Clinical Impression Research Articles

La Atención a las Necesidades en Salud Mental de los Profesionales Sanitarios durante la COVID-19

Healthcare professionals are in the front line of care for patients with COVID-19, presenting greater risk of contagion and emotional distress. The aim of the study is to describe the results of a psychological intervention protocol for professionals; 47 workers from Vall d’Hebron University Hospital who requested psychological support were included during the first month and a half of the crisis. Before and after the intervention a checklist of clinical symptoms, the Clinical Anxiety Scale and the Clinical Global Impression Scale were administered. Professionals who consulted were mostly women, nursing staff, and assistant nursing care technicians, presenting hyperconcern, sadness, sleep, and eating disturbances. Significant improvements were observed on clinical symptoms (z = 4.6, p ≤ .0001), acute stress (z = 2.5, p = .012), anxiety (z = 5.3, p ≤ .0001), and clinical impression (z = 4.1, p ≤ .0001). A brief psychological intervention, based on anxiety management, emotional regulation, and values oriented-behavior, was shown to be effective in reducing emotional symptoms in professionals.

Scaffolding the Brain: Key Areas of Evaluation in Infant Parent Psychotherapy

ABSTRACT Clinicians are often challenged by the complexity involved in early childhood infant/parent dyadic assessments and interventions. Working within a right hemisphere developmental period requires clinicians to have a good enough natural relational style that moves easily between the nonverbal implicit worlds of the infant and parent while attending to the parent’s verbal narrative. The author suggests using an evidence informed neurobiological scaffold called Integrative Regulation Therapy (iRT) with evidence based Infant Parent Psychotherapy (IPP) and introduces an iRT assessment that creates a Probable Map of the parent’s neurobiological organization to facilitate intervention by assessing clinical impressions in nine key areas: 1) attachment experience, 2) self-concept, 3) arousal organization, 4) soothing of dysregulated states, 5) use of defenses, 6) use of instinct, 7) use of reflection, 8) hopes and desires, and 9) current level of agency. A composite case will be presented illustrating the clinical use.

Dependent functional status rather than age is a better predictor of adverse outcomes after excision of an infected abdominal aortic graft

ObjectiveThe optimal management of infected abdominal aortic grafts is complete surgical excision plus in situ or extra-anatomic revascularization in patients who can tolerate this morbid operation. In addition to using age and the presence of comorbidities for risk assessment, physicians form a global clinical impression when deciding whether to offer excision or to manage conservatively. Functional status is a distinct objective measure that can inform this decision. This study examines the relative impact of age and functional status on outcomes of infected abdominal aortic graft excision to guide surgical decision-making. MethodsCurrent Procedural Terminology code 35907 was used to identify patients undergoing excision of infected abdominal aortic graft in the 2005 to 2017 American College of Surgeons – National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by the upper age quartile (75 years old) as a cutoff, and then by functional status, independent vs dependent (as defined by NSIQIP). The patients were then stratified into four groups: Younger (<75)/Independent, Younger (<75)/Dependent, Older (≥75)/Independent, and Older (≥75)/Dependent. Outcomes measured included 30-day mortality and major organ-system dysfunction. ResultsThere were 814 patients who underwent infected abdominal aortic graft excision: 508 patients (62%) were Younger/Independent, 89 patients (11%) were Younger/Dependent, 176 patients (22%) were Older/Independent, and 41 patients (5%) were Older/Dependent. There was no statistically significant difference in 30-day mortality for Younger/Dependent (odds ratio [OR], 1.66; 95% confidence interval [CI], 0.90-3.09; P = .536) or Older/Independent (OR, 1.31; 95% CI, 0.78-2.19; P = .311) patients when compared with Younger/Independent patients, which suggests that neither old age nor dependent functional status by itself adversely affects mortality. However, when both factors were present, Older/Dependent patients had three times higher mortality when compared with Younger/Independent patients (41.5% vs 13.4%, respectively; OR, 3.13; 95% CI, 1.46-6.71; P = .003). Furthermore, as long as patients presented with independent functional status, old age by itself did not adversely affect major organ-system dysfunction (ORs for Older/Independent vs Younger/Independent were 0.76 [P = .454], 1.04 [P = .874], and 0.90 [P = .692] for cardiac, pulmonary, and renal complications, respectively). On the contrary, even in younger patients, dependent functional status was significantly associated with higher pulmonary complications (Younger/Dependent vs Younger/Independent: OR, 2.22; 95% CI, 1.33-3.73; P = .002) and higher rates of unplanned reoperation (OR, 2.67; 95% CI, 1.62-4.41; P < .0001). ConclusionsDependent functional status has significant association with adverse outcomes after excision of infected abdominal aortic grafts, whereas old age alone does not. Therefore, this procedure could be considered in appropriately selected elderly patients with otherwise good functional status. However, caution should be applied in dependent patients regardless of age due to the risk of pulmonary complications.

Maxillomandibular Development after Mandibular Distraction Osteogenesis in Isolated Pierre Robin Sequence Patients

Mandibular distraction osteogenesis (MDO) is a favored surgical technique for addressing the airway difficulties that result in patients with Pierre Robin sequence. Devices are placed to distract the micrognathic mandible forward and generate bone at bilateral mandibular osteotomies.1 Though it is generally accepted that these patients will continue to develop with disproportionate maxillomandibular growth after distraction2, the timeline for relapse back to a skeletal class II relationship, as well as differences between male and female development post-distraction, is not well-described.The purpose of this study is to characterize a timeline of maxillomandibular growth for patients with isolated Pierre Robin sequence (iPRS) after MDO during infancy based on Steiner's analysis and clinical impressions, as well as to identify differences in post-distraction growth between males and females. The researchers hypothesized that these patients would demonstrate disproportionate growth after distraction and that females would relapse at a faster rate than males. By improved understanding of this timeline, clinicians may better educate parents with expectations for their child's craniofacial development after distraction.Department records were retrospectively reviewed to identify patients with iPRS who underwent MDO during infancy from 2004 through 2016. Patients with post-distraction imaging from which cephalometric data could be traced (i.e., lateral cephalograms or cone beam computerized tomography [CBCT] scans) were included. These were traced by 2 independent reviewers for SNA, SNB, and ANB angles, according to Steiner's analysis to determine skeletal classification. Patients with pre- and post-distraction lateral profile photos were assessed by 1 reviewer for skeletal classification based on clinical appearance. Patient age at distraction, sex, time from initial distraction to imaging study, and prior maxillomandibular surgeries were abstracted. Descriptive statistics and significance testing were performed; 38 patients with iPRS who underwent MDO were identified. Of these, 15 (39.5%) had at least 1 postoperative lateral cephalogram. Average time from surgery to initial lateral cephalogram (TAS) was 67.81 months for all patients (range 25.53 to 129.93 months). The majority of patients (n = 12) had an ANB > 2° at the time of lateral cephalogram. One patient (TAS 25.53 months) had an ANB of 1.3°, whereas 2 patients (both with prior cleft palate repair) had an ANB < 0° (TAS 32.67 and 97.17 months). Nine (60%) of all patients with lateral cephalogram data fell within 1 standard deviation of average TAS (39.52 to 96.1 months), with corresponding average SNA, SNB, and ANB angles of 80.97, 73.99, and 7.03, respectively; 33% of these patients (n = 3) had prior palatal surgery. Of the 38 patients, 37 had pre- and post-distraction lateral photographs; 13 of 15 (86.7%) females, and 12 of 22 (54.5%) males relapsed to a skeletal class II relationship by the last follow-up appointment (P = .04). The mean postoperative follow-up months for females (69.3 months) and males (79.9 months) was similar (P = .50). Based on post-distraction cephalometric tracing, 80% of patients reverted back to a skeletal class II relationship by an average of 68 months. Based on post-distraction clinical appearance, 68% of patients reverted to a class II relationship by an average of 76 months. Furthermore, a more significant percentage of females relapsed to a skeletal class II relationship compared to males at similar follow-up points. These findings may help clinicians and parents better understand and prepare for the maxillomandibular developmental timeline of these patients post-distraction.

Maxillomandibular Development after Mandibular Distraction Osteogenesis in Isolated Pierre Robin Sequence Patients

Mandibular distraction osteogenesis (MDO) is a favored surgical technique for addressing the airway difficulties that result in patients with Pierre Robin sequence. Devices are placed to distract the micrognathic mandible forward and generate bone at bilateral mandibular osteotomies.1 Though it is generally accepted that these patients will continue to develop with disproportionate maxillomandibular growth after distraction2, the timeline for relapse back to a skeletal class II relationship, as well as differences between male and female development post-distraction, is not well-described.The purpose of this study is to characterize a timeline of maxillomandibular growth for patients with isolated Pierre Robin sequence (iPRS) after MDO during infancy based on Steiner's analysis and clinical impressions, as well as to identify differences in post-distraction growth between males and females. The researchers hypothesized that these patients would demonstrate disproportionate growth after distraction and that females would relapse at a faster rate than males. By improved understanding of this timeline, clinicians may better educate parents with expectations for their child's craniofacial development after distraction.Department records were retrospectively reviewed to identify patients with iPRS who underwent MDO during infancy from 2004 through 2016. Patients with post-distraction imaging from which cephalometric data could be traced (i.e., lateral cephalograms or cone beam computerized tomography [CBCT] scans) were included. These were traced by 2 independent reviewers for SNA, SNB, and ANB angles, according to Steiner's analysis to determine skeletal classification. Patients with pre- and post-distraction lateral profile photos were assessed by 1 reviewer for skeletal classification based on clinical appearance. Patient age at distraction, sex, time from initial distraction to imaging study, and prior maxillomandibular surgeries were abstracted. Descriptive statistics and significance testing were performed; 38 patients with iPRS who underwent MDO were identified. Of these, 15 (39.5%) had at least 1 postoperative lateral cephalogram. Average time from surgery to initial lateral cephalogram (TAS) was 67.81 months for all patients (range 25.53 to 129.93 months). The majority of patients (n = 12) had an ANB > 2° at the time of lateral cephalogram. One patient (TAS 25.53 months) had an ANB of 1.3°, whereas 2 patients (both with prior cleft palate repair) had an ANB < 0° (TAS 32.67 and 97.17 months). Nine (60%) of all patients with lateral cephalogram data fell within 1 standard deviation of average TAS (39.52 to 96.1 months), with corresponding average SNA, SNB, and ANB angles of 80.97, 73.99, and 7.03, respectively; 33% of these patients (n = 3) had prior palatal surgery. Of the 38 patients, 37 had pre- and post-distraction lateral photographs; 13 of 15 (86.7%) females, and 12 of 22 (54.5%) males relapsed to a skeletal class II relationship by the last follow-up appointment (P = .04). The mean postoperative follow-up months for females (69.3 months) and males (79.9 months) was similar (P = .50). Based on post-distraction cephalometric tracing, 80% of patients reverted back to a skeletal class II relationship by an average of 68 months. Based on post-distraction clinical appearance, 68% of patients reverted to a class II relationship by an average of 76 months. Furthermore, a more significant percentage of females relapsed to a skeletal class II relationship compared to males at similar follow-up points. These findings may help clinicians and parents better understand and prepare for the maxillomandibular developmental timeline of these patients post-distraction.

Accuracy of Roche SARS-CoV-2 Rapid Antigen Test in Nasopharyngeal Swab: Clinical Impression Matters

Background: In COVID-19 pandemic, the diagnosis and treatment must be as early as possible to save the life of each patient. Moreover, screening of asymptomatic carriers, close contacts or healthy subjects must not be delay to prevent transmission to publics. For confirmation of diagnosis of SARS-CoV-2 infection, nasopharyngeal swab must be tested either by real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR) tests or Rapid Antigen Test (RAT). RAT is faster, easier and cheaper; thus, it is suitable for health service in developing country. Objectives: The aim of this study was to assess the diagnostic accuracy of Roche SARS-CoV-2 Rapid Antigen Test (RAT) in diagnosing SARS-CoV-2 infection. Methods: Hospital based exploratory study was done in out-patient department and fever clinic, and molecular laboratory of No. (1) Defence Services General Hospital. Nasopharyngeal swabs were taken, and the Roche SARS- CoV-2 RAT was conducted in parallel with RT-PCR test (reference standard). Results: Among the 932 patients/subjects recruited, RT-PCR was positive in 468 individuals, corresponding to a prevalence of 50.2%. The RAT was positive in 363 patients (60.4%), false positive in 120 patients; it was negative in 569 individuals (39.6%), false negative in 225 patients. The overall sensitivity of the RAT was 51.9% (95% Confidence Interval [CI] 47.29-56.53) and, the specificity was 74.1% (95% CI 69.9-78.07); positive predictive value was 66.9% and negative predictive value was 60.5%. The sensitivity varied with Ct value; 78% in clinical samples with Ct values &lt; 20, 57.5% in those with Ct values between 21 and 25, 41.8% in samples with Ct values between 26 and 30, and, 36.4% in samples with Ct value &gt; 30. Conclusion: The accuracy of the SARS-CoV-2 Roche RAT in diagnosing SARS-CoV-2 infections was inferior to RT-PCR and manufacturer’s data. The sensitivity was with low Cycle threshold values &lt; 20 which were inversely related to the viral load. RAT test should be used in association with clinical impression of physicians. In hospital setting especially in emergency department, the role of RAT should be reconsidered in those patients presenting with anosmia and some cases of dyspnoea, late symptoms in the course of disease, as the RAT results would be false negative. Other errors may arise if the operator for RAT has to handle more than recommended tests per hour especially in the peak of epidemics.

69.2 DISTORTED COGNITION: A CLINICAL EXAMPLE FROM A PEDIATRIC ACUTE CARE EXPERIENCE

Objectives: This case study illustrates the complexities of evaluation and care of delirium symptoms in a hospital-based, acute care setting. Methods: A detailed review of case data is performed, with a focus on cognition, and is summarized for presentation. Results: This is an anonymized case example of an elementary school–aged patient who developed a several-day onset of “behavioral difficulties” that were noted by parents and teachers. This young patient presented with affective, cognitive, and behavioral symptoms, which had puzzled, concerned, and confused the community and hospital healthcare professionals from pediatrics, family medicine, pediatric neurology, emergentology, and pediatric psychiatry. The symptom profile and clinical impressions raised the concern for anxiety. Key contextual factors included the COVID-19 pandemic, and related environmental and schooling changes. The clinical team ultimately diagnosed and treated the delirium syndrome and the primary encephalopathic illness. Persisting cognitive challenges are elaborated. Conclusions: The patient’s illness evolution and presentation were perplexing for the family, school, and healthcare teams, complicated by the cognitive changes associated with the child’s syndrome of delirium. The case review provides an opportunity to identify challenges inherent to the assessment and treatment of distorted cognition in acute illness and thereafter. There is emphasis on the value of interprofessional collaborations in the care practices given such clinical scenarios, with attention to risk for potentially negative impacts on illness management and outcomes. COG, DIAG, NEPSYC

The use of atypical antipsychotics in the therapy of depressive episodes in patients with bipolar disorder

This literature review addresses the effi cacy and safety of atypical antipsychotics in patients with bipolar depression. Th e results of randomized studies and systematic meta-analyses of recent years were revised in detail. The effi cacy of the drug intake was reviewed for the following key research points: Clinical General Impression of Condition Severity Scale (CGI-S) and Montgomery-Asberg Depression Rating Scale (MADRS). A systematic literature search was carried out using Scopus, Web of Science, MedLine, elibrary, and other databases.

Redback spider bites in children in South Australia: A 10-year review of antivenom effectiveness.

To describe the South Australian paediatric redback spider bite experience and to examine the hypothesis that redback antivenom (RBAV) treatment in children is clinically effective. Retrospective chart review of all children under 18 years of age presenting to the EDs of the three major paediatric or mixed hospitals in Adelaide, South Australia, with a discharge diagnosis of redback spider envenomation between 1 January 2010 and 31 March 2020. The main outcome measures include: patient and bite demographics; presenting symptoms and signs; treatment provided; clinical effects at 2h post RBAV administration on pain, diaphoresis, blood pressure, heart rate and systemic features; overall clinical impression of RBAV effectiveness and resolution of symptoms prior to discharge. There were 256 patient encounters involving 235 patients. Latrodectism was described in one-third (34%) of the cases. Sixty-one patients received RBAV and in 57 (93%) patients the RBAV had good clinical effect. Two hours post RBAV administration, pain resolved in 71%, hypertension resolved in 62%, diaphoresis resolved in 43% and tachycardia resolved in 82%. There were no cases of urticaria or anaphylaxis and one case of serum sickness. This retrospective review of redback spider envenomation in South Australian children over a 10-year period has demonstrated clinical effectiveness of RBAV in paediatric patients across all age groups, observed in both clinician perceived results and measurable outcomes. RBAV remains an effective treatment for redback envenomation in children.

Expertise as a domain of epistemics in intensive care shift-handovers

This paper examines how expertise is treated as a separable domain of epistemics by looking at simulated intensive care shift-handovers between resident physicians. In these handovers, medical information about a patient is transferred from an outgoing physician (OP) to an incoming physician (IP). These handovers contain different interactional activities, such as discussing the patient identifiers, giving a clinical impression, and discussing tasks and focus points. We found that with respect to (factual) knowledge about the patient, the OPs display an orientation to a knowledge imbalance, but with respect to (clinical) procedures, reasoning, and activities, they display an orientation to a knowledge balance. We use ‘expertise’ to refer to this latter type of knowledge. ‘Expertise’ differs from, and adds to, how knowledge is often treated in epistemics in that it is concerned with professional competence or ‘knowing how’. In terms of epistemics, the participants in the handovers orient to a steep epistemic or knowledge gradient when it concerns the patient, while simultaneously displaying an orientation to a horizontal expertise gradient.

Endoscopic features for early decision to evaluate superior mesenteric artery syndrome in children

BackgroundDiagnostic delay of superior mesenteric artery syndrome (SMAS) is common due to its rarity and lack of index of clinical suspicion. Early diagnosis under suspicion is pivotal for adequate treatment. Present study aims to explore the endoscopic features for early decision to evaluate SMAS in children.MethodsIn case controlled observation study, the recruitment was limited to patients who had endoscopic finding I or finding 1 plus more as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s (finding I), a marked dilation of the duodenal first and second part during air insufflation at the third part of the duodenum (finding II), a bile mixed fluid collection (bile lake) in the stomach (finding III). SMAS was confirmed with UGI series or hypotonic duodenography in enrolled patients. We analyzed positive endoscopic findings related with SMAS.ResultsThe enrolled 29 patients consisted of 18 (62.1%) with SMAS and 11 (37.9%) without SMAS. The three most common presenting symptoms were abdominal pain, postprandial discomfort, and early satiety. The clinical impressions based on history and physical examination before endoscopy were functional dyspepsia (34.6%), gastritis or gastric ulcer (31.0%), and SMAS (17.3%). The constellation of three endoscopic findings (finding I + II + III, feature D) observed in 13 (72.2%) patients of SMAS group and 3 (27.3%) patients of non SMAS group (P = 0.027). Of 16 patients with features D, SMAS was diagnosed in 13 patients (81.2%) and not detected in 3 patients (18.8%) on UGI series or hypotonic duodenography.ConclusionsEndoscopic examination to the third part of the duodenum can provide a clue making a decision to evaluate SMAS, which consists of features of three endoscopic findings as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s, a marked dilation of the first and second part of the duodenum, and a bile lake in the stomach.

Perinatal Sacroiliitis Diagnostic Challenges: A Case Report

Background: Lumbo-pelvic (LPP) pain is common and non specific problem during pregnancy and post partum. Despite the fact that perinatal pyogenic sacroiliitis (PSI) during this period is rare, it should be considered as a vital differential diagnosis in women who have debilitating lower back and pelvic girdle pain. Case: A 34 years old primigravida presented to the emergency department with extreme right sided lower back pain radiating to the right gluteal region and down to the back of the right thigh. This pain began twelve days prior to her presentation and eventually worsened to the point that she couldn't stand or walk. Her vital signs were within normal limits, and she was febrile. Apart from a slight widening of the symphysis pubis, her pelvic and lumbo-sacral plain x-rays revealed no important findings. With the clinical impression of right LPP, the patient was admitted for pain management and further inquiries. Conclusion: Despite the fact that lower back and pelvic girdle pain are normal throughout pregnancy and the postpartum period, perinatal PSI is uncommon. It's a tough diagnosis to make because the symptoms and signs aren't clear, and the tests aren't definitive. When pathognomonic clinical and radiologic signs indicate an infectious process and isolation of pathogenic bacteria is not possible, medical management with empirical antibiotics should not be delayed.

Congenital hepatic fibrosis and its mimics: a clinicopathologic study of 19 cases at a single institution

BackgroundCongenital hepatic fibrosis (CHF) is a rare inherited form of ductal plate malformation associated with polycystic kidney disease. The diagnosis requires histopathologic confirmation, but can be challenging to distinguish from other undefined fibrocystic liver diseases. We aimed to describe the clinicopathologic features of congenital hepatic fibrosis (CHF), with comparisons to other entities that may clinically and/or histologically mimic CHF.MethodsNineteen cases that carried a clinical and/or histologic impression of CHF were identified at our institution, of which the histology was reassessed and reappraised into two categories: CHF (n=13) and mimics (n=6). The clinicopathologic features between the two groups were analyzed and compared.ResultsThe CHF group was further sub-classified into those with clinical suspicion (CHF-c, n=8) and those as incidental histology findings (CHF-i, n=5). Patients of CHF-i were much older than CHF-c or mimics (P<0.05). Male and female were equally affected. Six of 8 CHF-c (66.7%) had concurrent kidney diseases, including 5 polycystic kidney diseases. Five of 6 mimics (83.3%) had various kidney diseases, including nephronophthisis, Alport syndrome, renal agenesis, and nephrolithiasis. None of the CHF-i patients had kidney disease, but 3 were associated with hepatic carcinomas. Histology analysis demonstrated characteristic triads (bile duct abnormalities, portal vein hypoplasia, and fibrosis) in all CHF cases. One mimic had paucity of intrahepatic bile ducts, while the other 5 mimics showed abnormal portal veins and nodular regenerative hyperplasia consistent with hepatoportal sclerosis (HPS).ConclusionsOur study demonstrates classic histology triad of CHF despite a wide spectrum of clinical presentations. HPS is unexpectedly a clinical mimicker of CHF, which can be distinguished histologically.

Effect of Powder/Water Ratio Variation on Viscosity, Tear Strength and Detail Reproduction of Dental Alginate Impression Material (In Vitro and Clinical Study).

Background: Alginate impression is a common dental polymeric material, presented as powder to be mixed with water. Aim: 1. To analyze the effect of alginate powder/water ratio variation on viscosity, tear strength and detail reproduction by in vitro tests, and 2. To evaluate this variation’s effect on patients’ impressions. Materials and methods: Two commercial alginate products were mixed in different viscosities. Viscosity was measured by a viscometer. For the tear strength test, V-shaped specimens were used. For detail reproduction, a die with three scribed lines was used. Clinical dental impressions were examined by stereomicroscope. Results: The alginate specimens mixed with a higher powder/water ratio showed a higher viscosity and tear strength compared to those with a lower powder/water ratio. Both alginate mixtures reproduced two scribed lines in a detail reproduction test. On the other hand, no clear clinical difference was detected when examining dental impressions mixed with a different powder/water ratio. Conclusion: Although increasing the powder/water ratio of mixed alginate raised the resultant viscosity and tear strength by an in vitro test, clinically, no clear difference in tearing was detected. Detail reproduction was minimally affected by the variation in powder/water ratio.

Pancreatic Cysts after Endoscopic Ultrasonography-Guided Ethanol and/or Paclitaxel Ablation Therapy: Another Mimic of Pancreatic Pseudocysts

Background: Endoscopic ultrasound-guided ablation (EUS-A) therapy is a minimally invasive procedure for pancreatic-cystic tumors in patients with preoperative comorbidities or in patients who are not indicated for surgical resection. However, histopathologic characteristics of pancreatic cysts after ablation have not been well-elucidated. Methods: Here, we analyzed pathological findings of 12 surgically resected pancreatic cysts after EUS-A with ethanol and/or paclitaxel injection. Results: Mean patient age was 49.8 ± 13.6 years with a 0.3 male/female ratio. Clinical impression before EUS-A was predominantly mucinous cystic neoplasms. Mean cyst size before and after ablation therapy was similar (3.7 ± 1.0 cm vs. 3.4 ± 1.6 cm; p = 0.139). Median duration from EUS-A to surgical resection was 18 (range, 1–59) months. Mean percentage of the residual neoplastic lining epithelial cells were 23.1 ± 37.0%. Of the resected cysts, 8 cases (67%) showed no/minimal (<5%) residual lining epithelia, while the remaining 4 cases (33%) showed a wide range of residual mucinous epithelia (20–90%). Ovarian-type stroma was noted in 5 cases (42%). Other histologic features included histiocytic aggregation (67%), stromal hyalinization (67%), diffuse egg shell-like calcification along the cystic wall (58%), and fat necrosis (8%). Conclusion: Above all, diffuse egg shell-like calcification along the pancreatic cystic walls with residual lining epithelia and/or ovarian-type stroma were characteristics of pancreatic cysts after EUS-A. Therefore, understanding these histologic features will be helpful for precise pathological diagnosis of pancreatic cystic tumor after EUS-A, even without knowing the patient’s history of EUS-A.

Why is the histomorphological diagnosis of tumours of minor salivary glands much more difficult?

There is a widespread perception among clinicians and pathologists that the histomorphological assessment of minor salivary gland (MinSG) tumours is more difficult and hampered by more misdiagnoses than that of major salivary gland tumours. This is based on a vague, subjective clinical impression, lacking scientific proof. The aim of the present study was to identify and statistically verify potential reasons that could explain this difference. We identified 14 putative clinical, pathological and combined clinicopathological reasons that, altogether, could explain the phenomenon of the perceived greater diagnostic difficulty associated with MinSG tumours. We performed a comprehensive literature search and a statistical comparison of data from a large personal consultation series (biased for difficult cases) with cumulated data from straightforward, unselected (non-consultation) series from the literature. By performing this comparison, we identified, with statistical significance, a comprehensive series of reasons, as well as of consequences, of the greater difficulty in diagnosing MinSG tumours. Among the 14 criteria, high frequencies of initial incisional biopsies and of a low-grade category in malignant tumours emerged as the two most important reasons for enhanced diagnostic difficulty. Very rare entities, unusual locations, shortcomings in clinicopathological communication, and pecularities of the special anatomical location of the hard palate, such as tumour necrosis, mucosal ulceration, pseudoinvasion, and the peculiar phenomenon of 'tumoral-mucosal fusion', contribute to further diagnostic difficulties. The awareness of these shortcomings and pitfalls enables us to provide a series of recommendations for clinicians and pathologists that might aid in assessment and reduce the rate of misdiagnosis of MinSG tumours.

Uterine fibroids and risk of preterm birth by clinical subtypes: a prospective cohort study

BackgroundFibroids are present in approximately one in ten pregnancies and are inconsistently linked with preterm birth. We sought to determine the association between fibroids and preterm birth in a prospective cohort with standardized research ultrasounds for characterizing fibroids in early pregnancy while accounting for the clinical paths that precede preterm birth.MethodsParticipants who were pregnant or planning a pregnancy were recruited from communities in three states between 2000 and 2012. Members of this prospective cohort had a research ultrasound in the first trimester to establish pregnancy dating and to record detailed information about the presence, size, number, and location of fibroids. Baseline information from time of enrollment and a detailed first trimester interview contributed key information about candidate confounders. Birth outcomes, including clinical classification of type of preterm birth (preterm labor, preterm premature rupture of membranes, and medically indicated preterm birth) were cross-validated from participant report, labor and delivery records, and birth certificate data.ResultsAmong 4,622 women with singleton pregnancies, 475 had at least one fibroid (10.3%) and 352 pregnancies resulted in preterm birth (7.6%). Prevalence of fibroids was similar for women with preterm and term births (10.2% vs. 10.3%). Fibroids were not associated with increased risk of preterm birth after taking into account confounding (risk ratio adjusted for race/ethnicity and maternal age, 0.88; 95% confidence interval, 0.62–1.24) nor any clinical subtype of preterm birth. No fibroid characteristic or combination of characteristics was associated with risk.ConclusionsIf fibroids increase risk of preterm birth, the effect is substantially smaller than previous estimates. Given lack of effect in a large population of women from the general population, rather than higher risk academic tertiary populations previously most studied, we encourage a reconsideration of the clinical impression that presence of fibroids is a major risk factor for preterm birth.

Efficacy and safety of N-acetyl-l-leucine in Niemann\u2013Pick disease type C

ObjectiveTo investigate the safety and efficacy of N-acetyl-l-leucine (NALL) on symptoms, functioning, and quality of life in pediatric (≥ 6 years) and adult Niemann–Pick disease type C (NPC) patients.MethodsIn this multi-national, open-label, rater-blinded Phase II study, patients were assessed during a baseline period, a 6-week treatment period (orally administered NALL 4 g/day in patients ≥ 13 years, weight-tiered doses for patients 6–12 years), and a 6-week post-treatment washout period. The primary Clinical Impression of Change in Severity (CI-CS) endpoint (based on a 7-point Likert scale) was assessed by blinded, centralized raters who compared randomized video pairs of each patient performing a pre-defined primary anchor test (8-Meter Walk Test or 9-Hole Peg Test) during each study periods. Secondary outcomes included cerebellar functional rating scales, clinical global impression, and quality of life assessments.Results33 subjects aged 7–64 years with a confirmed diagnosis of NPC were enrolled. 32 patients were included in the primary modified intention-to-treat analysis. NALL met the CI-CS primary endpoint (mean difference 0.86, SD = 2.52, 90% CI 0.25, 1.75, p = 0.029), as well as secondary endpoints. No treatment-related serious adverse events occurred.ConclusionsNALL demonstrated a statistically significant and clinical meaningfully improvement in symptoms, functioning, and quality of life in 6 weeks, the clinical effect of which was lost after the 6-week washout period. NALL was safe and well-tolerated, informing a favorable benefit-risk profile for the treatment of NPC.Clinicaltrials.gov identifierNCT03759639.

Feasibility of implementing Extubation Advisor, a clinical decision support tool to improve extubation decision-making in the ICU: a mixed-methods observational study

ObjectivesAlthough spontaneous breathing trials (SBTs) are standard of care to extubation readiness, no tool exists that optimises prediction and standardises assessment. In this study, we evaluated the feasibility and clinical...

Development and evaluation of a new method to combine clinical impression survey data with existing laboratory data for veterinary syndromic surveillance with the Canada West Swine Health Intelligence Network (CWSHIN)

The Canada West Swine Health Intelligence Network (CWSHIN) is a surveillance system imbedded in an intelligence network. It has been conducting syndromic surveillance in the four western provinces of Canada since 2012. The quarterly activities include repeated clinical impression surveys, compilation of laboratory data, discussion of trends with an expert group (practitioners, laboratory diagnosticians) and swine health reports for producers and swine practitioners. However, due to the lack of standardized population identifiers across data sources usual methods of combining data could not be applied and the collated data were not being fully utilized and analysed. Therefore in 2019, CWSHIN underwent a substantial review resulting in the “Next Generation CWSHIN”.The objectives of this study were to develop and evaluate a new data merging method to combine CWSHIN’s clinical impression survey and laboratory data; and to provide examples of analyses and modeling based on these data.The data for analysis were restricted to repeated clinical impression surveys (2019–2020) from veterinary practitioners and laboratory diagnostic data (2016–2020). Merging surveillance data from existing sources can be challenging. Therefore, as an alternative to merge data using a hierarchy of population identifiers, we developed a Disease Map to link surveillance data from all our data-sources. The resulting Data Repository allowed monitoring of temporal trends of syndromes, clinical diseases, and laboratory identified organisms, but it cannot provide estimates of disease occurrence. Two main reasons were the lack of denominators and using existing data on routine diagnostic tests. Therefore, discussion in the expert group (veterinary practitioners, laboratory diagnosticians, swine health experts) was critical to the system’s success. Based on repeated clinical impression surveys a stochastic scenario tree model for freedom from Foot and Mouth Disease (CWSHIN Blister model) was also developed.In conclusion, the method to link existing data systems from multiple divergent sources by means of a Disease Map improved CWSHIN’s veterinary syndromic surveillance. Together the Data Repository and Disease map provided flexibility to monitor temporal trends, define populations and diseases, and allow analysis. However, it is critical that the surveillance is coupled with a good intelligence network that can help interpret the results and disseminate knowledge to veterinarians and producers.