Past History Research Articles

BRASH syndrome with a complete heart block- a case report

IntroductionBRASH syndrome (Bradycardia, Renal failure, Atrioventricular (AV) nodal blocking agent, Shock and Hyperkalemia) is a recently emerging diagnosis that describes the profound bradycardia seen in patients on AV nodal blockers who present with acute kidney injury (AKI) and hyperkalemia.Case presentationWe present a case of a 68 years old female patient with past history of hypertension taking atenolol and Enalapril presented to emergency department with the complaint of loss of consciousness of 02 hours duration. She had 03 days history of fatigue, poor oral intake, decreased urine output, appetite loss, vertigo and global headache. Her vital signs were blood pressure of 60/40 mmHg, absent radial pulse and temperature of 36.4 °C. Her systemic examination was remarkable for dry buccal mucosa; apical heart rate was 22 beats per minute. Glasgow Coma Scale was 13/15. Her laboratory tests showed creatinine of 1.83 mg/dL, blood urea nitrogen of 89 mg/dL and potassium elevated to the level of 6.39 mEq/dL. ECG revealed complete heart block with a normal QT interval and T waves and no U waves with ventricular rate of 22 beats per minute. Her previous medications were discontinued and the patient was resuscitated with intravenous (IV) fluids. She was given 03 doses of 1 mg atropine every 5 minutes but there was no increment in heart rate. She was given 50% dextrose with 10 international units of regular insulin, 1 g of calcium gluconate and Intravenous perfusion of norepinephrine and dopamine. Subsequently, after 14 hours of ICU admission the patient had a cardiac arrest with asystole and resuscitation was attempted but she couldn’t survive.ConclusionBRASH syndrome is largely an under-recognized life threatening clinical diagnosis. Physicians should have high index of suspicion for BRASH when they encounter patients with bradycardia, hyperkalemia, and renal failure, as timely diagnosis is crucial in the management.

Clinical profile of 1208 newly diagnosed colorectal cancer patients in Tamil Nadu-A multi-centric survey.

An increasing incidence of colorectal cancer (CRC) is being reported in developing countries, including India. Most Indian studies on CRC are retrospective and single-centered. The present study is an attempt to understand the current clinical profile and stage of newly diagnosed CRCs across multiple centers in Tamil Nadu, India. A multi-centric observational survey was conducted between September 1,2021, and August 31,2022, under the aegis of the Indian Society of Gastroenterology - Tamil Nadu chapter. Patients 18 years of age and older with a recent diagnosis of CRC fulfilling the inclusion criteria were prospectively recruited at the participating centers. Their demographic, clinical, biochemical, endoscopic, histopathologic, radiologic and risk factor details were systematically collected and analyzed. Across 23 centers in Tamil Nadu, 1208 patients were recruited. The male:female ratio was 1.49:1, while mean (SD) age was 57.7 (13.5) years. A majority (81.9%) were Tamils and 78.5% belonged to lower socioeconomicclasses. The predominant symptoms were hematochezia (30.2%) and a change in bowel habits (27.5%). The most common locations were the rectum (34.3%) and rectosigmoid (15.1%). Synchronous CRCs were seen in 3.3% and synchronous colorectal polyps in 12.8%. Predisposing factors for CRC were seen in 2%. A past history of any cancer among CRC patients was obtained in 3.1% and a family history of any cancer was found in 7.6%. Patients who were either overweight or obese constituted 46.4% of the study population. At presentation, the predominant stages were stage III (44.7%) and stage IV (20.8%). A majority of patients with newly diagnosed CRC in Tamil Nadu belonged to the lower socioeconomicclasses. About 60% had CRCs located within the reach of the flexible sigmoidoscope. Two-thirds of the patients exceeded stage II disease at presentation. Not applicable.

Untangling the link between experiential avoidance and non-suicidal self-injury: a multidimensional approach

ABSTRACT Objective Experiential avoidance, an individual’s unwillingness to experience uncomfortable internal feelings/emotions, has been found to be associated with history of self-injury. This association is mainly found in studies that use global measures of experiential avoidance. However, experiential avoidance is purported to be a multidimensional construct. This study aims to test both unidimensional and multidimensional measures of experiential avoidance and their associations with self-injury. Method University students (n = 632, M = 25.01, SD = 7.13, 78.8% female, 70.9% with lived experience of self-injury) completed well-validated self-report measures of self-injury, experiential avoidance (The Brief and the Multidimensional Experiential Avoidance Questionnaire). Results As expected, all sub-scales of multidimensional measure of experiential avoidance were highly correlated with the global score for experiential avoidance. The global measure of experiential avoidance differentiated individuals with no history, with past history, and recent history of self-injury. When assessed using the multidimensional measure, only the sub-factors behavioural avoidance and repression and denial differentiated those with no history of self-injury from those with recent history and those with recent history from those with past history of self-injury. Conclusion Findings raise the possibility that associations between experiential avoidance and self-injury may be down to two specific aspects of experiential avoidance, namely 1) behavioural avoidance and 2) repression/denial. If true, this will have important theoretical, clinical, and measurement implications for research into self-injury.

From formal subsumption under capital to primitive accumulation of capital: On the separation of labour from the objective conditions of production in Marx’s Capital

In contemporary Marxist studies, there has been a revival of two classic categories of the Critique of Political Economy, namely, ‘formal subsumption of labour under capital’ and ‘primitive accumulation of capital’. In contradistinction to traditional usages, Marxists authors consider that both belong, not to the historical past of capitalist production, but to its actuality. Regrettably, this recuperation has not been accompanied by a more thorough assessment of the methodological and political dimensions that are contained in both categories. This article aims to address this issue in the light of Marx’s use of the categories of formal subsumption of labour under capital and primitive accumulation of capital. In doing so, it will be demonstrated that they refer to the same process, namely, the separation of labour from the objective conditions of production, and that, given this internal connection, they co-evolve throughout Marx’s economic works, from Grundrisse to Capital, volume I. Moreover, it will be seen that the substitution of primitive accumulation for formal subsumption must be understood in Marx’s shift from a systematic to a historical approach to the historical process by which the capitalist mode of production came to life; and that Marx adopted this new perspective on both methodological and political grounds. The article also discusses the importance of contemporary Marxist scholarship of this examination of the methodological and political premises of Marx’s use of the notions of formal subsumption and primitive accumulation.

Calcific bursitis of the Gruberi bursa: a case report

BackgroundBursitis is the inflammation of a synovial bursa, a small synovial fluid-filled sac that acts as a cushion between muscles, tendons, and bones. Further, calcific bursitis results from calcium deposits on the synovial joint that exacerbates pain and swelling. The Gruberi bursa is located dorsolaterally in the ankle, between the extensor digitorium longus and the talus. Despite limited literature on its pathophysiology, the aim of this case is to discuss the bursa’s association with calcific bursitis and its management via a case presented to our clinic.Case presentationA 47-year-old Caucasian female with no past medical or family history presents with acute right ankle pain following a minor injury 3 months prior with no improvement on analgesic or steroid therapy. Imaging demonstrated incidental calcium deposits. The day prior to presentation, the patient stated she used 1-pound ankle weights that resulted in mild swelling and gradual pain to the right dorsoanterior ankle. Physical exam findings displayed a significant reduction in the range of motion limited by pain. Imaging confirmed calcification within the capsule of the talonavicular joint, consistent with Gruberi bursitis. Initial management with prednisone yielded minimal improvement, requiring an interventional approach with ultrasound-guided barbotage that elicited immediate improvement.ConclusionThe presented case report highlights a rare and unique instance of acute ankle pain and swelling caused by calcific Gruberi bursitis in a young female. Although the Gruberi bursa is a relatively new discovery, it contains inflammatory components that may predispose it to calcification and should be considered in the differential of ankle swelling. Therefore, utilizing a systematic approach to a clinical presentation and considering all differential diagnoses is essential.

Adult case of slipped capital femoral epiphysis initially requiring in situ fixation with revision to total hip arthroplasty after failure of index surgery

Introduction: Slipped capital femoral epiphysis (SCFE) is a disorder classically associated with pediatric patients in which the femoral head is displaced through the physis. In rare cases of metabolic and hormonal disorders, SCFEs can be identified in adult patients as a result of persistent growth plates. Optimal definitive surgical management of these patients is still unknown and more information is needed in order to provide appropriate care for these patients. Case Report: A 31-year-old male with past medical history of hypopituitarism presented with left hip pain after a seizure. He was found to have a left slipped capital femoral epiphysis on initial radiographs for which he was taken to the operating room for open treatment of the left SCFE with in situ screw fixation. Approximately four weeks later he returned to the hospital after a fall with left hip pain and inability to ambulate. Radiographs demonstrated cutout of the cannulated screw in the setting of a SCFE with further displacement. He returned to the operating room for conversion to an uncemented total hip arthroplasty. His post-op course was uneventful and he was discharged home in stable condition. Conclusion: This cases highlights a condition uncommonly identified in adult patients which was further complicated by failure of the initial surgical repair and need for revision surgery. This case is unique in that total hip arthroplasty as a definitive treatment for acute SCFE, rather than treatment for end stage arthritis secondary to chronic SCFE, has not been reported upon this author’s review.

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study.

Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics. First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history. A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases. One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated. Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests. Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder. Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

Predicting myopic changes in children wearing glasses using the Plusoptix photoscreener

IntroductionWith high increase in myopia prevalence, we aimed to assess whether Plusoptix_A09 can be used in myopic children over spectacles to predict visual acuity (VA) and myopic refraction changes.MethodsMyopic children underwent a complete ophthalmological examination. Plusoptix_A09 was performed over spectacles. VA changes, refraction changes and time since previous glasses prescription, were determined. Age, current or past history of amblyopia, presence of strabismus and self-perception of VA changes were registered.ResultsIn total, 199 patients were included. Spherical power (SP) and spherical equivalent (SE) measured by Plusoptix_A09 over spectacles predicted both VA changes (p < 0.001) and refraction changes (p < 0.001). Values of SP < − 0.06D or SE < − 0.22D indicated a VA decrease (AUC > 0.9, p < 0.01) for sensitivity and specificity of 85.1%, 82.1% and 82.6%, 83.3%, respectively. Age and ophthalmological comorbidities did not influence Plusoptix_A09 measurements (p > 0.05). Plusoptix_A09 over spectacles was a stronger predictor of VA changes when compared to children's self-perception, either in 4–9-year-old patients (p < 0.001 versus p = 0.628) and in 10–18-year-old children (OR < = 0.066 versus OR = 0.190). A decrease in SP and SE of − 0.10D in Plusoptix_A09 predicted a myopia progression of − 0.04D and − 0.05D, respectively.Conclusion/RelevanceThis study unveiled new features for the Plusoptix, a worldwide available photoscreener used inamblyopia screening. When Plusoptix is performed in children with their glasses on, it can rapidly predict myopia progression.For each decrease of − 0.10D in Plusoptix, a myopia progression of -0.05D is expected. Moreover, Plusoptix is more reliablethan children's self-perception of visual acuity changes, making it a useful tool either in primary care or ophthalmologypractice

Intergenerational effects of child maltreatment on adolescents’ anxiety and depression in Ethiopia: the important mediating and moderating roles of current psychological distress

BackgroundChild abuse is widespread around the world, and one continent with particularly high rates is Africa. Research in high- and middle-income countries shows the cascading effect of parental history of child abuse and neglect on adolescents’ maltreatment and, in turn, on mental health problems. This cascade has been reported in young children but has rarely been studied in parent-adolescent dyads or in low-income countries (LICs). The goal of this study was to test intergenerational associations of child abuse and neglect and to examine how these experiences are in turn associated with youth anxiety and depression in an LIC.MethodsA total of 231 adolescents (age: 13–21 years) and 185 of their parents (n = 90 fathers and n = 95 mothers) were recruited from secondary schools in Addis Abeba, Ethiopia. Using a cross-sectional design, participants completed a set of questionnaires assessing child maltreatment (in adolescence and own past history in parents), parental psychological distress, youth depression and anxiety, and sociodemographic factors.ResultsThe frequencies of child maltreatment exposure were 68% for adolescents and 65% for their parents (when they were a child). Fifty-one percent and 42% of adolescents had borderline to clinical levels of anxiety and depression symptoms, respectively. Adolescents of parents with a history of child abuse and neglect also reported higher exposure to maltreatment themselves (p < 0.001). Current paternal, but not maternal, psychological distress mediated this intergenerational association of maltreatment experiences (95% CI [1.164, 9.467]). We further found parents’ psychological distress to be a significant moderator of the indirect pathways of the intergenerational effect of child maltreatment on adolescents’ anxiety and depression (95% CI [− 0.770, − 0.012]).ConclusionsWe found child maltreatment to be intergenerationally associated, and this effect subsequently affected adolescents’ anxiety and depression through different pathways supporting the cascading effects across generations. Intervention plans may be effective through an array of possible indirect pathways and encourage the implementation of multiple access points to facilitate change in the lives of affected youth in Africa.

Outcomes after chronic isolated epididymal pain A retrospective study.

Despite being a commonly encountered urologic condition, there remains a paucity of understanding and literature on the management and natural history of isolated epididymal pain. Typically, patients who do not respond to conservative management undergo an epididymectomy; however, the literature on its efficacy is also scarce, with success rates varying from 10-90%. Our goal was to better describe the etiology and natural history of isolated epididymal pain and to describe the rates of success associated with epididymectomy. A retrospective, case-control study was conducted at the Manitoba Men's Health Clinic, with the approval of the University of Manitoba Research Ethics Board. All patients presenting with chronic epididymitis, defined as discomfort or pain localized to the epididymis for at least three months, were identified. Information regarding patient demographics, past medical and surgical history, duration of pain, localization of pain, findings on previous ultrasounds, prior conservative therapies trialed, and response rates, as well as response rates to surgical therapy were collected. From April 2022 to April 2023, a total of 275 patients with chronic orchialgia were identified; among them, 74 patients presented with chronic isolated epididymal pain. On average, 22.9% of patients experienced symptoms for 3-6 months, 10% for 6-12 months, and 67.1% for over 12 months; 13.5% (n=10) had associated ejaculatory pain, 8.1% (n=6) had lower urinary tract symptoms, and 4.1% (n=3) had erectile dysfunction. Ultrasound findings were observed in 68.9% of patients, with 31.1% having an epididymal cyst, 27.1% having a varicocele, 5.4% having a spermatocele, and 4.1% having a hydrocele. Among those who underwent conservative therapy, only 36.2% of patients reported a positive response. Surgical intervention was performed on 23 patients, including 16 who underwent epididymectomy, three who underwent cord denervation, and two who underwent vasovasostomy and spermatocelectomy each. Most (81.3%, n=13) patients who underwent epididymectomy had a positive response to the surgical intervention, defined as no pain on followup, while all patients undergoing other surgical interventions experienced a positive response. Chronic epididymal pain is a condition with limited data surrounding its management. Prior to referral, a large proportion of patients did not undergo any conservative treatment, and of those that did, there was limited response. For those who underwent surgical intervention, all were pain-free on followup, except three patients who underwent epididymectomy.

Contributions and Challenges of Psychodynamic Play Therapy- With Foster Children and Their Many Parents

This article describes the important contributions provided by the psychodynamic approach to the psychotherapy and treatment of children in foster care. It was written in consideration of the dearth of literature about foster care of children in Israel. Foster care comprises transient substitute parenting, whose aim is to provide a family experience with benevolent parental figures to foster children whose parents were unable to raise them, and to provide for these children have experienced extensive cumulative trauma during their childhood. Removing a child from their home inevitably adds an additional traumatic experience, and their adjustment to foster care is dependent on their past and particularly, their past history of attachments. Internal models of attachment figures who were experienced as neglectful or abusive, impede the attachment of children to new benevolent attachment figures. The characteristics of the therapeutic encounter with foster children are illustrated by means of a clinical case. Difficulty in establishing a trusting relationship, absence of playfulness, deep deprivation of primary needs, traumatic reenactments and an interal world sated with destruction and loss, manifested in the play and in the therapeutic relationship. Reflective observation of the transference processes and those of the countertransferences and projective identifications opened an avenue to explore and rehabilitate the internalized representations of the childr treated and contributed to the expansion of the emotional capacities of the therapist to contain the difficult experiences. The therapeutic sessions with children in foster care challenge therapists with their intense emergent emotions. Consequently, it is important to provide parallel accompanying supervision to therapists as this enhances the containment of their internal worlds and supports their capacities to consider therapeutic interventions and to contain the relationships that develop. In the parallel process the therapists who facilitate the expression of the needs and feelings of the child in the process, provide essential support to the child in connecting to themselves to their latent hopefulness and their inner resources. By means of the benevolent therapeutic presence and encounter that is experienced, a corrective internalization may be acquired by the child, in contrast to the experiences of arbitrariness, instability and loss that were experienced in their pasts.

Queering history: palimpsestuous bodies and theirstories in Zen Cho’s The Order of the Pure Moon Reflected in Water

ABSTRACT In her fantasy novella, The Order of the Pure Moon Reflected in Water (2020), transnational Malaysian writer Zen Cho agitates and disrupts Malaysia’s heteropatriarchal and ethnocentric history as well as Eurocentric LGBT discourses with the revisionary reinscriptions of gender and sexuality to give voice to decolonial theirstories, particularly those belonging to the minority and subaltern community of queer identities. Emphasising difference and heterogeneity, these reinscriptions not only critique and rewrite – effectively queering – Malaysia’s monolithic historical past and postcolonial present, but also reveal the palimpsestuousness of queer bodies as the discursive boundaries between history and fiction, real and fantasy, self and other, are deliberately blurred, even dismantled, in the intertwined narratives of masculinity and femininity, heterosexuality and homosexuality. Drawing on the intersections of queer and palimpsest, this essay moreover examines how the queering of history involves queer retrospection through the recuperation of forgotten or erased theirstories, notably the ‘queer’ religious discourse and history represented by the gender ambiguous and fluid Buddhist figure of Guanyin. By confronting a monolithic past, the novella ultimately illuminates the path for the speculation of queer futures.

A100 HEREDITARY HEMORRHAGIC TELANGIECTASIA: MORE THAN JUST ANOTHER RECTAL BLEED

Abstract Background Hereditary hemorrhagic telangiectasia (HHT), previously known as Osler-Weber-Rendu syndrome, is an autosomal dominant disorder characterized by widespread telangiectasia and visceral arteriovenous (AV) malformations. Diagnosis of HHT is commonly guided by The Curaçao Diagnostic Criteria. Molecular genetics can help confirm the clinical diagnosis. Genes involved include ENG, ACVRL1, SMAD4, and GDF2, which affect the bone morphogenic protein signaling pathway important in maintaining vascular endothelial integrity. Aims This report aims to review the case of a young male from a rural community in Northern Alberta with a possible new diagnosis of HHT, presenting with rectal bleeding in the setting of family history of telangiectasias. Methods Retrospective review of one patient. Results We report the case of a 33-year-old male who presented with a 1-day history of rectal bleeding (bright red turning to black) with hemoglobin at 116g/L. Past medical history was significant for occasional epistaxis since age 8, previous gastrointestinal bleed and laparotomy with pathology showing small intestinal vascular malformation at the age of 15, and small bowel obstruction secondary to adhesions requiring resection at the age of 26. There was no history of iron deficiency anemia. Family history was positive for a mother who had Von Willebrand disease and partial colectomy at the age of 28 due to bowel telangiectasias. His mother had no formal HHT diagnosis, but it was unclear if molecular genetics had been performed. Inpatient colonoscopy showed no culprit lesions but free-floating blood clots throughout the colon (Image). EGD and push enteroscopy were normal. CT enterography was then performed showing AV fistula in the distal ileum and venous malformations in the jejunum. Video capsule endoscopy followed revealed a few non-bleeding telangiectasia and petechiae. The patient was assessed to have possible HHT by The Curaçao Diagnostic Criteria. He was supplemented with IV iron and started on short-acting octreotide. On discharge, he received funding approval for long-acting octreotide and was referred to the Edmonton HHT clinic for follow up and further screening. Conclusions HHT remains underdiagnosed in both children and adults. Maintaining a strong suspicion and prompt diagnosis via the Curaçao Criteria is crucial for appropriate screening of the multisystem complications which stem from the AV malformations. This multidisciplinary approach can aid in reducing morbidity and mortality. Funding Agencies None

A160 A CASE OF BREAST CANCER METASTASIS MASQUERADING AS SIGNET RING CELL ADENOCARCINOMA OF THE STOMACH

Abstract Background Gastric cancer has a poor prognosis, particularly at advanced stages. Endoscopic submucosal dissection (ESD) can be used to treat selected early-stage gastric cancers. This case study explores the challenge of diagnosing and managing patients when metastatic lesions mimic primary gastric cancer, as seen in this case of breast cancer metastasis resembling signet ring cell adenocarcinoma of the stomach. Aims The aim of this case report is to describe an unusual case of breast cancer metastasis to the stomach identified unexpectedly on random gastric biopsies, initially diagnosed as a primary gastric signet ring cell adenocarcinoma. Methods Clinical and pathological records of the described patient were reviewed retrospectively. Furthermore, a review of the relevant literature was also performed. Results A 68 year-old-woman underwent gastroscopy for nausea and vomiting. Her past medical history was remarkable for bilateral mastectomies ten years ago for invasive lobular carcinoma, with metastatic bone disease diagnosed by imaging five years prior. She had been well controlled on letrozole taken intermittently due to side effects. At endoscopy, while the stomach appeared grossly normal, random biopsies done for Helicobacter pylori identified a single focus of signet ring cell adenocarcinoma. Subsequent chromoendoscopy identified an area of subtle mucosal abnormality for which the patient declined surgery and was instead managed by ESD which surprisingly yielded no dysplasia. A follow up gastroscopy with random biopsies also failed to identify any areas of dysplasia, but random biopsies on a subsequent gastroscopy again identified a minute focus of adenocarcinoma with signet ring cell morphology. Given the unusual presentation of apparent signet ring cell adenocarcinoma in two distinct areas in the stomach without any visible endoscopic abnormality an in-depth pathological analysis was conducted. By immunohistochemistry the tumor cells stained positive for Estrogen Receptor, GATA3, and CK7 and negative for antibodies targeting CK20 and CDX2, which supported an interpretation of minute multifocal breast cancer metastases to the stomach from hematogenous spread. Conclusions In this case, repeated endoscopic investigations and immunohistochemical staining revealed minute multifocal breast cancer metastases to the stomach. Conventional tumor staging methods often cannot identify microscopic metastases, potentially impacting disease progression and patient care. A high level of suspicion for metastatic breast cancer and a detailed pathological analysis allowed for the correct diagnosis in this patient. Funding Agencies None

Whole-Genome sequencing in routine Mycobacterium bovis epidemiology - scoping the potential.

Mycobacterium bovis the main agent of bovine tuberculosis (bTB), presents as a series of spatially-localised micro-epidemics across landscapes. Classical molecular typing methods applied to these micro-epidemics, based on genotyping a few variable loci, have significantly improved our understanding of potential epidemiological links between outbreaks. However, they have limited utility owing to low resolution. Conversely, whole-genome sequencing (WGS) provides the highest resolution data available for molecular epidemiology, producing richer outbreak tracing, insights into phylogeography and epidemic evolutionary history. We illustrate these advantages by focusing on a common single lineage of M. bovis (1.140) from Northern Ireland. Specifically, we investigate the spatial sub-structure of 20 years of herd-level multi locus VNTR analysis (MLVA) surveillance data and WGS data from a down sampled subset of isolates of this MLVA type over the same time frame. We mapped 2108 isolate locations of MLVA type 1.140 over the years 2000-2022. We also mapped the locations of 148 contemporary WGS isolates from this lineage, over a similar geographic range, stratifying by single nucleotide polymorphism (SNP) relatedness cut-offs of 15 SNPs. We determined a putative core range for the 1.140 MLVA type and SNP-defined sequence clusters using a 50 % kernel density estimate, using cattle movement data to inform on likely sources of WGS isolates found outside of core ranges. Finally, we applied Bayesian phylogenetic methods to investigate past population history and reproductive number of the 1.140 M. bovis lineage. We demonstrate that WGS SNP-defined clusters exhibit smaller core ranges than the established MLVA type - facilitating superior disease tracing. We also demonstrate the superior functionality of WGS data in determining how this lineage was disseminated across the landscape, likely via cattle movement and to infer how its effective population size and reproductive number has been in flux since its emergence. These initial findings highlight the potential of WGS data for routine monitoring of bTB outbreaks.

A170 A RARE CASE OF CELIAC DISEASE WITH PULMONARY HEMOSIDEROSIS AND DILATED CARDIOMYOPATHY

Abstract Background Celiac disease (CD) is a primary disease of the intestine but patients also present with extra intestinal manifestations like iron deficiency anemia, dermatitis herpetiformis, selective IgA deficiency, thyroid disorders, diabetes mellitus and various connective tissue disorders but rarely with pulmonary hemosiderosis and dilated cardiomyopathy. Aims We present a rare case of CD associated with pulmonary hemosiderosis and dilated cardiomyopathy in a 10 year old child. Methods Patient interview and chart review was conducted. Literature reveiw was performed using pub med data base. Results A 10 year old presented with a 1 day of cough and hemoptysis. His past medical history includes Constipation and low percentile for weight and height. His first cousin is recently diagnosed with celiac disease, otherwise his family history is unremarkable. He is pale on exam and has a BMI of 13.64 which is ampersand:003C1% for age. He had fine crackles on bilateral lung fields but no signs of respiratory distress. His pericardium was active but no murmur or gallop. CXR showed cardiomegaly and Echo was suggestive of dilated cardiomyopathy. ECG was significant for LBBB. Chest CT showed bilateral confluent symmetric ground glass densities with possibility of pulmonary hemosiderosis. His blood work was significant for iron deficiency anemia, low selenium of 0.94umol/L and zinc 8.4umol/L. His antibody screen was positive for ANA, a tTGA of ampersand:003E4,965.5 and positive EMA. The cardiomyopathy and pulmonary hemosiderosis in this case are considered to be secondary findings as both have been reported in the context of celiac disease and patient was initiated on gluten free diet (GFD). Patient was blood transfused and kept on oral iron and multivitamins. He was also started on aldactazide 1 tab daily, 20mg twice daily enteresto and carvedilol 3.125mg twice daily as part of his heart failure management. At one month follow up, patient was having abdominal discomfort due to his constipation and follow up labs showed improvement of his anemia. Conclusions Patients with pulmonary hemosiderosis occuring with CD demonstrate improvement of their symptoms with GFD highlighting the importance of screening all pulmonary hemosiderosis patients for CD. Cardiomyopathy associated with celiac disease is also another very rare occurrence and only few studies have been reported so far. In conclusion, although a rare occurrence, the association of CD with pulmonary hemosiderosis and cardiomyopathy has huge therapeutic implications emphasizing the need to have high index of suspicion and routine screening for CD among patients with pulmonary hemosiderosis and dilated cardiomyopathy. Funding Agencies The hospital for sick children/sick kids hospital

The first presentation of a case of nail-patella syndrome newly diagnosed at the onset of rheumatoid arthritis: a case report

/SummaryBackgroundNail-patella syndrome (NPS) is a rare autosomal dominant disorder that is characterized by dysplasia of the nails, hypoplasia and/or dislocation of the patella and the presence of iliac horns. Using the CARE guidelines, we present the first reported case of NPS that was newly diagnosed at the onset of rheumatoid arthritis (RA).Case presentationA 74-year-old man was admitted to our hospital due to an 8-month history of arthralgia in bilateral wrists, elbows and fingers. He had a past history of glaucoma and left patella dislocation that had been operatively recentered at the age of 15 years. Laboratory data showed elevated levels of serum C-reactive protein and rheumatoid factor and an elevated titer of anti-SS-A antibodies, while estimated glomerular filtration rate (eGFR), titers of other antibodies and the results of a urinary test were normal. An X-ray showed deformity of bilateral radial heads and the right elbow, and magnetic resonance imaging (MRI) of his hands showed synovitis and erosion in the multiple swollen joints of the wrists and fingers. In addition to these typical features of RA, he had bilateral thumb nail dysplasia with mild hypoplasia of bilateral patellae and iliac horns as shown by the X-ray. He was diagnosed as having autosomal dominant disorder NPS co-existing with RA and he was treated with methotrexate in combination with an oral Janus kinase (JAK) inhibitor, leading to induction of remission.ConclusionsWe have presented a rare case of NPS that was newly diagnosed at the onset of RA. Clinical and radiographic findings of NPS are highlighted in this case report for diagnosing NPS on the basis of typical manifestations.

Evaluate the value of prolonging the duration of tiopronin for injection administration in preventing hepatotoxicity

As part of supportive therapy, prophylaxis with tiopronin for injection (TI) against common hepatotoxicity complications has often been used. However, methods to prevent hepatotoxicity have not been established. Therefore, our study was aimed to find out the relationship between the periods of TI prophylaxis and post-treatment hepatotoxicity, and evaluated the value of prolonging the duration of TI administration in preventing hepatotoxicity. Hepatotoxicity was detected through liver transaminases, bilirubin, alkaline phosphatase, and clinical features of liver insufficiency. Multivariable logistic regressions were conducted to examine the association of the periods of TI prophylaxis and post-treatment hepatotoxicity. Between January 2022 and March 2023, a total of 452 patients with gynecological cancer were enrolled in the study, of which 93 (20.58%) participants were post-treatment hepatotoxicity positive. TI with different prevention days were no significant difference among participants with or without post-treatment hepatotoxicity in crude model (P > 0.05). The P-value, the odds ratios (OR) and 95% confidence intervals (CI) of participants with TI prophylaxis for 1 day for post-treatment hepatotoxicity were 0.040, 3.534 (1.061–11.765) in fully adjusted model. Past history of hepatotoxicity is a confounding variable, and there was no significant difference for post-treatment hepatotoxicity when stratified by past history of hepatotoxicity (P > 0.05). The study indicate that the periods of TI prophylaxis is not associated with post-treatment hepatotoxicity, suggesting that prolonged the periods of TI prophylaxis might be an invalid method for the prevention of post-treatment hepatotoxicity.

Forms of Historical Oblivion and Figures of Silence in Commemorative Practices of the Black Lives Matter Movement: A Comparative Analysis of Media Discourses in English-Speaking Countries

The Black Lives Matter (BLM) social movement has emerged as a prominent challenge to the principles and values of contemporary societies. Concurrently, the practices of cancel culture extend to the historical past as well. The primary objective of this article is to conduct a comparative analysis of forms of historical forgetting and figures of silence within the commemorative practices of BLM, as depicted in media discourses across the English-speaking countries. Making use of the critical discourse analysis methodology of N. Fairclough and S. Jäger, this study analyzes the discursive aspects of monument cancellations and key figures of silence in the media portrayal of BLM commemorative practices in the USA, Canada, the UK, and Australia.&#x0D; The research reveals that, despite the unique characteristics of media discourses in Australia and Canada, particularly concerning the memory of indigenous peoples, the canceling practices in the countries examined exhibit similar features. These include general forms of oblivion associated with the formation of a new identity, as outlined by P. Connerton, and the use of forgetting as a weapon, as described by A. Assmann, in the quest for symbolic capital. This study identifies and examines key figures of silence within BLM as a community of memory, including a-historical perspective of colonial era events, disproportionate focus on selected cancellation facts, invocation of collective guilt, silence over morally questionable traits of the oppressed, absence of a constructive program linking past and future, and unchecked emotional expression regarding the past.

Myelin oligodendrocyte glycoprotein (MOG) associated optic neuritis in a patient with idiopathic intracranial hypertension (IIH) and compressive optic neuropathy case report

BackgroundMyelin oligodendrocyte glycoprotein-associated disease (MOGAD) has a wide phenotypic expression and should be considered in a differential diagnosis of patients with optic disc edema and increased intracranial pressure because MOGAD can mimic IIH and compressive optic neuropathy.Case presentationA 53-year-old woman with a history of presumed idiopathic intracranial hypertension (“IIH”) presented with new headache and visual loss. She had a BMI of 35.44 kg/m2 and a past medical history significant for depression, hepatitis C, hyperlipidemia, and uterine cancer post-hysterectomy. She had undergone multiple lumboperitoneal shunts for presumed IIH and had a prior pituitary adenoma resection. Her visual acuity was no light perception OD and counting fingers OS. After neuro-ophthalmic consultation, a repeat cranial MRI showed symmetric thin peripheral optic nerve sheath enhancement of the intra-orbital optic nerves OU. Serum MOG antibody was positive at 1:100 and she was treated with intravenous steroids followed by plasma exchange and rituximab.ConclusionsThis case highlights the importance of considering MOGAD in the differential diagnosis of optic neuropathy. Although likely multifactorial, we believe that the lack of improvement in our case from presumed IIH and despite adequate neurosurgical decompression of a pituitary adenoma with compression of the optic apparatus reflected underlying unrecognized MOGAD. Clinicians should consider repeat imaging of the orbit (in addition to the head) in cases of atypical IIH or compressive optic neuropathy especially when the clinical course or response to therapy is poor or progressive.