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Introduction D13 is a nationally agreed bespoke medical training package for specialist firearms police officers introduced in 2010. Patient report forms are completed after every episode of care provision. Methods A review of patient report forms submitted by police firearms officers in five regions of England over the five years since the introduction of D13. Results Officers attended a large range of incidents, both traumatic and medical, minor and life critical. The majority (69.5%) were responded to as part of a normal police response, while 30.5% of cases were due to primary firearm deployments. Catastrophic haemorrhage was dealt with in 8.1% of cases including the use of haemostatic dressings and tourniquet application. Airway interventions were required in 36.1% of patients and 50.4% required interventions for external bleeding. Discussion From a background of a minimum of 18 h for Standard and 24 h for Enhanced courses and with regular simulation refreshers, specialist police officers, who are part of a robust clinical governance process, play an important role in providing immediate medical care in non-permissive or dangerous environments where ambulance personnel will not be present and when the officers are frequently first on scene.

Introduction – Pain is one of the most common symptoms presented by patients of all ages to ambulance services, however very few children receive analgesia. Analgesic treatment of pre-hospital injured children is viewed as ‘suboptimal’. The aim of this study was to explore current analgesia given to traumatically injured children in the pre-hospital setting and examine whether a clinically meaningful reduction in pain was achieved. Methods – We evaluated electronic patient report forms over a two-year period (2013–2014) within a UK ambulance service NHS trust. All traumatically injured children within the age range 1–17 with a clinical impression of a fracture, dislocation, wound or burn were included. Patients with a Glasgow Coma Scale of < 15 were excluded. The outcome measure was a reduction in numeric pain rating scale or Wong and Baker faces of 2 or more out of 10. Results – Of the evaluable patients (N = 11,317), 90.8% had a documented pain score, or a reason why a pain score could not be documented. For patients reporting pain (N = 7483), 51.6% (n = 3861) received analgesia, 9.6% (n = 717) received no analgesia but did receive alternative treatment and 38.8% (n = 2905) received no analgesia and no alternative treatment. Morphine sulphate IV, oral morphine, Entonox, paracetamol suspension and poly-analgesia all achieved a clinically meaningful median reduction in pain score; –3.0 (IQR, –5.0 to –2.0), –2.0 (–5.0 to –2.0), –2.0 (–4.0 to –1.0), –2.0 (–4.0 to 0.0) and –3.0 (–4.0 to –1.0), respectively. Conclusions – Analgesia administered to traumatically injured children in the pre-hospital setting within this UK ambulance service NHS trust produces clinically meaningful reductions in pain for these patients. The concern is that a large number of patients received neither analgesia nor alternative treatment. There is a real need to identify barriers to analgesia administration in this patient group.

The rapid development of technology can help people solve their problems faced every day. One of them is the problem in transportation sector related traffic accident data often occur in Jember. Many agencies and institutions that play a role, making the existing data to be different. Traffic accident report from police and patient report in emergency room from hospital is collected from 2012 to 2014. The result of this research is a good integration traffic accident database system between police and hospital using PostgreSQL, an information system about traffic accident recording with the location can be presented in digital map using Microsoft Visual Basic 6.0, and a recommendations to improve the accuracy of existing traffic accident data. Keywords :Integrasi, sistem database, sistem informasi data kecelakaan lalu lintas.

Background: Surgical site infections (SSIs) are the third most common hospital-associated infection and can lead to significant patient morbidity and healthcare costs. Identification of SSIs is key to surveillance and research but reliable assessment is challenging, particularly after hospital discharge when most SSIs present. Existing SSI measurement tools have limitations and their suitability for post-discharge surveillance is uncertain. Aims: This study aimed to develop a single measure to identify SSI after hospital discharge, suitable for patient or observer completion. Methods: A three-phase mixed methods study was undertaken: Phase 1, an analysis of existing tools and semi-structured interviews with patients and professionals to establish the content of the measure; Phase 2, development of questionnaire items suitable for patients and professionals; Phase 3, pre-testing the single measure to assess acceptability and understanding to both stakeholder groups. Interviews and pre-testing took place over 12 months in 2014–2015 with patients and professionals from five specialties recruited from two UK hospital Trusts. Findings: Analyses of existing tools and interviews identified 19 important domains for assessing SSIs. Domains were developed into provisional questionnaire items. Pre-testing and iterative revision resulted in a final version with 16 items that were understood and easily completed by patients and observers (healthcare professionals). Conclusion: A single patient and observer measure for post-discharge SSI assessment has been developed. Further testing of the validity, reliability and accuracy of the measure is underway.

A 47-year-old man with progressive anemia possibly due to digestive tract bleeding was referred to our hospital. Contrast-enhanced computed tomography of the abdomen showed a 2-cm tumor lesion arising near the small intestine. Enteroscopy revealed a 3-cm submucosal tumor at the ileum. A gastrointestinal stromal tumor of the small intestine was suspected, and the patient underwent surgery. During the operation, a diverticulum approximately 60 cm orad to the terminal ileum and a tumor at the top of the diverticulum were observed. Considering the location, Meckel’s diverticulum was suspected. No lymphadenopathy was present in the mesentery. Laparoscopy-assisted resection of the diverticulum without lymph node dissection was performed. The histological diagnosis of the tumor was a well-differentiated neuroendocrine tumor. Given the possibility of lymph node metastasis, we performed a second operation to remove the small intestine and lymph nodes. Histologically, 7 of the 18 dissected lymph nodes were metastatic. The postoperative course was uneventful, and the patient survived without tumor recurrence for another 2 years 8 months. Neuroendocrine tumors of Meckel’s diverticulum are aggressive. Therefore, small intestinal resection along with lymph node dissection might be necessary as part of the surgical strategy.

Schinzel-Giedion syndrome (SGS) is a rare autosomal dominant disorder that results in facial dysmorphism, multiple congenital anomalies, and an increased risk of malignancy. Recently, using exome sequencing, de novo heterozygous mutations in the SETBP1 gene have been identified in patients with SGS. Most affected individuals do not survive after childhood because of the severity of this disorder. Here, we report SETBP1 mutation confirmed by molecular analysis in a case of SGS with congenital megacalycosis.

Despite overall advances in treatment, wound infection remains one of the leading causes of morbidity and mortality in patients with severe burn injuries. Burn injury to the face can lead to scarring and contractures that may impair oral competence for articulation, feeding, airway intubation access, oral/dental hygiene, aesthetics, and facial expression. These cases reports are related to oral assistance to 2 patients with orofacial burns. The first patient had 47% of the body burned after a gas explosion in the kitchen and the second 60% after a plane crash. The cause of both was an explosion. The aim of this case report is to present a protocol for orofacial care in burns. Until now there is no agreement regarding orofacial contracture, and treatment continues to be predominantly guided by clinical experience. There is an urgent need for studies to inform dentistry approach in these cases.

We present an unusual case of cystic pilomatricoma. A 13-year-old Japanese boy was referred to our department for evaluation of a 10-day history of a small reddish nodule on his right cheek. Histopathological examination showed a well-circumscribed cystic structure showing a central empty cavity in the dermis. The wall of the cyst was composed of basophilic cells. Inner layers of the wall were covered with flattened epithelial cells having trichohyalin granules. Based on these findings, a diagnosis of cystic pilomatricoma was made. To our knowledge, there has been no report of cystic pilomatricoma with an empty cavity. Dermatologists should be aware of pilomatricoma in the early stage showing a central empty cavity.

One complication of an autogenous arteriovenous fistula (AVF) for hemodialysis is the formation of a venous aneurysm. The treatment of a massive aneurysmal AVF generally involves ligation or resection with the use of prosthetic interposition. We present the case of a 46-year-old man in whom an AVF aneurysm was successfully treated by placating the excess free wall of the aneurysm with sutures. This method is a simple and effective intervention for managing aneurysm-associated complications. In addition, this approach helps to maintain the benefits of autogenous access while conserving future dialysis sites.

Tongue abscess is a serious clinical entity which scarcely affects the tongue. It should be treated urgently to prevent airway obstruction or dissemination of infection to a more deep or distant area of the body. This article presented the first clinical report of tongue abscess in Iraq which discussed its clinical presentation, diagnosis, and treatment with a review of literature.

A case of 75-year-old woman with sebaceous epithelioma was reported. The histological features were distinct in that it had a sinusoidal and carcinoid-like growth pattern, which has been reported in its malignant counterpart. Immunostaining for adipophilin was positive in the area with lipid-laden vacuolated cells, but the rest of tumor, which had cord-like nests, was negative. MIB index was 2%. CK5/6 and p40 were positive in the cord-like nesting areas. CK7, CK20, alpha SMA, and epithelial membrane antigen were negative in both the cord-like nesting areas and the adipose-like areas. The tumor was diagnosed as sebaceous epithelioma with a trabecular pattern. Dermatopathologists should be aware of this atypical histological pattern of benign sebaceous epithelioma.

Category: Sports, Achilles Tendon Introduction/Purpose: Achilles tendon rupture is a common injury with increasing incidence in adults. While multiple studies have been conducted to determine the optimal surgery for an Achilles rupture, there is a lack of consensus around which surgical method serves as the best treatment. The predominant surgical options that are currently performed include open repair and minimally invasive or percutaneous Achilles rupture surgery (PARS), with comparative studies between open and PARS showing similar functional results. However, there is a lack of objective patient reported outcomes (PRO) for these procedures in the literature. To our knowledge, our study is the first prospective study to use validated patient reported outcomes (PROMIS®) to compare pre-operative and post- operative outcomes for the PARS surgery. Methods: Pre- and post-operative data for the PROMIS Physical Function and Pain Interference Computer Adaptive Tests (CATs) was collected for over 100 Achilles rupture patients at a major tertiary care facility and level I trauma center starting in 2014. Each of these patients were contacted at regular intervals for repeat survey evaluation at multiple post-operative time points via email or phone. Patients treated for chronic Achilles rupture as well as patients without adequate post- operative follow up of a minimum of 2 years were excluded. We conducted a preliminary analysis on a total of 21 patients with acute Achilles rupture Injury treated with PARS and 2 years post- operative PROMIS follow up. For each outcome, a Wilcoxon signed-rank test was used to assess the mean difference between pre-operative and post-operative scores. The statistical analysis was conducted by statisticians who were blinded and worked independently of the orthopedics department. Results: Based on the Wilcoxon signed-rank test, there was significant mean difference between pre-op and post-op physical function scores (p=0.0009 < 0.05) and no significant mean difference between pre-op and post-op pain scores (p=0.1743 > 0.05). Mean post-operative scores were at the 54th percentile for function and 44th percentile for pain. Conclusion: While our study is a preliminary investigation into the use patient-reported outcomes in determining the outcomes of PARS, we aim to expand on our findings as more patients reach 2-year post- operative status. Our preliminary findings are however consistent with the literature regarding the viability of PARS in treating acute Achilles ruptures with positive results similar to other techniques. While patients’ experience a minor loss in post-operative physical function as compared to their pre- injury status, PARS restores physical function scores to that of the mean population while restoring pain scores to baseline levels.

Bowel management is an outpatient program used to treat fecal incontinence. The clinician selects an appropriate treatment modality, either oral stimulant laxatives or a mechanical program (once daily rectal or antegrade enema). The therapy is adjusted throughout the course of a devoted week according to the patient report and daily abdominal radiograph findings. Whether using an oral stimulant laxative or rectal enema washout, the goal of treatment in both cases is to stimulate a daily bowel movement and empty the colon. The child should then not have another bowel movement or soiling for 24 hours until the next treatment and thereby will be clean and able to wear normal underwear.

Background Rates of reported gonorrhea cases have increased in recent years among all groups in the U.S. Expanded screening, particularly extragenital screening among men who have sex with men (MSM), results in increased case finding, complicating interpretation of reported case rates. Monitoring trends in symptomatic presentation through enhanced surveillance may provide insight into changes in case rates. Methods Randomly sampled cases from 54 counties in 5 U.S. states 2010–2017 were interviewed; symptom status (patient report of ‘any STD symptoms’) and sex-of-sex partner(s) were elicited. Interviewed cases were weighted to be representative of all reported cases in participating jurisdictions. Proportion of cases presenting with symptoms and symptomatic rate per 100,000 were calculated, stratified by gender and sex-of-sex partners. Trends over time were evaluated by Cochran-Armitage and Pearson’s trend tests. Results During 2010–2017, 21,006 cases were interviewed, representing over 500,000 reported cases. Symptom status was available for 97.1%; the estimated number of symptomatic cases increased 125.9% (30,883 to 69,772). The proportion of women and non-MSM males reporting symptoms increased by 15.3% (48.3% to 55.7%) and 11.5% (80.1% to 89.3%), respectively. Conversely, the proportion of MSM cases reporting symptoms decreased by 23.2% (72.5% to 55.7%). Relative increase in estimated symptomatic case rate from 2010 to 2017 was 82.8% among women (56.0 to 102.4 per 100,000) , 82.8% among non-MSM males (67.0 to 122.5 per 100,000) and 185.9% among MSM (946.2 to 2705.2 per 100,000). All trends were significant at p Conclusion Decreases in the proportion of MSM cases reporting symptoms suggests increased case rates among MSM are partially attributable to expanded screening. Yet a significant, increasing trend in the symptomatic case rate among MSM suggests a real increase in gonorrhea transmission. The proportion symptomatic and symptomatic case rates for non-MSM males and females are also rising, suggesting more transmissions in these groups as well. Disclosure No significant relationships.

Machine learning has earned a remarkable position in healthcare sector because of its capability to enhance the disease prediction in healthcare sector. Artificial intelligence and Machine learning techniques are being used in healthcare sector. Nowadays, one of the world's crucial health related problem is kidney disease. It is increasing day by day because of not maintaining proper food habits, drinking less amount of water and lack of health consciousness. So we need some technique that will continuously monitor health condition effectively. Here, we have proposed an approach for real time kidney disease prediction, monitoring and application (KDPMA). Our aim is to find an optimized and efficient machine learning (ML) technique that can effectively recognize and predict the condition of chronic kidney disease. In this work, we used ten most popular machine learning technique to predict kidney disease. In this process, the data has been divided into two sections. In one section train dataset got trained and another section got evaluated by test dataset. The analysis results show that Decision Tree Classifier and Gaussian Naive Bayes achieved highest performance than the other classifiers, obtaining the accuracy score of 100% and 1 recall(Sensitivity) score. Now we are developing mobile application based on the best output results classifier technique to predict Kidney Disease from patient report.

Background: Flares are inherent to the rheumatoid arthritis (RA) disease course and associated with poor clinical outcomes. The self-administered Flare Assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire was devised and validated for detection of current and recent flares in RA, taking into account both patient and provider perspectives [1, 2]. The FLARE-RA questionnaire includes arthritis-related subscale and general subscale. The overall score for the questionnaire is defined as the global scale, with scoring from 0 (no flare) to 10 (maximum flare). Objectives: To define the cross-cultural criterion validity of the FLARE-RA questionnaire and cut-off(s) for definition and decision in four different countries, using different anchor items in patients with RA. Methods: This cross-sectional study included adult patients with prevalent RA (per 2010 ACR/EULAR criteria) attending outpatient rheumatology clinics in France (n=138), Denmark (n=253), USA (n=75), and Argentina (n=105). Flare occurrence over the past 3 months was assessed using the FLARE-RA questionnaire. The cut-offs for the FLARE-RA score were defined using the following anchor items obtained at the same encounter: 1) Patient report of flare; 2) DAS28-CRP>3.2; 3) Change of anti-rheumatic treatment. Detection of the optimal cut-off for the FLARE-RA questionnaire was performed with distance (0,1) method, based on the area under the receiver operating characteristic curve (AUC). Results: The study included 571 patients with RA (mean age 56.9 years, 75.3% female). The discrimination for the FLARE-RA was acceptable-to-excellent: AUC for the global FLARE-RA score ranged from 0.71 to 0.92. The summary of optimal cut-offs for the FLARE-RA questionnaire is presented in the Table. The cut-offs for the FLARE-RA score were overall lowest using “patient’s report of flare” and highest using “change of anti-rheumatic treatment” as an anchor item: cut-offs for the global score for patients with RA duration 2-5 years: 1.82 and 4.55, respectively; for patients with RA duration >5 years – 2.18 and 3.18, respectively. The cut-offs corresponding to DAS28-CRP>3.2 were lower in patients with RA disease duration >5 years than in those with RA duration 2-5 years. Conclusion: The FLARE-RA questionnaire has acceptable-to-excellent discriminative capacity across the tested anchor items. Patient report of flare corresponds to a lower FLARE-RA cut-off score than DAS28-CRP and change of anti-rheumatic treatment, suggesting the hierarchy of flare recognition from flare self-perception to its detection by DAS28 to treatment change by the rheumatology provider. More studies are needed to ensure the early recognition of flares and the appropriate alignment between flare and the adjustment of anti-rheumatic and other medications. References [1] Berthelot JM, et al. Ann Rheum Dis 2012, 71(7):1110-6. [2] Fautrel B, et al. Arthritis Rheumatol 2017, 69(2):309-19. Disclosure of Interests: Elena Myasoedova Grant/research support from: Pfizer, Annette de Thurah: None declared, Marie-Line Erpelding: None declared, Emilce Schneeberger: None declared, Thomas Maribo: None declared, Gustavo Citera: None declared, John Davis Grant/research support from: Pfizer, Eric Matteson Grant/research support from: Eric Matteson has received research grants from Pfizer and Sun Pharmaceutical Industries, Ltd. for work on the pathobiology of rheumatoid arthritis., Consultant for: Eric Matteson has received consultancy fees from Boehringer Ingelheim for an advisory board., Cynthia S. Crowson: None declared, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant for: AbbVie, Biogen, BMS, Celgene, Janssen, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, Sanofi-Aventis, Sanofi Genzyme, SOBI, UCB, Francis Guillemin Grant/research support from: Expanscience

Background/aims Health plan administrative claims data present a cost-effective complement to traditional trial-specific ascertainment of clinical events typically conducted through patient report or a single health system electronic health record. We aim to demonstrate the value of health plan claims data in improving the capture of endpoints in longitudinal pragmatic clinical trials. Methods This retrospective cohort study paralleled the design of the ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) trial designed to compare the effectiveness of two doses of aspirin. We applied the ADAPTABLE identification query in claims data from Anthem, an American health insurance company, and identified health plan members who met the ADAPTABLE trial criteria. Among the ADAPTABLE eligible members, we selected overlapping members with PCORnet Clinical Data Research Networks in the 2 years prior to the index date (1 April 2014). PCORnet Clinical Data Research Networks consist of network partners (or healthcare systems) that store their electronic health record data in the same format to support multi-institutional research. ADAPTABLE outcome events—cardiovascular hospitalizations including admissions for myocardial infarction, stroke, or cardiac procedures; hospitalizations for major bleeding; and in-hospital deaths—were evaluated for a 2-year follow-up period. Events were classified as within or outside PCORnet Clinical Data Research Networks using facility identifiers affiliated with each hospital stay. Patient characteristics were examined with descriptive statistics, and incidence rates were reported for available Clinical Data Research Networks and claims data. Results Among 884,311 ADAPTABLE eligible health plan members, 11,101 patients overlapped with PCORnet Clinical Data Research Networks. Average age was 70 years, 71% were male, and average follow-up was 20.7 months. Patients had 1521 cardiovascular hospitalizations (571 (37.5%) occurred outside PCORnet Clinical Data Research Networks), 710 for major bleeding (296 (41.7%) outside PCORnet Clinical Data Research Networks), and 196 in-hospital deaths (67 (34.2%) outside PCORnet Clinical Data Research Networks). Incidence rates (events per1000 patient-months) differed between available network partners and claims data: cardiovascular hospitalizations, 4.1 (95% confidence interval: 3.9, 4.4) versus 6.6 (95% confidence interval: 6.3, 7.0), major bleeding, 1.8 (95% confidence interval: 1.6, 2.0) versus 3.1 (95% confidence interval: 2.9, 3.3), and in-hospital death, 0.56 (95% confidence interval: 0.47, 0.67) versus 0.85 (95% confidence interval: 0.74, 0.98), respectively. Conclusion This study demonstrated the value of supplementing longitudinal site-based clinical studies with administrative claims data. Our results suggest that claims data together with network partner electronic health record data constitute an effective vehicle to capture patient outcomes since >30% of patients have non-fatal and fatal events outside of enrolling sites.

Medication errors occur despite best intentions and are often the result of medication discrepancies. Medication reconciliation reduces the likelihood of errors by addressing medication discrepancies that result from multiple points of care, transitions in care, or patient report. Providers and practices may feel overwhelmed by new record systems and regulatory requirements, but multiple resources are available to assist providers to perform medication reconciliation with their patients. Providers and practices should implement medication reconciliation strategies, such as adoption of a multidisciplinary approach, engagement of patients to track medications, and identification of patients who are at high risk for medication list discrepancies and errors. Medication reconciliation will ultimately improve quality of care.

Gastrointestinal stromal tumor (GIST) is the most common submucosal tumor of the stomach. GISTs are often detected by esophagogastroduodenal endoscopy. We have previously reported on endoscopically invisible medium-sized exophytic type GISTs. We present here a case of small exophytic GIST detected by transabdominal ultrasonography (TUS) in which the natural history of the tumor could be traced retrospectively through incidental findings obtained during follow-up for intraductal papillary mucinous neoplasm by magnetic resonance of imaging or computed tomography over about 10 years. The tumor appeared 7 years before its detection, and the doubling time was calculated as 6.9 years. In conclusion, low-risk exophytic GIST was estimated to have taken at least about 7 years to reach a size detectable by TUS.

ObjectiveTo describe the criteria used to clear athletes to return to sport (RTS) following primary ACL reconstruction.DesignScoping review.Data sourcesMEDLINE, Embase, CINAHL and SPORTDiscus electronic databases were searched using keywords related to ACL and RTS.Eligibility criteriaProspective or retrospective studies reporting at least one RTS criterion for athletes who had primary ACL reconstruction with an autograft.ResultsIn total, 209 studies fulfilled the inclusion criteria. RTS criteria were categorised into six domains: time, strength, hop testing, clinical examination, patient-report and performance-based criteria. From the 209 included studies, time was used in 178 studies (85%), and in 88 studies (42%) was the sole RTS criterion. Strength tests were reported in 86 studies (41%). Sixteen different hop tests were used in 31 studies (15%). Clinical examination was used in 54 studies (26%), patient report in 26 studies (12%) and performance-based criteria in 41 studies (20%).SummaryTime and impairment-based measures dominated RTS criteria, despite sport being a complex physical and biopsychosocial activity with demands across all aspects of function. Time was included as a criterion in 85% of studies, and over 80% of studies allowed RTS before 9 months. Whether RTS tests are valid—do they predict successful RTS?—is largely unknown.

We report the case of a 6-year-old male who developed recurrent erythema nodosum (EN) at the age of 3 years. The patient exhibited hypertelorism, low-set ears, micrognathia, moderate intellectual disability, thin long fingers, loose anagen hair, and prominent palmoplantar wrinkles. A heterozygous single nucleotide variant in the SHOC2 gene (c.4 A > G, p.S2G) was identified. Patients with a SHOC2 mutation exhibit a unique combination of ectodermal abnormalities including darkly pigmented skin and loose anagen hair. This report is the first to describe EN in a patient with SHOC2 mutation, and to examine the patient’s hair using scanning electron microscopy. We hypothesize that the RAS/MAPK pathway is associated with the pathogenesis of cutaneous lesions in patients with SHOC2 mutations via autoinflammation and disturbance of epithelial stem cells.

Key Points Question Among primary care patients, what is the prevalence of electronic health record documentation of medical cannabis use and health conditions for which cannabis use might have benefits and risks? Findings In this cross-sectional study of 185 565 patients, 2% had past-year medical cannabis use documented in their electronic health records. Among patients with documented medical cannabis use, 44.5% had documented health conditions for which cannabis use might confer benefits, and 54.5% had conditions for which it might confer risks. Meaning These findings suggest that primary care practitioners should be prepared to discuss potential risks as well as potential benefits of cannabis use with patients., Importance Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners’ documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use. Objectives To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use. Design, Setting, and Participants This cross-sectional study assessed adult primary care patients who completed a cannabis screen during a visit between November 1, 2017, and October 31, 2018, at a large health system that conducts routine cannabis screening in a US state with legal medical and recreational cannabis use. Exposures Three mutually exclusive categories of EHR-documented cannabis use (medical, other, and no use) based on practitioner documentation of medical cannabis use in the EHR and patient report of past-year cannabis use at screening. Main Outcomes and Measures Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine’s review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression. Results A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits (49.8%; 95% CI, 48.3%-51.3%) compared with patients with other cannabis use (39.9%; 95% CI, 39.4%-40.3%) or no cannabis use (40.0%; 95% CI, 39.8%-40.2%). In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks (60.7%; 95% CI, 59.0%-62.3%) compared with patients with other cannabis use (50.5%; 95% CI, 50.0%-51.0%) or no cannabis use (42.7%; 95% CI, 42.4%-42.9%). Conclusions and Relevance In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients., This cross-sectional study describes the prevalence and clinical characteristics of primary care patients with cannabis use documented in their electronic health records.

We presented a 38-year-old woman suffering from acute cerebral infarction due to arteritis limited to bilateral internal carotid arteries without a condition of giant cell arteritis or granulomatosis with polyangitis. Our case is unprecedented and characterized by a young woman with wall enhancement in the internal carotid arteries on contrast-enhanced magnetic resonance imaging (MRI), therapeutic effects of steroids, and positive status for human leucocyte antigen-B39, -B51 and -DR4. These disease characteristics were not in accordance with existing diagnostic criteria of vasculitis, such as Takayasu's arteritis, giant cell arteritis, granulomatosis with polyangiitis, and Behcet's disease. We suggested consideration of a novel "isolated internal carotid arteritis" disease concept.

Objective The present study aims to determine the agreement between paramedic and ED or hospital working diagnosis in dyspnoeic patients. Methods Non-consecutive written patient report forms were retrospectively audited for patients suffering from dyspnoea, who were transported to a tertiary hospital ED by ambulance paramedics. Accuracy of the paramedic working diagnosis was assessed by comparing agreement with either the primary or secondary ED diagnoses or hospital discharge diagnosis. Results The study cohort was 293 patients. Exact agreement between paramedic versus ED or hospital diagnosis was 64%, 95% CI 58–69, k = 0.58, 95% CI 0.52–0.64. Only 226 (77%) had a ‘clearly documented’ paramedic diagnosis. Among these, agreement with either ED or hospital diagnosis was 79%, and there was a trend towards more agreement as paramedic level of practice increased (74%, 78% and 87% for Basic, Intermediate and ALS paramedics, respectively, P = 0.07). Conversely, ALS paramedics were less likely to document a working diagnosis (30/98, 31%) compared with Intermediate (22/102, 23%) and BLS paramedics (15/93, 16%), P = 0.008. Diagnostic agreement varied according to medical condition, from anaphylaxis (100%) and asthma (86%) to acute pulmonary oedema (46%). Conclusions There was moderate agreement between paramedic and ED or hospital diagnosis. The number of cases with no clearly documented working diagnosis suggested that a singular working diagnosis may not always serve the complexity of presentation of some dyspnoea patients: more open descriptors such as ‘mixed disease’ or ‘atypical features’ should be encouraged.

Background Anesthesiologists need tools to accurately track postoperative outcomes. The accuracy of patient report in identifying a wide variety of postoperative complications after diverse surgical procedures has not previously been investigated. Methods In this cohort study, 1,578 adult surgical patients completed a survey at least 30 days after their procedure asking if they had experienced any of 18 complications while in the hospital after surgery. Patient responses were compared to the results of an automated electronic chart review and (for a random subset of 750 patients) to a manual chart review. Results from automated chart review were also compared to those from manual chart review. Forty-two randomly selected patients were contacted by telephone to explore reasons for discrepancies between patient report and manual chart review. Results Comparisons between patient report, automated chart review, and manual chart review demonstrated poor-to-moderate positive agreement (range, 0 to 58%) and excellent negative agreement (range, 82 to 100%). Discordance between patient report and manual chart review was frequently explicable by patients reporting events that happened outside the time period of interest. Conclusions Patient report can provide information about subjective experiences or events that happen after hospital discharge, but often yields different results from chart review for specific in-hospital complications. Effective in-hospital communication with patients and thoughtful survey design may increase the quality of patient-reported complication data.

Umbilical melanoma is extremely rare. Among the past English reports on umbilical melanoma, there are only 8 reports in which histopathology was described in detail, and there has been no report with a review of the histopathology of previously reported cases. We experienced a case of umbilical melanoma and reviewed previously reported cases including our case. Because of the anatomical location, it is difficult to become aware of the umbilical melanoma unless there are some concomitant symptoms such as discharge or swelling. Even with these symptoms, patients tend to postpone a hospital visit for unknown reasons, resulting in increased risk of tumor growth and metastasis. When performing resection of umbilical melanoma, a portion of the peritoneum should also be removed. Sentinel lymph nodes can be axilla or inguinal lymph nodes. There is a possibility of metastasis to the preoperative abdominal cavity or to nearby skin through hematogenous spread. Preoperative evaluation of tumor spread and postoperative observation are important for umbilical melanoma in order to detect recurrence or metastasis because of its unique anatomical location.

Objective To assess the exchangeability of self-reported and administrative health care resource use measurements for cost estimation. Study Design and Setting In a systematic review (NHS EED and MEDLINE), reviewers evaluate, in duplicate, the methodological reporting quality of studies comparing the validation evidence of instruments measuring health care resource use. The appraisal tool Methodological Reporting Quality (MeRQ) is developed by merging aspects form the Guidelines for Reporting Reliability and Agreement Studies and the Standards for Reporting Diagnostic Accuracy. Results Out of 173 studies, 35 full-text articles are assessed for eligibility. Sixteen articles are included in this study. In seven articles, more than 75% of the reporting criteria assessed by MERQ are considered “good.” Most studies score at least “fair” on most of the reporting quality criteria. In the end, six studies score “good” on the minimal criteria for reporting. Varying levels of agreement among the different data sources are found, with correlations ranging from 0.14 up to 0.93 and with occurrences of both random and systematic errors. Conclusion The validation evidence of the small number of studies with adequate MeRQ cautiously supports the exchangeability of both the self-reported and administrative resource use measurement methods.

Objectives We implemented the “High-Impact Testing for Injection Drug Users”, or the “HIT IDU” initiative, an emergency physician (EP)–based hepatitis C virus (HCV) testing program. The objective of this study was to evaluate the outcomes of this clinical protocol. Methods This was a prospective observational pilot study. The HIT IDU initiative encouraged EPs to integrate targeted HCV testing into care, with an emphasis on screening all people who inject drugs (PWID). Physicians selected the primary indication for HCV testing from a drop-down menu integrated into the electronic ordering process. The primary outcome was the absolute number and overall proportion of EP-based HCV antibody positive tests, further stratified by the indication for testing. Results Over the 3-month study period, 14,253 unique patients were evaluated, and EPs tested 155 patients for HCV (1.1%; 95% confidence interval [CI], 0.9%-1.2%), of which 40 (26%, 95% CI, 19%-33%) were HCV antibody positive. The proportion of HCV antibody positivity by testing indication was as follows: PWID 47% (34/73; 95% CI, 35%-59%), patient requested test 10% (4/40; 95% CI, 3%-24%), confirm patient report 67% (2/3; 95% CI, 9%-99%), liver disease of uncertain etiology 0% (0/3; 95% CI, 0%-71%), and other 0% (0/36; 95% CI, 0%-10%). There were 22 patients chronically infected, 19 had a follow-up appointment arranged, 3 attended their follow-up appointment, and 1 patient was treated at 1 year of follow-up. Conclusions Although the overall number of EP-based HCV tests performed was low, high rates of infection were identified, particularly among PWID. There were significant challenges with linkage to care.

Background Previous studies have found that adults with intellectual disabilities (ID) are hospitalised more often than the general population (GP). This study investigates hospital discharge rates and main diagnostic causes for hospitalisation among administratively defined people with ID compared with the GP in Norway. Method Data from the Norwegian Labour and Welfare Service was combined with data from the Norwegian Patient Register (Ntotal = 1 764 072 and NID = 7573) for the period 2008–2011. Data from a Norwegian patient report generator and Statistics Norway are also analysed. Results During the study period, 11% of people with ID and 11.5% of the GP were admitted to hospitals. The length of the average hospital stay was just over 4 days for both groups. Among those who were hospitalised, the majority were only admitted to hospital once during the study period: ID 66% and GP 70%. People with ID were admitted somewhat more often than people in the GP. Contrary to the GP, adults with ID were more frequently hospitalised at a younger age and less frequently at old age. The most common International Classification of Diseases diagnostic group for hospitalisation among people with ID is injury, poisoning and certain other consequences of external causes, whereas for the GP, it is diseases of the circulatory system. Conclusion This study finds that the proportion of people being hospitalised per year is statistically, but only slightly, different among adult people with ID and the GP. The results must be interpreted in light of the organisation of the health care system in Norway.

Temporomandibular joint dislocation causes considerable pain, discomfort, and swelling. The anatomic construction of the articular fossa and the eminentia articularis may predispose to dislocation, and weakness of the connective tissue forming the capsule is believed to be a predisposing factor. The capsule may be stretched and, more rarely, torn. Dislocation may be unilateral or bilateral and may occur spontaneously after stretching of the mouth to its extreme open position, such as during a yawn or during a routine dental operation. Manual reduction with the patient under muscle-relaxing condition or anesthesia is recommended method. After the reduction of an acute dislocation, immobilization of the jaw is recommended to allow the stretched and sometimes torn capsule to heal, thus preventing recurrence. A Barton's bandage may be applied for 2 to 3 weeks to prevent the patient from opening the jaw too wide. But, it results in recurrent dislocation in the neurologically disabled patient, because of loose intermaxillary fixation. This is a case report about management of recurrent temporomandibular joint dislocation by multiple loop wirings and intermaxillary elastics in cerebrovascular accident patient.

OBJECTIVE Few data are available to inform clinical expectations about course and prognosis of severe obsessive-compulsive disorder (OCD). Such information is necessary to guide clinicians and to inform criteria for invasive interventions for severe and intractable OCD. This study sought to examine course and prospective predictors of a chronic course in patients with severe OCD over 5 years. METHOD A selected subset of adults in the Brown Longitudinal Obsessive-Compulsive Study (BLOCS) was included. Adult BLOCS participants were enrolled between 2001 and 2006. All participants in the current study (N = 113) had DSM-IV OCD diagnosis, severe OCD symptoms at baseline, and at least 1 year of follow-up data. RESULTS Cox proportional hazard models were used to examine the general pattern of course in the severe OCD sample based on Longitudinal Interval Follow-Up Evaluation (LIFE) psychiatric status ratings, as well as test predictors of chronically severe course. Results indicated that approximately half of patients with severe OCD at baseline had illness drop to a moderate or lower range of severity during 5 years of follow-up (50.4%) and that marked improvement was rare after 3 years of severe illness. The only unique predictor of a more chronically severe course was patient report of ever having been housebound for a week or more due to OCD symptoms (P < .05). CONCLUSIONS Findings of this study were 3-fold: (1) half of participants with severe OCD have symptom improvement over 5 years of follow-up, (2) the majority of participants that drop out of the severe range of symptom severity do so within the first 3 years of follow-up, and (3) patient-reported history of being housebound for 1 week or more due to OCD is a significant predictor of OCD's remaining severe over the 5-year follow-up.

The purpose of this paper was to report the case of a 23-year-old patient suffering from bilateral acute visual loss who received the diagnosis of hypertensive retinopathy. After systemic evaluation, he was diagnosed with bilateral renal disease and chronic renal failure, requiring a kidney transplantation to manage the systemic illness, followed by gradual improvement of his visual acuity.

Background: Tranexamic Acid (TXA) has been shown by the CRASH-2 study to reduce the risk of death by bleeding. This evaluation assesses the use of TXA by the Great North Air Ambulance (GNAAS), and considers the individual patient outcomes in hospital, including the need for blood products and venous thromboembolism (VTE) rate. Methods: A service evaluation was performed with the analysis of patient outcome by the review of patient report forms over a 1-year period. Patients who received pre-hospital TXA were identified and further analysis of their outcomes was performed at the two receiving local major trauma centres. Results: 106 patients received pre-hospital TXA, all within 3 hours. The majority (73%, n=77) had been involved in a road traffic collision. Thirty per cent (n=32) of patients also received a pre-hospital blood transfusion; 73% (n=58) were subsequently shown to have an injury severity score (ISS) ≥15, which traditionally defines major trauma. Six (6.3%) patients were later found to have a VTE (five pulmonary embolism and one deep-vein thrombosis) within 1 month of injury, although no patients died of VTE. Almost half of the patients received an in-hospital transfusion 45% (n= 45). Conclusion: TXA is a life-saving drug in the bleeding trauma patient, and within this study population, TXA was administered promptly and appropriately. A VTE incidence of 6.3% is in line with other literature, and there were no recorded deaths from VTE. TXA is available to pre-hospital clinicians across the UK, where the author believes its use should be encouraged.

We report a case of adenocarcinoma affecting the chin of a 48-year-old man. The tumor showed signs of apocrine differentiation and had infiltrated the muscle. The patient had no history or clinical evidence of breast cancer. We made a diagnosis of cutaneous apocrine adenocarcinoma. Apocrine adenocarcinoma rarely arises in areas with scarce apocrine glands. We reviewed the literature on apocrine adenocarcinoma of the face in areas other than the eyelids and auditory canal, where specialized apocrine glands are present.

The UAB Pediatric Sickle Cell Clinic cares for patients at both an academic center and satellite clinics. One difference in clinics is that CBC results are not available at the time of patient care during satellite clinics, but are available at the academic center. Therefore, hydroxyurea (HU) dosing adjustments are made within seven days through telehealth; after reviewing faxed CBC results, a sickle cell nurse calls families and educates them on any revised HU dosing plans and reinforces adherence to HU. We hypothesized that this type of telehealth HU dosing adjustments would not impact HU laboratory response. Methods: We performed a one-year retrospective review of 172 HbSS and HbSB0 thalassemia patients prescribed HU during 2019 that were cared for in both the academic center (Birmingham) and satellite clinics (Montgomery, Tuscaloosa, Opelika). We excluded patients on HU and a second sickle cell disease modifying therapy. We abstracted from the EMR: age, sex, clinic location, diagnosis, HU dose (mg/kg), WBC, Hb, MCV, Platelets, Absolute Reticulocyte, HbF, and ANC. We recorded the total number of well-clinic visits and categorized clinic visit/year as ≤ 2or >2; satellite clinic visits are fixed either monthly to every three months which limited our ability to reschedule patients with missed visits. We also recorded the number of ED visits and admissions to the hospital for a) pain and b) all sickle cell complications except for scheduled procedures. We collected acute visit data from the EMR at the academic center for onsite participants and from patient report from satellite participants. We evaluated dosing adjustment as whether dosing was increased for ANC > 4000 per institutional standard of care. We categorized correct dosing adjustments if > 65% of visits had a dose adjustment per institutional protocol; we categorized patients as a deviation from protocol if the physician did not increase the dose based on ANC. We performed descriptive statistics, t-test for continuous variables, chi-square for categorical variables, and regression modeling using JMP Pro 14 (Cary, NC). P-values Results: The mean age of the 172 participants was 11±5 years, mean Hb was 8.5±1.1g/dL, mean MCV was 91.3±10.1 fL, mean HbF% was 12.7±6.7, and mean ANC was 4.9±2.3. Fifty two percent of participants were female. We identified 107 participants prescribed HU at the academic center and 65 participants from satellite clinics. We identified no significant differences in HU monitoring laboratory values for Hb (p=0.6), MCV (p=0.7), HbF (p=0.13), ANC (p=0.9) by clinic location. We did not identify a difference in sex of participants by clinic location (p=0.9); also, HbF% (p=0.6) and HU dose (p=0.3) were not associated with sex. We did not identify a difference in all admissions to the hospital (p=0.5) or pain admissions to the hospital (p=0.6) between academic center vs. satellite clinic patients. However, academic center patients did have a higher number of acute pain visits (p=0.03) to either the ED or UAB pediatric pain clinic. As expected, among all participants, non-adherence to HU (HbF 2 clinic visits. HbF response was significantly associated with clinic visits (p=0.03). Finally, HbF response was significantly inversely correlated with age (p=0.003). Adjusting for clinic location, number of clinic visits, and age, HbF % was associated with age (p=0.006) and clinic visits (p=0.006), but not associated with clinic location. Conclusion: Our data demonstrate that telehealth for HU dosing provided a similar level of HU response to in-person HU dosing adjustments. This finding importantly suggests that telehealth for monitoring and adjusting HU in patients with poor access to a Pediatric Hematologist or during a pandemic should not impact HU response. Strategies to improve overall adherence need prospective evaluation at our institution, but are not related to telehealth dosing of HU. Disclosures Lebensburger: Novartis: Consultancy.

107 Background: About 30 million people in the US report Limited-English Proficiency (LEP). LEP cancer pts are less likely to understand their medical condition(s) and are at increased risk of LHL, emergency department (ED) visits or hospitalizations. We examined the relationship between LEP, LHL, and ED visits/hospitalization in oncology. Methods: Dana-Farber Cancer Institute’s New Pt Intake Questionnaire (NPIQ) documents clinical and social determinants of health, including LHL. Pts reported LHL if they responded “a little bit”, “somewhat” or “not at all” to 1 of 2 questions: 1) “How confident are you in filling out medical forms?” and 2) “How confident are you in understanding medical statistics?”. Pts reported LEP if they noted a primary language other than English at registration. ED visits/hospitalizations were determined from Partners Healthcare System records. Statistically significant relationships between LEP, LHL and ED visits/hospitalizations and pt demographics (age, sex, race/ethnicity, zip code) and clinical (disease center, treatment intent) characteristics were determined with χ2 tests. Results: From 5/30/15 – 4/30/20, 21570 of 98200 eligible pts responded to NPIQ (response rate 22.0%). LHL differed by age (p-value < 0.001), gender (p-value < 0.001) and race/ethnicity (p-value = 0.007). Among LEP pts reporting LHL, financial distress (p-value = 0.004), emotional distress (PROMIS score; p-value = 0.014), and prior cancer (p-value = 0.006) were more prevalent; however, there was no significant statistical increase in ED visits (p-value = 0.237) or hospitalizations (p-value = 0.965) compared to LEP not reporting LHL. Conclusions: The results indicate that sociodemographic and other pt characteristics contribute to ED and hospital utilization in LEP cancer pts. Future studies will employ prospective data to examine the covariates’ predictive ability for resource utilization with LHL among LEP pts. [Table: see text]

We investigated the reasons why the transition from paper to electronically formatted records during patient handover between ambulance crews and emergency department staff in a North East England Emergency Department has not always been viewed positively. Interviews with seven paramedics and three emergency department staff were conducted in addition to observations of 74 ambulance staff during 37 handovers in the emergency department. In just over half of the handovers (20), paramedics found it necessary to provide written information to aid emergency department staff, in addition to that recorded electronically. There were a number of issues that impeded the ready utilisation of electronic records in this context. The major factors identified as contributing to this were the choice of system architecture, the design of user interfaces, and the procurement process used by the National Health Service. We have made some suggestions about how the system could evolve from one focused on providing management information to one that also supports operational needs.

The standard procedure for remnant gastric cancer after esophago-proximal gastrectomy is total resection of the remnant stomach considering blood supply. However, sometimes surgery may be too invasive due to severe adhesion in the thoracic and mediastinal cavity. The blood supply to the remnant stomach depends on the right gastroepiploic artery and the right gastric artery. Therefore, preservation of the proximal region of the remnant stomach is thought to be anatomically impossible. We report a case of remnant gastric cancer that developed more than 12 years after lower thoracic esophagectomy plus proximal gastrectomy for Siewert Type I squamous cell carcinoma. We used intra-operative indocyanine green (ICG) venous-injection to evaluate blood flow and distal gastrectomy of the remnant stomach was performed by preserving the proximal stomach in the thoracic cavity through an abdominal approach. There were no complications of the remnant stomach or the anastomosis to the jejunum after surgery. In this case, we focused on the blood supply by collateral circulation through the anastomotic line from the remnant esophagus. After confirming blood supply with intra-operative evaluation using ICG fluorescence, less-invasive distal gastrectomy was successfully performed. As the intra-operative ICG-based evaluation for blood supply is a simple and safe method, it might be useful for determining the resection margin of various organs and be effective for the introduction of less invasive surgery. Here, we report a case and a review of the literature.

Portal vein stenosis, which results in serious clinical conditions such as gastrointestinal variceal bleeding and liver failure, is caused by hepatobiliary pancreatic cancer or major postoperative complications after hepatobiliary pancreatic surgery. In recent years, portal vein stenting under interventional radiology has been applied as a more useful treatment method for portal vein stenosis than invasive surgery. We herein report the successful use of a vascular stent for portal vein stenosis after pancreatoduodenectomy. A 66-year-old man with distal cholangiocarcinoma underwent subtotal stomach-preserving pancreatoduodenectomy with resection of the portal vein because of direct invasion to the main portal vein at our hospital. The portal vein was reconstructed without a venous graft. He developed jejunal bleeding near the pancreatojejunostomy on postoperative day (POD) 2. Although embolization of the responsible vessel achieved hemostasis, an intraoperatively inserted drainage tube was needed for a long period of time postoperatively because the embolized afferent jejunum was perforated. He was discharged on POD 39 after removal of the drainage tube. On POD 282, he was readmitted with melena and severe fatigue. Computed tomography revealed an obstruction of the reconstructed portal vein and varices at the hepaticojejunostomy site. We diagnosed variceal bleeding and performed percutaneous transhepatic stenting in the obstructed portal vein. The patient was discharged in good clinical condition on day 15 after stenting. In conclusion, portal vein stenting is a useful and less invasive therapy for portal vein stenosis.

The effectiveness of exercise programs for chronic low back pain (CLBP) is dependent upon patient adherence which is problematic to measure accurately. This cross-sectional observational study aimed to compare patient-reported levels of adherence with physiotherapists' perceptions of patient adherence; and to explore the proportion of patients who could accurately recall and demonstrate the exercises contained within their prescribed exercise program for CLBP. Participating patients (

Aim There has been a drive towards an increase in community-based management of heart failure. When patients experience acute heart failure (AHF), the complex nature of this condition poses diagnostic uncertainty for first responders. It is widely accepted that all patients should be transferred promptly to hospital, however with the introduction of pre-hospital diuresis, nitrate therapy and more recently non-invasive ventilation (NIV), the debate into the appropriateness and limitations of so-called ‘stay-and-play’ management strategies for patients in AHF has been re-ignited. We examine the current clinical assessment and management of AHF within the London Ambulance Service. Method Ambulance Patient Report Forms (PRFs) from cases that were coded with heart failure, shortness of breath, cardiac problem and in cases of GTN administration. These cases were further analysed by a clinical review panel to identify patients with suspected AHF. Results 182 patients were included in the analysis between April and November 2016. There was a 68% compliance with national guidelines for clinical assessment (history, examination and ECG). 51 (28%) patients presenting with AHF were appropriately identified and given a primary diagnosis of AHF by the attending clinician. 136 (76%) patients in the analysis received sublingual nitrate therapy. 90 (49%) patients received nitrates where there was no clinical indication. No patients in the analysis received NIV. Conclusion Some aspects of AHF assessment and management are not consistent with national guidelines. Our work has further demonstrated the diagnostic challenges facing pre-hospital clinicians and the potential overuse of nitrate therapy in this patient group. Conflict of interest None Funding None

We report a case of squamous cell carcinoma manifested as a cutaneous horn. A 92-year-old man was referred to our department for evaluation of a 3-month history of a keratotic cutaneous horn on the left side of his neck. The height of the cutaneous horn was larger than the diameter of erythema at the base. Histopathological examination showed a hyperkeratotic horn developing over a mass of large atypical keratinocytes with large hyperchromatic and pleomorphic nuclei. Based on these findings, a diagnosis of squamous cell carcinoma was made. A recent study showed that cutaneous horns in association with invasive squamous cell carcinoma had a tendency to have less height than the diameter of the base. In our case, however, the height of the cutaneous horn was larger than the diameter of the base, indicating that invasive squamous cell carcinoma sometimes shows a cutaneous horn that is higher than the diameter of the base. Thus, clinical finding of erythema at the base of the cutaneous horn would be a reliable feature for early detection of squamous cell carcinoma.

Schizencephaly and porencephaly are extremely rare types of cortical dysplasia. Case 1: Prenatal magnetic resonance imaging (MRI) showed wide clefts in the frontal and parietal lobes bilaterally. On postnatal day 3, MRI T2-weighted images showed multiple hypointensities in the clefts and ventricular walls, suggestive of hemosiderosis secondary to intracranial hemorrhage. Case 2: Prenatal MRI showed bilateral cleft and cyst formation in the fetal cerebrum, as well as calcification and hemosiderosis indicative of past hemorrhage. T2-weighted images showed hypointensities in the same regions as the calcification, corresponding with hemosiderosis due to intracranial hemorrhage on postnatal day 10. Thus, prenatal MRI was useful for diagnosing schizencephaly and porencephaly. Schizencephaly and porencephaly were thought to be due to fetal intracranial hemorrhage, which, in the porencephaly case, may have been related to a mutation of COL4A1.