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Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient– a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities. How to cite this article: Lahoti O, Abhishetty N, Shetty S. Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7–14-year Follow-up. Strategies Trauma Limb Reconstr 2021;16(2):96–101.

Objectives Central diabetes insipidus (DI) is a known complication following surgical resection of a suprasellar mass. There are limited data analyzing the outcomes of a standardized protocol for the management of postoperative DI in the pediatric population. We sought to fill this gap and hypothesized that utilizing a standardized protocol for fluid management (3-bag system) would reduce serum sodium fluctuations in the postoperative period after suprasellar surgery. Methods A retrospective chart review was performed. Patients were identified with the following criteria: age ≤ 18 years, undergoing a surgical procedure for suprasellar mass that also had postoperative DI. The primary outcome was the variability in serum sodium during the first 48 h and between 48 and 120 h postoperatively. Results There were 21 encounters pre-protocol and 22 encounters post-protocol for neurosurgical procedures. Use of the standardized protocol was associated with a lower range of sodium within 48 h postoperatively (p=0.065) and 83% lower odds of hypernatremia (Na>150 mmol/L) within 48 h postoperatively (CI 0.039–0.714) after controlling for age, gender, and prior DI diagnosis. History of DI conferred a lower risk of hypernatremia as well as less sodium fluctuation within 48 h postoperatively. Younger patients, those Conclusions In patients with postoperative DI after suprasellar surgery, using a standardized protocol for fluid management (3-bag system) appears to reduce serum sodium variability in the first 48 h after surgery.

Suppression of menstruation and/or ovarian function in adolescent girls may be desired for a variety of reasons. Numerous medical options exist. The choice of the appropriate modality for an individual patient depends on several factors based on differences in the efficacy of achieving menstrual suppression as well as in their side effect profiles. Adolescence is also a period of bone mass accrual in girls, and several of these modalities may negatively influence peak bone mass. This review focuses on the efficacy of achieving menstrual suppression and the effect on bone health of the various options through an overview of the current literature and also highlights areas in need of further research.

BACKGROUND AND OBJECTIVE: Dilation and examination during retinopathy of prematurity (ROP) screening can cause systemic complications and even life-threatening adverse events (AEs). The main objective of this study is to assess the prevalence and significance of AEs and changes in vital signs during ROP screenings, and to correlate birth weight, gestational age, and length of exam as possible predictors of these changes. PATIENTS AND METHODS: This is a prospective, observational study that includes 1,360 screening exams from 680 premature infants in two neonatal intensive care units. Systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, and oxygen saturation were monitored from the time that dilating drops were administered until 4 hours after the examination was completed. Any clinical deterioration or complication was documented. RESULTS: Of 1,360 infant screening exams, 153 (11%) screening exams resulted in at least one change in vital sign that alerted the monitor. There was one serious AE requiring bag valve mask resuscitation 30 minutes after dilating drops were placed. Gestational age, birth weight, and length of ROP exam were not significant predictors of AEs. There were statistically significant changes when comparing pre- and post-vital signs following dilation and funduscopy exam. CONCLUSIONS: Although ROP screening exams are essential for at-risk neonates, mydriatic drops and retinal exams can result in changes to vital signs and AEs. It is important to closely monitor neonates during these examinations. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:458–463.]

IOT is expected to be one of the fastest-growing fields in the future years, with a significant impact on the health-care industry. IOT connects individuals by enabling their health and wealth in a smart way. On the Internet of Things, smart health is an essential application. People who require constant monitoring, which cannot be done outside of hospitals, would benefit from smart healthcare. It's especially crucial in rural areas like villages, where surrounding clinics can communicate with city hospitals regarding their patient’s health. This project shows a smart health monitoring system that utilizes biomedical sensors to monitor the patient’s health and the internet to notify concerns. Here are some biomedical sensors. To read the data, they are connected to an Arduino UNO controller. It is then connected to a serial monitor or LCD display look at the outcome. Data is uploaded to a server and stored there so that it can be viewed on a Smartphone. The primary goal of this project is to do thorough study on acquiring sensor data, evaluating it, and delivering feedback to doctors and concerns based on parameters of health.

Oral cancer has posed a challenge to us with its incidence as high as around 20% of total body cancers aim of the study was to quantify serum cotinine level as tobacco exposure-related biomarker in controls, chronic tobacco chewers (High risk for oral cavity malignancy) and oral cavity cancer patients. This was a hospital-based case-control study of 24 months duration in controls, chronic tobacco chewers and oral cancer patients. A total of 150 subjects had enrolled after meeting the inclusion & exclusion criteria. The commonest age group of oral cavity malignancy was 41 to 50 years. Males were found to be more affected than females. Tobacco chewing was the most common habits in a male patient and mishri application in female patients. In this study, 90% of patients had a history of tobacco consumption for the last ten years or more. Frequency of tobacco chewing was more in chronic tobacco chewers (30% in more than ten times a day) compared to oral cavity malignancy group (16% in more than ten times a day). The majority (more than 50%) of patients had tumour arising from the buccal mucosa, and histopathological studies revealed that 48% of patients had well-differentiated squamous cell carcinoma. Serum cotinine level in non-tobacco exposure group is less than 1 ng/mL. Conclusion- Tobacco chewing habit is a high-risk factor for oral cancer. Chronic tobacco chewers can be included in the high-risk group for oral cavity cancer. Serum cotinine level can be used as a tumour marker for oral cancer patients.

Objective: The objective of the present study was to prepare tacrolimus liposomal gel formulations using ethanolic injection technique for efficacious and cost-effective treatment of atopic dermatitis. Methods: The liposomes were prepared using ethanolic injection technique at the drug concentration of 0.1% w/v and optimized by varying the lipid component/ cholesterol ratio and by monitoring particle size, polydispersity and entrapment efficiency. The optimized composition was incorporated into 0.5% Carbopol Ultrez 10 gel for topical application. The developed liposomal gel was evaluated with respect to physicochemical parameters such as pH, viscosity, rheometery and spreadability. Stability study was performed at different temperatures (4°C, 25°C and 40°C) to evaluate the long-term stability. In vitro permeation of tacrolimus gel was studied using freshly excised rat skin on Franz diffusion cell. The therapeutic efficacy study was performed on allergic contact dermatitis model in rats. Results: Stable tacrolimus liposomal gel was successfully formulated using ethanolic injection technique. In-vitro permeation study indicated higher release of the drug (69.7%) as compared to free drug in hydroalcoholic solution (32.8%) and marketed ointment (63.7%). The formulation also showed shear thinning performance, which is a required property of topical formulation. The therapeutic efficacy study in rats indicated that liposomal gel containing 0.1% tacrolimus exhibited better activity as compared to 0.1% marketed tacrolimus ointment. Conclusion: The study indicated that tacrolimus can be effectively incorporated in liposomes by commercially viable rapid ethanolic injection method and can be more efficient for the treatment of atopic dermatitis.

Purpose To describe endogenous endophthalmitis in the setting of Covid-19 pneumonia post recovery. Methods Retrospective review of five patients of endogenous endophthalmitis following Covid-19 disease done. Results All five cases had received systemic corticosteroid for a mean duration of 7 days during severe Covid-19 treatment. Decrease vision was presenting symptom between 1 and 31 days following Covid-19 recovery. All patients had presumed fungal endogenous endophthalmitis based on clinical profile. Four out of five patients subjected to pars plana vitrectomy had microbiologically proven aspergillus species endogenous endophthalmitis on vitreous fluid assessment; two cases each of aspergillus niger and aspergillus fumigates. Four eyes underwent pars plana vitrectomy with silicone oil injection had shown satisfactory anatomical outcome with control of the infection; however, no significant visual gain achieved. Conclusion We reported five cases of aspergillus endogenous endophthalmitis in Covid-19 recovered patients to document the likely presentation of this rising entity and avoid misdiagnosis.

Rhino-orbital-cerebral mucormycosis (ROCM) with intracranial extension is a fatal disease. A case of extensive ROCM, with rare intracranial fungal granuloma, seen in a COVID-19 positive young male is described. A successful therapy consisting of a multidisciplinary approach for sinuses debridement, orbital exenteration, and intracranial granuloma excision was done. Nonseptate hyphae of Mucor and septate filamentous Aspergillus grew concurrently from exenterated orbital specimen.

Purpose: In this study our purpose is to measure the gap length between esophageal atresia and tracheoesophageal fistula and to identify weather different gap lengths play any role in outcome of the patients. Introduction: Tracheoesophageal fistula is an abnormal fistula communication between the oesophagus and trachea. Tracheoesophageal fistula is common surgically correctable congenital anomaly for which newborn admitted in hospital. Outcome of TEF repair depends on many factor like maturity, birth weight, and age at time of presentation, general condition, presence or absence of pneumonia, associated anomaly and gap length. One of such factor is gap length between EA and TEF. We were studding the outcome of the patients with corresponding gap lengths. Material and Method: A total no. of 50 cases were studied during the period of 2 years from November 2017 to November 2019. The cases were divided into two groups according to the measured gap lengths Group A gap length 2 cm (long gap length) total 22 of total 50 cases. The gap between the two oesophageal pouches was meticulously measured with the help of a Vernier calliper and divider scale intra operatively before ligating the TE fistula and before upper pouch mobilization. The final outcome was recorded as the proportion of survivors in these two gap length groups at the time of discharge from the hospital. Result: Most of the reported cases were full term (68%), low birth weight beby (76%) presented at pnd 1(56%) and male to female ratio is nearly equal. Associated anomaly were arm(55%).outcome were assessed, In group A mortality rate is 64.28% and survival rate is 35.71% while in group B mortality rate 90.99%and survival rate is 9.09% Overall survival rate found to be significantly higher in patients with short gap length as compared to long gap length. Post-operative complication were also studied like sepsis, anastomotic leak, vomiting, respiratory distress, dysphagia, recurrent pneumonia and failure to thrive. Conclusion: Mortality rate was found to have a direct proportional relationship with the gap length... Overall mortality found to be higher in patients with long gap length as compared to short gap length, thus concluded that gap length is an important predictor of the outcome of treatment or survival of the patients in cases of oesophageal atresia with tracheoesophageal fistula.

Adrenal insufficiency (AI) remains a significant cause of morbidity and mortality in children with 1 in 200 episodes of adrenal crisis resulting in death. The goal of this working group of the Pediatric Endocrine Society Drug and Therapeutics Committee was to raise awareness on the importance of early recognition of AI, to advocate for the availability of hydrocortisone sodium succinate (HSS) on emergency medical service (EMS) ambulances or allow EMS personnel to administer patient's HSS home supply to avoid delay in administration of life-saving stress dosing, and to provide guidance on the emergency management of children in adrenal crisis. Currently, hydrocortisone, or an equivalent synthetic glucocorticoid, is not available on most ambulances for emergency stress dose administration by EMS personnel to a child in adrenal crisis. At the same time, many States have regulations preventing the use of patient's home HSS supply to be used to treat acute adrenal crisis. In children with known AI, parents and care providers must be made familiar with the administration of maintenance and stress dose glucocorticoid therapy to prevent adrenal crises. Patients with known AI and their families should be provided an Adrenal Insufficiency Action Plan, including stress hydrocortisone dose (both oral and intramuscular/intravenous) to be provided immediately to EMS providers and triage personnel in urgent care and emergency departments. Advocacy efforts to increase the availability of stress dose HSS during EMS transport care and add HSS to weight-based dosing tapes are highly encouraged.

Background: Esophageal atresia (EA) with or without Tracheoesophageal fistula (TEF) is most common congenital anomalies encountered in pediatric surgery and the management of these neonates require high degree of skill, manpower and tertiary care. This clinical study was undertaken to evaluate the outcome and postoperative complication of Esophageal atresia (EA) with or without Tracheoesophageal fistula (TEF) admitted in pediatrics surgery in M.Y. Hospital Indore.Objective: The aims of this study cases of EA and TEF regarding management and outcome.Methods: This prospective study included 220 patients of EA with TEF were enrolled in this study from Sep. 2016 to august 2018 who underwent surgical intervention. Their clinical profile, time of presentation, sex distribution, birth weight, type of EA and TEF and their effect on mortality and morbidity were observed.Results: Mortality was high (68.42%) among patients who reached the tertiary centre late i.e. >24 hours. The incidence of low birth weight babies is approximately 74% and mortality rate increased with low birth weight. EA with or without TEF More common in male then female but survival rate was high in female (71.60%). Type C was the most common (71.42) followed by type A. Septicemia and leak were most common complication. The mortality in septicemia patients is high 90.66%. Early surgical intervention improved the survival of EA and TEF. The overall survival rate was 48.63% and mortality was 51.36%. Conclusions: Esophageal atresia (EA) with Tracheoesophageal fistula (TEF) is the most common type of anomaly. Maturity, birth weight, early diagnosis are the most important factors that affect the outcome. Remarkable success has been achieved based on improvement in neonatal anesthesia & surgical technique, ventilator support & neonatal intensive care.

Understanding of the epidemiology, outcomes, and management of spontaneous subarachnoid hemorrhage (sSAH) during pregnancy is limited. Small, single center series suggest a slight increase in morbidity and mortality.To determine if incidence of sSAH in pregnancy is increasing nationally and also to study the outcomes for this patient population.A retrospective analysis was performed utilizing the Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project for the years 2002-2014 for sSAH hospitalizations. The NIS is a large administrative database designed to produce nationally weighted estimates. Female patients age 15-49 with sSAH were identified using the International Classification of Diseases, 9th Revision, Clinical Modification code 430. Pregnancy and maternal diagnosis were identified using pregnancy related ICD codes validated by previous studies. The Cochran-Armitage trend test and parametric tests were utilized to analyze temporal trends and group comparisons. Main Outcomes and Measures: National trend for incidence of sSAH in pregnancy, age, and race/ethnicity as well as associated risk factors and outcomes.During the time period, there were 73,692 admissions for sSAH in women age 15-49 years, of which 3978 (5.4%) occurred during pregnancy. The proportion of sSAH during pregnancy hospitalizations increased from 4.16 % to 6.33% (P-There is an upward trend in the incidence of sSAH occurring during pregnancy. There was disproportionate increase in incidence of sSAH in the African American and younger mothers. Outcomes were better for both pregnant and nonpregnant women treated at teaching hospitals and in pregnant women in general as compared to nonpregnant women.

Elbow injuries are common in children and while majority heal very well, some result in deformities of the elbow. Although deformities such as cubitus varus and non-progressive cubitus valgus are considered cosmetic by the paediatric orthopaedic surgeons and intentionally ignored, they are not always benign and can result in functional deficit due to instability, pain, tardy nerve palsies and osteoarthritis later in life. Similarly congenital and developmental conditions that do not cause major functional loss in childhood, become very disabling in adults due to increasing functional demands. Congenital radial head dislocation and radioulnar synostosis fall into this category. In this paper we discuss clinical presentation, treatment options and outcomes of common elbow conditions presenting later in the life.

Heart failure affects 1-2% of the adult population and one of the main contributors to its development is cardiomyopathy. Assessing a patient's risk for adverse events in heart failure is challenging and made more difficult by the heterogenous phenotypic expression of the disease. Cardiac MRI has long been a gold standard measure of myocardial function and anatomy due to its high spatial and temporal resolution. More recently, it has been posited to play a more critical role in the diagnosis and prognosis of cardiomyopathy-related heart failure. Given the limitations of more commonly used imaging modalities, increasing the clinical use of cardiac magnetic resonance imaging could potentially improve the prognosis of specific subgroups of patients at risk of adverse cardiac events.Lay abstract Heart failure is a condition where the heart is unable to pump out enough blood to meet the body's daily needs. It can affect up to 2% of the adult population. One of the causes of heart failure is an intrinsic disease of the heart muscle, called cardiomyopathy. Assessing a patient's risk for events such as hospitalization and death in heart failure is challenging, and made more difficult by the wide variety of ways a patient can present with heart failure clinically. Cardiac MRI has long been a highly regarded imaging technique for heart function and shape due to the high level of detail it can show. More recently, it has been thought to play a more important role in investigating and predicting the course of cardiomyopathy-related heart failure. Given the limitations of more commonly used measurement techniques, increasing the clinical use of cardiac magnetic resonance imaging would potentially improve the outcomes and quality of life for patients suffering with cardiomyopathy.

Objective Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). In established T1D patients, DKA is frequently a result of insulin omission or inadequate insulin administration during illness or stress. Ethnic minorities and patients with lower socioeconomic status are affected disproportionately. We hypothesized that implementation of intensive sick day rules with frequent reinforcement would reduce hospitalizations secondary to DKA in T1D youth irrespective of their demographics. Methods Intensive sick day rules were implemented beginning January 2016. All T1D patients seen in the pediatric endocrinology clinic or hospital between January 1st 2015 through December 31st 2017 were included for chart review. Categorical variables were analyzed with Chi-square test. For the continuous variables, t test was used. Episodes of DKA per 100 patients were compared using the trends test over the three-year period. Patients who had DKA in 2015 were analyzed as a subgroup. Results The frequency of DKA episodes per 100 patient years for 2015 was 19.1, for 2016 was 15.2 and was 12.4 for 2017. This decrease was statistically significant (p=0.006). The decline was also statistically significant for the subgroup of patients who developed DKA in 2015 and followed longitudinally. The decline was not uniform across all patient groups and DKA episodes remained associated with African- American race, Medicaid insurance status and higher HbA1c throughout the years. Conclusion Implementation of intensive sick day rules led to a decrease in total number of DKA admissions in our population with T1D youth. However, this intervention did not reduce the health disparity in this population and African-Americans on Medicaid insurance continued to form the disproportionate majority of admissions with DKA. This study highlights the need for further research into interventions that can improve outcomes across racial and socio-economic barriers.

Priapism is a prolonged penile erection lasting for more than 4 hours, rarely seen in children. Our patient is a 12 year old previously healthy male patient who presented to emergency with complaints of painful Penile erection. On workup, hemogram coupled with bone marrow aspiration investigations revealed acute lymphoblastic leukemia L1 to be the root cause. Emergency decompression under penile block by aspiration from corpora cavernosa by a lateral approach (3 o clock and 9 o clock position) was done followed by injection of phenylephrine (sympathomimetic agent) in the cavernosa muscles to relieve the ischaemic priapism. The presence of dark, deoxygenated blood conrms ischaemic priapism. Priapism in paediatric age group is a very rare occurance. Ischaemic priapism is the most common type of priapism in children and is a surgical emergency.

Superior limbic keratoconjunctivitis (SLK) is characterized by chronic inflammation of the superior limbus and superior bulbar and tarsal conjunctivae. Patients also often have fine punctate staining of the limbus and adjacent area, superior limbic proliferation seen as thickening of the limbal epithelium and surrounding conjunctiva, and occasionally filaments at the superior limbus and upper cornea. SLK frequently presents with ocular irritation, foreign body sensation, and photophobia. SLK can be associated with other ocular and non-ocular conditions, such as thyroid disease. Although the pathogenesis of SLK is still unknown, it is thought to be related to mechanical injury, tear film instability, or an autoimmune/inflammatory etiology. Many patients with SLK can be asymptomatic or have symptoms that resolve or remit spontaneously. For symptomatic SLK, patients are managed medically with treatments such as lubricants, topical anti-inflammatory or immunomodulatory medications, punctal occlusion, and bandage contact lenses. Patients with symptoms refractory to medical management may need surgical interventions. We detail the current literature on the epidemiology, clinical manifestations, associated conditions, histopathology, pathogenesis, and treatment of SLK.

Treatment-induced neuropathy of diabetes (TIND) is a small fiber neuropathy precipitated by rapid correction of hyperglycemia. Literature on TIND in pediatric diabetes is scarce. We present 7 cases of TIND in children and young adults, increasing awareness of this condition in pediatric diabetes and broadening the scope of published knowledge.

Background: Pediatric endocrine practices had to rapidly transition to telemedicine care at the onset of the novel coronavirus disease 2019 (COVID-19) pandemic. For many, it was an abrupt introduction to providing virtual healthcare, with concerns related to quality of patient care, patient privacy, productivity, and compensation, as workflows had to change. Summary: The review summarizes the common adaptations for telemedicine during the pandemic with respect to the practice of pediatric endocrinology and discusses the benefits and potential barriers to telemedicine. Key Messages: With adjustments to practice, telemedicine has allowed providers to deliver care to their patients during the COVID-19 pandemic. The broader implementation of telemedicine in pediatric endocrinology practice has the potential for expanding patient access. Research assessing the impact of telemedicine on patient care outcomes in those with pediatric endocrinology conditions will be necessary to justify its continued use beyond the COVID-19 pandemic.

A high-functioning middle-aged successful businessman developed a rapid decline in his cognitive, behavioral, and motor abilities within one year. He was initially diagnosed with dementia by a neurologist and was then diagnosed with pseudo-dementia secondary to major depressive disorder with catatonia by a psychiatrist who initiated treatment with Ativan. He was referred to our psychiatric facility for an evaluation to undergo electroconvulsive therapy (ECT) as a potential treatment for medically refractory depression complicated with catatonia and pseudo-dementia. The neurology team and internal medicine team were consulted by a psychiatrist for clearance to begin a course of ECT. In this process, with a coordinated effort and prompt workup and evaluation, including neurological testing, imaging, and positive cerebrospinal fluid analysis for real-time quaking inverse conversion (RT-QuIC) and 14-3-3, the patient was diagnosed with Creutzfeldt-Jakob’s disease. There are many organic causes of dementia and catatonia that should be explored in depth, especially when the clinical picture is challenging and atypical.

Rationale & Objective The approved therapeutic indication for immune checkpoint inhibitors (CPIs) are rapidly expanding including treatment in the adjuvant setting, the immune related toxicities associated with CPI can limit the efficacy of these agents. The literature on the nephrotoxicity of CPI is limited. Here, we present cases of biopsy proven acute tubulointerstitial nephritis (ATIN) and glomerulonephritis (GN) induced by CPIs and discuss potential mechanisms of these adverse effects. Study design, setting, & participants We retrospectively reviewed all cancer patients from 2008 to 2018 who were treated with a CPI and subsequently underwent a kidney biopsy at The University of Texas MD Anderson Cancer Center. Results We identified 16 cases diagnosed with advanced solid or hematologic malignancy; 12 patients were male, and the median age was 64 (range 38 to 77 years). The median time to developing acute kidney injury (AKI) from starting CPIs was 14 weeks (range 6–56 weeks). The average time from AKI diagnosis to obtaining renal biopsy was 16 days (range from 1 to 46 days). Fifteen cases occurred post anti-PD-1based therapy. ATIN was the most common pathologic finding on biopsy (14 of 16) and presented in almost all cases as either the major microscopic finding or as a mild form of interstitial inflammation in association with other glomerular pathologies (pauci-immune glomerulonephritis, membranous glomerulonephritis, C3 glomerulonephritis, immunoglobulin A (IgA) nephropathy, or amyloid A (AA) amyloidosis). CPIs were discontinued in 15 out of 16 cases. Steroids and further immunosuppression were used in most cases as indicated for treatment of ATIN and glomerulonephritis (14 of 16), with the majority achieving complete to partial renal recovery. Conclusions Our data demonstrate that CPI related AKI occurs relatively late after CPI therapy. Our biopsy data demonstrate that ATIN is the most common pathological finding; however it can frequently co-occur with other glomerular pathologies, which may require immune suppressive therapy beyond corticosteroids. In the lack of predictive blood or urine biomarker, we recommend obtaining kidney biopsy for CPI related AKI.

BackgroundPremature adrenarche has been described as clinical and biochemical hyperandrogenism before the age of 8 years in girls and 9 years in boys and absence of signs of true puberty. Adrenal pathology such as adrenal tumors or non-classical congenital adrenal hyperplasia (NCCAH) and exogenous androgen exposure need to be excluded prior to diagnosing (idiopathic) premature adrenarche. Premature adrenarche is more common among black girls compared to white girls and other racial groups. Adrenal pathology such as NCCAH is less common as a cause for premature adrenarche compared with idiopathic premature adrenarche. The evaluation guidelines for premature adrenarche however are not individualized based on racial/ethnic differences. Few studies have been done to evaluate a largely black population with premature adrenarche to assess the incidence of adrenal pathology.MethodsThis cross-sectional retrospective study evaluated characteristics of prepubertal patients seen in an endocrine clinic for premature adrenarche.ResultsTwo hundred and seventy three subjects had signs of early adrenarche. Three subjects were found to have CAH (2 with NCCAH and 1 with late diagnosis classical CAH). None were black. Exogenous androgen exposure was etiology in 4 additional subjects. These 7 patients were excluded from further analysis. The remaining subjects had idiopathic PA (n = 266); 76.7% were females. The mean age at initial visit was 6.42 +/− 1.97 years (with no racial difference) although black subjects were reported symptom onset at a significantly younger age compared to non-Hispanic white patients.ConclusionsOur study showed organic pathology was very uncommon in a predominantly black population with premature adrenarche. Patient factors that influence the probability of an underlying organic pathology including race/ ethnicity should be considered to individualize evaluation.

Background Elective abdominal surgeries in patients with cirrhosis have been discouraged due to the high risk of complications. This study investigates the outcomes and safety of surgeries for hernias, and laparoscopic cholecystectomies in cirrhotic patients. Methods A retrospective cohort study that compared 91 cirrhotic patients to a control group of non-cirrhotic patients operated by liver transplant surgeons was conducted between 2009 and 2015. Results No statistical significance found in re-admission rates or complication rates (p = 0.21). Hernia recurrent rates were similar (p = 0.27). Survival rates among cirrhotic versus non cirrhotic group was 93.4% and 98.9% respectively (p = 0.0539). Amongst the 91 cirrhotic patients, there was a 100% survival rate for both ventral herniorrhaphies and laparoscopic cholecystectomy. Survival in umbilical and inguinal herniorrhaphies was 88.2% and 89.5% respectively. Mortality rate for umbilical and inguinal hernias was 11.7% and10.5% respectively. Mortality by Child-Pugh (CP) class were; 8.8% for CP B and 10.7% for CP class C. All CP class A patients survived. Conclusions Our study indicates that elective operations could be performed safely with acceptable mortality in cirrhotic patients.

Pulmonary sequestration is a rare embryonic malformation of lung tissue with no identifiable bronchial communication receiving its blood supply from one or more anomalous systemic arteries or aorta. The authors present a case report of an adult woman who presented with untreatable hemoptysis. She was treated with anti-Koch's therapy for her nonresolving hemoptysis. She underwent preoperative vascular embolization and operative surgical resection.

Introduction: Diffusion-weighted imaging (DWI) is an important part of magnetic resonance imaging (MRI) in the evaluation of specific organs, including the breast, kidney, liver, and prostate. Prostate cancer lesions are composed of tightly packed cells with reduced extracellular space, which can be visualized on DWIs as areas of restricted diffusion (i.e., high-signal intensity), with corresponding low-signal intensity on apparent diffusion coefficient (ADC) maps and low mean ADC value. Objective: The objective of this study is to identify the appropriate cutoff and mean ADC value to diagnose neoplastic prostatic lesions in central India. Materials and Methods: Sixty-six patients with suspected prostatic pathology were included in this study. All patients underwent MRI on a 1.5-T scanner with a phased-array body coil. MRIs were evaluated compared with the histopathological staging. Results:: The diagnostic accuracy of DWI in predicting malignancy was 39/41, i.e., 95.12%, which is the positive predicted value. The mean ADC for benign category was 1.14 with standard deviation (SD) of 0.14 while mean for prostatitis was 0.91 with SD of 0.26 and for carcinoma was 0.75 with SD of 0.19. The difference in the means was statistically highly significant. Conclusion: DWI demonstrates the restriction of diffusion and the reduction of ADC values in neoplastic tissue and improves the diagnostic accuracy in lesion characterization. This technique allows short acquisition time and provides high-contrast resolution between neoplastic and normal tissue. This technique can be a useful adjunct to the established dynamic contrast-enhanced-MRI.

Background: MTX-induced neurotoxicity is often associated with leukoencephalopathy, and the diagnostic radiological feature in magnetic resonance imaging (MRI) is white matter hyper intensities. The clinical significance of these white matter changes is unknown. The risk factors of MTX-induced acute leukoencephalopathy are not well established. Few authors have suggested increased homocysteine or alteration of Central Nervous System (CNS) folate, vitamin b12 homeostasis may be associated with CNS toxicity. It is a usual clinical practice to withhold methotrexate during further duration of chemotherapy after an episode of leukoencephalopathy but the risk of neurotoxicity must be weighed against the risk of relapse of leukemia. Moreover, there is limited data on continued treatment with High-dose methotrexate (HD-MTX) or Intrathecal Methotrexate (IT-MTX) or Oral-MTX in patients who developed leukoencephalopathy. Objective: The study aims to 1) identify the risk and prevalence of leukoencephalopathy in patients of Acute Lymphoblastic Leukemia (ALL) receiving intrathecal or high dose or oral methotrexate therapy through sequential MRI Brain study. 2) Safety of re-administration of methotrexate in patients with documented toxic leukoencephalopathy 3) The relationship of serum homocysteine, vitamin b12 and folate levels with methotrexate induced leukoencephalopathy Methods: Our study enrolled 34 newly diagnosed pediatric ALL / Lymphoblastic Lymphoma (LBL) patients (age ≤18 years) between June 2019 & June 2020. Induction chemotherapy was initiated as per modified ALL IC BFM 2002 protocol after obtaining informed consent. Apart from the Hematological investigations, Bone Marrow Aspiration and Biopsy, Flow Cytometry/Immunohistochemistry (IHC), Cytogenetics, Molecular study were done. All the patients underwent MRI Brain and Serum homocysteine, Vitamin B12, Folate level measurement (sequentially as per protocol at 4 different time points). 1st time point - AT DIAGNOSIS, i.e. before starting methotrexate, 2nd time point - POST CONSOLIDATION, 3rd time point - POST EXTRACOMPARTMENT THERAPY, 4th time point - IN MAINTENANCE, thus analyzing leukoencephalopathy secondary to different modes of administration of methotrexate therapy. At all-time points serum folate, vitamin b12 or homocysteine level were done before administering methotrexate and any association with development of leukoencephalopathy was analyzed. Results: We identified Leukoencephalopathy secondary to methotrexate in 6.03% (7/116) on MRI brain in 5 of 33 (15.15%) patients of which 1 (3.03%) had symptomatic LE and 4 (12.12%) were clinically asymptomatic. All our LE patients were in the age group more than or equal to 10 years. We found no increase in the incidence of leukoencephalopathy secondary to methotrexate: leucovorin ratio, also there was no difference in the incidence with respect to mode of administration of MTX (IT/HD/ORAL), even there was no increase in incidence after 4 courses of high dose methotrexate. MRI at baseline was not a predictor of development of leukoencephalopathy. 3 out of 5 patients with LE had abnormal b12/folate/homocysteine with corresponding abnormal MRI Brain at pre-specified time point. Also 4 patients with abnormal b12/folate/homocysteine levels had intractable cytopenias while on chemotherapy and more after HD MTX therapy which got corrected after supplementation with vitamin b12 and folic acid. Conclusion: MTX-induced clinical leukoencephalopathy is transient, and most patients can be re-challenged with subsequent MTX without recurrence of acute or subacute symptoms. MRI at baseline was not a predictor of development of leukoencephalopathy. More multi institutional prospective studies of large number of patients are needed to study the incidence of MTX-induced leukoencephalopathy and its relation with folic acid, vitamin b12 and homocysteine level. Disclosures No relevant conflicts of interest to declare.

Introduction This study estimated the percentage of breast cancer cases, total number of incident cases, and total annual medical care costs attributable to alcohol consumption among insured younger women (aged 18–44 years) by type of insurance and stage at diagnosis. Methods The study used the 2012–2013 National Survey on Drug Use and Health, cancer incidence data from two national registry programs, and published relative risk measures to estimate the: (1) alcohol-attributable fraction of breast cancer cases among younger women by insurance type; (2) total number of breast cancer incident cases attributable to alcohol consumption by stage at diagnosis and insurance type among younger women; and (3) total annual medical care costs of treating breast cancer incident cases attributable to alcohol consumption among younger women. Analyses were conducted in 2016; costs were expressed in 2014 U.S. dollars. Results Among younger women enrolled in Medicaid, private insurance, and both groups, 8.7% (95% CI=7.4%, 10.0%), 13.8% (95% CI=13.3%, 14.4%), and 12.3% (95% CI=11.4%, 13.1%) of all breast cancer cases, respectively, were attributable to alcohol consumption. Localized stage was the largest proportion of estimated attributable incident cases. The estimated total number of breast cancer incident alcohol-attributable cases was 1,636 (95% CI=1,570, 1,703) and accounted for estimated total annual medical care costs of $148.4 million (95% CI=$140.6 million, $156.1 million). Conclusions Alcohol-attributable breast cancer has estimated medical care costs of nearly $150 million per year. The current findings could be used to support evidence-based interventions to reduce alcohol consumption in younger women.

Multiple myeloma (MM) is a common hematologic malignancy, and has renal involvement in up to 50% of cases. Patients with myeloma-related end-stage renal disease (ESRD) have a higher mortality rate ...

We present a rare case of an intraorbital dermoid which was associated with a small temporal region dermal sinus in a 3-year-old child. This got infected and the child presented with orbital cellulitis. Definitive surgery involved excision of all the dermal elements using a superficial and intraorbital approach. We stress the need to evaluate, apparently benign lateral facial dermal sinuses as they may be the pointers of the underlying pathological deep dermoid cysts to avoid complications.

Introduction In India, most MSD-BMTs are conducted in private hospitals and are associated with a cost of $20-30,000, which most poor families cannot afford. To serve children with limited financial resources (below the poverty line or with a yearly family income of Methods Collaboration Model- Figure Team Two general pediatricians were trained for 6 months at Columbia University, NY, where they developed SOP and protocols. Blood Bank Able to provide PRBC and platelets, could perform plasma but no RBC depletion. Patient Recruitment HLA typing camps were conducted in 5 cities, 253 families were typed, 72 pts had 10/10 HLA MSD. DKMS Germany performed HLA typing free of cost. Financial Support To provide free BMT, Airport Authority of India and Bina Refinery provided financial support through corporate social responsibility. Conditioning Regimen Majority of patients (pts) received r-ATG-6mg/kg, FLU-150mg/m2, BU-12.8-16mg/kg (without PK studies) and cytoxan-200mg/kg. Prophylaxis; aGVHD: CSA/MTX. Acyclovir until day 100. Fluconazole until ANC >1000/mm3. Bactrim for PCP. G-CSF was not routinely administered. Follow-Up Pts stayed in the hospital vicinity for up to 6 months post-BMT. The majority of outpatient medications were also provided free of charge. Results Donors: 13F and 7M, median age 8 yrs (2-18). The median number of CD34+ cells harvested from bone marrow was 5.5 × 106/kg (1.5-21.6); only 2 donors were G-CSF mobilized. Patients First BMT was conducted in April 2018. Median FU 9 months (3-17). Of the first 20 pts, 12 were males. Pts were ages 2-5Y (n=9), 5-10Y (n=8) and >10Y (n=3). 19/20 pts were heavily transfused. Thalassemia spectrum (16/20), SCD (n=1), MDS (n=1), SAA (n=1), and CML (n=1). 4 pts with major ABO incompatibility underwent RBC desensitization. Median time for ALC >500/mm3, neutrophil and platelet engraftment was 19d (12 -30), 27d (14-33) and 25d (15-50), respectively. Two pts had graft failure (one died). At last follow up, two pts have stable mixed chimerism and 16 (80%) have donor chimerism >90%, all 18 engrafted pts are transfusion independent. Overall survival is 95%. The median cost of BMT was $11,000 ($6,000-22,000). Conclusion Early results demonstrate the feasibility of our model. With appropriate remote supervision and dedicated general pediatricians and nurses with limited BMT training, we can successfully conduct MSD BMT in a resource-constrained set up. Despite living in remote villages, poverty, facing socio-cultural challenges, families can be trained to provide appropriate care at home. Multi-drug resistant bacteraemia and GI infections remain a major concern.

Sodium-glucose co-transporter 2 Inhibitors (SGLT2i) were initially developed as therapeutic options for patients with type 2 diabetes mellitus (T2DM). Recently, randomized clinical trials have investigated their effects in cardiorenal protection through major adverse cardiovascular event reduction and reductions in diabetic nephropathy. While multiple mechanisms are proposed for this protection, microvascular protection is the primary component of their efficacy. While not primarily emphasized in clinical trials, evidence in other studies suggests that SGLT2i may confer retinoprotective effects via some of the same mechanisms in the aforementioned cardiorenal trials. Diabetic patients are susceptible to vision loss with chronic hyperglycemia promoting inflammation, edema, and retinal pathological changes. Targeting these pathways via SGLT2i may represent opportunities for providers to decrease retinopathy in high-risk T2DM patients, reduce disease progression, and lower drug burden in diabetic retinopathy patients. Further comprehensive clinical trials investigating these associations are needed to establish the potential retinoprotective effects of SGLT2i.

The bidirectional relationship between cancer and chronic kidney disease (CKD) is complex. Patients with cancer, particularly those with hematological malignancies such as multiple myeloma and lymphoma, are at increased risk of developing acute kidney injury and CKD. On the other hand, emerging evidence from large observational registry analyses have consistently shown that cancer risk is increased by at least 2- to 3-fold in kidney transplant recipients, and the observed increased risk occurs not only in those who have received kidney transplants but also in those on dialysis and with mild- to moderate-stage CKD. The interactions between cancer and CKD have raised major therapeutic and clinical challenges in the management of these patients. Given the magnitude of the problem and uncertainties, and current controversies within the existing evidence, Kidney Disease: Improving Global Outcomes (KDIGO) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology to identify key management issues in nephrology relevant to patients with malignancy. This report covers the discussed controversies in kidney disease in hematological malignancies, as well as cancer after kidney transplantation. An overview of future research priorities is also discussed.

Acute kidney injury (AKI) remains a common complication of cancer treatment and entails increased length of stay, cost, and mortality. The etiology of AKI may be direct injury from the underlying malignancy, drug toxicity, related to stem cell transplant, or from treatment complications. Advances in immunotherapy and targeted therapy have also highlighted the nephrotoxic potential of many of these drugs. Patients with liquid tumors (leukemia, lymphoma, myeloma) have the highest incidence of AKI, especially in the critical care setting. Although AKI does tend to improve in survivors, renal recovery is less likely with more severe grade of AKI. Baseline chronic kidney disease also confers an increased risk of AKI during cancer treatment. Although cancer itself is not a contraindication for starting renal replacement therapy (RRT), the benefits of RRT must be weighed against the overall prognosis of the patient and quality of life. A multidisciplinary discussion between the patient, nephrologist, oncologist, intensivist, and palliative care physician is often necessary to make an informed clinical decision.

© 2020 Kidney Disease:Improving Global Outcomes (KDIGO)The association between kidney disease and cancer is multifaceted and complex. Persons with chronic kidney disease (CKD) have an increased incidence of cancer, and both cancer and cancer treatments can cause impaired kidney function. Renal issues in the setting of malignancy can worsen patient outcomes and diminish the adequacy of anticancer treatments. In addition, the oncology treatment landscape is changing rapidly, and data on tolerability of novel therapies in patients with CKD are often lacking. Caring for oncology patients has become more specialized and interdisciplinary, currently requiring collaboration among specialists in nephrology, medical oncology, critical care, clinical pharmacology/pharmacy, and palliative care, in addition to surgeons and urologists. To identify key management issues in nephrology relevant to patients with malignancy, KDIGO (Kidney Disease: Improving Global Outcomes) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology in December 2018. This report covers issues related to kidney impairment and solid organ malignancies as well as management and treatment of kidney cancer. Knowledge gaps, areas of controversy, and research priorities are described.

Introduction: The Cincinnati Prehospital Stroke Severity scale (C-STAT), Los Angeles Motor Scale (LAMS), Rapid Arterial Occlusion Evaluation (RACE) score, and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scales were designed to aid emergency responder identification of patients with stroke related to large vessel occlusion (LVO). We hypothesized that the addition of a known history of atrial fibrillation (AF) without anticoagulation to currently used scales would improve LVO detection. Methods: Medical records of patients admitted to a Comprehensive Stroke Center with acute ischemic stroke in 2014-2015 were reviewed. LVO identification using the C-STAT, LAMS, RACE, and FAST-ED scores and the AF variable were compared using univariable analyses. The areas under the receiver operating curves (AUCs) were then compared for each score, the AF variable, and each score with the addition of the AF variable. Results: The sample included 233 patients without and 188 patients with an LVO. A history of known AF, history of AF with no anticoagulation, and the C-STAT, LAMS, RACE, and FAST-ED scores were each associated with LVO in univariable analyses. The AUCs for C-STAT, LAMS, RACE, and FAST-ED were similar. The addition of the known AF and no anticoagulation variable did not appreciably change these AUCs. Conclusion: Although known AF with no anticoagulation was associated with LVO in patients with acute ischemic stroke, this historic feature did not improve the accuracy of existing LVO detection scales.

Aseptic meningitis as an initial and isolated manifestation of systemic lupus erythematosus (SLE) is extremely rare. About a third of patients with SLE have neuropsychiatric manifestations; however, less than 2% develop aseptic meningitis. Therefore, SLE as a cause of aseptic meningitis is commonly overlooked and leads to delayed or even missed diagnosis. We report a case of aseptic meningitis that was later discovered to be SLE and where instituting appropriate treatment led to clinical improvement.

The objective of this project is to automate the detection of Diabetic Retinopathy and evaluate the severity with high efficiency, through an overall feasible approach. This project explores the use of various Convolutional Neural Network Architectures on images from the dataset after being subjected to appropriate image processing techniques like local average color subtraction to aid in highlighting the germane features from a fundoscopy, thereby augmenting the detection and evaluation process of Diabetic Retinopathy as well as serve as an expert guidance system for practitioners around the world.

Background: Pseudohypoaldosteronism (PHA) Type 1 usually present in the newborn period as failure to thrive, hyponatremia and hyperkalemia. The spectrum of manifestation however ranges from asymptomatic to severe. Initial presentation may be easily confused with more common disease process like poor feeding with inadequate calorie intake, dehydration, Congenital Adrenal Hyperplasia (CAH), adrenal insufficiency (AI), urinary tract abnormality and hypoaldosteronism. Patients with PHA Type 1 have supraphysiological aldosterone and renin levels appropriate for the electrolyte abnormality but ineffective due to an abnormality in mineralocorticoid receptor or epithelial sodium channel (ENaC). Clinical case: We present a Caucasian female who was admitted for failure to thrive. At 3 weeks of age, she was found to have lost 14.5% of birth weight. She was afebrile and there was no vomiting. She had hyperkalemia, hyponatremia, hypercalcemia, and mild transaminitis (Na 129mmol/L (134-142mmol/L), K 6.8mmol/L (4-6.2mmol/L), Cl 91mmol/L (96-110mmol/L), Ca 11.8mg/dl (9-10.9mg/dl), ALT 35unit/L (8-32 units/L) with increased urine output (6-6.5ml/kg/hr (4-5ml/kg/hr). Genital examination, newborn screen, ECG, renal US, thyroid function, 17-OH progesterone, and ACTH stimulation tests were normal. No family history of similar electrolyte abnormalities. Treatment with sodium containing IVF and kayexalate improved her electrolytes. Her diagnosis at discharge was inadequate calorie intake and dehydration. Increased calorie intake resulted in continuous weight gain and resolution of electrolyte abnormality at discharge (Na 137mmol/L, K 5.6mmol/L, Cl 97, Ca 10.8mg/dl). Despite improvement in weight gain and being asymptomatic, follow up outpatient monitoring of electrolyte levels showed persistent hyponatremia and hyperkalemia (Na 129 mmol/L, K 7.8mmol/L). No gastrointestinal symptoms or skin abnormalities. Given her electrolyte abnormalities, the differential diagnoses included SIADH, Adrenal Insufficiency and hypoaldosteronism. The diagnosis of PHA Type 1 was made based on increased aldosterone and renin levels (Aldosterone 1031ng/dl (5-90ng/dl), Renin 277pmol/L (2-37pmol/L). She was started on oral Nacl supplement and high dose fludrocortisone resulting in resolution of electrolyte abnormality. Genetic evaluation is underway. Conclusion: PHA Type 1 is a rare clinical entity that can masquerade as other more common causes of malnutrition and electrolyte abnormality. Delay in prompt diagnosis and treatment of PHA Type 1 can be associated with morbidity and mortality. Follow up monitoring of serum and urine electrolyte levels is important in children presenting with malnutrition and electrolyte abnormalities to enable early recognition and adequate treatment initiation.

Background: Deficiency of vitamin D can lead to multiple health issues in children. Though it can be asymptomatic in early stages, it can lead to symptomatic illnesses if severe/ prolonged including seizures and rickets. Deficiency can be prevented by adequate dietary vitamin D intake with/without supplementation in those at higher risk. However, there has been a recent reemergence and increase in the incidence of vitamin D deficiency in European nations, noted as early as 2008 and at least upto 2018. Hence, we performed a 10 year retrospective study of severe vitamin D deficiency in hospitalized patients at a Children’s Hospital in USA. Methods: Electronic medical record was searched to identify patients with the following inclusion criteria: admitted at our hospital between 1/1/2010 and 12/31/2019 and had a 25-OH vitamin D (25-OH D) level Results: Between 1/1/2010 and 12/31/2019, there were 109 hospital admissions with 25-OH D deficiency with or without hypocalcemia. Median 25-OH D level was 9.7 ng/mL. Admissions per year increased from 2010 to 2019 as follows: 2 in 2010, 5 in 2011, 4 in 2012, 6 in 2013, 6 in 2014, 7 in 2015, 12 in 2016, 13 in 2017, 23 in 2018, 25 in 2019. Median patient age was 27 months (range 0,228). Of those /= 7.5 mg/dL. Conclusions: Our hospital has witnessed a significant increase in severe vitamin D deficiency in admitted patients between 2010 and 2019. A large proportion of these were Blacks, on state sponsored insurances and infants not on vitamin D supplementation. Greater than 3/4th of patients had hypocalcemia and over 50% patients had hypocalcemia that required a median of 3 days to correct. This is a concerning trend of an often easily preventable morbidity and another health issue that highlights disparities in our health system.

Background Pneumonia is a serious but a preventable stroke complication. Prediction scales for post-stroke pneumonia have been proposed with an intent to improve surveillance and prevention but they remain under-utilized in clinical practice. Most existing scales were developed using both ventilated and non-ventilated patients which may affect their accuracy. We derived and validated a novel, pragmatic scale to predict hospital-acquired pneumonia (HAP) after stroke employing only a non-ventilated stroke cohort. Methods All consecutive patients admitted with acute stroke to a large hospital in Boston, Massachusetts, were identified using International Classification of Diseases, 9th revision (ICD-9) codes for acute ischemic strokes, intracerebral hemorrhages and confirmed by chart review. The following exclusion criteria were used: stroke occurring after hospitalization, pneumonia on admission, intubation, presence of brain or lung neoplasms, admission Results A total of 1644 patients met study criteria; 144 (8.8%) developed HAP. An 8-point pneumonia prediction scale (ACDD 4 ) was derived using significant covariates (age ≥ 75 = 1; congestive heart failure = 1; dysarthria = 1; dysphagia = 4). The risk of pneumonia varied between 2% and 33.9% with scores of 0 to 7, respectively. The c-statistic of the final model was 0.82 and bootstrap validation c-statistic was 0.81. Conclusion ACDD 4 scale is a promising tool for predicting HAP in non-ventilated stroke patients that can be easily computed at the patient's bedside. Subject term: cerebrovascular disease/stroke

Background: As the search for reliable clinical indicators for management of human immunodeficiency virus/AIDS continues, mucocutaneous manifestations of HIV are considered among key clinical indicators for prediction of underlying degree of immunosuppression, systemic opportunistic infections, and disease progression. Objectives: (1) To study the prevalence of mucocutaneous manifestations in HIV-seropositive patients attending the ART center of our hospital (2) To correlate mucocutaneous manifestations with CD4 cell counts. Materials and Methods: A total of 200 HIV-seropositive patients of adult age group visiting our hospital were included in the study. Information on demographics such as age, sex, transmission route, socioeconomic status, educational status, CD4 counts, and mucocutaneous findings was collected through interview administered survey and case records followed by oral and cutaneous examination. Results: Mean CD4 cell count of asymptomatic HIV/AIDS patients was 580.96 cells/mm3. In comparison with the CD4 cell count of asymptomatic HIV-positive patients, (mean 580.96 cells/mm3) CD4 cell count of HIV-positive patients with various mucocutaneous manifestations (mean 409.65 cells/mm3) was correlated using student t-test and was statistically significant (P = 0.017). Conclusion: This study revealed maximum mucocutaneous lesions in the CD4 count range of 200–500. Nail changes accounted for the most common cutaneous manifestation with 53%, and pigmentation accounted for the most common oral manifestation with 39%. Mucocutaneous manifestations can arouse one to suspect the diagnosis of HIV infection in an otherwise healthy unwary patient. They can serve as a dependable marker of HIV disease.

Disorders of plasma and B cells leading to paraproteinemias are associated with a variety of renal diseases. Understanding the mechanisms of injury and associated nephropathies provides a framework that aids clinicians in prompt diagnosis and appropriate adjunctive treatment of these disorders. Glomerular diseases that may be associated with paraproteinemias include amyloid deposition, monoclonal Ig deposition disease, proliferative GN with monoclonal Ig deposits, C3 glomerulopathy caused by alterations in the complement pathway, immunotactoid glomerulopathy, fibrillary GN, and cryoglobulinemia. Tubular lesions include the classic Fanconi syndrome, light–chain proximal tubulopathy, interstitial fibrosis, and cast nephropathy. These paraproteinemic renal diseases are distinct in their pathogenesis as well as their urinary and kidney biopsy findings. Renal pathology is usually initiated by deposition and direct involvement of the intact monoclonal Ig or Ig fragments with resident cells of the nephron. Our review summarizes current insights into the underlying molecular pathogenesis of these interesting kidney lesions.

Background The Texas Department of Family and Protective Services (DFPS) created a statewide network of child abuse pediatricians working at 6 academic centers in 2006. Methods Case data for the period 9/1/2012–8/31/2014 were reviewed for child demographics, risk factors, physician determinations, injury descriptors, and information made available to the physician. Results 8061 of 410,315 DFPS cases (2%) were referred during the period. Network utilization rates ranged from 7.5% in counties served by San Antonio to 1.4% in Austin-served counties. Cases from outlying counties were less likely to involve older children. African American children were over-represented in referrals, and Caucasian and Asian children were underrepresented. Prevalent risk factors included prior DFPS history, single parent-household, mental illness, substance abuse, and domestic violence. Network providers found no or only nonspecific evidence for maltreatment in 45% of cases. Determinations were hindered by poor quality photographs in 188 cases and inadequate skeletal surveys in 121. Insufficient information precluded case completion for 65 cases of children Conclusions Our data indicate that child abuse centers in Texas are underutilized, and there are practice differences with respect to medical referrals across different regions. Our findings concerning ethnic differences and risk factors are consistent with national trends. The problems of inadequate photographs and case information may improve with better training of workers; the issue of poor quality skeletal surveys requires further study. Standard DFPS criteria for referrals to child abuse pediatricians should mitigate some of the problems identified by this study.