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Background: Reconstruction of the defects created by extirpative surgery or radiation for gynecologic cancer can be challenging for both patients and surgeons. In the subset of patients who present with recurrent gynecologic cancer after previously successful treatment and radiation therapy, wounds to irradiated tissue are difficult to heal, requiring a collaborative effort between the gynecologic oncologists and the plastic and reconstructive surgeons. Other factors that may hinder successful repair include comorbidities, history of radiation, ongoing tobacco use, and overall protein malnutrition. To maximize repair success, decrease recurrence, and optimize aesthetic outcome, gynecologic oncologists and plastic and reconstructive surgeons need to communicate the anticipated anatomic and physiologic obstacles to each other and to the patient. Purpose: To create a systematic approach from our current method of gynecologic oncologic reconstruction that facilitates communication among general surgeons, gynecologic oncologists, and plastic and reconstructive surgeons to optimize gynecologic oncologic reconstructive and aesthetic outcomes while minimizing wound complications. Methods: A retrospective chart review was conducted on patients who underwent gynecologic oncologic surgery for vulvar, vaginal, cervical, and uterine cancer over a 10-year period. A step-by-step method and categorization for gynecologic reconstruction was generated from our experience, and a pictorial essay was created to demonstrate this method and highlight the most common complications. Results: The pictorial essay serves as a template for gynecologic oncology or plastic and reconstructive surgeons to follow and effectively close gynecologic tumor defects and facilitate patient care. The most common complications were seroma and distal skin necrosis, managed by early excision and closure without consequence. Satisfaction with surgical outcomes was high among the patients. Conclusion: Successful repair of primary and recurrent gynecologic tumors requires communication between the gynecologic oncologist and the plastic and reconstructive surgeon. The procedures are challenging and require resilience from both the patient and the surgeons. Incision placement is important for adequate flap reconstruction to prevent wound and skin breakdown. Wound breakdown is likely and requires preoperative counseling. High protein nutritional stores are important for expeditious healing.

Faecal incontinence (FI) is a debilitating condition which reduces quality of life (QOL). Conservative management with education, pelvic floor exercise and pharmacological agents are first-line treatment. Following which, biofeedback therapy (BFT) is recommended. Although well described in the West, existing literature on its efficacy in Asian populations remains sparse. The primary aim of our study is to evaluate the efficacy of BFT in improvement of symptoms, QOL and overall satisfaction in our Asian population.Patients with moderate FI in Singapore General Hospital between 2012 and 2016 were enrolled. Rockwood FI quality of life scale (FIQL) and Wexner scale were used to evaluate QOL across four domains, and symptom severity respectively. They were scored at baseline and again after four sessions of BFT, with an additional overall satisfaction score (OSS).A total of 137 patients were included. Mean age was 62 years and 72.3% were female. Majority demonstrated improvement in Wexner score (68.6%) and FIQL (65%). Sixty-five patients (47.4%) reported improvement in both. Positive correlation was found between Wexner score and OSS (r = 0.206), and Wexner score and FIQL across all four domains. Only one FIQL domain-coping/behaviour, showed statistically significant correlation with OSS (r = 0.263).BFT is effective in our Asian population in both symptom reduction and improving QOL. Wexner score demonstrated low correlation with FIQL and OSS-suggesting that FI requires a multi-dimensional approach beyond symptom treatment, of which ability to cope appears crucial. BFT, consistent with the biopsychosocial model, shows benefit in this regard.

Protective factors that build students’ resilience are known. A six-week digital resilience training program was developed on the basis of theory, evidence, and contextual information. The feasibility study sought to evaluate the acceptability, appropriateness, demand, implementation, and limited efficacy of a digital resilience skills enhancement program for undergraduate students. A single group, pre-test, post-test, concurrent mixed methods design among 10 undergraduate students was conducted in one university in Singapore. The content analysis concluded that students accepted and perceived the digital resilience skills enhancement program as appropriate. Students also proposed several improvements, such as the initiation of the program and revisions to the content. The Wilcoxon signed-rank test found significant improvements in resilience (p = 0.02) and meta-cognitive self-regulation (p = 0.01) scores with medium (d = 0.79, 95% CI: −0.15 to 1.74) and very large effect sizes (d = 1.31, 95% CI: 0.30–2.33), respectively. Students found the digital resilience program appropriate and were able to apply their newly acquired skills to promote their resilience and learning. Although, several improvements are proposed to enhance the rigor of the digital resilience program, the findings of this study suggests that digital resilience programs are important for students’ well-being.

Hintergrund: Immuncheckpoint-Inhibitoren sind wirksame Therapien für ein breites Spektrum von bösartigen Erkrankungen. Ihre zunehmende Verbreitung hat zu einer Vielzahl von immunbedingten Nebenwirkungen geführt, unter anderem zu Haut-, Magen-Darm-, Lungen-, endokrinen, kardialen und neurologischen Komplikationen. Fallbericht: Wir stellen den Fall eines 72-jährigen weißen Mannes mit nichtkleinzelligem Lungenkrebs vor, der nach 2 Zyklen Durvalumab wegen Dyspnoe aufgenommen wurde. Bei ihm wurden signifikant erhöhte Kreatinin-Kinase- und Troponin-Werte im Serum festgestellt, die Herzkatheteruntersuchung war negativ. Während seines Krankenhausaufenthalts entwickelte er eine fortschreitende Dyspnoe und eine neu aufgetretene axiale Schwäche, was schließlich zur Diagnose einer Durvalumab-induzierten Myokarditis, Myasthenia gravis und Myositis führte. Schlussfolgerungen: Soweit uns bekannt ist, handelt es sich hierbei um den ersten Fall einer Kombination aus Myokarditis, Myasthenia gravis und Myositis, die durch den Antikörper gegen PD-L1 (programmed cell death ligand 1) ausgelöst wurde. Der Einsatz immunologischer Wirkstoffe hat zwar insgesamt zu besseren Behandlungsergebnissen bei Krebs geführt, aber auch zu einem breiten Spektrum immunbedingter Nebenwirkungen. Wir geben einen Überblick über die Diagnostik und Behandlung von Patienten mit diesen immunbedingten Nebenwirkungen und betonen, wie wichtig eine frühzeitige Erkennung ist, da es zu einer schnellen Verschlechterung kommen kann.

OBJECTIVES To determine the all-cause health care resource utilization and costs among long-term nursing home (LTNH) residents with and without overactive bladder (OAB). DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Minimum Data Set (MDS)-linked Medicare Part A, B, and D claims data from 2013 to 2015 were analyzed. LTNH residents aged 65 years or older with a diagnosis of OAB (n = 216,731) were propensity score matched with LTNH residents without OAB (n = 300,327) (non-OAB cohort). METHODS We measured health care resource utilization and costs associated with OAB by setting (inpatient, outpatient, emergency department, or prescription) during the 6 months following nursing home admission. Descriptive and multivariate (negative binomial for health care resource utilization and 2-part model for costs) analyses were performed to examine the health care resource utilization and costs among LTNH residents with and without OAB. The annual cost attributed to OAB was calculated as the difference between total annual OAB costs and total annual non-OAB costs. RESULTS A total of 214,505 patients were included in each matched cohort. Across all health care resource categories, LTNH residents with OAB had higher health care resource utilization and costs compared to the non-OAB cohort (all P

Background Immune checkpoint inhibitors are effective therapies for a wide range of malignancies. Their increased use has led to a wide range of immune-related adverse effects including skin, gastrointestinal, pulmonary, endocrine, cardiac, and neurologic complications. Case presentation We present the case of a 72-year-old Caucasian man with non-small cell lung cancer who was admitted for dyspnea after two cycles of durvalumab. He was found to have significantly elevated levels of serum creatinine kinase and troponin with a negative cardiac catheterization. During his hospitalization, he developed progressive dyspnea and new-onset axial weakness, ultimately leading to the diagnosis of durvalumab-induced myocarditis, myasthenia gravis, and myositis. Conclusion This is, to our knowledge, the first reported case of anti-programmed cell death ligand 1-induced combination of myocarditis, myasthenia gravis, and myositis. While the use of immunologic agents has resulted in overall improved cancer outcomes, their increased use has led to a vast spectrum of immune-related adverse effects. We review the diagnostic workup and management of patients with these immune-related adverse effects, underscoring the importance of early identification given the potential for rapid deterioration.

Introduction This study sought to compare healthcare resource utilization (HCRU), costs, and workplace productivity among patients with depression, with and without overactive bladder (OAB). Methods This retrospective, case–control cohort analysis compares HCRU, costs, and workplace productivity among propensity score matched patients with depression and OAB (case cohort) and patients with depression without OAB (control cohort). Patients were aged 18 years or older, insured/on Medicare, and had diagnosed depression and an antidepressant medication claim pre index. First OAB-related event was index for cases; controls were assigned a proxy (study period 12 months). Comparisons of HCRU and costs and regression models assessed the relationship between OAB and costs. For the workplace productivity subset analyses cases and controls were balanced on baseline covariates for the short-term disability analyses but as they were unbalanced for the absentee analyses, multivariate regression analyses were used for this subset. Results The study criteria were met by 39,085 cases and 308,736 controls, from which, 37,997 patients were successfully matched 1:1 (mean age 55 years; 81% female). Most depression-related HCRU measures were similar across cohorts; however, outpatient visits, ER visits, and number of unique depression medications were significantly higher (all p

462 Background: Little is known about treatment and QOL of la/mUC in Saudi Arabia, South Korea, Turkey, and Taiwan. Therefore, this study assessed patient (pt), tumor, and disease characteristics; treatment sequencing; and QOL in pts with la/mUC treated in these countries. Methods: Data were drawn from the Adelphi mUC Disease-Specific Programme, a real-world, multinational, point-in-time study using validated methodology (Anderson et al. Curr Med Res Opin. 2008;24:3063-72) and included physician surveys, chart reviews, and pt questionnaires (Saudi Arabia, Turkey, and Taiwan only). Data were collected (12/2021–3/2022) from oncologists and urologists and adult pts with confirmed la/mUC. EQ-5D visual analogue scale (VAS; scores: 0 [worst health] to 100 [best health]) and the global health status (QL2) from the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 (scores: 0 [low functioning] to 100 [high functioning]) questionnaires were used to assess QOL. Results: Data were provided by 175 physicians for 988 pts (Turkey, n=300; Saudi Arabia, n=240; South Korea, n=298; Taiwan, n=150) with la/mUC. Mean pt age was 66.3 y; 77% were men. Most (77%) pts had no family history of urothelial carcinoma (UC); 30% recorded no risk factors (eg, genetic risk, smoking, occupational exposure). At initial UC diagnosis, the bladder was the initial tumor location in 82% of pts, of whom 67% had la/mUC, and 83% of pts had an Eastern Cooperative Oncology Group performance status 0–2. At data collection, the most common metastatic sites were the lymph nodes (53%), lungs (29%), liver (27%), and bone (21%). Biomarker/tumor testing was not done in 45% of pts. In pts initially diagnosed with nonmetastatic UC (n=346), 28% received neoadjuvant and 31% received adjuvant therapy. Of pts receiving ≥1 line of therapy (LOT) for la/mUC (n=988), 74% received gemcitabine, 60% received cisplatin, 18% received carboplatin, 17% received a programmed cell death protein 1/ligand 1 (PD-1/L1) inhibitor, and 4% received best supportive care (BSC) in the first-line (1L) setting; mean duration of therapy (DOT) in 1L was 5.7 mo. Of pts receiving ≥2 LOTs for la/mUC (n=290), 63% received a PD-1/L1 inhibitor and 35% received chemotherapy in the second-line (2L) setting; mean DOT in 2L was 4.9 mo. Of pts receiving ≥3 LOTs for la/mUC (n=87), 59% received chemotherapy (most often cisplatin [46%] or gemcitabine [38%]), 34% received a PD-1/L1 inhibitor, and 10% received BSC only in the third-line (3L) setting; mean DOT in 3L was 4.3 mo. Questionnaires were available for 319 pts. Mean (SD) EQ-5D VAS score was 51.8 (15.6); EORTC QL2 score was 44.6 (19.9). Conclusions: Pts with la/mUC in this multinational study generally received 1L platinum-based and 2L PD-1/L1 inhibitor therapies. These results highlight the need for therapies that improve clinical and QOL outcomes.

Objective: Many laparoscopic cholecystectomy operations are performed with at least overnight admission. Current research shows that laparoscopic cholecystectomy is safe and feasible to do as a day case. Patient centred outcomes are less well understood. Material and Methods: Elective laparoscopic cholecystectomy patients at a single metropolitan hospital in Melbourne, Australia were surveyed 24 hours after surgery using the 15-question Quality of Recovery (QoR-15) survey. A comparison was made between day case surgeries and multi-day surgeries. Results: One hundred and eight patients were recruited consisting of 34 day case and 74 multi-day patients. Patient groups did not differ in terms of age, sex or postoperative morbidity. The multi-day group had a higher proportion of comorbid patients (p-value = 0.03). There was no significant dif- ference in overall QoR-15 score between the two groups, although there was an observed trend towards a higher score in the day case group (132.0 vs 127.9, p= 0.147). QoR-15 individual question results showed that day cases rated significantly better for sleep quality and for less feelings of anxiety or worry. The differences narrowed when comparing patient groups as they were booked (intention-to-treat). There were no identified sub-groups that had a significantly higher score if admitted multi-day. Conclusion: Quality of recovery following day case laparoscopic cholecystectomy is just as good, if not better, than multi-day cases. Laparoscopic cholecystectomy as a day case is both safe and economically superior to multi-day management. This gives further weight to current recommendations suggesting that the majority of laparoscopic cholecystectomy operations could be performed as day cases.

BACKGROUND Cardiac rehabilitation is known to improve morbidity and mortality; however, it is underutilized. OBJECTIVE This pilot initiative will: 1) determine if a smartphone app is able to detect meaningful differences in cardiorespiratory fitness after participation in traditional cardiac rehabilitation, 2) observe cardiac rehabilitation referral patterns and 3) monitor patient engagement in cardiac rehabilitation. METHODS During February 2020, n = 34 patients were enrolled in outpatient phase II cardiac rehabilitation at our institution and included in the initiative. A mobile phone app, Heart Snapshot, was used to estimate VO2 max at baseline and after 4 weeks of participation in cardiac rehab. Providers were surveyed about referral patterns. The plan-do-check-act cycle was used to assess improvement. RESULTS The mean age was 67 (SD: 13) and ischemic heart disease was the main reason for referral. Improvement in app-derived VO2 max was positively correlated with improvement in METs. The survey revealed provider lack of understanding of conditions benefitting from cardiac rehabilitation and discrepancy regarding responsibility referring to cardiac rehabilitation. CONCLUSIONS Cardiac rehabilitation is an important yet underutilized intervention. There is room for improvement in provider education and ownership for cardiac rehabilitation referrals. An app-based VO2 estimate may be a solution for remotely monitoring fitness improvement.

Author(s): Louthan, Michael; Ng, Daniel | Abstract: Case Presentation: We describe a complete right hemithorax Westermark sign found in a patient with a near-complete, right pulmonary artery trunk occlusion secondary to a pulmonary embolus.Discussion: We review the sensitivity and specificity of a Westermark sign in the identification of a pulmonary embolism, and how this aided us in managing our patient in the emergency department.

Methyl CpG binding protein 2 (MECP2) duplication syndrome is a rare X-linked genetic disease. Core phenotypes include infantile hypotonia, developmental delay, and minimal speech with mild dysmorphic features. Many have refractory epilepsy and recurrent infections, which are the leading causes of mortality. This article presents a case of a patient with MECP2 duplication syndrome who required general anesthesia for respiratory workup and reviews the anesthetic management for these patients, which includes induction technique, choice of drugs, and other major anesthetic concerns.

Sequential window acquisition of all theoretical fragment-ion spectra (SWATH) is a data-independent acquisition (DIA) strategy that requires a specific spectral library to generate unbiased and consistent quantitative data matrices of all peptides. SWATH-MS is a promising approach for in-depth proteomic profiling of Chinese hamster Ovary (CHO) cell lines, improving mechanistic understanding of process optimization, and real-time monitoring of process parameters in biologics R&D and manufacturing. However, no spectral library for CHO cells is publicly available. Here we present a comprehensive CHO global spectral library to measure the abundance of more than 10,000 proteins consisting of 199,102 identified peptides from a CHO-K1 cell proteome. The robustness, accuracy and consistency of the spectral library were validated for high confidence in protein identification and reproducible quantification in different CHO-derived cell lines, instrumental setups and downstream processing samples. The availability of a comprehensive SWATH CHO global spectral library will facilitate detailed characterization of upstream and downstream processes, as well as quality by design (QbD) in biomanufacturing. The data have been deposited to ProteomeXchange (PXD016047)., Measurement(s) Proteomic Profile • database type spectral library Technology Type(s) mass spectrometry • SWATH MS protein profiling assay • computational modeling technique Sample Characteristic - Organism Cricetulus griseus Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.12480386

Morel-Lavallée lesions are closed degloving soft tissue injuries that should be considered in post-traumatic patients with persistent pain or swelling. Physicians must keep a high index of suspicion for this commonly missed entity, as early diagnosis is critical to preventing complications. We describe a case of a 46-year-old male who presented to the emergency department following a motorcycle accident. Initial radiographic imaging did not show evidence of osseous injury, and he was discharged home. He later returned with worsening right thigh pain and swelling. Further imaging showed a large fluid collection between the muscle and subcutaneous tissues consistent with a Morel-Lavallée lesion. This case report discusses the common presentation, diagnostic modalities, and treatments to help improve the identification and management of Morel-Lavallée lesions.

As silicon scaling closer to physical limit, future reduction of the gate oxide does not lower down the cost per transistor. But the demand of higher functionality and lower cost of electronic devices do not slow down. Development of electronic devices metaphor to high-density package integration. What the electronic industries do is to break down a large die to a chiplet-based devices for improving yield and lower the total cost. Chiplet package become a key technology to continue Moore’s law. With the intensive researches, multiple chiplet packages are evolved such as multi chips on Si interposer using TSV (2.5D), die to die stack on each other (3D), Fan-Out Multi Chip Module (FOMCM), and EMIB (Embedded Multi-Die Interconnect Bridge). These packages are developed for the server, high performance computing, router, and switcher markets.But, the integration of high bandwidth memory devices and multiple ASIC dies together requires very high I/O counts and signal transmitting. Thus, a much higher RDL (Redistribution Layer) layer counts, finer bump pitch and smaller line- space (L/S) are designed. Each of these chiplets has its limitations. Large 2.5D package has its cost concerns on large Si interposer and mismatch of the Si interposer with substrate on reliability test. Whereas, large FO-MCM technology is limited by finer L/S and higher layers count of RDL. Presently, the package is heading the bottleneck at 1/1 μm L/S, 5 layers RDL and 2 reticle size chip module. As for EMIB technology, it is constrained by L/S that could only down to 5/5 μm.In this paper, we have successfully developed a scalable chiplet package technology, namely Fan-Out Embedded Bridge (FOEB). This chiplet package enables near monolithic short reach BEOL connections between dies. FOEB can have multiple RDL layers and Si bridge that has much finer L/S for interconnection. In addition to, multiple dies can be bridged together into one single chip module. In this paper, the demonstration of FOEB test vehicle, which integrate chips by 1 ASIC die and 4 memory dies (1+4) with 4 embedded bridge dies on mold-based interposer, 3 layers of RDL are presented. By comparing packages using FOMCM and 2.5D to fabricate. FOEB package has much lower warpage and 2 x lower stress value as compare to 2.5D. But similar to FOMCM. Owing to this reason, the FOEB chiplet package were tested 2x longer temperature cycle with condition-G without single failure as compared to 2.5D. The assembly yield of FOEB is comparable to FOMCM. And much higher than that of EMIB.Assembly of FOEB chiplet package adopts organic interposer. The wafer warpage changes from concave to convex shape after die attachment on the molded interposer. This limits some of the machines handling and induces wafer cracking. By properly select the right molding compound, and glass carrier CTE, we have successfully developed this FOEB chiplet and validated through reliability test. This chiplet allows us to scale the package to much higher I/O density, finer L/S, higher RDL layers, and number of dies that can be integrated into one single chip module.