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Phyllodes tumor (PT) is a rare benign tumor with malignant potential. There have been few case reports that have described this condition. We report the case of a 61-year-old woman with a “giant” borderline PT who underwent a modified radical left breast mastectomy with left axillary lymph node dissection, followed by chest wall reconstruction using serratus anterior and pectoralis major muscle flap coverage. A breast tissue measuring 22.5 × 18.5 × 12.5 cm and weighing a total of 5.2 lbs was resected. A case report like this can provide further information on surgical management of the tumor and the importance of an early diagnosis. In addition, PTs are rare to find in patients and this case will further contribute to the literature regarding PT. J Curr Surg. 2021;11(3):69-72 doi: https://doi.org/10.14740/jcs445

Background: In October 2016 the American Joint Committee on Cancer published the early eighth edition breast cancer prognostic staging system, incorporating biomarkers into previously accepted staging. The updated and current eighth edition became effective nationwide in January 2018 after a large update to its staging guidelines. This study’s aim was to compare patients’ anatomic seventh edition (anatomic), early eighth (pre-update, prognostic), and current eighth (post-update, prognostic) pathological stages and to assess the utility of recent inclusions to staging criteria. Additionally, we observed how the aforementioned stage changes aligned with breast cancer histologic subtypes. Methods: An Institutional Review Board (IRB)-approved retrospective chart review was performed. Inclusion criteria included female patients between the ages of 35 to 95 years with a diagnosis of invasive ductal or lobular carcinoma of the breast (n = 100) at three Hackensack Meridian Health hospitals. The study evaluated any trends in patients’ stage changes between the seventh edition, early eighth edition, and current eighth edition breast cancer staging guidelines. Breast cancer restaging was performed using a novel staging tool on Microsoft Excel. Results: Only 26% of patients’ stages changed when comparing the seventh edition stage vs. current eighth edition prognostic staging, most of which were downstaged. When comparing the seventh with early eighth edition prognostic staging, 38% of the patients’ stages changed, with a majority of them being upstaged. Lastly, 95% of total stage changes were downstages between the early eighth and current eighth edition staging guidelines. Conclusions: When comparing the seventh edition vs. current eighth edition staging, few patients (especially those with early stage cancer) underwent a stage change. However, there were significant changes in stage when comparing early eighth vs. current eighth stages. Considering these changes were mostly downstages and many patients reverted to their original seventh edition stage, the current eighth edition is based on a personalized, less radical staging approach, one that is more synonymous with original seventh edition staging. J Clin Med Res. 2019;11(6):407-414 doi: https://doi.org/10.14740/jocmr3803

Background Despite evidence that high-sensitivity cardiac troponin (hs-cTn) levels in women are lower than in men, a single threshold based on the 99th percentile upper reference limit of the overall reference population is commonly used to diagnose myocardial infarction in clinical practice. This trial aims to determine whether the use of a lower female-specific hs-cTn threshold would improve the diagnosis, treatment, and outcomes of women presenting to the emergency department with symptoms suggestive of myocardial ischemia. Methods/Design CODE-MI (hs-cTn—Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women) is a multicenter, stepped-wedge, cluster-randomized trial of 30 secondary and tertiary care hospitals across 8 Canadian provinces, with the unit of randomization being the hospital. All adults (≥20 years of age) presenting to the emergency department with symptoms suggestive of myocardial ischemia and at least 1 hs-cTn test are eligible for inclusion. Over five, 5-month intervals, hospitals will be randomized to implement lower female hs-cTn thresholds according to the assay being used at each site. Men will continue to be assessed using the overall thresholds throughout. Women with a peak hs-cTn value between the female-specific and the overall thresholds will form our primary cohort. The primary outcome, a 1-year composite of all-cause mortality or readmission for nonfatal myocardial infarction, incident heart failure, or emergent/urgent coronary revascularization, will be compared before and after the implementation of female thresholds using mixed-effects logistic regression models. The cohort and outcomes will be obtained from routinely collected administrative data. The trial is designed to detect a 20% relative risk difference in the primary outcome, or a 2.2% absolute difference, with 82% power. Conclusions This pragmatic trial will assess whether adopting lower female hs-cTn thresholds leads to appropriate assessment of women with symptoms suggestive of myocardial infarction, thereby improving treatment and outcomes.

BACKGROUND The Chedoke Arm and Hand Activity Inventory (CAHAI) is an assessment of upper limb function designed for use in the stroke population. The CAHAI has strong reliability and validity in this population; however, it is unknown whether this measure can be used with other clinical populations such as acquired brain injury (ABI). PURPOSE The purpose of this study was to estimate the inter-rater reliability of the CAHAI when used with persons with ABI. METHODS The research design was an observational parameter estimation study. The administration of the CAHAI was videotaped for 6 persons with ABI. To estimate inter-rater reliability each video was assessed independently by 6 clinicians yielding a total of 36 assessments. A Latin square design was used to balance the order raters evaluated the videos. Shrout and Fleiss Type 2,1 intra class correlation coefficients (ICC) and standard error of measurement (SEM) were calculated to estimate inter-rater reliability of the CAHAI. RESULTS Inter-rater reliability was high ICC = 0.96 (95% CL: 0.88, 0.99) and the SEM was 3.35 (95% CL: 2.63, 4.63) CAHAI points. CONCLUSIONS These results suggest that the CAHAI, although designed for use in the stroke population, can be used reliably in the ABI population.

Summary Background Acute Graft Versus Host Disease (GVHD) affects about 20%–80% of the patients after the hematopoietic stem cell transplant (HSCT) and it is amongst the main causes of morbidity and mortality both in children and adults. The intestine is one of the most affected organs by GVHD causing important alterations in the nutritional status and quality of life, considering that the dysfunctional intestine could decrease food intake as well as an inappropriate dietary plan could worsen the clinical condition. In addition to GVHD, chemotherapy conditioning regimen suppresses the immune system, promotes mucositis and increases the risk of infectious complications. Taking the above into consideration, when per oral diet is possible; the food choices should be carefully planned and monitored to promote nutritional support and avoid worsening the intestinal function and clinical condition. Objective This work was aimed to present a practice guideline proposal, to be validated, based on literature review, regarding to oral dietary recommendations for acute intestinal GVHD after HTSC. Methods Two research phases were defined: Phase one: evidence-based literature review; Phase 2: Practice Guideline Proposal. 1: Evidence based literature review Search methods A literature review (1997–2019) was performed including PubMed, in English, and Lilacs, in Portuguese electronic database to address the subject of dietary intervention for intestinal GVHD related to the HSCT, with children and adults, whose receiving oral or tube feeding nutrition therapy. Selection criteria The study selection was based on the PRISMA method. Controlled clinical trials were searched. Randomization was not possible considering the rare condition. Data collection and analysis Two independent authors assessed the abstracts of the selected studies to determine the articles feasible to compose the review as the base to elaborate the practice guideline proposal protocol, object of the present study. To determine the level of evidence of the selected article, GRADE criteria were used. Main results One controlled clinical trial study was included. The study was developed in Japan with a total of 35 patients. The dietary plan was characterized by gradual increasing food consistency/density. They found better nutritional parameters in the treated group, however, following GRADE criteria, we rated the quality of evidence as very low. Authors' conclusions We could not demonstrate confidence in the effect estimate based on the selected study. However, considering the lack of literature information and the relevance of the topic, we decided to proceed and propose a practice guideline for an oral diet protocol for acute intestinal GVHD as a reference to be a starting point to validate protocols in future clinical trials. 2: Practice Guideline Proposal The criteria to elaborate the protocol were based on the RIGHT Statement. In addition to the literate information about diet and intestinal health, recommendations already adopted in the Service of Bone Marrow Transplant in the Complex Hospital of Clinics of Curitiba, in the state of Parana, Brazil, were also considered.

e14146 Background: Breast cancer (BC) is the most common invasive cancer in adult females.The role of preoperative MRI in assessing the extent of primary breast cancer remains controversial. This study’s objective is to determine if MRIs performed after the diagnosis of invasive/non-invasive-breast cancer will identify additional breast cancers. We hypothesize that preoperative MRIs will result in the discovery of additional significant lesions, leading to changes in surgical treatment. Methods: A retrospective study of 389 BC patient charts were reviewed, dated from January 2000- July 2019. Files were collected from an office in the Breast Cancer Surgery Department. Information on each patient’s imaging studies, treatment, demographics, surgery, and pathology were collected and stored in anonline cloud system. Summary statistics, including proportions, percentages, and difference of proportion hypothesis tests were utilized to interpret the data. All statistical tests were conducted at a 95% confidence interval. Results: We reviewed the charts of 335 patients that met eligibility criteria. In 221 newly diagnosed cancers, a preoperative MRI was taken before treatment. 127 cancers (57.5%)showed additional finding.In BC patients with additional preoperative MRI findings, we observed 61.4%true positive and 38.6%false positive results. These values are comparable to prior studies.We determined that the treatment plan was altered in 17.6%of all patients who received an MRI and in 30.7%of patients with a true positive MRI finding, which is also consistent with previous literature.A majority of the treatment changes were from Lumpectomy to Mastectomy. Conclusions: Literature on MRI use in BC diagnosis exists; our study differs by focusing on newly diagnosed breast cancers.We discovered 35.3% of preoperative MRIs identified a true additional finding in known breast cancer. In addition, our true positive rate (61.4%) and false positive rate (22.2%) of MRI findings is comparable to those of previous studies. Plans were changed in 30.7% of additional findings supporting the idea that preoperative MRI studies are useful when organizing surgical treatment. Further studies to demonstrate the impact on local recurrence rates and overall survival, may clarify the true role of pre-operative MRI in these cases.

Purpose: The purpose of this study was to estimate the interrater reliability of three shortened versions of the Chedoke Arm and Hand Activity Inventory (CAHAI-7, CAHAI-8, CAHAI-9) when used with persons with acquired brain injury (ABI). The CAHAI is an assessment of upper limb function with high reliability in the stroke and ABI populations. In the stroke population, three shortened versions of the measure have established reliability. Clinicians report time constraints as a barrier to using standardized assessments; thus, establishing the reliability of the shortened versions of the CAHAI in the ABI population may increase the use of this measure. Method: This was an observational, parameter estimation study. The participants were recruited from an in-patient ABI rehabilitation programme. The administration of the CAHAI to six persons with ABI was video recorded, and the video recordings were assessed by six clinicians to estimate interrater reliability. A Latin square design was used to balance the order in which the raters evaluated the videos. A repeated-measures analysis of variance was performed, and the variance components were used to calculate an intra-class correlation coefficient (ICC) and standard error of measurement (SEM) with 95% confidence limits (CLs) for each of the shortened versions. Results: Interrater reliability was high for all three versions: CAHAI-7, ICC=0.96 (95% CL: 0.89, 0.99; SEM 2.65); CAHAI-8, ICC=0.96 (95% CL: 0.90, 0.99; SEM 2.72); and CAHAI-9, ICC=0.95 (95% CL: 0.85, 0.99; SEM 3.49). Conclusions: These results suggest that the three shortened versions of the CAHAI demonstrate high reliability in the ABI population. These versions may be particularly useful when time constraints or patient tolerance are an issue.

Spasticity is a common impairment following an upper motor neuron lesion in conditions such as stroke and brain injury. A clinical issue is how to best quantify and measure spasticity. Recently, research has been performed to develop new methods of spasticity quantification using various systems. This paper follows up on previous work taking a closer look at the role of transversal forces obtained via rehabilitation robot for motions in the para-sagittal plane. Results from 45 healthy individuals and 40 individuals with acquired brain injury demonstrate that although the passive upper motions are vertical, horizontal forces into and away from the individual's body demonstrate a relationship with the Modified Ashworth Scale. This finding leads the way to new avenues of spasticity quantification and monitoring.

Introduction Assessment of velocity dependent resistance (VDR) can provide insights into spasticity in individuals with upper motor neuron syndrome. This study investigates the relationship between Modified Ashworth scores and a biomechanical based representation of VDR using a rehabilitation robot. Comparisons in VDR are made for the upper limb (UL) between individuals with acquired brain injury and healthy controls for the para-sagittal plane. Methods The system manipulates the individual’s limb through five flexion and extension motions at increasing speeds to obtain force profiles at different velocities. An approximation of VDR is calculated and analyzed statistically against clinical scales and tested for interactions. Results All individuals (aged 18–65), including healthy controls exhibited VDR greater than 0 (P Conclusion The robot can detect and quantify VDR that captures information relevant to UL spasticity. Results suggests a better categorization of VDR is possible and supports further development of rehabilitation robotics for assisting spasticity assessment.

The purpose of this exploratory study was to determine the feasibility and effectiveness of using guided interactions with horses as a nonpharmaceutical intervention to improve the physiological and behavioral states of persons with dementia. A convenience sample of persons with dementia was recruited from an adult day health center (n = 16). A multi-component intervention was implemented comprised of opportunities for grooming, painting, and leading horses. Using a randomized pretest-posttest crossover design, researchers compared participants receiving the equine-assisted intervention with participants receiving treatment as usual. Older persons with Alzheimer's disease and related dementias engaged positively in animal-assisted therapy with horses. A reduction in behavioral problems was found post intervention in contrast to the comparison group. Pre-intervention measures showed that participants exhibited lower levels of disruptive behaviors compared with the control group on the days they wer...

This paper describes initial testing of a spasticity assessment system for passive elbow flexion/extension motions using a robotic manipulator. Quantitative force data was collected from healthy individuals. As repetition and speed were increased, significant differences in measured force were found in a study with a high speeds (n=48), but were not found in a study with a lower speeds (n=52). This result assists clinicians who now possess a baseline of healthy data to which quantitative patient data can be compared. Future developments include contrasting healthy baseline values to clinical trial data from individuals with stroke or acquired brain injury.

Pneumonia is the third most frequent admission diagnosis at Macomb Hospital Center. The average length of stay for this diagnosis (DRGs 89 and 90) was 9.07 days. After the initiation of a critical pathway that begins in the emergency department, the average length of stay decreased to 7.11 days. Quality of care also improved in two areas: the time elapsed before delivery of antibiotics and availability of X-ray reports. This article reviews the implementation and results of the critical pathway for pneumonia.

This is a randomised cross-over study designed to access the effect of position on urodynamic investigation of women with urinary incontinence. Women were investigated in the supine and sitting positions. There was small, not statistically significant difference in total bladder volume. Total bladder volume was nearer to women's actual bladder capacity in the sitting position. There was no difference in bladder volume at first sensation or normal desire in both positions. There was a small, not statistically significant difference in bladder volume at strong desire and urgency. Women felt strong desire and urgency at lower bladder volumes in the sitting position. There was no clear patient preference for one position over the other.

The case study presented involved an 87-year-old Hispanic man who was transferred to the emergency department (ED) of an acute care hospital. The patient was complaining of left hip pain and hitting his head. The patient had fallen backward upon standing from a wheelchair, lost his balance, and suffered an occipital laceration with hematoma. There was a brief loss of consciousness after hitting his head. An external pelvic stabilizer was placed on the patient's pelvis in an attempt to stabilize the comminuted pelvic fractures. Because of the patient's comorbidities and unstable condition, the consulting physician specialists determined that the patient was not a surgical or interventional candidate. Self-tamponed of retroperitoneal bleeding occurred without intervention of angiogram with embolization or laparotomy. A decision was made among the patient, the patient's stepchildren, and the attending physicians for a do-not-resuscitate order. The patient was then transferred to a palliative care unit outside the hospital. This case discusses the physiological changes in geriatric patients and the management of geriatric patients with pelvic trauma and retroperitoneal bleeding.

Objective Preoperative lymphoscintigraphy (PLS) combined with intraoperative gamma probe (GP) localization is standard procedure for localizing the sentinel lymph nodes (SLN) in melanoma and breast cancer. In this study, we evaluated the ability of a novel intraoperative handheld gamma camera (IHGC) to image SLNs during surgery. Methods The IHGC is a small-field-of-view camera optimized for real-time imaging of lymphatic drainage patterns. Unlike conventional cameras, the IHGC can acquire useful images in a few seconds in a free-running fashion and be moved manually around the patient to find a suitable view of the node. Thirty-nine melanoma and eleven breast cancer patients underwent a modified SLN biopsy protocol in which nodes localized with the GP were imaged with the IHGC. The IHGC was also used to localize additional nodes that could not be found with the GP. Results The removal of 104 radioactive SLNs was confirmed ex vivo by GP counting. In vivo, the relative node detection sensitivity was 88.5 (82.3, 94.6)% for the IHGC (used in conjunction with the GP) and 94.2 (89.7, 98.7)% for the GP alone, a difference not found to be statistically significant (McNemar test, p = 0.24). Conclusion Small radioactive SLNs can be visualized intraoperatively using the IHGC with exposure time of 20 s or less, with no significant difference in node detection sensitivity compared to a GP. The IHGC is a useful complement to the GP, especially for SLNs that are difficult to locate with the GP alone.

It was a cold and windy January day in Montreal. The pediatric emergency department’s (PED) waiting room was full of sick children. Most of them had high fever and were either coughing, crying, or vomiting. The average waiting time to see a doctor was more than 8 hours. Exhausted parents were asking the triage nurse why the waiting time was so long in the brand new emergency department (ED). Couldn’t the nurse understand that their small baby was sick and should have triage priority? As one parent became aggressive, the triage nurse called security. The waiting room looked more like a battlefield.

The success of the Global Polio Eradication Initiative promises to bring large benefits, including sustained improvements in quality of life (i.e., cases of paralytic disease and deaths avoided) and costs saved from cessation of vaccination. Obtaining and maintaining these benefits requires that policymakers manage the transition from the current massive use of oral poliovirus vaccine (OPV) to a world without OPV and free of the risks of potential future reintroductions of live polioviruses. This article describes the analytical journey that began in 2001 with a retrospective case study on polio risk management and led to development of dynamic integrated risk, economic, and decision analysis tools to inform global policies for managing the risks of polio. This analytical journey has provided several key insights and lessons learned that will be useful to future analysts involved in similar complex decision-making processes.

Although pseudomembranous colitis is relatively common following antibiotic exposure, there have been few reported cases of pseudomembrane formation involving the small intestine. Herein we report a case of pseudomembranous enteritis of the small and large intestine that occurred after antibiotic exposure. The etiologic organism appears to be Clostridium difficile, as evidenced by the characteristic pseudomembranous lesions and a positive ELISA for toxin A in an ileal tissue specimen.

Programs that are effective in training health care providers to recognize and meet the needs of victims of intimate partner violence must be identified and replicated. The Centers for Disease Control and Prevention (CDC) has developed criteria for use in developing, enhancing, and evaluating such programs. CDC developed these criteria as a result of continuing efforts to provide useful products for constituents through literature reviews and consultations with experts in the field; evaluations of training programs; creation of an inventory and annotated bibliography of health care provider training programs in the United States and Canada; and development of a framework to assist hospitals and health centers in evaluating their training programs. Training should begin while providers are in professional school and continue in the health care setting. Curricula should be multidisciplinary and should provide information, promote clinical skills, and effectively link providers with resources. Evaluation should assist programs in determining providers' needs and identifying appropriate materials, trainers, and training strategies. CDC is working to establish scientific evidence that provider training programs are effective and to share successful models with others. Providers have an important role in stopping and ultimately preventing intimate partner violence, but they are not alone in this effort. They need to know how to access the growing network of assistance including women's advocates, the criminal justice system, and other members of increasingly dynamic community coalitions.

The diagnosis of stroke, which is diagnosis-related group (DRG) 014, is the fourth most frequent discharge DRG at Macomb Hospital Center, Warren, Michigan. The length of stay for stroke was 7.52 days before intervention. Quality improvement techniques identified areas of delay that presented opportunities for improvement. After the initiation of a critical pathway that begins its interventions in the Emergency Department, the length of stay decreased to 6.33 days. Quality of care was also improved in delivery time of carotid artery ultrasound examinations, as well as in timeliness of obtaining head computed tomography scans and reports. This article describes the development, implementation, and results of a stroke critical pathway that was implemented to address excessive length of stay.

Drosophila photoreceptor cells (R cells) develop from the eye imaginal during the third instar larval stage and acquire their adult morphology during pupation. We show that orthodenticle (otd), a homeobox gene, is required for R-cell morphogenesis during pupation. otdUV-insensitive (otduvi) is a hypomorphic allele of otd that only affects R-cell development. The R-cell rhabdomeres are disorganized in otduvi, and there is a disruption of proximal-distal development in the eye. The otd genomic structure was determined and resulted in the identification of a deletion in the third intron of otduvi. Sequences encompassing this deletion are able to direct expression of the lacZ reporter gene at all stages of the developing visual system, including the photosensitive cells of Bolwig's organ, the ocelli, and the adult eye. The third intron enhancer is the primary regulatory element controlling otd in the R cells and is not under the control of the glass gene.

Background Spasticity is a motor disorder that causes significant disability and impairs function. There are no definitive parameters that assess spasticity and there is no universally accepted definition. Spasticity evaluation is important in determining stages of recovery. It can determine treatment effectiveness as well as how treatment should proceed. This paper presents a novel cross sectional robotic pilot study for the primary purpose of assessment. The system collects force and position data to quantify spasticity through similar motions of the Modified Ashworth Scale (MAS) assessment in the Sagittal plane. Validity of the system is determined based on its ability to measure velocity dependent resistance. Methods Forty individuals with Acquired Brain Injury (ABI) and 45 healthy individuals participated in a robotic pilot study. A linear regression model was applied to determine the effect an ABI has on force data obtained through the robotic system in an effort to validate it. Parameters from the model were compared for both groups. Two techniques were performed in an attempt to classify between healthy and patients. Dynamic Time Warping (DTW) with k-nearest neighbour (KNN) classification is compared to a time-series algorithm using position and force data in a linear discriminant analysis (LDA). Results The system is capable of detecting a velocity dependent resistance (p