Initial Prognosis Research Articles

PS1012 PREDICTING A PML‐RARA FUSION GENE IN PATIENTS WITH ACUTE MYELOID LEUKEMIA BY CONVOLUTIONAL NEURAL NETWORKS

Background:Acute myeloid leukemia (AML) is a prevalent hematological malignancy worldwide. The estimated incidence of AML was 2.4 per 100,000 standard population in Taiwan in 2016. Bone marrow studies are essential for the initial workup in most cases. However, these examinations require a thorough evaluation of the histopathology slides by hematopathologists. Acute promyelocytic leukemia (APL) is a subtype of AML. APL has completely different initial treatment and prognosis from the other subtypes of AML. Convolutional neural network (CNN) is the state‐of‐the‐art technology of image recognition and has been shown to successfully predict common gene mutations by using cancer pathology images (Nicolas et al. 2018 Nature Medicine).Aims:We planned to use the whole‐slide scanning images of bone marrow aspiration smears to examine the utility of CNN in predicting APL in AML patients.Methods:We collected the whole‐slide scanning images of patients with newly diagnosed AML at Taipei Veterans General Hospital between November 2009 and September 2017. The final cohort consisted of 261 AML cases. The patients’ age, sex, bone marrow blast percentage, cytogenetics and molecular studies, such as FLT3‐ITD and NPM1 and outcomes, were collected. The cohort was split into a training set (80%) and a testing set (20%). In addition, two AML cohorts from Far Eastern Memorial Hospital (n = 19) and Kaohsiung Veterans General Hospital (n = 29) were served as external validation cohorts. Inception V3 was used as the baseline model. Stochastic gradient descent was employed to refine the weights in the CNNs using the training set. The finalized model was tested on the held‐out test set. Prediction accuracy and the area under the receiver operating characteristic curves (AUCs) were analyzed to evaluate the performance of the algorithms. All CNN models were trained using Keras version 2.1.5 with Tensorflow 1.7.0, and statistical analysis was performed with R version 3.5.1.Results:The median age of the AML patients at diagnosis was 65 (range 17–96) years and 58.9% of them were male. CNN classified APL from the other subtypes of AML with high accuracy (AUC 0.92). In addition, CNN also could predict other chromosomal abnormalities, such as complex karyotypes, and molecular abnormalities, such as NPM1 mutation. Furthermore, CNN successfully predicted patients’ overall survival by using its classification.Summary/Conclusion:CNN successfully predicted genetic alterations of AML patients by using the histopathology images of the bone marrow aspiration smears. These results demonstrated the utility of convolutional neural networks in predicting common genetic mutations. Our developed methods are generalizable to other hematological malignancies or other cancers.image

Clinical and automated gait analysis in patients with vestibular, cerebellar, and functional gait disorders: perspectives and limitations.

This article outlines recent developments in the clinical and automated assessment of neurological gait disorders. With a primary focus on vestibular, cerebellar, and functional gait disorders, we discuss how instrumented gait examination may assist clinical decision making in these disorders with respect to the initial differential diagnosis and prognosis as well as the objective monitoring of disease progression and therapeutic interventions. We delineate strategies for data handling and analysis of quantitative gait examinations that can facilitate the clinical characterization and interpretation of walking impairments. These strategies include data normalization and dimensionality reduction procedures. We further emphasize the value of a comprehensive, standardized gait assessment protocol. Accordingly, the examination of walking conditions that challenge patients with respect to their biomechanical, sensory, or cognitive resources are particularly helpful to disclose and characterize the causes underlying their gait impairment. Finally, we provide a perspective on the emerging implementation of pattern recognition approaches within the framework of clinical management of gait disorders and discuss their potential to assist clinical decision making with respect to the differential diagnosis and the prognosis of fall risk in individual patients.

SUN-337 Anti-tumorigenic Effects Of The Maternal Leucine Zipper Kinase (MELK) Inhibitor, OTSSP167, In Pre-clinical In Vivo Models Of Adrenocortical Carcinomas (ACC)

ACC is an aggressive endocrine cancer with limited therapeutic options and poor survival rates. In patients with progressive disease, standard EDP (etoposide, doxorubicin and cisplatin) chemotherapy is associated with only a modest response and progression free survival of 5 months. Mitotane, the only adjuvant FDA approved therapy for ACC is associated with 30% stable disease or partial response, as well as an association with toxicity and intolerability. The lack of pre-clinical models has also contributed to slow progress in the field. Previously, we developed CU-ACC1 and CU-ACC2 patient derived xenografts (PDX) and their corresponding ACC cell lines to study potential targets in ACC tumorigenesis. In this study we characterized a third ACC PDX, CU-ACC9. CU-ACC9 PDX was derived from a mild cortisol producing 15 cm primary ACC tumor involving adrenal, kidney, distal pancreas with an inferior vena cava (IVC) thrombus in a 55 year-old female patient. On analysis, the CU-ACC9 tumor had a T53 p.R248W mutation, intermediate microsatellite instability, and loss of MSH2 and MSH6 staining by immunohistochemistry, all suggestive of Lynch syndrome. Despite the initial poor prognosis associated with IVC thrombus, the patient underwent radical resection and subsequent therapy with anti-PD1 checkpoint inhibitor and mitotane, and survived for 2 years. STR profiling confirmed a 96% match between the CU-ACC9 PDX and the original tumor tissue. Immunohistochemistry of the PDX revealed positive expression of the adrenal markers, inhibin alpha and SF-1. Further gene expression studies using RNA seq revealed that CU-ACC9 PDX and CU-ACC1 PDX had high MELK expression, a kinase we previously identified as a potential therapeutic target in ACC. Our prior studies demonstrated a dose dependent induction of apoptosis by the MELK inhibitor, OTSSP167, in H295R, CU-ACC1 and CU-ACC2 cells which correlated with endogenous MELK expression. To test effects of the MELK inhibitor in vivo, we treated the F13 generation of CU-ACC1 and F7 generation of CU-ACC9 PDX with OTSSP167. Accounting for the variable tumor growth rate between the two PDXs, OTSSP167 treatment for 18 days and 28 days in CU-ACC1 and CU-ACC9 PDXs, respectively resulted in a 4 fold (p= 0.02) and 2.2-fold ( p<0.001) inhibition in tumor growth. The tumor inhibitory growth index (TGII) for both explants were <20 % suggesting a response to the single agent therapy with OTSSP167. There was no evidence of systemic toxicity as assessed by changes in body weight. These data establish the therapeutic potential of OTSSP167 in ACC and suggest that targeting MELK could have efficacy in a subset ACC patients. Future studies will focus on enhancing the therapeutic efficacy by combining OTSSP167 with other rational based therapies in our ACC PDX models, towards Phase I studies in patients with ACC. Funding: CLC grants, K08, Doris Duke CU-FRCS, VA Merit Review

Features and prognosis of giant cell arteritis in patients over 85 years of age: A case-control study

BackgroundWe examined the initial features, course, and prognosis of giant cell arteritis (GCA) in patients ≥ 85 years of age (≥85 year) and compared them to those of younger patients. MethodsThe present retrospective study included all patients who were newly diagnosed with GCA in the Internal Departments of two French University Hospitals from 1976 or 1998 to 2017 and who were followed up for at least 6 months. Logistic regression analyses were conducted to identify baseline and prognostic characteristics associated with being ≥85 year. ResultsOf the 865 patients assessed in this study, 87 were ≥85 year. Compared to younger patients, patients ≥ 85 year had more comorbid conditions (odds ratio [OR] = 1.11–1.74, p < 0.01), less often exhibited polymyalgia rheumatica (PMR; OR = 0.33–0.96, p = 0.04), and more often developed permanent visual loss (OR = 1.29–3.81, p < 0.01). The older patients also showed less dependence on glucocorticoid (GC) medications (OR = 0.23–0.94, p = 0.04), had fewer relapses (OR = 0.31–0.87, p = 0.015), less often recovered from GCA (OR = 0.22–0.69, p < 0.01), and more often died during treatment (OR = 1.45–4.65, p = 0.001) compared to younger patients. Being ≥85 year was the only factor associated with an increased 1-year mortality (hazard ratio = 1.77–5.81, p = 0.0001) for the whole cohort. ConclusionsGCA in very elderly patients was characterized by a higher rate of severe ischemic complications and an increased risk for early death compared to younger patients. Thus, there is a need for the early diagnosis of GCA and close clinical monitoring in this unique population.

Royal Medical Entourages: Analysis of the Roles of Doctors during the Episodes of Madness of King George III

King George III (1738–1820) had episodes of major mental illness in 1788–9 and 1810–20. Detailed records clearly indicate conflict within and between the medical entourages, based on their experience and clinical knowledge as well as their differing political allegiances. The apparent ignorance of the physicians concerning important contemporary knowledge of mental illness, particularly that published by Dr William Black (1750–1829), was highlighted during their questioning by the Parliamentary Committees. In 1788, initial treatment by the royal physicians was unsuccessful and potentially fatal. The King’s recovery in early 1789 was largely attributed instead to the ‘mad doctors’ (psychiatrists) Dr Francis Willis and his sons, who minimised toxic medications and employed essentially broad spectrum psychotherapy. Had their treatment failed the Prince of Wales would most probably have replaced William Pitt’s Tory government with a Whig administration. In 1810, there was a further relapse which did result in the imposition of a regency. Although the initial prognosis was favourable, by 1812 it was clear that the King was unlikely to achieve an adequate remission. Advice given to the Prince of Wales as Regent by the then leading royal physician Sir Henry Halford (1766–1844), again prevented a change of government. These scenarios demonstrate that royal physicians varied in their knowledge of up-to-date medical practice, and that their words and actions impacted the political course of government.

Protocolo de tratamiento del ictus hemorrágico en fase aguda

Because the morbility and mortality rates of intracerebral hemorrhage (ICH) are high and show an uncertain initial prognosis, its clinical management in the acute phase has to be aggressive. The treatment is mainly focused to prevent hematoma expansion and intracranial hypertension (IIH). In order to prevent severe complications, all emergency treatments should be carried out at neurologic/neurosurgical intensive care unit. The adequate management of blood pressure, the rapid reversal of anticoagulation and prevention and treatment of ICH are essential. Large cerebellar or life-threatening cerebellar hematomas should be evacuated urgently. Nevertheless, because surgical indication does not improve functional outcome, its use controversial and has to be tailored in supratentorial ICH. Minimally invasive surgery shows promising results and it might indicate the path to follow in the future.

Rapidly progressive neurologic decline and morbilliform rash presenting in a patient with lymphoma.

A 67-year-old male with past medical history of mantle cell lymphoma and atrial fibrillation presented with a truncal rash, bilateral lower extremity weakness, and confusion. Within three days of presentation, his condition rapidly deteriorated with the onset of diffuse flaccid paralysis, aphasia, and severe alteration in mental status. Initial results from serum studies, lumbar puncture, magnetic resonance imaging, and electroencephalogram were not diagnostic. However, on the ninth day after initial presentation, the West Nile Virus (WNV) immunoglobulin M antibody returned positive from the cerebrospinal fluid. West Nile Virus encephalitis is endemic worldwide, and is the most common viral encephalitis in the United States. WNV presents in a variety of ways, and the recognition by physicians is crucial due to the estimated 2-12% mortality rate and significant longterm morbidity of neuroinvasive disease. The initial management and long term prognosis are points of ongoing research. This case represents a particularly profound example of neuroinvasive WNV. Our patient made a significant recovery after his initial presentation with aggressive supportive care, however still suffers from bilateral lower extremity weakness more than a year later.

Palliative Care in Adolescents and Young Adults With Cancer-Why Do Adolescents Need Special Attention?

Meeting shortfalls in the provision of care to adolescents and young adults with cancer has focused largely on improving outcomes and psychosocial support. A significant percentage of adolescents and young adults with cancer will die of disease because of initial poor prognosis conditions or disease relapse. In adults, progress has been made in the concept of an integrated cancer/palliative care service. In pediatric oncology, the application of this philosophy of care has lagged behind somewhat. In the case of adolescents, particularly those with advanced cancer, the palliative care needs, in a broader sense than only end-of-life care, are often not adequately met, irrespective of whether treatment is delivered in a pediatric or adult cancer service. There are a number of age-specific aspects to palliative and supportive care for adolescents. Complex interactions between clinicians, parents, and patients potentially limit the young person's ability to influence care planning. The wide variation in real or perceived competency at this age, the developmental challenges in relation to behavior, communication, and coping strategy all require particular professional expertise that is not always available.

Injectable Chemotherapy Downstaged Oral Squamous Cell Carcinoma from Nonresectable to Resectable in a Rescue Dog: Diagnosis, Treatment, and Outcome

This case report documents the diagnosis, treatment, and outcome of a nonresectable oral squamous cell carcinoma in a dog with initial poor prognosis. An approximately 4-year-old female Staffordshire Bull Terrier presented with a large mass on the front of lower jaw which was diagnosed as oral papillary squamous cell carcinoma by histopathology. CT scans revealed invasion of the cancer to the frenulum of the tongue. The mass was inoperable due to location, expansiveness, and metastatic lymph nodes. The dog received 4 treatments of intralesional hyaluronan-platinum conjugates (HylaPlat™, HylaPharm LLC, Lawrence, Kansas) at 3-week intervals. Clinical chemistry and complete blood count were performed one week after each treatment and results were within normal limits. Complications included bleeding due to tumor tissue sloughing, as well as a single seizure due to unknown causes. Upon completion of chemotherapy, CT showed that the mass had regressed and was no longer invading the lingual frenulum, and multiple lymph nodes were free of metastasis. The mass thus became resectable and the dog successfully underwent rostral bilateral mandibulectomy. Over one year after chemotherapy and surgery, the cancer remains in complete remission.

Prenatal renal parenchymal area as a predictor of early end-stage renal disease in children with vesicoamniotic shunting for lower urinary tract obstruction

Vesicoamniotic shunting (VAS) and other bladder drainage techniques for fetal lower urinary tract obstruction (LUTO) have been proven to ameliorate pulmonary hypoplasia and increase survival in patients with an initial poor prognosis. Currently there are limited prognostic tools available during gestation to evaluate and predict postnatal renal function. The aim was to describe the prenatal growth of the renal parenchymal area (RPA) in patients with LUTO and determine its application as a predictor of renal function at one year of life. The study population comprised a retrospective cohort of all infants who survived the fetal VAS to birth. Renal growth and size were measured using imageJ software to calculate the RPA in sequential prenatal ultrasounds. The parenchymal area was measured from the image of each kidney with the greatest longitudinal length. These measurements were further correlated and analyzed as a predictor of end-stage renal disease (ESRD) within the first year of life. Etiologies of LUTO in the 15 male fetuses included eight posterior urethral valves, four Eagle-Barrett/prune belly syndrome, two urethral atresia, and one megacystis microcolon intestinal hypoperistalsis syndrome. All patients had patent shunts, in place, at birth. Furthermore, ultrasonographic parameters such as oligohydramnios, keyhole sign, and bladder wall thickness showed no statistical difference between groups. Renal parenchymal growth correlated with postnatal renal function in both the ESRD (r=0.409, p=0.018) and the non-ESRD (r=0.657, p<0.001) groups. Most notably, RPA during the 3rd trimester predicted ESRD with the best cut-off point determined to be 8cm2 (sensitivity, 0.714; specificity, 0.882; and positive likelihood ratio, 6.071) (Table). Despite definitive VAS for LUTO, postnatal morbidity and mortality remain high, emphasizing the role of renal dysplasia in postnatal renal failure, in spite of urinary diversion. Renal growth statistically differs between groups in the 3rd trimester of gestation; RPA development appears stagnant in patients that developed ESRD within the first year of life. In contrast, patients that did not develop ESRD continued to have renal parenchymal growth in a linear fashion. This suggests that prenatal RPA may be predictive of postnatal ESRD. RPA measurement during the prenatal period could play an important role as a non-invasive tool to predict postnatal renal function and to anticipate postnatal clinical interventions.

Management of cardiogenic shock complicating myocardial infarction.

Up to 10% of acute coronary syndromes are complicated by cardiogenic shock (CS) with contemporary mortality rates of 40-50%. The extent of ischemic myocardium has a profound impact on the initial, in-hospital, and post-discharge management and prognosis in this patient population. Individualized patient risk assessment plays an important role in determining appropriate revascularization, drug treatment with inotropes and vasopressors, mechanical circulatory support, intensive care support of other organ systems, hospital level of care triage, and allocation of clinical resources. This review will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of CS complicating acute coronary syndromes with a focus on (a) potential therapeutic issues from the perspective an interventional cardiologist, an emergency physician, and an intensive care physician, (b) the type of revascularization, and (c) new therapeutic advancements in pharmacologic and mechanical percutaneous circulatory support.

Abstract P5-17-01: Lobular breast cancer alliance - Advocates advancing research, screening, treatment and follow-up care for lobular breast disease

Abstract Introduction Thirty patient advocates attended the First International Invasive Lobular Breast Cancer Symposium in 2016 at the University of Pittsburgh Cancer Center. The conference underscored that invasive lobular breast cancer (ILC) and other lobular pathologies are understudied. Specifically: ILC is the sixth most prevalent cancer of women and the second most frequently diagnosed histological subtype of breast cancer impacting up to 34,000 patients a year in the US. ILC is a molecularly distinct breast cancer with unique subtypes and variants with differences in presentation and behavior, including physical findings of thickening and a tendency to metastasize to unique locations. While ILC is frequently associated with a good initial prognosis, recent analysis suggests that long-term outcomes of ILC may be worse than those stage-matched to ductal breast cancer. Current imaging tools are less reliable for early detection of lobular disease and detection of distant recurrence. Standard of care chemotherapy and endocrine therapies may have different effectiveness applied to ILC and IDC. Challenges Growing interest in ILC research requires improved methods to identify, communicate with and link patients with ILC to clinical trials and research. Advocates with advanced science training are needed as partners for research proposals and grant reviews. Lobular breast cancer is under-represented in key meetings and literature. Encouraging opportunities to share ILC research as agenda topics and fostering collaborations between researchers, clinicians and advocates can accelerate progress and refine clinical practices for screening, treatment and follow-up. Patients living with ILC lack a central on-line source of lobular breast cancer information and resources. This information gap is a barrier to help patients recognize signs of lobular breast cancer's unique presentation and metastatic behaviors. Results The Lobular Breast Cancer Alliance (LBCA) was formed by patient advocates who attended the First International ILC Symposium in response to advocate-identified opportunities to advance research, refine treatments and enhance patient education. LBCA's mission is to bridge patients, clinicians and researchers to increase our knowledge of lobular breast disease and promote research that leads to advancements in prevention, diagnosis, treatment and patient follow-up care. Conclusions LBCA is driving an increased awareness of lobular breast cancer with specific goals: Build a clinically accurate, patient centered website devoted to lobular breast cancer at www.LobularBreastCancer.org. Elevate lobular research and foster opportunities for researcher, advocate and clinician collaborations at prominent conferences and meetings. Identify barriers to conduct research on ILC and metastasis and link patients and advocates to ILC tumor research and clinical trials. Initiate peer-to-peer clinician outreach strategy through targeted literature, meetings and education services to share information on ILC presentation, metastatic patterns and screening and treatment challenges of patients with ILC. Build partnerships with existing breast cancer organizations to integrate ILC into existing information resources and work on common goals. Citation Format: Petitti L, Axelrod J, Campbell-Kotler M, Frank E, Jaremek J, Levine J, McWilliams M, Migyanka F, Ryan N, Viggiano E, Metzger-Filho O, Oesterreich S, Pate L. Lobular breast cancer alliance - Advocates advancing research, screening, treatment and follow-up care for lobular breast disease [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-17-01.

Diagnosis and management of a fatal case of sepsis caused by Candida parapsilosis sensu stricto in a neonate with omphalocele

We present a fatal case of persistent neonatal candidemia by Candida parapsilosis following omphalocele, without other anomalies. Despite an encouraging initial prognosis, after surgical correction and closure of the abdominal wall the case became difficult to treat, as in addition to the exposure of the patient to multiple risk factors for candidemia, antifungal therapy apparently was not adequate.

The ethics of caring for hospital-dependent patients

BackgroundHospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients.Main bodyAmong physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources.ConclusionOur current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system.

Clinical overview of the current state and future applications of positron emission tomography in bone and soft tissue sarcoma

Positron emission tomography (PET) provides a noninvasive, functional assessment providing incremental diagnostic value over magnetic resonance imaging (MRI) and computed tomography (CT) for the initial staging, restaging, response assessment, and prognosis of bone and soft tissue sarcomas. The purpose of this article is to review the current state and future applications of PET in sarcoma imaging, including the clinical roles of 18F-fluorodeoxyglucose (FDG) and other PET radiotracers as well as the use of PET with concurrent MRI. A PubMed search using the query “(‘positron emission tomography’ OR PET) AND (‘CT’ OR ‘computed tomograph*’ OR ‘MR*’ OR ‘magnetic resonance’) AND (FDG OR hypox* OR prolif*) AND sarcoma*” for PET examinations involving bone and soft tissue sarcoma studies up to February 1, 2017 were performed. Additionally, analogous Google Scholar, Scopus, and Web of Science search queries were also performed. Subsequently, references for the retrieved articles were reviewed, and the relevant publications on the subject were also included. A total of 30 studies were included in the review. FDG-PET with concurrent computed tomography (CT) can provide incremental diagnostic value relative to MRI to provide additional insight into the grading, staging, restaging, and response assessment in sarcomas, particularly when neoadjuvant therapy is an option. FDG-PET/CT can be used for noninvasive prediction of tumor grade and assess regional heterogeneity, providing guidance for tissue sampling and reducing the risk of undergrading and understaging. In addition, early clinical studies of sarcoma PET imaging using hypoxia and cellular proliferation agents suggest incremental diagnostic benefit over FDG-PET. The use of PET/MRI is under active investigation and may yield additional clinically impactful findings over PET/CT. PET imaging used with concurrent CT or MRI provides a unique noninvasive way to assess regional biological and biochemical features for bone and soft tissue sarcomas.

Magnetic resonance imaging study of cryptococcal neuroradiological lesions in HIV-negative cryptococcal meningitis

Magnetic resonance (MR) scanning has become an important diagnostic and management tool in cryptococcal meningitis (CM). However, there are only isolated case reports documenting neuroradiological findings in human immunodeficiency virus (HIV)-negative patients with CM and none has clearly addressed the relationship between cerebral lesions on magnetic resonance imaging (MRI) and prognosis. The MR brain images available from 114 HIV-negative patients with CM were retrospectively analysed. Patients were divided into Group I with one or more CM-related lesions and Group II without CM-related lesions. Initial clinical and biochemical markers and prognosis were collected and compared between the two groups. In the present study, the most common pattern of CM-related lesions by MRI was radiological meningitis, following by Virchow-Robin (VR) dilatation, hydrocephalus, intracerebral nodules and pseudocysts, which was different from previous studies reporting that the main MR findings of cerebral cryptococcosis in HIV-infected patients include dilated VR spaces, masses and pseudocysts. Compared to the patients without CM-related lesions, patients with CM-related lesions presented with a higher percentage of male patients, a higher frequency of altered mental status, a higher positive rate of Cryptococcus culture in cerebrospinal fluid (CSF) and a lower ratio of CSF glucose/blood glucose. Poor outcomes were more frequent in patients with presence of CM-related lesions compared to patients without CM-related lesions. In conclusion, the main pattern of cryptococcosis-related lesions on MR scanning differ between non-HIV- and HIV-positive patients with CM. The presence of CM-related lesions was significantly associated with predictors for poor outcome. Neuroimaging on MR scanning is a useful tool to evaluate the initial severity and prognosis of CM without HIV infection.

Novel approach for independent control of brain hypothermia and systemic normothermia: cerebral selective deep hypothermia for refractory cardiac arrest

A 38-year-old man was found unconscious, alone in the driver's seat of his car. The emergency medical team identified his condition as pulseless ventricular tachycardia. Defibrillation was attempted but failed....

Flail chest in a polytraumatized patient: Management and treatment - case report

Introduction. Management of a polytraumatized patient is a problem that requires a multidisciplinary approach, in order to optimise patient?s outcome. The purpose of this study was to show the approach in the treatment of a patient with a severe life-threatening polytrauma, including a personalized healthcare approach with the positive outcome after the inadequate initial treatment. Case report. We presented a case of a young polytraumatized patient with trauma as a result of road traffic accident. The patient had chest, abdominal and right arm injuries. He was diagnosed of hepatic rupture with conquasation and retroperitoneal hematoma and the patient underwent liver tamponade. Chest trauma due to bilateral serial rib fracture with flail chest was treated by chest drainage. After the adequate multidisciplinary interventions for the patient, the patient was discharged. Conclusion. This case report is of great importance since it shows that severe polytraumatized patients with bad initial prognosis can successfully receive a lifesaving treatment.

Teledermatology and Mobile Applications in the Management of Patients with Skin Lesions.

Teledermatology and smartphone mobile applications have been at the forefront of advances in the screening and management of patients with skin lesions over the past decade. The Spanish teledermatology network, established in 2004 in the area surrounding the dermatology clinic in Seville, has now managed over 50,000 teleconsultations and has led to validated improvements in waiting times for referral and surgery, allowed patients to be treated in local settings, and improved the early diagnosis and initial prognosis of patients diagnosed with melanoma. Both teledermatology and smartphone mobile applications can be used as training tools to improve the diagnostic skills of physicians and dermatologists. They can also serve as rapid and reliable methods to prioritize patient care and ensure that specialized services and treatments are accessible regardless of patient circumstances.

Neuroimaging and Psychotherapy: Tales From the Messy Middle

Neuroimaging and Psychotherapy: Tales From the Messy Middle