Double Trouble Research Articles

Incidental finding of APC deletion in a child: double trouble or double chance? \u2013 a case report

Background22q11.2 deletion syndrome is one of the most common genomic disorders, characterized by the variable presence of facial dysmorphisms, congenital cardiac defects, velopharyngeal insufficiency/cleft palate, thymic hypoplasia/aplasia, immunodeficiency, parathyroid hypoplasia, developmental delay, learning disabilities, psychiatric disorders, renal, ocular, and skeletal malformations, hearing loss and laryngeal abnormalities. Chromosomal microarray (CMA) hybridization is one of the most performed diagnostic tests but as a genome wide analysis, it can point out relevant incidental copy number variations.Case presentationWe report the case of a 2-year-old boy that came to our attention for mild psychomotor delay, poor growth, and minor facial anomalies. Considering a diagnosis of 22q11.2 deletion syndrome, we performed CMA that not only confirmed our diagnosis, but also pointed out an additional de novo 5q21.3q22.2 microdeletion, encompassing APC gene. As a result of the genetic testing we enrolled the patient in a tailored surveillance protocol that enabled the early detection of a hepatoblastoma. The child underwent surgical and chemotherapic treatments with complete cancer eradication.ConclusionsThe concurrent finding of an expected result and an additional deletion of APC gene represents an example of a relevant issue about the health and ethical management of secondary findings revealed by genome-wide tests. Furthermore, this report highlights the need to develop dedicated surveillance guidelines for children with APC-related polyposis and raise the question whether to suspect and screen for APC-related conditions in cases of sporadic hepatoblastomas.

“Double Trouble”: Severe Meningoencephalitis Due to Borrelia burgdorferi and Powassan Virus Co-Infection Successfully Treated with Intravenous Immunoglobulin

Patient: Male, 76-year-oldFinal Diagnosis: Powassan virus encephalitisSymptoms: Confusion • fever • respiratory distressMedication: Immunoglobulin • ceftriaxoneClinical Procedure: —Specialty: Infectious Diseases • General and Internal Medicine • NeurologyObjective:Rare co-existance of disease or pathologyBackground:Powassan virus (POWV) is an emerging tick-borne flavivirus transmitted to humans by ticks. While infection is asymptomatic in some people, others develop life-threatening encephalitis with high mortality rates. Co-infection between POWV and Borrelia burgdorferi is rare despite the fact that both pathogens can be transmitted through the same tick vector, Ixodes scapularis. It is unclear if co-infection leads to more severe clinical presentation and worse outcome.Case Report:A 76-year-old Wisconsin man was admitted for meningoencephalitis complicated by hypoxemic and hyper-capnic respiratory failure requiring endotracheal intubation. The patient had no known tick bites but lived in a heavily wooded area. Extensive work-up for infectious, autoimmune, and paraneoplastic causes was positive for Borrelia burgdorferi and Powassan virus infection (POWV). Following treatment with ceftriaxone for neuroborreliosis and supportive care for POWV infection, the patient failed to improve. Intravenous immunoglobulins (IVIG) were started empirically, and the patient attained gradual neurological improvement and was successfully extubated.Conclusions:Treatment for POWV infection is supportive, and at this time there are no approved targeted antivirals for this disease. At this time, it remains unclear if co-infection with 2 pathogens leads to a more severe clinical presentation and higher mortality. In the absence of contraindications, IVIG might be beneficial to patients with POWV infection who are not improving with supportive care.

Double Trouble: Does Job Loss Lead to Union Dissolution and Vice Versa?

AbstractA now-substantial literature claims that job loss and union dissolution (the end of a marriage or cohabiting relationship) each increase individuals’ risk of the other, highlighting that major negative life events in the labour market and family can spill over across domains. We address three limitations of this research using UK data. First, these associations might arise from unmeasured factors which jointly predispose individuals to the two events. Second, the distinction between job loss (an event) and unemployment (the state it may lead to) has been neglected. Third, where the impact of unemployment has been considered, its duration has not. We simultaneously model both processes: does job loss (or being unemployed) lead to union dissolution, and does union dissolution (or being divorced/separated) lead to job loss? To investigate the role of unobserved, time-invariant confounders, we model the individual-specific effects as random variables allowed to correlate across the models for the two outcomes. Upon allowing such cross-process correlations, we find that job loss and union dissolution have modest and non-significant prospective associations with one another. We also find no support for a connection between being divorced/separated and subsequent job loss. Unemployment appears to increase risk of union dissolution; by attending to duration we uncover gender differences in this relationship.

A Novel Method of Laparoscopic Approach in A Giant Bladder Diverticulum With Renal Cell Carcinoma "Double Trouble" - Literature Review and Case Study

A Novel Method of Laparoscopic Approach in A Giant Bladder Diverticulum With Renal Cell Carcinoma "Double Trouble" - Literature Review and Case Study

'Double Trouble' -Antimicrobial resistance and COVID-19 A study on health care associated infections and multidrug resistant organisms in critical care units during the global pandemic

INTRODUCTION: Healthcare-associated infections (HAIs) contribute to mortality and morbidity in critical care units. The influence of the ongoing coronavirus disease (COVID-19) pandemic on the already existing silent pandemic of antimicrobial resistance, especially in a critical care setting in our experience, is discussed here in this perspective.MATERIALS AND METHODS: In our prospective single-centred study over three months (July to September 2020), 123 COVID-19-positive patients admitted in the medical and surgical intensive care units (ICUs) were enrolled after institutional ethical clearance and informed consent. Patient characteristics and risk factors for HAIs were studied using univariate analysis. Antimicrobial usage was monitored based on high-end antibiotic usage monitoring policy.RESULTS: Of 123 COVID-19 patients, 98 were mechanically ventilated and 47% (46/98) developed ventilator-associated pneumonia (VAP) with predominant strain of multidrug-resistant (MDR) Klebsiella pneumoniae. In patients with central line, 26% (10/38) developed central line-associated bloodstream infection (CLABSI) with coagulase-negative Staphylococcus. In catheterised patients, 51% (23/45) developed catheter-associated urinary tract infection (CAUTI) with predominant MDR K. pneumoniae and Acinetobacter baumannii complex. The significant risk factors for VAP were acute respiratory distress syndrome (ARDS), acute kidney injury, duration of mechanical ventilation, steroid therapy and longer ICU length of stay. Patients with CAUTI had diabetes and chronic kidney disease, were on steroids and had a longer ICU stay. Patients with CLABSI had more ARDS, had diabetes, were mechanically ventilated longer and had longer ICU stay. A 57%–84% increase in consumption of antibiotics was seen in our set-up with Azithromycin, Colistin, Meropenem and newer β-lactam/β-lactamase inhibitor combinations like Ceftazidime/Avibactam.CONCLUSION: HAIs in a critical setting with patients admitted with COVID-19 need special focus in terms of prevention and control. In our study, we highlight the incidence of VAP and a need to monitor these key quality indicators including antimicrobial prescription practices.

A Novel Method of Laparoscopic Approach in a Giant Bladder Diverticulum with Renal Cell Carcinoma "Double Trouble"

A Novel Method of Laparoscopic Approach in a Giant Bladder Diverticulum with Renal Cell Carcinoma "Double Trouble"

Chronic Obstructive Pulmonary Disease and COVID-19: A Double Trouble

Coronavirus Disease 2019 (COVID-19) is a respiratory and systemic illness that may progress to severe Acute Respiratory Distress Syndrome (ARDS). There is a pressing need to identify clinical predictors of severe COVID-19 which can help in risk stratification and prognostication. The COVID-19 pandemic tends to have more severe clinical presentation in older age group and in chronic diseases;Chronic Obstructive Pulmonary Disease (COPD) is one of them. COPD is the common cause of high mortality and morbidity worldwide. It is obvious to fear for patients with underlying COPD. Acute episode of exacerbation and COVID-19 pneumonia are the two pivotal differential diagnoses in contemporary era, in patients of COPD presenting with worsening dyspnoea. Mortality rate have been higher among COPD group of patients with the development of hypoxemia. Literature shows that pre-existing COPD worsens the risk of COVID-19 progression and leads to poorer prognosis. Even after recovery from the acute event, proper adherence to maintenance therapy for COPD (inhalational agents) continues to be of paramount importance and remains the standard of care. Because COPD remains a subset that is highly vulnerable for adverse outcomes with COVID-19 infection, preventive therapy should be directed towards-attenuation of contact with droplets, proper hand hygiene and maintenance of adequate nutritional status. The aim of this brief review is to know the burden and impact of COPD on COVID-19 pandemic and challenges in diagnosis and management of COPD patients.

Double trouble and the pitfalls of confirmation bias- A case report of acute appendicitis, arising in a duplex appendix

With an incidence of 0.004% [1], the likelihood of discovering a duplex appendix is very rare. Here, we present a case of a 43 year old man, whom underwent a laparoscopic appendicectomy and washout for what appeared to be a simple case of appendicitis, as confirmed by CT scanning. Despite an uncomplicated operation, the patient continued to spike high grade fevers with persisting abdominal pain. A repeat laparoscopic exploration was conducted, revealing a 2nd gangrenous appendix. Upon removal of the 2nd appendix, the subsequent histopathology report established that both appendix samples had a base and a tip, confirming that two distinct appendices had indeed been removed. This case highlights the pitfalls and confirmation bias: Namely, a tendency to preferentially look for information that confirms a pre-conceived diagnosis, simultaneously dismissing information which may point to an alternative diagnosis. In doing so, we prematurely stop searching for alternative or additional explanations for the patient’s presentation - which in this case resulted in a missed 2nd appendix.

The Slave Metaphor and Gendered Enslavement in Early Christian Discourse: Double Trouble Embodied by Marianne Bjelland Kartzow

Reviewed by: The Slave Metaphor and Gendered Enslavement in Early Christian Discourse: Double Trouble Embodied by Marianne Bjelland Kartzow Mary Ann Beavis marianne bjelland kartzow, The Slave Metaphor and Gendered Enslavement in Early Christian Discourse: Double Trouble Embodied (Routedge Studies in the Early Christian World; New York: Routledge, 2018). Pp. xiii + 167. $140. This study sets out to explore the slave metaphor, which is ubiquitous in early Christian discourse, using perspectives from metaphor, intersectionality, and embodiment theory. [End Page 149] The “double trouble” of the subtitle refers to the fact that the metaphor of slavery to God/Christ is not “merely a manner of speaking—it is a way of using some people’s vulnerable bodies and lives as source material to talk about abstract and concrete realties in God’s world” (p. 146). Marianne Bjelland Kartzow uses the device of “imaginary scenes” (following Carolyn Osiek and Margaret Y. MacDonald, A Woman’s Place: House Churches in Earliest Christianity [Minneapolis: Fortress, 2006] 18–19) to reconstruct the experience of the enslaved in the ancient ecclesia. Kartzow’s analysis ranges from well-known NT passages to the underinterpreted Shepherd of Hermas (chap. 5) and the explicit portrayal of Jesus as a slave trader in the Acts of Thomas (chap. 6). For example, in chap. 2, “Embodying the Slavery Metaphor: Female Characters and Slavery Language,” K. points out that Mary’s self-designation as “female slave of the Lord” (Luke 1:38) resonates with scriptural accounts of the slave girls Hagar, Bilhah, and Zilpah, who served as surrogate mothers for their barren mistresses, and in the interests of patriarchal lineages (pp. 50–51): “When used on a young girl such as Mary, . . . being a woman in reproductive age who is asked to give birth to her master’s son, the metaphor is ‘made real’” (p. 54). K. places the enslaved girl with a python spirit (Acts 16:16–19), dismissed by the text (and by most interpreters) as a nuisance, at the center of attention. By “freeing” the girl from spirit possession, K. notes, Paul causes her to lose her economic value to her owner(s), thus leaving her vulnerable to an uncertain, and likely worse, future (pp. 54–57). In both cases, Paul the “slave of Christ” and his free male com-patriots have very little in common with the metaphorical and real slave women of these narratives. Chapter 3 (“Metaphor and Masculinity”) examines the “no longer slave” formulations of John 15:15 and Gal 4:7, noting that this discourse assumes changes in relationships that are available only to males, whether slave or free: “Women rarely become acknowledged as friends or sons or heirs” (p. 83). Moreover, as chap. 4 argues, if all believers are slaves of the Lord, some (the actually enslaved) are more slaves than others. Chapter 5, on the Shepherd of Hermas, explores a text where a formerly enslaved church leader, the freedman and prophet Hermas, negotiates his transformation from slave of a female owner to metaphorical slave of God—Hermas’s favorite designation for believers. K. pays special attention to the striking parable of the slave and the son (Sim. 5.2), where a faithful slave is not only manumitted but adopted as son and co-heir with his master’s biological son. She speculates, “Perhaps he [Hermas] moved from being a slave of his owner to being a slave of God because he, like the slave in the parable, showed himself worthy of being a freed man and an heir” (p. 113). Paradoxically, K. observes, although metaphorical slavery pervades the Shepherd, actual slaves—apart from the putative author—are invisible, Hermas’s concern for the poor and marginalized notwithstanding (pp. 115–18). For Hermas, especially, the bodily experience of male enslavement and manumission intersects with the metaphorical usage. The last main chapter (“Jesus, the Slave Trader: Metaphor Made Real in The Acts of Thomas”) considers a fictive narrative in which a metaphorical slave of Christ is transformed into a “real” slave when Jesus sells the apostle Thomas to a merchant from India. K. ably unpacks the many ways in which the slave metaphor operates in the text, and how it works with respect not only...

Double trouble: Gaia reveals (proto)planetary systems that may experience more than one dense star-forming environment

ABSTRACT Planetary systems appear to form contemporaneously around young stars within young star-forming regions. Within these environments, the chances of survival, as well as the long-term evolution of these systems, are influenced by factors such as dynamical interactions with other stars and photoevaporation from massive stars. These interactions can also cause young stars to be ejected from their birth regions and become runaways. We present examples of such runaway stars in the vicinity of the Orion Nebula Cluster (ONC) found in Gaia DR2 data that have retained their discs during the ejection process. Once set on their path, these runaways usually do not encounter any other dense regions that could endanger the survival of their discs or young planetary systems. However, we show that it is possible for star–disc systems, presumably ejected from one dense star-forming region, to encounter a second dense region, in our case the ONC. While the interactions of the ejected star–disc systems in the second region are unlikely to be the same as in their birth region, a second encounter will increase the risk to the disc or planetary system from malign external effects.

599: Self-Induced Bleeding due to Double Trouble: A Very Rare Case of Evans Syndrome

Drekolias, Dimitrios1; Gadela, Naga Vaishnavi2; Wasserman, Evan2; Gonuguntla, Karthik2; Perosevic, Nikola2 Author Information

Double trouble with triple bubble: A rare case of double small bowel atresia in a neonate

We experienced a rare case of double small bowel atresia (SBA) at our centre. A premature baby boy was born at 35 weeks of gestation. Antenatal scans had already shown a grossly dilated stomach and bowel. Postnatal abdominal X-ray (AXR) showed a triple bubble sign. During emergency laparotomy, we found that there was a Type III atresia at the second part of duodenum and a Type I atresia at the duodenojejunal junction. Duodeno-duodenostomy, duodeno-jejunostomy, duodenal plication and appendicectomy were done. Post-operatively, he was fasted for almost two weeks due to persistently high nasogastric aspirates. However, with the help of prokinetic drugs, he was finally able to tolerate breast feeding and was discharged home well.

Under the Red White and Blue: Patriotism, Disenchantment and the Stubborn Myth of The Great Gatsby

Under the Red White and Blue: Patriotism, Disenchantment and the Stubborn Myth of <i>The Great Gatsby</i>

Double trouble: could Ichthyophthirius multifiliis be a vehicle for the bacterium associated with red mark syndrome in rainbow trout, Oncorhynchus mykiss?

Red mark syndrome (RMS) is a disease of farmed rainbow trout, Oncorhynchus mykiss (Walbaum, 1792), one of the most widespread freshwater farmed species in Europe. The disease emerges at water temperatures below 16 °C and consists of one or more bright red skin lesions on the fish body. Mortality due to RMS is reportedly rare, but the disease leads to downgrading of the product and subsequent economic losses. Despite the disease impact, the causative agent for RMS is still formally undetermined although increasing evidence points to a bacterium ascribed to the Midichloriaceae family (order Rickettsiales), hereafter referred to as RMS-Midichloria like organism (RMS-MLO).Intriguingly, recently deposited sequences revealed the presence of RMS-MLO-like bacteria associated with Ichthyophthirius multifiliis, a common protozoan skin parasite of freshwater fish frequently harboring bacterial endosymbionts. Therefore, we hypothesized that I. multifiliis could be a vehicle for RMS-MLO. This was tested by infecting RMS-diseased rainbow trout with I. multifiliis theronts, and subsequently investigating the presence of RMS-MLO in tomonts detached from the fish.Real time PCR analyses showed clearly that I. multifiliis previously exposed to RMS-affected fish become positive to RMS-MLO suggesting that this bacterium can be at least transiently acquired and carried by the protozoan. Moreover, statistical analyses suggested a possible level of vertical transmission in I. multifiliis from one trophic stage to the next one. Further studies will be necessary to prove whether I. multifiliis has a role in the horizontal transfer of RMS-MLO bacteria from diseased RMS fish to healthy ones.

Double trouble: Bacillus depends on a functional Tat machinery to avoid severe oxidative stress and starvation upon entry into a NaCl-depleted environment

The widely conserved twin-arginine translocases (Tat) allow the transport of fully folded cofactor-containing proteins across biological membranes. In doing so, these translocases serve different biological functions ranging from energy conversion to cell division. In the Gram-positive soil bacterium Bacillus subtilis, the Tat machinery is essential for effective growth in media lacking iron or NaCl. It was previously shown that this phenomenon relates to the Tat-dependent export of the heme-containing peroxidase EfeB, which converts Fe2+ to Fe3+ at the expense of hydrogen peroxide. However, the reasons why the majority of tat mutant bacteria perish upon dilution in NaCl-deprived medium and how, after several hours, a sub-population adapts to this condition was unknown. Here we show that, upon growth in the absence of NaCl, the bacteria face two major problems, namely severe oxidative stress at the membrane and starvation leading to death. The tat mutant cells can overcome these challenges if they are fed with arginine, which implies that severe arginine depletion is a major cause of death and resumed arginine synthesis permits their survival. Altogether, our findings show that the Tat system of B. subtilis is needed to preclude severe oxidative stress and starvation upon sudden drops in the environmental Na+ concentration as caused by flooding or rain.

First data on latent tuberculosis infection in Syrian refugees with diabetes in Lebanon

ObjectiveThe association between diabetes mellitus and tuberculosis is a health-threatening double trouble. Vulnerable populations such as refugees and conflict-displaced populations may be at higher risk of both diseases. Here, we examined the prevalence of latent tuberculosis infection (LTBI) and its associated risk factors in a population of Syrian refugees with diabetes in North Lebanon. Study designThis is a cross-sectional study. MethodsA total of 87 Syrian refugees with diabetes were enrolled. Demographic and clinical data were collected using a structured questionnaire, and a blood sample was obtained from each patient. LTBI was examined using the last generation QuantiFERON-TB Gold Plus assay. ResultsThe mean age of the study population was 54.1 ± 10.5 years, and the majority were women (79.3%). LTBI was found in 1 in 5 (17/87; 19.5%) enrolled patients, with the majority being originated from Aleppo (47.05%). Infection was significantly associated only with age (P = 0.009), and its risk was 4-fold higher in patients aged ≥60 years (odds ratio: 4.1, confidence interval: 1.4–12.5, P = 0.018). ConclusionThis study highlights the need to implement effective tuberculosis control strategies among refugees with diabetes, with particular attention to those at older age.

The Slave Metaphor and Gendered Enslavement in Early Christian Discourse: Double Trouble Embodied, written by Marianne Bjelland Kartzow

The Slave Metaphor and Gendered Enslavement in Early Christian Discourse: Double Trouble Embodied, written by Marianne Bjelland Kartzow

Double trouble: diagnostic dilemma in a rare association of proximal ureteric valve with orthotopic ureterocele\u2014case report

BackgroundAssociation of the ureterocele and proximal ureteral valve is a rare congenital anomaly which can lead to quick detoriation of renal function due to double obstruction. Though ureteral valves have been associated with other ureteral anomalies, this specific association is extremely rare.Case presentationA 7-month-old boy was referred to us for antenatally detected hydronephrosis. Provisional diagnosis of orthotopic ureterocele with pelviureteric junction (PUJ) obstruction was made based on preoperative imaging. Endoscopic incision of ureterocele was done and retrograde pyelography showed tight obstruction at PUJ which necessitated a pyeloplasty. Examination of resected specimen confirmed a ureteral valve. Postoperatively, the patient had good improvement in kidney function.ConclusionTo conclude, congenital ureteral valves are a rare cause of ureteric obstruction and its association with ureterocele is rarer still. Identification of an ureterocele should not deter us from searching for an associated pathology like a ureteric valve when imaging shows more severe hydronephrosis suggestive of more proximal obstruction.

Double Trouble: A Rare Association between Chronic Total Occlusion of the Left Main Coronary Artery and Colonic Malignancy

AbstractEmerging evidence has shown an association between cardiovascular (CV) disease and cancer due to shared risk factors and biological mechanisms especially chronic inflammation. The objective of this case report is to highlight the association between these two lethal diseases and the challenges in the management of coronary artery disease in patients with coexisting malignancy.A 65-year-old nonsmoker, nondiabetic, and normotensive male presented with a history of abdominal pain and significant weight loss. Colonoscopy and biopsy showed adenocarcinoma of the ascending colon, and he was planned for right hemicolectomy. Electrocardiogram exercise stress test performed as a part of preoperative evaluation was strongly positive. Coronary angiography was suggestive of Chronic total occlusion of the left main coronary artery. Though the syntax score was intermediate, coronary artery bypass grafting was decided as the revascularization strategy as he needed early surgery for the colonic malignancy. A month later, he underwent right hemicolectomy.Clinicians should be aware of the association between CV disease and cancer as they are likely to face similar situations where both coexist. Understanding the connections between heart disease and cancer will help to formulate combined preventive guidelines.

COVID 19 with Dengue Virus – Coinfection Double trouble?

COVID 19 with Dengue Virus – Coinfection Double trouble?