBV without IM-like symptoms is difficult to distinguish from AIH and may be misdiagnosed. In some steroid resistant AIH cases, evaluating for CAEBV may be valuable.

We report herein a case of gallbladder cancer with biliary intraepithelial neoplasia (BilIN) complicated by pancreaticobiliary maljunction (PBM). A 60-year-old woman was referred to our hospital for thickening of the gallbladder wall diagnosed via ultrasonography at the referring clinic. The Radiographic images showed thickening of the gallbladder wall and a high confluence of pancreaticobiliary ducts outside the duodenal wall without dilatation of the bile duct. The amylase level in the bile duct was highly elevated. The patient was initially diagnosed with PBM without biliary dilatation, and laparoscopic cholecystectomy was performed. Histopathology of the resected specimen revealed gallbladder cancer localized in the mucosa propria with widespread BilIN. Immunohistochemical analyses showed positive results for S100P,IMP3 and p16(ink4a) in tumor cells, but a positive result for only IMP3 in adenocarcinoma. Expression of p53 was negative. Oncogenic KRAS mutations were not detected in tumor cells. The patient was diagnosed with gallbladder cancer with BilIN complicated by PBM. This case report may be useful in clarifying the carcinogenic process and genetic mutations for gallbladder cancer associated with PBM.

Pyloric gland metaplasia in the biliary epithelium is a precancerous lesion and has been confirmed in patients with congenital biliary dilatation presenting with overt biliary tract cancer. A patient was found to have an intra-abdominal cyst on fetal ultrasonography and was born at 37 weeks of gestation with a body weight of 2,636 g. Abdominal distension and repeated vomiting appeared 2 days after birth. Congenital biliary dilatation was diagnosed by imaging, wherein the common bile duct was enlarged to 9–10 cm in size, and the surrounding organs were extensively compressed; however, there was no sign of pancreatitis or cholangitis. Biliary drainage was performed through the gallbladder at 6 days of age, but it was insufficient because of the narrow and twisted cystic duct and changed to common bile duct at 18 days to relieve the compression. Because the body weight gain was poor due to loss of large amount of bile, the dilated bile duct and gallbladder were resected and hepatic duct Roux-Y jejunostomy was performed at 115 days of age with 4,500 g of body weight. Intraoperative imaging showed a pancreaticobiliary maljunction, and the pancreatic enzyme activities of the bile in the biliary system were remarkably elevated. Histopathological examination revealed pyloric gland metaplasia in the gallbladder epithelium and cystic duct. The patient is now over 2 years old and has been doing well without any complications. Based on our experience, precancerous pyloric gland metaplasia of the biliary epithelium may already occur even in a 3-month-old infant presenting with congenital biliary dilatation.

In defecation training, parent-mediated intervention via teleconsultation is helpful because the number of instructions for establishing defecation habits is limited. In the case report of the present study, defecation training was conducted based on gradual target setting and differential reinforcement through teleconsultation via email for a Caucasian 5-year-old boy with autism spectrum disorder (ASD) who lived in Greece. As a result of the intervention, namely the gradual target setting and differential reinforcement, in-bowl defecations increased at home.

This report describes a rare case of brachial artery dissection associated with closed elbow dislocation caused by a snowboarding injury. After peripheral ischaemic findings in the right upper extremity were confirmed, urgent duplex-sonography was performed to diagnose the brachial artery injury. Urgent revascularisation surgery was promptly performed, and arterial dissection was diagnosed by intraoperative findings, in which the adventitia of the brachial artery was intact and the intima was disrupted. In this case, because there was no golden time window before undertaking urgent revascularisation surgery, duplex-sonography was very useful for making an emergency diagnosis. To diagnose arterial dissection, because the adventitia of the brachial artery is intact, it is necessary to perform arteriotomy to identify intimal disruption in the brachial artery. When diagnosing traumatic elbow dislocation, it is important to suspect arterial dissection.

Upper tract urothelial carcinoma (UTUC) is a relatively rare disease that accounts for 5% to 10% of all urothelial carcinomas (UCs). Radical nephroureterectomy (RNU) with a bladder cuff is the current gold standard for the management of UTUC; however, endoscopic ablation is also an option for low-risk UTUC to preserve kidney function. Herein, we present two cases of solitary kidney with a right lower ureteral tumor. Both patients underwent left RNU in the past. An 82-year-old man with a right ureteral tumor whose histopathological examination revealed low-grade UC. Laser ablation was performed with ureteroscopy, and there was no recurrence for 7 years after treatment. A 67-year-old woman with a right lower ureteral tumor whose histopathological examination also revealed low-grade UC. Laser ablation was performed, and there was no recurrence for 5 years after the treatment. We closely followed-up our two patients after RNU. This allowed for early detection of tumor recurrence, after which we could perform laser ablation therapy.

Intractable pneumothorax with poor lung function that has received multiple conservative treatments may occur. Case 1 was a 70-year-old woman with aspergilloma who was admitted for pneumothorax. Case 2 was a 68-year-old man with acute exacerbation of interstitial pneumonia who developed pneumothorax. In both cases, multiple conservative therapies were administered, but the leak continued; thus, operations using veno-venous extracorporeal membrane oxygenation (ECMO) were planned. By video-assisted thoracoscopic surgery (VATS), we obtained the optimal surgical field by lung collapse. We removed many blood clots that were used for pleurodesis, ligated the bulla in case 1, and covered the leak point with strengthening agents in case 2. For cases of intractable pneumothorax, lung collapse by ECMO is advantageous because we can check details and leak points even in blood clots or in poor condition of the lung, and we can maneuver the lung in poor condition with a clear surgical field.

We report a case of robot-assisted total hysterectomy in a patient with extremely rare pelvic anatomy. Robot-assisted total laparoscopic hysterectomy was performed for lobular endocervical glandular hyperplasia on the left side of the uterus. The sigmoid colon was present between the two uterine corpora of a uterine didelphys and was attached to the bladder via the mesentery and fat. During surgery, the surgeon left the console and confirmed the magnetic resonance images. The surgery was then completed safely after the surgeon understood the anatomy. The postoperative condition was good, and the patient was discharged on postoperative day 5. Robot-assisted surgery has various advantages, including a good field of view, accuracy of instrument movement, and ease of viewing information in the medical record by pausing the operation. Robot assisted surgery improves not only safety and operational precision but also intraoperative convenience. Further studies are needed regarding the specific anatomy seen in this case.

Surgical removal of tumor is the primary treatment of choice for glomus tympanicum (GT). However, because the tumor has abundant blood flow, bleeding control is crucial, and preoperative embolization may be performed. Here, we report the case of a 46-year-old female who visited our hospital with a complaint of right pulsatile tinnitus. A red pulsatile mass was found in the right tympanic cavity, and she was diagnosed with class B1 GT and subsequently underwent surgical treatment. We judged that bleeding could be controlled by intratympanic cavity manipulation alone and decided to perform transmeatal tumor resection without preoperative arterial embolization. After creating a tympanomeatal flap and performing an atticotomy, some pieces of Spongel(®) were inserted between the tumor and the tympanic wall. The Spongel(®) absorbed the blood and created a space between the tumor and tympanic wall, which allowed for the insertion of the tip of the Vesalius(®) handpiece to coagulate the tumor. The coagulation caused the tumor to shrink, thereby widening the space and allowing for further resection. Although the surgical manipulation caused bleeding, complete resection was achieved by the application of Spongel(®) and coagulation with Vesalius(®). Since the tip of the Vesalius(®) was not burned, hemostasis was successfully achieved, and the operation proceeded while maintaining a clear field of view. There was little bleeding and no postoperative complications. The patient was discharged on the sixth postoperative day. One year after surgery, pure tone audiometry showed no change in the level of bone conduction. Spongel(®) and Vesalius(®) are useful tools that allow to safely perform surgeries even in narrow spaces such as the tympanic cavity.

Background: Traumatic injuries to maxillary anterior teeth are seen in children and adolescents to major extent resulting into anterior teeth fractures. Different treatment strategies are available for its management, although tooth fragment reattachment is considered to be a feasible treatment option due to its comprehensibility, aesthetics, and functional success. Case Description: Present case reports a case of a 10-year-old girl patient with a fractured permanent maxillary left central incisor (Ellis class II) with emphasis on hydration and reattachment of the fractured fragment. The present paper reports the reattachment of the stored fractured fragment in milk as a hydrating medium. The fragment was reattached using an adhesive bonding system and a resin composite material on the mesioincisal angle of 21 and the distoincisal angle was built up with traditional method. At 2-years follow up tooth maintain its vitality along with aesthetics and function. Conclusion: The retrieved fractured fragment of anterior teeth can be stored in milk till patient report to clinic followed by hydrating the fractured fragment using normal saline in dental office before reattachment. Clinical Significance: Management of available fractured tooth fragment by reattachment technique, offers a feasible and minimal non-invasive option for the dental clinician.

INTRODUCTION The management of multiple dimensions in orthognathic surgery often requires careful planning. Too large discrepancies could require a sequential procedure to make alignment of the archs possible. REPORT OF CASE The authors report a case of a 30-year-old partially edentulous man with severe maxillary hypoplasia caused by an untreated ankyloglossia. The transverse deficiency was estimated at more than 15 mm and the sagittal discrepancy shows a negative overjet of 11.5 mm. These wide deficits needed a 2-step surgery and the use of computed-aided design/computed-aided manufacturing. The first step was a palatal expansion by a fan-shaped Le Fort I osteotomy. The second step treated sagittal discrepancy and re-expanded the maxilla.At the end, the sagittal dimension got normal and the maxilla have been widened to almost 7 mm. CONCLUSION Custom-made surgery is very useful for uncommon cases, in particular for toothless patients. It facilitates complex operations and allows precise results.

Joanne Blair, 1 Kelly Warth, 2 Yashasvi Suvarna, 3 Marco Cappa 4 1Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK; 2Instar, London, UK; 3Global Medical Affairs, Novo Nordisk Global Business Services (GBS), Bangalore, India; 4Endocrinology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, ItalyCorrespondence: Joanne BlairDepartment of Endocrinology, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP, UKTel +44 151 252 5335 Fax +44 151 282 4606Email Jo.Blair@alderhey.nhs.ukPurpose: This study investigated why some clinicians switched growth hormone (GH) brands in pediatric patients with GH-related disorders to Norditropin® since the start of the COVID-19 pandemic, the clinicians’ perceptions of the results, and whether observations from this period of disruption could inform clinical practice in the future.Patients and Methods: Clinicians (N=106) from the UK, France, Italy, and Japan who had switched at least one patient to Norditropin® from a GH therapy manufactured by a different pharmaceutical company between February and November 2020 participated. They completed an online survey and submitted patient report forms for up to three switched patients.Results: Since the start of COVID-19, 39– 54% of the reported consultations were virtual (ie, via telephone or online means) in the UK, France, and Italy. Overall, 17% of patients seen by respondents in the survey were switched to a different GH brand; approximately two-thirds of switches were to Norditropin®. Clinicians’ top considerations in choosing a GH brand were patient/carer feedback, patient support programs, and the need for easy-to-use therapies in the context of virtual consultations. The top reasons for switching patients to Norditropin® included ease of use, device features and benefits, better patient/carer feedback, and ease of training in device use via virtual consultations. Norditropin® was considered suitable for use in virtual or in-person consultations or a mixture of both. Based on patient/carer feedback, 66% of clinicians believed that patients preferred Norditropin® to their previous therapy in terms of overall satisfaction.Conclusion: In this survey, key considerations in prescribing GH therapy were ease of use and acceptability to patients and carers. If virtual consultations increasingly replace in-person ones, ease in training patients/carers in device use will be particularly important. A majority of clinicians considered that their patients preferred Norditropin® to their previous therapy.Keywords: growth disorders, somatropin, virtual consultations, ease of use, Norditropin&reg

Gorham-Stout disease, a rare and intractable disease of unknown etiology, causes systemic bone lysis and replacement with lymphoid tissue. Here, we report a case of Gorham-Stout disease with cerebrospinal fluid leakage in a 16-year-old boy. The patient complained of nasal discharge, right ear obstruction, fever, and headache. A computed tomography scan of the head showed osteolysis around the right internal carotid artery, vestibule, and cochlea and osteolytic changes in the left parietal bone. It was suggested that the patient had bacterial meningitis owing to the leakage of cerebrospinal fluid from the fistula caused by the temporal bone osteolysis. He was treated with meropenem, and a transmeatal fistula closure and a bone biopsy of the left parietal bone were performed. Intraoperatively, osteolysis was observed on the promontory and around the internal carotid artery. The fistula was closed by dense filling and compression around the fistula, in the middle ear cavity, and in the external auditory canal. The symptoms disappeared after the surgery. Bone biopsy showed the presence of a lymphangioma, and Gorham-Stout disease was diagnosed. Prophylactic bisphosphonate therapy was initiated. A 4-year follow-up revealed no progression of the disease.

Objectives To explore how patients describe their diagnoses following Emergency Department (ED) discharge, and how this compares to electronic medical record (EMR) documentation. Methods We conducted a cohort study of patients discharged from three EDs. Patients completed questionnaires regarding their understanding of their diagnosis. Inclusion criteria: adult ED patients aged 18 and older seen within the last seven days. We independently compared patient-reported new diagnoses following discharge to EMR-documented diagnoses regarding diagnostic content (identical, insignificantly different, different, not enough detail) and the level of technical language in diagnostic description (technical, semi-technical, lay). Results The majority of participants (n=95 out of 137) reported receiving a diagnosis and stated the given diagnosis. Of those who reported their diagnosis, 66%, were females (n=62), the average age was 43 (SD 16), and a fourth (n=24) were Black and 66% (n=63) were white. The majority (84%) described either the same or an insignificantly different diagnosis. For 11% the patient-reported diagnosis differed from the one documented. More than half reported their diagnosis using semi-technical (34%) or technical language (26%), and over a third (40%) described their diagnosis in lay language. Conclusions Patient-reported diagnoses following ED discharge had moderate agreement with EMR-documented diagnoses. Findings suggest that patients might reproduce verbatim semi-technical or technical diagnoses they received from clinicians, but not fully understood what the diagnosis means for them.

BackgroundRadiotherapy plays an important role in the management of skull base meningioma. The aim of the study was to investigate patient-reported outcomes.MethodsA questionnaire of 20 items was sent to 192 patients with meningioma of the skull base who have been treated with proton therapy at a single institution. The survey included dichotomous, scaling, and open questions about symptoms, social distancing, rehabilitation, work, reintegration, limitations in recreational activities, as well as daily life activities and correlating diagnoses. Additionally, symptoms were reported retrospectively by the patients at different time points. In total, 128 patients (66.7%) responded. The median age at the time of RT was 55 years (range: 28-91); the majority were female (79%). The median time between the treatment of meningioma and the survey was 38.5 months (range: 7-100).ResultsThe most common initial symptoms were visual impairment (N=54, 42.2%), dizziness (N=38, 29.7%), and double vision (N=32, 25%). The most limiting symptom in daily life at the time of the survey was fatigue (N=31, 24.2%); a significant proportion of patients reported depression as associated with diagnosis (31.3%). Only 53% of patients reported occupational activity before treatment, this number did not increase with time. Only N= 40 (31.3%) and N=35 (27.3%) patients reported no limitations in daily household chores or recreational activities by the disease and treatment. The course of cognitive function after treatment showed a temporary deterioration with subsequent improvement. Except for the improvement in emotional functioning, most domains showed a temporary deterioration during radiotherapy, still, the values reached after 6 months differed weekly or moderately from the initial values.ConclusionBesides neurological deficits, patients with skull base meningioma experience a variety of unspecific symptoms, which can be most limiting in daily life. Even successful treatment does not necessarily translate into the alleviation of those symptoms. A greater focus on the characterization of those symptom complexes is necessary. Greater focus on functional structures such as the hippocampus might improve the results. Due to the retrospective character, this study is hypothesis-generating.

Objectives The prehospital identification of stroke patients with large vessel occlusion (LVO) enables appropriate hospital selection and reduces the onset-to-treatment time. The aim of this study was to investigate whether the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale could be reconstructed from existing prehospital patient reports and to compare its performance with neurologist's clinical judgement using the same prehospital data. Materials & Methods All patients transported by ambulance using stroke code on a six-month period were registered for the study. The prehospital patient reports were retrospectively evaluated using the FAST-ED scale by two investigators. The performance of FAST-ED score (>= 4 points) in LVO identification was compared to neurologist's clinical judgement ('LVO or not'). The presence of LVO was verified using computed tomography angiography imaging. Results A total of 610 FAST-ED scores were obtained. The FAST-ED had a sensitivity of 57.8%, specificity of 87.2%, positive predictive value (PPV) of 37.3%, negative predictive value (NPV) of 93.4% and area under curve (AUC) of 0.724. Interclass correlation coefficient for both raters over the entire range of FAST-ED was 0.92 (0.88-0.94). The neurologist's clinical judgement raised sensitivity to 79.4%, NPV to 97.1% and PPV to 45.0% with an AUC of 0.837 (p < .05). Conclusions The existing patient report data could be feasibly used to reconstruct FAST-ED scores to identify LVO. The binary FAST-ED score had a moderate sensitivity and good specificity for prehospital LVO identification. However, the FAST-ED was surpassed by neurologist's clinical judgement which further increased the sensitivity of identification.

Fecal impaction is the impaired excretion of a large fecal mass, and mild cases are treated by enema and osmotic laxatives. However, treatment-resistant cases need more invasive alternatives. A woman in her 60s presented with abdominal discomfort. Her abdomen was soft and without tenderness. Computed tomography revealed a large mass of feces in her sigmoid colon and no intestinal dilatation proximal to the mass. Endoscopy confirmed a fecal mass occupying the lumen. A glycerin enema, oral administration of polyethylene glycol, and enteral administration of amidotrizoic acid during colonoscopy were ineffective. We maneuvered a guidewire to form a loop at the tip of an endoscope, with which we subdivided the mass for successful removal. The patient’s abdominal discomfort disappeared immediately. Endoscopic disimpaction is far less invasive than surgery and should be considered when treating fecal impaction cases, without severe obstructive colitis, which are nonresponsive to conservative treatment.

Background Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the difficult-to-quantify patient perspective frames and modifies the impact of these quantifiable risk factors. Study design We identified consecutive adult inpatient colorectal surgery patients from 2017 to 2018. This mixed methods study merged data from electronic health records and in-depth patient interviews. Results We enrolled 258 participants, surveyed 167, and interviewed 18. Depressive symptoms represent one of many risk factors confirmed to increase non-routine healthcare utilization (RR 1.85, 95% CI 1.02–3.37), though the patient perspective explained why these symptoms seemed to greatly impact some patients more than others. Additionally, consistent with patient report, patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p Conclusion Patient perspectives add depth and understanding of the impact of risk factors on non-routine post-discharge care. This expanded knowledge explains why one patient is more likely to visit an ED close to home whereas another patient might prefer to visit their surgeon’s clinic directly. Effective strategies to reduce unplanned postdischarge care should be tailored.

We present a rare case of concurrent resection of pancreatic and gastric cancer in which indocyanine green (ICG) fluorescence was used to evaluate the remnant stomach. An 80-year-old man was referred with a tumor in the distal pancreas. Computed tomography showed a 25-mm mass in the pancreatic tail; endoscopic ultrasound-guided fine-needle aspiration revealed adenocarcinoma. Upper gastrointestinal endoscopy and subsequent upper gastrointestinal series revealed advanced gastric cancer in the mid-stomach. Concurrent resection of the pancreatic and gastric tumors was performed. After distal pancreatectomy and distal gastrectomy, ICG evaluation of the stomach showed fluorescence extending only 3 cm distal from the cardia. To avoid ischemic change at the remnant stomach, total gastrectomy was performed. Since remnant gastric necrosis and anastomotic leak following ischemia can lead to fatal outcomes, the use of ICG to evaluate blood supply at anastomotic sites can help determine the extent of safe resection in such cases.

We report the case of a 65-year-old male who presented with a 1-week history of right periorbital pain and progressive visual loss. He had a history of ulcerative colitis and was taking oral corticosteroids and mesalazine. Neurological and radiological examination demonstrated a rare case of invasive fungal rhinosinusitis that began with orbital apex syndrome. Initial endoscopic sinus surgery was performed and fungal culture identified Aspergillus fumigatus. Although antifungal treatment was started empirically before the operation, the patient had improved orbital pain but continued to have decreased right vision. Five months after the first surgical procedure, his condition deteriorated, including loss of consciousness, and a right temporal lobe abscess was found and surgically drained. Since then, the patient received antifungal treatment for 4 years without recurrence. Invasive fungal rhinosinusitis with orbital apex syndrome should be treated with long-term postoperative antifungal medication. It should be noted that even in immunosuppressive individuals such as ulcerative colitis, fungal rhinosinusitis with orbital apex syndrome may become severe.

Professional standards committees have generally applied the diagnostic criteria for premature ejaculation only to situations involving (presumed) heterosexual men having penile-vaginal intercourse. This paper reviews the existing evidence supporting expansion of the criteria for use among non-straight men engaging in sexual activities that do not include vaginal intercourse. In brief, estimated ejaculation latencies appear similar across men identifying with different sexual orientations, and various partnered sexual activities (oral, vaginal, and manual) tend to be well correlated. In contrast, masturbation latency patterns are different between men with and without premature ejaculation, and ejaculatory control and bother/distress may be less critical to gay men than straight men during partnered sex. Finally, it should be noted that existing patient report outcomes (PROs) require modification for use with non-straight men.

Recent studies have shown that complete lymph node dissection (CLND) performed immediately did not improve the overall survival in patients with sentinel lymph node (LN)-positive melanoma. According to these results, nodal observation with ultrasonography becomes standard. However, it still has some limitations for detection of metastatic LNs. A 74-year-old woman was diagnosed with acral lentiginous melanoma of her left sole. The sentinel LN was positive for metastasis, but she refused CLND. Sixteen months after operation, ultrasonography showed an abnormal LN in the inguinal region. There was no other abnormal LNs around the LN. We resected the abnormal LN. The resected LN was black in color, and the adjacent LN that showed normal appearance in ultrasonography was also black. A recent study showed only 6.6% sensitivity in preoperative ultrasonographic detection of metastatic melanoma in a LN. We should keep in mind the limitation of ultrasonography for detection of a metastatic LN.

Cetuximab is an effective drug used to treat patients with recurrent or metastatic head and neck squamous cell carcinoma. Skin toxicities such as paronychia and skin exsiccation are common adverse events caused by cetuximab. Skin toxicities may cause significant physical and psychosocial discomfort. The goal of managing skin toxicities is to minimize the detrimental effects on quality of life and continue the treatment. In one patient, skin toxicities became severe, up to grade 2, during treatment. The pain induced by paronychia and skin exsiccation made daily life difficult. Ten days after starting Unseiin, symptoms and finger findings resolved significantly. The patient could resume daily activities. No adverse effects induced by Unseiin were observed during treatment. Unseiin was effective on paronychia and skin exsiccation in this case and may contribute to successful treatment of skin toxicities induced by cetuximab.

Study design This was a retrospective review. Objective Provide a validated method of radiographic evaluation of cervical disk replacement (CDR) patients linked to outcomes. Summary of background data Preoperative radiographic criteria for CDRs and the impact of intraoperative positioning remain without formalized guidelines. The association between preexisting degenerative changes, optimal implant positioning, and patient-reported outcome measures (PROMs) are not well understood. Our study establishes a systematic radiographic evaluation of preoperative spondylosis, implant placement, and associated clinical outcomes. Methods Preoperative radiographs for CDR patients were evaluated for disk height, facet arthrosis, and uncovertebral joint degeneration. Postoperative radiographs were scored based on the position of the CDR implant on anterior-posterior (AP) and lateral radiographs. PROMs including Visual Analogue Scale (VAS) arm pain, VAS neck pain, Neck Disability Index (NDI), Short Form 12 physical health (SF12-PCS) and mental health (SF12-M) were collected preoperatively, at early follow, and at late follow-up. Results A total of 115 patients were included. Preoperative disk height had the highest reliability, intraclass correlation coefficient of 0.798). Facet arthrosis had the lowest intraclass correlation coefficient at 0.563. Preoperative disk height scores showed a significant correlation with AP radiographs and implant positioning score. Patients with more advanced uncovertebral degenerative changes showed less improvement 6 months postoperatively, based on SF-12 PCS scores (R=0.446, P=0.025). Postoperative implant position on lateral radiograph showed a significant correlation with SF-12 MCS scores at follow-up beyond 6 months (R=0.385, P=0.011). Overall postoperative implant position scores demonstrated significant correlation with SF-12 PCS (R=0.350, P=0.046) scores. Conclusion This study provides a systematic method of evaluation of preoperative and intraoperative radiographs that can optimize outcomes. On the basis of our study, spine surgeons performing cervical disk replacement surgery should consider: (a) the presence of preexisting uncovertebral joint degeneration can negatively impact outcomes, (b) achieving optimal implant positioning can be increasingly difficult with more severe loss of disk height, and (c) overall implant position as judged on AP and lateral fluoroscopy can impact outcomes.

The Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) is a valid and reliable instrument (61 items across 5 domains) of patients' perceptions of safety. Stakeholder feedback has supported shorter versions for improving choice and facilitating uptake of routine patient-centered evaluation. We sought to develop 2 shorter versions of PREOS-PC: one including the shortest possible scales that met established measurement performance standards and a screening version including a single item per domain.A total of 1244 patients from 45 general practices across England completed PREOS-PC questionnaires. All scale items in PREOS-PC underwent Item Response Theory analysis, applying standard criteria for the item reduction. Cognitive debriefing from 10 patient interviews allowed for the assessment of the instruments' readability. The instruments' psychometrics properties were reassessed in a validation sample of 1557 patients in 21 English general practices."PREOS-PC Compact" includes 25 items and 2 open-ended questions across the 5 domains, 44% of the length of the original instrument. "PREOS-PC Screen" consists of 6 items: the best-performing single items for 2 domains, 1 item modified from original items for each of the remaining 3 domains, and 1 open-ended question. The evaluation of the instruments confirmed they were acceptable to patients and met standards for readability; construct, convergent, and divergent validity; and reliability.PREOS-PC Compact meets high-performance standards while reducing patient burden for routine monitoring of patient safety in primary care. PREOS-PC Screen is a concise tool apt for incorporation into audits and to target more in-depth review as needed.

Uterine adenomyosis is an estrogen-dependent tumor and one of the most common benign diseases in sexually mature women. The frequency of endometrial cancer associated with adenomyosis has been reported to be 18%–66%. On the other hand, endometrial cancer arising in adenomyosis (EC-AIA) is extremely rare. EC-AIA is now considered a different entity from and has a worse prognosis than endometrial cancer with adenomyosis (EC-A). In the present study, we report a case of endometrial cancer with adenomyosis in which endometrial biopsy failed to provide a definitive diagnosis. A 63-year-old female patient presented with endometrial thickening. Endometrial cytology was positive, and magnetic resonance imaging (MRI) showed small lesions suggestive of endometrial cancer with shallow invasion and adenomyosis. However, an endometrial biopsy showed only metaplasia, and careful follow-up was initiated. Subsequent endometrial cytology showed enlarged and round nuclei, uniform chromatin distribution, no thickening of nuclear margins, and abundant cytoplasm appearing in a sheet-like arrangement, suggesting atypical cells of endometrial glands with metaplasia. Three suspicious positive results and one positive result were observed, but repeated biopsies did not lead to the diagnosis of malignancy. The patient underwent diagnostic hysterectomy 19 months after the initial visit. The postoperative histopathological diagnosis was stage IA endometrial cancer (endometrioid carcinoma G1). This case of endometrial cancer associated with adenomyosis was difficult to diagnose. Our findings demonstrate that EC-AIA should be considered even if no lesions were detected by endometrial biopsy.

This study determined the frequency and impact of symptoms on quality of life (QoL) in patients diagnosed with limb girdle muscular dystrophy (LGMD). Participants with a diagnosis of LGMD in registries based at the Coalition to Cure Calpain-3, the Jain foundation, and the Global FKRP Registry competed a survey to report the frequency and relative impact of themes and symptoms of LGMD. Frequency, mean impact, and population impact scores were calculated, and responses were categorized by age, symptom duration, gender, employment status, use of assistive devices, and LGMD subtypes. 134 participants completed the survey. The most prevalent themes included an inability to do activities (100%), limitation with mobility (99.3%), and lower extremity weakness (97.0%). Themes with the greatest impact were: limitations with mobility, lower extremity weakness, and an inability to do activities. Symptom duration and the use of assistive devices were associated with the presence of multiple themes. Employment was associated with the impact of several themes with no differences in frequency. The prevalence and impact of these themes vary in the LMGD population. The most prevalent and impactful themes were related to weakness, but additional concerns related to emotional challenges should also be considered in clinical and research settings.

Lichen nitidus and morphea are common diseases, but an associated localization of both lesions is rare. Here, we describe the first case of lesions distributed along Blaschko's lines. A 24-year-old Japanese woman was referred to our clinic for evaluation of band-like plaques of 18-months history on the right lateral side of her abdomen. In addition, multiple milky-white papules were seen within the plaques. Histopathological examination showed there was sclerosis in the lower half of the dermis and well-circumscribed, dense, papillary dermal lymphohistiocytic aggregations showing a so-called "claw clutching a ball." Immunohistochemical analysis revealed that the morphea and lichen nitidus had similar characteristics. We speculated that unique immunologic events led to the development of lichen nitidus and morphea in our patient.

We report a case of GCTB in an 84-year-old Japanese man who had a tumor in his left iliac bone and was treated safely with denosumab. The patient noticed a painful mass, with gradual enlargement, in his left low back next to the iliac region. Magnetic resonance imaging revealed that the tumor measured 94 × 66 × 90 mm and was located in the left iliac bone. Histologically, the tumor was composed of proliferative oval-shaped mononuclear cells, admixed with large number of osteoclast-like giant cells. Immunohistochemically, a strong positivity for histone 3.3 G34W mutant protein was observed in the nuclei of the mononuclear cells, confirming the diagnosis of GCTB. Because it was considered as unresectable tumor, the patient was treated with denosumab without any side effects.

Herein, we report a case of atypical spindle cell lipomatous tumor (ASCLT) on both sides of the tongue in a 74-year-old male patient. The patient was referred to our department for treatment of the masses in the tongue. Several elastic soft indolent masses were detected during the first examination. The masses were well defined, and their consistency was similar to that of adipose tissues. No signs of induration were observed in the surrounding tissues. The patient was not aware of the masses, which were only detected during his visit at the dental clinic that referred him to our institution. Thus, the onset of the masses remains unknown. ASCLT was identified via histopathological examination. Then, tumor excision was performed under general anesthesia. Thirteen months after surgery, the condition of the patient was good, and signs of local recurrence or postoperative metastasis were not observed.

Background Forgotten Joint Score (FJS) has become a popular tool for total knee arthroplasty (TKA), but almost all studies had assessment performed 1 year after surgery. There is a need for a sensitive tool for earlier outcome assessment. The aim of this study was to investigate the usefulness of FJS within the first year after TKA. Methods This was a cross-sectional study. Patients within the first year after primary TKA were recruited. FJS was translated into the local language with a cross-cultural adaptation and was validated by assessing the correlation with the Western Ontario and McMaster Universities Arthritis Index score (WOMAC). Ceiling and floor effects (highest or lowest 10% or 15%) of both scores were compared. Skewness of scores was assessed with a histogram. Results One hundred sixty-three subjects were recruited: 84 (51.5%) had evaluation at 3 months after the operation, 56 (34.4%) at 6 months, and 23 (14.1%) at 12 months. FJS had fewer patients at the highest 10% (10.7% vs. 16.1%, P = 0.046) or 15% (19.6% vs. 32.1%, P = 0.027) at 6 months and within the first year overall (6.7% vs. 13.5%, P P P P P P P Conclusions FJS has a low ceiling effect but a high floor effect in the first year after TKA. Such characteristics make it less useful for the general assessment of early patient report outcome after operation.

Reconstruction of bone and soft-tissue defects in the forearm is a surgery that often proves unsuccessful. Free fibular osteocutaneous flaps are a useful material for reconstruction that enable simultaneous reconstruction of bone, skin, and soft tissues. However, in free fibular osteocutaneous flaps, the fibula, skin, and vascular pedicle are tightly bound together by the posterior intermuscular septum and the perforators that pass through the septum, giving the disadvantage of a low degree of freedom when setting these structures in place. We take into account the 3-dimensional structure of the free skin flap when selecting which lower leg to use as the donor. We report here the case of a 61-year-old man with defects in the radius, skin, and soft tissues after resection of spindle cell carcinoma of the right forearm, which was reconstructed using a free fibular osteocutaneous flap harvested from the left lower leg. Two years postoperatively, recovery has been uneventful with no complications. Donor-side selection of free fibular osteocutaneous flap is an important factor for safely completing composite radius reconstruction.

Desmoplastic fibroma (DF) is a rare benign but aggressive fibrous lesion with an unknown etiology. It has an affinity for the mandible. DF has a high rate of recurrence after surgical resection. In this study, we report the therapeutic management of a recurrence of DF in the lower jaw in a 2-year-old boy. He responded well to second surgical intervention with wide resection and immediate reconstruction with plate. The purpose of this case report is to emphasize the particularity of the case, treatment modalities, and differential diagnosis in DF.

Hajjul Kamil,1 R Rachmah,1 Elly Wardani,1 Catrin Björvell2 1Nursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia; 2Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, SwedenCorrespondence: Elly WardaniNursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, IndonesiaEmail ellywardani@unsyiah.ac.idIntroduction: Hospitals in Indonesia are obligated to implement Integrated Patient Progress Notes (IPPNs), also known as the “Catatan Perkembangan Pasien Terintegrasi”. A progress note contains the entire interaction between patients and health professionals, including physicians, nurses, pharmacists, dietitians, and physiotherapists. However, since the first launch in 2012, obstacles and problems in completing this integrated documentation remains nationwide.Aim: The objective of this investigation was to identify health professional’s perspectives on obstacles and problems using IPPNs and facilitators that may optimize their use.Methods: Five focus group discussions (FGDs) involving 37 participants took place. All FGDs were recorded, translated, and transcribed verbatim. A thematic analysis was used to interpret the data.Results: The thematic analysis of the material revealed three main categories for each of the two topics; Topic 1. Perceived problems hindering integrated documentation: lack of supervision, competence, workload; topic 2: perceived strategies to optimize integrated documentation: organizational support, joint practices, integrating technology with IPPN.Conclusion: The results indicate that health professionals see the importance of using IPPNs but only if implemented with educational and organizational support and that the use of an electronic patient record may be more effective than a paper record. To continue the implementation of IPPNs, it is suggested that it is preceded by educational and organizational support.Keywords: integrated documentation, Indonesia, patient report, safety, service quality

Hajjul Kamil,1 R Rachmah,1 Elly Wardani,1 Catrin Björvell2 1Nursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia; 2Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, SwedenCorrespondence: Elly WardaniNursing Leadership and Management Department, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, IndonesiaEmail ellywardani@unsyiah.ac.idIntroduction: Hospitals in Indonesia are obligated to implement Integrated Patient Progress Notes (IPPNs), also known as the “Catatan Perkembangan Pasien Terintegrasi”. A progress note contains the entire interaction between patients and health professionals, including physicians, nurses, pharmacists, dietitians, and physiotherapists. However, since the first launch in 2012, obstacles and problems in completing this integrated documentation remains nationwide.Aim: The objective of this investigation was to identify health professional’s perspectives on obstacles and problems using IPPNs and facilitators that may optimize their use.Methods: Five focus group discussions (FGDs) involving 37 participants took place. All FGDs were recorded, translated, and transcribed verbatim. A thematic analysis was used to interpret the data.Results: The thematic analysis of the material revealed three main categories for each of the two topics; Topic 1. Perceived problems hindering integrated documentation: lack of supervision, competence, workload; topic 2: perceived strategies to optimize integrated documentation: organizational support, joint practices, integrating technology with IPPN.Conclusion: The results indicate that health professionals see the importance of using IPPNs but only if implemented with educational and organizational support and that the use of an electronic patient record may be more effective than a paper record. To continue the implementation of IPPNs, it is suggested that it is preceded by educational and organizational support.Keywords: integrated documentation, Indonesia, patient report, safety, service quality

We present the case of a 58-year-old Japanese woman with a natural killer T (NK/T)-cell lymphoma complicated by brain abscess. NK/T-cell lymphomas represent a rare type of lymphoma derived from either activated NK cells or, rarely, cytotoxic T cells. They are aggressive Epstein-Barr virus (EBV)-associated lymphomas that involve mainly the nasal cavity. Brain abscess associated with primary extranodal nasal-type NK/T-cell lymphoma is extremely uncommon: to our knowledge, this is the first reported case of this lymphoma with brain abscess as the initial clinical manifestation. Endoscopic surgery was performed for definitive diagnosis under intraoperative navigation system. Chemotherapy followed by radiotherapy was performed and was effective: 72 months later the tumor has not recurred. Recommendations of endoscopic management for diagnosis and treatment of this rare neoplasm are discussed.

We present a very rare case of a laparoscopically-assisted repair of a small bowel perforation secondary to multiple metastases of undifferentiated pleomorphic sarcoma from the posterior mediastinum. A 46-year-old man presented with middle to upper abdominal pain during chemotherapy for lung metastases from undifferentiated pleomorphic sarcoma. Computed tomography revealed intra-abdominal free air, and emergency laparoscopy was performed. Consequently, a perforation was detected in the jejunum, and partial jejunal resection was performed by mini-laparotomy. Pathological examination demonstrated an ulcerated tumor with perforation and four additional tumors in the resected jejunum. Pathological examination also revealed undifferentiated pleomorphic sarcoma in all five tumors. To our knowledge, our case is the first report of a laparoscopically-assisted repair of a small bowel perforation secondary to metastasis of undifferentiated pleomorphic sarcoma. Although the perforation site was unclear preoperatively, laparoscopic observation readily identified the lesion in this patient. Therefore, minimally invasive surgery could be performed successfully with mini-laparotomy following laparoscopic observation. Laparoscopic techniques for the small intestine are viable options, even in acute and uncommon situations, and small bowel perforation secondary to metastasis should be considered in patients with undifferentiated pleomorphic sarcoma and acute abdomen.

A 79-year-old Japanese woman presented with a rare case of metastatic renal cell carcinoma to the left sphenoid sinus with left nasal bleeding. She had previously had right radical nephrectomy for renal cell carcinoma at the age of 64 years and brain and spinal cord infarction at 74 years. Endoscopic examination revealed no mass in the nasal cavity. CT and MRI revealed a tumor in the left sphenoid sinus. The size of the tumor increased gradually from 12 to 15 years after the radical nephrectomy. Complete resection with endoscopic surgery was performed without preoperative embolization. The tumor cells had clear cytoplasm and were arranged in a trabecular pattern lined by a layer of endothelial cells. These findings were identical to the pathological findings of the surgical specimen of the renal cell carcinoma from 15 years previous. A pathological diagnosis of metastatic renal cell carcinoma of clear cell type (grade 1) was made. PET-CT demonstrated no metastasis. The patient’s condition was successfully managed with excision of the tumor, and she remains well with no evidence of recurrence and metastasis 36 months after treatment. Metastatic renal cell carcinoma to the sphenoid sinus is rare, but it might be considered in the differential diagnosis of masses in the paranasal sinus even long after initial treatment of renal cancer.

Adenomatoid odontogenic tumor is a benign hamartomatous odontogenic neoplasm. This entity is more commonly seen in young individuals in second decade of life. It occurs commonly in the anterior maxillary region usually in association with impacted maxillary canine. Here, a case report in which the tumor occurred at an early age of 8 years (in the first decade of life) and associated with an unerupted first premolar tooth (which is an unusual situation) has been reported. Priority should be made on early diagnosis and proper treatment planning.

Objective The aim of this study was to evaluate the knowledge and practice about dentine hypersensitivity (DH) among dental practitioners. Materials and Methods A pilot-tested questionnaire was sent to practicing dentists (n = 588) working in private and public sectors in Lahore, Pakistan. The questions assessed dentists’ knowledge about type of pain and predisposing factors of DH. The dentists were asked about their preferred methods of diagnosing and managing the condition. Statistical Analysis Basic statistics, chi-squared test, and multivariate logistic regression were performed. Results Most dentists (64.3%) reported examining one to five patients with DH per week in their dental clinics. A large majority (85.4%) indicated DH as a stimulated short pain from a tooth. Recession of gums (96.6%), aggressive brushing (88.2%), and frequent use of teeth whitening procedures (83.1%) were most frequently reported predisposing factors of DH. Among most commonly used methods of diagnosis, spontaneous pain after the application of air blast was reported by 74.8% of the participants and followed by spontaneous patient report confirmed by dental examination (57.7%). Most widely used management approaches of DH included the use of fluoride products (96.2%), use of desensitizing potassium nitrate toothpastes (75%), and application of bonding agents (56.2%). Female versus male dentists (odds ratio [OR]: 7.79, p < 0.001) and private practitioners versus public dentists (OR: 7.34, p < 0.001) were more likely to examine greater number of patients with DH. Conclusion Dentists used various methods for diagnosing and managing patients with DH. Application of air blast to evaluate spontaneous pain and use of fluoride products were most widely used diagnostic and management preferences, respectively.

We report a case of subcutaneous panniculitis-like T-cell lymphoma with diffuse indurated lesions without erythema. A 27-year-old man was referred to us with a 1-month history of fever, general fatigue and indurated skin lesions. The initial examination revealed indurated skin lesions without erythema and subcutaneous tumors in the right lower abdomen, back and buttocks. Histopathology showed a panniculitis predominantly in lobular pattern, and infiltration of atypical lymphocytes in the subcutaneous tissue. Characteristically, there was rimming of individual fat cells by surrounding atypical lymphocytes. Results of laboratory examinations showed hemophagocytic syndrome (HPS). Based on these findings, we made a diagnosis of subcutaneous panniculitis-like T-cell lymphoma without erythema and subcutaneous tumors with HPS. To our knowledge, there has been no report of SPTCL with diffuse indurated lesions without erythema, tumors, or plaque, all of which are considered to be typical characteristics of SPTCL. Positron emission tomography / computed tomography (PET/CT) showed noticeable thickening of diffuse subcutaneous involvement throughout the body. Hence, PET/CT is a useful for the detection of SPTCL as well as its distribution.

Introduction: “Long COVID” is a multisystem disease that lasts for 4 or more weeks following initial symptoms of COVID-19. In the UK, at least 10% of patient report symptoms at 12 weeks following a positive COVID-19 test. The aims of this quality improvement survey were to explore patients’ acute and post-acute “long” COVID-19 symptoms, their experiences of community services and their recommendations for improving these services. Methods: Seventy patients diagnosed with COVID were randomly selected from 2 large socially and ethnically diverse primary care practices. Of those contactable by telephone, 85% (41/48) agreed to participate in the quality improvement survey. They were interviewed by telephone using a semi-structured questionnaire about community services for COVID-19 patients. Interviews lasted 10 to 15 minutes. Results: Forty-nine percent of patients reported at least 1 post-acute COVID-19 symptom. The most common were severe fatigue (45%), breathlessness (30%), neurocognitive difficulties (such as poor memory), poor concentration and “brain fog” (30%), headaches (20%), and joint pain (20%). Many patients felt isolated and fearful, with scant information about community resources and little safety netting advice. Patients also expected more from primary care with over half (56%) recommending regular phone calls and follow up from healthcare staff as the most important approach in their recovery. Conclusions: In line with patients’ requests for more support, the practices now routinely refer patients with long COVID to an on-site social prescriber who explores how they are getting on, refers them to the GP or practice nurse when required, and sign posts them to support services in the community.

The National Children's Study (NCS) statistics and item response theory group was tasked with promoting the quality of study measures and analysis. This paper provides an overview of six measurement and statistical considerations for the NCS: (1) Conceptual and Measurement Model; (2) Reliability; (3) Validity; (4) Measurement Invariance; (5) Interpretability of Scores; and (6) Burden of administration. The guidance was based primarily on recommendations of the International Society of Quality of Life Research.