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Moving the capital of Indonesia from the Jakarta area to the island of Kalimantan is an inevitable necessity due to economic, political, socio-cultural and environmental factors, which require other areas of the archipelago to be developed. It has been decided that the green city and smart city concepts will be applied in the development of the new capital, using a state-of-the-art approach, including metaverse technology. The methodology employed in this study includes in-depth interviews, focus group discussions, direct field observations, and documentation. The findings of this research consist of an analysis of the readiness of IKN and its surrounding area for the implementation of metaverse technology in IKN. This paper examines whether metaverse technology is needed in the construction of the new capital city. If so, what are the needs for the development of the new capital's metaverse, and what are the advantages (and disadvantages) of using the metaverse. The results are expected to provide a more comprehensive view of the use of metaverse technology in the new capital.

An administrator is employed to identify network security breaches in their organizations by using a Network Intrusion Detection and Prevention System (NIDPS), which is presented in this paper that can detect and preventing a wide range of well-known network attacks. It is now more important than ever to recognize different cyber-attacks and network abnormalities that build an effective intrusion detection system plays a crucial role in today's security. NSL-KDD benchmark data set is extensively used in literature, although it was created over a decade ago and will not reflect current network traffic and low-footprint attacks. Canadian Institute of Cyber security introduced a new data set, the CICIDS2017 network data set, which solved the NSL-KDD problem. With our approach, we can apply a variety of machine learning techniques like linear regression, Random Forest and ID3. The efficient IDPS is indeed implemented and tested in a network environment utilizing several machine learning methods. A model that simulates an IDS-IPS system by predicting whether a stream of network data is malicious or benign is our objective. An Enhanced ID3 is proposed in this study to identify abnormalities in network activity and classify them. For benchmark purposes, we also develop an auto encoder network, PCA, and K-Means Clustering. On CICIDS2017, a standard dataset for network intrusion, we apply Self-Taught Learning (STL), which is a deep learning approach. To compare, we looked at things like memory, Recall, Accuracy, and Precision.

Harvesting energy from ambient sources has been a recent topic of interest. A typical linear harvester is effective only near resonance, limiting its frequency bandwidth. In order to increase the efficiency and bandwidth of harvesters, various strategies have been proposed. Using multiple harvesters in a single device can harvest enough power over wider frequency band. In the present work, the effect of torsional coupling of the harvesters for low frequency vibration energy harvesting is investigated. Two pendulums with electromagnetic induction as the energy conversion mechanism is proposed. The performance of the device is studied theoretically and numerically. Cubic polynomials are used to model the pendulum nonlinearity. Fundamental harmonic oscillation are assumed to obtain the analytical solution. The effect of torsional coupling and pendulum length on the power harvested are reported.

Abstract Introduction Acute compartment syndrome is a surgical emergency requiring immediate fasciotomy. Spontaneous onset of acute compartment syndrome of the lower limbs is rare. We present a very rare case of pneumococcal sepsis leading to spontaneous acute compartment syndrome. Case presentation A 40-year-old Caucasian man presented as an emergency with spontaneous onset of pain in both legs and signs of compartment syndrome. This was confirmed on fasciotomy. Blood culture grew Streptococcus pneumoniae. Conclusion Sepsis should be strongly suspected in bilateral acute compartment syndrome of spontaneous onset.

Background/aim: Uveal melanoma is an ocular malignancy whose prognosis severely worsens following metastasis. In order to improve the understanding of molecular physiology of metastatic uveal melanoma, we identified genes and pathways implicated in metastatic vs non-metastatic uveal melanoma., Patients and Methods: A previously published dataset from Gene Expression Omnibus (GEO) was used to identify differentially expressed genes between metastatic and non-metastatic samples as well as to conduct pathway and perturbagen analyses using Gene Set Enrichment Analysis (GSEA), EnrichR, and iLINCS., Results: In male metastatic uveal melanoma samples, the gene LOC401052 is significantly down-regulated and FHDC1 is significantly up-regulated compared to non-metastatic male samples. In female samples, no significant differently expressed genes were found. Additionally, we identified many significant up-regulated immune response pathways in male metastatic uveal melanoma, including "T cell activation in immune response". In contrast, many top up-regulated female pathways involve iron metabolism, including "heme biosynthetic process". iLINCS perturbagen analysis identified that both male and female samples have similar discordant activity with growth factor receptors, but only female samples have discordant activity with progesterone receptor agonists., Conclusion: Our results from analyzing genes, pathways, and perturbagens demonstrate differences in metastatic processes between sexes., (Copyright © 2024, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Multiple myeloma (MM) is a hematological malignancy that arises when plasma cells undergo malignant monoclonal proliferation. This study aimed to assess the demographic disparities and temporal trends in the mortality rates of this disease., Patients and Methods: We employed the Center for Disease Control and Prevention's Wide-ranging ONline Data for Epidemiologic Research (CDC WONDER) database., Results: We found that for the overall U.S. population, the age-adjusted mortality rate per 1,000,000 (AAMR) decreased from 1999 to 2020. However, rates differed between demographic groups. In addition, we sought to find a significant average annual percent change (AAPC) in mortality rate from 1999 to 2020 for various demographic populations and compared groups to find disparities in mortality rate trend. In 2020, the AAMR due to MM was 38.0 and for women 24.1. The AAPC in AAMR from 1999 to 2020 in men was -1.0% (95%CI=-1.3 to -0.7) and in women was -1.6% (95%CI=-1.6 to -2.3). A significant difference in trend by sex was found, where women had a higher rate of decline. In 2020, the AAMR for the American Indian or Alaska Native (AI/AN) population was 15.0, the Asian American and Pacific Islander (AAPI) had 14.8, the Black and African American population had an AAMR of 55.6 and the White population had an AAMR of 28.1. The AAPC for the AI/AN population was -2.2% (95%CI=-3.5 to -0.9), for the AAPI population it was -0.9% (95%CI=-1.5 to -0.4), the Black and African American population had -1.5% (95%CI=-2.2 to -0.8) and the AAPC for the White population was -1.1% (95%CI=-1.6 to -0.6). A significant difference in trend of decline was found between the AAPI and Black and African American populations and between the AI/AN and Black and African American populations. When assessing the U.S. by states, the mid-southeast U.S. had the greatest density of the states with high AAMRs., Conclusion: These findings suggest which populations are at increased risk for mortality due to multiple myeloma and where we should apply additional resources and research., Competing Interests: The Authors have no conflicts of interest to disclose in relation to this study., (Copyright 2024, International Institute of Anticancer Research.)

Background/aim: Renal cell carcinoma (RCC) accounts for 90% of malignant neoplasms of the kidney., Patients and Methods: In this report, the CDC WONDER database was accessed to retrieve age-adjusted mortality data from 1999 to 2020 due to RCC, defined as ICD-10 Code: C64 Malignant neoplasm of kidney except renal pelvis, for various demographics to investigate trends and potential disparities., Results: In 2020, the overall age-adjusted mortality rate (AAMR) due to RCC in the USA was 42.4 per 1,000,000. The average annual percent change (AAPC) for the USA from 1999 to 2020 was -0.6%. Notably, in 2020, men had a higher AAMR than women, 63.9 compared to 25.7, and a significant difference in AAPC trend was identified between men (-0.5%) and women (-1.0%). When investigating trends according to race in 2020, the Asian population displayed the lowest AAMR at 18.9. When determining AAPC from 1999 to 2020 according to race group, the American Indian group demonstrated the greatest decline in AAPC at -1.3%, followed by the Black (-1.2%) and White populations (-0.5%). The Asian population did not exhibit a significant AAPC. Moreover, the rates between these three groups were statistically significantly different- indicating disparities in trend based on race., Conclusion: This investigation assesses the AAMR for different demographic groups of the USA population to identify disparities and guide resource allocation strategies., Competing Interests: The Authors have no conflicts of interest to disclose in relation to this study., (Copyright 2024, International Institute of Anticancer Research.)

Detecting pancreatic duct adenocarcinoma (PDAC) in its early stages and predicting late-stage patient prognosis undergoing chemotherapy is challenging. This work shows that the activation of specific oncogenes leads to elevated expression of mRNAs and their corresponding proteins in extracellular vesicles (EVs) circulating in blood. Utilizing an immune lipoplex nanoparticle (ILN) biochip assay, these findings demonstrate that glypican 1 (GPC1) mRNA expression in the exosomes-rich (Exo) EV subpopulation and GPC1 membrane protein (mProtein) expression in the microvesicles-rich (MV) EV subpopulation, particularly the tumor associated microvesicles (tMV), served as a viable biomarker for PDAC. A combined analysis effectively discriminated early-stage PDAC patients from benign pancreatic diseases and healthy donors in sizable clinical from multiple hospitals. Furthermore, among late-stage PDAC patients undergoing chemotherapy, lower GPC1 tMV-mProtein and Exo-mRNA expression before treatment correlated significantly with prolonged overall survival. These findings underscore the potential of vesicular GPC1 expression for early PDAC screenings and chemotherapy prognosis., (© 2023 The Authors. Advanced Science published by Wiley-VCH GmbH.)

Given the tubal origin of high-grade serous ovarian cancer (HGSC), we sought to investigate intrauterine lavage (IUL) as a novel method of biomarker detection. IUL and serum samples were collected from patients with HGSC or benign pathology. Although CA-125 and HE4 concentrations were significantly higher in IUL samples compared to serum, they were similar between IUL samples from patients with HGSC vs benign conditions. In contrast, CA-125 and HE4 serum concentrations differed between HGSC and benign pathology ( P  =.002 for both). IUL and tumor samples from patients with HGSC were subjected to targeted panel sequencing and droplet digital PCR (ddPCR). Tumor mutations were found in 75 % of matched IUL samples. Serum CA-125 and HE4 biomarker levels allowed for better differentiation of HGSC and benign pathology compared to IUL samples. We believe using IUL for early detection of HGSC requires optimization, and current strategies should focus on prevention until early detection strategies improve., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.A.H. is a co-founder and officer with equity interest of Lime Therapeutics Inc., co-founder with equity interest of Selectin Therapeutics Inc. and Resident Diagnostics, Inc., and a member of the scientific advisory boards of Concarlo Therapeutics Inc., Nanorobotics Inc., and Mediphage Bioceuticals Inc. B.W. reports research funding by Repare Therapeutics, outside of the submitted work. E.S. reports honoraria from Dilon Technologies, Inc. D.A.L. is a full-time employee of Merck & Co., Inc. (Rahway, NJ, USA) and a co-founder with equity interest of Resident Diagnostics, Inc. N.A.R. reports grant funding from GRAIL paid to the institution. D.S.C. reports personal fees from Apyx Medical, Verthermia Inc., Biom 'Up, and AstraZeneca, as well as recent or current stock/options ownership of Apyx Medical, Verthemia, Intuitive Surgical, Inc., TransEnterix, Inc., Doximity, Moderna, and BioNTech SE. K.L.R. reports travel support from Intuitive Surgical. T.Y.S and M.F. have no conflicts of interest to report., (© 2024 The Authors. Published by Elsevier Inc.)

Aim: The aim of this study is to determine if the core size or size with spicules has a better correlation with the final histologic size of spiculated mass lesions., Methods: A retrospective study of 48-month duration from January 2014 to December 2017 of biopsy-proven invasive ductal carcinoma presenting as spiculated mass lesions on mammogram was conducted., Results: There were 195 patients in the study. The mean of the core size was 16.6 mm; when spicules were included the mean size was 27.4mm and final histologic size 21.1 mm. Using unpaired Student 't' test difference in the means was statistically significant (p<0.0001). Pearson number (R) core size versus final histologic size was 0.535 (P < 0.001) and for size with spicules versus final histologic size was 0.495 (P < 0.001)., Conclusion: Our study demonstrated that the core size has a stronger positive correlation to final histologic size and should be used preoperatively in decision-making about surgery., (Copyright © 2022 Copyright: © 2022 Journal of Cancer Research and Therapeutics.)

Importance: Melanoma accounts for most of the deaths due to skin cancer. In the past decade, effective US Food and Drug Administration (FDA)-approved therapies for melanoma have emerged., Objective: To review changes in the long-term melanoma mortality rate (MMR) trends in the US and determine whether they have any temporal association with the FDA approval of new agents., Design, Setting, and Participants: This cross-sectional study used population data from the Surveillance, Epidemiology, and End Results (SEER) database and retrospectively reviewed the age-adjusted MMR trends in adult patients (aged ≥18 years) from 1975 to 2019 in the US population. The timeline of the FDA approvals for melanoma treatment was also reviewed. Data were analyzed from March 15 to August 15, 2022., Exposures: Outcomes were assessed in association with FDA approval of drugs for the treatment of melanoma., Main Outcomes and Measures: Mortality rates are from the SEER database, reported per 100 000 population and age-adjusted to the 2000 US standard population. The annual percent change (APC) has been used to report long-term trends., Results: After the introduction of newer treatments in 2011 (most after 2013), a significant reduction in MMR was seen from 2013 to 2017 in the US for the first time in the past 40 years. Rates increased from 1975 to 1988 (APC, 1.65% [95% CI, 1.30%-2.00%]; P < .001). No statistically significant change in MMR was seen from 1988 to 2013 (APC, 0.01% [95% CI, -1.10% to 0.12%]; P = .85). The MMR decreased significantly from 2013 to 2017 (APC, -6.28% [95% CI, -8.52% to -3.97%]; P < .001)., Conclusions and Relevance: These findings suggest a benefit associated with the availability of effective therapies in the past decade and further suggest that the use of new pharmacological therapies is associated with decreased MMR in the US population. These data are very encouraging and support the continued development of such therapies. Additionally, the accessibility of these treatments and the associated health care costs need to be addressed.

Background Coronavirus disease 2019 (COVID-19) infection can vary from asymptomatic infection to multi-organ dysfunction. The most serious complication of infection with COVID-19 is death. Various comorbid conditions and inflammatory markers have been associated with an increased risk of mortality, specifically within the immediate post-infection period; however, less is known about long-term mortality outcomes. Objectives Our objective is to determine risk factors associated with six-month mortality in hospitalized COVID-19 patients. Methods This is a single-institution, retrospective study. We included patients hospitalized with COVID-19 from the University of Toledo Medical Center in Toledo, Ohio, who were admitted from March 20, 2020, to June 30, 2021. This study was approved by a biomedical institutional review board at the University of Toledo. Patients with available pre-stored blood samples for laboratory testing were included, and hospital charts were assessed up to six months from the date of a positive COVID-19 test result. Two groups were created based on the mortality outcome at six months from COVID-19 positive test results: survivors and non-survivors. The clinical variables or outcomes and laboratory values were compared between the two groups using non-parametric methods due to the small sample size and non-normality of the data. Either the Mann-Whitney U-test for continuous variables or Fisher's exact test for categorical variables was used for statistical analysis. Results Lactate dehydrogenase (LDH) and D-dimer levels on admission were found to be significantly higher in non-survivors than in survivors. The median high D-dimer level in non-survivors was 5.96 micrograms/milliliter (μg/mL) (interquartile range (IQR): 3.95-11.29 μg/mL) vs 1.82 μg/mL (IQR 1.13-5.55 μg/mL) in survivors (p = 0.019). Median LDH levels were also higher in non-survivors vs survivors, i.e., 621.00 international units per liter (IU/L) (IQR 440.00-849.00 IU/L) vs 328.00 IU/L (IQR 274.00-529.00 IU/L), respectively (p = 0.032). The demographic profile, comorbidity profile, and laboratory data (typically associated with short-term mortality, inflammation, and organ dysfunction) were similar between survivors and non-survivors, except for LDH and D-dimer. Conclusion Higher LDH and D-dimer levels on admission were found to be associated with an increased six-month mortality rate in hospitalized COVID-19 patients. These hematologic data can serve as risk stratification tools to prevent long-term mortality outcomes and provide proactive clinical care in hospitalized COVID-19 patients., Competing Interests: Separate study data from this study has been published from the same project in this journal. https://www.cureus.com/articles/104450-prevalence-and-clinical-significance-of-antiphospholipid-antibodies-in-hospitalized-patients-with-covid-19-infection., (Copyright © 2022, Kahlon et al.)

An elevated risk of myeloma precursor disease, monoclonal gammopathy of undetermined significance (MGUS), was identified among Fire Department of the City of New York (FDNY) World Trade Center (WTC)-exposed firefighters. Further investigation was needed to determine if these findings were reproducible in a more heterogeneous WTC-exposed rescue/recovery workers cohort, the Stony Brook University-General Responder Cohort GRC (SBU-GRC). MGUS risk was compared between the cohorts and to published general population estimates from Olmsted County, MN, USA. In this observational seroprevalence study, odds ratios (OR) and age-standardized risk ratios (RR) of MGUS (M-spike and light-chain-MGUS combined), M-spike, and light-chain-MGUS were estimated using logistic regression. Age-standardized prevalences were calculated for white males aged 50-79; RRs were estimated by comparing risk in the WTC-exposed cohort with the Olmsted County screened cohort. SBU-GRC had elevated odds of MGUS compared with FDNY (OR = 1.38; 95%CI = 1.00-1.89). The age-standardized prevalence of MGUS was 9.0/100 persons (95%CI = 7.5-10.6), over two-fold higher than the general population (RR = 2.08; 95%CI = 1.72-2.51); the age-standardized prevalence of light-chain-MGUS was 3.5-fold higher (RR = 3.54; 95%CI = 2.52-4.97). This study adds to mounting evidence supporting an association between WTC/environmental exposures and MGUS among rescue/recovery workers. Access to MGUS screenings for the entire WTC-exposed cohort could allow for treatment interventions that improve survival., (© 2022. The Author(s).)

Background: Coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of arterial thromboembolic events (ATE) and venous thromboembolic events (VTE). Hypercoagulability associated with COVID-19 infection is multifactorial, and underlying pathogenic mechanisms potentially responsible for thrombosis include inflammation resulting in endothelial damage, platelet activation and the presence of antiphospholipid antibodies (APAs). Antiphospholipid antibody syndrome is one of the very few causes which is associated with venous and arterial thromboembolic events. COVID-19 patients have a high prevalence of APAs as well as both ATE and VTE, but their clinical significance in COVID-19 patients is not fully understood yet., Objectives: In this study, we intend to find the prevalence of APAs in hospitalized COVID-19 patients at the time of diagnosis and determine whether their presence has any clinical significance., Methods: This is a retrospective single-institution study involving patients hospitalized for the management of COVID-19 infection at The University of Toledo Medical Center. After obtaining approval from the biomedical institutional review board at The University of Toledo, antiphospholipid antibody (APA) testing was done on pre-stored blood samples of these patients and hospital charts were reviewed till six months from the positive COVID-19 test result. Two groups were created based on the patients' APA testing results (APA positive and APA negative) and used for statistical comparison. Any patients with positive lupus anticoagulant (LA) or abnormal titers APA antibodies were labeled as positive. Demographic data, prognostic outcomes and laboratory values were compared either using Mann-Whitney U-test for continuous variables or Fisher's exact test for categorical variables., Results: The prevalence of APAs in hospitalized COVID-19 patients at the time of diagnosis was 39.3% in this study. There was no difference in demographic variables between the APA-positive and APA-negative groups. The prevalence of APAs was higher in smokers, where 91% of the APA-positive patients were smokers. There was no statistically significant difference in prognostic outcomes including six-month mortality between APA-positive and APA-negative patients. The comorbidity profile was the same in the two groups. APA-positive patients were found to have lower nadir of absolute lymphocyte count and higher nadir levels of C-reactive protein during hospitalization., Conclusions: The prevalence of APA positivity in hospitalized COVID-19 patients is higher in our study than in historical studies involving non-COVID-19 hospitalized patients, particularly in smokers. However, there is no correlation between APA positivity and prognostic outcomes including six-month mortality. At this point, it is unclear whether APAs are just bystanders or have a pathogenic role. Routine testing of APA in COVID-19 patients is not indicated. Further prospective studies to elucidate the persistence and clinical implications of APAs are needed., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Kahlon et al.)

Background: Maintaining body weight is a delicate balance achieved by proper nutrition, optimal sleep, stress management and adequate exercise. The COVID-19 pandemic and the subsequent lockdown presented unique challenges including access to a proper diet and/or right physical activity and change in stress levels as well as changes in sleep duration and pattern., Methods: Patients in an outpatient practice were handed the survey questionnaire which they patients completed and handed back at check out. This was a one-time survey. Questions included information about weight before and after lockdown/stay at home order, food intake, physical activity, sleep and stress levels. Using IBM SPSS Statistics Software analysis of variance was calculated for each group with a determined alpha value of 0.05. This was used to determine statistical significance in weight change between the groups., Results: A significant difference in weight change based on patients' self-report of change in stress levels was found with p = 0.04. Of individuals who reported a decrease in stress had a mean weight loss of 3.58lbs, while individuals who reported an increase in stress reported a weight gain of 2.39lbs., Conclusion: In our study, we did find that the COVID restrictions have impacted all the above-mentioned lifestyle contributors, but we could only derive significant association between decreased stress and weight loss. Although we did see weight changes with change in all the above variables, it was not statistically significant., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Cellular therapies including allogeneic hematopoietic cell transplant (allo-HCT) and autologous hematopoietic cell transplant (auto-HCT) and chimeric antigen receptor (CAR) T-cell therapy render patients severely immunocompromised for extended periods after therapy, and data on responses to COVID-19 vaccines are limited. We analyzed anti-SARS-CoV-2 spike IgG Ab (spike Ab) titers and neutralizing Ab among 217 recipients of cellular treatments (allo-HCT, n = 149; auto-HCT, n = 61; CAR T-cell therapy, n = 7). At 3 months after vaccination, 188 patients (87%) had positive spike Ab levels and 139 (77%) had positive neutralization activity compared with 100% for both in 54 concurrent healthy controls. Time from cellular therapy to vaccination and immune recovery post-cellular therapy were associated with response. Vaccination against COVID-19 is an important component of post-cellular therapy care, and predictors of quantitative and qualitative response are critical in informing clinical decisions about optimal timing of vaccines and the requirement for booster doses., Significance: Identifying predictors of response to vaccination against SARS-CoV-2 in patients following cellular therapy is critical to managing this highly vulnerable patient population. To date, this is the most comprehensive study evaluating quantitative and qualitative responses to vaccination, providing parameters most predictive of response and potentially informing booster vaccination strategies. See related article by Chung et al., p. 568 . This article is highlighted in the In This Issue feature, p. 549 ., (©2021 American Association for Cancer Research.)

Coronavirus disease-19 (COVID-19) vaccine response data for patients with hematologic malignancy, who carry high risk for severe COVID-19 illness, are incomplete. In a study of 551 hematologic malignancy patients with leukemia, lymphoma, and multiple myeloma, anti-SARS-CoV-2 spike IgG titers and neutralizing activity were measured at 1 and 3 months from initial vaccination. Compared with healthy controls, patients with hematologic malignancy had attenuated antibody titers at 1 and 3 months. Furthermore, patients with hematologic malignancy had markedly diminished neutralizing capacity of 26.3% at 1 month and 43.6% at 3 months, despite positive seroconversion rates of 51.5% and 68.9% at the respective time points. Healthy controls had 93.2% and 100% neutralizing capacity at 1 and 3 months, respectively. Patients with leukemia, lymphoma, and multiple myeloma on observation had uniformly blunted responses. Treatment with Bruton tyrosine kinase inhibitors, venetoclax, phosphoinositide 3-kinase inhibitors, anti-CD19/CD20-directed therapies, and anti-CD38/B-cell maturation antigen-directed therapies substantially hindered responses, but single-agent immunomodulatory agents did not., Significance: Patients with hematologic malignancy have compromised COVID-19 vaccine responses at baseline that are further suppressed by active therapy, with many patients having insufficient neutralizing capacity despite positive antibody titers. Refining vaccine response parameters is critical to guiding clinical care, including the indication for booster vaccines, for this vulnerable population. See related article by Tamari et al., p. 577 . This article is highlighted in the In This Issue feature, p. 549 ., (©2021 American Association for Cancer Research.)

A previously healthy 10-year-old boy presented to the emergency department with central abdominal pain, loose stool and vomiting. He was diagnosed with gastroenteritis, but was well enough to be discharged. The next day he reattended with ongoing diarrhoea and vomiting, with the pain now localised to the right iliac fossa (RIF). Acute appendicitis was suspected, and he was taken for laparoscopic appendicectomy. At surgery, a gangrenous appendix was found, with pus extending from the pelvis up to the liver. The appendix was excised and thorough peritoneal washout performed. Postoperatively, he received 48 hours of intravenous antibiotics and was discharged home. Unfortunately the boy presented again 11 days later with right lower quadrant pain and fever. Ultrasound revealed a collection in the RIF, and he returned to theatre for washout. His recovery was slow until the peritoneal pus sent for bacterial culture grew Salmonella enteritidis, identification of which facilitated appropriate antibiotic treatment., (2016 BMJ Publishing Group Ltd.)

Introduction: Informed consent, as the declaration of patients' will, forms the basis of legality of medical procedures. A standard form based on the Department of Health model is widely used in the National Health Service (NHS). The aim of this audit process was to assess the current consent practice in comparison to the UK's General Medical Council guidance and local policy and make any appropriate improvements., Patients and Methods: 254 adult consent forms were reviewed during the patients' admission. Data collected included legible documentation, grade of health professional completing the consent form, providing additional written information, use of abbreviations, securing the consent form in the medical records and, providing a copy to the patient. After initial assessment, interventions in an attempt to improve adherence to guidelines were introduced. A repeat audit of a further set of 110 notes was completed to assess the effectiveness of our interventions., Results: Our baseline assessment of 254 consent forms comprised of 198 (78%) elective and 56 (22%) emergency procedures. 87 (34%) consent forms were secure in the medical records. Grade of health professional was recorded in 211 (83%). 191 (75%) forms were legible. 48 (19%) patients were given copy of the consent. Only 24 (9%) patients were given additional written information. Abbreviations were used in 68 (27%) forms. Only 12 (5%) of consent forms met all criteria simultaneously. Re-audit after intervention assessed 110 consent forms; 30 (27%) for elective and 80 (72%) for emergency procedures. 52 (47%) of consent forms were secure in medical records, grade of health professional was recorded in 94 (85%), 101 (75%) forms were legible, 42 (38%) patients received copy of consent and 41 (37%) of patients received additional written information., Conclusion: Initially only 5% of consent forms completely met GMC guidelines. This demonstrates an alarmingly poor adherence to such guidance that plays a vital role in patient safety, patient ethics autonomy, not to mention potential medico-legal and clinical governance implications for surgical practice. Our intervention has improved the quality of consenting within our hospital according to these guidelines. With these interventions set to continue and further develop, we expect that the quality of the consenting process will continue to provide patients with all that it is designed to.

Background: Diagnostic thyroid lobectomy is performed to resolve the dilemma of indeterminate (Thy3) cytology of thyroid nodules. But on final histology most nodules are benign thereby subjecting this group of patients to surgery with its associated risks., Aim: To determine the proportion of cancers in patients with indeterminate thyroid nodules., Patients and Methods: This is a retrospective observational study of 621 patients who underwent fine needle aspiration cytology (FNAC) of their thyroid nodules over a 60 month period in a district general hospital. Patient demographics, cytology and final histology results were extracted from the hospital database., Results: On final analysis, 48 patients had an indeterminate cytology (7.7%) and 12 patients had cancer in this group (25%) following diagnostic lobectomy., Conclusion: Till an alternative robust technology becomes widely available we need to continue to perform diagnostic lobectomy in patients with indeterminate cytology in view of the high incidence of thyroid cancer in this group of patients.

Introduction: We present a case of primary gastrointestinal tuberculosis that has culminated in ulcer formation, in the absence of pulmonary involvement in an immunocompetent patient., Presentation of Case: A 28-year-old Asian male presented to casualty with a 1-week history of epigastric cramping abdominal pain and several episodes of non-bilious vomiting. The patient deteriorated clinically, becoming more cachectic and given his unexplained weight loss, an oesophageal-gastro-duodenal endoscopic imaging confirmed a duodenal ulcer. The biopsy of the non-healing ulcer was the hallmark of the disease, revealing evidence of granulomatous inflammation consistent with tuberculosis bacilli., Discussion: Gastrointestinal tuberculosis with ulceration is rare with respect to the oesophagus, stomach and duodenum. This case proves to be unique, as our patient had experienced primary isolated gastric tuberculosis in the absence of pulmonary tuberculosis in a healthy individual. Immunohistochemical staining, histopathology and radiological investigations have demonstrated their importance in confirming abdominal tuberculosis and the extent of bowel involvement., Conclusion: This case has illustrated the difficulties associated with a prompt diagnosis of an unusual case of primary duodenal tuberculosis from chronic peptic ulcer disease in an immunocompetent patient., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The pre-operative size of breast tumour is the most important factor in determining feasibility of breast conserving surgery in operable breast cancer. Currently there is no consensus on the most accurate modality to measure tumour size. A prospective study of consecutive and unselected symptomatic patients with invasive breast cancer who had primary surgery between January 2006 and December 2007 was conducted. Patients with multi-focal and multi-centric tumours were excluded. The aim of this study was to find the correlation between histological size of invasive breast cancer and pre-operative tumour size as measured by ultrasound. Over this two year period, data for 192 patients was analysed for this study. The mean tumour diameter on ultrasound and histology was 19.5mm and 29 mm respectively. The difference between the means in the two modalities was found to be statistically significant (P<0.001).Ultrasound underestimates the true size of breast tumours as determined histologically. Inaccurate tumour size measurements may result in re-operations to achieve adequate margins.

Objective: This study was undertaken to examine the outcomes of surgery for active infective endocarditis., Methods: Fifty consecutive patients underwent surgery for active infective endocarditis in a tertiary care center between January 2000 and June 2003. Modified Duke Criteria was used to include the patients in the study., Results: Mean age of the patients was 55.72 years (range 18-89 years). Underlying heart disease was the most common cause of acute infection, accounting for 30 % of all the cases. 16 % patients had a recent dental procedure and 10 % had a recent surgical procedure. The most common infective organism was staphylococcus aureus (24%), followed by streptococcus viridians (20%). The most common indications for surgery were congestive heart failure (CHF) (52%), embolic phenomenon (18%) and septic shock (10%). Most common postoperative complication was respiratory failure (30%) followed by renal failure (24%) pacemaker implantation 22%; stroke 18%, bleeding 16% and GI bleeding 2 %. Seven out of 50 patients died during hospital course that accounts for 14% of the motility rate., Conclusions: Surgery for endocarditis continues to be challenging and associated with high operative mortality and morbidity. Age, shock, prosthetic valve endocarditis, impaired ventricular function, and recurrent infections adversely affect long-term survival.

Aims and Objectives: To study the effect of Heart Rate Variability (HRV) and QT dispersion (QTd) in patients presenting with Acute ST elevation myocardial infarction (STEMI)., Methods: This is a retrospective study conducted on patients admitted with the diagnosis of acute ST elevation myocardial infarction. In all 100 patients with acute myocardial infarction in one year were subjected to a complete evaluation in terms of history and examination. Besides routine investigations standard 12 lead ECG was evaluated in all cases on admission, after 4 hrs, 24 hrs, 48 hrs and on discharge., Results: The most common presenting symptoms were chest pain (88%) and dyspnea (50%). Tachycardia was seen in 56% while congestive heart failure was present in 29% patients. Patients who died had a higher QTd in comparison to patients who survived., Conclusions: Markers of autonomic regulation of heart like QTd provides valuable information about the future course of events in a patient following acute STEMI which can be utilized to plan the future course of management in patients especially predisposed to adverse and catastrophic outcomes.

Introduction: Gastro-intestinal stromal tumours are the most common mesenchymal tumours of the gastro-intestinal tract. This case report highlights the necessity of early surgical intervention in such cases to avoid mortality due to rebleeding and to raise the awareness of rare causes of upper gastrointestinal bleed and their management., Case Presentation: A 61-year-old male presented to the accident and emergency department with a one-day history of haemetemesis with coffee ground vomiting. After initial resuscitation, he underwent upper gastrointestinal endoscopy under sedation which demonstrated a large, bleeding, gastric mass with a central crater along the greater curvature of the stomach. A partial gastrectomy was performed taking a wedge of the stomach with clearance from the tumour, with no signs of extraperitoneal disease., Conclusion: Early surgical intervention, either open or laparoscopic resection, is the treatment of choice to prevent rebleeds. In general, complete surgical resection is accomplished in 40-60% of all gastro-intestinal stromal tumours patients, and in >70% of those with primary non- metastatic gastro-intestinal stromal tumour. In our case we had completely excised the tumour. Following surgery, all patients must be referred to centres which have more experience in treating gastro-intestinal stromal tumours. Imatinib is proven to be the first effective systemic therapy in cases of unresectable or metastatic disease. All gastro-intestinal stromal tumours have the potential for aggressive behaviour with the risk being estimated from tumour size and mitotic count.

Patients who present with a co-existing connective tissue disorder add a degree of complexity to operative intervention. We present an unusual case of a 53-year-old Caucasian female patient with Ehlers Danlos syndrome who presented with an occult perforation of the distal ileum. The patient had known small bowel diverticulae yet the perforation occurred within the normal bowel wall. The pre-operative CT only showed malrotation of the large bowel and did not correlate with the intra-operative findings. Our case has highlighted that although small bowel perforation is a rare occurrence, it may be more common in Ehlers Danlos and may present with atypical features. Perforation may also occur alongside normal bowel as well as diverticulae within the bowel. Where diverticulae exists within a patient with Ehlers Danlos syndrome and there is some diagnostic uncertainty, there should be a lower threshold for operative intervention. We present in the discussion a number of salient features and learning points.