Normal Exam Research Articles

S3738 Agent Orange as a Possible Cause of Helicobacter pylori Negative Gastric Mucosa-Associated Lymphoid Tissue Lymphoma

Introduction: Gastric mucosa-associated lymphoid tissue (MALT) lymphoma was first described in 1983 as the most common extranodal site of non-Hodgkin lymphoma. Helicobacter pylori (H. pylori) infection is implicated in 90% of all gastric MALT lymphoma cases. Agent Orange (AO), with traces of oncogenic 2,3,7,8-tetrachlorodibenzo-p-dioxin, has also been classified as a causative agent in non-Hodgkin lymphoma, which includes gastric MALT lymphoma. Here we report a case of H. pylori negative gastric MALT lymphoma in a patient with history of significant AO exposure. Case Description/Methods: A 75-year-old Caucasian male veteran who served in the Vietnam War with significant AO exposure, as well as history of chronic gastroesophageal reflux disease, was referred for endoscopy to evaluate a reported history of un-staged Barrett’s esophagus 5-years prior but with two subsequent normal endoscopies at an outside facility. He noted symptoms of burning chest pain and dyspepsia following large meals, all of which were worsened with spicy foods and improved with omeprazole. Family history was negative for a history of gastric cancer, and he had a 25-pack year smoking history but quit 20 years prior to presentation.Initial esophagogastroduodenoscopy (EGD) revealed abnormal folds in the gastric fundus and erythema in the gastric antrum, but otherwise normal exam including normal duodenum and esophagus. Random gastric biopsies and biopsies of the abnormal folds were consistent with gastric MALT lymphoma, negative for H. pylori and t(11;18)(q21;q21). Repeat EGD 1 month later for further sampling demonstrated identical findings (Figure 1A). Stool testing for H. pylori antigen was also negative. The patient was referred to oncology and after staging imaging was found to have stage IE gastric MALT lymphoma. He was treated with involved site radiation therapy and EGD 3 months later showed both endoscopic and pathologic resolution (Figure 1B). Discussion: The 10% of cases of H. pylori negative gastric MALT lymphoma have an unclear etiology, although dysregulation of nuclear factor-kappa B (NF-κB) principally via translocations t(11;18)(q21;q21) is thought to be a potentially causative genetic alteration. In this patient, neither H. pylori nor the common t(11,18) genetic alteration were present. Given AO is implicated in non-Hodgkin lymphoma and the most common site of extranodal non-Hodgkin lymphoma is the gastric mucosa, AO exposure should be considered a risk factor for development of gastric MALT lymphoma.Figure 1.: (A) EGD demonstrating abnormal gastric mucosa with prominent gastric fundus folds seen on retroflexion during EGD prior to ISRT (radiation) therapy. (B) Post-radiation EGD demonstrating resolution of the abnormalities seen with the pre-treatment EGD including disappearance of the prominent gastric fundus folds.

Development and Validation of a New Design Selfassessment logMAR Visual Acuity Test (“Chudjane” iPhone- and iPad-based Application) in a Normal Eyes Population

Objective: To validate and further design the “Chudjane” application (app), a new design self- assessment logMAR test for distance visual acuity (VA), by comparing the results against the use of a standard numeric ETDRS chart in normal eye population.Materials and Methods: In total, 52 volunteers who had a normal eye exam and best-corrected VA score by numeric ETDRS (NE) chart equal to or better than 6/6 (logMAR score 0.00 or less) were included. The “Chudjane” app with 3 patterns of optotypes (Arabic numbers (AN), Tumbling-E (TE) and Landolt-C (LC)) was used twice to assess VA individually.Results: The mean VA in each test NE, AN, TE, LC from the first round were -0.06, -0.10, -0.08 and -0.04, respectively compared to -0.07, -0.12, -0.09 and -0.05 from the second round respectively. Comparing results from the first and second round revealed that NE and LC had higher test-retest reliability (ICC=0.712, 0.789 respectively) than AN and TE (ICC=0.140, 0.495 respectively). For validity, result from NE was compared to each app test using the second round values. Modified Bland-Altman plot showed the mean differences (95% LOA) for NE-AN, NE-TE and NE-LC of 0.05 (-0.11 to 0.20), 0.02 (-0.11 to 0.15) and -0.03 (-0.19 to 0.13) respectively. Simple linear regression analysis of the difference (i.e. NE-AN, NE-TE and NE-LC) on NE showed that the difference did not depend on the NE value with slope close to zero.Conclusion: The study demonstrated that by using the «Chudjane» application, LC had higher test-retest reliability and higher validity than TE and AN compared to the standard ETDRS chart.

Traumatic Miosis In A Soccer Player

HISTORY: A 24 year old previously healthy male soccer player was struck in the face by a kicked ball during a game. He did not lose consciousness and presented to the athletic trainer and covering physicians on the sidelines for evaluation of a possible head injury. He had full recall of the event and mild blurring of his vision that he attributed to lacrimation. He denied ocular pain, floaters, headaches, and dizziness. There was no prior history of eye injuries and he did not wear glasses or contacts. PHYSICAL EXAMINATION: Sideline exam revealed marked asymmetric miosis of the left pupil without a direct or consensual response to light (pictures obtained). There was an abrasion over the inferior orbital rim but no tenderness to palpation. He had mild conjunctival erythema, ocular movements were normal and without pain, and his visual fields were full with normal acuity. There was no infiltration into the anterior chamber of eye or covering of the pupil. The remainder of his cranial nerves were normal, as was an upper and lower limb gross motor screen. Balance and coordination were also normal. DIFFERENTIAL DIAGNOSIS: -Subconjunctival hemorrhage-Corneal abrasion-Traumatic iritis-Orbital fracture-Hyphema-Concussion TEST AND RESULTS: Normal eye exam 48 hours later by an optometrist FINAL WORKING DIAGNOSIS: Traumatic iris spasm without iritis TREATMENT AND OUTCOMES: The patient was withheld from the remainder of the game. Within 45 minutes his pupil size had normalized and had become responsive to direct and consensual light. He continued to be free of concussion related symptoms and was seen by an optometrist for a complete eye exam 48 hours later. This exam was normal and there was no evidence of iritis. He returned to sports the following day and had no further complications or symptoms.

LUXATION DE LARTICULATION TEMPOROMANDIBULAIRE LORS DUNE ANESTHESIE GENERALE : A PROPOS DUN CAS

The incidence of temporomandibular joint (TMJ) dislocation in anaesthesia is poorly reported. Patients with a history of TMJ dislocation, algodysfunctional syndrome of the mandatory apparatus or retro mandibular facial dysmorphosis are predisposed to this complication. We report a case of TMJ dislocation, diagnosed just after a general anaesthesia for a vicious callus of a humeral palette fracture in a patient without risk factors for this dislocation. The patient had a normal pre-anaesthetic clinical exam. The clinical diagnosis is simple. Its reduction is an emergency which can be performed with or without sedation by any practitioner familiar with the Nelaton manoeuvre.

Incidental Finding: Urine Alzheimer-Associated Neuronal Thread Protein (AD7c-NTP) and Serum Vitamin D25.

National and international experts have been attempting to find diagnostic tools for the early identification of symptoms to facilitate early identification and intervention of the disease. Detection of urine Alzheimer-associated neuronal thread protein (AD7c-NTP) and serum 25-hydroxyvitamin D (25(OH)D) in the diagnosis of Alzheimer's disease (AD). Subjects aged >50 years who underwent a physical examination at the Taihu Sanatorium of Jiangsu Province, had no clinical evidence of AD-related issues, and had normal Mini-Mental State Exam and Montreal Cognitive Assessment scores were enrolled in the present study. There were 35 males and 15 females, who were aged 51-91 years. Urine AD7c-NTP levels and serum 25(OH)D concentrations were measured. The Pearson correlation analysis revealed that the urine AD7c-NTP levels in these subjects were negatively correlated with the serum 25(OH)D concentrations (r = -0.460, p < 0.001). Combined with previous studies, it was considered that cognitive function might be the only link for the correlation between AD7c-NTP and 25(OH)D. This finding might provide a starting point to investigate the potential value of the interaction between urine AD7c-NTP and serum 25(OH)D in chronic diseases. Further large-scale studies are needed to validate the results of the present study.

Transabdominal Ultrasound Measurement of the Diameter of Rectal Ampulla as a Less Invasive Modality for Digital Rectal Examination in Children with Functional Constipation

Background: Constipation is one of the most common complaints in children. Guidelines on functional constipation recommend digital rectal examination (DRE) when constipation is suspected. However, diagnosis of megarectum by ultrasonography would differentiate children with constipation from those with dysfunctional defecation. Objectives: In this research, we evaluated the utilization of ultrasonography to measure the diameter of rectal ampulla for the diagnosis of functional constipation. Methods: In this study, 94 patients < 14 years old diagnosed with functional constipation were included. Patients were examined by both DRE and ultrasonography before and after a conventional stool softener treatment. Results: The diameter of the rectal ampulla was significantly wider in patients with large stool mass in DRE than in patients with normal digital rectal exams. There was a significant relationship between fecal incontinence and pre-treatment DRA. By increasing the severity of fecal incontinence, the average DRA in patients increased significantly. Additionally, there was a significant statistical difference between the patient’s DRA before and after treatment. Finally, the relationship between constipation and DRA adjusted model showed that the risk of abnormal DRA was 3.1 times larger in patients with three and four symptoms than in patients with two symptoms and this relationship was statistically significant. Conclusions: Ultrasonography can be a suitable replacement for DRE; however, further investigations are required.

NASAL NECROSIS ASSOCIATED WITH POSITIVE P-ANCA: A DIAGNOSTIC AND MANAGEMENT CHALLENGE

A 33-year-old woman developed necrosis in the left nostril. Granulomatosis with polyangiitis, tuberculosis, lymphoma, lethal midline granuloma, and vasculitis were the diagnostic hypotheses. Lymphoma and tuberculosis were ruled out after a normal blood count exam, negative nasal bacilloscopy, and positive p-ANCA. Multiple biopsies were performed in the left nostril at different locations and intervals. Histopathologic analysis ruled out malignancy, and clinically, the hypothesis of unspecified vasculitis with positive p-ANCA was sustained. To treat the disease and relieve pain, cyclophosphamide, haloperidol, morphine, methadone, and carbamazepine were prescribed. Despite therapeutics, there was a progression of nasal necrosis and infection, with intense pain, tooth mobility, and negative pulp thermal test of the upper anterior teeth. Thus, the patient started receiving radiotherapy and was prescribed methotrexate, prednisone, venlafaxine, and gabapentin. Approximately 2 years after the initial manifestation, the patient had persistent pain, increased nasal necrosis, and evolution of visual and auditory changes despite the therapeutic protocol. Nonspecific p-ANCA-positive maxillofacial lesions are infrequently reported in oral medicine literature and represent a multiprofessional diagnosis and therapeutic challenge.

Presentation, management and outcome of surgically managed pediatric thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a rare disorder involving compression of the brachial plexus, subclavian artery, and subclavian vein. There is a paucity of data for this pathology's surgical treatment within pediatrics. The objective of this study is to explore the presentation, management, and outcome of pediatric TOS. A retrospective chart review was conducted for 44 patients at a single institution undergoing surgery for TOS. Data was collected on demographics, pre- and postoperative factors, and outcomes. Forty-four patients underwent 50 surgeries (8 bilaterally). The average age was 15.5years with 72% female. The most common symptoms were numbness (72%) and pain (66%), with a normal exam in 58%. The average symptom duration prior to surgery was 35.2months. A supraclavicular approach was performed in all patients, with anterior scalene section(90%), rib resection (72%), neurolysis (92%), and intraoperative EMG (84%) commonly used. Two patients had a lymphatic leak. All patients reported subjective improvement of preoperative symptoms of numbness (26%), pain (22%), and weakness (6%). Differences between vTOS (n = 9) and nTOS (n = 35) included higher preop swelling (p < 0.012), decreased symptom duration (p < 0.022), higher venogram usage (p < 0.0030), and higher preoperative thrombolytics/angioplasty (p < 0.001) in vTOS compared to nTOS. A comparison of soft tissue and soft tissue with bone decompression did not reveal any outcome differences. Pediatric TOS benefits from a multidisciplinary approach, showing good outcomes in postoperative symptom resolution. In our cohort, a supraclavicular approach provided an effective window for decompression with a low complication rate.

Rates of pathologic nodal disease among cN0 and cN1 patients undergoing routine axillary ultrasound and neoadjuvant chemotherapy.

Routine axillary ultrasound (AxUS) in patients receiving neoadjuvant chemotherapy (NAC) remains controversial. Here, we report rates of AxUS-detected nodal disease among patients with normal clinical exams, and rates of pathologic nodal disease after NAC based on method of nodal disease detection. Clinicopathologic findings were prospectively collected for stage I-III breast cancer patients selected for NAC. All patients had pre-treatment AxUS, suspicious nodes were biopsied. The following four patient cohorts were examined: patients with suspicious exam or AxUS but negative biopsy (Suspicious cN0); those with normal exam and normal AxUS (Not Suspicious cN0); those with normal exam but suspicious AxUS and positive biopsy (AxUS-detected cN1); and those with abnormal exam and positive biopsy (exam-detected cN1). Sentinel (SLN) and non-sentinel lymph nodes (non-SLN) were evaluated by immunohistochemistry; nodal metastases of any size were considered positive. 500 patients were included. Of 310 patients with normal axillary exams, 160 had suspicious AxUS, 65 were biopsy-negative (Suspicious cN0) and 95/310 (30.6%) were biopsy-positive (AxUS-detected cN1). Of 190 with abnormal axillary exams, 166 were biopsy-proven node-positive (exam-detected cN1) and 24 were AxUS or biopsy-negative (Suspicious cN0). Rates of pathologic nodal disease were 20/150 (13.3%) among Not Suspicious cN0 patients, 12/89 (13.5%) among Suspicious cN0 (p = 0.97). Rates of residual nodal disease were 55/95 (57.9%) among AxUS-detected cN1 patients, 102/166 (61.4%) among exam-detected cN1 (p = 0.57). AxUS detected nodal disease in 30.6% of patients with normal clinical exams selected for NAC. Rates of pathologic nodal disease were similar among AxUS-detected and exam-detected cN1 patients.

Non-surgical Treatment of Metastatic Liver Tumors with Microwave Ablation.

With all the measures taken, the trend of liver cancer cases has increased worldwide, as a consequence, this is accompanied by an increase in mortality by 43% (10.3 per 100,000 in 2016 (USA)) [1, 2].&#x0D; Liver cancer is also associated with the lowest 5-year survival rate among all types of cancer (19%) [1].&#x0D; Liver cancer (including intrahepatic bile duct cancer) was the ninth leading cause of cancer death in 2000 and rose to sixth in 2016 [3].&#x0D; This shows that the identification of safe and effective treatments for liver cancer is urgent now.&#x0D; Microwave ablation is a thermal ablation modality that has particular applicability in treating hepatic malignancies primary tumors or metastases. Microwaves can generate very high temperatures in short time periods, potentially leading to improved treatment efficiency in larger ablation zones.&#x0D; We will show a patient male 55 years old. Post-surgery of colon cancer 6 months ago. Normal exam. There is e liver metastasis in the right lobe subcapsular 22mm. The patient was a good candidate for MWA.&#x0D; Conclusions&#x0D; MWA is an effective and safe alternative in patients/tumors that are not suitable for resection. Survival and recurrence outcomes after MWA are significantly improved with significantly shorter hospital stays and operative times, with little or no intraoperative blood loss and minor complications. Its use should be extended more and more in the field of treatment of these patients depending on the therapeutic indications

Laryngeal Radioanatomy

The larynx, a specialized segment of the airways, is the essential organ of phonation, breathing and protection of the lower airways when swallowing by a complex anatomic structures organized around a cartilaginous skeleton. We realized a prospective study on three months, ranging from March 01 to May 31 2020, of patients referred to our service for cervical CT scan or MRI exploration in different contextes. We retained the normal exams. For scanographic exploration we used a multi-slice CT scan consisting of 64 rows of detectors. Helical acquisition in native axial slices 0.627 mm thick from the base of the skull to the arch of the aorta was performed in indifferent breathing after asking the patient not to swallow. Iodinated contrast product was injected according to the administration protocol in a single bolus of 90 ml at an average flow rate of 1.5 ml / s and to perform the acquisition with 50 second delay. A dynamic phonation maneuver (saying “eee” continuously and evenly) was used to analyse the true and false vocal cords. On MRI exploration of the larynx, we used a high-field device (1.5Tesla) with a semi-circular specific surface antenna, the phase oriented in an anteroposterior direction, the 3DT1 spin echo sequence without fat signal saturation was performed. In ultrasound, we used literature data. Knowledge of laryngeal radioanatomy contributes to the diagnosis of laryngeal cancers which occupy an important place in all cancers of the upper aerodigestive tract. They can be diagnosed early and the refinement of their endoscopic exploration and imaging allows them to make a precise extension assessment.

Towards a data-driven system for personalized cervical cancer risk stratification

Mass-screening programs for cervical cancer prevention in the Nordic countries have been effective in reducing cancer incidence and mortality at the population level. Women who have been regularly diagnosed with normal screening exams represent a sub-population with a low risk of disease and distinctive screening strategies which avoid over-screening while identifying those with high-grade lesions are needed to improve the existing one-size-fits-all approach. Machine learning methods for more personalized cervical cancer risk estimation may be of great utility to screening programs shifting to more targeted screening. However, deriving personalized risk prediction models is challenging as effective screening has made cervical cancer rare and the exam results are strongly skewed towards normal. Moreover, changes in female lifestyle and screening habits over time can cause a non-stationary data distribution. In this paper, we treat cervical cancer risk prediction as a longitudinal forecasting problem. We define risk estimators by extending existing frameworks developed on cervical cancer screening data to incremental learning for longitudinal risk predictions and compare these estimators to machine learning methods popular in biomedical applications. As input to the prediction models, we utilize all the available data from the individual screening histories.Using data from the Cancer Registry of Norway, we find in numerical experiments that the models are strongly biased towards normal results due to imbalanced data. To identify females at risk of cancer development, we adapt an imbalanced classification strategy to non-stationary data. Using this strategy, we estimate the absolute risk from longitudinal model predictions and a hold-out set of screening data. Comparing absolute risk curves demonstrate that prediction models can closely reflect the absolute risk observed in the hold-out set. Such models have great potential for improving cervical cancer risk stratification for more personalized screening recommendations.

Is there Really a Lump in My Throat? The Incidence and Implication of Vocal fold Abnormalities in Patients Presenting with Globus

To identify the prevalence of vocal fold abnormalities in patients with a primary complaint of globus sensation. Secondly, to determine the relationship between globus, vocal fold abnormality, and patient-reported quality of life questionnaire score. Retrospective chart review. A retrospective chart review was performed to identify all new patients evaluated at a tertiary academic care laryngology practice between January 2018 and December 2018 presenting with a chief complaint of globus. Variables of interest include age, gender, laryngeal symptoms, self-reported quality-of-life questionnaire results, and laryngostroboscopy findings. Questionnaires selected for this investigation include the reflux symptom index (RSI), eating assessment tool-10 (EAT-10), and voice handicap index-10 (VHI-10). Two hundred twenty-eight subjects with an average age of 54 ±17 years, were categorized based on one of three laryngostroboscopic findings: absence of vocal fold abnormality, vocal fold paresis/paralysis (motion abnormality), or a vocal fold mass lesion. Fifty percent of patients reporting globus had a normal laryngeal exam, and 50% had a mass lesion or motion abnormality. Twenty five percent had vocal fold motion abnormality (paresis, paralysis, or supraglottic squeeze); 19% had a mass lesion; and 3% had both a lesion and motion abnormality. The average self-reported survey scores were compared among the three groups. Patients with dysphonia had a significantly higher VHI-10 (P=0.00), and a significantly higher RSI (P= 0.00) than those without dysphonia. Those patients with dysphagia had significantly higher EAT-10 (P=0.00) and RSI (P=0.02) scores than those who did not have dysphagia. Patients with vocal fold motion abnormality had significantly higher VHI-10 than those with normal vocal fold mobility (P=0.02) CONCLUSIONS: Identifying the etiology of globus presents a significant challenge to laryngologists. Data presented here suggest that vocal fold abnormalities may contribute to the sensation of globus and should therefore be considered in the differential when managing these patients.

Care Practices of Indian Pediatricians for the Screening and Diagnosis of Developmental Dysplasia of the Hip.

Pediatricians play a key role in identifying neonates with hip instability or at risk for developmental dysplasia of the hip (DDH); however, the clinical practices related to screening and further management in India are unknown. A web-based survey was circulated to members of the National Neonatology Forum of India (NNFI). Of the 231 eligible responses, about 92% were from an urban setup. It was noted that 38% (88/231) had not diagnosed any DDH in the past 12 mo, 8% (17/224) had diagnosed cases beyond walking age, 50% (116/231) would pursue further evaluation in children < 3 mo with risk-factors and normal hip exam, 53% (122/229) were aware of hip-safe swaddling, 30% (68/226) were comfortable with performing Ortolani and Barlow maneuvers and < 50% (107/226) were aware of the current guidelines for the management of DDH. Almost all respondents (97.3%, 220/226) felt a need for a DDH care pathway for screening and early management in India. Thus, substantial deficits and variability in screening practices for DDH amongst pediatricians in India.

Combining the strengths of radiologists and AI for breast cancer screening: a retrospective analysis

We propose a decision-referral approach for integrating artificial intelligence (AI) into the breast-cancer screening pathway, whereby the algorithm makes predictions on the basis of its quantification of uncertainty. Algorithmic assessments with high certainty are done automatically, whereas assessments with lower certainty are referred to the radiologist. This two-part AI system can triage normal mammography exams and provide post-hoc cancer detection to maintain a high degree of sensitivity. This study aimed to evaluate the performance of this AI system on sensitivity and specificity when used either as a standalone system or within a decision-referral approach, compared with the original radiologist decision. We used a retrospective dataset consisting of 1 193 197 full-field, digital mammography studies carried out between Jan 1, 2007, and Dec 31, 2020, from eight screening sites participating in the German national breast-cancer screening programme. We derived an internal-test dataset from six screening sites (1670 screen-detected cancers and 19 997 normal mammography exams), and an external-test dataset of breast cancer screening exams (2793 screen-detected cancers and 80 058 normal exams) from two additional screening sites to evaluate the performance of an AI algorithm on sensitivity and specificity when used either as a standalone system or within a decision-referral approach, compared with the original individual radiologist decision at the point-of-screen reading ahead of the consensus conference. Different configurations of the AI algorithm were evaluated. To account for the enrichment of the datasets caused by oversampling cancer cases, weights were applied to reflect the actual distribution of study types in the screening programme. Triaging performance was evaluated as the rate of exams correctly identified as normal. Sensitivity across clinically relevant subgroups, screening sites, and device manufacturers was compared between standalone AI, the radiologist, and decision referral. We present receiver operating characteristic (ROC) curves and area under the ROC (AUROC) to evaluate AI-system performance over its entire operating range. Comparison with radiologists and subgroup analysis was based on sensitivity and specificity at clinically relevant configurations. The exemplary configuration of the AI system in standalone mode achieved a sensitivity of 84·2% (95% CI 82·4-85·8) and a specificity of 89·5% (89·0-89·9) on internal-test data, and a sensitivity of 84·6% (83·3-85·9) and a specificity of 91·3% (91·1-91·5) on external-test data, but was less accurate than the average unaided radiologist. By contrast, the simulated decision-referral approach significantly improved upon radiologist sensitivity by 2·6 percentage points and specificity by 1·0 percentage points, corresponding to a triaging performance at 63·0% on the external dataset; the AUROC was 0·982 (95% CI 0·978-0·986) on the subset of studies assessed by AI, surpassing radiologist performance. The decision-referral approach also yielded significant increases in sensitivity for a number of clinically relevant subgroups, including subgroups of small lesion sizes and invasive carcinomas. Sensitivity of the decision-referral approach was consistent across the eight included screening sites and three device manufacturers. The decision-referral approach leverages the strengths of both the radiologist and AI, demonstrating improvements in sensitivity and specificity surpassing that of the individual radiologist and of the standalone AI system. This approach has the potential to improve the screening accuracy of radiologists, is adaptive to the requirements of screening, and could allow for the reduction of workload ahead of the consensus conference, without discarding the generalised knowledge of radiologists. Vara.

Signs of Cardiac Injury in Critically Ill Paediatric Patients with COVID-19: a Single-Center Experience in Brazil.

ResumoFundamento Alguns pacientes com COVID-19 apresentam injúria miocárdica.Objetivo Detectar a injúria miocárdica em pacientes criticamente doentes, e comparar o envolvimento cardíaco entre crianças com síndrome respiratória aguda grave (SARS) e crianças com síndrome inflamatória multissistêmica (MIS-C).Métodos Todas as crianças acometidas da COVID-19 admitidas em uma unidade de terapia intensiva de referência foram cadastradas de forma prospectiva e fizeram uma ecografia transtorácica bidimensional (ETT-2D) e um teste de troponina I cardíaca (cTnI) nas primeiras 72 horas. Para a análise estatística, um p <0,05 bilateral foi considerado significativo.Resultados 33 pacientes foram incluídos, dos quais 51,5% apresentaram cTnI elevada e/ou ETT-2D anormal e 36,4% precisaram de suporte cardiovascular, que foi mais frequente em pacientes com cTnI elevada e anormalidades em ETT-2D do que em pacientes com exames normais (83,3% e 33,3%, respectivamente; p 0,006, 95% IC = 0,15-0,73). Os achados de ETT-2D mais comuns foram efusão pericárdica (15,2%) e regurgitação tricúspide/mitral (15,2%). Sinais de envolvimento cardíaco foram mais comuns na MIS-C que na SARS. Pacientes com MIS-C também apresentaram um índice mais alto de necessidade de suporte cardiovascular (66,7% X 25%, p 0,03, 95% IC = -0,7 a -0,04) e um índice mais frequente de cTnI elevada (77,8% X 20,8%; p 0,002, 95% IC = 0,19 a 0,79). Os valores preditivos negativos de cTnI para detecção de anormalidades de ETT-2D foram 100% para pacientes com MIS-C, e 73,7% para pacientes com SARS.Conclusão Sinais de injúria cardíaca foram comuns, especialmente em pacientes com MIS-C. As anormalidades na ETT-2D foram sutis. A realização de um teste de cTnI na admissão pode ajudar os prestadores de assistência de saúde a discriminar os pacientes com uma necessidade mais urgente de uma ETT-2D.

Genetic variants in the SHISA6 gene are associated with delayed cognitive impairment in two family datasets.

Studies of cognitive impairment (CI) in Amish communities have identified sibships containing CI and cognitively unimpaired (CU) individuals. We hypothesize that CU individuals may carry protective alleles delaying age at onset (AAO) of CI. A total of 1522 individuals screened for CI were genotyped. The outcome studied was AAO for CI individuals or age at last normal exam for CU individuals. Cox mixed-effects models examined association between age and single nucleotide variants (SNVs). Three SNVs were significantly associated (P < 5 × 10-8 ) with AAO on chromosomes 6 (rs14538074; hazard ratio [HR] = 3.35), 9 (rs534551495; HR = 2.82), and 17 (rs146729640; HR = 6.38). The chromosome 17 association was replicated in the independent National Institute on Aging Genetics Initiative for Late-Onset Alzheimer's Disease dataset. The replicated genome-wide significant association with AAO on chromosome 17 is located in the SHISA6 gene, which is involved in post-synaptic transmission in the hippocampus and is a biologically plausible candidate gene for Alzheimer's disease.

The Utility of CTA in Pediatric Oropharyngeal Trauma: A Systematic Review and Meta-Analysis.

To analyze the utility of computed tomography angiography (CTA) in identifying internal carotid artery (ICA) injury and reducing cerebrovascular accident (CVA) incidence in children presenting with normal neurologic exams after oropharyngeal trauma (OT). PubMed, Scopus, CINAHL, and Cochrane. A systematic review and meta-analysis were performed following PRISMA guidelines. Of 1,185 studies screened, 95 studies of pediatric OT met inclusion criteria. Meta-analysis of proportions was performed. A total of 1224 children with OT were analyzed. Excluding case reports, the weighted proportion of a CVA after OT was 0.31% (95% CI 0.06-0.93). If a child presented without neurologic deficits, 0.30% (95% CI 0.05-0.95) returned with new neurologic deficits. An ICA injury was identified in 0.89% (95% CI 0.16-2.74) of screening CTAs. No difference in CVA incidence was seen in children with screening CTA (0.52% [95% CI 0.02-2.15]) compared to children without screening CTA (0.42% [95% CI 0.06-1.37]). Patients who developed CVA had a higher proportion of injuries >2 cm, injuries at the posterior pillar or tonsil, and injuries with a writing utensil or popsicle stick compared to patients without CVA. The proportion of children experiencing an ICA injury leading to CVA after sustaining OT is low. CTAs infrequently show ICA changes in children with normal neurological exams. Children who receive CTAs do not have a significantly lower incidence of CVAs than children who do not receive CTAs. Clinicians should weigh the risks and benefits of a CTA based on an individual child's presentation and discuss this with caregivers for shared decision-making. Laryngoscope, 133:25-37, 2023.

A ensemble methodology for automatic classification of chest X-rays using deep learning

Chest radiographies, or chest X-rays, are the most standard imaging exams used in daily hospitals. Responsible for assisting in detecting numerous pathologies and findings that directly interfere in the patient's life, this exam is therefore crucial in screening patients. This work proposes a methodology based on a Convolutional Neural Networks (CNNs) ensemble to aid the diagnosis of chest X-ray exams by screening them with a high probability of being normal or abnormal. In the development of this study, a private dataset with frontal and lateral projections X-ray images was used. To build the ensemble model, VGG-16, ResNet50 and DenseNet121 architectures, which are commonly used in the classification of Chest X-rays, were evaluated. A Confidence Threshold (CTR) was used to define the predictions into High Confidence Normal (HCn), Borderline classification (BC), or High Confidence Abnormal (HCa). In the tests performed, very promising results were achieved: 54.63% of the exams were classified with high confidence; of the normal exams, 32% were classified as HCn with an false discovery rate (FDR) of 1.68%; and as to the abnormal exams, 23% were classified as HCa with 4.91% false omission rate (FOR).

An Unusual Presentation of Obstructed Hemivagina with Ipsilateral Renal Agenesis Presenting as Suspected Fecal Incontinence: A Case Report

Background: Obstructed hemivagina with ipsilateral renal agenesis (OHVIRA) syndrome typically presents with worsening dysmenorrhea, pelvic pain, and vaginal or rectal pressure. There is often a delay in diagnosis due to non-specific symptoms and normal external vaginal exam. The objective of this case is to describe an unusual presentation of OHVIRA syndrome that was initially missed on both exam and imaging.