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Clinical experience with an innovative, dual-action, in-office bleaching regimen that has both chemical and photoactivated mechanisms is described. This internal bleaching procedure was performed in three patients, each with different characteristics. In general, the results obtained were satisfactory. In the 6-month period of follow-up, no adverse effects related to the application of the bleaching agent were found. The different factors that may have influenced the results achieved are discussed. [ABSTRACT FROM AUTHOR]

Small fellowship programs face challenges in providing learners with sufficiently diverse experiences and patient populations. The Fellows Most Difficult Case Conference is designed to broaden geriatric medicine fellows' exposure to cases and to faculty and fellows from around the country through a monthly telephone conference. We describe this innovative approach to a national monthly complex case conference that fellows from almost one‐third of geriatrics fellowship programs attend, including its value to geriatric fellows and faculty and administrative costs. Once per month, a fellow presents a case, a moderator leads the discussion, and 2 faculty members provide teaching points during the 60‐minute session. Participants rated the conference's value using an 11‐item on‐line survey followed by a debriefing held during a regularly scheduled 2017 monthly conference. Thirty‐six percent of eligible participants responded to the survey (67/186), with 75% of respondents reporting that they applied knowledge gained from the conferences to their patient care at least 1 or 2 times per month and 41% that they applied it at least once per week. Participants appreciated the inclusion of multiple programs, the duration of the conference, and the interactive approach. Our administration time was less than 5 hours per month, plus a few additional hours annually to create the academic year schedule. We believe that this national case conference, the first of its kind in the country, involving almost one‐third of geriatrics fellowship programs, is an innovative and valuable way for fellows to explore complex cases and variations in regional perspectives and to connect with additional colleagues. [ABSTRACT FROM AUTHOR]

Ginkgo biloba extract (GBE), derived from the leaves of Ginkgo biloba L. , is one of the most widely used traditional Chinese medicines worldwide. Due to high structural diversity and low abundance of chemical constituents in GBE, conventional reversed-phase liquid chromatography has limited power to meet the needs of its quality control. In this study, an off-line hydrophilic interaction × reversed-phase two-dimensional liquid chromatography (HILIC × RP 2D-LC) system coupled with diode array detection (DAD) and quadrupole time-of-flight mass spectrometry (qTOF-MS) was established to comprehensively analyze the chemical constituents of GBE. After optimizing the chromatographic columns and mobile phase of 2D-LC, a Waters XBridge Amide column using acetonitrile/water/formic acid as the mobile phase was selected as the first dimension to fractionate GBE, and the obtained fractions were further separated on an Agilent Zorbax XDB-C18 column with methanol/water/formic acid as the mobile phase. As a result, a total of 125 compounds were detected in GBE. The orthogonality of the 2D-LC system was 69.5%, and the practical peak capacity was 3864 and 2994, respectively, calculated by two different methods. The structures of 104 compounds were tentatively characterized by qTOF-MS analysis, and 21 of them were further confirmed by comparing with reference standards. This established HILIC × RP 2D-LC-qTOF/MS system can greatly improve the separation and characterization of natural products in GBE or other complicated herbal extracts. [ABSTRACT FROM AUTHOR]

Alveolar rhabdomyosarcoma (ARMS) commonly occurring in children and adolescents, is a rare and aggressive soft tissue malignancy. Here, a rare case of pleural ARMS is reported in a boy presenting dyspnea for two weeks. The pathology of a biopsy specimen from pleura showed ARMS. PAX3-FKHR fusion protein is positive and the PAX7-FKHR fusion protein is negative as detected by fluorescence in situ hybridization. The prognosis of this patient was poor and nonresponsive to chemotherapy. [ABSTRACT FROM AUTHOR]

Background: The present paper discusses the lexical and grammatical peculiarities of English language medical case reports, taking into account their communicative purposes and intentions.Methods: The objective of the research is to clarify the principal mechanisms of producing an effective English language medical case report and thus to provide recommendations and guidelines for medical professionals who will deal with this genre. The analysis of medical case reports will largely focus on the most significant linguistic peculiarities, such as the use of active and passive voice, the choice of particular verb tenses, and pronouns. The selected medical case reports will be considered using methods of lexico-grammatical analysis, quantitative examination, and contextual, structural, narrative, and stylistic analyses.Results: The research revealed a range of important stylistic features of medical case reports which markedly distinguish them from other genres of medical scientific writing: educational and instructive intentions, conciseness and brevity, direct and personal tone, and material presented in a narrative style. The present research has shown that the communicative strategies of the analyzed discourse, mentioned immediately above, are effectively implemented by means of specific lexical units and grammatical structures: the dominance of active voice sentences, past simple tense, personal pronouns, and modal verbs. The research has also detected the occasional use of the present perfect, present simple, and future simple tenses and passive voice which also serve particular communicative purposes of medical case reports.Conclusions: Medical case reports possess a range of unique characteristics which differ from those of research articles and other scientific genres within the framework of written medical discourse. It is to be emphasized that it is highly important for medical professionals to master the major stylistic principles and communicative intentions of medical case report as a genre in order to share their findings with fellow researchers from all over the world. Hence, in the process of training future medical researchers, the analysis of the basic mechanisms of writing a medical case report should be an integral part of the curricula in English for Specific Purposes at universities. [ABSTRACT FROM AUTHOR]

A 21-year-old Warmblood mare was referred to the Equine Department, Vetsuisse Faculty, University of Zurich, because of recurrent unilateral nasal discharge 3 months after partial removal of a large cyst from the left maxillary and frontal sinuses. Endoscopic, radiographic and computed tomographic examinations showed that the remnant of the cyst, which originally had extended from the left maxillary and frontal sinuses into the left nasal cavity, had expanded and was obliterating the left middle nasal meatus. A direct surgical approach to the cyst through the left nasal and maxillary bones rostral to the facial crest was chosen, which allowed evaluation and removal of the entire cyst. Endoscopic examination 3 days post operatively showed no remnants of the cyst, and the mare was discharged in good health. Re-examination one year later showed no recurrence of the cyst. [ABSTRACT FROM AUTHOR]

Cardiac rupture is defined as a full-thickness myocardial tear; this injury after blunt chest trauma is rare, and is associated with high mortality. Blunt cardiac rupture typically presents with either cardiac tamponade or massive hemothorax, and is often unrecognized in the context of blunt chest trauma. It is a little known fact that pericardial effusions can decrease due to pericardial lacerations. Hence, cardiac rupture with pericardial lacerations may be easily overlooked especially by chest surgeons. We herein report a case of hemothorax caused by rupture of the left atrial appendage. An 80-year-old male was involved in a motor vehicle crash. We made the diagnosis of hemothorax on the basis of bloody thoracic effusion and left pleural effusion on computed tomography (CT). CT also showed small pericardial effusion in amount and non-displaced rib fractures. We made a tentative diagnosis of intercostal artery injury with rib fractures, we performed left thoracotomy. However, in the operating room, we recognized that cardiac rupture led to massive hemothorax, and that hemothorax was not associated with intercostal artery injury. We repaired left atrial appendage rupture, and his postoperative course was uneventful. Cardiac rupture can present as slight pericardial effusion with hemothorax. On the basis of this case, we propose that cardiac rupture should be considered at the time of hemothorax examination with careful attention to pericardial effusions. [ABSTRACT FROM AUTHOR]

The front cover of the journal is presented along with the issue's editors and information on membership and subscriptions.

Ten months after orthotopic liver transplant, a 53-year-old male patient developed cough and fever. Imaging revealed diffuse ground-glass opacities involving all lobes, and subsequent bronchoscopic washings revealed Scopulariopsis brumptii infection. The patient initially had significant clinical deterioration requiring intubation and extracorporeal membrane oxygenation. However, combination antifungal therapy, including posaconazole and terbinafine, eventually proved successful in eradicating the infection. [ABSTRACT FROM AUTHOR]

Key Clinical Message Drug-Drug interactions is important when caring for warfarin-treated patients. We examined the impact on INR with coadministration of warfarin and caspofungin and showed no affect on the INR. Coadministrations of fluconazole lead to a marked increase in INR. We concluded that administration of caspofungin and warfarin was safe. [ABSTRACT FROM AUTHOR]

Introduction: Idiopathic pulmonary arterial hypertension is defined as a group of diseases characterized by a progressive increase in pulmonary vascular resistance that results in right heart failure and premature death. Although therapies exist to improve hemodynamic instability and symptoms, there is no cure for pulmonary arterial hypertension and it remains a life-threatening condition. A recent study performed in China reported, for the first time, the effect of pulmonary arterial denervation on functional capacity and hemodynamics in patients with refractory idiopathic pulmonary arterial hypertension.Case Presentation: We report a case of a 60-year-old white Brazilian man, with controlled hypertension and stage 2 obesity who complained of progressive fatigue with moderate to light exertion of approximately 1 year's duration. During this period, he underwent myocardial perfusion scintigraphy without evidence of obstructive ischemic disease. He had no clinical evidence of systolic heart failure. He had undergone biological mitral valve replacement 3 years previously for mitral valve stenosis and ablation of atrioventricular nodal reentry tachycardia 18 months previously. At the time of valve replacement, he had no reported evidence of pulmonary arterial hypertension. His echocardiogram showed normal function of a mitral prosthesis, normal global left ventricular systolic function (left ventricular ejection fraction 62 % measured using the Teichholz method), stage I diastolic dysfunction, and a mean systolic pulmonary arterial blood pressure of 50 mmHg. In the 6-minute walk test, the patient walked 104 meters. Catheterization of his right heart chambers and pulmonary arteries confirmed the diagnosis of pulmonary hypertension. Electroanatomic reconstruction of the right ventricular outflow tract and pulmonary artery was performed under direct fluoroscopic visualization, and a merger was made with a formatted image of cardiac computed tomography angiography. Then we performed irrigated cardiac catheter ablation of the pulmonary trunk.Conclusions: At the patient's 3-month follow-up, he showed improvement in functional class for fatigue on major exertion, increased distance walked in the 6-minute walk test, and reductions in pressure of both the right cavities and the pulmonary artery. Currently, with 6 months of clinical follow-up, the patient has maintained his functional classification and is pedaling his bicycle. [ABSTRACT FROM AUTHOR]

The article presents a case study of a five-year-old unimmunized boy who was presented with asymptomatic, raised, skin-colored papules of sudden onset that extend over his extremities, trunk and face. He also experienced continuous moderate fever, dark colored urine, and yellowish discoloration of skin. He was diagnosed with idiopathic hypereosinophilic syndrome (IHES).

The article describes two cases of human myiasis in Canada. A 45-year-old woman, who had been camping in Ontario, presented to the emergency department with a three-week history of swelling and redness around the left eye while a 33-year-old underwent an assessment of skin nodules after a 12-day trip to rural Belize. Topics include the clinical manifestation of myiasis, diagnosis based on the presence of a visible punctum, and extraction of the larvae and treatment recommendation.

The article discusses research which reviewed the occurrence of posterior reversible encephalopathy syndrome in Henoch-Schönlein purpura, considered the most common systemic vasculitis in childhood. Topics discussed include the search of the terms "posterior reversible encephalopathy syndrome" and "anaphylactoid purpura" in the U.S. National Library of Medicine and Excerpta Medica database, and the documented cases of Henoch-Schönlein purpura.

Melatonin secretion is usually increased during the daytime and decreased at night in Smith–Magenis syndrome (SMS) and consequently is not a pertinent marker of the circadian phase of the clock in these cases. No data on temperature rhythm is available in SMS, another reliable marker of circadian clock activity. For this reason, we assessed the 24 h profiles of core temperature, sleep–wake cycle, hormones (plasma cortisol and melatonin) and plasma and urine 6sulfatoxy-melatonin, the main hepatic melatonin metabolism in a 31-year-old man diagnosed with a SMS. All circadian rhythms, especially temperature rhythm showed a phase-advance, associated with reverse melatonin secretion. Plasma and urine 6sulfatoxy-melatonin profiles showed normal melatonin catabolism and confirmed the reversed melatonin secretion. Taking in consideration the reverse melatonin secretion and the phase-advanced temperature rhythm, which is driven by the suprachiasmatic nucleus, we hypothesize that the central clock is more sensitive to afternoon than to morning melatonin. This different responsiveness to melatonin according to the time of the day (i.e. chronaesthesia) corroborates the phase response curve of melatonin secretion to exogenous melatonin. [ABSTRACT FROM AUTHOR]

This is the case of a 64-year old hypertensive, diabetic patient, known to have liver cirrhosis, with a history of pulmonary thromboembolism, with permanent electrical cardiac stimulation, who was hospitalized for a newly diagnosed giant popliteal hematoma. The patient is currently discharged and following oral anticoagulant treatment. [ABSTRACT FROM AUTHOR]

The hemolytic uremic syndrome (HUS) is defined by the triad of hemolytic anemia, thrombocytopenia, and acute renal failure. The typical presentation of HUS occurs following a diarrheal prodrome. Diarrhea is infectious, usually due to Shiga toxin-producing Escherichia coli. In typical HUS, the history may include exposure to contaminated food. Symptoms develop 24 hours to 8 days following ingestion of the offending agent. Atypical HUS (aHUS) is being described in a growing body of literature and is more commonly associated with neurologic impairment. Central nervous system involvement may occur in almost half of patients and symptoms vary from mild (lethargy, irritability) to severe (seizures, paresis, coma). Atypical HUS may be caused by a variety of etiologies, each with a different trigger resulting in the final common pathway of inflammatory cascade causing renal endothelial and vascular injury and resultant thrombotic microangiopathy. This report describes the case of a 50-year-old female who developed HUS. [ABSTRACT FROM AUTHOR]

Central nervous system (CNS) involvement represents almost 1% of all cases of active tuberculosis. It represents a form with a high level of morbidity and mortality in spite of appropriate treatment. There isn't any agreement regarding the duration of the antituberculous treatment. We report a case related to cerebral tuberculomas and another case related to interactions between antiepileptic drugs and antituberculous treatment. The first case involves cerebral tuberculomas discovered on brain imaging (CT scan, cerebral MRI) and secondary epilepsy. The patient did an antituberculous treatment for pulmonary tuberculosis and tuberculous meningitis for one year, consisting of 4 drugs (HRZE). Six months later, he checked into our clinic with a tonic clonic seizure and we discovered tuberculomas on the cerebral MRI. Shortly thereafter we started the treatment with 5 drugs (HRZES) and anticonvulsants. Five months later the MRI showed multiple enhancing lesions described as "a bunch of grapes", potentially matching multiple tuberculomas. The second case shows the interaction between anticonvulsants and antituberculous drugs in concomitant pulmonary tuberculosis and epilepsy with tonic clonic seizures. We measured the concentration of anticonvulsants in the blood during the antituberculous treatment. [ABSTRACT FROM AUTHOR]

Pancreatic neuroendocrine tumors have a rare annual incidence in the general population and they are classified into functional and non-functional tumors. Non-functioning tumors represent the majority. We report an uncommon non-functional neoplasm that developed into the pancreatic isthmus. A 70-year-old woman presented at the hospital with abdominal pain, nausea and vomiting. The abdominal echography revealed a hypoechoic mass of 65/54 mm with dilatation of the upstream Wirsung duct. Non-contrast-enhanced computed tomographic demonstrated a well-enhanced mass of 4/5/6.5 cm on the head of the pancreas. An endocrine tumor of the pancreas was considered as a preoprerative diagnosis and pancreatectomy was performed with pancreatojejunum anastomosis- the Beger surgery. As a result, a non-functional endocrine tumor of the pancreas was confirmed anatomo-pathologically. The clinical manifestation of non-functioning endocrine pancreatic tumors is characterized by nonspecific symptoms. They represent a group of neoplasms which can delay the real diagnosis. Currently, CT scans are most used for detection. A rare case of non-functional neuroendocrine pancreatic neoplasm with extensive growth within the head and isthmus part of the pancreas was presented. An early detection of non-functioning endocrine neoplasm of the pancreas is very important and curative resection should be tried for a good prognosis. [ABSTRACT FROM AUTHOR]

We report the case of a 48 years-old man diagnosed with Leriche syndrome. The patient had no angina, rare palpitations and intermittent claudication with a walking perimeter about 500 meters. The patient had numerous cardiovascular risk factors and he underwent a percutaneous transluminal coronary angioplasty (PTCA) on right coronary artery (RCA) and on left anterior descending (LAD) artery thirteen years ago. In-stent restenosis was found two years after PTCA thus, a primary isolated coronary artery bypass graft (CABG) surgery was performed using an in situ left internal mammary artery (LIMA) graft to LAD and a radial artery graft on RCA. Eleven years post-CABG surgery, a coronary CT angiography examination revealed that the radial graft on RCA and the native right coronary artery were occluded, but in situ LIMA graft was permeable. The CT angiography of the abdominal aorta and lower limbs showed that the aortic bifurcation and common iliac arteries were occluded. [ABSTRACT FROM AUTHOR]

Due to the fact that vitamin B12 is important in the myelination of the central nervous system, vitamin B12 deficiency is associated with neurologic and psychiatric manifestations. It causes reversible megaloblastic anemia and the most frequent cause of severe vitamin B12 deficiency is the loss of the intrinsic factor in autoimmune atrophic gastritis. Vitamin B12 deficiency can cause both the demyelination of the cervical, dorsal and lateral columns of the spinal cord, and the demyelination of white matter in the brain. We report a case of a 34 year-old man who was admitted in our clinic with ataxic paraparesis and schizoaffective structure with depressive decompensations. Laboratory exams detected a severe hyporegenerative macrocytic anemia and increased values of vitamin B12 (> 2000 pg/mL). Clinical and paraclinical tests that showed improvement under B12 treatment became paradoxical and raised many questions. We found in the literature that it is possible that a false normal vitamin B12 level may have been caused by interference from a high-titer of intrinsic factor antibody. The patient was diagnosed with autoimmune gastritis and secondary loss of intrinsic factor in the gastroenterology department and he had a complete remission of the symptoms and the hematological parameters after vitamin B12 treatment. [ABSTRACT FROM AUTHOR]

Known by more than two centuries as cells described by Paul Erlich, mast cells still remain the most actively involved cells in allergy pathogeny, including its most severe manifestation, anaphylaxis shock. Brutal mast cells degranulation, due to contact with an allergen, is followed by the release of preformed or newly synthesized factors which would be associated to an entire spectrum of clinical manifestations that may eventually be lethal. Within this context, we present the case of a man who died by anaphylaxis shock after exposure to a great number of bee bites. Standard microscopy and anti-tryptase immunohistochemistry, revealed in necroptic specimens, edema, vascular congestion, extensive hemorrhages, and an increased number of perivascular mast cells within the inflammatory reaction in lesional skin, tongue base, epiglottis, larynx, extended more than subepithelial location up to periglandular and perimuscular locations. The histopathological picture provides a better understanding of clinical symptoms that lead to death in such cases. [ABSTRACT FROM AUTHOR]

The article provides information on the journal "Clinical Case Reports" including its aims and scopes, copyright, and editors.

The article describes the case of a 67-year-old woman who was diagnosed with osteoarthritis of the knees. Topics covered include the medical history of the patient, differential diagnosis of osteoarthritis and interventions for the management of knee osteoarthritis. Also explored are treatment options for osteoarthritis.

The hydatid cyst with double location (lung and liver) is a challenge for the thoraco-abdominal border surgery mainly due to the difficulty of choosing the approach (thoracotomy and laparotomy versus thoracotomy and phrenotomy). We present a case of hydatid cyst with dual location (right lung and left hepatic lobe) resolved by right thoracotomy and right transphrenic approach. [ABSTRACT FROM AUTHOR]

Characterized by progressive cerebellar ataxia, cutaneous and conjuctival telangiectasia, ocular apraxy, immunodeficiency, and increased risk of malignancy, ataxia-telangiectasia is a rare neurodegenerative disorder that shows signs of autosomal recessive transmission. The ataxia-telangiectasia gene is located in chromosome 11 q22-23. Various degrees of abnormalities in T and B cell immunities have also been described. It is known that the incidence of both T cell and B cell leukemia and lymphoma increased compared with the general growth of the population in Turkey. T cell malignancy can be seen at any age though B cell malignancy is more common at older ages. This report presents the case of two siblings who were diagnosed with ataxia-telangiectasia. The two siblings formerly had another sibling who was diagnosed with ataxia-telangiectasia and died from leukemia. Taking these two cases as the staring point, this study focuses on the clinical manifestations, affected systems and treatment of ataxia-telangiectasia. [ABSTRACT FROM AUTHOR]

Abstract: The idea of the therapeutic landscape has been widely used to describe the relationship between place and improvements in mental health. This paper uses data from a qualitative study conducted with people with mental health problems to outline the role of the public library as a therapeutic landscape. It situates the public library as a space that is simultaneously familiar and welcoming, comforting and calming, and empowering. Further, the paper reflects on the impact of proposed library closures in light of these previously hidden benefits, thinking about the library's role as an environment and not as a service provider. [Copyright &y& Elsevier]

This report described a case in which diagnostic radiographs showed irregular dense radiopaque strings and curved lines in the head and neck area. These artifacts could lead to misinterpretation since they may obscure anatomical structures and/or mask critical structures/pathologies. A more detailed history of the patient indicated that these strings originated from a facelift procedure in which a gold-wire technique was used. Considering that such intervention may cause a radiodiagnostic burden, it should be included in the anamnesis prior to radiography. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Program Evaluation is the property of University of Toronto Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In clinical research an early and prompt detection of the risk class of a new patient may really play a crucial role in determining the effectiveness of the treatment and, consequently, achieving a satisfying prognosis of the patient's chances. There exists a number of popular rule-based algorithms for classification, whose performances are very attractive whenever data of large number of patients are available. However, when datasets only include data of a few hundred patients, the most common approaches give unstable results and developing effective decision-support systems become scientifically challenging. Since rules can be derived from different models as well as expert knowledge resources, each of them having its advantages and weaknesses, this article suggests a “hybrid” approach to address the classification problem when the number of patients is too small to effectively use a single technique only. The hybrid strategy was applied to a case study and its predictive performance was compared with performances of each single approach: due to the seriousness of a misclassification of high-risk patients, special attention was paid on the specificity. The results show that the hybrid strategy outperforms each single strategy involved. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Crush trauma to the extremities, even if not involving vital organs, can be life threatening. Crush syndrome, the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation, leads to metabolic derangement and acute kidney injury. Although common in disaster scenarios, emergency physicians also see the syndrome in patients after motor-vehicle collisions and patients “found down” due to intoxication. Objective: The objectives of this review are to discuss the pathophysiology of crush syndrome, report on prehospital and emergency department treatment, and discuss the relationship between crush syndrome and compartment syndrome. Discussion: We present the case of a young man found down after an episode of intoxication, with compartment syndrome of his lower extremity and crush syndrome. Although he eventually required an amputation, aggressive fluid resuscitation prevented further kidney injury and metabolic derangement. Conclusions: Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome. Providers must be aware of the risk of hyperkalemia shortly after extrication. Ongoing resuscitation with i.v. fluids is the mainstay of treatment. Compartment syndrome is a common complication, and prompt fasciotomies should be performed when compartment syndrome is present. [Copyright &y& Elsevier]

The article discusses the rationale for case report guidelines for open-access electronic case report journals. It explores phenomena that have further obscured the role of case reporting in modern medical practice. It suggests several ways to improve case report standards. It also presents a recommended checklist for reporting and publishing case reports.

Highlights: [•] We model care processes and apply questions distilled from the DM concepts. [•] Application of DM–PM approach to a fall management program provided useful insights. [•] Application of DM–PM approach exposed many important shortcomings in the processes. [•] Application of DM–PM approach gave way to improvement suggestions. [ABSTRACT FROM AUTHOR]

A 35-year-old man complaining of progressive paresis in his lower extremities presented to the neurosurgical ward. The patient had history of spinal hydatid cysts and had undergone surgical resection 5 years ago. Multiple lesions were observed at the regions of previous surgery on spine magnetic resonance imaging. Thus, this patient had recurrent spinal cord hydatid cysts. Patient was prescribed albendazole 400 mg twice a day and then underwent surgical resection of the hydatid cyst withT-12 to L-4 laminectomy. Following surgery, patient's symptoms improved gradually after the surgery and with regular physiotherapy sessions during the follow-up period. In addition to the limb weakness, the patient recovered control of urination and defecation with time. [ABSTRACT FROM AUTHOR]

In this paper, we propose a two-phase approach for designing a weekly scheduling template for outpatient clinics providing multiple types of services. In many outpatient clinics, various service types are categorized to address the operational challenge of substantial changeover time between certain pairs of services. In the first phase of our approach, a mixed-integer program is formulated to assign service categories to clinic sessions during a week and determine the optimal number of appointments reserved for each service type in each clinic session. The objective in the first phase is to balance the workload of the providers among clinic sessions. In the second phase, a stochastic mixed-integer program is formulated for each clinic session to assign each contained appointment with a starting time based on several time-based performance measures. To solve the formulated stochastic program, we develop a Monte Carlo sampling based genetic algorithm. The two-phase approach is tested numerically with cases derived from a real women's clinic. Our results demonstrate that the two-phase approach can efficiently find promising weekly appointment scheduling templates for outpatient clinics. In addition, our results suggest that the best suboptimal scheduling templates found become more sensitive to the weighting coefficients of the time-based measures as the provider workload increases. [ABSTRACT FROM AUTHOR]

Abstract: Background: In Hong Kong Emergency Departments (EDs), the timeliness of providing high-quality services has been compromised by the increasing attendance of non-emergent patients in addition to the unpredictable arrival of emergency patients. Objectives: We sought to quantify the impact of the presence of emergent patients and other related factors on the delay in service for non-emergent patients. Methods: We conducted a retrospective study in patients who visited the ED of a large hospital in Hong Kong from July 1, 2009 to June 30, 2010. We estimated waiting and length of stay (LOS) for individual non-emergent patients registered during day and evening shifts. Using multiple linear regression, we estimated waiting time and LOS as a function of the presence of emergent patients and other related factors such as patient demographics and clinical factors. In particular, we evaluated the influence of the arrival or presence of emergent patients on the odds of violating the 120-min waiting time target for semi-urgent patients. Results: The arrival of a new emergent patient prolonged the waiting time and LOS of a non-emergent patient by 14.9% (95% confidence interval [CI] 14.2–15.5) and 10.8% (95% CI 10.6–11.0), respectively. An additional patient-hour needed for an emergent patient increased the probability of violating the waiting time target for non-emergent patients (odds ratio 2.3, 95% CI 2.2–2.4). Conclusions: The arrival of an emergent patient significantly prolonged the waiting time and LOS for non-emergent patients. Discouraging non-urgent ED utilization and building a real-time decision-support system are critical methods needed to relieve staff pressure and guide contingent resource reallocation when emergent patients arrive. [Copyright &y& Elsevier]

We report a case study of a semantic dementia patient, whose episodic memory consolidation was tested over a 2-month period. The results reveal that despite early retention of information, the patient lost all explicit information of the newly learnt material after 2 weeks. By contrast, he retained implicit word information even after a 4-week delay. These findings highlight the critical time window of 2–4 weeks in which newly learnt information should be re-encoded in rehabilitations studies. The results also indicate that learnt information can be still accessed with implicit retrieval strategies when explicit retrieval fails. [ABSTRACT FROM PUBLISHER]

Abstract: Trisomies of 12q23q24 have been described rarely in literature. Only a few case-reports have been published so far almost exclusively reporting on neonates or young infants. We present a 16-year-old patient with a trisomy of 12q23.3q24.3. Full phenotypic evaluation at this age comprised: severe growth retardation, developmental delay, intellectual disability and characteristic facial dysmorphisms. Initially, in the proband an insertion was cytogenetically mapped at chromosome 16: der(16)dir ins(16; 12)(q12.1; q24.11q24.31). The mother appeared carrier of a balanced insertion. Subsequent SNP-array analysis in the proband revealed a 16.3 Mb gain of 12q23.3 → 12q24.31. The clinical and molecular findings in this patient are compared with previous literature on cases with overlapping isolated 12q trisomies. The common phenotype observed consists of severe growth retardation, intellectual disability and characteristic facial features with hypertelorism, flat nasal bridge, down-turned mouth and poorly lobulated/low set ears. In addition, pediatric follow up into adolescence showed feeding difficulties requiring gastric tube feeding, recurrent otitis media, progressive contractures of joints and genito-renal problems, speech, communication and behavioral problems. These symptoms should be taken into account in the care and management of children with this condition. [Copyright &y& Elsevier]

Purpose: This study is aiming to investigate the feasibility and effect of applying modified Nuss procedure on recurrent pectus excavatum following previous open repair. Methods: By retrospectively reviewing patients of pectus excavatum enrolled in our department from July 2007 to August 2012, we find 27 cases of recurrent PE who received open repair previously. Twenty-six patients received Nuss repair, while one patient refused. Relevant data are collected and processed. A 3-month follow-up after operation is also reviewed. Analysis of data is conducted. Results: Twenty-six recurrent patients underwent modified Nuss procedure safely. Pneumothorax after operation occurred in one case. Pleural effusion occurred for every case, most were mild in quantity except two cases whose pleural effusion were moderate. All patients left hospital within 2 weeks after operation except one patient who died of respiration failure. Mean postoperative Haller Index is significantly different from the preoperative one. Cosmetic effect was excellent for 5 cases, good for 15 cases, moderate for 6 cases. In a 3-month follow-up, no bar displacement or rejection happened and pleural effusion was completely absorbed. Conclusion: Although technically challenging, Nuss procedure is feasible and good for recurrent PE after open repair. [ABSTRACT FROM AUTHOR]

Abstract: To quantify clinical differences for volumetric modulated arc therapy (VMAT) versus intensity modulated radiation therapy (IMRT) in terms of dosimetric endpoints and planning and delivery time, twenty head and neck cancer patients have been considered for VMAT using Nucletron Oncentra MasterPlan delivered via an Elekta linear accelerator. Differences in planning time between IMRT and VMAT were estimated accounting for both optimization and calculation. The average delivery time per patient was obtained retrospectively using the record and verify software. For the dosimetric comparison, all contoured organs at risk (OARs) and planning target volumes (PTVs) were evaluated. Of the 20 cases considered, 14 had VMAT plans approved. Six VMAT plans were rejected due to unacceptable dose to OARs. In terms of optimization time, there was minimal difference between the two modalities. The dose calculation time was significantly longer for VMAT, 4 minutes per 358 degree arc versus 2 minutes for an entire IMRT plan. The overall delivery time was reduced by 9.2 ± 3.9 minutes for VMAT (51.4 ± 15.6%). For the dosimetric comparison of the 14 clinically acceptable plans, there was almost no statistical difference between the VMAT and IMRT. There was also a reduction in monitor units of approximately 32% from IMRT to VMAT with both modalities demonstrating comparable quality assurance results. VMAT provides comparable coverage of target volumes while sparing OARs for the majority of head and neck cases. In cases where high dose modulation was required for OARs, a clinically acceptable plan was only achievable with IMRT. Due to the long calculation times, VMAT plans can cause delays during planning but marked improvements in delivery time reduce patient treatment times and the risk of intra-fraction motion. [Copyright &y& Elsevier]

To retrospectively review our first 20 Contura high dose rate breast cases to improve and refine our standardized procedure and checklists. We prepared in advance checklists for all steps, developed an in-house Excel spreadsheet for second checking the plan, and generated a procedure for efficient contouring and a set of optimization constraints to meet the dose volume histogram criteria. Templates were created in our treatment planning system for structures, isodose levels, optimization constraints, and plan report. This study reviews our first 20 high dose rate Contura breast treatment plans. We followed our standardized procedure for contouring, planning, and second checking. The established dose volume histogram criteria were successfully met for all plans. For the cases studied here, the balloon-skin and balloon-ribs distances ranged between 5 and 43mm and 1 and 33mm, respectively; air_seroma volume/PTV_Eval volume≤5.5% (allowed≤10%); asymmetry<1.2mm (goal≤2mm); PTV_Eval V90%≥97.6%; PTV_Eval V95%≥94.9%; skin max dose≤98%Rx; ribs max dose≤137%Rx; V150%≤29.8cc; V200%≤7.8cc; the total dwell time range was 225.4 to 401.9 seconds; and the second check agreement was within 3%. Based on this analysis, more appropriate ranges for the total dwell time and balloon diameter tolerance were found. Three major problems were encountered: balloon migration toward the skin for small balloon-to-skin distances, lumen obstruction, and length change for the flexible balloon. Solutions were found for these issues and our standardized procedure and checklists were updated accordingly. Based on our review of these cases, the use of checklists resulted in consistent results, indicating good coverage for the target without sacrificing the critical structures. This review helped us to refine our standardized procedure and update our checklists. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the dynamic computed tomography (CT), magnetic resonance imaging (MRI), and clinicopathological characteristics of perivascular epithelioid cell tumours (PEComas), thus improving the diagnosis of the tumour. Materials and methods: A retrospective analysis was undertaken of the dynamic CT, MRI, and clinicopathological characteristics of 32 PEComas diagnosed at histopathology during the period 1 January 2005 to 1 March 2012 at two hospitals. Results: The age of the patients ranged from 14–80 years (mean 43.3 years). There were more women in this group (19/32). Solitary tumours were identified in kidney (n = 16), liver (n = 7), gynaecological organs (n = 2), retroperitoneal soft tissue (n = 2), lung (n = 2), palate (n = 1), left groin (n = 1). One patient had multiple tumours in the liver, kidney, and retroperitoneal soft tissue. Dynamic CT (32 cases) and MRI (15 cases) demonstrated tumours that were of low density or hypointense on T1-weighted imaging (WI) and hyperintense on T2WI; some were isodense with fat (CT: 10/32; MRI: 6/15). The tumours usually had well-defined borders and were of a regular shape (CT: 26/32; MRI: 12/15). Tumour diameters ranged from 1.5–18 cm (mean 5.1 cm). Most tumours (CT: 21/32, MRI: 10/15) enhanced heterogeneously and significantly on arterial and venous phases. Tumours appeared slightly hypodense on delayed CT imaging, although some (6/32) had delayed enhancement. The expression rate of HMB-45 (human melanoma black monoclonal antibody) was 100% (32/32). Histological classification in 22 cases (22/32) was epithelioid angiomyolipoma (AML), three (3/32) were clear cell “sugar” tumours (CCSTs), two (2/32) were lymphangioleiomyomatosis (LAM), and two (2/32) were clear cell myomelanocytic tumours of the falciform ligament/ligamentum teres (CCMMT). Three tumours did not have a specific classification. Conclusion: Knowledge of dynamic CT, MRI, and clinicopathological characteristics could help improve the diagnosis of PEComa. [Copyright &y& Elsevier]

Background: There is a known association between the development of papillary thyroid cancer (PTC) after a primary nonthyroidal cancer (NTC). However, the prevalence of synchronous or antecedent NTCs in patients with PTC is undetermined, as are the clinicopathologic characteristics of PTC in these patients. Study Design: A review was performed of our prospectively maintained PTC database between January 1995 and December 2010. Information collected included patient and tumor characteristics, medical history, PTC presentation, and treatment modality. Results: Four hundred and thirty-three adult patients underwent thyroid resection and had PTC on final pathology. Sixty-seven cases of synchronous or antecedent NTCs were observed in 60 patients (13.9%). The most commonly associated antecedent NTCs were breast (n = 11), prostate (n = 8), and melanoma (n = 5), whereas renal cell carcinoma (n = 3) and melanoma (n = 3) were the synchronous NTCs most observed. Compared with patients without an NTC, those with an NTC were older (56.4 ± 15.5 years vs 44.9 ± 14.2 years; p < 0.0001), had experienced radiation exposure (35.0% vs 3.5%; p < 0.001), and more commonly presented with a thyroid mass incidentally on imaging (41.7% vs 9.1%; p ≤ 0.001). Papillary thyroid cancer tumor characteristics were similar between groups, except that NTC patients presented at a more advanced stage. However, when analyzed independently, primary tumor size, and nodal and distant metastases were comparable. Conclusions: The prevalence of synchronous or antecedent NTCs in patients surgically treated for PTC is 13.9%. These patients present with PTC tumor characteristics similar to those without additional NTCs, and should therefore be managed equivalently. In addition, surgeons should be aware of the frequency of synchronous PTC with these types of tumors and consider evaluation of the neck at the time of NTC diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of a research prioritization partnership that aimed to influence the research agenda relating to urinary incontinence (UI). Study Design and Setting: Research often neglects important gaps in existing evidence so that decisions must be made about treatments without reliable evidence of their effectiveness. In 2007-2009, a United Kingdom partnership of eight patient and 13 clinician organizations identified and prioritized gaps in the evidence that affect everyday decisions about treatment of UI. The top 10 prioritized research questions were published and reported to research funders in 2009. A year later, new research or funding applications relating to the prioritized topics were identified through reviews of research databases and consultation with funding organizations, elements of the research community, and organizations that participated in the partnership. Results: Since dissemination of the prioritized topics, five studies are known to have been funded, three in development; five new systematic reviews are under way, one is being updated; five questions are under consideration by a national research commissioning body. Conclusion: The partnership successfully developed and used a methodology for identification and prioritization of research needs through patienteclinician consensus. Prioritization through consensus can be effective in informing the development of clinically useful research. [ABSTRACT FROM AUTHOR]

Background: The development of Herceptin® is welcomed as a major advance in breast cancer treatment, while Myriad's development of BRACAnalysis® is a widely used diagnostic. However useful and successful this product is, its presence in the public eye is tainted by predominantly negative press about gene patenting and business practices. Discussion: While retrospection invites a sharp contrast between Genentech's triumphal narrative of scientific achievement and Myriad's public image as a controversial monopolist, a comparative history of these companies' products reveals two striking consistencies: patents and public discontent. Despite these similarities, time has reduced the narrative to that of hero versus villain: Genentech is lauded - at least for the final outcome of the Herceptin® story - as a corporate good citizen, Myriad as a ruthless mercenary. Since patents undergird both products yet the narratives are so different, the stories raise the question: why have patents taken the fall as the scapegoat in current biotechnology policy debate? Summary: A widely publicized lawsuit and accompanying bad press have cast Myriad as a villain in the evolving narrative of biotechnology. While the lawsuit suggests that this villainy is attributable to Myriad's intellectual property, we suggest through a comparative case study that, at least in the Myriad case, it is not simply about the patents but also other business strategies the company chose to pursue. Patents were a necessary but not sufficient cause of controversy. [ABSTRACT FROM AUTHOR]

Abstract: A rich body of work has reported levels of infection with Toxocara species in definitive hosts, and the frequency of eggs in the environment, in many different regions and situations. These have greatly increased our understanding of the relationship between egg excretion from companion and wild animals and the risk of human infection by inadvertent ingestion of eggs from soil and other environmental reservoirs. Nevertheless, it is difficult to compare studies directly because of vagaries in sampling and laboratory methods, a preponderance of prevalence rather than abundance data, and a lack of studies that systematically sample different sympatric definitive host populations. Such comparisons could be instructive, for example to determine the relative contributions of different definitive host populations and categories to environmental contamination in specified areas, and hence guide priorities for control. In this article we use estimates of host density and infection levels in the city of Bristol, UK, as a case study to evaluate the relative contribution of sympatric cats, dogs and foxes to overall environmental contamination with eggs. Results suggest that dogs, especially those less than 12 weeks of age, dominate total egg output, but that this is modified by degree of access to public areas and removal of faeces, such that foxes could take over as the primary source of eggs. Results and conclusions are likely to differ among specific locations. The general aim is to show how an improved quantitative framework for epidemiological studies of Toxocara spp. egg contamination can help to advance understanding and the effectiveness of control strategies in future. [Copyright &y& Elsevier]

Abstract: Background: Control and reduction of cardiovascular-disease-related readmissions is clinically, logistically and politically challenging. Recent strategies focus on 30-day readmissions. A screening tool for the detection of potential cases is necessary to make further case management more efficient. Methods: Cohort study. Hospital administrative data were analyzed in order to obtain information about cardiac-related hospitalizations from 2003 to 2009 at a Spanish academic tertiary care center. Predictor-variables of admissions that presented or did not present 30-day cardiac-related readmission were compared. A prediction model was constructed and tested on a validation sample. Model performance was assessed for all cardiac diseases and for 24 main-cardiac-disease-sets. Results: The study sample was 35531 hospital-admissions. The model included 11 predictors: number of previous emergency admission in 180days, residence out of area, no procedure applied during hospitalization, major or minor therapeutic procedure applied during hospitalization, anemia, hypertensive disease, acute coronary syndrome, congestive heart failure, diabetes and renal disease. The performance indicators applied on all cardiac diseases were: C-statistic=0.75, Sensitivity=0.66, Specificity=0.70, Positive predictive value=0.10, Negative predictive value=0.98, Positive likelihood ratio=2.21 and Negative likelihood ratio=0.48. Diseases for discriminative prediction are: stenting, circulatory disorders, acute myocardial infarction and defibrillator and pacemaker implantation. Conclusions: This study provides a prediction model for 30-day cardiac-related diseases based on available administrative data ready to be integrated as a screening tool. It has reasonable validity and can be used to increase the efficiency of case management. [Copyright &y& Elsevier]

Objective: The purpose of this article is to reveal the meaning of the mourning period in nurses that have had to deal with the death of cancer-stricken children. The death of a cancer-stricken child affects the nursing staff deeply, bringing on feeling of powerlessness, frustration, and shame; these feelings can result in burnout. Method: Qualitative case-based research was undertaken based on Husserl, and ten cases of pediatric oncology nurses who faced the death of child patients under their care were reported. The study took place from June to November 2011 through verbatim-reported in depth interviews. Results: Undertaken using Streubert's method, this casestudy revealed three essential issues: the nurses experience the death of a child by shifting between their own approaches to loss and the professional care they provide. This path brings life teachings, given the empathy of working in cancer units and the bonds created in this environment, thus allowing the nursing staff to provide unique nursing care. Conclusion: The study concluded that by providing patients with loving care, nurses have a dynamic approach to their experience of loss. [ABSTRACT FROM AUTHOR]